Accepted Manuscript

Effects of acute morning and evening exercise on subjective and objective sleep
quality in older individuals with insomnia

Yuko Morita, Taeko Sasai-Sakuma, Yuichi Inoue

PII: S1389-9457(17)30150-8
DOI: 10.1016/j.sleep.2017.03.014
Reference: SLEEP 3356

To appear in: Sleep Medicine

Received Date: 12 September 2016

Revised Date: 26 January 2017
Accepted Date: 8 March 2017

Please cite this article as: Morita Y, Sasai-Sakuma T, Inoue Y, Effects of acute morning and evening
exercise on subjective and objective sleep quality in older individuals with insomnia, Sleep Medicine
(2017), doi: 10.1016/j.sleep.2017.03.014.

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 ACCEPTED MANUSCRIPT
Effects of acute morning and evening exercise on subjective and objective sleep quality in older individuals with

insomnia

Yuko Morita a, Taeko Sasai-Sakuma b,c, Yuichi Inoue b,d,*

a
Department of Liberal Arts, Faculty of Science and Technology, Tokyo University of Science, Chiba, Japan
b
Department of Somnology, Tokyo Medical University, Tokyo, Japan

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c
Department of Life Sciences and Bioinformatics, Division of Biomedical Laboratory Sciences, Graduate

School of Health Sciences, Tokyo Medical and Dental University, Tokyo, Japan

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d
Japan Somnology Center, Institute of Neuropsychiatry, Tokyo, Japan

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* Corresponding author. Japan Somnology Center, Institute of Neuropsychiatry, 1-24-10 Yoyogi, Shibuya-ku,

Tokyo, Japan. Tel.: +81 3 3374 9112; fax: +81 3 3374 9125.

E-mail address: inoue@somnology.com (Y. Inoue).

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ABSTRACT

Objectives: The aims of this study were to compare the effects of acute morning or evening exercise on

nocturnal sleep in individuals with two subjective insomnia symptoms: difficulty in initiating sleep (DIS), and

early morning awakening (EMA), separately for the first vs the second halves of the night.

Methods: Older individuals (55–65 years old) with DIS (N = 15) or EMA (N = 15) and age- and sex- matched

controls (N = 13) participated in this non-randomized crossover study. Participants were assigned to two

exercise conditions (morning exercise and evening exercise) in counterbalanced order following the baseline

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condition with a 2-week interval between conditions. A single session of aerobic step exercise was performed

during each exercise condition. Nocturnal polysomnography was carried out to evaluate objective sleep quality.

Patient global impression of change scale scores for nocturnal sleep were obtained to subjectively evaluate the

different groups.

Results: Acute physical exercise did not improve subjective sleep quality. Morning exercise decreased the

number of stage shifts over the whole night. The arousal index and the number of stage shifts were decreased

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especially during the second half of the night in all groups. Furthermore, morning exercise decreased the

number of wake stages during the second half of the night in the DIS group, but not in the EMA group.

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Conclusions: Acute morning exercise can improve nocturnal sleep quality in individuals with difficulty

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initiating sleep, especially during the later part of the night.

Keywords:

Insomnia
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Older adults

Acute exercise
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1. Introduction

The prevalence of insomnia increases with age, and no less than 20–30% of older adults from

developed countries report symptoms of insomnia [1–6]. Given that the presence of insomnia may lead to

secondary medical problems, including depression, anxiety disorders, metabolic syndrome, and other

lifestyle-related diseases [7–13], it is desirable to prevent and improve insomnia symptoms in the older

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population.

A previous review reported that physical exercise improves not only subjective sleep quality,

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but also objective sleep quality among patients with insomnia [14]. Several previous studies have revealed

that chronic afternoon exercise over 16 weeks or longer leads to improved subjective sleep quality, as

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evaluated by the Pittsburgh Sleep Quality Index or a sleep diary, as well as improved objective sleep

quality, as evaluated by nocturnal polysomnography (n-PSG) in middle-aged or older adults with

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insomnia symptoms [15–17]. To the best of our knowledge, however, only one study has explored the
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effects of acute exercise. This study revealed that both objective sleep (reduction in sleep onset latency

and total wake time, and increase in total sleep time and sleep efficiency, as assessed using n-PSG) and
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subjective sleep (reduction in sleep onset latency and increase in total sleep time, as indicated by sleep

logs) were improved after an afternoon of moderate intensity aerobic exercise in young adults with
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chronic primary insomnia [18]. Thus, the effects of acute exercise on sleep quality in middle-aged and
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older adults with insomnia symptoms remain unknown.

Some previous studies have demonstrated that the time of the day of exercise (eg, morning vs
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late afternoon) has no impact on the effects of exercise on objective and subjective sleep quality [19,20].

However, the effects of the timing of exercise (either acute or chronic) on different types of insomnia

symptoms have not been investigated. Among the main symptoms of insomnia, such as difficulty
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initiating sleep (DIS) or early morning awakening (EMA) [21], EMA is more frequently observed in
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older adults compared to other symptoms [5]. Furthermore, these symptoms are associated with circadian

core body temperature. DIS has a delayed core body temperature rhythm, while EMA has an advanced

rhythm [22]. Given this observation, it may be speculated that the effects of morning or evening physical

exercise on nocturnal sleep might differ depending on the specific type of insomnia symptoms, as well as

the timing of exercise. These effects may also differ between the first and second halves of the night

depending on difference in intrinsic circadian rhythms between aforementioned types of insomnia

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symptoms. To clarify this issue, nocturnal sleep quality, especially as assessed using n-PSG variables,

should be evaluated separately for the first and second halves of the night in each group and for each

exercise condition.

