Meta-analysis points to exercise as effective treatment strategy for insomnia

Exercise interventions such as yoga, Tai Chi, and walking or jogging help improve sleep outcomes for people with insomnia, according to the results of a meta-analysis.

Pooled data from 22 trials showed that compared with active controls (eg, usual care, lifestyle modifications), yoga increased total sleep time by nearly 2 hours (mean difference [MD], 110.88 min, 95 percent confidence interval [CI], 58.66–163.09; moderate-certainty evidence). It also improved sleep efficiency (MD, 15.59 percent, 95 percent CI, 5.76–25.42; low-certainty evidence), reduced wake after sleep onset (MD, −55.91 min, 95 percent CI −98.14 to −13.68; low-certainty evidence), and shortened sleep onset latency (MD, −29.27 min, 95 percent CI, −50.09 to −8.45; low-certainty evidence). [BMJ Evid Based Med 2025;doi:10.1136/bmjebm-2024-113512]

Walking or jogging, on the other hand, was associated with a roughly 10-point reduction in Insomnia Severity Index (ISI) scores compared with active controls (MD, −9.57 points, 95 percent CI, −12.12 to −7.02; low-certainty evidence).

Meanwhile, Tai Chi vs active controls improved total sleep time by more than 50 min (MD, 52.07 min, 95 percent CI, 25.53–78.61; low-certainty evidence), reduced poor sleep quality scores on the Pittsburgh Sleep Quality Index (PSQI) by more than 4 points (MD, −4.57 points, 95 percent CI, −7.50 to −1.63; low-certainty evidence), shortened sleep latency by around 25 min (MD, −24.76 min, 95% CI −41.07 to −8.46; low-certainty evidence), and reduced the time spent awake after falling asleep by more than half an hour (MD, −36.11 min, 95 percent CI −62.81 to −9.42; low-certainty evidence).

In sensitivity analyses, Tai Chi performed significantly across all assessed sleep diary and combined objective sleep measures outcomes for up to 2 years of follow-up.

Science behind the exercises’ effectiveness

These findings, according to the investigators, may have plausible biological explanations. First, yoga’s effect on subjective sleep quality may be tied to its focus on body awareness, controlled breathing, and attentional training. “Neurophysiological evidence indicates that yoga may enhance GABAergic activity and inhibit amygdala hyperactivation, thereby alleviating anxiety and depressive symptoms that often impair sleep initiation and perception,” they said. [Med Hypotheses 2012;78:571-579; Health Psychology Review 2024;19:257-277]

In a similar vein, Tai Chi—a slow, rhythmic mind-body practice that emphasizes breath control and physical relaxation—can help enhance parasympathetic tone and decrease sympathetic nervous system, thereby mitigating physiological hyperarousal. Additionally, it may also reduce pro-inflammatory cytokines over longer durations, increase brain-derived neurotrophic factor (BDNF) levels, and promote neuroplasticity and circadian regulation mechanisms. [J Gerontol A Biol Sci Med Sci 2006;61:1177-1180; Front Psychol 2018;9:1476; Neurorehabil Neural Repair 2018;32:142-149; Am J Geriatr Psychiatry 2024;32:1215-1230]

“These underlying mechanisms may partially account for the dual therapeutic profile of Tai Chi identified in the subgroup analysis, characterized by both rapid onset of efficacy and sustained long-term benefits,” the investigators pointed out.

Finally, walking or jogging may promote better sleep through increased energy expenditure, reduced cortisol levels, improved emotional regulation, elevated melatonin secretion, and enhanced proportions of deep sleep. [J Behav Med 2015;38:427-449]

From adjunctive to primary treatment

Taken together, the present data highlight the therapeutic potential of exercise interventions in the treatment of insomnia. The investigators believed these interventions could transition from just being used as supportive care to primary treatment options.

“Although current clinical guidelines make only limited mention of exercise, this study provides relatively comprehensive comparative evidence that may inform the development of more specific and actionable clinical recommendations… Furthermore, different forms of exercise may exert differential effects on specific insomnia symptoms, underscoring the importance of individualized treatment planning,” they said. [J Sleep Res 2023;32:e14035; Chin J Neurol 2024;57:560-584]

The randomized controlled trials included in the meta-analysis involved 1,348 participants and 13 different treatment approaches for insomnia, seven of which were exercise-based, as follows: yoga, Tai Chi, walking or jogging, aerobic plus strength exercise, strength training alone, aerobic exercise combined with therapy, and mixed aerobic exercises. These interventions ranged between 4 and 26 weeks in duration. Active controls included low-intensity, nonspecific interventions such as usual care, lifestyle advice, and stretching.