Good evening. We are lucky today to have Dr. Tom Howard with us talking about overtraining. Dr. Howard went to United States Military Academy at West Point and went on to have. Went on to train further at the Uniformed Services University of Health Science School of Medicine and completed his residency of family practice at DeWitt Army Community Hospital, and then was a primary care sports medicine fellow at the US UHS and Nursial Orthopedic Sports Clinic in Arlington, Virginia. He was a residency director of the family practice residency and department chair of family practice at DeWitt Army Community Hospital. Prior to his retirement from the Army in 2004 after 29 years of service. After retiring he practiced at the Fairfax family practice in Virginia as a program director for sports medicine fellowship and a busy sports position where clinicians, excuse me, where he developed a comprehensive program for diagnostic musculoskeletal sonography and regenerative medicine. He left Northern Virginia and joined North Carolina State Student Health in February 2015, and then joined philanogenics and June of 2016. Dr. Howard is going to talk to us today about overtraining and he is definitely an excellent candidate to give this talk. He has more publications than I am able to list in this time and has written multiple chapters on overtraining and some of the books that most of us refer to regularly including the complete book of running medicine, Just the Facts, Up to Date, ACSM, Sports Medicine Comprehensive Review, Running Medicine, and others, Elsevier Sports Medicine. So, some pretty impressive chapter writing there and has presented at all our major conferences in sports medicine and in uniformed services. So, we're thrilled to introduce Dr. Howard and when you're ready, go ahead. Thank you very much. So, we, I have a normally which is a fairly long lecture that we're going to try and squeeze down into a short timeframe, so that we can get it done within the, the time we have allotted. But, but I want to. I'm going to interrupt for a second. I forgot to mention that if anyone has any questions, please put them in the chat and we'll address them when we can. So, we're going to talk about it. I want to talk about obviously terminology, we're going to talk about the etiology and the epidemiology and we'll talk, obviously most important for us clinicians, talk about the presentation, how we would work it up, work it up versus the management and prevention of these of this condition. As you know, when we train, we're trying to overload or stress ourselves to the point that we create a stimulus that we can adapt to improve our performance and adaptation is that in that physiologic response that allows us to perform better in the future. In order to adapt, we have to recover. Recovery starts when we we displace this homeostasis, and it but we have to think about recovery is not just physiologic but there is there's psychologic recovery and even social recovery. If you think about the components of recovery, you could break it down into nutrition and hydration and rest and sleep, relaxation, emotional support, stretching and active rest. We can't just say stay immersed in our sports, because we'll eventually start to fatigue, just emotionally. But if you think about the athlete, a lot of us, we live in this world, this is where we see the athlete participate in their sports with their coach their team, but don't forget, they have a home situation whether they're there have siblings and or parents, and they, in most cases are working and so they have these, there's three tiered list of different stressors on them in addition to participate in the sport. So, fatigue is is the presenting symptoms when we see patients that we think are suspect or overtrade, but we can define fatigue, sometimes as physiologic in the sense of, we expect fatigue. We can't have an adequate sleep jet lag in pregnancy. If there's excessive competition and overreaching and we're going to find this term in a minute, and even nutritional deficiency, as opposed to pathologic fatigue, where now I have some infectious problem where they have a metabolic condition, or some other conditions that is part of the differential diagnosis that it's really up to us to try and sort through. Is it really that they're over trained or over, over reached, or is there something more serious going on. The athletes, when they and their coaches when they design their schedules, they design periods of increased stress and decreased stress, such that they can manage this recovery process and hopefully prevent these over training stresses and and loss in performance associated with it. So what is functional overreaching is a term we use for athletes will have a lot of the symptoms of overreaching. They usually follows a an acute phase of increased training intensity and duration, where they have a clearly have a deterioration in performance, whether it's a self assessment or some time trial or other assessment tool. They may feel fatigued. But the important thing about functional overreaching is that it resolves rather quickly if they if they rest or change the level of their intensity. Non functional overreaching is a term that's used for this, this junction between when they're really over trained, and if they're just functionally overreached and really it's similar type decreases in performance. But the recovery may take up to a month to six weeks, and yet they do recovery recover in a relatively short period of time. So over training being, again, this maladaptive response to training, but the recovery is is much much longer, and in fact can take months to two years to recover. It's oftentimes