Introduction
Speech-Language-Hearing Sciences (SLHS) encompass various areas related to human communication
other functions of the orofacial and cervical myofunctional systems, in all their
aspects and life cycles. Since it aims at promoting health and improving the quality
of life, SLHS prevent, assess, diagnose, guide, habilitate, rehabilitate, and improve
SLHS aspects related to peripheral and central hearing functions, oral language, written
language, learning to read and write, fluency, voice, speech articulation, orofacial
and cervical structures and functions involved in breathing, sucking, masticating,
and swallowing, vestibular function (balance), and supplementary, augmentative, and
alternative communication systems.[1]
[2]
[3]
Given these responsibilities, the concern with these disorders has always been part
of the scope of the SLHS. Clinical questions about the characteristics of sleep are
included in medical history survey protocols in all SLHS areas. The characteristics
of sleep have always been addressed as possible etiological, contributing, and/or
aggravating factors of SLHS issues.[4] It is relevant to seek information on the sleep of babies, children, adolescents,
adults, and older adults. Such information is decisive to occupational voice users
and those who want to improve SLH aspects or solve congenital, developmental, or acquired
problems with neurological impairments or other important comorbidities – in which
even the SLH therapy's effectiveness depends on the patient's being awake, attentive,
and alert.
Efficient restful sleep is a multidimensional biological need, responsible for regulating
various systems that play a critical role in well-being, similar to breathing, eating,
drinking, and speaking. However, sleep can be affected by countless factors, greatly
impacting human physical and mental health.[5]
[6]
[7] Sleep deprivation and disorders can negatively interfere with metabolic functioning
in organs and systems, contributing to the onset or aggravation of various diseases,
including cardiovascular problems.[6]
[8] The consequences are not limited to when the person is asleep, as they importantly
affect the time awake, impairing physical and mental development, cognitive aspects,
attention, memory, learning, mood, and disposition, compromising the quality of life
and longevity.[6]
[8]
The interface of sleep disorders with SLHS first appeared in international literature
in the 1960s when certain aspects of communication performance were identified as
sensitive to sleep deprivation, and Morris et al. described its effects on communication
and speech. The most striking conditions verified in sleep deprivation include unclear
communication and changes in the speech rhythm and tone of voice.[9] Particularly, performance in tasks that require sustained attention decreases sharply
as sleep deprivation increases. Moreover, other frequent changes are associated with
sleep deprivation, such as apathy, irritability, increased restlessness, incapacity
to concentrate, and visual illusions. Later studies[10]
[11] point out that speech fluency and spontaneous word generation based on given letters
or categories are likewise significantly impaired by sleep deprivation, even after
a single night without sleeping.[11] More recently, SLHS have specifically focused on sleep and sleep disorders, in an
area referred to as sleep-focused SLHS.
Given the broad field of SLHS practice, its first specialties were defined in Brazil
in 1996: Audiology, Language, orofacial myofunctional field (OMF), and Voice.[12] By 2021, it encompassed 14 specialty areas[13]: Audiology, Dysphagia, Fluency, Occupational SLH Pathology, Educational SLH pathology,
Hospital SLH Pathology, Neurofunctional SLH Pathology, Gerontology, Language, OMF,
Neuropsychology, Forensic SLH Analysis, Public Health, and Voice.
Given the objectives of SLHS in each specialty, it was necessary to broaden SLH skills,
including more in-depth diagnoses of sleep problems and their consequences in all
age ranges. SLHS interfaces not only with various pathologies but also with other
health professionals. Hence, they seek associative factors regarding the issues that
make patients look for professional SLH treatment – which may include consequences
of sleep problems to their health, involving practically all SLHS specialties.[14]
SLHP are currently included in sleep-focused interdisciplinary teams in various public
and private services. The involvement of SLHS with sleep was disseminated at first
mainly through the approach of OMF to sleep-disordered breathing (SDB), particularly
obstructive sleep apnea (OSA) and snoring.
Brazil has unquestionably pioneered in this field of practice. The first study was
published in the late 1990s, showing the main characteristics of oropharyngeal soft
tissues in patients with OSA.[15] After 10 years, another study from the same author, published in the international
literature, addressed the effectiveness of an SLH therapy program to treat OSA,[16] using oropharyngeal myofunctional exercises and approaching mastication, swallowing,
and breathing. The abovementioned study was used in patients with moderate OSA and
had positive results in decreasing OSA signs and symptoms, including improved polysomnographic
parameters. Further studies were conducted based on this research, demonstrating the
effectiveness of orofacial myofunctional therapy (OMT) in reducing the frequency and
intensity of snoring,[17] improving the adherence to the use of continuous positive airway pressure (CPAP)
devices in combined treatments,[18] and possibly modifying tongue structure and functioning in these patients' treatments.[19] These studies address various therapy programs, according to the initial approach;
however, they generally focus on the oropharyngeal muscles and the importance of orofacial
functions to rebalance the upper airway (UA).
In 2014, the SLHS were officially included in the Brazilian Sleep Association (Associação Brasileira do Sono – ABS, in Portuguese), which grants accreditation in sleep-focused SLHS since 2016,
via specific examination, supported by the Brazilian SLH Society (Sociedade Brasileira de Fonoaudiologia – SBFa) and the Brazilian Orofacial Myofunctional Association (Associação Brasileira de Motricidade Orofacial - ABRAMO). Thus, SLH pathologists (SLHP) who are granted this accreditation have
their work recognized in multidisciplinary teams focused on studying, researching,
preventing, assessing, diagnosing, guiding, habilitating, and treating sleep disorders
related to areas encompassed by SLHS. These scientific institutions – SBFa,[20] ABRAMO,[21] and ABS[22]–developed and publicized official reports on sleep-focused SLHS, complying with
ethical and professional norms. In the same year, the Federal SLH Council (Conselho
Federal de Fonoaudiologia – CFFa) passed a resolution that regulates and officializes
the work of SLHP in the area of sleep.[23]
The pioneering initiative in Brazilian SLHS is renowned worldwide in the fields of
SDB due to randomized clinical trials cited in systematic literature reviews and meta-analyses
by national and international authors; publications on sleep from various SLHS specialties
available in indexed journals; the evaluation of scientific institutions and trade
associations on the scope of sleep-focused SLHS; the inclusion of SLHP in conferences
and interdisciplinary discussions on sleep. However, the reach of their work is not
widely known yet in terms of their involvement with sleep and its disorders, interface
possibilities with areas of SLH expertise, and practices that go beyond diagnostic-therapeutic
procedures.
Hence, it was found necessary to reach a consensus on sleep-focused SLHS based on
Brazilian specialists' expertise and the extant literature. These recommendations
are intended for SLHP and other professionals involved in the area of sleep, such
as physicians, dentists, physical therapists, psychologists, nutritionists, physical
educators, primary healthcare personnel, among others.
The process was based on the Delphi method, which is widely used to reach consensus
and is deemed effective in guiding decision-making based on the opinions of specialists
on the topic, leading to reliable results regarding complex and encompassing topics.
This study aimed to develop a consensus on sleep-focused SLHS, based on specialists'
expertise and recommendations previously pointed out in the literature, to indicate
the scope of the area and thus improve the quality of the professional approach.
