Sleep-related Breathing Disorders Research Articles

EEG Power Spectral Density in NREM Sleep is Associated with the Degree of Hypoxia in Patients with Obstructive Sleep Apnea.

Obstructive sleep apnea (OSA) is a prevalent sleep-related breathing disorder. Research conducted on patients with OSA using electroencephalography (EEG) has revealed a noticeable shift in the overnight polysomnography (PSG) power spectrum. To better quantify the effects of OSA on brain function and to identify the most reliable predictors of pathological cortical activation, this study quantified the PSG power and its association with the degree of hypoxia in OSA patients. This retrospective study recruited 93 patients with OSA. OSA patients were divided into three groups based on their apnea-hypopnea index (AHI) scores. The clinical characteristics and sleep macrostructure of these patients were examined, followed by an analysis of PSG signals. Power spectral density (PSD) in five frequency bands was analyzed during nonrapid eye movement (NREM) sleep, rapid eye movement (REM) sleep, and wakefulness. Finally, correlation analysis was conducted to assess the relationships among PSD, PSG parameters, and serum levels of S100β and uric acid. Obstructive sleep apnea occurred during both the NREM and REM sleep phases. Except for a decrease in the duration of N2 sleep and an increase in the microarousal index, there were no significant differences in sleep architecture based on disease severity. Compared to the mild OSA group, the theta and alpha band PSD in the frontal and occipital regions during NREM sleep and wakefulness were significantly decreased in the moderate and severe OSA groups. Correlation analysis revealed that theta PSD in N1 and N3 stages were negatively correlated the AHI, oxygen desaturation index, SaO2<90% and microarousal index. These findings imply that patients with more severe OSA exhibited considerable NREM hypoxia and abnormal brain activity in the frontal and occipital regions. Therefore, sleep EEG oscillation may be a useful neurophysiological indicator for assessing brain function and disease severity in patients with OSA.

An Automated System for Sleep Apnea Detection

Sleep apnea (SA) is a common sleep-related breathing disorder that can occur hundreds of times per night and can lead to catastrophic cardiovascular and neurological disorders if it happens frequently enough. Polysomnography (PSG) is the standard diagnostic tool for sleep apnea. However, it requires suspected patients to spend one to two nights in the lab and capture roughly 16 signals under professional supervision. The broad use of PSG in public health applications is hampered by complex processes. Some researchers have recently advocated using a single-lead ECG signal to detect SA. These techniques are based on the assumption that SA only uses the current ECG signal segment. SA, on the other hand, is time-dependent; that is, the SA of the preceding ECG segment has an impact on the current SA diagnosis. The authors present a time window artificial neural network that takes advantage of the time dependence between ECG signal segments while requiring no prior assumptions regarding training data distribution. The proposed method's performance has been greatly improved when compared to classic on-time window machine learning approaches as well as previous work after being verified on a genuine ECG signal dataset.

Management of Persistent, Post-adenotonsillectomy Obstructive Sleep Apnea in Children: An Official American Thoracic Society Clinical Practice Guideline.

Background: Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. Although adenotonsillectomy is first-line management for pediatric OSA, up to 40% of children may have persistent OSA. This document provides an evidence-based clinical practice guideline on the management of children with persistent OSA. The target audience is clinicians, including physicians, dentists, and allied health professionals, caring for children with OSA. Methods: A multidisciplinary international panel of experts was convened to determine key unanswered questions regarding the management of persistent pediatric OSA. We conducted a systematic review of the relevant literature. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to rate the quality of evidence and the strength of the clinical recommendations. The panel members considered the strength of each recommendation and evaluated the benefits and risks of applying the intervention. In formulating the recommendations, the panel considered patient and caregiver values, the cost of care, and feasibility. Results: Recommendations were developed for six management options for persistent OSA. Conclusions: The panel developed recommendations for the management of persistent pediatric OSA based on limited evidence and expert opinion. Important areas for future research were identified for each recommendation.

"Count on Sleep": an OSA awareness project update.

Martin JL, Rowley J, Goel N, etal. "Count on Sleep": an OSA awareness project update. J Clin Sleep Med. 2024;20(2):303-307.

Risk of dementia and psychiatric or sleep disorders after diagnosis of adrenal adenomas: a population-based cohort study.

