Nasal positive airway pressure therapy for sleep apnea golfers may improve their game

American College of Chest PhysiciansNov 3 2009

Men Find New Motivation for Using CPAP

Golfers who undergo treatment for sleep apnea may improve their golf game as well as their overall health, shows new research. A new study presented at CHEST 2009, the 75th annual international scientific assembly of the American College of Chest Physicians (ACCP), found that golfers with obstructive sleep apnea (OSA) who received nasal positive airway pressure (NPAP) for their disorder improved their daytime sleepiness scores and lowered their golf handicap by as much as three strokes. Researchers suggest that the possibility of improving your golf game may be a significant motivator to improve NPAP compliance rates among golfers.

"More so than many sports, golf has a strong intellectual component, with on-course strategizing, focus, and endurance being integral components to achieving good play," said Marc L. Benton, MD, FCCP, Atlantic Sleep and Pulmonary Associates, Madison, NJ. "OSAS can lead to daytime sleepiness, fatigue, and cognitive impairment, all side effects which can negatively impact a person's ability to golf to the best of one's ability."

Dr. Benton and colleague Neil S. Friedman, RN, RPSGT, from Morristown Memorial Hospital, Madison, NJ, evaluated the impact of NPAP on the golf handicap index (HI) of 12 golfers with diagnosed moderate to severe OSA. HI was recorded upon study entry, as was the Epworth sleepiness scale (ESS), a validated questionnaire used to assess daytime sleepiness, and a sleep questionnaire (SQ) developed by the authors. After 20 rounds of golf while receiving NPAP treatment (approximately 3 to 5 months), the treatment group demonstrated a significant drop in average HI, 12.4 (+/- 3.5) to 11.0 (+/- 4.7). Patients in the study group also improved their ESS score, 11.8 (+/- 6.6) to 5.5 (+/- 3.6), and the SQ score, 14.3 (+/- 7.5), to 3.1 (+/- 3.1). A control group of 12 subjects demonstrated no change in HI, ESS score, or SQ score during this study.

"As any golfer knows, when your ability to think clearly or make good decisions is compromised, the likelihood of playing your best is greatly diminished," said Dr. Benton. "Through treatment with NPAP, we can improve many cognitive metrics, such as attention span, memory, decision-making abilities, and frustration management, which may, in turn, positively affect a person's golf game."

Results of the study also showed that the best golfers, defined as HI <12, had the biggest improvements in their game. Within this group, the average HI dropped from 9.2 (+/- 2.9) to 6.3 (+/- 3.0); the SQ score from 10.8 (+/- 1.9), to 2.8 (+/- 2.6).

"The biggest handicap improvements occurred in the lower handicap, often older golfers. This group typically would be expected to trend in the opposite direction due to age-related deterioration in strength and endurance," said Mr. Friedman. "The drop in handicap among the better golfers probably reflected that the major limiting factor was not golf skill but cognitive compromise that improved when the sleep apnea was treated."

Dr. Benton estimates that there are 1 to 3 million regular golfers (regular defined as 10 or more rounds per year) who have OSA, and most are undiagnosed or untreated. However, even when proper treatment is offered, it is only effective if it is used regularly. In men, studies have reported compliance rates as low as 40 percent. Patients cite many reasons for noncompliance with NPAP, including discomfort, inconvenience, cost, noise, or embarrassment. In the current study, nearly all patients in the treatment group had a compliance rate of above 90 percent.

"Providers typically attempt to maximize compliance with NPAP by promoting its medical benefits or warning patients of the risks involved in not being treated, but this approach does not always work," said Dr. Benton. "In the case of this study, the possibility of improving one's ability to play golf appears to have been a significant motivation to improve treatment compliance."

"Compliance with CPAP therapy is an ongoing issue in the treatment of patients with sleep apnea," said Kalpalatha Guntupalli, MD, FCCP, President of the American College of Chest Physicians. "Finding new and more effective ways to increase CPAP compliance based on individual motivations is definitely encouraged."