# Exercise as it relates to Disease/The Effects of Moderate Aerobic activity on middle aged sufferers of primary Insomnia
## What is the background to this research?

The article “Exercise Improves immune function, Antidepressive response, and Sleep Quality in Patients with Primary Chronic Insomnia” by Giselle Soares Passos discusses the effects of moderate aerobic exercise on Chronic Primary insomnia. Chronic Primary Insomnia is a sleeping disorder that leads to a low level of sleeping health, which in turn affects various components of an individual’s lifestyle.. The symptoms for Primary Insomnia are:
* Long-term difficulties with initiating and maintaining sleep
* Waking-up earlier than should occur
* Non-restorative sleep
* Daytime impairment, including moodiness, decreasing concentration which contributes to a poor quality of life.
Primary Insomnia effects between 10-15% of people worldwide with it occurring more in women than in men. There are currently three known treatments for Chronic Primary Insomnia. These are pharmacological based interventions, cognitive and behavioral therapies and exercise interventions. Pharmacological interventions are one of the most commonly used methods for treatment. A major drawback of such treatment, according to Walsh, is that once the medication ceases, the sufferer’s symptoms return. This is a major issue as the long-term use of medication is not recommended by medical professionals. Cognitive or behavioral therapies have been shown to have lasting effects on patients. These therapies achieve results through stimulus control and the reduction of activities that promote bed-time arousal. In order to be effective cognitive or behavioral therapies, require multiple treatments. These are expensive and time consuming and are likely not easily affordable to the majority of sufferers. Exercise interventions seek to utilize moderate physical exercise as a mechanism to decrease the symptoms of primary insomnia. A number of reviews have suggested that this form of intervention has similar longevity to the cognitive and behavioral therapy but is significantly cheaper. The clinical study and associated article, ‘Exercise Improves Immune Function, Antidepressive Response, and Sleep Quality in Patients with Chronic Primary Insomnia’ published in BioMed Research Int studies aim was to evaluate the effects that moderate aerobic exercise had on; sleep, depressive symptoms, immune function and cortisol levels among sufferers of Chronic Primary Insomnia.

## Where is the research from?

The article indicates that prior to its conduct approval was sought and gained by the University Human Research Ethics Committee and that it complied with the principles outlined in the Declaration of Helsinki, indicating that globally accepted research processes were followed. A majority of the researchers have been published in a number peer recognized journals. Giselle Soares Passos has published more than 12 articles relating to this chronic disease. The main focus of this research was middle-aged men and women. Previous studies have examined the effects of exercise on Chronic Primary Insomnia in relation to older adults. There is no evidence to suggest that there would be biased research due to outside organizational and sponsorship links.

## What kind of research was this?

This was an intervention-based study, spanning over the length of a 4-month period. Pre- and post-examinations were used to measure both subjective and objective responses to the exercise stimulus within the study. There was no control group and interim examinations were not conducted. Evidence from other studies regarding the implementation of exercise as a treatment for Chronic Primary Insomnia support the conclusion that moderate aerobic exercise, as an intervention, is effective in improving sleep quality.

## What did the research involve?

The participants were predominantly middle-aged men and women who underwent a series of interviews and tests to determine their suitability. While a number of previous studies have focused on examining the effects of exercise on Chronic Primary Insomnia in relation to older adults, this study’s focus on a different age group was relatively original. Although the testing regime was important to reduce external factors, it resulted in a relatively small sample size, with only 21 people participating. They were required to perform 50 minutes of continuous aerobic exercise of a moderate intensity 3 days per week. The exercise performed as a group at a pre-determined location. There were a number of limitations within this study. The lack of a control group meant that it couldn’t be ascertained whether or not the exercise intervention was the main contributing factor to the shift in the pre- and post-test scores. The researches identified a number of other stimulants that were experienced by the participants that could also have impacted the outcomes. Examples include socialization and the impact of light, (exercise activities were conducted in front of large windows). The decision to only conduct two testing activities, one at the beginning and one at the end resulted in an inability to determine the duration required before results were achieved.

## What were the basic results?

Based on the pre- and post-intervention objective and subjective sleep data there was a definitive increase in both total sleep time and sleep efficiency with an improvement in their subjective sleep test score.
| | Pre | Post |
| PSQI (Pittsburgh Sleep Quality Index) (Score) | 11.2 ± 3 | 6.8 ± 2 |
| Total Sleep Time (Hours) | 5.7 ± 0.8 | 6.1 ± 0.5 |
| Sleep Efficiency (%) | 82.2 ± 10 | 88.9 ± 8 |
The researches interpreted the results to show that moderate aerobic physical activity created significant improvements in both objective and subjective sleep data whilst also reducing depressive symptoms. Although there is improvement in the post intervention results, a PSQI of greater than 5, suggests that the subjects still have issues with their sleep quality. While this improvement in sleep quality didn’t increase the participant’s sleep to the recommended amount of sleep hours (7-9), it is likely that individuals were able to increase the amount of time they slept to 6 hours. According to the National Sleep Foundation this is within the acceptable range.

