Personalizing Sleep Medicine for You

Episode Intro:

Welcome to Dr. Ruscio Radio, providing practical and science-based solutions to feeling your best. To stay up to date on the latest topics, as well as all of our prior episodes, make sure to subscribe in your podcast player. For weekly updates, visit DrRuscio.com. The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking with your doctor. Now, let’s head to the show.

DrMichaelRuscio:

Hey, everyone. Today I speak with Dr. Zac Cupples. We go further into detail regarding how we can personalize some of the available tools in sleep medicine to your system, and really try to lay a hierarchy of intervention so that you are moving through the various supports to improve your sleep health in the most logical order. We really zoomed into the spectrum of people having their diet, lifestyle, and gut health items in order, but they may still be suffering with certain hallmark symptoms that could indicate a problem with sleep – fatigue, brain fog, impairment, chronic pain or aches, heart disease risk/prevention, and mood problems… How do you then proceed through applying these various therapies? We go into the home tests, which are inexpensive and readily available, namely the WatchPAT ONE, and into a bit more detail regarding interpretation of those results.

DrMR:

And then how we can look at the results in juxtaposition to someone’s symptoms and look at both of those next to this linear order of interventions, so you have the highest likelihood of resolving your symptoms and improving your sleep with the least invasive/least expensive measure, but you also have other potential therapies to then escalate to. So just one of many a conversation we’ve had on sleep, and per the usual, the more conversations we have, the more dialed in and into focus the process to work through becomes. So, I hope you will enjoy this conversation as much as I did. And just a quick reminder, if you have not gotten your dietary lifestyle and gut health house in order, so to speak, Healthy Gut, Healthy You, was my three year attempt to give you everything you need in order to do so. So I’ll just remind you about that as a resource that’s available in print, in Kindle, and in audio format should you need some more help there. Here we go to the conversation now with Dr. Zac Cupples.

DrMR:

Hey everyone. Welcome back to Dr. Ruscio Radio. This is Dr. Ruscio today with Dr. Zachary Cupples, and we are going to be comparing clinical notes on what can we do to help people sleep better. Zac is a doctor of PT – physical therapy. He does a lot with myofunctional therapy. his is a great chance for us to peer through someone’s perspective, who is getting into the oral airway using therapy. Hopefully this will give us an even better understanding of what myofunctional therapy and other things in his toolkit can help; what the limitations may be, and just help us better understand how we can dial in this phenomenally important aspect of our health – which is sleep.

DrMR:

Zach was recommended from Dr. Mike T. Nelson (who has been on the podcast now maybe five times). Super high level of respect for Dr. Mike. He also does my exercise programming. I’ve learned not to criticize Dr. Mike on the podcast because when I do, he beats the living crap outta me with the programming I have to do the following week. So I will only say nice things about Mike on the podcast. All joking aside, Mike vouched very highly for Zac. Zac- really excited to connect with you and better understand what you’re seeing on the sleep side of things.

ZacharyCupples:

Yeah. Dr. Ruscio – it’s an honor to be chatting with you. I’ve followed you for a long time and, I will echo what you say about our dear friend, Mike. He is a great human being. So, I’m excited to dive into all things airway.

DrMR:

Tell us what you’re seeing. You’re working in this clinical setting where I’m assuming you’re seeing a variety of different presentations, and you’re using myofunctional therapy along with other therapeutics. Give us the bird’s eye of what you’re seeing as it pertains to sleep. And then maybe we can zoom in on some of the nuances.

Background & Client Symptomatology

DrZC:

Sure. It would probably help if we look at where I started and where I’ve gone. So, a lot of my early physical therapy experience involved utilizing various breathing and airway techniques for basically the neck down to maximize someone’s movement capabilities. I found that when you help someone only from about C7 on down, that is very limiting. Inevitably, that made my study drift towards more things above the neck and having some sleep difficulties myself over the years, that led me into learning a bit more about things upper airway. And I have to give credit to a lot of my colleagues – Dr. Joe Cicinelli, Dr. Ashley Summers – they are also physical therapists up in the Bay Area. They put me in tune with a lot of different providers who are doing various treatment strategies for all things upper airway.

DrZC:

And because I started studying in that field as well, I was becoming more privy to some potential symptomatology that I think a lot of my clients were dealing with, but I wasn’t really asking the right questions. Namely, the big thing I’m seeing is that we have a very large population of people who either are not sleeping enough or their sleep quality is low or they’re snoring. I have a woman right now who snores so loud that she hasn’t slept in the same bed as her husband for many years. When you look at the research on how someone who might present with a sleep disorder (such as sleep apnea) and how that impacts the health of the spouse, it’s showing that has negative health effects for them as well. You eventually get enough tired people in your clinic and you’re like – I really need to find something to help these folks because if you’re not sleeping that has not just profound effects from how you live your days, but a lot of the negative health complications of something like sleep apnea or even upper airway resistance syndrome. We can dive into what those are.

