Posts by: Momentum

Autism and Headaches

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autism and headaches

 

The level of stress and/or anxiety that a child is experiencing depends on a variety of causalities including their diagnosis. Naturally, the more severe the autism is, the higher the level of daily stress will be. Headaches are one of the common symptoms of stress, and more people complain of headaches than any other medical ailment. The average age onset for headaches is between 9-12 years old.  A huge role for physicians now is to identify stress triggers and problem-solve a treatment plan utilizing coping mechanisms.  Because each child’s sensory processing abilities are different, there may never be a “standard” level of coping or known vulnerability to depression. More areas must be studied in terms of manifestations of stress and different triggers.  Chronic stress during childhood causes social skills to decline, and limits the ability to participate in academic opportunities and extracurricular activities. As doctors, it is our duty to restore our patients’ quality of life and with more research in this area of medicine, hopefully stress will be less of an obstacle for autistic people in the future.

 

Please click here to read the full article on stress, autism and headaches.

Eye Disorders in Adults

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How many of you have struggled with different eye disorders?  Did you ever think that they could be related to Obstructive Sleep Apnea (OSA)?  A multitude of symptoms are associated with OSA, as we have discussed in the past.  This month we will focus on the side effects that relate to your eyes.

There are many reasons for eye-related headache, and many of them can be directly or indirectly associated with the structures connected to the temporomandibular joint or as a result of its dysfunction.

The Sphenomandibularis is an important muscle that borders 1) the lateral and medial tendons of the temporalis, 2) the mandibular head of origin of the superior pharyngeal constrictor, and 3) the zygo mandibularis muscle—all of which have the potential to cause similar pain symptoms from within the mouth.  Dr. Janet Travell documented 50 years ago that trigger points in the Trapezius muscle may often refer pain above the eye on the ipsilateral side.  All of the structures mentioned above can, and often do, stimulate or refer headache pain near the orbit of the eye.

Facies temporalis ridge on sphenoid bone representing origin site for sphenomandibularis muscle:

eye disorders in adults

The Sphenomandibularis muscle was discovered at the University of Maryland by Dunn, Hack, Robbins and Koritzer in 1995 and reported in 1996 in the Journal of Craniomandibular Practice.  I originally read of this muscle prior to its publication in the Journal. It was mentioned in the Wall Street Journal.  Upon reading this I called Dr Gary Hack and discussed his research findings and that very day provided a Marcaine injection at the mandibular attachment of the Sphenomandibularis in a patient with retro-orbital pain and noted that within 20 minutes of the procedure… the retro-orbital pain had ameliorated.  This protocol has been successfully provided for the past 20 years in my practice and when initially provided in the 1990’s was denied by IME doctors who stated that I was making it up and documented that I should not be paid for injecting a non-existing muscle.

A few other common ophthalmic conditions associated with OSA include the following:

  1. Floppy Eyelid Syndrome (FES)
  2. Glaucoma
  3. Papilledema
  4. Keratoconus (KC)
  5. Retinal Vein Occlusion (RVO)
  6. Central Serous Chorioretinopathy (CSC)
  7. Nonarteritic Anterior Ischemic Optic Neuropathy (NAION)

Floppy Eyelid Syndrome

Floppy eyelid syndrome

Image Courtesy University of Iowa

Floppy eyelid syndrome (FES) is a condition where the upper eyelids essentially turn inside out.  This leaves the eye vulnerable to pain and/or discomfort, and also visual symptoms and/or disturbances.

Studies suggest that most patients with FES suffer from OSA, however, only between 2% – 5% of patients with OSA have FES as well.  FES in patients with OSA signifies a greater severity of the disease.  Another interesting fact is patients with FES often experience symptoms on the side on which they sleep.

Doctors who are treating patients with possible OSA may identify FES by asking about symptoms of pain in/around the eyes, visual disturbances, blurred vision, excessive watering, etc.  Patients with dry eyes sometimes experience excessive tearing, which is the body’s response to underlying dryness.  Doctors who already specialize in treating OSA typically know to ask about any eye-related symptoms.

Airway collapse in patients with OSA occurs due to connective tissue compromise in direct relation to neck thickness, and patients with FES display tissue redundancy and exhibit a connective tissue weakness as well.

Glaucoma

Glaucoma diagram

Image Courtesy Alaska Sleep Clinic

Believe it or not, Glaucoma is the 2nd leading cause of blindness worldwide.  There are several different types of Glaucoma including the following:

-Open Angle Glaucoma (OAG)

-Normal Tension Glaucoma (NTG)

-Angle-Closure Glaucoma (ACG)

Glaucoma is a chronic, progressive visual condition associated with high pressure and visual deficits.  While the exact cause is not clear, many theories propose nerve damage and vascular mechanisms.  Intraocular pressure (IOP) compresses the optic nerve, which causes the damage to the eye.

One of the biggest challenges for Ophthalmologists is to pinpoint Glaucoma in asymptomatic patients. Initially, the visual discrepancies may be hard (if not impossible) to identify.  Once the symptoms finally are detected, it may be too late.  Sometimes irreversible nerve damage has already occurred.

