Enhancement of nighttime alertness and performance with bright ambient light

Objective levels of alertness and performance efficiency were measured in twenty-five healthy young adults during two simulated night shifts. Following the first night shift, during which all subjects worked under dim ambient light (10-20 lux), subjects were assigned to one of three ambient lighting conditions (10-20 lux, 100 lux or 1000 lux) for the second night of work. Subjects exposed to 1000 lux ambient light maintained significantly higher levels of alertness across the 8-hour shift than did subjects exposed to the dimmer lighting conditions. Cognitive performance was also significantly enhanced under the bright light condition, whereas simple reaction time was not. The findings indicate clearly that ambient lighting levels can have a substantial impact on nighttime alertness and performance and that bright ambient illumination may be effective in maintaining optimal levels of alertness during night shift operations.     

Exposure to bright light and darkness to treat physiologic maladaptation to night work

Working at night results in a misalignment between the sleep-wake cycle and the output of the hypothalamic pacemaker that regulates the circadian rhythms of certain physiologic and behavioral variables. We evaluated whether such physiologic maladaptation to nighttime work could be prevented effectively by a treatment regimen of exposure to bright light during the night and darkness during the day. We assessed the functioning of the circadian pacemaker in five control and five treatment studies in order to assess the extent of adaptation in eight normal young men to a week of night work. In the control studies, on the sixth consecutive night of sedentary work in ordinary light (approximately 150 lux), the mean (+/- SEM) nadir of the endogenous temperature cycle continued to occur during the night (at 3:31 +/- 0:56 hours), indicating a lack of circadian adaptation to the nighttime work schedule. In contrast, the subjects in the treatment studies were exposed to bright light (7000 to 12,000 lux) at night and to nearly complete darkness during the day, and the temperature nadir shifted after four days of treatment to a significantly later, midafternoon hour (14:53 +/- 0:32; P less than 0.0001), indicating a successful circadian adaptation to daytime sleep and nighttime work. There were concomitant shifts in the 24-hour patterns of plasma cortisol concentration, urinary excretion rate, subjective assessment of alertness, and cognitive performance in the treatment studies. These shifts resulted in a significant improvement in both alertness and cognitive performance in the treatment group during the night-shift hours. We conclude that maladaptation of the human circadian system to night work, with its associated decline in alertness, performance, and quality of daytime sleep, can be treated effectively with scheduled exposure to bright light at night and darkness during the day.     

Bright light exposure at night and light attenuation in the morning improve adaptation of night shift workers

With practical applicability in mind, we wanted to observe whether nocturnal alertness, performance, and daytime sleep could be improved by light exposure of tolerable intensity and duration in a real work place. We also evaluated whether attenuating morning light was important in adaptation of real night shift workers. Twelve night shift nurses participated in this study. The study consisted of three different treatment procedures: Room Light (RL), Bright Light (BL), and Bright Light with Sunglasses (BL/S). In RL, room light exposure was given during the night shift and followed by 1 hr exposure to sunlight or 10,000 lux light the next morning (from 08:30 to 09:30). In BL, a 4-hour nocturnal light exposure of 4,000-6,000 lux (from 01:00 to 05:00) was applied and followed by the same morning light exposure as in RL. In BL/S, the same nocturnal light exposure as in BL was done with light attenuation in the morning. Each treatment procedure was continued for 4 days in a repeated measures, cross-over design. Nocturnal alertness was measured by a visual analog scale. Computerized performance tests were done. Daytime sleep was recorded with actigraphy. The most significant overall improvement of sleep was noted in BL/S. BL showed less improvement than BL/S but more than RL. Comparison of nocturnal alertness among the 3 treatments produced similar results: during BL/S, the subjects were most alert, followed by BL and then by RL. Real night shift workers can improve nocturnal alertness and daytime sleep by bright light exposure in their work place. These improvements can be maximized by attenuating morning light on the way home.     

