Inflammatory Conditions in Athletics: More Than Just

Overtraining

Charlie Hoolihan, CSCS*D, NASM-CES/PES

Pelican Athletic Club Personal Training Director

Welcome to your conference?

Did you cram 40 hours of work into three and a half days, sleep less, feel irritable, eat out or skip meals more because you were working so much, plan or are worrying about next week’s task, increased your self-medicants (alcohol, comfort food or others), cut back or double your workout time and basically live on caffeine, guarana and aspartame all week. Did you fly or drive six hours here on an oh so comfortable airline or car seat?

An individual with an allergy/asthma does not get much sleep at night because he/she is stressed out at work/school that consists of sitting at a computer terminal/desk and is having trouble with a friend, relative or significant other.

They are time-crunched at school or work, have big projects due, been eating fast food five or six meals per week and consider themselves overweight or out of shape.

They solve this by getting up early before work/school and commit to more workouts. Right before the workout they have a fight with a housemate about household divsision of labor?

AND THE BIG MEET IS IN SIX DAYS!

Do any of your swimmers sound like this?

Self examination• Do you less than 7-8 hours of sleep per day.• Do you eat less than five or more servings of vegetables and fruits a

day? • Do you eat fast food or eat out more than three times per week?• Are your workouts over 90 minutes?• Do you have an “itis”?

– Sore joints - Tendonitis?– Dry or itchy skin or scalp – dermititis?

• Are you allergic to anything? Right now?• Do you have any aches and pains?• Any emotional stressors going on with significant others?• Any increased mental/emotional stressors at work?• Are you over 50 years old?• Do you fall asleep with box of Ho Hos, chips and a six pack in your

lap watching TV?

If you answered yes………

Inflammation

• Inflammito – Latin for: To set on fire.• Pro-inflammatory or anti-inflamatory.

• Water or gasoline.• Turn the heat up or turn the heat down.• Raging forest fire or boiling cauldron

Inflammation is supposed to be a good thing

• A protective mechanism• A vital component of our immune system• A part of our natural defense system against

infection, irritants, toxins.• Pain or irritation is a warning that something is

amiss.• It is a very efficient system that must be

acknowledged and cared for proactively.

That has evolved into a bad thing• Modern life style is causing the natural balance of immune

system to shift into a state of chronic inflammation.• More and more inflammatory conditions that were rare are

becoming common, almost accepted as inevitable.– Asthma, mood disorders, ADHD, metabolic syndrome, Alzheimers,

obesity, arthritis.

• More and more our society is trying to develop medications for these maladies rather than choose lifestyle changes.– Fybromyalgia? CFS? Obesity virus!? Obesity genes!?

• More and more we are opting for surgeries and procedures that could be substitute with lifestyle changes.

• More and more super-bugs are getting into our system.• More and more irritants are getting into our system.

Chronic vs. Acute Inflammation

• Acute inflammation is a natural body function to help repair damaged tissue or ward off viruses and bacteria.

• Chronic inflammation occurs when non-stop pro-inflammatory conditions maintain a constant state of low or high grade inflammation.

Ailments directly associated with inflammation• Cardiovascular disease• Gingivitis• Dermatitis• Rhinitis• Arthritis• Allergy - histamines• Diabetes Mellitis• Mood disorders• Cancer *• Obesity*• Asthma• Tendonitis• Gastritis or IBS• To name a few.

*Both cancer tumors and adipose tissues develop their own inflammatory system.

Inflammation is caused by:• Tissue damage

– Physical Trauma• Accidents -Workouts – Repetitive stress –

misalignments.

• Mental and emotional stressors.– FEAR – false expectations appearing real.

• Lifestyle stressors.– Sleep– Nutrition– Environment

Inflammation is regulated by• Immune system

– Interleukin-1 (IL-1), Interleukin-6 (IL-6) and Tumor Necrosis Factor alpha (TNF-a). As we will see, these cytokines along with C-reactive protein

• Nervous system– Chemicals, physical stress, or mechanical manipulation (pushing

or pressing on the nerve) are all capable of causing inflammation this way. Adrenaline and Noradrenaline

• Endocrine System – – controls much of the body’s regulating hormones, the body's pH,

body temperature, and the chemicals in the bloodstream, all of which have precise relationships to each other that should not be altered for significant lengths of time. Testosterone, Cortisol GH

Inflammation is caused by direct tissue damage or invasion

• Physical trauma– Injury or intensive exercise bouts.– Virus – immune response.– Allergens - histamines and immune response.– Toxins – immune and liver response.– Intra-abdominal fat – develops its own system of pro-

inflammatories - and cytokines – TNF and IL-6 and CRP which also trigger a cortisol response.

