By Cyndee Williams Bowen, SLP
Guimarães K.C., Drager L.F., Genta P.R., Marcondes B.F., Lorenzi-Filho G. Effects of oropharyngeal exercises on patients with moderate obstructive sleep apnea syndrome. Am J Respir Crit Care Med 2009; 179:962-966.
Sleep apnea is a disorder characterized by repeated episodes of breathing stops/starts while sleeping. People with Obstructive Sleep Apnea (OSA) demonstrate weakness and dysfunction of the oral and pharyngeal (throat) musculature. Continuous Positive Airway Pressure (CPAP) therapy is considered the best treatment for OSA (Walkove et al, 2008). Unfortunately, CPAP is not a viable treatment option for everyone due to contraindicating conditions or quality of life concerns. Studies show that approximately 54% of patients diagnosed with OSA demonstrate long-term compliance with prescribed CPAP therapy (Walkove et al).
A friend approached me for help in early 2013. S/he presented with a history of loud snoring, asthma, claustrophobia, and now a recent, unconfirmed diagnosis of obstructive sleep apnea (OSA). All the signs and symptoms were there, but s/he declined a sleep study for several reasons and was searching for alternative solutions. S/he discovered an intriguing research article and asked me to consider providing the therapy described.
My first response was to decline, saying Continuous Positive Airway Pressure (CPAP) is pretty much the gold standard treatment for OSA. You need to see a sleep specialist. Reconsider polysomnography. S/he offered compelling reasons for avoiding CPAP, other appliances, surgery, etc. S/he asked me to just read the article and consider a therapeutic trial. I relented and quickly found that Guimarães et al, 2009 was a randomized, controlled study conducted with a total of 31 subjects, and results were favorable. The procedures were non-invasive and easily replicated. Based on this published evidence and my friend’s strong motivation and goals, I agreed to review the study.
The researchers in Guimarães 2009 hypothesized that oropharyngeal exercises — like those used therapeutically by speech-language pathologists — could benefit people with mild or moderate OSA who cannot or are unwilling to comply with CPAP therapy. They developed a 13 week exercise protocol that focused on improving the strength and range of motion of the velum (soft palate), lingua (tongue), facial muscles, and stomatognathic functions (breathing/speech and swallowing/chewing).
Guimarães et al. applied their protocol to a total of 31 subjects objectively diagnosed via polysomnography with OSA and demonstrating Apnea-Hypopnea Index (AHI) scores in the mild-to-moderate range. Participants were randomly assigned to either the therapeutic exercise group (n=16) or a sham therapy control group (n=15). At the conclusion of the protocol, the exercise group demonstrated approximately 40% improvement in Apnea Index Scores obtained via follow up polysomnography.
Given the Guimarães results and my friend’s goals and quality of life concerns, I agreed to proceed with an initial assessment to further inform my clinical judgment and decision making.
Client reported history of snoring “loud enough to disturb the entire household” and waking frequently each night due to apnea events. S/he presented as an active, fit, middle-aged subject and reported no history of obesity or heavy alcohol consumption. Spouse had slept in a separate room for over a year due to client’s snoring. S/he stated that CPAP was not an option due to a history of asthma and claustrophobia.
Evaluation revealed speech and swallowing functions within normal limits; however, several areas of oral motor weakness were noted. The Iowa Oral Performance Instrument (IOPI) was employed to measure lingual and labiobuccal pressures.
Alveolingual pressures were borderline but fell between the 10th and 20th percentiles, within one standard deviation of the mean. Linguavelar and both right and left labiobuccal pressures fell more than one standard deviation below the mean, with left labiobuccal measures slightly lower (2 kPa) than right. Visualization of the posterior pharyngeal wall was obscured by the weakened lingual body and velum, which rested deep into the retropharynx
Based upon my initial findings, Guimarães et al., 2009, and my client’s goals and motivation, I exercised my clinical judgment and agreed to conduct a therapeutic trial to replicate the published protocol.
