Should certain forms of physical activity be considered as a primary treatment strategy for poor sleep?
Yoga, Tai Chi, walking and jogging may improve sleep quality and ease insomnia – findings that have the potential to change Australian clinical guidelines.
Characterised by early morning awakening and difficulties falling and staying asleep, insomnia is associated with heightened risks of various mental and physical health conditions, including dementia and cardiovascular disease.
Exercise is not currently included in the RACGP Handbook of Non-Drug Interventions (HANDI) for the treatment of insomnia.
But Chinese researchers have now found that when compared to existing treatments, yoga increased total sleep time by nearly two hours and improved sleep efficiency by nearly 15%.
It also cut time spent awake after falling asleep by nearly an hour and shortened sleep latency by around 30 minutes.
Tai Chi increased total sleep time by almost an hour and reduced time spent awake throughout the night by over half an hour. It also reduced poor sleep quality scores by more than four points and shortened sleep latency by around 25 minutes.
Insomnia severity was reduced by nearly 10 points from walking or jogging.
The comparative pooled meta-analysis of 22 randomised clinical trials included nearly 1400 participants and 13 different treatment approaches, seven of which were exercise based.
Other approaches in the studies included CBT, sleep hygiene, Ayurveda, acupuncture or massage, existing treatment or no treatment. The programmes ranged from between four and 26 weeks in length.
Two validated sleep scoring systems were used: the Pittsburgh Sleep Quality Index (PSQI) and the Insomnia Severity Index (ISI45). Subjective measures included total sleep time, sleep latency (time taken to fall asleep), sleep efficiency (percentage of time in bed spent asleep) and number of wake ups throughout the night.
Researchers told the media that insomnia can affect up to 22% of the population, and drug treatments are not without side effects. Cognitive behavioural therapy (CBT) is the gold standard treatment but is not always accessible, they said.
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Professor Paul Glasziou, chair of the HANDI project team and emeritus professor of evidence-based practice at Bond University, told TMR that the analysis was completed to a good standard.
“We will consider for HANDI, but note that many outcomes are low quality evidence, and none appear better than CBT,” he said.
The study showed that CBT resulted in the largest increase in total sleep time. This was based on subjective sleep diary data and compared to existing treatment. Professor Glasziou noted CBT had a larger effect size and narrower confidence intervals than any types of exercise, and higher quality evidence supporting its use in insomnia.
Improvements to sleep efficiency and sleep latency from CBT were also sustained over various follow-up periods, the researchers noted.
Suggested mechanisms of yoga to ease insomnia included the potential alleviation of anxiety and depressive symptoms that often interfere with sleep by focussing on body awareness, controlled breathing and attentional training.
Tai Chi, which emphasises breath control and physical relaxation, has been shown to decrease sympathetic nervous system activity and dampen hyperarousal, researchers explained. The combination of meditative movement and mindfulness may promote emotional regulation and curb the production of inflammatory chemicals.
Further analysis showed that Tai Chi performed significantly better on all assessed outcomes, both subjective and objective, than existing treatments for up to two years.
Researchers explained that walking or jogging may reduce insomnia severity by increasing energy expenditure, regulating cortisol, improving emotional regulation, boosting melatonin secretion and enhancing the amount of deep sleep.
The research did have limitations, such as a lack of standardised quantifiable metrics for the frequency or intensity of exercise. Some sample sizes were small and 68% of the trials had flaws in design or methodology.
Despite this, researchers concluded that exercise interventions have therapeutic potential as a primary treatment strategy for poor sleep patterns.
“Although current clinical guidelines make only limited mention of exercise, this study provides relatively comprehensive comparative evidence that may inform the development of more specific and actionable clinical recommendations,” they said.
“Given the advantages of exercise modalities such as yoga, Tai Chi, and walking or jogging—including low cost, minimal side effects, and high accessibility—these interventions are well-suited for integration into primary care and community health programmes.”
