Acupuncture treatment for Sleep Apnea

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    Sleep Apnea

    And

    Chinese Medicine

    5 CEUS

    OPTIONS FOR WELLNESS, INC.

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    www.myacupunctureceus.comCEU PROVIDER

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    Sleep Apnea was first identified as a medical condition in 1965. The word Apnea is Greek, and

    literally means "without breath." In all types of sleep apnea, the person stops breathing

    repeatedly during their sleep. No matter what type of sleep apnea exists, the brain signals the

    person to awaken briefly so that they may resume breathing. This sometimes happens an

    astounding 20-30 times per hour and hundreds of times per night. The results are fragmented,

    poor quality sleep, leaving sufferers of this condition unrefreshed in the morning and fatigued

    during the day.

    The individual with sleep apnea is rarely aware of having difficulty breathing or of being

    awakened so many times. Sleep apnea is usually recognized as a problem by others witnessing

    the individual during episodes, ie, a sleeping partner, or is suspected because of its effects on the

    body. The person suffering from this syndrome may view daytime sleepiness and fatigue asnormal .

    Sleep Apnea is categorized as three types:

    Obstructive (most common): Obstructive sleep apnea (OSA) is caused by a blockage of the

    airway, usually when the soft tissue in the rear of the throat collapses and closes during sleep.

    Individuals with decreased muscle tone, increased soft tissue around the airway (e.g., due to

    obesity), and structural features that give rise to a narrowed airway are at high risk for

    obstructive sleep apnea. Older people are more likely to have OSA than younger people. Men are

    more typical sleep apnea sufferers, although the condition is not unusual in women or children.

    Common symptoms include loud snoring, restless sleep, and sleepiness during the daytime.

    Central: Central sleep apnea -- the airway is not blocked but the brain fails to signal the muscles

    to breathe. The brain's respiratory control centers are imbalanced during sleep. Blood levels of

    carbon dioxide, and the neurological feedback mechanism that monitors it do not react quickly

    enough to maintain an even respiratory rate. The sleeper stops breathing, and then starts again.

    There is no effort made to breathe during the pause in breathing: there are no chest movements

    and no struggling. After the episode of apnea, breathing may be faster (hyperpnea) for a period

    of time, a compensatory mechanism to blow off retained waste gases and absorb more oxygen.

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    Mixed and Complex: Some people with sleep apnea have a combination of both types. When

    obstructive sleep apnea syndrome is severe and longstanding, episodes of central apnea

    sometimes develop. Complex sleep apnea has recently been described by researchers as a novel

    presentation of sleep apnea. Patients with complex sleep apnea exhibit Obstructive Sleep Apnea,

    but upon application of positive airway pressure (through a device), the patient exhibits

    persistent central sleep apnea.

    Sleep apnea doesnt just lead to fatigue. It is a serious, potentially life-threatening condition and

    may lead to hypertension, dysrhythmia, heart attack, and stroke. It is sometimes implicated in

    sudden infant death syndrome (SIDS) and motor vehicle accidents. Sleep apnea may also lead to

    poor memory, weight gain, headaches, impotence, and job impairment.

    According to studies, over 12 million Americans suffer from sleep apnea. While anyone of any

    age can develop this condition, risk factors include being male, overweight, and over 40 years of

    age. Other risk factors include alcohol use, smoking, and ethnicity, with studies showing Afro-

    Americans, Pacific Islanders, and Mexicans being at greater risk than Anglo-Europeans.

    Clinical symptoms:The presenting symptoms of sleep apnea are loud snoring, excessive

    daytime sleepiness, high blood pressure or other cardiovascular disease, morning headaches,

    memory problems, depression, reflux, choking sensations, nocturia (awakening from sleep at

    night to pass urine), and impotence. While many people snore without having apnea, snoring is

    almost a uniform finding in an individual with this syndrome. The loudness of the snoring is not

    indicative of the severity of obstruction. If the upper airways are tremendously obstructed, there

    may not be enough air movement to make much sound. The sign that is most suggestive of sleep

    apneas occurs if snoring stopsalong with breath. When breathing starts again, there is typically

    a deep gasp, and then the resumption of snoring.

