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Abstract

Changing times and advancements in technology have taken a toll on human health. Poor sleep quality is rampant in every age group thus an apharmacological cure is slowly becoming a necessity of the times. Exercises/physical activities are a strong contender in the race. But still a lot work has to be done to finally conclude about its efficacy as the treatment. This article aims at reviewing the relation between sleep quality and exercise. This article reviews the experimental and epidemiological work done on the topic along with the reviews published on the same. The emphasis here is on the studies done and the possible mechanisms underlying the relationship. The article also talks about the lacunae in research and future directions for research.
International Journal of Scientific and Research Publications, Volume 2, Issue 8, August 2012 1
ISSN 2250-3153
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Sleep Quality Improvement and Exercise: A Review
ZubiaVeqar, M EjazHussain
Centre for physiotherapy and rehabilitation sciences, JamiaMilliaIslamia, New Delhi, India
Abstract- Changing times and advancements in technology
have taken a toll on human health. Poor sleep quality is rampant
in every age group thus an apharmacological cure is slowly
becoming a necessity of the times. Exercises/physical activities
are a strong contender in the race. But still a lot work has to be
done to finally conclude about its efficacy as the treatment. This
article aims at reviewing the relation between sleep quality and
exercise. This article reviews the experimental and
epidemiological work done on the topic along with the reviews
published on the same. The emphasis here is on the studies done
and the possible mechanisms underlying the relationship. The
article also talks about the lacunae in research and future
directions for research.
Index Terms- Acute exercises, chronic exercise, exercise,
physical activity, sleep, sleep quality
I. INTRODUCTION
leep is a functional state that comprises a complex
combination of physiological and behavioural processes
which includes a natural lie down for humans.1,2. It is an
instinctive state of rest characterised by a reduction in voluntary
body movement and decreased awareness of the surrounding 3. It
has some characteristic manifestations, such as a cyclic pattern,
relative immobility and an increase in the response threshold to
external stimuli.
Since the discovery of REM sleep a number of articles/ reviews
have been published regarding the various mechanisms,
functions etc of sleep. But still we are very far away from
complete understanding of sleep which makes it an enigma even
now. In coming times because of the change in lifestyle and work
patterns the urgency of understanding it is even more. The
functions of sleep can be summarized as (1) boosts immune
function (2)has a role in brain maturation(4)development of the
body(5)increase in brain mass(6) memory
consolidation(7)increase in performance(8)modulates metabolic
processes at molecular level(10)maintains catecholamines in the
brain2-15. Sleep is multifaceted and hence difficult to review from
all aspects.
Exercise is physical activity that is planned, structured, and
repetitive for the purpose of conditioning any part of the body16.
For the purpose of this review the articles with physical activity
also have been considered and the term exercise will be used for
both. Exercise is used to improve health, maintain fitness and it
is a very important treatment method for physical therapist.
Exercise give various health benefits the details of which are out
of the domain of this article but the effects on quality of sleep
will be discussed in detail. There are various types of exercises
and with all of them having different effects.
The purpose of this article is to write a comprehensive review on
the effects of exercise on sleep. The article is planned as
following:
1. Sleep-a basic understanding
2. Exercise- relevance and type
3. Sleep and exercise
4. Acute exercise studies
5. Chronic exercise studies
6. Possible mechanisms for the effects of exercise on sleep
quality
7. Summary and conclusion
8. Future research
9. References
II. SLEEP A BASIC UNDERSTANDING
Sleep had always been an enigma because of its multifaceted and
multidimensional features. Even today it is difficult to
understand it completely without the holistic view. It has been a
topic of discussion right from biblical times. The Bible and the
Talmud have numerous references from varieties of sleep (“he
provides as much for his loved ones while they sleep
psalms127:2), to stages of sleep)”a sleep which is not sleep, a
wakefulness which is not wakefulness” Talmud Pesahim 120b),
functions of sleep, effects of deprivation etc.17. In some
references it has also been compared to death-“The deepest sleep
resembles death”(Bible, I Samuel 26:12)or it was also called the
brother of death(Homer’s Iliad, circa 700 BC).
