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Text word count: 2475 (limit: 2500)
Abstract word count: 237
Effects of oropharyngeal exercises on snoring: a randomized trial
Short title:
Oropharyngeal exercises and snoring
Vanessa Ieto, PhD
1
; Fabiane Kayamori
1
; Maria I. Montes, MD
2
; Raquel P. Hirata,
MS
1
;
Marcelo G. Gregório, MD, PhD
1
; Adriano M. Alencar, PhD
3
; Luciano F. Drager, MD, PhD
1
; Pedro R. Genta, MD, PhD
1
; Geraldo Lorenzi-Filho, MD, PhD
1
Authors’ affiliations:
1
Sleep Laboratory, Pulmonary Division, Heart Institute (InCor), University of São Paulo
Medical School, São Paulo, Brazil
2
Neurology Department, University of Antioquia, Medellín, Colombia
3
Physics Institute, University of São Paulo, São Paulo, Brazil
Address for Correspondence: Geraldo Lorenzi-Filho, Sleep Laboratory, Insitituto do
Coração, Av. Eneas Carvalho de Aguiar, 44
São Paulo, Brazil, Zip Code 05403-900
E-mail: geraldo.lorenzi@gmail.com
Correspondence and requests for reprints should be addressed to Geraldo Lorenzi-
Filho, MD, PhD, Sleep Laboratory, Pulmonary Division, Heart Institute (InCor), University
of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, CEP 05403-904,
São Paulo, Brazil. E-mail: geraldo.lorenzi@incor.usp.br
Conflict of Interest Statement: The authors have reported to CHEST that no potential
conflicts of interest exist with any companies/organizations whose products or services
may be discussed in this article.
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Funding information: This work was supported by Fundação de Amparo à Pesquisa
do Estado de São Paulo (FAPESP) and Conselho Nacional de Desenvolvimento
Científico e Tecnológico (CNPq).
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Abstract
Background: Snoring is extremely common in the general population and may indicate
obstructive sleep apnea (OSA). However, snoring is not objectively measured during
polysomnography, and no standard treatment is available for primary snoring or when
snoring is associated with mild forms of OSA. This study determined the effects of
oropharyngeal exercises on snoring in minimally symptomatic patients with a primary
complaint of snoring and diagnosis of primary snoring or mild-to-moderate OSA.
Methods: Patients were randomized for 3 months of treatment with nasal dilator strips
plus respiratory exercises (Control) or daily oropharyngeal exercises (Therapy). Patients
were evaluated at study entry and end by sleep questionnaires (Epworth, Pittsburgh)
and full polysomnography with objective measurements of snoring. Results: We studied
39 patients (age: 46±13 years, body mass index: 28.2±3.1 kg/m
2
, apnea hypopnea
index (AHI): 15.3±9.3 events/hour, Epworth: 9.2±4.9, Pittsburgh: 6.4±3.3). Control
(n=20) and Therapy (n=19) groups were similar at study entry. One patient from each
group dropped out. Intention-to-treat analysis was used. No significant changes
occurred in the Control group. In contrast, patients randomized to Therapy experienced
a significant decrease in the Snore Index (snores > 36dB /h): 99.5 [49.6-221.3] vs. 48.2
[25.5-219.2], P = .017 and Total Snore Index (total power of snore/h): 60.4 [21.8-220.6]
vs. 31.0 [10.1-146.5], P = .033. Conclusions: Oropharyngeal exercises are effective in
reducing objectively measured snoring and are a possible treatment for a large
population suffering from snoring.
Clinical trial registered with www.clinicaltrials.gov (NCT01636856).
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Abbreviation List
AHI: apnea hypopnea index
BMI: body mass index
OSA: obstructive Sleep Apnea
DAC: digital audio recorder
dB: decibel
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Introduction
Obstructive sleep apnea (OSA) is a common condition characterized by recurrent
upper airway obstruction during sleep.
1,2
Snoring is one of the most common symptoms
associated with OSA and is caused by vibration of soft tissues obstructing the pharynx
during sleep.
3,4
Among patients with OSA, snoring is common (70-95%), and there is an
association between snoring intensity and OSA.
