# Exercise as it relates to Disease/Exercise as a treatment for Obstructive Sleep Apnea

This is an analysis of the journal article “Effects of oropharyngeal exercises on patients with moderate obstructive sleep apnea syndrome” by Guimarães et al. (2009)

## What Is The Background To This Research?

Obstructive sleep apnea (OSA) is an increasingly common sleep disorder, with moderate to severe disease that affected 17% of men and 9% of women in the middle-aged population. OSA is a global health problem that is an independent risk factor for hypertension, diabetes, stroke and cardiac rhythm disturbances.

### What Is Obstructive Sleep Apnea Syndrome (OSAS)

Obstructive sleep apnea (OSA) can be described as a condition characterized by repetitive obstruction of the throat (also known as "pharynx" or "upper airway" during sleep. The usual consequences of upper airway obstruction are blood oxygen levels reduction and awakening from sleep, noisy snoring and daytime sleepiness. These symptoms mostly accompanied by cognitive and attention inadequacy which affects the individual’s quality of life. The pathophysiology of OSA is unknown. However, the genesis of OSAS is assumed to be multifactorial and includes anatomical and physiological factors.

### What Are OSA Treatments

Indicators OSA include a family history of the disease or physical characteristics such as a small oropharyngeal airway or markers of obesity (eg, large neck circumference). The most commonly accepted interventions in the treatment of OSA include continuous positive airway pressure (CPAP). CPAP is mostly effective for patients with sever OSA. However, for moderately affected patients in whom the apnea-hypopnea index (AHI) is between 15 and 29.9 events/hour, CPAP therapy may not be suitable for a significant proportion of patients. In addition, many patients are unable to tolerate and initiate CPAP treatment. While moderate OSA patients make up high percentage of all OSA population, alternative treatments including mandibular advancement, weight loss, and surgery need to be considered. The target of this prospective study was to look into whether doing oropharyngeal exercises can improve pharyngeal patency and treat OSA.

## Where is this research from?

This study was conducted on eligible patients between 25 and 65 years of age who were diagnosed as moderate OSA evaluated in the sleep laboratory, Pulmonary Division, Heart Institute (InCor), University of São Paulo Medical School.

## What kind of research was this?

This randomized controlled analysis tested the effect of oropharyngeal exercises during 3 months in patients with moderate OSAS in two groups of study and control.

## What did the research involve?

This research involved in comparing results of fake therapy in control group and oropharyngeal exercise in study group. Fake therapy made of 30 min deep breathing through the nose while sitting, once a day and washing nostrils with saline three times a day. On the other hand, oropharyngeal exercises were obtained from speech language pathology and consisted of isometric and isotonic tongue, soft palate (flexible part towards the back of the roof of the mouth) and facial muscle exercises as well as stomatognathic (mouth, jaws, and closely associated structures) function exercises (Table). Patients who failed to perform at least 85% of each exercises were excluded from the study. Authors made a video to show the exercise tasks.https://www.youtube.com/watch?v=RB3nCDA1uic
| Involved Body Part | Exercise |
| Soft palate | Pronounce an oral vowel intermittently and continuously |
| Tongue | Including: brushing the tongue and three different pushing exercises with tongue |
| Facial | Including: lip, cheek, mouth angel muscles exercises |
| Stomatognathics functions | Including: Breathing/Speech and Swallowing/Chewing |

## What were the basic results?

Total 31 patients (Control n=15, Therapy n=16) included in the final analysis were largely middle-aged males, overweight or obese. In comparison, therapy patients had significantly decreased neck circumference, snoring symptoms, subjective daytime sleepiness, and quality of sleep score. In addition, patients assigned to oropharyngeal exercises experienced a significant decrease in AHI as well as a great increase in minimal oxygen saturation compared with control group. Finally, in the treatment group 62.5% of patients shifted from moderate to mild OSA.

## How Did The Researchers Interpret The Results?

This randomized controlled study was the first in its time inspecting the effect of oropharyngeal muscles exercise in patients with moderate OSAS. A randomized control study supported the concept that tongue muscle training during daytime will reduce snoring in OSA patients by decreasing upper airway collapsibility during sleep. Another randomized trial study revealed that 4 months upper airway muscle training with playing the didgeridoo, a wind instrument of the indigenous Australians, significantly alleviated OSA severity and associated symptoms. In this study evaluations showed that 39% the severity of OSAS reduced after three months of muscles training. The treatment group had a significant decrease in OSA severity from a baseline AHI of 22 ± 5 decreasing to 14 ± 9 (p < 0.01). In a 3-months randomized trial, Leto et al, found that oropharyngeal exercises are effective in reducing objectively measured snoring. Patients with OSAS typically have elongated and floppy soft palate and uvula, enlarged tongue, and inferior displacement of the hyoid bone. Therefore, in this study prominent reduction in neck circumference is suggesting that the exercises caused upper airway remodeling. However, in a survey that was conducted on orchestra players who play wind instruments, results showed that risk of OSA did not decrease with playing a wind instrument. This study had limitations including:
* Small sample size
* Lack of assessing the effect of each exercise separately
* Lack of using evidence based exercises
* Correct way of doing all the exercises completely depends on special training

