Sleep Apnea and The Didgeridoo
by Ed Drury
Basically, three types of sleep apnea exist: Obstructive, Central and Complex. The most common type is obstructive sleep apnea. The most noticeable sign of obstructive sleep apnea is snoring, although not everyone who has obstructive sleep apnea snores and not everyone who snores has sleep apnea. Apnea means quite literally an absence of breathing. People who suffer from sleep apnea have pauses in breathing during sleep which may or may not awaken them. It is estimated that approximately 18 million people in American alone may have obstructive sleep apnea. The symptoms may include loud snoring, daytime drowsiness, frequent sleep disruptions, trouble concentrating, mood or behavior changes, gasping or choking at night, morning headaches and memory loss.
People who suffer from obstructive sleep apnea are at greater risk for high blood pressure, heart disease, strokes, diabetes and depression. Risk factors for obstructive sleep apnea include obesity, family history of sleep apnea, age, use of alcohol and smoking. Men are more likely to develop obstructive sleep apnea than women.
Obviously, sleep apnea is a very serious condition. One should seek the advice of a physician regarding diagnosis and treatment if they suspect they suffer from either obstructive, central or complex sleep apnea. This article is written in response to many inquiries I have received concerning published reports, media articles and advertising claims about the didgeridoo and it's potential use in therapy to reduce both snoring and sleep apnea . I discuss the study itself and present a rational approach to trying to recreate the positive effects suggested by the study results.
Mild obstructive sleep apnea can and usually does progress to moderate and eventually severe sleep apnea. It is complicated by the damage chronic sleep apnea does to receptors in the body that monitor CO2 in the arterial blood.. During apnea, CO2 levels in the arterial blood rise. These CO2 receptor sites send signals to the brain to increase breathing, which the body tries to do against the resistance of the partially obstructed airway. Snoring gets louder. Ever snore so loudly that you wake up?
If this pattern is repeated enough times, over time, these receptor sites get tired. The body tolerates higher levels of blood carbon dioxide till only a low Oxygen level in the blood will alarm a different set of receptors in the body that do the work of monitoring blood oxygen levels. Thus a very dangerous cycle goes from bad to worse. The receptors that monitor oxygen levels in the blood don't kick in until carbon monoxide levels are far above normal and aren't as sensitive to hypo-ventilation as their carbon monoxide monitoring counterparts are. This vicious cycle works over time to lead to some of the chronic conditions associated with sleep apnea. It's good to get a jump on this early in the game for sure. And it is early in the game that playing the didgeridoo may be of the most benefit.
Sleep Apnea and the Didjeridu
In December of 2005, the British Medical Journal published a study called , “ Didgeridoo playing as alternative treatment for obstructive sleep apnoea syndrome : Randomized controlled trial.” News of the paper spread through various media and very soon after adds from didgeridoo shops started appearing throughout cyberspace using tag lines like , “Snoring? Play the didgeridoo!” For several years I've been in contact with various people who are suffering from sleep apnea and I have cautiously encouraged them to try it. I think it's time to discuss the study a bit, How to use this information and what is reasonable or not reasonable to expect from adding didgeridoo playing as an adjunct to therapy for sleep apnea.
The first good step is to read the original study, if you haven't already. Here is the link to the original study and I would encourage readers to read the follow up comments as well as some of them raise some very important considerations. I'll talk a bit about those when I cover expectations. Here then, is the link to the article in the BMJ that started it all : http://www.bmj.com/cgi/content/full/332/7536/266 .
The study doesn't really give a clear answer to the question of how playing the didgeridoo improves upper airway flow during sleep. I suspect that it the answer has probably more to do with the strengthening of muscles that surround the soft tissues of the upper airway and less to do with sound vibration. Though I do not completely discount sound frequencies playing a role here. Consider this video from youtube:
There are several things to consider about the study that aren't mentioned in most of the media releases, videos and references to it. The study used a fairly small sample size, which is an important thing to consider before making broad statements about the results. Also, very often when we have good studies on something, the results are not reproducible in subsequent trials. And as of this writing, I'm not aware of anyone trying to repeat the study. Nor would I hold my breath waiting for one (sorry, bad pun that!). If we were talking about a new drug for sleep apnea, studies would be plentiful. Funding for clinical trials of exercise techniques is considerably less appealing to private funders. A follow up survey at five years with the participants would be a golden opportunity to see what the long term benefits of this may be as well. Perhaps this has been done and not yet published.
