Overtraining Syndrome: Causes, Diagnosis, and What's Actually Going On

[SPEAKER_01]: There's a word that gets applied to a tired marathon runner, a burned out cross-fitter, and a power lifter who has missed the working set weights for multiple weeks. [SPEAKER_01]: That word is overtrained. [SPEAKER_01]: The assumption embedded in that word is that these three people share the same underlying condition, though this is almost certainly wrong. [SPEAKER_01]: In 2022, researchers conducted the most rigorous systematic review ever performed on overtraining syndrome.

[SPEAKER_01]: They were looking specifically for studies that could objectively document a human being transitioning from healthy training state to an overtraining state under controlled experimental conditions. [SPEAKER_01]: Zero studies met those criteria. [SPEAKER_01]: Now this isn't an argument that something real isn't happening to these athletes.

[SPEAKER_01]: There's substantial observational, retrospective, and case-based evidence that athletes experience something during periods of prolonged excessive training load. [SPEAKER_01]: But what that finally does tell us is that over training syndrome, as a concept, has been built on observation and retrospect. [SPEAKER_01]: Not the kind of controlled experimental evidence we need to confidently explain what it is, how to identify it, or even what to do about it.

[SPEAKER_01]: And as we'll argue today, the problem may not just be that we lack its studies, it may be that the concept itself is pointing in the wrong direction. [SPEAKER_01]: Today, we're going to pull apart what the evidence actually shows, where it ends, and what that means practically for how you train and how you recover. [SPEAKER_01]: I'm Dr. Jordan Vigambam, and this is the Barbo Medicine podcast.

[SPEAKER_01]: and to help me manage today's training load within appropriate recovery resources. [SPEAKER_01]: It's the second most handsome Dr. North American Dr. Austin Brocky, what's going on, man? [SPEAKER_00]: Wait, doing all right, just finish them training. [SPEAKER_00]: This morning myself, despite my best efforts, I still have not yet found a way to do too much, but here we are. [SPEAKER_00]: But you're trying.

[SPEAKER_01]: So, [SPEAKER_01]: Let's start why this is actually a difficult problem to solve, because we were simple, somebody would have done it already. [SPEAKER_01]: And I think it starts with the labeling, like the word overtraining appears in coaching certifications, wearable device dashboards on social media, and also even in clinical sports medicine guidelines. [SPEAKER_01]: And in each of those different contexts, it means something different.

[SPEAKER_01]: So the same word overtraining is doing at least four different jobs at the same time. [SPEAKER_01]: Within a coaching certifications text, it can mean a deliberate, training stimulus, the year supposed to apply to drive a fitness adaptation, just also called overreaching.

[SPEAKER_01]: Or it could also be a dangerous failure state that you're supposed to avoid at all costs, but the same manual, sometimes uses the same word for both, without acknowledging that these are distinctly different things. [SPEAKER_01]: like wearable tech, go watch or something like that. [SPEAKER_01]: It can mean whatever the algorithm that device was trained on, senses that you're, quote, overtrain without having anything to do with the clinical definition.

[SPEAKER_01]: In social media, it means I trained a lot and now I feel bad, which is decidedly vague. [SPEAKER_01]: Yeah. [SPEAKER_01]: And in this sports medicine literature, it refers to a specific diagnosis of exclusion that requires really now things like thyroid dysfunction, anemia, low energy availability, depression, illness, et cetera, where you can apply the label. [SPEAKER_01]: Now, these aren't minor variations of the same concept.

[SPEAKER_01]: They're just different phenomena that imply different sort of management. [SPEAKER_01]: And so if a coach tells an athlete, they are overtrained. [SPEAKER_01]: compared to when a sports medicine physician uses the same word they mean different things. [SPEAKER_01]: And so it's understandable like this confusion around overtrain and not only what it is, but what to do about it, at least four different definitions.

[SPEAKER_01]: And I think this is not a unique problem to sports medicine or exercise science. [SPEAKER_01]: This happens all the time. [SPEAKER_01]: Austin, if you've seen this in medicine where like the same word is used across maybe different to mean different things in [SPEAKER_00]: Yeah, it's hard to think of a ton of examples just off the top of my head, but sometimes like lay person language slips into clinical conversations and that leads to like in precision around things.

[SPEAKER_00]: One that immediately comes to mind now is that the claim or describing somebody is being dehydrated. [SPEAKER_00]: And so if we have any like nephrologists in the audience, they will know what I'm talking about because when you say that somebody is dehydrated. [SPEAKER_00]: from a medical physiologic nephrologist perspective, it means they don't have enough free water in their body, and they should be hyper-natremic.

[SPEAKER_00]: And things like that, whereas if somebody is hyper-volemic, that has a different implication, but people use those words interchangeably, and so they actually have quite different management strategies.

[SPEAKER_00]: And so that in precision leads to confusion when the terms are applied vaguely, although in practice a lot of the time, [SPEAKER_00]: when I hear somebody use the term dehydration, they often, I recognize that they really mean hypovalemia, and I'm like, yeah, I know what you mean. [SPEAKER_00]: But sometimes when I'm feeling a little little spicy, I'll pick on them for it. [SPEAKER_00]: But yeah, it happens in a lot of contexts.

[SPEAKER_01]: You see a lot of time also when they're like the wellness industry, you know, gut health, spine health, brain health, and it's like, all right, what are we talking about, exactly? [SPEAKER_01]: Yeah. [SPEAKER_01]: And so that, you know, there's more of an issue than just the terminology, it's kind of like what the origin story, the villain arc of overtrainings syndrome, how to become a diagnosis in the first place. [SPEAKER_01]: It's kind of just retrospective in nature.

[SPEAKER_01]: The actual science field, [SPEAKER_01]: Sports Medicine field observed a pattern, some individuals after periods of high training loads experienced prolonged performance decrements. [SPEAKER_01]: They also had mood disturbances and hormonal changes sometimes that did not resolve with the reduction in training load. [SPEAKER_01]: And so they called that over training syndrome.

[SPEAKER_01]: And then, and this is the step that matters, they started treating the name as though it identified a specific disease or pathology with a specific mechanism, and then their diagnostic criteria were built around the label, decades of research followed that, studied the label rather than kind of the underlying biology.

[SPEAKER_01]: We should state that, you know, naming something, a pattern is not the same, is identifying a disease, naming a syndrome, is not the same as identifying a disease. [SPEAKER_01]: The athletes or individuals are experiencing something real for sure, but whether those symptoms share a single underlying cause or whether overtraining syndrome is several different problems producing similar presentations, never really been established in the opener.

[SPEAKER_01]: I stated, you know, [SPEAKER_01]: We've been trying to identify, like, how do you cause overtraining syndrome, right? [SPEAKER_01]: And like, how do you take somebody from a, you know, healthy, right, normally training, you know, with the given training load, and then generate overtraining syndrome is never been done.

[SPEAKER_01]: So the concept of overtraining syndrome may be pointing in the wrong direction, which has consequences for how we ultimately kind of diagnose people and manage people, who supposedly have overtraining syndrome.

[SPEAKER_00]: Part of the challenge is how what will get to I'm sure generally like quote unquote non specific the symptoms are here and so when you collect a bunch of non specific symptoms and you put them into a syndrome then yeah you can probably end up with a whole bunch of different ways that you could get there. [SPEAKER_00]: So it's not fundamentally going to be like one thing.

[SPEAKER_00]: Additionally, is it reasonable to think that if you had different athletes in different sports, training in different ways that each of them could have the same overtraining syndrome? [SPEAKER_00]: No, it's all going to be different based on the sport, the training, and the person. [SPEAKER_00]: But again, the non-specifficity of symptoms. [SPEAKER_00]: It leaves the door open for a lot of other possible causes and contributors.

[SPEAKER_00]: And so if all you know is overtraining syndrome, then you're going to miss a lot of other potential causes, contributors, risk factors. [SPEAKER_00]: Things that might be treatable and easily resolved in other ways to a point where maybe the person can ultimately tolerate that level of training. [SPEAKER_00]: And when the training itself wasn't the underlying problem at all.

[SPEAKER_01]: Yeah. [SPEAKER_01]: Yeah, but there's a problem with labeling, you know, somebody with overtraining syndrome, especially if it's used maybe too aggressively, you know, rather than with restraint, you know, people will say you're CNS's fraud, your journals are cooked or fatigued, your nervous system, you know, needs to recover. [SPEAKER_01]: Not only of these phrases, not supported by science.

[SPEAKER_01]: But ultimately, they can produce a negative effect on the individual, hearing them. [SPEAKER_01]: They go from, you know, I have a set of solvable input problems that the training load may be to, I have a broken system that needs protecting, which can produce a fear of training load.

[SPEAKER_01]: Might call somebody to prematurely, d-load or reduce how much exercise they're doing and otherwise attribute normal training induced fatigue to a syndrome that almost certainly doesn't apply. [SPEAKER_01]: And actually it's been a recent systematic review that found that no sebo effects in sport and exercise had approximately twice the magnitude of effect as placebo effects when it came to performance.

[SPEAKER_01]: This is based on 20 studies of varying quality, but the mechanism is not really hard to explain. [SPEAKER_01]: Language about fatigue states and negative sort of outcomes. [SPEAKER_01]: They have physiological consequences. [SPEAKER_01]: The word overtrained if it's applied in precisely is not neutrals, not just a throwaway word.

[SPEAKER_01]: So Austin, can you walk us through the Nocebo mechanism here how you think about it because the claim that a coaching phrase produces a physiological consequence gets dismissed as purely psychological and it isn't what what's actually going on here. [SPEAKER_00]: Yeah, and well, I would say that in the same way that when we talk about the quote unquote placebo effect, it's actually not just referring to a single thing.

[SPEAKER_00]: There are numerous different placebo effects that have been kind of characterized mechanistically. [SPEAKER_00]: If somebody really wants to nerd out on this, there's a book by a well-known Italian guy in this space. [SPEAKER_00]: Ben Adedi, I think his first name is Fabrizio, Fabrizio Ben Adedi's book titled placebo effects. [SPEAKER_00]: where he goes into great detail, characterizing the research that is characterized the different mechanisms of placebo type effects.

[SPEAKER_00]: There are some that proceed by way of like endogenous opioid-related pathways, for example, for placebo mediated pain relief, others through other signaling mechanisms, including some of the interesting stuff, for example, are unlike dopamine signaling, and there's the placebo effect, even in like treating Parkinsonism and things like that, which is all. [SPEAKER_00]: super interesting.

[SPEAKER_00]: And so I would be unsurprised to learn that no sebo different effects proceed by way of various different mechanisms, whether it relates to increasing pain intensity, increasing the experience of anxiety, fear, all sorts of other things that can ultimately play into this. [SPEAKER_00]: But I think the problem here is when people try to silo out psychology as some sort of separate process that is not intimately linked with biology.

[SPEAKER_00]: Ultimately, [SPEAKER_00]: if we wanted to be ultra reductionist, everything is biology one way or another. [SPEAKER_00]: And then, well, then there's going to be the chemists who argue everything's chemistry, and then the physicists who argue everything's physics, and then the mathematicians who argue everything is math. [SPEAKER_00]: I think there was an old comic strip that I remember that made that argument. [SPEAKER_00]: But there is biology underlying all of these things.

[SPEAKER_00]: Psychology is like an emergent property of the underlying biological processes. [SPEAKER_00]: And so I would not say that it is fair to dismiss Nocebo as purely psychological in the same way. [SPEAKER_00]: say it's unfair to dismiss placebo as purely psychological. [SPEAKER_00]: There are interactions between the psychological aspects and underlying neurology, biology, immunology, all sorts of other things. [SPEAKER_00]: There's a whole field dedicated to this branch of study.

[SPEAKER_00]: And so when somebody does receive those sorts of external cues, whether more favorable in the context of placebo or negative in the context of [SPEAKER_00]: changes in attention, as well as changes in kind of underlying biology that can lead to variations in how people might experience the same subsequent event, either more favorably or more negatively.

[SPEAKER_01]: Yeah, imagine if you walk into a gym, you're a cross-fitter, right, and the class in front of you is just getting done. [SPEAKER_01]: And, you know, there's all 25 people who took the previous class are on the ground, panting, writhing, or whatever, maybe they're sitting blood. [SPEAKER_01]: Yeah, exactly right. [SPEAKER_01]: your expectation, your alert system is going to be elevated most likely. [SPEAKER_01]: And so you're going to subsequent experience that work out differently.

[SPEAKER_01]: And so it's all connected. [SPEAKER_01]: You can't reduce it. [SPEAKER_01]: And I think your expectations, your mood stay, how you've been primed in a way to experience what's coming next or what the intervention is. [SPEAKER_01]: Yeah, it all kind of makes sense, and the idea that humans experience a negative sort of effect more prominently than a positive one.

