FITNESS AND EXERCISE
| JOGGERS’ FATIGUE —William R. Vollmar, MD, Director of Sports Medicine, and Director of Family Practice Residency,
Lancaster General Hospital, Lancaster, Pennsylvania
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| Overtraining syndrome: not only in elite athletes; causes—endocrine or metabolic events; infection; anemia; respiratory
issues; mental health issues; complaints—not getting stronger despite extensive training; unexplainable tiredness;
lack of endurance; athletes—good patients; less depression and anxiety; goal oriented; often sure their training methods
are best; take risks, but not excessively
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| Definition: failure of body to continue to adapt to increasing exercise; traditionally, people have positive adaptations as they
train, and performance improves as training slowly increases (eg, run longer, get stronger, run faster); point at which performance
falls off positive adaptation mode
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 | Etiology: body’s self-defense mechanism; hormonal controls; sympathetic controls; parasympathetic controls
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| Presentation: performance—decreased strength; decreased endurance; lower training tolerance (tired more quickly;
sore longer than normal; recovery time increased); decreased coordination skills; more technical faults
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| Physiology of overtraining: not well understood; alterations—heart rate (HR) pattern; blood pressure (BP) pattern;
respiration pattern; elevation of basal HR—once believed to define overtraining syndrome; great variability prevents
this from being valid marker; physical changes—decreased body fat and decreased postexercise body weight, compared
to what athlete once showed; increased VO 2max , ventilation rate, and HR during submaximal work
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| American College of Sports Medicine: publishes studies on overtraining syndrome in journal Medicine and Science
in Sports and Exercise; includes many exercise physiologists; “hard-core” research on physiology of overtraining
syndrome
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| Physiology: decreased lactate response; increased basal metabolic rate (BMR); sleep disorders; eating disorders; changes in
menstrual cycle; increased headaches; overuse injuries from which athlete cannot recover; chronic fatigue—even at rest; differs
from normal fatigue caused by exercise or lack of sleep; constant; gastrointestinal (GI) distress—irritable bowel–type
symptoms
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| Psychologic factors in overtraining: depression; apathy; decreased self-esteem; decreased concentration on athletic activities
and activities of daily living (ADL); decreased self-efficacy; sensitivity to stress
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| Changes in immunologic system: increased occurrence of illness (athletically active people usually have decreased occurrence
of illness); decreased healing rates; impaired immune function
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| Biochemical changes: hypothalamic dysfunction; cortisol levels rise and fall out of coordination with systemic requirements;
increased serum cortisol; decreased free and total testosterone; decreased serum hemoglobin, iron, and ferritin;
decreased muscle glycogen—muscle biopsies in depressed or fatigued athletic or nonathletic people show significantly
lower glycogen concentrations than in those not having symptoms; negative nitrogen balance—athletes eating as much
as they can, but body breaking down protein; nitrogen output greater than nitrogen input
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| Diagnosis: no biochemical markers; more prediction than diagnosis; recognition of patterns of overtraining; mood
states—Profile of Mood States (POMS) best predictor of when athlete approaching overtraining
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| Treatment: drastically reduce volume and intensity of training—easiest treatment method for physician to prescribe;
hardest treatment for athlete to accept; psychologic support—intellectually and emotionally disorienting for athlete accustomed
to being very healthy
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| Prevention: increase intensity or volume 10% weekly; increasing both does not work
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| Nutrition: ensure adequate nitrogen balance; elite athletes should consume 8 g/kg body weight of carbohydrate per day
(3500-5000 cal/day); 1.2 to 1.8 g/kg body weight of protein per day (lower end for endurance athletes; higher end for
strength athletes); fats <25% of total daily calories; muscle most receptive to taking in glycogen during first hour after exercise,
so athletes participating in activities that take >1 to 2 hr to complete (eg, triathlons, marathons, half marathons) should
take in 2 g carbohydrate per kilogram body weight in first 30 min after finishing activity; no evidence for eating >2 g/kg
body weight of protein per day
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| Hydration: weight before and after training helps establish hydration needs; difference in weight equals water loss that must
be replaced before repeating activity; water adequate for hydration for events that last 1 to 2 hr; sports drinks with <7 g%
carbohydrate can be beneficial and enhance performance in activities that last >2 hr; drink should be cool or room temperature
(ice water sits in stomach until it reaches body temperature; during marathons, taking iced drinks every mile can produce
vomiting)
