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Sleep Medicine

From WikiSM

Other Names

  • Sleep Medicine
  • Sleep Medicine in Athletes
  • Sleep Disorders in the Athlete

Introduction

Checklist for athletes to consider for improved sleep[1]
5 key recommendations for sleep and athletic performance[2]
Evaluation tools for sleep assessment[2]

General

  • Sleep is critical to overall health for athletes who exercise at all levels
  • Sleep deprivation has clear negative effects on performance, including reaction time, accuracy, vigor, submaximal strength, and endurance
  • Cognitive functions including judgement, decision-making also suffer
  • Improved sleep quality can positively affect reaction times, mood, sprint times, tennis serve accuracy, swim turns, kick stroke efficiency, and increased free throw and 3-point accuracy
  • Banking sleep may also improve performance
  • In an effort to improve sleep, athletes may use supplements with serious side effects
  • Improving sleep quality is often simple and effective

Terminology

  • Sleep Extension: scheduling longer sleep than normal when opportunity allows
  • Sleep Efficiency: quality of sleep
  • Sleep Insufficiency: individual does not get enough sleep to function well
    • Sometimes termed sleep inadequacy
  • Banking Sleep: intentional sleep extension prior to a night of sleep deprivation
  • Chronotype: person's preferred time to sleep and be active, is a reflection of their circadian rhythm
  • Travel fatigue: associated with disruption and demands of travel
    • Such as getting to the plane and poor prior sleep
    • Can become an enduring problem for elite competitors in sports such as basketball (National Basketball Association) and hockey (National Hockey League), who endure high frequency domestic flights[3]
  • Jet lag: associated with the resynchronization of the body clock to the new environment
    • Resolves at a rate of about 1 day per time zone crossed
  • Sleep onset latency (SOL): amount of time it takes to fall asleep after turning off the lights and going to bed

Need for Sleep

  • Two types of sleep
    • REM
    • Non REM Sleep: continuum from ‘light’ sleep in stages 1 and 2, through to ‘deep’ sleep in stage 3[4]
  • Normal duration of sleep[5]
    • 8–10 hours for an adolescent (57% light sleep, 22% deep, 21% REM sleep)
    • 7–9 hours for a young adult (61% light sleep, 16% deep sleep, 23% REM sleep)
  • Most adults require 7–9 h of sleep per night[6]

Functions of Sleep

  • Maintain cognitive function
  • Learning and memory consolidation
  • Well being
  • Grown and cellular repair
  • Glucose metabolism
  • Immune Function, response to vaccination
  • Resistance to respiratory infection

Measuring Sleep

  • Sleep Measurements
    • Sleep architecture (sleep staging)
    • Sleep duration
    • Measured or estimated sleep efficiency (quality)
    • Sleep-onset latency (SOL: time taken to fall asleep)
    • Wake after sleep onset (WASO)
  • Measurement Modalities
    • Polysomnography[7]
      • Also known as a sleep study
      • Considered the gold standard for evaluating sleep
      • Assessment of eye movement, brain activity, heart rate, muscle activity, oxygen saturation, breathing rate and body movement
    • Activity Monitoring: wearable devices that record movement
    • Nearables and smartphone applications
    • Sleep diaries and questionnaires
      • Sleep Hygiene Index
      • Insomnia Severity Index
      • Epworth Sleepiness Scale
      • Morningness Eveningness Questionnaire
      • Pittsburgh Sleep Quality Index (PSQI)
    • Athlete specific questionnaires
      • Athlete Sleep Screening Questionnaire (ASSQ)
      • Athlete Sleep Behavior Questionnaire (ASBQ)

Sleep Societies

  • American Academy of Sleep Medicine (AASM)
  • Sleep Research Society (SRS)
  • National Sleep Foundation (NSF)

Sleep Deprivation In Athletes

Factors contributing to sleep disturbance in athletes[2]
FActors impacting diagnosis and treatment of sleep disorders[8]

General

  • May also be termed sleep inadequacy
  • Athletes are known to get less sleep than non-athletes[9]
  • Even when athletes do get adequate sleep, they often have longer sleep latency/ lower sleep efficiency[10]

