Module 3 Rehabilitation, Recovery and Restoration. Rehabilitation

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1 Module 3 Rehabilitation, Recovery and Restoration Rehabilitation When dealing with injuries, the roles and responsibilities of strength and conditioning coaches are: playing a key role in communication between the strength and conditioning staff, the athlete, the medical staff, coaching staff and team administrators (athletic director or general manager); working in tandem with the medical staff to create and administer a seamless transition from rehabilitation to reconditioning and finally return to practice; conducting baseline testing of all healthy athletes to establish criteria for returning to practice following an injury; and designing individualized programs for injured athletes who have been cleared by the athletic trainers to participate in limited training before returning to practice. Communication between all members of the sports medicine team is vital to ensure a seamless transition for an injured athlete throughout the entire process of returning to practice. Each member plays a distinct role in ensuring an injured athlete s return to function; although the job of each professional is different, the tasks of each complement those of the other members of the sports medicine staff. Strength and conditioning coaches and athletic trainers must communicate to ensure the diagnosis of an injury and the subsequent indications (a form of treatment required for the rehabilitating athlete) and contraindications (an activity or practice that is inadvisable or prohibited due to the given injury) are properly understood by all members of the sports medicine staff. To make communication as effective and efficient as possible, when rehabilitating an injured athlete, it may be beneficial to develop a set of forms for strength and conditioning coaches and athletic trainers. A strength and conditioning summary form can be used for communication between athletic trainers and strength and conditioning coaches to ensure proper supervision of an injured athlete. A rehabilitation form can be used to specify and relay indications and contraindications between athletic trainers and/or medical staff to the strength and conditioning coaches, as well as communicate what was done under the supervision of the athletic training/medical staff. This will eliminate any duplication when an athlete performs exercises under the supervision of athletic trainers in the training room or strength and conditioning coaches in the weight room. This will also make certain an athlete is performing only exercises that will benefit his or her recovery throughout the entire rehabilitation process. Using these forms will ensure that everything done with an athlete, during the rehabilitation process, is documented for liability reasons and to aid in the development of future rehabilitation protocols for similar injuries. Finally, this will also make certain all members of the sports medicine team are aware of all the exercises an athlete is performing on a daily basis and how an athlete is responding to the prescribed exercises.

2 Members of the medical staff and the strength and conditioning staff also need to be certain they are communicating with an athlete throughout the entire rehabilitation process. Constant communication will keep an athlete engaged and motivated. Communication is also vital to make certain an athlete is not performing contraindicated exercises on their own time. Highly-motivated athletes will be very eager to return to practice and competition as soon as possible and will often attempt to take matters into their own hands. This cannot always be prevented, but keeping an open line of communication will alert the training staff to these behaviors as soon as possible, and hopefully help prevent an athlete from performing activities on their own that may slow the healing process. Return to Practice The goals of communication between the entire staff are to not harm an athlete and help them return to practice as quickly and safely as possible, based on baseline testing. Opinions on what is contraindicated for a rehabilitating athlete can differ among members of the staff and an administrative structure needs to be put into place which will determine who has final say in the event of a difference of opinion. Quantitative and qualitative baseline testing of the athlete before the injury will help set the parameters for when an athlete can return. These baseline measurements will take the guess work out of the criteria for returning to practice and help individualize the parameters for each athlete. Quantitative testing may include, but is not limited to: strength, anaerobic power, anaerobic endurance, aerobic capacity, speed, and agility. Qualitative testing may include, but is not limited to: mobility, stability, balance, coordination, and rhythm. Performing baseline tests is vital when assessing an athlete s readiness to return to practice. An athlete may be cleared by the athletic trainer, as well as be completely pain-free, but there is a question that must be asked; is that athlete physically ready to safely compete in a practice or competition? To eliminate any guess work when assessing an athlete s readiness to return to practice, strength and conditioning coaches should perform baseline testing when an athlete is healthy. Strength and conditioning coaches should then retest the athlete after their symptoms have subsided (and they can safely complete the same test), and then compare the test results. During the retest, if the athlete is unable to perform at the same level prior to the injury, strength and conditioning coaches should continue training the athlete to enhance their physical readiness to compete. The athlete should not be given clearance to return to practice and competition until their retest results are comparable to their baseline tests. This will take the guess work out of clearing an athlete for return to practice and ensures an athlete is physically ready to safely participate in practice and competitions. Exercise Strategies for Each Phase Following an Injury

