Sleep and Health Among Collegiate Student Athletes

Abstract

Although the link between sleep, health, and performance has been well documented, research on this link in collegiate student athletes is still in its infancy. A large body of evidence indicates that collegiate student athletes are not obtaining enough sleep, but less is known about their sleep quality, patterns, and the impact on health and performance. Consequently, short sleep negatively affects physical and mental health, as well as several domains of performance (ie, aerobic, anaerobic, sport-specific, cognitive). The majority of studies examining the links between short sleep, health, and performance have been conducted with healthy adults or noncollegiate athlete samples; however, collegiate student athletes have demands unlike those of their nonathlete or noncollegiate athlete counterparts. Poor sleep health and sleep disorders are of increasing concern among the college athlete population and have recently been recognized by national and international sports governing bodies. The purpose of this review is to summarize the available literature on sleep and its impact on health and performance among athletes, specifically addressing gaps where little to no data is available on collegiate student athletes. Consideration is also given to evidence-based sleep interventions that have been utilized with athletes, as well as recommendations for future research and intervention development.

Sleep health is of growing concern among collegiate athletes given the detrimental impact of poor sleep on health and performance. Collegiate student athletes have been shown to obtain inadequate sleep duration and poor sleep quality.¹ Poor sleep health is associated with health problems, risk of injury, and decreased performance.^{2, 3, 4} Although consequences of sleep deprivation in the general population are well documented, less is known about sleep patterns and habits of collegiate athletes. A number of reviews have been conducted on the role of sleep in athletic populations.^{5, 6, 7} However, to our knowledge, no review specifically addresses collegiate athletes at US institutions. This population is important given the time demands and responsibilities within their dual roles as students and athletes, all of which may be affected by poor sleep.

This need has recently been recognized and addressed by national and international sport governing bodies, including the National Collegiate Athletic Association Interassociation Task Force on Sleep and Wellness and the International Olympic Committee.^{8, 9} Recently, the International Olympic Committee recognized insufficient sleep duration, poor sleep quality, and sleep disorders as important issues affecting athlete health. Despite sleep being recognized as an important area of student-athlete health requiring routine assessment, identification, and intervention, little research on sleep and its direct impact on collegiate athletes’ health and performance exists.

The current review highlights research on collegiate athlete sleep health, including the impact on health and performance, sleep interventions, and future recommendations. Key words included “sleep quantity” OR “sleep quality” OR [“sleep restriction” OR “sleep deprivation” OR “sleep extension”] AND [“student athlete” OR “collegiate athlete”] AND [“health” OR “mental health” OR “injury” OR “performance”]. The databases searched included PubMed, PsycINFO, and MEDLINE, with the initial search conducted prior to November 2017 and a follow-up search conducted through May 2019. Although the focus of the current article is on collegiate student athletes, research from samples of other athletes were included where data on collegiate student athletes is lacking.

Sleep Duration, Sleep Quality, and Sleep Disorders

Self-reported sleep duration of 6.98 h per night was reported in a large sample of Division I US collegiate student athletes, with 39.1% sleeping < 7 h.¹ This finding is comparable, or possibly less, than their nonathlete college counterparts as college students (n = 1,125) endorsed approximately 7.02 h, with 25% obtaining < 6.5 h of sleep per night.² Sleep duration < 7 h per night is problematic, and this issue is reflected in public health recommendations of 7 to 9 h per night for the college-age group.^{7, 10} Elite athletes have been shown to obtain less sleep prior to morning training and have difficulties altering bedtime to accommodate for morning training sessions.¹¹ A few studies suggest collegiate student athletes have shortened sleep duration, and this finding is consistent with other noncollegiate athlete samples.^{12, 13}