Adrenal adenomas are commonly encountered in clinical practice. To date, population-based data on their impact on cognition, mental health, and sleep are lacking. We aimed to study possible associations between adrenal adenomas and dementia, psychiatric or sleep disorders. Population-based cohort study, Olmsted County, MN, 1995-2017. Patients with adrenal adenoma and absent overt hormone excess were age- and sex-matched 1:1 to a referent person without adrenal adenoma. Outcomes were baseline and incident diagnoses of dementia, psychiatric or sleep disorders, assessed using ICD codes. Of 1004 patients with adrenal adenomas, 582 (58%) were women, and median age at diagnosis was 63 years. At baseline, and after adjusting for age, sex, education, BMI, and tobacco use, patients with adenoma had higher odds of depression (adjusted odds ratio, aOR: 1.3, 95% CI, 1.1-1.6), anxiety (aOR: 1.4, 95% CI, 1.1-1.8), and substance abuse (aOR: 2.4, 95% CI, 1.7-3.4) compared to referents. During a median follow-up of 6.8 years, and after adjusting for age, sex, socioeconomic status, BMI, tobacco, and substance abuse, patients demonstrated a higher risk of psychiatric and sleep disorders [adjusted hazard ratio (95% CI)]: depression [1.7 (1.3-2.2)], anxiety [1.4, CI (1.1-1.7)], insomnia [1.4 (1.0-1.9)], sleep-related breathing disorders [1.5 (1.1-1.9)], hypersomnias [2.1 (1.0-4.2)], parasomnias [2.1 (1.0-4.2)], and sleep-related movement disorders [1.5 (1.0-2.1)], but not dementia. Patients with adenomas demonstrate a higher incidence of psychiatric and sleep disorders, possibly due to the underlying subtle increase in cortisol secretion.

Detecting Sleep-Related Breathing Disorders Using FMCW Radar

Polysomnography (PSG) is currently the sole method for detecting breathing disorders that occur during sleep, such as apnea and hypopnea. However, PSG monitoring is quite inconvenient for test subjects. This study proposes a non-contact method for detecting sleep-related breathing disorders that uses frequency-modulated continuous wave (FMCW) radar. The proposed method effectively extracts respiratory signals from radar signals and uses the degree of reduction in the amplitude of the respiratory signals and the duration of the reduction interval as data to detect breathing disorder intervals. The experimental results show that the respiratory signals extracted using the proposed method are similar to the actual respiratory signals. Furthermore, the breathing disorder intervals detected during sleep using FMCW radar are consistent with the actual apnea and hypopnea intervals as confirmed by the PSG results. These results demonstrate that the proposed method is suitable for non-contact detection of breathing disorders during sleep using FMCW radar.

Sleep disorders after COVID-19 in Czech population: Post-lockdown national online survey

ObjectiveThis study aimed to determine the frequency, type, and correlates of a broad spectrum of sleep disorders in adults with COVID-19 up to 32 months after infection. MethodsWe conducted a national online survey (Jun 2021–Dec 2022), gathering information on COVID-19 diagnosis, acute disease course, and the subsequent development of sleep disorders from 1507 respondents (mean age 44.5 ± 13.1 years, 64.1% women). Results81.3% (1223) reported at least one sleep difficulty that either worsened or first appeared with COVID-19. Females reported a higher number of symptoms (2.03 ± 1.44 versus 1.72 ± 1.43 in men, p < 0.0001). Most common were insomnia symptoms (59.4%), followed by night sweats (38.4%), hypersomnolence (33.3%), vivid dreams or nightmares (26.4%), restless leg syndrome (RLS) (22.8%), and sleep-related breathing disorders (11.1%). All symptoms were associated with a more severe acute disease. A mild decreasing trend in the persistence of sleep symptoms with a longer latency since infection was observed, with 66.7% reporting at least half of their symptoms present at 3–5 months after acute infection, compared to 64.9% at 6–8 months, and 62.4% at 9–11 months (p = 0.0427). However, among those after 12 or more months, over half of the symptoms persisted in 69.5%. The frequency of vivid dreams and nightmares increased in association with COVID-19 in 32.9% (p < 0.001). 9.4% (141) reported new-onset or increased parasomnic manifestations after the infection. ConclusionsOur research shows that sleep disturbances are a common and persistent manifestation of COVID-19 that affects a large proportion of the population and deserves careful monitoring.

