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Practice recommendations for the role of physiotherapy in the management of sleep disorders

Updated: Apr 6

the 2022 Brazilian Sleep Association Guidelines


Cristina Frange, Aline Marques Franco, [...], and Luciano F. Drager


Abstract


This clinical guideline supported by the Brazilian Sleep Association comprises a brief history of the development of Brazilian sleep physiotherapy, outlines the role of the physiotherapist as part of a sleep health team, and describes the clinical guidelines in respect of the management of some sleep disorders by the physiotherapist (including sleep breathing disorders, i.e., obstructive sleep apnea, central sleep apnea, upper airway resistance syndrome, hypoventilation syndromes and overlap syndrome, and pediatric sleep breathing disorders; sleep bruxism; circadian rhythms disturbances; insomnia; and Willis-Ekbom disease/periodic limb movement disorder. This clinical practice guideline reflects the state of the art at the time of publication and will be reviewed and updated as new information becomes available.


Keywords: Sleep, Sleep Disorders, Physiotherapy, Rehabilitation, Sleep Health


1. INTRODUCTION


Almost 10 years after the first Brazilian Consensus on Sleep Physiotherapy1, the field of sleep physiotherapy (PT) has changed and improved with advances in many areas due to investigations and research. There is a need to update this knowledge and to create a solid bridge between “the bench and the bedside”, translating into clinical practice the scientific advances. When we understand “where we are” in the field of sleep PT, we can see “where to go”, and the avenues that open to meet the needs of our patients. Sleep PT is still an incipient field worldwide, but is a very promising area. There is already a great deal of teamwork being applied to investigate, create, discover, test, and apply new developments in clinical practice for its unique purpose: to help patients with sleep disorders, including those with a range of comorbid conditions, and improve their quality of life.


The purpose of this consensus is to provide patient-centered clinical guidelines based on a critical analysis of the latest high quality clinical research and the experience of PTs in clinical practice to enable them to make the best decisions in respect of the care of patients with sleep disorders, in addition to describing the area of practice of PT in Brazil. This evidence-based clinical guideline provides a single source of information about the physiotherapeutic management of sleep disorders, integrating contributions from clinical experts, and formulating reliable recommendations for sleep PT practice in Brazil.


The recommendations regarding the physiotherapeutic management of some sleep disorders (obstructive sleep apnea, central sleep apnea, other sleep breathing disorders, i.e., upper airway resistance syndrome, hypoventilation syndromes and overlap syndrome, pediatric sleep breathing disorders, sleep bruxism, disturbances of circadian rhythms, insomnia, and Willis-Ekbom disease/periodic limb movement disorder) were made by subgroups and evaluated together with the task force commission. The approach adopted by the authors included several online meetings with discussions by the different groups of experts in respect of specific sleep disturbances. The discussion was open in nature and driven by the experience and opinions of the participating experts. The task force was formed primarily of 23 sleep PTs involved in teaching, research and clinical practice from a wide cultural and geographical area in Brazil. The literature search strategy was primarily designed to identify meta-analyses and systematic reviews, followed by randomized clinical trials, observational studies, clinical practice guidelines, and case studies. After the literature search, a meeting was held to discuss the evidence identified and the current clinical practice in Brazil carried out according to the relevant laws. Editing of the consensus continued until all authors were in full agreement. The consensus was then presented twice to the task force commission and was open to all authors for discussion. After agreement was reached on the final form and content of the consensus document, which was based not only on a synthesis of the high-quality clinical research, but also on expert opinion, this document was written.


The recommendations of each subgroup were classified according to the Strength of Recommendations Taxonomy (SORT) scale2. This scale classifies the level of evidence according to the quality and the consistency of the studies, through an algorithm. The SORT levels of evidence are classified as A, B or C depending on the quality and consistency of the evidence available (Table 1)2. In addition to the 3 SORT scale definitions (A, B and C) we added 2 more: “not recommended” and “there is no evidence to support the recommendation of these practices”. The classification of “not recommended” means that there is scientific evidence against the modality, or that in our clinical experience this modality did not present positive outcomes that justify its use/incorporation. The classification “there is no evidence to support the recommendation of these practices” means that we could not even formulate a recommendation, either for or against the modality/intervention due to a lack of literature in respect of the modality and/or a lack of evidence from clinical practice, i.e., scientific and empirical evidence. These classifications should be considered when practitioners are deciding whether to use certain modalities within PT.