Regarding sleep quality, 42.4% of a large sample of Division I student athletes were classified as poor sleepers as indicated on the Pittsburgh Sleep Quality Index (PSQI) scores > 5.¹ Poor sleep quality has also found to be prevalent in 78% of Canadian adolescent athletes, 83% of Paralympic sport athletes, and 50% of elite rugby and cricket players.^{14, 15} Approximately 50% of elite Gaelic athletes reported poor sleep quality, taking > 30 min to fall asleep compared with only 5.6% of good sleepers.¹⁶ These findings are inconsistent with those of professional ballet dancers, who exhibit normal PSQI scores.¹² Sleep efficiency, measured by the ratio of time asleep to total time in bed, has not been directly assessed in collegiate student-athlete samples. A commonly used cutoff for low sleep efficiency in research is 85%.¹⁷ Average sleep efficiency, measured by wrist activity, in a sample of Olympic athletes over 4 days was 80.6% compared with 88.7% of nonathlete control subjects.¹⁸ Sleep efficiency has also been shown to differ between training and rest days. Actigraphy-measured sleep efficiency among elite Australian athletes ranged from 71% to 77% during a 14-day period of high-intensity training, with higher sleep efficiency on rest days.¹⁹ Similarly, actigraphy-measured sleep efficiency was reduced following night games compared with rest days.²⁰ In a sample of professional volleyball athletes, actigraphy-measured sleep efficiency was highest 2 days following a game (86.7%) compared with the night prior to the game (81.1%) and one night following the game (80.7%).²¹

Sleep-wake behaviors may differ between age, sex, and sport types. Among US collegiate student athletes, male athletes reported poorer sleep quality than female athletes.¹ Collegiate athletes ages 17 to 21 years reported average weekday sleep time < 7 h per night, whereas student athletes between the ages of 22 and 26 years reported an average of 7.4 h of sleep. Furthermore, almost one-half of the collegiate athlete sample were classified as poor sleepers (PSQI scores > 5), but significant variability was observed within and between individual and team sports.¹ Variability in sleep between sports has also been observed among Australian athletes; football players were found to experience greater sleep disturbance than soccer or rugby players as evidenced by longer sleep latency (> 8 min), more minutes awake throughout the night (> 13 min), and greater nighttime movement (> 16 min).²² More research is needed on the sleep patterns of collegiate student athletes to better understand factors that underpin this variability.

The prevalence of sleep-wake disorders, as defined according to the third edition of the International Classification of Sleep Disorders: Diagnostic and Coding Manual,²³ is relatively unknown among college athletes. Sleep-disordered breathing (SDB) in college football players has been estimated to be approximately 8%.²⁴ Likewise, approximately 14% of professional football players experience SDB, and 34% are considered high risk²⁵; other studies have found lower estimates (4.4%) of SDB in those with moderate respiratory disturbance.²⁶ Certain risk factors, including larger neck circumference and higher body weight and BMI, may put athletes at greater risk for SDB given that such structural risk factors place higher mechanical load on the upper airway and are associated with greater oxygen desaturation.²⁴ Regarding the broader spectrum of sleep disorders, one in four professional ice hockey players met criteria for a clinical sleep disorder (eg, OSA, insomnia).²⁷ Similarly, 46.6% of Japanese student-athletes were identified as experiencing some type of sleep disorder.²⁸ Given the prevalence of sleep-wake disorders in noncollegiate athlete samples, undiagnosed and untreated sleep disorders are likely prevalent among US collegiate student athletes.

Risk Factors for Sleep-Related Problems

Salient risk factors for poor sleep health and sleep disorders among student athletes include fatigue due to travel, poor or inconsistent sleep hygiene, substance use, academic and time demands, and use of electronic devices and social media. A systematic review of 37 studies on sleep loss and elite sports showed that primary risk factors for athletes include travel, training, and competition.²⁹

Travel fatigue due to stress, disruptions in daily routine, reduced mobility, air quality, and pressure changes in the cabin environment may interfere with sleep and impair performance.^{30, 31} Travel fatigue is associated with short-term symptoms of fatigue, poor sleep, headaches, and appetite changes that often resolve within 1 day.³² Collegiate student athletes most commonly travel via bus or domestic flights for competition or training that requires early wakeup times, late bedtimes, and disruption of normal sleep patterns. However, one study found that Division I collegiate student athletes reported better sleep quality while traveling than at home on campus.¹ Individual variability in travel demands, sleep environment, and academic stress may contribute to these differences, but more research is needed on the contributing factors that affect travel fatigue in collegiate student athletes. Although collegiate student athletes do not routinely travel internationally, those who travel long distances by air may experience symptoms of jet lag and reduced performance due to sleep and circadian rhythm disruption.^{33, 34, 35}

