On CrossFit and Risk

The responsibility falls on each one of us to evaluate and decide how much risk we are willing to take on in order to reap the potential rewards of our actions.
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Growing up, my mom would often tell me "When I was ten, I broke my ankle taking a giant step in the backyard playing a game of SPUD. Heck, if you can break your ankle taking a giant step, you might as well go out and do something more fun." Fortunately, she has supported me through many such fun experiences over the years. But, like most parents, she has also instilled in me the fact that there is a certain amount of risk associated with doing just about anything in life. The responsibility falls on each one of us to evaluate and decide how much risk we are willing to take on in order to reap the potential rewards of our actions.

I have become increasingly familiar with the concept of balancing risks and benefits through my medical training. Though every medication comes with a laundry list of side effects, and there is risk with "going under the knife" for any surgical procedure, these treatments regularly save lives and reduce the burden of disease. Ironically, the hospital -- the place to which we go for life-saving interventions -- is also one of the most dangerous places to spend time as a patient. Deaths related to medical errors have been reported at 98,000 -- 400,000 per year, the upper limit of which would make preventable medical errors the third leading cause of death in the U.S. behind heart disease and cancer. (1-2) Despite ongoing and diligent efforts to improve patient safety, receiving medical care at a hospital is still accompanied by substantial risk. Yet, in times of compromised health, the potential benefits of hospital care still greatly outweigh this risk.

While preparing for my career in medicine, I've also spent the past five years involved in CrossFit. Although I am aware of frequent discussions in the media of its "dangers," my decision to participate in CrossFit is no different than any other -- I heed my mother's advice and work to reasonably mitigate the risks and maximize the benefits. The benefits of CrossFit are incontrovertible: increased work capacity across broad time and modal domains, in other words, increased fitness. Whether measuring fitness with a maximal effort treadmill test or the ability to stand from a seated position on the floor, it is well-established that increased fitness reduces one's risk of death. (3-5) In fact, having a better level of fitness decreases your risk of death more than controlling other risk factors such as your blood pressure, cholesterol and blood sugar. (6) Quite simply, performing constantly varied, functional movements at high intensity (aka CrossFit) will result in increased fitness, and therefore better your chances of living a longer, healthier, more functional life.

The story of Pete, a middle-age member of CrossFit Painesville, exemplifies the positive impact CrossFit can have. After a decade of being overweight and requiring an intensive medication regimen to keep his cardiac risk profile "within normal limits," Pete walked into his local affiliate to give CrossFit a try. Despite challenging workouts and persistent soreness in the initial weeks, he decided to continue with his training. Eventually the soreness subsided and he became stronger, faster, and learned several new skills -- his fitness improved. He went on to lose more than 30 pounds and cure his diabetes, hypertension and sleep apnea. Instead of continuing down a road of worsening chronic disease and more medications with their inherent side effects, he chose to endure CrossFit's discomforts in order to reap the benefits of a fully functional and medication-free life. Pete's story is not uncommon -- nearly every affiliate around the world is likely to share a similar story about at least one of its members.

Yes, the risks of participating in a CrossFit program are also undeniable, ranging from soreness (highly likely), to a temporary musculoskeletal injury (less likely), to a catastrophic injury that permanently reduces physical capacity (very unlikely). Although stories of injuries sustained doing CrossFit run rampant on the internet, these same injuries and much worse are seen in our favorite sports and recreational activities.

Personally, I've had more severe injuries over my years competing in gymnastics than in CrossFit, but no one ever suggested I should stop doing gymnastics. In honor of the glorious winter we've just survived, we can also examine the similar examples of skiing and snowboarding. According to CNN, there are about two to three injuries from snow sports per 1000 participants per day.(7)

When high-profile skiing accidents bring scrutiny to the danger of winter sports, the International Society for Skiing Safety responds appropriately by advocating professional instruction, taking your time, and using correct equipment as ways to decrease the risk of injury. Under these guidelines, more than 100 million individuals still chose to take to the slopes in 2013 alone.

