Thanks for having me. I'm honored to be a part of the panel. It's late in the afternoon. I'm talking about sleep. A little intimidating, but hang with me. I'll try to make it as interesting as I can for you. Let's see here. There we go. So the old mantra. I think most of us in the room probably grew up athletes in some capacity, and this probably looks familiar. Sleep was weak when I was growing up. Honestly, there's some inherent bias in me that sees it that way in a lot of ways. But honestly, it's not. And this is the way we've thought about sleep up until probably the last five, six years. And I kind of chalk it up to some of the professional athletes, honestly, that came forward saying how important sleep was to them, especially LeBron and Kobe, all these guys saying that they're sleeping 12 hours a night and optimizing that for performance. Kobe was kind of well ahead of his time in saying that sleep perhaps is the best performance enhancer that we have. And I hope we think about that as we go along through this talk and maybe something you take away from it is sleep is free of charge, right? It's free. It's legal. And it works. How many other things do that, right? So that's pretty cool. So great. So here's what we're going to talk about. We're going to talk a little bit about athlete sleep in general, why we think they sleep differently, why it matters, and how we can intervene. So here's my disclosure. I have no financial disclosures, but I'm not the best sleeper. Even doing the work that I've done to some extent, I still want to stay up later than I should. So all right. The first question, do athletes sleep differently? The answer seems to be yes. Recent literature, there's a little bit of conflict there with regards to why and how. Cameron et al. in this study demonstrated that in professional athletes, and I know we're talking about the youth athlete here, but I'm doing the best we can with what available literature we have. The professional football players were compared to age match controlled. The duration of sleep didn't seem to be a problem in that cohort, which is a little confusing and in conflict with some of the other published literature out there. But the efficiency, sleep efficiency, the quality of the sleeps did seem to be affected. And that is for various reasons that we'll get into. In contrast, this other study, it's a large review that came out the same year by a group of Greek authors, demonstrated some interesting findings. They did find some adverse effects on sleep duration in athletes. Now, it should be noted that this cohort, this group of studies did not have controls. So this is up against, or it's compared to recommendations from the American Sleep Academy and other organizations. But you can see, in athletes in general, the total sleep time is 7.2 hours. For a healthy adult, non-athlete, the recommended sleep is 7 to 9 hours per night, right? So it's on the low end of that, and we generally think that the young athlete, or the young person in general, and the athlete needs longer, needs more sleep. And you'll read 8 to 10, 9 to 11, somewhere in there hours per night. So 7.2 is on the low end. But look at the young athlete there, 6.3 hours, and that's in the age group of 7 to 16. Perhaps that's a little more applicable to what we're talking about today. But they're significantly lower, and that's just not enough sleep for someone in that age group. I think we can agree to that. We don't need necessarily guidelines to point that out. Another parameter I really find interesting here is the amount of time awake after sleep onset. You see it at the bottom on the right there, 74 minutes for a young athlete, that they're awake after falling asleep initially. For athletes in general, about 53 minutes. So there's something happening in the youth brain, in the youth athlete's brain, that is keeping them awake after they fall asleep. But an hour and 15 minutes a night, that's a lot. So why do we think they sleep ineffectively? It's generally agreed upon that they do. And there's so many stressors on athletes, you guys don't need me to talk about that. But both sport specific and outside of their sport, multiple, multiple stressors that are playing a role. And it leads to basically an increased state of arousal at times when they really should be sleeping. And also circadian rhythm disruption. These intertwine a lot. There's a lot of overlap there. So I've combined them for the most part. So training. Training itself does have adverse effects on sleep, we think. We're training late at night. We're up early in the morning to train. And this study in 2019 demonstrated that in athletes that train between the hours of 7 p.m. and 10 p.m., they did advance their sleep phase later. So they went to bed later than their natural tendencies. And those who had competition at 7 a.m., so early in the morning, seemed to advance. So they went to bed earlier. Now that makes logical sense that they would want to do so to prepare. But that is kind of against their natural tendencies. So there is some sleep disturbance in association with training. Performance anxiety seems to play a role. This was an interesting study by Roberts that demonstrated on the night of a big competition, athletes seemed to sleep about 60 minutes less. The outcomes or what effect that has is somewhat wasn't looked at in this study, but it is interesting to note. Travel. I think all of us agree that travel has effect on sleep. There's not a ton of great studies out there, especially not in athletes about this. But I've mentioned two here. In the Fowler study, this is a group of rugby players from the U.K. who traveled across the globe to Australia to play. And they noticed subjective detrimental findings on sleep and performance, interestingly. The second study