DrZC:

So, I just started recommending people do at home sleep studies in the beginning. We use the WatchPAT ONE – that’s typically what we recommend you. You can get it on Amazon very reasonably priced. And it’s got a lot of efficacy in the research, although it might underestimate the severity of the results in comparison to polysomnography. And I just kept finding mild sleep apnea, moderate sleep apnea. One of my coworkers had severe sleep apnea or had upper airway resistance syndrome. It was like, wow. It was very hard for me to find a sleep study that didn’t have something. That led me to how can I best advocate for my patients to help them deal with these issues so they could sleep better.

DrZC:

And that’s led me to spending more time learning about myofunctional therapy, as well as other potential treatments that you can utilize to improve someone’s ability to sleep. Because if you look at the typical methods that are used to deal with something such as sleep apnea, which is potentially positional therapy where your side lying in your sleep, and of course the CPAP. The six month compliance rate with a CPAP is about 50%. So, clearly that’s likely not a long term solution. And also the cardioprotective effects utilizing a CPAP are not there. The other one that’s typically utilized is an oral appliance. So, something to essentially bring the jaw down and forward. That would open up the airway and that does have cardioprotective effects, but there’s potential long term negative effects on the occlusion. Namely, you could potentially develop a posterior open bite over the long term, which is where you can no longer contact the back of your teeth or the molars effectively. That has its problems as well. And so then it’s like, okay, well, our standard treatments might help. And no doubt, if that’s all you can do, it’s probably worthwhile to do that, but are there other ways that we can help our people get better? And that’s where I think all of these other potential avenues could be useful.

DrMR:

Right. Perfect. So, we’re really well lined up. We’re approaching patient care with this broad overview. We’re going to look at things like their lifestyle. I’m assuming you’re doing a lot with people with those low hanging fruit bits, right? Are you just watching the news before you go to bed? Grrr… I wonder why you can’t fall asleep. I think we can gloss over a lot of that because I think our audience probably has already learned that in multiple places, including on this podcast. We’ve discussed that on the podcast before. Super important, not to discount the importance of that for people in case you’re newer to this conversation. But because I want to try to get into some of the nitty gritty with how we navigate things like WatchPAT ONE… myofunctional therapy… let me just acknowledge the diet and lifestyle pieces are the foundation and you want to start there.

DrMR:

I’d also include with that gut health. As I learned myself, there’s a growing body of research supporting that inflammatory (and other) imbalances in the gut can cause problems with sleep. At the clinic, we start with this diet, lifestyle, and gut health foundations model, and we watch how someone’s symptoms respond. To try to best look at someone’s presentation and know if they should go further down on the sleep road, I look for a few key symptoms. The reason why I look for a few key symptoms is tying in exactly with something you said earlier. I’ll see a number of WatchPAT ONE’s that are mild or moderate; that means they correlate clinically. And if you’re seeing symptoms that suggest, then treat them.

DrMR:

But if you’re not seeing symptoms that suggest, they may not require treatment. Now, maybe you don’t agree with that, but let me pin that to the board just for one second and come to the symptoms first. There seems to be a fairly general consensus on fatigue/daytime sleepiness, brain fog or cognitive impairment, cholesterol perturbations, and/or just heart disease risk in general or prior events, and also chronic aches and pains as some of the hallmark symptoms that start to shade in what someone who is being impacted by a sleep disorder may look like. Thoughts on that?

DrZC:

I definitely agree with that wholeheartedly. I think it’s very easy to go looking for something wrong when you deep dive into studying anything. I predominantly work a lot of orthopedics and an analogous example would be finding abnormal things on imaging anywhere in the body, but then also being asymptomatic, which that’s very prevalent. And I think you could definitely have that as well here. Great example when it comes to all things – sleep studies and things of that nature. You definitely have to have some symptoms. To your point, the symptoms may not necessarily be related to energy or brain fog or things like that. And that’s where looking at heart disease and things of that nature could also be a useful thing to consider because the risk of cardiac events for someone who does have sleep apnea is a bit higher.

DrZC:

And I also think too — If you’ve been under-slept for a very long time, your perception of what it means to be well rested is significantly altered. You kind of don’t know what you don’t know. The other thing I think that might be worth adding to that would be if someone has a difficult time nasal breathing. Or they have chronic congestion and things of that nature. Now, obviously with a lot of the fundamentals that you espouse, Michael – doing things such as diet and things like that – those can be contributing factors to someone having congestion. But there’s also potentially structural factors or even factors in tongue positioning and myofunctional stuff that could be worthwhile. I also think another thing, too is looking at things that could potentially be impacted by an inability to position and maneuver the tongue. So, someone who has difficulty chewing, swallowing, things of that nature – even though you might not really go far down the rabbit hole – those types of folks could benefit from myofunctional therapy. Also, if someone presents with snoring and things of that, that would be another example where maybe you’re not going to go all the way down, but even doing something as simple as some various tongue exercises could potentially be very impactful for those folks.

