pii: sp-00423-14

http://dx.doi.org/10.5665/sleep.4652

MYOFUNCTIONAL THERAPY TO TREAT OSA: REVIEW AND META-ANALYSIS

Myofunctional Therapy to Treat Obstructive Sleep Apnea: A Systematic Review
and Meta-analysis
Macario Camacho, MD1; Victor Certal, MD2; Jose Abdullatif, MD3; Soroush Zaghi, MD4; Chad M. Ruoff, MD, RPSGT1; Robson Capasso, MD5;
Clete A. Kushida, MD, PhD1
Department of Psychiatry, Division of Sleep Medicine, Stanford Hospital and Clinics, Redwood City, CA; 2Department of Otorhinolaryngology/
Sleep Medicine Centre, Hospital CUF Porto; CINTESIS, Center for Research in Health Technologies and Information Systems, University of Porto,
Porto, Portugal; 3Department of Otorhinolaryngology, Hospital Bernardino Rivadavia, Buenos Aires, Argentina; 4Department of Head and Neck
Surgery, University of California, Los Angeles, CA; 5Department of Otolaryngology, Head and Neck Surgery, Sleep Surgery Division, Stanford
University Medical Center, Stanford, CA
1

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 MetaAnalysis (PRISMA) statement was followed.
Results: Nine adult studies (120 patients) reported polysomnography, snoring, and/or sleepiness outcomes. The pre- and post-MT apneahypopnea 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 pediatricstudies (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 apnea-hypopnea index 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 adjunctto other obstructive sleep apnea treatments.
Keywords: exercise therapy/methods, myofunctional therapy/methods, obstructive sleep apnea, sleep apnea syndromes
Citation: Camacho M, Certal V, Abdullatif J, Zaghi S, Ruoff CM, Capasso R, Kushida CA. Myofunctional therapy to treat obstructive sleep apnea:a systematic review and meta-analysis. SLEEP 2015;38(5):669–675.

INTRODUCTION
Several medical and surgical treatment modalities exist as
treatment for obstructive sleep apnea (OSA).1–3 Four pathophysiological traits seen in patients with OSA are: the passive
critical closing pressure of the upper airway (Pcrit), arousal
threshold, loop gain, and muscle responsiveness (PALM) withcategories of 1, 2, 2a, 2b, and 3.4 It has been demonstrated
that patients in four of five PALM categories will benefit fromanatomic interventions.4 Because the dilator muscles of theupper airway play a critical role in maintaining an open airway
during sleep, researchers have explored exercises and otherairway training (singing, didgeridoo, instrument playing) thattarget oral cavity and oropharyngeal structures as a method totreat OSA.5–7 Myofunctional therapy (MT) and proper tongue
positioning in the oral cavity have been described since 1918
to improve mandibular growth, nasal breathing, and facial

appearance.8 Guimaraes has proposed MT as a treatment for
OSA since the 1990s.9 MT is composed of isotonic and isometric exercises that target oral (lip, tongue) and oropharyngeal structures (soft palate, lateral pharyngeal wall).7,10 There
have been an increasing number of studies evaluating the effect of MT in the form of case studies, case series, and mostrecently, two randomized controlled trials.7,10–13
The most comprehensive MT exercises are described by
Guimaraes et al.7 and involve the soft palate, tongue, and facial muscles and address stomatognathic functions. For soft
palate exercises, patients pronounce oral vowel sounds either
continuously (isometric exercises) or intermittently (isotonic
exercises).7 Tongue exercises include moving the tongue along
the superior and lateral surfaces of the teeth, positioning
the tongue tip against the anterior aspect of the hard palate,pressing the entire tongue against the hard and soft palate, andforcing the tongue onto the floor of the mouth.7 Facial exercises
address the lip (i.e., contraction and relaxation of the orbicularis oris), buccinators (i.e., suction movements and applicationof intraoral finger pressure against the buccinator muscles),and jaw muscles (i.e., lateral jaw movements).7 In addition, stomatognathic functions are addressed by instructing patients toinhale nasally and exhale orally without and then with balloon
inflation, and performing specific swallowing and chewing
exercises (i.e., swallowing with the teeth clenched together,
tongue positioned in the palate and without contraction ofSubmitted for publication July, 2014
Submitted in final revised form August, 2014
Accepted for publication August, 2014
Address correspondence to: Macario Camacho, MD, Major, MC, US
Army, Department of Psychiatry, Division of Sleep Medicine, 2nd Floor,
Stanford Hospital and Clinics, 450 Broadway Street, Redwood City, CA
94063; Tel: (650) 723-6601; Fax: (650) 721-3448; Email: drcamachoent@
yahoo.com
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perioral muscles; alternating chewing sides).7 A newer study
describes a device that conditions and strengthens oral andtongue muscles.12
The objective of this study is to systematically review theliterature for articles evaluating MT or oral/oropharyngeal exercises as treatment for OSA in both children and adults andto perform a meta-analysis on the available polysomnographic
and sleepiness data.

