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Did you know that playing the Didgeridoo could help you decrease snoring?

One thing that sets physiotherapists apart from other forms of manual therapy is that we love giving out exercises to help the underlying issue. As a physio working in the head, neck and jaw area my exercises don’t always look like what a general musculoskeletal physio would give. So when I saw the literature regarding the use of didgeridoo to strengthen the muscles of the upper airways, I was very intrigued.

A question I ask every person who comes in with head, neck and jaw issues is “how do you sleep?”. There is 2 reasons for this; the first is poor sleep almost always affects your symptoms (read more about that here) and secondly some people report snoring which then tells me a little bit about the integrity of their upper airways.

The sound of snoring occurs when there is vibration of the lips, tongue, muscles of the throat and diaphragm. The vibration occurs due to these muscles having less tension and tone, when this occurs the tongue falls back and the throat narrows. The more relaxed these muscles get, the more vibration and the more vibration the louder the sound. If there is enough relaxation then the throat closes up and you are unable to get oxygen in which then would be classed as obstructive sleep apnoea (OSA).

When someone tells me they snore I have suspicions that they may not be getting a restful sleep each night (and neither would their partner!) and that they may need some training and strenghthening of their upper airways.

A recent randomised control study looked at 25 patients with a apnoea-hypopnea index (an index used to show the severity of sleep apnea) of 15-30 (classified as moderate sleep apnoea). They gave these individuals 4 months training of playing the Aboriginal instrument, the didgeridoo.

What the training involved was:

  • Teaching the participants the lip technique to produce and hold a note for 20-30 seconds
  • Circular breathing, which involves inhaling through the nose while maintaining airflow through the didgeridoo using the cheeks
  • Mastering the complex of the lip and vocal tract allowing the vibrations to move from the upper airway to the lower airways
  • Practising at home for 20 minutes 5 days a week

What the researchers found was that there were improvements with day time sleepiness and that the apnoea-hypopnoe index improved. So why did this happen?

Playing the diderigoo trains the muscles of the upper airways, it is these muscles that maintain airway dilation improving the stiffness of the walls. This is mainly done through the circular breathing process which uses the tip and mid portion of the tongue, cheek muscles and diaphragm. Do these muscles sound familiar? They are in fact the muscles that relax and vibrate with snoring!

Now don’t get me wrong, there are many ways to skin a cat, I mean through my speciality of treating the head, neck and jaw I focus a lot on training the muscles of the lips, tongue and cheeks using different techniques in order to strengthen the tongue and inevitably stabilise the jaw. However I love the sound of the didgeridoo and I am sure there may be many other people out there who feel the same. There is something very soothing and meditative about the drone sound it creates and I feel we need to remember that there are different strokes for different fokes and for some individuals the exercises I would normally provide to strengthen the orofacial muscles may be very boring and unmotivating and there may be some people out there who feel that playing the didgeridoo would mean practising an instrument they have always been fond of and at the same time they would be getting the upper airway strengthening they may need.

This study showed didgeridoo playing improved daytime sleepiness in people with moderate snoring and obstructive sleep apnoea but of course this doesn’t mean that if you snore that you need to go out and purchase a didgeridoo from your local music store! Like many studies, more extensive research needs to be produced, but if you already own a didgeridoo or have always wanted to learn how to play and you know you snore why not play a little more or give it a go and see what happens with your snoring.

References:

Wuhan et al. (2005) Didgeridoo playing as alternative treatment for obstructive sleep apnoea syndrome: randomised controlled trial BMJ; 332

How your tongue could be connected to your TMJ (jaw) dysfunction in my opinion …..

You probably may not associate the tongue as being a part of an average physiotherapy treatment, however from a very young age your tongue function starts to have a direct relationship to your TMJ joint by affecting the development of the bones that make up your jaw, affecting muscle function and breathing ability. So within a head, neck and jaw physiotherapy treatment the tongue is definitely one component of a whole picture that we look at.

We tend to forget that the tongue is a muscle, in fact it is more than just one muscle, it is a series of muscles that are grouped into extrinsic and intrinsic muscles. Some of these attach to the mandible (the moving bone that makes up the jaw joint), the soft palate and hyoid bone (the horse shoe shaped bone that sits on the anterior neck). In general, physiotherapists deal with muscles but more commonly it may be a speech therapist that deals with the muscle we call the tongue. However as a physio treating the TMJ and orofacial area, it is impossible not to at least assess and look at what the tongue is doing.

