What is overtraining syndrome

Overtraining syndrome appears to be a maladapted response to excessive exercise without adequate rest, resulting in disturbances of multiple body systems (neurologic, endocrinologic, immunologic) coupled with mood changes ¹. Past terminology includes burnout, “staleness”, failure adaptation, under-recovery, training stress syndrome, and chronic fatigue. Some researchers refer to overtraining as unexplained underperformance syndrome ². However, overtraining syndrome remains a clinical diagnosis with arbitrary definitions per the European College of Sports Science’s position statement ³.

Table 1. Terminology from position statement on overtraining by European College of Sport Science

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Differentiation of nonfunctional overreaching (NFO) and overtraining syndrome is clinically difficult and can be made often only after a period of complete rest ⁴. The difference between the 2 is based on time to recovery and not necessarily the degree or type of symptoms ⁴.

Many consider overreaching and overtraining as a continuum ⁵. Others question anecdotal evidence suggesting that nonfunctional overreaching (NFO) precedes overtraining syndrome ⁶. Unfortunately, much of the literature has been done on overreached rather than overtrained athletes by current terminology. Some studies used overtrained athletes but failed to show that these athletes suffered from performance impairment ⁶. Recent reports highlight the importance of psychological and/or social stressors in addition to physiologic stress in the development of nonfunctional overreaching/overtraining syndrome ⁷. An individual’s stress capacity plays a role in the development of nonfunctional overreaching/overtraining syndrome ⁸.

Generally speaking, athletes train to increase performance. Performance increases are achieved through increased training loads. Increased loads are tolerated only through interspersed periods of rest and recovery—training periodization. Overreaching is considered an accumulation of training load that leads to performance decrements requiring days to weeks for recovery ³. Overreaching followed by appropriate rest can ultimately lead to performance increases ⁶. However, if overreaching is extreme and combined with an additional stressor, overtraining syndrome (OTS) may result ³. Overtraining syndrome may be caused by systemic inflammation and subsequent effects on the central nervous system, including depressed mood, central fatigue, and resultant neurohormonal changes ⁹.

Table 2. Symptoms of overtraining syndrome

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Epidemiology

Epidemiologic studies use varied terminology. It appears that Overtraining Syndrome is extremely rare, but exact prevalence and incidence data are lacking. *One study found a nonfunctional overreaching (NFO) lifetime prevalence of ~60% in elite male and female runners, compared with 33% in nonelite female runners ¹⁰. A multicenter, multicountry survey found that 35% of adolescent swimmers had been “overtrained” at least once ¹¹. Estimates of “staleness” were reported in 5% to 30% of swimmers over a season ¹² and in 15% of British elite athletes ¹³. In the most recent survey of elite adolescent athletes, ~30% reported nonfunctional overreaching (NFO) at least once in their careers—they averaged 2 episodes lasting 4 weeks. The risk was significantly increased in individual sports, low physically demanding sports (such as golf), females, and elite athletes ¹⁴.

Causes of Overtraining Syndrome

Numerous hypotheses have been proposed for Overtraining Syndrome, each with strengths and weaknesses (Table 3). In attempting to understand Overtraining Syndrome mechanistically and clinically, it is crucial to seek an explanation that accounts for the many symptoms of this complicated entity.

Table 3. Common hypotheses of overtraining syndrome etiology (arranged in order of complexity)

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Diagnosis of Overtraining Syndrome

History

Patients will primarily present with unexplained underperformance. Diagnosis of Overtraining Syndrome is clinical and accomplished through history, which should demonstrate the following ³:

1. Decreased performance persisting despite weeks to months of recovery,
2. Disturbances in mood, and
3. Lack of signs/symptoms or diagnosis of other possible causes of underperformance.

The list of organic diseases that can result in underperformance is extensive and not limited to the following ³:

• undiagnosed asthma/bronchial hyperreactivity,
• thyroid disease,
• adrenal disease,
• diabetes mellitus
• diabetes insipidus,
• iron deficiency with or without anemia,
• infection (myocarditis, hepatitis, HIV, etc), and
• malnutrition (due to eating disorders, celiac sprue, etc).

An extensive nutrition history should be obtained along with an assessment of caloric expenditure.

If an athlete presents with underperformance without a period of rest and recovery, Overtraining Syndrome cannot be diagnosed. By definition, such patient has functional overreaching (FO) versus nonfunctional overreaching (NFO) with possible Overtraining Syndrome ³. The diagnosis from history can be made only in retrospect given the definitions of nonfunctional overreaching (NFO) and overtraining syndrome. If less than 14 to 21 days of rest are required for return to previous performance, nonfunctional overreaching (NFO) would be diagnosed. If it has been greater than 14 to 21 days of rest, Overtraining Syndrome is diagnosed by some ³.

Often, underperformance will be met with an increase in training volume and intensity to improve results. History should include assessment of possible triggers (Table 4) ³. In addition, certain historical clues should raise suspicion of nonfunctional overreaching (NFO)/overtraining syndrome over organic diseases. These clues include the ability to start a training session but the inability to complete and/or a loss of finishing kick ¹⁵. While mood symptoms can coexist with organic processes, the presence of pervasive mood changes in the proper setting may signal nonfunctional overreaching (NFO)/overtraining syndrome versus a primary mood disorder ¹⁶.

