Application function, and availability
This App is a smartphone App created in a collaboration between the Sleep Units of Hospital Quirónsalud Marbella and Campo de Gibraltar and their Engineering Informatics Departments and developed by Apnea Bye company. It was presented last November 2018.
We can think of this App as a portable gym with athletes instead of patients and trainers instead of therapists. The novelty of this App is that it is the first in the health-care market where the patient can interact directly with the smartphone without any other device, which provides feedback about the efficacy of the exercises performed and focused on sleep apnea disease. There are nine exercises based on MT that attempt to enhance the tonicity of the various muscles involved in the pathogenesis of OSAHS. Before every exercise, there is an animated gif demonstration that shows the patient how to perform the exercise (Figs. 1a–c). App’s users can follow the development of their activity daily over time (Figs. 2a–c). At the conclusion of each exercise, the patient receives feedback about the success of their performance with a point score (Fig. 3). When the patient finishes the exercises, they are saved on networked online storage (in the Cloud) and a therapist (Fig. 4) can evaluate the performance of the exercises and achievements. A chat function is available where the patient can contact the therapist directly. There is a reminder every 5 days if the patient “forgets” to perform the exercises. The English-language version of this App is now available on Android and the iOS platform via Google Play and the App Store, respectively. Full information about the App is provided in a Web Page https://airwaygym.App/. Therapists can use it to enroll and follow up their patients.
This App was developed with the most cutting-edge technologies (e.g., Ionic, Angular provided by Google and TypeScript by Microsoft) and the most consolidated software languages (such as HTML5, CSS3, and PHP). The App takes advantage of 3D Touch technology, a capacity available in the latest Apple devices to accurately measure the pressure that is produced on the mobile screen. This App complies with regulation 2002/58/CE and (UE) 2016/679 about Data protection.
The main objective of these exercises was to increase the tone of the extrinsic muscles of the tongue (genioglossus,hyoglossus,styloglossus and palatoglossus).
The exercises are based on those described by Guimaraes in 2009(KCC 2009), adapted to obtain a feedback with the phone.
Due to hygienical reasons we recommend to cover the screen with cling film or a hypoallergenic plastic wrap in all exercises.
Exercise 1. Snake
With your elbows touching your body, hold the phone with both hands as you do when holding a mirror in front of your face.
Stick your tongue out and press the screen with it for 5 s and release. The tongue should not touch your teeth or lips.
Repeat the exercise 15 times.
Exercise 2. Pressure with your chin
Fit your jaw 2 finger above the center of your phone. If you’ve got a beard place your finger between your phone and your jaw.
Open your mouth and keep pushing the screen for 5 s, close your mouth and rest. While doing the exercise say /a/.
Repeat the exercise 15 times.
Exercise 3. Chameleon up
Place the phone at a certain distance in front of you, as if it were a mirror.
Stick out your tongue and press on the square at the bottom. The tongue must not touch your teeth or lips.
Put your tongue up and keep the pressure on the screen 5 s, close your mouth and rest.
Repeat the exercise 15 times.
Exercise 4. Chameleon down
Due to hygienical reasons we recommend to cover the screen with cling film or a cleaning wipe.
Place the phone at a certain distance in front of you, as if it were a mirror.
Stick out your tongue and press on the square at the bottom. The tongue must not touch your teeth or lips.
Put your tongue down and keep pressing the screen for 5 s, close your mouth and rest.
Repeat the exercise 15 times.
Exercise 5. Tongue left cheek
Press with the tip of your tongue the inside of the left cheek. Allow the screen of your phone to touch gently your cheek.
Contract the muscles of your cheek while pushing with the tongue towards the cheek. Keep the pressure for 5 s.
Repeat the exercise 15 times.
Exercise 6. Tongue right cheek
Press with the tip of your tongue the inside of the right cheek. Allow the screen of your phone to touch gently your cheek.
Contract the muscles of your cheek while pushing with the tongue towards the cheek. Keep the pressure for 5 s.
Repeat the exercise 15 times.
Exercise 7. Pressure under chin
Hold the phone with both hands with the screen facing up. If you’ve got a beard place your finger between your phone and your jaw.
Sitting upright put the phone under your chin so there is no contact with the chin.
Bend your head forward like you are going to drink from a cup and contact your chin on the phone.
Keep the contact and move your head from side to side during 10 s with your mouth closed. Lift your head and rest.
Repeat the exercise 15 times.
Exercise 8. Left mandibular pressure
Bring the phone closer to the origin of the jaw on the left side. As if you were talking on the phone but with the screen to the outside.
Turn your jaw towards the phone and keep the pressure with your index finger on the screen for 5 s. Say /i/ while doing it.
Release the pressure and rest. Repeat the process 15 times.
Exercise 9. Right mandibular pressure
Bring the phone closer to the origin of the jaw on the right side. As if you were talking on the phone but with the screen to the outside.
Turn your jaw towards the phone and keep the pressure with your index finger on the screen for 5 s. Say /i/ while doing it.
Release the pressure and rest. Repeat the process 15 times.
Patients and methods
This preliminary cross-sectional study Approved by the local Ethics Committee AWGAPN-2019-01. Study started January 2019 and all patients were studied in a comparable frame of time. The inclusion criteria were adult patients diagnosed with OSAHS by poligraphy and were non-compliant with any therapy and had a mobile. The exclusion criteria were patients with previous surgery in the UA, UA malformation (i.e., significant tongue tie). All patients gave informed consent.
Data including sex, age, body mass index (BMI), Epworth Sleepiness Scale (ESS), Minimal Oxigen Saturation (O2MIN) and apnea–hypopnea index (AHI) obtained by poligraphy (Sleep & Go, Sibelmed 2018) .
All sleep studies were manually interpreted by a sleep technician according to the standard criteria of the American Academy of Sleep Medicine (AASM) Manual for the Scoring of Sleep and Associated Events and were reviewed by certified physicians (Adams et al., n.d.). Apnea was defined as an absence of airflow for a period lasting at least 10 s and hypopnea was defined as at least a 30% reduction in airflow associated with a 4% or greater decrease in oxygen saturation. The AHI was defined as the number of episodes of apnea and hypopnea per hour of Total Sleep Time (American Academy of Sleep Medicine 2007). Finally, the adherence to treatment (those who performed the exercise at least 5 days a week) were collected. Then, patients were reevaluated after 90 sessions with the App with the same tests, or after 3 months in the control group by the same physician who blindly evaluated the results achieved from each group. All patients were instructed by the same therapist about the use of the App prior to enroll in the study.
Statistical analysis
Quantitative variables were assessed by calculating the arithmetic mean and standard deviation and group of differences were assessed using a two-sample paired t test, or using a Mann–Whitney rank sum test if the variable was not normally distributed. P < 0.05 was considered significant. IBM SPSS Statistics for Windows software (version 20; IBM Corp, Armonk, NY, USA) was used for statistical analysis.