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Sleep quality evaluation, chronotype,
sleepiness and anxiety of Paralympic Brazilian
athletes: Beijing 2008 Paralympic Games
Andressa Silva, Sandra Souza Queiroz, Ciro Winckler, et al.
Br J Sports Med published online December 20, 2010
doi: 10.1136/bjsm.2010.077016
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BJSM Online First, published on December 20, 2010 as 10.1136/bjsm.2010.077016
Original article
Sleep quality evaluation, chronotype, sleepiness and
anxiety of Paralympic Brazilian athletes: Beijing 2008
Paralympic Games
Andressa Silva,1,2,4 Sandra Souza Queiroz,1,2 Ciro Winckler,1,4 Roberto Vital,3,4 Ronnie
Andrade Sousa,4 Vander Fagundes,5 Sergio Tufik,1,2,6 Marco Túlio de Mello1,2,6
1Universidade Federal de São
ABSTRACT Games, Brazilian athletes fi nished ninth overall
Paulo (UNIFESP), São Paulo, Objective The objective of this study was to evaluate with 16 gold medals and a total of 47 medals.4
Brazil
2Centro de Estudos em the sleep quality, sleepiness, chronotype and the anxiety The Paralympics become more competitive and
Psicobiologia e Exercício level of Brazilian Paralympics athletes before the 2008 garner more interest each year. Thus, the study of
(CEPE), São Paulo, Brazil Beijing Paralympic Games. variables that directly interfere with both team
3Universidade Federal do Rio
Design Cross-sectional study. and individual athlete results and performance are
Grande do Norte, Natal, Brazil
4 Comitê Paraolímpico Setting Exercise and Psychobiology Studies Center the focus of significant attention from researchers
Brasileiro (CPB), Brasília, Brazil (CEPE) and Universidade Federal de São Paulo, an urban and scholars. It is known that these variables are
5Universidade Federal de city in Brazil. linked to technical/tactical, physical and physi-
Uberlândia (UFU), Uberlândia, Participants A total of 27 Paralympics athletes of both ological/psychological aspects that are directly
Brazil genders (16 men and 11 women) with an average age related to performance.
6Pesquisador CNPq
of 28±6 years who practised athletics (track and field Even though the athletes are well trained
Correspondence to events) were evaluated. technically/tactically and physically, Becker and
Marco Túlio de Mello, Main outcome measures Sleep quality was Samulski5 suggest that athletes respond differ-
Departamento de evaluated using the Pittsburgh Scale and the Epworth ently to external stimuli during a competition
Psicobiologia, Universidade
Sleepiness Scale to evaluate sleepiness. Chronotype since pressure from training and competition
Federal de São Paulo, Rua
Francisco de Castro, 93, Vila was determined by the Horne and Östberg questionnaire is transferred to an emotional realm. Therefore,
Clementino—SP-04020-050, and anxiety through the State-Trait Anxiety Inventory. well-prepared athletes can present reductions
São Paulo, Brazil; The evaluations were performed in Brazil 10 days before of physical and emotional performance during
tmello@demello.net.br the competition. competition when they are under strong pressure
Results The study’s results demonstrate that 83.3% of to perform well.6 However, other athletes can
Accepted 1 November 2010 the athletes that presented excessive daytime sleepi- improve their performance if they present a good
ness also had poor sleep quality. The authors noted that level of precompetitive anxiety associated with an
71.4% were classified into the morning type and 72% appropriate emotional and physical balance.6
of the athletes who presented a medium anxiety level The effects of excessive anxiety before the com-
also presented poor sleep quality. Athletes with poor petition led to several consequences for the ath-
sleep quality showed significantly lower sleep efficiency letes.7 If anxiety levels are within normal levels,
(p=0.0119) and greater sleep latency (p=0.0068) these effects can be positive; if they surpass those
than athletes with good sleep quality. Athletes who levels, however, they can cause severe emotional
presented excessive daytime sleepiness presented reactions, including a decrease in performance.
