An Examination of Chronic Fatigue Syndrome in Athletes
How to Prevent Low Performance

By Matt Poe


Overuse injuries, overtraining, and burnout among athletes of all ages are a growing problem in the United States. Although inactivity and obesity are on the rise, the number of athletes who participate in organized, professional, or recreational athletics has grown considerably over the past 2 decades. It is estimated that 30 to 45 million youth, 6 to 18 years of age participate in some form of athletics(3,6,11). Sports participation is more accessible to all youth, from recreational play and school activities, to highly organized and competitive traveling teams, to pre-Olympic training opportunities. There are an additional 5 million professional athletes that participate and their athletic performance is counted on to bring them a supporting income for their families as well as themselves(5,12).

The variety of available, organized sporting activities has also grown from the typical American favorites, such as football, baseball, and soccer, to include lacrosse, field hockey, rugby, cheerleading, and dance, each with its own list of sports medicine concerns. This report will highlight specific overtraining issues such as participation in endurance events, weekend athletic tournaments, year-round training on multiple teams, and the multi-sport athlete as it relates to athletic burnout also known as chronic fatigue syndrome.

Athletic burnout is an increasing issue for many professional and amateur athletes. Athletic burnout causes athletes to have complete physical and emotional exhaustion. As a result, athletes are not performing at the expected levels for their coaches and team mates. It has created losses physically, emotionally, and financially resulting in increased non-participation as a whole. High levels of perceived burnout have been reported in a variety of service professions, including social workers, physicians, psychologists, police officers, lawyers, and counselors.

The detrimental effects of burnout have been documented, and the importance of managing stress that is an after math of burnout has been established by the medical community(4,7,9). However, the limited literature on burnout in sport has focused on coaches and sport officials. Burnout has been defined as a reaction to chronic stress that involves negative interactions between environmental and personal characteristics. Burnout has also been characterized as a chronic condition that develops when one is working too hard for too long in a high-pressure situation.

Furthermore, burnout is conceptualized as uncontrollable, negatively perceived events occurring over a period of time that lead to negative psychological responses such as depersonalization, emotional exhaustion, and a lack of personal accomplishment(1,5,10). Attrition has also become a concern facing the professional athlete. Many professional athletes retire before reaching their physical or psychological “prime,” not necessarily due to injuries, rather a loss of compassion and excitement that initially drew them to the profession(12). Therefore this report will investigate the best professional practices presently used to prevent athletic burnout and address some of the issues associated with chronic fatigue syndrome and its prevention.

Question: Could proper performance training and a creatine monohydrate supplement

prevent chronic fatigue syndrome (burnout) in high performance athletes?   

Data Sources: The data resources in this paper are found in data collection knowledge systems,

online databases, and mandated medical reports published in online journals. Peer reviewed

articles were used and compared to other related articles. All resources were dated from 1999 to

present. Research terms used were “creatine,” “athletic burnout,” “chronic fatigue syndrome,”

and “over training.” Numerous resources were available to provide statistical data to answer the

research question and provide information on other related topics.

Annotated Bibliography

1. Dempsey, Rania L. Does oral creatine supplementation improve strength? A meta-analysis - Original Research. Available at: Accessed on October 23, 2009.

The objective of this study was to investigate whether creatine supplementation increases maximal strength and power in healthy adults and athletes. Oral creatine is the most widely used nutritional supplement among athletes. The research group contracted experts in the field to obtain and catalog various sources of unpublished data. Randomized or matched placebo controlled trials comparing creatine supplementation with placebo in healthy adults and atheletes were considered in this study. Research articles on MEDLINE from 1966 through 2000 and the Cochrane Controlled Trials Register, through June 2001, were used to obtain a wide variety of data content data from these studies. The study design was a meta-analysis of existing literature. Two independent reviewers abstracted data, and a third reviewer resolved differences. After reviewing titles and available abstracts of more than 500 articles, the researchers retrieved 66 potentially relevant studies, 16 of which met inclusion criteria for the analysis.

So, 16 studies were used and were included into this meta-analysis, along with 41 articles that are referenced in this study.
The results of the study and conclusions were that oral creatine supplementation combined with resistance training increases maximal weight lifted in young men. However, there was no evidence that performance was improved in older individuals or women. The study also concluded that how safe is creatine to use, remains unproven. However, these issues are not being addressed in the previous studies and this study suggests that creatine should not be universally recommended.
2. Logan, Alan C, Rao, Venket, Irani, Dinaz. Chronic Fatigue Syndrome: Lactic Acid Bacteria May be of Therapeutic Value. Elsevier Science Ltd [online]. 2003:10.1016/S0306-9877(03)00096-3. Available from: Medical Hypotheses Science Direct. Accessed October 14, 2009.

