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Because many people (myself included) observed that their CFS started during a period of intense exercise, I eventually found myself reading the reports of people who developed OTS. Just as CFS is a recognized but poorly understood syndrome in medicine, OTS is a recognized but poorly understood syndrome in athletics. Although they're probably different syndromes, there many similarities between OTS and CFS, both in their presentations and in their underlying causes. There's a very brief summary at the bottom of the page. Here are some of the symptoms of OTS
I've found discussions of these subjects to be hampered by muddled thinking, largely due to ambiguously defined terms, so let me make some definitions and take a moment to discuss aerobic/anaerobic metabolism. There will be a lot of information in this post that is already well understood by people on this forum, but I've included it anyway for those who don't know much about these topics.
Energy Metabolism
Maffetone's Theory
Treating CFS and OTS
Caveats
With all this said, these strategies may not work for most or even many PWC. For example some people who are bedridden with CFS may not have enough reserve to do exercise without becoming GA. Other people may not recover until some underlying problem like a chronic infection is addressed (although as the story above illustrates, chronic infection like EBV certainly does not preclude recovery). I also think that many of us may benefit from avoiding LA exercise as well as GA exercise, and that it may be necessary to limit total daily energy expenditure ("spoon theory"); the autonomic system is involved in OTS and CFS for many people, a point which I haven't addressed. That said, I do think this could work for many of us, particularly those of us whose CFS may have been caused in part by exercise.
Summary
CFS and Maffetone's ideas about OTS both seem to involve a damaged aerobic system. Pacing and low intensity aerobic exercise guided by heart rate may help in recovery for some PWC, particularly those whose CFS seemed to be caused in part by exercise.
- Washed-out feeling, tired, drained, lack of energy
- Mild leg soreness, general aches, and pains
- Pain in muscles and joints
- Sudden drop in performance
- Insomnia
- Headaches
- Decreased immunity (increased number of colds, and sore throats)
- Decrease in training capacity / intensity
- Moodiness and irritability
- Depression
- Loss of enthusiasm for the sport
- Decreased appetite
- Increased incidence of injuries
- Hormone imbalance includes elevations of cortisol with secondary lowering of testosterone and DHEA levels
- Premenstrual syndrome and menopausal symptoms may be secondary complaints for women, but amenorrhea is a common problem
- Sexual dysfunction may be a problem for both sexes, typically producing reduced sexual desire and sometimes infertility
- Mental and emotional stress, including mild or clinical depression and anxiety is not uncommon
I've found discussions of these subjects to be hampered by muddled thinking, largely due to ambiguously defined terms, so let me make some definitions and take a moment to discuss aerobic/anaerobic metabolism. There will be a lot of information in this post that is already well understood by people on this forum, but I've included it anyway for those who don't know much about these topics.
Energy Metabolism
The energy currency of cells is adenosine triphosphate or ATP, a molecule of adenosine attached to three phosphates. When ATP is used for an energy consuming reaction, one phosphate is removed and the result is ADP (adenosine diphosphate). Thus regenerating energy amounts to converting ADP back into ATP. There are three energy systems most cells use to generate energy.
Here are the key points to take away.
- Creatine phosphate in cells is a form of stored energy; it can rapidly donate phosphate to convert ADP back into ATP. Creatine phosphate runs out quickly (after a few seconds of sprinting), and requires on the order of minutes to recover.
- Glucose, fatty acids, and amino acids can be degraded into H2O, CO2, and ammonia to generate ATP; this process generally consumes oxygen, many of its steps occur in mitochondria, and it is called aerobic metabolism. This process generates most of the body's energy needs. Aerobic metabolism is why animals breathe in oxygen and breathe out CO2.
- The first step of glucose degradation in aerobic metabolism involves cleaving it into two molecules of pyruvate, which are then further broken down; this splitting of glucose (glycolysis) actually generates a small amount of ATP on its own, so if the cell needs energy to be produced faster than aerobic metabolism can supply it, glucose will be split faster than pyruvate can be degraded. The pyruvate is converted to lactate, which accumulates in the tissues and, if enough lactate is being produced by enough cells, in the blood.
Here are the key points to take away.
- Processes 1 and 3 don't require oxygen, so they're both described as anaerobic; you can see that the use of the term anaerobic to describe an activity is thus pretty ambiguous, especially since processes 1 and 3 are physiologically very different. For example, doing a low rep weighlifting workout with lots of rest between sets, and running a 5 minute mile, both involve anaerobic metabolism, but they're very different exercises.
