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Development of the athlete sleep behavior questionnaire: A tool for identifying maladaptive sleep practices in elite athletes

Development of the athlete sleep behavior questionnaire: A tool for identifying maladaptive sleep... Athlete sleep behavior questionnaire ORIGINAL ARTICLE Development of the athlete sleep behavior questionnaire: A tool for identifying maladaptive sleep practices in elite athletes 1-4 Matthew W Driller ABSTRACT Cheri D Mah Introduction: Existing sleep questionnaires to assess sleep behaviors may not be sensitive in Shona L Halson determining the unique sleep challenges faced by elite athletes. The purpose of the current study was to develop and validate the Athlete Sleep Behavior Questionnaire (ASBQ) to be used as a University of Waikato, Health, Sport practical tool for support staff working with elite athletes. Methods: 564 participants (242 athletes, and Human Performance - Hamilton - 322 non-athletes) completed the 18-item ASBQ and three previously validated questionnaires; the Waikato - New Zealand. Sleep Hygiene Index (SHI), the Epworth Sleepiness Scale (ESS) and the Pittsburgh Sleep Quality University of California, Human Index (PSQI). A cohort of the studied population performed the ASBQ twice in one week to Performance Center - San Francisco - assess test-retest reliability, and also performed sleep monitoring via wrist-actigraphy. Results: California - USA. Comparison of the ASBQ with existing sleep questionnaires resulted in moderate to large correlations Australian Institute of Sport, (r=0.32 - 0.69). There was a significant difference between athletes and non-athletes for the ASBQ Physiology - Canberra - ACT - global score (44±6 vs. 41±6, respectively, p<0.01) and for the PSQI, but not for the SHI or the ESS. Australian. The reliability of the ASBQ was acceptable (ICC=0.87) when re-tested within 7 days. There was High Performance Sport New Zealand, a moderate relationship between ASBQ and total sleep time (r=-0.42). Conclusion: The ASBQ is a Performance Physiology - Auckland - valid and reliable tool that can differentiate the sleep practices between athletes and non-athletes, Auckland - New Zealand. and offers a practical instrument for practitioners and/or researchers wanting to evaluate the sleep behaviors of elite athletes. The ASBQ may provide information on areas where improvements to individual athletes’ sleep habits could be made. Keywords: Surveys and Questionnaires; Actigraphy; Polysomnography; Sleep Hygiene; Athletes. Corresponding author: Matthew W Driller. E-mail: [email protected] E-mail: [email protected] Received: November 1, 2017; Accepted: January 30, 2018. DOI: 10.5935/1984-0063.20180009 Sleep Sci. 2018;11(1):37-44 38 Driller, et al. INTRODUCTION can be achieved in elite athletes, through simple sleep-behavior education and subsequent changes in maladaptive habits . There is increasing recognition that sleep plays a Therefore, the purpose of the current study was to significant role in aiding the recovery process in highly-trained 1-3 4 5 develop an athlete-specific sleep questionnaire and validate athletes . According to Halson and Leeder et al. , sleep is it against both objective (wrist-actigraphy) and subjective reported to be the single best psycho-physiological recovery (validated questionnaires) sleep measures in both athletes and strategy available to elite athletes. Therefore, the quantification non-athletes. A further aim of the study was to determine the and measurement of sleep amongst athletic populations has test-retest reliability of the questionnaire. become commonplace in the sport setting . Objective methods of measuring sleep such as polysomnography and actigraphy METHODS require a somewhat intrusive and expensive assessment of Participants sleep, coupled with the need for specialized expertise, making The survey was completed by a convenience sample of them difficult to administer across large numbers of athletes. 564 participants (282 male/282 female, mean±SD, age; 25±7 y) Different questionnaires and scales used for surveying sleep across 9 countries (Australia, Canada, England, India, Malaysia, have been validated in the literature, with little focus on athlete- New Zealand, Portugal, Sweden, USA). The study population specific measures. Indeed, research has shown that athletes may was divided into athletes (n=242) and non-athletes (n=322) for display different sleeping patterns and habits compared to the 5,7-9 analysis (Table 1). All participants for both groups were aged non-athlete population , likely due to the unique physiological between 18-45 y at the time of taking part in the study. New and psychological demands of being an elite athlete. parents (children <2 y) and individuals with diagnosed sleep It has been reported that sleep may be compromised in disorders were excluded from taking part in the study. elite athletes due to a number of factors, including the increase in core temperature following exercise , increases in muscle 11,12 Table 1. Participant demographics. tension, fatigue and pain following training and competition , Athletes (n=242) Non-athletes (n=322) frequent international travel , disruption from light and noise 14 7 Age (y) 22±5 25±6 and increases in psychological stress . Juliff et al. reported from 283 elite athletes, that 64% of athletes reported sleep Male (n=) 87 195 disturbances due to nervousness or over-thinking before Female (n=) 155 127 competition and more than half of the sample suffered sleep Team sport (n=) 128 N/A disturbances following a late training session or competition. Individual sport (n=) 114 Other sleep disturbances that seem to be magnified in elite athletes include the use of long naps in the afternoon interrupting The criteria for the ‘athlete’ population used in the current night-time sleep, the use of stimulants (e.g. caffeine), frequent study was: representation of their country at either national or travel, sleeping in different environments (e.g. hotels), and either international-level (semi-professional or professional) for their 14-16 over-hydration or dehydration prior to bed . Existing surveys, chosen sport. Athletes were surveyed across 18 different sports scales and questionnaires that evaluate sleep behavior in the (team sport athletes = 128 and individual sport athletes = 114) general population may not be specific enough to detect these and completed the survey during the in-season phase of their unique differences in an athlete’s sleeping patterns and habits. training (minimum of 4-weeks into their competition season). A plethora of sleep questionnaires have been evaluated Athletes from the following sports were surveyed: badminton in the research literature. Some of these include the Pittsburgh (n=8), baseball (n=9), basketball (n=15), boxing (n=5), cricket 17 18 Sleep Quality Index , the Sleep Hygiene Index , and the (n=10), cycling (n=15), football/soccer (n=12), golf (n=10), Epworth Sleepiness Scale . While these questionnaires and hockey (n=18), netball (n=19), rowing (n=17), rugby league scales may be appropriate for general or clinical populations, (n=14), rugby union (n=24), swimming (n=14), track and field they lack specific questions that are tailored towards the sleep (n=26), tennis (n=6), triathlon (n=13) and water-polo (n=7). challenges faced by elite athletes. The criteria for the ‘non-athlete’ population included To our knowledge, the only athlete-specific sleep participants that; a) were not members of any regional or questionnaire in the literature is the Athlete Sleep Screening national-level sporting team, and