October 1, 2025 • 54 mins
We asked Dr. Im about the role of sleep in injury recovery, what is considered optimal sleep, and when someone should be referred for pathological sleep.
Timestamps
(8:50) What signs & symptoms may indicate less than optimal sleep
(11:09) Sleep and recovery
(17:16) Stages of sleep
(18:23) Adapting stages of sleep
(21:32) Recommendations to improve sleep quality
(25:40) Special considerations for maintaining optimal sleep
(27:21) Role of naps in improving sleep quality
(30:39) Optimal timing of naps
(31:49) Relationship of mental health and sleep
(34:40) Pathological sleep
(41:05) Changing the circadian rhythm
(43:59) When to refer an athlete with pathological sleep
(46:30) Monitoring sleep
Action Item: What are some talking points you use with athletes to educate about their sleep and importance of sleep?--
AT CORNER FACEBOOK GROUP: https://www.facebook.com/groups/atcornerpodcast
Instagram, Website, YouTube, and other links: atcornerds.wixsite.com/home/links
EMAIL US: atcornerds@gmail.com
SAVE on Medbridge: Use code ATCORNER to get $101 off your subscription
Want to host a podcast like ours? Use our link to sign up for Zencastr, the service we use to record our interviews: https://zencastr.com/?via=atcorner
Music: Jahzzar (betterwithmusic.com) CC BY-SA
--
-Sandy & Randy
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:02):
Hey, this is Sandy. And Randy?
And we're here on at Corner. Being an athlete trainer comes
with ups and downs and we're here to showcase it all.
Join us as we share our world insports medicine.
Welcome back to another episode of At Corner.
For this week's episode, we willbe talking about what I think
(00:23):
everyone would agree we need more of.
Oh, that's a good, that's a goodstatement.
And I'm sure everyone's first guess was sleep.
Or hours in the day. For sleep.
True. Honestly, what would you do with
extra hours in the day? Probably sleep.
(00:44):
Yeah 100%. Honestly, I keep saying it to
all my student athletes who would again probably agree that
I don't understand how we get rid of nap time after
kindergarten. I feel like I need it more now
than I did in kindergarten. Yes.
I'm voting for nap time. Bring it back.
I mean, the ATR is kind of a napspace.
(01:07):
Not for me. True, the kiddos.
Do I have had some student athletes?
They'll ask, can I nap here? I'm like yes until I need the
table then I will wake you up and kick you off.
So if you don't already know thebenefits of sleep, we are going
to go in a deep dive of this rather than the and we kind of
(01:27):
talked about it too, instead of just the tip of the iceberg that
we've kind of been hitting on 'cause I feel like we've kind of
been talking about sleep a lot lately.
Totally a coincidence, but Doctor M is just the perfect
person to talk about this. And he's a board certified UCI
health psychiatrist who specializes in psychiatry and
(01:48):
Sleep Medicine. He's earned his medical degree
from Seoul National University College of Medicine in Korea.
He completed a combined residency in internal medicine
and psychiatry, followed by a fellowship in Sleep Medicine at
the University of Iowa in Iowa City.
So he, in this episode we talkeda lot about different sleep
(02:08):
disorders, how to improve your sleep, circadian rhythms,
insomnia, narcolepsy, restless leg syndrome, how anemia can
affect your sleep and so on so forth.
It's, it's pretty fascinating all the things that we talked
about and, and things that I didn't really expect us to talk
(02:29):
about, which I think is just goes to show how much sleep
really does affect. Absolutely.
So without further ado, here's Doctor M All.
Right. So at AT Corner, we definitely
like to like combine the evidence with the experience.
(02:49):
So if you can, kick it off with a story or maybe a case study
about the importance of sleep regarding working with athletes.
Yeah, I see. I can come up with an A case,
but it's not going to be the exact same case.
But as I have seen quite many student athletes, especially
college athletes, especially with quite many sleep problems,
(03:10):
I can come up with at this one. So this is a young 19 year old,
I think freshman or sophomore team sports.
I can say that it's a man's, a soccer player who came in with
anxiety and insomnia, which he has had for about like several
(03:33):
months, six months or close to half a year between the two.
Like insomnia and anxiety. I mean, both were pretty
significant problems. But from his standpoint, he
thought that insomnia started 1st and because of his inability
to fall asleep or staying asleep, he started building some
(03:54):
more like anxiety about his own sleep itself as as the
consequence. I mean, as a freshman or
sophomore, young, younger in theteam, he's not really expected
to be like a plane as a starter.But he, he felt like his
performance even during the practice was not going well as
(04:15):
expected. So he started having even more
anxiety about his own performance as well.
So that's when we saw him. And we of course, in the sports
psychiatric clinic, we go through a lot of screening
questionnaire. And the important thing is
what's called SMACKED developed by International Olympic
Committee or IOC. In short, we use the SNAP.
(04:39):
But as we are also specializing in more in sleep and sleep
disorders, we added more questionnaires and he screened
positive for what's called restless legs syndrome.
Oh wow. OK.
So restless leg syndrome is as the name exactly sort of
describes, you feel restless andin the legs and that is going to
(05:04):
be happening more towards the night time compared to the day
or some oftentimes exclusively during the night or at the time
of wanting to fall asleep. In fact, having the rest of the
stack syndrome was resulting in these insomnia or so-called, I
mean so-called insomnia, but in describing more it's difficulty
(05:26):
falling asleep. So he was absolutely having this
difficulty falling asleep, not necessarily because of those
quote UN quote insomnia disorder, but from these
restless deck syndrome. OK, So what we approach, how we
approach clinically when we identify arrested select
syndrome is that for the diagnosis itself to establish
the diagnosis, we don't really need any fancy like a blood test
(05:48):
or sleep study. It's just like a questionnaire
based subjective symptoms of having an urge to move the legs,
getting better by moving, worse at rest and worse at night time
meeting all those four simple questionnaires answering yes,
yes, then you do have these restless sex syndrome.
(06:09):
So as the one of the common cause of restless sex syndrome
is low iron or iron insufficiency.
We tested for iron and it was low, which is not very common
for young healthy male athlete which is I mean these low iron
is much more common in women female athlete because of having
(06:33):
like periods and also like issues with the diet or
nutrition. But we just supplemented iron
and within a few weeks he actually got so much better that
he really didn't require any other sleep.
AI mean he in the past tried like some sleep aids but more
common like over the counter melatonin and unisom or
(06:55):
Benadryl. He didn't really try.
He didn't want to try these prescription sleep aid because
of many of those dating sleep aid, Although I can talk about
it more later, But from the athletes standpoint, he was sort
of hesitant to try those prescription sleep aid because
of the worries that it'll probably hinder with his daytime
(07:17):
funk or ability to stay more like awake or focused.
So he was refusing to take any of those sleep aid, but he was
still taking sort of melatonin. But after supplementing iron, he
got better. He didn't require any melatonin.
He was able to fall asleep. And also as a result, his
anxiety, which was probably secondary to these insomnia or
(07:41):
insomnia symptoms from RASTAC syndrome, got so much better
that he didn't require any further medication management
other than just regularly checking these iron panel and
continuing with the supplementation of the iron.
And he's not really coming to see us anymore after about four
or five visits. So that's probably one of the
(08:03):
story that can be overlapping some areas of mental health from
the anxiety standpoint and sleepand insomnia.
Wow, that's amazing. Yeah, I was going to say that's
really fascinating because I feel like it's definitely not
the the easiest, like point A topoint B.
(08:24):
It's not the most obvious, I should say, but it's really cool
that you guys were able to notice that in the questionnaire
that you guys had, which also leads me to the question.
So you, you said that you were able to notice this like through
a screening, but without like formal questions and, but just
like from an athletic training standpoint, especially we're
(08:47):
seeing these athletes like oftenevery day.
So what signs and symptoms mightwe notice in an athlete with a
lack of a good quality sleep? Yeah.
So I mean that that's a great question.
The answer, my answer answer canbe in fact pretty lengthy.
But in terms of signs and symptoms of not getting good
(09:09):
night's sleep and good night's sleep from quality and quantity
standpoint, I mean quantity standpoint, not getting good
enough sleep, it's kind of obvious.
I mean even the athlete itself, they know how many hours of
sleep they get. I mean, it's kind of a
guesswork, but as a consequence of not getting enough hours
(09:32):
quantity wise, not enough hours of sleep, that can result in
many different problems from just as simply speaking daytime
fatigue, daytime sleepiness, issues with focus or
performance, irritability. And also I mean, if we are to
talk about those colleges student athlete, they're even
(09:55):
academic performance can be affected quality standpoint.
That's all a bit of tricky thingbecause when someone is getting
hours hour wise, good enough hours of sleep but still feeling
like not getting good quality ofsleep, that's probably in
relation to possible underlying sleep related disorders or sleep
(10:19):
disorders. Then we can possibly observe
some of those signs and symptoms, not necessarily a
consequence of not getting good night's sleep, but we may see
notice some of those symptoms ofsleep breathing disorders or
symptoms and signs of sleep related movement disorders or
behavior disorders or some specific disorders when somebody
(10:42):
having relatively rare disorderslike narcolepsy, for example.
I mean all those are possible. But just simply speaking from
these different aspects standpoint, I mean there are
physical issues, there are cognitive issues, emotional
issues and also as an athlete wecan see some performance
(11:02):
changes. So going into that kind of like
that performance standpoint, what role does sleep play in
that recovery process, whether it's from just normal working
out and training or even the injury and concussion
standpoint? Yeah, that's that's great.
