Applied Nursing Research 32 (2016) 104–110

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Applied Nursing Research

journal homepage: www.elsevier.com/locate/apnr

Comparing the effects of music and exercise with music for older adults
with insomnia
Chiung-Yu Huang, PhD, RN a, En-Ting Chang, MD b, Hui-Ling Lai, PhD, RN b,⁎
a
Department of Nursing, I-Shou University, No.8, Yida Rd., Kaohsiung City, 82445,Taiwan, R.O.C
b
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 a b s t r a c t

Article history: Aim: To examine the effects of a soothing music intervention before bedtime and a treadmill brisk walking exer-
Received 6 November 2015 cise combined with music in the evening on sleep quality of sedentary older adults with chronic insomnia.
Revised 21 February 2016 Background: There is evidence to support the use of complementary interventions to improve sleep. They are
Accepted 19 June 2016 rarely applied in Taiwanese elderly population.
Methods: Using a crossover controlled trial, 38 participants aged 50 to 75 years were randomly assigned to a
Keywords:
music intervention/brisk walking sequence or a brisk walking/music intervention sequence. Each participant
Music
Insomnia
completed two intervention sessions (separated by 1 week). Each intervention lasted 30 min. An actigraph ex-
Exercise tended with electroencephalography (EEG) and questionnaires were used to assess the sleep quality.
Pittsburgh sleep quality index Results: Both interventions exhibited beneficial effects on subjective sleep quality in adults with insomnia. Also
Electroencephalography 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 wak-
ing, 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 in-
somnia 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: snowjade@mail.tcu.edu.tw (H.-L. Lai).
such as exercise and music, have been proposed in the health care in-
dustry 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 in-
flammation (Thompson et al., 2011), diabetes (Cappuccio, D'Elia,
Strazzullo, & Miller, 2010), and obesity (Cappuccio et al., 2008). Early in-
tervention and treatment of insomnia are necessary because the symp-
toms 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

http://dx.doi.org/10.1016/j.apnr.2016.06.009
0897-1897/© 2016 Elsevier Inc. All rights reserved.
 C.-Y. Huang et al. / Applied Nursing Research 32 (2016) 104–110
consistently resulted in improvement in sleep in middle-aged and older
adults, no study has been conducted to evaluate the effects of short pe-
riod 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 im-
plementation is common, so our study design would accurately repre-
sent 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 in-
convenient to their schedule. However, Buman, Phillips, Youngstedt,
Kline, and Hirshkowitz (2014) reported that evening exercise was ben-
eficial 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 multi-
factorial. It has been suggested that the effects of exercise on sleep are re-
lated 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 ex-
pected to improve sleep quality. Approximately 40% to 50% of the pop-
ulation uses music therapy as a self-help strategy to improve sleep
(Furihata et al., 2011). Researchers conducting studies using meta anal-
ysis 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 out-
come. 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 trig-
gers 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 interven-
tion 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.
105
Hypothesis 3. : Objective sleep quality scores do not differ between
listening to soothing music and performing brisk walking exercise com-
bined with music.
Hypothesis 4. : Subjective sleep quality scores do not differ be-
tween listening to soothing music and performing brisk walking exer-
cise 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 advertise-
ments. This study used purposive sampling to recruit 38 eligible partic-
ipants 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 re-
peated measures (Chang et al., 2012; Su et al., 2013), the size of each se-
quence 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 expe-
rienced 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. Ex-
clusion 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 walk-
ing 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
106 C.-Y. Huang et al. / Applied Nursing Research 32 (2016) 104–110
same day of the week for each person to reduce the influence of varia-
tions 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 be-
fore bedtime, and go to sleep only when they had listened to the com-
plete 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 lis-
tening 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, Tai-
chung, 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 subjec-
tive sleep were assessed using electroencephalography (EEG) and visu-
al analogue scale (VAS).
4.4.2. Electroencephalography
Objective sleep quality was measured using a one-channel EEG sen-
sor together with the actigraph to be able to define light-sleep and slow-
wave-sleep, and to detect REM-phases in the EEG (SOMNO-medics
GmbH, Germany). This one-channel-EEG recorded on an actigraphy de-
vice 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 porta-
ble 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 efficien-
cy (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 indi-
cated 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 as-
sesses 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 participa-
tion 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 in-
terval 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 Invento-
ry and VAS was 0.78 (Davey et al., 2007). The anxiety score was mea-
sured 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 pre-
ferred. 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 includ-
ed in the study. Eligibility was assessed one week prior to commencing
the study. After baseline data were collected at the research center, ran-
dom 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 ex-
ercise 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 con-
secutive 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 approxi-
mately 5:30 to 7:30 pm for preparing and performing the treadmill ex-
ercise. 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
 C.-Y. Huang et al. / Applied Nursing Research 32 (2016) 104–110 107