Table 1: Classification of Strength of Recommendations Taxonomy scale2.
Courtesy of PMC9670776

Classification of Strength of Recommendations Taxonomy scale2.


We hope that the consistent use of these recommendations will improve the ability and quality of the practice of PTs in the sleep field and help to expand future research to generate new therapeutic options in sleep PT.


2. PRINCIPLES OF SLEEP PHYSIOTHERAPY AND ITS LEGAL REGULATION IN BRAZIL


2.1. The history of sleep physiotherapy in Brazil


PTs initially had a modest role in the work carried out in sleep research centers and small sleep research groups within intensive care, cardiorespiratory and neurological care groups. In the late-1990s, the use of positive airway pressure (PAP) therapy was incorporated into the treatment of sleep apnea. The demand for PAP devices gradually increased, which helped the growth of sleep PT and its expansion to other aspects of sleep care, not only those related to sleep breathing disorders (SDB).


During this period, the first polysomnography (PSG) course for health professionals took place at the Instituto do Sono in Sao Paulo. The knowledge obtained by the (very few) PTs who attended this course was passed on in their respective workplaces, and thus some physical therapists became early adopters and advocates of the use of PT in the sleep field.


In the field of research, in the 2000s a number of PTs took part in latu and strictu-sensu postgraduate courses at the Sleep Laboratory of the Heart Institute (InCor), the Neurosurgery Laboratory, and the Pulmonology Department, among other departments at the Faculty of Medicine of the University of São Paulo (USP). The same occurred at the Federal University of São Paulo (UNIFESP), in the Departments of Psychobiology and Neurology/Neurosurgery. Since then, some extension and specialization courses in sleep have also emerged and spread throughout Brazil. Several research groups including PTs were formed in this period, allowing new opportunities for the PT in the field.


Sleep associations contributed to the development of the area of sleep PT. In 2005, the first PT Commission of the Brazilian Sleep Association (ABS) was formed through an initiative with the associated PTs. In 2014, the Brazilian Association of Cardiorespiratory Physiotherapy and Physiotherapy in Intensive Care (ASSOBRAFIR) requested to the Brazilian Federal Council of Physical Therapy (COFFITO) the recognition of PT applied to sleep disorders. In 2021, the ABS in partnership with ASSOBRAFIR, introduced the first certification in sleep PT, with 28 PT from several Brazilian states being certified in respect of their performance and experience in both research and clinical settings3.


Through research, teaching and clinical practice, several PT have contributed significantly to clinical practice, including studies on the most effective types of PAP therapy4-7, and have collaborated in work to define the guidelines of the American Academy of Sleep Medicine (AASM) regarding the importance of using the nasal mask as the first route of choice in PAP therapy for the treatment of SDB8. In 2013, the “Brazilian Consensus on Sleep Physiotherapy” was published1. In 2015, one of the first scientific articles on the role of PT in the treatment of SDB was published9. Subsequently, other Brazilian studies have emerged covering subjects, as sleep rehabilitation10, the timing of rehabilitation in relation to circadian preference, the use of therapeutic exercise11, and other PT modalities12 as treatments, as well as studies related to pain, an area that has long been known by PT to be influenced by sleep13. In parallel with research and clinical activities, since the early 2000s PTs have begun to work in large national and multinational companies that offer products and services in the sleep field.


Thus, the role of PTs in the field of sleep expanded rapidly, working not only in research, clinics, and hospitals but in commercial settings and as consultants. However, there is a lack of sleep PT education, a field that needs to be addressed but is beyond the focus of this consensus.


2.2. Legal regulation of sleep physiotherapy in Brazil


Over the years, several PTs were engaged in calling for official recognition of the work of sleep PT. This was accomplished in 2021 by COFFITO Resolution #53614, which recognized sleep as an area of work of Brazilian PTs. We highlight the epidemiological, physiological, and pathophysiological knowledge of the PT profession, including evaluation, the adherence, compliance and titration of PAP for SDB treatment, as well as the PT prescription, based on physiotherapeutic diagnosis through the International Classification of Functioning and Health (ICF)15, published in 2001 by World Health Organization (WHO).