And in fact, our team doctor Unjong Chu and I wrote a an
(11:27):
article published last year, only last year in Sports
Psychiatry Journal, which was a case and a case based review of
an athlete who was having multiple injuries and also
unexplained medical symptoms. And that was probably due to
overtraining and what what we call an overarching as well, or
(11:50):
sometimes there is a lot of different terminology.
But from specifically from injury standpoint, sleep is
very, I mean, it's crucial to have good night of sleep in good
amounts. So from physical injury
standpoint, regardless what typeof injury it is, I mean, most
(12:13):
common injury might be like a muscle injury, right?
And also it could be like a joint ligaments, but those
connective tissue injuries, growth hormone is very important
thing to have enough to for, forthose recovery mechanism, right?
And growth hormone is much more abundant during a certain sleep
(12:35):
stages like deep sleep or non REM stage of three sleep and
that those deeper non REM stage of three is much more
concentrated during a certain time of the night.
So being able to capture those good enough deeper or slow wave
sleep is important for that likeendocrinology or hormone based
(12:56):
standpoint in injury recovery standpoint.
One thing is about like especially about brain related
issues, which is most commonly concussion, right?
That part can be tricky because either traumatic brain injury,
TBI or concussion itself actually heavily affect our
(13:18):
sleep. So many patients or athletes
with the TBR concussion actuallywould complain about significant
change in their sleep from the moment of this conclusion event.
And or so it can actually last over easily over six months to a
year. Wow.
It can affect sleep in either direction, resulting in
(13:41):
significant insomnia, but more commonly sleepiness and sort of
a foggy brain, those resulting in either excessive sleepness or
excessive amount of sleep. So in medical term either
hypersomnolence or hypersomnia. So many people, athletes with
(14:06):
the TBI would experience those excessive amount of sleep or
sleep need. But that gets better and better
over time, but that takes like asix months to a year or so.
However, there might be reason why they actually require that
much of sleep because just it's although it's a sort of an
assumption to get recovered fromthose brain direct heat to the
(14:28):
brain. I think what our actual brain
really needs a much longer amount of time being in sleep
because our brain is being refreshed or cleared while we
are in sleep, right? So from that standpoint, I think
it's very important. Sometimes I guess sleep specific
(14:51):
sleep stages, specific changes may occur.
I, I just talked about like importance of sleep, sleep in
having good enough growth hormone to the body, but other
sleep stage called REM sleep or rapid eye movement sleep might
be important in building these muscle memories.
(15:15):
Although it's all still kind of a speculation.
There was an, a good hypothesis or theory about someone with a
spinal cord injury, even like a quadiplasia having these muscle
twitches while they are in rapideye movement sleep or REM sleep.
(15:36):
I mean, we normally in REM sleep, our bodies, some muscles
are completely paralyzed, but our body, normal body may
actually go through some period of muscle twitches in REM sleep.
But people with spinal cord injury actually may have even
more muscle twitches in REM sleep.
(15:58):
And there was some trial of probably bringing more muscle
twitches in REM sleep to accomplish some sort of a
recovery from spinal cord injury.
I don't know what happened thereafter, but we do believe
that there's something about this REM sleep.
I mean, the other sort of indirect evidence might be,
(16:22):
which is an interesting thing like about REM sleep baby like
newborn baby and infant have a lot of REM sleep.
So as a newborn more than 50% oreven more than 2/3 of your
sleep, you are in R.E.M. rapid movements.
(16:44):
And that may be related to they're building all those like
muscle strength and also muscle memories to get stronger.
And eventually they start crawling, standing up and
walking, right. So as they can do, they are able
to do so their amount of Rems toactually decrease further down.
(17:04):
So by the age of like toddler, the amount of these Rems to be
about the same as an adult, about like a 20 to 25% of their
sleep time. Wow, that's cool.
That's really interesting. What are some of the other
phases of sleep? Others other than REM sleep.
So REM sleep and non REM sleep, right when there is rapid
(17:25):
movements of sleep, there is nonREM.
But I as I said, REM sleep is only about like 20% or 25% of
the entire sleep time. So the rest are non REM sleep.
And these non REM sleep can be classified into 123 in the past
down to four in the past. But those are sleep staging
(17:48):
system was simplified in 2007. So we have now non NEM stage 1-2
and three or we call it N1 N 2, N 3.
And as the number goes down, it's sort of a deeper sleep
stage. So N 3 is what we often call a
deep sleep. And if you look at the brain
(18:09):
wave during this deep sleep, ourbrain wave is very slow, much
slower than the other sleep stage or awake.
So it's called a slow wave sleepor deep sleep.
Is there a way that we can affect how much deep sleep or
how much of like REM sleep or ordifferent the different phases,
(18:30):
can we affect that at all? So that's an interesting
question and it can be sometimespractical.
I mean, for example, let's say that I mean, you 2 are still too
young to have some teenage kid. But I, I do have two teenage
boys and both are in fact athletes.
(18:52):
I'm not tall, so they are not really tall either.
Hold on. One thing is like I said, growth
hormone is being produced and secreted much more efficiently
during these N3 sleep, right? So to get taller, right, grow
faster or taller, you'd like to have more N3 sleep, right?
(19:15):
Oh, OK. So if there is some strategy to
increase the amount of N3, that'll be great, right?
Yeah. So I thought of those a lot,
right, to help my kids as well. There's no like magic, but the
sleep stage progression overnight is with a certain like
(19:36):
a pattern or characteristics. It's not like cycling of those
sleep stages with the similar pattern.
I mean, although we do have these progression of sleep
stages into stepwise and it cycles about four or five times
throughout the night. However, within this, while it's
(19:59):
cycling through the night, N3 sleep is much more concentrated
during the beginning portion. So we have longer more prolonged
N3 at the beginning and shorter RAM and as it cycles through we
have shorter N 3. And more R.E.M., meaning that at
(20:21):
the beginning of the sleep at night we tend to have more and
three and towards the end of thenight we tend to have more
R.E.M. And assuming that you have
regular, relatively regular circuit and rhythm, if you are
actually missing the beginning portion of your sleep hour,
(20:42):
basically you're going to have relative and three sleep
deprivation and three depth. Or if you're actually waking up
normally at let's say 7:00 AM, but some like in a row, you are
told to wake up at 4:00 AM for some reason, then you're going
to actually have less of those REM sleep, less opportunity to
(21:07):
go into the REM. So you're going to actually
develop some REM sleep debt, right?
So the timing of the night, thatcan be one way to sort of
regulate. So if you, if you'd like to
actually have more M3 sleep, youshould really miss this first
several hours of good M3 opportunity, right?
(21:27):
Does that make sense? For sure, yeah.
So is there like, what would therecommendation be for athletes,
whether it's like how long they should shoot for, like a length
of time for their sleep or even ways that maybe they can just
improve the quality of sleep that they're getting?
Yeah. So in fact, that's number one
(21:48):
question that we get and that's why out of those five bullet
points that we put onto the the education posture for our
college athletes, the number onetop what point was to get enough
hours of sleep. But what we say it said in the
the second line was 7 to 9 hours, not necessarily aiming
(22:11):
for 8 hours, but we put 7 to 9 hours, which is also based on
the consensus statement from about four years ago.
There, there is a an article published which was a consensus
statement by so-called state experts published in British
(22:32):
Medical Journal or British Job Sports Medicine.
That journal article is also recommending 7 to 9 hours.
But that's pretty like broad, right?
But that means that there is an individual variability of how
much is sleep we need. Why not 8 to 9?
Why did we put 7? So that there is another
(22:55):
explanation. But several years ago, National
Sleep Foundation changed their recommended sleep time from 8
hours down to seven hours. One of the reason is because
when the recommended sleep hoursis 8 hours, while there is in
fact an individual variability, some people, some person may
actually do OK with the seven hours of sleep, but oh, I'm not
(23:17):
getting 8 hours. What's wrong?
Am I having like having the period of insomnia or is there
something wrong that can result in so much anxiety and that can
result in actually insomnia itself when there's nothing
wrong? So 79 hours.
However, there is an interestingthing about the so the second
bullet point in our poster made by Doctor Cho was be still be
(23:42):
flexible. Your mindset about these hours
of sleep, it has to be really flexible because you're not
really staying in one area or your schedule is not the same.
You're going to competition sometimes often involving
trouble and travel across time zones, right?
Or even without crossing the time zone.
(24:05):
Like if you watch like U.S. Open the first day yesterday
after it's still played out until like 1:00 AM or sometimes
even 2:00 AM, right? Even though you actually still
live in New York City, you play for that and you are playing in
a very weird time. Yeah, for sure.
You have to be have, you have tohave these mindset to be ready
(24:28):
to be flexible about sleep hoursincluding in fact sleep time and
also sleep hours and you have. That means that oftentimes you
might be actually sleep deprivedor during this competition or
travel. So there is a concept of what's
called banking sleep. OK.
(24:50):
I talked about debt. Random sleep debt or not, a slow
way to sleep debt. There's a way to bank, right?
So if there is a concept of banking sleep and it may
actually help. So if you're expecting to go for
competition or travel during which you know that you're going
(25:11):
to lose some sleep, then you canactually bank by allowing
yourself more sleep hours or sleep opportunity for a week or
two, whatever time frame prior to that event.
And that is proven to be of helpin performance as.
Well, oh, that's really, that's really fascinating.