Effect of a single 3-hour exposure to bright light on core body temperature and sleep in humans

Seven human subjects were exposed to bright light (BL, approx. 2500 lux) and dim light (DL, approx. 6 lux) during 3 h prior to nocturnal sleep, in a cross-over design. At the end of the BL exposure period core body temperature was significantly higher than at the end of the DL exposure period. The difference in core body temperature persisted during the first 4 h of sleep. The latency to sleep onset was increased after BL exposure. Rapid-eye movement sleep (REMS) and slow-wave sleep (SWS; stage 3 + 4 of non-REMS) were not significantly changed. Eight subjects were exposed to BL from 20.30 to 23.30 h while their eyes were covered or uncovered. During BL exposure with uncovered eyes, core body temperature decreased significantly less than during exposure with covered eyes. We conclude that bright light immediately affects core body temperature and that this effect is mediated via the eyes.     

Behavioral Control of Respiration in Sleep and Sleepiness Due to Signal-Induced Sleep Fragmentation

The effects of sleep fragmentation on behavioral control of sleeping respiration and on daytime sleepiness were investigated in 20 college students. All were polygraphically monitored both during nighttime sleep and during daytime naps. Ten experimental subjects were informed while awake that tones would be presented to them during nighttime sleep. Their task was to terminate the tones by taking a deep breath. Half of the subjects first received tones every 4 min; the other half received them every 8 min. After 4 consecutive nights subjects received 3 days off and conditions were reversed for 4 more consecutive nights. Tones started at 45dB and, in the absence of a response, increased 10dB every 10 seconds up to 95dB. Control subjects (N = 10) did not receive tones. The absolute number of arousals to tones was greater but the percentage of arousals was lower under the 4-min condition. Full awakenings occurred infrequently. Probability of making a breathing response remained high across days for both fragmentation conditions, but latency to respond was shorter and probability higher under the 8-min condition. Sleep fragmentation, whether “frequent” (4-min) or “infrequent” (8-min), did not induce greater daytime sleepiness than did the nonfragmentation control condition, and sleepiness did not differ between the two experimental conditions. Implications for developing behavioral techniques for treating sleep-related breathing disorders are discussed.     

Dynamics of EEG slow-wave activity and core body temperature in human sleep after exposure to bright light.

In seven subjects sleep was recorded after a single 3-hour (2100-0000 hours) exposure to either bright light (BL, approx. 2,500 lux) or dim light (DL, approx. 6 lux) in a crossover design. The latency to sleep onset was increased after BL. Whereas rectal temperature before onset and during the first 4 hours of sleep was higher after BL than after DL, the time course of electroencephalographic (EEG) slow-wave activity (SWA, EEG power density in the range of 0.75-4.5 Hz) in nonrapid eye movement sleep (NREMS) differed only slightly between the conditions. After BL, SWA tended to be lower than after DL in the first NREMS-REMS cycle and was higher in the fourth cycle at the time when the rectal temperature did not differ. The differences in SWA may have been due to a minor sleep-disturbing aftereffect of BL, which was followed by a rebound. The data are not in support of a close relationship between SWA and core body temperature.     

Modification of internal temperature regulation for cutaneous vasodilation and sweating by bright light exposure at night

Bright light (BL) exposure at night leads to suppressed secretion of melatonin and an attenuated fall in internal temperature at rest from the night to the early morning. However, it is unknown at the present whether typical diurnal variations in reflex responses to thermal challenges are similarly affected by BL exposure at night. We investigated the control of cutaneous vasodilator and sweating responses to hyperthermia in the early morning after artificial BL exposure at night, compare with dim light (DL) exposure. Six subjects stayed awake in a semi-supine position under DL (120 lx) or BL (2800 lx) conditions between 21.00 and 04.30 h. Urine samples were collected at 04.30 h. Beginning at 05.30 h, the lower legs were immersed for 50 min in 42°C water. The subjects remained awake for 21 h until the end of hot water immersion. Urinary 6-sulphatoxymelatonin levels following BL were significantly lower than after DL. Oesophageal temperature (T_es) before heating was significantly higher following BL [36.41±0.10 (DL) vs. 36.55±0.09 (BL)°C]. The T_es thresholds for the onset of cutaneous vasodilation and sweating were significantly higher with BL than with DL conditions (approximately 0.15°C, respectively). We found that the internal temperature threshold for thermoregulatory control of cutaneous vasodilation and sweating responses to passive heating in the early morning can be modified by the level of light exposure the prior night. Thus both basal internal temperature and the regulation of internal temperature are modified by BL exposure at night.     

Photostimulation of blackheaded bunting: subjective interpretation of day and night depends upon both photophase contrast and light intensity.

