On the Plausibility of Upper Airway Remodeling as an Outcome of Orofacial Exercise

Below is an article on facial / throat exercises for sleep apnea. It addresses the issues with the tounge and the strength and placement to improve obstructive sleep apnea. Once FCR corrects the nasal airway and widens the maxilla then these exercises are prescribed. The results are in the 90% with the combination of both.


Dr. John Lieurance



(941) 330-8553


American Journal of Respiratory and Critical Care Medicine Vol 179. pp. 858-859, (2009)
© 2009 American Thoracic Society
doi: 10.1164/rccm.200901-0016ED 


On the Plausibility of Upper Airway Remodeling as an Outcome of Orofacial Exercise

Catriona M. Steele, Ph.D.

Toronto Rehabilitation Institute 
University of Toronto 
Toronto, Canada

In this issue of the Journal (pp. 962–966), Guimarães and colleagues report improvements in obstructive sleep apnea (OSA) in patients who practiced (30 min daily, over 3 mo) exercises derived from traditional speech therapy techniques (1). Theauthors acknowledge a lack of previous evidence regarding the effectiveness of such exercises (2) for speech or swallowing rehabilitation and argue that their contribution cannot be appreciated in terms of the specific actions of individual exercises. Rather, they conclude that the collective effect was a remodeling of the upper airway extensive enough to carry over from wakeful exercise to alter the pharyngeal airspace in sleep. We review the treatment tasks used by these authors in an attempt to elucidate their results and the mechanisms by which they may have arisen.

Obstructive sleep apnea results from decreased upper airway muscle tone during sleep and associated collapsibility of themuscles in the hypopharynx (3). The genioglossus, an extrinsic tongue protrusive muscle, has been especially implicated. Sublingual electrical stimulation of the protrusive and retrusive tongue muscles improves flow dynamics during moderate upper airway obstruction (3). Genioglossus activity correlates strongly with negative pharyngeal pressures measured at the epiglottis (4). Tongue protrusive force is directly correlated with maximum inspiratory pressures; a high wakeful ratio reduces the propensity to OSA (5). Such studies lay a theoretical foundation for the possibility that exercising the hypopharyngeal musculature might alleviate conditions contributing to OSA.

Guimarães and colleagues used an exercise approach to improve upper airway function in moderate OSA (1). To appreciatetheir results, it is necessary to consider the goals of the exercises included, and explore whether principles of neuromuscular rehabilitation were followed such that the reported results are plausible. The use of orofacial exercises to ameliorate speech and swallowing difficulties is highly controversial; nonspeech oral motor exercises are not thought to be effective for improving speech intelligibility (6). Amid this controversy, clinicians are exhorted to base their exercise selection on best evidence and sound theoretical principles and to tailor exercises to the specific functional deficits that they wish to treat (2). It is important to determine whether the goal of an exercise is one of strengthening, building endurance, restoring optimal muscle tone, or facilitating speed/range/power during movement (2). Typical approaches for tone restoration in the limb musculature (e.g., tapping, stretching, and application of vibration, heat or cold) are unlikely to affect the lips and tongue, which lack muscle spindles (7). For treatments targeting muscle strength and endurance, elements of exercise load and intensity must be considered, as well as the frequency and duration of treatment (8). Muscle strength is a questionable goal in speech rehabilitation because speech production is not a high effort task (2). For swallowing rehabilitation, however, tongue strength improves with 6 to 8 weeks of resistance exercises (compression of an air-filled pressure bulb placed between the tongue and the hard palate) when these exercises are practiced with 60 to 180 repetitions, 3 days per week, at loads between 60 and 80% of maximum isometric tongue pressure capacity (9, 10).

Returning to Guimarães and colleagues (1), we can ask whether the tasks included in the treatment regime have suitableneuromuscular goals and task specificity and whether the intensity (load), frequency, and duration of exercise was sufficient to be likely to achieve the reported changes in the targeted musculature. Guimarães and colleagues identified three specific targets: long/floppy soft palates, habitual tongue postures leading to enlarged tongue bulk, and inferiorly displaced hyoid bone position. For now, we will discount the lip and cheek exercises that were included; the remote locations of these structures make these exercises unlikely to have contributed meaningfully to remodeling of the oropharyngeal airway.

Soft palate function and lateral pharyngeal wall motion have clear anatomical relevance to OSA; they were targeted by Guimarães and colleagues (1) with oral vowel production tasks. Although clinical supervision was provided weekly to ensure that adequate effort was used, evidence suggests that vowel production is very unlikely to be a sufficiently effortful task to induce muscle changes (2). However, another of the tasks used by Guimarães and colleagues involved nasal inhalation and oral balloon inflation (1). The authors cite a recent related study of didgeridoo playing as a treatment for OSA, which yielded favorable results (11). It seems reasonable to conclude that both didgeridoo playing and balloon inflation involve sufficient air pressure to apply resistance against the mucosal walls of the nasopharynx. Changes in the tone or strength of the underlying musculature appear to be plausible outcomes of these exercises, provided that they are practiced with high effort and sufficient frequency over a period of 4 to 8 weeks (8).