[SPEAKER_01]: I mean, I think it's been some well-established psychiatric research where we tend to identify things that are negative more easily and perhaps that's a [SPEAKER_01]: evolutionary response on some level to like protect us. [SPEAKER_01]: But anyway, it's not. [SPEAKER_01]: It wasn't surprising for me to learn this. [SPEAKER_01]: It was surprising for me to see that this was still well studied in sport because often there's a gap there so that was kind of interesting to me.

[SPEAKER_01]: Yeah. [SPEAKER_01]: All right. [SPEAKER_01]: And the last thing I want to talk about before we get into the labeling or the taxonomy of this over training syndrome is that this is, you know, most importantly a diagnosis of exclusion, because when we label somebody or when somebody is labeled with over training syndrome, that means that effectively no other condition or underlying cause has been identified.

[SPEAKER_01]: You think about the [SPEAKER_01]: prevalence of anemia, of hypothyroidism or thyroid disorders, of low energy availability, not only in sport, but also just in the general population. [SPEAKER_01]: And their presentations are very similar to overtraining syndrome, but they're far more likely to have happened than overtraining syndrome.

[SPEAKER_01]: And so if you just label somebody, you have overtraining syndrome, we got to reduce your [SPEAKER_01]: and fail to account for any of these other possibilities, that delays diagnosis, which could be a problem here. [SPEAKER_01]: And again, I just think about, what is the prevalence of anemia?

[SPEAKER_01]: Just in the general population, it's like, okay, you know, when you hear hoof beats, think Horses and Adzebras, to me, over training syndrome is like a definitive zebra, here, even in, you know, people who train a lot, [SPEAKER_01]: uh compared to just these run in the middle, I've, you know, and I'm not dismiss somebody's an experience, but these more common sort of medical conditions. [SPEAKER_01]: Is that ring true to you? [SPEAKER_01]: Is that seem right?

[SPEAKER_00]: Yes, and it also gives me an opportunity to step back onto a familiar soap box, but ultimately what you're describing is that [SPEAKER_00]: These non-specific symptoms are common for a variety of reasons, just because somebody trains, and even if they train what seems to be a fair amount, does not automatically mean that their non-collection of non-specific symptoms that we call a syndrome is being driven by the training.

[SPEAKER_00]: Now, the training itself might be poorly matched to the person for a variety of reasons. [SPEAKER_00]: And so if that is the basis on which you are concluding that they are overtraining, that's a little bit of an odd way to frame it, but I kind of see how you get there. [SPEAKER_00]: It's just that more so that this is not a good fit for them at this moment in time because of the other variable that has yet to be identified.

[SPEAKER_00]: And a common common example is going to be what you mentioned with iron deficiency. [SPEAKER_00]: The prevalence of iron deficiency in like reproductive age women in the United States, [SPEAKER_00]: have iron deficiency. [SPEAKER_00]: Now, prevalence is impacted by where you set your cut-offs on lab testing, and I have, you know, rented about this at length in public and with individual patients.

[SPEAKER_00]: When you measure a ferritin level and the reference range is like the lower limit of normal's 15, that is an incorrect lower limit of normal, and it should be at least 30 in my opinion, closer to 50 would be the appropriate lower limit of normal. [SPEAKER_00]: So depending on where you set your target, [SPEAKER_00]: that'll define the prevalence, but almost half of women in that demographic are higher deficient.

[SPEAKER_00]: And so if they train and they say, I'm tired, and you conclude they're over trained, it's like, well, if I just got there fair to an up to 75, and they tolerate training just fine, were they over trained or was it just a poor fit for their higher deficient state? [SPEAKER_00]: And so what's the, you know, what's the, is this purely semantics or is there something more meaningful underlying? [SPEAKER_00]: And I think that's what we're getting at here.

[SPEAKER_01]: Yeah, maybe we'll keep returning to this sort of mystery symptom or mystery cause hidden cause. [SPEAKER_01]: Come back to that. [SPEAKER_01]: But before we get into the science of overtraining, we need to get the vocabulary right, because a single word is being used to describe at least three distinct states and without that information in place, everything that follows is ambiguous.

[SPEAKER_01]: So let's start with the definitions. [SPEAKER_01]: First up is functional overreaching. [SPEAKER_01]: This is defined as short-term performance decreased that resolves in days to approximately two weeks. [SPEAKER_01]: After which performance returns to or exceeds baseline, this is, quote, super compensation, working as design people get fitness adaptations from their training.

[SPEAKER_01]: What most people listen to as podcasts have experienced, when they've done workouts and gotten stronger, improve their cardiovascular fitness, increase muscle size, et cetera. [SPEAKER_01]: Non-functional overreaching is when the decrease in performance extends for weeks to months. [SPEAKER_01]: The super compensation effect is lost effectively. [SPEAKER_01]: No fitness adaptation is realized. [SPEAKER_01]: Moode disturbances and measurable neuroendocrine changes are also present.

[SPEAKER_01]: Some of the time. [SPEAKER_01]: Recovery is expected, but the timeline is challenging to predict in advance. [SPEAKER_01]: It's defined retrospectively by how long resolution takes and now when we get into this sort of definition, it seems to be more squishy than the functional overreaching one, and it gets worse from here.

[SPEAKER_01]: Because overtraining syndrome is when the decrement and performance [SPEAKER_01]: Sometimes there are significant hormonal abnormalities that are observed, sometimes you also see psychological conditions that happen alongside of this, and by definition, in the consensus statement on these definitions themselves. [SPEAKER_01]: It is a diagnosis of exclusion. [SPEAKER_01]: You can only arrive to it after systematically ruling out everything else that produces the same presentation.

[SPEAKER_01]: And in fact, voting directly here, one of the guidelines related articles says, you can only differentiate between non-functional overreaching and overtraining syndrome, only after a period of complete rest. [SPEAKER_01]: So at the moment, an athlete presents with fatigue and declining performance. [SPEAKER_01]: You can't determine if they are non-functional overreaching, right then or if they're overtrained, they just have to rest.

[SPEAKER_01]: And then you got to monitor them, which Austin's already shaken is [SPEAKER_01]: It's a great question. [SPEAKER_01]: What is the point of all this? [SPEAKER_01]: Now, if you want to name it, if you think that helps your management or at least how you think about it, that's one thing. [SPEAKER_01]: And maybe a very in the lead here. [SPEAKER_01]: I don't think this is helpful. [SPEAKER_01]: But there's another problem here.

[SPEAKER_01]: After any sufficiently hard workout, force production performance is measureably reduced. [SPEAKER_01]: Using the strict functional overreaching definition every athlete is technically functionally overreaching until they recover.

[SPEAKER_01]: The boundaries between these categories are squishy, again, and the retrospective labels assign based on recovery duration, which is itself a function of training history, nutrition, sleep, life stress, genetics, et cetera, and measurement timing, all of that contributes here. [SPEAKER_01]: Right? [SPEAKER_01]: What if somebody, you know, their forced production goes down after a workout, they're functionally overreached.

[SPEAKER_01]: And then weeks go by and they never get stronger. [SPEAKER_01]: And it turns out you're non-functionally overreached. [SPEAKER_01]: We didn't know, how does that affect your your management here? [SPEAKER_00]: It kind of treats you know, whether they just, you know, weren't training in an intelligent way that led to the adaptations that you were looking for.

[SPEAKER_00]: Like this, there's this distinction of like where you're training appropriately for the goal that we had in mind, you know, exactly. [SPEAKER_01]: So this taxonomy that we just described is built on a model of training adaptation that we should probably examine directly because the model has a flaw that explains most of the confusion in my opinion.

[SPEAKER_01]: This is this stress recovery adaptation model, and I'd like you to walk us through this, at least the start of it, because all starts with this Han cell ways, general stress physiology work from the 1950s. [SPEAKER_01]: How do you use that or apply that with your own programming logic? [SPEAKER_01]: Like when you're either designing a training program or assessing your own response, do you use stress recovery adaptation and maybe define it for the audience at home?

[SPEAKER_00]: I've not, this is, this is a topic, it's been some years, I think, since we've, you know, launched some, launched some attacks at this, and so I think we're overdue to come back to it. [SPEAKER_00]: It is a model based on his original research that I believe originated in rats just to be clear, not on like human subjects who were performing training. [SPEAKER_00]: And so it is a, I would say a pretty distant extrapolation from that.

[SPEAKER_00]: And as we like to say, it's one of those models or those explanations that make sense if you don't think about it, at least too hard. [SPEAKER_00]: And but it does lead to a set of nice neat tidy, you know, downstream implications and conclusions that that feel right and leads to nice simplistic ways to arrange training and things like that that.

[SPEAKER_00]: at least in the early stages of somebody's training career might seem to be working out as you would predict, but tend to break down relatively quickly beyond that. [SPEAKER_00]: So the core logic of this paradigm will call it is that you initially apply some form of a physiologic or a quality psychophysiologic stressor to the organism, this disrupts the organism from homeostasis, and then you recover from that stimulus and in the course of recovery, you have

[SPEAKER_00]: We'll say built up additional defenses and resilience and ability to tolerate that same stressor in the future and that adaptation leads you to end up kind of above the starting point and that's where that term of quote unquote super compensation kind of came from.

[SPEAKER_00]: And so when this paradigm is applied to training and to programming, it really suggests it as a neat linear punctuated and very predictable process, where there's this discrete stressor, this dip when you are stressed and thereby recovering, and then when you return to baseline and then when you kind of compound your adaptations above the baseline.

[SPEAKER_00]: And then you have to time the next dresser perfectly during that subsequent kind of super compensated phase so that you can repeat it. [SPEAKER_00]: And then you just kind of oscillate back and forth with a gradual trend upwards over time.

[SPEAKER_00]: So yeah, when somebody enters the gym for the first time and they do a workout and then they're like, oh, I came back a couple of days later and I could [SPEAKER_00]: confirmatory experience of this model for them, and it leads it to be pretty compelling. [SPEAKER_00]: Again, if you train long enough, then it requires increasing mental gymnastics to keep that model as the central paradigm of your training approach. [SPEAKER_01]: How does that sound to you?

[SPEAKER_01]: Yeah, it sounds to me it's kind of like you're describing this like, you know, process is a one clean wave, you know, where where it happens as predictable manner, you got to catch the wave at the right time and if you miss it, well now you're you missed out on games from from exercise right. [SPEAKER_01]: What's really happening though under the hood is that the body's running multiple systems simultaneously on completely different timescales.

[SPEAKER_01]: So for example, neural adaptations, with respect to how quickly and how robust the electric signal is to the muscles. [SPEAKER_01]: Those adaptations take days to weeks. [SPEAKER_01]: hypertrophy, you know, takes weeks to months, connective tissue, remodeling, and adaptation takes months to even longer than that. [SPEAKER_01]: And they don't synchronize into a single wave that crests at a predictable moment after each session.

[SPEAKER_01]: The model describes this sort of idealized single system response that gets applied to, you know, multi system, multiple things going on at one time in the human body.

[SPEAKER_01]: The second problem here is this window of opportunity at the peak of [SPEAKER_01]: So, if there was an optimal moment to apply the next training stimulus, the next stressor, the window after recovery where the system is briefly about baseline, then missing that window means missing the adaptation, which produces weird programming decisions. [SPEAKER_01]: Like, am I recovered enough? [SPEAKER_01]: Did I time this right? [SPEAKER_01]: Am I over-training or under-trained?

[SPEAKER_01]: But none of this has evidentiary support. [SPEAKER_01]: The window doesn't work the way the model implies for most real training scenarios. [SPEAKER_01]: And I think this all breaks down to this recovery versus adaptation sort of issue. [SPEAKER_01]: The model obscures why functional over-efficient non-functional over-efficient look identical at presentation. [SPEAKER_01]: Recovery from a session means return to baseline performance capacity.

[SPEAKER_01]: Adaptation means improvement above it. [SPEAKER_01]: These are different things on different timescales driven by different processes. [SPEAKER_01]: Not completely different. [SPEAKER_01]: There's some overlap. [SPEAKER_01]: The Venn diagram does overlap in the middle, but they're not identical. [SPEAKER_01]: and conflating them as what makes this taxonomy, you know, feel meaningful and when it's not in reality.

[SPEAKER_01]: At the moment, an athlete or lifter presents with fatigue and declining performance. [SPEAKER_01]: You can't distinguish between someone who's in the trough, you know, of their recovery, right? [SPEAKER_01]: And an athlete who's lost the ability to respond to exercise entirely, could be the same point, but different trajectories, same presentation. [SPEAKER_01]: That taxonomy only resolves post-talk, you know, and retrospect.

