Treatment Options - Positional Therapy (PT)
Positional therapy is tailored to patients with positional OSA, which occurs when the majority of obstructive hypopnoeas and apnoeas can be attributed to sleep supine-predominant sleep position.
The level of evidence for treatment is based on GRADE ratings.1, 2, 3, 4, 5, 6
Positional therapy for OSA includes a position therapy device that is worn around the chest or neck, which gives feedback through vibration and can be individually adjusted, and tennis ball therapy (TBT). Positional therapy devices can be considered for people who have confirmed OSA and who want an alternative to CPAP, manufactures include Philips and ResMed. Tennis ball therapy is a traditional method of controlling the position during sleep in which the patient uses a physical device to avoid the supine posture during sleep.
Efficacy of PT
Table. PT vs. control
| Percentage of sleeping time in the supine position
Moderate GRADE | |
| Apnoea-hypopnoea index (AHI)
Low GRADE | |
| Oxygen saturation (Oxygenation desaturation index (ODI))
Low GRADE | PT (position therapy and tennis ball therapy) may improve ODI in patients with positional OSA and an AHI 5-30
PT (position therapy and tennis ball therapy) is comparable to MAS and seems to improve ODI in patients with positional OSA and AHI 5-301,3,5,2 |
| Sleepiness (Epworth sleepiness scale (ESS))
Very low GRADE | |
| Quality of life (Functional outcomes of sleep questionnaire (FOSQ))
Very low GRADE |
Table. PT vs. Mandibular advancement splint (MAS)
| Apnoea-hypopnoea index (AHI)
Low GRADE | |
| Oxygen saturation (Oxygenation desaturation index (ODI))
Low GRADE | |
| Sleepiness (Epworth sleepiness scale (ESS)
Very low GRADE | |
| Quality of life (Functional outcomes of sleep questionnaire (FOSQ))
Very low GRADE |
Table. Combination of PT and MAS
| Apnoea-hypopnoea index (AHI)
Very low GRADE | Combination of PT (position therapy) and MAS, when compared with either therapy alone, may be more effective at reducing AHI in selected OSA patients4 |
| Oxygen saturation (Oxygenation desaturation index (ODI)) Very low GRADE | Combination of PT (position therapy) and MAS, when when compared with either therapy alone, may be more effective at reducing ODI in selected OSA patients4 |
The GRADE system
The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system
provides a transparent approach to grading quality (or certainty) of
evidence and strength of recommendations. Many international
organizations have provided input into the development of the GRADE
approach which is now considered the standard in guideline development.
The OSA resource’s treatment-options GRADE-evidence ratings are based on the recommendations of the Dutch Medical Specialists Federation ‘Federatie Medisch Specialisten (www.kennisinstituut.nl)’ published in ‘Obstructief slaapapneu (OSA) bij volwassenen’ on June 1st 2018 (https://richtlijnendatabase.nl). And the American Academy of Sleep Medicine’s most recent meta-analysis and GRADE assessment on the effectiveness of CPAP.
Further clinical practice guidelines for the management of OSA in adults reviewed include the American Academy of Sleep Medicine (AASM), the American Thoracic Society (ATS), the American Cllege of Physicians (ACP), the Canadian Thoracic Society and the International Geriatric Sleep Medicine Taskforce.
AHI - Apnoea-Hypopnoea Index
BBTi - Brief Behavioural Therapy for Insomnia
BMI - Body Mass Index (kg/m2)
BQ - Berlin Questionnaire
CBTi - Cognitive Behavioural Therapy for Insomnia
CELL - Coblation Endoscopic Lingual Lightening
COPD - Chronic Obstructive Pulmonary Disease
CVA - Cerebrovascular Accident
CPAP - Continuous Positive Airway Pressure
CSA - Central Sleep Apnoea
DASS - Depression Anxiety Stress Scale
DBAS - Dysfunctional Beliefs and Attitudes about Sleep
DBP - Diastolic Blood Pressure
DIMS - Difficulties Initiating and/or Maintaining Sleep
DISE - Drug-Induced Sleep Endoscopy
DISS - Daytime Insomnia Symptom Scale
ENT - Ear Nose and Throat
ESS - Epworth Sleepiness Scale
FOSQ - Functional Outcomes of Sleep Questionnaire
FSH - Follicle-Stimulating Hormone
FTP - Friedman Tong Position
GP - General Practitioner
HANDI - RACGP Handbook of Non-Drug Interventions
HGNS - Hypoglossal Herve Htimulation
ISI - Insomnia Severity Index
K10 - Kessler Psychological Distress Scale
MAD - Mandibular Advancement Device
MAS - Mandibular Advancement Rplint
MBS - Medicare Benefits Schedule
MMA - Maxillomandibular Advancement Surgery
MRA - Mandibular Repositioning Appliance
ODI - Oxygenation Desaturation Index
OSA - Obstructive Sleep Apnoea
PLMD - Periodic Limb Movement Disorder
PT - Positional Therapy
PTSD - Post-Traumatic Stress Disorder
PSG - Polysomnography
QSQ - Quebec Sleep Questionnaire
REM - Rapid Eye Movement
RFTB - Radiofrequency Thermotherapy of the Tongue Base
SBP - Systolic Blood Pressure
SCI - Sleep Condition Indicator
SE - Sleep Efficiency
SF36 - Short-Form (36) Health Survey
SMILE - Submucosal Minimally Invasive Lingual Excision
SNRIs - Serotonin-Norepinephrine Reuptake Inhibitors
SOL - Sleep Onset Latency
SSRI - Selective Serotonin Reuptake Inhibitors
TFTs - Thyroid Function Tests
TIB - Time In Bed
TORS - Transoral Robotic Surgery
TST - Total Sleep Time
UPPP - Uvulopalatopharyngoplasty
WASO - Wake After Sleep Onset