downloaded the articles for inclusion. The decision to include
the articles was made by consensus, and if necessary the final
decision was made by author MC. Data collected included
patient age, body mass index (BMI), polysomnographic data
(AHI, lowest oxygen saturation), snoring, and sleepiness data.
If data were missing from the articles, then the corresponding
author was contacted in an attempt to obtain the data. The corresponding author of the study by Suzuki et al.12 was contacted
and confirmed that the reported oxygen saturation data were
for lowest oxygen saturation and that tongue training was involved as part of the MT device training.
The National Institute for Health and Clinical Excellence(NICE) quality assessment tool was used to evaluate the qualityof the included studies. The instrument consists of eight items
that are assessed for each individual study.

METHODS
Search Strategy
A search was performed on Web of Science, Scopus, MEDLINE, and The Cochrane Library, initially January 18, 2014,
with an update on June 18, 2014. MeSH terms and keywords
used for the search included various combinations of the following: “myofascial reeducation,” “myofunctional therapy,”“obstructive sleep apnea,” “orofacial myotherapy,” “oral myotherapy,” “oropharyngeal exercises,” “sleep,” “sleep apnea
syndromes,” “speech therapy,” “upper airway exercises,” and“upper airway remodeling.” One example of a MEDLINE
search is: (((“Myofunctional Therapy”[MeSH]) AND “Sleep
Apnea Syndromes”[MeSH])) OR (“sleep” AND (“myofascial
reeducation” OR “myofunctional therapy” OR “orofacial myotherapy” OR “oral myotherapy” OR “oropharyngeal exercises”
OR “speech therapy” OR “upper airway exercises” OR “upper
airway remodeling”)).
For each of the searches, the titles and abstracts werescreened and the full text versions of articles that met criteria
were downloaded. Full texts were reviewed and any referenced articles that were not already obtained were ordered andobtained. “Related citations” were also reviewed during thesearches, and the “cited by” function on Google Scholar was
also used to identify any additional studies.

Statistical Analysis
The statistics were performed with the IBM Statistical
Package for Social Sciences software (SPSS) version 20.0 (Armonk, New York, USA). Means and standard deviations were
calculated before and after myofunctional therapy. Studies
providing raw patient data without means and standard deviations were manually input into SPSS for calculation; or if
individual scatterplots with pretreatment and posttreatment
data were available, the estimated data point values were used
to calculate the means and standard deviations. The null hypothesis for this study is that there is no difference in outcome
data before and after myofunctional therapy. For combining
data, a two-tailed, paired t test was performed (P < 0.05
was the cutoff for significance). Review Manager (RevMan)[Computer program] Version 5.3 (Copenhagen: The Nordic
Cochrane Centre, The Cochrane Collaboration, 2014) wasused for meta-analysis. A random-effects model was used ifheterogeneity existed and a fixed-effects model was used if noheterogeneity existed. When pooling the data in studies, themeans, standard deviations, and 95% confidence intervals (CI)were calculated by REVMAN. Heterogeneity was assessed by
I 2 statistic (inconsistency levels: low = 25%, moderate = 50%
and high = 75%)14 and the Cochran Q statistic (with significant
heterogeneity being considered when P ≤ 0.1 was obtained).15
If heterogeneity existed, then a sensitivity analysis was performed by removing each of the studies individually to identify the source(s).
The Preferred Reporting Items for Systematic Reviews andMeta-Analysis (PRISMA) guidelines were downloaded andfollowed during this review.16