lower sleep efficiency compared to non-sleepy athletes Some evidence suggests that regular physical
(p=0.0241). practice produces a variety of physiological ben-
Conclusions The authors conclude that the majority efits. Adaptability to physical exercises can be
of athletes presented poor sleep quality before the com- found in young, adult and older populations as
petition. This information should be taken into consider- well as populations that are healthy or influenced
ation whenever possible when scheduling rest, training by some pathology and/or disability. Several fac-
and competition times. tors, such as the initial level of physical fitness, the
design and duration of the fitness program, genetic
factors, age and gender, should be considered in
INTRODUCTION this long list of adaptabilities.8 9
The Paralympics date back to 1960, the year of the Samulski and Noce10 carried out a study on
fi rst Paralympic Games in Rome. After the Second the psychological preparation of the Brazilian
World War, the sports designed for athletes with Paralympic athletes and showed that the most
disabilities advanced in the contexts of preven- important reasons for becoming involved in a
tion as well as physical, social and psychic reha- sport were the enjoyment derived from practice
bilitation.1 2 Currently, the Paralympics are an and the need for rehabilitation. The majority of
evolving process focusing on the participation of athletes mentioned the following stress factors:
disabled athletes at different levels and capabili- sleeping problems, pressure to win and interper-
ties. Additionally, the Games focus on scientific sonal confl icts.
development that furthers the understanding of Several studies have been carried out to evalu-
the influence of disabilities on exercise and sports ate the relationship between physical exercise and
performance. 3 In the 2008 Beijing Paralympic sleep quality. The most common change observed
Silva A, Queiroz SS,ArticleC, et al. Br J Sports Med (2010). doi:10.1136/bjsm.2010.077016
Copyright Winckler author (or their employer) 2010. Produced by BMJ Publishing Group Ltd under licence. 5
1 of

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Original article
is the increase in slow wave sleep.11–15 Some studies have dem- determine the chance of falling sleep in each of the presented
onstrated increased rapid eye movement (REM) sleep latency situations, scoring likelihood from 0 (no chance) to 3 (high
and a decreased percentage of time spent in this stage,11 15 chance). The reference values are: Epworth Sleepiness Scale (SE)
whereas others have noted an increase in total sleeping time normal, from 0 to 6; SE limit, from 7 to 9; SE slight, from 10 to
and a reduction in sleep latency.16 14; SE moderate, from 15 to 20; SE high, above 20.20
Very few studies related to Paralympic athletes’ sleeping In addition to the above data describing sleep quality, this
patterns and physical activities are available in the literature. instrument is important for verifying sleepiness levels in peri-
This may be due to the fact that the sleeping patterns of this ods when athletes should be awake and attentive.
population do not differ widely from those of Olympic ath-
letes. One of the few studies in this area demonstrates a higher Horne and Östberg Questionnaire (chronotype)
frequency of periodic leg movements in individuals with spi- Chronotype evaluation was performed using the Horne and
nal cord injury; such sleep disturbances are associated with Östberg21 Questionnaire, which classifies subjects with regard to
greater sleep fragmentation and less successful physical and morningness and eveningness using the following scale: 16–33,
mental recovery.17 evening type; 34–44, moderate evening type; 45–65, indifferent;
Vuori and collaborators18 collected epidemiological data 66–76, moderate morning type; 77–86, morning type.
from 1600 individuals aged 31–50 years and these individuals
were interviewed with the aim of determining the influence of
State-Trait Anxiety Inventory
physical activity on sleeping. The authors report that social and
Anxiety-E is a provisional emotional state characterised by
physiological factors, conditions of the sleeping location, sleep
consciously noticed tension and apprehension of varying
pattern, lifestyle and conditions of the individuals directly
intensity over time. People with high levels of Anxiety-E have
influence sleep quality and physical performance. However,
a tendency to react more frequently to situations as if they
the authors concluded that moderate or vigorous exercise is
were threatening or dangerous. 22 The anxiety scale consists of
associated with improvements in sleep quality.
