Background:
Although sleep has been identified as an important modifiable risk factor for sports injury, the effect of decreased sleep on sports injuries in adolescents is poorly studied.
Purpose:
To systematically review published literature to examine if a lack of sleep is associated with sports injuries in adolescents and to delineate the effects of chronic versus acute lack of sleep.
Methods:
PubMed and EMBASE databases were systematically searched for studies reporting statistics regarding the relationship between sleep and sports injury in adolescents aged <19 years published between 1/1/1997 and 12/21/2017. From included studies, the following information was extracted: bibliographic and demographic information, reported outcomes related to injury and sleep, and definitions of injury and decreased sleep. Additionally, a NOS (Newcastle-Ottawa Scale) assessment and an evaluation of the OCEM (Oxford Center for Evidence-Based Medicine) level of evidence for each study was conducted to assess each study’s individual risk of bias, and the risk of bias across all studies.
Results:
Of 907 identified articles, 7 met inclusion criteria. Five studies reported that adolescents who chronically slept poorly were at a significantly increased likelihood of experiencing a sports or musculoskeletal injury. Two studies reported on acute sleep behaviors. One reported a significant positive correlation between acutely poor sleep and injury, while the other study reported no significant correlation. In our random effects model, adolescents who chronically slept poorly were more likely to be injured than those who slept well (OR 1.58, 95% CI 1.05 to 2.37, p = 0.03). OCEM criteria assessment showed that all but one study (a case-series) were of 2b level of evidence—which is the highest level of evidence possible for studies which were not randomized control trials or systematic reviews. NOS assessment was conducted for all six cohort studies to investigate each study’s individual risk of bias. Five out of six of these studies received between 4 to 6 stars, categorizing them as having a moderate risk of bias. One study received 7 stars, categorizing it as having a low risk of bias. NOS assessment revealed that the most consistent source of bias was in ascertainment of exposure: all studies relied on self-reported data regarding sleep hours rather than a medical or lab record of sleep hours.
Conclusions:
Chronic lack of sleep in adolescents is associated with greater risk of sports and musculoskeletal injuries. Current evidence cannot yet definitively determine the effect of acute lack of sleep on injury rates. Our results thus suggest that adolescents who either chronically sleep less than 8 hours per night, or have frequent night time awakenings, are more likely to experience sports or musculoskeletal injuries.
Figure 1.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Flow Diagram
Figure 2.
Random Effects Model Pooling the Following Studies: Von Rosen et al.17, Picavet et al.19, Kim et al.20
Table 1.
Study Characteristics, by publication year
Study | Year | Mean age (range), years | Questionnaire Timing | No. of Patient Respondents | No. of Females | Patient Population | Sport/Activity |
---|---|---|---|---|---|---|---|
von Rosen et al.17 | 2017 | 17.1 (16-19) | 1 questionnaire during “autumn semester” & 1 questionnaire during “spring semester” | 340 | 162 | “Swedish adolescent elite athletes” from 21 “National Sports High Schools”; “To attend the National Sports High Schools, the adolescent athletes must exhibit high national performance achievement and practice at the highest national level for their age group” | “Athletics, cross-country skiing, orienteering, handball, downhill skiing, ski orienteering, and freestyle skiing” |
