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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 2012 46: 150-154 originally published online

December 20, 2010
doi: 10.1136/bjsm.2010.077016

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Original article
1Universidade Federal de São
Paulo (UNIFESP), São Paulo,
Brazil
2Centro de Estudos em
Psicobiologia e Exercício
(CEPE), São Paulo, Brazil
3Universidade Federal do Rio
Grande do Norte, Natal, Brazil
4 Comitê Paraolímpico
Brasileiro (CPB), Brasília, Brazil
5Universidade Federal de
Uberlândia (UFU), Uberlândia,
Brazil
6Pesquisador CNPq
Correspondence to
Marco Túlio de Mello,
Departamento de
Psicobiologia, Universidade
Federal de São Paulo, Rua
Francisco de Castro, 93, Vila
Clementino—SP-04020-050,
São Paulo, Brazil;
tmello@demello.net.br
Accepted 1 November 2010
Published Online First
20 December 2010
150
Downloaded from bjsm.bmj.com on October 30, 2013 - Published by group.bmj.com
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
ABSTRACT
Objective The objective of this study was to evaluate
the sleep quality, sleepiness, chronotype and the anxiety
level of Brazilian Paralympics athletes before the 2008
Beijing Paralympic Games.
Design Cross-sectional study.
Setting Exercise and Psychobiology Studies Center
(CEPE) and Universidade Federal de São Paulo, an urban
city in Brazil.
Participants A total of 27 Paralympics athletes of both
genders (16 men and 11 women) with an average age
of 28±6 years who practised athletics (track and field
events) were evaluated.
Main outcome measures Sleep quality was
evaluated using the Pittsburgh Scale and the Epworth
Sleepiness Scale to evaluate sleepiness. Chronotype
was determined by the Horne and Östberg questionnaire
and anxiety through the State-Trait Anxiety Inventory.
The evaluations were performed in Brazil 10 days before
the competition.
Results The study’s results demonstrate that 83.3%
of the athletes that presented excessive daytime
sleepiness also had poor sleep quality. The authors
noted that 71.4% were classified into the morning type
and 72% of the athletes who presented a medium
anxiety level also presented poor sleep quality. Athletes
with poor sleep quality showed significantly lower
sleep efficiency (p=0.0119) and greater sleep latency
(p=0.0068) than athletes with good sleep quality.
Athletes who presented excessive daytime sleepiness
presented lower sleep efficiency compared to non-
sleepy athletes (p=0.0241).
Conclusions The authors conclude that the majority
of athletes presented poor sleep quality before the
competition. This information should be taken into
consideration whenever possible when scheduling rest,
training and competition times.
INTRODUCTION
The Paralympics date back to 1960, the year of the
fi rst Paralympic Games in Rome. After the Second
World War, the sports designed for athletes with
disabilities advanced in the contexts of preven-
tion as well as physical, social and psychic reha-
bilitation.1 2 Currently, the Paralympics are an
evolving process focusing on the participation of
disabled athletes at different levels and capabili-
ties. Additionally, the Games focus on scientific
development that furthers the understanding of
the influence of disabilities on exercise and sports
performance. 3 In the 2008 Beijing Paralympic
Games, Brazilian athletes fi nished ninth overall
with 16 gold medals and a total of 47 medals.4
The Paralympics become more competitive and
garner more interest each year. Thus, the study of
variables that directly interfere with both team
and individual athlete results and performance are
the focus of significant attention from researchers
and scholars. It is known that these variables are
linked to technical/tactical, physical and physi-
ological/psychological aspects that are directly
related to performance.
Even though the athletes are well trained
technically/tactically and physically, Becker and
Samulski5 suggest that athletes respond differ-
ently to external stimuli during a competition
since pressure from training and competition
is transferred to an emotional realm. Therefore,
well-prepared athletes can present reductions
of physical and emotional performance during
competition when they are under strong pressure
to perform well.6 However, other athletes can
improve their performance if they present a good
level of precompetitive anxiety associated with an
appropriate emotional and physical balance.6
The effects of excessive anxiety before the com-
petition led to several consequences for the ath-
letes.7 If anxiety levels are within normal levels,
these effects can be positive; if they surpass those
levels, however, they can cause severe emotional
reactions, including a decrease in performance.
