SLEEP AND RECOVERY
SLEEP AS A
RECOVERY TOOL
FOR ELITE ATHLETES
THE ATHLETE SLEEP SCREENING
QUESTIONNAIRE©
– Written by Charles Samuels and Lois James, Canada
“If your athletes go to bed, fall asleep
within 30 minutes, sleep through the night
with brief awakenings, feel refreshed within
60 minutes of waking most days (5/7 days/
week) then congratulations: your athletes are
normal sleepers!”
– Dr Samuels, 2013
We know from decades of research
that sleep is important for human
performance1-3. So, why would we even
think about screening athletes when it
comes to sleep? Why not just apply basic
principles of sleep and generalise from the
research that’s been done in other areas
such as law enforcement4-7, the military8-11 or
aviation12-15? As a result of this research and
knowledge athletes, coaches, sport medicine
physicians and trainers are interested in
understanding the relationship of sleep
to training, recovery and performance in
athletes. The complicating factor is that
athletes, and elite athletes in particular, are
48
very different than the average individual
or members of occupational groups such
as law enforcement and the military, on
whom prior research is based. Athletes
have unique physical and mental demands,
have to accommodate rigorous competition
and training schedules and have to adapt
to difficult travel regimes. So we have to be
careful and specific about applying what
we know about sleep to athletes. There is
a clear need for developing valid, reliable
tools to screen and monitor athlete sleep
behaviours as the basis for understanding
and developing effective interventions.
Most countries are developing high
performance training programmes for
National/Olympic team athletes and are
committed to investing in every available
tool to help them succeed. We know from
the scientific study of sleep that it promotes
physical and mental recovery16,17. However,
the theoretical principles behind the
relationship between sleep and recovery
have only just started to be explored in
athletic populations. Without a structured
assessment of relevant sleep behaviours
and the development of valid, reliable
tools to acquire accurate data we will have
nothing upon which to base useful research
questions. Without these tools there will be
no way to drive data collection, analyse the
data and determine how sleep may affect
training, recovery and performance. Finally,
valid, reliable data collection methods are
necessary to monitor the effectiveness of
therapeutic interventions.
Over the past several years the
University of Calgary Sport Medicine
Sleep and Human Performance Research
Initiative has developed the Athlete Sleep
Screening Questionnaire (ASSQ) ©. This
tool is designed to capture athlete sleep
behaviours, identify athletes with abnormal
sleep and primary sleep disorders and
 Table 1
Total sleep time Sleep difficulty score
Sport
mean hours/night (SD) mean (SD)

Paralympics (n=13) 7.94 (1.26) 8.15 (2.44)

Bobsleigh skeleton
7.70 (0.86) 9.30 (4.16)
(n=10)
determine the frequency with which
athletes have difficulty with sleep when
travelling. The ASSQ© screening system
Speed skating (n=34) 8.00 (1.09) 8.74 (3.29)
stratifies athletes into those who require
basic sleep education, assessment with the Swimming (n=11) 7.86 (1.18) 9.91 (4.11)
sport medicine physician and those who
require a sleep medicine consultation and
investigations. The goal of this article is to Volleyball (n=6) 8.62 (0.68) 8.83 (4.36)
provide:
1. A clear understanding of the relationship
between sleep and recovery. Waterpolo (n=11) 7.82 (1.02) 8.64 (4.03)
2. An understanding of the ASSQ©, and
how it can be used to benefit elite
Wrestling (n=6) 7.71 (1.27) 8.83 (3.82)
athletic teams.
3. A summary of ASSQ© results collected
from teams and athletes to date. Table 1: Total sleep time and sleep difficulty score by athletic team.

THE RELATIONSHIP BETWEEN SLEEP AND

RECOVERY
Sleep factors have been shown to have
a direct effect on executive cognitive
function18, metabolic control of energy
balance, appetite and weight19,20 and tissue
repair21. Cognition, metabolism and tissue
repair are critical physiological processes
that contribute to training capacity, recovery
and performance. Recent research on athlete
populations has provided objective evidence
that confirms the importance of sleep in
athlete development and performance16,22.