Study Selection
Criteria for inclusion included peer-reviewed studies (published articles or abstracts) evaluating oral or oropharyngeal
MT as an isolated treatment for either adult or pediatric OSA;
studies needed to report quantitative polysomnographic,
snoring, and/or sleepiness data pretreatment and posttreatment
or they needed to report the percentage of difference between
pretreatment and posttreatment outcomes. All languages
were included. Exclusion criteria included studies evaluating
singing, instrument playing, and studies without quantitative
data. If individual patient data were reported and patients lost
10% or more of their body weight, then those patients were
excluded. Studies in which the MT patients also underwent additional interventions such as continuous positive airway pressure therapy, mandibular advancement device therapy, sleep
apnea surgery, allergy management, weight loss management,or any other intervention that could also contribute to improved sleep apnea outcomes were excluded (unless the additional interventions were performed in control groups and thedata were provided separately for both MT and control groups).

RESULTSA total of 226 studies were screened for relevance, and204 were excluded. After identification of 22 potentially relevant studies, they were downloaded and the reviews of thereference lists yielded an additional 6 studies, for a total of
28 studies.7–13,17–36 Nine were review articles,8,20,22,27,30,32–34,36
two reported no intervention,24,31 two studied lip exercises andthe effect on lip thickness,21,37 one reported breathing exercises not involving oral cavity or oropharyngeal structures,28
one was a letter to the editor,11 and two studies were abstracts
in which data were later reported in the authors’ journal articles.19,25 Eleven studies met criteria and were included in

Data Abstraction and Study Quality Assessment
Authors MC, JA, and SZ independently performed asearch of the literature and screened titles and abstracts and
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this review. Individual patient data were reported by one pediatric study35 and one adult study,12 whereas the remaining
nine studies reported outcomes with means and standard deviations.7,9,10,13,17,18,23,26,29 Figure 1 summarizes the flow for study
selection.
Methodological Quality of the Included Studies
The studies included in this review included one abstract,26
one retrospective case report,23 three retrospective case series,9,10,18 three prospective case series,12,17,29 one randomized
trial,35 and two randomized controlled trials.7,13 Most of thestudies satisfied four to six of the eight NICE quality assessment tool items (presented in Table S1 of supplemental material). The main limitations were that the total number ofpatients in most studies was low, the studies
were at single institutions (except one thatwas multicentered) and most studies did not
explicitly state that patients were consecutive.
Adult Studies
A total of nine adult studies (120 patients,
age 44.5 ± 11.6 y, BMI 28.9 ± 6.2 kg/m 2 )reported polysomnography and/or sleepiness outcomes (Table 1). Baz et al.17 reported
using American Academy of Sleep Medicine(AASM) scoring criteria but did not specify
which year, Diaferia et al.13 and Guimaraes
et al.7 reported using 1999 AASM scoring
criteria, Suzuki et al.12 scored based on the2005 update to AASM scoring criteria, andthe remaining five studies did not specify
which polysomnography scoring criteria
were used.9,18,23,26,29
The pre- and post-MT AHI mean ± standard deviation (M ± SD; 82 patients) decreased from 24.5 ± 14.3/h to 12.3 ± 11.8/h,with a mean difference (MD) of −14.26 [95%CI −20.98, −7.54], Z score of 4.16 (P < 0.0001)(Figure 2). Both the I 2 statistic (91%) and the Q statistic (valueof < 0.00001) demonstrated significant heterogeneity; therefore,studies were individually excluded to identify the source(s).
Exclusion of the studies by Suzuki et al.12 and Berreto et al.18
resulted in no heterogeneity in the remaining 73 patients, with
the I 2 statistic = 0% and the Q statistic value of 0.6. The meandifference for the remaining studies was −10.49 26 [95% CI−12.67, −8.31]. In adult studies in which MT was performed
for at least 3 mo, the mean AHI reduced from 25.2 ± 14.6/h to12.6 ± 12.2/h, which is a 50% reduction.
The lowest oxygen saturation improved in 82 patientsfrom 83.9 ± 6.0% to 86.6 ± 7.3%, MD of 4.19 [95% CI 1.85,
6.54], with an overall Z score of 3.5 (P = 0.0005); see Figure 3.
Both the I 2 statistic (59%) and the Q statistic (value of 0.05)

