How Myofunctional Therapy and Sleep Medicine Can Help 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:

Hi, everyone. Today we performed a follow-up episode on sleep and sleep medicine. I want to underscore again that if you’re having fatigue, mood issues or brain fog, there could be a sleep impediment present and something that could be treated without much rigmarole. I want to point out a few things from the conversation today with Nikolas Hedberg. He himself was diagnosed with moderate sleep apnea and actually, central sleep apnea. He gives his first person account of how he navigated the field of sleep medicine, as well as some of the bad advice he got and some of the good advice he got. We also discuss how to work through improving your sleep. There are a couple things here that are new to the conversation that I want to point to, which is cognitive behavioral therapy for people who are having a hard time sleeping and feeling stressed, worried or anxious about that.

DrMR:

CBT – cognitive behavioral therapy – can be used to help these individuals. I think that’s really important for people like me with a history of sleeping poorly, and you’ve seen a lot of improvements, but you still get a little bit freaked out when you can’t sleep well. If the major organic driver has been addressed – let’s say it was IBS or SIBO causing gut problems – and as you’ve addressed that (as some of the evidence shows) your sleep has improved, but sometimes you don’t sleep that well and you get really anxious about it. This is where cognitive behavioral therapy has a fair amount of merit. We discuss myofunctional therapy, mandibular advancement devices, home sleep tests, home tracking devices and a new device that I’m actually quite excited about.

DrMR:

It’s the O2Ring by Wellue, which is essentially a really inexpensive pulse oximeter-like ring that can give you data on what your respiration (while sleeping) looks like. We also discussed how weight loss ties into apnea and what expectations one should be having when undergoing myofunctional therapy; how quickly it will lead to improvements in things like fatigue and cognition. So, a really rich conversation. Per the usual, the more episodes we do on a topic, the more refined the topic becomes and the advice is. So, I’m excited to offer another episode on sleep, sleep medicine and things that you should be on the lookout for if you’re trying to feel your best; that fall underneath the sleep umbrella that seem to elude some people. So with that, we will go to the discussion with Nik Hedberg. Just a quick reminder – If the podcast has been helping you, reviews are always deeply appreciated so pop over to iTunes (or wherever you listen) and leave us a review. Okay, here we go.

DrMR:

Hey, everyone. Welcome back to Dr. Ruscio Radio. This is Dr. Ruscio here again with my friend and colleague Dr. Nikolas Hedberg. We’re going to be comparing notes on our respective forays into sleep medicine – the good and the bad, what we’ve learned and what I think our audience should be aware of, especially if you have non-responsive fatigue, brain fog or mood issues amongst other symptoms. I think those are a few of the most prominent. We’ve both had similar experiences, which for a decent measure was not very noteworthy, and in fact, some of it was pretty terrible. I wanted not only to get Nik’s perspective on how he’s thinking about sleep medicine, given some of his own personal experience, but also to share some of our notes on not being fear-based, not being overzealous and not reading more into tests than those tests can show.

DrMR:

We both saw numerous examples of where that was all done incorrectly. I think it’s important to showcase that so people understand it’s not me just strawmanning the occasional, overzealous practitioner, but rather that this is fairly commonplace. Anyway, those are a few of my initial thoughts, Nik. I’m definitely looking forward to exploring this topic a bit more with you. For our audience, sleep is this fundamental pillar. It can be innocuous in some cases in terms of “Do you have a sleep problem?” If you’re suffering with non-responsive symptoms, your sleep health is definitely something worthy of giving further attention to.

DrNikolasHedberg:

Looking forward to this conversation. I think it’s going to help a lot of people. I think we can give some good tips to look for. Just going through our own story about it can help shed some light on this subject, as well.

DrMR:

Yeah. What I think worked out nicely – from a timing perspective – is we were going through this pretty much at the same time with no intention to. We just ping each other notes back and forth here on random topics, and you and I were both looking into sleep health for our own health around the same time. It really helped us triangulate on what is working, what seems odd and cross-referencing that with what some of the published literature shows. Maybe we can start with just giving people some of your backstory on what was going on. Why were you thinking about sleep? I’ve already shared my perspective so I don’t want to bore our audience with that, but I’m sure they’d be keen to hear the lead up to the investigations.