- The term anaerobic is ambiguous for a second reason. Suppose I do bicep curls with a 10lb dumbbell to failure; at a certain point my bicep muscle cells will run out of creatine phosphate and will start relying on glycolysis and lactate will accumulate in my biceps muscle cells. However, the biceps is a relatively small muscle, so any lactate it produces will enter the blood, travel to other tissues, and be metabolized there; in other words, blood lactate will probably not accumulate. Thus we need to distinguish between activities that cause only tissue lactate accumulation somewhere, vs activities that cause both tissue lactate accumulation somewhere and blood lactate accumulation.
- An activity is globally anaerobic (GA) if it causes blood lactate to rise. The aerobic capacities of enough cells have been exceeded by a large enough margin that enough pyruvate is being produced and converted into lactate to exceed the body's ability to metabolize lactate. For example, a fast mile, or a full out sprint farther than ~60m.
- An activity is locally anaerobic (LA) if it causes tissue lactate to rise somewhere but doesn't cause blood lactate to rise. For example, high rep bicep curls with low weight, high rep calf raises. GA activities must be LA (the lactate in the blood must be coming from some tissue), but LA activities in general aren't GA (eg high rep bicep curls).
- An activity is brief if in theory the creatine phosphate system has enough stored energy to supply all of the activity's energy demands. For example, a golf swing, a jump, calf raises or bicep curls for a few moderate reps. These activities should in theory not cause any lactate accumulation anywhere, and in theory should not even require much increase in aerobic metabolism.
Maffetone's Theory
One of the reasons I buy into Maffetone's ideas is that they are well grounded in the established biochemistry above. Maffetone's basic idea can be boiled down to three premises
Notice the language used here: "cardio". Cardio is a vague term that includes both aerobic and GA exercise. Most people who start doing cardio pay little attention to whether they're actually functioning primarily aerobically. Here is a typical example, taken from the comments section of this article https://philmaffetone.com/the-overtraining-syndrome/ (many other stories can be found in the comments).
Even the American Heart Association's recommendations for exercise don't respect these biochemical principles:
If Maffetone is correct, these recommendations are counterproductive for many people or even overtly dangerous.
- The aerobic system is how cells obtain energy for maintenance and repair, so the aerobic system is the foundation of health. Since the aerobic system relies heavily on mitochondria, good health requires to having a lot of well functioning mitochondria.
- You develop the aerobic system by doing aerobic exercise. A healthy body can tolerate lots of aerobic exercise.
- Globally anaerobic (GA) exercise is physiologically stressful and among other things wears down the aerobic system. Recovery from GA exercise (or any stressor really) relies on the aerobic system. A combination of excess GA exercise and insufficient aerobic capacity results in overtraining; in other words, OTS results in part from a combination of excess training stress and insufficient recovery.
Notice the language used here: "cardio". Cardio is a vague term that includes both aerobic and GA exercise. Most people who start doing cardio pay little attention to whether they're actually functioning primarily aerobically. Here is a typical example, taken from the comments section of this article https://philmaffetone.com/the-overtraining-syndrome/ (many other stories can be found in the comments).
Over the course of 3 years from 2012-2015 I lost 55kg. It was insane. During the year 2013 alone I lost 30kg. The first period of weight loss at times I was eating no more than 600-800 cals a day, constantly hungry. But the results were so encouraging. Ofcourse the eating was then increased and increased to realistic numbers, but also I had started to get very interested in fitness. I started running in 2014 and really got into it in 2015. Towards the end of 2015 I was running 2-3x 13km a week and I was so happy at my fitness. At no point would I say I was going crazy, but I was dedicated.
2015 was also the year of injuries. In rapid succession (6-8 months) I got achilles tendonitis, pectoral pulls then tendonitis, groin tendonitis, shoulder bursas. I was going crazy. With each injury all I was worried about was how it would stop me from continuing my path to being more athletic. I would go to doctors thinking I have a horrible disease that makes my tendons jelly. I just didn’t (and still really dont) understand why I was getting so much injuries when I really wasn’t doing SO much. I mean sure I was running, but who wasn’t. I still suffer from these injuries.
