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Sleep_dr gold

The "old school" definition of fibromyalgia (FM) used to be a sleep disorder that produced muscle pain. It was a textbook phenomenon identified by Harvey Moldofsky, M.D., of
the nose, travels down the wind-pipe the size of the airway opening (includ- Toronto, Canada, of awake-like brain (trachea) and into the lungs where ing swelling from infections or waves (alpha) interspersed throughout oxygen is exchanged for carbon allergens), could potentially lead to sleep and could be documented by a dioxide (the by-product of respira- sleep study using an electroencephalo- tion), which is then exhaled. The As you examine Diagrams A and gram (EEG). This alpha-EEG was process is simple: the lungs expand to B, keep in mind the list below of noticed in other medical conditions, draw in air and they contract to expel structural defects that may interfere so it carried little weight as a diagnos- it. Along the way, however, a number with breathing, especially during sleep tic tool. In fact, for the past ten years of structural and physiological defects when the head is in the reclined the sleep disorder concept of FM, as may place a damper on this simple, position (see Diagram C).
well as chronic fatigue syndrome rhythmic process. Also, some people 9 Small nostrils and/or wide (devi- (CFS), has been shelved. Today, the are less fortunate than others, possess- focus is primarily on the symptom of ing several of these glitches and 9 Excessive cartilage in the nose causing a greater resistance to airflow.
9 Large, swollen turbinates (often Sophisticated tools are being used As a result, the breathing "system" for due to allergens or infections) to study FM pain and its many symp- each person is uniquely shaped by 9 Upward arched hard palate toms that are somehow linked to the genetics (e.g., structure) and the 9 Long, dangling soft palate (uvula) plethora of scientific findings associ- environment (e.g., allergens).
9 Small nasopharnyx or oropharnyx ated with the syndrome. Research is The best way to point out the 9 Large tongue in comparison to further complicated by the fact that common problems that may interfere chin size (e.g., recessed chin) individuals with FM/CFS are a with breathing is through the use of 9 Narrow upper maxillary bone diverse group of patients.
illustrations. In Diagram A, a cross- (smaller than normal distance But, what if FM/CFS was not so sectional drawing of the nose, mouth between back molars) complicated? What if the unifying and throat highlights the path that air 9 Tonsils and/or adenoids present element among patients relates to must follow from the nose to the (especially if swollen due to structural abnormalities in the air- ways—from the tip of the nose to the bronchial tubes entering the lungs? Diagram A
Sounds too good to be true, doesn't it? More studies are needed, but in the meantime, Fibromyalgia Network will let you decide whether researchers have stumbled upon the solution to the FM equation as we bring you back to the classroom to learn the basics of sleep, and the most crucial element of life itself: the ability to breathe.
‘Refresher Course' in
structuresmay impede air flow.
Obviously, Breathing occurs so automatically, it's easy to overlook. Air from the Fibromyalgia Network • (800) 853-2929 • www.fmnetnews.com

significant portion of the night with years have documented that snoring is 9 Protruding discs; soft tissue injury their blood oxygen concentration well not a prerequisite for Upper Airway
below optimal levels. Lario suggested Resistance Syndrome (UARS).
9 Enlarged thyroid gland (e.g., that alterations in breathing during Graves' disease withgoiters and sleep reduced muscle tissue oxygen- UARS School of
Hashimoto's may increase scar ation. This in turn produced morning pain and other FM/CFS symptoms.
Three years later, Margherita
If you take the structures in the In addition to the above, the Sergi, M.D., of Italy published a
nose and throat (Diagrams A and B), masseter muscle that stretches from report on a possible link between and place them in a supine sleeping the upper check bone to the lower jaw nighttime breathing and FM.2 An
position (Diagram C), it is clear to see bone is often tight or knotted in erratic breathing pattern was found in how the airways can become ob- people with FM. Taut masseter 15 out of 17 female FM patients, structed—partially (UARS) or fully muscles will draw the jaw up and compared to 2 of the 17 controls.
(OSAS). The size of the airway is one back towards the throat, especially Again, the interrupted sleep pattern major factor, but the characteristics of when laying down. This may reduce did not meet the criteria for OSAS, the surrounding tissue (such as the the size of the oropharnyx, and the but it did produce twice as many strength of the muscles and the same is true of other tight muscles arousals per hour in the patient group amount of fat deposits in the area) around the face or neck.
compared to the controls. The amount also plays a role. For many people of disturbed breathing during the night with airway restrictions, difficulty in FM patients correlated with symp- sleeping and a variety of symptoms toms of daytime fatigue and pain.
reminiscent of FM/CFS will develop.
FM patients often say they wake Pulmonary volumes were the same in As the lungs expand to suck in air, up stiff and achy. This would make the two groups, reducing the likeli- there is so much resistance in the sense if the oxygen supply to the hood that the findings were caused by airway that it takes much more effort muscles was impaired during the tight chest wall muscles.
to draw in each breath. This is hard on night. Yet, people with Obstructive
The investigators suspected that the heart, which is why physicians Sleep Apnea Syndrome (OSAS), who
the breathing pattern could be caused check for OSAS. Unfortunately, have airflow blockages occurring at by upper airway resistance (or flow methods for testing UARS have only least 5-10 times per hour, usually restrictions) in the nose and throat recently been developed, so this don't have widespread pain. Their regions, but discounted this possibility disorder is often overlooked.
primary symptoms are morning because many of the patients did not Over ten years ago, scientists headaches and daytime fatigue. FM/ snore. Although snoring is always began studying people with UARS.3
CFS patients have these symptoms, present OSAS (the loud vibrating Researchers placed a small sensor and many more. Could another sleep noise produced when the airway device in the nasal passage to measure disorder explain this? tissues collapse), researchers in recent the amount of resistance in the airway Alvarez Lario,
M.D., of Spain
Diagram C
addressed this
question and pub-
lished a follow-up
report in 1996.1 He
found that the level
of blood oxygenation
dropped significantly
during the night in 28
FM patients (all
female), compared to
15 healthy controls.
