Practice recommendations for the role of physiotherapy in the management of sleep disorders: the 2022 Brazilian Sleep Association Guidelines.

This clinical guideline supported by the Brazilian Sleep Association comprises a brief history of the development of Brazilian sleep physiotherapy, outlines the role of the physiotherapist as part of a sleep health team, and describes the clinical guidelines in respect of the management of some sleep disorders by the physiotherapist (including sleep breathing disorders, i.e., obstructive sleep apnea, central sleep apnea, upper airway resistance syndrome, hypoventilation syndromes and overlap syndrome, and pediatric sleep breathing disorders; sleep bruxism; circadian rhythms disturbances; insomnia; and Willis-Ekbom disease/periodic limb movement disorder. This clinical practice guideline reflects the state of the art at the time of publication and will be reviewed and updated as new information becomes available.

Physical exercise as a therapeutic approach for adults with insomnia: systematic review and meta-analysis.

OBJECTIVE: To systematically review the effects (benefits and harms) of different types of physical exercise on insomnia outcomes in adult populations with no mood disorders. Objective and subjective sleep outcomes and related mismatches were analyzed. METHODS: Systematic review and meta-analysis. Quality of evidence was also examined. RESULTS: Six studies including 295 participants with insomnia diagnosis were selected. Yoga, Tai Chi, resistance exercise and aerobic exercise were used in protocols with different duration, intensity and frequency. Studies involved different populations, including inactive or sedentary individuals, older adults and postmenopausal women. Physical exercise improved subjective sleep quality (very low quality of evidence) and reduced insomnia severity (high quality of evidence). CONCLUSION: Findings suggest individualized physical exercise must be addressed to design optimal protocols, with standardized type, duration, intensity, and frequency. For the time being, physical exercise may be considered an alternative and/or ancillary therapeutic modality for patients diagnosed with insomnia. Physical exercise can be used to improve subjective complaints, but not objective sleep outcomes.

Effects of resistance exercise training and stretching on chronic insomnia

Objective: The aim of this study was to assess the effects of resistance exercise and stretching on sleep, mood, and quality of life in chronic insomnia patients. Methods: Three 4-month treatments included: resistance exercise (n=10), stretching (n=10), and control (n=8). Sleep was evaluated with polysomnography, actigraphy, and questionnaires. Mood and quality of life were assessed with the Profile of Mood States (POMS) and the Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36), respectively. Results: There were no significant treatment differences between resistance exercise and stretching. However, compared with the control treatment, resistance exercise and stretching led to significantly greater improvements in Insomnia Severity Index scores (-10.5±2.3, -8.1±2.0 vs. 2.3±1.8, respectively), and actigraphic measures of sleep latency (-7.1±4.6, -5.2±1.9 vs. 2.2±2.1 min), wake after sleep onset (-9.3±2.8, -7.1±3.0 vs. 3.6±4.2 min), and sleep efficiency (4.4±1.8, 5.0±0.8 vs. -2.3±2%). Pittsburgh Sleep Quality Index (PSQI) global scores (-5.3±0.8, -3.9±1.5 vs. -0.1±0.8) and sleep duration (1.2±0.3, 1.6±0.6 vs. -0.1±0.2 h) also improved following both experimental treatments compared with control. PSQI-Sleep efficiency increased after resistance exercise compared with control (19.5±3.9 vs. 2.1±4.3%). No significant differences were observed in polysomnography or quality of life measures. Tension-anxiety was lower in the stretching group than the control group. Conclusion: Moderate-intensity resistance exercise and stretching led to similar improvements in objective and subjective sleep in patients with chronic insomnia. Clinical trial registration: NCT01571115

Effects of resistance exercise training and stretching on chronic insomnia.

