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Review

Mindfulness-Based Movement Intervention to Improve Sleep Quality: A Meta-Analysis and Moderator Analysis of Randomized Clinical Trials

by
Jiayi Yang
1,
Yan Du
2,
Haoran Shen
3,4,
Shujie Ren
5,
Zhiyuan Liu
6,
Danni Zheng
6,
Qingqing Shi
6,
Youfa Li
1,* and
Gao-Xia Wei
3,4,*,†
1
Collaborative Innovation Center of Assessment for Basic Education Quality, Beijing Normal University, Beijing 100875, China
2
School of Nursing, Health Science San Antonio, University of Texas, Austin, TX 78712, USA
3
CAS Key Laboratory of Behavioral Science, Institute of Psychology, Chinese Academy of Sciences, Beijing 101408, China
4
Department of Psychology, University of Chinese Academy of Sciences, Beijing 101408, China
5
School of Education, Beijing Sport University, Beijing 100084, China
6
School of Psychology, Beijing Sport University, Beijing 100084, China
*
Authors to whom correspondence should be addressed.
†
Chinese Academy of Sciences contributed most to this work, nearly half of our work was done in Chinese Academy of Sciences.
Int. J. Environ. Res. Public Health 2022, 19(16), 10284; https://doi.org/10.3390/ijerph191610284
Submission received: 15 July 2022 / Revised: 15 August 2022 / Accepted: 15 August 2022 / Published: 18 August 2022
(This article belongs to the Section Sport and Health)
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Review Reports Versions Notes

Abstract

:
(1) Background: Given that the most effective dose, optimal type, and most beneficial population for improving sleep with mindfulness-based movement (MBM) remains unknown, we conducted a systematic review and meta-analysis with moderator analysis of randomized controlled trials (RCTs) to assess these effects. (2) Methods: Three electronic databases (PubMed, Web of Science, and EBSCO) were systematically searched for RCTs published through August 2021 for analysis. The risk of bias of the included studies was assessed with Review Manager 5.3, and the meta-analysis was performed in Stata 16.0. (3) Results: A meta-analysis of 61 RCTs with 2697 participants showed that MBM significantly improved sleep quality compared to controls (SMD = −0.794; 95% CI: −0.794 to −0.994, p < 0.001, I2 = 90.7%). Moderator analysis showed that a long-term MBM (SMD = −0.829; 95% CI: 0.945 to 0.712; p < 0.001) had a larger effect size on sleep than a short-term MBM (SMD = −0.714; 95% CI: 0.784 to 0.644; p < 0.001). Practicing at least twice per week (SMD = −0.793; 95% CI: −0.868 to −0.718; p < 0.001) was more effective compared to practicing once per week (SMD = −0.687; 95% CI: −0.804 to −0.570; p < 0.001). Studies with a total intervention time of more than 24 h also revealed better sleep quality improvement (SMD = −0.759; 95% CI: −0.865 to −0.653; p < 0.001). In addition, the healthy population and older adults gained more from MBM than the patients and younger adults. (4) Conclusions: MBM can effectively improve subjective sleep quality, and the optimal intervention dose of MBM can be utilized in future intervention studies to treat or improve sleep disturbance (MBM more than twice a week for more than three months, with a total intervention time of more than 24 h).

1. Introduction

Sleep disturbances have become a significant public health concern worldwide. It is a potential risk factor for a wide variety of somatic diseases and common symptoms of mental disorders [1]. The most widely recognized treatments for sleep disturbances are pharmacological therapy and psychotherapy. Apart from the direct and indirect costs of diseases, the clinical benefits of these two first-line treatments have been criticized [2]. Pharmacological therapy can produce side effects [3,4], while psychotherapy requires time-consuming input from health professionals [5]. Currently, an increasing number of studies have examined whether mindfulness practices can effectively alleviate some aspects of sleep disturbance. A meta-analysis of 18 trials showed that compared with specific active controls, mindfulness meditation significantly improved sleep quality [6]. However, considering the improved efficacy of perceived sleep quality, a recent randomized controlled trial found that the exercise group had a better effect compared with the mindfulness group and the waitlist group [7].
With the development of mindfulness practice, integrative practice combining mindfulness and other exercise regimens has been explored. Mindfulness-based movement (MBM) has received the most attention for its alternative efficacy in many psychotic disorders [8]. It is a group of integrative techniques, including yoga, Tai Chi Chuan, Pilates, Baduanjin, and Qigong. Compared with monotherapies, MBM integrates mindfulness and aerobic exercise characteristics to boost the interaction between the brain, mind, and body by performing musculoskeletal stretching, slow breathing, and body control [9]. A meta-analysis of 49 studies assessed the effects of MBM on insomnia, indicating that MBM improved perceived sleep quality and reduced insomnia severity [10]. However, an earlier review demonstrated that nearly one-fourth of studies on mind–body interventions failed to observe their beneficial effects on sleep outcomes [11]. Therefore, the results of the MBM-induced improvement in sleep quality are inconclusive. One possible explanation for this inconsistency might be the different intervention protocols performed in the included studies. For instance, Chen et al. used an intervention protocol of 70 min per session, three times per week for 24 weeks [12], which found a beneficial effect of MBM on sleep quality. In contrast, 90 min per session, twice per week for 16 weeks, failed to find significant improvements in sleep with MBM [13]. In addition, the heterogeneity of participant characteristics may lead to inconsistent results. Yeh et al. found significant improvement in sleep quality with MBM in heart failure patients with a mean age of 59 ± 14 years [14], whereas Sakuma et al. did not observe such a benefit in healthy female child-care workers with a mean age of 32.6 ± 11.5 [15]. With the increase in the number of relevant studies in recent years, there is a need to update existing MBM studies to explore the best intervention protocols and the most beneficial populations.
To address these questions, we conducted a systematic review and meta-analysis of RCTs to assess the effectiveness of MBM on sleep quality in different populations and compare the effect sizes of improved sleep quality induced by varied intervention doses of MBM, which provided insight into health promotion among non-clinical individuals and the strategy for clinical treatment of sleep disorders.