associated with overuse injuries significant mood disturbances blood chemistry changes that we're going to discuss an immune dysfunction. If you think of the over training model, you know we train to to increase our performance. If we become overreached, we get into this, this period where we have a decrement in in performance. If we adequately respond to this with relative rest we can increase our train our capacity. But if we can't we continue to decline because we haven't adequately respond responded to this the symptoms associated being overreached. So what's a common scenario that we see is someone is overreached. They have a decrease in their performance. They fail to regenerate, and so they get into a panic, and I must not be doing enough, I need to train harder I need to train longer, and they push themselves over the top to where they can't recover. One of the other terms that you'll find in European literature about this is people will define it as under recovery syndrome, or training fatigue but I like this under recovery, implying that a lot of what we're going to talk about as far as treatment and monitoring and such is all about trying to improve and monitor recovery. This is the oldest reference that I found when I first started doing some research in this but this is from the predecessor to the New England Journal of Medicine, back in 1923, and Dr Parmenter described this over training or staleness, way back then, and to be honest, there's not much more to it, it is just what he described 100 years ago in the New England Journal. Research findings, there's no specific diagnostic criteria, although I'll show you some research that is showing more promise in being more specific and making a diagnosis, but many of the studies that you read with it there are very small numbers. It's really hard to establish controls or lab models, and many of the studies are just too short in duration. And then you have confounding influences in the subjects with illness and injuries, menstrual issues, and different training methods and their differences within the athletes, and the ability to be able to generate a consistent model that you can reproduce. It's estimated that as many as 20% of elite athletes at any one time are overtrained and two thirds of elite runners will in some point in their career experience overtraining. Oftentimes we see this in the endurance events and particular swimming, running and cycling as well you see most of the literature about overtraining. There is overtraining in powerlifting and certainly we can see it in other competitive sports. It probably is a little different. And a lot of the focus I'm going to do is more the endurance activities that we're going to talk about with respect to this condition. There may be some predictability, the profile of mood states I'll talk more about it later but it is a tool, a questionnaire that can sometimes identify individuals that are more predisposed to overtraining. There may be some, those athletes who are designing their own training program and scheduling their own competitions, they may be more subject to this than those with a coach who is actually monitoring their progress and their performance. We've seen this in various athletes that we've covered but poor performance during key events like an Olympics or state competition, injuries, illness and then unfortunately premature retirement from the sport. Hypotheses, there are several hypotheses that are out there right now. And I'm going to go through them briefly. And all of these hypotheses they came up over the last 20 years to try and explain some of the clinical findings, as well as some of the biochemical and laboratory findings that we see in these individuals that are overtrained. And I'll just cut to the chase that we're going to end up saying you know the most perceivable theory that really makes sense nowadays, the modern theory is this cytokine hypothesis. Now the branch chain amino acid hypothesis, or the amino acid disbalance theory, the idea is that sustained exercise creates a glycogen deplete state. And that the body, then, will start using branch chain amino acids as a fuel. And this branch chain amino acid consumption can change the the ratio of branch chain amino acids and free tryptophan in the brain. And with this there you get increased levels of tryptophan and therefore serotonin in the brain, and at least can lead to central fatigue. The problem is, is that may extend explain central fatigue but it doesn't explain a lot of the physiologic findings we finding in the in the rest of the body. There's an automatic imbalance hypothesis. Where prolonged strenuous exercise leads to increase catecholamines, cortisol, T3 and other stress hormones, and this actually down down down regulates the adrenal receptors. And peripherally, it creates a lower sympathetic resting tone peripherally, and it can also increase brain tryptophan and hence fatigue. The glycogen depletion hypothesis is strictly a nutritional hypothesis. This inadequate energy intake, as well as loss of glycogen supplies can create a release of some of the stress hormones cortisol and such and and decrease the resting testosterone. Many of the findings that we see in these overtrained athlete, and leading to fatigue. The one problem and I found a study and I don't think I cited it here but they actually did this. They looked at the glycogen levels in wrestlers at the towards the end of the wrestling season, and they found a pretty much near complete. All the all the the wrestlers on the on the survey had decreased glycogen levels and that none of them really were overtrained, so it doesn't explain it may cause a little fatigue, but