89. Conquering the Sleep Struggle with Roger Seheult, MD

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Linda Bluestein, MD (00:02.25)

Wow, this is gonna 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 Alred 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.

Roger Seheult, MD (01:18.466)

Thank you so much, Linda. Dr. Blustein, it's great to be here.

Linda Bluestein, MD (01:22.942)

I'm so thrilled to chat with you.

Welcome back, every bendy body. This is the bendy bodies podcast and I'm your host and founder, Dr. Linda Blustein, the hypermobility MD. This is going to be a great episode, so be sure to stick around until the very end so you won'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. 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. Why should we care a lot about this topic?

Roger Seheult, MD (01:59.61)

Oh, sleep is incredible. You know, 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. It's there's an analogy I like to give. I had a friend in high school who worked at Disneyland and he worked at Disneyland.

when everybody went home, he was part of the night crew. And if you've ever been to Disneyland in Southern California, Anaheim, it's a busy place to be, especially during the summertime. But boy, it's even busier, some could say at night. And 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 at whatever time it opens up the next day. The same thing happens in our body. Disneyland is a very complicated place, but our body is even more complicated than Disneyland. And so all of the bodies restored of things that are timed on a circadian rhythm, we'll talk more about that, occurs when we sleep. So we really ought to be getting the best type of sleep that we know how.

Linda Bluestein, MD (03:08.61)

Ha ha ha.

Linda Bluestein, MD (03:22.41)

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. And can you explain what that is and why people should care about it?

Roger Seheult, MD (03:35.774)

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, that'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 super chiasmatic 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. And 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, thousands, millions, if you would, studies, hundreds of thousands of studies, let's say,

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 re-looked at because when you have medication side effects, it's actually dependent on what time of the day you've taken that medication. Here's something that's even more mind blowing that will might hit closer to home. My wife was a really big believer in...

our kids being breastfed. And our kids, let's put it this way, they didn't like to be naturally breastfed, so my wife would pump and she would store the milk in a fridge. And we didn't realize this at the time, but it's actually starting to show, scientists have actually done work on this, that there are certain hormones, chemicals, things of that nature of breast milk that is expressed during the day versus at night versus this time versus the other. And so to the point is, is that this is actually in training the baby

in terms of what time of day it is. And so I bring these up as an 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. And I'll give you some hard examples here. For instance, we now know that insulin, which is the hormone responsible for putting glucose into our cells, the response of insulin to the body is actually

Roger Seheult, MD (06:03.014)

more sensitive in the morning than it is at any other time of the day. So that you would have, 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. 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, to the point of that when athletes are training for a particular race or people who are very aware of this in terms of studying for an examination, they have been trained to actually make sure that they're doing that training at the same time of day that they will know that they will be tested at that same time of the day at a later date. That's how important

Linda Bluestein, MD (06:34.938)

Mm.

Roger Seheult, MD (06:59.39)

circadian rhythm actually is.

Linda Bluestein, MD (07:02.134)

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, it seems like more night games. And then now they're having some games in Europe, for example. So then that's a really interesting, yeah.

Roger Seheult, MD (07:15.53)

Yes. And imagine, imagine teams on the East coast having to fly to the West coast and having those games for them much later in their circadian rhythm than it would normally be. Absolutely.

Linda Bluestein, MD (07:22.286)

Mm-hmm.

Linda Bluestein, MD (07:28.758)

Yeah, yeah, definitely. And I...

Roger Seheult, MD (07:30.75)

So yeah, so getting back to that, the supra chiasmatic nucleus is the master clock that entrains all of the other clocks to be working at the same time. If you wanna imagine it this way, imagine a symphony, a symphony orchestra, and you have the first violins, the second violins, the third violins, the tuba, the timpani, the brass section, the woodwinds. I hope I'm not missing anybody there. But all of those have a particular music.

Linda Bluestein, MD (07:54.7)

Ha!

Roger Seheult, MD (07:59.466)

right, 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 gonna 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's when 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.

And that's what the master clock does. And 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 is speed up the conductor that 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 is basically we are the performance of that piece.

Linda Bluestein, MD (08:52.79)

Wow, and it's the supra-kiatic nucleus. I didn't say it quite that way. Chi-os-matic. Okay, and where is that located?

Roger Seheult, MD (08:56.234)

Super chiasmatic nucleus, it's the SCN, yes, the SCN. That is located around the thalamus, a 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.

Linda Bluestein, MD (09:20.122)

Oh, I can't wait to get to that. That's going to be super, super helpful and super important. Okay. So light, I know you have so many fantastic videos about light and I have to confess, I just, I've purged, binged, 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 and especially...

when people have chronic illness.

Roger Seheult, MD (09:51.55)

Yeah, so there are two aspects of light that we can talk about. The first aspect of light 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 and healing. And it's the type of light that we're not getting as much of. And we can talk about that on a second half, but

Let's go back to the first half. So the first part of light and the circadian rhythm aspect of light. So 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. And so 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. So what are these things that affect

circadian rhythm timing. They have a German term for them. They're called zeitgebers. And it's a funny word to use. But 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 like eating food, activity, all of these things are zeitgebers. But the single most powerful zeitgeber or the thing that's going to influence your circadian rhythm is light. And let me give you an example of what would happen.

and this happens a lot in society, is there are inputs from the back of our eye, from the retina, that 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. And 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 nine o'clock at night. For some people it's two o'clock in the morning and everywhere in between. 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. Okay. And everyone, the audience quiets down, the performers then turn their attention to the conductor and they're ready to play the piece.

Roger Seheult, MD (12:15.234)

That would be what we call dim light melatonin onset. So DLMO, this is where we're getting ready for sleep. The pineal gland starts to secrete a substance called melatonin, okay? And this is when the magic happens, when people start to get sleepy and they go to sleep. Now, the problem here though, is this, is that when the eyes are exposed to light, that will shut down melatonin production. Now,

I want to be very clear about this because this is when you think of, oh, I don't really expose my eyes to light. No, no, no. Even a photon of light in some cases, mic, just very minimal light, even light that is outside that is able to go through your eyelid and get into your eye and go 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 air pollution, light pollution at night. All of these things can affect that in a way so that when the circadian rhythm is getting ready for sleep and it sees light, what is hardwired in the circadian rhythm is this. Hey, 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.

Linda Bluestein, MD (13:35.318)

Mm.

Roger Seheult, MD (13:37.538)

Therefore, I, the circadian rhythm conductor, must be too early. It must be too early for the concert. Therefore, I must delay. I must tell everybody we're in the wrong period of the day. We must delay. And so what happens is, is that repeated exposure to light at night causes the circadian rhythm to become delayed. So instead of falling asleep or feeling tired at nine o'clock or 10 o'clock, after repeated ab-

bouts of sunlight exposure or artificial light exposure, this is gonna cause your circadian rhythm to delay and you're gonna feel sleepy later and later and later and later until finally, your circadian rhythm may not be ready to go to sleep until one or two o'clock in the morning. And that's a problem if you have to get up at six and you need to get a full night's sleep because you're hearing everybody telling you that you need seven or eight hours of sleep. So you go to bed at 10 o'clock at night.

and you go into a bed and you're not ready for sleep. That's a problem and that's the symptom of insomnia. And we have a huge problem in this country of insomnia. People wanting to go to bed, people trying to fall asleep at a specific time, but not being able to do that. And so what happens is you wake up at six because nobody cares how you feel or you've just got to go to work, right? So you wake up at six and what happens is that

because the circadian rhythm has delayed itself because of light exposure at night, instead of falling asleep at 10 and the circadian rhythm ready to arouse the body at six o'clock in the morning, it's now said, oh, I was late, sorry, I was too early. And so now I am having you go to bed at two o'clock in the morning, but we are not ready for you to get up from your sleep until do the math, right? What's that, like 10 o'clock in the morning?

