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Effects of orofacial myofunctional therapy on the symptoms and physiological parameters of sleep breathing disorders in adults: a systematic review

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Recently, the orofacial myofunctional therapy (OMT) has appeared as a possible alternative treatment for obstructive sleep apnea (OSA). Systematic reviews are required to achieve scientific evidence, seeking to direct the decision on therapeutic issues. The aim of this study was to systematically review the literature about the OMT proposals in adults with OSA related to symptoms and physiological parameters. Data sources were Lilacs, MEDLINE, Pubmed, Cochrane and Scielo using the descriptors: obstructive sleep apnea; myofunctional therapy; oropharyngeal exercises; breathing exercises; upper airway exercises; speech therapy. Studies published from 2000 to 2017 that evaluated the treatment with isolated OMT in subjects with OSA were included, obligatorily with polysomnographic data, pre and post therapy. Eight studies, out of 124 articles, were eligible according to the criteria adopted. Two systematic reviews, one clinical trial, three randomized clinical trials, and two case reports were included. Six studies showed a decrease in the Apnea and Hypopnea Index (AHI), five studies showed improvement in the minimum SpO2, decrease in the Epworth Sleepiness Scale (ESS) and in snoring. OMT proposals refer to a three-month program changing the parameters related to partial reduction of AHI, ESS index, snoring, and partial increase of SpO2. There are few randomized studies.
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(1) Pontifícia Universidade Católica de São
Paulo (PEPG-PUCSP), São Paulo, SP,
Brazil.
Research support source: National
Postdoctoral Program/ Coordination for
the Improvement of Higher Education
Personnel (PNPD/CAPES).
Conict of interest: Nonexistent
Effects of orofacial myofunctional therapy on
the symptoms and physiological parameters of
sleep breathing disorders in adults:
a systematic review
Fabiane Kayamori(1)
Esther Mandelbaum Gonçalves Bianchini(1)
Received on: August 29, 2017
Accepted on: October 17, 2017
Mailing address:
Fabiane Kayamori
Alameda Jaú, 1767, conjunto 51,
Cerqueira César
CEP: 01420-002 - São Paulo,
São Paulo, Brasil
E-mail:fabianekayamori@gmail.com
ABSTRACT
Recently, the orofacial myofunctional therapy (OMT) has appeared as a possible alter-
native treatment for obstructive sleep apnea (OSA). Systematic reviews are required to
achieve scientic evidence, seeking to direct the decision on therapeutic issues. The
aim of this study was to systematically review the literature about the OMT proposals
in adults with OSA related to symptoms and physiological parameters. Data sources
were Lilacs, MEDLINE, Pubmed, Cochrane and Scielo using the descriptors: obstruc-
tive sleep apnea; myofunctional therapy; oropharyngeal exercises; breathing exercises;
upper airway exercises; speech therapy. Studies published from 2000 to 2017 that
evaluated the treatment with isolated OMT in subjects with OSA were included, obli-
gatorily with polysomnographic data, pre and post therapy. Eight studies, out of 124
articles, were eligible according to the criteria adopted. Two systematic reviews, one
clinical trial, three randomized clinical trials, and two case reports were included. Six
studies showed a decrease in the Apnea and Hypopnea Index (AHI), ve studies sho-
wed improvement in the minimum SpO2, decrease in the Epworth Sleepiness Scale
(ESS) and in snoring. OMT proposals refer to a three-month program changing the
parameters related to partial reduction of AHI, ESS index, snoring, and partial increase
of SpO2. There are few randomized studies.
Keywords: Obstructive Sleep Apnea; Snoring; Myofunctional Therapy; Speech,
Language and Hearing Sciences; Oropharynx
Review articles
13317
Rev. CEFAC. 2017 Nov-Dez; 19(6):868-878 doi: 10.1590/1982-0216201719613317
Rev. CEFAC. 2017 Nov-Dez; 19(6):868-878
Myofunctional therapy and sleep apnea | 869
INTRODUCTION
Orofacial myofunctional therapy (OMT) is a set
of techniques and procedures intended to change
orofacial muscular and functional patterns using
isotonic and isometric exercises for orofacial and
oropharyngeal muscles targeting the functions of
breathing, mastication, swallowing and speech1.
For the past 10 years, Speech, Language and
Hearing Sciences intervention using OMT have been
presented in this eld as one of the possible treatments
for snoring and obstructive sleep apnea (OSA), with
evidence found specially in studies on Sleep Breathing
DIsorders in adults1-4.
Every new eld of study with its specic techniques
needs researches that provide evidence of the benets
of each therapy. The rst publications on OMT for
obstructive sleep apnea date from 19995, but the rst
randomized clinical trial (RCT) to use the therapy as
alternative treatment for patients with moderate OSA
was published in 20091. The study reported a decrease
of approximately 40% in the Apnea and hypopnea index
(AHI), a reduction in cervical circumference, reduction
in snoring intensity and frequency, reduction of daytime
sleepiness and better sleep quality after the OMT
program. Right after this rst international publication,
the same journal published an editorial questioning
the benets and objectives of OMT procedures for
improving OSA6.
Physiologically, the pharynx is a highly collapsible
area in the entirety of its extension. The activity of
dilating pharynx muscles, especially the genioglossus
and tensor palatini muscles oppose to the tendency
of the pharynx to collapse as a protective mechanism.
Changes in such mechanism are associated with
the syndrome of obstructive sleep apnea disorder7.
In that sense, OMT applied to OSA has the objective
of strengthening the nasopharynx and oropharynx
musculature contributing to reduce collapse of the
airway during sleep1-4. However, the exact mechanisms
by which OMT helps with Sleep Breathing Disorders
are still not clear to this day.
Contemporary studies show OMT efcient results
in improving the quality of life2, in the reduction of
intensity and frequency of snoring3 and in the better
adherence of CPAP (Continuous Positive Airway
Pressure)4. Such studies endorse the Speech,
Language Therapist interest in this eld and validate
the presence of that professional in the interdisciplinary
realm of Sleep Breathing Disorders, especially in Brazil
with the existence of a specic certication for Speech,
Language and Hearing Sciences in the eld of sleep
disorders8.
At the present stage, systematic reviews are
necessary to attest the level of scientic evidence of
OMT effects in OSA and in snoring, as well as to set
methodological parameters for the decision-making
in therapy matters. However, such parameters are not
always clear or coincident, making difcult a consistent
verication of OMT effects for individuals with Sleep
Breathing Disorders.
The objective of this study is to systematically
analyze the scientic literature available on OMT
programs for adults with Sleep Breathing Disorders,
their effects on symptoms and physiological param-
eters, trying to argue for the relevance of the practice-
based evidence (PBE).
METHODS
Research strategies
The fundamental questions that guide this literature
review are:
“What are the methodological parameters in
orofacial myofunctional therapy programs for Sleep
Breathing Disorders?”
“What are the effects of the isolated orofacial
myofunctional therapy in adults considering symptoms
and physiological parameters of Sleep Breathing
Disorders?”.
Our search was performed in the following online
databases: “Literatura Latino-Americana e do Caribe
em Ciências da Saúde” (Lilacs); ‘‘Medical Literature
Analysis and Retrieval System Online’’ (MEDLINE),
‘‘US National Library of Medicine National Institutes
Health’’ (Pubmed), ‘‘Cochrane Library’’ (Cochrane)
and ‘‘Scientic Electronic Library’’ (Scielo) and we have
selected the studies published between the year 2000
and April 2017.