5,6
On the other hand, subjects who
suffer from snoring do not necessarily have OSA. The prevalence of snoring in the
general population varies widely (from 15 to 54%) mainly because most studies rely on
subjective reports.
7-10
Self-perception of snoring is imprecise
11
and is largely dependent
on subjective reports from bed partners.
12
The social problems caused by snoring are
most likely underestimated. Snoring is frequently denied, because it is a stigmatizing
symptom that is poorly perceived by the beholder. In addition to the social problems
caused by snoring, the vibration of the upper airway associated with snoring may
contribute to pharyngeal neurogenic lesion,
13
progression of carotid artery
atherosclerosis due to vibration transmitted locally,
7
as well as sleep disruption when
associated with respiratory event-related arousal.
14
Despite the evidence that snoring is
a major burden to our society, the management of patients with primary snoring or
patients with mild forms of OSA has been poorly investigated.
The treatment of primary snoring varies widely and includes general
measurements, such as avoiding alcohol and sedatives, avoiding the supine position,
weight reduction, treatment of nasal problems, palate and upper airway surgeries, and
use of a mandibular advancement device.
15,16
However, the vast majority of the studies
have not objectively measured snoring, and results are based on subjective
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questionnaires.
17
Therefore, new forms of treatment for snoring are necessary. Recent
studies show that training the upper airway muscles either by playing a wind instrument
(didgeridoo)
18
or oropharyngeal exercises
19
can ameliorate moderate OSA. A recent
meta-analysis demonstrated that oropharyngeal exercises provides a reduction in AHI of
50% in adults and decreases snoring.
20
Oropharyngeal exercises are therefore an
attractive possibility to treat patients suffering from snoring. In the present randomized
controlled study, we tested the effects of oropharyngeal exercises on the snoring of
minimally symptomatic patients with primary snoring and mild-to-moderate OSA. In
contrast to most studies on this subject, snoring was measured objectively.
Methods
Patients
We considered eligible patients between 20 and 65 years of age referred to the
Sleep Laboratory InCor-HCFMUSP, with a primary complaint of snoring and a recent
diagnosis of primary snoring or mild-to-moderate OSA. Patients with body mass index
(BMI) ≥40 kg/m
2
, smokers, history of alcohol abuse, edentulous, severe nasal
obstruction, hypertrophic tonsils grade 3 or 4, craniofacial malformations, on regular use
of hypnotic medications, and severe comorbidities were excluded. The local ethics
committee approved the study, and all patients gave written informed consent
(CAPPESQ 0140/11).
Polysomnography
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All patients were evaluated by full polysomnography as previously described
21
with
the inclusion of a snore recording. Snore sound was captured by microphone, located at
1m from the surface of the bed, of a digital audio recorder (DAC), ZoomH4n. The clocks
of the snoring recorder and the polysomnography computer were synchronized. Since
snoring is a predominantly low-frequency sound, a band pass filter between 80 and
300Hz was used. Snoring was automatically detected by using an algorithm with an
intensity threshold cutoff of 36dB. The World Health Organization guidelines indicate
that indoor continuous sound pressure level above 30dB should be avoided during
sleep.
22
Our threshold was based on pilot studies in our sleep laboratory that evaluated
the best threshold to discriminate between snoring and ambient sounds. In addition, all
automatically detected snoring sounds were listened to and validated by one single
researcher in a blinded fashion (V.I.). Results are expressed as Snore Index (total
number of snores/total sleep time) and Total Snore Index (sound intensity power
generated by all snoring episodes/total sleep time, expressed in arbitrary unit/10
7
).
Primary snoring, mild OSA, and moderate OSA were defined as an AHI<5; ≥5 and <15;
and ≥15 and ≤30 events/h, respectively. The investigator who scored the sleep study
was blinded to the group allocation. Apnea was defined as the complete cessation of
airflow for at least 10 seconds; hypopnea was defined as a significant reduction (>30%)
in respiratory signals for at least 10 seconds associated with an oxygen desaturation
≥3%.