Sleep was explained by people all over history in different
manners. Lucretius called it absence of wakefullness18. Santos
called it a functional state that comprises a complex combination
of physiological and behavioural processes2. But sleep can also
be defined by the physiological and physical changes which
occur during sleep18. This includes position and movement of the
body as a whole or its parts like eyes etc and physiological
changes like thermal changes, decreased brain activity etc. The
characteristics of sleep may be summarised as:
1. Decreased voluntary movement and appreciation of the
surroundings3,19
2. State of generally decreased activity.19
3. Human sleep involves lying down posture1,19
4. Even though it a state of decreased consciousness,
arousal is possible because of internal or external
stimuli 19
5. Brain activity has certain characteristic features 3,19
Depending upon the physical as well as the physiological
parameters sleep may be of two stages-Rapid eye movement
S
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(REM) sleep and Non rapid eye movement (NREM) sleep1,3,19.
According to American association of sleep medicine (AASM)
scoring manual NREM is further divided into N1, N2 ,N3 on the
basis of EEG waves. REM sleep has two phases Tonic and
Phasic ; REM and NREM move in a cyclic manner with an
average of 90-110mins.
The sleep patterns are also related and do get altered because of a
number of factors like age, sex stress, psychological state,
disease conditions, occupation1-20
Keeping in mind that almost all living beings have a phase of
sleep, the functions of sleep must be numerous and it must be
one of the most important things for survival. The postulated
functions of sleep have been discussed earlier. Most of these
functions have been deduced from sleep deprivation studies
which have also tried to establish that wakefulness is associated
positively with sleep propensity 21. Sleep propensity can be
explained as the likelihood of sleep at any level of organisation
(global or local) 21.
Sleep regulation will always have to be studied in relation to
wakefulness and they both are said to be regulated by basically
two factors circadian rhythm and homeostasis2, 3, 19, 22-25. The
need to sleep can be understood as physiological (highly
vulnerable periods of sleep) or subjective (individual’s
perception)24
III. EXERCISE RELEVANCE AND TYPE
According to “The origin of species- Charles Darwin”
environment brings about a change in the genes, that indicates
that our day to day existence decides our fate26,27. Human beings
have always been a hunter-gatherer which most of the times
along with other factors like brain development made us superior
to other animals hence ensured better evolution26-28.
Development and technological advancements brought with them
the sedentary lifestyle which lead to an endemic of lifestyle
disorders 26-29. These effects of sedentary lifestyle can be tackled
by regular physical activity and/ or exercises thus decreasing
morbidity and mortality26,27.
Human body responds to progressively increasing repetitive
physical activity by introducing physiological, biochemical, and
anatomical changes in the major systems of the body even in
older adults29-32. These changes depend on a number of factors
like intensity, duration, frequency of exercises, age, sex and
physical condition of the person exercising 30,34. Body’s response
to exercise involves simultaneous coordination of multiple
systems of the human body 32.
In sleep literature exercise have been studied as acute or chronic
and as aerobic or anaerobic. They have been defined as following
for the purpose of this review:
Acute exercises: They are the set of exercises which are executed
as a single bout followed by the examination of the effects on
primary outcomes.
Chronic exercise: They are the set of exercises invoving multiple
sessions, longer in duration followed by analysis of its various
effects and benefits in a broad perspective.
Aerobic exercise: These are physical exercises of a relatively low
intensity and long duration. It depends primarily on aerobic
energy system. These can also be called endurance training or
conditioning exercises35.
Anaerobic exercise: These are physical exercises of a relatively
high intensity and short duration. It depends primarily on
anaerobic energy system36
IV. SLEEP AND EXERCISE
According to the American sleep disorder association (ASDA)
exercise is one of the apharmacological intervention used to
promote sleep29, 37. The principle that exercise promotes to sleep,
remains a constant thus breaking all the barriers of civilizations,
races, religions even though empirical research does not support
it much38. It is one of the most widely studied daytime behaviour
associated with sleep. This was further reinforced by a landmark
survey conducted in Finland published in the year 1988.
Individuals were randomly selected (n=1190) and open ended
question about the factor which is the best for promotion of their
sleep was inquired. Results declared found exercise as the most
important factor 39, 40. Despite of all these numerous studies
conducted the results are still inconclusive. This difference in
belief and science can be attributed to following factors as
reported in various studies38-46.
