Original Article

Effects of moderate aerobic exercise training on chronic primary insomnia

Giselle Soares Passos
a
, Dalva Poyares
a
, Marcos Gonalves Santana
b
, Carolina Vicaria Rodrigues DAurea
a
,
Shawn D. Youngstedt
d,e
, Sergio Tuk
a,c
, Marco Tlio de Mello
a,c,
a
Department of Psychobiology, Universidade Federal de So Paulo, So Paulo, SP, Brazil
b
Universidade Federal de Gois, Campus Jata, Gois, Brazil
c
Researcher Conselho Nacional de Desenvolvimento Cientco e Tecnolgico - CNPq, Braslia, Brazil
d
Department of Exercise Science, University of South Carolina, Columbia, SC, USA
e
Research and Development, WJB Dorn VA Medical Center, USA
a r t i c l e i n f o
Article history:
Received 5 November 2010
Received in revised form 27 January 2011
Accepted 9 February 2011
Available online 22 October 2011
Keywords:
Insomnia
Physical activity
Sleep
Mood
Quality of life
Polysomnography
a b s t r a c t
Objective: To evaluate the effect of long-term moderate aerobic exercise on sleep, quality of life, and
mood of individuals with chronic primary insomnia, and to examine whether these effects differed
between exercise in the morning and exercise in the late afternoon.
Methods: Nineteen sedentary individuals with chronic primary insomnia, mean age 45.0 (standard error
[SE] 1.9) years, completed a 6-month exercise training protocol, randomized to morning and late-after-
noon exercise groups.
Results: Combining polysomnographic data across both time points, this study found a signicant
decrease in sleep onset latency (from 17.1 [SE 2.6] min to 8.7 [SE 1.4] min; P < 0.01) and wake time after
sleep onset (from 63.2 [SE 12.8] min to 40.1 [SE 6.0] min), and a signicant increase in sleep efciency
(from 79.8 [SE 3.0]% to 87.2 [SE 1.6]%) following exercise. Data from sleep diaries revealed signicant
improvement in sleep onset latency (from 76.2 [SE 21.5] min to 80.3 [SE 7.4] min) sleep quality (from
41.5 [SE 5.2]% to 59.4 [SE 6.6]%) and feeling rested in the morning (from 50.8 [SE 5.3] to 65.1 [SE 5.0]).
There were generally no signicant differences in response between morning and late-afternoon exercise.
Following exercise, some quality-of-life measures improved signicantly, and a signicant decrease was
seen in the following Prole of Mood State measures: tensionanxiety (from 7.2 [SE 1.0] to 3.5 [SE 1.0]),
depression (from 5.9 [SE 1.2] to 3.3 [SE 1.1]) and total mood disturbance (from 9.2 [SE 4.8] to 1.7 [SE
4.8]). These effects did not vary between morning and late-afternoon exercise.
Conclusion: Long-term moderate aerobic exercise elicited signicant improvements in sleep, quality of
life and mood in individuals with chronic primary insomnia.
2011 Elsevier B.V. All rights reserved.
1. Introduction
Chronic primary insomnia is a sleep disorder characterized by
long-term difculties with initiating and maintaining sleep, wak-
ing up too early, non-restorative sleep, and daytime impairment,
including fatigue, poor mood, impaired concentration, and poor
quality of life [14]. The prevalence of chronic insomnia worldwide
is between 10% and 15% [5]. In Brazil, a recent study in the city of
So Paulo demonstrated that approximately 35% of the population
complained of insomnia, with the problem being more prevalent
among women (40%) [6].
Drug therapy is the most commonly prescribed treatment for
insomnia. However, sleep medications may cause side effects and
are not recommended for long-term use [7]. Thus, various non-
pharmacological therapies have been proposed in the literature,
especially cognitive and behavioural therapies [811].
However, cognitive or behavioural therapies may be very
expensive as frequent treatment is required. As such, physical
exercise as a non-pharmacological, low cost, and easily accessed
treatment alternative has been suggested [10,12,13]. The well-
established anxiolytic and antidepressant effects of exercise could
help to alleviate psychological comorbidities, which may also be
involved in the aetiology and perpetuation of insomnia [14].
Epidemiological studies have reported an association between
exercise and decreased complaints of insomnia [15,16], as well as
a relationship between low levels of physical activity and a greater
prevalence of insomnia [17]. However, there has been very limited
experimental investigation of the effects of aerobic exercise train-
ing on sleep in individuals with insomnia [18,19]. The studies have
1389-9457/$ - see front matter 2011 Elsevier B.V. All rights reserved.
doi:10.1016/j.sleep.2011.02.007

Corresponding author at: Universidade Federal de Sao Paulo, Department of

Psychobiology, Francisco de Castro, 93, Vila Clementino, CEP: 04020-050 Sao Paulo,
SP, Brazil. Tel./fax: +55 11 5572 0177.
E-mail addresses: gisasoares@hotmail.com (G.S. Passos), tmello@demello.net.br
(M.T. de Mello).
Sleep Medicine 12 (2011) 10181027
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been limited primarily to subjective sleep assessments; however,
positive effects of exercise on both subjective and actigraphic mea-
sures of sleep have been found.
The optimal time of day for performing exercise to promote sleep
is not clear. Earlier reviews, mainly from literature involving acute
exercise and normal sleepers, suggested a slight advantage for exer-
cise in the late-afternoon [12,13,20], and a recent study by the pres-
ent authors found a signicant improvement in sleep among
insomniacs following acute afternoon exercise [21]. However, it is
plausible that morning exercise may be at least as benecial for pro-
moting chronic sleep improvement for insomniacs (e.g., by promot-
ing phase advances and stabilization of the circadian system).
