What's New in S.H.I.N.E. — Part 3: Common Sleep Disorders
In the first two parts of my multi-part series reviewing the core elements of the SHINE protocol for CFS and fibromyalgia — Sleep, Hormones, Infections, Nutrition and Exercise — I talked about sleep problems that are common in CFS/FM and how you can address them using natural remedies, better sleep hygiene, and multiple, low-dose sleep medications.
In part 3, I continue my discussion on sleep with a special focus on four specific sleep-related disorders that are frequently found in people with CFS/FM. These are:
- Sleep Apnea, a type of sleep-disordered breathing (SBD)
- Upper Airway Resistance Syndrome (UARS), another SBD
- Restless Legs Syndrome (RLS)
- Periodic Limb Movements In Sleep (PLMS)
That may seem like a lot of acronyms to keep track of — particularly when you're trying to fall asleep! But keep reading. You'll find that each of these disorders is simply and clearly explained, and that I offer remedies for each condition that are simple, surprising and very effective!
1 & 2. Restless Legs Syndrome (RLS) & Periodic Limb Movements in Sleep (PLMD)
Do your legs kick around a lot at night? Are your sheets and blankets scattered around when you wake up? Does your spouse note that your legs jump at night, or that you kicked them! If so, you probably have PLMD (often called RLS in the lay press), and it's contributing to your fatigue and pain. Although you may be asleep throughout the night, your legs are running a marathon — and you wake up exhausted! RLS/PLMD is very common in CFS/FM, affecting an estimated one-third of patients.
The suspected cause of PLMD/RLS is a deficiency of the "pleasure/reward" brain chemical dopamine. This is not caused by a Requip medication deficiency. Instead, RLS is usually caused by iron deficiency!
- Take 25 to 30 milligrams (mg) of iron. It works better than Requip, the dopamine-boosting prescription drug usually prescribed for RLS. In a 3-month study, RLS patients that supplemented with iron had an 89% greater improvement than people taking a placebo — an improvement twice that usually seen with Requip! If your blood test for ferritin (the stored form of iron) is lower than 60, iron deficiency may be triggering your RLS (some labs still ridiculously consider a ferritin level over 12 to be "normal," when it's not). If ferritin is low, take an iron supplement containing 25 to 30 (mg) of iron and at least 100 mg of vitamin C, which aids iron absorption and is also good for RLS. Take iron on an empty stomach at bedtime, and at least 6 hours before or after you take thyroid medication (iron blocks its absorption). If you develop side effects from the iron, such as constipation, take it every other day.
- Take 200 mg of magnesium at bedtime. It can settle RLS and help sleep. Eat a sugar-free, high-protein diet, with a protein snack at bedtime. Low blood sugar during the night can worsen the problem.
- The herbs in an herbal supplement that promotes healthy sleep may also be helpful.
- Try medications. If these natural remedies don't work, consider the medications Ambien, Neuronton or Klonopin, all of which are highly effective for the problem (Klonopin, however, can be addictive). If one of my patients is taking Neurontin for insomnia, I tell them to adjust the dose not only to get adequate sleep, but also to keep the bedcovers in place — and stop kicking their spouse!
- Watch out for antidepressants and antihistamines. They can worsen RLS.
- Some other (but much less important) therapies for RLS include: Take 400 IU of vitamin E, using mixed tocopherols. It can help RLS, but takes 6 to 10 weeks to work.
- Consider 15 mg daily of folic acid. Some cases of RLS (in which numbness and lightning stabs of pain are relieved by movement or local massage) are helped by 5 mg of folic acid, 3 times a day (an amount available by prescription). RLS without those symptoms isn't helped by folic acid. This is rarely needed.
- Consider the amino acid L-tryptophan. Several cases studies suggest that it can help.
- Try 5-HTP. I also recommend this tryptophan-boosting supplement for people with RLS. If on antidepressants, do not take over 200 mg at bedtime without your health practitioners OK. This takes 6 weeks to work and may help fibromyalgia in general.
3. Obstructive Sleep Apnea (OSA)
The most common type of sleep apnea — and the one that is common in CFS/FM — is obstructive sleep apnea. In this condition, the soft tissue at the back of your throat (the soft palette) obstructs the airway during sleep, repeatedly cutting off your breathing and rousing you into a semi-awake state. As the sagging soft tissue vibrates, you snore. In severe sleep apnea, you can have more than a dozen episodes of breathlessness every hour. This is like being suffocated with a pillow dozens of times a night while sleeping — so you wake up feeling tired.
The main cause of sleep apnea is being overweight and accumulating extra fat everywhere in the body, which includes the soft palette. I generally recommend that any CFS/FMS patient who is overweight, snores and has high blood pressure (a symptom of sleep apnea) consider being tested for the problem. Another clue is if you fall asleep easily during the day, for example while driving. If that happens to you, check for sleep apnea.