1. Most of the studies were conducted on normals. This
can be explained on the basis of ceiling and floor effects
as described by Youngstedt43. According to this the
efficacy of sleep promoting stimuli should be
proportional to the degree of pre-stimulus sleep
impairment. Because of these it is difficult to achieve a
statistically significant improvement.
2. The sample sizes were generally small in interventional
studies
3. Exercises prescribed are difficult to follow and
implementation of daily routine for sedentary workers
makes it a difficult permanent apharmacological
management especially for patients who are already
tight pressed for their time.
4. Most of the work done is on slow wave sleep.
5. Most of the studies are short term studies. There are no
studies to the best of my knowledge which have worked
on long term effects and followup.
6. Sleep itself is very subjective and difficult to study.
There is a vast amount of interplay between numerous
factors affecting it.
7. Smaller factors like age and sex of the participant, time,
duration and type of exercise have not been studied very
well.
The studies done with exercise as an intervention can be broadly
be classified as:
1. Acute exercise studies
2. Chronic exercise studies
These studies have been done on normal individuals, certain
population eg geriatric46,44, medical students20etc, certain
conditions like insomnia44 etc.
V. ACUTE EXERCISE STUDIES
This area of study is majorly unexplored. This may be due to
inconclusive evidence regarding the usage and implementation of
these exercises as a treatment strategy. It is speculated that acute
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exercise during the day time leads to an increase in sleep. This
was reported in an epidemiological study done in Finland which
also reported that it was the single most important factor in the
positive result 41, 45, 46. However some positive results have been
reported in a few studies following acute exercises. The effects
reported are on slow wave sleep (SWS), REM, repeated eye
movement latency (REM-L) and total sleep time (TST) 45 but
no effect has been reported on sleep latency (SL) and
wakefulness after sleep onset (WASO) 39. The improvement in
SWS is especially important as some studies have reported an
increase in SWS being associated with a decrease in REM
sleep39,47, 48.
But in spite of all these effects being quoted the major lacunae is
the focus on good sleepers who are unlikely to have any major
improvement due to floor- ceiling effect. So, further research is
indicated to validate the results on patients with sleep
deprivation, so that the results may be used as a standard adjunct
treatment protocol.
VI. CHRONIC EXERCISE STUDIES
The studies included have used resistance exercise, moderate
intensity exercises, high intensity exercises, endurance exercises,
physical activity or regular exercises as an intervention38-54
A study on sedentary workers with 50% of 1RM concluded no
significant effect on the quality of sleep. This could be
contributed to various factors like type of exercise, sample type
or dose of exercise. The floor and ceiling effect was not ruled out
either51. In another study where older adults were prescribed
moderate intensity exercises positive effects was found on SWS.
On PSQI significant improvement was found on sleep duration,
sleep disturbance and daytime dysfunction. On PSG the numbers
of awakenings were lesser and stage 2 and SWS had increase. It
was concluded that there is a positive impact of regular moderate
intensity on sleep parameters 49.
A Cochrane review published on physical exercise on sleep
problems in adults aged 60+ have reported improvement in Sleep
Onset Latency (SOL), total sleep duration & global sleep quality.
But the review concluded that there was a lack of well-designed
trials to come to a conclusion but the intervention is worth
investigating 44.
The effects of chronic exercises include significant differences
on increased total sleep time, increased SWS and reduction in
sleep latency and reduction in REM38,39,41,42,46,50,53,54,55.
Some evidence also suggests that chronic endurance exercises
may be more helpful in enhancing SWS as compared to other
modes 38.
To summarize, it may be suggested that chronic exercise and its
effects may be used as behavioral modification tool to bring
about an improvement in quality of sleep but substantial data is
still required to calculate the exact dosimetry of the intervention
along with the time of intervention.
VII. POSSIBLE MECHANISMS OF EFFECTS OF EXERCISE ON
SLEEP
1. Effect On Mental Health
According to a number of studies done till date, the effect of
exercise on mental health is closely related to depression and
anxiety56-57. According to Daniel M Landers57, the benefits of
exercise on anxiety and depression are similar to as reported by
other treatment.