Sleep Apnea: Diagnosis & Therapy Advice

DrNH:

Right. So, I was experiencing fatigue – mainly in the late afternoon. My energy would crash and cognitive function was declining a little bit. I’d also been dealing with pelvic pain from a vasectomy for about four years at the time that I just couldn’t get past. The more I was digging around, the more I started looking towards sleep and possibly sleep apnea. Now, the first thing that threw me off was this Epworth Sleepiness Scale (ESS), which is what your dentist or sleep doctor will give you. You have to score a 9 or higher for that to be a concern. My score was a 1. So, that was the first thing that was odd to me. After I did that and I did a home sleep test, I found out I was mild to moderate sleep apnea. That was the original diagnosis on the home sleep test.

DrNH:

So, I went to my dentist who does mandibular advancement devices (MAD’s). He actually talked me out of the MAD and urged me to see a myofunctional therapist who had very good success with sleep apnea. He also recommended a wind instrument (or something like that) could also be helpful. I ended up doing a full PSG (polysomnography) before I went to the myofunctional therapist, and I saw a Johns Hopkins MD/PhD board-certified neurologist in sleep medicine. He said that I had complex sleep apnea. This is supposedly a combination of obstructive and central sleep apneas. Later, when I was combing through the literature, I found that complex sleep apnea doesn’t actually exist, and there’s much more to it than that. So, he prescribed an ASV machine, which is very similar to a CPAP machine, but it has an advanced algorithm that’s designed to deal with central apneas.

DrNH:

Now, the literature is pretty clear that if you have central apneas and you have obstructive apneas, the first line is not an ASV, it’s just a CPAP machine. So, I was told I had something that didn’t exist and I was prescribed a machine that is the second line after a CPAP. On top of that, he told me that myofunctional therapy has no evidence behind it. He actually snickered about it. I mentioned the wind instrument and he just laughed and brushed that off. So, I was really given misinformation from the beginning with the sleep specialist. That’s kind of up to speed on where I am now. I mean, there are other things we can get into in more detail.

DrMR:

What’s interesting is some of that early advice was pretty on the mark in terms of not starting with the mandibular advancement device, although I think that’s an understandable recommendation early phase. I feel that myofunctional therapy is probably a better place to start. So, that’s good advice. That’s really unfortunate that the quality of the advice from there seemed to go downhill pretty quickly. What a good example of the ASV machine being this more advanced treatment, but really unnecessary; just another example of how even with really smart people, the new and shiny bell and whistle seems to pull people in. Maybe this is because the routine clinical algorithm gets boring after a while and smart people just crave novelty. They want to feel like they’re doing new stuff because we tend to assume that updates and newness is good… like an update for the cell phone. I think very few people refuse their software upgrades, but that may not be the case in healthcare. The initial advice seems to have been what you ultimately ended up doing and seeing the most results from. Am I correct? I don’t want to over speak on your behalf.

DrNH:

Right. Before I started the myofunctional therapy, I was recommended by a dentist to start mouth taping. With just mouth taping, I noticed about a 60% to 80% improvement in my energy and my cognitive function. Just that simple thing – taping your lips shut and forcing you to breathe through your nose through the night – made a huge difference right off the bat. The myofunctional therapy took a couple of months after I was done with it to really notice the big changes. So, that’s another thing to think about if someone were to do that. It can take a little bit of time for the body to adapt to that. There are some studies on some antioxidants like N-Acetylcysteine: 600 milligrams – 3x/day. I started taking that. That’s actually been shown to be effective for obstructive sleep apnea.

Sleep Positioning & Apneas

DrNH:

One of the things that was really interesting is that on all of my sleep studies, I had no sleep apneas on my sides. The only time I had sleep apneas were supine – lying on my back. So, the tongue is obviously just collapsing into the throat. There are ways to train yourself to sleep on your side. There are things you can buy to strap onto your lower back or your back to make it uncomfortable to sleep on your back. I know you had mentioned that you had looked into one of those?

DrMR:

Yeah. There is this pillow called the ‘Smart Nora.’ I actually have it here. I just haven’t experimented with it yet, but apparently it will listen to the sounds that you’re making. If you start snoring, the pillow inflates so that your head gets nudged gently from the inflation either to tip left or right. So, in effect, it pushes your head on its side. It doesn’t obviously position your whole body. There was one study where both the snoring person and their partner were rated and both partner and participant saw improvements in snoring. There’s also these tennis ball-like magnets that you magnetize to the upper back area of your shirt and can discourage back sleeping. I think that’s a really great place to start. Depending on the person, maybe not everyone wants to do the myofunctional therapy. It’s maybe five minutes of exercises, a few times per day, as a rough description. For some people who are really overwhelmed, maybe that’s too much for them. So, you use a positional device to start.

