Conquering the Sleep Struggle with Roger Seheult, MD

[00:35] Dr. Linda Bluestein: Welcome back, every bendy body. This is the Bendy Bodies Podcast, and I'm your host and founder, Dr. Linda Bluestein, the Hypermobility MD. This is going to be a great episode, so be sure to stick around until the very end so you don't miss any of our special hypermobility hacks. As always, this information is for educational purposes only and is not a substitute for personalized medical advice. Wow, this is going to be such a great conversation. The questions about sleep and chronic illness, chronic pain, and joint hypermobility just flooded in. And so I'm so thrilled to introduce your guest today, Dr. Roger Seheult. Sleep medicine is just one of his four board certifications. Dr. Seheult is currently an associate clinical professor at UC Riverside School of Medicine and an assistant clinical professor at the Loma Linda School of Medicine and Allied Health. He practices as a critical care physician, pulmonologist, and sleep physician at Optum California. Dr. Seheult lectures routinely across the country at medical conferences. And not only that, he actually founded a medical education company, MedCram LLC, with Kyle Allred. Their CME-accredited videos are utilized by hospitals, medical schools, and hundreds of thousands of medical professionals from all over the world. And he actually has over 1 million YouTube subscribers. Incredible. His passion is promoting healthy lifestyles and regularly lectures to schools, hospitals, and media outlets. His passion is demystifying medical concepts, and he has received many awards for his amazing work. Dr. Seheult, hello and welcome so much to Bendy Bodies.

[02:23] Roger Seheult, MD: Thank you so much, Linda, Dr. Bluestein. It's great to be here.

[02:28] Dr. Linda Bluestein: Okay, Dr. Seheult, I'm so excited to chat with you about sleep. This is such an important topic. Why should people who have chronic illness, chronic pain, and joint hypermobility care a lot about this topic?

[02:40] Roger Seheult, MD: Sleep is incredible. It's something that we do for hopefully a third of our life, and it's during that time of sleep that most of the body's repair processes occur. So it's really, really important that we get enough sleep, that the sleep that we do get is good quality, because it's going to make our lives so much better.
[03:02] There's an analogy I like to give. I had a friend in high school who worked at Disneyland, and he worked there when everybody went home. He was part of the night crew. And if you've ever been to Disneyland in Southern California, in Anaheim, it's a busy place to be, especially during the summertime. But it's even busier, some could say, at night. It's because at night when the park shuts down and the people go home — this is our analogy for sleep — that's when the engineers come in and they inspect the rides. That's when the gardeners come in and they dig the weeds out. They basically make the park acceptable and rejuvenated, ready to open up the next day.
[03:44] The same thing happens in our body. Disneyland's a very complicated place, but our body is even more complicated than Disneyland. And so all of the body's restorative things that are timed on a circadian rhythm — we'll talk more about that — occur when we sleep. So we really ought to be getting the best type of sleep that we know how.

[04:03] Dr. Linda Bluestein: I love that analogy. That's really fabulous. I think a lot of people can relate to that. So that's great. Let's talk about the circadian rhythm, because that's so incredibly important. Can you explain what that is and why people should care about it?

[04:16] Roger Seheult, MD: Yeah. So in every one of our cells in our body is a clock that tells it when things need to happen. That's actually being worked out with genes and proteins. And it turns out that these processes take about 24 hours, but there is a master clock. There's sort of like the atomic clock in Greenwich, England that we have for the world that tells us what time it really is. We have one of those master clocks in our brain. It's located in something called the suprachiasmatic nucleus. And this is the master clock that tells the whole body when the timing is for all these sorts of processes that occur in the body.
[04:54] We may think, yeah, sleep is one of those things, but in fact, almost all of the processes in our body are actually attached to this clock. For instance, this was mind-blowing to me when I found this out, but we've done hundreds of thousands of studies on medications, on medication side effects, on medication effects. And it's turned out that some scientists have looked at all of this data and have said now that it all needs to be sort of relooked at, because when you have medication side effects, it's actually dependent on what time of the day you've taken that medication.
[05:36] Here's something that's even more mind-blowing that might hit closer to home. My wife was a really big believer in our kids being breastfed, and our kids didn't like to be naturally breastfed. So my wife would pump and she would store the milk in a fridge. We didn't realize this at the time, but scientists have actually done work showing that there are certain hormones, chemicals, and things of that nature in breast milk that are expressed during the day versus at night. And the point is that this is actually training the baby in terms of what time of day it is. I bring these up as examples to tell you that this idea about the circadian rhythm is not just about sleep, but it actually impacts just about every aspect of our life.
[06:30] I'll give you some hard examples here. We now know that insulin, which is the hormone responsible for putting glucose into our cells, is actually more sensitive in the morning than at any other time of the day. So if you were to eat a bolus of glucose or some sugary food in the morning versus in the evening, it would take higher amounts of insulin in the evening to deal with that same amount of carbohydrate than it would if you had that carbohydrate in the morning time.
[07:05] Another example would be alertness, our ability to concentrate, our ability to do hand-eye coordination. These are maximal in the early afternoon and less so in the evening — to the point that when athletes are training for a particular race, or people who are very aware of this when studying for an examination, they have been trained to make sure that they're doing that training at the same time of day they will be tested. That's how important circadian rhythm actually is.

[07:38] Dr. Linda Bluestein: That's fascinating because the NFL, I'm thinking, used to have games pretty consistently in terms of time of day, and now they're having more night games, and now they're having some games in Europe. So that's a really interesting —

[07:59] Roger Seheult, MD: And imagine teams on the East Coast having to fly to the West Coast and having those games fall much later in their circadian rhythm than it would normally be. Absolutely.

[08:09] Dr. Linda Bluestein: Yeah, definitely.

[08:12] Roger Seheult, MD: Getting back to that, the suprachiasmatic nucleus is the master clock that entrains all of the other clocks to be working at the same time. If you want to imagine it this way, imagine a symphony orchestra. You have the first violins, the second violins, the third violins, the tuba, the timpani, the brass section, the woodwinds. All of those have particular music that they have to play. They know what that music is. They've practiced it by themselves. But when they come together to play as a group, they can't all decide when they're going to start playing. That's when you need a conductor to say, we're going to start the music now. And it's only when you have that conductor putting all of these musical instruments together that you have the ability to have a performance of a symphony or a concert. The word "concert" means "together," and that is why it's called a concert.
[09:07] And that's what the master clock does. We'll talk about this in this podcast, but there are certain things that affect the timing of that conductor. There are things that delay the conductor. There are things that speed up the conductor. There are things that suppress the conductor. And all of those things are going to affect the performance of the piece. And that's what we are — we are the performance of that piece.

[09:33] Dr. Linda Bluestein: Wow. And it's the suprachiasmatic nucleus. I didn't say it quite right.

[09:34] Roger Seheult, MD: Suprachiasmatic nucleus.

[09:37] Dr. Linda Bluestein: Chiasmatic.

[09:39] Roger Seheult, MD: SCN. Yes. SCN.

[09:41] Dr. Linda Bluestein: And where is that located?

[09:41] Roger Seheult, MD: That is located around the thalamus, hypothalamus area. It's at the base of the brain. It's actually not too far away from the pineal gland, which is one of the major outputs and inputs of that. And that is the creation and the production of melatonin, which we'll talk more about as well.

[10:01] Dr. Linda Bluestein: I can't wait to get to that. That's going to be super helpful and super important. Okay. So light — I know you have so many fantastic videos about light. I have to confess, I've binged on your MedCram videos because they're so helpful and you have so much depth of information on there. And you talk a lot about light. Can you talk about why light is so important, especially when people have chronic illness?

