What’s Going On With Sleep Medicine?

DrMichaelRuscio:

Hey everyone. Welcome back to Dr. Ruscio Radio. Today, let’s discuss my personal journey into the world of sleep medicine, good and bad. Unfortunately, there is more bad here to report than there is good. And by bad, I mean not bad diagnostic findings or personal health challenges, but bad advice. Unfortunately, I was subjected to a lot of the same stuff that I criticize the field for doing to others. There was an overreading of tests, there was an unnecessary imbuing of fear, and making me feel like I was far worse off than I actually was.

DrMR:

I also want to admit I struggle with the fact that some of this came even from people who’ve been on the podcast and people whose opinions I generally appreciate and have learned from, but it was incredibly disheartening for me to consult with some of these individuals as a patient or a client and see how quickly things devolved. I’m not going to mention any names because the purpose of this is not to call anyone out individually. It is to call attention to the fact that these problems in medicine and healthcare are very common.

DrMR:

There are definitely times I struggle with and wonder if I am too critical, because oftentimes I’m criticizing things on the podcast. But then I have an experience like this, and gosh, it makes me realize, if I may say so, how special and important I think what we are doing at the clinic is, because the way I was treated led to quite a degree of stress. I remember having to go for a walk at night and just trying to decompress. We’ll go into all of the things that were said to me that were quite damaging. If it wasn’t for all my experience in this field, I could’ve very easily got swept up into it.

DrMR:

So the context or background here. I’m always trying to improve my health and look for new and novel ways to do so. You probably know my individual story, but I’m feeling pretty great overall. Consistent energy and focus, pretty darn good athletic output, little to no GI problems, a high degree of food tolerance, but I’m trying to optimize. I’m wondering why my Oura scores never got much above the lower mid-eighties at their best. And I had noticed that I had to be really “good” to get a suitable sleep score on my Oura Ring, anything above 80. Now, “good” I say somewhat loosely, because my definition of good may not have been ample enough.

DrMR:

Getting to bed by 10:30 or 11:00 was a shift I had to make. I guess I was hoping to be able to game the system, go to bed at 12:00, and still get a good sleep score. But part of this was me just having to learn that, at least for me, it doesn’t really work that way. That’s been fairly widely reported, and also that I couldn’t eat or exercise too late in the day. These were all important realizations that I had to figure out, and helped me better calibrate to the fact that these recommendations exist for a reason.

DrMR:

I was trying not to follow them or kind of telling myself, “Well, eating at 8:30 isn’t too bad if you’re going to bed at 11:00.” Exercising intensely, let’s say at 6:30, getting in the sauna at 7:45, and then not eating until 8:30 and not being done with eating until 9:00. In part, these were why I was not able to get the sleep score that I wanted to.

DrMR:

As I’m figuring all this out, I’m reaching out to some of these consultants to figure out what else could be done. My theory was perhaps there’s some sort of breathing impediment because I’ve had braces, headgear, and maybe there’s an oral airway health issue that could be optimized, therefore I could go to bed later and not have some of these consequences. So that’s kind of what prompted my investigation.

DrMR:

So I took my Oura Ring data in and I saw a number of people and got different opinions and perspective. At first, I was told solely based upon imaging that I would need mandibular maxillary advancement surgery. MMA is one of the acronyms that’s used for it. Brian Hockel mentioned there’s a more contemporary term to describe the same thing, but they essentially crack your face open and move your bones forward. So I was told, “Oh, you’re going to need the surgery, and this is going to be a long road.” There was this very laborious analysis done based upon imaging, which I had learned from my training prior that there is not a good correlation, at least from a structural perspective, between what you see in an X-ray or potentially also in an MRI and the function of let’s say a joint.

DrMR:

So there are people who can have suboptimal findings. And this is something we discussed with Devin Waterman, where some people may have a degree of degenerative disc disease, and they have no pain and full function, and someone else may actually have better looking imaging studies and more pain and more dysfunction. So that was helpful, but this is a different realm, so I wasn’t sure how much the anatomical imaging findings mapped on to a prognostic indicator.

DrMR:

So, as I start down this road, it felt to me after reflection like I could see the provider making that assertion if I was doing all the right stuff and I had chronic fatigue. Let’s talk about some of the identified factors that would indicate a sleep impediment is present and a finding should be moved on. Fatigue, daytime sleepiness, cognitive dysfunction, mood disorders, hypertension, heart disease, or stroke. Of which I really had none.

