Page 150 - JSOM Summer 2022

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feedback, and consider frequency.” Psychological recovery their initial training pipeline and tracked over time to detect
monitoring in a SO population may be essential following crit- the early symptoms of NFO/OTS. 40
ical deployments, sustained military operations, and rigorous
training courses. In this dimension, there are several effective enzyme indicators
of OTS. The testosterone (anabolic hormone)/cortisol (cat-
Qualitative questionnaires and measures that can be used to abolic hormone) (T/C) ratio can be used with a difference of
assess recovery in sports neglect the multidimensional facet >30% between the hormones (T/C), serving as a critical indi-
30
of assessing overall individual recovery (e.g., internal/external cator that the participant is in a state of OTS. Additionally,
stress). For instance, the visual analog scale pain scale has high enzyme markers such as lactate dehydrogenase and CK should
test-retest reliability for assessing delayed-onset muscle sore- also serve as reliable markers in diagnosing OTS. Researchers
ness; however, it provides only a unidimensional measurement have reported that an increase in CK in the blood of 500 U/L
of muscular pain perception, not accounting for internal phys- is associated with a skeletal muscle injury. However, CK can
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iological stress. The Profile of Mood States (POMS), although be difficult to measure, and the measure can be variable. Al-
often used in sport-specific recovery research and practice, though the critical indicators suggested are not all-inclusive,
primarily focuses on stress-related behavior. Assessing an in- multiple inflammatory markers allow for a more precise and
dividual’s mood-state change in response to training loads is accurate indication of long-term dysregulation of the endocrine
not considered a sport-specific instrument, and the dimensions system because of their pleiotropic nature. Critical hormones
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assessed within the POMS do not adequately gauge the recov- released in response to stress include corticotrophin-releasing
ery portions of sport extensively. 62,63 hormone, adrenocorticotropic hormone (ACTH), cortisol,
growth hormone (GH), and insulin-like growth factor-1. ACTH
The Subjective Ratings of Perceived Exertion (RPE) Scale is and GH can distinguish between NFO/OTS. The critical weak-
another method routinely used in combination with recovery ness in using the indicators within this dimension is the need
questionnaires in detecting symptoms of NFO or URS/OTS. for routine blood samples. Besides the inconvenience, blood
However, Urhausen and Kindermann found that overtrained sampling is also sensitive to sampling conditions and time, di-
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athletes reported only minor changes in their RPE scale rat- urnal variations of hormones, poor reproducibility, and varying
ings, revealing that the RPE scale does not adequately address methods and techniques used to assess hormonal variations. 30,38
athletes’ multidimensional recovery stress status. 65
The Functional Movement Dimension
Researchers and practitioners routinely administer the Acute Over the years, SOs can develop upper and lower body lateral
Recovery and Stress Scale (ARSS) and Short Recovery and functional asymmetries. Such alterations in muscular activa-
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Stress Scale (SRSS) within the elite competitive athletic arena. tion patterns can be measured noninvasively during real-world
These questionnaires provide weekly performance and health situational training using wearable technology. 67-69 For exam-
information regarding the current recovery-stress status of ple, Athos is a promising and validated technology consisting
an individual. The ARSS and SRSS measure the emotional, of compression apparel that individuals wear directly against
mental, physical, and overall aspects of acute recovery-stress the skin during “real-time” training exercises to detect move-
states. The instrument uses a 7-point Likert Scale. Both ques- ment deficiencies. After each physical training session, Athos
tionnaires have acceptable reliability and have been validated artificial intelligence evaluates the participant’s physical per-
in athletes aged 16 and older. 32 formance on nine key injury-prevention markers and assigns
them to an injury risk category. Athos assigns the individual
The Recovery-Stress Questionnaire (RESTQ) is a 36-item lower body supplemental exercises supporting their injury
inventory comprised of six sport-specific scales and six gen- risk category to help the participant progress toward health-
eral scales that requires the individual to rank each item on ier movement patterns. The results from three experiments
a Likert scale from 0 to 6 (0, does not apply at all, to 6, fully showed that the output from Athos wearable surface-electro-
applies). The RESTQ identifies individual imbalances in re- myography sensor technology is valid and reliable and that the
covery stress status, which correlates with performance factors measures are repeatable and predictable. 67-72
and biomarkers of stress, such as testosterone, cortisol, and
creatine kinase (CK). 30,34 The RESTQ is especially useful for
gauging the physiological consequences of potentially stressful Conclusions and Implications
events while also helping to show disparities in the individual’s This review highlights knowledge gaps that deserve explora-
recovery-stress state. Ultimately, the information gleaned from tion, especially in the domain of longitudinal implementation,
the RESTQ can aid in the early detection of an individual’s risk health, and recovery monitoring in the special operations pop-
for NFO/OTS. 34 ulation. Our findings indicate that contributing factors leading
to dysregulation of the neuroendocrine system and ANS likely
The Biomarker Dimension stem from the combined rigors of training and continuous
According to the Joint Consensus Statement of the European deployment demands on SOs throughout their careers. These
College of Sport Science and the American College of Sports recurring demands can result in a chronically high burden of
Medicine, the scientific literature concurs that NFO/OTS physical and psychological stress known as allostatic overload.
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should be observed on a continuum with a disturbance, an We identified four central biomarkers in the literature that are
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adaptation, and lastly, a maladaptation of the HPA axis. associated with allostatic overload: cortisol, adrenaline, nor-
Although biomarker reference ranges are proper for general- adrenaline, and DHEA. These biomarkers accurately measure
ized populations, clinicians and human performance experts HPA neuroendocrine responses to stress.
should consider establishing individualized mean reference
ranges for SOs. For instance, these individualized “normal’ Our review found that allostatic imbalance in SOs may occur
values can be appropriately set upon Operators’ entry into when supramaximal demands are prolonged and repeated;

146 | JSOM Volume 22, Edition 2 / Summer 2022