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Exercise can improve sleep quality: A systematic review and meta-analysis

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Background Insomnia is common. However, no systematic reviews have examined the effect of exercise on patients with primary and secondary insomnia, defined as both sleep disruption and daytime impairment. This systematic review and meta-analysis aimed to examine the effectiveness/efficacy of exercise in patients with insomnia. Methods We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov to identify all randomized controlled trials that examined the effects of exercise on various sleep parameters in patients with insomnia. All participants were diagnosed with insomnia, using standard diagnostic criteria or predetermined criteria and standard measures. Data on outcome measures were subjected to meta-analyses using random-effects models. The Cochrane Risk of Bias Tool and Grading of Recommendations, Assessment, Development, and Evaluation approach were used to assess the quality of the individual studies and the body of evidence, respectively. Results We included nine studies with a total of 557 participants. According to the Pittsburgh Sleep Quality Index (mean difference [MD], 2.87 points lower in the intervention group; 95% confidence interval [CI], 3.95 points lower to 1.79 points lower; low-quality evidence) and the Insomnia Severity Index (MD, 3.22 points lower in the intervention group; 95% CI, 5.36 points lower to 1.07 points lower; very low-quality evidence), exercise was beneficial. However, exercise interventions were not associated with improved sleep efficiency (MD, 0.56% lower in the intervention group; 95% CI, 3.42% lower to 2.31% higher; moderate-quality evidence). Only four studies noted adverse effects. Most studies had a high or unclear risk of selection bias. Discussion Our findings suggest that exercise can improve sleep quality without notable adverse effects. Most trials had a high risk of selection bias. Higher quality research is needed.
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Submitted 10 February 2018
Accepted 16 June 2018
Published 11 July 2018
Corresponding author
Masahiro Banno,
solvency@med.nagoya-u.ac.jp
Academic editor
Andrew Gray
Additional Information and
Declarations can be found on
page 17
DOI 10.7717/peerj.5172
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2018 Banno et al.
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Exercise can improve sleep quality: a
systematic review and meta-analysis
Masahiro Banno1,2, Yudai Harada2, Masashi Taniguchi3,4, Ryo Tobita3,
Hiraku Tsujimoto5, Yasushi Tsujimoto6,7, Yuki Kataoka5,8and Akiko Noda9,10
1Department of Psychiatry, Seichiryo Hospital, Nagoya City, Aichi Prefecture, Japan
2Department of Psychiatry, Nagoya University Graduate School of Medicine, Nagoya City, Aichi Prefecture,
Japan
3Division of Physical Therapy, Rehabilitation Units, Shiga University of Medical Science Hospital, Otsu City,
Shiga Prefecture, Japan
4Department of Physical Therapy, Graduate School of Medicine, Kyoto University, Kyoto City,
Kyoto Prefecture, Japan
5Hospital Care Research Unit, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki City, Hyogo
Prefecture, Japan
6Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto
University, Kyoto City, Kyoto Prefecture, Japan
7Department of Nephrology and Dialysis, Kyoritsu Hospital, Kawanishi City, Hyogo Prefecture, Japan
8Department of Respiratory Medicine, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki City,
Hyogo Prefecture, Japan
9Chubu University Graduate School of Life and Health Sciences, Kasugai City, Aichi Prefecture, Japan
10 Clinical Laboratory Technical Education Center, Chubu University, Kasugai City, Aichi Prefecture, Japan
ABSTRACT
Background. Insomnia is common. However, no systematic reviews have examined
the effect of exercise on patients with primary and secondary insomnia, defined as both
sleep disruption and daytime impairment. This systematic review and meta-analysis
aimed to examine the effectiveness/efficacy of exercise in patients with insomnia.
Methods. We searched the Cochrane Central Register of Controlled Trials, MEDLINE,
Embase, PsycINFO, World Health Organization International Clinical Trials Registry
Platform, and ClinicalTrials.gov to identify all randomized controlled trials that
examined the effects of exercise on various sleep parameters in patients with insomnia.
All participants were diagnosed with insomnia, using standard diagnostic criteria
or predetermined criteria and standard measures. Data on outcome measures were
subjected to meta-analyses using random-effects models. The Cochrane Risk of Bias
Tool and Grading of Recommendations, Assessment, Development, and Evaluation
approach were used to assess the quality of the individual studies and the body of
evidence, respectively.
Results. We included nine studies with a total of 557 participants. According to
the Pittsburgh Sleep Quality Index (mean difference [MD], 2.87 points lower in the
intervention group; 95% confidence interval [CI], 3.95 points lower to 1.79 points
lower; low-quality evidence) and the Insomnia Severity Index (MD, 3.22 points lower
in the intervention group; 95% CI, 5.36 points lower to 1.07 points lower; very low-
quality evidence), exercise was beneficial. However, exercise interventions were not
associated with improved sleep efficiency (MD, 0.56% lower in the intervention group;
95% CI, 3.42% lower to 2.31% higher; moderate-quality evidence). Only four studies
noted adverse effects. Most studies had a high or unclear risk of selection bias.
How to cite this article Banno et al. (2018), Exercise can improve sleep quality: a systematic review and meta-analysis. PeerJ 6:e5172;
DOI 10.7717/peerj.5172
Discussion. Our findings suggest that exercise can improve sleep quality without
notable adverse effects. Most trials had a high risk of selection bias. Higher quality
research is needed.
Subjects Epidemiology, Evidence Based Medicine, Psychiatry and Psychology, Statistics
Keywords Meta-analysis, Exercise, Physical activity, Sleep disorders, Systematic reviews
INTRODUCTION
Approximately 30% of the general population experience sleep disruption, while 10%
experience both sleep disruption and daytime dysfunction consistent with a diagnosis of
insomnia as defined by the National Institutes of Health (National Institutes of Health,
2005). Patients with insomnia are at high risk of developing hypertension, atherosclerosis,
and acute myocardial infarction (Laugsand et al., 2011;Fernandez-Mendoza et al., 2012;
Nakazaki et al., 2012). Insomnia is strongly correlated with mental illness and poses an
additional risk for depression as well as suicidal ideation and behavior (Baglioni et al., 2011;
Bjorngaard et al., 2011;Pigeon, Pinquart & Conner, 2012). Pharmacotherapy is an effective
treatment for patients with insomnia. However, the use of hypnotics is associated with
increased mortality (Kripke, 2016), and the frequency of falls and hip fractures increases
when hypnotics are used in elderly individuals (Allain et al., 2005). Cognitive behavioral
therapy for insomnia (CBT-I), the first-line treatment for insomnia (Morin et al., 2006),
requires frequent monitoring and has a high cost (Passos et al., 2012).
Exercise is a nonpharmacological therapy for insomnia, is readily available, and costs
less than other nonpharmacological treatments for insomnia; notably, its effects depend
upon exercise type and evaluation methodology (Youngstedt, O’Connor & Dishman, 1997;
Driver & Taylor, 2000;Youngstedt, 2005). Recent randomized controlled trials (RCTs)
have confirmed that exercise has positive effects on sleep quality, sleep onset latency,
total sleep time, sleep efficiency, and insomnia severity (Passos et al., 2010;Reid et al.,
2010;Hartescu, Morgan & Stevinson, 2015). Epidemiological studies have clarified the
association between exercise and decreased complaints of insomnia (De Mello, Fernandez
& Tufik, 2000;Youngstedt & Kline, 2006), as well as a relationship between lower levels of
physical activity and a greater prevalence of insomnia (Morgan, 2003). Among the main
symptoms of insomnia, such as difficulty initiating sleep (DIS) or early morning awakening
(EMA) (Lichstein et al., 2003), EMA is more frequently observed in older adults than other
symptoms (Kim et al., 2000). These symptoms are associated with circadian core body
temperature. Patients with DIS have a delayed core body temperature rhythm, whereas
those with EMA have an advanced rhythm (Lack et al., 2008). However, experimental
investigations of the effects of exercise on sleep in individuals with insomnia are lacking.
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
and the third edition of the International Classification of Sleep Disorders (ICSD-3)
made major revisions to their definitions of insomnia. The DSM-5 and ICSD-3 abolished
the distinction between primary and secondary insomnia. The revision was based on
the findings that insomnia: (1) often accompanies another disease, (2) is preceded by a
Banno et al. (2018), PeerJ , DOI 10.7717/peerj.5172 2/23
comorbid condition, (3) persists even after effective treatment for the comorbid condition,
and (4) exacerbates the symptoms of the comorbid condition (Riemann et al., 2015).
Previous systematic reviews and/or meta-analyses investigated the effects of exercise
in people with sleep complaints or chronic insomnia (Passos et al., 2012), undefined
populations (Kubitz et al., 1996;Youngstedt, O’Connor & Dishman, 1997;Kredlow et al.,
2015), and patients with sleep problems (Montgomery & Dennis, 2002;Montgomery &
Dennis, 2004;Yang et al., 2012). A previous review also examined the effects of exercise
on sleep in specific subpopulations (e.g., cancer survivors) (Mercier, Savard & Bernard,
2017). However, no previous systematic reviews have examined the effect of exercise in
patients with primary and secondary insomnia as defined by having both sleep disruption
and daytime impairment. Investigating the effect of exercise in patients with primary and
secondary insomnia would be beneficial in clinical practice since DSM-5 and ICSD-3
abolished the distinction between the two.