3. THE APPROACH TO THE PATIENT IN SLEEP PHYSIOTHERAPY


There is a consensus that good sleep is essential for good health. Still, there have been few attempts to define exactly what constitutes sleep health16. Sleep health is defined as “a multidimensional pattern of sleep-wakefulness, adapted to individual, social and environmental demands, that promotes physical and mental well-being”16. This is in line with the definition of health in general produced by the WHO, which is based on positive attributes, rather than simply on a lack of disease17. Sleep health is related to individual, social and contextual factors18. Increasing evidence demonstrates the association of sleep disorders with other comorbidities and indicates the crucial role of sleep deprivation and/or dysfunction in the development of these diseases18,19.


The 3rd International Classification of Sleep Disorders (ICSD-3) describes more than 80 sleep disorders divided into 6 main categories: insomnia, SDB, central disorders of hypersomnolence, circadian rhythm sleep-wake disorders, parasomnias, and sleep-related movement disorders20. Obstructive sleep apnea (OSA) is a common sleep disorder, with epidemiological studies indicating a prevalence in adults of between 25 and 46%21,22, with the São Paulo sleep study reporting a prevalence of 33%21. A population-based study in the city of São Paulo Brazil reported a prevalence of insomnia of 32%23. Another very frequent sleep disorder is Willis-Ekbom’s disease (commonly called restless legs syndrome), with a prevalence ranging from 2 to 21% in the world population24 and 6.4% in Brazil25.


The different sleep disorders can be monitored using the International Statistical Classification of Diseases and Related Health Problems (ICD), which, in its 11th edition, presents a chapter on sleep-wake cycle disorders26. ICD can be considered the main coding tool for mortality and morbidity problems27. Nevertheless, this information does not express the needs and difficulties that people with different health conditions experience. We suggest that sleep PTs understand and use the International Classification of Functioning, Disability, and Health (ICF), which, like the ICD, is part of the WHO Family of International Classifications. The ICF presents functioning as an indicator of health, complementary to mortality and morbidity.


Functioning is the key indicator for rehabilitation28 and thus can be considered an important clinical outcome for the PT. In rehabilitation, we seek to restore the functioning of the individual to improve their quality of life and health. For this, the individual is considered in their entirety, relating the problem presented to relevant personal and environmental factors29, creating a facilitating physical and social environment, strengthening psychological aspects, and, finally, translating the potential of these improvements into health28.


Conceptually, functioning is the generic term for body functions, body structures, activities, and participation, which is influenced by health conditions, environmental and personal factors30. The sleep PT must understand the dynamism linked to this concept, since functioning is a continuum states that, depending on the influence exerted on its components, can range from full functioning to total disability31.


3.1. Evaluation of sleep physiotherapy


3.1.1. Main complaint


The evaluation begins with questioning related to the main complaint, which will direct the continuity of the anamnesis, the physical examination, and the subsequent development of the objectives and conduct of the sleep PT. Questions like, “Why are you looking for my help right now?” and “What bothers you most about your sleep?” can help outline the main complaint. Assessing the patient’s perception of the quality of their sleep, and in specific cases (children, dementia syndromes, language impairment, and parasomnias), input from a partner can be significant.


Sleep PTs should be aware that sleep disorders do not only impact the sleep period, but can also have negative daytime consequences, and in different aspects of functioning, (e.g., difficulty driving, focusing on work, or engaging in social activities)32. Thus, the main complaint may not necessarily be related to the sleep period itself. Assessing functioning-related problems associated with sleep complaints is, thus, valuable in identifying issues to be worked on during treatment.


When questioning the patient about the main complaint, the sleep PT may come across situations in which the patient reports that they are not the source of the complaint but blame the bed partner. In these cases, to assess whether the patient recognizes, or denies, the possible existence of a sleep disorder will help to identify how ready they are to start PT treatment.


3.1.2. Identification of the motivational stage


Many interventions proposed by the sleep PT involve the promotion of behavioral changes to increase adherence to the treatment of sleep disorders. Identifying the motivational stage of the patient can help to direct the intervention proposed by the sleep PT. According to the Transtheoretical Model of Behavioral Change, there are 5 behavioral stages: pre-contemplation, contemplation, preparation, action, and maintenance33 (Figure 1).


