Amitha Kalaichandran
Amitha Kalaichandran
By backing away from major sports tournaments, three high profile athletes have prioritized their healing above all else
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We rarely discuss ‘rest’ as a strategy for well-being.
However, over the last month, three professional athletes withdrew from major tournaments in order to prioritize rest for both their emotional and physical recovery, which has prompted some necessary conversation.
First, 23 year-old Naomi Osaka withdrew from the French Open (and later, Wimbledon), citing her mental health as the need to step away to recover. Then, 39-year-old Roger Federer announced he was stepping back from the French Open to give himself time to heal from a series of knee injuries. And most recently, Steph Curry, 33, of the Golden State Warriors made the surprising announcement that he wouldn’t be participating in the Tokyo Olympics, as he wanted to ‘focus on rest.’
Indeed, all three high-ranking athletes have set a precedent for professional athletes to speak up about the need to take a break as part of their healing, placing their mental and physical health above the push to perform. They also offer a chance to revisit the science of why it’s crucial to promote rest for recovery — not just for sports but for all of us.
The idea that athletes specifically are subject to grueling schedules isn’t new.
In the world of professional sports, pushing through pain in order to participate in a game is commonplace. Injuries in recent years among athletes run the gamut: from the more notorious chronic traumatic encephalopathy to blood clots — both of which can be devastating for athletes’ health and can ultimately end careers. Just recently, after collapsing on the field, soccer star Christian Eriksen was diagnosed with an arrhythmia, requiring a defibrillator. In each of these examples, playing the sport itself contributed to poor health.
These themes are echoed in other industries too. Everyone from journalists to doctors cited burnout secondary to excessive demands during to the Covid-19 pandemic. Indeed, in Japan, the term “karoshi” (as in death due to overwork) is recognized as a healthcare problem.
Sleep itself, as I’ve written about before, has healing effects: everything from how quickly wounds heal to improving our mental health. But amount and quality of sleep can also impact how likely it is for athletes to get injured. A 2019 metanalysis of sleep loss and sports injuries in adolescents found that chronic sleep deprivation significantly increased the odds of injury, replicating findings from 2014.
In 2019, Michael Grandner, a sleep researcher who directors the Sleep and Health Research Program at University of Arizona, found that athletes rated as having clinically moderate to severe insomnia were at a higher concussion risk.
Grandner emphasizes that sleep is an active process. “The main job of the immune system is to regenerate every cell of the body, and that happens most often during sleep,” Grandner told me.
Last year, his team delineated the potential mechanisms of how sleep impacts recovery. One mechanism involves the mediating impact of sleep and decreases in inflammatory markers which affect the immune system and affect how well muscles are able to recover and repair damage from training and athletic performance.
Meeta Singh is a Detroit-based psychiatrist and sleep medicine specialist who advises several professional sports leagues such as the NBA and NFL. She underscores the element of circadian clock, and how restorative sleep allows injuries to be repaired more efficiently.
“If you don’t get enough sleep, you’re more likely to feel pain and the requirement for pain medication actually increases, so recovery and healing can be affected by this for instance because the higher need for medications can interrupt the healing process,” Singh told me.
Rest, however, must be distinguished from sleep in that ‘rest’ involves more generally taking a break from a specific form of ‘overuse.’ This can be physical overuse as seen often in athletes, or mental or emotional overuse. Each form of overuse may have factored into the decisions made by Osaka, Federer, and Curry.
Athletic performance can also be impacted by rest and sleep. In 2019, Grander’s team found that student athletes who were less sleep deprived performed better. Similar patterns were found in male division I college basketball: increasing their sleep duration to between 6.6 to 8.5 hours translated to a significant increase in free throw accuracy, and shaved up to 0.7 seconds off their sprint times. Knowing sleep schedules may even help predict NBA team performance: East coast teams typically lose when playing on the West coast due in part to the circadian rhythm impact.
In February, Singh’s team published a paper that assessed the role of sleep among players in the NBA, which was followed up by a commentary in April on sleep in professional sports in general, and another in June, about sleep in the NBA bubble. The consequence of poor quality sleep and insufficient (less than 7 hours’) sleep is clear: it negatively affects athletes’ mental and physical health, increases risk of injury, and decreases performance. The February paper cites Sacramento Kings assistant coach Jason March, in an interview where he shared: “You ask anybody in the room, the thing I talk about is sleep…I think in a couple of years [sleep deprivation] will be an issue that’s talked about, like the NFL with concussions.”
So why, with all the research we have around about the harms of not prioritizing rest and sleep to our brain, recovery, and performance, does it still seem shocking when an athlete announces they’ll be stepping back to rest?