So lets talk a little a bit about anatomy. There are two bones that make up what we call the “jaw” – the maxilla and the mandible. The tongue sits inside the mandible and has a strong role in supporting our airways, studies have shown that some of the muscles that make up the tongue dilate the upper airways and help stabilise it.

Often in an assessment I will ask this question; “If you think about where your tongue is resting in your mouth, could you tell me what it is touching and if it is sitting high or low”. In almost every occasion I am given a very odd look in return. “Um I am not sure, I’ve never thought about that” is the likely answer! To tell you the truth most of us don’t need to think about it as the correct resting tongue position should really be something that automatically happens and isn’t something we have to put too much thought into.

So what is the correct tongue position?

The tongue when at rest should be sitting on the roof of the mouth behind the top front teeth. It naturally goes to this position when you say the letter “N”, try it! When it sits here it causes the airways to be tense and because of this the airways are strengthened resulting in normal breathing patterns.

It knows how to do this naturally because this neural pattern starts as an infant through the act of breastfeeding. When the tongue spends a lot of time in the top palate it begins to mould the very pliable palate and allows for a normal U shaped arch to form. If this doesn’t occur the person is often left with a narrow palate and a V shaped arch as an adult. When the palate is narrow the tongue sits at the bottom of the mouth and the muscles of the tongue can’t hold the airways open as they are designed to. You’ve heard the saying “use it or lose it”, when your tongue isn’t used the way it should it leads to decrease muscle tone, I mean you have to remember it is just like all the other muscles if you don’t use it they way it is designed it will start to lose it’s strength and endurance.

U shaped palate Vs V shaped palate

When the palate is narrow and pushes upward it starts looking like a cathedral arch and when this happens it starts to push up into it’s neighbours house, the nasal cavity and begins to infringe on its space. When the palate is pushed up so is the nasal cavity, decreasing the entire nasal space which can make breathing through the nose difficult.

What can then happen is open mouth breathing… Your body will do whatever it needs to to get oxygen! Open mouth breathing tends to change muscle function. This cascade of changes inevitably causes imbalances in the orofacial area which could lead to TMJ (temporomandibular joint) dysfunction and neck problems.

So if you have problems with your jaw, have a think about where your tongue sits at rest, you may be surprised by what you find.

If you would like to know more contact me at hello@mettapphysiotherapy.com

References:

Palmer, B. (1998). The Influence of Breastfeeding on the Development of the Oral Cavity: A Commentary. Journal of Human Lactation, 14(2), 93–98. doi:10.1177/089033449801400203

Ono, T. (2012). Tongue and upper airway function in subjects with and without obstructive sleep apnea. Japanese Dental Science Review, 48(2), 71–80. doi:10.1016/j.jdsr.2011.12.003

How your posture is related to your teeth … in my opinion

Until recently (the last few years) I have never thought about the link between straight teeth and ‘good’ posture, it wasn’t something taught in my physiotherapy studies at university. However having worked as a head, neck and jaw physio for a few years now I have gone down the rabbit hole of everything to do with the mouth including the teeth. I mean you have to become familiar with the teeth when you are treating the jaw… the systems are working together!

In the past the jury has been out in terms of finding a clear link in the literature between postural control (the ability to assume and maintain an upright position that is considered neutral) and occlusion (another name for the way your teeth meet together). However; a recent study found has found that there is a positive relationship with posture and occlusion. What the researchers found in the study was that postural control was improved when the diverse malocclusions of the participants were corrected artificially by positioning the jaw into a neutral position. The results were not as strong (statistically weak) when the participants were standing in a stable condition but there was a lot stronger correlation when the person was fatigued or standing on unstable conditions.

The researchers have a neurological explanation for this relationship, they think that sensory information from the trigeminal nerve, a cranial nerve that is responsible for innervating the muscle’s of mastication, is having an effect on postural control.

How is this all likely to be happening?

First lets look at the basic dental occlusions in the picture below.

Dental occlusion could be altering the position of the head and neck which then has an effect on the muscles of the this area. It is likely to alter the functional pattern of the muscles and then alter our sense of balance. So let’s talk a little bit about class II occlusion. Studies have found that Class II is linked to altered head position as well as altering the functional pattern of the masticatory muscles. As well as this some have suggested there is an increase in cervical hyperlordosis (a deeper than normal curve of the neck) and weak body posture.