The descriptors in Health Sciences (DeCs)
used for retrieving the articles, language limiters
considered for Portuguese and English languages,
were: apneia obstrutiva do sono (obstructive sleep
apnea) [All elds]; terapia miofuncional (myofunctional
therapy) [All elds]; exercícios (exercises) [All elds];
exercícios orofaríngeos (oropharyngeal exercises)
[All elds]; exercícios respiratórios/ /exercícios da via
aérea (breathing exercises / upper airway exercises
[All elds]; Fonoaudiologia (Speech, Language and
Hearing Sciences / speech therapy) [All elds]. The
Kayamori F, Bianchini EMG Myofunctional therapy and sleep apnea
Rev. CEFAC. 2017 Nov-Dez; 19(6):868-878
870 | Kayamori F, Bianchini EMG
search was performed with associated descriptors
(e/and).
Selection criteria
The selection of studies published followed the
steps described below:
The search for materials according to the associate
descriptors and that had been published between the
year 2000 to 2017 (April) in the referred databases with
full version available online; the selection of studies
whose titles and abstracts were related to the proposed
subject; observation of inclusion and exclusion criteria;
reading and analysis of the full text articles.
The considered articles should published in
Portuguese or English and approach the method-
ological parameters for the OMT programs related
to Sleep Breathing Disorders or present studies
describing the procedures and effects of isolated OMT
in adults considering the symptoms and physiological
parameters of Sleep Breathing Disorders (snoring
and/or OSA) necessarily reporting polysomnographic
data (pre and post therapy), at least for the Apnea and
Hypopnea Index (AHI).
Repeated articles recovered from different
databases were not considered. An initial selection
was made after reading of titles and abstracts and
exclusion of those that did not match the criteria. The
full text articles were downloaded and the studies were
read and analyzed in their entirety. The references were
evaluated, the studies were identied and listed.
Data analysis
The following topics were tabulated for the articles’
analysis: name of authors, year of publication, infor-
mation on the type of study, study risk of bias (consid-
ering selection, performance, detection, friction and
publishing biases), number of subjects, demographic
characteristics (gender, age), type of Sleep Breathing
Disorder, level of OSA severity, methodological
parameters with respect to therapeutic procedures and
description of results post OMT.
A specic protocol was developed for the present
research based on the selected articles and trying to
answer the question on the methodological param-
eters that guide OMT proposals for Sleep Breathing
Disorders.
The specic research protocol based on method-
ological parameters included:
Therapeutic parameters: procedures, frequency
and period of therapy, therapy follow up;
Parameters for evaluation and reevaluation:
Physiologic parameters: anthropometric measure-
ments such as body mass index (BMI) and cervical
circumference (cc) pre and post OMT, polysomno-
graphic data such as Apnea and Hypopnea Index
(AHI) for each hour of sleep and minimum blood
oxygen saturation (SpO2) and period with SpO2 under
90% pre and post OTM;
Symptomatology: data on daytime sleepiness
(Epworth Sleepiness Scale)9 and snoring reported by
complaint or part of Berlin questionnaire (referring to
intensity and frequency)10.
LITERATURE REVIEW
One hundred and twenty four articles were screened
considering the methodology for this literature review,
initially excluding the studies that did not involve
snoring and/or OSA (N=28) and that did not provide
some form of therapy (N=67). 29 potentially relevant
studies were set apart and their references checked for
other studies not present in our initial search. 10 more
studies were included. After verifying the total of 39
articles, 31 of them were eliminated and 8 articles were
kept for detailed analysis.
The uxogram (Figure 1) illustrates the trajectory
of the present study. It is interesting to point out that 4
studies involve specically the applicability and results
of OMT for children11-14, two case-control reports13,14 and
two retrospective studies11,12.
Rev. CEFAC. 2017 Nov-Dez; 19(6):868-878
Myofunctional therapy and sleep apnea | 871
with systematic literature review15,16, three RCT1-4, one
clinical study17 and two case reports18,19. A description
of the studies can be found in Tables 1 and 2.
Considering the focus of the present systematic liter-
ature review on the effects of isolated OMT for adults
with OSA, 8 studies were considered, two of them
Figure 1. Systematic literature review information uxogram: studies selection stage
Selected articles
(excluding repeated articles)
N=124
Potential relevant studies
N=29
Eligible complete studies
Adults N=8
Additional studies
identied on the
references
N=10
Excluded articles / details:
- does not mention snoring / OSA (N=28)
- no therapy report (N=67)
Excluded articles / details: (N=31)
- airway resistance syndrome (N=1)
- general therapy review (N=6)
- related treatment review/ OMT (N=2)
- non intervention (N=7)
- children (N=4)
- editorial (N=2)
- no date (N=1)
- not OMT treatment (N=8), being:
Electric stimulation (N=1); singing and blowing
instrument (N=3); physiotherapy (electric
stimulation+exercises) (N=1); exercises for the
adherence of the mandibular advancement splint
(N=1); periorbicular musculature therapy (N=1);
intraoral dispositive therapy (N=1)
Table 1. Eligible literature review articles description
Author, year Objective Meta-analysis Number of listed
articles Conclusion
Camacho et al,
2015(16)
Systematic literature review
considering OMT for the
treatment of OSA in children and
adults performing meta-analysis
of polysomnography, snoring and
sleepiness
Yes 9
Data on the adults:
myofunctional therapy reduces AHI
in approximately 50%, improves
SpO2 and snoring.
Valbuza et al,
2010(15)
Literature review on methods
of treatment for OSA improving
musculature tonus as revealed in
the AHI.
No 3
No accepted scientic evidence that
the methods are effective for AHI
decrease under 5.
Rev. CEFAC. 2017 Nov-Dez; 19(6):868-878
872 | Kayamori F, Bianchini EMG
The three RCT were analyzed reported on Table
2 observing, when possible, the possibility of bias
according to the Cochrane Collaboration criteria for the
development of systematic reviews of interventions20.
Little information on this item could be recovered in the
complete version of the published articles or even in
the respective thesis, which were secondarily checked.
To give an example, only one of the studies3 mentions
the intention of treating, which is recommended in the
cases of dropout or loss of subjects in the RCT and this
being a better model for this type of study. The RCT
also presented performance bias in the blinding of the
professionals performing the clinical evaluations pre
and post OMT. That is something important to be taken
into account in future studies.
The last three studies: the clinical study17 and the
case reports18,19 do not provide data related to possible
biases. For the present literature review all types of
studies were analyzed despite possible biases.
Data related to the establishment the studies’
sample, type of Sleep Breathing Disorder, level of
severity of the OSA and therapeutic parameters can be
found in Table 3.
The two systematic literature reviews listed in our
search differ in relation to the objectives and criteria
of analysis (Table 1). Data from the literature review16
performed through meta-analysis attest for the
positive effects of OMT in adults based in parameters
from polysomnography, indicating approximately
50% decrease in AIH, improvement in minimum
blood oxygen saturation and snoring. However, the
systematic literature review previously published15, with
focus in the increase of muscle tonus with exercises did
not present favorable effects for AIH reduction under
ve15. We should reinforce that given the criteria of the
described literature review potential results above this
level were not considered as they would be later16,
understanding that the AIH criteria under ve events
per hour indicates remission of the disorder.
Considering two of the RCTs2,4, they originally
correspond to the same study and although they
bring additional information, the data are from the
same subjects and so were counted only once in our
systematic literature review.
