Overtraining
Syndrome
Thomas
M. Howard, M.D.
Francis
G. O’Connor, M.D., FACSM
Sports
Medicine
Objectives
Review
the terminology of overtraining.
Review
the epidemiology and etiology of overtraining syndrome.
Describe
the clinical presentation, diagnosis, management and prevention of this
disorder.
Terminology
Training
Adaptation
Recovery
Periodization
Overwork/Overreaching
Overtraining
Syndrome
Training
Progressive
overload to displace homeostasis and create stimulus for adaptation
Improved
performance
Adaptation
Physiologic
response to stress (training load) to better respond to similar stress
in the future.
Recovery
from Exercise
Recovery
is initiated by a disturbance in homeostasis; unclear when complete.
The
necessary process that links training and adaptation.
Individual
capacities/thresholds:
Psychologic
Physiologic
Social
ATHLETE
Coach
Team
Teacher/Boss
Peer
Parent/spouse
Sibling/child
SPORT
HOME
WORK/SCHOOL
Influences
on the Athlete
Recovery
Nutrition
and hydration
Rest
and sleep
Relaxation
and emotional support
Stretching
and active rest
Inadequate
Recovery = Fatigue
Physiologic
Fatigue
Insufficient
Sleep
Nutritional
Jet
Lag
Pregnancy
Training
induced
Excessive
competition
Overreaching
Pathologic
Fatigue
Medical
Infectious,
Neoplastic, Hematologic, Endocrine, Toxic, Iatrogenic, Psychiatric
Chronic
Fatigue Syndrome
Overtraining
Syndrome
Fatigued
Athlete Myopathic Syndrome
Periodization
Planned
sequencing of training loads and recovery periods within a training
program.
Series
of microcycles (1 wk), mesocycles (4-12 wks), macrocycles (1 yr) and
phases designed to emphasize unique aspects of training and adaptation.
The
final phase of a macrocycle is the transition phase which allows for
restoration.
Periodization
Performance Capacity =
Intrinsic
Capacity +
Accumulated Fitness - Accumulated Fatigue
Overwork/Overreaching
Acute
phase during which training load (intensity or volume) is significantly
increased
Short-term
deterioration in performance
Usually
< 2 weeks
Overtraining
Maladaptive
response to training from an extended period of overload
Usually
> 2 weeks
“Staleness”
with failure to improve performance
Overuse
injuries, mood disturbance, blood chemistry changes, immune dysfunction
Overtraining
Model
Overtraining
Progression
Overreaching
Decreased
Performance
Failure
to Regenerate
Panic
Training
Overtraining
Syndrome
Epidemiology
of Overtraining Syndrome
“Overtraining or staleness
is the bug-a-boo of every experienced trainer…it is a condition often
difficult to detect and still more difficult to describe… consider
nutrition, training load, competition stress, and a psychologic predisposition…go
slow and maintain balance between sleep, work, and recreation”
Some
medical aspects of the training of college athletes
Parmenter,
Boston Medical and Surgical Journal 1923
Research
Findings
No
diagnostic criteria
Inconsistent
data
small
numbers studied
difficult
to establish controls and lab models
most
studies too short
Confounding
influences
illness,
injury, menstruation, different training methods for different sports
Overtraining
Epidemiology
Incidence
7-20%
elite athletes at any one time
2/3rds
of elite runners over the course of a career
Sports
Endurance
events
Swimming,
running, cycling
Power
lifting, basketball
“Cousin”
to physician “burn-out”
Overtraining
Susceptibility
Highly
motivated, goal-oriented individuals
POMS
(Profile of Mood States) testing demonstrates that athletes tend to
be somewhat focused, conventional and conservative
Exercise
regimens designed by the athlete
Psychologic
predisposition?
Risks of
Overtraining Syndrome
Prolonged
poor performance
Injury
Illness
Premature
retirement
Etiology
of
Overtraining Syndrome
Current
Hypotheses
BCAA
Hypothesis
Autonomic
Imbalance Hypothesis
Glycogen
Depletion Hypothesis
Glutamine
Deficiency Hypothesis
Cytokine
Hypothesis
BCAA Hypothesis
“Amino
Acid Dysbalance Theory”
Severe
sustained exercise leads to glycogen depletion
BCAA
consumed as fuel
Increased
brain levels of tryptophan with an increased synthesis of serotonin
Fatigue
BCAA:f-Try ratio
Autonomic
Imbalance Hypothesis
Parasympathetic
OTS is dominant form, with decreased intrinsic sympathetic activation.
Prolonged
strenuous exercise leads to an increased concentration of free circulating
catecholamines, Cortisol, T3, and ?
Sustained
levels lead to a down regulation of adrenoreceptors.
