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Yoga Therapy For Sleep Apnea

Sleep apnea is a disorder in which breathing stops and starts.  By definition, this syndrome occurs during sleep, with apnea meaning cessation of breathing. It's a common condition, with around 35-40% of adults having it.  Causes include increasing rates of obesity, genetic predispositions, hormonal influences, and age-related changes.  It can also be seen in young children with tonsillar and adenoid enlargement and again with obesity (1)

About this post

This post was expanded from the More Than Anatomy Videocast with Dr Amit Anand, a faculty member in the Division of Pulmonary Critical Care and Sleep Medicine at the Beth Israel Deaconess Medical Center and an Instructor in Medicine at the Harvard Medical School.  You can see this videocast on the MTA YouTube Channel or just below.👇

MTA Videocast Episode 1

This syndrome has two broad categories:

Obstructive Sleep Apnea (OSA)


Somewhere between the opening of the nose and the opening of the windpipe, the upper airway collapses during sleep. So the muscles of respiration don't stop working, but they can't work effectively because air can't get in and out of the lungs because the airway is closed. Once they experience arousal during sleep, the airway reopens, and breathing is restored.

Central Sleep Apnea (CSA)


The centers of the brain controlling breathing do not correctly signal the muscles of respiration. This may be seen in those with cardiovascular, neuromuscular, and neurological diseases and those who may abuse opiates or alcohol. With central sleep apnea, in contrast to obstructive, the muscles of respiration wax and wane in terms of their movement..  

There is sometimes considerable overlap between both obstructive and central sleep apnea, making distinction difficult at times. We call this Complex Sleep Apnea. Both OSA and CSA are associated with the same symptoms and complications (Eckert et al., 2007)

Obstructive Apnea

One of the key areas typically involved is the oro-pharynx. Around 5 inches in length, this tube lies between the larynx and nasal cavities and connects these to the lungs and stomach. It's therefore crucial for both respiration and digestion. This area lacks rigid support from bone or cartilage, so remaining open relies heavily on muscle activity (3). In the upper airway alone, there are over 20 muscles, and aside from their role in helping maintain airway stability, they are involved in speech, chewing, swallowing, and breathing (4).

When these muscles don't' work properly, the airway can collapse, preventing air from reaching the lungs (3,5) and breathing to stop. It leads to oxygen (O2) and carbon dioxide (CO2) fluctuations in the body that the brain senses.  When it does, the brain signals the body to wake with a gasp. The individual may or may not be aware of this event, and it may even be a partner who is the first to notice its taking place.

O2 and CO2 level changes are not the only effects. It also leads to abrupt increases in heart rate and blood pressure and decreases in the quantity of blood pumped by the heart (6). Therefore, you can imagine if this is frequently occurring, perhaps 25 times, or even more in severe cases, every hour during sleep, this can have very adverse effects on the cardiovascular system. For example, it can lead to heart arrhythmia, chronic hypertension, and in severe cases, heart failure.

And it can impact in other ways because the individual can't catch up on their lost sleep. Every time they do go to bed, sleep is disturbed. Poor sleep quality can affect memory, attention fatigue, and feeling sleepyy throughout the day. Other symptoms may be snoring, waking up in panic, dry mouth or headache, and acid reflux. Changes to mood and depression can also occur.

During sleep breathing may stop 25 times or even more EVERY SINGLE HOUR. This can have very adverse effects on the cardiovascular system.

Contributing Factors

There are usually multiple contributing factors. However, some degree of upper airway impairment is present that must be addressed (7).

Obesity
Around 50% of sufferers are overweight (8) and have short, thick necks. There may also be increased size of the soft palate and tongue. 

Jaw Structure
Some individuals may have a receding jaw that results in insufficient room for the tongue. This can decrease the size of the upper airway, which, in conjunction with poor muscle tone in this region, and gravity in the supine position impedes the flow of air (9). 

