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• W3034281457 abstract "Free AccessReview ArticlesThe 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 Fawn N. van der Weijden, MSc Search for more papers by this author , Frank Lobbezoo, PhD Search for more papers by this author , Dagmar E. Slot, PhD Search for more papers by this author Published Online:September 15, 2020https://doi.org/10.5664/jcsm.8628Cited by:3SectionsAbstractPDFSupplemental Material ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutABSTRACTStudy 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.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.INTRODUCTIONHuman 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.1The 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 ventilation, 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.4The 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.2Several 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 alternative 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 (intermittent) movements involving the tongue, soft palate, and facial muscles, as well as stomatognathic functions like suction, swallowing, 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 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 approximately 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 review 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.15If 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 airway 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 instrument or singing on sleep, snoring, and/or OSA.METHODSProtocolThe 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 criteriaThe 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.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 searchThe 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 literature 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.).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.Study selectionThe 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 resultsWhen provided, information about the characteristics of the study sample population, intervention, comparison, and outcomes 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 synthesized into a meta-analysis (D.E.S., F.N.W.). In studies consisting 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 comparisons. 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 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 possible. 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.25Figure 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.26Download FigureRisk of bias in individual studiesTwo 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 analysisSeveral factors were used to evaluate the clinical and methodological 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 significant 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.30Considerable 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, consistency 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.RESULTSStudy selectionThe 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.39–44Figure 2: Flowchart of search and selection.Download FigureStudy characteristicsThe 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).Table 2 Study characteristics of the included papers.Study (Risk of Bias)Study DesignPopulation (Country)ParticipantsConclusions of the Original AuthorsBrown et al44 (Low)Cross-sectionalProfessional orchestra members registered by the International Conference of Symphony and Opera Musicians (ICSOM). (USA and Puerto Rico)369 wind instrument players: 175 brass players, 194 wood-wind instrument players, 233 men, 110 women, 26 missing sex, mean age 46.7 (12.26) yearsPlaying a wind instrument was not associated with a lower risk of OSA.Internet-based questionnaire736 nonwind instrument players: 330 men, 360 women, 46 missing sex, mean age 46.8 (12.46) yearsPai et al42 (Moderate)Cross-sectionalSingers from two London-based, mixed-sex choirs. The nonsinger group consisted of healthy volunteers also recruited in London. (United Kingdom)52 singers: 20 men, 32 women, mean age 46.3 (26–70) yearsSinging practice may have a role in the treatment of snoring but does not appear to influence daytime somnolence.Questionnaires55 healthy volunteers: 22 men, 32 women, mean age 43.3 (16–74) yearsPuhan et al39 (Low)RCTParticipants aged > 18 years with self-reported snoring and an AHI of 15–30 (determined by a specialist in sleep medicine within the past year). (Switzerland)Intervention group: 12 men, 2 women, mean age 49.9 (6.7) yearsRegular didgeridoo playing is an effective treatment alternative well accepted by patients with moderate OSA.Didgeridoo lessons and practice at home (at least 20 minutes on at least 5 days a week) for 4 monthsSleep recordings and questionnairesNonintervention group: 9 men, 3 women, mean age 47.0 (8.9) yearsSingle blinded (person who analyzed the sleep recordings)Subramanian et al43 (Serious)Cross-sectionalParticipants mainly from villages in and around Madurai who have been playing the instrument for nearly more than 10 years. (India)64 wind instrument players: 45 Nathasvaram (= double reed instrument), 10 trumpet (= brass instrument), 10 clarinet (= single reed instrument)OSA risk is reduced in wind instrument players.Questionnaire65 controls: participants who did not play any form of wind instrument and singers were also excludedWard