Thoracic and Sleep Group Queensland People caring for how you breathe and sleep

Sleep and pain are bidirectional; pain can interfere with sleep and sleep disruption can intensify pain. This can become in a vicious cycle and cause serious issues for many people. Sleep patterns share common pathways with nociceptive stimuli. Several important factors are reviewed in considering connections between sleep and pain. Causes for sleep fragmentation include sleep disordered breathing; abnormal leg movements, including restless legs syndrome and periodic limb movements; and underlying mood disorder, which may be exacerbated by physical symptoms.

Recently one article was published by ScienceDaily where cited one research form the University of Warwick in United Kingdom[1] which describes that medical conditions such us back pain, fibromyalgia, and arthritis are directly linked with negative thoughts about insomnia and pain, and this can be effectively managed by cognitive-behavioural therapy (CBT).

This group of researchers have done psychometric evaluation and validation of the scale called Pain-Related Beliefs and Attitudes about Sleep (PBAS), it was tested on four groups of patients suffering from long-term pain and bad sleeping patterns [2], the results show that this is a reliable instrument for evaluating the role of beliefs about the sleep-pain interaction, in chronic pain patients, Because, people who consider they are not able to sleep, could as a result of their pain are more likely to suffer insomnia, thus causing worse pain. The results show that the scale was essential in predicting patients’ level of insomnia and pain difficulties. With better sleep, pain problems are significantly reduced, especially after receiving a short course of CBT for both pain and insomnia.

References:

[1] University of Warwick. (2016, September 21). Sleep is key to curing chronic pain. ScienceDaily. Retrieved September 29, 2016 from www.sciencedaily.com/releases/2016/09/160921084808.htm

[2] Afolalu EF, Moore C, Ramlee F, Goodchild CE, Tang NK. Development of the pain-related beliefs and attitudes about sleep (PBAS) scale for the assessment and treatment of insomnia comorbid with chronic pain. J Clin Sleep Med 2016;12(9):1269–1277

Some people who have suffered chronic insomnia tend to perceive less amount of sleep. This misconception of sleep causes one predisposition to recognize their sleep as wakefulness without objective evidence of sleep disturbances. This topic has been examined in Belgium for a group of researchers in the University of Leuven[1] and in California in the University of California[2].   They had as aim to investigate the mechanisms underlying this tendency and examined the role of pre-sleep cognitive arousal and overgeneralization.

The perception of insufficient sleep generates in the patients anxiety and a distress about sleeplessness and daytime dysfunctions, which, in combination with high levels of physiological arousal and emotional distress, directly interfere with getting sleep according. Harvey (2002). Moreover, in order to escape this sleep-related anxiety, people who believe that they suffer from a lack of sleep tend to employ some healthy behaviour establishing maladaptive sleep habits such us remaining longer in bed, drinking excessive alcohol or taking sedatives, and cancelling appointments to take a nap. The patients can overestimate their sleep onset latency (SOL) and underestimate their total sleep time (TST), relative to objective measures.

The study developed in Belgium provides data that show that the misperception of sleep occurs in two different cases:

• in the case of estimations for a single night, which is uniquely associated with excessive arousal, and
• in the case of estimations across multiple nights, which is uniquely linked to the tendency to overgeneralize.

This topic has implications for assessment, definition, and treatment and involves the objective measures trying to figure out the importance of the sleep studies for a precise diagnostic and treatment in this sleep disorders.

References:

[1] Takano K, Boddez Y, Raes F. I sleep with my Mind’s eye open: Cognitive arousal and overgeneralization underpin the misperception of sleep. J Behav Ther Exp Psychiatry. 2016 Sep;52:157-65. doi: 10.1016/j.jbtep.2016.04.007. Epub 2016 Apr 26.

[2] Harvey AG, Tang NK. (Mis)perception of sleep in insomnia: A puzzle and a resolution. Psychological Bulletin, Vol 138(1), Jan 2012, 77-101. http://dx.doi.org/10.1037/a0025730.

