Training while on rat poison

[Bleve]

G'day Rip,

I'm about to start working with a young (16y/o) cyclist, he's all of 50kg wringing wet at 180cm tall, so about as lean as you can imagine a boy can be without having an eating disorder or a tapeworm. He's a very good track endurance cyclist for his age group but oddly enough he can's sprint his way out of a wet paper bag ... There's next to no muscle on him at all. He's just recently been diagnosed with a blood clot and his doctor has put him on a 12 week program of warfin, which is a rat poison, it's an anti coagulant, it's the main active ingredient in many rodent poisons.

Anyway ... I've been at him and his dad to get him into the gym to put some muscle onto him and this is the first chance I'm going to get to do it. I hope anyway.

He's never been in a gym and the most I'm going to be able to get him into it will be for, initially, one session a week, and hopefully I'll ramp that up to 2 or 3 after a few weeks, we'll be doing squats initially, teaching him and his dad the techniques etc, then we'll introduce deadlifts and press, bench press and finally power cleans as he learns and gets proficient. There'll be metcon work on a bicycle ergo as well. As the bike is his sport and he is very good at it that's not something I can (or want to!) take away from him, but I can alter the ratios around and make sure he's eating plenty.

My concern is the warfin, as it's an anticoagulant. He's not allowed to ride his bike on the road or track for fear of a crash and thus a bad bleed, but do you know of any reason not to have him in the gym lifting Heavy Stuff and doing Hard Things? Obviously we'll need to be super-careful with handling of weights so nothing gets dropped on him etc, but have you worked with anyone on this stuff before? Anything to keep an extra special eye on, or should he avoid it altogether? I hope not, I want to build him up, and this may be the only chance I get.

[Mark Rippetoe]

The drug is actually called "warfarin". Where is the clot, and what is presumed to be the cause?

[METAL VIPER]

I had heart surgery to correct a heart condition and have been on Coumadin, which is the same as Warfarin for 11 months and have to remain on for the rest of my life. Hasn't stopped me from doing shit in or out of the gym.

[Bleve]

The drug is actually called "warfarin". Where is the clot, and what is presumed to be the cause?

The clot is somewhere around his collarbone and I don't know what the cause is. They noticed it when one of his hands started changing colour.

[Mark Rippetoe]

That will be a brachial plexus thing. I am more concerned about the clot than I am the warfarin at this point. Is he still symptomatic?

[Bleve]

That will be a brachial plexus thing. I am more concerned about the clot than I am the warfarin at this point. Is he still symptomatic?

I don't think so, they gave him some big dose of something else that cleared it, but I'm only going on 3rd hand info at the moment. I'll find out more, anything in particular I should ask his dad? They're coming for their first session on Wednesday (your Tuesday) and we'll be doing squat technique to start with so that'll be my next chance to question them.

[drlvegas]

A client of mine is the local Zee Medical distributor. He showed me some stuff they carry called Quick Relief: http://zeemedical.com/zeemedical/NewZee/Catalog2005/index.jsp. They are only a distributor, so I'll bet you can find it packaged under a different name in your area. They sell a lot of it to people on blood thinners. I have used it twice(I'm not on blood thinners, but I am a bleeder) & it works amazingly well. Stops bleeding within about 5-10 seconds.

[Mark Rippetoe]

Just make sure the kids dad knows the risks. The clot didn't get there by chance, so you should familiarize yourself with the situation. I have seen a couple of subclavian arterial clots that have scarred into a permanent lesion.

[Bleve]

Just make sure the kids dad knows the risks. The clot didn't get there by chance, so you should familiarize yourself with the situation. I have seen a couple of subclavian arterial clots that have scarred into a permanent lesion.

I'm not exactly sure of what the risks are, above any from normal living anyway. Presumably the risk of stroke is greater than for someone without a history of a clot, but if that's increased through strength training or not I don't know. I wouldn't have thought so, and would imagine that the heart strengthening from strength work would decrease the risk of stroke, but don't really have anything to base that on.

