Digeridoo for Sleep Apnea

Can you tootle apnea away?

Studies Hint Mouth and Throat Exercise May Help

Playing the oboe, the difficult instrument that Danny Kaye once described as “an ill wind that no one blows good,” may actually be good for you. That’s the tentative conclusion reached by Dr. Christopher P. Ward and six colleagues, who found that musicians who play double-reed woodwind instruments–oboes, bassoons and English horns–appear to have a significantly lower risk of obstructive sleep apnea than musicians who play other instruments, including other wind instruments.The study was presented at the annual Sleep meeting sponsored by the Associated Professional Sleep Societies held in June 2009 in Seattle, WA. It was the most recently reported of a number of studies, all of them small, that point toward possible exercise treatments for sleep apnea alternative to continuous positive airway pressure machines.

Ward and his coauthors, Kaki M. York, Kaylee K. Vance, Andrew S. Calzadilla, Frank J. Walch, Jennifer J. Song, and Masha Sharf, surveyed 901 musicians, 847 of whom were college musical instrument instructors across the United States, with the remaining 54 being members of orchestras in the Houston, TX, area. Their conclusions differed dramatically from a similar study conducted by Devin L. Brown of the University of Michigan Medical School and others that found wind musicians were no less prone to OSA than those who play other instruments. The Brown study of 1,111 musicians, “Risk of Sleep Apnea in Orchestra Members,” was e-published by Sleep Medicine in November 2008 and then appeared in the June 2009 print issue of the journal.

Ward, a professor of psychology at the University of Houston Clear Lake, said that his group came to their different finding by analyzing the varying risks of sleep apnea displayed by players of different kinds of wind instruments. This led them to discover that, contrary to their initial hypothesis, players of high-pressure brass instruments–trumpets and French horns–had twice the risk of OSA as that of double-reed players, in fact the highest risk of any of the musicians surveyed. Players of single-reed woodwinds (flutes, clarinets, and saxophones), low-pressure brass (trombones, euphoniums, and tubas), and nonwind instruments were arrayed between the two extremes.

Had his team assessed their sample of wind players as a single group, Ward said, they too would have seen no difference in apnea risk between wind and nonwind instrumentalists.

The possibility that certain exercises of the mouth and throat, muscle movements that might be involved in the playing of wind instruments, could affect sleep apnea won additional support in another recent report. That study, written by Katia C. Guimaraes and others, is titled “Effects of Oropharyngeal Exercises on Patients with Moderate Obstructive Sleep Apnea Syndrome”; it appeared in Vol. 179 (2009) of the American Journal of Respiratory and Critical Care Medicine. The study of 31 moderate OSA patients found significant decreases in neck circumference, snoring, daytime sleepiness, and apnea-hypopnea incidents after three months of exercises by the 16 patients assigned to treatment. In fact eight of the patients saw their OSA diminish from moderate to mild and in two it dropped to zero. In contrast, no significant changes occurred among the 15 patients in the control group, who were assigned three months of sham deep breathing exercises.

The apparently effective set of exercises, most of which can be viewed online at http://tiny.cc/asaamouthmoves, were originally designed for use in speech therapy. Guimaraes, who is a speech pathologist, instructed the patients in the daily exercises and met with them once a week during the three-month study to monitor their performance. Participants in the study were recruited from the sleep laboratory of the University of Sao Paulo Medical School in Brazil.

Guimaraes and her coauthors conceded that owing to the way their study was constructed they had no way of knowing which of the exercises might have utility. An accompanying editorial in the journal by Dr. Catriona M. Steele of the Toronto Rehabilitation Institute assessed the physiological plausibility of the exercises. She questioned whether tongue brushing, chewing, or sliding the tongue along the roof of the mouth had any effect, but said that inflating a balloon five successive times while inhaling through the nose (not shown in the video) and repeatedly pressing the tongue against the roof of the mouth might indeed lead over time to a remodeling of the upper airway.

Dr. Vicki Thon, a board member of the American Sleep Apnea Association, who monitors research on alternative treatments of OSA for the ASAA, cautioned that all the studies discussed in this article are highly preliminary. They are either surveys or investigations conducted with extremely small numbers of participants. “No one should discontinue CPAP on the basis of these studies,” she said. On the other hand, she added, “they may point to promising therapies on the horizon.

“The first published article on the possible effect of playing a wind instrument on OSA was an investigation of playing the didgeridoo, a drone instrument traditional among Australian aborigines. Results of the study, conducted in Switzerland by Milo A. Puhan and others, were published online by the British Medical Journal in December 2005.Puhan and his colleagues worked with 25 patients with moderate obstructive sleep apnea (apnea-hypopnea indexes between 15 and 30). Fourteen were supplied four-foot-long plastic didgeridoos, given four lessons on the instrument spaced over an eight-week period, and instructed to practice at least 20 minutes a day five days a week. The 11-person control group was placed on a four-month waiting list for their own didgeridoos and lessons.

The physiological benefit of didgeridoo playing is believed to stem from an action called circular breathing, in which the player inhales through the nose while maintaining an uninterrupted outflow into the instrument through the mouth, using the cheeks as bellows. This produces a continuous note sustained far longer than would be possible with a single breath. This link shows how to circular breathe. At the conclusion of the four months, the investigators found that the didgeridoo players’ apnea-hypopnea index had dropped from an average of 21 to 11.6. (The AHI of the untreated control group decreased as well, but only to 15.4.) The didgeridoo players also showed a marked improvement in their level of daytime sleepiness. And the participants proved to be enthusiastically compliant with their instructions, honking on their instruments an average of almost six days a week although five was all that was asked for.

FrOm Wake-up Call, Summer 2009