Snoring
Snoring during sleep is an indicator of increased upper airway resistance. But snoring at night does not mean the individual has sleep apnea. It's snoring that stops because breathing has stopped; that is concerning. Simple nasal congestion from a cold or allergy can cause snoring but won't typically stop breathing. However, certain factors that contribute to snoring may contribute to sleep apnea.

Changes to Posture
Posture, particularly of the upper spine and neck, can also play a role. Sufferers may be seen to have upper cervical hyperextension, with anterior head carriage and marked thoracic kyphosis (10, 11, 12). The altered position of the neck affects the stability of the upper airways because of the direct anatomical support that the cervical spine provides to the pharynx (10). You can assess someone's posture the Modified Wall Angel and Prone Thoracic Extension Tests (see below).

Modified Wall Angel Test

This video, from the Shoulder Course, describes a simple way to assess upper body posture.

Prone Thoracic Extension Test

Thoracic kyphosis (an increased rounding of the upper spine) can sometimes be postural or structural.  This test explains these differences and what they mean.  (Video from the Shoulder Course).

Medical Management

Ideally, a Dr specialising in this condition should assess the patient. Diagnosis is via a home sleep apnea test, where the individual will wear a device at night, which monitors breathing, snoring, oxygen and heart rate.  A home sleep apnea test is essential if there is known upper airway narrowing, hypertension, or arrhythmia. Whilst this aids diagnosis, the cause can have multiple origins. These need to be established, considering posture, neck circumference, weight, jaw, tongue and signs of grinding the teeth (bruxism).

The obstructive component is a problem with the plumbing! Simply put: the pipes have to be reopened. That might be via a mechanical strut, such as a dental appliance or surgical intervention, for example, to correct a  deviated septum.

Machines called CPAP (Continuous Positive Airway Pressure) can deliver constant and steady air pressure that help to keep the airways open. These involve wearing a mask and must be continually worn at night to be effective. They can be very tedious to use and may cause anxiety in some.

Training the upper airway muscles may be a part of the therapy, as improving this can help prevent it from collapsing during sleep. A study from Australia in 2006 (13) assessed the use of the didgeridoo, an Aboriginal wind instrument, in those with OSA. After four months of practice, participants had less disturbed sleep, reduced daytime sleepiness and showed evidence that collapsibility of the upper airways had decreased.

Another study (14) had patients practice exercises derived from speech therapy involving suction, swallowing, chewing, breathing, and speech. After three months of treatment, the severity of the syndrome improved by nearly 40%. There was significantly decreased snoring symptoms, daytime sleepiness, and quality of sleep.  Whilst there was no change in BMI (all participants were obese), there was a significant decrease in neck circumference. This suggests toning the muscles of this region.

And guess what? With specific yoga techniques, this is also possible.

Yoga Therapy - Considerations

Ideally, the student has been properly assessed by a specialist, and the origins of the condition have been determined.

Each student will have their own unique set of circumstances, and these should be considered to develop an individual therapy program. The followng are a few areas to consider with each student.

Weight
As obesity is a common factor assisting the student in this area may be important. The awareness of oneself yoga cultivates alone can lead to better food choices and weight loss.  Referral to a dietition or Ayurvedic doctor should be considered.

Posture
Key things to look for are kyphosis and anterior head carriage (see videos above), as well as scoliosis. Utilise asana to help develop a better awareness of alignment.  Refer to a specialist if there are any concerns.

Movement
Consider the spines mobility. If kyphosis is seen, is this a rigid or flexible kyphosis? Introduce asana that helps to make the spine more flexible and more robust.

Neck
Alignment, size and strength of the neck may be a factor. The cervical spine has a role to play in providing the structural support of the pharynx and the muscles that help maintain it. Gentle neck toning exercises can be helpful to use, such as Brahma Mudra (see below).

Muscles of the upper Airway
As a yoga therapist, you won't be able to assess these muscles, but there are so many things you can do to stimulate them and improve their tone. With obstructive sleep apnea, this will typically need addressing.