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| Salt: supplementation should be considered with prolonged or excessive sweating; supplementation means small amount
of salt in food
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| Causes other than overtraining: other syndromes with similar presentation must be ruled out; endocrine and other
metabolic causes—hypothyroidism; hyperthyroidism (can look like exercise-induced asthma); hypoparathyroidism; acromegaly;
diabetes; hypogonadism; anabolic steroid abuse; infection—normal exercise enhances immune system; viral
syndrome does not decrease performance, so does not explain diminished activity; do not exercise with fever (additive with
body heat from exercise; increases risk for heat injury); athlete may exercise with illness from neck up as long as no fever
present; athlete should not exercise with illness below neck, even without fever; anemia—in athletes, causes fatigue with
exertion; iron deficiency anemia most common form in athletes (iron deficiency without anemia not shown to affect performance);
microcytic anemia caused by blood loss (athletes’ red blood cells [RBCs] injured during activity and have shorter
lives); macrocytic anemia (check reticulocyte count in avid runner; if not elevated, consider diagnosis of runner’s anemia);
runner’s anemia due to plasma expansion during exercise (after 4 wk of no running, increased hematocrit with macrocytosis
and minimally elevated reticulocyte count diagnostic); exercise-induced bronchospasm—in 15% to 40% of athletic population;
cough most common presenting symptom; most common complaint, “I’m more short of breath than I should be for
what I’m doing”; diagnosis by pre- and postexercise pulmonary function testing (PFT); if abnormal before exercise, treat as
asthma; if normal before exercise and abnormal after, start with β2 -agonists; corticosteroids not indicated; nonpharmacologic
methods); mental illness—less likely than in nonathletic population; reactive disorders common in athletes (from, eg,
competition; medication not indicated); endogenous disorders (eg, depression) often require medication
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| Medications: be aware of side effects; some increase risk for heat illness and dehydration, eg, tricyclic antidepressants, diuretics;
medications that affect weight poor choice for athletes; do not prescribe banned substance that could disqualify athlete
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| Eating disorders: one man for every 100 women; 10% to 20% mortality rate in women; associated with female athlete
triad (eating disorder, amenorrhea, and osteoporosis); amenorrhea most common presentation; proper referral essential
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| PRESCRIBING EXERCISE: Gabe Mirkin, MD, Associate Clinical Professor, Georgetown University School of Medicine, Washington,
DC
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| Exercise and health: lack of exercise better predictor of heart attack than excess weight; exercise testing reliable measure
for predicting all causes of mortality; people who exercise regularly live longer than those who do not; C-reactive protein
(CRP)—more dependable predictor of heart attack than cholesterol; exercise lowers CRP; intensity of exercise—more important
than less intense exercise done more frequently in preventing myocardial infarction (MI); 10-yr study showed only
vigorous exercise associated with lowered risk for death from heart attack
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| Recovery HR: best measure of fitness; take HR exercising intensely, slow down, then take HR 1 min later; greatest 1-min
reduction in HR indicates highest fitness; strong predictor of future susceptibility to MI; more intensity, not duration, of
exercise determines better recovery HR
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| Lowering risk factors: all coronary risk factors lower in faster marathon runners compared to slower ones; exercise
prevents heart attacks in postmenopausal women, and those who spend most time exercising have greatest protection
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| Exercise programs: difficult to get people, particularly those in middle age, to start; 85% of middle-aged people who start
program drop out in 6 wk; personal trainer, training with spouse, or organized program increases chances of staying; continuous
exercise—weight lifting does not significantly strengthen heart; jogging, cycling, and dancing can be done continuously
and in groups; beginners most likely to injure selves during exercise (from, eg, sudden death, acute MI); volume
before intensity—build up with very low intensity; when doing large volume, build up intensity; heart stress—measured
by how long pulse stays up after exercise; increased HR >30 min poor sign
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| Hard-easy principle: based on stress and recovery; exercise hard enough to damage muscles and cause soreness, then go easy
until soreness disappears; after warm-up period (easy until going 20-30 min/day), start training; exercise to burn (muscle damage),
easy until soreness disappears, exercise intensely again; never stress sore muscles; exercise to burn, not through burn; recovery
faster by doing nothing than by exercising at reduced intensity; HR as intensity measure—try to work up to maximum HR,
back off when feeling pain, muscle burning, or excessive shortness of breath (SOB); on easy days, as little force on muscles as
possible, with HR not >30 beats per minute (BPM) above resting HR; maximum HR means fastest heart can beat and still pump
blood; training HR means rate that requires faster and deeper breathing; if not increasing need for O2 , not becoming more fit (gardening
and slow walking do not make one fit); people lose 1 BPM of maximal HR each year; formula for maximum HR—220