b) were performing ≤3 planned Questionnaire (ASSQ) . The ASSQ was designed to provide exercise training sessions per week. The ‘non-athlete’ population clinical screening with cut-off scores associated with the was a random selection of participants also surveyed from the specific clinical interventions to manage sleep disorders. While 9 aforementioned countries. All participants were recruited via initial reports of the ASSQ have shown that it is a valid tool in National Sporting Organisations, various social media channels screening athletes for sleep disturbances, there remains a need for and word-of-mouth advertising. The questionnaire was not an instrument that can provide useful information on the sleep translated into any other languages, and therefore it was a behavior practices of elite athletes, allowing for individualized requirement that all participants were fluent English speakers. feedback and behavioral modifications based on their responses. The study was approved by the Institutions Human Research Indeed, recent research has shown that improvements in sleep Ethics Committee (Ethics number: FEDU066/16) and as Sleep Sci. 2018;11(1):37-44 39 Athlete sleep behavior questionnaire outlined to participants, by completing the survey, informed sleep quality. The PSQI has been demonstrated to have good consent to take part in the study was given. internal reliability, validity and is perhaps the most commonly- used subjective sleep measure not only in the research literature, Instruments but also in the sleep community . The following four sleep questionnaires were administered to all participants via an electronic online Reliability survey (Survey Monkey, Palo Alto Inc. CA, USA). All four The test-retest reliability and sleep-monitoring questionnaires were filled out in a single sitting and average time component of the study was completed by 50 participants (27 to complete the questionnaires was 8.5 minutes. On average, the male/23 female, 19 team sport athletes/31 individual athletes, ASBQ took 1.5 minutes to complete. All questionnaires asked mean ± SD; age: 23±5 y) from the athlete cohort. Athletes were participants to answer the questions relating to their normal randomly selected and the following sports were included in the sleeping patterns over the previous month. reliability (and actigraphy) analysis: cycling (n=7), football (n=3), netball (n=9), rugby league (n=7), rowing (n=10), swimming The Athlete Sleep Behavior Questionnaire (ASBQ) (n=4), track and field (n=10). All participants completed the The ASBQ is the survey that has been specifically ASBQ two times separated by exactly 7 days. The test was designed for evaluation in the current study. A combination of performed at the same time of day on both occasions and the Sleep Hygiene Index , the International Classification of took place during an in-season, non-competitive week. The day Sleep Disorders , and previous research describing the most that the ASBQ was filled out on both occasions was preceded 7,23 common sleep issues in elite athletes and recommended tips by a rest day, where no athletic training or competition was 10,15,21 and strategies to address these issues was used to develop performed. The reliability component of the current study was the ASBQ. The ASBQ is an 18-item survey that includes assessed concurrently with the measurement of sleep through questions on sleeping behavior and habits thought to be wrist-actigraphy. common areas of concern for elite athletes (Table 2) and was designed as a practical tool to identify areas where improvements Actigraphy in sleep behavior could be made, rather than a clinical screening A total of 50 athletes from the current study (same tool. The survey asks participants how frequently they engage cohort as described in the reliability component above) wore in specific behaviors (never, rarely, sometimes, frequently, a wrist activity monitor to evaluate their sleeping patterns. always). Weightings for each response (1 = never, 2 = rarely, 3 = Participants were required to wear the activity monitor (SBV2 sometimes, 4 = frequently, 5 = always) were summed to provide Readiband™, Fatigue Science, Honolulu, USA), continuously an ASBQ global score. A higher global score is indicative of over a 7-day period with the exception of time spent in water, poor sleep behaviors. bathing or showering. Participants were instructed to maintain their usual sleep habits and general daily activity patterns during The Sleep Hygiene Index (SHI) the monitoring period. The SHI is a 13-item self-administered index intended Sleep indices used for comparison to the ASBQ global to assess the presence of behaviors thought to comprise sleep score were: total time in bed, total sleep time, sleep efficiency hygiene. Participants are asked to indicate how frequently they and sleep latency. Each morning during the monitoring period, engage in specific behaviors (always, frequently, sometimes, athletes were also asked to rate their perceived sleep quality on a rarely, never). Item scores were then summed providing a global scale from 1-5 (1 = very poor, 5 = excellent). Participants were score for sleep hygiene. Higher scores are indicative of more also asked to record their sleep and wake times in a diary, to maladaptive sleep hygiene status. The SHI has been shown to be allow for cross-checking and corrections with the actigraphy both valid and reliable in a healthy population . data. The accuracy and inter-device reliability of the Readiband 26,27 device has been deemed acceptable, as described elsewhere . Epworth Sleepiness Scale (ESS) The Epworth Sleepiness Scale (ESS) is a self-reported Statistical Analysis 8-item questionnaire that produces a global score from 0-24. Descriptive statistics are shown as means ± SD unless Scores greater than 10 suggest significant daytime sleepiness . stated otherwise. Statistical analysis was performed using SPSS The ESS is commonly used to differentiate between individuals V22.2 (IBM Corporation; Chicago, IL, USA). Comparison of with and without sleep disorders and has also shown to correlate athletes to non-athletes were performed for each questionnaire with objective measures of sleepiness . and each item of the ASBQ using independent samples t-tests, with statistical significance set at p<0.05. There were no outliers The Pittsburgh Sleep Quality Index (PSQI) in the data, as assessed by inspection of a boxplot. Global scores The PSQI is a self-rated 19-item instrument intended for each questionnaire and each item of the ASBQ were normally to assess sleep quality and sleep disturbance over a 1-month distributed, as assessed by Shapiro-Wilk’s test (p>0.05), and there period in clinical and nonclinical populations . Global scores was homogeneity of variances between groups, as assessed by range from 0 to 21 with higher scores indicating poorer overall Levene’s test for equality of variances (p>0.05). Cohen’s effect Sleep Sci. 2018;11(1):37-44 40 Driller, et al. Table 2. The Athlete Sleep Behavior Questionnaire (ASBQ). No. In recent times (over the last month)… Never Rarely Sometimes Frequently Always 1 I take afternoon naps lasting two or more hours 2 I use stimulants when I train/compete (e.g caffeine) 3 I exercise (train or compete) late at night (after 7pm) 4 I consume alcohol within 4 hours of going to bed I go to bed at different times each night (more than ±1 hour variation) 6 I go to bed feeling thirsty 7 I go to bed with sore muscles I use light-emitting technology in the hour leading up to bedtime (e.g laptop, phone, television, video games) I think, plan and worry about my sporting