    Fifty percent of people with sleep apnea have high blood pressure. When high blood pressure is

    caused by Obstructive Sleep Apnea, it is distinctive in that the readings do notdrop significantly

    when the individual is sleeping. Stroke is associated with obstructive sleep apnea.Sleep apnea

    sufferers also have a 30% higher risk of heart attack or death than those unaffected

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    Diagnosis: The diagnosis of sleep apnea is not simple. Definitive diagnosis typically requires

    polysomnography. This is a test which is done in a sleep laboratory or sleep clinic which

    measures 16 different parameters during sleep, such as EEG, EKG, eye movements, chin

    movements, chest movements, leg movements, airflow, etc. The Multiple Sleep Latency Test

    (MSLT) measures the speed in which a person falls asleep during the day when ordinarily they

    would be awake. For most people, it takes at least 10-20 minutes to fall asleep during the day.

    Patients with sleep apnea commonly fall asleep in five minutes due to being so fatigued.

    Treatment: Some typical medical treatments involve lifestyle changes, such as avoiding

    alcohol , muscle relaxants or other medication that slows the respiration. Losing weight, and

    quitting smoking are recommended. Many people benefit from sleeping at a 30 degree angle or

    higher, as if in a recliner. This is especially true for back sleepers. Doing so helps preventgravity from collapsing the airway. Lateral positions (sleeping on your side) are also

    recommended as a treatment for sleep apnea, largely because the airway-collapsing effect of

    gravity is not as strong to collapse the airway. Some people benefit from various kinds of oral

    appliances to keep the airway open during sleep. "Breathing machines" like the Continuous

    Positive Airway Pressure (CPAP) may help. The most common treatment for sleep apnea is the

    use of a positive airway pressure device (PAP), which 'splints' the patient's airway open during

    sleep with a flow of pressurized air into the throat.

    In addition, a dentist specializing in sleep disorders can prescribe Oral Appliance Therapy

    (OAT). The oral appliance is a custom made mouthpiece that shifts the lower jaw forward which

    opens up the airway. OAT is usually successful in patients with mild to moderate obstructive

    sleep apnea. OAT is a relatively new treatment option for sleep apnea in the United States, but it

    is much more common in Canada and Europe.

    There are also surgical procedures to remove and tighten tissue and widen the airway.

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    Chinese Medicine & Sleep Apnea

    We live in a complex world, where disease patterns are not uniform. The patient with Sleep

    Apnea is probably not coming to your office for a diagnosis. They may not even recognize they

    have this syndrome. The above information is so that you will be more aware if they have been

    diagnosed with sleep apnea or if they have symptoms that make you believe that Sleep Apnea

    could be a problem. As practitioners of Chinese Medicine, we would look for the root of the

    problem and perhaps help them resolve some or all of their issues. In order to do that, we must

    determine why there is a blockage in the airway causing snoring and choking and why there

    might be a suspension of breathing. Something is inhibiting the qi mechanism is it qi

    stagnation, phlegm dampness, blood stasis, external warm or cold ? Most will have some

    element of phlegm is it hot or cold? There are always different theories, but according to LiDong-Yuans Treatise on the Spleen and Stomach -- "The spleen is the root of phlegm

    engenderment, but the lungs are the place where phlegm is stored." Both the lungs and the heart

    receive their qi from the spleen. It is important to keep the Spleen healthy because it is the

    source for qi and blood production for the body. An important saying in Chinese medicine states,

    "The Spleen hates cold and the Spleen hates dampness." Spleen vacuity occurs when the

    process of transformation and transportation malfunctions, thus causing dampness to gather and

    stagnate instead of transforming which further weakens T&T. Then a vicious cycle begins.

    Spleen vacuity is a causative factor in all cases that have symptoms of fatigue. Treatment has

    to be based on the patient's signs and symptoms. There is no one size fits all That type of

    thinking is pharmaceutically based.

    Published clinical trials suggest that cure rates of more than 80% and total amelioration rates of

    over 90% are possible with Chinese medicinals prescribed based on pattern discrimination.

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    Herbal Treatments:

    The following patterns have all been used in published treatments of patients with snoring andSleep Apnea in China. Most are classical formulas that are used to treat the pattern, however,

    some are not listed in Formula texts, so I have listed the herbs so you can get an idea of intention.

    These first two patterns come from studies on snoring:

    1. Wind warm heat snoring (Wind-Heat disorder with a slight Yin Deficiency)

    Wei Rui Tang aka Polygonum Odoratum Decoction

    Release the Exterior ; Disperse Wind-Heat

    ActionsClears HeatReleases the Exterior

    Nourishes Yin.