von Rosen et al.18 | 2017 | 17 (15-19) | Questionnaires weekly or bi-weekly (depending on sport) for 52 weeks | 496* | 226* | “Swedish adolescent elite athletes” from 24 “National Sports High Schools” | Sports reporting weekly questionnaires: Skiing, Orienteering, Handball, and Athletics. Sports reporting bi-weekly questionnaires: Water ski, Canoe, Rowing, Wrestling, Bowling, Triathlon, Golf, Cycling, and American football. |
Watson et al.12 | 2016 | 15.5 (+/-1.6)^ | Questionnaires given daily for 20 weeks (length of 1 soccer season) | 75 | 75 | “female youth soccer athletes” | Soccer |
Picavet et al.19 | 2016 | (11-14)^^ | Questionnaire given once at age 11 and again at age 14 | 2517 | 1251 | Children & adolescents in the Netherlands | -- |
Kim et al.20 | 2015 | 14.50/14.81 (12-18)^^^ | Unspecified | 17232 | Unspecified | Korean adolescents from 7th through 12th grades | Bicycle riding |
Milewski et al.4 | 2014 | 15 (12-18) | One time questionnaire | 112 | 58 | United States adolescent athletes in high school or middle school | Unspecified |
Luke et al.15 | 2011 | 13.8 (6-18) | One time questionnaire given during sports medicine clinic visit | 360 | Unspecified | Patients visiting university-based sports medicine clinics in the US & Canada | Football, basketball, hockey, Soccer, wrestling, running, gymnastics, baseball, softball, “other” |
^Not specified whether 1.6 was absolute range or standard deviation
^^no average reported
^^^No overall mean was reported. Mean age of patients injured in bicycle accidents was 14.50 years; Mean age of patients not injured in bicycle accidents was 14.81
*30 of the total no. of patient respondents did not respond regarding sleep (unspecified how many of these 30 were female)
Table 2.
Outcomes & Definitions, by publication year
Study | Year | Definition of “Poor” Sleep | Definition of Injury | Probability Statistic (univariate analysis) | Probability Statistic (multivariate analysis) | Multivariate Control Variable(s)/adjustment | Other Form of Outcomes reported |
---|---|---|---|---|---|---|---|
von Rosen et al.17 | 2017 | Chronic; proportion of athletes (failing) to reach “the recommendation of sleep” (<8 hours) during weekdays; average amount of sleep during weekdays | “Injury was defined any physical complaint resulting in reduced training volume, experience of pain, difficulties participating in normal training or competition, or reduced performance in sports […] and was self-reported by the athletes” | OR 2.4 (95% CI: 1.0-5.9; p = 0.047)* | OR 2.6 (95% CI: 1.1, 6.3; p=0.038)* | “Proportion [of] athletes reaching the recommendation of nutrition intake of fish, fruits and vegetables.” Authors define recommendation “as national recommendation” (Sweden), sex, age | -- |
von Rosen et al.18 | 2017 | Chronic; “Sleep ≤ 8 hours during weekdays”; Surveys emailed weekly in first year, surveys emailed bi-weekly in second year | “Any new physical complaint that affected participation in normal training or competition, led to reduced training volume, experience of pain, or reduced performance in sports. Thus, both acute/overuse injuries were included.” | HR 1.32 (95% CI: 0.98 -1.78; p = 0.064) | HR 2.25 (95% CI: 1.46-3.45; P<.01) | Nutrition Index, Competence-based self-esteem, increased training load, decreased sleep volume (“dichotomized variable,” not defined) | -- |
Watson et al.12 | 2016 | Acute; “sleep volume in hours” of the night preceding the injury; no hour cut off given | “injuries […] entirely acquired during soccer events” | RR 0.98 (95% CI: 0.58 -1.7; p = 0.93)** | -- | -- | Sleep Hours On Days w/out an injury: 8.0 (SD: 0.65); Sleep Hours on Days w/ an injury: 7.97 (0.52); p- value 0.64; Cohen’s d: 0.06 |
Picavet et al.19 | 2016 | Chronic; “‘Sleeping problems’ was a composite variable based on the frequency and duration of nighttime awakenings. Those who reported being awake sometimes or every night, and reported being awake for a while or for a long time, were considered as having sleeping problems. “ | Injuries were musculoskeletal complaints (MSCs); “Musculoskeletal complaints were measured as part of a list of 15 conditions […] in the past 12 months” (5 past year).” | -- | Model 1: OR 1.83 (95% CI: 1.46- 2.30); Model 2: OR 1.51 (95% CI: 1.15 -1.97) | Model 1: Age, sex; Model 2: Not specified beyond “variables that were statistically significantly associated with a P value of 0.05 or lower.” | -- |
