Effects of exercise training on sleep apnea: a meta-analysis

Impacts of conservative treatment on the clinical manifestations of obstructive sleep apnea-systematic review and meta-analysis

INTRODUCTION

Obstructive sleep apnea (OSA) is a chronic disease with a high populational prevalence that is characterized as airway closure during sleep. Treatment is multidisciplinary and varies according to each case. Continuous positive airway pressure (CPAP), oral appliances, and surgery are the primary therapeutic options. Non-invasive conservative treatments such as sleep hygiene, positional therapy, physical exercises, and weight loss aim to reduce the worsening of the disease while being complementary to the invasive primary treatment.

OBJECTIVE

To analyze the impact of non-invasive conservative therapies on the clinical manifestations of OSA syndrome (OSA), compared with other interventions.

METHOD

This was a systematic review with meta-analysis. The searches were performed without filters for the time period, type of publication, or language. Randomized clinical trials on subjects over 18 years of age diagnosed with untreated OSA were included. Responses to non-invasive conservative treatment were compared with responses to the primary intervention. Primary outcomes were assessed using the Epworth Sleepiness Scale and/or Functional Outcomes of Sleep Questionnaire (FOSQ).

RESULTS

A total of eight studies were included in the review. The heterogeneity of the effect was estimated at 89.77%. Six studies compared conservative treatment with CPAP, one with oral appliances, and one with oropharyngeal exercises. Using the Epworth Sleepiness Scale measurements, the standardized difference in the estimated means, based on the random-effects model, was 0.457 (95% CI (1.082 to 0.169)) and the mean result did not differ significantly from zero (z = 1.43; p = 0.153). The conservative therapies assessed in this study improved the subjective quality of sleep, although the post-treatment ESE scores did not show significant results. The reduction in AHI and better outcomes in the evaluated domains, as well as in cognition and mood, were superior in the groups that received CPAP and IOD.

CONCLUSION

The most commonly used treatments of choice for OSA are invasive, including the use of CPAP, oral appliances, and surgeries, being the most utilized options. This study demonstrated that non-invasive conservative treatments, such as sleep hygiene, yield results as effective as invasive treatments. Further studies are needed to confirm this result and to predict whether invasive treatment can be used as the primary treatment or only as a supplement.

Unfolding the role of exercise in the management of sleep disorders

Sleep disorders are prevalent among the general population and even more in individuals suffering from chronic diseases. Recent data reveal promising effects of physical exercise as a non-pharmacological approach for improving sleep and managing various sleep disorders. However, more studies with proper design and methodology should be conducted in the future to obtain a clearer understanding of the subject. The role of exercise in preventing and improving sleep disorders is probably much higher than what is currently exploited. To fully exploit the potential benefit of physical activity on sleep disorders in the future, it is necessary to identify the relevant tools to assess sleep-wake disorders and establish specific exercise protocols tailored to different sleep disorders. The present manuscript aims to review the literature on the use of exercise in managing selected sleep disorders. Regular exercise, including short-term aerobic activity, resistance training, and mind-body exercises, can effectively improve sleep quality, particularly in cases of insomnia and sleep-disordered breathing. Additionally, increasing evidence supports the effectiveness of aerobic and strength training, and body-mind exercises such as yoga in managing sleep-related movement disorders. Exercise can be a safe, affordable, and efficient tool in enhancing sleep quality and improving sleep disorders. Per se, regular exercise could play an adjuvant role alongside with established therapies, or a valid alternative when the pharmacological approach is limited by side effects, interactions, or inefficacy. More research is needed to define how exercise affects the physiology of sleep, and consequently how to use exercise in patients with sleep disorders.

Sleep, psychological health, and physical activity level in patients with hypertension

The aim of this study was to compare sleep, daytime sleepiness, and psychological health in physically active versus inactive patients with hypertension. A cross-sectional design included thirty-seven participants (ACTIVE, n = 15; INACTIVE, n = 22). Sleep was assessed by polysomnography, the Pittsburgh Sleep Quality Index (PSQI) and a one-week daily sleep diary. The sleepiness was assessed with the Epworth Sleepiness Scale and the psychological health was assessed with the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI) and Profile of Mood States (POMS). Habitual physical activity was assessed with 7 day-step counts recorded by a pedometer and questionnaire. Significantly lower PSQI score (mean ± S.D.; 7.3 ± 3.4 vs 10.1 ± 3.6) and daytime sleepiness (8.7 ± 4.5 vs. 11.9 ± 4.4) were found in the physically active versus inactive participants, respectively. In addition, higher PSQI-total sleep time (6.9 ± 1.3 vs 5.6 ± 1.1) and vigor/activity (19.7 ± 3.9 vs 16.0 ± 3.9), and lower depressed mood on the POMS scale (8.2 ± 7.9 vs 13.8 ± 10.0) and lower POMS total mood disturbance (21.0 ± 27.0 vs 43.5 ± 32.5) were observed in the active participants compared with the inactive participants. Combining data across both groups, leisure time sport participation correlated negatively with PSQI (r = -0.35; p < 0.05) and BDI (r = -0.42; p < 0.05), and positively with POMS-vigor/activity (r = 0.43; p < 0.05). The results showed regular physical activity was associated with better sleep and psychological health in patients with hypertension.

Obstructive sleep apnoea in obesity: A review

Obstructive sleep apnea is a common comorbidity that occurs in individuals with obesity. It classically manifests with excessive daytime sleepiness, resulting in reduced quality of life, workplace productivity, and an increased risk of motor vehicle accidents. Weight gain plays an important role in its pathogenesis through worsening upper airway collapsibility, and current treatment options are targeted towards mechanically overcoming upper airway obstruction and weight loss. Continuous positive airway pressure therapy remains the most widely prescribed treatment for obstructive sleep apnea but poor tolerance is a common barrier to effective treatment. Sustainable weight loss is an important treatment option but can be difficult to achieve without bariatric surgery. The recent advances in incretin-based pharmacotherapies represent a promising avenue not only in achieving long-term weight loss but also in treating obstructive sleep apnoea and alleviating the burden of its symptoms and comorbidities.

A Pilot Randomized Trial of Combined Cognitive-Behavioral Therapy and Exercise Training Versus Exercise Training Alone for the Management of Chronic Insomnia in Obstructive Sleep Apnea

Insomnia treatment among individuals with comorbid insomnia and obstructive sleep apnea is suboptimal. In a pilot randomized controlled trial, 19 individuals with comorbid insomnia and obstructive sleep apnea were allocated to one of two arms: EX + EX, consisting of two 8-week phases of exercise training (EX), or RE + CBTiEX, encompassing 8 weeks of relaxation training (RE) followed by 8 weeks of combined cognitive-behavioral therapy and exercise (CBTiEX). Outcomes included Insomnia Severity Index (ISI), polysomnography, and cardiorespiratory fitness measures. A mixed-model analysis of variance revealed a Group × Time interaction on peak oxygen consumption change, F(1, 14) = 10.1, p = .007, and EX increased peak oxygen consumption (p = .03, g' = -0.41) and reduced ISI (p = .001, g' = 0.82) compared with RE (p = .49, g = 0.16) post-8 weeks. Post-16 weeks, there was a significant Group × Time interaction (p = .014) driven by RE + CBTiEX yielding a larger improvement in ISI (p = .023, g' = 1.48) than EX + EX (p = .88, g' < 0.1). Objective sleep was unchanged. This study showed promising effects of regular EX alone and combined with cognitive-behavioral therapy for insomnia on ISI in comorbid insomnia and obstructive sleep apnea.

Home-Based Aerobic Interval Training Combined with Resistance Training Improved Daytime Dysfunction in Adults with Obesity and Sleep-Disordered Breathing

Introduction  There have been many barriers to exercising at a gym due to the coronavirus disease 2019 (COVID-19) pandemic worldwide. Home-based aerobic interval training (AIT) combined with resistance training (RT) may be helpful for obese adults with sleep-disordered breathing (SDB) to overcome those barriers and improve their subjective sleep disorders. Thus, the present study aimed to examine the effects of home-based AIT combined with RT on subjective sleep disorders in obese adults with SDB. Material and Methods  This study has a one-group pretest-posttest design. Twenty-one adults with obesity and SDB were assigned to perform 8 weeks of AIT combined with RT. Subjective sleep disorder variables including the Pittsburgh Sleep Quality Index (PSQI), Berlin Questionnaire, and Epworth Sleepiness Scale were defined as primary outcomes. Anthropometric variables, physical fitness components, and blood biomarkers were assigned as secondary outcomes. All outcome measurements were examined at baseline and after 8 weeks of training. Results  Daytime dysfunction of PSQI was significantly improved after 8 weeks of the exercise program ( p  < 0.05). Upper and lower chest expansion and estimated maximum oxygen consumption were significantly increased after 8 weeks of the exercise program (all p  < 0.05). None of the blood biomarkers changed after 8 weeks of training. Conclusion  This study suggests that home-based AIT combined with RT effectively alleviates daytime dysfunction and seems to be more helpful in improving global PSQI in adults with obesity. Future studies with a larger sample size, under a controlled trial are recommended to prove the benefits of the exercise program.