[SPEAKER_01]: Now after the outcome is known, we think that, you know, instead of trying to time this peak, you instead would add load once that peak has already occurred, right? [SPEAKER_01]: You add weight because you got stronger, not to get stronger. [SPEAKER_01]: Fitness accrues continuously when the inputs are adequate, things like sleep, nutrition, training load, life stress, recovery capacity.

[SPEAKER_01]: The question is never whether you timed the next session to hit the super compensatory peak, the question is whether the inputs were adequate over time. [SPEAKER_01]: When they are, adaptation happens and when they're not, it doesn't.

[SPEAKER_01]: The consequence of the model being too literally applied, in my opinion, is that coaches and athletes again make weird decisions based on a mental model of fitness that does not reflect how adaptation actually works in response to exercise. [SPEAKER_01]: And it's weird to me that it kind of fails in two different directions at the same time. [SPEAKER_01]: On the one end.

[SPEAKER_01]: trying to add weight to the bar every single time you go on the gym, whether the adaptation is actually occurred. [SPEAKER_01]: You're trying to hit this imaginary super compensatory window before it at closes. [SPEAKER_01]: On the other hand, you reduce volume when progress stalls, on the assumption that a failure to improve means that you're overtrained, you're doing too much and you need more recovery times. [SPEAKER_01]: You train less.

[SPEAKER_01]: The irony is that both errors can coexist in the same program. [SPEAKER_01]: Intensity stays high because the model implies that this adaptation or super-compensatory signal requires a maximal stimulus while volume gets cut in the name of recovery. [SPEAKER_01]: So the athlete ends up simultaneously being overloaded by intensity demands and underloaded by the reduction in total training load because volume is cut. [SPEAKER_01]: We could think of it this way.

[SPEAKER_01]: Fitness is less like a wave that you need to catch at just the right time, is more like a bank account. [SPEAKER_01]: Deposits accumulate over time, and what matters is whether the balance of inputs and recovery is positive over weeks and months, not whether you timed a single transaction perfectly. [SPEAKER_01]: Is that makes sense to you? [SPEAKER_00]: I think so.

[SPEAKER_00]: And I think that the longer you train, the more, as I said, mental gymnastics, you have to do to keep the original paradigm in mind. [SPEAKER_00]: And the more apparent it becomes that things are a lot more complex and a lot more variables are dynamic and interacting all the time, especially at the much later stages of our training career where we recognize that like, [SPEAKER_00]: Yeah.

[SPEAKER_00]: It takes a lot of consistent training, a lot of training itself, and we need like a lot of other stars to align for us to be able to put up a PR maybe a couple times a year. [SPEAKER_00]: Like, if we're lucky, and yet it is still possible for us to make progress, but there is like no possible way that we could draw out some sort of like, you know, predictable, you know, a stress rate at a recovery adaptive. [SPEAKER_00]: cycle at this stage in our career.

[SPEAKER_00]: There's just too much mess going on. [SPEAKER_00]: And if you think about it, even at the beginning of someone's training career, even though it might appear to be simpler that somebody is able to progress a little bit more quickly, there are still tons of variables that are going into that process, right? [SPEAKER_00]: And as you said, there are a lot of, you know, collapsing it all down into, quote, adaptation.

[SPEAKER_00]: itself as an oversimplification because of the all the different adaptations that are happening. [SPEAKER_00]: You will have neurological adaptations within during the training session, right? [SPEAKER_00]: Yeah. [SPEAKER_00]: As you develop the skill and maybe you, if you have a coach or you're like refining your technique or something is like self-organizing, you're like literally having neurological skill adaptations while you're doing the lifts.

[SPEAKER_00]: That is like the fastest shortest term, [SPEAKER_00]: Whereas the process to lay down additional muscle cross-sectional area is going to take a substantially longer period of time during that phase. [SPEAKER_00]: But all of these things ultimately are what are contributing to the performance improvements that we observe over whatever time scale we're looking at. [SPEAKER_00]: So it's just way more complicated.

[SPEAKER_00]: And the simplistic elements while appealing for explanatory purposes, because humans we like breaking things down into parts and generating simple explanations for them. [SPEAKER_00]: That's only useful if it leads to, you know, the correct management as a result. [SPEAKER_00]: And the problem here is this simplistic paradigm leads to people making the wrong decisions in their training more often than it leads them to make the right ones.

[SPEAKER_01]: Yeah, most often under training, like not doing enough training, but simultaneously making the training too hard because they think that's the primary signal.

[SPEAKER_01]: Yeah, John Kylie, a friend of the show, he's given us some good feedback on our [SPEAKER_01]: We respect him, published a paper in sports medicine in 2018 called Puritization Theory, confronting an inconvenient truth that makes this argument directly, that the super-compensation model is imported into exercise training without the scientific foundation to support it. [SPEAKER_01]: It's in the show notes. [SPEAKER_01]: You want to take a read?

[SPEAKER_01]: Also, great name and convenient truth. [SPEAKER_01]: Who knew? [SPEAKER_01]: That was interesting. [SPEAKER_01]: With that in mind, this functional overreaching, non-functional overreaching, overtraining syndrome taxonomy was built on top of this model. [SPEAKER_01]: Functional overreaching is defined specifically as the overload that triggers adaptation.

[SPEAKER_01]: But if the stress recovery adaptation cycle doesn't work the way the model assumes, where each workout is the stress, [SPEAKER_01]: recovery happens between sessions and adaptation is the result of that specific stimulus, then the categories built around at our shaker than they appear.

[SPEAKER_01]: In my opinion, a more accurate description would be that every fitness adaptation is the result of the training load that has accrued over weeks and months, which is built on top of years of prior history, if available.

[SPEAKER_01]: There's no discrete cycle that resets after each session, the timescale is continuous and cumulative, and it varies based on the athlete's history, not a [SPEAKER_01]: The clinical taxonomy descriptors are real in that people experience them, but functional overreaching non-functional overreaching and over-trains syndrome are points on a continuum that can only be identified after the fact.

[SPEAKER_01]: Not distinct categories with clear boundaries, you can locate at the time of the presentation so again to your point.

[SPEAKER_01]: does class find somebody is I think it's functional overreaching versus non-functional overreaching versus over training syndrome that change your management if you haven't observed what's happened them after you've done something after you've intervened get to me it doesn't and I think here's an interesting thing that it actually takes us into the next section on resistance training and

[SPEAKER_01]: We kind of miss this, you know, you said neural adaptations happen, you know, while you're doing the workout that can happen. [SPEAKER_01]: Also, you know, days, hours after a session, but connective tissue, tendons, ligaments, joint structures, bones, one of the more slowly adapting systems. [SPEAKER_01]: It's also the tissue that's most likely to fail under accumulated load.

[SPEAKER_01]: This is one of the reasons why injury tends to intervene on overuse injury, for example, tends to pop up before over training syndrome does in resistance training populations. [SPEAKER_01]: This sort of maybe structural limit hits before any other limiter does. [SPEAKER_01]: And it's one of the reasons why the resistance training picture looks a whole lot different from what the endurance literature would predict, which is exactly where we're going.

[SPEAKER_01]: But before we get there, Austin, [SPEAKER_01]: Walk me through like a clinical differential for an athlete presenting with fatigue and the climbing performance in the gym. [SPEAKER_01]: Show us where over training syndrome actually sits on that list in your in your brain. [SPEAKER_00]: Man, you're asking an internist to elaborate a differential diagnosis for you, which means you've got to buckle up. [SPEAKER_00]: This could go wild.

[SPEAKER_00]: No, I'll try to keep it brief, but the differential truly is very, very large for fatigue in general. [SPEAKER_00]: And so obviously the way that I would start to approach the problem is with a much more detailed history. [SPEAKER_00]: specifically focusing on the nature of any more specific symptoms that I can gather and the timeline that the person has been experiencing this on.

[SPEAKER_00]: So if it's been like much more abrupt onset fatigue over the past few hours, days, weeks versus it's been going on for months, if not years. [SPEAKER_00]: And then whether there's any other associated symptoms mainly to help me try to localize a potential problem. [SPEAKER_00]: So somebody with like fatigue.

[SPEAKER_00]: in any sort of thoracic symptom, for example, like chest discomfort or breathing difficulty or something like that might pull me towards a cardiovascular cause or a pulmonary issue or something like that. [SPEAKER_00]: If it's much more generalized, then that makes it again, a harder part of my job.

[SPEAKER_00]: And I might look for more systemic things than something that's very localized to a particular organ that might be going wrong, but looking for anemia and iron deficiency and endocrine opethes. [SPEAKER_00]: hormone disorders because again blood and hormones go everywhere in the body and so it's much harder to localize those types of things.

[SPEAKER_00]: Other metabolic issues like what if the person has new onset type 2 diabetes or type 1 diabetes that hasn't been that hasn't manifested in more obvious ways. [SPEAKER_00]: Things like fatigue up front, I'm also looking for evidence of sleep apnea or just poor sleep hygiene habits, things like that in general, as like probably one of the most common things. [SPEAKER_00]: But I started out with like the quote unquote no missed types of issues.

[SPEAKER_00]: Again, there's like more dangerous cardiopulmonary causes that can lead an athlete to like die. [SPEAKER_00]: But that's much less common in this situation. [SPEAKER_00]: It's just the way that our brains are trained to think. [SPEAKER_00]: And then [SPEAKER_00]: I'd be curious, based on the timing of onset, for example, sometimes I'll see folks who tell me that there's been struggling with fatigue. [SPEAKER_00]: Tell me what did you observe when this first started?

[SPEAKER_00]: Oh, it onset right after I had this like horrible illness. [SPEAKER_00]: Like post viral fatigue syndromes, super common can be persistently debilitating for long periods of time. [SPEAKER_00]: as well as like autoimmune and inflammatory issues and things like that. [SPEAKER_00]: So there's a pretty broad list of I'd say cardiovascular pulmonary, endocrine, metabolic autoimmune, inflammatory, and then kind of more nebulus types of things from there that I would be thinking through.

[SPEAKER_00]: There would be probably some basic lab evaluation that would happen, looking at blood counts, metabolic panels, certain hormones, not all hormones necessarily.

[SPEAKER_00]: It's easy to go way too far down the hormone testing rabbit hole in a very unhelpful way And it can also be a problem because sometimes the same sorts of hormone Things that you might think are causing the syndrome can also be the result of it as well So determine in that causality can be challenging Checking iron panels is something that I do very aggressively if you couldn't tell based on my soapbox earlier Things like that so the differential obviously is massive and I think that most people

[SPEAKER_00]: especially coaches who casually throw around the term overtraining are insufficiently qualified to really try to tease apart and differentiate some of these things and certainly to evaluate for them directly. [SPEAKER_01]: Yeah, no, that's well-stated. [SPEAKER_01]: So with that hierarchy in mind, most of this audience is primarily training with weights and the differential for a strength athlete looks different from what this might apply for an endurance athlete.

[SPEAKER_01]: The evidence on resistance training and over training center specifically is worth going through directly because it changes the picture at least in my mind. [SPEAKER_01]: And I'll be the first to say this. [SPEAKER_01]: I don't think that overtraining syndrome in resistance training has ever been adequately characterized, and not that it hasn't that people haven't tried to do it.

[SPEAKER_01]: Let me go through what the resistance training evidence base on overtraining actually looks like, because it changes the picture significantly compared to what the endurance literature would otherwise imply. [SPEAKER_01]: First, the background. [SPEAKER_01]: In 2020, there was a systematic review that pulled together every study that could be found on overtraining syndrome in resistance exercise.

[SPEAKER_01]: 22 studies total, 10 of them, nearly half, reported zero performance decline under the overload conditions that the researchers deliberately imposed. [SPEAKER_01]: Of the studies that did show a decrement, only eight had followed up data long enough to say anything meaningful about recovery. [SPEAKER_01]: The conclusion, no marker has been reliably established as an indicator of overtraining in resistance exercise. [SPEAKER_01]: Not cortisol, not testosterone, not HRV.

[SPEAKER_01]: The one thing that consistently tracked the condition was a sustained drop in performance, which you would have [SPEAKER_01]: So with that background, here's what people have actually tried in order to induce over training syndrome. [SPEAKER_01]: In 2024, coal men did a supervised nine weeks study with extremely high training volumes.

[SPEAKER_01]: The program included Smith machine squads, leg extensions, calf raises, all for five sets of eight to twelve, two minutes rest, and each of these sets was taken a failure. [SPEAKER_01]: For the upper body, they did shoulder press, lap pull downs, chest press, biceps curl, and triceps press downs. [SPEAKER_01]: Again, five sets of eight to twelve reps, taking a failure with two minutes of rest.

[SPEAKER_01]: They did each of these sessions twice per week for a total of roughly 90 working sets per week. [SPEAKER_01]: Yeah, 90 working sets per week. [SPEAKER_01]: Nobody met over training syndrome criteria. [SPEAKER_01]: In fact, they got fitter.

