Sleep quality in elite athletes : Normative values, reliability and understanding contributors to poor sleep

Journal article


Halson, Shona L., Johnston, Rich D. Johnston, Appaneal, Renee N., Rogers, Margot A., Toohey, Liam A., Drew, Michael K., Sargent, Charli and Roach, Gregory D.. (2021). Sleep quality in elite athletes : Normative values, reliability and understanding contributors to poor sleep. Sports Medicine. pp. 1-10. https://doi.org/10.1007/s40279-021-01555-1
AuthorsHalson, Shona L., Johnston, Rich D. Johnston, Appaneal, Renee N., Rogers, Margot A., Toohey, Liam A., Drew, Michael K., Sargent, Charli and Roach, Gregory D.
Abstract

Background
The aims of this retrospective study were to (i) provide a description of sleep quality in elite athletes as measured by the Pittsburgh Sleep Quality Index (PSQI), (ii) provide normative PSQI data, (iii) identify differences across sex and sport, (iv) identify components that contribute to high PSQI scores and (v) assess PSQI test–retest reliability.

Methods
The PSQI was completed by 479 athletes (371 female and 108 male) across 20 Olympic team and individual sports. For ordinal and categorical variables, the Wilcoxon rank sum test and Chi Squared tests were used, respectively. A random forest regression was built to determine the importance of each PSQI component. Test–retest reliability was assessed using two-way mixed effects intraclass correlation coefficients.

Results
Fifty-two percent of athletes had a global PSQI score ≥ 5. Team sport athletes reported significantly longer sleep onset latency times but longer sleep durations compared with individual sport athletes. Sleep onset latency and sleep quality made the greatest contribution to the global PSQI scores. The PSQI demonstrated variability over periods of 2 months or more, with a minimal detectable change of 3 arbitrary units (AU).

Conclusion
Long sleep onset latency and poor perceived sleep quality made the greatest contribution to the high PSQI scores observed in approximately half of elite athletes investigated. The PSQI should be administered at regular intervals due to variability within individuals over periods of 2 months or more. Individual questionnaire items or component scores of the PSQI may be useful for practitioners in guiding decision-making regarding sleep interventions in athletes.

Year2021
JournalSports Medicine
Journal citationpp. 1-10
PublisherSpringer Nature Switzerland AG
ISSN0112-1642
Digital Object Identifier (DOI)https://doi.org/10.1007/s40279-021-01555-1
Scopus EID2-s2.0-85115405653
Open accessPublished as green open access
Research or scholarlyResearch
Page range1-10
Author's accepted manuscript
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Open
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Output statusIn press
Publication dates
Online23 Sep 2021
Publication process dates
Accepted30 Aug 2021
Deposited16 Dec 2021
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Michael Kellmann, Maurizio Bertollo, Laurent Bosquet, Michel Brink, Aaron Coutts, Rob Duffield, Daniel Erlacher, Shona Halson, Anne Hecksteden, Jahan Heidari, Wolfgang Kallus, R Meeusen, I Mujika, Claudio Robazza, Sabrina Skorski, Ranel Venter and Jürgen Beckmann. (2018). Recovery and performance in sport: Consensus statement. International Journal of Sports Physiology and Performance. 13(2), pp. 240-245. https://doi.org/10.1123/ijspp.2017-0759
Development of the athlete sleep behavior questionnaire: A tool for identifying maladaptive sleep practices in elite athletes
Matthew W Driller, Cheri D Mah and Shona Halson. (2018). Development of the athlete sleep behavior questionnaire: A tool for identifying maladaptive sleep practices in elite athletes. Sleep Science. 11(1), pp. 37-44.
