Sleep Apnea Treatment Improves Golf Performance!

 

A new study suggests treating obstructive sleep apnea with continuous positive airway pressure, or CPAP therapy, improves golf performance in middle-aged men.

 

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Up to six months of CPAP treatment was associated with significant improvements in excessive daytime sleepiness.
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CPAP patients also experienced better quality of life and an 11% drop in their average handicap index.

Among the more skilled golfers with baseline handicaps of 12 or less, the average handicap dropped by 31%.

Patients attributed their enhanced performance to improved concentration, endurance and decision making.

Click here to take an on-line test to see if you might have a sleep disoder.

Click here to find out more about sleep disorders in general.

And find out more about the Comprehensive Sleep Medicine Program at Monmouth Neuroscience Institute.

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Narcolep…… ZZZZZZ

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Posted by Ayushi Desai, MSIV, Drexel University College of Medicine

Fatigue. I imagine it ranks highly among the most unifying experiences shared by Americans in this day and age. Amidst torturously busy schedules, sleep deprivation, taxes, and the unyielding restraints of a day comprised of only 24 hours, I can blame no one for being tired, just, ALL the time.

Sometimes I wonder whether those of us who are affected by this obnoxious, unremitting daily fatigue secretly have undiagnosed narcolepsy.

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Let’s be serious — how many of us can really sit through some performance in a dark theater without catching even a few Zs? And aren’t we all jealous of kindergarteners, whose workday includes a mandatory scheduled nap?

I’m embellishing, of course, but I may not be too far off. As we delve further into the study of sleep, we are starting to realize that narcolepsy is, indeed, hopelessly underdiagnosed.

Down to the basics, narcolepsy is a sleep disorder characterized by the early intrusion of REM in the sleep cycle, which eventually translates into excessive daytime fatigue and resultant episodes of irrepressible need to sleep.

How this happens is slightly complicated and represents an unfortunately vicious cycle:

In a nutshell, restful sleep occurs during stages 3 and 4 — at this time brain waves are slow, and we are allowed to recuperate in so-called “deep sleep.”  In contrast, brain waves seen on polysomnography during the REM stage are fast and essentially the same as those seen when someone is awake with their eyes closed… Which means that in REM, our brains act as if we are awake. It becomes easier, then, to imagine how (8 hours or not) a night spent predominantly in REM equates to extremely poor sleep quality. This poor sleep quality in a narcoleptic leads to the aforementioned characteristic excessive daytime fatigue, and suddenly, we have a person who is almost involuntarily taking REM naps and doing other sorts of REM things throughout the day, everyday.

These other REM things? During REM, we have “awake” brains, we have dreams, and our bodies lose all muscle tone (USUALLY rendering us completely unable to move). Those suffering from narcolepsy manifest the latter two during the day and undergo peculiar experiences: CataplexyHypnaGOgic Hallucinations (vivid dream-like hallucinations experienced while GOing to sleep), and the ever-terrifying Sleep Paralysis.

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Sleep Paralysis (yikes)

As we can imagine, these key sleep pathologies are likely a source of significant embarrassment and suboptimal quality of life in sufferers of narcolepsy.

So how do we treat it? The most important aspect is, of course, in diagnosing it! Which means recognizing when a patient might have it — a ballgame in which it seems we have been falling behind. Unless the disease process is frank and severe, it may be difficult for a narcoleptic patient to recognize the characteristic “buzzword” signs and symptoms (or even that there may actually be something underlying their round-the-clock tiredness). So perhaps it might be prudent to consider the diagnosis of narcolepsy in a person experiencing chronic daily fatigue, with the first step being simply to ask if our perpetually half-awake patient sometimes experiences symptoms that sound somewhat like cataplexy, hypnagogic hallucinations, or sleep paralysis. We can throw in an Epworth Sleepiness Scale to get a baseline of how terribly the tiredness affects activities of daily living, and after that, sleep studies are the way to go.

