To listen to the episode, click here.
Today we continue the conversation around sleep and fibromyalgia by looking into sleep apnea, another common medical condition in those with fibromyalgia.
For those meeting me for the first time, I am Dr. Michael Lenz, a pediatrician, an internist, and a lifestyle medicine physician. I have been a doctor for over 26 years. I blend the best of lifestyle medicine and medical management using an evidence-based approach. Fibromyalgia is complex and, for too long, has been ignored as a real problem, deserving of honest answers and practical solutions for real people struggling with pain, exhaustive fatigue, and debilitating brain fog.
While fibromyalgia is more common in women than men, sleep apnea is often considered in men, being eight times more likely to be recognized than in women. There are different reasons for this. Men are likelier to have classic sleep apnea symptoms such as snoring, witnessed apnea, and daytime sleepiness. Women are more likely to have less obvious symptoms like morning headaches, fatigue, insomnia, and exhaustion. These symptoms are more easily recognized as depression and fibromyalgia. As we heard in last week's episode, sleep problems precede the development of fibromyalgia. Last week you heard how those with fibromyalgia often have disrupted sleep due to different brain processing demonstrated by alpha waves with delta wave disruption during Non-Rapid Eye Movement sleep.
These sleep apnea symptoms of fatigue, insomnia, cognitive disorders, and morning headaches in female patients with FM overlap, indicating a common pathophysiology. Does the diagnosis of FM in female patients make us overlook the diagnosis of sleep apnea?
A study with the link in the show notes looked at how common sleep apnea was in women with fibromyalgia. It also looked at the intensity of impact sleep apnea severity had on fibromyalgia symptoms.
OSA was detected in 66% of the participants. Of the 9 patients with moderate OSA, 6 underwent a CPAP titration study following PSG, along with all eight patients with severe OSA. The sleep laboratory made an appointment for a CPAP titration study for three patients with moderate OSA. Additionally, seven patients who used the CPAP device for at least one month significantly improved their pain and SIQR symptom scores after treatment compared to the pre-treatment scores. The SIQR is the same as the fibromyalgia impact score and is a helpful tool to assess the impact of interventions like treating sleep apnea. The results of the present study are consistent with those of a study that reported a significant improvement in FM symptoms following a 3-week course of CPAP therapy in 14 patients with OSA and FM.
A separate study showed that 50% of the women with obstructive sleep apnea or upper airway resistance syndrome had chronic pain and more than 11 tender points. This prevalence is about ten times the average population. This observation strongly supports screening for sleep apnea in those with fibromyalgia.
The prevalence increases as you get older, have a higher body mass and go through menopause in women.
What is obstructive sleep apnea?
Obstructive sleep apnea is a public health problem, and it is associated with impairment in the quality of life.
According to the literature, sleep-disordered breathing (SDB) is defined as obstructive breathing episodes occurring exclusively during sleep. It is related to the relaxation of the pharynx and the consequent increase in upper airway resistance. The muscles that support your pharynx have both involuntary and voluntary muscle control. We can initiate swallowing, but the automatic rhythmic movement of food to our esophagus prevents us from aspirating foods into our lungs. It is an incredible coordination of muscles we take for granted until it stops working well. Voluntary control is important because when we are sleeping, our voluntary muscles relax throughout our bodies. This relaxation of our throat muscles, anatomical variation, crowding from weight gain, and general laxity of tissues can cause the pharyngeal area in the back of our throat to narrow. The degree of pharyngeal occlusion varies. If there is a reduced airway, airflow can be restricted enough to cause snoring, also known as audible breathing. What is worrisome is when the airflow is greatly limited to the point where the intake of oxygen and release of carbon dioxide is compromised. This reduced airflow can lead to major consequences, including increased upper airway resistance causing the individual to awaken. There can also be hypopnea, which means minimal airflow well below your body's needs to function optimally. Complete collapse of the pharynx causes apnea, where no airflow occurs and oxygen levels drop even more. This causes an increase in arousal, also known as awakenings or sleep disruptions, where sleep is broken but is usually unaware. This can be measured by in-house sleep studies where brain waves are measured. These arousals fragment sleep and result in nonrestorative sleep, excessive daytime sleepiness, fatigue, decreased libido, headaches, and body pain, as well as mood disorders, such as anxiety, lack of concentration, irritability, apathy, and symptoms of depression.
A quick screening tool is the STOP-BANG questionnaire.
The STOP-BANG acronym stands for: Snoring history, Tired during the day, Observed stoppage of breathing while asleep, High blood pressure, BMI more than 35 kg/m2, Age more than 50 years, Neck circumference more than 40 cm, and male Gender.
If you have witnessed apnea by itself by your partner, that in itself should prompt an evaluation for sleep apnea. The tricky part is that your sleep apnea could be missed if you don't have a partner or your partner is such a deep sleeper they have yet to report sleep apnea to you. They may have informed you that you snore, however. Sometimes the apnea can sound like choking or gasping for air after the adrenaline release prompting arousal and movement. This repeated adrenaline release puts the sympathetic nervous system into action throughout the night. Two nervous systems control automatic functions in the body; One is the sympathetic, and the other is the parasympathetic systemic. An easy way to remember the differences is to think of a parachute where you are gently floating and relaxing. This system should be active while sleeping to get the needed recovery that your body needs.
Unfortunately, the sympathetic system gets activated in sleep apnea throughout the night. This can cause an increase in potentially deadly consequences such as a fatal heart rhythm or even a heart attack or stroke, let alone feeling exhausted the next day. It can also lead to fatal consequences during the day, including driving impairment equal to and surpassing driving while intoxicated.
