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Three Part Question

Patient group: Patients with obstructive sleep apnea
Intervention: Oropharyngeal exercises
Outcome: Reduction in symptoms

In [patients with obstructive sleep apnea (OSA)] is [an oropharyngeal, lingual and orofacial exercise program] effective in [reducing symptoms of OSA]?

Clinical Scenario

A 40 year old male presents with moderate obstructive sleep apnea. He is frustrated and non-compliant with his continuous positive airway pressure (CPAP) and does not want to have surgery. There are no complicating factors.

Search Strategy

Medline
Cochrane
Index of Chiropractic Literature
("sleep apnoea"[All Fields] OR "sleep apnea syndromes"[MeSH Terms] OR ("sleep"[All Fields] AND "apnea"[All Fields] AND "syndromes"[All Fields]) OR "sleep apnea syndromes"[All Fields] OR ("sleep"[All Fields] AND "apnea"[All Fields]) OR "sleep apnea"[All Fields]) AND ("tongue"[MeSH Terms] OR "tongue"[All Fields] OR "lingual"[All Fields]) AND ("exercise"[MeSH Terms] OR "exercise"[All Fields] OR "exercises"[All Fields] OR "exercise therapy"[MeSH Terms] OR ("exercise"[All Fields] AND "therapy"[All Fields]) OR "exercise therapy"[All Fields])

Search Outcome

Orofacial exercises and obstructive sleep apnea, 5 results (2 relevant) Lingual exercises and obstructive sleep apnea, 16 results (5 relevant)
Oropharyngeal exercises and obstructive sleep apnea, 11 results (5 relevant)
In addition key references were searched from all papers, 1 additional relevant paper was found.
There was crossover of 4 articles between searches.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Puhan, Milo A., et al. December 23, 2005 Switzerland	25 patients over 18 years old with apnea hypopnea index (AHI) between 15 and 30 and with snoring complaints	Randomized controlled trial (2b)	Reduction in OSA symptoms measured by: Epworth Sleep Scale (ESS), Pittsburgh Sleep Qualtiy Index, Bed partner VAS and AHI.	After 4 months of didgerdoo playing 5.9 days (avg) per week at 25.3 minutes per day (avg), the training group average ESS score decreased 3 points (P=0.03), Pittsburgh sleep quality score decrease was not significant (P=0.27), partner VAS decreased 2.8 (P=<0.01) and AHI decreased 6.2 points (P=0.05)	Small sample size and mostly male population
Guimaraes, Katia C. et al. May 15, 2009 Brazil	31 pts with moderate OSAS. Randomly assigned to 2 groups - 1 sham therapy group and 1 oropharyngeal exercise group	Randomized controlled trial (1b)	Anthropological measurments (abdominal and neck circumference), snoring frequency and intensity, Epworth Sleep Scale, Pittsburgh Sleep Quality questionnaires and polysomnography	Following 3 months of oropharyngeal exercises (30 minutes daily), the exercise group showed decreased neck circumference (39.6 to 38.5), snoring frequency (4 to 3) and intensity (3 to 1), sleepiness (14 to 8) and OSAS severity per polysomnography (AHI 22.4 to 13.7). There was no change in the control group.	Small study (N=31), otherwise high quality study.
Engelke, Wilfreid, et al. October 2010 Germany	125 primary snorers, 101 males (avg age 52.4, BMI 28.1) and 24 females (avg age 55.2, BMI 26.8)	Case Series (4)	VAS of bed partner assessing snoring	Bed partner reported VAS (Avg) decreased from 8.4 to 4.1 after 4.6 months (avg) of training with the tongue repositioning maneuver and nocturnal oral shield	No control group and no comparative treatment group. High variation in individual subject study lengths
Valbuza, Juliana Spelta, et al. December 2010 Brazil	3 trials eligible for review N=20 – O’Jay et al. N=25 – Puhan et al. N=10 Elliot et al.	Systematic review (2b)	Measures of frequency and intensity of snoring and apnea hypopnea index (AHI)	2 studies showed subjective and objective improvements, 1 showed decrease in snoring frequency and intensity, none showed decrease in AHI	Small selection of literature, only 1 reviewer of papers
Angelo, Jose A. and Brass, Steven October 2012 USA	N/A	Narrative Review (5)	Measures of OSA pathophysiology	Oropharyngeal exercises showed good outcomes in the papers reviewed. However, the authors recommended additional research before a conclusive clinical recommendation could be made.	No methods section, no description of literature review process, no selection criteria for the included papers, and no review criteria for the selected papers were provided
Chwiesko-Minaroska S, et. al. December 2013 Poland	39 articles on various OSA therapies	Systematic review (2b)	Measures of OSA pathophysiology	Oropharyngeal exercises may be beneficial for OSA patients, especially those non-compliant to continuous positive airway pressure (CPAP) or mandibular advancement device (MAD).	Individual study sizes were small, quality of studies specific to oropharyngeal exercise for OSA was poor
Villa, MP, et al. 2014 May 26 Italy	27 children average age 4.82 years All post adenotonsilectomy (AT) with residual OSA diagnosed via polysomnography	Prospective case-control (2b)	Reduction in OSA symptoms as measured by labial seal and tone, apnea hypopnea index (AHI)	After 2 months of oropharyngeal exercises: significant reduction in oral breathing, increased labial seal and tone, significant decrease in AHI and sleep clinical record (SCR) scores	Small sample size, mostly male population and short duration of treatment program. Patients had a surgical procedure (AT) prior to training program, limiting generalizability to other populations
Bellur, Nurel, Et al. Sept. 2012 Turkey	26 patients randomized to an oropharyngeal exercise group or a control group receiving standard medical treatment. Both groups had very similar baseline characteristics	Random control trial (Too little information provided to adequetly score study)	Decrease in anthropological measurements of BMI, neck and waist circumference. ESS and Pittsburgh sleep quality questionnaires. Full night polysomnography (PSG) including snoring frequency and intensity.	After 3 months of oropharyngeal exercises BMI and abdominal circumference had no significant change. Oropharyngeal exercise group saw a significant decrease in neck circumference, snoring intensity and frequency, ESS and Pittsburgh scores.	Conference proceeding abstract, full publication not available
Erturk, Nurel, Et al. Sept. 2013 Turkey	41 patients with OSA randomly put in 3 groups: 15 in inspiratory muscle training (IMT), 14 in Oropharyngeal exercises (OE) and 12 in the control group	Random control trial (Too little information provided to adequately score study)	Decrease in anthropological measurments (neck and abdominal circumference), respiratory muscle strength, exercise capacity (6 minute walk test), polysomnography, quality of life and fatigue severity surveys.	After 12 weeks of IMT, OE and no training the 3 groups saw no significant change in exercise capacity. The OE group saw significant decrease in neck circumference. Significant improvement also seen in respiratory muscle strength, quality of life and fatigue surveys in both the IMT and OE groups.	Conference proceeding abstract, full publication not available

