Comparing the effects of music and exercise with music for older adults with insomnia

Applied Nursing Research 32 (2016) 104–110

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Comparing the effects of music and exercise with music for older adults with insomnia☆,☆☆ Chiung-Yu Huang, PhD, RN a, En-Ting Chang, MS, MSN b, Hui-Ling Lai, PhD, RN b,⁎ a b

Department of Nursing, I-Shou University, No.8, Yida Rd., Kaohsiung City, 82445,Taiwan, R.O.C Department of Chest Medicine, Buddhist Tzu Chi General Hospital, No. 701, Section 3, Zhongyang RD, Hualien, 97004, Taiwan

a r t i c l e

i n f o

Article history: Received 6 November 2015 Revised 21 February 2016 Accepted 19 June 2016 Available online xxxx Keywords: Music Insomnia Exercise Pittsburgh sleep quality index Electroencephalography

a b s t r a c t Aim: To examine the effects of a soothing music intervention before bedtime and a treadmill brisk walking exercise combined with music in the evening on sleep quality of sedentary older adults with chronic insomnia. Background: There is evidence to support the use of complementary interventions to improve sleep. They are rarely applied in Taiwanese elderly population. Methods: Using a crossover controlled trial, 38 participants aged 50 to 75 years were randomly assigned to a music intervention/brisk walking sequence or a brisk walking/music intervention sequence. Each participant completed two intervention sessions (separated by 1 week). Each intervention lasted 30 min. An actigraph extended with electroencephalography (EEG) and questionnaires were used to assess the sleep quality. Results: Both interventions exhibited beneficial effects on subjective sleep quality in adults with insomnia. Also listening to soothing music before bedtime significantly shortened the wake time after sleep onset measured by EEG, compared with brisk walking in the evening. Conclusions: The interventions applied in this study could be applied as the evidence-based nursing interventions for insomnia older adults. © 2016 Elsevier Inc. All rights reserved.

1. Introduction Difficulty with initiating or maintaining sleep, early morning waking, or nonrestorative sleep are characteristics of insomnia, as broadly defined by sleep experts (Schutte-Rodin, Broch, Buysse, Dorsey, & Sateia, 2008). Insomnia is associated with adverse effects on quality of life and daytime functioning (Komada et al., 2012). The prevalence of insomnia worldwide is 30% (Roth, 2007). A recent study demonstrated that approximately 39.4% of the Chinese population (Wong & Fielding, 2011) and up to 60% of older adults (Almeida, Alfonso, Yeap, Hankey, & Flicker, 2011) complain of insomnia. Prescription medication is one of the remedies people with insomnia use to improve their sleep quality (Bertisch, Herzig, Winkelman, & Buettner, 2014). However, the side effects of hypnotics (DeMartinis, Kamath, & Winokur, 2009), reduction of their therapeutic effect because of long-term use, and drug tolerance and dependence (Buscemi et al., 2007; O'Malley, 2007) are frequent pharmacological management problems. Therefore, the nonpharmacological and pharmacological management of sleep should be simultaneously considered. Various nonpharmacological therapies, ☆ Funding: This study was funded by a grant (TCRPP101001) from Tzu Chi University, Taiwan, R.O.C. ☆☆ Declaration of conflicting interests: No conflicts of interest are declared by the authors. ⁎ Corresponding author. Tel.: +11 886 3 8565301x2220; fax: +11 886 3 8574767. E-mail address: [email protected] (H.-L. Lai). http://dx.doi.org/10.1016/j.apnr.2016.06.009 0897-1897/© 2016 Elsevier Inc. All rights reserved.

such as exercise and music, have been proposed in the health care industry as alternative interventions for sleep disturbances due to their relative low cost, easily accessed, and easily self-administered. 2. Literature review 2.1. Sleep and nonpharmacological interventions Acute reductions in sleep can alter the immune function (Besedovsky, Lange, & Born, 2012). Less than 6 hours of sleep time is associated with high mortality (Hublin, Partinen, Koskenvuo, & Kaprio, 2007), chronic inflammation (Thompson et al., 2011), diabetes (Cappuccio, D'Elia, Strazzullo, & Miller, 2010), and obesity (Cappuccio et al., 2008). Early intervention and treatment of insomnia are necessary because the symptoms of insomnia and their daytime effects are exacerbated even in mild cases (Komada et al., 2012). 2.1.1. Exercise and sleep Few experimental studies have examined the effects of exercise on sleep in middle-aged adults and elderly people with sleep problems, and these studies have revealed small to moderate improvements in sleep quality after exercise interventions such as Nordic walking (Erlacher, Erlacher, & Schredl, 2014), aerobic exercise (Wang & Youngstedt, 2014), treadmill walking (Passos et al., 2011), and walking and stationary bicycle (Reid et al., 2010). Although exercise studies have

