Curriculum Vitae

Dr. dr. Tirza Z. Tamin, SpKFR-K

• Birth Place / Date : Medan, March 14th 1964
• Home Address : Jl. Tanimbar Blok H No. 228 Cinere Megapolitan, Depok.
• Phone number : 081212160835
• Office Address : Medical Rehabilitation Department . RSUPN Dr Cipto Mangunkusumo
Phone number / Fax number : 021. 3915593 / 3907561
Curriculum Vitae
• Educational Background :
 2006 – 2009 : Doctoral Program, Medical Faculty University of Indonesia, Jakarta
 1994 – 1998 : Physical Medicine and Rehabilitation Specialist, Medical Faculty University of Indonesia, Jakarta
 1983 – 1989 : General Practitioner, North Sumatera University, Medan
• Position :
 January 2002 – Now : Head Division of Sport Injury, Physical Medicine and Rehabilitation Department,
RSUPN Cipto Mangunkusumo, Jakarta
 November 2007 – 2013 : Secretary of Specialist Program Physical Medicine and Rehabilitation RSUPN Cipto
Mangunkusumo, Jakarta / Medical Faculty University of Indonesia
 December 2013 - Now : Coordinator of Vokasi and Undergraduate (S0 –S1) Program RSUPN Cipto
Mangunkusumo, Jakarta / Medical Faculty University of Indonesia
• Organization :
 IDI
 PERDOSRI
 PEROSI
Management of Medical Rehabilitation
in OSA & Obese Patients
Dr. dr. Tirza Z. Tamin Sp KFR-K
Medical Rehabilitation Departement,
Sport Injury Division and Obesity Clinic
Faculty Medicine of University of Indonesia/
Cipto Mangunkusumo Hospital, Jakarta
 Obstructive Sleep Apnea Hypopnea
Syndrome (OSAHS)
Repetitive upper airway obstruction during sleep
resulted in repeated pauses in breathing, leading
to sleep fragmentation, hypercapnia, and
decreases in oxyhemoglobin saturation.
 Factors Predisposing to OSAHS include :

Obesity (70 %)
Old age, male gender, and post-menopausal women
Increase neck circumference
Narrowed upper airway
Anatomical: retrognatia or micrognatia, macroglossia, collapse of
the soft palate
Smoking and use of alcohol or transquilizers
High blood pressure (hypertension) and diabetes
Chronic nasal congestion
Enlarged tonsil or adenoids (Adenotonsilitis hyperthrophy)
• Altered the upper airway structure and function
• Increase leptin that has negatively effect on respiratory drive and load
compensation
• Insulin resistance linked with sleep deprivation or symphatetic activation
• Location of fat deposit in neck and viscera contribute to OSAHS susceptibility

Obesity OSAHS
Two-ways relationship

• Altered the regulation of hormonal regulation specific to appetite and satiety

• Increase preference of energy dense food and increase caloric intake
• Change in sleep duration, that decrease physical activity that lead to lethargy and
daytime sleepiness
Obesity As a Risk Factor of OSAHS
• In a population study involving 2148, prevalence of
obesity was significantly higher in those with OSAHS
than those without, whether male (22 % vs 8 %) or
female (32 % vs 18 %)

• Another study of 161 obese patients (BMI ≥ 30 kg/m2)

showed that OSAHS was present in over 50 % , and in
25 % this was severe
 Obesity As a Risk Factor of OSAHS
• Amongst the morbidity obese patients (BMI ≥ 40 kg/m2 ),
prevalence of OSAHS as high as 98 % has been reported
• Several studies have confirmed obesity and BMI as
predictors of OSAHS
• OSAHS seems to be much more common in patients who
have obesity class II and III
 Obesity as a Risk Factor of OSAHS
• Studies utilizing magnetic resonance imaging have found
deposition of adipose tissue adjacent to the upper airway which
was significantly greater in individuals with OSAHS (Shelton et al.
, 1993; Horner et al., 1989).

