ArticlePDF Available

The role of oral myofunctional therapy in managing patients with mild to moderate obstructive sleep apnea

Authors:

Abstract and Figures

Introduction: Oral Myofunctional therapy could be considered as a new therapy for snoring and obstructive sleep apnea syndrome (OSAS), because of its direct action on oral motility. Aim of this work: to evaluate the effect of Oral Myofunctional therapy as a simple method for treatment of patients with mild to moderate Obstructive Sleep Apnea Syndrome (OSAS). Materials and methods: 30 patients with mild to moderate OSAS were subjected to the following: 1-Thorough history taking with stress on symptoms of OSAS (snoring, fragmented sleep, witnessed apneas, morning headache and daytime sleepiness) and calculation of Epworth sleepiness scale. 2-Physical examination with stress on neck circumference, body mass Index (BMI), and vocal tract examination to exclude space occupying lesions in the nose, mouth and larynx. 3-Full night polysomonography for objective diagnosis of OSAS 4- All patients were treated by Oral myofunctional therapy. 5- Full night polysomonography repeated 3 month after the myofunctional therapy. Results: There was significant decrease of apnea hypopnea index (AHI), arousal index after myofunctional therapy as compared to before myofunctional therapy (p < 0.001 for all). Also there were significant decrease in desaturation parameters (desaturation index, average duration SaO2 < 90%, % total sleep time SaO2 < 90%) after myofunctional therapy (p < 0.001). Conclusion: myofunctional therapy can achieve subjective improvement in OSAS symptoms, as well as polysomonographic abnormalities in patients with mild to moderate OSAS and so can be considered as an alternative method of treatment. Keywords: Myofunctional therapy, Obstructive Sleep Apnea Syndrome, Snoring.
Content may be subject to copyright.
Hemmat Baz, et al.
PAJR, Vol. 2, No. 1, March, 2012
17
PAN Arab Journal of Rhinology, Vol. 2, No. 1, March, 2012
The role of oral myofunctional therapy in managing patients with mild to
moderate obstructive sleep apnea
Hemmat Baz,1 Mohsen Elshafey,2 Shawky Elmorsy,3Mohamed Abu-Samra3
1Phoniatrics Unit, 2Thoracic Medicine Department 3ENT Department. Faculty of Medicine, Mansoura University, Egypt
Correspondence to: Shawky Elmorsy, Email: shawky_morsy2003@yahoo.com
Introduction: Oral Myofunctional therapy could be considered as a new therapy for snoring and obstructive sleep apnea
syndrome (OSAS), because of its direct action on oral motility.
Aim of this work: to evaluate the effect of Oral Myofunctional therapy as a simple method for treatment of patients with
mild to moderate Obstructive Sleep Apnea Syndrome (OSAS).
Materials and methods: 30 patients with mild to moderate OSAS were subjected to the following: 1-Thorough history
taking with stress on symptoms of OSAS (snoring, fragmented sleep, witnessed apneas, morning headache and daytime
sleepiness) and calculation of Epworth sleepiness scale. 2-Physical examination with stress on neck circumference, body
mass Index (BMI), and vocal tract examination to exclude space occupying lesions in the nose, mouth and larynx. 3-Full
night polysomonography for objective diagnosis of OSAS 4- All patients were treated by Oral myofunctional therapy. 5-
Full night polysomonography repeated 3 month after the myofunctional therapy.
Results: There was significant decrease of apnea hypopnea index (AHI), arousal index after myofunctional therapy as
compared to before myofunctional therapy (p < 0.001 for all). Also there were significant decrease in desaturation
parameters (desaturation index, average duration SaO2 < 90%, % total sleep time SaO2 < 90%) after myofunctional
therapy (p < 0.001).
Conclusion: myofunctional therapy can achieve subjective improvement in OSAS symptoms, as well as
polysomonographic abnormalities in patients with mild to moderate OSAS and so can be considered as an alternative
method of treatment.
Keywords: Myofunctional therapy, Obstructive Sleep Apnea Syndrome, Snoring.
INTRODUCTION
Obstructive sleep apnea Syndrome (OSAS) is
characterized by recurrent episodes of upper airway
collapse and obstruction during sleep. These episodes of
obstruction are associated with recurrent oxyhemoglobin
desaturations and arousals from sleep.(1) The upper
airway is a compliant tube and, therefore, is subjected to
collapse.(2)
Most patients with obstructive sleep apnea (OSAS)
demonstrate upper air way obstruction at either the level
of the soft palate, or the level of the tongue. Research
indicates that both anatomic factors (e.g., enlarged tonsils;
volume of the tongue, soft tissue, or lateral pharyngeal
walls; length of the soft palate; abnormal positioning of
the maxilla and mandible) and/ or associated
neuromuscular insults are the main etiological factors
predisposing to OSAS.(3,4)
The role of oral myofunctional therapy in managing patients with mild to moderate obstructive sleep apnea
18 PAN Arab Journal of Rhinology
Many treatment modalities had been implicated in
managing OSAS including; Continuous positive airway
pressure which is considered the most effective line of
treatment in cases of OSAS patients, mainly those who
present expressive drop of the oxygen saturation (SaO2),
moderate OSAS and severe OSAS.(5)
Intra-oral devices, lingual retainers, and jaw (mandible)
positioners are indicated in OSAS patients from mild to
moderate, and retrognathic OSAS patients who are not
above the ideal weight, and have not severe oxemoglobin
desaturations.(6)
Surgical techniques that vary from otorhinolaryngologic
surgeries (as Laser-assisted uvulopalatoplasty (LAUP), or
Radiofrequency-assisted uvulopalatoplasty (RAUP)), to
maxillary functional orthopedic surgeries present variable
results.(7) The most common procedures reach between
40% and 50% of efficiency and many times more than one
technique must be combined, as one- stage or two- stage
procedure.
Another form of the treatment modalities is the loss of
corporal weight through diet regimen or surgery,
ponderal reductions of 10% of corporal weight may lead
to the reduction of up to 50% of AHI, and with 20% of
corporal weight loss, the patient may become
asymptomatic. However, the long term success rates are
discouraging with the regaining of weight and
reappearance or aggravation of the OSAS.(8)
The treatment modalities aforementioned may act in a
palliative way, since they may not effectively treat the
factor that precipitates the installation of the OSAS, or
they are of difficult acceptance by the patients (high cost,
long term difficult maintenance, etc.). Thus, in the pursuit
of searching for other therapeutic methods, the hypothesis
of the phoniatrics intervention in managing OSAS through
the myofunctional therapy was raised, to bring benefits
for these patients. As in patients with OSAS there was a
significant reduction of the muscular tonus and increase of
the resistance of the upper airway during sleep.(5) It is also
believed that the dilating force of the upper airway
muscles is the only force responsible for counterbalance
the forces which promotes the collapse, represented by the
negative pharyngeal transmural pressure and for the
weight of the structures which form the upper airway,
these facts justify the rehabilitation of the orofacial and
pharyngeal musculature of these individuals.(5)
Aim of the work: The aim of this work was to evaluate the
effect of oral myofunctional therapy as a simple method
for treatment of patients with mild to moderate
obstructive sleep apnea syndrome.