Identifying Sleep-related Breathing Disorders in Young Patients

Identifying Sleep-related Breathing Disorders in Young Patients

Sleep disorders and suicide attempts following discharge from residential treatment

IntroductionSuicide is a significant public health concern and its prevention remains a top clinical priority of the Veterans Health Administration. Periods of transition in care (e.g., moving from inpatient to outpatient care) represent a period of increased risk. Sleep disorders are prevalent amongst Veterans and are modifiable risk factor for suicide. The present study examined the relationship of sleep disorders to time to suicide attempt amongst Veterans known to have attempted suicide in the 180 days following discharge from a Mental Health Residential Rehabilitation Treatment Program.MethodThe present sample was comprised of all Veterans enrolled in services with the Veterans Health Administration known to have attempted suicide following discharge from a Mental Health Residential Rehabilitation Treatment Program during Fiscal Years 13 and 14 (N = 1,489). To create this sample, electronic medical record data were extracted from two VHA data sources: the Corporate Data Warehouse and the Suicide Prevention Application Network.ResultsCox regression models revealed that Veterans with a sleep disturbance (N = 1,211) had a shorter time to suicide attempt than those without a sleep disturbance [Hazard Ratio (HR) = 1.16, CI (1.02–1.32)]. A subsequent Cox regression model including age, insomnia, nightmare disorder, and alcohol dependence revealed that sleep-related breathing disorders [HR = 1.19, CI (1.01–1.38)], alcohol dependence [HR = 1.16, CI (1.02–1.33)], and age group were associated with increased risk.ConclusionFindings indicate that sleep disturbance, primarily driven by sleep-related breathing disorders, was associated with time to suicide attempt in this sample of high-risk Veterans known to have attempted suicide in the 180 days following their discharge from a Mental Health Residential Rehabilitation Treatment Program. These findings reveal an opportunity to reduce risk through the screening and treatment of sleep disorders in high-risk populations.

Obstructive sleep apnea heterogeneity and autonomic function: a role for heart rate variability in therapy selection and efficacy monitoring.

Obstructive sleep apnea is a highly prevalent sleep-related breathing disorder, resulting in a disturbed breathing pattern, changes in blood gases, abnormal autonomic regulation, metabolic fluctuation, poor neurocognitive performance, and increased cardiovascular risk. With broad inter-individual differences recognised in risk factors, clinical symptoms, gene expression, physiological characteristics, and health outcomes, various obstructive sleep apnea subtypes have been identified. Therapeutic efficacy and its impact on outcomes, particularly for cardiovascular consequences, may also vary depending on these features in obstructive sleep apnea. A number of interventions such as positive airway pressure therapies, oral appliance, surgical treatment, and pharmaceutical options are available in clinical practice. Selecting an effective obstructive sleep apnea treatment and therapy is a challenging medical decision due to obstructive sleep apnea heterogeneity and numerous treatment modalities. Thus, an objective marker for clinical evaluation is warranted to estimate the treatment response in patients with obstructive sleep apnea. Currently, while the Apnea-Hypopnea Index is used for severity assessment of obstructive sleep apnea and still considered a major guide to diagnosis and managements of obstructive sleep apnea, the Apnea-Hypopnea Index is not a robust marker of symptoms, function, or outcome improvement. Abnormal cardiac autonomic modulation can provide additional insight to better understand obstructive sleep apnea phenotyping. Heart rate variability is a reliable neurocardiac tool to assess altered autonomic function and can also provide cardiovascular information in obstructive sleep apnea. Beyond the Apnea-Hypopnea Index, this review aims to discuss the role of heart rate variability as an indicator and predictor of therapeutic efficacy to different modalities in order to optimise tailored treatment for obstructive sleep apnea.

Sleep Disorders Associated with Neurodegenerative Diseases.

Sleep disturbances are common in various neurological pathologies, including amyotrophic lateral sclerosis (ALS), multiple system atrophy (MSA), hereditary ataxias, Huntington's disease (HD), progressive supranuclear palsy (PSP), and dementia with Lewy bodies (DLB). This article reviews the prevalence and characteristics of sleep disorders in these conditions, highlighting their impact on patients' quality of life and disease progression. Sleep-related breathing disorders, insomnia, restless legs syndrome (RLS), periodic limb movement syndrome (PLMS), and rapid eye movement sleep behavior disorder (RBD) are among the common sleep disturbances reported. Both pharmacological and non-pharmacological interventions play crucial roles in managing sleep disturbances and enhancing overall patient care.

