Travel Guideline

This guideline advises on how to manage athletes and teams when travelling via plane for competitions around the world.

The following travel guidance information has been developed by World Rugby with support from Professor Greg Roach and Dr Charli Sargent from the Appleton Institute for Behavioural Science, CQ University, Australia.

Travel Fatigue

Travel fatigue refers to a collection of symptoms that include fatigue, disorientation, and/or headaches, primarily caused by the sleep loss, dehydration, hypoxia, and discomfort associated with being confined to an aircraft during long-haul flight.

How to minimise travel fatigue during flight

The main difficulties with long-haul flights are dehydration, physical discomfort, and sleep loss:

• Dehydration – Drink water regularly and avoid/minimise consumption of diuretics (i.e. alcohol, coffee, tea, coke).
• Discomfort – Stretch regularly when seated. Take a walk every hour or two when awake.
• NB. Standing/walking during flight could increase the risk of injury during unexpected turbulence.
• Sleep Loss (timing) – It can be difficult to obtain good sleep on an aircraft. The best strategy is to stay awake when it is daytime in your departure city, and sleep when it is night-time in your departure city.
• NB. Do not be tempted to miss sleep by playing games or watching movies during your sleep target zones.
• Sleep Loss (environment) – When attempting to sleep, recline the seat, keep head stable with headrest, use eye masks and ear plugs if required, and ask flight attendants not to disturb you.

How to manage sleep after travel

The sleep loss associated with travel (and sleeping in a new time zone) may make you sleepy during the daytime, particularly on the first two days after travel. To deal with daytime sleepiness, you could take a short nap during the day. The nap should not exceed 1 hour, and it should not be too close to bedtime, or it may interfere with your night sleep. If you have to nap, set an alarm to wake yourself up after no more than 1 hour.

Use of drugs to aid sleep after travel

Melatonin – Despite being an effective sleeping tablet, it is recommended that melatonin is not used to induce sleep because melatonin may shift the timing of your body clock which may result in more difficulty in adapting to the new time zone. If used melatonin should only be taken under supervision and as part of an overall plan to shift the body clock. If melatonin is used, a responsible party must ensure that it is not a prohibited substance under the relevant drug code, and that it is sourced from a reputable supplier (known dose and purity).

Sleeping Tablets – We recommend that you do not use sleeping tablets to aid sleep unless under direct medical supervision. Sleeping tablets can increase the amount of sleep obtained, but they can impair concentration, co-ordination and alertness, and issues of tolerance and dependence may arise. If sleeping tablets are prescribed, non-benzodiazepines (e.g. zolpidem, zopiclone, zaleplon) are preferred to benzodiazepines as they have less negative impact on waking function.

Coping With Jet Lag

Overview

Jet lag refers to a collection of symptoms that include headaches, irritability, daytime sleepiness, difficulty sleeping at night, poor mental and physical performance, and/or poor gastrointestinal function. These symptoms may occur after long-haul air travel due to the mismatch between the internal body clock, which is synchronised to the departure time zone, and local time cues, which are synchronised to the destination time zone.

How to adapt your sleep patterns to a new time zone

In the first few days after a large time zone change, you may have problems staying awake during the day and/or falling asleep at night.

• To deal with daytime sleepiness, you could take a short nap during the day. The nap should not exceed 1 hour, and it should not be too close to bedtime, or it may interfere with your night sleep. If you have to nap, set an alarm to wake yourself up after no more than 1 hour.
• To minimise difficulties sleeping at night, you should keep to a schedule where you have a regular bedtime at night, you should not take long naps during the day (i.e. no longer than 1 hour), you should not nap in the evening, and you should avoid caffeine from the mid-afternoon onwards.

How to adapt your body clock to a new time zone

To overcome jet lag, you need to shift the timing of your body clock so that it becomes aligned with your new time zone. As a rule of thumb, the body clock shifts about 1 hour/day in a new time zone, so adaptation takes about one day for each time zone crossed.

There are two main ways to shift the timing of your body clock so that it becomes aligned with your new time zone: (i) exposure to, and avoidance of sunlight (or other bright light), and (ii) use of chronobiotic (body clock adjusting) drugs (e.g. melatonin). There are some issues that complicate the use of melatonin (e.g. prohibited substance, dosage required, purity issues, availability, soporific (drowsy) effects) so it may be simpler to use light exposure/avoidance on its own.