Because of this increased risk, patients who have been diagnosed with OSA can benefit from a referral to the eye doctor from their Sleep Medicine Physician.  Obviously, everyone should still maintain a regularly scheduled (yearly) eye exam even if you don’t have OSA.

Papilledema

Papilledema vs Normal eye

Papilledema is a bilateral swelling of the optic disc (the raised disc on the retina and point of entry for the optic nerve) caused by elevated intracranial pressure.  It is associated with increased blood flow and interrupted breathing as well.  If untreated, complete vision loss can occur.

Other symptoms associated with Papilledema include headaches, nausea and/or vomiting, vertigo, and tinnitus.

MRI or CT evaluation of the brain and/or spine is typically done to identify papilledema.

The Papilledema Grading System is as follows:

Stage 0 – Normal Optic Disc – blurred vision can occur

Stage 1 – Very Early Papilledema – disruption of the nerve fiber layers & subtle gray halo

Stage 2 – Early Papilledema – all borders are obscured; complete peripapillary halo

Stage 3 – Moderate Papilledema – increased diameter of optic nerve; obscured blood vessels

Stage 4 – Marked Papilledema – nerve head is completely elevated; peripapillary halo

Stage 5 – Severe Papilledema – dome-shaped protrusions; optic cup is destroyed

Keratoconus

Keratoconus vs Normal eye

Keratoconus (KC) is another eye disorder in which the cornea becomes thinned over time.  The cornea is the dome-shaped “window” at the front part of the eye.  This disorder makes the cornea bulge outward like a cone.  Usually both eyes are affected simultaneously.

This can result in double vision, blurred vision, astigmatism, nearsightedness, and photophobia (light sensitivity).  The cause of this is thought to be a combination of genetic, hormonal and environmental influences.

For most people, this will stabilize after a few years if treated accordingly.  Usually special contacts are prescribed.

Retinal Vein Occlusion 

OSA-related hypoxia (deficiency in oxygen reaching tissues) can be a major cause of RVO, or, retinal vein occlusion (blockage in artery of vein).  This means that the retina is not getting enough oxygen.  Just as arteries and veins carry blood to and from the heart, if a retinal vein is blocked, it cannot drain blood from the retina.  This leads to leaking fluids and bleeding.  RVO is the second most common cause of blindness from vascular disease in the retina.

The main symptoms of RVO include vision loss (central or peripheral) and/or blurred vision.  Patients with severe OSA are more at risk for developing RVO.

Retinal Vein Occlusion

 

There are 2 types of retinal vein occlusion (RVO):

-CRVO – central retinal vein occlusion – blockage of main retinal vein

-BRVO – branch retinal vein occlusion – blockage of smaller branch veins

In a study of 40 patients having been treated for RVO, 37% of these patients demonstrated sleep-disordered breathing as measured by nocturnal pulse oximetry.  In another series of patients with RVO, OSA prevalence was found to be 77% among patients selected for screening based on nighttime symptoms. (Ocular Manifestations of OSA – J Clin Sleep Med)

Central Serous Chorioretinopathy 

This eye disorder is referred to as CSC, and is a condition where fluids accumulate beneath the retina.  CSC causes a fluid-filled (serous) detachment, in addition to loss of vision.  Objects can appear distorted, blurry or dim, and depth perception is diminished.

Risk factors for developing CSC include high stress levels and increased levels of cortisol.  Patients with OSA have increased levels of epinephrine and norepinephrine, which are both also risk factors for CSC.

Central Serous Chorioretinopathy

Sometimes, CSC can show no signs or symptoms, it all depends on the location and amount of subretinal fluid.

Studies suggest that patients being treated for OSA can simultaneously accelerate the treatment time and recovery period for CSC.

Nonarteritic Anterior Ischemic Optic Neuropathy

Nonarteritic anterior ischemic optic neuropathy (NAION) is a sudden, painless, irreversible loss of vision.  A loss of blood flow to the optic nerve occurs, which the optic nerve is essentially the “lifeline” between the eye and the brain.

Patients who are on multiple medications for hypertension are at high risk for developing this disorder. Physicians caring for patients with OSA may clarify a history of NAION by asking about any instances of abrupt visual loss upon waking.  Most often this disorder occurs first thing in the morning upon the patient awakening from sleep.

It is hypothesized that OSA can possibly cause NAION as a result of increased blood pressure, hypoxemia or intracranial pressure, leading to nerve edema.

A meta-analysis found that patients with NAION had a five-fold increased odds of having OSA. (Ocular Manifestations of OSA – J Clin Sleep Med)

Eyes with red veins

Early diagnosis and management of OSA is critical in reducing or eliminating the risk of visual dysfunction.  Because OSA has so many ocular side effects, it is important that the right intake questions are asked during the consultation appointment.  Usually, if you don’t specifically ask your patients about their sleep history, they won’t bring it up on their own.  If you are concerned about eye pain or have patients with OSA related eye problems, I hope this information was helpful, posted as a SLEEPACHES from www.michiganheadandneck.com

References

Grover DP.  OSA and Ocular Disorders. Curr Opin Ophthalmol. 2010 Nov; 21(6):454-8. doi: 10.1097/ICU.0b013e32833f00dc

