Posts by: Momentum

The Link Between Sleep & Pain

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poor sleep

We’ve all heard the quote “Which came first, the chicken or the egg?”, and this week’s blog will focus on a similar scenario – the link between sleep and pain.  Pain makes it hard to fall/stay asleep, and alternatively, lack of sleep creates a gateway for pain. Each person has to determine what is the chicken and what is the egg and treat which came first.  Is the pain a manifestation of OSA, or is the pain the cause of poor sleep?

Man waking up with back pain


The National Sleep Foundation’s 2015 Sleep in America Poll found that pain is a key factor affecting how adults sleep. When asked how often they get a good night’s sleep, less than half those with acute pain and only 39 percent with chronic pain said “always or often,” and one quarter of chronic pain sufferers reported poor or very poor sleep quality. What’s even more interesting? People with pain averaged 42 minutes of weekly “sleep debt” (the gap between the sleep they need and the sleep they get). The greater the level of pain, the greater the sleep debt.

Cloud with Zs illustration

Yes, pain is a clear obstacle for quality sleep.  Poor sleep can make your tolerance to pain deteriorate. However, you can be proactive and make changes in your routine to improve your sleep. I want to share some tips with you, and hopefully you can put them to use, or help a loved one suffering from chronic pain.

  1. Make sleep a priority – People who are motivated to get enough sleep actually sleep more, an average of 36 minutes per night (That’s 4.2 hours of extra sleep each week).
  1. Create a bedtime routine – People with chronic pain who have a bedtime routine sleep more. Set a start time for your routine (at least 30 minutes before bed) when you put away work, shut off electronics, and put stressful matters on hold.
  1. Maintain the condition of your bedroom – If you’re in pain, that means you’re more sensitive to your surrounding environment. Use dark curtains or black-out shades, keep the temperature cool, keep electronics out of the bedroom and make sure you have a suitable mattress.
  1. Ease your mind – Pain is associated with stress. Chronic pain sufferers usually think they have less “control” over their sleep and worry about lack of sleep affecting their health. Breathing exercises, meditation or other relaxation techniques can be very helpful in these situations.

sleep and pain

The relationship between pain and sleep quality is well documented in the literature.  Sleep complaints are present in up to 88% of chronic pain disorders and at least 50% of patients presented with insomnia also suffer chronic pain.  The longer that you have pain and therefore disturbed sleep, the greater the chance for a permanently disrupted sleep-wake cycle.  Sleep impairment can more accurately predict future episodes of chronic pain, as compared to pain predicting sleep deficits.

If you are suffering from chronic pain and think you may also have an underlying sleep disorder, please contact our office today at (586) 573-0438.  Please click here to take the Sleep Disorder Test


Hemmeter U, Kocher R, Ladewig D, Hatzinger M, Seifritz E, Lauer CJ, Holsboer-Trachsler E. Sleep Disorders in Chronic Pain and Generalized Tendomyopathy. Schweiz Med Wochenschr. 1995 Dec 9; 125 (49): 2391-7.

Roehrs T, Roth T. Sleep and Pain: interaction of two vital functions. Neurol. 2005 Mar; 25(1): 106-16.

National Sleep Foundation Website

Body In Mind (BiM Org) Website

Mann, D. Pain: The Sleep Thief. February 2010 WebMD Archives.


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national sleep awareness week 2017

We will be celebrating National Sleep Awareness Week 2017 at Michigan Head and Neck from March 5-11. 

In honor of National Sleep Awareness Week, I am launching my blog entitled Sleep Aches.  The purpose of this blog is to inform doctors, in any field, of the signs and symptoms of sleep disorders, and the pain associated with TMJ disorders. I chose Sleep Aches to encompass all associated symptoms of craniomandibular pain (ie. ear, eye, neck, face, head and jaw problems), and Sleep Breathing Disorders.

In 1985, I founded the Michigan Head & Neck Institute to provide a place for people to get specific treatment who suffer from Sleep and TMJ disorders. My focus is on my patients and restoring their quality of life, and I feel the need to pass along as much information as I can to other doctors. I want to create awareness and an environment that allows different doctors to work together instead of in competition, and I want to provide new treatment options that may not have been available for patients in the past.

