Cramping Syndromes Sodium Loss and Sickle Cell Trait E. Randy - PowerPoint PPT Presentation

Cramping Syndromes Sodium Loss and Sickle Cell Trait E. Randy Eichner, MD Team Internist, OU Sooners OU Health Sciences Center

Not All Cramps Are Alike None Below from Salty Sweating • Writer’s cramp • Fiddler’s cramp • Golfer’s yips • Hurdler hamstring • Runner side stitch • Hypervent. tetany • Sleeper calf cramp • Sickler cramping

Heat-Cramping Controversy Muscle fatigue and what else ? • Dehydration? • Low potassium? • Low calcium? • Low magnesium? • Muscle spindle/Golgi organ? • Is it quinine deficiency? • Or the dreaded Cramp-O-Ray?

Heat Cramps: Salty Solutions • Stokers • Miners • Military • Hoover Dam • McCance • Tennis • Football

Hoover Dam Saline Solution Talbott & Michelsen, JCI 1933 • “An important criterion (was) …marked relief after (infusing)… normal saline. All cases…free from symptoms within six hours…”

King of Tennis Mike Bergeron (JSMS 2003) • 17 male players • All crampers, but heat-acclimatized • Hot/humid match • Sweat 2.6 L/hr • Na+ loss/hr 2.7 g • One lost 12 g salt an hour!

Chris Legh in Lab Top Australian Triathlete • 2-hr run; 2-h bike • Mimic Kona clime • Lost 8.8 L sweat • Drank 5.5 L fluid • Lost 3.8% body wt • Lost > 25 g salt!

Cystic Fibrosis? • One gene: 1 in 20 or 25 whites • Mitigates typhoid, cholera • Sweat sodium up to 60-80 mmol? • Cake with salt

Heat-Fit Football Player • 250 lb, 60-65% H2O • 17-18 gal water • 100 gm sodium or 50 tsp salt • In hot game, can sweat 1-2 gal fluid, 5-10 tsp salt

Fluid Turnover in 2-a-Days Stofan JR et al., at ACSM 2005 10.3 ± 2.2 L/d (9 - 14 L/d) Players Crampers 11.2 L/d Non-crampers 9.7 L/d Note that top turnover is 3.5 gallons of fluid a day! No wonder they’re thirsty!

SWEATY SOONER STUDY Two groups (n=5): Crampers vs. Non-Crampers Matched: Age, Weight, Race, Position Measures: Sweat out, fluids in, sweat [Na], [K] Pilot Studies: June, July (Field Skills, Indoor Weights) Final Study: August (2-a-days; 2.5 hr practices)

Crampers Are “Salty Sweaters” Cram p Non-Cram p Sweat sodium levels Sweat Sodium, mEq/L are always higher in 100 1.7 1.4 2.1(P<.01) crampers… 80 Trends similar in all 60 three studies, June, 40 July, August… 20 0 June July August OU Studies

Crampers Dehydrate More ES = 0.98 ES = 0.32 C NC C NC 0 Despite drinking, high -0.2 sweat rates dehydrate -0.4 % -0.6 n tio ra -0.8 d y h e D -1 -1.2 -1.4 -1.6 Morning Evening

Crampers Lose More Salt Grams sodium 6 5 4 3 C N C 2 � Sweat [Na] x � Sweat rate = 1 0 GREATER TOTAL LOSS (P=.01) A M PM ES = 1.8 ES = 1.1

Salt Depletion: NFL 2-a-Days Godek et al, ACSM 2004 • 6 NFL players, age ~ 26, wt. ~ 104k • Serum Na+ fell, 140 to 137 mmol/L, by Day 3 (~ 200 mEq Na+ lost) • Or ~ 12 gm of salt lost by Day 3! • Plasma volume fell ~ 5% by Day 3 • Conclusion: They need more Na+ during early 2-a-days

Clues to Salt Depletion Warning signs for athletes • Salt on your skin • Your sweat – Burns eyes – Stings abrasions – Tastes salty • Heat cramping • Dizzy standing up

Get More Salt in Diet! And in Sports Drinks Onfield • Tomato juice • Salty soups • Baked beans • Pickles • Pretzels • Pizza • GLytes • Endurance formula

The Water Hazard - HS linebacker locks up in 2 nd half - Quaffs 9 L water - Seizure, Na + 120 - College LB locks up in practice - Quaffs 12 L water - Goofy, Na + 121 - College FB player with leg cramps - Given 8 L hypotonic fluid IV and po - Goofy, wet lungs, Na + 121

Cramp-Prone? • Lean and fit • Explosive • Many reps • Intense • Heavy sweater • Cakes in salt • Low salt diet

Methods Methods • Measure • Measure – Body weight change – Body weight change – Fluid intake – Fluid intake – Core temperature – Core temperature • Calculate • Calculate – Sweat rate – Sweat rate – % dehydration – % dehydration

8 subjects 129 +12 kg 190 +3 cm 22% fat Pre-session USG: Pre-session USG: 1.025 +0.007 (1002 mOsm/kg) 1.025 +0.007 (1002 mOsm/kg)

