Myofunctional Therapy for Obstructive Sleep Apnea: The Ignored Adjunct

To the Editor,

Myofunctional therapy has emerged as a significant noninvasive treatment option for obstructive sleep apnea (OSA), a condition characterized by repeated episodes of partial or complete blockage of the upper airway during sleep. Obstructive sleep apnea is associated with various health risks, including cardiovascular disease, diabetes, and reduced quality of life. Traditional treatments, such as continuous positive airway pressure (CPAP) therapy and surgical interventions, though effective, can be uncomfortable or invasive. Myofunctional therapy offers an alternative by targeting the underlying neuromuscular dysfunctions contributing to OSA.^1,2

Understanding Myofunctional Therapy

Myofunctional therapy involves exercises designed to strengthen the oropharyngeal region’s muscles, including the tongue, soft palate, and throat muscles. The treatment focuses on correcting dysfunctional breathing patterns, improper tongue positioning, and inadequate muscle tone, all of which can contribute to airway collapse during sleep.³ By improving the strength and coordination of these muscles, myofunctional therapy helps maintain airway patency and reduces the severity of OSA.

Mechanisms of Action

The effectiveness of myofunctional therapy in OSA hinges on several fundamental mechanisms:

• Muscle Strengthening: Exercises target the muscles involved in maintaining the airway. Stronger muscles can better resist collapse during sleep, reducing apneic episodes.

• Improved Tongue Positioning: Proper tongue posture is critical in keeping the airway open. Exercises that promote a forward and upward resting position of the tongue can prevent it from falling back and obstructing the airway.

• Enhanced Nasal Breathing: Many myofunctional exercises encourage nasal breathing, improving airflow and reducing the likelihood of airway obstruction. Nasal breathing promotes a more stable tongue posture and enhances overall muscle function.

• Reduction of Oral Habits: The therapy can help eliminate detrimental oral habits such as mouth breathing, thumb sucking, and improper swallowing patterns, which can contribute to the development and exacerbation of OSA.

Evidence of Efficacy

Several studies have demonstrated the efficacy of myofunctional therapy in reducing the severity of OSA. Research indicates that myofunctional therapy can significantly decrease the apnea hypopnea index (AHI), which measures the number of apnea and hypopnea events per hour of sleep. A study published in the “American Journal of Respiratory and Critical Care Medicine” found that participants who underwent myofunctional therapy experienced a significant reduction in AHI compared with those who did not receive the therapy.⁴

In addition to improving AHI, myofunctional therapy has been shown to enhance daytime symptoms such as snoring, daytime sleepiness, and overall sleep quality. A meta-analysis published in “Sleep Medicine Reviews” highlighted that myofunctional therapy reduces AHI, improves subjective measures of sleep quality, and reduces snoring intensity.

Implementation and Practice

Myofunctional therapy typically involves a series of exercises prescribed by a trained therapist. These exercises are often performed daily and can include:

• Tongue Exercises: Strengthening the tongue through movements such as pressing it against the roof of the mouth or moving it in specific patterns.

• Soft Palate Exercises: Elevating the soft palate to enhance muscle tone, such as producing certain sounds that engage these muscles.

• Breathing Exercises: Promoting nasal breathing through techniques like alternate nostril breathing, diaphragmatic breathing, and Buteyko breathing. All these exercises promote nasal breathing and reduce mouth breathing to improve airway patency and reduce apnea events.

• Swallowing Exercises: Improving the coordination of swallowing to ensure proper tongue and muscle function.

Patients are usually advised to practice these exercises regularly, often several times a day, over a period of weeks to months to achieve optimal results.

Limitations and Considerations

While myofunctional therapy offers promising results, it is not suitable for all OSA patients. Its efficacy may vary based on the severity of OSA, patient adherence to the exercise regimen, and individual anatomical differences. Furthermore, myofunctional therapy is generally most effective as an adjunctive treatment, potentially enhancing the outcomes of other OSA treatments like CPAP or oral appliances.

In conclusion, myofunctional therapy presents a viable and effective option for managing OSA, particularly for those seeking noninvasive treatment alternatives. Targeting the neuromuscular factors contributing to airway obstruction can significantly reduce the severity of OSA and improve overall sleep quality and daytime functioning. As research continues to validate its efficacy, myofunctional therapy will likely become an integral part of comprehensive OSA management.

ORCID

Pranav Ish https://orcid.org/0000-0003-1701-4970

Vidushi Rathi https://orcid.org/0000-0002-9735-3915

Sreyas Sharma https://orcid.org/0009-0005-8156-5381

REFERENCES

1. Mittal A, Ish P, Rathi V, et al. Rehabilitation in obstructive sleep apnea: An ignored treatment adjunct. Monaldi Arch Chest Dis 2024. DOI: 10.4081/monaldi.2024.3014.

2. Kumawat SK, Ish P, Kumar R, et al. Pulmonary rehabilitation in obstructive sleep apnea – the ignored modality. Indian Sleep Med 2024;19(1):9–10. DOI: 10.5005/jp-journals-10069-0126.

3. Yoshioka J, Nagano T, Sekiya R, et al. Effects of tongue strength training on patients with mild to moderate sleep-disordered breathing: A randomized controlled trial. Prog Rehabil Med 2024;9:20240010. DOI: 10.2490/prm.20240010.

4. Poncin W, Willemsens A, Gely L, et al. Assessment and rehabilitation of tongue motor skills with myofunctional therapy in obstructive sleep apnea: A systematic review and meta-analysis. J Clin Sleep Med 2024. DOI: 10.5664/jcsm.11074.

5. Jacobowitz O, Afifi L, Alkan U, et al. On behalf Governing Council of the World Sleep Society. Endorsement of “European Respiratory Society guideline on non-CPAP therapies for obstructive sleep apnoea” by World Sleep Society. Sleep Med 2024;113:293–298. DOI: 10.1016/j.sleep.2023.10.004.