PATIENTS AND METHODS
This prospective study was conducted upon 40 patients
diagnosed as having mild to moderate OSAS. Ten
patients were excluded from the study because they were
reluctant in performing the oral myofunctional therapy
(2008-2011). Approval of ethic committee and informed
consent were obtained. The study excluded patients with
Body mass index > 40, craniofacial malformation, using
hypnotics, hypothyroidism, previous stroke,
neuromuscular disease, heart failure, coronary artery
disease, severe OSAS, physical obstruction in nose or
throat, abnormally large tonsils, uncorrected deviated
septum, drug/alcohol abuse, depression, and previous
treatment for snoring (surgical or non-surgical). All
participants were underwent the following:
1. Thorough history taking with stress on symptoms of
OSAS (snoring, fragmented sleep, witnessed apneas,
morning headache and daytime sleepiness) and
calculation of Epworth sleepiness scale.
2. Physical examination with stress on neck
circumference, body mass index (BMI), vocal tract
examination to exclude space occupying lesions in the
nose and mouth, and dental examination (teeth and
gum).
3. Full night polysomonography (Jaeger sleep screen)
for objective diagnosis of OSAS, performed in a sleep
center in the presence of specially trained technicians.
During polysomnography, multiple body functions
are monitored. Sleep stages are recorded via an
electroencephalogram, electrooculogram, and chin
electromyogram.
Breathing is monitored, including airflow at the nose
and mouth (using both a thermal sensors and a nasal
pressure transducer), effort (using inductance
plethysmography), and oxygen saturation.
The breathing pattern is analyzed for the presence of
apneas and hypopneas,(definitions have been
standardized by the American Academy of Sleep
Medicine (AASM)),this breathing pattern analysis is
repeated later on 3 months after the oral
myofunctional therapy.
4. Oral myofunctional therapy including variety of
training strategies according to Galye Burditt 9 and
Cuimaraes et al. 10 from these strategies we focused
on certain training strategies to the tongue, soft palate,
and the pharynx, aiming at increasing the tone and
endurance of the targeted muscles. The therapy were
given to patients on three months period, twice
sessions weekly in a hierarchal manner, providing to
teach the patients to practice the therapy regularly at
home by a rate of three to five times per day with
minimum 10 minutes for each time.
Hemmat Baz, et al.
PAJR, Vol. 2, No. 1, March, 2012
19
Oral myofunctional therapy can be divided into:
A) Non articualtory oral myofunctional therapy:
1. Tongue stabilization:
- Push tongue tip forward just in front of lips
without touching teeth or lips for about 30 seconds.
- Spread centre of the tongue, so the sides of the
tongue touch bottom of upper teeth for about 30
seconds.
2. Tongue protrusion outside the mouth (tip forward,
tip lift and tip down).
3. Tongue lateralization: push tongue to right/left
corner of the mouth keep it pointed
4. Tongue elevation:
- Place tongue tip as far as possible on the roof of the
mouth.
- Place tongue on the roof of the mouth with tip
against upper front teeth while sucking it against
roof of the mouth.
5. Holding the tongue tip between teeth anteriorly while
trying to swallow
6. Resistive therapy in which tongue press against palate
and against hand resistance applied to the check on
both sides.
7. Palatal elevation with and without yawn (to feel the
soft palatal lift).
B) Articulatory therapy:
1. Production of Lingovelar sounds (produced by
contacting the dorsum of the tongue and the velum)
G, K, separately several times each.
2. Production of Uvular sounds Y, X, and Q (produced
by contraction of the uvula) separately several times
each.
Statistics: Data were analyzed using SPSS (Statistical
Package for Social Sciences) version 10. Qualitative data
was presented as number and percent. Comparison
between groups was done by Chi-square test. Normally
distributed data was presented as mean ± SD. Pearson’s
correlation coefficient was used to test correlation between
variables. P<0.05 was considered to be statistically
significant.
RESULTS
The mean age of the studied cases was 44.07± 7.54 years,
73.3%were males and 26.7% were females, mean BMI was
33.59± 1.98 mean neck circumference was 42.77 ± 1.67 cm
(Table 1). There was significant improvement of OSAS
symptoms (snoring, excessive daytime sleepiness,
morning headache) after oral myofunctional therapy as
compared to before the therapy (p=0.008, 0.003, 0.014
respectively) while there were lower percentages of
nocturnal choking and witnessed apnea after oral
myofunctional therapy as compared to before
myofunctional therapy but without statistical significance
(p=0.083 and 0.083 respectively) (Table 2). There were
significant decrease in neck circumference and ESS after
oral myofunctional therapy as compared to before the
therapy (p < 0.001 for both) while there were no
significant change in BMI (p=0.232)
(Table 3). There were significant decrease of AHI, arousal
index and % total sleep time in snoring after
myofunctional therapy as compared to before
myofunctional therapy
(p<0.001 for all). Also there were significant
decrease in desaturation parameters (desaturation index,
average duration SaO2 < 90%, % total sleep time
SaO2 < 90%,) after myofunctional therapy as compared to
before myofunctional therapy (p< 0.001 for all), while
there was significant increase in minimum SaO2 %
(p=0.006) after myofunctional therapy as compared to
before myofunctional therapy (Table 4). There were
significant positive correlation between changes
of AHI and changes of neck circumference (r=0.561
p<0.001) while no significant correlation between
changes of AHI and changes of BMI (r = 0.418 p=0.121)
during the period of the oral myofunctional therapy
(Table 5).
Table 1. Demographic data of the studied cases.
Mean ± SD
Age ( years)
BMI (kg/m2)
Neck circumference(cm)
Sex [No (%)]
Male
Female
44.07 ± 7.54
33.59 ± 1.98
42.77 ± 1.67
22 (73.3%
8 (26.7%)
The role of oral myofunctional therapy in managing patients with mild to moderate obstructive sleep apnea
20 PAN Arab Journal of Rhinology
Table 2. Symptoms of studied cases with OSA before and after upper airway exercises.
Symptoms Before upper airway exercises After upper airway exercises P value
No % No %
Snoring 30 100 16 53.3 0.008
Excessive day time sleepiness 30 100 12 40 0.003
Morning headache 18 60 6 20 0.014
Nocturnal choking 12 40 6 20 0.083
Witnessed apnea 10 33.3 4 13.3 0.083
Table 3. Anthropometric variables and ESS before and after upper airway exercises.
Before upper airway
exercises Mean ± SD After upper airway
exercises Mean ± SD P value
Neck circumference(cm) 42.77 ± 1.67 42.01 ± 1.96 < 0.001
BMI(kg/m2) 33.59 ± 1.98 33.50 ± 2.04 0.232
ESS 16.40 ± 1.96 9.27 ± 2.89 < 0.001
Table 4. Polysomnographic variables before and after upper airway exercises.
Before upper airway
exercises Mean ± SD After upper airway
exercises Mean ± SD P value
AHI 22.27 ± 4.51 11.53 ± 5.38 < 0.001
Desaturation index 14.53 ± 5.04 9.27 ± 4.27 < 0.001
Average duration SaO2 < 90% 18.27 ± 6.79 9.40 ± 3.29 < 0.001
% total sleep time SaO2 < 90% 2.01 ± 1.22 1.09 ± 0.72 < 0.001
Minimum Sao2% 84 ± 4 87 ± 5 = 0.006
Arousal index 28.87 ± 8.41 15.33 ± 6.11 < 0.001
% total sleep time snoring 14.05 ± 4.89 3.87 ± 4.12 < 0.001
Table 5. Correlation of changes of AHI with changes of neck circumference and BMI.
Changes in AHI
R P
Changes in neck circumference (cm) 0.561 < 0.001
Changes in BMI(kg/m2) 0.418 =0.121
Hemmat Baz, et al.