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consistently resulted in improvement in sleep in middle-aged and older adults, no study has been conducted to evaluate the effects of short period of time of music and exercise combined music interventions on sleep quality in this population. In clinical practice nurses, evaluating the effectiveness of a short period of time of intervention after their implementation is common, so our study design would accurately represent contemporary clinical practice. The timing of exercise is another consideration of the effectiveness of sleep quality according to the sleep hygiene consensus. Standard sleep hygiene experts widely advise that exercise close to bedtime should be avoided. People might be unwilling to exercise when it is inconvenient to their schedule. However, Buman, Phillips, Youngstedt, Kline, and Hirshkowitz (2014) reported that evening exercise was beneficial rather than detrimental to sleep quality. Nonetheless, other sleep scientists have presented opposing opinions (Horne, 2014). Thus, the associations between the effects of exercise in the evening and the sleep quality are unclear, and additional studies are required. The mechanisms by which exercise improve sleep quality are multifactorial. It has been suggested that the effects of exercise on sleep are related to antidepressant effects, anxiety reduction (Wen et al., 2014), increase in peripheral levels of beta-endorphins (Dearman & Francis, 1983; Droste, Greenlee, Schreck, & Roskamm, 1991), changes in serotonin levels (Soares, Naffah-Mazzacoratti, & Cavalheiro, 1994), and a decrease in sympathetic activity (Thoren, Floras, Hoffman, & Seals, 1990). Hence, relaxation is improved, which in turn improves sleep quality. 2.1.2. Soothing music and sleep Studies have reported that music reduces circulating noradrenaline (Mockel et al., 1994; Jiménez-Jiménez, García-Escalona, Martín-López, Vera-Vera, & Haro, 2013), which is associated with sleep onset (Irwin, Thompson, Miller, Gillin, & Ziegler, 1999; Ingram, Simpson, Malone, & Florida-James, 2015). Therefore, a soothing music intervention is expected to improve sleep quality. Approximately 40% to 50% of the population uses music therapy as a self-help strategy to improve sleep (Furihata et al., 2011). Researchers conducting studies using meta analysis have also demonstrated the association between a soothing music intervention and the improvement of subjective sleep quality (de Niet, Tiemens, Lendemeijer, & Hutschemaekers, 2009). Recent studies have verified the beneficial effects of music on the objective sleep quality of ICU patients (Su et al., 2013) and healthy adults with insomnia (Chang, Lai, Chen, Hsieh, & Lee, 2012). Nonetheless, results have been inconsistent (Chang et al., 2012; Lazic & Ogilvie, 2007; Su et al., 2013). Thus, the effects of soothing music on objective sleep quality must be examined to establish an evidence-based music intervention. 3. Purpose In summary, previous studies of exercise interventions have not assessed the effects of short period of time of intervention on sleep outcome. Results from experimental music studies on sleep have been mixed. Listening to music and doing exercise were commonly used as interventions for sleep quality. However, which intervention that triggers sleep better is unclear. Therefore, the purpose of this randomized crossover trial was to examine the effects of a peaceful soothing music intervention before bedtime and a brisk walking exercise combined with music in the evening on the subjective and objective sleep quality of sedentary middle-aged and older adults with chronic insomnia. The current study considered the following hypotheses: Hypothesis 1. : Participants who receive a soothing music intervention before bedtime for two nights exhibit higher sleep quality scores than no-music baseline scores. Hypothesis 2. : Participants who perform brisk walking exercise combined with music in the evening for two nights exhibit higher sleep quality scores than no-exercise baseline scores.