[SPEAKER_01]: Before that, Dr. Mike Zordos, from the show, took three competitive strength athletes, two power lifters and one weight lifter, who agreed to attempt a 1 rep max squat every single day for 30 consecutive days, plus they did additional volume work at sub-maximal loads. [SPEAKER_01]: Get not every few days, but every day, for a month, and all three improved.

[SPEAKER_01]: One of the power lifters took their squat from 473 pounds to 500 pounds, another took their squat from 275 pounds to 303 pounds. [SPEAKER_01]: The weight lifter went from 44 to 530 pounds. [SPEAKER_01]: Three subjects, it is a case series so you can't generalize as widely, but the directional signals hard to reconcile with the overtraining narrative. [SPEAKER_01]: And there's a similar study where seven people max out their bench press every single day for 34 days.

[SPEAKER_01]: Now worked up to a heavy single, but they actually attempted a one rep maximum every day, followed by either five sets of three at 85% of the one rep max or five sets of two at 90% of the one rep max. [SPEAKER_01]: All seven improved. [SPEAKER_01]: The study is small and we're not recommending Daily Maxine, although we have tried it before. [SPEAKER_01]: But here's what's relevant. [SPEAKER_01]: Daily One Rep Max is fluctuated throughout.

[SPEAKER_01]: Some days worse, some days were better. [SPEAKER_01]: One participant was weaker on the average, her second week than her first. [SPEAKER_01]: If a coach had checked in at day 14 and compared that to day seven, they would have called it a regression. [SPEAKER_01]: which she went on to improve 23% anyway. [SPEAKER_01]: The person who made the biggest gains, 50 pounds on their bench press, tested 20 pounds below their peak on the final day.

[SPEAKER_01]: That's performance variability on top of a strongly upward trend. [SPEAKER_01]: And the most experienced lift her in the group had the noisiest day to day numbers. [SPEAKER_01]: More training history means more short-term variability, not less. [SPEAKER_01]: A studying 2017 took 5 trained men and they did daily arm training for 21 consecutive days, but they alternated what type of training was done on each arm. [SPEAKER_01]: One arm did a one-ret max each session and that was it.

[SPEAKER_01]: The other arm did higher volume sub-maximal work. [SPEAKER_01]: Both arms got stronger, by about 2 kilograms above baseline after the 21 days, but there was no over training. [SPEAKER_01]: The volume arm also hypertrophy to got bigger, whereas the one-ret max only arm didn't, which is its own finding about what actually drives muscle growth, but that's a separate conversation. [SPEAKER_01]: Now the question is, can you actually produce overtraining through resistance training?

[SPEAKER_01]: And the answer is maybe. [SPEAKER_01]: Fry and colleagues try to do it in 1994. [SPEAKER_01]: Will they took 11 trained males and had them perform 10 sets of one? [SPEAKER_01]: At their one rep max, honest myth machine, every single day, for 14 consecutive days. [SPEAKER_01]: That's 140 maximal singles total. [SPEAKER_01]: The overtraining groups, one rep max, dropped by about 12 kilos.

[SPEAKER_01]: And when they try to stimulate the legs using electrically stimulated force production, [SPEAKER_01]: Then the hormonal data came back, and it didn't look like what the endurance overtraining literature had primed everyone to expect. [SPEAKER_01]: Typically, they're looking at a decline in testosterone and cortisol ratio, but in this case, exercise induced cortisol went down and testosterone slightly increased.

[SPEAKER_01]: The testosterone and cortisol ratio, again, the marker that's most commonly cited in coaching contexts as the overtraining signal, moved in the wrong direction. [SPEAKER_01]: The classical endurance overtraining syndrome biomarkers don't seem to apply to high intensity resistance training. [SPEAKER_01]: Now, in contrast to the fry data, a similar study also did daily lake training for two weeks, but this time, at sub-maximal loads. [SPEAKER_01]: One rep max increased 6%.

[SPEAKER_01]: Yeah, increased 6%. [SPEAKER_01]: Fatigue resistance improved. [SPEAKER_01]: Compare this directly to the fry data. [SPEAKER_01]: Maximal loads produced a transient decrease in one rep max, whereas sub-maximal daily training produced an improvement. [SPEAKER_01]: In resistance training, intensity, not necessarily frequency, appears to be the necessary ingredient for overreaching or in this case over training.

[SPEAKER_01]: You can train every day and get stronger if the training is dosed correctly. [SPEAKER_01]: In fact, we think that training frequency is just an instrument or a tool to distribute the training load. [SPEAKER_01]: More frequency doesn't necessarily mean more training load unless volume increases. [SPEAKER_01]: But in this case, it's training intensity that seem to be the linchpin.

[SPEAKER_01]: The Margona study from 2007 is the one resistance training study that potentially crossed into overtraining syndrome territory. [SPEAKER_01]: Twelve males went through 12 weeks of progressive loading on seven exercises. [SPEAKER_01]: They did a bench press, squat, snatch, hang, clean, deadlift.

[SPEAKER_01]: They did some biceps curls, they did some rowing, and they started originally at two days per week, built to six days per week by the third phase, with intensity climbing from [SPEAKER_01]: Then they did a taper, then they did three weeks of complete rest. [SPEAKER_01]: The primary strength marker was the hang clean, which is a problem. [SPEAKER_01]: It's a highly technical lift and performance on it reflects skill as much as it does strength.

[SPEAKER_01]: When you look at the numbers though, the hang clean one rep max actually peaked during the high volume phase and it never dropped below baseline after that. [SPEAKER_01]: By the time the rest period rolled around, it was still above where it started, but down from the peak during the high volume phase. [SPEAKER_01]: Given that it was after weeks of rest, that looks more like a skilled decay thing, rather than overtraining.

[SPEAKER_01]: So the claim that this study produced genuine overtraining syndrome is shaker than it's usually presented. [SPEAKER_01]: The one performance biomarker that they tracked, it was the wrong one for the population, performance on it, never even collapsed below baseline, calling it confirmed overtraining syndrome overstates what the actual data shows.

[SPEAKER_01]: So to summarize, no study has cleanly induced overtraining syndrome [SPEAKER_01]: The most likely explanation is that there's something else that tends to intervene first. [SPEAKER_01]: We think that's probably overuse injury. [SPEAKER_01]: When training load is too much for somebody to currently tolerate, they're more likely to suffer on overuse injury before they ever get anywhere close to over training syndrome. [SPEAKER_01]: Or because we're just really, really adaptable.

[SPEAKER_01]: And like the more, you know, provided you don't get injured, ratcheting up your training load over time, it seems like people are just gonna get better.

[SPEAKER_01]: You know, if you give them a long enough window to adapt. [SPEAKER_01]: So Austin, if a strength athlete came to you saying they felt over trained and that they're training four days a week, what is the actual probability in your clinical experience that training volume is the primary driver here.

[SPEAKER_00]: Typically low, I think in my experience and I suspect in yours as well, I'm going to similarly take a detailed history about what do they mean when they say they feel over-trained question one and then question two, tell me about your training.

[SPEAKER_00]: And it might be a moderate to even a high volume training program, but much more often, you know, the question of my mind is the idea here is if training volume is the primary driver, [SPEAKER_00]: then it means that this person is essentially incapable of tolerating that level of training volume. [SPEAKER_00]: And most often, we find that that is not the case.

[SPEAKER_00]: They may or may not truly need that level of training volume to make the kind of progress they're looking for, but much more often, it's a more complex byproduct of multiple variables coming together. [SPEAKER_00]: the intensity might be too high for the amount of training volume that they're doing. [SPEAKER_00]: They may also have some iron deficiency that's been undiagnosed or their nutrition might not be you know where it needs to be.

[SPEAKER_00]: Their sleep is often not in a great situation. [SPEAKER_00]: So there might be there are very often numerous variables at play that need to be modified.

[SPEAKER_00]: And so, you know, if on the back end, because this is again something that you can only determine kind of more retrospectively, but let's say is there a scenario on the back end where [SPEAKER_00]: The person, we have a training setup for them where they're actually doing at least as much training volume if not more, but the other variables have been modified such that they're able to tolerate it.

[SPEAKER_00]: That very often is the case, and then by definition the training volume was not the primary driver upfront. [SPEAKER_00]: It was the collection of all of these variables that ultimately a mismatch between the training and the person much more so than they were just like up. [SPEAKER_00]: You're just doing too much, and this is like a hard limit that you're not going to be capable of ever tolerating.

[SPEAKER_01]: Yeah, yeah, what I typically see in this type of scenario is not the volume per say literally just the number of sets and reps it's either as you alluded to a sort of life load right if if training load is not only how much training you're doing, but the nature of the training life load is everything else that's going on outside the gym.

[SPEAKER_01]: So what's your nutrition look like, what's your sleep look like, what's your life stress, your occupational relationship stress, et cetera, psychological state, medical, you know, health, sort of stuff. [SPEAKER_01]: How does that, you know, effectively, that is your life load. [SPEAKER_01]: And if that starts to creep up, you have less sort of resources to deal with training loads.

[SPEAKER_01]: So that can sort of lead to the sort of transient shift towards, well, no longer can I tolerate my previous training. [SPEAKER_01]: not over-training syndrome because over-training syndrome requires people to stop training, to rest, and there's no resolution of their symptoms, right? [SPEAKER_01]: And also, by the way, they can't get fitter from the exercise that they were doing.

[SPEAKER_01]: The other thing that I see is that volume actually stays the same sets, reps, et cetera, but the intensity goes up to a level that they can no longer tolerate. [SPEAKER_01]: Generally, this would be an RPE, you know, rate of perceived exertion, [SPEAKER_01]: For example, which basically indicates they are trying to add training load via intensity before the adaptation has actually occurred making them stronger. [SPEAKER_01]: And we come back to this all the time.

[SPEAKER_01]: Your training shouldn't get harder over time. [SPEAKER_01]: It should stay the same relative level of hardness but you get fitter so you're doing more, right? [SPEAKER_01]: You know, you [SPEAKER_01]: You're very first day in the gym. [SPEAKER_01]: If we had you max out, that's going to feel the certain level of hardness. [SPEAKER_01]: It's going to feel the same level of hardness later on, but it's going to be heavier weight. [SPEAKER_01]: Right.

[SPEAKER_01]: So what people will do is I got to add weight. [SPEAKER_01]: I got it. [SPEAKER_01]: I got it. [SPEAKER_01]: Or I got to add, uh, you could theoretically add volume before again, you're, you've actually gotten fitter. [SPEAKER_01]: And so now at this point, the train load has actually been rationed up to a point where no, no longer can they [SPEAKER_01]: they tolerate.

[SPEAKER_01]: So again, it's all a mismatch, but as far as like what side of the equation the mismatch is coming from can vary, but that's typically what I see. [SPEAKER_01]: Now with all that in mind, what actually causes over training syndrome? [SPEAKER_01]: We come back from the break. [SPEAKER_01]: We'll cover the leading theories.

[SPEAKER_01]: All right, we're back here on the Barbell Medicine podcast. [SPEAKER_01]: We're talking about over training syndrome [SPEAKER_01]: So there are six primary hypotheses in the literature, understanding where each one comes from, what it explains, and where it falls short, tells you something important about how genuinely unresolved this condition still is. [SPEAKER_01]: Let's go through it. [SPEAKER_01]: First is the sort of anchor here that we have one HPA response.

[SPEAKER_01]: Hypothalamic, but to a adrenal response. [SPEAKER_01]: This is basically how you respond to stress. [SPEAKER_01]: Okay, so you can think of this as a central command that decides how your body responds to any stressor coming in. [SPEAKER_01]: It doesn't label the stressors coming in. [SPEAKER_01]: It doesn't know if it's from a heart training week, bad sleep, work crisis, family situation. [SPEAKER_01]: It's just how your body responds to stress.

[SPEAKER_01]: It only knows that total. [SPEAKER_01]: So what we're really talking about when we're talking about over training syndrome is a ratio. [SPEAKER_01]: Total life load relative to recovery capacity. [SPEAKER_01]: And when that ratio stays unfavorable for long enough, something can break down. [SPEAKER_01]: Now, training is not inherently pathological.

[SPEAKER_01]: You can take the same athlete, the same program, and produce overreaching in one context and normal adaptation in another, be like college athletes during finals week, for example. [SPEAKER_01]: But these six hypotheses are all trying to answer the same downstream question. [SPEAKER_01]: Once that threshold is crossed, what is the biological chain of events that produces the performance decline and the symptom constellation that we call over training syndrome?

[SPEAKER_01]: So the first up is very simple. [SPEAKER_01]: It's the glycogen theory. [SPEAKER_01]: glycogen depletion specifically. [SPEAKER_01]: This is from the late 90s. [SPEAKER_01]: This was proposed that insufficient carbohydrate availability depletes the muscle and liver glycogen stores, and the resulting substrate deficit explains the fatigue and the performance decrement. [SPEAKER_01]: I guess it made sense when it was proposed.