PAJR, Vol. 2, No. 1, March, 2012
21
DISCUSSION
Maintenance of pharyngeal patency during breathing
requires the coordinated activity of pharyngeal and
thoracic respiratory muscles. During inspiration,
subatmospheric pressures are produced in the upper
airway as a result of inspiratory muscle contraction. The
tendency for the pharyngeal lumen to collapse is opposed
by the activation and contraction of the upper airway
muscles including dilators, such as the sternohyoid and
the omohyoid, and pharyngeal lumen regulators, such as
the geniglossus and digastric muscles.(11) Genesis of OSAS
is multifactorial and includes anatomical and
physiological factors. Upper airway dilator muscles are
crucial to the maintenance of pharyngeal patency and may
contribute to the genesis of OSAS.(12) the aim of this work
was to evaluate the effect of myofunctional therapy as a
simple method for treatment of patients with mild to
moderate obstructive sleep apnea syndrome. Out of 40
cases, 30 cases with mild to moderate OSAS were eligible
for the study and completed the course of oral
myofunctional therapy
(3 months). The symptoms of OSAS (snoring excessive
daytime sleepiness and morning headache) showed
significant decrease after myofunctional therapy as
compared to before myofunctional therapy (p=0.008,
0.003, and 0.014 respectively) also the significant decrease
in % total sleep time of snoring (p<0.001) and in Epworth
sleepiness scale (p<0.001) confirmed the subjective
significant improvement in snoring and excessive daytime
sleepiness. These were in accordance to Cuimaraes et al.(10)
who reported significant improvement in snoring
frequency and intensity (by using visual analogue scale)
and in excessive daytime sleepiness (by Epworth
sleepiness scale) p=0.001, 0.001 and 0.006 respectively after
use of myofunctional therapy for 3 months. Also this was
in accordance to Puhan et al.(13) who reported
improvement in snoring and daytime sleepiness after 4
months training of upper airway muscles by didgeridoo
playing (a wooden wind instrument that is may be from
3-10 feet in length which is common among the
indigenous people of northern Australia). Ojay and
Ernest(14) by using singing therapy reported some
improvement in the mean value of recorded snoring per
hour slept (pretreatment 6.1 ± 1.8 minutes versus post
treatment 5.1± 2.6 minutes, mean reduction 17.6%) post
therapy (p=0.04). This can be explained by the existence of
elongated and floppy soft palate and uvula, enlarged
tongue and inferior displacement of hyoid bone in
OSAS.(15) Specific therapy were developed targeting
tongue repositioning. The facial muscles are also recruited
during chewing and were also trained with intention of
training muscles that promote mandibular elevation,
avoid mouth opening and so may affect the propensity to
myofunctional edema and collapsibility.(16) There was
significant decrease in neck circumference after oral
myofunctional therapy in comparison to before
myofunctional therapy (p<0.001) and this decrease
correlate positively with the decrease in AHI (p=0.029)
while BMI does not change significantly after
myofunctional therapy (p=0.232) and did not correlate
significantly with changes in AHI (p=0.121). This was in
accordance to Cuimaraes et al. 10 who reported significant
decrease in neck circumference (p = 0.01) but no
significant change in BMI (p=0.65) after myofunctional
therapy. This illustrate that the changes in neck
circumference cannot be attributed to changes in BMI
during this period of therapy as there were no significant
changes in BMI and so these changes in neck
circumference can be attributed to myofunctional
remodeling. Carrera et al.(17) reported that snoring and
OSAS patients have a prevalence of type 11 muscle fiber,
probably because of inflammatory trauma promoted by
vibration, affecting and decreasing the myofunction of
upper airway. Blottner et al.(18) reported that
improvement of muscle tone by physical training was
associated with increase in the proportion of type I muscle
fibers and in the size of type 11 muscle fibers as
demonstrated by muscle biopsy (type 1 having endurance
and type 11 having speed capability). Methods to increase
muscle tone of the upper airway are based on gain of
endurance and strength properties. So increase in type 1
muscle fibers by therapy resulting in improvement in
OSAS manifestation. There was significant decrease in
AHI and arousal index after myofunctional therapy
(p<0.001 for both). This was in accordance to Cuimaraes et
al.(10) who reported significant decrease in apnea index
and hypopnea index (p=0.004, 0.007 respectively). The
decrease in AHI in our study was from 22.27 to 12.93
events/ hour which represent 41.9% decrease while in
study of Cuimaraes et al.(10) it was from 22.4 to 13.7
events/ hour which represent 39.3% decrease.this
decrease in AHI approach what reported by review about
mandibular advancement by Hoffstein19 which was 42%.
Pitta et al.(5) reported improvement in two patients with
severe OSAS by application of oral myofunctional therapy
for a period of 16 week (a decrease in AHI, ESS, snoring
and an improvement in oxygen desaturation). So this
gives the potential use of this treatment in patients with
severe OSAS especially if CPAP cannot be tolerated by the
patients. Puhan et al.(13) reported marginal improvement
in AHI (p=0.05) by using didgeridoo playing for 4
months. This marginal improvement can be explained by
the non-specific myofunctional therapy applied by
didgeridoo playing in comparison to specified oral
myofunctional therapy applied in our study and study of
Cuimaraes et al.(10) (myofunctional therapy, tongue
therapy and pronounced voice for soft palate). Four cases
showed normalization of AHI (AHI <5 events/hour) after
oral myofunctional therapy and 14 cases showed >50%
decrease in AHI but without normalization of AHI while
12 cases showed less than 50 % decrease in AHI. The BMI
of cases that showed response (>50% decrease in AHI)
ranged from 30-32 while of those that showed no response
(<50% decrease in AHI) ranged from 35-36.7. This
illustrate that patients selection is critical for potential
The role of oral myofunctional therapy in managing patients with mild to moderate obstructive sleep apnea
22 PAN Arab Journal of Rhinology
benefits from therapy (those with low BMI) because
obstruction is caused not only by weak and collapsing
muscles but also by bulk formed by deposits around the
tongue and throat in obese patients The desaturation
index, average duration SaO2 <90%, % total sleep time
SaO2 <90% were significantly decreased after
myofunctional therapy (p<0.001 for all) while the
minimum SaO2 < 90% was significantly increased (from
84 ± 4 to 87± 5, p=0.006). This was in accordance to
Cuimaraes et al.(10) who reported significant increase in
minimum SaO2 from 83 ± 6 to 85 ± 7% (p<0.001). This
illustrates that only slight improvement occurred in SaO2
(about 3%) and so this method can be applied to cases of
OSAS with slight decrease in SaO2. The limitation of this
study is the application on small number of cases together
with the dependence of the results on the compliance of
the patients on regular application of the therapy. Another
limitation was absence of standardization of the
maneuvers and duration of the therapy that can achieve
maximum effect. It is not clear how long the therapeutic
effects in the responders persist and whether a longer
duration of training beyond 3 months or repetition of
training after an interval might be beneficial.
CONCLUSION
- Oral myofunctional therapy can achieve subjective
and objective improvement in OSAS symptoms and
their polysomonographic abnormalities in patients
with mild to moderate OSAS.
- Oral myofunctional therapy can be considered as
alternative method of treatment of mild to moderate
OSAS.
- Future studies will be needed to determine optimal
treatment elements (i.e., load/intensity, frequency,
and duration) and to confirm the hypothesized need
for ongoing practice to maintain beneficial treatment
effects.
REFERENCES
1. Young T, Evans L, Finn L, Palta M. Estimation of the
clinically diagnosed proportion of sleep apnea syndrome in
middle-aged men and women. Sleep. 1997;20:705-6.
2. Patil SP, Schneider H, Schwartz AR, Smith PL. Adult
obstructive sleep apnea: pathophysiology and diagnosis.
Chest. 2007;132:325-37.
3. Savage CR, Steward DL. Snoring: a critical analysis of
current treatment modalities. Does anything really work?
