Scientific production of Brazilian speech language pathologists in sleep medicine

Introduction: Previous diagnosis and intervention in patients with sleep-disordered breathing involves several health professionals. Speech-Language and Hearing Sciences (SLHS) performance has been solidified through scientific production. Objective: To describe the inclusion of Brazilian Speech-Language Pathologists (SLP) in the field of sleep disorders, through the description of studies, scientific publications and participation in scientific events. Data Synthesis: A search and an analysis of the Brazilian SLP publications in the field of sleep disorders were carried out, including articles, monographs, dissertations, thesis and abstracts published in annals of events. The databases Lilacs, SciELO, Pubmed, Google Scholar tool and Lattes platform were accessed, with final search in January 2018. The analysis consisted of a description of the year of publication, type of publication, area of the SLHS, place of publication and/or event. 40 articles were found in national and international journals, from 1999 to 2017. In relation to publications in books, one book about the subject was published in 2009 and eight chapters of books were published. In the monograph format, 21 studies were carried out, there are 13 dissertations and eight thesis. A total of 151 abstracts were published in annals of scientific events, from 2001 to 2017 and 63 lectures were conducted by SLP. Conclusion: The inclusion of Brazilian SLP in the area of sleep disorders has been supported by scientific publications in the format of articles in national and international journals, monographs, thesis, dissertations, books and publications in event annals.


INTRODUCTION
Sleep disorders are frequent problems and compromise the quality of life and general health of affected patients [1][2][3] . Because they are associated with different etiological factors and consequences, the diagnosis and treatment of sleep disorders require interdisciplinary teams 4 . The inclusion of the Speech-Language Pathologists' (SLP) approach, specifically related to sleep-disordered breathing, has been recommended by several scientific articles, Brazilian SLPs being pioneers in this area.
In 2009, the first Brazilian study for which an SLP was part of the team and led a treatment, a randomized clinical trial, was published in an international scientific journal. The authors demonstrated the effectiveness of oropharyngeal exercises in patients with moderate obstructive sleep apnea (OSA) 5 . However, their research started earlier, the authors publishing a monograph in 1999 and an abstract in a national interdisciplinary event in 2001 6,7 .
Since then, the Brazilian scientific pioneering in the field of sleep disorders has been solidified, with an increasing number of publications of articles, abstracts in annals of scientific events, and lectures given at national and international events 8 .
These publications are essential to disseminate the diagnosis and treatment modalities of SLPs and reinforce the interface with other professionals of the multi-professional team, such as physicians and dentists 9 . The professional activities of SLPs solidify their interactions as being more assertive in the area of diagnosis and treatment of sleep-disordered breathing 9 .
Thus, the objective of the present study was to describe the inclusion of Brazilian Speech-Language and Hearing Science (SLHS) in the field of sleep disorders, by the review of studies and scientific publications, as well as participation in scientific events.

REVIEW OF LITERATURE
The authors conducted a survey and analysis of the publications of Brazilian SLPs, without limits of time, in the field of sleep disorders, including articles, monographs, dissertations, thesis, abstracts published in the annals of events, and lectures.
As a search strategy of scientific articles, the authors assessed the interfaces of the Lilacs, SciELO (The Scientific Electronic Library Online), PubMed, and Google Scholar (referring to the first five pages containing 10 results each), using the following descriptors and free terms: ·1 st search strategy: "speech pathology" AND "apnea"; ·2 nd search strategy: "speech pathology" AND "sleep disorders"; ·3 rd search strategy: "speech pathology" AND "snoring"; ·4 th search strategy: "oropharyngeal exercises" AND "apnea"; ·5 th search strategy: "oropharyngeal exercises" AND "sleep disorders"; ·6 th search strategy: "oropharyngeal exercises" AND "snoring." · 7 th search strategy: "speech therapy" AND "apnea"; · 8 th search strategy: "speech therapy" AND "sleep disorders"; · 9 th search strategy: "speech therapy" AND "snoring." In addition, the authors reviewed the references of the articles to include articles that were missed using the search strategy.
For the inclusion of abstracts published in annals and presentations in events, the authors performed a manual search on the Lattes platform-CAPES of the authors' names for the included articles. The coauthors were also considered, and their names were included in the search on the Lattes platform.
As inclusion criteria, the authors considered studies that included a Brazilian SLP in the publication team and that addressed all kinds of interactions of SLPs with patients with sleep disorders, from health promotion to assessment and treatment, with no language restriction. Articles not relevant to the proposed theme, as well as those for which all authors were from countries other than Brazil, were excluded.
The analysis consisted of the description of the year of publication, type of publication, area of SLHS, and locale of publication and/or event.
The last access was in January 2018.

