2. Unexplained Underperformance Syndrome Dr Richard Budgett Chief Medical Officer London 2012 7 th April 2008

3. London 2012:Unexplained Underperformance Syndrome 07 April 2008 3 The diagnostic dustbin Case histories Research Prevention and management

4. London 2012:Unexplained Underperformance Syndrome 07 April 2008 4 The Diagnostic Dustbin Overtraining Syndrome Burnout Staleness Chronic fatigue in Athletes Under recovery syndrome Sports fatigue syndrome Depression

5. London 2012:Unexplained Underperformance Syndrome 07 April 2008 5 Over-reaching Fatigue Underperformance Depression Most recover quickly (Steinacker JM) A few fail to recover ………… Chronic fatigue +/- frequent infections

6. London 2012:Unexplained Underperformance Syndrome 07 April 2008 6

7. London 2012:Unexplained Underperformance Syndrome 07 April 2008 7 New definition: Unexplained Underperformance Syndrome (UUPS) Persistent unexplained performance deficit (agreed by coach and athlete) despite 2 weeks of relative rest. The following have been reported in UPS: Fatigue and unexpected sense of effort Also History of heavy training and competition Frequent minor infections

8. London 2012:Unexplained Underperformance Syndrome 07 April 2008 8 Other Reported Symptoms Loss of energy Unexplained heavy, stiff and/or sore muscles Mood Disturbance: Anxiety, Depression Irritability, Emotional Lability Loss of competitive drive Loss of libido Loss of appetite Change in expected sleep quality Underperformance with an inability to increase the pace at the end of a race.

9. London 2012:Unexplained Underperformance Syndrome 07 April 2008 9 Swimmer January :Doubled training Full time and new coach Loss of control over training Moved house February :Improved performance

10. London 2012:Unexplained Underperformance Syndrome 07 April 2008 10 March :Fatigue, heavy muscles, loss of motivation, raised resting pulse rate, submaximal performance maintained April :Underperformance May :Recovery programme Aug:World Championships

11. London 2012:Unexplained Underperformance Syndrome 07 April 2008 11

12. London 2012:Unexplained Underperformance Syndrome 07 April 2008 12 Size Fatigue Resistance 2b 2a 1

13. London 2012:Unexplained Underperformance Syndrome 07 April 2008 13 Increased Prolactin release in response to a 5HT releasing agent (m-CPP) in athletes with UUPS L Castell, R Budgett Prolactin concentration (µM) (+/- SEM) Time after (or before) administration mCPP -30mins0mins120mins 150mins Control 128 (12) 137 (27) 202 (28)236 (28) UPS 198 (21) 180 (20) 300 (42)325 (48) p < 0.01NS p< 0.001 p<0.001

14. London 2012:Unexplained Underperformance Syndrome 07 April 2008 14 Prevention Optimise training Remember recovery and regeneration

15. London 2012:Unexplained Underperformance Syndrome 07 April 2008 15 Other Reported Symptoms Loss of energy Unexplained heavy, stiff and/or sore muscles Mood Disturbance: Anxiety, Depression Irritability, Emotional Lability Loss of competitive drive Loss of libido Loss of appetite Change in expected sleep quality Underperformance with an inability to increase the pace at the end of a race.

16. London 2012:Unexplained Underperformance Syndrome 07 April 2008 16 Individual monitoring Performance POMS/questionnaires H.R. Lactates/RPE CK/Urea C:T ratio NAd/Ad Eccentric/concentric ratio Heart rate variability Experience of coach and athlete

17. London 2012:Unexplained Underperformance Syndrome 07 April 2008 17 Management Exclude other illness Treat as ‘U.P.S.’ Label as “under recovery syndrome” or “sports fatigue syndrome” Convince coach and athlete of need for 6-12 weeks relative rest. Regeneration strategies

18. London 2012:Unexplained Underperformance Syndrome 07 April 2008 18 Light exercise: HR 120-140 10 minutes --- 20 minutes --- 30 minutes --- 1 hour Volume then intensity

19. Graded Exercise therapy in Chronic fatigue syndrome BART’S TRIAL 12 weeks exercise OR flexibility 55% better in exercise group 27% better in flexibility group (Fultcher and White 1997)

20. London 2012:Unexplained Underperformance Syndrome 07 April 2008 20 Manchester Trial 4 Groups: 6 months fluoxetine and exercise, just fluoxetine, just exercise or placebo Improvement with exercise (non significant trend) and depressed patients only helped if treated with fluoxetine (Wearden et al 1998)

21. London 2012:Unexplained Underperformance Syndrome 07 April 2008 21 Short Sprints –Maximum 10 seconds –Minimum 3 minutes rest –2-3 times per week

22. London 2012:Unexplained Underperformance Syndrome 07 April 2008 22 Athletes with UPS are different from patients with Chronic Fatigue –Underperformance –Present earlier –Less severely affected –Recovery more quickly –Major stresses are exercise and competition –Rehabilitative exercises - hold back

23. London 2012:Unexplained Underperformance Syndrome 07 April 2008 23 Summary –Over reaching with fatigue and underperformance is normal in athletes. –Underperformance lasting 2 weeks despite tapering is not normal and is best described as Unexplained Underperformance Syndrome. –If a current medical problem is excluded then the management is similar whatever the cause

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