Then I started developing some fatigue. The emphasis here on ‘some’ as you will learn later below about where I am now. It was the type where you wake up sluggish and yawn a bit too much at work. As my injuries worsened I decided to start seeing a physiotherapist to address these problems. I was also diagnosed with a very mild anemia (cause unknown). The anemia went away but I had become obsessed with this idea that I was developing chronic fatigue syndrome. My anxiety was growing.
Then disaster struck later in November 2015. I had a PT session that was very intense. The PT clearly didn’t know where I was on the performance scale and asked me to do very straining exercises, pull-ups, heavy weights. All in 30 mins. I came back home SHATTERED. Over the next few days I would recover during the day, but every night I would feel like I was hit by a train. I’d come home unable to stand properly. Legs were like jelly and tiredness would strike me hard. I would hardly be able to cook dinner then go to bed. But it was only a week of this before it got worse. I started waking up feeling like the night before, I was not recovering at all. My anxiety struck and I was living the horror show of my life. I even had to take 3 weeks away from work which I mostly spent in bed.
To avoid boring you, I did see plenty of doctors in that period. All blood tests would come back normal. They told me to go home. But I wasnt getting better so I started seeing a functional practitioner. I changed my diet to be fully Paleo. Cut out grains, dairy, legumes, sugar, inflammatory oils, etc. Sleep was regulated. But anxiety wouldnt go away, and my biggest fear of chronic fatigue would get worse every day I didn’t heal. We did a cortisol test twice. It would show that my cortisol was VERY high in morning and afternoon, but it was normal during the day and late in evenings (though still high normal).
That was 8 months ago! Many symptoms improved, including a boost of testosterone (which was initially dismally low) and I have plugged plenty of nutritional gaps (which we have tested). But what doesn’t seem to improve at all is this chronic fatigue characterised by anaerobic metabolism. It seems that my body just isn’t able to efficiently produce energy, and it keeps falling back to glycolysis whenever I do anything. This then generates a high level of lactic acid which leaves my muscles tired and fatigued. I fear my metabolism has been damaged by my weight loss and overtraining. Is that possible?
I fear I am in stage 4, if that exists! My body is making improvements in many areas but not fatigue, which remains my biggest mental obstacle. And this in turn has caused me grave anxiety and depression. I dont feel I am a normal person and I fear I will remain like this forever. Is there hope in fixing this if I continue down my path of healing? I am also seeing an osteopath who aides in correcting postural issues I have and helps give me a light programme of exercise. But even that is difficult.
What would you advise me to do extra? I do walk daily for around 30-40 minutes but it brings with it significant fatigue and muscle aches. I am unable to do more than this without really struggling, eventually my legs get extremely tired and weak. The fatigue wears off slowly though, and after a good night’s sleep I wake up better. Not normal, but certainly better than the night before! I just don’t understand why many people lose weight and train okay but for me it was this disastrous…
we suggest at least 150 minutes per week of moderate exercise or 75 minutes per week of vigorous exercise (or a combination of moderate and vigorous activity)
I believe that me and many people on this forum have CFS induced by an excess of GA exercise, perhaps with other factors (eg infection) as contributing stressors. I think that severe OTS can become or can appear similar to CFS.
Note that in Maffetone's view, even many endurance athletes have surprisingly poorly developed aerobic systems, even if they have competitive race times. These people are heavily globally anaerobic even at relatively slow paces. Being fit and healthy are two different things. In theory a fit and healthy person should be able to run pretty fast without becoming globally anaerobic.
Note that in Maffetone's view, even many endurance athletes have surprisingly poorly developed aerobic systems, even if they have competitive race times. These people are heavily globally anaerobic even at relatively slow paces. Being fit and healthy are two different things. In theory a fit and healthy person should be able to run pretty fast without becoming globally anaerobic.
Treating CFS and OTS
In order to fix OTS it is necessary to develop the aerobic system by doing aerobic exercise. The higher your heart rate during a given exercise, the more energy you're consuming. So we can expect heart rate to correlate with how hard you're pushing your aerobic system and more generally how much you're stressing your physiology. We can use heart rate as a guide to determine which training intensities will develop the aerobic system and avoid overtraining.
