Contrary to my usual practice of putting only recent research articles on this website, this time I have put up something which is not an article at all, but an exchange of e-mail opinions among members of a sleep clinicians’ interest group. The initial question and answer led to quite a protracted debate! For those unfamiliar with the key terms, positional sleep apnea, it refers to the tendency of some patients with OSA to have much more apnea when lying on their backs than on their sides. This is quite common, perhaps because the force of gravity pulls down the tongue and soft tissues of the neck, closing off the airway. Some patients may have obstructive apneas only when lying on their backs. This may be more frequent among non-obese patients with less severe apnea. It may also apply to central apneas. Positional apnea is also associated with NREM sleep and may not apply during REM sleep. Note that a previous article reviewed at this website (#12, "The Effect of Polysomnography on Sleep Position: possible Implications on the Diagnosis of Positional Obstructive Sleep Apnea") pointed up the issue that the various measurement devices attached to the patient during polysomnography may constrain body movement and position to the extent of increasing the amount of time spent sleeping on the back and thereby possibly overestimating the usual frequency of apneas in the unconstrained sleeping situation at home. The "Tennis Ball Technique" represents a means of discouraging patients from sleeping on their backs. A pocket is sewn into the back of the pajamas or a t-shirt to be worn while sleeping. An object, such as a tennis ball, is placed in this pocket. Perhaps more simply, the ball can be placed in a sock which is pinned to the back. This should make it uncomfortable for the patient to sleep on his back, though some patients can accomodate to this and resume their supine sleeping position despite it. Of course, one can try using larger objects. There are also variations, such as audible alarms and restraints, to impede supine sleeping.One advantage of this approach to treatment is the negligible expense contrasted with a CPAP machine. Of course, as with any treatment for sleep apnea, not only a diagnostic but periodic follow-up polysomnograms are necessary to assure that the disease remains in good control with whatever treatment is used. It might also be worth mentioning here that elevation of the head of the bed seems beneficial to some patients with sleep apnea. The page is long, with 13 entries, but whatever you do, don’t miss the last one (#13)!

Opinion #1 Dear Dr. James: I believe that at one time the tennis-ball technique was recommended by the American Association of Otolaryngology as a first approach to management of sleep apnea. I, also, have suggested it to patients without much success. From discussions with an on-line apnea support group, I gather it is considered antiquated and quaint. Many people know without being told that pushing their spouse on his side will lessen his snoring. Some patients already know before being studied that they sleep better on their sides than their backs, and do so, perhaps with a little help from their wives! The problem is, that what we have learned about the complications and hazards of sleep apnea makes such a "course of treatment" border on negligence. It may have cut down on the patient's noisy snoring, and even reduced his overall respiratory distress index, but we don't know whether it has actually eliminated apneas, hypopneas, desaturations, and arousals from other sources (such as upper airway resistance syndrome) that may contribute to impaired attention and memory, hypertension, cardiac arrhythmias, obstructive pulmonary disease, auto accidents, etc. With these in mind, one cannot take such a casual approach to treatment. One really needs to know from laboratory polysomnography that whatever treatment measure has been used, has eliminated these arousals and desaturations or at least reduced them to "normal" limits. It is also becoming increasingly clear that one cannot rely on the patient's self-report of drowsiness or absence thereof. So I'm sure it's not that positional change is worthless as a measure to reduce apneas; it's just inadequate in the light of current knowledge to adequately control a disease with potentially fatal consequences. Kerrin White, M.D.

Opinion #2 Date: Mon, 27 Oct 1997 17:32:13 CST From: Rosalind Cartwright I have read with surprise and amusement the responses. Position training is not antiquated, foolish, irresponsible. It is appropriate for 60 to 65 % of all apneics. This is the published data on the number whose A+HI is 2x as severe in the supine as in the lateral position. If you don't look you won't see. Nor is it only for the mild cases. See Mile, L and Broughton R eds. Medical Monitoring in the Home and Work Environment p 123-128. There is a study of 20 positional apneics mean supine rate 68. After positional training man A+HI 11. Trouble is you lose the effect as obesity goes up. (Round balls have no sides). But for $15 you can help 60% of the patients better than you can with a $15000 surgery. Many are within normal limits in the lateral position they just have to learn to go from side to side. If they are so heavy they can't feel the tennis balls..try wiffel balls. Rosalind Cartwright

Opinion #3 Date: Tue, 28 Oct 1997 From: Scott Howard (who first brought up the subject to the Sleep Discussion Group) From the variety of responses regarding the efficacy in the use of "snore balls" (or tennis ball approach) for "simple snoring," I think a randomized, controlled clinical study is in order.