2. Methods

This study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [16] and the Cochrane Collaboration recommendations for systematic reviews and meta-analyses [17].

2.1. Search Strategies

Three English-language databases (PubMed, Web of Science, and EBSCO) were systematically searched. A similar systematic review was conducted from its inception to the end of 2006. This study focused only on those from January 2007 to August 2021. Relevant terms were searched based on three search levels: (i) yoga, Tai Chi/Taiji, Pilates, Qigong/Ch’i Kung, mind-body therapy/practice or meditative movement; AND (ii) sleep or insomnia; AND (iii) randomized or randomized controlled trial. Furthermore, reference lists of other reviews and relevant studies were manually searched.

2.2. Study Eligibility

The lead author conducted an independent literature search to screen the titles, abstracts, and manuscripts of eligible studies. The studies were considered to be included if an article (1) used RCT design; (2) was published in a peer-reviewed journal; (3) used an intervention that was solely or mainly based on yoga, Tai Chi Chuan, Pilates, Baduanjin, and Qigong, or combined mode; (4) included at least two groups: one was the intervention group, the other was the control group (active control or waitlist group); and (5) included studies with at least one primary outcome related to sleep (the score of sleep scale or sleep physiology outcome). The excluded criteria included observational studies, case reports, controlled trials with no randomization, and review studies.

2.3. Data Extraction and Management

The retrieved articles were independently reviewed and extracted by five authors (JY, SJ, ZY, QQ, DN) to select relevant articles. For the included studies, the following information was extracted: study characteristics; the characteristics of participants (sample size, gender, mean age, and health status); intervention protocol; and outcomes measured. The primary outcomes were subjective sleep quality measured by self-report questionnaires or objective sleep data measured by polysomnography (PSG). The number of participants in the intervention and control groups and the mean ± standard deviation (SD) at baseline and after the intervention were input from each study. We contacted the corresponding author via email for data requests if the data were insufficient or missing. Complete data extraction information is available in the Supplementary Materials.

2.4. Assessment of Methodological Quality

The methodological quality of the selected trials was assessed using the Cochrane Risk of Bias Tool [18]. The original scale consists of 11 items, including randomness of allocation order (selection bias), allocation order concealment (selection bias), blinding of participants and staff (performance bias), blinding in outcome assessment (detection bias), incomplete outcome data (attrition bias), and selective outcome reporting (reporting bias). Given the impracticality of blinding participants and instructors during the intervention, this item was removed from the original scale, leading to a final number of 6 items in the scale. Each individual item was examined to objectively evaluate the risk of bias across trials. The criteria were categorized as high risk of bias, unclear risk of bias, or low risk of bias. Points were awarded high scores, indicating better methodological quality.

2.5. Data Synthesis and Data Analysis

We performed a sensitivity analysis to examine whether individual studies disproportionately influenced the results. The trim-and-fill method, as a measurable effect on potential publication bias (asymmetry of the funnel plot), was used for estimating and adjusting pooled standardized mean differences (SMDs) based on the funnel plot. All analyses of pooled effectiveness were conducted using STATA version 16.0 [19]. The random effects method was applied to the heterogeneous population involved in this study [20]. SMD with 95% confidence intervals (CIs) was calculated as the difference in means between groups divided by the pooled standard deviation. We categorized the magnitude of the intervention effect, with SMD as 0.2–0.5 indicating small effect, 0.5–0.8 indicating moderate effect, and 0.8 and above indicating large effect [21].
Between-study heterogeneity was evaluated using the I2 statistic (low heterogeneity = 0~25%, moderate heterogeneity = 26~50%, substantial heterogeneity = 51~75%, and considerable heterogeneity = 76~100%) [17].
We conducted moderator analyses with meta-regressions to provide more detailed prescription recommendations for MBM intervention doses. The moderator variables were the population based on their health status; participants’ age; the type of MBM; duration of intervention; frequencies of intervention; and total duration of intervention.

3. Results

3.1. Trial Selection

Both electronic and manual searches resulted in 1574 studies (Figure 1). After removing duplicates, 1206 studies were included according to the inclusion criteria, and 64 eligible RCTs were eventually entered into the systematic analysis after stepwise screening. The detailed trial selection process of the study is illustrated in Figure 1.