DrMR:

So there’s the evidence-based perspective on if you see these things, these symptoms plus these findings, it’s fairly suggested that those anatomical findings, those oral airway suboptimal findings, are causing the symptoms. But in someone who has no symptoms, surprise, surprise, telling them or treating just a lab but not the individual is not the right call for most things, as we’ve discussed in GI. And a good kind of parallel there is someone may have mild or moderate SIBO findings or certain organisms on a stool sample that are not clearly pathogenic, and in the absence of any symptoms, those are likely not a problem. As we’ve discussed, lab findings have to be looked at in conjunction with three or four other data points to really allow you to make a full and correct decision. Now, there are some labs that are very clear cut, but as I’m wading into these waters, these are all the things I’m grappling with and trying to learn.

DrMR:

So it was very disheartening to get the opinion that this is going to be a long road and I would need surgery. I did some home sleep tests and I said, “Well, let me be a little bit pragmatic here. Let me at least start with a home asleep test like the WatchPAT One that we’ve now been using at the clinic for a few months,” which is essentially a watch-like device hooked up to a finger sensor, pulse oximeter, and also a sticky note that goes on your chest to record sleeping sounds and snoring.

DrMR:

So I did two of these tests, and they essentially find moderate obstructive sleep apnea. I will put screenshots in the images associated with the transcript for this podcast. Findings were positive for mild obstructive sleep apnea, moderate desaturations were noted, no significant central apneas were noted. Okay, so now this has my attention. I’m also thinking, “Good, perhaps there’s something here to be optimized.” It was unsettling thinking that the path or optimization was most likely going to be this long road with surgery, but there was also a ray of hope in the sense that this was something that could be addressed and lead to me having even better well-being. So that’s one important data point, and again, I’ll put these images in the podcast transcript page.

DrMR:

When I went to another consultant to get a different perspective, I kind of brought that narrative I just gave you forward, saying, “Well, I’m feeling pretty great, no real complaints. I’m just looking to optimize. Perhaps I’d have even better athletic recovery if I optimized.” And I was told, “Oh no, you’re in denial. You’re sick.” I said to myself, “Are you kidding me?” I’m also open because I was thinking this is a new area for me and I don’t want to have this hubris, but it’s like alarm bells going off when I hear this and was told I was in denial. I’m thinking denial regarding what? I’m not refuting these findings. I’m trying to establish if these findings guarantee some sort of disease, pathology, or symptoms, and if so, where is the disease, the pathology, or the symptoms. And I was told, “Well, you need more testing. You must do an overnight sleep study because these home sleep tests can under-report.”

DrMR:

So I went and I did an overnight in-person sleep study at a clinic. That report actually found I did not have apnea. So the overnight attended, even though I slept terribly and hated the experience, did not reinforce the home sleep test findings. So I take away from that there’s likely something present but hard to say exactly what. Now, how I interpret these two differing tests is potentially because I slept so poorly, there may not have been an ample sample when I was at the clinic doing the overnight to allow these moderate apneic events to present themselves. That’s at least my theory.

DrMR:

When Brian Hockel came on the podcast he did mention something along those same lines where there may be some better accuracy vis-a-vis better sleep quality with the home sleep tests. I don’t know this body of literature enough to really be able to comment, but zooming way out there is this principle of starting with the least invasive and least expensive diagnostic testing, using that to recommend various therapeutic interventions, and considering more invasive, more expensive diagnostic testing down the road. Does this sound familiar? Kind of this sequential hierarchy that is incredibly valuable because it takes all these potential things and gives you a somewhat linear sequence to work through so you’re focused, efficient, and not wasteful.

DrMR:

So I did the follow-up study and it kind of ruled out the initial finding. And then going back to the consultant, it was interesting to see that he was so keen on having me do the overnight sleep study to further prove how screwed up I was. Then when that study disproved that I had an issue and was negative, he was then trying to backpedal and tell me all the reasons why we need to look more discerningly at the data, and it’s actually worse than I think. So after that experience, it seems that they’re just searching for the worst possible outcome here, and really no acknowledgement that I feel pretty good overall. And the other thing that really bothered me was that there was no plan. There was so much fervor about theory, hypotheses, and biomarkers, but then when it came to decide what should be done, there was no organization and no follow-through.

DrMR:

Again, I want to just quickly aside and say I appreciate everything that I’ve learned from the individuals who I’ve had on the podcast, who I’ve consulted with personally, and I think all of that, good and bad, is actually beneficial because it allows me to take this and integrate it into our clinical model and hopefully stand upon some of these shoulders and offer up something better. So I do want to be careful in the criticism.

DrMR:

I want to give you the criticism packed with the emotion that I felt, so as a clinician or as a patient, you can understand my perspective there of frustration, fear, and feeling that this was mishandled. But I don’t want this to be construed as me attacking the providers. I think the providers were probably doing the best that they could. It’s just I feel we need to have more of this paradigm of organizing all of this data into more linear, hierarchical, or algorithmic application, because unless you do, nothing moors you and prevents you from just chasing down the newest and most exotic stuff because it’s the most interesting to you.