    SymptomsBreathing difficultyHeaviness of the body

    Sweating

    2. Internal heat & external cold snoring

    Qing Yan Li Ge Tang aka Clear the Throat and Benefit the Diaphragm Decoction

    Clear Heat and Relieve Toxicity

    ActionsClears Heat and relieves toxicityRegulates the Qi

    SymptomsFeverLaryngitisSore throatSore throatSwelling of the throat

    These next patterns come from studies on Sleep Apnea:

    Formulas 3, 4, 5, 6 all involve phlegm blocking and inhibiting the free flow of the throat :

    3. Spleen vacuity damp heat with phlegm turbid ity congesting and stagnating

    Xiang Chang Ping Dan Tang (Agastaches & Acorus Level the Gallbladder Decoction):

    Herba Agastachis Seu Pogostemi (Huo Xiang)Radix Angelicae Dahuricae (Bai Zhi),Rhizoma Acori Graminei (Shi Chang Pu)Caulis Bambusae In Taeniis (Zhu Ru)Rhizoma Pinelliae Ternatae (Ban Xia)Fructus Citri Aurantii (Zhi Ke)

    Cortex Magnoliae Officinalis (Hou Pa)Scierotium Poriae Cocos (Fu Ling)Rhizoma Atractylodis (Cang Zhu)Semen Pruni Armeniacae (Xing Ren)Fructus Cardamomi (Bai Dou Kou)Medulla Tetrapanacis Papyriferi (Tong Cao)Semen Coicis Lachryma-jobi (Yi Yi Ren),Radix Salviae Miltiorrhizae (Dan Shen)

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    4. Yin vacuity & damp heat with phlegm confounding the heart orifices

    Liu Huang Xing Shen Tang (Six Yellows Arouse the Spirit Decoction):

    uncooked Radix Rehmanaiae (Sheng Di)

    cooked Radix Rehmanniae (Shu Di)Radix Scutellariae Baicalensis (Huang Qin)

    Rhizoma Coptidis Chinensis (Huang Lian)

    Cortex Phellodendri (Huang Bai)Radix Astragali Membranacei (Huang Qi)

    Radix Angelicae Sinensis (Dang Gui)

    Rhizoma Atractylodis (Cang Zhu)Radix Angelicae Dahuricae (Bai Zhi)

    Caulis Bambusae In Taeniis (Zhu Ru)

    Rhizoma Acori Graminei (Shi Chang Pu)

    5. Phlegm dampness internally obstruc ting with qi s tagnation & blood stasis

    Jia Wei Xue Fu Zhu Yu Tang (Added Flavors Blood Mansion Dispel Stasis Decoction):

    Rhizoma Acori Graminei (Shi Chang Pu)

    Radix Angelicae Dahuricae (Bai Zhi)Fructus Trichosanthis Kirlowii (Quan Gua

    Lou)Caulis Bambusae In Taeniis (Zhu Ru)

    Radix Angelicae Sinensis (Dang Gui)

    uncooked Radix Rehmanniae (Sheng Di)

    Flos Carthami Tinctorii (Hong Hua)

    Radix Cyathulae (Chuan Niu Xi)Semen Pruni Persicae (Tao Ren)

    Radix Bupleuri (Chai Hu)Radix Glycyrrhizae (Gan Cao)

    Radix Ligustici Wallichii (Chuan Xiong)

    Radix Platycodi Grandiflori (Jie Geng)

    6. Depressive heat & recalcitrant phlegm joining and binding, obstructing and block ing the qipassageways

    (Unnamed formula containing):

    Pericarpium Citri Reticulatae (Chen Pi)Rhizoma Pinelliae Ternatae (Ban Xia)Radix Scutellariae Baicalensis (Huang Qin)Caulis Bambusae In Taeniis (Zhu Ru)Rhizoma Acori Graminei (Shi Chang Pu)Semen Pruni Armeniacae (Xing Ren)Herba Houttuyniae Cordatae Cum Radice (YuXing Cao)

    uncooked Lapis Micae Seu Chloriti (Meng Shi)Sclerotium Poriae Cocos (Fu Ling)Tuber Curcumae (Yu Jin)Fructus Trichosanthis Kirlowii (Quan Gua Lou)Pumice (Hai Fu Shi)Fructus Amomi (Sha Ren)Lignu Aquilariae Agallochae (Chen Xiang)