Figure 1—Flow diagram demonstrating myofunctional therapy for obstructive sleep apnea(OSA) study selection. N, number of articles.

Table 1—Adult pre- and post-myofunctional therapy outcomes.
Study
Authors, Year
Design N
Suzuki et al., 2013 *PCS
6Kronbauer et al., 2013
PCS
8
Diaferia et al., 2013
RCT 27Baz et al., 2012
PCS 30
Guimaraes et al., 2009
RCT 16de Paula Silva et al., 2007 RCR
1Berreto et al., 2007
RCS
2
Guimaraes et al., 2003
ABS 10
Guimaraes et al., 1999
RCS 20
Total
120

Age
(years)22.0 ± 0.5(40–65)45.2 ± 13.0
44.1 ± 7.5
51.5 ± 6.8
60
46 ± 12.7–(33–55)44.5 ± 11.6

BMI
(kg/m²)23.8 ± 1.8–
25.0 ± 7.4
33.6 ± 2.0
29.6 ± 3.8
23.3
24.2 ± 2.9––
28.9 ± 6.2

AHI (events/h)
Pre-MT
Post-MT15.1 ± 3.4 9.2 ± 1.5––
28.0 ± 22.7 13.9 ± 18.5
22.3 ± 4.5 11.5 ± 5.4
22.4 ± 4.8 13.7 ± 8.5
443
44.5 ± 5.7 6.0 ± 3.7
36.1
11.3
–
−48%
24.5 ± 14.3 12.3 ± 11.8

low O2 (%)
Pre-MT Post-MT
90.0 ± 2.9 96.8 ± 0.8––
83.7 ± 7.7 84.9 ± 8.8
84 ± 487 ± 583 ± 685 ± 783
92
78 ± 1.4 85 ± 2.8––––
83.9 ± 6.0 86.6 ± 7.3

ESS
Pre-MT Post-MT
–
–
11.75
4.25
13.7 ± 3.2 7.5 ± 3.7
16.4 ± 2.0 9.3 ± 2.9
14 ± 58±6––12.5 ± 0.7 4.5 ± 3.5
11
7.6
–
–
14.8 ± 3.5 8.2 ± 4.1*Study authors confirmed the reported oxygen saturation data was for lowest oxygen saturation. –, not reported, %, percent; ABS, abstract; AHI, apneahypopnea index; BMI, body mass index; ESS, Epworth Sleepiness Scale; events/h, events per hour; kg/m2, kilograms per meter squared; low O2, lowest
oxygen saturation; MT, myofunctional therapy; N, number of myofunctional therapy patients in the study; PCS, prospective case series; RCR, retrospective
case report; RCS, retrospective case series; RCT, randomized controlled trial.
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Figure 2—Adult premyofunctional and postmyofunctional therapy outcomes for apnea-hypopnea index (events per hour). CI, confidence interval;
MT, myofunctional therapy; SD, standard deviation; Tx, treatment.

Figure 3—Adult premyofunctional and postmyofunctional therapy outcomes for lowest oxygen saturation (percent). CI, confidence interval; MT, myofunctional
therapy; SD, standard deviation; Tx, treatment.