DrMR:

If you’ve doing this stuff for a few years, now you want to go deeper and deeper into the nuance and to the esoteric. But even though that’s exciting to you because it’s new and it’s stimulating, it’s not best for the patient. And that’s where some discipline, some bridling, and working through an evidence-based algorithm is really the best approach.

DrMR:

Again, why this sort of approach that I was subjected to is so harmful and makes me appreciate what we are doing at the clinic is because it legit scared me and I was stressed out about it. And then I realized this is treating the labs and not the person per the usual, and it was upsetting to see how this pervades even sleep medicine. No one was operating in a simple, practical, but effective evidence-based hierarchy.

DrMR:

So here are a few thoughts and questions that support my assertion here. How could you possibly recommend surgery before myofunctional therapy? Well, what’s your evidence for that statement, Mike? How about this — “Myofunctional Therapy to Treat Obstructive Sleep Apnea, a Systematic Review and Meta-analysis.” Listen to this, “Conclusion: current literature demonstrates that myofunctional therapy decreased apnea hypoxia index by approximately 50% in adults and 62% in children.” So you have a one-in-two chance that by doing some exercises for your tongue, mouth, and throat for four to six weeks, you could reduce your apneas. And this is a systematic review of meta-analysis data. This isn’t just one cherry-picked study, and this is not the only study of its kind. So my claim is not an evidence-less claim. My claim is actually very evidence-based that myofunctional therapy is noninvasive, it is non-expensive, and it could reduce these apneic events.

DrMR:

Okay, how does one recommend an oral corrective device that needs to then be followed with at least six months of braces before myofunctional therapy? How does one overlook data? And we’ll be releasing more about this, but to my understanding there is one study that I still need to fact check that found that N-Acetylcysteine could reduce obstructive sleep apnea, and other data showing that devices like these little magnets you put on your back that encourage you to sleep on your side that lead to positional changes can also reduce apneic events. Which by the way, if you look at another image I’ll include, you can clearly see from my WatchPAT One home sleep test, the vast majority of my apneic events were occurring when sleeping on my back. So, boy, it seems to me like there’s a whole lot that could be done.

DrMR:

Let’s continue a little bit further into what some of the evidence says that would suggest these simple interventions could be used first. Another study, “Cardiovascular Effect of Oral Appliance Therapy and Obstructive Sleep Apnea.” Essentially, what they found in this study was that oral appliances like a mandibular advancement device worked about as well as a C-PAP. So perhaps we could have someone start with myofunctional therapy, hierarchy step one. Well, it wouldn’t really be true step one; true step one would be sleep hygiene. But assuming people are doing the sleep hygiene stuff, the interventional step one beyond the basics could be myofunctional therapy.

DrMR:

And hopefully that suffices, but perhaps there is such an underdevelopment of the jaw that the airway just doesn’t have enough room. Like I talked about on the podcast with Hockel where you do that exercise where you stand up really straight. If you really stand up straight and you breathe, can you kind of feel an encroachment? And then if you jut your lower jaw forward, did it go away? You can hear it with me if I stand up totally straight, and that’s kind of the position that you’re in when you sleep. So this indicates a mandibular advancement device, which is a couple hundred dollars or so to have fitted and made for you, can improve the airway, improve the apnea as has been found in a comparative meta-analysis versus C-PAP.

DrMR:

So it seems to me that there is a better way to work through this where I could have been recommended any of these things first. I think which one we put first is debatable. Perhaps some nutritional interventions paired with myofunctional therapy, and then a reassessment of my symptoms and a repeat of the at-home, simple, non-invasive home sleep test, and then consider escalating to a mandibular advancement device and maybe a positional change support. And then perhaps more end phase or final phase could be some sort of corrective device, and then the last thing might be a referral for surgery, just to paint a loose hierarchy and then give you some hints in terms of how we’re starting to apply this at the clinic.

DrMR:

So I am still mid-stream. I’d say I’m actually early stream in this road because I’ve been figuring this out over the past few months. Also full disclosure, I’m not supremely motivated here because this is an optimization. So when push comes to shove, over the past few months as I’ve been working way more than I’m accustomed to service the growing needs of the clinic and ensure that we are delivering the highest quality of care which takes exquisite oversight, communication, training, feedback, systems development, et cetera, and these things have kind of fallen by the wayside. But it hasn’t thwarted me ordering these tests at the clinic, referring some patients for myofunctional therapy, and I’ll be curious to see at our follow-up with a reassessment of subjectives paired with some of these re-tests plus or minus Oura Ring tracking tracking when patients are willing to purchase an Oura Ring, I’ll be curious to report what I’m finding.