Linda Bluestein, MD (15:28.539)

10 o'clock.

Roger Seheult, MD (15:29.706)

Right, and that's exactly what we would rather be if we're left to our own devices on the weekend till 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. And so we feel very irritated. We need to get to work. And so we take stimulants to get our body accustomed to feeling sleepy so we can actually take on the day, usually in the form of coffee or caffeine. There's whole...

industries that have made their profits of the whole issue of us exposing our eyes to bright light at night. And then what happens is that the cycle repeats itself and it reinforces itself. And so 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 enforced that circadian rhythm. 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.

amount of light. What is that? That's a measure of how much light there is. And we need to go outside to be able to get that. 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 of the circadian rhythm. That actually switches it the other way. What's going on there? 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 to the conductor, the super-chiasmatic nucleus, that light, and it's saying, oh, wow, the light has come early. I am too late. I need to shift everything the other direction. And so here's the long and short of it, is that we currently live in a society that is definitely skewed to one of those problems. And that is excessive light at night.

Linda Bluestein, MD (17:25.614)

Yeah.

Roger Seheult, MD (17:47.446)

And what that has done is it has caused a huge delay generally to many people in the working industry so that we are going to bed too late and we are still having to get up in the morning to get to work. What I would highly recommend for those of you who have insomnia at night is to make sure that you are doing a couple of things. You are going full force hitting all cylinders on all of the zeitgebers that tell us to be awake. So what are those...

What are the major zeitgebers? We said that light is a major zeitgeber. We said that eating and food is a major zeitgeber. And there's something else that's also a major zeitgeber and that's exercise. So if you are someone that doesn't fall asleep at night, it takes a long time to fall asleep and you feel very groggy in the morning, highly recommend the following. Number one, getting up early in the morning, exposing your eyes to bright light outside.

And if you're in a situation where you live in a high latitude where that's not happening because the sun is not up at that time, then I would recommend investing in a light box, 10,000 lux, it's about $20 on Amazon, and exposing your eyes to that amount of light for about 20 minutes in the morning. Getting some exercise in the morning, that's another zeitgeber. And then having a good breakfast in the morning when your insulin levels are the most sensitive.

to get those calories in and then tapering off the amount of food at lunch and then finally at dinner time. So the problem here we have in the United States is we do the opposite of what we should be doing in the Western world. 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 and that's a recipe for lack of sleep.

Linda Bluestein, MD (19:26.188)

Mm-hmm.

Linda Bluestein, MD (19:37.782)

Wow, yeah, I was thinking as you were saying all 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 seems like that's like, it's really hard to not get an LED light. And I was fascinated when you said it's really just takes like a photon and just such a tiny amount of light. So that's really, really.

challenging, but I think the morning part is the part that people can really maybe act on most easily. So that's really, really important. And you also had mentioned something about timing of eating and does intermittent fasting or time-restricted eating, does that make a difference?

For the below timestamps, please add 24 minutes as this was recorded in two parts.

Roger Seheult, MD (20:22.262)

Absolutely. So here we go again. Imagine if the gardener showed up at Disneyland at two o'clock in the afternoon. That would just, Walt Disney's mind would explode because he was very careful about making sure the experience of the park goers was that this was a stage, right? You didn't wanna see any of the, so this is 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. So the basis of intermittent fasting is this. People think of intermittent fasting, oh, you're eating less and you're losing weight. It's another way to lose weight. No, no, no. That may be a side effect or a nice side effect of intermittent fasting. But the proof of intermittent fasting is the following. And that is this, is when you stop eating

particularly carbohydrates, but any type of fuel. What happens after about four to five hours after you stop putting calories into your mouth is that your body switches over to a different form of metabolism called basically ketosis. So 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.

occurs, it actually triggers the production of genes and gene products, proteins that are involved in repairing and restoring bodily functions. Now, this happens automatically when you go to sleep, unless of course you're sleep eating, which is a diagnosis, but it's not a very common one. And so you are built into this is that 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, you go to bed and that's the time period that you have for the gardeners to come in and the engineers to come in and the cash register people and the restocking people to come in. But none of that's happening because you are not getting the maximum benefit because those people are not available to come in because you haven't gone into a fasting mode.

Roger Seheult, MD (22:46.898)

intermittent fasting maximizes those time periods. It says, let's have the gardeners and the engineers available when the park closes at night. What I'm meaning to say here to get to the more biological is 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 four to five hours before you go to bed.

Now I know that's difficult, that goes completely against our societal nature, but you may remember an expression from many, many years ago, probably over a hundred years ago, that said you should eat breakfast like a king and you should eat lunch like a... Do we just lose?

Roger Seheult, MD (00:02.96)

There's this expression from over a hundred years ago where it says we should eat breakfast like a king. We should have 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 like to be with the family at night, we sit down, we sort of talk about the day and that's a great time to have dinner. And so I would skip breakfast and not really understanding.

Linda Bluestein, MD (00:14.37)

Yeah.

Roger Seheult, MD (00:29.588)

how the circadian rhythm worked and realizing that I was kind of swimming upstream when I did that. So I would skip breakfast, have lunch and dinner. But then when I started to switch back and did it the other way, which is not easy for some people have breakfast and then lunch, and then have skip out on dinner in the evening or have a very light dinner, I think that actually works much better.

Linda Bluestein, MD (00:51.326)

Yeah, that's super interesting. And I can see where like people who are working out of the home during the day, and there can be a lot of challenges. And then I know a lot of people who have, for example, autonomic dysfunction, they'll eat small meals and a lot of people who have other chronic illnesses, 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 know, you mentioned several times about people that are like falling asleep at two

if they wake 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?

Roger Seheult, MD (01:29.44)

Probably not. I'll tell you the diagnosis of this would be if it was causing some social issues. Like 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 that the issue with having your circadian rhythm so off of what it should be in terms of sunlight, it makes the...

hours of sunlight less available to you and the benefits of that sunlight. 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, much bigger influence on the health of our human body than just vitamin D. I'm not minimizing vitamin D.

Linda Bluestein, MD (02:00.742)

Mm-hmm.

Roger Seheult, MD (02:26.748)

It's important, but there's so many other aspects to sunlight that we get a benefit from. We could talk about, you know, this goes beyond the scope of this discussion, but there's evidence that sunlight, near infrared radiation, near infrared light, complete biological spectrum lighting improves mitochondrial disease, has an effect on mood. We know about seasonal affective disorder. There's just so many aspects to light. We have so much data on this that people who live

in areas where there's a lot of near infrared light in green spaces, for instance, they just have better outcomes, better health outcomes. There is the Sweden study, it's called the SSS study, the South Sweden study, thousands and thousands of Swedish women in that study that showed that people who undertook light avoiding behavior had higher incidences of cancer, melanoma actually.

and that those that were sun avid behaviors had lower incidences of cancer and metabolic syndrome.

Linda Bluestein, MD (03:28.138)

That's so fascinating. So many of my patients with chronic illness, they actually are 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, you know, it's afternoon and 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.

