https://doi.org/10.5664/jcsm.

8628

REVIEW ARTICLES

The effect of playing a wind instrument or singing on risk of sleep apnea:

a systematic review and meta-analysis
Fawn N. van der Weijden, MSc; Frank Lobbezoo, PhD; Dagmar E. Slot, PhD
Academic Centre for Dentistry Amsterdam (ACTA), a joint venture between the Faculty of Dentistry of the University of Amsterdam and the Faculty of Dentistry of the Vrije
Universiteit Amsterdam, Amsterdam, The Netherlands

Study Objectives: To systematically survey the scientific literature concerning the effect of playing a wind instrument or singing on sleep, snoring, and/or
obstructive sleep apnea.
Methods: The PubMed, EMBASE, and Cochrane databases were searched up to December 2019. Observational studies and (Randomized) Controlled Clinical
Trials that assessed sleep, snoring, or obstructive sleep apnea as clinical outcome or via a questionnaire were included. For the individual studies, the potential risk
of bias was scored. Data between oral musicians and control participants were extracted. Descriptive analysis and meta-analysis were performed.
Results: Six eligible studies (5 cross-sectional, 1 randomized controlled trial) were retrieved, with an estimated potential bias ranking from low to high. The
sample sizes ranged from 25 to 1,105 participants. Descriptive analysis indicated that players of a double-reed instrument have a lower risk of obstructive sleep
apnea and that singers snore less compared with control participants. Playing a didgeridoo showed a positive effect on apnea-hypopnea index, daytime sleepiness,
and partner’s rating for sleep disturbance. The descriptive analysis could not be substantiated in the meta-analysis. The magnitude of the effect was zero to small,
and the generalizability was limited because of long (professional) rehearsal time or small sample size.
Conclusions: Playing a wind instrument and singing may have a small but positive effect on sleep disorders. Considering the practicality and investment of
(rehearsal) time, didgeridoo and singing are the most promising interventions to reduce obstructive sleep apnea and snoring, respectively. However, the results of
this review are based on few studies and the synthesis of the evidence is graded to have low certainty.
Keywords: wind instrument, singing, sleep, snoring, OSA, sleep apnea
Citation: van der Weijden FN, Lobbezoo F, Slot DE. The effect of playing a wind instrument or singing on risk of sleep apnea: a systematic review and meta-
analysis. J Clin Sleep Med. 2020;16(9):1591–1601.

INTRODUCTION
Human beings spend about one-third of their life either sleeping
or attempting to sleep. Sleep is essential for normal cognitive
functioning and survival. Yet it can be disturbed or abnormal.1
The pharyngeal airway lacks substantial bony or rigid support.
Thus, the patency of the pharyngeal airway is largely dependent
on the activity of various pharyngeal dilator muscles. As long as
these muscles are sufficiently active, the patency of the airway is
maintained.2 When the muscles relax during sleep, soft tissue in the
back of the throat can collapse, causing turbulence and vibration
(snoring) or even partial or complete obstruction of the upper
airway (obstructive sleep apnea, OSA).3,4 In the case of OSA, the
(largely) obstructed pharyngeal airway prevents effective venti-
lation, producing either partial reductions (hypopneas) or complete
stops (apneas) in breathing. In either case, these (hypo)apneas will
lead to reduced oxygen levels and elevated carbon dioxide levels in
the blood. The brain responds to this by alerting the body, causing
a brief arousal from sleep that re-establishes the airway patency
and normal breathing. This pattern can occur hundreds of times in 1
night.2,4 The severity of OSA is expressed according to the apnea-
hypopnea index (AHI), a measure that represents the combined
number of apneas and hypopneas that occur per hour of sleep.4
The result of OSA is a fragmented sleep that often produces
excessive daytime sleepiness,4 which in turn can compromise
safety on the roads and reduce work productivity.5–7 OSA is also
associated with an increased risk of hypertension,8 cardiovascular
disease,9 incident heart failure,10 and myocardial infarction,11
among other possible consequences. The susceptibility for OSA
may vary by individual and can be influenced by several factors,
such as the size of the pharyngeal airway, the size of the tongue
and/or the tonsils, and mandibular retrognathism.2
Several treatments have been developed over the years to treat
snoring and OSA. Many of them are invasive and involve either
surgery or wearing a device during sleep.4,12 Therefore, an al-
ternative treatment approach that is noninvasive, safe, and effective
would be beneficial. Because the dilator muscles of the upper
airway play a critical role in maintaining an open airway during
sleep, researchers have explored exercises that target oral cavity and
oropharyngeal structures as an alternative method to treat OSA,13
such as oropharyngeal exercises. These are derived from speech
therapy and consist of isomeric (continuous) and isotonic (inter-
mittent) movements involving the tongue, soft palate, and facial
muscles, as well as stomatognathic functions like suction, swal-
lowing, chewing, breathing, and speech. The series of exercises are
based on the concept that muscle training while awake will reduce
upper airway collapsibility during sleep.14 A significant decrease
in snoring frequency, snoring intensity, daytime sleepiness, sleep
quality score, and OSA severity (measured using AHI) has been
observed among patients who had performed these exercises for