The effects of intensified training on resting metabolic rate (RMR), body composition and performance in trained cyclists
Woods, Amy L., Rice, Anthony J., Garvican-Lewis, Laura A., Wallett, Alice M., Lundy, Bronwen, Rogers, Margot A., Welvaert, Marijke, Halson, Shona, McKune, Andrew and Thompson, Kevin G.. (2018). The effects of intensified training on resting metabolic rate (RMR), body composition and performance in trained cyclists. PLoS ONE. 13(2), pp. 1 - 24. https://doi.org/10.1371/journal.pone.0191644
An integrated, multifactorial approach to periodization for optimal performance in individual and team sports
Mujika, Iñigo, Halson, Shona, Burke, Louise M., Balagué, Gloria and Farrow, Damian. (2018). An integrated, multifactorial approach to periodization for optimal performance in individual and team sports. International Journal of Sports Physiology and Performance. 13(5), pp. 538 - 561. https://doi.org/10.1123/ijspp.2018-0093
Evening electronic device use: The effects on alertness, sleep and next-day physical performance in athletes
Jones, Maddison J., Peeling, Peter, Dawson, Brian, Halson, Shona, Miller, Joanna, Dunican, Ian C., Clarke, Michael W., Goodman, Craig and Eastwood, Peter R.. (2018). Evening electronic device use: The effects on alertness, sleep and next-day physical performance in athletes. Journal of Sports Sciences. 36(2), pp. 162 - 170. https://doi.org/10.1080/02640414.2017.1287936
The psychomotor vigilance test: A comparison of different test durations in elite athletes
Jones, Maddison J., Dunican, Ian C., Murray, Kevin, Peeling, Peter, Dawson, Brian, Halson, Shona, Miller, Joanna and Eastwood, Peter R.. (2018). The psychomotor vigilance test: A comparison of different test durations in elite athletes. Journal of Sports Sciences. 36(18), pp. 2033 - 2037. https://doi.org/10.1080/02640414.2018.1433443
Lower limb sports compression garments improve muscle blood flow and exercise performance during repeated-sprint cycling
Broatch, James R., Bishop, David J. and Halson, Shona. (2018). Lower limb sports compression garments improve muscle blood flow and exercise performance during repeated-sprint cycling. International Journal of Sports Physiology and Performance. 13(7), pp. 882 - 890. https://doi.org/10.1123/ijspp.2017-0638
Applied sport science of Australian football: A systematic review
Johnston, Richard, Black, Georgia M., Harrison, Peter W., Murray, Nick B. and Austin, Damien J.. (2018). Applied sport science of Australian football: A systematic review. Sports Medicine. 48(7), pp. 1673 - 1694. https://doi.org/10.1007/s40279-018-0919-z
Cold-water immersion for athletic recovery: One size does not fit all
Jessica M. Stephens, Shona Halson, Joanna Miller, Gary Slater and Christopher D. Askew. (2017). Cold-water immersion for athletic recovery: One size does not fit all. International Journal of Sports Physiology and Performance. 12(1), pp. 2-9. https://doi.org/10.1123/ijspp.2016-0095
A multifactorial evaluation of illness risk factors in athletes preparing for the Summer Olympic Games
Drew, Michael K., Vlahovich, Nicole, Hughes, David, Appaneal, Renee, Peterson, Kirsten, Burke, Louise, Lundy, Bronwen, Toomey, Mary, Watts, David, Lovell, Gregory, Praet, Stephan, Halson, Shona, Colbey, Candice, Manzanero, Silvia, Welvaert, Marijke, West, Nic P., Pyne, David B. and Waddington, Gordon. (2017). A multifactorial evaluation of illness risk factors in athletes preparing for the Summer Olympic Games. Journal of Science and Medicine in Sport. 20(8), pp. 745 - 750. https://doi.org/10.1016/j.jsams.2017.02.010
Greater effect of east versus west travel on jet lag, sleep, and team sport performance
Fowler, Peter M., Knez, Wade, Crowcroft, Stephen, Mendham, Amy E., Miller, Joanna, Sargent, Charli, Halson, Shona and Duffield, Rob. (2017). Greater effect of east versus west travel on jet lag, sleep, and team sport performance. Medicine and Science in Sports and Exercise. 49(12), pp. 2548 - 2561. https://doi.org/10.1249/MSS.0000000000001374
Team sport athletes' perceptions and use of recovery strategies: A mixed-methods survey study