3 As long as the injured area of an athlete is not compromised, training to maintain power, strength and endurance of the musculoskeletal tissues and the function of the cardiorespiratory system can be implemented while an athlete is rehabilitating. Training to maintain other areas of performance and fitness while an athlete is rehabilitating an injury can decrease the time needed to return to practice. For example, if an athlete is rehabilitating a lower extremity injury, that athlete can continue to train strength, power and endurance with the upper extremities. An athlete can continue to perform their regular upper body lifts, if no contraindicated strain in placed on the lower extremity, which will allow the athlete to maintain upper body strength and power. An athlete could also perform cardiovascular work on an arm ergometer to maintain as much cardiovascular conditioning as possible. By maintaining cardiovascular conditioning during the rehabilitation process, an athlete will be in far better condition when their injury heals than if they would have only completed rehabilitation exercises. Inflammatory phase The inflammatory phase is the body s initial response to an injury and results in an initial decrease in function. Inflammation is necessary to promote proper healing. After tissues are damaged, a locally hypoxic environment leads to tissue death that allows the release of several chemical mediators, including histamine and bradykinin. These substances further increase blood flow and capillary permeability thereby allowing edema. Edema inhibits contractile tissues and can significantly limit an injured athlete s function. The substances present during this phase may stimulate sensory nerve fibers, causing an injured athlete to sense pain that may further contribute to the decrease in function. This phase typically lasts 2 3 days following an acute injury but may last longer with compromised blood supply and more severe structural damage. While the inflammatory phase is critical to tissue healing, if it does not end within a reasonable amount of time, the phases that follow may not occur, thereby delaying the rehabilitation process. The goal for treatment during the inflammatory phase is to prevent disruption of new tissue. A healthy environment for new tissue regeneration and formation is essential for preventing prolonged inflammation and disruption of new blood vessel and collagen production. Athletic trainers provide the majority of passive treatment for an athlete during this phase. It is vital to realize that a quick return to function relies on the health of other body tissues. Therefore, the power, strength, and endurance of the musculoskeletal tissues and the function of the cardiorespiratory system must be maintained. Strength and conditioning coaches should consult with the athletic trainers to determine which types of exercises are indicated and contraindicated for the specific injury. Maximal protection of the injured structures is the primary goal during this phase. Assuming the injured area is not compromised, training to maintain power, strength and endurance of the musculoskeletal tissues and the function of the cardiorespiratory system can be implemented. Repair phase The repair phase beings when the inflammatory phase ends. The repair phase allows for the replacement of tissues that are no longer viable following an injury. In an attempt to improve tissue

4 integrity, tissue identical to the injured tissue is produced, and scar tissue is formed. New capillaries and connective tissue form in the area, and collagen fibers are randomly laid down to serve as the framework upon which the repair takes place. Because the collagen fibers are positioned somewhat haphazardly, the alignment is such that optimal strength of the new tissue is not achieved immediately. Collagen fibers are strongest when they lie longitudinally to the primary line of stress, however many of the new fibers are positioned transversely, which limits their ability to transmit force. This phase of tissue healing begins as early as two days after injury and may last up to two months depending on the severity of the injury. The treatment goal during the repair phase is to prevent excessive muscle atrophy and joint deterioration of the injured area. A precarious balance must be maintained in which disruption of the newly formed collagen fibers is avoided, but low-load stresses are gradually introduced to allow increased collagen synthesis and prevent loss of joint motion. The maintenance of muscular and cardiorespiratory function is essential for the uninjured areas of the body. Strength and conditioning coaches play a vital role in this phase in regard to the selection of appropriate exercises and activities for the injured area as well as the uninjured areas to preserve as high of a conditioning level as possible, minimizing the time needed to return to practice. Exercise strategies to protect the new, relatively weak collagen fibers, include avoiding heavy resistive exercise involving the damaged tissue. Too little activity can also have a detrimental effect on the injured area, as newly formed fibers will not optimally align and may form adhesions, preventing full motion. Possible exercise forms during the repair phase include strengthening of the healthy extremities and areas proximal and distal to the injury, aerobic and anaerobic exercise, and improving strength and neuromuscular control of the involved areas. The following exercises should be used during the repair phase only after consultation with the team physician, athletic trainer, or physical therapist. Isometric exercise may be performed, provided it is pain-free. Submaximal isometric exercise allows an athlete to maintain neuromuscular function and improve strength with movements performed at an intensity low enough that the newly formed collagen fibers are not disrupted. Isometric strengthening is specific to the joint angle, meaning strength gains occur only at the angles used. Therefore, an athlete should perform isometric exercises at multiple angles if indicated. Isotonic exercise, movements with constant external resistance, can also be utilized during the repair phase. The speed at which the movement occurs can be a program design variable. Specifically controlling variables within a controlled environment will allow an athlete to progress to more challenging exercises in the next stage of healing as soon as possible. Specifically, more acute injuries may require slower movement and the later phases of healing may allow for faster, more sport-specific movement. Exercises can be manipulated through alterations in surface stability, vision, and speed to improve neuromuscular control following an injury. Miniature trampolines, balance boards, and stability balls can be used to create unstable surfaces for upper and lower extremity training. An athlete can perform common activities such as

5 squats and push-ups on uneven surfaces. Exercises may also be performed with eyes closed, thus removing visual input to further the challenge. Remodeling phase The remodeling phase is the time when tissue produced during the repair phase is strengthened and aligns with the line of stress placed on it. Production of collagen fibers during the remodeling phase decreases significantly, allowing the newly formed tissue to improve its structure, strength, and function. With increased loading, the collagen fibers of the newly formed scar tissue hypertrophy and align themselves along the lines of stress. The thicker and more optimally aligned collagen fibers become, the stronger they will be, allowing an injured athlete to return to normal training and practice sooner. Although the strength of the collagen fibers improves significantly, the new tissue will likely never be as strong as the original tissue. Tissue remodeling can last two to four months, depending on the severity of the injury. The primary goal during the remodeling phase is to optimize tissue function with progressive tissue loading. Exercise strategies could include improving function by continuing the exercises performed during the repair phase and progressing to more advanced, sport-specific exercises that apply progressive stresses to the healing tissue. It is important to remember that while there may be less pain with activity at this point, injured tissues have not healed completely. The point where pain drops below the pain threshold, but tissue strength is not completely restored, is the time when an athlete is at the highest risk for injury. While an athlete may be pain-free, proper progression of exercise is a necessity to prevent the athlete from doing too much, too soon resulting in another injury. Progressive tissue loading promotes improved collagen fiber alignment and fiber hypertrophy. Ultimately, exercises during the remodeling phase should transition from general exercises to sportspecific, mimicking movements an athlete will perform during practice and competition. Specificity of movement speed is another important program design variable, and movement speed of the exercises being performed in the remodeling phase should be progressed according to the level of tissue healing. Strengthening exercises are velocity-specific, that is, the speed at which an athlete trains is directly related to the speed at which strength increases. Examples of velocity-specific exercise include isokinetic, plyometric, and speed training. Exercise during the remodeling phase should be progressed from open kinetic chain exercises to closed kinetic chain exercises to better emulate the movements during practice and competition. A closed kinetic chain exercise is one in which the terminal joint meets with considerable resistance that prohibits or restrains its free motion; that is, the distal joint segment is stationary. An open kinetic chain exercise uses a combination of successively arranged joints in which the terminal joint is free to move; open kinetic chain exercises allow for greater concentration on an isolated joint or muscle. Lower extremity closed kinetic chain exercises have often been classified as a more functional form of exercise compared with open kinetic chain exercises because most sport-related activities are