    7. Heart-spleen yang vacuity with water dampness internally collecting

    Wu Ling San aka Poria Five Powder or Hoelen 5 Powder

    Eliminate Dampness, Diuretic, Tonifies theSpleen, Warms Yang

    Rhizoma Alismatis (Ze Xie)

    stir-fried Rhizoma Atractylodis

    Macrocephalae (Bai Zhu)

    Sclerotium Poriae Cocos (Fu Ling)Sclerotium Polypori Umbellati (Zhu Ling)

    Ramulus Cinnamomi Cassiae (Gui Zhi)

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    8. Central qi downward falling

    Bu Zhong Yi Qi Tang aka Ginseng and Astragalus Decoction or Supplement the Center & Boostthe Qi Decoction

    Tonify , Tonify the Qi, Raises Qi and Yang

    Tonifies the Qi of the Middle Burner

    Radix Astragali Membranacei (Huang Qi)

    Radix Angelicae Sinensis (Dang Gui)

    Radix Panacis Ginseng (Ren Shen)Rhizoma Atractylodis Macrocephalae (Bai

    Zhu)

    Radix Bupleuri (Chai Hit)

    Rhizoma Cimicifugae (Sheng Ma)

    Pericarpium Citri Reticulatae (Chen Pi)

    Fructus Zizyphi Jujubae (Da Zao)Radix Glycyrrhizae (Gan Cao)

    dry Rhizoma Zingiberis (Gan Jiang)

    Acupuncture Treatments:

    In China, Huang Tie-qun has treated one case of spleen qi vacuity weakness and phlegm obstructing theqi mechanism ( Obstructive Sleep Apnea) by needling:

    Dan Zhong (CV 17),

    Nei Guan (Per 6),

    Bai Hui (GV 20),

    Si Shen Cong extra points aka Gods Cleverness Four Spirit Ability

    location 4 points, 1 cun to the front, back and sides of GV 20

    Feng Long (St 40),

    Tai Xi (Ki 3),

    Lion Quan (CV 23).

    Huang needled these seven points once each day, retaining the needles for 15-30 minutes each time. Asthe condition became less severe, he needled less points each time. One month equaled one course ofsuch treatment. At the same time, Huang counseled the patient to restrict their diet and increase theirphysical activity. After one month of therapy, night-time snoring and cessation of breathing and daytimesomnolence and fatigue had completely disappeared.

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    A STUDY ON HOW ACUPUNCTURE IMPROVES SLEEP -

    A recent study shows that acupuncture as a treatment for obstructive sleep apnea (OSA) has immediate effects in

    reducing nocturnal respiratory events, sleep disruptions, and desaturations (low oxygen levels in the blood). The

    researchers hypothesize that this improvement is due to acupunctures effects on serotonergic pathways and also

    acupunctures anti-inflammatory effects. Both manual acupuncture and 10Hz electro-acupuncture techniques

    were found effective. Both techniques produced superior clinical outcomes compared with 2Hz electro-

    acupuncture.

    Acupuncture Technique used by AcupuncturistsThe researchers used classical acupuncture techniques and acupuncture points in their study. The acupuncture

    points chosen for the study were: Lu6, Lu7, LI4, LI20, GV20, CV23, St36, St40, Sp6, K6, and extra point

    Shanglianquan (located near the hyoid bone). Copper-handle 40 X 0.25mm needles were used and inserted to

    traditional depths. Electro-acupuncture was applied to the neck points CV23 and Shanglianquan and a separate

    pair were connected to LI4 and St36. Electro-acupuncture stimulation had wave pulses of 0.45 ms2at 10Hz and

    increased to an intensity of between 0.6 - 0.8 mA which produced a mild twitch. The manual acupuncture group

    receive manual stimulation to the needle untildeqi(sensation of heaviness or numbness) was achieved at each

    acupuncture point. The needles were retained for 30 minutes.

    Acupuncture Testing ProceduresLaboratory findings used electroencephalography, electromyography, and electrocardiography. This tested

    respiration, mouth flow, and pulse oximetry with the use of an oximeter. Subjects were chosen for the study from

    a randomized process. Blinded independent researchers followed four groups: manual acupuncture, electro-acupuncture at 10Hz, electro-acupuncture at 2Hz, control group. The researchers note that the electro-acupuncture

    was not tested for analgesia but rather for its effects on the lack of motor competence as a result of inflammation

    and other mechanisms responsible for reducing the activity of airway muscles.