Poor sleep hygiene is also prevalent and may facilitate the development of sleep problems among collegiate student athletes. Noise was cited as the most problematic environmental barrier to sleep among collegiate student athletes (68%), followed by temperature (55.4%), sunlight (42%), and roommates (30.6%).¹ College students generally have reported delayed bedtime and rise time on weekends, taking prescription or over-the-counter medication to alter sleep/wakefulness, and emotional and academic stress that negatively affects sleep.² Moreover, inconsistency in sleep schedules may be worse prior to games/competition as observed in other elite athlete samples.²⁰ Although the use of electronics prior to bed has been shown to negatively affect sleep quality,³⁶ the removal of electronic devices prior to bed did not result in earlier sleep times or greater sleep duration.³⁷

The use of caffeine, alcohol, and nutritional supplements is also prevalent in athletic environments and might negatively affect sleep. Although athletes may experience performance benefits with caffeine use,^{38, 39, 40, 41} caffeine is also associated with prolonged sleep latency and delayed wakeup times if consumed in the evening because caffeine takes approximately 4 to 6 h to metabolize in the body.⁴² Similar to elite athletes who were observed to have higher postgame salivary caffeine levels, prolonged sleep latency, and reduced sleep duration following a night game,⁴³ collegiate student athletes likely experience similar sleep disruption with nighttime caffeine consumption. Although alcohol may decrease sleep latency, sleep disturbance occurs as alcohol metabolizes in the body.⁴⁴ Binge drinking episodes are prevalent on college campuses and are associated with a wide range of sleep-related disturbances⁴⁵ and delayed bedtime.^{46, 47}

Regarding supplements, melatonin may assist in shifting circadian rhythm and inducing sleep onset, but has not shown effectiveness for the treatment of clinical sleep disorders.⁴⁸ Resistance-trained athletes who were administered 100 mg of melatonin prior to bed for 4 weeks reported outcomes consistent with circadian rhythm shifts characterized by changes in wrist temperature, motor activity, body position rhythmicity, and sleep onset.⁴⁹

Sleep and Health in Student Athletes

Sleep is an important aspect of an athlete’s overall health, including the prevention and management of illness, injury, concussion, and mental health concerns. Sleep plays a key role in regulating the immune system as one study found that individuals administered nasal drops containing rhinovirus were three times more likely to develop a common cold when obtaining < 7 h of sleep per night.⁵⁰ Downregulation of the hypothalamic-pituitary-adrenal axis occurs with sleep initiation and aids in the suppression of cortisol, epinephrine, and norepinephrine.⁵¹ Elite Gaelic athletes with poor sleep quality reported more health issues, increased stress, and confusion; although currently unknown, it is expected that collegiate student athletes experience similar health concerns associated with poor sleep health.¹⁶

Sleep deprivation places athletes at greater risk for injury.^{3, 52} Adolescent athletes who slept < 8 h per night were 1.7 times more likely to sustain an injury than those with ≥ 8 h of sleep.³ Sleep deprivation and increased training load were found to be independently associated with increased injury risk and made the greatest impact when in combination.⁵² Individuals who are awake for a 24-h period are two times as likely to experience a motor vehicle crash, highlighting the detrimental consequences that could occur within and outside athletic environments.⁵³ Pain is also problematic because it may occur in isolation or with athletic injury.⁵⁴ Physiological impairments of short sleep may result in altered tissue sensitivity that gives rise to pain.⁵⁵ Hainline et al⁵⁶ offers a comprehensive review of factors, such as sleep, that affect pain among athletes.

