Effects of Exercise in Patients with Obstructive Sleep Apnoea
, Luis Vasconcello-Castillo 1,†, Homero Puppo 1,†, Ignacio Cabrera-Aguilera 2, Matías Otto-Yáñez 3, Javiera Rosales-Fuentes 1 and Jordi Vilaró 4
Round 1
Reviewer 1 Report
In this review article authors discussed the impact of physical exercise, oropharyngeal exercise and respiratory muscle training as adjunct therapies in OSA pts. Although this is an interesting issue I think that the authors could present better the data in this review article - as follows:
1) More detailed data are required about each exercise program (duration, intencity, etc) and resulting effects on primary (AHI) and secondary outcomes (symptoms - aleepiness or insomnia, comorbidities, weight loss)
2) The authors should describe possible underlying mechanisms to justify the reduction of AHI, independently of BMI (sleep efficiency and stages, daytime weakfulness, mood)
3) A recent meta-analysis Lung. 2014 Feb; 192(1): 175–184 could be cited
4) Data about RMT in pure (without comorbidities) OSA pts are inoclusive. What about sleep apneic pts with cohexisting congestive heart failure or COPD?
Author Response
Response to Reviewer 1 Comments
Point 1: More detailed data are required about each exercise program (duration, intencity, etc) and resulting effects on primary (AHI) and secondary outcomes (symptoms - aleepiness or insomnia, comorbidities, weight loss)
Response 1: Thank you very much for this comment. We agree that the reporting of the characteristics of each of the studies was not homogeneous. For that reason we add the description of the studies of Desplan et al., Kuo et al., Diaféria et al., Guimaraes et al., and Wheeler et al. Additionally, we added outcomes related to sleep quality, sleepiness and quality of life in the authors who reported it among their results.
Point 2: The authors should describe possible underlying mechanisms to justify the reduction of AHI, independently of BMI (sleep efficiency and stages, daytime weakfulness, mood)
Response 2: Thanks for this suggestion. We added a paragraph at the end of the section "Effects of physical training", the most common possible explanations found in the literature.
Point 3: A recent meta-analysis Lung. 2014 Feb; 192(1): 175–184 could be cited
Response 3: Thanks for this suggestion. The article by Iftikhar et al. it was already cited in reference 35. Additionally, in reference 22 we also include a more updated meta-analysis (network) by the same author.
Point 4: Data about RMT in pure (without comorbidities) OSA pts are inoclusive. What about sleep apneic pts with cohexisting congestive heart failure or COPD?
Response 4: Thank you very much for this suggestion. We conducted a search for the training of patients with apnea and comorbidities, especially cardiovascular ones, however, we did not find any available literature.
In any case, we consider it relevant to evaluate the effect in patients with overlap between COPD and OSA and more interestingly in those with overlap between OSA and heart failure. For that reason, we added a paragraph at the end of “Effects of respiratory muscles training”, with this recommendation for future studies.
Best regards
Rodrigo Torres
Reviewer 2 Report
Dear authors,
I reviewed the article entitled “Effects of the exercise in patients with obstructive sleep apnea”. The review is quite interesting but still needs some considerations to make. In the following sections below, you will find several comments/suggestions to improve the quality of the manuscript.
Specific comments:
- The figures or supplementary tables, figures, and video in general are quite informative but not cited explained in the manuscript. Please refer them to respective places and explain to general readers.
- The terms used in figure 2 needs to be explained either in figure legends or in the manuscript. Too much specific!
- In line 135, the Epworth sleepiness scale (ESS) is abbreviated but never got used again. So, please be careful with this and make sure others follow similar trends.
In general, the abstract and Introduction section seems alright. But as there is no specific discussion section this can be combined with an introduction. The conclusion section gives a good overview of the issues and findings of this review.
Good Luck!
Author Response
Response to Reviewer 2 Comments
Point 1: The figures or supplementary tables, figures, and video in general are quite informative but not cited explained in the manuscript. Please refer them to respective places and explain to general readers.
Response 1: Thank you very much for this comment. We added information at the bottom of each figure to explain what was represented. Additionally, we cite them in the text.
Point 2: The terms used in figure 2 needs to be explained either in figure legends or in the manuscript. Too much specific!
Response 2: Thank you very much for your comment. We add a more detailed explanation at the bottom of the figure. In addition, we add a paragraph complementing the information in the figure.
Point 3: In line 135, the Epworth sleepiness scale (ESS) is abbreviated but never got used again. So, please be careful with this and make sure others follow similar trends.
Response 3: Thanks for this suggestion. We removed the abbreviation for the Epworth Sleepiness Scale. Additionally, we review all abbreviations in search of a similar situation.
Best regards
Rodrigo Torres Castro
Reviewer 3 Report
Dear authors,
"Effects of the exercise in patients with obstructive sleep apnea"
The topic of this narrative review is quite interesting for practical applications; however, several previous systematic reviews and meta-analyses have reported more structured findings.
