1. Sleep: The Good, The Bad, and the Ugly
Ian Dunican
School of Anatomy, Physiology and Human Biology – Centre of Sleep Science
School of Sport Science, Exercise and Health
Maddison Jones
Applied Physiology Conference, Perth
19th November 2015

2. Analysis Advice Accessories
Presentation Outline
Analysis
Advice
Accessories

3. Analysis – The Good Validated Actigraphy
Scientifically validated activity monitors that measure sleep and wake patterns.
Research grade devices include the Actigraph, Readiband and Actical.
Requires programming, download and interpretation by qualified person.
Should be used in conjunction with a sleep and wake diary.
Limitations:
May not be able to be worn in the water
Adornment aesthetics – clashes with other jewellery

4. Measures from Actigraphy
Actigraph measure
Explanation
WASO: Wake After Sleep Onset
Minutes
SOL: Sleep Onset Latency
Minutes to fall asleep
SD:Sleep Duration
Minutes of sleep for the entire sleep period
SE: Sleep Efficiency
Utilization measure of time on bed
SO: Sleep Onset
Time of day that the person fell asleep
WE: Wake Episodes
Number of times the person woke up
WUT: Wake Up Time
Time of the day they awoke from a sleep period

5. Actigraph outputs - Readiband
Individual reports include actigraphy, sleep summary, mental effectiveness analysis, and historical risk summary.
Sleep Statistics
Effectiveness
Historical Risk
Actigraphy
Can be used by the organization and for the individual

6. Analysis – The Bad Wearable technology
The Fitbit, Jawbone & Garmin monitors are worn on the wrist.
Pedometer and altimeter (to count steps or hills climbed).
The analysis of movement provides sleep- related metrics based on presumed sleep time.
There are only two published validations of the accuracy of the sleep- wake metrics of the Jawbone compared to PSG.
Can be good for the general population for general information on movement and sleep.
Kelly et al,2012 and Chen,2013,de Zambotti M et al ,2015
Fitbit (Available for Consumer Purchase). The Fitbit monitor is a small device that can be worn on the wrist, clipped to clothing, or carried in a pocket. The features include a pedometer and altimeter (to count steps or hills climbed), a calorie counting feature (extrapolated from the estimate of steps walked), movement detection by actigraphy, and a clock. The analysis of movement yields standard sleep- related metrics such as a distinction between sleep and wake, total sleep time, sleep latency, and an “arousal index” based on episodes of movement during presumed sleep time. There are published validations of the accuracy of the sleep- wake metrics of the Fitbit compared to PSG or to standard actigraphy watch devices.

7. Analysis – The Bad Sleep/Training diaries and Questionnaires
Sleep, wake and training diaries to use in conjunction with wearable technology.
Can be used to highlight differences in self reported sleep periods and actual sleep periods.
Questionnaires can be used to assess the potential prevalence of sleep disorders. Examples include:
Insomnia Severity Index (ISI) – Insomnia
Epworth Sleepiness Scale (ESS) –Daytime sleepiness
Berlin questionnaire – Obstructive Sleep Apnea
Bastien, C.H. et al, 2001,Chervin, R.D, et al, 1997,Emsellem, H.A. and K.E. Murtagh, 2005.
Demographic variables were collected and included gender, age, training per week, hours of work per week, living conditions, children, general health, medication, years training in judo, sleep history, alcohol, tobacco and caffeine consumption.
Insomnia the validated Insomnia Severity Index (ISI) was administered. The ISI consists of five separate questions that ask the participant to self rate their own experience with insomnia from a scale of 0-4. The questions relate to severity, satisfaction, noticeability and worry or distress associated with their insomnia. Scores are aggregated and assessed against a criterion. A score greater than 15 indicates clinical insomnia [27].
Daytime sleepiness the Epworth Sleepiness Scale (ESS) was administered. Daytime sleepiness is often a consequence of an underlying sleep related disorder. The ESS is a self reported scale How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired from 0 –no chance of dozing to 3 a high chance of dozing. Scores in excess of 9 indicate excessive daytime sleepiness and further specialist advice required [28].
Obstructive Sleep Apnoea (OSA) risk. There is little known about the prevalence and presentation of apnoea in athletes and its potential effect on athletic performance [29]. To assess the prevalence of Obstructive Sleep Apnoea the Berlin questionnaire was utilised [30]. The berlin aims to categorise the presence and frequency of snoring behaviour, wake time sleepiness or fatigue and a history of obesity and/or hypertension. A positive indication of two or more of these aims indicates the subject is at risk for OSA.