Knutson R, Skorin L Jr.  Ophthalmic Diseases in Patients with Obstructive Sleep Apnea. J Am Osteopath Assoc. 2016 Aug 1;116(8):522-9. doi: 10.7556/jaoa.2016.105

*Santos M, Hofmann RJ. Ocular Manifestations of Obstructive Sleep Apnea. J Clin Sleep Med. 2017 Nov 15; 13(11):1345-1348. doi: 10.5664/jcsm.6812

West SD, Turnbull C. Eye Disorders Associated with Obstructive Sleep Apnoea. Curr Opin Pulm Med. 2016 Nov;22(6):595-601. doi: 10.1097/MCP.0000000000000322

Kara N, Sayin N, Bayramoglu SE, Savas AU. Peripapillary retina nerve fiber layer thickness and macular ganglion cell layer thickness in patients with obstructive sleep apnea syndrome. Eye (Lond). 2018 Apr;32(4):701-706. doi: 10.1038/eye.2017.279. Epub 2017 Dec 22.

McNab AA. The Eye and Sleep Apnea. Sleep Med Rev. 2007; 11(4):269–276. [PubMed].

De Groot V. Eye diseases in patients with sleep apnea syndrome: a review. Bull Soc Belge Ophtalmol. 2009; (312):43-51.

Stuart A. Obstructive Sleep Apnea and the Eye: The Ophthalmologist’s Role. EyeNet Magazine – February 2013. https://www.aao.org/eyenet/article/obstructive-sleep-apnea-eye-ophthalmologist-s-role

Sassani JW. Association between Obstructive Sleep Apnea and Optic Neuropathy. Published in Eye Care – Journal Scan / Research · June 06, 2018. https://www.nature.com/articles/s41433-018-0088-1

Sun MH, Liao YJ, Lin CC, Wei JC. Association between Obstructive Sleep Apnea and Optic Neuropathy: A Taiwanese Population-Based Cohort Study. Eye (London, England) MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine. Eye (Lond) 2018 Apr 26; [EPub Ahead of Print].

Modern Medicine Network. How Sleep Apnea Affects the Eye – October 9, 2015. http://www.optometrytimes.com/modern-medicine-cases/how-sleep-apnea-affects-eye

Alaska Sleep Clinic – Sleep Education Center. Posted by Jennifer Hines on Feb 21, 2018 http://www.alaskasleep.com/blog/5-eye-issues-and-sleep-disorders-the-ocular-component-of-sleep-apnea

Science Daily – Mayo Clinic. Eye Conditions Linked With Obstructive Sleep Apnea. November 13, 2008. https://www.sciencedaily.com/releases/2008/11/081110154040.htm

American Optometric Association. Sleep Apnea’s Effect on the Eyes – Excerpted from page 53 of the July/August 2015 edition of AOA Focushttps://www.aoa.org/news/clinical-eye-care/sleep-apneas-effect-on-the-eyes

Sleep Deprivation vs Alcohol Effects

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Most patients today aren’t getting the recommended 7-9 hours of sleep per night.  Ultimately, the circadian process regulating the body’s internal processes and levels of alertness becomes affected. This leads to cognitive lapses, which make it difficult to process and react to decisions of daily life.  The brain is slowed down, and therefore it takes longer to register new information.  Sleep deprivation affects neurons in the temporal lobe, causing interferences with vision, perception and memory.  While neurons typically have a rapid response time in a well-rested patient, all brain cell activity becomes diminished if the brain is not properly rested.  This weakening in the brain’s network can resemble a person being under the influence of alcohol. Sleep deprivation vs alcohol effects are incredibly similar to one another.

 

Please click here to read the full article on the recent study.

Economic Cost of Sleep Deprivation

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Between 1975 and 2006, there was a 22% increase in people getting less than six hours of sleep per night, which ultimately impairs our decision-making abilities.  This could be due to multiple factors – long shift hours, commute times, job demands, etc.  Whatever the reason, insufficient sleep has been linked to several of the leading causes of death in the US, among them, cardiovascular disease, diabetes, hypertension and motor vehicle accidents.  Sleep deprived employees are getting sick and missing work, and those who are working have decreased productivity levels and are high risk for industrial accidents and medical errors.  Doctors and hospital interns are expected to work long shifts that allow for very little sleep, and require very intense decision-making skills.  The RAND (research and development) study estimates that lack of sleep is costing the U.S. economy approximately $411 billion per year.  Drowsy drivers alone account for 20% of motor vehicle accidents (according to the NHTSA that means 1 million crashes).  There have been numerous high-profile disasters that have been linked to sleep deprivation like the 1979 nuclear accident at Three Mile Island and the 1986 nuclear meltdown at Chernobyl, costing the US billions of dollars. As physicians it is our duty to impress onto our patients the importance and significance of good quality sleep.  We have to ability to save lives.

 

Please click here to read the online article on sleep as an economic burden.

