Ramadan Observance Exacerbated the Negative Effects of COVID-19 Lockdown on Sleep and Training Behaviors: A International Survey on 1,681 Muslim Athletes

Objective

Disrupted sleep and training behaviors in athletes have been reported during the COVID-19 pandemic. We aimed at investigating the combined effects of Ramadan observance and COVID-19 related lockdown in Muslim athletes.

Methods

From an international sample of athletes (n = 3,911), 1,681 Muslim athletes (from 44 countries; 25.1 ± 8.7 years, 38% females, 41% elite, 51% team sport athletes) answered a retrospective, cross-sectional questionnaire relating to their behavioral habits pre- and during- COVID-19 lockdown, including: (i) Pittsburgh sleep quality index (PSQI); (ii) insomnia severity index (ISI); (iii) bespoke questions about training, napping, and eating behaviors, and (iv) questions related to training and sleep behaviors during-lockdown and Ramadan compared to lockdown outside of Ramadan. The survey was disseminated predominately through social media, opening 8 July and closing 30 September 2020.

Results

The lockdown reduced sleep quality and increased insomnia severity (both p < 0.001). Compared to non-Muslim (n = 2,230), Muslim athletes reported higher PSQI and ISI scores during-lockdown (both p < 0.001), but not pre-lockdown (p > 0.05). Muslim athletes reported longer (p < 0.001; d = 0.29) and later (p < 0.001; d = 0.14) daytime naps, and an increase in late-night meals (p < 0.001; d = 0.49) during- compared to pre-lockdown, associated with lower sleep quality (all p < 0.001). Both sleep quality (χ² = 222.6; p < 0.001) and training volume (χ² = 342.4; p < 0.001) were lower during-lockdown and Ramadan compared to lockdown outside of Ramadan in the Muslims athletes.

Conclusion

Muslim athletes reported lower sleep quality and higher insomnia severity during- compared to pre-lockdown, and this was exacerbated by Ramadan observance. Therefore, further attention to Muslim athletes is warranted when a circadian disrupter (e.g., lockdown) occurs during Ramadan.

Lockdown Duration and Training Intensity Affect Sleep Behavior in an International Sample of 1,454 Elite Athletes

Objective: To investigate the effect of 1) lockdown duration and 2) training intensity on sleep quality and insomnia symptoms in elite athletes.

Methods: 1,454 elite athletes (24.1 ± 6.7 years; 42% female; 41% individual sports) from 40 countries answered a retrospective, cross-sectional, web-based questionnaire relating to their behavioral habits pre- and during- COVID-19 lockdown, including: 1) Pittsburgh sleep quality index (PSQI); 2) Insomnia severity index (ISI); bespoke questions about 3) napping; and 4) training behaviors. The association between dependent (PSQI and ISI) and independent variables (sleep, napping and training behaviors) was determined with multiple regression and is reported as semi-partial correlation coefficient squared (in percentage).

Results: 15% of the sample spent < 1 month, 27% spent 1–2 months and 58% spent > 2 months in lockdown. 29% self-reported maintaining the same training intensity during-lockdown whilst 71% reduced training intensity. PSQI (4.1 ± 2.4 to 5.8 ± 3.1; mean difference (MD): 1.7; 95% confidence interval of the difference (95% CI): 1.6–1.9) and ISI (5.1 ± 4.7 to 7.7 ± 6.4; MD: 2.6; 95% CI: 2.3–2.9) scores were higher during-compared to pre-lockdown, associated (all p < 0.001) with longer sleep onset latency (PSQI: 28%; ISI: 23%), later bedtime (PSQI: 13%; ISI: 14%) and later preferred time of day to train (PSQI: 9%; ISI: 5%) during-lockdown. Those who reduced training intensity during-lockdown showed higher PSQI (p < 0.001; MD: 1.25; 95% CI: 0.87–1.63) and ISI (p < 0.001; MD: 2.5; 95% CI: 1.72–3.27) scores compared to those who maintained training intensity. Although PSQI score was not affected by the lockdown duration, ISI score was higher in athletes who spent > 2 months confined compared to those who spent < 1 month (p < 0.001; MD: 1.28; 95% CI: 0.26–2.3).

Conclusion: Reducing training intensity during the COVID-19-induced lockdown was associated with lower sleep quality and higher insomnia severity in elite athletes. Lockdown duration had further disrupting effects on elite athletes’ sleep behavior. These findings could be of relevance in future lockdown or lockdown-like situations (e.g., prolonged illness, injury, and quarantine after international travel).