Yoga Therapy - Face, Tongue & Neck

Simhasana - Lion Pose

Sitting in a comfortable position, on a forceful exhale protrude the tongue out as far as possible whilst taking the gaze up between the eyebrows.  Repeat 5 times

Benefits
Interesting posture in the way it stimulates the tongue and many facial muscles, both of which may be useful to employ. 

Contraindications
If you have jaw issues be cautious not to open the mouth too wide, particularly if the jaw is unstable.  if you have eye issues consult with your optician before its practice.

Jiva Bhanda - Tongue Lock

This lock involves the tongue being pressed into the roof of the mouth. Whilst maintaining this pressure slowly open the mouth as wide as possible.   Repeat 5 times.

Benefits
This stretches the frenulum, the piece of tissues that helps anchor the tongue to the floor of the mouth.  This lock will strengthen the tongue and stimulate the head. 

Bramha Mudra

This involves moving the head in all directions in a slow controlled manner.  Start by turning the head to the left, then to the right, back to the centre, look up and then look down.  All four movements should take around a minute to complete.  Repeat 5 times.

Benfits
Tones the neck muscles, maintains neck mobility.  Said to decrease Vata in this region and is one of the preparatory practices recommended immediately before pranayama.

Cautions
Those with neck pain should only move in the pain-free range.  Those with inner ear problems or vertigo again move slowly, limiting or avoiding movements that aggravate. 

Yoga Therapy - Pranayama

Breathing techniques like Brahmari Black Bee) pranayama, can tone up the hypoglossal muscles. These muscles help with speech, swallowing and moving food around in your mouth. In a small study, individuals practising Bhramari were seen to have reduced snoring, indicating that air was moving more freely (15).

Pranayama will also help to re-calibrate the entire respiratory system. It will encourage longer, deeper breaths and more controlled exhalation. This not only helps to tone the muscles of respiration, particularly the diaphragm but also to activate the vagus nerve and parasympathetic system.  This is vital to help deal with excessive stress.

Ujayyi - Victorious Breath

Inhalation: Inhale through both the nostrils, gentle constricting the throat.  The movment of the breath should be audible as it passes through the throat.
Exhalation: Close the right nostril, exhale through the left

The exhale should be twice as long as the inhale. This can be hard to achieve when first starting.  So work well within your capacity and never strain. Each round should be steady and comfortable to perform.  If you become tired lay down in Shavasana.

Sheetali - Cooling/Hissing Breath

Technique
Inhalation: curling the tongue and protrude it out through the mouth and then draw air over it.
Exhalation: Relax the tongue and close the mouth.  Exhale through both the nostrils.

Exhalation should be double that of the inhale.

Benefits.
The careful positioning of the tongue can help build control and tone of it.  This is considered a cooling pranayama and is said to reduce excess heat in the body.

Bramari - The Black Bee

Technique
Inhalation:  through both nostrils
Exhalation: though both nostrils whilst constricting the glottis and make the humming sound (see video).

Exhalation should be double that of the inhale. 

Benefits
This humming pranayama is excellent to calm the mind and toning the muscles of the throat.  Its practice is ideally done at the end of other pranayama practices or before meditation.

Chanting

Simple Om chanting requires careful control of the vocal cords and breath. The recitation of mantra, when practised correctly, provides potentially an excellent way to tone the muscles of the oropharynx as well as of the respiratory system. It requires careful manipulation of the vocal cords and tongue to produce the precise sounds every mantra needs

Yoga Therapy - Combat Stress

Those with central sleep apnea in particular tend to be predisposed to heightened sympathetic tone in the daytime. They have elevated heart rate and blood pressure, and it is important to use yoga techniques such as pranayama to help down-regulate the sympathetic nervous system. Pranayama, or any other kind of routine that helps modulate sympathetic tone in a healthy way, can help a great deal and lead to better sleep.

Assess the individual and understand their unique needs.  Then decide how best to wind the system down and re-regulate.   