Study objectives
This review aimed to examine the effects of exercise in patients with insomnia.
MATERIALS AND METHODS
This systematic review was conducted according to the PRISMA statement (Liberati et al.,
2009). Table S1 shows the PRISMA 2009 checklist. The detailed methods are described in
CRD42016046064 in the National Institute for Health Research PROSPERO register.
Eligibility criteria
Study type
We included all published and unpublished RCTs, including those that were only abstracts
or letters. Crossover trials and cluster-, quasi-, and non-randomized trials were excluded.
Studies in any language from any country were accepted for screening. Studies were
included regardless of the follow-up period.
Participants
Participants included those diagnosed with insomnia using any standard diagnostic criteria
such as DSM, International Classification of Diseases, ICSD, Research Diagnostic Criteria
(RDC) for insomnia, or predetermined criteria and standard measures (i.e., Pittsburgh Sleep
Quality Index (PSQI); Buysse et al., 1989), Insomnia Severity Index (ISI) (Bastien, Vallieres
& Morin, 2001), and a sleep questionnaire). The American Academy of Sleep Medicine
developed standard definitions for insomnia disorders, such as the RDC for insomnia
(Edinger et al., 2004). We utilized the PSQI and ISI in our inclusion criteria because
both are appropriate screening tools for insomnia (Chiu et al., 2016). All participants
had insomnia-related daytime impairments or were screened using sleep questionnaires
including items about such impairments. Recent RCTs were beyond the scope of this review
because participants in these studies did not have insomnia-related daytime impairments
(Gebhart, Erlacher & Schredl, 2011;Chen et al., 2016;Tan et al., 2016).
The cutoff value for the PSQI global score used to diagnose a sleep disorder was defined
by the trial list. If a study did not specify a cutoff value, we surmised that a PSQI global score
Banno et al. (2018), PeerJ , DOI 10.7717/peerj.5172 3/23
>5 would be considered insomnia (Backhaus et al., 2002). We included patients of any age,
sex, race, and setting, but excluded those with sleep apnea syndrome. We also checked
the inclusion criteria for insomnia and the sleep questionnaire to determine whether the
screening process selected those with daytime impairment.
Interventions
The interventions were predetermined exercise programs. Interventions of any intensity,
duration, and frequency were included. We included exercise in combination with
medication if participants in the intervention and control groups were taking the same
medication. We excluded interventions recommending that patients increase physical
activity or encouraging improvement in self-efficacy through CBT, a mind-body bridging
program, a mindfulness meditation program, massage therapy, or breathing techniques
without physical activity. We examined the following interventions and comparisons:
(1) Exercise versus non-exercise and non-medication control; and
(2) Exercise plus medication versus medication alone.
We excluded the following intervention: Exercise combined with another treatment
(e.g., CBT).
Outcome measures
The following primary outcomes were measured:
1. Sleep quality according to the PSQI;
2. Sleep efficiency defined by the percentage of time spent in bed asleep as measured
objectively by a sleep device (e.g., polysomnography [PSG], actigraphy) or by
reports/diaries kept by a partner or nursing staff; and
3. Insomnia severity according to a standard measure (ISI).
Secondary outcomes were as follows:
1. Quality of life (QOL) as measured by standardized questionnaires with established
reliability and validity, such as the Short Form 36 (SF-36);
2. Sleep onset latency as measured objectively by sleep devices (e.g., PSG, actigraphy) or
reports/diaries maintained by a partner or nursing staff;
3. Total sleep time as measured objectively by a sleep device (e.g., PSG, actigraphy) or
reports/diaries maintained by a partner or nursing staff;
4. All adverse events (defined by the trial list);
5. Sleepiness during daily life according to a self-report using a standardized measure,
e.g., the Epworth Sleepiness Scale (ESS);
6. Current sleepiness according to a self-report using a standardized measure, e.g., the
Stanford Sleepiness Scale (SSS);
7. Wake after sleep onset (WASO) as measured objectively by a sleep device (e.g., PSG,
actigraphy) or reports/diaries maintained by a partner or nursing staff;
8. Anxiety according to a standardized questionnaire with established reliability and
validity (e.g., State-Trait Anxiety Inventory); and
9. Depression according to a standardized questionnaire with established reliability and
validity (e.g., Beck Depression Inventory).
Banno et al. (2018), PeerJ , DOI 10.7717/peerj.5172 4/23
We consulted an expert in sleep medicine (AN) and experts in exercise therapy (MT
and RT) and selected the moderator (primary and secondary outcomes, prioritization of
outcomes, and subgroup analysis items) in terms of clinical importance.
Search methods for study identification
Electronic searches
To identify relevant trials, we searched the following electronic databases on October 9,
2016 and updated the electronic searches on October 4, 2017:
1. The Cochrane Central Register of Controlled Trials (CENTRAL);
2. MEDLINE via EBSCOhost;
3. Embase; and
4. PsycINFO via PsycNET.
See Appendix S1 for details about the search strategies.
Searches of other resources
We also searched the following registries to identify completed but unpublished trials and
investigate reporting bias.
1. World Health Organization International Clinical Trials Registry Platform; and
2. ClinicalTrials.gov.
See Appendix S1 for details of the search strategies.
We also manually searched reference lists in clinical guidelines on exercise for insomnia
and in related guidelines (Morgenthaler et al., 2006;Bauer et al., 2007;Wilson et al., 2010;
NICE, 2012;Bauer et al., 2013;NICE, 2013;University of Texas at Austin School of Nursing,
2014;Bauer et al., 2015;NICE, 2015;Qaseem et al., 2016), reference lists of extracted studies,
and articles citing the extracted studies.
We contacted authors if the extracted studies lacked the necessary information.
Data collection and analysis
Study selection
Two of the five authors (MB, YH, HT, YT, and YK) independently screened the titles and
abstracts of the articles identified in the search. Two of the five authors were assigned
to each article to reduce the burden on each author. They assessed eligibility based on a
full-text review. Disagreement was resolved by discussion; if necessary, YK or YT (if YK
and an author other than YT were the two authors) or MB (if YK and YT were the two
authors) provided arbitration. We followed a pre-defined protocol to screen the abstracts
and full texts and used pre-defined criteria in the registered protocol. One lead author
(MB) checked all included studies and the exclusion criteria for all records subjected to the
full-text screening procedure. Therefore, the decision would not differ systematically.
Data extraction and management
The data were extracted on prespecified forms that were piloted using a random sample
of 10 studies. Two of the four authors (MB, HT, YT, and YK) independently extracted the
data. MB and another author were assigned to each article to reduce the burden on each
author. We contacted the authors of studies lacking sufficient information as necessary.
Differences in data extraction opinions were resolved by discussion and arbitrated by YK
Banno et al. (2018), PeerJ , DOI 10.7717/peerj.5172 5/23
or YT (if YK was the other author) when necessary. See Appendix S2 for details of the
extracted information.
Assessment of risk of bias of the included studies
Two of the four authors (MB, HT, YT, and YK) independently assessed the risk of bias of
the included studies using the Cochrane Risk of Bias Tool (Higgins & Green, 2011). MB
and another author were assigned to each article to reduce the burden on each author.
Differences in opinion about the assessment of risk of bias were resolved by discussion and
through arbitration by YK or YT (if YK was the other author) as necessary.
Measures of treatment effect
For continuous outcomes (sleep quality, sleep efficiency, insomnia severity, QOL, sleep
onset latency, total sleep time, sleepiness during daily life, current sleepiness, WASO,
anxiety, and depression), the standardized mean difference (SMD) or mean difference
(MD) with 95% CI was calculated as recommended by the Cochrane handbook (Higgins &
Green, 2011). We used MD when data including meta-analyses were derived from the same
indicator. We used SMD when data including meta-analyses were derived from different
indicators or we compared the data in the meta-analysis with data in a previous study using
SMD. Adverse events were narratively summarized since the definition of these outcomes
varied among studies.
Assessment of heterogeneity
We first assessed heterogeneity by visual inspection of the forest plots. We also calculated
I2statistics and analyzed them according to recommendations in the Cochrane handbook
(0–40%, might not be important, 30–60%, may represent moderate heterogeneity, 50–
90% may represent substantial heterogeneity, and 75–100% may represent considerable
heterogeneity). When heterogeneity was detected (I2>50%), we attempted to identify
possible causes.
Data synthesis
We pooled the data using a random-effects model. The DerSimonian and Laird method was
used in the random-effects meta-analysis (DerSimonian & Laird, 1986). All analyses were
conducted using Review Manager software (RevMan 5.3; The Nordic Cochrane Centre,
The Cochrane Collaboration, Copenhagen, Denmark).
