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Overtraining syndrome: A clinical review, part 2

Navy Smith, Timothy Mirtz, and Torrance Williams

Excessive exercise leads to overtraining and a number of signs and symptoms.

Read Part 1 of this article here.

Overtraining Syndrome (OTS) is a result of progression from the state of overreaching defined as extended periods of performance impairment from having a prolonged imbalance between fatigue and recovery.1 Typically, overreaching occurs due to intensified training but is considered a normal outcome mainly from the short period of recovery time (around two weeks).2 OTS is simply not well–understood. The purpose of this article is to discuss the clinical aspects of OTS.   

Clinical 

The stress from the loads put on athletes shifts their psychological and physical well-being from homeostasis to acute fatigue, which progresses from overreaching, to OTS, to clinical symptoms and up to, potentially, death.3 Overtraining is often accredited to the imbalance between training stimulus and rest periods (frequently aerobic training); therefore, the individual is subject to high intensity and/or volumes without proper rest time.4  

The identification of OTS is difficult due to a lack of gold standard markers and individualized testing protocols with isolated symptoms.5 No sign or symptom is specific to OTS.6 Apparently, there are no accurate biomarkers to diagnose FOR/NFOR/OTS, even though studies have found results of altered reactions of creatine kinase (CK) to eccentric exercises, decreased plasma glutamine levels and reductions in maximal lactate concentrations.7 Yet, CK holds some potential as a biomarker. OTS reflects the human body’s attempt to cope with physiological stressors, among many others.8 The pathology behind OTS has also found that CK is typically higher, lactate is lower and hormonal responses to exercise are diminished.7 An increase in circulating CK can be a result of vigorous exercise.9 CK is a biomarker of exercise-induced muscle damage.9 Thus, an intensity threshold is used for reference to know when a load exceeds the limit to create a substantial rise in CK.9 Given there is a poor relation to functional outcomes of CK’s rise in circulation post-exercise, CK is more of a qualitative indicator showing some trauma has occurred to skeletal muscle rather than a quantitative marker representing the extent of damage done to the muscle.9 From this, CK as a biomarker may have more to do with overuse injury with OTS than as a specific biomarker for OTS.  

Treatment and rehabilitation

The treatment and rehabilitation of patients with OTS is just as challenging as the diagnosis, as the literature is scant and mainly based on anecdote due to the absence of validated diagnostic and preventative tools.10 However, some current findings suggest there is no known treatment for OTS other than “rest from training.”11 Treating overtraining syndrome involves attenuation of psychological and physical symptoms.12 The extent of overtraining varies between athletes; therefore, the athlete’s response to the training load must be individualized and reduced or increased.13 

Physical symptoms should be addressed first.12 Treating physical symptoms may involve sleeping and reducing training time to allow adequate recovery from possible illnesses or stress fractures.12 Common sense means ensuring adequate recovery includes the following: keeping a training log and measuring easy physiologic markers, such as weight, morning heart rate and maximal heart rate.10 Trends of weight can signal hydration status and potentially nutritional status. Morning heart rate may help signal excessive catecholamines, increased sympathetic tone or loss of parasympathetic tone, while maximal heart rate often is used as a measure of sympathetic and parasympathetic balance.10 

For a gradual return to the athlete’s previous training levels, physicians can use observable signs of OTS as a guideline.12 The best way to treat psychological symptoms of overtraining is psychological reprogramming.12 Studies have found alterations in training can reduce staleness by scheduling time off from training sessions, even during in-season, or planning mental break periods from physical activity.12 Severe psychological staleness may require complete abstention from training.12,14 One study noted some rehabilitative measures for nonfunctional overreaching/overtraining syndrome, such as:  

  1. Periodization of training
  2. Ensuring six or more hours of rest period between exercise bouts
  3. Ensuring adequate hydration
  4. Adjusting training volume/intensity based on the athlete’s mood and performance
  5. Tapering for competition
  6. Ensuring athletes have an adequate amount of calories and carbohydrates for training/exercise

Conclusion

OTS remains a clinical entity that has no easy answers. Although the research focuses on those of an elite athletic status, OTS can occur to those who exercise of all ages and conditions. This research article did not consider such things as burnout, overuse injury and tapering. The concept of OTS and its multitude of potential theories as part of the overall equation should be considered. While most focus on the actual training of those involved in exercise and athletics, the clinical aspects of the recovery process require further attention in order for them to fully grasp OTS.  

Glossary of terms

Overtraining syndrome (OTS): When athletes have a persistent imbalance between training and recovery, which can lead to fatigue and decreased performance.7

Overreaching (OR): Extended periods of performance impairment.1 

Functional overreaching (FOR): When there is a very short-term (days to few weeks) decrement in performance and supercompensation (improvement in performance) after recovery.7 

Non-functional overreaching (NFOR): When performance worsens for a short period (but longer than FOR, between weeks to months) and a full recovery (although not always the previous performance capacity) is observed after a proper recovery period.7 

 

NAVY SMITH, BS, is currently a Master of Athletic Training student at the University of Alabama in Tuscaloosa, Ala. She can be reached at navy.o.smith@students.cookman.edu. This clinical review is based on Smith’s senior research thesis at Bethune-Cookman University in Daytona Beach, Fla.  