Roger Seheult, MD (03:54.608)

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

Linda Bluestein, MD (04:24.534)

How long do you think for the average person?

Roger Seheult, MD (04:27.188)

takes about two to three 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. That's when you've trained your body and your body is adjusted to that. So if you make a change to deliberate change to be hungry or to eat, I should say 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.

Linda Bluestein, MD (04:29.065)

Okay.

Roger Seheult, MD (04:55.292)

for you to take in that meal at that time.

Linda Bluestein, MD (04:57.782)

Okay, and a follow-up to this is, you know, 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?

Roger Seheult, MD (05:10.)

Yeah, exactly. So this is known as psychophysiological insomnia. So imagine that you have struggled to fall asleep in your bedroom. And let's just back up here a little bit. We here living in the Western world, in the first world, we have bedrooms, right? We have rooms that are designed specifically for sleep. Not everybody has that, even here. I mean, we have one room, apartments and things, but for those of us that have, quote, bedrooms,

that are designed for us to sleep in, that's our war room. That's the room that we go in every night and battle with this issue of not being able to sleep. And so what we're doing is we're associating all of those anxieties and battles with that room. I hear this all the time with my patients who have insomnia and it's this psychological insomnia where 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 that are associated with inability and not being able to do something comes back to them and makes them exactly the wrong thing to do if you want to be falling asleep, which is anxiety. The way I like to analogize this is imagine going out onto the hall of Carnegie Hall. So you're walking out onto stage, but instead of a piano there for you to play, or a violin, there's a bed.

and you're being asked, go and sleep in that bed. How many people would be able to go into that bed and sleep? It's very 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. And so what we need to do is we need to take the battle out of that bedroom. The solution...

for psychophysiological insomnia is to no longer make a mountain out of a molehill. It's to take the battle out of the bedroom. If you go to bed, 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 wanna dilute the signal, subconscious signal, of you falling asleep in that bed by diluting that signal with other things in the bedroom. So working in the bedroom, being on your laptop.

Roger Seheult, MD (07:29.916)

watching television, doing all of these things that dilute that subconscious signal that it's now time for bed, is not a good thing and you should not do that in the bedroom. So basically, kind of jokingly, humoristically, the bedroom should only be for two things, and if you don't get one, well, the other isn't so bad either.

Linda Bluestein, MD (07:49.486)

I love it. 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? And so if we can talk about, 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, you know, we know there's central sleep apnea and obstructive sleep apnea. So if you could talk about that a little bit.

Roger Seheult, MD (08:14.396)

Yeah, so real briefly, obstructive sleep apnea, 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. And so what happens is that the nerves that try to keep that airway open, which is not a rigid airway, it's a flexible airway, they 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 and it might sound like this.

Roger Seheult, MD (08:54.376)

Silence, okay? 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. But this will happen and people sometimes, if it's really bad, will wake themselves up because they can no longer breathe. When you can no longer breathe and when air no longer gets into the lungs, the oxygen levels in your blood drops.

Linda Bluestein, MD (08:58.908)

Oh.

Roger Seheult, MD (09:21.352)

And 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 to all over your body. So your heart rate goes up, your blood pressure goes up, and you arouse out of your sleep. So those are the two things, is the arousal out of your sleep, that's one. And number two, the sympathetic nervous system push, or basically stimulation.

to the point that your airway opens up. That's exactly what it's supposed to do, is if you can't breathe, you're gonna get that opened up, air is going to rush back in again, it may sound like this. Hhh, hhh, hhh. Okay, so I'm giving you a little bit of a dramatic demonstration there. You may have, you may wake up out of your sleep, you may be having a dream, or maybe even a terrible dream that you wake up out of, because you can't sleep, because you're getting a sympathetic drive. And so,

at the root cause of sleep apnea is the laxity of tissue. And so it should not be too surprising to understand and realize that people with lax joints, and there's down loads, et cetera, have an increased risk of obstructive sleep apnea in those populations. And so because the problem is a mechanical problem, the solutions are generally mechanical solutions. There's no medications.

or things of that nature that will reverse the issues of obstructive sleep apnea. So the most studied, the longest used, the most efficacious thing, or intervention for obstructive sleep apnea is positive airway pressure or CPAP. So what's going on there? You can imagine a flat tire. This is your airway and it's collapsed.

So what we wanna do is we wanna 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. And then the way they do that is by having a device that 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 what this does is it 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. And this is, boy, this has done so much for so many people.

Roger Seheult, MD (11:41.464)

Because here's the problem. The problem is that when you have continuous arousals out of sleep when you have continuous Sympathetic nervous system discharge at night that leads to issues of excessive daytime sleepiness accidents stroke hypertension atrial fibrillation congestive heart failure all of these things are related to people who have these conditions and it can be related to obstructive sleep apnea when you put CPAP on

and it opens up that airway and it prevents that from happening. You no longer have the arousals. You are now able to go into nice deep sleep and stay there and not be aroused out of it continuously. And by the way, what I mean continuously is there are some people that, well, we define sleep apnea as anyone who have symptoms and where this happens more than five times per hour. Five times per hour, right? So that's once every 12 minutes, okay? But I've seen as high as a hundred times an hour. So this is...

Linda Bluestein, MD (12:38.593)

Oof.

Roger Seheult, MD (12:39.272)

They literally cannot sleep and breathe at the same time. And so it's really important that we reduce the incidences of these things. I could show you so much data that would just be mind blowing. I could show you, for instance, the impulse of the sympathetic nervous system in a normal person and in somebody with sleep apnea during the day. So this repeated stimulation of the sympathetic nervous system at night when you're sleeping.

translates over to during the day you have increased sympathetic nervous system activity. That means higher blood pressure, faster heart rate, all of the bad things that you don't want to have. This is causing those problems. So relieving that obstruction is really important. Okay, but there are other treatments that you can also do. There are other things that will keep that airway open. One of those things is a dental device. So if you can imagine, I can do it really well because I have this problem, but if you take your lower two fingers, put it on your lower jaw and

your lower jaw in front of your upper jaw. So in other words that the two incisors on the bottom of your teeth are in front of the two incisors on the top of your teeth. Because the tongue is anchored to your jaw, what you're doing is essentially you're pulling the tongue forward, which is the major problem in sleep apnea because what happens is the tongue falls back and it 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. So wearing a dental device can be something that you can do instead of wearing a CPAP device. There's also another device called Inspire, which is more for moderate to severe that does something very similar, except it doesn't move the lower jaw forward. It simply activates the muscle that sticks your tongue out like this. That's the genioglossal muscle. And the way it does it,

is 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 it sends a signal to that muscle that they implant into your neck to stimulate that genioglossus muscle to contract, and it moves the tongue forward every time that you breathe. So that's another way of doing it. That one's a little bit more invasive, and it does have some side effects to it, but those are the three main ways.

Roger Seheult, MD (14:59.236)

that we now have today that are approved to treat people with obstructive sleep apnea.

Linda Bluestein, MD (15:05.962)

And I'm thinking about that middle way. And if someone has TMD or temporal mandibular dysfunction, that could be potentially problematic in terms of that option, yeah.