3.2. Study Characteristics

The study characteristics of the selected trials are summarized in Table A1 [12,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84]. These studies involved 2697 participants aged from 6 to 78 years. Nineteen studies included younger adults under 45 years old, 20 studies included middle-aged adults between 45–59 years, and 18 studies included older adults above 60 years. As for health status, 19 studies examined healthy populations; subjects in 28 studies had clinically physical illnesses with significant distress and/or dysfunction (e.g., diabetics, cancer patients, hemodialysis patients, etc.), and 17 had psychiatric disorders (insomnia, depression, menopause, and anxiety). Twenty-three studies included both males and females, 11 studies included only females, and two studies included only males.
Regarding the type of MBM, 25 studies used yoga/Pilates, 18 used Tai Chi/Qigong/Baduanjin, and 18 used MBM combined with mindfulness or muscle relaxation techniques. The duration of the intervention varied widely, ranging from 1 week to 12 months, with most studies providing an 8-week intervention (n = 9). The intervention frequency varied from once every two weeks to three times a day, with the studies frequently including once-a-week practice (n = 14) or twice-a-week practice (n = 13). Subjective measures of sleep quality were used in all 64 articles. Six studies used PSG to assess the physiological index related to sleep quality. No adverse events related to MBM were reported in the included articles.

3.3. Study Quality Assessment

The risk of bias is summarized in Figure 2. According to the Cochrane Risk of Bias Tool, the overall risk of literature bias was low in 64 studies. All studies were RCTs and used sufficient randomization. After removing the studies with inconsistent baseline periods [72], there was no heterogeneity in baseline sleep indicators between the two groups (I2 = 19.2%, p = 0.062 > 0.05).
To detect the consistency in the effect of MBM on sleep quality, a sensitivity analysis was performed to remove two studies with outrageous effect sizes based on visually asymmetrical funnel plots (SMD = 0.5; SMD = 0.46) [48,53] (Figure 3). Egger’s test indicated that the other 61 studies had low publication bias with good symmetric characteristics (p = 0.191 > 0.05) (Table S1). Sensitivity analysis confirmed the stability of the results (Figure 4).

3.4. Effects of MBM on Sleep Quality Measured by Scales

Due to the large heterogeneity test (I2 = 90.7%, p < 0.001), a random-effects model analysis was employed for the overall effect. For the meta-analysis with 61 studies, compared with controls, aggregated results showed significant benefit in favor of MBM on sleep quality (SMD = −0.794, 95% CI: −0.794 to −0.994, p < 0.001, I2 = 90.7%, Figure 5).

3.5. Effects of MBM on Sleep Quality Measured with PSG

A total of six studies reported data on PSG to assess participants’ sleep quality. Moon et al. [76] measured salivary cortisol and blood pressure changes, and Buchanan et al. [85] had incomplete polysomnographic data, so these two articles were excluded. Four other studies reported total sleep time (TST) data. The meta-analysis found no significant difference in total sleep time between the participants receiving MBM and the controls (SMD = −0.126; 95% CI: −0.479 to 0.227; p = 0.485; I2 = 0%).

3.6. Moderator Analysis

To further identify the moderator effects in MBM studies, we considered the following variables: subgroup of the population (the healthy population, the patients with somatic diseases, and the patients with psychiatric illnesses), the age of participants (youth: <45 years; middle age: 45~59 years; older adults: >60 years), duration of the intervention (≤3 months, >3 months), types of MBM (yoga/Pilates, Tai Chi/Qigong/Baduanjin, MBM combined with mindfulness or muscle relaxation techniques), intervention frequencies (≤1/week; >1/week), and total intervention duration (≤24 h; >24 h). We used a random-effect model to conduct the moderator analyses. The number of studies included in each moderator analysis varied due to incomplete data. The number of studies and participants are provided in Tables S2–S7.
In terms of the subgroup of participants, the healthy population showed the largest effect size compared with other subgroups, although MBM intervention showed a significantly improved sleep quality in all these subgroups: healthy population (SMD = −0.899; 95% CI: −1.000 to −0.798; p < 0.001), the patients with somatic diseases (SMD = −0.627; 95% CI: −0.736 to −0.519; p < 0.001), and the patients with psychiatric illnesses (SMD = −0.618; 95% CI: −0.720 to −0.516; p < 0.001) (Table S2). As shown in Table S3, all three age groups showed significant improvements in sleep quality after the intervention. MBM had a greater benefit on sleep quality in older adults (SMD = −0.873; 95% CI: 0.985 to 0.761; p < 0.001) compared to younger adults (SMD = −0.618; 95% CI: 0.715 to 0.520; p < 0.001) and middle-aged adults (SMD = −0.691; 95% CI: 0.803 to 0.579; p < 0.001).
Compared with the MBM combined with mindfulness or muscle relaxation techniques (SMD = −0.741; 95% CI: −0.849 to −0.633; p < 0.001) and Taijiquan intervention (SMD = −0.567; 95% CI: −0.680 to −0.455; p < 0.001), the intervention of yoga/Pilates (SMD = −0.808; 95% CI: −0.901 to −0.715; p < 0.001) had greater effects on sleep quality (Table S4). In terms of the duration of MBM (short-term or long-term), long-term interventions (>3 months) were more effective (SMD = −0.829; 95% CI: 0.945 to 0.712; p < 0.001) than short-term interventions (≤3 months) (SMD = −0.714; 95% CI: 0.784 to 0.644; p < 0.001) in improving sleep (Table S5). Another moderator analysis on frequency showed that ≥2 times per week (SMD = −0.793; 95% CI: −0.868 to −0.718; p < 0.001) had a greater impact on improving participants’ sleep than once per week (SMD = −0.687; 95% CI: −0.804 to −0.570; p < 0.001) (Table S6). In a moderator analysis of the total intervention duration, a greater effect on sleep improvement was observed for total intervention time above 24 h (SMD = −0.759; 95% CI: −0.865 to −0.653; p < 0.001) than for total intervention duration below 24 h (SMD = −0.746; 95% CI: −0.827 to −0.665; p < 0.001) (Table S7).