An essential component of injury prevention is adequate recovery from training and competition.⁵⁷ Short sleep may impede muscle growth and recovery, increasing risk of injury and performance disruption.⁵⁸ Although sleep has emerged as a primary modality for recovery, the mechanisms that underlie sleep and injury are less clear.⁵⁹

A total of 3.8 million sport and recreation-related concussions occur annually in the United States.⁶⁰ In US college athletes, moderate to severe insomnia and daytime sleepiness two or more times per month increased the risk of sustaining a concussion.⁶¹ Headaches, dizziness, and psychiatric symptoms postconcussion have been correlated with sleep disorders.⁶² In addition, sleep problems are common following concussion, and insufficient sleep may lengthen recovery times three- to fourfold.⁶³ Poor sleep prior to a baseline concussion assessment has led to postconcussive symptoms (eg, sensitivity to light, irritability) being endorsed at a rate two to four times higher than those with > 7 h of sleep.⁶⁴ This finding is problematic because many college athletic departments conduct baseline concussion assessments and use them as a premorbid baseline once an athlete sustains a head injury.

Poor sleep has been linked to a multitude of psychological health concerns, including anxiety, depression, substance abuse, suicidal thoughts, increased risk for violence, and greater somatic symptoms.⁶⁵ College coincides with a developmental period most common for the onset of mental health disorders, and poor sleep may exacerbate these concerns.⁶⁶ Collegiate weight lifters reported increases in negative affect and fatigue as a result of a full night of sleep deprivation.⁶⁷ Given the bidirectional relation between sleep and mental health, athletes with greater psychological distress may experience exacerbated sleep problems. A recent study observed greater salivary cortisol concentrations and poor sleep among elite athletes following a game, but not during practice or rest days, suggestive of psychological stress associated with competition.⁶⁸

Sleep and Performance

Optimizing athletic performance is a priority for many student athletes, with some receiving athletic scholarships and aiming to secure a career in professional sport. Sleep deprivation can interfere with such goals by adversely affecting multiple domains of performance, including aerobic, anaerobic, sport-specific skills, and neurocognitive functioning.

To our knowledge, no studies to date have examined the impact of sleep restriction or deprivation on aerobic and anaerobic performance in collegiate student athletes. In other athlete samples, laboratory-induced sleep deprivation has resulted in reduced time to exhaustion on a cycling test⁶⁹ and less distance covered on a submaximal treadmill run.⁷⁰ However, it is unclear how these results may transfer to real-world settings given that student athletes may be more likely to experience long-term sleep restriction rather than a full night of sleep deprivation. Sleep restriction of 3 h per night over the course of 1 week has resulted in increases in both heart rate and blood lactate levels.⁷¹ Similarly, performance on a 3-km cycling time trial following 1 day of heavy exercise was significantly worse in the sleep-restricted group compared with a group obtaining a full night of rest.⁷² Decreased glycogen stores have been reported in athletes following a night of sleep deprivation, even prior to training or competing.⁷³ Although it is evident that sleep loss impairs aerobic performance through reducing time to exhaustion and hindering submaximal performance, it is unclear how results translate to college athletes.

Regarding anaerobic performance, the link with poor sleep is less clear. Some studies have found no change in anaerobic power among weight lifters following sleep deprivation.^{67, 74} However, sleep restriction has resulted in impairments on submaximal weight-lifting tasks⁷⁵ and decreased peak and mean anaerobic power.⁷⁶ In addition, slower sprint times were observed in male athletes following a 30-h sleep deprivation.⁷³ Other studies have found no change in mean or peak power following partial sleep restriction (ie, 4 h of sleep) or a full night of sleep deprivation.^{74, 77} Available data on sleep and anaerobic performance are limited to small samples with variability in methods and sleep restriction and deprivation protocols.

Short sleep is associated with impairments in sport-specific skills. Serving accuracy was reduced from 53% to 37% following a night of sleep restriction in tennis players,⁷⁸ whereas serving accuracy improved from 36% to 41% following 1 week of sleep extension (2 h per night).⁷⁹ Similarly, sleep deprivation may be related to a player’s longevity as 72% of players on Major League Baseball teams who scored a 5 on the Epworth Sleepiness Scale were still in the league three seasons later, compared with only 39% of players who scored a 10, and 14% who scored a 15 on the scale.⁸⁰

Neurocognitive functioning is also affected by poor sleep. Individuals with acute sleep loss demonstrated slower reaction times, processing speed, difficulties with attention, and visuospatial skills.^{81, 82} High school and college athletes who obtained < 7 h of sleep performed worse on measures of reaction time, verbal memory, and visual memory tasks.⁸³ Reduced positive affect and inhibitory control, with subsequent increased risk-taking behaviors, were observed following one night of sleep deprivation in young adults.⁸⁴ It is hypothesized that similar neurocognitive findings would be evident among collegiate student athletes experiencing sleep loss, but more research is needed to better define this relation and its impact on both athletic and academic endeavors. Fullagar et al⁸⁵ offers a detailed review of sleep and athletic performance. Table 1 presents an overview of sleep and performance.^{67, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 81, 82, 83, 84}

Table 1.