The aims of this study were (1) to compare the effects of morning and evening exercise on

subjective and objective sleep quality in middle-aged and older adults with insomnia symptoms, and (2)

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to compare the effects of morning and evening exercise on objective sleep-related variables in individuals

with two types of insomnia symptoms, EMA and DIS. We analyzed the first and second halves of the

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night separately.

2. Materials and methods

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2.1. Participants

The ethics committee of the Institute of Neuropsychiatry reviewed and approved the current study.

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Study participants were recruited from members of a private clinical research corporation’s research
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panel. Among the members who were motivated to participate in the current study, individuals fulfilling

the following three conditions were eligible: (1) individuals with a primary insomnia complaint of DIS;
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(2) individuals with a primary insomnia complaint of EMA; and (3) control individuals with no insomnia

symptoms. All participants in the study were Japanese and fulfilled the following inclusion criteria: (1)
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age of 55–65 years; (2) body mass index of less than 28 kg/m2; (3) systolic arterial pressure less than 180
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mmHg and diastolic pressure less than 100 mmHg; (4) less than 30 min per week of physical exercise

according to the Japanese official physical activity guidelines for health promotion established by the
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Health, Labour, and Welfare Ministry in Japan; (5) a score of less than 11 on the Epworth Sleepiness

Scale [23], and (6) maintenance of a normal sleep–wake schedule with bed time between 21:00 and 01:00,

and wake time between 05:00 and 09:00. Participants meeting the following exclusion criteria were
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excluded: (1) current smokers; (2) living alone (to exclude individuals who may have a sleep disorder that
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cannot be verified by a family member); (3) history or current morbidity of cardiovascular disease,

diabetes, respiratory disease, cerebrovascular disease, or psychiatric disorders; (4) limit on exercise

imposed by a physician; and (5) subjective symptoms strongly suggestive of sleep disorders other than

insomnia, such as sleep apnea, restless leg syndrome, or rapid eye movement sleep behavior disorder, as

determined using self-administered questionnaires.

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Participants in the DIS group were required to fulfill the following additional inclusion criteria: (1)

score of 6 or higher on the Athens Insomnia Scale (AIS); (2) subjective sleep latency of 30 min or longer

three times or more per week; and (3) answer of “not earlier” or “a little earlier” to the “Final awakening”

subscale on the AIS. Participants in the EMA group were required to fulfill the following criteria: (1)

score of 6 or higher on the AIS; (2) answer of “markedly earlier” or “much earlier or did not sleep at all”

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on the “Final awakening” subscale on the AIS; and (3) answer of “no problem” or “slightly delayed” on

the “Sleep induction” subscale on the AIS. The subjects in the control group had scores of less than 6 on

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the AIS. In addition, electrocardiography (ECG) and n-PSG were carried out in participants who met the

above inclusion criteria. Participants who had an abnormal ECG or evidence of sleep disorders on PSG,

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such as sleep apnea (apnea–hypopnea index [AHI] ≥ 15/h) or periodic leg movements during sleep

(PLMS; PLM index [PLMI] ≥ 15/h), were screened out.

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Seventy-three participants met the above inclusion criteria. Among these participants, two were
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excluded for abnormal ECG findings, 12 were excluded for sleep apnea, and 16 were excluded for

PLMS. Consequently, 43 participants (DIS, N = 15; EMA, N = 15; control, N = 13) participated in the
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experimental intervention trial (Fig. 1).

2.2. Design and Procedures

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The current study was conducted using a repeated-measures non-randomized crossover design. All
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experimental procedures were conducted at the Yoyogi Sleep Disorder Center. Fig. 2 shows the

experimental protocol. At the first visit (visit 1), all participants who gave informed consent had an ECG
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examination. At visit 2, which was performed within 1 week of visit 1, participants underwent a pre-

exercise session followed by n-PSG, which was performed both to adapt the participant to the recording

and to screen for the above-mentioned sleep disorders. At visit 3, which was performed within 1 week of
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visit 2, participants underwent baseline n-PSG and were asked to respond to the patient global impression
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of change (PGI-C) scale, which measures subjective sleep quality (baseline condition).

Scheduled aerobic step exercise was conducted at visits 4 and 5. Visit 4 was scheduled 2 weeks

after visit 3, and visit 5 was scheduled 2 weeks after visit 4. Half of the participants were assigned to the

morning exercise condition at visit 4 and the evening exercise condition at visit 5, and the remaining half

were assigned to the two conditions in the reverse order. The order of these conditions was determined by

the participants’ daily schedules (e.g., jobs, family obligations, etc.). In the morning exercise condition,

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participants performed the step exercise program from 09:30 to 11:00 followed by n-PSG on the same

day. In the evening exercise condition, participants performed the exercise program from 17:30 to 19:00

followed by n-PSG. In both conditions, participants responded to the PGI-C scale just after n-PSG

recording in the next morning.

All participants were instructed not to consume caffeine or alcohol and to avoid naps 24 h prior to

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each visit. The participants were instructed to go to bed between 21:00 and 01:00, and to wake up

between 05:00 and 09:00 (according to their usual sleep–wake schedules), and to spend at least 6 h per

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night in bed during the experimental period. The participants’ sleep–wake schedules were assessed using

a sleep diary and an activity monitor (ActiSleep BT Monitor; Actigraph LLC, Pensacola, FL, USA) for a

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week prior to each visit. Bedtime and wake time were set to 22:00 and 06:00, respectively, on n-PSG

nights in all conditions.