Patients did not meet
the criteria for OSAS,
but they did spend a
Diagram B
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during sleep, so that people with Half of the patients were recruited because the effort required to exhale UARS could be identified. As with from their sleep center in Stony kept them awake. Fortunately, CPAP any "new" entity in medicine, UARS Brook, NY, and the other half were is not the only way to treat UARS.
is the subject of "put-downs" because enrolled from a previous "survey many doctors believe that OSAS is the type" FM study that had nothing to do OSAS or UARS?
only sleep-disordered breathing with sleep. The investigators of the . depends on how you grade them
condition that exists.4 UARS chal-
study wanted to include FM patients lenges this traditional way of thinking, who had not sought help for their The foregoing study described the just as fibromyalgia challenges the sleep difficulties.
high prevalence of UARS in women concept of real pain without obvious Evaluation of the airflow dynam- with FM. What about the overlap tissue disease! UARS and FM/CFS ics in all FM patients was compared to between OSAS and FM? In 1993, have more in common than just that of 11 female UARS patients who Kimberly May, M.D., looked for
had been identified by previous sleep apnea in patients with FM (92 If the sleep disorder of FM/CFS research projects. Between the over- females and 25 males). The incidence might really be that of UARS, why night sleep lab data and the physical of OSAS was low in the women (2%), haven't you been tested for it? In findings about the airflow openings, but it turned out to be exceptionally today's world, apnea remains King .
the study revealed that 27 of the 28 high (44%) in the group of men with and there appears to be little room for FM patients met the criteria for FM.7 She concluded that sleep apnea
a Queen. Most physicians have been UARS. The FM group averaged 30 may be a marker for undiagnosed FM taught (and still may believe) that arousals per hour, which was similar in men. In addition, when the apnea apnea is the only sleep-related breath- to that found in the UARS group. In was identified and treated, half of the ing disorder that warrants further addition, application of nasally patients showed significant improve- testing. The health insurance industry administered continuous positive air- ment in their sleep and FM symptoms.
further promotes this mindset by not way pressure (CPAP) to overcome the Therapies targeting OSAS and covering sleep studies for the sole resistance to air flow provided proof UARS can produce a dramatic reduc- purpose of diagnosing UARS, al- that the frequent arousals were due to tion in symptoms, so they are impor- though many labs are capable of the airway resistance. After three tant to identify. The distinguishing performing the necessary measure- weeks on nasal CPAP, a substantial features of OSAS and UARS are ments. However, symptoms of chronic reduction in FM symptoms (ranging indicated in Diagram D. UARS insomnia and suspicion of OSAS are from 23-47%) was achieved.
involves a restriction in airflow during usually sufficient grounds for ordering Despite dramatic symptom sleep, produces an alpha-EEG sleep a sleep evaluation.
improvements, only 36% of the pattern similar to that found in FM, Christian Guilleminault, M.D.,
patients placed on CPAP were still and causes more frequent arousals at the Stanford Sleep Center in using it nine months later. Although it than OSAS. In fact, studies in recent California, has directed a large may seem odd that patients would years have documented that individu- number of the studies on UARS. He discontinue a therapy that helped als with UARS exhibit many symp- discovered that UARS patients have a them, there are many valid reasons toms in common with FM, such as higher frequency of structural abnor- why FM patients halted CPAP.
daytime fatigue, difficulty falling malities in their upper airway than Two-thirds of the patients in the asleep (insomnia), headaches, irritable those without UARS, and has looked study had rhinitis (at least two of the bowel syndrome, and bruxism (teeth at blood pressure, age, gender, and following symptoms: chronic nasal grinding caused by unconscious jaw menopause as predisposing risk stuffiness, post-nasal drip or nasal movements during sleep).8 Even low
factors for the condition.5
allergies). When chronic sinus prob- blood pressure, which is a frequent lems exist, it increases nasal resis- sign of orthostatic intolerance, and FM Study Scores A+
tance and impairs one's ability to cold extremities, are significantly breathe nasally. Other situations that more common in people with UARS.5
Due to the similarities between prevented the CPAP usage included OSAS and UARS are at two ends UARS and FM, sleep researcher skin rashes caused by the device's of the spectrum of sleep-disordered Avram R. Gold, M.D., at SUNY-
mask, inability to vary sleep position, breathing, but OSAS occurs more Stony Brook in New York, collabo- and difficulty breathing against a often in men while the prevalence of rated with Joan Broderick, Ph.D., to
positive pressure. Many could not fall UARS is greater in women.9 The
determine how often UARS occurred asleep while breathing against a blood oxygen levels typically dip in 28 women diagnosed with FM.6
steady stream of pressurized air, below 88% several times an hour in Fibromyalgia Network • (800) 853-2929 • www.fmnetnews.com
Symptoms begin in early (Approximately 40% men with FM) childhood; prevalence (Potentially most women with FM) increases with age Higher incidence in men Higher incidence in women, with (3:1 ratio of men to women) significant rises at puberty & menopause Blood oxygenation often dips below 90%, Blood oxygenation hovers between 88-94%, but number of arousals caused by breathing but number of arousals caused by breathing difficulties less than UARS.
difficulties greater than OSAS.
Patient always snores.
Snoring not always present.
Alpha-EEG anomaly rarely present.
Alpha-EEG anomaly usually present.