Methods
This consensus was based on a modified Delphi method, following the guidelines from
CREDES (Guidance on Conducting and REporting DElphi Studies)[24] and EQUATOR (Enhancing the QUALity and Transparency Of health Research).[25]
Delphi studies were initially developed by the RAND Corporationa to reach consensus on military strategy issues,[26] being successfully adapted to health research as a reputable method to reach consensus
on a given topic.[26]
[27] It is currently one of the most recognized methodologies to reach consensus on biomedical
topics, based on specialists' opinions and contributions from specialists,[24]
[26]
[28] especially when evidence is limited, controversial, or not applicable.[27]
[29]
[30]
The Delphi method varies considerably between studies,[28]
[30]
[31]
[32] but it is usually based on iterative rounds with a group of specialists who participate
anonymously, giving their opinions and voting on predefined topics, with the possibility
of reconsidering their votes based on controlled feedback, until they reach a consensus.
The sections below detail how the Delphi method was structured to reach the current
consensus.
Selection of participants
The participants of this Delphi study were divided into four organization levels:
steering committee, core committee, specialist panel, and advisory board. Their names
are listed per level in [Supplementary Table S1] (online only). Their responsibilities and attributions are listed below.
-
Steering committee (comprising LMSP, EMGB, and GNP): Responsible for managing all
works, which included nominating the other participants, defining the questions on
which they would vote, managing voting rounds, analyzing the results of each Delphi
round, and giving feedback to all participants.
-
Core committee: Comprising all members of the ABS SLHS Committee (n = 4) and one invited member, who participated in previous SLH committees. They were
responsible for helping the steering committee define the method for this study, assisting
in the results of each Delphi round when necessary, and organizing work groups to
develop and revise the final report.
-
Panel of specialists: The following were invited to participate in the specialist
panel: Brazilian SLHP accredited by ABS in sleep-focused SLHS and Brazilian SLHS researchers
who authored publications on sleep in the past 10 years, identified through a search
in the CAPES and SCOPUS databases. The panel had 47 SLHP – 32 of them were accredited
by ABS in sleep-focused SLHS, and the other 15 were SLHS researchers, hereinafter
referred to as “panelists.” They were responsible for suggesting new items besides
the ones initially listed by the steering committee and voting in the subsequent rounds.
Only SLHP could participate in the specialist panel, which means that non-SLHP who
participated in the other authorship levels did not vote in any Delphi round. Steering
committee members were not part of the specialist panel (hence, they could not vote)
to avoid possible biases, whereas core committee members were also included in the
specialist panel. Panelists who did not participate at any other level are recognized
in the authorship group named “Consensus Group on Sleep-focused SLHS.”
-
Advisory board: Comprising non-SLHP (sleep physicians, dentists, physical therapists),
whose responsibilities were limited to advisory and consulting roles on specific topics.
All panelists signed an authorship form agreeing with the participation terms regarding
the order of authorship, their inclusion as members of the Consensus Group on sleep-focused
Speech-Language-Hearing Sciences, and obligation to participate in all voting rounds.
Moreover, all participants confirmed they are aware that this consensus is a systematized
collective position in the area; hence, the final document may have statements and
recommendations that do not reflect the personal and professional opinions of each
individual author.
Delphi panel
This Delphi panel had four rounds, as described below. In general, panelists could
vote in these rounds to reach consensus on specific points related to professional
sleep-focused SLH practices or propose items to be voted on. All rounds were developed
in Google Forms, with no synchronous meetings between panelists. All participations
were exclusively online and asynchronous, and panelists had ∼2 weeks to fill in each
round. Also, each panelist did not know who the other ones were, had no access to
their participation, and could not share their responses with anyone to ensure secrecy
in the process.
During the voting stage, all practical items were written and presented in a standard
form, always as affirmative statements (avoiding negative ones) related to the definition,
constitution, and professional practice of the sleep-focused SLH Sciences. In each
item, panelists could vote as one of three options: “agree,” “disagree,” or “I don't
know.” In each author's form, panelists could also give open feedback on voted items.
All items were analyzed based on the panelists' percentage of agreement. Each item
was considered as a consensus when ⅔ (66.6%) of the valid responses were on a same
answer (either “agree” or “disagree”). Items that reached a consensus were not voted
on again, whereas those that did not reach a consensus in the first round were submitted
to voting again in the following round. If no consensus was reached in the second
round, it was considered as “no consensus.” From one round to the next, each panelist
received their own answers and the general descriptive results of the previous panel
(but with no access to the other panelists' individual responses) for them to reassess
and reconsider their votes from one round to the other. Each round's procedures and
activities are presented below.
-
Round #1: Once all Delphi panel members confirmed their participation and agreed with
the authorship criteria, they participated in round #1, which consisted of questions
about sociodemographic data and general directions about the consensus. Sociodemographic
questions aimed to map and describe the participants, including questions on age,
time of professional experience, SLH specialty, work setting (public or private clinic,
hospital, or university), and geographical region. Then, an open question was presented
to obtain their opinion on the constitution of sleep-focused SLH practices, and what
activities should be included in the professional practice in this field. These questions
were intentionally open to generally guide the steering committee and define items
to be voted on in the second round.
-
Round #2: Based on the panelists' contributions in round #1, the steering committee
listed practical items for voting. Some special instructions were organized for panelists
to be attentive to some particularities, especially regarding two important topics.
The first one referred to the nature of the questions, as some addressed SLHS in general,
while others were specifically about sleep-focused SLHS. The second one referred to
the type of sleep disorder – some questions addressed sleep disorders in general,
while other ones were specifically related to SDB. At the end of the voting round,
participants could suggest new items to be voted on in round #3.
-
Round #3: Comprising voting on three types of items: those for which consensus was
not reached in the previous round, new items proposed by the panelists, and items
for which the writing was considered unclear on the previous round. This round included
only voting and suggestions of new items were not allowed.
-
Round #4: It consisted of a voting round only for the items suggested by the panelists
in round #2 and that did no reached consensus on round #3.
Development of practical items for voting rounds
The steering committee was responsible for defining and developing items for voting,
based on the panelists' contributions and with the assistance of the core committee.
All practical items were prepared as soon as round #1 had finished. Altogether, 91
items were developed to be voted on in round #2, distributed into four categories:
professional qualification, diagnosis, treatment, and other topics ([Tables 1]
[2]
[3]
[4] to [5]).