Sleep and Performance

Study	Participants	Sleep Protocol	Performance Test	Findings
Aerobic
Chase et al, 201772	Recreational cyclists (N = 7)	Early waking SR (2.4 ± 0.2 h)	3 km cycle TT following an evening with heavy exercise	SR group: ↑3 km TT time
Oliver et al, 200970	Recreational athletes (N = 11)	30 h of sleep deprivation	Submaximal treadmill run (60% VO2max) and self-paced run	↓Distance covered
Azboy and Kaygisiz, 200969	Male runners and volleyball players	25-30 h sleep deprivation	Time to exhaustion cycling	↓Time to exhaustion
Mougin et al, 199171	Cyclists (N = 7)	3 h SR for 1 wk	20 min 75% VO2max + ergometer time to exhaustion	↑Heart rate ↑VE ↑Blood lactate levels
Anaerobic
Blumert et al, 200767	Collegiate weight lifters (N = 9)	24 h sleep deprivation	Maximal weight-lifting protocol	No significant change ↓Cortisol concentration ↓Vigor ↑Fatigue
Taheri and Arabameri, 201274	Physical education students (N = 18)	1 night sleep deprivation	Wingate test Reaction time test	No change in anaerobic performance ↑Reaction time
Reilly and Piercy, 199475	Physically active males (N = 8)	3 h SR for 3 nights	Submaximal lifts: bicep curls, bench press, leg press, and dead lift Maximal lift	↓All submaximal lifts ↓Maximal lifts but not bicep curl
Abedelmalek et al, 201376	Football players (N = 12)	1 night 4 h of sleep	Wingate test	↓Peak and mean power at 6:00 pm
Skein et al, 201173	Male team sport athletes (N = 10)	30 h sleep deprivation	Intermittent sprint protocol	↑Sprint time ↓Distance covered ↓Muscle glycogen
HajSalem et al, 201377	Judokas (N = 21)	Partial sleep deprivation	Wingate test	↓Peak and mean power No significant change in hand grip
Sport-specific
Reyner and Horne 201378	Tennis players Study 1: N = 16 Study 2: N = 12	2-2.5 h SR	40 serves	↓Serving accuracy
Schwartz and Simon, 201579	College tennis players (N = 1)	1 week sleep efficiency (+2 h)	Serving accuracy	↑35.7% to 41.8%
Neurocognitive
Hurdiel et al, 201481	Sailors (N = 12)	SR during 3 races (22 ± 30 min, 92 ± 34 min, 172 ± 122 min)	Reaction time	↓Reaction time
Jarraya et al, 201382	Handball players (N = 12)	SR (4-5 h for 2 nights)	Reaction time Stroop test Barrage test	↑Reaction time ↓Selective attention ↓Visual spatial
McClure et al, 201483	Nonconcussed athletes (N = 3,686; 3,305 high school, 381 college)	Retrospective sleep categories < 7 h 7-9 h ≥ 9 h	ImPACT	< 7 h/night = ↓Reaction time ↓Verbal memory ↓Visual memory No difference in processing speed
Rossa et al 201484	Young adults (N = 19)	SR (bedtime prior to 10:30 pm, woken up at 4:00 am)	PPVT PBART PVT Go/No-go Task PANAS	↑Risk taking ↓PVT ↓Positive affect No change in negative affect No significant reaction to Go/No-go

ImPACT = immediate postconcussive assessment and cognitive testing; PANAS = positive negative affective schedule; PBART = balloon analog risk tasking; PPVT = perceptual vigilance task; PVT = psychomotor vigilance task; SR = sleep restriction; TT = time trial; V_E = ventilation; VO_2max = maximal oxygen uptake.