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2.3. Measurements
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2.3.1. Subjective sleep quality

To evaluate subjective sleep quality in each condition, the following seven items on the PGI-C were
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assessed: subjective sleep latency, wake time after sleep onset, total sleep duration, feeling of deep sleep,

fatigue and sleepiness at the time of awakening, and feeling that sleep was restorative [24]. Each item on
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the PGI-C is rated on an 11-point numerical rating scale from -5 (much worse) to 5 (much improved)
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compared to the participant’s usual condition (with 0 representing the participant’s usual condition).

2.3.2. n-PSG
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n-PSG recordings were conducted on adaptation and baseline nights, and on two nights following

exercise using a standard system (Alice 5; Respironics Inc., Murrysville, PA, USA) with video

monitoring. The n-PSG used six scalp electroencephalogram channels (F3/A2, F4/A1, C3/A2, C4/A1,
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O1/A2, and O2/A1), bilateral electrooculograms, and two electromyograms obtained from the mentalis
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muscle. Nasal/oral airflow using sensors, percutaneous oxygen saturation with oximetry, snoring sounds

using a microphone, chest/abdominal respiratory effort, and leg movements (bipolar derivations with two

electrodes placed 3 cm apart on the belly of the anterior tibialis muscle of the right and left legs) were

recorded on the adaptation night to screen for the above-mentioned sleep disorders.

n-PSG data were scored according to the scoring criteria set by the American Academy of Sleep

Medicine (AASM) [25]. The following sleep variables were obtained from each recording: sleep period

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time; total sleep time; sleep efficiency; sleep onset latency; wake after sleep onset; N1, N2, N3, and rapid

eye movement (REM) stage percentages of sleep time; arousal index; number of stage shifts; duration of

early morning awakening (from last epoch scored as sleep to 06:00), AHI, and PLMI.

2.3.3. Pre-exercise session

During the pre-exercise session, the height of the step platform was adjusted to maintain each

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participant’s heart rate (HR) reserve (HRR) at 59%, which is considered to be moderate intensity [26].

Participants wore a heart rate monitor (RS800CX; Polar Electro Inc., North New Hyde Park, NY, USA),

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and stepped up and down 120 times per minute with the aim of increasing heart rate. The height of the

step platform was set at 10 cm at the beginning of the session and then increased by 2.5 cm every 5 min

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until each participant’s HR was increased to the target HR.

Sixty percent of HRR was calculated for each participant based on Karvonen’s formula: target HR

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= [(maximum HR – resting HR) × % exercise intensity] + resting HR [27]. Maximum HR was calculated
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based on a predictive formula reported by Gellish et al.: HR max = 207 0.7 × age [28]. Resting HR

was measured at the time of ECG measurements during the first visit.
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2.3.4. Exercise intervention

Each exercise condition consisted of four sets of 10-min aerobic step exercise with 5-min rest
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periods between sets. A previous study reported that only moderate-intensity aerobic exercise improves
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sleep quality [18]. Thus, we conducted aerobic step exercise with moderate intensity. During each 10-min

set, the participants were instructed to move up and down a step platform with a height determined in the
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pre-exercise session. Prior to the four sets of step exercise, a stretching exercise and a slow-tempo (80

bpm) step exercise were performed as a warm up for 20 min. At the end of the exercise session, a 15-min
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stretching exercise was performed to cool down. All exercise was performed in a group setting.

2.4. Statistical Analyses

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One participant dropped out during the study period due to an orthopedic injury sustained during

routine daily activities. Additionally, two participants who could not follow the study protocol were

excluded from subsequent analyses. Consequently, data from 40 participants (DIS: N = 12, EMA: N = 15,

control: N = 13) were included in the final analyses (Fig. 1).

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Chi-square tests were used for group comparisons of categorical variables and independent t-tests

and one-way analyses of variance (ANOVAs) followed by Bonferroni’s post hoc tests were used for

continuous variables.

To assess subjective sleep quality, scores on the PGI-C were compared among groups using a two-

way repeated-measures ANOVA (groups: DIS, EMA, and control; conditions: baseline, morning exercise,

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and evening exercise) followed by Bonferroni’s post hoc test.

To compare n-PSG variables between the two groups (DIS and EMA), a two-way repeated-

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measures ANOVA (group × condition) followed by Bonferroni’s post hoc test was conducted. For

exploratory analysis, nocturnal sleep was divided into the first and second half of the night based on time

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in bed (240 min per half). To investigate the effects of morning and evening exercise on n-PSG variables

in the first and second halves of the night among the DIS, EMA, and control groups, n-PSG variables in

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each half were compared using two-way repeated-measures ANOVAs (group × condition). All statistical
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analyses were conducted using SPSS software (SPSS, v11.5; SPSS Inc., Chicago, IL, USA). Statistical

significance was indicated by a p-value of less than 0.05.

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3. Results

3.1. Baseline participant characteristics

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Baseline participant characteristics are presented in Table 1. No differences in the variables were
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found between the three groups, except for the AIS, which was used to select participants for each group.