Curr Opin Otolaryngol Head Neck Surg. 2007;15:177-9.
4. Schwab RJ, Pasirstein M, Pierson R, et al. Identification of
myofunctional anatomicrisk factors for obstructive sleep
apnea with volumetric magnetic resonanceimaging. Am J
Respir Crit Care Med. 2003;168:522-30.
5. Pitta DB, Pessoa AF, Sampaio AL, et al. Oral myofunctional
therapy applied on two cases of severe obstructive sleep
apnea syndrome. Intr Arch Otorhynolaryngology.
2007;ii:350-4.
6. Nowara S, Lowe et al. Oral appliances for treatment of
snoring and sleep apnea: a review. Sleep. 1995;18:501-10.
7. Lim DJ, Kang SH, Kim BH, Kim HG. Treatment of primary
snoring using radiofrequency-assisted uvulopalatoplasty Eur
Arch Otorhinolaryngol. 2007;264:761-7. Epub. 2007.
8. Charuzi I, Ovnat A, Peiser J, et al. The effect of surgical
weight reduction in sleep apnea quality in obesity-related
sleep apnea syndrome. Surgery. 1985;95:535.
9. Galye Burditt. Oral sensory and motor treatment. Visual
health information. 1996. Tacoma, W A. USA.
10. Cuimaraes KC, Drager LF, Genta PR, et al. Effect of
oropharyngeal therapy on patients with moderate
obstructive sleep apnea syndrome. Am J Respir Crit
CareMed. 2009;179:962-6.
11. Van Lunteren E, Vafaie H, Salomone RJ. Comparative effects
of aging on pharyngeal and diaphragm muscles. Respir
Physiol. 1995;99:113-25.
12. Schwartz AR, Patil L, Laffan AM, et al. Obesity and
obstructive sleep apnea: pathogenic mechanism and
therapeutic approaches. Proc Am Thorac Soc. 2008;5:185-92.
13. Puhan MA, Suarez A, Cascio cl, et al. Didgeridoo playing as
alternative treatment for obstructive sleep apnea syndrome.
BMJ. 2005;332:266-70.
14. Ojay A, Ernest E. Can singing therapy reduce snoring!
A pilot study. Complement Ther Med. 2000;8:151-6.
15. Arens and R, Marcus CL Pathophysiology of myofunctional
obstruction, a developmental perspective. Sleep. 2003;27:997-
1019.
16. Chiu KL, Ryan CM, Shiota S, ET AL. Fluid shift by lower
body positive pressure increases pharyngeal resistence in
healthy subjects. Am J Respir Crit Care Med.
2006;174:1378-83.
17. Carrera M, Babe E, Sauleda J. Effect of obesity upon
genioglosus strcture and function in obstructive sleep apnea.
Eue Respir J. 2004;23:425-9.
18. Blottner D, Salavnova A, Butmarin B. Human skeletal muscle
structure and function preserved by vibration muscle
therapy following 55 days of bed rest. Eur J Appl Phsiol.
2006;97:261-71.
19. Hoffstein V. Review of oral appliances for treatment of sleep
-disordered breathing. Sleep Breath. 2007;11:1-22.
... The mechanism of OPR is to restore, reconstruct, and reeducate the upper airway for OSA patients [4][5][6]. Recent studies have indicated that the terminology of OPR also includes oropharyngeal exercise [7], myofunctional therapy [8], myofascial reeducation [9], oropharyngeal-lingual exercises [10], oropharyngeal motor training [11], and upper airway exercise [12], which are basically local muscle exercises of upper airway. However, more extensive applications of OPR, the term we used in the study, can be referred to more than local muscle exercise. ...
... Risk-of-bias assessment Table 1 summarizes the basic demographics of the participants and both the exercise contents and exercise prescriptions of intervention programs. Of the eight included studies [7,8,12,[53][54][55][56][57], three were RCTs [7,54,55], one was a non-RCT [56], and four were cohort studies [8,12,53,57]. All the studies provided both inclusion and exclusion criteria: age, severity of OSA, and BMI. ...
... Risk-of-bias assessment Table 1 summarizes the basic demographics of the participants and both the exercise contents and exercise prescriptions of intervention programs. Of the eight included studies [7,8,12,[53][54][55][56][57], three were RCTs [7,54,55], one was a non-RCT [56], and four were cohort studies [8,12,53,57]. All the studies provided both inclusion and exclusion criteria: age, severity of OSA, and BMI. ...
Article
Full-text available
Objectives: Obstructive sleep apnea (OSA) is a sleep-related breathing disorder associated with dysfunction of oropharyngeal muscles to maintain upper airway patency during sleep. Oropharyngeal rehabilitation (OPR) was developed to restore, reconstruct, and reeducate oropharyngeal muscle function, but current protocols and effectiveness of OPR have been inconsistent. The purpose of this study was to review (1) indications of OPR, (2) protocols of OPR, and (3) effectiveness of OPR. Methods: We searched MEDLINE, EMBASE, and the Cochrane Library and then conducted both meta-synthesis and meta-analysis according to the statement of Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Results: A total of eight studies with 203 patients were included. By means of meta-synthesis, the patients with middle age, BMI < 40 kg/m2, mild-to-moderate OSA, and non-severe upper airway anatomical abnormality were found to benefit from OPR. The protocol of OPR was summarized to be an anatomically based, multilevel approach, including the retropalatal, retroglossal, hypopharyngeal, TMJ, and facial levels. By using meta-analysis, overall outcomes were presented as apnea hypopnea index (AHI) with significant improvement from 25.2 ± 7.8/h to 16.1 ± 6.6/h (mean difference [MD] - 9.8 [95% CI - 11.0 to - 8.6], p < 0.0001); the lowest oxygen saturation (LSAT) improved from 80.2 ± 4.7 to 83.8 ± 2.9% (MD 3.0% [95% CI 2.0 to 4.0], p < 0.0001); Epworth sleepiness scale (ESS) improved from 11.8 ± 1.9 to 6.3 ± 1.6 (MD - 5.9 [95% CI - 7.5 to - 4.2], p < 0.001), neck circumference (NC) from 35.2 ± 1.1 to 34.7 ± 0.9 cm (MD - 0.6 [95% CI - 0.9 to - 0.2], p = 0.002), BMI from 24.8 ± 3.7 to 24.8 ± 4.1 kg/m2 (MD - 0.0; 95% CI - 0.5 to 0.5, p = 0.95). All outcomes except BMI demonstrated significant improvement from OPR. Conclusions: Meta-analysis of previous OPR reports shows an improvement in AHI of 39%, compared with the usual surgical definition of success at 50%. Only mild and moderate cases of OSA were referred for OPR in the prior studies. In order to improve outcomes with OPR, a comprehensive approach to rehabilitation should be emphasized.
... The mean age pondered by the sample size and excluding systematic reviews and meta-analyses was 51.19 years. The search strategy retrieved three meta-analyses [5,10,15], one systematic review [23], nine randomized clinical trials [8, [11][12][13]19,21,[24][25][26], seven quasiexperimental studies [9,[16][17][18]20,22,29], one cohort study [14], one case series [27], and no case-control studies. Table 1 summarizes the available evidence for each research question. ...
... Is MFT useful for treating SDB? (PSG variables) 2 meta-analyses [5,10], 2 systematic reviews [23,28], 7 RCTs [11,12,14,19,21,24,25], 1 cohort [14], 5 quasi-experimental [9,16,17,22,29], and 1 case series [27] Level 1a ...
