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Fatigue And Multiple Sclerosis, Along With UARS

There are probably a thousand different reasons for someone to be tired. Many people with neurologic conditions tend to report being overly tired. Not too surprisingly, fatigue was found to be reported as the first symptom with multiple sclerosis (MS), long before the first signs of MS show up. We know that MS is an autoimmune condition, where various parts of the brain are affected, leading to a number of different symptoms. But one thing I’ve noticed is that almost every person with MS also seems to have the upper airway anatomy of someone with upper airway resistance syndrome (UARS).

Women are more likely to suffer from both UARS and MS. They typically are thin, and won’t snore. Both groups in general tend to avoid back sleeping, and have narrow jaws with high arched hard palate. Women with (UARS) are more likely to have autoimmune conditions. Many will also have cold hands and feet, and have at least one parent that snores heavily. Whenever I look at their airways with an endoscope, the space just behind the tongue is usually only a few millimeters, especially when lying flat on their back.

My suspicions must be proven with prospective studies, but the similarities are pretty striking. Since we know that sleep-breathing problems can cause major structural and biochemical damage to the brain, I wouldn’t be surprised if someone proves that these two conditions are strongly connected. Just to be clear, I’m not talking about obstructive sleep apnea. Rather, people with UARS are unable to attain deep quality sleep due to frequent microobstructions and arousals, without frank apneas or hypopneas.

If anyone reading this has MS, do you have cold hands or feet? Can you sleep on your back at all? Do your parents snore heavily?

How Peripheral Neuropathy Can Be Caused By Sleep Apnea

Here’s a study that shows how obstructive sleep apnea can cause peripheral neuropathy. The authors studied nerve function in the arms of patients with sleep apnea and found abnormal conduction measures which improved after CPAP treatment. They also mentioned that chronic intermittent hypoxia is a major aggravator of nerve conduction abnormalities. This could explain various numbness and tingling complaints that are rampant in the sleep-breathing disorders population. It could also explain Raynaud’s phenomenon, where your hands, feet, or other distal extremities can feel cold. Anecdotally, I’ve had a handful of patients tell me that their cold or numb hands and feet got better after treating obstructive sleep apnea.

Since it’s well known that diabetics have similar issues with peripheral neuropathy, and obstructive sleep apnea is a major risk factor for insulin resistance and elevated sugar levels, could it be possible that an underlying sleep-breathing process could also aggravate neuropathies in diabetics? Additionally, if peripheral nerves are affected, why can’t it affect your brain’s nerves as well?

How many of you with sleep apnea have peripheral neuropathy? If so, did it ever go away after sleep apnea treatment?

Miscarriages & Heart Disease, From Sleep Apnea?

If you’ve been following my blog, I alluded to how infertility and miscarriages can be aggravated by obstructive sleep apnea or upper airway resistance syndrome. A recent study showed that having 3 miscarriages increases your chances of having heart disease by over 5 times normal.

If you think about the physiology, it makes sense: Breathing pauses during sleep, whether or not it’s an apnea, can cause a physiologic state of stress. In other words, you’ll have too much adrenaline, which you need to fight or run from danger. It’s also common knowledge that if you’re in a fight or flight situation, the last thing you need to do is to reproduce. Physiologically, stress has a way of diminishing or reducing nervous innervation and blood flow to your reproductive organs and digestive system (as well as your skin, hands and feet).

Since people with obstructive sleep apnea or upper airway resistance syndrome have narrowed upper airways, it’s not surprising that women who have frequent miscarriages can develop heart disease later on in life. Every time I see a patient that has a history of miscarriages or infertility, I see the same upper airway anatomy: small jaws and narrowed space behind the tongue. Most will not be able to sleep on their backs, have either cold hands or feet, or suffer from various gastrointestinal problems.

How many women with sleep apnea who are reading this blog had a miscarriage or infertility issues?

Breast Implants, Autoimmune Disease, & Sleep Position

I wrote about breast implants and sleep problems a few weeks before, but I wanted to address an additional aspect of breast implants that deserves even more attention. In past years, there was a push to move towards saline-based over silicone-based implants, since there were reports autoimmune diseases with silicone implants. Studies performed at that time were inconclusive, but for the most part, most surgeons now recommend saline implants, although patients still seem to prefer silicone.