EEG during the study nights, with continuous recording of sleep param- Table 1
eters during the night. After the 2-week study was completed, the par- Participants' characteristics (N = 38).

ticipants were asked to rate which intervention they preferred. They Variables N %
also rated how peaceful the soothing music sounded to them on a Gender
scale of VAS. All sleep scoring was performed by a certified sleep Male 8 21.1
technician. Female 30 78.9
Marital status
Married 31 81.6
4.6. Ethical consideration Single (widow/widower/divorced) 7 18.4
Ethnicity
This study was approved by the Research Ethics Committee of the Chinese 2 5.3
Taiwanese 33 86.8
hospital. The study procedures were conducted after obtaining the in-
Hakka 3 7.9
formed consents from the participants. Participation in this study was Religious
voluntary. Participants had the right to withdraw from the study at None 8 21.1
any time. Buddhist 19 50.0
Taoist 8 21.1
Protestant Christian 3 7.9
4.7. Statistical analysis Education completed (n = 20)
Primary/Junior high school 3 7.9
Data were analyzed using PASW 18.0 for Windows (SPSS Inc., Chica- High school 14 36.8
Bachelor's degrees 2 52.6
go, IL, USA). Data were reported as means and standard deviation (SD).
Master's degrees 1 2.6
Analysis of variance (ANOVA) was used to evaluate within-group com- Employment
parisons. Based on the two-condition crossover design, generalized es- Unemployed 21 55.3
timating equation (GEE) analysis was used to address carry-over Employed 17 44.7
effect and period effect and to control for changes in time and baseline Possible range Mean SD
values (Liang & Zeger, 1986). GEE can be used to account for the corre- Mean age in years 56.42 6.35
lation between observations in generalized linear regression models. By Sleep quality (PSQIa) 0–21 8.92 3.08
using GEE, the response can be scale, counts, binary, or events-in-trials. Anxiety (VASb) 0–10 5.6 2.24
a&b
Also it can be used to model correlated data from longitudinal or repeat- were both measured at onset of the study.
a
ed measures studies. Baseline outcome measurements were used as co- PSQI = Pittsburgh Sleep Quality Index.
b
VAS = Visual Analogue Scale.
variates 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.
Hypothesis 2 was also partially supported. In brisk walking interven-
tion, the SOL changed over the three points of measurement (from day 1
5. Results to day 3). ANOVA revealed significant differences in SOL for brisk walk-
ing intervention (F = 6.124(1,36), p = .003; Table 2). The post hoc t tests
5.1. Demographic characteristics revealed that SOL on day 3 was significantly shorter (p = .002) than the
no-exercise baseline data. Furthermore, a trend for WASO was observed
Participants in this study were middle-aged and elderly adults with in the brisk walking session, although the decreased time did not reach
insomnia, who did not exercise regularly (Table 1). In this study, partic- statistical significance.
ipants served as their own control because they were exposed to both Regarding Hypothesis 3 (Table 3), GEE results for WASO also differed
music and brisk walking conditions, and were therefore equivalent in significantly between music and brisk walking (p b .001), indicating
demographic characteristics. Table 1 presents the frequency distribu- that listening to soothing music before bedtime significantly shortened
tion of the descriptive variables of the sample. The 38 participants had the WASO compared with brisk walking in the evening. Therefore, the
ages ranging from 50 to 75 years (mean age = 56.42 years, SD = findings partially support Hypothesis 3. No significant differences
6.35), and most were female (n = 30, 78.9%), married (n = 31, were observed in any other objective sleep parameters (Table 2). Fur-
81.6%), and Taiwanese (n = 33, 86.8%). The mean scores for the global thermore, no other significant differences were observed between the
PSQI and state anxiety were 8.92 and 5.6, respectively, indicating that two interventions in the mean TST, SE, N1–N3 stages, REM stage, or
the participants were in states of insomnia and moderate anxiety. No number of awakenings.
significant correlations were observed between any sleep parameters
and anxiety.
5.3. Subjective sleep data
5.2. Electroencephalography sleep data
Regarding the four aspects of subjective sleep, no differences be-
Table 2 displays the objective and subjective sleep parameters at the tween the two conditions were observed in any subjective sleep param-
baseline (day 1) and after music and brisk walking interventions (day 2 eter (Table 3). These results revealed that both the soothing music and
& 3). We used the generalized estimating equation (GEE) method to es- brisk walking exercise combined with music exhibited the same effects
timate the carry-over effect and period effect, and determined that the on subjective sleep quality. These findings supported Hypothesis 4.
order of interventions, previous intervention, and interaction did not Moreover, participants reported averages between 5.95 and 7.39 at
reach statistical significance, indicating that no carry-over effect or peri- the baseline on the self-reporting questionnaires (Table 2). Using
od effect was present in this study. ANOVA analysis to compare the effects of music and exercise with
Testing Hypothesis 1, ANOVA revealed significant differences in SOL music on the subjective sleep parameters at different time points, we
(p = .04) and WASO (p b .001) across time for the music intervention determined that the ease of falling asleep, perceived quality of sleep,
(Table 2). The post hoc t test revealed that SOL was significantly shorter ease of awakening from sleep, and daytime functioning values exhibited
(p = .02) on day 3 than the baseline data for the music intervention. significant differences (all p b .01; Table 2), indicating that the subjec-
Moreover, WASO was significantly shorter (p b .001) on day 2 compared tive sleep quality differed when participants either listened to soothing
to the no-music baseline. These findings partially supported H1. music or performed brisk walking while listening to music.
108 C.-Y. Huang et al. / Applied Nursing Research 32 (2016) 104–110

