Did you know there’s a quick, easy way to significantly reduce (or outright eliminate) obstructive sleep apnea?
It’s called “positional therapy”, and it simply means changing the position that you sleep in.
If you sleep on your back, reducing or eliminating your obstructive sleep apnea (OSA) might simply be a matter of sleeping on your side or stomach.
While that might seem too good to be true, there’s been a lot of research going back thirty years (that’s right – thirty!) that proves the effectiveness of positional therapy for people whose sleep apnea is caused primarily by their sleep position.
In this plain English guide you’ll learn:
Let’s jump in!
What is Positional Obstructive Sleep Apnea?
Among people who have obstructive sleep apnea (OSA), there is a large proportion of patients whose OSA is greatly worsened by sleeping in the “supine” position (on their backs) 1. Such patients are said to have “positional” obstructive sleep apnea (POSA) 1.
Simply put, if a person’s sleep apnea is much worse when they sleep on their back (versus on their side or stomach) then they’re considered to have POSA.
There are many ways that sleep specialists can determine if your OSA is due to sleeping on your back. The gold standard clinically is the apnea-hypopnea index (AHI), which is most widely used to quantify the severity of OSA 1.
Before getting into more information regarding POSA, it’s helpful to know terms that are commonly used by sleep specialists related to OSA. In the next section we cover the most frequent definitions used by sleep clinicians.
Basic Definitions Related to Obstructive Sleep Apnea
Classification of Obstructive Sleep Apnea Severity
As mentioned, the AHI (apnea-hypopnea index) is used to quantify severity of OSA. Severity of OSA is as follows:
All apnea measurements, including the measure of the flow of air through the upper airway, the blood oxygen saturation percentage, and the electroencephalogram (EEG), are all recorded through a night of sleep.
This is conducted (somewhat uncomfortably for the patient!) overnight in a sleep lab and constitutes a “sleep study”, which we refer to as polysomnography (PSG). PSG is the key to making the diagnosis of almost all sleep disorders that exist. As you shall see, it is also vital for the further investigation and progress made in POSA and its potential treatment.
Positional Obstructive Sleep Apnea: A Formal Definition
A formal definition of positional obstructive sleep apnea (POSA) was first put forward by Cartwright 2 in the early 1980s.
According to this definition, patients were considered to have POSA if their apnea-hypopnea index (AHI) was double or more in the supine position versus their side or stomach 2,3.
You Have Positional Obstructive Sleep Apnea If…
- You have double (or more) apnea events when you sleep on your back
Over the years, various modifications to these basic criteria for POSA have occurred but for the most part remained very similar. It is using a combination of these similar POSA definitions that it becomes possible to get a good idea of the prevalence of POSA.
Hence, it has been estimated that of patients with OSA, officially diagnosed using polysomnography, up to 53% of these patients have POSA, and in other similar studies the estimate of those with POSA is even higher at ~77%3-7.
Characteristics of People with Positional Obstructive Sleep Apnea
It is interesting to note the typical differences observed by physicians in the clinical characteristics (physical traits and features of the illness) of patients with POSA as compared to non-positional OSA.
POSA patients are almost opposite in many ways to typical non-positional OSA patients in that they tend, on average, to be:
Significantly, POSA patients tend to have no hypertension (high blood pressure) or a normal blood pressure, in comparison to the often severe hypertension characteristic of non-positional OSA patients 3.
POSA patients score lower on seemingly all the various screening instruments and questionnaires used to identify potential OSA, which we will cover in some greater detail 3.
In this case, there is evidence that POSA patients have a lower Mallampati Class and lower scores on the Berlin questionnaire, STOP questionnaire and the Epworth Sleepiness Scale (ESS) 3.
Polysomnogram Data for POSA
Polysomnography data is also far more encouraging for patients with POSA compared to their non-positional OSA counterparts 3.
PSG parameters indicate POSA patients have an overall lower AHI, greater sleep efficiency, a lower index of arousals, actually spend more time sleeping in a non-supine position and have a lower oxygen desaturation index (their blood oxygen saturation drops by smaller amounts and less frequently) 3.
POSA patients, on average, get proportionately more rapid eye movement (REM) sleep and spend a greater fraction of total sleep time in stage three (slow wave, restorative sleep) compared to patients with non-positional OSA 3. Bear in mind, however, that these are POSA patients held in comparison to non-positional OSA patients not to healthy controls.
The Seriousness of POSA Vs Non-Positional OSA
It is worth remembering that POSA patients still have significant, and sometimes very severe, symptoms that frequently lead to significant morbidity. However, the PSG data does seem to indicate strongly that, on the average, patients with non-positional OSA are more ill than their POSA counterparts.