(25:32):
That's really interesting. I've never really heard of
sleep. Sleep banking, that's pretty
good. Also, I was wondering if that
recommendation, does that vary by like age or gender or sport
or season or or are there certain factors that you would
would carry more weight in termsof how long or how short someone
(25:55):
sleeps? So that's an interesting
question, but we don't really know much about how the
different sleep hours would affect or vice versa, how the
age or gender or type of sports would affect the need of sleep.
Although sleep is very importantand everyone sleeps and everyone
(26:18):
knows what sleep means, the association between sleep and
sports hasn't been really researched or objectively
tested. But what's for sure is in fact
the season versus offseason thatbanking of sleep banking was
(26:38):
sort of introduced in an expectation of steep loss during
the competition and travel, right.
So I mean, you probably don't really need much steep banking
if this is an offseason and you're training routine or
practice schedule is relatively regular.
But in expectation of those changes of steep hours that you
(27:01):
can get, I mean those steep banking will probably have to
occur during the season before the upcoming travel, right?
So kind of going on that flip side of like if maybe someone
wasn't able to bank their sleep or maybe this could even be a
part of it. What role does nap napping play?
(27:23):
And maybe the sleep banking process, but also maybe trying
to recover some of the sleep that you might have lost.
Right. So that that's great questions.
I mean, there are some research done about how nap, especially
short naps affect at its performance or reaction time or
(27:44):
focus and concentration. What we know is that short naps,
like 20 to 30 minutes of short naps can definitely affect it
and that's what I would recommend to routinely utilize
during whether it's a season or offseason, during the practice.
(28:06):
I mean, if you feel like you arenot getting enough hours of
sleep overnight or if you feel tired during the day midday,
it's very OK to have short naps.20 to 30 minutes of nap OK.
I wouldn't recommend lengthier naps like a 60 to 90 minutes.
However, some experts suggest that even 60 to 90 minutes nap
(28:30):
may actually help. I mean, as a layperson, you may
actually raise a head and then ask this question.
Doctor, wouldn't 60 to 90 minutes of nap better than 20 to
30 minutes because it's longer nap, right?
That's sort of common sense. But from just the regular sleep
hygiene standpoint or sleep science standpoint, 20 to 30
(28:53):
minutes of shorter naps are OK to have routine drink as a nap,
whereas these are 60 to 90 minutes nap.
Actually that can certainly affect your ability to sleep at
night time. So we generally do not recommend
this lengthier nap. The other thing is that when you
are taking this lengthier nap, what ends up happening as you're
(29:16):
waking up from nap is that you may actually feel even more
groggy and tired depending on what sleep stage you are waking
up from. Whereas a 22 short 30 minutes
nap, you would never really go into the deeper slow wave sleep
or REM sleep. So it can be relatively short
and refreshing. That's what we often see from
(29:38):
the the patient's or normal population.
So we do really do not recommendthis lengthy or neck.
However, from the sleep banking standpoint during the season
expecting future upcoming sleep loss for banking the the sleep,
it may not be enough to just enforce longer sleep window
(30:02):
overnight. I mean, when banking sleep, what
they're recommending is like sleep window to be about 10
hours overnight, but that doesn't really result in
actually longer sleep. It's more of a sleep window,
right? From that standpoint, if you
really need to bank your sleep more than this, lengthier net
(30:24):
may be of benefit, but not really close to evening hours.
I mean, it'll probably still be limited to the up to midday.
Actually, that was going to be my next question was like timing
of it. How like is it best to be kind
of in that midpoint or is it best when you're feeling groggy
or is it kind of like flexible as long as you don't get close
(30:46):
to those evening hours, like right before you go to bed?
So from a short nap standpoint, 20 to 30 minutes nap, I think it
can be any time you feel tired or sticky, although there's no
science behind it. Probably limit that to before
like four or five PMI mean if it's too close to bedtime, even
(31:07):
if it's a short nap, it can certainly affect the ability to
sleep at night time. From those longer nap standpoint
with the purpose of sort of banking sleep, I would say
probably not after two or three PM.
That's, that's going to be my recommendation.
If I have to come up with some sort of a a sleep regimen for my
(31:29):
athletes, that's what I'm going to use.
Yeah. And I've, I've noticed that for
me, like if I nap after 5, like it jacks me up, like I can't
sleep after that. So yeah, I've definitely noticed
that you're at the beginning of this episode, your kind of case
study kind of brought this to light.
But what what does, what role does mental health play with
(31:51):
sleep and maybe vice versa? How does sleep also affect maybe
mental health as well? Yeah, it's the question is
really broad, right. I mean, we have to probably
define like what mental health is and what sleep is and how it
those are sort of separated. I mean when it's really not
separated. I mean, my simple answer is that
bidirectionally it's heavily affecting each other.
(32:16):
If you look at people with anxiety, depression like top two
most common mental health conditions, even chronic
depression and chronic anxiety which anybody can actually have
at some point in their life, presence or absence of steep
(32:40):
problems or insomnia. If you look at the association
like odds, the odds ratio is just huge, oftentimes 10 or 20
times based on whether you have sleep problem or not.
I'm not saying that having sleepproblem is going to result in
depression and anxiety. It's just bidirectional, but so
(33:02):
strongly associated. The other thing is that when we
are treating mental health conditions, depression or
anxiety for example, we may see those symptoms get better and
better or actually stay the same.
Oftentimes in the case what how their sleep is going, that can
be a marker of where they are from the underlying baseline
(33:26):
mental health problem standpoint.
So sleep can be a marker of the progressional improvement of
their underlying mental health conditions.
The other thing is that we really have to take a sleep into
consideration in choosing the proper psychotropic medications
because depending on the underlying symptoms, even if we
(33:49):
choose a medication for depression, we may have to
choose totally different type ofthe medications depending on
whether they have insomnia versus hypersomnia and and
things like that. So the association between the
two direction and how those two affect each other, it's just a
(34:09):
lot. Interesting.
Actually you, you kind of touched upon it with, I feel
like we talked about insomnia a lot.
And when you, when you think, when people talk about sleep and
quality of sleep or inability tosleep, they, they really, that's
the first thing they think of isinsomnia.
(34:30):
But we never really talk about excess sleep or if someone just
is, is just sleeping so much. And how can you talk a little
bit about that or even other sleep pathologies that maybe are
common, but we don't really talkabout as much as like insomnia?
(34:50):
In fact, I really like this question, especially as a sleep
disorder expert. When someone comes in
complaining or saying that I have insomnia, really have to
dig into more what it means by saying insomnia.
Like the case example we talked about that athlete who came in
(35:12):
with insomnia which resulted in anxiety.
It was not actually a true insomnia disorder.
It was just the symptom of insomnia secondary to the other
underlying sleep related disorders.
In his case was restless tech syndrome.
But there are other common causeof insomnia which is not
(35:34):
insomnia disorder but insomnia symptoms.
For example, like sleep apnea, obstructive sleep apnea, which
is common, not like very common in young athletes or college
athletes, but obstructive sleep apneas are so common that it can
cause insomnia in that the sleepcontinuity is interrupted.
(35:59):
And oftentimes as a result of chronic untreated sleep apnea,
people actually can have difficulty falling asleep as
well. Your brain does not want you to
be in asleep because the brain knows that you are going to be
in danger repeatedly overnight from not breathing.
So you may actually develop thiseven initial insomnia.
So when you see someone who is saying insomnia, you really have
(36:23):
to think insomnia initially as asymptom rather than going into
labeling as an insomnia disorderand recommending like a sleep
aid over the counter or prescription sleep aid.
Those are not really the right approach.
You really have to allow the person, athlete in our cases to
describe what it means by insomnia and then we can
(36:46):
actually go over some other potential sleep technology.
I mean, you mentioned about excessive sleepness or
hypersomnolence, but one of those condition which is rare,
like narcolepsy, you've probablyheard of the term narcolepsy.
That is a rare condition, but often used to describe someone
who is having a lot of daytime sleepiness and sleep attack who
(37:10):
just doses off anywhere, right anytime.
We often describe it as a narcoleptic person, but even
that narcoleptic person may not really have narcolepsy, but that
excessive sleepness may be a result of not getting good night
sleep or having very poor sleep quality and the quantity.
(37:30):
So even when someone saying I, Ihave so much sleepiness during
the daytime, you actually have to think about what's happening
at the night time. And the other common conditions
that we really have to either ruled out or ruled in in
assessing for sleep quality is these sleep related breathing
(37:51):
problem. Like I just said, sleep apnea is
very common and also sleep related movement problem like
restless tech syndrome. And also there is a sleep
equivalent, I mean restless techsyndrome resulting in what's
called a periodic Lyme movement PLM, which is a sleep equivalent
(38:12):
of restless tech syndrome, whichmay be possibly more common in
athletes. We are, we are trying to look at
that the, the difference in the prevalence of restless like
syndrome in our system. But those are the things that we
have to look for. And there are two other things
which we do not commonly think about is 1 is circadian rhythm.
(38:38):
If you're to deal with a lot of like athletic trainers work for
college athletes or college at university systems.
But those young young adults or even like late teen teenagers
tend to have delay in the sleep phase.
They are basically a lot of times night out not because they
are like lazy or just it's not because they are just living
(39:03):
their life as whatever happens to their body and the brain.
It's in fact a norm that almost anyone in this young adulthood
have tendency to have delayed sleep phase.
So we may actually have to accommodate their this different
sleep time. Although in that case, should we
(39:27):
actually see this as a disorder or just a variant in the
normalcy based on their age? The other thing we have to look
at is the travel result, like resulting in jet lag.
I mean, a lot of college and athletes after travel,
especially with these change in the conference these days, like
(39:48):
ACC, Atlantic across the whole entire nation, right?
