Diving Post-Rhabdomyolysis

[kmrEMTPRN]

I had an episode (for lack of better terminology) of exercise-induced rhabdomyolysis in June this year. It occurred after a spinning class that lasted about 45 minutes. It was my first time spinning, and I had been exercising regularly for about 5 months prior and am otherwise healthy. My CK peaked at 36000 and I spent 6 days in the hospital with treatment of IV hydration, pain control and lab monitoring. I was fortunate enough to NOT suffer any significant increase in BUN/creat and LFT were increased but all levels have returned to normal. I spent 2 months off of work (as an ER nurse) and have finally made it back to work full-time recently. After a muscle biopsy that was negative for underlying conditions, my PMD thinks that I may have been a bit dehydrated prior to the spinning class and that MAY have been the cause. But no real way to know for sure....

At 2 1/2 months post-incident, I am now able to work my full-time job (on my feet) for 12 hour shifts, but I do suffer from some muscle soreness/weakness if I really push it. There seems to be a cumulative effect if I work multiple days in a row.

As a medical professional myself, my concern is how long should I wait to resume diving?? Is there a logical answer here? My physician, who is not familiar with dive medicine had no good answer for me. As diving is not common in my area and we do not see dive related injuries, my ER physicians don't really have a good answer either. Does this episode of rhabdo pre-dispose me to dive-related conditions??

As I obviously have not resumed diving as of yet... I am hoping to be able to dive in Cozumel in October. But I really want to know that I am safe to do so. As I am anxious to get back in the water, I also consider my buddy/husband and want to make sure that I am a reliable dive buddy for him also. I am also smart enough to know that if I do have muscle weakness/soreness, I will not put myself at risk.... the reason I have not YET resumed diving.

Thanks for any feedback you can offer!!

 

[DocVikingo]

Hi kmrEMTPRN,

"Exercise-induced rhabdomyolysis (EIR)," or exertional rhabdomyolysis, indeed is a well-recognized disorder. It usually follows an event of strenuous to very strenuous exercise, but can occur after only moderately strenuous activity. Typically serum creatinine levels are significantly elevated; urine may be darkened and test positive for blood without frank hematuria. BUN generally is not elevated to clinically meaningful levels. Most often, abnormal LFTs return to normal over time.

EIR is more common in out of shape individuals who commence exercise with a vengeance, but can be seen in persons who give a history of regular exercise. Dehydration certainly could contribute to the development of EIR and it appears that beginning a new type of strenuous exercise, such as spinning (1), possibly could contribute.

Given that all other probable causes of rhadbo have been ruled out, the normal exercise regimen has been resumed without worrisome incident, there are no other contraindications to SCUBA, the diver is physically and psychologically fit and has the stamina for SCUBA, and medical clearance to participate in the recreation has been received, there appears no compelling reason that a single event of EIR 4-5 months previously should pre-dispose to dive-related conditions such as DCI or increase the risks of recreational diving under friendly conditions.

The affected individual will want to dive conservatively and avoid conditions of strenuous activity such as sustained high current, heavy surge and arduous surface swims. Care should be taken not to confuse possible signs and symptoms of DCS with an episode of EIR. Hydration should be maximal and high heat loads avoided. If EAN cert, use of nitrox on appropriate dives might be considered.

Helpful?

Best of luck,

DocVikingo

This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice to you or any other individual and should not be construed as such.

(1) "Eur J Emerg Med. 2004 Dec;11(6):358-9

Abstract

Spinning-induced rhabdomyolysis: a case report.Young IM, Thomson K.

Accident and Emergency Department, Royal Alexandra Hospital, Paisley, Scotland, UK. iain.young@rah.scot.nhs.uk

Exercise induced rhabdomyolysis has previously been described as occurring in unfit adults or those attempting exhaustive exercise, but is rarely seen in previously fit adults undertaking moderate exercise. This case report describes what we believe to be the first reported case of exercise induced rhabdomyolysis due to the patient completing a 'spinning class' at her local gymnasium. The report also covers diagnosis and management of this condition."

 

[Bubbletrubble]

To expand on what DocVikingo has written...

There has been little to no research conducted on the long-term DCS risks of scuba divers with a one-time history of rhabdomyolysis. In the medical literature, there have been reports of DCS and/or AGE causing rhabdomyolysis...but not vice versa.

