Accurate Education – Sleep – Insomnia

Sleep – Insomnia

 

See also:

Insomnia – CAM Treatment Options

Sleep Apnea

 

And:

Benzodiazepines

Gabapentin (Neurontin) & Lyrica

Melatonin

Cognitive Behavior Therapy (CBT)

Hypnosis

Meditation & Mindful Exercises

Yoga & Tai Chi

 

Also:

Anxiety

Depression

 

 

Key to Links:

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“Through practice, I’ve come to see that the deepest source of my misery is not wanting things to be the way they are. Not wanting myself to be the way I am. Not wanting the world to be the way it is. Not wanting others to be the way they are. Whenever I’m suffering, I find this war with reality to be at the heart of the problem.”

 – Stephen Cope

Sleep

Sleep is a state characterized by changes in the level of consciousness, unresponsiveness to the surrounding environment, and inactivity of voluntary muscles. Sleep restores people physically and psychologically, with recent research identifying sleep as the time during which metabolic toxins are eliminated from the brain.

 

The Physiology of Sleep

Sleep is divided by polysomnographic criteria into rapid eye movement (REM) sleep and non–rapid eye movement (NREM) sleep. NREM sleep amounts to approximately 75% to 80% of total sleep time, whereas REM sleep accounts for the remaining 20% to 25% of total sleep time. REM sleep is associated with dreaming, learning, and memory consolidation. Slow Wave Sleep (SWS) is also thought to be important in learning.

 

Sleep Disorders

It is estimated that over 50% of the US population will suffer from a sleep disorder at some point in their life. The most common sleep disorder is insomnia and the prevalence of insomnia increases with age making this growing problem as our national average age becomes higher. Sleep apnea is the next most common sleep disorder. For those with chronic pain, sleep disruption is experienced in 50-80% of patients.

 

Sleep Apnea

Sleep apnea is a common disorder that negatively impacts up to 20% of the population with an even greater frequency amongst patients with chronic pain. Untreated, sleep apnea leads to many medical complications including increased risk for heart attack, stroke, diabetes, high blood pressure, obesity, fatty liver… the list goes on. Of particular significance to patients taking opioids, untreated sleep apnea is a dangerous condition because when combined with the sedative, respiratory-depressant effects of opioids, the reduced oxygen levels associated with sleep apnea may lead to increased risk of death, heart attack or stroke. It is likely a major contributory factor in unintentional opioid related deaths.

See: Sleep Apnea

 

Insomnia

Insomnia is characterized by difficulty in initiating sleep and/or maintaining sleep, non-restorative sleep or poor-quality sleep. Sleep disturbances cause people to suffer from mental dysfunction and daytime sleepiness and can lead to various health and socioeconomic issues. People who suffer from insomnia for long time periods may also suffer from depression and experience a decreased quality of life. Patients with chronic pain are particularly victimized by insomnia.

 

Sleep remains one of the most poorly understood biological processes and effective solutions to insomnia often remain elusive. Worse still, “solutions” for sleep sometimes result in even worse outcomes as dependence on hypnotic medications such as the benzodiazepines (Valium, Xanax, Klonopin etc.) develop making them difficult to discontinue, even when they are not effective.

 

The search for sleep for those with chronic pain and insomnia is particularly challenging. Despite the lure of hypnotic medications as a solution,  they are only recommended for short term use due to failure to maintain effectiveness over time, the development of dependence and associated withdrawal syndromes and their potentially dangerous medication interactions, especially with opioids. In the case of the benzodiazepines, the side effects can include frequent memory disorders, daytime drowsiness, falls, fractures, birth defects and increased risk for motor vehicle accidents.