The Michigan State University College of Osteopathic Medicine is launching a new interprofessional education initiative that will explore collaborative and community outreach partnerships between Michigan physicians and dentists. I have been an adjunct clinical professor at MSU Osteopathic Medical School for 5 years and am past Chair of the Oakland County Dental Association’s Education Committee. I have been providing noon lectures for residents at St. John Oakland and St. John Macomb Hospitals for 16 years. My passion is to help you and your patients live longer with a more satisfying and healthier life by understanding the ramifications of sleep and pain disorders.

Approximately 1 in 25 adults aged 18 years or older report that they have fallen asleep while driving at least once in the previous 30 days.  Being sleep deprived is potentially more dangerous than drunk driving. The National Highway Traffic Safety Administration estimates that 100,000 police-reported accidents are related to driver fatigue annually. Drowsy driving is one of the “four D’s” of impaired driving (drowsy, drunk, drugged and distracted).  Drowsiness causes drivers to have a slower reaction time, pay less attention to the road conditions, and make poor driving decisions.  If you happen to get drowsy while driving, the best thing you can do is pull over to a safe place and take a 15-20 minute nap, or grab a cup of coffee.  Simply turning up the music and rolling down the windows won’t do. To learn more about drowsy driving, please click here to read the full article.

The Link Between Insomnia and Cardiovascular Disease

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What is the most common sleep complaint?  If you guessed insomnia, then you are correct.  Insomnia is the most common sleep complaint in the general population, with a prevalence of approximately 10%. It is described by difficulty falling and staying asleep, accompanied by some kind of daytime fatigue and/or impairment.

difficulty falling and staying asleep

The disturbance may consist of one or more of three features: (1) difficulty in initiating sleep; (2) difficulty in maintaining sleep; or (3) waking up too early. A fourth characteristic, nonrestorative or poor-quality sleep, has frequently been included in the definition.


  1. Do you have Difficulty Falling Asleep? (DFA)
  2. Do you have Sleep Continuity Disturbances? (SCD)
  3. Do you wake up feeling exhausted and Non-Restored? (NRS)


*A combination of 3 sleep complaints (DFA, SCD, NRS) predicted a slightly increased risk of cardiovascular disease but not hypertension, and a complaint of either DFA or SCD predicted increased hypertensive risk

There are 2 types of insomnia – primary and secondary insomnia (secondary being the most common type).  If you have secondary insomnia, it means that your insomnia is a side effect of an underlying problem (or multiple problems).  These could include things like OSA or other sleep disorders, TMD pain and related symptoms, anxiety, depression, medications, substances like caffeine or alcohol, restless leg syndrome, etc. Other common comorbidities would include things like ADHD and substance abuse.

Because insomnia sufferers cannot achieve good quality sleep, their blood pressure and nervous system levels remain abnormally higher than someone without insomnia. Insomnia can elevate the resting heart rate, which leads to hypertension and cardiovascular disease (CVD).  Congestive heart failure insomnia is prevalent in these cases. Alternatively, patients with CVD are more likely to suffer from insomnia. This can be due to rapid eye movement during sleep, sleep-disordered breathing, angina pain, OSA, or paroxysmal nocturnal dyspnea (PND).

insomnia and cardiovascular disease

Many patients with insomnia can be predisposed to CVD, especially people who sleep less than 6 hours per night. Other predictors include being of the female sex, older age and/or psychiatric conditions. It has been proven that more women than men die of CVD, and it is the leading cause of death throughout the Western World.

congestive heart failure insomnia

By the year 2020, it is estimated that nearly 40% of all deaths worldwide will be due to CVD (more than twice the percentage of deaths from cancer).


Spiegelhalder K, Scholtes C, Riemann D. (2010). The Association Between Insomnia and Cardiovascular Diseases. Nature and Science of Sleep. 2: 71–78.

Phillips B, Mannino DM. Do Insomnia Complaints Cause Hypertension or Cardiovascular Disease? J Clin Sleep Med 2007. 35: 489–494.

Willerson JT, Ridker PM. Inflammation as a Cardiovascular Risk Factor. Circulation. 2004 Jun 1;109 (21 Suppl 1):II2-10.

ASA (American Sleep Association) website

Phillips B1, Mannino DM. Does Insomnia Kill? Sleep. 2005 Aug 1;28 (8):965-71.