Maffetone recommends the following formula for healthy people to determine that heart rate: 180 - Age; this is called the maximum aerobic function heart rate (MAFHR). For example, he recommends healthy people undergo an aerobic base building period during which they train at just under this heart rate, carefully avoiding exceeding it. A typical example would be maybe 90 minutes per day, 5 days per week, for 6 months. During this time one should see improvements in their performance at the MAF HR. For example, a 20 year old might go from running an 10 minute mile at a HR of 160 to running an 8 minute mile at the same HR.
For people who are in the earlier stages of overtraining, he recommends the formula 170 - Age. Now, the question is what heart rate should someone with severe overtraining or CFS use? This is going to depend on the individual - for one person it may be 95, for another 120 - but the point is that HR monitoring should play a central role in guiding pacing and exercise. For pacing, you should in theory stay under your anaerobic threshold. But for exercise, in order to improve your aerobic function, you need to regularly approach your MAFHR (without exceeding it).
In summary we have the following two recommendations:
What's interesting to me is Workwell's exercise recommendations. They advise against aerobic exercise and instead recommend repeated brief exercise (recall the definition of "brief" above) with rest to allow creatine phosphate to regenerate (https://www.ncbi.nlm.nih.gov/pubmed/20185614). Now, from a pacing point of view this makes complete sense, since in theory PWC have well functioning creatine phosphate systems, so repeated exercise using only this energy system might be well tolerated. But this almost completely avoids stressing the aerobic system, so their protocol might not adequately stimulate aerobic development.
In other words, Workwell's recommendations are good for management of CFS, but they're no cure.
The reason I made this post is because there are a lot of similarities between Maffetone's ideas and what is known about CFS, but neither group seems to know much about the other. It seems that Maffetone's ideas and the success of his method are not well known in the CFS community, and similarly CFS is not well known in the endurance or athletic community. I think it would help if both groups know about each other. I think there should be some experimentation with low HR exercise among PWC, particularly those whose CFS may have been caused by exercise.
Finally, here are a couple of people I've found who used Maffetone's ideas to recover from CFS (https://www.stevehoggbikefitting.com/outcome/recovering-from-cfs/).
This person used milnacipran along with the Maffetone method. (http://www.healingwell.com/community/default.aspx?f=15&m=3700103).
Maffetone recommends the following formula for healthy people to determine that heart rate: 180 - Age; this is called the maximum aerobic function heart rate (MAFHR). For example, he recommends healthy people undergo an aerobic base building period during which they train at just under this heart rate, carefully avoiding exceeding it. A typical example would be maybe 90 minutes per day, 5 days per week, for 6 months. During this time one should see improvements in their performance at the MAF HR. For example, a 20 year old might go from running an 10 minute mile at a HR of 160 to running an 8 minute mile at the same HR.
For people who are in the earlier stages of overtraining, he recommends the formula 170 - Age. Now, the question is what heart rate should someone with severe overtraining or CFS use? This is going to depend on the individual - for one person it may be 95, for another 120 - but the point is that HR monitoring should play a central role in guiding pacing and exercise. For pacing, you should in theory stay under your anaerobic threshold. But for exercise, in order to improve your aerobic function, you need to regularly approach your MAFHR (without exceeding it).
In summary we have the following two recommendations:
- Pace yourself by staying under your MAFHR.
- Exercise regularly by approaching - but not exceeding! - your MAFHR.
What's interesting to me is Workwell's exercise recommendations. They advise against aerobic exercise and instead recommend repeated brief exercise (recall the definition of "brief" above) with rest to allow creatine phosphate to regenerate (https://www.ncbi.nlm.nih.gov/pubmed/20185614). Now, from a pacing point of view this makes complete sense, since in theory PWC have well functioning creatine phosphate systems, so repeated exercise using only this energy system might be well tolerated. But this almost completely avoids stressing the aerobic system, so their protocol might not adequately stimulate aerobic development.
In other words, Workwell's recommendations are good for management of CFS, but they're no cure.
The reason I made this post is because there are a lot of similarities between Maffetone's ideas and what is known about CFS, but neither group seems to know much about the other. It seems that Maffetone's ideas and the success of his method are not well known in the CFS community, and similarly CFS is not well known in the endurance or athletic community. I think it would help if both groups know about each other. I think there should be some experimentation with low HR exercise among PWC, particularly those whose CFS may have been caused by exercise.
Finally, here are a couple of people I've found who used Maffetone's ideas to recover from CFS (https://www.stevehoggbikefitting.com/outcome/recovering-from-cfs/).