performance when I am in bed I think, plan and worry about issues not related to my sport when I am in bed 11 I use sleeping pills/tablets to help me sleep 12 I wake to go to the bathroom more than once per night 13 I wake myself and/or my bed partner with my snoring I wake myself and/or my bed partner with my muscle twitching I get up at different times each morning (more than ±1 hour variation) At home, I sleep in a less than ideal environment (e.g too light, too noisy, uncomfortable bed/pillow, too hot/cold) 17 I sleep in foreign environments (e.g hotel rooms) Travel gets in the way of building a consistent sleep-wake routine Scoring: Never = 1, Rarely = 2, Sometimes = 3, Frequently = 4, Always = 5 Total Global Score: _________ sizes (d) were calculated between athletes and non-athletes for extract three underlying dimensions of the questionnaire. PCA each questionnaire and interpreted using thresholds of 0.2, 0.5, revealed that the three factors that had eigenvalues greater than 0.8 for small, moderate and large, respectively . Comparison of the one and visual inspection of the scree plot confirmed that three previously validated sleep questionnaire global scores and the components should be retained . Interpretation of these three ASBQ global score was achieved with Pearson product-moment components was consistent with themes of routine/environ- correlation analysis for the entire sample (n=564). mental related factors for factor 1, behavioral factors for factor Correlation between the ASBQ and measured sleep 2 and sport-related factors for factor 3 (Table 6). variables were also assessed in a cohort of the study population RESULTS (n=50). The magnitude of correlation between the ASBQ and the other questionnaires/sleep measures was assessed using the There were no significant differences between male and following thresholds: <0.1, trivial; 0.1-0.3, small; 0.3-0.5, moderate; female participants for the ASBQ global score within either 0.5-0.7, large; 0.7-0.9, very large; and 0.9-1.0, almost perfect. Test- athlete (p=0.20) or non-athlete groups (p=0.21), nor were there retest reliability of the ASBQ were analyzed using an Excel differences for team vs. individual sport athletes (p=0.69), spreadsheet for reliability with data shown as intra-class therefore, both the athlete group and non-athlete groups were correlation coefficients (ICC), Pearson correlations ( r), typical pooled for comparison with each other. error of measurement (TEM) and coefficient of variation There was a significant difference between athlete and percentage (CV%). non-athlete groups for the ASBQ global score (43.5 and 40.6, Internal reliability/consistency of the ASBQ was de- respectively, p<0.01, d=0.47, Table 3), which included a significant termined using Cronbach’s α. A principal component analysis difference between groups in 10 of the 18 items in the questionnaire (PCA) was run on the 18-item questionnaire and the suitability (Figure 1). There were no significant differences between groups for of the PCA was assessed prior to analysis via the Kaiser-Meyer- the SHI or the ESS and both associated with trivial effect sizes (Table Olkin measure and the Bartlett’s test of sphericity . Explorato- 3). The PSQI global score was significantly higher in the non-athlete ry factor analysis using PCA with a varimax rotation was used to group (p<0.01, d=0.36, Table 3). Sleep Sci. 2018;11(1):37-44 41 Athlete sleep behavior questionnaire Table 3. Global scores for the four sleep questionnaires between athletes and non-athletes including p-values and effect-size comparisons between groups. Data shown as means ± SD. Athletes Non-Athletes Raw Difference Effect-Size p-value (mean ± SD) (mean ± SD) (Non-Athlete - Athlete) d ASBQ 0.47 43.5±5.8 40.6±6.1 -2.9 <0.01 Small SHI 0.02 32.3±6.1 32.4±6.4 0.1 0.81 Trivial ESS 0.18 5.7±3.4 5.2±3.3 -0.6 0.06 Trivial PSQI 0.36 5.1±2.5 6.1±2.9 1.0 <0.01 Small ASBQ = Athlete Sleep Behavior Questionnaire; SHI = Sleep Hygiene Index; ESS = Epworth Sleepiness Scale; PSQI = Pittsburgh Sleep Quality Index. Figure 1. Legenda: Mean scores (out of 5) for Non-athletes (n=322, black bar) and Athletes (n=242, white bar) for each item of the 18-question Athlete Sleep Behavior Questionnaire (ASBQ). * Indicates significant difference between groups (p<0.05). The ASBQ was shown to have moderate to large of the variance. The factor matrix showed that every item-factor correlations with the existing validated sleep questionnaires loading was above the criterion of 0.45. Item loadings ranged (r=0.38 – 0.69, Table 4). The correlation between the ASBQ and from 0.45 to 0.61 (Table 6). objective sleep indices resulted in a small relationship for total The sleep monitoring period in a cohort of the athlete time in bed and sleep efficiency (r=-0.18, -0.16, respectively), a population (n=50) used for correlation to the ASBQ resulted moderate relationship for total sleep time and sleep quality (r=- in the following mean ± SD values: total time in bed = 552±61 0.42, -0.39, respectively) and a trivial correlation for sleep latency mins, total sleep time = 441±38 mins, sleep efficiency = (r=0.07, Table 4). 85±8%, sleep latency = 38±20 mins and subjective sleep quality The ASBQ resulted in acceptable levels of reliability = 3.7±0.6. (ICC=0.87, r=0.88, TEM = 2.3 AU, CV = 6.4%) when tested DISCUSSION twice in one week (Table 5). The mean difference between test one and two was just 0.1±3.2 AU (Table 5). The internal The results from the current study would support the use consistency of the ASBQ resulted in a Cronbach’s α of 0.63. of the proposed 18-item Athlete Sleep Behavior Questionnaire The PCA factoring for the three-factor structure was performed for use as a practical tool for identifying maladaptive sleep with varimax rotation, which collectively accounted for 69.6% practices in elite athletes. The ASBQ was a valid measurement tool Sleep Sci. 2018;11(1):37-44 42 Driller, et al. Table 4. Pearson’s correlation coefficient (r) between the ASBQ global score and the three other questionnaires (n=564 participants) and between the ASBQ and sleep indices as measured by wrist-actigraphy (n=50 participants). Total Time in Bed Total Sleep Time Sleep Efficiency Sleep Latency Sleep Quality SHI ESS PSQI (mins) (mins) % (mins) (1 - 5 AU) 0.69 0.32 0.38 -0.18 -0.42 -0.16 0.07 -0.39 ASBQ Large Moderate Moderate Small Moderate Small Trivial Moderate ASBQ = Athlete Sleep Behavior Questionnaire; SHI = Sleep Hygiene Index; ESS = Epworth Sleepiness Scale; PSQI = Pittsburgh Sleep Quality Index; AU = Arbitrary Units. Table 5. Test-retest reliability of the Athlete Sleep Behavior Questionnaire (n=50) when performed twice over 7-days. Mean data shown along with intra- class correlation coefficients (ICC), coefficient of variation % (CV%) and typical error of measurement (TEM), with 90% confidence intervals (90% CI). Test 1 Test 2 Raw Difference r ICC TEM CV% (mean±SD) (mean±SD) (mean±SD) (90% CI) (90% CI) (90% CI) (90% CI) ASBQ Global 0.88 0.87 2.3 6.4 38.6±6.6 38.7±5.6 0.1±3.2 Score (0.81-0.92) (0.80-0.92) (2.0-2.7) (5.4-7.7) Table 6. Factor loadings for the Athlete Sleep Behavior Questionnaire as determined via Principal Component Analysis with a varimax rotation method. ASBQ items Factor loading Factor 1 - Routine/environmental factors Q1. I take afternoon naps lasting two or more hours 0.52 Q5. I go to bed at different times each night (more than ±1 hour variation) 0.45 Q15. I get up at different times each morning (more than ±1 hour variation) 0.48 Q16. At home, I sleep in a less than ideal environment (e.g too light, too noisy, uncomfortable bed/pillow, too hot/cold) 0.51 Q17. I