Roger Seheult, MD (15:15.804)

Yes, it could. On the flip side, for those that grind their teeth at night, this could be a twofer, where this dental device would prevent them from grinding their teeth and would move the tongue out of the way. So my recommendation would be is if you feel that you have this, is to get a sleep test, and we can talk more about sleep tests, but also to try either CPAP or to see a sleep certified dentist.

who is trained in this area and they can actually make the dental device. Now you may say that I don't have dental insurance. Here's the good news, is 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.

Linda Bluestein, MD (16:00.706)

That is great information. That is really good to know. And let's talk about home versus lab sleep studies because will that detect obstructive versus central sleep apnea? And what are the pros and cons of the different options?

Roger Seheult, MD (16:16.828)

Absolutely. So central sleep apnea, before we go on, is this idea that you, in both cases, obstructive and central, you stop breathing. In obstructive sleep apnea, the reason why someone stops breathing is because the airway has closed and clearly you will see that their chest and their abdomen is trying to get a breath in, but because it's closed up here, they can't get that breath in. 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 and therefore these people are not breathing and there is no movement in the chest and the abdomen. So that's how you would tell the difference. Generally speaking in those cases, it's because of carbon dioxide levels and trigger thresholds that could cause that. And 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. All right, so let's talk about tests. So back in the old days, we used to, everybody would have to go into the sleep lab and everybody would be hooked up with wires all over their head. And it basically, it 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 and they're all, they're FDA approved.

where if you see somebody, let's say somebody comes into your office, in 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 into their mouth and they've got a large tongue, and I'm like, this guy is a slam dunk for sleep apnea. Do I need to send him now to do this 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's these sensors that can tell when they're trying to take a breath in and out. So this is a much cheaper way of doing it, but there are limitations with these home tests. These home tests do not recognize very well central apneas. And so therefore, if I have a patient who has a risk factor for having central apnea, like a stroke, they are...

Roger Seheult, MD (18:41.008)

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 that has a detector there by the nose. Those are the ones that I send to the lab to have the full out studies done. Those are only about 10% of the people that I send for sleep tests in general. Home testing has really revolutionized and made more simple the ability to check for sleep apnea. Now there's a newer technology. It's been out for a little while.

And it's based on not checking to see if somebody is breathing like these traditional home tests are doing, but rather looking at the response of the pulse. So what happens is when somebody has an arousal because they have an obstructive event that we talked about, 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. And you can actually do treatment based on that as well. So there's a variety of tests. Probably what will happen is if you are a patient and you suspect this, that your physician is going to have already set up a relationship with a testing corporation or testing company that will decide, and you and he and the physician will decide, do you get a...

in-house exam, a home exam, or the watch pad.

Linda Bluestein, MD (20:09.374)

Okay. And some other people who have EDS are more prone to things like carry malformation. Sometimes it's pretty subtle. And so those might be people too that would benefit from an in-lab because of the risk of central apnea. Okay. Great. And what about, I've also heard that, well, as an anesthesiologist, of course, I'm used to...

Roger Seheult, MD (20:23.101)

Yes, exactly.

Linda Bluestein, MD (20:30.914)

doing a lot of these 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, is that, can that be helpful?

Roger Seheult, MD (20:34.877)

Yes.

Roger Seheult, MD (20:41.04)

Yes, so it depends on what the results of the sleep study show. So 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 is 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 sleep on their side so that the gravity doesn't pull the tongue back.

There's a number of devices that have come out to try to encourage people to sleep on their back. There's one that kind of 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. It's kind of an interesting, I've actually got a shirt once when I was a sleep physician from a company they just wanted to trial it and they sent it to me. It had this shirt that if you put it on the wrong way, you would have like these three big.

Linda Bluestein, MD (21:23.002)

Right. Yep.

Roger Seheult, MD (21:38.28)

things in front of you, but you have to make sure that you put it on the back. It looked like a cow. I mean, it looked like these udders. But no, 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 your back. But I would caution people to say, you know, that's me. You would be surprised what happens when you're asleep and you don't know. The best way to find out—

Linda Bluestein, MD (21:45.106)

That's funny.

Roger Seheult, MD (22:08.564)

what happens is to actually do the sleeve test.

Linda Bluestein, MD (22:12.919)

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?

Roger Seheult, MD (22:26.08)

There's a number of ways that could potentially affect it. If the cervical spine in a sense is been manipulated or is malaligned, I've seen patients who have elevated hemidiaphragms because the phrenic nerve is not able to, is not, the phrenic nerve is the nerve from the brain that tells the major breathing muscle, the called the diaphragm to contract and to breathe. And if that's not intact, then these people are susceptible to not getting enough of a breath at night.

And if that's the case, then I would almost exclusively want to treat these people with positive airway pressure, but not in a continuous way to keep the airway open, but to help them with those volumes. We call that bi-level or bipap. Another way that's potential is with the kyphosis or the scoliosis. These are all curvatures of the spine, which make the lung volume suboptimal and cause the same situation. So if they're not taking in enough volume when they're sleeping at night, and they're not...

breathing enough volume, the carbon dioxide is not coming off, and that causes the carbon dioxide levels to build up, and that can cause headaches in the morning, that can cause elevated pulmonary artery pressure, and this can lead to cardiovascular complications.

Linda Bluestein, MD (23:37.674)

Yeah, we definitely want to try to avoid those if we possibly can, for sure. Let's switch gears again and talk about sleep medications. There's it seems like there's just more and more that are coming on the market. Yet I'm so glad we talked about light first, because, you know, it's like we're trying to fix these problems, maybe the wrong way a lot of the time. But but what should we know about sleep medications?

Roger Seheult, MD (23:40.671)

Right.

Roger Seheult, MD (23:52.21)

Yes.

Roger Seheult, MD (23:58.921)

Yes.

Sleep medications, talking to 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. Like for instance, if they have had a death in the family and they're having difficulty sleeping, you need to do it for a very short period of time. Realize that these medications can be potentially addictive, depends on which one, we can talk about a few of them. And really, according to the studies that have been done,

the long-term use of sleep aids has really not been very effective at treating the sleep problem and may have significant down effects, side effects in the long run. There's actually one study, it was not definitive, it was a associative study that showed that even the use of these FDA approved medications for sleep like Ambien, like Lunesta and some of these other ones.

can actually increase the risk of falls and it was actually associated with the increased risk of mortality in older patients. In fact, after they came out with the dose of Ambien, they actually had to rescale back the dose, particularly for women. They also recommended it for men as well because there was a high incidence of people doing these automatic behaviors the next morning. And it actually says on the label that you should not drive 24 hours after you take this medication. So if you're taking it every night, you really just can't drive.

if you're actually taking this medication. Yeah, so it's, if I have a patient with a chronic sleep problem, I am going to do sleep hygiene going through their entire sleep list of things that they do before they go to bed. I'm going to even look at something called cognitive behavioral therapy, which is actually much more powerful than sleep medication and much more longer lasting.

Linda Bluestein, MD (25:30.966)

Really? Wow.

Roger Seheult, MD (25:57.768)

than sleep medication. The types of things that we're talking about is something that we've talked about already, is not only looking at sleep hygiene, but asking them about, you know, how they perceive their issues with sleep. Even doing sleep restriction therapy to see. There's a lot of behavioral things, oh boy, we could talk for an hour, about the things that people do when they can't sleep that actually make the problem worse.

Linda Bluestein, MD (26:15.586)

Ha ha ha!