The relationship between sleep and
post-exercise recovery and regeneration can
be viewed in a structured fashion:
1. Sleep length (total sleep requirement:
hours/night, plus naps).
2. Sleep quality (sleep disorders,
environmental disturbance or sleep
fragmentation).
3. Sleep phase (circadian timing of sleep).
These three parameters of sleep are the
key factors affecting the overall recuperative
outcome of the sleep state23. They affect
an athlete’s ability to train, maximise the
training response, perform and recover24.
Capitalising on the restorative power of
sleep will help maximise energy, mood,
decision-making skill and reflex response.
In addition, attending to the importance of
sleep will reduce the risk of overtraining/
under-recovery, enhance resistance to
illness and improve recovery from injury25.
SLEEP LENGTH
For sleep to be recuperative it must be
of adequate duration. This is a universal
principle, but applies especially to athletes
whose physical recovery may need to be
greater than the average individual. Sleep
requirements change over the course of an
individual’s life; in particular the amount
of sleep required. For example, 8 to 12 year
olds need about 9.5 to 10 hours, 12 to 16 year
olds need about 9 hours, and 16 to 22 year
olds need about 9 to 10 hours per night.
Naps can count towards total sleep time,
should be restricted to 30 minutes and
should be scheduled between 2 to 4 pm
for the average sleeper. Strategic napping
may be particularly beneficial for young
athletes who, due to school commitments
and training, may not be able to achieve the
recommended amount of sleep per night.
SLEEP QUALITY
Maintaining a regular sleep/nap routine,
establishing a comfortable sleeping
environment and monitoring for sleep
disorders can maximise sleep quality. A
key indicator of sleep disorders is excessive
sleepiness, despite adequate sleep length.
This is due to ‘non-restorative’ sleep, which is
poor quality due to interruptions from sleep
disorders such as insomnia, sleep apnoea or
restless legs syndrome. Sleep disorders are
common and treatable, but often remain
undiagnosed. It’s especially important
to find out if young athletes suffer from
sleep disorders because intervention at a
young age could make a huge difference for
their long-term athletic development and
performance. Travel can also affect sleep
quality, so jet lag management and sleep
scheduling while traveling is critical26.

POST-EXERCISE RECOVERY TARGETED TOPIC 49

SLEEP AND RECOVERY
Table 2
Total sleep time Sleep difficulty score
Sport
mean hours/night (SD) mean (SD)
BMX (n=11) 8.11 (0.94) 8.83 (4.21)
Curling (n=27) 8.12 (1.07) 7.93 (3.06)
Rugby (n=50) 7.71 (1.16) 9.30 (2.86)
Alpine skiing (n=30) 7.80 (1.14) 8.83 (4.21)
Biathlon (n=6) 8.38 (0.86) 8.83 (2.23)
Bobsleigh (n=12) 7.85 (0.90) 8.50 (2.97)
Cycling (n=21) 8.20 (1.10) 8.33 (3.01)
Table 2: Total sleep time and sleep difficulty score by athletic team.
SLEEP PHASE affects daytime performance, alters mood,
The circadian system regulates the increases appetite and impairs post-exercise
feeling of sleepiness and wakefulness recovery23.
throughout the day, which directly affects From a clinical perspective, we want
athletic performance. After awakening in information on athletes’ sleep behaviours
the morning the average individual feels to solve existing problems and help
alert until about 2 pm, when the ‘afternoon them improve post-exercise recovery
siesta’ feeling kicks in. This tends to last for 30 and regeneration. However, it’s equally
to 60 minutes and then alertness rises again important to gather data from athletes at
with a peak in the evening around 6 to 8 pm. the aggregate level to start drawing some
After this point sleepiness increases, which inferences or 'best practices' that can apply
facilitates the onset of sleep at bedtime. Each to particular sports or athletes in general.