TMJ Sleep Apnea Mouth Piece

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oral sleep apnea appliance

The answer is YES; you can have both TMD (temporomandibular joint disorder) and OSA (obstructive sleep apnea).  Sometimes it can be hard to know which symptoms belong to which disorder, as many are overlapping.  For example, some overlapping symptoms of TMD and OSA are as follows:

  • Headaches (especially upon wakening)
  • Jaw Pain
  • Facial Pain
  • Chronic Fatigue
  • Frequent Illness
  • Irritability
  • Difficulty Concentrating
  • Memory Problems
  • Depression

A study published in the Journal of Clinical Sleep Medicine stated, “PSG (overnight sleep test) recordings showed that nearly 36% of TMD patients meet diagnostic criteria for insomnia, and more than 28% meet criteria for obstructive sleep apnea.” (Dubrovsky, et al)

There are a multitude of reasons why you could be suffering from TMD, OSA or both.  Muscle strain, trauma, or pre-existing bite problems are a few examples of causes.  Now you are probably wondering which one you treat first.  You’ll be happy to know that you can actually treat both at the same time!

Believe it or not, wearing an appliance can in some cases also reduce the severity of your sleep apnea and TMJ symptoms.  Wearing a mandibular intraoral TMJ sleep apnea appliance moves your mandible (lower jaw) into a forward position, opening up the airway.  In mild Obstructive Sleep Apnea the repositioning of mandible to cranium may be enough to control, but the more severe the OSA, the less successful is an oral appliance for OSA since the mandible cannot be advanced to the point of creating pain or TMD.

If you have the proper amount of air flowing through your system, the chances of you suffering from a sleep breathing disorder are automatically reduced.  Depending on the severity of a person’s OSA, both a CPAP and TMJ sleep apnea appliance may be necessary for maximum benefit/relief.

During sleep, airway obstruction may occur anywhere between the nasopharynx and the larynx – the most common areas being behind the base of the tongue (retroglossal) and behind the soft palate (retropalatal).

nasopharynx and the larynx graphic

 

There have been several studies that indicate advancement of the mandible forward can open up the airway and reduce pharyngeal collapsibility.  Additionally, anterior movement of the tongue decreases the gravitational effect on the soft palate.

The mandible is limited in the amount of advancement necessary for OSA and the centralization of condyles within the glenoid fossae (the back of the jaw as it hinges in the TM joint) may not be sufficient to preventing airway collapse in the back of the throat, even if that is the correct position to control TMD.

Face with oral appliance

                   Jaw moving forward = Tongue moving forward = Opened airway

 In regards to TMD treatment, moving the lower jaw (mandible) forward with the use of an TMJ sleep apnea appliance takes pressure off of the jaw joints.  Space is created in the joint compartment/s for the displaced disc/s to return to their normal anatomical position.

The first goal is to relieve the muscle spasm and pain using the removable TMJ sleep apnea appliance, and hopefully restore the dislocated disc/s within the jaw joint/s to normal anatomical position.  Once the jaw joints are stabilized, your treatment advances into the second phase, which is to correct your bite.

As seen in the illustration below, the orthotic device will move the lower jaw forward, taking pressure off the jaw joint.

The educational model below is invented and patented by Dr. Richard Klein

tmj sleep apnea

With Oral Appliance air flows normally                             Without Oral Appliance air cannot flow into                                                                                                              lungs

Most TMD cases can be controlled with an orthotic and/or physical medicine technique.  Treatment with an intraoral TMJ sleep apnea appliance should always be tried first, before any surgical intervention.  Depending on the severity of the case, there is a possibility that the disc/s could go back into place.  A treatment time of anywhere from 1-2 years is recommended, prior to a consultation with a maxillofacial surgeon.

If the tissues of the jaw joint/s are severely damaged to such an extent that they do not respond to appliance therapy, or only partially respond, then surgery may be necessary to obtain the desired result.

For more information on TMD or OSA, please call our office at (586) 573-0438 to schedule a consult as soon as possible.  You can also visit us online at www.michiganheadandneck.com.

References

Hui DS. Craniofacial Profile Assessment in Patients with Obstructive Sleep Apnea. Sleep. 2009;32(1):11-12.

Smith MT, Wickwire EM, Grace EG, Edwards RR, Buenaver LF, Peterson S, Klick B, Haythornthwaite JA. Sleep Disorders and their Association with Laboratory Pain Sensitivity in Temporomandibular Joint Disorder. Sleep. 2009 Jun; 32(6):779-90.

Dubrovsky B, Raphael KG, Lavigne GJ, et al. Polysomnographic Investigation of Sleep and Respiratory Parameters in Women with Temporomandibular Pain Disorders. Journal of Clinical Sleep Medicine : JCSM : Official Publication of the American Academy of Sleep Medicine. 2014;10(2):195-201. doi:10.5664/jcsm.3452

Rener-Sitar K, John MT, Pusalavidyasagar SS, Bandyopadhyay D, Schiffman EL. Sleep Quality in Temporomandibular Disorder Cases. Sleep Medicine. 2016;25:105-112. doi:10.1016/j.sleep.2016.06.031

Epker J, Gatchel R J. Prediction of Treatment-seeking Behavior in Acute TMD Patients: Practical Application in Clinical Settings. J Orofac Pain. 2000 Fall;14(4):303-9.

Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: Recommendations of the International RDC/TMD Consortium Network and Orofacial Pain Special Interest Group. Journal Orofac Pain. 2014;28(1):6-27.