Roger Seheult, MD (26:21.464)

There's things called precipitating factors like death in the family or a new job, good stress, bad stress, all of these things can precipitate it. But the key thing that causes us to be chronically insomniac are the perpetuating factors. Let me give you an example of what might happen. So 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 I'm gonna try to get some sleep. Tell me, what's gonna happen if you go to bed earlier and you're not ready for sleep? You're not gonna fall asleep. And you're gonna feel and you're gonna associate that insomnia and your inability to fall asleep and all of the feelings of inadequacy and your poor health and you're gonna project that onto your room so that the next time you come in, that is built into the equation. So you're slipping more and more into this deep hole of chronic insomnia. 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. To give you a quick explanation of what that does is we restrict people's sleep from eight hours a day. You have eight hours to sleep. Go ahead and do it however you want. Let's say I give them eight hours of sleep but they only sleep for four or five hours during that period of time. Then what I would do is I say, okay, now I'm only gonna give you four or five hours to sleep, make the most of it.

And what's gonna happen is that after that first night, this is called sleep restriction therapy, they don't feel very well because they haven't slept very well and they're extremely tired. And they're like, why did I even go see this doctor? But what happens is that next night, that sleepiness is the drive for them to fall asleep. And eventually what happens is, and we keep doing this every night until they can do this, is that their sleep efficiency improves to about 80 to 90%, which means that 80 to 90% of the five hours that I gave them to sleep.

They're sleeping, they fall asleep quickly and they're doing a good job. What does that do? It builds confidence. It's now, now instead of you walking out onto Carnegie Hall stage and 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. Uh, you do. Okay. You are now this tremendous piano player and you're walking out and you're ready to play that piano. You're ready. You're, you know, that piano isn't going to play you. You're going to play that piano.

Linda Bluestein, MD (28:28.151)

Ha ha!

Linda Bluestein, MD (28:32.918)

I do.

Roger Seheult, MD (28:43.684)

And so now you have confidence you're able to do this. And so what I do is I then give them 15 minutes back and I do this, this is a slow, slow process. This is not my technique. 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 part of a, you know, you're not a truck driver or a airplane pilot. So you have to do this under supervision, but I'm just giving you a flavor.

Linda Bluestein, MD (29:05.902)

Sure.

Roger Seheult, MD (29:11.524)

the types of things that I would rather and the science is showing that is much more effective at getting you to sleep Rather than chasing all of these medications, which are basically just covering up the symptoms of the problem I mean, it's a terrible thing to say but think about people that have died because they just could not sleep and they took too Many medications. I mean we know who those we know some examples off the top of our top of our head But it's what people would do

Linda Bluestein, MD (29:36.414)

Oh yeah, for sure.

Roger Seheult, MD (29:40.5)

to be able to get a good night's sleep. Oh man, it's incredible. Yeah. So how do you get a good night's sleep? Here's the real quick thing. Exercise in the morning, sunlight in the morning. This really cues your circadian rhythm to get that done. Making sure that you're not exposing your eyes to bright light or any kind of light at night is really important. And let me just tell you an anecdotal story real quick. I went to do a recording similar to this one and we went off to a place where we did it and they actually hosted us and they put us up into a room and they had like, they had a sauna.

And I had never really been in a sauna, but I'll tell you, the host took me and Kyle, who's the other half of MedCram, we went into the sauna and we had a wide ranging discussion. And every 20 minutes I would go outside and have a cold shower and come back into the sauna. And we had a wide ranging discussion. We just completely lost sense of time. And as it turned out, we spent, this must've been 170 degrees, 174 degree sauna. We spent, I spent about two hours in that sauna, okay?

Linda Bluestein, MD (30:37.55)

Ha ha.

Roger Seheult, MD (30:39.268)

And I went to bed that night. I cannot remember a night that I slept so soundly than that night right after that sauna. And so sure enough, I've looked online for evidence of this. And I see that Rhonda Patrick, who does, yeah, 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.

Linda Bluestein, MD (30:54.154)

Love her. Yeah, she's amazing.

Roger Seheult, MD (31:05.972)

that actually saunas are very beneficial for getting good night's sleep. They increase all sorts of slow wave sleep, all sorts of things. If people are listening to this or interested in doing that, I think that'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. So that's the quick, like if I wanted to just boil it down and juice it down to something that you could drink,

Um, the, the big top things, if you want to get a good night's sleep is exercise in the morning, bright light exposure without glasses going outside into the sun. You don't look at the sun, but be outside, avoiding light at night, do that continuously multiple times over a week, two weeks, a month, and, uh, maybe consider son and see if that helps.

Linda Bluestein, MD (31:57.846)

So the first thing that comes to my mind as I'm hearing this too is, okay, so if you're not watching TV, and then I guess reading, especially reading on an iPad would be bad. I don't know, reading with like a lower Kelvin light, I don't know if that would be recommended, but what are you doing in the evening if you're, yeah.

Roger Seheult, MD (32:16.06)

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 you know, some versus a very low lit dim, uh, traditional light reading a book. And the differences were stark. Uh, it was orders of magnitude, more light with the, with the e-reader than there was with the soft light. And as we've just talked about, we know that what that effect is going to have on melatonin. And 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 on just the e-reader. So imagine watching full television, bright light, LED, all this sort of stuff. So what do you do at night? So avoid that, avoid technology, avoid lights. There was a gentleman that I heard on a podcast who was really into this and went like maybe to an extreme, but he made sure that none of the ceiling lights were on. He only put low level lighting, like literally low, like 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 the melatonin are concentrated in the lower portion of the retina. Now, 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 fields are going to be reflected on the lower retinal area and vice versa. And so

what they have determined is because these receptors are in the lower retinal area, that light that is high up is the type of light that is going to quickly shut down melatonin production. So, and by the way, these melatonin receptors or these light receptors were more towards the blue side of it. And 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 and light that is more towards the red zone.

if you're going to have any type of light at all. So just to be clear, no light is the best. Then light that is low in the visual field and redder is second best. And then of course, everything else goes from there. So if you think about that real quick, imagine how we lived life 100, 200, 300, a thousand years ago. What type of light would we have at night? It would typically be a fire that is low on the ground, that is red.

Roger Seheult, MD (34:44.056)

I mean, all of this stuff 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, a hundred years is we've had the technology to do things to our body that we never had the capability to do. We have the freedom to eat any time. We have the freedom to work anytime. Yes, we have that freedom, but it may not be good for us.

Linda Bluestein, MD (35:09.726)

Right. And then we also have in that period of time, I think more and more caffeine use. And we also have things like stimulants, ADHD medications. And then of course, there's also been other medications that are FDA approved for promoting daytime wakefulness. What do you think about those medications?

Roger Seheult, MD (35:18.793)

Yes.

Roger Seheult, MD (35:23.412)

Yes.

Yes.

So 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. They are, 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. So I have them on CPAP and I can see that they're compliant with the CPAP machine. Then I will add those medications. Yeah.

Linda Bluestein, MD (36:15.25)

Okay, and what about supplements for sleep? There's a lot on the market, of course.

Roger Seheult, MD (36:19.228)

Yes, yes, there are a lot. And it's because sleep is such a problem. Again, I would say that even the supplements, although they probably don't have the same negative effects as some of the prescription medications, they are also covering up the symptoms of the problem rather than solving the problem. Now there are some exceptions. Some of them do actually have some significant side effects. Anything that is an antihistamine is going to...

take away histamine. Now what is histamine? Histamine is an alerting substance, a 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. You're not going to be able to process as well, but you are going to maybe be able to go to sleep better at night. The problem is that we don't know for sure, but there are some studies that have associated long...

term antihistamine use with dementia. And that's not a good thing in my book. So I would try to avoid that. Again, I would look at the underlying causes and try to fix those things.