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FN van der Weijden, F Lobbezoo, and DE Slot
3 months, as has a significant reduction in neck circumference.
The latter suggests that the exercises induced upper airway
remodeling. 14 A meta-analysis performed by Camacho et al13
demonstrated that oropharyngeal exercises decrease AHI by ap-
proximately 50% in adults and 62% in children. Lowest oxygen
saturations, snoring, and sleepiness outcomes improved. The
authors concluded that oropharyngeal exercises could serve as an
adjunct to other OSA treatments. A more recent systematic re-
view by the same authors based on both subjective questionnaires
and objective sleep studies indicated that, with oropharyngeal
exercises, a reduction in snoring by approximately 50% in adults
can be achieved.15
If oropharyngeal exercises are indeed effective for reducing
snoring and the risk of OSA, it could be useful to explore those
individuals who have spent years engaging in training of the air-
way muscles as part of their hobby or profession: wind-instrument
musicians. The whole complex of anatomical structures around the
mouth, as well as the way in which they are used in playing a wind
instrument, is called “embouchure.”16 The 3 main embouchure
components are the tongue, the teeth, and the cheek and lip
muscles, but the palate and pharynx also play an important role.16,17
Other airway training involves singing, which requires control of the
muscles of the larynx, hypopharynx, oral pharynx, and oral cavity.18
To our knowledge, no systematic review or meta-analysis has
been published of studies evaluating sleep, snoring, or OSA
among oral musicians compared with controls. Therefore, the
aim of this systematic review is to comprehensively search the
scientific literature to identify, critically appraise, analyze, and
synthesize studies that address the effect of playing a wind in-
strument or singing on sleep, snoring, and/or OSA.
METHODS
Protocol
The recommendations for strengthening reporting were followed
in accordance with the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA),19 in combination with
the guidelines for Meta-analyses Of Observational Studies in
Epidemiology (MOOSE),20 and the PRISMA extension for
abstracts.21 The protocol that details the review method was
developed a priori following an initial discussion among the
members of the research team, and registered in PROSPERO
(International Prospective Register of Systematic Reviews)
(CRD42019134672).
Focused question and eligibility criteria
The PICOS-question (Population, Intervention, Comparison,
Outcomes and Study)22 to be answered in the present review is:
In observational studies and (randomized) controlled clinical
trials, what is the observed effect on sleep, snoring, and OSA in
people who play a wind instrument or are singers compared with
those who do not play a wind instrument or do not sing?
The following criteria were imposed for inclusion in the
systematic review:
· Observational studies and (randomized) controlled
clinical trials describing the effect of playing a wind
instrument or singing compared with controls.
Journal of Clinical Sleep Medicine, Vol. 16, No. 9
Do musicians sleep well?
· Any clinical outcome or questionnaire evaluating sleep,
snoring, and OSA, such as daytime sleepiness, quality of
sleep, snoring score, risk of OSA, diagnosis of OSA, or AHI.
The exclusion criteria were as follows:
· Editorial letters, narrative reviews, case series, case
reports, protocols, and abstracts.
Information sources and search
The PubMed-MEDLINE, EMBASE, and Cochrane-CENTRAL
databases were searched from initiation up to December 2019
(F.N.W.). The search strategy is listed in Table 1. Gray lit-
erature was also searched via Google Scholar. Additionally, the
reference lists of all selected studies were hand-searched for
additional relevant articles (F.N.W., D.E.S.).
Study selection
The titles and abstracts of the studies obtained from the searches
were screened independently by two reviewers (F.N.W.,
D.E.S.) and were categorized as definitely eligible, definitely
not eligible, or questionable. No language restrictions were
imposed. No attempt was made to conceal the names of authors,
institutions, or journals from the reviewers while making the
assessment. If eligible criteria were present in the title, the paper
was selected for further reading. If none of these criteria were
mentioned in the title, the abstract was read in detail to screen for
suitability. Papers that could potentially meet the inclusion
criteria were obtained and read in detail by the 2 reviewers
(F.N.W., D.E.S.). Disagreements in the screening and selection
process concerning eligibility were resolved by consensus or, if
disagreement persisted, by arbitration through a third reviewer
(F.L.). The papers that fulfilled all of the inclusion criteria were
processed for data extraction.
Data collection process, summary measures, and
synthesis of results
When provided, information about the characteristics of the
study sample population, intervention, comparison, and out-
comes were extracted independently from the selected studies
by two reviewers (F.N.W., D.E.S.). As age, BMI, and male sex
are well-known risk factors for snoring and OSA, these data
were also extracted when reported for further analysis. Means
and standard deviations were extracted (Table S1 and Table S2
in the supplemental material) or, if missing, requested from the
original authors. If a confidence interval was reported, the
standard deviation was calculated based on the mean and
the number of participants.23 As a summary, a descriptive data
presentation was used for all the studies.
If feasible, the data from the included studies were synthe-
sized into a meta-analysis (D.E.S., F.N.W.). In studies con-
sisting of multiple comparisons and data from one particular
group compared with more than one other group, the number of
subjects (n) in the group was divided by the number of com-
parisons. A meta-analysis was only performed if at least 2
studies could be included. The difference of means or risk ratio
between test and control was calculated for each index/scale
using a “random effects” model (Review Manager, version 5.3
for Windows, The Nordic Cochrane Centre, The Cochrane
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FN van der Weijden, F Lobbezoo, and DE Slot
Table 1—Search strategy for PubMed.
(<wind instrument*> OR <music AND instrument> OR <didgeridoo OR didjeridu OR yidaki> OR <singing or “singing”[MeSH]>)
AND
(<“Sleep Apnea, Obstructive” [MeSH]> OR <(sleep OR nocturnal) AND (apnea OR hypopnea OR apnea OR (breath* AND disorder*))> OR <OSA OR OSAS
OR OSAHS> OR <”snoring” [MeSH] OR snore> OR <sleepiness OR somnolence OR (quality AND sleep)>)
The search strategy was customized according to the database being searched. The asterisk was used as a truncation symbol.
Collaboration, Copenhagen, Denmark). The goal was to estimate the
mean effect in a range of studies where the overall estimate was not
overly influenced by any one of them.24 A subgroup analysis was
conducted relative to the type of musical performance (singing
and different types of wind instruments, Figure 1) when pos-
sible. In addition, a meta-analysis of common risk factors was
performed. Formal testing for publication bias was performed
when possible using the method proposed by Egger et al.25
Risk of bias in individual studies
Two reviewers (F.N.W., D.E.S.) scored the potential risk of bias
for the included studies. For assessment of the studies with a
cross-sectional design, a checklist was used as proposed by Van
der Weijden et al28 (Table S3). For randomized controlled trials
(RCTs), a checklist was used as proposed by Van der Weijden
et al29 (Table S4).
Assessment of heterogeneity and sensitivity analysis
Several factors were used to evaluate the clinical and methodo-
logical heterogeneity of the characteristics across the different
studies: study design, intervention (wind instrument playing/
singing), and variables used to assess sleep, snoring, and OSA.
As part of the meta-analysis, heterogeneity was statistically
tested using the chi-square test and the I2 statistic. A chi-square
test resulting in a P <.1 was considered an indication of sig-