The effects of exercise programs on sleep architecture in obstructive sleep apnea: a meta-analysis of randomized controlled trials

OBJECTIVES

Exercise is an effective intervention for obstructive sleep apnea (OSA). However, the effects of exercise on objective sleep architecture in patients with OSA remain unknown. This meta-analysis aimed to collect data from randomized controlled trials of exercise interventions in patients with OSA, with a specific focus on objective sleep parameters derived from polysomnography.

METHODS

Randomized control trials that targeted patients with OSA aged >18 years, measured sleep using polysomnography after exercise programs, and reported the proportion of sleep stages were included for meta-analysis. Bias was assessed using the revised Cochrane risk-of-bias tool and funnel plots. The random effects model was applied.

RESULTS

Six studies with a total of 236 patients were included in the meta-analysis. There were no significant differences in the total sleep time (TST), sleep efficiency, sleep onset latency, stage N1 sleep, or rapid eye movement sleep between the exercise and control groups. Participation in an exercise program lasting >12 weeks significantly decreased stage N2 and increased stage N3 sleep as observed in the subgroup analysis. Although this tendency did not reach statistical significance in the total-group analysis, it was significant after excluding the possible confounding effects of heart disease.

CONCLUSIONS

The exercise program decreased N2 and increased N3 proportions over the TST among patients with OSA, which may correspond to subjective sleep quality. The beneficial effects were significant when the program lasted >12 weeks and after excluding the confounding effects of heart disease. Exercise program duration should be considered when providing clinical advice.

Weight loss and lifestyle intervention for cardiorespiratory fitness in obstructive sleep apnea: The INTERAPNEA trial

INTRODUCTION

Although recent trials have shown benefits of weight loss and lifestyle interventions on obstructive sleep apnea (OSA) severity and comorbidities, the effect of these interventions on cardiorespiratory fitness (CRF) remains unknown. This study aimed to investigate the effects of an interdisciplinary weight loss and lifestyle intervention on CRF and self-reported physical fitness in adults with OSA.

METHODS

Eighty-nine men aged 18-65 years with moderate-to-severe OSA and a body mass index ≥25 kg/m2 were randomly assigned to a usual-care group or an 8-week interdisciplinary weight loss and lifestyle intervention. CRF was assessed through the 2-km walking test, and the International Fitness Scale (IFIS) was used to assess self-reported physical fitness.

RESULTS

As compared with usual-care, the intervention group had greater improvements at intervention endpoint in objective CRF (6% reduction in 2-km walking test total time, mean between-group difference, -1.7 min; 95% confidence interval, -2.3 to -1.1), and self-reported overall physical fitness (18% increase in IFIS total score, mean between-group difference, 2.3; 95% CI 1.2 to 3.3). At 6 months after intervention, the intervention group also had greater improvements in both 2-km walking test total time (10% reduction) and IFIS total score (22% increase), with mean between-group differences of -2.5 (CI 95%, -3.1 to -1.8) and 3.0 (CI 95%, 1.8 to 4.1), respectively.

CONCLUSIONS

An 8-week interdisciplinary weight loss and lifestyle intervention resulted in significant and sustainable improvements in CRF and self-reported physical fitness in men with overweight/obesity and moderate-to-severe OSA.

STUDY REGISTRATION

ClinicalTrials.gov registration (NCT03851653).

Effects of respiratory exercises in sleep bruxism and associated obstructive sleep apnea: a double-blind, placebo-controlled randomized clinical trial

PURPOSE

The aim of this study is to assess the effects of respiratory exercises (inspiratory and expiratory) in individuals with sleep bruxism (SB) and associated obstructive sleep apnea (OSA).

METHODS

This is a double-blind, placebo-controlled randomized clinical trial including individuals with SB and associated respiratory events in OSA. Respiratory physical therapy was performed using inspiratory (Threshold® IMT), expiratory (Threshold® PEP) muscle training, and compared with a placebo group. A total of 30 daily respiratory cycles (inspiration and expiration) were performed five times a week for 12 weeks. Individuals were reassessed at two times, at baseline (T1) and after 12 weeks of training (T2) by means of the Pittsburgh Sleep Quality Index and Polysomnography.

RESULTS

Awakening was significantly different (p ≤ 0.05) between the inspiratory group and placebo 12 weeks after respiratory physical therapy. The number of contractions of the masseter muscle differed between the inspiratory, expiratory, and placebo groups (p ≤ 0.05).

CONCLUSION

Respiratory physical therapy for OSA improved awaking levels in 80 and 67% of the number of masseter muscle contractions, when compared to placebo.

TRIAL REGISTRATION

Brazilian Registry of Clinical Trials (No. RBR-9F6JKM).

Effects of combined exercise training with sleep education in older adults with obstructive sleep apnea: protocol for a randomized clinical trial

Background

Obstructive sleep apnea (OSA) is a common disorder that affects approximately 1 billion people worldwide. Advanced age is a significant risk factor. Various treatment options have been explored to reduce the severity of OSA symptoms and physical exercise has emerged as a potential alternative therapy. Therefore, this study aims to investigate the effects of a combined exercise program with sleep education on sleep quality and on the severity of OSA in older adults.

Methods

This is a randomized clinical trial with two parallel groups that will involve individuals of both genders aged between 60 and 79 years who have an apnea-hypopnea index (AHI) of more than 15 events per hour and who have not received or are currently undergoing treatment for OSA. Older adults who have engaged in regular exercise in the last six months and individuals with contraindications to exercise will be excluded. The study will assess outcomes related to OSA, including AHI, oxygen desaturation index, minimum and mean oxyhemoglobin saturation, sleep efficiency, sleep latency, and the type of respiratory events. Additionally, sleep quality-related outcomes, daytime sleepiness, physical activity, physical fitness, aerobic capacity, cognitive status, anthropometric measures, and health-related quality of life will be analyzed. Participants will be randomized to two groups: a combined exercise group (involving both resistance and aerobic training) with sleep education, and a control group that will receive only educational recommendations for managing OSA. The intervention will last 12 weeks and will consist of three sessions per week, totaling 36 exercise sessions. Sample size calculation indicates a minimum number of 36 participants.

Discussion

If the hypothesis is confirmed, this clinical trial will indicate an effective non-pharmacological intervention for treating OSA in older adults. This intervention could be used as an adjunct to existing approaches designed to improve OSA management.

Clinical trail registration

Brazil Clinical Trials Registry (ReBEC), identifier RBR-9hk6pgz.

Novel Approaches to Sleep Apnea in Heart Failure

Sleep apnea is a serious comorbid condition affecting patients with heart failure. Present in 50% to 75% of heart failure patients, it is often underrecognized, underdiagnosed, and undertreated. Patients with sleep apnea and heart failure are at increased risk of adverse cardiovascular events and sudden death. Treatment of sleep apnea has shown mixed results in reduction of adverse outcomes by sleep apnea type and intervention strategy. Evolving home-based technologies and device therapies present an exciting frontier for patients with sleep apnea and heart failure and an opportunity to improve outcomes. This article reviews novel approaches to sleep apnea in heart failure.

Lower handgrip strength in short-sleeper individuals with obstructive sleep apnea

BACKGROUND

Obstructive sleep apnea (OSA) is a frequently observed and remarkably incapacitating disorder worldwide. As a multisystem disorder, OSA has been linked to a plethora of clinical parameters though physical parameters like muscle strength have been scantily studied. Hand grip strength (HGS) is a practical marker of physical function that has been associated with mortality and an array of clinical outcomes as well as physiological parameters like sleep duration. A few seminal studies have observed no link between HGS and OSA severity while no studies evaluated the relationship between objectively determined sleep duration and HGS in OSA.

OBJECTIVE

The present study aimed to evaluate the HGS indices among both OSA severity groups and objectively determined sleep duration groups in OSA.

