Exercise Appears to Improve Sleep Apnea Symptoms (CME/CE)

Action Points

• Exercise was found to be an effective stand-alone treatment for obstructive sleep apnea (OSA) in a newly published meta-analysis, but more research will be needed to determine the mechanism behind the observed association.
• Note that the study suggests that exercise should be recommended as a potentially effective treatment strategy for reducing OSA symptoms, especially in patients who find CPAP and other treatments ineffective or who are noncompliant with these treatments.

Exercise was found to be an effective stand-alone treatment for obstructive sleep apnea (OSA) in a newly published meta-analysis, but more research will be needed to determine the mechanism behind the observed association, researchers say.

In the analysis of eight small studies with a total of 182 patients, both supervised and unsupervised exercise was associated with significant decreases in the apnea/hypopnea index (AHI) and improvements in other sleep measures, including the Epworth sleepiness scale (ESS), researcher Martina Mookadam, MD, of the Mayo Clinic, Scottsdale, Arizona, and colleagues wrote.

Their meta-analysis was published online ahead of print in the journal Respiratory Medicine.

"The reduction in OSA indices may need to be further explored via comparison of larger participant numbers, supervised and unsupervised exercise programs, frequency of treatment, treatment duration and exercise protocols," the team wrote. "Though lifestyle intervention, upper airway surgery, mandibular advancement, and CPAP [continuous positive airway pressure] have shown similar decreases in OSA indices, exercise programs as treatment reduce AHI and the underlying cause of OSA."

In an interview with MedPage Today, Mookadam said anecdotal observations of symptom improvement in OSA patients who were exercising for other reasons led to the meta-analysis.

"We noticed that a number of patients who began exercise programs for other conditions, such as hypertension or diabetes, showed improvements in their OSA symptoms which were confirmed when we went back and redid their polysonography," she said.

OSA severity is determined using the apnea/hypoxic index, based on the number of apnea or hypopnea events per hour of sleep, with severity categorized as mild ( AHI ≥5 to <15), moderate (AHI ≥15 to <30), and severe (AHI ≥30).

Exercise has been shown to greatly reduce the risk and severity of diseases associated with OSA, including diabetes, cardiovascular disease, hypertension, and obesity. Earlier research has also shown improvements in OSA symptoms linked to exercise, but these studies have been small, the researchers noted.

"It is not fully understood how exercise reduces OSA symptoms, but previous reviews have indicated that the impact of exercise on OSA is not related to reduction of body weight or BMI in both epidemiologic and experimental studies."

The meta-analysis included studies with pre- and post-exercise intervention measures of AHI in adult patients with OSA without other major comorbidities, including heart failure, COPD, and neuromuscular disorders.

The investigators' initial search of various research databases yielded more than 8,000 studies, but just eight met the criteria for inclusion. Seven of these studies compared mean AHI scores pre-and post-intervention for a control and experimental group, and one study measured the respiratory disturbance index (RDI) and was not included in the AHI meta-analysis.

Among the main findings:

• Exercise was associated with a reduction in AHI after treatment (unstandardized mean difference [USMD], -0.536, 95% CI -0.865 to -0.206, I² = 20%);
• A total of 4 studies compared mean ESS scores pre- and post-intervention for a control group and experimental group. Exercise was associated with having a lower decrease in the total ESS after treatment (USMD, -1.246, 95% CI -2.397 to -0.0953, I² = 0%);
• A total of 4 studies compared mean BMI scores pre- and post-intervention for a control group and experimental group. Exercise was not found to have a statistically significant effect on BMI (USMD, -0.0473, 95% CI -0.0375 to 0.280, I² = 0%); and
• Relative risks (RR) and odds ratios (OR) showed decreases in AHI (OR; 72.33, 95% CI 27.906 to 187.491 and RR; 7.294, 95% CI 4.072 to 13.065) in patients who exercised.

"Our meta-analysis represents the most recent literature on OSA and exercise; however, our study selection was restricted by our inclusion and exclusion criteria and was not exhaustively inclusive of all articles or studies of OSA, OSA and exercise, and OSA management."

Despite this limitation, Mookadam said exercise should be recommended as a potentially effective treatment strategy for reducing OSA symptoms, especially in patients who find CPAP and other treatments ineffective or who are noncompliant with these treatments.

"The beauty of exercise is that it does so many good things," she said. "Exercise decreases cardiovascular risk, and it helps with hypertension, diabetes, depression, and many other conditions."

She said the team hopes to conduct larger studies examining the mechanism or mechanisms that explain how exercise improves sleep apnea symptoms. It has been suggested that exercise improves muscle tone or improves neurovascular derangements that happen over time in OSA patients.

"It does seem to be independent of weight loss," she said. "Most of our sleep apnea patients are overweight, but a significant number are not. There is definitely more going on here."

The investigators declared no relevant relationships with industry related to this research.

• Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco

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Exercise Appears to Improve Sleep Apnea Symptoms (CME/CE)