SLEEP & PERFORMANCE

Lisa R. Callahan MDChief Medical Officer, MSG Sports

Associate Professor of Clinical Medicine, Weill Cornell Medical CollegePrimary Care Sports Medicine Service, Hospital for Special Surgery

What is Sleep?

A naturally recurring state characterized by:Altered consciousness, yet active brain Relatively inhibited sensory activityInhibition of nearly all voluntary musclesReduced interactions with surroundings

Why do we sleep?Physical regeneration (NREM)

Mental development/memory (REM)

REM sleep is essential for the development of the mammalian brain

Why should a strength coach care?Because the following occur during sleep:Secretion of hormones, including growth hormone

Blood supply to muscles increases, leading to tissue growth and repair

Immune system support

Regulation of hunger hormones

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Why should a strength coach care? Deleterious effects of sleep deprivation: Reduced CV performance

Reduced sprinting ability

Reduced shooting accuracy (FTs and 3 pt)

Emotional instability

Head-scratching decision making

Why does a strength coach care?

Continued negative effects…

Reaction times (Foul prone) Coordination (Unforced Errors/Injury Risks) Agility (Injury Risks)Energy (Reduced Endurance)Mood (More Irritable/Sensitive)Decision Making (Poor Judgement)

Insomnia & Sleep DeprivationIncreases levels of cortisol (major stress

hormone) Decreases activity of HGH (which is critical for

tissue repair)Decreases protein synthesis (all that weight-

training down the drain…)Decreases glycogen synthesis (energy storage

and energy production: hello, fatigue!)

How much sleep is enough?Studies show athletes who get 7.5 hours have:

Less injuries & fatigueFaster reaction & recovery Higher endurance Improved decision making

<6 hours of sleep increases death from all causes

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Stages of SleepNon-Rapid Eye Movement

(NREM) sleepStage I Stage II

Stages I & II are light sleepStage IIIStage IV

Stages III & IV are deep sleep

Rapid Eye Movement (REM) sleep

Stages of Non REM SleepStage 1: Light sleep; drift in and out of sleep, can be awakened easily, eyes move

very slowly and muscle activity slows

Stage 2: Eye movements stop and brain waves slow

Stage 3: Extremely slow brain waves called delta waves begin to appear, interspersed with smaller, faster waves

Stage 4: The brain produces delta waves almost exclusively; no eye movement or muscle activity

Difficult to wake someone during stages 3 & 4: deep sleep– people awakened during deep sleep often feel groggy and disoriented for several minutes after they wake up

Rem SleepBreathing becomes more rapid, irregular, and shallowEyes jerk rapidly in various directionsLimb muscles become temporarily paralyzedHeart rate increasesBlood pressures increasesMales develop penile erectionsDREAMS!

First REM sleep period usually occurs about 70 to 90 minutes after falling asleep

A complete sleep cycle takes 90-110 minutes on average

The first sleep cycles each night contain relatively short REM periods and long periods of deep sleep

As the night progresses, REM sleep periods increase in length while deep sleep decreases

Rem Sleep

Normal Sleep Pattern

REM Sleep~20% of night

NREM Sleep~80% of night

Wake2/3 of life

Physical Recovery

MENTAL RECOVERY

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What causes sleepiness? Process C: circadian rhythm (ie, the internal biologic

clock)

Process S: linear increase in sleepiness/Sleep Drive

What does light have to do with sleep?

www.fullcircleconfidential.org Cortisol

What does darkness have to do with sleep?

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Melatonin2am peak

So….why is this a problem?

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Why is this a problem?

Googleimages.com

What is Insomnia?A general term for sleep difficulty

Signifies sleep is inadequate or abnormal

A symptom, not a disease so very difficult to measure

Fairly common problem in general public and in sports

Sleep Disorders Classification

Acute or TransientFew days to 2-4 weeks

Chronic or PersistentPersisting >1-3 months

What to ask players who say their sleep is “terrible”

Can’t fall asleep? Can’t stay asleep? Too brief? Too light or easily

disrupted? Non-refreshing? Fitful and restless? Any known triggers?