Subgroup analysis and investigation of heterogeneity
We further aimed to identify possible causes of heterogeneity. The following prespecified
subgroup analyses of the primary outcomes were planned: (1) sex; (2) primary and
secondary insomnia; (3) exercise duration: short-term (<2 months), medium-term (2
to <6 months), long-term (6 months); (4) exercise intensity: aerobic versus anaerobic
exercise; (5) exercise type: aerobic (walking), resistance, and aerobic plus resistance; and
(6) exercise setting or location: home, physical therapy center, hospital, or elsewhere.
Banno et al. (2018), PeerJ , DOI 10.7717/peerj.5172 6/23
Table 1 Summary of findings
Outcomes (time frame) Number of
participants (studies)
in follow-up
Quality of
evidence
(GRADE)
Relative
effect
(95% CI)
Anticipated
absolute effectsa
(95% CI)
Risk with
control
Risk difference
with exercise
Total PSQI score (8 wks to 6 mos) 361 ⊕ ⊕  MD 2.87 point lower
Scale: 0 to 21 (6 RCTs) LOWb,c,d (3.95 lower to 1.79 lower)
Sleep efficiency (%) (1 d to 6 mos) 186 ⊕⊕⊕ MD 0.56% lower
assessed with: polysomnography and
actigraphy
(4 RCTs) MODERATEd(3.42 lower to 2.31 higher)
Scale: 0 to 100
Total ISI score(4–6 mos) 66   MD 3.22 point lower
Scale: 0 to 28 (2 RCTs) VERY LOWb,c,d,e,f (5.36 lower to 1.07 lower)
Sleep onset latency (minute)
(1 d to 6 mos)
206 ⊕ ⊕  MD 1.9 minutes higher
(5 RCTs) LOWd,g (3.63 lower to 7.43 higher)
Total sleep time (minute)
(1 d to 6 mos)
206 ⊕ ⊕  MD 4.32 minutes higher
(5 RCTs) LOWd,g (9.19 lower to 17.84 higher)
All adverse events (2–6 mos) 150  
(4 RCTs) VERY LOWb,c,d,h,i
Notes.
aThe risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
bParticipants were not blinded.
cThe outcome assessors were not blinded.
dSample size was small. Sample size did not meet criteria of optimal information size (OIS) (400). OIS was 400 if alpha =0.05, beta =0.2, delta =0.2.
eAllocation concealment was not done in 40% of participants.
fThere were incomplete outcome data in 40% of participants.
gThere were incomplete outcome data in 25% of participants.
hThere were incomplete outcome data in 50% of participants.
iAllocation concealment was not done in 30% of participants.
ISI, Insomnia Severity Index; MD, mean differences; OIS, optimal information size; GRADE, Grading of Recommendations, Assessment, Development, and Evaluation;
OR, odds ratio; PSQI, Pittsburgh Sleep Quality Index; RCTs, randomized controlled trials; RR, risk ratio.
GRADE working group grades of evidence: High quality, We are very confident that the true effect lies close to that of the estimate of the effect; Moderate quality, We are
moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but a substantial difference is possible; Low quality, Our confidence
in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect; Very low quality, We have very little confidence in the effect esti-
mate: The true effect is likely to be substantially different from the estimate of effect.
Sensitivity analysis
The following prespecified sensitivity analyses of the primary outcomes were planned:
(1) repeating the analysis but restricting it to studies with low risks of bias from random
sequence generation and allocation concealment, using the Cochrane Risk of Bias Tool
(Higgins & Green, 2011); (2) repeating the analysis using a fixed-effects model instead of
random-effects model; and (3) excluding studies with ‘‘a per-protocol analysis’’ or ‘‘analysis
including imputed data.’’
Summary of findings tables
The main results of our review are presented in the Summary of findings table (Table 1),
which includes an overall grading of the evidence related to each of the main outcomes using
Banno et al. (2018), PeerJ , DOI 10.7717/peerj.5172 7/23
the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE)
approach (Guyatt et al., 2011;Higgins & Green, 2011).
Registration
We registered the protocol in the National Institute for Health Research PROSPERO register
(http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016046064).
RESULTS
Search results
After removing duplicates, we identified 4,085 records during the search conducted
in October 2016 and updated the electronic searches on October 4, 2017 (Fig. 1). We
included 17 trials in the qualitative synthesis and detected seven unpublished trials and one
completed trial without outcomes data (Chan et al., 2017). Ultimately, 557 participants in
nine trials were included in the quantitative synthesis.
Table 2 summarizes the published studies included in the qualitative synthesis. Table S2
shows the characteristics of the seven unpublished trials. Table S3 shows the sleep
medications used in the included completed trials.
The bias risk of the quantitative synthesis is shown in Figs. 2A and 2B.
Primary outcomes
Sleep quality
Data from six trials comprising 361 participants that measured sleep quality were
pooled in our meta-analysis (Reid et al., 2010;Tang, Liou & Lin, 2010;Irwin et al., 2014;
Hartescu, Morgan & Stevinson, 2015;Chan et al., 2016;Tadayon, Abedi & Farshadbakht,
2016) (Fig. 3A). All trials measured PSQI and had an intervention period of eight weeks
to six months. There was a significant effect noted in favor of the intervention (MD, 2.87
points lower in the intervention group; 95% CI, 3.95 points lower to 1.79 points lower;
P<0.001; low-quality evidence). A lower score was more beneficial in PSQI. Substantial
heterogeneity was observed (Tau2=1.18; I2=68%).
Sleep efficiency
Data from four trials that examined sleep efficiency in 186 participants were pooled in our
meta-analysis (Passos et al., 2010;Afonso et al., 2012;Irwin et al., 2014;Hartescu, Morgan &
Stevinson, 2015) (Fig. 3B). All trials measured sleep efficiency with PSG and actigraphy and
had an intervention period of 1 day to 6 months. There was no significant improvement
in favor of the intervention (MD, 0.56% lower in the intervention group; 95% CI, 3.42%
lower to 2.31% higher; P=0.70; moderate-quality evidence). A higher percentage was
more beneficial for sleep efficiency. No statistical heterogeneity was indicated (Tau2<0.001;
I2=0%).
Insomnia severity
Data from two trials that measured insomnia severity in 66 participants were pooled in our
meta-analysis (Afonso et al., 2012;Hartescu, Morgan & Stevinson, 2015) (Fig. 3C). All trials
measured ISI and had an intervention period of four to six months. There was significant
Banno et al. (2018), PeerJ , DOI 10.7717/peerj.5172 8/23
Table 2 Summary of the published studies including qualitative synthesis.
Source Setting Patients, NAge Inclusion criteria Exercise type Exercise
frequency
Exercise
duration
Afonso et al. (2012) Elsewhere 61 50 to 65 years Postmenopausal women
with primary insomnia
meeting DSM-4
Aerobic (other aero-
bic)
2 session/wk 4 mos
Chan et al. (2016) Elsewhere 52 60 years or older Older adults with cognitive
impairment with CPSQI
>5
Aerobic (other aero-
bic)
2 session/wk 2 mos
Chan et al. (2017) Elsewhere Unknown 18 years or older Participants with mild to
moderate depression and
PSQI >5
Aerobic (other aero-
bic)
3 session/wk 8 wks
Guilleminault et al.
(1995)
At home 32 34 to 55 years Patients with psychophys-
iologic insomnia meeting
predetermined criteria
Aerobic (walking) 7 d/wk 4 wks
Hartescu, Morgan &
Stevinson (2015)
At home 41 40 years or older Inactive adults meeting
RDC for insomnia
Aerobic (walking) 5 d/wk 6 mos
Irwin et al. (2014) Elsewhere 123 34 to 55 years Older adults with chronic
and primary insomnia
meeting DSM-IV-TR and
ICSD-2
Aerobic (other aero-
bic)
1 d/wk 4 mos
Passos et al. (2010) Exercise laboratory 48 30 to 55 years Primary insomnia meeting
DSM-IV-TR and ICSD-2
Aerobic (walking,
other aerobic)
Acute One time
Reid et al. (2010) Elsewhere 17 55 years or older Older adults with insomnia
meeting predetermined cri-
teria
Aerobic (walking,
other aerobic)
4 times per wk 16 wks
Tadayon, Abedi &
Farshadbakht (2016)
At home 112 Mean 52.39 (SD
1.65) years
Postmenopausal women
with PSQI >5
Aerobic (walking) 7 d/wk 12 wks
Tang, Liou & Lin
(2010)
At home 71 Mean 51.80 (SD
12.13) years
Cancer patients with PSQI
>5
Aerobic (walking) 3 d/wk 8 wks
Notes.
Chan et al. (2017) was included in the qualitative synthesis but excluded in the quantitative synthesis because the trial did not include outcomes data for a meta-analysis.
DSM, Diagnostic and Statistical Manual of Mental Disorders; ICSD, International Classification of Sleep Disorders; PSQI, Pittsburgh Sleep Quality Index; RDC, research diagnostic criteria.