... Specific MFT programmes from the selected studies are summarized in Table S3. [5,[9][10][11][12][13][15][16][17]19,[21][22][23][24][25]28,29], including two meta-analyses [5,10] and two systematic reviews [23,28]. We note that the meta-analysis of Hsu et al. [10] and the review by Valbuza et al. [23] reported studies using MFT and respiratory exercises, as well as protocols that included singing exercises and playing wind instruments, which were not considered to be MFT in the meta-analysis of Camacho et al. [5] or in our review. ...
Article
Full-text available
Myofunctional therapy (MFT) may have a role in improving muscle tone and alleviating upper airway collapse in sleep-disordered breathing. The purposes of this state-of-the-art review are to first review systematically the current literature on the effectiveness of MFT in treating sleep-disordered breathing and then to provide an overview of the current understanding of patient selection, side effects, type and duration of exercises, guidance of exercise performance, evaluation of results, and how best to promote adherence. PubMed (Medline), the Cochrane Library, and the EMBASE, Scopus and SciELO databases were checked for relevant studies by three authors, and a total of 23 studies were included. This review focuses only on adults with sleep-disordered breathing. The available evidence shows a positive effect of MFT in reducing sleep apnoea, as measured using polysomnography and clinical variables (including snoring). There is no evidence of the utility of MFT for treating upper airway resistance syndrome, the duration of the effects of MFT, or regarding which MFT protocol is best. Despite these knowledge gaps, the available evidence suggests that MFT is a safe treatment modality.
... Only two studies (including 43 patients) were randomized controlled trials (RCTs) [49,55]. The nonrandomized studies reported that after MT, patients with mild or moderate OSA showed significant reductions in AHI [60][61][62] and AI [60][61][62] and an increase in lowest oxygen saturation [60][61][62]. Only one study analyzed the effects of MT in a group of patients with severe OSA; this study showed a reduction in mean AHI, but the reduction was nonsignificant [62]. ...
... Only two studies (including 43 patients) were randomized controlled trials (RCTs) [49,55]. The nonrandomized studies reported that after MT, patients with mild or moderate OSA showed significant reductions in AHI [60][61][62] and AI [60][61][62] and an increase in lowest oxygen saturation [60][61][62]. Only one study analyzed the effects of MT in a group of patients with severe OSA; this study showed a reduction in mean AHI, but the reduction was nonsignificant [62]. ...
... Only two studies (including 43 patients) were randomized controlled trials (RCTs) [49,55]. The nonrandomized studies reported that after MT, patients with mild or moderate OSA showed significant reductions in AHI [60][61][62] and AI [60][61][62] and an increase in lowest oxygen saturation [60][61][62]. Only one study analyzed the effects of MT in a group of patients with severe OSA; this study showed a reduction in mean AHI, but the reduction was nonsignificant [62]. ...
Article
Full-text available
Obstructive sleep apnea (OSA) is characterized by repetitive episodes of upper airway obstruction caused by a loss of upper airway dilator muscle tone during sleep and an inadequate compensatory response by these muscles in the context of an anatomically compromised airway. The genioglossus (GG) is the main upper airway dilator muscle. Currently, continuous positive airway pressure is the first-line treatment for OSA. Nevertheless, problems related to poor adherence have been described in some groups of patients. In recent years, new OSA treatment strategies have been developed to improve GG function. (A) Hypoglossal nerve electrical stimulation leads to significant improvements in objective (apnea-hypopnea index, or AHI) and subjective measurements of OSA severity, but its invasive nature limits its application. (B) A recently introduced combination of drugs administered orally before bedtime reduces AHI and improves the responsiveness of the GG. (C) Finally, myofunctional therapy also decreases AHI, and it might be considered in combination with other treatments. Our objective is to review these therapies in order to advance current understanding of the prospects for alternative OSA treatments.
... After reading the 24 articles in full, 14 were excluded on the basis of the selection criteria: one study of two cases 11 and 13 studies without a control gr oup 10,27,29,59,76,77,78,82,104,116,117,133,142 . ...
Article
Full-text available
Introduction: Obstructive sleep apnoea syndrome (OSA) is a widespread and under-diagnosed condition, making it a major public health and safety problem. Orofacial myofunctional reeducation (OMR) has been shown to be effective in the multidisciplinary treatment of OSA in children, adolescents and adults and is prescribed at several stages of OSA management. Objectives: The main objective of this systematic literature review was to evaluate the effectiveness of active or passive orofacial myo-functional reeducation (OMR) in the treatment of obstructive sleep apnoea syndrome in children, adolescents and adults. Methods: The systematic literature review was un-dertaken from the three electronic databases: Medline (via PubMed), Cochrane Library, Web of Science Core Collection, and supplemented by a limited grey literature search (Google Scholar) in order to identify the studies evaluating the effectiveness of the OMR on OSA. The primary outcome of interest was a decrease in the Apnea-Hypopnea Index (AHI) of at least five episodes per hour compared to the baseline state. Secondary outcomes were an improvement in subjective sleep quality, sleep quality measured by night polysomnography and subjectively measured quality of life. Results: Only ten studies met all the inclusion criteria. Eight were randomized controlled clinical trials, one was a prospective cohort study and another was a retrospective cohort study. Six studies were devoted to adult OSA and four to pediatric OSA. All included studies were assessed as "low risk of bias" based on the 12 bias risk criteria of the Cochrane Back Review Group. Based on the available evidence, RMO allows a significant reduction in AHI, up to 90.6% in children and up to 92.06% in adults. It significantly reduces the intensity and frequency of snoring, helps reduce daytime sleepiness, limits the recurrence of OSA symptoms after adenoamygdalectomy in children and improves adherence to PPC therapy. Passive RMO, with the assistance provided to the patient by wearing a custom orthosis, increases adherence to reeducation, significantly improves snoring intensity, AHI and significantly increases the upper airway. Conclusions: Published data show that orofa-cial myofunctional rééducation is effective in the multidisciplinary treatment of OSA in children, adolescents and adults and should be widely prescribed at several stages of OSA management. Passive RMO, with the pearl mandibular advancement orthosis designed by Michèle Hervy-Auboiron, helps to compensate for the frequent non-compliance observed during active RMO treatments.treatment.
... A meta-analysis by Camacho et al. [50] of nine studies consisting of 120 patients confirmed the efficacy of OMT in the treatment of OSA, with a 50% improvement rate in AHI (24.5 ± 14.3 to 12.3 ± 11.8 events/h), non-significant improvements in the average lowest SaO 2 (83.9 ± 6.0 to 86.6 ± 7.3%), significant improvements in reported snoring and Epworth sleepiness scale (ESS). A study by Baz et al. [51] reported a 10% reduction of snoring from pre-to post-OMT. ...
Article
Full-text available
Obstructive sleep apnea (OSA) syndrome is a multi-factorial disorder. Recently identified pathophysiological contributing factors include airway collapsibility, poor pharyngeal muscle responsiveness, a low arousal threshold, and a high loop gain. Understanding the pathophysiology is of pivotal importance to select the most effective treatment option. It is well documented that conventional treatments (continuous positive airway pressure (CPAP), upper airway surgery, and dental appliance) may not always be successful in the presence of non-anatomical traits, especially in mild to moderate OSA. Orofacial myofunctional therapy (OMT) consists of isotonic and isometric exercises targeted to oral and oropharyngeal structures, with the aim of increasing muscle tone, endurance, and coordinated movements of pharyngeal and peripharyngeal muscles. Recent studies have demonstrated the efficacy of OMT in reducing snoring, apnea–hypopnea index, and daytime sleepiness, and improving oxygen saturations and sleep quality. Myofunctional therapy helps to reposition the tongue, improve nasal breathing, and increase muscle tone in pediatric and adult OSA patients. Studies have shown that OMT prevents residual OSA in children after adenotonsillectomy and helps adherence in CPAP-treated OSA patients. Randomized multi-institutional studies will be necessary in the future to determine the effectiveness of OMT in a single or combined modality targeted approach in the treatment of OSA. In this narrative review, we present up-to-date literature data, focusing on the role of OSA pathophysiology concepts concerning pharyngeal anatomical collapsibility and muscle responsiveness, underlying the response to OMT in OSA patients.
