Oropharyngeal Exercises and Post-Stroke Obstructive Sleep Apnea

April 12, 2023 updated by: Sunnybrook Health Sciences Centre

Strengthening Oropharyngeal Muscles as a Novel Approach to Treat Obstructive Sleep Apnea After Stroke: A Randomized Feasibility Study

This study evaluates the feasibility and effectiveness of an oropharyngeal exercise (O-PE) regimen in treating post-stroke obstructive sleep apnea, as an alternative therapy to continuous positive airway pressure (CPAP). Eligible patients will be randomized (1:1) to treatment using a pre-specified schedule of O-PEs vs. a sham control arm.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

BACKGROUND Obstructive sleep apnea (OSA) is characterized by recurrent obstruction of the upper airway during sleep due to intermittent loss of pharyngeal dilator muscle tone. OSA is both a risk factor for stroke, as well as a common post-stroke co-morbidity with approximately 72% of patients with stroke or transient ischemic attack (TIA) having OSA. Post-stroke OSA is linked to post-stroke, fatigue, which is a top research priority for stroke patients. Moreover, post-stroke OSA is associated with greater mortality, a higher risk of recurrent stroke, poorer cognition and lower functional status. In addition, stroke patients with OSA spend significantly longer times in rehabilitation and in acute care hospitals. Since OSA has a significant impact on the health of stroke patients, it is imperative that effective treatments are used to assist patients. Continuous positive airway pressure (CPAP) is the gold standard treatment for patients with moderate to severe OSA. However, despite having been demonstrated to improve post-stroke cognition, motor and functional outcomes,and overall quality of life, rates of CPAP adherence are low. Reasons for poor post-stroke CPAP adherence are multi-factorial and often not easily modifiable. Overall, there is a major clinical need to develop an alternative effective and well-tolerated treatment for OSA.

Oro-pharyngeal exercises (O-PEs) are commonly used by speech-language pathologists to improve oro-motor strength and range of motion and serve as a promising alternative approach to treat OSA. For example, in a randomized controlled trial in which patients with moderate OSA underwent 3 months of daily exercises focusing on strengthening oro-pharyngeal musculature, OSA severity and symptoms were demonstrated to be significantly reduced compared to sham exercises.Similarly, use of the didgeridoo, a wind instrument that strengthens muscles of the upper airway, has also been demonstrated to reduce OSA severity.

METHODS Research Question: Is a randomized controlled trial (RCT) of an O-PE regimen in post-stroke OSA feasible?

Primary Objective: To examine whether an RCT of an O-PE regimen is feasible in stroke patients with OSA who are unable to tolerate CPAP. (i) The O-PE regimen will be considered feasible if >80% of enrolled patients complete >80% of the study exercises. (ii) We will also track the monthly number of eligible vs. recruited patients from Dr. Boulos' stroke and sleep disorders clinic. Hypothesis: An RCT of an O-PE regimen in post-stroke OSA will be feasible in that >80% of enrolled patients will complete >80% of the study exercises.

Secondary Objectives: To explore whether an O-PE regimen, compared to sham activities, might be effective in (i) improving various objective sleep metrics (i.e. OSA severity and nocturnal oxygen saturation), (ii) improving various measures of oropharyngeal physiology and function (i.e. oro-pharyngeal deficits and dysarthria, tongue/lip/jaw weakness, and oro-facial kinematics), and (iii) enhancing self-reported sleep-related symptoms. Hypothesis: Compared to the sham activities, O-PEs will positively influence the outcomes noted above.

Study Type

Interventional

Enrollment (Actual)

33

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

Study Contact Backup

Study Locations

  • Canada
    • Ontario
      • Toronto, Ontario, Canada, M4N 3M5
        • Sunnybrook Health Sciences Centre

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

  • Child
  • Adult
  • Older Adult

Accepts Healthy Volunteers

No

Description

Inclusion Criteria:

  • Imaging-confirmed stroke or stroke specialist-diagnosed transient ischemic attack (TIA)
  • Prior diagnosis of OSA by a physician at any time in the past.
  • Unable to tolerate CPAP after a 2-week trial of CPAP

Exclusion Criteria:

  • BMI > 40 kg/m2
  • The presence of conditions known to compromise the accuracy of portable sleep monitoring, such as moderate to severe pulmonary disease or congestive heart failure.
  • Oxygen therapy (e.g. nasal prongs), a nasogastric tube, or other medical device that would interfere with the placement of the home sleep apnea test
  • Cranial malformations/nasal obstruction
  • Significant depressive symptoms
  • Regular use of hypnotic medications
  • Other neuromuscular diseases or conditions affecting oropharyngeal muscles
  • Montreal Cognitive Assessment (MoCA) < 18
  • Aphasia
  • Oral or apraxia of speech

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Quadruple

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: Oro-pharyngeal exercises
Use of oro-pharyngeal exercises
Behavioral: Oropharyngeal exercises
Oro-pharyngeal exercises that improve oro-pharyngeal and tongue strength. Instructions will be delivered via a tablet-based app.
Sham Comparator: Sham control
Use of sham exercises.
Behavioral: Sham control
Simple mouth movements that have no impact of oro-pharyngeal strength. Instructions will be delivered via a tablet-based app.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Percentage of enrolled participants completing >80% of the study exercises
Time Frame: 6-10 weeks (post-training)
The study exercise regimen will be deemed feasible if >80% of enrolled patients complete >80% of the study exercises. Patient adherence with study exercises in both treatment arms will be recorded (in minutes) via use of the App that will deliver the oropharyngeal exercises/sham exercises. Completion of >80% of the study exercises would be indicated by >720 recorded minutes (if post-training visit is after 6 weeks) or >1200 recorded minutes (if post-training visit is after 10 weeks).
6-10 weeks (post-training)