6 performed with the feet fixed to the surface. Closed kinetic chain exercises have several advantages, including increased joint stability and functional movement patterns; during sport activity, joints are not typically used in isolation but rather work in concert with the adjacent joints and surrounding musculature. Although closed kinetic chain exercises are often viewed as more functional, most activities involve both closed and open kinetic chain movements (2). In some situations, an open chain exercise may therefore be an equally appropriate choice. The Role of Strength and Conditioning Coaches in Rehabilitation Strength and conditioning coaches must consider both an athlete s subjective response to injury and the physiological mechanisms of tissue healing as both are essential in relation to an athlete s return to optimal performance. While the goal is rapid resumption of activity, it is important to remember that each athlete responds differently to injury and thus progresses uniquely during rehabilitation. During injury rehabilitation, healing tissue must not be overstressed. During tissue healing, controlled therapeutic stress is necessary to optimize collagen matrix formation, but too much stress can damage new structures and significantly slow an athlete s return to practice and competition. It is vital that a load be selected which will neither overload nor under load an athlete s healing tissue. The plane of movement is another necessary consideration during rehabilitation. During the initial healing phases, the plane of movement in which the injury took place should be avoided. An athlete must meet specific objectives to progress from one phase of healing to the next. These objectives depend on range of motion, strength, activity and/or subsequent tests compared to baseline measurements when the athlete was healthy. It is the responsibility of the team physician, athletic trainer, physical therapist, or a combination of these professionals to establish these guidelines. Throughout the entire rehabilitation process, as with any training program, it is vital that strength and conditioning coaches keep the NSCA s Six Principles at the forefront of their design protocols. NSCA s Six Principles 1. Principle of individuality Every athlete is unique, therefore will respond differently to the same training stimulus experienced by another athlete. Some of these differences can be influenced by many characteristics (e.g., biological age, training age, gender, body size and shape, and past injuries). 2. Principle of specificity Training adaptations for an athlete will occur specifically to the muscle groups that are trained, the intensity of the exercise, the metabolic demands of the exercise, and/or specific movements and activities. In an attempt to perfect a specific skill or activity, an athlete must perform that skill or activity with proper body mechanics to have correct technique. 3. Principle of overload

7 In order for an athlete to achieve a certain training adaptation, their body must be gradually stressed by working against a stimulus or load that is greater than what is accustomed. Whether the stimulus comes from added weight in strength training or added difficulty in cardiovascular training, the body will adapt and need further overload to continuously improve. 4. Principle of progression To continually achieve the desired training adaptations for a certain activity or skill, the training stimulus that an athlete is exposed to must gradually and constantly increase. This implies an optimal level and time frame for overload to occur. If overload increases too quickly, poor technique, improper muscle firing patterns and injury may result. If overload progresses too slowly, improvements will be minimal or non-existent. Rest and recovery must also be included in the progression, as training hard all of the time can result in chronic fatigue, a decrease in performance, and eventually injury. 5. Principle of diminishing returns Performance gains are related to the level of training (training age) of each athlete. Athletes that have never participated in a training program before can see huge initial performance gains in their program. On the other hand, athletes that have been lifting for several years will see smaller gains over longer periods of time. As an athlete nears their genetic potential, gains in performance will be much harder to obtain. The key is to continue to show progress in areas of weakness. 6. Principle of reversibility When a training stimulus is taken away from an athlete for an extended period of time, they will not be able to maintain a certain level of performance that he or she is accustomed. Over time, the gains that were achieved from a certain training program will return to the original level. Program Design for Rehabilitation and Reconditioning The area in which strength and conditioning coaches can best contribute to the rehabilitation and reconditioning process is the provision of resistance and aerobic training programs. All training programs, whether resistance or otherwise, should be properly adapted to fit an injured athlete s needs. Although protocols do exist for exercise prescription following injury, many do not incorporate sport-specific program design variables; the same principles used to design resistance and aerobic training programs for uninjured athletes should be applied during rehabilitation and reconditioning. When designing a resistance program for an injured athlete, the demands of the given sport and the contraindications of the injury must be kept in mind. The program must be individualized to effectively return the athlete to normal function, practice, and ultimately, competition. Designing reconditioning programs for an injured athlete necessitates a careful examination of the sport requirements and a thorough understanding of both the healing process and therapeutic exercise.