Categories of Sleep Disorder

  • Short-term sleep deprivation
  • Long-term sleep restriction
  • Circadian misalignment
  • Untreated sleep disorders

Prevalence

  • Reported to be high among elite athletic populations
    • Disruptive training and competition schedules that limit the opportunity for sleep
  • Characterised by habitual sleep durations <7 hours[11]
  • Studies suggest[12]
    • 50-70% of elite athletes experience sleep disturbance
    • 22%–26% suffer highly disturbed sleep
  • General Population
    • Children (34%), high school students (75%), adults (33%) fail to get a sufficient duration of sleep on a regular basis[13]

Risk Factors for Sleep Dysfunction in General Population

  • Mental health: Depression, anxiety, other mental health conditions
  • Medical conditions: neurological conditions, heart disease, lung disease, cancer, diabetes, and chronic pain
  • Medications /drugs: Caffeine, nicotine, alcohol, and recreational drugs
  • Schedule changes: Shift work, jet lag, and irregular schedules
  • Aging: increased age associated with increase risk of sleep dysfunction
  • Family history: family history
  • Social and environmental conditions: Poorer neighborhoods, higher crime rates, and exposure to more nighttime light
  • Sex: female > male

General Risk Factors for Sleep Deprivation in Athletes

  • General risk factors
    • Female gender
    • Spinal cord injury
    • Increasing age
    • Poor mental health[14]
  • Schedules are often rigorous combined with travel obligations and time zone changes
  • Athletes may downplay the importance of sleep
  • Smartphones and electronic devices are known to disrupt sleep[15]
    • Blue-light emissions from screens disrupt the body’s natural melatonin production
  • Stress and anxiety before the upcoming match may impair healthy sleep[16]

Sport-specific Risk Factors for Sleep Inadequacy

  • Athlete risk profiles and the challenges to athlete sleep vary between different sports
  • Schaal et al reported[17]
    • Long-term sleep problems were particularly prominent in contact sports, combat sports, aesthetic sports
  • It is not currently known why some sports have higher risk of sleep inadequacy
  • Hypotheses include
    • History of concussion in combat sports
    • Influence of generalised anxiety disorder, negative perfectionism and low energy availability in aesthetic sport competitor
  • Individual vs Team Athletes
    • Individual sport athletes obtain less sleep than team athletes[18]
    • This difference was enhanced during of study in elite german athletes during competition[19]

Over-reaching/ Overtraining and Sleep Disturbance

  • Sleep disturbances are frequently reported as one of the many symptoms of over-reaching/ overtraining[20]
  • Magnitude of these sleep alterations is quite modest in terms of both the reduction in sleep efficiency (<5%) and sleep duration (<30 min)
    • When compared to sleep disorder patients, athletes with jet lag
  • Unclear whether sleep disturbance is a cause or an effect in terms of over-reaching and overtraining

Impact of Training and Competition Schedules on Sleep

  • Impact of training and competition schedules on athletes’ sleep is well established
  • Early morning training and competition reduce athletes’ sleep duration, increase pretraining fatigue levels
  • Matches performed in the evening are associated with later sleep onset time, shorter time in bed, less total sleep obtained[21]

Negative Effects of Sleep Deprivation: General Population

  • General
    • Increased mortality/ risk of death
  • Neurocognitive Dysfunction
    • Slower/less accurate cognitive performance
  • Metabolic Dysfunction
  • Immunologic Dysfunction
    • Increases pro-inflammatory cytokines, which impairs immune system function
  • Cardiovascular Dysfunction
  • Nutritional
    • May crave unhealthy foods, affecting glucose sensitivity, glycogen stores, appetite, food intake and protein synthesis[22]
  • Endocrine
    • Affects growth hormone, cortisol function[23]
  • Musculoskeletal
    • Impedes muscle recovery and repair from damage
  • Neurological
    • Autonomic nervous system imbalance
    • Altered pain perception
  • Oncological
    • Increased risk of cancer

