trojian speaker 2 fatigue in the athletes...
TRANSCRIPT
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Evaluating Fatigue In the Athlete
Thomas Trojian, MDDrexel University
ttrojian,drexelmed,edu
Lab test, or not lab test?
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Conflict Statement
• I have NO conflicts to declare.
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Objectives
• The participants will be able to – Define fatigue in an athlete– Describe the most important part of the evaluation of fatigue in an athlete
– Develop a differential diagnosis for fatigue– Identify common infectious causes of fatigue– Implement an evidence based plan for evaluation
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Fatigue Facts• 6 ‐ 7 % prevalence in general population• $136 billion in lost productivity• 7 million office visits
• In primary care:• 21 to 33 % report “Significant fatigue”
• 1/3 of adolescents report it
Rosenthal, T, Fatigue: An Overview, AFP, 2008;78:1173-1179
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Definition – Clinical Fatigue• Inability to initiate activity
– perception of generalized weakness, in the absence of objective findings
• Reduced capacity to maintain activity– easy fatigability with exertion
• Difficulty with concentration, memory, and emotional stability
– mental fatigue
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Case 1
• 25 year old male runner with about 4 weeks of fatigue with exercise, mild shortness of breath and cough post‐exercise. He notices it worse in the January/February if runs outdoors, and May when allergies “kick in”.
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Case 2
• 26 year old female curler with about 2 months of fatigue with exercise, and non‐specific leg heaviness and irresistible urge to move the limbs
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Case 3
• 16 year old male high school student with about 8 weeks of generalized fatigue, worse with exercise, he is having trouble getting to practice, as well as some motivation and concentration problems with school work. He has done well in sports. Mom is okay with him not playing football.
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Case 4
• 18 year old female college student‐athlete with about 2 weeks of fatigue with exercise, diminished performance in her sport, feels like she is not rested after sleep.
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Case 5
• 28 year old male professional soccer player with about 8 weeks of fatigue with exercise, mild shortness of breath with exercise, some generalized daytime fatigue, and feeling sadness.
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Fatigue in Athletes
• Real or perceived:–Decrease in performance (exercise capacity)– Plateau in performance– Lack of improvement with training– Intolerance to increased training intensity– “Run down” without specific complaint
• Patient‐driven or from peers, coaches, family
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Basic Assumptions
• Healthy population
• New onset
• Reliable historians
• No secondary gain
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Red Flags
• Fever/Chills• Night sweats• Hemoptysis• Weight loss• Bleeding disorders• Trouble with daily activities• Amenorrhea, Low BMI (<15)• Stress fracture
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Red Flag Concerns
• Diabetes• Leukemia / cancer• Heart disease
– Congenital– Myocarditis
• Hypercalcemia (PTH)• Acute infection
– HIV, Hepatitis– Pulmonary embolism
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Br J Sports Med 2006;40:541–544.
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Br J Sports Med 2006;40:541–544.
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Fatigue
Neuropsych
Infectious
Functional
Metabolic
Nutrition
Exercise
Sleep
PregnancyAsthma
Allergies
Celiac
Stress
Diabetes
Thyroid Anemia
IronVitamin D
Depression
Grief
Adjustment Disorder
Concussion
Domestic violence
Substance abuse
Mono
CMV
HIV
Chronic Infection
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History
• Onset ‐ abrupt or gradual, related to event or illness• Course ‐ stable, improving or worsening• Duration and daily pattern• Factors that alleviate or exacerbate symptoms• Impact on daily life ‐ ability to work, socialize, participate
in family activities• Accommodations patient has made to adjust
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History – Social and ROS important– Depression/anxiety, Past trauma or abuse– Interest in school, social activities/support system, hours in work/school
– Current life stress, relationships, school, work– Change in activity or diet– Medications, substance use– History of anemia, iron deficiency, mood or eating disorders
– Menstrual patterns– Family history
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More History...