The aim of this study was to expand on previous ndings by eval-
uating the inuence of long-term aerobic exercise on polysomno-
graphic and subjective sleep measures, and on measures of quality
of lifeandmoodinindividuals diagnosedwithchronic primaryinsom-
nia. Additionally, the authors assessed whether these effects differed
between exercise in the morning and exercise in the late afternoon,
and whether sleep changes were associated with mood changes.
2. Materials and methods
2.1. Recruitment and sample selection
Ethical approval for all experimental procedures was granted by
the University Human Research Ethics Committee and conformed
to the principles outlined in the Declaration of Helsinki. The partic-
ipants were recruited through advertisements in newspapers,
magazines, and radio shows. The inclusion criteria were: (1) 30
55 years of age; (2) clinical diagnosis of primary insomnia accord-
ing to the Diagnostic and Statistical Manual of Mental Disorders
[1]; (3) complaints of insomnia for more than 6 months; and (4)
at least one complaint of daytime impairment due to insomnia
(in mood, cognition, or perceived fatigue). The exclusion criteria
were: (1) evidence that the insomnia was directly related to a
medical condition or to side-effects from medications; (2) use of
medications or psychotherapeutic drugs for insomnia or another
psychiatric disorder; (3) diagnosis of depression or another psychi-
atric disorder; (4) apnoeahypopnoea index >15; (5) periodic leg
movement index >15; (6) shift worker or all-night worker; (7) car-
diac abnormalities; and (8) regular physical exercise (more than
once per week) over the previous 6 months.
Prospective participants interested in participating in this re-
search were subjected to the following sequence of evaluations:
First, they received an initial screening over the telephone, com-
posed of questions related to the inclusion and exclusion criteria,
such as age, use of medications and the practice of physical exer-
cise. Next, prospective participants who appeared to be qualied
based on the telephone screening were invited to the laboratory
for a further interview and orientation to the study. Those who ap-
peared to be qualied were invited to sign a written informed con-
sent form approved by the Research Ethics Committee. During this
visit, participants also completed the Beck Depression Inventory
[22,23]. Next, prospective participants were assessed by a sleep
medicine physician to diagnose primary insomnia and exclude
other sleep disorders (see above).
Prospective participants who passed these initial screening
stages were randomized to either morning or late-afternoon exer-
cise groups (see below). The Research Ethics Committee at the study
institute strictlyprohibits the use of non-effective control or placebo
treatments, so assessments were limited to the effects of exercise
training on sleep and related morbidity in a sample of insomniacs.
Following screening, baseline study assessments were adminis-
tered. The participants were instructed to refrain from exercise
during the baseline assessments.
2.2. Baseline assessments
Following a 12-h fast, body composition was assessed in the
exercise laboratory of the Center of Psychobiology and Exercise
Studies. After a light breakfast, the participants completed the Pro-
le of Mood States (POMS) and Short Form-36 (SF-36) question-
naires. Following completion of the questionnaires, participants
received a clinical consultation and an electrocardiogram at rest
and under maximal stress during a cardiopulmonary exercise test
(CPET). The CPET was performed on a treadmill (Life Fitness 9500
HR, Illinois, USA) with an initial velocity of 4 km/h and increasing
increments of 0.5 km/h each minute until voluntary exhaustion.
Breath-by-breath assessments were made with a metabolic system
(Quark PFT4, Rome, Italy). The highest pulmonary oxygen uptake
(
_
V O
2
) value obtained during the last 20 s of the test was consid-
ered to be peak oxygen uptake (
_
V O
2
peak). Ventilatory threshold
(VT1) was estimated by inspecting the inection point of
_
V CO
2
with respect to
_
V O
2
(modied V slope). A certicate attesting to
the patients ability to participate in the exercise protocol was pro-
vided by the physician, and served as the nal screen for participa-
tion in the study.
Forty-eight hours after the completion of exercise testing, par-
ticipants underwent polysomnographic recording at the Sleep
Institute. This rst night served as an adaption night, and partici-
pants returned 48 h later for another night of polysomnography.
Participants arrived at the sleep laboratory at 21:00 h and the
examination started and nished according to each participantss
habitual sleep schedule. Participants left the Sleep Institute with
a 7-day daily sleep diary and instructions for completing the diary
each morning.
2.3. Six-month exercise protocol
Immediately after completion of the 1-week sleep diary, the
participants started the 6-month exercise intervention. Training
was performed in the exercise laboratory 3 days/week on a tread-
mill (Life Fitness HR 1500, Illinois, USA) for 50 continuous min/ses-
sion. Participants randomized to the morning group exercised at
10:00 1 h and participants randomized to the late-afternoon
group exercised at 18:00 1 h. All exercise sessions were per-
formed in groups (four or ve participants) in the presence of
one or two staff, and were preceded by 5 min of warm-up exercises
and followed by 5 min of active recovery and stretching of the
upper and lower limbs [24]. The participants did not listen to mu-
sic or watch television while they exercised. The intensity of exer-
cise was determined by the data obtained in the CPET. The speed
relative to VT1 [25,26] was used as the training intensity for both
groups. The intensity was controlled and monitored by means of
heart rate (5 beats/min), which was measured with a heart rate
monitor (Polar FS1, Kempele, Finland).
Post-treatment assessments of body composition,
_
V O
2
peak,
POMS, and SF-36 were initiated 48 h after the completion of exer-
cise training. As described above, polysomnographic recordings
were made 48 and 96 h after the completion of exercise training,
followed by 1 week of sleep diary assessments. Participants were
instructed not to exercise during this period. Thus, changes can
be attributed to long-term effects of exercise training rather than
acute exercise effects.
2.4. Measures
2.4.1. Body composition
Body composition was obtained through plethysmography with
the Bod Pod Body Composition System (Life Measurement Inc,
Concord, CA USA). This system includes an electronic scale, a ple-
thysmograph, a cylinder for calibration, and a computer with the
G.S. Passos et al. / Sleep Medicine 12 (2011) 10181027 1019
equipments software. The Bod Pod body composition system uses
total body densitometry, which is obtained from dividing the body
mass by the body volume of the individual. Through plethysmog-
raphy, it was possible to obtain the body fat percentage and free
fat mass [27].