... The function of this therapy is to promote changes in the upper airways' muscles. The AHI before and after OMT reported by the articles reviewed in this study decreased and the ∆AHI%: (AHI before − AHI after)/AHI before × 100) [44] was 38.8% in Guimarães et al. [45], 48.2% in Baz et al. [46], 50.4% in Diaféria et al. [47,48], 28.4% in Ieto et al. [49], 58.0% in Villa et al. [50], 2.0% in Verma et al. [51], and 22.5% in Mohamed et al. [52]. It was found that OMT was indicated to treat residual OSA in children after surgical treatment. ...
Article
Full-text available
Aim: To systematically review international literature related to rapid maxillary expansion (RME) as the treatment for obstructive sleep apnea syndrome (OSAS) in children less than 18 years-old, followed by a meta-analysis of the apnea-hypopnea index (AHI) before and after RME, with or without a previous adenotonsillectomy (AT). Methods: Literature on databases from PubMed, Wiley online library, Cochrane Clinical Trials Register, Springer link, and Science Direct were analyzed up to March 2020. Two independent reviewers (S.G. and R.J.M.) screened, assessed, and extracted the quality of the publications. A meta-analysis was performed to compare AHI values before and after the treatment with RME. Results: Six studies reported outcomes for 102 children with a narrow maxillary arch suffering from OSAS with a mean age of 6.7 ± 1.3. AHI improved from a M ± SD of 7.5 ± 3.2/h to 2.5 ± 2.6/h. A higher AHI change in patients with no tonsils (83.4%) and small tonsils (97.7%) was detected when compared to children with large tonsils (56.4%). Data was analyzed based on a follow-up duration of ≤3 year in 79 children and >3 years in 23 children. Conclusion: Reduction in the AHI was detected in all 102 children with OSAS that underwent RME treatment, with or without an adenotonsillectomy. Additionally, a larger reduction in the AHI was observed in children with small tonsils or no tonsils. A general improvement on the daytime and nighttime symptoms of OSAS after RME therapy was noted in all the studies, demonstrating the efficacy of this therapy.
... Après lecture intégrale des 24 articles, 14 d'entre eux ont été exclus sur la base des critères de sélection : une étude de deux cas 11 et treize études sans groupe contrôle 10,27,29,59,76,77,78,82,104,116,117,133,142 . ...
Article
Full-text available
ABSTRACT – The contribution of orofacial myofunctional reeducation to the treatment of obstructive sleep apnoea syndrome (OSA): a systematic review of the literature. Introduction: Obstructive sleep apnoea syndrome (OSA) is a widespread and under-diagnosed condition, making it a major public health and safety problem. Orofacial myofunctional reeducation (OMR) has been shown to be effective in the multidisciplinary treatment of OSA in children, adolescents and adults and is prescribed at several stages of OSA management. Objectives: The main objective of this systematic literature review was to evaluate the effectiveness of active or passive orofacial myofunctional reeducation (OMR) in the treatment of obstructive sleep apnoea syndrome in children, adolescents and adults. Methods: The systematic literature review was undertaken from the three electronic databases: Medline (via PubMed), Cochrane Library, Web of Science Core Collection, and supplemented by a limited grey literature search (Google Scholar) in order to identify the studies evaluating the effectiveness of the OMR on OSA. The primary outcome of interest was a decrease in the Apnea–Hypopnea Index (AHI) of at least five episodes per hour compared to the baseline state. Secondary outcomes were an improvement in subjective sleep quality, sleep quality measured by night polysomnography and subjectively measured quality of life. Results: Only ten studies met all the inclusion criteria. Eight were randomized controlled clinical trials, one was a prospective cohort study and another was a retrospective cohort study. Six studies were devoted to adult OSA and four to pediatric OSA. All included studies were assessed as “low risk of bias” based on the 12 bias risk criteria of the Cochrane Back Review Group. Based on the available evidence, RMO allows a significant reduction in AHI, up to 90.6% in children and up to 92.06% in adults. It significantly reduces the intensity and frequency of snoring, helps reduce daytime sleepiness, limits the recurrence of OSA symptoms after adenoamygdalectomy in children and improves adherence to PPC therapy. Passive RMO, with the assistance provided to the patient by wearing a custom orthosis, increases adherence to reeducation, significantly improves snoring intensity, AHI and significantly increases the upper airway. Conclusions: Published data show that orofacial myofunctional rééducation is effective in the multidisciplinary treatment of OSA in children, adolescents and adults and should be widely prescribed at several stages of OSA management. Passive RMO, with the pearl mandibular advancement orthosis designed by Michèle Hervy-Auboiron, helps to compensate for the frequent non-compliance observed during active RMO treatments. KEYWORDS: Sleep Disordered Breathing / Obstructive sleep apnea syndrome / Orthodontics / Orofacial myofunctional rééducation / Prefabricated Functional Appliances RÉSUMÉ – Introduction : Le syndrome d’apnées obstructives du sommeil (SAOS) est une affection très répandue et insuffisamment diagnostiquée, ce qui en fait un problème majeur de santé publique et de sécurité. La rééducation myofonctionnelle orofaciale (RMO) a été montrée efficace dans le traitement multidisciplinaire des SAOS de l’enfant, de l’adolescent et de l’adulte et elle est prescrite à plusieurs étapes de ces prises en charge. Objectifs : L’objectif principal de cette revue systématique de la littérature était d’évaluer l’efficacité de la rééducation myofonctionnelle orofaciale (RMO), active ou passive, dans le traitement du syndrome d’apnées obstructives du sommeil chez les enfants, les adolescents et les adultes. Matériel et méthodes : La revue systématique de la littérature fut entreprise à partir des trois bases de données électroniques : Medline (via PubMed), Cochrane Library, Web of Science Core Collection, et complétée par une recherche limitée de la littérature grise (Google Scholar) afin d’identifier les études évaluant l’efficacité de la RMO sur le SAOS. Le critère de jugement principal était une diminution de l’indice d’apnées/hypopnées (IHA) d’au moins cinq épisodes par heure par rapport à l’état initial. Les critères de jugement secondaires étaient une amélioration de la qualité subjective du sommeil, de la qualité du sommeil mesurée par polysomnographie nocturne et de la qualité de vie mesurée subjectivement. Résultats : Seulement dix études répondaient à tous les critères d’inclusion. Huit étaient des essais cliniques contrôlés randomisés, une était une étude de cohorte prospective et une autre était une étude de cohorte rétrospective. Six études étaient consacrées au SAOS de l’adulte et quatre au SAOS pédiatrique. Toutes les études incluses ont été évaluées à « faible risque de biais » d’après les douze critères de risque de biais du Cochrane Back Review Group. D’après les données probantes disponibles, la RMO permet une réduction significative de l’IAH, jusqu’à 90,6 % chez l’enfant et jusqu’à 92,06 % chez l’adulte. Elle permet une diminution significative de l’intensité et de la fréquence du ronflement, participe à une réduction de la somnolence diurne, limite la réapparition des symptômes d’apnée obstructive du sommeil (AOS) après adénoamygdalectomie chez l’enfant et améliore l’adhésion au traitement par ventilation en pression positive continue (PPC). La RMO passive, avec l’assistance apportée au patient par le port d’une orthèse sur mesure à bille, augmente l’observance à la rééducation, permet une réduction significative de l’intensité du ronflement, de l’IAH et un accroissement significatif des voies aérifères supérieures. Conclusions : Les données publiées montrent que la rééducation myofonctionnelle orofaciale est efficace dans les traitements multidisciplinaires des SAOS de l’enfant, de l’adolescent et de l’adulte et devrait être largement prescrite à plusieurs étapes de ces prises en charge. La RMO passive, avec l’orthèse d’avancée mandibulaire à bille conçue par Michèle Hervy-Auboiron, aide à pallier les fréquents défauts d’observance observés lors des traitements par RMO active. MOTS CLÉS : Troubles respiratoires obstructifs du sommeil / Syndrome d’apnées obstructives du sommeil / Orthodontie / Rééducation myofonctionnelle orofaciale / Gouttières préfabriquées
Article
Introduction Myofunctional therapy (MT) improves obstructive sleep apnea (OSA) in patients. Areas Covered We systematically reviewed publications to evaluate MT as a treatment for OSA. We identified relevant articles and performed a meta-analysis on apnea-hypopnea index (AHI) scores, lowest oxygen saturation (LSAT), and Epworth Sleepiness Scale (ESS). Search databases were retained as primary data sources with the search performed through June 18, 2021. Expert Opinion Fifteen studies with 237 patients provided OSA outcomes before and after MT, which were analyzed for this meta-analysis. The mean AHI scores decreased from 28.0±16.2/h to 18.6±13.1/h. The AHI standard mean difference (SMD) is -1.34 (large effect) [95% CI -0.84, -1.85], (P < 0.00001). LSAT (197 patients) improved from 83.18±6.10% to 85.13±7.01%. The LSAT SMD is 0.44 [95% CI 0.75, 0.12], (P < 0.007). Sleepiness measured via ESS (156 patients) demonstrated a decrease from 12.71±5.73 to 8.78±5.80. The ESS SMD is -1.0 [95% CI -0.50, -1.50], (P < 0.0001).
