What does positional therapy for obstructive sleep apnea involve?

What Positional Therapy Involves

Positional therapy consists of using a device (such as a vibratory alarm worn on the neck or chest, backpack, pillow, or tennis ball) that keeps patients in a non-supine sleeping position to prevent upper airway collapse that occurs predominantly when lying on the back. 1

Core Mechanism and Devices

Positional therapy works by preventing patients from sleeping in the supine position, where the upper airway area decreases, particularly in the lateral dimension, leading to increased airway collapse. 1

Device Options Include:

• Vibratory devices worn around the neck (Night Shift device) or chest (NightBalance device) that provide subtle vibrating stimuli when supine position is detected 1
• Traditional methods such as backpacks with soft balls, tennis ball technique (TBT), or specialized pillows 1
• Positioning monitors that objectively track body position during sleep 1

The European Respiratory Society specifically recommends vibratory devices over traditional methods due to superior long-term adherence. 1

Patient Selection Criteria

Positional therapy is appropriate for patients meeting specific criteria:

• Position-dependent OSA defined as supine AHI at least twice as high as non-supine AHI 1
• Non-supine AHI less than 15 events per hour 1
• Mild to moderate OSA severity (typically AHI 15-30 events/hour) 1
• Patients who prefer alternatives to CPAP, fail CPAP, or are not appropriate CPAP candidates 1

Before initiating positional therapy as primary treatment, correction of OSA by position must be documented with polysomnography (PSG), because not all patients normalize AHI when non-supine. 1

Clinical Effectiveness

Efficacy Data:

• AHI reduction: Positional therapy reduces AHI by approximately 54% (mean difference of 11.3 events/hour) 2
• Supine time reduction: Decreases percentage of total sleep time in supine position by 84% (33.6% reduction) 2
• Comparison to CPAP: CPAP shows slightly better AHI reduction (CPAP reduces by 4 events/h more than positional therapy), but positional therapy demonstrates superior adherence (+2.5 hours per night compared to CPAP) 1

Symptomatic Outcomes:

• Sleepiness: No clinically relevant difference in Epworth Sleepiness Scale scores between CPAP and positional therapy 1
• Quality of life: Health-related quality of life (SF-36) shows no significant difference between treatments 1
• Side effects: Generally mild and less frequent than CPAP, including shoulder/neck pain and skin irritation 1

Practical Implementation

Initiation Steps:

1. Confirm position-dependent OSA with baseline PSG showing appropriate supine/non-supine AHI ratio 1
2. Select appropriate device (preferably vibratory type for better adherence) 1
3. Consider objective position monitoring to establish home efficacy 1
4. Perform follow-up PSG after substantial weight loss or to verify ongoing need for therapy 1

Monitoring Parameters:

• Self-reported compliance 1
• Objective position monitoring data 1
• Side effects assessment 1
• Symptom resolution 1

Adherence Considerations

A critical caveat: Traditional positional therapy methods (tennis ball technique, backpacks) show poor long-term adherence, with only 29% of patients continuing use after 2 years. 3 However, newer vibratory devices demonstrate markedly improved tolerance and compliance, with studies showing 73.7% nightly usage over 3 months 4 and mean adherence of 68.9% at 4+ hours per night on 5+ days per week. 1

Important Limitations

• Not recommended for severe OSA where CPAP should be the initial trial 1
• Not effective for non-positional OSA or patients with elevated non-supine AHI (≥15 events/h) 3, 5
• Requires close follow-up by sleep specialists to monitor long-term efficacy and adherence 1
• Head positioning devices (stabilizing head without flexion/inclination) show insufficient therapeutic efficacy and cannot be recommended 1