Crowther, Fiona, Sealey, Rebecca, Crowe, Melissa, Edwards, Andrew and Halson, Shona. (2017). Team sport athletes' perceptions and use of recovery strategies: A mixed-methods survey study. BMC Sports Science, Medicine and Rehabilitation. 9(1), pp. 1 - 10. https://doi.org/10.1186/s13102-017-0071-3
Cold-water immersion and contrast water therapy: No improvement of short-term recovery after resistance training
Argus, Christos K., Broatch, James R., Petersen, Aaron C., Polman, Remco, Bishop, David J. and Halson, Shona. (2017). Cold-water immersion and contrast water therapy: No improvement of short-term recovery after resistance training. International Journal of Sports Physiology and Performance. 12(7), pp. 886 - 892. https://doi.org/10.1123/ijspp.2016-0127
Changes in rugby league tackling ability during a competitive season : The relationship with strength and power qualities
Speranza, Michael J. A., Gabbett, Tim J., Greene, David A., Johnston, Rich D. and Sheppard, Jeremy M.. (2017). Changes in rugby league tackling ability during a competitive season : The relationship with strength and power qualities. Journal of Strength and Conditioning Research. 31(12), pp. 3311-3318. https://doi.org/10.1519/JSC.0000000000001540
Prevalence of illness, poor mental health and sleep quality and low energy availability prior to the 2016 Summer Olympic Games
Drew, Michael, Vlahovich, Nicole, Hughes, David, Appaneal, Renee, Burke, Louise, Lundy, Bronwen, Rogers, Margot, Toomey, Mary, Watts, David, Lovell, Gregory, Praet, Stephan F. E., Halson, Shona, Colbey, Candice, Manzanero, Silvia, Welvaert, Marijke, West, NIcholas P., Pyne, David and Waddington, Gordon. (2017). Prevalence of illness, poor mental health and sleep quality and low energy availability prior to the 2016 Summer Olympic Games. British Journal of Sports Medicine. 52(1), pp. 1 - 8. https://doi.org/10.1136/bjsports-2017-098208
Wearable microtechnology can accurately identify collision events during professional rugby league match-play
Hulin, Billy T., Gabbett, Tim J., Johnston, Rich D. and Jenkins, David G.. (2017). Wearable microtechnology can accurately identify collision events during professional rugby league match-play. Journal of Science and Medicine in Sport. 20(7), pp. 638-642. https://doi.org/10.1016/j.jsams.2016.11.006
Protein ingestion before sleep increases overnight muscle protein synthesis rates in healthy older men: A randomized controlled trial
Kouw, Imre W.K., Holwerda, Andrew M., Trommelen, Jorn, Kramer, Irene Fleur, Bastiaanse, Jacqueline, Halson, Shona, Wodzig, Will K.W.H., Verdijk, Lex B. and Van Loon, Luc. (2017). Protein ingestion before sleep increases overnight muscle protein synthesis rates in healthy older men: A randomized controlled trial. The Journal of Nutrition. 147(12), pp. 2252 - 2261. https://doi.org/10.3945/jn.117.254532
Influence of physical maturity status on sprinting speed among youth soccer players
McCunn, Robert, Weston, Matthew, Hill, John KA, Johnston, Richard and Gibson, Neil V.. (2017). Influence of physical maturity status on sprinting speed among youth soccer players. Journal of Strength and Conditioning Research. 31(7), pp. 1795 - 1801. https://doi.org/10.1519/JSC.0000000000001654
Software thresholds alter the bias of actigraphy for monitoring sleep in team-sport athletes
Fuller, Kate L., Juliff, Laura E., Gore, Christopher J., Peiffer, Jeremiah John and Halson, Shona. (2017). Software thresholds alter the bias of actigraphy for monitoring sleep in team-sport athletes. Journal of Science and Medicine in Sport. 20(8), pp. 756 - 760. https://doi.org/10.1016/j.jsams.2016.11.021
Influence of recovery strategies upon performance and perceptions following fatiguing exercise: A randomized controlled trial
Crowther, Fiona, Sealey, Rebecca, Crowe, Melissa, Edwards, Andrew and Halson, Shona. (2017). Influence of recovery strategies upon performance and perceptions following fatiguing exercise: A randomized controlled trial. BMC Sports Science, Medicine and Rehabilitation. 9(1), pp. 1 - 9. https://doi.org/10.1186/s13102-017-0087-8
Effect of different repeated-high-intensity-effort bouts on subsequent running, skill performance, and neuromuscular function