Sleep Interventions

Research on the development of sleep interventions for student athletes is in its infancy. Developing and disseminating sleep interventions are critical as almost one-half of athletes report having no strategies to assist with poor sleep.⁸⁶ Interventions previously proposed and showing support include sleep hygiene,^{33, 87, 88, 89, 90, 91} sleep extension,^{79, 92, 93} naps,^{94, 95, 96, 97} and use of melatonin.^{49, 98, 99, 100, 101}

Sleep hygiene is the practice of behaviors and habits that promote good sleep health.⁸⁷ Sleep hygiene interventions have had an impact on increasing sleep duration^{87, 88, 89, 90, 102} and changing sleep behaviors.¹⁰³ However, the impact on sleep efficiency is mixed, with some finding improvements in actigraphy-measured sleep efficiency,⁸⁹ and others finding no change⁸⁷ or even reduced activity-measured sleep efficiency.⁹⁰ Nevertheless, proper sleep hygiene has been beneficial for improving sleep duration following games⁸⁸ and improving perceived sleep quality, vigor, and decreasing fatigue when implemented over a period 1 month.^{89, 91} Sleep hygiene in conjunction with bright light therapy has led to reductions in travel fatigue and improvements in sleep duration following simulated travel.¹⁰² Although actigraphy monitoring is preferred, large positive correlations have been found between self-reported sleep duration and objective sleep measurement, indicating sleep diaries may be a beneficial and low-cost tool for monitoring in clinical contexts when obtaining objective measurement is not possible.⁹⁰

Sleep extension protocols have been effective at improving objective sleep duration, time in bed, sleep quality, physical performance, and subjective mood.^{79, 92, 93} Male Division I college basketball players who extended time in bed (10 h/night) for 5 to 7 weeks exhibited increased sleep duration (6.6 to 8.5 h), reduced sprint times (16.2 to 15.5 s), and increased free throw accuracy (9% increase), free throw percentage, and three-point field goals (9.2% increase).⁹² Similarly, collegiate tennis players who underwent a week-long sleep extension period exhibited improved sleep duration (7.14 to 8.85 h) and serving accuracy (35.7% to 41.8%).⁷⁹ Although both sleep extension protocols enhanced athletes’ sleep and performance, limitations exist. Both studies required athletes to sleep more but did not address sleep barriers or provide strategies for increasing sleep, which may be problematic for real-world settings. In addition, some participants had difficulties adhering to time in bed, possibly due to competing demands such as academic responsibilities.⁹² To rectify this issue, interventions that combine sleep extension with education might provide athletes with the necessary knowledge and support to improve sleep. For example, one such study used a 3-week sleep extension protocol with supplemental education to assist with sleep behaviors.⁹³ As a result, improvements in sleep quality, total sleep time, time in bed, and perceived vigor increased, while cortisol levels, reaction time, and subjective fatigue decreased. Taken together, results from sleep extension protocols, particularly when combined with education or intervention, show promising results for improving sleep. However, sleep extension also has limitations, with increased time in bed placing athletes at higher risk for problematic sleep hygiene (eg, scrolling through telephone in bed),¹⁰³ increased sleep latency as measured according to polysomnography,⁹⁵ and reduced sleep efficiency as measured according to actigraphy.⁸⁸

The impact of napping on nocturnal sleep and performance of collegiate student athletes is unknown. Drawn from other healthy samples, napping has been shown to improve alertness, reaction time, short-term memory, sleepiness, and sprint times.^{94, 97} Greater slow-wave sleep duration was found 2 h posttraining, but not 1 h posttraining, indicating naps that occur later following training may be more effective.⁹⁶ The impact of postlunch naps on sleep and sprint performance has been examined in athletes with simulated jet lag.⁹⁵ No changes in sprint times were found following naps in either the jet lag condition or control group. However, among nonregular nappers with shifted sleep time, longer sleep onset times were reported, indicating that timing of naps is important.⁹⁵ One contraindication to napping is that it has been associated with difficulties falling asleep at night and reduced sleep efficiency in studies using polysomnography.