Article
Full-text available
Background: Critically compromised by upper airway anatomical impaired properties, obstructive sleep apnea (OSA) can be categorized into different phenotypic traits, mainly including oropharyngeal muscle dysfunction. The upper airway muscle strength training was targeted on oropharyngeal muscle dysfunction by re-educating the oropharyngeal muscles to maintain the upper airway patency. OSA was characterized with multilevel collapsibility of the upper airway; however, the programs are still inconsistent and the effects are unknown. Therefore, the purpose of this study was to investigate the effects of a comprehensive physical therapy on OSA. Methods: Fifteen subjects with newly diagnosed moderate or severe OSA (AHI ≥ 15) were randomized into intervention and control groups. The intervention group underwent a 12-week-intervention of hospital based physical therapy, while the control group was kept on waiting for 12 weeks. Polysomnography (PSG) data, oropharyngeal and respiratory muscle performance were measured before and after intervention. Results: In intervention group (n = 8), AHI was significantly improved (from 46.96 ± 19.45 to 32.78 ± 10.78 events/h, p = 0.017); in control group (n = 7), AHI was significantly increased (from 35.77 ± 17.49 to 42.96 ± 17.32 events/h, p = 0.043). While the control group remained no change between pre- and post- intervention, the intervention group demonstrated that other PSG outcomes significantly improved, including arousal index (46.04 ± 18.9 versus 32.98 ± 8.35/h), mean SpO2 (92.88 ± 2.1 versus 94.13 ± 1.46%), and oxygen desaturation index (ODI) (31.13 ± 19.48 versus 20.57 ± 7.83/h). Conclusion: This comprehensive physical therapy can be prescribed for the significant clinical improvement on sleep apnea for the patients with moderate and severe OSA.
Article
Full-text available
We used sophisticated volumetric analysis techniques with magnetic resonance imaging in a case-control design to study the upper airway soft tissue structures in 48 control subjects (apnea-hypopnea index, 2.0 +/- 1.6 events/hour) and 48 patients with sleep apnea (apnea-hypopnea index, 43.8 +/- 25.4 events/hour). Our design used exact matching on sex and ethnicity, frequency matching on age, and statistical control for craniofacial size and visceral neck fat. The data support our a priori hypotheses that the volume of the soft tissue structures surrounding the upper airway is enlarged in patients with sleep apnea and that this enlargement is a significant risk factor for sleep apnea. After covariate adjustments the volume of the lateral pharyngeal walls (p < 0.0001), tongue (p < 0.0001), and total soft tissue (p < 0.0001) was significantly larger in subjects with sleep apnea than in normal subjects. These data also demonstrated, after covariate adjustments, significantly increased risk of sleep apnea the larger the volume of the tongue, lateral pharyngeal walls, and total soft tissue: (1) total lateral pharyngeal wall (odds ratio [OR], 6.01; 95% confidence interval [CI], 2.62-17.14); (2) total tongue (OR, 4.66; 95% CI, 2.31-10.95); and (3) total soft tissue (OR, 6.95; 95% CI, 3.08-19.11). In a multivariable logistic regression analysis the volume of the tongue and lateral walls was shown to independently increase the risk of sleep apnea.
Article
Full-text available
To assess the effects of didgeridoo playing on daytime sleepiness and other outcomes related to sleep by reducing collapsibility of the upper airways in patients with moderate obstructive sleep apnoea syndrome and snoring. Randomised controlled trial. Private practice of a didgeridoo instructor and a single centre for sleep medicine. 25 patients aged > 18 years with an apnoea-hypopnoea index between 15 and 30 and who complained about snoring. Didgeridoo lessons and daily practice at home with standardised instruments for four months. Participants in the control group remained on the waiting list for lessons. Daytime sleepiness (Epworth scale from 0 (no daytime sleepiness) to 24), sleep quality (Pittsburgh quality of sleep index from 0 (excellent sleep quality) to 21), partner rating of sleep disturbance (visual analogue scale from 0 (not disturbed) to 10), apnoea-hypopnoea index, and health related quality of life (SF-36). Participants in the didgeridoo group practised an average of 5.9 days a week (SD 0.86) for 25.3 minutes (SD 3.4). Compared with the control group in the didgeridoo group daytime sleepiness (difference -3.0, 95% confidence interval -5.7 to -0.3, P = 0.03) and apnoea-hypopnoea index (difference -6.2, -12.3 to -0.1, P = 0.05) improved significantly and partners reported less sleep disturbance (difference -2.8, -4.7 to -0.9, P < 0.01). There was no effect on the quality of sleep (difference -0.7, -2.1 to 0.6, P = 0.27). The combined analysis of sleep related outcomes showed a moderate to large effect of didgeridoo playing (difference between summary z scores -0.78 SD units, -1.27 to -0.28, P < 0.01). Changes in health related quality of life did not differ between groups. Regular didgeridoo playing is an effective treatment alternative well accepted by patients with moderate obstructive sleep apnoea syndrome. Trial registration ISRCTN: 31571714.