On the Road to Camarón: The Sleep of an Ultra-Endurance Athlete Cycling 10,000 km in 24 Days

The impact of sleep on performance is fundamental for ultra-endurance athletes, but studies on this issue are rare. The current investigation examined the sleep and performance of a cyclist engaged in a simulated 10,000 km tour. The sleep behavior of the athlete (age, 57; height, 1.85 m; mass, 81 kg) before, during (i.e., 23 nights), and after the tour was monitored using a reduced-montage dry-electroencephalographic (EEG) device. The daily performance (i.e., number of kms) was recorded throughout the race. The cyclist set a new world record, completing 10,358 km in 24 days with a mean daily distance of ≈432 km in approximately 16 h, i.e., an average speed of ≈27 km/h. Sleep duration throughout the tour (5:13 ± 0:30) was reduced compared to the baseline sleep duration (7:00 ± 1:00), with a very large difference (ES = 2.3). The proportion of N3 during the tour (46 ± 7%) was compared to the measured N3 proportion during the baseline (27 ± 5%) and was found to be systematically outside the intra-individual variability (mean ± 1 SD), with a very large difference (ES = 3.1). This ultra-endurance event had a major influence on sleep-duration reduction and a notable modification in sleep architecture. The increase in slow-wave sleep during the race may be linked to the role of slow-wave sleep in physiological recovery.

COVID-19 Lockdowns: A Worldwide Survey of Circadian Rhythms and Sleep Quality in 3911 Athletes from 49 Countries, with Data-Driven Recommendations

Objective

In a convenience sample of athletes, we conducted a survey of COVID-19-mediated lockdown (termed ‘lockdown’ from this point forward) effects on: (i) circadian rhythms; (ii) sleep; (iii) eating; and (iv) training behaviors.

Methods

In total, 3911 athletes [mean age: 25.1 (range 18–61) years, 1764 female (45%), 2427 team-sport (63%) and 1442 elite (37%) athletes] from 49 countries completed a multilingual cross-sectional survey including the Pittsburgh Sleep Quality Index and Insomnia Severity Index questionnaires, alongside bespoke questions about napping, training, and nutrition behaviors.

Results

Pittsburgh Sleep Quality Index (4.3 ± 2.4 to 5.8 ± 3.1) and Insomnia Severity Index (4.8 ± 4.7 to 7.2 ± 6.4) scores increased from pre- to during lockdown (p < 0.001). Pittsburgh Sleep Quality Index was predominantly influenced by sleep-onset latency (p < 0.001; + 29.8%), sleep efficiency (p < 0.001; − 21.1%), and total sleep time (p < 0.001; − 20.1%), whilst Insomnia Severity Index was affected by sleep-onset latency (p < 0.001; + 21.4%), bedtime (p < 0.001; + 9.4%), and eating after midnight (p < 0.001; + 9.1%). During lockdown, athletes reported fewer training sessions per week (− 29.1%; d = 0.99). Athletes went to bed (+ 75 min; 5.4%; d = 1.14) and woke up (+ 150 min; 34.5%; d = 1.71) later during lockdown with an increased total sleep time (+ 48 min; 10.6%; d = 0.83). Lockdown-mediated circadian disruption had more deleterious effects on the sleep quality of individual-sport athletes compared with team-sport athletes (p < 0.001; d = 0.41), elite compared with non-elite athletes (p = 0.028; d = 0.44) and older compared with younger (p = 0.008; d = 0.46) athletes.

Conclusions

These lockdown-induced behavioral changes reduced sleep quality and increased insomnia in athletes. Data-driven and evidence-based recommendations to counter these include, but are not limited to: (i) early outdoor training; (ii) regular meal scheduling (whilst avoiding meals prior to bedtime and caffeine in the evening) with appropriate composition; (iii) regular bedtimes and wake-up times; and (iv) avoidance of long and/or late naps.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40279-021-01601-y.

