professor, department of family medicine and community ...forms.acsm.org/15tpc/pdfs/40 johnson...
TRANSCRIPT
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Rob Johnson, MD, FACSM, CAQ Professor, Department of Family Medicine and Community Health, University of Minnesota Team Physician, University of Minnesota Athletics Director Emeritus, Sports Medicine Fellowship Minneapolis, MN
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I have no disclosures or conflicts of interest
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Objectives
• Understand the concept of overtraining
• Identify potential causes of fatigue in the athlete
• Recognize potential therapeutic interventions for the fatigues athlete
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The Problem
• Fatigue is common – Prevalence via survey 6.0 – 7.5% – 2-week period prevalence in US workers 38% – 21-33% patients seeking care at primary care
clinics report fatigue as a symptom
And me…?
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The problem, a broad differential diagnosis
Moeller JL: The athlete with fatigue. Curr Sports Med Rep 2004, 3:304–309
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Overtraining
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Overtraining
• Persistent unexplained, underperformance
syndrome. • Occurs in 10-20% of elite endurance
athletes. • Occurrence in non-elite endurance
participants?
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Incidence Morgan WP, Brown DR, Raglin JS, et al. Psychological moni-toring of overtraining and staleness. Br
J Sports Med 1987; 21(3): 107-14
5-10% in swimmers training up to 14,000 m/day O’Connor PJ, Morgan WP, Raglin JS, et al. Mood state and salivary cortisol levels following
overtraining in female swim-mers. Psychoneuroendocrinology 1989; 14 (4): 303-10 Hooper S, MacKinnon LT, Hanrahan S. Mood states as an indication of staleness and recovery. Int J
Sport Psychol 1997;28: 1-12
5-10% in swimmers over 6-month period Raglin JS, Morgan WP. Development of a scale for use in monitoring training-induced distress in
athletes. Int J Sports Med 1994; 15 (2): 84-8
6.8 % “stale”, but 32.1% showed training “distress” Koutedakis Y, Sharp NC. Seasonal variations of injury and overtraining in elite athletes. Clin J Sport
Med 1998; 8 (1):18-21
Elite athletes from British national teams, 15% overtrained; male 17%, female 11%
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Definition: Overreaching
An accumulation of training and/or non-training stress resulting in short-term decrement in performance capacity with or without related physiological and psychological signs and symptoms of overtraining in which restoration of performance capacity may take from several days to several weeks.
Halson SL, Jeukendrup AE: Sports Med 2004;34(14)
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Functional Overreaching
• Utilized by athletes during a typical training cycle to enhance performance • Intensified training can result in a decline in
performance; but, with appropriate recovery, ‘supercompensation’ effect may occur resulting in enhanced performance
• Recovery from a state of overreaching occurs within a 2-week period (taper)
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Definition: Overtraining
Accumulation of training and/or non-training stress resulting in long-term decrement in performance capacity with or without related physiological and psychological signs and symptoms of overtraining in which restoration of performance capacity may take several weeks or months.
Halson SL, Jeukendrup AE: Sports Med 2004;34(14)
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Overreaching/Overtraining
• Threshold for this syndrome varies for every athlete • Stress due to training, psychological stress, illness? • Dx of exclusion • Rx: rest for ?? Carfagno DG, Hendrix, JC: Overtraining syndrome in the athlete: current clinical practice. Curr Sports Med Rep 2014;13(1): 45-51
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Reported symptoms
• Fatigue • Unexplained sense of effort • History of heavy training and
competition • Monotonous training • Frequent minor infections • Unexplained heavy, stiff, sore
muscles
• Mood disturbance • Change in sleep quality • Loss of energy • Loss of competitive drive • Loss of appetite • Loss of libido
Fry RW, Morton AR, Garcia-Webb P, et al. Biological responses to overload training in endurance sports. Eur J ApplPhysiol 1992; 64 (4): 335-44 29% decline in performance using time-to-fatigue protocol
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Profile of Mood State (POMS)
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Overtraining hypotheses
• Glycogen depletion hypothesis (decreased glycogen stores lead to decreased levels of BCAA – Unsupported by current research
• Hypothalamic hypothesis (dysregulation of HPA axis) – Unsupported
• Branched chain amino acid hypothesis (decreased amino acids lead to increased tryptophan leads to fatigue) – Inadequate scientific support
• Cytokine hypothesis
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Cytokine hypothesis Carfagno DG, Hendrix, JC: Overtraining syndrome in the athlete: current clinical practice. Curr Sports Med Rep 2014;13(1): 45-51
Little supporting evidence
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University of Minnesota
Confirmatory tests
• Creatine kinase • Urea • Ammonia • Uric acid • Nocturnal urinary excretion of
catecholamines • Testosterone/cortisol • Heart rate variability • IGFBP-3
• Not • Not • Not • Not • Not
• Holds promise, but… • Holds promise, but… • Holds promise, but…
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Without confirmatory testing, the overtraining syndrome is a diagnosis of exclusion.
Consider: Other more common causes of fatigue in athletes…
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Treatment
• Relative rest
• Relative rest
• Relative rest
• Relative rest
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So, let’s be practical
Consider other common causes of fatigue in
the student-athlete population The evidence for this is Level ? Best Experience
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My differential dx at 516 15th Ave. SE
• Sleep deprivation • Illness • Inadequate nutrition • Iron (ferritin) deficiency • Vitamin D deficiency • Exercise-induced bronchoconstriction • Depression • Staleness/Overtraining
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Illness
• Hx of sx of recent illness, exposure to others with illness, or current sx.
• Post-viral asthenia • Infectious mononucleosis
– If sx atypical, obtain EBV IgG, IgM
• Rx
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Sleep Hygiene
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Iron (Ferritin) Deficiency
• Common cause of fatigue, poor training and performance (aerobic capacity, anaerobic activities)
• More to come on Sunday…
Beard J, Tobin B: Iron status and exercise. Am J Clin Nutr 2000, 72(Suppl):594S–597S.
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Vitamin D Deficiency
• Ubiquitous in climate at 45°N, 93°W – Vitamin D modulates
• Bone homeostasis • Immune system • Skeletal muscle • Cardiac muscle
• Normal (30-80) • Some suggest levels > 50 for optimal
performance • Rx: Vit D replacement
Moran DS, McClung JP, Kohen T, Lieberman HR: Vitamin D and Physical performance. Sports Med 2013;43:601-611
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Exercise-Induced Bronchoconstriction
• Important to consider as diagnostic possibility.
• Sx: fatigue, but usually associated with cough (during or after exercise).
• Athlete may not appreciate shortness of breath
• 10% of general population, 40% in those with allergies, 90% in those with asthma
• Rx: appropriate use of inhaled meds
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Inadequate Nutrition
• Demands of training may not be met by dietary intake
• Dietary changes that occur in the college athlete
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Depression • 12% of adult population presenting to
primary care offices suffer from depression
• Prevalence in adolescent population 5-8% • Fatigue may be only presenting complaint • Associated sx
– Sleep disturbance – Loss of appetite – Apathy – Rx: meds and/or psychiatric consultation
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Summary
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Bibliography
In addition to those cited in presentation, Carafagno DG, Hendrix JC: Overtraining Syndrome in the Athlete: Current Clinical
Practice. Curr Sports Med Rep 2014;13(1):45-51 Halson SL, Jeukendrup AE: Does Overtraining Exist? An Analysis of Overreaching
and Overtraining Research. Sports Med 2004;34(14): 967-981 Robson P: Elucidating the Unexplained Underperformance Syndrome in
Endurance Athletes The Interleukin-6 Hypothesis. Sports Med 2003; 33 (10): 771-781