Table 2
Mean objective sleep parameters in the two conditions during the study nights (N = 38).

Parameters Condition Day 1 (baseline) mean (SD) Day 2 mean (SD) Day 3 mean (SD) F p

Objective sleep parameters

TST (min) Soothing music 336.26 (92.24) 340.13(100.35) 324.39(86.07) 0.49 0.613
Brisk walking with music 337.45(97.62) 342.39(94.46) 337.52(73.78) 0.03 0.975
SOL (min) Soothing music 28.76(23.09) 20.70(20.40) 17.47(21.55) 3.28 0.04
Brisk walking with music 29.65(22.90) 23.18(22.41) 17.31(13.10) 6.12 0.003
WASO (min) Soothing music 30.85(15.03) 14.25(7.91) 14.07(8.20) 15.56 b0.001
Brisk walking with music 27.06(18.15) 24.18(18.40) 20.32(15.16) 1.94 0.152
SE (%) Soothing music 76.66(13.57) 79.23(15.84) 79.41(15.12) 0.48 0.622
Brisk walking with music 78.30(17.58) 80.56(13.72) 80.01(11.80) 0.72 0.492
Stage N1, % of TST Soothing music 14.10(12.84) 16.16(17.79) 16.25(13.94) 0.92 0.404
Brisk walking with music 13.25(10.22) 16.06(13.20) 14.93(11.50) 2.15 0.124
Stage N2, % of TST Soothing music 55.98(12.34) 58.19(16.75) 55.39(12.48) 0.99 0.378
Brisk walking with music 57.62(11.41) 55.72(13.06) 57.49(10.61) 0.42 0.658
Stage N3, % of TST Soothing music 20.61(9.56) 18.43(11.49) 19.57(8.96) 0.941 0.395
Brisk walking with music 20.80(10.28) 20.32(10.64) 19.65(9.99) 0.304 0.739
Stage REM, % of TST Soothing music 9.29(7.65) 7.23(5.68) 8.76(7.47) 1.604 0.208
Brisk walking with music 8.14(6.35) 7.90(6.84) 7.90(6.83) 0.04 0.965
Number of awakenings Soothing music 23.60(10.57) 21.92(12.74) 25.5(14.57) 2.25 0.113
Brisk walking with music 24.84(12.42) 24.26(13.01) 24.84(11.69) 0.00 N .999
Subjective sleep parameters
Ease of falling sleep Soothing music 5.95(2.14) 6.92(2.14) 7.13(1.64) 10.29 0.003
Brisk walking with music 6.03(2.22) 7.00(1.95) 7.34(2.16) 8.78 b0.001
Perceived quality of sleep Soothing music 6.05(2.34) 7.26(1.76) 7.58(1.78) 8.37 0.001
Brisk walking with music 6.76(2.22) 7.61(1.71) 7.68(1.75) 5.69 0.005
Ease of awakening from sleep Soothing music 7.26(1.79) 8.08(1.42) 8.18(1.33) 6.38 0.003
Brisk walking with music 7.21(1.59) 7.89(1.33) 8.45(1.28) 11.23 b0.001
Daytime functioning Soothing music 7.39(1.62) 8.08(1.42) 8.24(1.42) 5.026 0.009
Brisk walking with music 7.32(1.72) 8.30(1.39) 8.50(1.24) 14.15 b0.001

