Orthopedic sleep and novel analgesia pathway: a prospective randomized controlled trial to advance recovery after shoulder arthroplasty.

BACKGROUND: Lack of sleep is associated with adverse effects on postsurgical pain and recovery. We hypothesized that a multimodal sleep pathway, including nonpharmacologic sleep hygiene interventions and the use of zolpidem and melatonin, could improve patient analgesia and sleep after total shoulder arthroplasty. METHODS: We performed a prospective randomized controlled study in which patients undergoing anatomic and reverse total shoulder arthroplasty were treated with or without an interventional multimodal sleep pathway. This pathway included nursing-directed nonpharmacologic measures that promote sleep hygiene and pharmacologic interventions with low-dose zolpidem and melatonin at bedtime. All patients underwent a standardized multimodal analgesia protocol with scheduled acetaminophen, naproxen, and gabapentin, as well as a single-shot interscalene regional nerve block. RESULTS: This study enrolled 125 patients (64 in control group and 61 in interventional group) with similar demographic characteristics. The interventional group showed less oral morphine milligram equivalent (MME) consumption on postoperative day (POD) 0 (44.8 ± 36.1 MMEs vs. 60.9 ± 42.1 MMEs, P = .01) and showed a trend toward lower POD 0 visual analog scale pain scores (2.6 ± 1.8 vs. 3.3 ± 3.0, P = .06). Visual analog scale pain scores and MME consumption were similar on POD 1. The interventional group showed a longer objective sleep duration by quantitative wrist actigraphy (5.9 ± 3.1 hours vs. 4.6 ± 2.7 hours, P = .008), with better sleep quality assessed by the Leeds Sleep Evaluation Questionnaire (0-100 scale; 50.3 ± 26.8 vs. 38.5 ± 27.8, P = .01). The 2 groups showed similar satisfaction with pain management (89.2% vs. 79.6%, P = .16) and sleep management (82.1% vs. 76.8%, P = .48). There was no difference in the length of inpatient stay (32.2 ± 14.8 hours vs. 34.1 ± 12.8 hours, P = .44). CONCLUSION: In the setting of a regional and multimodal analgesia recovery plan for shoulder arthroplasty patients undergoing inpatient observation, the use of an interventional sleep pathway appears to be safe and beneficial, with improved analgesia, reduced opioid use, increased sleep duration, and improved reported sleep quality during the postoperative recovery period.

Sleep Duration Correlates With Performance in Ultra-Endurance Triathlon.

The relationship between sleep duration, sleep quality, and race completion time during each stage of a 3-day ultra-endurance triathlon (stage 1: 10-km swim, 146-km cycle; stage 2: 276-km cycle; and stage 3: 84.4-km run) was investigated. Seventeen triathletes partook in sleep analysis throughout the ultra-endurance multiday triathlon using an actigraphy wristband. The participants wore the band to record objective sleep outcomes for approximately 4 days (1-2 d prerace, 3 race days, and 1 d postrace), except while racing. The total sleep time (TST; prerace: 414.1 [95.3] min, prestage 1: 392.2 [138.3] min, prestage 2: 355.6 [62.5] min, and prestage 3: 299.7 [107.0] min) significantly decreased over time (P < .05). Significant Pearson moment-product correlations were found between TST and subsequent race-day performance for race stage 1 (r = -.577; P = .019) and stage 3 (r = -.546; P = .035), with further analysis revealing that TST explained 33% and 30% of the variation in performance for stages 1 and 3, respectively. During a 3-day ultra-endurance triathlon, the TST was reduced and had a significant negative correlation to exercise performance, indicating that sleep loss was associated with slower performances. Sleep onset latency, wake episodes, and sleep efficiency did not significantly change over the course of this investigation, which may stem from the close proximity of exercise to sleep.

Sleep restriction impairs maximal jump performance and joint coordination in elite athletes.

The study objective was to examine the effects of three days of sleep restriction on maximal jump performance and joint coordination. Eleven elite cyclists obtained a one-week baseline of habitual sleep then restricted sleep to 4 h/night (SR) for three nights assessed through self-report and actigraphy. Pre and post-intervention measures were a box drop maximal vertical jump with 3D motion capture to assess physical performance and biomechanical changes, and Psychomotor Vigilance Task (PVT) assessed changes in response time. Associations between biomechanical, physical, and cognitive performance measures were assessed. Participants restricted reported sleep from 7.4 ± 0.5 h/night at baseline to 4.0 ± 0.2 h/night and actigraphy indicated 6.7 ± 0.7 to 3.7 ± 0.2 h/night. Following SR, jump height decreased (0.44 ± 0.09 vs. 0.42 ± 0.10 m, p = 0.02, g = 0.21). Hip sagittal/knee frontal (Δ15.5°, p = 0.04, g = 0.40) and hip frontal/knee frontal (Δ11.0°, p < 0.01, g = 0.44) plane coordination variability increased after SR. Hip sagittal/knee frontal plane coordination variability after SR was associated with increasingly slower PVT response time (r = 0.63, p = 0.03). These findings suggest SR for three days decreased maximal jump performance. SR increased joint coordination variability and was associated with greater impairment in response time. SR leads to deviations from preferred movement patterns, which may have implications for decrements in athlete performance and increased injury risk.

Development of the athlete sleep behavior questionnaire: A tool for identifying maladaptive sleep practices in elite athletes.