Banno et al. (2018), PeerJ , DOI 10.7717/peerj.5172 9/23
Figure 1 PRISMA 2009 flow diagram. CENTRAL: Cochrane Central Register of Controlled Trials; IC-
TRP, International Clinical Trials Registry Platform; RCTs, randomized controlled trials
Full-size DOI: 10.7717/peerj.5172/fig-1
improvement in favor of the intervention (MD, 3.22 points lower in the intervention group;
95% CI, 5.36 points lower to 1.07 points lower; P=0.003; very low-quality evidence). A
lower score was more beneficial in ISI. No statistical heterogeneity was indicated (Tau2
<0.001; I2=0%).
Banno et al. (2018), PeerJ , DOI 10.7717/peerj.5172 10/23
Figure 2 (A) Risk of bias graph (B) Risk of bias summary. (A) Review author judgments about the risk
for each bias item presented as percentages across all included trials. (B) Review author judgments about
the risk for each bias item in all included trials.
Full-size DOI: 10.7717/peerj.5172/fig-2
Banno et al. (2018), PeerJ , DOI 10.7717/peerj.5172 11/23
Figure 3 (A) Forest plot of comparison: Total PSQI score (B) Forest plot of comparison: Sleep efficiency (%) (C) Forest plot of comparison: To-
tal ISI score. (A) Total PSQI score was measured subjectively. IV, inverse variance; PSQI, Pittsburgh Sleep Quality Index (B) Sleep efficiency was
measured objectively by the devices (e.g., PSG, actigraphy). IV, inverse variance; PSG, polysomnograph (C) Total ISI score was measured subjec-
tively. ISI, Insomnia Severity Index; IV, inverse variance
Full-size DOI: 10.7717/peerj.5172/fig-3
Banno et al. (2018), PeerJ , DOI 10.7717/peerj.5172 12/23
Secondary outcomes
QOL
Five trials examined QOL, but the data were not subjected to the meta-analysis or assessed
by the GRADE approach because concepts of QOL measures differed among the trials. The
12-item medical outcomes study short form health survey version 2.0 (SF-12v2) or SF-36
had two types of scores (physical component summary and mental component summary).
Other QOL instruments had a single total score. Therefore, we did not calculate the SMD
of the QOL instruments. Significant effects in favor of the intervention were noted in all
trials (Figs. S1S14;Table S4).
Sleep onset latency
Data from five trials that measured sleep onset latency (min) in 206 participants were
pooled for the meta-analysis (Guilleminault et al., 1995;Passos et al., 2010;Afonso et al.,
2012;Irwin et al., 2014;Hartescu, Morgan & Stevinson, 2015). All trials measured sleep
onset latency using PSG and actigraphy and had an intervention period of one day to six
months. There was no significant improvement in favor of the intervention (MD, 1.90 min
higher in the intervention group; 95% CI, 3.63 min lower to 7.43 min higher; P=0.50;
low-quality evidence). Shorter duration was more beneficial for sleep onset latency. No
statistical heterogeneity was indicated (Tau2< 0.001; I2=0%) (Fig. S15;Table S4).
Total sleep time
Data from five trials that examined total sleep time (min) in 206 participants were pooled
for the meta-analysis (Guilleminault et al., 1995;Passos et al., 2010;Afonso et al., 2012;Irwin
et al., 2014;Hartescu, Morgan & Stevinson, 2015). All trials measured total sleep time using
PSG and actigraphy and had an intervention period of one day to six months. There
was no significant improvement in favor of the intervention (MD, 4.32 min higher in
the intervention group; 95% CI, 9.19 min lower to 17.84 min higher; P=0.53; low-
quality evidence). Longer duration was more beneficial for total sleep time. No statistical
heterogeneity was indicated (Tau2< 0.001; I2=0%; Fig. S16;Table S4).
All adverse events (defined by the trial list)
Four trials comprising 150 participants measured adverse events. Three trials found no
adverse events in any of the participants (Reid et al., 2010;Afonso et al., 2012;Chan et al.,
2016). One trial described one adverse event, a mild sprained ankle, in the intervention
group (Hartescu, Morgan & Stevinson, 2015). Follow-up was two to six months (very
low-quality evidence).
Other secondary outcomes (Secondary outcomes not including Summary
of findings table)
Anxiety and depression were significantly ameliorated in favor of the intervention (Figs. S17
and S18;Table S4). ESS and WASO did not detect a significant effect in favor of the
intervention (Figs. S19 and S20;Table S4). None of the trials measured SSS (Fig. S21;
Table S4).
Banno et al. (2018), PeerJ , DOI 10.7717/peerj.5172 13/23
Additional analyses
We performed subgroup analyses of sleep quality because the outcome showed an I2>50%.
We conducted an ad-hoc subgroup analysis for exercise frequency (acute or regular) because
the underlying mechanisms may differ between acute exercise and regular exercise. We
also conducted an ad-hoc subgroup analysis of background variables (cancer patients,
postmenopausal women, and others). The exercise type subgroups differed significantly
(P<0.001; Table S4) and other pre-specified and ad-hoc subgroups of sleep quality did
not differ significantly (Table S4). Sleep efficiency did not improve significantly in favor
of the intervention with acute exercise (MD, 0.50% lower in the intervention group; 95%
CI, 8.31% lower to 7.31% higher; P=0.90) or regular exercise (MD, 0.56% lower in the
intervention group; 95% CI, 3.64% lower to 2.52% higher; P=0.72; Table S4). A higher
percentage was more beneficial for sleep efficiency.
We conducted sensitivity analysis by restricting the analyzed studies to those that had a
low risk of selection bias; however, the results were the same as those obtained in the original
analysis (Table S4). Moreover, the results did not change with the use of a fixed-effects
model instead of a random-effects model (Table S4). We were unable to estimate the ISI
results, as none of the trials showed a low risk of selection bias (Table S4).
When studies using imputed data or per-protocol analysis were excluded, PSQI (two
trials with 164 participants) did not exhibit a significant effect in favor of the intervention
(MD, 2.21 points lower in the intervention group; 95% CI, 5.34 points lower to 0.92 point
higher). A lower score was more beneficial for PSQI. Sleep efficiency (one trial with 48
participants) did not significantly improve in favor of the intervention (MD, 0.50% lower
in the intervention group; 95% CI, 8.31% lower to 7.31% higher). A higher percentage
was more beneficial for sleep efficiency. We were unable to estimate the ISI results because
no trials remained after exclusion of those with imputed data or per-protocol analysis
(Table S4).
We conducted an ad-hoc sensitivity analysis by excluding one study with acute exercise
because it was an experimental RCT. When the study with acute exercise was excluded,
sleep efficiency did not significantly improve in favor of the intervention (MD, 0.56% lower
in the intervention group; 95% CI, 3.64% lower to 2.52% higher). A higher percentage was
more beneficial for sleep efficiency.
DISCUSSION
The pooled results revealed that exercise improves PSQI and ISI scores. These results were
consistent across the included trials despite the indication of substantial heterogeneity in
the PSQI. The heterogeneity of PSQI seemed to be explained by exercise type. Whether
exercise improves QOL was inconclusive in our study, although exercise did have some
adverse effects which were of little importance. These results suggested that exercise was
an effective nonpharmacological treatment because improved sleep quality is one of the
primary treatment goals (Schutte-Rodin et al., 2008). Furthermore, a recent comprehensive
narrative review strongly recommended aerobic exercise in subjects with sleep disorders
(Chennaoui et al., 2015). Exercise can be as promising a nonpharmacological intervention
for patients with insomnia as CBT-I.
Banno et al. (2018), PeerJ , DOI 10.7717/peerj.5172 14/23
Results compared to those of prior studies
A three-point change in PSQI score was chosen to indicate a minimal clinically important
difference (MCID) (Hughes et al., 2009). Therefore, the effect of exercise on PSQI in favor
of the intervention (low-quality evidence) was considered small. A previous study (Yang
et al., 2012) found a small-to-moderate effect (SMD, 0.47; 95% CI [0.08–0.86]) of exercise
on PSQI among patients with sleep complaints, whereas our study found that exercise
exerts a large effect (SMD, 1.00; 95% CI [0.48–1.53]) on the PSQI. These results suggest
that exercise may provide more beneficial effects on PSQI in patients with insomnia than
in participants with sleep complaints. There is a possible ceiling and floor effect of exercise
on sleep in patients with sleep complaints compared to those with insomnia (Chennaoui et
al., 2015). For example, baseline total PSQI scores may be higher in patients with insomnia
than in those with sleep complaints, which may explain the differences in the results of
these studies.
Since a change in ISI score greater than 7 would be considered moderate improvement
(Morin et al., 2011), the effect of exercise on ISI (MD, 3.22 points lower in the intervention
group; 95% CI, 5.36 points lower to 1.07 points lower; very low-quality of evidence) in
favor of the intervention was considered small. The only previous study using PSG (Yang
et al., 2012) detected no change in sleep efficiency or onset latency, which was consistent
with results on these two parameters in our study.
