Some controlled trials have reported that stretching and flexibility activities, such as tai chi 22 , 23 and yoga, 24 have led to improvements in self-reported sleep quality in older adults. However, the effects of stretching on chronic insomnia also are not well established, although some studies have described positive effects in postmenopausal woman and older adults.
The purpose of this study was to assess the effects of resistance exercise and stretching on insomnia severity, objective and subjective sleep, mood, and quality of life in patients with chronic insomnia. We hypothesized that resistance exercise would lead to greater improvements in sleep than stretching, but that both treatments would more effectively reduce insomnia complaints and improve objective sleep, mood states, and quality of life than a control treatment. The participants were recruited through newspaper, magazine, and radio advertisements. Interested prospective participants contacted the researchers and were initially screened in a phone interview.
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The initial exclusion criteria were: a use of psychoactive drugs; b history of psychiatric diseases; c a shift work schedule; d regular exercise in the last 6 months. Prospective participants who passed the phone screening were invited to the Sleep Clinic for further orientation. During the visit, the prospective participants signed a written informed consent form approved by the ethics committee.
A medical screening determined clinical diagnosis of insomnia based on modified DSM-IV criteria, including minimum symptom duration of 6 months and minimum frequency of at least 3 times a week , electrocardiogram abnormalities, a history of cardiac disease contraindicating exercise, and the coexistence of major depression. Patients unavailable for the intervention program were assigned non-randomly to the non-intervention control treatment.
The resistance exercise sessions were scheduled three times a week for four months 48 total sessions , focusing on the upper and lower limbs, abdominals, and paravertebral areas. Each session included four exercises for the upper limbs: biceps, triceps, back, and pectorals; four exercises for the lower limbs: flexors, extensors, abductors, and adductors; one trunk flexion exercise for the abdominal area; and one trunk extension exercise for the paravertebral area spinal stabilizers.
Each exercise was performed in three series of 12 repetitions with s intervals between series and 1-min intervals between the different types of exercise. Each full training session lasted approximately 50 min.
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All exercise sessions were performed at the same time of the day, 5 to 6 p. Stretching followed the Tworoger et al. The session began with a 5-min walk around the room, followed by 45 min of stretching exercises involving the upper and lower limbs, with types for each body region. The design included two evaluations: baseline pre-intervention and after the 4-month intervention not during the intervention or after the control treatment.
All evaluations were conducted according design in all three experimental groups Figure 1. It is a short and easy self-applied scale with seven items scored from 0 to 4, with a total score varying from 0 to The total score is interpreted as follows: absence of insomnia ; sub-threshold insomnia ; moderate insomnia ; and severe insomnia SOL, sleep duration, and SE ratio between sleep duration and total time in bed x were obtained. The participants were instructed to use the Octagonal Sleep Watch 2. They were also instructed to record their bedtime and wake-up time by pressing the event button.
During the recording period, the participants were requested to keep a sleep and activity diary for later comparison with the actigraphy data.
Analysis of the events during PSG was carried out by two investigators, who used international criteria and were blind to volunteer grouping. It consists of 65 items in six domains: tension-anxiety, depression, anger-hostility, vigor-activity, fatigue, and confusion-bewilderment. The total mood disturbance score is derived by subtracting the vigor-activity score from the sum of the scores on the other subscales.
It includes eight components: physical function, physical role, body pain, general health, vitality, social functioning, emotional role, and mental health. All scores ranged from 0 to , with a higher score indicating better quality of life. A 1RM strength test was used to assess maximum strength in the exercise group.
The participants were instructed to warm up on an ergometric bicycle for 5 min; the warm-up routine also included specific movements with fitness equipment that were assessed in the test. Four one-repetition attempts were then performed to establish the 1RM load, which was only validated when the movements were correctly performed.
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The recovery periods between attempts lasted from 3 to 5 min. The following Technogym muscle workout equipment was used: adductor for the thigh adductors; abductor for the thigh abductors; leg extension for the quadriceps; leg curl for the hamstrings; abdominal crunch for the abdominal region; lower back for the paravertebral muscles; chest press for the pectoral area; vertical traction for the shoulders; arm curl for the biceps; and arm extension for the triceps.