This research explained Chronic fatigue syndrome (CFS) as a medically unexplained illness, characterized by persistent and relapsing fatigue. It included in the research a list of symptoms such as cognitive dysfunction, headaches, joint pains, central nervous system disturbances, and a variety of other symptoms, many CFS patients complain of gastrointestinal disturbances. Research supports that lactic acid bacteria may be of therapeutic value in the treatment of CFS. CFS patients at the University of Newcastle, Australia. This patient study was conducted over a number of years staring in 1998. The instruments used in the study was to integrate the information in alterations of the intestinal microflora for chronic fatigued people to support a hypothesis that lactic acid bacteria may be of therapeutic value in the treatment of chronic fatigue syndrome.
To determine the degree of the relationship between two or more variables, these researchers used a statistical instrument called a correlation coefficient. This research study selected two groups that differ on the independent variable, which was the mean distribution of Escherichia coli levels in fecal microbial flora. The dependent variable was measures of Bacteroides. This research design was corollary, CFS patients verses a control group. The patients experiencing chronic fatigue were compared to patients that were not having issue.     Generally, correlational research studies can be either relationships or a predictive study. This study was to investigate the precise extent of the relationship between total aerobic flora and the mean distribution of Escherichia coli in CFS patients and a control group. Researchers analyzed the data by calculating a correlation coefficient.

The research concluded that the intestinal microflora in CFS patients is markedly different than that of healthy control groups. Stress-induced alterations in microbial flora, specifically diminished lactobacilli, bidobacteria, and anaerobes in general, will amplify the domination of Th2 cytokines which contribute to a person’s fatigue.

3. Vernon, Suzanne D. Reeves, William C. Division of Viral and Rickettsial Diseases National Center for Infectious Diseases. Evaluation of autoantibodies to common and neuronal cell antigens in Chronic Fatigue Syndrome. Available at: Access on October 6, 2009.

Few theoretical models of burnout have been proposed and investigated. This research has made empirical progress by proposing a theoretical framework on enzyme-linked immunosorbent oassay. It is also referred to as ELISA, enzyme immunoassay or EIA It is a biochemical technique used mainly in immunology to detect the presence of an antibody or an antigen in a sample. This is what the physicians used during this study. The ELISA has been used as a diagnostic tool in medicine and plant pathology, as well as a quality control check in various industries. Performing an ELISA involves at least one antibody with specificity for a particular antigen. Older ELISAs utilize chromogenic substrates, though newer assays employ fluorogenic substrates enabling much higher sensitivity. This is what demonstrated reliability of the research.

Subjects were derived from studies that were distinct in design and geographic location. Each study was analyzed separately.  The researchers derived an estimate of confidence using stratified groups and were compared using a non-parametric chi square test. This was used to determine to validate if an association with auto-antibodies existed.

The hypothesis of the is that the appearance of cell-specific autoimmune antibodies may define subsets of Chronic Fatigue Syndrome (CFS or burnout) that gave clues to the etiology and pathogenesis that helped explain objectively why neurocognitive symptoms experienced by CFS patients.  An objective account is one which attempts to capture the nature of the object studied in a way that does not depend on any features of the particular subject who studies it. This research reflects an objective account. The study commented on short-term adverse effects of creatine supplementation. This study found no difference between creatine and placebo. The study reported gastrointestinal upset, rash, or headache in several subjects taking creatine and no adverse effects in subjects taking placebo. However, the study focused on the autoimmune system and was not designed to evaluate long-term adverse effects of creatine supplementation and did not report of longer-term follow up.

4. Ekstedt, Mirjam. Karolinska Institute Department of Public Health Sciences. Burnout and Sleep. Available at: . Accessed on October 1, 2009

This study was a descriptive approach using qualitative interviews to reach a deeper understanding of the experiences of burnout. Several studies were conducted. Study II and II were field studies with both a "within" and "between" groups design. The diurnal patterns of sleepiness and mental fatigue was evaluated within each group and patterns of sleep and mood were measured "between."  So a t-test of the null hypothesis was used to measure the means of two normally distributed populations to show they were equal.  The research tested  two or more independent groups subjecting the subjects to repeated measures, so a factorial mixed-design ANOVA, in which one factor was used as  a between-subjects variable and the other is within-subjects variable. Post hoc test was used as research group and test VI. The post-hoc analysis, in the context of this design and analysis of experiments, the data was reviewed after the experiment has concluded. Patterns that were not specified a priori were reviewed to prevent data dredging that may evoke the sense that the more one looks the more likely something will be found. More subtly, each time a pattern in the data is considered, a statistical test is effectively performed (both t-test and ANOVA). This greatly inflates the total number of statistical tests and necessitates the use of multiple testing procedures to compensate.