et al40 (Moderate)Cross-sectionalCollegiate instrumental music instructors and other professional musicians. (USA)76 double-reed instrument players: 27 men, 49 women, mean age 41.7 (14.5) yearsPlaying a double-reed musical instrument was associated with a lower risk of OSA.204 single reed instrument players: 110 men, 94 women, mean age 43.8 (13.6) yearsOnline questionnaire or paper and pencil version124 high brass instrument players: 94 men, 30 women, mean age 42.0 (12.8) years122 low brass instrument players: 108 men, 13 women, mean age 44.0 (14.4) years380 nonwind instrument players: 210 men, 170 women, mean age 42.7 (13.3) yearsWardrop et al41 (Low)Cross-sectionalProfessional orchestra members. (United Kingdom)81 wind instrument players: mean age 41.58 (10.16) yearsNo significant difference between the snoring severity or daytime sleepiness of brass/wind players and other professional orchestral musicians.154 nonwind instrument players: mean age 43.56 (10.19) yearsQuestionnaire undertaken during rehearsalSignificantly more male wind players than nonwind playersRisk of bias within studiesTo 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 analysisData 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, 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.Table 3 Summary of significant differences between wind instrument players/singers and controls for sleep/snoring/OSA parameters.StudyInterventionSleepSnoringOSAComparisonPQSESSPRSDSOSSSSAHIDOBQPai et al42Singers0-NonsingersWardrop et al41Wind instrument players00Nonwind instrument playersSubramanian et al43Wind instrument players (70% double reed)-Nonwind instrument playersWard et al40Double-reed instrument players00-Nonwind instrument playersWard et al40Single-reed and flute instrument players000Nonwind instrument playersBrown et al44Woodwind* instrument players00Nonwind instrument playersBrown et al44Brass instrument players00Nonwind instrument playersWard et al40High brass instrument players000Nonwind instrument playersWard et al40Low brass instrument players000Nonwind instrument playersBrown et al44Wind instrument players using circular breathing00Nonwind instrument playersPuhan et al41Didgeridoo lessons0---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.Meta-analysisA meta-analysis was feasible for the following outcome parameters: 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 included 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 players and controls, with a heterogeneity of 0%, except for high risk of OSA (I2 = 81%, P <.001).Table 4 Meta-analysis for Epworth Sleepiness Scale, high risk of OSA, diagnosis of OSA, and risk factors age, BMI, and male sex.ComparisonIncluded StudiesOutcome ParametersDiffMRisk RatioTest for OverallTest for HeterogeneityForest Plot95% CIP valueI2Tau2Chi2P valueSupplemental MaterialWind instrument vs. controlPuhan et al39; Ward et al40 (4 subgroups); Wardrop et al41ESS−0.16−0.65, 0.33.520%01.73.89Figure S1aBMI0.65−0.65, 1.91.3280%1.9224.54< .001*Figure S1bAge0.10−1.37, 1,57.900%04.700.45Figure S1cMale sex1.140.90, 1.45.2782%0.0728.13< .001*Figure S1dWind instrument vs. controlBrown et al44; Subramanian et al43; Ward et al40 (4 subgroups)High risk of OSA (BQ)0.850.58, 1.24.3981%0.1726.71< .001*Figure S2aDiagnosis of OSA (by a physician)1.260.85, 1.87.240%02.86.58Figure S2bBMI0.94−0.37, 2.24.1685%1.8325.86< .001*Figure S2cAge0.06−1.11, 1.23.920%01.29.86Figure S2dMale sex1.180.93, 1.49.1887%0.0630.27< .001*Figure S2e*Statistically significant difference. BMI = body mass index, BQ = Berlin Questionnaire, CI = confidence interval, DiffM = difference of means, ESS = Epworth Sleepiness Scale.Risk factors, heterogeneity, sensitivity analysis, and publication biasA 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 discrepancies 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 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. Consequently, for the ESS, 4 of the 6 studies/subgroups were excluded; 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, although 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.Table 5 Sensitivity analysis for Epworth Sleepiness Scale and risk factors age, BMI, and male sex.ComparisonIncluded StudiesOutcome ParameterDiffMRisk RatioTest for OverallTest for HeterogeneityForest Plot95% CIP valueI2Chi2P valueSupplemental MaterialWind instrument vs. controlPuhan et al39; Ward et al40 (only single-reed instrument and flute players)ESS−0.50−1.39, 0.39.270%0.84.36Figure S3aBMI−0.10−1.19, 0.99.860%0.001.00Figure S3bAge1.87−1.03, 4.77.210%0.13.72Figure S3cMale sex0.990.82, 1.19.900%0.16.69Figure S3dBMI = body mass index, CI = confidence interval, DiffM = difference of means, ESS = Epworth Sleepiness Scale.Testing for publication bias could not be performed, because fewer than 10 studies could be included in the meta-analysis.25Rating 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.31,32Table 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) rehearsal time or small sample size. Reporting bias could not be ruled out. The magnitude of the effect is zero to small. Consequently, the degree of certainty surrounding the effect is low.Tab" @default.
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• W3034281457 title "The effect of playing a wind instrument or singing on risk of sleep apnea: a systematic review and meta-analysis" @default.
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