Perfection impedes achievement

Dealing with Sleep Apnea

Preceding pages

Overview

As discussed in the above pages, I suffer from severe sleep apnea. Over the years, I have developed a treatment which allows me to manage my sleep apnea with only a mouth appliance. This treatment combines the following:

Some of the above elements are preventative (lifestyle, discipline) others are curative (back exercises). As I discuss each of these in separate sections below, please bear in mind that the treatment requires all elements to be used in conjunction with each other. The final section summarises how these elements work together as a therapy:

Context - Who am I

First of all, to place this treatment into context, let me briefly describe myself.

At the time of this writing, I am in my mid fifties. I started to suffer from sleep apnea in my late forties and have now been using this treatment for the last 3 years. I am approximately 185 cm tall with broad shoulders. My weight fluctuates around 100 kg however because of wide frame I only appear slightly overweight. I am reasonably fit, love playing fast eye-hand co-ordination sports but have to live with my farming ancestry that endowed me with flat feet and weak knees.

There are 2 additional aspects which assist with context:

  1. I don’t move when I go to sleep. I wake up in the same position that I was in when I fell asleep.
  2. Several times during my life, my local doctor has mentioned how tight my back muscles were. Nothing further was done about this nor did I worry about it as it did not seem to adversely affect me in any way.

Disclaimer - Please note the following: I am not a doctor nor a health professional. You should discuss this treatment’s suitability with your health professional before using it. Also this is not a mainstream sleep apnea therapy. I recommend being familiar with mainstream therapies before reading about this alternative therapy.

Therapy

Now let’s discuss the therapy.

Detection

The first step in this treatment is to know when you have sleep apnea and then determine which sections of your air passage are affected. You should be able to carry out this detection both when you are asleep and when you are awake. Being able to detect sleep apnea while you are awake allows you to practise this skill so you can do it more efficiently when you wake up at night. It also allows you to get a better understanding of your body; its susceptibility to sleep apnea and patterns which bring it about. The following 3 tests can be used:

Raspy breathing test

Raspy breathing (like snoring) or snorting sounds while breathing are good indicators of sleep apnea. If you wake and your breathing is raspy (like snoring) then you are almost certainly suffering from sleep apnea. However it can be more subtle than that. If your sleep apnea is mild, your muscles may automatically compensate while you are awake to keep your air passages open. To check for mild sleep apnea, follow the steps below:

  1. Stand up straight but maintain a relaxed state.
  2. Ensure your neck, shoulders and back are not tense.
  3. Breathe.

Most likely the sleep apnea is caused by your airways being slightly constricted and the air vibrating the relaxed walls of your air passageways. By tensing sections of your neck, shoulders, chest and back, you can determine which parts of your air passage are constricted and are interfering with the airflow. Being able to quickly detect which part of your air passage is constricted way will assist with treating it during sleep periods so it is useful to practise this technique while awake.

Chest breathing test

Breathing can be carried out in 2 regions of your body: chest and stomache. Generally, stomache breathing is the recommended breathing method. It allows you to use your entire lung capacity and delivers more oxygen into your bloodstream.

Sleep apnea can deactivate your lower back muscles and prevent your abdominal area from expanding. If this occurs, your body may compensate with chest breathing. If your upper back muscles are not yet affected, the air passage down to your chest will not be constricted and your breathing will not be raspy. However already the level of oxygen transferred to the bloodstream is reduced and it is quite likely that it will reduce further if sleep apnea starts to deactivate the upper back muscles.

So chest breathing is an indicator that sleep apnea is on the way.

To test for it you first need to be familiar with your normal breathing style. Do you use your chest, stomach or both? Then, when you wake up in the middle of the night with shallow breathing, you can quickly check if your breathing is not using your stomach region in the normally way.