Melatonin is an endogenous hormone secreted from the pineal gland that regulates the sleep-wake cycle and, as a supplement, may be a short-term option for improving sleep phase advances or delays.⁴⁹ In physically active individuals, melatonin prior to bed has been shown to increase sleep duration, decrease nighttime wakenings, assist with sleep advancement, and reduce nocturnal activity,^{49, 101} while having no impact on performance the next day.⁹⁸ However, the impact of melatonin ingested in the morning prior to training is mixed, with some studies showing reduced physical performance¹⁰⁰ and others showing reduced alertness, reaction time, and short-term memory but no change in short-term performance.⁹⁹ In addition to melatonin, athletes may be prescribed hypnotic medications for sleep difficulties or sleep disorders. The use of prescription medications for treatment of sleep disorders is beyond the scope of the current review, but another recent review highlights medication use in athletes.¹⁰⁴ However, clinical guidelines for the treatment of insomnia recommend at least one behavioral intervention as a first-line treatment, such as cognitive-behavioral therapy for insomnia.¹⁰⁵ An overview of sleep interventions are provided in Table 2.^{49, 79, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 100, 101, 102, 103}

Table 2.

Sleep Interventions

Study	Participants	Sleep Protocol	Measurement	Outcomes
Sleep hygiene
O’Donnell and Driller, 20187	Elite female netball athletes (N = 26)	1 sleep hygiene education session; 1 wk prior to and following sleep monitoring	Wrist actigraphy	↑TST ↓Wake variance and duration No change in SL, sleep efficiency, TTB, SOT, WT, or WE
Kaier et al, 2016103	Division I collegiate athletes (N = 104)	Brief psychoeducation sleep workshop	Self-report	51% ≥ 1 sleep behavior change ↓Daytime sleepiness ↑Daytime functioning ↑Problematic sleep hygiene ↑Knowledge of sleep
Fullagar et al, 201688	Two amateur soccer teams (N = 40)	Randomized crossover design with sleep hygiene strategy or normal postgame routine	Objective sleep measures (sleep deprivation, SL, sleep efficiency, WE); Countermovement jump; yo-yo test Blood draw; Perceived recovery; stress markers	↑Sleep deprivation, WE No difference in SL or sleep efficiency No difference in physical performance, blood markers, or perceived recovery
Van Ryswyk et al, 201789	Australian football league players (N = 25)	6-wk sleep program	Sleep diaries, actigraphy, self-report, PVT	↑Sleep deprivation, sleep efficiency ↑Vigor ↓Fatigue
Harada et al, 201691	University soccer players in Japan (N = 84)	1 mo sleep education	Sleep diaries Self-report questionnaires	↑Sleep quality, mental health and performance ↓Irritation
Fowler et al, 2015102	Physically active male subjects (N = 13)	Randomized crossover design 24 h simulated travel with and without sleep hygiene + artificial bright light	Actigraphy Oxygen saturation	Intervention group ↓Travel fatigue sleep deprivation ↑Approached significance No change in performance
Caia et al, 201890	Professional rugby athletes (N = 24)	Two 30 min sleep hygiene education seminars	Sleep diaries Actigraphy	Session 1: earlier bedtime, ↑TTB, ↑sleep deprivation Session 2: ↑time in bed, ↓sleep efficiency
Sleep extension
Mah et al, 201192	Division I MBB players (N = 11)	5-7 sleep extension (10 h/night)	Actigraphy, sleep logs, RT, basketball performance	↑Objective sleep deprivation, free throw accuracy ↓Sprint time, RT, ESS
Schwartz and Simon, 201579	Division III tennis players (N = 12)	1 wk sleep extension (9 h/night including naps)	Self-reported sleep (ESS, Stanford Sleepiness Scale) Serving accuracy	↑Sleep deprivation ↑Serving accuracy
Swinbourne et al, 201893	Professional rugby players (N = 25)	3 wk sleep extension protocol (10 h/night) with education	Sleep-actigraphy, immune functioning, SNS activity, physiological stress, RT	↑Sleep quality, TST, TTB, vigor ↓Cortisol, RT, fatigue
Naps
Waterhouse et al, 200794	Healthy male subjects (N = 10)	Postlunch nap (30 min) following night of short sleep	Alertness; short-term memory; temp; HR; RT; grip strength; sprint times	↓HR, temperature, sleepiness, sprint times ↑Alertness, short-term memory No change in RT or grip strength
Petit et al, 201495	Healthy male subjects (N = 16)	Nap in normal 8 h sleep condition vs 5 h shift	Sleep (PSG) VO2max	↑SL in shifted condition No change in physical performance
Davies et al, 201096	Physically trained male subjects (N = 6)	90-min nap 1 or 2 h posttraining	Sleep (PSG) Subjective sleep quality, alertness, and preparedness to train	↑SWS following later nap No other changes in sleep
Daaloul et al, 201997	National karate athlete (N = 13)	30-min nap following sleep deprivation or normal sleep	RT, mental rotation test, jump tests	↑RT, mental rotation test ↑Alertness following sleep deprivation No impact on subjective fatigue and physical performance
Melatonin
Atkinson et al, 200198	Physically active subjects (N = 12)	5 mg melatonin prior to sleep vs placebo	Subjective sleep quality, intra-aural temperature, grip strength, 4-km cycle	No change
Ghattassi et al, 2016100	Soccer players (N = 12)	Morning melatonin (5 mg immediate release)	Cognitive and physical performance 8:00 am, 12:00 pm, 4:00 pm	↓Physical performance 0800 No other changes in physical or cognitive performance
Leonardo-Mendonça et al, 201549	Resistance-trained male students (N = 24)	100 mg melatonin 30-60 min prior to bed for 4 wk	Salivary melatonin, wrist temp, motor activity, body rhythmicity	1 h phase advance wrist temperature prior to bed ↑Nocturnal steady state ↓Nocturnal activity
Cheikh et al, 2018101	Adolescent athletes (N = 10)	10 mg single dose of melatonin in the evening following training	Sleep (PSG), yo-yo test, RT, hand grip, jump	↑TST, sleep efficiency, stage 3 sleep, REM ↓SL, stages 1 and 2 sleep, nocturnal awakenings ↑Speed and performance
Atkinson et al, 200599	Physically active participants (N = 12)	5 mg melatonin vs placebo at 11:45 am	Subjective alertness, intra-aural temperature, RT, short-term memory, grip strength, RPE, HR	↓ Intra-aural temperature ↓ Alertness, short-term memory, exercise HR, RT No change in RPE or short-term performance