3.2. Subjective sleep parameters

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Table 2 presents the subjective sleep parameters measured using the PGI-C in each group for each

condition. Two-way repeated-measures ANOVA revealed no significant main effect of either group or

condition and no significant interaction on any PGI-C item. Statistical F-values for each item on the PGI-
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C are as follows: sleep latency (main effect: F(2, 74) = 0.09, interaction effect: F(4, 74) = 0.09), wake after
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sleep onset (main effect: F(2, 74) = 0.58, interaction effect: F(4, 74) = 0.11), total sleep duration (main effect:

F(2, 74) = 0.28, interaction effect: F(4, 74) = 0.90), feeling of deep sleep (main effect: F(2, 74) = 1.45,

interaction effect: F(4, 74) = 0.48), fatigue upon awakening (main effect: F(2, 74) = 0.18, interaction effect:

F(4, 74) = 0.68), sleepiness upon awakening (main effect: F(2, 74) = 0.06, interaction effect: F(4, 74) = 0.33),

and feeling that sleep was restorative (main effect: F(2, 74) = 0.59, interaction effect: F(4, 74) = 0.75).

3.3. n-PSG variables

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3.3.1. Effects of morning and evening exercise on n-PSG variables across the entire night

Table 3 presents the n-PSG variable following morning exercise compared to those following evening

exercise across the entire night. There were no significant differences in n-PSG variables among the

groups at baseline. Two-way repeated-measures ANOVA (group × condition) revealed no interaction

effects for any n-PSG variables. A significant main effect of condition was detected in the number of

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stage shifts (F(2, 74) = 4.54), such that the number of stage shifts was lower in the morning exercise

condition compared to baseline (P = 0.009).

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3.3.2. Effects of morning and evening exercise on n-PSG variables in the first and last halves of the night

Two-way repeated-measures ANOVA revealed no significant main effect or interaction effect for any

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n-PSG variable during the first half of the night (Table 4). In the second half of the night, a significant

main effect of condition was found in the number of stage shifts and the arousal index, such that both the

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number of stage shifts and the arousal index were significantly decreased in the morning exercise
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condition (F(2,74) = 3.87 and F(2,74) = 4.67, respectively). Furthermore, a significant interaction was

detected in the number of wake stages (F(2,74) = 2.93, ηn2 = 0.15, p=0.015). Bonferroni’s post hoc analysis
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revealed that the number of wake stages decreased in the morning exercise condition when compared to

baseline in the DIS group (p<0.001), while this number decreased in the evening exercise condition in the
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EMA group (p=0.049).

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4. Discussion

In the present study, neither acute morning nor acute evening exercise improved subjective sleep
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measures in any of the groups. This finding is inconsistent with those of a previous study in patients with

chronic insomnia, which reported that acute moderate-intensity aerobic exercise improves subjective

sleep quality, as evaluated by sleep logs, sleep onset latency, and total sleep time [18]. This discrepancy
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might be partially ascribed to differences in the populations studied, as the severity of insomnia in our
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participants may have been milder than in the participants in the previous study.

Acute morning exercise decreased the number of stage shifts during the entire night in all three

groups, although the n-PSG results revealed no major improvements in objective sleep measures, such as

reduction of sleep latency in the DIS group or reduction of early morning wake time in the EMA group,

following exercise [18,29]. The aforementioned modest effect of morning exercise in all groups was

observed especially during the later part of nocturnal sleep. The decreased arousal index and stage shifts

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were observed during in the second half of the night. However, modest improvements in n-PSG

parameters did not lead to improvements in subjective sleep quality. Although the improvements

observed in our study were not as dramatic as those observed in previous studies, which included

reductions in both sleep onset latency and wake after sleep onset, as well as improvements in sleep

efficiency, reductions in the arousal index, and stage shifts during the second half of the night, morning

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exercise is speculated to induce stabilization of nocturnal sleep.

Our results raise the possibility that morning exercise increases sleep pressure, which in turn leads

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to maintenance of stable sleep throughout the night, when compared to evening exercise. Another

possibility is that exercise influences the autonomic nervous system during sleep. A recent study

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demonstrated that morning exercise enhanced parasympathetic nervous activity during subsequent

nocturnal sleep, whereas evening exercise enhanced sympathetic nervous activity [30]. The change in

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autonomic balance toward parasympathetic dominance is known to promote the transition from
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wakefulness to sleep [31,32]. Inconsistent with the present results, several previous studies have reported

a positive effect of evening exercise on sleep variables. For example, evening exercise has been reported
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to cause a steeper decline in core body temperature before bedtime, resulting in a greater amount of slow-

wave [33,34], shorter sleep latency, and increased sleep efficiency [18,34]. One possible reason for the
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inconsistency between our study and the previous studies is differences in the ages of participants across
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the studies. In general, compared to young adults, middle-aged or older adults are known to have

difficulty alternating from the sympathetic nervous system predominance to the parasympathetic one.
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This may result in a slower response to change in core body temperature after evening physical exercise

[35]. Thus, in the present study of middle-aged and older adults, slow recovery from the elevated core

body temperature after evening exercise may have diminished the sleep-promoting effects of evening
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exercise.
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In this study, the mild positive effect of morning exercise on objective sleep variables was observed

only during the second half of the nocturnal sleep period. The reason for this phenomenon is unclear.

However, it is possible that the aforementioned autonomic nervous response occurs at a later time after

sleep onset in the middle-aged and older participants in our study. In general, the autonomic balance

shifts toward parasympathetic predominance just after sleep onset in young adults. In contrast, in middle-

aged and older adults, the parasympathetic predominance during sleep is weaker and occurs later than it

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does in younger adults due to the delayed onset of slow-wave sleep [36,37]. This is why the mild impact

of morning exercise was observed only on the second half of the nocturnal sleep episode in older

individuals.