Figure 1: The 5 behavioral stages are according to the Transtheoretical Model of Behavioral Change.
Courtesy of PMC9670776

The 5 behavioral stages are according to the Transtheoretical Model of Behavioral Change.


In the pre-contemplation stage, the patient denies the existence of the problem and is reluctant to consider what needs to change in their habits. At this time, it is relevant to question the patient to increase their perception of the problem.


In the contemplation stage, the patient begins to realize that they have a problem, but fear and insecurity prevent them from acting. In this stage, the patient tends to be very defensive and justifies their position, when deep down they would like to start the process of change. In this period of ambivalence, the PT needs to draw the patient’s attention to the risks associated with not changing their behavior and encourage them to believe in the possibility of change.


In the preparation stage, the patient is beginning to understand and realize how some changes can be beneficial. The role of the PT is to guide the patient in respect of the most appropriate way to get the changes they desire so that they can then move to the next stage, the action.


In the action stage, the patient takes the first steps to modify their behavior and begins to make some changes. The PT should facilitate this process by helping the patient to make this a habit.


The fifth and final stage is maintenance, in which discipline is necessary to avoid relapses. The sleep PT will help in building strategies to maintain the target behavior and overcome the factors that can threaten this.


In the Transtheoretical Model of Behavioral Change the individual does not necessarily progress through the stages in a precise linear way, but can move forward or back through the stages before reaching their ultimate goal33. The assessment of the motivational stages should be made by the sleep PT listening carefully to the patient, with the patient activating their motivation for change and the consequent adherence to treatment.


3.1.3. History of current and previous disease


In the development of the history of the current disease, the sleep PT should explore the process that led to the main complaint chronologically and seek to identify the factors that aggravate or relieve the condition.


In the previous history, the presence of neurological, cardiac, pulmonary, otorhinolaryngologic, and psychiatric diseases should be noted and their relationship with the main complaint should be considered. Conditions, such as chronic pain, dementia, asthma, heart failure, depression, and anxiety disorders are often observed when dealing with complaints of insomnia; patients with hypothyroidism, obesity, and inflammatory diseases often complain of excessive sleepiness; anemia, kidney disease, and pregnancy can cause or exacerbate Willis-Ekbom disease; cough, choking, heartburn and gastric reflux, as well as changes in libido and sexual impotence, may be associated with SDB34.


Seeking information about cognitive functions, (i.e., lack of concentration, attention and memory), can be complaints associated with poor sleep quality or reduced sleep duration, as can complaints related to mood. Excessive sleepiness, fatigue, restless sleep, dry mouth upon awakening, and headache are symptoms that need to be evaluated and may be associated with different sleep disorders34.


When investigating obstructive types of SDB, ask about previous surgical procedures, especially nasal and upper airway (UA) surgeries. Information about current or previous smoking should be considered as nicotine dependence can be associated with a range of sleep disorders35.


As for the sleep routine, an interesting approach is to ask the patient to describe their sleep routine, specifying the time they go to bed, go to sleep, wake, and get up; the regularity of these times; the maintenance of these schedules on weekends and activities carried out before bed (reading, watching television or activities involving screens/light emission). Observations of the patient’s satisfaction in respect of their sleep schedules, sleep latency, and sleep fragmentation are warranted. Individuals with insomnia often report inadequate nighttime sleep and may have difficulty in respect of sleep onset, maintaining sleep, waking up too early, or returning to sleep (more details in the Section 11). In patients with SDB, for example, it is common the complain of difficulties in maintaining sleep, but these patients usually have a lower sleep onset latency due to excessive sleepiness34. Among the reasons that lead to awakenings, nocturia, characterized by the presence of at least 2 arousals to urinate, is an aspect to evaluate and may be associated with SDB36. Information related to night shift work, and sleep time preferences need to be investigated34.


The patient should be questioned in respect of their sleeping environment to evaluate whether it is optimum to promote sleep; the essential aspects of the evaluation are luminosity, the presence of noise, temperature, the presence of bed partners and/or pets, the activities performed and the characteristics of the bed. The ideal environment should be dark, quiet, thermally pleasant, and used only for sleeping and having sex.