Opinion #4 I often prescribe "Tennis Ball Therapy" to patients with exclusively or predominantely supine obstructive apnea. I have had patients tell me that they could not tolerate this and request alternative therapy i.e. surgery or nCPAP application. I do not recall any patients telling me that they were compliant with this measure. However, this type of apnea is usually mild and their correspondant symptoms i.e. daytime sleepiness are usually mild. I do not recall reading anything regarding compliance rates or symptomatic improvement with "Tennis Ball Therapy." It just seems intuitively obvious this should work.

Opinion #5 A few years ago I did a study for my masters thesis on the use of tennis balls in sleep position training. The results were presented at APSS in Nashville (Abstract #415), and were generally favorable. However, I used two tennis balls rather than one--this was based on pilot work which showed that one was ineffective. At the same APSS meeting, another presenter had two reports on a different sleep position training aid which consisted of a large piece of PVC pipe (about 12 inches long by 8 inches in diameter) wrapped in some sort of cushioning material and placed in a backpack. This thing was about the size of a football, and was quite effective (more so than tennis balls). I believe one of the CPAP manufacturers was supposed to be developing a commercial version of this device, but I have not heard anything else about this. Dr. Rosalind Cartright has also published two studies using a position alarm, which I think is also commercially available. The results were very good with this device also. If anyone is interested, I can send references for the studies above, plus a couple of earlier abstracts on the use of tennis balls. If the patient is completely positional, a position alarm or other positional training aid should work well, and in most cases will be more acceptable to the patient than CPAP. However, it would be a good idea to document (via polysomnography) that any device used actually works for a given patient. In my thesis, I had one subject who had no problem sleeping with two tennis balls underneath his back! In addition, the conditioning effect is variable, so most patients would probably need to use the training aid every night.

Opinion #6 Actually, I have had a number of patients who seem to benefit from this technique, though there are a few caveats to follow: 1. You have to be dealing with a specifically supine postion obstructive problem. If the scorable events are occurring while on the back, but the patient is having signifigant sleep related upper airway resistence in the decubitus position, the tennis ball is probably not going to be notably effective. Be sure to check out the videotape record of time spent on the side, before deciding that position is the answer. 2. the patient must understand the physics and aerodynamics of apnea and have reviewed with you the results and your reasoning enough to understand why you would be "asking him to do such dumb thing"...they have to see and understand why you believe this will work for them. It helps also with compliance if the patient sees other benefits to this approach, chief of which are (a) it is very inexpensive, and (b) no signifigant chance of side effects (except for a few Quasimodo jokes the first night.) 3. the construction of the ballshirt is very important. The shirt itself must be a t-shirt (with arms) that is about one size too small for the patient. In other words, snug enough that the ball cannot wander over into the armpit or such. The ball must be sewn onto the shirt, (tightly down like a button) directly over the midline, level with the bottom tips of the shoulder blades. Shoving a ball in the breast pocket of a t-shirt worn backwards will not work at all. 4. finally, use sense and knowledge about the patient and his sleep environment. A four hundred pound trucker is going to be able to lie on a regular tennis ball and probably not even feel it. Similarly, this will not work on a full flotation water bed (or any bed with enough give to simply swallow the ball up) Michael Westmoreland

Opinion #7 I think that you have come to the right conclusion. Positional training with a tennis ball, and probably with other techniques, is a useless exercise, and delays effective therapy. Most people find it difficult to sleep only on their side, and over time, the OSA starts to occur in that position, also. The only time I ever prescribe this approach is when there are no other options due to age or medical illnesses which prevent the use of other therapies. But, broaden your horizons beyond CPAP- many patients with positional apnea will respond to a dental device, and airway surgeries. Virgil Wooten