• The body responds in a wonderful way to heal the trauma or rid our system of invaders.

Physiological disturbances1. Allergies – histamines – immune alert that starts the pro-inflammatory response to a foreign invader.2. Physical traumas – injuries or muscle damage.3. Excess intra-abdominal fat – fat cells, manufacture pro-inflammatory hormones and cytokines – TNF and IL-6 and CRP which also trigger a cortisol response.4. Environmental stressors – pollution, sick building syndrome.5. Invading virus, bacteria, fungi etc.

The immune and nervous system respond to…

Muscle Structure – lots of kindling

Copyright ©2003 BMJ Publishing Group Ltd.

Toumi, H et al. Br J Sports Med 2003;37:284-286

Figure 1. Proposed mechanism of the relation between the inflammatory response to mechanical injury and further muscle damage. The initial mechanically induced damage produces myofibre tearing and inflammatory cell infiltration. Neutrophils may promote further damage through the

release of oxygen free radicals.

Produce the same systemic response as the other stressors.

1. High intensity or long workouts are necessary to improve athletic performance.

2. Working out hard increases inflammation because muscles are being injured and repaired in order to come back stronger. The immune and hormonal responses are similar to physical injury.

3. Improper posture during workouts – add joint stress and inflammation to the mix!

Workout stressors

Muscle Damage Inflammation

• Eccentric weight training• Lengthy training sessions of 90 minutes or more.• Excessive cardiovascular sessions.• High intensity sessions lasting 20 minutes or more

Exercise Anabolic HormonesGood hormones that build

TestosteroneGrowth

Hormone InsulinIGF-1

Blocks Cortisol

Stimulates Protein Synthesis

Stimulates:

Bone Growth

Cartilage Growth

Protein Synthesis

Stimulates growth of:

Bone

Cartilage

Muscle

Stimulates:

Protein Synthesis

Glycogen Repletion

Exercise Catabolic HormonesHormones that breakdown tissue

Glucagon Epinephrine&

Norepinephrine

Cortisol

Stimulates Fat & Liver Glycogen

Breakdown

Stimulates Fat & Liver Glycogen

Breakdown Stimulates Fat and Muscle Protein

Breakdown

Overtraining:Too much of a good thing releasing to many bad

things.

Repetitive training exercise inflammation cascade

1. Misalignment of joints and musculature – Remember those negative emotions!

Inflammation is nature’s way of fixing the body when it is injured or irritated. Chronic misalignment and pain increase inflammation and all the negative hormonal responses – cortisol, interleukens, CRP.

There are a lot of procedures and medications that can be limited or avoided with proper alignment.

Arthokinetic stressors

Musculoskeletal Imbalances

Gait Homonculous Observed Relational Tabulator (GHORT) Pelvic tilt short leg syndrome

Head Tilt

Shoulder Drop

Arm length and swing

Back midline

Hip drop

Relative “Q” angle

Patellar positioning

Tibial variation

STJ EROMSTJ neutral positioningRearfoot positionForefoot position

Even if it is “healthy”

Knee and foot alignment are critical to long term health.

Squats with true alignment develop strength and joint health.

Muscles:Their Testing and Function, Kendal. McCrery and Provance, pg.97

A structure note! Swimmer alertHypermobility is not a good thing

upright and on land Muscles: Testing and Function, pg. 96

Sciatic nerve impingement

Hip flexor impingment

Scapular impingements

Thoracic Spine flexion

•

Weight of the upper body falls on the sternum. Can gravity win

Or will these muscles remain stressed.

HeadachesNeck aches.Stretched and strained nervesMuscle pulls.Exercise inducedInjuries.

Thoracic FlexionElevated or upright posture opens up chest cavity. The heart and aorta have ample room to deliver blood and oxygen to the body. The lungs can expand to full capacity. 

An extreme example of how a slouched posture can compress heart, lungs, aorta and interfere with proper cardiovascular activity

Another extreme example but compression can also occur in the lower organs like stomach, liver, spleen, uterus

Lymphatic system and hip flexors

• Diaphragm stimulates the natural pumping action of lymphatic system. White blood cells.– Heart transplant study. Lymphatic system efficiency is

increased by up to 700% via exercise.