Unrefreshing sleep Difficulty sleeping (insomnia) Irritable bowel (abdominal pain/diarrhea) Muscle pain and tenderness Attention deficits Tendency towards high blood pressure Bruxism (teeth grinding) Tendency towards low blood pressure Common FM/CFS symptoms
(except high blood pressure) Diagram D
OSAS patients, but there is no evi- an ear, nose and throat (ENT) special- dence of alpha-EEGs or awake-like ist for treatment. Many of them had brain waves intruding upon deep their tonsils and/or adenoids removed, sleep—a finding in patients with but the choice of therapy was left up UARS. This alpha-EEG in UARS How can researchers be certain to the ENT. Three months after suggests that the brain is in a constant that sleep-disordered breathing is therapy, 55 children still had symp- state of arousal, even during sleep, caused by airway restrictions and not toms of sleep-disordered breathing, and this could be why the two syn- by aging, hormones, or other factors? but none met the adult criteria for dromes exhibit different symptoms.10
The answer to this comes from sleep OSAS. Guilleminault re-graded their Conversely, the blood oxygen levels studies performed on children ages 2 sleep study charts according to less in UARS patients hover between 88- to 12. Guilleminault analyzed the strict criteria for OSAS (e.g., pediatric 92% throughout the entire night (a medical records of 400 youngsters guidelines) and 31 patients received phenomenon observed in the FM who had undergone overnight sleep the OSAS score. The other 24 patients studies by both Lario and Sergi).
tests because their parents noticed were scored as UARS.
OSAS and UARS are bad for one's irregular breathing patterns during The OSAS group was slightly health, but UARS tends to be more sleep. He compared them to 60 age- older than the UARS children and destructive to the sleep process.11 This
matched healthy kids who did not consisted of more boys than girls. Of may also explain why UARS patients have any signs of sleep-disordered interest, close to 50% of the UARS have more symptoms, which happen breathing.12 This latter group served as
group had already been diagnosed to overlap with those found in FM/ controls and were subsequently with attention deficit hyperactivity CFS patients. It is quite possible that evaluated by an overnight sleep test disorder. All 55 children were treated many diagnosed with FM or CFS also for comparison purposes.
more aggressively (adenoids and have UARS, but they are not being All 400 of the children with tonsils removed; turbinates cut back), treated for the latter.
breathing problems were referred to and almost all symptoms went away.
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In a separate study, Guilleminault Lario BA, et al. Am J Med 101:54-60,1996.
the fact that OSAS and UARS begin Sergi M, et al. Eur Respir J 14:203-8,1999.
evaluated children in this same age very early in life.
Guilleminault C, et al. Chest 104:781-7, 1993.
group to determine why OSAS Gutierrez AL, Rodenstein DO. Eur Respir J develops in a child as opposed to 17:835-37, 2001.
Guilleminault C, et al. Am J Respir Care Med UARS.13 Children with the structural
164:1242-7, 2001.
features outlined on page 12 were Gold AR, et al. SLEEP 27(3):459-66, 2004.
more likely to have sleep-disordered May KP, et al. Am J Med 94:505-8, 1993.
Treatments for UARS vary from Gold AR, et al. Chest 123(1):87-95, 2003.
breathing. Those who had high blood invasive surgeries to simple, self- Collop NA. Chest 120(5):1432-33, 2001.
pressure tended to meet the pediatric Guilleminault C. Chest 123(1):12-14, 2003.
administered remedies. Typically, Guilleminault C, et al. Eur Respir J 17:838-47, guidelines for OSAS, while those with multiple approaches are needed and low blood pressure (less than 80/60) Guilleminault C, et al. Arch Pediatr Adolesc sometimes the best place to start is tended to have UARS. This difference Med 158:153-61, 2004.
with a sleep study to determine if Guilleminault C, et al. Pediatric Res 55:76-84, implies that the autonomic nervous you have UARS, and if so, its system is dysfunctional in both severity. Even if you don't have conditions. However, the nervous UARS, learn the best methods for system is responding to the airway keeping your airways clear so that resistance by two different mecha- breathing difficulties don't compound nisms, generating two separate your sleep disorder, pain, and other conditions. Both studies underscore Reprinted with permission from: Fibromyalgia Network Journal
October 2004 (Issue #67) Tucson, AZ 85751-1750 To join, call toll-free (800) 853-2929
or visit www.fmnetnews.com
$28 a year / $30 USD in Canada Articles are for informational purposes only. You must consult your physician for treatment. Fibromyalgia Network • (800) 853-2929 • www.fmnetnews.com

Insomnia and Obstructive Sleep
cannot be applied Apnea Syndrome (OSAS) are the two
most common sleep disorders. The typical person with overlap between the two is substantial (40% of people with OSAS battle insomnia).1 The reverse is also true:
many people with insomnia also what about those who are younger, Guilleminault writes, " . nonrecogni- exhibit some form of sleep-disordered female, and not overweight? These tion of the syndrome (UARS) and the breathing (apnea and the newly people are rarely referred to sleep anatomic abnormalities surrounding identified Upper Airway Resistance
centers for overnight studies. If they the upper airway responsible for its Syndrome or UARS). Despite the
have UARS, it will go undetected and symptoms will lead to complications apparent link between the two condi- untreated. In fact, these people will and perhaps even development of tions, they have remained on two likely be given sleeping pills or sent to sides of a rift, with insomnia on one psychotherapy (a common approach to According to Guilleminault, "A side, and sleep-disordered breathing treating chronic insomnia), but neither study looking at the long term evolu- on the other.
will correct a person's airflow limita- tion of UARS has been done." The Barry Krakow, M.D., director of
tions during sleep.
