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Didgeridoo playing as an alternative therapy method for obstructive sleep apnoea syndrome
Study team:
Dr. med. Milo A. Puhan, Horten Zentrum für patienten-orientierte Forschung, Zurich University
Alex Suarez, asate, Wattwil, www.asate.ch
Dr. med. Christian Lo Cascio, Zürcher Höhenklinik Wald
Alfred Zahn, Zürcher Höhenklinik Wald
Dr. med. Markus Heitz, Lungenpraxis Morgenthal, Zurich
Dr. med. Otto Brändli, Zürcher Höhenklinik Wald
Summary
We studied the effect of training the upper airways on day tiredness and quality of sleep in patients with a medium sleep apnoea syndrome. 25 participants were randomised to train to play Didgeridoo for four months or to form part of the control group. After the four-month period we were able to report that the participants of the Didgeridoo group showed a lower day tiredness and severity of the sleep apnoea syndrome in comparison to the control group. In addition, their respective partners felt significantly less disturbed by the snoring during their nights’ sleep. The study demonstrates that a training of the upper airways by Didgeridoo playing over a sufficiently long training period will result in a significant improvement of the symptoms and the severity of the sleep apnoea syndrome.
Original results: This study was published in the British Medical Journal, www.bmj.com.
Registration of the study: This study was registered under number ISRCTN31571714 in the International Standard Randomised Controlled Trial Number Register.
Sponsoring of the study: Zürcher Lungenliga and Zürcher Höhenklinik Wald
Snoring and the obstructive sleep apnoea syndrome are two frequently occurring sleep disorders. They occur when the soft parts (connective tissue, muscles) of the upper airways collapse during sleep, disturbing respiration. If respiration is stopped completely or partly for more than 10 seconds, this is called hypopnoea (decreased breathing) and apnoea (respiratory arrest). This reduces the quality of sleep.
The most frequent symptom of the sleep apnoea syndrome is increased day tiredness. The day tiredness can be so prominent that dangerous situations, for example when driving, may occur. For patients with a distinct sleep apnoea syndrome there is an efficient respiration treatment during the night which keeps the airways open (so-called positive pressure breathing). This therapy reduces day tiredness and the patient’s performance can be restored. Patients with a sleep apnoea syndrome should be offered this therapy, depending on the degree of severity.
However, there are patients who do not want this respiration therapy or use it only seldom. Other effective therapies are required for this group of patients. In 2001, the Didgeridoo teacher Alex Suarez noticed for himself and for some of his students that day tiredness and snoring were reduced after several months’ Didgeridoo playing. An examination in the sleep laboratory of the Zürcher Höhenklinik Wald showed an actual reduction of apnoea and hypopnoea (measured by the apnoea-hypopnoea index), confirming Alex Suarez’s subjective impression.
We therefore hypothesized that the soft parts of the upper airways in patients with a medium sleep apnoea syndrome and snoring can be trained by playing Didgeridoo, thus achieving a better quality of sleep and reduced day tiredness.
Design of the study:
We asked 59 patients complaining about snoring or day tiredness when consulting a pulmonologist in the Zürcher Höhenklinik Wald or Lungenpraxis Morgenthal, Zurich, whether they would like to participate in the study. Of these 59 patients we included into the study those who suffered from a medium sleep apnoea syndrome (apnoea-hypopnoea index between 15 and 30) and were not currently using respiration therapy, drank only small amounts of alcohol and were not markedly overweight or already played the Didgeridoo.
25 patients fulfilled these criteria and they all gave their written consent to participate in the study. The flowchart below shows the study design:
14 participants of the study were randomised to learn how to play Didgeridoo and 11 were assigned to form a control group where they had to wait for 4 months for the Didgeridoo lessons to begin. The study participants randomised in the Didgeridoo playing group attended 4 private lessons. In the first lesson, they learned to produce the keynote of the Didgeridoo. In the second lesson, two weeks after the beginning of the study, Alex Suarez, Didgeridoo teacher and member of the study team, explained the principle of circular breathing. Circular breathing enables the player to hold the note for a long time because breathing in is through the nose while producing a continued airflow with one’s cheeks. In the third and fourth lessons, four and eight weeks after the beginning of the study respectively, Alex Suarez went into more detail with the participants to the study with regard to their playing technique, above all focusing on the coordination between lips, respiratory tract and circular breathing. All participants were instructed how to practise from now on at least 5 of 7 days for 20 - 30 minutes.
The participants were given a standardized Didgeridoo from Perspex developed by Alex Suarez for this study, which enables easier learning how to play the Didgeridoo than using traditional wooden Didgeridoos.
For measurement of day tiredness, quality of sleep, disturbance of the partner and the quality of life, we used standardized questionnaires as are used in many studies. In addition, the participants of the study spend one night in the sleep laboratory at the end of the study, in order to again assess the degree of severity of their sleep apnoea syndrome.
For further details of the methods and statistical analysis we refer to the complete publication in the British Medical Journal, www.bmj.com.
Results
The participants of the study were on average a little under 50 years of age, mainly male (84%) and stated to have snored for a mean of 9 years. The average day tiredness at the beginning of the study was significantly higher (11.8 on a scale of 0 - 24 in the Didgeridoo group and 11.1 in the control group) than in the general population (5.7), and the partners felt very much affected with regard to their night’s rest due to the snoring.
All participants of the study appeared very motivated to train on the Didgeridoo. They practised on an average of 5.9 days per week for 25 minutes. In the control group, the day tiredness decreased by 1.4 points from 11.1 to 9.7 and in the Didgeridoo group by 4.4 points from 11.8 to 7.4. The improvement was therefore statistically significant greater in the Didgeridoo group.
The partners of the participants of the Didgeridoo group stated a clear reduction of the nightly disturbance while this did not change for the partners of the participants of the control group. The quality of sleep also improved among the Didgeridoo group, however, the difference was not significant in comparison to the control group. In terms of quality of life, no effect of the Didgeridoo playing could be shown.
The sleep examination confirmed the results stated above. The number of evident respiration interruptions during sleep in the Didgeridoo group decreased significantly (from 22.3 to 11.6 per hour), while the number in the control group decreased only slightly (from 19.9 to 15.4 per hour).
Comment
We found in this study that a four-month training of Didgeridoo playing reduced the day tiredness of patients with a medium sleep apnoea syndrome. The sleep examinations show that Didgeridoo playing actually reduces the collapsing of the upper airways’ soft parts during sleeping. An important result is also that the nightly disturbance of the partners decreased in the Didgeridoo group.
One of the challenges in treating patients with a sleep apnoea syndrome is to offer a therapy which they actually comply with. Alternative treatments for respiration therapy should therefore be not only effective but also accepted by the patients. Didgeridoo playing seems to fulfil these requirements. All participants to the study were very motivated and practised nearly 6 days a week. Whether this motivation was particularly high in our study and whether it can be sustained over a longer period remains to be seen.
Conclusively, Didgeridoo playing significantly reduced the day tiredness and the nightly disturbance of the partners. Larger studies shall be required to confirm our results. However, these results demonstrate that training of the upper airways by playing the Didgeridoo presents a form of therapy which seems promising for treatment of the patients and their partners.
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