sleep in foreign environments (e.g hotel rooms) 0.43 Q18. Travel gets in the way of building a consistent sleep-wake routine 0.55 Factor 2 - Behavioral factors Q2. I use stimulants when I train/compete (e.g caffeine) 0.58 Q4. I consume alcohol within 4 hours of going to bed 0.48 Q8. I use light-emitting technology in the hour leading up to bedtime (e.g laptop, phone, television, video games) 0.47 Q10. I think, plan and worry about issues not related to my sport when I am in bed 0.61 Q11. I use sleeping pills/tablets to help me sleep 0.56 Q12. I wake to go to the bathroom more than once per night 0.56 Q13. I wake myself and/or my bed partner with my snoring 0.48 Factor 3 - Sport-related factors Q3. I exercise (train or compete) late at night (after 7pm) 0.49 Q6. I go to bed feeling thirsty 0.57 Q7. I go to bed with sore muscles 0.45 Q9. I think, plan and worry about my sporting performance when I am in bed 0.53 Q14. I wake myself and/or my bed partner with my muscle twitching 0.45 when compared to three other established sleep questionnaires While there was a significant difference between groups for the and was sensitive enough to determine the difference in sleep PSQI, this was actually in favor of the athlete group, suggesting behavior scores in athletes when compared to non-athletes. The that sleep quality may be higher in athletes vs. non-athletes, 5,23,32 ASBQ was shown to have high levels of test-retest reliability, which is in direct contrast to previous literature . further supporting its use in both research and practical settings. Even though both groups can be classified as “poor When compared to sleep monitoring via wrist-actigraphy, in a sleepers” according to the PSQI threshold of >5, it is still cohort of the studied population, the ASBQ displayed a moderate important to speculate why non-athletes had a higher global relationship with one of the key sleep measures, total sleep time. PSQI score. This may be explained by evaluating the individual We would suggest that the ASBQ is a useful tool to identify the components of the PSQI, where there was a significant difference sleep behaviors of elite athletes. for athletes compared to non-athletes for one component of the Perhaps one of the pertinent issues with the existing questionnaire. Component #4 refers to sleep efficiency (time sleep questionnaires, is their inability to adequately differentiate spent sleeping divided by time spent in bed). While total sleep the unique sleep problems faced by elite athletes. Indeed, the time between groups was similar, non-athletes had lower sleep current study would support this, as evidenced through the non- efficiency, due to longer time spent in bed (531±96 minutes) significant differences and trivial effect sizes for athletes vs. non- when compared to the athlete group (519±104 minutes). When athletes in the SHI and ESS global scores (p>0.05, Table 3). comparing the ASBQ between the athlete and non-athlete Sleep Sci. 2018;11(1):37-44 43 Athlete sleep behavior questionnaire populations, results showed that the scores for 10 out of the 18 The authors acknowledge that the Cronbach’s α of items/questions were significantly greater in the athlete group, 0.63 for the ASBQ is below the usually accepted threshold of indicating poorer sleep behaviors (Figure 1). 0.70, however, given this is a measure of internal consistency While there were no significant differences between for the relationship between items in a questionnaire, this was groups for the 8 remaining items, the authors would suggest not the aim of the practical tool being developed in the current that these are still valuable questions for gaining specific study. Indeed, the ASBQ was intentionally designed to measure information on the habits of individual athletes, based on different aspects of sleep behavior, and therefore, it was not 15 7 previous recommendations . As identified by Juliff et al. , one critical that all items on the questionnaire are related. The of the major challenges for athletes was problems falling asleep authors also acknowledge that the female athlete population due to their thoughts about competition. The current study was greater than the male athlete population surveyed, however, would support this, with one of the highest ratings by athletes given there were no significant differences between male and (indicative of a challenge to sleep) in question #9 - “I think, plan female ASBQ scores, we did not see this as an issue impacting and worry about my sporting performance when I am in bed” the validity or reliability of this questionnaire. (Figure 1). Other questions with the highest ratings by athletes The authors would suggest that a ASBQ global score in the current study were question #7 - “I go to bed with sore of ≤36 would equate to “good sleep behavior” and ≥42 = muscles” and question #2 - “I exercise late at night” (Figure 1). “poor sleep behavior”. These thresholds are based on the The test-retest reliability of the ASBQ was very high, authors’ interpretation of the data and represent a conservative with a mean difference of only 0.1 on the global score between assessment of threshold range descriptors. The lower threshold the two tests (Table 5). This difference was associated with an of ≤36 would represent an average response of “rarely” for r value of 0.88, an ICC of 0.87, a TEM of 2.3 and a CV of all 18-items, while the upper threshold of ≥42 would require 6.4%. In contrast to the other scales used in the current study, more than one response of either “sometimes”, “frequently” our results would suggest that the ASBQ is comparable, or even or “always”. However, these thresholds are suggested as a guide more reliable in a test-retest setting. Authors reported an r value only and are subject to adjustment in future studies assessing the of 0.71 when evaluating the SHI in a test-retest trial, with 4 weeks sensitivity and specificity of the ASBQ in athletic populations. between each test . The original study to develop the PSQI The ASBQ that has been proposed and developed in reported a test-retest correlation of r=0.85 , however, the time phase one of the current study is an 18-item questionnaire duration between tests is somewhat unclear, with an average of that is a fast (<2 mins), easy to administer, valid and reliable 28.2 days reported, but the specified range was 1 - 265 days. tool that can help to identify the maladaptive sleep practices The ESS, when administered to 87 healthy students twice in 5 and challenges faced by athletes. The ASBQ offers a practical months, resulted in a test-retest r value of 0.82 . Unfortunately, instrument for practitioners, coaches and/or researchers the differing range of methodologies implemented between wanting to evaluate the sleep behaviors of elite athletes. The studies make it difficult to draw comparisons with the reliability ASBQ is not designed to be a clinical sleep tool, but simply a of the ASBQ in the current study. practical solution to find out some of the key challenges faced A potential limitation of the current study was the by athletes in terms of their sleep behaviors. The ASBQ may relatively short (one week) test-retest time frame for assessing also be a valuable tool for tracking changes in sleep habits over the reliability of the ASBQ. However, given the ASBQ asks for time, or for testing the efficacy of sleep-hygiene interventions the participants’ normal habits over the previous month, the to improve sleep. 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DOI: http://dx.doi.org/10.1093/sleep/15.4.376 Sleep Sci. 2018;11(1):37-44 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Sleep Science Pubmed Central