Wieckiewicz M, Boening K, Wiland P, Shiau Y, Paradowska-Stolarz A. Reported Concepts for the treatment modalities and pain management of temporomandibular disorders. J Headache Pain. 2015;16:106. Epub 2015 Dec 7. doi: 10.1186/s10194-015-0586-5

Guarda-Nardini L, Manfredini D, Mion M, Heir G, Marchese-Ragona R. Anatomically Based Outcome Predictors of Treatment for Obstructive Sleep Apnea with Intraoral Splint Devices: A Systematic Review of Cephalometric Studies. J Clin Sleep Med 2015;11(11):1327–1334. doi: 10.5664/jcsm.5198

Olaithe M, Bucks R. Executive Dysfunction in OSA Before and After Treatment: a meta-analysis. Sleep. 2013 Sep 1;36(9):1297-305. doi: 10.5665/sleep.2950

Gauer RL, Semidey MJ. Diagnosis and Treatment of Temporomandibular Disorders. Am Fam Physician. 2015 Mar 15;91(6):378-86.

Stansbury RC, Strollo PJ. Clinical Manifestations of Sleep Apnea. J Thorac Dis. 2015 Sep;7(9):E298-310. doi: 10.3978/j.issn.2072-1439.2015.09.13

Aarab G, Lobbezoo F, Wicks DJ, Hamburger HL, Naeije M. Short-term Effects of a Mandibular Advancement Device on Obstructive Sleep Apnoea: an open-label pilot trial. J Oral Rehabil. 2005 Aug;32(8):564-70.

Chantaracherd P, John MT, Hodges JS, Schiffman EL. Temporomandibular Joint Disorders’ Impact on Pain, Function, and Disability. J Dent Res. 2015 Mar;94(3 Suppl):79S-86S. Epub 2015 Jan 8.  doi: 10.1177/0022034514565793

Performance Suffers with Sleep Deprivation

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It’s true that when we don’t get enough sleep, our performance suffers the next day.  We feel groggy and unmotivated, and if repeated enough, we can even begin to feel depressed.  During the holidays especially, there is a lot of extra pressure on us to buy gifts for everyone, hit all the sales, visit family and friends, and attend (or host) various holiday parties.  It seems like there is never enough time.  I often hear friends say “If there were only a few more hours in the day…” We need to change our way of thinking and make sure to incorporate enough time for sleep so that our bodies can properly rest.  In a study done by Microsoft, cognitive performance was influenced by sleep duration, timing and circadian rhythms.  Findings of this study show that 2 consecutive nights with less than 6 hours of sleep can decrease performance for a period of up to 6 days.  The full study can be found here.  While we tend to “make up” for lost sleep with caffeine and naps, our bodies never regain that lost time that should be used for rejuvenation.

 

Please click here to read the online article on sleep deprivation and cognitive function.

How Do Sleep Disorders Affect Relationships?

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How many people out there can relate to the following scenario – you are woken up by your spouse in the middle of the night due to snoring. Chances are, this is either happening to you, or someone you know.  Unfortunately, the person doing the snoring isn’t always willing to get the help they need, and don’t think that snoring is a real problem that can affect their health (or marriage).  If these awakenings become chronic, then the person losing sleep will most likely be tired or fatigued, their mood affected, and also their work performance harmed.  It is only natural that they may blame their bed partner for this, and in response, that person will feel attacked emotionally. Lack of sleep affects relationships, and many people do not realize the extent of this issue.

lack of sleep affects relationships

Over time, sleep deprivation leads to:

  • Resentment – unable to get a good night’s sleep
  • Blame – the sleepless spouse blames things on the one getting the sleep
  • Mood Change – depression, anxiety, and unable to process emotions properly
  • Lack of Intimacy – couples stop sleeping together
  • Impaired Communication – sleeping separately creates distance

Aside from feeling lousy the next day, you may also be vulnerable to stress-related inflammation and chronic illnesses.  Inflammation is associated with diabetes, high blood pressure, cardiovascular disease and arthritis, among other things.  Additionally, not getting enough quality sleep leads couples to become hostile towards each other.  Because their brains have not rested, they are unable to resolve conflict and process emotions in a calm manner.  All rational thought goes out the window and arguments occur more frequently.

The CDC reports that 35% of Americans get less than 7 hours of sleep per night.  If both partners get less than 7 hours of sleep, there is an even higher chance that they will be argumentative with each other and use unhealthy conflict-resolution tactics.

More than a third of US adults don't get enough sleep chart

One person’s restlessness impacts the other person’s quality of sleep.  For example, women who live with a spouse who snores are 3 times more likely to suffer from insomnia than women who live with non-snorers.  Along with insomnia comes headaches, migraines, fatigue, daytime sleepiness, depression, TMD or grinding teeth.  Recent studies suggest that sleep problems (including OSA, SDB and insomnia) in one or both partners contribute to marital problems.

According to the 2005 National Sleep Foundation poll, one-quarter to one-third of married or cohabitating adults report that their intimate relationships are adversely affected by their own or their spouse’s excessive sleepiness or sleep problems.  This is why some married couples choose to start sleeping in separate bedrooms.  In fact, this arrangement seems to be accepted as the norm nowadays.

Two doors one with sign that reads Mr. and one with a sign that reads Mrs.

