Sleep Health in High Performance Populations—Considerations to Optimize Athletic Potential

Introduction of Sleep Health in Elite Sports

Sleep is an essential component to perform optimally in elite sport, and there is an abundance of research supporting the importance of sleep to achieve maximal athletic potential (3,16,21,24). In addition to physical training and nutritional influences on performance, sleep is often overlooked, but critical in support for recovery (4). Since sleep is a complex physiological process to summarize with numbers, discussing basic facts and quantitative data in high performance populations can provide more insight with the importance of sleep. In fact, about 70 million Americans experience sleep problems that can lead to performance decrements, decreased quality of life, and reduced overall well-being (5). Moreover, 35.2% of adults in the United States average less than seven hours of sleep per night (25). Additionally, a recent article by Nahban et al. performing health screening for 940 Olympic and Paralympic athletes found that over 20% of the athletes screened positive for poor sleep quality. A similar article from Ritland et al. identified that tactical athletes were found to have an average sleep quality rating in between poor and fair by 22% in subjects, and an average sleep time of 6.17 ± 3.24. Such results are concerning for a tactical athlete’s marksmanship accuracy due to the risk of short sleep durations that can be associated with cognitive impairments, such as alertness, attention span, and memory (19). In addition, people who suffer from severe insomnia due to insufficient sleep are seven times more prone to experience an accident at work compared to those with sufficient sleep (25). Furthermore, the consequences of insufficient sleep pose risks for performances in the physical and cognitive domains.

The contextual challenges of sport, such as training schedules, competition schedules, travel, work and media obligations, social, personal, and environmental factors, can lead to insufficient sleep quality and sport performance (3). Specifically, sleep deprivation can negatively affect physical health factors, posing a risk for injuries, illnesses, metabolic dysfunction, and motor function, thus affecting sport performance (3,6,15). For example, insufficient sleep can lead to metabolic dysfunction and inflammatory processes, such as changes in the hormonal biomarkers of leptin, ghrelin, testosterone, and cortisol (6). In addition, sleep deprivation can negatively influence mental health factors, such as stress, anxiety, and depression, and may lead to alterations in cognitive performance (3,6,15). These effects pose serious implications for athletes that train at a high level daily with decrements in sport-specific performance if not properly addressed (1). The application of the most current evidence and anecdotal-based practices can drive realistic interventions to positively influence sleep health and sport performance (1). Furthermore, sleep hygiene strategies can combat poor sleep health to improve health, well-being, and athletic potential (27).

The training schedule for high performance populations is highly influential, since accumulated load affects planning sessions for technical and tactical skills, physical training, nutrition, recovery, and sleep practices (21). According to the American Academy of Sleep Medicine and Sleep Research Society, general population adults should attain 7 – 9 hr of sleep to physiologically and psychologically recover from daily activities (6). However, it is recommended that elite athletes attain 9 – 10 hr of sleep for preparation in high-level sports (4). Most recently, Sargent et al. measured habitual sleep duration in 175 elite athletes from team and individual sports reporting 6.7 ± 0.8 hours compared to their 8.3 ± 0.8 hours self-assessed need to feel rested (20). In a similar study, Sargent et al. identified that 70 elite athletes averaged 6.5 hr of sleep while Lastella et al. found that elite athletes average 6.8 hr of sleep due to varied bed and bedtime routines (13,21). It can be seen in the literature that total sleep duration can have serious implications for cognitive and physiological health (14). Therefore, a good understanding of required sleep need on an individual basis can shed light on requirements for high performance populations (21).

The Need for a Sleep Toolkit for Performance Practitioners

The prevalence of insufficient sleep with athletes calls for proper adherence to guidelines and recommendations to optimize health, well-being, sport performance, and tactical performance (26). Identifying trends with average sleep duration, in addition to observing bed and wake time behaviors, can provide an opportunity to self-monitor habits for an individualized, effective and quality sleep health program (26). The contextual challenges of high performance populations with their daily workload requirements (e.g., training schedule, travel, personal obligations) can benefit from direct feedback with sleep data tracking to influence decision making with prioritized efforts to maximize readiness and performance (26). Therefore, a sleep toolkit can provide resources to improve sleep health to optimize health and human performance.

Sleep interventions promoting sleep hygiene strategies can elicit cognitive and physical performance improvements in high performance sport (3,7,18). The scope of this article is to provide the framework for a “sleep toolkit” for use in high performance populations. The toolkit includes access to education materials, guidelines for sleep screening, and wearable product information for consumers to drive interventions to improve sleep health, training, and recovery for elite sport. The recommendations will allow tactical facilitators to interpret evidence and practically-based sleep health information advice to improve sleep health in high performance athletes.

Sleep Measurement Tools

The availability of sleep measurement tools continues to rapidly increase, due to the growth in scope and depth of sleep research for optimal health, well-being, and sport performance (27). There are objective (wearables) and subjective (questionnaires and diaries) ways to monitor sleep. Objective tools, such as smart watches, rings, and wrist straps, can provide short- and long-term data monitoring on routines to improve sleep health awareness, increase coach-athlete interactions, and provide direct feedback (27). Such wearables can measure sleep duration, sleep efficiency, and sleep latency (time to fall asleep). For example, the Oura® ring (finger wearable) and the FitBit Ionic® (wrist wearable) are among some of the most validated devices for sleep health (8,9,12,26). Stone et al. assessed the accuracy of the Oura ring and FitBit Ionic reporting lower percent error values compared to seven other commercial devices in regard to total sleep time, sleep efficiency, and total wake time (26). These data provided evidence to support those two wearables while the others tested overestimated or underestimated such sleep metrics (26).

