Sleep in Athlete March 29, 2015 Iris A. Perez, M.D. Assistant Professor of Clinical Pediatrics Keck School of Medicine of USC Division of Pediatric Pulmonology and Sleep Medicine Children s Hospital Los Angeles
Disclosure I have no relevant financial relationships with the manufacturer s of any commercial product(s) and/or provider(s) of commercial products or services discussed in this activity. I do not intend to discuss unapproved or investigative use of commercial product(s) or device (s) in my presentation. 2
Roadmap Basic concepts of sleep Patterns, timing, duration Importance of sleep in athletic performance Factors and processes that affect sleep Strategies to achieve good sleep Sleep and Travel 3
Purpose of Sleep WHY IS SLEEP IMPORTANT 4
The Purpose of Sleep The Restorative Theory: Sleep is for relief of bodily or cerebral deficits caused by waking activity. Sleep is for energy conservation Sleep is for memory consolidation 5
Not Fragmented Sufficient amount Appropriate timing Adequate Sleep 6
Sleep distribution across the years H.P. Roffwarg, et al. Science, 152: 604-619, 1966. 7
Hours of sleep 16 14 12 10 8 6 4 2 0 10 13 National Sleep Foundation Suggested Nightly Sleep Duration 9 11 8 10 9 9 7 7 7 3-5 6y-13 14-17 18-25 26-64 65+ Age in years 8 Minimum Upper limit http://sleephealthjournal.org 8
Pattern of Sleep Progression of Sleep Across the Night Chokroverty S. Sleep Disorder Medicine, 2nd, 1999. 9
Sleep Stage Volumes Over One Night % of Sleep Time 3.5 24.5 22 50 N1 N2 N3 REM 10
2 Process Model: Sleep Regulation Process C Process S
Circadian Rhythms Light Output Rhythms Physiology Behavior Suprachiasmatic Nuclei (SCN)
What is Circadian Rhythm Body clock Duration: 24.3 hours Measured by distinct rise and fall of body temperature, and blood levels of certain hormones and other bodily conditions. Influenced by exposure to sunlight Helps determine when we sleep and wake. Some people can t go to sleep until late; others can t sleep in. The New Yorker MARCH 11, 2013 Up All Night BY ELIZABETH KOLBERT CREDITILLUSTRATION BY NISHANT CHOKSI 13
Mechanism of Sleep Disorder Fragmented sleep Insufficient sleep Inappropriate timing of sleep period Sleep Deprivation 14
Neurocognitive deficit Performance Deficit Mood instability Cardiovascular disease Sleep Deprivation Impaired Glucose metabolism Immune Function Diabetes Impaired Appetite Regulation Obesity
Sleep Deprivation Factoids Acclimation to sleep loss does not occur--rather there is a continuous decline in performance that may not be perceived Circadian variations in alertness mean that 1200-0800 is the most vulnerable time for lapses in performance Caffeine and exertion promote alertness, but this does not always correlate with performance Warm ambient temperature, decreased body temperature, and food intake decrease alertness
SLEEP AND ATHLETIC PERFORMANCE
Sleep and Athletic Performance: Factoids Circadian peak in performance occurs in the late afternoon and lowest at 3 am. Competing close to circadian peak in performance results in a significant athletic advantage over those competing at other times. Athletes sleep poorly prior to important sleep competitions mainly due to nervousness and thoughts. Some athletes do not have strategies to overcome the poor sleep experience. 18
Sleep and Performance: Effect of Circadian Timing Athletic performance shows significant diurnal variation. Personal best performance times differ significantly between circadian phenotypes ( lark vs. owl ). Morning types ( larks ): mid-day Evening types ( owls ): evening Internal biological time predicts peak performance time Morning types : 5.5 hrs after entrained wake up time Evening types : 11 hrs after entrained wake up time 19
Sleep Stage 24.5 22 % of Sleep Time 3.5 50 N1 N2 N3 REM Stage 2 sleep is important in the memory of motor tasks. REM sleep : recall of spatial and temporal memory 20
Progression of sleep stages overnight ( hypnogram ) in a healthy school-age child. Stores G Arch Dis Child 2009;94:63-69 Copyright BMJ Publishing Group Ltd & Royal College of Paediatrics and Child Health. All rights reserved.