Blackheaded buntings were exposed to constant dim light (approximately 2 lux) for 77 days and subsequently to 12:12 illumination, consisting of either dim light:complete darkness (dl:dk) (2:0 lux) or bright light:dim light (bl:dl) (10, 35, and 90 lux:2, 10, and 35 lux, respectively, with 180 degrees bl:dl transitions) for 2-3 weeks each. Birds were unstimulated until day 100, under dim LL (dl:dl) and 12dl:12dk. Photostimulation with a significant increase (p less than 0.001) in average body weight and testis volume occurred on exposure to 12bl:12dl (10:2 lux); birds remained fat and testes were enlarged until the end (day 173) of the experiment. Locomotor activity also did not have a discernible pattern under the nongonadostimulatory photoregimes. Birds became active in the bright photophase (subjective day) of 12bl:12dl (10:2 lux) on day 5 (day 105 of the experiment), but beginning on day 113 more intense perch-hopping was initiated in the dim photophase (subjective night), indicating the appearance of nocturnal migratory restlessness in the caged birds. A 180 degrees transition in the bl:dl photophases at this time for 2 weeks resulted in complete shift in the timing of daytime and nighttime activity. This trend is maintained under all subsequent 12bl:12dl exposures. These results suggest that the light intensity required for photostimulation in the blackheaded bunting is absolute, and that the subjective interpretation of day and night depends upon the photophase contrast, as well.     

Sleepiness/alertness on a simulated night shift following sleep at home with triazolam

Physiological sleep tendency during a simulated night shift schedule was examined in 15 middle-aged subjects following daytime sleep after administration of triazolam or placebo. A double-blind, counterbalanced, crossover design involving two tours of five laboratory nights and four daytime home sleep periods was used. Triazolam lengthened daytime sleep as measured by wrist actigraph and improved nighttime alertness as measured by the MSLT. Sleepiness was most profound during the early morning hours (0430 to 0630) but improved significantly across nights for both conditions. Repeated test of sustained wakefulness latencies and simulated assembly line task performance decreased slightly across the night, but there were no significant condition effects. Subjective data tended to support objective measures, although Stanford Sleepiness Scale ratings indicated that subjects did not perceive improved alertness at night after triazolam-aided daytime sleep.     

Entrainment of the circadian activity rhythm to the light cycle: Effective light intensity for a Zeitgeber in the retinal degenerate C3H mouse and the normal C57BL mouse

Effective light intensities for entrainment of activity rhythms were obtained in the retinal degenerated C3Hf/He mice and the normal C57BL/6J mice. The circadian activity rhythms of the mice were examined under LD 12:12 cycles with one of five different levels of light (L phase) and complete darkness (D phase). The thresholds of a Zeitgeber, defined as the light intensity effective for 50% entrainment, were estimated between 1 lux and 5 lux in the C3H and lower than 0.01 lux in the C57BL mice. These results suggest that at least two different kinds of photoreceptor including rods and cones participate in the photic entrainment of the circadian activity rhythms.     

Effects of Experimentally-Induced Sleep Fragmentation on Sleep and Sleepiness

The effects of two levels of sleep fragmentation on sleep and daytime sleepiness were investigated in young adult males. Experimental subjects were informed while awake that tones would be presented periodically throughout the night and that their task was to terminate the tone by taking a deep breath. Eight subjects received tones after each minute of sleep and 8 received tones after each 4 min of sleep. Control subjects (N=8) HI did not receive (ones. The subjects were tested for daytime sleepiness using the Multiple Steep latency Test. It was found that: 1) subjects responded reliably lo tones presented during sleep; 2) behavioral control was accompanied by brief electro-physiological indices of arousal on almost all trials, and occasionally led to fall awakenings; 3) sleep was markedly altered in the 1-min condition; 4) a relatively small effect on sleep (reduced stage 4 sleep) was produced by the 4-min condition, and 5) daytime sleepiness was increased by the 1-min condition but not the 4-min condition. It was concluded that the most parsimonious explanation of these results is (he Continuity of Sleep hypothesis.     

