Strengthening oropharyngeal muscles as an approach to treat post-stroke obstructive sleep apnea: A feasibility randomised controlled trial.

This study aimed to determine the feasibility of a randomised controlled trial (RCT) evaluating oropharyngeal exercise (OPE) intervention as an alternative therapy for obstructive sleep apnea (OSA) in patients with stroke or transient ischaemic attack (TIA). Despite the high prevalence of OSA in this population, the standard therapy, continuous positive airway pressure (CPAP), is often poorly tolerated. Thirty stroke/TIA patients with OSA unable to tolerate CPAP were randomly assigned to an oropharyngeal exercise or sham exercise protocol. They performed exercises for 6 weeks, 5 days per week, 30 minutes twice per day. Feasibility was ascertained by the proportion of enrolled patients who completed more than 80% of the OPE regimen. Isometric tongue pressures, apnea-hypopnea index (AHI), oxygen desaturation index (ODI), daytime sleepiness, and quality of life (QOL) outcomes were collected at baseline, post-training (6-week follow-up), and retention (10-week follow-up) to document preliminary efficacy. Adherence to study exercises was excellent, with 83% of participants completing more than 80% of the exercises. The isometric tongue pressures were observed to improve in the oropharyngeal exercise group (compared with the sham group), along with a decrease in OSA severity (measured by the AHI and ODI), reduced daytime sleepiness, and enhanced quality of life outcomes following the exercise programme. Only the effects on posterior isometric tongue pressure and daytime sleepiness remained significantly different between groups at the retention session. In conclusion, an RCT evaluating the efficacy of oropharyngeal exercises on post-stroke/TIA OSA is feasible and our preliminary results suggest a clinically meaningful effect.

Normal multiple sleep latency test values in adults: A systematic review and meta-analysis.

Sleep latency is a measure of time it takes to enter sleep. Very short sleep latencies are indicative of excessive daytime sleepiness and pathological sleep conditions such as narcolepsy. The normal range of mean sleep latency calculated from the multiple sleep latency test in healthy adults is not well-established. We provide a review of normative mean sleep latency values on the multiple sleep latency test by synthesizing data from 110 healthy adult cohorts. We also examine the impact of demographic variables such as age, sex, body mass index, sleep architecture and sleep-disordered breathing as well as methodological variables such as sleep onset definitions and multiple sleep latency test protocols. The average mean sleep latency was 11.7 min (95% CI: 10.8-12.6; 95% PI: 5.2-18.2) for cohorts evaluated using the earlier definition of sleep onset and 11.8 min (95% CI: 10.7-12.8; 95% PI: 7.2-16.3) for those evaluated using the later definition. There were no significant associations between mean sleep latency and demographic or methodological variables. A negative association of -0.29 per one unit increase (95% CI: -0.55 to -0.04) was found between mean sleep latency and apnea-hypopnea index on prior night polysomnography. Establishing updated ranges for mean sleep latency among healthy adults may guide clinical decision-making surrounding sleep pathologies and inform future research into the associations between patient variables, daytime sleepiness, and sleep pathologies.

Association of Periodic Limb Movements With Medication Classes: A Retrospective Cohort Study.

BACKGROUND AND OBJECTIVES: To investigate the association between various medication classes and the periodic limb movement index (PLMI) in a clinical cohort of adults who completed in-laboratory polysomnography. METHODS: A single, diagnostic, overnight, in-laboratory polysomnogram was completed for 3,488 patients consecutively referred from 2010 to 2015 to determine PLMI. Medication use and medical comorbidities were collected through patient questionnaires. Associations between medication classes and PLMI were ascertained using multivariable ordinal logistic regression models. RESULTS: The median age of the cohort was 56.0 years (48.2% male). After adjusting for age, sex, body mass index, relevant comorbidities, and sleep measures, the use of selective serotonin reuptake inhibitors (SSRIs) (odds ratio [OR] 1.52) and serotonin-norepinephrine reuptake inhibitors (SNRIs) (OR 1.99) was associated with increased PLMI. Conversely, gabapentinoids (OR 0.71), stimulants (OR 0.52), benzodiazepines (OR 0.79), and dopamine agonists (OR 0.38) were associated with decreased PLMI. A non-statistically significant trend for decreased PLMI with neuroleptic use was observed. No significant associations were found between PLMI and the use of antihypertensives, statins, tricyclic antidepressants, bupropion, anticoagulants, antiplatelets, modafinil, and antihistamines. DISCUSSION: The use of SSRIs and SNRIs was associated with elevated PLMI while the use of gabapentinoids, stimulants, benzodiazepines, and dopamine agonists was associated with decreased PLMI. These results can assist physicians in managing periodic limb movements in sleep (PLMS) and invite further research into the relationship between PLMS and medications with the modulating effects of dose, formulation type, and time of administration. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that SSRIs and SNRIs are associated with elevated PLMI while gabapentinoids, stimulants, benzodiazepines, and dopamine agonists are associated with decreased PLMI.