Sleep ergonomics should be evaluated as the choice of the sleeping position may be related to SDB and pain conditions that can lead to sleep fragmentation.


The evaluation of the sleep PT should also cover the presence of other comorbid sleep disorders, as hypersomnias, parasomnias, other sleep respiratory disorders, and circadian rhythm and movement disorders related to sleep. If the patient sleeps accompanied, the reports of the partner, including the presence of snoring, breathing pauses, grinding of the teeth, somniloquy, or excessive movements in bed are useful. It is helpful to obtain the patient’s report about their perception of the quality of their sleep. The assessment of psychosocial, occupational, academic, and physical activity, as well as satisfaction with personal relationships can provide valuable information about the impact of sleep disorders on the patient’s life.


Table 2 describes the aspects related to sleep that should be investigated during the PT evaluation, and which should be directed according to the patient’s main complaint and clinical history.


Table 2: Aspects related to sleep to be investigated during the physiotherapeutic evaluation.
Table 2: Aspects related to sleep to be investigated during the physiotherapeutic evaluation.
Table 2: Aspects related to sleep to be investigated during the physiotherapeutic evaluation.
Courtesy of PMC9670776

Aspects related to sleep to be investigated during the physiotherapeutic evaluation.


3.2. Knowing the patient: contextual information


3.2.1. Age and sex


The age of the patient is essential information in the evaluation performed by the sleep PT. Quantity and distribution of sleep stages are usually different as age groups change37. The prevalence of some sleep disorders changes according to age and sex, as well as their etiological factors21,38. The functioning is directly influenced by these individual characteristics.


3.2.2. Work and family context


The involvement (or not) in work activities can impact the habits and routines of the patient and, in turn, influences the sleep routine. There is scientific evidence that social support can influence adherence to treatment39,40. The sleep PT should collect information about the family context, whether the patient sleeps accompanied in the same room and whether they live with their children, among other factors. This enables the PT to identify whether the family acts as a barrier or as a facilitator to the treatment, and then to include the family in the educational sessions to adjust their behaviors to provide better adherence.


3.2.3. Eating habits and physical activity


Eating habits and physical activity play important roles as synchronizers of the circadian rhythm. Information on alcohol and caffeine consumption, their amounts and schedules are needed since these substances have a direct effect on sleep patterns and quality34. A conversation about eating habits and mealtimes can reveal valuable information about the general state of health of the patient. Similarly, questioning the frequency and intensity of physical activity and their schedules can help the sleep PT better understand the patient’s habits.


3.2.4. Medications in use


Although the sleep PT does not intervene in the prescription of medications, knowledge about the drugs used by the patient is fundamental, including herbal medicines and dietary supplements. Special attention should be paid to medications and substances used to change the waking-sleep cycle. Drugs may have adverse effects that promote sedation or wakefulness. Understanding medications and their effects help the sleep PT to have a global view of the patient’s health, as well as better understand their signs and symptoms, which may or may not be related to sleep disorders and/or their therapeutic behaviors. Sleep PT is part of an interdisciplinary team and can refer the patient to a specialist whenever necessary.


3.3. Physical examination


3.3.1. Vital signs


It is suggested that the sleep PT starts the physical exam by measuring pulmonary auscultation, peripheral oxygen saturation, and heart rate during waking at rest.


3.3.2. Anthropometric assessment


The assessment of weight, height, and body mass index provides essential information for the sleep PT. Some sleep disorders are directly related to being overweight and, in addition, changes in these aspects over time may require changes in behavior.


It is suggested that the sleep PT evaluate the neck circumference, especially in cases of suspected OSA. Neck circumference varies between genders41. In an epidemiological investigation in Brazil, the cutoff point for mild to severe OSA for men was 40.2cm (accuracy 70%) and in women 36.2cm (accuracy 76%)42. Other measures to consider include abdomen circumference and waist-to-hip ratio as they reflect body fat distribution and cardiovascular risk. The cut points for waist circumference are >102cm for men and >88cm for women in respect of identifying those with increased cardiovascular risk43.