Table 1
Consensus on items related to professional training.
|
Item
|
Consensus index
|
Voting rounds until reaching a consensus
|
|
Sleep-focused SLH Sciences can only be practiced by professionals who have a bachelor's
degree in SLH Sciences.
|
97.9%
|
1
|
|
Sleep-focused SLH pathologists must be trained or accredited by competent trade associations
or professional societies*.
|
91.5%
|
1
|
|
Sleep-focused SLH pathologists must be specifically trained in the areas of sleep.
|
97.9%
|
1
|
|
Sleep-focused SLH pathologists must be experienced in the area of sleep, verified
with clinical activities.
|
93.6%
|
1
|
|
Sleep-focused SLH Sciences training must encompass the following topics:
|
|
Sleep physiology
|
100.0%
|
1
|
|
Physiopathology of sleep disorders
|
100.0%
|
1
|
|
Diagnostic criteria for sleep disorders
|
97.8%
|
1
|
|
Diagnostic and assessment methods in sleep medicine
|
97.8%
|
1
|
|
Therapeutic modalities in sleep medicine
|
100.0%
|
1
|
|
Sleep-focused SLH Sciences is related to the following SLH specialties:
|
|
Audiology
|
78.7%
|
1
|
|
Dysphagia
|
97.9%
|
1
|
|
Fluency
|
76.6%
|
1
|
|
Occupational SLH pathology
|
74.5%
|
1
|
|
Educational SLH pathology
|
83.0%
|
1
|
|
Hospital SLH pathology
|
83.0%
|
1
|
|
Neurofunctional SLH pathology
|
76.6%
|
1
|
|
Gerontology
|
97.9%
|
1
|
|
Language
|
93.6%
|
1
|
|
Orofacial Myofunctional Field
|
100.0%
|
1
|
|
Neuropsychology
|
74.5%
|
1
|
|
Public Health
|
85.1%
|
1
|
|
Voice
|
87.2%
|
1
|
|
Sleep-focused SLH pathologists can work in the following settings:
|
|
|
|
Clinics
|
100.0%
|
1
|
|
Outpatient centers
|
100.0%
|
1
|
|
Hospitals
|
95.7%
|
1
|
|
Schools
|
72.3%
|
1
|
|
Supervising scientific research in the area of sleep does not grant the status of
a Sleep-focused SLH pathologist**.
|
89.4%
|
2
|
|
Conducting scientific research in the area of sleep does not grant the status of a
Sleep-focused SLH pathologist**.
|
83.0%
|
2
|
* The only association that grants accreditation in Sleep-focused SLH Sciences in Brazil
to date is the Brazilian Sleep Association (Associação Brasileira do Sono - ABS).
** All items were voted as positive statements, but items whose consensus was obtained
as “disagree” were rewritten to make clear the direction of the recommendation.
Table 2
Consensus on items related to diagnosis.
|
Item
|
Consensus index
|
Voting rounds until reaching a consensus
|
|
Sleep problems interfere with memory, learning, behavior, emotional regulation, and
communication skills. Hence, the assessment of sleep disorder symptoms and complaints
is included in the SLH pathologists' responsibilities.
|
95.7%
|
1
|
|
Sleep-focused SLH pathologists perform orofacial myofunctional assessments and diagnoses
of sleep-disordered breathing.
|
97.9%
|
1
|
|
Orofacial myofunctional assessments and diagnoses of sleep-disordered breathing are
the exclusive responsibility of sleep-focused SLH pathologists.
|
72.3%
|
2
|
|
Sleep-focused SLH pathologists can request multidisciplinary clinical assessments
of sleep-disordered breathing.
|
100.0%
|
1
|
|
SLH pathologists are responsible for referring patients for thorough sleep assessment
with multidisciplinary and/or interdisciplinary teams.
|
91.5%
|
1
|
|
The work of sleep-focused SLH pathologists encompasses referrals for specialized multidisciplinary
diagnoses.
|
97.9%
|
1
|
|
Sleep-focused SLH pathologists can request the following examinations:
|
|
|
|
Type-I (complete laboratory) and type-II (complete home) polysomnography
|
74.5%
|
2
|
|
Types III and IV polysomnography (cardiorespiratory polygraphy)
|
72.3%
|
2
|
|
Sleep-focused SLH pathologists can accompany complementary instrumental examinations
of sleep disorders (e.g., sleep endoscopy and nasal endoscopy).
|
95.7%
|
1
|
|
SLH pathologists CANNOT emit polysomnography reports*.
|
78.7%
|
1
|
|
Sleep-focused SLH pathologists can apply questionnaires and other subjective tools
to assess sleep disorders and symptoms (e.g., sleep diaries, Epworth Scale, Pittsburgh
Sleep Quality Index (PSQI), Child Obstructive Apnea Syndrome Questionnaire-18 (OSA-18),
etc.).
|
100.0%
|
1
|
|
Sleep-focused SLH pathologists can take anthropometric measures (body mass index and
cervical and abdominal circumference).
|
95.7%
|
1
|
|
Sleep-focused SLH pathologists assess and treat patients at any age with SLH demands
related to sleep disorders.
|
95.7%
|
1
|
|
Sleep-focused SLH pathologists are responsible for sleep-related assessments and clinical
guidance associated with coexisting issues, such as:
|
|
Changes in oral and/or written language
|
95.7%
|
1
|
|
Psycholinguistic skills
|
83.0%
|
1
|
|
Cognitive skills
|
89.4%
|
1
|
|
Central auditory processing
|
87.2%
|
1
|
|
Balance
|
80.9%
|
1
|
|
Hearing
|
89.4%
|
1
|
|
Speech fluency
|
91.5%
|
1
|
|
Voice
|
97.9%
|
1
|
|
Orofacial Myofunctional Field
|
100.0%
|
1
|
|
Dysphagia
|
100.0%
|
1
|
|
Gerontology
|
100.0%
|
1
|
|
Public health
|
91.5%
|
1
|
|
Other fields of SLHS competence
|
85.1%
|
1
|
* All items were voted as positive statements, but items whose consensus was obtained
as “disagree” were rewritten to make clear the direction of the recommendation.
Table 3
Consensus on items related to treatment.
|
Item
|
Consensus index
|
Voting rounds until reaching a consensus
|
|
Sleep-focused SLH pathologists' scope of action encompasses the identification of
risks for sleep disorders.
|
100.0%
|
1
|
|
Sleep-focused SLH pathologists can help diagnose sleep disorders.
|
97.9%
|
1
|
|
SLH pathologists must suspect of and assess sleep disorders whenever signs and symptoms
are present, even if it is not the patient's original complaint.
|
91.5%
|
1
|
|
Sleep-focused SLH pathologists' procedures to treat sleep-disordered breathing include
Orofacial Myofunctional Field competencies.
|
97.9%
|
1
|
|
Sleep-focused SLH pathologists indicate specific orofacial myofunctional therapy for
sleep-disordered breathing alone.
|
76.6%
|
2
|
|
Sleep-focused SLH pathologists indicate specific orofacial myofunctional therapy for
sleep-disordered breathing in combination with other types of treatments.
|
95.7%
|
1
|
|
Sleep-focused SLH pathologists indicate specific orofacial myofunctional therapy for
sleep-disordered breathing as complementary to first-choice treatments, such as surgery.
|
95.7%
|
1
|
|
In Brazil, SLH pathologists are the professionals trained to conduct orofacial myofunctional
therapy for sleep-disordered breathing alone, in combination, or as a complement.
|
93.6%
|
1
|
|
In Brazil, SLH pathologists have the exclusive right to conduct orofacial myofunctional
therapy for sleep-disordered breathing.
|
83.0%
|
1
|
|
Sleep-focused SLH pathologists can help fit different types of continuous positive
airway pressure masks in the multidisciplinary treatment of sleep-disordered breathing.
|
72.3%
|
1
|
|
Sleep-focused SLH pathologists can help choose and fit intraoral appliance models
in the multidisciplinary treatment of sleep-disordered breathing.
|
83.0%
|
2
|
|
Sleep-focused SLH pathologists assess and treat orofacial functions in patients with
diagnosed or suspected sleep-disordered breathing.
