Oropharyngeal Exercises for Snoring – What’s the Evidence?

Introduction

Snoring occurs when the muscles in your upper airway relax, restricting airflow which in turn causes these tissues to vibrate and make sound.

Conventional snoring remedies treat the symptom, not the cause. Whilst they may stop the sound in the short term, they don’t address the root of the problem – weak muscles in the airway.

Increasing volumes of research are highlighting that snorers don’t need to be committed to a snoring remedy that they switch on or wear for the rest of their lives, but rather, they can incorporate inexpensive and effective techniques into their daily lives to stop snoring without artificial assistance.

Using techniques adapted from speech and language therapy, various research groups have employed the use of a set of oropharyngeal exercises which address weaknesses and develop muscular tone in the tongue, soft palate, throat, cheeks and jaw. This is with a view to reducing snoring, decreasing the severity of sleep apnea, mitigating disturbance of bed partners and producing better sleep and quality of life [1].

In this article, we summarise their findings.

Effects of Oropharyngeal Exercises on Patients with Moderate Obstructive Sleep Apnea Syndrome – Guimaraes et al, 2009 [2]

Overview of study

Kátia Guimaraes is a speech and language therapist from Brazil and is one of the first people to propose that oropharyngeal exercises can produce positive outcomes for obstructive sleep apnea [3].

This study uses an exercise regime that has become the basis for many subsequent experiments (though now, usually somewhat redacted). It is the first of its kind, has a robust design and is the most extensive.

Study design

Patients selected for the study met the following criteria:

  • Aged 25-65
  • BMI under 40
  • Previous diagnosis of moderate obstructive sleep apnea (AHI 15-30) via a sleep study

Guimaraes and colleagues designed a randomised-controlled trial. This means that as well as getting some patients to perform the prescribed exercises under scrutiny, another group of patients were given “sham therapy” and nasal irrigation as a control. The sham therapy consisted of simple deep breathing exercises and had to be performed with the same frequency as the study group’s exercises. This is a similar concept to a placebo in a drug trial.

The study group

The study group of sixteen patients were given a set of exercises designed to work out a variety of muscles. These exercises included:

  • Tongue brushing
  • Sliding tip of the tongue back along hard palate
  • Sucking tongue against roof of the mouth
  • Forcing tongue down into the floor of the mouth whilst the tip stays in contact with the lower front teeth
  • Pursing lips
  • Sucking movements with the cheek
  • Using cheek muscles to pull against a finger
  • Elevation of soft palate

These exercises were repeated daily including a once weekly supervised session with a speech pathologist. The duration of the study was three months.

In addition to the exercises themselves, patients also supplemented their therapy with bilateral chewing (using both sides of the mouth to chew) with a focus on correct tongue, teeth and lip positioning.

Patients in both groups underwent a sleep study before starting their treatment and again after the three months. Polysomnography was conducted by professionals blind to the group allocation of the patients.

The patients in both groups also used the Epworth Sleepiness Scale (0-24) and answered questions about perceived snoring frequency and intensity (0-4).

Results

The findings from PSG comparisons before and after are as follows:

  • There were significant decreases in the severity of sleep apnea in the study group.
  • Average AHI in the study group significantly decreased from 22.4 to 13.7 – a 39% reduction.
  • Average AHI in the control group showed a non-significant increase from 22.4 to 25.9.
  • 62.5% of study group patients shifted their severity classification from moderate obstructive sleep apnea to mild or none.
  • The lowest recorded oxygen saturations improved for the study group: 83% at baseline, 85% after 3 months.
  • The lowest recorded oxygen saturations worsened for the control group: 82% at baseline, 80% after 3 months.

In addition to the objective, quantifiable findings from PSG analysis, patients and their partners also answered a series of questionnaires about snoring frequency and intensity, and sleepiness:

  • In the study group, snoring frequency and intensity significantly decreased from 4 to 3 and 3 to 1 respectively (in the control group, there was no change in snoring frequency and intensity).
  • In the study group, the Epworth Sleepiness Scale score significantly decreased from 14±5 to 8±6 (in the control group, there was no change in sleepiness).