Besides the obvious, though, traditional treatments are aimed largely at helping to improve symptoms (as we’ve not yet struck the gold in finding a cure). CNS stimulants such as methylphenidate (Ritalin), amphetamine (Adderall), modafinil (Provigil), and armodafinil (Nuvigil) have achieved moderate success in eliminating the chronic fatigue. We’ve even used tricyclic antidepressants (clomipramine/imipramine) and other medications with anticholinergic side effects to alleviate cataplexy. However, I am most intrigued by the eventual advent of an orexin-receptor agonist. While we aren’t yet quite sure how exactly narcolepsy develops, it is widely believed that the neurotransmitter orexin (aka hypocretin) is deficient in narcoleptics. It is hypothesized that finding a way to upregulate the production of orexin in narcoleptic patients may lead to disease remission without all the nasty side effects of medications.

So… are most of us realistically secret narcolepsy victims? Probably not. But here’s a link to the Epworth Sleepiness Scale in case you want to assess how well you’ve fared in the fight against fatigue.

Based on my results, I’ve likely been asleep during this entire blogging experience.

Living The Dream? The Medical Mysteries of REM Sleep

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A dream is a succession of images, ideas, emotions, and sensations that occur involuntarily in the mind during REM sleep.

So during REM sleep our subconscious minds are supposed to be active, while we lie unaware with our bodies perfectly still. However, two unusual phenomena can occur during REM sleep:

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1. Lucid dreams

A lucid dream is when a person is aware they are dreaming, and may have some control over their own actions in the dream or even the characters and the environment of the dream.

This is different from simply having a passive memory of a dream, which can sometimes happen if we awake directly from REM sleep.

when a person recognizes he or she is dreaming while in a dreaming state and often manipulates events within the dream.”Read more at: http://phys.org/news202059647.html#jCp

Sound like Inception? It should, the screenplay was inspired by the phenomenon of lucid dreaming:

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Scenes from the Matrix have also been compared to the mind control techniques used by lucid dreamers:

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Stephen LaBerge is a psychophysiologist who did research on lucid dreaming at Stanford University in the 1970s.

He found that subjects who could control their dreams had more volitional (and not random) eye movements during REM sleep.

He now runs the Lucidity Institute, which aims to train people how to achieve lucid dreaming:

Proponents of lucid dreaming claim they can control their dreams to enjoy fantasies and over come nightmares.

This might have been a skill that would helped those ill fated victims of Freddy Kruger in Nightmare on Elm Street Part 3: Dream Warriors:

Click here to listen to a RadioLab podcast about Lucid Dreaming.

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2. REM Sleep Behavior Disorder

REM sleep behavior disorder (RBD) is in a sense the opposite of lucid dreaming. Affected patients lose the motor inhibition that is a typical feature of normal REM sleep, and regain the motor strength to “act out” their unconscious dreams. This is an uncommon disorder, and can be associated with underlying neurodegenerative disorders like Parkinson’s Disease.

Or, if you prefer the Disney interpretation of RBD:

RBD video clips courtesy of Matthew J. Davis.

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The medical mysteries of REM sleep:

So, during REM sleep our conscious minds and bodies are supposed to be switched off, while our subconscious brain performs a scandisk generating passive dreaming. If our conscious brain somehow switches on during this time we experience lucid dreaming. Of our bodies switch on, and we start unconsciously reacting to these dreams we have REM sleep behavior disorder. If both were to happen simultaneously, we’d be awake!

Restless Leg Syndrome and early death?

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A recent study in Neurology got a lot of press recently when it suggested that men with restless leg syndrome (RLS) are at a 40% higher risk of death from all causes than similar men  without the condition.  Dr. Xiang Gao, and his colleagues at Harvard, followed 18,000 men over 8 years and found evidence of increased mortality in men with RLS, even when controlling for other risk factors.

RLS typically causes discomfort in the legs and feet during the night.  This discomfort is often relieved by moving the legs, rubbing the feet, or walking around.  It often can impact sufferers’ ability to fall asleep and stay asleep.  In severe cases, it can affect the arms and can also occur during the day.