Table 4. Potential triggers of overtraining syndrome

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Testing for overtraining syndrome

Ruling out organic diseases leading to underperformance is driven by history ³. The sports medicine provider may consider screening tests to include comprehensive metabolic panel (including kidney function, potassium, magnesium, and glucose), complete blood count, erythrocyte sedimentation rate, C-reactive protein, iron studies, creatine kinase, and thyroid stimulating hormone. Metabolic issues (ie, mitochondrial, glycogen storage, and lipid peroxidation diseases) and cardiovascular disease should be considered in athletes new to higher intensities and volumes ¹⁷. Cardiovascular disease should be investigated in master athletes or someone with a positive family history.

In one of the few studies describing evaluation of underperforming athletes, a cause for repeated infections and/or fatigue was found in 68% of regional- or higher-level athletes ¹⁸. Ninety-three percent of the athletes reported decreases in performance. This evaluation was significant for a more extensive and costly laboratory evaluation, including B12, folate, serology for viral hepatitis, toxoplasmosis, cytomegalovirus/Epstein-Barr virus titers, Epstein-Barr virus DNA in saliva, serum and salivary immunoglobulins (serum immunoglobulin G subclasses and specific serum immunoglobulin E to aeroallergens), and antinuclear antibodies ¹⁸. Such extensive testing should be considered only in the appropriate setting. In those athletes with atopic complaints (allergic rhinitis, dyspnea and/or exertional cough, eczema), pulmonary function tests should be considered ¹⁸.

Biochemical markers have been studied in a variety of athlete populations. There have been no specific or sensitive levels defined for creatine kinase, urea, or iron ¹⁹. Recently, oxidative stress biomarkers have been found to correlate well with training load and overreached status,26 but such markers remain impractical in standard laboratories. Hematologic markers have also been disappointing. Recently plasma viscosity > 1.44 was found to be specific but not sensitive for NFO ²⁰.

Immunologic markers have also been studied with variable results. Two studies have found increased levels of T cell activation, but such testing lacks practicality ²¹. Most recent studies focus on salivary immunoglobulin A. In endurance athletes, lower levels of salivary immunoglobulin A have been correlated with increased incidence of upper respiratory tract infection symptoms ²². One study showed 18% to 32% lower levels in athletes with symptoms of overtraining, but no performance measures were reported ²³. However, another study did not find a statistically significant decrease of salivary immunoglobulin A after intensified training in cyclists ²⁴. Most would agree that excessive exercise, functional overreaching (FO), nonfunctional overreaching (NFO) and Overtraining Syndrome can result in impairment in cell-mediated immunity, but there does not appear to be an immunologic marker that differentiates them ³.

Hormonal markers have shown some promising results but have a multitude of confounding variables (ie, diurnal and seasonal timing, phase of menstrual cycle, nutritional status) ³. Resting cortisol levels have not differentiated between athletes with and without nonfunctional overreaching (NFO) or Overtraining Syndrome. Testosterone results have been contradictory. Some have suggested that a decreased testosterone:cortisol ratio can be diagnostic of nonfunctional overreaching (NFO) and/or Overtraining Syndrome. However, the ratio represents the physiologic strain of training rather than the athlete’s maladaption to that stress. The utility of testosterone:cortisol ratio has not been supported by the literature ²⁵.

Cortisol has a peak during the day with nadir during night ²⁶. Morning cortisol does not accurately reflect levels of free cortisol ²⁶. Free cortisol is filtered by the kidney at a constant rate; therefore, 24-hour and overnight urinary-free cortisol have been more studied ²⁶. However, even overnight excretion shows high interindividual variability ²⁶. Cortisol (catabolic and anti-inflammatory) is converted to inactive cortisone by 11β-HSD2. A prospective study found a clinically significant increase in overnight urinary cortisol:cortisone ratio during a high training load period in triathletes, who subsequently underperformed and reported fatigue ²⁶. It is proposed that cytokines may inhibit 11β-HSD2 activity and result in relative increases in cortisol and, hence, catabolism ²⁶. However, overnight urinary cortisol:cortisone ratio remains in the research realm and awaits validation.