Negative Effects of Sleep Deprivation: Athletes

  • Physical effects
    • Decreased running performance
    • Decreased muscle glycogen concentration
    • Reduced submaximal strength, isokinetic peak torque
    • Reduced minute ventilation, distance covered, sprint times,
    • Reduced tennis serve accuracy
    • Reduced soccer kicking skills
    • Decreased time to exhaustion
  • Cognitive effects
    • Decreased psychomotor functions, mood, and vigor
    • Increased reaction time and confusion
    • Impaired judgement, decision-making
  • Time to onset
    • Studies showed impairments with 24–36 h of sleep deprivation
    • Many studies show negative effects with just 2-4 hours of sleep loss per night

Sleep Extension

Benefits of increasing sleep duration among those who are sleep deprived

  • Physical
    • Natural recovery of anabolic hormones[24]
    • Improves sprint times[25]
    • Increased tennis serve accuracy[26]
    • Improved swim turn and kick stroke efficiency, swim sprint[27]
    • Basketball shooting accuracy(free throw and 3-point accuracy)[28]
    • Half-court and full-court sprints
    • Time to exhaustion[29]
  • Cognitive
    • Improved reaction times
    • Improved psychomotor vigilance tasks
    • Increased alertness, vigor, and mood
    • Decreased fatigue, sleepiness

Sleep Hygiene

General

  • Introducing a simple sleep hygiene/sleep optimization education program for athletes can improve sleep time and sleep efficiency[30]
  • Naps appear to be beneficial, especially if athlete can not get adequate nocturnal sleep
  • Banking sleep improved performance in athletes anticipating sleep deprivation

Goals

  • Most studies agree on increasing sleep by 2 h for athletes
  • Goal for athletes is to achieve 9 hours of sleep per night

Daily Variations in Components of Sports Performance

  • There are specific times of day when rhythms associate with peak sporting performance
    • This is true regardless of any travel or jet-lag considerations
  • Tasks that require fine motor coordination, learning game tactics[31]
    • E.g. such as standing on a wobble board
    • Achieved more easily in the morning (08:00–09:00 hours)
  • Tasks that require complex hand-eye-coordination skill
    • E.g. accuracy of tennis or badminton serves
    • Peak around 13:00– 15:00 hours
  • Self-paced endurance performance (total work done in 1 hour)
    • Comparable in the morning (08:30 hours) and early evening (17:30 hours) in temperate conditions[32]
  • Gross muscular tasks (i.e. back and leg strength, sprint performance, time trials)
    • Maximum (17:00– 20:00) and minimum (~05:00 hours)[33]
    • Performance parallel to those of core body temperature
  • Timing of exercise matters
    • Exercising in the evening can phase shift your circadian rhythm to later at night[34]
    • Exercising at night has been shown to delay the release of melatonin

Jet Lag and Sports Performance

  • The body's natural clock is important for optimizing sleep timing and duration
  • Sleep quality can suffer if the athlete is out of their natural circadian phase
    • For example, athletes who are jet lagged or changed time zones
  • Three lines of evidence support the rationale for adjusting strategies when crossing multiple time zones[35]
    • 1st: evidence that the body clock influences sporting performance
    • 2nd: observed negative effects while adjusting the body clock to the new time zone
    • 3rd: findings of meta-analyses of win-loss records of basketball, hockey and American football teams travelling across time zones before matches
  • NFL study comparing East/West coast teams playing on opposite time zones[36]
    • Comparison of east coast teams playing in west coast games/ west coast teams playing in east coast games
    • No difference in performance during the 1 PM, 4 PM games
    • For evening games, the east coast teams playing in the west coast consistently underperformed
    • This finding was consistent across 40 years of NFL games

Jet Lag Considerations

  • Negative effects of jet lag
    • Negative effects on sleep and subjective fatigue, motivation, and feelings of jet lag[37]
    • Decreased vigor, impaired wake up time
    • Sprint performance decreased for 72 hours
  • Duration of travel
    • Long haul duration (up to 30h) but short (up to 6.5 h) both impair sleep quality, increased fatigu[38]
    • Longer haul flights have more substantial impact
  • Rough guide for jet lag symptoms
    • Symptoms may last for about one day per time zone crossed when traveling eastward
    • May last half-day per time zone crossed when traveling westward
  • North/South Travel
    • Not well understood
    • There may be a change in light exposure moving towards or away from the equator
  • As adjustment of the body clock to the new time zone occurs[39]
    • Improvement in nocturnal sleep
    • Symptoms of daytime fatigue, poorer motivation and poorer mental performance subside