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 subjective sleep. The soothing music that was selected by the investiga-
After the study was completed, the participants rated their prefer- tors that consisted of 30-min peaceful Buddhist songs that were used
ence of interventions. The majority of participants (n = 35, 92.1%) pre- before bedtime also reduced the values of the WASO, compared with
ferred listening to soothing music to the brisk walking intervention for the baseline values.
improving their sleep quality. Moreover, the participants rated the Because very few studies have used EEG to examine the effects of
soothing music as peaceful (higher than 9.13 of 10 points). short period of time of brisk walking combined with music intervention
in the evening on sleep quality, we cannot compare our results with
6. Discussion those of other studies. Although the duration of interventions differed
between our study and previous studies (Erlacher et al., 2014; Passos
This study revealed that both a soothing music intervention and et al., 2011; Reid et al., 2010), these findings indicate that interventions
brisk walking combined with music resulted in improvements in objec- involving moderate exercise reduce sleep latency in sedentary adults
tive and subjective sleep. EEG revealed that both interventions short- with insomnia. Passos et al. (2011) observed a reduction in polysomno-
ened SOL, compared with the baseline scores for adults with insomnia. graphic SOL and WASO in older adults with sleep complaints after a 6-
Soothing music had stronger effect on the WASO than the brisk walking month program of moderate aerobic exercise. Another study of older
did. No differences between the two interventions were observed in adults with chronic insomnia, performed by Reid et al. (2010), revealed
an increase in the self-reported sleep quality after a moderate 4-month
Table 3
aerobic exercise program with sleep hygiene education in people with
GEE analysis to estimate sleep condition differences (N = 38). primary insomnia. These previous studies on the effects of exercise
training on sleep have focused on effects of longer duration of interven-
Outcome measure β Exp(β) 95% CI p-value
tions. Unlike previous studies, the current study determined that brisk
Objective sleep parameters walking combined with music in the evening exerts effects on SOL re-
TST (min) −0.04 0.96 0.81, 1.16 0.67
duction (Table 2), and also improves subjective sleep quality. The re-
SOL (min) −0.01 0.99 0.76, 1.29 0.94
WASO (min) −0.49 0.61 0.51, 0.73 b0.001 sults of this study supported the propositions of Buman et al. (2014),
SE (%) −0.04 0.96 0.89, 1.03 0.25 who suggested that evening exercise is a positively perceived interven-
Stage N1, % of TST 0.22 1.25 0.98, 1.59 0.07 tion with therapeutic benefits for sleep quality.
Stage N2, % of TST −0.06 0.96 0.87, 1.05 0.35 Although some studies have confirmed the effects of soothing music
Stage N3, % of TST 0.26 1.30 0.95, 1.78 0.10
on objective sleep quality, results have been inconclusive. In the present
Stage REM, % of TST 0.04 1.04 0.67, 1.64 0.85
No. of awakenings −0.03 0.97 0.71, 1.35 0.87 study, music was effective in reducing SOL and WASO, as measured
Subjective sleep parameters using EEG. However, Chang et al. (2012) observed that music exerted
Ease of falling sleep 0.01 1.00 0.84, 1.20 0.99 little effect on stage 2 and REM sleep in a group of 50 chronic insomniac
Perceived quality of sleep −0.06 0.94 0.83, 1.07 0.33
adults. A recent study using polysomnography revealed that 45 min of
Ease of awakening from sleep −0.05 0.95 0.86, 1.06 0.37
Daytime functioning −0.05 0.96 0.86, 1.07 0.41 soothing music is an effective treatment approach for improving the
stage 3 sleep quality and self-reported sleep quality in ICU patients
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
(Su et al., 2013). A key reason for this inconsistency might be the distinct
after sleep onset; REM: rapid eye movement sleep. Baseline data of sleep parameters study populations used, which included diverse degrees of insomnia
were controlled for in the model. and even people without insomnia (Lazic & Ogilvie, 2007). However,
 C.-Y. Huang et al. / Applied Nursing Research 32 (2016) 104–110
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. Al-
though 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 implement-
ed 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 interven-
tion may require improving sleep quality. We collected the data imme-
diately 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 base-
line 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 de-
termining a clinical improvement than did the objective data.
This study was unique because it was one of the first studies to im-
plement 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 ben-
eficial effects on sleep, because all participants rated the music as peace-
ful (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 in-
somnia 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 qual-
ity, 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 partici-
pants withdrew during the study period, likely because of the advan-
tages of portable EEG, which comprise few sleep disturbances, easy
application, and the opportunity to record multiple day and night pe-
riods 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.
7. Limitations and implications
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 com-
plimentary interventions for sleep quality.
Second, the findings of this study demonstrate that health care
workers can use soothing music and brisk walking exercises combined
109
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. Ad-
ditional 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 associ-
ated 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 prefer-
ence 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 par-
ticipants, which depends on their body weights. Future studies can ex-
amine 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.
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 exer-
cise with music intervention on the subjective and objective sleep pa-
rameters of adults with insomnia. Both interventions exhibited the
same beneficial effects on subjective sleep quality. Portable EEG re-
vealed 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 contrib-
ute 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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