As you know, adopting healthy lifestyle habits is a tool of choice for our patients in the prevention of certain chronic diseases¹. The Canadian Physiological Society (CPS) offers us a model for adopting an active lifestyle over a 24-hour period by moving more, limiting our sedentary behaviours and ensuring we get enough sleep  (https://csepguidelines.ca/guidelines/adults-18-64/)²

Sleeping well? This is not the type of question we asked ourselves a few years ago! As healthcare professionals with a bio-psycho-social approach to our patients, the question of sleep becomes inescapable. For example, a good quantity and quality of sleep favours the rehabilitation process during the management of a musculoskeletal disorder³.  But what questions are important to ask our patients?  To summarize, here are some points to discuss:

• Hours of sleep per night (CPS recommendation is between 7 to 9 hours per night)².
• The number of nighttime awakenings (in general). Do you have good sleep quality? Meaning, do you feel rested after a night of sleep? 
• Do you have a sleep routine with a regular bedtime and wake-up time? 
• Do you have a sleep condition such as insomnia or obstructive sleep apnea (OSA)? 

For many patients, the fourth question is often answered in the negative. Obstructive sleep apnea, for some of them, could be the cause. According to the Quebec Lung Association, about 1 in 20 people are diagnosed with OSA, considering that 80% of people who suffer from it have not been diagnosed yet⁴. Indeed, this seems like a lot, and it is precisely in this sense that you, as a healthcare provider, can become a key player in reducing this percentage and helping your patients. 

Obstructive Sleep Apnea

The most common form of OSA is when the muscles in the throat relax, preventing air from flowing properly and creating several episodes of micro-awakening. Signs and symptoms⁵ include :

• Snoring;
• Nocturnal respiratory arrest noticed by another person;
• Fatigue during the day despite a supposedly normal amount of sleep;
• Feeling as if you have woken up and have not recovered (headaches);
• Feeling like waking up and not having recovered (headaches); Taste, or even need to take one or more naps during the day;
• Decreased energy and alertness, memory loss and feeling irritable;
• Decreased libido;
• Depression and anxiety.

The consequences of untreated OSA are multiple and can affect the sufferer both psychosocially and physically. In the long term, OSA is a risk factor for the development of: atrial fibrillation (and therefore an increased risk of stroke); coronary heart disease (hypertension, angina and heart attack); type 2 diabetes; and depressive or anxiety syndromes⁵. More insidiously, OSA increases the risk of motor vehicle accidents (by increasing the risk of death). More insidiously, OSA increases the risk of motor vehicle accidents (falling asleep at the wheel), divorce, and difficulties at work.

The Epworth Questionnaire to Assess Sleepiness

If you have a reasonable suspicion that a patient has OSA, it may be advisable to ask them to complete the Epworth questionnaire ( https://fondationsommeil.com/troubles-du-sommeil/testez-sommeil/echelle-somnolence/)⁶.

 The questionnaire asks how likely (0=none; 1=low; 2=moderate and 3=high) you are to doze off or fall asleep for the following situations:

• Sitting and reading
• Watching television.
• Sitting idle in a public place (e.g., movie theater or meeting).   
• As a passenger in a car for more than an hour without stopping.
• During an occasional rest in the middle of the day.
• While sitting and talking to someone.
• While sitting quietly after a meal without alcohol
• In a car temporarily stopped in traffic.

If the score is greater than 10, it is strongly recommended that your patient be referred to a physician for further investigation. Sleep laboratory polysomnography is the diagnostic tool of choice for sleep apnea, although more and more tests are being performed at home⁷. If the score is below 10, it may be worthwhile to suggest strategies to your patient to simply improve sleep quality.  For example, suggest a reduction in blue light emitted by screens before going to bed). 

Treatment modalities 

Once the patient has been diagnosed with sleep apnea (family physician and respirologist), he or she will often be referred to respiratory therapists in order to begin treatment with continuous positive airway pressure (CPAP). CPAP remains the approach of choice due to its clinical efficacy⁸. However, one of the major difficulties with this approach is patient adherence to treatment⁹. In a comprehensive care setting, as a therapist, you can become a proactive player by reminding your patient of the importance of adherence to this therapy. It should be noted that RAMQ and many insurance companies may pay for CPAP therapy.

Another emerging alternative to CPAP treatment is the use of a mandibular advancement orthosis¹⁰ . This alternative is more expensive, however, as it is not covered by the RAMQ and by few group insurance plans. This orthosis is made by a dentist or an orthodontist specialized in sleep apnea. It is often recommended that patients undergoing this type of therapy be followed by a therapist specialized in TMJ treatment in order to reduce the tensions or discomforts sometimes associated with it. 

As an adjunct to treatment, the following modalities can be considered: 

• Weight loss¹¹; 
• Cardiovascular exercises¹²; 
• Sleep positioning¹³ (avoid the supine position and favor a lateral side position);
• Limiting excessive alcohol consumption¹⁴ ;
• Doing specific throat exercises (e.g., playing the didgeridoo)¹⁵ . 
• All of these non-surgical and non-pharmaceutical examples may be interesting complementary avenues to explore.

Conclusion

In conclusion, sleep is a cornerstone of optimal health, so we need to pay more attention to it. This article gives you a foundation to act quickly if you have any doubts about obstructive sleep apnea.