Allergic rhinitis or what is commonly referred to as hay fever is emerging as a major health issue within developing countries such as Australia. It is estimated that 4.1 million Australians or almost 20% of the population suffer with some type of allergic disease. Allergic rhinitis occurs when allergens in the air are breathed in by someone that is allergic to them, causing irritation and inflammation of the nasal passages. Allergens include dust mites, pollen, moulds, or animal hair. During sleep allergic rhinitis can become exacerbated and the impact of allergic disorders on your quality of life can become diminished. Research on the consequences on the quality of sleep and allergic rhinitis found that all dimensions of sleep were somehow impaired, particularly as the severity of the disease increased. Symptoms of sleep apnoea syndrome such as increased snoring, poor sleep quality, frequent nocturnal awakenings, insomnia and daytime sleepiness are more prevalent with people suffering allergic rhinitis.

The sleeping disorder obstructive sleep apnoea can be linked with allergic rhinitis. It is important for people that have both these conditions to reduce nasal congestion and inflammation to decrease symptoms such as snoring, daytime fatigue and sleepiness. Allergens such as dust mites and animal hair that build up within your bed room and bed will increase the severity of allergic rhinitis. Mould found within your home can be problematic and harmful, potentially having a serious impact on your health. Most people who live in mouldy conditions will develop hay fever-like symptoms or allergic rhinitis, a sensitivity to mould could also develop and your airways may become irritated and aggravate asthmatics. For that reason you should alleviate the irritation that may occur from allergens in your home, particularly those found in your sleep environment. Here are some tips to reduce allergens from your sleep environment:

• Regularly clean your bedding, mattresses and carpeting for dust mites and animal hair.
• If you have already been diagnosed with obstructive sleep apnoea and use a CPAP machine be diligent in your cleaning routine to avoid mould developing in your tubing or mask.
• To prevent mould in your home check any porous areas such as bathroom, clothing, furniture or carpets and clean and remove as soon as possible.
• If you are sensitive to pollens then try and keep them away from your sleep environment.

Symptoms of asthma occur when the upper airway becomes inflamed and constricts to make breathing difficult. Although asthma affects people of all ages, it often starts in childhood and is more common in children than adults.  Incidences of asthma are on the rise but exactly what causes asthma is still not entirely clear. Whether it is the result of environmental or genetic factors, what triggers asthma can be extremely variable between people and age groups. All asthmatics should be aware of the most common triggers; allergens (including mould), animal dander, strong odours, smoke, dust and dust mites, colds, flu and viruses, weather, exercise, reflux disease, foods, laughter and  even particular medications. It is important for an individual to recognise what causes an asthma attack for them and take precautions to avoid exposure.

Often people with asthma can suffer from night time coughing and wheezing and have shortness of breath and chest tightness during the night which can highly disrupt sleep and lead to daytime tiredness and irritability. It is thought that sleep itself or circadian rhythm has an influence on promoting these night time disturbances, leading to the term Nocturnal Asthma, although exactly how is not entirely clear.

Throughout the night airway resistance increases regardless of whether you are asleep or not, although it is more predominant if you are asleep. In combination with increased airway resistance nocturnal asthma symptoms may result from or be exacerbated by decreased respiratory function during sleep. Hormone sections that follow a circadian pattern may also have a contributing affect.

Although it is obvious that the afore mentioned environmental triggers can provoke an attack, studies report that when allergen exposure occurs in the evening, the body is more susceptible to having a late phase response of grater severity than if occurred during the morning. Late phase asthmatic response is characterised by an increase in airway responsiveness, development of bronchial inflammation and a more prolonged period of airway obstruction.

There are also a number of other underlying factors which may also help to explain why night time seems to exacerbate asthma symptoms:

Increased mucus or sinusitis with asthma is quite common. Increased drainage from the sinuses can also trigger asthma in highly sensitive airways.

Internal Triggers relating to sleep are being investigated as research suggests that breathing tests in nocturnal asthma sufferers are worse four to six hours after falling asleep.