Effects of Oropharyngeal Exercises on Snoring – Ieto et al, 2015 [4]

Overview of study

This study looked at the influence of exercises on primary snoring as opposed to obstructive sleep apnea. The subjects were described as being “a population poorly evaluated by the scientific community […] composed of middle-aged and overweight patients who were disturbed by snoring, were on average not sleepy and did not present severe OSA”. In short, unlike much of the research into sleep-disordered breathing, this research assesses the “normal snorers”.

There are fewer exercises in this study than used by Guimaraes et al [2], and the 5 exercises used in this study form the basis of subsequent work. Importantly, this study shows that the workouts don’t need to be done in excess of 30 minutes per day to have a positive effect. 8 minutes per day for 3 months was shown to reduce snoring.

Study design

Patients selected for the study met the following criteria:

  • Aged 33-59
  • BMI under 40
  • Complaints of primary snoring with recent diagnosis confirming such, or of mild-moderate obstructive sleep apnea (AHI 5-30)

Ieto and her team used a control group (20 subjects) as well as a therapy group (19 subjects). Each group was randomly allocated. The study duration was 3 months.

The patients underwent polysomnography at baseline and after the 3 months to objectively measure snoring. This was done by creating a “snore index” which assessed the number of times per hour the patient broke a threshold of 38 db.

Subjects also answered questions on sleepiness using the Epworth Sleepiness Scale and sleep quality using the Pittsburgh Sleep Quality Index before and after the study.

5 exercises were performed at a set number of reps in one session per day which takes roughly 8 minutes:

  • Push the tip of the tongue against the hard palate and slide backwards – repeat 20 times.
  • Suck the tongue upward against the hard palate and press – repeat 20 times.
  • Force the bottom of the tongue against the floor of the mouth whilst the tip maintains contact with the lower incisors – repeat 20 times.
  • Elevate soft palate and uvula whilst saying “ah” – repeat 20 times.
  • Use cheek muscles to pull against finger – repeat 10 times on each side.

In addition to these exercises, when eating, subjects were told to alternate bilateral chewing and swallowing pushing the tongue into the hard palate.

The control group performed a “sham therapy” of deep-breathing exercises as well as wearing nasal strips during sleep and performing nasal irrigation 3 times per day.

Results

Objectively measured snoring using the snoring index did not change for the control group but showed a significant decrease in the treatment group:

  • Frequency of snoring reduced by 36%
  • Total power of snoring reduced by 59%
  • The objective snoring reduction was corroborated by a significant subjective decrease in the perception of snoring by bed partners.

Whilst not the primary focus of this study, a decrease in average AHI was also observed for the small subset of snorers (8 subjects) recently diagnosed with moderate OSA from an average AHI of 25.4 to 18.1 (a reduction of 29%).


Oropharyngeal exercises in the treatment of obstructive sleep apnoea – Verma et al, 2016 [5]

Overview of study

Another study with its primary focus on obstructive sleep apnea, this study stands out due to the findings beyond snoring, particularly on sleepiness and sleep quality.

The types of exercise in this study are more extensive and require a greater investment of time and effort.

Study design

As a case report, this study has a less robust design as it is missing a control group who don’t receive the intervention under investigation.

20 patients with mild to moderate obstructive sleep apnea (AHI 5-30) were given a rigorous set of oropharyngeal exercises. These exercises were split into 3 grades of difficulty, with patients stepping up a grade for every month of the 3 month study. Each exercise had to be repeated for 10 reps, 5 times per day.

The Epworth Sleepiness Scale, subjective snoring questionnaires and full PSG were performed at baseline and after 3 months.

Results

After the three month trial, the researchers found the following:

  • 85% of patients in the study showed a significant reduction in sleepiness.
  • Patients spent on 1.6 hours in deep sleep, compared to 0.97 at baseline – a 65% increase.
  • The average snoring as measured on the snoring intensity scale (0-4, lowest to highest) decreased significantly from 2.8 to 1.7.
  • Significantly less time was spent at oxygen saturations below 90%.

The effects of oropharyngeal-lingual exercises in patients with primary snoring – Nemati et al, 2015 [6]

Overview of study

Similar to the study conducted by Ieto et al, this study addressed the effect of exercises on primary snoring – not obstructive sleep apnea.

In addition to their explorations of the impact on snoring intensity and frequency, Nemati and colleagues also took the interesting step to look at the psychological and emotional impacts of snoring – assessing the relationship between changes in snoring intensities and conflicts had with roommates.