nificant statistical heterogeneity. As an approximate guide to
assessing the possible magnitude of inconsistency across studies,
an I2 statistic of 0–40% was interpreted to indicate unimportant
levels of heterogeneity. An I2 statistic of 30–60% may represent
moderate heterogeneity; an I2 statistic of 50–90% may represent
substantial heterogeneity; a statistic of greater than 75% was
interpreted to indicate considerable heterogeneity.30
Considerable heterogeneity was evaluated with sensitivity
analysis to assess effect modification (F.N.W.). Outliers were
explored as being the source of heterogeneity. If there was a
significant difference between the test and control group for any
of the risk factors, these studies/subgroups were removed in the
sensitivity analysis.
Rating the certainty of the evidence (GRADE)
To appraise the evidence emerging from this review, the Grading
of Recommendations Assessment, Development and Evaluation
(GRADE) system proposed by the GRADE working group was
used. Two reviewers (F.N.W., D.E.S.) rated the strength of the
evidence according to the following factors: risk of bias, consis-
tency of results, directness of evidence, precision and publication
bias, and magnitude of effect.31,32 Any disagreement between the
2 reviewers was resolved with additional discussion.
Journal of Clinical Sleep Medicine, Vol. 16, No. 9
Do musicians sleep well?
RESULTS
Study selection
The search on PubMed-MEDLINE, EMBASE, and Cochrane-
CENTRAL resulted in 194 unique papers (Figure 2). Screening
of the titles and abstracts resulted in 18 potentially suitable papers,
of which 3 experiments each had 2 publications. The full text of 7
papers was not retrievable: 3 were registered protocols and could not
be retrieved as full manuscripts, and 4 were congress abstracts.33–36
For 8 papers, the full texts were obtained and read in full. Two
studies were excluded. One had no control group,37 and the other
was a summary of 1 of the included papers.38,39 Google Scholar
and the reference lists of the selected full text papers yielded no
additional suitable papers. Thus, in total, 6 papers (Figure 2)
were included in the present systematic review.39–44
Study characteristics
The study characteristics of the 6 included papers are listed in
Table 2. Five of the eligible papers had a cross-sectional study
design, whereas one was an RCT. In the RCT, the intervention
consisted of didgeridoo lessons. Three cross-sectional studies
compared professional wind and nonwind instrument players,
one study compared experienced (> 10 years) wind instrument
players with participants who did not play a wind instrument and
were not singers either, and one study compared singers with
healthy volunteers. The sample sizes ranged from 25 to 1,105
participants. Three continents were represented (Europe, North
America, Asia).
Risk of bias within studies
To estimate the potential risk of bias, the methodological
qualities of the included studies were assessed (Table S3 and
Table S4). Overall, the potential risk of bias in the included
studies was estimated to be “high” for 1,43 “moderate” for 2,39,42
and “low” for the remaining 3.39,41,44 In the studies that were
judged to have a moderate risk of bias, the sample size was not
justified and satisfactory. Besides that, in the study with an
estimated potential high risk of bias, the study participants were
not described in detail.
Descriptive analysis
Data extracted from the included studies are presented in
Table 3, which provides a summary overview of sleep/snoring/
OSA parameters between wind instrument players/singers and a
control group. According to the results of 3 of the included
studies,40,41,44 there seems generally to be no difference in sleep,
snoring, and OSA between wind instrument players and
controls. Two exceptions are double-reed instrument players,
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FN van der Weijden, F Lobbezoo, and DE Slot
Figure 1—Classification of different types of
wind instruments.
(A) Brass instruments (eg, trumpet, trombone, horn, tuba) are placed outside the
mouth by pressing the bowl-like mouthpiece against the upper and lower lip.
Both upper and lower anterior teeth provide support for the lips. Depending on
the height of the tone, the lips are pulled tight and set in vibrato.16,27 (B) With
playing single-reed instruments (eg, clarinet, saxophone), a wedge-
shaped mouthpiece, on which at the underside a reed is attached, is
placed partly in the mouth and between the lips. The maxillary incisors rest
on the sloping upper surface of the mouthpiece, while the lower lip is
placed between the lower surface of the reed and the mandibular incisal
edges (single-lip embouchure).16,27 (C) Double-reed instruments (eg,
oboe, bassoon) have a mouthpiece made from 2 bamboo reeds bound
together with a cord. The 2 reeds are placed in the mouth, between the
upper and lower lips, which cover the underlying incisal edges (double-lip
embouchure).16,27 (D) When playing the flute and the piccolo, the
mouthpiece is held against the lower lip, whereby the lower anterior teeth
serve as a support. The upper lip is pushed downward to form a small slit-
shaped opening between the lower and upper lip, through which air is
directed toward the opposite rim of the blowhole. The embouchure of the
flute is partly controlled by the position of the flute in relation to the upper
lip. This is done by a rotation movement of the flute in the plica mentalis in
combination with alternating protrusion and retrusion of the mandible.16,27
Reprinted with permission from British Dental Journal.26
who are found to have a lower risk of OSA compared with
controls,40,43 and didgeridoo players, who are found to have
lower AHI, daytime sleepiness, and partners’ rating for sleep
disturbance compared with controls.39 Singers are found to have
a lower Snoring Scale Score (SSS) compared with controls,42
but no difference was found in daytime sleepiness.
Meta-analysis
A meta-analysis was feasible for the following outcome pa-
rameters: Epworth Sleepiness Scale (ESS), high risk of OSA
(measured using the Berlin Questionnaire [BQ]), and diagnosis
of OSA (by a physician). The following studies could be in-
cluded in the meta-analysis: Brown et al,44 Puhan et al,39 Ward
et al,40 Wardrop et al,41 and Subramanian et al43 (Table 4). Meta-
analysis shows no difference in the ESS, high risk of OSA (BQ),
or diagnosis of OSA (by a physician) between wind instrument
Journal of Clinical Sleep Medicine, Vol. 16, No. 9
Do musicians sleep well?
Figure 2—Flowchart of search and selection.
players and controls, with a heterogeneity of 0%, except for high
risk of OSA (I2 = 81%, P <.001).
Risk factors, heterogeneity, sensitivity analysis,
and publication bias
A meta-analysis was also performed on the risk factors: age29,
body mass index (BMI), and sex (Table 4). There was no
significant difference in the means or risk ratio between wind
instrument players and controls. BMI and male sex were factors
that showed significant heterogeneity (I2 = 80–87%, P < .001).
The large heterogeneity for the high risk of OSA parameter
(I2 = 81%, P <.001) is due to the fact that some studies/subgroups
point in different directions (Figure S2a). The study by Brown
et al44 showed higher risk of OSA among wind instrument
players compared with controls, while the study by Subramanian
et al43 showed the opposite. The double-reed instrument players
subgroup in the study by Ward et al40 also showed a tendency for
a lower risk of OSA compared with controls. These discrep-
ancies correspond to the significant heterogeneity of the BMI
and male sex risk factors. The wind instrument group in the
study by Brown et al44 consisted of more males and a higher
BMI compared with the control group (Figure S2, c and e). The
double-reed instrument players subgroup in the study by Ward
et al40 had more women and a lower BMI compared with the
control group, whereas the high and low brass instrument
players subgroups had more men and a higher BMI (Figure S1,
b and d, Figure S2, c and e). In the study by Wardrop et al,41
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Table 2—Study characteristics of the included papers.