2019 = https://pubmed.ncbi.nlm.nih.gov/31116901/
2020 = https://pubmed.ncbi.nlm.nih.gov/32045849/
2020 = https://pubmed.ncbi.nlm.nih.gov/31911659/
2020 = https://pubmed.ncbi.nlm.nih.gov/32662419/
The authors are required to turn the review into an integrative review following international guidelines (Hopia et al. Reviewing the methodology of an integrative review. Scand J Caring Sci. 2016;30:662–9) or even into a systematic review following the PRISMA guidelines. This would have a more reproducible contribution to the literature that assesses the effect of the combination of diet, physical exercise, and oropharyngeal exercises (respiratory muscles training) if we consider that diet + exercise has already reviewed recently (check previous links). A native English speaking editor would be greatly appreciated.
Specific comments:
Line 15-16: Grammar editing. Include a comma after "mortality". Replace "economic expenditure on health" with "healthcare expenditure".
Line 17: Erase the abbreviation CPAP because it only appears once in the abstract.
Line 18-19: Are the oropharyngeal exercises an alternative for weight loss? Please re-organize this sentence for better readability. Authors might let "diet and physical exercise" within parenthesis.
Again, AHI only appears once.
Line 20: The aim of the review should be after the background sentence (at the beginning of the abstract).
Line 22-23: Please be careful with the conclusion because you did not analyze systematically the available evidence.
Line 29: Grammar editing.
Line 30-32: Please specify the context of the population from where this range has been reported.
Line 44: Mild, moderate, or severe patients?
Line 53-55: Please rephrase since, as you know, association does not mean causality.
Line 60: Could the authors please explain why oropharyngeal exercises would support weight loss?
Line 69: Please replace "Physical training" with "Physical exercise". Same hereinafter.
Line 71-72: Please rewrite since this was already mentioned in lines 63-64.
Line 73-75: Replace "body weight" with "body mass". Also, "fatty tissue" by "fat mass". In fact, these might not be mechanisms but also consequences of physical exercise. Authors are expected to discuss the effects of exercise on cardiorespiratory fitness (e.g., VO2max) and also the improvement in metabolic profile in the overweight/obese population. Mechanisms underlying these effects have been well-described by previous studies (although more research is needed in certain mechanistic processes). Check the following references:
- https://doi.org/10.1016/j.cmet.2015.05.011
- https://doi.org/10.1155/2014/964627
- https://dx.doi.org/10.1098%2Frsfs.2014.0040
Line 76: ... are not ONLY related to...
Authors should highlight here the improvement in body composition, especially the reduction in fat mass.
Line 85: m2 squared. Please erase the word "aerobic".
Line 88-89: Please report effect size if available.
Line 78-89: Although these two studies have shown important improvements, they are not a representative sample of the whole literature. This would be a sort of discussion section after you report the specific procedure you use for the collection of studies (Boolean search, databases, inclusion criteria, items or variables to evaluate, etc.). This is one of the main flaws of the review and has to be overcome by turning this into an integrative or systematic review.
Line 93: Nice figure.
Line 97-98: Please highlight that is not weight loss but the improvement in body composition (especially reduction in fat mass).
Line 99-103: Could the authors discuss more the interactions between visceral fat, physical exercise, and OSA?
Line 121-122: Please support this with references.
Line 122-124: Please place this sentence further back.
Line 155: Could the authors please explain the difference between the oropharyngeal exercises and the respiratory muscles training? Is it suitable to have two sections that are very related to each one?
Line 195-196: Why a matter of discussion? Several systematic reviews with meta-analyses have analyzed this phenomenon recently (see references at the beginning of this report).
Line 199-201: Considering the so-study effect of diet+exercise on OSA, the authors should focus this review (as an integrative or systematic) on the combination of diet+exercise and respiratory muscles training.
Line 205-206: Please erase this if no supplementary material is available.
Author Response
Thank you for your comments. It really helped improve the manuscript.
The point by point is attached in *.doc format
Author Response File: 
Author Response.docx
Round 2
Reviewer 1 Report
Physical exercise is always proposed in OSA pts. However the effectiveness of this procedure still a matter of discussion. It is interesting this review of the available data.
Author Response
Thank you for your feedback. It really helped improve the manuscript.
Best wishes
Reviewer 2 Report
In my opinion, the authors addressed well all my concerns and suggestions.
The manuscript is interesting, important to the field, and also an excellent point of reference for individuals interested in the topics.
Author Response
Thank you for your comments. It really helped improve the manuscript.
Reviewer 3 Report
Dear authors "Effects of exercise in patients with obstructive sleep apnoea",
Thanks for addressing all comments/recommendations besides providing answers to my questions.
I understand modifying the structure to integrative or systematic review is a time-demanding process; however, you should consider this for future reviews (as mentioned in your response). Please locate the aim of the review (and the question) at the end of the introduction section. Also, it would be fair to give credit to the software and/or licensed images you used (and accession date).