Objective: Impact of sleep deprivation on injury rates in young athletes 112 adolescent athletes, 12-18 yrs old, 50% F completed an online questionnaire Injury log from school s athletic training room was reviewed. Milewski, M, ET AL. J Pediatric Orthop 2014; 34:129-133. 22
Questionnaire How many weeks a year do you participate in organized sports? During the average week, how many hours are spent in sports including training, practice, and competition? Have you had a private coach outside of normal school or club teams? If so, how many hour per week? During the season, how many hours of sleep, on average do you get? Do you participate in strength training on a regular basis? How many times per week? How long is each session? How many sports do you participate in each year on a school or club? How much fun are your having in sports right now ( scale 1-10). 23
Athletes who slept an average of < 8 hours per night were 1.7 times more likely to have had an injury compared with athletes who slept on average 8 hours. Milewski, M, ET AL. J Pediatric Orthop 2014; 34:129-133. 24
Identify whether sleep problems exist A Few Practical Tips If present, identify how, when, and why do they occur. If persistent, consider sleep professional to improve quantity and quality of sleep ( follow sleep hygiene practices). If possible, avoid early morning training session following sleep disruption. Be aware that poor sleep prior to training could influence motivation and training. Where possible, align training session to competition times to adjust circadian rhythms. Adapted from Practical recommendattons for sporting practitioners. Sports Med 2015; 45:161-186 25
RECOGNIZING SLEEP PROBLEM 26
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SLEEPY?
Screening for Pediatric Sleep Disorder B edtime problems E xcessive daytime sleepiness A wakenings during the night R egularity of sleep S noring Owens JA. Sleep Med 2005,6:63-69. 29
Overnight Polysomnography 31
Actigraphy
Actogram: Average total sleep time: 4-1/2 hrs 33
Sleep In Teens Tendency for sleep timing to become later. Early wake-up times on school days (6:00-7: a.m.) Shortened time in bed: 6.5-9 hours Bedtime is 1-2 h later on weekends than weekdays Decrease in average sleep duration despite stable sleep need
Sleep changes in adolescence Accumulation of sleep pressure (Process S) is slower in late adolescence. Circadian phase delay favors later bedtime and rise time Principles and Practice of Pediatric Sleep Medicine, 2 nd ed.
Biology Adolescent Sleep Trifecta Favoring eveningness Increased demands on wake time : Sports and other enrichment activities School start time : zero period Increased homework Afterschool and evening jobs Social /peer interactions Media/screen time Significant variability in weekday vs weekend schedules
Delayed Sleep Phase Syndrome Inability to fall asleep at desired conventional clock time and inability to awaken at desired socially acceptable time. Problem of timing rather than sleep quality. Prevalence of 7-16% in adolescents Predisposing/Precipitating factors: Evening type Decreased exposure to morning light; exposure to light late in the evening. Family history
HOW TO PROMOTE HEALTHY SLEEP HABITS 38
Good Sleep Hygiene Allow for adequate sleep time Maintain a consistent sleep-wake pattern Create a suitable sleep environment Reduce physiologic barriers to sleep Establish a relaxing bedtime routine 39
Allowing for Adequate Sleep Time Limit after school and evening activities to ensure early bedtime Prepare for the next day to allow for later wake time. Establish consistent timeframe for daytime napping ( early afternoon) Monitor nighttime socialization 40
Maintaining a Consistent Sleep-Wake Pattern Sleep at same time each night and wake up same time each morning (weekdays and weekend Limit light exposure in the evening TV, video games, computer Sunlight exposure in the morning. Do not exercise 3 hours prior to bedtime Avoid heavy meals at least 3 hours prior to bedtime If needed, nap early in the afternoon no more than 1 hour 41
Creating a Suitable Sleep Environment Dark, cool, and quiet room A comfortable bed, used only for sleep Music or white noise Evaluate sleep environment for potential allergens Keep television, video games, and computers out of room 42
Reducing physiologic barriers to sleep Avoid vigorous play or physical exertion 3 hours prior to bedtime. No caffeinated beverages 4 hours prior to sleep Light snack Address anxiety 43
Healthy Sleep Practices Teens Set appropriate bedtime for your teenager. Promote good sleep hygiene Dark environment at night; avoid bright screens Light exposure in am Encourage your teen to keep a consistent sleep-wake schedule across the week, including weekends. School: Later school start Avoid late evening activities 44