23
Questionnaires
Snoring of the patient was evaluated by the patient as well as by the bed partner
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(whenever present) using questions derived from the Berlin questionnaire: snoring
frequency (ranging from 0: never to 4: every day) and snoring intensity (1: similar to
breathing to 4: very loud).
24
Subjective daytime sleepiness and quality of sleep were
evaluated with the Epworth questionnaire
25
and Pittsburgh sleep quality questionnaire
26
,
respectively.
Control Group
Patients were instructed to use nasal dilator strips during sleep, to perform nasal
lavage with saline solution 3 times a day and to perform deep breathing exercises
through the nose while sitting.
Therapy Group
Patients were instructed to perform nasal lavage 3 times a day followed by
oropharyngeal exercises for approximately 8 minutes. The oropharyngeal exercises
from our previous study
19
were simplified and included: (1) push the tip of the tongue
against the hard palate and slide the tongue backward (20 times); (2) suck the tongue
upward against the palate, pressing the entire tongue against the palate (20 times); (3)
force the back of the tongue against the floor of the mouth while keeping the tip of the
tongue in contact with the inferior incisive teeth (20 times); (4) elevation of the soft
palate and uvula while intermittently saying the vowel "A" (20 times). After gaining
control and coordination of movement (typically after 3-5 weeks), elevation of the soft
palate and uvula was performed without vocalization for 5 seconds; (5) recruitment of
the buccinator muscle against the finger that is introduced in the oral cavity, pressing the
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buccinator muscle outward (10 times each side); (6) alternate bilateral chewing and
deglutition using the tongue in the palate, without perioral contraction, whenever
feeding. The patients were instructed to incorporate this mastication pattern whenever
they were eating.
Experimental Design
After fulfilling entry criteria, patients were randomized for 3 months to either Control
or Therapy group. The two groups attended weekly visits. The Therapy group performed
oropharyngeal exercises under supervision. The Control group performed exercises of
deep breathing through the nose under supervision. The Control group received nasal
dilators once a week, and the number of units used in the previous week was counted.
All patients were also asked to keep a diary to record compliance to the 8-minute set of
exercises prescribed 3 times a day of either oropharyngeal exercises (Therapy) or deep
breathing exercises (Control) The patient had to mark with a pen whether the assigned
exercise section for that period of the day was performed (“yes”) or not. The diary was
returned to the investigator once a week and provided information about patient
compliance in the previous week. Compliance was expressed as a percentage and
calculated as the number of sections answered with "yes” divided by the total number of
sections on the week. Anthropometric measures, questionnaires, and polysomnography
with recording of snoring were performed at the beginning and end of the study. The
primary outcome was snoring analysis as expressed by the snore index and the total
snore index.
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Statistical Analysis
Statistical analysis was performed using SPSS 20.0 and R statistic software.
Normality was assessed using the Kolmogorov-Smirnov test. We anticipated a 50%
reduction in objective snoring in patients randomized to oropharyngeal exercises based
on our previous research.
19
We included 38 patients (β=80%, α=95%). Data are
presented as mean and standard deviation or median (25-75%) percentile when
appropriate. Baseline characteristics were compared using 2-tailed unpaired t tests or
Mann-Whitney test when appropriate. Paired t test or Wilcoxon test was performed to
evaluate within-group changes over the study period. Repeated measures analysis of
variance (ANOVA) was used to compare the interaction between the 2 groups (Control
and Therapy) and the 2 moments (baseline and after 3 months). In addition, we used
the generalized estimation equation (GEE) to determine the influence of the time in a
supine position on the results. Comparisons were performed by intention-to-treat
analysis. Missing data at study termination were repeated from baseline according to
Last Observation Carried Forward methods
27
. A value of P < .05 was considered
significant.
