Understand the Basics and Science of Sleep

Obstructive Sleep Apnoea(OSA) is a sleep disorder in which a person experiences difficulty in breathing while sleeping. It is characterised by repetitive cessation of breathing at night due to  complete or partial upper airway collapse. It is a chronic disorder that affects mostly middle aged men. 

Tracing a single cause of OSA is extremely difficult as there are complex interplay of anatomical and neuromuscular factors that cause upper airway collapsibility. When one is unable to breathe, the heart rate drops due to decrease in the body’s oxygen levels. That is when our involuntary reflexes come into action and we startle and wake up at the end period of not breathing. Frequent recurrence of apnoea affects our body adversely. It causes a rise in blood pressure and thickening of the heart walls due to increased workload, leading to an overall change in the heart structure.

Sleep apnoea has serious effects on our body as well as our regular life. It causes daytime fatigue, increases the risk of hypertension, diabetes, heart diseases and liver problems. The chances of complications post surgery is also higher. Keeping these in mind, it is important that OSA is managed and treated well at the right time. A few treatment options have been listed below. 

Treatment of OSA:

Adenotonsillectomy – This is the first line of treatment during childhood. It involves the removal of adenoids and tonsils, thereby providing an open airway to enhance breathing.  

Continuous positive airway pressure (CPAP) – In this method, a constant air pressure higher than the atmospheric pressure is applied to the upper respiratory tract. This constant positive pressure prevents collapse of the upper airway.

Mandibular advancement device – It is effective in case of mild to moderate apnoea. It is a non continuous method of providing positive pressure to the upper respiratory pathway.   

Irrespective of these options, there is a need for alternative methods to treat OSA because these are of very little help to some people. They are unable to respond well to these methods. Myofunctional therapy is at the focal point of complementary treatment methods for OSA.   

What is Myofunctional therapy?

Myofunctional therapy(MT) is a set of specific exercises that target the facial muscles involved in chewing and swallowing. These exercises strengthen the tongue. It is composed of isotonic and isometric exercises that target oral (lip, tongue) and oropharyngeal structures (soft palate, lateral pharyngeal wall). It works for almost everyone. It is generally performed in kids above 4 years and does work very well for adults.  

There are dilator muscles in the upper airway which are crucial for keeping it open during sleep. Targeting these muscles along with the oral cavity and the orofacial structures with the help of exercises and airway training (such as singing, playing an instrument) can alleviate OSA. Myofunctional therapy has  been suggested for the same since 1918.  MT exercises involve the soft palate, tongue, and facial muscles and address stomatognathic functions. 

Orofacial myofunctional disorders are abnormal patterns of the oral and orofacial muscles that interfere with the normal growth, development and function of these muscles. It includes sucking of thumb and other fingers, tongue thrust, resting always with the lips apart etc. These are accompanied with other comorbidities like blocked airway and obstructive sleep apnoea. Consulting an oral myofunctional therapist to deal with this is a good help for the patient concerned.  

Breathing is adversely affected in OSA. Therefore, pairing myofunctional therapy with breath retraining can be of great help. The objective of this is to have normal breath while awake and sleeping.

How does Myofunctional therapy work?

Myofunctional therapy focuses on the following:

  • Strengthening the facial muscles.
  • The exercises are designed such that continuous breathing becomes possible.
  • Correct swallowing
  • Sealed lips 
  • Correct tongue position and oral rest posture.

There are exercises that strengthen the muscles around the upper airway and in the orofacial region. Some of them are:

Tongue exercises – The tip of the tongue is placed on the hard palate and is pressed against it for 5 seconds. It is made to touch the tip of the nose and the bottom of the chin and is held for 10 seconds.

It is also moved along the superior and lateral surfaces of the teeth. Tongue rolling is also included. 

Facial exercises – These include exercises that target various facial muscles e.g. contraction and relaxation of the orbicularis oris, which are muscles around the lips, suction movements and application of intraoral finger pressure against the buccinator muscles present under the cheek and lateral jaw movements to strengthen the jaw muscles. For soft palate exercises, patients pronounce oral vowel sounds either continuously or intermittently.  

Stomatognathic exercises– First, the patients are instructed to inhale nasally and exhale orally without a balloon. This process is again repeated with a balloon. Specific swallowing and chewing exercises, for example, swallowing with the teeth clenched together, tongue positioned in the palate and without contraction of perioral muscles; alternating chewing sides are also included. 

Most of these myofunctional therapy exercises are also effective for management of mouth breathing.

Does myofunctional therapy work?

Extensive research has been conducted to check the effectiveness of this therapy. It has been observed that:

MT provides a reduction in AHI. According to a study by Suzuki et al.,(Journal of prosthodontic research, 2013) oral myofunctional therapy has the potential to improve respiration during sleep. They concluded that this therapy had the potential to increase labial closure force, improve the SpO2 levels and AHI scores. These results were observed after two months of training.  

MT decreases snoring. Guimaraes et al.,(American journal of respiratory and critical care medicine, 2009) conducted a study in which patients with moderate OSA were made to perform oropharyngeal exercises for a period of 3 months. These patients had a significant decrease in snoring intensity, excessive daytime sleepiness and had an improved sleep quality score as compared to the control group.

A meta analysis conducted in 2015 by Camacho et al., published in Sleep, reported that myofunctional therapy could reduce the apnea – hypopnea index by around 50% in adults and upto 62% in children. It can be very effective when combined with other treatment options.

Myofunctional therapy should always be performed under the supervision of a professional. Each patient has a different problem to address. Hence, there are specific sets of exercises recommended for each individual.  Hence, myofunctional therapy training becomes essential for the same. There are various training academies that have quality training programmes for this therapy. It is very popular among dentists, sleep therapists, speech therapists, physiotherapists and occupational therapists. 

There are numerous health hazards of living with sleep disorders. Hence, it is very important to get to the root cause and get treated for it. Various online myofunctional therapy training are available for people in the field of  healthcare, that can enable them to help affected individuals to get back to a good quality sleep and lead a happy and healthy life.   

References:

Camacho, M., Certal, V., Abdullatif, J., Zaghi, S., Ruoff, C. M., Capasso, R., & Kushida, C. A. (2015). Myofunctional Therapy to Treat Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. Sleep, 38(5), 669–675. https://doi.org/10.5665/sleep.4652

Guimarães, K. C., Drager, L. F., Genta, P. R., Marcondes, B. F., & Lorenzi-Filho, G. (2009). Effects of oropharyngeal exercises on patients with moderate obstructive sleep apnea syndrome. American journal of respiratory and critical care medicine, 179(10), 962–966. https://doi.org/10.1164/rccm.200806-981OC

Suzuki, H., Watanabe, A., Akihiro, Y., Takao, M., Ikematsu, T., Kimoto, S., Asano, T., & Kawara, M. (2013). Pilot study to assess the potential of oral myofunctional therapy for improving respiration during sleep. Journal of prosthodontic research, 57(3), 195–199. https://doi.org/10.1016/j.jpor.2013.02.001

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