4. Discussion

This systematic review and meta-analysis with moderator analysis updated the evidence from RCTs using MBM as an intervention for sleep problems in both non-clinical populations and patients with illness/disorders. The pooled results indicate that MBM improved sleep quality, as measured by self-report scales rather than by PSG. Further, the moderator analysis demonstrated that MBM with >3 months, twice or more per week, and longer than 24 h of total intervention had larger effect sizes on sleep than other protocols. In addition, healthy people and older adults gained more from MBM than patients with physical or psychiatric disorders or younger and middle-aged individuals. Such promising results suggest that MBM is an alternative or augmentation strategy for improving sleep quality. Additionally, as reflected in our assessment of the quality of all studies in Section 3.3, the relatively high quality of the included RCTs makes our conclusions comparatively reliable. Similarly, our results are reliable according to the consistency of Egger’s test and the sensitivity analyses.
Two previous meta-analyses of cancer patients and insomnia have illustrated that the effect of MBM on alleviating sleep quality was significant [10,86], which was roughly in line with this study with moderate to large effect sizes (Section 3.4). Wang et al. found that the effect size of MBM-induced improvement of sleep quality was moderate after reviewing 49 studies, including meditation, between 2004 and 2018 [10]. A recent meta-analysis of cancer patients found that although the effect of MBMs was smaller than that of aerobic exercise, both of these interventions significantly improved sleep outcomes [86]. Similarly, our study adds to the fuller evidence of the effect of MBM on sleep quality.
A moderator analysis was performed for the different groups. We found that MBM had a greater impact on sleep quality in healthy individuals than in clinical populations and psychiatric patients. A possible explanation might be the complications of somatic disease [87,88] or mental disorders [89] in those clinical patients. Chronic pain [90], failure of emotional regulation [91] or medication side effects [92,93], and other medical conditions are essential variables when considering the reduced effect of MBM in those patients [94]. Healthy individuals are more likely to be capable of attending to their bodies and minds during practice, resulting in a better intervention effect.
Our study suggests that older adults benefit more from MBM than other age groups. For older adults, MBM has been shown to help prevent falls [95], improve depression [96], reverse metabolic disease [97], and reduce systemic inflammation [98,99]. A single-site qualitative study found that some older adults lose the stress of work and activity after retirement, so MBM may provide them with a new way to increase physical activity, reduce anxiety, decrease inflammatory factors [100], and consequently improve sleep quality. Unexpectedly, we found that yoga/Pilates practice had a greater effect on sleep compared to other MBMs. Although we cannot provide the reason for clarifying this finding so far, it is tempting to speculate about the potential reason, which might be due to the involvement of more females in Yoga/Pilates intervention. Therefore, gender differences should be fully considered when examining the association between MBM and sleep quality in future investigations.
In this study, we found that the improvement in sleep with MBM was most pronounced when the total intervention time exceeded 24 h, at least twice a week, and for more than three months. Our findings on the dose-response are consistent with the previous meta-analysis reporting that improvements in sleep quality were greater when the intervention’s frequency, duration, and total duration were achieved [10]. Several studies have shown that only MBM intervention longer than three months leads to significant improvements in metabolic profiles [101,102], proinflammatory cytokine [103], and mental health [104,105,106]. Furthermore, the inverted U-shaped hypothesis proposes that moderate-intensity exercise has the most significant cognitive benefits [107,108]. Thus, a minimum dose of physical exercise is crucial to gain measurable benefits. Regarding exercise intensity, MBM belongs to practice with low-to-moderate intensity [109], so higher frequency and intervention length may predict better overall intervention outcomes.
Considering the mechanisms underlying the effect of MBM on sleep quality, several key factors, including appropriate emotional regulation, maintaining homeostatic effect in the autonomic nervous system, and altering the inflammatory process, might contribute to improving sleep quality [110].
First, the improvement in sleep quality induced by MBM could be closely associated with the role of alleviating negative moods. Self-reported sleep problems and emotional disorders mutually affect each other. Oh et al. found that 21.7% of patients with insomnia had anxiety disorders, 7.2% had depression, and 18.6% had both anxiety and depression [111]. In turn, 74% of patients with anxiety disorders reported sleep disturbances [112]. Although the exact cause and effect between emotional disorders and poor sleep quality remain unknown, it has been shown that MBM has the potential to effectively treat both major depressive disorder [113,114,115] and sleep problems [81,103]. The alleviated negative moods often accompany improved sleep quality after practicing MBM [81,116,117]. A randomized controlled trial of a mind-body-spirit intervention found that changes in depressive symptoms mediated treatment effects on nighttime sleep quality and daytime functioning [116]. Additionally, a growing body of brain imaging studies has shown that MBM induces structural and functional changes in key brain regions associated with emotional regulation [118]. For instance, Tai Chi Chuan practitioners exhibited greater cortical thickness in the middle frontal sulcus [119] and elderly yoga practitioners showed significantly cortical thickness in the left prefrontal lobe [120]. The prefrontal cortex, as an “immune system of the mind”, is a flexible hub for regulating an individual’s negative emotions. MBM will likely implement its function in mediating sleep via neural pathways between the prefrontal cortex and limbic system related to emotional processing [118]. Therefore, MBM could possibly improve sleep quality by reorganizing the anatomical structures or functions of emotional circuits.
Second, another physiological factor may explain why MBM could positively influence sleep quality in almost all subgroups. It is known that the autonomic nervous system plays a fundamental role in maintaining physiological function and body homeostasis [121]. Many studies have used non-invasive techniques to assess the changes in heart rate and heart rate variability (HRV) in autonomic nervous system activity after performing MBM practice. For instance, a study used traditional electrocardiogram recordings to examine Tai Chi practice-induced changes in HRV, which indicated that Tai Chi could improve vagal activity and the balance between sympathetic and parasympathetic activity during the relaxation state [122]. Another meta-analysis, including 19 medium-to-high quality RCTs, also demonstrated that mind–body practice could significantly benefit HRV parameters and improve sympathetic–vagal balance [123]. Higher HRV during wakefulness is associated with higher sleep efficiency and better sleep quality [124,125,126]. Therefore, the action of HRV alteration may be an important mechanism by which MBM ameliorates the symptoms of insomnia or poor sleep quality. Moreover, studies have shown that high sleep onset latency and poor sleep quality are associated with higher resting heart rates [127], which indicates that heart rate is a crucial physiological marker that reflects sleep quality. Regular moderate MBM strengthens the heart muscle and increases the oxygenation efficiency of the heart [128,129], which can improve sleep quality by lowering an individual’s resting heart rate.
Third, a possible explanation might also be associated with the altered inflammatory processes. Many studies have shown that inflammatory biomarkers, such as Nuclear Factor-kappa B (NF-κB) play a critical role in activating inflammation in chronic insomnia [130,131,132]. Acute sleep loss can induce a rapid increase in the activation of the transcription factor NF-κB in peripheral blood mononuclear cells [133,134]. Recent studies examining changes in gene expression induced by meditation and related MBM have found that these practices are associated with downregulation of the NF-κB pathway [31,135,136], suggesting that MBM practices may lead to a reduced risk of inflammation-related diseases, including insomnia [137]. Future interdisciplinary studies are warranted to further investigate the interaction between the molecular and psychological changes associated with MBM.
Our study has some limitations. First, we searched only three databases for studies published in English, which may limit the generalizability of our results to some extent. We will consider ongoing updates and replenishment of the databases in the future. Second, only a limited number of studies and a relatively small sample size provided physiological measures of sleep duration. Although a significant effect was observed on subjective sleep outcomes, we were unable to detect improved sleep quality measured by physiological parameters. Further investigation of subjective and physiological sleep is needed in future studies. Third, our review did not consider gender differences in the meta-analysis because 25 studies did not report the male-to-female ratio of participants, and 23 studies had participants of mixed gender. In the future, more comparative RCTs explicitly targeting the effect size of different gender groups are needed to determine the role of gender in the effect of MBM on sleep quality.