Figure 4—Adult premyofunctional and postmyofunctional therapy outcomes for Epworth Sleepiness Scale. CI, confidence interval; MT, myofunctional
therapy; SD, standard deviation; Tx, treatment.

demonstrated significant heterogeneity, therefore, studies
were individually excluded to identify the source(s). Exclusionof the studies by Suzuki et al.12 and Berreto et al.18 resulted
in no heterogeneity in the remaining 73 patients, with the I 2
statistic = 0% and the Q statistic value of 0.56. Oxygen desaturation index was reported by one study, and demonstrated a
reduction from 14.53 ± 5.04 to 9.27 ± 4.27, pre- and post-MT,
respectively.17 Sleepiness decreased in all studies reporting theoutcome. The Epworth Sleepiness Scale (ESS)38 decreased in
75 patients from 14.8 ± 3.5 to 8.2 ± 4.1, MD of −6.81 [95% CI−7.79, −5.82], with an overall Z score of 13.55 (P < 0.00001); see
Figure 4. Both the I 2 statistic (0%) and the Q statistic (value of0.8) demonstrated no heterogeneity.

therapy and 16 snored after therapy, P = 0.008 (yes versus no;
article did not specify if patient or bed partner was asked) andthe polysomnography demonstrated that the percent of total
sleep time spent snoring decreased from 14.05 ± 4.89% to3.87 ± 4.12% (before and after, respectively), P < 0.001.17 Guimaraes et al.7 found snoring frequency decreased by 25% (article did not specify if patient or bed partner was asked) from4 to 3 (based on 0 = never to 4 = everyday), P = 0.001, andthe snoring intensity decreased by 66% from 3 to 1 (based on
1 = similar to breathing and 3 = very loud) with P = 0.001;
whereas the control groups had no change in snoring frequency
or intensity. The case study by de Paula Silva et al.23 demonstrated a decrease in snoring intensity after 8 sessions. Berreto et al.18 described two patients who decreased from a (bedpartner) snoring score of 3 down to 2 (0 = snoring absence,
1 = heavy breathing, 2 = light snoring, 3 = snoring that disturbs
the bed partner and 4 = snoring that can be heard outside thebedroom).

Snoring
Snoring changes were evaluated by 4 studies, Baz et al.,17
Berreto et al.,18 de Paula Silva et al.23 and Guimaraes et al.7;
see Table 2. Baz et al.17 reported that 30 patients snored before
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Table 2—Snoring outcomes based on mean values pre and post-myofunctional therapy.
Authors, YearBaz et al., 2012
Guimaraes et al., 2009de Paula Silva et al., 2007
Berreto et al., 2007

N
30
16
1
2

Subjective Snoring
Pre-MT
Post-MTYes = 30; No = 0
Yes = 16; No = 14
Very loudSimilar to breathing
Snoring
Decreased snoring
Disturbs bedpartner
Light snoring

PSG %TST Snoring
Pre-MT
Post-MT14.05 ± 4.89%
3.87 ± 4.12%
–
–
–
–
–
–

MT, myofunctional therapy; %TST, percentage of total sleep time. Snoring outcomes are based on quantified definitions pre- and post-myofunctional
therapy by all studies except de Paula Silva et al. (case report).

Pediatric Studies
A total of two pediatric studies (25 patients, age 8.4 ± 3.1 y)reported polysomnography and/or sleepiness outcomes. Bothpediatric studies reported using 2007 AASM scoring criteria,
and Guilleminault et al.10 also specified that hypopneas werescored with a 50% reduction in nasal cannula curve and an
associated 3% or more reduction in oxygen saturation and/orwith associated arousals, while Villa et al.35 did not specify the
hypopnea scoring criteria. The study by Villa et al.35 was aprospective randomized controlled trial in which postadenotonsillectomy patients were randomized to either oropharyngeal exercises or control group. The treatment group in thisstudy consisted of 14 patients and the pre- and post-MT AHI
was evaluated after 2 mo of oropharyngeal exercises. The AHI
M ± SD reduced from 4.87 ± 3.0/h to 1.84 ± 3.2/h, P = 0.004(a 62% reduction).35 The control group had minimal change
in AHI during the 2-mo period (4.56/h down to 4.11/h).35 The
study by Guilleminault et al.10 was a retrospective chart review,
evaluating 24 children who were cured by the combinationof adenotonsillectomy and palatal expansion (AHI 0.4 ± 0.3);
and 11 of the children received MT (intervention group) and 13
children did not receive MT (controls).10 At the 4-y follow-up,
the children who practiced MT over the long term remained
cured of OSA (AHI 0.5 ± 0.4), compared to children who were
never trained to perform the exercises and subsequently had
a recurrence of OSA (AHI 5.3 ± 1.5/h).10 Although both pediatric MT studies compared the intervention groups to control
groups, neither study reported pretreatment and posttreatment
lowest oxygen saturation or sleepiness outcomes.