Comment(s)

Two additional randomized controlled trials are worth mentioning. They were both presented at the European Respiratory Society Annual Congress, one study presented in 2012, the other in 2013. The studies were presented in a poster session and only abstracts are available. Nonetheless, the studies both have very relevant and important findings. In the 2012 study (Bellur et al.), 26 OSA patients were randomized into a treatment group doing oropharyngeal exercises and the other group was treated with standard medical care. After 3 months of therapy the oropharyngeal exercise group had a significant decrease in neck circumference, snoring intensity and frequency as well as a decreased Epworth Sleep Scale score. The 2013 study (Erturk et al.) had 41 OSA patients randomly assigned to 3 groups; 15 in an inspiratory muscle training (IMT) group, 14 in an oropharyngeal exercise (OE) group, and 12 in a control group (no details provided). After 12 weeks of training the OE group showed significant decrease in neck circumference. The IMT and OE groups both had significant improvement in respiratory muscle strength. In addition, both groups showed improvement of quality of life and fatigue survey scores. The evidence presented in the table and preceding paragraph has a clear clinical use. The current strategies for treating OSA are continuous positive airway pressure (CPAP) and mandibular advancement devices (MAD), which are effective for reducing symptoms when used properly; however, these devices have negative side effects and poor long-term adherence. Furthermore these therapies do not address the underlying problem. Surgery has fairly mixed reviews; when successful surgery has very positive results, but can be at the expense of negative side effects. There are no known negative side effects to performing oropharyngeal exercises as a part of OSA therapy, and the evidence suggests that these exercises may be helpful to patients suffering from OSA, especially those patients with moderate to severe OSA. In theory, these same very low risk exercises could be used to help prevent the progression of mild OSA to moderate or severe OSA or could be used to prevent snoring from progressing to OSA. Of course patients should always be encouraged to use their CPAP, mandibular advancement device, etc. until their sleep test results indicate their OSA severity has reduced to a level where these devices may no longer be necessary.

Clinical Bottom Line

Simple exercises for the oropharynx, tongue and face appear to help improve the symptoms of sleep apnea. Further research is needed to determine the patient population (e.g., age, BMI) best suited for an oropharyngeal exercise program. Further research is also needed to determine the most effective specific exercises, the optimum number of sets and repetitions for those exercises, and the most effective program duration.

References

1. Puhan, Milo A., et al. Didgeridoo playing as an alternative treatment for obstructive sleep apnoea syndrome: randomized control trial British Medical Journal 2005; Online
2. Guimaraes, Katia C. et al. Effects of oropharyngeal exercises on patients with moderate obstructive sleep apnea syndrome American Journol of Critical Care Medicine 2009; 962-966
3. Engelke, Wilfreid, et al. Functional Treatment of Snoring based on the Tongue-repositioning manoeuvre European Journal of Orthodonics 2012; 490-495
4. Valbuza, Juliana Spelta, et al. Methods for increasing upper airway muscle tonus in treating obstructive sleep apnea: systematic review. Sleep Breathe 2010 Dec:299-305
5. Angelo, Jose A. and Brass, Steven New and Unconventional Treatments for Obstructive Sleep Apnea Neuropathics 2012 Oct; 702-709
6. Chwiesko-Minaroska S, et. al. Rehabilitation of patients with obstructive sleep apnea syndrome international Journal of Rehabilitation Research 2013 Dec; 291-297
7. Villa, MP, et al. Oropharyngeal exercises to reduce symptoms of OSA after AT Sleep Breathe 2014 May 26
8. Bellur, Nurel, Et al. Effects of oropharyngeal exercises on anthropological measures and symptoms in patients with obstructive sleep apnea syndrome European Respiratory Journal Sept. 2012 (40)
9. Erturk, Nurel, Et al. Comparison of the effect of inspiratory muscle training and oropharyngeal exercise training in patients with obstructive sleep apnea syndrome European Respiratory Journal Sept. 2013 (42)