DrMR:

I hope one thing here is really shining through, which is there’s this kind of confection of various therapies in any given field, and there’s a tremendous amount of value in being able to organize these in a logical sequence of application. This way you prevent someone like me, if I had not been discerning here, I would probably at the transition point where I was removing an oral appliance that probably would’ve helped me in expanding my jaws essentially, or the oral airway or arch, but I’d now be transitioning into six months of braces. And this is very inconvenient for me for a number reasons. It’s also possible that I could have fully resolved the symptoms and achieved the same symptomatic gain if I had done a course of four to six weeks of myofunctional therapy.

DrMR:

So in any case, I wanted to share some of my personal experience and also as I’m familiarizing myself more with the body of evidence here in sleep medicine and starting to integrate this into the clinic, explain how I’m thinking about it, what I’m learning, and what I’m doing.

DrMR:

Coming back to something from a little bit earlier, another note that I wanted to make is this is something that I’m excited about, but I’m also trying to bridle myself and not fall into the trap of thinking that new is going to be vastly effective. But I am excited about the prospect this holds for individuals who have otherwise non-responsive fatigue, brain fog, and mood problems, because there’s a subset of these I see at the clinic. Now, with hypertension and heart disease, I’m also interested to see how this tracks, but it’s something that I’m less involved with at the clinic, at least right now.

DrMR:

For this cohort of people who still have this fatigue, cognitive dysfunction, brain fog, and problems with their mood, I’m very curious to see if maybe we don’t probe into mold when there’s only the mildest of evidence that mold is an issue because we have no other viable hypothesis. Perhaps now we say, “Hmm, there’s more evidence in this individual that there might be some sort of sleep-disordered breathing,” which is an umbrella term under which we can organize both obstructive sleep apnea and upper airway resistance syndrome.

DrMR:

Let’s say this person reports symptoms that have been nonresponsive to everything else, even though their gut symptoms have now improved, and some of their other symptoms have improved as they improve diet and their lifestyle. They had braces, they report a mild degree of snoring, they sometimes notice dry mouth or drool on their pillow. Maybe this is the missing key, not testing your adrenals and telling you how there’s this minimal imbalance in ratios of cortisol production, cortisol recycling, or you had one mycotoxin test that found one mycotoxin elevated even though there’s no other good historical or environmental support for that hypothesis.

DrMR:

So that’s where my excitement lies, but I as a clinician really have to do my due diligence now and look to see if there will be a noticeable, appreciable, symptomatic improvement when patients do this. That’s the other unknown, which is experientially, symptomatically, subjectively, when these patients see, as some of the studies have found, these reductions or eliminations of apneic events and improved sleep quality, does that correlate with improved well-being?

DrMR:

Now, from what I’ve gathered anecdotally, two for two. One, actually a family member was fitted for a mandibular advancement device, and it was a game changer for him. And one colleague went through myofunctional therapy, did a repeat test, and saw a complete elimination of his apneic events. It actually took several weeks for the symptomatic improvements to fully manifest. But so far, anecdotally, two for two. I’m assuming it’s going to be a pretty good response, but I’m going to be trying to poke holes in and tear down this hypothesis, because what I care most about is the end result for the individual. I am excited about the prospect of these hypotheses and these therapeutics, but again, I am more than willing to throw out even the most attractive hypothesis if it doesn’t seem to correlate with clinical improvement.

DrMR:

So, that is kind of the long of the long-short of my personal and also professional clinical foray into sleep medicine. This is something I’m very excited to be offering and exploring at the clinic responsibly, so that if there are those out there who aren’t so terribly impacted by and have a highly severe case of apnea, if there’s people who aren’t so obvious that they’ve been eluding detection, that we can help them. And again, responsibly offer them a hierarchy of intervention that will really have their emotional well-being, their financial well-being, and the minimal effective testing and minimal effective therapeutic intervention as one of our chief aims.

DrMR:

So those are my thoughts. If you’re in need of help with this, please reach out to the clinic. Again, I am excited to help people who may have evaded diagnosis elsewhere get the care that they need, because some of this care is actually fairly simple, like exercises for the mouth or maybe a mouth guard. That seems to be something that can help a lot of people. So if there is this non-responsive fatigue, brain fog, or mood issues and you’re not sure where it’s coming from, I invite you to pop over to the clinic and we can look into what might be driving some of that.

DrMR:

Okay. Well, if this was helpful, again, please leave us a review on iTunes and/or if you’re personally in need of help, please reach out to the clinic. We would be more than happy to help walk you through some of this. All right guys, thanks. Talk to you next time. Goodbye.

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