adult studies reporting AHI had a follow-up duration of at least
3 mo between polysomnography studies. Had the study been
extended to 3 mo, there may have been additional improvement in AHI. In studies with control groups, there was little tono improvement in the AHI for the control groups comparedto improvement in the MT intervention group. There is alsoa clear improvement in lowest oxygen saturation by approximately 3–4%, with the meta-analysis of 81 patients demonstrating a mean difference pre- and post-MT of 4.19%, [95%CI 1.85, 6.54]. The oxygen desaturation index (ODI) was only
reported by Baz et al.,17 demonstrating a 36% reduction, but thearticle did not specify whether the ODI in the study was basedon 3% or 4% desaturation.
Second, MT decreases snoring both subjectively and objectively. Four studies compared the pre- and post-MT outcomes
and it was noted that snoring decreased after therapy (threeof four studies quantified the snoring). The polysomnographydemonstrated a 72.4% reduction in snoring pre- versus postMT (14.05 ± 4.89% to 3.87 ± 4.12%, before and after, respectively), P < 0.001.17 With regard to subjective improvement insnoring intensity, the three studies quantifying the outcomes
reported that during posttreatment there was a decrease insnoring to either light snoring, or the sound was similar tonormal breathing.
Third, subjective sleepiness also improves post-MT as
demonstrated by a clear reduction in ESS score for the 93
patients in which it was administered, with a reduction from
14.8 ± 3.5 to 8.2 ± 4.1 (in 75 patients in whom M ± SDs werereported).7,13,17,18,26,29 The posttreatment ESS is below thethreshold for hypersomnia, which is generally considered tobe 11 or higher on the scale.39 Additionally, the 1999 study
by Guimaraes9 reported a subjective reduction in sleepiness; however, the use of a validated sleepiness scale was not
specified.9
Fourth, despite the heterogeneity in oral and oropharyngeal
exercises, overall the improvements in polysomnographic outcomes and sleepiness were consistent. MT was performed foras little as 5 min, twice daily, 4 days a week for 2 mo12 to as
many as 10 min, three to five times daily for 3 mo.17 The longest published experience with MT for adult OSA has beenthat of Guimaraes,9 which is 6 mo. Guimaraes9 has also published thorough instructions for performing the exercises thatinvolve the soft palate, tongue, facial muscles, and stomatognathic functions to be performed 30 min a day.7
Fifth, future research is needed to help explain the pathophysiology and mechanism of action of MT as treatment for

DISCUSSION
This systematic review and meta-analysis of nine adult andtwo pediatric studies evaluating the effect of MT on OSA has
five main findings. First, MT provides a reduction in AHI of
approximately 50% in adults and 62% in children. The preand post-MT AHI for adults decreased from 24.5 ± 14.3/h to12.3 ± 11.8/h, MD of −14.26 [95% CI −20.98, −7.54] (P < 0.0001).
For pediatric patients, the pre- and post-MT M ± SD for AHI
decreased from 4.87 ± 3.0/h to 1.84 ± 3.2/h, P = 0.004. Additionally, the study by Guilleminault et al.10 reported that 11
children remained cured of OSA (AHI of 0.5 ± 0.4/h) after continuing MT for 4 y. There was heterogeneity, and the studies
by Suzuki et al.12 and Berreto et al.18 were shown to be thesources. The study by Suzuki et al.12 had six patients, who used
an oral exercise device to help train, but the length of time
between polysomnography was 2 mo, whereas the remaining
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Myofunctional Therapy for OSA—Camacho et al.