METHODS

111 treatment-naïve mostly middle-aged individuals with OSA (86 males) were recruited in a tertiary sleep center. Three OSA severity groups were determined by the Apnea-Hypopnea Index while three sleep duration groups were objectively determined by Total Sleep Time (TST). Dominant and non-dominant maximum and average HGS were calculated using a digital hand dynamometer.

RESULTS

Short-sleeper individuals with OSA were found to have lower HGS indices than intermediate or sufficient sleepers with OSA while no differences in HGS indices among OSA severity groups were observed. All HGS indices correlated with TST.

CONCLUSIONS

Future insights can be gleaned from the present results regarding the conceivably transdiagnostic relationship between sleep duration and HGS as well as the potential use of HGS as a marker in OSA.

Modified oropharyngeal muscle training and scientific vocalization are effective in treating mild-to-moderate obstructive sleep apnea hypoventilation syndrome in adults

BACKGROUND

Obstructive Sleep Apnea-hypopnea Syndrome (OSAHS) has become a major public health challenge globally. Most patients have a concomitant voice disorder. The existing treatment methods have problems.Aims/Objectives: This study investigates the therapeutic effect of adding scientific vocalization to oropharyngeal muscle training on OSAHS patients.

MATERIAL AND METHODS

A total of 30 patients were selected from September 2020 to October 2022. They underwent overnight polysomnography (PSG) and were identified as having mild to moderate obstructive sleep apnea hypoventilation syndrome. They were then chosen for a three-month period of modified oropharyngeal muscle training combined with scientific vocalization.

RESULTS

Out of the 30 selected patients, 26 patients completed the training. Results showed a significant changes in multiple sleep-related indicators. he clinical outcomes were as follows: 7 cases were cured, 13 cases were effective, and 6 cases were ineffective. The overall effective rate was 76.92%.

CONCLUSIONS AND SIGNIFICANCE

The combination of oropharyngeal muscle training and scientific vocalization for the treatment of mild to moderate OSAHS in adults significantly improves several measures used in the treatment of the condition. The method is easy to learn, effective, safe to use, and affordable. It provides more options for the treatment of OSAHS.

Obstructive Sleep Apnea and a Comprehensive Remotely Supervised Rehabilitation Program: Protocol for a Randomized Controlled Trial

BACKGROUND

Obstructive sleep apnea (OSA) is characterized by recurrent, intermittent partial or complete obstruction of the upper respiratory tract during sleep, which negatively affects the patient's daily quality of life (QoL). Middle-aged and older men who smoke and have obesity are most at risk. Even though the use of continuous positive airway pressure (CPAP) during sleep remains the gold standard treatment, various rehabilitation methods, such as exercise, respiratory therapy, myofunctional therapy, and nutritional lifestyle interventions, also appear to be effective. Moreover, it is increasingly recommended to use alternative or additional therapy options in combination with CPAP therapy.

OBJECTIVE

This study aims to evaluate if a comprehensive home-based, remotely supervised rehabilitation program (tele-RHB), in combination with standard therapy, can improve OSA severity by decreasing the apnea-hypopnea index (AHI); improve objective parameters of polysomnographic, spirometric, anthropometric, and body composition examinations; improve lipid profile, maximal mouth pressure, and functional capacity tests; and enhance the subjective perception of QoL, as well as daytime sleepiness in male participants with moderate to severe OSA. Our hypothesis is that a combination of the tele-RHB program and CPAP therapy will be more effective by improving OSA severity and the abovementioned parameters.

METHODS

This randomized controlled trial aims to recruit 50 male participants between the ages of 30 and 60 years with newly diagnosed moderate to severe OSA. Participants will be randomized 1:1, either to a 12-week tele-RHB program along with CPAP therapy or to CPAP therapy alone. After the completion of the intervention, the participants will be invited to complete a 1-year follow-up. The primary outcomes will be the polysomnographic value of AHI, Epworth Sleepiness Scale score, 36-Item Short Form Health Survey (SF-36) score, percentage of body fat, 6-minute walk test distance covered, as well as maximal inspiratory and expiratory mouth pressure values. Secondary outcomes will include polysomnographic values of oxygen desaturation index, supine AHI, total sleep time, average heart rate, mean oxygen saturation, and the percentage of time with oxygen saturation below 90%; anthropometric measurements of neck, waist, and hip circumference; BMI values; forced vital capacity; forced expiratory volume in 1 second; World Health Organization's tool to measure QoL (WHOQOL-BREF) score; and lipid profile values.

RESULTS

Study recruitment began on October 25, 2021, and the estimated study completion date is December 2024. Analyses will be performed to examine whether the combination of the tele-RHB program and CPAP therapy will be more effective in the reduction of OSA severity and improvement of QoL, body composition and circumferences, exercise tolerance, lipid profile, as well as respiratory muscle and lung function, compared to CPAP therapy alone.

CONCLUSIONS

The study will evaluate the effect of a comprehensive tele-RHB program on selected parameters mentioned above in male participants. The results of this intervention could help the further development of novel additional therapeutic home-based options for OSA.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04759456; https://clinicaltrials.gov/ct2/show/NCT04759456.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47460.

Would the Actigraph Always be Sufficient for Sleep Analysis in Exercise-Based Studies? A Case Report of Negative Response of Sleep to Exercise

Introduction  Sleep deprivation is common after coronary artery bypass grafting (CABG). It is mostly managed well by exercise. The number of reported post-CABG cases that respond negatively to exercise is scanty. The etiology is usually associated with the underlying sleep pathology, and how it responds to exercise. Cases with undiagnosed central sleep apnea post CABG have not been reported before. Case description  A medically stable male patient, 63 years old, hypertensive, but not diabetic, had entered coronary artery bypass grafting (CABG) 8 weeks before attending the outpatient cardiac rehabilitation unit and was referred for a cardiac rehabilitation program at this time. He entered a study in the cardiac rehabilitation center utilizing either aerobic or combined aerobic and resistance training for 10 weeks to improve sleep architecture and functional capacity post-CABG. After randomization, he entered the group doing combined aerobic and resistance exercises. All of the patients in this group improved except him, his sleep quality worsened, but his functional capacity improved. After a complete analysis of sleep on polysomnography, it was revealed that the patient had central sleep apnea that was mostly worsened by resistance training. The patient was withdrawn from the study by the 8th week, and his sleep condition improved gradually. After then, he was asked to attend the cardiac rehabilitation center again to share in aerobic exercise, having evidence that central sleep apnea does not respond negatively to this form of training. After 12 months of follow-up, the patient still shows no signs of sleep deprivation. Conclusion  Sleep deprivation is prevalent in post-CABG patients, but with different presentations and it can generally improve by exercise. Identification of the underlying cause of the sleeping difficulty is a cornerstone of targeted treatment.

Exercise training and depression and anxiety in musculoskeletal pain patients: a meta-analysis of randomized control trials

BACKGROUND

Depression and anxiety in patients with musculoskeletal pain harm health and exercise can be effective in improving the condition of these patients. This study was aimed at systematically reviewing and providing a meta-analysis of the effect of exercise training on improving depression and anxiety in patients with musculoskeletal pain.

METHODS

The search was done in three databases including PubMed, the Cochrane Library, and Google Scholar up to August 2021. For each of the studies included in the meta-analysis, the mean, standard deviation, and sample size were extracted in the post-test, and the effect size was calculated. Publication bias and heterogeneity were assessed in studies at the end of the analysis.

RESULTS

Nineteen randomized control trials were included in the meta-analysis. Exercise training has a positive effect on depression in patients with musculoskeletal pain, so exercise reduces depression and Hedges' g was equal to -0.21, with confidence intervals of -0.40, -0.02. Exercise training has a positive effect on anxiety in patients with musculoskeletal pain, so exercise reduces anxiety and Hedges' g was equal to -0.63, with confidence intervals of -1.08, -0.19.

CONCLUSIONS

It was found that exercise training is effective in improving depression and anxiety in patients with musculoskeletal pain and therefore this treatment should be given more attention from clinical specialists.

Exercise as an Adjunct Treatment to Cognitive Behavior Therapy for Insomnia

The question that guided this review is whether exercise can add to the improvements in insomnia in patients treated with cognitive behavioral therapy for insomnia (CBT-I). CBT-I has long been recommended as the first-line treatment of chronic insomnia. However, CBT-I is not effective for as many as 30% to 40% of patients with insomnia. There is accumulating evidence for positive effects on insomnia following acute and chronic exercise. However, to the best of our knowledge, the effects of CBT-I combined with exercise have not been explored in clinical trials. In this article, we develop a rationale for combining CBT-I with exercise.

