The development of an exercise intervention framework as a modality of treatment for individuals with obstructive sleep apnea, in the South African public healthcare setting

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Introduction: Obstructive sleep apnoea (OSA) is described as a breathing-related sleep disorder wherein your ventilation is impaired during sleep, due to the narrowing and collapse of the upper airway. Untreated OSA has been shown to increase the number of severe cardiovascular and cerebrovascular events. Common treatment modalities for OSA, including surgical intervention and continuous positive airway pressure therapy are effective but remain extremely expensive. It is thus often inaccessible to those in a low-income, under-resourced setting, or those without access to healthcare, as is the case for the majority of South Africans. Since addressing weight loss is a key component of OSA treatment, exercise may provide the benefits of addressing both weight loss and inflammation in OSA patients, as well as lowering the risk of cardiovascular disease, depression, and comorbidities that arise from obesity. Aims: The aims of this study were to understand the nature of, and perception to, current physical activity (PA) habits as well as barriers to exercise, faced by individuals with obstructive sleep apnoea (OSA group) compared to a control group of individuals without OSA (CON group). This information was then used to design an exercise intervention framework for OSA patients which can be implemented in an under-resourced setting, such as in the public healthcare system in South Africa. Methods: This is a secondary analysis of data already collected as part of a larger study investigating “Physical activity and sedentary behavior among patients with obstructive sleep apnoea in South Africa” (HREC Ref: 142/2021). The parent observational study made use of custom and validated questionnaires answered by adults diagnosed with moderate to severe OSA and control participants with no OSA. Participants were asked to report on current and past exercise habits, perceptions, enablers, and barriers to PA, as well as preferred modes of exercise, which were further analyzed. Results: A total of thirty-seven adults were included in the current study; eighteen of whom had been diagnosed with OSA, matched with nineteen CON adults for age, BMI, neck circumference, waist circumference, and blood pressure (all p>0.050). Self-reported current participation in PA was lower in the OSA group (61%) compared to the CON group (74%), although not significantly different (p=0.410), with lower levels of PA between the two groups reported as being due to time constraints, dark/unsafe environment, laziness, covid restrictions, a lack of interest, motivation, and illness/injury/surgery within the OSA group specifically, There was a high presence of structural pain within the OSA group (83%) compared to the CON group (58%), although not significantly different (0.091), which was aggravated by PA (33% and 36% respectively). Frequency of PA was most commonly recorded as four to seven days per week by both the CON and OSA group (p=0.975, with a self-reported medium intensity ranging between 4-7 out of 10 (p=0.281) based on a subjectively designed 10-point scale (1: very low intensity, 10: very high intensity). Walking was the preferred form of PA within the OSA group (72%), as well as within the CON group (63%) (p=0.556), and both groups identified the ‘lack of motivation' as a barrier to participation in PA (p=1.000). Conclusion: Taking into account the observations 7 from evidence-based reviews in Chapter 1 and the results from Chapter 2, the proposed framework should include an exercise intervention that considers a moderate frequency of three to five times/week, a medium and building up to a higher intensity of 40-80% HRR, shorter sessions of 25-40 minutes per session but building up to 60 minutes where possible, and inclusion of aerobic and resistance exercises with a focus on walking as well as lower body activities. Group sessions should be considered to allow space for social interactions through physical activity which may help work around the barrier of motivation. Patient education on OSA and its consequences, the role of sleep, sleep hygiene, and disease management should also be included as part of the exercise intervention. Importantly, our results provide a basis for further development on this framework to establish an exercise Intervention as an adjunct therapy for OSA patients, specifically in lower income settings. Future studies can explore the efficacy of these exercise interventions in the management of OSA in adults from low income settings.