overtraining and chronic fatigue - american college of ...forms.acsm.org/tpc/pdfs/40 best.pdf ·...
TRANSCRIPT
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Overtraining And Chronic Fatigue
Thomas M. Best, MD, PhD, FACSM
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Learning Objectives • Recognize common symptoms of overtraining in
endurance athletes. • Expand the differential diagnosis for
underperforming endurance athletes. • Apply available evidence to assist in the
diagnosis and management of the underperforming endurance athlete.
Sports Medicine
I have no commercial, financial, or research relationships or interests within the past 12 months that affect my ability to provide a fair and balanced presentation for the proposed CME activity.
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The Underperforming Athlete Symptoms
• loss of endurance • chronic fatigue • high exercise heart rate • low power • frequent injury • recurring illness • loss of interest in exercise • Irritability • Poor appetite • Increased incidence and duration of colds and infections
This sounds like over-training!
Sports Medicine
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Different Patterns of Fatigue
• Fatigue on arising to face the day – depressed?
• Energetic in the morning but need afternoon nap – lingering Mono or hepatitis?
• Feel fine at rest all day; fatigue only on max exertion – mild anemia?
Sports Medicine
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Physiological & Psychological Fatigue in Extreme Conditions
Purvis D et al., Am Acad Phys Med Rehab 2:442-50, 2010
• Most recent review of OTS in elite athletes • Agrees with prior reviews that answers are few • Has Dr. Raglin’s training distress questionnaire:
– Rate how you feel today – Hours sleep last night? – Sick in past week? – Rate how hard yesterday’s workout – Rate how your muscles feel – Score moods: friendly, worthless, miserable, helpful, bad-
tempered, guilty, unworthy, peeved, cheerful, sad
Sports Medicine
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Fatigued Athletes: Interview Dyment PG, Phys Sportsmed 21:47-54, 1993
• Employs a structured psychological interview • Uses HEADS pneumonic, 1 question each about:
Home, Education/Employment, Activities/Alcohol, Drugs/Depression, Sexual Activity/Orientation
• If positive response or hint in any area, pursue it • Also: What do you think is causing your fatigue? • Asks them to list 3 major stresses they have • Teaches them stress-coping skills; makes them
active partners in their healthcare • This seems to help college students with fatigue
Sports Medicine
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Clinical investigation of athletes with persistent fatigue and/or recurrent infections
Reid VL, et al Br J Sports Med. 2004 Feb;38(1):42-5
• 41 competitive athletes (22 male, 19 female) with persistent fatigue and/or recurrent infections
• 68% of athletes with conditions with potential to
cause fatigue and/or recurrent infections
Sports Medicine
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0
5
10
15
20
25
30
% o
f Fat
igue
d A
thle
tes
Conditions Identified Humoral Immune Deficiency
Hypoglycemia
Unresolved Infections
EBV
Allergic Disease
Sleep Disorder
Asthma
EIB
Upper Airway Dysfunction
Thyroid Disease
Low Serum Ferritin
Sports Medicine
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Many Other Possibilities • Infection (Lyme, EBV, Hepatitis,
Respiratory) • Allergies • Iron Deficiency +/- Anemia • Asthma • Over-reaching/training • Thyroid Disease • Systemic Disease (i.e. cancer,
leukemia) • Diabetes • Cardiovascular Problem
(CAD,HCM, arrythmia) • GI Problem (parasitic, IBD,
malabsorption) • Renal Disorders
• Muscle Dysfunction • Autoimmune Disease • Medication or side effect:
– Antidepressants,antihistamines, anxiolytics, beta-blockers
• Postconcussive syndrome • Pregnancy • Substance abuse • Inadequate nutrition
– carbs, protein, iron • Eating Disorder • Performance anxiety • Primary mood disorder:
Anxiety, depression, adjustment • Psychosocial stress • Sleep Disorders
Sports Medicine
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Do athletes get sick more often?