Would breath holding through a rep have any effect on clot formation or dislodgement etc? The temporary increase in blood pressure due to a breath hold during a heavy squat would increase or decrease the risk of a clot forming or moving etc?

I don't want to kill or maim the kid, and want to know if strength training would increase any risks of that under his circumstances. I don't have any experience working with clients who have a history of clots so I don't know what to ask or what to tell them that they need to accept as risks. If I tell them to go see a doctor to get a medical clearance, they'll get the 'do lots of reps at light weights on a leg extension machine and breathe in and out' bullshit, which won't be very helpful.


Just make sure the kids dad knows the risks. The clot didn't get there by chance, so you should familiarize yourself with the situation. I have seen a couple of subclavian arterial clots that have scarred into a permanent lesion.



This is the text of an email I've just sent to his dad, I'd much appreciate your comments on this for the kid's sake more than anything else :


G'day XXX,
I've been asking around the S&C community for any special information on training with warfarin and with clots.

It seems the main concern is not so much the warfarin itself, but the clot, what caused the clot and if it's still around. As nothing we do will be high impact, there's very low risk of any bleeds so the warfarin isn't going to be an issue, as best I can glean from the S&C people I've asked anyway.

Training, as you know, increases arterial blood pressure, dramatically at high levels of exertion (sprints, high intensity E3's, weight training etc) and I guess my concern is that I don't know what caused the clot and if it's likely to move etc when we do some hard work.

Before we start, can you fill me in a bit more on what you know about the clot, what caused it and what the doctors have recommended he do and not do, while it's clearing up? The last thing any of us want is YYYY to have some sort of long term injury and I don't want to put him into any greater risk category than he is already.

Thanks!

Carl

[Mark Rippetoe]

Looks good. Perhaps Dr. Prewitt has a more informed opinion, if he has time to post.

[Bleve]

Looks good. Perhaps Dr. Prewitt has a more informed opinion, if he has time to post.

This is their reply, edited of fluff :



YYYY has no genetic problems that lead to clotting all of his bloods came
back clear, the Dr said that clot was just one of those things.
The clot is a axillary thrombosis and is small, it has now adhered to the
vein wall and hopefully the warfarin will reduce it in size, but this will
take a while. The Dr said that the risks of it moving now were very small
more the opposite once the clot has adhered can be very stubborn to move.

So I think he can start the 12 week training program. The Dr's do not want
him doing any riding where he is at any risk of falling so hence the ergo.


So I think we're ok to get him starting strength. Thanks for your council, Rip, it's much appreciated.

[ldraper]

I am more concerned about the clot than I am the warfarin at this point. Is he still symptomatic?

That's what I was thinking. Dave's been training hard while on warfarin for about 25 years, no problems on that end.

Bloody noses take a long time to stop, though.

[BJB82]

I came down with 4 DVTs in my left calf in June. I've been on a dose of coumadin since then and will be the rest of my life due to a genetic blood clotting disorder.

A very good vascular surgeon whom is more than well respected told me nothing I do with a barbell is of concern while on coumadin as far as the blood clots are concerned. The real risk I have is from the bleeding associated with the possibility of trauma. A cut from a barbell on the noggin is manageable, the problem comes from the bleeding that you may not see. So falling and getting hit in the head may cause internal bleeding that may otherwise not have happened if not on thinners.

The only thing it has stopped me from doing is rope climbing and max height box jumps.

I DL, SQ, press, Oly lift heavy and hit the occasional hard METCONS with no real problems. As a matter of fact, since being on coumadin I have increased strength and my METCONs are getting faster....no idea why but it definitely has increased my performance.

I will caveat all this with the fact that any blood clot above the knee seems like a bigger deal than what I had below the knee. Everything may change because of that, who knows.

Hope this helps

[TPrewittMD]

So I think we're ok to get him starting strength. Thanks for your council, Rip, it's much appreciated.

Hmm. For this case, I am not so confident that we can easily suggest forging ahead with weight training.

