Overtraining SyndromeOvertraining Syndrome

Dr Isstelle Joubert

2nd year M Sports Medicine

2012

Patient History...Patient History...

15yo blonde girl

3 week history of being tired (Nov 2011)

poor sport performance

Level of participation:

youngest in school’s u/19 netball team

chosen to go to Mauritius in April 2012

Academically: top 3 in her class

Patient History...Patient History...

Presenting Sx:

tired

poor sport performance

mood swings

Patient History...Patient History...

Other history:

No menarche

Exercise programme

Sleep pattern

Diet

Drugs / supplements

Exercise ProgrammeExercise Programme

  Morning Afternoon

Mon1 h gym: 20ˈ treadmill, 20ˈ stepper /

cycling and 20ˈ circuit with weights

1 h jogging and netball programme

or 1h tennis

Tues 40km outdoors cycling1 h jogging and netball programme

or 1h tennis

Wed1 h gym: 20ˈ treadmill, 20ˈ stepper /

cycling and 20ˈ circuit with weights

1 h jogging and netball programme

or 1h tennis

Thurs 40km outdoors cycling1 h jogging and netball programme

or 1h tennis

Fri1 h gym: 20ˈ treadmill, 20ˈ stepper /

cycling and 20ˈ circuit with weights

1 h jogging and netball programme

or 1h tennis

Sat 40km outdoors cycling  

Sun 40km outdoors cycling  

Sleep Pattern

Sleep pattern:

getting up at 04:30 every morning (except Saturday and Sunday)

going to bed as 21:30 or 22:00

Diet

Breakfast:

muesli, all bran and full cream milk

Midmorning snack: apple

Noon: chicken / red meat

Mid afternoon snack: 1x fruit

Supper: jogurt or carrots with 3 provitas

 

Fluids: 8 x 500ml water a day, fusion shake 200ml sometimes after cycling

 

Total daily kJ intake:

3913.4

Drugs & SupplementsDrugs & Supplements

Medication:

Caltrate plus i tab daily

Vitamine C and Spirulina

Fusion shake sometimes after cycling

No anabolic steroids

On examination:

Weight 45kg

Height 158cm

BMI 18.0

Vitals within normal limits

Examination...Examination...

Special Investigations...Special Investigations...

• Urea 7.3 (1.8-6.4mmol/L)

• Creatinine 67 (53-97umol/L)

• Glucose 3.55 (mmol/L)

• Insulien 2.2 (2.6-11.1ul/ml)

• cholesterol 3.9 (mmol/L)

• trigliserides 0.5 (mmol/L)

• HDL Cholesterol 1.45 (0.75-2.30mmol/L)

• LDL Cholesterol 2.2 mmol/L

• total iron 11.0 (9.0-30.4umol/L)

• Transferrin 2.41 (2.03-3.60g/L)

• Ferritin 50.26 (7-140ng/ml)

• % saturation 20.4 (20-55%)

Blood Tests:

Three Stage Assessment...Three Stage Assessment...

Biological

re-evaluate health status as BMI is low, diet changes

risk for osteoporosis 

Personal / Psychological

fear of making mistakes and letting down the team

feeling anxious and jittery one month before competitions

Social / contextual

family disrupted due to strict diet and ex programme

OTS

Female athlete triad

Iron deficiency

 

Differential Diagnosis...Differential Diagnosis...

Management Plan...Management Plan...

Dietician – 9920kJ !! (3914kJ)

Exercise programme

Psychologist – athlete and family

DISCUSSION ON...DISCUSSION ON... Overtraining SyndromeOvertraining Syndrome

Female TriadFemale Triad

Terminology...Terminology...

process of excessive training in high performance athletes –

lead to persistent fatigue

performance decrements

neuro-endocrine changes

alterations in mood states

frequent illnesses (especially URTI)

months to years to recover

OVERTRAINING

failed adaptation to overload training

(inadequate regeneration)

= neuro-endocrine disorder - ?result from process of

overtraining

reflects accumulated fatigue during periods of excessive

training with inadequate recovery

inappropriate training loads and recovery periods

depression of performance capacity and maladaptation

OVERTRAINING SYNDROME...

Polman RCJ and Houlahan KA. Sports Med: Int J 2004

same Sx

more transitory in nature

resolved with short periods of rest or recovery (2w)

associated with poor performance

OVERREACHING...

Budgett R. 1994.

Functional overreaching

Non-Functional overreaching

performance decrements and fatigue

reversed within pre-planned

recovery period,

no negative consequences in long term

performance doesn’t improve

feelings of fatigue don’t disappear

after recovery.

OTSSevere NFO

disturbed mood profile

decreased physical performance

organic disease or infections

dietary caloric restriction (negative energy balance)

insufficient CH / protein intake

iron / magnesium deficiency

allergies

Complaining of...

Exclusion of...

Prevention, diagnosis and treatment of OTS. ECSS position statement “task force”. European Journal of Sport Science.

2006

DIAGNOSIS OF OTS...

highest incidence

endurance sport

high volume intense training

4-6h per day 6/7 a week

swimming

triathlon

road cycling

power sports - weight lifting

judo

 

INCIDENCE...7 – 20%

PARAMETERSASSOCIATED WITH OTS

PARAMETERSASSOCIATED WITH OTS

Performance decrements

Persistent high fatigue ratings

Reduced maximal heart rate by 5-10 beats per minute

∆ in blood lactate threshold, lactate concentration at a

given work rate or maximal blood lactate level

Neuro-endocrine changes:

↑resting p-NA-levels and ↓resting p-NA-excretion

High self-reported stress levels and sleep disturbances 

Parameters scientifically shown to be associated with OTS

CHANGES IN OTS...CHANGES IN OTS...