INTRODUCTION: Existing sleep questionnaires to assess sleep behaviors may not be sensitive in determining the unique sleep challenges faced by elite athletes. The purpose of the current study was to develop and validate the Athlete Sleep Behavior Questionnaire (ASBQ) to be used as a practical tool for support staff working with elite athletes. METHODS: 564 participants (242 athletes, 322 non-athletes) completed the 18-item ASBQ and three previously validated questionnaires; the Sleep Hygiene Index (SHI), the Epworth Sleepiness Scale (ESS) and the Pittsburgh Sleep Quality Index (PSQI). A cohort of the studied population performed the ASBQ twice in one week to assess test-retest reliability, and also performed sleep monitoring via wrist-actigraphy. RESULTS: Comparison of the ASBQ with existing sleep questionnaires resulted in moderate to large correlations (r=0.32 - 0.69). There was a significant difference between athletes and non-athletes for the ASBQ global score (44±6 vs. 41±6, respectively, p<0.01) and for the PSQI, but not for the SHI or the ESS. The reliability of the ASBQ was acceptable (ICC=0.87) when re-tested within 7 days. There was a moderate relationship between ASBQ and total sleep time (r=-0.42). CONCLUSION: The ASBQ is a valid and reliable tool that can differentiate the sleep practices between athletes and non-athletes, and offers a practical instrument for practitioners and/or researchers wanting to evaluate the sleep behaviors of elite athletes. The ASBQ may provide information on areas where improvements to individual athletes' sleep habits could be made.

Poor sleep quality and insufficient sleep of a collegiate student-athlete population.

OBJECTIVE: Poor and inadequate sleep negatively impact cognitive and physical functioning and may also affect sports performance. The study aim is to examine sleep quality, sleep duration, and daytime sleepiness in collegiate student-athletes across a wide range of sports. DESIGN: Questionnaire. SETTING: University setting. PARTICIPANTS: 628 athletes across 29 varsity teams at Stanford University. MEASUREMENTS: Athletes completed a questionnaire inquiring about sleep quality via a modified Pittsburgh Sleep Quality Index (PSQI), sleep duration, and daytime sleepiness via Epworth Sleepiness Scale. Sleep quality on campus and while traveling for competition was rated on a 10-point scale. RESULTS: Collegiate athletes were classified as poor sleepers (PSQI 5.38 ± 2.45), and 42.4% of athletes experience poor sleep quality (reporting PSQI global scores >5). Athletes reported lower sleep quality on campus than when traveling for competition (7.1 vs 7.6, P< .001). Inadequate sleep was demonstrated by 39.1% of athletes that regularly obtain <7 hours of sleep on weekdays. Fifty-one percent of athletes reported high levels of daytime sleepiness with Epworth scores ≥10. Teen student-athletes in the first and second year of college reported the highest mean levels of daytime sleepiness. Greater total sleep time was associated with daytime functioning including lower frequency of difficulty waking up for practice or class (P< .001) and lower frequency of trouble staying awake during daily activities (P< .001). CONCLUSIONS: Collegiate athletes frequently experience poor sleep quality, regularly obtain insufficient sleep, and commonly exhibit daytime sleepiness.

The impact of circadian misalignment on athletic performance in professional football players.

OBJECTIVE: We hypothesized that professional football teams would perform better than anticipated during games occurring close to their circadian peak in performance. DESIGN: We reviewed the past 40 years of evening and daytime professional football games between west coast and east coast United States teams. In order to account for known factors influencing football game outcomes we compared the results to the point spread which addresses all significant differences between opposing teams for sports betting purposes. One sample t-tests, Wilcoxon signed ranked tests, and linear regression were performed. Comparison to day game data was included as a control. SETTING: Academic medical center. PARTICIPANTS: N/A. INTERVENTIONS: N/A. RESULTS: The results were strongly in favor of the west coast teams during evening games against east coast teams, with the west coast teams beating the point spread about twice as often (t = 3.95, P < 0.0001) as east coast teams. For similar daytime game match-ups, we observed no such advantage. CONCLUSIONS: Sleep and circadian physiology have profound effects on human function including the performance of elite athletes. Professional football players playing close to the circadian peak in performance demonstrate a significant athletic advantage over those who are playing at other times. Application of this knowledge is likely to enhance human performance.

The effects of sleep extension on the athletic performance of collegiate basketball players.

STUDY OBJECTIVES: To investigate the effects of sleep extension over multiple weeks on specific measures of athletic performance as well as reaction time, mood, and daytime sleepiness. SETTING: Stanford Sleep Disorders Clinic and Research Laboratory and Maples Pavilion, Stanford University, Stanford, CA. PARTICIPANTS: Eleven healthy students on the Stanford University men's varsity basketball team (mean age 19.4 ± 1.4 years). INTERVENTIONS: Subjects maintained their habitual sleep-wake schedule for a 2-4 week baseline followed by a 5-7 week sleep extension period. Subjects obtained as much nocturnal sleep as possible during sleep extension with a minimum goal of 10 h in bed each night. Measures of athletic performance specific to basketball were recorded after every practice including a timed sprint and shooting accuracy. Reaction time, levels of daytime sleepiness, and mood were monitored via the Psychomotor Vigilance Task (PVT), Epworth Sleepiness Scale (ESS), and Profile of Mood States (POMS), respectively. RESULTS: Total objective nightly sleep time increased during sleep extension compared to baseline by 110.9 ± 79.7 min (P < 0.001). Subjects demonstrated a faster timed sprint following sleep extension (16.2 ± 0.61 sec at baseline vs. 15.5 ± 0.54 sec at end of sleep extension, P < 0.001). Shooting accuracy improved, with free throw percentage increasing by 9% and 3-point field goal percentage increasing by 9.2% (P < 0.001). Mean PVT reaction time and Epworth Sleepiness Scale scores decreased following sleep extension (P < 0.01). POMS scores improved with increased vigor and decreased fatigue subscales (P < 0.001). Subjects also reported improved overall ratings of physical and mental well-being during practices and games. CONCLUSIONS: Improvements in specific measures of basketball performance after sleep extension indicate that optimal sleep is likely beneficial in reaching peak athletic performance.