Results
We recruited 156 patients and 117 were excluded, leaving 39 patients in the final
analysis. The reasons for exclusion were described in Figure 1. One patient in each
group withdrew from the study after randomization. The demographic and sleep
characteristics and symptoms of the population, according to the group assigned, are
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presented in Table 1. Patients assigned to control and therapy groups had similar
baseline characteristics (Table 1). The demographic characteristics, questionnaires,
polysomnographic and snore characteristics of the patients assigned to control or
oropharyngeal exercises at baseline and after 3 months are presented in Table 2. The
percentage of adhesion the exercises according to the weekly diaries was >75% for all
patients and was on average 85±8%. No changes occurred in the Control group in all
variables during the study period, except on the subjective frequency of snoring reported
by the patient. No changes in BMI or abdominal circumference during the study period
were observed in patients randomized to oropharyngeal exercises (Table 2). In contrast,
patients treated with oropharyngeal exercises had a small but significant decrease in
neck circumference after 3 months (Table 2). Snoring perception as reported by the bed
partner also decreased (Table 2). Objectively measured Snore Index (Figure 2) and
Total Snore Index (Figure 3) did not change in the control group and decreased
significantly in the patients assigned to oropharyngeal exercises. The mean AHI of the
population studied was relatively low at study entry (15.3±9.3 events/h) and did not
change significantly in either group. However, in the subgroup of patients with moderate
OSA at study entry, AHI decreased significantly in the patients assigned to
oropharyngeal exercises (n=8, AHI: 25.4 [22.1-28.7] vs. 18.1 [15.4-24.1], P = .017,
baseline and study termination, respectively) (Figure 4).
Discussion
This randomized controlled study was designed to objectively measure the
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effects of oropharyngeal exercises on snoring in patients with primary snoring and mild-
to-moderate OSA. We showed that 3 months of oropharyngeal exercises significantly
reduced both the frequency of snoring by 36% and the total power of snoring by 59%.
The objective decrease in snoring was associated with a decrease in the perception of
snoring by the bed partner but not by the patient.
This study shows the beneficial effects of oropharyngeal exercises in a
population that is poorly evaluated by the scientific community. The population studied
was composed of middle aged and overweight patients who were disturbed by snoring,
were on average not sleepy (Epworth= 9,2±4.9) and did not present severe OSA
(AHI=15.3±9.3 events/h). This group of patients benefit from a sleep study because
severe OSA is ruled out. However they typically do not receive standardized medical
follow up. The prevalence and significance of snoring in the general population varies
widely in epidemiological studies (from 15 to 54%).
7-10
It is plausible, although not
proven, that every night vibration of the palate caused by snoring may contribute to
upper airway neurogenic lesion
13
and progression of mild forms of OSA.
28
In addition,
primary snoring (ie, AHI<5 events/h) may be associated with disrupted sleep due to
respiratory events, related arousals,
14,29
or progression of carotid atherosclerosis due to
vibration.
7
Independent of the possible health problems aggravated by snoring, most
patients with mild forms of OSA must have some degree of social burden generated by
snoring.
30,31
For instance, a Goggle search using the key words “snoring” and
“treatment” showed over 5 million results, indicating that snoring is a major burden to the
society.
In contrast to well established metrics like the apnea-hypopnea index, snoring is
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not a standard measurement during full polysomnography.
32
In a previous study, our
group proposed a simple and accurate method to identify OSA based on time intervals
between snoring events.
33
In this study, we objectively quantified the frequency and
intensity of snoring. We used a similar distance of the microphone to the patient (1m)
34,35
and adopted the Snore Index to express our results as previously reported.
34,36-38
In
addition, we used the Total Snore Index to represent the total snore intensity power
generated during sleep. The objective reduction in snore indexes among patients
randomized to oropharyngeal exercises occurred in conjunction with an improvement in
the perceived snoring evaluated by the bed partner. Our study is in line with previous
studies that showed the beneficial effects of different forms of oropharyngeal exercises,
such as didgeridoo playing,
18
singing,
39,40
and specific oropharyngeal exercises
19
on
upper airway physiology during sleep. Upper airway exercises have been also used to
treat children and teenagers with promising results.
41,42,43
Our study was based on
exercises previously reported by our group. We extended our previous study by
reducing the number of exercises by 50% that were applied for 3 months.