DrMR:

Fully agreed. Those are some really important, additional pieces of context that you tie in. And this is part of what we have on our paperwork so that we can be watching how someone is responding and looking at other factors, some of which you mentioned – Are they snoring?… Do they have braces?… Do they have drool on their pillow? Do they wake up with a dry mouth? Do they have jaw pain? Do they have trouble swallowing? We can look at that and also nasal congestion or a hard time nasal breathing. I’d also put on this list of symptoms – coming back to those for a second – I’m not sure if you’ve seen that published anywhere, but I would not be surprised if mood would be something. Just looking at my own experience that if I’m under-slept for a while, I’m not as happy of a guy. Would you agree with mood? Are there any other symptoms, maybe just anecdotally, that you’re seeing that you suspect flag a sleep problem?

DrZC:

Yeah. It’s funny you had mentioned that because I believe there are some studies looking at upper airway resistance syndrome. For those listening sleep apnea would be if you go for longer periods of time without breathing. And typically it’s 10 seconds or more according to what the sleep studies look at. The upper airway resistance is anything that’s basically less than that. Or if you have frequent arousals, so on and so forth. And they did show in some of the articles that I read, alterations in mood as being a potential symptom of someone with upper airway resistance syndrome.

DrMR:

Well, that’s good to know.

DrZC:

So, I’m definitely on board with that.

DrMR:

As you’re in your clinician’s mind and trying to evaluate – do we go down the sleep road? We’ve established there’s a number of historical factors. There’s snoring, braces, drool, dry mouth, jaw pain, trouble swallowing, congestion, mouth breathing, and perhaps non-responsive issues with mood, fatigue, brain fog, pain. So, if all those things flag, it’s easy, but typically what you’ll see is a smattering of some of these, right? So, it’s easy to say – if we have 10 out of 10 on the checklist, it’s a yes, right? But if you have 3 out of 10 on a historical finding checklist and you have 2 of 7 symptoms, then it gets a touch harder to interpret this. One of the things that I’ve been experimenting with as an initial test is having someone mouth tape.

Nasal Breathing & Nasal Cardio

DrMR:

I don’t think this is a perfect test, but it’s at least one data point. When we’re suspicious and we’re making this pivot, we’ll have them do a WatchPAT ONE. And then between now and the next visit where we will cover those test results, we’ll also have them do an experimental trial of mouth taping. If I see a positive response to the mouth taping, it tells me we’re on the right track. There’s probably a degree of nocturnal mouth breathing. Conversely, if someone says – I can’t do it, I always wake up with the tape ripped off (at least from what I’ve heard, and this makes sense to me) – that’s also an indirect diagnostic that there is a problem. The imbalance is so severe that the mouth taping isn’t enough to resolve that. I look at either a positive response to the mouth taping as diagnostic or a really hard time and aversion to the mouth taping as also a diagnostic. Curious what you think about that?

DrZC:

Yeah, I think that would be an immensely useful, quick diagnostic tool. And also not only that, but it would help the client attain some buy-in with potentially exploring this further. I think one thing you could potentially add to that as well, especially for the people who are a bit more adverse to mouth taping, is potentially adding something to facilitate greater nasal breathing capabilities along with that. The thing is you can close the mouth, but that doesn’t ensure that the tongue is going to go to the roof of the mouth, which then alters the pressurization capabilities in the nose. And then that theoretically could enhance one’s nasal breathing capabilities. So, you could also utilize either a Breathe Right strip… I’ve used personally the Mute Nasal Dilators, which are these little things that you shove up your nose that open up the airway. There’s another one that uses magnets called the Intake. I would be curious to see if you combined both of those interventions simultaneously to see if that’s a positive impact and maybe you get them started with just that to see how that goes. And then, from an intervention standpoint, you might be coalescing that with myofunctional therapy,

DrMR:

Great idea. I’m going to incorporate this into that test to give them a parallel recommendation along with mouth taping to use some sort of nasal airway expander, so to speak. Are the Breathe Right strips (or something like that) the easiest starting point?

DrZC:

Yeah. That or the Mute, and the Mute is also pretty inexpensive. You can get the trial pack for, I believe, $16. There’s a video I did on YouTube where I did a self-experiment on that if anyone’s interested in that. Because you can see when I was doing nasal breathing, my nose would collapse as you inhale. And actually a quick test you could do in clinic – Michael or anyone who’s listening in – is if you try to breathe through your nose and you see either the nose collapse or is very congested – if you put your index fingers on the sides of your nose and you spread the skin outward or laterally, and that makes it easier, that could also be a telltale sign that you might benefit from one of these nasal orthotics essentially, which is what they

DrMR:

That’s a great, simple home test. I like that. What about nasal cardio? I would be surprised if asking people to also do some nasal cardio would not be beneficial. I also would not be surprised if it didn’t resolve everything, but as I started doing this, I noticed that the (said really bluntly) the middle of my face had a whole bunch of muscle contraction going on. It just felt like these muscles (I didn’t even really appreciate how much they can work) were lifting the middle third of my face outward and upward. It actually felt very right. There are some things that I’ll do and it kind of feels like I’m sliding back into more of an ancestral norm and this was one of those. Wondering what your thoughts there are?