Actigraphic detection of periodic limb movements: development and validation of a potential device-independent algorithm. A proof of concept study.

STUDY OBJECTIVES: We propose a unique device-independent approach to analyze long-term actigraphy signals that can accurately quantify the severity of periodic limb movements in sleep (PLMS). METHODS: We analyzed 6-8 hr of bilateral ankle actigraphy data for 166 consecutively consenting patients who simultaneously underwent routine clinical polysomnography. Using the proposed algorithm, we extracted 14 time and frequency features to identify PLMS. These features were then used to train a Naïve-Bayes learning tool which permitted classification of mild vs. severe PLMS (i.e. periodic limb movements [PLM] index less than vs. greater than 15 per hr), as well as classification for four PLM severities (i.e. PLM index < 15, between 15 and 29.9, between 30 and 49.9, and ≥50 movements per hour). RESULTS: Using the proposed signal analysis technique, coupled with a leave-one-out cross-validation method, we obtained a classification accuracy of 89.6%, a sensitivity of 87.9%, and a specificity of 94.1% when classifying a PLM index less than vs. greater than 15 per hr. For the multiclass classification for the four PLM severities, we obtained a classification accuracy of 85.8%, with a sensitivity of 97.6%, and a specificity of 84.8%. CONCLUSIONS: Our approach to analyzing long-term actigraphy data provides a method that can be used as a screening tool to detect PLMS using actigraphy devices from various manufacturers and will facilitate detection of PLMS in an ambulatory setting.

Normal polysomnography parameters in healthy adults: a systematic review and meta-analysis.

BACKGROUND: Existing normal polysomnography values are not truly normative as they are based on small sample sizes due to the fact that polysomnography is expensive and burdensome to obtain. There is a clear need for a large sample of truly normative data for clinical management and research. This study is a comprehensive meta-analysis of adult polysomnography parameters scored using recent criteria and establishes normative values adjusted for age and sex. METHODS: For this meta-analysis of adult polysomnography parameters, we searched Scopus for studies of any design published between Jan 1, 2007, and July 31, 2016, that reported polysomnographic parameters scored using recent American Academy of Sleep Medicine criteria (2007 or 2012) collected during an overnight level 1 in-laboratory sleep study in healthy controls. We excluded studies of patients with conditions or subjected to treatments that might affect sleep and studies not available in English. Study endpoints were the pooled estimates of 14 reported polysomnographic parameters. Estimates for each parameter were pooled using a random-effects meta-analysis. The influence of age and sex was ascertained using multivariate mixed-effects meta-regressions. This study is registered with PROSPERO, number CRD42017074319. FINDINGS: Of 3712 articles, 169 studies, comprising 5273 participants, were eligible for inclusion. We report normative data stratified by age and sex. For each decade of age, total sleep time decreased by 10·1 min (95% CI 7·5 to 12·8), sleep efficiency decreased by 2·1% (1·5 to 2·6), wake after sleep onset increased by 9·7 min (6·9 to 12·4), sleep onset latency increased by 1·1 min (0·3 to 1·9), arousal index increased by 2·1 events per h (1·5 to 2·6), percentage of N1 sleep increased by 0·5% (0·1 to 0·8), apnea-hypopnea index increased by 1·2 events per h (0·9 to 1·4), mean oxygen saturation decreased by 0·6% (0·5 to 0·7), minimum oxygen saturation decreased by 1·8% (1·3 to 2·3), and periodic limb movement index increased by 1·2 events per h (0·8 to 1·6). Changes with age in the percentage of N2 sleep (0·0%, 95% CI -0·1 to 0·1), N3 sleep (-0·1%, -0·1 to 0·0), and rapid eye movement (REM) sleep (0·0%, -0·1 to 0·0) were not significant. Every 10% increase in the percentage of male participants was associated with reduced REM latency (0·9 min decrease, 95% CI 0·1 to 1·6) and mean oxygen saturation (0·1% decrease, 0·0 to 0·1), and greater arousal index (0·3 events per h, 0·0 to 0·5) and apnea-hypopnea index (0·2 events per h, 0·1 to 0·3). INTERPRETATION: These normative values serve as a useful control reference for clinicians and for future research where it might be difficult to obtain polysomnographic controls. The resulting normative trends by age and sex might also be hypothesis-generating for a broad range of investigations. FUNDING: None.