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Hypothesis 3. : Objective sleep quality scores do not differ between listening to soothing music and performing brisk walking exercise combined with music. Hypothesis 4. : Subjective sleep quality scores do not differ between listening to soothing music and performing brisk walking exercise combined with music. Except for the four hypotheses, the participants' perceptions of the interventions were also evaluated. 4. Method 4.1. Design A randomized controlled crossover trial was conducted to compare the effectiveness of listening to soothing music before bedtime and performing a treadmill brisk walking exercise combined with music in the evening. Participants were randomly assigned to a 2-week sequence that involved (a) listening to soothing music for two consecutive days (Chang et al., 2012) in the first week, followed by brisk walking while listening to music in the next week for another two days, or (b) brisk walking combined with music for two days in the first week, followed by the soothing music intervention in the second week for two days. No adaptation night prior to the study nights was necessary because the participants were not required to sleep in unfamiliar environments. The two interventions were separated by one week (Lai, Li, & Lee, 2012). 4.2. Participants Participants were invited for the study through the flyer advertisements. This study used purposive sampling to recruit 38 eligible participants who were community-residing older adults with chronic initiating and the maintaining of sleep complaints. To achieve a power of 0.8 at α = 0.05, two-tailed, with a medium effect size (de Niet et al., 2009; Wang, Sun, & Zang, 2014), a medium correlation among repeated measures (Chang et al., 2012; Su et al., 2013), the size of each sequence was computed to be 30 (Stevens, 1996) and 25% was added for attrition. Consequently, 38 participants were recruited. To qualify for participation in the study, participants were required to: (a) have experienced insomnia N5 (Pittsburgh Sleep Quality Index; PSQI) at screening (Buysse, Reynolds, Monk, Berman, & Kupfer, 1989) for at least one month; (b) be N50 years of age; (c) exhibit normal cognitive functioning (≥9 correct answers on the Short Portable Mental Status Questionnaire: Pfeiffer, 1975); and (e) be sedentary (b20 min of exercise, no more than three times/week) for at least 6 months before entering the study. Exclusion criteria were as follows: (a) sleep apnea (American Academy of Sleep Medicine, 2005), (b) psychiatric or neurological problems, (c) history of alcohol or drug abuse, (d) taking sleeping pills habitually, and (e) heart disease. Over a 15-month period, 59 adults were contacted; 21 were disqualified because five exercised regularly, five disliked the selected music, and 11 were too young to participate in the study. The remaining 38 were volunteers who completed the study assessments. 4.3. Experimental intervention Interventions alternated between listening to soothing music and performing a treadmill brisk walking exercise while listening to music and vice versa. Each intervention lasted for 30 min each day, 2 days a week, and was then alternated to another intervention for 2 days in the following week. The soothing music intervention was implemented at the homes of the participants (Chang et al., 2012), but the brisk walking exercise combined with music was implemented at our research center. No participants traveled across time zones within the 2-week study period. The two intervention sessions were conducted on the

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same day of the week for each person to reduce the influence of variations in daily schedules on outcomes. 4.3.1. Soothing music intervention The music used in this study included three peaceful Buddhist songs: Praise Buddha, Song of Praise Sambo, and Namo Shakyamuni Buddha. The length of the three pieces of music was 30 min in total. The music had tempos ranging from 60 to 80 beats/min, minor tonalities, and smooth melodies to achieve a deep relaxing effect (The Joanna Briggs Institute, 2011). The participants were instructed to play the music before bedtime, and go to sleep only when they had listened to the complete 30-min music session. Music volume was adjusted by the participants to a comfortable listening level. During this intervention, the participants were instructed to sit in a comfortable chair while listening to the music. The participants were also instructed to play the music at a comfortable volume with a comfortable room temperature, wearing comfortable nightclothes with lights out, and eyes closed. 4.3.2. Brisk walking exercise with music intervention For the brisk walking intervention, participants were instructed to perform walking bouts on treadmills (Performance 40,700 X-BIKE, Taichung, Taiwan) for 30 min from approximately 5:30 pm to 7:30 pm for two days. Walking velocity (WV) was set at 100/min. Walking speed was sent at 3.5 mph. During the brisk walking session, music (Staying Alive, Zounds Music, Germany) was played to maintain the constant walking tempo and speed of the participants. The tempo of this music piece was also 100 beats/min. The participants were prepared for the interventions and sleep study by a trained registered nurse. 4.4. Variables and measures 4.4.1. Insomnia In this study, insomnia was defined as a difficulty in initiating or maintaining sleep, or as nonrestorative sleep accompanied by decreased daytime functioning (American Academy of Sleep Medicine, 2005), which persisted for at least one week (Schutte-Rodin et al., 2008). In the present study, the outcome measurements of objective and subjective sleep were assessed using electroencephalography (EEG) and visual analogue scale (VAS). 4.4.2. Electroencephalography Objective sleep quality was measured using a one-channel EEG sensor together with the actigraph to be able to define light-sleep and slowwave-sleep, and to detect REM-phases in the EEG (SOMNO-medics GmbH, Germany). This one-channel-EEG recorded on an actigraphy device for sleep analysis versus polysomnographic sleep diagnostics shows high conformity among adults with sleep disordered breathing (Fietze et al., 2015). Sleep recordings were scored at 30-second intervals for each stage of sleep, using standard criteria (American Academy of Sleep Medicine and Iber, 2007). EEG data were analyzed using the DOMINO software (DOMINO 2.2.0 Germany). The advantage of a portable sleep-EEG device is that participants can sleep at home in familiar surroundings. The device provided an assessment of total sleep time (TST), sleep period time (SPT), sleep onset latency (SOL), sleep efficiency (SE%), stages 1 to 4, REM-sleep, REM-sleep latency, and wake after sleep onset (WASO). The sensitivity of the device was up to 0.004 G, with a range of +/−8.7 G. The sampling rate of the EEG (F4/M1) was 256 Hz. Sleep polygraphs were visually analyzed by a certified sleep technician, applying standard procedures. 4.4.3. Visual analogue scale Four aspects of sleep were assessed: ease of falling sleep, perceived quality of sleep, ease of awakening from sleep, and daytime functioning (Lai et al., 2015). To assess subjective experiences, the VAS is a more sensitive tool than a Likert-type scale (Gift, 1989). The scale consisted