An individualized mobile health intervention to promote physical activity in adults with obstructive sleep apnea: An intervention mapping approach

Objective

Combining continuous positive airway pressure with physical activity (PA) might be a promising strategy to treat obstructive sleep apnea (OSA). This article describes how intervention mapping (IM) can guide the development, content, and mechanisms of action of a mobile application to promote PA in adults with OSA.

Methods

To develop the program, the IM approach was followed. This article presents the first three steps of IM to develop a mixed intervention (with interventionists and a digital application) aiming to: (1) assess patients' health problems and needs in a literature review to determine their expectations and perceived facilitators and barriers to PA behavior change and thus select the determinants of behavior; (2) formulate the expected intervention outcomes and objectives to be met to achieve the overall program goals; and (3) select and implement the behavior change techniques (BCTs) to achieve the change objectives.

Results

The literature review identified the relevant determinants (e.g., self-efficacy, coping, planning, and habit) of PA behavior using the health action process approach and multiprocess action control. These results were used to specify the program outcomes for PA adapted to physical, psychological, and social parameters. Overall, 11 performance objectives and 30 change objectives were defined. Lastly, BCTs and practical applications were identified.

Conclusions

The study provides a theoretical and methodological basis for researchers and practitioners given the current paucity of evidence-based PA interventions for adults with OSA. It addresses the lack of BCTs (framing and prompts/cue techniques) and meaningful behavioral determinants (identity and habit) in most interventions.

Exercise and obstructive sleep apnoea: a 24-week follow-up study

Objective

Report on long-term follow-up results in the apnoea hypopnea index (AHI) and self-reported daytime sleepiness in participants with moderate to severe obstructive sleep apnoea at 12 weeks after completion of a high-intensity exercise training or control intervention.

Methods

Twenty-six participants with obstructive sleep apnoea (body mass index (BMI) 37 (36-39) kg/m, age 52 (49-55) years, apnoea-hypopnoea index 40.5 (31.3-50.2) events/hour), randomised to either 12 weeks of supervised high-intensity interval training (HIIT) (4×4 min of treadmill running or walking at 90%-95% of maximal heart rate) or no intervention (control), underwent a sleep evaluation follow-up 24 weeks after intervention initiation. Respiratory measures during sleep were registered at baseline, 12 weeks (postintervention) and 24 weeks (long-term follow-up).

Results

At the 24-week follow-up, there were no statistically significant differences between the groups in the AHI (HIIT 30.7 (17.2-44.1) and control 38.7 (22.8-54.5) events/hour), Epworth score (HIIT 7.0 (4.7-9.3) and control 5.5 (3.9-7.0)), mean oxygen saturation (HIIT 93.2 (92.5-93.9) and control 92.0 (91.1-92.8)) or oxygen desaturation events (HIIT 32.9 (20.4-45.4) and control 44.3 (27.3-61.3) n/hour). BMI remained unchanged from the baseline in both groups. In the HIIT group, only two participants reported having continued with HIIT at 24 weeks.

Conclusion

The effect of 12 weeks of supervised high-intensity exercise training on AHI and self-reported daytime sleepiness was lost at the 24-week follow-up.

Effects of Exercise on Patients with Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis

With exercise being more frequently utilized in treatment for obstructive sleep apnea (OSA), a systematic review of the intervention efficacy of exercise on OSA is necessary. PubMed, EBSCO, Web of Science, VIP, and CNKI databases were searched to collect randomized controlled trials (RCTs) of exercise applied to OSA from January 2000 to January 2022. The literature screening, data extraction, and risk of bias assessment of included studies were conducted independently by two reviewers. Meta-analysis was then performed using Rev Man 5.4 software. A total of 9 RCTs were included, including 444 patients. Compared with the control group, exercise made an improvement in apnea-hypopnea index (AHI) [MD = -6.65, 95% CI (-7.77, -5.53), p < 0.00001], minimum oxygen saturation (SaO_2min%) [MD = 1.67, 95% CI (0.82, 2.52), p = 0.0001], peak oxygen uptake (VO_2peak) [SMD = 0.54, 95% CI (0.31, 0.78), p < 0.00001], Pittsburgh sleep quality index (PSQI) [MD = -2.08, 95% CI (-3.95, -0.21), p = 0.03], and Epworth Sleepiness Scale (ESS) values [MD = -1.64, 95% CI, (-3.07, -0.22), p = 0.02]. However, there were no significant changes in body mass index (BMI). As for the results of subgroup analysis, aerobic exercise combined with resistance exercise [MD = -7.36, 95% CI (-8.64, -6.08), p < 0.00001] had a better effect on AHI reduction than aerobic exercise alone [MD = -4.36, 95% CI (-6.67, -2.06), p = 0.0002]. This systematic review demonstrates that exercise reduces the severity of OSA with no changes in BMI, and the effect of aerobic exercise combined with resistance training is better than aerobic exercise alone in AHI reduction. Exercise also improves cardiopulmonary fitness, sleep quality, and excessive daytime sleepiness.

Relationships between sleep efficiency and lifestyle evaluated by objective sleep assessment: SLeep Epidemiology Project at University of Tsukuba

Objectively measured sleep efficiency has recently been shown to be associated with health problems. Although several factors have previously been reported to be associated with sleep efficiency, most of these studies were conducted on older or younger adults, and the factors associated with sleep efficiency in healthy workers remain unknown. The aim of this study was to investigate the relationship between sleep efficiency and lifestyle factors using sleep measurement data recorded by an activity meter worn by workers. In total, 693 workers (male, 43.6%; mean age, 42.7 ± 11.3 years) were recruited from five offices in 2017. Sleep was measured over the period of 1 week by actigraphy. Workers' attributes, lifestyle habits, and occupational stress were identified using a questionnaire, and the association of sleep efficiency with lifestyle, occupational stress, and attributes was explored by logistic regression analysis. A logistic regression analysis using attributes and occupational stress as adjustment variables revealed that "longer sleeping hours on weekends than on weekdays" [odds ratios (OR), 0.66; 95% confidence interval (CI), 0.47-0.94], "water ingestion at bedtime" [OR, 2.09; 95% CI, 1.28-3.41], and "smartphone use at bedtime" [OR, 1.90; 95% CI, 1.28-2.83] were associated with decreased sleep efficiency. This study found that lifestyle habits were associated with sleep efficiency among workers. It is necessary to verify whether intervention in these lifestyle habits would contribute to the improvement of sleep efficiency in future studies.

Asian Pacific Society of Cardiology Consensus Statements on the Diagnosis and Management of Obstructive Sleep Apnoea in Patients with Cardiovascular Disease

Obstructive sleep apnoea (OSA) is strongly associated with cardiovascular disease (CVD). However, evidence supporting this association in the Asian population is scarce. Given the differences in the epidemiology of CVD and cardiovascular risk factors, as well as differences in the availability of healthcare resources between Asian and Western countries, an Asian Pacific Society of Cardiology (APSC) working group developed consensus recommendations on the management of OSA in patients with CVD in the Asia-Pacific region. The APSC expert panel reviewed and appraised the available evidence using the Grading of Recommendations Assessment, Development, and Evaluation system. Consensus recommendations were developed and put to an online vote. Consensus was reached when 80% of votes for a given recommendation were in support of ‘agree’ or ‘neutral.’ The resulting statements provide guidance on the assessment and treatment of OSA in patients with CVD in the Asia-Pacific region. The APSC hopes for these recommendations to pave the way for screening, early diagnosis and treatment of OSA in the Asia-Pacific region.