• Sleep habits, quality• Nutrition: Food frequency questionnaire• Digestive: diarrhea, bloating, discomfort• Exercise: frequency, intensity, duration, effect on symptoms
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Concussion• Remember to ask about recent head injury
• “Follow up accident (MVA)” visits – Many patients are not educated about concussion– Leave ER with lots of normal xrays– Lingering effects on mood, energy, sleep and concentration are common
• CDC Concussion information is excellent:• http://www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.html
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Physical Exam• General
– Alertness, appearance, mood/affect• Neck
– Lymphadenopathy, goiter, thyroid nodules• Chest
– Murmurs, crackles, wheezing• Neurologic
– Tone, bulk, reflexes• Extremities
– Edema
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Lab Workup
• Unknown etiology– CBC with differential– TSH, with reflex freeT4– Ferritin, ESR
• Consider–Urinalysis– EBV/Mono, Pregnancy, Vitamin D, HIV– PPD/Interferon gold
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Olympic Team Blood Workup
• RBC, Hgb, Hct, WBC, Differential • Chemistry, Creatine Kinase (CK), LDH• Ferritin, Iron, TIBC, Transferrin Saturation• Cortisol• Lipids, Urine specific gravity
Br J Sports Med. 2008 May;42(5):334-7.
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Exercise Fatigue Test
• 15 min of constant‐load exercise specific to his or her sport
• The exercise was performed at 85% of HRM, 15 or ‘‘Heavy’’ on Borg’s 6–20 RPE scale
• All tests were performed outdoors. • Venous blood (4 mL) was collected from an antecubital vein immediately before and within 5 min after exercise.
Locke S, Scand J Med Sci Sports 2011: 21: 90–97
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Locke S, Scand J Med Sci Sports 2011: 21: 90–97
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Clinical Indicators for Lab Tests• Hemoglobin/Ferritin
– Pallor, tachycardia, dyspnea, symptoms of anemia– Dietary, personal or family history of anemia risk:
• vegetarians (18%) and omnivores (13%) ferritin <12 microg/L
• White blood cell count– Fever, evidence of infection– Weight loss, lymphadenopathy
• Erythrocyte sedimentation rate (ESR)– Arthralgia, arthritis, concern for malignancy
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Clinical Indicators for Lab Test• Thyroid Stimulating Hormone (TSH)
– Dry hair/skin, change in bowel habits, abnormal menses, depression
• Electrolytes– Medications: Diuretics, steroids
• Renal function– Elevated blood pressure, edema, pruritis– Medication affecting renal function
• Glucose– Polydipsia, polyuria, polyphagia, family history
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Lab Utility
• Primary care– 5% hit rate– Higher in athletes?
• Useful in Athletes– Positive• Iron, anemia, mono, thyroid
– Negative• Depression, stress, sleep, nutrition, overtraining
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Blood Tests
• A low yield from a selection of test results used to identify underlying pathology in athletes presenting with persistent symptoms of fatigue.
• Complete blood count, ESR, and thyroid function tests yielded clinically relevant abnormal results.