Linda Bluestein, MD (37:26.59)

Right, it's kind of like in the EDS world and patients who have mast cell activation syndrome and yes, you can use different medications, but at the end of the day, you really wanna make sure that you're removing the triggers that are causing the mast cell degranulation in the first place. Okay.

Roger Seheult, MD (37:38.047)

Yes.

Yeah, I mean, 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. And so there are some patients where we can get away with lifestyle choices, but there are some patients that we need to do lifestyle, but we also need to add some medications, at least in the short run, to get them out of danger.

Linda Bluestein, MD (38:01.898)

Right, right, for sure. So we had so many questions that came in after I posted. This was such a quick turnaround, which I love it. It was fantastic to get to chat with you on such a short notice for both of us. But so I want to throw some of these questions at you. So the first question is, what do you think about sleep watches and other monitoring devices, like there's the Aura Ring, and there's a whole host of things?

Roger Seheult, MD (38:27.156)

So at first my response to those devices was skeptical, but after looking at the data, they're actually very accurate. They've actually done a very good job of picking up this stuff, such to the point that a number of these technologies have now made it and are FDA approved like the Watchpad. So yeah, I do not poo that at all. I think there's a lot of good data on there. We've actually tried to on our MedCram channel.

try 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.

Linda Bluestein, MD (39:01.97)

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?

Roger Seheult, MD (39:29.368)

Yeah, I would say this is that it's so diverse that I would pick the position whatever position works best for them in terms of their ability to have the least amount of pain. Obviously, that's going to be the best position for them. Now, that being said, if they also have sleep apnea, and they probably should be tested if that's what they have, because if there's a laxity of joints and tissue, then there's probably also a laxity up here as well. So getting tested for that, that generally speaking, although this is not 100%, generally speaking.

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 the 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 then not only if they have sleep apnea, but some people have sleep apnea and it doesn't matter what position they sleep on. They still have sleep apnea. So

Linda Bluestein, MD (40:22.912)

Mm-hmm.

Roger Seheult, MD (40:24.648)

that can all be answered in a sleep test. They will definitely be able to answer whether or not they have sleep apnea and whether or not there's a particular position that it is worse in.

Linda Bluestein, MD (40:34.334)

And even those home tests actually can tell you about the positional aspects. Okay.

Roger Seheult, MD (40:38.16)

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. Even the prone position, it can tell. Yeah.

Linda Bluestein, MD (40:46.931)

Okay, great. And then also there were people who commented that they get paresthesias or numbness tingling in their hands or other body parts. Can you just explain why that happens and what people...

Roger Seheult, MD (40:54.172)

Yes.

Roger Seheult, MD (40:57.788)

Yes. So I have the same thing. So I can speak from this from experience. When I was in medical school, I did a lot of reading, obviously back in the days when we went to medical school, we didn't have YouTube videos. So I was leaning a lot on my elbows. And what that caused later, I found out was something called a tennis elbow or entrapment of the ulnar nerve. So the ulnar nerve is right, goes around this part, the medial aspect of the elbow.

Linda Bluestein, MD (41:11.595)

No, we didn't.

Linda Bluestein, MD (41:15.266)

Mm.

Roger Seheult, MD (41:27.516)

and wraps around there through a little tunnel. And if what sometimes can happen is it gets entrapped and it gets tight. And so what will happen is if you sleep with your elbow flexed like this, the nerve conduction down the ulnar nerve won't be so great. And it will affect the, it will make the pinky completely numb and half generally speaking of the ring finger. But all of these, 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 and that can be happening because of golfing elbow, I guess it's called. So it just depends on which fingers are numb. If the pinky is numb, then it's probably a result of a ulnar nerve entrapment. And 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 I taped it up and I basically put my arms through it. So when I was sleeping at night, I would keep my arms straight.

It's probably not good to keep it completely straight, maybe slightly flexed a little bit. But I even had an EMG done because it was very irritating for me to have numbness and pain there because I would play the piano and all sorts of things. So it eventually went away after I learned to keep my arm straight. But occasionally I'll wake up and I'll have numbness and tingling. Now if you have numbness and tingling in the other fingers, then the most likely problem is that you've got a carpal tunnel situation where there is increased...

of the median nerve as it goes through the wrist, and there is a way to release that so you can get feeling back. So 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 probably, you can get something as conservative as a splint, but I don't want you to, I don't want to miss an issue because if you have enough nerve compression, not only is it a sensory nerve issue, it's also a motor nerve issue, and you could actually get atrophy of those muscles.

seeing a neurologist or primary care and then a neurologist to see if that's something that you need. And then maybe even an EMG, hopefully not, but maybe just a brace so that when you sleep, you keep that joint in the neutral position.

Linda Bluestein, MD (43:35.638)

Okay, great. And someone had asked about pillow recommendations if someone has cervical instability. I don't know if you have any thoughts about that because obviously this is pretty highly specific.

Roger Seheult, MD (43:45.776)

Yeah, that's a little out of my area field. I would probably consult with a specialist who deals with that. I have seen all sorts of advertisements. My wife is somebody that has gone through a lot of pillows. And what I would recommend though is this, is I don't know the shape or the size of the pillow, but I will comment on this, is that if you're gonna go to get a pillow and you have any history of allergies or asthma or post-nasal drip,

make sure you don't have down feathered pillows in there because that can make your allergy and asthma much worse. Imagine you're putting your nose next to something for hopefully a good six, seven, eight hours a day. And if that is something that you're allergic to, it's gonna change your life for the worst. And it's something that you probably wanna avoid.

Linda Bluestein, MD (44:33.142)

Sure. And when I was dealing with some issues with my neck, I know my physical therapist said to avoid like the gel pillows and the things that were a little more like solid that you want. Maybe maybe like a down alternative type of pillow that your head could kind of sink into more and be a little more supportive. So, okay, great. Any tips for people who frequently wake up in pain.

Roger Seheult, MD (44:52.308)

Excellent.

Roger Seheult, MD (44:59.772)

It depends on where the pain is. Generally speaking, what we do in those situations is we identify the pain. We 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. And we usually refer them to a pain specialist, which you being an anesthesiologist would know all about that. There are actually, as you know, some specialties in anesthesia that deal just with pain. And there's a lot of...

creative ways of dealing with pain. But I would say this, is it's a well-known fact that if people get enough sleep, if you can do that, then pain tolerance improves dramatically. I remember this when I was on call. There was this feeling, my wife and I, because she was also a physician, she was a resident at the time, whenever we would do our 36 hour shift and we'd come home, we'd have that post-call feeling.

everything just seemed to hurt. In fact, I remember my wife telling me, she's like, 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 very simply because we hadn't slept. It was very illuminating, very illuminating. And to realize that 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. Yeah.

Linda Bluestein, MD (45:58.584)

Yeah.

Linda Bluestein, MD (46:04.462)

Wow.

Linda Bluestein, MD (46:21.354)

And that, right, right. That's really fascinating that your wife would have made that comment. And I practiced for over 20 years in the operating room, and now I do pain management for people with EDS and HSD. And so we talk a lot about sleep, and I can't wait to refer every single person I know to this conversation, so they can listen to these great tips. Because we talk about sleep a lot in our sessions, a lot. And it's a problem for a lot of people. And I totally agree with you about the sensitivity to pain and that kind of thing.