DrZC:

Yeah. In fact, if I either have someone doing a movement-based meditation or I’m programming some type of cardiovascular exercise, if you can nasal breathe throughout that, it can also be another useful strategy. If you’re someone who responded well to spreading the sides of the nose apart, doing that with either a Breathe Right strip or a Mute can be quite impactful. I can speak on my behalf utilizing that. I’ve dealt with a lot of nasal congestion when I’m pushing the limit, whether it’s hiking or cardiovascular stuff. And also if I was really pushing any type of physical activity, I’d get a lot of neck pain. And when I used the Mute, it was pretty much instantaneous relief of all of those symptoms. And I’ve had another one of my clients who had similar results. The nice thing is it’s not like you have to break your face open with surgery or get orthodontic appliances like I had. It’s quick, dirty, and it can be effective for a lot of people. And I think the more conservative you can go in the beginning, the better it is.

DrMR:

Fully agreed there.

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The Apnea-Hypopnea Index & Respiratory Disturbance Index

DrMR:

Pivoting over to testing. Now that I’ve had a chance to review a number of WatchPAT ONE’s, I am seeing mostly mild to moderate, and I’ll correlate this with their AHI (apnea-hypopnea index). For the audience, this is a sliding scale that tells you severity of apnea. Are you finding any ways of further interpreting of that test beneficial? I’ll look for… Is it not even apnea? Is it upper airway resistance syndrome? (This is a more mild subset/cousin to apnea.) Is it mild to moderate apnea? If it is apnea, I’m looking for how often there are these desaturation events, trying to color in how severe this may be. I’m making the assumption that the desaturation events are (this is where you don’t have oxygen) probably the signals that someone being the most negatively impacted, but some of this is just my best attempt to tease out further meaning. What are you finding if you have any interpretation heuristics helpful?

DrZC:

Yeah, absolutely. I will preface, obviously, that because I’m a PT, I can’t make diagnoses. That said, I’ve learned a lot from one of the ENT’s that I work with – Dr. Soroush Zaghi. You definitely wanna check AHI – the apnea-hypopnea index – because if someone has apnea, you should do something because that’s likely the most deleterious from a health standpoint. Now, the other one that I would look at would be the RDI – that’s the respiratory disturbance index. That generally is going to be a bit higher with folks who have upper airway resistance syndrome. One thing regarding upper airway resistance syndrome – It’s not necessarily a milder form of sleep apnea if you look at the literature. I’m sure you probably find this as well – the amount of controversy in this domain is so high, as well as the the tribalism, which we can get in that if we want.

DrMR:

That seems to be a human constant.

DrZC:

Yeah. I know. It never escapes. There was one study I recall reading where the symptoms of mild to moderate upper airway resistance syndrome were actually more deleterious than mild sleep apnea. We have to take upper airway resistance syndrome seriously, especially the greater the severity is. So, the RDI is very important. The other thing that I would look at as well is the amount of deep and REM sleep someone’s getting. This was really interesting. So, I sent one of my clients to Dr. Zaghi because she was complaining of snoring, gets really good benefit from myofunctional therapy, but as you know, as soon as she doesn’t do her tongue exercises one day, it’s back to snoring. I got her sleep study and it was very clean – the AHI and the RDI were both less than five.

DrZC:

And I was like – that’s really weird, especially given some of her mouth profile and things of that nature. So, I wasn’t sure what was going on. So then Dr. Zaghi looked at the sleep study and it turned out that her deep and REM sleep were very low. I think you want to have between 20 to 25% of sleep being in both of those domains, and hers were significantly less than that. The reason why her AHI and her RDI were so low was because she was hyperventilating while she slept. And that threw off those numbers. So, you have to look at those as well. Of course, some of the desaturation numbers and things that you had mentioned, would also be things that I would be looking at. I think there’s a lot more to interpreting the sleep study than we think. Having that light bulb moment made me wanna look back at some of the people who still had sleep issues, but the sleep study was clean for all intents and purposes.

DrMR:

Right. With the AHI is there is a point that you’re saying – this threshold above or below is when I’m thinking there is an issue or there’s not?

DrZC:

If you look at the literature when they classify it, anything between 5 to 15 is considered mild sleep apnea. Again, my bias is if someone does have sleep apnea, and especially if they’re younger, just because of the way our tissues change as we get older, that’s going to tend to get worse over time. So, you probably should do something about it because if you’re going periods of time where you’re not breathing, that’s significantly long. Well, we can’t last that long living if you’re not breathing.