evolution from UARS to OSAS was a sleep center in Albuquerque, NM, So, what are the implications for slow, but 6-7% of patients in the five- explained in his 2004 editorial how fibromyalgia (FM) patients? UARS year study developed OSAS. This insomnia is usually pushed aside to be has been documented in a diverse soon-to-be published study could be viewed from a purely psychological group of people with a variety of highly significant, given that OSAS perspective (i.e., a defect that should primary symptom complaints, such as develops over many decades.
be treated by mental health profes- young children and teenagers with The expansion of FM sleep sionals).2 Conversely, OSAS is judged
attention deficits, as well as adults research to include UARS is good as a "real" disease that is rigorously with fatigue, irritable bowel, trouble news. However, one of the major investigated and treated by pulmonary sleeping, headaches, and the wide- obstacles for detecting UARS with a specialists. Referring to this division, spread pain of FM.3 Since not all FM
high degree of accuracy is that pa- Krakow says, "It's as though the right patients fit the "OSAS profile," it is tients must swallow a small transmit- hand doesn't know what the left hand important for treating physicians to ter to measure the pressure in the recognize that airflow can be re- esophagus during sleep. The device is Now that the tracks have been laid stricted by a number of mechanisms, tiny and inexpensive, but is seldom to make a connection between insom- and not simply the one that produces used outside the realm of UARS nia and sleep-disordered breathing, research (i.e., it is not used to evaluate sleep medicine is at a crossroads.
If UARS is a likely cause of apnea . not even for research).
Which direction should sleep experts insomnia, and OSAS is on the flip Fortunately, a less expensive (but less go? Krakow recommends that sleep side of the "insomnia coin," does this accurate) tool for detecting UARS doctors consider sleep-disordered mean that there may also be a connec- was developed. In the meantime, sleep breathing and insomnia as two sides tion between UARS and OSAS? studies that evaluate people with of the same coin.
Recently, Guilleminault published an insomnia, UARS, and mild OSAS Breathing difficulties during article reflecting the progress made in may all lead to a better understand- sleep, particularly UARS, may be the the field of UARS over the past ten ing of the nighttime frustrations cause of most cases of insomnia.
years.4 He indicates that people with
faced by millions of patients with Unfortunately, most doctors are only UARS usually have structural abnor- on the lookout for OSAS, and are malities that restrict airflow, while Smith S, et al. Sleep Med 5:449-456, 2004.
unaware of UARS. Christian
OSAS is neurological in nature. They Krakow B. Sleep Med 5:431-433, 2004.
Guilleminault, M.D., of Stanford
appear to be two distinct syndromes, Gold AR, et al. CHEST 123:87-95, 2003.
University, has shown that the com- but research shows that, over time, Bao G, Guilleminault CG. Curr Opin PulmMed 10:461-467, 2004.
mon profile for people with OSAS UARS may actually become OSAS.
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If you manage to sleep an extra endings—were both increased during major drawback of both of these hour or two, is it a waste of valuable the day. Cytokines are markers of studies: Upper Airway Resistance time? What if you are overwhelmed systemic inflammation and are known Syndrome (UARS) during sleep was with work and decide to cut your to cause symptoms of pain and not evaluated in the patients with sleep time short in order to get things fatigue. Not surprisingly, they have done? Given that FM/CFS patients are been found to be elevated in patients often exhausted and feeling short- with FM.2,3 Cortisol, an alerting
changed on time, these are important hormone, was also impacted by the questions. Certainly, you want to do sleep restriction. While the total what is best for your health. Recogniz- amount of cortisol produced was There is evidence that insomnia ing the connection between sleep and unaffected, it peaked two hours earlier may be caused by airway resistance health, patients who responded to a in the morning following the pattern (e.g., UARS). If this is the case, and if nondrug Fibromyalgia Network of a two-hour decrease in sleep.
insomnia and apnea are on different survey rated maintaining a consistent Since reducing sleep time has sides of the same coin (see previous sleep routine as the third most effec- serious consequences, does sleeping article), then logically, there must be tive self-help measure for controlling more have a positive impact? A recent some connection with cytokines and study examined the benefits of apnea. As it turns out, there is! Day- increased sleep time.4 College stu-
time levels of IL-6 are elevated in Toying with Sleep
dents (ages 18 to 23) were allowed to people with apnea, which could ignore their alarm clocks and sleep in explain their daytime fatigue (IL-6 (on average an extra hour). After eight causes fatigue in insomnia patients Two studies indicate that extra days, researchers found that in com- too).7 After a one-month treatment of
sleep should not be viewed as op- parison to baseline values, the ex- apnea patients with Continuous
tional, but rather, as a priority for tended sleep led to substantial im- Positive Airway Pressure (CPAP),
healthy living and maximizing day- provements in daytime alertness, which kept the airways open at night time function. The first study looked reaction time, vigor, fatigue, and so that patients could obtain restful at the effects of modestly restricting sleep, the levels of IL-6 were signifi- the sleep of 25 healthy subjects (who cantly decreased. A recent study found had no sleep complaints) for one that administering CPAP to FM week.1 For the purpose of comparison,
patients who also met the criteria for the participants were first observed in UARS substantially reduced their pain an overnight sleep lab for four days, Cytokines IL-6 and TNF are both and fatigue. One can speculate that, with no changes to their sleep sched- fatigue-inducing substances, so their like the apnea patients, symptom ule. Then, every day for one week, the production during the daytime can improvements in UARS and FM subjects (13 men and 12 women) were greatly hinder a person's performance.
should coincide with a drop in awakened after only six hours of Ordinarily, their peak secretion is sleep. The participants were not around 9 p.m., which explains why allowed to nap and were told to stick people get sleepy at this time of to their regular schedules.
night. A study looking at people with Vgontzas AN et al. J Clin & Metab89(5):211902126, 2004.