• EBV Reactivation • Upper Respiratory
Infections
exposure to airborne pathogens is increased due to the higher rate and depth of breathing
Sydney 2000 Olympic Games 33% of consultations with the New Zealand medical team were for respiratory tract illnesses (excluding asthma)
Sports Medicine
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Incidence, Etiology, and Symptomatology of Upper Respiratory Illness in Elite Athletes
Spence et al MSSE 2007
Sports Medicine
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Immunological Changes with Exercise
• Increased Neutrophil/Lymphocyte Ratio • Decreased neutrophil activity (oxidative burst
activity) • Low blood leukocyte counts • Low levels of salivary IgA • Increases in inflammatory cytokines (IFN-a,
TNF, IL- 1, 2 and 6, CRP) that influence leukocyte functions
• Depressed plasma glutamine (required for optimal functioning of some leukocytes)
Sports Medicine
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Causes or Triggers of CFS? Shephard RJ, J Sports Med Phys Fit 45:381-92, 2005
• Overtraining (physical/emotional stress) • Hormonal disorder (including HPA axis) • Disorder of personality or affect • Immune suppression or activation • Chronic infection or nutritional deficit • Physical deconditioning from any of the above • Autonomic disorder from stress/deconditioning • BUT: None of these is observed consistently • Rx: Exercise, encouragement, psychotherapy
Sports Medicine
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Overtraining Syndrome (OTS)
Sports Medicine
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What is it?
“Unexplained underperformance, that is not resolved following at least two weeks of rest”
Sports Medicine
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Definition of Overtraining and the Overtraining Syndrome
• Overtraining: A sharp increase in training volume, intensity, or frequency, up to near max capacity for the individual, that can be endured for only a short time (i.e., < 1 month).
• Overtraining Syndrome: The result of overtraining, a long-term fall in performance capacity, with RPE and fatigue increased and energy and mood decreased. (Also known as staleness.)
Sports Medicine
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Overtraining Symptoms • Poor, non-restorative
sleep • Anxiety, irritability,
sadness, loss of enjoyment
• Loss of appetite • Gastrointestinal
Disturbance • Recurrent Infection
• Muscle soreness and weakness
• Poor Performance with the same or increased training
• Increased morning HR • Reduced motivation • Increased exercise
RPE
Sports Medicine
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Overtraining Risk Factors
• Excess competition • Attempts to follow regular
training while ill or injured • Attempts to make up for
time lost to illness/injury by increased training
• Psychosocial Stressors • Poor nutrition
• Too much volume • Too much intensity • Too little recovery
Not enough sleep! Sports Medicine
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How an athlete recovers is as important as how he/she trains !
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What accounts for the observed symptoms?
• Immunosuppression ? • neurohormonal imbalances ? • chronic inflammation ?
• NO single objective physical or physiological marker that
identifies OTS • OTS more easily detected by decreases in physical
performance and alteration in mood state
Sports Medicine
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POMS – Profile of Mood State
tension, depression, confusion, anger, fatigue,
Vigor
Inversed “iceberg profile”
Psychological Markers
Sports Medicine
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Immunological Markers
• McKinnon et al (2000) provided good argument that lowered immunity markers reflect acute exercise strain and not necessarily OTS
0
1
2
3
4
5
Fl units
NHS OTS
CD4+ CD45RO+ Expression
Maybe T-lymphocyte CD4+/CD45RO+ expression Gabriel et al 1998
Sports Medicine
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Biochemical Markers NOT confirmed useful in systematic studies
• Creatine Kinase (CK) – Marker for muscle damage
and impaired ability for muscle glycogen restoration
• Urea, Uric Acid – ? Marker for protein
breakdown – Influenced by diet and
recent exercise • Ammonia • Reduced serum
Glutamine – Influenced by diet, illness,
recent exercise
Sports Medicine
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Hormonal Markers • Decreased nocturnal urinary excretion of catecholamines
– (lowered intrinsic sympathetic activity)
• Blunted cortisol response to exercise – Salivary ELISA test available
• Decrease in free testosterone:cortisol ratio – Marker of “anabolic-catabolic balance”
• Increase in IL-6, other cytokines – Peripheral metabolic effects which inhibit healing – Central hypothalamic receptors which may contribute to mood disturbances