Table 2. Eligible clinical studies description considering type of study and biases
Author, year Type of
study
Selection
bias
Selection
bias
Performance
bias Detection bias Attrite bias Report bias
Random
sequence
generator
Omitted
allocation
Participants and
professional
blinding
Final reviewers
blinding
Incomplete
results
Selective results
report
Diaféria G
et al, 2013(2)
and 2016(4)
RCT unknown unknown
yes (participants)
no(professional
speech therapist)
yes
(polysomnography) unknown unknown
Verma et al,
2016(17) CR NR NR NR NR NR NR
Ieto et al,
2015(3) RCT unknown unknown
yes (participants)
no(professional
speech therapist)
yes
(polysomnography) unknown
Treatment
recommendation,
low risk of bias
Guimarães
et al, 2009(1) RCT unknown unknown
yes (participants)
no(professional
speech therapist)
yes
(polysomnography) unknown unknown
Silva et al,
2007(18) CR NR NR NR NR NR NR
Pitta et al,
2007(19)
CR2
cases NR NR NR NR NR NR
Subtitles: CR=case report; CE=clinical study; RCT=randomized clinical trial; NR=no record
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Myofunctional therapy and sleep apnea | 873
The three RCT1-4 counted on a control group
as intended for this type of study. The subjects did
not undergo OMT, only receiving orientations and/
or nasal wash as placebo effect in order to minimize
performance bias. Trying to analyze the effects of OMT
associated to other forms of therapy, other studies2,4
have considered four groups, one control group
(N=24), one OMT group (N=27), CPAP (N=27) and
a mixed group (CPAP e OTM) (N=22). This literature
review considered only the results referring to OMT
alone, following the methodological criteria.
The analysis section of the studies1-4,17 did not
include sample calculation, which we consider to be a
relevant matter. The challenge of gathering a relevant
number of participants in the groups, especially for this
kind of studies is a known fact, mainly in the search for
homogeneity in the sample. However, observing the
number of subjects in the clinical studies’ OMT group,
we notice a gradual increase in that aspect through the
years, which we consider to be a positive factor.
The Sleep Breathing Disorders and their level of
severity have also changed through the years. Starting
Table 3. Description of data from the studies considering subjects characterization, type of disorder and level of OSA severity and
therapeutic parameters
Author, year
Subjects characterization in the
studies Type and
severity of
the OSA
Therapeutic procedures
(OMT)
Frequency/
Period of OMT Follow up
N Gender Age
(years)
Diaféria et al,
2013(2)
and 2016(4) 27 male 45.2±13.0
mild,
moderate
and severe
OSA
Exercise program:Tongue,
soft palate, pharynx
musculature, facial
musculature.Functional:
breathing, swallowing and
mastication
12 sessions
3 daily
practices, 20
minutes each
After 3
weeks wash
out: decrease
in AHI
Verma et al,
2016(17) 20 male (75%)
female (25%) 41.1±10.6
mild and
moderate
OSA
3 stages exercise
program:Tongue, soft palate,
facial musculature and
mandible musculature.
12 sessions
10 repetitions
5 series per
day
NR
Ieto et al,
2015(3) 19 male (57.9%)
female (42.1%) 48±14
snoring,
mild and
moderate
OSA
Nasal washShort exercise
programTongue, soft
palate, facial musculature.
Functional: mastication
12 sessions
Daily practice
3 times a day,
8 minutes each
NR
Guimarães
et al, 2009(1) 16 male 63 Moderate
OSA
Nasal washExercise
program:Tongue, soft
palate, facial musculature
and mandible musculature.
Functional: speech,
breathing, swallowing and
mastication
12 sessions
Daily practice
30 minutes
each
NR
Silva et al,
2007(18) 1 female 60 Severe OSA
Nasal washExercises
forTongue, soft palate, facial
musculature.Functional:
Breathing and mastication
12 sessions
Note.:1st PSG
10 months
previous to
therapy)
NR
Pitta et al,
2007(19)
1 male 37 Severe OSA Exercises forTongue, soft
palate, pharynx musculature,
facial musculature and
mandible musculature.
16 sessions NR
1 female 55 Severe OSA 16 sessions NR
Subtitles: N=number of subjects; OSA= obstructive sleep apnea; OMT= orofacial myofunctional therapy; AHI= Apnea and hypopnea Index per hour of sleep; NR=no
record; PSG=Polysomnography
Rev. CEFAC. 2017 Nov-Dez; 19(6):868-878
874 | Kayamori F, Bianchini EMG
with clinical case reports of severe OSA19,20, going to
RCT with moderate OSA1, to mild or moderate OSA 3,17
to RCT2,4 with all three levels of OSA severity. We were
able to notice that the search for data on OMT effects
has grown for all levels of OSA.
Regarding the methodological therapeutic param-
eters applied to each of the studies1-4,17,19, the approach
and procedures in OMT were the same considering the
period of therapy, being prescribed 12 sessions, one
time per week. They differ nevertheless in the selection
of exercises, number of repetitions, frequency and
period of daily practice and also in the type of functional
approach. The specicities of the practices were not
properly justied regarding the choices made in each
of the studies.
The analysis section of the case reports are clearly
more specic and direct considering the case matter.
On those studies, the selected exercises are not
described, nor is the amount of exercises. On the
RCTs those descriptions are found. On one of the
case reports17 the amount of exercises changes along
three stages of practice: 13 exercises for the two rst
stages and seven for the third one. The other three
RCTs1-4 seem to suggest the following up of exercises
and functional practice progress without considering
stages. Two of the studies indicate programs with a
higher amount of exercises1,2,4 and another3 shows
a great reduction of such number, maybe trying to
facilitate the technique for the patient or because of the
main focus of the study, which was primary snoring.
It is important to indicate that mostly because of
the type of study, techniques were previously dened
and equally applied for the entire study group in each
of researches regardless of the myofunctional changes
that each of the participants could present. For RCT
studies that is a required procedure in order to observe
the effects of a certain technique. However, studies with
consistent justication for the exercise selection and
its functional approach seem to be necessary to better
fund the therapeutic practice targeted to those cases.
The description of therapeutic parameters only
similar among the studies is probably due to the variety
of aspects and matters that involve a orofacial myofunc-
tional therapeutic approach, besides the recent
presence of such therapy in the eld of sleep disorders.
Other relevant data refer to the follow up of the
studies in relation to the effects obtained with OMT.
Only one of the studies in the present systematic review
brought this important concern2,4, revealing a downsize
of the results previously obtained. Considering that the
follow up was only after a few weeks, it was possible to
attest the necessity of maintaining the therapy program
to solidify the results previously obtained. New studies,
with medium and long term follow ups seem to be
necessary.
The data regarding the methodological param-
eters for evaluation and reevaluation post OMT are
found in Tables 4 and 5. Considering this aspect,
the randomized trials follow similar parameters for
evaluation and reevaluation and they are based on
symptomatology data, specic anthropometric data
and polysomnographic data.