Study design

Interestingly, all measurements from this study were obtained from roommates of the snorer. 53 snorers were assessed before and after 3 months of soft palate, tongue and facial exercises totalling 30 minutes per day, at least 5 times per week. This was done by asking their roommates to report on the severity their snoring using a sliding scale of 0 (no snoring) to 10 (unbearable snoring).

In part due to the lack of a control group, this study describes itself as “semi-experimental”. That said, a sample size of 53 is good.

Results

Before versus after the exercise intervention:

  • Average snoring severity significantly decreased from 7.01 to 3.09 – a 56% reduction.
  • This reduction in the severity of snoring had a significant relationship the number of conflicts with roommates.

The role of oral myofunctional therapy in managing patients with mild to moderate obstructive sleep apnea – Baz et al, 2012 [7]

This prospective study evaluated the effect of oropharyngeal exercises on 30 patients with mild to moderate obstructive sleep apnea.

The exercises – similar to those outlined by Guimaraes et al [2] – were conducted in twice weekly supervised sessions plus at home for 3-5 times a day for at least 10 minutes at a time.

After the three months of therapy, patients showed some very positive, statistically significant changes:

  • 47% of patients reported not snoring any more.
  • Only 40% (compared to 100% at baseline) reported still experiencing excessive daytime sleepiness. This was reflected on the Epworth Sleepiness Scale with an average decrease from 16.4 to 9.27.
  • Average AHI reduced from 22.27 to 11.53.
  • Time spent at an oxygen saturation below 90% was halved.

Effect of speech therapy as adjunct treatment to continuous positive airway pressure on the quality of life of patients with obstructive sleep apnea – Diaferia et al, 2013 [8]

Speech and language therapy techniques underpin anti-snoring exercises. This study looked at the effectiveness of speech therapy in addition to the more conventional treatment of CPAP for obstructive sleep apnea.

In a nicely robust study design, there were four groups of similar sample sizes:

  • Speech therapy alone (n = 27)
  • Sham therapy alone (n = 24)
  • CPAP alone (n = 27)
  • Combination of CPAP with speech therapy (n = 22).

Speech therapy alone was shown to drastically reduce the average AHI for these patients (28.0 to 13.9). When supplemented with CPAP, the average reduction was even more marked, dropping from 30.4 (just over the “severe” threshold) to 3.4 (below the “mild” threshold).

In terms of sleepiness, speech therapy alone showed comparable results to using CPAP alone. The sham therapy control showed no difference in either sleepiness or AHI.


Other studies

The aforementioned studies have shown that a clearly defined set of exercises, repeated over time can produce very positive outcomes in terms of snoring reduction and reduction of sleep apnea severity amongst other facets like sleep quality and partner disturbance.

We believe this structured approach is ideal for working into your daily routine. However, the evidence extends beyond these sets of exercises.

Research groups have shown that you can work out your snoring muscles via other means. It could even be said that these earlier studies inspired the research into oropharyngeal exercises fo snoring. These techniques combat snoring via the same mechanisms as the prescribed exercises, so their findings are certainly worth a mention.

Can Signing Exercises Reduce Snoring? – Ojay and Ernst, 2000 [9]

Alise Ojay, a choir director, singer, composer and research fellow at the University of Exeter in the UK developed a series of singing exercises for a group of 20 snorers.

The group sung these songs for 20 minutes a day for three months. These songs weren’t the typical tunes you might hum to yourself, but were instead focussed on projecting strong vowel sounds with exaggerated mouth movements.

Ojay’s team saw significant improvements in the snoring of those who consistently sung. More in-depth studies have since confirmed Ojay’s findings, showing improvements in sleepiness, frequency and volume of snoring for a larger group of 93 patients in a recent randomised controlled trial [10].

Ojay continues to advocate singing as a therapy for snoring with her “Singing for Snorers” CDs.


Didgeridoo playing as an alternative treatment for obstructive sleep apnea syndrome – Puhan et al, 2006 [11]

In this small but well-known study, 25 patients with moderate obstructive sleep apnea (AHI 15-30) were randomised to 2 groups. The study group of 14 patients were given didgeridoo lessons for four months and told to practice regularly at home. The remaining 11 were left on a waiting list as a control.