If you don't have sleep apnea, but your partner does, this can also cause significant sleep disruptions, especially if you have a more vigilant fibromyalgia-type nervous system. You are more likely to be a light sleeper, sensitive to noises, and less likely to be able to get into the deep sleep that is needed leading to fragmented sleep. We talked about this last week with fibromyalgia symptoms being turned on by playing noises during sleep lab experiments to people who didn't have fibromyalgia. Your partner must get treated, but until then, you need to move to a different bedroom if possible. One of my patients whose wife snored loudly cured his migraines by wearing earplugs at night, allowing him to get deep sleep.
The good news is that sleep apnea is very treatable. Sleep apnea can be effectively treated with a CPAP machine. CPAP stands for continuous positive airway pressure. This pressure prevents the throat from collapsing and, with proper coaching, works in about 90% of patients.
Other options include a mandibular oral device that moves the lower jaw forward and the back of the tongue out of the way.
Another option is Hypoglossal nerve stimulation involving an implanted medical device created by Inspire Medical Systems. It treats patients with obstructive sleep apnea by stimulating the hypoglossal nerve in a rhythm synchronized with the patient's breathing. This stimulation helps keep the patient's airway clear during sleep.
The hypoglossal nerve is a motor nerve that stimulates several muscles in the tongue. These are involved in movements that make the tongue protrude (push forward) and retract (pull back).
Patients with OSA have decreased muscle tone in the genioglossus muscle, one of several muscles stimulated by the hypoglossal nerve. This results in the tongue retracting back into the throat during sleep, obstructing the airway, blocking the flow of air, and reducing oxygen levels in the body. While continuous positive airway pressure (CPAP) therapy keeps the airway open using continuous air pressure, the hypoglossal nerve stimulation implant sends a gentle pulse synchronized with the patient's breathing. This pulse signals the hypoglossal nerve to move the tongue forward, relieving the airway obstruction and allowing uninterrupted airflow.
Once the device is implanted, the physician will program the settings. The person with the implant is then given a sleep remote, which they can use to turn on the device before bed and turn it off upon waking. They can also adjust stimulation within a range determined by their physician. It is like a pacemaker but for the tongue and not the heart.
It is also important to mention the benefit of weight loss in treating sleep apnea. The prevalence of obesity in FM patients is about 40%, and of overweight is about 30%.
Excess weight creates fat deposits in a person's neck called pharyngeal fat. Pharyngeal fat can block a person's upper airway during sleep when the airway is already relaxed.
Additionally, increased abdominal girth from excess fat can compress a person's chest wall, decreasing lung volume. Increased abdominal fat can limit the excursion of the diaphragm. This reduced lung capacity diminishes airflow making the upper airway more likely to collapse during sleep. OSA risk continues to increase with a rising body mass index. Even a 10% weight gain is associated with a six-fold increase in OSA risk. Looking on the positive side, a 10% weight loss can lower sleep apnea significantly
Losing weight can also significantly reduce many sleep apnea related symptoms, such as daytime sleepiness. Irritability and other neuropsychiatric dysfunctions markedly improve as well. There is an overall improvement in cardiovascular health, high blood pressure, insulin resistance, type 2 diabetes, and in particular, quality of life. Weight loss of just 10-15% can reduce the severity of OSA by 50% in moderately obese patients. Unfortunately, while weight loss can provide meaningful improvements in OSA, it usually does not lead to a complete cure, and many sleep apnea patients need additional therapies.While excess weight has long been known to be a risk factor for OSA, an increasing amount of evidence suggests that obstructive sleep apnea increases the risk of weight gain. One reason is that sleep deprivation is associated with decreased leptin (an appetite-suppressing hormone). Also, there is increased ghrelin (an appetite-stimulating hormone), which may increase cravings for calorie-dense foods. These are significant obstacles to overcome.
It also appears that OSA patients, in particular, may be more susceptible to weight gain than people who have the same BMI and health status but do not suffer from sleep apnea. in one study that showed people with OSA around 16 pounds in the year leading up to their OSA diagnosis compared with BMI-matched people without OSA.
Sleep apnea can also deplete people of the energy they need to maintain healthy body weight. Evidence suggests excessive sleepiness may lead sleep apnea sufferers to exert less physical activity during waking hours. This may be particularly problematic for obese people, who frequently experience shortness of breath and chest discomfort with physical effort, resulting in reduced exercise. Without dietary changes, decreased activity levels can lead to additional weight gain. This reduction in activity is significant for those with fibromyalgia because regular exercise is also needed to reduce fibromyalgia symptoms.
These all combine to being caught up in a metaphorical quicksand that seems almost impossible to escape, leading to despair. If this is you or someone you know, there is hope. At a minimum, today, I hope you have learned that getting evaluated for sleep apnea is essential, but it is even more critical for those with fibromyalgia.
Treatment of fibromyalgia takes a multifaceted approach. It is very complex, with many bi and tri-directional relationships that need to be navigated. It can seem unfair, but at least you are growing your understanding which is a big start. Suppose you are trying to be able to conquer your fibromyalgia. In that case, you need an excellent scouting report, a thorough understanding, and perspective. My goal with the book and podcast has been to inform you of these challenges so you can be better prepared to tackle them.
One of the biggest compliments you can do if you have enjoyed the show is to leave a review, and a 5-star rating, hit the like or subscribe button, and share with others.
Next week will discuss other continued sleep challenges to your battle with fibromyalgia.
Until next week, Go, team Fibro.