20 statements in which the subject is instructed to choose the
Therefore, the present study aimed to evaluate sleep qual-
best option that defi nes his feeling at a determined moment.
ity, chronotype and anxiety levels of Brazilian athletes that
The answer options are: absolutely not, a little, quite a lot
competed in the Beijing 2008 Paralympic Games.
and a lot, with scores ranging from 1 to 4, respectively. The
State-Trait Anxiety Inventory (STAI) was designed to be a
MATERIALS AND METHODS self-assessed inventory and can be performed individually or
Subjects in groups, with an average time for completion of 20 min.
A total of 27 Paralympic athletes of both genders (16 men and
11 women) competing in the track and field were evaluated. Statistical procedures
They were selected by the Brazilian Paralympics Committee Data are displayed in tables and graphs. Data normality was
to compete in the Beijing 2008 Paralympic Games. verified with the Shapiro–Wilk test.
Descriptive statistics confi rmed the mean calculation and
Procedures SD for all of the continuous and semicontinuous data with
All evaluations were carried out in periods during which the a normal distribution. Data with asymmetrical distribution
athletes were not involved in other activities and after obtain- underwent natural log (base e) transformation and are repre-
ing consent from the technical committee of the respective sented via the geometric mean and 95% CI. Categorical data
modality. All evaluations were performed during the prepara- are expressed in absolute and relative frequencies.
tion period in the city of São Paulo, Brazil (August, 2008). The In order to evaluate differences between the sleep efficiency
athletes were evaluated with regard to sleep, sleepiness, chro- and latency between the good and poor sleep groups, a Student
notype and anxiety between 9:00 and 11:00 a.m. as an attempt t test was used for independent samples. The same test was
to avoid collecting data at physically and emotionally stressful used to compare sleep efficiency between the sleepiness and
moments after practices. non-sleepiness groups. The variation coefficients were com-
pared with the Levene test, but no significant differences were
Pittsburgh Questionnaire noted; therefore, the Welch correction was not needed.
The Pittsburgh Sleep Quality Index consists of 21 items that For the analyses, SPSS Statistics 17.0 software for Windows
evaluate sleep quality and disturbances through a report card (SPSS, Inc, Chicago, IL) and Prism 5.0 for Windows (GraphPad
of the last month that includes seven components: sleep sub- Software, Inc, San Diego, CA) were used. The value of ≤5%
jective quality, sleep latency, sleep duration, sleep efficiency, was defi ned to be statistically significant.
sleep disturbance, use of sleeping pills and daytime dysfunc-
tion.19 It was considered as the cut-off point when classifying Ethics
the following: ≥5 point was poor quality and <4 good quality The research was approved by the Ethics Committee of the
sleep. Federal University of São Paulo (CEP #1148/08). Participants
signed informed consent forms authorising collection of data.
Epworth Sleepiness Scale All of the individuals participated in the tests voluntarily and
This scale evaluates sleepiness in active and passive situations, were aware of their processes and objectives.
including sitting and reading; watching TV; sitting in a public
place; sitting on a train, car or bus (non-stop for 1 h); lying down; RESULTS
lying down for an afternoon nap; sitting and talking to some- Sample characterisation
one; sitting quietly for lunch; abstaining from alcohol use; and A total of 27 Paralympic athletes (16 male and 11 female) from
driving but stuck in traffic for a few minutes. The athlete has to track and field sports were included in the current study. The
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Original article
subjects had an average age of 28±6 years, average weight of is fundamental for good physical recuperation. Additionally, it
62.7 kg (±9.6) and height of 164.6 cm (±30.8). The athletes is during the REM sleep phase that memory consolidation and
competed in the different events described below: field (4 ath- recovery of the cognitive aspects occur. In the current study,
letes) and track (23 athletes). the athletes with poor sleep quality showed a sleep efficiency
Table 1 shows that 83.3% of the athletes that presented value of only 78.5%; to be considered normal, subjects’ sleep
excessive morning sleepiness also presented poor sleep qual- efficiency value should be at least 85%. 23
ity, as evaluated by the Pittsburgh Questionnaire. We also Therefore, low sleep efficiency can directly affect physical
highlight that 71.4% of the athletes presented as morning and cognitive aspects during the practice and competition
types. Finally, 72% of the athletes that exhibited a medium phases. Hence, monitoring of this aspect is fundamental for
level of anxiety presented poor sleep quality. optimal practice and competition performance. This fi nding
Figure 1 shows that sleep latency was higher in the group and hypothesis is confi rmed in figures 1 and 2, in which we
with poor sleep quality. show that athletes with greater sleep latency presented lower
Figure 2 demonstrates that non-sleepy athletes exhibited sleep efficiency and greater sleepiness during the wakefulness
significantly greater sleep efficiency than sleepy athletes period. These data demonstrate the low physical and cogni-
(p=0.0241). tive recuperation achieved during both the resting period and
Athletes with good sleep quality demonstrated significantly recuperation phase, which occurs during the dark phase and
greater sleep efficiency than athletes with poor sleep quality, main sleep.