• ? Of usefulness of ferritin
Journal of Science and Medicine in Sport (2007) 10, 351—355
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Psychiatric• Depression / Anxiety• Adjustment disorder, somatization
Stress, expectationsFamily/relationshipDomestic violence
• Disordered eatingAnorexia, Bulimia
• Substance abuse• Grief
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Feeling bad on Facebook
• 200 Facebook profiles were evaluated• 25% displayed depressive symptoms
–2.5% met criteria for Major Depressive Episode
• References to depression were more common when a response to prior disclosure occurred
• Moreno, MA, Feeling bad on facebook: Depression disclosures by college students on a social networking site, Depression and Anxiety, 2011, 0:1‐9
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Depression• Seen in 2‐10 % of college population• Overlap with
– Adjustment disorder– Grief– Stress & Anxiety– Sleep disturbances
• Responsive to:– Counseling– Medication
• Self‐management
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Depression
• Loss of interest in pleasure• Loss of motivation• Loss of sense of control• Functional impairment may not relate with severity of depression
• Denial is frequent• Ask about mood, stressors, and suicide
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Depression Screening & Treatment
• We’re implementing screening with PHQ‐2, followed by Zung, or Beck or PHQ‐9
• Need release signed to help care manager between counseling and medical sides
• Screening is a gateway to conversation about mood, sleep, suicidal thoughts
• Objective measure of mood for tracking• Tools for providers to assess, diagnose, treat and track are available in EMR (medical record)
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Infectious
• Acute, subacute, chronic• Mono, CMV, HIV• Athletic lifestyle can cause:
– Inadequate recovery– Impaired healing– Weakened immunity
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50 Fatigued Aussie Athletes
}50%
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Mononucleosis
• Epstein‐Barr Virus• Upper respiratory infection followed by fatigue/malaise– Posterior cervical nodes
• Splenic rupture– Risk estimates ~ 1:500– Spontaneous, Valsalva or traumatic
• Rest from sports, strenuous activity for 4 weeks
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Mononucleosis
• 4‐6 week incubation• No quarantine• EBV serology to confirm, simultaneous Strep common• Splenic rupture most likely in first 3 weeks• If feeling well, light exercise at 2 weeks, progress slowly• Contact sports at 3 weeks, collision 4 weeks• rare prolonged fatigue syndrome• typical recovery by 6‐8 weeks
Clin J Sport Med. 2008 Jul;18(4):309-15.
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Natural History of Mono
• 150 patients aged 16 and up, followed for 6 months
Symptom Initial % 1 Mo 2 Mo 6 Mo
Sore Throat 74 16 11 11
Fatigue 77 28 21 13
Sleeping too much 45 18 14 9
Headache 50 15 15 16
Sore muscles 28 14 11 11
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Rea TD, JABFP, 2001; 14(4): 234-42.
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Endocrine/Hematologic
• Iron deficiency• Anemia• Hypothyroid• Diabetes
– Polydipsia, Polyphagia– Polyuria, Weight loss
• Vitamin D deficiency
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Iron deficiency• History
–Meat restriction (Vegetarians 18%, Omnivores 13%)– Insidious onset of fatigue– Females
• Screening– CBC, Ferritin, perhaps iron studies
• Treatment–Oral iron, nutrition
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Iron deficiency• ferritin < 35 ng/ml• precedes anemia• declining MCV• absorbed in proximal small bowel• give with vitamin C or OJ• plan 3‐4 months of iron• recheck at 4‐6 weeks• female vegans have 40% risk
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Decline in iron during boot camp
• Basic Combat Training, female recruits–7% at start were iron deficient–18% at end–iron status correlated with running performance
• 1 to 1.5 hours of exercise–4‐6 days/week, for 9 weeks–16,000 steps/day vs 8,000 for civilians
• ~1 lb weight gain over 9 weeks
McClung, JP Br J Nutr, 2009; 102: 605-9
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Added iron in female soldiers• 219 female Army soldiers
•8 week basic combat training•20% had iron deficiency anemia
• 100 mg of ferrous sulfate daily vs placebo–Iron improved Vigor scores
– Profile of Mood States (POMS)
–Limited iron loss associated with BCT•Did NOT eliminate it at this dose
–Improved running performance only if anemic
McClung, JP,. Am J Clin Nutr 2009;90:124-31
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Iron status in young athletes• Elite athletes from 11‐25 years old• Most females failed to meet iron RDA
•63% vs 19% for males• Low ferritin <35 more common
•57% vs 31% for males• Low levels associated with:• diet in females• higher expenditures in males
Koehler K, Eur J Appl Physiology, 2011
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Iron and the body• Iron deficiency affects:
– physical endurance– immune response– temperature regulation– energy metabolism– cognitive performance– behavior disturbances
