While there are no magic bullets that target recovery, athletic performance enhancement, and injury prevention, good sleep hygiene may be today’s athlete’s closest thing to it. With today’s compressed competition and training schedules, lack of sleep quantity, quality and consistency are taking their toll. Interestingly, recent evidence suggests that elite athletes actually require a greater sleep duration and quality than the average individual, however, paradoxically they are getting two-to-three hours less sleep than the regular population, and demonstrate worse measures of sleep quality. The aim of this month’s newsletter and information packet is to highlight the consequences of poor sleep behaviors and provide the membership with evidence-based solutions to promote optimal sleep behaviors in NBA athletes.
The Consequences of Decreased Sleep Duration & Poor Sleep Hygiene
Poor sleep behaviors can ultimately be broken down into two domains, sleep duration and sleep hygiene. Sleep duration is simply the length of time habitually slept over the course of a 24-hour period. Sleep hygiene is a more recent descriptor, representing both the pre-bedtime routine, sleeping environment, and sleep-wake schedule. Collectively, irregularities in aspects of either sleep duration and / or sleep hygiene can have detrimental consequences for the elite NBA athlete.
Sleep deprivation and poor sleep hygiene perhaps take their largest toll on an athlete’s physical performance. The evidence is clear that poor sleep behaviors decreases multiple domains of athletic performance. Specifically, decreased endurance, power output, shooting accuracy, fatigability, and absolute strength. Recent studies in basketball athletes have identified sleep deprivation to decrease time to exhaustion during continuous treadmill running tasks. Furthermore, it appears poor sleep behaviors directly influence an athlete’s sense of perceived effort during athletic activities. A recent study compared running distances covered by athletes in “normal” and “sleep-deprived” conditions. For the same perceived effort, athletes covered shorter distances in the “sleep-deprived” condition compared to the “normal” sleep condition. Consequently, the NBA athlete may indeed “think” they are putting forth a maximal effort when sleep-deprived, yet will not be capable of achieving their maximal performance output as they would in normal sleep conditions. These findings are explained by increased circulating stress hormones and reductions in available muscle and systemic glycogen stores identified in sleep-deprived athletes prior to performance in the above performance assessments.
As we all have experienced it, a lack of sleep simply makes us “feel tired,” but what are the exact measures of “feeling tired” that we can attribute to poor sleep behaviors? Sleep directly impacts three primary domains of neurocognition; (1) Attention, (2) Decision Making / Strategy, (3) New Skill Acquisition. Simply put, poor sleep behavior contributes to an inability to focus during competition, strength and conditioning sessions, and practice. While a sporadic lack of focus in the above is understandable in today’s NBA athlete, consistently poor sleep behaviors contributing to a lack of focus over time will impede player development. Furthermore, the concept of “catching up” on sleep does not have an acute benefit for improving attention and requires multiple days to recover. Thus, a consistent sleep duration or supplementation with napping is vital as will be discussed below.
Interestingly, some athletes are more susceptible to the effects of poor sleep habits on impairments in neurocognition – decision making / strategy, while others are more resilient. Unfortunately, it is not possible to identify who is more or less susceptible with any testing procedures, and an athlete’s perception of the effects of sleep behaviors on executive function are poor. Thus, it is important to pre-emptively instill ideal sleep behaviors regardless of the athlete’s perceived decision making / strategy capacity. Ultimately, the evidence base suggests that poor sleep impairs optimal in-game decision making, play reading / reacting to opposing team offensive and defensive activity, and implementation of specific game strategy.
Lastly, within the neurocognitive performance realm, sleep deprivation has a direct negative effect on player development by inhibiting new skill acquisition. Interestingly this consequence is most notable in young adults aged 18-25, NBA athletes commonly requiring the greatest need for player development. Specifically, poor sleep behaviors restrict an athlete’s ability to consolidate memories and result in a decreased capacity to develop a new skill . The decreased ability to consolidate memory from training results in decreased motor and tactical skill acquisition, such as lifting technique / form and shooting accuracy respectively.
Overall Health & Injury
Currently, there is a high level of evidence linking poor sleep behaviors to detrimental systemic effects. Specifically, lack of sleep and poor sleep hygiene have been directly linked to an increased risk of type-II diabetes, cardiovascular disease, and overall mortality. Within sport there appears to be an epidemiological link between injury and poor sleep, with almost a 2X elevation in injury risk in adolescent athletes sleeping less than eight hours on average per night per week. The increases in injury risk have been attributed to the increased reaction times with less sleep.
Limited sleep duration and poor hygiene are also associated with an elevated susceptibility to general illnesses secondary to a depressed immune response. Evidence implicates individuals achieving a greater volume of sleep are able to decrease the severity of and length of common flu signs and symptoms explained by markers of increased immune system function. Furthermore, long-term cohort studies have observed that individuals who report good sleep behaviors experience less frequency of signs and symptoms of general illness. Additionally, good sleep behaviors support healthy immune response to vaccinations, demonstrating a synergistic effect with common vaccination procedures such as those used for the seasonal flu.