Sleep Review Magazine

Insomnia Patients Have Higher Risk of Dying from Cardiovascular Disease

January 25, 2017

Hearing Loss and TMD

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I first learned about how TMD causes ear problems in the 1970’s.  An 8-year-old girl came in to my office (as I was one of the best ear wax removal doctors), and after reading the forms that her parents filled out, I learned that she had lost her hearing.  Her ENT (Ear, Nose & Throat Specialist) had no idea why, as her structural anatomy was perfect.  Her previous dentist had extracted an upper baby tooth, and because that upper tooth had nothing to bite against, it grew downward and was longer than all of her other teeth. This caused an uneven bite (malocclusion), so I evened out the bite. I was just practicing dentistry, I was not thinking about her hearing loss.  About a month later, her mom came in with a cake and said her daughter’s hearing came back. I said, “I have no idea why, but thanks for the cake.”

temporomandibular jointI thought, “I’m going to find out why.”  So I went to the hospital library and found an ENT textbook, which of course is obsolete by the time it’s published. It said “The TMJ and ear maculas (patches of sensory cells) comes from a tiny piece of cartilage, and as a child or adult, they are both innervated (supplying an organ with nerves) by the same nerve pathway, and therefore they confuse each others symptoms.”  At the same time, I saw Bob Seger 5 nights in a row at a local concert venue in Michigan and I had muffled hearing. That was well known back then – loud noises can impaired hearing. The tensor veli palatini (a broad, thin, ribbon-like muscle in the head that tenses the soft palate) muscle pulls on the eardrum to protect it from all the noises. That’s what happened with that little girl – she had a TMJ problem. I thought, “Can TMJ cause ear problems?”

Who has hearing loss? Chart

One of the most frustrating effects of a TMJ disorder is hearing loss. While there are many causes, most people have no idea that TMJ disorder is one of them. Consequently, this problem often goes unresolved.  People who suffer from TMD may struggle for months or even years with clogged ears, tinnitus, earaches, and vertigo. Among different TMJ connections, TMJ and tinnitus can be extremely common. However these people continue to suffer with no answers. They may see a number of specialists including an ENT who tells them that their ear looks healthy, and they may blame it on allergies.  Alternatively, they are diagnosed them with Meniere’s disease or prescribed hearing aides.  Or, they simply go on living with it lacking an explanation.

Whispering into someone's ear

There are different types of hearing loss including conductive, sensorineural and mixed.

Conductive – caused by any condition or disease that impedes the conveyance of sound in its mechanical form through the middle ear cavity to the inner ear.  This results in reduction of intensity (loudness), so the energy reaching the inner ear is lower or less intense than originally intended.

Sensorineural – caused by inner ear or auditory nerve dysfunction. This may result from an inability of the hair cells to stimulate the nerves of hearing or a metabolic problem in the fluids of the inner ear. It can also result from damage to the inner ear organs.

Mixed – a combination of the above 2 types, where in addition to some irreversible hearing loss caused by an inner ear or auditory nerve disorder, there is also a dysfunction of the middle ear mechanism that makes the hearing worse than the sensorineural loss alone.

Location alone is one reason that jaw joint irritation transfers easily to the ear.  The presence of structures that connect the middle ear with the temporomandibular joint and the common innervation of the masticatory muscles tell us why 85% of TMD patients report aural symptoms.

The TMJ is adjacent to the ear, so swelling and inflammation often has a direct effect on the ear/s. Inflammation can cause blocked Eustachian tubes, and if the fluid in these tubes cannot drain properly, hearing is almost always affected (stuffiness, clogging, pain and/or hearing loss).


tmj and tinnitus

The following is an example of the sequence of events in the body:


  1. Nerves send a message to the brain that there is TMJ pain
  2. The pain message crosses through the inner ear canal
  3. The brain receives the pain message from the ear and TMJ
  4. The ear reacts by contracting craniofacial muscles (ie: medial pterygoid)
  5. Bones become misaligned due to frequent contractions
  6. The tensor palatini muscle (mentioned above) pulls on the eardrum and leads to Eustachian tube malfunction

So can TMJ cause hearing loss? Absolutely. If you are suffering from ear pain, stuffiness, hearing loss or vertigo, and you think it may be related to your jaw dysfunction, please call our office.  Dr. Klein is someone who understands the relationships of these diseases and disorders, including TMJ and hearing loss, and he is here to help. His years of practice will allow him to find the best course of TMJ hearing loss treatment for each patient.  To schedule your consultation, please call us at (586) 573-0438.