In the present study, exercise did not improve sleep efficiency, sleep onset latency, or total
sleep time, and there was no evidence of heterogeneity across studies. The non-randomized
crossover study demonstrated an acute morning exercise decrease in the arousal index and
the number of stage shifts during the second half of the night in older individuals with
insomnia (Morita, Sasai-Sakuma & Inoue, 2017). A polysomnographic and subjective sleep
study found a significant decrease in sleep onset latency and wake time after sleep onset
as well as a significant increase in sleep efficiency following a six-month exercise training
program, but no significant differences were seen between morning and late-afternoon
exercise in chronic primary insomnia (Passos et al., 2011). Inconsistent subjective and
objective results regarding the effects of exercise on sleep, which may be related to variations
in exercise intensity, and time between exercise and sleep, were reported. Moreover, acute
exercise affects the endocrine system (Tuckow et al., 2006), metabolism (Scheen et al.,
1996), and core body temperature (Murphy & Campbell, 1997;Gilbert et al., 2004). Regular
exercise affects the endocrine system (Kern et al., 1995), metabolism (Scheen et al., 1996),
circadian rhythm and body core temperature (Murphy & Campbell, 1997). Sleep loss may
affect metabolism, the central nervous system, the endocrine system, inflammation, and
the autonomic nervous system (Chennaoui et al., 2015). Some studies have focused on the
sleep process in insomnia. Regular daytime exercise can increase melatonin secretion in and
improve the sleep quality of patients with insomnia (Taheri & Irandoust, 2018). Insomnia
can also result in cognitive dysfunction because sleep may restore cognitive function and
maintain attentional mechanisms (Taheri & Arabameri, 2012). Thus, the beneficial effects
of exercise on sleep efficiency and onset latency contribute to the interaction between
Banno et al. (2018), PeerJ , DOI 10.7717/peerj.5172 15/23
circadian rhythm and metabolic, immune, thermoregulatory, and endocrine effects. Future
trials to investigate the effects of exercise on sleep cycle and sleep process in patients with
insomnia are required.
Summary of the findings and recommendatons
We first performed a systematic review and meta-analysis of the effects of exercise on sleep
in patients with insomnia (diagnosed using criteria or screened with questionnaires). Our
findings suggest that the effects of exercise on sleep were greater in patients with insomnia
than in other populations and should be an effective nonpharmacological intervention.
Exercise interventions may alleviate symptoms in patients with insomnia without use of
hypnotics. The American Academy of Sleep Medicine report does not include exercise as
a viable recommendation for treating insomnia (Morgenthaler et al., 2006). Our findings
suggest that future clinical practice guidelines should include exercise as a recommendation
for treating patients with insomnia.
Strengths
The primary strength of this study was its careful and rigorous screening, extraction, and
scoring process. The secondary strength was the extensive subgroup analyses that explored
the heterogeneity of the results.
Limitations
Our study has several limitations. First, only four of the nine included trials examined
adverse effects (Reid et al., 2010;Afonso et al., 2012;Hartescu, Morgan & Stevinson, 2015).
Therefore, unreported outcomes and important unmeasured outcomes such as adverse
effects (for example, arrhythmia) may exist (Andersen et al., 2013). Second, most studies
had a high or unclear risk of selection bias, although our sensitivity analysis revealed that the
results were unchanged when studies were restricted to those that had a low risk of selection
bias (Table S4). In the future, trials with low risks of selection bias need to be conducted
verify our findings. Third, our review did not consider menopause in the meta-analysis
because none of the included studies reported subgroup data by postmenopausal status. In
the future, trials with subgroup data on postmenopausal women compared with women of
other age groups are needed to determine the effects of exercise in patients with insomnia.
CONCLUSIONS
Our findings suggest that exercise can improve sleep quality without notable adverse effects
in patients with insomnia. Most of the trials included in our review suggested a high risk
of selection bias in some domains. Therefore, higher quality research is needed to clarify
the effects of exercise on sleep in patients with insomnia.
ACKNOWLEDGEMENTS
We are grateful to Mr. Rui Afonso (Departamento de Psicobiologia, Universidade Federal de
São Paulo, Sao Paulo), Prof. Helena Hachul (Departamento de Psicobiologia, Universidade
Federal de São Paulo, Sao Paulo; Departamento de Ginecologia, Universidade Federal de
Banno et al. (2018), PeerJ , DOI 10.7717/peerj.5172 16/23
São Paulo, Sao Paulo), Dr. Iuliana Hartescu (Clinical Sleep Research Unit, Loughborough
University, Loughborough), Dr. Arun Kumar (Department of Physiology, Seth G. S.
Medical Collage & K. E. M. Hospital, Mumbai), Dr. Kathryn J. Reid (Department
of Neurology and Center for Circadian and Sleep Medicine, Northwestern University
Feinberg School of Medicine, Chicago, IL), Prof. Phyllis C. Zee (Department of Neurology
and Center for Circadian and Sleep Medicine, Northwestern University Feinberg School
of Medicine, Chicago, IL) and Assistant Professor Dr. Aileen WK Chan (The Nethersole
School of Nursing, The Chinese University of Hong Kong, Hong Kong), the authors of
the included study, for providing the detailed information. We thank Dr. Jessie Chan and
Prof. Cecilia Chan from Department of Social Work and Social Administration, Centre
on Behavioral Health, The University of Hong Kong, Hong Kong, for kindly providing
valuable unpublished data. We are grateful to Dr. Kiyomi Shinohara (Department of Health
Promotion and Human Behavior, Kyoto University Graduate School of Medicine/ School
of Public Health, Kyoto) for helping to make scope of the review and providing information
for PsycNet to enable screening in PsycINFO. We are grateful to Dr. Kazuhiro Uda (Office
for Infectious Control, National Center for Child Health and Development, Tokyo) for
helping collect references. We would like to thank Editage (http://www.editage.jp) for
English language editing.
ADDITIONAL INFORMATION AND DECLARATIONS
Funding
This work was supported by Japan Society for the Promotion of Science (KAKENHI Grant
Number 25282210), Nagoya University Academy of Psychiatry, and self-funding. The
funders had no role in study design, data collection and analysis, decision to publish, or
preparation of the manuscript.
Grant Disclosures
The following grant information was disclosed by the authors:
Japan Society for the Promotion of Science: 25282210.
Nagoya University Academy of Psychiatry.
Competing Interests
Masahiro Banno has received speaker honoraria from Dainippon Sumitomo, Eli Lilly, and
Otsuka; honoraria for a manuscript from Seiwa Shoten Co., Ltd, SENTAN IGAKU-SHA
Ltd and Kagakuhyoronsha Co., Ltd.; and travel fees from Yoshitomi Pharmaceutical
Industries Ltd. Yuki Kataoka received research funds from Eli Lilly. The other authors
declare no competing interests.
Author Contributions
Masahiro Banno, Hiraku Tsujimoto, Yasushi Tsujimoto and Yuki Kataoka conceived and
designed the experiments, performed the experiments, analyzed the data, contributed
reagents/materials/analysis tools, prepared figures and/or tables, authored or reviewed
drafts of the paper, approved the final draft.
Banno et al. (2018), PeerJ , DOI 10.7717/peerj.5172 17/23
Yudai Harada performed the experiments, authored or reviewed drafts of the paper,
approved the final draft.
Masashi Taniguchi, Ryo Tobita and Akiko Noda conceived and designed the experiments,
authored or reviewed drafts of the paper, approved the final draft.
Data Availability
The following information was supplied regarding data availability:
The raw data are provided in a Supplemental File.
Supplemental Information
Supplemental information for this article can be found online at http://dx.doi.org/10.7717/
peerj.5172#supplemental-information.
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Supplementary resources (30)

... (1) Physical activity and exercise have been attracting attention as nonpharmacological treatment alternatives for patients with insomnia, (2) since physically active people have better sleep quality, less sleep-related complaints and less daytime sleepiness and fatigue. (3) In healthy adults, regular exercise improves subjective (4)(5)(6) and objective sleep quality parameters such as total sleep time (TST), sleep efficiency (SE), slow wave sleep (SWS) and sleep onset latency (SOL), (7) which can be measured using polysomnography (PSG) or actigraphy (ACT). ...
... Therefore, further investigations are warranted. (8) According to a more recent metaanalysis, exercise improves subjective sleep quality (6) in patients with insomnia. ...
... (19) The effects of exercise on insomnia have been investigated in prior studies in which mood disorders were a confounding factor. (6,20,21) Physical exercise interventions were considered effective whenever the following goals were met: improvement in sleep quality and/or duration and improvement of insomnia symptoms (SOL <30 minutes and/or WASO <30 minutes and/or decreased frequency of awakenings or other sleep complaints and/or TST >6 hours and/or SE >85%). (22) To the best of our knowledge, systematic reviews aimed specifically at examining the effects of exercise on insomnia patients who do not suffer from mood disorders have not been carried out to date. ...
Article
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Objective: To systematically review the effects (benefits and harms) of different types of physical exercise on insomnia outcomes in adult populations with no mood disorders. Objective and subjective sleep outcomes and related mismatches were analyzed. Methods: Systematic review and meta-analysis. Quality of evidence was also examined. Results: Six studies including 295 participants with insomnia diagnosis were selected. Yoga, Tai Chi, resistance exercise and aerobic exercise were used in protocols with different duration, intensity and frequency. Studies involved different populations, including inactive or sedentary individuals, older adults and postmenopausal women. Physical exercise improved subjective sleep quality (very low quality of evidence) and reduced insomnia severity (high quality of evidence). Conclusion: Findings suggest individualized physical exercise must be addressed to design optimal protocols, with standardized type, duration, intensity, and frequency. For the time being, physical exercise may be considered an alternative and/or ancillary therapeutic modality for patients diagnosed with insomnia. Physical exercise can be used to improve subjective complaints, but not objective sleep outcomes.