2.4.2. Medical outcomes study SF-36 questionnaire
The SF-36 is a multidimensional questionnaire that covers eight
components: physical functioning, role limitations due to physical
health problems, role limitations due to emotional health prob-
lems, social functioning, vitality, general health perception, body
pain, and mental health. All scores ranged from 0 to 100, with a
higher score indicating better quality of life [28].
2.4.3. POMS questionnaire
The POMS questionnaire is an instrument to evaluate the acute
prole of mood. It has 65 items and 6 domains: tensionanxiety,
depression, angerhostility, vigouractivity, fatigue, and confu-
sionbewilderment. The total mood disturbance score is derived
by subtracting the vigouractivity score from the the sum of scores
from the other subscales [29].
2.4.4. Polysomnography
Polysomnographic recording included an electroencephalo-
gram, an electrooculogram, an electromyogram, and an electrocar-
diogram. Measurements of air ow (oral and nasal), respiratory
effort (thoracic and abdominal), body movement, and oxygen sat-
uration were also taken. The measured variables included total
sleep time, sleep efciency (ratio between total sleep time and to-
tal recorded time multiplied by 100), sleep onset latency, wake
after sleep onset, arousals, sleep stages (I, II, III, and IV of non-rapid
eye movement [non-REM] sleep and REM sleep), latencies for each
sleep stage (Stage 1, Stage 2, and Stages 3 and 4), and REM sleep
latency. Two researchers who were blinded to the study design
performed the staging and analysed the polysomnographic events
using international criteria [3032].
2.4.5. Sleep diary
The sleep diary was used to evaluate the subjective perceptions
of sleep. Participants were instructed to complete the diary every
morning after waking for 1 week. The parameters evaluated were
sleep onset latency, wake after sleep onset, total time in bed, num-
ber of arousals, sleep quality, feeling rested in the morning, and
sleep efciency (calculated retrospectively by the researchers as
the ratio of reported total sleep time and reported total time in
bed multiplied by 100 [9]). These data were averaged for each vol-
unteer for pre- and post-treatment assessment weeks.
2.5. Data analysis
STATISTICA Version 6.0 (Statsoft, Inc., Tulsa, USA) was used for
the analyses. For the variables that did not present normal distri-
butions in the Shapiro-Wilks test, a logarithmic transformation
(log10) was performed. Data were analysed via group x time
(two groups two times) repeated-measures analysis of variance
(ANOVA). Analysis of covariance was used for variables that dif-
fered signicantly between groups at baseline, with covariate con-
trol for baseline. Students t-test for independent groups was used
to compare the mean age of drop-outs and those who completed
the study.
Cohens effect size (d) was calculated for all variables for the
morning, late-afternoon, and combined data by subtracting the -
nal value from the initial value and dividing by the pooled standard
deviation. According to convention, effect sizes of 0.20.3, 0.5, and
P0.8 are considered small, medium, and large, respectively [33].
Spearman rank-order correlations were conducted to assess
whether changes in sleep between morning and late-afternoon
exercise were associated with changes in POMS measures and t-
ness level (
_
V O
2
peak and maximum heart rate [HR
max
]). The data
are presented as mean (SE). P < 0.05 was taken to indicate
signicance.
3. Results
3.1. Recruitment, drop-outs, and adherence to the exercise protocol
Two hundred and sixty-seven people were interested in taking
part in the study, and contacted the researchers by telephone or e-
mail. Of these, 229 did not meet the initial inclusion criteria and
were excluded (Fig. 1). Thirty-eight participants (29 women, 9
men) passed the initial screening and were randomized to the
morning exercise group (n = 19) or the late-afternoon exercise
group (n = 19). However, 3 men and 5 women withdrew from
the study during the baseline period before commencing exercise
training.
Thus, the exercise protocol began with 14 participants in the
morning exercise group and 16 participants in the late-afternoon
exercise group. However, during the protocol, 4 participants in
the morning exercise group (3 women, 1 man) and 7 participants
in the late-afternoon exercise group (6 women, 1 man) withdrew
from the study. Of these 11 participants (36.6%), 9 (30%) withdrew
due to problems with the programme schedule, which could not be
changed during the protocol. 6 (66.6%) of these nine drop-outs
were in the late-afternoon exercise group. In addition, one partic-
ipant withdrew after moving to a different city, and one participant
withdrew because of health problems. The mean age of drop-outs
was 42.5 (SE 3.1) years and the mean age of participants who com-
pleted the study was 45.0 (SE 1.9) years; the difference was not sig-
nicant (P = 0.47). As a result, the nal sample size was 10
participants in the morning exercise group and 9 participants in
the late-afternoon exercise group.
These 19 participants exhibited good adherence to the study
protocol (>90%), based on class attendance and spending >90% of
exercise time working at the prescribed intensity. Descriptive data
for these participants are displayed in Table 1. There were no sig-
nicant differences between the morning exercise group and the
late-afternoon exercise group for any of these measures.
3.2. Physiological parameters
No signicant differences in body composition were observed
following exercise training (Table 2). Signicant increases in
_
V
O
2
peak (P < 0.01, d = 1.30) and walking velocity (P < 0.001,
d = 3.32) were observed after the intervention. No signicant group
x time interaction was found for these physiological variables.