• Murray‐Kolb, LE, Iron treatment normalises cognitive functioning in young women, Am J Clin Nutr, 2007; 85:778‐87
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Iron Supplementation Improves:
•Performance (ferritin below 20)– Increased speed on 15 km bike ergometer– Increased VO2Max, and oxygen consumption– “Maximal voluntary contraction strength” in
knee extension (response to training effect)•Labs: Increase in ferritin, may see Hgb rise•Subjective (ferritin below 35)
– Decreased sensation of “Fatigue” – in adult females (non‐athletes)
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Iron and cognition– Blinded, placebo controlled study comparing:
• Normal vs Iron deficient (ID) vs Iron deficiency anemia (IDA)– (Hb >= 10.5 and < 12)
– IDA < ID < Normal on baseline cognitive testing– Increased Ferritin responders
• Attention and Learning scores increased significantly• Memory score increased as well (p<0.07)
– Increased Hemoglobin responders• Attention and memory scores increased• Learning task speed improved
• Murray‐Kolb, LE, Iron treatment normalizes cognitive functioning in young women, Am J Clin Nutr, 2007; 85:778‐87
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Hematologic Screening• Australian Institute of Sport
– CBC, ferritin, iron, transferrin– 120 males, and 174 females over 2 years
• Males – 8 % had abnormal results– 4 % had low ferritin
• Females– 51 % had abnormal results– 16 % had low ferritin– One had hemachromatosis (persistent ↑ iron)
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Anemia
• History– Prior diagnosis– Unable to donate blood
• Trial with iron • Check response
• Check Reticulocyte count in 6‐8 days after starting iron– dilutional or sports anemia– Thalassemia trait ‐ anemia will not respond to iron supplements
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Anemia• Fatigue with activity• Pica ‐ compulsive ingestion of non‐nutratives• Pagophagia ‐ ice chewing• Anemia can be relative• Additional workup when appropriate
Eichner, ER. Iron Deficiency Anemia, Cur Sp Med Rep, 2010; 9(3): 122-3
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Hypothyroid
• 15% of women• 3‐4% of men• weight gain, fatigue, cold intolerance,
constipation, weakness• thyroid stimulating hormone (TSH), usually
reflex fT4• levothyroxine replacement
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Vitamin D ‐ Basics• Both a hormone and vitamin
– Calcium absorption, utilization and release– Affects parathyroid levels– Receptors for gene signaling
• Diet sources and direct conversion in skin with light (UV) exposure
• Symptoms: Nonspecific musculoskeletal complaints, fatigue, weakness, fractures/rickets
• Risk factors: Malabsorption, low dietary intake, limited sun exposure, darker skin coloration
Sports Med. 2014 Oct 3.
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Vitamin D ‐ Diagnosis• Measure:
– 25 hydroxy‐vitamin D 25‐OH‐D• Deficiency (insufficiency) is common (ages > 11):
– > 30% deficient (less than 20 ng/ml 25‐OH‐D)– > 70% insufficient (less than 32 ng/ml 25 OH‐D)
• Target levels are controversial– 30‐50 ng/ml
• Sun absorption/exposure varies greatly• Treat for 2‐3 months, discuss on going dosage
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Vitamin D
• RDA 800 iu/day D3• Max routine daily intake 4000 iu/day D3• Daily 800‐4000 iu D3 (cholecalciferol)• Weekly 50,000 iu D3
– or D2 (ergocalciferol)• Ensure 1000 mg of calcium/day• Other research findings:
– 500,000 iu once a year D3 was NOT effective– toxicity at 60,000 iu D3 DAILY– 1500/day=10,500/week=45000/month
Curr Sports Med Rep. 2010 Jul-Aug;9(4):220-6.
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Vitamin D
• Some evidence for mood benefits in depression
• Some evidence in restless leg syndrome• Some evidence in stress fractures
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Cardiopulmonary
• Myocarditis– Recent infection with new chest pain and fatigue
• Asthma–Diminished exercise capacity– Allergic– Exercise‐induced
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Exercise Challenge
• 8‐10 minutes minimum of hard exercise without warm‐up, following by serial spirometry post exercise
• Reproduces environment more accurately• More sensitive than indoor treadmill tests• Lack of standardization in methods and interpretation of
results– Positive test: >10% drop in FEV1
• Requires access to spirometry to be accurate– PEF less reliable
• Requires available trained personnel to administer
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Eucapnic Voluntary Hyperventilation
• Voluntary hyperventilation of dry air containing 5% carbon dioxide– Steady state protocol: 85% max ventilation for 6 minutes
• Similar airway response to exercise at the same ventilation
• High specificity for asthma– 100% with 20% drop of FEV1
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Medical Treatment For AsthmaInhaled Steroids
• First line therapy for chronic asthma• Also consider in elite athletes who train nearly daily and require
consistent prophylaxis• Inhaled Corticosteroids
– Triamcinolone (Azmacort)– Beclomethasone (Vanceril, Beclovent)– Flunisolide (AeroBid)– Fluticasone (Flovent)
Phys Sportsmed. 2013 Sep;41(3):50-7.
