What is positional therapy? Can it help reduce snoring and sleep apnea?

positional therapyAround 50% of people with snoring and sleep apnea have it more prominently when they are sleeping on their back, or supine, compared to their side. But, does keeping off your back really reduce snoring and sleep apnea, and what can be used to keep off your back during sleep?

Why does snoring and sleep apnea occur more on your back?

Snoring occurs when there is narrowing in the airway between the back of the nose and the voice box or larynx. When we go to sleep, muscles, including those in the upper airway, relax and can cause the airway to narrow. The largest muscle in the upper airway is the tongue. The tongue falling back towards the back of the airway is the most common cause of airway narrowing. When the airway partially narrows, airflow becomes turbulent, which then sets up vibration of soft tissues and generates a snoring noise. Sleep apnea is when the airway gets narrower again, and either blocks completely or is narrow enough, that breathing is more difficult. The brain senses this during sleep and reacts by breathing harder and even causing short awakenings, called arousals, from sleep. These breathing changes can be measured during a sleep study and counted to determine how many times per hour they are occurring. This is called the apnea-hypopnea index or AHI.

One way of defining whether sleep apnea is supine-predominant is comparing how often the airway narrows on the back compared to on the side. Some people suggest that when sleep apnea is twice as often on the back this should be considered supine predominant. However, recent research suggests that a finding on a sleep study of 4 times more sleep apnea on the back than the side is a more reliable measure. Before considering using positional therapy as a treatment for snoring or sleep apnea it’s also important to ensure that there is no significant sleep apnea sleeping on the side or non-supine position. Given this some people will also define positional sleep apnea as having an apnea hypopnea index in the normal range (<5) in the non-supine position.

Does keeping off your back reduce sleep apnea?

The short answer is yes it can. But, the longer answer is not for everyone, and keeping off your back as a long-term treatment can be tough. One of the reasons I will do a sleep study in people with snoring and sleep apnea is to look at the effect of body position to consider whether people are suitable for positional therapy. For people who are shown on a sleep study to have little snoring or sleep apnea on their side or non-supine, positional therapy can be an effective treatment.

Zzoma pillow

A study of 38 people with positional sleep apnea showed that avoiding sleeping on their back using a mechanical device (Zzoma positional sleeper – pictured) worked as well for controlling sleep apnea as continuous positive airway pressure (CPAP). This only looked at the effectiveness over 1 night, but did show that in principle of keeping people off their back was helpful to reduce snoring and sleep apnea. However, in the longer-term,a study looking at long-term use of devices such as this at home showed that by 30 months only 10% of people were still using them.

Better long-term effectiveness has been shown with a less intrusive device, the Night Shift. This gives a vibratory signal to the back of the neck whenever people roll on to their back and has been shown in a recent study to remain effective out to 12 months, with 88% of people still using the device at 12 months.

What can be used to keep off your back during sleep?

A range of devices have been used to help people stay off their back during sleep. The 2 main groups of devices are mechanical devices which use pillows or cushions and electronic devices which alert people when they sleep on their back. Just trying to keep off your back doesn’t work, with video monitoring showing that people who report not sleeping on their back spend up to 30% of the night on their back.

  • Mechanical devices: such as the Zzoma positional sleeper (pictured above) are FDA approved for the treatment of positional snoring and sleep apnea. Personally I have concerns about poor long-term effectiveness with these forms of treatment, with few people being compliant with these treatments in the longer term. It’s also not possible to measure the effectiveness or use of these devices.
  • Night ShiftElectronic devices: such as Night Shift are also FDA approved for use as treatment for positional snoring and sleep apnea. Long-term use of Night Shift has been shown to be effective at keeping people off their back during sleep for out to 12 months. The Night Shift also allows data to be stored for up to a year to show how often it has been used and how effective it has been at keeping people off their back during sleep. Check out this video for an interview with the inventor of Night Shift.

What about other treatments?

Other treatments that are used for snoring and sleep apnea, can also be used in positional sleep apnea, either as a stand-alone treatment or as an add-on treatment to positional therapies such as the Night Shift device.

  • Oral appliances: such as mandibular advancement splints can be effective treatments for snoring and sleep apnea that is more prominent in the supine position. As the main problem is the tongue base falling back towards the back of the airway, using an oral appliance to hold the tongue forward often works well. More information on the use of oral appliances for the treatment of snoring and sleep apnea can be found in this video.
  • Other therapies: such as surgery, weight loss or nasal EPAP (Theravent or Provent) haven’t been specifically tested for supine-related snoring and sleep apnea, but can be used as part of a combined approach.

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  • Peta

    I was sent for a sleep study in a private hospital lab quite a few years ago where they told me my AHI was in the lower end of the range that should be treated. I did one night sleeping with the machine in the lab which I found didn’t make me feel much different but went on and trialled the hire machine anyway. Frankly I couldn’t stand the thing. The concern I had was that the lab test required me to be wired up with so many sensors that it prevented me from sleeping in any position other than a supine position – and I have always been as much a side and stomach sleeper as I do supine. I suggested at the time that I though this would mean the test wasn’t very accurate in terms of what I experience each night, but I got the strong impression that they didn’t want to consider any possibility that the test could be inaccurate in any way or that I would not be anything other than delighted with the results I would get from using CPAP. I do know people who swear by the machines so I am sure they are of great benefit to some people, but I feel that there is a very real financial imperative that leads to a less than critical self-evaluation of the testing procedures for OSA and how they might not provide a particularly fair assessment of all the factors to be considered when determining if someone actually would benefit from using CPAP. All in all I felt like it was almost a pressure-sales situation.

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