Morning exercise decreased the number of wake stages during the second half of the night only in

the DIS group. This may be due to increased sleep pressure, as discussed above. That is, increased sleep

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pressure following morning exercise maintains the subjects’ sleep propensity until early morning. In

contrast, we did not observe an effect of morning exercise during the later part of the night in the EMA

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group. One possible reason for this finding may be a difference in intrinsic sleep–wake rhythms between

the DIS and EMA groups. Individuals with DIS have a delayed core body temperature rhythm and those

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with EMA have an advanced rhythm [22]. Therefore, in the EMA group, the wake propensity in the early

morning diminishes the effects of morning exercise during the later part of the night. The observed

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increase in the number of wake stages might support the fact that morning exercise can bring about sleep
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stabilization, especially during the later part of the night. These small but significant changes may

indicate mild improvements in objective sleep quality following acute morning exercise. In addition, in
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clinical settings, feedback from changes in objective parameters following acute exercise is necessary for

patients to maintain their motivation to improve their nocturnal sleep by performing physical exercise. An
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accumulation of this effect on objective sleep quality following regular morning exercise is expected to
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lead to more significant improvements in subjective and objective sleep quality. Future studies should

explore the effect of long-term morning exercise on objective and subject sleep quality in older
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individuals. Furthermore, these results provide evidence that the effects of acute physical exercise differ

both among individuals with different types of insomnia and between earlier and later sleep periods. This

study therefore suggests the establishment of practical physical exercise as a therapy for insomnia,
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although the specific type of insomnia symptoms and the timing of the exercise should be considered.
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The current study has several limitations. First, the severity of insomnia symptoms was relatively mild

in our participants because participants were selected on the basis of the AIS score only. We did not

conduct a clinical interview to assess daytime dysfunction, which are listed in the International

Classification of Sleep Disorders – Third Edition (ICSD-3) criteria for chronic insomnia [39]. A possible

reason that these changes in objective sleep parameters were not large enough to improve the

participants’ subjective sleep quality may be that the participants’ symptoms of DIS and EMA were not

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so severe as to be differentiated by objective sleep parameters at baseline. We need to determine whether

a positive effect of physical exercise on nocturnal sleep is observed in participants with more severe

insomnia symptoms (eg, worsened objective sleep variables or clinical insomnia). Second, neither core

body temperature nor heart rate variability was evaluated in the current study. These physiological

markers should be measured in a future study to clarify the impact of physical exercise on autonomic

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nervous system activity and sleep quality during the night following exercise. Third, we used a single-

session exercise protocol. Thus, we were unable to assess the impact of physical exercise on the subjects’

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circadian rhythms. To determine the optimal exercise timing for patients with different insomnia

symptoms, the impact of exercise on circadian rhythms should be explored using long-term exercise

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interventional trials.

5. Conclusion

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Acute morning exercise moderately improved objective sleep variables, as determined by n-PSG, in
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all groups. Although these improvements were not dramatic, reductions in the arousal index and stage

shifts during the second half of the night following acute morning exercise may manifest as mild
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improvements in objective sleep quality. Furthermore, in the DIS group, the number of wake stages

during the second half of the night decreased following morning exercise. This effect was not observed in
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the EMA group. These results indicate that the effects of acute physical exercise differ in individuals with
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different types of insomnia and during earlier vs later sleep periods. This study thus contributes to the

establishment of practical physical exercise as a therapy for insomnia.

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Conflict of interest

This study was supported by The Ministry of Education, Culture, Sports, Science and Technology
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KAKENHI Grant-in-Aid for Research Activity Start-up No. 25882030. This study was supported by the
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industry. Dr Inoue provided expert testimony for and payment for lectures from Takeda Pharmaceutical

Company Limited and MSD K.K. The other authors have indicated that they have no financial conflicts

of interest.

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Fig. 1. Flow chart of participants through the study. The order of exercise conditions was determined by
the participants’ daily schedules. BL, baseline condition; ME, morning exercise condition; EE, evening
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exercise condition.
Fig. 2. Experimental protocol. Half of the participants were assigned to the morning exercise condition
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followed by the evening exercise condition, and the remaining half were assigned to the two conditions in
reverse order. EEG, electroencephalogram; PGI-C, patient global impression of changes.
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Table 1. Baseline participant characteristics

Control DIS EMA
N = 13 N = 12 N = 15 ES p
Sex [male/female] 6/7 4/8 5 / 10 0.12 0.765
Age [years] 58.8 (2.9) 58.9 (3.6) 57.7 (2.9) 0.00 0.539
BMI [m/kg2] 22.9 (2.0) 22.2 (2.3) 21.1 (1.8) 0.02 0.069
SBP [mmHg] 117.5 (9.2) 115.4 (10.3) 124.5 (12.5) 0.02 0.083

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DBP [mmHg] 73.3 (8.1) 73.4 (11.0) 77.8 (10.6) 0.00 0.484
Resting heart rate [bpm] 64.9 (10.3) 71.2 (12.5) 68.2 (12.6) 0.00 0.429
Bedtime 23:21 (1 h 16 min) 23:55 (58.4 min) 23:38 (53.0 min) 0.00 0.403
Rise time 06:25 (1 h 09 min) 06:40 (51.7 min) 06:18 (54 min) 0.00 0.626
AHI [events/hour] 4.3 (4.2) 2.7 (2.1) 2.2 (1.9) 0.01 0.151

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PLMI [events/hour] 1.0 (2.0) 2.7 (5.2) 1.8 (3.6) 0.00 0.495
AIS score 1.7 (1.7) 10.2 (2.9)* 9.1 (2.4)* 0.53 <0.001
ESS score 3.2 (3.4) 4.1 (2.7) 4.5 (3.2) 0.00 0.512