Opinion #8  Arie Oksenberg, Ph.D., on 29 October 1997: ...there are only very few studies...on the effectiveness of the tennis ball technique...This is surprising, especially in light of the pioneering work of R. Cartwright...who about 14 years ago showed encouraged data...Unfortunately, for some unknown reason, no data on the long-term effect of using this technique is yet available. In our Sleep Disorders Unit, we have been very much involved in studying the effect of body position on OSA. We recently published an article comparing anthropomorphic, polysomnographic and MSLT data between position (PP) vs Non position (NPP) OSA patients. (Chest 112(3):629-639, 1997). Of 574 OSA patients we found that 55.9% were PP, i.e., their RDI in the back (supine) position was at least double the RDI in the lateral posture. This PP group is younger and thinner, has less severe breathing abnormalities, and consequently enjoys better sleep quality and is less sleepy during the day hours than the NPP group. In addition we have investigated the effect on 24 hr blood pressure (BP) of using the tennis ball technique for a one month period in 13 PP OSA subjects. This paper will appear shortly in the Journal of Human Hypertension. The mean awake, sleep and 24 hr BP fell significantly with this treatment. The magnitude of the fall in BP was significantly greater in the hypertensive than in the normotensive group...if confirmed this form of non-pharmacological therapy could be relevant for the high percentage of OSA patients who also have hypertension...

Opinion #9 (from Rosalind Cartwright, 5 Nov 1997) ...The point I have tried to make is this: treatment has to be tailored to what the patient needs AND what they will use. No doubt CPAP is our best treatment at this time and no doubt compliance with it over time is a problem in some not all. Positional training is not for everyone either. Not for the obese, not for those who can’t learn, not for those with shoulder pain, etc., but for the 60% of all apneics who are positional about two-thirds learn within two weeks to move from side to side and demonstrate this in the lab without a tee-shirt...you know when they are in trouble from gaining weight and may need to go to CPAP.

Opinion #10 From Dr. Ronald L. Rosenthal (7 Nov 97) calls to attention two articles on an adjustable oral appliance for OSA...”Both of these crossover studies demonstrated that patients who had the same relief of symptoms from each treatment modality [oral appliance vs. CPAP] ‘overwhelmingly’ prefer dental appliances to CPAP.”

Opinion #11 Terry M. Brown, D.O., ABSM, (10 Nov 97) comments briefly: “An oral appliance comment by one patient given one. ‘It’s like sleeping with a football in my mouth.’”

Opinion #12 Rosalind Cartwright (11 Nov 97) rebuts: Boy oh boy! I am the last one who should be scolded about the usefulness of oral appliances since I too have many published studies on their efficacy. The debate was about those with positional apnea...not mild apnea. The two are not co-equal. The point was to do the least that would have the most effect. Oral appliances are varied and there is not a good way yet to know who should get what. They can be expensive too. I send many patients [to an orthodontist] who charges a flat fee to try jaw positioners and/or tongue retainers as many as necessary until one works. That I like.

Opinion #13 From Ronald L. Rosenthal, D.D.S., Med, FAGD, Executive Director, the S.I.D.S. Research Group (19 Nov 97): One of the presenters told an interesting story. He and some other researchers “hand-picked” 20 really well-respected physicians to interview a “patient.” These hand-picked physicians were simply told to evaluate the patient with the aim of finding out everything they could to ensure that they could provide adequate care to ensure the patient the “best quality of life.” How do you think these physicians did? How many of them questioned the patient about possible sleep disorders? In the final analysis, not one of these “hand-picked” top-dogs asked even ONE question related to sleep disorders. Recently...a physician from Atlanta told of three MD’s being sued by the families of three men who had heart attacks and strokes, one of whom died, another was in critical condition. It turns out the proximal cause of their medical crises was obstructive sleep apnea. The families were suing the MD’s of these men for not looking into their possibly having sleep apnea. Thanks to all of you who have contributed your time, effort, and opinion. This may be the most valuable forum for discussion of these topics available to many of us anywhere. This is what the internet is all about. I’ve learned so much from all of you. Please, whatever you do, don’t let this die out.



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