3.3. Quality of life
After exercise training, there were signicant increases and
large associated effect sizes for the following SF-36 measures: so-
cial functioning (P < 0.01, d = 1.95), general health perception
(P < 0.01, d = 1.46), and role limitations due to emotional health
problems (P < 0.001, d = 1.39). However, no signicant group x
time interaction was found for any of these variables. No signi-
cant time or group x time effects were found for the other SF-36
variables (Table 3), although there were large and moderate effect
sizes for improvement in bodily pain (d = 1.07) and mental health
(d = 0.74), respectively. Moreover, Chi-squared analyses revealed
no signicant differences between the morning-exercise group
1020 G.S. Passos et al. / Sleep Medicine 12 (2011) 10181027
and the late-afternoon exercise group for any of the SF-36
measures.
3.4. Mood
After exercise training, there were signicant improvements
and large associated effect sizes in the following POMS measures:
tensionanxiety (P < 0.01, d = 1.98), depression (P = 0.04,
d = 1.18), angerhostility (P = 0.03, d = 0.94), and total mood
disturbance (P = 0.04, d = 1.18) (Table 4). There were no signi-
cant group x time interactions for any of these variables, nor were
there any signicant Chi-squared results comparing the percentage
improvement between groups. No signicant time, group x time, or
Chi-squared effects were found for the other POMS measures,
although moderate to large effect sizes showed improvement for
fatigue (d = 1.34) and confusionbewilderment (d = 0.94).
3.5. Polysomnography
After exercise training, signicant reductions and large associ-
ated effect sizes were observed in the following polysomnographic
measures: sleep onset latency (P < 0.01, d = 0.96), Stage 2 latency
(P < 0.04, d = 1.21), and REM sleep latency (P < 0.001, d = 2.89).
In addition, exercise resulted in a signicant decrease in wake after
sleep onset (P = 0.04, d = 1.66), and a signicant increase in sleep
efciency (P < 0.01, d = 1.91). No signicant group x time effects
were found for any of these variables. A group x time interaction
was observed in Stage 1 sleep, demonstrating that the percentage
of sleep in this stage was reduced in the morning exercise group
and increased in the late-afternoon exercise group (Table 5). How-
ever, when the percentage of change was compared with Chi-
squared analysis, no signicant difference was found between
the groups. No signicant time, group x time, or Chi-squared ef-
fects were found for any of the other polysomnographic variables,
Patients assessed for
elegibility (n=267)
Patients excluded (n=229)
47 reported a previous diagnosis of depression
20 reported a diagnosis of other psychiatric disorders
39 practised systematic physical exercise
16 were shift workers
15 had AHI or PLMI >15
70 reported regular use of medication for insomnia
22 did not present evidence of insomnia at the time of
evaluation
Patients randomized
(n=38)
Morning group (n=19)
Drop-outs (n=5)
Late-afternoon group (n=19)
Post-intervention (n=10)
Pre-intervention (n=14)
Drop-outs (n=4)
Drop-outs (n=3)
Post-intervention (n=9)
Pre-intervention (n=16)
Drop-outs (n=7)
Fig. 1. Participant owchart. AHI, apnoeahypopnoea index; PLMI, periodic leg movement index.
Table 1
Baseline characteristics of the sample.
Variable Morning exercise
(n = 10)
Late-afternoon exercise
(n = 9)
Gender (male/female) 2/8 2/7
Age (years) 42.3 (2.6) 48.0 (2.5)
Duration of insomnia
(years)
10.2 (2.8) 11.1 (3.2)
Body mass index (kg/m
2
) 24.9 (1.7) 24.8 (1.4)
Beck Depression Inventory
(score)
9.5 (0.7) 9.1 (1.4)
Students t-test; P > 0.05; data presented as mean (standard error).
G.S. Passos et al. / Sleep Medicine 12 (2011) 10181027 1021
Table 2
Physical evaluation and physiological parameters.
ANOVA (P)
Variable Groups Pre-intervention Post-intervention Effect size Cohens d Group Time Group x time
Body mass (kg) Morning 63.0 (4.4) 62.2 (4.1) 0.14 ns ns ns
Late afternoon 63.0 (4.6) 62.3 (4.0) 0.12
Combined 63.0 (3.1) 62.2 (2.9) 0.13
Body fat (%) Morning 31.2 (3.6) 33.1 (3.0) 0.46 ns ns ns
Late afternoon 31.4 (3.6) 31.9 (3.0) 0.44
Combined 31.1 (2.3) 33.0 (2.1) 0.46
Free fat mass (%) Morning 68.8 (3.6) 66.9 (3.0) 0.46 ns ns ns
Late afternoon 68.6 (3.6) 68.1 (3.0) 0.45
Combined 68.9 (2.3) 67.0 (2.1) 0.46
_
V O
2peak
(ml/kg/min)
Morning 29.2 (2.0) 31.6 (2.3) 0.8 ns <0.01 ns
Late afternoon 26.0 (1.8) 30.7 (2.2) 2.06
Combined 27.7 (1.2) 31.1 (1.5) 1.3
HR
max
(beats/min) Morning 176.6 (3.3) 178.8 (4.5) 0.41 ns ns ns
Late afternoon 162.9 (3.5) 167.8 (4.7) 0.87
Combined 170.1 (2.8) 173.6 (3.4) 0.57
Speed at VT1 (km/h) Morning 5.6 (0.2) 6.5 (0.2) 2.76 ns <0.001 ns
Late afternoon 4.9 (0.2) 6.2 (0.2) 4.44
Combined 5.3 (0.2) 6.4 (0.1) 3.32
_
V O
2
at VT1, (ml/kg/min)
Morning 16.8 (1.1) 17.7 (1.3) 0.48 ns ns ns
Late afternoon 15.3 (1.2) 17.5 (1.3) 1.59
Combined 16.1 (0.8) 17.6 (0.9) 0.93
HR at VT1 (beats/min) Morning 118.9 (4.6) 117.4 (3.7) 0.33 ns ns ns
Late afternoon 111.6 (4.8) 122.9 (3.9) 1.69
Combined 115.4 (3.3) 120.0 (2.7) 0.78
Repeated-measures analysis of variance (ANOVA).
