Combining Tongue Muscle Training with PAP Therapy for Sleep Apnea
There is insufficient evidence to recommend combining tongue muscle training with PAP therapy, as current guidelines do not address this specific combination and available research shows tongue training alone does not reduce apnea severity when tested as an adjunct intervention.
Current Guideline Position on Tongue-Based Interventions
The evidence base for tongue muscle training combined with PAP therapy is notably absent from established guidelines:
Oropharyngeal exercises cannot be recommended as standard treatment for OSA, as they have shown only limited effects on respiratory disturbances 1.
Tongue retaining devices (mechanical, not exercises) are not recommended for OSA patients generally, though they may be considered in selected patients with mild-to-moderate OSA when other treatments have failed 1.
PAP therapy remains the gold standard first-line treatment for OSA, with alternative therapies reserved for PAP-intolerant patients 2.
Research Evidence on Tongue Training
Tongue Training Alone (Without PAP)
Recent research provides mixed results on tongue muscle training as a standalone intervention:
A 2022 randomized controlled trial found that 6 weeks of isolated tongue elevation training did not significantly reduce apnea-hypopnea index (AHI) in patients with moderate OSA, though it did improve daytime sleepiness and tongue endurance 3.
Daytime neuromuscular electrical stimulation (NMES) of tongue muscles reduced snoring by 41% in patients with primary snoring and mild OSA, with improvements in sleep quality, but this study did not evaluate combination with PAP therapy 4.
Oropharyngeal exercises (including tongue exercises) showed improvements in sleep indices in mild-to-moderate OSA, including oxygen saturation and arousal index, but were not tested in combination with PAP 5.
Combination Approaches (Not with PAP)
The only relevant combination study examined oral appliances, not PAP therapy:
A 2012 study combined mandibular advancement with tongue retention in an oral appliance, showing decreased AHI from 33.5 to 18.1 events/hour, but this involved a mechanical tongue retention device during sleep, not muscle training exercises 6.
This mechanical combination approach is fundamentally different from adding exercise training to PAP therapy and does not inform the clinical question at hand 6.
Clinical Reasoning and Practical Considerations
Why This Combination Lacks Support
Tongue muscle training aims to increase pharyngeal muscle tone and responsiveness, which theoretically addresses non-anatomical OSA traits 7.
However, PAP therapy mechanically splints the airway open, making the additional benefit of improved muscle tone unclear and potentially redundant during PAP use 2.
The isolated tongue training RCT specifically enrolled patients with low PAP adherence (mean use <4 hours/night), but did not test whether training improved PAP effectiveness or adherence 3.
Potential Role in Clinical Practice
If considering tongue training in PAP users, the rationale would be:
Improving residual symptoms or events in patients with adequate PAP adherence but persistent complaints 7.
Potentially improving PAP adherence through increased awareness of upper airway function, though this has not been studied 7.
Addressing daytime symptoms like sleepiness, which improved with tongue training even without AHI reduction 3.
Practical Algorithm for Decision-Making
For patients on PAP therapy with persistent symptoms:
First, optimize PAP therapy (pressure titration, mask fit, humidification, treatment of nasal obstruction) 2.
Verify adequate PAP adherence (≥4 hours/night on ≥70% of nights) before considering adjunctive therapies 2.
If residual daytime sleepiness persists despite optimized PAP, consider evaluation for other causes (insufficient sleep duration, depression, medications) before adding tongue training 3.
Tongue muscle training may be considered as an adjunct only after the above steps, with realistic expectations that it may improve symptoms but not objective apnea severity 3.
Monitor outcomes objectively with repeat sleep studies if implementing tongue training, as symptom improvement does not reliably predict AHI reduction 1.
Important Caveats
No studies have directly evaluated tongue muscle training as an adjunct to PAP therapy, making any recommendation extrapolated from indirect evidence 3.
The time and effort required for daily tongue exercises (typically 20 minutes daily for 6+ weeks) may be better invested in improving PAP adherence 4, 3.
Oropharyngeal myofunctional therapy is multi-component, and isolating tongue training alone may not capture the full potential benefit of comprehensive programs 7, 5.