Another weaknesses of the study are the somewhat subjective standards use to access the results. The improvements seem largely based on the observations of the participants partners, the Pittsburg Sleep Quality Index , apnoea-hypopnoea index, Health-related quality of life and the Epworth Sleepiness Scale. Also to keep in mind, obese subjects where excluded from the study. The group had only moderate and not severe sleep apnea and from looking at the blood pressure measurements it would seem likely than none of them suffered from hypertension. In other words, this was a group that had some advantages over people with more severe and long standing sleep apnea. Further studies on a wider variety of people including various body types, alcohol consumption and smoking history would be very nice to have. A point not to be missed here is that if you are concerned about sleep apnea or even just loud snoring there are somethings you should consider doing in addition to playing the didgeridoo. Getting as close to ideal body weight as possible through diet and exercise if weight is an issue. Cessation of smoking if you do smoke. Finally, limiting your alcohol consumption to a modest level. These steps may not only improve the chances of didgeridoo playing being helpful, but may have a much more profound effect that any of the other treatments including CPAP.
But, I've been playing the didgeridoo for years and I snore!
I know! So do I and believe me, I've roomed with lots of didgeridoo players and heard them snore as well. But perhaps we haven't been practicing the techniques we did in the beginning when we were first learning to circular breath and initially using the muscles involved for the first time. Now, circular breathing to us is pretty much done effortlessly. Also, as we go along as players all the muscles around the lips have developed and practiced the lip buzzing techniques to a degree that we probably don't use the techniques we first learned to achieve a drone while breathing in through the nose. Bounced breaths place heavy emphasis on the diaphragm and are performed quickly. If you watched the video and listened to the playing style, these players are more “airplane” style players than staccato rhythm machines. Score one in the column that it is the circular breathing that provides the benefit vs just sound vibration.
If it was just sound therapy alone, just using the right frequency instrument would produce the desired effect. Still, can't rule out that it is the combination of sound frequencies and circular breathing that produced the improvement in this group. Thus, I recommend anyone wanting to use didgeridoo to improve sleep, decrease snoring and hopefully also periods of apnea, try to follow the example of the study as closely as possible. If you are already playing, you're going to devote some of your practice time to going back to basics as it were, circular breathing away for 25 or 30 minutes a day. Good time to work on tone, harmonics, breath support and perhaps a little meditation.
In order to secure the best chance of a positive result I believe one should follow the procedures used in the study as closely as possible. It is the best model we have of successful use of the instrument in this application so far. Why not try to reproduce the same steps used in the study as closely as possible. I don't go so far as replicating the exact instruments used in the study group. But if you have access to the same materials that they used, I say go for it. In my opinion, approximating the basic dimensions and tonal frequencies of the instruments described in the study is probably good enough. The instruments used were 130 cm long (51.2”), a diameter of 4cm (~1.57”) and a mouthpiece diameter of between 2.8 and 3.2 cm. What I suggest as a good enough copy is schedule 40 white PVC 1.5” pipe cut to a length of approximately 51” with a hand molded beeswax mouth piece that is 1 to 1.25 inches in diameter.
If your shopping for a ready made instrument, a slide didjeridu that can play in the key of C or a wooden, bamboo or agave didgeridoo which plays in the key of C. Just for the purpose of staying as close as possible to the kind of back pressure and playing response of the instruments used in the study, one would do well to consider a nice agave or bamboo instrument that plays in the key of C. Would an instrument with stronger back pressure do just as well or better? Short answer: I don't know. There is some evidence that actually an instrument with higher resistance (back pressure) may be better. Consider this study. But if the goal is to get the same results as the participants in the study did, I favor duplicating the study instruments as closely as possible.