Vivid dreams test

Research has shown that sleep apnea sufferers can experience vivid dreams. So if you wake up in the middle of the night and strongly remember a dream, then it is likely that you have sleep apnea. Do NOT immediately rollover and go back to sleep. Use the other 2 tests to check whether you are suffering from sleep apnea.

Sleeping Posture

Posture is important for sleep however it is even more so when you suffer from sleep apnea. As mentioned above, I do not move when I fell asleep and will wakeup in the same position I went to sleep in. So it is extremely important to work out what sleeping position best delays the onset of sleep apnea and the constriction of the air passage in your throat, neck and chest.

I suspect that the optimum sleeping position will differ from person to person. Most likely some experimentation is required to determine what position works best for you. My experimentation has (so far) suggested that the following works best for me.

  • I sleep on my side on a pillowtop mattress. The mattress is firm but not very firm. Since I do not move or turnover during sleep, I find that very firm mattresses cause pressure sores on my hips.
  • It is important that my pillow supports my head so that my neck aligns with my spine in a straight line. This requires that the pillow support my head at the correct height within 1 centimetre. Any greater deviation and snoring will be introduced into my breathing due to my air passageway not being straight. Firm pillows are the best however they have to be quite high (especially if you have broad shoulders like I do.) You can buy high firm pillows from specialty sleep stores but they are expensive. A good alternative is to buy a high foam memory pillow and place a skinny flat pillow on top of it. The combination makes a surprisingly firm pillow. It also makes it easy to adjust to get the correct height - especially if you get the contoured foam memory pillows which have different heights at their long edges.

  • When sleeping on your side, the main supports for your torso are your shoulder and your hips. Your back can sag between these two support points causing your air passage to lose its straight alignment. In my case, this loss of alignment causes the onset of severe sleep apnea within a couple of hours after going to sleep. My solution to this is to use a towel to provide extra support for my torso. I roll it up and position it on the bed just below where my shoulders lie. That is, the top part of my chest is supported by the rolled up towel. It takes a lot of experimentation to figure out a placement of the towel that works well. It needs to be sufficiently rolled up to provide the correct amount of support for your chest. Not enough roll-up and there will be insufficient support to counteract the sag. Too much roll-up and it will put your back out of alignment by pushing your chest up too high. If you roll it up too tight, it will be too painful to sleep on. I find that if I position it too close to my shoulders, then it can restrict blood flow to my arm causing me to wake up with my arm tingling (or asleep) due to lack of blood flow. I have also found that by placing the towel at an angle to my body instead of 90 degrees perpendicular (closer to my feet at the front), I can position the towel closer to my shoulder where it seems more effective.

  • In regards as to how to position my arms, legs, knees, head etc., I have come to the conclusion that it is best to do what is comfortable. Any benefits in reducing sleep apnea are minor and are outweighed by the importance of comfort giving a good night’s sleep.

Mouth Appliance

A mouth appliance (or oral appliance) is typically considered as a sleep apnea treatment in its own right. In this therapy, it is just one component - an important component - but not more so than other cornponents.

Mouth appliances are very effective at reducing sleep apnea in the neck & throat. Their therapeutic effect can be extended a short distance down the back by forcing the lower jaw forwards. However once a person’s sleep apnea condition extends down into their back (is no longer mild), then a mouth appliance itself is no longer sufficient for a good night’s sleep. When this occurs, you can replace it with an alternative treatment such as CPAP, or you can use it in conjunction with a treatment which targets the sleep apnea in your back see next section

In this therapy, mouth appliances are only used to treat sleep apnea in the throat. It is configured accordingly. For a start, no attempt is made to use the mouth appliance to force the lower jaw forward. This makes it a lot more comfortable to ‘wear’ at night.

For me, the most important function of my mouth appliance is to increase the separation between the rear of my upper and lower jaw. That is, it pushes the back of my upper jaw up a bit and pushes the back of my lower jaw down a bit. Some pictures of my mouth applicance can be viewed here.