OBJECTIVE: The aim of this study was to assess the effects of resistance exercise and stretching on sleep, mood, and quality of life in chronic insomnia patients. METHODS: Three 4-month treatments included: resistance exercise (n=10), stretching (n=10), and control (n=8). Sleep was evaluated with polysomnography, actigraphy, and questionnaires. Mood and quality of life were assessed with the Profile of Mood States (POMS) and the Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36), respectively. RESULTS: There were no significant treatment differences between resistance exercise and stretching. However, compared with the control treatment, resistance exercise and stretching led to significantly greater improvements in Insomnia Severity Index scores (-10.5±2.3, -8.1±2.0 vs. 2.3±1.8, respectively), and actigraphic measures of sleep latency (-7.1±4.6, -5.2±1.9 vs. 2.2±2.1 min), wake after sleep onset (-9.3±2.8, -7.1±3.0 vs. 3.6±4.2 min), and sleep efficiency (4.4±1.8, 5.0±0.8 vs. -2.3±2%). Pittsburgh Sleep Quality Index (PSQI) global scores (-5.3±0.8, -3.9±1.5 vs. -0.1±0.8) and sleep duration (1.2±0.3, 1.6±0.6 vs. -0.1±0.2 h) also improved following both experimental treatments compared with control. PSQI-Sleep efficiency increased after resistance exercise compared with control (19.5±3.9 vs. 2.1±4.3%). No significant differences were observed in polysomnography or quality of life measures. Tension-anxiety was lower in the stretching group than the control group. CONCLUSION: Moderate-intensity resistance exercise and stretching led to similar improvements in objective and subjective sleep in patients with chronic insomnia. CLINICAL TRIAL REGISTRATION: NCT01571115.

Association of subclinical inflammation, glycated hemoglobin and risk for obstructive sleep apnea syndrome.

OBJECTIVE: To investigate the inter-relation between high sensitivity C-reactive protein and glycated hemoglobin in prediction of risk of obstructive sleep apnea. METHODS: We included all individuals participating in a check-up program at the Preventive Medicine Center of Hospital Israelita Albert Einstein in 2014. The Berlin questionnaire for risk of obstructive sleep apnea was used, and the high sensitivity C-reactive protein and glycated hemoglobin levels were evaluated. RESULTS: The sample included 7,115 participants (age 43.4±9.6 years, 24.4% women). The Berlin questionnaire showed changes in 434 (6.1%) individuals. This finding was associated with high sensitivity C-reactive protein and glycated hemoglobin levels (p<0.001). However, only the association between the Berlin questionnaire result and glycated hemoglobin remained significant in the adjusted multivariate analysis, for the traditional risk factors and for an additional model, including high-density lipoprotein cholesterol and triglycerides. CONCLUSION: The glycated hemoglobin, even below the threshold for diagnosis of diabetes, is independently associated with obstructive sleep apnea syndrome, even after adjustment for obesity and C-reactive protein. These findings suggest a possible pathophysiological link between changes in insulin resistance and obstructive sleep apnea syndrome, independently from obesity or low-grade inflammation. OBJETIVO: Investigar a inter-relação entre proteína C-reativa de alta sensibilidade e hemoglobina glicada na predição do risco de apneia obstrutiva do sono. MÉTODOS: Foram incluídos todos os indivíduos participantes do programa de check-up do Centro de Medicina Preventiva Hospital Israelita Albert Einstein em 2014. Foi aplicado o questionário de Berlin sobre risco de apneia do sono, e avaliadas as dosagens de hemoglobina glicada e proteína C-reativa de alta sensibilidade. RESULTADOS: Foram incluídos 7.115 participantes (idade 43,4±9,6 anos, 24,4% mulheres). A prevalência de alteração no questionário de Berlin foi de 434 (6,1%). A alteração do questionário de Berlin associou-se positivamente aos resultados da proteína C-reativa de alta sensibilidade e da hemoglobina glicada (p<0,001). No entanto, apenas a associação entre o resultado do questionário de Berlin e a hemoglobina glicada permaneceu significativa na análise multivariada ajustada tanto para fatores de risco tradicionais quanto para um modelo adicional, que incluiu também lipoproteína de alta densidade-colesterol (HDL-c) e triglicérides. CONCLUSÃO: A hemoglobina glicada, mesmo em valores abaixo do critério diagnóstico para diabetes mellitus, está associada de forma independente ao risco para síndrome da apneia obstrutiva do sono, mesmo após ajuste para obesidade e proteína C-reativa. Estes achados sugerem possível ligação fisiopatológica entre alterações na resistência insulínica e a síndrome da apneia obstrutiva do sono, que independe da obesidade ou inflamação de baixo grau.