of a horizontal 100-mm line with an affixed scale, and was administered at baseline and at each intervention. Higher values indicated higher quality sleep. A total of 30 community-residing elderly people with sleep disturbance participated in the reliability test of the VAS before the study commenced. The test–retest reliability was awarded at two time points separated by a 2-week interval. The test–retest correlation coefficients of the variables ranged from 0.86 to 0.95. The results indicated satisfactory instrument reliability. The VAS was used in this study as the outcome measurement. 4.4.4. Pittsburgh sleep quality index The PSQI (Buysse et al., 1989) is a self-report questionnaire that assesses sleeping habits during the previous month, and consists of 19 self-rated questions. The 19 items are grouped into seven component scores. The sum is a sleep quality score ranging from 0 to 21 (global PSQI score), with higher scores indicating lower sleep quality. Scores N5 points identified participants suffering from poor sleep quality (Buysse et al., 1989). Cronbach's α for the seven components was 0.83. The Chinese version of the PSQI score N 5 exhibited a sensitivity and specificity of 98% and 55%, respectively, for people with insomnia (Tsai et al., 2005). PSQI was used to determine eligibility for participation in this study. 4.4.5. Anxiety A 1-item VAS (Davey, Barratt, Butow, & Deeks, 2007) was used in our study to evaluate the anxiety participants felt at a particular moment. The VAS is a 0-cm horizontal line marked by a vertical line at a 1 cm interval to show subjects' anxious levels. The VAS anxiety scale ranged from not anxious at all to extremely anxious. The correlation between the two anxiety scores measured using the State–Trait Anxiety Inventory and VAS was 0.78 (Davey et al., 2007). The anxiety score was measured before each intervention as a covariate for the study. 4.4.6. Intervention evaluation Two items were used to evaluate the subjective experiences of the participants associated with the intervention conditions. The first item was used to ask the participants to rate which intervention they preferred. The second item was used to evaluate the peacefulness of the soothing music. The evaluation of the peacefulness of the soothing music applied a VAS, which used a horizontal 100-mm line with an affixed scale; the left end of the scale represented not at all, and the right end of the scale represented very much. 4.5. Procedures A screening questionnaire was used before participants were included in the study. Eligibility was assessed one week prior to commencing the study. After baseline data were collected at the research center, random drawing of lots was used to select which sequence each participant would be assigned to first (soothing music followed by a treadmill brisk walking exercise with a music sequence, or a treadmill brisk walking exercise with music followed by a soothing music sequence). Participants were instructed to refrain from using caffeine and alcohol during the study period; they were also instructed on how to use the portable EEG and ensure that they could self-administer it at home at bedtime. Participants took the sleep recording equipment home, and used it at bedtime. After collecting baseline sleep data on the first night each week, the two intervention conditions were implemented in two consecutive weeks, one week for each intervention. Each intervention lasted for two consecutive nights. Participants in the brisk walking group were instructed to arrive at the research center from approximately 5:30 to 7:30 pm for preparing and performing the treadmill exercise. Participants in the music group received an MP3 file, and were instructed to listen to the music for 30 min just before their sleep time. All participants slept in their usual home environment, and were asked to maintain their usual sleep–wake rhythm; they wore a portable