Here are my main recommendations:
- Videotape yourself while asleep. A test for OSA in the sleep lab costs about $2,600. A much cheaper method is to videotape yourself for an hour or two while you sleep. Simply set up the camera at the foot of your bed so it tapes your legs and face, hit record and go to sleep. Leave your blanket off and use just the sheet (you'll most likely pull the blanket on later during the night). Review the tape in the morning. If you see that you were snoring and you stopped breathing repeatedly, you have sleep apnea and should do a formal sleep lab study. An even easier method is to just ask your spouse! If you snore, are overweight and fall asleep easily during the day, and your spouse says you stop breathing during the night, then you have sleep apnea.
- Sleep with a tennis ball sewn into the back of your shirt. If your snoring occurs mostly while you are lying on your back, wear a tight pajama top or a T-shirt at night with a tennis ball sewn into the area at the small of your back. This helps stop you from sleeping on your back, which can eliminate the problem. If you snore just as much while lying on your side, then this won't help.
- Lose weight. Losing just 10 to 15 pounds may be enough to clear up sleep apnea.
- Try an oral appliance. Maybe you've noticed that many athletes protect their teeth during competition with a mouth guard. An oral appliance is a related type of device, worn during sleep. It adjusts your mouth and jaw in a way that helps keep your airway open. Talk to your dentist about a customized oral appliance, as over-the-counter versions don't work well.
- Use continuous positive airway pressure (CPAP). This shoebox-sized machine generates a constant flow of pressurized air into a flexible tube connected to a strapped-on breathing mask, which you wear during sleep. CPAP can be very helpful in sleep apnea. For the first few weeks, don't be surprised if you pull it off while asleep. Your body will eventually get used to it and it can leave you feeling much better.
- Ask your doctor about surgery. A 5-minute outpatient surgery called the Pillar procedure stops the soft palette from sagging and can be very effective for permanent relief of sleep apnea.
4. Upper Airway Resistance Syndrome (UARS)
Sleep apnea is well-known. But we're learning about another, milder form of sleep-disordered breathing, called Upper Airway Resistance Syndrome. It's triggered by difficulty breathing through the nose during sleep. Causes include small nostrils, nasal obstructions such as polyps, and nasal congestion caused by chronic sinusitis and Candida overgrowth. The symptoms of UARS almost exactly mimic those of CFS/FMS, such as insomnia and daytime fatigue. (In fact, UARS is often misdiagnosed as CFS/FM.) If you snore, you may have either sleep apnea or UARS. Fortunately, the problem is very addressable if it's detected — though it's typically not detected by standard sleep studies in a sleep lab.
What are some clues that you might have UARS? The characteristics signs of the condition include:
- Chronic insomnia, with frequent awakenings and the inability to fall back asleep. (People with sleep apnea sleep very poorly, too — but they may not be awake enough to realize it.)
- Complaints of daytime fatigue (not daytime sleepiness, which is more common in sleep apnea).
- Unlike sleep apnea, you will likely not be overweight.
- About 50% of those with UARS are women, compared to 8% with sleep apnea.
- UARS is often accompanied by spastic colon and low blood pressure, with lightheadedness on standing. Sleep apnea is associated with high blood pressure.
- People with UARS usually have cold hands and feet and other symptoms of hypothyroidism.
- Have a sleep study at a sleep lab — but make sure the sleep lab knows how to test for UARS. Sleep apnea prevents air from getting into your body and causes the oxygen levels in your blood to drop — both of which are very measurable during a sleep study, confirming sleep apnea. But UARS doesn't cause a decrease in airflow or a drop in oxygen. It simply increases the work of breathing, which tends to repeatedly disrupt sleep during the night. If you have a sleep study at a sleep lab, talk to the personnel at the lab beforehand to make sure they will check for UARS, and know how to do it right. That includes looking for pressure changes in your nose or alterations in your breathing (and even changes in your pulse).
- Try the "nose test." To screen at home, there is a simple "nose test" to see if you are suffering from nasal resistance. Looking in a mirror, press the side of one nostril to close it. With your mouth closed, breathe through the other nostril two ways: first without help, and then while holding it open with the flat side of a toothpick. If breathing is easier with your nostril held open, you may have UARS.
- Use a nasal dilator. A simple nasal dilator called Nozovent (available at many websites) has proved to be one of the most popular and easy-to-use devices to enhance nasal breathing. Another option is "Breathe Right" nose strips.
- Try a nasal spray. A prescription nasal spray is often very effective at addressing the nasal congestion and sinusitis that can trigger UARS. Ask your physician to call in a prescription, and use 1 to 2 sprays in each nostril, 2 times a day. When the bottle is done, you can continue using the spray as needed.
Try the dilator, strip and spray for a month, separately or together. If they don't help, consider an oral appliance or CPAP.
Jacob Teitelbaum, M.D. is one of the world's leading integrative medical authorities on fibromyalgia and chronic fatigue. He is the lead author of four research studies on their treatments, and has published numerous health & wellness books, including the bestseller on fibromyalgia and chronic fatigue syndrome From Fatigued to Fantastic! and his newer The Fatigue and Fibromyalgia Solution. Dr. Teitelbaum is one of the most frequently quoted fibromyalgia experts in the world and appears often as a guest on news and talk shows nationwide including Good Morning America, The Dr. Oz Show, Oprah & Friends, CNN, and Fox News Health.