DrMR:

I want to circle back really quick to something you said – which was the MD/PhD sleep specialist who snickered at myofunctional therapy. This is something that I find so egregious… people who do not know the answer to a question (Is there any good evidence for myofunctional therapy?) act as if they do… so much so to where it’s laughable that you even ask the question because the evidence is just so poor… when you and I have discussed that there are meta-analyses that have found myofunctional therapy to be of similar effectiveness to CPAP.

DrMR:

There is just nothing that irritates me more. Nik – If someone wasn’t as savvy as you are, they may be like, “Well, I read some article online about myofunctional therapy, but the doctor laughed at it so it must not be worth any further investigation.” It just does people such a huge disservice and it’s extremely arrogant and reckless. If you don’t know the answer to a question, you shouldn’t act as if you do just because it seems outside of your paradigm. So, I just want to flag that because that is one of the most annoying and irritating things that I see healthcare providers do. For our practitioner audience – a good reminder for all of us. If you don’t know the answer to a question, don’t pretend like you do. I think people really appreciate it when you say, “I don’t know.”

CPAP Machines & Apneas

DrNH:

Exactly. The other thing I mentioned as well about his misdiagnosis was this complex sleep apnea, which the latest literature on that says that doesn’t exist. If you have central sleep apnea, you do a polysomnography. If it comes back positive, then they want you to come back so they can hook you up to a CPAP and titrate it so they know what pressure to set for you. It’s fairly common to be hooked up to a CPAP machine for the first time, and all of a sudden your brain stem starts firing central sleep apneas because it’s something it has never experienced before. It can take about a month or two for central sleep apneas to go away. In the vast majority of people who have central apneas – if they do myofunctional therapy or a MAD or a CPAP – those go away overwhelmingly.

DrMR:

Yeah. For our audience, central apnea is essentially central brain isn’t telling you to breathe during sleep. I always had an extremely hard time reconciling how that could even be a thing. Right? How could the brain just stop telling someone to breathe? It seemed to me that had to be secondary to something else. From an evolutionary perspective, it didn’t seem like something that would have made its way through the population and/or could just start all of a sudden; there had to be some sort of trigger or was a secondary phenomenon. I remember so many nights just thinking, “How can I reconcile that?” What was the name of the researcher who wrote that paper…?

DrNH:

Ishikawa.

DrMR:

Ishikawa. I think that’s really important to flag, especially if there is anyone who is on a CPAP and being told, “Well, you’re going to need the CPAP forever because you have apnea – both obstructive and central.” What a huge gift to be able to offer people. If you want to keep using the CPAP, you can. There’s a good chance that the CPAP will address the central. However, at some point, if you wanted to use other therapeutics that were less invasive like myofunctional therapy (among other things), you may be able to free yourself from the CPAP. That is huge. I don’t see enough people discussing that. I certainly don’t see this being discussed anywhere with the sleep conversations. It’s usually a lot of good stuff – it’s hygiene… timing… blue light… pre-bed… timing of caffeine… Again, all good things, but this bit about apnea just seems to be totally flying underneath the radar.

DrNH:

The other issue with the misdiagnosis is that an ASV machine is not covered by insurance. They are $3,500… sometimes $4,000. You can get a good regular CPAP for maybe $500… $600, but insurance does pay for CPAP’s. So, he recommended something that I had to buy out of pocket. For someone like me, I could just buy it, but think about all the people out there that can’t, and it’s not even covered by insurance. There were just multiple levels of incompetence and all I can think about is the thousands of people that go in and out of that sleep center who really aren’t getting the help they need.

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Mouth Taping

DrMR:

Now, circling back to mouth taping, this is something that’s interesting and another really simple intervention. This is something I’ve been recommending in the clinic for several months now. It hits and it lands and people notice something, but it’s – at least in my observation – a minority of cases. I’d say maybe 15%… 20% of people will remark, “Wow. That really helped. I noticed I slept more soundly. I had better energy. I had better cognition.” I’m assuming there’s probably a subset of people who are mouth breathing and another subset who are not, and maybe that’s why… or perhaps something different than that mechanistically that leads to a subset to respond to this and not others. I wasn’t someone who noticed a response from mouth taping, subjectively nor from my Oura Ring scores. Nik, I’m wondering – Are you recommending this for patients? What sort of time to response and what sort of percentage of people are you finding respond?