it doesn't explain overtraining. The glutamine hypothesis is trying to focus on how can I explain some of the immune effects that we see associated with overtraining. And so, again, chronic exercise with inadequate recovery creates this glutamine deficiency. And then it creates immunologic open windows for infection that glutamine is the most abundant amino acid in the, in the muscle and plasma. And it's also a fuel for lymphocytes and macrophages and natural killer cells. And so, in a glutamine deficiency, you can see that there can be effects on the immune function. And it's also a fuel for lymphocytes and macrophages and natural killer cells. And so, in a glutamine deficiency, you can see that there can be effects on the immune function. There's a linear relationship has been demonstrated between plasma and glutamine and exercise intensity, such that glutamine will decline as the intensity goes up, and it may take considerable time to recover this. There was one study that was done that showed 50% reduction in resting levels of glutamine in athletes after a 10 day overload training period. The confounding factors with glutamine is it varies in us anyway. And there certainly can be dietary changes to your glutamine levels, as well as infection will decrease your glutamine levels, because of the consumption by the white blood cells. So the most, the theory that makes the most sense and that most people are hanging their hat on nowadays is the cytokine hypothesis. And the hypothesis is that in within the muscles, you have adaptive trauma, microtrauma, part of the training cycle that creates a local inflammatory response. If there's inadequate recovery, this acute inflammatory response can lead to a chronic inflammatory response, with release of systemic immune and inflammatory products that can cause many of the effects. So you see this cartoon here and you can see you have this muscle trauma and you have release of these pro-inflammatory cytokines, in particular interleukin 1 beta, tumor necrosis factor, and interleukin 6. And these are all pro-inflammatory cytokines released by the muscles through the systemic circulation. They will induce a sickness or the fatigue response in the central nervous system. It will inhibit the various hormonal axes in the brain. It affects the liver, as well as your immune cells. And this seems to make the most sense. The biggest, when you see studies about that, you'll see a lot of it is written about either all three of these or at least one of these where they have been affected. And in these overtrained athletes, you see changes in these immune cytokines. This was an old study in military medicine, but they took 26 French soldiers and at first three weeks of intense training. And they had decreased secretory IgA that we see a lot of the overtrained athletes as well as DHEA, prolactin, and testosterone. But they had a significant injury increase in this pro-inflammatory cytokine IL-6. This was in medicine, science, and sports and exercise. Again, they were looking wrestling season and they were looking cytokines and growth factors. And they saw a significant increase in some of these inflammatory cytokines in this group of wrestlers that rebounded after the season. This was another exercise that looked again in medicine, science, and sport, and exercise. It was a while ago, but it showed changes in inflammatory levels with intense exercise, but actually increase in anti-inflammatory interleukin-10 with a balanced exercise program. And then finally, I found this in the occupational therapy literature, but they had a group of people with repetitive hand overuse injuries. And these repetitive hand overuse injuries induced a chronic inflammatory condition manifested by increased in pro-inflammatory cytokines. So how do they present? Well, the most commonly is they can't meet their performance standards. They may note that their recovery is slower. They may have weight loss. They may notice an increased resting heart rate that we'll talk more about. Or they may have some overuse injuries that are repetitive in nature that brings them to your office. Oftentimes, they have some apathy, sleep disorders, and some emotional issues. Diagnostically, unfortunately, there's no specific diagnostic criteria or specific lab parameter where you can diagnose overtraining syndrome. And this is what I've given lectures in the past and written. This has been the feelings for years. The differential diagnosis is broad. And we talked about that pathologic fatigue. And certainly, part of it is up to us to try and screen these patients and identify these metabolic problems and other systemic illnesses that may be the presentation of the fatigue and not that it's just that they're overtrained. This is what I was alluding to as far as diagnostic testing. In the late 1920s, the teens, this Categiani and Cotter, as well as several other colleagues, but a lot of the literature you'll see with Categiani and Cotter, this study, the endocrine and metabolic response to overtraining syndrome, or the EROS study, they produced quite a few papers on overtraining out of this. And this is just one of those that came out in 2020. But they used a combination of clinical markers using some of the, and we'll talk more about the profile of mood states, but changes in these parameters in the profile of mood state, dietary consumption of total protein, total calories, body fat mass, looking at these biochemical markers. And down here, this is the insulin tolerance test to measure the glucoformin, cortisol, ACTH, and prolactin. But they reported that in using these group of tests that they could eliminate the confounding factors and diagnose