Study Population Conclusions of the
Study Design Participants
(Risk of Bias) (Country) Original Authors
Cross-sectional 369 wind instrument players:
175 brass players, 194 wood-
Professional orchestra wind instrument players, 233
members registered by the men, 110 women, 26 missing
sex, mean age 46.7 Playing a wind instrument was
Brown et al44 International Conference of
(12.26) years not associated with a lower risk
(Low) Symphony and Opera
of OSA.
Internet-based questionnaire Musicians (ICSOM). 736 nonwind instrument
(USA and Puerto Rico) players: 330 men, 360 women,
46 missing sex, mean age 46.8
(12.46) years
Cross-sectional Singers from two London- 52 singers: 20 men, 32 women,
based, mixed-sex choirs. The mean age 46.3 (26–70) years Singing practice may have a
Pai et al42 Questionnaires nonsinger group consisted of 55 healthy volunteers: 22 men, role in the treatment of snoring
(Moderate) healthy volunteers also 32 women, mean age 43.3 (16– but does not appear to
recruited in London. 74) years influence daytime somnolence.
(United Kingdom)
RCT
Didgeridoo lessons and practice Intervention group: 12 men, 2
at home (at least 20 minutes on Participants aged > 18 years women, mean age
at least 5 days a week) for with self-reported snoring and 49.9 (6.7) years Regular didgeridoo playing is
Puhan et al39 4 months an AHI of 15–30 (determined by an effective treatment
(Low) a specialist in sleep medicine alternative well accepted by
Sleep recordings within the past year).
and questionnaires Nonintervention group: 9 men, patients with moderate OSA.
(Switzerland) 3 women, mean age
Single blinded (person who 47.0 (8.9) years
analyzed the sleep recordings)
Cross-sectional 64 wind instrument players: 45
Nathasvaram (= double reed
Participants mainly from villages instrument), 10 trumpet (= brass
in and around Madurai who have instrument), 10 clarinet (= single
Subramanian et al43 OSA risk is reduced in wind
been playing the instrument for reed instrument)
(Serious) instrument players.
Questionnaire nearly more than 10 years. 65 controls: participants who did
(India) not play any form of wind
instrument and singers were
also excluded
Cross-sectional 76 double-reed instrument
players: 27 men, 49 women,
mean age 41.7 (14.5) years
204 single reed instrument
players: 110 men, 94 women,
mean age 43.8 (13.6) years
Collegiate instrumental music
124 high brass instrument Playing a double-reed musical
Ward et al40 Online questionnaire or paper instructors and other
and pencil version players: 94 men, 30 women, instrument was associated with
(Moderate) professional musicians.
mean age 42.0 (12.8) years a lower risk of OSA.
(USA)
122 low brass instrument
players: 108 men, 13 women,
mean age 44.0 (14.4) years
380 nonwind instrument
players: 210 men, 170 women,
mean age 42.7 (13.3) years
81 wind instrument players:
Cross-sectional No significant difference
mean age 41.58 (10.16) years
between the snoring severity
Professional orchestra 154 nonwind instrument
Wardrop et al41 or daytime sleepiness of
members. players: mean age 43.56
(Low) brass/wind players and
(United Kingdom) (10.19) years
other professional
Questionnaire undertaken Significantly more male wind orchestral musicians.
during rehearsal players than nonwind players