DrNH:

Right. I am recommending the mouth taping as one of the first things to do. Off the top of my head, probably 60% to 80% of the patients are saying they notice some difference. I don’t think any of them have had the response I had – 60% to 80% – but, some level of improvement and that could just be placebo. We don’t really know. That’s about what I’m seeing with the mouth taping. Now, my Oura Ring scores were (even in the beginning) around a 90 to a 92. This was before I even did anything. So, they didn’t really get better and they didn’t get worse doing any of this, but my symptoms improved, which had me start wondering about the Oura Ring and how accurate they are. There are some pros and cons to those. I’ve actually just put mine away in the drawer. I don’t think it’s healthy for me to continue to focus on a score that doesn’t really change at all, and I’m feeling okay. What do you think about the Oura Ring?

The Oura Ring & Dangers of Constant Scoring

DrMR:

Your observations with the Oura Ring were really helpful and eye opening for me. My experience was different in the sense that I had other problems I needed to resolve — exercising late in the day, eating late and close to bed and going to bed too late. I do notice those things have a demonstrable impact on my Oura scores, but that might be because for me, staying up late… eating late… exercising late are the things I really needed to address. Were you pretty consistent about your bedtime and were those factors not that much of an issue for you?

DrNH:

Right. Yeah. I’m very, very consistent. I go outside and get some sunset light every night within an hour of the sun setting. If you do that for anywhere from 5 to 10 minutes every night, that really helps to set your clock. My clock is very consistent and feeding time is pretty consistent. Based on my research, you want to be done eating at least 3 hours before you go to bed. I found that helps. Anything closer to bedtime than that for me does cause some disruption. So, the eating, the activities, the light exposure and things like that have kept me very consistent.

DrMR:

That’s where I think the Oura Ring for me was helpful. The things that you had dialed in, I was kind of dragging my feet on. The Oura Ring, in that regard, really helped me to see that my scores – which oftentimes would be high 60’s to mid-70’s – would only get into the low to mid-80’s. That’s really where I tend to peak – anywhere from 78 for my sleep score up to maybe 85 if I’m doing all those lifestyle things right. For patients in terms of “Oura Ring or the at home sleep test… which one should I do?”… I’ve been recommending both. I look at the Oura Ring as more of a barometer for hygiene and lifestyle practices as they pertain to sleep.

DrMR:

If people have those boxes checked, I think the Oura has less to offer. If we’re thinking there’s some sort of airway impediment, then that’s where I think the home sleep tests have most of their merit. I also just want to quickly agree with you that there comes a point where tracking with the Oura Ring every night for me – I pretty much know what I’m going to get. By this, I mean – If I am in bed at 10:30, I ate at the right time and I had the appropriate wind down, things are going to be good. However, if it’s a Friday night and there’s a group of people going out, grabbing dinner and drinks… you have a few drinks and you’re going to bed at 12:30, I pretty much know I’m going to see at least a 10 or 15 point reduction in my sleep score and in my readiness score. I’m not expecting those things to be healthy for me. So, at what point does further verification that those things are bad help you – as opposed to just making you a little bit neurotic? I think that is really important to flag so people don’t beat their head against the wall too much.

DrNH:

Yeah. One of the most effective things for sleep problems/insomnia is cognitive behavioral therapy. That gets you to remove your focus on not being able to sleep. So, for me, looking at a score every day could potentially create some barriers there to good sleep. I wanted to mention one other thing – going back to the sleep center I did my PSG’s at. The sleep tech was very knowledgeable. We exchanged information and were in contact in between appointments. He said to me, “I’m really struggling because there are some things I want to say that I can’t say because I work under the doctor’s supervision. I can’t ethically counter what he says.” Basically, the sleep tech was in disagreement about every single aspect of my diagnosis and my care.

DrNH:

He recommended the Wellue O2Ring, which you and I exchanged some information on. This is a ring that tracks your oxygen and your pulse while you sleep. So, I got that and ran it for about a week. My oxygen was coming in at very consistent 94% every night. I was having maybe one or two (at the most) drops in oxygen. He said that this is a very good indicator of apneas and difficulty breathing while you sleep. Did you end up getting that and trying it out?

DrMR:

I did. I have this reaction to certain types of light. I notice this with my platinum LED. If I use it too much, it’ll cause insomnia. I’ve noticed the same thing with a few of the Capillus laser helmets for your hair. There’s a threshold and/or a type of either laser light or LED light – or just light in general – where I seem to have this weird idiosyncratic reaction that actually causes insomnia. I had that reaction two times with the ring. I was actually so excited to use this because I love that it can give you, essentially, pulse ox data at such an inexpensive cost and is so easy to use. Unfortunately for me – and I’m definitely an outlier so I don’t want people to be dissuaded from using this – I do have this peculiar reaction to some forms of light where it seems to stimulate me and causes me to stay up. Sadly, I haven’t been able to get too far into that experiment, but I actually look at that as probably the best way to do ongoing monitoring with a home sleep test. I think it’s far better than having people do repeat overnight attended sleep studies due to the cost and the invasiveness. So, I love the idea of that.