Table 1 Effects of exercise on mental health 39,42,46,49,56-57
Decreased Anxiety
Decreased Depression
Aerobic exercises
give best result
Patient who have
a high level of
anxiety to start
with respond
earlier
Patients who have
low fitness levels
to start with give
better results
Regular exercise
gives better result
if performed for
longer duration
Regular exercises
gives better
results if done
regularly
Exercises done
several times a
week gives better
results
Vigorous
exercises give
better results
Patients with an
increased level of
depression to start
with gives better
results
Number of awakenings in the night is one of the important
indicators of anxiety which is effectively decreased by exercises.
Various studies have been published about a positive role played
by acute exercises in decreasing trait anxiety 39,56,57. Petruzello et
al examined the results of 27 narrative reviews and concluded
that approximately 81% authors, physical activity and or fitness
led to a decrease in anxiety. 19% of the studies concluded that
most of the findings support reduction of anxiety with exercise.
But even though the results varied, none of the studies had
concluded that there was no relationship 57.
The work on exercises and depression can be traced long back in
history. Across the meta analysis published ,it was said that acute
and chronic exercises are related to a reduction in depression.
The effects were found to begin very early and they continued
even after the cessation of the exercises. These results were
found to be consistent across age, gender, exercises group size,
type of depression inventory 39,42,46,49,56-57.
2. Effects on thermoregulatory mechanism
Temperature regulation is an important aspect of homeostasis. It
is the maintenance of the core body temperature within a narrow
range by controlling the dissipation and absorption of heat to and
from the body.58
Modulation in core body temperature affect the sleep
parameters59-65 .This change in core body temperature can be
brought about actively (by exercises etc.) or passively (by warm
bath, thermo suit, electrical blankets, warm footbath etc.)61-64
These methods of increasing the temperature can be implemented
at various times (before sleep61-62,64-65 or during sleep63). The
time of application also seems to play a role as reported in
various studies61-65. In a review article, Liao et al reported that
slow wave sleep can be increased and the sleep fragmentation
can be decreased with passive body heating that changes the core
temperature in the evening. Similar results were reported by
different researchers using different methods to decrease the
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temperature before sleep.38,39,46 Fletcher et al used electrical
blanket to bring about an increase in core body temperature
during sleep and they report decreased efficiency and more
number of arousals.63 further proves that there is a relationship
between core body temperature and sleep.
Neuroanatomical studies also concluded that preoptic area or
anterior hypothalamus plays a key role in thermoregulation.
Initiation of sleep can be brought about by increased firing rate
of the neurons of the preoptic area which in turn may be brought
about by warming them. These neurons can be warmed by
changes in core body temperature. Hence the hypothesis that
sleep might serve as a down regulation function can be
supported39,52.
Horne et al has conducted studies on relationship between
exercise and sleep. They reported a positive relationship between
SWS and exercise 58,59.
3. Effects on circadian Rhythm
Circadian rhythm is the 24 hour interval clock which responds to
endogenous factors like core body temperature etc. and to
exogenous factors like light etc. A disturbance in either of these
factors leads to a disturbance in the rhythm which in turn affects
sleep. It is suggested by various studies that one of the most
important factor here is light.46Various studies have been done to
implicate exercise and sleep. Some important studies here were
the impact of time of exercise on sleep39,66 and the correlation
between effects of exercise on circadian rhythm parse.38,46
Aerobic exercises performed late in the evening has reported to
be associated with poor sleep quality as compared to exercises in
the afternoon.56
It is postulated by Driver and Taylor that exercise done in a well
lighted area may improve the sleep for individuals with altered
circadian rhythm. They also suggested further research to find
out the relation between light, exercise and sleep38.
There seems to be an agreement in the reviews regarding shift
work and its ill effects on health. Physical activity has been
suggested to decrease fatigue levels, improving the tolerance of
shifts but at the same time there is a problem of poor adherence
to exercises too52, 67. It has also been reported that exercise acts
as a zeitgeber and it brings about a shift in the phase response
curve68. There are various other additional factors which are
responsible for the effects.