• Psoas and QL are attached to the diaphragm via fascia.

• Restrictions in the thoracic spine, restricts breathing which restricts lymphatic circulation.– (Principles of Manual Therapy)

Diaprhagm and muscle attachments

Back study

Primary characteristic of most back issues is the inability to internally rotate at the hip.

Then the pain was differentiated either by

Bilateral limitation – lumbar pain.

Asymmetrical limitation – sacral pain.

Shoulder study

• Those with slumped shoulders had a 24 degree reduction in range of movement and a 12% reduction in strength

Inflammation is caused by stressors.

• Mental and emotional external stressors.– Work related.– People related.– Monkey chatter related.

• Constant internal dialogue

• Self-criticism

– Environment – non-stop stimulation. • A life at 180 BPM

What a zebra does with stress

What we do with stress

• Mental/Emotional stress.• Cortisol is produced in the body as a response to stress. But

it is not designed to be a long term stressor. • Increased cortisol shuts down immune system, decreases

anti-inflammatory hormones and increases insulin production leading to hyperinsulemia.

• Chronic stress leads to cortisol overloads.• In experimental studies, cortisol has been shown to decrease levels

of connective-tissue growth factors and inhibit the activity of bone-building cells (osteoblasts), muscle-building cells (satellite cells), and cartilage-building cells (chondrocytes).

Mental stressors

Mental States Related to Inflammation

• Increased perceived exertion and pain perception• Delayed onset muscle soreness (24-48 hrs post

ex.) • Varies with individual training status• increased resting cortisol and basic metabolic

functioning• changes in resting cardiovascular parameters

(sympathetic stimulation of norepinephrine)

Inflammation is caused by lifestyle

• Sleep habits

• Nutrition

• Environment

• Overstimulation– Multi-tasking– No quiet time

• Decreasing sleep from 8 to 6.5 hours per week increases cortisol and insulin levels.

• Night shift workers suffer from higher % of CVD, GI ailments, mood disorders than day shift.

• Reduces immune function.• Four hours per night for two weeks produced same test

scores as those who stayed up 3 days/nights.• A six year lifestyle study of one million Americans

determined that 4 hrs per night had highest mortality rate. Re-confirmed with same pop. 9 years later.

• Study on obesity and sleep• 4 hours or less per night – 70% chance of being obese.• 5 hours or less – 50% chance.• 6 or less – 30% chance.• Obese, not overweight. Lack of serotonin? growth hormone?

Sleep stressors

• Modern Diet – high glycemic foods• Increased insulin – increased inflammation.• Increased production of pro-inflammatory cytokin Interleukin-6

and C-reactive protein. Increased CRP is now a biomarker for potential heart disease.

• High fructose corn syrup.

• Modern diet – Fats• Trans-fats and Omega-6 fats – increase pro-inflammatory hormones. • Vegetable oils – corn, safflower, soy

• Modern diet – nutritional intake patterns.• Skipping meals – next meal is generally larger than needed.• Large portions – insulin spikes. Digestive system stressors.• Hydration concerns.

• Modern diet – food sensitivities and allergies• Too much of same nutrients• Corn, dairy, wheat, soy,

Nutrition stressors

Inflammation cascade • Combined factors increase inflammation

which increases physiological disturbance.– Japanese cedar study

• Pollen for centuries produced no allergic reaction.• Introduction of diesel exhaust increased levels of allergic

reaction.– Many mood disorders are combined with a wide variety of

inflammatory ailments.– Link between gum disease and CVD – CRP.– Autoimmune disorders. CFS – Rhinitis, mood disorder, fatigue.

• Fibromyalgia – all this and joint pain.– Soldiers exposed to 5 days of extreme exercise, starvation and sleep

deprivation had increased cortisol levels that did not return to normal even after 5 days of rest and refueling.

Inflammation and muscle loss

• Increased IL-6, TNF, neutrophils and macrophages limit muscle regeneration after intense exercise.

What are our current solutions to alleviate chronic inflammation?

• Ignore it till a medical manifestation occurs.– Medicate.

• Mood meds, corticosteroids, RLS med., obesity virus drug, fibromyalgia drug, asthma meds.

– Operate• Back surgery, joint replacements, nerve deadening.

– Vacate• Quit whatever activity that was painful.