Reclining position may also predispose the body to nocturnal asthma problems. Many factors can cause this, such as accumulation of secretion in the airways (postnasal drip), increased blood volume in the lungs, decreased lung volumes and increased airway resistance.

Air Conditioning or breathing colder air at night may also cause loss of heat from the airways. Moisture loss and airway cooling have been implicated in nocturnal asthma and are also important triggers of exercise induced asthma.

Hormones that circulate in the blood have well-characterised circadian rhythms. Epinephrine levels and peak expiratory flow rates are lowest at about 04:00am while histamine levels peak at this time. Epinephrine helps to keep the muscle in the walls of the bronchi relaxed so the airways remains wide and also supresses the release of histamine. Histamine can cause mucus secretion and bronchospasm. The decrease of Epinephrine during the early hours before morning may predispose the body to nocturnal asthma during sleep.

In addition to modifications to lifestyle and self-directed disease management, most people with asthma use a combination of quick-fix and long-term medicinal remedies. There is no cure for nocturnal asthma but daily asthma medications, such as inhaled steroids, are effective at reducing inflammation and preventing nocturnal symptoms. Long-acting inhaled corticosteroids may also be of benefit. Avoidance of potential allergy triggers such as dust mites or feathers in a down blanket may also be helpful in preventing nocturnal asthma attacks, so make sure that the bedroom is clean and free of dust.

It is important to note that sleep disturbance or insomnia is sometimes a side effect of asthma medication. Also, there is some evidence that people with asthma are at greater risk of developing sleep apnoea, a condition in which breathing is briefly and repeatedly interrupted during sleep. It is always recommended to discuss any sleep and respiratory problems with a health care professional. According to type and severity of asthma a doctor can prescribe treatment to help resolve nocturnal asthma and/or further refer for sleep testing at a centre if sleep disturbances are persistent after cessation of asthma symptoms.

Story source and further reading:

National Sleep Foundation

https://sleepfoundation.org/sleep-disorders-problems/asthma-and-sleep

Nocturnal Asthma

http://www.webmd.com/asthma/guide/nocturnal-asthma-nighttime-asthma

In 2004 a driver suffering an epileptic seizure crashed into another car and 22 month old Jet was killed. As a consequence this prompted the introduction of medical condition reporting legislation named Jet’s Law, whereby if you hold a QLD driver licence you are required to notify the Department of Transport and Main Roads of any long-term or permanent medical condition that may affect your driving ability. If you have any of the following medical conditions you should talk to your doctor regarding your duties as a driver licence holder;

• Alcohol or drug dependency
• Blackouts or fainting
• Diabetes
• Epilepsy
• Eye problems – e.g. cataracts
• Hearing problems
• Heart disease – e.g. ventricular assist devices
• Psychiatric disorders
• Sleep disorders – e.g. obstructive sleep apnoea
• Stroke

For people that have been diagnosed with a sleeping disorder such as obstructive sleep apnoea, a conditional licence, for either private or commercial purposes, needs to be considered by the driver licencing authority subject to periodic review and information provided by the treating doctor. However, this depends on the following two criteria: compliance with treatment and the response to treatment is satisfactory. Particularly commercial vehicle drivers diagnosed with obstructive sleep apnoea and require treatment, are required to have an annual review by a sleep specialist to ensure that adequate treatment is maintained. Failure to report your medical condition can result in a penalty of more than a $6000 fine and or disqualification from driving. Online forms are available at www.tmr.qld.gov.au/medicalconditions to report the medical condition or download the Medical Certificate for Motor Vehicle Driver form.

Effective from October 1 2016 there have been no fundamental changes to driving and sleep disorders. For some of the aforementioned medical conditions there have been some important changes made to the information presented in the 2016 Austroads guidelines for driving safety. The Assessing Fitness to Drive medical standards and guidelines are produced by the National Transport Commission and Austroads, with the aim to increase road safety by helping health professionals assess the fitness of their patients to drive, promote responsible behaviour of their patients with respect to their health and driving, conduct medical examinations for licensing of drivers as licensing author requirements and provide information to inform conditional licence decisions. Please take the time to view the link to the Austroads 2016 Driving and Your Health information fact sheet http://www.austroads.com.au/images/assessing-fitness/AFTD2016_Patient_Factsheet.pdf.