Article
Full-text available
Between 1982 and 2006, there were 89 distinct publications dealing with oral appliance therapy involving a total of 3,027 patients, which reported results of sleep studies performed with and without the appliance. These studies, which constitute a very heterogeneous group in terms of methodology and patient population, are reviewed and the results summarized. This review focused on the following outcomes: sleep apnea (i.e. reduction in the apnea/hypopnea index or respiratory disturbance index), ability of oral appliances to reduce snoring, effect of oral appliances on daytime function, comparison of oral appliances with other treatments (continuous positive airway pressure and surgery), side effects, dental changes (overbite and overjet), and long-term compliance. We found that the success rate, defined as the ability of the oral appliances to reduce apnea/hypopnea index to less than 10, is 54%. The response rate, defined as at least 50% reduction in the initial apnea/hypopnea index (although it still remained above 10), is 21%. When only the results of randomized, crossover, placebo-controlled studies are considered, the success and response rates are 50% and 14%, respectively. Snoring was reduced by 45%. In the studies comparing oral appliances to continuous positive airway pressure (CPAP) or to uvulopalatopharyngoplasty (UPPP), an appliance reduced initial AHI by 42%, CPAP reduced it by 75%, and UPPP by 30%. The majority of patients prefer using oral appliance than CPAP. Use of oral appliances improves daytime function somewhat; the Epworth sleepiness score (ESS) dropped from 11.2 to 7.8 in 854 patients. A summary of the follow-up compliance data shows that at 30 months, 56-68% of patients continue to use oral appliance. Side effects are relatively minor but frequent. The most common ones are excessive salivation and teeth discomfort. Efficacy and side effects depend on the type of appliance, degree of protrusion, vertical opening, and other settings. We conclude that oral appliances, although not as effective as CPAP in reducing sleep apnea, snoring, and improving daytime function, have a definite role in the treatment of snoring and sleep apnea.
Article
Obesity-related sleep apnea syndrome (SAS) was diagnosed in 13 patients evaluated for gastric bypass surgery. A diagnostic sleep study was performed whenever a specially designed questionnaire revealed characteristic signs of sleep disturbances. Pretreatment polyhypnographic recordings of patients with SAS demonstrated considerable reduction of deep and rapid eye movement (REM) sleep stages with a correspondent prolongation of wake within sleep or non-REM sleep stages I and II. After surgical weight reduction repeated polyhypnographic recordings revealed considerable improvement or even a complete recovery of breathing in sleep and a normalization of sleep structure. Non-REM deep sleep stages (III and IV) augmented from 5.51% +/- 2.53% (mean + SEM) to 22.69% +/- 3.56% (p less than 0.002), and the REM stage increased from 9.91% +/- 1.78% to 18.15% +/- 2.13% (p less than 0.005). Surgical weight reduction in obesity-related SAS is a valuable therapeutic measure for this respiratory derangement, as well as for sleep quality.
Article
This paper, which has been reviewed and approved by the Board of Directors of the American Sleep Disorders Association, provides the background for the Standards of Practice Committee's parameters for the practice of sleep medicine in North America. The 21 publications selected for this review describe 320 patients treated with oral appliances for snoring and obstructive sleep apnea. The appliances modify the upper airway by changing the posture of the mandible and tongue. Despite considerable variation in the design of these appliances, the clinical effects are remarkably consistent. Snoring is improved and often eliminated in almost all patients who use oral appliances. Obstructive sleep apnea improves in the majority of patients; the mean apnea-hypopnea index (AHI) in this group of patients was reduced from 47 to 19. Approximately half of treated patients achieved an AHI of < 10; however, as many as 40% of those treated were left with significantly elevated AHIs. Improvement in sleep quality and sleepiness reflects the effect on breathing. Limited follow-up data indicate that oral discomfort is a common but tolerable side effect, that dental and mandibular complications appear to be uncommon and that long-term compliance varies from 50% to 100% of patients. Comparison of the risk and benefit of oral appliance therapy with the other available treatments suggests that oral appliances present a useful alternative to continuous positive airway pressure (CPAP), especially for patients with simple snoring and patients with obstructive sleep apnea who cannot tolerate CPAP therapy.
Article
We hypothesized that aging is associated with alterations in pharyngeal muscle structural and contractile properties. Sternohyoid and geniohyoid muscles from young (3-4 months) and old (20-21 months) Fischer 344 rats were compared with diaphragm muscle. The pharyngeal muscles had significantly lower proportions of slow oxidative (SO) fibers compared to the diaphragm, and the percentage of fast glycolytic (FG) fibers was significantly higher in the sternohyoid than in both the geniohyoid and the diaphragm. With senescence, there was a small but significant increase in the proportion of FG fibers and a corresponding reduction in the proportion of fast oxidative glycolytic (FOG) fibers in all three muscles. The sternohyoid muscle had significantly faster isometric contractile kinetics and lower fatigue indexes than the diaphragm. Aging was associated with significant worsening of sternohyoid endurance, but no significant alterations in sternohyoid twitch kinetics or diaphragm properties. These results indicate that in rats the pharyngeal dilator muscles have larger proportions of fast fibers, fast contractile kinetics and worse endurance than the diaphragm. Furthermore, aging was associated with a shift to a higher proportion of FG fibers with a concomitant reduction in proportion of FOG fibers, as well as a decline in pharyngeal muscle endurance.
Article
The proportion of sleep apnea syndrome (SAS) in the general adult population that goes undiagnosed was estimated from a sample of 4,925 employed adults. Questionnaire data on doctor-diagnosed sleep apnea were followed up to ascertain the prevalence of diagnosed sleep apnea. In-laboratory polysomnography on a subset of 1,090 participants was used to estimate screen-detected sleep apnea. In this population, without obvious barriers to health care for sleep disorders, we estimate that 93% of women and 82% of men with moderate to severe SAS have not been clinically diagnosed. These findings provide a baseline for assessing health care resource needs for sleep apnea.
Article
Snoring is not merely a common nuisance but has been identified as a risk factor for poor health. Last resort treatments for palate-based snoring are surgical - reducing the amount of soft palate and/or stiffening it by causing scarring. They carry a burden of risk and expense and have a high recurrence rate. This pilot study was a first step in determining whether singing exercises could be used as a non-invasive treatment to increase muscle tone in the tissues of the throat and thereby reduce snoring. The duration of snoring of 20 chronic snorers was recorded by voice-activated tape recorder for 7 nights both before and after treatment. The therapeutic intervention consisted of instruction in singing technique and singing exercises which subjects were directed to practice for 20 minutes a day for 3 months. Compliance was encouraged by a further visit and regular telephone follow-ups. Snoring was on average reduced, especially in subjects who performed the exercises accurately and consistently and who were not overweight. Those who did best, in addition, had no nasal problems and began snoring only in middle age. A further randomized controlled study focusing on this group would appear justified and is being planned.
Article
The obstructive sleep apnea syndrome (OSAS) occurs in patients of all ages, from the premature infant to the elderly. Much remains unknown about the pathophysiology of the syndrome. However, research suggests that OSAS in all age groups is due to a combination of both anatomic airway narrowing and abnormal upper airway neuromotor tone. The anatomic predisposing factors for OSAS differ over the lifespan. However, a smaller upper airway is noted in all age groups and probably predisposes to airway collapse during sleep. Despite the known anatomic factors, such as craniofacial anomalies, obesity, and adenotonsillar hypertrophy, that contribute to OSAS throughout life, a clear anatomic factor cannot always be identified. This suggests that alterations in upper airway neuromotor tone also play an important role in the etiology of OSAS. Infants and children are less likely than adults to arouse in response to upper airway obstruction and do not compensate for prolonged increases in inspiratory resistive load. The overall ventilatory drive is probably normal in patients of all ages with OSAS. However, upper airway neuromotor tone and reflexes during sleep vary with age and are increased in normal infants and children compared to adults, perhaps as a compensatory response for their relatively narrow airway. This compensatory response appears to be blunted in children with OSAS. Further research is needed to fully understand the complexities of upper airway structure and function during both normal development and disease.