[10:32] Roger Seheult, MD: Yeah, so there are two aspects of light that we can talk about. The first aspect is about circadian rhythm, and we'll talk about that right now. But there's another whole aspect of light that sort of bypasses circadian rhythm, and this is the type of light that we get from natural sunlight that can penetrate deep down into the body and actually be very beneficial in healing. It's the type of light that we're not getting as much of. We can talk about that in a second half, but let's go back to the first part.
[11:03] So the first part of light and the circadian rhythm aspect of light. There are some inputs that come into this master conductor. The master conductor knows how to conduct the orchestra, but the master conductor needs to know when the concert is going to begin. You can't have the conductor starting early or starting late, because if you arrive to the concert and you're already halfway through the second movement, that does you no benefit.
[11:28] So what are these things that affect circadian rhythm timing? They have a German term for them. They're called zeitgebers. A zeitgeber is anything that affects the timing of your circadian rhythm. One of the most powerful zeitgebers is light. There are other things like social aspects, eating, food, and activity. All of these things are zeitgebers, but the single most powerful zeitgeber — the thing that's going to influence your circadian rhythm the most — is light.
[11:58] Let me give you an example of what would happen, and this happens a lot in society. There are inputs from the back of our eye, from the retina. They go back into the brain, and they go directly to the suprachiasmatic nucleus and also to the pineal gland, which is where melatonin is produced. What happens here is that as the circadian rhythm is moving on during the day and it's getting to the point where it's ready for sleep — and by the way, that may be different in some people. Sleep may come on for some people normally at around 9 o'clock at night. For some people, it's 2 o'clock in the morning and everywhere in between.
[12:37] But when that happens, there is an effect that goes out. It's kind of like the conductor getting ready for sleep would be him tapping the baton on the music stand, and everyone in the audience quiets down, the performers then turn their attention to the conductor, and they're ready to play the piece. That would be what we call dim light melatonin onset — DLMO. This is where we're getting ready for sleep. The pineal gland starts to secrete a substance called melatonin. And this is when the magic happens — when people start to get sleepy and they go to sleep.
[13:11] Now, the problem here is that when the eyes are exposed to light, that will shut down melatonin production. I want to be very clear about this, because you might think, oh, I don't really expose my eyes to light. No, no, no. Even a photon of light in some cases — just very minimal light, even light that is outside that is able to go through your eyelid and get into your eye and hit the retina — that is enough in some situations to shut down melatonin production. So certainly being on an iPad, being on your computer, having lights on at night, having too much light pollution at night — all of these things can affect that. When the circadian rhythm is getting ready for sleep and it sees light, what is hardwired in the circadian rhythm is this: we're getting ready for sleep, but yet I am seeing light. Therefore, it must not be as late as I thought it was, because light can only come from the sun. Therefore, I, the circadian rhythm conductor, must be too early. I must delay. I must tell everybody we're in the wrong period of the day.
[14:32] And so what happens is that repeated exposure to light at night causes the circadian rhythm to become delayed. So instead of falling asleep or feeling tired at 9 or 10 o'clock, after repeated bouts of artificial light exposure, your circadian rhythm delays, and you're going to feel sleepy later and later and later until finally your circadian rhythm may not be ready to go to sleep until 1 or 2 o'clock in the morning. And that's a problem if you have to get up at 6 and you need to get a full night's sleep, because you're hearing everybody telling you that you need 7 or 8 hours. So you go to bed at 10 o'clock at night and you go into bed and you're not ready for sleep. That's a problem. And that's the symptom of insomnia. We have a huge problem in this country of insomnia — people wanting to go to bed, trying to fall asleep at a specific time, but not being able to do that.
[15:33] So what happens is you wake up at 6:00 because nobody cares how you feel, or you've just got to go to work. And because the circadian rhythm has delayed itself because of light exposure at night, instead of falling asleep at 10:00 and the circadian rhythm being ready to arouse the body at 6:00 in the morning, it's now said, oh, I was too early, so I'm having you go to bed at 2 o'clock in the morning, but I'm not ready for you to get up from your sleep until — do the math — 10 o'clock in the morning.

[16:08] Dr. Linda Bluestein: 10 o'clock, yeah.

[16:08] Roger Seheult, MD: Right, and that's exactly where we would rather be if we're left to our own devices on the weekend, to sleep till 10 o'clock in the morning. So what happens is we feel very sleepy in the morning and we haven't gotten our rest. We feel very irritated, we need to get to work. And so we take stimulants to get our body moving, usually in the form of coffee or caffeine. There are whole industries that have made their profits off of us exposing our eyes to bright light at night. And then the cycle repeats itself and it reinforces itself. We have a lot of work to do that we haven't done because we've gotten up later. We're not able to complete it. We burn the midnight oil thinking that this is a heroic thing to do. And at the same time, we go to bed late again, and we've reinforced that circadian rhythm delay.
[17:03] So, this is the role of light. Now, I've talked about light in the evening that delays the circadian rhythm. There is good news, because exposing your eyes to that same bright light — and when I'm talking about bright light, unfortunately, the amount of light that is necessary in the evening is such an infinitesimal amount to cause a problem. However, in the morning, what we need is a huge amount of light. We need 100,000 lux. That's a measure of how much light there is, and we need to go outside to be able to get that.
[17:41] So what happens is when you go outside in the morning time, as soon as you get up, or even an hour before you would normally get up, that has the opposite effect on the circadian rhythm. That actually switches it the other way. The conductor is getting ready to say, oh, it's time to get up in the morning, but we haven't seen the sun yet. And now you're exposing the suprachiasmatic nucleus to that light, and it's saying, oh, the light has come early — I am too late. I need to shift everything the other direction.
[18:13] So, here's the long and short of it. We currently live in a society that is definitely skewed to one of those problems, and that is excessive light at night. What that has done is caused a huge delay generally in many people in the working world, so that we are going to bed too late and still having to get up in the morning.
[18:40] What I would highly recommend for those of you who have insomnia at night is to make sure that you are hitting all cylinders on all of the zeitgebers that tell us to be awake. Light is a major zeitgeber. Eating and food is a major zeitgeber. And there's something else that's also a major zeitgeber, and that's exercise.
[19:07] So, if you are someone that doesn't fall asleep at night, takes a long time to fall asleep, and you feel very groggy in the morning, I highly recommend the following. Number one: get up early in the morning and expose your eyes to bright light outside. If you live at a high latitude where the sun is not up at that time, I would recommend investing in a light box — 10,000 lux, about $20 on Amazon — and exposing your eyes to that for about 20 minutes in the morning. Get some exercise in the morning, that's another zeitgeber, and then have a good breakfast in the morning when your insulin levels are the most sensitive, get those calories in, and then taper off the amount of food at lunch and then at dinnertime.
[19:55] The problem we have in the United States is we do the opposite of what we should be doing. Number one, we have very large late dinners. We stay up and entertain ourselves on screen devices — iPads, televisions. And we still have to get up early in the morning. That's a recipe for lack of sleep.

[20:18] Dr. Linda Bluestein: Wow. Yeah. I was thinking as you were saying all that, that that is exactly the opposite of what most of us are doing. And we're getting more and more, it seems like we have brighter lights like LED. I just recently moved and it seems like all of the lights are LED — it's really hard to not have LED lights. And I was fascinated when you said it really just takes a photon, such a tiny amount of light. That's really, really challenging. But I think the morning part is the part that people can really maybe act on most easily. That's really, really important. And you also mentioned something about timing of eating. Does intermittent fasting or time-restricted eating make a difference?