In Appendix 1 you will find advice that should enable you to adapt to time zone changes as quickly as possible. The strategy that you use will depend on (i) the number of time zones crossed (3, 6, 9, 12), (ii) the direction of travel (west, east), and (iii) the timing of arrival in the new time zone (morning, afternoon, evening).

Quick guide to using the schedules for shifting the body clock:

• When the schedule requires exposure to bright light, it is best to be outside in sunlight without sunglasses. A possible strategy is to combine light exposure with training. If it is dark outside, you can use bright indoor light, or a light box, or light-emitting glasses.
• When the schedule requires avoidance of bright light, it is best to be inside with lights off or as dim as possible. If you must be outside and it is light, wear wrap-around sunglasses.

Common Questions

Generally teams assume they should adopt the destination time zone rather than departure time zone when considering on-plane sleep. Why is this not the recommendation?

It is common for people to recommend that travellers switch straight to ‘destination time’ as soon as they are on-board.  But if players attempt to sleep on-board during ‘body clock’ daytime because that aligns with night in the next destination, they are likely to get less sleep and have more travel fatigue than if they attempt to sleep on-board during ‘body clock’ night-time.

The advice to switch to destination time asap is usually given because people are concerned that plane sleep could interfere with sleep at the destination.  But plane sleep is usually so poor that it does not interfere with sleep after flight.

The use of sleeping tablets is not recommended as part of this jetlag management program. Most sporting teams would use mild benzodiazepines on arrival for 2-3 days. Why isn’t this recommended?

Our view is that the potential benefits (more sleep, but not necessarily good sleep) do not sufficiently outweigh the potential costs (impaired function next day) to warrant blanket recommendation to all... but there are individual differences in the size of positive/negative effects, so the team doctors may well have players for whom they know that the benefits are greater than the costs.

Questions related to ‘Shifting body clock schedules’ tables shown below

If bright light exposure is recommended on the day of arrival between 1400-1630, and an afternoon sleep (less than one hour) is required what is the best time for this afternoon sleep considering the need to obtain bright light exposure and avoid sleep that is too late in the afternoon so that the night time sleep is not impaired?

If you have just crossed 12 time zones with a morning arrival, travel has been quite long. Some players may want to have a short sleep as soon as they get to the hotel.  But if they want an afternoon sleep, it is best to sleep straight after lunch (1300-1400h). This will allow the players to be outside for light exposure at 1400h.

Bright light exposure requirement is recommended in some of the scenarios below late at night, are you recommending that players stay up until late even after midnight to obtain this bright light exposure?

Timing of bright light moves every day and the most effective time relative to the changing body clock is provided.  It has been assumed that this bright light exposure will only be accessed if the player is awake. On average players should aim for 8 hours sleep each night however during recovery from flying this 8 hour period may be moved forward-back depending on personal/team preference. The change in the 8 hour sleep time may support light exposure at unusual times identified below.

Can you define ‘dim light’?

Technically, dim light is < 15 lux – at that level it will not affect the body clock.  In practice, dim light means as dark as possible – even dark.... so inside with lights off or corner lamp only on, or inside with sunglasses on if lights can’t be turned off, or if you have to be outside then wrap-around sunglasses are essential (preferably those that block blue light).

Melatonin is advised to be taken every day in some routines and in other routines, days are missed. Is this correct?

On days where it appears to be missed, potentially there is >24h between administration. Using melatonin adds another layer of complexity so light should be considered to be the basic plan and melatonin + light to be the advanced plan.

I note in some plans melatonin is recommended to be taken during sleep. I would assume this is only if the player wakes during that night. Is this correct?

Yes.

Appendix 1

Schedule 1 (A,B,C). Shifting the body clock after air travel.
[WESTWARD travel – 3 time zones – morning/afternoon/evening arrival]

NB. If players are attempting to shift body clock time without pharmacological interventions, ignore advice regarding melatonin and use bright light exposure/avoidance alone.