This research determined the correct amount of sleep athletes need to meet high performance. It has already been determined that sleep deprivation will cause low performance in athletes with respect to reaction time and sustained attention. The research suggests that 8 hours is recommended and needed for not only sports performance but also everyday activities.

Performance deteriorates markedly after 88 hours of continuous wakefulness, a duration comparable to staying up for three nights and long enough to show circadian patterns of alertness and sleepiness. Performance is consistently better in the day than at night, a reflection of humans' innate programming to stay alert in the day and sleep at night was well documented in this research. The research also determined that napping is not a good idea. Naps have a downside, right after awakening, athletes often manifest performance deficits termed “sleep inertia.” They're foggy and clumsy. This effect intensifies with progressive sleep loss, especially at night.

5. Suzanne D Vernon and William C Reeves. Evaluation of autoantibodies to common and neuronal cell antigens in Chronic Fatigue Syndrome. J Autoimmune Dis. 2005; 2: 5

This research suggested that dysfunction of the immune system may be important in the pathophysiology of CFS. Chronic fatigue syndrome (CFS) is defined as persistent or relapsing fatigue that is not necessarily alleviated by rest alone. The research stated that fatigue cannot be explained by medical or psychiatric conditions and must be accompanied by at least 4 of 8 specified symptoms. The research determined that there is considerable discrepancy in results between studies from different institutions and that markers of CFS and its pathophysiology has not been elucidated. This is what drove the research, that is to better determine if CFS resemble other illnesses.

In particular, antinuclear antibodies (ANA) and other common autoantibodies have been evaluated in people with CFS in this research. There were unfortunately, variable results. For example, one study found that 52% of tertiary care- CFS referral-patients had antibodies to nuclear envelope antigens while another study found the same ANA antibody rates in both CFS and controls. It was also reported that antibodies to the human muscarinic cholinergic receptor 1 may provide a biologic explanation for the cognitive impairment observed in people with CFS.

Because the subjects were derived from studies that are distinct in design and geographic location, each study had to be analyzed separately. The distribution of autoantibodies between CFS and non-fatigued controls was compared by Fisher exact probability test. To derive an estimate of confidence, stratified groups were compared by the non-parametric chi square test. To determine associations, subjects were stratified by sex, age, and CFS for all MAP2, NFT and ssDNA. The association of autoantibodes in CFS subjects was compared by grouping by sex, age, age at illness onset, and duration of illness. CFS subjects were stratified by sex, age (<40 years, 40–40 years, >50 years), onset type (gradual versus sudden) and duration of illness (<5 years, >5 years) to determine whether an association with autoantibodies existed.

Although women predominated in both study groups other demographic and clinical characteristics differed and reflected basic differences between patients with CFS who obtain medical care and those in the general population. Of note, CFS cases from physician surveillance were somewhat younger than those identified in the population mean 39 and 46 years of age respectively, and controls were similarly different. The findings of this study hint that evaluation of certain autoantibodies may give clues to etiology and ongoing pathology in subsets of CFS subjects. A few of the physician surveillance CFS cases from the youngest age category had autoantibodies to ssDNA. There was no evidence of higher rates of the common autoantibodies in people with CFS. However, there were certain subsets of CFS subjects that had higher rates of antibodies to microtubule-associated protein 2 (MAP2) and ssDNA. Autoantibodies to specific host cell antigens may be a useful approach to stratify CFS subjects and provide clues to CFS etiologies.

6.  Logan, Alan C, Rao, Venket, Irani, Dinaz. Chronic Fatigue Syndrome: Lactic Acid Bacteria May be of Therapeutic Value. Elsevier Science Ltd [online]. 2003:10.1016/S0306-9877(03)00096-3. Available from: Medical Hypotheses Science Direct. Accessed October 14, 2009.

This research article contained a large amount of quantitative data on dietary requirements that were unique to the ageing athletes and fatigue “burnout.”  This study also reiterated results of previous studies concerning burnout. Endurance domains were used to categorize proxy variables that reinforced the quality of the program’s descriptions.  The textual content described difficult terms with defining detail.  Causal comparative contrasts and meta-analysis were used to measure the effects of overtraining, mainly endurance athletes. The articles explanation of a condition of chronic fatigue with respect to underperformance graphically displayed an increased vulnerability to infection leading to athletic non-participation. The statistical section included ANOVA and a t-test.
The researchers made available a synopsis table of their findings. Statement of the treatment and positive effects to return athletes to their level of performance were factual. Explanation of why the findings were positive in returning athletes to perform at their normal strength training, as well as increased strength and endurance were measured. The post-hoc analysis, in the context of this design and analysis of experiments, the data was reviewed after the experiment has concluded. Patterns that were not specified a priori were reviewed to prevent data dredging that may evoke the sense that the more one looks the more likely something will be found. More subtly, each time a pattern in the data is considered, a statistical test is effectively performed (both t-test and ANOVA). This greatly inflates the total number of statistical tests and necessitates the use of multiple testing procedures to compensate.