Once you have an instrument, time to get to work! In the study, the participants were given an initial lesson on tone production and taught to maintain tone for 20 to 30 second intervals. They worked on this for a period of one week and then received another lesson from a didgeridoo instructor on the basics of circular breathing. After four weeks, the instructor repeated the lesson and finally again at eight weeks. The didgeridoo students were asked to practice at home at least 20 minutes per day five days a week. Which begs the question, “do I need to find a didgeridoo teacher?” Of course you can. Is it absolutely necessary? People have different learning styles. Some people are quite comfortable learning from printed manuals, some need to hear the information to learn it, and some people are very visual and learn best from observation. But most of us are some combination of all of the above. There is a wealth of instructional material available in the form of audio recordings, books and video. A large chunk of it is free. Having an instructor is a great way to get good feedback about your playing. But for many, a simple audio CD may give enough information and examples to learn the basics of circular breathing.
You're going to play at least 20 minutes a day, five days a week. In the study, participants averaged 25.3 minutes per day for an average of 5.9 days per week. And, if the study is our gold standard, it's going to be some weeks before you see some if any results for your effort. The good news here is that this type of playing does have some benefits aside from potentially improving your breathing during sleep. It is relaxing. It should calm you (especially if you try not to be overly self critical or impatient during the learning process. I did a little experiment on myself. For two weeks I measured my blood pressure before and after playing the didgeridoo for 20 minutes in a calm setting. What I found in my simple exercise was that my systolic and diastolic blood pressure readings were consistently about 2 to 5 mm/Hg lower after playing. I'd love someone to do a clinical trial on the effects on blood pressure by didgeridoo playing because my little uncontrolled experiment makes me suspect there is a good chance that for some people at least, didgeridoo playing may play a role in blood pressure. But that's for another conversation.
How will I know if it's doing anything?
Remember it's going to take weeks to months to notice an improvement. Like most holistic approaches to health care, it may be quite subtle and it may only address part of the overall picture. You'll definitely want to confront as many of the factors associated with obstructive sleep apnea that are within your control. That is to not only just add didgeridoo playing to your daily routine, but strive to attain your ideal body weight, quit or at least reduce your consumption of tobacco and limit your consumption of alcohol.
I would suggest keeping some kind of journal for a few months. This will serve to document any improvements in sleep quality, decrease in daytime drowsiness and changes in overall health. It will also give you feedback that helps you stay on task. Record the amount of time you spent playing the didgeridoo that day and any notes or comments about the practice session you feel important. Make an entry at least once a day that reflects the issues which concern you about sleep apnea. For example, if you are in a relationship and your partner is willing to contribute to the journal, a daily note on how much you are snoring would be great. Trust me, they will have noticed your snoring! Also record the things that you feel affect your health goals. Blood pressure, if you can measure it at home. Weight reduction, if you are fighting that battle. Number of cigarettes you've smoked if you are a smoker. Number of alcoholic beverages you've consumed in the past twenty four hours if you think that is something you need to monitor as well. But most important, a quick note on how you feel. Did you wake up with a headache? Have you had trouble concentrating on simple tasks, remembering appointments, or even doing the daily crossword? How is your energy? A journal like this can really be of value when you are trying to make life style changes and it can also really help you to give your doctor a good solid history of what's going on with you.
Periodically, review your journal and look for trends. For example, on days that you do not have any alcohol did you feel more rested and alert the next day? On days you had the fewest or no cigarettes? If your weight is going down, is your blood pressure also going down? Since most of the indicators of sleep apnea outside a controlled environment like a sleep study lab are in fact subjective a journal will be very helpful as you look at your overall quality of life. Playing the didgeridoo is an inexpensive, enjoyable activity that is available. One which I think has many potential benefits to the player. One benefit may well be improved ventilation during sleep which translates to improved quality of life.
Comments and corrections should be sent to firstname.lastname@example.org
British Medical Journal Artlicle on Didgeridoo Playing and Sleep Apnea
BMJ Rapid Responses Section to BMJ article
Epworth Sleepiness Scale Research page
the Pittsburg Sleep Quality Index
Health-related quality of life
Apnea Support Forum – ApneaSupport.org
Snoring and Sleep Apnea forum
AFFP Paper on benefits of treating Sleep apnea
Sleep Apnea Impairs Blood Pressure Regulation
John Hopkin's article on link between Hypertension and Sleep Apnea
Learn to Play the Didgeridoo to treat Sleep Apnea
My Life and Sleep Apnea Blog
LA Outback's Sleep Apnea and Snoring page
Didjerinews Index Page
Learn to Play the Didjeridu