Suppression of sleepiness and melatonin by bright light exposure during breaks in night work

Night work is non-optimal for performance and recuperation because of a lack of circadian influence that fully promote a night orientation. Our study assessed, in an industrial setting, the effects of bright light exposure (BL) on sleepiness, sleep and melatonin, during night work and during the following readaptation to day work. In a crossover design, 18 workers at a truck production plant were exposed to either BL (2500 lx) during breaks or normal light during four consecutive weeks. Twenty minute breaks were initiated by 67% of the workers between 03:00 and 04:00 hours. Sleep/wake patterns were assessed through actigraphs and ratings were given in a sleep/wake diary. Saliva melatonin was measured at 2-h intervals before, during and after night shift weeks. A significant interaction demonstrated a reduction of sleepiness in the BL condition particularly on the first two nights at 04:00 and 06:00 hours. Day sleep in the BL condition was significantly lengthened. Bright light administration significantly suppressed melatonin levels during night work and most strongly at 02:00 hours. Daytime melatonin during the readaptation after night work remained unaffected. The present findings demonstrate the feasibility and benefits of photic stimulation in industrial settings to increase adaptation to night work.     

Nighttime dim light exposure alters the responses of the circadian system

The daily light dark cycle is the most salient entraining factor for the circadian system. However, in modern society, darkness at night is vanishing as light pollution steadily increases. The impact of brighter nights on wild life ecology and human physiology is just now being recognized. In the present study, we tested the possible detrimental effects of dim light exposure on the regulation of circadian rhythms, using CD1 mice housed in light/dim light (LdimL, 300 lux:20 lux) or light/dark (LD, 300 lux:1 lux) conditions. We first examined the expression of clock genes in the suprachiasmatic nucleus (SCN), the locus of the principal brain clock, in the animals of the LD and LdimL groups. Under the entrained condition, there was no difference in PER1 peak expression between the two groups, but at the trough of the PER 1 rhythm, there was an increase in PER1 in the LdimL group, indicating a decrease in the amplitude of the PER1 rhythm. After a brief light exposure (30 min, 300 lux) at night, the light-induced expression of mPer1 and mPer2 genes was attenuated in the SCN of LdimL group. Next, we examined the behavioral rhythms by monitoring wheel-running activity to determine whether the altered responses in the SCN of LdimL group have behavioral consequence. Compared to the LD controls, the LdimL group showed increased daytime activity. After being released into constant darkness, the LdimL group displayed shorter free-running periods. Furthermore, following the light exposure, the phase shifting responses were smaller in the LdimL group. The results indicate that nighttime dim light exposure can cause functional changes of the circadian system, and suggest that altered circadian function could be one of the mechanisms underlying the adverse effects of light pollution on wild life ecology and human physiology.     

Timed exposure to bright light improves sleep and alertness during simulated night shifts.

Many of the health and safety problems reported by shift workers result from the chronic sleep deprivation associated with shorter, fragmented daytime sleep. This reduction in the quality and duration of sleep has been attributed to a change in the phase relationship between the work period and the circadian system, timing the propensity for sleep and wakefulness. This study examined the extent to which appropriately timed exposure to bright light would accelerate the circadian readjustment of physiological parameters thought to contribute to impaired performance in shift workers. A control (n = 7) and treatment group (n = 6) underwent a 3-day transition to simulated night work. The treatment group received a single 4-hour pulse of bright light (6,000 lux) between 2400 and 0400 hours on the first night shift and dim light (less than 200 lux) for the remainder of the study. The control group received dim light throughout. By the third night shift, the phase position of the core body temperature rhythm for the treatment group had delayed by 5-6 hours whereas the control group had delayed by only 2-3 hours. When compared to the control group, the greater delay in core temperature rhythm for the treatment group was associated with significantly higher alertness across the night shift and improved sleep quality during the day. By the third day sleep, mean sleep efficiency in the treatment group was not significantly different from normal night sleep. Similarly, onshift alertness was improved relative to the control group. The treatment group did not show the typical decline in alertness observed in the control group between 0300 and 0700 hours. These data indicate that a single 4-hour pulse of bright light between midnight and 0400 hours is effective in ameliorating the sleep and alertness problems associated with transition to night shift.     