athlete has a preferred sleep schedule that The Athlete Sleep Screening Questionnaire©
suits his or her circadian phase; however, (ASSQ) has both strong clinical relevance,
training, school, exposure to technology and but also allows us to gather population-level
work commitments can have a substantial data, learn about trends in athlete sleep
impact on the athlete’s ability to match behaviour and start providing the athletes,
their circadian phase to the available time coaches and support staff with some
for sleep. If the circadian phase and sleep answers about how they should manage
schedule are not matched (out of phase), athletes’ sleep.
the amount of sleep that can be achieved,
as well as the quality of that sleep, will be THE ATHLETE SLEEP SCREENING
affected. For example, adolescents have a QUESTIONNAIRE
natural tendency to become night owls, The ASSQ© has been about 6 years
delaying bedtime. The delay in sleep onset in the making. Our goal was to create a
(12 am to 1 am) in combination with having questionnaire that gathered information
to get up for school (7 to 8 am) and the fact on athlete sleep behaviours to enable
that adolescents need 9 to 10 hours of sleep nationwide screening of a large population
per day results in a chronic sleep debt that of athletes, provide efficient data gathering
50
for research and validation and to
implement targeted clinical intervention.
The ASSQ© is derived from standard sleep
screening questionnaires and made up
of 23 items representing four domains
that capture the essence of the key sleep
parameters of interest. The sleep difficulty
score is used to categorise respondents
into four meaningful categories that are
associated with specific interventions:
1. No clinical problem = education.
2. Mild clinical problem = education and
monitoring.
3. Moderate clinical problem = see the
sport physician.
4. Severe clinical problem = sleep
physician.
We wanted the tool we created to provide
practical answers. We retain the theoretical
concepts of sleep length, sleep quality and
sleep phase; but translate results into simple
‘do this/don’t do that’ recommendations.
In a nutshell, we are illuminating sleep
problems, educating athletes that don’t
suffer, finding the athletes that do and
getting those athletes help.
The ASSQ© process is very
straightforward. A team physician typically
requests access to the questionnaire and is
emailed a link to the online site. The athlete
goes online and fills out the questionnaire,
we download the response, review the
results, and send a letter back to the doctor
giving them advice for their athlete. If an
athlete presents with a moderate or severe
clinical problem a Skype consultation is set
up with the principal investigator, and a
visit to a sleep doctor scheduled if necessary.
RESULTS FROM THE ASSQ©
Between its launch in 2011 and the end
of 2013, 307 elite athletes completed the
ASSQ©. Of these, 132 were male and 168
female. Athletes have participated from
BMX, curling, rugby, alpine skiing, biathlon,
bobsleigh, cycling, paralympic athletes,
skeleton, speed-skating, swimming,
volleyball, water-polo and wrestling.
Some athletes have also participated
anonymously, where sport is not reported.
Tables 1 and 2 show the number of
participating athletes where the team is
known (248/307), the average hours slept per
night and the average sleep difficulty score
for each team. Sleep difficulty scores greater
than 12 indicated clinically significant
sleep disturbance and required follow-up
consultation.
Within these teams, distinctive sleep
profiles have started to emerge. For example,
skeleton, swimming and rugby athletes
tend to sleep less and experience greater
sleep difficulty, whereas curling and cycling
athletes tend to sleep more and experience
less difficulty sleeping than other sports.
Approximately 13% of athletes screened
with the ASSQ to date have had sleep
difficulty scores requiring them to have
follow-up Skype consultations. Females
have tended to have slightly higher sleep
difficulty scores than males, although not
significantly so. Athletes’ increasing age and
reduced sleep were significantly associated
(P=0.01). Also, increasing age and increased
sleep difficulty were significantly associated
(P=0.03). Not surprisingly, a significant
relationship was found between total sleep
time and sleep difficulty score, with athletes
who sleep less tending to have higher sleep
difficulty scores (rho=-0.52).
Athletes who reported satisfaction with
their sleep tended to have total sleep times
averaging over 8 hours per night, whereas
athletes reporting dissatisfaction with
their sleep tended to have total sleep times
averaging less than 7 hours per night. This
finding is consistent with previous research
demonstrating that extended hours of sleep
are related to increased performance in
intercollegiate athletes27. As dissatisfaction
with sleep increased, so did average sleep
difficulty score, suggesting that athletes are
pretty good judges of their own sleep – if
they are dissatisfied, chances are they are
getting poor quality sleep.