8 Resistance training Resistance training programs for both the healthy and healing tissue of an injured athlete require the same basic design principles of programs for healthy athletes. According to the specific adaptation to imposed demands principle (SAID), the system will adapt to the demands placed upon it. Therefore, the goal of training (specific adaptation) should dictate the design of the resistance training program. Aerobic and anaerobic training Although research has yet to determine an optimal aerobic training program for use in the rehabilitation setting, an aerobic or anaerobic program should mimic specific sport and metabolic demands. The demands of the sport (aerobic and/or anaerobic) and the contraindications of the injury need to be kept in mind when designing a training program. With these factors in mind, the same principles for healthy athletes can be applied to an injured athlete to allow for an uncomplicated return to practice and competition. A variety of options exist to modify both aerobic and anaerobic training. These include, but are not limited to: an upper body ergometer, deep water running, biking, and elliptical machines. Strategies to maintain cardiorespiratory fitness must be implemented even during the inflammatory phase. Maintaining cardiorespiratory fitness during the rehabilitation process will allow an athlete to return to practice as soon as the injury allows. If cardiovascular fitness is not maintained during the rehabilitation process, the time it takes to return to practice will increase because the athlete will need to spend time regaining lost fitness levels. Recovery plan Recovery is what allows the body to return to a state of performance readiness following the physiological and structural damage that takes place with training and/or competition. Taking the proper time to recover allows the body to adapt to the training stimulus. If the body is not given enough time to recover from, and adapt to, the training stimulus, the body will not be at peak performance leading into the next training session or competition. Recovery is the period that allows the intended adaptations to take place and should receive the same level of attention as training. Anyone can work hard and break themselves down, but a scheduled recovery plan is needed to allow the intended adaptations to take place. Functions or benefits of a proper recovery plan: Eliminate symptoms of extreme fatigue, irritability, disorientation, and improve concentration Allow consistent and improved performance during competition Facilitate the restoration of nutrient and energy stores Allow the achievement of better and more consistent results from training Allow athletes to push themselves to their physical limit during competition and training Decrease the likelihood of illness and injury for athletes by allowing the immune system to operate properly Keep serum cortisol levels low to promote an anabolic environment

9 Properly incorporating recovery into a training program increases in importance as athletes advance in training age. Early in training, athletes realize an improvement in performance with an increase in training volume and intensity. As training age increases, athletes will begin to see diminishing returns from their training and need to have a recovery plan in place to continue to train at a level that will allow adaptations to take place. This increased need for recovery generally takes place between training ages of four to six (18). The need for recovery also becomes more important as the number of competitions an athlete competes in increases. The more an athlete competes, the more their training program will need to be adapted to allow time for recovery. Overtraining and overreaching are unique and should not be viewed in the same light. Overreaching is a positive training adaptation and is a necessary to improve performance, especially in elite-level athletes. Overtraining, on the other hand, is a negative training adaptation which causes a long-term reduction in performance. Overreaching can be properly scheduled into a training program to achieve desirable adaptations, while every effort should be made to avoid overtraining with any athlete at any level. Once an athlete enters a state of overtraining it is a difficult and timely process to reverse the symptoms. The time to recover from the symptoms of overtraining can cost an athlete an entire competitive season in some cases. Overtraining Overtraining is a culmination of several factors that result in a decline in performance and the ability to train. Below is a list of contributing factors to overtraining: Abuse of alcohol and other toxic substances Loss of weight or extreme fluctuations in weight and can be common in sports with weight requirements for competition (e.g., wrestling, boxing, running, gymnastics, weightlifting, bodybuilding) Lifestyle stress Poor nutrition or a diet that does not compliment training goals and intended adaptations Neglect or lack of planned recovery Stagnant workout loads or repetitive programming that targets the same energy system Travel, especially repetitive travel to different time zones that disrupts sleeping and eating patterns Lack of/or poor planning of workouts Having too many competitions, too close together can lead to a cumulative break down of physiological performance Compromised health Rapid increases in intensity Rapid increases in volume Drive to succeed (the same attribute that leads many athletes to success can lead to overtraining without proper guidance)

10 Sequence of training: Overtraining may be more linked to the sequence of work rather than the total training load and volume. For example, if training volume or load is at an appropriate level for a given training cycle, an athlete can still be pushed into a state of overtraining if there are too many consecutive days performed with a heavy training load or volume. If two training cycles have the same overall training load and volume, but one of them has all the high-volume or high-load days pushed together, it can lead to overtraining more quickly than a training cycle that has the same overall training load and volume, but has the high-load or volume days spread out. Prevention of overtraining When an athlete enters a state of overtraining in can cost them a competitive season or in severe cases, even their career. Overtraining is a difficult and timely condition to recover from and every effort should be made to include proper recovery in a training program to prevent overtraining. Recovery should be a central theme of any training program, not an afterthought. Recovery needs to be a proactive part of a well-designed training program. Proactively incorporating proper recovery strategies and tools into a training program, and constantly monitoring signs and symptoms of overtraining, will improve the likelihood of successfully preventing overtraining. Overtraining prevention strategies may differ for athletes depending on the nature of their sport. Athletes who compete in individualized sports can be more susceptible to overtraining. Athletes who compete in endurance sports can also be highly susceptible to overtraining due to the volume of training and competition. Special consideration should be given to recovery for both athletes who compete in individual and endurance sports. For athletes who compete in speed and power sports, intensity, not volume, is often the cause of overtraining. When developing a recovery prevention strategy, strength and conditioning coaches need to consider the individual characteristics of an athlete as well as the demands of the sport. An effective strategy to prevent overtraining is to monitor the status of an athlete. A subjective rating on how an athlete feels can be the most accessible and effective way to assess an athlete s physiological readiness to train. How an athlete feels and their eagerness to train can often be the first warning sign of potential overtraining and will often appear before the physiological symptoms of overtraining. If an athlete waits until the physiological symptoms appear, the athlete may already be in an advanced stage of overtraining. Psychological disturbances appear in athletes who are overtraining before the onset of physiological factors. To minimize the risk of overtraining, strength and conditioning coaches should closely monitor an athlete s training and response to training. Keeping a detailed log of an athlete s training, and how the athlete responds allow coaches to identify early markers of overtraining and implement strategies to prevent it before it becomes a serious problem. Monitoring both training and an athlete s response to that training, ensures and improves recovery as well as improves the overall effectiveness of a training program. Tracking training volume and responses to that volume also allow coaches to monitor and analyze the affects of outside stressors on training sessions and subsequent adaptations. By tracking outside