minus age
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| Sore muscles: taking extra protein during recovery helps speed recovery; nonsteroidal anti-inflammatory drugs
(NSAIDs)—decrease blood creatine kinase (CPK) levels; no data to show faster healing; lactic acid buildup—nothing
to do with muscle damage; stretching and massage—do not prevent muscle soreness; not shown to speed recovery
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| Hard and easy days: hard days—exercise to burn, back off, then exercise to burn; repeat sequence; stop when muscles
start to stiffen; easy days—exercise at pace that does not put much pressure on muscles or produce SOB
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| Stationary bicycle: in speaker’s opinion, best exercise for all; spinning bicycle ideal; no sudden shock to joints or muscles;
constant rate with constant spinning force; control workout by controlling resistance in pedals; muscle damage
comes from resistance, not cadence; muscle recovery comes from high cadence with low resistance; standing on bike increases
HR 5 to 7 BPM with same resistance
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| Training for competition: interval training; short intervals—<30 sec; very intense until “gasping for breath,” catch
breath, then very hard again; fixed number of repetitions at fixed distance, time, or recovery; builds up little lactic acid, so
many repetitions possible; long intervals—intense for 2 min; large amounts of lactic acid, so few possible; program—
Sunday, very long, hard, and fast (“long ride”; depletes glycogen to teach muscles to hold even more); Tuesday and Thursday,
100 fast short intervals with slow recovery between; 4 recovery days
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| Training program for patients: 2 hard workouts per week; 2 days off; 3 recovery days; achieves higher level of fitness
than doing same workout each day
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| THE WEEKEND WARRIOR —Bryan K. Ganter, MD, Assistant Professor of Physical Medicine and Rehabilitation, Mayo
Clinic College of Medicine, Scottsdale, Arizona
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| Definition: any person who participates in very little or no exercise during week, then during weekend participates in some
physical activity; intensity of activity far too vigorous for individual’s condition
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| Injuries: acute traumatic injuries—collisions; twists; falls; result in contusions, acute muscle strains, and ligamentous sprains;
inherent to activity, so difficult to prevent; overuse injuries—more common; load placed on muscle-tendon complex much
more than ability of complex to manage load; result in muscle strains, ligamentous sprains, and tendonopathies; prevention possible;
“microfailures” of collagen fibrils become tensile failures with further stress, leading to macroscopic damage (eg, tendon
rupture); in most cases, tissue injury occurs long before injury perceived
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| Risk factors for injury: progressive decline in strength; progressive decline in endurance; poorly flexible muscle; degenerative
tissue changes (eg, tendonosis); high-impact or high repetitive-load activity
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| Acute-phase treatment: rest, ice, compression, elevation (RICE); short-term immobilization; decrease pain, swelling,
and hematoma; assist with formation of connective tissue bridges; 24 to 48 hr after injury; anti-inflammatory drugs—
primarily for pain relief; may help with muscle recovery; use should be short-term (1-2 wk)
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| Subacute treatment: rehabilitation phase; remobilization helps stimulate tissue repair and align muscle fibers; stretching
helps stimulate organized repair and begins to restore flexibility; strengthening exercises—begin correcting imbalances;
should be done in pain-free range; concentric strengthening—shortening of muscle; early part of strengthening; isometric
strengthening—pain-free range; gradual progression; eccentric strengthening—load higher than concentric; pain free;
slow, gradual progression
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| Preventing overuse injuries: de-emphasize weekend part of warrior; encourage regular exercise throughout week;
emphasize strength, flexibility, and endurance; benefits of stretching questionable
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| Core: based on kinetic chain theory; sequence of links (ie, limbs) in coordinated fashion to accomplish planned task; athletic
activity has center of energy in hip and trunk; weak core creates inefficient movement, reduces ability to stabilize against
normal forces, sets stage for injury; comprised of muscles of back, abdomen, and hip
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| Core strengthening: athlete first needs to learn how to fire muscles; abdominal hollowing during other activities; abdominal
bracing; curl-ups; side bridging; “bird dog”; more advanced—physio ball; abdominal crunches; seated ball exercises; “Superman”
prone exercises; modified push-ups; further progression—functional activities with strength and stabilization of core;
multiplanar exercises that mimic chosen sport
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Educational Objectives
| The purpose of this program is to educate the listener about recognizing and preventing joggers’ fatigue, prescribing
exercise programs, and dealing with the “weekend warrior”. After hearing and assimilating this program, the clinician
will be better able to:
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| Identify athletes who are at risk for overtraining syndrome.