[21:03] Roger Seheult, MD: Absolutely. So, here we go again. Imagine if the gardener showed up at Disneyland at 2 o'clock in the afternoon. Walt Disney's mind would explode, because he was very careful about making sure the experience of the parkgoers was that this was a stage. He didn't want them to see the operations behind the scenes.
[21:25] What's going on is that you eating late at night is like the gardener coming in and doing the weeding in the middle of the day. These are processes that are not designed to be occurring when your body is going through repair.
[21:42] People think of intermittent fasting as eating less and losing weight — just another way to lose weight. No, no, no. That may be a nice side effect of intermittent fasting. But the real basis of intermittent fasting is this: when you stop eating, particularly carbohydrates, but any type of fuel, what happens after about 4 to 5 hours is that your body switches over to a different form of metabolism called ketosis. This is where the body is no longer getting carbohydrates and it needs to switch over to breaking down your own fatty acids. When that happens, the product of that is something called ketones, and this ketogenesis actually triggers the production of genes and gene products — proteins that are involved in repairing and restoring bodily functions.
[22:44] Now, this happens automatically when you go to sleep, unless of course you're sleep eating, which is a diagnosis, but not a very common one. You are built into this: at the time that your body is doing the rest and the repair, it's getting help because it's signaling the genes that it needs to do that rest and repair. Unless, of course, you're eating right before you go to bed. Because if you are eating right before you go to bed, that's the time period that you have for the gardeners and the engineers and the restocking people to come in, but none of that's happening because you haven't gone into a fasting mode.
[23:27] So intermittent fasting maximizes those time periods. To be more biological about it: let's have the sirtuins, let's have the gene products that need to be happening in a fasting state be available for the time that your body is undergoing rest and repair. That means ideally that you should not eat about 4 to 5 hours before you go to bed.
There's an expression from over 100 years ago that says we should eat breakfast like a king, lunch like a prince, and dinner like a pauper. And there actually may be some truth to that. When I was doing intermittent fasting at first, because of my schedule, I liked to be with the family at night. We'd sit down, talk about the day, and that was a great time to have dinner. So I would skip breakfast and not really understanding how the circadian rhythm worked, I was kind of swimming upstream. When I started to switch back and do it the other way — which is not easy for some people — having breakfast, then lunch, and skipping dinner or having a very light dinner in the evening, I think that actually works much better.

[24:46] Dr. Linda Bluestein: Yeah, that's super interesting. And I can see where people who are working from home during the day can face a lot of challenges there. And I know a lot of people who have, for example, autonomic dysfunction eat small meals, and a lot of people with other chronic illnesses as well. But that's great information and something that I definitely do not do myself, and I will definitely give that a try. What about — you mentioned several times about people that are falling asleep at 2 and getting up at 10. If you don't have to wake up early, is there anything wrong with going to bed at 2 and getting up at 10?

[25:22] Roger Seheult, MD: Probably not. The diagnosis of this would really be if it was causing some social issues — if someone you were living with had a widely different sleep pattern to where it caused distress, then it would be something that we would look into. But I think the issue with having your circadian rhythm so off from what it should be in terms of sunlight is that it makes the hours of sunlight less available to you and the benefits of that sunlight.
[25:55] And that kind of leads into the second part of what we talked about, which is the beneficial effects of sunlight on the human body, not even having to do with circadian rhythm. And there's a lot of data on that. Everybody knows, of course, about vitamin D, but natural sunlight has a much bigger influence on the health of our human body than just vitamin D. Not that I'm minimizing vitamin D — it's important — but there are so many other aspects to sunlight that we benefit from. There's evidence that sunlight, near-infrared radiation, near-infrared light, complete biological spectrum lighting, improves mitochondrial function, has an effect on mood. We know about seasonal affective disorder. There are just so many aspects to light that we have data on. People who live in areas where there's a lot of near-infrared light, in green spaces for instance, just have better health outcomes.
There is a Sweden study — the SSS study, the South Sweden study — with thousands and thousands of Swedish women that showed that people who undertook light-avoiding behavior had higher incidences of cancer, melanoma actually, and that those with sun-avid behaviors had lower incidences of cancer and metabolic syndrome.

[27:22] Dr. Linda Bluestein: That's so fascinating. So many of my patients with chronic illness are actually staying up really late and they're often sleeping for 10 or 12 hours and they're so incredibly fatigued, but they're only awake really when it's either dark out or it's starting to get darker. So that might explain a lot of what's going on there, but it's really hard to make that shift sometimes.

[27:49] Roger Seheult, MD: It is, and your body is accustomed to it. And when you start to make shifts, I'll make this point very clear: you're not going to be used to it at first. You're going to be hungry when you're used to having food, and you're not going to want to eat food at times you're not used to having food. But I have good news for you. We have data that shows that when you change the time of day that you eat, it actually changes the expression of certain genes. And eventually you will start to be agreeable to eating at those new times, but it will take some time for that to happen.

[28:19] Dr. Linda Bluestein: How long do you think for the average person?

[28:21] Roger Seheult, MD: It takes about 2 to 3 months to really get into that. The reason why you are hungry during the time of the day that you regularly eat is because your body has been trained to be hungry at that time. You've trained your body, and your body is adjusted to that. So if you make a deliberate change to eat at the other time of the day, in the morning for instance, your body will make the changes necessary, but it will take some time.

[28:52] Dr. Linda Bluestein: Okay. And a follow-up to this is — I'm thinking about people who fall asleep while they're watching TV in the evening, they're just drifting off, but then they get in bed and they're wide awake. What's going on there?

[29:04] Roger Seheult, MD: Yeah, exactly. So this is known as psychophysiological insomnia. Imagine that you have struggled to fall asleep in your bedroom. We here living in the Western world have bedrooms — rooms that are designed specifically for sleep. For those of us that have bedrooms designed for us to sleep in, that becomes our war room. That's the room that we go into every night and battle with this issue of not being able to sleep. And so we're associating all of those anxieties and battles with that room.
[29:48] I hear this all the time with my patients who have insomnia. They are ready to go to bed, they are exhausted, they're ready to go to sleep. And as soon as they walk into that room, all of those subconscious feelings associated with inability and not being able to do something comes back to them — which causes exactly the wrong thing if you want to be falling asleep, which is anxiety.
[30:11] The way I like to analogize this is: imagine going out onto the stage of Carnegie Hall. Instead of a piano there for you to play or a violin, there's a bed. You're being asked to go sleep in that bed. How many people would be able to go into that bed and sleep? It's incredibly difficult to do that. And yet that's what it's like for some people when they go into their bedroom. It's a performance. And the anxiety of that performance actually inhibits that performance.
[30:52] So what we need to do is take the battle out of that bedroom. The solution for psychophysiological insomnia is to no longer make a mountain out of a molehill. If you go to bed and you can't sleep, we highly recommend that you get out of that bed, go to another part of the house, and have that battle somewhere else. Also, we don't want to dilute the subconscious signal of you falling asleep in that bed by mixing it with other activities in the bedroom. Working in the bedroom, being on your laptop, watching television — all of these things dilute that subconscious signal that it's now time for bed, and you should not do that in the bedroom.
[31:33] So, kind of jokingly, the bedroom should only be for two things. And if you don't get one, well, the other isn't so bad either.

[31:44] Dr. Linda Bluestein: I love it. Okay. That's fantastic information. And let's switch gears and talk about sleep apnea. This is something that obviously is incredibly common, right? So if you could talk about what relationship there is, if any, with chronic illness, chronic pain, and connective tissue disorders like Ehlers-Danlos syndromes. And also we know there's central sleep apnea and obstructive sleep apnea. If you could talk about that a little bit.

