Portal de Periódicos da CAPES

“A Stitch in Time” and “If 6 was 9”

2016; Lippincott Williams & Wilkins; Volume: 15; Issue: 3 Linguagem: Inglês

10.1249/jsr.0000000000000251

1537-8918

E. Randy Eichner,

Thermoregulation and physiological responses

Introduction The good news: We are preventing exertional sickling collapse (ECAST) and death in National Collegiate Athletic Association (NCAA) division 1 football. Although ECAST continues apace as a bane and a killer in the U.S. military, the NCAA program of screening and tailored precautions for sickle cell trait (SCT) has now been statistically proven to save lives. The bad news: Outbreaks of "team rhabdomyolysis" continue to put athletes in hospitals. It seems we are slow to learn the cardinal lessons that will prevent these outbreaks of acute exertional rhabdomyolysis (ER). Let me explain, starting with ECAST. "A Stitch in Time": Preventing ECAST in Football From 2000 to early 2010 in NCAA division 1 football, 10 ECAST deaths occurred from intense conditioning for the game. Mandated screening and tailored precautions for SCT in division 1 began in mid-2010, and since then, only one football ECAST death has occurred. Assuming media reporting is correct, this tragic death was from an intense, sustained football conditioning workout that failed to heed NCAA guidelines for SCT (8,16). So we had 10 ECAST deaths in the 10 yr before SCT screening and precautions began, and only one such death afterward. Analyzed as years with or without an ECAST death, before and after the SCT program began, the result is significant (P = 0.0498) by the two-tailed Fisher exact test. The numbers are small, but the trend is clear: We are preventing ECAST deaths in college football. Not so in the U.S. military. As I said 2 yr ago in reply to essayists, ECAST deaths continue apace in the Army and Air Force (1,4,15). Most collapsed while running, trying to pass a 1.5- or 2-mile fitness test. The trigger is sustained maximal intensity, not exertional heat illness. We have reported ECAST deaths in Army recruits (7), and in just the past year, four more reports of ECAST — severe or fatal — have appeared in military journals (6,10–12). All four reports urge greater awareness of the ECAST syndrome in the military, and two reports call for greater awareness of SCT status in the Army (10,12). A new sweeping review of SCT in athletes (14) concludes that a case can be made for targeted screening, for example, of black football players, but notes that "it has yet to be demonstrated how far the diagnosis of SCT reduces the risk of death when exercising in an adverse environment." We have shown that, via SCT screening and precautions, we can significantly reduce ECAST deaths in the harsh "environment" of intense conditioning for college football. Let us hope the Army takes note. "If 6 was 9": Lessons from Team Rhabdomyolysis So a stitch in time saves nine. But what if, to paraphrase the title of the Jimi Hendrix anthem to individualism, "6 was 9"? As Jimi sang it: "Now if a 6 turned out to be 9, I don't mind, I don't mind." As it turns out, for recent outbreaks of team rhabdomyolysis, 6 has turned out to be 9. When I last covered acute rhabdomyolysis in diverse team sports, there were six recent well-described outbreaks (5). Now there are nine. Why? Because, as they say in politics, "mistakes were made." And, alas, lessons are not being learned. So it is time for straight talk. Five well-described outbreaks are covered in the section on ER in the NCAA Sports Medicine Handbook (9). All were caused by novel overexertion enforced by coaches. It is always "too much, too fast, too soon." The Hawkeye football outbreak, which put 13 University of Iowa players in the hospital, was from an unduly intense back squat drill led by strength coaches who seemed intent on punishing players for perceived poor performance (3). The outbreak on the Oregon high school football team, which put 12 players in the hospital (and three got fasciotomies), was from an unduly intense triceps-focused drill conjured up by a new coach (2). Two outbreaks of ER occurred on NCAA women's lacrosse teams. One outbreak was from an unduly intense drill with weights on day 1 of team training after a 3-month hiatus. The other outbreak, which put six players in the hospital, was from an unduly intense, novel, upper body workout after the team lost a big game. The athlete who tried the hardest and did the most exercise in this coach-directed drill suffered the worst and longest course of ER. The outbreak of ER on an NCAA swim team, which put seven athletes, men and women, in the hospital, was caused by an unduly intense, novel, day 1 drill enforced by a new swim coach. I recently covered a sixth outbreak of ER on a college softball team in Kansas. It was caused by a strange novel-overexertion drill designed by a new strength coach intent on building Rome in a day. On day 1 of team training, he took all 21 players to a steep incline, the grassy face of a dam, and had them jog up it and walk down it backward, four times. Six players ended up in the hospital with ER of the calves (5). Now 6 is 9. On a high school football team in Maryland, a new coach came up with a novel drill, "triangulated push-ups" while on three chairs, one for each arm and one for the feet. Players had to do 125 push-ups, five repeats of 25 each. This novel-overexertion drill, which sent three players to the hospital, was right after spring break. One player needed fasciotomies for triceps compartment syndrome and spent 17 d in the hospital. In another outbreak, after trying out for the basketball team at a middle school in Mississippi, three 13-yr-old boys spent 1–2 wk in the hospital for ER. The tryout was described as "extreme" by the media, but only as "short and concentrated on leg muscles" by school officials. It involved bear crawls, lunges, and frog jumps. One boy said that, late in the drill, "If I tried to bend over or squat, my legs would give out and I would fall over." The ninth outbreak occurred in January 2016 and at this writing is still under investigation. At a small high school in East Texas, after Christmas break, three to five football players were sent to the hospital with ER after their coaches made them do hundreds of squat jumps for 2 or 3 d in a row, apparently as punishment for leaving the locker room messy. The head football coach resigned in February (13). So there you have it. The pattern is clear. Coaches who are feckless or reckless are putting our kids in hospitals with extreme drills that have no place in sensible training for sport. Maybe the drill is well meant and just dumb, as when, after a losing season, a new coach tries to build Rome in a day. Or worse, maybe the drill is meant to intimidate or punish the athletes. In any case, this is on the coaches and it harms our kids. It should end. We can do better than this.