Faculty of Health Sciences Section Sports Medicine MEDICAL CHALLENGES: EFFECTS of TRAVEL FATIGUE and JET LAG Prof Christa Janse van Rensburg Rheumatologist & Sports Physician MD MMed MSc MBChB FACSM FFIMS IOC ATPC 2017 Turkey Charles H. Samuels. Jet Lag and Travel INTRODUCTION Fatigue: A Comprehensive Management Plan for Sport Medicine Physicians and High- Performance Support Teams. Clin J Sport • International & National Travel: Med, 2012, 22(3): 268-273 = lifestyle for elite athletes disruption of regular routine, preparation concerns, competition anxiety, etc. • Factors that come into play 1. Substantial environmental changes 2. Disruption of the body’s circadian timing mechanisms 3. Travel fatigue / travel stress / jet lag • Potential mechanisms of impact on performance • Management 1. ENVIRONMENTAL CHANGES Covered by Olaf Schumacher 2. CIRCADIAN RHYTHM SHIFTS • Loss of synchrony occurs between internal circadian rhythms, e.g. body temperature, and 24h light-dark cycle • For every 15° travelled (i.e. 1 time zone) the body's biological clock has to move 1 hour into a new time zone • To adapt & resynchronise completely ± 1 day / time zone crossed • Direction of travel influences the severity (east vs. west) • Physiological adjustments occur (superchiasmatic nucleus) • Endogenous circadian rhythms = relatively slow to adjust 2017 Nobel Prize Winners CIRCADIAN RHYTHM SHIFTS Michael Rosbash Michael W. Young The light-dark cycle seems to be the strongest influence Jeffrey Hall Pioneering discovery that our circadian clocks are regulated by a small group of genes working at the individual cell level John Hogenesch from the University of Pennsylvania estimates around 50% of the mammalian genome cycle is under circadian control Purpose of body clock Ensure physical & mental state Active day Sleep at night 3. TRAVEL FATIGUE & JET-LAG Controllable factors Uncontrollable factors • Journey anxiety • Passenger next to you • Nutrition • Confined space • Hydration • Length of flight (extra 15-20ml for each hour in flight) • Crossing time zones • Time of sleep • Altitude changes • Body temperature • Air pressure fluctuations • Movement / activity • Stopovers /Delays • Turbulence Reilly T et al. Nutrition for travel. Jnl Sports Greenleaf J, et al. Airline chair-rest deconditioning: Induction of immobilisation Sc, 2007, 25(S1): S125-134 thromboemboli. Sports Med, 2004, 34(11): 705-725 Travel fatigue Jet lag Definition Temporary exhaustion, tiredness TemporaryBody`s daily disorder rhythms / outdesynchronosis of sync with destination time zone Mechanism / Associated with any long journey Rapid long-distance, trans-meridian Cause (irrespective of mode of transport) travel Flight’s direction > length Direction of N S W E travel Seasonal change Shift in local time e.g. Depart from JHB at 30°C, disembark in e.g. Depart 10h00 from London, arrive 13h00 Frankfurt at 0°C in NY (watch indicating London time 18h00) W E = 8-hour flight across 5 time zones 2 time zones in any direction 3 time zones in directions E-W / W-E Travel fatigue Jet lag Duration • Subsides next day / after shower / • Lasts several days to weeks night’s sleep • Resolves with resynchronisation • Quicker overcome BUT can • 1 day/time zone accumulate over course of season • Can be persistent & impact athlete’s capacity to recover & perform Severity • Vast inter- & intra-individual variations • Frequency of trips & length of season play a role Travel fatigue Jet lag Characteristics • Cumulative • Episodic • Persistent fatigue • Intermittent fatigue • Recurrent illness • Impaired concentration NB! • Behaviour and mood • Sleep disturbance (daytime sleepiness, Travel: • Direction changes intermittent fatigue, sleep deprivation) • Distance • Frequency • Loss of motivation • GIT disturbance (indigestion, diarrhoea, Length of season constipation) Travel direction and Body Clock Eastward Westward Phase shift • Advance (!!only if <8 hrs time zone difference, • Delay (up to 12 hrs time zone difference) Body clock cycle otherwise same as westward) • Shortens 60 min/d (each day in new time • Extends 90 min/d (each day in new time zone) zone) • More difficult (easier for morning type • Easier