Stanford and Berkeley are in thePacific, but they are in ACC.
For example, the Big 10. It used to be Midwest.
State University, but now it's across the whole entire nation,
right? They travel a lot.
So we really have we have to be very mindful about jet lag.
(40:09):
The the last category of sleep disorder is what's called
parasomnias, meaning sleep having a certain type of sleep
related behaviors commonly I guess sleepwalking sleep terrors
which are more common in like pre teenagers which they often
(40:29):
grow odd. But our athletes are much more
pointed about these persomnias because of their erratic sleep
schedule and relative sleep deprivation.
So they are point to develop those conditions as well.
So there are these six big categories of sleep disorders.
We have to possibly look for insomnia, hypersomnia, circuit
(40:52):
and rhythm problem, sleep related breathing problems,
movement problems and the sleep delay behaviors.
Speaking of circadian rhythm, isit possible to change your
circadian rhythm? If I have to choose between yes
and no, it is possible. It's a yes.
(41:14):
But is it easy? It's not very easy, but textbook
wise we know. We know what to do and how to
change. OK.
OK, interesting. Yeah.
So I mean just as simply speaking, our circulated rhythm
is regulated heavily by the presence and absence of light.
(41:36):
Our says 24 hours. Why is that?
It's because the earth rotating the facing the sun and away from
the sun, it's the it's 24 hours,right.
So basically light is the strongest sort of what we call a
sitecapper, time keeper of our brain's circuit and rhythm
(41:59):
system. So exposure to the bright light
at a certain time of the day, that can be the best way to
regulate our circuit and rhythm.OK, interesting.
For sleep behaviors, you said sleepwalking, did you also say
sleep talking? Sleep, I said.
Sleep terror. Sleep talking is also in fact
some of those prosomnia behaviors or sleep related
(42:22):
behaviors. The phenomena itself, sleep
talking and sleep is not normal.But is it considered a sleep
disorder? No, it's not.
Anybody can actually have a sleep talking, so we do not
consider it as a sleep disorder.It's just a normal variant that
can happen to anybody. Is there a genetic component to
(42:42):
it? That's a good question, but as
sleep talking is not really a disorder I don't think people,
scientists or experts paid attention to that.
That makes sense. But other persomnias during non
REM sleep as persomnias a certain type of behavioral
(43:05):
experience that's happening during sleep.
And as we talked about sleep is either REM sleep or non REM
sleep. So those prosomnia can be
categorized into non REM relatedprosomnia and REM sleep related
prosomnias. And typical non R.E.M. prosomnia
would include sleepwalking and sleep terror.
(43:27):
And those are sleepwalking and sleep terror when someone is
having this. And if you ask family history,
certainly there is very strong family history.
Oh, his, his father did that toountil age 5 or 6.
There's very strong family history.
But is there a, a certain gene type?
I don't. I mean, there might be, but
(43:49):
probably people haven't really looked into that in detail.
Got it. So for some of those pathologies
that you kind of talked about, what are some things that the
athlete trainer should be kind of noticing in their history or
maybe just hearing the athletes talk about, like when we should
probably refer someone based on sleep and then who exactly
(44:09):
should we refer them to? There was out of our five bullet
points in our poster, that was #5 because number 1234 were more
about sleep hygiene and sleep education, what to do and what
not to do. But #5 is regardless, I mean a
person may actually try almost everything to sleep well but
(44:30):
when a person has a underlying sleep related disorders like
sleep apneas restless tech syndrome, the quality and the
quality of sleep cannot be good enough right?
So from sleep, breathing standpoint, if someone is having
loud snoring or weakness apneas,then that should be signs or
(44:54):
symptoms which needs some medical attention.
If someone is having these restless legs, having an urge to
move the legs, discomfort in thelegs, that's much more
pronounced at night time that also needs an attention which
can be often ignored. I mean, especially athletes may
ignore that saying they're thinking that, oh, I have this
(45:15):
because of my practice meaning today, right?
Which might be to some degree true.
But when it's much more pronounced at night time and as
a result, not having a good night's sleep or having
difficulty falling asleep, that could be in fact restless back
syndrome. So that needs to be tested.
And the other persomnia symptomslike a sleepwalking sleep
(45:38):
terror, those are so apparent. So having a roommate doing this,
I think it may be wise to recommend to seek some workups
with a psychiatrist or sports psychiatrist as well.
Any psychiatrist or Sleep Medicine physician should be the
right person to further evaluatefor those.
(46:00):
And if someone's daytime steepness is too much excessive
more than what can be expected from the effect of the previous
night's sleep quality or quantity, like if it's excess in
excess, then that daytime hypersomnolence or sleepiness
has to be evaluated as well. Perfect.
(46:23):
Just a follow up on that with the like how long of someone
sleeping? Is there a way that you
recommend athletes to monitor their sleep?
Or do you recommend them not monitoring their sleep because
it would cause some anxiety likesomething you mentioned earlier?
Or is it individualized? Yeah, right.
That's a great question with no one right or wrong answer.
(46:45):
But if this is a normal population, just no more adult
who's not really athlete who comes to see me into the sleep
clinic or psychiatric clinic worried about their sleep hours,
then my general recommendation is not even like touch any like
monitoring devices. I mean these days we do have all
(47:05):
those gadgets and wearables, Apple Watch, Fitbit or rings.
There are so many. But when you already have these
sleep problems or so-called insomnia relying on the
objective data using these, you may think oh it's a good way to
monitor but often times it may not because a person is already
(47:29):
having too much thought and anxiety provoking thoughts on
this. And adding more data to that it
can actually result in more problem.
Even there's a condition labeledas what's called orthosomnia
like insomnia. But orthosomnia is a someone who
is having two rigid thoughts, obsessive thoughts about what's
(47:51):
right amount of sleep, also thinking about sleep insomnia
resulting problem. But for athletes who's not
really having much like actual sleep problems, just who wants
to monitor their sleep for better sleep health and
awareness, right. In that case, I think those
wearable devices might be of help our other expert doctor Cho
(48:15):
in her some of those program that really hasn't really
started she's recommending wearing.
I mean using some of those wearable devices to monitor
their steep hours and steep timing that can.
There are some evidence that having this awareness of their
(48:36):
own sleep amongst the athletes can result in better sleep hours
and performance enhancement as well.
Awesome. Yeah.
All right. Actually, I was going to ask
really quick before before the action item.
It kind of ties in though, so there were five bullet points.
(48:57):
Did we hit all 5 bullet points or are we missing any?
So let me actually look at my poster.
I think the action item might get them.
So number one was enough sleep time, at least the 79 hours per
night. Our number 2 was wake up at a
consistent time but be flexible during the competition and the
(49:17):
travel #3 was avoid large meal, bright light and heavy exercise
within two to three hours beforesleep.
Number 4 was avoid stimulating drugs or supplements after two
or three PM that. Would be like caffeine.
(49:38):
Right, Right. Exactly.
Yeah. Oh, good to know about the
three. PM. 3:00 PM.
A lot of efforts you actually use caffeine and interestingly,
caffeine is the only substance that's not really banned,
although NCAA limits the amount,right?
Yeah, it's what's called so-called ergogenic.
(50:00):
Yeah, it. Can enhance the performance.
Still not banned and it can regulate their sleep to some
degree or wakefulness to some degree.
A lot of people use caffeine, but it's not wise to use
caffeine or energy drink with caffeine in it after a certain
time. And athletes have to be really
careful these days. A lot of electrolytes drinks
(50:22):
have caffeine in it. So you really have to have to
look at the label of those drinks, beverages.
Yeah, that's a really good point.
Yeah, for sure. I've been noticing that too a
lot. A lot of these sport drinks are
starting to add caffeine. Yes, OK, you.
Want to wrap it up? Yep.
So to put a nice little bow finishing up with a little
(50:43):
action item, what are some talking points you use with
athletes to educate about their sleep and perform importance of
sleep? In fact, we talked about those
five bullet points and I just went through 1234 already.
So those four things will be very important for according to
good sleep hygiene, especially as an athlete, but be flexible.
(51:05):
You may want to utilize those sleep banking practice if you
want to. But I think I would be a little
bit careful because doing this during mean, of course, sleep
banking is to compensate for upcoming sleep debt.
But I would say try it before doing the offseason to see what
(51:26):
your pattern is like. And then the other thing, the
last thing is we went through these symptoms and signs of
potential sleep disorders. So if you have those, talk to
your AT and then have an arrangement to be referred to
the sleep experts. I mean if we are talking about
the sleep disorders especially then refer to the sleep
(51:49):
physician. Those will be important.
So those will be the main actionitem.
I think what was really awesome chatting with Doctor M about is
just understanding when someone should probably be referred
about sleep. Have you?
Ever referred someone for their sleep?
No, but now I'm thinking, man, maybe we should have.
(52:10):
And not only that, but where do you refer them to?
Yeah, that was that was a big one.
Right. The psychiatrist, I probably I
wouldn't have wouldn't have put the two and two together at
first. But after talking to him, like
it makes so much sense. Like that's totally up his
alley. Yeah, and with just how much of
(52:34):
an emphasis just within athletics in general has now
been putting on sleep, hopefullywe as a profession and just us
in like the athletic realm will start to see more tools for
athletic trainers to help identify someone who might be
having pathological sleep. Yes, absolutely.
(52:56):
So if you guys are new, we do every episode as either an
interview like this one, which we have a lot of this season, or
a story episode where we take stories from real life athletic
trainers and put them together all about one feature topic.