Some evidence suggests that regular physical
practice produces a variety of physiological ben-
efits. Adaptability to physical exercises can be
found in young, adult and older populations as
well as populations that are healthy or influenced
by some pathology and/or disability. Several fac-
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
this long list of adaptabilities.8 9
Samulski and Noce10 carried out a study on
the psychological preparation of the Brazilian
Paralympic athletes and showed that the most
important reasons for becoming involved in a
sport were the enjoyment derived from practice
and the need for rehabilitation. The majority of
athletes mentioned the following stress factors:
sleeping problems, pressure to win and interper-
sonal confl icts.
Several studies have been carried out to evalu-
ate the relationship between physical exercise and
sleep quality. The most common change observed
Br J Sports Med 2012;46:150–154. doi:10.1136/bjsm.2010.077016

is the increase in slow wave sleep.11–15 Some studies have dem-
onstrated increased rapid eye movement (REM) sleep latency
and a decreased percentage of time spent in this stage,11 15
whereas others have noted an increase in total sleeping time
and a reduction in sleep latency.16
Very few studies related to Paralympic athletes’ sleeping
patterns and physical activities are available in the literature.
This may be due to the fact that the sleeping patterns of this
population do not differ widely from those of Olympic ath-
letes. One of the few studies in this area demonstrates a higher
frequency of periodic leg movements in individuals with spi-
nal cord injury; such sleep disturbances are associated with
greater sleep fragmentation and less successful physical and
mental recovery.17
Vuori and collaborators18 collected epidemiological data
from 1600 individuals aged 31–50 years and these individuals
were interviewed with the aim of determining the influence of
physical activity on sleeping. The authors report that social and
physiological factors, conditions of the sleeping location, sleep
pattern, lifestyle and conditions of the individuals directly
influence sleep quality and physical performance. However,
the authors concluded that moderate or vigorous exercise is
associated with improvements in sleep quality.
Therefore, the present study aimed to evaluate sleep qual-
ity, chronotype and anxiety levels of Brazilian athletes that
competed in the Beijing 2008 Paralympic Games.
MATERIALS AND METHODS
Subjects
A total of 27 Paralympic athletes of both genders (16 men and
11 women) competing in the track and field were evaluated.
They were selected by the Brazilian Paralympics Committee
to compete in the Beijing 2008 Paralympic Games.
Procedures
All evaluations were carried out in periods during which the
athletes were not involved in other activities and after obtain-
ing consent from the technical committee of the respective
modality. All evaluations were performed during the prepara-
tion period in the city of São Paulo, Brazil (August, 2008). The
athletes were evaluated with regard to sleep, sleepiness, chro-
notype and anxiety between 9:00 and 11:00 a.m. as an attempt
to avoid collecting data at physically and emotionally stressful
moments after practices.
Pittsburgh Questionnaire
The Pittsburgh Sleep Quality Index consists of 21 items that
evaluate sleep quality and disturbances through a report card
of the last month that includes seven components: sleep sub-
jective quality, sleep latency, sleep duration, sleep efficiency,
sleep disturbance, use of sleeping pills and daytime dysfunc-
tion.19 It was considered as the cut-off point when classifying
the following: ≥5 point was poor quality and <4 good quality
sleep.
Epworth Sleepiness Scale
This scale evaluates sleepiness in active and passive situations,
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;
lying down for an afternoon nap; sitting and talking to some-
one; sitting quietly for lunch; abstaining from alcohol use; and
driving but stuck in traffic for a few minutes. The athlete has to
Br J Sports Med 2012;46:150–154. doi:10.1136/bjsm.2010.077016
Original article
determine the chance of falling sleep in each of the presented
situations, scoring likelihood from 0 (no chance) to 3 (high
chance). The reference values are: Epworth Sleepiness Scale (SE)
normal, from 0 to 6; SE limit, from 7 to 9; SE slight, from 10 to
14; SE moderate, from 15 to 20; SE high, above 20.20
In addition to the above data describing sleep quality, this
instrument is important for verifying sleepiness levels in peri-
ods when athletes should be awake and attentive.