Johnston, Rich D., Gabbett, Tim J., Jenkins, David G. and Speranza, Michael J.. (2016). Effect of different repeated-high-intensity-effort bouts on subsequent running, skill performance, and neuromuscular function. International Journal of Sports Physiology and Performance. 11(3), pp. 311-318. https://doi.org/10.1123/ijspp.2015-0243
The chronotype of elite athletes
Lastella, Michelle, Roach, G. D., Halson, Shona and Sargent, C.. (2016). The chronotype of elite athletes. Journal of Human Kinetics. 54(1), pp. 219 - 225. https://doi.org/10.1515/hukin-2016-0049
Superior inhibitory control and resistance to mental fatigue in professional road cyclists
Martin, Kristy, Staiano, Walter, Menaspà, Paolo, Hennessey, Tom, Marcora, Samuele, Keegan, Richard J., Thompson, Kevin G., Martin, David, Halson, Shona and Rattray, Ben. (2016). Superior inhibitory control and resistance to mental fatigue in professional road cyclists. PLoS ONE. 11(7), pp. 1 - 15. https://doi.org/10.1371/journal.pone.0159907
Importance of standardized DXA protocol for assessing physique changes in athletes
Nana, Alisa, Slater, Gary J., Hopkins, Will, Halson, Shona, Martin, D. T., West, N. P. and Burke, Louise Mary. (2016). Importance of standardized DXA protocol for assessing physique changes in athletes. International Journal of Sport Nutrition and Exercise Metabolism. 26(3), pp. 259 - 267. https://doi.org/10.1123/ijsnem.2013-0111
Are three contact efforts really reflective of a repeated high-intensity effort bout?
Johnston, Rich D., Gabbett, Tim J., Walker, Shane, Walker, Ben and Jenkins, David G.. (2015). Are three contact efforts really reflective of a repeated high-intensity effort bout? Journal of Strength and Conditioning Research. 29(3), pp. 816-821. https://doi.org/10.1519/JSC.0000000000000679
Nutrition and recovery
Halson, Shona and Burke, Louise Mary. (2015). Nutrition and recovery. In Tennis science : How player and racket work together pp. 116-135 University of Chicago Press. https://doi.org/10.7208/chicago/9780226139623.001.0001
The impact of a simulated grand tour on sleep, mood, and well-being of competitive cyclists
Michelle Lastella, Gregory D Roach, Shona Halson, David Martin, Nicholas P West and Charli Sargent. (2015). The impact of a simulated grand tour on sleep, mood, and well-being of competitive cyclists. The Journal of Sports Medicine and Physical Fitness. 55(12), pp. 1555-1564.
Understanding sleep disturbance in athletes prior to important competitions
Juliff, Laura E., Halson, Shona and Peiffer, Jeremiah John. (2015). Understanding sleep disturbance in athletes prior to important competitions. Journal of Science and Medicine in Sport. 18(1), pp. 13 - 18. https://doi.org/10.1016/j.jsams.2014.02.007
Sleep/wake behaviour of endurance cyclists before and during competition
Lastella, Michelle, Roach, Gregory D., Halson, Shona, Martin, David T., West, Nicholas P. and Sargent, Charli. (2015). Sleep/wake behaviour of endurance cyclists before and during competition. Journal of Sports Sciences. 33(3), pp. 293 - 299. https://doi.org/10.1080/02640414.2014.942690
Confounding compression: The effects of posture, sizing and garment type on measured interface pressure in sports compression clothing
Brophy-Williams, Ned, Driller, Matthew W., Shing, C., Fell, James W. and Halson, Shona. (2015). Confounding compression: The effects of posture, sizing and garment type on measured interface pressure in sports compression clothing. Journal of Sports Sciences. 33(13), pp. 1403 - 1410. https://doi.org/10.1080/02640414.2014.990489
The influence of physical fitness and playing standard on pacing strategies during a team-sport tournament
Johnston, Rich, Gabbett, Tim and Jenkins, David. (2015). The influence of physical fitness and playing standard on pacing strategies during a team-sport tournament. International Journal of Sports Physiology and Performance. 10(8), pp. 1001 - 1008. https://doi.org/10.1123/ijspp.2015-0005
Sleep hygiene and recovery strategies in elite soccer players