DrNH:

Yeah. The PSG’s are difficult for some people. They were difficult for me because I had to go to a hotel, you’re not at home and at the place I went, there was a fair amount of light in the room. You’re hooked up to so many leads and you can’t move around like you normally do. I think that has to be taken into account when those are being interpreted, which reminds me of the AHI – the apnea-hypopnea index. This is what the sleep apnea diagnosis is based on. I don’t know if this is true or not, but a well-known dentist I worked with told me that he knows the doctor who invented the AHI. He said that one of his biggest mistakes in his career was coming up with the AHI.

DrNH:

I don’t know if that’s true or not, but it’s this range of apneas that you can have. If you’re in 5 to 15, then you have apnea. If you’re below that, then you’re okay. If you’re higher than that, you have severe apnea. I did a repeat home study and I still had some apneas, even though I didn’t really have any symptoms anymore. So, I was still classified as mild to moderate sleep apnea and it still showed that I had no apneas on my sides – only on my back. So, that’s where I am right now. I’m just taking a break from really focusing on all of this for a while and just enjoying how I’m feeling now with my health, rather than putting so much focus and to sleep for awhile.

DrMR:

Right… and monitoring… and testing, which is really important. To use an example that may be a little trite, but I think is worth repeating — The person who is doing serial SIBO re-tests and they’re concerned that a 10 point fluctuation in their hydrogen could be why they’re seeing an array of symptoms return. You end up seeing these people get so focused on testing and how they’re feeling. Every time they’re not feeling great, they get concerned that there has been this major backslide. They forget that happens to even the healthiest people. Like I was just telling you before we got on the line, my sister just got married. So, to and from Massachusetts… a number of nights up late visiting family… some bad food… some alcohol. So, today I’m not feeling great, but I’m not concerned that I have candida or SIBO is back. Right? These things that just have so much more of a piercing, visceral fear-like reaction associated with them as opposed to “Yeah. I had some fun, kind of over withdrew from my health savings account, so to speak. Now, I’m in a little bit of a debt, so I’ll focus on sleep recovery and it’s not a big deal.” So, I fully agree that we should be light with our touch regarding diagnoses, prognoses, testing and monitoring. I think it’s always helpful to echo that.

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Myofunctional Therapy: What to Expect

DrMR:

Coming back to the myofunctional therapy – this is something I’d be curious to hear more of your experience in. What was the daily time commitment? How long until you noticed improvements? What kind of maintenance is associated with it? What was the therapy like? What did you notice in terms of time and response? Any ongoing maintenance? You alluded to that, but I’d love to have you share that a little more for people who are going through it. They can set their expectations accordingly.

DrNH:

The therapist I worked with was a speech pathologist and a myofunctional therapist. She claimed over 20 years treating sleep apnea with myofunctional therapy. Her results were over 90%, according to her. I did a seven week program with her and the exercises are really only 5 to 10 minutes a day for that seven week period. Then, she gives you maintenance exercises to do ongoing every day. Those only take a couple of minutes. That was basically it as far as the myofunctional therapy for me.

DrMR:

In terms of how long it took – was it a couple of months until you finish the plan? That’s the other thing I think people – and myself – are really looking to learn from. If we follow up with someone and they just completed a month course… should we be expecting a response then? I’m not sure how deeply you’ve dug into the response time in any of the meta-analyses. I haven’t gotten that far yet. I’m not sure if you have, but I’d be curious to get whatever you have to share there.

DrNH:

Right. I did talk to the therapist about this. In her 20 years of experience, everyone is very different. Some people will continually progress through her plan and beyond, some people won’t change until the end and then some people (like me) won’t really notice any changes until a month or two after it’s complete. What I suspect is that myofunctional therapy is a corrective measure. For example, I started firing central apneas when I was hooked up to a CPAP. The CPAP eliminated the obstructive apneas, and so my body adapted and started firing central apneas. As we know, those go away within a month or two in most people. My thinking is that myofunctional therapy also corrects the obstructive apneas. I may have been continuing to fire central apneas during that time, or for a month or two after that. However, those then went away. On my last sleep test, I did not show any obstructive sleep apneas. So, in that sense, it was effective.