In comparison, a study published in the Journal of Strength and Conditioning Research, albeit small and with high potential for bias, reports an injury rate of 3.1 per 1000 hours trained using CrossFit.(8) Similarly, joining an affiliate and working with a qualified trainer, adhering to CrossFit's mantra of "mechanics, consistency, intensity," avoiding overtraining, and spending time on recovery (hydration, nutrition, sleep, mobility) are important ways to decrease your risk of an injury while still reaping the benefits of CrossFit training. Just as with snow sports, the risks of participating in a CrossFit program should not dissuade responsible participation.

Every once in a while, risks associated with the things we do become real -- they exit the realm of statistics and remind us that we are human, as they did for many CrossFit athletes in the case the spinal cord injury sustained by Kevin Ogar in January. Of note, it is important to distinguish the elevated risk assumed by a high-level competitor over that of a recreational athlete. In pursuit of the benefits of high-level competition, we increase our training hours, perform more advanced maneuvers, and more aggressively push the limits of our bodies.

Kevin's accident forced me to pause and realize the risks I assume by competing in a high-level sport, as I'm sure it did most of my peers around the world. But what I can also state with confidence is that none of us has since thrown in the towel. The rewards we reap in the pursuit of peak fitness are too great to abandon for a small risk of a catastrophic event over which we have very little control.

In fact, the rewards of improved functional physical capacity are exactly those which best prepare us to endure and recover from such an injury. Kevin continues to do CrossFit today because he understands its importance to his well-being and his rehabilitation.

Similarly, after breaking her neck in a car crash, the strength Miranda Oldroyd had developed through CrossFit likely saved her from being paralyzed and also aided her quick and complete recovery. In these cases, the reasons for training functional movements become more obvious -- in order to most successfully navigate life, we must build capacity in the movements life demands of us. When injury befalls us, these movements also provide the best rehab for meeting life's demands.

Whether you are taking a giant step, racing down black-diamond slopes, or performing constantly varied functional movements at high intensity, life is dangerous. Everything we do has some associated level of risk and benefit. We walk around every day not knowing the exact level of risk and benefit associated with most of our actions, yet it remains our responsibility to decide what's worth pursuing. I, for one, see an overwhelming benefit to pursuing increased fitness, despite its risks. The soreness, pain and even emotional ups and downs I experience in this pursuit are worthwhile knowing that I am preparing my body to surmount any physical task, recover from a catastrophic injury, and live a long, functional life with as few visits as possible to the "oh-so-dangerous" hospital.

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  1. IOM (Institute of Medicine). To Err is Human-Building a Safer Health System. Washington, DC: The National Academies Press; 2000. http://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf
  2. James JT. A new, evidence-based estimate of patient harms associated withhospital care. J Patient Saf. 2013 Sep;9(3):122-8.
  3. Blair SN, Kohl HW 3rd, Paffenbarger RS Jr, Clark DG, Cooper KH, Gibbons LW. Physical fitness and all-cause mortality. A prospective study of healthy men and women. JAMA. 1989;262(17):2395.
  4. Berry JD, Willis B, Gupta S, Barlow CE, Lakoski SG, Khera A, Rohatgi A, de Lemos JA, Haskell W, Lloyd-Jones DM Lifetime risks for cardiovascular disease mortality by cardiorespiratory fitness levels measured at ages 45, 55, and 65 years in men. The Cooper Center Longitudinal Study. J Am Coll Cardiol. 2011 Apr;57(15):1604-10.
  5. de Brito LB, Ricardo DR, de Araújo DS, Ramos PS, Myers J, de Araújo CG. Ability to sit and rise from the floor as a predictor of all-cause mortality. Eur J Prev Cardiol. 2012 Dec 13.
  6. Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood JE. Exercise capacity and mortality among men referred for exercise testing. N Engl J Med. 2002;346(11):793
  7. http://edition.cnn.com/2013/01/14/sport/skiing-risks-deaths-injuries/index.html
  8. Hak PT, Hodzovic E, Hickey B. The nature and prevalence of injury during CrossFit training. J Strength Cond Res. 2013 Nov 22
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