Myofunctional therapy (oropharyngeal - mouth and throat - exercises) for people with obstructive sleep apnoea

Background

Obstructive sleep apnoea (OSA) is a sleeping disorder. People with OSA have periods where their breathing stops during the night. OSA can cause snoring, unsatisfactory rest, daytime sleepiness, low energy or fatigue, tiredness, initial insomnia and morning headaches.

Continuous positive airway pressure (CPAP) is considered the first treatment option for most people with OSA. However, adherence to CPAP is often poor. A CPAP machine uses a hose and mask or nosepiece to deliver constant and steady air pressure. People who use CPAP often say that using the machine is uncomfortable, causes nasal congestion and abdominal bloating. They can feel claustrophobic and the machine is noisy. The noise can disturb bed partners.

Myofunctional therapy teaches people to do daily exercises to strengthen their tongue and throat muscles. Myofunctional therapy may reduce the intensity of the OSA symptoms and reduce daytime sleepiness on its own, or combined with CPAP.

Key results

We found nine RCT studies that analysed a total of 347 participants, 69 of them women, and 13 children.

In adults, compared to sham therapy, myofunctional therapy probably reduces daytime sleepiness, may increase sleep quality, may result in a large reduction in Apnoea-Hypopnoea Index (the number of apneas or hypopnoeas recorded during the polysomnography study per hour of sleep), may have little to no effect in reduction of snoring frequency and probably reduces subjective snoring intensity slightly.

Compared to waiting list, myofunctional therapy may reduce daytime sleepiness, may result in little to no difference in sleep quality and may reduce AHI.

Compared to CPAP, myofunctional therapy may result in little to no difference in daytime sleepiness and may increase AHI.

Compared to CPAP plus myofunctional therapy, myofunctional therapy alone may result in little to no difference in daytime sleepiness and may increase AHI.

Compared to respiratory exercises plus nasal dilator strip, myofunctional therapy may result in little to no difference in daytime sleepiness, probably increases sleep quality slightly and may result in little to no difference in AHI.

Compared to standard medical treatment, myofunctional therapy may reduce daytime sleepiness and may increase sleep quality.

In children, compared to nasal washing alone, adding myofunctional therapy to nasal washing may result in little to no difference in AHI.

Certainty of the evidence

Our level of certainty about the results of the studies ranges from moderate to very low for all comparisons, mainly due to problems related to risk of bias (for inadequate blinding of participants and incomplete outcome data in some studies) and imprecision.

Most of the participants in the studies were men and we could not undertake separate analyses for women.

Conclusions

Compared to sham therapy, myofunctional therapy probably reduces daytime sleepiness and may increase sleep quality in the short term in patients with obstructive sleep apnoea. New blinded studies, with more participants and longer times of treatment and follow-up, are needed.

The review is current to May 2020.

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.

Read the full abstract...
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 strategy: 

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).

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