After just one week of this chronic insomnia found that IL-6 Wallace DJ, et al. Rheumatology 40:743- relatively modest (25%) sleep restric- production shifted to the middle of tion, the subjects' performance on the day (2 to 3 p.m.), while TNF Salemi S, et al. J Rheumatol 30(1):146-50, 2003.
various tests measurably declined.
secretion was elevated throughout the Kamdar BB et al. Sleep Medicine 5:441-448, This corresponded with significant daytime hours.5 In a separate report,
changes in the body's production of the same research team also found Vgontzas AN et al. Metabolism 51(7):887-892, 2002.
several important substances. Among that cortisol was overproduced in Vgontzas AN, et al. J Clin Endo Metab these, cytokine chemicals IL-6 and people with insomnia, so even if they Yokoe T et al. Circulation 107:1129-1134, TNF—produced by the immune wanted to fall asleep, this arousing system but secreted through nerve hormone could keep them awake.6 A
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In the previous Network newslet- like," says Gold. Only during the ter, we reported that Continuous
sleep study, when the pressure setting Positive Airway Pressure (CPAP)
is determined, must patients sleep on reduced the symptoms of FM pain, their back. "The airway is most fatigue, sleep disorder, and gas- Aggressive treatment of nasal collapsible in this position." trointestinal disturbances by 40 to congestion tops the list for benefitting If you already have insomnia, you 50%—a success rate unmatched by your breathing at night. Sleeping may think the CPAP machine will any other therapy. Avram Gold,
position is also important. Laying on keep you awake. Gold says that M.D., at Stony Brook University in
one's back will force the base of the patients are often prescribed Ambien New York was the lead author.1 When
tongue and other structures to fall to help them adjust to sleeping with a Fibromyalgia Network asked Dr. Gold back and occlude the airway. Ideally, a mask and that symptoms of insomnia about his approach for reducing the person should sleep on their side, with actually improve over time .
symptoms of FM, he emphasized, "I a cervical neck support to keep the do not treat FM; I DO treat flow trachea straight.2 A tennis ball or
limitation during sleep in FM pa- something similar can be attached to the back of a nightshirt to prevent Patients who are unable to tolerate Even after months of follow-up, people from sleeping on their back.
CPAP due to difficulties with the the success rate does not improve.
Weight loss has long been promoted mask, such as skin rash or problems Why might this be? Three-quarters of for the treatment of sleep apnea, but breathing through the nose, may have the FM patients in Gold's study had recent research shows that it is of little greater success with oral appliances.
chronic allergic rhinitis (AR) and These devices are designed to bring Gold suspects that the "high rate of the lower jaw forward during sleep poor nasal breathing in FM" could be and were developed as an alternative partially responsible for limited to CPAP for patients with apnea.
CPAP is considered the first- treatment success. "I cannot rule out, Impressions of your upper and lower choice therapy for UARS because the however, that some other mechanism teeth are used to make appliances out pressure setting can be individualized.
is also playing a role in causing the of plastic. They are not as effective as It consists of a snug-fitting nasal mask CPAP at preventing the airways from with tubes connecting it to a machine "I am quite convinced that when collapsing, but for people with mild that pressurizes the air flowing into the work is done, it will demonstrate airflow limitations (UARS and mild the nose for breathing. Two types of that inspiratory flow limitations apnea), these devices may work well.5
machines are available, one which during sleep are the unrecognized A study involving mild apnea patients automatically adjusts the amount of cause of much human suffering," says indicates that they often prefer the pressure according to need, and Gold. "Six years of working with appliance over the CPAP machine, so another which produces a "fixed" women with UARS (Upper Airway
they may represent your next-best pressure throughout the night. The Resistance Syndrome) has convinced
auto CPAP delivers a lower average Four key points about oral devices pressure and may be preferred by What are the primary approaches include: (1) dentists specializing in some patients. However, sudden used for treating UARS, which in turn sleep medicine and temporomandibu- changes in air pressure may cause should improve FM/CFS? Therapies lar disorders are most likely to cus- frequent arousals, so if you find you for UARS may be divided into four tomize an appliance for you, (2) if cannot acclimate to one type of categories in order of increasing cost your physician is not aware of a machine, try the other one before and invasiveness: (1) Inexpensive/ provider, The American Academy of giving up.4
Self-Help Strategies, (2) CPAP, (3) Dental and Sleep Medicine's Web site "Patients can sleep with nasal Oral Appliances, and (4) Nasal at www.dentalsleepmed.org may be
CPAP at home in any position they Fibromyalgia Network • (800) 853-2929 • www.fmnetnews.com
helpful, (3) sore teeth and jaw in the with insomnia seldom undergo a sleep therapy), less money will be spent on morning are common side effects that study. This is particularly true for non- medications and doctor's visits. She should wear off shortly after removing obese women. Fortunately, UARS is will also be more alert behind the the device . contact your provider for steering wheel and less likely to have adjustments if your jaw pain or sleep Criteria: Asking Gold if any persis-
an auto accident that could be a very worsens, and (4) major medical tent symptoms should prompt doctors expensive affair. These letters are insurance companies often pay for to order a sleep study, he responded: remarkably effective." oral appliances as "durable medical "Fatigue/sleepiness . PERIOD. In my Study Preparation: Many patients
experience (since 1999), it is rare to fear that in order to undergo a sleep find a patient with this symptom who study, they must go off all of their does not have inspiratory flow limita- medications. Barry Krakow, M.D.,
tions (e.g., UARS) during sleep." who routinely evaluates patients for The fatigue of FM/CFS is usually When asked if other tests could take UARS, indicates that "people should not viewed in relationship to chronic the place of an overnight sleep study, not change their sleep regimen for the inflammation of the nasal or sinus Gold's answer was "no." This is study unless narcolepsy is suspected." tissues (e.g., rhinosinusitis or AR). A because large drops in blood oxygen Otherwise, Krakow says that sleep recent study by Alexander Chester,
levels (a detectable sign for most doctors first want to evaluate patients M.D., of Georgetown University, may
apnea patients using a portable "as is." This includes bringing in all help change this often overlooked device) don't occur in UARS.
of your pillows and other comforts to cause of fatigue! At the October 2004 Finding a Sleep Center: If your
best mimic your home environment.
meeting of the American Association doctor prescribes a sleep study, you After The Network published the for CFS, Chester posed the question: will need to locate a sleep center.