as shown in figure 3. The influence of physical practice on sleep quality in the
physical disabled has also been studied by our group. De Mello
DISCUSSION and collaborators17 24 –26 carried out polysomnography (sleep
The results of this sleep evaluation demonstrate that the major- study) in athletes with spinal cord injury who performed acute
ity of athletes presented poor sleep quality and excessive day- (maximum effort test) and chronic (practicing during 44 days
time sleepiness. These are concerning data because scientific at a ventilatory threshold of 1) exercise. When sleeping, these
investigations suggest that the non-REM sleep delta (NREM) athletes demonstrated a significant decrease in periodic limb
movements (PLMs). The effect of physical practice was not
Table 1 Epworth, chronotype, and Anxiety-E of athletes with good significantly different from the results obtained in volunteers
and poor sleep quality treated with l-dopa, which is a standard pharmacologic treat-
ment for PLMs. Therefore, physical practice demonstrates an
Evaluations Good Quality Poor Quality Total
ability to minimise that disorder in individuals with spinal
Epworth Non-Sleepy 6 (40%) 9 (60%) 15 (100%) cord injury. Other researchers have specifically focused on the
Sleepy 2 (16.7%) 10 (83.3%) 12 (100%) incidence of PLMs in paraplegics.17 27 28
Chronotype Extreme 2 (28.6%) 5 (71.4%) 7 (100%) De Mello and collaborators29 observed that most of the time,
morningness
the physically disabled individual initiating a fitness program
Moderate 4 (28.6%) 10 (71.4%) 14 (100%)
shows characteristics like depression and sleep disturbance.
morningness
Through a questionnaire, these authors also evaluated sleep
Indifferent 1 (20%) 4 (80%) 5 (100%)
patterns and complaints in individuals with full medullar sec-
Anxiety-E Low Level 1 (50%) 1 (50%) 2 (100%)
tion syndrome. A total of 59 individuals with medullar sec-
Middle Level 7 (28%) 18 (72%) 25 (100%)
tioning were evaluated and divided into athletic and sedentary
groups. The results demonstrated that athletes spent more
total time sleeping during the week. Significant differences
were also observed between athletes and sedentary subjects
with regard to snoring incidence (20% and 47%, respectively),
night-time waking (64% and 35%, respectively) and lower-
body movements (72% and 38%, respectively). These results
can be explained by greater excitability of the spinal intrin-
sic circuits that generate muscle tone and higher automatisms
in the athletes that minimise PLM frequency in this specific
population. 30
Great alterations in REM sleep have been verified in visually
impaired individuals. Congenitally blind individuals present
some differences during dreaming; in this sleeping phase, they
do not show ocular movements but olfactory, tactile and audi-
tory alterations. In individuals with acquired visual impair-
ments, this condition may not be reduced so significantly and
can appear normal in comparison to non-visually impaired
individuals. 26
Another important aspect to be highlighted is the predomi-
nance of the morning chronotype among the Paralympic ath-
letes. The option of practising and competing during that period
thus offers a good strategy, as better results may be achieved
when the athletes’ physical capacity, biological rhythm and
Figure 1 Comparison of sleep latency using the Pittsburgh chronotype are matched. However, these athletes can show
Questionnaire. 5% is defined as statistically significant. great difficulty adapting to evening practices or transmeridian
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Original article
Paralympic athletes to the Sydney time zone showed excellent
results and contributed to the number of medals achieved by
the Brazilian Paralympic team.