We also have CU episodes where our latest five are free
category AC us. Thank you so much to clinically
(53:18):
pressed and athletic training chat where Randy takes a bunch
of research articles, he reads them and we talk about them in a
conversational format. So you don't have to.
And then we have this year we'redoing, we're going back to our
BOCIRL episodes, which are wherewe take BOC topics and we talk
(53:41):
about them in real life. So like what does that look like
beyond the textbook? And those this year are brought
to you by AT Study Buddy. So.
Stay tuned for those. We're, we're releasing our first
one up here pretty soon and I think that's all I have.
(54:02):
Thank you for helping us showcase athletic training
behind the tape. Bye.
Hey, this is Sandy. And Randy?
And we're here on at Corner. Being an athlete trainer comes
with ups and downs and we're here to showcase it all.
Join us as we share our world insports medicine.
Welcome back to another episode of At Corner.
For this week's episode, we willbe talking about what I think
(00:23):
everyone would agree we need more of.
Oh, that's a good, that's a goodstatement.
And I'm sure everyone's first guess was sleep.
Or hours in the day. For sleep.
True. Honestly, what would you do with
extra hours in the day? Probably sleep.
(00:44):
Yeah 100%. Honestly, I keep saying it to
all my student athletes who would again probably agree that
I don't understand how we get rid of nap time after
kindergarten. I feel like I need it more now
than I did in kindergarten. Yes.
I'm voting for nap time. Bring it back.
I mean, the ATR is kind of a napspace.
(01:07):
Not for me. True, the kiddos.
Do I have had some student athletes?
They'll ask, can I nap here? I'm like yes until I need the
table then I will wake you up and kick you off.
So if you don't already know thebenefits of sleep, we are going
to go in a deep dive of this rather than the and we kind of
(01:27):
talked about it too, instead of just the tip of the iceberg that
we've kind of been hitting on 'cause I feel like we've kind of
been talking about sleep a lot lately.
Totally a coincidence, but Doctor M is just the perfect
person to talk about this. And he's a board certified UCI
health psychiatrist who specializes in psychiatry and
(01:48):
Sleep Medicine. He's earned his medical degree
from Seoul National University College of Medicine in Korea.
He completed a combined residency in internal medicine
and psychiatry, followed by a fellowship in Sleep Medicine at
the University of Iowa in Iowa City.
So he, in this episode we talkeda lot about different sleep
(02:08):
disorders, how to improve your sleep, circadian rhythms,
insomnia, narcolepsy, restless leg syndrome, how anemia can
affect your sleep and so on so forth.
It's, it's pretty fascinating all the things that we talked
about and, and things that I didn't really expect us to talk
(02:29):
about, which I think is just goes to show how much sleep
really does affect. Absolutely.
So without further ado, here's Doctor M All.
Right. So at AT Corner, we definitely
like to like combine the evidence with the experience.
(02:49):
So if you can, kick it off with a story or maybe a case study
about the importance of sleep regarding working with athletes.
Yeah, I see. I can come up with an A case,
but it's not going to be the exact same case.
But as I have seen quite many student athletes, especially
college athletes, especially with quite many sleep problems,
(03:10):
I can come up with at this one. So this is a young 19 year old,
I think freshman or sophomore team sports.
I can say that it's a man's, a soccer player who came in with
anxiety and insomnia, which he has had for about like several
(03:33):
months, six months or close to half a year between the two.
Like insomnia and anxiety. I mean, both were pretty
significant problems. But from his standpoint, he
thought that insomnia started 1st and because of his inability
to fall asleep or staying asleep, he started building some
(03:54):
more like anxiety about his own sleep itself as as the
consequence. I mean, as a freshman or
sophomore, young, younger in theteam, he's not really expected
to be like a plane as a starter.But he, he felt like his
performance even during the practice was not going well as
(04:15):
expected. So he started having even more
anxiety about his own performance as well.
So that's when we saw him. And we of course, in the sports
psychiatric clinic, we go through a lot of screening
questionnaire. And the important thing is
what's called SMACKED developed by International Olympic
Committee or IOC. In short, we use the SNAP.
(04:39):
But as we are also specializing in more in sleep and sleep
disorders, we added more questionnaires and he screened
positive for what's called restless legs syndrome.
Oh wow. OK.
So restless leg syndrome is as the name exactly sort of
describes, you feel restless andin the legs and that is going to
(05:04):
be happening more towards the night time compared to the day
or some oftentimes exclusively during the night or at the time
of wanting to fall asleep. In fact, having the rest of the
stack syndrome was resulting in these insomnia or so-called, I
mean so-called insomnia, but in describing more it's difficulty
(05:26):
falling asleep. So he was absolutely having this
difficulty falling asleep, not necessarily because of those
quote UN quote insomnia disorder, but from these
restless deck syndrome. OK, So what we approach, how we
approach clinically when we identify arrested select
syndrome is that for the diagnosis itself to establish
the diagnosis, we don't really need any fancy like a blood test
(05:48):
or sleep study. It's just like a questionnaire
based subjective symptoms of having an urge to move the legs,
getting better by moving, worse at rest and worse at night time
meeting all those four simple questionnaires answering yes,
yes, then you do have these restless sex syndrome.
(06:09):
So as the one of the common cause of restless sex syndrome
is low iron or iron insufficiency.
We tested for iron and it was low, which is not very common
for young healthy male athlete which is I mean these low iron
is much more common in women female athlete because of having
(06:33):
like periods and also like issues with the diet or
nutrition. But we just supplemented iron
and within a few weeks he actually got so much better that
he really didn't require any other sleep.
AI mean he in the past tried like some sleep aids but more
common like over the counter melatonin and unisom or
(06:55):
Benadryl. He didn't really try.
He didn't want to try these prescription sleep aid because
of many of those dating sleep aid, Although I can talk about
it more later, But from the athletes standpoint, he was sort
of hesitant to try those prescription sleep aid because
of the worries that it'll probably hinder with his daytime
(07:17):
funk or ability to stay more like awake or focused.
So he was refusing to take any of those sleep aid, but he was
still taking sort of melatonin. But after supplementing iron, he
got better. He didn't require any melatonin.
He was able to fall asleep. And also as a result, his
anxiety, which was probably secondary to these insomnia or
(07:41):
insomnia symptoms from RASTAC syndrome, got so much better
that he didn't require any further medication management
other than just regularly checking these iron panel and
continuing with the supplementation of the iron.
And he's not really coming to see us anymore after about four
or five visits. So that's probably one of the
(08:03):
story that can be overlapping some areas of mental health from
the anxiety standpoint and sleepand insomnia.
Wow, that's amazing. Yeah, I was going to say that's
really fascinating because I feel like it's definitely not
the the easiest, like point A topoint B.
(08:24):
It's not the most obvious, I should say, but it's really cool
that you guys were able to notice that in the questionnaire
that you guys had, which also leads me to the question.
So you, you said that you were able to notice this like through
a screening, but without like formal questions and, but just
like from an athletic training standpoint, especially we're
(08:47):
seeing these athletes like oftenevery day.
So what signs and symptoms mightwe notice in an athlete with a
lack of a good quality sleep? Yeah.
So I mean that that's a great question.
The answer, my answer answer canbe in fact pretty lengthy.
But in terms of signs and symptoms of not getting good
(09:09):
night's sleep and good night's sleep from quality and quantity
standpoint, I mean quantity standpoint, not getting good
enough sleep, it's kind of obvious.
I mean even the athlete itself, they know how many hours of
sleep they get. I mean, it's kind of a
guesswork, but as a consequence of not getting enough hours
(09:32):
quantity wise, not enough hours of sleep, that can result in
many different problems from just as simply speaking daytime
fatigue, daytime sleepiness, issues with focus or
performance, irritability. And also I mean, if we are to
talk about those colleges student athlete, they're even
(09:55):
academic performance can be affected quality standpoint.
That's all a bit of tricky thingbecause when someone is getting
hours hour wise, good enough hours of sleep but still feeling
like not getting good quality ofsleep, that's probably in
relation to possible underlying sleep related disorders or sleep
(10:19):
disorders. Then we can possibly observe
some of those signs and symptoms, not necessarily a
consequence of not getting good night's sleep, but we may see
notice some of those symptoms ofsleep breathing disorders or
symptoms and signs of sleep related movement disorders or
behavior disorders or some specific disorders when somebody
(10:42):
having relatively rare disorderslike narcolepsy, for example.
I mean all those are possible. But just simply speaking from
these different aspects standpoint, I mean there are
physical issues, there are cognitive issues, emotional
issues and also as an athlete wecan see some performance
(11:02):
changes. So going into that kind of like
that performance standpoint, what role does sleep play in
that recovery process, whether it's from just normal working
out and training or even the injury and concussion
standpoint? Yeah, that's that's great.
And in fact, our team doctor Unjong Chu and I wrote a an
(11:27):
article published last year, only last year in Sports
Psychiatry Journal, which was a case and a case based review of
an athlete who was having multiple injuries and also
unexplained medical symptoms. And that was probably due to
overtraining and what what we call an overarching as well, or
(11:50):
sometimes there is a lot of different terminology.
But from specifically from injury standpoint, sleep is
very, I mean, it's crucial to have good night of sleep in good
amounts. So from physical injury
standpoint, regardless what typeof injury it is, I mean, most
(12:13):
common injury might be like a muscle injury, right?
And also it could be like a joint ligaments, but those
connective tissue injuries, growth hormone is very important
thing to have enough to for, forthose recovery mechanism, right?