overtraining 100% of the time. Problem is that most of us don't have access and don't use a lot of these tests in our clinical practices. So our medical evaluation obviously is designed to really ferret out those possible pathologic conditions. So you certainly want to have a good interview, talk about their training program. And I'll give you one example. Whenever I hear from an athlete coming in who said they wanted to run a marathon, but now they're fatigued. And it's not uncommon, especially in less accomplished runners, that they may be wanting to run a marathon and lose weight. And so anytime someone's trying to run and lose weight, that's a big red flag that there probably is some nutritional issue. But certainly with the review of systems, your physical exam, we want to kind of ferret out all these other conditions that oftentimes will exist. Usually lab-wise, I stick to very basic labs, getting a chemistry profile, sed rate, and a blood count, thyroid functions, certainly beta HCG in the women. And based on whatever your history and your review of systems determines, you may consider some other tests to rule out certain conditions. Other things you could consider, again, based on the history, maybe if you have access to the profile of moot state, maybe you want to refer them to a nutritionist because you think there are some nutritional issues. Maybe they need to see a sports psychologist. Maybe you need to do a drug screen because there's too much nightlife. So I really, this comprehensive physical, their dietary evaluation, talk about their diary. And the most important thing, the prescription for me is decreased intensity for two to three weeks. And sometimes just depending on the intensity of the athlete, it may be non-participation in their sport. Sometimes you can get them to comply with decreasing the intensity and duration of their workouts for at least two weeks. When they come back, if they're not improved, then either there is pathologic fatigue or perhaps you've got someone, they have non-functional overreaching or are in fact overtrained. You may consider further testing. Certainly I'm going to prescribe more rest. If they're improved, then they were overreached. They need to look at their training schedule, consider better periodization than training schedule. Perhaps there was some issues with sleep disorder, jet lag or other conditions that may be coexisting that we talked about in that physiologic fatigue. So management, well, the hardest thing for these athletes is that word, is rest. Trying to tell them to slow down and really trying to get out of the stressful situations from their training for a period of time, whether it's two weeks, six weeks, it is the hardest thing to do. Certainly you're going to have to get cooperation from their support, their family, their spouse, their coach for sure. And they can work on counseling. You may consider looking at diet. Again, we talked about the nutritional consult and maybe doing other studies to look for evidence of depression, whether it's primary or secondary to this training fatigue. Some people, there's some belief that branched chain amino acid supplements may help in mitigating energy and fatigue associated with exercise. Certainly it has shown that by supplementing with branched chain amino acids, you can affect this reversal in the tryptophan to branched chain amino acid ratio, specifically tryptophan levels in the brain. You can improve profile and mood scores. However, there's a limit to how much you can tolerate. It's about five to 8% in the oral hydration solutions. Beyond that, you can get some significant GI side effects. Some people have tried glutamine supplementation, but there's been no demonstration of any improvement really in immune modulation. It really is just essentially becomes another fuel, but it's not been shown to be beneficial. More important is trying to prevent this condition. Nutrition and their lifestyle program, the flexible programs, trying to control and monitor this recovery process. Then I want to emphasize this monitoring. With monitoring, it has been shown that the psychiatric indicators, that which you can see on various surveys and such, they'll change before you have changes in performance deficits and certainly before you have changes in the biologic markers. Poor markers for recovery, body mass has not been shown to be beneficial, certainly not serum ferritin levels or the CVC and certainly not CK levels or the various hormones. The resting heart rate has been shown to be a reasonable indicator for inadequate recovery. Remember we talked about that the psychiatric indicators will change sooner than some of these other parameters, so the profile mood state can be beneficial. Certainly, if you are testing cortisol and testosterone, you can monitor the ratio of the cortisol-testosterone ratio and looking for that, but this is not a value unless you have previous baseline tests on these individuals. The same thing with following glutamine. It's been shown that glutamine-glutamine ratio can really monitor for this recovery process, but this is again beneficial in the setting of having baseline tests. Then the heart rate variability at night can be determined and followed as a monitoring tool. Again, it requires some baseline testing and the wearing of the monitor overnight. Resting heart rate is that one monitoring tool that many coaches will use and many runners use and has been shown that oftentimes when there's under-recovery, there is this reversal of the training-related bradycardia that we see often in athletes. A lot of times what people look for is about a 10-beat or 10% increase in the resting heart rate might