Another important aspect observed in some studies is anxi-
ety, which points to an interaction between sleep and anxi-
ety. 31– 34 Anxiety is a signal of alertness that is determined
by the presence of an internal confl ict responsible for alert-
ing an individual to eminent danger and it allows the indi-
vidual to react to the threat.12 It is probable that everyone has
experienced anxiety at some point. 35 In the present study, an
increase in anxiety was observed in the Paralympic athletes
the day before the main competition via STAI-E evaluation.
The moment of data collection, however, can be considered
a situation of normal anxiety levels. Better observation of
this aspect is important in cases demonstrating increased
stress and anxiety under non-competitive conditions because
this variable can trigger insomnia and reduce the total sleep-
ing period; such alterations completely change the process of
recovery and recuperation for these athletes.
In summary, almost all sleep disorders are harmful for the
recovery process. Such disorders result in greater sleep fragmen-
tation, reduced sleep quality and efficiency, increased irritabil-
ity and reduced physical and cognitive performance; these are
the classical effects of any sleep disturbance. Almost all sleep
Figure 2 Comparison of sleep efficiency using the Epworth disturbances provoke a reduction in the percentage of time
Sleepiness Scale. 5% is defined as statistically significant. spent in Delta sleep stage (stages 3 and 4) and REM sleep, with
a consequent increase in stage 2 in NREM sleep. These altera-
tions impair both physical recovery as well as the reduction of
the anabolic processes during Delta sleep, which consequently
reduces recovery capacity between practices and during com-
petition. Further, REM sleep reduction has consequences for
cognitive processes and short-term memory. Thus, REM sleep
is a period of great importance that allows athletes to engage
in good decision-making processes and concentrate during
competitions and games. If the REM sleep phase is perturbed,
therefore, consequences can include an increase in irritability,
memory loss and injury for high-performance athletes.
Olympic and Paralympic athletes who experience non-recu-
perative sleep due to the lack of sleep and reduction in the per-
centage of Delta and REM sleep phases may be more tired at
practices because these athletes are not obtaining recuperating
benefits from these sleep phases.
We conclude that 72% of the athletes presented precompeti-
tion stress. This value may be within the realm of normality
if the period during which they were evaluated is considered.
However, 70% presented low sleep efficiency, which can cause
significant reductions in the physical and mental recovery pro-
cesses and reduce athletic performance during practices and
competitions. Therefore, it is essential to evaluate and deter-
mine athletes’ sleep quality to determine a good prophylactic
regimen. Such prophylaxis is critical and decisive for postex-
Figure 3 Comparison of sleep efficiency using the Pittsburgh ercise recovery and competition performance for athletes that
Questionnaire. 5% is defined as statistically significant. present some kind of sleep disorder.
trips that cross several time zones; such changes may impair Acknowledgements The authors want to thank the Psychopharmacology
performance if the athletes are not well adapted. Incentive Fund Association (Associação Fundo de Incentivo a Psicofarmacologia—
With regard to transmeridian trips, evidence suggests that AFIP), the Exercise and Psychobiology Studies Center (Centro de Estudos em
Psicobiologia e Exercício—CEPE), the Sleepiness and Accident Multiprofessional
practice can alter the speed of biological clock adjustment. A Studies Center (Centro de Estudos Multiprofissional em Sonolência e Acidentes—
combination of light exposure, eating habits, outdoor prac- CEMSA), FAPESP (Cepid/Sono 98/143033), CNPq, the Brazilian Paralympic
tices and relaxation in the dark represents a method by which Academy—Brazilian Paralympics Committee and FADA—UNIFESP. The authors
to facilitate these adjustments in athletes. Such a procedure would like to thank Leandro Stetner Antonietti for the help with the statistical
analysis.
was developed for the Brazilian Paralympic athletes that com-
peted in the 2000 Sydney Paralympics Games. The study by Competing interests None.
De Mello and collaborators on the adjustment of Brazilian Patient consent Obtained.
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