And growth hormone is much more abundant during a certain sleep
(12:35):
stages like deep sleep or non REM stage of three sleep and
that those deeper non REM stage of three is much more
concentrated during a certain time of the night.
So being able to capture those good enough deeper or slow wave
sleep is important for that likeendocrinology or hormone based
(12:56):
standpoint in injury recovery standpoint.
One thing is about like especially about brain related
issues, which is most commonly concussion, right?
That part can be tricky because either traumatic brain injury,
TBI or concussion itself actually heavily affect our
(13:18):
sleep. So many patients or athletes
with the TBR concussion actuallywould complain about significant
change in their sleep from the moment of this conclusion event.
And or so it can actually last over easily over six months to a
year. Wow.
It can affect sleep in either direction, resulting in
(13:41):
significant insomnia, but more commonly sleepiness and sort of
a foggy brain, those resulting in either excessive sleepness or
excessive amount of sleep. So in medical term either
hypersomnolence or hypersomnia. So many people, athletes with
(14:06):
the TBI would experience those excessive amount of sleep or
sleep need. But that gets better and better
over time, but that takes like asix months to a year or so.
However, there might be reason why they actually require that
much of sleep because just it's although it's a sort of an
assumption to get recovered fromthose brain direct heat to the
(14:28):
brain. I think what our actual brain
really needs a much longer amount of time being in sleep
because our brain is being refreshed or cleared while we
are in sleep, right? So from that standpoint, I think
it's very important. Sometimes I guess sleep specific
(14:51):
sleep stages, specific changes may occur.
I, I just talked about like importance of sleep, sleep in
having good enough growth hormone to the body, but other
sleep stage called REM sleep or rapid eye movement sleep might
be important in building these muscle memories.
(15:15):
Although it's all still kind of a speculation.
There was an, a good hypothesis or theory about someone with a
spinal cord injury, even like a quadiplasia having these muscle
twitches while they are in rapideye movement sleep or REM sleep.
(15:36):
I mean, we normally in REM sleep, our bodies, some muscles
are completely paralyzed, but our body, normal body may
actually go through some period of muscle twitches in REM sleep.
But people with spinal cord injury actually may have even
more muscle twitches in REM sleep.
(15:58):
And there was some trial of probably bringing more muscle
twitches in REM sleep to accomplish some sort of a
recovery from spinal cord injury.
I don't know what happened thereafter, but we do believe
that there's something about this REM sleep.
I mean, the other sort of indirect evidence might be,
(16:22):
which is an interesting thing like about REM sleep baby like
newborn baby and infant have a lot of REM sleep.
So as a newborn more than 50% oreven more than 2/3 of your
sleep, you are in R.E.M. rapid movements.
(16:44):
And that may be related to they're building all those like
muscle strength and also muscle memories to get stronger.
And eventually they start crawling, standing up and
walking, right. So as they can do, they are able
to do so their amount of Rems toactually decrease further down.
(17:04):
So by the age of like toddler, the amount of these Rems to be
about the same as an adult, about like a 20 to 25% of their
sleep time. Wow, that's cool.
That's really interesting. What are some of the other
phases of sleep? Others other than REM sleep.
So REM sleep and non REM sleep, right when there is rapid
(17:25):
movements of sleep, there is nonREM.
But I as I said, REM sleep is only about like 20% or 25% of
the entire sleep time. So the rest are non REM sleep.
And these non REM sleep can be classified into 123 in the past
down to four in the past. But those are sleep staging
(17:48):
system was simplified in 2007. So we have now non NEM stage 1-2
and three or we call it N1 N 2, N 3.
And as the number goes down, it's sort of a deeper sleep
stage. So N 3 is what we often call a
deep sleep. And if you look at the brain
(18:09):
wave during this deep sleep, ourbrain wave is very slow, much
slower than the other sleep stage or awake.
So it's called a slow wave sleepor deep sleep.
Is there a way that we can affect how much deep sleep or
how much of like REM sleep or ordifferent the different phases,
(18:30):
can we affect that at all? So that's an interesting
question and it can be sometimespractical.
I mean, for example, let's say that I mean, you 2 are still too
young to have some teenage kid. But I, I do have two teenage
boys and both are in fact athletes.
(18:52):
I'm not tall, so they are not really tall either.
Hold on. One thing is like I said, growth
hormone is being produced and secreted much more efficiently
during these N3 sleep, right? So to get taller, right, grow
faster or taller, you'd like to have more N3 sleep, right?
(19:15):
Oh, OK. So if there is some strategy to
increase the amount of N3, that'll be great, right?
Yeah. So I thought of those a lot,
right, to help my kids as well. There's no like magic, but the
sleep stage progression overnight is with a certain like
(19:36):
a pattern or characteristics. It's not like cycling of those
sleep stages with the similar pattern.
I mean, although we do have these progression of sleep
stages into stepwise and it cycles about four or five times
throughout the night. However, within this, while it's
(19:59):
cycling through the night, N3 sleep is much more concentrated
during the beginning portion. So we have longer more prolonged
N3 at the beginning and shorter RAM and as it cycles through we
have shorter N 3. And more R.E.M., meaning that at
(20:21):
the beginning of the sleep at night we tend to have more and
three and towards the end of thenight we tend to have more
R.E.M. And assuming that you have
regular, relatively regular circuit and rhythm, if you are
actually missing the beginning portion of your sleep hour,
(20:42):
basically you're going to have relative and three sleep
deprivation and three depth. Or if you're actually waking up
normally at let's say 7:00 AM, but some like in a row, you are
told to wake up at 4:00 AM for some reason, then you're going
to actually have less of those REM sleep, less opportunity to
(21:07):
go into the REM. So you're going to actually
develop some REM sleep debt, right?
So the timing of the night, thatcan be one way to sort of
regulate. So if you, if you'd like to
actually have more M3 sleep, youshould really miss this first
several hours of good M3 opportunity, right?
(21:27):
Does that make sense? For sure, yeah.
So is there like, what would therecommendation be for athletes,
whether it's like how long they should shoot for, like a length
of time for their sleep or even ways that maybe they can just
improve the quality of sleep that they're getting?
Yeah. So in fact, that's number one
(21:48):
question that we get and that's why out of those five bullet
points that we put onto the the education posture for our
college athletes, the number onetop what point was to get enough
hours of sleep. But what we say it said in the
the second line was 7 to 9 hours, not necessarily aiming
(22:11):
for 8 hours, but we put 7 to 9 hours, which is also based on
the consensus statement from about four years ago.
There, there is a an article published which was a consensus
statement by so-called state experts published in British
(22:32):
Medical Journal or British Job Sports Medicine.
That journal article is also recommending 7 to 9 hours.
But that's pretty like broad, right?
But that means that there is an individual variability of how
much is sleep we need. Why not 8 to 9?
Why did we put 7? So that there is another
(22:55):
explanation. But several years ago, National
Sleep Foundation changed their recommended sleep time from 8
hours down to seven hours. One of the reason is because
when the recommended sleep hoursis 8 hours, while there is in
fact an individual variability, some people, some person may
actually do OK with the seven hours of sleep, but oh, I'm not
(23:17):
getting 8 hours. What's wrong?
Am I having like having the period of insomnia or is there
something wrong that can result in so much anxiety and that can
result in actually insomnia itself when there's nothing
wrong? So 79 hours.
However, there is an interestingthing about the so the second
bullet point in our poster made by Doctor Cho was be still be
(23:42):
flexible. Your mindset about these hours
of sleep, it has to be really flexible because you're not
really staying in one area or your schedule is not the same.
You're going to competition sometimes often involving
trouble and travel across time zones, right?
Or even without crossing the time zone.
(24:05):
Like if you watch like U.S. Open the first day yesterday
after it's still played out until like 1:00 AM or sometimes
even 2:00 AM, right? Even though you actually still
live in New York City, you play for that and you are playing in
a very weird time. Yeah, for sure.
You have to be have, you have tohave these mindset to be ready
(24:28):
to be flexible about sleep hoursincluding in fact sleep time and
also sleep hours and you have. That means that oftentimes you
might be actually sleep deprivedor during this competition or
travel. So there is a concept of what's
called banking sleep. OK.
(24:50):
I talked about debt. Random sleep debt or not, a slow
way to sleep debt. There's a way to bank, right?
So if there is a concept of banking sleep and it may
actually help. So if you're expecting to go for
competition or travel during which you know that you're going
(25:11):
to lose some sleep, then you canactually bank by allowing
yourself more sleep hours or sleep opportunity for a week or
two, whatever time frame prior to that event.
And that is proven to be of helpin performance as.
Well, oh, that's really, that's really fascinating.
(25:32):
That's really interesting. I've never really heard of
sleep. Sleep banking, that's pretty
good. Also, I was wondering if that
recommendation, does that vary by like age or gender or sport
or season or or are there certain factors that you would
would carry more weight in termsof how long or how short someone
(25:55):
sleeps? So that's an interesting
question, but we don't really know much about how the
different sleep hours would affect or vice versa, how the
age or gender or type of sports would affect the need of sleep.
Although sleep is very importantand everyone sleeps and everyone
(26:18):
knows what sleep means, the association between sleep and
sports hasn't been really researched or objectively
tested. But what's for sure is in fact
the season versus offseason thatbanking of sleep banking was
(26:38):
sort of introduced in an expectation of steep loss during
the competition and travel, right.
So I mean, you probably don't really need much steep banking
if this is an offseason and you're training routine or
practice schedule is relatively regular.
But in expectation of those changes of steep hours that you
(27:01):
can get, I mean those steep banking will probably have to
occur during the season before the upcoming travel, right?