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Functional
• Nutrition– Disordered eating– Inadequate caloric intake
• Inadequate recovery• Sleep, sleep, sleep• Pregnancy• Female athlete triad
– disordered eating– amenorrhea/oligomenorrhea– osteopenia
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Functional
• Suspect nutrition:• Change in activity intensity• Weight loss• Intense exercise
• Sleep/rest are essential• Deficient sleep is common
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Female athletic performance
• Strong relationship between caloric restriction and vegetarian diet
• Causal relationship between energy balance and menstrual dysfunction
• Energy deficit associated with poor athletic performance
Van Heest, JL, Cur Sp Med Reports, 2007; 6:190-194
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Iatrogenic• Medications
– hypnotics– muscle relaxants – Antidepressants– antihistamines– beta blockers– antibiotics
• Paradoxical fatigue • with imposed rest• especially in active individuals
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Exercise improves (relieves) fatigue
• Acute: Over 6 weeks, increased vigor and decreased fatigue in college students
• Chronic: 10 to 20 weeks, increased energy in fatigued subjects
Dishman, RK,. Psychophysiology, 2010; 47(6): 1066-74 O'Connor, PJ, Med Sci Sports Exerc, 2005; 37(2):299-305
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Case 1• 25 year old male runner with about 4 weeks of fatigue with exercise,
mild shortness of breath and cough post‐exercise. He notices it worse in the January/February if runs outdoors, and May when allergies “kick in”.
• Spirometer in office was normal.• Trial of short‐acting beta‐agonist not helpful• Exercise EIB testing revealed 20% drop in FEV1
• Started inhaled corticosteroid since daily sx and SABA prior to exercise. Allergy treatment.
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Case 2• 26 year old female curler with about 2 months of fatigue with
exercise, and non‐specific leg heaviness and irresistible urge to move the limbs
• Vitamin D 25 OH <10, rest normal• DX: Vitamin D deficiency• Symptoms resolve with vitamin D replacement
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Case 3• 16 year old male high school student with about 8 weeks of
generalized fatigue, worse with exercise, he is having trouble getting to practice, as well as some motivation and concentration problems with school work. He has done well in sports.
• History reveals: Crying spells, getting angry easily, Zungs’ depression scale 70 (abnl)
• Normal labs• DX: Depression• Treated with bupropion
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Case 4• 19 year old female college student‐athlete with about 2 weeks of fatigue with exercise,
diminished performance in her sport, feels like she is not rested after sleep.
• History: distance runner with decrease performance. Dietary and menstrual history normal. Examination: posterior cervical nodes
• Mono test and EBV titers positive.• DX: EBV Infection recent
• Rest and then re‐initiate training after 1 week pacing back over 2 ‐4 weeks.
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Case 5• 28 year old male professional soccer player with about 8 weeks of
fatigue with exercise, mild shortness of breath with exercise, some generalized daytime fatigue, and feeling sadness.
• History: Asthma workup was negative, depression scale was 35.
• Labs: Elevated TSH• DX: Hypothyroid ‐ Responds well to levothyroxine replacement
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FATIGUE
FunctionalNutrition, OvertrainingPregnancy, AsthmaAllergies, CeliacSleep, Stress
NeuropsychDepression, GriefAdjustment DisorderConcussionDomestic violenceSubstance abuse
MetabolicDiabetes, ThyroidAnemia, IronVitamin D
InfectiousMono, HIV,SinusitisChronic Infection
Multifactorial Nature of Fatigue
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Summary of guidelines for fatigueConsensus for:
• Maintenance of a diet to ensure sufficient calories to meet the energy expenditure demand.