Perhaps shared between performance enhancement, recovery capacity, and general health, good sleep behavior benefits optimal desired body composition for the NBA athlete. Sleep is conceivably identified as the primary regulator of metabolic hormones in the healthy athlete. Poor sleep behaviors have been identified to increase stress hormone (cortisol) known to promote storage of fat deposits and cause muscle catabolism, while simultaneously inhibiting the secretion of the anabolic human growth hormone (HGH) which normally promotes muscle tissue hypertrophy, recovery, and other tissue repair mechanisms. Consequently the sleep deprived athlete suffers from a hormonal profile promoting wasting of lean muscle tissue and storage of fat, facilitating an undesirable body composition.
Improving an athlete’s sleep behaviors is by no means an easy task. Prior to intervening to improve sleep duration and hygiene it should be understood that it is important to communicate the underlying consequences of poor sleep and alternatively the targeted benefits of sleep optimization. Simply telling an athlete “sleep is good for you” likely will have minimal impact.
It is important to highlight the benefits of optimal sleep and reinforce these behaviors with consistent messaging and monitoring to build positive habits. The remainder of this newsletter will discuss strategies to facilitate optimal sleep behaviors within the athlete to promote recovery capacity, athletic performance, and decrease injury. By no means are these recommendations exhaustive, but they provide an overview of best practices that apply broadly to the NBA athlete population.
Increasing Sleep Duration
While variable within the broad population, the restorative physiological benefits of sleep are realized with durations ranging from seven to nine hours. However, the young adult population requires approximately nine hours of sleep to optimize physical and neurocognitive performance. While the exact duration is variable and athlete specific, promoting sleep extension beyond 8-9 hours has been identified to be beneficial resulting in an enhanced anabolic / recovery response and improved athletic performance in basketball athletes. While at an extreme, there is some evidence that support total sleep volume should reach 80 hours per week in the athlete population.
80 hours per week seems unrealistic, which would result in ~11.4 hours per day, per week. However, leveraging napping during the off-season and travel may help athletes achieve this recommended total volume. Realistically this may be impossible for today’s NBA athlete in-season. However, during periods of recovery from injury, and off-season training the 80 hour target may be feasible, and should be recommended. While total sleep volume is important, acutely “forcing” an athlete to achieve greater sleep durations may be detrimental, prompting “sleep anxiety” which may actually result in difficulty falling asleep. Thus, when recommending sleep extension to an athlete, it is important to recommend a program to increase daily sleep no more than 15 – 30 minutes per evening.
To reinforce behaviors to increase sleep duration it is recommended that athletes and staff use a “sleep record / diary” paired with serial performance assessments. A general recommendation is to initiate a sleep extension program recommending 15-30 minute increases in sleep per evening for two weeks. Over the course of the two weeks the strength and conditioning coach can serially test the athlete’s performance (sprint times, agility, upper body power, vertical jump etc.) to “show” the benefits of sleep extension. While direct increases in performance may not always ensue. Various valid sleep and recovery questionnaires can be employed to determine the perceived benefits of sleep extension to the athlete.
Lastly, building and / or planning sleep duration increases during specific scenarios or points in the season may provide a recovery and performance benefit:
- Aim to achieve anabolic / hypertrophic response
- Recovery from injury
- Aim to decrease fat mass
- Aim to acutely increase athletic / tactical performance without timing / schedule for conditioning and skill development (i.e. compressed schedule, playoffs)
Improving Sleep Quality & Habits (Sleep Hygiene)
When improving sleep hygiene there are two primary areas of intervention; sleep environment and sleep routines. An optimal sleep environment can succinctly be described as one that is cool, quiet, dark, and comfortable. Whereas sleep routines can be broken down into pre-sleep activity and wake time anchoring.
Recommendations for an optimal sleep environment include:
- Dark room (interior room with no windows or light blocking curtains)
- Sleep masks work for some as well, but some consider them uncomfortable
- Room temperatures 60°-70° F are conducive to sleep
- Mattress – generally preference & individual specific
- Appropriate firmness
- Low noise (springs)
- Cool (consider cooling mattress pads)
- Comfortable sheets (preference)
- Sleepwear (preference)
- Quiet as possible (consider insulation at home)
- Use of “white noise” / blocking devices
Establishing Pre-Sleep Routines
What NOT To do
- Caffeinated Substance Consumption
- Limit caffeine consumption 3-7 hours prior to bedtime
- (While caffeine may be used as a performance enhancement aid, consider the timing of consumption when building into schedules – understandably this may be difficult to avoid)
- Limit caffeine consumption 3-7 hours prior to bedtime
- Alcoholic Substance Consumption
- Limit alcohol consumption 3-4 hours prior to bedtime
- Although initially sedating, it is important to limit consumption, as there is substantial evidence that metabolism of alcohol during sleep impairs the natural sleep cycle and limits “deep / restorative sleep” and anabolic hormone release
- Excessive Light Exposure
- Exposure to screens (television, cell-phone, tablet, computer etc.) 1-2 hours prior to bedtime delays and limits serotonin release, which promotes “falling asleep”
- Even if athletes note they can “fall asleep to screens” there is evidence that exposure proximal to bedtime similarly limits the volume of “deep restorative sleep” over the course of a sleep cycle
Good Behaviors – What you SHOULD do
- Establish an overall sleep routine
- Consistent bedtime (travel considerations are barriers)
- **Consistent wake time – “ANCHORING the wake time”**
- Identified to be one of the most influential factors in promoting beneficial consistency is to anchor the time athletes wake up in the morning regardless of time to bed and lost total duration
- While this may be unlikely with schedules and achieving a critical mass volume of sleep, best efforts to maintain a wake time is ideal. Thus, in order to effectively to “calm down” after a late competition or other scenarios it is important to build in a “relaxation buffer” period 30-60 mins prior to target sleep time.