Light response of the neuronal firing activity in the suprachiasmatic nucleus of mice

To investigate the neural mechanisms underlying the mammalian photic entrainment of circadian rhythms, the response of neuronal extracellular firing activity to retinal light stimulation was investigated in the suprachiasmatic nucleus (SCN) of anesthetized mice during nighttime and daytime. In nighttime, most recorded SCN cells (83%) increased their firing frequency in response to retinal illumination. Some SCN cells (11%) responded by decreasing their firing rate. In daytime, the retinal illumination increased the firing rate in only 26% of the SCN cells, and no response was observed in the remaining cells. The light intensity threshold for the activation of SCN cells at zeitgeber time (ZT) 16 was approximately 3 x 10(11) photons cm(-2)s(-1) and the maximum response was observed at approximately 1 x 10(14) photons cm(-2)s(-1). Therefore, photic response in the firing of mouse SCN cells may be phase-dependent and have a higher threshold, which corresponds to properties of the photic entrainment in locomotor activity of mice.     

Complete or partial circadian re-entrainment improves performance, alertness, and mood during night-shift work

STUDY OBJECTIVES: To assess performance, alertness, and mood during the night shift and subsequent daytime sleep in relation to the degree of re-alignment (re-entrainment) of circadian rhythms with a night-work, day-sleep schedule. DESIGN: Subjects spent 5 consecutive night shifts (11:00 pm-7:00 am) in the lab and slept at home in darkened bedrooms (8:30 am-3:30 pm). Subjects were categorized by the degree of re-entrainment attained after the 5 night shifts. Completely re-entrained: temperature minimum in the second half of daytime sleep; partially re-entrained: temperature minimum in the first half of daytime sleep; not re-entrained: temperature minimum did not delay enough to reach daytime sleep. SETTING: See above. PARTICIPANTS: Young healthy adults (n = 67) who were not shift workers. INTERVENTIONS: Included bright light during the night shifts, sunglasses worn outside, a fixed dark daytime sleep episode, and melatonin. The effects of various combinations of these interventions on circadian re-entrainment were previously reported. Here we report how the degree of re-entrainment affected daytime sleep and measures collected during the night shift. MEASUREMENTS AND RESULTS: Salivary melatonin was collected every 30 minutes in dim light (<20 lux) before and after the night shifts to determine the dim light melatonin onset, and the temperature minimum was estimated by adding a constant (7 hours) to the dim light melatonin onset. Subjects kept sleep logs, which were verified by actigraphy. The Neurobehavioral Assessment Battery was completed several times during each night shift. Baseline sleep schedules and circadian phase differed among the 3 re-entrainment groups, with later times resulting in more re-entrainment. The Neurobehavioral Assessment Battery showed that performance, sleepiness, and mood were better in the groups that re-entrained compared to the group that did not re-entrain, but there were no significant differences between the partial and complete re-entrainment groups. Subjects slept almost all of the allotted 7 hours during the day, and duration did not significantly differ among the re-entrainment groups. CONCLUSIONS: In young people, complete re-entrainment to the night-shift day-sleep schedule is not necessary to produce substantial benefits in neurobehavioral measures; partial re-entrainment (delaying the temperature minimum into the beginning of daytime sleep) is sufficient. The group that did not re-entrain shows that a reasonable amount of daytime sleep is not enough to produce good neurobehavioral performance during the night shift. Therefore, some re-alignment of circadian rhythms is recommended.     

Shaping the light/dark pattern for circadian adaptation to night shift work

This is the second in a series of simulated night shift studies designed to achieve and subsequently maintain a compromise circadian phase position between complete entrainment to the daytime sleep period and no phase shift at all. We predict that this compromise will yield improved night shift alertness and daytime sleep, while still permitting adequate late night sleep and daytime wakefulness on days off. Our goal is to delay the dim light melatonin onset (DLMO) from its baseline phase of ∼ 21:00 to our target of ∼ 3:00. Healthy young subjects (n = 31) underwent three night shifts followed by two days off. Two experimental groups received intermittent bright light pulses during night shifts (total durations of 75 and 120 min per night shift), wore dark sunglasses when outside, slept in dark bedrooms at scheduled times after night shifts and on days off, and received outdoor light exposure upon awakening from sleep. A control group remained in dim room light during night shifts, wore lighter sunglasses, and had unrestricted sleep and outdoor light exposure. After the days off, the DLMO of the experimental groups was ∼ 00:00-1:00, not quite at the target of 3:00, but in a good position to reach the target after subsequent night shifts with bright light. The DLMO of the control group changed little from baseline. Experimental subjects performed better than control subjects during night shifts on a reaction time task. Subsequent studies will reveal whether the target phase is achieved and maintained through more alternations of night shifts and days off.     