The sleep clinic, (SleepWise), which fitted my mouth appliance was very helpful and created my appliance with the amount of rear jaw separation I requested. Before my fitting appointment, I had worked out the jaw configuration (mainly the amount of rear separation) that I wanted. During the appointment, they provided me with an oversized mockup of the appliance. I tried it on while lying down and provided them with feedback regarding the fit. Based on my feedback they shaved back the mockup until I was satisfied with the fit. They then used this mockup as a template for sizing my mouth appliance.

I have now (Dec 2017) had this appliance for about 4 years. It broke a couple of times in the first year but then SleepWise repaired it with some metal reinforcing and it has been good ever since. Actually not just good but great! It’s comforting to know that when I putting it into my mouth at night, it will prevent sleep apnea in my throat. It doesn’t help with sleep apnea in my back but that is addressed in the next section.

Back Exercises

As discussed in the preceding page, I believe that the main issue with acute sleep apnea is inactive back muscles not maintaining the air passage down to the lung to allow unrestricted airflow and preventing tummy breathing by not assisting diaphram expansion. To fix this problem, we need to reactivate these muscles.

The key to activating these muscles is to give them a gentle semi circular rolling prod. Let’s call this a «roll prod». The roll prod is very localised. Imagine your back is a grid of squares, each being approximately 1 centimetre wide and high. The grid extends from your shoulders to the bottom of your back and wraps around to the sides of your back. Each square in this grid needs to be «roll prodded».

So what is a «roll prod»? Focus on the bottom of the square. Imagine you are rolling over that square; push it up and then push it in at the top (the prod). You are obviously not rolling over the muscle under that square. It is just a slight upwards twist with a prod at the end of the twist.

While sitting down, start at the top/centre of your back; at the base of your neck. Perform a roll prod at this square. Then move to the squares either side of this (to the left and right). Do a roll prod at these 2 squares. Repeat with squares moving towards the side of your back. Once you reach the side, move down to the next row and roll prod all squares from your sides back to the centre (your spine). Repeat going all the way down your back.

It is easy to do 2 roll prods at once if the squares are at symmetrical positions on your back. That is, on same row and same distance from centre (to left & right). By doing 2 at once, it halves the time it takes to reactivate all the muscles in your back. Typically this takes me about 15 minutes.

When performing the prod part of the «roll prod», there will normally be a gentle crunch sensation. I am not exactly sure what causes this. If you repeat the prod at the same location, the crunch sensation will be less and it will generally not occur for any further prods at that location. However, important note: Do NOT prod a rectangular location more than once. The soft crunch probably results in some irritation of the bone or muscle at that location. A single prod does not seem to cause any irritation. You may want to discuss this aspect of this therapy with your relevant health professional.

As you proceed with this therapy down your back, you will notice that your breathing improves. As you reactivate the muscles, your breathing becomes less raspy. By the time you reach the small of your back your breathing should no longer be raspy. However do not stop at the small of your back. Continue to the bottom of your back to reactivate the muscles that assist with stomach breathing.

Very occasionally when you roll prod, a click will occur as a bone moves back into place. If you have been to a chiropractor, you will recognise the click as the same that occurs when the chiropractor works your back. It actually feels quite good - and when it occurs, there is a substantial improvement to your breathing. However, if you are concerned, please consult your health practitioner.

For me, the second most hardest part of the back exercises is getting up at night to perform them. Almost every time I wake up at night, I need to perform these exercises. On a cold night, when you are warm in bed, it is very tempting to roll over to your other side and go back to sleep. This is a mistake! Always check for sleep apnea, and if it is present, perform the back exercises. The alternative is to suffer the zombie like tiredness the next day. Nowadays I mostly only have to get up once a night, however on a bad night, I may need to carry out these exercises 3 times.