Playing the didgeridoo is hard and requires strong mouth, tongue and throat muscles. A different and fun activity, adherence to the “treatment” was high, patients averaging 5.9 days a week of practice for 25.3 minutes per day.

Compared to the control group, the didgeridoo group showed on average less sleepiness (3 points less on the Epworth Sleepiness Scale), reduced OSA severity (reduced AHI score by 6.2) and disturbed the sleep of partners less.


Conclusion

The studies mentioned are the best examples of using oropharyngeal exercises to combat snoring and sleep apnea, but are non-exhaustive. There have been plenty of other case reports that have produced positive outcomes [1].

The studies in this article used the same time span of three months, and subtly varied the types of exercise and the time spent doing them. Despite this heterogeneity, the results are consistent and can be summarised as follows:

  • Oropharyngeal exercises reduce snoring both objectively and subjectively.
  • Exercises reduce the severity of obstructive sleep apnea, often changing the classification from moderate to mild or even none.
  • Subjective feelings of tiredness significantly reduce after consistently performing these exercises, with some studies objectively measuring greater time spent in deep sleep.
  • Partners report feeling less disturbed and conflicts arising from snoring reduce.
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References

  1. Macario C, et al. Oropharyngeal and tongue exercises (myofunctional therapy) for snoring: a systematic review and meta-analysis. Sleep 2015; 38(5): 669-675. https://www.ncbi.nlm.nih.gov/pubmed/25348130
  2. Guimaraes KC, et al. Effects of Oropharyngeal Exercises on Patients with Moderate Obstructive Sleep Apnea Syndrome. American Journal of Respiratory and Critical Care Medicine 2009; 179(10): 962-966. https://doi.org/10.1164/rccm.200806-981OC
  3. Guimaraes KC. Soft tissue changes of the oropharynx in patients with obstructive sleep apnea. J Bras Fonoaudiol 1999; 1: 69-75.
  4. Ieto V, et al. Effects of Oropharyngeal Exercises on Snoring. Chest 2015; 148(3): 683-691. https://pdfs.semanticscholar.org/36a8/e559e74d123e9f1087538ab1731f00a1ea84.pdf
  5. Verma RK, et al. Oropharyngeal exercises in the treatment of obstructive sleep apnoea: our experience. Sleep & Breathing 2016; 20(4); 1193-1201. https://doi.org/10.1007/s11325-016-1332-1
  6. Nemati S, et al. The effects of oropharyngeal-lingual exercises in patients with primary snoring. European Archives of Oto-Rhino-Laryngology 2015; 272(4): 1027-1031. https://doi.org/10.1007/s00405-014-3382-y
  7. Baz H, et al. The role of oral myofunctional therapy in managing patients with mild to moderate obstructive sleep apnea. PAN Arab Journal of Rhinology 2012; 2(1): 17-22. http://www.academia.edu/12781370/The_role_of_oral_myofunctional_therapy_in_managing_patients_with_mild_to_moderate_obstructive_sleep_apnea
  8. Diaferia G, et al. Effect of speech therapy as adjunct treatment to continuous positive airway pressure on the quality of life of patients with obstructive sleep apnea. Sleep Med 2013; 14: 628–35. http://www.sleepclinic.be/wp-content/uploads/Effect-of-speech-therapy-as-adjunct-treatment-to-continuous-positive-airway-pressure-on-the-quality-of-life-of-patients-with-obstructive-sleep-apnea.pdf
  9. Ojay A and Ernst E. Can Singing Exercises Reduce Snoring? A Pilot Study. Complementary Therapy Medicine 2000; 8: 151-156. https://doi.org/10.1054/ctim.2000.0376
  10. Hilton MP, et al. Singing Exercises Improve Sleepiness and Frequency of Snoring among Snorers – A Randomised Controlled Trial. International Journal of Otolaryngology and Head & Neck Surgery 2013; 2: 97-102. https://www.creativenz.govt.nz/assets/ckeditor/attachments/1086/singing_reduces_snoring_by_o_jay_and_ernst.pdf?1413517377
  11. Puhan MA, et al. Didgeridoo playing as an alternative treatment for obstructive sleep apnea syndrome: randomized controlled trial. British Medical Journal 2006; 332(7536): 266-270. https://www.ncbi.nlm.nih.gov/pubmed/16377643

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