Help them sleep
Using Osteopathy and Ayurveda to shift
paradigms and help patients sleep
Heather Ferrill DO, MS
AAO Convocation 2016
Goals
 The brief synopsis of the physiology of sleep
 The physiology of sleep debt
 Sleep disorders, a shift in paradigms
 Using Ayurvedic doshas to gain a different persective
 Treating sleep disorders
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An Ayurvedic approach to sleep hygiene
An Osteopathic approach to treatment
Marma for sleep
Yoga as a tool to help sleep
Purpose of sleep
 Three major theories
 Repair and restoration
 Time for the brain to metabolically and chemically repair
 Evolutionary (adaptive) theory
 Sleep evolved as a means of conserving energy
 Information consolidation
 Based on cognitive research that suggests that sleep is necessary for processing events of the day, preparing for
the day to come, and cement events and information into long term memory
 Consolidation during sleep promotes both quantitative and qualitative changes in memory representations
Stage 1: light sleep
 Easy to wake; jumpiness
Stage 2:
 eye movement stops and brain waves slow, marked
by sleep spindles
Stages of sleep
Stage 3 & 4 (NREM)
 Slow wave sleep
 Predominates in early sleep
 Benefits consolidation of declarative memory
(newly encoded memories with pre-existing longterm)
 Conserves energy, restores CNS , cools body and
brain, promotes immune function (Bryant et al 2004)
Stage 4: REM
 Theta sleep
Diekelmann S, Born J. The memory function of sleep. Nature Reviews Neuroscience 11, 114-126 (February 2010)
 Predominates in late sleep
 Preferentially benefits the consolidation nondeclarative (short term to long term) memory
(emotional and procedural)
 Psychological and emotional adaptation through
dreaming, facilitates CNS development, provides
sentinel role to allow for periodic awakening to
survey environment (adaptive function) (Bryant et al 2004)
 "A macroscopic waste clearance system"
for the brain
The
glymphatic
system
 Architecture
 An intricate network of perivascular tunnels
formed by astroglial cells to promote
efficient elimination of soluble proteins and
metabolites from the nervous system.
 CSF and intestitial fluid continuously
interchange. CSF driven into Virchow-Robin
space (space surrounding penetrating
arterioles at the pia/brain interface), into the
interstitial space, to the perivenous spaces
of the large veins, and out of the brain
parenchyma into the cervical lymphatic
system
 Dramatic changes in brain architecture and
fluid flow during sleep
http://io9.gizmodo.com/the-real-reason-why-sleep-deprivationcan-destroy-you-1447241194
 60% increase in interstitial space, with marked
increase in CSF/interstitial fluid convective flux in
sleep and anesthetized states
 Lateral recumbent position most efficient (compared
to supine or prone)
Jessen, NA, et al. The Glymphatic System: A beginner's Guide.
Neurochem Res (2015) 40:2583-2599 DOI: 10.1007/s11064-015-1581-6
Sleep and the endocrine system
 Sleep (Deep) inhibits the HPA axis; Activation of the HPA axis leads to
arousal and sleeplessness
 Almost every hormone is influenced by circadian rhythm
 24hr cortisol. ACTH, and pro-inflammatory markers IL-6 and TNF all
increase proportional to the level of sleep disruption in a night as well
as over time.
(Chrousos 2016)
The good news? Naps are good….
Naps after a sleepless night
decreases sleepiness,
improves performance and
has a beneficial effect on
cortisol and IL-6 secretion
(Vgontzas
2007)
Autonomic regulation of sleep
Neuroanatomy
 Cell populations that regulate sleep are
closely situated to cell populations that
help regulate autonomic function
 Sleep:
 Sleepiness: Thalamus
 Wakefulness: Pons, basal forebrain,
hypothalamus
 Autonomics:
 Hypothalamus: heart rate, blood pressure,
energy metabolism, GI motility
 Medulla: baroreceptors, chemoreceptors,
cardioreceptors, respiratory receptors all
via Glossopharyngeal and Vagus nerves
http://sleepdisorders.sleepfoundation.org/chapter-1-normal-sleep/neurobiology-of-sleep/
Sleep and the autonomic system:
normal NREM
 In normal stage 1-3 NREM sleep we see
 Increased PNS: decreased HR, BP and cardiac output
 Decreased SNS: decreased PVR and BP
 HR reaches nadir during stage 3 nREM sleep
 Autonomic respiratory control
 Breathing slows and gets more regular
 During stage transitions there are bursts of vagal tone
 Physiologic sinus arrhythmia and sinus pauses
Sleep and the autonomic system:
normal REM
 Cholinergic discharges lead to muscle atonia and dream enactment
 Increased eye movements are accompanied by increased SNS and
decreased PNS activity
 BP and HR fluctuate quite a bit in REM sleep, often reaching levels much higher than waking state
The autonomics and sleep deprivation:
Short term
 Short term deprivation and restriction leads to mild and temporary
increases in the activity of the major neuroendocrine stress systems:
 autonomic sympatho-adrenal
 Hypothalamic-pituitary-adrenal axis
 Initial signs of alterations in the way we deal with challenges
under the influence of sleep restriction appears to be on the
level of emotional perception
The autonomics and sleep deprivation:
Long term
INSUFFICIENT SLEEP SENISITIZES INDIVIDUALS TO STRESS RELATED
DISORDERS
 Gradually alters the neuroendocrine response system AND
 Central mechanisms involved in regulating NEI responses (central
sensitization)
 Changes brain systems and NEI systems in manners similar to that of
depression and other stress related disorders
 Decreased serotonin receptor activity and altered regulation of the HPA axiS
Sleep restriction and deprivation, by any
means, is as important a risk factor for a
variety of diseases that are linked to stress
including mood disorders and cardiovascular
disease.