Improving Sleep Hygiene

The sleep health team for athletes[8]
Sleep supplements to consider[8]

General

  • Healthy sleep can be trained
  • Improve by utilizing regular routines
  • Create an optimal environment for sleep

General Recommendations

  • Waking up at the same time each day
  • Establish the same evening routine before bed
  • Avoid stimulants and distractions
  • Avoid alcohol, nicotine, caffeine before bed
  • Eat dinner a few hours before bed
  • Reserve bed for sleep/ sex only
  • Have a ritual to wind down at night
  • Sleep in a cool, dark and quiet environment
  • Put away cell phones/ electronic devices, avoid blue light

Sleep Education

  • In a study of 86 coaches/sports science staff, less than half had promoted sleep hygiene[40]
  • Promoting sleep information specific to the athlete’s sport
    • E.g. sleep need, adjusting to training times and emphasis on the impact of sleep on performance
    • Key to create buy-in and behavioural change
  • Sleep presentations have been shown to increase sleep duration
    • Presentation from 30 to 60 min have been shown to increase sleep duration by an average of 20–90 min[41]
    • However, these improvements were not maintained 1 month later
  • In order to maintain benefit, staff may need
    • Repeat sleep education sessions throughout the season
    • Frequent check-ins with the athlete about their sleep

Sleep Disorder Screening

  • This is an integral part of managing an athletes health
  • Team physicians can identify sleep dysfunction
    • Refer athlete to specialist for clinical diagnosis when necessary
  • If a sleep disorder is untreated, sleep-focused strategies are unlikely to be effective

Encourage Nap Opportunities

  • Benefits of napping[42]
    • Improved alertness, concentration, mood
    • Improved motor performance
    • Improved cognitive performance
  • Nap can by supplemental to athletes who can not get enough night time sleep
    • Can also be beneficial even if athlete is getting sufficient nocturnal sleep
  • Recommended duration is less than 30 minutes
    • This is to avoid sleep inertia (ie, grogginess) from getting into the deeper stages of sleep
  • Coffee-Nap[43]
    • Caffeine consumed in doses of 150–200 mg just prior to a mid-afternoon nap
    • Shown to be an effective countermeasure to mid-afternoon sleepiness
  • Increasing post nap wakefulness
    • Exposure to bright light
    • Face washing
  • Reasons to avoid naps
    • If athlete is having trouble falling asleep at night

Additional Options

  • Get natural light
  • Avoid blue light
  • Stress reduction and meditation
  • Food
  • Melatonin

When Traveling

  • Bringing objects from the home sleep/wake environment (pillows, blankets, photos, favorite coffee mug) can ease the transition
  • Some individuals turn to sleep aids such as supplements and medications
    • Generally not recommended as they can have significant side effects
    • May not improve circadian rhythm or decrease jet lag

Nutritional Strategies to Enhance Sleep

  • Research in this area is in its infancy and definitive conclusions are currently difficult to formulate
  • Dietary intake prior to sleep, specifically carbohydrate intake and the timing of ingestion, has the potential to influence sleep[44]

Caffeine and Sleep

  • Systematic review of highlights the negative effects of caffeine on sleep[45]
    • Increases sleep onset latency
    • Decreases sleep duration
    • Decreased sleep efficiency
    • Decreased perceived sleep quality
  • There are currently no evidence based guidelines or recommendations for caffeine consumption in athletes when considering sleep

Sleep Banking and Extension

  • Banking sleep: getting extra sleep before an anticipated period of sleep loss
    • This may benefit performance[46]
  • Sleep extension: scheduling longer sleep than normal when opportunity allows
    • In collegiate basketball players, sleep extension improved reaction time, sprint times, mood and free-throw shooting accuracy