11 stressors (e.g., family, school, work) and how an athlete s training was affected by those stressors, coaches will be better prepared to adjust a training program accordingly the next time the athlete is in a similar situation. Tracking outside stress levels should be done before a workout is completed, which will be referred to as pre-workout monitoring, to ensure a training day can be altered if there is a need. Pre-workout monitoring can alert coaches to potential training hazards. An athlete who is experiencing a high level of outside stress and rates their energy level very low may not be able to safely complete a heavy or intense workout. In this situation, if a heavy or taxing workout is scheduled, it can be adjusted to decrease the risk of injury during the session and decrease the likelihood the athlete reaches an overtrained state. Tracking training and responses to training allow coaches to gather and analyze data from past sessions to increase the effectiveness of future sessions. This information can be used to determine how much training volume was too much for an athlete, how much was too little, and how the athlete responded to different training stimuli during different phases of the season. By tracking the volume of training and the athlete s response to that volume, coaches can use that data to help determine the appropriate training volume for following seasons. Tracking responses to training volume is often done by the athlete after each workout and will be referred to as post-workout monitoring. Another key benefit to tracking an athlete s response to training is to allow coaches to objectively monitor the effectiveness of the intended level of intensity. If an athlete or team is continuously rating a workout higher or lower than what was intended, the workout needs to be adjusted accordingly. Training is not something coaches do to an athlete; rather, it should be something coaches do with the athlete. This monitoring system will allow strength and conditioning coaches to get honest feedback from their athletes regarding the intensity of a program and adjust the workouts as needed. Individual athletes may also respond to workouts differently and handle some stimuli better or worse than others. Using this information, coaches can individualize the intensity or layout of a program for each athlete. Two athletes may complete the same workout and appear to be working at the same level, however using a rating of perceived exertion may reveal one athlete had to work much harder than the other to complete the same workload. Without properly monitoring the level of perceived exertion for each workout, an athlete who is having to continuously work harder than his or her teammates will be at a higher risk for overtraining. A post-workout monitoring system should be used to ensure each workout achieves the desired effect for each athlete. The athlete training tracker should include both a pre-workout section containing outside stressors (e.g., sleep, stress, diet) as well as a post-workout section for the rating of perceived exertion of the workout. Rating of perceived exertion is an effective way to monitor the difficulty of a training session. It should be quick, and easy to fill out, to save time and ensure an athlete is able to fill it out before and after training each day. The coach training tracker should be as detailed as possible regarding the workout an athlete or team complete. This will allow coaches to breakdown and track

12 individual parameters as needed. The training logs provided are just examples and may need to be altered for a given program. Specifically, the coach training tracker should be much more detailed to include the weight and repetitions an athlete completes for each exercise as well as the total volume of work completed each day. Physiological symptoms of overtraining Persistent joint pain and muscle soreness Decreased appetite and loss of weight Increased susceptibility to colds, fevers, sore throats, and possibly allergic reactions Tenderness, soreness, and swelling of the lymph nodes Profuse sweating with minimal exertion Increased heart rate during rest, submaximal exercise, and recovery Increased O 2 consumption during submaximal exercise Reduced maximal exercise capacity Restless and/or interrupted sleep without cause, as well as waking up tired after a quality night of sleep Swelling of lymph glands Increased susceptibility to bacterial infections Blood measures: Increase in lymphocytes and eosinophils Performance symptoms of overtraining Prolonged recovery after training sessions and/or competition Reduced tolerance of training load and inability to complete workouts previously completed Decreased muscular strength Loss of coordination, decreased technical skills, and technique Shortness of breath during warm-up and the feeling that the warm-up is a workout A gradual decline in performance from one competition to the next and/or a reduced performance compared to the same time in previous seasons Psychological symptoms of overtraining Lethargy outside of workouts and competition Changes in mood and irritability toward people and situations that do not normally bother the athlete Decreased ability to concentrate Decreased self-esteem Fear of competition Biochemical symptoms of overtraining Reduced muscle glycogen concentration