The hardest part (for me) is falling back to sleep. If I carry out the exercises early in the night, then I normally fall back to sleep reasonably easily. However if morning is only a couple of hours away or work is presenting stressful issues, then I may not be able to fall back to sleep. To handle this, I need strategies that allow me to catch up on sleep. This is discussed further below.

Two final warnings:

  1. Only carry out these back exercises when your back muscles are deactivated (that is, when you wake up at night and your breathing is raspy). It is possible to do these exercises during the day - say, for example, when you are sitting down at work and notice that your breathing is a bit raspy. Avoid doing the exercises in these circumstances. Your muscles/bones will become irritated and sore and may take a day to recover. Most likely this not good for your back in the long run.
  2. Do not perform these back exercises while standing up. While it is easy enought to perform these at night while standing or walking, I have found that this also tends to irritate your bone/muscles. Make sure you are seated while performing these exercises.

Once again, discuss with your health professional for more information.

These back exercises are both the hardest and the most important part of this sleep apnea therapy. It will take a bit of practise and discipline to get them right. But it is worth it. It is such a joy, ,, after completing them, to go back to bed and have your breathing working properly.

Exacerbation Factors

So what causes sleep apnea? What makes your muscles stop performing properly. I certainly don’t know the answer to these questions. However I have found that some factors exacerbate the condition - make the muscles go to sleep more quickly after going to going to bed at night. Below are a few factors that I believe have an impact.

Sleeping Temperature

Most people probably like a warm cosy sleeping environment. I personally find that getting the right amount of blankets/doonas (3 in winter, 1 in summer) to get a comfortable temperature in bed makes a big difference to how well I sleep. However with sleep apnea, I have found that it is better to have the temperature a little bit on the cooler side. Still in the comfortable range but if you are unsure about the extra doona, then leave it off.

Tiredness Management

Avoid going to bed being over-tired! During the night, you want to be woken up as soon as sleep apnea starts affecting your breathing. When this occurs, you need to immediately get up and carry out back exercises. If you are very tired, this can either:

  1. delay your waking up.
  2. make it too hard to get up and do your back exercises when you do wake up.

If you do not get up, then eventually, as the night progresses, you will not be able to sleep as the sleep apnea restricts your breathing more and more. However by this stage it will be too late. You will have to face the headaches, lethargy, extreme tiredness and zombie like experience the next day.

Develop good sleep habits. There are lots of sites on the website which discuss sleep habits (an example). Below is my abbreviated list of things I do to manage tiredness

  • Go to sleep when you are become tired at night - preferably around the same time.
  • Develop routines at night time that calm and settle you (eg. watch a few ad breaks of TV, talk to your partner, do the dishes). Experiment to determine what works for you.
  • Be careful about what you eat for dinner. I find some foods make it much harder to get a good night sleep. Once again work out what works and stick to it.
  • Try and not use the alarm to wake up in the morning. If you find you need an alarm, then try and get to bed earlier.
  • Try not to carry sleep debt. If you have a bad night’s sleep, see if you can organise your next day to catch up on sleep (not easy to do). Use the weekend to catch up on missed sleep. My work can be quite demanding and I often need to get extra sleep across the weekends to pay off sleep debt.

I know it all sounds very boring. Shouldn’t go out; spending your weekends sleeping; becoming very conservative with your food choices. But that’s the price you (well at least I) have to pay for being able to walk around when you are awake with enthusiasm and a twinkle in your eye.

Exercise

Getting the right amount and type of exercise has a huge impact on sleep apnea. It is probably obvious that no exercise is bad. However strenuous exercise also seems to have a detrimental impact on sleep apena. It seems that consistent exercise with mild impact on your back is best.

Walking is great. If I don’t do any other exercise, I make sure that I walk for at least 90 minutes a day. Its actually easy on workdays because my travelling to and from work requires that amount of walking. Cycling is also good but I expect long periods in the saddle would be detrimental. Swimming is ok if you stick to gentle breast stroke.