5. Conclusions

This meta-review suggests that MBM could be applied as a complementary or supplementary therapy to improve sleep quality. The optimized dose of the intervention (twice a week for more than three months, with a total intervention time of more than 24 h) is recommended in future interventions, both in clinical patients and in healthy individuals. Future research should address more objective measurements of the methodological aspects and individual difference issues.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/ijerph191610284/s1, Table S1: Egger’s test with pseudo 95% confidence limits; Tables S2–S7. Moderator analysis.

Author Contributions

G.-X.W. and Y.L. participated in the conception and design of this study. J.Y., H.S., S.R., Z.L., D.Z. and Q.S. performed the material preparation, data collection, and analysis. J.Y. wrote the first draft, and all authors commented on it. Y.D. provided significant scientific review and edited the manuscript. All authors have read and agreed to the published version of the manuscript.

Funding

National Natural Science Foundation of China: 31671163; Research Program Funds of the Collaborative Innovation Center of Assessment for Basic Education Quality at Beijing Normal University: 2021-01-049-BZK01, The Scientific Foundation of Institute of Psychology, Chinese Academy of Sciences, No. E2CX3815.

Institutional Review Board Statement

The study did not require ethical approval.

Informed Consent Statement

All persons gave their informed consent before enrolling in the original studies included in this review. Details that might disclose the identity of the subjects under study were omitted.