Axelsson R, Tullberg M, Ernberg M, Hedenberg-Magnusson B.  Symptoms and signs of temporomandibular disorders in patients with sudden sensorineural hearing loss.  Swed Dent J. 2009;33(3):115-23.

Kempf HG, Roller R, Mühlbradt L.  Correlation between inner ear disorders and temporomandibular joint diseases.  HNO. 1993 Jan;41(1):7-10.

Ramírez LM, Ballesteros LE, Sandoval GP.  Otological symptoms among patients with temporomandibular joint disorders.  Rev Med Chil. 2007 Dec;135(12):1582-90.

Ciancaglini R, Loreti P, Radaelli G.  Ear, nose, and throat symptoms in patients with TMD: the association of symptoms according to severity of arthropathy.  J Orofac Pain. 1994 Summer;8(3):293-7.

Kaygusuz I, Karlidağ T, Keleş E, Yalçin S, Yildiz M, Alpay HC.  Ear symptoms accompanying temporomandibular joint diseases.  Turk Jour of ENT. 2006;16(5):205-8.

Are Women Getting More Sleep Than Men?

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When was the last time that you had a “good night’s sleep”? The average American adult requires between 7 – 9 hours of sleep per day, but it is rare that you will actually talk to someone who is getting that much. The causes of sleep loss fall under two major categories: lifestyle and occupation. Are you working long hours or overtime? Do you have jet lag from travel? Do you have a sleep disorder? All of these factors can influence your sleep schedule.

The National Health Interview Survey (NHIS) run by the Centers for Disease Control and Prevention (CDC) included the following question in the 1977, 1985, 1990 and 2004 cycles: “On average how many hours of sleep do you get a night (24-hour period)?”

Over the last 20 years, the percentage of men and women who sleep less than 6 hours per night has increased significantly. More than 35 years ago, adults reported sleeping 7.7 hours per night. The increase in sleep loss is driven largely by societal changes, including greater reliance on longer work hours and easier access to the Internet and television.
symptoms of obstructive sleep apnea

The more of your brain that you use during the day, the more of it that needs to recover and, consequently, the more sleep you need. As we know, women tend to multi-task and always try to do 10 things at once. Because of that, their sleep need is greater. Similarly, a man with a complex job involving a lot of decision-making may also need more sleep than the average male (although probably still not as much as a woman).

On average, women sleep about 20 minutes more per night than men. Over the course of a year, that equates to women sleeping an additional 5 full days.
There are also differences in how we sleep as we age. Teenagers need between 8 – 10 hours for optimal functionality (National Sleep Foundation). Typically, we get the least amount of sleep when we are middle-aged, when we are focused on our careers, traveling and caring for our families. As we age and start heading towards retirement, the gap between women and men gradually lessens and quantity of sleep increases. The question becomes: do women need more sleep than men?

Sleep by age and gender in the US chart


In the United States, teens get the most sleep on average, although far less than the NSF recommends. In eastern countries like Japan and China, this trend is reversed.

In addition to societal reasons that women tend to sleep more than men, there are biological reasons as well. Some research has explored the possibility that women need more sleep to recuperate before/after childbirth. Women expend more mental energy than men. Core body temperatures are different between women and men. Melatonin rhythms are different. Nighttime alertness is also higher among women.

Sleep disorders affect men and women differently, both in prevalence and in presentation of symptoms. There are a countless number of symptoms of obstructive sleep apnea. Women have a 40-percent higher risk than men for insomnia, whereas men are twice as likely to develop Obstructive Sleep Apnea. When a person sleeps less than 7 hours per night, there is a dose-response relationship between sleep loss and obesity: the shorter the sleep, the greater the obesity, as typically measured by body mass index (BMI). According to the CDC, the average 30 – 39 year old male has a BMI of 29, just one point below the medical definition of obese.

Women seem to be more affected by sleep deprivation than men. Women have a higher incidence of depression, and increased hostility/anger with lack of sleep.

are women getting more sleep than men
Even though OSA is more prevalent in men than women, many women still suffer from OSA. If you think you may be suffering from a sleep disorder such as Obstructive Sleep Apnea (OSA), please contact Dr. Klein’s office to schedule a consultation. At Michigan Head & Neck Institute, we exclusively offer treatment for Obstructive Sleep Apnea that consists of creating a custom-fit oral appliance (mouthpiece) which is comfortable and can be adjusted to meet the requirements of each patient. Visit our webpage here.