Marital problems and sleep problems seem to coincide, especially during significant life transitions (childbirth, new job, moving, or an illness).  In a healthy relationship, the partner serves as a positive influence and stress-buffer, allowing for encouragement and healthy sleep patterns.  By contrast, unhealthy relationships have a negative impact on sleep, causing emotional and psychological arousal, and poor health habits.

how do sleep disorders affect relationships

Additionally, spouses exert influence on their partner’s awareness of any sleep disorders, and adherence to a treatment plan.  Bed partners play a huge role in the diagnosis and treatment of OSA – the “disease of listeners”.  They must provide their input so that their spouse receives the best possible treatment for their condition.

Do you wake up feeling fully refreshed and full of energy with a good level of concentration?  If you don’t, you might have an undiagnosed sleep disorder that could be extremely dangerous.  At Michigan Head & Neck Institute, we offer treatment exclusively 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.  There are over 100 different types of oral appliances that are made for OSA, and Dr. Klein works with each patient to provide the best options for their specific treatment.  Please contact our office at (586) 573-0438 for more information, or visit our website at www.michiganheadandneck.com.

References

Beninati W, Harris CD, Herold DL, Shepard JW. The Effect of Snoring and Obstructive Sleep Apnea on the Sleep Quality of Bed Partners. Mayo Clinic Proceedings. 1999;74:955–958.

Kahn-Greene ET, Lipizzi EL, Conrad AK, Kamimori GH, Killgore WDS. Sleep Deprivation Adversely Affects Interpersonal Responses to Frustration. Personality and Individual Differences. 2006;41:1433–1443.

Snyder DK, Heyman RE, Haynes SN. Evidence-based Approaches to Assessing Couple Distress. Psychological Assessment. 2005;17(3):288–307.

Kiecolt-Glaser JK, Newton TL. Marriage and Health: His and Hers. Psychological Bulletin. 2001;127(4):472–503.

Wilson SJ, Jaremka LM, Fagundes CP, Andridge R, Peng J, Malarkey WB, Habash D, Belury MS, Kiecolt-Glaser JK. Shortened Sleep Fuels Inflammatory Responses to Marital Conflict: Emotion Regulation Matters. Psychoneuroendocrinology, May 2017;(79)74-83. doi: 10.1016/j.psyneuen.2017.02.015

Ashtyani H, Hutter DA. Collateral Damage: the effects of obstructive sleep apnea on bed partners. Chest. 2003;124(3):780–1.

Ulfberg J, Carter N, Talback M, Edling C. Adverse Health Effects Among Women Living with Heavy Snorers. Health Care for Women International. 2000;21:81–90.

Troxel WM, Robles TF, Hall M, Buysse DJ. Marital Quality and the Marital Bed: Examining the covariation between relationship quality and sleep. Sleep Medicine Reviews. 2007;11(5):389-404. doi:10.1016/j.smrv.2007.05.002.

Richter K, Adam S, Geiss L, Peter L, Niklewski G. Two in a Bed: The influence of couple sleeping and chronotypes on relationship and sleep. An overview. Chronobiology International. 2016;33(10):1464-1472. doi:10.1080/07420528.2016.1220388.

Ohio State University Wexner Medical Center. (2017, June 26). Lack of sleep fuels harmful inflammatory response to marital stress. ScienceDaily. Retrieved February 26, 2018 from www.sciencedaily.com/releases/2017/06/170626105142.htm.

Chloe Tejada. (2017, July 7). Lack of Sleep Can Contribute to the End of your Marriage. It’s Also Super Bad for your Health. Huffington Post. Retrieved February 26, 2018 from

http://www.huffingtonpost.ca/2017/07/07/lack-of-sleep-marriage_a_23020919/.

National Sleep Foundation (2005 poll). NSF Website.  Retrieved February 26, 2018 from https://sleepfoundation.org/sites/default/files/2005_summary_of_findings.pdf.

Benefits of Physical Activity and Exercise

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We all know that exercise is beneficial for us.  The issue for most of us is making time for exercise.  We are so busy all the time that it is way too easy to make excuses and skip going to the gym.  The best way to start incorporating exercise back into your life is to integrate it into your daily activities.  Park at the far end of the parking lot and walk to your destination, take the stairs instead of the elevator, or walk around your office during your lunch break.  Even simple things like housework can provide an exercise keep you healthy:

Vacuuming and scrubbing the floor are enough exercise to protect heart and extend life, study finds. The Daily Telegraph, September 21 2017

benefits of physical activity and exercise

exercising list

Cardiovascular disease (CVD) is the leading cause of death, globally.  Studies have shown that approximately 8% of mortalities and 4.6% of cardiovascular diseases (CVD) could be prevented if everyone would adhere to physical activity standards and/or recommendations (minimum of 150 minutes per week).

In 1995, the CDC (Centers for Disease Control and Prevention) and the ACSM (American College of Sports Medicine) published a preventive recommendation that “Every US adult should accumulate 30 minutes or more of moderate-intensity physical activity on most, preferably all, days of the week”.  Then in 2007, the ACSM and the AHA (American Heart Association) published detailed recommendations for different levels of activity, pertaining to various age groups.