Tongue function was targeted by Guimarães and colleagues with anterior-to-posterior sliding of the tongue tip along thehard palate, pressing the tongue body up against the hard palate, forceful lowering of the tongue base while anchoring the tongue tip behind the lower incisors, and bilateral bread chewing with the tongue positioned in midline behind the teeth (1). Although orofacial regulation therapy approaches (which target tongue position within the oropharynx with exercises such as these tongue base–lowering and chewing tasks) are popular, particularly in Europe, evidence of their effectiveness is essentially nonexistent. Tongue brushing (also included) is a technique usually used to promote muscle relaxation; because the tongue lacks muscle spindles, brushing is very unlikely to have contributed to the reported outcomes (2). This leaves the anterior-to-posterior tongue tip–palatal slide and tongue body press-to-palate tasks as candidates for contributing to the reported changes. The tongue tip sliding task appears most likely to be a range of motion task and is unlikely to have influenced muscle tone or strength. The tongue press-to-palate task appears similarto the tongue pressure resistance exercises used by others in swallowing rehabilitation (910) and is a plausible exercisefor altering muscle strength and tone in the region of interest. Shepherd and colleagues (5) have demonstrated a direct relationship between tongue protrusion force and maximum inspiratory pressures. Consequently, there seems to be reasonable logic to targeting tongue strength as a potential mechanism for remodeling the upper airway.

Further research is required to confirm whether wakeful nasopharyngeal and tongue pressure resistance exercises can be used effectively to ameliorate upper airway collapsibility during sleep. Future studies will also be needed to determine optimal treatment elements (i.e., load/intensity, frequency, and duration) and to confirm the hypothesized need for ongoing practice to maintain beneficial treatment effects.


    1. 1.Guimarães KC, Drager LF, Genta PR, Marcondes BF, Lorenzi-Filho G. Effects of oropharyngeal exercises on patients with moderate obstructive sleep apnea syndrome. Am J Resp Crit Care Med 2009; 179:962–966.[Abstract/Free Full Text]

    1. 2.Clark HM. Neuromuscular treatments for speech and swallowing: a tutorial. Am J Speech Lang Pathol 2003;12:400–415.[Abstract/Free Full Text]

    1. 3.Oliven A, Schnall RP, Pillar G, Gavriely N, Odeh M. Sublingual electrical stimulation of the tongue during wakefulness and sleep. Respir Physiol 2001;127:217–226.[CrossRef][Medline]

    1. 4.Pillar G, Fogel RB, Malhotra A, Beauregard J, Edwards JK, Shea SA, White DP. Genioglossal inspiratory activation: central respiratory vs. mechanoreceptive influences. Respir Physiol 2001;127:23–38.[CrossRef][Medline]

    1. 5.Shepherd KL, Jensen CM, Maddison KJ, Hillman DR, Eastwood PR. Relationship between upper airway and inspiratory pump muscle force in obstructive sleep apnea. Chest 2006;130:1757–1764.[Abstract/Free Full Text]

    1. 6.Lof GL, Watson MM. A nationwide survey of nonspeech oral motor exercise use: implications for evidence-based practice. Lang Speech Hear Serv Sch 2008;29:392–407.

    1. 7.Kent R. The uniqueness of speech among motor systems. Clin Linguist Phon 2004;18:495–505.[CrossRef][Medline]

    1. 8.Burkhead LM, Sapienza CM, Rosenbek JC. Strength-training exercise in dysphagia rehabilitation: principles, procedures, and directions for future research. Dysphagia 2007;22:251–265.[CrossRef][Medline]

    1. 9.Robbins J, Kays S, Gangnon R, Hewitt A, Hind J. The effects of lingual exercise in stroke patients with dysphagia.Arch Phys Med Rehabil 2007;88:150–158.[CrossRef][Medline]

    1. 10.Yeates EM, Molfenter SM, Steele CM. Improvements in tongue strength and pressure-generation precision following a tongue-pressure training protocol in older individuals with dysphagia: three case reports. Clin Interv Aging2008;3:735–747.[Medline]

  1. 11.Puhan MA, Suarez A, Cascio CL, Zahn A, Heitz M, Braendli O. Didgeridoo playing as alternative treatment for obstructive sleep apnoea syndrome: randomised controlled trial. BMJ 2005;332:266–270.[CrossRef][Medline]


Effects of Oropharyngeal Exercises on Patients with Moderate Obstructive Sleep Apnea Syndrome

Kátia C. Guimarães, Luciano F. Drager, Pedro R. Genta, Bianca F. Marcondes, and Geraldo Lorenzi-Filho
AJRCCM 2009 179: 962-966. [Abstract] [Full Text]