RESULTS
Of the articles that were selected (Table 1 and Figure 1), 40 articles were published in national and international journals during the period of 1999 to 2017. Table 2 classifies this material by year of publication, title, and journal.  Table 3 classifies by year, type of publication, and title of the 21 monographs, 13 dissertations, 8 theses, 1 book, and 8 book chapters that were included.
This search strategy resulted in the location of 214 participations in events of Brazilian SLPs, 63 lectures, and 151 presentations of scientific abstracts during the period from 2001 to 2017. The presentations and lectures occurred, in addition to Brazil, in eight other countries: Canada, the USA, Portugal, Spain, Chile, Peru, Colombia, and Argentina. Table 4 shows the year of the event, name, place of event, organizing institution, and name of the presentation/lecture.

DISCUSSION
SLHS involves activity in the prevention, assessment, diagnosis, and treatment of speech, language, social communication, cognitive communication, and swallowing disorders in children and adults 313 . Therefore, performance in sleep disorders is based on the interface of the areas of competence, especially concerning voice, breathing, chewing, swallowing, and human communication in general. Any performance should be based on scientific evidence 314 . Thus, the authors reviewed the participation of Brazilian SLPs in treatment of sleep disorders, targeting the best benefits for the patient 315 .
Among the 40 articles found, only 12 of them were published in journals that presented impact factor, a fact that is related to the low citation index of the journals focused on SLHS 316 (Figure 1, Table 1, and Table 2).
Carrying out randomized studies and publication in a journal with high international impact resulted in greater interest for further investigations in scientific research in Brazil, with the development of techniques of orofacial myofunctional therapy in moderate OSA 5 . In 2015, a systematic review and meta-analysis 317 showed that from a total of nine studies involving outcomes with reported polysomnography and sleepiness of adult patients, four of these studies were by Brazilians.
The publication of a randomized trial of techniques of orofacial myofunctional therapy in moderate OSA in an international journal with high impact encouraged Brazilian SLPs to conduct further scientific research in this area 5 . A high number of dissertations realized in public federal or state institutions were published in the years 2012, 2014, and 2015 (see Table 3). Therefore, a systematic review and meta-analysis of the outcomes of myofunctional therapy in obstructive breathing disorders during sleep in adults, published in 2015 317 , showed that from a total of nine studies, four were conducted by Brazilian SLPs.
As highlighted in Table 4, the lectures and presentations occurred at events organized by national and international associations/societies with strong scientific participation in the areas of both SLHS and sleep. The most frequent location of the events was Brazil, but we found participation in eight other countries (two from Europe, two from North America, and four from South America).
The number of scientific productions in this area more than doubled from 2010 to 2011; however, the highest production rates were observed in 2015 and 2016 (Table 5). Certainly, the advance in the knowledge of sleep medicine and its widespread dissemination in the media are notorious and are generating the interest of health professionals from all areas, including SLPs.
The search strategy of this article was not designed to provide any systematic or comprehensive results, but rather to provide an overview of the Brazilian contribution to the field. Future research employing a proper systematic review methodology is warranted in order to gather together and summarize all the available evidence in a broad a comprehensive manner.
There are innumerable public health problems related to sleep disorders, affecting occupational cases 1-3 and interfering in everyday life 318,319 . Although the most frequent SLP approach refers to sleep-breathing disorders, we may note a growing interest in the understanding of the relationship of sleep disorders with other complaints and disorders, such as attention deficit disorder, written language disorders, hearing loss, and so on. 19 The efficacy of orofacial myofunctional therapy is still questioned, and SLPs' interventions are not widely recognized nationally or internationally. The main reason for this is the lack of randomized studies that evaluate its efficacy for the treatment of sleep-disordered breathing, for improvement of the quality of life, and/or for the improvement of adherence to CPAP. 17 Likewise, most published studies are recent and present transversal evaluations or short-term follow-up results. There is a need for long-term follow-up studies and posterior reviews to enhance the evidence; thus, studies of the performance of SLPs in sleep disorder treatment should be encouraged.

CONCLUSIONS
Brazilian SLHS shows a pioneering approach in the performance of SLPs in diagnosis and treatment of sleep disorders, mainly obstructive breathing disorders during sleep. This statement is supported by the increasing number of scientific publications in the formats of articles in national and international journals, monographs, thesis, dissertations, books, and abstracts in annals of events, most of these at interdisciplinary events of national and international scope. Scientific articles are published in journals of the area of SLHS, thus remaining with a lower dissemination. Efforts to improve the publications in multidisciplinary journals with a higher impact factor should be made.