Clinically, it would be helpful to know what level of training signals the change from functional overreaching (FO) to nonfunctional overreaching (NFO) and from nonfunctional overreaching (NFO) to overtraining syndrome. However, there are no specific and validated blood markers for nonfunctional overreaching (NFO) or overtraining syndrome ¹⁹. Therefore, some have focused on physiologic tests. A couple recent studies show promise for discriminating nonfunctional overreaching (NFO) from overtraining syndrome. A 2-bout maximal exercise protocol reportedly diagnoses functional overreaching (FO), nonfunctional overreaching (NFO) and overtraining syndrome by investigating the HPA (hypothalamic-pituitary-adrenal) axis response ²⁷. The bouts of maximal exercise are separated by 4 hours. It is believed that functional overreaching (FO), nonfunctional overreaching (NFO) and overtraining syndrome represent a disturbance, an adaptation, and eventual maladaption of the HPA (hypothalamic-pituitary-adrenal) axis. In an early study, functional overreaching (FO) athletes had a less pronounced hormonal response to a second bout of maximal exercise in comparison with the extremely exaggerated response in nonfunctional overreaching (NFO) athletes ²⁸. These findings were in contrast to the extreme response to the first bout of exercise and absence of response to the second bout in overtraining syndrome athletes ²⁷. This first study displayed great utility in picking up functional overreaching (FO) before nonfunctional overreaching (NFO) ²⁸. In the most recent study of 2-bout maximal exercise protocol, reliable differentiation of nonfunctional overreaching (NFO) from overtraining syndrome was achieved. However, the diagnosis of nonfunctional overreaching (NFO) and overtraining syndrome was made retrospectively and arbitrarily defined overtraining syndrome as greater than 1 year of symptoms. Athletes were tested after having symptoms ranging from 2 weeks to 1 year and prospectively followed for resolution of symptoms. After a second bout, nonfunctional overreaching (NFO) athletes showed very large increases in adrenocorticotropic hormone and prolactin, whereas overtraining syndrome athletes showed absent or very limited increases. The study’s authors propose that the different responses are due to hypersensitivity of glucocorticoid receptors in nonfunctional overreaching (NFO) compared with insensitivity in overtraining syndrome. This would seem to confirm a disturbance in the HPA (hypothalamic-pituitary-adrenal) axis and give credence to the close relationship between overtraining syndrome and other stress-related syndromes, such as major depression and posttraumatic stress disorder ²⁷. If findings can be replicated, 2-bout maximal exercise protocol may have prognostic value by identifying athletes requiring greater than 1 year to recover.

Physiologic testing with resting heart rate, maximal heart rate, and heart rate variability do not show consistent results, nor do they allow differentiation of FO, NFO, and overtraining syndrome. Researchers have argued that use of performance tests for diagnosis is “polluted” by the underperformance inherent to NFO and overtraining syndrome ²⁹. However, the most consistent finding is a diminished maximal lactate in overtraining syndrome, but it was not sensitive enough to rule out NFO ³. In an analysis of the literature, greater performance decreases were found in studies that report time to fatigue versus studies that report more functional performance measures (ie, 100- or 400-m swim, 15-minute time trial) ²⁵.

Most agree that psychological distress is required for diagnosis of overtraining syndrome. The best-studied measure is Profile of Mood States scores. In 2 studies, 81% of “stale” swimmers were identified with the Profile of Mood States questionnaire ³⁰. However, increased scores can be seen in athletes with increased training without FO/NFO ³¹ and have not always been reported with performance measures ³⁰. Regardless, mood questionnaires can be prospectively followed, are cheap, and are quickly available. Variables such as timing of testing in relation to training must be standardized. In a case study of an NFO athlete, it was suggested that decreased Profile of Mood States vigor score may be more specific to overreaching than the Profile of Mood States fatigue score. It is suggested that fatigue is a “normal experience” in athletes, whereas decreased vigor can be viewed as maladaptive ³².

Treatment of overtraining syndrome

Treatment varies based on the etiology for the underperformance ³, and any organic disease should be treated appropriately. No treatment is required for FO other than balancing overload training with appropriate recovery ³. Treatment of NFO and overtraining syndrome is rest; however, some propose that relative rest is more appropriate ³³. It is recommended to build up volume prior to intensity, starting from 5 to 10 minutes daily until 1 hour is tolerated ³³. It is unclear which strategy is best, so the motivation for exercise, internal versus external, should be considered when recommending complete versus relative rest. Given the significant psychological overlay, one may consider involving a sports psychologist or other mental health expert in multidisciplinary management ³. If stress, depression, and/or anxiety are increased with full rest, relative rest with well-defined expectations should be provided ³.

Treatment with selective serotonin reuptake inhibitor is suggested by some based on similarities between neuroendocrinologic changes between depression and overtraining syndrome ³⁴. However, one should be cautious of increased heat stress and possible decreased performance with antidepressant treatment in athletes. In addition, if sleep complaints are prominent, treatment with trazodone or amitriptyline could be considered ³⁴.

Prevention of overtraining syndrome

Given the unethical nature of inducing overtraining syndrome in athletes and uncertain pathogenesis, there are no evidence-based means of preventing overtraining syndrome. However, observation of training load, performance measures, and mood questionnaires can help interrupt the progression from FO to NFO/overtraining syndrome ³. A study has shown a decrease in “burnout” in collegiate swimmers from 10% to zero when altering training load in response to the Profile of Mood States questionnaire. When the mood state decreased, training load was also decreased ³¹.

Major components of prevention are screening and education. One should educate athletes at risk for overtraining that one of the initial signs of overreaching is increased rating of perceived exertion for a given workload ³¹. In addition, sports medicine providers may consider preemptively asking if training has increased to compensate for decreases in performance. History of athletes should include inquiry about training (monotony, excessive load, sudden increase, caloric/hydration needs in relation to load) and personal stressors (interpersonal, family, sleep, travel) (Tables 5).

Table 5. Preventative measures for nonfunctional overreaching/overtraining syndrome

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