Another study has shown that patients with POSA snore less frequently than non-positional OSA patients9. The same study reinforced the findings of POSA patients having a comparatively higher average oxygen saturation level during sleep and a higher nadir oxygen saturation point (the lowest point reached in the night) than non-positional OSA patients9.
From prevalence data collected by Mador7 and his fellow researchers, the prevalence of POSA was highest (49.5%) in those that were classified as having mild OSA and then decreased quite steeply all the way to 6.5% of the patients classified as having severe OSA 3.
Other findings have found similar, although somewhat less dramatic trends, as demonstrated by Mador 7, regarding the dropping proportionate prevalence of POSA correlating closely with worsening of the OSA clinical severity among the non-positional OSA patients 10 3.
Most Common Cause of Positional Obstructive Sleep Apnea
There are multiple causes of OSA, but in a large percentage of patients the cause is a weakening and collapse of the soft tissue and musculature of the upper airway, as well as the backward and downward collapse of the tongue. Together, these factors severely narrow the airway and lead to severe OSA.
This is especially the case when a person is (a) overweight, and/or (b) elderly – because being overweight typically means you have excess tissue in your upper airway, and being elderly typically means the muscles in your upper airway will be weaker (simply due to the atrophying of muscles that comes with old age).
So how does relate to the position you sleep in?
When you sleep in the “supine” position (i.e. lying on your back), gravity makes the collapse of the tissue and backward movement of the tongue more likely to occur, and with greater severity.
What Causes Positional Obstructive Sleep Apnea (POSA)
POSA is caused by the tissue and muscles of your upper airway, as well as the base of your tongue, collapsing into your upper airway, thereby closing off your upper airway and cutting off oxygen to your body.
What is Positional Therapy for Obstructive Sleep Apnea?
Given that gravity significantly contributes to the collapse of tissue and backward movement of your tongue, it makes sense to change your sleeping position to reduce the effects of gravity. Hence the effectiveness of “positional therapy” for sleep apnea.
Positional therapy (PT) tried to emerge in the mid-eighties - somewhat unsuccessfully - with the so-called “Tennis Ball Technique” (TBT), which we discuss in more detail below, and PT failed to gain any academic research momentum 1.
However, it is in the last five to ten years that PT is undergoing a renaissance of sorts with the advent of various new and seemingly effective technologies and equipment like vibratory positional therapy devices 1.
Therefore, PT is once again an active area of research, which is good news, as PT and its technological spinoffs could hold much promise for those patients who continue to suffer from POSA 1.
Positional Therapy for Obstructive Sleep Apnea: A Definition
There are various ways to define positional therapy (PT). One way is to consider PT as any sleeping posture (or any mechanism used to attain such a posture) whereby a patient avoids their worst sleeping position (WSP).
By definition, the WSP should be considered the position which leads to positional obstructive sleep apnea (POSA) in its most severe form for that patient 3.
At this point I will not go further into details regarding the pathogenic processes and mechanical forces which are thought to lead to the supine position being the WSP. Suffice it to say, the WSP in most patients with POSA is the completely flat, supine position (i.e. flat on your back).
By definition, then, the alternative postures available to the patient with POSA include anything besides the flat, supine position.
However, in practicality patients will sleep in either the lateral position (further divided into lateral body and lateral head), the prone position and the elevated, supine position.
It is to some degree dependent on a whole host of different patient factors which alternative position results in the best sleeping position (BSP) for each individual patient with POSA. However, it is the alterations in sleep posture described above, which form the fundamental basis of PT.
What are the Different Types of Positional Therapy?
Given that positional obstructive sleep apnea is made worse by sleeping on one’s back (because of the effect that gravity has on closing off the upper airway), there are three positions to sleep in that reduce the effect gravity:
What are the Types of Devices for Positional Therapy?
Some POSA patients find it difficult – if not impossible – to stay off their back while sleeping.
If that’s you, and you aren’t able to sleep in one of the beneficial positions mentioned above (on your side; on your back but with your head to the side; or on your stomach), there are numerous devices that can help:
Below I briefly describe each one:
Positional Pillows for Obstructive Sleep Apnea
Positional pillows are simply pillows that encourage you (or force you) to sleep with your head in a particular position.
For POSA sufferers, that means using a pillow that positions your body (or, at a minimum, your head) to the side, so your upper airway remains open during sleep.
Positional pillows are one of the easiest, effective ways to reduce your positional sleep apnea.