Development of the athlete sleep behavior questionnaire: A tool for identifying maladaptive sleep practices in elite athletes

Driller, Matthew W; Mah, Cheri D; Halson, Shona L
Sleep Science , Volume 11 (1) – Jan 1, 2018
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Athlete sleep behavior questionnaire ORIGINAL ARTICLE Development of the athlete sleep behavior questionnaire: A tool for identifying maladaptive sleep practices in elite athletes 1-4 Matthew W Driller ABSTRACT Cheri D Mah Introduction: Existing sleep questionnaires to assess sleep behaviors may not be sensitive in Shona L Halson determining the unique sleep challenges faced by elite athletes. The purpose of the current study was to develop and validate the Athlete Sleep Behavior Questionnaire (ASBQ) to be used as a University of Waikato, Health, Sport practical tool for support staff working with elite athletes. Methods: 564 participants (242 athletes, and Human Performance - Hamilton - 322 non-athletes) completed the 18-item ASBQ and three previously validated questionnaires; the Waikato - New Zealand. Sleep Hygiene Index (SHI), the Epworth Sleepiness Scale (ESS) and the Pittsburgh Sleep Quality University of California, Human Index (PSQI). A cohort of the studied population performed the ASBQ twice in one week to Performance Center - San Francisco - assess test-retest reliability, and also performed sleep monitoring via wrist-actigraphy. Results: California - USA. Comparison of the ASBQ with existing sleep questionnaires resulted in moderate to large correlations Australian Institute of Sport, (r=0.32 - 0.69). There was a significant difference between athletes and non-athletes for the ASBQ Physiology - Canberra - ACT - global score (44±6 vs. 41±6, respectively, p<0.01) and for the PSQI, but not for the SHI or the ESS. Australian. The reliability of the ASBQ was acceptable (ICC=0.87) when re-tested within 7 days. There was High Performance Sport New Zealand, a moderate relationship between ASBQ and total sleep time (r=-0.42). Conclusion: The ASBQ is a Performance Physiology - Auckland - valid and reliable tool that can differentiate the sleep practices between athletes and non-athletes, Auckland - New Zealand. and offers a practical instrument for practitioners and/or researchers wanting to evaluate the sleep behaviors of elite athletes. The ASBQ may provide information on areas where improvements to individual athletes’ sleep habits could be made. Keywords: Surveys and Questionnaires; Actigraphy; Polysomnography; Sleep Hygiene; Athletes. Corresponding author: Matthew W Driller. E-mail: [email protected] E-mail: [email protected] Received: November 1, 2017; Accepted: January 30, 2018. DOI: 10.5935/1984-0063.20180009 Sleep Sci. 2018;11(1):37-44 38 Driller, et al. INTRODUCTION can be achieved in elite athletes, through simple sleep-behavior education and subsequent changes in maladaptive habits . There is increasing recognition that sleep plays a Therefore, the purpose of the current study was to significant role in aiding the recovery process in highly-trained 1-3 4 5 develop an athlete-specific sleep questionnaire and validate athletes . According to Halson and Leeder et al. , sleep is it against both objective (wrist-actigraphy) and subjective reported to be the single best psycho-physiological recovery (validated questionnaires) sleep measures in both athletes and strategy available to elite athletes. Therefore, the quantification non-athletes. A further aim of the study was to determine the and measurement of sleep amongst athletic populations has test-retest reliability of the questionnaire. become commonplace in the sport setting . Objective methods of measuring sleep such as polysomnography and actigraphy METHODS require a somewhat intrusive and expensive assessment of Participants sleep, coupled with the need for specialized expertise, making The survey was completed by a convenience sample of them difficult to administer across large numbers of athletes. 564 participants (282 male/282 female, mean±SD, age; 25±7 y) Different questionnaires and scales used for surveying sleep across 9 countries (Australia, Canada, England, India, Malaysia, have been validated in the literature, with little focus on athlete- New Zealand, Portugal, Sweden, USA). The study population specific measures. Indeed, research has shown that athletes may was divided into athletes (n=242) and non-athletes (n=322) for display different sleeping patterns and habits compared to the 5,7-9 analysis (Table 1). All participants for both groups were aged non-athlete population , likely due to the unique physiological between 18-45 y at the time of taking part in the study. New and psychological demands of being an elite athlete. parents (children <2 y) and individuals with diagnosed sleep It has been reported that sleep may be compromised in disorders were excluded from taking part in the study. elite athletes due to a number of factors, including the increase in core temperature following exercise , increases in muscle 11,12 Table 1. Participant demographics. tension, fatigue and pain following training and competition , Athletes (n=242) Non-athletes (n=322) frequent international travel , disruption from light and noise 14 7 Age (y) 22±5 25±6 and increases in psychological stress . Juliff et al. reported from 283 elite athletes, that 64% of athletes reported sleep Male (n=) 87 195 disturbances due to nervousness or over-thinking before Female (n=) 155 127 competition and more than half of the sample suffered sleep Team sport (n=) 128 N/A disturbances following a late training session or competition. Individual sport (n=) 114 Other sleep disturbances that seem to be magnified in elite athletes include the use of long naps in the afternoon interrupting The criteria for the ‘athlete’ population used in the current night-time sleep, the use of stimulants (e.g. caffeine), frequent study was: representation of their country at either national or travel, sleeping in different environments (e.g. hotels), and either international-level (semi-professional or professional) for their 14-16 over-hydration or dehydration prior to bed . Existing surveys, chosen sport. Athletes were surveyed across 18 different sports scales and questionnaires that evaluate sleep behavior in the (team sport athletes = 128 and individual sport athletes = 114) general population may not be specific enough to detect these and completed the survey during the in-season phase of their unique differences in an athlete’s sleeping patterns and habits. training (minimum of 4-weeks into their competition season). A plethora of sleep questionnaires have been evaluated Athletes from the following sports were surveyed: badminton in the research literature. Some of these include the Pittsburgh (n=8), baseball (n=9), basketball (n=15), boxing (n=5), cricket 17 18 Sleep Quality Index , the Sleep Hygiene Index , and the (n=10), cycling (n=15), football/soccer (n=12), golf (n=10), Epworth Sleepiness Scale . While these questionnaires and hockey (n=18), netball (n=19), rowing (n=17), rugby league scales may be appropriate for general or clinical populations, (n=14), rugby union (n=24), swimming (n=14), track and field they lack specific questions that are tailored towards the sleep (n=26), tennis (n=6), triathlon (n=13) and water-polo (n=7). challenges faced by elite athletes. The criteria for the ‘non-athlete’ population included To our knowledge, the only athlete-specific sleep participants that; a) were not members of any regional or questionnaire in the literature is the Athlete Sleep