The findings of low levels of bifidobacteria in CFS are of particular significance, as the available evidence suggests that this specific group of LAB, when reduced or diminished, indicates an unhealthy state. The microbes of the gastrointestinal tract appear intricately involved
with the systemic immune and nervous systems and perhaps their role in functional conditions such as CFS is currently underestimated. LAB have not been the subject of controlled studies in CFS, however, based on the research reviewed in this paper, it seems plausible that they would be of therapeutic value and certainly warrant further investigation.

7. Rania L. Dempsey, Michael R. Mazzone, Linda N. Meuer. Does oral creatine supplementation improve strength? A meta-analysis - Original Research Journal of Family Practice, Nov, 2002 by Rania L. Dempsey, Michael R. Mazzone, Linda N. Meuer

According to this research, oral creatine is the most widely used nutritional supplement among athletes. Purpose of the research was to investigate whether creatine supplementation increases maximal strength and power that will aid in reducing athletic burnout. Presupplementation and postsupplementation change in maximal weight lifted, cycle ergometry sprint peak power, and isokinetic dynamometer peak torque were measured. The study included sixteen additional studies that were identified. The summary difference in maximum weight lifted was 6.85 kg (95% confidence interval [CI], 5.24-8.47) greater after creatine than placebo for bench press and 9.76 kg (95% CI, 3.37-16.15) greater for squats; there was no difference for arm curls. In 7 of 10 studies evaluating maximal weight lifted, subjects were young men, younger than 36 years,  engaged in resistance training. There was no difference in cycle ergometer or isokinetic dynamometer performance.

Oral creatine supplementation combined with resistance training increases maximal weight lifted in young men. There is no evidence for improved performance in older individuals or women or for other types of strength and power exercises. Also, the safety of creatine remains unproven. Therefore, until these issues are addressed, its use cannot be universally recommended. However, some benefit to reduction in burnout was noted. Oral creatine supplementation combined with resistance training increases maximal weight young men can lift. It is unknown whether this increase in strength translates into improvement in sports performance. Evidence in the existing literature is insufficient to draw conclusions about the effect of creatine in women or older individuals. Because no long-term studies have been performed on the safety of creatine supplementation, its use should not be universally recommended.

Creatine has gained widespread popularity dining the past decade as a possible performance-enhancing agent among professional and recreational athletes. It is the most widely used performance enhancing supplement among youth aged 10 to 17 years, with 15% to 30% of high school athletes and 48% of male Division I college athletes reporting creatine use.

Considered a nutritional supplement, it is not regulated by the United States Food and Drug Administration nor is it banned by the International Olympic Committee or National Collegiate Athletic Association. Because of the widespread use of creatine, primary care providers must be knowledgeable about its effectiveness and safety. Oral creatine monohydrate increases skeletal muscle creatine concentration by 16% to 50%, but whether it is an effective ergogenic aid remains controversial.

This research produced multiple studies that have investigated this question, but many have been small, often including fewer than 10 subjects, and results have been conflicting. Several reviews have addressed the effectiveness of creatine, but there has not been a systematic and comprehensive meta-analysis to resolve the uncertainties in the literature or to quantify the magnitude of the effect of creatine. To evaluate whether oral creatine supplementation improves strength and power in healthy adults, and further to quantify the effect, this study did produce a meta-analysis of randomized and matched controlled trials investigating creatine supplementation and strength.

The methodological quality of this study was generally low. The mean quality score was 3.5  or -1.2 mean and -SD out of a possible 10 (range, 2-5.5). However, this study did not identify the method of randomization used or specifically reported an intention-to-treat analysis. It was not specifically reported masking of outcome assessment. In general, these significant flaws in study design would tend to result in overestimation of the benefit of creatine supplementation.

The study showed that there was no significant difference in 1-repetition maximum arm flexor strength with creatine supplementation (WMD = 1.53 kg; 95% CI, -1.07 to 4.13; n = 60. However, 2 trials of the 3 evaluating this outcome studied subjects older than 60 years and did not employ adjuvant weight training programs: The study that incorporated resistance training and evaluated younger subjects found a modest (29.9% vs 16.5%) improvement in 1-repetition maximum arm flexor strength with creatine compared with placebo.