4. Effects on restoration of the body
Aristotle had proposed the humoral mechanisms of sleep control
69. Although the mechanism of their control is not the same as
suggested by him but there is an existence of sleep regulatory
mechanism which has been proved 68. Some of these factors are
Growth Regulating Hormone(GHR), cytokines, interleukin-1,
prostaglandin D2, adenosine, tumour necrosis factor(TNF),
prolactin 100, corticotropin like intermediate lobe peptide
vasoactive intestinal peptide3,28,35,69,70,71,72. Acute exercises have
been shown to bring about an increase in cytokines which in turn
can be related to regulation of sleep. This may be one of the
restorative mechanisms though others like muscle repair46,73 have
also been discussed along with compensation of high energy
expenditure 46,73. All these factors work towards the restoration
effects.
In conclusion , it may be said that a number of hypothesis’ exist
regarding the mechanism underlying the effects of exercise on
sleep primarily due to complex nature and ambiguity in
mechanisms controlling it.
VIII. SUMMARY AND CONCLUSION
Sleep is an enigma even now primarily because of the huge
amount of interaction which takes place between external and
internal factors to bring about sleep. The problems with sleep
research have been discussed earlier. The general
recommendations after most of the reviews are still inconclusive.
But a few points may still be commented upon which are as
follows:
1. Exercise is a positive behavioral modification tool for
all age groups to bring about an improvement in sleep
quality.
2. Exercise can be very effective in older populations for
not only for improvement in sleep but also for other
ailments.
3. Acute exercises don’t seem to be very effective in
bringing about an improvement in quality of sleep but
the number of studies done is still lesser so it is not very
conclusive either.
4. Effects of aerobic and resistance training done for long
duration may bring about improvement in sleep quality.
5. Exercises done just before bedtime seem to have
negative effect on sleep quality.
IX. FUTURE RESEARCH
Future research may be directed towards analysis of:
1. Effect of acute exercises on poor sleepers but not
insomniacs
2. Effect of resistance exercises on poor sleepers but not
insomniacs
3. Effects of exercises on patients with different training
levels egsedentary, moderately trained and trained.
4. Effects of temperature variations on sleep quality.
5. Effect of time of intervention on sleep quality.
6. Exercise as apharmacological management of sleep.
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S.no
Investigator
Size
Sample
characteristi
cs
Intervention
Outcome
measure
Key results
1.
Ferris LT et
al 28
8
Sedentary
older adults
Resistance
training to
improve
upper& lower
body strength
PSQI
Strength
Mean body strength-
significant improvement
Global PSQI- significant
improvement
2.
Youngstedt
SD et al 45
401
-
Acute
exercise
SOL
stage 2
sleep
SWS
REM sleep
REM-L
TST
WASO
SOL-not significant
Stage2-significant increase
SWS-significant
REM-significant reduction
REM-L-Significant delay
TST-significant increase
WASO-unchanged
3.
King CA et
al49
43
50-76 yrs,
sedentary
lifestyle,
moderate
sleep
complaint at
baseline
Aerobic
exercise
gradually
increasing(4day
s/wk for 16
wks)
PSQI
Global score-significant
improvement
SOL- significant decrease
TST- significant
improvement
4.
Faria AP et
al51
27
Sedentary
men aged 20-
40 yrs, good
sleep quality
Resistance
exercises with
50% of 1
RM(acute
exercise)
PSG
No significant change
5.
Singh NA et
al54
32
(28
for
outc
oes)
Depressed
patients(ful
filled
DSMIV
criteria)
Age>60
Progressive
resisted
exercise
(3days/wk for
10 wks)
Sleep(PSQI
&likert
scale)
Activity
level
Depressio
n
Quality of
life
Improvement in both
parameters of sleep as
compared to
control(significant)
Significant change in total
physical activity level and
strength
Significant improvement in
depression
Trend towards improvement
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Table 2: Studies done to find out the effect of exercise on sleep
PSQI-Pittsburg sleep quality index, PSG-Polysomnography, RCT- randomised control trial, SOL-sleep onset latency, SWS-Slow
wave sleep, REM- repeated eye movement, REM-L- repeated eye movement latency, TST- total sleep time, WASO- wakefulness
after sleep onset, TWT- total wake time,OSA-Oguri-Shirakawa-azumi sleep inventory, KSS-Kanseigakuin sleepiness scale.