Association of subclinical inflammation, glycated hemoglobin and risk for obstructive sleep apnea syndrome / Associação entre inflamação subclínica, hemoglobina glicada e risco de apneia obstrutiva do sono

ABSTRACT Objective To investigate the inter-relation between high sensitivity C-reactive protein and glycated hemoglobin in prediction of risk of obstructive sleep apnea. Methods We included all individuals participating in a check-up program at the Preventive Medicine Center of Hospital Israelita Albert Einstein in 2014. The Berlin questionnaire for risk of obstructive sleep apnea was used, and the high sensitivity C-reactive protein and glycated hemoglobin levels were evaluated. Results The sample included 7,115 participants (age 43.4±9.6 years, 24.4% women). The Berlin questionnaire showed changes in 434 (6.1%) individuals. This finding was associated with high sensitivity C-reactive protein and glycated hemoglobin levels (p<0.001). However, only the association between the Berlin questionnaire result and glycated hemoglobin remained significant in the adjusted multivariate analysis, for the traditional risk factors and for an additional model, including high-density lipoprotein cholesterol and triglycerides. Conclusion The glycated hemoglobin, even below the threshold for diagnosis of diabetes, is independently associated with obstructive sleep apnea syndrome, even after adjustment for obesity and C-reactive protein. These findings suggest a possible pathophysiological link between changes in insulin resistance and obstructive sleep apnea syndrome, independently from obesity or low-grade inflammation.

RESUMO Objetivo Investigar a inter-relação entre proteína C-reativa de alta sensibilidade e hemoglobina glicada na predição do risco de apneia obstrutiva do sono. Métodos Foram incluídos todos os indivíduos participantes do programa de check-up do Centro de Medicina Preventiva Hospital Israelita Albert Einstein em 2014. Foi aplicado o questionário de Berlin sobre risco de apneia do sono, e avaliadas as dosagens de hemoglobina glicada e proteína C-reativa de alta sensibilidade. Resultados Foram incluídos 7.115 participantes (idade 43,4±9,6 anos, 24,4% mulheres). A prevalência de alteração no questionário de Berlin foi de 434 (6,1%). A alteração do questionário de Berlin associou-se positivamente aos resultados da proteína C-reativa de alta sensibilidade e da hemoglobina glicada (p<0,001). No entanto, apenas a associação entre o resultado do questionário de Berlin e a hemoglobina glicada permaneceu significativa na análise multivariada ajustada tanto para fatores de risco tradicionais quanto para um modelo adicional, que incluiu também lipoproteína de alta densidade-colesterol (HDL-c) e triglicérides. Conclusão A hemoglobina glicada, mesmo em valores abaixo do critério diagnóstico para diabetes mellitus, está associada de forma independente ao risco para síndrome da apneia obstrutiva do sono, mesmo após ajuste para obesidade e proteína C-reativa. Estes achados sugerem possível ligação fisiopatológica entre alterações na resistência insulínica e a síndrome da apneia obstrutiva do sono, que independe da obesidade ou inflamação de baixo grau.

Chronotype and anxiety are associated in patients with chronic primary insomnia

Objective: To assess the interaction of chronotype with anxiety in patients with chronic primary insomnia. Methods: Sixty-four patients (50 women) with mean age 43.9±8.1 years were investigated with the Horne and Östberg Morningness-Eveningness Questionnaire (MEQ) and State-Trait Anxiety Inventory (STAI). Results: Significant negative correlations of chronotype-MEQ score with STAI state-anxiety (r = -0.40, p < 0.05), STAI trait-anxiety (r = -0.40, p < 0.05), and STAI pre-sleep state anxiety (r = -0.30, p < 0.05) were observed. Eveningness preference was associated with higher trait, state, and pre-sleep state anxiety. Conclusions: These results suggest that chronotype may be an important parameter to identifying the origin and significance of a vicious anxiety-insomnia-depression cycle in patients with chronic primary insomnia.

Chronotype and anxiety are associated in patients with chronic primary insomnia.