 

Management of Insomnia – Overview

Current, Best Recommendations for Managing Insomnia

  1. Perform moderate, regular physical exercise, especially in the morning. Do not eat or exercise before retiring for sleep.
  2. Sleep Hygiene: Reduce all unnecessary light and sound from your sleep environment and avoid activities in the bed outside of sex and sleep.
  3. Take a warm bath with epsom salts in the evening hours before retiring.
  4. Practice a mindful exercise (meditation, prayer, music etc.) of preference for at least 20 minutes prior to retiring for sleep.
  5. Consider the use of a foam sleep wedge that safely and comfortably facilitates sleep positioning for optimal breathing that can reduce fatigue and improve energy (See below).
  6. Learn about certain foods that can contribute to  swelling in the nasal passages and sinuses and interfere with optimal air exchange while sleeping – see our registered dietitian.
  7. Sleep Restriction: Sleep restriction therapy is a behavioral treatment for insomnia that works to decrease variability in the timing of sleep while increasing the depth of sleep. The goal is to shorten the amount of time spent in bed in order to consolidate sleep (See behavioral solutions below).
  8. When resorting to a hypnotic, start with magnesium supplements or epsom salt baths at bedtime then consider CAM alternatives first (see CAM Sleep).
  9. If a prescription hypnotic is indicated, try doxylamine or diphenhydramine first. Studies show no major difference in effectiveness versus benzodiazepines and related drugs. The main adverse effects of sedative antihistamines are daytime drowsiness/altered vigilance, and dry mouth. If used every night, however, these medications usually lose effectiveness.
  10. If a benzodiazepine is prescribed, avoid consistent use for more than two weeks.

 

Accurate’s Sleep Right Program

At Accurate Clinic we offer some simple but often overlooked approaches to improve sleep quality. Changing one’s sleep positioning by elevating the head is an effective means of improving air flow and oxygenation while asleep. Some people elevate the head of their bed but another simple alternative is the use of a foam sleep wedge that safely and comfortably facilitates sleep positioning that can reduce fatigue and improve energy. For the convenience of our patients we offer the foam wedge at an affordable price at Accurate Clinic.

Sleep Wedge

To learn more about certain foods that can contribute to  swelling in the nasal passages and sinuses and interfere with optimal air exchange while sleeping, make an appointment with our registered dietitian. Reducing congestion with simple dietary interventions can make a significant difference in your quality of sleep.

 

Behavioral Solutions for Insomnia

Experts agree that behavioral solutions for insomnia are the best, safest means for effective long term management. Behavioral solutions include sleep hygiene in which activity and environment are maintained in support of sleep including avoiding exercise and eating before retiring for sleep, turning of the TV and radio, keeping the lights dim and avoiding activities in the bed outside of sex and sleep. Additional behavioral approaches include deep relaxation techniques, self-hypnosis and cognitive behavioral techniques.

See: CBT, meditation and hypnosis

 

Sleep Restriction

The goal is to shorten the amount of time spent in bed in order to consolidate sleep by decreasing variability in the timing of sleep while increasing the depth of sleep. Sleep restriction therapy is considered by many as the most effective sleep hygiene technique available. It is as effective as hypnotic medication, yet with a longer-lasting effects. It does require commitment to the process for success. It takes several weeks of maintaining your sleep schedule in order to see results. Initially, one may feel sleepier and experience more disrupted sleep but your insomnia will improve gradually and the benefits will persist.

See: Sleep Restriction Therapy instructions

 

Medications for Sleep

Prescription medications for sleep include antidepressants, antihistamines, benzodiazepines, the “Z” drugs and others. Common examples of antidepressants effective for sleep include trazadone, amitriptyline  (Elavil), doxepin, Remeron and others. Ramelteon (Rozerem), a prescription hypnotic medication that acts on melatonin receptors, has been shown to be helpful in insomnia.

 

Antihistamines

OTC antihistamines including doxylamine and diphenhydramine and prescription hydroxyzine and others showed no major difference in effectiveness versus benzodiazepines and related drugs. However they tend to build tolerance relatively quickly if used on consecutive nights. The main adverse effects of sedative antihistamines are daytime drowsiness, impaired thinking/memory and dry mouth.

 

Antidepressants

The antidepressants are the most commonly used hypnotic medications outside of the benzodiazepines which have now gone out of favor for safety reasons. Trazadone is a common preferred choice and there is also some evidence that it can synergistically improve pain when taken with pregabalin (Lyrica).

 

Tricyclic antidepressants (TCAs)

The tricyclic antidepressants (TCAs) doxepin, nortriptyline and amitriptyline (Elavil) are commonly used. Doxepin is one of the few FDA approved drugs for insomnia at low dose (5mg) and is associated with fewer side effects than amitriptyline. Desipramine is less sedating than doxepin or amitriptyline and can be tried if these are too sedating, although desipramine can sometimes impair sleep. TCAs decrease sleep latency (time required to fall asleep), increase sleep efficiency and increase total sleep time.