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EEG during the study nights, with continuous recording of sleep parameters during the night. After the 2-week study was completed, the participants were asked to rate which intervention they preferred. They also rated how peaceful the soothing music sounded to them on a scale of VAS. All sleep scoring was performed by a certified sleep technician. 4.6. Ethical consideration This study was approved by the Research Ethics Committee of the hospital. The study procedures were conducted after obtaining the informed consents from the participants. Participation in this study was voluntary. Participants had the right to withdraw from the study at any time. 4.7. Statistical analysis Data were analyzed using PASW 18.0 for Windows (SPSS Inc., Chicago, IL, USA). Data were reported as means and standard deviation (SD). Analysis of variance (ANOVA) was used to evaluate within-group comparisons. Based on the two-condition crossover design, generalized estimating equation (GEE) analysis was used to address carry-over effect and period effect and to control for changes in time and baseline values (Liang & Zeger, 1986). GEE can be used to account for the correlation between observations in generalized linear regression models. By using GEE, the response can be scale, counts, binary, or events-in-trials. Also it can be used to model correlated data from longitudinal or repeated measures studies. Baseline outcome measurements were used as covariates in the data analysis. Statistical significance was determined by p b .05. The Bonferroni corrections were used for performing post hoc multiple t-tests comparisons at various time points. 5. Results 5.1. Demographic characteristics Participants in this study were middle-aged and elderly adults with insomnia, who did not exercise regularly (Table 1). In this study, participants served as their own control because they were exposed to both music and brisk walking conditions, and were therefore equivalent in demographic characteristics. Table 1 presents the frequency distribution of the descriptive variables of the sample. The 38 participants had ages ranging from 50 to 75 years (mean age = 56.42 years, SD = 6.35), and most were female (n = 30, 78.9%), married (n = 31, 81.6%), and Taiwanese (n = 33, 86.8%). The mean scores for the global PSQI and state anxiety were 8.92 and 5.6, respectively, indicating that the participants were in states of insomnia and moderate anxiety. No significant correlations were observed between any sleep parameters and anxiety.

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Table 1 Participants' characteristics (N = 38). Variables Gender Male Female Marital status Married Single (widow/widower/divorced) Ethnicity Chinese Taiwanese Hakka Religious None Buddhist Taoist Protestant Christian Education completed (n = 20) Primary/Junior high school High school Bachelor's degrees Master's degrees Employment Unemployed Employed Possible range Mean age in years Sleep quality (PSQIa) Anxiety (VASb) a&b a b

0–21 0–10

N

%

8 30

21.1 78.9

31 7

81.6 18.4

2 33 3

5.3 86.8 7.9

8 19 8 3

21.1 50.0 21.1 7.9

3 14 2 1

7.9 36.8 52.6 2.6

21 17

55.3 44.7

Mean 56.42 8.92 5.6

SD 6.35 3.08 2.24

were both measured at onset of the study. PSQI = Pittsburgh Sleep Quality Index. VAS = Visual Analogue Scale.

Hypothesis 2 was also partially supported. In brisk walking intervention, the SOL changed over the three points of measurement (from day 1 to day 3). ANOVA revealed significant differences in SOL for brisk walking intervention (F = 6.124(1,36), p = .003; Table 2). The post hoc t tests revealed that SOL on day 3 was significantly shorter (p = .002) than the no-exercise baseline data. Furthermore, a trend for WASO was observed in the brisk walking session, although the decreased time did not reach statistical significance. Regarding Hypothesis 3 (Table 3), GEE results for WASO also differed significantly between music and brisk walking (p b .001), indicating that listening to soothing music before bedtime significantly shortened the WASO compared with brisk walking in the evening. Therefore, the findings partially support Hypothesis 3. No significant differences were observed in any other objective sleep parameters (Table 2). Furthermore, no other significant differences were observed between the two interventions in the mean TST, SE, N1–N3 stages, REM stage, or number of awakenings.

5.3. Subjective sleep data 5.2. Electroencephalography sleep data Table 2 displays the objective and subjective sleep parameters at the baseline (day 1) and after music and brisk walking interventions (day 2 & 3). We used the generalized estimating equation (GEE) method to estimate the carry-over effect and period effect, and determined that the order of interventions, previous intervention, and interaction did not reach statistical significance, indicating that no carry-over effect or period effect was present in this study. Testing Hypothesis 1, ANOVA revealed significant differences in SOL (p = .04) and WASO (p b .001) across time for the music intervention (Table 2). The post hoc t test revealed that SOL was significantly shorter (p = .02) on day 3 than the baseline data for the music intervention. Moreover, WASO was significantly shorter (p b .001) on day 2 compared to the no-music baseline. These findings partially supported H1.