sleep debt and brain
changes
Neuropsychologic results in pretreatment OSA showed
impairments in most cognitive areas, and in mood and
sleepiness. These impairments were associated with
focal reductions of gray-matter volume in the left
hippocampus (entorhinal cortex), left posterior parietal
cortex, and right superior frontal gyrus. After
treatment, we observed significant improvements
involving memory, attention, and executivefunctioning that paralleled gray-matter volume
increases in hippocampal and frontal structure
"The cognitive and structural deficits in OSA may be
secondary to sleep deprivation and repetitive
intermittent nocturnal hypoxemia."
Canessa N, et al. "Obstructive Sleep Apnea: Brain Structural Changes and Neurocognitive Function
before and after Treatment", American Journal of Respiratory and Critical Care Medicine, Vol. 183, No.
10 (2011), pp. 1419-1426.
The best bridge between despair and hope is a
good night's sleep.
~E. Joseph Cossman
Sleep deprivation and emotional disorders
 Multiple studies link sleep deprivation
with affective disorders such as
depression and anxiety
 73% of adolescents with depressive
disorders also suffer sleep disorders (Lui et al 2007)
 Bidirectional relationship between sleep
disturbance and mental health (Cortese 2013)
 Sleep disturbance is a precursor to the
development of depressive symptoms in
adolescents (Lovato 2014)
 Sleep restriction to 6.5 hours (!) for 5 days
resulted in increased reports of tension,
anxiety, fatigue, poorer emotional
regulation, and opposition with parents in
adolescents 12-17 y/o. (Baum et al 2014)
www.brooklynartproject.com
Sleep deprivation and emotional stability
Nearly all psychiatric and neurological sleep disorder display some degree of
affective imbalance
Lack of sleep inappropriately modulates the human emotional brain in
response to negative aversion: sleep deprivation leads to a hyper-limbic
response by the amygdala to negative emotional stimuli, with loss of
functional connectivity to the MPFC suggesting a loss of pre-frontal control.
Amygdala activity
+
Pre-frontal control
=
Decreased emotional stability
Yoo SS, et al. The human emotional brain
without sleep-a prefrontal amygdala
disconnect. Current Biology Vol 17 No 20
R878
Get off the "devices"!
 Smartphone ownership in adolescents:
 Less than 3% of adolescents without
smartphone
 Later bedtimes
 Increased nighttime usage (TV,
movies, texting, internet surfing, etc)
 There is an interrelationship between
electronic media usage before bedtime,
sleep disturbance, and depressive
symptoms in all age groups. (Lemola 2015)
 Increasing evidence that electronic device
usage is related to, and may cause, sleep
disturbance. (Cain & Gradisar 2010)
 Predictive role of nighttime media use
with the development of depression (Primack
et al. 2009)
 MOST correlative media usage with
depression is spending time surfing online
(Facebook, chat rooms, etc) (Lemola 2011)
Keep it out of the bedroom!
 Blue light from electronic media
inhibits melatonin release delaying
sleep onset
 National sleep foundation
recommends getting it OUT of the
bedroom
 If not able, dim to lowest setting
and keep 14 inches away from
head to reduce the amount of blue
light entering the eyes
 And NO exposure in the last hour
before bedtime
In college students, both daytime and nighttime media usage has
been found to
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Impact sleep quality as well as quantity
Increase “nomophobia”
Increase anxiety
Negatively impact executive functioning (attention, concentration, train of
thought)
 Negatively impact impulse control
(Rosen et al. 2016)
Without sleep, we all become like tall two year olds.