Roger Seheult, MD (46:39.211)

Hahaha

Linda Bluestein, MD (46:51.239)

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 if they have sleep apnea for sure Okay

Roger Seheult, MD (46:57.48)

Yes. Yeah. And it's probably the main reason. Yeah. If I have a patient that comes to me and they have nightmares, and what's the difference between nightmares and night terrors? Well, 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 in a night tear, if they can remember what the dream was, they will never remember what the dream was.

even immediately, whereas a nightmare, they'll tell you exactly in explicit detail 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.

Linda Bluestein, MD (47:43.522)

Fascinating.

Roger Seheult, MD (47:44.336)

And by the way, just to sort of dovetail into the pathophysiology, the reason why is that during REM sleep, your body becomes paralyzed because you are dreaming. And it's a very important defense mechanism that you don't want the patient 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. And that's why we typically see that if someone has sleep apnea, it's almost always worse during REM sleep.

And so this is kind of an unfortunate situation because people with sleep apnea almost never get the benefit of REM sleep because they exit out of it because of that arousal. And so when you treat people with sleep apnea, I see this all the time, people have had sleep apnea for a long time and you put them on a CPAP machine and you look and see what happens. They go into REM sleep and they stay in REM sleep. It's almost as if the body's like, oh, please, thank you, we finally.

Linda Bluestein, MD (48:23.724)

Hmm.

Roger Seheult, MD (48:40.008)

And I've had patients come back to me, at least at the very beginning phases of starting therapy for sleep apnea. And they're like, I had the most amazing dreams that lasted for so long. And eventually kind of evens out and it goes back to normal, but it's just fascinating to see that.

Linda Bluestein, MD (48:55.414)

Yeah, that is really fascinating. And for people who have really vivid dreams, if they are really bothersome, besides addressing their sleep apnea, is there anything else that they can do, if they have sleep apnea, of course.

Roger Seheult, MD (49:07.184)

Yeah, if they have vivid dreams, what we will typically do is, 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 prosthetic hypertrophy. So they're not typically too, in terms of side effects, they could get a little bit of dizziness if they stand up, at least initially, because it blocks that sympathetic nervous system.

But in terms of holistic things, cognitive behavioral therapy is used, although I haven't done it for nightmares.

Linda Bluestein, MD (49:43.694)

Okay. And we talked about supplements earlier. We've talked about melatonin, off and on. Is it safe to take? What are your thoughts about taking?

Roger Seheult, MD (49:48.548)

Oh, yes. Oh, excellent, yeah. So melatonin, boy, I'm surprised it's been this long in the talk and we haven't gotten to melatonin. So here's the thing about 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. The problem is, is that when you take melatonin and it gets into the blood, it's a signal.

Linda Bluestein, MD (49:55.051)

Huh!

Roger Seheult, MD (50:15.08)

that it's time for your body to go to sleep. Again, it's that conductor tapping the music stand. So you don't wanna take melatonin at any other time except right before you're gonna go to bed. And the problem that we find is that the more melatonin you take, the more paradoxical a result that you get. So one to three milligrams of melatonin can be sleep inducing at least to get you to sleep and then maybe not necessarily stay asleep, but at least get you to sleep.

But if you start to go up on the dose, five milligrams, eight milligrams, 10 milligrams, there's actually this opposite effect that occurs where people just become more irritated and they don't fall asleep. The other problem with melatonin, at least in the United States, is that it's not regulated. And so if you buy melatonin over the counter, you know, you're kind of taking, you know, what's the chances that you're actually getting what they say is on the label actually in the tablet or in the capsule. So...

My recommendation would be, yeah, obviously you need to buy melatonin over the counter, but to make sure that whatever brand you buy is been inspected by a third party that has said that this is actually in there, and buy it from a reputable brand. So the two big things are, is that make sure you're getting what you believe is melatonin, and there's a way to do that. And number two, start off at a very low dose, because the higher the dose that you go, the less likely it is to work, at least in a sleep inducing manner. And then thirdly is,

Just take it at night, maybe about an hour before you go to bed. Now, I do have a video, by the way, on jet lag, and you can use melatonin in a way to get around jet lag. We actually did it this year when we went to Europe. Works great when you're going to the East. We hardly had any jet lag at all. And a reason why I say that is because in those situations, you wanna take it actually at six o'clock in the evening for a certain amount, three days before you travel East, and it helps.

And there's more information on our YouTube channel there for jet lag how to crush jet lag is the name of the thing But generally if you're just doing it and you're not going on a jet taking it about an hour before you go to bed It's probably the best thing to do

Linda Bluestein, MD (52:22.194)

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 syndrome syndromes and hypermobility spectrum disorders is that they're not covered sufficiently in medical education.

Roger Seheult, MD (52:35.72)

Yeah.

Linda Bluestein, MD (52:49.45)

Of course, you and I know there's a lot to fit in, 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, can you explain to people why this is the case and if this should be changed or not, or where we could get more education so that people could be recognized sooner, the symptoms that they're having and get.

Roger Seheult, MD (52:52.383)

Yes.

Linda Bluestein, MD (53:18.294)

better care basically.

Roger Seheult, MD (53:19.568)

Yeah, edge. Oh boy. Education is so key. My father was a science school teacher and he became a you decide to go to into dentistry at the age of 40. So I think it kind of rubbed off on me. Yeah, I was I was into tutoring in college in a medical school. And I became a pulmonary critical care. And then I had this student named Kyle already who was a PA student that was coming out. And this was probably in 2011 2012. And he said to me,

Linda Bluestein, MD (53:29.654)

Oh wow.

Roger Seheult, MD (53:46.712)

And we, you know, they would come out to the rotation. We'd sit down, we'd go over lectures. And I did the same lectures every month for all the PA students. And he said, you know, Dr. Schwalb, students don't learn the way that they used to learn. Uh, we use YouTube videos and we, we find the shortest video on the topic that we possibly can. And, you know, you know how it was with us, uh, Linda, I mean, we used to go to the library, have a checkout card and a copy card to copy journals, right? I don't know what year did you graduate?

Linda Bluestein, MD (54:10.358)

Yup, yup.

I graduated from med school in 90. So I'm sure I'm older than you. Yeah, yeah.

Roger Seheult, MD (54:15.352)

Oh, wow. Okay. So I graduated in 2000. So even more so. So, um, so that was, that was a real, uh, eye-opener for me. But what really caught my attention was his suggestion. We should make YouTube videos on specific topics. And I, I really loved that for one reason. It was kind of a selfish reason, but I loved it for one reason that I could refer my, my students every month to the same videos. And then this was when they went home at night and then they could come back the next day and we could talk about

what they had learned and we'd be able to save time and be able to push the envelope even further, maybe associate it with a case or show an example of what they had learned. So we started doing this and we started to pick the most difficult topics that are classically difficult 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 know, including the professor at the end of class what they had just said.

And so people would be going home at night, trying to scramble what this was. So we tried to fill those gaps and then we just started to expand and people started to watch. And initially our videos were geared to healthcare providers. But because we were explaining it so clearly, I believe, we started to get an audience in the non-medical field who are interested in medicine, interested in empowering themselves. And so that's what we've come to today is we've come to a situation where I believe

Linda Bluestein, MD (55:14.232)

Right.