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| Develop treatment strategies for athletes with overtraining syndrome.
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| Establish fitness goals for sedentary middle-aged patients.
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| Set up an exercise program that increases fitness, endurance, and strength.
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| Diagnose and treat overuse injuries in the “weekend warrior.”
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Suggested Reading
Angeli A et al: The overtraining syndrome in athletes: a stress-related disorder. J Endocrinol Invest 6:603, 2004;
Armstrong LE, VanHeest JL: The unknown mechanism of the overtraining syndrome: clues from depression
and psychoneuroimmunology. Sports Med 32(3):185, 2002; Aoyagi Y et al: Walking velocity measured over 5 m as
a basis of exercise prescription for the elderly: preliminary data from the Nakanojo Study. Eur J Appl Physiol 93(1-
2):217, 2004; Budgett R et al: Redefining the overtraining syndrome as the unexplained underperformance syndrome.
Br J Sports Med 34(1):67-8, 2000; Hreljac A: Impact and overuse injuries in runners. Med Sci Sports Exerc
36(5):845, 2004; Irwin ML et al: Influence of demographic, physiologic, and psychosocial variables on adherence
to a yearlong moderate-intensity exercise trial in postmenopausal women. Prev Med 39(6):1080, 2004; Lakier
Smith L: Overtraining, excessive exercise, and altered immunity: is this a T helper-1 versus T helper-2 lymphocyte
response? Sports Med 33(5):347, 2003; Lee IM et al: The "weekend warrior" and risk of mortality. Am J Epidemiol
160(7):636, 2004; Lipton L: Case studies in writing the exercise prescription. JAAPA 18(2):33, 2005; Little P et
al: A randomised controlled trial of three pragmatic approaches to initiate increased physical activity in sedentary patients
with risk factors for cardiovascular disease. Br J Gen Pract 54(500):189, 2004; MacKinnon LT: Special feature
for the Olympics: effects of exercise on the immune system: overtraining effects on immunity and performance
in athletes. Immunol Cell Biol 78(5):502, 2000; Meeusen R et al: Hormonal responses in athletes: the use of a two
bout exercise protocol to detect subtle differences in (over)training status. Eur J Appl Physiol 91(2-3):140-6, 2004;
Nadler SF et al: Sport-specific shoulder injuries. Phys Med Rehabil Clin N Am 15(3):vi, 607, 2004; Niemuth PE
et al: Hip muscle weakness and overuse injuries in recreational runners. Clin J Sport Med 15(1):14, 2005; [No authors
listed] The exercise prescription. Postgrad Med 117(4):inside back cover, 2005; Pearce PZ: A practical approach
to the overtraining syndrome. Curr Sports Med Rep 1(3):179, 2002; Singh MA: Exercise and aging. Clin
Geriatr Med 20(2):201, 2004; Urhausen A, Kindermann W: Diagnosis of overtraining: what tools do we have?
Sports Med 32(2):95, 2002
Faculty Disclosure
| In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
there is nothing to report.
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Dr. Mirkin was recorded March 14, 2005, and Dr. Vollmar, March 17, 2005, at the annual Spring Family Practice Review,
sponsored by the Temple University School of Medicine, Philadelphia, and held at the Lancaster General Hospital
in Lancaster, Pennsylvania. Dr. Ganter spoke March 17, 2005, at Clinical Reviews 2005: A Primary Care Update,
sponsored by the Mayo Clinic Scottsdale, held in Scottsdale, Arizona. The Audio-Digest Foundation thanks the
speakers and the sponsors for making this program possible.
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