Given the popularity of nutritional supplements among all levels of athletes, clinicians cannot avoid questions about the effectiveness and safety of creatine supplementation. This meta-analysis demonstrated that oral creatine does improve performance during maximal resistance exercises in young men. However, no benefit was found for outcomes other than maximal weight lifted, suggesting that creatine may not improve actual performance in more complex movements requiring strength, speed, and coordination of multiple muscle groups.

8. James Fell. Exercise induced fatigue and recovery in aging athletes. Comparisons of older and younger groups. School of medical Science & School of Physiotherapy and Exercise Science Gold Coast Campus Griffith University, Australia 12 December 2005

There has been a common belief among older athletes that intense training becomes more difficult with ageing. This study investigated one of the reasons attributed to this performance limitation. It is with the impairment of recovery processes that can prolong the time taken for the body to adequately adapt between training sessions or after competition. However, there has been limited research to address this assumption through the investigation of recovery of performance after training or competition in well-trained older athletes.

This research reviewed the literature pertaining to ageing and exercise with particular reference to athletic performance, muscle damage and muscle repair/regeneration, with the intention of exploring the effects of ageing on training, overload, recovery and burnout from exercise in the well-trained ageing athlete. Two arguments are presented for an impaired recovery from training and competition in the older athlete. The first is that muscle damage after exercise is greater in the older athlete, and the second is that tissue repair is slower, both factors potentially prolonging recovery duration. The importance of adequate nutrition for recovery in athletes is recognized and discussed in regard to optimising recovery and to identify any specifc dietary requirements or limitations that might be unique to the ageing athlete, this included creatine suppliments in the diets of aging athlete.

For the measures of functional performance there were no significant differences between the two age groups (young and old). Both groups maintained their time trial performance over the three days of intense endurance exercise. The average height jumped in the countermovement jump decreased slightly (2.6%, p less than 0.05) over the three days. There was also a significant decrease in average heart rate during the TT30 over the three days (~3 b.min-1) for both groups. In response to the testing protocols serum CK activity was significantly elevated for both age groups on days two and three (combined age data: T1- 122 ± 43, T2- 178 ± 90, T3- 166 ± 87, p less than 0.05). For the perception and report of soreness, fatigue and recovery, non-parametric statistics indicated that the veteran group reported a significant (P less than 0.05) change in SOR (6.2 ± 2.6 to 28.2 ± 14.1), FAT (1.7 ± 1.2 to 2.2 ± 0.09), and TQR (15.8 ± 2.5 to 13.8 ± 2.1) over the T1 to T3, while these changes in the young group were non-significant (SOR: 15.5 ± 15.5 to 24.2 ± 17.1, FAT: 1.7 ± 1.1 to 2.2 ± 0.9 and TQR: 16.3 ± 2.6 to 15.1 ± 2.9). The change in muscle soreness was significantly (p less than 0.05) greater in the veteran group than in the young group (Veteran, 22 ± 14; Young, 9 ± 12).

This investigation has provided the first comprehensive description of recovery from exercise in well-trained veteran endurance athletes. The common perception of a delayed recovery with ageing was supported by the longer reported duration required to recover between intense training and competition in athletes 30 years and older. This slower recovery does not appear to be due to major dietary differences between young and veteran athletes. In contrast to the perception of slower recovery repeated days of intense endurance cycling exercise was similarly tolerated by young and veteran athletes with respect to performance. However, there is
a greater change in the perception of, muscle soreness and significant changes in fatigue and recovery in veteran athletes. This finding has implications for the effective monitoring of training load in the older athlete.

9. Michelle L Kania, MS ATC,1 Barbara B Meyer, PhD,2 and Kyle T Ebersole, PhD ATC2. Personal and Environmental Characteristics Predicting Burnout Among Certified Athletic Trainers at National Collegiate Athletic Association Institutions

This research in the health care professions has shown that specific personal and environmental characteristics can predict burnout, which is a negative coping strategy related to stressful situations. Burnout has been shown to result in physiologic manifestations such as headaches, difficulty sleeping, poor appetite, psychological increased negative self-talk, and depression.  This research examined the relationship between selected personal and environmental characteristics and burnout among certified athletic trainers and their athletes. The study was a cross-sectional survey. Most athletes and trainers surveyed experienced low to average levels of burnout.

Personal characteristics predicted 45.5% of the variance in emotional exhaustion (P < .001), 21.5% of the variance in depersonalization (P < .001), and 24.8% of the variance in personal accomplishment (P < .001). Environmental characteristics predicted 16.7% of the variance in emotional exhaustion (P = .005), 14.4% of the variance in depersonalization (P = .024), and 10.4% of the variance in personal accomplishment (P = .209). Stress level and coaches' pressure to medically clear athletes predicted ratings on all 3 subscales of burnout.