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Table 3—Summary of significant differences between wind instrument players/singers and controls for sleep/snoring/
OSA parameters.
Sleep Snoring OSA
Study Intervention Comparison
PQS ESS PRSD SOS SSS AHI DO BQ
Pai et al42 Singers 0 - Nonsingers
41
Wardrop et al Wind instrument players 0 0 Nonwind instrument players
Subramanian et al43 Wind instrument players (70% double reed) - Nonwind instrument players
Ward et al40 Double-reed instrument players 0 0 - Nonwind instrument players
Ward et al40 Single-reed and flute instrument players 0 0 0 Nonwind instrument players
Brown et al44 Woodwind* instrument players 0 0 Nonwind instrument players
Brown et al44 Brass instrument players 0 0 Nonwind instrument players
Ward et al40 High brass instrument players 0 0 0 Nonwind instrument players
Ward et al40 Low brass instrument players 0 0 0 Nonwind instrument players
Brown et al44 Wind instrument players using 0 0 Nonwind instrument players
circular breathing
Puhan et al41 Didgeridoo lessons 0 - - - Waiting list

*Woodwind instrument players = double-reed + single-reed + flute. - = significantly lower for the wind instrument/singer group. 0 = no significant difference.
Empty boxes indicate that no data are available. AHI = apnea-hypopnea index, BQ = Berlin Questionnaire (Risk of OSA), DO = diagnosis of OSA (by a
physician), ESS = Epworth Sleepiness Score (daytime sleepiness), OSA = obstructive sleep apnea, PQS = Pittsburgh Quality of Sleep index, PRSD = Partner’s
Rating for Sleep Disturbance, SOS = Snore Outcomes Survey score (snore severity), SSS = Snoring Scale Score.

the wind instrument group consisted of more men than the

control group (Figure S1d).
For the sensitivity analysis (Table 5), studies/subgroups
were removed if there was a significant difference between
the test and control group for any of the risk factors. Conse-
quently, for the ESS, 4 of the 6 studies/subgroups were ex-
cluded; only the study by Puhan et al39 and the subgroup of
single-reed instrument and flute players from the study by Ward
et al40 remained. A sensitivity analysis with these 2 groups also
showed no significant difference in the ESS between wind
instrument players and controls (I2 = 0%) (Figure S3a). The
overall result was not affected by the sensitivity analysis, al-
though it did have an effect on the statistical heterogeneity
expressed by I2. The result for the ESS can be regarded with a
higher degree of certainty. For high risk of OSA (BQ) and
diagnosis of OSA (by a physician), 5 of the 6 studies/subgroups
were excluded. Only the single-reed instrument and flute
players subgroup from the study by Ward et al40 remained. As a
result, the predefined minimum of 2 studies for a meta-analysis
was not reached.
Testing for publication bias could not be performed, because
fewer than 10 studies could be included in the meta-analysis.25
Rating the certainty of the evidence (GRADE)
Table 6 summarizes the various factors used to rate the strength
of the evidence according to the criteria as proposed by the
GRADE working group.31,32 Table S3 and Table S4 show that
the estimated potential risk of bias is low to high. The data that
emerged are rather consistent and rather precise; however, the
generalizability is limited because of long (professional) re-
hearsal time or small sample size. Reporting bias could not be
ruled out. The magnitude of the effect is zero to small. Con-
sequently, the degree of certainty surrounding the effect is low.
DISCUSSION
Answer to the focused question
This review was initiated to evaluate various aspects of sleep
disturbance in oral musicians. The results of the descriptive
analysis (Table 3) show that playing a double-reed instrument
or didgeridoo as well as singing have a positive effect on sleep, snoring,
and/or OSA. The descriptive analysis could not be substantiated by
meta-analysis (Table 4 and Table 5), in which all wind instruments
were pooled. The single study that evaluated the effect of singing
(Table 3) showed a positive effect on snoring compared with
nonsingers. The only RCT that evaluated the effect of playing a
didgeridoo showed a positive effect on AHI, daytime sleep-
iness, and partner’s rating for sleep disturbance.
Risk factors
Well-known risk factors for snoring and OSA are ageing,45–47
excess body weight,46–50 and male sex.45–48,51 A systematic
review found a prevalence of OSA (AHI ≥ 5 events/h) to be
9–38% and higher in men. It increased with age and, in some
groups of older people, was as high as 90% in men and 78% in
women. With an AHI ≥ 15 events/h, the prevalence in the
general adult population ranged from 6 to 17%, and was as high
as 49% in advanced ages. OSA prevalence was also greater in
men and women with obesity.46
The meta-analysis showed a large heterogeneity for high risk
of OSA, which can be explained by the heterogeneity for BMI
and male sex between the study groups. The results of 2 in-
cluded studies did not show a difference between wind in-
strument players and control participants (Table 3). These 2
studies, however, did confirm that age, BMI, and male sex were
positively associated with snoring severity,41 a high risk of
OSA,44 or physician’s diagnosis of OSA.44