_
V O
2
, pulmonary oxygen uptake;
_
V O
2
peak, peak oxygen uptake; CF, cardiac frequency; HR, heart rate; HR
max
, maximum heart rate; VT1, ventilatory threshold 1; ns, not
signicant.
Morning exercise, n = 10; late-afternoon exercise, n = 9.
Data are displayed as mean (standard error). P < 0.05 taken to indicate signicance.
Table 3
Quality of life evaluated by the Short Form-36 Questionnaire.
ANOVA (P)
Variable Groups Pre-intervention Post-intervention Effect size Cohens d Group Time Group x time
Physical functioning Morning 87.5 (4.0) 88.5 (2.6) 0.19 ns ns ns
Late afternoon 92.8 (4.2) 92.8 (2.7) 0.24
Combined 90.0 (2.9) 90.0 (1.9) 0
Rolephysical Morning 87.5 (7.8) 82.5 (10.4) 0.48 ns ns ns
Late afternoon 83.3 (8.2) 80.5 (11.0) 0.35
Combined 85.5 (5.5) 80.5 (7.7) 0.39
Body pain Morning 62.7 (6.2) 68.8 (6.7) 0.64 0.04 ns ns
Late afternoon 74.0 (6.5) 91.7 (7.1) 1.86
Combined 68.0 (4.6) 78.5 (5.6) 1.07
General health perception Morning 74.8 (3.7) 89.1 (3.6) 2.71 ns <0.01 <0.01
Late afternoon 88.8 (3.9) 90.8 (3.8) 0.24
Combined 81.4 (3.1) 89.5 (2.7) 1.46
Vitality Morning 66.5 (6.0) 68.0 (4.6) 0.16 ns ns ns
Late afternoon 69.4 (6.4) 71.7 (4.8) 0.5
Combined 67.9 (4.3) 69.7 (3.4) 0.25
Social functioning Morning 80.6 (6.0) 86.2 (4.0) 0.81 ns <0.01 ns
Late afternoon 69.4 (6.7) 94.4 (4.2) 3.59
Combined 75.0 (4.7) 89.6 (3.1) 1.95
Roleemotional Morning 69.9 (11.4) 86.7 (8.1) 1.32 ns <0.001 ns
Late afternoon 70.4 (12.0) 91.6 (8.5) 1.56
Combined 70.1 (8.0) 88.9 (6.0) 1.39
Mental health Morning 76.4 (4.5) 79.6 (5.4) 0.4 ns ns ns
Late afternoon 76.0 (4.7) 83.1 (5.7) 1.29
Combined 76.2 (3.2) 81.3 (4.0) 0.74
Repeated-measures analysis of variance (ANOVA).
ns, not signicant.
Morning exercise, n = 10; late-afternoon exercise, n = 9.
Data are displayed as mean (standard error). P < 0.05 taken to indicate signicance.
1022 G.S. Passos et al. / Sleep Medicine 12 (2011) 10181027
although there were large effect sizes for increases in total sleep
time (d = 0.97), reduction in Stage 4 sleep (d = 0.97), and reduc-
tion in latency for Stages 3 and 4 (d = 1.35).
3.6. Sleep diary
After exercise training, there was a signicant decrease and a
large associated effect size in the sleep diary measure of sleep on-
set latency (P < 0.01, d = 1.25), and a signicant increase in the
sleep diary measures of sleep quality (P = 0.02, d = 1.92) and feeling
rested in the morning (P < 0.01, d = 1.70). No signicant group x
time effects were found for these variables. Chi-squared analysis
indicated that the proportion of improvement in sleep quality
was signicantly greater following morning exercise compared
with late-afternoon exercise (P = 0.03); the proportion of improve-
ment in feeling rested in the morning was also marginally greater
after morning exercise compared with late-afternoon exercise
(P = 0.06). No signicant effects were found for the other sleep
diary parameters (Table 6).
3.7. Correlation of POMS and tness level with sleep data
Signicant correlations were found between a decrease in
POMS-depression and improvements in the following sleep diary
measures: sleep quality (r = 0.58, P < 0.05), sleep onset latency
(r = 0.56, P < 0.05), and feeling rested in the morning (r = 0.81,
P < 0.05). However, there were no other signicant correlations be-
tween changes in POMS measures with changes in subjective or
objective sleep, or between the changes in sleep and changes in t-
ness level (
_
V O
2
peak and HR
max
).
4. Discussion
This study showed signicant improvements in objective and
subjective sleep, as well as quality of life and mood measures, fol-
lowing exercise training in individuals with chronic primary
insomnia. The results are consistent with other research showing
the benets of exercise training for individuals with disturbed
sleep.
Much of the research on the effects of exercise training on sleep
has focused on older adults, often under the assumption that exer-
cise may have the greatest potential to benet age-related sleep
disturbance. King et al. [34] found a reduction in self-reported
sleep onset latency and an increase in reported sleep duration in
older adults with sleep complaints following a 16-week pro-
gramme of moderate aerobic exercise. Another study of older
adults with sleep complaints performed by King et al. demon-
strated an increase in morning feeling of restfulness and a reduc-
tion in subjective sleep onset latency after a long-term exercise
intervention (12 months) [35]. Reid et al. [19] recently observed
improvements in self-reported sleep quality, depressive symp-
toms, and daytime sleepiness following a moderate 16-week aero-
bic exercise programme in individuals with primary insomnia.
Studies that have focused on nursing home or assisted living
residents, who typically have disrupted sleep, have reported mixed
results. For example, Alessi et al. [36] found that 9 weeks of exer-
cise had no effect on actigraphic sleep in nursing home residents.
Ferris et al. [37] found improvements in subjective sleep compared
with baseline following 3 months of circuit weight training, but not
following 6 months of training. However, exercise has helped to re-
duce fragmentation of the restactivity rhythm [38] as well as
mood disturbance in this population [39].