There has not been any convincing evidence that it is otherwise dangerous, however.  In fact, several previous studies looking at the condition did not show a link to early death.

Because RLS is shown to cause sleep fragmentation and insomnia, it could be argued that the increased mortality risk seen in this study is a result of generally poor sleep, and not RLS per se.  Therefore, these results should be interpreted with extreme caution.

This study, if nothing else, indicates the need for further research on this elusive disorder.

Why it happens and what it means are still generally unknown.

It can profoundly impact sleep quality and therefore quality of life.

There are some who do not believe RLS is a legitimate disorder. Those who live with the disorder would disagree.

RLS can be quite debilitating.  However, many treatment options exist for RLS and many of the symptoms can be improved.

If you think you may have RLS, seeing a neurologist or a sleep specialist is often the best step.

Neuromuscular respiratory failure

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Each lung is composed of >300 million tiny membrane bound sacs of air sacs (alveoli) which if spread out would cover a piece of ground roughly the size of a tennis court.  The purpose of this giant membrane is to exchange oxygen from the air for carbon dioxide from the blood stream.

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If the lungs become congested (or filled with fluid) from infection (pneumonia) or heart failure, it becomes harder to extract oxygen from the air:

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Treatment includes adding extra oxygen to the air to make this process more efficient.

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However, gas exchange across the alveoli can only occur if fresh air is brought into the lungs, and stale air is moved out, a process known as ventilation.  The diaphragm and muscles of the chest wall act like a giant bellows to make this happen:

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These muscles can become weak in nerve or muscle diseases such as Guillain-Barré syndrome, polio, amyotrophic lateral sclerosis (ALS), Duchenne Muscular Dystrophy and myasthenia gravis.

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These patients are evaluated by pulmonary function testing, which will usually show a low forced vital capacity, low cough flow, and in advanced cases, elevated end-tidal carbon dioxide level.

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Patients with this type of ventilatory failure do not need extra oxygen, their lungs can extract oxygen from air normally, they need mechanical assistance moving air across their lungs:

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Early neuromuscular respiratory muscle weakness causes nocturnal hypoventilation.  This is because the weakened diaphragm is even more inefficient when laying supine in bed with the stomach contents pressing up on it.

Nocturnal hypoventilation presents with daytime sleepiness, early morning headaches, fatigue, and impaired cognition.

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Click here to take an on-line test, and find out how sleepy you are during the day.  If you score 10 or higher, you might have a problem!

Nocturnal hypoventilation is best treated using a non-invasive respirator at night, either with a face or nose mask:

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Other patients use a negative pressure respirator vest, or cuirass, which requires the patient to wear an upper body shell  attached to a pump which actively controls the respiratory cycle:

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Neuromuscular respiratory failure also leads to an ineffective cough, which in turn predisposes patients to aspiration, retention of secretions, or pneumonia.  Affected patients need to learn to use the cough assist machine when they get a minor respiratory tract infection to help them clear their secretions and prevent pneumonia:

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More severe neuromuscular ventilatory failure leads to rapid shallow breathing, accessory respiratory muscle use, thoracoabdominal paradox (inward motion of the abdomen during inspiration), and ultimately high blood levels of carbon dioxide.

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Thoracoabdominal paradox – Normal (upper) abdomen moves outward with inspiration (diaphragm contraction). NM weakness (lower) abdomen moves in when patient inspires using accessory muscles.

In these cases, respiratory support is needed day and night.

Some patients can continue to use non invasive respiratory support, sleeping with a face or nose mask, and using a mouth piece intermittently during the day:

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Others cannot tolerate noninvasive ventilation or have anatomic abnormalities that preclude fitting of noninvasive ventilators.  Some disease, such as advanced ALS and Duchenne muscular dystrophy, affect the upper airway muscles as well as the diaphragm, impairing swallowing and compromising airway protection from aspiration.  These patients can chose to be managed with invasive respiratory support using a tracheotomy and conventional ventilator.

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Click here and and here to find out more about the management of neuromuscular respiratory failure.