be an indicator that there's been inadequate recovery from the recent training load. We talked about the profile mood state. This is a 65-question questionnaire, so it's not something that you can administer real quick. It assesses these six scales, five negative scales and one positive, tension and anxiety, anger, hostility, fatigue and inertia, depression and dejection, confusion and bewilderment, and vigor and activity. You can, again, get a baseline, but then you can monitor these as you go through a training cycle. This profile of mood state may be able to predict, as I said in the beginning, those individuals that may be predisposed based on their patterns within this profile of mood state. This was a study that was done in military medicine a while ago, but they looked at the effects of a four-day forced march on gonadotropin and mood state. What they found in this, there wasn't a big change in the biologic markers, but they did see some pattern of change in their profile of mood state, indicating that this could be a reasonable monitoring tool in the absence of changes in hormones that are being monitored. Rescue sport is another questionnaire that's out there. Again, it's still a fair number of questions, but, again, it gives you these various stress scales, and they're beneficial in the setting of, you got to have a baseline test in the non-exercised athlete. I like this total quality recovery, and there's a total quality of recovery, or TQR, action where an athlete would self-assess how adequately did they hydrate, did they sleep and rest, did they relax, and did they stretch and do active rest, and could assign a point scale based on how well they think they did this. And then there is a perceived recovery where they, in using a reverse Borg scale, they assess how well did they recover, and therefore they, in the setting of, I really recovered well, then they can train hard, and if they're not adequately recovered, they shouldn't train as hard. So I, my recommended monitoring tools is certainly exercise diaries, sleep patterns, monitoring the resting heart rate, monitor this, the TQR that we talked about, especially the TQR perceived, and then coaches a lot of times will use time trials, at least in running athletes, as a metric to track performance and identify performance decrements as they start. I think that's it, what I was going to talk about, and I think we were going to open it up to questions. If not, I have a couple of questions to ask the group. Let's go ahead and ask your questions to the group, and then we can talk some more as people come up with questions as we go. Okay, Daniel, do you have those questions? Andy. Yeah, no problem, get them ready to go whenever you're ready. Okay, yeah, let's go ahead, okay, yeah, let's go ahead, let's put up the first one. So hypotheses for overtraining include all of the following, except the glycogen hypothesis, cytokine hypothesis, central fatigue hypothesis, mood distorter hypothesis, and autonomic imbalance. So, people, you can go ahead and click on what you think is the correct answer, and it'll be collected. Okay, is that enough time? So, Dr. Howard, go ahead and give your explanation. So the correct response is the mood disorder hypothesis. We certainly talked about the glycogen hypothesis was a nutritional theory and cytokine, and they are the different theories. The autonomic imbalance was one of the theories that we talked about, as well as the central fatigue hypothesis. But mood disorder, certainly mood disorder is associated with overtraining, but it's not specifically one of the identified hypotheses when we talk about this condition. Effective monitoring tools for overtraining or inadequate recovery include all of the following except CPK levels, resting heart rate, serum glutamine to glutamate ratio, the profile of mood states, and heart rate variability. So most everybody got that. The CPK is really not a reliable monitoring tool. There's lots of fluctuations with that with various conditions as well as exercise. Glutamine to glutamate ratio is a monitoring tool. However, as you recall, it is limited by having baseline testing before going through a training cycle. Profile of mood states is a very, very good monitoring tool. The only difficulty is a 65 questionnaire and a little bit difficult to administer. Heart rate variability is found a lot in the literature is a very good monitoring tool, but does require monitoring equipment and then interpretation of that variability in the overnight tracings. And resting heart rate is widely used by people to monitor this recovery process knowing that an increase in the resting heart rate might be an indicator of inadequate recovery. Dr. Howard, I think that with so many watches coming out that can monitor your heart rate variability that we're gonna see more and more use of that. I think so. And we're probably gonna have to be able to interpret it for athletes more and more. And can we have the last question? Psychologic monitoring tools for overtraining and recovery process include all of the following except. So the profile of mood states, the total quality perceived, MMPI, the recovery stress questionnaire or rescue and the total quality recovery action. And we're just looking for the one that's not really an appropriate monitoring tool. So yeah, and everybody got that pretty much right. Yeah, MMPI is a very comprehensive long test and not appropriate in this setting as a monitoring tool. Certainly the total quality recovery. If you recall, we talked about the total quality perceived and action, action where an athlete self-assesses how much sleep and rest, hydration and emotional recovery that they completed