APRIL 2011
Newer Development
Exercise in Sleep Disorders
Jasvinder Kaur, Charu Sharma
Department of Physiotherapy, Dr. RML Hospital & PGIMER, New Delhi
A healthy amount of sleep is paramount to
living a healthy life. Good quality sleep is an
important part not only for living healthy but also
for leading a productive life, physically and
mentally. Chronic sleep restriction in todays
demanding lifestyle, however, is very common 1 .
Sleep deprivation and other sleep disorders can have
serious effects on health.
Research shows that all mammals need sleep,
and that sleep regulates mood and is related to
learning and memory functions. Inadequate rest
impairs a persons ability to think, handle stress,
maintain a healthy immune system and control
emotions.
People who regularly engage in exercise have
fewer episodes of sleeplessness. Exercise promotes
improved sleep quality by allowing smoother and
more regular transition between the cycles and
phases of sleep. Moderate exercises lasting 20 to
30 minutes four to five times a week helps in
sleeping better.
Vigorous exercise during the day and mild
exercise at bedtime not only aids in falling asleep
easily but also increases the amount of time spent
in deepest stage 4 sleep. For some people, exercise
alone is sufficient to overcome their sleep prob-
lems2-4.
Stanford University School of Medicine resear-
chers studied the effects of exercise on the sleep
patterns of adults aged 55 to 75 years who were
sedentary and troubled by insomnia. These adults
were asked to exercise for 25 to 30 minutes every
other day in the afternoon by walking, engaging in
low-impact aerobics, and riding a stationary bicycle.
The result showed that time required to fall asleep
was reduced by half, and sleep time increased by
almost one hour.
Benefits of Exercise in Sleep Disorders
Exercise improves sleep by producing a
significant rise in body temperature,
followed by a compensatory drop a few
Delhi Psychiatry Journal 2011; 14:(1) Delhi Psychiatric Society
DELHI PSYCHIATRY JOURNAL Vol. 14 No.
hours later. The drop in body temperature,
which persists for 2 to 4 hours after
exercise, makes it easier to fall asleep and
stay asleep.
Exercise improves sleep by acting as a
physical stressor to the body. The brain
compensates for physical stress by increas-
ing deep sleep.
Increased flexibility with stretching: You
become less flexible once you get older.
Your flexibility has an impact on your
breathing muscles and the muscles that
support your structure. It will be harder to
breathe if muscles of chest and abdomen
are less flexible. Exercise and stretching
helps your breathing muscles flexibility
which reduces snoring.
Improved lung capacity: If you do not
exercise regularly, your lung capacity
reduces over time in response to the lower
need. Full breathe takes effort but fuller the
size of breathe, the easier it is to breathe in
your normal range. If you dont keep your
capacity up then it falls finally to a level
where your full capacity is your normal
breathe and even normal breathing
becomes forced and difficult.
Toned muscles: If you exercise more
including breathing muscles, they become
more toned. If you breathe more through
your nose, it is easier to breathe through
your nose and your nasal passages are less
likely to collapse.
Balanced muscles: Due to unbalanced
muscle groups, airways get collapsed and
causeobstructivesleepapnea.Ifneckand
throat muscles become unbalanced, it can
lead to snoring and sleep apnea.
Exercise and stretching means more
balanced muscles. Neck length and size are
related to snoring. If you have short or thick
neck, you are more likely to snore.
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Exercise increases the bodys production
of endorphins, which create a sense of well-
being and reduce anxiety spells that
interfere in restful sleep.
Exercise can improve sleep quality without
the potential side effects of sleep medica-
tions.
Sleep and Health
Effects of Sleep Deprivation
Without adequate sleep, the brains ability to
function can quickly deteriorate. Insufficient rest
can even cause hallucinations and contribute to
anxiety disorders and other psychiatric problems.
Possible effects of sleep deprivation include:
Excessive daytime sleepiness
Fatigue
Slower reaction times
Irritability
Impaired physical and mental performance
Depression
Heart disease
Hypertension
Obesity
Types of Sleep Disorders
According to the American Academy of Sleep
Medicine, 81 different sleep disorders exist, some
of the common types are:
Insomnia
Sleep apnea
Snoring
Sleep walking
Narcolepsy
Night terrors
REM sleep behavior disorder
Restless leg syndrome
Insomnia
Insomnia is the second most common complai-
nt, after pain, in the primary care settings1. It is
defined as the experience of inadequate/poor quality
sleep, difficulty in initiating sleep and/or maintain-
ing sleep, and sleep that is not restorative and/or
refreshing1,3. Insomnia is the most common sleep
disorder. Psychophysiological insomnia, a subcate-
gory of insomnia, is the most extensively researched
sleep disorder 4 .