[32:09] Roger Seheult, MD: Yeah. So, real briefly, let's talk about obstructive sleep apnea so it's very clear. When your brain goes to sleep, unfortunately, your airway also goes to sleep a little bit. The nerves that try to keep that airway open — which is not a rigid airway, it's a flexible airway — tend to relax. And so when your lungs are taking in a breath at night, that airway can get more collapsed until finally the negative pressure in that lumen from you breathing air in can close it and prevent any air from getting down into your lungs.
[32:40] It might sound like this: silence. I can do that really well because I'll confess I have sleep apnea. And I figured out that I had sleep apnea long after I was trained in sleep medicine, so there was no denying it. I knew exactly what was going on.
[33:00] This will happen, and people sometimes — if it's really bad — will wake themselves up because they can no longer breathe. When air no longer gets into the lungs, the oxygen levels in your blood drop. When that happens, it sets off two consequences in your brain. Number one, the part of your brain that senses oxygen is very disturbed and sends out sympathetic nervous system outputs all over your body. So your heart rate goes up, your blood pressure goes up, and you arouse out of your sleep. Those are the two things: the arousal out of your sleep, and this sympathetic nervous system stimulation, to the point that your airway opens up. That's exactly what it's supposed to do — if you can't breathe, you're going to get that opened up, air is going to rush back in again.
[33:55] You may wake up out of your sleep, you may be having a dream, or maybe even a terrible dream, because you're getting the sympathetic drive.
[34:10] So at the root cause of sleep apnea is the laxity of tissue. And so it should not be too surprising to understand that people with lax joints — Ehlers-Danlos, etc. — have an increased risk of obstructive sleep apnea. And because the problem is a mechanical problem, the solutions are generally mechanical. There are no medications that will reverse the issues of obstructive sleep apnea.
[34:42] The most studied, longest used, most efficacious intervention for obstructive sleep apnea is positive airway pressure, or CPAP. If you can imagine a flat tire — this is your airway and it's collapsed — what we want to do is put just enough pressure in the airway to pump up the tire, if you will, and leave it open so that it stays open while you're breathing. The device fits either over your nose and your mouth, or just your nose if you keep your mouth closed when you're breathing at night. And this keeps that tissue away from each other so that when you're breathing, it's always open and you can exchange air without a problem.
[35:27] This has done so much for so many people. The problem is that with continuous arousals out of sleep, with continuous sympathetic nervous system discharge at night, you get excessive daytime sleepiness, accidents, stroke, hypertension, atrial fibrillation, congestive heart failure. All of these things are related to sleep apnea.
[35:59] When you put CPAP on and it opens up that airway, you no longer have the arousals. You are able to go into nice deep sleep and stay there. And by the way, when I say "continuously," we define sleep apnea as anyone who has symptoms and where this happens more than 5 times per hour — once every 12 minutes. But I've seen as high as 100 times an hour. These people literally cannot sleep and breathe at the same time.
Now, there are other treatments that you can also do. There are other things that will keep that airway open. One of those is a dental device. If you take your lower two fingers, put them on your lower jaw, and put your lower jaw in front of your upper jaw — so the two bottom incisors are in front of the two top incisors — because the tongue is anchored to your jaw, you're essentially pulling the tongue forward. That's the major problem in sleep apnea, because what happens is the tongue falls back and causes the airway to collapse. So if we can get the tongue off of the back of the airway, especially in mild to moderate sleep apnea, that can also be a solution.
[38:02] There's also another device called Inspire, which is more for moderate to severe cases. It doesn't move the lower jaw forward; it simply activates the muscle that sticks your tongue out — that's the genioglossus muscle. There's an implantable device that goes on the other side of where a pacemaker usually goes. It looks very similar to a pacemaker. It detects when you're about to take a breath at night when you're sleeping and sends a signal to a sensor implanted in your neck to stimulate that genioglossus muscle to contract, moving the tongue forward every time you breathe. That one's a little bit more invasive and does have some side effects to it. But those are the 3 main ways that we have today that are approved to treat obstructive sleep apnea.

[38:56] Dr. Linda Bluestein: And I'm thinking about that middle way — if someone has TMD or temporomandibular dysfunction, that could potentially be problematic in terms of that option.

[39:07] Roger Seheult, MD: Yeah, it could. On the flip side, for those that grind their teeth at night, this could be a twofer where the dental device would prevent them from grinding their teeth and would move the tongue out of the way. So my recommendation would be, if you feel that you have this, to get a sleep test. And also to try either CPAP or to see a sleep-certified dentist who is trained in this area — they can actually make the dental device. Now, you may say that you don't have dental insurance. Here's the good news: because obstructive sleep apnea is a medical problem, your medical insurance will pay for you to see the dentist to make a dental device for your medical problem.

[39:51] Dr. Linda Bluestein: That is great information. That is really good to know. And let's talk about home versus lab sleep studies, because will those detect obstructive versus central sleep apnea? What are the pros and cons of the different options?

[40:07] Roger Seheult, MD: Absolutely. So central sleep apnea, before we go on, is this: in both cases — obstructive and central — you stop breathing. In obstructive sleep apnea, the reason someone stops breathing is because the airway has closed. You will see that their chest and their abdomen is trying to get a breath in, but because it's closed up in the airway, they can't. Central sleep apnea is different. It's where the brain, for whatever reason, is not wanting to take a breath, and it's not sending a signal down to the chest and the abdomen. Therefore these people are not breathing and there is no movement in the chest and the abdomen. That's how you would tell the difference.
[40:46] Generally speaking, in those cases, it's because of carbon dioxide levels and trigger thresholds that could cause that. We typically see that in people with congestive heart failure or strokes, or even in lung disease patients. But generally, that's a smaller subset. There are people that can get central apneas after they are treated for obstructive sleep apnea, but that's a little bit different.
[41:10] All right, so let's talk about tests. Back in the old days, everybody would have to go into the sleep lab and be hooked up with wires all over their head. It basically cost a lot of money to make a very simple diagnosis — it was overkill. And so there's been an explosion of devices that can be used, all FDA approved.
[41:34] If somebody comes into my office, they're overweight, they have a very large neck, their mother and their father both had sleep apnea, I open their mouth and I look in and they've got a large tongue — this person is a slam dunk for sleep apnea. Do I need to send them to do an expensive overnight test where they're checking for everything? No. I can do a very simple home sleep test where they basically wear a device on their head. It checks their oxygen saturation. It can tell what position they are lying in. There's a little device that comes down to their nose that can tell when they're taking a breath in and when they're taking a breath out. And there are sensors that can tell when they're trying to take a breath in and out. This is a much cheaper way of doing it.
[42:16] But there are limitations with these home tests. They do not recognize central apneas very well. So therefore, if I have a patient who has a risk factor for having central apnea — like a stroke, or they are a congestive heart failure patient, or even if they have lung disease and they're on oxygen — clearly I can't be putting oxygen on somebody who has a detector by the nose. Those are the ones that I send to the lab to have the full studies done. And those are only about 10% of the people that I send for sleep tests in general.
[43:26] So home testing has really revolutionized the ability to check for sleep apnea. Now, there's a newer technology that's been out for a little while, and it's based not on checking to see if somebody is breathing like these traditional home tests are doing, but rather looking at the response of the pulse. What happens is when somebody has an arousal because they have an obstructive event, their heart rate is going to do a specific pattern. Well, that can be picked up on a watch. So there's something called WatchPAT that is actually being used where you can make a definitive diagnosis of sleep apnea based on this pattern that they see on the pulse alone.
[44:15] So there's a variety of tests. Probably what will happen is if you are a patient and you suspect this, your physician is going to have already set up a relationship with a testing company, and you and the physician will decide together: do you get an in-house exam, a home exam, or the WatchPAT?

[44:37] Dr. Linda Bluestein: Okay. And some of the people who have EDS are more prone to things like Chiari malformation. Sometimes it's pretty subtle. And so those might be people too that would benefit from an in-lab study because of the risk of central apnea.

[44:50] Roger Seheult, MD: Yes, exactly.

[44:51] Dr. Linda Bluestein: Okay, great. And what about — as an anesthesiologist, I'm used to doing a lot of maneuvers to open the airway and putting a wedge to elevate the head relative to the rest of the body. Does elevating the head of the bed — can that be helpful?

[45:08] Roger Seheult, MD: Yes. It depends on what the results of the sleep study show. What they do very nicely on these sleep studies is they add up the events based on what position the patient was in. And if we see a patient that has what we call positional sleep apnea — meaning that when they're on their back, or supine, that's when we're getting the worst effects of sleep apnea — then it may be beneficial not only for them to sleep with the head of the bed elevated, but also to sleep on their side so that gravity doesn't pull the tongue back.
There are a number of devices that have come out to try to encourage people to sleep on their side. There's one that alarms when they sleep on the wrong side. There's also the old-fashioned way of sewing some pockets in an old t-shirt and putting some tennis balls in there. You're already laughing because I think you've seen that too.
[45:52] I actually got a shirt once when I was a sleep physician from a company — they wanted to trial it and they sent it to me. It had these 3 big things on the back. It looked like a cow. It looked like udders. That's funny. But it's effective in that it keeps you off of your back. And for some people, that's all they need because there's such a stark difference between when they are sleeping on their side versus when they're sleeping on their back.
[46:27] But I would caution people to not just assume. The best way to find out what happens is to actually do the sleep test.

[46:40] Dr. Linda Bluestein: Yeah, for sure. And what about alignment problems? Like, for example, if you have kyphosis or problems with your cervical spine, can that affect breathing in your sleep?

