Written by: Kurt Ela, PsyD and Liz Delasobera, MD

Sleep is one of the most vital functions for cognitive, emotional, and physical well-being. Yet, the Centers for Disease Control and Prevention (CDC) estimates that about a third of U.S. adults do not get enough of it. There are many psychological and physical reasons as to why we are not sleeping the recommended minimum of seven hours per night. Stress, sleep disorders, and chronic pain are a few often cited reasons for this, although there are many other factors. For NHL players, add in multiple time zone changes in each month; sleeping in different hotel rooms; and being away from their home environment.

The impact of poor sleep can be enormous, both on well-being and performance, especially for athletes. Specifically, elite athletes tend to sleep less on average than non-athletes. There is also evidence that poor sleep puts the athlete at higher risk for injury, including concussion. Regarding performance, a number of studies highlight the adverse impact of poor sleep on athletic performance. Thus, addressing sleep disturbance early and successfully is good for the athlete as well as the organization as a whole by helping to keep our players safe, healthy, and at their best.

In the not so recent past, a primary course of treatment was the use of prescription medication such as zolpidem (Ambien), eszopiclone (Lunesta), or zaleplon (Sonata). These drugs can be effective in the short term, but also run the risk of dependence and sometimes have serious side effects, including muscle weakness, difficulty concentrating, and balance problems. There are also potential longer term health implications, such as worsening insomnia when discontinued and even evidence of higher incidents of dementia.

Fortunately, there are alternate interventions, including lifestyle changes, sleep “hygiene,” and cognitive behavioral therapy techniques that have been empirically validated to be helpful for sleep disturbance. Many professional sports teams are utilizing these strategies for sleep disturbance, with positive outcome.

The first line of treatment is looking at lifestyle changes and sleep hygiene. The training and medical team can ask players several questions to identify any potential sleep disturbance, which can spark a broader conversation:

• How did you sleep last night?
• Generally, do you have difficulty falling asleep, staying asleep, or waking earlier than desired?

The staff can also look for any change in a player’s demeanor or performance as a sign that they might need additional sleep support. If a player is dealing with pain or discomfort, it is especially important to be attuned to this, as it can impact sleep. The same is true of lifestyle changes such as a new baby, family stressors, or any other important life transition.

The following sleep hygiene and lifestyle strategies should always be reinforced as a first line of treatment:

• Establish a routine in order to set the circadian rhythm (sleep-wake cycle). This is notoriously difficult to achieve during the season, especially when on the road, but can be done if structure is put into place on the road and at home.
• Limit screen time 30 minutes before bedtime since the blue light can disrupt natural melatonin production.
• Avoid eating too late in the evening and discontinuing caffeine outside of the morning hours.
• Sleep in a dark room cool room (ideal temperature 65-68 degrees F). Use a sleep mask if needed to block out all light.
• Use ear plugs or white noise as needed to drown out sound (especially in busy hotels or when there are small children at home)

These basic steps often help to establish a better relationship with sleep. In some cases, however, the challenges may run deeper. In these instances, there are mental health strategies that can be used to improve sleep quality and duration. The next step is often stress or pain management, as these can be a primary cause of sleep disturbance.

Having a team psychologist can be helpful, especially for the more complicated cases, as the psychologist can confidentially address any increase in stress level due to these family concerns, performance issues, or life in general. If these exist, some techniques that can be helpful as next steps include:

• Relaxation strategies can help reduce stress hormones such as adrenaline and cortisol. Physiologically speaking, one cannot be stressed and relaxed at the same time. Thus, it is important to utilize all available strategies to promote the latter, especially around bedtime. One technique, progressive muscle relaxation, consists of tensing a part of the body for approximately 5 seconds and then relaxing it for 15 seconds. One generally starts with the feet and works upward to the head and face, finishing with tensing the entire body before relaxing.
• Journaling has the benefit of clearing the mind of anything the player might be worrying about or reliving in his mind, which can interfere with the sleep process. It can also be useful to establish a sort of “worry time” of approximately 5-10 minutes earlier in the day. This allows ample time to respect real concerns a player may have while limiting it to a discrete window outside of bedtime when these worries tend to resurface.
• Cognitive Behavioral Therapy for Insomnia (CBT-I) is a structured, multi-session protocol that includes stimulus control, cognitive restructuring, and relaxation strategies. It includes pairing one’s bed only with positive associations related to successful and restorative sleep (versus wakefulness or frustration). It also includes challenging any automatic negative thoughts related to past sleep difficulties and breaking any negative sleep cycles. The full protocol can also include sleep restriction and compression, although this is not a realistic intervention during the season.
• Mindfulness strategies allow players to practice aspects of the human experience that are conducive to both stress reduction and sleep improvement: staying in the present and accepting reality as it exists without judgment.
• Acceptance and Commitment Therapy is a useful addition to any of the above strategies. A psychologist can help players to align their behavior with their values; develop personalized coping strategies; and focus on a healing versus negative outlook. This is useful when a player inevitably sleeps poorly despite the best of intentions. Instead of panicking or predicting that he will not perform well, the player learns to accept the situation as it is, stay grounded, and rely on the talent and effort that has allowed him to reach the highest level of professional hockey.

In closing, sleep disturbance remains a primary concern in the general population, but even more so among elite athletes, including many of our players. Poor sleep puts them at risk for injury, emotional and physical health concerns, and diminished performance. Identifying the concern and working with the athlete to help address the disturbance quickly and successfully allows them to maintain an optimal level of well-being and performance.

Dr. Kurt Ela, PsyD is a licensed clinical psychologist and associate professor at Georgetown University Medical Center. He treats a range of psychological concerns, with a current emphasis on wellness and performance. Kurt currently spends part of his time working with the Washington Capitals players, families, and staff.

Dr Bronson (Liz) Delasobera is a primary care sports medicine and emergency medicine physician for MedStar Health, and an Associate Professor of Emergency Medicine at Georgetown School of Medicine. She is in her 10th year working for the Washington Capitals and currently is their lead primary care sports medicine physician.