Poster (Health Services, Economics and Policy Change) ID 1969166

Background We studied the feasibility of a home-based screening sleep test (HBSST), the validity of four questionnaires used to screen for sleep-related breathing disorders (SRBDs), and the potential association between SRBD and clinical features in individuals with spinal cord injury (SCI). Methods Adults with subacute/chronic (&amp;gt;1 month post-injury) SCI were recruited for the cross-sectional study and qualitative analysis. Feasibility of the HBSST was objectively evaluated and participants shared their experience. We also examined the validity of the Berlin, STOP, Medical Outcomes Study Sleep Scale [MOS-SS], and STOP-Bang screening questionnaires. We investigated the association between the degree of SRBD and three features (i.e., neck circumference, body mass index [BMI] and oropharynx opening as assessed using the Modified Mallampati classification [MMC]). Results There were 13 females and 18 males with ages varying from 20 to 86 years (mean age: 54.7 years) with motor complete (n=8) or incomplete SCI at cervical (n=21) or thoraco-lumbar levels. Time since SCI varied from 1.5 to 474 months. Overall, 28 individuals completed the HBSST and endorsed its feasibility. Mean apnea-hypopnea index (AHI) was 17.3 events/hour (range: 0.5-83.7). AHI was significantly correlated with Berlin (p=0.036) and STOP-Bang scores (p=0.009). There was no significant correlation between AHI and MOS-SS (p=0.348) or STOP (p=0.165). AHI was not associated with neck circumference (p=0.614), BMI (p=0.958), or MMC (p=0.335). Conclusions Our results suggest that HBSST is a feasible screening method, and Berlin and STOP-Bang are valid screening questionnaires for the SCI population. AHI was not correlated with BMI, neck circumference, or MMC.

Can the OSA patient be managed within an ERAS protocol? A narrative review

Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder among surgical patients and is associated with an increased risk of perioperative cardiopulmonary complications leading to increased health expenses. Therefore, preoperative OSA screening should be instituted to inform patients of their increased perioperative risk and measures can be taken in to decrease this risk. Meanwhile ERAS (Enhanced recovery after surgery) guidelines are becoming standard of care and being widely implemented. The purpose of these recovery programs is to standardize medical care, enhance outcomes and decrease health care expenses using evidence-based protocols. According to the current evidence it is unclear if OSA patients could benefit from these protocols. The first part of this narrative review states the current evidence on OSA definition, classification, pathophysiology and risk factors, postoperative complications, endotypes and their relevance for the anesthesiologist. The second part investigated the feasibility of ERAS measures within the OSA-population. Preoperatively there are many parallels to be drawn between the ERAS measures and Society of Anesthesia and Sleep Medicine (SASM) guidelines on OSA management: Risk stratification by OSA-screening, information counselling on the increased perioperative risk and optimization of preoperative health conditions by initiation of CPAP-therapy. Perioperatively the use short acting anesthetics allows for both early mobilization and avoid postoperative respiratory compromise by sustained drug effect. ERAS measures to maintain the patient in the zone of normovolaemia are advantageous for OSA patients as excessive fluid administration can worsen OSA. The use of multimodal analgesia sparing opioids might be the most important element beneficial for OSA patients they are more prone to develop opioid induced respiratory depression (OIRD). As OSA patients are at risk for venous thromboembolism appropriate thromboprophylaxis should be applied. Postoperatively OSA patients should be closely monitored in the prevention of OIRD. In conclusion many ERAS measures seem to be applicable or of benefit for OSA patients. However, large prospective randomized controlled trials are needed to evaluate if these patients can be managed within an ERAS protocol.

Contactless camera-based AHI score estimation in SAS patients

Abstract Sleep apnea syndrome (SAS) is a common sleeprelated breathing disorder characterized by recurring cessations of airflow during sleep. The gold standard for diagnosing SAS is polysomnography (PSG) which requires the patient to spend one or several nights in a sleep clinic. A PSG involves a significant amount of contact-based sensors, which leads to discomfort and deviations in sleep behavior. In this work, a contactless, multispectral camera-based approach for the autonomous detection of events of nocturnal airflow reduction is presented. The detected events are further employed in estimators of sleep diagnostic metrics, such as the apnea-hypopnea index (AHI) and the SAS stage. The AHI estimation resulted in a Pearson correlation coefficient of r = 0.9993. The SAS stage estimator correctly predicted the SAS stage for all three recruited patients.