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Employee 3 (23.1) 3 (25.0) 4 (26.7) 0.04 0.976

Continuous variables are expressed as mean (standard deviation), and categorical variables are expressed
as number of subjects (percent). AHI, apnea–hypopnea index; AIS, Athens Insomnia Scale; BMI, body

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mass index; DBP, diastolic blood pressure; DIS, difficulty in initiating sleep; EMA, early morning
awakening; ES, effect size; ESS, Epworth Sleepiness Scale; PLMI, periodic limb movements index; SBP,
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systolic blood pressure. Effect size is expressed as ηp2 (one-way analysis of variance) following Cramer’s
V (2 × 3 chi-square test).
*p<0.05 vs control.
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Table 2. Subjective sleep parameters assessed using the patient global impression of change in each
condition.
Main effects
Morning Evening of conditions Interaction
Baseline
exercise exercise
ES p ES p
Sleep latency
Control 0.5 (2.5) -0.2 (3.0) 0.1 (3.4)

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DIS -0.8 (2.6) -0.2 (3.0) -0.2 (2.9) 0.00 0.919 0.03 0.707
EMA -0.7 (2.4) -0.1 (2.7) -0.9 (2.8)
Number of awakenings

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Control -1.2 (2.8) -0.8 (2.4) -0.8 (2.8)
DIS -1.2 (2.3) -0.7 (2.7) -0.3 (1.8) 0.02 0.561 0.01 0.980
EMA -1.5 (2.0) -1.2 (1.9) -1.3 (2.1)

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Total sleep duration
Control 0.0 (3.2) -0.8 (2.2) -0.1 (2.7)
DIS -0.3 (2.5) 0.9 (3.0) 0.3 (2.9) 0.00 0.759 0.05 0.466

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EMA -0.4 (2.1) 0.2 (2.6) -0.4 (2.9)
Feeling of deep sleep
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Control -0.7 (2.9) -0.6 (2.5) -0.1 (2.8)
DIS -0.8 (2.6) -0.1 (3.1) -0.4 (2.9) 0.04 0.24 0.03 0.751
EMA -1.4 (2.3) 0.1 (2.8) -0.5 (2.8)
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Fatigue upon awakening

Control -1.4 (1.9) -0.9 (2.3) -0.3 (2.0)
DIS 0.0 (2.0) -0.3 (2.4) -0.5 (2.7) 0.01 0.833 0.04 0.611
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EMA -0.9 (1.6) -0.7 (2.3) -0.7 (1.8)

Sleepiness upon awakening
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Control -0.7 (1.0) -0.9 (2.1) -0.2 (2.1)

DIS -0.2 (1.3) -0.1 (2.3) -0.4 (2.4) 0.00 0.944 0.02 0.854
EMA -0.7 (1.4) -0.6 (2.5) -0.6 (2.2)
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Feeling that sleep was restorative

Control -1.4 (1.6) -1.2 (2.4) -0.4 (2.8)
DIS 0.1 (1.9) -0.5 (3.0) -0.2 (2.6) 0.02 0.559 0.04 0.562
EMA -1.3 (1.6) -0.6 (2.6) -0.8 (2.2)
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DIS, difficulty in initiating sleep; EMA, early morning awakening; ES, effect size. ES is expressed as ηp2.
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Table 3. Effects of morning and evening exercise on nocturnal polysomnography variables over the entire

night.

Main effects
Morning Evening of Interaction
Baseline
exercise exercise conditions
ES p ES P

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SPT (min)
Control 471.7 ± 16.1 471.8 ± 12.2 475.0 ± 6.8
DIS 469.0 ± 8.7 468.2 ± 20.3 474.3 ± 7.1 0.01 0.828 0.05 0.456
EMA 471.9 ± 13.3 469.9 ± 13.8 466.1 ± 21.1

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TST (min)
Control 431.7 ± 29.9 433.0 ± 31.1 430.7 ± 38.2
DIS 425.3 ± 25.0 427.6 ± 50.6 434.0 ± 28.7 0.00 0.866 0.01 0.906
EMA 429.3 ± 34.4 434.3 ± 23.6 428.3 ± 32.4

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SE (%)
Control 91.5 ± 4.9 91.8 ± 5.7 90.7 ± 7.6
DIS 90.7 ± 4.5 91.1 ± 8.0 91.5 ± 5.2 0.01 0.639 0.02 0.879
EMA 90.9 ± 6.6 93.1 ± 4.2 91.8 ± 4.1

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Sleep onset latency (min)
Control 6.7 ± 10.7 4.2 ± 3.3 4.8 ± 6.9
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DIS 9.5 ± 8.4 6.5 ± 6.6 3.4 ± 2.2 0.06 0.105 0.08 0.185
EMA 3.2 ± 2.1 3.5 ± 2.8 4.0 ± 3.0
REM sleep onset latency
(min)
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Control 74.5 ± 25.0 82.1 ± 48.9 106.2 ± 57.8