Approach to Athlete and Sleep Disorders

  • Measurement tools validated in athletes
    • Athlete Sleep Screening Questionnaire (ASSQ)
    • Athlete Sleep Behavior Questionnaire (ASBQ)
  • ASBQ was developed by Driller et al[47]
    • Consists of an 18-item questionnaire to identify faulty sleep behaviors in athletes
    • Helps determine which athletes would benefit from preventive measures and which athletes suffer from significant sleep problems
  • ASSQ was developed by Samuels et al[48]
    • Consists of 15 items, is reliable and consistent
    • Tool to screen athletes for sleep problems
  • Both ASSQ and ASBQ are used to
    • Guide the formulation of the athlete’ sleep optimization strategy
    • May include sleep coaching, cognitive behavioral therapy, sleep medicine consultation, and or medication

Sleep Disorders

General

  • Sleep dysfunction may be blamed on stress or training but athletes may have at true sleep disorder
  • Difficult to self diagnose, athletes don't know if they snore/ have disrupted sleep
  • The athlete may be uncomfortable or afraid to inquire or speak up

Indications for Evaluation

  • Sleep problems that affect their daily life
  • Signs of sleep disturbance
    • Difficulty falling or staying asleep
    • Waking up in the middle of the night
    • Snoring a lot
    • Feeling exhausted during the day
    • Struggling to stay awake at work or while driving

Disorders

  • Sleep breathing disorders
    • Obstructive sleep apnea (OSA)
    • Central sleep apnea (CSA)
    • Sleep-related hypoventilation
    • Hypoxemia OSA
  • Parasomnias
    • Sleepwalking
    • Talking in your sleep
    • Nightmares or night terrors
    • Sleep paralysis
    • Repetitive teeth grinding
    • Eating in your sleep
  • Sleep movement disorders
    • Restless legs syndrome
    • Periodic limb movement disorder (PLMD)
    • Sleep-related leg cramps
    • Sleep-related rhythmic movement disorder (SRRMD)
    • Sleep bruxism
  • Circadian rhythm disorders
  • Hypersomnias
    • Narcolepsy
    • Idiopathic hypersomnia (IH)
    • Kleine-Levin syndrome (KLS)

Insomnia

  • Key treatment strategies
    • Cognitive behavioral therapy
    • Sleep supplements
    • Exercise interventions