|
100.0%
|
1
|
|
SLH pathologists have the exclusive right to assess and treat orofacial functions
in patients with diagnosed or suspected sleep-disordered breathing.
|
87.2%
|
1
|
|
Sleep-focused SLH pathologists can use complementary resources such as laser therapy,
incentive spirometers, therapeutic ultrasound, surface electromyography, electromyographic
biofeedback, and so forth to treat patients with sleep-disordered breathing.
|
97.9%
|
1
|
|
Sleep-focused SLH pathologists can provide clinical reports on the follow-up of cases
of sleep disorders.
|
93.6%
|
1
|
|
Sleep-focused SLH pathologists can request clinical reports on the follow-up of cases
of sleep disorders.
|
97.9%
|
1
|
|
Sleep-focused SLH pathologists CANNOT prescribe cognitive-behavioral therapy*.
|
66.0%
|
1
|
|
Sleep-focused SLH pathologists CANNOT conduct cognitive-behavioral therapy*.
|
95.7%
|
1
|
|
Sleep-focused SLH pathologists can suggest specific assessments on the feasibility
of treatment with cognitive-behavioral therapy, to be conducted by another professional
when the signs and symptoms indicate the need for this therapy.
|
93.6%
|
1
|
|
Sleep-focused SLH pathologists can prescribe positional therapy to treat sleep-disordered
breathing.
|
90.9%
|
1
|
|
Sleep-focused SLH pathologists can conduct positional therapy to treat sleep-disordered
breathing.
|
70.2%
|
1
|
|
Sleep-focused SLH pathologists CANNOT prescribe physical exercises to treat sleep-disordered
breathing*.
|
78.7%
|
1
|
|
Sleep-focused SLH pathologists CANNOT conduct physical exercises to treat sleep-disordered
breathing*.
|
100.0%
|
1
|
|
Sleep-focused SLH pathologists can suggest specific assessments of the feasibility
of treatment with physical exercises in cases of sleep-disordered breathing, to be
conducted by another professional, when the signs and symptoms indicate the need for
this therapy.
|
100.0%
|
1
|
|
Sleep-focused SLH pathologists CANNOT prescribe weight loss therapy to treat sleep-disordered
breathing*.
|
72.3%
|
1
|
|
Sleep-focused SLH pathologists CANNOT conduct weight loss therapy to treat sleep-disordered
breathing*.
|
97.9%
|
1
|
|
Sleep-focused SLH pathologists can suggest specific assessments on the feasibility
of treatment with weight loss therapy in cases of sleep-disordered breathing, to be
conducted by another professional, when the signs and symptoms indicate the need for
this therapy.
|
97.9%
|
1
|
|
Sleep-focused SLH pathologists CANNOT prescribe intraoral appliances to treat sleep-disordered
breathing*.
|
93.6%
|
1
|
|
Sleep-focused SLH pathologists CANNOT conduct therapy with intraoral appliances to
treat sleep-disordered breathing*.
|
95.7%
|
1
|
|
Sleep-focused SLH pathologists can suggest specific assessments on the feasibility
of treatment with intraoral appliances in cases of sleep-disordered breathing, to
be conducted by another professional, when the signs and symptoms indicate the need
for this therapy.
|
95.7%
|
1
|
|
Sleep-focused SLH pathologists CANNOT prescribe therapy with continuous positive airway
pressure devices to treat sleep-disordered breathing*.
|
87.2%
|
1
|
|
Sleep-focused SLH pathologists CANNOT conduct therapy with continuous positive airway
pressure devices to treat sleep-disordered breathing*.
|
80.9%
|
1
|
|
Sleep-focused SLH pathologists can suggest specific assessments on the feasibility
of treatment with continuous positive airway pressure devices to treat sleep-disordered
breathing, to be conducted by another professional when the signs and symptoms indicate
the need for this therapy.
|
93.6%
|
1
|
|
Sleep-focused SLH pathologists can suggest specific assessments on the feasibility
of treatment with skeletal surgeries in cases of sleep-disordered breathing, to be
conducted by another professional, when the signs and symptoms indicate the need for
this therapy.
|
95.7%
|
1
|
|
Sleep-focused SLH pathologists can suggest specific assessments on the feasibility
of treatment with oropharyngeal soft tissue surgery in cases of sleep-disordered breathing,
to be conducted by another professional, when the signs and symptoms indicate the
need for this therapy.
|
95.7%
|
1
|
* All items were voted as positive statements, but items whose consensus was obtained
as “disagree” were rewritten to make clear the direction of the recommendation.
Table 4
Consensus on items related to other topics.
|
Item
|
Consensus index
|
Number of voting rounds until reaching a consensus
|
|
Sleep-focused SLH pathologists can work in multidisciplinary teams in the area of
sleep.
|
100.0%
|
1
|
|
Sleep-focused SLH pathologists can coordinate multidisciplinary teams in the area
of sleep.
|
89.4%
|
1
|
|
Sleep-focused SLH pathologists can teach and coordinate courses in the area of sleep.
|
97.9%
|
1
|
|
Sleep-focused SLH pathologists can coordinate initiatives and campaigns in the area
of sleep.
|
97.9%
|
1
|
|
Sleep-focused SLH pathologists can hold administrative positions in the area of sleep.
|
97.9%
|
1
|
|
Sleep-focused SLH pathologists can be the technical professionals responsible for
devices and appliances related to sleep.
|
68.1%
|
1
|
|
Sleep-focused SLH pathologists' scope of action in multidisciplinary teams can involve
the management and conduction of scientific studies and research.
|
97.9%
|
1
|
|
Sleep-focused SLH pathologists can work in preventing sleep disorders through guidance
and participation in initiatives and campaigns to instruct the population.
|
100.0%
|
1
|
|
Sleep-focused SLH pathologists can address sleep disorders through guidance on sleep
hygiene.
|
97.9%
|
1
|
|
Sleep-focused SLH pathologists' scope of action encompasses guidance and adjustment
of orofacial myofunctional aspects that predispose to sleep-disordered breathing.
|
100.0%
|
1
|
* All items were voted as positive statements, but items whose consensus was obtained
as “disagree” were rewritten to make clear the direction of the recommendation.
Table 5
Items on which no consensus was reached.
|
Category
|
Item
|
Consensus index
|
|
Professional training
|
Sleep-focused SLH Sciences is related to the following SLH specialties: [Forensic
SLHS Analysis]
|
51.1%
|
|
Diagnosis
|
Sleep-focused SLH pathologists can request the following examinations: [Actigraphy]
|
63.8%
|
|
Others
|
Is it the sleep-focused SLH pathologists' role to sell positive airway pressure devices?
|
57.4%
|
All these items were submitted to two voting rounds, but they did not reach 66.6%
of equal responses on either occasion.
a RAND Corporation is a nonprofit, non-partisan research organization that develops
solutions for public policy challenges, aiming to make worldwide communities safer,
healthier, and more prosperous.
The steering committee reserved the right to remove or exclude items at any moment,
as long as its members reached an absolute consensus on it. The possible reasons for
it include logical inconsistencies (e.g., more restrictive items reaching a consensus
when broader ones had not), unclear phrasing, or political inconsistencies (e.g.,
items inconsistent with laws, SLH prerogatives, or other professions' prerogatives).