Effects of exercise training on brain metabolism and cognitive functioning in sleep apnea

Impaired glucose metabolism reflects neuronal/synaptic dysfunction and cognitive function decline in patients with obstructive sleep apnea (OSA). The study investigated the extent to which exercise training (ET) improves cerebral metabolic glucose rate (CMRgl) and cognitive function in patients with OSA. Patients with moderate to severe OSA were randomly assigned to ET (3 times/week, n = 23) or no intervention (control, n = 24). Echocardiography and apolipoprotein ε4 (APOEε4) genotyping were obtained at baseline. Both groups underwent cardiopulmonary exercise testing, polysomnography, cognitive tests, brain magnetic resonance imaging, and ¹⁸F-fluoro-2-deoxy-d-Glucose positron emission tomography (¹⁸FDG-PET) at baseline and study end. Compared with control, exercise-trained group had improved exercise capacity, decreased apnea–hypopnea index (AHI), oxygen desaturation and arousal index; increased attention/executive functioning, increased CMRgl in the right frontal lobe (P < 0.05). After ET an inverse relationships occurred between CMRgl and obstructive AHI (r = − 0.43, P < 0.05) and apnea arousal index (r = − 0.53, P < 0.05), and between the changes in CMRgl and changes in mean O₂ saturation during sleep and non-rapid eye movement sleep (r = − 0.43, P < 0.05), desaturation during arousal (r = − 0.44, P < 0.05), and time to attention function testing (r = − 0.46, P < 0.05). ET improves OSA severity and CMRg in the frontal lobe, which helps explain the improvement in attention/executive functioning. Our study provides promising data that reinforce the growing idea that ET may be a valuable tool to prevent hypoxia associated with decreased brain metabolism and cognitive functioning in patients with moderate to severe OSA.

Trial registration: NCT02289625 (13/11/2014).

Sleep Quality: A Narrative Review on Nutrition, Stimulants, and Physical Activity as Important Factors

Sleep is a cyclically occurring, transient, and functional state that is controlled primarily by neurobiological processes. Sleep disorders and insomnia are increasingly being diagnosed at all ages. These are risk factors for depression, mental disorders, coronary heart disease, metabolic syndrome, and/or high blood pressure. A number of factors can negatively affect sleep quality, including the use of stimulants, stress, anxiety, and the use of electronic devices before sleep. A growing body of evidence suggests that nutrition, physical activity, and sleep hygiene can significantly affect the quality of sleep. The aim of this review was to discuss the factors that can affect sleep quality, such as nutrition, stimulants, and physical activity.

Management of Obstructive Sleep Apnea in Patients With Heart Failure

Sleep apnea is traditionally classified as obstructive sleep apnea (OSA), which occurs when the upper airway collapses due to the relaxation of oropharyngeal musculature, and central sleep apnea occurs when the brainstem cannot stimulate breathing. Most sleep apnea in patients with heart failure (HF) results from coexisting OSA and central sleep apnea (CSA), or complex sleep apnea syndrome. OSA and CSA are common in HF and can be involved in its progression by exposure to the heart to intermittent hypoxia, increased preload and afterload, activating sympathetic, and decreased vascular endothelial function. A majority of treatments have been investigated in patients with CSA and HF; however, less or short-term randomized trials demonstrated whether treating OSA in patients with HF could improve morbidity and mortality. OSA could directly influence the patient's recovery. This review will focus on past and present studies on the various therapies for OSA in patients with HF and summarize CSA treatment options for reasons of reference and completeness. More specifically, the treatment covered include surgical and non-surgical treatments and reported the positive and negative consequences for these treatment options, highlighting possible implications for clinical practice and future research directions.

Obstructive Sleep Apnea Syndrome: The Effect of Acute and Chronic Responses of Exercise

Obstructive Sleep Apnea Syndrome (OSAS) is a sleep disorder with high prevalence in general population, but alarmingly low in clinicians' differential diagnosis. We reviewed the literature on PubMed and Scopus from June 1980–2021 in order to describe the altered systematic pathophysiologic mechanisms in OSAS patients as well as to propose an exercise program for these patients. Exercise prevents a dysregulation of both daytime and nighttime cardiovascular autonomic function, reduces body weight, halts the onset and progress of insulin resistance, while it ameliorates excessive daytime sleepiness, cognitive decline, and mood disturbances, contributing to an overall greater sleep quality and quality of life.

OSA and cardiorespiratory fitness: a review

The effects of untreated obstructive sleep apnea (OSA) on cardiopulmonary function remain unclear. Cardiorespiratory fitness (CRF), commonly reflected by VO₂ max measured during cardiopulmonary exercise testing, has gained popularity in evaluating numerous cardiopulmonary conditions and may provide a novel means of identifying OSA patients with the most clinically significant disease. This emerging testing modality provides simultaneous assessment of respiratory and cardiovascular function with results helping uncover evidence of evolving pathology in either organ system. In this review, we highlight the current state of the literature in regard to OSA and CRF with a specific focus on changes in cardiovascular function that have been previously noted. While OSA does not appear to limit respiratory function during exercise, studies seem to suggest an abnormal cardiovascular exercise response in this population including decreased cardiac output, a blunted heart rate response (ie, chronotropic incompetence), and exaggerated blood pressure response. Surprisingly, despite these observed changes in the cardiovascular response to exercise, results involving VO₂ max in OSA remain inconclusive. This is reflected by VO₂ max studies involving middle-aged OSA patients showing both normal and reduced CRF. As prior studies have not extensively characterized oxygen desaturation burden, we propose that reductions in VO₂ max may exist in OSA patients with only the most significant disease (as reflected by nocturnal hypoxia). Further characterizing this relationship remains important as some research suggests that positive airway pressure therapy or aerobic exercise may improve CRF in patients with OSA. In conclusion, while it likely that severe OSA, via an abnormal cardiovascular response to exercise, is associated with decreased CRF, further study is clearly warranted to include determining if OSA with decreased CRF is associated with increased morbidity or mortality.

CITATION

Powell TA, Mysliwiec V, Brock MS, Morris MJ. OSA and cardiorespiratory fitness: a review. J Clin Sleep Med. 2022;18(1):279-288.

Myofunctional therapy for OSA: a meta-analysis

INTRODUCTION

Myofunctional therapy (MT) improves obstructive sleep apnea (OSA) in patients.

AREAS COVERED

We systematically reviewed publications to evaluate MT as a treatment for OSA. We identified relevant articles and performed a meta-analysis on apnea-hypopnea index (AHI) scores, lowest oxygen saturation (LSAT), and Epworth Sleepiness Scale (ESS). Search databases were retained as primary data sources with the search performed through 18 June 2021.

EXPERT OPINION

Fifteen studies with 237 patients provided OSA outcomes before and after MT, which were analyzed for this meta-analysis. The mean AHI scores decreased from 28.0 ± 16.2/h to 18.6 ± 13.1/h. The AHI standard mean difference (SMD) is -1.34 (large effect) [95% CI -0.84, -1.85], (P < 0.00001). LSAT (197 patients) improved from 83.18 ± 6.10% to 85.13 ± 7.01%. The LSAT SMD is 0.44 [95% CI 0.75, 0.12], (P < 0.007). Sleepiness measured via ESS (156 patients) demonstrated a decrease from 12.71 ± 5.73 to 8.78 ± 5.80. The ESS SMD is -1.0 [95% CI -0.50, -1.50], (P < 0.0001).

Effect of exercise training on body composition in patients with obstructive sleep apnea: a systematic review and meta-analysis

Reduction in adiposity is considered a cornerstone in the treatment of obstructive sleep apnea (OSA). Exercise training is one of the interventions used in the treatment of OSA. However, it remains unclear whether exercise training alleviates OSA by improving body composition. This study aimed to verify the effect of exercise training on body composition and the apnea-hypopnea index (AHI) in patients with OSA. This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered in PROSPERO. PubMed/Medline, Scopus, and Cochrane databases were used for systematic review. Analyses were performed using Review Manager software (version 5.3; R Foundation for Statistical Computing, Vienna, Austria). Exercise training significantly reduced body mass index (mean difference = -0.55 kg/m²; 95% CI = -0.95 to -0.15), body fat percentage (mean difference = -1.19%; 95% CI = -2.03 to -0.35), neck circumference (mean difference = -0.55 cm; 95% CI = -1.08 to -0.02), total body weight (mean difference = -2.13 kg; 95% CI = -4.30 to 0.04), and AHI -8.06 events/hour; 95% CI = -10.47 to -5.66). Although body composition was improved by exercise, this improvement was clinically small. Moreover, improvement in AHI by exercise may not be entirely due to improvements in adiposity. PROSPERO #: CRD42020210509.

The Biological and Motivational Effects of Aerobic Exercise With Virtual Reality

Purpose: There is no significant evidence of both biological and motivational effects between virtual reality exercises to traditional/conventional exercise. The aim of this study is to assess the biological and motivational effects of aerobic exercises with virtual reality and traditional exercise methods. Methods: 20 students participated as control and 60 students were divided randomly and equally into two groups, virtual reality exercise group (VRE) and traditional exercise group (TE). Two groups completed the exercise training. Tests were applied to the three groups at the beginning and in the end of the study. An activity monitor and pulse oximeter were used to measure energy expenditure during exercises. Results: After eight weeks, the data from pulse oximeter showed no statistical significance between the exercise groups. The active energy expenditure, PAL and step counts were statistically significant in TE group. There was a statistically significant increase in the sleep quality of the TE group (p = .000). There was no statistical significance among the anxiety scores of all groups. In the spring semester, there was a statistically significant increase in both VRE and TE groups compared to the fall semester (p < .05). Conclusion: The virtual reality exercises produce greater motivational effects, whereas traditional exercises bring greater physical improvements.