OSA. It can be hypothesized that the exercises improve oral
and/or oropharyngeal muscle tone and also may decrease theamount of fatty deposition of the tongue, but this has not been
proven. It can be recommended that future researchers consider using the standardized exercises, which have been developed and used over a period of several years by Guimaraes etal.7 because they have the most experience with the therapy. As
pointed out by Guimaraes et al.,7 because MT is based on an
integrative approach with several exercises, it is not possible todetermine the effects of specific exercises to determine which
ones contribute the most to improvement in outcomes7; therefore, future studies could consider exploring the effect of individual exercises. Individual patient data were not available formost studies; therefore, a subanalysis could not be performed
for BMI, AHI, age, etc. based on the current literature. However, with regard to BMI, Guimaraes et al.7 and Baz et al.17
had significant reductions in AHI in overweight (BMI M ± SD
29.6 ± 3.8) and obese patients (BMI M ± SD 33.6 ± 2.0). With
regard to age, the MT has been shown effective in children andadults of all ages studied thus far, ranging from 3 to 60 y.

of interest. The work was performed at Stanford Hospital andClinics, Stanford, CA. The views herein are the private viewsof the authors and do not reflect the official views of the Department of the Army or the Department of Defense.
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15. Lau J, Ioannidis JP, Schmid CH. Quantitative synthesis in systematic
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myofunctional therapy in managing patients with mild to moderate
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R, Guiot Tavares M, Tavares P. Oral myofunctional therapy applied on
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Limitations
A total of 145 patients (including 25 children) were includedin this meta-analysis; however, the magnitude of the effects
was highly significant. Although there were nine adult studies,a significant limitation for pediatric studies is that currently
only two articles have been published. Additionally, long-term
follow-up for more than 6 mo is limited. Except the study by
Guilleminault et al,10 which followed patients for 4 y, all of theother studies spanned 2 to 6 mo. The study by Guilleminault
et al.10 demonstrates a long-term (4 y) maintenance of reduction in AHI and alleviation of OSA symptoms in patients who
continued to perform MT exercises, compared to the control
group that had recurrence of symptoms and recurrence of anelevated AHI at 4-y follow-up.10 Because this is the only study
that has reported outcomes longer than 6 mo after initiation of
MT exercises, additional long-term studies are needed to demonstrate the lasting effects of continued MT. Questions thathave not been addressed that could be studied in the future
include whether there is a relationship with the tongue exercises and changes in the tongue and palatal muscle tone and/or strength, tongue size (tongue fat), and overall upper airway
volume changes pretreatment and posttreatment.
CONCLUSION
Current literature demonstrates that myofunctional therapy
decreases AHI by approximately 50% in adults and 62% inchildren. Lowest oxygen saturation, snoring, and sleepinessoutcomes improve in adults. Myofunctional therapy could
serve as an adjunct to other OSA treatments.
DISCLOSURE STATEMENT
This was not an industry supported study. Dr. Kushida hasreceived research support from Aerial BioPharma, Pacific
Medico Co., Ltd., Resmed, Apnex Medical, Impax Laboratories,
Inc., and Cephalon; has consulted for Apnex, Seven Dreamers
Laboratories, Noven Pharmaceuticals, UCB, Philips-Respironics, Zephyr; and has received royalties from Philips Respironics. The other authors have indicated no financial conflicts
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33. Valbuza JS, Oliveira MM, Conti CF, Prado LB, Carvalho LB, Prado
GF. Methods to increase muscle tonus of upper airway to treat snoring:systematic review. Arq Neuropsiquiatr 2008;66:773–6.
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symptoms of OSA after AT. Sleep Breath 2014.
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treatment of pediatric sleep-disordered breathing. Sleep Med Clin
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workers. Sleep 1997;20:844–9.