Discussion
Sleep-focused SLHS is a promising area, which has played an essential role in sleep
disorders management interdisciplinary teams. The interest in the area increased by
the late 1990s when the first studies and clinical approaches aimed to identify orofacial
myofunctional issues in patients with OSA and snoring[15] and understand the impact of sleep disorders on contexts related to SLHS specialties,
such as language, voice, speech fluency, and hearing.[33]
This consensus aimed to address the SLHP's training, their work in the area of sleep,
details on specific SDB therapy, and other multidisciplinary relationships. The SLHP
who participated in this study reached a consensus that sleep-focused SLHS should
be practiced exclusively by professionals with a degree in SLHS (97.9%) with specific
training in the area of sleep (97.9%).
SLHS in Brazil currently encompasses 14 specialties thanks to its scope in practices
regarding communication and eating processes and disorders. SLHS undergraduate programs
address specific topics such as sleep disorders, but they are only approached in-depth
in postgraduate improvement or specialization programs. In undergraduate studies,
topics on sleep disorders are usually addressed in OMF courses, as this area has a
greater interface with SDB treatment with OMT. These results reinforce the need to
review the pedagogical frameworks of undergraduate SLHS programs, as the participants
also reached a consensus that the sleep-focused SLHS are related to various other
specialties, such as Audiology, Dysphagia, Fluency, Occupational SLH Pathology, Educational
SLH Pathology, Hospital SLH Pathology, Neurofunctional SLH Pathology, Gerontology,
Language, Neuropsychology, Public Health, and Voice ([Table 1]).
The CFFa aimed to officialize the scope and criteria of SLHS practice in 2009, including
the responsibility for SLH assessment and therapy of SDB in the official document
– the 3rd edition of the Brazilian Classification of SLH Procedures (CBPFa).[34] Even though orofacial myofunctional treatment of SDB is included in OMF, countless
other SLHS productions point to the importance of various SLHS specialties in the
procedure and management of different sleep disorders.[33]
Sleep changes can interfere with voice quality[35] or impair communicative competence, as it interferes with speech-motor functions.[11]
[36] Sleep deprivation can also lead to language changes when this function is being
developed.[37] Impacts on the sleep of children and adolescents with stuttering have also been
observed – they were found to be four times as likely to have insomnia or sleep difficulties
as individuals who did not have this disorder.[38]
Sleep also interferes directly with cognitive processes, which in turn interact with
communication and eating – skills encompassed in the domain of SLHP. Sleep architecture
and other parameters such as sleep latency, efficiency, and total time are associated
with cognitive functions.[39] Evidence indicates that naps impact preschoolers' vocabulary performance[40] and that sleep has an essential role in consolidating adults' declarative memory.[41]
Sleep-related problems may interface simultaneously with various SLHS fields. The
assessment of children of different ages clearly shows that obstructive SDB impacts
oral language, oral reading, and hearing skills.[42] Indicated treatment, usually adenotonsillectomy, and longitudinal follow-up improved
these skills, although they do not always level with the control population,[43] with the continuity of habitual mouth breathing and residual apnea and/or hypopnea.
Hence, SLHP have an important role in assessing communication skills as early as possible
and identifying possible sleep changes to proceed with the appropriate treatment and
minimize cognitive impacts.
There was no consensus only in the area of Forensic SLHS Analysis, which led to presenting
the question again in the subsequent research round. However, agreement was still
low (52.2%). The divergence may be due to the recent recognition of this specialty
as an area of the SLHS.[44] This field of practice is related to legal and administrative processes, which can
be related to the area of sleep as sleep disorders poses greater risks of accidents
in traffic[45] and at work.[46] This topic may also be involved in homicide processes.[47]
[48]
The first internationally relevant randomized clinical trial approaching the effects
of OMT on reducing moderate OSA signs and symptoms was published in 2009. Its results,
based on the physiological parameters analyzed, showed significant differences in
anthropometric measures related to reduced cervical circumference with no decrease
in the body mass index (BMI). Physiological data obtained with polysomnography verified
an ∼40% decrease in the apnea-hypopnea index (AHI). Parameters on the symptomatology
analyzed also showed a decrease in snoring intensity and frequency and daytime sleepiness
and improved quality of sleep after applying for the OMT program. This pioneer publication
was an important landmark in the national and international recognition of SLH practice
regarding sleep disorders.[16] This study motivated further randomized clinical research that helped consolidate
this therapeutic approach.
Clinical studies conducted so far have presented encouraging results regarding the
effects of OMT on mild and moderate OSA treatment. In a specific study that verified
the effects of OMT on snoring,[17] this therapeutic approach reduced the index, total power, frequency, and intensity
of snoring[17] and AHI and improved breathing patterns and the quality of sleep in affected individuals.[18]
[19]
[49]
OMF sustains the possibility of SLHS practice in the alternative treatment of oral
and nasopharyngeal obstructions during sleep, with the probability of potentializing
pharyngeal permeability with oropharyngeal exercises and adjustments in orofacial
functions. A systematic review of eight studies demonstrated that this treatment is
an option for obstructive disorders, although further investigations are needed to
direct the eligibility for this treatment[50] and longitudinal results follow-up.
OMF specialists are knowledgeable of the anatomy and physiology of the stomatognathic
system, which encompasses UA oropharyngeal muscles and the other structures related
to breathing, mastication, swallowing, and speech. Hence, they are apt to manage orofacial
myofunctional disorders associated with SDB. Dysphagia and Voice specialists also
master these issues, focused on the health, safety, and rehabilitation of swallowing
and voice, respectively. However, these competencies may not be enough for the professional
practice encompassing sleep disorders. Participants reached a consensus that sleep-focused
SLHP must also master the following topics: physiopathology of sleep (100%), physiopathology
of sleep disorders (100%), diagnostic criteria for sleep disorders (97.8%), sleep
assessment and diagnostic methods (97.8%), and therapeutic modalities to treat sleep
disorders (100%). Hence, minimum training programs for sleep-focused SLHP must have
these items in their course content.
Scientific societies' evaluation reports reinforce the SLHS practice to address sleep
disorders and point out the need for specific training in the area, interdisciplinary
teamwork skills, and OMF training to perform OMT aimed at cases of snoring and OSA.
The documents reinforce the work of SLHP regarding sleep disorders and highlight the
scientific associations' recognition of this field of practice.[21]
[22]
[23]
Continuing education is essential for professionals to update on scientific and technological
advancements. SLHP must be attentive to updates in the area of sleep and participate
in courses, workshops, conferences, and study groups in this field to improve and
develop specific theoretical-practical skills for such practice. A consensus was reached
that sleep-focused SLHP must be experienced in the area of sleep, verified with clinical
activities (93%). However, supervising (98.4%) or conducting (83%) scientific studies
in the area of sleep does not grant the status of a sleep-focused SLHP.
Sleep-focused SLHP must be trained or accredited by a competent trade association
or professional society, according to the SLHP participating in the consensus (91.5%).
So far, ABS is the only association that accredits sleep-focused SLHP in Brazil. ABS
is a worldwide recognized interdisciplinary institution, which includes various Brazilian
professionals that study sleep – e.g., basic experimental areas, biologists, polysomnography
technicians, physical therapists, SLHP, psychologists, dentists, physical educators,
nutritionists, and physicians. ABS has accredited sleep-focused SLHP yearly since
2016 by analyzing their curricula vitae and applying theoretical and practical tests.