 

Tricyclic antidepressants have pro-serotonergic, noradrenergic, dopaminergic and sodium channel blocking effects that likely account for their effiectiveness in both depression and pain, including neuropathic and central pain.

See: Neurobiology of Pain

 

SSRIs (Selective Serotonin Reuptake Inhibitors)

The SSRIs (Selective Serotonin Reuptake Inhibitors such as Prozal, Zoloft and Paxil etc) can be helpful in some patients but are not commonly used for insomnia. However, they can be especially helpful for sleep when the insomnia is secondary to anxiety and/or depression.

 

Mirtazapine (Remeron)

Mirtazapine is an antidepressant with sedating qualities due to antagonism of type I histaminergic and serotonin type II receptors. At doses 15-30 mg it improves sleep latency, total sleep time and sleep efficiency, and decreases frequency of awakenings. Interestingly, while it is effective at doses of 15-30 mg, it becomes less effective at higher doses.

 

Mirtazapine has also been shown to improve appetite which can lead to significant weight gain so it must be monitored for this.

 

Advantages of the Antidepressants

The advantages of the antidepressants include significant pain benefits in certain chronic pain syndromes, notably neuropathic pain syndromes and fibromyalgia. They also maintain their effectiveness well with limited tolerance. The antidepressants (both TCAs and SSRIs), however, are known to reduce REM sleep which can impair learning.

 

Side Effects of the Antidepressants

The side effects of the antidepressants, including excessive sedation, impaired thinking and dry mouth can be significant, limiting their usefulness. All antidepressants can sometimes trigger a worsening of depression when they are started, even leading to suicidal thoughts or behaviors. While this reaction is not common, it does occur especially in young adults and should be monitored for and the medication immediately discontinued if depression develops after starting. Weight gain and sexual dysfunction are also sometimes seen with antidepressants.

 

Gabapentinoids: Gabapentin (Neurontin) and Pregabalin (Lyrica)

Clinical observations and recent research confirms that gabapentin, and possibly pregabalin, can be effective for insomnia. Sleep studies indicate gabapentin normalizes stages of sleep, improves sleep efficiency and reduces spontaneous arousal in patients with primary insomnia (not due to other conditions). The use of gabapentin in normal subjects caused no disruption in sleep stages of significance.

 

Because nightime use of alcohol is known to disrupt sleep by causing increased awakenings and reduced SWS, a 2005 study looked at the use of gabapentin in subjects given a nightcap of alcohol as a model of disrupted sleep that might mimic other conditions associated with increased awakenings including stress and sleep apnea. In this study a single dose of 300-600 mg gabapentin one hour before bedtime improved sleep by decreasing awakenings and improving SWS in subjects who drank alcohol (4 ounces of 40% alcohol). No differences were seen in any of the subjective tests of drowsiness and performance.

 

Gabapentin was studied in alcoholics in treatment, when insomnia is a significant problem. After at least 4 weeks of abstinence, alcoholic patients with persistent insomnia reported significant sleep improvement during treatment with either gabapentin or trazodone. Although the overall sleep of each medication group improved significantly over time, patients who received gabapentin improved significantly more than did patients who received trazodone.

 

Another study that looked at the use of gabapentin in subjects with disrupted sleep evaluated a 500 mg dose of gabapentin taken 30 minutes before bedtime in subjects who went to bed 5 hours before their usual sleep time. In this model of disrupted sleep, (called sleep phase advance disruption), gabapentin showed significantly longer sleep duration and greater depth compared to placebo.

 

Studies also indicate that gabapentin and possibly pregabalin are effective in treating the insomnia associated with benzodiazepine (Xanax, Klonopin, Valium etc.) withdrawal.

 

Side Effects of the Gabapentinoids

The side effects of gabapentin and pregabalin include the potential for depression, rarely severe, drowsiness, impaired cognition, swelling of the extremities, weight gain. Gabapentin may offer fewer side effects compared with pregabalin but this varies from individual to individual.