Our study has strengths and limitations. First, the oropharyngeal exercises are
based on an integrative approach and therefore do not allow determining the effects of
each specific exercise on the overall result. Moreover, these exercises are derived from
oral motor techniques to improve speech and/or swallowing activity, an area that lacks
the empirical support necessary for evidence-based practices
44
. As compared to our
previous study that evaluated the effects of oropharyngeal exercises on moderate OSA,
the number of exercises proposed in the present study was reduced by 50%. In contrast
to the original study, we found no overall significant reduction in AHI after oropharyngeal
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exercises, which could be due to a reduction in the exercises protocol
19
. However, our
clinical experience accumulated over the last 5 years has shown that reducing the
number of exercises does not affect the effectiveness of therapy. Moreover, there was a
significant reduction in AHI of patients with moderate OSA at study entry randomized to
oropharyngeal exercises. The most likely explanation is that a "floor effect" in the AHI
prevented the observation of any effect on this metric among patients with mild or no
OSA at study entry. Our results point out that snoring rather than AHI is probably the
best metric to follow patients with mild forms of OSA in whom the most significant
complaint is snoring. On the other hand, we acknowledge that there are no standard
methods to measure snore and the field needs to be developed. Finally, there is a
perceived concept that exercises are difficult to incorporate. To this end, the simplified
protocol is a feasible series of 8 minutes (3 times a day) that could be more easily
incorporated into daily activities, such as immediately after tooth brushing or commuting
to work.
In conclusion, oropharyngeal exercises can reduce the objective measurements of
frequency and intensity of snoring. This set of oropharyngeal exercises is a promising
treatment for large populations suffering from snoring that are currently largely ignored
by the medical community.
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Acknowledgments:
Fundação Zerbini, São Paulo, Brazil.
This work was supported by Fundação de Amparo à Pesquisa do Estado de São Paulo
(FAPESP) and Conselho Nacional de Desenvolvimento Científico e Tecnológico
(CNPq).
Author contributions:
VI: contributed to study design, data collection and analysis, and manuscript draft. She
takes responsibility for the integrity of the work as a whole, from inception to published
article.
FK: contributed to data collection.
Dr. MIM: contributed to analysis and interpretation.
RPH: contributed to data collection, analysis, and interpretation.
Dr. MGG: contributed to data collection, analysis, and interpretation.
Dr. PRG: contributed to study design and manuscript draft.
AMA: contributed to study design and manuscript draft.
Dr. LFD: contributed to study design and manuscript draft.
Dr. GL-F: contributed to study design and manuscript draft.
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Table 1 - BASELINE DEMOGRAPHIC CHARACTERISTICS, QUESTIONNAIRES,
POLYSOMNOGRAPHIC AND SNORE CHARACTERISTICS OF THE PATIENTS ASSIGNED TO
CONTROL OR OROPHARYNGEAL THERAPY
Control
(n=20)
Therapy
(n=19)
P
value
Demographic characteristics
Male, n(%) 11 (55%) 11 (57.9%) 1.000
Age, yr 45 ± 13 48 ± 14 .458
BMI, kg/m
2
28.3 ± 2.5 28.1 ± 2.7 .818