Physical activity and sleep: An updated umbrella review of the 2018 Physical Activity Guidelines Advisory Committee report

Physical activity (PA) is widely considered to improve sleep, but a comprehensive review of the research on this topic has not been performed. In this umbrella review, conducted initially for the 2018 Physical Activity Guidelines for Americans Advisory Committee and updated to reflect more recent research, we examined whether PA enhances sleep outcomes across the lifespan as well as among individuals with sleep disorders. Systematic reviews and meta-analyses were utilized to assess the evidence. We also examined dose-response considerations and whether the association between PA and sleep was moderated by various factors (e.g., timing, sociodemographic characteristics). We found strong evidence that both acute bouts of PA and regular PA improved sleep outcomes. Moderate evidence indicated that longer bouts of PA (both acute and regular) improved sleep, and that the effects of PA on sleep outcomes were generally preserved across adult age groups and sex. Finally, moderate evidence demonstrated that PA improved sleep in adults with insomnia symptoms or obstructive sleep apnea. Several important areas in need of future research were also identified. Overall, the review supported the claim that PA improves sleep, but highlighted gaps that need to be addressed to facilitate more widespread utilization of PA for improving sleep.

Improving Diabetes Self-management by Providing Continuous Positive Airway Pressure Treatment to Patients With Obstructive Sleep Apnea and Type 2 Diabetes: Qualitative Exploratory Interview Study

Background

There is a high prevalence of unexplained and unexplored obstructive sleep apnea (OSA) among patients with type 2 diabetes. The daytime symptoms of OSA include severe fatigue, cognitive problems, a decreased quality of life, and the reduced motivation to perform self-care. These symptoms impair the management of both diabetes and daily life. OSA may therefore have negative implications for diabetes self-management. Continuous positive airway pressure (CPAP) therapy is used to treat OSA. This treatment improves sleep quality, insulin resistance, and glycemic control. Although the benefits of using CPAP as a treatment for OSA are clear, the noncompliance rate is high, and the evidence for the perceived effect that CPAP treatment has on patients with type 2 diabetes and OSA is poor.

Objective

The purpose of this study was to analyze the impacts that comorbid diabetes and OSA have on the daily lives of older adults and to investigate the perceived effect that CPAP treatment for OSA has on patients’ diabetes self-management.

Methods

A qualitative follow-up study that involved in-depth, semistructured dyad interviews with couples before and after CPAP treatment (N=22) was conducted. Patients were recruited from the Hilleroed Hospital in Denmark and were all diagnosed with type 2 diabetes, aged >18 years, and had an apnea-hypopnea index of ≥15. All interviews were coded and analyzed via thematic analysis.

Results

The results showed that patients and their partners did not consider OSA to be a serious disorder, as they believed that OSA symptoms were similar to those of the process of aging. Patients experienced poor nocturnal sleep, took frequent daytime naps, exhibited reduced cognitive function, and had low levels of physical activity and a high-calorie diet. These factors negatively influenced their diabetes self-management. Despite the immediate benefit of CPAP treatment, most patients (11/12, 92%) faced technical challenges when using the CPAP device. Only the patients with severe OSA symptoms that affected their daily lives overcame the challenges of using the CPAP device and thereby improved their diabetes self-management. Patients with less severe symptoms rated CPAP-related challenges as more burdensome than their symptoms.

Conclusions

If used correctly, CPAP has the potential to significantly improve OSA, resulting in better sleep quality; improved physical activity; improved diet; and, in the end, better diabetes self-management. However, there are many barriers to undergoing CPAP treatment, and only few patients manage to overcome these barriers and comply with correct treatment.

Exercise capacity and comorbidities in patients with obstructive sleep apnea

STUDY OBJECTIVES

There are few studies evaluating (1) exercise capacity as assessed by the 6-minute walking distance (6MWD) test in large populations with obstructive sleep apnea (OSA); and (2) correlations with patients' comorbidities.

METHODS

This study presents a cluster analysis performed on the data of 1,228 patients. Severity of exercise limitation was defined on the basis of 6MWD.

RESULTS

Sixty-one percent showed exercise limitation (29.2% and 31.9% mild and severe exercise limitation, respectively). About 60% and 40% of patients were included in cluster 1 (CL1) and 2 (CL2), respectively. CL1 included younger patients with high prevalence of apneas, desaturations, and hypertension with better exercise tolerance. CL2 included older patients, all with chronic obstructive pulmonary disease (COPD), high prevalence of chronic respiratory failure (CRF), fewer apneas but severe mean desaturation, daytime hypoxemia, more severe exercise limitation, and exercise-induced desaturations. Only CRF and COPD significantly (P < .001) correlated with 6MWD < 85% of predicted value. 6MWD correlated positively with apnea-hypopnea index, oxygen desaturation index, nocturnal pulse oxygen saturation (SpO₂), resting arterial oxygen tension, mean SpO₂ on exercise, and negatively with age, body mass index, time spent during night with SpO₂ < 90%, mean nocturnal desaturation, arterial carbon dioxide tension, and number of comorbidities. Patients without severe comorbidities had higher exercise capacity than those with severe comorbidities, (P < .001). Exercise limitation was significantly worse in OSA severity class I when compared to other classes (P < .001).

CONCLUSIONS

A large number of patients with OSA experience exercise limitation. Older age, comorbidities such as COPD and CRF, OSA severity class I, severe mean nocturnal desaturation, and daytime hypoxemia are associated with worse exercise tolerance.

Physical activity is associated with reduced prevalence of self-reported obstructive sleep apnea in a large, general population cohort study

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is a common condition with significant symptoms and long-term adverse cognitive, mental health, vascular, and respiratory sequelae. Physical activity has been recognized as a key determinant for good health and has been associated with lower risk of these sequelae. We hypothesized that increased physical activity may be associated with a decreased prevalence of OSA.

METHODS

This cross-sectional study used baseline questionnaire data from the Ontario Health Study, a population-based cohort of residents of Ontario, Canada. Participants were adults who provided lifestyle, medical, socio-demographic, and sleep health information. The study sample consisted of 155,448 men (39.8%) and women (60.2%). The prevalence of physician-diagnosed OSA in this cohort was 6.9%. Logistic regression models were used to investigate the association of OSA with physical activity. Missing data were imputed using a multiple imputation by chained equation approach.

RESULTS

In multivariable analyses adjusted for potential confounding factors, increased total physical activity (metabolic equivalent [h/wk]) (odds ratio [OR] = .98, 95% confidence interval [CI] = .96 to 1.00), vigorous-intensity activity (OR = .98, 95% CI = .97 to 1.00), and walking (OR = .98, 95% CI = .96 to 1.00) were all associated (all P ≤ .045) with decreased prevalence of OSA. Moderate-intensity activity was not associated with risk of OSA (P = .826).

CONCLUSIONS

Independent of known risk factors for OSA, including body mass index, increased levels of physical activity, including walking, were associated with a prevalence of OSA. Our results highlight the importance of physical activity as a preventive measure for sleep apnea.

Comparison of the Effects of the Somatotype on the Physical Activity, Kinesiophobia, and Fatigue Levels of Obstructive Sleep Apnea Syndrome Patients and Healthy Individuals

Background:

We aimed to compare the physical activity, kinesiophobia, and fatigue levels of obstructive sleep apnea syndrome (OSAS) patients and healthy individuals in terms their somatotypes.

Methods:

A total of 165 individuals were enrolled referred to the Department of Chest Diseases Sleep Disorders Center Outpatient Clinic of Inonu University, Malatya, Turkey in 2018. The somatotype analysis was conducted using the Heath-Carter method, the fatigue level was assessed using the Functional Assessment of Chronic Illness Therapy (FACIT) fatigue scale, the kinesiophobia level was assessed using the Tampa Scale for Kinesiophobia (TSK), and the physical activity level was assessed using the International Physical Activity Questionnaire (IPAQ).