So kind of going on that flip side of like if maybe someone
wasn't able to bank their sleep or maybe this could even be a
part of it. What role does nap napping play?
(27:23):
And maybe the sleep banking process, but also maybe trying
to recover some of the sleep that you might have lost.
Right. So that that's great questions.
I mean, there are some research done about how nap, especially
short naps affect at its performance or reaction time or
(27:44):
focus and concentration. What we know is that short naps,
like 20 to 30 minutes of short naps can definitely affect it
and that's what I would recommend to routinely utilize
during whether it's a season or offseason, during the practice.
(28:06):
I mean, if you feel like you arenot getting enough hours of
sleep overnight or if you feel tired during the day midday,
it's very OK to have short naps.20 to 30 minutes of nap OK.
I wouldn't recommend lengthier naps like a 60 to 90 minutes.
However, some experts suggest that even 60 to 90 minutes nap
(28:30):
may actually help. I mean, as a layperson, you may
actually raise a head and then ask this question.
Doctor, wouldn't 60 to 90 minutes of nap better than 20 to
30 minutes because it's longer nap, right?
That's sort of common sense. But from just the regular sleep
hygiene standpoint or sleep science standpoint, 20 to 30
(28:53):
minutes of shorter naps are OK to have routine drink as a nap,
whereas these are 60 to 90 minutes nap.
Actually that can certainly affect your ability to sleep at
night time. So we generally do not recommend
this lengthier nap. The other thing is that when you
are taking this lengthier nap, what ends up happening as you're
(29:16):
waking up from nap is that you may actually feel even more
groggy and tired depending on what sleep stage you are waking
up from. Whereas a 22 short 30 minutes
nap, you would never really go into the deeper slow wave sleep
or REM sleep. So it can be relatively short
and refreshing. That's what we often see from
(29:38):
the the patient's or normal population.
So we do really do not recommendthis lengthy or neck.
However, from the sleep banking standpoint during the season
expecting future upcoming sleep loss for banking the the sleep,
it may not be enough to just enforce longer sleep window
(30:02):
overnight. I mean, when banking sleep, what
they're recommending is like sleep window to be about 10
hours overnight, but that doesn't really result in
actually longer sleep. It's more of a sleep window,
right? From that standpoint, if you
really need to bank your sleep more than this, lengthier net
(30:24):
may be of benefit, but not really close to evening hours.
I mean, it'll probably still be limited to the up to midday.
Actually, that was going to be my next question was like timing
of it. How like is it best to be kind
of in that midpoint or is it best when you're feeling groggy
or is it kind of like flexible as long as you don't get close
(30:46):
to those evening hours, like right before you go to bed?
So from a short nap standpoint, 20 to 30 minutes nap, I think it
can be any time you feel tired or sticky, although there's no
science behind it. Probably limit that to before
like four or five PMI mean if it's too close to bedtime, even
(31:07):
if it's a short nap, it can certainly affect the ability to
sleep at night time. From those longer nap standpoint
with the purpose of sort of banking sleep, I would say
probably not after two or three PM.
That's, that's going to be my recommendation.
If I have to come up with some sort of a a sleep regimen for my
(31:29):
athletes, that's what I'm going to use.
Yeah. And I've, I've noticed that for
me, like if I nap after 5, like it jacks me up, like I can't
sleep after that. So yeah, I've definitely noticed
that you're at the beginning of this episode, your kind of case
study kind of brought this to light.
But what what does, what role does mental health play with
(31:51):
sleep and maybe vice versa? How does sleep also affect maybe
mental health as well? Yeah, it's the question is
really broad, right. I mean, we have to probably
define like what mental health is and what sleep is and how it
those are sort of separated. I mean when it's really not
separated. I mean, my simple answer is that
bidirectionally it's heavily affecting each other.
(32:16):
If you look at people with anxiety, depression like top two
most common mental health conditions, even chronic
depression and chronic anxiety which anybody can actually have
at some point in their life, presence or absence of steep
(32:40):
problems or insomnia. If you look at the association
like odds, the odds ratio is just huge, oftentimes 10 or 20
times based on whether you have sleep problem or not.
I'm not saying that having sleepproblem is going to result in
depression and anxiety. It's just bidirectional, but so
(33:02):
strongly associated. The other thing is that when we
are treating mental health conditions, depression or
anxiety for example, we may see those symptoms get better and
better or actually stay the same.
Oftentimes in the case what how their sleep is going, that can
be a marker of where they are from the underlying baseline
(33:26):
mental health problem standpoint.
So sleep can be a marker of the progressional improvement of
their underlying mental health conditions.
The other thing is that we really have to take a sleep into
consideration in choosing the proper psychotropic medications
because depending on the underlying symptoms, even if we
(33:49):
choose a medication for depression, we may have to
choose totally different type ofthe medications depending on
whether they have insomnia versus hypersomnia and and
things like that. So the association between the
two direction and how those two affect each other, it's just a
(34:09):
lot. Interesting.
Actually you, you kind of touched upon it with, I feel
like we talked about insomnia a lot.
And when you, when you think, when people talk about sleep and
quality of sleep or inability tosleep, they, they really, that's
the first thing they think of isinsomnia.
(34:30):
But we never really talk about excess sleep or if someone just
is, is just sleeping so much. And how can you talk a little
bit about that or even other sleep pathologies that maybe are
common, but we don't really talkabout as much as like insomnia?
(34:50):
In fact, I really like this question, especially as a sleep
disorder expert. When someone comes in
complaining or saying that I have insomnia, really have to
dig into more what it means by saying insomnia.
Like the case example we talked about that athlete who came in
(35:12):
with insomnia which resulted in anxiety.
It was not actually a true insomnia disorder.
It was just the symptom of insomnia secondary to the other
underlying sleep related disorders.
In his case was restless tech syndrome.
But there are other common causeof insomnia which is not
(35:34):
insomnia disorder but insomnia symptoms.
For example, like sleep apnea, obstructive sleep apnea, which
is common, not like very common in young athletes or college
athletes, but obstructive sleep apneas are so common that it can
cause insomnia in that the sleepcontinuity is interrupted.
(35:59):
And oftentimes as a result of chronic untreated sleep apnea,
people actually can have difficulty falling asleep as
well. Your brain does not want you to
be in asleep because the brain knows that you are going to be
in danger repeatedly overnight from not breathing.
So you may actually develop thiseven initial insomnia.
So when you see someone who is saying insomnia, you really have
(36:23):
to think insomnia initially as asymptom rather than going into
labeling as an insomnia disorderand recommending like a sleep
aid over the counter or prescription sleep aid.
Those are not really the right approach.
You really have to allow the person, athlete in our cases to
describe what it means by insomnia and then we can
(36:46):
actually go over some other potential sleep technology.
I mean, you mentioned about excessive sleepness or
hypersomnolence, but one of those condition which is rare,
like narcolepsy, you've probablyheard of the term narcolepsy.
That is a rare condition, but often used to describe someone
who is having a lot of daytime sleepiness and sleep attack who
(37:10):
just doses off anywhere, right anytime.
We often describe it as a narcoleptic person, but even
that narcoleptic person may not really have narcolepsy, but that
excessive sleepness may be a result of not getting good night
sleep or having very poor sleep quality and the quantity.
(37:30):
So even when someone saying I, Ihave so much sleepiness during
the daytime, you actually have to think about what's happening
at the night time. And the other common conditions
that we really have to either ruled out or ruled in in
assessing for sleep quality is these sleep related breathing
(37:51):
problem. Like I just said, sleep apnea is
very common and also sleep related movement problem like
restless tech syndrome. And also there is a sleep
equivalent, I mean restless techsyndrome resulting in what's
called a periodic Lyme movement PLM, which is a sleep equivalent
(38:12):
of restless tech syndrome, whichmay be possibly more common in
athletes. We are, we are trying to look at
that the, the difference in the prevalence of restless like
syndrome in our system. But those are the things that we
have to look for. And there are two other things
which we do not commonly think about is 1 is circadian rhythm.
(38:38):
If you're to deal with a lot of like athletic trainers work for
college athletes or college at university systems.
But those young young adults or even like late teen teenagers
tend to have delay in the sleep phase.
They are basically a lot of times night out not because they
are like lazy or just it's not because they are just living
(39:03):
their life as whatever happens to their body and the brain.
It's in fact a norm that almost anyone in this young adulthood
have tendency to have delayed sleep phase.
So we may actually have to accommodate their this different
sleep time. Although in that case, should we
(39:27):
actually see this as a disorder or just a variant in the
normalcy based on their age? The other thing we have to look
at is the travel result, like resulting in jet lag.
I mean, a lot of college and athletes after travel,
especially with these change in the conference these days, like
(39:48):
ACC, Atlantic across the whole entire nation, right?
Stanford and Berkeley are in thePacific, but they are in ACC.
For example, the Big 10. It used to be Midwest.
State University, but now it's across the whole entire nation,
right? They travel a lot.
So we really have we have to be very mindful about jet lag.
(40:09):
The the last category of sleep disorder is what's called
parasomnias, meaning sleep having a certain type of sleep
related behaviors commonly I guess sleepwalking sleep terrors
which are more common in like pre teenagers which they often
(40:29):
grow odd. But our athletes are much more
pointed about these persomnias because of their erratic sleep
schedule and relative sleep deprivation.
So they are point to develop those conditions as well.
So there are these six big categories of sleep disorders.
We have to possibly look for insomnia, hypersomnia, circuit
(40:52):
and rhythm problem, sleep related breathing problems,
movement problems and the sleep delay behaviors.
