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Ingiting the CrossFit Debate

Imagine all the people…

No, I never could. As I penned my article, “CrossFit’s Dirty Little Secret,” last week, I wouldn’t have guessed that within a week I’d be getting interviewed for a news story on Good Morning America. But clearly, the article hit a nerve, and a sensitive one at that.

One of my students tweeted this question to me:

@EricRobertson, How does it feel to be the most polarizing person in the world of exercise?

In a short amount of time, it seemed I had become the Antichrist of CrossFit and perhaps exercise in general. One Twitter commenter called me a modern-day Mark David Chapman!

Whoa! Let’s all pump the brakes. I didn’t shoot John Lennon. But, I did ignite an important debate.

Response Themes

I’d like to address several themes I’ve observed in the reaction to the article. Among them is the concept of personal responsibility, some confusion over rhabdomyolysis, misconceptions about urinary incontinence, and most of all, about my stance on CrossFit. Let’s begin with a story.

Last weekend, I was teaching a lab-intensive course to a group of fellows-in-training. The group, all physical therapists, were learning advanced manual therapy skills. As the course was occurring, I was keeping an eye on the swelling stats of the Dirty Little Secret piece. Naturally, the article became a point of conversation in the class.

It was an interesting group of individuals included. Several were participants in CrossFit, and all were advanced-level physical therapists with serious years of experience. Their opinions on CrossFit varied. They asked me, “Are you totally against CrossFit?”

“Certainly not,” I replied. “I’ve seen people get really fit doing CrossFit. The point isn’t to be against any type of exercise regime, after all, we like people exercising versus not. My point is that serious injuries do occur, and rhabdomyolysis may be occurring in CrossFit participants at an increased rate versus other training regimes. As physical therapists, we can partner with patients and coaches to help people understand the risk, employ sound training principles, and be there when injuries do occur. In no way is it productive to take a stand against a particular workout.”
CrossFit and Rhabdomyolysis: The Statistics
Image by CrossFitFever via Flickr

First things first. As many pointed out, I don’t have stats and my tale of one person (n=1) is a poor sample size. I agree. My article was not intended to serve as a scientific manuscript, an intent of which, I’m sure is completely evident to scientists. Stats specific to CrossFit? Empirical studies investigating CrossFit specifically have not been performed. The only piece of evidence we have is buried in the form of a dropout rate from a Ohio State University study that examined CrossFit effects, reviewed here nicely. What did that study find? CrossFit improved physical fitness. Impressively so. But, about 1-in-5 dropped out of the study. The most commonly cited reason for dropout was injury.

In research, investigations begin with a hypothesis. I posed a collection of questions in my conclusion:

    “…is this workout worth the risk? Can the culture adapt to one that embraces safe training principles? Do coaches truly have the ability to detect what a proper training load is for their athletes? Only time will tell, but the future of CrossFit may depend on it.”

That’s right, my conclusion was more questions! Careful readers may have recognized this important point. My stance is not against CrossFit. I do encourage research into the safety as well as the effectiveness of the discipline. Many defenders of the regime brought up an important point when they mentioned that the risk of not exercising may be greater than the risk of injury itself. That critical epidemiological question warrants investigation. Cardiovascular disease is the single biggest economic burden to our health system. Safe strategies to remedy that are needed. Does CrossFit qualify as one of these? We need to see what the research bears.
Personal Responsibility and Avoiding Rhabdomyolysis

This was one of the most robustly supported rebuttals to my article. To address this, I’d like to point out a critical aspect of what happens when you get rhabdomyolysis.

It happens after you’re done working out.

This critical feature makes the argument for personal responsibility logically flawed when discussing rhabdomyolysis. It’s not like you can tell that you just pulled your rhabdo muscle! You don’t have one! This is a slowly developing response to a workout stress, not an acute state that’s perceptible during the workout.

What are factors that contribute to developing rhabdomyolysis? Oh, I’m glad you asked!

Risk Factors and Causes of Rhabdomyolysis

MedlinePlus has a useful page on the condition. I suggest you check this out. CrossFit is not the only thing that causes rhabdomyolysis. Statins, a form of anti-cholesterol drugs have been implicated as a cause. Elderly folks sometimes get it from falls after they get stuck on the floor, essentially a form of crush injury. As I originally pointed out, ultra-endurance athletes, some military trainees, and even football players can experience this. In terms of exertional rhabdomyolysis, ultra intense exercise is the culprit.

Risk factors for exertional rhabdomyolysis include high temperatures during a workout, dehydration, drug use (especially those statins), electrolyte imbalance, and failure to ensure proper rest breaks and recovery during a workout. Two groups are also at risk, those who just begin a workout, and those who are extremely fit and have the cardiovascular endurance to push past the limits of their muscle fibers without their cardiovascular system calling it quits.

Avoiding Rhabdomyolysis

Rhabdomyolysis is an easily avoided condition when proper training principles are employed. It’s important to always have a clear understanding of what exactly these training principles are.

    Build a good core of aerobic conditioning and muscle endurance before any workout that is “extreme.”
    Slowly progress your performance in terms of repetitions. Even if you are fit, a workout that included hundreds of reps of something you haven’t been doing is potentially very dangerous.
    Understand and maintain proper form during an exercise. When you lose form, your muscles are tired and the benefit from continued additional reps is exponentially less.
    Provide ample rest and recovery. Stress loads the system, improvement happens during recovery when your body rebuilds.
    Stay hydrated, with balanced nutrition, ensuring you have enough carbohydrates on hand for energy while you exercise.
    If it’s really hot where you exercise, consider using early morning or late evening workouts to reduce the risk of dehydration and electrolyte imbalance.
    If you feel like you have questions about these steps or the risk factors, consult a health provider. Physical therapists and physicians are great choices here.

On Peeing Your Pants…

Many people took outrage to a minor point in the article, when I declared that involuntary urination isn’t something otherwise healthy people need to tolerate. I stand by this. While there are some conditions that preclude that statement, if you have one of those, you probably know it. Incontinence, especially during effort, is a sign that you have pelvic floor insufficiency. Training and reeducation of those muscles with a pelvic floor physical therapist can cause dramatic improvements in this condition. While many people suffer from this, please don’t confuse common with normal. Again, the American Physical Therapy Association has a great radio spot and resources about this on Stress-induced urinary incontinence is largely avoidable and you don’t have to endure this despite what the cultural beliefs of any specific group may imply or teach.

Moving the Debate Forward Positively

This is not a CrossFit versus everyone else debate. In fact, for a lot of reasons, physical therapists and CrossFit coaches can make excellent partners. CrossFit is clearly in the crosshairs of the debate due to the extreme nature of the workouts, but they don’t stand alone. As interest in running marathons continues to increase and ultra endurance events like the Badwater 135, the Tour Divide and Leadville 100 see increasing registration numbers, understanding the negative effects of pushing your body to physiologic extremes is critical. This debate is important to have. Blanket condemnations on one side or another have no place. Remember that “no pain, no gain” is a dangerous approach to exercise. Extremes once in a while are alright, but are not a good idea for a sustainable long term exercise strategy on a daily basis, even for combat training. Finally, the risk of not exercising is significant and real and not a sustainable solution for anyone.

I was happy to see many continue the debate on blogs and in the news, and I hope it results in an increased awareness about exercise and how to stay healthy. I had hundreds of people reach out to me who were injured participating in CrossFit, including those who experienced rhabdo. I had even more reach out to express stories of their success and fitness gains. One thing is for sure, while those inside of CrossFit have known about and have been managing the rhabdo issue for some time, external to CrossFit, it isn’t a secret anymore.

Eric Robertson in Health & Fitness