While wearables can provide direct feedback via smartphones, with the exponential growth of technology advancements to measure sleep duration, it is critical to acknowledge the need for a quality and effective personalized program to influence daily readiness and recovery (26). While there are highly accurate sleep measurements performed in clinical settings, there are limitations to measuring sleep stage subcategories (e.g., awake, light, rapid eye movement [REM], deep sleep) from wearables (10,22,23,26). This can be caused by the ever-improving advancements in technology and science and the varying validation methods in laboratory and third-party settings (10,22,23,26). Consequently, wearable sensors designed for sleep staging require further validation due to varying evaluation methods and risk of biases. Thus, it is recommended that products undergo a rigorous system and method design to measure overall accuracy in sensing, modalities, signals, and sleep stage categorization (10). While refining the sleep staging measurement process is continually changing with advances in technology, quantifying total duration remains a focal point of sleep health programs because of the prevalence of sleep deprivation. Therefore, it becomes vital for athletes, practitioners, and researchers to accurately measure sleep with valid and reliable devices to prompt the experience for the most optimal and consistent improvements in optimal functioning for performance (22).

Subjective tools, such as questionnaires and sleep diaries, can provide simple and cost-effective assessments to track bed and wake times, napping, and sleepiness (27). The most common and validated questionnaires include the Pittsburgh Sleep Quality Index (PSQI), Athlete Sleep Screening Questionnaire (ASSQ), and Athlete Sleep Behavior Questionnaire (ASBQ), because of their ease of use for practical applications (26). However, it is important to acknowledge that while personal perceptions can provide valuable information, emotions may lead to response biases; therefore, the availability of options to measure sleep for tactical facilitators must consider the limitation of subjective measures that fit the needs of their populations. Furthermore, the information provided by sleep measurement tools can provide in-depth details about sleep to drive interaction for an individualized performance program (26).

Application of Findings

There is no one-size-fits-all approach when it comes to sleep recommendations for athletes. Recommendations should be athlete-centered and specific to the contextual setting (tactical, sport or fitness-related) with consideration of sleep requirements, adjustments to work hours, training times, and the influence of sleep on eliciting behavior change through buy-in (27). Below are the top three components for sleep health considerations:

1. Sleep Education: Sleep education is a critical aspect of increasing awareness of the perceived barriers from a lack of sleep knowledge. Tactical facilitators can seek out information from organizations like the Centers for Disease Control and Prevention (CDC), American Academy of Sleep Medicine (AASM), and National Sleep Foundation (NSF) to develop intervention protocols that cater to the needs and wants for their desired population (Table 1). Resources such as presentations, educational videos, statistics, and scheduled check-ins can bridge the gap between sleep and performance.
2. Sleep Screening: Sleep screening can allow tactical facilitators to identify sleep disturbances, implement strategies for an action plan, and refer to specialists when needed. It can help manage athlete health and well-being and is critical in addressing sleep disturbances that may be preventing sleep hygiene strategies from being effective.
3. Choose Sleep Measurement Tools Wisely: Monitoring sleep with objective and/or subjective tools can be used to provide feedback for the athlete. Athlete-specific questionnaires, such as the ASSQ and ASBQ, can alert practitioners with sport-specific maladaptive sleep behaviors contexts associated with contact and noncontact sports (2,27). In turn, the practitioner must observe, interpret, and apply the findings of the data, thus understanding the limitations that exist between sleep monitoring tools.

Figure 1. Top Three Sleep Recommendations

Figure 2. Sleep Disturbance Factors (27)

(Figure adapted from Walsh et al., 2021)

Figure 3. Sleep Measurement Comparisons (27) Advantages and Disadvantages of Wearable Types

(Figure adapted from Walsh et al., 2021)

The tradeoffs that exist for sleep wearables include battery life, size, weight, and human factors (e.g., wearable etiquette for training and bedtime), that may cause constraints with compliance (10). Therefore, size and comfort play a larger role with wrist-based devices, such as watches and straps, compared to smaller devices, such as rings. In addition, the cost of devices can range from $80 to over $300, leading to budgetary concerns. However, this is only a fraction of the cost of laboratory-based tests of sleep parameters (26). In all, these less invasive and cost-effective devices can present valuable information for long-term monitoring to create a sleep profile that provides details to positively influence health and human performance.

Challenges and Future Research

Increases in sleep health awareness will lead to further advancements in research and development with wearable devices due to more robust evaluations, quality, effectiveness of application, and price. It is important to acknowledge the individual constraints that are linked to the usability, suitability, and limitations associated with wearables for long-term sleep monitoring to influence training and recovery (10). A foundational understanding of sleep physiology to assess sleep duration and efficiency must be considered when seeking to distinguish sleep stages (26). Furthermore, research should continue to evaluate and validate the accuracy of sleep staging, thus creating a new field in sleep research (10,26).

Practical Applications

The ability to understand current sleep habits with bed and wake routines, total sleep time, and sleep latency can provide insights into improving health, well-being, and performance (26). Sleep monitoring can help with identifying the health and safety of athletes by managing fatigue and reducing the risk of decreased reaction time, thus reducing a multitude of physical and mental factors linked to poor sport performance (23). Thus, sleep measurement tools that are validated can increase sleep awareness and drive athlete-staff interaction to prompt further discussions regarding optimal performance (9,11,12,26). The monitoring of sleep can provide high performance populations health-related data to adjust their lifestyle and training load with biofeedback to influence decision making on recovery and readiness to perform.

Table 1. Sleep Resources

This article originally appeared in TSAC Report, the NSCA’s quarterly, online-only publication geared toward the training of tactical athletes, operators, and facilitators. It provides research-based articles, performance drills, and conditioning techniques for operational, tactical athletes. The TSAC Report is only available for NSCA Members. Read more articles from TSAC Report 

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