As mentioned above, I enjoy fast hand/eye co-ordination sports like tennis and table tennis. I find that sleep apnea is somewhat worse on the night after a demanding match however there seems to be a beneficial carry over effect on subsequent nights. In my view, the positives from participating in these sports are way in excess of the extra sleep apnea caused on the following night which can be easily managed by an extra back exercise session during the night.

Diet

I am sure that diet affects sleep apnea. However I have only identified one food that made an obvious difference. Spinach! There seems to be a strong correlation between eating spinach and delaying the onset of sleep apnea after falling asleep. I think that some other green leafy vegetables (chinese broccoli?) have a similar beneficial effect however spinach seems to be the most effective.

Skills

There are lots of elements in this therapy but the 2 main skills you need are:

Muscle control

To carry out the back exercises you need to be able to exercise muscles in your back in very specific locations. Typically we do not think about exercising individual muscles. We just carry out a movement, like say lifting our arms, and all the relevant muscles perform to carry out that task. Many years ago, I went to a physiotherapist who assisted me with rehabilitating my knee after some arithroscopy surgery. He wanted me to exercise specific muscles in my knee. I did not think this was possible but with his guidance, I learnt how exercise these muscles. It really just needed for me to very much focus on that muscle. The more I practised, the better I became at exercising specific muscles.

The same applies to doing the back exercises. Focus on a specific point on your back and exercise the muscle at that point. With practise it becomes easy. Once you can do it at one point, you should then try and do it at 2 points at once where the 2 points are at the same left/right symmetrical position on your back.

If you would like some further assistance with these back exercises, you could consider the assistance of a physiotherapist - preferably one with musculoskeletal/orthopedics specialist skills. The therapist would need to review this sleep apnea therapy so that they develop an understanding of what you are aiming to do. Also I would advise you meet the therapist as early as possible in the morning as the exercises are easier to do when your back muscles are not ‘too’ activated by daily activities.

Discipline

Discipline is needed in several aspects of this therapy. The most important discipline challenge is getting up at night to do the back exercises. You wake up at night; warm in bed; breathing seems to be ok; it may be cold outside; you may not get back to sleep easily if you spend 20 minutes doing back exercises. It is so tempting to stay in bed, roll over, and go back to sleep. You need the discipline to at least get up and properly check for sleep apnea. Most likely it will be present and you will need the discipline to do the back exercises. Hopefully the consequences of not getting up will be sufficient to encourage you to quickly develop this discipline.

Then there is the lifestyle changes. Getting to bed early, avoiding specific foods you may like, making sure you exercise appropriately. I believe this even more harder than getting up at night for back exercises. Chances are that it will take a long time to make these lifestyle changes. The discipline here is with perserverance. Work hard to build up the new habits needed. Whenever you fall back to the old habits, as I suspect you will, maintain the discipline to recommit to the struggle to to build the new habits.

Putting it all together

Let me summarise the main points of this therapy in a short list:

  • Learn to recognise sleep apnea when you are awake.
  • Get an oral mouth appliance which maintains vertical separation between the back of your upper and lower jaw.
  • Work out a sleep posture that keeps your neck and back aligned in a straight line during the night.
  • Whenever you wake up at night, check for sleep apnea and carry out back exercises if it is present.
  • Make sure you get enough sleep.
  • Walk at least one hour a day (or an alternative exercise)

I have been using this therapy for several years now and it has successfully allowed me to manage my sleep apnea. The only times I can remember experiencing the delibating effect of zombie like tiredness caused by sleep apnea is when I have gone away and forgotten to take my Mouth Appliance. But everyone is different. Your sleep apnea may be different from mine. Remember that I am NOT a sleep specialist. This is just a therapy I worked out by experimentation that works for me.

So talk to your health or sleep specialist. Experiment with the techniques I have discussed above. If it helps you, or anyone you know, overcome the scourge of sleep apnea, then send some karma my way.

Good luck, good health and most importantly, a good night sleep.