Patients with insomnia often have symptoms
like tension, anxiety, depression, fatigue and irrita-
134 Delhi Psychiatry Journal 2011; 14:(1) Delhi Psychiatric Society
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bility5-7. Frequently, insomnia begins in conjunction
with significant stress8,9. A study results showed
increased rectal temperature, heart rate, basal skin
resistance and phasic vasoconstriction 30 minutes
before sleep and during sleep in patients with
insomnia as compared to normal sleepers10. Thus,
it has been hypothesized that insomnia can develop
entirely from physiological activation.
Other studies have shown that patients with
problems falling asleep had increased frontalis7,11-
13
and mentalis electromyogram (EMG) 12,13 ,
increased heart rate10, increased finger temperature
and more beta and less alpha frequencies in
electroencephalo-gram(EEG).
The primary treatment of insomnia is medica-
tions and pharmacological agents 14-16 associated
though with disadvantages 17,18 , side-effects19-22 ,
tolerance17,22 and rebound effects at withdrawal22-
26
. Drug therapy does not address the underlying
etiological and perpetuating factors.
Insomnia improves with regular exercise,
according to a report from the American Academy
of Sleep Medicine (2008). Moderate exercise seems
to help reduce anxiety that interferes with sleep.
Exercises aid sleep by releasing tension and
contributing to a drop in body temperature that
makes it easier to fall asleep.
Exercise Options for Insomniacs
Insomniacs lead more sedentary lives than good
sleepers. The lack of physical activity can contribute
to insomnia by inhibiting the daily rise and fall of
the body-temperature rhythm. As a result, many
people get caught in a cycle of insomnia, reduced
energy and physical activity, and worsened
insomnia27-29.
Aerobic exercises are the best to combat
sleeplessness. These cardiovascular exercises
increase the amount of oxygen that reaches the
blood. To get maximum benefit, aim for some type
of cardiovascular exercise at least 4 to 5 times a
week, and for 20 to 30 minutes. Examples of aerobic
exercises are walking, jogging, swimming, station-
ary bicycle, jumping rope, dancing, kick-boxing,
etc. These exercises involve vigorous use of leg
muscles and the fatigue produced acts as a tranqui-
lizer.
The most beneficial time to exercise for
insomniacs is in the late afternoon or early evening.
APRIL 2011
This raises body temperature above normal a few
hours before bed, allowing it start falling just prior
to bed-time. Decrease in body temperature triggers
sleep.
Sleep Apnea
Sleep apnea is believed to affect at least 1 out
of every 200 Americans, 70 to 90 percent of them
men, mostly middle-aged and over weight. The most
common form of this disorder is Obstructive Sleep
Apnea (OSA), a serious health issue strongly
associated with excess body weight. OSA is a
common syndrome that has been estimated to affect
4% of middle-aged men and 2% of middle-aged
women, with prevalence increasing with age30-32.
The pathophysiology of OSA involves repeated
complete or partial obstruction of the upper airway
during sleep, with associated brief arousals leading
to significant sleep fragmentation.
Patients with OSA often have symptoms like
loud and intermittent snoring, choking sensation
during sleep, early morning headache, extreme
daytime sleepiness and other consequences of sleep
disruption such as impairments in cognitive
function33,34. During an apnea attack, the snorer may
seem to gasp for breath, and oxygen level in the
blood may become abnormally low.
Exercise Options in Sleep apnea
Exercise can be an effective mechanism for
reducing the severity of OSA both in association
with, and independent of, reduction in body weight.
Increased exercise has been suggested as a potential
intervention for OSA, particularly for patients with
mild to moderate clinical severity.
Norman et al32 evaluated the effects of a 6-
month exercise program in the management of
individuals with OSA and found significant post
training improvements in weight, body mass
index(BMI), apnea-hypopnea index(AHI), total
sleep time, sleep efficiency and arousal index.
Minimizing weight gain and promoting weight loss
is the critical strategy in the management of OSA.
Aerobic and endurance exercises that help in
reducing body fat are most effective for weight loss.
Also, incorporate light weight lifting and stretching
pre and post workout into exercise program to get
the most benefit.
A study has shown that exercising muscles in
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DELHI PSYCHIATRY JOURNAL Vol. 14 No.1
the upper airway may help improve the symptoms
of moderate OSA32,33 . A set of oropharyngeal
exercises is a promising alternative for the treatment
of moderate OSA.
