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-   -   Top 10 Ways to Avoid Giving a Client Rhabdo (http://board.crossfit.com/showthread.php?t=38220)

Ahmik Jones 10-15-2008 08:57 PM

Top 10 Ways to Avoid Giving a Client Rhabdo
 
We have all heard about the recent law suit.

In this case it looks like the client was given an appropriate beginner workout and it was a fluke that he got rhabdomyolysis. However, there are several things that have led to rhabdo. Here are some ways to avoid it in your clients.

10. Avoid giving new or prospective clients tough workouts to impress them into joining your gym. This is one of the toughest things to do especially when you are starting out. You have to be confident in your program and yourself. Not only will you avoid hurting people, in the long run you will get more clients this way.

9. Be very judicious when lowering weight or increasing assistance to help someone get through a workout. While this practice is used extensively with more established clients, it can be dangerous with new people. For example, I made the mistake a couple of years ago when training a large group of people at work, of having letting people help their partners through a workout after they failed. The workout was 1 pull-up the first minute, 2 the second, 3 the third... I thought the workout would be too easy, because most of the people could not do very many pull-ups. So when they failed I had them keep going with assistance. Of the 50 people, 49 were fine, but one got rhabdo.
Lowering weight or adding assistance is fine when done in a slow workout to let people finish, but if it is done when someone reaches muscle failure and continues to push hard it can be dangerous.

8. Avoid giving new people a weight that is too light. Sometimes weight is protective. It makes people slow down due to muscle failure. We had a group of people do Fight Gone Bad with PVC and a 4 lb Dynamax ball and people were throwing, up because there was no need to stop. Give people something that is heavy enough to make the workout legitimate as long as they can lift it with proper form and they will rest enough to keep themselves safe. Once people have been doing this for a while they can do things like light Fran to work on speed without worrying, but it can be dangerous at first.

7. Be careful when doing exercises with a pronounced eccentric component. Jumping pull-ups, kettlebell swings and thrusters are disproportionately represented in the rhabdo cases. These are excellent exercises, but when people are new they can be devastating. A study of prison inmates, found 36 cases of rhabdo in inmates that had done high rep low weight thrusters.

6. Have a slow ramp up period when starting new clients. Many affiliates have 3 session introductory courses. While this is more cost effective in the short term it is not long enough to allow people to adapt to the workouts. It is my opinion that an 8 session course taking at least 2 weeks is more appropriate, both for learning the movements and avoiding rhabdo. 4 weeks is even better. A course like this should focus on proper form with little to no emphasis on time or competition. There is plenty of time for competition after your introductory course, and of course the workouts get harder later in the course.

5. Encourage clients to take breaks at first. This allows muscles to get oxygen and can help them avoid damage. Once they have been doing CrossFit for a while they will be able to push their muscles continuously without risk, but not at first.

4. Learn to pick out people likely to get rhabdo. It has been documented that for the most part the people who are most likely to get rhabdo are either in good shape by everyone but CrossFit's standards, or who were once in good shape. People like prior athletes, prior military or law enforcement are very common. Generally, the more mentally tough the client and the more athletic the are or once were, the bigger the risk and the more you have to hold them back.

3. Encourage clients to drink water. This is always a good idea. This doesn’t mean force them to drink during a workout, but it does help to keep thems hydrated in general.

2. Tell clients about rhabdo so they will be aware. With every new client we give them a long talk about what CrossFit is and why we take 8 sessions to get them into our group classes. At the end of this discussion is a description of rhabdo and how to avoid it. It has been very effective.

1. The final thing to watch for is people who have done CrossFit for a while, took a break and want to start up again. This is almost a sure recipe for rhabdo. I can think of 5 cases off the top of my head involving our gym and other local affiliates of people returning after a break with the mental ability to push themselves much harder than there body is able to safely accomplish. The classic story involves a woman who gave birth and came back to CrossFit, but it can happen with anyone who takes a break. The better the CrossFitter the more likely it is that they will give themselves rhabdo.



If one of your clients does get rhabdo, these are some of the signs: Not everyone gets all of these symptoms, some people don’t even have much pain.