6.
Passos GS et
al55
48
Insomnia
patients
Moderate
intensity
aerobic
exercise
High intensity
aerobic
exercise
Moderate
intensity
resistance
exercise
PSG
Anxiety
scale
SOL<
TWT<
TST>
SE>
Reduction in anxiety scale
All the above in Moderate
intensity aerobic exercise
7
King CA et
al74
50-76 yrs,
sedentary
lifestyle,
moderate
sleep
complaint at
baseline
Moderate
intensity
aerobic
exercise(5days/
wk for 52 wks)
PSG
Sleep log
Self rated-<disturbance,
SOL, >rested
PSG-<awakenings &stage-1
PSG- >stage -2
8.
Sherrill DL et
al 75
722
Randomly
selected
adults
Some form of
physical activity
done regularly
Self
reported
question
naire
Regular exercise is
associated with lesser
incidence of disturbed sleep
9.
Yoshida H et
al76
5
Healthy
university
male students
Interventions
at diff times of
day
aerobic
PSG
OSA
KSS
Good sleep effects with late
evening exercises
10.
Singh NA et
al 77
60
Depressed
sedentary
older adults
Progressive
resisted
exercise at 80%
&20% RM (3
days/wk for 8
wks)
PSQI
PSQI global score- significant
improvement
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AUTHORS
First Author Zubia Veqar, BPT, MPT(Osteomyology), PhD
(pursuing), Assistant professor, Centre for physiotherapy and
rehabilitation sciences, JamiaMilliaIslamia, New Delhi -110025,
India
Email- veqar.zubia@gmail.com
zubiaveqar@rediffmail.com
Second Author - Prof M EjazHussain, Mphil, PhD, Director &
Professor, Centre foe physiotherapy and rehabilitation sciences
Jamia Millia Islamia, New Delhi -110025, India
Email-ejaz58@yahoo.com
CorrespndingAuthor - ZubiaVeqar, BPT, MPT
(Osteomyology), PhD (pursuing), Assistant professor, Centre for
physiotherapy and rehabilitation sciences, Jamia Millia Islamia,
New Delhi -110025, India
Email- veqar.zubia@gmail.com
zubiaveqar@rediffmail.com
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... En estos trabajos se ha señalado, cuando se comparan los patrones de sueño entre indivi-duos sedentarios e individuos activos físicamente, que el ejercicio parece que influye en el sueño, entre otras cuestiones, produciendo un aumento del tiempo de sueño, un aumento en la fase N3 de sueño y una disminución del tiempo de la fase REM (Kubitz, Landers, Petruzzello & Han, 1996;Driver & Taylor, 2000;Santos et al., 2007;Lang et al., 2013;Kalak et al., 2012;Aguilar-Farias, Martino-Fuentealba & Chandia-Poblete, 2020). Veqar & Hussain (2012) recogen un importante número de trabajos en los que se señalan efectos del ejercicio físico sobre el sueño en la línea de los señalados en el párrafo anterior, planteando que sus efectos pueden ser utilizados como herramienta de modificación de la conducta para llevar una mejora en la calidad del sueño, pero siguen siendo necesarios más estudios que permitan calcular la dosimetría exacta de la intervención junto con el periodo adecuado del día para la práctica del ejercicio. ...
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Since publication of the first edition in 1994, the second edition in 1999, and the third edition in 2009, many new advances in sleep medicine have been made and warrant a fourth edition. This comprehensive text features 19 additional chapters and covers basic science, technical and laboratory aspects and clinical and therapeutic advances in sleep medicine for beginners and seasoned practitioners. With the discovery of new entities, many new techniques and therapies, and evolving basic science understanding of sleep, Sleep Disorders Medicine, Fourth Edition brings old and new knowledge about sleep medicine together succinctly in one place for a deeper understanding of the topic. Neurologists, internists, family physicians, pediatricians, psychiatrists, psychologists, otolaryngologists, dentists, neurosurgeons, neuroscientists, intensivists, as well as those interested in advancing their knowledge in sleep and its disorders, will find this edition to be an invaluable resource to this bourgeoning field. © Springer Science+Business Media New York 1994, 1999, 2009, 2017. All rights reserved.
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