So how do we get a class II occlusion?

Well this all starts before the age of 7. To develop a class 1 occlusion you really need your jaw and cranial bones to have developed well, when this happens you will grow a straight dental arch as an adult. As well as this you need good tongue posture, have a nasal breathing pattern and good lip muscles that allow lip closure. A fantastic blog post from functional dentist Dr Steven Lin explains this in his post What causes crooked teeth.

If you would like to know more about this subject feel free to contact me at hello@mettaphysiotherapy.com

References:

Julià-Sánchez, S., Álvarez-Herms, J., Gatterer, H., Burtscher, M., Pagès, T., & Viscor, G. (2015). Dental Occlusion Influences the Standing Balance on an Unstable Platform. Motor Control, 19(4), 341–354. doi:10.1123/mc.2014-0018

The use sauna to improve your health … in my opinion

I have recently been posting a lot of photos of myself sitting in an infrared sauna at my local yoga studio. It probably comes at a surprise to the Brisbane community as the average temperature here has been 30 degrees + every day for the last 2 weeks!! But since moving to the area, I have been going twice a week to sit in the infra red sauna set to 60 degrees celsius for 30 minutes…. & I love it! I started to ask myself, why I love the sauna experience so much, seeing as most might find it counterintuitive to sit in a hot room when outside might just do the trick! Once I thought about it I realised there is not only the obvious relaxation I get while I am in the sauna but after, there is a re-energizing feeling. So I decided to do some research to see if there was some scientific evidence to back up my feelings.

The use of saunas isn’t new. Humans have been doing it since the middle ages around Europe. In particular the people in the Scandinavian regions such as Finland love it and they are as common as the family car. In fact going down the research rabbit hole I read a statistic that said there are 5 million inhabitants in Finland and 3 million saunas which averages out to be 1 per household. It makes sense, it gets cold in places like Finland but I really feel there is more to saunas then just keeping warm.

Before we go into seeing what the evidence says lets think about what happens physiologically. When we sit in a sauna our body endures thermal stress and as a result the following happens:

  • Heart rate increases
  • Cardiac output (the amount of blood that the heart pumps through the circulatory system in a minute) increases
  • There is an increase in peripheral resistance and increasing circulation (arteries dilate decreasing the pressure needed for the blood to flow through them)
  • There can be a decrease in blood pressure
  • Metabolic rate increases

Do these effects sound familiar? I mean if you went for a brisk walk with your dog the physiological effects would be similar! But don’t get me wrong there is really nothing that can replace regular exercise but it makes sense that it would be great as an adjunct therapy!

Historically there has been a small amount of low quality evidence that has shown that the use of regular saunas can assist with respiratory function to those who have asthma and bronchitis (although contraindicated in acute respiratory infection). The use of sauna in these individuals resulted in an increase in Forced Vital Capacity (the total amount of air exhaled during the Forced Expiratory Volume test), Peak expiratory flow (maximum speed of expiration) and Forced expiratory volume (forced expiratory volumes that a person can do in 1 second).

A study that looked at 2315 middle aged Finnish men over a 20 year period, showed that regular sauna use (4-7 days a week) could in fact extend your life span. The study showed that an increase frequency of sauna use is associated with a decrease risk of coronary heart disease (CHD), cardiovascular disease (CD) and all causes of mortality. The researchers suspect this happens because there is a physiological effect that is similar to low to medium intensity physical exercise, such as, an increase in heart rate up to 100-150 beats per minute. With repeated treatments there is an improvement of endothelial function (the endothelial is a thin membrane that lines the inside of the heart and blood vessels) in patients with CHD and therefore there it could have a preventative role in improving the integrity of our blood vessels.

What about the use of saunas for exercise and sports recovery?

A very small study looking at male distance runners found that using a sauna after exercise resulted in an increase in blood volume and as a result an improvement in their endurance running performance. After 3 weeks of using saunas after exercise they could run 32% further before exhaustion.

As well as all the changes in circulation there was also an experiment with rats that showed intermittent heating releases specific proteins called heat shock proteins. What the researchers found was that when the rats were immobilised (not using their muscles) and then mobilised and heated the heating improved muscle growth up to 30%.

Now with most of the literature out there, confounders make it very difficult to confidently make definite statements about correlations and because of this there is always a need for more research. If you unsure if it is safe to use a sauna regularly then check with your health professional first otherwise give it a go and see how it feels for yourself.