The research were similar to those of other studies of burnout among NCAA Division I athletes, trainers, coaches, and coach-teachers. The results also support the Cognitive-Affective
Model of Athletic Burnout proposed by Smith. Finally, these results indicate new areas of concentration for burnout research and professional practice. The study found that 32.0% of athletic trainers reported burnout, which was a lower level when compared with the level reported for athletic trainers in other studies. Also, the personal characteristics, stress level was predictive of all 3 subscales of burnout, and leisure time was predictive of personal accomplishment. Of the environmental characteristics, pressure from a coach to medically clear an athlete was predictive of all 3 subscales of burnout, injury-type frequency was predictive of emotional exhaustion, number of sports for which the athletic trainer was primarily responsible was predictive of depersonalization, and number of athletes for whom the athletic trainer was primarily responsible was predictive of personal achievement.

    Two instruments in the assessment of burnout and characteristics related to burnout were used. The MBI-HSS, 15 which is a valid and reliable assessment inventory measuring the 3 subcategories of burnout (EE, DP, PA), and a demographic survey measuring personal and environmental characteristics thought to predict burnout. Burnout was measured using the MBI-HSS, which is the primary instrument used in the study of burnout among health care professionals. The validity and reliability of the MBI-HSS have been demonstrated in various populations of health care professionals; as such, it is considered the best instrument available to assess burnout in athletes.  Internal consistency reliability for the 3 subscales ranged from α = .71 to α = .90 (P < .001), with test-retest reliability ranging from r = 0.71 to r = 0.90.2 Validity for the MBI-HSS has been established in many forms.

Convergent validity has been demonstrated by external verification of personal experiences, dimensions of the job experience, and personal outcomes, and divergent validity has been established by distinguishing the MBI-HSS from other psychological constructs, such as job satisfaction, alleged to be confounded with burnout. The MBI-HSS consists of 22 questions measuring the 3 dimensions of burnout. The items are scored on a 7-point, fully anchored, Likert-type scale, with the 2 extremes of never feel the effects and feel the effects every day. Scores on each subscale are computed by summing the numeric responses. Scores range from 0 to 54 on the EE subscale, from 0 to 30 on the DP subscale, and from 0 to 48 on the PA subscale. A high degree of burnout is reflected by high scores on the EE and DP subscales and a low score on the PA subscale.

Descriptive statistics, frequency distribution, mean, SD, were calculated for all demographic and burnout variables. This was to determine the extent to which personal and environmental characteristics predict burnout, we used multiple regression analysis. Six separate regressions were performed, pairing each burnout subscale with either the environmental or personal characteristics variable group. Specifically, these regression calculations were used to determine which personal and environmental characteristics best predicted EE, DP, and PA. The change in shared variance was calculated for each subscale to quantify the amount of variance in the dependent variable that each independent variable explained. The study determined that 206 participants in the research study, response rate = 33.3%, had an average age of 32.7 ± 8.7 years. Of those participants, 52% (n = 108) were male, 95% (n = 195) were white, 47% (n = 97) were married, and 80% (n = 165) held a master's degree.

10.  Peter R Giacobbi, Jr,, PhD Low Burnout and High Engagement Levels in Athletic Trainers: Results of a Nationwide Random Sample National Athletic Trainers' Association, Inc

    This research assessed the prevalence of occupational burnout, engagement, and somatic health complaints and the associations among these constructs experienced by certified athletic
trainers and their athletes. A secondary objective was to examine differences between men and women, those with more versus less postcertification experience. The design of this research was survey-based, stratified, proportionate random sample of full-time athletes and their trainers. Data was collected online from athletic trainers employed full time in the college or university, secondary school or youth, and industrial or clinical settings. Of 3998 invited to participate in the survey, 934 replied, for a response rate of 24%. The mean age of the participants was 33.84 ± 8.29 years, and each athletic trainer worked with an average of 90 clients. The dependent variables were perceived stress, occupational burnout, engagement, and somatic health complaints.

    The results of this study, although 17.2% of participants were in the most advanced stages of burnout, low levels of burnout and high degrees of occupational engagement were observed. Women athlete trainers and those working in the college or university settings scored higher for burnout, whereas men and those in the clinical or industrial settings scored higher for engagement. Women also reported significantly more somatic health complaints than men The overall prevalence of burnout in athletes and their trainers was relatively small, but sex and occupational-setting differences were observed and deserve greater scrutiny.
A phase model of the burnout syndrome recently has gained acceptance within the occupational burnout literature. This model makes use of all possible patterns of scores that can be obtained with the MBI16 and posits a progressive sequence of psychological experiences (ie, subscale scores on the MBI) related to the burnout construct. The burnout syndrome begins with depersonalization, considered the least potent; the erosion of personal accomplishment is an intermediate step; emotional exhaustion occurs last and is the most potent characteristics burnout. Indeed, emotional exhaustion is considered most detrimental to the health and well-being of athletes.