• Wisconsin Sleep Cohort Study of 700 subjects, a 10% weight

gain predicted a 32% increase in AHI score; conversely a 10%
weight loss predicted a 26% decrease in AHI score over a 4 year
period.
Management
Indications for the management of obstructive sleep apnoea
based on the apnoea hypopnoea index (AHI)

• To reduce primary snoring, consider weight reduction and

AHI < 5 behavioral intervention

• In the presence of symptoms or cardiovascular morbidity

AHI 5-15 treat with CPAP or oral appliance or positional therapy

• Treat with CPAP or oral appliance or positional therapy

AHI >15
 THERAPEUTIC STRATEGIES FOR OSAHS
CPAP
• Maintain a positive phyaryngeal
transmural pressure and increase
end expiratory lung volume
• First line treatment for moderate
to severe OSA
• Symptom release and
cardiovascular protection
• Intolerable for some people
Sleep hygiene and changes in
lifestyle habits
• Weight loss
• Discontinuation or replacement of
drugs that directly interfere with
upper airway muscle function
• Reducing alcohol consumption,
smoking cessation, regular physical
activity, changing body position
during sleep (avoid supine
position)
Mandibula repositioning splints
• Treatment for mild OSAHS and
primary snoring
• Prevent the oropharynx and base
of tongue from collapsing during
sleep
• As an alternative of CPAP
intolerance
• Contraindication: Predominance of
central apneas , active periodontal
disease , and temporomandibular
joint dysfunction
 Exercise Program
Effective in mitigating harmful
Low cost Easy effects of OSAHS
• Cardiovascular disorder
• Glucose intolerance
• Fatigue

Focused on exercise program for patients with

OSAHS

There were significant decrease > 50% of Apnea Hypopnea Index (AHI),
arousal index, and % total sleep time Sa02 >90% in snoring after upper airway
exercise as compared to before upper airway exercise. Cuimaraes et al. (2009)
 Exercise Program
Data from the Sleep Heart Health Study demonstrate that
vigorous exercise performed for at least 3 hours each week is
associated with decreased odds of developing OSA.

Joseph et al. (2000) reported that after a six month

supervised exercise program, there is a significant decrease in
AHI along with improvement in total sleep time, sleep
efficiency, number of awakening/ hour, arousal/ hour, apnea
index, and mean exercise training workload.
 Exercise Program
Upper airway muscle function plays a major role in
maintenance of the upper airway patency especially during
sleep. Ahmed et al. (2016) found that upper airway exercises
is a new and simple technique to improve ESS, AHI,
02 saturation and snoring.

Some studies reported that regular exercise is associated with

reduction in blood pressure and in the prevention of CVD (two
of the most serious comorbidities associated with OSA).
 Exercise Program
Devon et al. (2015) conducted a controlled trial experiment
among older obese people with a supervised exercise
(3 days/week) and a calories restricted diet. After 12 weeks,
there were reduction in 9% body weight and 5% percentage
total body fat and 8% trunk fat, while aerobic capacity
increase by 20%, reduced in AHI index by 10 events per
hour.

.
 Exercise Program
In meta-analysis study, Iftikhar et al. (2016) found OSAHS
patients undergoing regular exercise had a 32% reduction in
the AHI (a redution of 6.27 event/hour) and a 28% reduction
in daytime sleepiness, as well as a 5.8% increase in sleep
efficacy

Sengul et al. (2013) conducted a supervised exercises for 12

weeks consists of aerobic exercise and breathing exercise
3 days/ weeks of 20 patients with mild to moderate OSAHS
resulted in reduced AHI, improved exercise capacity, sleep
quality, and quality of life.
 EXERCISE-RELATED PHYSIOLOGICAL
ADAPTATIONS IN OSAHS PATIENTS
Increase upper airway dilator
muscle tone

Reduce fluid accumulation in

neck

Increase Slow-wave sleep

Reduce body weight

Reduce systemic
inflammatory response
CLINICAL BENEFITS OF EXERCISE

Reduce
Increase
daytime
VO2 peak
sleepiness
Reduce Increase
Independently
OSAHS sleep
weight loss
severity efficiency

Indirect Effect :
• Decrease blood pressure
• Improve metabolic profile
• Reduce overall cardiovascular risk
 Another Benefits of Exercise in Sleep
Disorders

Improves sleep by
Increased flexibility with
producing a significant Improved lung capacity
stretching
rise in body temperature