UARS article in the last issue, no "Does functional endoscopic sinus According to Gold, the best screening physician or researcher in the FM surgery reliably improve the fatigue question is: "Do you make the diagno- field has commented about it. Gold associated with chronic sis of UARS?" The most accurate suspects that "the medical community rhinosinusitis?" He presented a review method of detecting UARS requires is uncertain of what to make of this" of the medical literature, showing that patients to swallow a tiny pressure (referring to UARS) because it the fatigue levels greatly improve in sensor, but this tool is used primarily contradicts current opinions. He adds patients after this form of surgery.7,8,9
in the research setting. Fortunately, that more studies are needed to What type of surgery is Chester Gold points out a new alternative that strengthen the concept that flow referring to? It's an outpatient proce- is capable of detecting most cases of limitations during sleep could cause or dure and the only form of surgery that UARS. "Today, there is a new tool for be partially responsible for FM/CFS.
Dr. Gold advocates for his patients. "It measuring airflow during sleep that Yet, Gold believes that with new is surgery to improve nasal breathing simplifies the detection of mild flow medical ideas, "the tail can wag the (trimming back the turbinates, correc- limitation. It is a nasal/oral trans- dog. Patients demanding answers will tion of deviated nasal septum, removal ducer." Only 25% of sleep centers lead their physicians to learn new of polyps)," says Gold. "These have this device, so inquire about it procedures reduce nasal resistance before scheduling a study.
and at the very least, they can improve Insurance Coverage: "All of our
a patient's compliance with nasal patients have their studies covered by Gold AR, et al. SLEEP 27(3):459-66, 2004.
CPAP." The procedure also improves their insurers (as well as their treat- Kushida CA, et al. Sleep Res Online 2(1):7- sleep and reduces daytime fatigue due ment) using the code 780.53 (sleep Levy P, et al. SLEEP 19(9):S101-S110, 1996.
to enlargement of the airway. Aside apnea with fatigue) and sometimes Marrone O, et al. Sleep Medicine 5:247-51, from this approach, other forms of 780.51 (sleep apnea with insomnia)," surgery are generally considered a last says Gold. "All of these patients have Yoshida K. J Prosthetic Dentistry 87:427-30,2002.
fatigue/sleepiness and many have mild Randerath W, et al. Chest 122(2):569-75, snoring. In cases where the patient Ragab SM, et al. Laryngoscope 114(5):923- does not snore, the physician can When & How they should be done
write a letter to the insurance com- Chester AC. Arch Intern Med 163(15):1832-6, pany citing my recent paper in SLEEP Bhattacharyya N. Arch Otolaryngol H & N Surg Typically, overnight sleep studies and Dr. May's paper from 1993.1,10 I
are only ordered if a person is sus- explain to the company that if we can May K, et al. American J Med 94:505-8, 1993.
pected of having apnea, so people get this woman on CPAP (or similar Fibromyalgia Network • (800) 853-2929 • www.fmnetnews.com

It turns out that a stuffy nose can AR symptoms peak between 5-6 a.m., So how does AR congestion be detrimental to the quality of your whereas they may be less bothersome impact sleep? A study published over sleep. Recent research reveals that around 3 p.m. Morning stuffiness is twenty years ago showed that nasal congestion leads to daytime usually about 20% worse than any of microarousals (or disturbances) in drowsiness.1 Allergic rhinitis (AR),
your daytime nasal symptoms.
sleep were ten times higher in patients the medical term for sneezing and Several factors may make your with AR than in easy-breathing, nasal congestion, is a risk factor for stuffy nose worse in the early morning healthy controls.5 In addition, these
developing sleep apnea, as well as its hours.4 First, the nasal cavity swells
arousals were associated with abnor- cousin, Upper Airway Resistance
up when you are laying down, causing mal breathing patterns in the people Syndrome (UARS).2 AR causes
nighttime secretions to accumulate.
with AR. Today, chronic nasal conges- serious sleep disruption, which in turn Second, your cortisol levels are the tion is known to impede airflow and leads to excessive sleepiness, de- lowest at night. Cortisol is known for increase the incidence of snoring— creased alertness, concentration its role in suppressing the immune both of which may cause or worsen deficits, irritability, and a diminished system, so at low levels, immune existing UARS and Obstructive Sleep
quality of life. Job performance and substances are more likely to be Apnea Syndrome (OSAS).
learning skills may also be impaired.
released, causing nasal inflammation Clearly, nasal congestion can The vast majority of patients with and congestion. Third, the nervous restrict breathing, which in turn FM/CFS put up with the chronic system promotes an expansion of the impacts your sleep. So why doesn't nuisance of AR. In fact, the symptom blood vessels at night, which leads to your doctor prescribe therapies that cycles of FM and AR are strikingly swelling of sinus tissues.
target AR when you complain of similar. FM symptoms fluctuate over a
24-hour period in a cycle that was
documented by researcher Harvey
Daily 24-hour Cycles for FM Pain/Fatigue,
Moldofsky, M.D., of Toronto,
Canada. A graph of this cycle is
AR Symptoms and Cytokines IL-6/TNF
superimposed over the AR symptomcycle below. The pattern of thefatigue-enhancing cytokine shift (asdescribed on the previous page forinsomnia/apnea) is also shown forcomparison.