Colten HR, Altevogt BM. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington (DC): National Academies Press (US); 2006.

Jawbone Magazine – 10/21/15
Who Gets More Sleep: Men or Women?
By Jason Donahue & Brian Wilt

New York Magazine – 9/13/16
Going to Bed Earlier Is the Key to Toppling the Patriarchy
By Susan Rinkunas

Extent and Health Consequences of Chronic Sleep Loss and Sleep Disorders.

National Sleep Foundation Website

Diane B. Boivin, Ari Shechter, Philippe Boudreau, Esmot Ara Begum, Ng Mien Kwong, Ng Ying-Kin. Diurnal and Circadian Variation of Sleep and Alertness in Men vs. Naturally Cycling Women. PNAS 2016 113 (39) 10980-10985.

Center for Disease Control Website

Sleep Apnea and Type 2 Diabetes

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Have you just been diagnosed with Type II Diabetes?  And if so, would you ever think it could be related to your Obstructive Sleep Apnea (OSA)?  According to recent studies, the majority of people with Type II Diabetes also have Sleep Apnea.  Out of those suffering from Diabetes, many have undiagnosed OSA, which leads to even more health complications. The sleep apnea and diabetes connection is very real.

According to the CDC (Center for Disease Control), Diabetes affects 25.6 million adults today, with an estimated 1.9 million new diagnoses per year.

The 2 different types of Diabetes are as follows:

Type I – the result of an immune system malfunction wherein the body destroys cells that produce insulin; diagnosed at a young age

Type II – when your body is not able to use insulin the right way; typically diagnosed in adulthood, although with increases in childhood obesity, Type II is becoming more prevalent at a younger age

Two main characteristics of OSA, oxygen deprivation and sleep fragmentation, can affect the metabolism in negative ways.  Reduced sleep can cause changes in the way your body processes glucose, increasing your risk of developing Type II Diabetes.  Diabetes increases the risk of neuropathy in the nervous system, which may lead to dysfunction of upper airway muscles and increased risk of OSA.

Side effects of OSA like chronic fatigue and depression lead to a more sedentary lifestyle.  This can result in obesity, limited physical activity, excess dietary intake (more unhealthy foods and sugars/carbs), and poor habits and decisions.

sleep apnea and diabetes connection


A vicious cycle is created because your blood sugar levels can affect your sleep, and in turn, sleep can affect your blood sugar levels. As the amount of sleep decreases, blood sugar increases, escalating the issue.


According to the CDC, 35% of U.S. adults aged 20 years or older may have Prediabetes.  Prediabetes is a condition in which blood sugar is high, but not high enough to be labeled as Type II Diabetes. The CDC estimates that approximately 70% of Prediabetic individuals eventually develop Type II Diabetes.

Weight loss is typically the first thing that is recommended, however there have been studies showing that OSA can be associated with insulin resistance and glucose intolerance independent of obesity.  Unfortunately, OSA remains unrecognized a lot of the time, so the patient is not aware of treatment options or how to better their situation. Again, this just becomes a cycle that leaves the patient unable to care for themself.

sleep deprivation and diabetes


Interactions between OSA, Diabetes and Obesity are very complex and the public needs to have a better understanding of the relationship among them.  The PCP in many instances overlooks the sleep apnea and diabetes connection, which continues to be unrecognized due to comorbidities that go along with diabetic symptoms.  More emphasis needs to be placed on overall patient health, lifestyle changes, adequate sleep and healthy diets.  All of these disorders are interrelated and if everyone increases their awareness, maybe we will start seeing a decline in these types of health issues.

Dr. Klein is someone who understands the relationships of these diseases and disorders, namely Obstructive Sleep Apnea. He is well versed in the connection between sleep deprivation and diabetes. Effective treatment of OSA may prevent the development of Type II Diabetes, or at least reduce its severity.



Pamidi, S., & Tasali, E. (2012). Obstructive Sleep Apnea and Type 2 Diabetes: Is There a Link? Frontiers in Neurology, 3, 126.

Kono M., Tatsumi K., Saibara T., Nakamura A., Tanabe N., Takiguchi Y., Kuriyama T. (2007). Obstructive Sleep Apnea syndrome is associated with some components of metabolic syndrome. Chest 131, 1387–1392.