The present study found differences between subjective sleep
reports and polysomnographic measures, particularly for sleep on-
set latency and total sleep time. These data are consistent with
other studies which have reported that people diagnosed with pri-
mary insomnia often report worse sleep than can be veried with
objective sleep recordings [40,41].
Compared with the objective data, the subjective data are in
better agreement with the participants anecdotal accounts. The
anecdotal accounts indicated that the participants felt there had
been a remarkable improvement in sleep. It is worth noting that
subjective complaints are the primary means of dening insomnia,
and subjective feelings of improvement remain the primary means
of determining improvement clinically. Moreover, a limitation of
Table 4
Prole of Mood States questionnaire.
ANOVA (p)
Variable Groups Pre-intervention Post-intervention Effect size Cohens d Group Time Group x time
TA (score) Morning 7.7 (1.4) 4.8 (1.2) 1.39 ns <0.01 ns
Late afternoon 6.2 (1.5) 1.7 (1.4) 3.61
Combined 7.2 (1.0) 3.5 (1.0) 1.98
Depression (score) Morning 5.1 (1.8) 4.1 (1.4) 0.45 ns 0.04 ns
Late afternoon 6.5 (2.0) 2.0 (1.4) 2.68
Combined 5.9 (1.2) 3.3 (1.1) 1.18
AH (score) Morning 3.1 (2.3) 4.8 (1.2) 0.58 0.02 0.03 ns
Late afternoon 8.5 (2.5) 1.4 (1.3) 4.94
Combined 5.9 (1.7) 3.5 (1.0) 0.94
VA (score) Morning 18.7 (1.6) 17.6 (1.6) 0.47 ns ns ns
Late afternoon 19.9 (1.8) 18.6 (1.8) 0.47
Combined 19.3 (1.1) 18.1 (1.2) 0.52
Fatigue (score) Morning 6.4 (1.3) 5.1 (1.2) 0.66 ns ns ns
Late afternoon 6.5 (1.4) 3.4 (1.3) 2.64
Combined 6.5 (0.9) 4.2 (0.9) 1.34
CB (score) Morning 3.9 (1.4) 1.7 (1.2) 1.08 ns ns ns
Late afternoon 3.6 (1.6) 2.9 (1.4) 0.7
Combined 3.6 (1.0) 1.94 (0.9) 0.94
TMD (score) Morning 6.3 (7.0) 2.9 (6.1) 0.33 ns 0.04 ns
Late afternoon 11.5 (7.8) 7.2 (6.8) 3.14
Combined 9.2 (4.8) 1.7 (4.8) 1.18
Repeated-measures analysis of variance (ANOVA).
TA, tensionanxiety; AH, angerhostility; VA, vigouractivity; CB, confusion bewilderment; TMD, total mood disturbance; ns, not signicant.
Morning exercise, n = 10); late-afternoon exercise, n = 9.
Data are displayed as mean (standard error). P < 0.05 taken to indicate signicance.
G.S. Passos et al. / Sleep Medicine 12 (2011) 10181027 1023
the polysomnographic data in this study, and many other studies,
was that it was only assessed on one night, whereas the sleep diary
data were averaged over 1 week. Considering the high nightly var-
iability in sleep, particularly among individuals with insomnia
[42,43], several nights of assessment with actigraphic assessment
may be preferable for the detection of treatment effects.
Nonetheless, as subjective sleep data may be more susceptible
to various behavioural confounds (e.g., demand and expectancy
biases) than objective sleep data, demonstration of signicant
improvements in both objective and subjective sleep measures
provides perhaps the most compelling evidence of improvements
in sleep following exercise training. Previous studies of the effects
of exercise training on insomnia have generally been limited to
subjective measures. One notable exception by Guilleminault
et al. [18] examined changes in actigraphic and diary measures
of sleep following 4 weeks of moderate aerobic exercise in mid-
dle-aged adults with sleep complaints. The effects of exercise on
actigraphic measures were not signicantly different from the ef-
fects of a control sleep hygiene treatment, and the associated exer-
cise effect sizes (e.g., d for sleep onset latency = 036, d for wake
after sleep onset = 0.16) were smaller than those observed in
the present study, perhaps due to the relatively short duration of
this study.
The lack of a signicant increase in objective or subjective mea-
sures of total sleep time in the present study is inconsistent with
some [18,34], but not all, other research showing elevations in to-
tal sleep time following exercise training [35]. Notwithstanding
these ANOVA results, the large Cohens effect sizes observed for
Table 5
Sleep variables obtained with polysomnography.