## What conclusions can we make?

In conclusion, in patients with moderate OSAS, oropharyngeal exercises improved objective measurements of OSAS severity and subjective measurements of snoring, daytime sleepiness, and sleep quality. Same results were seen in an equivalent recent study. Verma et al concluded that graded oropharyngeal exercise therapy reduces the severity of mild to moderate OSAS. With regards to negative results and study limitations, we need further research to support this alternative treatment and explore new therapeutic options.

## What Are The Implications Of This Research?

Oropharyngeal exercises are new, non-invasive, cost effective and promising treatment modality for the treatment of moderate obstructive sleep apnoea.

## Further reading

For further information regarding OSA and the treatments, click on the links below.
* Snore Australia: http://www.snoreaustralia.com.au/obstructive-sleep-apnoea.php
* Sleep Health Foundation: http://www.sleephealthfoundation.org.au/fact-sheets-a-z/191-obstructive-sleep-aponea.html
* Sleep Centres: http://www.sleepcentres.com.au/obstructive-sleep-apnea.html

## References

* 1 2 3 4 5 6 7 8 9 1. Guimarães KC, Drager LF, Genta PR, Marcondes BF, Lorenzi-Filho G. (2009) ‘Effects of oropharyngeal exercises on patients with moderate obstructive sleep apnea syndrome’. Am J Respir Crit Care Med. vol 179(10) pp 962-966.
* ↑ 2. Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. (2013) ‘Increased prevalence of sleep-disordered breathing in adults’. Am. J. Epidemiol. vol 177 pp 1006-14.
* 1 2 3 4 3. Jordan AS, McSharry DG, Malhotra A. (2014) ‘Adult obstructive sleep apnoea’. Lancet. vol 383(9918) pp 736-47. doi: 10.1016/S0140-6736(13)60734-5.
* 1 2 3 4. De Dios JA, Brass SD. (2012) ‘New and Unconventional Treatments for Obstructive Sleep Apnea’. Neurotherapeutics. vol 9(4) pp 702-709.
* 1 2 Sutherland K, Cistulli PA. (2015) ‘Recent advances in obstructive sleep apnea pathophysiology and treatment’. Sleep and Biological Rhythms. vol 13(1) pp 26-40.
* ↑ 6. Randerath WJ, Galetke W, Domanski U, Weitkunat R, Ruhle KH. (2004) ‘Tongue-muscle training by intraoral electrical neurostimulation in patients with obstructive sleep apnea’. Sleep. vol 27 pp 254–258.
* ↑ 7. Puhan MA, Suarez A, Cascio CL, Zahn A, Heitz M, Braendli O. (2005) ‘Didgeridoo playing as alternative treatment for obstructive sleep apnoea syndrome: randomised controlled trial’. BMJ. vol 332 pp 266– 270.
* ↑ 8. Ieto V, Kayamori F, Montes MI, Hirata RP, Gregório MG, Alencar AM, Drager LF, Genta PR, Lorenzi-Filho G. (2015) ‘Effects of Oropharyngeal Exercises on Snoring: A Randomized Trial’. Chest. vol 148(3) pp 683-691. doi: 10.1378/chest.14-2953.
* ↑ 9. Davidson MT. (2003) ‘The Great Leap Forward: the anatomic basis for the acquisition of speech and obstructive sleep apnea. Sleep. vol 4 pp185–194.
* 1 2 10. Brown DL, Zahuranec DB, Majersik JJ, Wren P a, Gruis KL, Zupancic M, et al. (2009) ‘Risk of sleep apnea in orchestra members. Sleep. vol 10(6) pp 657–60.
* ↑ 11. Clark HM. (2003) ‘Neuromuscular treatments for speech and swallowing: a tutorial’. Am J Speech Lang Pathol. vol 12 pp 400-415.
* ↑ 12. Verma RK, Johnson J JR, Goyal M, Banumathy N, Goswami U, Panda NK. (2016) ‘Oropharyngeal exercises in the treatment of obstructive sleep apnoea: our experience’. Sleep Breath. doi: 10.1007/s11325-016-1332-1.