Sleep and the athlete: narrative review and 2021 expert consensus recommendations

Elite athletes are particularly susceptible to sleep inadequacies, characterised by habitual short sleep (<7 hours/night) and poor sleep quality (eg, sleep fragmentation). Athletic performance is reduced by a night or more without sleep, but the influence on performance of partial sleep restriction over 1-3 nights, a more real-world scenario, remains unclear. Studies investigating sleep in athletes often suffer from inadequate experimental control, a lack of females and questions concerning the validity of the chosen sleep assessment tools. Research only scratches the surface on how sleep influences athlete health. Studies in the wider population show that habitually sleeping <7 hours/night increases susceptibility to respiratory infection. Fortunately, much is known about the salient risk factors for sleep inadequacy in athletes, enabling targeted interventions. For example, athlete sleep is influenced by sport-specific factors (relating to training, travel and competition) and non-sport factors (eg, female gender, stress and anxiety). This expert consensus culminates with a sleep toolbox for practitioners (eg, covering sleep education and screening) to mitigate these risk factors and optimise athlete sleep. A one-size-fits-all approach to athlete sleep recommendations (eg, 7-9 hours/night) is unlikely ideal for health and performance. We recommend an individualised approach that should consider the athlete's perceived sleep needs. Research is needed into the benefits of napping and sleep extension (eg, banking sleep).

Personality traits, stress appraisals and sleep in young elite athletes: A profile approach

The aim of this study was to identify young elite athletes' personality profiles using a person-centred approach and to investigate whether the profiles significantly differ in stress and sleep. 260 athletes from a variety of sports completed a questionnaire package to assess neuroticism and conscientiousness traits, stress appraisals (i.e. intensity and directional interpretation of stress, challenge and threat appraisals), and various indicators of sleep (i.e. sleep quality, social jet lag, Ford insomnia response to stress test (FIRST)). A latent profile analysis (LPA) approach was used to identify personality profiles based on the scores of neuroticism and conscientiousness. A multivariate analysis of variance was performed to examine if the athletes belonging to different personality profiles differ on stress appraisals and indicators of sleep. Three profiles emerged: Maladaptive profile (high levels of conscientiousness and neuroticism); Highly adaptive profile (moderate level of conscientiousness and low level of neuroticism); Adaptive profile (high level of conscientiousness and moderate level of neuroticism). Results showed that athletes from the adaptive profile reported significantly lower scores of stress intensity and threat appraisal than those from other profiles. Athletes from the maladaptive profile reported significantly higher levels of FIRST than those from other profiles as well as worse sleep quality and lower levels of challenge appraisal than the athletes from the highly adaptive profile. These results suggest that investigating personality profile may be useful in identifying athletes at higher risk of stress sensitivity and worsening sleep that are likely to benefit from preventive actions (e.g. cognitive behavioural therapy interventions).

[Recovery strategies in elite sport : focus on both quantity and quality of sleep]

Elite athletes participate in multiple competitions and are exposed to important training load. There is a need to match the recovery process against such a number of competitions and important training load, with the aim of preventing overtraining and injury. Several recovery strategies exist. Some strategies such as hydration, diet, cold water immersion and sleep are effective in their ability to counteract the fatigue mechanisms. Elite athletes regularly display compromised sleep quantity and quality with sleep quality being most vulnerable prior to major competitive events, during periods of high-intensity training and following long-haul travel to competitions. Compromised sleep quantity and/or quality may be detrimental to the outcome of the recovery process after training and competition. Future studies should focus on the interest of sleep hygiene strategies to optimise recovery, performance and preventing injury.

[Renal transplantation on vascular prosthesis]

INTRODUCTION

In front of a very calcified aortoiliac axis, renal transplantation with implantation of the artery on vascular prosthesis can be proposed. This rare intervention is considered difficult and morbid. The main objective of this work was to evaluate the overall and specific survival of the transplant in this situation. The secondary objective was the study of the complications and the evolution of the transplant's renal function.

MATERIAL AND METHODS

From a multicenter retrospective data collection of the DIVAT cohort (6 centers) added with data from 4 other transplant centers, we studied transplants with prosthetic arterial anastomosis.

RESULTS

Thirty four patients was included. The median duration of follow-up was 2.5 years. 4 patients died in the month following transplantation, 16 were hemodialysis and 9 were transfused. The median survival of the transplant was 212 days. Functional arrests of the transplant were mostly associated with nephrological degradation and return to dialysis (about 80%) while 10% were related to a death of the recipient directly attributable to renal transplantation. The surgical complications of the transplantation were marked by one arterial stenosis, one fistula and 4 urinary stenoses.

CONCLUSION

Thus, renal transplantation with arterial anastomosis on vascular prosthesis, on selected patients, offers an alternative to dialysis. A national compendium of transplanted patients on vascular prosthesis would allow a long-term follow-up of transplant's survival and define selection criteria prior to this kind of surgery.

LEVEL OF EVIDENCE

3.