    Discussion of Acupuncture and Airflow

    The researchers note that the acupuncture points of the neck are of specific interest because they stimulate the

    genioglossus muscle (secondarily, the mylohyoid muscle) on deep insertion. They note that stimulation of this

    lingual muscle affects airflow dynamics and may be a key reason as to why acupuncture is effective for improving

    the symptoms of patients with sleep apnea.

    Reference:

    Immediate effect of acupuncture on the sleep pattern of patients with obstructive sleep apnea, Anaflvia O Freire,

    Gisele C M Sugai, Snia Maria Togeiro, Luiz Eugnio Mello, Srgio Tufik; Acupunct Med 2010;28:115-119.

    Department of Physiology, Universidade Federal de Sao Paulo, Unifesp Rua Botucatu 862, 04023-062 So Paulo/SP,

    Brazil. [email protected]

    Abstract

    BACKGROUND: Most patients with obstructive sleep apnea (OSA) do not tolerate treatment with nasal

    continuous positive airway pressure, the 'gold standard' treatment for this condition. It was shown in a pilot study

    that acupuncture was more effective than placebo treatment (sham acupuncture) in producing significant changes

    in the respiratory events assessed by polysomnography (PSG).

    OBJECTIVES: To investigate the immediate effect of manual acupuncture (MA) and electroacupuncture (EA)

    on the sleep pattern of patients presenting with moderate OSA.METHODS: 40 patients with an Apnea-Hypopnea Index (AHI) of 15-30/h were randomly allocated to MA

    treatment (n=10), EA 10 Hz treatment (n=10), EA 2 Hz treatment (n=10) and a no-treatment control group

    (n=10). The patients received MA or EA (2 or 10 Hz) just before the PSG study at 20:00.

    RESULTS: The AHI (p=0.005; p=0.005), the Apnea Index (p=0.038; p=0.009) and the respiratory events

    (p=0.039; p=0.014) decreased significantly in the MA and EA 10 Hz groups, respectively (AHI (21.9, 11.2),

    Apnea Index (5.15, 0.7), respiratory events (120.5, 61.0) in the MA group before and after. AHI (20.6, 9.9),

    Apnea Index (8.2, 0.3), respiratory events (117.0, 56.0) in the EA 10 Hz group before and after). The micro-

    arousals decreased only in the MA group (146.0 vs 88.5, p=0.0002). There were no significant changes in the EA

    2 Hz group or in the control group.

    CONCLUSION: A single session of either MA or EA 10 Hz had an acute effect in reducing the AHI as well as

    the number of nocturnal respiratory events of patients presenting with moderate OSA.

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    Questions for Sleep Apnea course:

    1. Sleep Apnea was first identified as a medical condition in __________________________

    2. Apnea literally means _______________________________________________________

    3. In all types of sleep apnea, the person ___________________________________________

    _____________________________ during sleep.

    4. How many types of sleep apnea are there? ________________________________________

    5. The most common type of sleep apnea is__________________________________________

    6. According to studies, over ___________________________________Americans suffer from

    sleep apnea.

    7. Risk factors include being male, ____________________________ and over ____________

    years of age. Other risk factors include _____________________________________________

    _____________________________________________________________________________

    8. Fifty percent of people with sleep apnea have _______________________________________

    9. Sleep apnea sufferers also have a 30% higher risk of _________________________________

    ______________________________________________ than those unaffected.

    10. Definitive diagnosis typically requires a test which is done in a sleep laboratory or sleep

    clinic. This test is a ____________________________________________________________

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    11. As a TCM practitioner, your diagnosis would be based on ___________________________

    ______________________________________________________________________________

    12. Studies in China have shown that herbal treatments are effective in treating sleep apneawhen pattern discrimination is used.

    TRUE FALSE

    Name _____________________________________ License # ____________

    Address ________________________________________________________

    City _______________________State ________ Zip ____________________

    Telephone ___________________E-Mail______________________________

    Signature________________________________________________________

    My signature confirms that I have read the material and answered the questions on my own toreceive Continuing education units.

    Return these answers only to the address provided. There is no need to return the

    entire booklet.