[SPEAKER_01]: If you can't fuel the engine, the engine fails. [SPEAKER_01]: The problem is that overtrain in syndrome symptoms persist even with adequate carbohydrate intake by definition. [SPEAKER_01]: And athletes meeting the overtrain in syndrome criteria can't refuel their way out of it. [SPEAKER_01]: You can't overeat and just get back into the game. [SPEAKER_01]: This model explains bonking maybe during endurance events, but it doesn't explain the syndrome.

[SPEAKER_01]: The next up is this serotonin branch chenomeno acid theory. [SPEAKER_01]: It's a little more sophisticated, central fatigue via serotonin. [SPEAKER_01]: The logic goes like this. [SPEAKER_01]: Intense exercise oxidase is branch chenomeno acids, which competes with trip to fan for transport across the blood brain barrier. [SPEAKER_01]: So you've depleted some of the branch chenomeno acids and more trip to fan gets through.

[SPEAKER_01]: more trip to fan means more brain serotonin and more brain serotonin means central fatigue sleepy amino acid. [SPEAKER_01]: It's elegant. [SPEAKER_01]: It sounds truthy if you will. [SPEAKER_01]: The problem is that branch chain amino acid supplementation doesn't prevent overtrain syndrome. [SPEAKER_01]: Also, the serotonin levels vary wildly in athletes.

[SPEAKER_01]: So if the mechanism were correct, you would see sort of reliable changes without only branch changing, we know acid supplementation, but also like trip to fan levels, serotonin levels, et cetera, and we just don't. [SPEAKER_01]: On third hypothesis is the autonomic bias. [SPEAKER_01]: This is one of the oldest frameworks in literature. [SPEAKER_01]: It's actually a two-type model that there's sympathetic over-training and parasympathetic over-training.

[SPEAKER_01]: Now, your autonomic nervous system, again, is comprised of two major arms, parasympathetic and sympathetic. [SPEAKER_01]: sympathetic being fighter flight, parasympathetic being rest and digest. [SPEAKER_01]: So with the sympathetic type overtraining, you'd see an elevated resting heart rate, irritability, sleep disruption, reduced appetite.

[SPEAKER_01]: And if it's parasympathetic, overtraining, you see a low resting heart rate, deep fatigue, mood depression, motivational decreases. [SPEAKER_01]: The two-time model still gets cited to date, but the limitation here is that autonomic changes appear to be downstream effects.

[SPEAKER_01]: Basically, whatever the primary disruptor is, not necessarily the cause of it, and also, again, people are very wildly when it comes to overtraining syndrome when those who have been diagnosed with it. [SPEAKER_01]: The next theory has to do with cytokines, heavy training produces muscular damage, muscle damage, triggers uninflammatory cascade of interlucin6, interlucin1 beta, TNF alpha, and sustained cytokine elevation produces what immunologists can call sickness behavior.

[SPEAKER_01]: The fatigue, mood disruption, and hedonia, people don't take any pleasure in activities, reduce motivation to train. [SPEAKER_01]: This, again, is intuitively appealing for athletes who look, quote, unquote, depleted and feel sick the problem with this chronic cytokine picture and over training syndrome is that it doesn't replicate cleanly across studies and acute exercise induced cytokine elevation resolved normally with adequate recovery usually in like hours to days.

[SPEAKER_01]: So you'd expect a distinct signature that persists in true over training syndrome. [SPEAKER_01]: Again, if things don't resolve in, you know, [SPEAKER_01]: Which brings us to the hypothesis with the strongest current evidence, HPA access dysregulation. [SPEAKER_01]: So the hypotherlamic to a teri adrenal access dysregulation, your stress response is pickled.

[SPEAKER_01]: Again, this is the central coordinator of your stress response, but under conditions of chronic, unrelenting training load, the system shows a pattern of dysregulation, not at the level of the adrenal glands, which sit on top of your kidneys, but upstream. [SPEAKER_01]: the pituitary glands, specifically has reduced ACTH output. [SPEAKER_01]: That's a specific hormone that basically causes the adrenal glands to spit out some cortisol down the road.

[SPEAKER_01]: Now, this is an important distinction because people talk about adrenal fatigue, which implies adrenal insufficiency, where the glands themselves are failing to produce cortisol, but that is not what is happening here. [SPEAKER_01]: The adrenals aren't tagged. [SPEAKER_01]: They appear to respond normally. [SPEAKER_01]: The problem would be in the brain.

[SPEAKER_01]: The regulatory signal from the arbitrary gland is decreased, which means the adrenals really receive less instruction to respond, and so you can have a normal resting cortisol and still have significant HPA dysregulation because the problem is in the responsiveness of the access, not the baseline output. [SPEAKER_01]: This is really famous study. [SPEAKER_01]: You get sighted all the time in the over-training syndrome, literature called the E-Rose study.

[SPEAKER_01]: They found ACT H Blontine in 78.6% of the athletes meeting over-training syndrome criteria. [SPEAKER_01]: They used what's called an insulin tolerance test. [SPEAKER_01]: You familiar with this test? [SPEAKER_01]: I have never done an insulin tolerance test for ACT HX, that's a testing. [SPEAKER_01]: Yeah, right, very specialized endocrinologist level.

[SPEAKER_01]: So basically it takes some insulin and it induces hypoglycemia, so low blood sugar, which is a physiological stressor that should drive the full cascade of the hypothalamus, the pituitary gland, and the adrenal gland. [SPEAKER_01]: The hypothalamus releases [SPEAKER_01]: So this one once you are age, that goes to the two tree gland which causes it to release ACTH and then that travels to the adrenal glands to make it release cortisol.

[SPEAKER_01]: So basically you can see is the system intact or not. [SPEAKER_01]: And 11 out of 14 athletes. [SPEAKER_01]: this test produced a level of cortisol 17.9 which compared to adrenal insufficiency is 18. [SPEAKER_01]: So pretty close there. [SPEAKER_01]: I think the methodology here is actually pretty rigorous more than critics usually give it credit for, but we're only talking about 14 athletes and they were all classified [SPEAKER_01]: are you going to access it?

[SPEAKER_01]: Like, if you've never done one of these tests in the hospital and you have access to it, you're telling athletes to mate, you should go get an insulin tolerance test and to see if you're over trained. [SPEAKER_01]: So the main takeaway from this is that maybe there's something going on at the level of the hypothalamus pituitary gland. [SPEAKER_01]: It's not really happening at the adrenal gland. [SPEAKER_01]: So when people say adrenal fatigue, we can kind of write that off.

[SPEAKER_01]: That's not really what's [SPEAKER_01]: you know, implement this, this studies findings in your exercise prescription, big shoulder shrug, because no one's doing this test, right? [SPEAKER_01]: And further, even if you had results from this test, how does it just, you know, affect your management? [SPEAKER_01]: If somebody did this test and like, look, my levels, you know, 17.7, and you're like, okay, but how do you feel?

[SPEAKER_00]: Yeah, and the other aspect is I still am unconvinced in terms of how much of this is an effect of the syndrome rather than a cause of it, right? [SPEAKER_00]: Because we know that there are endocrine disruptions from all sorts of things. [SPEAKER_00]: Our endocrine system is not static. [SPEAKER_00]: It is dynamic and responds to our environment.

[SPEAKER_00]: And we've talked about, for example, how in the context of obesity, for example, you know, testosterone levels tend to go down. [SPEAKER_00]: When somebody has that state of low energy availability, a lot of their thyroid hormone, your thyroid function might decline as an adaptive mechanism. [SPEAKER_00]: They're going to add, you know, going to add a tropans in their testosterone and things like that might also go down as an adaptive mechanism.

[SPEAKER_00]: And so the idea that in this state, you know, the HPA access might also turn down a little bit. [SPEAKER_00]: I find to be a plausible result of the syndrome, at least as much as something if we're trying to dig into like the cause, it might be that it wasn't able to, you know, I guess the proponents of it as a causal theory are that the system broke down because it wasn't able to tolerate the stressor, but at the same time it might be an adaptive mechanism to like, hey,

[SPEAKER_00]: rain the person in, this is, you know, they might not be able to tolerate this, and so things get turned down on the on the back end, because the, an implication or another way to test this would be, oh, if I were able to stimulate that access, would it resolve your syndrome? [SPEAKER_00]: Because there are ways to do that. [SPEAKER_00]: I have ways to stimulate your HPA access. [SPEAKER_00]: I actually do that test in the hospital all the time.

[SPEAKER_00]: We call it a co-centropin stem test to see what happens to, can I yell at your adrenals enough to spit out enough cortisol to, [SPEAKER_00]: handle whatever physiologic stressor you need to be able to handle. [SPEAKER_00]: And so doing that type of testing can can illustrate that, but would that resolve somebody's overtraining? [SPEAKER_00]: I syndrome if they were met the clinical criteria for it, I doubt it.

[SPEAKER_00]: So this whole world is pretty messy and the direction of causality is not clear to me. [SPEAKER_01]: Yeah. [SPEAKER_01]: Yeah. [SPEAKER_01]: The other thing is like, [SPEAKER_01]: They recruit people into this study. [SPEAKER_01]: They used symptoms that overlap with HPA access dysregulation anyway. [SPEAKER_01]: So it's like, okay, you recruited people in here that experiencing symptoms that map to this condition and then you found this condition and it's like,

[SPEAKER_01]: It'd been nice if you did it early before they were quote overtrained to see like oh and then it subsequently changed that would make you feel better about this maybe being causal but it could also just be like yeah this happened at the same time and again you can't do this test so like yeah unclear of how useful it is. [SPEAKER_01]: So the sixth and final framework isn't actually a mechanism.

[SPEAKER_01]: It's sort of like a metal level observation about why we don't have a single mechanism. [SPEAKER_01]: This is from a 2022 paper from Armstrong that proposes that treating over-trained syndrome as an emergent complex systems phenomenon. [SPEAKER_01]: There's no single pathway that produces over-trained syndrome, no single biomarker reflexed.

[SPEAKER_01]: It arises when multiple systems are simultaneously affected from, [SPEAKER_01]: chronic training load, this may point at a deeper problem as well. [SPEAKER_01]: If overtraining syndrome is what happens when multiple systems are simultaneously pushed past their adaptive ceiling. [SPEAKER_01]: And experimental data keeps failing to produce it through resistance training alone.

[SPEAKER_01]: The question we're sitting with is whether overtraining syndrome is a distinct pathological entity or whether it's simply what severe prolonged training load recovery mismatch always looks like and overtraining syndrome [SPEAKER_01]: The residual case that true, load-induced overtrain syndrome is an adequately nourished, well-rested, psychiatric healthy athlete without PED exposure, has never been cleanly characterized.

[SPEAKER_01]: The defining features of overtrain syndrome versus overreaching, prolonged performance decrement, almost always has an unaddressed or hidden variable underneath it. [SPEAKER_01]: But we can say what confidence? [SPEAKER_01]: You can't confirm over-training syndrome with a single biomarker because there is no confirm mechanism. [SPEAKER_01]: You're looking for a pattern and the pattern can only be assembled after the fact, which is why this remains a diagnosis of exclusion.

[SPEAKER_01]: Satisfactory to you? [SPEAKER_00]: Yeah, I keep coming back to this mismatch type of a paradigm instead of just the training load itself. [SPEAKER_00]: I suspect that when the most of those other variables are inline, what you mentioned adequately [SPEAKER_00]: I suspect that structural issues are likely to emerge before you end up in this, like, quote unquote, overtraining syndrome type state.

[SPEAKER_00]: In other words, injury, like when we think about, like, yeah, Olympic level athletes, they are able to tolerate and do a massive amounts of training on the quadranial cycle to prep for the Olympic Games. [SPEAKER_00]: And there is certainly a high degree of selection bias and survivorship bias in that population, right? [SPEAKER_00]: They're already elite genetic freaks who are able to do that. [SPEAKER_00]: And then they have all the resources and depending on the support.

[SPEAKER_00]: Of course, the time and the nutrition and the recovery to be able to get there. [SPEAKER_00]: And those who are not able to survive that, I suspect, are either not of the genetic stock to get to that level. [SPEAKER_00]: But also get selected out earlier in life through injury, through setbacks, through other things like that. [SPEAKER_00]: And so you're right that this is a complex multi-variable thing rather than just too much training in the vast majority of cases.

[SPEAKER_01]: Yeah. [SPEAKER_01]: Yeah. [SPEAKER_01]: So let's let's move on. [SPEAKER_01]: There's a couple of gaps here that have been established because of this taxonomy. [SPEAKER_01]: It's fundamentally retrospective. [SPEAKER_01]: It's built on continuous variables that are treated as discrete categories. [SPEAKER_01]: And the model of adaptation was imported from the general stress physiology without validation in sport.