Toned muscles Balanced muscles

 Stomatogniatics
Function Exercise

Aerobic Exercise Resistance Exercise

Exercises on

OSASH

Oropharyngeal
Stretching Exercise
Exercises
 AEROBIC,
RESISTANCE,
STRETCHING EXERCISE
 Activity Aerobic Exercise
Days/ week 4 2
Description Supervised moderate –intensit
y aerobic activity (60% of HRR
, monitored with heart rate tel
emetry) performed primarily o
n the treadmill; 5 min warm u
p and cool down not included
in dose calculation
Weekly dose 150 min
Initial progression Ramp of weekly aerobic dose
from 50 min in week 1 to 150
min in week 5; full dose from
week 5-on
Resistance Exercise Stretching
2
Following aerobic exercise on Supervised session
nonconsecutive days, exercise s involving 10-15
included shoulder press, lat pull stretches, held for
down, chest press, upright row, 15-30 s for 2 sets,
leg press, and abdominal designed to impro
crunches, leg extension/leg curl ve whole-body flex
and biceps curls/ triceps extensi ibility
on were alternated between ses
sions
2 sets of 12 repetition each exer 60 min
cise
Once a week with one set of ex none
ercise for weeks 1-2, twice week
ly with one set for weeks 3-4; fu
ll dose from week 5-on
 STRESS TEST
• Each patient underwent a submaximal exercise treadmill test
monitored on a 3 lead electrocardiogram, consisting of lead II
and modified leads V3 and V5
• Depending on the patient’s initial physical condition, either a
Bruce protocol or Naughton protocol was utilized to have the
subject exercise up to 85% of age-predicted maximum heart
rate.
• The results were used to design an individualized exercise
training program for each patient and to rule out cardiac
ischemia.
 STRESS TEST
• Aerobic and resistance exercises improve sleep quality.
• Gary and Lee reported that a 12-weeks walking program
increased the total sleep time for patients by 20 % improving
their quality of life.
• Improvement in their chronic pain and functional capacity of
elderly population.
• Supports the role of sleep in the conservation of energy, in
muscle recovery and body temperature regulation.
 STRESS TEST
• Joseph et al. (2000), reported that regular exercise
training had a positive impact on the AHI, aerobic
capacity, body mass index and QOL.
• Chronic exercise training program had similar effects
on sleep latency and total sleep time as those
reported by Youngstedt el al. (1997), with acute
exercise training.
Benefits of Weight Reduction in Patients with OSA
Include the Following:
Lowered blood pressure
Improved pulmonary function and arterial blood gas values

Improved sleep efficacy and reduce snoring

Possible reduction of optimum CPAP pressure required

OROPHARYNGEAL
EXERCISE
Oropharyngeal exercises consists of :
Soft Palate Exercise

Tongue Exercise

Facial Muscle Exercise

SOFT PALATE EXERCISE
 BLOWING
Method:
Inhale air through your nose. Exhale via your mouth. As you exhale
press your lips together. This action forms a resistance. When you
exhale tighten your abdomen. Maintain the blowing for 5 seconds.

Repetition: 10 times each movement, 4 times a day

Purpose: the soft palate and uvula are elevated during this exercise.
The pharynx will expand and be enlarged.
 VOWEL PRONOUNCIATION
• Method:
Pronounce an oral vowel intermittently (isotonic exercise) and continuously
(isometric exercise) and really exaggerate the movement of your mouth.

• Repetition: 5 times for each vowel and were performed once a week
under supervision to ensure adequate effort.

• Purpose: to stretch your mouth and throat muscles-and exercise your

soft palate.
TONGUE EXERCISE
 TONGUE BRUSHING
Method: Brushing the superior and lateral surfaces of the
tongue while the tongue is positioned in the floor of the mouth
Repetition: 5 times each movement, 3 times a day
Purpose: strengthen the tongue muscles-with the added
advantage of maintaining oral hygiene
 TONGUE SLIDE
Method:
Placing the tip of the tongue against the front of the palate
and sliding the tongue backward

Repetition: 10 times

Purpose: to tone and strengthen the tongue and throat

muscles.
 TONGUE FORCES
Method:
a) Forced tongue sucking upward against the palate, pressing the
entire tongue against the palate. Hold this position for 4 seconds.
b) Forcing the back of the tongue against the floor of the mouth
while keeping the tip of the tongue in contact with the inferior
incisive teeth Hold this position for 4 seconds.