See Also

References

  1. ↑ Image courtesy of https://www.iusca.org/
  2. ↑ 2.0 2.1 2.2 Walsh, Neil P., et al. "Sleep and the athlete: narrative review and 2021 expert consensus recommendations." British journal of sports medicine 55.7 (2021): 356-368.
  3. ↑ Samuels CH. Jet lag and travel fatigue: a comprehensive management plan for sport medicine physicians and high-performance support teams. Clin J Sport Med 2012;22:268–73.
  4. ↑ Berry RB, Brooks R, Gamaldo CE, et al. The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications. Darien, IL: American Academy of Sleep Medicine, 2017.
  5. ↑ Ohayon, Maurice M., et al. "Meta-analysis of quantitative sleep parameters from childhood to old age in healthy individuals: developing normative sleep values across the human lifespan." Sleep 27.7 (2004): 1255-1273.
  6. ↑ Mukherjee S, Patel SR, Kales SN, Ayas NT, Strohl KP, Gozal D, Malhotra A. American thoracic society ad hoc committee on healthy sleep. An official american thoracic society statement: the importance of healthy sleep. Recommendations and future priorities. Am J Respir Crit Care Med 2015; 191: 1450–1458
  7. ↑ Roomkham, Sirinthip, et al. "Promises and challenges in the use of consumer-grade devices for sleep monitoring." IEEE reviews in biomedical engineering 11 (2018): 53-67.
  8. ↑ 8.0 8.1 8.2 Creado, Shane A., and Shailesh Advani. "Sleep disorders in the athlete." The Psychiatric Clinics of North America 44.3 (2021): 393-403.
  9. ↑ Lastella M, Roach GD, Halson SL, Sargent C. Sleep/wake behaviours of elite athletes from individual and team sports. Eur J Sport Sci 2015; 15: 94–100
  10. ↑ Leeder J, Glaister M, Pizzoferro K, Dawson J, Pedlar C. Sleep duration and quality in elite athletes measured using wristwatch actigraphy. J Sports Sci 2012; 30: 541–545
  11. ↑ Roberts, Spencer Stuart Haines, Wei-Peng Teo, and Stuart Anthony Warmington. "Effects of training and competition on the sleep of elite athletes: a systematic review and meta-analysis." British journal of sports medicine 53.8 (2019): 513-522.
  12. ↑ Swinbourne, Richard, et al. "Prevalence of poor sleep quality, sleepiness and obstructive sleep apnoea risk factors in athletes." European journal of sport science 16.7 (2016): 850-858.
  13. ↑ U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2030. Increase the proportion of children who get sufficient sleep — EMC-03. https://health.gov/healthypeople/objectives-and-data/browse objectives/children/increase-proportion-children-who-get-sufficient-sleepemc-03.
  14. ↑ Kalmbach, David A., Jason R. Anderson, and Christopher L. Drake. "The impact of stress on sleep: pathogenic sleep reactivity as a vulnerability to insomnia and circadian disorders." Journal of sleep research 27.6 (2018): e12710.
  15. ↑ Chang AM, Aeschbach D, Duffy JF, Czeisler CA. Evening use of light-emitting eReaders negatively affects sleep, circadian timing, and next-morning alertness. Proc Natl Acad Sci USA 2015; 112: 1232–1237
  16. ↑ Halson S Stealing sleep: Is sport or society to blame? Br J Sports Med 2016; 50: 381
  17. ↑ Schaal, Karine, et al. "Psychological balance in high level athletes: gender-based differences and sport-specific patterns." PloS one 6.5 (2011): e19007.
  18. ↑ Lastella, Michele, et al. "Sleep/wake behaviours of elite athletes from individual and team sports." European journal of sport science 15.2 (2015): 94-100.
  19. ↑ Erlacher, Daniel, et al. "Sleep habits in German athletes before important competitions or games." Journal of sports sciences 29.8 (2011): 859-866.
  20. ↑ Meeusen R, Duclos M, Foster C, et al. Prevention, diagnosis, and treatment of the overtraining syndrome: joint consensus statement of the European College of sport science and the American College of sports medicine. Med Sci Sports Exerc 2013;45:186–205.
  21. ↑ Sargent, Charli, and Gregory D. Roach. "Sleep duration is reduced in elite athletes following night-time competition." Chronobiology international 33.6 (2016): 667-670.
  22. ↑ Morselli L, Leproult R, Balbo M, Spiegel K. Role of sleep duration in the regulation of glucose metabolism and appetite. Best Pract Res Clin Endocrinol Metab 2010; 24: 687–702
  23. ↑ Mougin F, Bourdin H, Simon-Rigaud ML, Nguyen Nhu U, Kantelip JP, Davenne D. Hormonal responses to exercise after partial sleep deprivation and after hypnotic drug-induced sleep. J Sports Sci 2001; 19: 89–97
  24. ↑ Chennaoui M, Arnal PJ, Drogou C, Sauvet F, Gomez-Merino D. Sleep extension increases IGF-I concentrations before and during sleep deprivation in healthy young men. Appl Physiol Nutr Metab 2016; 41: 963–970