The categories are broken down into the following, and keep in mind that combinations of these types can be performed to meet the requirements:

-Moderate intensity aerobic activity

-Vigorous intensity aerobic activity

-Muscle strengthening activity

exercising icons

Moderate intensity

It is recommended that adults need moderate intensity aerobic activity 5 days per week, for a minimum of 30 minutes per day. This type of exercise results in a noticeable increase in heart rate and breathing (i.e. a brisk walk). Pilates Instructor Training is one of the most efficient ways to get the heart pumping and keeping co-morbidities at bay.

 Vigorous intensity

It is recommended that adults need vigorous intensity aerobic activity 3 days per week, for a minimum of 20 minutes per day. This type of exercise results in a large increase in heart rate and breathing (i.e. kickboxing class).

Muscle strengthening

It is recommended that 8-10 different exercises be performed 2 or more days per week – preferably nonconsecutive days – using major muscle groups.  Adding resistance (weights) to your regimen will maximize strength development, and also increase balance and gait.

The above activities are recommended in addition to routine activities of daily living, like cooking, cleaning, and doing laundry.  Obviously, the more physical activity you get, the greater overall benefit you will experience.  Older adults especially should aim to exceed the minimum requirements.

Muscles will be stronger, coordination and balance improve, existing diseases/conditions will be more easily managed, future risk for additional chronic disease is reduced, chances of depression associated with the aging process are lessened and mortality rate decreases.

ACSM issued a separate recommendation for older adults (men and women age 65 and above).  Balance exercises are recommended for older adults (10 minutes, 2 days per week) to prevent falls, and injuries associated with chronic falls.  Especially for older adults with mobility issues, balance exercises can only improve their balance and coordination. Flexibility exercises are also recommended (10 minutes, 2 days per week) to maintain the flexibility necessary for necessary activities of daily life.

Man doing stretches illustration

To avoid a sedentary lifestyle, it is also recommended that an activity plan is put into place.  We all know that cognitive function and brain function declines with age.  Malfunctions of this type are associated with Alzheimer’s and Dementia, so the goal is to slow the progress of cognitive decline and improve the quality of life.

As you can see from this physiotherapy service in Ontario, participation in an exercise program can effectively improve cognitive function among aging patients.  Staying motivated and providing encouragement is the most important part.  This allows older adults to maintain their independence and avoid slipping into a depression. Continuity in a routine will only improve the physical health and sense of wellbeing.

At Michigan Head & Neck Institute, our focus is on restoring our patients’ quality of life. For more information on this topic or to find out more ways to incorporate exercise into your daily life, please contact our office at (586) 573-0438.

References

Franklin B, Whaley M, Howley E, Ballady G. ACSM’s Guidelines for Exercise Testing and Prescription:6th Edition, 2000;137–164.

Hu J-P, Guo Y-H, Wang F, Zhao X-P, Zhang Q-H, Song Q-H. Exercise improves cognitive function in aging patients. International Journal of Clinical and Experimental Medicine. 2014;7(10):3144-3149.

Lee I, Skerrett P. Physical activity and all-cause mortality: what is the dose-response relation? Med. Sci. Sports Exerc, 2001;33(6):S459–S471.

Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN, Franklin BA, Macera CA, Heath GW, Thompson PW, Bauman A. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Med. Sci. Sports Exerc, 2007; 39:1423–1434.

Pate R, Pratt M, Blair S, et al. Physical activity and public health: A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA, 1995;273:402–407.

Northey JM, Cherbuin N, Pumpa KL, et al. Exercise interventions for cognitive function in adults older than 50: a systematic review with meta-analysis. Br J Sports Med, 24 April 2017. doi:10.1136/bjsports-2016-096587

Dittus K, et al. Exercise interventions for individuals with advanced cancer: a systematic review. Preventative Medicine, November 2017;(104)124-132. doi:10.1016/j.ypmed.2017.07.015

Lear S, et al. The effect of physical activity on mortality and cardiovascular disease in 130,000 people from 17 high-income, middle-income, and low-income countries: the PURE study. The Lancet, December 2017;390(10113), 2643-2654.

Nelson ME, Rejeski WJ, Blair SN, Duncan PW, Judge JO, King AC, Castaneda-Sceppa C. Physical activity and public health in older adults; Recommendation from the American College of Sports Medicine and the American Heart Association. Circulation, 2007;116(9),1094-1105. doi:10.1161/CIRCULATIONAHA.107.185650

US Department of Health and Human Services. Healthy People 2010, 2nd edition: With Understanding and Improving Health Objectives for Improving Health, 2000; 22,22–39.

Household chores could save your life: The tiny amounts of physical activity from cleaning the floor and tidying up cut your risk of death by 28%, study finds. Mail Online, September 22 2017, accessed Feb 16 2018.