OBJECTIVE:: To assess the interaction of chronotype with anxiety in patients with chronic primary insomnia. METHODS:: Sixty-four patients (50 women) with mean age 43.9±8.1 years were investigated with the Horne and Östberg Morningness-Eveningness Questionnaire (MEQ) and State-Trait Anxiety Inventory (STAI). RESULTS:: Significant negative correlations of chronotype-MEQ score with STAI state-anxiety (r = -0.40, p < 0.05), STAI trait-anxiety (r = -0.40, p < 0.05), and STAI pre-sleep state anxiety (r = -0.30, p < 0.05) were observed. Eveningness preference was associated with higher trait, state, and pre-sleep state anxiety. CONCLUSIONS:: These results suggest that chronotype may be an important parameter to identifying the origin and significance of a vicious anxiety-insomnia-depression cycle in patients with chronic primary insomnia.

Objective short sleep duration is associated with the activity of the hypothalamic-pituitary-adrenal axis in insomnia.

OBJECTIVE: To evaluate the association between objective short sleep duration in patients with insomnia and changes in blood parameters related to hypothalamic-pituitary-adrenal (HPA) axis activity. METHOD: A cross-sectional pilot study was conducted in 30 middle-aged adults with chronic insomnia who were divided into 2 groups according to polysomnography (PSG) total sleep time (TST) (TST > 5h and < 5h). All patients underwent subjective analysis of sleep quality, anthropometric measurements, PSG, and determination off asting blood parameters. RESULTS: The results revealed lower sleep efficiency and higher sleep latency for those with a TST < 5h. The subjective sleep quality was worse in the TST < 5h. Significantly, higher glucose and cortisol levels were observed with a TST < 5h. Glucose, cortisol and ACTH levels were inversely correlated with the PSG total sleep time. CONCLUSION: Patients with insomnia with objective short sleep duration had HPA-associated endocrine and metabolic imbalances chronically linked to increases in cardiovascular risk observed with this more severe insomnia phenotype.

Brain-derived neurotrophic factor gene polymorphism predicts interindividual variation in the sleep electroencephalogram.

Previous studies have suggested that brain-derived neurotrophic factor (BDNF) participates in the homeostatic regulation of sleep. The objective of this study was to investigate the influence of the Val66Met functional polymorphism of the BDNF gene on sleep and sleep EEG parameters in a large population-based sample. In total 337 individuals participating in the São Paulo Epidemiologic Sleep Study were selected for analysis. None of the participants had indications of a sleep disorder, as measured by full-night polysomnography and questionnaire. Spectral analysis of the EEG was carried out in all individuals using fast Fourier transformation of the oscillatory signals for each EEG electrode. Sleep and sleep EEG parameters in individuals with the Val/Val genotype were compared with those in Met carriers (Val/Met and Met/Met genotypes). After correction for multiple comparisons and for potential confounding factors, Met carriers showed decreased spectral power in the alpha band in stage one and decreased theta power in stages two and three of nonrapid-eye-movement sleep, at the central recording electrode. No significant influence on sleep macrostructure was observed among the genotype groups. Thus, the Val66Met polymorphism seems to modulate the electrical activity of the brain, predicting interindividual variation of sleep EEG parameters. Further studies of this and other polymorphic variants in potential candidate genes will help the characterization of the molecular basis of sleep.

Esteatose hepática e estilo de vida ativo: revisão de literatura / Hepatic Steatosis and active lifestyle: Review of Literature