OBSTRUCTIVE SLEEP APNEA AND ITS PROSTHODONTIC MANAGEMENT: A DENTAL OUTLOOK

Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder with periodic reduction or cessation of airflow during sleep. Prevalence of obstructive sleep apnea is favored in men more than woman. Risk factors include nasal obstruction, obesity, gender, craniofacial anatomy, and smoking. Polysomnography is proved to be the golden-standard method for diagnosing obstructive sleep apnea. Treatment of OSA varies from simple measures such as oral appliances and nasal continuous positive airway pressure (CPAP) to surgical procedures. Oral appliance, namely, mandibular advancement device (MAD) is the recommended treatment appliance for the patient with mild to moderate OSA. For the dental profession in general and in prosthodontists speciality, the subject of sleep medicine continues to offer great challenges and opportunities in diagnosis, treatment planning, and treatment based on qualitative evidence. This article discusses the various aspects and prosthodontic perspectives of obstructive sleep apnea in detail.

Prevalence of sleep disturbance among adolescents with substance use: a systematic review and meta-analysis

PurposeSleep disturbance has become a major challenge among adolescents worldwide. Substance use is among the most common factors contributing to sleep disturbance. This systematic review and meta-analysis examined the prevalence and categories of sleep disturbance among adolescents with substance use.MethodsWe comprehensively searched for relevant studies published in the following databases from inception to August 2022: CINHAL (via EBSCOhost), PubMed, Scopus, Ovid Medline, Embase, ProQuest, and Web of Science. Data analysis was performed using Comprehensive Meta-Analysis version 3 software. We used a random-effects model to pool prevalence rates with 95% confidence intervals (CIs). Forest plots and p values for the Cochran Q statistic were used to evaluate heterogeneity among studies. Subgroup and meta-regression analyses were performed to compare the groups and identify the sources of heterogeneity.ResultsWe examined 18 studies that reported insomnia, hypersomnolence, sleep-related breathing disorders as sleep disturbances among adolescents with the use of alcohol, smoking, marijuana, and coffee. The total sample was 124,554. The overall prevalence rate of sleep disturbance was 29% (95% CI: 0.201–0.403). Subgroup analysis revealed that the prevalence rates of insomnia and hypersomnolence were higher among alcohol users (31%; 95% CI: 0.100–0.654) and smokers (46%; 95% CI: 0.232–0.700). The study design and method of assessment groups were the significant moderators that showed the source of variation in the included studies.ConclusionSleep disturbance is highly prevalent among adolescents with substance use. Insomnia and hypersomnolence are more prevalent among alcohol users and smokers, respectively. On the basis of our findings, health-care providers can develop effective targeted interventions to reduce substance use, prevent sleep disturbance, and promote healthy sleep habits among adolescents.

Variation of respiratory and pulse events in multiple system atrophy

IntroductionA study is eagerly awaited that will reveal the unknown mechanisms of multiple system atrophy (MSA), in which the risk of sudden death is the greatest during sleep. The blunted pulse response to nocturnal respiratory events suggests an abnormal cardiac response to a sleep-related breathing disorder. Patients with MSA have a lower pulse event index (PEI), despite a greater hypoxic burden and a similar frequency of respiratory events. However, the evidence is speculative and not directly proven, and many limitations require further study. MethodsWe conducted a retrospective analysis of 26 patients with MSA who had undergone overnight oximetry between April 2016 and December 2022. ResultsThe median 4% oxyhemoglobin desaturation index (ODI) was 11.6/h, the 6-bpm PEI was 8.9/h, and the PEI/ODI ratio was as low as 0.91. There were three patients with suspected sudden death; all had low PEI/ODI ratios. The PEI/ODI ratio was followed over time in seven patients, all of whom had a decrease in the ratio. However, the PEI was higher than the ODI in 12/26 (46%) of the patients. ConclusionA low PEI/ODI ratio, reflecting a blunted pulse response to nocturnal respiratory events in patients with MSA, may indicate a worse prognosis. This finding and the significance of the longitudinal decrease in the PEI/ODI ratio will require a prospective study.