Two separate MANOVAs were computed using time since certification, sex, and occupational setting as fixed factors and subscale scores on the MBI16 and OES18 as dependent variables. An analysis of variance also was computed with the somatization scale of the SCL-90 as a dependent variable.

11. Hanneo, Dr. Nora. Overtraining in Athletes Paparo
OlympicInformationCenter/OlympicReview/1983/ore194/ORE194s.pdf. Accessed November 23, 2009.

This research study investigated Olympic athletes. According to the study, athletes train regularly with increasing amount and intensity of work, in the training sessions, in an attempt to achieve the best possible results. The development of “sports form”, a final high level of training, is related to the positive changes their bodies have undergone. If the requirement of the training and the total amount of effort in everyday life are in accordance with the abilities of the athlete, a normal development of sports form will occur and the athlete will attain good results. If however, the total amount and intensity of the effort surpass the body’s abilities, a progressive fatigue occurs which leads to decreased athletic performance. The study had several cases in which performance failed to progress in spite of uninterrupted training. Subjects tried their best but without very little success.

    The investigation into over training has emphasized the fact that many predisposing factors may cause Chronic Fatigue Syndrome. The main factor sited in the study’s finding was undoubtedly improper training and inadequate recuperation after the training sessions. Even with an appropriate amount and intensity of training, overtraining may occur if one or more of the following predisposing factors are present. These factors were monotony of training, continuous camp training, training away from family and friends, inappropriate nutrition, lack of sleep, bioclimatic factors, unsuitable life style, and mental conflict situations. This study also suggested that the development of Chronic Fatigue Syndrome is manifested with a level that does not continue to increase; however, there may be no deterioration. There are many subjective signs such as nervousness, lack of interest in training and sleeplessness. Another factor was the objective findings and complaints mentioned by athletes such as bioclimatic factors and their unsuitable life styles.

    This study assisted the research to document the complaints of the customers and determine if the “sports form” is correct for the person training. The diagnosis of overtraining is not easy. However, this study emphasized the fact that in most of the athletes a few symptoms appeared which are not specific for overtraining such as nervousness, disturbances in sleep, and feeling of fatigue with a loss of appetite. Obviously these athletes were in the first stage of overtraining.

12. Hickie,Ian Davenport, Tracey and  Wakefield, Denis. Post-infective and chronic fatigue syndromes precipitated by viral and non-viral pathogens: prospective cohort study. Accessed November 11, 2009.

The objective of this study was to delineate the risk factors, symptom patterns, and longitudinal course of prolonged illnesses after a variety of acute infections leading to Chronic Fatigue Syndrome. The design of the study was done with a cohort group that followed patients from the time of acute infection and leading to Chronic Fatigue Syndrome. Participants of the study were 253 patients that enrolled and were followed at regular intervals over 12 months by self reporting, structured interview, and clinical assessment.

The outcomes measured detailed medical, psychiatric, and laboratory evaluations at six months to apply diagnostic criteria for chronic fatigue syndrome. Illness characteristics were recorded to define risk factors for chronic fatigue syndrome. Self reported illness phenotypes were compared between infective groups. The results of prolonged illness have been characterized by disabling fatigue, musculoskeletal pain, neurocognitive difficulties, and mood disturbance. This was evident in 29 (12%) of the 253 participants at six months, of whom 28 (11%) met the diagnostic criteria for chronic fatigue syndrome. This post-infective fatigue syndrome phenotype was stereotyped and occurred at a similar incidence after each infection. The syndrome was predicted largely by the severity of the acute illness rather than by demographic, psychological, or microbiological factors.

    This study defined chronic fatigue syndrome as a persistent or relapsing fatigue that cannot be explained by other medical or psychiatric conditions. Although chronic fatigue syndrome is commonly reported to develop after an acute infective illness, many case-control studies have failed to find consistent associations between chronic fatigue syndrome and either known or novel infectious agents. Population based prospective studies of the spectrum of post-infective fatigue states are therefore needed to delineate the key symptoms and longitudinal course of the post-infective fatigue syndrome. So this study was able to identify demographic, microbial, immunological, and psychological risk factors. This study helped determine whether disparate pathogens can precipitate chronic fatigue syndrome, and they do.

    The conclusion of this study is that a relatively uniform post-infective fatigue syndrome persists in a significant minority of patients for six months or more after clinical infection with several different viral and non-viral micro-organisms. Post-infective fatigue syndrome is a valid illness model for investigating one important pathological-physiological pathway to chronic fatigue syndrome.