Regarding the four aspects of subjective sleep, no differences between the two conditions were observed in any subjective sleep parameter (Table 3). These results revealed that both the soothing music and brisk walking exercise combined with music exhibited the same effects on subjective sleep quality. These findings supported Hypothesis 4. Moreover, participants reported averages between 5.95 and 7.39 at the baseline on the self-reporting questionnaires (Table 2). Using ANOVA analysis to compare the effects of music and exercise with music on the subjective sleep parameters at different time points, we determined that the ease of falling asleep, perceived quality of sleep, ease of awakening from sleep, and daytime functioning values exhibited significant differences (all p b .01; Table 2), indicating that the subjective sleep quality differed when participants either listened to soothing music or performed brisk walking while listening to music.

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Table 2 Mean objective sleep parameters in the two conditions during the study nights (N = 38). Parameters Objective sleep parameters TST (min) SOL (min) WASO (min) SE (%) Stage N1, % of TST Stage N2, % of TST Stage N3, % of TST Stage REM, % of TST Number of awakenings Subjective sleep parameters Ease of falling sleep Perceived quality of sleep Ease of awakening from sleep Daytime functioning

Condition

Day 1 (baseline) mean (SD)

Day 2 mean (SD)

Day 3 mean (SD)

F

p

Soothing music Brisk walking with music Soothing music Brisk walking with music Soothing music Brisk walking with music Soothing music Brisk walking with music Soothing music Brisk walking with music Soothing music Brisk walking with music Soothing music Brisk walking with music Soothing music Brisk walking with music Soothing music Brisk walking with music

336.26 (92.24) 337.45(97.62) 28.76(23.09) 29.65(22.90) 30.85(15.03) 27.06(18.15) 76.66(13.57) 78.30(17.58) 14.10(12.84) 13.25(10.22) 55.98(12.34) 57.62(11.41) 20.61(9.56) 20.80(10.28) 9.29(7.65) 8.14(6.35) 23.60(10.57) 24.84(12.42)

340.13(100.35) 342.39(94.46) 20.70(20.40) 23.18(22.41) 14.25(7.91) 24.18(18.40) 79.23(15.84) 80.56(13.72) 16.16(17.79) 16.06(13.20) 58.19(16.75) 55.72(13.06) 18.43(11.49) 20.32(10.64) 7.23(5.68) 7.90(6.84) 21.92(12.74) 24.26(13.01)

324.39(86.07) 337.52(73.78) 17.47(21.55) 17.31(13.10) 14.07(8.20) 20.32(15.16) 79.41(15.12) 80.01(11.80) 16.25(13.94) 14.93(11.50) 55.39(12.48) 57.49(10.61) 19.57(8.96) 19.65(9.99) 8.76(7.47) 7.90(6.83) 25.5(14.57) 24.84(11.69)

0.49 0.03 3.28 6.12 15.56 1.94 0.48 0.72 0.92 2.15 0.99 0.42 0.941 0.304 1.604 0.04 2.25 0.00

0.613 0.975 0.04 0.003 b0.001 0.152 0.622 0.492 0.404 0.124 0.378 0.658 0.395 0.739 0.208 0.965 0.113 N .999

6.92(2.14) 7.00(1.95) 7.26(1.76) 7.61(1.71) 8.08(1.42) 7.89(1.33) 8.08(1.42) 8.30(1.39)

7.13(1.64) 7.34(2.16) 7.58(1.78) 7.68(1.75) 8.18(1.33) 8.45(1.28) 8.24(1.42) 8.50(1.24)

10.29 8.78 8.37 5.69 6.38 11.23 5.026 14.15

0.003 b0.001 0.001 0.005 0.003 b0.001 0.009 b0.001

Soothing music Brisk walking with music Soothing music Brisk walking with music Soothing music Brisk walking with music Soothing music Brisk walking with music

5.95(2.14) 6.03(2.22) 6.05(2.34) 6.76(2.22) 7.26(1.79) 7.21(1.59) 7.39(1.62) 7.32(1.72)

Note: TST: minutes of total sleep time; SOL: sleep onset latency; WASO: wake time after sleep onset; SE: sleep efficiency (total sleep time/total recording time); REM: rapid eye movement sleep.