With technology being a major part of our busy lives today, there is no wonder that an increasing amount of people are having trouble letting go and falling asleep.  Electronic devices, such as televisions, mobile phones, tablets, and computers emit a blue light that mimics the act of daylight thus reducing the natural release of melatonin in the body.  This is a hormone which regulates our normal body clock sleep rhythm and is produced to make us feel sleepy and help get some Zzz’s.  However, keeping technology near us while trying to ‘hit the hay’ and decreasing our melatonin levels makes it harder to unwind and fall asleep.  Here are some tried and tested tricks for the next time your brain just wants to keep buzzing along.

1. Change your Sleep Environment.

 By dimming the lights as bedtime is approaching, melatonin is more likely to be released at appropriate levels.  This, combined with turning down the temperature, is suggested to be the best environment to sleep in.  Body temperature naturally decreases to initiate sleep, so proposing temperatures between 17-23^OC are optimal in facilitating this.

2. Ditch the Tech and Calm the Mind.

During the evening it is important to avoid caffeine and alcohol for the best night’s sleep as they generally stimulate the mind instead of relaxing it.  Before heading to bed it is more beneficial to drink warm milk or herbal tea as a soothing night time ritual.  Combine your drink while reading a simple book instead of using technological related devices to relax the mind even more.

Slowing breathing by inhaling through the nose and exhaling completely through the mouth is helpful in calming the mind.  Alternatively, lying on your left side and gently pressing on the right nostril to breathe in and out of the left nostril (or visa versa) can have the same soothing effect.

3. Sleepy Exercises (not the strenuous kind!)

Progressive relaxation exercises through self-induced tension can aim at relaxing the body from the day’s events.  Lying comfortably in bed, curl the toes, holding for a few seconds before releasing. Next, squeeze the calf muscles, hold and relax. Continue working your way up through the body and by time you get to the upper portion, you should be feeling sleepy.

The body has three acupressure points that are also linked to sleep onset.  There is one between the eyebrows, at the two of the nose.  A second spot is at the indent between the big toe and second toes, and a third just below the toenail of the big toe.  Pressing firmly on each spot and holding for 20 seconds helps release tension and relaxes the body.

So next time, if you’re having trouble falling asleep give these tricks a go and get a better night’s sleep, technology free.

Sleep disorders can inhibit the amount and quality of REM sleep we get, which not only impacts on the physiological benefits of REM (mood, memory and ability to learn), but perhaps the psychological benefits too.

Part 2

Before we delve into the type of exercise or medical cures that can help stop snoring, it is important to determine whether the type of snoring is indicative of a more serious health issue. If you notice any of the following sleeping/snoring behaviours; snoring loudly and heavily (+ feeling tired during the day), waking up gasping for air, waking up feeling like you are choking, falling asleep during activities such as driving or eating a meal, then snoring may be a warning sign. If you are concerned please see your Doctor to help investigate and/or rule out an underlying sleep disorder such as obstructive sleep apnoea (OSA) or other sleep-related breathing issues. It is important to rule out a sleep disorder, because if you have a sleep disorder the treatments below will only mask a symptom of the disorder; snoring.

Throat exercises to stop snoring

The muscles in the upper respiratory tract may be strengthened by performing the following throat exercises to stop snoring. Some of these may seem silly at first, but they are easy simple exercises that can be combined with every day activities such as when you’re in your car, walking your dog or while you are cooking.

• Close your mouth and purse your lips, hold for 30 seconds.
• Open your mouth and move your jaw to the left (hold 30 seconds) and then to the right (hold 30 seconds).
• Open your mouth and contract the muscle at the back of your throat (move the uvula – the dangling bit) for 30 seconds.
• Say a-e-i-o-u out loud for around three minutes.
• Move the tip of your tongue behind your front teeth and slide it backwards and forwards continually for around three minutes.

Medical cures for snoring

Following a Doctor’s consultation these medical cures can stop snoring.

