Sleep interruption in the collegiate dormitory setting is intuitively common. Most studies focus on either the effect of 1 to 3 d of acute sleep deprivation or of longitudinally restricted sleep. The effects of sleep deprivation on perception are remarkable. When reaction time and vigilance were measured during acute sleep deprivation over 88 h, van Dongen and Dinges found that during the first 16 h of wake time, there were few mistakes. Thereafter, reaction time and missed cues increased in a pattern that followed the circadian rhythm and accumulated with progressive sleep loss (5). Moreover, one to two nights of recovery sleep did not completely restore performance to baseline, suggesting that a weekend of “catch up” sleep may not be adequate. Similar results were found for chronic sleep restriction. Examining the learning and vigilance of a population that included college-aged individuals, they examined 4, 6, and 8 h sleep/night over a 2-wk period (15). There was a dose-dependent deterioration over the 2 wk where those sleeping 8 h per night had preserved performance, but lapses increased for the 6 h per night group and even more for the 4 h sleep per night group. Again, 2 d of recovery sleep was insufficient for the 4 h and 6 h sleep per night groups to return to the 8 h per night group baseline. Of significance, sleep-deprived participants consistently underestimated their degree of impairment (5,21). Chronic sleep deprivation over 2 wk was just as performance-limiting as 2 d of total sleep deprivation. Sport requires recognition, correct analysis, and then reaction/execution based on vigilance; sleep deprivation increases errors in judgment and results in slower reaction time.
Sleep deprivation may influence data obtained during presport and in-sport testing (27). Baseline computer-based neurocognitive measurements are frequently performed for concussion prior to the start of competition. Interrupted sleep is a hallmark of the immediate postconcussion period (28,29), and history of concussion may influence sleep and quality-of-life indices in the collegiate population (30). In their study, low sleep quantity the night before testing was correlated with greater number of symptoms and higher symptom severity score (27). Examining the effect of prior night's sleep on IMPACT® scores, McClure et al. found that athletes with fewer than 7 h of sleep before baseline testing performed worse on reaction time, verbal memory, and visual memory scores compared with longer sleeping controls (31). Finally, in the postconcussion period, athletes who were concussed and had lost more than 1 h of their usual sleep per night report more symptoms and increased severity on serial evaluations (28). Evaluating sleep may be indicated before baseline testing is performed since return to play decisions are in part made in comparison to baseline.
Appropriate intervention in the college athlete depends on the underlying cause of sleep deprivation. Sleep itself will not improve performance; the preponderance of data suggests that neurologic function is improved by sleep when the individual is sleep-deprived. Mah et al. well illustrated the effect of sleep prolongation (32) on athletic performance. A group of Stanford basketball players were evaluated on skill, speed, and mood. After a baseline of 4 wk of their usual sleep (approximately 6.7 h per night by actigraphy), athletes were asked to increase sleep over the next 5 to 7 wk (to an average of 8.5 h per night by actigraphy). After sleep extension, the group demonstrated significant improvements in free throw shooting (9%), three-point shooting (9.2%), and faster sprint times after a 6-wk trial of sleep extension. In addition, they had improvements in fatigue and sleepiness scales as well as mood profile scores.
The effect of increased sleep on performance has been replicated in other sports. An acute night of sleep deprivation (5 h vs usual 7.5 h) resulted in decreased tennis serve accuracy in college-aged semiprofessional players (33). In a similar population of college tennis players, 1 wk of 2-h sleep extension (to 9 h daily) improved serve accuracy from 35% to 42% and improved sprint times (34). Sleep deprivation did not influence power or performance in collegiate weight lifters, but did adversely affect mood, confusion, fatigue, and vigor (35). Most studies have small study populations and low power but suggest that suboptimal sleep time impairs neurologic function; whereas improvements in sleep time allow for improved neurologic function and therefore improved performance in terms of accurate replication of learned gross motor-firing patterns. Sleep extension in this context improves performance.
In search of the competitive edge, educating the college athlete about sleep and its connection to performance is the new battleground. The traditional approach to addressing college student sleep issues has been didactic in nature. These include classroom interventions and either direct (36) or online-based education (37,38). Specific interventions, such as cognitive behavioral therapy, can be very helpful but is usually reserved for students with specific sleep issues, such as insomnia, due to difficulty falling asleep because of pervasive thoughts or early waking from anxiety or depression (39,40).