Neck circumference, cm 38.0 ± 3.5 38.0 ± 2.6 .994
Abdominal circumference 94.3 ± 10.2 93.9 ± 5.7 .872
Polysomnography
TST, (hs) 6.2 ± 0.6 6.1 ± 0.8 .755
Sleep efficiency, (%) 84.4 ± 7.5 86.0 ± 9.7 .565
Arousal index, events/h 15.3 ± 5.4 20.0 ± 10.2 .080
AHI, events/h 15.1 ± 9.5 15.6 ± 9.3 .875
SpO
2
min 85.1 ± 5.8 85.5 ± 7.5 .844
Desaturation Index, events/h 12.3 ± 8.7 10.8 ± 8.8 .600
Snoring measures
Snore index, events/h 180.6 ± 203.1 156.1 ± 164.4 .682
Total snore index, events/h 54.4 [3.5-386.6] 60.4 [21.8-220.6] .613
Questionnaires
Patient
Pittsburgh sleep quality 6.9 ± 3.4 6.0 ± 3.2 .427
Epworth Sleepiness Scale 9.0 [7.0-13.5] 7.0 [3.0-11.0] .154
Subjective snore intensity 3.0 ± 1.0 2.3 ± 1.1 .037
Subjective snore frequency 4.0 [3.0-4.0] 3.0 [2.0-4.0] .070
Bed partner n=12 n=13
Subjective snore intensity 3.5 [2.3-4.0] 4.0 [2.5-4.0] .858
Subjective snore frequency 4.0 [3.0-4.0] 4.0 [3.0-4.0] .698
Definition of abbreviations: BMI=body mass index; TST=total sleep time;
AHI=apnea hypopnea index; SpO
2
min=lowest oxygen saturation;
Plus-minus values are mean ± SD. Epworth Sleepiness Scale, Subjective snore frequency,
Subjective snore intensity, and Total Snore Index are presented as median [25–75%] because
of skewed distribution
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Table 2 –DEMOGRAPHIC CHARACTERISTICS, QUESTIONNAIRES, POLYSOMNOGRAPHIC AND
SNORE CHARACTERISTICSOF THE PATIENTS ASSIGNED TO CONTROL OR OROPHARYNGEAL
THERAPY ON BASAL AND AFTER 3 MONTHS
Control (n=20) Therapy (n=19)
Baseline 3 months p Baseline 3 months P
Demographic characteristics
BMI, kg/m
2
28.3 ± 2.5 28.2 ± 3.5 0.453 28.1 ± 2.7 28.2 ± 2.8 .469
Neck
Circumference, cm 38.0 ± 3.5 37.9 ± 3.4 0.628 37.9 ± 2.5 37.5 ± 2.4 .000*
Abdominal
Circumference, cm
94.3 ±10.2 94.6 ± 10.4 0.673 93.9 ± 5.7 93.7 ± 4.5 .687
Questionnaires performed with the patient
Pittsburgh 6.9 ± 3.4 6.4 ± 3.9 0.459 6.0 ± 3.2 4.0 ± 2.6 .004
Epworth 9.0 [7.0-13.5] 8.0 [3.5-12.5] 0.190 7.0 [3.0-11.0] 7.0 [4.0-10.0] .084
Subjective Snore
Intensity 3.0 [2.0-4.0] 3.0 [2.0-3.0] 0.083 2.0 [2.0-3.0] 2.0 [1.0-2.0] .155
Subjective Snore
Frequency 4.0 [3.0-4.0] 3.5 [2.0-4.0] 0.010 3.0 [2.0-4.0] 2.0[1.0-4.0] .030
Questionnaires performed with bed partner
Subjective Snore
Intensity 3.5 [2.3-4.0] 3.0 [2.0-4.0] 0.194 4.0 [2.5-4.0] 1.0 [1.0-2.0] .003*
Subjective Snore
Frequency 4.0 [3.0-4.0] 3.5 [3.0-4.0] 0.180 4.0 [3.0-4.0] 2.0[1.5-3.0] .004*
Polysomnography
TST, hs 6.2 ± 0.6 6.2 ± 1.1 0.894 6.1 ± 0.8 6.5 ± 0.9 .079
Sleep efficiency, % 84.4 ± 7.5 85.0 ± 11.1 0.776 86.0 ± 9.7 86.3 ± 8.6 .825
Arousal index 15.3 ± 5.4 16.9 ± 5.2 0.239 20.0 ± 10.2 6.2 ± 1.4 .077
Lowest oxygen
saturation 85.1 ± 5.8 84.0 ± 7.6 0.325 85.5 ± 7.5 83.8 ± 8.9 .120
Desaturation Index 12.3 ± 8.7 12.1 ± 6.9 0.881 10.8 ± 8.8 9.7 ± 6.0 .437
Questionnaires
Patient
Pittsburgh 6.9 ± 3.4 6.4 ± 3.9 0.459 6.0 ± 3.2 4.0 ± 2.6 .004
Epworth 9.0 [7.0-13.5] 8.0 [3.5-12.5] 0.190 7.0 [3.0-11.0] 7.0 [4.0-10.0] .084
Subjective Snore
Intensity 3.0 [2.0-4.0] 3.0 [2.0-3.0] 0.083 2.0 [2.0-3.0] 2.0 [1.0-2.0] .155
Subjective Snore
Frequency 4.0 [3.0-4.0] 3.5 [2.0-4.0] 0.010* 3.0 [2.0-4.0] 2.0[1.0-4.0] .030
Bed partner n=12 n=13
Subjective Snore
Intensity 3.5 [2.3-4.0] 3.0 [2.0-4.0] 0.194 4.0 [2.5-4.0] 1.0 [1.0-2.0] .003*
Subjective Snore
Frequency 4.0 [3.0-4.0] 3.5 [3.0-4.0] 0.180 4.0 [3.0-4.0] 2.0[1.5-3.0] .004*
Definition of abbreviations: BMI=body mass index; TST=total sleep time;
* P < .05 for the comparisons using repeated measures analysis of variance (ANOVA): compare the