Results - Pre-Season Core Temp, ºC • Heat Stress 40.5 40 WBGT 22.9 +07 ºC 39.5 No radiant contribution 39 38.5 • Sweat rate 38 37.5 1.5 +0.3L/h 37 • Dehydration 36.5 36 0.8 +0.4% 35.5 35 Pre End Peak avg 39.4 +0.6 ºC

DB 23.9 +0.3 25 +0.4 ~24ºC RH 77.5 +1.6 76.8 +1.7 75% WBGT 22.3 +0.4 23.4 +0.5 22.5 ºC 3.5 3.0 Change in Tc from Baseline, °C 2.5 2.0 1.5 1.0 0.5 0.0 Field Drills (Vest) Heavy Lifting (Wts) Break, then Sprints -10 0 10 20 30 40 50 60 70 80 90 100 Time (min)

Lessons Learned Radiopills hold promise in football • Can heat up fast and even cramp up • In a June drill • No football gear • Dehydrated at start • Salt-depleted too? • Cool fast when stop, despite cramping

Features of Heatstroke • Fuzzy thinking - Confused, can’t follow plays, runs wrong way • Bizarre behavior - Blank stare, talks nonsense - Yells in rage, wants to fight • Physical decline - Incoordination, N/V, hyperventilation - Wobbles, staggers, collapses - Seizure, coma

Day One Death in Dallas Eric Brown, 17, Carter High, 8/2/04 • Starting center • 3 ½-hr practice • Heat index 105 • Sprints at end • Collapsed once? • Got through it • Seizure at home

Risky Ways for 2-a-Days High schools; Dallas Morning News; Aug ’04 • “Our first practice the longest” (3.5 h) • Breaks in sun • End with 16 sprints • K+ pills at end • If collapse: “Get fluid in them” • Wrong! Get them in fluid! (Ice bath)

immersion Ice water on-site

Dehydration Curbs Cycling Walsh et al: Int J Sports Med 1994 • Twice, in the heat, 6 cyclists ride for 1 hr at 70% VO2 peak, then closing sprint to exhaustion at 90% • One trial, oral fluids; one, without • Without fluids, dehydrated 1.8% • Without fluids, sprint 7 minutes • With fluids, sprint 10 minutes

Learn Your Sweat Rate And drink to match; don’t overdrink! • Weight lost in drill (in oz) • Plus fluid drunk in drill (in oz) • Equals how much to drink • Example: – If loses 3 pounds (3 pints: 48 oz) – And drinks 16 oz (1 pint) – Drink 48 + 16 = 64 oz (4 pints) next drill

Sickling Forces in Football • Severe hypoxemia • Hyperthermia • Acidosis • Dehydration

12 Deaths, College Football All From Sickling; Some Controversial • 1974 Colo., ran 800 m • 1985 Ark., ran ¾ mile • 1986 Miss., ran 1 mile • 1987 Ind., ran 1200 m • 1989 Utah, ran ¾ mile • 1990 NM, ran 800 m • 1992 Ga., ran 1000 m • 1995 Ariz., ran 900 m • 2000 Tenn., ran 800 m • 2001 Fla., 1 hr. mat drill • 2004 Ohio, ran ~ 10 min. • 2005 Mo., 1 hr. field drill

Sickle Cell Trait Another “Do or Die” Syndrome • 1 in 12 blacks • 1 in 10,000 whites • Generally benign • No anemia • No barrier to top athleticism (e.g., NFL)

Sickling Deaths in Military • All deaths in basic training of 2 M. recruits in 5 yrs. ( NEJM 1987 ) • Risk of puzzling sudden death 28-40 times higher with sickle trait • 12 such deaths; all tied to exertion • Absolute risk: One in ~ 3,000

Air Force Cadets • 3 of 20,000: acute renal failure from rhabdo • All 3 sickle trait; all fit; one set record • 2 the same year, when just 10 had sickle trait

Death at Bowling Green Aaron Richardson, Died 9/15/04 • 3-sport HS athlete • Track champ, 100 to 400 m • Walked on for FB • Day 1, sprints for 10 min: cramps • Died, locker room • Autopsy: Sickling

Risk: All-out exertion for 2-3 minutes without a breather • Windsprints, e.g., 300-m repeats x 3-4 • Timed miles or half-miles • Running repeat hills, steps, ramps • Intense mat or conditioning drills • Accelerated weight lifting • Rarely, even in the game itself

Sickle Trait Precautions • No d. 1 fitness test • No sprints > 500 m • No timed miles • Regular fluids • Stop at 1 st sign of trouble • Report to trainer

Treatment: Presumed Sickling • Lie down • Oxygen by face mask • Vital signs • Immediate cooling • If not improved in 5 min., or if vital signs or alertness decline – Call 911, attach AED, start an IV, to ER fast

Conclusions • Salty sweating: key in heat cramping • Radiopills: can prevent heatstroke? • If you lose weight: Drink more • If you gain weight: Drink less • If in doubt: Ice ’em down! • Mandatory testing and precautions for sickle cell trait!