DIS 120.1 ± 45.3 96.1 ± 29.5 86.8 ± 17.0 0.01 0.587 0.10 0.094
EMA 86.6 ± 39.2 80.5 ± 19.0 91.3 ± 50.9
Time of early morning
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awakening (min)
Control 1.6 ± 5.5 4.0 ± 9.9 0.7 ± 1.7
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DIS 1.5 ± 3.5 5.3 ± 16.5 2.3 ± 7.3 0.02 0.467 0.03 0.655
EMA 4.9 ± 13.8 6.7 ± 13.3 9.9 ± 19.8
WASO (%)
Control 8.5 ± 4.9 8.2 ± 5.8 9.3 ± 7.6
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DIS 9.3 ± 4.5 8.9 ± 8.0 8.5 ± 5.2 0.01 0.776 0.10 0.941
EMA 9.1 ± 6.6 7.5 ± 4.9 8.2 ± 4.1
N1 stage (%)
Control 13.9 ± 6.9 11.5 ± 4.9 12.1 ± 5.1
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DIS 11.4 ± 4.7 11.1 ± 5.9 11.6 ± 3.8 0.03 0.286 0.02 0.762
EMA 11.2 ± 5.5 10.2 ± 5.6 11.2 ± 4.1
N2 stage (%)
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Control 59.1 ± 7.8 59.3 ± 9.6 59.9 ± 10.1

DIS 61.6 ± 6.7 60.3 ± 8.3 61.1 ± 5.0 0.00 0.980 0.02 0.877
EMA 61.7 ± 9.1 62.5 ± 7.8 60.6 ± 7.5
N3 stage (%)
Control 0.5 ± 0.8 0.5 ± 1.0 0.9 ± 1.5
DIS 0.9 ± 2.0 0.3 ± 0.6 0.8 ± 1.3 0.07 0.057 0.07 0.279
EMA 0.7 ± 1.2 0.4 ± 1.1 0.5 ± 0.6
REM stage (%)
Control 18.0 ± 7.0 20.5 ± 5.9 17.9 ± 6.1
0.08 0.050 0.02 0.767
DIS 16.8 ± 4.7 19.3 ± 3.9 18.1 ± 6.0

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EMA 17.3 ± 4.6 19.3 ± 4.1 19.5 ± 3.9

Stage shift (number)
Control 164.6 ± 35.8 139.5 ± 32.4 146.0 ± 33.4
DIS 149.0 ± 33.7 131.0 ± 41.5 148.5 ± 35.9 0.11 0.014 0.03 0.758
EMA 143.7 ± 47.2 131.1 ± 39.5 139.0 ± 22.2
Arousal index (events/h)
Control 11.2 ± 4.4 10.2 ± 4.4 10.1 ± 2.9
DIS 16.5 ± 21.5 9.4 ± 4.5 9.7 ± 3.9 0.06 0.109 0.05 0.450

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EMA 10.2 ± 3.9 8.1 ± 2.6 10.0 ± 2.9
Shifting to wake stage
(number)
Control 33.3 ± 10.3 31.2 ± 11.1 29.8 ± 9.9

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DIS 32.2 ± 12.2 25.9 ± 10.4 32.4 ± 11.8 0.04 0.213 0.05 0.460
EMA 30.5 ± 17.7 29.1 ± 11.2 28.8 ± 8.5

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DIS, difficulty in initiating sleep; EMA, early morning awakening; ES, effect size. REM, rapid eye

movement;SE, sleep efficiency; SOL, sleep onset latency; SPT, sleep period time; TST, total sleep time;

WASO, wake after sleep onset. ES is expressed as ηp2.

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Table 4. Effects of morning and evening exercise on nocturnal polysomnography (PSG) variables in the first and second halves of the night.
First half of the night Second half of the night

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Main Main
Morning Evening effects of Interaction Morning Evening effects of Interaction
Baseline Baseline
exercise exercise conditions exercise exercise conditions

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ES p ES p ES P ES P
SPT (min)
Control 233.2 ± 10.7 235.8 ± 3.3 235.2 ± 6.9 238.2 ± 5.5 236.0 ± 9.9 239.3 ± 1.7

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DIS 230.6 ± 8.4 234 ± 6.0 236.5 ± 2.2 0.07 0.066 0.07 0.274 238.5 ± 3.5 234.7 ± 16.5 237.7 ± 7.3 0.03 0.371 0.01 0.985
EMA 236.8 ± 2.1 236.6 ± 2.8 236.7 ± 2.6 235.1 ± 13.7 233.3 ± 13.3 234.6 ± 11.9
TST (min)

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Control 217.3 ± 16.2 218.5 ± 13.1 217.2 ± 25.0 214.3 ± 22.6 214.5 ± 22.9 213.6 ± 19.9
DIS 211.5 ± 14.4 218.6 ± 16.1 222.5 ± 8.8 0.02 0.576 0.05 0.383 215.5 ± 25.1 209.0 ± 45.6 211.5 ± 24.9 0.00 0.921 0.01 0.906

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EMA 222.1 ± 15.0 225.4 ± 11.3 216.0 ± 25.1 207.2 ± 32.2 208.9 ± 22.0 212.3 ± 20.7
SE (%)
Control 90.6 ± 6.8 91.0 ± 5.4 90.5 ± 10.4 89.3 ± 9.4 89.4 ± 9.5 89.0 ± 8.3

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DIS 88.1 ± 6.0 91.1 ± 6.7 92.7 ± 3.7 0.02 0.580 0.05 0.384 89.8 ± 10.4 87.1 ± 19.0 88.1 ± 10.4 0.00 0.921 0.01 0.906
EMA 92.6 ± 5.6 93.9 ± 4.7 90.0 ± 10.5 86.3 ± 13.4 87.0 ± 9.2 88.5 ± 8.6
WASO (%)