Evaluation HISTORY

Precipitating factorsPsychiatric and medical disturbancesMedications (and alcohol, caffeine and nicotine)Sleep hygieneCircadian tendencies

SLEEP DIARY (very helpful-but hard do)

Investigating Insomnia

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Evaluation with Actigraphy

Polysomnography PSG

MORE COMPLICATED Not a first resortDefinitive but cumbersomeNot routinely employed in

the evaluation of transient or chronic insomnia

Should not be substituted for a careful clinical history

Athletes will most likely not agree to this

Actigraphy Motion Sensor (an accelerometer)Wrist movements have been found to indicate

sleep/wake patterns and has been validated using PSGEase of useCost benefitObjective measure of sleep/wakeReliableValidated with PSGAmbulatory, long term data

Treatment Options

EducationSleep hygiene tipsCognitive behavior therapy (CBT)Nutrition manipulation?Progressive muscle relaxationBiofeedback, stimulus control Medication

PharmacotherapyPrescription Medications

Hypnotics, newer meds, antidepressantsOTC

Antihistamines (benadryl)Herbs (valerian)Melatonin

Self-medicationAlcoholNyquil

Benzodiazepines  Dose Half-life Comments

Flurazepam(Dalmane) 15,30 mg Long Daytime drowsiness common; rarely used

Clonazepam(Klonopin) 0.5-2 mg Long Used for PLM, REM behavior disorder; can cause morning drowsinessTemazepam (Restoril) 15,30 mg Intermediate  

Estazolam (ProSom) 1-2 mg Intermediate Can cause agranulocytosis

Triazolam (Halcion) 0.125,0.25 mg Short Rebound insomnia may occur

Zolpidem (Ambien) 5,10 mg Short A nonbenzodiazepam

Zopliclone (Sonata) 5,10 mg Short , 1-1.5 hours  

 

 

 

A nonbenzodiazepam

Recent Sleep MedicationsLunesta (for trouble falling & staying asleep)

Ambien CR/Zolpimist (long acting/short-acting spray)

Sonata (very short ½ life; can take in middle of night if can’t fall back asleep)

 Silenor (for trouble staying asleep)

Rozerem (Ramelton) works similarly to melatonin; treats poor

sleep onset; non habit forming

Alternative Medications

AntidepressantsNot much researchSome, including SSRIs, can cause daytime drowsiness

MelatoninGood for jet leg, but not much information on long-term use

Benadryl ( and other OTC meds with histamine)Rarely indicated, can cause a hangover

Herbal supplementsEfficacy?  Safety?

Sleep Hygiene Tipsimprove performance

Light and noise are enemies of sleepAvoid stressful people and things 1 to 2 hours before

bedtime Avoid caffeine, alcohol, nicotine 4 to 6 hours before bedGet into bed ONLY when sleepyGet out of bed if Not SleepingBed is for sleep and sex only (no tv/laptop, etc)Dark Cool Room (70 or just below)

Sleep Hygiene Tipsimprove performance

Wake up at same time Have a Pre-Bed RoutineTake 20 min naps if tired/ LONGER if you will be

up lateUse Relaxation/Stress Management &

MINDFULNESS Techniques before bed time or if you get up in middle of night

Only light snack before bedtime

Power Nap SecretsThe Caffeine Nap

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1. Drink Caffeine

2. Set alarm clock for 15-20 mins

3. Go straight to bed in dark/cool room

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NAPS: What You Should Know

Nutrition IdeasProtein

Pay attention to the amino acid tryptophanHelps make serotonin and melatoninIngesting other forms of protein (large neutral amino acids)

can cause competition for transport of Trp into brain

CarbohydratesStimulate muscles to uptake LNAA, leaving trp for the brainHigh GI index better?Solids better than liquids?

Tart Cherry Juice

Studies show it improves insomnia

Contains antioxidants and anti-inflammatory phytochemicals

? Influence on melatonin

Cognitive Behavioral Therapy-InsomniaLongest lasting improvements

“counseling” or “talk through” therapy for thoughts and attitudes that may be leading to the sleep disturbances

Identifying anxiety and stressors

Relaxation Response

Relaxation response:your personal ability to make your body release chemicals

and brain signals to:

Relax muscles

Increase blood flow to the brain

HELPS with sleep

Thank you!