Team case study:
The Canadian Women’s National
Curling Program was very invested in sleep
screening in preparation for the Olympic
Trials and the 2014 Sochi Olympic Games.
The national team coach initiated the
screening and 22 athletes were screened
from across the country. The data from the
athletes who were screened were analysed
at the team level to provide a sleep profile
for the team as a whole:
• The median hours slept a night was 8
hours (with a range of 5.30 hours to 9.15
hours).
• Comment: while the median was
reassuring the range revealed
that there was at least one athlete
(possibly more) who was/were
severely sleep deprived (<6 hours/
night).
• On average the athletes took 2 to 3 naps
per week (average nap length 31 to 60
minutes).
• Comment: it was encouraging that
athletes napped, however routine
napping for 20 to 30 minutes a day
was recommended for all athletes.
• On average it took the athletes 15
minutes or less to fall asleep.
• Comment: this was a normal sleep
onset latency.
• Very few of the athletes had trouble
staying asleep, or used medication to
help them fall or stay asleep.
• Comment: this was very
encouraging. Inappropriate use of
sedative medication is common
amongst athletes and should be
monitored and controlled.
• The average level of satisfaction with
sleep was 'somewhat satisfied' or
'neither satisfied nor dissatisfied'.
• Comment: this question is the
most predictive question for high
probability of a clinically significant
sleep disturbance.
• The majority of the athletes did not
snore or routinely gasp, cough or choke
in their sleep.
• Comment: while the likelihood
of sleep apnoea is low in this
population, the impact of the disease
is significant and if treated can have
Attending to the importance of sleep
will reduce the risk of overtraining/
under-recovery, enhance resistance
to illness and improve recovery from
injury.
substantial implications for the
athlete.
• The median sleep difficulty score for the
athletes was 10.
• Comment: the early validation data
suggests that a score greater than 12
indicates clinically significant sleep
disturbance and requires follow-up
consultation.
• 30% (n=7) of the athletes had a sleep
difficulty score greater than 12, and
required follow-up Skype consultation
• The majority of the athletes experienced
difficulty sleeping while travelling
for their sport, however, the majority
did not experience performance
disturbance while travelling.
• Comment: this indicated that there
was value in developing a jet lag and
travel fatigue programme to assist
athletes with this disturbance.
CONCLUSION
Sleep is the foundation of recovery and
critical to the management of athletic
training regimens. Sleep is often ignored
and compromised by athletes as a result of
their busy schedules, other demands such
as work and school and most importantly
by the intrusion of technology (cell phones,
computers and tablets) into their life.
This technology inhibits normal sleep
physiology and fosters a heightened state
of arousal, which acts as a barrier to the
onset and maintenance of the sleep state.
Understanding the actual sleep behaviours
of athletes, how sleep parameters affect
training and performance, and the impact
of specific interventions on sleep and
POST-EXERCISE RECOVERY TARGETED TOPIC 51
SLEEP AND RECOVERY
performance is important. This information
will provide athletes, coaches and support
staff with the tools necessary to manage
sleep and improve athletes’ tolerance of
strenuous training regimens. A better
understanding of sleep behaviour and
the effect of interventions will provide
important solutions for the management
of the negative impact of travel on athlete
health and performance. The ASSQ© and
global sleep screening of large populations
of elite athletes will provide the information
necessary to develop research methods,
design informative studies and provide
effective interventions. This article provides
insight into how this can be achieved along
with examples and early results of the work
accomplished by the Canadian Own the
Podium programme in preparation for the
Sochi Winter Olympics.
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Charles H. Samuels M.D., C.C.F.P., D.A.B.S.M.
Medical Director, Centre for Sleep and
Human Performance
Clinical Assistant Professor, Faculty of
Medicine, University of Calgary
Institute of Public Health
Lois James Ph.D.
Research Assistant Professor
Department of Criminal Justice and
Criminology
Sleep & Performance Research Center
Canada
Contact: lois_james@wsu.edu