I’d reached rock bottom after my Glandular Fever had become CFS. I’d been ill for over 18 months and at my worst I couldn’t even walk 20 meters without feeling totally exhausted. I’d managed to get back on the bike sporadically but I wasn’t getting better, I was making all the same mistakes – trying to get back to racing fitness and pushing myself only to be side-lined with fatigue for weeks – I was in a constant circle of decline.
Steve took the time to explain to me where I was going wrong. What I needed to do to get right and what I should be eating. He recommended that I buy a book by Dr Phil Maffetone; The Big Book of Endurance Training and Racing . I read the book cover to cover and the penny finally dropped. 20 years of mistakes all beautifully explained in this book. I followed the advice of Steve and this book. It’s important to explain here that it was combination of the two sources of advice; low intensity riding, diet and sleep. The key is to still ride for serotonin and health benefits but strictly at low intensity. I started out with short rides at no more than 130 hr. My diet ditched the cheap carbs and instead I started eating more salads, fruit, nuts and good fats. I was eating 4500 calories a day yet my body fat and weight dropped like a stone. I felt great!!
I continued at this HR for several months, building up my stamina and getting stronger. My distance increased and so did my speed, yet all at low heart rates. The best thing was I no longer felt ill. I felt absolutely fantastic. I had energy in abundance. No more waking up feeling like I hadn't slept. Instead I was waking up feeling positive and energised about the day.
I have had CF and Fibromyalgia for over 8 years and hope a couple of things that helped me will help others. I am not going into symptoms and all I've been through. Just want to give people a couple options to talk over with your doctor.
I first took cymbalta, and it didn't help me much. My doctor found a new drug 6 years ago that was the first one made for this called Savella. I noticed an improvement immediately but it was still a long slow journey to feeling better. It got me out of bed and able to attend family functions. Eventually I was able to run 5ks, take care of myself and my home, and have a life. Don't know if it's an option for everyone, but it made a huge difference to me. I started out at the maximum dose of 200 mg and worked my way down to 50 mg.
about 8 months ago I did way too much and relapsed. I had to go back up to 200 mg. I discovered from internet research that we process oxygen differently than others and need to stay below the anaerobic threshold at all times. You can keep this under control by keeping your heart rate low. For some people this may be 95 and for others it could be 107. I bought a heart rate monitor and went to stay with my daughter. I did absolutely nothing but go for 2 or 3 mini-walks (1/4 to 1/2 mi) a day, take naps, and sleep till I felt like getting up. After about 2 weeks I was able to walk about 40 minutes. I did not do anything else.
I am back home now and have lowered my dose to 100 mg. I keep my heart rate below my anaerobic threshold at all times. I cannot mow my lawn with a push mower because it raises my heart rate too high and I become sick for days, so I use a rider and my family does the trim work. I can now walk 4 miles at a much faster pace and still maintain the same heart rate. I have signed up for a 5k in January and hope, by that time, to be able to run most of it at that same heart rate. According to the 'Maffetone Method' if you continually maintain a steady heart rate you can work up from barely walking to running at the same heart rate.
I firmly believe that if you stay inactive and because of the problem with oxygen intake you will continue to become sicker. I started feeling better the minute I started a consistent regimen of walking and resting.
It took me 8 years to learn what I should have learned the 1st year about keeping intensity low. I thought I felt better and I could conquer the world. So even when you're feeling better keep your heart rate low and build up duration and fitness. Hope this helps someone.
Caveats
With all this said, these strategies may not work for most or even many PWC. For example some people who are bedridden with CFS may not have enough reserve to do exercise without becoming GA. Other people may not recover until some underlying problem like a chronic infection is addressed (although as the story above illustrates, chronic infection like EBV certainly does not preclude recovery). I also think that many of us may benefit from avoiding LA exercise as well as GA exercise, and that it may be necessary to limit total daily energy expenditure ("spoon theory"); the autonomic system is involved in OTS and CFS for many people, a point which I haven't addressed. That said, I do think this could work for many of us, particularly those of us whose CFS may have been caused in part by exercise.
CFS and Maffetone's ideas about OTS both seem to involve a damaged aerobic system. Pacing and low intensity aerobic exercise guided by heart rate may help in recovery for some PWC, particularly those whose CFS seemed to be caused in part by exercise.
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