If you’re a stomach sleeper, and you elect to undergo breast implants, there’s a good chance that you’ll have to sleep on your back after your procedure. If you have smaller jaws than normal (almost everyone these days), then your sleep efficiency will go downhill the longer you stay on your back. Poor sleep quality not only increases your adrenaline levels and stress hormones, it also will over-activate your immune system. Once this happens, your immune system won’t be able to differentiate your own body’s tissues vs. foreign bodies or invaders. As a result, various areas of your body can be damaged, including your joints, kidneys, skin, your bowels, and even your brain.

This may be a big leap, but could it be possible that poor sleep quality due to poor breathing makes you sleep on your side or stomach to begin with, but when made even worse by forcing you to sleep on your back, is it enough to cause your body’s immune system to go onto overdrive and attack it’s own tissues?

What do you think about my theory? Please enter opinions in the comments box below.

UARS: The Hidden Sleep Condition

You’ve gained some weight over the years and you’re just not sleeping well. Your husband says you’ve begun snoring. You know that your father has obstructive sleep apnea and is doing well with CPAP. You mention this to your doctor and she orders a sleep study. The sleep study comes back completely normal. Now what?

The Real Reason for Your Chronic Fatigue

Before you begin searching for other reasons for your chronic fatigue, don’t rule out a sleep-breathing problem too quickly, even if you don’t have obstructive sleep apnea. In fact, a sleep-breathing problem can cause if not aggravate conditions such as hypothyroidism, chronic fatigue syndrome, depression, insomnia, and even irritable bowel syndrome.

Sleep doctors have defined obstructive sleep apnea as having at least 5 apneas or hypopneas every hour on average. An apnea means you stop breathing completely for 10 seconds or longer. Hypopneas are similar 10 second or longer pauses but with restricted airflow. But what what happens if you stop breathing 25 times every hour but each episode lasts only a few seconds?

In the early 1990s, Dr. Christian Guilleminault of Stanford University looked at young, thin men and women who were tired all the time, no matter how long they slept. These people were found not to have obstructive sleep apnea after undergoing formal sleep studies. However when they placed thin pressure catheters in their chest and throat, they found the they had frequent episodes of partial obstruction which led to subtle, but significant limitation of nasal airflow, along with very negative vacuum pressures in the throat. Most of these minor episodes were not apneas or hypopneas, but still lead to an arousal—from deep to light sleep. What was happening was multiple partial obstructions and arousals that were not severe enough to be called apneas or hypopneas, but enough to wreak havoc on deep sleep quality.

It’s been shown that even very subtle levels of restricted breathing can lead to deep brain stimulation and arousals that prevents your ability to stay in deep sleep. These reflex signals to the brain can be so weak that it doesn’t even reach the outer layers of the brain where standard scalp electrodes can pick up these disturbances.

Blame It On Your Parents (And Your Jaws)

The fundamental problem in UARS is due to smaller upper airway anatomy, caused by having smaller jaws and dental crowding. The smaller the space behind the tongue, the more likely you’ll obstruct while breathing when on your back (due to gravity, the tongue can fall back), and when in deeper levels of sleep (when your muscles relax). This is why most people with UARS can’t, or prefer not to sleep on their backs. The problem is that you can still have breathing problems despite sleeping on your side or stomach, just not as bad as being on your back.

Lack of sleep and especially lack of deep sleep has been found to cause a whole host of physiologic changes. In general this happens due to chronic overstimulation of your sympathetic nervous system. This is the fight-or-flight half of your involuntary nervous system. Since your body thinks it’s under attack, it heightens your nervous system, making you en garde, edgy, hypersensitive or overreact to normal situations. This also leads to diversion of blood flow, energy and resources away from less essential body parts and organs, such as your digestive system, reproductive organs, skin, hands, feet, and other “end organs.”

Due to this “hypersensitivity,” the nose and sinuses can be overly sensitive, reacting to stimulants such as weather changes, chemicals, scents, and even allergies. Chronic stress that results from sleep deprivation also can heighten your immune system.