for most travellers person) Sleep pattern • Difficult to fall asleep • Sleepy early evening • Difficult to wake up • Wake up early Simmons E, et al. Jet Lag Modification. Curr Sport Med Report, 2015, 14,2:123-128 POTENTIAL MECHANISM OF IMPACT Peter M. Fowler. Performance Recovery Following Long-haul International Travel in Team Sport Athletes. Sports Medicine Journal. www.Aspetar.Com/Journal p.502-509 Schwellnus M, Derman W, Page T, Lambert M, Readhead C, Roberts C, et al. Illness during the 2010 Super 14 Rugby Union tournament–a prospective study involving 22 676 player days. BJSM, 2012;46(7):499-504 Non-Pharmacological Management General On arrival Journey planning • Eastbound: Arrive at night fall • Westbound: Arrive mid afternoon Pre-adaptation • Eastbound:Eastbound: Rise 1 hour earlier • Full adaptation not • Westbound:Westbound: Stay up 1hr later recommended for • not>1hr p.d before departure trips only 1-2d long Bright light • Minimum Core Temp (@ home ±4:30am) • Natural light better therapy ✓ Eastbound:Eastbound: Just after • Avoid screen time in evening ✓ Westbound:Westbound: Shortly before Timing NB in relation • Blue light (stimulate) to core • Amber lenses (block) temperature Non-Pharmacological Management General During flight On arrival Sleep • Adequate sleep before travel • Night time at • Follow time pattern of destination • More rigid sleeping habits more symptoms destination • Good night`s sleep • Schedule flight during sleeping hours at destination • Power naps (20-30min) • Least amount of connecting flights • Consistent bed and wake times • Set watch to destination time • Cool, dark, quiet room Diet • Timing more important than type of meal • Light energy meals • ? High protein meal improves arousal • Argonne Anti-Jet Lag Diet • Avoid alcohol • Alcohol 2-3x more • ? High CHO meal improves sleepiness • Avoid• caffeineHarvard at Anti night-Jet time Lag Fast potent at flight • Morning caffeine increase alertness altitude • Hydrate with water (Limited Evidence) • Hydrate with water Exercise • Not proven to shift circadian rhythm • Frequent movement • Low to moderate intensity • May maintain arousal level • Compression socks • Higher risk of injury 1st few days • Change training routine (not coincide with circadian nadir of 2-4am at departure zone) Simmons E, et al. Jet Lag Modification. Curr Sport Med Report, 2015, 14,2:123-128 Pharmacological Management General During flight On arrival Melatonin • Derived from serotonin/tryptophan To induce sleep and/or shift To induce sleep and/or shift the body • Cochrane review in 2002 concluded the body clock clock exogenous use effective and safe • Eastbound:Eastbound: 3mg on • Eastbound:Eastbound: Low dose (0.75mg) mid • Chronobiotic (phase shifter, 0.5mg) boarding afternoon to bedtime advances clock • Chronohypnotic (sleep initiator, 3-10mg) • WestboundWestbound: 0.75mg on • Westbound:Westbound: Low dose (0.75mg) • Product quality may be a concern rising (day of flight) during early morning delays clock Sleeping tablets • Short acting • No evidence • Recommended in athletes with • Zolpidem + Melatonin increase daytime persistent insomnia that have somnolence tolerated it well before Stimulants • Most stimulants are banned substances • Consider for team management to assist with daytime sleepiness (Modafinil) Melatonin • Ramelteon and Tasimelteon • No evidence • No evidence agonists • Longer duration of action than Melatonin Melatonergic • Agomelatine • No evidence • No evidence anti-depressants • Treatment of depressive sx`s associated with jet lag Venkatramanujam S, et al. Jet Lag, Circadian Rhythm Sleep Disturbances, and Depression: the Role of Melatonin and its Analogs. Adv Ther, 2010, 27(11):796-813 Conclusion • Travel fatigue and jet lag poses a big problem for travelling athletes with RF`s including: sleeping habits / chronotype / sex / time zones crossed / flight direction / physical fitness / age / time of destination / previous experience • Many uncertainties on methods to advance or delay the body clock • Jet lag calculators: www.britishairways.com/travel/drsleep/public/en_gb www.jetlagrooster.com Email: [email protected] [email protected]: @ChristaJVR.