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Control 6.9 ± 4.4 7.3 ± 5.3 7.8 ± 9.6 10.0 ± 9.0 9.2 ± 8.0 10.7 ± 8.3
DIS 8.4 ± 4.3 6.7 ± 5.2 6.0 ± 3.2 0.01 0.674 0.04 0.561 9.7 ± 10.4 11.9 ± 16.4 11.2 ± 9.1 0.00 0.999 0.02 0.820

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EMA 6.2 ± 5.4 4.7 ± 4.8 8.7 ± 10.7 12.0 ± 12.3 10.4 ± 8.1 9.5 ± 7.6
N1 stage (%)
Control 12.9 ± 7.3 11.7 ± 5.9 10.8 ± 6.9 14.8 ± 7.9 11.2 ± 6.7 13.3 ± 7.0
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DIS 11.4 ± 6.3 11.3 ± 7.0 9.5 ± 5.0 0.01 0.689 0.03 0.644 11.3 ± 5.5 11.0 ± 6.4 13.8 ± 5.9 0.07 0.066 0.09 0.138
EMA 10.5 ± 6.9 9.8 ± 8.3 11.6 ± 4.7 11.9 ± 5.4 10.7 ± 4.2 10.4 ± 4.2
N2 stage (%)
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Control 64.6 ± 8.1 61.9 ± 9.7 66.3 ± 11.7 53.7 ± 11.3 56.6 ± 15.6 53.5 ± 10.1
DIS 65.9 ± 9.8 67.3 ±11.4 68.1 ± 7.3 0.00 0.961 0.04 0.500 57.4 ± 13.3 52.7 ± 13.8 54.1 ± 9.1 0.01 0.742 0.04 0.557
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EMA 67.9 ± 8.8 68.8 ±9.1 65.2 ± 12.9 55.5 ± 11.6 56.0 ± 8.8 55.0 ± 10.6
N3 stage (%)
Control 1.0 ± 1.5 1.0 ± 2.0 1.9 ± 2.9 0.0 ± 0.1 0.0 ± 0.1 0.0 ± 0.1
DIS 1.6 ± 3.8 0.6 ± 1.3 1.5 ± 2.5 0.07 0.083 0.07 0.271 0.2 ± 0.7 0.0 ± 0.0 0.0 ± 0.1 0.01 0.686 0.07 0.224
EMA 1.5 ± 2.5 0.9 ± 2.2 0.9 ± 1.1 0.0 ± 0.1 0.1 ± 0.2 0.2 ± 0.4

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REM stage (%)

Control 14.6 ± 8.9 18.1 ± 6.7 13.3 ± 8.0 20.8 ± 9.6 22.9 ± 7.6 22.4 ± 9.5

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DIS 12.6 ± 5.5 14.1 ± 7.4 15.1 ± 7.1 0.04 0.212 0.04 0.588 20.8 ± 5.9 24.5 ± 6.5 21.0 ± 10.0 0.04 0.249 0.03 0.703
EMA 14.0 ± 6.1 15.9 ± 6.0 13.6 ± 7.8 20.7 ± 9.9 22.8 ± 6.3 25.0 ± 5.1
Stage shifts (number)

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Control 81.2 ± 26.5 75.2 ± 21.4 74.4 ± 24.2 84.2 ± 20.4 65.2 ± 22.7 72.5 ± 23.8
DIS 76.9 ± 26.0 73.8 ± 26.3 75.7 ± 24.2 0.04 0.190 0.04 0.547 72.9 ± 27.1 58.3 ± 19.0 73.8 ± 21.5 0.11 0.012 0.11 0.070
EMA 75.9 ± 27.0 63.1 ± 24.5 77.5 ± 9.5 68.7 ± 25.1 68.8 ± 20.7 62.2 ± 16.8

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Arousal index (h-1)
Control 11.5 ± 5.9 11.5 ± 5.7 10.6 ± 5.1 11.0 ± 4.5 8.9 ± 5.2 9.8 ± 3.8
DIS 11.2 ± 5.7 11.0 ± 7.5 9.4 ± 4.4 0.01 0.721 0.07 0.244 9.7 ± 4.9 8.2 ± 3.2 10.3 ± 5.4 0.10 0.025 0.03 0.728

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EMA 9.8 ± 4.7 7.9 ± 3.7 10.9 ± 3.2 10.5 ± 3.8 8.4 ± 2.8 9.0 ± 3.7
Number of wake stages

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(number)
Control 13.4 ± 5.1 15.3 ± 6.0 11.4 ± 5.7 19.7 ± 7.6 15.8 ± 7.5 18.5 ± 8.8
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DIS 14.7 ± 7.1 13.4 ± 6.1 14.3 ± 4.0 0.00 0.902 0.07 0.273 17.3 ± 9.7 12.3 ± 6.3 17.9 ± 8.3 0.07 0.060 0.15 0.014

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EMA 13.6 ± 9.5 11.8 ± 6.2 14.4 ± 4.3 16.8 ± 10.7 17.2 ± 6.3 12.9 ± 4.4*

DIS, difficulty in initiating sleep; EMA, early morning awakening; ES, effect size; REM, rapid eye movement; SE, sleep efficiency; SOL, sleep onset latency; SPT,

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sleep period time; TST, total sleep time; WASO, wake after sleep onset. ES is expressed as ηp2.

* p<0.05 vs baseline, analyzed by Bonferroni’s post hoc test.

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Highlights

Acute morning exercise may moderately improve objective sleep in older adults.

Effect of acute exercise was observed during later part of nocturnal sleep.

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Effect of acute physical exercise differs between types of insomnia.

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