Not there yet; the challenge of treating sleep-disordered breathing in people living with spinal cord injury/disease

SLEEP, 2024 · DOI: https://doi.org/10.1093/sleep/zsae068 · Published: March 7, 2024

Spinal Cord Injury Sleep Medicine Pulmonology

Simple Explanation

This editorial discusses a study by Badr et al. that aimed to improve adherence to positive airway pressure (PAP) therapy in veterans with spinal cord injury or disease (SCI/D) and sleep-disordered breathing (SDB). The study compared usual care with usual care plus a combined sleep and PAP adherence program called "BEST". Despite a high prevalence of obstructive sleep apnea (OSA) in SCI/D, access to screening, testing, diagnosis, and treatment is poor, and adherence to PAP therapy is challenging. The "BEST" intervention was based on a previous RCT targeting veterans without SCI/D who had insomnia and newly diagnosed OSA. The editorial highlights the need for more collaborative, intensive, and individualized management of sleep disorders in SCI/D, as well as investigating alternative, non-specialist models for managing uncomplicated OSA to overcome barriers to care.

Study Duration

3 months

Participants

Veterans living with spinal cord injury or disease (SCI/D)

Evidence Level

Level 1, Editorial regarding RCT study

Key Findings

1
The Badr et al. study found no significant difference in PAP usage between the intervention and control groups, despite a comprehensive intervention aimed at improving adherence.
2
PAP adherence in SCI/D ranges from 20% to 40%, which is comparable to CPAP adherence rates in the non-SCI/D population.
3
The traditional 4-hour usage target for PAP therapy is difficult to achieve for many people with SCI and OSA, but even low usage can have significant associations with improved outcomes.

Research Summary

This editorial discusses the challenges of treating sleep-disordered breathing (SDB) in people living with spinal cord injury/disease (SCI/D), focusing on a recent study by Badr et al. that investigated a comprehensive intervention to improve positive airway pressure (PAP) adherence. The editorial highlights the persistent issue of low PAP adherence in this population, despite various interventions, and emphasizes the need for alternative approaches, such as non-specialist models of care and consideration of mandibular advancement devices (MAD). The authors assert that inadequate management of SDB in SCI/D is a healthcare inequity and call for more collaborative, intensive, and individualized management of sleep disorders, as well as accessible, evidence-based management strategies.

Practical Implications

Improved Access to Care

Explore and implement non-specialist models of care for managing uncomplicated OSA in SCI/D to overcome barriers to accessing specialist services.

Alternative Therapies

Investigate the use of mandibular advancement devices (MAD) as an alternative to PAP therapy for OSA in people with SCI/D.

Individualized Management

Develop more collaborative, intensive, and individualized management plans for sleep disorders in SCI/D, considering the specific needs and challenges of each patient.

Study Limitations

1
The editorial is based on a single study (Badr et al.) and other existing literature, which may have limitations in terms of generalizability and methodology.
2
The editorial focuses primarily on PAP adherence and does not extensively address other aspects of sleep-disordered breathing management in SCI/D.
3
The editorial acknowledges the lack of research on MAD use in SCI/D, indicating a gap in the current evidence base.

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