Horne and Östberg Questionnaire (chronotype)
Chronotype evaluation was performed using the Horne and
Östberg21 Questionnaire, which classifies subjects with regard to
morningness and eveningness using the following scale: 16–33,
evening type; 34–44, moderate evening type; 45–65, indifferent;
66–76, moderate morning type; 77–86, morning type.
State-Trait Anxiety Inventory
Anxiety-E is a provisional emotional state characterised by
consciously noticed tension and apprehension of varying
intensity over time. People with high levels of Anxiety-E have
a tendency to react more frequently to situations as if they
were threatening or dangerous. 22 The anxiety scale consists of
20 statements in which the subject is instructed to choose the
best option that defi nes his feeling at a determined moment.
The answer options are: absolutely not, a little, quite a lot
and a lot, with scores ranging from 1 to 4, respectively. The
State-Trait Anxiety Inventory (STAI) was designed to be a
self-assessed inventory and can be performed individually or
in groups, with an average time for completion of 20 min.
Statistical procedures
Data are displayed in tables and graphs. Data normality was
verified with the Shapiro–Wilk test.
Descriptive statistics confi rmed the mean calculation and
SD for all of the continuous and semicontinuous data with
a normal distribution. Data with asymmetrical distribution
underwent natural log (base e) transformation and are repre-
sented via the geometric mean and 95% CI. Categorical data
are expressed in absolute and relative frequencies.
In order to evaluate differences between the sleep efficiency
and latency between the good and poor sleep groups, a Student
t test was used for independent samples. The same test was
used to compare sleep efficiency between the sleepiness and
non-sleepiness groups. The variation coefficients were com-
pared with the Levene test, but no significant differences were
noted; therefore, the Welch correction was not needed.
For the analyses, SPSS Statistics 17.0 software for Windows
(SPSS, Inc, Chicago, IL) and Prism 5.0 for Windows (GraphPad
Software, Inc, San Diego, CA) were used. The value of α ≤5%
was defi ned to be statistically significant.
Ethics
The research was approved by the Ethics Committee of the
Federal University of São Paulo (CEP #1148/08). Participants
signed informed consent forms authorising collection of data.
All of the individuals participated in the tests voluntarily and
were aware of their processes and objectives.
RESULTS
Sample characterisation
A total of 27 Paralympic athletes (16 male and 11 female) from
track and field sports were included in the current study. The
151
 Original article

subjects had an average age of 28±6 years, average weight of investigations suggest that the non-REM sleep delta (NREM)
62.7 kg (±9.6) and height of 164.6 cm (±30.8). The athletes is fundamental for good physical recuperation. Additionally, it
competed in the different events described below: field (4 ath- is during the REM sleep phase that memory consolidation and
letes) and track (23 athletes). recovery of the cognitive aspects occur. In the current study,
Table 1 shows that 83.3% of the athletes that presented the athletes with poor sleep quality showed a sleep efficiency
excessive morning sleepiness also presented poor sleep qual- value of only 78.5%; to be considered normal, subjects’ sleep
ity, as evaluated by the Pittsburgh Questionnaire. We also efficiency value should be at least 85%.23
highlight that 71.4% of the athletes presented as morning Therefore, low sleep efficiency can directly affect physical
types. Finally, 72% of the athletes that exhibited a medium and cognitive aspects during the practice and competition
level of anxiety presented poor sleep quality. phases. Hence, monitoring of this aspect is fundamental for
Figure 1 shows that sleep latency was higher in the group optimal practice and competition performance. This fi nding
with poor sleep quality. and hypothesis is confi rmed in figures 1 and 2, in which we
Figure 2 demonstrates that non-sleepy athletes exhibited show that athletes with greater sleep latency presented lower
significantly greater sleep efficiency than sleepy athletes sleep efficiency and greater sleepiness during the wakefulness
(p=0.0241). period. These data demonstrate the low physical and cogni-
Athletes with good sleep quality demonstrated significantly tive recuperation achieved during both the resting period and
greater sleep efficiency than athletes with poor sleep quality, recuperation phase, which occurs during the dark phase and
as shown in figure 3. main sleep.