Speaking of circadian rhythm, isit possible to change your
circadian rhythm? If I have to choose between yes
and no, it is possible. It's a yes.
(41:14):
But is it easy? It's not very easy, but textbook
wise we know. We know what to do and how to
change. OK.
OK, interesting. Yeah.
So I mean just as simply speaking, our circulated rhythm
is regulated heavily by the presence and absence of light.
(41:36):
Our says 24 hours. Why is that?
It's because the earth rotating the facing the sun and away from
the sun, it's the it's 24 hours,right.
So basically light is the strongest sort of what we call a
sitecapper, time keeper of our brain's circuit and rhythm
(41:59):
system. So exposure to the bright light
at a certain time of the day, that can be the best way to
regulate our circuit and rhythm.OK, interesting.
For sleep behaviors, you said sleepwalking, did you also say
sleep talking? Sleep, I said.
Sleep terror. Sleep talking is also in fact
some of those prosomnia behaviors or sleep related
(42:22):
behaviors. The phenomena itself, sleep
talking and sleep is not normal.But is it considered a sleep
disorder? No, it's not.
Anybody can actually have a sleep talking, so we do not
consider it as a sleep disorder.It's just a normal variant that
can happen to anybody. Is there a genetic component to
(42:42):
it? That's a good question, but as
sleep talking is not really a disorder I don't think people,
scientists or experts paid attention to that.
That makes sense. But other persomnias during non
REM sleep as persomnias a certain type of behavioral
(43:05):
experience that's happening during sleep.
And as we talked about sleep is either REM sleep or non REM
sleep. So those prosomnia can be
categorized into non REM relatedprosomnia and REM sleep related
prosomnias. And typical non R.E.M. prosomnia
would include sleepwalking and sleep terror.
(43:27):
And those are sleepwalking and sleep terror when someone is
having this. And if you ask family history,
certainly there is very strong family history.
Oh, his, his father did that toountil age 5 or 6.
There's very strong family history.
But is there a, a certain gene type?
I don't. I mean, there might be, but
(43:49):
probably people haven't really looked into that in detail.
Got it. So for some of those pathologies
that you kind of talked about, what are some things that the
athlete trainer should be kind of noticing in their history or
maybe just hearing the athletes talk about, like when we should
probably refer someone based on sleep and then who exactly
(44:09):
should we refer them to? There was out of our five bullet
points in our poster, that was #5 because number 1234 were more
about sleep hygiene and sleep education, what to do and what
not to do. But #5 is regardless, I mean a
person may actually try almost everything to sleep well but
(44:30):
when a person has a underlying sleep related disorders like
sleep apneas restless tech syndrome, the quality and the
quality of sleep cannot be good enough right?
So from sleep, breathing standpoint, if someone is having
loud snoring or weakness apneas,then that should be signs or
(44:54):
symptoms which needs some medical attention.
If someone is having these restless legs, having an urge to
move the legs, discomfort in thelegs, that's much more
pronounced at night time that also needs an attention which
can be often ignored. I mean, especially athletes may
ignore that saying they're thinking that, oh, I have this
(45:15):
because of my practice meaning today, right?
Which might be to some degree true.
But when it's much more pronounced at night time and as
a result, not having a good night's sleep or having
difficulty falling asleep, that could be in fact restless back
syndrome. So that needs to be tested.
And the other persomnia symptomslike a sleepwalking sleep
(45:38):
terror, those are so apparent. So having a roommate doing this,
I think it may be wise to recommend to seek some workups
with a psychiatrist or sports psychiatrist as well.
Any psychiatrist or Sleep Medicine physician should be the
right person to further evaluatefor those.
(46:00):
And if someone's daytime steepness is too much excessive
more than what can be expected from the effect of the previous
night's sleep quality or quantity, like if it's excess in
excess, then that daytime hypersomnolence or sleepiness
has to be evaluated as well. Perfect.
(46:23):
Just a follow up on that with the like how long of someone
sleeping? Is there a way that you
recommend athletes to monitor their sleep?
Or do you recommend them not monitoring their sleep because
it would cause some anxiety likesomething you mentioned earlier?
Or is it individualized? Yeah, right.
That's a great question with no one right or wrong answer.
(46:45):
But if this is a normal population, just no more adult
who's not really athlete who comes to see me into the sleep
clinic or psychiatric clinic worried about their sleep hours,
then my general recommendation is not even like touch any like
monitoring devices. I mean these days we do have all
(47:05):
those gadgets and wearables, Apple Watch, Fitbit or rings.
There are so many. But when you already have these
sleep problems or so-called insomnia relying on the
objective data using these, you may think oh it's a good way to
monitor but often times it may not because a person is already
(47:29):
having too much thought and anxiety provoking thoughts on
this. And adding more data to that it
can actually result in more problem.
Even there's a condition labeledas what's called orthosomnia
like insomnia. But orthosomnia is a someone who
is having two rigid thoughts, obsessive thoughts about what's
(47:51):
right amount of sleep, also thinking about sleep insomnia
resulting problem. But for athletes who's not
really having much like actual sleep problems, just who wants
to monitor their sleep for better sleep health and
awareness, right. In that case, I think those
wearable devices might be of help our other expert doctor Cho
(48:15):
in her some of those program that really hasn't really
started she's recommending wearing.
I mean using some of those wearable devices to monitor
their steep hours and steep timing that can.
There are some evidence that having this awareness of their
(48:36):
own sleep amongst the athletes can result in better sleep hours
and performance enhancement as well.
Awesome. Yeah.
All right. Actually, I was going to ask
really quick before before the action item.
It kind of ties in though, so there were five bullet points.
(48:57):
Did we hit all 5 bullet points or are we missing any?
So let me actually look at my poster.
I think the action item might get them.
So number one was enough sleep time, at least the 79 hours per
night. Our number 2 was wake up at a
consistent time but be flexible during the competition and the
(49:17):
travel #3 was avoid large meal, bright light and heavy exercise
within two to three hours beforesleep.
Number 4 was avoid stimulating drugs or supplements after two
or three PM that. Would be like caffeine.
(49:38):
Right, Right. Exactly.
Yeah. Oh, good to know about the
three. PM. 3:00 PM.
A lot of efforts you actually use caffeine and interestingly,
caffeine is the only substance that's not really banned,
although NCAA limits the amount,right?
Yeah, it's what's called so-called ergogenic.
(50:00):
Yeah, it. Can enhance the performance.
Still not banned and it can regulate their sleep to some
degree or wakefulness to some degree.
A lot of people use caffeine, but it's not wise to use
caffeine or energy drink with caffeine in it after a certain
time. And athletes have to be really
careful these days. A lot of electrolytes drinks
(50:22):
have caffeine in it. So you really have to have to
look at the label of those drinks, beverages.
Yeah, that's a really good point.
Yeah, for sure. I've been noticing that too a
lot. A lot of these sport drinks are
starting to add caffeine. Yes, OK, you.
Want to wrap it up? Yep.
So to put a nice little bow finishing up with a little
(50:43):
action item, what are some talking points you use with
athletes to educate about their sleep and perform importance of
sleep? In fact, we talked about those
five bullet points and I just went through 1234 already.
So those four things will be very important for according to
good sleep hygiene, especially as an athlete, but be flexible.
(51:05):
You may want to utilize those sleep banking practice if you
want to. But I think I would be a little
bit careful because doing this during mean, of course, sleep
banking is to compensate for upcoming sleep debt.
But I would say try it before doing the offseason to see what
(51:26):
your pattern is like. And then the other thing, the
last thing is we went through these symptoms and signs of
potential sleep disorders. So if you have those, talk to
your AT and then have an arrangement to be referred to
the sleep experts. I mean if we are talking about
the sleep disorders especially then refer to the sleep
(51:49):
physician. Those will be important.
So those will be the main actionitem.
I think what was really awesome chatting with Doctor M about is
just understanding when someone should probably be referred
about sleep. Have you?
Ever referred someone for their sleep?
No, but now I'm thinking, man, maybe we should have.
(52:10):
And not only that, but where do you refer them to?
Yeah, that was that was a big one.
Right. The psychiatrist, I probably I
wouldn't have wouldn't have put the two and two together at
first. But after talking to him, like
it makes so much sense. Like that's totally up his
alley. Yeah, and with just how much of
(52:34):
an emphasis just within athletics in general has now
been putting on sleep, hopefullywe as a profession and just us
in like the athletic realm will start to see more tools for
athletic trainers to help identify someone who might be
having pathological sleep. Yes, absolutely.
(52:56):
So if you guys are new, we do every episode as either an
interview like this one, which we have a lot of this season, or
a story episode where we take stories from real life athletic
trainers and put them together all about one feature topic.
We also have CU episodes where our latest five are free
category AC us. Thank you so much to clinically
(53:18):
pressed and athletic training chat where Randy takes a bunch
of research articles, he reads them and we talk about them in a
conversational format. So you don't have to.
And then we have this year we'redoing, we're going back to our
BOCIRL episodes, which are wherewe take BOC topics and we talk
(53:41):
about them in real life. So like what does that look like
beyond the textbook? And those this year are brought
to you by AT Study Buddy. So.
Stay tuned for those. We're, we're releasing our first
one up here pretty soon and I think that's all I have.
(54:02):
Thank you for helping us showcase athletic training
behind the tape. Bye.
Popular Podcasts
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com
The Breakfast Club
The World's Most Dangerous Morning Show, The Breakfast Club, With DJ Envy, Jess Hilarious, And Charlamagne Tha God!