13 Elevated serum cortisol Decreased serum ferritin Mineral depletion Menstrual dysfunction (oligomenorrhea, amenorrhea) Decreased bone mineral density Risk factors for overtraining Perfectionist/obsessive-compulsive personality Excessive level of motivation A training approach of more is better regardless of competition results Resistant to taking time off Sport specialization at an early age Eating disorders Competitive schedule designed to chase points or money High stress lifestyle Endurance sports Growth spurts in adolescent athletes Excessive training in response to a poor performance Training alone, with no coaching interaction and objective monitoring Training with athletes far above their skill level Change in training environment (e.g., altitude, heat, humidity) Treatment The treatment required for overtraining will depend on the level of overtraining. Complete rest may be required depending on the level of overtraining, but athletes who are accustomed to high levels of activity may fare better with mild, active rest. Active rest should differ from normal training activities and should be scheduled and monitored by coaches. Active rest should be carefully designed to provide just enough stimuli for normal appetite and sleep. If active recovery sessions are left unmonitored, highly motivated athletes will often push themselves too hard and exacerbate the problem. In severe cases of overtraining, medical intervention may be necessary, especially in cases where an athlete is iron deficient, has mononucleosis, or suffers from rhabdomyolysis. Along with altering the physical activity level of an athlete, nutritional and psychological intervention may be necessary. For an athlete with decreased glycogen levels, nutritional therapy consisting of increased levels of carbohydrate and/or protein may be needed depending on the level of overtraining. Psychological counseling may be necessary an athlete who has an addictive and obsessive personality and/or training pattern which contributed to their overtrained state. Once an athlete reaches a state of overtraining, in all likelihood, that competitive season is lost. If slight overtraining is caught very early, there is a chance a portion of the season can still be salvaged, but only if the athlete responds positively to the recovery plan and all signs and symptoms subside. Due to the severity of

14 overtraining and the potential for decreased performance and/or lost seasons, every effort should be made to ensure athletes have scheduled recovery in their program to prevent overtraining altogether, rather than focusing on treatment once overtraining occurs. Rhabdomyolysis Rhabdomyolysis is the breakdown of muscle fibers to the point where muscle membranes rupture and fail to contain their cellular contents, resulting in the release of muscle fiber contents (i.e., myoglobin) into the bloodstream. Muscle fiber contents released into the blood stream can be harmful to the kidneys, lead to kidney damage and, in severe cases, be life threatening (21). Exertional rhabdomyolysis Exertional rhabdomyolysis is a serious form of muscle damage and subsequent breakdown that is brought on by overly intense exercise. Without proper treatment, exertional rhabdomyolysis can result in kidney failure and hospitalization is often needed to prevent kidney failure and other serious side effects. If left untreated, rhabdomyolysis can be fatal (20). Exertional rhabdomyolysis can occur in otherwise healthy individuals when exercise is taken too far (1). While the risk of rhabdomyolysis is higher when dehydration is present, healthy individuals can suffer from exertional rhabdomyolysis in the absence of dehydration (39). While rhabdomyolysis has been documented in the presence of dehydration and extreme heat, neither of these are necessary for rhabdomyolysis to occur if an exercise protocol is too intense. Exertional rhabdomyolysis can occur in anyone from novice exercisers to elite-level athletes when high levels of overexertion take place during exercise (49). Exertional rhabdomyolysis can occur in young healthy adolescents as well. In a physical education class, a 12 year-old boy was required to do over 250 jump squats as punishment for talking during class. The boy was hospitalized the next day with exertional rhabdomyolysis (8). It is vital that strength and conditioning coaches are aware of the dangers of exertional rhabdomyolysis as well as the signs and symptoms. Rhabdomyolysis symptoms Dizziness Muscle pain and stiffness Dark colored, reddish-brown urine Increased serum creatine kinase levels Muscle weakness General fatigue Other factors that contribute to rhabdomyolysis Viral infections Alcohol

15 Drug use Recovery Recovery is a combination of planned actions, using various techniques and tools, which aid an athlete s return to physiological readiness following training and/or competition. A well-designed training program should be built around a proper recovery plan to allow time to repair the physiological damage done by training and competition. The goal of each training session is to provide athletes with the appropriate stimuli to elicit the targeted adaptations and ensure they are physiologically ready for the next training session or competition. Recovery is often overlooked in the early stages of training. Recovery should be implemented from the very beginning of training to teach athletes how to recover properly and ensure overtraining does not become a problem. A recovery plan can include everything from active and passive rest, to various techniques and tools. The following topics should be areas of focus during a recovery plan. Active rest Active rest is time off from training with light physical activity that does not stress the nervous system. Active rest should be vastly different from training and competition and be well-designed and monitored by strength and conditioning coaches to ensure an athlete does not push too hard during training. Active rest allows the muscles to perform light work to maintain eating and sleeping patterns, while the nervous system rests. Passive rest Passive rest is time off from training with no physical activity outside of activities of daily living. While complete rest may be necessary in some occasions, complete rest can be a negative shock to the body because an athlete is accustomed to a certain level of activity. An athlete who is accustomed to a high level of activity will often return from a day of complete rest flat, rather than restored. Extended periods of complete rest can interfere with appetite, sleep, and general mood state, making the return to training and competition a difficult transition. Restore glycogen levels The primary nutritional goal of recovery is to restore glycogen levels that were depleted during training and/or competition. The aim of glycogen replenishment is to restore glycogen to preexercise levels. One of the keys to restoring glycogen to pre-exercise levels is proper post-exercise nutrition. Restoring glycogen levels is a key to recovery, due to the fact that low glycogen levels result in fatigue, dizziness, light-headedness, sleeplessness, and muscle soreness. To ensure an athlete is physically ready for the next training session or competition, special attention needs to be paid to restoring glycogen to pre-exercise levels. Minimize the breakdown of muscle