Positional T-shirts (aka “Tennis Ball T-Shirts) for Obstructive Sleep Apnea
Positional t-shirts started out as “tennis ball t-shirts” back in the 1980s, in which a tennis ball was sewn into the back of a t-shirt. The idea was that the wearer would start a night’s sleep on their side, then when they tried to roll onto their back during sleep the tennis ball would prevent them from doing so.
Since then, positional t-shirts have advanced – but only a little bit! They’re still pretty primitive devices for preventing supine sleeping.
Positional Vests for Obstructive Sleep Apnea
Positional vests work similar to positional t-shirts in that they typically have an object in the back of the best that prevents the wearer from rolling onto their back while asleep.
One of the benefits of a vest over a t-shirt is that the bulky object in the back is more firmly in place and tends to stay put during sleep.
Positional Belts (aka “Bumper Belts”) for Obstructive Sleep Apnea
Positional belts are a variation on vests and t-shirts in that they’re meant to physically stop you from rolling over onto your back, but some people might find them a little easier to use because they aren’t worn over your whole upper body.
Sleep Position Trainers for Obstructive Sleep Apnea
Sleep position trainers are the new breed of positional devices and they use sophisticated technology to keep patients off their back while sleeping.
Position trainers are typically worn around the neck or chest, and they can sense when you’re about to turn over onto your back. At that point they send out a little vibration to keep you on your side.
Adjustable Beds for Obstructive Sleep Apnea
Adjustable beds allow you to adjust the head of the bed so it’s elevated, which counteracts the effect of gravity on your sleep apnea. The beauty of these beds is they can also deal with other health conditions, such as acid reflux. They’re pretty popular online.
Recliner Chairs for Obstructive Sleep Apnea
These are exactly what they sound like! (Think Lay-Z-Boy.)
While not most recommended way to sleep, recliner chairs are slept in by a surprising number of people, and by sleeping in an upright positon the tissue of your throat and base of your tongue are less likely to fall back into your upper airway.
Oral Appliances for Obstructive Sleep Apnea
“Oral appliance” is a fancy name for a mouthpiece that keeps your tongue and jaw in place while you sleep.
Like the other devices for positional sleep apnea, oral appliances work by counteracting the forces of gravity.
Positional Therapy Effectiveness: What is the Success Rate?
There have been dozens of academics studies conducted over the past thirty years that have conclusively proven the effectiveness of positional therapy for obstructive sleep apnea.
We have an entire section of this site that contains summaries of nearly 100 studies and links to the original papers. Please do check it out to see the substantial amount of proof that positional therapy is an effective and simple solution for some people who suffer from positional obstructive sleep apnea.
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- 3Yingjuan M, Siang WH, Alvin TKL, Poh HP. Positional Therapy for Positional Obstructive Sleep Apnea. Sleep Medicine Clin. 2019;14(1):119–33.
- 4Oulhaj A, Dhaheri Al S, Bin Su B, Al-Houqani M. Discriminating between positional and non-positional obstructive sleep apnea using some clinical characteristics. Sleep Breath. 2017;21(4):877–84.
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- 9Teerapraipruk B, Chirakalwasan N, Simon R, Hirunwiwatkul P, Jaimchariyatam N, Desudchit T, et al. Clinical and polysomnographic data of positional sleep apnea and its predictors. Sleep Breath. 2012 Dec;16(4):1167–72.
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- 12de Vries GE, Hoekema A, Doff MHJ, Kerstjens HAM, Meijer PM, van der Hoeven JH, et al. Usage of positional therapy in adults with obstructive sleep apnea. J Clin Sleep Medicine Jcsm Official Publ Am Acad Sleep Medicine. 2015;11(2):131–7.
- 13Jackson M, Collins A, Berlowitz D, Howard M, O'Donoghue F, Barnes M. Efficacy of sleep position modification to treat positional obstructive sleep apnea. Sleep Med. 2015 Apr;16(4):545–52.
- 14Jokic R, Klimaszewski A, Crossley M, Sridhar G, Fitzpatrick MF. Positional Treatment vs Continuous Positive Airway Pressure in Patients With Positional Obstructive Sleep Apnea Syndrome. CHEST. Elsevier; 1999 Mar 1;115(3):771–81.
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- 17Zuberi NA, Rekab K, Nguyen HV. Sleep Apnea Avoidance Pillow Effects on Obstructive Sleep Apnea Syndrome and Snoring. Sleep Breath. 2004;8(4):201–7.
- 18Bidarian-Moniri A, Nilsson M, Attia J, Ejnell H. Mattress and pillow for prone positioning for treatment of obstructive sleep apnoea. Acta Oto-laryngol. 2015;135(3):271–6.
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