Squad management, injury and match performance in a professional soccer team over a championship-winning season

Squad management, injury and physical, tactical and technical match performance were investigated in a professional soccer team across five consecutive league seasons (2008-2013, 190 league games) with specific focus on a championship-winning season (2010/11). For each player, match participation and time-loss injuries were recorded, the latter prospectively diagnosed by the team's physician. Defending and attacking tactical and technical performance indicators investigated included ball possession and possession in opponents' half, passes, forward passes, completed passes and forward passes, crosses and completed crosses, goal attempts and goal attempts on target, successful final third entries, free-kicks and 50/50 duels won/lost. Physical performance measures included total distance and distance covered at high-speeds (≥19.1 km/h). Results showed that during the 2010/11 season, squad utilisation was lowest potentially owing to the observed lower match injury occurrence and working days lost to injury thereby increasing player availability. In 2010/11, the team won both its highest number of points and conceded its lowest number of goals especially over the second half of this season. The team also won its highest number of games directly via a goal from a substitute and scored and conceded a goal first on the highest and lowest number of occasions, respectively. While multivariate analysis of variance (MANOVA) detected a significant difference in some attacking and defensive performance indicators across the five seasons, these were generally not distinguishing factors in 2010/11. Similarly, univariate ANOVAs showed a significant difference in running distances covered across seasons, but the trend was for less activity in 2010/11.

Recovery in soccer : part ii-recovery strategies

In the formerly published part I of this two-part review, we examined fatigue after soccer matchplay and recovery kinetics of physical performance, and cognitive, subjective and biological markers. To reduce the magnitude of fatigue and to accelerate the time to fully recover after completion, several recovery strategies are now used in professional soccer teams. During congested fixture schedules, recovery strategies are highly required to alleviate post-match fatigue, and then to regain performance faster and reduce the risk of injury. Fatigue following competition is multifactorial and mainly related to dehydration, glycogen depletion, muscle damage and mental fatigue. Recovery strategies should consequently be targeted against the major causes of fatigue. Strategies reviewed in part II of this article were nutritional intake, cold water immersion, sleeping, active recovery, stretching, compression garments, massage and electrical stimulation. Some strategies such as hydration, diet and sleep are effective in their ability to counteract the fatigue mechanisms. Providing milk drinks to players at the end of competition and a meal containing high-glycaemic index carbohydrate and protein within the hour following the match are effective in replenishing substrate stores and optimizing muscle-damage repair. Sleep is an essential part of recovery management. Sleep disturbance after a match is common and can negatively impact on the recovery process. Cold water immersion is effective during acute periods of match congestion in order to regain performance levels faster and repress the acute inflammatory process. Scientific evidence for other strategies reviewed in their ability to accelerate the return to the initial level of performance is still lacking. These include active recovery, stretching, compression garments, massage and electrical stimulation. While this does not mean that these strategies do not aid the recovery process, the protocols implemented up until now do not significantly accelerate the return to initial levels of performance in comparison with a control condition. In conclusion, scientific evidence to support the use of strategies commonly used during recovery is lacking. Additional research is required in this area in order to help practitioners establish an efficient recovery protocol immediately after matchplay, but also for the following days. Future studies could focus on the chronic effects of recovery strategies, on combinations of recovery protocols and on the effects of recovery strategies inducing an anti-inflammatory or a pro-inflammatory response.

Recovery in soccer: part I - post-match fatigue and time course of recovery

In elite soccer, players are frequently required to play consecutive matches interspersed by 3 days and complete physical performance recovery may not be achieved. Incomplete recovery might result in underperformance and injury. During congested schedules, recovery strategies are therefore required to alleviate post-match fatigue, regain performance faster and reduce the risk of injury. This article is Part I of a subsequent companion review and deals with post-match fatigue mechanisms and recovery kinetics of physical performance (sprints, jumps, maximal strength and technical skills), cognitive, subjective and biochemical markers. The companion review will analyse recovery strategies used in contemporary professional soccer. Soccer involves many physically demanding activities including sprinting, changes in running speed, changes of direction, jumps and tackles, as well as technical actions such as dribbling, shooting and passing. These activities lead to a post-match fatigue that is linked to a combination of dehydration, glycogen depletion, muscle damage and mental fatigue. The magnitude of soccer match-induced fatigue, extrinsic factors (i.e. match result, quality of the opponent, match location, playing surface) and/or intrinsic factors (i.e. training status, age, gender, muscle fibre typology), potentially influence the time course of recovery. Recovery in soccer is a complex issue, reinforcing the need for future research to estimate the quantitative importance of fatigue mechanisms and identify influencing factors. Efficient and individualized recovery strategies may consequently be proposed.