TIMOTHY MIRTZ, DC, PHD, is an associate professor and chair of the Department of Secondary and Physical Education at Bethune-Cookman University. He can be reached at mirtzt@cookman.edu. 

TORRANCE WILLIAMS, DHSC, ATC, LAT, is an associate professor and chair of the Department of Rehabilitation Sciences and Program Director for Athletic Training Education at Bethune-Cookman University and can be reached at williamsto@cookman.edu.  

 

References

  1. Cheng AJ, et al. Intramuscular mechanisms of overtraining. Redox Biol. 2020;35:101480. PubMed website. https://pubmed.ncbi.nlm.nih.gov/32179050/. Accessed Nov. 8, 2023. 
  2. Halson SL, Jeukendrup AE. Does overtraining exist? An analysis of overreaching and overtraining research. Sports Med. 2004;34(14):967-81. PubMed website. https://pubmed.ncbi.nlm.nih.gov/15571428/. Accessed Nov. 8, 2023. 
  3. Schwellnus, et al. How much is too much? (Part 2) International Olympic Committee consensus statement on load in sport and risk of illness. Br J Sports Med. 2016;50(17):1043-52. PubMed website. https://pubmed.ncbi.nlm.nih.gov/27535991/. Accessed Nov. 13, 2023. 
  4. Viana, et al. Identifying the predisposing factors, signs and symptoms of overreaching and overtraining in physical education professionals. PeerJ. 2018;6:4994. PubMed website. https://pubmed.ncbi.nlm.nih.gov/29915702/. Accessed Nov. 13, 2023. 
  5. Bell, et al. Is It Overtraining or Just Work Ethic? Coaches’ Perceptions of Overtraining in High-Performance Strength Sports. Sports (Basel). 2021;9(6):85. PubMed website. https://pubmed.ncbi.nlm.nih.gov/34200179/. Accessed Nov. 13, 2023. 
  6. Savioli FP. Diagnosis of overtraining syndrome. Revista Brasileira de Medicina do Esporte. 2018;24(5):391-394. Research Gate. https://www.researchgate.net/publication/328563586_Diagnosis_of_overtraining_syndrome. Accessed Nov. 13, 2023. 
  7. Cadegiani FA, Kater CE. Basal Hormones and Biochemical Markers as Predictors of Overtraining Syndrome in Male Athletes: The EROS-BASAL Study. J Athl Train. 2019;54(8):906-914. PubMed website. https://pubmed.ncbi.nlm.nih.gov/31386577/. Accessed Nov. 8, 2023. 
  8. Meeusen R, et al. Prevention, diagnosis, and treatment of the overtraining syndrome: joint consensus statement of the European College of Sport Science and the American College of Sports Medicine. Med Sci Sports Exerc. 2013;45(1):186-205. PubMed website. https://pubmed.ncbi.nlm.nih.gov/23247672/. Accessed Nov. 13, 2023. 
  9. Koch AJ, et al. The creatine kinase response to resistance exercise. J Musculoskelet Neuronal Interact. 2014;14(1):68-77. PubMed website. https://pubmed.ncbi.nlm.nih.gov/24583542/. Accessed Nov. 13, 2023. 
  10. Kreher JB. Diagnosis and prevention of overtraining syndrome: an opinion on education strategies. J Sports Med. 2016;7:115-122. PubMed website. https://pubmed.ncbi.nlm.nih.gov/27660501/. Accessed Nov. 8, 2023. 
  11. Hackney AC, Battaglini C. The overtraining syndrome: Neuroendocrine imbalances in athletes. Brazilian Journal of Biomotricity. 2007;1(2):34-44. Research Gate. https://www.researchgate.net/publication/26495564_The_overtraining_syndrome_Neuroendocrine_imbalances_in_athletes. Accessed Nov. 13,2023. 
  12. Johnson MB, These SM. A review of overtraining syndrome-recognizing the signs and symptoms. J Athl Train. 1992;27(4):352-354. PubMed website. https://pubmed.ncbi.nlm.nih.gov/16558192/. Accessed Nov.8, 2023. 
  13. Budgett R. Fatigue and underperformance in athletes: The overtraining syndrome. Br J Sports Med. 1998;32(2):107-10. PubMed website. https://pubmed.ncbi.nlm.nih.gov/9631215/. Accessed Nov. 13, 2023. 
  14. Kreher JB, Schwartz JB. Overtraining syndrome: a practical guide. Sports Health. 2012;4(2):128-138. PubMed website. https://pubmed.ncbi.nlm.nih.gov/23016079/. Accessed Nov. 8, 2023. 

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