Performing breathing exercises is one treatment
technique which strengthens the throat muscles,
reducing sleep apnea symptoms. People who suffer
from heart problems, hypertension, panic attacks,
or migraine headaches should avoid any breath
holds.
Women and Sleep Disorders
Women experience sleep difficulties more
frequently than men, according to the National
Sleep Foundation. A complex interaction between
sleep and hormones causes some of the sleep
disorders in women. During pregnancy, sleep levels
and patterns need to change dramatically to
accommodate the physical and hormonal changes
taking place in a womans body. Possible pregnancy
sleep disorders include snoring, sleep apnea and
restless leg syndrome.
Sleep and menopause symptoms are also
related, with many women experiencing sleep
problems due to hot flushes and night sweats.
Disrupted sleep and hormones that are in a state of
transition can cause mood swings and depression34.
Regular physical exercise activates endocrine
system and helps to reduce mood swings caused by
hormonal fluctuation in women. Furthermore,
relaxation techniques and breathing exercises
reduce stress symptoms.
Old age and Sleep Disorders
Sleep problems become more common with
age. The American Academy of Family Physicians
(1999) reports over 50 percent of people 65 years
old and older live with the effects of sleep disorders,
such as sleep deprivation symptoms, sleep apnea
and periodic limb movement disorder. Regular
exercise not only decreases the sleep deprivation
symptoms but also increases life expectancy and
improves overall health. A daily walk lasting for
about 20 to 30 minutes is recommended for geriatric
population with sleep disorders. Physical exercise,
taken regularly, may promote relaxation and raise
core body temperature in ways that are beneficial
to initiate and maintain sleep.
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Breathing Exercises in Sleep Disorders
Quiet Mind and Body
Learning to do deep breathing exercises helps
to shift the mind away from worrisome thoughts.
Deep breathing often feels backward to many
people so it takes concentration to master. Taking
slow deep breaths also sends signals to the brain
that you are calm, which in turn can slow down
your heart rate and nervous activity.
Breathe Correctly
The idea is to focus on allowing your
diaphragm to drop when you inhale so your lungs
can fully expand. You then want to allow the dia-
phragm to rise as you exhale, which will compress
the lungs and push the air out as you breathe out.
Nasal Breathing
Breathing through the nose is physiologically
more relaxing for the body. Your nasal cavity is
especially designed to warm and filter air you
inhale. The mouth does not have these same
structures. Breathing through the nose allows your
body to process the air more efficiently, which will
slow down the activity of your heart and nervous
system.
The Technique
Inhale through your nose and allow the belly
to move outward. As the abdomen moves out, room
is created for the diaphragm to drop. Then exhale
through the nose and let the belly move inward so
the diaphragm presses up. If you are dealing with
sinus or respiratory issues, try breathing in through
the nose and exhaling through pursed lips.
Focus Attention
To help slow down the mind to encourage sleep,
keep your attention on the movement of the breath.
Make each breath a little slower and a little deeper.
With each exhale, allow your body to feel heavy
and sink into the bed.
Relaxation Techniques
In the face of sleep disorders, relaxation
techniques are the key to a good nights sleep. Sleep
relaxation techniques decrease the wear and tear
on the mind and body and reduce stress symptoms.
In general, relaxation techniques involve re-
focusing the attention to something calming and
increasing awareness of the body.
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Health Benefits of Relaxation Techniques:
Slowing the heart rate and breathing rate
Lowering blood pressure
Increasing blood flow to major muscles
Reducing muscle tension and chronic pain
Boosting confidence to handle problems
Improving concentration
Types of Relaxation Techniques
Autogenic relaxation: In this relaxation techni-
que, both imagery and body awareness is used to
reduce stress. Repeat words or suggestions in the
mind to relax and reduce muscle tension. Imagine
a peaceful place and then focus on controlled,
relaxing breathing, slowing the heart rate, or feeling
different physical sensations, such as relaxing each
arm or leg one by one.
Progressive muscle relaxation: Start by tensing
and relaxing the muscles in the toes and progre-
ssively work up to the neck and head. Tense the
muscles for at least 5 seconds, then relax for 30
seconds, and repeat. Focus on slowly tensing and
then relaxing each muscle group, becoming more
aware of physical sensations.
It doesnt necessarily matter which relaxation
technique one choose, only that to practice relaxa-
tion regularly to reap benefits. These techniques
are skills, and the ability to relax improves with
practice. Dont let the effort to practice these techni-
ques become yet another stressor.
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