Kim et al.20 | 2015 | Chronic; Sleeping <7.5 but ≥ 6.5 hours across the past 7 weeks | “Bicycle riding accident” | OR 0.99 (95% CI: 0.87–1.12) | Model 1: OR 1.18 (95% CI: 1.03– 1.34); Model 2: OR 1.17(95% CI: 1.03–1.33) | Model 1: Age, sex; Model 2: Age, sex, obesity, economic level, and region of residence | -- |
Milewski et al.4 | 2014 | Chronic; < 8 hours/night on average | “Any injury that necessitated a visit to the athletic trainer’s room for evaluation and/or treatment…over a 21 month period” | RR 2.0 (95% CI, 1.3-3.2; P = 0.003) | RR 1.7 (95% CI, 1.0-3.0; P = 0.04) | Grade in School | -- |
Luke et al.15 | 2011 | Acute; <6 hours the night before | “A new sports- related or other physical activity–related injury […] based on [a] physician’s interpretation of whether the injury was related to sports or other physical activity.” | -- | -- | -- | No methods or results beyond: “Sleeping 6 or fewer hours the night before the injury was associated with all the fatigue-related injuries (P = 0.028).” |
OR = Odds Ratio; HR = Hazard Ratio; RR = Relative Risk
*Calculated from reciprocal OR
**Authors ambiguous about whether OR or RR. Values were calculated from Poisson regression, therefore assumed to be RR. Authors ambiguous about size of confidence interval; assumed to be 95% because statistical significance was defined as p<0.05
Table 3.
Oxford Center for Evidence-Based Medicine Level of Evidence (OCEM LOE) and Newcastle-Ottawa Scale (NOS) Assessment
Study | Oxford Criteria for Evidence-Based Medicine Level of Evidence, study design | Total Stars, Risk of Bias | Representativeness of the Exposed Cohort | Selection of the Non- Exposed Cohort | Ascertainment of Exposure | Demonstration That Outcome of Interest Was Not Present at Start of Study | Comparability of Cohorts on the Basis of the Design or Analysis | Assessment of Outcome | Follow-Up Was Long Enough for Outcomes to Occur | Adequacy of Follow Up of Cohorts |
---|---|---|---|---|---|---|---|---|---|---|
von Rosen et al. 201717 | 2b, prospective individual cohort | 5, moderate risk | c | a* | c | b | a*, b* (multiple confounders controlled in probability ratios) | c | a* | b* |
von Rosen et al. 201718 | 2b, prospective individual cohort | 6, moderate risk | c | a* | c | a* | a*, b* (multiple confounders controlled in probability ratios) | c | a* | b* |
Watson et al. 201612 | 2b, prospective individual cohort | 6, moderate risk | b* | a* | c | b | a*, b* (gender, age group, and sport matched in design) | c | a* | b* |
Picavet et al. 201619 | 2b, prospective individual cohort | 6, moderate risk | a* | a* | c | b | a*, b* (multiple confounders controlled in probability ratios) | c | a* | b* |
Kim et al. 201520 | 2b, cross- sectional/retrospective individual cohort | 6, moderate risk | b* | a* | c | b | a*, b* (multiple confounders controlled in probability ratios) | c | a* | a* |
Milewski et al. 20144 | 2b, cross- sectional/retrospective individual cohort | 7, low risk | a* | a* | c | b | a*, b* (age group and locality of adolescents matched in design, grade in school controlled for in probability ratios) | b* | a* | b* |
Luke et al. 201115 | 4, case-series | - | - | - | - | - | - | - | - | - |
*indicates that this grade merits a star per NOS criteria
-, Luke et al.’s study was not a cohort study and thus did not qualify for Newcastle-Ottawa Scale Assessment
References used in tables and full manuscript
Barber Foss KD, Myer GD, Hewett TE. Epidemiology of basketball, soccer, and volleyball injuries in middle-school female athletes. Phys Sportsmed. 2014;42(2):146-153.