16 Excessive muscle breakdown is rarely the result of one workout; rather it is a cumulative process of several hard training sessions or demanding competitions. These workouts or competitions result in a catabolic state in the body which leads to tissue breakdown. To reverse this process, the body must have a chance to return to an anabolic state to halt the breakdown of tissue. A combination of active rest, passive rest, and various recovery techniques and tools discussed later can help return the body to an anabolic state to prevent muscle breakdown. Restore depleted electrolytes The restoration of depleted electrolyte levels is an ongoing process that should be addressed during and after training and competition to return electrolyte levels to pre-exercise levels. By focusing on electrolyte replacement during training and competition, an athlete can decrease the level of depletion during those events and shorten the time needed to restore electrolytes to pre-exercise levels. Hydration and rehydration Proper hydration levels stabilize blood volume and help prevent cramping and muscle pulls during training and competition. Rehydration needs to be addressed during and after training and competition. Offset the effects of free radicals During exercise, free radicals are created by the production of energy. Free radicals can damage and break down healthy cells. Certain antioxidant nutrients (e.g., vitamin C, vitamin E, and β-carotene) and minerals (e.g., selenium, zinc) inhibit the production of free radicals. Reduce inflammation Inflammation is a natural mechanism following exercise, triggered by microscopic tears in the muscle that stimulate healing and blood flow to the damaged tissue. This is a necessary process, but efforts should be taken to reduce excess inflammation that may inhibit movement during a subsequent training session or competition. Reduce muscle soreness Delayed onset muscle soreness (DOMS) is characterized by the athlete getting progressively sorer the second and third day following training. DOMS is most prevalent following intense resistance training, especially intense resistance training involving eccentric movements. Soreness is a result of the micro trauma that takes place during training. While this is a natural result of training, efforts should be made to prevent excessive soreness that will hinder future training or competition. Boost the immune system High-intensity and/or high-volume training over long periods of time severely stress the immune system. It is imperative to plan recovery to give the immune system adequate time to recover and diminish the risk of illness.

17 Acquire adequate sleep Sleep is a vital part of a recovery plan because this is when adaptations to training occur. Chronic sleep deprivation can lead to subtle changes in hormone levels (particularly those related to stress), decreased muscle recovery and increase mood swings. Sleep deprivation also leads to decreased glycogen synthesis, increased cortisol levels, and decreased activity of human growth hormone. It is generally recommended that an athlete get at least 8 hr of sleep, but more may be necessary depending on the level of training. Post-Exercise Nutrition Post-exercise nutrition is a vital component of recovery because muscles are the most receptive to producing new glycogen within the first few hours following exercise. During this glycogen reproduction window, cells are the most sensitive to insulin, which promotes glycogen synthesis in cells. The rate in which glycogen replacement takes place has been directly linked to the rate of recovery following exercise (59). To maximize the recovery benefits of this glycogen replenishment window, a combination of carbohydrates and protein should be consumed within the first 45 min following exercise. A combination of carbohydrates and protein, in a ratio between 3:1 and 4:1 respectively, has shown to maximize the insulin spike and subsequent glycogen reproduction following exercise (27). The elevated levels of insulin and glycogen replenishment associated with a combination of carbohydrates and protein are greater than with carbohydrates or protein alone (7). This combination has also shown to reduce muscle damage and soreness following resistance exercise (4). The accumulation of these factors creates a favorable anabolic environment immediately following resistance training (53). This favorable anabolic environment helps counter the catabolic effects of cortisol to further aid recovery. As stated previously, proper post-exercise nutrition is a key factor in recovery, and a plan needs to be in place to ensure athletes get the nutrition they need. There are a variety of ways to accomplish this; the important thing is to make certain athletes have easy access to post-exercise workout meals, or nutrition shakes, within 45 min of the conclusion of a workout or competition, to maximize glycogen replenishment. The number of calories consumed by each athlete will depend on the body composition goals of the athlete, but the carbohydrate-to-protein ratio should be between 3:1 and 4:1. This can be done with customized menus athletes can select meals from, or if they have access to a training table, nutrition shakes they can drink immediately following a workout. Nutrition shakes can be purchased ready-to-drink or mixed by the strength and conditioning staff to ensure the proper carbohydrate-to-protein ratio. Regardless of whether it is done through a training table, pre-planned meals or supplement shakes, the most important thing is to ensure athletes take in an appropriate number of calories with the proper carbohydrate-to-protein ratio. Nutrition During Exercise

18 The benefits of nutrition during exercise vary depending on the type of physical activity being performed. During aerobic endurance exercise, a mixture of carbohydrates plus a moderate amount of protein can improve aerobic endurance at exercise intensities near the ventilatory threshold (15). A mixture of carbohydrates and protein has been shown to enhance aerobic endurance more than a traditional 6% carbohydrate supplement with higher calories (15). For aerobic endurance training and competition, a combination of carbohydrates and protein should be used to enhance endurance. The benefits of carbohydrate supplementation during resistance training depend upon the timing of the exercises and when the supplement is taken. Carbohydrate supplementation has shown no effect on rating of perceived exertion during resistance training (54). Carbohydrate supplementation has also shown no enhancement of the performance of squats, performed with 85% of a 1-repetition maximum (1RM), to volitional failure (29). While carbohydrate supplementation has shown no effect on resistance training within a given set or training session, carbohydrate supplementation has shown benefits on subsequent training sessions. Carbohydrate supplementation of 0.3 g/kg enhances the performance of multiple sets of resistance exercises performed to exhaustion during the second workout of the day (22). Carbohydrate supplementation has shown little to no effect on resistance training within a given set or training session, but does enhance the performance of resistance training if multiple workouts are being performed in the same day. The implementation of nutrition or supplementation during exercise will depend on the type of exercise being performed. For aerobic endurance training, a combination of carbohydrates and protein should be used during training and competition to increase endurance. This can be accomplished through a number of commercially available sports drinks (ones that include protein and carbohydrates) or through a mix made by the strength and conditioning staff from powders or other combinations. These drinks should be made readily available to athletes during both competition and training. This same approach can be used for a wide variety of sports practices. For example, during a college basketball practice or competition, commercial sports drinks or pre-made drink mixes should be made available during breaks in practice or timeouts during competition to improve players endurance. For resistance training, no supplementation is needed during a workout to enhance performance. If two workouts are performed on the same day, carbohydrate supplementation should be given to athletes between workouts to increase performance during the second workout. This can be done in a variety of ways from commercial sports drinks and pre-made drink mixes to any number of food items. Glycogen Loading Glycogen loading is the process of increasing caloric intake in the days leading up to a competition in an effort to increase glycogen stores. Glucose from glycogen is used at an extremely rapid rate during anaerobic performance and can often be the limiting factor in performance. Glycogen availability is one of the key performance limiting factors during anaerobic exercise and glycogen loading is one technique used to increase the glycogen available for competition.