Results:

The results of the somatotype analysis revealed 3 different somatotypes in the healthy individuals and the OSAS patients’ mesomorph endomorph, endomorphic mesomorph, and mesomorphic endomorph. When comparing the somatotypes of the healthy individuals and the OSAS patients, statistically significant differences were found in the FACIT scores of the mesomorph endomorphs, the IPAQ and FACIT scores of the endomorphic mesomorphs, and the TSK and FACIT scores of the mesomorphic endomorphs (P<0.05).

Conclusion:

In all three somatotypes of the OSAS patients, the fatigue index scores were higher when compared to those of the healthy individuals. Moreover, when compared with the healthy individuals, the physical activity levels of the endomorphic mesomorphs with OSAS were low, while the kinesiophobia scores of the mesomorphic endomorphs with OSAS were high. Based on the results of this study, in OSAS patients, the endomorphic mesomorph somatotype could be a risk factor for reduced physical activity, while the mesomorphic endomorph somatotype could be a risk factor for increased kinesiophobia.

Longer-term effects of supervised physical activity on obstructive sleep apnea and subsequent health consequences

Although recent trials have shown promising benefits of exercise on obstructive sleep apnea (OSA) severity, the long-term effect of these interventions remains unknown. The aim of this study was to assess the effect of a 9-month community physical activity program on OSA severity one year later in free-living conditions. OSA patients, previously included in a 9-month randomized controlled trial (EXESAS study) evaluating the effects of supervised community physical activity on OSA severity, were invited to participate in an extra one-year observational study. Twenty-eight patients completed the study. Although OSA severity did not significantly worsen over the real-life period (9 to 21 months of follow-up), reductions in apnea-hypopnea index (AHI) and oxygen desaturation index were no longer significant after 21 months of follow-up compared to baseline (baseline AHI: 22.2 ± 6.3 /h; 9 months: 16.3 ± 6.4 /h; 21 months: 18.7 ± 8.9 /h). Benefits observed at 9 months on daytime sleepiness and mental health were preserved at 21 months, whereas cardiorespiratory fitness slightly decreased. Per-protocol analysis revealed that patients who stopped exercise at 9 months had worsened OSA severity compared to those who continued exercise during the real-life period (AHI: +9.0 ± 8.8 vs. -1.3 ± 5.3 /h; p < .01). In conclusion, our study suggested that improvements in OSA severity remain transient and is dependent on long-term adherence to regular physical activity practice.

An exploration of clinical, behavioral, and community factors associated with sleep duration and efficiency among middle-aged Black/African American smokers

STUDY OBJECTIVES

We examined the most important correlates to sleep duration and efficiency from a comprehensive array of multilevel factors.

METHODS

Baseline data from a cohort of 216 Black/African American smokers aged 40-65 years were examined. The binary outcomes of healthy sleep duration (6-8 h/night) and efficiency (≥85%) were ascertained from 14 consecutive days of actigraphy. Seventy-three independent variables from socio-demographic, individual behavioral, individual physiological, interpersonal, and community domains were assessed. Random survival forest decision trees were generated for each outcome, and variable importance metrics used to rank the predictive abilities of exposure variables. The 5 most predictive exposure variables for each outcome were entered into a regression model of the respective outcome (with age and sex).

RESULTS

Study participants (N = 216) had a mean age of 54.57 years (SD = 6.17) and 57% were male. Healthy sleep duration was achieved by 56.5% and healthy sleep efficiency by 13.6% of the sample. Regression models showed every additional minute of light physical activity was associated with 1% increased odds, while every unit decrease in the inflammation marker of interleukin-8 was associated with 12% increased odds, of achieving a healthy sleep duration. Every unit increase in total social support was associated with a 34% increased odds, while every unit increase in the hazardous drinking score corresponded with 30% decreased odds, of achieving healthy sleep efficiency.

CONCLUSIONS

Light physical activity, social support, and alcohol consumption may be key modifiable intervention targets to improving sleep duration and sleep efficiency in this population.

Effects of Exercise in Patients with Obstructive Sleep Apnoea

Obstructive sleep apnoea (OSA) constitutes a public health problem, with various systemic consequences that can increase cardiovascular morbidity and mortality as well as increase healthcare expenditure. This review discusses the rationale and effects of using general physical exercise, oropharyngeal exercises, and respiratory muscle training as an adjunctive treatment for patients with sleep apnoea. The recommended treatment for OSA is the use of continuous positive airway pressure, which is a therapy that prevents apnoea events by keeping the airways open. In the last decade, coadjuvant treatments that aim to support weight loss (including diet and physical exercise) and oropharyngeal exercises have been proposed to lower the apnoea/hypopnoea index among patients with OSA. Based on the available evidence, health professionals could decide to incorporate these therapeutic strategies to manage patients with sleep apnoea.

The beneficial impact of cardiac rehabilitation on obstructive sleep apnea in patients with coronary artery disease

STUDY OBJECTIVES

To assess the impact of cardiac rehabilitation for decreasing sleep-disordered breathing in patients with coronary artery disease.

METHODS

The study included 121 patients aged 60.01 ± 10.08 years, 101 of whom were men, with an increased pretest probability of OSA. The cardiac rehabilitation program lasted 21-25 days. The improvement in cardiorespiratory fitness was assessed using the changes in peak metabolic equivalents, the maximal heart rate achieved, the proportion of the age- and sex-predicted maximal heart rate, and the Six-Minute Walk Test distance. Level 3 portable sleep tests with respiratory event index assessments were performed in 113 patients on admission and discharge.

RESULTS

Increases were achieved in metabolic equivalents (Δ1.20; 95% confidence interval [CI], 0.95-1.40; P < .0001), maximal heart rate (-Δ7.5 beats per minute; 95% CI, 5.00-10.50; P < .0001), proportion of age- and sex-predicted maximal heart rate (Δ5.50%; 95% CI, 4.00-7.50; P < .0001), and the Six-Minute Walk Test distance (Δ91.00 m; 95% CI, 62.50-120.00; P < .0001). Sleep-disordered breathing was diagnosed in 94 (83.19%) patients: moderate in 28 (24.8%) patients and severe in 27 (23.9%) patients, with a respiratory event index of 19.75 (interquartile range, 17.20-24.00) and 47.50 (interquartile range, 35.96-56.78), respectively. OSA was dominant in 90.40% of patients. The respiratory event index reduction achieved in the sleep-disordered breathing group was -Δ3.65 (95% CI, -6.30 to -1.25; P = .003) and was in parallel to the improvement in cardiorespiratory fitness in the subgroups with the highest effort load and with severe sleep-disordered breathing: -Δ6.40 (95% CI, -11.40 to -1.90; P = .03) and -Δ11.00 (95% CI, -18.65 to -4.40; P = .003), respectively.

CONCLUSIONS

High-intensity exercise training during cardiac rehabilitation resulted in a significant decrease in OSA, when severe, in parallel with an improvement in cardiorespiratory fitness in patients with coronary artery disease.

The Association of Sleep Apnea and Cardiorespiratory Fitness With Long-Term Major Cardiovascular Events

OBJECTIVE

To determine the risk of long-term major adverse cardiovascular events (MACE) when sleep-disordered breathing (SDB) and decreased cardiorespiratory fitness (CRF) co-occur.

METHODS

We included consecutive patients who underwent symptom-limited cardiopulmonary exercise tests between January 1, 2005, and January 1, 2010, followed by first-time diagnostic polysomnography within 6 months. Patients were stratified based on the presence of moderate-to-severe SDB (apnea/hypopnea index ≥15 per hour) and decreased CRF defined as <70% predicted peak oxygen consumption (VO₂). Long-term MACE was a composite outcome of myocardial infarction (MI), coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), stroke or transient ischemic attack (TIA), and death, assessed until May 21, 2018. Cox-proportional hazard models were adjusted for factors known to influence CRF and MACE.

RESULTS

Of 498 included patients (60±13 years, 28.1% female), 175 (35%) had MACE (MI=17, PCI=14, CABG=13, stroke=20, TIA=12, deaths=99) at a median follow-up of 8.7 years (interquartile range=6.5 to 10.3 years). After adjusting for age, sex, beta blockers, systemic hypertension, diabetes mellitus, coronary artery disease, cardiac arrhythmia, chronic obstructive pulmonary disease, smoking, and use of positive airway pressure (PAP), decreased CRF alone (hazard ratio [HR]=1.91, 95% confidence interval [CI], 1.15 to 3.18; P=.01), but not SDB alone (HR=1.26, 95% CI, 0.75 to 2.13, P=.39) was associated with increased risk of MACE. Those with SDB and decreased CRF had greater risk of MACE compared with patients with decreased CRF alone (HR=1.85; 95% CI, 1.21 to 2.84; P<.005) after accounting for these confounders. The risk of MACE was attenuated in those with reduced CRF alone after additionally adjusting for adequate adherence to PAP (HR=1.59; 95% CI, 0.77 to 3.31; P=.21).