Circadian rhythms of melatonin, cortisol, and clock gene expression during simulated night shift work

STUDY OBJECTIVES: The synchronization of peripheral circadian oscillators in humans living on atypical sleep/wake schedules is largely unknown. In this night shift work simulation, we evaluate clock gene expression in peripheral blood mononuclear cells (PBMCs) relative to reliable markers of the central circadian pacemaker. DESIGN: Participants were placed on a 10-hr delayed sleep/wake schedule simulating nighttime work followed by a daytime sleep episode. SETTING: Baseline, intermediate and final circadian evaluations were performed in the temporal isolation laboratory. PARTICIPANTS: Five healthy candidates, 18-30 years. INTERVENTIONS: Polychromatic white light of (mean +/-SEM) 6,036 +/-326 lux (approximately 17,685 +/-955 W/m2) during night shifts; dim light exposure after each night shift; an 8-hr sleep/darkness episode beginning 2 hrs after the end of each night shift. MEASUREMENTS: Melatonin and cortisol in plasma; clock genes HPER1, HPER2 and HBMAL1 RNA in PBMCs. RESULTS: Following 9 days on the night schedule, hormonal rhythms were adapted to the shifted schedule. HPER1 and HPER2 expression in PBMCs displayed significant circadian rhythmicity, which was in a conventional relationship with the shifted sleep/wake schedule. Changes in the pattern of clock gene expression were apparent as of 3 days on the shifted sleep/wake schedule. CONCLUSIONS: This preliminary study is the first documentation of the effects of a shifted sleep/wake schedule on the circadian expression of both peripheral circadian oscillators in PBMCs and centrally-driven hormonal rhythms. In light of evidence associating clock gene expression with tissue function, the study of peripheral circadian oscillators has important implications for understanding medical disorders affecting night shift workers.     

The relationship between waking time and urinary epinephrine in bed-rested humans under conditions involving minimal stress

The correlation between urinary excretion of epinephrine and percent of waking time during time allotted for sleep was evaluated for both daytime and nighttime bed-rest under minimally stressful conditions. The experiment was performed on 6 male subjects. Polysomnographic recordings were made throughout each 8-h bed-rest period, and free epinephrine excretion was measured at intervals of 2.5 h. Epinephrine excretion showed a strongly positive correlation with percent of waking time during bed-rest in the daytime and at night (average correlation coefficient: day: r = 0.89, P less than 0.001; night: r = 0.68, P less than 0.001). The possibility that levels of epinephrine excretion could be used as an indicator of sleep disturbance is discussed.     

More daytime sleeping predicts less functional recovery among older people undergoing inpatient post-acute rehabilitation

STUDY OBJECTIVES: To study the association between sleep/wake patterns among older adults during inpatient post-acute rehabilitation and their immediate and long-term functional recovery DESIGN: Prospective, observational cohort study. SETTING: Two inpatient post-acute rehabilitation sites (one community and one Veterans Administration). PARTICIPANTS: Older patients (aged > or = 65 years, N = 245) admitted for inpatient post-acute rehabilitation. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Based on 7-day wrist actigraphy during the rehabilitation stay, mean nighttime percent sleep was only 52.2% and mean daytime percent sleep was 15.8% (16.3% based on structured behavioral observations). Using the Pittsburgh Sleep Quality Index (PSQI), participants reported their sleep was worse during rehabilitation compared to their premorbid sleep. Functional recovery between admission and discharge from rehabilitation (measured by the motor component of the Functional Independence Measure) was not significantly associated with reported sleep quality (PSQI scores) or actigraphically measured nighttime sleep. However, more daytime percent sleep (estimated by actigraphy and observations) during the rehabilitation stay was associated with less functional recovery from admission to discharge, even after adjusting for other significant predictors of functional recovery (mental status, hours of rehabilitation therapy received, rehospitalization, and reason for admission; adjusted R2= 0.267, P < 0.0001). More daytime sleeping during rehabilitation remained a significant predictor of less functional recovery in adjusted analyses at 3-month follow-up. CONCLUSIONS: Sleep disturbance is common among older people undergoing inpatient post-acute rehabilitation. These data suggest that more daytime sleeping during the rehabilitation stay is associated with less functional recovery for up to three months after admission for rehabilitation.