3.3.3. Inspection and palpation of craniofacial and neck structures


The evaluation of craniofacial structure is significant, especially when there is suspicion of SDB44. Characteristics such as a long or short face; the size, proportions, and positioning of the maxilla and mandible, as well as the shape of the palate and the volume of the intraoral structures (i.e., tongue, uvula, and soft palate) help to identify risk factors for OSA. Modified Mallampati classification or Friedman tongue position classification are used for evaluation of the oropharynx region45.


Regarding SDB, the nasal cavity requires special attention. It is suggested that the sleep PT asks the patient about their preference for the nasal or oral route of breathing, both during wakefulness and during sleep. In addition, they should ask about nasal dryness and the oral cavity. It is suggested that the PT evaluate the patient’s nose about its size, shape, and possible deviations that can be identified externally.


Regarding sleep bruxism, the evaluation of craniofacial structure associated with the evaluation of the neck and thoracic spine, and upper limbs are essential for treatment. It may be necessary for the PT to refer the patient to a dentist. It is up to the PT to recognize changes in function, in respect of muscle activity; movement of the temporomandibular joint (TMJ); reduced range of movement in the TMJ, mobility, and muscle strength, including in antagonistic and synergistic muscles related to the movement of the TMJ; positioning at rest and at movement of the TMJ (more details in the Section 9).


3.3.4. Inspection and palpation of other structures


The assessment of the spine and its curvature may be necessary (some scoliosis may compromise ventilation or contribute to chronic pain that may interfere with positioning during sleep). The evaluation of edema in the lower limbs is of paramount importance for SDB, to control and/or treat the rostral displacement of fluids during the recumbent position.


In pain conditions, a pain map, in which the patient colors/shades the pain sites, as well as the visual or numerical pain scale, can be used. Although pain is a personal and subjective experience, the use of these instruments can help to understand the intensity of and the evolution of pain during treatment46.


3.4. Questionnaires and scales: subjective evaluation


The sleep PT should know the main assessment tools used for the screening and clinical follow-up of patients with sleep disorders. Among the questionnaires and scales described in the literature, some of them are disease-specific, relating to factors (e.g., drowsiness or the presence of awakenings), while others evaluate sleep in a more general way, especially in respect of sleep quality or circadian preference. Table 3 summarizes the self-administered questionnaires translated, validated, and culturally adapted for the Brazilian population.



Questionnaires and scales for the evaluation of sleep disorders and/or conditions were translated into Portuguese and adapted, and culturally validated for use in Brazil.


Some measurement instruments have been translated unofficially. Although they are used in clinical practice and research, they lack specificity and sensitivity because they have not been validated. These instruments include the Stanford sleepiness scale, and sleep diaries. The latter is used concomitantly with the use of actigraphy and is important in the evaluation of the sleep-wake pattern through recording the time to go to bed, sleep, wake up, night awakenings, and daytime naps. This allows the analysis of routine and habits related to pre-and post-sleep using subjective data gathered over an extended period59.


3.5. Interpretation of sleep tests: objective evaluation


The sleep PT should have extensive knowledge of the diagnostic methods available. Each method has its particularities, limitations, and specific indications and can help in the physiotherapeutic evaluation.


The type I sleep study, also known as type I PSG, or complete polysomnography, among other names, is considered the most complete way to evaluate the various variables that affect human sleep. It comprises an electroencephalogram, an electrooculogram, an electromyogram of the chin and tibial anterior muscle, an electrocardiogram, monitoring of airflow channels, respiratory effort sensors, oximetry, audio/video recording, position and snoring sensors. PSG is performed with the supervision of a PSG technician trained to identify potential artifacts and reposition sensors when necessary60. It is widely used in clinical practice and scientific research and is considered the gold standard for the nosological diagnosis of SDB, REM behavior disorder, and periodic limbs movement disorder. PSG performed in the sleep lab can provide split-night tests, with the initial portion being used for diagnostic purposes and the final portion for positive pressure titration.


The type II sleep study, known as in-home PSG, records the same variables as type I studies, with the main difference being that it is not performed in a sleep lab, and there is no supervision by a PSG technician. This type of study can be performed in a home environment, in a hospital, or in another environment. The main advantages associated with this method are the possibility of examining the patient’s usual sleep environment, and that it can be applied to patients with mobility restrictions who are unable to travel to a sleep laboratory. This method is subject to a greater number of artifacts due to the absence of a trained professional who can ensure the technical quality of the record. Taking this into account, the analysis of the report, which is composed of the same information of type I tests, should be done with care.