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Myofunctional therapy and sleep apnea | 875
Table 4. Description of data considering the results with orofacial myofunctional therapy (OMYT) based on physiological parameters
Author, year
Anthropometric measurements Polysomnography
BMI (kg/m2) CC (cm) AHI (events/hour) Minimum SpO2 (%)
pre post pre post pre post Pre post
Diaféria G
et al, 2013(2)
and 2016(4)
25.0±7.4 26.7±2.9 41.6±3.7 41.5±2.3 28±22.7 13.9±18.5* 83.7 ±7.7 84.9±8.8
Verma et al,
2016(17) 25.6±3.1 25.4±3.2 38.4±1.3 37.8±1.6* 20.1±9.1 19.7±9.4 87.6 ±1.1 88.5 ±1.6*
Ieto et al,
2015(3) 28.1±2.7 28.2±2.8 37.9±2.5 37.5±2.4**
25.4 (22.1-
28.7)
#
18.1 (15.4-
24.1)
# ***
85.5±7.5 83.8±8.9
Guimarães
et al, 2009(1) 29.6±3.8 29.5±4.3 39.6±3.6 38.5±4.0* 22.4±4.8 13.7±8.5* 83±6 85±7*
Silva et al.
2007(18) 23.3 NC NC NC 44 3 83 92
Pitta et al.
2007(19)
26.3 27.7 NC NC 48.5 8.6 79 87
22.2 22.2 NC NC 40.4 3.3 77 83
Subtitles: Data presenting mean and standard deviation. except for #. which presents the results in median. minimum and maximum; BMI= body mass index; CC=
cervical circumference; AHI= Apnea and Hypopnea Index per hour of sleep; SpO2 = blood minimum saturation; * P signicant (<0.05) test T; ** P signicant
considering test with variation according to period and group; *** P relevant only for the group with moderate OSA; NR= no record.
Table 5. Description of data considering the results with orofacial myofunctional therapy (OMT) based on symptomatological parameters
Author. Year
Symptomatology
Life quality
Sleep quality ESS Intensity of snoring Frequency of snoring
pre post pre post pre post pre post
Diaféria G
et al. 2013(2)
and 2016(4)
FOSQ
WHOQoL-
Bref SF-36(2)
FOSQ
WHOQoL-
Bref *
SF-36*
13.7±3.2(2) 7.5±3.7* 8.5±2.3(4) 4.9±3.2* 7.7±2.3(4) 4.3±2.8*
Verma et al.
2016(17) NC NC 15.4±2.3 13.6±3.1* 2.8±0.5 1.7±0.6 * NC NC
Ieto et al.
2015(3)
Pittsburgh
6±3.2
Pittsburgh
4±2.6*
7 (3-11)
#7 (4-10) #
2(2-3) S
4(2.5-4) C
#
2(1-2) S
1(1-2)C*
#
3(2-4) S
4(3-4) C
#
2(1-4) S
2(1.5-3)C*
#
Guimarães
et al. 2009(1)
Pittsburgh
10.2±3.7
Pittsburgh
6.9± 2.5* 14±5 8±6* 3(3-4)
#
1(1-2)*
#
4(4-4)
#
3(1.5-3.5)*
#
Silva et al.
2007(18) NR NR NR NR NR NR NR NR
Pitta et al.
2007(19)
NR NR 12 10 Disturbs the
partner mild NR NR
NR NR 13 7Disturbs the
partner mild NR NR
Subtitles: Data presenting mean and standard deviation. except for #. which presents the results in median. minimum and maximum; ESS=Epworth Sleepiness Scale;
* P signicant (<0.05) test T; S= information given by the subject of the research; C= information provided by the roommate; NR= no record.
Rev. CEFAC. 2017 Nov-Dez; 19(6):868-878
876 | Kayamori F, Bianchini EMG
Table 4 shows the data of the results obtained with
OMT based in physiologic parameters and they show
signicant differences in relation to anthropometric
measurements considering the reduction in cervical
circumference without BMI reduction in three clinical
studies1,3,17. The authors indicate that the improvement
in oropharynx musculature may have determined such
reduction since the subjects did not lose weight and
their BMI was not altered.
Considering physiologic data obtained with
polysomnography, all three RCT1-4 revealed signicant
differences in OMT showing decrease in AIH. It is worth
to point out that in one of the studies3, which also
considered subjects with primary snoring and mild
OSA, the relevant statistic difference was only for the
subjects with moderate OSA. The author justies that
the AIH for mild OSA is already close to the minimum
limit and thus not provide signicant reduction.
The two articles with case reports18,19 are the ones
presenting a better improvement in the level of apnea
with great differences in AIH, maybe because they
had an individual focus. Those studies also present
improvement in the minimum SpO2, as well as in one
of the ECR1 and the clinical essay17, indicating one
other relevant benecial effect of OMT.
In order to analyze the effects of OMT on snoring
in an instrumental way, a RCT3 measured snoring
recording it with a microphone and then presented a
total snoring index considering sound intensity divided
by the total period of sleep. The analysis of such data
pre and post OMT, comparing the results in both groups
(therapy and control) showed signicant reduction of
snoring considering the snoring index and also consid-
ering the total snoring index in the OMT group 3.
The results in the studies referring to the symptom-
atology pre and post OMT are found in table 5, which
brings the data in quality of life, quality of sleep,
excessive daytime sleepiness, intensity and frequency
of snoring, reported and analyzed with specic
questionnaires.
Only one of the RCT2 brought data on quality of
life using three different questionnaires (FOSQ21,
WHOQoL-Bref22 and SF-3623). Comparing the results
of the group pre and post OMT. Signicant differences
were found in: physical domain of the instrument
WHOQoL-Bref and functional quality of the SF-36,
revealing the effects of OMT in those aspects.
The observation of the quality of sleep was reported
in two studies1,3 using the Pittsburgh24 questionnaire.
The data show improvement with signicant differences
post OMT, although not indicating in which compo-
nents specically.
The data on the symptom of daytime sleepiness
were based on the Epworth Sleepiness Scale (ESS)9 in
four of the clinical essays1-4,17 and in one of the case
reports19. Excluding the results in one of the RCT3, the
studies indicate a signicant reduction of the symptom
after a OMT program.
Considering the data related to snoring, the clinical
studies analyzed the intensity and frequency of the
snoring according to the Berlin questionnaire1,3,17 or
the analogic subjective visual scale4. They indicate a
reduction in intensity1,3,4,17 and frequency of snoring1,3,4.
One of the RCT3 separates the Berlin questionnaire
answers when applied to the subject himself or his
roommate, showing signicant improvement in the
answers of the roommate when comparing pre and
post data for the OMT and the control group. In general
terms, the report on snoring by the patient himself is
uncommon and when it happens is due to information
previously given by the roommate. He is the one that
listens to the subject snoring and is able to report on
changes and is thus the most relevant information for
that variable.
In relation to the case reports, one of them19 analyzed
excessive daytime sleepiness and snoring data in two
cases. The data followed the Epworth Sleepiness Scale
(ESS) and show a relief of the symptom. The data on
snoring, on its turn, followed a scale of 0 to 4 (0 =
absence of snoring, 1= resonate; 2 = light snore, 3
= snoring disturbing partner, 4 = snoring disturbing
family). In both cases there was a reduction in the
symptom post OMT. The other case report18 only brings
information on high intensity snoring and the report of
sleepiness previous to OMT, going to moderate snoring
after OMT with evidence on polysomnographic data.
The lack of data uniformity does not allow us to infer
how those characteristics related to the effects of OMT
in the study.
Considering the data in general, it is worth noticing
that the clinical study17 and one of the RCTs3,4, statistical
analysis were presented in terms of mean and standard
deviation. However, two of the RCTs1,3,4 included
median, minimum and maximum, probably because of
the number of subjects in the sample. Methodological
differences were also identied between the RCTs1-4
and the clinical study17. The RCTs compared changes
pre and post OMT between the study and control
groups after the indicated period and the results
were statistically analyzed. The clinical study brought
Rev. CEFAC. 2017 Nov-Dez; 19(6):868-878
Myofunctional therapy and sleep apnea | 877
statistical analysis considering the changes in study
group post OMT compared with data from previous
evaluation. Regardless of those methodological differ-
ences, which can difcult the comparison of results, the
studies conrm the positive effects of OMT for patients
with OSA.