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Table 4—Meta-analysis for Epworth Sleepiness Scale, high risk of OSA, diagnosis of OSA, and risk factors age, BMI, and
male sex.
Test for Overall Test for Heterogeneity Forest Plot
Outcome Risk
Comparison Included Studies DiffM P Supplemental
Parameters Ratio 95% CI I 2
Tau2 Chi2 P value
value Material
ESS −0.16 −0.65, 0.33 .52 0% 0 1.73 .89 Figure S1a
Wind Puhan et al39; Ward BMI 0.65 −0.65, 1.91 .32 80% 1.92 24.54 < .001* Figure S1b
instrument et al40 (4 subgroups);
vs. control Wardrop et al41 Age 0.10 −1.37, 1,57 .90 0% 0 4.70 0.45 Figure S1c
Male sex 1.14 0.90, 1.45 .27 82% 0.07 28.13 < .001* Figure S1d
High risk of 0.85 0.58, 1.24 .39 81% 0.17 26.71 < .001* Figure S2a
OSA (BQ)
Brown et al44; Diagnosis of OSA 1.26 0.85, 1.87 .24 0% 0 2.86 .58 Figure S2b
Wind
Subramanian et al43; (by a physician)
instrument
Ward et al40
vs. control BMI 0.94 −0.37, 2.24 .16 85% 1.83 25.86 < .001* Figure S2c
(4 subgroups)
Age 0.06 −1.11, 1.23 .92 0% 0 1.29 .86 Figure S2d
Male sex 1.18 0.93, 1.49 .18 87% 0.06 30.27 < .001* Figure S2e

*Statistically significant difference. BMI = body mass index, BQ = Berlin Questionnaire, CI = confidence interval, DiffM = difference of means, ESS = Epworth
Sleepiness Scale.

Table 5—Sensitivity analysis for Epworth Sleepiness Scale and risk factors age, BMI, and male sex.
Test for
Test for Overall Forest Plot
Outcome Risk Heterogeneity
Comparison Included Studies DiffM
Parameter Ratio P P Supplemental
95% CI I2 Chi2
value value Material
ESS −0.50 −1.39, 0.39 .27 0% 0.84 .36 Figure S3a
Puhan et al39; Ward et al40
Wind instrument (only single-reed BMI −0.10 −1.19, 0.99 .86 0% 0.00 1.00 Figure S3b
vs. control instrument and Age 1.87 −1.03, 4.77 .21 0% 0.13 .72 Figure S3c
flute players)
Male sex 0.99 0.82, 1.19 .90 0% 0.16 .69 Figure S3d

BMI = body mass index, CI = confidence interval, DiffM = difference of means, ESS = Epworth Sleepiness Scale.

Table 6—Rating the certainty of the evidence (GRADE).31,32

Determinants of Quality Overall
Study design Cross-sectional, RCT
Number of studies 6
Risk of bias Low to high
Consistency Rather consistent
Directness Limited generalizability
Precision Rather precise
Reporting bias Cannot be ruled out
Magnitude of the effect Zero to small
Strength of the propositions emerging from this review Low
Overall recommendation Considered advising patients who snore or have (risk of developing) obstructive sleep apnea to
practice singing or to play the digeridoo or a double-reed instrument. However, the degree of
certainty surrounding the expected effect is low.

Of the 4 studies that did show a positive effect of singing or
playing the didgeridoo or a double-reed instrument, 3 studies
adjusted outcomes for the risk factors of age, BMI, and sex
distribution. In the study that showed that singers have a lower
SSS compared with controls,42 the findings were adjusted
for age and BMI. The sex ratio was comparable between the
singer group (20:32, men to women) and nonsinger group (23:
32, men to women). In the RCT in which didgeridoo players
were found to have lower AHI, daytime sleepiness, and part-
ners’ rating for sleep disturbance compared with controls,
findings were adjusted for weight change during the study.39
In 1 of the 2 studies in which double-reed instrument players