[SPEAKER_01]: a resistance training evidence base that has largely failed to produce overtraining syndrome despite deliberate attempts at doing so. [SPEAKER_01]: And six mechanistic hypotheses with partial inconsistent support, the best supportive which requires a test that most clinicians have never run, and athletes don't have access to. [SPEAKER_01]: So there's this vacuum in this evidence base.

[SPEAKER_01]: And that vacuum has been filled by two specific narratives and coaching practices that the data doesn't support. [SPEAKER_01]: Let's address both. [SPEAKER_01]: First, it has to do with cortisol and testosterone and cortisol ratio. [SPEAKER_01]: and also heart rate variability. [SPEAKER_01]: It's like, well, look, if it's not any of these other things, it's got to be maybe some sort of tests we can monitor.

[SPEAKER_01]: These two tools have been put forth as instruments for diagnosis, diagnosing and monitoring over training syndrome, which shades how sports medicine workups have been structured in what coaching certifications teach, and what commercial wearable companies market. [SPEAKER_01]: Here's what the evidence shows about that. [SPEAKER_01]: First off, cortisol. [SPEAKER_01]: Resting cortisol is normal in at least 75% of individuals who have been diagnosed with overtraining syndrome.

[SPEAKER_01]: Oh, again, it's like how did they get diagnosed with overtraining syndrome? [SPEAKER_01]: If not, you've seen the cortisol level, but it's normal in at least three quarters of that. [SPEAKER_01]: disaster on a cortisol ratio is very influential by the time of day, it's taken the training type, the fitness level of the individual and whether total or free testosterone is measured, acute drops happen routinely after intense exercise like a marathon normalizes within days.

[SPEAKER_01]: It's never been validated against clinical outcomes as an individual diagnostic for over training syndrome. [SPEAKER_01]: Performance, on the other hand, can be useful. [SPEAKER_01]: Performance potential, however, is driven by many factors. [SPEAKER_01]: And the way I think about this is that your performance potential on a given day equals your fitness adaptations, minus the current fatigue that you're carrying on board in a specific environment.

[SPEAKER_01]: Fatigue is transient and expected from exercise, but most self-diagnosed over-training is an athlete testing performance during intentional load accumulation, [SPEAKER_01]: intentionally fatiguing sort of protocols and interpreting as a pathology. [SPEAKER_01]: Much of the biomarker literature has the same problem, hormones are sampled when fatigue is deliberately elevated from exercise. [SPEAKER_01]: A recent study compared subjective versus objective monitoring tools.

[SPEAKER_01]: So subjective measures like mood perceived fatigue, sleep quality, well-being ratings, et cetera, that tracked training [SPEAKER_01]: greater consistency than objective measures, which include various hormones, resting heart rate and heart rate variability. [SPEAKER_01]: When the two diverge in practice, we should probably wait the subjective. [SPEAKER_01]: It just correlates better. [SPEAKER_01]: We've been saying this for years.

[SPEAKER_01]: We prefer RPE when a given set session RPE for training session monitoring that over time versus like what was your testosterone and cortisol ratio. [SPEAKER_01]: Well, is your creatin kinase? [SPEAKER_00]: It feels like the biomarker has to be better, but it really just isn't just asking people, talking to them, how do you feel is way more useful to me than biomarkers in these types of situations?

[SPEAKER_01]: Yeah. [SPEAKER_01]: There's one interesting study that I think it's worth mentioning. [SPEAKER_01]: They took people who had been kind of not self-diagnosed, but they've been classified as having an overtrained syndrome, and they had them do two max exercise stress test basically within four hours, and they did cereal blood draws after both.

[SPEAKER_01]: Those that had overtraining syndrome showed a blunted ACT H response on the second bout, whereas those who didn't showed an exaggerated response effectively like they were more primed for the second maximum exercise test. [SPEAKER_01]: The problem is it's only 10 athletes. [SPEAKER_01]: Yeah. [SPEAKER_01]: And like, what does that mean? [SPEAKER_01]: And so again, if you're trying to identify overtraining, do you have like a, you had a wind gate or a treadmill in your office?

[SPEAKER_01]: And then you're going to do some blood sampling afterwards? [SPEAKER_01]: Yeah. [SPEAKER_01]: Austin, if you ever had a patient come in and you're telling medicine services with concern about something that they're wearable device, told them like something with a heart rate variability or like their woo pro coverage scores or strain or something like that. [SPEAKER_01]: How does that conversation go and like how are you waiting the clinical value of that data?

[SPEAKER_00]: Yeah, I actually have more so relating to either resting heart rate or heart rate variability is something that I've seen come up a handful of times. [SPEAKER_00]: And this is something we're seeing a bit more when people are being alerted to these things, especially in the era of GLP1 receptor agonists.

[SPEAKER_00]: Because [SPEAKER_00]: We know that in some, you know, on average, there's a modest increase in resting heart rate, a few beats per minute on average, on GLP-1 receptor agonists that is thought to be due to multiple different factors. [SPEAKER_00]: Some people have a little bit of a disproportionate increase of it more than average, and then HRV tends to actually go down, which is like the not desirable direction for HRV to go.

[SPEAKER_00]: For most people, this is of no meaningful consequence to them. [SPEAKER_00]: They generally are, [SPEAKER_00]: in a better spot, being on the medicine than off in terms of their general health, their other biomarkers, their how they feel, their performance, and so in those situations, it's more straightforward to kind of dismiss that data or to like not keep track and not monitor it.

[SPEAKER_00]: There are other people who have had who also in, you know, simultaneously to reporting those types of things, maybe they have a disproportionate increase in the resting heart rate and a disproportionate decrease in their HRV meaning it goes in that in the undesirable direction more than I would expect. [SPEAKER_00]: And they're telling me that they feel really terrible. [SPEAKER_00]: That's a little bit harder to tease apart.

[SPEAKER_00]: How much of it is all, you know, legitimately under the hood, things are not going the direction I want versus, [SPEAKER_00]: This person puts a ton of stock into the data that they're getting from their watch and they're, you know, versus like a nissy bow type component, but I'm not going to tell them that what they're feeling is not real.

[SPEAKER_00]: And so then I might do some medical tinkering with their with their therapy to see if we can get things going in the right direction, either because the biomarkers, they prefer to see them going that direction or legitimately, they're having a negative consequence from the medicine that's being reflected that way. [SPEAKER_00]: I would say that's the most common area where I'm seeing it these days, and it's just a case by case basis.

[SPEAKER_01]: Yeah, as well said, before we go further on the biomarker, specifically HRV, heart rate variability, there is a specific pattern that gets misread as overtraining in quite often in the extra science and sports medicine world. [SPEAKER_01]: It probably needs its own framing. [SPEAKER_01]: This is called the exercise hypogonatal male condition EHMC. [SPEAKER_01]: This is first observed in the 80s in marathon runners.

[SPEAKER_01]: Now, has been recognized in some high volume strength power athletes as well. [SPEAKER_01]: It affects anywhere from 15 over 50% of elite male endurance competitors. [SPEAKER_01]: And ultimately, we see some of the fitness athletes alive present with testosterone levels that are comparable to sedentary 80 year olds. [SPEAKER_01]: But this is not over training syndrome. [SPEAKER_01]: EHMC involves simultaneous dysfunction at two levels of the hypotherlamic pituitary genital axis.

[SPEAKER_01]: Effectively, you're brained a ball's pathway for producing testosterone. [SPEAKER_01]: Essentially, at the level of the brain, the hypotheralamus reduces GNRH, pulse frequency, which suppresses loonizing hormone, LH, and testosterone production. [SPEAKER_01]: Peripherally, [SPEAKER_01]: Even when the testes in these individuals are stimulated experimentally with the exogenous HCG, which would normally testosterone production by passing the need for the brain's signal entirely.

[SPEAKER_01]: EHMC athletes produce 15 to 40% less testosterone than healthy controls. [SPEAKER_01]: Effectively, the chronically high training load has reduced the functional capacity of the late excels in the testes themselves, not just regulatory signal coming in. [SPEAKER_01]: The timeline to these testosterone levels is also faster than some people might assume.

[SPEAKER_01]: One military study involving high energy expenditures, they were using a lot of calories with low energy intake, so they didn't have enough coming in. [SPEAKER_01]: And sleep deprivation on top of that showed a 50% drop in testosterone in just eight days. [SPEAKER_01]: But the clinical distinction here from overtraining syndrome is performance. [SPEAKER_01]: EHMC athletes continue to perform at a high level despite profoundly suppressed testosterone levels.

[SPEAKER_01]: The body has seemingly adapted and reallocated resources, or perhaps it's just something that happens that has no real effect on their performance level at all.

[SPEAKER_01]: In overtraining syndrome, there is a precipitous drop in strand speed recovery capacity ultimately performance. [SPEAKER_01]: The practical implication of these differences are straightforward. [SPEAKER_01]: If someone is performing well with what looks like a broken hormone panel, they're not overtrained. [SPEAKER_01]: But a poorly performing athlete with normal hormones might be. [SPEAKER_01]: Performance is the major distinction here.

[SPEAKER_01]: And hormone levels in trained athletes are noisy, context dependent, that require its own interpretation that's very, very carefully done. [SPEAKER_01]: Austin, this EHMC presentation, high-performing athlete, testosterone levels that look like a set in Terry's 70-year-old. [SPEAKER_01]: How do you approach that clinically? [SPEAKER_01]: Like, if you ever seen a patient with that personally, and then what does that conversation go like? [SPEAKER_00]: Yeah, not terribly often.

[SPEAKER_00]: Certainly people have a approach with these kind of concerns, and it similarly is just a very individualized conversation starting with like why was this checked in the first place? [SPEAKER_00]: Of course, most of the time it's just like because of curiosity or somebody told me that I should because of optimization or something like that.

[SPEAKER_00]: And if I'm going to fish in my history for specific signs or symptoms that would be suggestive of a clinical and a cronopathy of clinically significant testosterone deficiency or something like that before [SPEAKER_00]: potential recommendation for therapy, but if we're coming up empty handed, then yeah, this ultimately ends up coming back to a couple different questions.

[SPEAKER_00]: And one of them might also be like, if you're checking this over time, did you have a prior baseline, maybe prior to this training that looked way better?

[SPEAKER_00]: Maybe you like live at this and this is your normal in general, maybe it's adaptive to your training for all the reasons that you just laid out or maybe it is pathological in which case I would be looking for some signs or symptoms and then kind of going from there because each person is going to kind of equilibrate at a given level over time based on their receptor sensitivity and all sorts of other things that are beyond our scope here today so.

[SPEAKER_00]: super individualized getting a sense of why it was tested what their expectations are, what they're worried about if anything, and then if they're like, oh, it was just curious, then it's often a lot easier to say, okay, well, nothing to worry about carry on. [SPEAKER_00]: If they're like very high-provisual and focused, then we need to dig in a little bit more. [SPEAKER_01]: Yeah, yeah, it's like, why was it tested? [SPEAKER_01]: Like, are you feeling okay?

[SPEAKER_01]: Like, yeah, yeah, I can almost talk in somebody off talking about the ledge. [SPEAKER_01]: You know what's interesting? [SPEAKER_01]: You see people brag about their testosterone levels, all the time? [SPEAKER_01]: If testosterone levels, 900 nanograms, for desoliter. [SPEAKER_01]: And it's like, are you training a lot? [SPEAKER_01]: Yeah, because when I see that in somebody who I would assume who's doing a lot of training, I'm like, either this test, you're lying about the test.

[SPEAKER_01]: or something else is going on. [SPEAKER_01]: It's like a TRT level testosterone level and somebody with a high volume of training. [SPEAKER_01]: Not that I expect universally across the board, anyone who's training it with a high training load to have a low normal testosterone level or even people low, but I don't expect it to be maxed. [SPEAKER_01]: the just just generally speaking from what we know about how testosterone responds to exercise.

[SPEAKER_01]: Generally speaking, exercise doesn't increase testosterone levels chronically in the short term like 30 minutes after a workout short, but like over time, if you're doing a lot of training load, it's more likely that it's going to go down slightly than increase unless you've also simultaneously a loss body fat and it was previously too high to be good with fun anyway. [SPEAKER_01]: There's a lot of caveats there, but does that ring true to you?

[SPEAKER_01]: Like you [SPEAKER_00]: Spuriously high testosterone level in someone you'd expect to be doing a ton of training you're like I don't know it kind of depends on how high there's just so much variation here like you Remember that I although it was you know because I was invited and gifted a free test that I was Doing for investigative purposes. [SPEAKER_00]: I mean, I trained a fair amount.