... Exercise, including resistance training and aerobic exercise, demonstrates promising results for improving sleep quality and quantity in older adults [47,48]. Meta-analysis results show that exercise improves sleep quality, but may be less effective in improving sleep efficiency [49]. Exercise interventions vary in approaches including weightbearing and non-weightbearing activity, aerobic exercise, resistance training, and strength training. ...
... Sleep hygiene consists of sleep advice and practical information about how to achieve a good sleep environment, for example keeping the bedroom dark, removing electronics. This is the first step to improving sleep but has limited effectiveness as a standalone treatment [49]. Best practice is to combine sleep hygiene with other sleep interventions. ...
Article
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Background Up to 20% of patients experience long-term pain and dissatisfaction after total knee replacement, with a negative impact on their quality of life. New approaches are needed to reduce the proportion of people to go on to experience chronic post-surgical pain. Sleep and pain are bidirectionally linked with poor sleep linked to greater pain. Interventions to improve sleep among people undergoing knee replacement offer a promising avenue. Health beliefs and barriers to engagement were explored using behaviour change theory. This study followed stages 1–4 of the Medical Research Council’s guidance for complex intervention development to develop a novel intervention aimed at improving sleep in pre-operative knee replacement patients. Methods Pre-operative focus groups and post-operative telephone interviews were conducted with knee replacement patients. Before surgery, focus groups explored sleep experiences and views about existing sleep interventions (cognitive behavioural therapy for insomnia, exercise, relaxation, mindfulness, sleep hygiene) and barriers to engagement. After surgery, telephone interviews explored any changes in sleep and views about intervention appropriateness. Data were audio-recorded, transcribed, anonymised, and analysed using framework analysis. Results Overall, 23 patients took part, 17 patients attended pre-operative focus groups, seven took part in a post-operative telephone interview, and one took part in a focus group and interview. Key sleep issues identified were problems getting to sleep, frequent waking during the night, and problems getting back to sleep after night waking. The main reason for these issues was knee pain and discomfort and a busy mind. Participants felt that the sleep interventions were generally acceptable with no general preference for one intervention over the others. Views of delivery mode varied in relation to digital move and group or one-to-one approaches. Conclusion Existing sleep interventions were found to be acceptable to knee replacement patients. Key barriers to engagement related to participants’ health beliefs. Addressing beliefs about the relationship between sleep and pain and enhancing understanding of the bidirectional/cyclical relationship could benefit engagement and motivation. Individuals may also require support to break the fear and avoidance cycle of pain and coping. A future intervention should ensure that patients’ preferences for sleep interventions and delivery mode can be accommodated in a real-world context.
... For optimal sleep, one should regularly engage in physical activity which meets at least the recommended minimum threshold [28,29,[32][33][34]. Although there are reports of acute exercise in the form of cycling providing more sleep benefits than running [35], engaging in any form of exercise irrespective of type is more important than being sedentary for better sleep benefits. ...
... A negative association of sleep disorders with fitness level is thus possible to some extent [28]. Regular physical and mind-body exercise like yoga and tai-chi may be one of the effective non-pharmacological therapies for sleep disorders like insomnia, thereby improving subjective sleep quality, insomnia severity, and daytime sleepiness, etc., especially with moderate aerobic exercise; and for sleep-disordered breathing like obstructive sleep apnea, etc. [32][33][34]40]. For the sleep-disordered patients, adequate preparticipation health screening and physical including cardiovascular check-up and examination should be done before initiating any progressive physical activity and exercise program, which should start at low intensity with the close watch for possible exerciseassociated illness especially acute cardiovascular events, and injuries [33]. ...
... Previous meta-analyses suggest that elderly people who exercise constantly have better sleep quality and less insomnia compared to elderly people who do not regularly exercise [13,14]. This article aims to perform an updated meta-analysis to survey the effects of physical activity programs on the quality of sleep in healthy elderly individuals aged 60 years or older, using the PSQI as a tool. ...
... The results are consistent with those of Banno et al. [13], who suggested in 2018 that exercise can improve sleep quality. Rubio-Arias [40] et al., in a study evaluating middleaged women, found different results according to the exercise protocol applied: while there was no significant improvement in groups that performed low-intensity exercise (yoga), groups that engaged in moderate exercise (aerobic exercise) showed improvement in sleep quality. ...
Article
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Abstract: Introduction: Aging is directly related to sleep problems. Primary insomnia has a negative impact on the lives of elderly adults, altering cognitive and metabolic functions. Physical activity is positively related to improvement in sleep quality. The objective of this systematic review was to analyze the effects of physical activity programs in healthy elderly individuals aged 60 years or older, using the Pittsburgh Sleep Quality Index (PSQI) as a tool. Methods: The search was performed in the PubMed and Scielo databases, July 2021. Only randomized clinical trials that evaluated the role of physical exercise in the sleep quality of elderly patients were selected by two independent reviewers. Results: The result of the PSQI analysis showed that compared with the control condition, the exercise intervention was beneficial for the groups with insomnia (SMD: −0.57; 95% CI: −0.73 to −0.4; p < 0.00001; I2 = 53%) and without insomnia (SMD: −0.61; 95% CI: −0.75 to −0.47; p < 0.00001; I 2 = 73%) and for the two groups combined (SMD: −0.59; 95% CI: −0.70 to −0.49; p < 0.0001, I 2 = 68%). Conclusion: The systematic and continuous practice of physical exercise significantly improves perceived sleep quality in elderly individuals. Therefore, physical activities can be used as a tool to prevent sleep disorders and improve health in general. Future studies may clarify the comparison between aerobic and resistance exercises, evaluate the dose–response relationship and include more participants. Keywords: physical exercise; elderly; aging; sleep; sleep wake disorders; circadian rhythm
... A meta-analysis found total sleep time and several measures of sleep quality significantly decreased with ageing (Ohayon et al., 2004). This may also be linked to declining physical activity levels with ageing, given exercise can improve sleep quality (Banno et al., 2018). These findings have important implications for changes in fat mass, given a meta-analysis of 14 longitudinal studies found short (≤ 5-6 hours) sleep duration was associated with an increased incidence of obesity compared with those who slept 7-8 hours (Odds Ratio [OR] = 1.45, 95% CI: 1.25 to 1.67) (Wu et al., 2014). ...
Thesis
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Maintaining a healthy brain has been recognised as an important health challenge facing women, given global estimates indicate almost twice as many women die of dementia than men. In part, this is due to their increased longevity, however, this does not explain all of the difference. Other contributors include different exposure to risk factors as well as sex-related physiological differences. This thesis focused on the latter, specifically in relation to possible impacts of menopause, as this stage of life has been suggested to involve particular risks to brain health. To address this question, five studies were conducted to precisely characterise and quantify (1) changes in fat mass during menopause; (2) lipid profile differences during menopause; (3) heterogeneity of menopause nomenclature used in peer-reviewed literature; (4) changes in fat mass and the brain; and (5) menstruation history (including menopausal status and age at menopause) and the brain. Moreover, an important conceptual and theoretical question embedded throughout this thesis has been to determine how much of the observed effects were attributable to ageing, rather than a possible effect of menopause. This has been a significant challenge, given menopause and ageing co-occur. The first two studies revealed that fat mass was higher in postmenopausal compared to premenopausal women across most measures, with the exception of leg fat which decreased, indicative of a potential change in fat mass distribution after menopause. However, the change in fat mass quantity was predominantly attributable to increasing age with menopause having no detectable additional influence. Furthermore, lipoproteins were significantly higher in postmenopausal women than premenopausal women, with the exception of high-density lipoprotein, which was not significantly different between groups. Measures of ageing explained some, but not all of the differences in lipid levels. The third study found a significant amount of heterogeneity associated with the definition of "premenopause", compared with "postmenopause". The fourth study demonstrated that those who suffered from overweight or obesity had smaller hippocampal volumes than those who maintained a normal weight. Furthermore, those who suffered from overweight or obesity in the past, but currently had a normal level of fat mass also had a smaller hippocampus than those who had always maintained a normal weight. The fifth study revealed an association between menopause and the brain, beyond typical ageing effects. Notably, postmenopausal women had larger brain volumes than premenopausal women but also experience greater decreases in total brain volume, but not hippocampal volume, over time. In addition, delayed age of menopause was negatively associated with brain volume. The findings from this thesis have demonstrated an association between menopause and the brain, which cannot be uniquely explained by ageing. Specifically, although menopause alone was not found to be negatively associated brain health, it was associated with somewhat poorer brain health when considered concurrently with other changes around menopause. Moreover, when considering that women tend to gain abdominal fat around menopause, as well as develop an unfavourable lipid profile, and given extensive evidence in the literature that higher abdominal fat and lipid levels are associated with a greater risk of cerebro-vascular disease and dementia, hypothesising a link between menopause and poorer brain health seems warranted but will require further confirmation in future research. As a whole, the findings from this thesis paint an optimistic picture for women's health, since the risk factors identified and linked with deleterious brain health outcomes are modifiable. If adequate support is available at a health policy, clinical and community level, these specific risks to brain health may be reduced or prevented.