The main goals of the process of accrediting in sleep-focused SLHS are to assess the
pathologist's theoretical-practical mastery of the implications, diagnosis, and treatment
of sleep disorders and prove their professional competence in the area of sleep. A
minimum training in the area of sleep is a sine qua non condition to apply to the
accreditation test. Applicants must have more than 3 years of professional experience
as an SLHP, according to their CFFa registry, and prove they are apt to work as a
sleep-focused SLHP, according to their training in the previous 10 years, as indicated
in the announcement of the proposing institution. Lastly, the candidate is submitted
to a theoretical and a practical test to be recognized as an accredited sleep-focused
SLHP.
There was a consensus that SLHP can work in clinical, outpatient, hospital, and school
settings, which reinforces the range of possibilities and the interaction of sleep-related
problems with different interfaces in SLHS, regardless of the field of practice, from
sleep disorders prevention to specific SDB rehabilitation.
Concerning the consequences of sleep disorders, participating SLHP reached a consensus
(95.7%) that sleep problems interfere with memory, learning, behavior, emotional regulation,
and communication skills – hence, the assessments of symptoms, complaints, and sleep
disorders are part of the SLHP's responsibilities.[51]
[52]
[53]
[54]
[55]
Participants also reached a consensus that sleep-focused SLHP assess and diagnose
orofacial myofunctional disorders regarding SDB (97.9%) and that this competence is
exclusive to sleep-focused SLHP (72.3%). Considering that SLHP are the professionals
officially trained to assess and diagnose orofacial myofunctional conditions,[34] a consensus was reached that, in the case of SDB, this responsibility is exclusive
to sleep-focused SLHP – hence, other health professionals should not conduct this
assessment. Thus, analyzing the diagnostic assessment process as a guide to decision-making
and therapy planning, in addition to specific assessments by the other professionals
who follow up on the case, it is essential to have specific knowledge of the area
of sleep.
The complexity of sleep-related pathologies requires medical guidance and multidisciplinary
observation, which often determines the need for referrals and complementary assessments.
The results of this consensus (100%) indicate that sleep-focused SLHP can request
multidisciplinary clinical SDB assessments. It is the SLHP's responsibility to refer
patients for thorough sleep assessment by multidisciplinary teams (91.5%), as well
as specialized multidisciplinary diagnosis (97.9%).
SLHP can request previous examinations from the physician responsible for the case,
as long as they have the competence to analyze the examinations and it is decisive
to reach an SLH diagnosis and define SLH therapy strategies. As for sleep disorders
examinations, they should also be competent and trained in the area of sleep and have
specific knowledge of the examination equipment, procedures, and parameters obtained
and analyzed. SLHP are not responsible for nosologic diagnoses, but they must be apt
to understand and interpret the parameters assessed in the examinations, as the results
may pose criteria for SLH indications or the ineligibility of SLH therapy. Hence,
the interdisciplinary team approach favors case discussion and a more accurate definition
of procedures, as complementary examinations requested by the physician responsible
for the case may provide important data to sleep-focused SLHP.
The consensus on complementary examinations is considered as a prerogative that these
and other complementary assessments be requested from the sleep physicians responsible
for the case. This study reached a consensus that sleep-focused SLHP can request to
physicians and patients (if they already have them) type-I (complete laboratory),
type II (complete home) (74.5%), and types-III and IV polysomnography (cardiorespiratory
polygraphy) (72.3%) necessary to the SLH practice, case discussion in interdisciplinary
teams, SLH diagnosis, and progress of the SLH treatment. When the SLHP is the first
professional visited by the patient, referring them to a sleep physician is decisive
in reaching a diagnosis and requesting complementary examinations when necessary to
enable sleep-focused SLHP to discuss the case and define their procedures.
Following the same interdisciplinary parameter, it was a consensus that SLHP can accompany
complementary instrumental sleep disorders examinations (e.g., sleep endoscopy and
nasal endoscopy) (95.7%), certainly as long as they are authorized by the physician
performing the examination. As expected, it was a consensus that sleep-focused SLHP
are not responsible for emitting polysomnography reports.
No consensus was reached on the request for actigraphy by sleep-focused SLHP. This
result may be related to SLHP's little knowledge of this procedure.
Conducting SLH assessments in cases of sleep disorders will depend on the SLHS interface
to which sleep disorders is related. It was a consensus that it is the role of sleep-focused
SLHP to assess and direct clinical procedures regarding sleep associated with coexisting
issues, such as changes in oral and/or written language (91.7%), psycholinguistic
skills (83.0%), cognitive skills (89.4%), central auditory processing (87.2%), balance
(80.9%), hearing (84.4%), speech fluency (91.5%), Voice (97.9%), OMF (100%), Dysphagia
(100%), Gerontology (100%), Public Health (91.5%), and the other fields of SLHS competence
(85.1%). These results are due to the evidence in the cited areas.[38]
[56]
[57]
[58]
[59]
[60]
[61]
[62]
[63]
[64]
[65]
[66]
[67]
In cases of SDB, the goal of SLH assessment is to determine muscle and functional
imbalances that may affect UA permeability during sleep.[19] The eligibility for SLH therapy intervention alone is related to these patients'
lack of impeditive factors, such as mechanical airway obstruction, craniofacial changes,
neuromuscular diseases, and orofacial myofunctional disorders.[68] In this context, the association of SLH demands with sleep pathologies will determine
such procedures.
It was a consensus that sleep-focused SLHP can take anthropometric measures (BMI and
cervical and abdominal circumference) (95.7%). The use of specific standardized protocols
to assess orofacial structures and functions,[69]
[70]
[71] the assessment of anthropometric measures, and the observation of proportions between
oral and pharyngeal structures – such as the modified Mallampati index and palatine
tonsil classification regarding the percentage of pharyngeal light obstruction[71]
[72]–are part of the SLH process of assessing SDB. A study points out that SLHP experienced
in the area of sleep are apt to assess and classify the oropharyngeal region and identify
predictive factors for OSA and snoring.[73] It is highlighted that physicians are responsible for diagnosing pharyngeal obstructions
and/or pathologies.
SLH assessment includes questionnaires and other subjective tools to assess sleep
disorders and symptoms, such as sleep diaries, the Epworth Scale, Pittsburgh Sleep
Quality Index (PSQI), Berlin Questionnaire, Child Obstructive Apnea Syndrome Questionnaire-18
(OSA-18), and so forth, according to all participants in this consensus study. Most
of them are easy to apply and, though not intended for diagnosis, can support the
indication to other professionals and help monitor therapy intervention results.
It was a consensus that the practice of sleep-focused SLHP includes the identification
of risks that may lead to sleep disorders (100%) and help diagnose sleep disorders
(97.9%). Hence, the abovementioned questionnaires can be used to screen and identify
sleep disorders signs and symptoms.
SLHP must suspect and assess sleep disorders whenever signs and symptoms are present,
even if it is not the patient's and/or the group's original complaint, according to
consensus results (91.5%) ([Table 3]). SLHP assessed Brazilian adolescents' quality of sleep during the COVID-19 pandemic
with no specific demand, considering that social distancing could impair young students'
sleep during this moment in history and have cognitive-behavioral impacts on learning.