here, Fulger et al., demonstrated that distance travel affected sleep most notably on the first and second nights of travel, or first and second days of travel. So it does seem to have an effect, even in these small studies. There's a lot of talk out there about social media, about electronics use before bed. Unfortunately, there's not a whole lot of good published evidence that it makes a huge difference yet. I think most sleep experts are going to tell you that they think it does. Anecdotally, I think it does. But these are some studies in non-athletes that are somewhat interesting and worth referencing when you're making your protocols. The Chang study was interesting. They looked at people that read e-books at night. So I'm sure there are people in here that read e-books before they go to sleep, as opposed to a paper book. And those compared to paper books that read e-books tended to have delayed sleep latency. So they went to sleep later. They were less tired at bedtime. And they were less alert in the morning. And their performance was affected by reading an e-book before bed. So keep that in mind, too. Our athletes are taking supplements, right? Caffeine especially. They read. They know it's an ergonomic aid to some extent. And it's legal in small doses. So they're taking this stuff. And do we need studies to tell us that caffeine has effects on sleep? I don't think so. But we have them. They're out there. The study by Ali looked at a group of female athletes that were allowed to drink caffeinated beverages as they normally would before an evening competition and noted subjective diminished sleep, multiple different sleep parameters, and subjective performance deleterious effects. The second study was an interesting rugby study on a small group of rugby players that were allowed to take in their normal amount of caffeine before an evening competition. And they noted that this group, they used wrist actigraphy, so the watch, basically. They noted that they went to sleep three hours later and lost 90 minutes of sleep on that after that competition. So does all this matter? Does it affect performance? Does it affect athlete well-being? Well, if you only read one study from my little talk here, and that includes the one that I wrote, I would read this one. And basically, it's a review of 13 different studies to try to come up with how sleep affects performance. And it's probably the most important one out there. It includes most of the true trials that have been done tying sleep to sports performance. So I think it's worth a read. The bottom line is not a shocker. More sleep equals better performance. Aerobic and anaerobic activities seem to be affected by sleep. Aerobic activities seem to be a little bit more sensitive. And long-term sleep deprivation seems to be the important thing to avoid here. Short-term does have an effect on performance, but it seems to be the long-term deprivation that is most detrimental. So that's worth bringing up with your sports medicine teams. Certain skills do seem to be affected by inadequate sleep. And some of these studies, and I'll mention a couple in a minute, do pinpoint specific skills. So free throws, percentage. So tennis serve percentage, rugby pass accuracy, this Taekwondo recovery test that I'm not familiar with myself, and a number of strength modalities here. So these all are affected by sleep such that when you enhance someone's sleep, numbers improve. When you deprive them of sleep, they diminish. I would be remiss if I didn't talk about this NFL study that now is kind of a historical study from 2013, but 40 years of NFL data. So a good bit of data here. But it wasn't a sleep study, I should mention. It was a travel study. But it demonstrated that those teams traveling from the East Coast to the West Coast for evening competitions consistently underperformed. And yes, it was not associated specifically with sleep in this study, but obviously disruption of the circadian rhythm had a deleterious effect on performance. So I think it's worth knowing. Injury rates seem to be associated with sleep deprivation as well. Musky et al. in 2014 demonstrated a risk ratio of 1.7 for athletes that slept less than eight hours versus those that slept more than eight hours on average for the week leading up to a performance. That is for injury risk in general. Concussion especially is sensitive to sleep. And I think most sports medicine physicians are familiar with this. But Bramley demonstrated a prolonged recovery of three to four times after a concussion for those that had significant sleep effects because of their head injury. Murdaugh et al. demonstrated increased neurocognitive symptoms and psychological symptoms associated with a concussion in those who had significant impairment in sleep after a head injury. So it's really important to counsel your patients that sleep optimization is critical when they're recovering from a concussion. There are multiple other studies that touch on other sports parameters, including specific skills. They're a little bit older. I didn't include them in this review. But I should mention there's one historical one in 2000 by Williamson et al. that was interesting. It concluded that moderate sleep deprivation was essentially equivalent to moderate alcohol intoxication when it came to cognitive performance. So that's kind of a nice quote to take to your sports medicine teams out there. I should mention and a take home point here is that there is not a study out there that demonstrates that sleep deprivation has positive effects on performance. I think it is wrong for us to encourage athletes to sacrifice sleep for training. It doesn't seem to work. Quite the contrary is the case. So I hope that that is something you can take home. So how do we intervene? So three ways. Really the top