DrMR:

So, you’re in agreement that even a mild finding – let’s say 5.3 – is something that shouldn’t be discounted. So, a five or a six (just over the cusp in that range labeled as mild 5 to 15) if you’re seeing that with symptoms, I think we make much more of a stronger argument. Yes. Do something. What about in a minimally asymptomatic individual? Would you still say – let’s say something that clocks in at six or seven – that would be worth pursuing? These are hard questions, I know, but I’m just wondering…

DrZC:

Here’s the other thing that we’re not really taking into consideration… How far are they willing to go? Because my next thought would be – if you have someone do a WatchPAT ONE and they get a mild finding, I have seen clinically (as well as some of my colleagues) that the WatchPAT may underestimate the number of apneic events. Perhaps you might consider doing an in lab sleep study to see what that says, and that could be something, but again, that’s also a bit of a harder sell if someone is having minimal symptoms.

DrMR:

This is one of the reasons why, again, I say that lab testing or lab value is one fourth of the information needed to make a decision. It’s these more mild cases that I think are potentially the most disserved. If you come in with something super severe that’s going to flag, it’s going to be easy to say we need to address this. It’s these other cases where there’s not something smacking you in the face obvious. I always try to be as astute as possible in determining – do we act or do we not act? It sounds like for even someone with a mild case of apnea or a mild elevation of the AHI (between that 5 to 15 threshold), they could need to act; their willingness, their symptom all play a role. Because some of the home sleep tests may under report, you may even interpret more strongly a mild finding. Is that a fair restatement?

DrZC:

Yeah, I would think so. Then at the same time too, that doesn’t mean that the intervention in a mild finding has to be drastic. It could it be a lot of the conservative measures that we had talked about. It could be that maybe you have them leave the clinic and put them in touch with a myofunctional therapist.

DrMR:

This is where I think the realm of functional and integrative care has so much to offer people. There’s a lot that can be done before someone does CPAP or oral airway expansive care, which can be quite the undertaking. So yes, fully 100% in agreement with you. Let’s pivot over for a second to the RDI (respiratory distress index). Are you looking at certain parameters where this is the line for which I see there being a problem, and if we’re below this, probably not a problem?

DrZC:

The way that they score the RDI is conveniently the same as they do for the AHI. Your mild cases are between 5 to 15 events. You also have to recognize, too that sometimes teasing out the difference between non-REM and REM can be useful, but generally the number of apneic events, as well as the RDI, are going to be a little bit higher during the REM stages of sleep. And that’s just because there’s more activity going on, changes in heart rate, et cetera. If someone is only an RDI change and let’s say the AHI is within normal limits, if there is no symptomology, it may be that it’s something that you just monitor over time and see if symptomology does kick in. With something like sleep apnea, there are potentially effects that could lead to cardiovascular events or death, which is why it’s a little bit more severe. Something such as upper airway resistance – probably not going to kill you – but it might have other symptoms. That’s where you’re using your clinical judgment as well as the patient preference to see if there’s anything that they want to do with that.

DrMR:

So you’re looking at the RDI in terms of the total event, and you’re looking at between 5 to 15 total events as putting someone in the mild category?

DrZC:

Yep. 5 to 15 would be mild; moderate would be 15 to 30; severe would be greater than 30. There are several different things that go into calculating that number. Sometimes people who might have an RDI, especially if it’s the WatchPAT, they may be having actually a fair amount of apneic events. It could be that the WatchPAT ONE or 200, whatever you’re using, might not be detecting that. If it is a bit higher and the symptoms are warranting, you could potentially go get a sleep study depending on how far the client is willing to go down the treatment pathway.

Positional Therapy Options

DrMR:

Sure. Before we move off of things you’re gleaning from the test, there’s one or maybe two other things here that we should touch on. You do get some positional information in terms of – are these events occurring moreso in someone’s supine/on their back, prone on their face, or on their right or left side? And at least the way I’m looking at this, I haven’t checked to see if these findings predict if someone will respond better to what’s known as a positional change device – like a little annoying thing you put on your back to ensure you’re not sleeping on your back and instead sleeping on your side. That would be one thing I would weave from the tests into the care recommendations. There’s a general trend that people tend to have most of these events on their back. I don’t know that we’d have to get super sophisticated with the analysis before making the recommendation. It may be a safe recommendation just to have people encourage themselves to side sleep. Would you agree with that, Zac?

DrZC:

Yeah. Absolutely. Side sleeping is one of the conventional things that people will recommend just because when you’re on your back, gravity is pushing downwards. It’s much harder to hold the tongue up to the roof of the mouth, especially as you’re relaxed. That device sounds terrible by the way, but there was a study done. Let’s say someone perhaps has pain when they lie on either side. So, maybe you’re looking at either back or stomach. You can also elevate the head of the bed. What they do is utilize two small bricks on the top legs of the bed, just to position it that way. That’s also been shown to help improve sleep. It may have been shown to improve some of the AHI findings, but that’s also another positional therapy that we could potentially consider.

DrMR:

To be fair, some of these are… you’re looking at a ball maybe the size of an apple, and it’s a magnet that just goes onto the shirt of your upper back. So it’s not like a little pin prick or anything too obnoxious. We certainly wanna make sure that whatever we are recommending is something that’s comfortable for the individual. Is there anything else on the test that you are gleaning valuable information from?

