Ask The Doc: Achieving Intensity in Training… Without Getting Rhabdo

by KYLE SELA|PT, DPT, SCS, OCS, CSCS, NICHOLE BLEUMLE|PT, DPT, MS, OCS, CSCS, & JARED WILLIAMSON|PT, DPT, SCS, OCS, CSCS

A recent article by a well-respected physical therapist has made some traction on social media with regard to CrossFit, rhabdomyolysis (“rhabdo”) and the potential dangers of poor programming in a competitive culture. Essentially, the article highlights the point that if you have a motivated and capable person perform a poorly programmed workout, the risk for rhabdo is increased. 

It is unfortunate when good intentions lead to serious injury. Any workout program, exercise routine, or athletic event comes with risks; those risks can be mitigated but never completely eliminated. We as athletes accept these remaining risks because they are preferable to a sedentary lifestyle and the insidious onset of preventable chronic disease. That being said, you can indeed have too much of a good thing — more is not always better, even when it comes to exercise. This article will explain how to prevent a potentially life-threatening medical condition with sound CrossFit-centric programming techniques.

Risk Perspective

We would like to address the debate with a solution rather than blanket criticism. Rhabdo and so many other training injuries really are preventable…even in CrossFit.

Let me tell you about a “sport” that’s very popular right now. People drop dead during competitions every year… and not just untrained first-timers who haven’t had a drink of water in the last 48 hours. We’re talking veterans of the sport and world-class athletes. Injury rates during training have been reported by upwards of 90% of its participants [Br J Sports Med 1996; 30: 324–6 ]. Its participants have an almost cultish dedication to the sport, getting tattoos and posting cryptic bumper stickers, wearing funny-looking shoes and training their bodies so hard that you can almost pick them out in a crowd just by looking at them.

The “sport” I’m talking about is marathon running. Surprising? Maybe you thought I was going to say CrossFit. When was the last time you read an article bemoaning the dangerous cultish-ness of running? Where are the outrage and spook articles by physical therapists and the greater medical community?

They’ve been done… thirty years ago, that is. When running a 5k was still a feather in your cap, there were plenty of skeptical articles by reputable clinicians. CrossFit and other “extreme conditioning programs” — as they are sometimes called — are just the jogging (pronounced, “yogging”…I think it’s Swedish, but you basically just run) of our day.

At Back to the Box, we feel that CrossFit has been a beneficial tool that has introduced millions of people to training for performance instead of merely for aesthetics. While it has some issues (just like any program), we embrace the opportunity to be part of this growing community and hope to help educate the athletes, coaches and programmers who really just want to improve health and fitness levels.

We would like to address the debate with a solution rather than blanket criticism. Rhabdo and so many other training injuries really are preventable… even in CrossFit. Instead of merely highlighting a potential problem, we’d like to suggest some areas of caution and emphasis in your programming.

Prevention: Training Smart, Programming Right

Time domains, time caps and short workouts are vitally important to effective CrossFit programming, and in my experience, this is where many CrossFit affiliates make mistakes.

Exercise-induced rhabdomyolysis is caused by excessive volume relative to an athlete’s current training status. I repeat, rhabdo from exercise is brought on by too much volume (think: crazy amount of reps, CrossFitters!). So the fix should be easy, right? Limit volume and you’ll avoid rhabdo in yourself or those you are training. While the answer is simple, implementation is not. There are certain factors inherent to the CrossFit setting that can make it challenging to avoid overdoing it with volume, but by no means impossible. Follow my logic below:

• CrossFit gyms are businesses, and to survive, they must make money. To make money the clients must be happy. Clients are happy if they feel they are getting a good workout and seeing results. CrossFit workouts are (well, should be) relatively short most days. For short workouts to be effective, clients must train with high intensity.

• CrossFit workouts are performed in groups, and in these groups are people of varying levels of fitness. Most clients do not know how to train with high intensity when they first start a CrossFit type program (think: years of long runs, back and biceps, and no longer in competitive sports). But some do. And that, my friends, is where the problem Dr. Eric Robertson highlighted in his article may have originated.

At the Level 1 CrossFit course, they teach the use of “time domains” as the primary way to program training intent, AND they encourage the use of “time caps” to preserve the training intent. The course also emphasizes that CrossFit workouts should predominantly fall in time domains under 16 minutes or so. This means the programmer chooses a timeframe, e.g. 4-6 minutes, that the workout should be performed, and then the athletes scale their loads given the movements involved and the time available. Time domains, time caps and short workouts are vitally important to effective CrossFit programming, and in my experience, this is where many CrossFit affiliates make mistakes. To understand why this can be an easy mistake to make, consider the following hypothetical programming scenario:

• Imagine I am a CrossFit coach planning training for my clients. If I ask a beast-mode, fire-breathing athlete to perform a 4-minute workout, she will push herself to the limits of complete exhaustion. Effective programming= happy client = good business.
  On the other hand, if I ask the new client who has been riding the elliptical for 45 minutes, 3 nights a week for the past 5 years to do the same 4-minute workout, she will likely apply the level of intensity with which she is most familiar.
   When I force her to stop at 4 minutes to enforce the training intent I’ve programmed, she is going to be incredibly unhappy because she didn’t get as much out of it as the fire-breather. Ineffective programming= unhappy client = bad business.

• If we ask these same two athletes to complete a 25-minute workout where they try to perform as many push-ups and shoulder presses as possible, we end up with a different outcome. We get a happy new client who feels she got her money’s worth and performed a safe amount of reps. Effective programming (in her mind), happy client, good business. On the other hand, we may get our fire-breathing bad ass with a raging case of rhabdo because she’s done 657 reps of 2 very similar movements. Ineffective (and injurious) programming, unhappy client, bad business.

The Point Is…

Correct implementation of time caps and rest cycles are two excellent ways to teach and allow athletes to train with intensity safely. These tools prevent excessive volume and keep our athletes in training and out of the hospital.

Intensity leads to great training results. Intensity decreases over time, so long workouts are not as intense as short workouts (in average work output). Intensity is a skill that must be taught, most especially to folks who are used to long cardio and traditional strength training routines. Intervals with rest cycles would be an effective tool in this situation as the new athlete will realize that they have more to give on sequential intervals.

Timing workouts is a simple way of gauging intensity. Allowing clients or athletes to consistently work past the programmed “time domain” can result in that athlete never learning how to train with intensity. They will likely plateau on your program alarmingly soon as they essentially apply the same stimulus to their body day after day. Correct implementation of time caps and rest cycles are two excellent ways to teach and allow athletes to train with intensity safely. These tools prevent excessive volume and keep our athletes in training and out of the hospital.

While the new client/athlete may not appreciate the 4-minute workout their first week at the Box, they will be forced to learn the all-important skill of intensity and eventually understand why experienced CrossFit athletes dread Fran more than Murph.

It falls on the trainer and the programmer to teach and implement intensity into the workouts and in the end workouts are more effective, clients are happy, business is good and everyone is protected against rhabdo.

We recommend our colleagues in the musculoskeletal health and injury prevention professions step up to the challenge, become more involved with and educated on the topics they criticize, and seize this opportunity to make a difference by following some simple advice:

Whatever the problem, be part of the solution. Don’t just sit around raising questions and pointing out obstacles. We’ve all worked with the person. That person is a drag. -Tina Fey

For more info on intelligent programming refer to these earlier Back To The Box articles by Dr. Jared N. Williamson: Considerations and Why before How