Rhabdomyolysis Case Study

Author/s

Kat Brock Lindsay Matijevich Evan Scher and Katy Wiggins from the Pathophysiology of Complex Patient Problems Program, Bellarmine University Physical Therapy Program.

Patient Characteristics

The patient is a 55 year old woman who reports to your practice low back pain and leg pain. She is a full-time teacher at a local high school. She has a history of hypertension, which is now controlled with diet and exercise, but no other comorbidities have been identified. patient revealed she had the flu last week, but has yet to be tested or confirmed. Prior to this treatment, she had not received other treatments.

Examination

Patients complain of back pain that makes it difficult to sit and work for long periods of time. She reported bilateral lumbar tenderness and generalized weakness in the lower extremities. She says she can’t afford to miss school anymore so it’s important to make her feel miserable solve quickly. She said she was still tired, but attributed it to being ill and still not fully recovered. During the evaluation, she also mentioned that she felt very hot and clammy. Her temperature was measured to be 101.3°F. when asked about any other Symptoms She’s Noticing She says that for the past week her urine has been unusually dark and almost bloody in appearance. She also said she had been experiencing some mild shortness of breath that had gotten worse over the past few days. This is again due to illness, dehydration and [1]

The patient had a history of hypertension, which was controlled through diet and exercise, and had not taken hypertension drugs for 5 years. Her father also had a history of congestive heart failure and type 2 diabetes. She had her gallbladder removed 7 years ago and has never had other major surgery. She is not currently taking any prescription medications on a regular basis, but has been taking the over-the-counter Aleve® for her back and leg pain.

Patient-reported outcome measures were used during the evaluation process for this case study. Patients completed the Visual Analog Scale (VAS), Lower Extremity Functioning Scale (LEFS) and Oswestry Disability Index (ODI). On the VAS, the patient reports her pain as 2/10 at best and 6/10 at worst, and Currently at a pain level of 3/10. On the LEFS, the patient scored 30/80, indicating she is functioning at 37% of her maximum. [2] On the ODI, the patient scored 33/50, indicating her disability rate of 66% in the severe back pain category. [3]

•  Figure 1: Urine from a patient with rhabdomyolysis exhibits the characteristic brown discoloration due to myoglobinuria [4]

Physical Examination 

AROM:

UE WNL

Trunk forward flexion 50% limited

Trunk extension 50% limited

Hip flexion 80% limited

All other LE WNL

Palpation: B swelling and pain of lumbar dorsal extensor muscles

MMT:

UE 4+/5

Hip flexion 4-/5

Hip abd/add 4-/5

Knee extension 4/5

Knee flexion 4/5

Ankle 5/5

Sensation: Normal

Reflexes: Normal

Clinical Impression

At first glance, our clinical impression is that the patient is still suffering from flu-like symptoms. Another possible diagnosis could be sciatica, as her pain was in her lower back and legs. Asking the patient to describe her pain type is crucial experience. Given that the patient’s pain was bilateral and that she had blood in her urine, we suspected that her pain was generalized. Many kidney diseases can cause blood in the urine, including urinary tract infections, kidney infections, kidney stones Glomerulonephritis A genetic disorder such as sickle cell anemia or advanced kidney cancer. [5] Because this patient had no complaints of painful urination, low back pain, no history of cancer or genetic disease, and no direct trauma to the kidneys, we suspected that rhabdomyolysis was caused by by infection.

Summarization of Examination Findings

With a working diagnosis of infectious rhabdomyolysis, the patient will be referred to a physician for immediate treatment.

Intervention

The treatment of rhabdomyolysis is mainly aimed at preserving renal function. Intravenous (IV) hydration must be started as early as possible. [1]

Once patients complete initial medical management, they should undergo physical therapy rehabilitation to restore full range of motion (ROM) muscle strength and full function before returning to full physical activity. There is no set formula for how to treat patients Rhabdomyolysis. Every treatment should be centered on adapting to the individual needs of the patient. Below are examples of treatments presented in the 2003 Journal of Orthopedics and Sports Physical Therapy. This rehabilitation program is used to diagnose acute exertional rhabdomyolysis (AER) secondary to high-intensity push-up training. [6] Using the framework in this protocol, a therapist can personalize interventions to a patient’s specific deficits. The basis behind the program is to progress gradually from prom to slowly building a tolerance for exercise-specific behaviors The affected muscle groups show no symptoms after each session.

• The above patients will be initiated on passive and active ROM to restore trunk mobility. Once full motion is pain-free, the therapist can begin to slowly strengthen the LE musculature and trunk stabilizers to the patient’s tolerance, starting with light walking on a treadmill or lying down Cycling for short periods of time and increasing the duration and intensity of exercise as the patient’s condition progresses without any further symptoms.

• Table 1: Rehabilitation program for patients with acute exertional rhabdomyolysis secondary to high-intensity push-up training. [7]

Outcomes

Typically, patients return to normal activities within a few weeks to months after treatment, depending on the severity. The sooner patients start treatment, including intravenous fluids and possibly dialysis, to reduce the risk of kidney damage, the better their prognosis. patient Left untreated, kidney failure may result, but it is rarely fatal. [8] Some patients may have residual muscle pain or fatigue that can be resolved with physical therapy intervention. [9] For the above conditions, physical therapy may be beneficial to the patient if the patient continues physical therapy Had lingering back and leg pain after her initial treatment. The protocols listed above were designed specifically for shoulder exertional rhabdomyolysis, but the core concept could be redesigned to accommodate other patients with residual muscle pain. (5) A step-by-step approach is beneficial to patients Muscle pain occurs after an episode of rhabdomyolysis in order to allow their body to return to normal activity needs without the risk of recurring muscle failure.

Discussion

Physiotherapists were probably one of the first healthcare professionals to see patients with rhabdomyolysis as the root cause of their pain, because their pain originated in the muscles. Being able to recognize red flags such as dark urine is critical for diagnosis and referral Patients are treated promptly, thereby reducing the risk of serious kidney injury. Patients may be reluctant to discuss changes they notice in their urine without being specifically asked by the therapist. Obtaining an accurate medical history from the patient can lead to asking the correct medical history Determine the problem to diagnose. It is also important to know the etiology of possible diseases. There are several known causes of rhabdomyolysis, the most common being infectious diseases (such as the flu) and overexertion during exercise. If the patient takes Muscle pain or fatigue and recent complaints of cold or strenuous exercise coupled with questions about the color of their urine may prove relevant to making the correct diagnosis.