Nédélec, Mathieu, Halson, Shona, Delecroix, Barthélémy, Abaidia, Abd-Elbasset, Ahmaidi, S. and Dupont, Gregory. (2015). Sleep hygiene and recovery strategies in elite soccer players. Sports Medicine. 45(11), pp. 1547 - 1559. https://doi.org/10.1007/s40279-015-0377-9
Fatigue and pacing in rugby league players
Johnston, Richard. (2015). Fatigue and pacing in rugby league players [Thesis]. https://doi.org/10.4226/66/5a9cbe35b0b9e
Stress, sleep and recovery in elite soccer: A critical review of the literature
Nédélec, Mathieu, Halson, Shona, Abaidia, Abd-Elbasset, Ahmaidi, S. and Dupont, Gregory. (2015). Stress, sleep and recovery in elite soccer: A critical review of the literature. Sports Medicine. 45(10), pp. 1387 - 1400. https://doi.org/10.1007/s40279-015-0358-z
Sleep/wake behaviours of elite athletes from individual and team sports
Lastella, Michelle, Roach, Gregory D., Halson, Shona and Sargent, Charli. (2015). Sleep/wake behaviours of elite athletes from individual and team sports. European Journal of Sport Science. 15(2), pp. 94 - 100. https://doi.org/10.1080/17461391.2014.932016
Influence of playing standard and physical fitness on activity profiles and post-match fatigue during intensified junior rugby league competition
Johnston, Rich, Gabbett, Tim and Jenkins, David. (2015). Influence of playing standard and physical fitness on activity profiles and post-match fatigue during intensified junior rugby league competition. Sports Medicine - Open. 1(18), pp. 1 - 10. https://doi.org/10.1186/s40798-015-0015-y
Relationship between a standardized tackling proficiency test and match-play tackle performance in semiprofessional Rugby League players
Speranza, Michael, Gabbett, Tim, Johnston, Rich and Sheppard, Jeremy. (2015). Relationship between a standardized tackling proficiency test and match-play tackle performance in semiprofessional Rugby League players. International Journal of Sports Physiology and Performance. 10(6), pp. 754 - 760. https://doi.org/10.1123/ijspp.2015-0044
Muscular strength and power correlates of tackling ability in semiprofessional Rugby League players
Speranza, Michael, Gabbett, Tim, Johnston, Richard and Sheppard, Jeremy. (2015). Muscular strength and power correlates of tackling ability in semiprofessional Rugby League players. Journal of Strength and Conditioning Research. 29(8), pp. 2071 - 2078. https://doi.org/10.1519/JSC.0000000000000897
Influence of contrast shower and water immersion on recovery in elite netballers
Juliff, Laura E., Halson, Shona, Bonetti, Darrell L., Versey, Nathan, Driller, Matthew W. and Peiffer, Jeremiah John. (2014). Influence of contrast shower and water immersion on recovery in elite netballers. Journal of Strength and Conditioning Research. 28(8), pp. 2353 - 2358. https://doi.org/10.1519/JSC.0000000000000417
Monitoring training load to understand fatigue in athletes
Halson, Shona. (2014). Monitoring training load to understand fatigue in athletes. Sports Medicine. 44(Suppl 2), pp. 139 - 147. https://doi.org/10.1007/s40279-014-0253-z
Does hydrotherapy help or hinder adaptation to training in competitive cyclists?
Halson, Shona, Bartram, Jason C., West, Nicholas P., Stephens, Jessica M., Argus, Christos K., Driller, Matthew W., Sargent, Charli, Lastella, Michelle, Hopkins, Will G. and Martin, David T.. (2014). Does hydrotherapy help or hinder adaptation to training in competitive cyclists? Medicine and Science in Sports and Exercise. 46(8), pp. 1631 - 1639. https://doi.org/10.1249/MSS.0000000000000268
Applied sport science of Rugby League
Johnston, Rich, Gabbett, Tim J. and Jenkins, David. (2014). Applied sport science of Rugby League. Sports Medicine: reviews of applied medicine and science in sport and exercise. 44(8), pp. 1087 - 1100. https://doi.org/10.1007/s40279-014-0190-x
Sleep or swim? Early-morning training severely restricts the amount of sleep obtained by elite swimmers
Sargent, Charli, Halson, Shona and Roach, Gregory D.. (2014). Sleep or swim? Early-morning training severely restricts the amount of sleep obtained by elite swimmers. European Journal of Sport Science. 14(Supplement 1), pp. 310 - 315. https://doi.org/10.1080/17461391.2012.696711