Educating students about basic sleep hygiene and sleep-habit optimization can alter their behavior. Unfortunately, many traditional “sleep hygiene” tenets (Table) fall outside of the control of a dormitory-dwelling athlete. For those under their control, a more tailored, personalized approach may have greater success. Herschel and O’Brien (41) recently reported a relatively individualized online educational tool in a randomized controlled study targeting sleep hygiene in college students. Students were referred to a web-based tool (sleeptostayawake.org), and a personalized profile was developed with education, including the importance of total sleep time, regular bed and wake times, avoiding electronics in the hours leading up to bed, and obtaining adequate sleep prior to examinations by limiting “all-nighters.” Only about 60% of those randomized for intervention participated in the study. Of those who did, about 75% reported incorporating what they learned into their sleep habits. At 8 wk, students who participated in the online education had significantly lower depression scores, improved sleep quality, and reported improvements in self-reported sleep-promoting behaviors, including stopping electronics earlier, earlier wake times during the week, having a more regular sleep schedule, and taking fewer naps. Their findings are particularly important in that the improvements were seen at 8 wk, suggesting that early-semester intervention may allow for behavior change prior to the deterioration in sleep patterns typically seen in the second half of the semester (Fig. 2).
Obtaining a simple sleep history during the preparticipation physical or during introductory student-athlete meetings that precede most athletic seasons may be helpful. Those athletes who score poorly on Epworth Sleepiness Scale (42), Pittsburgh Sleep Quality Index (43), or newer tools designed by sports physicians for elite athletes (44) may indicate need for intervention.
While education is effective, it does require time for the athlete to adjust and implement change. For faster results, students will often turn to either over-the-counter or prescribed medications to increase alertness or promote sleep. Caffeine is among the most commonly used and will promote alertness, especially the day after shortened sleep. Caffeine blocks adenosine receptors; adenosine accumulates in the CSF during wakefulness and promotes sleep onset. Taken late in the day, caffeine can cause insomnia by preventing the onset of sleep.
There are several common medications for inducing sleep. All have side effects, and some can be addictive and should be used with caution in the collegiate population. Over-the-counter (diphenhydramine) or prescription (doxepin (3 to 6 mg) antihistamines will induce sleep but may have residual morning grogginess and so should be used with caution for sleep induction if early morning function is required. Trazedone, commonly prescribed for insomnia, is not recommended for the college population. Common medications classes, such as benzo-diazepines (temazepam) and nonbenzodiazepine benzodiazepine-receptor antagonists (Zolpidem), have variable half-lives and are effective for sleep induction. Both types of drugs are known to promote sleep while also suppressing stage III and stage REM sleep. This latter effect also is observed as a side effect in several commonly prescribed drugs, including the antidepressant selective-seritonin reuptake inhibitors (fluoxetine). Medications to promote sleep may be best used sparingly, for short durations, and in conjunction with an education program designed to retrain students’ sleep hygiene habits (45).
Napping is common among college athletes. At Stanford, 80% of athletes reported taking at least one nap during the week and 11% routinely took pregame/competition naps (7). Napping is associated with higher academic performance (6). Naps may be insufficient to overcome accumulated deficits from several months or years of poor sleep and the data on effectiveness is mixed; naps have been shown to mitigate the effect of short-term sleep deprivation (5). The rationale for naps being ergogenic is based on the observation that alertness, reaction time, and sprint performance improved with a 30-min afternoon nap in the setting of sleep restriction the previous night (46). In karate, a 30-min nap improved subjective feelings of alertness and fatigue regardless if there was adequate sleep or partial sleep deprivation the previous night. Naps improved both cognitive and physical performance (47). Other data are conflicting, with a 40-min afternoon nap contributing to some deterioration in cognitive task performance in college students who habitually nap (48). Petit et al. found that a 20-min nap did not improve cycling performance and also did not alter postexercise sleep architecture (49). Short naps of 30 min or less are likely restorative, particularly in the setting of sleep deprivation. They are most effective for performance preservation when stage II sleep is present (50), are less likely to have postnap grogginess (sleep inertia) than naps of longer duration which have potential to disturb normal sleep architecture.
Sleep is essential for health, mood, academic, and athletic performance. Deficient sleep, regardless of cause, decreases neurologic function and is manifested by decreased performance. Sleep extension or napping, particularly in the context of sleep deprivation, improves neurologic function and as a result improves performance. Although further research investigation is warranted, there is sufficient evidence to justify clinical inquiry regarding sleep and sleep habits of student athletes. Educational intervention provides an opportunity for athletes to make lifestyle changes with goals of better performance and improvement in health and mental well-being.
The author declares no conflict of interest and does not have any financial disclosures.
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