[SPEAKER_00]: It's not like in ultra-indurance level A training but a fair amount across multiple different modalities and I think the level that came back was around seven hundred Isher something like that which is

[SPEAKER_00]: a solidly normal range level, if it was much higher than that, 900 to 1,200, I got, I'm starting to have some other questions starting to creep up a little bit, and then if it's like in the 3 to 400 range, again, there's some, that kind of takes me in a different direction in terms of my line of questioning.

[SPEAKER_00]: But if somebody is like a very high performing elite level athlete, definitely like an endurance or ultra endurance realm, I would generally expect the levels to be us like mid range to lower and not very high.

[SPEAKER_01]: Yeah, when somebody's like, it's 1200. [SPEAKER_01]: I'm like, yeah, that's probably something else going on. [SPEAKER_01]: I'm usually involved in a needle. [SPEAKER_01]: All right. [SPEAKER_01]: We'll back to back to this, this other marker heart rate variability. [SPEAKER_01]: It has been put forth similarly to testosterone and cortisol ratio. [SPEAKER_01]: Like, hey, look, we should use this to maybe monitor for overtraining syndrome.

[SPEAKER_01]: But it has the same interpretive problem that these other markers have. [SPEAKER_01]: You know, Harvey very variability measures the variation in time between heartbeats. [SPEAKER_01]: It's the sort of indirect window into the autonomic nervous systems state. [SPEAKER_01]: It's suggested to use a sort of seven day average of Harvey variability compared to the previous like four to six weeks, just to see like, hey, did Harvey variability go down, which would be, um,

[SPEAKER_01]: You know interpreted as training load too high compared to resources available to to tolerate it, and if heart rate variability went up that would be Observe say, oh, you could potentially do some more training Unfortunately, it doesn't actually map the over-trained syndrome nearly at all and and even resisting training as much worse So like strength recovery An Olympic weight lifters and this particular study occurred approximately 30 hours after the workout meaning they were back to baseline

[SPEAKER_01]: If you're using that to make training decisions, you'd miss an opportunity to training. [SPEAKER_01]: They're right, right. [SPEAKER_01]: Yeah, so I think if you're going to use hearty variability, you could certainly analyze the trend over weeks and the best use case of in my estimation is adding an additional session. [SPEAKER_01]: If your hearty variability is going up and up and you're like, oh my gosh, I'm just like, I guess things are going well.

[SPEAKER_01]: You could add more training. [SPEAKER_01]: Um, I don't necessarily think that if Harvey variability is going down that you should, you know, kind of diagnose yourself with overtraining syndrome and stop training, but you might want to investigate like, hey, how, how are my training resources, uh, or my available resources, um, I'm going how much time, um, an opportunity to have to sleep with my nutrition look like.

[SPEAKER_01]: Those would be the two biggest ones, um, instead of using Harvey variability testosterone [SPEAKER_01]: I will look for RPE creep. [SPEAKER_01]: In particular, it's session, RPE. [SPEAKER_01]: So if you think about the end of a session, you can rate it one through 10, 10 being this is the hardest thing I've ever done. [SPEAKER_01]: I feel terrible. [SPEAKER_01]: I got wrecked, hit by a bus, whatever, dramatic language you want to use.

[SPEAKER_01]: We don't really love dramatic language here, but for the purposes of edge attainment, you guys get it. [SPEAKER_01]: Or you can rate it a one. [SPEAKER_01]: Barely more than resting, effectively, I feel fine. [SPEAKER_01]: I could do the exact same training session again, no big deal. [SPEAKER_01]: So you're rate it one to 10. [SPEAKER_01]: If the training load is staying roughly the same, meaning you're hitting similar weights and or similar proximity to failure.

[SPEAKER_01]: So even if you've added weight, but it's not, you're still keep two reps left in the tank. [SPEAKER_01]: For example, and you're doing about the same volume, the amount of training. [SPEAKER_01]: But your session RPE is going up. [SPEAKER_01]: To me, that is a signal that the ratio of your total life load. [SPEAKER_01]: So everything that's happening, not only in the gym, but outside the gym, has gone up relative to your resources available to tolerate it.

[SPEAKER_01]: There's a mismatch that you're sort of uncovering. [SPEAKER_01]: That, to me, would be the best sort of test of, like, am I on the road to, quote, over-training syndrome, to the extent that it actually exists? [SPEAKER_01]: Or, in fact, am I underloading? [SPEAKER_01]: If it's going down, for example, your session RPG trend is going down. [SPEAKER_01]: You're like, I can probably train a little bit more.

[SPEAKER_00]: Yeah, I really continue to like the framing of the, you know, training program to person match or mismatch and then once you start seeing signs of that mismatch, you know, starting to develop and certainly if that mismatch is widening, then yeah, something's got to change for sure.

[SPEAKER_01]: The session RPE trend over weeks is the monitoring tool that maps most directly to what over training syndrome represents a ratio of training load to recovery capacity that has been unfavorable long enough to produce a clinical picture, not your wearable score, not your testosterone or cortisol ratio.

[SPEAKER_01]: Before we get into the practical decision framework, there's one more question worth addressing directly. [SPEAKER_01]: How common is overtraining syndrome and why does it persist when it does occur? [SPEAKER_01]: The prevalence data changes how you think about the differential in the first place. [SPEAKER_01]: Now, we said that there was this vacuum in the evidence that's led to some kind of interesting theories we talked about the first one.

[SPEAKER_01]: The people who try to fit in or shove in testosterone. [SPEAKER_01]: According to Israel ratio, heart rate variability, this and the other, well, the prevalence data on overtraining syndrome is not very good. [SPEAKER_01]: The 60% figure is most commonly cited over-training syndrome prevalence estimate, but should be noted that this is a retrospective study self-reported without any standardized definition, and it was conducted before the current taxonomy existed.

[SPEAKER_01]: The term used in this particular study was staleness. [SPEAKER_01]: And that figure almost certainly captures all three categories of the continuum. [SPEAKER_01]: So functional overreaching non-functional overreaching and overtraining syndrome. [SPEAKER_01]: And it may include presentations that would now be classified as reds or relative energy deficiency in sport, also could include clinical depression or even illness.

[SPEAKER_01]: Because again, all the rest can for us stay on this. [SPEAKER_01]: With that in mind, how prevalent is overtraining syndrome? [SPEAKER_01]: In resistance training populations, attempts to produce overtraining syndrome through resistance exercise have largely failed. [SPEAKER_01]: I've said that the outset, I did not see a good study showing like, yep, definitively this is overtraining syndrome.

[SPEAKER_01]: People don't get stronger on average and in fact what I would predict is that an overuse injury would happen before overtraining syndrome actually occurred. [SPEAKER_01]: There are additional confounders that nobody names directly, for example, aging out of support. [SPEAKER_01]: Natural performance decline, plus motivational drift, can meet several of these over-training syndrome diagnostic criteria. [SPEAKER_01]: It's never cleanly separated in the prevalence literature.

[SPEAKER_01]: PED use and cessation. [SPEAKER_01]: So think about an athlete coming off, the use of exogenous testosterone or Rithrop Wheaton, EPO, would show the exact same hormonal profile attributed to over-trained syndrome, a blunted HPA access mood disturbance, performance collapse for longer coverage, the over-trained syndrome largely ignores this variable, which is remarkable, given how often that elite athletes actually use performance enhancing drugs.

[SPEAKER_01]: Psychiatric conditions, or on it's another potential confounder, the overlap between overtraining syndrome and like major depressive disorder is remarkable, so any overtraining syndrome work up without a formal depression screen is incomplete, although I know you hate the depression screen, but it is a possible confounder. [SPEAKER_01]: One of the most well-known confounders, however, is low energy availability.

[SPEAKER_01]: In a recent study, 86% of over-training syndrome studies showed a co-occurrence with reduced energy availability with over-training syndrome-like presentations. [SPEAKER_01]: Now, causally, this is a leap that I'm taking here. [SPEAKER_01]: But the implications clear, you got to assess energy availability. [SPEAKER_01]: A person who's like, I'm over-trained. [SPEAKER_01]: It's like, [SPEAKER_01]: How's your weight been recently?

[SPEAKER_01]: Has there been any direct or maybe indirect change in your energy intake, so either on purpose or kind of something else going on? [SPEAKER_01]: Got to assess for that. [SPEAKER_01]: Which brings me to a thought I've been kind of beating around this entire time. [SPEAKER_01]: He is overtrained syndrome real.

[SPEAKER_01]: So if persistent low energy availability explains many cases, then over-training syndrome is not a separate entity from relative energy deficiency in sport or low energy availability. [SPEAKER_01]: If aging, PED cessation or psychiatric conditions explain most of the remainder, then over-training syndrome is a symptom of those things.

[SPEAKER_01]: The residual true training load induced over training syndrome in an adequately nourished, psychiatric healthy, non-PED using athlete, but it's never been characterized and I suspect would be a small sliver of any of the remaining cases. [SPEAKER_01]: My thought is that over-trained syndrome is almost always an unaddressed life variable that the athlete is either not disclosing or the researchers not measuring. [SPEAKER_01]: Awesome.

[SPEAKER_01]: How does that square with what you've heard so far? [SPEAKER_00]: It is provocative, and I think it's likely to get the people going as they say. [SPEAKER_00]: If you make that claim, I mean, some of this is interesting to think about in terms of the direction of causality, right? [SPEAKER_00]: So there are certainly some people for whom they have low energy intake at the outset that limits their ability to tolerate a given training load. [SPEAKER_00]: I also wonder how many people

[SPEAKER_00]: more so in that like ultra endurance realm, as a result of their training load, maybe if there's some degree of appetite suppression from it that leads to inadequate intake and then it kind of perpetuates a negative sort of a vicious cycle from there or like the syndrome itself leads to loss of appetite and then they end up under eating and then they manifest in these data sets as part of that high proportion of people with some low energy availability.

[SPEAKER_00]: So I could see. [SPEAKER_00]: both cohorts of people plausibly getting lumped into the same. [SPEAKER_00]: And so again, I think there's so many different ways or pathways that are involved here and relevant. [SPEAKER_00]: But I keep coming back to this idea of A. [SPEAKER_00]: There's probably a degree of training to a trainee mismatch.

[SPEAKER_00]: And then also the idea that if you do have this unicorn person that you were describing who is well-nourished, psychiatric, healthy, sleeping, well, not using PEDs, things like that. [SPEAKER_00]: If they are trying to train enough to plausibly lead to the syndrome, I feel like more often there's going to be some survivorship bias of injury, structural issues are going to take them out before they get to that point in the majority of cases.

[SPEAKER_00]: But yeah, your thoughts, I think you have a plausible and interesting argument. [SPEAKER_00]: And I suspect that there are people out there who have a... [SPEAKER_00]: them, both stronger and more weekly held opinions on this topic, who would be yet who will have some likely interesting responses in the comments, so we'll look forward to that.

[SPEAKER_01]: So, the epidemiologies uncertain, the well-documented confounders probably explain most persistent cases, and the residual case of true, load-induced over-trained syndrome in an otherwise healthy athlete may be vanishingly rare, which brings us to what's actually happening when a [SPEAKER_01]: In my experience, it's almost always one of three specific and correctable problems, none of which require the over-trained syndrome label to address.

[SPEAKER_01]: The first tier is this programming test mismatch. [SPEAKER_01]: So effectively, the person's programming does not reflect how they're assessing their progress correctly. [SPEAKER_01]: The body's adapting, but the program isn't just designed for how progress is being tested. [SPEAKER_01]: So imagine somebody's running like a full-on body building program, right? [SPEAKER_01]: Okay, well, you would expect some strength gains to happen in the lift that are being trained.

[SPEAKER_01]: That's just how we respond to exercise. [SPEAKER_01]: It's not really specific for the test that you care about the most, right? [SPEAKER_01]: Or if somebody is testing to one or at max squat, bench press or deadlift, but they're not seeing any of those exercises in the program. [SPEAKER_01]: It's like, [SPEAKER_01]: This isn't really indicative of like you're doing or you're over-trained, you're under-trained or whatever.

[SPEAKER_01]: It's just that the training is not matched to how you're assessing it. [SPEAKER_01]: The key here, again, is to monitor the session RPE. [SPEAKER_01]: And if you're sleeping nutrition or normal, there's probably a programming formulation issue in this case, meaning that how your training does not accurately reflect the variables that you're testing, the metrics that you're testing. [SPEAKER_01]: The second problem here is monitoring too often.

[SPEAKER_01]: We know the performance varies day-to-day. [SPEAKER_01]: Again, it's like your fitness adaptations on board, relative to the fatigue you have on board, in a particular environment, and all workouts simultaneously develop and also test performance. [SPEAKER_01]: So it can be hard not to anchor to historical performances. [SPEAKER_01]: So if you're a little weaker, you're like, huh, performance is down, or if it's a little better, like, oh, actually got stronger.