A Doença Hepática Gordurosa Não Alcoólica pode evoluir para a esteatose hepática (EH) sendo derivada do acúmulo de lipídeos nos hepatócitos, quando representa mais de 5% do peso desse órgão. Como a EH promove lesões hepáticas, tem sido considerada como uma das causas mais comuns de doenças hepáticas crônicas nos países desenvolvidos e em desenvolvimento. Considerando a forte associação com o estilo de vida, o objetivo do presente estudo foi apresentar, através de uma revisão na literatura, os principais fatores relacionados ao risco do desenvolvimento de EH e sua associação com o nível de atividade física. Assegura-se que o desenvolvimento da EH esteja relacionado ao estilo de vida, em especial com o histórico de inatividade física e hábitos alimentares pouco saudáveis, fatores associados ao desenvolvimento da síndrome metabólica. A prevalência da EH está associada ao excesso de peso e a obesidade; diabetes melitus do tipo 2 e inatividade fisica, apresentando prevalência entre 10 e 24% dapopulação mundial. A atividade física é considerada como um dos fatores moduladores mais eficazes na prevenção de doenças como a esteatose hepática, e a promoção da saúde. Assim, aumentar o nível de atividade física através das atividades da vida diária e pelo envolvimento em programas de exercícios são comportamentos desejáveis na prevenção de doenças crônicas. O presente estudo permite concluir que a EH como doença metabólica se associa com o ganho de peso e baixo nível de atividade física populacional. Os estudos indicaram que aumentar o nível de atividade física pode colaborar com a diminuição de gordura no fígado e prevenir o aparecimento do quadro de esteatose hepática. Importante frisar que outros hábitos na vida diária poderiam se associar a EH, destacando neste caso, o consumo de bebidas alcoólicas.

The nonalcoholic fatty liver disease, can be progress to hepatic steatosis (HS) or fatty liver that is derived from the accumulation of lipids in hepatocytes, representing more than 5 % by liver weight. As HS promotes liver injury, has been considered as one of the most common causes of chronic liver disease in developed countries and developing countries. The HS has a strong association with the lifestyle, so, the objective of this study was to present the principals risk factors related to the development of HS and the association with the level of physical activity. It ensures that the development of HS is related to lifestyle, especially with the history of physical inactivity and unhealthy eating habits, factors associated with the development of metabolic syndrome. The prevalence of HS is associated with weight gain and obesity, diabetes mellitus type 2 and physical inactivity, with prevalence between 10 and 24% of the world. Physical activity is considered as one of the factors modulating more effective in preventing diseases such as hepatic steatosis, and health promotion. Thus, increasing the level of physical activity through the activities of daily living and involvement in exercise programs are desirable behaviors in the prevention of chronic diseases. The present study shows that the HS as metabolic disease is associatedwith weight gain and low physical activity level population. Studies have indicated that increasing the level of physical activity can help in reducing fat in the liver and prevent the onset of hepatic steatosis frame. Important to note that other habits in daily life could be associated with HS, highlighting this case, the consumption of alcoholic beverages.

Effects of moderate aerobic exercise training on chronic primary insomnia.

OBJECTIVE: To evaluate the effect of long-term moderate aerobic exercise on sleep, quality of life, and mood of individuals with chronic primary insomnia, and to examine whether these effects differed between exercise in the morning and exercise in the late afternoon. METHODS: Nineteen sedentary individuals with chronic primary insomnia, mean age 45.0 (standard error [SE] 1.9) years, completed a 6-month exercise training protocol, randomized to morning and late-afternoon exercise groups. RESULTS: Combining polysomnographic data across both time points, this study found a significant decrease in sleep onset latency (from 17.1 [SE 2.6] min to 8.7 [SE 1.4] min; P<0.01) and wake time after sleep onset (from 63.2 [SE 12.8] min to 40.1 [SE 6.0] min), and a significant increase in sleep efficiency (from 79.8 [SE 3.0]% to 87.2 [SE 1.6]%) following exercise. Data from sleep diaries revealed significant improvement in sleep onset latency (from 76.2 [SE 21.5] min to 80.3 [SE 7.4] min) sleep quality (from 41.5 [SE 5.2]% to 59.4 [SE 6.6]%) and feeling rested in the morning (from 50.8 [SE 5.3] to 65.1 [SE 5.0]). There were generally no significant differences in response between morning and late-afternoon exercise. Following exercise, some quality-of-life measures improved significantly, and a significant decrease was seen in the following Profile of Mood State measures: tension-anxiety (from 7.2 [SE 1.0] to 3.5 [SE 1.0]), depression (from 5.9 [SE 1.2] to 3.3 [SE 1.1]) and total mood disturbance (from 9.2 [SE 4.8] to -1.7 [SE 4.8]). These effects did not vary between morning and late-afternoon exercise. CONCLUSION: Long-term moderate aerobic exercise elicited significant improvements in sleep, quality of life and mood in individuals with chronic primary insomnia.