Screening national-level sporting team, and b) were performing ≤3 planned Questionnaire (ASSQ) . The ASSQ was designed to provide exercise training sessions per week. The ‘non-athlete’ population clinical screening with cut-off scores associated with the was a random selection of participants also surveyed from the specific clinical interventions to manage sleep disorders. While 9 aforementioned countries. All participants were recruited via initial reports of the ASSQ have shown that it is a valid tool in National Sporting Organisations, various social media channels screening athletes for sleep disturbances, there remains a need for and word-of-mouth advertising. The questionnaire was not an instrument that can provide useful information on the sleep translated into any other languages, and therefore it was a behavior practices of elite athletes, allowing for individualized requirement that all participants were fluent English speakers. feedback and behavioral modifications based on their responses. The study was approved by the Institutions Human Research Indeed, recent research has shown that improvements in sleep Ethics Committee (Ethics number: FEDU066/16) and as Sleep Sci. 2018;11(1):37-44 39 Athlete sleep behavior questionnaire outlined to participants, by completing the survey, informed sleep quality. The PSQI has been demonstrated to have good consent to take part in the study was given. internal reliability, validity and is perhaps the most commonly- used subjective sleep measure not only in the research literature, Instruments but also in the sleep community . The following four sleep questionnaires were administered to all participants via an electronic online Reliability survey (Survey Monkey, Palo Alto Inc. CA, USA). All four The test-retest reliability and sleep-monitoring questionnaires were filled out in a single sitting and average time component of the study was completed by 50 participants (27 to complete the questionnaires was 8.5 minutes. On average, the male/23 female, 19 team sport athletes/31 individual athletes, ASBQ took 1.5 minutes to complete. All questionnaires asked mean ± SD; age: 23±5 y) from the athlete cohort. Athletes were participants to answer the questions relating to their normal randomly selected and the following sports were included in the sleeping patterns over the previous month. reliability (and actigraphy) analysis: cycling (n=7), football (n=3), netball (n=9), rugby league (n=7), rowing (n=10), swimming The Athlete Sleep Behavior Questionnaire (ASBQ) (n=4), track and field (n=10). All participants completed the The ASBQ is the survey that has been specifically ASBQ two times separated by exactly 7 days. The test was designed for evaluation in the current study. A combination of performed at the same time of day on both occasions and the Sleep Hygiene Index , the International Classification of took place during an in-season, non-competitive week. The day Sleep Disorders , and previous research describing the most that the ASBQ was filled out on both occasions was preceded 7,23 common sleep issues in elite athletes and recommended tips by a rest day, where no athletic training or competition was 10,15,21 and strategies to address these issues was used to develop performed. The reliability component of the current study was the ASBQ. The ASBQ is an 18-item survey that includes assessed concurrently with the measurement of sleep through questions on sleeping behavior and habits thought to be wrist-actigraphy. common areas of concern for elite athletes (Table 2) and was designed as a practical tool to identify areas where improvements Actigraphy in sleep behavior could be made, rather than a clinical screening A total of 50 athletes from the current study (same tool. The survey asks participants how frequently they engage cohort as described in the reliability component above) wore in specific behaviors (never, rarely, sometimes, frequently, a wrist activity monitor to evaluate their sleeping patterns. always). Weightings for each response (1 = never, 2 = rarely, 3 = Participants were required to wear the activity monitor (SBV2 sometimes, 4 = frequently, 5 = always) were summed to provide Readiband™, Fatigue Science, Honolulu, USA), continuously an ASBQ global score. A higher global score is indicative of over a 7-day period with the exception of time spent in water, poor sleep behaviors. bathing or showering. Participants were instructed to maintain their usual sleep habits and general daily activity patterns during The Sleep Hygiene Index (SHI) the monitoring period. The SHI is a 13-item self-administered index intended Sleep indices used for comparison to the ASBQ global to assess the presence of behaviors thought to comprise sleep score were: total time in bed, total sleep time, sleep efficiency hygiene. Participants are asked to indicate how frequently they and sleep latency. Each morning during the monitoring period, engage in specific behaviors (always, frequently, sometimes, athletes were also asked to rate their perceived sleep quality on a rarely, never). Item scores were then summed providing a global scale from 1-5 (1 = very poor, 5 = excellent). Participants were score for sleep hygiene. Higher scores are indicative of more also asked to record their sleep and wake times in a diary, to maladaptive sleep hygiene status. The SHI has been shown to be allow for cross-checking and corrections with the actigraphy both valid and reliable in a healthy population . data. The accuracy and inter-device reliability of the Readiband 26,27 device has been deemed acceptable, as described elsewhere . Epworth Sleepiness Scale (ESS) The Epworth Sleepiness Scale (ESS) is a self-reported Statistical Analysis 8-item questionnaire that produces a global score from 0-24. Descriptive statistics are shown as means ± SD unless Scores greater than 10 suggest significant daytime sleepiness . stated otherwise. Statistical analysis was performed using SPSS The ESS is commonly used to differentiate between individuals V22.2 (IBM Corporation; Chicago, IL, USA). Comparison of with and without sleep disorders and has also shown to correlate athletes to non-athletes were performed for each questionnaire with objective measures of sleepiness . and each item of the ASBQ using independent samples t-tests, with statistical significance set at p<0.05. There were no outliers The Pittsburgh Sleep Quality Index (PSQI) in the data, as assessed by inspection of a boxplot. Global scores The PSQI is a self-rated 19-item instrument intended for each questionnaire and each item of the ASBQ were normally to assess sleep quality and sleep disturbance over a 1-month distributed, as assessed by Shapiro-Wilk’s test (p>0.05), and there period in clinical and nonclinical populations . Global scores was homogeneity of variances between groups, as assessed by range from 0 to 21 with higher scores indicating poorer overall Levene’s test for equality of variances (p>0.05). Cohen’s effect Sleep Sci. 2018;11(1):37-44 40 Driller, et al. Table 2. The Athlete Sleep Behavior Questionnaire (ASBQ). No. In recent times (over the last month)… Never Rarely Sometimes Frequently Always 1 I take afternoon naps lasting two or more hours 2 I use stimulants when I train/compete (e.g caffeine) 3 I exercise (train or compete) late at night (after 7pm) 4 I consume alcohol within 4 hours of going to bed I go to bed at different times each night (more than ±1 hour variation) 6 I go to bed feeling thirsty 7 I go to bed with sore muscles I use light-emitting technology in the hour leading up to bedtime (e.g laptop, phone, television, video games) I think, plan