ANOVA (P)
Variable Group Pre-intervention Post-intervention Effect size Cohens d Group Time Group x time
TST (min) Morning 352.5 (17.6) 355.3 (11.0) 0.16 ns ns ns
Late afternoon 316. 5 (18.6) 351.5 (11.6) 1.71
Combined 335.5 (13.1) 353.5 (7.7) 0.97
SOL (min) Morning 16.8 (3.7) 10.5 (1.9) 1.67 ns <0.01 ns
Late afternoon 17.4 (4.4) 6.7 (1.8) 2.46
Combined 17.1 (2.6) 8.7 (1.4) 2.06
LREM (min) Morning 100.0 (15.8) 68.7 (5.8) 2.23 ns <0.001 ns
Late afternoon 122.4 (18.4) 72.8 (6.3) 3.56
Combined 110.6 (11.4) 70.6 (3.7) 2.89
SE (%) Morning 83.8 (4.1) 89.6 (2.1) 1.68 ns <0.01 ns
Late afternoon 75.4 (4.9) 84.6 (2.7) 2.16
Combined 79.8 (3.0) 87.2 (1.6) 1.91
WASO (min) Morning 52.5 (17.7) 30.7 (7.8) 1.45 ns 0.04 ns
Late afternoon 75.2 (20.6) 50.5 (10.5) 1.82
Combined 63.2 (12.8) 40.1 (6.0) 1.66
Arousals (events/h) Morning 10.9 (2.7) 13.8 (2.3) 1.36 ns ns ns
Late afternoon 19.6 (3.8) 17.5 (3.2) 0.31
Combined 15.0 (2.2) 15.5 (1.7) 0.18
S1 (%) Morning 4.6 (0.6) 3.1 (0.7) 1.86 ns ns <0.01
Late afternoon 2.8 (0.6) 4.1 (0.9) 1.28
Combined 3.7 (0.5) 3.6 (0.5) 0.16
S2 (%) Morning 53.8 (2.3) 57.7 (2.3) 1.04 ns ns ns
Late afternoon 60.1 (1.5) 57.5 (2.2) 0.84
Combined 56.8 (1.8) 57.8 (1.6) 0.31
S3 (%) Morning 4.2 (0.6) 3.9 (0.5) 0.4 ns ns ns
Late afternoon 4.6 (0.5) 4.9 (0.4) 0.07
Combined 4.4 (0.4) 4.4 (0.4) 0
S4 (%) Morning 15.4 (1.5) 13.1 (1.4) 0.98 ns ns ns
Late afternoon 15.1 (1.2) 13.8 (1.3) 0.9
Combined 15.2 (1.1) 13.3 (1.0) 0.97
REM (%) Morning 22.0 (1.9) 22.1 (1.4) 0.02 ns ns ns
Late afternoon 17.3 (0.8) 19.8 (0.9) 2,02
Combined 19.8 (1.4) 21.0 (1.0) 0.51
AHI (events/h) Morning 8.5 (2.8) 9.1 (3.1) 0.15 ns ns ns
Late afternoon 10.0 (3.0) 10.1 (3.9) 0.28
Combined 9.2 (1.9) 9.6 (2.2) 0.21
PLMI (events/h) Morning 1.8 (1.5) 0.5 (2.0) 1.24 ns ns ns
Late afternoon 2.6 (1.6) 3.7 (2.1) 0.31
Combined 2.2 (1.1) 1.9 (1.5) 0.09
L1 (min) Morning 84.5 (36.2) 62.1 (32.8) 0.5 ns ns ns
Late afternoon 115.0 (44.2) 71.5 (38.3) 0.82
Combined 98.9 (25.8) 66.3 (24.2) 0.68
L2 (min) Morning 19.3 (7.3) 11.4 (4.6) 2.07 ns 0.04 ns
Late afternoon 29.8 (10.6) 16.2 (6.7) 1.04
Combined 24.3 (5.3) 13.7 (3.3) 1.21
L34 (min) Morning 43.2 (16.5) 28.5 (6.9) 1.52 ns ns ns
Late afternoon 73.4 (23.4) 39.4 (9.2) 1.4
Combined 57.5 (12.2) 33.7 (5.1) 1.35
Repeated-measures analysis of variance (ANOVA).
TST, total sleep time; SOL, sleep onset latency; LREM, REM sleep latency; SE, sleep efciency; WASO, wake after sleep onset; S1, Stage 1; S2, Stage 2; S3, Stage 3; S4, Stage 4;
REM, rapid eye movement; AHI, apnoeahypopnoea index; PLMI, periodic leg movement index; L1, Stage 1 latency; L2, Stage 2 latency; L34, Stages 3 and 4 latency; ns, not
signicant.
Morning exercise, n = 10); late-afternoon exercise, n = 9.
Data are displayed as mean (standard error). P < 0.05 taken to indicate signicance.
1024 G.S. Passos et al. / Sleep Medicine 12 (2011) 10181027
both objective (d = 0.97) and subjective (d = 0.96) total sleep time
following exercise training is noteworthy.
The effects of exercise on sleep in the present study were sim-
ilar to the effects reported in studies of other long-term, non-phar-
macological treatments for chronic insomnia, such as paradoxical
intention therapy [44], phototherapy and sleep hygiene [18], pro-
gressive relaxation [45], and cognitive behavioural therapy [46].
The participants of the present study presented a similar quality
of life as reported in previous studies of people with mildsevere
insomnia [19,4749]. Improvements in mood and quality-of-life
measures are consistent with a vast literature showing the psycho-
logical benets of exercise training [5053]. Moreover, the data are
consistent with studies that have shown psychological benets of
exercise in individuals with sleep disorders [19,54]. For example,
following exercise training, individuals with obstructive sleep ap-
noea showed similar reductions in POMS-total mood disturbance
and similar improvements in quality of life as reported in the pres-
ent study [54]. Likewise, compared with the results of the present
study, Reid et al. [19] observed similar improvements in SF-36
measures and depression following 16 weeks of moderate aerobic
exercise in patients with primary chronic insomnia. Singh et al.
[55] observed improvements in subjective sleep quality, depres-
sion, and quality of life following a supervised weight-training pro-
gramme three times a week.
It has been posited that exercise training may promote sleep via
its anxiolytic or antidepressant effects. The authors found some
support for this hypothesis insofar as decreases in POMS-depres-
sion scores were signicantly correlated with improvements in
the following sleep diary measures: sleep quality (r = 0.58,
P < 0.05), sleep onset latency (r = -0.56, P < 0.05), and feeling rested
in the morning (r = 0.81, P < 0.05). Moreover, in post-hoc analyses
in which change in POMS-depression was controlled as a covariate,
only the changes in the sleep diary measure of feeling rested in the
morning remained statistically signicant. The association be-
tween sleep improvement and improved mood is particularly
noteworthy in light of the fairly low levels of baseline depression
scores, which were the result of exclusion for a high score on the
Beck Depression Inventory or clinical depression.