TMD and Aural Symptoms

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There are many theories surrounding the relationship between TMD and aural symptoms. Many of these theories are based off of the discovery by Costen in 1934, who initially associated TMD with aural dysfunction. A dislocated disc in the jaw joint increases pressure in the Eustachian tube, as well as the auriculotemporal nerve. The auriculotemporal nerve innervates the TMJ, giving stimulation, which then gives the sense of Otalgia. Additionally, a dislocated disc can lead to inflammation in the tensor palatini muscles, which can also cause Eustachian tube obstruction. This creates ear pain and fullness/stuffiness.  Another theory proposes that common innervation of the tensor veli palatini, tensor tympani, masseter, temporalis and pterygoid muscles is the underlying cause of the aural symptomatology in TMD patients. Studies have shown that the tensor tympani muscle is dysfunctional in TMD patients, making them subject to hearing loss. Severity is correlated with the degree of intraoral opening in addition to other symptoms. TMD patients have an impaired ROM, leading to poor Eustachian tube function, and impeding the performance of the tensor tympani. Tinnitus, Vertigo and Otalgia can all be a result of this malfunction.

 

Please click this link to read more about the relationship of TMD and aural symptoms.

Brainwaves During Sleep Stages

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brainwaves illustration

There have been multiple studies that focus on the correlation between sleep and memory.  We have been taught that poor sleep, especially among older adults, can lead to brain deterioration and extensive memory loss – even Dementia and Alzheimer’s.  This month’s topic will focus on brainwaves during sleep and how NREM sleep can support memory strengthening and consolidation.

Slow, continual brainwaves during sleep must sync up at certain times to essentially hit the “save” button in our brains and allow new memories to occur.  These oscillations occur hundreds of times per night during stage 2 NREM sleep.  Slow oscillations (SO’s) are the synchronized activity of large populations of neurons that consist of alternating (low frequency) active and silent periods.

brain waves during sleep stages

While young adults are typically able to process these brainwaves, the brainwaves in older adults don’t always make timely contact with spindles (quick, electrical bursts of neural oscillations).  Sleep spindles are produced by the TRN (thalamic reticular nucleus) and other thalamic nuclei for approximately .5 seconds at a time.  Only when the slow waves and spindles come together can the brain effectively accept new memories.

During slow wave sleep, hippocampal ripples are created.  This is when the hippocampus generates high-frequency oscillations while neurons replay preceding activity in a consolidated method.  Therefore, these ripples are responsible for reorganizing and strengthening information transfer and memory during resting periods.

Communication among these hippocampal ripples, SO’s and sleep spindles creates a hierarchy of information transfer necessary for memory retention (long-term memory).

medial frontal cortex

As the brain ages, it can’t always provide coordination and synchronicity between the SO’s and spindles.  This mistiming leads to memory loss, forgetfulness and impaired memory consolidation. The brain’s failure is typically due to degradation or atrophy of the medial frontal cortex, and deterioration within the frontal lobe disallows coordination between the slow waves and spindles.

The more severe the atrophy is, the more uncoordinated the brainwaves are.  The medial frontal cortex is responsible for generating restorative sleep, thus prefrontal deficits result in impaired NREM sleep (not present in younger adults).

Several studies have utilized a combination of memory assessment, MRI, PSG and EEG to monitor electrical brainwave activity.  EEG results have shown that spindles tend to peak early in the memory-consolidation cycle, and are therefore unable to sync up with the new SO’s.

New research suggests that a way to strengthen SO’s is to apply electrical brain stimulation to the frontal lobe.  Boosting the brainwaves and increasing SO “power” overnight can indirectly harmonize sleep spindle activity and would restore deep sleep in older adults, potentially improving and retaining their memory.

brainwaves during sleep

References

Abel T, Havekes R, Saletin JM, Walker MP. Sleep, plasticity and memory from molecules to whole-brain networks. Curr Biol. Sept 9, 2013; 23(17):R774-88.

Diekelmann S and Born J. The memory function of sleep. Nat. Rev. Neurosci. February 2010; 11(2): 114–126.

De Gennaro L and Ferrara M. Sleep spindles: an overview. Sleep Med. Rev. October 2003; 7, 423–440.

Frankland PW and Bontempi B. The organization of recent and remote memories. Nat. Rev. Neurosci. February 2005; 6, 119–130.

Rasch B and Born J. About sleep’s role in memory. Physiol. Rev. April 2013;93, 681–766.

Walker MP and Stickgold R. Sleep, memory, and plasticity. Annu. Rev. Psychol. January 2006;57, 139–166.

Clemens Z, Molle M, Eross L, Barsi P, Halasz P, and Born J. Temporal coupling of parahippocampal ripples, sleep spindles and slow oscillations in humans. Brain. November 2007;130(Pt 11):2868-78. Epub 2007 Jul 5.

Wei Y, Krishnan GP, Bazhenov M. Synaptic mechanisms of memory consolidation during sleep slow oscillations. J Neurosci. April 2016;36(15):4231-47.

Benchenane K, Tiesinga PH, Battaglia FP. Oscillations in the prefrontal cortex: a gateway to memory and attention. Curr Opin Neurobiol. June 2011;21(3)475-85. Epub 2011 Mar 21.

Buzsáki G. Hippocampal sharp wave-ripple: A cognitive biomarker for episodic memory and planning. Hippocampus. October 2015;25(10):1073-188.

Krishnan GP, Chauvette S, Shamie I, Soltani S, Timofeev I, Cash SS, Halgren E, Bazhenov M. Cellular and neurochemical basis of sleep stages in the thalamocortical network. Elife. 2016 Nov 16;5. pii: e18607. doi: 10.7554/eLife.18607.