The influence of physical practice on sleep quality in the
DISCUSSION physical disabled has also been studied by our group. De Mello
The results of this sleep evaluation demonstrate that the major- and collaborators17 24 –26 carried out polysomnography (sleep
ity of athletes presented poor sleep quality and excessive day- study) in athletes with spinal cord injury who performed acute
time sleepiness. These are concerning data because scientific (maximum effort test) and chronic (practicing during 44 days
at a ventilatory threshold of 1) exercise. When sleeping, these
athletes demonstrated a significant decrease in periodic limb
Table 1 Epworth, chronotype, and Anxiety-E of athletes with good movements (PLMs). The effect of physical practice was not
and poor sleep quality significantly different from the results obtained in volunteers
Evaluations Good Quality Poor Quality Total
treated with l-dopa, which is a standard pharmacologic treat-
ment for PLMs. Therefore, physical practice demonstrates an
Epworth Non-Sleepy 6 (40%) 9 (60%) 15 (100%) ability to minimise that disorder in individuals with spinal
Sleepy 2 (16.7%) 10 (83.3%) 12 (100%) cord injury. Other researchers have specifically focused on the
Chronotype Extreme 2 (28.6%) 5 (71.4%) 7 (100%) incidence of PLMs in paraplegics.17 27 28
morningness
De Mello and collaborators29 observed that most of the time,
Moderate 4 (28.6%) 10 (71.4%) 14 (100%)
morningness
the physically disabled individual initiating a fitness program
Indifferent 1 (20%) 4 (80%) 5 (100%)
shows characteristics like depression and sleep disturbance.
Anxiety-E Low Level 1 (50%) 1 (50%) 2 (100%)
Through a questionnaire, these authors also evaluated sleep
Middle Level 7 (28%) 18 (72%) 25 (100%)
patterns and complaints in individuals with full medullar sec-
tion syndrome. A total of 59 individuals with medullar sec-
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. α≤5% is defined as statistically significant. great difficulty adapting to evening practices or transmeridian

152 Br J Sports Med 2012;46:150–154. doi:10.1136/bjsm.2010.077016


Figure 2 Comparison of sleep efficiency using the Epworth
Sleepiness Scale. α≤5% is defined as statistically significant.
Figure 3 Comparison of sleep efficiency using the Pittsburgh
Questionnaire. α≤5% is defined as statistically significant.
trips that cross several time zones; such changes may impair
performance if the athletes are not well adapted.
With regard to transmeridian trips, evidence suggests that
practice can alter the speed of biological clock adjustment. A
combination of light exposure, eating habits, outdoor prac-
tices and relaxation in the dark represents a method by which
to facilitate these adjustments in athletes. Such a procedure
was developed for the Brazilian Paralympic athletes that com-
peted in the 2000 Sydney Paralympics Games. The study by
De Mello and collaborators on the adjustment of Brazilian
Br J Sports Med 2012;46:150–154. doi:10.1136/bjsm.2010.077016
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
anxiety, which points to an interaction between sleep and
anxiety. 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
disturbances provoke a reduction in the percentage of time
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-re-
cuperative sleep due to the lack of sleep and reduction in the
percentage of Delta and REM sleep phases may be more tired
at practices because these athletes are not obtaining recuperat-
ing 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-
ercise recovery and competition performance for athletes that
present some kind of sleep disorder.
Acknowledgements The authors want to thank the Psychopharmacology
Incentive Fund Association (Associação Fundo de Incentivo a Psicofarmacologia—
AFIP), the Exercise and Psychobiology Studies Center (Centro de Estudos em
Psicobiologia e Exercício—CEPE), the Sleepiness and Accident Multiprofessional
Studies Center (Centro de Estudos Multiprofissional em Sonolência e Acidentes—
CEMSA), FAPESP (Cepid/Sono 98/143033), CNPq, the Brazilian Paralympic
Academy—Brazilian Paralympics Committee and FADA—UNIFESP. The authors
would like to thank Leandro Stetner Antonietti for the help with the statistical
analysis.
Competing interests None.
Patient consent Obtained.
153
 Original article
Ethics approval The research was approved by the Ethics Committee of the
Federal University of São Paulo (CEP #1148/08).
Provenance and peer review Not commissioned; externally peer reviewed.
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