Reid et al. [19] observed a signicant association between
improvements in depressive symptoms and improvements in sub-
jective sleep quality in insomniacs. However, in contrast with the
results of the present study, improvements in sleep persisted after
controlling for changes in depression in the study by Reid et al.,
suggesting an independent sleep-promoting effect of exercise in
their study. Further exploration of this issue is warranted.
Few differences were found between the benets of morning
and late-afternoon exercise on sleep, mood, and quality-of-life
measures in this sample of insomniacs. Moderate to large effect
sizes were found for many of the sleep and mood, variables (and
some of the SF-36 variables) following morning and late-afternoon
exercise [33]. The data suggest that either morning or late-after-
noon exercise is benecial for patients with chronic primary
insomnia. There were more drop-outs in the late-afternoon exer-
cise group compared with the morning exercise group, but this
may have been related to logistical features of the study, such as
the fact that the journey to the laboratory took over 1 h for many
of the participants.
The drop-out rate of 30% following commencement of exercise
training, mainly due to scheduling problems, is consistent with
other long-term exercise interventions. The inability to choose
the time of exercise may have hindered adherence, as many indi-
viduals have a clear preference for the time of day for exercise. Bet-
ter adherence may be accomplished with either greater exibility
in training times or home-based interventions.
The present study had several notable limitations. First, without
a control treatment, it cannot be ascertained whether the results
were inuenced by a number of potential confounds associated
with participating in the study, including demand or expectancy
effects associated with recruiting for an exercise study for insom-
nia, social interaction between the participants and with staff,
and spontaneous remission. Moreover, the exercise training was
performed in front of large windows with a beautiful view of the
city, so the results may be partly explained by increased exposure
to bright light, which can have sleep and mood-promoting effects.
Post-hoc assessments of laboratory light levels at the exercise
times indicated 800 lux in the late afternoon and 500 lux in the
Table 6
Sleep variables obtained from the sleep diary (mean 7 days).
ANOVA (P)
Variable Groups Pre-intervention Post-intervention Effect size Cohens d Group Time Group x time
TST (h) Morning 4.8 (0.7) 6.2 (0.7) 1.65 ns ns ns
Late afternoon 5.5 (0.6) 5.5 (0.6) 0.00
Combined 5.1 (0.5) 5.7 (0.4) 0.56
TTB (h) Morning 6.5 (0.6) 7.1 (0.4) 1.03 ns ns ns
Late afternoon 7.3 (0.5) 7.0 (0.4) 0.42
Combined 6.8 (0.4) 6.9 (0.2) 0.00
SOL (min) Morning 59.5 (31.7) 25.9 (17.7) 3.09 ns <0.01 ns
Late afternoon 83.0 (27.5) 39.6 (15.3) 1.24
Combined 76.2 (21.5) 35.2 (12.1) 1.25
SE (%) Morning 79.1 (8.0) 86.3 (8.5) 1.1 ns ns ns
Late afternoon 76.9 (7.0) 80.3 (7.4) 0.24
Combined 78.5 (5.4) 83.1 (5.9) 0.5
Arousals (events/h) Morning 1.4 (0.5) 1.3 (0.5) 0.19 ns ns ns
Late afternoon 1.8 (0.5) 1.8 (0.4) 0.22
Combined 1.6 (0.3) 1.5 (0.3) 0.18
SQ (%) Morning 38.9 (7.9) 65.9 (9.9) 2.9 ns 0.02 ns
Late afternoon 43.8 (7.3) 54.4 (9.2) 0.49
Combined 41.5 (5.2) 59.4 (6.6) 1.92
FRM (%) Morning 41.9 (7.3) 62.9 (7.7) 2.23 ns 0.01 ns
Late afternoon 58.5 (6.7) 67.1 (7.1) 0.71
Combined 50.8 (5.3) 65.1 (5.0) 1.7
Repeated-measures analysis of variance (ANOVA).
TST, total sleep time; TTB, total time in bed; SOL, sleep onset latency; SE, sleep efciency; SQ, sleep quality; FR, feeling rested in morning; ns, not signicant.
Morning exercise, n = 10); late-afternoon exercise, n = 9.
Data are displayed as mean (standard error). P < 0.05 is taken to indicate signicance.
G.S. Passos et al. / Sleep Medicine 12 (2011) 10181027 1025
morning. However, it is unclear whether light had any impact on
the dependent variables, as these light levels are far below those
generally prescribed for depression, and it is unclear whether the
intervention had any impact on 24-h light exposure. Future re-
search should explore these issues more carefully.
Second, since interim data were not assessed, it is unclear how
long the intervention needs to be in order to produce these effects.
Third, post-training improvements in sleep may have been attenu-
atedby requiredinactivityfor 13 days after the study, as withdrawal
from regular exercise can elicit sleep impairments [56]. Fourth,
although drop-outs mainly complained about scheduling conicts,
it is plausible that theyalso respondedless positivelyto the exercise,
such that their removal from the study resulted in a positive bias.
Fifth, without statistical correction for multiple testing, some of
the signicant results may be attributed to Type I error.
Notwithstanding these limitations, the results suggest that
long-term moderate aerobic exercise, performed in the morning
or late afternoon, improves sleep (objective and subjective), mood,
and quality of life in patients with chronic primary insomnia. These
results are consistent with the results of other studies, indicating
that physical exercise may be a good non-pharmacological treat-
ment alternative for patients with chronic primary insomnia.
Conicts of Interest
The ICMJE Uniform Disclosure Form for Potential Conicts of
Interest associated with this article can be viewed by clicking on
the following link: doi:10.1016/j.sleep.2011.02.007.
Acknowledgements
The authors would like to thank all participants who volun-
teered their time to take part in the study. Giselle Soares Passos
had a fellowship from the FAPESP (2008/02862-1). The authors
would like to thank the institutions that made this manuscript pos-
sible: AFIP, FAPESP, CEPID/FAPESP, CEPE and FADA/UNIFESP.
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