CHANGES IN OTS...Hormonal:

↓NA excretion, ↑ p-NA levels

cortisol - resting levels unchanged, reduced maximal response

↓testosterone:cortisol ratio by ≥ 30% - followed over time in

individual athletes to establish baseline values

Blood lactate:

onset of blood lactate accumulation reflects ↑ in lactate output

from skeletal muscle

↑lactate levels in muscle - ↓pH - inducing fatigue

via inhibition of metabolic pathways

( esp anaerobic glycolysis, ↓ ATP production)

CHANGES IN OTS...Immunological:

↓ salivary IgA levels in OTS

↓ glutamine plasma levels

(= substrate for cells of immune systems, esp lymphocytes,

macrophage and NK cells)

Psychological:

POMS = profile of mood states scores ↑in OTS

(? predictor of onset)

anxiety, depression, apathy, lack of motivation, irritability,

inability to relax, lack of self confidence

CHANGES IN OTS...Central fatigue and depression:

alterations in neurotransmitters (serotonin)

chronically diminished BCAA and ↑p-tryptophan (metabolic

precursor of serotonin)

peripherally released inflammatory mediators

NB in development of OTS

CHANGES IN OTS...Central fatigue and depression:

2 hormonal axes

HPA-axis (catecholamines) and

SAM-axis (glucocorticoids)

both implicated in OTS

↓TSH, corticotropin releasing hormone response and GH,

circulating cytokines released

in association with state of chronic systemic inflammation induced

by overtraining

Rx: SSRI (Fluoxetine)

MONITORING

simplest and most effective

self analysis by athletes:

daily documentation & ratings of

stress

fatigue

muscle soreness

quality of sleep

irritability

perceived exertion during training

perceived exertion during standardized exercise test

changes in blood lactate concentration (threshold and

during exercise)

POMS (predictor, not reliable as diagnostic tool)

 

PREVENTION OF OTS...

good periodization with active recovery

regenerative techniques - massage, hydrotherapy, relaxation

increased fluid and carbohydrate intake

complete rest

as much sleep as possible over next 48 hours

?contributing factors →

physical and psychological problems

too high volume of training or too intense (follow 10% rule)

too little sleep

travel & jet lag

dehydration

poor eating habits

injuries, surgery or medication

family responsibilities / problems

financial problems

CONTRIBUTING FACTORS...

TREATMENT...

rest and recover

hydration

recognise risk / problem

cut back on exercise

counselling

hydration

muscle fuelling and repair

promote recovery –

meditation, relaxation exercises,

sports massage - (mentally and physically relaxing)

stretching, cold baths, sauna / steam room,

electric muscle stimulation

HYDRATION TIPS...

part of game plan

• always fluid available, not restricting of amount

start hydrated: 480ml 2-3 h before onset of exercise

teach how to monitor own hydration status:

• urine volume and color, normal = large amounts, light yellow or

clear

sports bottle - required equipment

call frequent water breaks

drink it, don’t splash it

what to hydrate with and when:

• water for short practices and mild temperatures

• energade / powerade for longer practices, humid and very hot

temp

active rehydration post-exercise: 2-3 cups after exercise

WHAT IS NEW IN OTS?WHAT IS NEW IN OTS?

WHAT IS NEW?

early morning heart rate (EMHR) as indicator of OTS –

empirical evidence failed to find changes

good evidence for max heart rate that ↓with 5-10 bpm

↓in blood lactate concentration accompanies OTS

urinary catecholamine output:

good indicator

not cost-effective

inconvenient for routine testing

Overtraining effects on immunity and performance in athletes. Laurel T Mackinnon. 2000.

WHAT IS NEW?

hypothesis: psychomotor speed decreased in OTS

similarities with chronic fatigue syndrome and with major

depression two meta-analyses - psychomotor slowness

consistently present in both syndromes.

Nederhof E. et al. Psychomotor speed: Possibly a new marker for overtraining syndrome. Sports Medicine. 2006 

FEMALE TRIADFEMALE TRIAD

3 Components...

osteoporosis

amenorrhea

disordered eating

low

circulatin

g

oestrogens?

low bone

formation

prevalence: 5.4-26.9%

start

ACSM Position Stand. 2007.

Prevention. Recognition. Treatment.

disordered eating

referred to mental health practitioner , dietician:

evaluation, diagnosis and recommendations for treatment,

nutritional counselling

BMD assessed

stress / low impact #

total of 6 months of amenorrhea, oligomenorrhea, disordered eating

amenorrhea

>16yo, if BMD is ↓with non-pharmacological management

despite adequate nutrition and body weight - OCP

Take Home Message...

If you don’t look for something,

you will not find it...

Do not get one-track-minded on the

complaint – see the bigger picture...

REFERENCES...REFERENCES...

Polman RCJ, Houlahan KA. Cumulative stress and training continuum model: a multidisciplinary approach to unexplained underperformance syndrome. Res Sports Med: Int J 2004;12:301-316

Budgett R. The overtraining syndrome. Br J Sport Med 1994;309:65-68

Prevention, diagnosis and treatment of OTS. ECSS position statement “task force”. European Journal of Sport Science. 2006;6:1(11-14)

Mackinnon LT. Special feature for the Olympics: Effects of Exercise on the Immune System. Immunology and cell Biology. 2000;78:502-509. Overtraining effects on immunity and performance in athletes.

Nederhof E, et al. Psychomotor speed: Possibly a new marker for overtraining syndrome. Sports Medicine. 2006. 36; 10(12)817-828

Brukner & Khan, 2006