Treatment of exertional rhabdomyolysis in athletes: a systematic review

BACKGROUND: Exertional rhabdomyolysis (ER) is the breakdown of skeletal muscle tissue following intense physical activity that results in impairment of the cell membrane, which allows intracellular contents to be released into the bloodstream. Signs and symptoms include myalgia, myoglobinuria and increased creatine kinase (CK) levels. Athletes are vulnerable to this condition due to their increased level of physical activity. The severity and effects of this condition vary between individuals; however, all athletes are at risk of significant muscle damage, renal failure and perhaps death if not recognized and treated quickly. Effective methods for treatment and return to activity following this condition should be established. OBJECTIVES: The objective of this review was to identify effective treatment methods associated with ER in athletes. INCLUSION CRITERIA TYPES OF PARTICIPANTS: Adult and adolescent patients (15 years of age and older) in the athletic population who have been diagnosed with ER. TYPES OF INTERVENTIONS: Fluid resuscitation/replacement or other treatment methods that aim to improve CK levels and decrease myoglobinuria and treat ER. TYPES OF STUDIES: Due to the absence of randomized control trials, the quantitative component of the review considered descriptive studies, case series and individual case reports for inclusion. OUTCOMES: PRIMARY OUTCOMES: CK and myoglobinuria levels. SECONDARY OUTCOMES: length of hospital stay; length of time from diagnosis to premorbid levels of physical activity. SEARCH STRATEGY: A comprehensive search of the following databases with no date limitation was conducted: CINAHL, PubMed, ProQuest, Embase, SPORTDiscus and Physical Education Index. Results were limited to those available in English. METHODOLOGICAL QUALITY: Two independent reviewers evaluated the retrieved articles for methodological quality using the standardized critical appraisal instrument from the Joanna Briggs Institute Meta-Analysis of Statistics and Review Instruments. DATA EXTRACTION: Data were extracted from the articles by two independent reviewers using the standardized Joanna Briggs Institute extraction tool. DATA SYNTHESIS: Narrative and tabular synthesis. RESULTS: Fourteen studies with a combined total of 53 participants were included. Aggressive intravenous (IV) fluid resuscitation was found to be the most commonly utilized treatment method for decreasing CK levels and resolving myoglobinuria. The addition of compounds within the IV fluid varied between studies. CONCLUSION: Due to the types of included studies and variation in reported treatment methods and outcomes for ER among athletes, effectiveness of treatment could not be determined. The limited evidence available indicates that IV fluid replacement, specifically normal saline, is the most commonly reported treatment for decreasing CK levels and myoglobinuria following ER. It appears that normal saline may be combined with other compounds including sodium bicarbonate, sodium chloride or potassium chloride to achieve reduction of CK levels and myoglobinuria. Clinically, early IV fluid replacement appears to be delivered at a rate of approximately 400 ml/hour, with adjustments ranging between 200 and 1000 ml/hour, depending on severity and volume states. Hospitalization time varies, depending on severity of condition, and return to activity is widely inconsistent among the athletic population