... This is of special concern, as physical activity (PA) and regular aerobic exercise are known to be potential protective factors for mental health (Holmes et al., 2020). In fact, pre-pandemic evidence shows convincing prevention and intervention effects of PA for depression, anxiety and sleeping disorders (Ashdown-Franks et al., 2020;Banno et al., 2018;Schuch et al., 2019;Schuch et al., 2018;Sporndly-Nees et al., 2017). Physical inactivity and a decrease in PA are also most likely associated with higher symptoms of depression and anxiety during COVID-19-induced social distancing measures (Wolf et al., 2021). ...
Article
Background: COVID-19-related confinements pose a threat to mental health. We investigated prevalence rates of symptoms of depression, generalized anxiety and insomnia in German adults. Furthermore, we explored associations of exercise behavior with disorder-specific symptoms and assessed whether specific affect regulation skills enhance the effect of exercise on symptom alleviation. Methods: Cross-sectional survey-based data collected during the first lockdown is presented: 4268 adults completed questionnaires on mental health, exercise behavior and Covid-related lifestyle factors. Primary outcome was depression (PHQ-9), secondary outcomes generalized anxiety (PHQ-D) and sleep quality (PSQI). Multiple linear regression analyses were performed to examine the association of exercise behavior with the outcomes. Results: Analyses resulted in elevated symptoms of psychological distress (probable cases of depressive disorder: 31.2%, anxiety disorder: 7.5%, sleeping disorder: 43.0%). A change towards less exercise during the lockdown was significantly associated with higher levels of depression (t=5.269; β=0.077, p<.001), anxiety (t=3.397; β=0.055, p<.001) and insomnia (t=3.466; β=0.058; p<.001). Physical activity (PA)-related affect regulation enhanced the effect of exercise on mental health. Conclusions: Results suggest a demand for measures which promote the maintenance of exercise during a pandemic and improve PA-related affect regulation to optimize effects of exercise on mental health.
Article
Objectives The elderly population is increasing, and one of the common problems in the elderly is a sleep disorder. Poor sleep quality causes various musculoskeletal problems, including chronic nonspecific Low back pain. In this regard, this study aimed to evaluate the effectiveness of pre-sleep exercises on sleep quality parameters and chronic nonspecific chronic low back pain after sleep in the elderly. Methods & Materials This study was quasi-experimental. A total of 40 retirees over 60 years old of Isfahan University of Technology with a Mean±SD age of 64.52±3.18 years, a weight of 81.99±7.35 kg, and a BMI of 27.91±2.21 in a targeted manner available were selected and randomly divided into two experimental and control groups of 20 people. The Pittsburgh Standard Questionnaire was used to assess sleep quality parameters; the VAS Pain Intensity Questionnaire was used to assess low back pain and the Oswestry Low Back Pain Disability Questionnaire. The exercise program intervention was performed for 28 sessions for 15 minutes. Descriptive statistics were used to analyze the data; also, the analysis of variance (ANOVA) with repeated measures was used. All analyzes were performed using SPSS software v. 24. Results The results showed a significant difference between groups in sleep quality parameters such as mental quality of sleep (P=0.001), delay in falling asleep (P=0.019), duration of sleep (P=0.006), sleep efficiency and effectiveness (P=0.001), sleep disorder (P=0.016), use of sleeping pills (P=0.001), inappropriate performance during the day (P=0.002). The overall sleep quality among elderly males was P=0.001. Also, bedtime exercises can significantly affect nonspecific chronic low back pain parameters such as pain intensity (P=0.039) and disability (P=0.014) in this age group. Conclusion Doing light exercise before bed on a light to moderate basis, according to the exercise program presented in this study, can improve the disability and reduce pain severity. This seems to be one of the most critical problems in old age, namely the quality of sleep and related parameters in the elderly male with nonspecific chronic low back pain. Therefore, it is recommended that the elderly engage in regular exercise.
Article
Introduction: Specific characteristics of sleep (e.g., duration, quality, and fatigue) are positively associated with (ED) behaviors, specifically binge eating (BE) potentially through decreased self-regulation and increased appetite. However, prior work has been largely cross-sectional and has not examined temporal relationships between sleep characteristics and next-day ED behaviors. Thus, the present study examined daily relationships between sleep and ED behaviors among individuals with binge-spectrum EDs. Method: Participants (N = 96) completed 7 daily ecological momentary assessment (EMA) surveys over 7-14 days; morning surveys assessed sleep characteristics and 6 randomly timed surveys each day captured ED behaviors. Analyses examined within-subject and between-subject effects of sleep quality, duration, and fatigue on BE, compensatory purging behaviors, and maladaptive exercise. Results: Within-subject sleep quality was significantly negatively associated with engagement in maladaptive exercise later that day. Additionally, between-subject sleep duration was significantly negatively associated with engagement in compensatory purging behaviors. Discussion: Within- and between-subjects associations between sleep quality and duration and compensatory behavior engagement indicate that sleep plays an important role in ED behaviors. Future research should incorporate sensor-based measurement of sleep and examine how specific facets of sleep impact BE and treatment response. Level of evidence: Level II: Evidence obtained from controlled trial without randomization.
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Background: There is a bidirectional relationship between depression and insomnia. Depression-related insomnia is common and remains a challenging medical condition. Although acupuncture might be a potential treatment option and increasing randomized controlled trials (RCTs) have emerged, currently available evidence regarding the effect and safety of acupuncture on depression-related insomnia remains inconclusive. Thus, this protocol aims to systematically synthesize the evidence about the efficacy and safety of acupuncture for depression-related insomnia. Methods and analysis: Eligible RCTs will be searched in nine representative databases and pooled in meta-analyses using RevMan 5.3. The methodological quality of included studies will be rated by Cochrane's risk of bias 2.0 tool. The quality of evidence will be appraised using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Subgroup analysis, sensitivity analyses, and publication bias will also be conducted. Discussion: This protocol outlines the planned scope and methodology for an upcoming systematic review meta-analysis, which will critically synthesize the evidence about the efficacy and safety of acupuncture on depression-related insomnia. Findings will shed light on fulfilling evidence gaps and influence evidence-based treatment decisions for clinicians in the treatment of depression-related insomnia.
Article
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The aim of the present study was to evaluate the scientific products in the field of physical activity of students in primary schools, using scientometrics and descriptive method and co-occurrence of keywords technique, Scopus and Pubmed databases were examined using VOSViewer and SPSS software. The findings identified 10 clusters in which the terms "obesity", "health promotion", "intervention" and "nutrition and health", "physical education" and "medical" in the most common category and "architecture and physical factors" it was one of the lesser-known areas. The growth of scientific production showed an upward trend that has accelerated since 2011. The share of the United States, Australia and Canada in the number of releases was the highest. Analysis of Iranian scientific products showed the highest level of cooperation with Malaysia, USA and New Zealand that 46.15% of the researches were focused on the medical, 23.07% nutrition, 15.38% rehabilitation and 7.69% on the field of behavioral and ergonomics.Most of these studies were conducted in primary schools in Tehran. More than 85% of these studies among the faculties of medical sciences and only 15% of the productions were the achievements of the faculties of architecture and management. Findings of this research, in addition to emphasizing the need to pay attention to the position of motor behavior in Iran due to the low trend of publication, will help future researchers to identify more of the leading gaps such as lack in non-medical fields, saving time by not dealing with repetitive topics, take steps to fill these gaps.
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ABSTRACT Study Objective: Epidemiological studies have shown a close correlation between obesity and sleep disorders which threatens the quality of life in the elderly. Thus, the purpose of this research was to study the effect of the aerobic exercise (with the aim of decreasing obesity) on quality of sleep in obese elderly women. Method: 34 obese elderly women with sleep disorder recognized by Pittsburgh Sleep Quality Index (PSQI), were recruited purposefully from the Preventive healthcare Center and randomly allocated to two groups either aerobic training (3 sessions a week for 12 wk.), or a control group. All Obesity indexes measures including Body Mass Index (BMI), Waist Hip Ratio (WHR), and Percent Body Fat (PBF) were measured using bioelectrical impedance analysis. Results: The results suggested that PSQI, Sleep quality, Sleep duration, Sleep Efficiency, Sleep disturbance, Sleep medications and Daytime dysfunction were significantly improved in experimental group, besides (p<0.05). All obesity indexes including BMI, PBF and WHR were significantly improved after exercise intervention (p<0.05). Conclusion: The exercise-induced weight loss improved the quality of sleep in obese elderly women. Keywords: Weight loss, sleep quality, obese, elderly
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Purpose Age-related cognitivee decline is a growing public health concern worldwide. More than a quarter of adults with cognitive impairment experience sleep disturbance. The objective of this pilot study was to evaluate the preliminary effects of tai chi qigong (TCQ) on improving the night-time sleep quality of older adults with cognitive impairment. Participants Older adults with cognitive impairment who complain of sleep disturbance. Methods A randomized controlled trial with two groups. Fifty-two subjects were recruited from two district elderly community centers and randomly assigned to either the TCQ group (n=27) or the control group (n=25). The intervention group received TCQ training consisting of two 60-minute sessions each week for 2 months. The control group was advised to maintain their usual activities. Sleep quality was measured by the Chinese Pittsburgh Sleep Quality Index. Quality of life was measured by Short-form 12, cognitive functions measured by mini-mental state examination, and subjective memory deficits measured by the memory inventory for Chinese. Results Data were collected at baseline, 2 months, and 6 months. Significant results were noted at 6 months in the Chinese Pittsburgh Sleep Quality Index global score (P=0.004), sleep duration (P=0.003), habitual sleep efficiency (P=0.002), and the Short-form 12 mental health component (P<0.001). The TCQ participants reported better sleep quality and a better (quality of life) mental health component than the control group. Conclusion TCQ can be considered a useful nonpharmacological approach for improving sleep quality in older adults with cognitive impairment. Clinical trial registration CUHK_CCT00448 (https://www2.ccrb.cuhk.edu.hk/registry/public/287).