Data Availability Statement

The study did not report any data.

Conflicts of Interest

The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results. All authors certify that they have no affiliations with or involvement in any organization or entity with any financial or nonfinancial interest in the subject matter or materials discussed in this manuscript.

Abbreviations

MBMmindfulness-based movement
PRISMApreferred reporting items for systematic reviews and meta-analyses
PSQIPittsburgh sleep quality index
PSGPolysomnography
RCTrandomized controlled trial
SMDstandardized mean difference

Appendix A

Table
Table A1. Characteristics of all randomized controlled trials.
Table A1. Characteristics of all randomized controlled trials.
AuthorYearCountries or Regions Where Studies ConductedPopulationIntervention of Experimental GroupIntervention of Control GroupMeasurements of Outcome
NumberGender
M/F		Mean Age, y ± SDIntervention NumberGender
M/F		Mean Age, y ± SDIntervention
Maryanna Klatt et al. [22]2017USABank employees2721/643.8 ± 9.2MIM3018/1242.0 ± 9.4WaitlistPSQI
Rshikesan et al. [23]2018IndiaObese urban males3737/040.03 ± 8.74Yoga3535/042.20 ± 12.06Walking activityPSQI
Curi et al. [24]2018BrazilOlder women310/3164.25 ± 0.14Pilates310/3163.75 ± 0.08No physical activityPSQI
Özkan and Rathfisch [25]2018TurkeyWomen in late pregnancy420/4227.93 ± 4.56Relaxation exercise420/4227.79 ± 3.90Usual carePSQI
McQuade et al. [26]2017USAMen with prostate cancer2121/062.2 ± 7.4Qigong/Tai Chi24100% male66.0 ± 8.4WaitlistPSQI
Aksu et al. [27]2018TurkeyPatients undergoing pneumonectomy13NR58.23 ± 13.50PMR13NR57.85 ± 6.95Postoperative rehabilitationPSQI
Kerekes et al. [28]2017SwedenPrison inmates in Swedish correctional institutions7767/1036.4 ± 9.4Yoga7566/934.9 ± 9.9WaitlistPSQI
Seyedi Chegeni et al. [29]2018IranPatients with chronic obstructive pulmonary disease (COPD) stage 3 and 44530/1557.37 ± 12.8PMR4624/2256.89 ± 14.6Usual carePSQI
Zhu et al. [30]2018ChinaWomen dependent on amphetamine-type stimulants (ATS)420/4233.74 ± 7.11Tai Chi380/3837.76 ± 9.85Usual carePSQI
Irwin et al. [31]2018USABreast cancer survivors with insomnia450/4559.6 ± 7.9Tai Chi450/4560 ± 9.3CBT-IPSQI
Chaoul et al. [32]2018USAWomen receiving chemotherapy for breast cancer740/7449.5 ± 9.8Yoga850/8549 ± 10.1Usual carePSQI
Ebrahimi et al. [33]2017IranWomen with diabetes130/1347.93 ± 2.86Yoga110/1148.18 ± 3.45No interventionPSQI
Hariprasad et al. [34]2013IndiaElderly people6240/2275.54 ± 6.46Yoga73NR39.96No interventionPSQI
Sun et al. [35]2013ChinaOlder adults with reduced sleep quality388/3070.76 ± 7.44PMR and meditation based on SHE3711/2668.59 ± 8.45SHEPSQI
Black et al. [36]2014USAOlder adults with moderate sleep disturbances248/1666.5 ± 6.3MAPs258/1766.1 ± 8.5SHEPSQI
Zhang et al. [37]2015ChinaPeople with chronic insomnia3016/1478.57 ± 2.94MBSR3019/1177.63 ± 3.01WaitlistPSQI
Chan et al. [38]2016ChinaOlder adults with cognitive impairment who complained of sleep disturbances270/2778.4 ± 7.1Tai Chi 258/1782.2 ± 6.7Maintained usual activitiesPSQI
Chandwani et al. [39]2014USAbreast cancer patients undergoing radiotherapy530/5352.38 ± 1.35Yoga540/5452.11 ± 1.34WaitlistPSQI
Ashrafinia et al. [40]2013IranPrimigravida postpartum women400/4024.6 ± 3.6Pilates400/4024.4 ± 3.6No interventionPSQI
Fang and Li [41]2015ChinaStaff nurses610/6135.13 ± 10.98Yoga590/5936.05 ± 9.91Not yogaPSQI
Chan et al. [42]2014ChinaPeople with chronic fatigue syndrome (CFS)7529/4639.1 ± 7.8Baduanjin/Qi gong7513/6238.9 ± 8.1No interventionPSQI
Blake et al. [43]2016AustraliaPeople with high levels of anxiety and sleeping difficulties6328/3514.48 ± 0.96Group sleep improvement based on cognitive behavior/mindfulness6022/3814.48 ± 0.96No interventionPSQI
Siu et al. [44]2021ChinaOlder adults with insomnia105NR66.5 ± 6.4Tai Chi110NR68.0 ± 8.2Preexisting Usual carePSQI
Shree et al. [45]2021IndiaElderly population48NR62.6 ± 3.9Yoga48NR65.5 ± 3.4WaitlistPSQI
Phansuea et al. [46]2020ThailandCommunity-dwelling older adults with mild to moderate depression339/2469 ± 6.3Qigong339/2471 ± 6.9Maintained their normal activitiesPSQI
Papp et al. [47]2020SwedenPatients with obstructive pulmonary disorders195/1461 ± 10.1Yoga178/967 ± 9.8Conventional trainingPSQI
Ozer and Ates [48]2021TurkeyHemodialysis patients3312/2162.67 ± 6.82Yoga3414/2060.32 ± 8.98Routine carePSQI
Gordon et al. [49]2021NRHealthy women from the community in the menopause transition52NR48.7 ± 3.0MBSR with Yoga52NR48.7 ± 3.7WaitlistPSQI
Barbosa et al. [50]2021BrazilWomen undergoing hormone therapy for breast cancer20NR52Pilates20NR59.8Maintained their usual activitiesPSQI
Fan et al. [51]2020ChinaSleep disturbances6712/5570.3 ± 5.7Baduanjin/Qigong7222/6071.8 ± 6.7Usual treatmentPSQI
Agustín et al. [52]2019SpainPostmenopausal women55NR69.98 ± 7.83Pilates52NR66.79 ± 10.14Usual treatmentPSQI
Zheng et al. [53]2019ChinaPeople at a high risk of ischemic stroke8530/5060.53 ± 6.29Baduanjin/Qigong8531/4959.75 ± 6.34Maintained their usual physical