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FN van der Weijden, F Lobbezoo, and DE Slot
Figure 3—Overview of intraoral pressure ranges in wind instruments and subglottal pressure of singing.
Reprinted with permission from the author.56
showed a lower risk of OSA, the double-reed group was
majority women.40 However, the covariate-adjusted regres-
sion model indicated that the observed effect was not the result
of sex distribution differences.40 The other study that found that
wind instrument players (70% double-reed) had a lower risk of
OSA did not report on the age, BMI, or sex of the participants.43
However, this was the only study taking into account smoking
as a potential risk factor. There was a trend toward a higher
number of smokers in the wind instrument group compared with
the control group (P = .06). Whether smoking is a risk factor for
OSA remains a matter of debate.52 A study containing 3,509
patients who were treated in a university hospital sleep clinic
revealed that heavy smokers (> 30 pack-year) had almost twice
the risk of having an AHI > 50 events/h compared with non-
smokers. However, after adjusting for age, BMI, and sex, this
difference was no longer significant.53 On the other hand, a
recent study of 660 participants observed that there is an in-
creased risk of OSA in heavy smokers.54
Different types of wind instruments and
circular breathing
Strayer,55 an orthodontist and professional bassoonist, estab-
lished a classification of 4 groups of wind instrument players
with different embouchure techniques: brass, single-reed,
double-reed, and flute (Figure 1). In the included studies, the
data were not analyzed in accordance with this classification.
Wardrop et al41 considered all wind instrument players as one
group and did not report on the different types of wind
Journal of Clinical Sleep Medicine, Vol. 16, No. 9
Do musicians sleep well?
instruments. Subramanian et al43 examined players of three
types of wind instruments (nadhaswaram, trumpet, and clari-
net), but pooled them all together in their analysis. Brown et al
made a distinction between woodwind and brass instrument
players and also performed a subgroup analysis.44 However,
that study did not consider different types of woodwind in-
struments. Ward et al40 distinguished between high brass, low
brass, and double-reed instruments, but considered players of a
single-reed instrument and flute as one group.
One wind instrument that cannot be assigned to any of the 4
groups defined by Strayer is the didgeridoo, an instrument
developed by Indigenous Australians. Playing the didgeridoo
requires the use of circular breathing. This is a technique used to
produce a continuous tone without break, achieved by using the
cheeks as a reservoir of air that is expelled to continue the note
while the player breathes in through the nose.39,41,44 The results
of one of the included studies suggest that practicing the
didgeridoo/circular breathing may train airway muscles, leading to
less collapse of oropharyngeal tissues during sleep, which results in
a beneficial effect on OSA.39 However, another included study
compared players of wind instrument who used circular
breathing with all other wind instrument players. The use of
circular breathing was not found to be related to either the risk of
OSA or OSA diagnosis.44 One explanation might be that didgeridoo
players use the technique much more consistently and thus may
achieve a greater level of oropharyngeal muscle training.
Players of double-reed instruments are found to have a lower
risk of OSA compared with controls,40,43 although no such
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FN van der Weijden, F Lobbezoo, and DE Slot
association was found for the other groups of wind instruments.
The mechanism behind this selective difference might be the
different types of embouchure, i.e., different patterns of muscle
activation used in various types of orchestral wind instruments
(Figure 1). Another explanation might be the difference in air
pressure required to make a sound. Goss56 provided an overview
of intraoral pressure ranges in wind instruments and subglottal
pressure of singing based on his own data and a survey of the
literature (Figure 3). At the top is the trumpet (maximum of 150
mbar), followed by the oboe (110 mbar), euphonium (100
mbar), singing (85 mbar), bassoon and French horn (70 mbar),
saxophone (55 mbar), clarinet (50 mbar), and flute (20 mbar).
This clearly marks that brass and double-reed instruments (in
particular the trumpet and oboe), together with singing, are
associated with the highest maximum pressures. This could also
explain the association between singing and a lower SSS.42
The included studies, however, do not show an association
between brass instrument playing and lower risk of OSA,
whereas such an association was observed for double-reed
instruments. This could be explained by the fact that oboe
players need to generate higher minimum pressure to start a note
than brass players (Figure 3).
Compliance and practice time
Playing a wind instrument or singing to train the oropharyngeal
musculature is an attractive approach to reducing OSA, because
these recreational activities are potentially enjoyable in their
own right.41 However, these treatments are not effective unless
they are practiced consistently.40 In one of the studies analyzed
for the present review, participants had to practice the did-
geridoo at home for at least 20 minutes at least 5 days a week.39
This might be an achievable schedule. Conventional orchestral
instruments might have greater appeal and relevance to western
patients.41 However, another study showed that among double-
reed instrument players, the number of hours per week the
instrumentalist played was a significant predictor of the level of
OSA risk. Double-reed instrumentalists at low risk for OSA
played on average 16.5 hours per week, while those at a higher
risk played on average 9.1 hours per week.40 Practicing 16.5
hours per week is likely far too much for amateur musicians with
OSA. Additionally, proper double-reed instrument playing is
not something that can be learned easily.40 Singing, however,
might be very accessible. In a third study included in this
review, semiprofessional singers were included, all of
whom had received formal training in singing. The fewest
number of years of choir singing was 5. 42 The question is
whether amateur singing has the same positive effect as
semiprofessional singing.
Comparison with studies not included in
this systematic review
One study was excluded from this systematic review because of
the lack of a control group.37 In that study, 20 people who were
chronic snorers received instruction in singing technique and
singing exercises that they were instructed to practice for
20 minutes a day for 3 months. The duration of snoring was
recorded by a voice-activated tape recorder for 7 nights, both
before and after treatment. Snoring was, on average, reduced,
Journal of Clinical Sleep Medicine, Vol. 16, No. 9
Do musicians sleep well?
especially in those who performed the exercises accurately and
consistently, were not overweight, had no nasal problems, and