[46:53] Roger Seheult, MD: There are a number of ways that could potentially affect it. If the cervical spine has been manipulated or is malaligned, I've seen patients who have elevated hemidiaphragms because the phrenic nerve — the nerve from the brain that tells the major breathing muscle called the diaphragm to contract and to breathe — is not intact. And if that's the case, then these people are susceptible to not getting enough of a breath at night. I would almost exclusively want to treat these people with positive airway pressure, but not in a continuous way to keep the airway open — rather, to help them with volumes. We call that bi-level or BiPAP.
Another potential issue is with kyphosis or scoliosis. These are all curvatures of the spine which make the lung volume suboptimal. If they're not taking in enough volume when they're sleeping at night, the carbon dioxide is not coming off, and that causes carbon dioxide levels to build up. That can cause headaches in the morning, elevated pulmonary artery pressure, and this can lead to cardiovascular complications.

[48:05] Dr. Linda Bluestein: Yeah, we definitely want to try to avoid those if we possibly can. Let's switch gears again and talk about sleep medications. It seems like there's just more and more coming on the market. Yet I'm so glad we talked about light first, because it's like we're trying to fix these problems the wrong way a lot of the time. What should we know about sleep medications?

[48:29] Roger Seheult, MD: Talking as a sleep specialist, I have no problem using sleep medications in a very short-term, targeted way for people that have very short-term issues with sleeping. For instance, if they have had a death in the family and they're having difficulty sleeping and need help for a very short period of time. Realize that these medications can be potentially addictive, depending on which one. And really, according to the studies that have been done, the long-term use of sleep aids has not been very effective at treating the sleep problem and may have significant side effects in the long run.
[49:13] There's actually one study — it was not definitive, it was an associative study — that showed that even the use of FDA-approved medications for sleep like Ambien and Lunesta can actually increase the risk of falls. And that was actually associated with an increased risk of mortality in older patients. In fact, after Ambien came out, they actually had to scale back the dose, particularly for women. They also recommended the reduction for men as well, because there was a high incidence of people doing automatic behaviors the next morning. It actually says on the label that you should not drive for 24 hours after you take this medication. So if you're taking it every night, you really just can't drive.

[49:58] Dr. Linda Bluestein: Really?

[49:59] Roger Seheult, MD: Yeah. So if I have a patient with a chronic sleep problem, I am going to do sleep hygiene — going through their entire list of things that they do before they go to bed. I'm also going to look at something called cognitive behavioral therapy, which is actually much more powerful than sleep medication and much longer lasting.
[50:26] The types of things we're talking about include not only sleep hygiene, but asking them how they perceive their issues with sleep, even doing sleep restriction therapy. There are a lot of behavioral factors. We could talk for an hour about the things that people do when they can't sleep that actually make the problem worse. There are things called precipitating factors like death in the family, a new job, good stress, bad stress — all of these things can precipitate insomnia. But the key thing that causes us to be chronically insomniac are the perpetuating factors.
[51:03] Let me give you an example. Let's say there's a death in the family or something stressful has happened, you can't sleep, and you know that sleep is so important to your health. And what you do now is you say, you know what, I'm going to go to bed earlier tonight and try to get some sleep. Tell me what's going to happen if you go to bed earlier and you're not ready for sleep. You're not going to fall asleep, and you're going to associate that insomnia and your inability to fall asleep and all the feelings of inadequacy with your room. So the next time you come in, that is built into the equation. You're slipping more and more into a deep hole of chronic insomnia.
[51:39] And what cognitive behavioral therapy does is it recognizes those behavioral issues, identifies them, and reverses them so that you are able to get to sleep — you have sleep confidence.
[51:54] To give you a quick explanation of sleep restriction therapy: we restrict people's sleep. Let's say I give them 8 hours to sleep, but they only sleep for 4 or 5 hours during that period of time. Then I say, okay, now I'm only going to give you 4 or 5 hours to sleep. Make the most of it. What's going to happen is that after that first night, they don't feel very well because they haven't slept very well, and they're extremely tired and wondering why they even went to see this doctor. But what happens is that the next night, that sleepiness is the drive for them to fall asleep. We keep doing this every night until their sleep efficiency improves to about 80 to 90%, which means that 80 to 90% of the 5 hours that I gave them to sleep, they're sleeping. They fall asleep quickly and they're doing a good job.
[52:45] What does that do? It builds confidence. Now, instead of you walking out onto the Carnegie Hall stage and being asked to sleep, you are ready to sleep. You are like Liberace. You are walking out onto Carnegie — I'm dating myself. Nobody knows who Liberace is.

[53:00] Dr. Linda Bluestein: I do.

[53:01] Roger Seheult, MD: You do? Okay. You are now this tremendous piano player and you're walking out and you're ready to play that piano. You know that piano isn't going to play you. You're going to play that piano. And so now you have confidence and you're able to do this.
[53:13] What I do is then give them 15 minutes back, very slowly. This is a well-known technique that any sleep physician would know how to do. It needs to be done carefully, because you can actually become more sleepy at the beginning. So you have to make sure that you're not a truck driver or an airplane pilot. This has to be done under supervision.
[53:36] But I'm giving you a flavor of the types of things that I would rather use — and the science shows it's much more effective at getting you to sleep than chasing all of these medications, which are basically just covering up the symptoms of the problem.
[54:12] So how do you get a good night's sleep? Here's a quick summary. Exercise in the morning, sunlight in the morning — this really cues your circadian rhythm. Making sure that you're not exposing your eyes to bright light or any kind of light at night is really important.
[54:26] And let me tell you an anecdotal story. I went to do a recording similar to this one, and they hosted us and put us up into a room, and they had a sauna. I had never really been in a sauna, but the host took me and Kyle — who's the other half of MedCram — and we went into this sauna. We had a wide-ranging discussion, going outside for a cold shower every 20 minutes and coming back in. We completely lost sense of time. As it turned out, we spent about 2 hours in that sauna — it must have been 170, 174 degrees. And I went to bed that night and I cannot remember a night that I slept so soundly.
[55:16] Sure enough, I've looked online for evidence of this, and I see that Rhonda Patrick —

[55:21] Dr. Linda Bluestein: Love her. Yeah.

[55:22] Roger Seheult, MD: Yeah, she's amazing. She just put out a podcast showing — and she's actually very interested in sauna work, we've actually hosted her before on that topic — that saunas are very beneficial for getting a good night's sleep. They increase all sorts of slow-wave sleep, among other things. If people are interested in doing that, I think it's really worthwhile looking into. This was a true traditional heat sauna — this was not an infrared sauna. I'm not saying that wouldn't work; I'm just telling you what the data shows.
[55:55] So if I wanted to boil it down to something practical: the big things if you want to get a good night's sleep are exercise in the morning, bright light exposure without glasses going outside into the sun — you don't look at the sun, but be outside. Avoid light at night. Do that continuously over a week, 2 weeks, a month. And maybe consider sauna and see if that helps.

[56:25] Dr. Linda Bluestein: So the first thing that comes to my mind is — okay, if you're not watching TV, I guess reading, especially reading on an iPad, would be bad. Reading with a lower Kelvin light — I don't know if that would be recommended. But what are you doing in the evening if you're not watching TV?

[56:44] Roger Seheult, MD: Yeah, so actually there was a study that looked at that very question. They compared an e-reader — which doesn't give off a lot of light, but some — versus reading a book with a very low-lit, dim traditional light. And the differences were stark. It was orders of magnitude more light with the e-reader than with the soft light. And as we've just talked about, we know what effect that's going to have on melatonin. Sure enough, the people that were on the e-reader went to sleep a full 15 to 20 minutes later than those that did not. So there was an impact there from just the e-reader. Imagine watching full television, bright light, LED, all this stuff.
[57:19] So, what do you do at night? Avoid technology, avoid lights. There was a gentleman I heard on a podcast who is really into this and went maybe to an extreme — he made sure that none of the ceiling lights were on. He only put low-level lighting, literally low, close to the floor. And the reason why he did that is because the receptors in the eye at night that pick up the light that shuts down melatonin are concentrated in the lower portion of the retina.
[57:57] Why is that important? When light comes into your eye and it hits the lens, it gets flipped upside down. So light that is in the high visual field is going to be reflected on the lower retinal area and vice versa. And so what they have determined is that because these receptors are in the lower retinal area, light that is high up is the type of light that is going to quickly shut down melatonin production. And by the way, these light receptors respond more towards the blue side of the spectrum.
[58:30] So if you wanted to be the antithesis of the type of light that would shut down melatonin, you'd want to have light low in your visual field that is more towards the red zone, if you're going to have any type of light at all. To be clear: no light is the best, then light that is low in the visual field and redder is second best, and then everything else goes from there.
[58:54] If you think about that, imagine how we lived life 100, 200, 300, 1,000 years ago. What type of light would we have at night? It would typically be a fire that is low on the ground and red. All of this starts to now fit into a nice neat little package, and we're starting to see that our body is really designed to fit around that type of environment. And what we've done in the last 50 to 100 years is we've had the technology to do things to our body that we never had the capability to do before. We have the freedom to eat any time. We have the freedom to work any time. Yes, we have that freedom, but it may not be good for us.