seen in OTS
• Leptin and IGF-1 – Play role in signaling energy balance and regulating cell growth and repair
Sports Medicine
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Professional cyclists 10 min x 2 hill climb
Gleeson et al (2000)
? Overtrained
Sports Medicine
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Testosterone: Cortisol Ratio
Influence of dietary carbohydrate Lane et al., Eur J Appl Physiol 108:1125-31, 2010
• 20 athletic men • Cycled hard, 1 hr., 3
days in a row • Same calories, but
30% vs. 60% CHO • fTC ratio fell only on
low-CHO diet • Cortisol rose and
testosterone fell
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Physiological Markers
• Ergometry • Blood Lactate • Ammonia • Heart Rate • Respiratory Exchange
Rate • Perception of Effort
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Ergometry
• Sport specific • Reduced VO2max • Reduced Max heart rate (3-5 beats/min) • Increased HR at specific Power Output • BEST: Reduced duration of sport specific, short-
term, high-intensive effort at 110% anaerobic threshold
Sports Medicine
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Blood Lactate
• Decreased lactate level in submaximal exercise – Low muscle glycogen
levels – Decreased
catecholamine response to exercise
Sports Medicine
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If Suspect OTS Reasonable Tests to Consider
• Blood lactate and plasma cortisol response to high intensity or incremental exercise
• Decreased nocturnal urinary excretion of catecholamines
• T-lymphocyte CD4+/CD45RO+ expression
Sports Medicine
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Prevention is KEY! • Training Log: track sleep quality, stress levels, fatigue, and
muscle soreness, exercise duration/RPE • Regular monitoring of max sport-specific performance • Daily Analyses of Life-demands for Athletes (DALDA) • Review Nutrition • Organize training around principles of periodization For Example:
at least 1 day a week of complete rest 1 lighter training week per month
Sports Medicine
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How Much Rest? Overreaching • 2-3 days complete rest • Decrease training volume 30-40% for 1-2 week • if no change then start thinking overtraining Overtraining • Rest 2 week or until symptoms start to improve • Limit weekly training to 0-3 10-20” easy (50-60%
VO2max) sessions • Use cross-training as much as possible • progress slowly, add 5 - 10“ per week, until an hour of
exercise is well tolerated. 6 to 12 weeks is typically required before symptoms resolve.
Sports Medicine
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The Informed Work-up
Sports Medicine
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The Athlete with Fatigue Moeller JL, Curr Sports Med Rep 3:304-9, 2004
• Covers practical workup for common causes – Cardiac causes (rare; new A Fib?) – Pulmonary causes (esp. EIA) – Overtraining (multifactorial) – Eating disorders – Anemia (esp. iron deficiency) – Infections (esp. Mono) – Endocrine (esp. hypothyroid, type 1 DM) – Depression
Sports Medicine
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Possible Approach
• History and Physical Exam • Thorough ROS for subjective complaints • Inventory of psychosocial stressors • Assessment of nutritional practices • Thorough review of training history, illlnesses
and injuries
Sports Medicine
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Tests Tier 1 • Complete Blood Count (CBC) • Serum Iron, Ferritin, TIBC • Glucose • Electrolytes, BUN/Creatine • EBV,CMV titers
Tier 2 • Creatine Kinase • Liver Function Tests • Serum B12, Folate • Thyroid function test • ESR • Serum Immunoglobulins • Hepatitis Serology • ECG • pre- and post-exercise flow
loop spirometry test • Allergy Screening • Muscle Biopsy
Sports Medicine
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Tests Athlete/Coach Expectations
Fallon Br J Sports Med 2007
0
10
20
30
40
50
60
70
80
90
100
History Exam Blood Test X-Ray
AthletesCoaches
Fatigue < 7days !
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Utility of Blood Tests
Fallon 2006 and Du Toit 2005 Short Duration Fatigue (<3 weeks) Blood Tests do not contribute to diagnostic
outcome
Sports Medicine
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Bottom Line
• Be thorough with History and Physical • OTS is a diagnosis of exclusion, but not unlikely
either • Tests will help verify what you suspect (not a blind endeavor!) • Nutrition and psychological stressors may often
be the answer • Athletes want answers and can be demanding!
Sports Medicine
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Acknowledgements
Sports Medicine
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Thank-You!
Sports Medicine