Is It Hormones or Your Breathing?

A number of other studies point out that UARS patients are more prone to have cold hands or feet, hypothyroidism, irritable bowel syndrome, depression, chronic fatigue, and various other “somatic” syndromes. I see this all the time in my practice. In fact, a recent study even showed that chronic long-term sleep deprivation caused significant lowering of the TSH and T4 levels, with women being much more susceptible to this effect compared with men.

With time, as people age, and especially as they gain weight, most people will progress into true obstructive sleep apnea. You’ll find that most younger, thinner people with UARS will have one or two parents with significant obstructive sleep apnea.

Now that you’re convinced that you may have this condition, what can you do about it? For the most part, it’s treated just like obstructive sleep apnea. You should start with all the conservative options first, such as weight loss (if you’re overweight), diet, exercise, improving your nasal breathing, and not eating late. If these options don’t work, then all the formal options for treating obstructive sleep apnea are possible including CPAP, oral appliances, and even surgery.

Unfortunately, if you don’t officially have a sleep apnea diagnosis based on a sleep study, then insurances generally won’t cover any of the treatments. The irony is that our health care system won’t treat or prevent diseases in the early stages, and would rather wait until it’s much more severe before covering for medical services.

If you think you may have upper airway resistance syndrome, you may be disappointed to find that the medical community in general will not be responsive to your queries. With a few exceptions, many sleep doctors are not convinced that UARS is even a legitimate condition, and would rather lump it into the spectrum of snoring to obstructive sleep apnea. Time after time, whenever I see patients who are told they don’t have obstructive sleep apnea and I treat the upper airway narrowing and inflammation, patients almost always feel better. Your best option is to continue to educate yourself and be persistent. Your first priority should be to be able to breathe better so that you can sleep better.

Raynaud’s and Sleep Apnea

There was an interesting Q&A article on Raynaud's in the New York Times. This is what I responded with:

 

Notice how almost everyone one of you with Raynaud's can't (or prefer not to) sleep on your back. The reason for this is that due to smaller jaw structures and narrowing of your upper airway, you literally can't breathe properly when you sleep. When normally on your back, your tongue fall back partially due to gravity. But if you have a smaller mouth, the tongue takes up relatively more space and falls back a bit more completely. This becomes a problem when when you're in deep sleep, since all your muscles (including your throat muscles) begin to relax. In this situation, you'll stop breathing and wake up to turn over to your side or stomach. This is something that began when you were a child, and most people compensate by normally sleeping only on their sides or stomach. 

Problems occur when you're suddenly forced to sleep on your back, such as from an injury or after undergoing an operation

Despite being able to compensate by avoiding the back position, it's usually not good enough. By definition, you won't be able to achieve deep, efficient sleep, which causes a low-grade physiologic stress response. This activates the sympathetic (fight or flight) nervous system which tends to constrict blood flow and nervous innervation to low-priority organs and body parts, such as your hands, feet, skin, digestive and reproductive organs. This is also why Raynaud's is also associated with autoimmune conditions.

Chronic low-grade physiologic stress over-activates your immune system, resulting in your body attacking its' own tissues. Not only is your immune system over-reactive, but your nervous system is also overly activated, leading you to be en garde, edgy, and hypersensitive in general. These symptoms are seen often in people with upper airway resistance syndrome.

Inefficient sleep leads to chronic fatigue issues. But most people compensate by staying active during the day, or participating regularly in intense physical activity.

Typically, most people with Raynaud's improve as they get older. But as you gain weight, many of you will begin to develop obstructive sleep apnea. Notice how one or both of your parents may snore heavily and have have cardiovascular disease. If you don't gain weight, then your Raynaud's may last longer. 

This is also why anything that helps to calm your nervous system (meditation, yoga, acupuncture, biofeedback, etc.) can help your symptoms. It also explains why when the breathing problem is taken care of definitively, Raynaud's symptoms can improve.

A Link Between Endometriosis and Sleep Apnea?