DrZC:

No, I would say those are the big things that I would be looking at. And then if there’s a finding and they wanted to explore this further, then we would be looking at imaging in the upper airway.

Light Reduction for Sleep Quality

DrMR:

Let’s come back to the imaging in a second because I do wanna unpack that a little bit more, but let’s pivot over just for a moment to some of the treatments. We talked about a positional change device – these are cheap supports. And perhaps if someone had very limited financial resources and they wanted to start as minimalistically as possible, maybe a step two intervention would be to have them continue using the step one recommendation of mouth taping + a Breathe Right strip, and then use some positional change device. This could be that magnet ball that I talked about that actually one of our mutual friends (I won’t name them), tried and saw some benefit from just recently. So, one anecdote of benefit from a $15 magnet ball device. Maybe they get a few extra pillows or they put the bricks underneath the foot of their bed. You start there.

DrMR:

Maybe we could say positional change would be this intervention #1 with some of these breathing supports. And I would look at myofunctional therapy maybe as a loose step two just because this is going to be a bit more of a time commitment and a little bit more of a cost commitment. It’s not hugely expensive, but if you do a self-study course, I think they maybe are around $100… $200. Or if you look at the therapist, you’re maybe looking at at least a few hundred dollars. Thoughts on that, Zac?

DrZC:

I think that would definitely be a nice step two recommendation. Maybe I’m making an assumption because I know you had mentioned diet and lifestyle, but also just making sure that you have an environment that is conducive to sleep. Is the temperature between 62 to 68 degrees Fahrenheit? Is the humidity like 40%? This was actually something I read recently. I live in Las Vegas and it’s as dry as dry can be. Simply changing the humidity on my humidifier has made a big impact. Making sure you have blackout curtains, or actually I like even better blackout film on the windows because that makes it completely pitch black. Things like that are also other ways that we could potentially improve sleep hygiene, as well as limiting electronics before bed.

DrMR:

Yes. Fully agreed. We should have all those measures in place. I wonder if there’s a subset of people for whom part of why they’re not sleeping well is because their diet is suboptimal, their gut’s inflamed. This is leading them to have higher levels of histamine, if you wanna name one potential underlying mechanism. They have nasal congestion because of that, and they’re not sleeping well due to that nasal congestion. You just make these few changes, and as so many people report, they have less congestion and/or better sleep and/or better energy. I do wanna push back a little bit on the pitch black. I don’t know that we have to go all the way to being pitch black. And as someone who used to do that and actually found sometimes I’d wake up in the middle of the night and not be able to find a light. That was a little bit dissettling.

DrMR:

Also, I’ve been tracking with Oura. I’ve noticed that plus or minus some light, as long as you’re only really getting ambient light (and I know ambient light can vary widely if you’re in the country or in the city). But, if you’re doing a reasonable best to reduce light and you’re getting to bed on time and hitting all these other factors, I haven’t noticed that my Oura data or how I feel changes demonstrably, depending on the light. Maybe there’s something that I’m missing, but my suspicion is most of the benefit comes from reducing light for an hour or two, or maybe even more, before you go to bed; really getting rid of the blue light, reducing the overall amount of light for the lead up to bed. And then while you’re in bed, making sure you don’t have the TV on all night or just a lot of ambient light. You’re getting rid of most of it, but we may not have to go fully to that extent. I don’t see any reason why you couldn’t. I just don’t wanna paint the expectation that you have to get to this blackout effect, unless there’s a data point that I’ve missed here.

DrZC:

I’d have to look. I know there was a systematic review that indicated light reduction to some extent was a recommendation that was made to improve someone’s sleep. What we don’t have is what is the minimal acceptable amount of lux that you’re being exposed to at night that would potentially negatively impact sleep. Conversely, what’s the minimum amount that you might need in the morning to favorably impact circadian hormones to simulate sleep later on at night as well, which is another thing that people may gloss over.

DrMR:

So, maybe the jury’s still a little bit out with what the minimum effective dose for light reduction is.

DrZC:

Yeah. I’ll have to look into that. It’s a really good question, Michael.

Myofunctional Therapy

DrMR:

Yeah. Let me know what you find, and I can always do a quick post at some point on this. We talked about positional change. The other thing I wanted to weave in is the loose hierarchy of therapeutic interventions. They would then be perhaps myofunctional therapy or mandibular advancement (MAD). I’ve become much less keen on mandibular advancement after exactly what you said, which is some of these potential longer term impacts. I wanna thank again, Brian Hockel, for pointing this out to me. I also tried an MAD and I did not like the feeling of being unable to move your jaw. It was a strange feeling, I really did not like it. So even though there’s some good research on the MAD’s, this is essentially like a mouth guard that connects both the top and bottom of your jaw and pulls attention to extend the lower jaw forward, so as to open up the oral airway. There’s pretty good evidence for these, I partially pause due to the potential longer term effects for the health of the airway. And also as a user, or someone who tried one, I didn’t really love the way that it felt. So, this really makes me favor myofunctional therapy as the next thing that we would do.