DrMR:

Yeah. This is a great point that people with both central and obstructive apneas – we’re just theorizing here – may be the ones most likely to take a few months until after completing myofunctional therapy to see their response. I think that’s important to echo for clinicians so they don’t have unrealistic expectations… and also for patients so they can be a little bit patient. If you’re working with a clinician like I’m doing – and I’m assuming, Nik, we’re doing something similar – you’re not going to be too heavy handed on the recommendation to actually do the PSG attended overnight sleep study because it’s a pain and it’s expensive. You’re not going to have the diagnostic information for whether this person has central apnea. So, it’s going to be a little bit of… “Well, we used the home sleep test and this found apnea. We don’t know if it’s both central and obstructive, but we’re going to do the myofunctional therapy.” Theoretically, if you have both types, you may take longer to respond. Let’s just put that out there so people understand that while some people may respond right away, it may be a few months until after myofunctional therapy until you see that symptomatic improvement.

Case Study: Sleep Apnea & Weight Loss

DrNH:

Exactly. I did want to mention a case study that I had sent you. It was published in a journal. One of the things we didn’t talk about tonight was weight loss. I learned from my dentist that men, especially after the age of 40, start to gain a little extra fat on the posterior portion of the tongue, and that can increase the chances of obstructive apneas. For example, the case study I sent you – a lot of it was about just losing a lot of weight. You’ll find various anecdotes – talking to people and things like that – that they got rid of their obstructive apnea by losing weight. That makes sense because there’s less tissue in the mouth and on the tongue, and that frees up the breathing. So, as far as one of the first line recommendations for me, it’s really getting the inflammation out of the body and getting their body fat down, if that is in fact an issue.

DrMR:

This brings up this ‘chicken or the egg’ issue (which is another thing on my list to look more into) to see if there is any consensus, or at least a trend, that could be teased out from the research literature. Weight gain may cause apnea, but apnea may also cause weight gain. I’m sure it’s probably a degree of both, but anything there insightful that you’ve come across?

DrNH:

Yeah. If you look at the pathophysiology of sleep apnea, there are many, many studies connecting sleep apnea to insulin resistance and metabolic syndrome. Also, when you have sleep apnea, you drive inflammatory cytokines and NF-kappaB. So, when you get this increase in inflammation – increased insulin resistance – that’s a recipe for weight gain. There are also studies out there on sleep apnea and the gut microbiome. As you know, dysbiosis can potentially lead to insulin resistance and weight gain. I would look at it as inflammation, insulin resistance and gut dysbiosis as really the top three factors in weight.

Cognitive Behavioral Therapy (CBT)

DrMR:

Yeah. It makes sense. Coming back to cognitive behavioral therapy – I’m really glad you mentioned that. It’s funny, you actually said that right as I was thinking of the follow-up questions I wanted to pose. I actually wasn’t aware of the utility of cognitive behavioral therapy for insomnia until just recently. It’s funny – sometimes you don’t realize there may be a facet of this in your practice until you come across it, and then the reticular cortex activates and you start making all these connections. A case study from our office (maybe at some point we’ll write this up) – he was the poster child of bad sleep hygiene. At first I thought this was just going to be a sleep hygiene case. We got him using blue light filters, getting off devices before bed, getting to bed at the right time, getting some sunlight exposure during the day and thought this guy will do awesome.

DrMR:

He did see a 70% improvement in his sleep from doing that – maybe not quite 70%, but fairly marked. However, even after all that, he was still having some problems with waking up and not being able to fall back to sleep. He pretty much served this up on a platter to me, but he said, “You know, when I wake up, I get so anxious about the fact that I’m up that I have a really hard time going back to sleep. I just feel like I’m really emotionally wound up.” So, I guess I’m just offering this for clinicians and patients alike. It doesn’t all have to be apnea, right? Perhaps he was waking up because he was having apneic events and that was leading to cortisol and the stress response, and that’s why he was feeling anxious. However, we actually had done a home sleep test on him and he had no apneas. In this case, I think it’s important to make sure there are a few different lines of therapy in your armament. For him, I recommended he seek out cognitive behavioral therapy for sleep. I had recently come across a sleep physician – who I believe was a psychologist – who focused on sleep. So, good connection there. We referred him to start doing therapy for that instance. We also ruled out any type of apnea and he did not have IBS or something where we were thinking gut/brain, so to speak. Do you have any additional thoughts on CBT and do you have any resources or good referral channels that people can plug into?