Endometriosis is a common condition that's estimated to occur in about 5 to 10% of all women. It's characterized by pelvic and abdominal pain, along with infertility, and not too surprisingly, hypothyroidism, chronic fatigue syndrome, fibromyalgia, autoimmune conditions, allergies and asthma. 

 

Does this list sound familiar? Right — upper airway resistance syndrome (UARS). Doing some more research, I came across a health-related website (CureTogether.com, an open source health research site) that anonymously aggregates patients' symptoms and and other conditions to give you statistical data. Here are the top symptoms and the top associated conditions for endometriosis.

 

If you look down the list of associated conditions, many are also seen in patients with UARS. Since endometriosis is more commonly seen in women during the reproductive years, you may not see obstructive sleep apnea as often. I'm willing to bet that many of these women will go on to develop obstructive sleep apnea, especially when much older and if they gain weight after menopause. If you look at their parents, one or both parents will snore heavily. In addition, Raynaud's (cold hands for feet) is also a common feature in both endometriosis and UARS.

 

Knowing that upper airway resistance syndrome can cause profound changes in women's physiology, all these findings are not surprising.

 

Do you or anyone you know have endometriosis? If so, how many of the above symptoms or conditions do you see? Please enter your observations in the comments box below.

Multiple Sclerosis And Obstructive Sleep Apnea: Is There A Link?

I participate on a medical forum called Medhelp.org, where I’m the sleep-breathing expert. I answer people’s questions on various topics related to sleep and breathing. Somehow, I stumbled onto the multiple sclerosis (MS) community and was surprised to see that many people have severe fatigue issues, cold hands and various sleep issues. Their symptoms sounded surprisingly like upper airway resistance syndrome, which I’ve described before. So I decided to take a poll: I asked three questions: 1. How many MS patients have cold hands or feet? 2. How many MS patients have one or both parents that snore heavily, and if so, what kind of medical problems do they have? And 3. What’s your favorite sleep position (back, side, or stomach)?

The answers to this informal and unscientific poll was surprisingly lopsided. Out of 36 responses, 31 people said that they had either cold hands or feet. Many had to wear socks before going to bed, but some had to kick them off later. Fifteen out of sixteen stated that a parent (usually their father) snored heavily, and many also had major heart disease. Lastly, 26/30 responded that they prefer to sleep on their sides or stomachs. Many complained of intense fatigue.

This is the exact pattern that I see in patients with upper airway resistance syndrome, where they also have cold hands or feet, has a parent that snores, and wears mittens and socks to bed. Typically one or both parents snore, and have various degrees of heart disease. As many people with UARS slowly gain weight over the years, their cold hands may get better, but they’ll slowly develop into obstructive sleep apnea.

It’s a given that both UARS and MS will have a physiologic stress response, for different reasons. This can lead to various autonomic nervous system dysfunctions, such as cold hands or feet. It’s also known that chronic low-grade physiologic stress can stimulate the immune as well as the nervous system, heightening both these systems, leading to various pain issues or autoimmune conditions. I can’t say if there’s a definite cause and effect relationship between UARS and MS, but one thing for sure is that both have problems staying in deep sleep. The only definitive way to find out is is examine these MS patients with a flexible fiberoptic camera to examine the airway.

Am I going too far with my sleep-breathing hypothesis, or could I be onto something big?

 

 

 

An ENT with ESP?

Three times this week, people have asked me if I have ESP. If they are in front of me, their eyes open wide and with a scary look and they asked me, “Do you have ESP?” I assured them that I do not. In all three situations, I had just asked these people questions from a list of common symptoms that people with airway resistance syndrome have. Some of these symptoms include: sleeping on their side or stomachs, never waking up refreshed, cold hands or feet, occasional dizziness or lightheadedness, frequent headaches, and a parent that snores heavily. More often than not, the parent that snores also has a complication of untreated obstructive sleep apnea such as hypertension or heart disease.

These list of symptoms are so consistent that I stopped asking if either of their parents snore, or which position they sleep in—their back, side or stomach. Instead, I now ask, which parent snores, or do you sleep on your side or stomach? Sure enough, about 99 % of the time, they’ll answer one or the other. 

Do you have any of the symptoms that I described above?

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