AR can exacerbate anyone's sleep problems. For people with FM/CFSwho are already tired and struggling toget a good night's sleep, a betterunderstanding of what causes AR andhow to treat it is essential.
Stuffy Nose and Sleep
While it is possible that an allergen in your bedroom is causing
you to wake up congested, there is a
more likely cause of this symptom.
Waking up each morning with a stuffy
nose is part of the AR symptom
cycle.3 Researchers have shown that
Fibromyalgia Network • (800) 853-2929 • www.fmnetnews.com
fatigue? A study indicates that people piqued after working with I. Jon
rarely voice strong complaints about Russell, M.D., Ph.D., at the Univer-
The possibility of a relationship their stuffy nose, especially if it isn't sity of Texas at San Antonio, to between leukotrienes and FM has not that bad in the doctor's office in the document the three- and fourfold been studied. Yet, out of all of the middle of the day.6 If you have a
increases in substance P and nerve nasal irritants produced by AR, these chronic runny nose or wake up to growth factor (respectively) in the substances cause the most congestion.
nasal congestion in the morning, make spinal fluid of patients with FM.
Two new drugs that block the action a point of addressing this symptom at Due to the lack of a blood-brain of leukotrienes have been approved your next doctor's visit.
barrier surrounding the sinuses, for prescription sale in the United substances released from the mast States. As you will read in the section cells into the nasal tissues have easy below, they should benefit your sleep . are also found in FM
access to the pain/fatigue regulating to a greater extent than drugs that centers in the brain, such as the target histamine.
The many sinus irritants involved thalamus. (The blood-brain barrier is in AR are listed in the table below, a boundary that prevents many along with a brief description of their substances from traveling from the effects on sleep and nasal obstruction.
bloodstream into the brain tissues.) At Cells within the nasal cavity, called a scientific meeting on FM, sponsored Now that the ties between AR and mast cells, can cause congestion and by the National Institutes of Health, disturbed sleep have been explained, induce sleep-disruption by releasing Larson discussed her work that shows it's time to make sure that your their irritating contents into the nearby cromolyn solution prevents mast cells nighttime breathing is as effortless as tissues. Examples include prostaglan- from releasing their contents, even possible! At first, decongestants might dins, histamine, cytokines, under conditions that would normally seem like the ideal treatment. Nasal leukotrienes, and neurotransmitters trigger them into action. Therefore, sprays in this category, such as Afrin, involved in pain, such as substance P cromolyn-based nasal sprays (such as take only 10 minutes to clear the and nerve growth factor. Although a over-the-counter NasalCrom) may upper airways. They work by shrink- link between AR and FM is not minimize the symptoms of AR. More ing the blood vessels and drying up established, University of Minnesota details about Larson's mast cell the tissue. The downside is that they neuroscientist Alice Larson, Ph.D., is
research can be found on the Web site make congestion worse if used for investigating the role of mast cells in for the American Fibromyalgia more than four days (they are strictly FM. Her interest in these cells was Syndrome Association (AFSA) at
to be used for one or two nights, if atall). Oral decongestants, such as pseudoephedrine (e.g., Sudafed), will clear your passages in 30 minutes, butthey are stimulating agents that Balances sleep/wake cycle destroy sleep and cause drying of thenasal membranes, which aggravates Increase deep level sleep Inflammatory Cytokines * Associated with sleep
Usually, when people think of (e.g., IL-1, TNF) allergies, they think of antihistamines.
Unfortunately, histamine in the brain plays a major role in maintaining Substance P *
Interferes with sleep wakefulness, so medications thatinterfere with its actions may cause Nerve Growth Factor *
Interferes with sleep sedation. The "first-generation"antihistamines, such as Benadryl, are * Reported elevated in FM patients
able to cross the blood-brain barrier All of the above are released from mast cells. For more information, visit the Ameri- and induce sleepiness as well as can Fibromyalgia Syndrome Association (AFSA) Web site at www.afsafund.org.
AFSA is an all-volunteer charity, whose overhead expenses are paid for by
cognitive dysfunction. Even if you Fibromyalgia Network. This enables AFSA to spend over 90% of its contributions
choose to take these agents only at directly on research. Contribute Online, or print out the order form to mail in your bedtime, they won't curb nasal contribution to AFSA today.
stuffiness in the morning because they Fibromyalgia Network • (800) 853-2929 • www.fmnetnews.com
only work for 4-5 hours. Besides, they usually administered dry out the nasal passages and provide twice daily. Due to the minimal help with congestion (they cyclic nature of AR Decongestants (Oral and Nasal)
primarily relieve symptoms of sneez- (worse in the morning ing and itching). If you elect to use and evening), it is this category of meds, avoid the optimal to use the popular cold-season combinations that spray immediately Oxymetazoline (Afrin, Dristan)*
include decongestants that are detri- upon waking and then Phenylephrine (Alconefrin, Neo-Synephrine, mental to sleep.
again before bedtime.
Vicks Sinex, etc.)*
mines have been purposefully de- of AR medications signed to work outside of the brain, so work by blocking the they don't cause as much sedation.