We can look to the controversy around the NBA’s Do Not Play (DNP)-Rest strategy, which San Antonio Spurs head coach Gregg Popovich helped pioneer, for clues. The strategy prevents players from participating in too many back-to-back games, to allow for adequate recovery and decrease the likelihood of fatigue and injury. In 2012, Popovich sat Tim Duncan out for a rest day — this was his first implementation of DNP-Rest.
But a 2017 article in the Baltimore Sun, which pointed to the positive impact of the approach on both the Cleveland Cavaliers and Golden State Warriors, suggested that DNP-Rest enrages fans, who just want to see their favorite players play. In March 2017, Lebron James took a rest day against the Clippers. He came back rejuvenated, scoring 34 points against the Lakers. Fans of that game were impressed, but the ones who bought tickets to the Clippers game were angry at having paid for a ticket to a game where “the King” didn’t play.
Not every team institutes DNP-Rest — it’s dependent on the coach. Pat Riley of the Miami Heat once claimed: “We don’t rest. I don’t believe in it. I think it’s gotten to the point where it’s become a travesty, an absolute travesty. Blatantly. I don’t care how many players you’re resting or who. Who are the ones entitled to get the rest versus who doesn’t rest? We don’t rest.”
Does DNP-Rest work? While a 2017 study found that performance and injury risk remained unchanged, correlation data collected by teams suggests that the number of games missed by players due to injury or illness declined dramatically when the policy was instituted.
Uniquely, as the COVID pandemic forced NBA players to play in a “bubble” in the same time zone, with one Athletic Trainer noting “This is the advantage that we have not had. We’re always tired…[now] our guys have been rested. They’ve been fresh. We’ve been able to get them recovered again and again.”
In December 2020, Singh’s team looked at the impact of these player bubbles, and found that removing the element of travel during pre-season NBA games, among other things, was associated with an increase in shooting accuracy, though it’s unclear if this was secondary to less circadian rhythm disruption, or the negative impact of excessive travel more generally.
At some level national sports culture plays a role in normalizing rest for recovery. In North America, the “hero” ideal of self-sacrifice and pushing beyond one’s limits to achieve a goal is prized and fans pay a premium on sports tickets to watch “their” player play. However, in European soccer, fans tend to be more concerned about player health, pushing coaches to sit players out if they seem fatigued or suffer an injury. In other words: soccer fans prioritize the long-term health of their favorite players, so that they can have the pleasure of watching them over the years.
What this suggests is that prioritizing rest for recovery in professional sports is less about the type of sport and culture, and more about the type of fan, and whether fans, who drive the billion-dollar global industry of professional sports would be ok with delayed gratification (seeing their favorite player sit out) if it meant their favorite athlete had the opportunity to recover, and thus perform at their best.
The conversation around wellness more broadly has for years centered around trends such as biohacking: fueling an industry pegged at over 4.5 trillion dollars. Some of the innovations in ‘self-care’ are justified, and are backed by evidence. However, true well-being and healing may rely more often on “not” doing something — over-exerting, overperforming, and overworking — as opposed to “adding” another trendy “wellness” element to our routines. This new recognition may be reflected in the post-COVID movement towards prioritizing the balance of rest and work, reflected in many choosing to work from home.
Indeed, over this past month, Osaka (who recently penned an Op-ed), Federer and Curry have modelled the idea that stepping back to heal, even in the midst of external pressures to push through, while the tougher choice, is often the most crucial to optimize well-being and long-term performance. And when we all understand the difference between the physical and mental implications of choosing ‘grit’ when what we most need is ‘rest,’ if recovery and healing is our goal, we’ll all be better for it.
**Originally published in Elemental July 2021**
The secret to sticking with your resolutions may be having a coach to help strategize and cheer you on.
My teenage patient looked nervous as I reviewed her glucose readings from her glucometer and her glucose logbook, which people with diabetes use to track their blood-sugar test results. There were a lot of high levels — ranges in the 12’s and 14’s, when the goal was around 7 or 8. The peaks were mostly in the middle of the day and on weekends. (This was in Canada; blood glucose readings of 12 to 14 are equivalent to 216 to 250 mg/dL in the United States.)
“What do you usually eat at home?” I asked. She said that her mother was careful to make her a breakfast that balanced carbohydrates with protein. Her dinners were similar.
“What do you usually eat at lunch?” I asked. My patient started tearing up. She ate whatever her friends were eating in her high school’s cafeteria that day — like spaghetti, hamburgers or pizza, and something like a cupcake for dessert. This was probably what led to her readings being so high.