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
OSA severity (as measured by the apnea-hypopnea index)
Time Frame: Baseline, 6-10 weeks (post-training), and 10-14 weeks (retention)
Measured by the apnea-hypopnea index (AHI). AHI quantifies the number of apneas and hypopneas per hour of sleep. It will be measured using a home sleep monitor that has been validated for use in the stroke population.
Baseline, 6-10 weeks (post-training), and 10-14 weeks (retention)
Lowest oxygen desaturation
Time Frame: Baseline, 6-10 weeks (post-training), and 10-14 weeks (retention)
Lowest oxygen desaturation will be measured using a home sleep monitor that has been validated for use in the stroke population.
Baseline, 6-10 weeks (post-training), and 10-14 weeks (retention)
Tongue/lip/jaw weakness
Time Frame: Baseline, 6-10 weeks (post-training), and 10-14 weeks (retention)
Measured by the Iowa Oral Performance Instrument & Flexiforce (max pressure, endurance)
Baseline, 6-10 weeks (post-training), and 10-14 weeks (retention)
Oro-facial kinematic capacity
Time Frame: Baseline, 6-10 weeks (post-training), and 10-14 weeks (retention)
Oro-facial kinematic capacity is defined by the range of facial motions (in mm) for lips and jaw, assessed during a standardized series of oro-motor tasks (e.g. Maximum mouth opening, syllable repetition)
Baseline, 6-10 weeks (post-training), and 10-14 weeks (retention)
Functional status (as measured by Functional Outcomes of Sleep Questionnaire)
Time Frame: Baseline, 6-10 weeks (post-training), and 10-14 weeks (retention)
Functional Outcomes of Sleep Questionnaire (FOSQ) encompasses 5 subscales: activity level, vigilance, intimacy and sexual relationships, general productivity, social outcome. An average score is calculated for each subscale and the 5 subscales are totaled to produce a total score. Subscale scores range from 1-4 with total scores ranging from 5-20. Higher scores indicate better functional status.
Baseline, 6-10 weeks (post-training), and 10-14 weeks (retention)
Daytime sleepiness (as measured by Epworth Sleepiness Scale)
Time Frame: Baseline, 6-10 weeks (post-training), and 10-14 weeks (retention)
Scores on Epworth Sleepiness Scale range from range from 0 to 24, with higher scores indicating higher average sleep propensity in daily life (daytime sleepiness).
Baseline, 6-10 weeks (post-training), and 10-14 weeks (retention)
Fatigue (as measured by Fatigue Severity Scale)
Time Frame: Baseline, 6-10 weeks (post-training), and 10-14 weeks (retention)
Fatigue Severity Scale measures the severity of fatigue and its effect on a person's activities and lifestyle. Scores range from 9 to 63, with higher scores indicating greater fatigue severity.
Baseline, 6-10 weeks (post-training), and 10-14 weeks (retention)
Quality of Life (as measured by Stroke Impact Scale)
Time Frame: Baseline, 6-10 weeks (post-training), and 10-14 weeks (retention)
Stroke Impact Scale (SIS) assesses multidimensional stroke outcomes through 8 domains: strength (raw score range: 4-20), hand function (5-25), activities of daily living (score range 10-50), mobility (score range 9-45), communication (score range 7-35), emotion (score range 9-45), memory and thinking (score range: 7-35), and participation (8-40). Each domain is scored separately. For each domain, raw scores are transformed using the following formula: Transformed Scale = (Actual raw score - lowest possible raw score)*100 / (Possible raw score range). Higher scores indicate greater quality of life.
Baseline, 6-10 weeks (post-training), and 10-14 weeks (retention)
Cognitive ability (as measured by Montreal Cognitive Assessment)
Time Frame: Baseline, 6-10 weeks (post-training), and 10-14 weeks (retention)
Montreal Cognitive Assessment (MoCA) is a screening test for detecting cognitive impairment. Scores range from 0 to 30, with higher scores indicating greater cognitive ability.
Baseline, 6-10 weeks (post-training), and 10-14 weeks (retention)
Oro-pharyngeal deficits and dysarthria (as measured by the second version of Frenchay Dysarthria Assessment)
Time Frame: Baseline, 6-10 weeks (post-training), and 10-14 weeks (retention)
The second version of Frenchay Dysarthria Assessment (FDA-2) is divided into 7 sections: reflexes, respiration, lips, palate, laryngeal, tongue, and intelligibility, each containing several individual items. Each item is rated on a scale from "0" to "7", where "0" means normal for age, and "7" means unable to undertake task/movement/sound. The total score of the 7 sections will determine the severity of dysarthria.
Baseline, 6-10 weeks (post-training), and 10-14 weeks (retention)

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Sunnybrook Health Sciences Centre

Collaborators

Unity Health Toronto
University of Toronto
Toronto Rehabilitation Institute
Sunnybrook Research Institute

Investigators

  • Principal Investigator: Mark Boulos, MD MSc FRCPC, Sunnybrook Health Sciences Centre
  • Principal Investigator: Yana Yunusova, MSc PhD, Sunnybrook Health Sciences Centre

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

April 1, 2019

Primary Completion (Actual)

December 9, 2022

Study Completion (Actual)

December 9, 2022

Study Registration Dates

First Submitted

December 17, 2019

First Submitted That Met QC Criteria

December 23, 2019

First Posted (Actual)

December 26, 2019

Study Record Updates

Last Update Posted (Actual)

April 14, 2023

Last Update Submitted That Met QC Criteria

April 12, 2023

Last Verified

April 1, 2023

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 313-2018

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

NO

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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