Understanding Adherence to Mandibular Advancement Device Therapy for Obstructive Sleep Apnea in Chronic Spinal Cord Injury: A Mixed-Methods Study.

BACKGROUND: Obstructive sleep apnea (OSA) is common among individuals with spinal cord injury (SCI). Whilst continuous positive airway pressure (CPAP) remains the primary treatment, adherence is low in SCI. Mandibular advancement devices (MADs) offer a viable alternative. Our prior research has demonstrated that MADs effectively treat moderate-to-severe OSA in chronic SCI. OBJECTIVES: To estimate adherence to MADs, report common side effects, and explore the barriers and enablers to using MADs from the perspectives of individuals with SCI. METHODS: Individuals with chronic SCI with an apnea-hypopnea index (AHI) ≥15/hour received a custom-made MAD. They attended appointments at 1 week and 1, 3, and 6 months after treatment initiation. Questionnaires and semistructured interviews were completed to assess adherence and side effects and to explore the participants' experience of using MAD. RESULTS: Forty participants were included, and 35 completed the study. After 1 month, 65% (26/40) met adherence criteria (≥4 hours/ night). At 6 months, adherence had increased to 70% (28/40). Adherent participants experienced significantly greater improvements in the AHI than nonadherent participants (19.4 ± 15.7 vs. 10.7 ± 5.2; P = .02). Motivating factors for accepting treatment included alleviating daytime fatigue and snoring and receiving care in the familiar rehabilitation facility. Temporary side effects, such as tooth discomfort or excessive salivation, were not reasons for discontinuation. CONCLUSION: MADs are an acceptable, well-tolerated treatment for OSA in SCI, with adherence rates approximately 3 times higher than reported for CPAP. Improving access to MADs could significantly increase the number of people with SCI being effectively treated for OSA.