Depressed yet?• Fear not

• Solutions are plentiful

Guidelines to lower risks associated with overtraining

• Keep life stresses to a minimum – or manage them more effectively.

• Eat well.• Avoid working out past the reserves during

high stress times.• Avoid rapid weight loss.• Sleep.• Stay fueled during long exercise efforts.

Exercise can reduce pro-inflammatory markers and increase

anti-inflammatory properties• Exercise efforts lasting 60 minutes or less reduces

inflammation markers.• Increases positive neurotransmitters and nerve

and circulatory growth factors.– Serotonin, Noradrenaline.

– Brain Derived Neurotrophic Factor. (BDNF)

– Vascular Endothelial Growth Factor. (VEGF)

– Fibroblast Growth Factor. (FGF)

– Insulin-like Growth Factor (IGF-1)

• Keep exercising and training but do it smartly Initial exercise bout

Muscle damage or injury

Adaptation

Connective Tissue Theory:Increases intramuscular tissue

Neural Theory: Changes in Nervous system

Cellular Theory: strengthen and protect muscle

Repeated bout of exercise

Less muscle damage

Strategies to Minimize Muscle Damage/Inflammation

• Non-Nutritional Strategies– Heat pad and cold press on sore muscles and joints. 1-2

min each for 10-20 min.

– Massage, foam roll, corrective exercise, flexibility

– Low intensity short duration exercise.

• Nutritional Strategies– Balance of Nutrients and caloric intake

– Timing of nutrients

– Supplements to aid in recovery

Some training strategies

• Assess workout demands and have back-up workouts for different demands in an athletes life.

• Provide plenty of restorative options – foam rolling, massage, flexiblity.

• Understand the overtraining model and plan effectively.• Understand the biomechanical repetitiveness of workouts

and try to diversify them in order to provide proper muscle balance and alignment.

Even high intensity and complex exercises are helpful

• High intensity of 70% + did better on a skill test than a 50% steady state group.

• Complex training – change of direction, agility work – did 20% better on a word recall list.

Balance the workouts

• By and large exercise has an anti-inflammatory function.

• It’s the duration that seems to be the issue.– 90 minutes or more has seen the most pro-

inflammatory responses.• Marathon finisher 24-72 hours later have all the heart attack

markers.– 60 minutes or less seems to be anti-inflammatory. Even

at high intensities.– If you have to train athletes longer – develop a solid

fueling strategy during that timeframe to lesson the stress of the workout.

1. Lifestyle:1. Calm energy vs. Tense energy

A. Develop calming strategies React calmly to tense situations

Take scenic drive homeTake joy and pleasure in little

thingsB. Short relaxation techniques

Relaxed breathing with eyes shutChange view – plants and happy

pixRelaxed and upright posture –

tension in upper body restricts O2 by 30%

Inflammation continuum solutions

SLEEEEEPSLEEEEEPSLEEEEEP

• Sleep allows the body to heal physically and mentally.

• Increases Anabolic Growth Hormone which has an inverse relationship with catabolic hormones insulin and cortisol.

1. Know when to say when: Make adjustments to allow for inflammatory factors.

2. Back off on some of the things you can control. Exercise. Do soothing movements, low intensity head clearing to stay in the groove and get the stress relief.

3. Improve some of the lifestyle things you can control.

4. Debilitating injury/illness and death are far worse options than whatever worry you are trying to handle.

5. It’s better to be 10% undertrained than 1% overtrained.

Inflammation continuum solutions

The Biology of Belief

Study designed to see what part of a standard knee surgery gave the most pain relief to individuals with osteoarthritis - shaving cartilage or flushing material from the joint thought to cause an inflammatory effect. A shaving group and flushing group were studied along with a control group that received a procedure complete with incisions designed to mimic surgery.

All three groups received the same post-operative care.

All three groups improved. One member of the control group who previously had to walk with a cane was playing basketball with his grandchildren two years later. (Lipton, 2005)

Nutritional Strategies• Encourage higher quality nutritional intake.• Provide clients with information on anti-

inflammatory foods and supplements.• Encourage regular meals.• Encourage sound pre and post exercise

strategies.• Encourage client testing of food

sensitivities.• Encourage hydration. Individual.

Nutrition and Muscle Damage

• Objective– To develop a nutritional strategy to minimize

damage/inflammation– Sufficient Caloric intake– Nutrient Timing (Critical)

• Carb/Protein Timing

– Proper Fueling/Hydration (before, during, and after exercise intense exercise)

– Potential Supplements of Benefit to aid in quicker recovery

During workout- Cortisol levels.

