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Am Fam Physician. 2020;101(1):16-17

Clinical Question

Is positional therapy effective for the treatment of obstructive sleep apnea (OSA)?

Evidence-Based Answer

Positional therapy for OSA reduces scores on the apnea-hypopnea index (AHI) and Epworth Sleepiness Scale compared with no treatment. Although continuous positive airway pressure (CPAP) improves AHI scores more than positional therapy, patients seem to better tolerate positional therapy and, therefore, have improved adherence vs. those treated with CPAP.1 (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.)

Practice Pointers

OSA affects 2% to 38% of the population in North America and Europe.2 The severity of OSA symptoms is estimated by the AHI and the Epworth Sleepiness Scale. OSA has been associated with higher morbidity and mortality rates, lower quality-of-life scores, and health problems such as atrial fibrillation, congestive heart failure, coronary artery disease, depression, diabetes mellitus, hypertension, and stroke.3 CPAP is the current first-line therapy; however, up to two-thirds of patients do not adhere to treatment.4 Positional therapies for OSA ideally prevent patients from lying in a supine position and promote side sleeping. Available positional therapy devices include lumbar or abdominal binders, backpacks, full-length pillows, tennis balls attached to the back of nightwear, and alarms with positional sensors.1

This Cochrane review of eight studies explored the effectiveness of positional therapy for OSA compared with CPAP (n = 72) and with an inactive control (n = 251).1 Three studies used vibration alarm devices, and five studies included physical positioning equipment such as pillows and semirigid backpacks. All of the trials were of relatively short duration, ranging from one night to two months.

CPAP reduced AHI scores compared with positional therapy (mean difference [MD] = 6.4 events per hour; 95% CI, 3.0 to 9.8; n = 33). However, patients used positional therapy more than CPAP (MD = 2.5 hours per night; 95% CI, 1.4 to 3.6; n = 20). No significant differences were found between the groups in reported quality of life measured using the 36-item Short Form Health Survey or the Functional Outcomes of Sleep Questionnaire, sleep quality using the mean percentages of slow wave and rapid eye movements sleep, or self-reported adverse effects. There were also no demonstrated differences in Epworth Sleepiness Scale scores between CPAP and positional therapy.

Two studies demonstrated that positional therapy significantly decreased Epworth Sleepiness Scale scores compared with an inactive control (MD = −1.58; 95% CI, −2.89 to −0.29; n = 187). Four studies showed that positional therapy also decreased AHI scores compared with an inactive control (MD = −7.38 events per hour; 95% CI, −10.10 to −4.70). At eight weeks there was no difference in adherence to positional therapy vs. an inactive control (odds ratio = 0.80; 95% CI, 0.33 to 1.94; n = 101).

The American Academy of Sleep Medicine published guidelines in 2009 recognizing that positional therapy could be effective as a second-line therapy or as a supplement to CPAP therapy in patients with a documented lower AHI score in nonsupine vs. supine positions.5 The American Academy of Sleep Medicine recommends performing a sleep study to document reduction in the AHI score with positional changes before initiating positional therapy, and it does not recommend any specific intervention. The guideline does acknowledge that alarms, pillows, backpacks, and tennis balls have been shown to be effective.5 Given the limited risks, discussion of positional therapy options between physician and patient could be considered if CPAP therapy is not tolerated.

The practice recommendations in this activity are available at

Editor’s Note: The numbers needed to treat reported in this Cochrane for Clinicians were calculated by the authors based on raw data provided in the original Cochrane review.

These are summaries of reviews from the Cochrane Library.

This series is coordinated by Corey D. Fogleman, MD, assistant medical editor.

A collection of Cochrane for Clinicians published in AFP is available at

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