Repetition: each exercise 5 times

Purpose: strengthen the tongue and tone your soft palate.

 TONGUE PRESS
Method:
Push your tongue against your hard palate (the top and front of your
mouth) and hold for 5 seconds. Slide your tongue backward to the
back of your mouth. The initial third of your tongue should be against
your hard palate (not just the tip). Keep your jaw open throughout the
exercise.

Repetition: 10 times

Purpose: Strengthen the genioglossus (the main muscle used for

sticking your tongue out), hyoid muscles, and hyoid bone.
 TONGUE WORKOUT
Method:
Open your mouth wide. Stick your tongue out. Try to touch your nose
with the tip of your tongue. When your tongue is at full stretch, hold i
t there for 5 seconds.

Repetition: 10 times

Purpose: exercise and strengthen the tongue muscles, and to exer

cise the throat and jaw muscles.
 Oropharyngeal Exercises for Children
• Adenotonsillectomy (AT) is the first-line treatment in
OSASH children with adenotonsillar hypertrophy
• Recent evidence suggests that residual OSASH persists
in some cases
• Bhattacharjee confirmed that AT cured OSASH in only
27,2% of obese and non obese children
 Oropharyngeal Exercises for Children
• Villa M et al. (2014) did a study of oropharyngeal
exercise for 6 months among children with symptoms
of OSAHS after adenotonsillectomy.
• The result was oropharyngeal exercise led to a
significant decrease in nasal obstruction, improved
nasal patency, allowing patients to regain nasal breathi
ng and strengthen the lips, and also allowed children
to regain correct labial seal.
 Oropharyngeal Exercises for Children
• Oropharyngeal exercices were divided into three
categories:
– Nasal breathing rehabilitation
– Labial seal and lip tone exercise
– Tongue posture exercises
• Repetition: 10-20 repetitions each time, every day,
at least 3 times a day
Oropharyngeal Exercises for Children
Oropharyngeal Exercises for Children
EXERCISE FOR THROAT AND NECK
 TIGER YELL
Method:
Open your mouth as wide as possible, and stick your tongue out in a
downward position. Your tongue needs to be stuck out as far as it can
be. The uvula needs to be lifted upwards as you stick your tongue out
. Hold this position for 5 seconds

Repetition: 10 times

Purpose: Exercise and strengthen all the muscles in the back of

your throat.
REACH FOR CEILING
Method:
Lift your head up as high as you can, while looking at the ceiling.
Stick your tongue out and upward, as though you’re attempting to
touch the ceiling with it. Hold this position for 10 seconds
Repetition: 5 times
Purpose: your trachea will be lifted upward, your throat muscles
will contract. All the muscles in the front of your neck are exercised
and stretched when the trachea is elevated. Your tongue will remain
in a neutral position rather than slipping back inside your throat-and
blocking your airway.
 CEILING SWALLOW
Method:
Bring your head right down so your chin is resting on your chest. Open
your mouth wide sticking your tongue out as far as possible. Gently bite
down on your tongue while lifting your head up towards the ceiling.
When you reach the top, looking up at the ceiling and with your tongue
still sticking out, you need to swallow.

Repetition: 5 times

Purpose: the swallowing action lifts the trachea and the throat muscles
contract, exercise and tone.
FINGER IN CHEECK
Method:
With your mouth open, place your first finger (next to your thu
mb) inside your cheek. Push your finger so that your cheek mo
ves outward. Contract the cheek muscles to resist the pushing.
Repetition: 10 times for each cheek, 4 times a day
Purpose: to strengthen facial and throat muscles and improv
e the resistance of the buccinator and orbicular muscles. Better
closure of the mouth will be gained. This exercise will also help
improving nasal breathing.
 A SMILE A DAY
Method:
Smile with your mouth shut and form an exaggerated smile.
Hold for 5 seconds.

Repetition: 10 times

Purpose: tighten and strengthen your neck muscles.

 TONGUE CLENCH
Method:
Place your tongue between your teeth. Gently bite down and
hold the tongue in position. Now swallow 5 times in a row.