Roger Seheult, MD (55:42.1)

that we need to educate not only healthcare providers and patients or patients or healthcare providers, whichever order you wanna put that in, we need to educate both on the idea that there are very simple, clear, natural, in fact, in some cases, lifestyle changes that we can make that have a huge impact on our health. It's things that take a long time to describe.

things that take a long time to educate on, things that maybe doesn't fit very well in a 20 minute session in a clinic when it's very easy just to prescribe a medication and fix the problem. But it's things that we need to do and take the time to explain. And that's what I've been trying to do. But I don't do it from the aspect of saying that we, you know, there's this and or false dichotomy, which is that no medications at all, we just need to do natural. Look, I'm a pulmonary critical care doctor.

If I didn't have medications, you know, there'd be so many patients that we would lose in the ICU. So I see the benefit of both. But I believe that if we were to, and I'll say this, if we were to employ some of these lifestyle changes earlier on and educate people on them, we wouldn't need as much of the of the pharmacological interventions that we often need to do to save someone's life, to give them the opportunity to make those lifestyle choices. So that's where I think 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, PAs, that there are lifestyle changes that you actually will see dramatic input in your patients.

Linda Bluestein, MD (57:22.358)

Yeah, absolutely. And that's what I practice integrative pain management, I actually don't do any interventional procedures, even though I, you know, I could do epidurals and, you know, see like plexus blocks or whatever. But because I feel like there's so many more, basically, you know, lack of education is so much more prevalent. So that's also why I do the podcast, so people can get this information and listen to it again and again. And so it's a great way to share information.

Roger Seheult, MD (57:40.264)

Yes.

Roger Seheult, MD (57:47.804)

No, I think it's great. So once we've reached that point, then we even go even further. And 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 coming into my ICU and they are not at peace. They are anxious about their life, 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 in terms of these things. Things go so much better. You know, the mind and the body are so connected. And when you have that alleviation, not just, you know, I think it's the root source. 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 urinary tract, take it out. And I feel that so many times there's this...

Linda Bluestein, MD (58:21.838)

Wow. Yes.

Roger Seheult, MD (58:45.492)

There's this rush to treat the symptoms but not get to the underlying cause. And I think that we're just starting to understand more and more about that.

Linda Bluestein, MD (58:53.226)

Yeah, 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?

Roger Seheult, MD (58:59.985)

Yes.

Roger Seheult, MD (59:03.344)

Yeah, so I primarily we are primary source of communication is the YouTube channel on YouTube, which is MedCram, M-E-D-C-R-A-M. But our website where we have videos specifically continuing medical education videos, CE videos, these are for providers that need to get credit that we offer. We actually offer credit for these courses is MedCram.com very easy, M-E-D-C-R-A-M dot com.

And so we'll be happy to be a continuing medical education provider as well.

Linda Bluestein, MD (59:35.746)

which 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 another ball game. So that's a-

Roger Seheult, MD (59:46.696)

Yes. So, well, I can give you a hint that makes it a lot easier is to find a CME provider and just ask to make content for them and they will certify your content. Yeah.

Linda Bluestein, MD (59:59.686)

Oh, that's a great suggestion. I appreciate it. Okay, very good.

Roger Seheult, MD (01:00:05.003)

Yeah, because I'll tell you, CME providers are looking for content. So it's not hard.

Linda Bluestein, MD (01:00:09.99)

Okay, okay, great. Much better than reinventing the wheel.

Roger Seheult, MD (01:00:14.384)

Yes, you don't want to, there's a lot of, there's a lot of regulation and making sure that you're showing that you're making improvements. You still need to do that sort of things on your end, but in terms of the paperwork and the accreditation, you really want to have a partner that does that for you.

Linda Bluestein, MD (01:00:29.642)

Yeah, definitely. Okay, very good. So last thing, can you tell us some of your favorite hypermobility hacks? And you shared some great things earlier with me. So, I'm going to start with a question

Roger Seheult, MD (01:00:39.532)

Yes, so one of the things that I have not learned about until recently because of the pandemic has forced me to look into some of the things that we used to do a long time ago is this thing 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.

people, there were hospitals where people would come for therapy in hydrotherapy. It was very labor intensive. You had to have somebody there attending you, heating the water, placing it on, all sorts of things. But what hydrotherapy can actually do for people specifically who have issues with hypermobility and flex is that the warmth of the water and the reason why water is used specifically and not a dry heat or a sauna is that water has something called a high energy of enthalpy. What does that mean?

That means it takes a lot of energy to raise a specific volume of water, a particular amount of degrees. And so therefore, if you put somebody in that water, it's going to give a lot of energy before it cools off. This is the problem, obviously with burns. So hot water can cause burns because it can transfer a lot of energy. So you have to be careful. So what does this do for someone with, for instance, Ehlers-Danlos, the warmth of the water can actually allow the muscles to relax.

and that can actually aid in a lot of joint pain alleviation. So that helps you to actually, to have less pain with that. And because if you're doing submersible water, like if you're going to a spa or a heated pool, that can also support your weight and take a lot of the pain off the joints. You can do this and it's a way to strengthen the muscles around the joint without putting a lot of stress on the joint. So, so.

relieving of pain, allowing you to exercise and strengthen the muscles in that area. The water, by the way, can also be used as resistance. So when you're moving around, it's actually causing resistance to your movement, which can actually improve muscle around that without having the issues of joints degradements. So we talked about water and the reduction of stress on the joints.

Roger Seheult, MD (01:02:58.152)

But the buoyancy of the water when you're in the water can also improve and allow you to improve balance, coordination, and posture, and also trunk control. So I think it's kind of like not even a two-fer, it's a three-fer or even a four-fer. Going into a pool or a heated pool or heated bath can do a lot of those things all at the same time. Now it's not easy to have one of those things, but I have seen recently that you can actually purchase

Linda Bluestein, MD (01:03:11.982)

I'm sorry.

Roger Seheult, MD (01:03:27.964)

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've got a hypermobility patient.

Linda Bluestein, MD (01:03:42.726)

and chronic pain and I think too the also the contact with the water can help with proprioception. So yeah water I think is a fantastic thing for people who have these kinds of problems so.

Roger Seheult, MD (01:03:44.541)

Yes.

Roger Seheult, MD (01:03:49.512)

Yes.

Roger Seheult, MD (01:03:56.264)

Yeah, and the reason why I got involved with that just briefly is because of its ability to simulate fever. So 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 and things of that nature if it's too hot or even, you know, pass out. The simulation of the body temperature can actually cause an increase in the innate immune systems secretion of interferon, which has a lot of beneficial properties.

especially if you're talking about the flu, the cold, or even COVID-19.

Linda Bluestein, MD (01:04:30.642)

Okay, that's super great to know because our immune system we want functioning at its very best. It's not like viruses and those kinds of things are ending 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 Schultz.

Roger Seheult, MD (01:04:37.982)

Absolutely.

Roger Seheult, MD (01:04:43.297)

Nope.

Linda Bluestein, MD (01:04:59.286)

Thank you so much, Dr. Schulte, 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.

Roger Seheult, MD (01:04:59.7)

Got it. Thank you.

Roger Seheult, MD (01:05:12.552)

Well, thank you so much, Linda. I really appreciate you having me on.

Linda Bluestein, MD (01:05:15.455)

Okay, great.