DrZC:

I would agree with that wholeheartedly. And the other thing, too is I think a lot of folks assume that the MAD is going to bring the jaw down and forward, but depending on the health of the temporal mandibular joints, as well as the facial development that one has, in some folks that the weight of the device itself may cause the jaw to tip down and back, as well. I do wonder if people who aren’t positively affected by that is because of that one contributing factor. I think we grossly underestimate how effective myofunctional therapy can be. Some of the studies I’ve seen have shown a reduction of snoring and improvement. In some of the sleep study numbers, snoring can be 50%, and you can get improvements on the sleep study.

DrMR:

Yes. I agree with you. This is why I’ve been so excited as we’ve dove further into the pool of research. There’s some great evidence for myofunctional therapy to help with snoring and with apnea indices. I think this is one of the best recommendations that we can bring to people because they can do so much. It can prevent the need for a MAD and prevent people from going down the road of expansive corrective work, which I learned was not a short road. It was this for six months. That wasn’t great because I had a lisp – it was a speech impediment that I could not afford to have given what I do vocationally. There are other devices that you wear at night that seem to have some good efficacy. To my understanding these would most likely require at least six months to some cases two years of braces afterward. That’s a big ask so the fact that myofunctional therapy can prevent a need for that makes it a really attractive therapeutic option.

Surgical Procedures, Posture & Upper Airway Capabilities

DrZC:

Yeah. I would agree with that to an extent. It’s at least worth trying myofunctional therapy because it does have significant improvements. And when you start going into corrective based things for some of the issues here, what you’ll find is it can be an endless rabbit hole. Depending on what you find with imaging in the upper airway, looking at a cone beam CT, you could have to do one of several treatments. I’ll speak on my myself, for example. I also see Dr. Hockel and I elected to also produce content while having a mild lisp for the next two years or whatever it is. I’ve had to do that with a tooth borne appliance and there’s several different appliances and some of them have negative complications, especially if you don’t have a practitioner who is very good.

DrZC:

Namely, if someone pushes the teeth too far out of the alveolar bone and you get severe tooth tipping that could have long term effects on the health of the teeth. So, there’s that, but then also too, if you have issues within your ability to nasal breathe, it could be that you might need procedures there. So then maybe you’re looking at a septoplasty and turbinate reduction, which I also had. I recently had a procedure called the VivAer, which is a radio frequency ablation to alter the shape of the nasal cartilage so it doesn’t dent in when I inhale. Tongue tire release – if someone has a tongue restriction, maybe you hit a brick wall with myofunctional therapy because you can’t increase the tongue excursion anymore. That’s a lot of time, that’s a lot of effort. There are several surgical procedures that some folks espouse and the hard thing is (like you said) you might be married for one, two, maybe five years.

DrZC:

It just depends on what all you need. That can be very daunting, which is why for most everyone who I work with, especially if they don’t have the financial means to go down this route, it’s worth exhausting every conservative measure possible. And another thing I think we might not be looking at – I wish they would do more research on this – is cervical range of motion and the impacts that that has on the airway. If I have someone who has a forward head posture, that’s going to potentially impact my ability to place my tongue on the roof of the mouth because the tongue generally sits lower. The funny thing is in the airway realm, everyone talks about forward head. But if you have someone who’s got more of a military neck posture where they got the double triple chin kind of thing going on, that reduces the dimensions of the airway. And so if you have someone who has neck restrictions, could that not also be a contributing factor? Of course my bias is as a physical therapist, but someone who’s well versed in increasing the dynamics of the neck could also be playing a role in improving someone’s upper airway dynamic capabilities, which could have a positive impact on sleep.

DrMR:

Fully agreed that we want to exhaust all these options first. And as you were saying that, you helped me better clarify one of the rules I’m going to follow going forward — if someone has done everything we’ve discussed, culminating with myofunctional therapy, and we’re unable to produce an improvement or resolution of symptoms and/or an improvement in their – let’s say follow up WatchPAT ONE results – you’ve now really qualified them to be referred to someone like Brian Hockel, do the imaging and do the corrective work. You’ve qualified that none of these other therapies are going to help you so now we really have to either pivot completely or combine them with some of the corrective work.

DrZC:

Yeah. I think that is the most reasonable course of action, for sure. The one time I might not consider that is if someone has moderate to severe symptoms that correspond with a sleep study. Again, my coworker (she’s my boss technically) had an Apnea Hypopnea Index of (I believe) 38, and hasn’t slept much most of her life. That was an immediate referral. She’s going to be undergoing an MMA procedure where they surgically move the maxilla and mandible forward and then rotate it counterclockwise to increase the space of the airway. So, for milder cases, I think that is a very reasonable course to go.

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DrMR:

Coming back to forward head posture for a moment. I’ve been looking at that in a little bit more of a chicken or the egg. Would someone who perhaps doesn’t have ideal oral facial development – have the neck forward head posture – really be an attempt to open up the airway? Is that something we should be looking at somewhat normal from an adaptive perspective? By this I mean this is the body’s best attempt to breathe better and trying to pull their neck backward may not be a good thing?