ESS = Epworth Sleepiness Scale; HR = heart rate; MBB = men’s basketball; PSG = polysomnography; REM = rapid eye movement; RPE = rating of perceived exertion; RT = reaction time; SL = sleep latency; SNS = sympathetic nervous system; SOT = sleep-onset time; SWS = slow wave sleep; TST = total sleep time; TTB = total time in bed; WE = wake episodes; WT = wake time. See Table 1 legend for expansion of other abbreviations.

Conclusions and Recommendations

Adequate sleep is vital to the health and performance of collegiate student athletes. Evidence indicates that many collegiate student athletes are not obtaining enough sleep; however, more data on student-athlete sleep risk factors and barriers, objective sleep quality measurement, factors that contribute to individual variability in sleep patterns (eg, age, sex, training), and the prevalence of sleep-wake disorders is needed to inform clinical trials. An overview of the relationship between sleep, health, and performance is provided in Figure 1. Future research should aim to include a diverse range of athlete samples. Intervention studies could improve upon methodologic issues by using randomized experimental designs, evidence-based behavioral sleep interventions (eg, cognitive-behavioral therapy for insomnia), and objective tracking when possible. To more appropriately address adherence to sleep protocols, such evidence-based interventions may include motivational strategies (eg, motivational interviewing), as well as cognitive and behavioral strategies to facilitate change. Furthermore, no research has examined the effectiveness of treatment for SDB among student athletes. The limited information on sleep among collegiate student athletes is problematic for health-care providers and sport professionals caring for collegiate student athletes in both medical and performance contexts. By better understanding poor sleep health and the impact on collegiate athletes’ health and performance, better education, assessment, and interventions can be developed and disseminated within sports medicine teams and university athletic departments.

Figure 1.

Understanding sleep, health, and performance among student athletes.