Systematic literature reviews are a growing
tendency in the eld of health sciences as to gather
evidence on the practice of a certain line of action,
trying to base changes in the works of prevention,
diagnosis, treatment and rehabilitation. The privilege
of a systematic literature review is the possibility of
a detailed approach focused on answering precise
questions. In the eld of Speech, Language and
Hearing Sciences, that is already a challenge, given the
variety of the aspects involved in each of the elds of
competence25,26. However, sleep studies in that context
are a recent and interdisciplinary eld of work and the
search for literature reviews that recover the effects of
therapies is necessary to guide upcoming studies as
well as the clinical practice.
The present systematic literature review found that
there are few controlled randomized trials with adults
and they are necessary to provide scientic evidence
to guide the eligibility criteria for undergoing OMT and
also determine the applicable therapy procedures.
CONCLUSION
The present systematic literature review shows
that the methodological parameters guiding orofacial
myofunctional therapy programs for Sleep Breathing
Disorders mostly compare data pre and post therapy
based on the analysis of: symptomatology related
to quality of life, quality of sleep, daytime sleepiness,
intensity and frequency of snoring; anthropometric data
related to body mass index and cervical circumference;
physiological parameters measured with polysomnog-
raphy related to Apnea and Hypopnea Index and blood
minimum saturation.
The parameters for therapy are related to the
practice of exercises for the orofacial and oropharynx
musculature daily, reinforced by functional practice for
the period of 3 months, with individual therapy one time
per week.
The most relevant effects of the isolated orofacial
myofunctional therapy in adults include: reduction of
daytime sleepiness and snoring, better quality of sleep,
partial decrease in the Apnea and Hypopnea Index and
partial increase in the blood minimum saturation.
There have been few controlled randomized blind
trials and they are important to attest the effects of the
technique based on evidences and guiding the thera-
peutic decisions considering evaluation and diagnosis
and the phenotype of the patient for an accurate
prognosis.
ACKNOWLEDGEMENTS
Coordination for the Improvement of Higher
Education Personnel (CAPES) National postdoctoral
program in the Program of Graduate Studies in Speech
Language Pathology and Audiology (PEPG/PUC-SP) at
the Ponticate Catholic University of São Paulo.
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... 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 ...
... Is MFT useful for treating SDB? (sleepiness and QoL) 2 meta-analyses [5,10], 2 systematic reviews [23,28] ...
... 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. ...
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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.
... If necessary, a behavioural approach is proposed with the introduction of a suitable diet, a physical activity programme 22 , reduction of sleeping pills, alcoholic beverages and tobacco consumption 122 , and the use of an anti-decubitus device in case of positional OSA 89 . Myofunctional reeducation (MFR), either active or passive 63 , is also prescribed and has been evaluated 18,73 . It contributes to improved quality of life 35 , reduced snoring 65 and adherence to CPAP 36 . ...
... The number of studies evaluating the effects of OMR in OSA patients is increasing 35,53,56,114,117 and narrative reviews 83,113 , systematic reviews 34,72,73,88,131 and meta-analyses 2, 18,20 are regularly published. ...
... The main objective of this systematic review of the literature was to evaluate the effectiveness of active and passive orofacial myofunctional reeducation (OMR) for the treatment of obstructive sleep apnoea syndrome in children, adolescents and adults. The difference between this systematic review and previous ones 2, 18,20,34,72,73,83,88,113,131 is its global approach to orofacial myofunctional reeducation (OMR), both active and passive, and its focus on the therapeutic strategies used by the various authors. ...
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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.
... La intervención fonoaudiológica desde la Terapia Miofuncional Orofacial (TMO) tiene como propósito tratar las disfunciones o secuelas en la respiración, masticación, deglución o habla que se generan como consecuencia de alteraciones estructurales o funcionales a nivel orofacial y cervical [1,2]. Desde hace más diez años, la fonoaudiología ha aportado sus conocimientos para trabajar uno de los temas de mayor preocupación en la salud pública mundial: los trastornos respiratorios del sueño. ...
... Desde hace más diez años, la fonoaudiología ha aportado sus conocimientos para trabajar uno de los temas de mayor preocupación en la salud pública mundial: los trastornos respiratorios del sueño. Se ha concentrado particularmente en lo que respecta al tratamiento del Síndrome de Apnea Obstructiva del Sueño (SAOS) [1,3,4]. ...
... Actualmente la principal evidencia referida de la TMO para el SAOS está compuesta por: (a) maniobras de higienización nasal, (b) ejercicios orofaríngeos, (c) intervención de la musculatura de soporte perioral y (d) ejercicios a partir de las funciones estomatognáticas de masticación, deglución y coordinación fonorespiratoria [1,[5][6][7][8]. Desde el punto de vista de composición epistémica, la evidencia apunta a una comprensión de la TMO que abarca desde la función muscular [1,6] hasta las técnicas de facilitación neuromuscular desarrolladas al interior de la fisiología del ejercicio. ...
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Introducción: el objetivo de este estudio es develar si la técnica Neuromuscular Funcional (NMF) puede ser considerada como opción de tratamiento en el Síndrome de Apnea Obstructiva de Sueño (SAOS) y si se complementa con la Terapia Miofuncional Orofacial o hace parte de ella. Métodos: la fenomenología trascendental de Husserl es el enfoque metodológico que se adoptó para este estudio, siguiendo la ruta para su desarrollo: epojé, reducción trascendental fenomenológica y síntesis. El contenido real se obtuvo mediante dos entrevistas semiestructuradas, aplicadas a un informante clave que contó con los criterios de inclusión presupuestados. Resultados: en la primera etapa se identificaron 10 noesis y 266 noemas, que fueron relacionados entre sí; en la fase de reducción trascendental las noesis se redujeron a 5 y los noemas a 14. Análisis y discusión: el Método Chiavaro como fenómeno se decanta en las dimensiones: (a) Enfoque Sistémico, (b) Técnica Neuromuscular Funcional y (c) Técnica Respiratoria. La prioridad del fenómeno NMF es la explicación de la alteración dentro del enfoque sistémico a partir de la lógica Función-Estructura-Función, de esta manera el SAOS se considera una manifestación de esas relaciones y como tal se le cataloga como adaptación o como función en disfunción. Conclusiones: la Técnica NMF hace parte de la neurorrehabilitación mientras que la TMO para intervenir el SAOS se inscribe en la fisiología del ejercicio.
... Speech therapy is an alternative to conservative treatment for OSA. Its effect is to remodel the upper airways by strengthening the muscles responsible for maintaining this patent pathway during sleep, thereby combatting the symptoms of OSA by lessening snoring, alleviating daytime sleepiness, and improving the subjective quality of sleep [19]. Despite extensive scientific literature on speech therapy in the treatment of OSA and descriptions of swallowing impairment in OSA patients, no studies have investigated swallowing therapy program for the treatment of oropharyngeal dysphagia in patients with OSA. ...