Clinical Implications

Oxidative stress plays a role in the development of Chronic Fatigue Syndrome. Oxidative stress is a term used to describe the body's prolonged exposure to oxidative factors that cause more free radicals than the body can neutralize. Free radicals are produced as a byproduct of normal metabolic functions. When there are enough free radical scavengers present, such as glutathione and vitamins C, E, and A, along with zinc and other nutrients, through normal metabolic functioning, the body will "mop up" or neutralize the free radicals. When free radicals are not neutralized, the body can become vulnerable to cellular destruction.

A relationship between abnormal oxidative stress and Chronic Fatigue Syndrome are related. Patients with Chronic Fatigue Syndrome had lower serum transferrin levels and higher lipoprotein peroxidation. These results indicate that patients with Chronic Fatigue Syndrome have increased susceptibility of LDL and VLDL to copper-induced peroxidation and this is related both to their lower levels of serum transferrin and to other unidentified pro-oxidizing effects of Chronic Fatigue Syndrome.

Exercise has been shown to increase the production of oxidants. Fortunately, regular endurance exercise results in adaptations in the skeletal muscle antioxidant capacity, which protects myocytes, muscle cells, against the deleterious effects of oxidants and prevents extensive cellular damage. Oxygen delivery to muscles in patients with Chronic Fatigue Syndrome found that oxygen delivery and oxidative metabolism was significantly reduced in Chronic Fatigue Syndrome patients after exercise, compared with sedentary controls.

Excessive training and a schedule that is simply too full can lead to burnout, to put it in simple terms. An athlete who is engaged in training for a major meet or has a daily schedule of cycling training while preparing for competition must, of course, be very focused. In fact, it is essential that this athlete have training goals at the top of his or her priority list. During this phase, creatine will be effective in the strength development of the athlete. The research has learned from these studies how to recognize the symptoms of burnout. However, the athlete that has not other interests or who does not allow time for relaxation is flirting with danger. The spectre of mental or physical breakdown is always there when the schedule pushes beyond reasonable limits. If this period of over training continues the chances increase for the athlete to begin to lose his or her motivation for training. Even if the training methods are innovative and enjoyable at first, the repetition can make training seem stale and, in the athletes mind, unnecessary. Several experts and experienced professionals have considered this phenomena in books and videos that deal with training for competition.

Future Research

The causes of Chronic Fatigue Syndrome in athletes are as yet undetermined, but studies have shown that multiple nutrient deficiencies, food intolerance, or extreme physical or mental stress may trigger chronic fatigue giving the athlete burnout. Studies have also indicated that
Chronic Fatigue Syndrome may be activated by the immune system, various abnormalities of the hypothalamic-pituitary axes, or by the reactivation of certain infectious agents in the body. Some Chronic Fatigue Syndrome patients were found to have low levels of PBMC beta-endorphin and other neurotransmitters. Thyroid deficiency may also be a contributing factor in Chronic Fatigue Syndrome.

The researcher will continue to do studies of the effects of creatine. Information was discovered that the research will continue to investigate such as creatine monohydrate in ALS (Amyotroph Lateral Scier) strengthens, reduces fatigue, and improves respiratory status and ALSFRS.  What are the effects of twenty-eight days of beta-alanine and creatine monohydrate supplementation on the physical working capacity at neuromuscular fatigue threshold? 

Also the researcher will continue to obtain never before information about the kind of effects of creatine loading on electromyographic fatigue threshold in cycle ergometry in college-age men and athletes. Additonal information to be investigated is the microscopic damage to muscle that may lead to raised creatine kinase levels if there is eccentric exercise. To investigate that exercise tolerance could also be influenced by manipulating the anaerobic capacity, creatine monohydrate supplementation, severe prior exercise or rate of metabolite accumulation such as sodium bicarbonate ingestion.

This all aimed to examine the acute hormonal and performance responses to resistance exercise with and without prior consumption of an amino acid/creatine/energy supplement.

The research will continue to do further research in these areas of study. The researcher has begun to use statistical tests learned in this class to track athletes that the researcher trains. Also the researcher will begin to survey his customers and implement the Cognitive-Affective Model of Athletic Burnout proposed by Smith in article 9 of this paper. Any program of exercise or training should start slowly and increase in moderate steps. Training schedules should be upgraded gradually so that the athlete does not get burned out. A good training program will include only necessary repetition. While repeating actions is essential for athletic success, there is usually a point at which results actually suffer, rather than improve, because of repetition. Alternating short periods of intense work with times of low physical and mental stress may even bring back some of the enthusiasm for training in an athlete that is approaching the trouble zone.