activity		PSQI
Michael et al. [54]2019USACancer Survivors19NRNRMindfulness-
based cancer survivor ship (MBCS)		17NRNRBreathing exercisesPSQI
Bai et al. [55]2019ChinaWomen undergoing
their first cycle of IVF		78NR30.23 ± 4.14Brief mindfulness78NR30.36 ± 4.82Guided
self-administered interventions		PSQI
Lu et al. [56]2019ChinaPeople with cancer-related fatigue4326/1555.60 ± 11.23Baduanjin/Qigong4430/1454.63 ± 11.88Usual treatmentPSQI
Liu et al. [57]2019ChinaPeople with osteosarcoma4528/1615.9 ± 5.2MBSR and music
therapy (MT)		4617/2816.2 ± 4.9Routine care with no psychological interventionPSQI
Cetin et al. [58]2020TurkeyPeople with systemic sclerosis (SSc)172/1253.35 ± 10.86Tai Chi141/1352.64 ± 9.45Usual treatmentPSQI
Habibollahpour et al. [59]2019IranElderly people suffering
from sleep disorders		3815/2367.95 ± 5.24Benson’s Relaxation Technique3719/1866.89 ± 4.10Usual treatmentPSQI
Gokmen et al. [60]2019TurkeyPeople with obstructive sleep apnea2513/1250.44 ± 8.38Tai Chi/
Qigong		2518/745.68 ± 7.64Home exercisePSQI
Bower et al. [61]2012USABreast cancer survivors160/1654.4 ± 5.7Yoga150/1553.3 ± 4.9Health educationPSQI
Chen et al. [12]2010Taiwan, ChinaElderly people in assisted living facilities31NRNRYoga24NRNRWaitlistPSQI
Chen et al. [62]2009Taiwan, ChinaOlder adults in living facilities62NRNRYoga66NRNRWaitlist control groupPSQI
Frye et al. [63]2011USASedentary older people23NRNRTai Chi21NRNRNon exercise controlPSQI
Lynch et al. [64]2012CanadaPatients with fibromyalgia533/5052.81 ± 8.91Qigong471/4652.13 ± 8.56Delayed practice groupPSQI
Nguyen and Kruse [65]2012VietnamElderly Vietnamese individuals4824/2469.23 ± 5.30Tai Chi4824/2468.73 ± 4.95Maintained their routine daily activitiesPSQI
Wang et al. [66]2010JapanElderly patients with cerebral vascular disorder (CVD)165/1176.53 ± 9.74Tai Chi133/1077.59 ± 12.33rehabilitationPSQI
Wolever et al. [67]2012USAAdults at worksites9024/6641.6 ± 10.1Yoga5310/4342.7 ± 9.7waitlist control groupPSQI
Gregoire et al. [68]2017NRBreast cancer patients680/6854 ± 11Yoga240/2452.5 ± 6.8Usual careISI
Duman and Timur Taşhan [69]2018TurkeyPostmenopausal women with insomnia810/8152.98 ± 4.33Progressive relaxation exercises800/8053.68 ± 4.43Regular careWomen’s Health Initiative Insomnia Rating Scale
Zupanec et al. [70]2017CanadaChildren with acute lymphoblastic leukemia (ALL)1110/16.3 ± 1.8Deep breathing and progressive muscle relaxation98/16.2 ± 2.0Usual careActigraphs Battery-powered Watch MiniMotionlogger
Greeson et al. [71]2014USACollege students and other emerging adults4515/3025.75 ± 6.84Mindfulness4516/2924.76 ± 4.15WaitlistMedical Outcomes Study Sleep Scale
Zhao et al. [72]2020ChinaBreast cancer survivors with insomnia68NR52.79 ± 6.54Mindfulness-based cognitive therapy for insomnia68NR53.29 ± 6.50WaitlistISI
Soriano-Ayala et al. [73]2020SpainUniversity students 26NR20.94 ± 18.31Mindfulness25NRNRUsual treatmentHealthy Lifestyle Questionnaire
Di Shao et al. [74]2020ChinaPatients With Breast Cancer72NR40.3 ± 7.0A self-help intervention based on mindfulness72NR44.4 ± 8.2Routine treatmentAthens Insomnia Scale
Ozer et al. [75]2021NRPatients with chronic respiratory disease (asthma and COPD)304/26NRYoga3010/20NRNursingAsthma and COPD Sleep Impact Scale
Moon et al. [76]2020USAPeople with Parkinson’s disease84/466.4 ± 8.1Qigong96/365.9 ± 5.4Sham QigongParkinson’s Disease Sleep Scale 2
Akodu et al. [77]2021NigeriaPatients with nonspecific chronic neck pain145/947.43 ± 9.22Pilates147/744.93 ± 6.26Neck dynamic isometric exerciseISI
Zhang et al. [78]2019ChinaPeople with insomnia35NR57.78 ± 11.12MBSR35NR58.45 ± 11.08Usual treatmentISI
de Bruin et al. [79]2020NetherlandsStudents262/2015.33 ± 1.42Yoga286/2215.64 ± 1.80All other forms of exercise were allowedBergen Insomnia Scale
Biegel et al. [80]2009USAAdolescent psychiatric outpatients5015/3515.7 ± 1.13MBSR5212/4015.0 ± 1.19Usual treatmentSleep quality by 1 to 7 scale
Chan et al. [81] 2012ChinaPatients with depression17NR47.06 ± 9.54DMBI16NR45.44 ± 8.25Waitlist control groupSleep items of Hamilton Psychiatric Rating Scale for Depression
Chan et al. [82]2012ChinaPatients with depression172/1547.06 ± 9.55DMBI164/1245.44 ± 8.26WaitlistTotal sleep time
Chattha et al. [83]2008IndiaClimacteric syndrome patients (perimenopausal)540/5449 ± 3.6Yoga540/5448 ± 4A set of physical exercisesVasomotor symptom checklist
Yurtkuran et al. [84]2007TurkeyHemodialysis patients209/1138 ± 14.2Yoga207/1341 ± 9.97Instructed not to change their lifestyle for the duration0–10 visual analog scale
USA: United States of America; M: male; F: female; MIN: Mindfulness in Motion; PSQI: Pittsburgh Sleep Quality Index; MAPs: Standardized Mindful Awareness Exercises; CBT-I: Cognitive behavioral therapy for insomnia; MBSR: Mindfulness-based stress reduction; PMR: Progressive muscle relaxation; SHE: Sleep hygiene education; DMBI: Chinese Chan-based Dejian Mind–Body Intervention; NR: Not reported; ISI: Insomnia Severity Index.