interaction between the 2 groups (Control and Therapy) and the 2 moments (baseline and after 3 months)
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Figure Legends
Figure 1. Flow diagram of the progress through the phases
Figure 2. Individual values for Snore Index. In the control group, the Snore Index from
baseline to 3 months was similar. In contrast, the Snore Index significantly declined in
the group randomized to oropharyngeal exercises. There were group X time interaction
effects (P = .017). Short horizontal lines and bars are mean ± SD. NS = not significant
Figure 3. Individual values for Total Snore Index. In the control group, the Total Snore
Index from baseline to 3 months was similar. In contrast, the Total Snore Index
significantly declined in the group randomized to oropharyngeal exercises. There were
group X time interaction effects (P = .033). Short horizontal lines and bars are mean ±
SD. NS = not significant
Figure 4. Individual values for Apnea Hypopnea Index (AHI) at baseline and after 3
months. There were no statistical differences on AHI in either group. However, the
subgroup of patients with moderate obstructive sleep apnea (OSA) (15 ≤ AHI ≤ 30)
randomized to oropharyngeal exercises had a significantly decreased AHI. In the control
group, the AHI from baseline to 3 months (from 25.3 [22.1-29.8] to 22.1 [18.2-28.1]
events/h) was similar. In contrast, the AHI significantly declined in the group randomized
to oropharyngeal exercises (from 25.4 [22.1-28.7] to 18.1 [15.4-24.1] events/h; P =
.017). Short horizontal lines and bars are medians (25–75%), because of skewed
distribution
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Figure 1. Flow diagram of the progress through the phases
254x190mm (72 x 72 DPI)
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Figure 2. Individual values for Snore Index. In the control group, the Snore Index from baseline to 3 months
was similar. In contrast, the Snore Index significantly declined in the group randomized to oropharyngeal
exercises. There were group X time interaction effects (P = .017). Short horizontal lines and bars are mean
± SD. NS = not significant.
313x168mm (150 x 150 DPI)
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Figure 3. Individual values for Total Snore Index. In the control group, the Total Snore Index from baseline
to 3 months was similar. In contrast, the Total Snore Index significantly declined in the group randomized to
oropharyngeal exercises. There were group X time interaction effects (P = .033). Short horizontal lines and
bars are mean ± SD. NS = not significant.
247x153mm (150 x 150 DPI)
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Figure 4. Individual values for Apnea Hypopnea Index (AHI) at baseline and after 3 months. There were no
statistical differences on AHI in either group. However, the subgroup of patients with moderate obstructive
sleep apnea (OSA) (15 ≤ AHI ≤ 30) randomized to oropharyngeal exercises had a significantly decreased
AHI. In the control group, the AHI from baseline to 3 months (from 25.3 [22.1-29.8] to 22.1 [18.2-28.1]
events/h) was similar. In contrast, the AHI significantly declined in the group randomized to oropharyngeal
exercises (from 25.4 [22.1-28.7] to 18.1 [15.4-24.1] events/h; P = .017). Short horizontal lines and bars
are medians (25–75%), because of skewed distribution.
247x122mm (72 x 72 DPI)
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