- Warm shower – promotes relaxation through peripheral vasodilation and sensory stimulus
- Self-Myofascial Release – Stretching
- Reading a book (paper – not tablet)
Deploying Countermeasures – The Realities of the Demands of the NBA Schedule
While the above recommendations for extending sleep duration and facilitating good sleep are supported by a substantially large evidence base, these recommendations are ideal. However, the realities of the NBA schedule present with many barriers to an ideal sleep program. Thus, it is necessary to present and deploy countermeasures to mitigate the effects of sub-optimal sleep behaviors. While these countermeasures are useful and effective, they by no means should be consistently applied to mask the underlying problems of limited sleep duration and hygiene. Regrettably, consistent application of these countermeasures will result in negative training responses, recovery capacity, and decreased performance over time. Ultimately the sleep behaviors as outlined above should be the primary focus of a sleep intervention aimed at optimizing performance in the NBA athlete. Below, countermeasures to mitigate the acute effects of poor sleep behaviors are described.
Napping to Increase Total Daily Sleep Volume
Napping throughout the day to increase total daily sleep volume has proved beneficial to make up for the effects of sleep deprivation on performance and can actually increase physical and cognitive performance acutely. However, improper napping techniques can lead to detrimental effects. Of primary concern are the effects of “sleep inertia” which causes excessive perception of fatigue when individuals wake from a nap at the incorrect time in their sleep cycle. A complete sleep cycle lasts approximately 90 minutes, with individuals entering deep sleep within 20-30 minutes. Awakening during a period of deep sleep results in increased sleep inertia. Thus, naps should either last no more than 20-30 minutes or on cycles of 90 minutes (1.5 hours, 3 hours, 4.5 hours etc.). Additionally, timing of naps can be important, it will likely be easiest to initiate napping in the early afternoon when “sleepiness” or “sleep drive” is known to increase.
Quick Napping Tips
- Duration: Aim for 20-30 minutes or cycles of 90 minutes
- Environment: Cool, quiet, dark, comfortable
- Time of Day: Early afternoon
Caffeine has proved to be an effective ergogenic aid. However, the ergogenic effects are only maximally realized with adequate sleep. There is evidence to support that caffeine can indeed mitigate the effects of poor sleep habits. These ergogenic affects are only acute and taper rapidly when an individual is sleep deprived which are potentially further compounded and inhibited by the diuretic effects of caffeine in a fatigued state. One beneficial synergistic application of caffeine is that when it is used in conjunction with napping. Low to moderate caffeine doses (8 oz coffee) consumed prior to a 20-30 minute nap has been shown to increase the acute benefits of napping described above, as well as mitigate the potential for sleep inertia.
Minimizing the Effects of Travel on Sleep
Perhaps one of the primary barriers to optimal sleep behaviors of NBA athletes is that of travel across time zones resulting in a misalignment between an athlete’s circadian rhythm / biological clock and the local time zone, otherwise
known as jet lag. Jet lag undeniably has been identified to decrease nighttime sleep quality as well as reduce daytime alertness. The general rule is that it requires approximately one day to adjust to a single hour deviation in time zone. While travel is persistent in the NBA, scheduling to adjust to longer periods of travel in a different time zone in one direction or another can provide some benefit. For example, two to three days prior to longer duration travel to a time zone(s) shift encouraging the athlete to sleep and wake on the intended travel destination’s time zone schedule can assist in adjustment upon arrival. However, shorter duration travel trips and various time zone shifts over an away schedule may prove the above recommendation ineffective. In such scenarios, napping as described will likely provide the most benefit to the athlete.
A Word on Sleep Disorders
Persistent sleep deprivation may indeed be pathological in nature. If focused in-house interventions are not successful over time, it may be beneficial to “dive deeper” and involve sleep specialists and / or physicians and make a referral for the application of cognitive behavioral therapy techniques. Evidence suggests cognitive behavioral therapy to be highly effective for the management and treatment of more advanced / serious sleep disorders. Using an assessment tool such as the Athlete Sleep Screening Questionnaire can assist in determining if referral is necessary.
Written by Barnett Frank PhD, LAT, ATC