  25. ↑ Waterhouse J, Atkinson G, Edwards B, Reilly T. The role of a short post-lunch nap in improving cognitive, motor, and sprint performance in participants with partial sleep deprivation. J Sports Sci 2007; 25: 1557–1566
  26. ↑ Schwartz J, Simon RD Jr.. Sleep extension improves serving accuracy: A study with college varsity tennis players. Physiol Behav 2015; 151: 541–544
  27. ↑ Mah CD. Extended sleep and the effects on mood and athletic performance in collegiate swimmers. Sleep 2008; 31: (Suppl.) A128
  28. ↑ Mah CD, Mah KE, Kezirian E, Dement WC. The effects of sleep extension on the athletic performance of collegiate basketball players. Sleep 2011; 34: 943–950
  29. ↑ Arnal PJ, Lapole T, Erblang M, Guillard M, Bourrilhon C, Leger D, Chennaoui M, Millet GY. Sleep extension before sleep loss: Effects on performance and neuromuscular function. Med Sci Sports Exerc 2016; 48: 1595–1603
  30. ↑ Van Ryswyk E, Weeks R, Bandick L, O’Keefe M, Vakulin A, Catcheside P, Barger L, Potter A, Poulos N, Wallace J, Antic NA. A novel sleep optimisation programme to improve athletes’ well-being and performance. Eur J Sport Sci 2017; 17: 144–151
  31. ↑ Reilly, Thomas, Greg Atkinson, and Jim Waterhouse. Biological rhythms and exercise. Oxford University Press, 1996.
  32. ↑ Reilly T, Garrett R. Effects of time of day on self-paced performances of prolonged exercise. J Sports Med Phys Fitness 1995;35:99–102.
  33. ↑ Giacomoni M, Edwards B, Bambaeichi E. Gender differences in the circadian variations in muscle strength assessed with and without superimposed electrical twitches. Ergonomics 2005;48:1473–87.
  34. ↑ Youngstedt SD, Elliott JA, Kripke DF. Human circadian phase-response curves for exercise. J Physiol 2019; 597: 2253–2268
  35. ↑ Roy, Jonathan, and Geneviève Forest. "Greater circadian disadvantage during evening games for the National Basketball Association (NBA), National Hockey League (NHL) and National Football League (NFL) teams travelling westward." Journal of Sleep Research 27.1 (2018): 86-89.
  36. ↑ Smith RS, Efron B, Mah CD, Malhotra A. The impact of circadian misalignment on athletic performance in professional football players. Sleep 2013; 36: 1999–2001
  37. ↑ Fowler PM, Knez W, Crowcroft S, Mendham AE, Miller J, Sargent C, Halson S, Duffield R. Greater effect of east vs. west travel on jet lag, sleep, and team sport performance. Med Sci Sports Exerc 2017; 49: 2548–2561
  38. ↑ Thornton HR, Miller J, Taylor L, Sargent C, Lastella M, Fowler PM. Impact of short-compared to long-haul international travel on the sleep and wellbeing of national wheelchair basketball athletes. J Sports Sci 2017; 5: 1–9
  39. ↑ Edwards, Ben J., et al. "Athletic performance; effects of sleep loss." (2023): 434-443.
  40. ↑ Miles KH, Clark B, Fowler PM, et al. Sleep practices implemented by team sport coaches and sports science support staff: a potential avenue to improve athlete sleep? J Sci Med Sport 2019;22:748–52.
  41. ↑ O’DONNELL, S. H. A. N. N. O. N., and Matthew W. Driller. "Sleep-hygiene education improves sleep indices in elite female athletes." International Journal of Exercise Science 10.4 (2017): 522.
  42. ↑ Milner, Catherine E., and Kimberly A. Cote. "Benefits of napping in healthy adults: impact of nap length, time of day, age, and experience with napping." Journal of sleep research 18.2 (2009): 272-281.
  43. ↑ Horne, Jim A., and Louise A. Reyner. "Counteracting driver sleepiness: effects of napping, caffeine, and placebo." (1996): 306-309.
  44. ↑ Afaghi A, O’Connor H, Chow CM. Acute effects of the very low carbohydrate diet on sleep indices. Nutr Neurosci 2008;11:146–54.
  45. ↑ Clark, Ian, and Hans Peter Landolt. "Coffee, caffeine, and sleep: A systematic review of epidemiological studies and randomized controlled trials." Sleep medicine reviews 31 (2017): 70-78.
  46. ↑ Arnal PJ, Lapole T, Erblang M, et al. Sleep extension before sleep loss: effects on performance and neuromuscular function. Med Sci Sports Exerc 2016;48:1595–603.
  47. ↑ Driller M, Mah C, Halson S. Development of the Athlete Sleep Behavior Questionnaire: a tool for identifying maladaptive sleep practices in elite athletes. Sleep Sci 2018;11(1):37–44.
  48. ↑ Samuels C, James L, Lawson D, et al. The Athlete Sleep Screening Questionnaire: a new tool for assessing and managing sleep in elite athletes. Br J Sports Med 2016;50(7):418–22.
Created by:
John Kiel on 5 January 2025 18:30:46
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7 January 2025 17:55:07
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