Van Cauter E, Mokhlesi B, Tasali E. (2008) Obstructive Sleep Apnea and Type 2 Diabetes: Interacting Epidemics. Chest 133(2): 496-506.

doi: 10.1378/chest.07-0828

Sanders, Mark et al. Sleep disordered breathing may not be an independent risk factor for diabetes, but diabetes may contribute to the occurrence of periodic breathing in sleep.

Sleep Medicine. Volume 4, Issue 4, 349 – 350.

Centers for Disease Control website

American Diabetes Association website


My TMJ is a Pain in the Neck

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Do you ever wonder where your neck pain is coming from?  Have you seen multiple doctors and they can’t give you a straight answer?  Can TMJ cause neck pain? Yes it can, and it may be that the underlying cause of the pain is in fact a TMJ (temporomandibular joint) disorder, which is usually overlooked. When your jaw bone becomes dislocated, the surrounding muscles go into spasm.  This includes your neck muscles.  Symptoms can include not just neck pain, but stiffness, wry neck/torticollis, numbness in the neck, inability to turn the head left or right, joint clicking sounds during neck movement, arthritis in the neck, etc.

can tmj cause neck pain

TMJ and neck pain may be due to the degeneration of muscles, ligaments and bone, or through congenital abnormalities in the joint. Disorders that result in hypermobility may also lead to patients experiencing multiple jaw dislocations and, over time, repeated damage to the bones and ligaments. If left untreated, TMD may also result in degeneration of the jaw, jaw dislocation and neck pain.

The muscles controlling the movement of the jaw (masseter, temporalis, medial & lateral pterygoids) are also a possible cause of jaw and TMJ neck pain.  Severe cramping in the jaw muscles can pull the TMJ out of position, and weakened muscles can cause the joint to move.

In addition to the bones and ligaments that make up the TMJ, there is also a blood supply from one of the most major arteries of the head (temporal artery). The nerves here are responsible for providing signals for movement in the TMJ.  The severe jaw and neck pain can result from damage to facial nerves.

Posture is another huge influence on the head and neck.  Certain postural changes and imbalances can have adverse effects.  One factor that has become all too common is the fact that most people’s jobs today require hours upon hours of computer work.  This requires that the arms and head be positioned more anterior to the rest of the body for extended periods of time.  Over time, this causes the cervical muscles to contract, which leads to chronic achiness and eventual chronic TMJ pain.

Click on the following link to read about the relationship between computer use and TMJ disorders


Examples of Good vs. Bad Posture:

Good Posture Bad Posture
Head erect, chin in Head forward or backward, or tilted
Chest up, but not exaggerated Chest down, shoulders turned in/down
Upper back slightly backward Upper back forward and rounded
Lower back slightly forward Lower back arched
Neutral position of hips/pelvis Hips/pelvis backward or forward
Knees relaxed (easy) Knees forward or backward or bent


Another cause of neck pain would be a motor vehicle accident (whiplash), or other type of traumatic TMJ injury (sports injury, punch in the face, etc).  Pain and stiffness may be present hours or days after an injury.  Symptoms immediately following an accident include muscle strain, loss of range of motion and pain. The nature of the pain varies, and can worsen with fatigue.


chronic tmj pain

For patients who have suffered a serious accident like this, chances are they have dislocated their jaw (bilaterally or unilaterally).  In addition to physical therapy, treatment with an intraoral orthotic will most likely benefit the patient.  This orthotic addresses the jaw dislocation and aims to conservatively treat the patient.

If you have any questions about your neck pain and think it may be related to your jaw, please contact Dr. Klein and schedule your consultation today (586) 573 – 0438.


Wiesel, S., Boden, S., Borenstein, D., Feffer, M. Neck Pain: 2nd Edition, 1992.

Scherping, S., Boden, S., Borenstein, D., Wiesel, S. Neck Pain: 3rd Edition, 2000.

Fernandez CE, Amiri A, Jaime J, Delaney P. The relationship of whiplash injury and temporomandibular disorders: a narrative literature review. Journal of Chiropractic Medicine. 2009;8(4):171-186.