Neurological Insights into Sleep Disorders in Parkinson's Disease.

Parkinson's disease (PD) is a common multidimensional neurological disorder characterized by motor and non-motor features and is more prevalent in the elderly. Sleep disorders and cognitive disturbances are also significant characteristics of PD. Sleep is an important physiological process for normal human cognition and physical functioning. Sleep deprivation negatively impacts human physical, mental, and behavioral functions. Sleep disturbances include problems falling asleep, disturbances occurring during sleep, abnormal movements during sleep, insufficient sleep, and excessive sleep. The most recognizable and known sleep disorders, such as rapid-eye-movement behavior disorder (RBD), insomnia, excessive daytime sleepiness (EDS), restless legs syndrome (RLS), sleep-related breathing disorders (SRBDs), and circadian-rhythm-related sleep-wake disorders (CRSWDs), have been associated with PD. RBD and associated emotional disorders are common non-motor symptoms of PD. In individuals, sleep disorders and cognitive impairment are important prognostic factors for predicting progressing neurodegeneration and developing dementia conditions in PD. Studies have focused on RBD and its associated neurological changes and functional deficits in PD patients. Other risks, such as cognitive decline, anxiety, and depression, are related to RBD. Sleep-disorder diagnosis is challenging, especially in identifying the essential factors that disturb the sleep-wake cycle and the co-existence of other concomitant sleep issues, motor symptoms, and breathing disorders. Focusing on sleep patterns and their disturbances, including genetic and other neurochemical changes, helps us to better understand the central causes of sleep alterations and cognitive functions in PD patients. Relations between α-synuclein aggregation in the brain and gender differences in sleep disorders have been reported. The existing correlation between sleep disorders and levels of α-synuclein in the cerebrospinal fluid indicates the risk of progression of synucleinopathies. Multidirectional approaches are required to correlate sleep disorders and neuropsychiatric symptoms and diagnose sensitive biomarkers for neurodegeneration. The evaluation of sleep pattern disturbances and cognitive impairment may aid in the development of novel and effective treatments for PD.

An Update on Obstructive Sleep Apnea Syndrome-A Literature Review.

Obstructive sleep apnea syndrome (OSAS) is the most common breathing-related sleep disorder. It is characterized by recurrent episodes of partial or complete airway obstruction during sleep, resulting in a reduction in or the total cessation of airflow, despite ongoing respiratory efforts, leading to oxygen desaturation and arousal. The purpose of this literature review is to evaluate the most common characteristics of this pathology, as well as to investigate the most effective treatment options, providing an update on the management of OSA patients.

Computational Biomechanics of Sleep: A Systematic Mapping Review.

Biomechanical studies play an important role in understanding the pathophysiology of sleep disorders and providing insights to maintain sleep health. Computational methods facilitate a versatile platform to analyze various biomechanical factors in silico, which would otherwise be difficult through in vivo experiments. The objective of this review is to examine and map the applications of computational biomechanics to sleep-related research topics, including sleep medicine and sleep ergonomics. A systematic search was conducted on PubMed, Scopus, and Web of Science. Research gaps were identified through data synthesis on variants, outcomes, and highlighted features, as well as evidence maps on basic modeling considerations and modeling components of the eligible studies. Twenty-seven studies (n = 27) were categorized into sleep ergonomics (n = 2 on pillow; n = 3 on mattress), sleep-related breathing disorders (n = 19 on obstructive sleep apnea), and sleep-related movement disorders (n = 3 on sleep bruxism). The effects of pillow height and mattress stiffness on spinal curvature were explored. Stress on the temporomandibular joint, and therefore its disorder, was the primary focus of investigations on sleep bruxism. Using finite element morphometry and fluid-structure interaction, studies on obstructive sleep apnea investigated the effects of anatomical variations, muscle activation of the tongue and soft palate, and gravitational direction on the collapse and blockade of the upper airway, in addition to the airflow pressure distribution. Model validation has been one of the greatest hurdles, while single-subject design and surrogate techniques have led to concerns about external validity. Future research might endeavor to reconstruct patient-specific models with patient-specific loading profiles in a larger cohort. Studies on sleep ergonomics research may pave the way for determining ideal spine curvature, in addition to simulating side-lying sleep postures. Sleep bruxism studies may analyze the accumulated dental damage and wear. Research on OSA treatments using computational approaches warrants further investigation.