[59:37] Dr. Linda Bluestein: Right. And in that period of time I think there's also more and more caffeine use. We also have stimulants, ADHD medications, and then of course there are also medications that are FDA-approved for promoting daytime wakefulness. What do you think about those medications?

[59:56] Roger Seheult, MD: I will use things like modafinil, armodafinil, Provigil. These are the types of medications that I use in my patients who are narcoleptics or in patients who have sleep apnea and are using their CPAP machine but still have excessive daytime sleepiness. Let's make no mistake about this: these are medications that are covering up the symptoms of the disease. So if someone is sleepy, I can make them more awake, but I need to make sure that I am treating the underlying condition that is making them sleepy. So I only will use these stimulants if I am showing that I'm actually treating the underlying condition. If I have them on CPAP and I can see that they're compliant with the CPAP machine, then I will add those medications.

[1:00:42] Dr. Linda Bluestein: Okay. And what about supplements for sleep? There's a lot on the market, of course.

[1:00:47] Roger Seheult, MD: Yes, there are a lot. And it's because sleep is such a problem. I would say that even the supplements, although they probably don't have the same negative effects as some of the prescription medications, are also covering up the symptoms of the problem rather than solving it.
[1:01:05] Now, there are some exceptions. Some supplements do actually have some significant side effects. Anything that is an antihistamine is going to reduce histamine. Histamine is an alerting neurotransmitter in the brain that makes us more alert. So if you take an antihistamine, it's simply going to make you less alert — which means you're not going to be able to think as well or process as well, but you may be able to go to sleep better at night. The problem is there are some studies that have associated long-term antihistamine use with dementia. And that's not a good thing. So I would try to avoid that. Again, I would look at the underlying causes and try to fix those things.

[1:01:54] Dr. Linda Bluestein: It's kind of like in the EDS world, patients who have mast cell activation syndrome. Yes, you can use different medications, but at the end of the day, you really want to make sure that you're removing the triggers that are causing the mast cell degranulation in the first place.

[1:02:08] Roger Seheult, MD: Yeah. There's a spectrum, and you and I know as physicians that we need to do what we need to do to reduce the risk and improve the benefit to the maximum amount that we can. So there are some patients where we can get away with lifestyle choices, but there are some patients where we need to do lifestyle and also add some medications, at least in the short run to get them out of danger.

[1:02:29] Dr. Linda Bluestein: Right, for sure. We had so many questions that came in after I posted. This was such a quick turnaround, which I love. It was fantastic to get to chat with you on such short notice for both of us. So I want to throw some of these questions at you. The first question is: what do you think about sleep watches and other monitoring devices? There's the Oura Ring and a whole host of things.

[1:02:55] Roger Seheult, MD: At first, my response to those devices was skeptical. But after looking at the data, they're actually very accurate. They've done a very good job of picking up this stuff, to the point that a number of these technologies have now become FDA approved, like the WatchPAT. So yeah, I do not dismiss that at all. I think there's a lot of good data there. We've actually tried on our MedCram channel to educate people on exactly what REM sleep is, what slow-wave sleep is, because you can actually find that on your devices and know more about it. So, yeah, definitely.

[1:03:29] Dr. Linda Bluestein: Okay, great. And we got so many questions about sleep positions. So people that have joint laxity, joint instability — they might sublux their joints or even dislocate their joints in their sleep. They have other positioning problems. They have pain when they sleep on a shoulder or hip or when they're sleeping on their back. Do you have any thoughts about positioning pillows, mattresses, some of these more mechanical-type issues?

[1:03:58] Roger Seheult, MD: I would say this: it's so diverse that I would pick whatever position works best for them in terms of having the least amount of pain. Obviously, that's going to be the best position for them.
[1:04:09] Now, that being said, if they also have sleep apnea — and they probably should be tested, because if there's a laxity of joint and tissue, then there's probably also a laxity in the airway as well. Generally speaking, although this is not 100%, sleeping on your back is not a good position if they do have sleep apnea. But I would hate for somebody who sleeps well on their back because of their joint laxity and pain issues to try to avoid that just because of that theoretical possibility. A better thing to do would be to be tested for sleep apnea. And some people have sleep apnea and it doesn't matter what position they sleep in — they still have sleep apnea. So that can all be answered in a sleep test. They will definitely be able to answer whether they have sleep apnea and whether there's a particular position that it is worse in.

[1:04:57] Dr. Linda Bluestein: And even those home tests can tell you about the positional aspects.

[1:05:05] Roger Seheult, MD: Absolutely. Yeah. There's an accelerometer in the machine that can tell when you're sleeping on your back or on your side or which side, even the prone position. Yeah.

[1:05:14] Dr. Linda Bluestein: Okay, great. And then there were people who commented that they get paresthesias or numbness and tingling in their hands or other body parts. Can you explain why that happens?

[1:05:25] Roger Seheult, MD: Yes. So I have the same thing, and I can speak from experience. When I was in medical school, I did a lot of reading, and obviously back in those days we didn't have YouTube videos, so I was leaning a lot on my elbows. What that caused later, I found out, was something called cubital tunnel syndrome — entrapment of the ulnar nerve. The ulnar nerve goes around the medial aspect of the elbow and wraps around through a little tunnel. What sometimes can happen is it gets entrapped and gets tight. So if you sleep with your elbow flexed, the nerve conduction down the ulnar nerve won't be so great, and it will make the pinky completely numb and generally half of the ring finger as well. But the middle finger, the index finger, and the thumb will be fine, because those are innervated by a completely different nerve called the median nerve, which runs on the other side.
[1:06:28] So it just depends on which fingers are numb. If the pinky is numb, then it's probably a result of ulnar nerve entrapment. What I would recommend doing — I kind of made a device for myself when I was in medical school. I basically got a piece of cardboard and taped it up and put my arm through it so that when I was sleeping at night, I would keep my arm straight. It's probably not good to keep it completely straight; maybe slightly flexed a little bit. I even had an EMG done because it was very irritating to have numbness and pain there, since I play the piano and other things. It eventually went away after I learned to keep my arm straight. But occasionally I'll still wake up with numbness and tingling.
[1:07:09] If you have numbness and tingling in the other fingers, then the most likely problem is carpal tunnel — increased compression of the median nerve as it goes through the wrist. Number one, it depends on which fingers you're talking about. If it's the pinky, it's probably an elbow issue. If it's the other three fingers, it's probably a wrist issue, and you should see someone about that. You can get something as conservative as a splint.
[1:07:37] But I don't want to miss an issue here: if you have enough nerve compression, it's not only a sensory nerve issue, it's also a motor nerve issue. You could actually get atrophy of those muscles. So seeing a primary care physician and then a neurologist to assess that — maybe even an EMG — but hopefully just a brace so that when you sleep, you keep that joint in the neutral position.

[1:08:03] Dr. Linda Bluestein: Okay, great. And someone had asked about pillow recommendations if someone has cervical instability. Do you have any thoughts about that, because obviously this is pretty highly specific?

[1:08:14] Roger Seheult, MD: That's a little out of my area. I would probably consult with a specialist who deals with that. But I will comment on this: regardless of the shape or size of the pillow, if you're going to get a pillow and you have any history of allergies or asthma or postnasal drip, make sure you don't have down feathered pillows, because that can make your allergy and asthma much worse. Imagine you're putting your nose next to something for hopefully 6, 7, or 8 hours a day. If that is something you're allergic to, it's going to change your life for the worse, and it's something you probably want to avoid.