and worry about my sporting performance when I am in bed I think, plan and worry about issues not related to my sport when I am in bed 11 I use sleeping pills/tablets to help me sleep 12 I wake to go to the bathroom more than once per night 13 I wake myself and/or my bed partner with my snoring I wake myself and/or my bed partner with my muscle twitching I get up at different times each morning (more than ±1 hour variation) At home, I sleep in a less than ideal environment (e.g too light, too noisy, uncomfortable bed/pillow, too hot/cold) 17 I sleep in foreign environments (e.g hotel rooms) Travel gets in the way of building a consistent sleep-wake routine Scoring: Never = 1, Rarely = 2, Sometimes = 3, Frequently = 4, Always = 5 Total Global Score: _________ sizes (d) were calculated between athletes and non-athletes for extract three underlying dimensions of the questionnaire. PCA each questionnaire and interpreted using thresholds of 0.2, 0.5, revealed that the three factors that had eigenvalues greater than 0.8 for small, moderate and large, respectively . Comparison of the one and visual inspection of the scree plot confirmed that three previously validated sleep questionnaire global scores and the components should be retained . Interpretation of these three ASBQ global score was achieved with Pearson product-moment components was consistent with themes of routine/environ- correlation analysis for the entire sample (n=564). mental related factors for factor 1, behavioral factors for factor Correlation between the ASBQ and measured sleep 2 and sport-related factors for factor 3 (Table 6). variables were also assessed in a cohort of the study population RESULTS (n=50). The magnitude of correlation between the ASBQ and the other questionnaires/sleep measures was assessed using the There were no significant differences between male and following thresholds: <0.1, trivial; 0.1-0.3, small; 0.3-0.5, moderate; female participants for the ASBQ global score within either 0.5-0.7, large; 0.7-0.9, very large; and 0.9-1.0, almost perfect. Test- athlete (p=0.20) or non-athlete groups (p=0.21), nor were there retest reliability of the ASBQ were analyzed using an Excel differences for team vs. individual sport athletes (p=0.69), spreadsheet for reliability with data shown as intra-class therefore, both the athlete group and non-athlete groups were correlation coefficients (ICC), Pearson correlations ( r), typical pooled for comparison with each other. error of measurement (TEM) and coefficient of variation There was a significant difference between athlete and percentage (CV%). non-athlete groups for the ASBQ global score (43.5 and 40.6, Internal reliability/consistency of the ASBQ was de- respectively, p<0.01, d=0.47, Table 3), which included a significant termined using Cronbach’s α. A principal component analysis difference between groups in 10 of the 18 items in the questionnaire (PCA) was run on the 18-item questionnaire and the suitability (Figure 1). There were no significant differences between groups for of the PCA was assessed prior to analysis via the Kaiser-Meyer- the SHI or the ESS and both associated with trivial effect sizes (Table Olkin measure and the Bartlett’s test of sphericity . Explorato- 3). The PSQI global score was significantly higher in the non-athlete ry factor analysis using PCA with a varimax rotation was used to group (p<0.01, d=0.36, Table 3). Sleep Sci. 2018;11(1):37-44 41 Athlete sleep behavior questionnaire Table 3. Global scores for the four sleep questionnaires between athletes and non-athletes including p-values and effect-size comparisons between groups. Data shown as means ± SD. Athletes Non-Athletes Raw Difference Effect-Size p-value (mean ± SD) (mean ± SD) (Non-Athlete - Athlete) d ASBQ 0.47 43.5±5.8 40.6±6.1 -2.9 <0.01 Small SHI 0.02 32.3±6.1 32.4±6.4 0.1 0.81 Trivial ESS 0.18 5.7±3.4 5.2±3.3 -0.6 0.06 Trivial PSQI 0.36 5.1±2.5 6.1±2.9 1.0 <0.01 Small ASBQ = Athlete Sleep Behavior Questionnaire; SHI = Sleep Hygiene Index; ESS = Epworth Sleepiness Scale; PSQI = Pittsburgh Sleep Quality Index. Figure 1. Legenda: Mean scores (out of 5) for Non-athletes (n=322, black bar) and Athletes (n=242, white bar) for each item of the 18-question Athlete Sleep Behavior Questionnaire (ASBQ). * Indicates significant difference between groups (p<0.05). The ASBQ was shown to have moderate to large of the variance. The factor matrix showed that every item-factor correlations with the existing validated sleep questionnaires loading was above the criterion of 0.45. Item loadings ranged (r=0.38 – 0.69, Table 4). The correlation between the ASBQ and from 0.45 to 0.61 (Table 6). objective sleep indices resulted in a small relationship for total The sleep monitoring period in a cohort of the athlete time in bed and sleep efficiency (r=-0.18, -0.16, respectively), a population (n=50) used for correlation to the ASBQ resulted moderate relationship for total sleep time and sleep quality (r=- in the following mean ± SD values: total time in bed = 552±61 0.42, -0.39, respectively) and a trivial correlation for sleep latency mins, total sleep time = 441±38 mins, sleep efficiency = (r=0.07, Table 4). 85±8%, sleep latency = 38±20 mins and subjective sleep quality The ASBQ resulted in acceptable levels of reliability = 3.7±0.6. (ICC=0.87, r=0.88, TEM = 2.3 AU, CV = 6.4%) when tested DISCUSSION twice in one week (Table 5). The mean difference between test one and two was just 0.1±3.2 AU (Table 5). The internal The results from the current study would support the use consistency of the ASBQ resulted in a Cronbach’s α of 0.63. of the proposed 18-item Athlete Sleep Behavior Questionnaire The PCA factoring for the three-factor structure was performed for use as a practical tool for identifying maladaptive sleep with varimax rotation, which collectively accounted for 69.6% practices in elite athletes. The ASBQ was a valid measurement tool Sleep Sci. 2018;11(1):37-44 42 Driller, et al. Table 4. Pearson’s correlation coefficient (r) between the ASBQ global score and the three other questionnaires (n=564 participants) and between the ASBQ and sleep indices as measured by wrist-actigraphy (n=50 participants). Total Time in Bed Total Sleep Time Sleep Efficiency Sleep Latency Sleep Quality SHI ESS PSQI (mins) (mins) % (mins) (1 - 5 AU) 0.69 0.32 0.38 -0.18 -0.42 -0.16 0.07 -0.39 ASBQ Large Moderate Moderate Small Moderate Small Trivial Moderate ASBQ = Athlete Sleep Behavior Questionnaire; SHI = Sleep Hygiene Index; ESS = Epworth Sleepiness Scale; PSQI = Pittsburgh Sleep Quality Index; AU = Arbitrary Units. Table 5. Test-retest reliability of the Athlete Sleep Behavior Questionnaire (n=50) when performed twice over 7-days. Mean data shown along with intra- class correlation coefficients (ICC), coefficient of variation % (CV%) and typical error of measurement (TEM), with 90% confidence intervals (90% CI). Test 1 Test 2 Raw Difference r ICC TEM CV% (mean±SD) (mean±SD) (mean±SD) (90% CI) (90% CI) (90% CI) (90% CI) ASBQ Global 0.88 0.87 2.3 6.4 38.6±6.6 38.7±5.6 0.1±3.2 Score (0.81-0.92) (0.80-0.92) (2.0-2.7) (5.4-7.7) Table 6. Factor loadings for the Athlete Sleep Behavior Questionnaire as determined via Principal Component Analysis with a varimax rotation method. ASBQ items Factor loading Factor 1 - Routine/environmental factors Q1. I take afternoon naps lasting two or more hours 0.52 Q5. I go to bed at different times each night (more than ±1 hour variation) 0.45 Q15. I get up at different times each morning (more than ±1 hour variation) 0.48 Q16. At home, I sleep in a less than ideal environment (e.g too light, too noisy, uncomfortable