Adirim TA, Cheng TL. Overview of injuries in the young athlete. Sports Med. 2003;33(1):75-81.
Valovich McLeod TC, Decoster LC, Loud KJ, et al. National Athletic Trainers’ Association position statement: prevention of pediatric overuse injuries. J Athl Train. 2011;46(2):206-220.
Milewski MD, Skaggs DL, Bishop GA, et al. Chronic lack of sleep is associated with increased sports injuries in adolescent athletes. J Pediatr Orthop. 2014;34(2):129-133.
Wheaton AG, Olsen EO, Miller GF, Croft JB. Sleep Duration and Injury-Related Risk Behaviors Among High School Students--United States, 2007-2013. MMWR Morb Mortal Wkly Rep. 2016;65(13):337-341.
Paruthi S, Brooks LJ, D’Ambrosio C, et al. Consensus Statement of the American Academy of Sleep Medicine on the Recommended Amount of Sleep for Healthy Children: Methodology and Discussion. Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine. 2016;12(11):1549-1561.
Watson NF, Badr MS, Belenky G, et al. Joint Consensus Statement of the American Academy of Sleep Medicine and Sleep Research Society on the Recommended Amount of Sleep for a Healthy Adult: Methodology and Discussion. Sleep. 2015;38(8):1161-1183.
Juliff LE, Halson SL, Hebert JJ, Forsyth PL, Peiffer JJ. Longer Sleep Durations Are Positively Associated With Finishing Place During a National Multiday Netball Competition. J Strength Cond Res. 2018;32(1):189-194.
Beedie CJ, Terry PC, Lane AM. The profile of mood states and athletic performance: Two meta- analyses. Journal of Applied Sport Psychology. 2000;12(1):49-68.
Panic N, Leoncini E, de Belvis G, Ricciardi W, Boccia S. Evaluation of the endorsement of the preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement on the quality of published systematic review and meta-analyses. PLoS One. 2013;8(12): e83138.
Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS medicine. 2009;6(7): e1000100.
Watson A, Brickson S, Brooks A, Dunn W. Subjective well-being and training load predict in- season injury and illness risk in female youth soccer players. Br J Sports Med. 2016.
Alricsson M, Domalewski D, Romild U, Asplund R. Physical activity, health, body mass index, sleeping habits and body complaints in Australian senior high school students. Int J Adolesc Med Health. 2008;20(4):501-512.
Wells G, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp.
Luke A, Lazaro RM, Bergeron MF, et al. Sports-related injuries in youth athletes: is overscheduling a risk factor? Clin J Sport Med. 2011;21(4):307-314.
University of Oxford Center for Evidence-Based Medicine. Oxford Centre for Evidence-based Medicine – Levels of Evidence. 2009; https://www.cebm.net/2009/06/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/.
von Rosen P, Frohm A, Kottorp A, Friden C, Heijne A. Too little sleep and an unhealthy diet could increase the risk of sustaining a new injury in adolescent elite athletes. Scand J Med Sci Sports. 2017;27(11):1364-1371.
von Rosen P, Frohm A, Kottorp A, Friden C, Heijne A. Multiple factors explain injury risk in adolescent elite athletes: Applying a biopsychosocial perspective. Scand J Med Sci Sports. 2017;27(12):2059-2069.
Picavet HS, Berentzen N, Scheuer N, et al. Musculoskeletal complaints while growing up from age 11 to age 14: the PIAMA birth cohort study. Pain. 2016;157(12):2826-2833.
Kim SY, Sim S, Kim SG, Choi HG. Sleep Deprivation Is Associated with Bicycle Accidents and Slip and Fall Injuries in Korean Adolescents. PLoS One. 2015;10(8): e0135753.