5.3.1. Evaluation of interventions After the study was completed, the participants rated their preference of interventions. The majority of participants (n = 35, 92.1%) preferred listening to soothing music to the brisk walking intervention for improving their sleep quality. Moreover, the participants rated the soothing music as peaceful (higher than 9.13 of 10 points). 6. Discussion This study revealed that both a soothing music intervention and brisk walking combined with music resulted in improvements in objective and subjective sleep. EEG revealed that both interventions shortened SOL, compared with the baseline scores for adults with insomnia. Soothing music had stronger effect on the WASO than the brisk walking did. No differences between the two interventions were observed in Table 3 GEE analysis to estimate sleep condition differences (N = 38). Outcome measure Objective sleep parameters TST (min) SOL (min) WASO (min) SE (%) Stage N1, % of TST Stage N2, % of TST Stage N3, % of TST Stage REM, % of TST No. of awakenings Subjective sleep parameters Ease of falling sleep Perceived quality of sleep Ease of awakening from sleep Daytime functioning

β

Exp(β)

95% CI

p-value

−0.04 −0.01 −0.49 −0.04 0.22 −0.06 0.26 0.04 −0.03

0.96 0.99 0.61 0.96 1.25 0.96 1.30 1.04 0.97

0.81, 1.16 0.76, 1.29 0.51, 0.73 0.89, 1.03 0.98, 1.59 0.87, 1.05 0.95, 1.78 0.67, 1.64 0.71, 1.35

0.67 0.94 b0.001 0.25 0.07 0.35 0.10 0.85 0.87

0.01 −0.06 −0.05 −0.05

1.00 0.94 0.95 0.96

0.84, 1.20 0.83, 1.07 0.86, 1.06 0.86, 1.07

0.99 0.33 0.37 0.41

Note: Reference group: brisk walking; TST: minutes of total sleep time; SOL: sleep onset latency; SE: sleep efficiency (total sleep time/total recording time); WASO: wake time after sleep onset; REM: rapid eye movement sleep. Baseline data of sleep parameters were controlled for in the model.

subjective sleep. The soothing music that was selected by the investigators that consisted of 30-min peaceful Buddhist songs that were used before bedtime also reduced the values of the WASO, compared with the baseline values. Because very few studies have used EEG to examine the effects of short period of time of brisk walking combined with music intervention in the evening on sleep quality, we cannot compare our results with those of other studies. Although the duration of interventions differed between our study and previous studies (Erlacher et al., 2014; Passos et al., 2011; Reid et al., 2010), these findings indicate that interventions involving moderate exercise reduce sleep latency in sedentary adults with insomnia. Passos et al. (2011) observed a reduction in polysomnographic SOL and WASO in older adults with sleep complaints after a 6month program of moderate aerobic exercise. Another study of older adults with chronic insomnia, performed by Reid et al. (2010), revealed an increase in the self-reported sleep quality after a moderate 4-month aerobic exercise program with sleep hygiene education in people with primary insomnia. These previous studies on the effects of exercise training on sleep have focused on effects of longer duration of interventions. Unlike previous studies, the current study determined that brisk walking combined with music in the evening exerts effects on SOL reduction (Table 2), and also improves subjective sleep quality. The results of this study supported the propositions of Buman et al. (2014), who suggested that evening exercise is a positively perceived intervention with therapeutic benefits for sleep quality. Although some studies have confirmed the effects of soothing music on objective sleep quality, results have been inconclusive. In the present study, music was effective in reducing SOL and WASO, as measured using EEG. However, Chang et al. (2012) observed that music exerted little effect on stage 2 and REM sleep in a group of 50 chronic insomniac adults. A recent study using polysomnography revealed that 45 min of soothing music is an effective treatment approach for improving the stage 3 sleep quality and self-reported sleep quality in ICU patients (Su et al., 2013). A key reason for this inconsistency might be the distinct study populations used, which included diverse degrees of insomnia and even people without insomnia (Lazic & Ogilvie, 2007). However,