... This may be explained by the fact that individuals with OSA most often have symptoms impair sleep quality [42]. Although the literature indicates the benefit of speech therapy intervention for the treatment of OSA and improvement of sleep quality in individuals with OSA [19], this study found no improvement in the sleep domain after therapy program. This is because the swallowing therapy program applied to the participants of this study was directed to the rehabilitation of swallowing and not to the treatment of OSA. ...
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Purpose To evaluate (i) the outcome of swallowing therapy program on the rehabilitation of oropharyngeal dysphagia in resistant hypertensive patients with obstructive sleep apnea (OSA) and (ii) the association between the clinical and anthropometric characteristics of these individuals and this outcome. Methods This was a prospective interventional study in which resistant hypertensives diagnosed with OSA by polysomnography and dysphagia by fiberoptic endoscopic evaluation of swallowing (FESS) participated. All participants underwent a FEES and assessment of the risk of dysphagia (Eating Assessment Tool, EAT-10) and swallowing-related quality of life (Swal–QoL) before and after the intervention. The therapeutic program was performed daily by the participants, with weekly speech-therapist supervision for eight weeks, including the following strategies: Masako, chin tuck against resistance, and expiratory muscle training. Results A total of 26 (78.8%) of the participants exhibited improvement in the degree of dysphagia in the intervention outcome. After the intervention, there was a statistically significant improvement in the level of penetration–aspiration (p = 0.007), the degree of pharyngeal residue (p = 0.001), the site of onset of the pharyngeal phase (p = 0.001), and the severity of dysphagia (p = 0.001) compared to before intervention. The EAT-10 score was 2 (0–6) before and 0 (0–3) after intervention (p = 0.023). Swal–QoL had a score on the symptom frequency domain of 92.8 (75–100) before and 98.2 (87.5–100) after intervention (p = 0.002). Conclusions Resistant hypertensive patients with OSA showed improved swallowing performance after swallowing therapy program.
... Si nécessaire, une approche comportementale est proposée avec l'instauration d'un régime alimentaire adapté, un programme d'activité physique 22 , la réduction de la prise de somnifères, de la consommation de boissons alcoolisées et de tabac 122 , et le port d'un dispositif anti-décubitus dorsal en cas de SAHOS positionnel 89 . La rééducation myofonctionnelle (RMO), active ou passive 63 , est également prescrite et a été évaluée 18,73 . Elle contribue à l'amélioration de la qualité de vie 35 , à la réduction du ronflement 65 et à l'adhésion à la PPC 36 . ...
... L'objectif principal de cette revue systématique de la littérature était d'évaluer l'efficacité de la rééducation myofonctionnelle orofaciale (RMO), active ou passive, pour le traitement du syndrome d'apnées obstructives du sommeil chez les enfants, les adolescents et les adultes. La différence entre cette revue systématique et les précédentes 2,18,20,34,72,73,83,88,113,131 est son approche globale de la rééducation myofonctionnelle orofaciale (RMO), tant active que passive et l'accent mis sur les stratégies thérapeutiques utilisées par les divers auteurs. ...
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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
... La rééducation myofonctionnelle orofaciale (RMOF) 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 4,6, 17,18,19,22,40,46,47,63,72,89,93 . La RMOF met principalement en oeuvre des exercices isotoniques et isométriques ciblant les structures buccales, oropharyngées 76 et associés à des exercices spécifiques de ventilation, de déglutition 74 et de mastication. ...
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La rééducation myofonctionnelle orofaciale (RMOF) a été montrée efficace dans le traitement multidisciplinaire des syndromes d’apnées obstructives du sommeil (SAOS) de l’enfant, de l’adolescent et de l’adulte et elle est prescrite à plusieurs étapes de ces prises en charge. La santé connectée fait appel à l’utilisation de messages électroniques, à une surveillance à distance, à des plateformes de télémédecine du sommeil et à des applications de santé mobile. Les objets connectés aident au diagnostic du SAOS, ils permettent la télésurveillance des patients traités par pression positive continue et facilitent la prise en charge des comorbidités liées au SAOS. La première application conçue pour réaliser une RMOF chez des patients souffrant de SAOS, nommée Airway Gym ® , a été conçue par O’Connor-Reina et al. en 2017. Elle permet au patient d’interagir directement avec le smartphone sans avoir besoin d’un autre appareil et elle vise à améliorer la tonicité des différents muscles impliqués dans la pathogenèse du SAOS. Un essai clinique randomisé a évalué les effets de l’application Airway Gym ® chez des patients atteints de SAOS sévère, et montré des améliorations significatives de l’IAH, du score de l’échelle de somnolence d’Epworth, de la saturation minimale en O2, du score maximal de la langue IOPI et du score maximal des lèvres IOPI.
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Dental sleep appliances achieve a 50% response in around 65% of patients with obstructive sleep apnea and a complete response in 35–40%. This means that all practitioners will need to augment the effect of a dental sleep appliance at some stage. There are many ways in which adjunctive therapies can be used to augment both the objective and subjective outcomes of DSA therapy. This chapter discusses the use of multiple adjunct therapies including positional therapies, positive airway pressure therapies, therapies aimed at stabilizing or improving compromised anatomy in the upper airway, and therapies aimed at improving the subjective outcomes of sleep.KeywordsDental sleep applianceObstructive sleep apneaPositional obstructive sleep apneaCognitive behavioral therapy for insomniaCircadian rhythm disordersBright light therapyOral EPAPNasal EPAP
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This chapter explores the use of orofacial myofunctional therapy in the treatment of sleep -related breathing disorders. Current literature demonstrates orofacial myofunctional therapy (OMT) decreases apnea-hypopnea index, reduces daytime sleepiness and snoring, arousal index, improvement in quality of sleep and quality of life in both children and adults. Oxygen saturation and snoring improve in adults. Orofacial myofunctional therapy increases adherence to continuous positive airway pressure and assists in forward-tongue position in conjunction with a dental sleep appliance. OMT is noninvasive and inexpensive. There is increasing evidence to support the use of OMT as adjunctive therapy in the multidisciplinary approach to the treatment of sleep-related breathing disorders.KeywordsOrofacial myofunctional therapyMyologyObstructive sleep apneaSleep disorder breathingContinuous positive airway pressure
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This chapter describes the experience report of the "Autismo Comunica" project, developed at the speech therapy school clinic at UFPE which aims to promote communicational accessibility through the use of alternative communication to children with ASD stimulating the development of social interaction and contributing to their learning process, social inclusion and quality of life. In this proposal, speech therapy is indicated for autistic children, without functional speech, and prioritizes the development of communication using Alternative Communication applied in accordance with the DHACA Method - Development of Communication Skills in Autism, based on the theoretical assumption the Sociopragmatic Theory. The alternative communication resource used is the visual communication book in which the figures are selected based on the proposal of "core words" (Banjee, 2003)