However, this side effect depends on leukotrienes. Two such the percentage of the drug that crosses the blood-brain barrier. For example, approved for prescrip- Triprolidine (Actifed, Allephed)*
fexofenadine (Allegra) doesn't cross tion sale in the United Loratadine (Claritin, Alavert)*
the blood-brain barrier at all, while States: Singulair Certirizine (Zyrtec) 30% of Zyrtec passes through. For (montelukast) and Desloratadine (Clarinex) this reason, Zyrtec is best taken at Accolate (zafirlukast), Fexofenadine (Allegra) bedtime. This class of histamines can but only Singulair has provide 24-hour relief and does not specific approval for Leukotriene Blockers (Oral)
cause as much drying. Antihistamines treating AR. Both have Montelukast (Singulair) in general do not effectively relieve Zafirlukast (Accolate) nasal congestion, but certain brands superior to other AR Nasal Sprays
may be better than others. Zyrtec and meds available in pill Clarinex (not the same as OTC form, particularly for Claritin) have been shown to be the reducing nasal conges- Azelastine (Astelin) most effective drugs in this class for tion and enhancing Budesonide (Rhinocort) sleep.3 Reduced nasal
Flunisolide (Nasalide, Nasarel) Nasal sprays are another treat- resistance and in- Fluticasone (Flonase) ment option, and are usually supple- creased airflow rates Mometasone (Nasonex) mental in AR therapy. Four categories found in patients Triamcinolone (Nasacort) of nasal sprays exist: antihistamines, taking these medica- Mast Cell Stabilizer:
steroids, cromolyn-based mast cell tions may be respon- Cromolyn Solution (NasalCrom)*
stabilizers, and saline solutions. The sible for the improve- latter two are available over-the- ments in sleep, espe- Saline Solution (Ocean, Ayr, etc.)*
counter. The role of cromolyn (e.g., cially since upper * Available over-the-counter
NasalCrom) was discussed in the airway resistance previous section. Saline solutions, appears to be the such as Ocean Spray, simply keep the primary cause of insomnia.
lead to better sleep. Using a nasal sinus membranes moist and help flush saline solution to flush and moisten the irritants out of the nose. A study The Ideal Therapy
the sinus membranes is useful no comparing antihistamine and steroid matter what pharmacological ap- nasal sprays (azelastine versus If money and insurance issues proach is tried. Also, mast cell stabi- flunisolide) demonstrated the superi- weren't factors, what would be the lizers, such as over-the-counter ority of dilute steroid solutions for ideal therapy for treating chronic nasal NasalCrom spray, have a high safety treating AR.8 In particular, the steroid
congestion and related AR symptoms? record and are an alternative option was shown to best reduce congestion Singulair is the best orally acting for people who cannot tolerate steroid and improve sleep. One drawback of medication. If side effects are not sprays. A second-generation antihista- steroid sprays, however, is that they tolerable, the next best is Accolate. A mine may help with itching, watery take up to two weeks to reach their steroid nasal spray can also be used to eyes, or a runny nose. Zyrtec and full effectiveness. These sprays are enhance breathing, which ought to Clarinex are the best two meds in this Fibromyalgia Network • (800) 853-2929 • www.fmnetnews.com
category because they also treatnasal congestion. Take the time to Q&A on UARS
find the AR treatment regimen thatworks for you. Your sleep is impor- Most questions on Upper Airway Resistance Syndrome (UARS) have been
tant, and breathing easier at night is answered on the pages that follow. Below are answers to the remaining the key to functioning better during Q How would Hyperbaric Oxygen Therapy affect UARS? What about
changes in barometric pressure? END A HBOT was found effective for treating FM and likely does so by reducing
Craig TJ, et al. J Allergy Clin Immunol UARS (it increases the inspiratory air pressure), but it is expensive. We 114:S139-45, 2004.
Young T, et al. J Allergy Clin Immunol previously reported that FM symptoms flared when the barometric pressure dropped. In light of UARS, this makes sense because lower atmospheric Ferguson BJ. Otolaryngol Head Neck Surg pressure also exacerbates airflow resistance.
Storms W W. J Allergy Clin Immunol Q Are there any medicines to treat UARS?
Drugs that increase serotonin (e.g., many antidepressants commonly Lavie, et al. Acta Otolaryngol 92(5-6):529-33, prescribed for FM) may "slightly" aid UARS and mild apnea. Mirtazapine Storms W, et al. J Allergy Clin Immunol 99(6 (Remeron), a sedating med that boosts serotonin may help as well, but causes substantial weight gain.
Nayak AS, Schenkel E. Allergy 56(11):1077-80, 2001.
Q Do age or hormones influence UARS?
Berlin JM, et al. J Amer Orthopedic Assoc Yes, during childhood and especially puberty, the tongue grows, thereby reducing the airway size and precipitating UARS in predisposed individu-als. After menopause, the airway tissues may sag, increasing the incidenceof UARS and apnea. Estrogen replacement minimizes this latter phenom-enon.
Additional comments: (1) gasping for breath may be a sign of apnea or
UARS, (2) grinding teeth at night highly correlates with the presence of UARS,
(3) morning stiffness in FM and fluid retention in female apnea patients both
respond to treatment with CPAP, (4) if a previous sleep study has ruled out
apnea, this does not necessarily rule out UARS, and (5) Lin Chen, M.D., of
Philadelphia, PA, looked at the charts of 135 FM patients and found that apnea
was present in 20% of the women and 32% of the men. She suspects that the
remaining patients may have had UARS, and comments: "These data provide
additional reasons to consider sleep studies in fibromyalgia."
Reprinted with permission from: Fibromyalgia Network Journal
January 2005 (Issue #68) PO Box 31750, Tucson, AZ 85751-1750 To join, call toll-free (800) 853-2929
or visit www.fmnetnews.com
$28 a year / $30 USD in Canada Articles are for informational purposes only. You must consult your physician for treatment. Fibromyalgia Network • (800) 853-2929 • www.fmnetnews.com

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