bed/pillow, too hot/cold) 0.51 Q17. I sleep in foreign environments (e.g hotel rooms) 0.43 Q18. Travel gets in the way of building a consistent sleep-wake routine 0.55 Factor 2 - Behavioral factors Q2. I use stimulants when I train/compete (e.g caffeine) 0.58 Q4. I consume alcohol within 4 hours of going to bed 0.48 Q8. I use light-emitting technology in the hour leading up to bedtime (e.g laptop, phone, television, video games) 0.47 Q10. I think, plan and worry about issues not related to my sport when I am in bed 0.61 Q11. I use sleeping pills/tablets to help me sleep 0.56 Q12. I wake to go to the bathroom more than once per night 0.56 Q13. I wake myself and/or my bed partner with my snoring 0.48 Factor 3 - Sport-related factors Q3. I exercise (train or compete) late at night (after 7pm) 0.49 Q6. I go to bed feeling thirsty 0.57 Q7. I go to bed with sore muscles 0.45 Q9. I think, plan and worry about my sporting performance when I am in bed 0.53 Q14. I wake myself and/or my bed partner with my muscle twitching 0.45 when compared to three other established sleep questionnaires While there was a significant difference between groups for the and was sensitive enough to determine the difference in sleep PSQI, this was actually in favor of the athlete group, suggesting behavior scores in athletes when compared to non-athletes. The that sleep quality may be higher in athletes vs. non-athletes, 5,23,32 ASBQ was shown to have high levels of test-retest reliability, which is in direct contrast to previous literature . further supporting its use in both research and practical settings. Even though both groups can be classified as “poor When compared to sleep monitoring via wrist-actigraphy, in a sleepers” according to the PSQI threshold of >5, it is still cohort of the studied population, the ASBQ displayed a moderate important to speculate why non-athletes had a higher global relationship with one of the key sleep measures, total sleep time. PSQI score. This may be explained by evaluating the individual We would suggest that the ASBQ is a useful tool to identify the components of the PSQI, where there was a significant difference sleep behaviors of elite athletes. for athletes compared to non-athletes for one component of the Perhaps one of the pertinent issues with the existing questionnaire. Component #4 refers to sleep efficiency (time sleep questionnaires, is their inability to adequately differentiate spent sleeping divided by time spent in bed). While total sleep the unique sleep problems faced by elite athletes. Indeed, the time between groups was similar, non-athletes had lower sleep current study would support this, as evidenced through the non- efficiency, due to longer time spent in bed (531±96 minutes) significant differences and trivial effect sizes for athletes vs. non- when compared to the athlete group (519±104 minutes). When athletes in the SHI and ESS global scores (p>0.05, Table 3). comparing the ASBQ between the athlete and non-athlete Sleep Sci. 2018;11(1):37-44 43 Athlete sleep behavior questionnaire populations, results showed that the scores for 10 out of the 18 The authors acknowledge that the Cronbach’s α of items/questions were significantly greater in the athlete group, 0.63 for the ASBQ is below the usually accepted threshold of indicating poorer sleep behaviors (Figure 1). 0.70, however, given this is a measure of internal consistency While there were no significant differences between for the relationship between items in a questionnaire, this was groups for the 8 remaining items, the authors would suggest not the aim of the practical tool being developed in the current that these are still valuable questions for gaining specific study. Indeed, the ASBQ was intentionally designed to measure information on the habits of individual athletes, based on different aspects of sleep behavior, and therefore, it was not 15 7 previous recommendations . As identified by Juliff et al. , one critical that all items on the questionnaire are related. The of the major challenges for athletes was problems falling asleep authors also acknowledge that the female athlete population due to their thoughts about competition. The current study was greater than the male athlete population surveyed, however, would support this, with one of the highest ratings by athletes given there were no significant differences between male and (indicative of a challenge to sleep) in question #9 - “I think, plan female ASBQ scores, we did not see this as an issue impacting and worry about my sporting performance when I am in bed” the validity or reliability of this questionnaire. (Figure 1). Other questions with the highest ratings by athletes The authors would suggest that a ASBQ global score in the current study were question #7 - “I go to bed with sore of ≤36 would equate to “good sleep behavior” and ≥42 = muscles” and question #2 - “I exercise late at night” (Figure 1). “poor sleep behavior”. These thresholds are based on the The test-retest reliability of the ASBQ was very high, authors’ interpretation of the data and represent a conservative with a mean difference of only 0.1 on the global score between assessment of threshold range descriptors. The lower threshold the two tests (Table 5). This difference was associated with an of ≤36 would represent an average response of “rarely” for r value of 0.88, an ICC of 0.87, a TEM of 2.3 and a CV of all 18-items, while the upper threshold of ≥42 would require 6.4%. In contrast to the other scales used in the current study, more than one response of either “sometimes”, “frequently” our results would suggest that the ASBQ is comparable, or even or “always”. However, these thresholds are suggested as a guide more reliable in a test-retest setting. Authors reported an r value only and are subject to adjustment in future studies assessing the of 0.71 when evaluating the SHI in a test-retest trial, with 4 weeks sensitivity and specificity of the ASBQ in athletic populations. between each test . The original study to develop the PSQI The ASBQ that has been proposed and developed in reported a test-retest correlation of r=0.85 , however, the time phase one of the current study is an 18-item questionnaire duration between tests is somewhat unclear, with an average of that is a fast (<2 mins), easy to administer, valid and reliable 28.2 days reported, but the specified range was 1 - 265 days. tool that can help to identify the maladaptive sleep practices The ESS, when administered to 87 healthy students twice in 5 and challenges faced by athletes. The ASBQ offers a practical months, resulted in a test-retest r value of 0.82 . Unfortunately, instrument for practitioners, coaches and/or researchers the differing range of methodologies implemented between wanting to evaluate the sleep behaviors of elite athletes. The studies make it difficult to draw comparisons with the reliability ASBQ is not designed to be a clinical sleep tool, but simply a of the ASBQ in the current study. practical solution to find out some of the key challenges faced A potential limitation of the current study was the by athletes in terms of their sleep behaviors. The ASBQ may relatively short (one week) test-retest time frame for assessing also be a valuable tool for tracking changes in sleep habits over the reliability of the ASBQ. However, given the ASBQ asks for time, or for testing the efficacy of sleep-hygiene interventions the participants’ normal habits over the previous month, the to improve sleep. 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Published: Jan 1, 2018

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