Article
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Objective Sleep disturbances are one of the most common psycho-physiological issues among postmenopausal women. This study was designed to evaluate the impact of walking with a pedometer on the sleep quality of postmenopausal Iranian women. Methods This randomized, controlled trial was conducted on 112 women who were randomly assigned to two groups. The women in the intervention group (n = 56) were asked to walk with a pedometer each day for 12 weeks and to increase their walking distance by 500 steps per week. A sociodemographic instrument and the Pittsburgh Sleep Quality Index were used to collect data. Sleep quality was measured at baseline, 4, 8, and 12 weeks after intervention. The control group (n = 56) did not receive any intervention. Results After 12 weeks, subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction improved to a significantly greater extent in the intervention group than in the control group (p < 0.05). The total sleep quality score was significantly higher in the intervention group than in the control group (0.64 vs. 0.98, p = 0.001). Conclusion This study showed that walking with a pedometer is an easy and cost-effective way to improve the quality of sleep among postmenopausal women. Use of this method in public health centers is recommended.
Article
Introduction Growing evidence has shown that Qigong exercise improves sleep quality and alleviates depressive symptoms. However, the mechanisms underlying the effects of Qigong exercise remain unclear. Methods A randomized waitlist-controlled trial was conducted to assess efficacy of Qigong exercise and investigate relationship between pro-inflammatory cytokines and self-reported symptoms among depressed persons with sleep disturbance. 173 participants were screened and recruited from the community. Intervention was eight 3-hour weekly sessions of Qigong training plus 30-minute self-practice at least 3 times per week. Self-reported questionnaires, including Pittsburgh Sleep Quality Index (PSQI), Center for Epidemiologic Studies Depression Scale (CES-D) and perceived stress scale (PSS) and measurement of pro-inflammatory cytokines interleukin (IL)-1β and IL-6 were assessed at baseline (T0), immediate post-intervention (T1) and 3-month post-intervention (T2). Results Compared with waitlist control group, independent t-tests showed that Qigong exercise significantly improved sleep quality and reduced depressive symptoms and perceived stress as measured by PSQI (-1.7 vs -0.7, p =.014), CES-D and PSS and lowered IL-6 (-0.21 vs 0.70, P = <.001) and IL-1β (-0.08 vs 0.00, P = .002) at T1. Significant association was found between PSQI change score and reduction in IL-1β level at both T1 and T2 following Qigong exercise, but not with IL-6 level; while reduction in IL-6 was significantly associated with changes in CES-D and PSS scores. Conclusion Qigong exercise alleviated sleep disturbance and depressive symptoms, and also reduced the levels of IL-1β and IL-6. Significant associations between reduction in IL-1β and sleep improvement were found following Qigong exercise. This study sheds light on possible underlying mechanism of regulating sleep by lowering the level of IL-1β. Further studies using polysomnography for recording NREM and REM sleep are warranted to confirm our preliminary findings. Support (If Any) The Centre on Behavioral Health Research Fund of the University of Hong Kong
Article
Objectives The aims of this study were to compare the effects of acute morning or evening exercise on nocturnal sleep in individuals with two subjective insomnia symptoms: difficulty in initiating sleep (DIS), and early morning awakening (EMA), separately for the first vs the second halves of the night. Methods Older individuals (55–65 years old) with DIS (N = 15) or EMA (N = 15) and age- and sex-matched controls (N = 13) participated in this non-randomized crossover study. Participants were assigned to two exercise conditions (morning exercise and evening exercise) in counterbalanced order following the baseline condition with a two-week interval between conditions. A single session of aerobic step exercise was performed during each exercise condition. Nocturnal polysomnography was carried out to evaluate objective sleep quality. Patient global impression of change scale scores for nocturnal sleep were obtained to subjectively evaluate the different groups. Results Acute physical exercise did not improve subjective sleep quality. Morning exercise decreased the number of stage shifts over the whole night. The arousal index and the number of stage shifts were decreased especially during the second half of the night in all groups. Furthermore, morning exercise decreased the number of wake stages during the second half of the night in the DIS group, but not in the EMA group. Conclusions Acute morning exercise can improve nocturnal sleep quality in individuals with difficulty initiating sleep, especially during the later part of the night.
Article
Exercise leads to several positive outcomes in oncology. However, the question as to whether exercise is a valuable option for improving patients' sleep, which is frequently disturbed in cancer patients, remains unanswered. The aims of this study were to conduct a systematic review and meta-analysis of randomized and non-randomized clinical trials that have investigated the effect of exercise on sleep outcomes, assessed subjectively and objectively. Relevant studies, published before May 2016, were traced through a systematic search of Pubmed, Embase, PsyInfo, SportDiscus and Cochrane Library databases. The review looked at twenty one trials, including 17 randomized controlled trials. Most interventions were home-based aerobic walking programs and breast cancer patients were the subgroup most represented. Sleep variables were most commonly used as secondary outcomes in the reviewed studies. Studies were highly heterogeneous in terms of methodology. The qualitative review of available evidence suggested a beneficial effect of exercise interventions on sleep in several studies (48%). However, the meta-analysis conducted on RCTs revealed no significant effect either on subjective and objective sleep measures. This lack of significant effect could be due, at least in part, to a floor effect. More rigorous studies are needed to assess the effect of exercise interventions in cancer patients, in particular randomized controlled trials conducted in patients with clinically significant sleep disturbances at baseline.
Article
Background: Insomnia is a highly prevalent health complaint in the modern societies; however, insomnia remains under-diagnosed and under-treated. Although screening tools, including the Insomnia Severity Index (ISI), Athens Insomnia Scale (AIS), and Pittsburg Sleep Quality Index (PSQI), are widely used for assessing the risk of insomnia, the diagnostic properties have yet to be summarized in a systematic manner. Objectives: To estimate and to compare the diagnostic accuracy of the ISI, AIS, and PSQI for insomnia screening. Data sources: We systematically searched EMBASE, PubMed, PsycINFO, CINAHL and Chinese Electronic Periodic Services for data from their inception to May 20, 2015. Data selection: Original articles that had assessed the sensitivity and specificity of the ISI, AIS, or PSQI against a reference standard in adult participants (age>18) were included. Results: A total of 19 studies comprising 4693 participants were included. The pooled sensitivity for the ISI, AIS, and PSQI was 88% (95% confidence interval [CI]=0.79 to 0.93), 91% (0.87 to 0.93), and 94% (0.86 to 0.98), respectively. The pooled specificity was 85% (0.68 to 0.94), 87% (0.68 to 0.95), and 76% (0.64 to 0.85); and the pooled DORs was 41.93 (8.77 to 200.33), 67.7 (23.4 to 196.1), and 53 (15.5 to 186.2), respectively. The summary estimates did not differ significantly among the ISI, AIS and PSQI (all P>0.05). Conclusions: The current evidence indicates that the ISI, AIS, and PSQI yield comparable diagnostic properties for insomnia screening.
Article
Description: The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the management of chronic insomnia disorder in adults. Methods: This guideline is based on a systematic review of randomized, controlled trials published in English from 2004 through September 2015. Evaluated outcomes included global outcomes assessed by questionnaires, patient-reported sleep outcomes, and harms. The target audience for this guideline includes all clinicians, and the target patient population includes adults with chronic insomnia disorder. This guideline grades the evidence and recommendations by using the ACP grading system, which is based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Recommendation 1: ACP recommends that all adult patients receive cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia disorder. (Grade: strong recommendation, moderate-quality evidence). Recommendation 2: ACP recommends that clinicians use a shared decision-making approach, including a discussion of the benefits, harms, and costs of short-term use of medications, to decide whether to add pharmacological therapy in adults with chronic insomnia disorder in whom cognitive behavioral therapy for insomnia (CBT-I) alone was unsuccessful. (Grade: weak recommendation, low-quality evidence).