She had met with diabetes educators before, and she knew what uncontrolled glucose does to a person with diabetes, from speeding up nerve damage in the feet to hastening blood vessel damage in the back of the eyes and the kidneys, to increasing her risk of heart disease.
I knew she could have told me all of that, so lecturing her wasn’t going to help.
Instead my patient needed empathy and the tools to help her make healthier decisions, and part of that required understanding what was important to her, specifically “fitting in” with her friends in high school, the ones who didn’t have a chronic disease. It also would have involved helping her find the motivation within herself to make the change.
But my skill set for helping her was limited, especially on top of everything else I had to cover within our allotted time of 45 minutes.
Research suggests that behavioral and lifestyle factors are a big part of what contributes to chronic disease. In medical training, we learn a lot about the body and how to prevent and treat disease, but little about how we can motivate a patient to change old habits or even stick with a current management plan.
It struck me that what my patient really needed was a coach. At this time of year when many of us have made resolutions to get healthier, working with a health coach might be one way to reach those goals.
A health coach is someone trained in behavior change, who primarily uses an interview style called “motivational interviewing” to help patients see their ability to make change. While some may have clinical training in fields like nursing or medicine, they hail from a wide variety of disciplines or train in health coaching as a secondary career.
As a relatively young field, it’s still finding its footing — for instance, a systematic review found that the definitions of “health coaching” varied widely, though the authors recommended that health coaches take a patient-centered approach to help with goal setting while encouraging self-discovery and accountability.
The evidence that health coaching may spur general lifestyle changes is mounting. A 2018 study looked at clinical trials for coaching for nutrition and weight management and found that over 80 percent of these studies found improvement. And a 2017 study found that coaching can lead to increased physical activity in older adults. Studies suggest that health coaching may also provide benefits for conditions such as obesity and diabetes as well as attention deficit hyperactivity disorder, chronic pain, hypertension and high cholesterol. A recent review found that health coaching can improve quality of life and reduce hospital admissions among patients with chronic obstructive pulmonary disease, and it may help patients to become more engaged in the health care system.
It may even improve health outcomes through encouraging patient adherence to medication.
“Health coaching recognizes that we cannot help people by expecting them to act if that person is not ready to act,” said Leila Finn, a health coach based in Atlanta. “We help people take big goals and break them down into accessible, bite-size pieces — not by telling clients what to do but by helping clients figure out what will work for them.”
Health coaching gets to the heart of what providing good health care is about: acceptance, partnership, compassion, and helping patients feel respected and understood.
Though my clinical training is in pediatric medicine, inspired by what I had read, I recently completed a certificate in health coaching myself. The experience was eye-opening and humbling. I learned new ways of communicating with my patients, specifically ways to encourage them to see their own ability to make lifestyle changes while setting manageable goals. I also learned ways to cheer them on when they reach their goals, without shaming them if they relapse: Both pieces are critical to the process of making sustainable change.
While research is beginning to show the value of health coaching, the principles of communicating with the intent to inspire and motivate are transferable to all health professions — and could reap dividends if taught early on in the training of nursing students, medical students, pharmacy students, and other allied health professionals.
And when I think back to my teenage patient with diabetes, while I was empathetic, that was only half of the solution. The second half could have involved coaching her to see which small changes she could begin to make moving forward. I’m hoping that choosing my words more effectively, even within the pressures of time, may make all the difference for my other patients.
**Originally published in the New York Times**
What if sleep were considered a continuous infusion of a medication that helped patients heal faster?
It was 11 p.m. and my 2-year-old patient was sleeping peacefully in her hospital bed, snuggled up with her mother and several stuffed animals. Her breathing was quiet and soft. Her bedside heart rate monitor, which glowed a faint yellow in the dark hospital room, was turned to “silent.”
“Sorry, I have to take a listen to her heart,” I whispered to her mother, tapping her shoulder lightly. Her mother and I had a good relationship: I had served as an advocate for her daughter several times during her seven-week stay in the ward. She had a rare disease that had been a medical mystery for many months, but she would be transferred to a more specialized center soon.
I hated to wake her, but recently, when I had offered to wait to examine a child until after a nap, my attending physician had scolded: “You can’t care about that. If you do, you’ll never examine them. They have to get used to it — they’re in the hospital, after all.”
But the poor girl was tired. She was poked three times a day for blood and taken to the M.R.I. or CT scanner at various times. I completed my exam: her vital signs, her heart, perfusion (how well her heart was pumping blood to her body), and palpated her abdomen to check her liver and spleen (which were enlarged, but no more than they had been). She seemed stable. I backed out slowly.