began snoring only in middle age.
Four potentially interesting paper titles were identified in the
initial search, but only the abstracts for these papers were
retrievable.33–36 In the study by Turk et al,36 10 patients with
OSA received didgeridoo lessons and practiced for 4 months.
Strong associations were found between didgeridoo playing and
a decrease in AHI (polysomnography) and in volume of para-
pharyngeal fat pads. Only a moderate association was found
with decrease in daytime sleepiness. This in itself is not sur-
prising because clinical symptoms such as daytime sleepiness
correlate poorly with OSA severity as measured by AHI.57,58 In
the study by Kim et al,35 19 Korean patients with OSA received
didgeridoo lessons and practiced for 16 weeks. A significant
improvement in snoring was found, but not in the AHI index.
Bader et al33 collected completed questionnaires of 213 pro-
fessional and 318 amateur musicians, of which 50% were
singers, 34% wind instrument players, and 16% controls. A
marked difference between sexes, but no significant difference
between the groups, was found for SSS, ESS, and score and
diagnosis of OSA. Antoniadou et al34 observed a low risk of
OSA (BQ) among 25 players of wind instruments and 5 singers;
however there was no control group in this study. The findings
reported in these abstracts are comparable with the results of the
studies included in the present systematic review.
Limitations
Following the search and selection, only 1 RCT could be
included.39 This was the only study that provided direct
data on the sleep of the participants. However, this study
also contributed to clinical and methodological heterogen-
eity, which may negatively impact the representativeness of
the results.
Because of the cross-sectional design of 4 of the 5 studies
included in this review, conclusions were drawn on associations
and not on causal relationships. Furthermore, the results of
these 4 studies are based on questionnaires. Therefore, OSA
was not diagnosed according to the gold standard, poly-
somnography. However, all studies used validated scales. The
response rate varied per study from 10–30% by email to up to
70–90% by direct solicitation.40,41,44 Respondents may have
been more likely than nonrespondents to be interested in OSA
or snoring.
While the sample sizes of the studies by Brown et al44 (n =
1,105) and Ward et al40 (n = 906) are large, the sample size of the
study by Puhan et al39 is very small (n = 25). Consequently, this
small sample size may have a negative impact on generaliz-
ability and on study power.
The control group of the RCT performed by Puhan et al39 was
generated randomly with stratification from OSA severity. The
cross-sectional study among singers had a control group con-
sisting of healthy volunteers.42 This is less than ideal compared
with a control group consisting of nonwind instrument players
(i.e., string, percussion, keyboard), which was used in the 3
cross-sectional studies among orchestra members.40,41,44 Fellow
orchestral musicians are likely to have similar lifestyles and
work patterns to the participants, which should therefore reduce
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FN van der Weijden, F Lobbezoo, and DE Slot
the effect of any confounding variables. Subramanian et al43 did
not specify the background characteristics of their control group.
However, this was the only study examining players of wind
instrument that properly excluded singers in the control group.
The study by Puhan et al39 showed a clinically significant
improvement in ESS score (mean change score in the didgeridoo
group was 4.4 and the difference between the intervention and
control groups was 3.0). In the study by Pai et al,42 however,
SSS values were low in both the singer and nonsinger groups,
and it is possible that many participants in this study were
unlikely to have problems with snoring anyway. Although there
is a statistically significant difference between the 2 groups in
SSS values (singers 2.5 vs. nonsingers 3.6 on a scale of 0 to 9),
the magnitude of this difference is small, and it is not possible to
determine whether or not it is clinically relevant. The Snore
Outcomes Survey Score and ESS scores in the study by Wardrop
et al41 and the ESS scores in the study by Ward et al40 were also
low for all groups.
Didgeridoo playing appeared to be the most promising
musical intervention for positively affecting sleep-breathing
disorders. A survey among patients with OSA demonstrated that
two-thirds of respondents expressed interest in participating in
a didgeridoo program.59 More and larger studies are needed to
assess the generalizability, long-term compliance, and imple-
mentation of didgeridoo playing as alternative for current
OSA treatments.
CONCLUSIONS
Playing a wind instrument and singing may have a positive but
small effect on sleep disorders. Considering the practicality and
investment of (rehearsal) time, didgeridoo and singing are the most
promising interventions to reduce OSA and snoring, respectively.
However, the results of this review are based on few studies and the
synthesis of the evidence is graded to have low certainty.
ABBREVIATIONS
AHI, apnea-hypopnea index
BMI, body mass index
BQ, Berlin Questionnaire
ESS, Epworth Sleepiness Score
GRADE, Grading of Recommendations Assessment,
Development and Evaluation
OSA, obstructive sleep apnea
PRISMA, Preferred Reporting Items for Systematic Reviews
and Meta-Analyses
RCT, Randomized Controlled Trial
SSS, Snoring Scale Score
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ACKNOWLEDGMENTS
The authors gratefully acknowledge Alexander Verhelst (dentist, periodontist, and
accredited OSA specialist) for help while preparing the manuscript and the following
authors for their response, time, and effort to search for additional data: Dr. P.J.C.
Wardrop, Dr. D.L. Brown, and Dr. Irumee Pai. The authors are also grateful to Clint
Goss for granting permission to reuse his figure and providing us with a high-quality
version and to Stephen Hancocks, editor-in-chief of the British Dental Journal, for
granting permission to reuse the figures of Porter.26
F.N.W. contributed to conception and design, search and selection, analysis and
interpretation, and drafted the manuscript. F.L. contributed to interpretation and critically
revised the manuscript. D.E.S. contributed to conception and design, selection, analysis
and interpretation, and critical revision of the manuscript.
SUBMISSION & CORRESPONDENCE INFORMATION
Submitted for publication January 10, 2020
Submitted in final revised form May 29, 2020
Accepted for publication May 29, 2020
Address correspondence to: Fawn N. van der Weijden, MSC, Academic Centre for
Dentistry Amsterdam (ACTA), a joint venture between the Faculty of Dentistry of the
University of Amsterdam and the Faculty of Dentistry of the Vrije Universiteit
Amsterdam, Gustav Mahlerlaan 3004, 1081 LA, Amsterdam, The Netherlands; Tel:
+31205980808; Email: f.n.vander.weijden@acta.nl
DISCLOSURE STATEMENT
All authors gave their final approval and agreed to be held accountable for all aspects of
the work, ensuring integrity and accuracy. The authors report no conflicts of interest.
1601 September 15, 2020