Client was trained in the OSA protocol as described in Guimarães et al., 2oo9. S/he demonstrated relatively good compliance with the daily exercise program assigned.
Five weeks of treatment with Guimarães 2009 OSA Protocol
The need for unrelated dental treatments prompted the client to discontinue exercises for approximately three months. Regression occurred, as seen below.
Six months post initial measures following a three month hiatus from treatment protocol.
The original OSA protocol was revised by omitting glottal attack vowels and adding the Masako Maneuver to target base of tongue and posterior pharyngeal wall strengthening and range of motion. Client was retrained and provided with detailed home exercise data tracking sheets. Motivation and compliance with the home exercise program improved, with remarkable results as pictured below.
The following photo was obtained nine months following initiation of the OSA therapeutic trial and three months of home exercise following the revised protocol outlined above.
3 months following revised protocol.
The client quickly demonstrated increased self-motivation and compliance with home exercises as s/he began to see improvement visually and anecdotally documented above. S/he discontinued the therapeutic trial due to scheduling constraints, and objective final measures were not obtained.
Client reports great satisfaction with results of the OSA protocol. S/he states that loud snoring is reduced from audible throughout the house to occasional, loud breathing. S/he self-monitors potential apnea events by recording them using an unspecified iOS application and reports improvement from loud snoring and numerous apnea events nightly prior to treatment to none detected today. S/he reports positive feedback from her family and recently stated that the program “…helped to eliminate sleep apnea from my life!”
Goals for the therapeutic trial were met given improvements as exhibited above and the client’s statement of satisfaction with results obtained.
Although the results of both Guimarães et al., 2oo9 and this therapeutic trial are promising, there are certainly limitations. A 40% improvement in AHI scores is relatively modest when one considers the serious impact of apnea on overall health, particularly cardiovascular function. On the other hand, 40% improvement can change a diagnosis of moderate OSA to mild or mild OSA to within normal limits. Researchers in Diaferia et al, 2013, which I reviewed here for Research Tuesday in May 2014, showed patient perceptions of quality of life increased when sleep apnea was treated via oropharyngeal exercsises with and without CPAP.
The American Sleep Apnea Association also raises a point that should not be forgotten. Reduction of snoring can provide a huge improvement in quality of life for people who snore and for those subjected to nightly sleep deprivation from that snoring; however, snoring is an effective early warning of the potential for sleep apnea. It is very important that patients who snore be monitored for sleep apnea regularly.
There is so much more to this story! Procedures, protocol, forms, strict candidacy criteria for participation in the program… Please feel free to contact me if you have further questions. In the meantime, I will close this post with a call for high quality research on this topic by professionals within our field of Communication Sciences and Disorders.
Diaferia G, Badke L, Santos-Silva R, et al 2013. Effect of speech therapy as adjunct treatment to continuous positive airway pressure on the quality of life of patients with obstructive sleep apnea. Sleep Medicine 2013;14: 628-635.
Website for the American Sleep Apnea Association
N Wolkove, M Baltzan, H Kamel, R Dabrusin, M Palayew. Long-term compliance with continuous positive airway pressure in patients with obstructive sleep apnea. Can Respir J 2008;15(7):365-369.
Disclaimer: The client depicted and described in this blog post has graciously provided written authorization for the dissemination of treatment circumstances, progress data, and photos included herein. All specifically identifying information about the client has been omitted from this post. Treatment was not conducted as a formal research study but a therapeutic trial provided in response to a client’s request, a published research study supporting viability of that request, and my clinical judgment. –Cyndee Bowen, SLP
Cyndee Williams Bowen, MS, CCC-SLP owns Bowen Speech-Language Therapy, LLC in Clearwater, FL. She is committed to collaboration with expertise and creativity for empowered communication, swallowing, and vocal quality. Visit the Obstructive Sleep Apnea page of the Bowen Speech Website for more information on the topic of this blog entry.