Silveira A, Gadotti IC, Armijo-Olivo S, Biasotto-Gonzalez DA, Magee D. Jaw Dysfunction Is Associated with Neck Disability and Muscle Tenderness in Subjects with and without Chronic Temporomandibular Disorders. BioMed Research International. 2015;2015:512792.

Warfel, John. The Head, Neck & Trunk: 5th Edition, 1985.


CPAP Compliance Requirements

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We all know someone who started using a CPAP machine, and then within a month or two, it ended up in a box in the closet. CPAP (Continuous Positive Airway Pressure) has long been the “Gold Standard” for the treatment of Obstructive Sleep Apnea (OSA) if used properly.  The drawback is patient compliance. The term “CPAP intolerant” probably comes to mind.  Despite great strides including different types of masks, enhanced portability and a quieter pump, adherence rates remain between 30% – 60%.

The CPAP machine is not the most convenient device for travel, nor is it appealing to your significant other or bed partner.  If you live alone, or your partner is not involved in your OSA treatment, CPAP use is significantly less than if there is support present. Some people have claustrophobia issues with the mask, some say it is inconvenient to tote around and some cannot even afford the basic cost of the CPAP/maintenance.  Whatever the reason may be, the recommended 7 hours of CPAP use per night remains uncommon for users.

cpap compliance requirements


According to several studies over the years, the number of people prescribed a CPAP who either stop using it altogether or don’t use it enough is sizeable, quite possibly the majority.  For example, if the CPAP is prescribed to someone with mild OSA who exhibits minimal symptoms, they probably won’t feel obligated to use it.  Additionally, most people aren’t getting 7 hours of sleep per night, especially during the work week, so they may only use it on the weekends.

Factors that influence CPAP adherence:

  1. Disease & Patient Characteristics                                                                                                                           a. Subjective sleepiness                                                                                                                                           b. Airway structure & nasal anatomy
  1. Treatment Titration Procedures                                                                                                                              a. Auto-titrating PAP vs. CPAP
  1. Psychological & Social Factors                                                                                                                                a. Depression and/or anxiety                                                                                                                                b. Patient perception of symptoms                                                                                                                      c. Claustrophobia
  1. Technological Device Factors & Side Effects                                                                                                        a. Nasal masks vs. Full face masks                                                                                                                      b. Cheap humidifier vs. top rated dehumidifier

There are various age groups that the CPAP would be prescribed for.  Even though the standard treatment for OSA in children is a tonsillectomy/adenoidectomy, CPAP is prescribed for those who don’t respond to the surgery or those whom the surgery is not recommended.  Compliance at this stage in life is high, because it is the parent forcing the child to use it.  Teenagers are less compliant and have different sleep patterns.  They may choose to not wear their CPAP for social reasons. The social awareness of OSA and CPAP continues to grow however, probably due to the relationship between childhood obesity and OSA.

For adults, adherence tends to be higher when they see an improvement in symptoms. In addition to support that they get from home, if their daytime sleepiness is lower and sleep disturbances are reduced, there is a good chance they are going to stick with the treatment. The caveat here is patients suffering from insomnia.  These adults tend to be more aware of the CPAP discomfort since they spend a large portion of their night restless and awake.  Also, if the adult patients have several other chronic health conditions, it will be harder for them to adhere to CPAP therapy.

No matter what age group it involves, CPAP compliance is highest when:

-the patient is educated about OSA diagnosis and treatment

-realistic goals and expectations for treatment are set

-initial assistance in the set up/use of CPAP

-available resources for troubleshooting/problem-solving

-clinical follow-up is set during the early stages of use

-a support person is included/involved in the entire process

To read more about the American Academy of Sleep Medicine’s clinical guidelines for the management of CPAP-treated OSA, please click on the following link:

If you are currently unhappy with your CPAP device, or know of someone who is, please contact Dr. Klein for information on CPAP alternatives.  Here at the Michigan Head & Neck Institute, we specialize in counseling patients about their OSA and offering various treatment modalities.  For more information, please call (586) 573-0438.

At Michigan Head & Neck Institute, we exclusively offer treatment for Obstructive Sleep Apnea that consists of creating a custom-fit oral appliance (mouthpiece) which is comfortable and can be adjusted to meet the CPAP compliance requirements of each patient. Each patient that chooses an oral appliance (OA) as their treatment will receive follow up sleep studies (either at-home or a in a sleep lab) to ensure the OA is positioned accordingly.

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