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Background: Obstructive sleep apnoea (OSA) is a syndrome characterised by episodes of apnoea (complete cessation of breathing) or hypopnoea (insufficient breathing) during sleep. Classical symptoms of the disease - such as snoring, unsatisfactory rest and daytime sleepiness - are experienced mainly by men; women report more unspecific symptoms such as low energy or fatigue, tiredness, initial insomnia and morning headaches. OSA is associated with an increased risk of occupational injuries, metabolic diseases, cardiovascular diseases, mortality, and being involved in traffic accidents. Continuous positive airway pressure (CPAP) - delivered by a machine which uses a hose and mask or nosepiece to deliver constant and steady air pressure- is considered the first treatment option for most people with OSA. However, adherence to treatment is often suboptimal. Myofunctional therapy could be an alternative for many patients. Myofunctional therapy consists of combinations of oropharyngeal exercises - i.e. mouth and throat exercises. These combinations typically include both isotonic and isometric exercises involving several muscles and areas of the mouth, pharynx and upper respiratory tract, to work on functions such as speaking, breathing, blowing, sucking, chewing and swallowing. Objectives: To evaluate the benefits and harms of myofunctional therapy (oropharyngeal exercises) for the treatment of obstructive sleep apnoea. Search methods: We identified randomised controlled trials (RCTs) from the Cochrane Airways Trials Register (date of last search 1 May 2020). We found other trials at web-based clinical trials registers. Selection criteria: We included RCTs that recruited adults and children with a diagnosis of OSA. Data collection and analysis: We used standard methodological procedures expected by Cochrane. We assessed our confidence in the evidence by using GRADE recommendations. Primary outcomes were daytime sleepiness, morbidity and mortality. Main results: We found nine studies eligible for inclusion in this review and nine ongoing studies. The nine included RCTs analysed a total of 347 participants, 69 of them women and 13 children. The adults' mean ages ranged from 46 to 51, daytime sleepiness scores from eight to 14, and severity of the condition from mild to severe OSA. The studies' duration ranged from two to four months. None of the studies assessed accidents, cardiovascular diseases or mortality outcomes. We sought data about adverse events, but none of the included studies reported these. In adults, compared to sham therapy, myofunctional therapy: probably reduces daytime sleepiness (Epworth Sleepiness Scale (ESS), MD (mean difference) -4.52 points, 95% Confidence Interval (CI) -6.67 to -2.36; two studies, 82 participants; moderate-certainty evidence); may increase sleep quality (MD -3.90 points, 95% CI -6.31 to -1.49; one study, 31 participants; low-certainty evidence); may result in a large reduction in Apnoea-Hypopnoea Index (AHI, MD -13.20 points, 95% CI -18.48 to -7.93; two studies, 82 participants; low-certainty evidence); may have little to no effect in reduction of snoring frequency but the evidence is very uncertain (Standardised Mean Difference (SMD) -0.53 points, 95% CI -1.03 to -0.03; two studies, 67 participants; very low-certainty evidence); and probably reduces subjective snoring intensity slightly (MD -1.9 points, 95% CI -3.69 to -0.11 one study, 51 participants; moderate-certainty evidence). Compared to waiting list, myofunctional therapy may: reduce daytime sleepiness (ESS, change from baseline MD -3.00 points, 95% CI -5.47 to -0.53; one study, 25 participants; low-certainty evidence); result in little to no difference in sleep quality (MD -0.70 points, 95% CI -2.01 to 0.61; one study, 25 participants; low-certainty evidence); and reduce AHI (MD -6.20 points, 95% CI -11.94 to -0.46; one study, 25 participants; low-certainty evidence). Compared to CPAP, myofunctional therapy may result in little to no difference in daytime sleepiness (MD 0.30 points, 95% CI -1.65 to 2.25; one study, 54 participants; low-certainty evidence); and may increase AHI (MD 9.60 points, 95% CI 2.46 to 16.74; one study, 54 participants; low-certainty evidence). Compared to CPAP plus myofunctional therapy, myofunctional therapy alone may result in little to no difference in daytime sleepiness (MD 0.20 points, 95% CI -2.56 to 2.96; one study, 49 participants; low-certainty evidence) and may increase AHI (MD 10.50 points, 95% CI 3.43 to 17.57; one study, 49 participants; low-certainty evidence). Compared to respiratory exercises plus nasal dilator strip, myofunctional therapy may result in little to no difference in daytime sleepiness (MD 0.20 points, 95% CI -2.46 to 2.86; one study, 58 participants; low-certainty evidence); probably increases sleep quality slightly (-1.94 points, 95% CI -3.17 to -0.72; two studies, 97 participants; moderate-certainty evidence); and may result in little to no difference in AHI (MD -3.80 points, 95% CI -9.05 to 1.45; one study, 58 participants; low-certainty evidence). Compared to standard medical treatment, myofunctional therapy may reduce daytime sleepiness (MD -6.40 points, 95% CI -9.82 to -2.98; one study, 26 participants; low-certainty evidence) and may increase sleep quality (MD -3.10 points, 95% CI -5.12 to -1.08; one study, 26 participants; low-certainty evidence). In children, compared to nasal washing alone, myofunctional therapy and nasal washing may result in little to no difference in AHI (MD 3.00, 95% CI -0.26 to 6.26; one study, 13 participants; low-certainty evidence). Authors' conclusions: Compared to sham therapy, myofunctional therapy probably reduces daytime sleepiness and may increase sleep quality in the short term. The certainty of the evidence for all comparisons ranges from moderate to very low, mainly due to lack of blinding of the assessors of subjective outcomes, incomplete outcome data and imprecision. More studies are needed. In future studies, outcome assessors should be blinded. New trials should recruit more participants, including more women and children, and have longer treatment and follow-up periods.
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PurposeData in the literature suggest that myofunctional therapy (MT) may be able to play a role in the treatment of children with sleep-disordered breathing (SDB). Our study investigated the effectiveness of MT in reducing respiratory symptoms in children with SDB by modifying tongue tone. Methods Polysomnographic recordings were performed at baseline to assess obstructive sleep apnea (OSA) severity in 54 children (mean age 7.1 ± 2.5 years, 29 male) with SDB. Patients were randomly assigned to either the MT or no-MT group. Myofunctional evaluation tests, an assessment of tongue strength, tongue peak pressure, and endurance using the Iowa Oral Performance Instrument (IOPI), and nocturnal pulse oximetry were performed before (T0) and after (T1) 2 months of treatment. ResultsMT reduced oral breathing (83.3 vs 16.6%, p < 0.0002) and lip hypotonia (78 vs 33.3%, p < 0.003), restored normal tongue resting position (5.6 vs 33.4%, p < 0.04), and significantly increased mean tongue strength (31.9 ± 10.8 vs 38.8 ± 8.3, p = 0.000), tongue peak pressure (34.2 ± 10.2 vs 38.1 ± 7.0, p = 0.000), and endurance (28.1 ± 8.9 vs 33.1 ± 8.7, p = 0.01) in children with SDB. Moreover, mean oxygen saturation increased (96.4 ± 0.6 vs 97.4 ± 0.7, p = 0.000) and the oxygen desaturation index decreased (5.9 ± 2.3 vs 3.6 ± 1.8, p = 0.001) after MT. Conclusions Oropharyngeal exercises appear to effectively modify tongue tone, reduce SDB symptoms and oral breathing, and increase oxygen saturation, and may thus play a role in the treatment of SDB.