~JoJo Jensen, Dirt Farmer Wisdom, 2002
Bidirectional relationship of sleep disorders and
pain
sensitivity
Schuh-Hofer s, et al. 2013:
 Total sleep deprivation for one night
 Increased sleepiness
 Increased anxiety
 Increased sensitivity to: heat, cold, pinprick, generalized
hyperalgesia
Okifuji & Hare 2011:
 Self-reported poor sleep, not objective, correlative with increased
next day pain
 Self reported poor sleep correlated to hyper-analgesia and decreased
distraction analgesia
 Sleep disturbance may decrease the effectiveness of analgesic
medications
MOST IMPORTANT: improved sleep is correlated
with improved pain scores
findingmyinnercourage.wordpress.com
 Sleep disturbance greater in children with sever headache v. mild
Sleep & Pain mechanisms
 Multifactorial & controversial
 Reduced sleep may reduce opioid
binding to mu-opioid receptors thus
reducing opioid effect. 5HT system
Valentina Kallias “Damaged”
 Some 5HT subtype antagonists administered
intrathecally to both REM deprived and nonREM deprived rats (others showed analgesic
effect)
 REM deprived rats showed a significantly
higher rate of pain behavior
 Cognitive behavioral
 Sleep deprivation leads to negative
cognition and mood
 Negative cognition and mood leads to
increased pain perception
(Lautenbacher et al 2006)
Sleep deprivation and memory
 12 hours of sleep deprivation
in mice affected hippocampal
function at the behavioral and
cellular levels
 Inability to perform new task
based on old patterns
 Reduction in hippocampal
neuronal function
 Stress hormones played little
to no role in these changes as
both control and deprived
mice had no statistical
difference in cortisol levels
Hagewood et al, 2010
Sleep deprivation and memory
 Learning new tasks, particularly emotionally charged or involved, affects REM sleep
in the hours and days after learning the task
 Duration
 Amount
 REM Sleep deprivation during this REM sleep windows impairs the short term
retention
 Slow wave sleep deprivation leads to impairment of short-term to long-term
memory
http://mashable.com/2014/01/07/memory-apps/#Wmasj6cs0uqQ
Sleep
Immune system
 Chronic insomnia associated with
significant decreases in certain T cells
and NK-cell responses.
(Inwim et al. 2003) (Savard J et al.
2003)
 OSA patients have elevated levels of
TNF and IL-6 with lower IL-10
supporting theory that OSA activates
pro-inflammatory state. (Bryant 2004)
 Sleep deprivation in the ICU led to an
increased risk of hospital acquired
infections (Weatherstone 2003)
 Sleep deprivation impacts immune
function , increasing proinflammatory indices by activating
responses similar to acute injury
(Okifuji &
Hare 2011)
Sleep: A poor substitute for caffeine.
The upshot: allostatic load
 Sleep deprivation over time elevates the allostatic load
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Increase appetite and energy expenditure
Increase proinflammatory sytokines
Decrease parasympathetic and increase sympathetic tone
Increase blood pressure
Increase evening cortisol, insulin, and blood glucose levels
 Affects functional AND structural brain activity in the Hippocampus,
Amygdala, and Prefrontal cortex
 Resulting in
 increased affective disorders such as depression and anxiety
 Cognitive functioning
 Long term health problems such as Diabetes and cardiovascular disease
McEwen 2006
sleep disorders
 Three big categories
 Those who can't get to sleep
 Those who wake during sleep
 Those who oversleep, or sleep too much
sleep disorders
 Three big categories
 Those who can't get to sleep
 Those who wake during sleep
 Those who oversleep, or sleep too much
Ayurvedic paradigm
 The Dosha's
 Vata
 The force of movement inspiration, and excitement
 Lightness, dryness,
 When disordered: anxiety, flighty, unable to focus
 Pitta
 The force of transmutation and transformation
 Sharp, direct, focused
 When disordered: anger, physical heat—reflux,
ulcers,
 Kapha
 The force of groundedness and cohesiveness
 Heavy, slow, sense of safety
seeing the sleep disorders from a different
perspective
 Pitta sleep disorders
 Can't fall asleep
 10pm-2am "second wind"
 Vivid fiery dreams will wake them but they can get back to sleep
 Vata sleep disorders
 Usually wakes during the night and can't fall back to sleep
 2-6 am wakers
 Kapha sleep disorders
 Heavy sleepers who tend to oversleep and wake sluggish in the morning
Lifestyle
changes
 Adequate fluid intake throughout the day
(preferably water)
 Adequate rest
 Meditation, approaching the day with a
restful state of mind
 7 hours sleep minimum associated with
decreased morbidity and mortality (Brant et
For everyone
al 2004)
 Stress management strategies
 Journaling, meditation, nature
 Decreased stimulants
 Appropriate before bed activity:
 Eliminate screen time
 Decrease reading in the hour before bed
 Earlier lighter dinners
 Make bedtime a ritual
 Oil massage, bath, meditation, quiet
activity, connection time
Restful Waves Dornberg
http://kl.imagekind.com/art/stunning/restful/oil_painting/fine-art-prints
 Vata has the quality of lightness and
mobility, the opposite of those
qualities that support sleep
 Need grounding, depth, 'heaviness'
 Exercise
 Timing and type matter
 Daytime exercise; avoid overstimulation, especially
in the evenings
 walking, hiking, gentle cycling, yoga, or chi
gong
 Lifestyle
 Thrive with routine, though they resist it and they love
change
 3 meals per day at regular times: warm, oily and spiced
 Increased oils and grounding foods (roots, grains, etc)
 Lots of fermented foods
 Oil massage regularly, especially at night
Images: heymonicab.com
Pitta is hot fiery and intense
 Exercise
 Make sure that exercise is not
overly intense, but do it with
relaxed effort instead.