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Figure 1. The detailed process of trial selection.
Figure 1. The detailed process of trial selection.
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Figure 2. Risks of Bias within Studies.
Figure 2. Risks of Bias within Studies.
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Figure 3. Funnel plot with pseudo 95% confidence limits.
Figure 3. Funnel plot with pseudo 95% confidence limits.
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Figure 4. Meta-analysis random effects estimates (linear form). Note: The vertical coordinate is the included studies, and the horizontal coordinate is the confidence interval limit.
Figure 4. Meta-analysis random effects estimates (linear form). Note: The vertical coordinate is the included studies, and the horizontal coordinate is the confidence interval limit.
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Figure 5. Forest plots of subjective outcomes in the overall analysis [12,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84].
Figure 5. Forest plots of subjective outcomes in the overall analysis [12,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84].
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Yang, J.; Du, Y.; Shen, H.; Ren, S.; Liu, Z.; Zheng, D.; Shi, Q.; Li, Y.; Wei, G.-X. Mindfulness-Based Movement Intervention to Improve Sleep Quality: A Meta-Analysis and Moderator Analysis of Randomized Clinical Trials. Int. J. Environ. Res. Public Health 2022, 19, 10284. https://doi.org/10.3390/ijerph191610284

AMA Style

Yang J, Du Y, Shen H, Ren S, Liu Z, Zheng D, Shi Q, Li Y, Wei G-X. Mindfulness-Based Movement Intervention to Improve Sleep Quality: A Meta-Analysis and Moderator Analysis of Randomized Clinical Trials. International Journal of Environmental Research and Public Health. 2022; 19(16):10284. https://doi.org/10.3390/ijerph191610284

Chicago/Turabian Style

Yang, Jiayi, Yan Du, Haoran Shen, Shujie Ren, Zhiyuan Liu, Danni Zheng, Qingqing Shi, Youfa Li, and Gao-Xia Wei. 2022. "Mindfulness-Based Movement Intervention to Improve Sleep Quality: A Meta-Analysis and Moderator Analysis of Randomized Clinical Trials" International Journal of Environmental Research and Public Health 19, no. 16: 10284. https://doi.org/10.3390/ijerph191610284

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