The type III study, known as respiratory polygraphy or home sleep apnea test, aims to evaluate the presence of OSA in patients at a clinical evaluation and is used in association with OSA risk stratification questionnaires. Composed only of nasal airflow signal, a respiratory effort sensor, oximetry, and sometimes a position sensor, this method is normally performed in the patient’s sleep environment. The practicality and greater comfort of this method may be offset to some extent due to its limitations, especially in respect of the absence of channels that assess the presence of sleep and its fragmentation, preventing the marking of respiratory effort related arousal (RERA) and hypopnea validated by arousal. The information available in the report are a respiratory event index (REI), the oxyhemoglobin desaturation index (ODI), and data related to the differentiation of the type and origin of events and body position, which should be interpreted carefully considering the limitations described. This method is not indicated for patients who, beyond the suspicion of OSA, have comorbidities or other associated sleep disorders61.


The type IV study, which is used as a screening tool for OSA, it comprises an oximetry record, heart rate and sometime airflow. Studies show a good correlation between ODI obtained by this method and the apnea and hypopnea index (AHI)62. Generally, the simplicity of the method means that it does not include relevant information, data on sleep and respiratory events.


Peripheral arterial tonometry evaluates arterial tone via peripheral sensors and detects changes in heart rate and desaturations associated with the end of respiratory events and can estimate the AHI63.


Actigraphy is an examination indicated to assess sleep/wake patterns in individuals with suspected circadian rhythm disorders and insomnia. The actigraphy estimates sleep using an accelerometer that detects the increase or reduction of activity (movement). This method can be used in a complementary way to simpler methods of evaluation of OSA, such as the type III and IV exams, which alone do not evaluate sleep variables64.


Finally, sleep endoscopy is an examination performed during drug-induced sleep to visualize the point of collapse of the UA. Sleep endoscopy can help in the investigation of possible causes that lead patients with OSA not to adapt to PAP therapy through the documentation of anatomical factors that impact adherence to PAP therapy65. However, because it is an invasive method and involves specialized medical training, its clinical applicability is limited to the evaluation of patients with OSA indicated for surgical interventions and in clinical research66.


When interpreting the results of these different examinations, the sleep PT needs to carefully consider the limitations of each method. Their knowledge about the sleep habits of the patient and the way the examination was conducted, and, in the case of PSG, whether the night in the sleep laboratory reflected a normal night’s sleep, should be taken into account when interpreting the information gathered. When there is a suspicion of respiratory disorders, the sleep PT must analyze variables, (e.g., AHI, RDI, REI, and ODI), the type of respiratory events (apnea versus hypopnea versus RERAs), the origin of the events (obstructive versus mixed versus central), the duration of the events, the association with desaturations and/or awakening, the relationship of the events with the body position adopted during sleep and the distribution of respiratory events at different stages of sleep (NREM versus REM). The analysis of this information is essential for the sleep PT to understand the potential phenotypes and endotypes associated with the respiratory disorder, and be able to establish the best treatment plan to restore patient functioning.


In addition to the descriptive and numerical variables, the production and interpretation of hypnograms (graphs representing the stages of sleep) and other graphical representations of the patient’s sleep can not only assist the sleep PT to understand the data but can be used to facilitate the process of education and awareness of the patient about the sleep disorder.


If necessary, the analysis of complementary tests such as blood gas and pulmonary function can help PTs to better understand the SDB that affects the patient. Although patients may have the same sleep disorder, the effects presented may be unique for each individual. A properly conducted evaluation process will allow the sleep PT to generate a significant amount of information regarding impairments in each functioning domain in respect of body function and structures, limitations in activity, and restrictions in participation - always considering the context in which the patient is inserted. It is not the nosological diagnosis that should be considered as the basis for the treatment of the patient’s problem, but the physiotherapeutic diagnosis based on the impact of the condition on the patient’s disability. After completing the evaluation, the sleep PT should use the collected data to establish specific goals and a therapeutic plan personalized as far as possible to meet the needs of each patient. The multidimensionality of sleep disorders and their relationships with so many concomitant variables can often require the involvement of other professionals from the transdisciplinary team.


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