References

  1. Laukkanen, T., Khan, H., Zaccardi, F., & Laukkanen, J. A. (2015). Association Between Sauna Bathing and Fatal Cardiovascular and All-Cause Mortality Events. JAMA Internal Medicine, 175(4), 542. doi:10.1001/jamainternmed.2014.8187
  2. Crinnion, W. (2011). Sauna as a Valuable Clinical Tool for Cardiovascular, Autoimmune, Toxicant- induced and other Chronic Health Problems. Altern Med Rev,16(3):215-225 .
  3. Scoon, G. S. M., Hopkins, W. G., Mayhew, S., & Cotter, J. D. (2007). Effect of post-exercise sauna bathing on the endurance performance of competitive male runners. Journal of Science and Medicine in Sport, 10(4), 259–262. doi:10.1016/j.jsams.2006.06.009
  4. Selsby, J. T., Rother, S., Tsuda, S., Pracash, O., Quindry, J., & Dodd, S. L. (2007). Intermittent hyperthermia enhances skeletal muscle regrowth and attenuates oxidative damage following reloading. Journal of Applied Physiology, 102(4), 1702–1707. doi:10.1152/japplphysiol.00722.2006

Changing habits with mindfulness in my opinion …

I have been working with people who suffer from temporomandibular joint dysfunction for a few years now and have noticed that an increase in oral habits such as biting nails, clenching, grinding, lip biting, biting hair (I could go on) can really exacerbate symptoms. As a result I ask people to watch out for their oral habits daily as it can be crucial for their rehabilitation. Over the years I have realised that when I ask people to try and stop their oral habits (which is easier said then done and perhaps even a little unrealistic) what I am really asking them to do is to be more present in their day to day lives.

What do I mean by “being present”?

I guess another word you could use is mindfulness. So how does one get better at being more mindful? I have found with my own health journey of trying to decrease old habits and trying to start new ones, meditation has really helped.

In contrary to what people might think, meditation doesn’t involve trying to stop your train of thoughts, rather, it involves watching the traffic of our mind, emotions and sensations, through this we can improve our ability to notice these gripping distractions within us – the trick is to notice these not just while we are meditating but also in our everyday life – for example – while we work, cook, exercise, parent, basically while we do life. By practising mediation we are able to increase our self awareness which is exactly what you need when you are trying to change a habit.

Habits are behaviours that are performed so frequently that they then become automatic. Often they are so automatic, they are deeply engrained and we don’t even know that we do them. This is why practicing mindfulness helps because when we are mindful we attend to what we are doing, what is happening and how we are feeling. When this happens we can actually catch ourselves doing things we never even knew we did. Practicing this self awareness helps most peoples see their habits and change, especially if it is the habit we are trying to decrease. If we don’t stop, we can pay attention to how we feel and possibly any triggers that are connected to our habits.

Working in the physiotherapy/manual therapy world I find meditation is a useful adjunct to the healing process as most of the time we are trying to decrease habits be it, favouring one leg, walking with an abnormal gait pattern, clenching etc. What mediation and mindfulness does is give more freedom from our conditioned responses, mental and physical. It is useful, as the process of meditation involves taking the time to pay attention to our bodies which is key, you can start asking “how I am standing while I’m waiting in this line at the supermarket?”. “What does my body do when I’m under the pump at work?”, “What is my go to sitting position?”.

I will admit it can be a long process changing a habit, because when you think about it the way to make a new habit is the same way you made the habit you are trying to get rid of! Repetition, repetition AND more repetition. Yep, you just have to keep at it. Your nervous system needs multiple times of doing the one thing before the pathway is strong, clear and direct. It is kind of like walking through the long grass and making a path, the first time you walk through the long grass you might only very slightly bend the grass, the second time you walk through it the grass gets a little more bent but you can only just make out the path you walked last time but if you repeat it enough the grass would have laid down and bent enough that it is a clear open space and it will be much quicker to walk through. Your nervous system works the same way.

I know that sometimes it seems like such hard work being present in your day to day movements but don’t worry this discipline will inevitably give you more freedom from your conditioned responses. So if you’ve been trying to stop a bodily habit in your life that isn’t serving you trying asking yourself these questions in your day to day; “how am I standing right now?”, “What am I doing with my mouth?”, “I feel really busy and overwhelmed right now, how am I breathing?”, “What does my normal walking pattern look like?”. Give it a go and feel free to tell me what happens.