three are all sleep extension. That's really what we want. We want people to sleep more because we think it's better for them in general and better for their performance. But there are also ways to reduce circadian rhythm disruptions and improve quality that we'll touch on. So sleep extension, how do we best do this? Ma et al. was included in that Kershian review that I mentioned that studied certain parameters. Their studies conclude or suggest at least that earlier bedtime is really the most effective way to extend sleep. Sleeping in is helpful, but earlier bedtime seems to be the way to go about this to be most effective when we're measuring performance. So consider that. I should mention though with sleep extension there are some inconclusive studies. No negative studies, but there are studies that don't show a significant difference. But the majority do. Napping. So I think any sleep expert out there will tell you that there is no substitute for uninterrupted nocturnal sleep. Bottom line. But with all the stressors on athletes and not just athletes, physicians as well and other people, that's not always possible. So napping is a tool that you can use with your athletes. This review by Subney et al. in 21 demonstrated improved performance measures as you can see here associated with daytime napping. So it can be a performance enhancer potentially in certain sports with certain athletes. Interestingly this review determined that optimum sleep time during the day for a nap was 90 minutes. Now that kind of flies in the face of some, you know, the power nap recommendations of 20 to 30 minutes, which you'll see written and talked about a good bit. But this particular review demonstrated at least with regards to sports performance and overall cognitive performance, 90 minutes seems to be the sweet spot. Sleep banking. This is what everybody's talking about now. It's kind of sleep doping, right? So basically sleep banking is extending sleep for a period of time leading up to a time when you expect to lose sleep, right? So leading up to a late night competition or a long distance travel. Sleep banking seems to be effective in preparing for that. Now there's not a whole lot of studies in athletes, especially young athletes, that demonstrate that this is effective yet. But there are a number of non-athlete studies that suggest it. These are in shift workers, these two studies that demonstrate kind of their overall work performance after a week of sleep banking leading up to a string of night shifts. So they know they're not going to sleep very well during the night shift and by banking that sleep it did seem to show improved performance. Granted, it's not athletic performance. Circadian rhythm disruptions. How do we combat this? Unfortunately, there are no great studies. Education is going to be the big one. This Fullerger study demonstrated that educating a group of female soccer players after an evening competition actually improved their sleep parameters moving forward in the coming weeks. So it seems like when we intervene from a sleep hygiene standpoint we can make a difference. I think most sleep experts are recommending that we limit electronics at bedtime, but I will say there's not a whole lot of good literature out there, especially recently. This study by Harris was done on high school students, high school athletes actually, and it unfortunately did not show a significant difference when their electronics were taken away after 10 p.m. It didn't show a significant difference. Now, it trended towards suggesting that those that were deprived of their electronic after 10 p.m. fared a little bit better with regards to sleep parameters and performance, but it didn't reach statistical significance. So sleep hygiene education seems to be a tool that we need to use. This is something we should be teaching our athletes, our coaches, our whole sports medicine team. There's a bunch of small studies out there, here's four of them, that all demonstrate that educating the group is really important. And the best way to do it, it seems like, is to start with a formal education session at the beginning of the year or the beginning of the season and then doing informal reminders basically as the year and the season goes along. That seems to be the most effective with improving sleep hygiene. It improves, the studies indicate that it improves total sleep time, that's TST, sleep efficiency, but also mood and mental health and performance. CBT, so Cognitive Behavioral Therapy for Insomnia, is a tool that's worth keeping in your mind. It hasn't really been studied on athletes, but does seem to have a significant effect on non-athletes. This was a study in 2018 of college students, so young folks, granted not competitive athletes, but they demonstrated a large improvement in mental health parameters and well-being parameters, predominantly, in those with sleep disorders, pre-existing sleep disorders, but also a moderate effect in those without. So it is used for athletes, it just hasn't been studied significantly, and I think it's worth keeping in mind for those that aren't responding to your basic interventions. Okay, so let's get down to what Irv and I actually wrote about. So medications, so this will be quick because I think it's the least important, right? So medications are really a last-ditch effort in most cases, and are really meant for short-term adjustment to circadian rhythm disruptions, mainly travel and jet lag. That's where medications seem to be most effective. Melatonin and caffeine are by far the two pharmaceuticals that are used most commonly, and are the safest ones to consider. How you use it is quite logical, I've outlined that in that table on the right side of the screen, it'll be available in the references as well, but it's very logical. There