Stare J, Maucort-Boulch D. Odds Ratio, Hazard Ratio and Relative Risk. Metodoloski Zvezki. 2016;13(1):59-67.
Watson AM. Sleep and Athletic Performance. Curr Sports Med Rep. 2017;16(6):413-418.
Stracciolini A, Stein CJ, Kinney S, McCrystal T, Pepin MJ, Meehan Iii WP. Associations Between Sedentary Behaviors, Sleep Patterns, and BMI in Young Dancers Attending a Summer Intensive Dance Training Program. J Dance Med Sci. 2017;21(3):102-108.
Stracciolini A, Shore BJ, Pepin MJ, Eisenberg K, Meehan WP, 3 rd. Television or unrestricted, unmonitored internet access in the bedroom and body mass index in youth athletes. Acta Paediatr. 2017;106(8):1331-1335.
Snyder Valier AR, Welch Bacon CE, Bay RC, Molzen E, Lam KC, Valovich McLeod TC. Reference Values for the Pediatric Quality of Life Inventory and the Multidimensional Fatigue Scale in Adolescent Athletes by Sport and Sex. Am J Sports Med. 2017;45(12):2723-2729.
Simpson NS, Gibbs EL, Matheson GO. Optimizing sleep to maximize performance: implications and recommendations for elite athletes. Scand J Med Sci Sports. 2017;27(3):266-274.
Liiv H, Jurimae T, Klonova A, Cicchella A. Performance and recovery: stress profiles in professional ballroom dancers. Med Probl Perform Art. 2013;28(2):65-69.
Van Der Werf YD, Van Der Helm E, Schoonheim MM, Ridderikhoff A, Van Someren EJ. Learning by observation requires an early sleep window. Proc Natl Acad Sci U S A. 2009;106(45):18926- 18930.
Lee AJ, Lin WH. Association between sleep quality and physical fitness in female young adults. J Sports Med Phys Fitness. 2007;47(4):462-467.
Mejri MA, Yousfi N, Hammouda O, et al. One night of partial sleep deprivation increased biomarkers of muscle and cardiac injuries during acute intermittent exercise. J Sports Med Phys Fitness. 2017;57(5):643-651.
Mejri MA, Yousfi N, Mhenni T, et al. Does one night of partial sleep deprivation affect the evening performance during intermittent exercise in Taekwondo players? Journal of exercise rehabilitation. 2016;12(1):47-53.
Hirshkowitz M, Whiton K, Albert SM, et al. National Sleep Foundation’s updated sleep duration recommendations: final report. Sleep health. 2015;1(4):233-243.
Dennis J, Dawson B, Heasman J, Rogalski B, Robey E. Sleep patterns and injury occurrence in elite Australian footballers. J Sci Med Sport. 2016;19(2):113-116.
Bergeron MF, Mountjoy M, Armstrong N, et al. International Olympic Committee consensus statement on youth athletic development. Br J Sports Med. 2015;49(13):843-851.
Riley M, Locke AB, Skye EP. Health maintenance in school-aged children: Part II. Counseling recommendations. Am Fam Physician. 2011;83(6):689-694.
Spector ND, Kelly SF. Sleep disorders, immunizations, sports injuries, autism. Curr Opin Pediatr. 2005;17(6):773-786.
Asarnow LD, McGlinchey E, Harvey AG. The effects of bedtime and sleep duration on academic and emotional outcomes in a nationally representative sample of adolescents. J Adolesc Health. 2014;54(3):350-356.
Dahl RE, Lewin DS. Pathways to adolescent health sleep regulation and behavior. J Adolesc Health. 2002;31(6 Suppl):175-184.
School start times for adolescents. Pediatrics. 2014;134(3):642-649.
Bland JM, Altman DG. The odds ratio. BMJ. 2000;320(7247):1468.