 Enjoy activities like walking,
hiking, light jogging, swimming,
cycling or yoga in the morning
or evening (when it is coolest),
and try to breathe through your
nose the entire time.
 Lifestyle
 Steady intake of dark leafy greens, sweet
fruits, non-oily foods
 Need a lot more focus on rest and ease to
counterbalance the tendency to be so
very intense.
Images: heymonicab.com
Kapha is dense, cohesive and slow
moving
 Routine is important
 Wake before 6 am
 Kapha is highest from 6-10am increasing the
likelihood of waking tired
 To bed soon after 10
 More vigorous exercise
 Best in the evenings and first thing in
the morning
 brisk walking, jogging, biking,
hiking, martial arts, and other
forms of strength-building,
aerobic exercise.
Images: heymonicab.com
Nature has no apology to offer. It does the work if you know how to
line up the parts; then food and rest that is required.
~A.T. Still, Osteopathy Research and Practice
[The] processes of Life must be kept in motion.
—AT Still, Philosophy of Osteopathy
My mentors taught me to always be sure to treat
the sacrum and to get the neck moving in all
sleep disorders
• Vedic anatomy
 Throat area is the place of physical,
mental/emotional, and spiritual purification.
 Inefficient processing leads to 'energetic' and
thus physical manifestations of blockage
(somatic dysfunction!)
• Sacrum
 Grounding
 Autonomic balancing
• Cranial base and OA
 Lymphatic flow
 Mid-brain motion
 Autonomics
Balancing the autonomics
The autonomic model of OMT targets
balancing of the SNS and PNS drive. MFR
of the following areas can affect
autonomic influences of sleep
Case study of sleep disorder and
anhidrosis following trauma revealed
resolution after one treatment of the
following areas with MFR:
 Rib raising
 Soft tissue
 Paraspinal inhibition
 Collateral ganglion
 Thoracolumbar region
Nobles T, Bach A, Boesler D. Case report of osteopathic treatment of insomnia and
traumatic anhidrosis. IJOM (2016), http://dx.doi.org/1-.1016/j.ijosm.2016.01.006
OCMM & sleep
In a pilot study by Cutler et al, CV4 was
shown to decrease sleep latency and
sympathetic nerve activity as compared to
CV4 sham treatment and no treatment.
Cutler M, et al. Cranial manipulation can alter sleep latency and
sympathetic nerve activity in humans: a pilot study. J Altern
Complement Med. 2005 Feb;11(1):103-8.
Marma points for sleep
disorders
Focus on balancing:
•
the Dosha's
•
The autonomic system
Yoga to support sleep
 Postures (asana's) can stimulate or ameliorate
the dosha's
• To support sleep
• Downward grounding energy
• Balance the predominant and disturbing
dosha
VATA postures
 Vajrasana
 Bhujangasana (cobra)
 Shirshasana (headstand)
 Halasana (plow)
 Pascimottanasana
Pitta balancing postures
 Janu shirshasana
 Dhanurasana (bow)
 Ardha navasana (half boat)
 Setu banda sarvangasana
 Ustrasana
 Sarvangasana
Kapha balancing
postures
 Ardha matsyendrasana
 Vrksasana
 Tadasana
 Parupurna navasana
 gomukhasana
http://www.saatchiart.com/art/Painting-Spirit-Life/18336/1106276/view
A good laugh and a long
sleep are the best cures in
the doctor's book.
~ Irish proverb
resources
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
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
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
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
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
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
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
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
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
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
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
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