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This spring, when Justin Urban, 41, a slender hotel waiter and covid-19 survivor from Falls Church, Va., reentered his condo building’s gym for his first workout in months, he committed to nothing more than five minutes of power walking on a treadmill. His caution was the result of what happened to him in 2018, the last time he hit the gym after a long hiatus: He was hospitalized for a week after completing 40 negative pull-ups.
Urban’s symptoms included stiff, sore elbows and a bout of brown urine (“the color of Coke,” he said). He was diagnosed with a rare condition called rhabdomyolysis (frequently shortened to rhabdo). Rhabdo results from overexertion typically brought on by repetitive, unfamiliar movement that stresses muscle cells to the point at which they essentially burst and die.
The cells then leak their toxic contents — especially creatine kinase (a muscle enzyme) myoglobin (a muscle protein) — into the bloodstream, with potentially fatal results. A National Institutes of Health review found that as many as 40 percent of rhabdo cases end in kidney failure.
The primary diagnostic tool for rhabdomyolysis is a blood test for creatine kinase. Urban’s results showed of more than 100,000 units per liter, an amount that risked causing kidney failure and either death or lifelong dialysis (normal levels of the enzyme range from 22 to 198 units per liter). His urine was not tested, but the discoloration was likely the result of the excess myoglobin. He was put on intravenous saline to wash out the toxins.
“It was just kind of a shocking thing,” he said. “Forty pull-ups put me in the hospital for a week.”
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There are roughly 42,000 cases of rhabdomyolysis a year among U.S. adults, but experts worry that the condition has found a fertile moment this summer among Americans experiencing weight gain. According to one 2021 study, pandemic stay-at-home orders led to a decline in physical activity. Another found that participants had gained an average of 1.5 pounds per month that they sheltered in place.
As people continue to return to gyms and broader daily life, the race to lose that weight has intersected with both beach body pressure and a synchronous kind of national high school reunion vibe in which the newly chubbier among us are eager for friends and colleagues to see us as we were pre-pandemic. A nation where 74 percent of adults are already overweight is now writhing in the triangulation of these stressors this summer — and high-body temperature is a risk factor for rhabdo.
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“We survived the pandemic because our bodies are built for survival,” said Ali Register, 40, a personal trainer for 12 years who is now the training director at the Balance Gym on Capitol Hill. “But for humans that usually means doing as little work as possible and consuming as much energy or calories as possible. Our bodies like us fat and lazy. We learned to run to escape danger, not to get fit.”
He detailed what he called a recent, major “tilt” among gymgoers: “Nine out of ten people now, they come in and the first thing they say to their trainer is something about their pre-pandemic body. That’s the standard. That’s the urgency. There’s a desperation to look better, and almost to be unaffected by the pandemic and everything we’ve been through.”
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That psychology can be amplified by gyms, which offer physical extremes usually unattainable during home or outdoor workouts, and group classes, where participants can frequently push past personal fatigue levels in the frenzy to keep up with everyone else.
At one point, CrossFit gyms displayed an “Uncle Rhabdo” mascot, and, in 2008, a Virginia man won a $300,000 settlement against his gym for a CrossFit-style workout that resulted in rhabdo.
While extreme workouts are ripe for rhabdo, cases have occurred after more conventional exercise, consider the woman hospitalized after one 45-minute spinning class, the police officer who died from a 1.5-mile run and the hospitalized college football players in Iowa and Nebraska.
The Centers for Disease Control and Prevention maintains a list of contributing risk factors, including alcohol, antibiotics, antidepressants, caffeine, cocaine, cholesterol-lowering drugs called statins, cold and allergy medicines, methamphetamines, and supplements including creatine and ephedra. Because of sickle cell disease, Black people are also at higher risk of rhabdo. Men, who tend to have more muscle mass, are more at risk than women.
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“I’m worried that there might be a spike with people going back into it with the reopenings,” said Maureen Brogan, associate professor of medicine at Albert Einstein College of Medicine in New York and a nephrologist at Montefiore Health System. “I feel like I’m starting to see younger. I’ve seen 18-year-old kids who get it. A lot are 30 or less,” said Brogan, who published a 2017 study on rhabdo cases in the American Journal of Medicine.
Part of the problem, she explained, is that rhabdo flourishes under the kinds of fads and novelties upon which gyms and fitness purveyors rely. “It could be from any repetitive motion of a muscle when the muscle has not been used in that way,” Brogan said. “It can be lots of sit-ups. It can be anything.”
She added that she has even seen rhabdo cases result from casual activities such as gardening, house painting and shoveling snow. And she warned that nonsteroidal anti-inflammatory drugs such as ibuprofen can compound rhabdo’s kidney failure risk with their own kidney damage, especially when people take the pills to relieve soreness or stiffness associated with rhabdo.
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Rhabdo also stands as a rebuttal to the conventional exercise wisdom of “no pain, no gain” or the urging to “feel the burn” that you hear from trainers. “ ‘No pain no gain’ is not anything you should ever follow,” said David Wang, a sports medicine physician at Hospital for Special Surgery, in New York, who specializes in the treatment of acute and overuse injuries and has served as a team physician for both college and professional athletes.
“We see [rhabdo] a lot in team settings, class settings, where people are trying to keep up with others, and they don’t want to look weak or that they can’t commit,” he said. “They’re not listening to themselves. They’re listening to other people.”
Wang is blunt about the dangers of trying to jump back into a pre-pandemic fitness routine. “It takes weeks and months to build up strength, and if you’re inactive for even just a week or two you lose all that strength and have to build it slowly back up again, so you’re not going to do what you were able to do a year ago or six months ago before the gyms closed.” Ignoring that reality, he said, is “the perfect setup to develop injuries, including rhabdo.”
“When rhabdo happens, it’s an utter and complete shock. It’s an emotional shock. It’s a physical shock. People have never heard that exercise can be bad for them,” said Joe Cannon, a personal trainer who has a master’s degree in exercise science. “And I don’t even like saying that, because we live in a country where the vast majority of Americans do not exercise. And when people hear stories like this they think, ‘Oh my gosh! I shouldn’t even exercise because it could be bad for you.’ ”
For his part, Urban, whose 40 pull-ups hospitalized him with rhabdo, has continued working out with a self-described “slow progression” of slightly longer runs — a common rule of thumb is not to increase runs by more than 10 percent weekly — and a slow build of complementary push-ups and sit-ups. But not too many. “I got rhabdomyolysis because I was an idiot. My ego got in the way,” he said. “I learned my lesson.”
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Richard Morgan, a freelance writer in New York, is the author of “Born in Bedlam,” a memoir.
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Rhabdo is rare but potentially fatal. Here’s why fitness experts fear a rise in cases this summer. - The Washington Post
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UPDATE: The deadline to submit letters of interest for the Town Seal Review Committee has been extended to July 16. 