## What conclusions can we take from this research?

Based on the limitations and evidence presented within this study there may be a link between the use of exercise and improved sleep quality of those suffering from Chronic Primary Insomnia. This does align with other studies of a similar nature, which have shown that exercise is able to improve the sleep quality and overall physical function of older Chronic Primary Insomnia sufferers. Studies have also shown that not only the intensity but also the duration and amount of steps taken during exercise that has an impact on the improvement in sleep quality.

## Practical advice

While the research findings are not conclusive, the implementation of moderate aerobic exercise is likely to reduce, at least, some of the issues associated with Chronic Primary Insomnia. To afford the best opportunities for success moderate aerobic exercise for 50 minutes a day, 3 days a week should be undertaken. The exercise can be performed at any time that is comfortable for the individual. It is low cost and will likely have a noticeable impact on sleep quality. It is important that before undertaking any exercise program that participants consult with a qualified medical professional. It is also recommended when trying to develop an exercise program to seek the assistance of a qualified professional. This will reduce associated health risks and will help to ensure that the maximum benefit is attained.

## Further information/resources

* PSQI questionnaire instrument and instructions on how to use it: http://www.psychiatry.pitt.edu/node/8240
* Behavioral and Cognitive interventions: http://apps.who.int/iris/bitstream/10665/58229/1/WHO_MNH_PSF_93.2H.pdf
* Criteria, Treatment goals and considerations for Chronic Primary Insomnia: : http://emedicine.medscape.com/article/291573-overview

## References

* 1 2 Diagnostic and statistical manual of mental disorders. Washington: American Psychiatric Publishing; 2014
* 1 2 Summers M, Crisostomo M, Stepanski E. Recent Developments in the Classification, Evaluation, and Treatment of Insomnia. Chest. 2006;130(1):276-286.
* ↑ Ohayon M. Epidemiology of insomnia: what we know and what we still need to learn. Sleep Medicine Reviews. 2002;6(2):97-111.
* 1 2 Edinger J, Wohlgemuth W, Radtke R, Marsh G, Quillian R. Cognitive Behavioral Therapy for Treatment of Chronic Primary Insomnia. JAMA. 2001;285(14):1856
* ↑ Walsh J, Schweitzer P. Ten-Year Trends in the Pharmacological Treatment Of Insomnia. Sleep. 1999;22(3):371-375.
* 1 2 3 Passos G, Poyares D, Santana M, D’Aurea C, Youngstedt S, Tufik S et al. Effects of moderate aerobic exercise training on chronic primary insomnia. Sleep Medicine. 2011;12(10):1018-1027.
* ↑ Driver H, Taylor S. Exercise and sleep. Sleep Medicine Reviews. 2000;4(4):387-402.
* 1 2 3 4 5 6 7 8 9 10 Passos G, Poyares D, Santana M, Teixeira A, Lira F, Youngstedt S et al. Exercise Improves Immune Function, Antidepressive Response, and Sleep Quality in Patients with Chronic Primary Insomnia. BioMed Research International. 2014;2014:1-7.
* ↑ Gisselle Soares Passos [Internet]. Google Scholar. 2017 [cited 16 August 2017]. Available from: https://scholar.google.com.au/citations?user=TQ0rsugAAAAJ&hl=en&oi=ao&cstart=0&pagesize=20
* ↑ Hartescu I, Morgan K, Stevinson C. Increased physical activity improves sleep and mood outcomes in inactive people with insomnia: a randomized controlled trial. Journal of Sleep Research. 2015;24(5):526-534.
* 1 2 Reid K, Baron K, Lu B, Naylor E, Wolfe L, Zee P. Aerobic exercise improves self-reported sleep and quality of life in older adults with insomnia. Sleep Medicine. 2010;11(9):934-940.
* ↑ Buysse D, Reynolds C, Monk T, Berman S, Kupfer D. The Pittsburgh sleep quality index: A new instrument for psychiatric practice and research. Psychiatry Research. 1989;28(2):193-213.
* ↑ Hirshkowitz M, Whiton K, Albert S, Alessi C, Bruni O, DonCarlos L et al. National Sleep Foundation’s sleep time duration recommendations: methodology and results summary. Sleep Health. 2015;1(1):40-43.
* ↑ Erlacher C, Erlacher D, Schredl M. The effects of exercise on self-rated sleep among adults with chronic sleep complaints. Journal of Sport and Health Science. 2015;4(3):289-298.