Repetition: 4 times

Purpose: to strengthen and exercise the muscles at the back

of your throat.
EXERCISE FOR JAW
 JAW CHEWING
Method:
Close your mouth and pretend that you’re chewing a piece of
gum. Ensure that your molars are positioned slightly apart
during chewing; then let them lightly touch together again.
While you chew make an “mmm” sound. The sound will enable
your throat to open. Check that your mouth remains closed in
the mirror.
Repetition: 4 times
Purpose: to strengthen and tone the muscles in the back of
your throat and to strengthen the jaw muscles.
 LIP WORKOUT
Method:
Pucker your lips together as though you’re about to kiss. Hold
the position for 10 seconds. Repeat 5 times. Then do the same
but with your mouth wide open. Don’t let your lips go together
. Hold the pucker for 5 seconds.

Repetition: 5 times

Purpose: to exercise, tone and strengthen the jaw and neck

muscles.
 JAW RESIST
Method:
Place a hand underneath your chin. Attempt to open your
mouth. Your hand needs to push against your lower jaw. The
hand’s trying to stop your mouth opening.

Repetition: 10 times, 2-4 times daily

Purpose: to strengthen and exercise the jaw muscles.

 FACIAL EXERCISE
The exercises of the facial musculature use facial mimicking to
recruit the orbicularis oris, buccinator, major zygomaticus,
minor zygomaticus, levator labii superioris, levator anguli oris,
lateral pterygoid, and medial pterygoid muscles.
 FACIAL EXERCISE
The exercises include:
• Orbicularis oris muscle pressure with mouth closed (isometric exercise).
Recruited to close with pressure for 30 seconds, and right after, requested
to realize the posterior exercise.
• Suction movements contracting only the buccinator. These exercises were
performed with repetitions (isotonic) and holding position (isometric).
• Alternated elevation of the mouth angle muscle (isometric exercise) and
after, with repetitions (isotonic exercise). Patients were requested to comple
te 10 intermittent elevations three times.
• Lateral jaw movements with alternating elevation of the mouth angle
muscle (isometric exercise).
STOMATOGNATICS FUNCTION
EXERCISE
STOMATOGNATICS FUNCTION EXERCISE

Breathing Exercise

Swallowing and Chewing Exercise

 BREATHING EXERCISE
Strengthens the throat muscles

Reducing sleep apnea symptoms

 BREATHING EXERCISE
Contraindication
of breath hold:

Migraine
Hypertension
Headache

Heart
Panic attack
problem
 Quiet MindExercises
Breathing and Body in Sleep Disorders
• Learning to do deep breathing exercises helps to shift
the mind away from worrisome thoughts
• Deep breathing often feels backwards to many people
so it takes concentration to master
• Taking slow deep breaths also sends signal to the
brain that you are calm, which in turn can slow down
you heart rate and nervous activity.
Breathing Exercises in Sleep Disorders

Focus
The Attention
Nasal Technique
Breathing Breathing
Correctly
Health Benefits of Relaxation Techniques:

Slowing the heart rate and breathing rate

Lowering blood pressure
Increasing blood flow to major muscles
Reducing muscle tension and chronic pain
Boosting confidence to handle problems
Improving concentration
Types of Relaxation Techniques
Autogenic relaxation

Progressive muscle
relaxation
Swallowing and Chewing

• Alternate bilateral chewing and deglutition, using the tongue in the

palate, closed teeth, without perioral contraction, whenever feeding.
• The supervised exercise consisted of alternate bread mastication.
• This exercise aims to correct position of the tongue while eating and
targets the appropriate functionality and movement of the tongue
and jaw
• The patients were instructed to incorporate this mastication pattern when
ever they were eating.
 Quality of Life
The most broadly accepted is a set of 36 questions known as Medical
Short Form (36) Health Survey  SF-36

This questionnaire can measure quality of life across a range of health

conditions.

We have used the SF-36 to assess the quality of life in obese people
 Take Home Messages
• Obesity has the highest risk percentage for OSASH (70%)
• Adenotonsillar hypertrophy is the most common cause of OSASH in
children
• Regular exercise training (aerobic exercise, resistance exercise,
stretching exercise, oropharyngeal exercises, stomatogniatics function e
xercise) had a positive impact on the AHI, aerobic capacity, body mass
index, total sleep, and QOL
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