DrNH:

Yeah, definitely. There’s a great book that I recommend to patients. It’s called ‘Quiet Your Mind & Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, Or Chronic Pain.’ That book is by Dr. Colleen E. Carney and Dr. Rachel Manber. That’s a cognitive behavioral therapy approach, and it’s been very, very effective for me and patients. That’s the book that I would recommend. Dr. Colleen Carney also came out with a sleep workbook. It goes along with that book, but the book does stand alone. They just get you to retrain how you think about sleep. One example is – if you can’t sleep, they teach you to think – “Who cares – then just don’t sleep.” Eventually, the days will go by, your body is just going to shut down and you’ll go to sleep. You might only have 4 or 5 hours of sleep for a few days or a week, but they train you not to worry about that. Over time, your body lets go of the anxiety and the issues with falling asleep. That tends to go away in most people taking that approach.

Wellue O2Ring

DrMR:

It almost sounds like limbic retraining in a loose way, in terms of someone who is worried about food, environmental or supplemental reactivity. It’s different, but it’s just getting them past some of that emotional and anxiousness hang up. That tends to be pretty freeing when people get past that point of resistance or worry. Coming back for a second to myofunctional therapy, I’m assuming you were not monitoring yourself while you were doing the myofunctional therapy without the Wellue O2Ring, right? Is that something that came on board later?

DrNH:

The O2Ring – I did that after. So, the only thing I was monitoring was the Oura Ring and my symptoms.

DrMR:

Gotcha. I think the way I’m going to be pivoting in the future is for people who have a degree of apnea, I think that’s going to be the best way to monitor that – as opposed to an Oura Ring. Maybe you’ll see some improvements with the Oura Ring scores – I think that is unknown. The Wellue ring seems to me to be, “Okay, let’s do this until we see a good response and then consider doing a repeat home sleep test.” Those are $200 and quite easy and non-invasive to do. That seems to be a good strategy. Are you doing something similar in your office?

DrNH:

Yeah. I think that’s the smart thing to do. There are two local dentists I know personally who do the mandibular advancement devices and really try to help people with sleep apnea. They’re doing what you’re doing. They both use a pulse ox ring, like the Wellue O2, for people to monitor them before and also when they’re adjusting to the mandibular advancement device. Using a ring like that is a pretty viable way to monitor people.

DrMR:

It’s so amazing that these things have really not permeated sleep medicine. It seems that the overnight attended seems to be so heavily leaned on. Who knows – maybe this is a combination of complacency, intellectual laziness and not wanting to think outside the box. As I’ve been able to see it, the apnea diagnosis seems to only be given to people who are desperate and incredibly severe – like the Epworth scale and that not registering positive for people who clearly are in need. Maybe this is just like, “Okay, we’re going to give insulin or Metformin to people who don’t want to stop drinking a bunch of soda and are just totally abusing their bodies.” You’re just going to get this chop shop medicine, and there hasn’t been enough interest in the field to spur innovation and different approaches.

DrNH:

Yeah. The sleep tech I mentioned earlier – who is very knowledgeable and who I’ve stayed in touch with – he said to me, “You’re not the typical person that I work with. The people I work with here at the center are just not going to do all the things that you do. They’re not going to give up their alcohol in the evening. They’re not going to quit smoking. They’re not going to change their diet to lose weight. They’re not going to do all these things that you’re willing to do.” So, that’s just how it is for people who aren’t going to make any healthy changes. The only options for them is a mandibular advancement device or a CPAP.

DrMR:

I think that’s important to acknowledge because the most jaded wing of alternative medicine may label these things as caused by monetary malalignments and conspiratorial underpinnings. Sure, those may exist, but I think oftentimes we can contribute things moreso to stupidity than this underlying malevolence. If most of the patients you’re seeing aren’t willing to do anything, then what motivation does a clinic have to offer more therapeutics if nobody is going to use them.

DrNH:

That’s exactly right.

Dr Ruscio Resources:

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Mandibular Advancement Device (MAD)

DrMR:

Coming back to the mandibular advancement device, I was more keen on these until I had a conversation with Brian Hockel. I thought he made a good point – and he was speculating – but, to push the lower jaw forward, you’re going to have an equal and opposite pressure on the upper jaw. His concern was over time, you’re going to actually push the upper jaw progressively backward, and that might actually exacerbate and make things worse. Again, I think context matters. Is this better than nothing? Yes. Could this be used in the short term to get someone feeling a bit better and then do myofunctional therapy? Sure. However, that’s given me a bit more pause in terms of how quickly I revert to that. What are your thoughts on that?

DrNH:

My dentist – who does mandibular advancement devices like I said in the beginning – talked me out of getting an MAD. He really pushed for myofunctional therapy and to do what I could to avoid that. He actually even said that if the myofunctional didn’t work, then you’d really want to do a CPAP before doing the MAD. I think he was influenced because he said a close colleague of his used an MAD, and after a few years, he had to have major reconstructive surgery on his jaw.