Effect on Cortisol Levels of Supplementation during Exercise

0

10

20

30

40

50

60

Carbohydrate SportsDrink

Water

Ch

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Pre

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Nieman, D. et al., Clinicals in Sports Med. (1999)

Nutrition timing during exercisers.

• NUTRIENT TIMING– Before – to be properly fueled

• Individuals must eat every three to four hours.• Be hydrated coming into the workout.

– During – to minimize muscle damage/inflammation• Some kind of healthy sugar carbohydrate beverage. Dilute.• Get protein after at the end or immediately after workout.

– 4:1 carb:protein mix– Peanut butter and jelly. Apples and almonds. Chocolate milk w-

out HFCS. Trail Mix,

– After – to aid in recovery process• 2 most important meals (immediately after and 2-3 hours after

workout)

Protein Synthesis after workoutEffect of Amino Acids and Carb Mixture on Protein Synthesis

Following Exercise

0

20

40

60

80

100

120

140

Carbohydrate Amion Acids Carb/AA

Nutrition

Pro

tein

Syn

thesis

(m

g/3

hr/

leg

)

Tarnopolsky, M et al. J of Applied Phys, 83: 1877-1883, 1997

Nutrient Delay and RecoveryEffect of Nutrient Delay on Muscle Anabolic Processes

0

100

200

300

400

500

600

700

Amino AcidUptake

ProteinSynthesis

Muscle Mass

Physiological Change

% C

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Immediately after exercise

Delay up to 3 hours after exercise

Anti-Inflammatory Foods

• Fish – salmon, tuna, halibut, sardines, mackerel.• Fresh Fruits and Vegetables – Flavonoids, Anthocyanins, Zeaxanthin, Lycopene,

Beta Carotene.• Olive Oil.• Extra-dark chocolate – with at least 70% cocoa content.• Red Wine – antioxidant Resveratrol.• Anthocyanin-rich cherries & acai berries.• Nuts – Almonds, Walnuts, Brazil Nuts, Pecans, and Cashews – high in Arginine

and Omega 3 Fatty Acids.• Allium Family of Foods – Garlic, onions, leeks, scallions, shallots, and chives

(High in Flavonoids).• Barley – high in soluble and insoluble fiber, low glycemic.• Herbs & Spices:

– capsaicin (red pepper)– green tea– Ginger – cancer fighting– turmeric (yellow spice in curry)

Omega-3’s

Lyon Heart Study of heart attack survivors

One group Omega-6 fats and standard AHA diet

Second group Omega-3 fats.

O-3 group: 70% reduction in number of fatal heart attacks and no sudden cardiovascular deaths which accounts for 50% of heart attack mortality rate.

Inflammation Continuum nutrition solutions

Beneficial SupplementsOmega 3’s

• Have anti-inflammatory properties– Slow muscle damage– Improve immune system function?

• May reduce joint pain• Best to take immediately after an exercise session

(2000 mg of DHA/EPA mix)• Adults

– Can increase Good Cholesterol (HDL)– Lower Triglycerides– Possibly lower blood pressure

Anti-Inflammatory Dietary Supplements

• Fish oil/Omega -3. • Glutamine.• Ginger - New Chapter’s Zyflamend.• Turmeric – New Chapter’s Zyflamend.• Digestive enzyme blends.• Probiotics – New Chapter.• Proteins/Aminos for muscle repair.• Vitamins C/E and other antioxidents.

Performance Athletic Supplements

• Glutamine

• Phosphotidylserine

• Vitamins C & E

• Whey & Casein Protein Mix– Ex. Myoplex Original

• Omega 3 Fatty Acids

Know clients/athletes• Periodization of their workouts according to their

life demands.• Understand their individual exercise thresholds for

strength and anaerobic capacity. It’s better to be 20% undertrained than 5% overtrained.

• Understand how that some types of motivation are inflammatory in more ways than one.

• Make sure alignment is correct. Add exercises that promote alignment.

• Provide them w anti-inflammatory lifestyle recommendations

Thanks!• My email Charlie@thepac.com

– The Anti-Inflammation Zone, by Barry Sears; The Inflammation Cure by William Meggs, Stopping Inflammation by Nancy Appleton, The Cortisol Connection by Sean Talbot Beyond Asprin by Thomas Newmark and Paul Schulick