[1:09:00] Dr. Linda Bluestein: Sure. And when I was dealing with some issues with my neck, I know my physical therapist said to avoid gel pillows and things that were a little more solid, that you want maybe a down-alternative type of pillow that your head could kind of sink into more and be a little more supportive. Excellent. Okay, great. Any tips for people who frequently wake up in pain?

[1:09:27] Roger Seheult, MD: It depends on where the pain is. Generally speaking, what we do in those situations is we identify the pain, try to figure out the best way to get it taken care of so that they can sleep, because it's very difficult to sleep when you have pain. We usually refer them to a pain specialist — which, you being an anesthesiologist, you know all about. There are actually subspecialties in anesthesia that deal just with pain, and there are a lot of creative ways of dealing with it.
[1:09:58] But I would say this: it's a well-known fact that if people get enough sleep, pain tolerance improves dramatically. I remember this when I was on call. My wife and I would feel — because she was also a physician, she was a resident at the time — whenever we would do those 36-hour shifts and come home, we'd have that post-call feeling where everything just seemed to hurt. In fact, I remember my wife saying, this is what it must feel like to have fibromyalgia, because it just seemed like every part of your body was hurting. And it was all simply because we hadn't slept. Very illuminating — to realize how lack of sleep could affect pain perception. Even though there was nothing there that was causing the pain. And it went away when we got enough sleep.

[1:10:50] Dr. Linda Bluestein: Right, that's really fascinating that your wife would have made that comment. I practiced for over 20 years in the operating room, and now I do pain management for people with EDS and HSD. We talk a lot about sleep in our sessions. I can't wait to refer every single person I know to this conversation so they can listen to these great tips, because it's a problem for a lot of people. I totally agree with you about the sensitivity to pain. And then other people wake up in the middle of the night feeling like their sympathetic nervous system is activated. And you gave us one reason for that — if they have sleep apnea, for sure.

[1:11:23] Roger Seheult, MD: And it's probably the main reason. If I have a patient that comes to me and they have nightmares — what's the difference between nightmares and night terrors? A little hint here from a sleep medicine specialist. Night terrors happen during slow-wave sleep. Nightmares happen during REM sleep. Night terrors — if you ask the person after you wake them up, which is difficult to do during a night terror — they will never remember what the dream was, even immediately. Whereas a nightmare, they'll tell you in explicit detail exactly where they were in the dream when they woke up out of it. And in the case of the REM sleep nightmares, those people often have sleep apnea as the trigger. We treat the sleep apnea, the nightmares go away.

[1:11:26] Dr. Linda Bluestein: Fascinating.

[1:12:12] Roger Seheult, MD: And just to dovetail into the pathophysiology: during REM sleep, your body becomes paralyzed because you are dreaming. It's a very important defense mechanism — you don't want the person moving around during their dream because they could hurt themselves. And so because the body becomes paralyzed, that affects the neck muscles even more, and they become even more susceptible to collapsing. That's why we typically see that if someone has sleep apnea, it's almost always worse during REM sleep.
[1:12:41] This is kind of an unfortunate situation, because people with sleep apnea almost never get the benefit of REM sleep — they exit out of it because of that arousal. So when you treat people with sleep apnea, I see this all the time: people who have had sleep apnea for a long time, you put them on a CPAP machine, and they go into REM sleep and stay in REM sleep. It's almost as if the body is like, oh, please — thank you. I've had patients come back to me at the very beginning phases of starting therapy for sleep apnea and say, I had the most amazing dreams that lasted for so long. It eventually evens out and goes back to normal, but it's just fascinating to see that.

[1:13:23] Dr. Linda Bluestein: Yeah, that is really fascinating. And for people who have really vivid dreams that are really bothersome — besides addressing their sleep apnea, is there anything else they can do?

[1:13:34] Roger Seheult, MD: Yeah, if they have vivid dreams, what we will typically do — it depends on if it's related to PTSD or a previous experience. There are alpha blockers that we can try. These are the same types of medications that we would put people on if they had benign prostatic hypertrophy. In terms of side effects, they could get a little bit of dizziness if they stand up, at least initially, because it blocks the sympathetic nervous system. But in terms of holistic things, cognitive behavioral therapy is used, although I haven't done it specifically for nightmares.

[1:14:11] Dr. Linda Bluestein: Okay. And we talked about supplements earlier. We've talked about melatonin off and on. Is it safe to take? What are your thoughts?

[1:14:19] Roger Seheult, MD: Excellent. So melatonin — it is secreted by the pineal gland. It is very important. It's a powerful, powerful antioxidant, probably more powerful than glutathione. And so people will be like, wow, I need to take a lot of melatonin.
[1:14:38] The problem is that when you take melatonin and it gets into the blood, it's a signal that it's time for your body to go to sleep. It's again that conductor tapping the music stand. So you don't want to take melatonin at any other time except right before you're going to go to bed.
[1:14:53] And the problem we find is that the more melatonin you take, the more paradoxical the result. So 1 to 3 milligrams of melatonin can be sleep-inducing — at least to get you to sleep, though maybe not necessarily to stay asleep. But if you start to go up on the dose, 5 milligrams, 8 milligrams, 10 milligrams, there's actually this opposite effect that occurs where people become more irritated and don't fall asleep.
[1:15:21] The other problem with melatonin, at least in the United States, is that it's not regulated. So if you buy melatonin over the counter, what are the chances that you're actually getting what they say is on the label? My recommendation would be to make sure that whatever brand you buy has been inspected by a third party that has verified that this is actually in there. Buy it from a reputable brand.
So the three big things are: make sure you're getting what you believe is melatonin; start off at a very low dose, because the higher the dose, the less likely it is to work; and take it at night, maybe about an hour before you go to bed.
[1:16:11] Now, I do have a video on jet lag, and you can use melatonin to get around jet lag. We actually did it this year when we went to Europe. It works great when you're going east — we hardly had any jet lag at all. In those situations, you want to take it actually at 6 o'clock in the evening for about 3 days before you travel east, and it helps. There's more information on our YouTube channel. "How to Crush Jet Lag" is the name of the video. But generally, if you're just doing it at home and not traveling, taking it about an hour before you go to bed is probably the best thing to do.

[1:16:49] Dr. Linda Bluestein: Okay. And I will definitely link that specific video in the show notes so people can find that easily. Okay. Last topic — short topic — before we wrap up. I would love to talk about medical education. It's fantastic what you're doing. And a huge frustration of people who have conditions like EDS and HSD, or Ehlers-Danlos syndromes and hypermobility spectrum disorders, is that they're not covered sufficiently in medical education. Of course, you and I know there's a lot to fit in.

Roger Seheult, MD: Yes.

[1:17:16] Dr. Linda Bluestein: And it's not like we start learning about specific conditions — there's a lot of laying the groundwork and things like that, of course. But you being someone who's so passionate about this and has done so much work in this area, can you explain to people why this is the case and if this should be changed, and where people could get more education so that their symptoms could be recognized sooner and they could get better care?

[1:17:46] Roger Seheult, MD: Oh boy, education is so key. My father was a science school teacher, and he decided to go into dentistry at the age of 40. I think it kind of rubbed off on me. I was into tutoring in college and medical school, and I became a pulmonary critical care physician. Then I had a student named Kyle Allred, who was a PA student coming through a rotation. We would sit down and go over lectures. I did the same lectures every month for all the PA students. And he said, you know, Dr. Seheult, students don't learn the way that they used to learn. We use YouTube videos and we find the shortest video on the topic that we possibly can. And you know how it was for us, Linda — we used to go to the library, have a checkout card and a copy card to copy journals, right?

[1:18:37] Dr. Linda Bluestein: Yep. I don't know — what year did you graduate?