Autonomic
Imbalance Hypothesis
Peripheral:
This
negative feedback results in a lower sympathetic resting tone
Central:
Increased
brain tryptophan also decreases sympathetic tone
Glycogen
Depletion Hypothesis
Inadequate
energy intake resulting in:
decreased
exercise induced rise in pituitary hormones, cortisol, & insulin
decreased
resting testosterone
decreased
protein and glycogen synthesis
Decreased
RQ (increased reliance on FFA)
Poor
subsequent response to training
“Fatigue”
Glutamine
Hypothesis
Chronic
exercise with inadequate recovery creates a glutamine deficient state
This
sets up immunologic “open windows” for infection that further stress
the system
Glutamine
Most
abundant AA in muscle and plasma
Synthesized
in muscle, lungs, liver, brain and fat tissues
Maintains
acid-base balance during acidosis
Glutamine=glutamate
+ NH3
Nitrogen
precursor for synthesis of nucleotides
for
cell replication
Fuel
for intestinal mucosal and immune system cells
(Lymphocytes,
Macrophages, NK Cells)
Glutamine
with Exercise
Linear
relationship with plasma glutamine and exercise intensity
Considerable
time may be required between training sessions to allow complete recovery
of plasma glutamine
50%
reduction of resting levels in athletes after 10-day overload period
Confounding
factors to Interpretation of Glutamine Levels
Diurnal
cycles
Max
10% over 24hrs
Dietary
Increase
up to 29% after meals esp if high protein
Infection
Increased
with viral or others
Cytokine Hypothesis
Adaptive Microtrauma
Local Chronic
Inflammation
Systemic Immune/Inflammatory
Response
Local Acute
Inflammation
Stress Cytokines
From
circulating monocytes
IL-6,
TNF-, IL-1
Induce
fever, stimulate ACTH, stimulate release of acute phase proteins
Activate
sympathetic nervous system and H-P-A axis and inhibition of H-P-G axis
Behavioral
changes
Lethargy,
anorexia, somnolence
26 French soldiers
3 weeks of intense combat training
Increased IL-6
Decreased secretory IgA, DHEA,
Prolactin, testosterone
Mil Med, 168, 12:1034, 2003
Smith, MSSE
32(2): 317-331, 2000
Cytokine
Theory
Cytokines and
growth factors during and after wrestling season in adolescent boys
During season
inc IL-1ra, IL-6, IGFBP-1&2, and BHBP w rebound post season; insignificant
change in TNF-α and IL-1β
Anabolic rebound
post-season
MSSE, Vol 36(5);794-800,
2004
Influence of
physical activity on serum IL-6 and IL-10 levels in healthy older men
Inc IL-10 and
dec IL-6 with balanced exercise program
MSSE 36(6):960-4,
2004
Systemic inflammatory
mediators contribute to widespread effects in work-related musculoskeletal
disorders
Repetitive,
forceful hand-intensive occupational tasks
Induction of
a chronic inflammatory conditions from persistent injury stimulus with
elevated IL-1& CTGF
Ex Sp Sci Rev
32(4);135-42, 2004
Clinical
Presentation of
Overtraining Syndrome
Case Report
16
y/o runner
Running
60+ miles per week
6
days/week
Working
2.5 hrs/day & going to school
Family
very goal-oriented; father is a General officer; applying to a service
academy
c/o
decreased performance, fatigue, increased URI frequency
Complaints
Sport-Specific
Performance
inability
to meet prior performance standards
prolonged
recovery time
Physiologic
weight
loss
increased
resting heart rate
injuries
Subjective
sleep
disorder
emotional
instability
apathy
Categories
of Overtraining
Sympathetic
Parasympathetic
Sympathetic
Overtraining
? Early
Overtraining “Classic
Form”
Increased
resting HR & BP
Decreased
appetite
Loss
of body mass
Irritability
Loss
of sleep
Poor
performance and fatigue
Parasympathetic
Overtraining
? Late
Overtraining
“Modern Form”
Impaired
performance and easily fatigued
Low
resting HR & BP
Long
periods of sleep and depression
Normal
appetite and constant weight
Decreased
libido, amenorrhea, loss of competitive desire
Diagnosis
of
Overtraining Syndrome
Diagnostic
Criteria
No
specific diagnostic criteria or useful lab parameters for overtraining
syndrome.
Diagnosis
of exclusion
“The
overtraining syndrome refers to a symptom complex characterized by non-adaptation
to training, decreased physical performance and chronic fatigue following
high-volume and/or high-intensity training and inadequate recovery.”
Eichner 1995
Differential
Diagnosis
Systemic
Illness
Mono,
CMV, Hepatitis, Cancer, Post-viral, Fibromyalgia, Chronic Fatigue Syndrome,
Collagen vascular disorder
Metabolic
Problem
anemia,
hypothyroid, hypoglycemia, glycogen storage disease
Substance
abuse
Primary
psychiatric process
Depression
Chronic
Fatigue Syndrome
In
a patient with severe fatigue that persists
or relapses for 6 months, with 4
symptom criteria:
Severe: fatigue of new or
definite onset, not alleviated by rest, resulting in a substantial reduction
in occupational, educational, or personal activities.
