What exercises, specifically for the neck, can help manage sleep apnea?

Neck and Oropharyngeal Exercises for Sleep Apnea

Oropharyngeal exercises cannot be recommended as a standalone treatment for obstructive sleep apnea, though they may provide modest improvements in snoring and daytime sleepiness when used as an adjunct to standard therapies like CPAP. 1

Guideline Recommendations

The European Respiratory Society explicitly states that oropharyngeal exercises have shown only limited effects on snoring and respiratory disturbances, and their role remains unclear—therefore, they cannot be recommended as standard treatment (Grade B recommendation). 1

What the Evidence Shows

Modest Benefits in Select Outcomes

When oropharyngeal exercises are performed, they may provide:

• Reduction in daytime sleepiness by approximately 4.5 points on the Epworth Sleepiness Scale compared to sham therapy 2
• Improved sleep quality with reductions of 2.8 points on the Pittsburgh Sleep Quality Index 2
• Decreased neck circumference and modest improvements in snoring intensity 1
• Limited reduction in apnea-hypopnea index (AHI), but not normalization of sleep apnea severity 1, 2

Important Limitations

The evidence quality is low to very low due to small study sizes, lack of blinding, and short follow-up periods. 2 Studies have shown that while exercises may help with symptoms, they do not adequately treat the underlying airway obstruction. 1

Respiratory Muscle Training as an Alternative

Inspiratory muscle training (IMT) shows more promise than neck exercises alone, with evidence suggesting:

• Significant improvement in daytime sleepiness (reduction of 4.45 points on Epworth scale) 3
• Better sleep quality (reduction of 2.79 points on Pittsburgh index) 3
• Increased inspiratory muscle strength by approximately 29.56 cmH₂O 3
• Potential blood pressure benefits with reductions in systolic (-12.3 mmHg) and diastolic (-5.0 mmHg) pressures 4

However, IMT does not significantly reduce AHI or cure the underlying sleep apnea. 3, 5

Clinical Algorithm for Exercise Therapy in OSA

When to Consider Exercises:

1. As adjunct therapy only in patients already using CPAP who want additional symptom management 6
2. In mild OSA where patients refuse or cannot tolerate CPAP and understand the limitations 2
3. For symptom control (snoring, daytime sleepiness) rather than as definitive treatment 1

When NOT to Use Exercises Alone:

• Moderate to severe OSA (AHI ≥15) requires CPAP as first-line therapy 1, 7
• Patients with cardiovascular comorbidities need definitive treatment, not exercises 1
• Any patient expecting cure or normalization of AHI from exercises alone 1, 2

What Should Be Done Instead

CPAP remains the gold standard treatment for moderate to severe OSA and should be the primary recommendation. 1, 7 For CPAP-intolerant patients, consider:

• Mandibular advancement devices for mild-to-moderate OSA 1, 7
• Weight loss programs (comprehensive lifestyle interventions with diet, exercise, and behavioral counseling) which significantly reduce AHI and improve outcomes 1
• Hypoglossal nerve stimulation for carefully selected CPAP-intolerant patients with moderate-severe OSA (AHI 15-65, BMI <32-40) 7

Critical Pitfalls to Avoid

• Do not present exercises as an alternative to CPAP in moderate-severe OSA—this delays definitive treatment and exposes patients to cardiovascular risks 1
• Do not expect normalization of AHI from any exercise program alone 1, 3, 2
• Recognize that symptom improvement does not equal disease control—patients may feel better but still have dangerous apneic events 2, 5