Axillary-Subclavian Vein Thrombosis (ASVT) is a problem that can actually be related to lifting. Seen in young men with low BMI who do repetitive upper arm/shoulder motions. Or activities that involve backward and downward rotation of the shoulder.

These upper extremity motions can cause small tears in the inner layer of the subclavian vein that predispose to a clot. One can also have thoracic outlet syndrome due to a first rib, hypertrophied anterior scalene, or a congenital band that constricts the flow of the vein. This is a pretty unusual entity but certainly well-described.

The clot is organized by now (meaning stuck down and contracting) and shouldn't be at risk to embolize to lungs, etc. The coumadin keeps the clot from migrating down the arm.

Long-term, he may be at risk for arm swelling and recurrent thrombosis due to chronic obstruction. (Rip mentioned that problem earlier, I believe.)

Sounds to me that the young man needs to be evaluated for a surgically-correctable cause of the thrombosis, e.g. thoracic outlet syndrome.

In terms of training, I wouldn't recommend presses, and might be a bit worried to do squats due to arm position when fixing the bar in the low-bar position. Seems like the stretching of the vein due to this position may be problematic.

A thoughtful consult with an experience peripheral vascular surgeon would be an appropriate next step. And with all due respect to those who I have posted their experiences with blood clots, I wouldn't extrapolate too much from DVT in the leg to this unfortunate situation.

(Remember, I am not a vascular surgeon and don't have a significant experience with this unusual entity. I see this related to ports we put in for chemotherapy, and I have started to put catheters into the neck in part to avoid this problem.)

Rip, we see a lot of interesting problems on the board, and we usually end up suggesting that folks proceed with training as appropriate. But this one makes me a bit uncomfortable.

tprewitt

[Mark Rippetoe]

Noted. Thanks for this input. Not available elsewhere. Tell all your friends.

[Bleve]

Hmm. For this case, I am not so confident that we can easily suggest forging ahead with weight training.

Axillary-Subclavian Vein Thrombosis (ASVT) is a problem that can actually be related to lifting. Seen in young men with low BMI who do repetitive upper arm/shoulder motions. Or activities that involve backward and downward rotation of the shoulder.

These upper extremity motions can cause small tears in the inner layer of the subclavian vein that predispose to a clot. One can also have thoracic outlet syndrome due to a first rib, hypertrophied anterior scalene, or a congenital band that constricts the flow of the vein. This is a pretty unusual entity but certainly well-described.

The clot is organized by now (meaning stuck down and contracting) and shouldn't be at risk to embolize to lungs, etc. The coumadin keeps the clot from migrating down the arm.

Long-term, he may be at risk for arm swelling and recurrent thrombosis due to chronic obstruction. (Rip mentioned that problem earlier, I believe.)

Sounds to me that the young man needs to be evaluated for a surgically-correctable cause of the thrombosis, e.g. thoracic outlet syndrome.

In terms of training, I wouldn't recommend presses, and might be a bit worried to do squats due to arm position when fixing the bar in the low-bar position. Seems like the stretching of the vein due to this position may be problematic.



Understood. We'll avoid presses then, and I guess that would also include chins, pullups and the like? And be pretty careful with squats and maybe racking the bar with cleans?. I'd expect deadlifts would be ok though?






A thoughtful consult with an experience peripheral vascular surgeon would be an appropriate next step. And with all due respect to those who I have posted their experiences with blood clots, I wouldn't extrapolate too much from DVT in the leg to this unfortunate situation.

(Remember, I am not a vascular surgeon and don't have a significant experience with this unusual entity. I see this related to ports we put in for chemotherapy, and I have started to put catheters into the neck in part to avoid this problem.)



I never thought about this, my partner has had a Hickmans catheter but we got her benchpressing (the rest, is a work in progress, but she does like deadlifting at least) - any likely complications for her?