Remember in some cases, there may be a central and obstructive component called a mixed phenotype of their apnea.  A specialist should have helped identify this which can then better guide yoga therapy

Final Thoughts

Remember, sleep apnea has so many manifestations, and it has multiple causes. It's not just an anatomical issue. Therefore different therapeutic approaches may work for some but not for others.  Over time as we learn more about this syndrome and more research is conducted, we will better know how to manage it.  

References

  1. Capdevila, O.S., Kheirandish-Gozal, L., Dayyat, E. and Gozal, D., 2008. Pediatric obstructive sleep apnea: complications, management, and long-term outcomes. Proceedings of the American Thoracic Society, 5(2), pp.274-282
  2. Eckert, D.J., Jordan, A.S., Merchia, P. and Malhotra, A., 2007. CHEST Postgraduate Education Corner. CHEST, 131, pp.595-607.
  3. Horner, R.L., Hughes, S.W. and Malhotra, A., 2014. State-dependent and reflex drives to the upper airway: basic physiology with clinical implications. Journal of applied physiology, 116(3), pp.325-336.
  4. Kubin, L., 2016. Neural control of the upper airway: respiratory and state-dependent mechanisms. Comprehensive Physiology, 6(4), p.1801.
  5. Schwartz, A.R., Patil, S.P., Laffan, A.M., Polotsky, V., Schneider, H. and Smith, P.L., 2008. Obesity and obstructive sleep apnea: pathogenic mechanisms and therapeutic approaches. Proceedings of the American Thoracic Society, 5(2), pp.185-192.
  6. Weiss, J.W., Launois, S.H., Anand, A. and Garpestad, E., 1999. Cardiovascular morbidity in obstructive sleep apnea. Progress in cardiovascular diseases, 41(5), pp.367-376.
  7. Osman, A.M., Carter, S.G., Carberry, J.C. and Eckert, D.J., 2018. Obstructive sleep apnea: current perspectives. Nature and science of sleep, 10, p.21.
  8. Peppard, P.E., Young, T., Barnet, J.H., Palta, M., Hagen, E.W. and Hla, K.M., 2013. Increased prevalence of sleep-disordered breathing in adults. American journal of epidemiology, 177(9), pp.1006-1014.
  9. Victor, L.D., 1999. Obstructive sleep apnea. American family physician, 60(8), p.2279.
  10. Clavel, L., Rémy-Neris, S., Skalli, W., Rouch, P., Lespert, Y., Similowski, T., Sandoz, B. and Attali, V., 2020. Cervical spine hyperextension and altered posturo-respiratory coupling in patients with obstructive sleep apnea syndrome. Frontiers in medicine, 7, p.30.
  11. Piccin, C.F., Pozzebon, D., Scapini, F. and Corrêa, E.C.R., 2016. Craniocervical posture in patients with obstructive sleep apnea. International archives of otorhinolaryngology, 20, pp.189-195.
  12. Sökücü, O., Okşayan, R., Uyar, M., Ademci, K.E. and Üşümez, S., 2016. Relationship between head posture and the severity of obstructive sleep apnea. American Journal of Orthodontics and Dentofacial Orthopedics, 150(6), pp.945-949.
  13. Puhan, M.A., Suarez, A., Cascio, C.L., Zahn, A., Heitz, M. and Braendli, O., 2006. Didgeridoo playing as alternative treatment for obstructive sleep apnoea syndrome: randomised controlled trial. Bmj, 332(7536), pp.266-270.  
  14. Guimarães, K.C., Drager, L.F., Genta, P.R., Marcondes, B.F. and Lorenzi-Filho, G., 2009. Effects of oropharyngeal exercises on patients with moderate obstructive sleep apnea syndrome. American journal of respiratory and critical care medicine, 179(10), pp.962-966.
  15. Taneja, M.K., 2016. Bhramari (Shanmukhi Mudra) Pranayama in presbyacusis and dementia. Indian Journal of Otology, 22(3), p.145