probably is a role for sedative hypnotics for our older athletes, so high school and beyond, for adjustment to travel especially. I think it's worth knowing about zolpidem because that's what you're going to be asked about probably to prescribe, and so it's worth knowing some of the pharmacokinetics of it. It's half-life is short, two and a half hours, it's on the short side, but I think we all know that people respond to medications very differently and a dose for one person is different than a dose for another, so keep that in mind. Non-athlete studies demonstrate improvement in sleep parameters, and so we think it does tend to help. It also tends to help in facilitating sleep during travel, so long-haul flights, it does seem to help with sleep during that flight. The caution is to make sure you allow adequate time for sleep after a dose, so eight hours is recommended. So as with any medication, we want to know the side effects, we want to know the safety parameters, and melatonin is not completely safe. First of all, it's not regulated by the FDA as a supplement, so we really don't know what's in it. There could be some banned substance in these, so in that particular competitive population, you want to be wary of that, but this interesting study in 2016 demonstrated a bit of a hangover effect with melatonin. What they did was they gave a cohort of athletes melatonin, had them take it at 1 a.m., and then did neurocognitive and physical objective tests at 8 a.m., noon, and 4 p.m., and they demonstrated decreased scores at 8 a.m., but no change, no worse scores at noon and 4. So it does seem to have an effect if you don't allow for that eight hours of sleep, which is recommended. Again, caffeine has effects on sleep, especially when you take it after 2 p.m., which Miller's study suggests taking it for evening training or competitions and late night does push sleep forward and decreases sleep time. This study about zolpidem demonstrated some decreased cognitive performance, again, if you don't allow adequate sleep. So please allow for adequate sleep if you're going to recommend these pharmaceuticals. Again, I can't stress it enough, these are for short-term adjustment, right? If you're using it for more than two weeks in an athlete, I would probably, you know, think about getting a sleep specialist involved or at least having a sit-down discussion with that athlete because they can certainly become dependent on some of these substances or at least think that they are, so keep that in mind. Ultimately, individualized treatment, as with so many things in medicine and sports medicine, is the ideal. Everybody sleeps differently. Our chronotypes are all different. So I think this quote kind of hits home. In summary, the literature base is not really robust with regards to sleep on athletes and sports performance, but they seem to sleep ineffectively versus their comparisons, but likely need more. And they seem to perform better when we enhance their sleep. And there are ways that we can intervene, which we went over. The predominant ones are education. I'll point out the NCAA guidelines that were updated in 2019. That's a good reference to use when you're building your protocols and you're advising your sports medicine teams. So there are a number of references, but I appreciate your attention. So, Matt, you mentioned that there's a lot of variability. You know, not so much in athletes, but you frequently hear in adults that, you know, I don't need that much sleep. I'm only a five or six hour a night sleeper. I don't need more. Is that true? Can those people be improved with more sleep? It's thought that less than 1% of the population functions optimally with less than the recommended amount of sleep. So those people that say that I only need four to six hours of sleep are either lying or they're not performing at their optimum. And that's not just coming from me. I do believe that. But sleep experts across the globe will usually quote that. But it's less than 1% typically. So next, oh, another question. Yes. Ma'am, we got time. Yes, I have a question. So in the context of sports medicine, right, we see in terms of wearable technologies, devices like Catapult from a biomechanical standpoint being adopted for load management, external workload, quantification. In the context of the physiological self or sleep monitoring, for example, how is sleep reported today to the clinician? And my second question then is this idea of subjective data versus objective data. Have you noticed discrepancies in the data that you're collecting for sleep when you then use that data for clinical decision making? To answer the last part first, there are some discrepancies between what a actigrapher, so basically a wrist watch monitor, will demonstrate versus true sleep. And the gold standard for sleep is PSG, so polysomnography or whatever. I don't do it myself, but obviously sleep experts do. But PSG is the gold standard. And when they compare that to the devices, there does appear to be some disconnect. Where sleep experts, where we think that those devices are potentially helpful is monitoring general activity. So seeing when they actually go down to sleep, assuming that they have their device on them. That's where it's helpful and where we can, maybe we can do some activity modification there or behavior modification. So there are sleep experts that will tout certain devices out there. There's never really been studies that demonstrate significant sleep improvement with them yet, but they're coming around all the time and I bet that there will be more that comes out. But my general thought is that it's probably not required at this time, but it can be helpful in monitoring an athlete's activity.

sleep

athletes

performance

sleep deprivation

recovery

concussions