• Continuous Positive Airway Pressure (CPAP) – the gold standard treatment for snoring and OSA. This device will blow pressurised air to keep your airway open during sleep.
• Traditional Surgery – Uvulopalatopharyngoplasty (UPPP), Thermal Ablation Palatoplasty (TAP) and Adenoidectomy – abnormalities (small airways, enlarged tonsils and adenoids) are surgically corrected by removing tissue to increase the size of your airway.
• Laser-assisted Uvulopalatoplasty (LAUP) – uses a laser to shorten the Uvula (dangly tissue at the back of the throat) to prevent the vibrations that create the sound when you snore.
• Palatial implants – small plastic implants are inserted into the soft palate (top of the throat) to help prevent collapse and cause the vibrations that create the sound when you snore.
• Somnoplasty – low levels of radiofrequency heat remove tissues of the uvula and soft palate (that vibrate during snoring). Procedure performed under local anaesthesia and takes about 30 minutes.

The recommended amount of sleep for an adult is around 7-9 hours. People who experience excessive sleepiness or hypersomnia go beyond the realm of the normal range and get too much sleep.  This is more than just catching up on lost sleep or recovering your sleep debt. The characteristics of hypersomnia can differ between individuals it is important to be aware of the symptoms. These can include;

• Need for daytime naps
• Sleeping for the recommended hours and still feeling drowsy
• Feeling tired all the time (once again regardless of hours slept)
• Your mind feels “foggy” making it difficult to think and make decisions
• Feeling apathetic
• Increased risk of accidents (specifically motor vehicle).

The causes of hypersomnia can be due to a wide range of effects or underlying conditions;

• Continually working long hours – can increase the need for extra sleep
• Shift work – if you work at night you may be out of sync with your circadian rhythm (body’s internal clock)
• Environmental factors – sounds waking you up (snoring partner, baby), temperature of room, mattress quality
• Mental state – anxiety and depression
• Medications – alcohol, caffeine, sleeping pills and antihistamines can all disrupt sleeping patterns
• Sleep disorders – underlying conditions such as sleep apnoea, restless leg syndrome, sleep walking, narcolepsy, idiopathic hypersomnia and insomnia could all disrupt sleep and cause fragmented sleep.

The following lifestyle changes such as good sleep hygiene could improve sleep quality and help with hypersomnia;

• Start a regular sleep routine – set bed time
• Exercise regularly and eat a well-balanced diet
• Try and relax before bedtime to prevent night-time anxiety
• Reduce or change sleep environment – room temperature, noise levels etc.
• Avoid alcohol, caffeine and even cigarettes before bed
• Brief “power” naps during the day

However, if you still experience hypersomnia despite making the advised lifestyle changes you should consider talking to a sleep disorders clinic to investigate an underlying sleep disorder.

Do you tend to have a different quality of rest whenever you spend the night somewhere new like staying in a hotel or a friend’s guestroom? A recent finding in the journal Current Biology reported that when you sleep in a new environment, only half of your brain is resting. During the first night of sleeping in a new environment, the left side of the brain is more awake than the right side of the brain. This could be a valid explanation as to why you feel tired after sleeping somewhere different or in a new place for the first time. Sleep researchers had previously coined this phenomenon as “first-night effect” after discovering that the first night of studying people in a sleep lab is usually so uncomfortable that the data collected may not be as consolidated as it would be in the home environment.

The report suggests that this common trait found in nature is seen amongst birds and sea mammals, as they frequently place half of their brain asleep, thereby allowing the other half of the brain to remain on guard. The study found slow-wave brain activity was greater in the right hemisphere of the brain than the left side. What is interesting was that as the study progressed, and after the first night of the study, there were no differences between the slow-wave activities of the two hemispheres of the brain. Apparently this involuntary behaviour stems from our natural instinct to be aware of predators while we sleep. Although for most of us that sleep in a secure environment, it is no longer necessary for the brain to be alert to respond to any kind of threat or danger. For now though, this seems a standard physiological response to a new environment.