EXERCISE IN SLEEP DISORDERS

APRIL 2011

DELHI PSYCHIATRY JOURNAL Vol. 14 No.1

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 today’s 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 person’s 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 problems2-4. Stanford University School of Medicine researchers 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

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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 increasing 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 don’t 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 cause obstructive sleep apnea. If neck and 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 body’s production of endorphins, which create a sense of wellbeing and reduce anxiety spells that interfere in restful sleep. Exercise can improve sleep quality without the potential side effects of sleep medications.

Sleep and Health Effects of Sleep Deprivation Without adequate sleep, the brain’s 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 complaint, after pain, in the primary care settings1. It is defined as the experience of inadequate/poor quality sleep, difficulty in initiating sleep and/or maintaining sleep, and sleep that is not restorative and/or refreshing1,3. Insomnia is the most common sleep disorder. Psychophysiological insomnia, a subcategory of insomnia, is the most extensively researched sleep disorder 4 . Patients with insomnia often have symptoms like tension, anxiety, depression, fatigue and irrita134

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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 frontalis7,1113 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 medications and pharmacological agents 14-16 associated though with disadvantages 17,18 , side-effects19-22 , tolerance17,22 and rebound effects at withdrawal2226 . 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, stationary bicycle, jumping rope, dancing, kick-boxing, etc. These exercises involve vigorous use of leg muscles and the fatigue produced acts as a tranquilizer. The most beneficial time to exercise for insomniacs is in the late afternoon or early evening.


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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 6month 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

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 woman’s 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 diaphragm 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 night’s sleep. Sleep relaxation techniques decrease the wear and tear on the mind and body and reduce stress symptoms. In general, relaxation techniques involve refocusing the attention to something calming and increasing awareness of the body. 136

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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 technique, 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 progressively 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 doesn’t necessarily matter which relaxation technique one choose, only that to practice relaxation regularly to reap benefits. These techniques are skills, and the ability to relax improves with practice. Don’t let the effort to practice these techniques become yet another stressor. References 1. Malhowald MW, Kader G, Schenck CH. Clinical categories of sleep disorders I. Continuum 1997; 3(4) : 35-65. 2. Stoller MK. Economic effects of insomnia. Clin Ther 1994; 16(5) : 873-897. 3. Vgontzas AN, Chrousos GP. Sleep, the hypothalamicpituitary-adrenal axis, and cytokines: multiple interactions and disturbances in sleep disorders. Endocrinol Metab Clin North Am 2002; 31 : 15-36. 4. NIH Consenss Development Conference Summary. Drugs and insomnia: the use of medication to promote sleep. JAMA 1984; 251(18) : 2410-2414. 5. Hrayr AP. Epidemiology of Insomnia. In Clinical Handbook of Insomnia (Hrayr P. Attarian, ed) Humana Press, 2004; pp.11-21. 6. Bonnet MH, Arand DL. Physiological Basis of Insomnia. In Clinical Handbook of Insomnia (Hrayr P. Attarian, ed) Humana Press, 2004;


