Chiropractic physicians are in a position to recognize the relationship between sleep and health, identify sleep quality concerns, administer sleep quality assessments, and determine appropriate referrals for further sleep quality evaluation. This is important because studies have shown that at least 50 percent of all primary care patients experience insomnia at some point; but only one in three will present the issue to their doctor while just one in 20 will seek therapy for it.1
The U.S. Department of Health and Human Services created a Sleep Health Objective to "increase the proportion of adults who get sufficient sleep" in Healthy People 2020, a federal initiative to improve the nation's health. Chiropractors can and should be part of this initiative.
Obstructive sleep apnea (OSA) occurs in 6-17 percent of the population, and is as high as 49 percent in those of advanced age.2 It has been linked to heart disease, hypertension, obesity, dementia,3 diabetes and depression; therefore, your management of short and poor quality sleep is critical to your patient's overall health.
The Clinical Sleep Workup
Exploring sleep quality and quantity as part of your workup is important for your patient's recovery and functional outcomes. The Epworth Sleep Scale (ESS) is the most commonly used patient-reported outcome measure to assess the impact of sleepiness and evaluate treatment. Other recommended tools include the Functional Outcomes of Sleep Questionnaire (FOSQ),4 the Pittsburgh Sleep Quality Index and STOP-Bang. A systematic review of the overall body of evidence confirms that advancing age, male sex, and higher body-mass index increase OSA prevalence.5
If mild to moderate sleep apnea is suspected, management of risk factors may be adequate. With more severe presentations, consider a home sleep study. These are becoming more common and can be easily ordered, but they have limitations and are not as comprehensive as the gold standard testing of polysomnogram (PSG) to confirm the diagnosis.
If a single home sleep apnea test is negative, inconclusive or technically inadequate, PSG should be performed for the diagnosis of OSA. In the setting of significant cardiac or respiratory disease or chronic opioid medication use, begin with referral for PSG.6
Addressing the Patient's Weight (if Relevant)
The existing evidence addressing obesity has been systematically reviewed and finds that weight loss could be clinically relevant in some patients by reducing obstructive sleep apnea severity.7 In addition, weight change was a stronger predictor of OSA severity reduction than change in fitness, suggesting weight loss should be emphasized in the behavioral treatment of OSA regardless of change in fitness.8
However, general conditioning exercises can also be effective. Exercise as a treatment option has been found to improve OSA indices.9 If you don't do so already, include weight management into your treatment plan when necessary.
Conservative Referral Options to Consider
Although CPAP is considered first-line therapy for symptomatic or moderate-to-severe obstructive sleep apnea, and mandibular-advancement devices and various surgical options are other approaches, compliance is an issue, so supportive treatment options should be considered.10 One such treatment option is acupuncture, which is effective for OSA patients in reducing apnea / hypoxia index (AHI) and ESS; and in improving the SaO2, especially in moderate and severe OSA patients.11
Another supportive treatment endorsed by current literature is myofunctional therapy, a program to address patterns of muscle function for swallowing, breathing and chewing. Myofunctional therapy has been shown to decrease AHI by approximately 50 percent in adults and 62 percent in children. Myofunctional therapy referral could serve as an adjunct to other obstructive sleep apnea treatments.12-13
Referral for dental consultation for a mandibular-advancing oral appliance should be considered. Current guidelines recommend that sleep physicians consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy.14
Clinical Pearls
References
When I graduated from chiropractic college in 1981 and started practice, I heard it all, and very little was positive. “You are a quack; you do not know what a subluxation is; you couldn’t get into a real health care program, so you chose the one that is slightly above a mail-order degree; you have no proof that chiropractic works; Are you really licensed?”, and so much more.
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A central challenge in creating our identity is that chiropractic is a method of care, not a technique or procedure. This is an important concept for us to promote. Our patients are treated with lifestyle modification, exercise, nutritional supplements, diet and a whole-body approach to accelerate the natural healing process. We are not simply CMT providers.
The results of a global survey released late last year (2023) unveiled some startling findings among medical and nursing students. The “Clinician of the Future: 2023 Education Edition” surveyed 2,212 students, of which 446 were in the United States, from 91 countries.