1. Pain out of proportion to the amount of soreness you would expect, often coming on much faster than you would expect after a workout, and often accompanied with weakness.

2. Swelling of the body part involved, either with or without pain.

3. Decreased urine output or dark urine. This is the scary one and the one that gets you admitted to the hospital.

If you think someone has rhabdo:

1. Get them to a doctor. You can't be sure how bad it is going to get. It may progressively get worse for days before it gets better.

2. Have them drink water. The only way to protect the kidneys is to ensure they have enough fluid to handle the toxins. If it is bad enough they will be put in the hospital with a catheter in one end and an IV in the other until they recover.

3. Avoid heat. Hot tubs can greatly exacerbate the release of muscle contents and can make a case of rhabdo much worse.

Although the practices above will help you avoid rhabdo in your clients, most people won't get rhabdo even if you do everything wrong. However, it is worth being cautious. One bad case of rhabdo can ruin all the good you have done for your other clients.

I am eager to hear other people's thoughts on the subject.

Ahmik Jones, M.D.

Zach Forrest 10-15-2008 09:29 PM

Re: Top 10 Ways to Avoid Giving a Client Rhabdo
 
Great post, Ahmik. I would actually vote to get this one "stickied" at the top of the forum. Thanks for the information.

Dan Donche 10-15-2008 11:25 PM

Re: Top 10 Ways to Avoid Giving a Client Rhabdo
 
Yeah, excellent post. I agree that education is another key element in preventing it in new people, but we forget a lot about experienced people who may have taken a break.

Only thing I can think of that wasn't mentioned is hot temperature outside (you mentioned heat, but not this kind). Most military people who get rhabdo are in basic training settings or outside in hot environments (usually also dehydration is a contributor). Here's a good article about it in the military though: http://afhsc.army.mil/msmr_pdfs/2008/v15_n02.pdf (WFS)

Samuel Friedman 10-16-2008 12:36 AM

Re: Top 10 Ways to Avoid Giving a Client Rhabdo
 
I second the motion to sticky this post...good stuff

Daniel Mick 10-16-2008 01:02 AM

Re: Top 10 Ways to Avoid Giving a Client Rhabdo
 
Third for the sticky.

Sean Manseau 10-16-2008 03:20 AM

Re: Top 10 Ways to Avoid Giving a Client Rhabdo
 
Thanks, Dr. Jones!

Ahmik Jones 10-16-2008 04:31 AM

Re: Top 10 Ways to Avoid Giving a Client Rhabdo
 
Quote:

Originally Posted by Dan Donche (Post 424298)
Yeah, excellent post. I agree that education is another key element in preventing it in new people, but we forget a lot about experienced people who may have taken a break.

Only thing I can think of that wasn't mentioned is hot temperature outside (you mentioned heat, but not this kind). Most military people who get rhabdo are in basic training settings or outside in hot environments (usually also dehydration is a contributor). Here's a good article about it in the military though: http://afhsc.army.mil/msmr_pdfs/2008/v15_n02.pdf (WFS)

You are right. The worst case of rhabdo I have ever seen was in a guy with heat stroke, and the classic case of exertional rhabdo happens on a hot day in someone who is dehydrated.

Heat makes everything worse.

Randy Tarasevich 10-16-2008 06:03 AM

Re: Top 10 Ways to Avoid Giving a Client Rhabdo
 
Great post Doc! Thank you very much.

Sticky it.

Neil Khant 10-16-2008 09:04 AM

Re: Top 10 Ways to Avoid Giving a Client Rhabdo
 
Thank you Dr.

For the health of all Crossfitters.

Ryan Wooley 10-20-2008 09:52 PM

Re: Top 10 Ways to Avoid Giving a Client Rhabdo
 
Thanks Ahmik,
This is an excellent post and a subject that I have been thinking about a bit lately as I take on new clients. The concept of keeping the loads from being to light had not occurred to me. I have always tended to err on the side of scale weights down for newbies. Do you know the source on the prisoner study? I would like to look at that.


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