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pp23-38. 7. Haynes SN, Follingstad DR, McGowen WT. Insomnia: Sleep patterns and anxiety level. J Psychosom Res 1974; 18 : 69-74. 8. Haynes SN, Adams A, Franzen M. The effects of presleep stress on sleep-onset insomnia. J Abn Psychol 1981; 90 : 601-606. 9. Hall M, Buysse DJ, Nowell PD, Nofzinger EA, Houck P, Reynolds CF et al. Symptoms of stress and depression as correlates of sleep in primary insomnia. Psychosom Med 2000; 62 : 227-30. 10. Monroe LJ. Psychological and physiological differences between good and poor sleepers. J Abn Psychol 1967; 72 : 255-264. 11. Freedman RR, Sattler HL. Physiological and psychological factors in sleep-onset insomnia. JAbn Psychol 1982; 91 : 380-389. 12. Freedman RR. EEG power spectra in sleeponset insomnia. Electroencephal. Clin Neurophysio 1986; 63 : 408-413. 13. Perlis ML, Kehr EL, Smith MT, Andrews PJ, Orff H, Giles DE. Temporal and stagewise distri-bution of high frequency EEG activity in patients with primary and secondary insomnia and in good sleeper controls. J Sleep Res 2001; 10 : 93-104. 14. Kirkwood CK. Management of insomnia. J Am Pharm Assoc1999; 39 : 688-96. 15. Wysowski DK, Baum C. Outpatient use of prescription sedative-hypnotic drugs in the United States, 1970 through 1989. Arch Intern Med 1991; 151 : 1779-83. 16. Walsh JK, Schweitzer PK. Ten-year trends in the pharmacological treatment of insomnia. Sleep 1999; 22 : 371-75. 17. Morin CM, Wooten V. Psychological and pharmacological approaches to treating insomnia: Critical issues in assessing their separate and combined effects. Clin Psychol Rev 1996; 16 : 521-42. 18. Nowell PD, Buysse DJ, Morin CM, Reynolds CF. Effective treatments for selected sleep disorders, In: Nathan PE, Gorman JM, editors. A guide to treatments that work. New York, NY: Oxford University Press; 1998; p.531-43. 19. Holbrook AM, Crowther R, Lotter A, Cheng C, King D. Meta-analysis of benzodiazepine use in the treatment of insomnia.CMAJ 2000; 162 : 225-33. 20. Gillin JC, Byerley WF. Drug therapy: The diagnosis and management of insomnia. N Eng

J Med 1990; 322 : 239-48. 21. Gillin JC. The long and the short of sleeping pills. N Eng J Med 1991; 324 : 1735-36. 22. Costae Silva JA. Foreward (to reports from the International Consensus Conference on Insomnia, 10/11/96, Paris). Sleep 1999; 22 : S416. 23. Soldatos CR, Dikeos DG, Whitehead A. Tolerance and rebound insomnia with rapidly eliminated hypnotics: a meta-analysis of sleep laboratory studies. Int Clin Psychopharmacol 1999; 14 : 287-303. 24. Hajak G, Clarenbach P, Fischer W, Roden-beck A, Bandelow B, Broocks A. et al. Rebound insomnia after hypnotic withdrawal in insomniac outpatients. Eur Arch Pschiatry Clin Neurosci 1998; 248 : 148-56. 25. Lader M. Withdrawal reactions after stopping hypnotics in patients with insomnia. CNS Drugs 1998; 10 : 425-40. 26. Espie CA, Lindsay WR, Brooks DN. Substituting behavioural treatment for drugs in the treatment of insomnia: an exploratory study. J Behav Ther Exp Psychiatry1988; 19 : 51-56. 27. Bonnet MH, Arand DL. Heart rate variability in insomniacs and matched normal sleepers. Psychosom Med 1988; 60 : 610-615. 28. John MW, Gay TJA, Masterton JP, Bruce DQ. Relationship between sleep habits, adrenocrortical activity and personality. Psychosom Med 1971; 33 : 499-508. 29. Mendelson WB, Garnett D, Gillin CG, Weingarner H. The experience of insomnia and daytime and nighttime functioning. Psychiatr Res 1984; 12 : 235-250. 30. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle aged adults. New Engl J Med. 1993; 328 : 1230-5. 31. Young T, Skatrud J, Peppard PE. Risk factors for obstructive sleep apnea in adults. JAMA. 2004; 291 : 2013-6. 32. Norman JF, Von Essen SG, Fuchs RH, McElligot M. Exercise training effect on obstructive sleep apnea syndrome. Sleep Res Online. 2003; 3 : 121-9. 33. Malhotra A, White DP. Obstructive sleep apnea. Lancent. 2002; 360(9328) : 237-47. 34. Lamarche CH, Ogilvie RD. Electrophysiological changes during the sleep onset period of psychophysiological insomniacs, psychiatric insomniacs, and normal sleepers. Sleep 1997; 20 : 724-33.


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