The investigation of the quality of sleep identified, among other aspects, that their
quality of sleep worsened, impacting their motivation to study.[3]
Sleep-focused SLHP assess and treat patients at any age with sleep disorders-related
SLH demands, according to the professionals who participated in this study (95.7%).
This is justified by the scope of SLH practice, which encompasses all life cycles.
In general, SLH intervention aims to attenuate symptoms and improve the patients'
quality of sleep and life. On the other hand, in specific terms, sleep-focused SLH
therapy must be based on the patients' phenotypes – hence, age is one of the decisive
factors to customize assessment criteria and establish therapeutic goals[74] ([Table 2]).
Participants reached a consensus (97.9%) that the procedures of sleep-focused SLHP
to treat SDB encompass OMF competence and specific OMT indication for SDB alone (76.6%),
in combination with other types of treatment (95.7%), and as a first-choice complementary
therapy to the first-choice treatment, as in surgical cases (95.7%). The recognition
of this competence certainly originates in the first published Brazilian studies[15]
[16] that point out the pioneering initiative of Brazilian SLHP in the orofacial myofunctional
treatment of SDB. It was a consensus that, in Brazil, SLHP are exclusively apt and
responsible for OMT for SDB alone, in combination, or complementarily (83%).
As mentioned above, some groups of patients have reserved OMT prognoses. Brazilian
randomized studies[16]
[17]
[49] excluded patients whose BMI was higher than 40 kg/m2 and who had craniofacial malformations and severe obstructive nasal diseases. Thus,
there is no evidence of the effect of OMT in these cases. These criteria must be carefully
assessed, as referrals by competent professionals to assess and correct changes are
often needed.
Age is another important factor for OMT indication. The same Brazilian randomized
studies[16]
[17]
[49] included adult patients up to 65 years old but did not indicate the efficiency of
this therapy in older patients. On the other hand, some clinical cases[75] and new randomized studies[76] demonstrate that OMT effectively reduced AHI and improved orofacial myofunctional
aspects in older patients with moderate to severe OSA.
Craniofacial malformations, for instance, interfere with the positioning and functioning
of orofacial muscles, causing functional adaptations,[77] and obstructive nasal diseases cause changes such as low tongue, absent lip sealing,
flaccid orofacial muscles, and breathing, mastication, and swallowing changes. Obesity,
which is the main risk factor for OSA – due to UA narrowing caused by the increase
in soft tissues and decrease in pulmonary volume, diminishing tracheal traction, and
pharyngeal wall tension[78]–also have orofacial myofunctional aspects that must be observed.[79]
A randomized clinical study showed that OMT had no significant effect on reducing
obese patients' snoring.[80] OMT, in these cases, can be combined with treatments to reduce and control weight,
as these factors compromise the success of OMT when applied alone.[81] On the other hand, research[17] compared two groups of patients whose BMI was 28.2 ± 3.1 kg/m2 and whose AHI was 15.3 ± 9.3 events/h and verified no significant change in the control
group and a significant decrease in the snoring index in patients submitted to SLH
therapy. In this randomized study, the control group comprised patients who used nasal
dilators and did breathing exercises, and the therapy group did daily oropharyngeal
exercises.
OMT aims to improve muscle function and control. Thus, among the many possible causes
or phenotype and endotype characteristics of the pathogenesis of OSA, this therapy
addresses non-anatomical causes, acting on the activity of the pharyngeal dilator
muscle during sleep. Identifying these characteristics through detailed assessments
and developing personalized therapies aiming selectively at one or more treatable
characteristics have the potential to optimize therapeutic results.[82] However, some studies demonstrate the possible anatomical effects of OMT on OSA
patients, such as the decrease in tongue volume and fat,[71] reaffirming the SLHS possibilities with judicious indication.
As seen in [Table 3], participants in this consensus study unanimously agreed that sleep-focused SLHP
can assess and treat orofacial functions in patients with diagnosed or suspected SDB.
SLHP's possibility of providing care to these patients has already been generally
legitimated internally by the SLHS[20]
[21]
[22] and Sleep Medicine.[8]
[23]
The degree of OSA based on AHI was until recently the main parameter to indicate OMT
to these patients – those with mild and moderate apnea were the main candidates for
this treatment modality. AHI is still an indicative parameter, but other aspects must
be considered, such as the oxyhemoglobin desaturation index, duration of breathing
pauses, sleep phase when apnea mostly occurs, microwakes index, and so on.
Besides the polysomnography parameters mentioned above, clinical warnings or impediments
to OMT must be considered as well. Patients with impaired nasal permeability, neuromuscular
diseases, craniofacial skeletal discrepancies, and cognitive limitations, for example,
may not benefit from SLH procedures alone. In this regard, a recent literature review[83] reconstructed the history of AHI creation and evolution, followed by a critical
assessment of its importance in research and medical clinical practice.
OMT is characterized by a set of procedures based on myofunctional exercises in the
orofacial and cervical regions, focused on the sensitivity, proprioception, mobility,
coordination, and strength of the structures involved to adjust breathing, mastication,
swallowing, and speech.[70] It is based on myofunctional exercises with isotonic and isometric contractions
that change orofacial and oropharyngeal patterns.[16]
[17]
[18]
[19] The process uses periodic muscle training to improve muscle coordination, tonicity,
and resistance, ease muscle fatigue, balance the contraction of pharyngeal muscles,[70]
[84]
[85] reduce the volume and fat of the structures involved, and attenuate UA collapses
during sleep.[19]
[86]
Despite the efforts to deconstruct the idea that OMT is based exclusively on exercises,
they are unquestionably one of its resources. However, considering the great variability
of exercises used in OMT approaches portrayed in scientific studies and referenced
in systematic literature reviews and meta-analyses,[70]
[87] clinical indication and individual adequacy must be the SLHP's main concern. The
intensity, number of repetitions, frequency of exercises, and duration of therapy
are often discussed in OMF clinical practice, being extended to sleep-focused SLH
therapy regarding SDB. Training programs and protocols must be changed or adapted
to meet specific populations and maximize the results. The exercise dose is an essential
component in any exercise-based therapy – hence, understanding the relationship between
the dose and the effectiveness of the treatment is essential to maximize the benefit
to the patient.[88]
Participants reached a consensus (97.9%) that complementary resources such as laser
therapy, incentive spirometers, therapeutic ultrasound, surface electromyography,
electromyographic biofeedback, and so forth are used by sleep-focused SLHP to treat
patients with SDB. OMF is increasingly using photobiomodulation. Despite the lack
of direct evidence of its effects in OMT in patients with SDB, laser therapy aims
to decrease edema and improve local sensitivity and muscle function. The indication
is to use it before the activity requested by the SLHP as a potentializing resource
to support OMT. It can be widely applied, encompassing the oropharyngeal region, tongue,
suprahyoid muscles, lips, and cheeks.[89]
Incentive spirometers are portable devices that train breathing muscles by strengthening
inspiratory and expiratory muscles and activating suprahyoid muscles and hyoid bone
movement. They were widely used in SLH therapy in cases of dysphagia and voice disorders.[90]
[91] Regarding SDB, Respiron was used in inhaling and exhaling in a recent study, opening
the space between lateral pharyngeal walls, as verified in fiberoptic nasolaryngoscopy
and semi-occluded vocal tract exercises with LaxVox tube.[92]
[93] This voiced breathing technique in a silicone tube for 20 minutes per day for 10
weeks improved the quality of sleep and decreased snoring in a case study.[94] Threshold IMT (Respironics, USA) is another incentive spirometer addressed in a
study that compared the effectiveness of oropharyngeal exercises with inspiratory
muscle training using this device. The results indicate no significant differences
in AHI between the groups, as both the oropharyngeal exercises and the device increased
the expiratory muscle strength, decreased excessive daytime sleepiness, and improved
the severity and frequency of snoring, fatigue, and quality of sleep.[95]
Customizing SLH care for patients with SDB goes beyond specific OMF issues and polysomnography
data. The detailed analysis of overall health, including the investigation of systemic
diseases and comorbidities, metabolic and cardiovascular diseases, arterial hypertension,
gastroesophageal reflux, depression, other diagnosed or reported sleep disorders,
allergies, respiratory obstructions, and other health issues must be recorded along
with the treatments that have been used for each one of them.[68] Moreover, it is important to listen attentively to the reported details of sleep
routines and habits. Even though OMT is based on specific premises, as mentioned above,
the treatment goal is the individual with sleep disorders and all issues related to
the sleep problem, not only the dysfunctional pharynx.