Sleep in elite athletes and nutritional interventions to enhance sleep
Halson, Shona. (2014). Sleep in elite athletes and nutritional interventions to enhance sleep. Sports Medicine. 44(Supplement 1), pp. 13 - 23. https://doi.org/10.1007/s40279-014-0147-0
Influence of Physical Contact on Pacing Strategies During Game-Based Activities
Johnston, Rich, Gabbett, Tim, Seibold, Anthony and Jenkins, David. (2014). Influence of Physical Contact on Pacing Strategies During Game-Based Activities. International Journal of Sports Physiology and Performance. 9(5), pp. 811 - 816. https://doi.org/10.1123/ijspp.2013-0424
Sleep quantity and quality in elite youth soccer players: A pilot study
Robey, Elisa, Dawson, Brian, Halson, Shona, Gregson, Warren, Goodman, Carmel and Eastwood, Peter R.. (2014). Sleep quantity and quality in elite youth soccer players: A pilot study. European Journal of Sport Science. 14(5), pp. 410 - 417. https://doi.org/10.1080/17461391.2013.843024
Evaluating the Kikuhime pressure monitor for use with sports compression clothing
Brophy-Williams, Ned, Driller, Matthew, Halson, Shona, Fell, James W. and Shing, C.. (2014). Evaluating the Kikuhime pressure monitor for use with sports compression clothing. Sports Engineering. 17(1), pp. 55 - 60. https://doi.org/10.1007/s12283-013-0125-z
Nitrate supplementation and high-intensity performance in competitive cyclists
Hoon, Matthew, Hopkins, William, Jones, Andrew, Martin, David, Halson, Shona, West, Nicholas, Johnson, Nathan and Burke, Louise. (2014). Nitrate supplementation and high-intensity performance in competitive cyclists. Applied Physiology, Nutrition and Metabolism. 39(9), pp. 1043 - 1049. https://doi.org/10.1139/apnm-2013-0574
Reliability of a 2-bout exercise test on a wattbike cycle ergometer
Driller, Matthew W., Argus, Christos K., Bartram, Jason C., Bonaventura, Jacinta, Martin, David T., West, Nicholas P. and Halson, Shona. (2014). Reliability of a 2-bout exercise test on a wattbike cycle ergometer. International Journal of Sports Physiology and Performance. 9(2), pp. 340 - 345. https://doi.org/10.1123/IJSPP.2013-0103
Physiological responses to an intensified period of rugby league competition
Johnston, Rich D., Gibson, Neil V., Twist, Craig, Gabbett, Tim. J., MacNay, Sophie A. and MacFarlane, Niall G.. (2013). Physiological responses to an intensified period of rugby league competition. Journal of Strength and Conditioning Research. 27(3), pp. 643-654. https://doi.org/10.1519/JSC.0b013e31825bb469
Relationship between measures of aerobic fitness, speed and repeated sprint ability in full and part time youth soccer players
Gibson, Neil V., Currie, J., Johnston, Richard and Hill, J.. (2013). Relationship between measures of aerobic fitness, speed and repeated sprint ability in full and part time youth soccer players. Journal of Sports Medicine and Physical Fitness. 53(1), pp. 9 - 16.
Influence of an intensified competition on fatigue and match performance in junior rugby league players
Johnston, Richard, Gabbett, Timothy and Jenkins, David. (2013). Influence of an intensified competition on fatigue and match performance in junior rugby league players. Journal of Science and Medicine in Sport. https://doi.org/10.1016/j.jsams.2012.10.009
Daily training with high carbohydrate availability increases exogenous carbohydrate oxidation during endurance cycling
Cox, Geoffrey, Clark, Sally, Cox, A, Halson, Shona, Hargreaves, M, Hawley, John, Jeacocke, N, Snow, Rod, Yeo, W and Burke, Louise. (2010). Daily training with high carbohydrate availability increases exogenous carbohydrate oxidation during endurance cycling. Journal of Applied Physiology. 109(1), pp. 126 - 134. https://doi.org/10.1152/japplphysiol.00950.2009
Cytokine responses to carbohydrate ingestion during recovery from exercise-induced muscle injury
Ross, M, Halson, Shona, Suzuki, K, Garnham, A, Hawley, John, Cameron-Smith, David and Peake, J. (2010). Cytokine responses to carbohydrate ingestion during recovery from exercise-induced muscle injury. Journal of Interferon and Cytokine Research. 30(5), pp. 329 - 337. https://doi.org/10.1089/jir.2009.0079