Rip, we see a lot of interesting problems on the board, and we usually end up suggesting that folks proceed with training as appropriate. But this one makes me a bit uncomfortable.

tprewitt

[TPrewittMD]

UPDATE
---------------------------
Rip, I ran this scenario by a vascular surgeon in our department who trained at a place with a big thoracic outlet surgery service. He said the following:

1. Should treat with lytic therapy (i.ie. "clot busting" drugs) if the ASVT is diagnosed within 1 week of symptoms.
2. Stent the vein if there is a stenosis after the vein is open.
3. For a young athlete, he then keeps the patient on a heparin infusion and takes them to surgery for a first rib resection. He says that this is a highly effective treatment.
4. The recurrence rate is quite high without surgery, something over 60-70%.
5. He questioned the use of coumadin, saying this was likely unnecessary. He pointed out that the clot would only extend to the first venous collateral (correcting what I said), so no benefit from that standpoint. And since the coumadin doesn't dissolve the clot, it may not affect anything other than an increased complication rate.

So, for this young cyclist, if he is early on in the course of this problem, he needs to see a vascular surgeon pronto. Also, coumadin may not provide a benefit yet expose him to risks.

Just one long-distance opinion from an academic medical center in the US with no information other than as described by a third party on a discussion board.

Maybe this will help someone else seek early intervention for the same problem.

[Bleve]

UPDATE
---------------------------
Rip, I ran this scenario by a vascular surgeon in our department who trained at a place with a big thoracic outlet surgery service. He said the following:

1. Should treat with lytic therapy (i.ie. "clot busting" drugs) if the ASVT is diagnosed within 1 week of symptoms.
2. Stent the vein if there is a stenosis after the vein is open.
3. For a young athlete, he then keeps the patient on a heparin infusion and takes them to surgery for a first rib resection. He says that this is a highly effective treatment.
4. The recurrence rate is quite high without surgery, something over 60-70%.
5. He questioned the use of coumadin, saying this was likely unnecessary. He pointed out that the clot would only extend to the first venous collateral (correcting what I said), so no benefit from that standpoint. And since the coumadin doesn't dissolve the clot, it may not affect anything other than an increased complication rate.

So, for this young cyclist, if he is early on in the course of this problem, he needs to see a vascular surgeon pronto. Also, coumadin may not provide a benefit yet expose him to risks.

Just one long-distance opinion from an academic medical center in the US with no information other than as described by a third party on a discussion board.

Maybe this will help someone else seek early intervention for the same problem.

Thankyou very much for this. I'm now in a bit of a bind (not half as much as the young lad is though ...) - I guess I should pass this on to his dad, but I also don't want to be interfering with their medical stuff, and that's not my turf at all.

Rip, what would you do? Keep him in the gym?

[Mark Rippetoe]

He and his dad need to decide that, after you've updated them with this new, quite important information that they obviously have not been provided with elsewhere.

[Bleve]

He and his dad need to decide that, after you've updated them with this new, quite important information that they obviously have not been provided with elsewhere.

I've informed them fully of all of this. They checked again with their specialist, and the doctor said 'go for it' WRT strength work so they want to do so. As such, I figure that's the best advice they can be given, and they want to proceed.

[TPrewittMD]

I never thought about this, my partner has had a Hickmans catheter but we got her benchpressing (the rest, is a work in progress, but she does like deadlifting at least) - any likely complications for her?

Yep, I have seen several of these. Different problem though. The clot from a subclavian line is due to the catheter, not an inherent anatomical problem. I have seen this present in cancer patients as shoulder pain.

If her line is already out, don't worry, just go to normal activity. If she has the line, just be aware of the tendency of these things to "saw" at the point where the line goes under the clavicle. The catheter can break at this point of contact and migrate to the heart. This is quite uncommon but can happen. The cardiologists have to go fetch it with a snare.

These are two reasons why I put venous access lines into the jugular vein in the lower part of the neck. Safer and easier to do, and there are fewer complications related to the line.

All that being said, good data exist on the benefits of exercise, including resistance training, in cancer patients. As one might imagine, I am a proponent of weight training.

This has become quite an arcane post, but maybe it will help.