Schedule 2 (A,B,C). Shifting the body clock after air travel.
[WESTWARD travel – 6 time zones – morning/afternoon/evening arrival]

NB1. Only take melatonin during scheduled sleep if spontaneously awake at appropriate time.
NB2. If players are attempting to shift body clock time without pharmacological interventions, ignore advice regarding melatonin and use bright light exposure/avoidance alone.

Schedule 3 (A,B,C). Shifting the body clock after air travel.
[WESTWARD travel – 9 time zones – morning/afternoon/evening arrival]

NB1. Only take melatonin during scheduled sleep if spontaneously awake at appropriate time.
NB2. If players are attempting to shift body clock time without pharmacological interventions, ignore advice regarding melatonin and use bright light exposure/avoidance alone.

Schedule 4 (A,B,C). Shifting the body clock after air travel.
[WESTWARD travel – 12 time zones – morning/afternoon/evening arrival]

NB1. Only take melatonin during scheduled sleep if spontaneously awake at appropriate time.
NB2. If players are attempting to shift body clock time without pharmacological interventions, ignore advice regarding melatonin and use bright light exposure/avoidance alone.

Schedule 5 (A,B,C). Shifting the body clock after air travel.
[EASTWARD travel – 3 time zones – morning/afternoon/evening arrival]

NB. If players are attempting to shift body clock time without pharmacological interventions, ignore advice regarding melatonin and use bright light exposure/avoidance alone.

Schedule 6 (A,B,C). Shifting the body clock after air travel.
[EASTWARD travel – 6 time zones – morning/afternoon/evening arrival]

NB. If players are attempting to shift body clock time without pharmacological interventions, ignore advice regarding melatonin and use bright light exposure/avoidance alone.

Schedule 7 (A,B,C). Shifting the body clock after air travel.
[EASTWARD travel – 9 time zones – morning/afternoon/evening arrival]

NB. If players are attempting to shift body clock time without pharmacological interventions, ignore advice regarding melatonin and use bright light exposure/avoidance alone.

Schedule 8 (A,B,C). Shifting the body clock after air travel.
[EASTWARD travel – 12 time zones – morning/afternoon/evening arrival]

NB1. Only take melatonin during scheduled sleep if spontaneously awake at appropriate time.
NB2. If players are attempting to shift body clock time without pharmacological interventions, ignore advice regarding melatonin and use bright light exposure/avoidance alone.

Medical issues and flying

Guidance for medical issues potentially affected by air travel are outlined below. In every medical situation the specific issue should be managed with the support of a medical expert.

Prevention of DVT

The following is general advice aimed at reducing the development of a DVT

• Exercise calf and foot muscles regularly:
  • Every half hour or so, bend and straighten your legs, feet and toes when you are seated.
  • Press the balls of your feet down hard against the floor or foot rest every so often. This helps to increase the blood flow in your legs.
  • Walk up and down the aisle every hour or so, when the aircraft crew say it is safe to do so.
  • Avoid having bags under the seat in front of you, and recline your seat where possible so that as much space as possible is available your legs to move.
  • Optimise movement and stretching of your legs, when there are stops in your journey.
• Drink plenty of water to avoid dehydration.
• Do not drink too much alcohol. Alcohol can cause dehydration and result in immobility.
• Do not sleep in a cramped position and avoid take sleeping tablets, which cause immobility.

Managing high risk patients for DVT prevention

In high risk cases when prophylaxis is required, each person should be evaluated and managed on a case-by-case basis by a medical expert.

Prophylactic management of high risk individuals may involve low-molecular-weight heparin and compression stockings. Examples and doses of low-molecular-weight heparin include:

• enoxaparin (Lovenox / Clexane) 40 mg daily given subcutaneously either prior to departure or for very high risk patients day before, day of and day after flying.
• dalteparin (Fragmin) 5,000 IU daily subcutaneously prior to departure.

Care with the use of prophylactic is required in patients with renal disease and a past history of bleeding disorders.

Travel following a chest injury

Players with a proven pneumothorax or suspected pneumothorax should not fly until cleared by a specialist. Patients can generally travel safely on commercial aircraft 2 weeks after resolution of a pneumothorax. Ideally, a chest x-ray should be obtained shortly before travel to confirm that the pneumothorax has resolved.

Helicopter travel is allowed at any time following a pneumothorax as flights are typically at or below 1,500 feet.