24. Diaféria G, Truksinas E, Haddad FLM, et al. Phonoaudiologicalassessment of patients with obstructive sleep apnea. Sleep Sci 2011;4:1–7.
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study [abstract]. Am J Respir Crit Care Med 2007:A755.
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sleep apnea. Sleep 2003;26(Abstract Suppl):A209.
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28. Khaleghipour S, Masjedi M, Kelishadi R. The effect of breathing
exercises on the nocturnal enuresis in the children with the sleepdisordered breathing. Iran Red Crescent Med J 2013;15:e8986.
29. Kronbauer KF, Trezza PM, Gomes CF. [Speech therapy proposals to thesnoring patient]. Distúrbios da Comunicação 2013;25:119–27.
30. Moeller JL. Orofacial myofunctional therapy: why now? Cranio
2012;30:235–6.
31. Sauer C, Schluter B, Hinz R, Gesch D. Childhood obstructive
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obstructive sleep apnea: systematic review. Sleep Breath 2010;14:299–
305.

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SUPPLEMENTAL MATERIAL
Table S1—General characteristics of included patients and quality criteria of included studies.
General Characteristics
Site Design N Follow-up BMI
Outcomes Analyzed
Pediatric Studies
Villa et al., 2014
Italy
RT
14
2 mo
21.6
AHI, O2 sat
Guilleminault et al., 2013 USA RCS 11
4y–
AHI, O2 sat
Adult Studies
Suzuki et al., 2013
Japan PCS
6
2 mo
23.8
AHI, O2 sat
Kronbauer et al., 2013
Brazil PCS
8
2.5 mo–
ESS, physical measurements
Diaferia et al., 2013
Brazil RCT 27
3 mo
25.0
AHI, AI, ESS, O2 sat
Baz et al., 2012
Egypt PCS 30
3 mo
33.6
AHI, ESS, O2 sat, snoring
Guimaraes et al., 2009
Brazil RCT 16
3 mo
29.6
AHI, AI, ESS, O2 sat, snoringde Paula Silva et al., 2007 Brazil RCR
1–
23.3 AHI, O2 sat, sleepiness, snoring
Berreto et al., 2007
Brazil RCS
2
4 mo
24.2
AHI, ESS, O2 sat, snoring
Guimaraes et al., 2003
Brazil ABS 10––
AHI, ESS
Guimaraes et al., 1999
Brazil RCS 20
6 mo–
AHI, sleepiness
Authors, Year

Quality Assessment of Included Studies a
1
2
3
4
5
6
7
8
No Yes Yes Yes Yes No Yes Yes
Yes Yes Yes Yes No No Yes Yes
No
No
No
No
No
NA
No
NA
No

Yes
Yes
Yes
Yes
Yes
NA
No
NA
Yes

Yes
No
Yes
Yes
Yes
NA
No
NA
No

Yes
Yes
Yes
Yes
Yes
NA
Yes
NA
Yes

Yes
Yes
Yes
Yes
Yes
NA
No
NA
Yes

No
No
Yes
No
No
NA
No
NA
No

Yes
Yes
Yes
Yes
Yes
NA
No
NA
Yes

No
No
Yes
No
Yes
NA
No
NA
No

Quality assessment of cases series studies checklist from National Institute for Health and Clinical Excellence (NICE): (1) Case series collected in morethan one center,i.e.,multicenter study? (2) Is the hypothesis/aim/objective of the study clearly described? (3) Are the inclusion and exclusion criteria(case definition) clearly reported? (4) Is there a clear definition of the outcomes reported? (5) Were data collected prospectively? (6) Is there an explicit
statement that patients were recruited consecutively? (7) Are the main findings of the study clearly described? (8) Are outcomes stratified? (e.g., by diseasestage,abnormal test results, patient characteristics)? –, not reported; AI, apnea index; AHI, apnea-hypopnea index; ESS, Epworth Sleepiness Scale; mo,months; N, number of patients with intervention; NA, not applicable; O2 sat, oxygen saturation; PCS, prospective case series; RCR, retrospective casereport; RCS, retrospective case series; RCT, randomized controlled trial; RT, randomized trial; y, years.

a

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Myofunctional Therapy for OSA—Camacho et al.