The patients were asked to sit, legs outstretched, facing a wooden box with the soles of their bare feet flat against the side of the box and their knees kept locked flat against the floor. At the beginning of the test, one palm was placed on top of the other, facing down, at the edge of the top surface of the box, which was fitted with a measuring line. Three attempts were made, and the best result was used for analysis. Changes in secondary outcomes sleep and mood were evaluated in an identical fashion to ISI scores.
Pearson correlations were used to verify associations between changes in sleep and mood. Changes in maximal strength and flexibility were also assessed using repeated measures ANOVA following the resistance exercise and stretching interventions, respectively. Of this total, did not meet the inclusion criteria. During the initial assessment stage, 30 of the remaining individuals were excluded in the medical screening. Thus 20 patients began the intervention programs and nine remained in the control group. One control group participant subsequently abandoned the study due to family problems.
All insomnia patients successfully completed the 48 exercise sessions. When a session was missed, it was rescheduled on any other weekday in the same week. Thus, all patients completed the session protocol. There were no significant baseline differences between treatments. The general characteristics of the participants are described in Table 1. Duncan post-hoc analysis showed significant differences between the control group and both the resistance exercise and stretching groups Table 2.here
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Post-hoc analysis showed significant differences between the control group and both the resistance and stretching groups for global PSQI score and sleep duration. Compared with the control group, PSQI-sleep efficiency improved only after resistance exercise Table 2. Post-hoc analysis showed significant differences between the control group and both the resistance exercise and stretching group for all above-described sleep variables Table 2.
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However, there were no significant post-intervention differences between the resistance exercise and stretching groups for actigraphic sleep. No significant differences were observed between groups for polysomnographic sleep measures. Post-hoc analysis showed significant differences between the control and stretching groups Table 3 , but not between the resistance exercise and stretching groups.
No significant correlations were observed between changes in tension-anxiety and sleep improvements. No significant quality of life differences were observed between groups Table 3. Table 4 summarizes the significant differences in maximum strength and flexibility between baseline, 2-month and post-intervention measures. The results did not support our first hypothesis that resistance exercise would lead to greater improvements in sleep than stretching. However, in agreement with our second hypothesis, both resistance exercise and stretching decreased insomnia severity ISI.
Moreover, both the resistance exercise and the stretching interventions improved sleep quality PSQI and actigraphic measures of home sleep SOL, WASO, and SE compared to the control group, but no significant differences between treatments were observed for polysomnographic variables. Stretching also reduced tension-anxiety, but no other significant treatment differences were observed for mood or quality of life.
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Previous studies have described the positive effects of moderate-intensity aerobic exercise on objective and subjective sleep in patients with chronic insomnia. However, resistance exercise has been shown to cause significant improvements in subjective sleep quality in older adults with depression. Sleep improvement after stretching has also been observed in previous studies on postmenopausal women 25 and older adults 26 using a similar protocol. These improvements could be indicative of the tension-reducing effects of stretching, which could work in a similar way to progressive muscle relaxation, an established non-pharmacologic treatment for chronic insomnia.
Similarly, Li et al. Nevertheless, no significant correlation was observed between sleep improvement and anxiety reduction in the present study. Our expectation that resistance exercise would lead to greater sleep improvements than stretching was based on the more extensive literature indicating sleep improvements following resistance exercise. To our knowledge, this is the first study to have investigated the chronic effects of resistance exercise on insomnia and the first study to have evaluated sleep after resistance exercise using actigraphy and PSG.
In the present study, the lack of significant improvements in PSG measurements of objective sleep could be attributable to the fact that PSG was assessed on only one night, whereas actigraphy was assessed over 15 nights. Actigraphy has been a reliable method for evaluating sleep patterns in patients with insomnia.
One limitation of the present study was that participants were randomly assigned to the resistance or stretching groups, but not to the control group. However, control participants may be assessed in the manner employed in this study if they refuse to enter an experimental protocol. There were no significant differences between the control group and the other participants in baseline measures see Table 1. Nevertheless, there could have been differences between individuals who were willing and able to participate in the experimental study and those who were not.
These differences could have favored greater improvements in the experimental participants, although the control group could not be considered non-volunteers, since they did devote considerable time to the study assessments. However, numerous other potential biases associated with non-randomization and fewer participant-researcher interactions in the control group could have resulted in greater improvements in the experimental treatments, including expectancy, demand, and Hawthorne effects.
The small sample size was also a limitation. However, there was adequate power to detect differences between the control and experimental treatments. In conclusion, the results suggest no significant differences between 4-month resistance exercise vs.