Encourage your teen to: Principles of Sleep Hygiene Practice a routine bedtime ritual Get adequate (8 to 10 hours) sleep before anticipated sleep loss banking sleep Avoid starting out with a sleep debt
SLEEP AND TRAVEL 46
Jetlag Body s internal clock ( circadian rhythm) is not aligned with new local time zone The clock is slow to reset, so that after time zones have been crossed, the signals for sleep and wakefulness do not match the local lightdark and social scheduled. Symptoms: insomnia, daytime sleepiness, dysphoric mood, decreased physical performance, cognitive impairment. 47
Jetlag Symptoms usually persist for 1 day for each time zone crossed until body realigns its circadian clock, regardless of direction travelled. Prolonged travel within a single time zone will not result in jet lag but can be associated with fatigue, which usually resolves in 1-2 days. 48
Jet Lag Factoids Worse in those with more rigid sleeping habits Morning types : better flying eastward Evening types : better flying westward Less fatigue in men after travelling 10 time zones in eastward direction. Worse after eastward flight, persists up to 7 days after arrival; peaks in first 3 days westward. 49
Strategies to Minimize Jetlag and Travel Fatigue Before Travel Travelling Westward Traveling Eastward Begin to reset body clock a. Shift timing of sleep 1-2 h later few days before travel b. Exposure to bright light in early evening Get adequate amount of sleep Select a flight that allows early evening arrival and stay up until 10 pm local time a. Do not leave packing and travel prep last minute b. Schedule flight at time that will not cut short sleep before travel Shift timing of sleep 1-2h earlier few days before travel Exposure to bright light in the morning 50
Strategies to Minimize Jetlag and Travel Fatigue In Flight Travelling Westward Traveling Eastward Optimize comfort Upon boarding the plane, change watch to the destination time zone Travel in business or 1 st class, if financially feasible Get hydrated a. Drink a lot of water b. Decrease caffeine c. No alcohol (if taking sleeping pill) Use sleeping medication (approved), if necessary 51
Strategies to Minimize Jetlag and Travel Fatigue On Arrival Travelling Westward Traveling Eastward Be prepared for changes in sleep pattern until adapted to local time Expect trouble staying asleep Take appropriate nap a. Nap after arrival at destination b. Subsequent days, nap if sleepy ( 20-30 min) Melatonin * Bright light exposure Evening Morning Drink caffeinated drinks (avoid after midday) Expect trouble falling asleep After crossing > 8 time zones, avoid bright light when it may prevent adaptation for the first 2 days: Westward: 2-3 hrs before dusk Eastward: 2-3 hrs after dawn 52
Strategies to Minimize Jetlag and Travel Fatigue On Arrival Travelling Westward Traveling Eastward Be prepared for changes in sleep pattern until adapted to local time Expect trouble staying asleep Take appropriate nap a. Nap after arrival at destination b. Subsequent days, nap if sleepy ( 20-30 min) Melatonin * Bright light exposure Evening Morning Drink caffeinated drinks (avoid after midday) Expect trouble falling asleep After crossing > 8 time zones, avoid bright light when it may prevent adaptation for the first 2 days: Westward: 2-3 hrs before dusk Eastward: 2-3 hrs after dawn 53
At Destination Avoid heavy meals ; snack ok; no chocolates Avoid heavy exercise close to bedtime; light exercise in the day (may be a problem with scheduled practice ice or competition schedule for some). Bring earplugs and blindfolds to dampen noise and block out unwanted light while sleeping Sunlight 54
Strategies to Combat Sleepiness Sleep banking Napping Drink caffeinated drinks
Tips to Avoid Travel Related Stress Bring elements from home to ease feeling of being in a new environment. Have calls handled by voice mail services through drapes Request 2 wake up calls 56
Sleep During Travel Have bedtime routines similar to home Keep room cool (> 54 0 F<75 0 F) dark, quiet White noise (fan, air conditioner) to block out noise Decrease sleep disturbance: in room noise, (TV) light shining drapes) Request hypoallergenic linens ( consider bringing your own pillows or covers) 57
Recommendations for Minimizing Jet Lag and Travel Fatigue. Sack RL. N Engl J Med 2010;362:440-447.
Resources National Sleep Foundation: http://sleepfoundation.org/ American Academy of Sleep Medicine: http://www.aasmnet.org/; http://www.sleepeducation.com/ American Thoracic Society: h http://www.thoracic.org/patients/patient-resources