DrMR:

Wow.

DrNH:

So, I think that was a big factor in his recommendations for me.

DrMR:

So, Hockel’s opinion might be a bit prescient then. I’m glad you said something about jaw surgery because one of the things that was fairly readily recommended to me without any due circumspection was Maxillomandibular advancement surgery (MMA). I think this enters us into some of the other opinions that we’ve gotten, which seem to be equally terrible in terms of obsessing over the structural findings on some of the scans that can be done; really looking at structure over the function. Let’s say structure wasn’t great (as in my case), but function was pretty good in terms of no symptoms. My PSG attended overnight found no apnea. My home sleep test found mild to moderate. So, maybe some functional findings in terms of airway occlusions, but in terms of symptomatic presentation – nil, but structure – not great. There was this desire – kind of like some chiropractors want to see everyone’s neck have the perfect curvature, and they’re just obsessed over getting to this ideal cervical, thoracic and lumbar curvature, which seems a bit divorced from the function. I know you had some similar experiences where there seemed to be this heavy banging on structure without regard for function. I’m wondering if you had any follow up thoughts on that?

DrNH:

Yeah. It was sort of a doom and gloom approach at the sleep center. He looked in my mouth and just said, “Oh wow, you have no space. You’re definitely going to need to be on a machine or using MAD.” He also mentioned a phrenic nerve device that they’re now implanting. There are some major problems with that in certain people. It’s an electronic device that basically triggers breathing when the breathing stops based on what’s going on with the diaphragm. It was just a negative experience there – the way I was treated and spoken to. The impression I got is that this is just the way sleep medicine is. There’s nothing anyone can really do about it. This is what has to be done.

DrMR:

Yeah. Same. That’s why I think it was so fortuitous that you and I were both like, “Hey, I had a conversation yesterday… how does this strike you?” I think that helped us both not get pulled into some of this craziness, keep our mooring, fact check a few things and thankfully come away with an algorithmic approach… here’s what works, here’s what doesn’t work… of what works, here’s what is expensive and invasive and here’s what is inexpensive and non-invasive… here’s how we can use a couple select lab findings to determine what of those therapies we navigate first and which ones we position later in the hierarchy. Again, it seems crazy that both conventional and alternative medicine don’t seem to be doing a great job.

DrMR:

I always take pause when I say that because I don’t want to sound like this contrarian, but you and I have been all over the map in terms of some of the better names in conventional and alternative medicine. More often than not, the advice we’ve gotten have been mirror images of one another, right? The alternative people want to just crack your face open and make the structure perfect. The conventional people want to just put you on a CPAP. If anyone has some license for excuse, it’s probably conventional medicine because their patients don’t express the motivation or perhaps the financial resources. In alternative medicine, people have both, and if they’re getting bad advice, I think that lands more squarely on the clinicians. So, this might be a good area for the alternative camp not to write itself any excuses and really do the best job it can to start offering up better solutions.

DrNH:

That’s really well said. I would just echo what you said. It’s just that the system is the way it is. 42% of Americans are obese… 75% are overweight… a lot of the people go into these sleep centers and just aren’t going to change. They’re just in a system that is moderately effective for some people. If someone can adapt to a machine like a CPAP or an ASV, and it works, that’s great… if an MAD works for certain people, that’s fine, too… but there are other things in the literature that can really help people not be attached to a machine or a mouth device.

DrMR:

What great news this is for both conventional and alternative providers alike who are operating in this functional integrative model. The bar of our competition is not really high, right? So, the one silver lining here is you don’t have to be great to be offering better solutions than perhaps most of the field.

DrNH:

Yes. I totally agree.

Episode Wrap-Up

DrMR:

Nik – Any closing thoughts you want to leave people with? And where would you point people to online if they wanted to learn more about you?

DrNH:

No closing thoughts regarding sleep apnea. As I said, there are multiple options out there. It’s just a matter of finding the right one for you. My practice website is drhedberg.com and my online functional medicine education platform for practitioners is hedberginstitute.com. That’s where practitioners can sign up for my functional medicine courses.

DrMR:

Awesome. Well, Nik – thanks for taking the time and thank you again for being there to compare notes with me. It really did help me keep my sanity when I was given some pretty dire sounding advice. Having you as a sounding board helped me not spin my wheels too much. So, thank you on both fronts.

DrNH:

Yeah. Thank you for the conversation and our ongoing conversations about this. They’ve been tremendously helpful. Thank you.

DrMR:

100%.

Outro:

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