Symptom
Criteria:
impaired
memory or concentration
multijoint
pain
sore
throat
new
headaches
tender
cervical or axillary nodes
unrefreshing
sleep
muscle
pain
postexertional
malaise
Medical
Evaluation
History
and Physical
Training
program
Goals
of program
Fitness,
to race, to lose weight
Diet
& medications/supplements
Nutrition
Illnesses
Review
of Systems
weight
loss, fever, sweats, rash, myalgia, arthralgia, STD’s,
Lab
Evaluation
CBC,
ESR
Chemistry
Profile
Monospot
Thyroid
Function
Urine
Analysis
Ferritin
bHCG
Other
labs as directed
Additional
Studies/Consultation
Drug
screen
MMPI
POMS
Nutrition
consultation
Exercise
Physiologist
Sports
Psychologist
First Visit
History
Physical
Examination
Dietary
evaluation
Training
Diary review
Lab:
CBC, ESR, TSH, Ferritin CMP,UA, b-HCG
for females
Consider
Monospot, Hep Panel, drug screen, CXR, BAL, Lyme titer
Rx:
Decrease intensity X 2-3 weeks
Follow
up Visit
Pathologic
fatigue
Overtrained
Further
w/u as indicated
TSH,
POMS,CXR, Nutrition consultation
Rx:
Rest/relative rest for 3-6 weeks
Physiologic
fatigue
Overreached
Modify
Schedule
Periodization
Not
improved
Improved
Case Report
CBC,
chemistries, TFT’s, Ferritin all WNL
Repeat
throat culture, CXR WNL
Management
of
Overtraining Syndrome
Treatment
Rest
(relative)
from
training and other situations
initially
one to two weeks
Short-term/limited
goals
Communication
training
Social
Support
Survey
for confounding factors
depression/drugs/diet/disease...
BCAA Supplements
NH3, but free Tryp:BCAA ratio
POMS scores
Improved
energy and decreased fatigue
Supplementation
limited by GI side effects
? Performance improvement
Glutamine
Supplementation
? Enteral
or parenteral supplementation to speed recovery
no
demonstrated immune modulation with glutamine supplementation in healthy
athletes
Case Report
No
response to a Z-pack
Three
week period of rest with sports psychology and nutrition consults. Declined
family counseling.
Readjusted
school, work, sleep habits.
Reintroduced
running at 2 miles/day.
Successfully
completed SATs.
Rejoined
Indoor track team; qualified for States in 1000 and 3000m.
Prevention
of
Overtraining Syndrome
Prevention
Nutrition
Life-style
factors
Flexible
programs
Control
stress and recovery within training cycles
Periodization
Monitoring
Monitoring
Psychiatric Indicators
Performance
Deficits
Biologic Markers
Detect
poor recovery (overreaching) before the development of overtraining
syndrome.
Poor Markers
Body
mass
CBC
Serum
ferritin
CK
Hormones
Indicators
of Insufficient Recovery
Increased
resting HR
Mood
evaluation (POMS)
Decreased
Free Testosterone/Cortisol Ratio
Anabolic/Catabolic balance
>
30% decrease from baseline
Serum
glutamine (serial)
Glutamine:Glutamate
ratio < 3.58
Decrease
HRV
Heart Rate
Monitoring
Most
coaches and athletes use increase in rest HR of 10% as significant.
“Reversal
of Runner’s Bradycardia with Training Overstress”
Runners
who developed a reversed bradycardia (RB) of greater than 10% with a
training stress, demonstrated a significant decrement in performance
compared to runners who did not develop a RB.
Clin J Sport Med
2000;10:279-285
Psychologic
Tools
Profile
of Mood States (POMS)
More
of a research tool
65
questions assessing mood state
5-neg
and 1-pos
Tension-Anxiety,
Anger-Hostility, Fatigue-Inertia, Depression-Dejection, Confusion-Bewilderment,
Vigor-Activity
Total
mood disturbance score (TMD)
Studies
have demonstrated a direct relationship between psychometric and physiologic
assessments.
May
predict at risk athletes and those predisposed
The effects
of a four-day march on the gonadotropins and mood states of army officers
No significant
change in gonadotropins (LH, FSH) or mood states (POMS-TMD ~130) but
indicate that psychological and physiological measurements could be
used to monitor
Mil Med 169;491-5,
2004
Psychologic
Tools
Total Quality Recovery
TQRaction
Nutrition
and Hydration 10 pts
Sleep
and rest 4 pts
Relaxation
and emotional spt 3 pts
Stretching
and Active rest 3 pts
TQRperceived
Reverse
Borg scale for recovery
Intensity
balanced with degree of recovery
20
20
19 Very, very good recovery
19 Very, very hard
18
18
17 Very good recovery
17 Very hard
16
16
15 Good recovery
15 Hard
14
14
13 Reasonable recovery
13 Somewhat hard
12
12
11 Poor recovery
11 Fairly light
10
10
9 Very poor recovery
9 Very light
8
8
7 Very, very poor recovery
7 Very, very light
6
6
Total Quality
Recovery
(TQR)
Relative Perceived
Exertion
(RPE)
TQR
perceived
Recommended
Monitoring
Day-to-day
Diary,
sleep patterns
HRrest
TQR
Microcycle
time
trials
Overtraining
in the Future
Further
identification of parameters of overtraining
Development
of reliable lab models
identification
of markers and patterns of response to specific loads
Use
of Immune Modulators and/or supplements