DrZC:

I would agree with that wholeheartedly because the forward head does allow the airway to open. I also would say though that as a physical therapist (and I can’t speak for other PTs), but the solution wouldn’t be to teach the person to hold their head the other. What I would be looking at is does that individual have all of their available neck and really upper thoracic range of motion. Any resting posture held long enough is going to lead to deleterious consequences. We want the people who we’re working with to be able to assume many different postures, movements, so on and so forth, and that’s a different animal. When I say utilizing interventions to improve neck dynamics, that that would be the course of action that I would recommend.

Maintenance of Results

DrMR:

Gotcha. That makes sense. With myofunctional therapy, you mentioned something earlier, which I wanted to get your perspective on. I haven’t quite got quite gotten here yet, which is maintenance of results that are obtained from myofunctional therapy. I’ve heard that you’ll have a very minimal plan. It might be one or two sessions per week; maybe 5 or 10 minutes to retain the results in most cases. I’m sure there’s probably some variance, but if we give people somewhat of a ballpark average, maybe it clocks in there. I’m curious – what does the back end of getting through the course of myofunctional therapy look like? What’s needed to be done, in most cases, to maintain those improvements?

DrZC:

The big key is generally having awareness of tongue placement when you are doing quiet breathing – so not talking to someone – as well as making sure you’re spending enough time chewing and you’re chewing an adequate amount, and focusing on tongue placement during swallowing. Those are probably the three key long term strategies that most people can probably do pretty well with to maintain some of the gains. Like anything, if you don’t use it, you lose it. So, if you do a course of myofunctional therapy and then you go right back to mouth breathing, the effects are probably not going to be long lasting. Technically, the way I approach myo is we’re looking at developing certain movement skills of the tongue, just like anything else. And so having the ability to demonstrate whether it’s a pointy tongue… taco tongue, things like that, it might be worthwhile just to check in to see if you can continue to do those things. An analogy I would give would be – let’s say you were someone who wanted to do the splits and let’s say you finally got the ability to do the splits. Well, it would probably behoove you to test that every so often just to maintain those gains. How much? As much as you needed to ensure that your tissues don’t stiffen up enough that you would lose the ability to perform the splits.

DrMR:

Right. This is where I’ve been liking this approach of having people do one appointment with a myofunctional therapist. We’ve been referring to Janet with Asheville Speech. She has a self-study course. I’ll tell people – do one appointment with her, get the okay that her self-help course is going to be sufficient and/or any modifications she wants to make. If you’re a straightforward case, you do the self-study course. If there’s some different recommendations, you make sure you can get those. That seems to be a good union because for some people they don’t want to do any more than a self-study course. They like the idea of a self-study course – less time, less cost – but I don’t want them to miss potentially more benefit. However, on the other end, I don’t want to say to just go over the top and do a fully personalized care plan because you may not need that. So, that’s the recommendation I’ve been making. It seems like it ties in some of what you’re saying, where you leave the door open for some of those nuances and personalizations, but you also help bring the cost down and make it easy by giving people this do-it-yourself basis.

DrZC:

Yeah. I think that’s a great idea. I like the idea of a self-study thing. What might be beneficial for that is having at least occasional check-ins with the myofunctional therapist. And I speak on this as a clinician who teaches people a lot of movement-based interventions. Sometimes, you can show someone some movement activities to do and they might do well when it’s done in front of you. But then when they go home, you have no idea how they’re actually doing it. And I think the same is true when it comes to tongue things. Someone might be able to get their tongue where they need it to go, but they might be kicking in a lot of neck. They might be scrunching their face. And these are things that someone who’s not versed in all things tongue placement and things of that nature might not be aware of that. It might be useful to have some follow-up with a myo beyond the first appointment.

Episode Wrap-Up

DrMR:

Gotcha. Awesome. Well, Zac – I think we really covered the gamut here and you’ve helped hone in a few of my quandaries with how to better serve people in this regard. It’s been a great call. Do you want to tell people where they can find out more and/or connect with you online?

DrZC:

Absolutely. And I really appreciate you having me. The best place to find me online is zaccupples.com. I run a blog, as well as YouTube channel that’s pretty much all housed there. I talk a lot about some of the concepts that we discussed here today, as well as other movement-based strategies. I also offer a lot of remote consultations, whether you want to improve your movement capabilities, or you need some help sifting through what we’ve discussed today. I’m more than able to help with that, as well as things like online personal training. Or if you are in wonderful Las Vegas, Nevada, and you need someone to help you in person, I work at Elevate Sports Performance & Healthcare there as a Physical Therapist and Director of Education.

DrMR:

Awesome. Well, thank you, my friend. Appreciate all the good work you’re doing. Again, thanks for letting me pick your brain. It was a lot of fun.

DrZC:

Likewise. Good chatting with you.

DrMR:

You too. Take care.

Outro:

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