Assuming that your episode was predominantly caused by overexertion/dehydrated state and not instigated by any genetic or pharmacologic factors, I really don't see any reason why you couldn't resume diving activities provided that you take the same precautions that any athlete exercising in a warm/humid environment should:

• Gradually increase your exercise tolerance until your fitness is at an appropriate level to dive safely.
• Stay within your normal limits of exercise (duration and magnitude of activity).
• Be sure to stay well-hydrated.
• If you've had an infectious illness recently, keep your workouts light.

If you are currently experiencing muscle soreness/weakness at the end of a work day and haven't resumed a regular exercise regimen yet, then I'd say that you aren't ready to go diving right now...but October is still more than a month away.

Cozumel offers world-class drift diving. Although significant currents exist there, in almost all cases you'll be following a divemaster and moving with the current...so overexertion shouldn't be a problem. If you find yourself surfacing downstream of the boat (for whatever reason) and the current is ripping, I'd recommend signaling the crew (with an appropriate surface signaling device SMB/whistle/horn if necessary) and waiting for the dive boat to pick you up. There's no reason to risk overexertion by kicking against the current.

It was prudent to consult your PMD and ER docs regarding this issue. You can contact DAN about this, but I'd be surprised if their medical staff has an official position on your case. You can take consolation in the fact that even triathletes and marathon runners can suffer from rhabdomyolysis. It is not unheard of for them to exhibit CK levels on par with your impressive 36000.

Good luck and I'm glad you are OK.

 

[kmrEMTPRN]

Thanks for your replies... I did in fact consult DAN regarding this also. Here is the reply, which is quite similar to your advice....

Realistically, there’s nothing we can provide other than a ‘Paracelsian educated guess’ here. I’ve just discussed your case with one of my colleagues here and your case doesn't seem to cause any heartburn on him either. As long as ‘you feel you can’, and as long as you start with very predictable environments, staying well within No-Deco limits and avoiding any strenuous swimming/kicking activities, you should probably be fine. If you can tolerate a 12-hour shift on your feet, you can most likely tolerate a couple of average shallow-reef dives. Now Cozumel tends to have a little south-to-north current, so just drift away and make sure your Dive Master does not have the clever idea to make you guys fight against it (sometimes they tend to do this, as if we were all 18 years old… mark my words, and discuss this with them on the briefing before the dive). You will probably have to keep in mind for some time that in case -for whatever reason- you do have a natural tendency to ‘rhabdomyolyze’, any strenuous physical activity like a high kicking/swimming demand could potentially trigger another yet another event. Finally, consider that after any dive you will be dehydrated just because of the fact of being immersed in a liquid, so be sure you drink plenty water before and after your dives. Another good idea would be to do no more than 2 dives per day, and to take a day off of diving every 2 days of diving. This will not only help you off-gas, but will also help you restore your fluids and electrolytes, your nutritional depletion and your aerobic capacity. Nitrox using air Tables? Why not. In the mean time, start testing your tolerance gradually, try with 15min to 20min spinning rides and see how you feel and how you urinate for the rest of the day. Always pay attention to hydration, since you only have two kidneys and you won’t grow another one if yours go south. You’re 31, so you still have live with these for a long time. Other than that, just be safe, and let us know how you go.

-So.... I plan to make my return to the gym this week. I'm going to see how that goes and possibly think about diving on Saturday. I'm not talking ANYTHING strenuous here... just want to go down and do some refresher stuff and buoyancy. I do not want my first time back in the water to be in Cozumel... If I'm not up to it, I WILL NOT dive. Thus the reason I have not yet resumed. Hopefully I'll have a good post this weekend!! Thanks again!

 

[kmrEMTPRN]

thank you docvikingo for citing that article.... the article describes my episode EXACTLY (with exception of hematuria, which was not visible), which is really pretty scary. that is the exact way that it presented in myself. my legs did "give way" immediately after stepping off of the bike, and I did not feel severe pain while participating in the class. it was about 40 hours post-spinning that I went to the ER... at that time, my thighs were probably double the size and I was unable to bend my legs due to the swelling.

 

[DocVikingo]

You're more than welcome, kmrEMTPRN.

The DAN reply includes the following: "Now Cozumel tends to have a little south-to-north current, so just drift away and make sure your Dive Master does not have the clever idea to make you guys fight against it...."

Fact is, some sites tend to have relatively vigorous currents on a regular basis, especially those up north like San Juan and Barracuda. These should be avoided. And strong and sometimes disorganized currents occasionally appear even on typically tame sites. Ask the DM how the site looks before diving it.

Do have fun.

Regards,

DocV