[SPEAKER_01]: But day-to-day and even weak to weak variability can be high. [SPEAKER_01]: We talked about that in our daily max studies that we cited earlier and fitness adaptations occur over time. [SPEAKER_01]: And like building a savings account requires deposits to accumulate over time.

[SPEAKER_01]: So when people are saying, look, I didn't get stronger compared to the last time I trained and you're like, well, one's the last time you trained, you're like, they say, yes, or do you're like, I wouldn't expect progress to happen. [SPEAKER_01]: Really, yes. [SPEAKER_01]: Last week. [SPEAKER_01]: Like, well, it's only one week. [SPEAKER_01]: Now, someone says, like, for months on end.

[SPEAKER_01]: That seems like a more reliable signal, not whether you're over-trained or under-trained, that can be hard to tease out. [SPEAKER_01]: Fortunately, we developed this training plateau action plan that we released a few months ago, and we think about forced strength. [SPEAKER_01]: that you're estimated one rep max or test a one rep max should go up somewhere in about four weeks over four weeks and that's relative to your most recent estimated one rep max.

[SPEAKER_01]: So not like historical, for example. [SPEAKER_01]: Same thing for conditioning to the extent that your cardiovascular fitness is going to go up, we would expect an improvement in that within about four weeks compared to again the start. [SPEAKER_01]: And then for hypertrophy six to eight weeks is a reasonable timeframe to seemingly observe an increase in muscle cross-sectional area.

[SPEAKER_01]: Assuming that the environment is supportive of these things and adequate amount of sleep, adequate nutrition, and that you're actually doing the training. [SPEAKER_01]: The third way that people get this wrong is the same thing we've been talking about the entire podcast. [SPEAKER_01]: A mismatch between your training load and the resources that you have to deal with it. [SPEAKER_01]: And this can have an in both directions.

[SPEAKER_01]: A person who's not progressing because they're genuinely overreached. [SPEAKER_01]: would probably warrant a load reduction, meaning that their life total life load has gone up. [SPEAKER_01]: They probably need to reduce their training load, an athlete who is not progressing because they've been systematically underloading and interpreting normal fatigue as a warning signal, probably needs to increase their training load.

[SPEAKER_01]: Similar presentations, not progressing, but opposite intervention, so it's the interpretation that matters here. [SPEAKER_01]: getting this wrong towards underloading is just as costly as getting it wrong towards overloading is probably more common. [SPEAKER_01]: I think in the population that reads and listens to overtraining content. [SPEAKER_01]: I just don't see people kind of getting to a truly overtrained state that often.

[SPEAKER_01]: Does that kind of square with your your assessment? [SPEAKER_01]: You've been in the space for a while? [SPEAKER_00]: Yeah. [SPEAKER_00]: I really have little to add. [SPEAKER_00]: I think to the way that you've flush this out in the way that we think about it a lot of this involves conversations with people to try to get a get a feel with how they've been approaching not just their, you know, they're training.

[SPEAKER_00]: program broadly, but what it's like for them to approach each individual training session, what it feels like, and we can often draw some conclusions and nudge them in a more favorable direction kind of over time.

[SPEAKER_00]: But yeah, I think I keep coming back to mismatch, which really, you know, there's even some utility and looking at this similar to how we talk to people about injury, [SPEAKER_00]: If you think about this type of a syndrome, it's quote unquote injury, we would approach it similarly. [SPEAKER_00]: We often will broaden the variation that they're exposed to, pull back. [SPEAKER_00]: You know, their RPE is how close to failure.

[SPEAKER_00]: They're getting and then tinker with other variables like volume and frequency really based on their preferences and their current tolerance. [SPEAKER_00]: But those aren't like the primary levers that we're often messing with even in like a rehab context. [SPEAKER_00]: So there's some interesting similarities there when we look at it as a mismatch between their tolerance and what's being asked of them. [SPEAKER_01]: Yeah, yep.

[SPEAKER_01]: And so as we discussed in the training plateau action plan, if somebody presents with performance going down and they're sore all the time their tire their motivation is decreased and their session RP has gone up and is climbing. [SPEAKER_01]: probably a good idea to reduce training looks is too high for the current resources. [SPEAKER_01]: If they're relatively fresh, they're not sore, motivation is high, their session RP is going to be going down or it's steady.

[SPEAKER_01]: Their training load is likely too low for the resources that they have on board. [SPEAKER_01]: And so they would likely increase that to get performance to do the thing that they want it to do. [SPEAKER_01]: And this is all covered in our free training plateau action plan. [SPEAKER_01]: You can check that out in the description. [SPEAKER_01]: So what do we do with all this?

[SPEAKER_01]: Got the vocabulary with the caveat that it imposes the sort of false precision on a continuous variable that's noisy. [SPEAKER_01]: We have some of the biological background with the acknowledgement that the subjective report of the individual outperforms laboratory testing most of the time and we have a very clear picture now of how challenging interpreting training results can be. [SPEAKER_01]: So what remains is like, what do you do about all this?

[SPEAKER_01]: we keep going back to assessing trends, right? [SPEAKER_01]: So with performance, what's happening over weeks in months for a day-to-day? [SPEAKER_01]: Day-to-day is almost irrelevant to me outside of like an acute injury, right? [SPEAKER_01]: Even if someone's strength was down, for example, it's down 30% I'm like, [SPEAKER_01]: Sounds like you had a bad run of it, you know, in the last few days, let's see what happens over the next week. [SPEAKER_01]: For example, sure.

[SPEAKER_01]: Session RP is it creeping up? [SPEAKER_01]: How is your session RP look over the last week, two weeks compared to the three to four weeks before that? [SPEAKER_01]: Again, trends, not what's happening on single day. [SPEAKER_01]: Same thing with environment. [SPEAKER_01]: What's your dietary pattern been looking like over the past few weeks? [SPEAKER_01]: How is your weight changed? [SPEAKER_01]: How is your sleep looked over the last few weeks?

[SPEAKER_01]: For example, what's your life stress look like? [SPEAKER_01]: Again, short term. [SPEAKER_01]: I missed a meal. [SPEAKER_01]: I slept, you know, poorly last night. [SPEAKER_01]: I had a pretty stressful day. [SPEAKER_01]: Yes, can there be some acute effect, especially severe?

[SPEAKER_01]: Sure. [SPEAKER_01]: But like everyone who's listening [SPEAKER_01]: That's had an out-of-body experience at least one time in the jam when they felt hung over, when they felt tired, when they missed a meal, when life stress has been high, training performance is just too noisy to sort of map to a single short-term single-day type issue. [SPEAKER_01]: So again, look at trends and those things. [SPEAKER_01]: Finally, look at Sornus mood and motivation relative to training load.

[SPEAKER_01]: If you're becoming gradually more sore, your mood is tendon suffer, your motivation is going down. [SPEAKER_01]: To me, those are the variables I'm using to tease apart is as too much training load for the person right now versus too little. [SPEAKER_01]: If performance is going down and these things are going up, session RPs, going up, Sornus is going up, motivations going down. [SPEAKER_01]: Consider the training load is probably too much, reduce the intensity of the volume.

[SPEAKER_01]: 20% reduction in both of those is a reasonable target admittedly. [SPEAKER_01]: I just made that up. [SPEAKER_01]: It's speculative. [SPEAKER_01]: If performance is going down, but these things are steady or improving. [SPEAKER_01]: Session RPE is not going up, it's maybe going down. [SPEAKER_01]: Your motivation to train is still there, you're not feeling too sore. [SPEAKER_01]: It's probably too little training stress, too little training low.

[SPEAKER_01]: So you can increase training low. [SPEAKER_01]: Usually volume, if previously responsive to that same program, about a 10% increase, so another set or two is a reasonable modification. [SPEAKER_01]: Again, it mentally speculative, but that's what I do in practice.

[SPEAKER_01]: If you weren't previously responding well to a program, your five weeks into it haven't gotten any fitness adaptations, there's something deeper going on there, potentially with the program, whether it's exercise selection, whether it's your average intensity, there's a lot of different changes you can make.

[SPEAKER_01]: I would start with increasing and volume up a little bit and maybe average intensity and then circling back around and saying that they look, was this actually a good formulation of training for you with respect to exercise selection, for example. [SPEAKER_01]: If changing the programming and addressing lifestyle factors does not resolve this sort of performance decline, consider a medical workup. [SPEAKER_01]: Austin, what would that look like for you?

[SPEAKER_01]: If you had a person who's, look, I've got the Barbomedicine training action, the Traim Plateau action plan.

[SPEAKER_01]: I went through all the steps, use your guys' programs, note nothing doing. [SPEAKER_01]: How do you start that work up and, you know, obviously can you're an internist, so this could go in legitimately. [SPEAKER_01]: Yeah. [SPEAKER_01]: Different directions. [SPEAKER_01]: But how would you, how would you do that? [SPEAKER_00]: Yeah. [SPEAKER_00]: I mean, the easiest answer here is to set up a consultation with a trusted healthcare professional that could be one of us.

[SPEAKER_00]: We, and I do these kind of consults with people semi-regardly. [SPEAKER_00]: We offer them through, through Barbara Medicine to be a bit self-serving there, I suppose, in the sense that hey, I recommend such a service if somebody is having trouble navigating

[SPEAKER_00]: clinician a resource that they can work through this with, but you know, I'm looking at based on the history that they're describing, again, are there localizing symptoms that make me more concerned of it a particular area or organ system or is it a more generalized process in which case I'm looking at more of these generalized things?

[SPEAKER_00]: In many patients, especially women, younger women, reproductive age women, [SPEAKER_00]: iron deficiency again, that prevalence is just so high and so many people don't test for it or they test for it improperly. [SPEAKER_00]: A blood iron level is not the right test. [SPEAKER_00]: A blood ferritin level is the right test, but there are caveats to interpretation. [SPEAKER_00]: You cannot trust lab reference ranges. [SPEAKER_00]: So I'm going to are you know rant about that again.

[SPEAKER_00]: sleep sleep apnea testing working with a sleep medicine physician if you need to looking for a prior history of post viral syndromes infections that triggered this kind of thing endocrine apathy is with a thyroid or testosterone things like that if the person's on other medications and supplements the how could those be impacting things so it's going to really involve a detailed history and then an individualized evaluation and and [SPEAKER_00]: assessment plan.

[SPEAKER_00]: It's not necessarily just like getting a massive panel of like every lab under the sun. [SPEAKER_00]: I do have people who come in with those sorts of like massive lab tests, panels that they've had done, whether they've self-sought those things out, whether somebody else has checked them.

[SPEAKER_00]: And honestly going through them, especially when it comes to hormone testing, a lot of the signal that we end up getting, or I'm not signal, a lot of the results that we end up getting, turn out to not be signal and end up being noise that is unhelpful and in many cases shouldn't have been tested at all. [SPEAKER_00]: So it can be messy and you need to work with someone [SPEAKER_01]: All right, here's the short version of everything.

[SPEAKER_01]: Over Training Syndrome is a retrospective diagnosis applied to a continuous variable. [SPEAKER_01]: We've divided into three categories that look identical at the time of presentation. [SPEAKER_01]: Zero control studies have taken a person from healthy to overtrained under experimental conditions. [SPEAKER_01]: The biomarkers, most commonly used to monitor it, don't reliably detect it. [SPEAKER_01]: The six mechanistic hypotheses are each partially supported in each fall short.

[SPEAKER_01]: What does that mean practically? [SPEAKER_01]: When performance goes down, we should probably start with sleep and dietary intake. [SPEAKER_01]: Calories and carbohydrates specifically before you touch training load. [SPEAKER_01]: If these can't be modified for some reason, reduce your training load by about 20% to match your current training resources better. [SPEAKER_01]: Now, to avoid getting there in the first place, should track your session RPE trend over weeks, not days.

[SPEAKER_01]: Three consecutive weeks of rising session RPE at the same relative training load is a real signal worth looking at. [SPEAKER_01]: One bad session is probably fine to ignore. [SPEAKER_01]: Now, if programming adjustments and lifestyle factors don't move the needle, consider a chat with a trained medical professional to see if you would benefit from a medical workup. [SPEAKER_01]: The people who get hurt by the over-training narrative are usually not the ones doing too much.

[SPEAKER_01]: They're the ones who reduced training they didn't need to reduce based on framing of normal fatigue as a system failure. [SPEAKER_01]: All of the studies are in the show notes, our training plateau action plan is free, on the website, it's a good practical tool for figuring out whether you're doing too much, too little, or testing the wrong thing. [SPEAKER_01]: Link is in the show notes below. [SPEAKER_01]: Thanks for listening to the barbell medicine podcast.

[SPEAKER_01]: I'm Dr. Jordan Feigambam. [SPEAKER_01]: We'll catch you next week.