• High pre‐exercise glycogen stores and glucose feeding during exercise.
• Use of vitamin C 1000 mg to offset immunosuppression.
• Use of fluid replacement strategies to ensure euhydration.
• Holistic monitoring of athlete stress.
Nimmo MA, Journal of Sports Sciences, 2007; 25(S1): S93 – S102
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Summary
• Careful history– Timing, habits, mood, nutrition, illness
• Screening labs when needed– CBC, ferritin, thyroid, infection, vitamin D
• Remember– Stress, mood, sleep, workload
• Athletes are at risk
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Objectives
• The participants will be able to – Define fatigue in an athlete– Describe the most important part of the evaluation of fatigue in an athlete
– Develop a differential diagnosis for fatigue– Identify common infectious causes of fatigue– Implement an evidence based plan for evaluation
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Thank you
• Questions
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References• Catassi, C, Celiac Disease, Cur Opin Gastroenterology, 2008; 24:687‐91• Eichner, ER. Iron Deficiency Anemia, Cur Sp Med Rep, 2010; 9(3): 122‐3• Fallon, K, Clinical utility of blood tests in elite athletes with short term fatigue ,BJSM, 2006;40:541–544• Fallon, K, Utility of Hematological and Iron‐Related Screening in Elite Athletes, CJSM, 2004;14:145–152• Killip, S, Iron Deficiency Anemia, AFP, 2007;75:671‐8 • Koehler, K, Iron status in elite young athletes: gender‐dependent influences of diet and exercise, Eur J Appl Physiology, 2011, DOI 10.1007/s00421‐
011‐2002‐4• Kurowski, K, Food Allergies: Detection and Management, AFP, 2008; 77(12):1678‐86• Kurpa, K, Diagnosing MIld Enteropathy Celiac Disease: A Randomized, Controlled Clinical Study, Gastroenterology, 2009; 136: 816‐23• McClung, JP, Longitudinal decrements in iron status during military training in female soldiers. Br J Nutr, 2009; 102: 605‐9• McClung, JP, Randomized, double‐blind, placebo‐controlled trial of iron supplementation in female soldiers during military training: effects on iron
status, physical performance, and mood. Am J Clin Nutr 2009;90:124‐31 • Moreno, MA, Feeling bad on facebook: Depression disclosures by college students on a social networking site, Depression and Anxiety, 2011, 0:1‐9 • Murray‐Kolb, LE, Iron treatment normalises cognitive functioning in young women, Am J Clin Nutr, 2007; 85:778‐87• O'Conor, P, Chronic Physical Activity and Feelings of Energy and Fatigue, Med Sci Sports Exer, 2005;37:299‐305 • Rea, TD, Prospective study of the natural history of infectious mononucleosis caused by Epstein‐Barr Virus, JABFP, 2001; 14(4): 234‐42.• Reid, VL, Clinical investigation of athletes with persistent fatigue and/or recurrent infections, BJSM, 2004;38:42‐45• Reynolds, Gretchen, Crash and Burnout, NY Times, 3/2/2008• Ricci, JA, J Occup Environ Med 2007;49:1• Rodenberg, R, Iron as an Ergogenic Aid: Ironclad Evidence?, CSMR, 2007;6:258‐264• Rosenthal, T, Fatigue: An Overview, AFP, 2008;78:1173‐1179• Rubio‐Tapia, A, Increased Prevalence and Mortality in Undiagnosed Celiac Disease, Gastroenterology, 2009; 137:88‐93• VanHeest, JL, Female Athletes: Factors Impacting Successful Performance, Cur Sp Med Reports, 2007; 6:190‐194• Verdon, V, Iron supplementation for unexplained fatigue in non‐anaemic women: double blind randomised placebo controlled trial, BMJ,
2003;326:1124• Zotter, H, Abnormally high serum ferritin levels among professional road cyclists, BJSM, 2004;38:704‐708