CONCLUSION

The incidence of MACE, especially mortality, was high in this sample. Moderate-to-severe SDB with concurrent decreased CRF was associated with higher risk of MACE than decreased CRF alone. These results highlight the importance of possibly including CRF in the risk assessment of patients with SDB and, conversely, that of screening for SDB in patients with low peak VO₂.

The Impact of Obstructive Sleep Apnea on Balance, Gait, and Falls Risk: A Narrative Review of the Literature

Falls-related hospitalization and injury rates are steadily increasing globally due to a growth in the aging population, and the associated health problems that increase risk of falls. One such associated health problem is sleep disturbances and disorders. Recent cohort studies have shown that subjectively reported poor quality sleep is associated with an increased risk of falls. Obstructive sleep apnea (OSA) is a common sleep disorder characterized by the repetitive reductions, or cessation, of airflow. Some studies have shown that OSA impairs posture/balance and gait with nocturnal hypoxemia the likely main cause. Emerging evidence suggests that treating OSA by continuous positive airway pressure (CPAP) can improve gait, but no studies to date have examined the effect of CPAP on posture/balance. The overall control of balance relies on a complex interaction between several physiological functions including vestibular, muscle, visual, and cognitive functions. We postulate that OSA impacts balance by affecting these different systems to various degrees, with the nocturnal hypoxic burden likely playing an important role. Importantly, these impairments in balance/posture and possible falls risk may be alleviated by OSA treatment. Larger mechanistic studies are needed to properly elucidate how OSA affects falls risk and future large-scale randomized control trials are needed to determine the effectiveness of OSA treatment in reducing the risk of falls.

Part 2: Bypassing TBI-Metabolic Surgery and the Link Between Obesity and Traumatic Brain Injury-A Review

Obesity is a common outcome of traumatic brain injury (TBI) that exacerbates principal TBI symptom domains identified as common areas of post-TBI long-term dysfunction. Obesity is also associated with increased risk of later-life dementia and Alzheimer's disease. Patients with obesity and chronic TBI may be more vulnerable to long-term mental abnormalities. This review explores the question of whether weight loss induced by bariatric surgery could delay or perhaps even reverse the progression of mental deterioration. Bariatric surgery, with its induction of weight loss, remission of type 2 diabetes, and other expressions of the metabolic syndrome, improves metabolic efficiency, leads to reversal of brain lesions seen on imaging studies, and improves function. These observations suggest that metabolic/bariatric surgery may be the most effective therapy for TBI.

Shorter Sleep Predicts Longer Subsequent Day Sedentary Duration in Healthy Midlife Adults, but Not in Those with Sleep Apnea

PURPOSE

Sedentary behavior and suboptimal sleep increase risks for chronic diseases. We hypothesized that sedentary behavior and sleep affect each other and that an underlying sleep disorder would alter these relationships. To test these hypotheses, we studied the bidirectional relationships between sedentary behavior and sleep (duration and efficiency) in healthy controls (HC) and people with untreated obstructive sleep apnea (OSA).

PATIENTS AND METHODS

Fifty-two volunteers (18 HC, 19 mild OSA [apnea/hypopnea index [AHI] range 5-14.9/hour], 15 moderate OSA [AHI range 15-29.9/hour]) were studied with actigraphy and sleep diaries across ~9 consecutive nights of self-selected consistent ~8-hour sleep episodes at home (range 4-21/nights per person). We analyzed whether total time asleep and sleep efficiency affected the subsequent daytime sedentary duration while controlling for body mass index and whether the severity of OSA altered this relationship. We also tested the reverse relationship, namely whether daytime sedentary duration affected the subsequent night's sleep and if any such relationship differed with OSA severity.

RESULTS

Overnight sleep duration and efficiency negatively predicted the subsequent day's sedentary duration in HC (p<0.02), but not in people with mild or moderate OSA (p>0.05). There was no significant reverse relationship between daytime sedentary duration and the subsequent night's sleep duration or efficiency (p≥0.2).

CONCLUSION

In healthy adults, short nighttime sleep predicts a longer duration of sedentary behavior on a subsequent day, but we did not observe this relationship in people with OSA. The mechanisms underlying this association in healthy individuals and its disruption in the presence of OSA need to be studied.

The Role of Vitamin C in Two Distinct Physiological States: Physical Activity and Sleep

This paper is a literature overview of the complex relationship between vitamin C and two opposing physiological states, physical activity and sleep. The evidence suggests a clinically important bidirectional association between these two phenomena mediated by different physiological mechanisms. With this in mind, and knowing that both states share a connection with oxidative stress, we discuss the existing body of evidence to answer the question of whether vitamin C supplementation can be beneficial in the context of sleep health and key aspects of physical activity, such as performance, metabolic changes, and antioxidant function. We analyze the effect of ascorbic acid on the main sleep components, sleep duration and quality, focusing on the most common disorders: insomnia, obstructive sleep apnea, and restless legs syndrome. Deeper understanding of those interactions has implications for both public health and clinical practice.

The role of exercise-induced peripheral factors in sleep regulation

BACKGROUND

Recurrently disrupted sleep is a widespread phenomenon in our society. This is worrisome as chronically impaired sleep increases the risk of numerous diseases that place a heavy burden on health services worldwide, including type 2 diabetes, obesity, depression, cardiovascular disease, and dementia. Therefore, strategies mitigating the current societal sleep crisis are needed.

SCOPE OF REVIEW

Observational and interventional studies have found that regular moderate to intensive exercise is associated with better subjective and objective sleep in humans, with and without pre-existing sleep disturbances. Here, we summarize recent findings from clinical studies in humans and animal experiments suggesting that molecules that are expressed, produced, and released by the skeletal muscle in response to exercise may contribute to the sleep-improving effects of exercise.

MAJOR CONCLUSIONS

Exercise-induced skeletal muscle recruitment increases blood concentrations of signaling molecules, such as the myokine brain-derived neurotrophic factor (BDNF), which has been shown to increase the depth of sleep in animals. As reviewed herein, BDNF and other muscle-induced factors are likely to contribute to the sleep-promoting effects of exercise. Despite progress in the field, however, several fundamental questions remain. For example, one central question concerns the optimal time window for exercise to promote sleep. It is also unknown whether the production of muscle-induced peripheral factors promoting sleep is altered by acute and chronic sleep disturbances, which has become increasingly common in the modern 24/7 lifestyle.

The mediation role of sleep quality in the association between the incidence of unhealthy movement behaviors during the COVID-19 quarantine and mental health

BACKGROUND

Our aim was to investigate the mediating role of worsening sleep quality in the association of the incidence of physical inactivity, high TV-viewing, and high computer/tablet use with loneliness, sadness, and anxiety.

METHODS

Data of 45,161 Brazilian adults from a nationwide behavior survey, conducted between April 24th and May 24th (2020), were used. Participants reported physical inactivity (PI; <150 min/week), high TV-viewing (TV; ≥4 h/day), and high computer/tablet use (PC; ≥4 h/day) before and during COVID-19 quarantine (exposures). For incidence indicators, we only considered participants without the risk behavior before quarantine. Changes in sleep quality during the quarantine period (maintained/got better or worsened) were treated as a mediator. Elevated frequencies of feelings of loneliness, sadness (feel sad, crestfallen, or depressed), and anxiety (feel worried, anxious, or nervous) during the pandemic period were the study outcomes. Analyses were adjusted for sex, age group, highest academic achievement, working status during quarantine, skin color, previous diagnosis of depression, and adherence to quarantine. Mediation models were created using the Karlson Holm Breen method.

RESULTS

The incidence of PI, high TV, and high PC use were associated with loneliness, sadness, and anxiety feelings. Worsening sleep quality partly mediated the association of the incidence of PI, high TV, and high PC use with loneliness (PI:30.9%; TV:19.6%; PC: 30.5%), sadness (PI:29.8%; TV:29.3%; PC: 39.1%), and anxiety (PI:21.9%; TV:30.0%; PC:38.5%).

CONCLUSION

The association of the incidence of physical inactivity and sedentary behaviors with mental health indicators is partly mediated by worsening sleep quality during the COVID-19 pandemic quarantine.