during their recovery period where total quality perceived was that reverse Borg scale where an athlete getting ready to go through a training session self-assesses, I don't feel very recovered from yesterday's training session. I'm gonna work out lighter today as opposed to the individual that says, I feel great, I'm gonna push hard. You know, if you have a team, how can you use that? You know, I think that we do see a lot of individuals that have issues, but they're part of a team and how do you adjust the training for the team? Yeah, and that is much more difficult for the coach. But I think you can find situations where the coach that is applying the same exact training program for every individual sometimes is gonna have some individuals that cannot tolerate that. And if the coach has the capacity to be able to individualize some of the training such that some are pushed harder on some days and others not as hard, you're gonna have a more overall better effort. But team sports where the coaches are trying to push team participation and everybody does the same thing, you're gonna find athletes that are not tolerant of that. I'm also very interested in the hormonal axis of females versus males and looking at how the US women's soccer team did follow their periods and looked at variability of training in relation to whether or not they were at a high estrogen state or a low estrogen state and really changed their training to be more weight building, like doing more weight lifting and more heavy pushing during the first half of their cycle and then more recovery in the second half and how it really did have a positive impact on how the team did and on their injury levels. And I'm hoping that as we move forward, we'll be able to incorporate that into trying to prevent overtraining in the female athletes. Yeah, no, I would agree. And those are great observations that people have made that contribute to the whole, the body of literature as far as what's the most effective way to train. It's not just, let's go practice five days a week. It's, you gotta mix it up and you have to be aware of the physiologic state of the individuals. And even taking it one step further, as I was saying earlier is individualized training programs. And certainly you have the more capacity as you go further up in the hierarchy of athletic participation and you get to the Olympic level and they're not all doing the exact same training schedule because they all have different capacities to respond and recover. I'll give one last example from the literature. So there was a book written, I have a signed copy from, Neil Bascom wrote a book in the early 2000s about Dr. Roger Bannister's accomplishments as he, to break the four minute mile. And at the time that Dr. Bannister, the few months before he was gonna break the four minute mile, he was training hard as he could. He was a resident. He was also doing research in the hospital at that time. He had a very, very busy work schedule in addition to trying to train. And he noticed that he was just felt flat. His legs felt heavy. His times were not improving despite training as hard as he could. And so he and a couple of friends took a week off and went rock climbing. And he came back after this week or 10 day period of rock climbing refreshed. And it was in the next weeks that he pushed forward and he was able to run his perfect mile to break the four minute mile. So it was a perfect example of overreaching in a story that a lot of us know about. And Dr. Howard, I had launched that last poll question. If you can see that there, I think most folks have answered it. So we'll go ahead and share that. Oh, I missed, I just minimized that. Oh, how do I call that up again? I thought I only sent you three questions, my bad. Can you read the question to me? I minimized it. Sure thing, it's examples of pathologic fatigue include all of the following except A, overtraining, B, thyroid dysfunction, C, substance abuse, D, mood disorder, or E, overreaching. Yeah, so if you look at those, we talked about pathologic fatigue was overtraining and these various other conditions. And the one condition there that would not be listed as a pathologic fatigue is the overreaching implying that yes, they're fatigued, but it is something that will recover in a very short period of time. But substance abuse and mood disorders and thyroid dysfunction, all are some of the examples of pathologic fatigue. And certainly what's not listed on there, all the various conditions, cancer, other metabolic disorders that can present in these athletes and you have to consider them in your differential diagnosis Dr. Howard, that was great. I really enjoy listening to you and talking about this. It's something that's definitely near close to my heart, taking care of kids and this whole generation of year round sports and whatnot, we really are trying to balance all the stresses, every day activity, the year round sports and the demands of school and all that. So it's nice to see some of the science and some of the theories behind things to be able to share with families and really encourage them to try and be more variable in their activity level and what they do and sort of teach appropriate recovery and all the different aspects. So I very much appreciate your knowledge and insight in sharing that with all of us today. If no one else has any questions, we can go on and enjoy and get a good night's sleep. Get a good night's sleep. Thank you.

3rd Edition, CASE 35

3rd Edition

Metabolic/Medical Conditions

overtraining

sports medicine

Dr. Tom Howard

functional overreaching

cytokine hypothesis

athlete recovery

training management

psychological support