The next morning, the girl’s mother mentioned that it had taken another hour for her to fall asleep again. Was there anything that we could do to allow her to sleep through the night? Wouldn’t a good night’s sleep help with her condition? She had a point.
This is a fundamental question we have to ask about all of our patients, as research now shows that sleep disruption isn’t just inconvenient and doesn’t merely affect our moods or increase risk of disease. Disrupted sleep can in fact drastically affect how well patients heal from the condition that brought them into the hospital in the first place.
If sleep were regarded as a continuous infusion of a medication that helped a patient heal faster, provided them with emotional stability, and ensured they were in the best mind-set to understand the risks and benefits of that care, we would think twice about disrupting it.
Matthew Walker, a professor of psychology and neuroscience at the University of California, Berkeley, and the author of “Why We Sleep,” explored this issue in his research.
“Sleep is one of the most powerful, freely available health care systems you could ever wish for,” Dr. Walker told me. “But the irony is that the one place a patient needs sleep the most is the place they’re least likely to get it: in a hospital bed on the ward.” This year, his research found that a lack of sleep can worsen pain perception.
Recently, a study in Nature found that sleep disruption is directly linked to atherosclerosis, a buildup of plaque in blood vessels. As such, it doesn’t just increase the propensity for a heart attack or stroke, but in patients admitted for a condition related to clogged arteries, interrupted sleep could actually affect how well they heal in a hospital.
A study published last year found that sleep affects wound healing, including wounds from surgery or any type of procedure. Using the Pittsburgh Sleep Quality Index score, the researchers looked at patients with inflammatory bowel disease, such as ulcerative colitis or Crohn’s disease. These diseases are characterized by wounds primarily in the bowel, treated most often by medications to suppress the immune system. The wounds took longer to heal among the patients who had lower sleep scores.
Similarly, researchers have hypothesized that the healing of diabetic foot ulcers may be affected by undiagnosed obstructive sleep apnea.
And recently, a study on sleep and healing published in the Journal of Applied Physiology concluded that wounds were less likely to heal when sleep was disrupted.
Sleep fragmentation or disruption is not just an issue for patients, of course. It also affects health care workers — particularly medical residents who may be on call for a 26-hour shift several times a week — or nurses and emergency medicine doctors who work irregular hours that often disrupt their circadian rhythms.
A recent study in the journal Anaesthesia found that sleep deprivation among health care workers was directly linked to DNA damage. Research has found that a lack of sleep among residents can be a predictor for depression. Sleep-deprived doctors are also over eight times more likely to omit a crucial patient-care issue. Extended shifts even put people at risk outside the hospital: They triple the risk of a hazardous driving event, with 40 percent of attending physicians reporting that they’ve fallen asleep while driving.
Dr. Michael Farquhar, a sleep expert based in Britain, writes that many hospitals remain unaware of the impact of this issue. Particularly for night shifts, he writes: “We are not evolved to be awake at night. Our circadian rhythm, the powerful drive that helps regulate wake and sleep, means that we are at a physiological low when working at night.” One London-based campaign, “HALT: Take a Break,” offers ways to reduce fatigue.
As Austin Frakt noted in The Upshot last year, several hospitals are taking steps to address the problem. For example, nurses at Yale-New Haven Hospital try to give patients their medications before they go to sleep to minimize sleep disruptions.
Dr. Walker has suggested giving patients ear plugs and an eye mask if they stay overnight in a hospital, and having doctors be more mindful about when they wake patients for a question or an assessment.
As to the standard argument that American doctors have to work brutally long hours to be properly trained, Dr. Walker counters, “Countries such as France, Switzerland and New Zealand train physicians in the same amount of time despite limiting resident shifts to less than 16 hours, yet these countries continue to rank in the top 10 for quality of medical care and practice.”
He added: “It’s worthwhile remembering that after being awake for 22 hours straight, you are as cognitively impaired as if you were legally drunk. Nobody would accept medical care from an inebriated doctor. Yet we must accept medical care from doctors who are similarly impaired due to the lack of sleep the system imposes on them.”
As for my 2-year-old patient, she was transferred to a different hospital a few days later and eventually discharged. She is now getting outpatient care and is back on a regular sleep schedule at home.
Would she have healed faster if her sleep had been less frequently interrupted in the hospital? I can’t say. Maybe the sleep interruptions were justifiable for other reasons that could have improved her care. But the opportunity to have stretches of restorative sleep in a more comfortable environment at home will probably be a big part of keeping her well. And knowing that, I sleep better, too.
**Originally published in the New York Times**