According to this consensus, sleep-focused SLHP can prescribe (90.9%) and conduct
(70.2%) positional therapy (PT) to treat SDB. It is known that the supine position
may be associated with increased obstructive events,[96] and the work of sleep-focused SLHP requires fundamental theoretical knowledge of
the physiology of sleep, the physiopathology of sleep, and types of multidisciplinary
approaches to sleep.[86] Hence, it is appropriate that SLHP conduct such guidance in interdisciplinary approaches
associated with OMT management, as long as they are updated on the effectiveness of
various PT devices available. The practice of sleep-focused SLHP also encompasses
guidance and adjustment of orofacial myofunctional aspects that predispose to SDB,
according to the results of this consensus study (100%), and addresses sleep disorders
through sleep hygiene instructions (97.9%).
Unquestionably, sleep disorders require a multidisciplinary approach.[97]
[98] However, the professionals reached a consensus in this study that prescribing and
performing physical exercises, prescribing and performing weight loss therapy, prescribing
and performing therapy with intraoral appliances (IOA), prescribing and performing
therapy with CPAP, and prescribing and performing cognitive-behavioral therapy are
not among the procedures to be performed by sleep-focused SLHP. On the other hand,
these pathologists can suggest specific feasibility assessments of treatment with
cognitive-behavioral therapy (93.6%), physical exercises (100%), weight loss therapy
(97.9%), IOA (95.7%), CPAP (93.6%), skeletal surgeries (95.7%), and oropharyngeal
soft tissue surgery (95.7%) in cases of SDB, to be conducted by other professionals
when the signs and symptoms suggest the need for such therapy.
CPAP is the first-choice OSA treatment, just as there is evidence of using IOA to
treat SDB.[8] However, it is known that they may cause immediate side effects such as aerophagia,
oral and nasal dryness, and exhaling difficulties in the case of CPAP, and excessive
salivation, oral dryness, muscle and temporomandibular joint discomfort, mastication
difficulties, and others related to IOA. These can impair the adaptation of such therapeutic
resources, consequently undertreating the patients. Nevertheless, part of the reported
difficulties may be related to orofacial structures and functions, which are within
the competence of SLHP. Moreover, people with SDB also have masticatory[99] and swallowing changes[66] and inadequate tongue and lip posture at rest, which are important factors that
hinder nasal breathing during sleep as well. In this context, sleep-focused SLHP can
help fit different types of CPAP masks (72.3%) and help choose and fit IOA models
(83%) in multidisciplinary approaches to treating SDB, according to the results of
this consensus study.
Combined treatments are commonly used in SLH procedures, as in the case of mouth-breathers,[100] denture wearers,[101] and patients with temporomandibular disorder.[102] In SDB, specifically, OMT is an alternative treatment used in combination with CPAP
to aid adherence to the use of the gold-standard device[18]
[49] and help decrease air escape through the oral cavity when using CPAP.[103] Regarding combined treatments, a randomized study[18] compared four groups of patients, as follows: submitted to placebo OMT, treated
with OMT, treated with CPAP, and treated with OMT in combination with CPAP. The participants'
AHI was 30.9 ± 20.6 events/h. The groups submitted to treatment had a decrease in
snoring and on the Epworth Sleepiness Scale, and the OMT group maintained such improvement
after the washout period. AHI decreased in all treated groups, more significantly
in the CPAP group. The OMT and combined groups improved tongue and soft palate muscle
strength, in comparison with the placebo group. The combined OMT and CPAP group had
greater adherence to CPAP than the CPAP group.
Sleep disorders has a multifactorial origin and various consequences, including genetic,
endotype, phenotype, and environmental factors, thus suggesting the need for multiprofessional
assistance.[88]
[98] SLHP have been increasingly included in multidisciplinary teams, as well as SLH
professors in improvement and specialization courses in the area of sleep. All participants
(100%) in this consensus study agreed that sleep-focused SLHP can work in multidisciplinary
teams in the area of sleep, in activities related to the management and conduction
of scientific studies and research (97.9%), coordination of multidisciplinary teams
(89.4%), and teaching and coordinating courses in the area of sleep (97.9%).
SLHP's professional prerogatives include “... emitting SLHS statements, opinions, evaluations, and reports; teaching; conducting
technical oversight, assistance, consultancy, coordination, administration, management,
guidance, inspection, expert analysis, auditing, and other practices necessary to
their full professional activity, complying with the recognized procedures and current
laws...”[104]. Sleep-focused SLHP can furnish clinical follow-up reports in cases of sleep disorders
(93.6%) and request such reports (97.9%).
It was an absolute consensus that sleep-focused SLHP can work in sleep disorders prevention
by providing guidance, participating in initiatives and campaigns to instruct the
population (100%), coordinating initiatives and campaigns in the area of sleep (97.9%),
and holding administrative positions in the area of sleep (97.9%). This has already
been practiced by sleep-focused SLHP in Brazil, as they coordinate yearly national
campaigns, such as Sleep Week, and participate in management, holding regional and
national coordination and board positions at ABS.
SLHP have been increasingly included in the area of sleep. Sleep has been approached
as a topic of SLHS research and publications, reflected and disseminated in the participation
of SLHP in conferences of related areas, such as medicine, dentistry, nutrition, education,
and so on. Practically all SLHS specialties deal with sleep and sleep disorders in
different ways, as both diagnosis and treatment of the countless SLH disorders are
interrelated and interdependent. This consensus study discussed and defined the SLH
practice regarding SDB as a treatment alternative with OMT alone (to reduce snoring,
OSA severity, and sleepiness) or in combination with other treatment modalities. However,
not all mechanisms to obtain these results are widely known, and longitudinal follow-up
studies are still scarce. Understanding such mechanisms may help inform what OSA phenotypes
are more likely to respond to this form of therapy.[84]