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PurposeFew studies have investigated myofunctional therapy in patients with obstructive sleep apnea syndrome (OSAS). The objective of this study was to evaluate the effect of myofunctional therapy on continuous positive airway pressure (CPAP) adherence. Methods The study was registered at ClinicalTrials.gov (NCT01289405). Male patients with OSAS were randomly divided into four treatment groups: placebo, patients undergoing placebo myofunctional therapy (N = 24); myofunctional therapy, undergoing myofunctional therapy (N = 27); CPAP, undergoing treatment with CPAP (N = 27); and combined, undergoing CPAP therapy and myofunctional therapy (N = 22). All patients underwent evaluations before and after 3 months of treatment evaluation and after 3 weeks of washout. Evaluations included Epworth sleepiness scale (ESS), polysomnography, and myofunctional evaluation. ResultsThe 100 men had a mean age of 48.1 ± 11.2 years, body mass index of 27.4 ± 4.9 kg/m2, ESS score of 12.7 ± 3.0, and apnea-hypopnea index (AHI) of 30.9 ± 20.6. All treated groups (myofunctional therapy, CPAP, and combined myofunctional therapy with CPAP) showed decreased ESS and snoring, and the myofunctional therapy group maintained this improvement after the “washout” period. AHI reduction occurred in all treated groups and was more significant in CPAP group. The myofunctional therapy and combined groups showed improvement in tongue and soft palate muscle strength when compared with the placebo group. The association of myofunctional therapy to CPAP (combined group) showed an increased adherence to CPAP compared with the CPAP group. Conclusions Our results suggest that in patients with OSAS, myofunctional therapy may be considered as an adjuvant treatment and an intervention strategy to support adherence to CPAP.
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Introduction Oropharyngeal exercises are new, non-invasive, cost effective treatment modality for the treatment of mild to moderate obstructive sleep apnoea. It acts by increasing the tone of pharyngeal muscles, is more physiological, and effects are long lasting. Aim of the study The aim of our present study was to evaluate the effect of oropharyngeal exercises in the treatment of mild to moderate obstructive sleep apnoea. Method Twenty patients of mild to moderate obstructive sleep apnoea syndrome (OSAS) were given oropharyngeal exercise therapy for 3 months divided into three phases in graded level of difficulty. Each exercise had to be repeated 10 times, 5 sets per day at their home. Oropharyngeal exercises were derived from speech–language pathology and included soft palate, tongue, and facial muscle exercises. Anthropometric measurements, snoring frequency, intensity, Epworth daytime sleepiness and Berlin sleep questionnaire, and full polysomnography were performed at baseline and at study conclusion. Results Body mass index (25.6 ± 3.1) did not change significantly at the end of the study period. There was significant reduction in the neck circumference (38.4 ± 1.3 to 37.8 ± 1.6) at the end of the study. Significant improvement was seen in symptoms of daytime sleepiness, witnessed apnoea, and snoring intensity. Significant improvement was also seen in sleep indices like minimum oxygen saturation, time duration of Sao2 < 90 %, sleep efficiency, arousal index, and total sleep time N3 stage of sleep at the end of study. Conclusion Graded oropharyngeal exercise therapy increases the compliance and also reduces the severity of mild to moderate OSAS.
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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. 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. We studied 39 patients (age: 46±13 years, body mass index: 28.2±3.1 kg/m2, 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. 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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Adenotonsillectomy (T&A) may not completely eliminate sleep-disordered breathing (SDB), and residual SDB can result in progressive worsening of abnormal breathing during sleep. Persistence of mouth breathing post-T&As plays a role in progressive worsening through an increase of upper airway resistance during sleep with secondary impact on orofacial growth. Retrospective study on non-overweight and non-syndromic prepubertal children with SDB treated by T&A with pre- and post-surgery clinical and polysomnographic (PSG) evaluations including systematic monitoring of mouth breathing (initial cohort). All children with mouth breathing were then referred for myofunctional treatment (MFT), with clinical follow-up 6 months later and PSG 1 year post-surgery. Only a limited subgroup followed the recommendations to undergo MFT with subsequent PSG (follow-up subgroup). Sixty-four prepubertal children meeting inclusion criteria for the initial cohort were investigated. There was significant symptomatic improvement in all children post-T&A, but 26 children had residual SDB with an AHI > 1.5 events/hour and 35 children (including the previous 26) had evidence of "mouth breathing" during sleep as defined [minimum of 44 % and a maximum of 100 % of total sleep time, mean 69 ± 11 % "mouth breather" subgroup and mean 4 ± 3.9 %, range 0 and 10.3 % "non-mouth breathers"]. Eighteen children (follow-up cohort), all in the "mouth breathing" group, were investigated at 1 year follow-up with only nine having undergone 6 months of MFT. The non- MFT subjects were significantly worse than the MFT-treated cohort. MFT led to normalization of clinical and PSG findings. Assessment of mouth breathing during sleep should be systematically performed post-T&A and the persistence of mouth breathing should be treated with MFT.
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Background: Although sleep apnea is common, it often goes undiagnosed in primary care encounters. Objective: To test the Berlin Questionnaire as a means of identifying patients with sleep apnea. Design: Survey followed by portable, unattended sleep studies in a subset of patients. Setting: Five primary care sites in Cleveland, Ohio. Patients: 744 adults (of 1008 surveyed [74%]), of whom 100 underwent sleep studies. Measurements: Survey items addressed the presence and frequency of snoring behavior, waketime sleepiness or fatigue, and history of obesity or hypertension. Patients with persistent and frequent symptoms in any two of these three domains were considered to be at high risk for sleep apnea. Portable sleep monitoring was conducted to measure the number of respiratory events per hour in bed (respiratory disturbance index [RDI]). Results: Questions about symptoms demonstrated internal consistency (Cronbach correlations, 0.86 to 0.92). Of the 744 respondents, 279 (37.5%) were in a high-risk group that was defined a priori. For the 100 patients who underwent sleep studies, risk grouping was useful in prediction of the RDI. For example, being in the high-risk group predicted an RDI greater than 5 with a sensitivity of 0.86, a specificity of 0.77, a positive predictive value of 0.89, and a likelihood ratio of 3.79. Conclusion: The Berlin Questionnaire provides a means of identifying patients who are likely to have sleep apnea.
Article
Objective To systematically review the literature for articles evaluating myofunctional therapy (MT) as treatment for obstructive sleep apnea (OSA) in children and adults and to perform a meta-analysis on the polysomnographic, snoring, and sleepiness data. Data Sources Web of Science, Scopus, MEDLINE, and The Cochrane Library. Review Methods The searches were performed through June 18, 2014. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement was followed. Results Nine adult studies (120 patients) reported polysomnography, snoring, and/or sleepiness outcomes. The pre- and post-MT apnea-hypopnea indices (AHI) decreased from a mean ± standard deviation (M ± SD) of 24.5 ± 14.3/h to 12.3 ± 11.8/h, mean difference (MD) -14.26 [95% confidence interval (CI) -20.98, -7.54], P < 0.0001. Lowest oxygen saturations improved from 83.9 ± 6.0% to 86.6 ± 7.3%, MD 4.19 (95% CI 1.85, 6.54), P =0.0005. Polysomnography snoring decreased from 14.05 ± 4.89% to 3.87 ± 4.12% of total sleep time, P < 0.001, and snoring decreased in all three studies reporting subjective outcomes. Epworth Sleepiness Scale decreased from 14.8 ± 3.5 to 8.2 ± 4.1. Two pediatric studies (25 patients) reported outcomes. In the first study of 14 children, the AHI decreased from 4.87 ± 3.0/h to 1.84 ± 3.2/h, P = 0.004. The second study evaluated children who were cured of OSA after adenotonsillectomy and palatal expansion, and found that 11 patients who continued MT remained cured (AHI 0.5 ± 0.4/h), whereas 13 controls had recurrent OSA (AHI 5.3 ± 1.5/h) after 4 y. Conclusion Current literature demonstrates that myofunctional therapy decreases AHI by approximately 50% in adults and 62% in children. Lowest oxygen saturations, snoring, and sleepiness outcomes improve in adults. Myofunctional therapy could serve as an adjunct to other OSA treatments.