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the effect of short period of time of music intervention on sleep quality was reported by these studies. The duration of music interventions might influence their effects. Although it has been suggested that 3 days (Chang et al., 2012) of music intervention were sufficient to attain positive effects on sleep quality, our study attained positive effects on WASO in only one night. However, the observations regarding the treatment effects were only implemented for two nights in the current study, which limited the findings on the efficacy of both interventions. Moreover, the SOL of the participants on day 3 was still 20 min long in the music session and 17 min long in the brisk walking session. After the interventions, the participants were still suffering from sleep problems. A longer period of time of the intervention may require improving sleep quality. We collected the data immediately after the intervention; thus, the intervention length required to produce these effects is clear. A single-session intervention after their implementation is common in clinical settings, so our study design would accurately represent contemporary clinical practice. We also observed that both interventions helped the participants to improve their subjective sleep quality. The scores of the four aspects of subjective sleep on both intervention nights were higher than the baseline scores. Our results agree with those of de Niet et al. (2009), who conducted a meta analysis and reported that music exerted a moderate effect on the subjective sleep quality of patients with sleep complaints. The subjective data agreed more closely with the primary means of determining a clinical improvement than did the objective data. This study was unique because it was one of the first studies to implement soothing music and brisk walking interventions for improving sleep quality, and the selected soothing music evaluated by the study participants was peaceful. The soothing music intervention might have contributed to the beneficial effects on sleep, because all participants rated the music as peaceful (higher than 9 of 10 points), which might have induced an inner peaceful state, and hence might have resulted in improved sleep. The Buddhist songs might also appeal to the Buddhist participants with insomnia as a method to induce sleep. The results of this study confirmed the Meyer theory (Meyer, 1956) that the most critical factor influencing the effects of music is the musical preference of the listener. Moreover, the preference of interventions can translate into improved sleep quality, as manifested by the shorter WASO determined using EEG. Our study design included an evaluation of the effectiveness of soothing music and brisk walking, using both objective and subjective assessments of sleep quality. A carry-over effect was not likely in this study, indicating that the one week was a sufficient washout period for this intervention. EEG sleep assessments were adopted, which are more accurate than self-report questionnaires. In this study, no participants withdrew during the study period, likely because of the advantages of portable EEG, which comprise few sleep disturbances, easy application, and the opportunity to record multiple day and night periods without interruption. Furthermore, sleep was monitored in the home environment, and was less susceptible to laboratory conditions. The results obtained did not show a substantial first-night effect for the primary outcome, indicating that no adaptation nights prior to study nights are required for performing portable EEG.

with music to improve sleep onset; however, our participants were healthy, older, sedentary, and mainly female, which negatively affected the ability to generalize results. Future studies can recruit diverse age groups and patients to produce results that are more comprehensive than those presented here. Third, listening to soothing music for as little as 30 min was shown to exert a positive effect on WASO, and listening to such music for two nights was shown to exert a positive effect on the SOL in this study. Additional research is recommended to test the effect of both interventions regarding various durations at various times for determining when the maximum benefits of music and exercise are achieved. However, the short period of time of music and brisk walking interventions might not have been strong enough to detect any substantial effects of music and exercise on other sleep parameters. Finally, an important aspect relates to the fact that music with such different musical characteristics has led to the same result when associated with exercise. Fast songs led to an increase in energy for the brisk walking exercise to be performed; the mechanisms between the two types of music used may be different. Moreover, regardless of preference for one intervention, similar results were observed. Hence, the mechanism that trigger sleep better in both interventions deserves to be further examined. We applied equal exercise intensities for all participants; however, sleep quality might be influenced by the energy expenditure of the participants, which depends on their body weights. Future studies can examine whether the intensity of exercise mediates any effect on sleep in older adults with insomnia. The brisk walking exercise was combined with music; thus, whether the effects were due to the music is unclear and additional studies are required to explore the secondary role of music associated to exercise.

7. Limitations and implications

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This study has some limitations. First, it is important to note that the level of sleep pathology was rather mild (baseline PSQI =8.92). The sleep efficiency at baseline was close to normal, suggesting that these participants have problems getting up too early in the morning, with neither of these interventions were likely to address. Additionally, the post intervention sleep parameters were still within pathological levels and thus, both interventions of the present study are considered complimentary interventions for sleep quality. Second, the findings of this study demonstrate that health care workers can use soothing music and brisk walking exercises combined

8. Conclusion This study is one of the first to compare the effects of short period of time of soothing music intervention and a treadmill brisk walking exercise with music intervention on the subjective and objective sleep parameters of adults with insomnia. Both interventions exhibited the same beneficial effects on subjective sleep quality. Portable EEG revealed that listening to soothing music can be beneficial for reducing the SOL and WASO. A treadmill brisk walking exercise combined with music provides another option for health care providers to improve sleep onset in sedentary adults with insomnia. These findings contribute to the knowledge in the general health and nursing literature on the effects of music and exercise on sleep. The interventions applied in this study could be used as the evidence-based nursing interventions provided to insomniac older adults by nursing staff. Acknowledgment The authors thank Li-Hua Lee of Tzu Chi University for assistance with data collection. We also thank Hsiu -Mei Wang of Tzu Chi Hospital for laboratory technical support.

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