8. Analysis – The Ugly Smartphone sleep apps
They cannot, with any accuracy, determine whether you’re in deep or light sleep, simply based on movement.
Using an electronic device prior to sleep may have negative affects to sleep onset and quality of sleep –light exposure.
May have interference from pets in the bedroom, sleeping partner moving about or vibration.
Shirazi, A.S., et al., Stippig, A., U. Hübers, and M. Emerich, 2014, Biggs,The Conversation,2015.

9. Advice – The Good Good Sleep Habits/Sleep Hygiene
Allow adequate time for sleep (7-9 hours for adults)
Maintain constant bed times and rising times
Avoid bright, blue light (screen & room)
Remove potential disruptors of sleep (e.g. TV, phone, laptop)
Avoid alcohol, caffeine and smoking near bedtime
Exercise regularly but avoid exercise just before bedtime
Relax before bedtime
Strategic daytime naps when necessary
Maintain a quiet, dark, comfortable bedroom (18-24°C)
Do not force sleep, and avoid clock watching
Sleep Health Foundation 2015

10. Advice – The Bad Getting to sleep, age, and waking up
“Alcohol can be used as a sleep aid”
Alcohol has been shown to affect sleep quality and quantity throughout the night and can have long term health effects.
“I'm getting older, so I need less sleep”
Adults may require less sleep than children, but 7-9 h is still the recommended amount.
“It’s best to train early in the morning”
Early training times (i.e. before 9:00am) may affect sleep duration. Naps and good sleep hygiene practices are essential.
Delayed sleep onset due to natural occurring chronotype
Dorrian & Skinner 2012, Sargent et al. 2014, Sargent, Halson & Roach 2014

11. BUT... Advice – The Bad Caffeine- ergogenic aid or sleep inhibitor?
Increased alertness
Faster reaction times
Enhanced endurance & short-term (~5min) intense exercise performance
BUT...
Caffeine affects individuals differently!
Can take up to an hour to take effect, and has a 4-hour ½ life.
 Avoid caffeine at least 4 hours before bedtime.
The alerting effects of caffeine, although they are disruptive to sleep, can be used strategically when it is necessary to stay awake.
Burke 2008, McLellan et al. 2005

12. Advice – The Ugly Sleep quantity, cycles and food
“We only need 5-6 hrs sleep per night.”
Only if you take naps during the day to achieve 8 hrs in a 24 hr period.
“Focus on 90 minute cycles instead of hours or quality of sleep.”
4 cycles is only 6 hrs.
“Eating and drinking just before bedtime will improve my sleep.”
The heavy feeling after eating does not improve sleep quality.
“Energy drinks are a substitute for sleep.”
Nothing is a substitute for sleep.
Carbohydrate, tryptophan, valerian, melatonin and other nutritional interventions have been investigated as possible sleep inducers and represent promising potential interventions. In this review, the factors influencing sleep quality and quantity in athletic populations are examined and the potential impact of nutritional interventions is considered. While there is some research investigating the effects of nutritional interventions on sleep, future research may highlight the importance of nutritional and dietary interventions to enhance sleep.
4 cycles will only give you 6 hours. This is an oversimplification of years of science and performance. 8 hrs+ for best performance.
Eating pasta or heavy food will not improve your sleep.
Mah et al, 2010

13. Accessories – The Good To prepare for sleep:
To fall asleep:
For travel/adjusting to time zone changes:
Filters or programs for computers to alter light wavelength
Meditation apps
Good, comfortable pillows and mattress
White noise
Ear plugs
Eye masks
Sunglasses
Re-timer

14. Accessories – The Bad Sleeping tablets TYPE DETAILS Melatonin
Modifies timing of circadian rhythms.
Over-the-counter vs. prescription
Antihistamines
(Restavit, Phenergan)
Short-term (days) use only.
May develop tolerance.
Benzodiazepines
Prescribed for insomnia.
Short-term (weeks) use only.
May become dependent.
Benzodiazepine receptor agonists
(Zolpidem, Stilnox)
Shorter duration of action than benzo’s.
Less addictive.
Antidepressants & anti-psychotics
Prescribed to treat mental health-related sleep problems (e.g. insomnia).
Long-term use possible
Melatonin: i.e. can induce earlier sleep onset if taken 1-2h before usual bedtime (~1h to peak plasma concentrations)
Antihistamines: less REM, more SWS.
Athletes should consult their relevant sporting organizations to comply with anti doping regulations, which may differ from sport to sport.

15. Accessories – The Ugly
Certain bedding or pillows will not solve sleep disorders such as obstructive sleep apnoea or snoring.
Massage will not solve Restless Leg Syndrome or Periodic Leg Movement Disorders.

16. Conclusions
Use of wearable technology for measuring sleep in athletes should be restricted to validated actigraphy devices only.
Be aware of sleeping tablets- seek alternative solutions if possible.
Athletes and coaching staff will benefit from advice on sleep hygiene and sleep management.