19 Muscle glycogen stores are used during both training and competition and can often be the limiting factor in performance. While glycogen stores are often only thought of in terms of long-term training or competition, muscle glycogen availability affects performance during both short-term and more prolonged high-intensity intermittent exercise (3). These results suggest that efforts should be made to maximize glycogen stores for athletes who compete in a wide range of sports. A variety of techniques can be used in an effort to maximize glycogen stores. One technique that has shown competition and training benefits is consuming liquid carbohydrates before training and/or competition. Consuming g/kg of liquid carbohydrates, 60 min prior to moderately intense prolonged exercise has shown to improve performance (50). In order to enhance performance during training and/or competition, athletes and coaches should make an effort to maximize glycogen stores as well as glycogen availability. One way to do this is to provide liquid carbohydrate supplements up to 1 hr before training or competition. There are a large number of commercially available sports drinks that are primarily carbohydrate-based. These drinks can be given to athletes to consume 1 hr before competition to enhance carbohydrate oxidation and improve performance. Aspects of Recovery The following topics are all important aspects of the recovery process and should be utilized based on the analysis of each specific case. Hydration Hydration is a key part of recovery as well as performance. Proper hydration levels allow the body to function properly and allow athletes to perform at peak levels. Hydration is a key component of any recovery program as well. Restoring body fluids following an intense competition or training bout is a key part of the total training recovery process and should be given a proper level of attention (36). Even small levels of dehydration, which an athlete may not notice, can negatively affect performance. As small as a 1% loss of body mass, through dehydration, adversely affects strength (46). This loss of strength can be recovered within 2 hr, with proper rehydration. Dehydration also negatively affects power. A 2 3% loss of body mass from dehydration decreases the ability to generate both upper and lower body power (25). These performance decrements brought on by dehydration inhibit an athlete s ability to train and perform at their highest levels and can even lead to injury. A 2% loss of fluid reserves can reduce work capacity during exercise by as much as 10 15% and a 5% fluid loss can result in heat-related injuries. Every effort should be made to prevent dehydration in athletes by properly maintaining hydration levels during training and competition. To monitor hydration levels, athletes can weigh in before practice or competition and then again following practice or competition. A weight loss of 1kg during practice or competition represents 1 L of sweat loss. For every 1 kg of sweat loss during practice or competition, an athlete should consume 1.5 L of liquid (a combination of fluids and electrolytes). It is imperative to consume

20 liquids, especially those containing carbohydrates, during practice or competition to stay hydrated and reduce the level of rehydration needed following training or competition. During post-training or competition, sodium in concentrations of 50 mmol-l -1 or greater, along with some potassium should be included in beverages. The volume of fluid replaced must exceed the amount lost during exercise, because the body is not 100% efficient in retaining the fluid that is consumed (5). In order to prevent significant fluid loss during training or competition, fluids should be given to athletes at every available opportunity. During a practice or training session, water and other rehydration beverages should be readily available, and scheduled drink breaks should be given, especially in hot or humid climates. As little as 100 ml of fluid replacement in intervals of 5 min have shown benefits on heart rate and rate of perceived exertion (41). While this may not be possible during competition, athletes should be given fluids during any possible downtime. With regular substitutions, moderate conditions, and a sound knowledge of correct hydration practice, hydration status can be well-maintained even during consecutive competitions or practices (33). Cool-down A cool-down is the moderate stimulation of the cardiovascular system, following exercise, through mild physical activity. Passive cool-down is a lack of mild physical activity immediately following a training session or competition. Active and passive cool-downs have both proven to be effective, depending on the type of activity being performed. Active and passive cool-downs can be used following competition and training as well as between exercise bouts during training and competition. During training or competition the form of cool-down that should be used will vary depending on the length of the rest period. In competition or training sessions with very short rest periods between bouts (30 s), passive recovery enables better performance and reduces overall fatigue (6). During training or competition bouts with longer rest periods (4 min or longer), active recovery has proven to be the most effective method to reduce lactate levels and increase performance during the following bout (9). Dynamic stretching can also be used as a form of active recovery between longer bouts of activity to enhance performance, and to improve cardiorespiratory and lactate responses during intermittent supramaximal exercise (38). During exercise bouts with shorter rest periods, passive recovery may be the most effective method of recovery, while exercise bouts with longer rest periods may require active rest to aid in the clearance of lactate and assist in subsequent performances. Following exercise or training, active cool-downs have shown superior results when compared with passive cool-downs. Active cool-downs show superior lactate clearance following exercise compared with both passive cool-downs and massage (35). Exercise order can also be used as a form of active cooldown. Performing core stabilization exercises during a recovery period significantly reduces lactate values. The reduction in lactate may be due to removal via increased blood flow or enhanced uptake

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