[1:18:39] Roger Seheult, MD: I graduated in 2000, so even more so. That was a real eye-opener for me. But what really caught my attention was his suggestion that we should make YouTube videos on specific topics. And I loved that for one reason — admittedly a somewhat selfish reason — I could refer my students every month to the same videos. Then they would go home at night and come back the next day and we could talk about what they had learned, save time, and push the envelope even further, maybe associate it with a case or show an example of what they had learned.
[1:19:20] So we started doing this and started to pick the most difficult topics that are classically hard to understand in medical school or PA school. Things like acid-base, things like interpretation of pulmonary function tests — things that professors would throw up on a PowerPoint screen and read the screen and nobody would understand, including sometimes the professor, at the end of class. People would go home at night trying to scramble to figure out what that was. So we tried to fill those gaps, and then we just started to expand, and people started to watch.
[1:19:49] Initially our videos were geared to healthcare providers, but because we were explaining things so clearly, we started to get an audience in the non-medical field — people who are interested in medicine and interested in empowering themselves. And so that's what we've come to today: a situation where I believe that we need to educate not only healthcare providers, but also patients. We need to educate both on the idea that there are very simple, clear, natural lifestyle changes we can make that have a huge impact on our health. These are things that take a long time to describe, things that maybe don't fit very well in a 20-minute clinic session when it's very easy just to prescribe a medication and fix the problem. But I think it's what we need to do and take the time to explain.
[1:20:52] But I don't do it from the aspect of saying that it's medications versus natural — that false dichotomy. Look, I'm a pulmonary critical care doctor. If I didn't have medications, we would lose so many patients in the ICU. I see the benefit of both. But I believe that if we were to employ some of these lifestyle changes earlier on and educate people on them, we wouldn't need as many of the pharmacological interventions that we often need to do just to save someone's life and give them the opportunity to make those lifestyle choices.
[1:21:30] So where I am right now in terms of education is not only educating patients that yes, it's a balance, but also educating physicians, providers, nurse practitioners, and PAs that there are lifestyle changes that will produce dramatic improvements in your patients.

[1:21:49] Dr. Linda Bluestein: Yeah, absolutely. And that's — I practice integrative pain management. I actually don't do any interventional procedures, even though I could do epidurals and nerve blocks or whatever. Because I feel like lack of education is so much more prevalent and needs to be addressed. That's also why I do the podcast — so people can get this information and listen to it again and again. It's a great way to share information.

[1:22:15] Roger Seheult, MD: I think it's great. And once we've reached that point, we can go even further. Because of my upbringing and faith, I believe that there is a hole in each one of us that needs to be filled with a spiritual aspect as well. I can't tell you how many times I've had patients come into my ICU who are not at peace — they are anxious about their life, about things that they have done. And when I give them the opportunity to discuss some of these things and they can be put at peace, things go so much better. The mind and the body are so connected.
[1:22:55] I mean, I have patients who have sepsis. What are we trained to do? Find the source of the sepsis and remove it. If there's an abscess, cut it out, drain it. If there's a urinary tract infection, treat it. If there's a stone blocking the ureter, take it out. And I feel that so many times there's this rush to treat the symptoms, but not get to the underlying cause. I think we're just starting to understand more and more about that.

[1:23:20] Dr. Linda Bluestein: Yeah, definitely. And before we get into the very final thing, which is the hypermobility hacks, can you tell people where they can find you online?

[1:23:32] Roger Seheult, MD: Our primary source of communication is the YouTube channel, which is MedCram — M-E-D-C-R-A-M. Our website, where we have videos and specifically continuing medical education videos — CE videos for providers that need to get credit — is medcram.com. Very easy. We'll be happy to serve as a continuing medical education provider as well.

[1:24:03] Dr. Linda Bluestein: I was thinking about offering a medical education course and I started to look into what that would entail. It's amazing that you're doing that because that is a whole other ball game.

[1:24:15] Roger Seheult, MD: I can give you a hint that makes it a lot easier: find a CME provider and just ask to make content for them, and they will certify your content.

[1:24:26] Dr. Linda Bluestein: Oh, that's a great suggestion. I appreciate it. Okay, very good.

[1:24:32] Roger Seheult, MD: CME providers are looking for content. So it's not hard.

[1:24:36] Dr. Linda Bluestein: Okay, great. Much better than reinventing the wheel.

[1:24:41] Roger Seheult, MD: Yes. There's a lot of regulation and making sure that you're showing improvements — you still need to do that sort of thing on your end. But in terms of the paperwork and the accreditation, you really want to have a partner that does that for you.

[1:24:56] Dr. Linda Bluestein: Yeah, definitely. Okay, very good. So, last thing — can you tell us some of your favorite hypermobility hacks? You shared some great things earlier.

[1:25:06] Roger Seheult, MD: Yes. One of the things that I have not learned about until recently — because of the pandemic, I was forced to look into some of the things that we used to do a long time ago — is something called hydrotherapy. So, hydrotherapy is the use of water, typically heated water, in the transfer of energy and heat into the body. It's used extensively in physical therapy. It used to be used a lot in the medical world, especially about 100 years ago. There were hospitals where people would come for hydrotherapy. It was very labor-intensive — you had to have somebody there attending you, heating the water, placing it on, all sorts of things.
[1:25:43] But what hydrotherapy can actually do for people specifically who have issues with hypermobility is this: the warmth of the water — and the reason water is used specifically, not a dry heat or a sauna, is that water has something called a high enthalpy. What does that mean? It takes a lot of energy to raise a specific volume of water by a particular number of degrees. So if you put somebody in that water, it's going to give off a lot of energy before it cools off. This is the problem obviously with burns — hot water can cause burns because it can transfer a lot of energy — so you have to be careful.
[1:26:24] What does this do for someone with Ehlers-Danlos, for instance? The warmth of the water can allow the muscles to relax, and that can actually aid in a lot of joint pain alleviation. And if you're doing submersible water — like going to a spa or a heated pool — that can also support your weight and take a lot of the load off the joints. You can do this to strengthen the muscles around the joint without putting a lot of stress on the joint itself.
So it offers pain relief, it allows you to exercise and strengthen the muscles in that area. The water can also be used as resistance — when you're moving around, it creates resistance to your movement, which can actually improve muscle strength without having the issues of joint stress.
[1:27:22] And the buoyancy of the water when you're submerged can also improve balance, coordination, posture, and trunk control. So it's not even a twofer, it's a threefer or even a fourfer. Going into a pool or a heated pool or heated bath can do a lot of those things all at the same time.
[1:27:47] Now, it's not easy to have one of those things, but I have seen recently that you can actually purchase some of these above-ground tubs or pools at a relatively low cost. And if it's something that is really interesting and beneficial for you, it might be something worth investing in, especially if you have a hypermobility condition.

[1:28:09] Dr. Linda Bluestein: And chronic pain. And I think the contact with the water can also help with proprioception. So yeah, water is a fantastic thing for people who have these kinds of problems.

[1:28:22] Roger Seheult, MD: Yes. And the reason why I got involved with that, just briefly, is because of its ability to simulate fever. If you have a very, very hot tub — and you would not want to do this alone, you'd want someone to be there because you can have arrhythmias or even pass out if it's too hot — the simulation of elevated body temperature can actually cause an increase in the innate immune system's secretion of interferon, which has a lot of beneficial properties, especially if you're talking about the flu, the cold, or even COVID-19.

[1:28:58] Dr. Linda Bluestein: That's super great to know, because we want our immune system functioning at its very best. Viruses and those kinds of things are not going away anytime soon, so we definitely want to have as much protection as we can. Okay, well, this has just been such a packed conversation, and you've been listening to Bendy Bodies with the Hypermobility MD podcast, and your guest today was Dr. Roger Seheult. Thank you so much, Dr. Seheult, quadruple board-certified physician with board certification in sleep medicine. This was such a fantastic conversation, and I know everyone's going to find it so valuable.

[1:29:37] Roger Seheult, MD: Well, thank you so much, Linda. I really appreciate you having me on.

[1:29:44] Dr. Linda Bluestein: Thank you for listening to this week's episode of the Bendy Bodies with the Hypermobility MD podcast. Visit our new website at bendybodiespodcast.com where you can now view guest profiles and show notes with links to products and journal articles. Leave me a comment, sign up for updates, leave a review or a voicemail, and access the podcast on your favorite player, all directly from our website. You may hear your voicemail in a future episode where we answer your question or dive into your gracious feedback.
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