See: Gabapentin (Neurontin) & Pregabalin (Lyrica),

 

Melatonin Agonists

Ramelteon (Rozerem) is a new hypnotic that, like melatonin, acts on the melatonin receptors  to facilitate sleep but it has a longer duration of action than melatonin. Recent research indicates melatonin to be effective for the insomnia related to fibromyalgia, suggesting that ramelteon may be a preferred choice for fibromyalgia patients. Studies also indicate that melatonin is effective in treating the insomnia associated with benzodiazepine (Xanax, Klonopin, Valium etc.) withdrawal.

 

Benzodiazepines

When benzodiazepine medications are used for sleep, it is best to limit them to intermittent and short-term use (< 2-3 weeks) as they are known to develop tolerance and dependence as well as to trigger abuse. While at one time immensely popular and frequently prescribed, the use of benzodiazepine have fallen out of favor over the last few years due to safety reasons. Long term use of benzodiazepines for greater than one year have been shown to often lose their effectiveness for sleep.

See: Benzodiazepines

 

Benzodiazepines – Potential Concerns

Long term use of benzodiazepines has been associated with increased depression. Also, benzodiazepines offer particular danger to patients concomitantly taking opioids as evidenced by the marked, 10-fold increase incidence of unintentional opioid-related overdose deaths compared to opioid use without benzodiazepines. Benzodiazepines are now known to be associated with memory impairment with both short-term and long-term use as well as having the potential for birth defects including cleft palate. Finally, the high degree of physical dependence coupled with extended withdrawal syndromes and difficulty discontinuing have argued strongly against their long term use, defined as greater than 2-4 weeks.

 

Benzodiazepines have also been found to trigger addictive behavior in some individuals and those with problematic alcohol use and alcohol or sedative addiction are at particular risk.

 

In sleep studies, benzodiazepines have been shown to reduce REM sleep and Slow Wave Sleep (SWS) that are stages of sleep important for learning. These effects may be responsible for observations that the long term use of benzodiazepines is associated with impaired cognitive function and memory impairment. Recent research has also raised significant concern for the possibility that the use of benzodiazepines may contribute to the development of Alzheimer’s Disease although this risk is controversial.

 

Short-acting and Long-acting Benzodiazepines

Short-acting benzodiazepines used for sleep include temazepam (Restoril), flurazepam (Dalmane) and alprazolam (Xanax). Long-acting benzodiazepines commonly used for anxiety but sometime prescribed for sleep include diazepam (Valium), clonazepam (Klonopin) and lorazepam (Ativan).

 

Tapering Down or Off Benzodiazepines

When tapering down or off benzodiazepines or especially if they are discontinued abruptly, benzodiazepine-related insomnia can be very problematic. It is always best to taper down/off benzodiazepines slowly to minimize or avoid the insomnia and other withdrawal symptoms. As sleep aids for treating benzodiazepine-related insomnia, the use of gabapentin (Neurontin), pregabalin (Lyrica), melatonin and valerian root have been shown to be beneficial.

For more information, see: Benzodiazepines

Also see: Gabapentin (Neurontin) & Pregabalin (Lyrica), Melatonin

 

The “Z-Drugs”

The “Z-drugs” include zolpidem (Ambien), eszopicione (Lunesta) and zalepione (Sonesta) and others. Chemically related to the benzodiazepines, the “Z-drugs” share the potential risks associated with the benzodiazepines but appear to offer the advantages of less risk for addiction or abuse. Additionally, studies have also shown that they appear to sustain their effectiveness over the long term, exceeding 8 months without the development of tolerance or rebound.

 

Ambien – Potential Concerns

Numerous reports have been published regarding unusual side effects with zolpidem (Ambien) and rarely with the other “Z-drugs” that include various nocturnal activities with amnesia. These activities include sleepwalking but also more complex behaviors including sleep-eating, sleep-sex and sleep-driving have been reported without memory of the activites. These behaviors appear to be more common in women and if this side effect Ambien they should be discontinued immediately.

 

Ambien also has sedative effects that are potentially dangerous, like benzodiazepines, when taken with opioids including buprenorphine due to the potential for increased respiratory depression and accidental overdose. Caution should be employed when combining the Z-drugs, especially Ambien, with opioids and alternative hypnotics tried when feasible.

 

Antipsychotic Medications (Seroquel) and Zyprexa)

Two of the newer, atypical antipsychotic medications, FDA-approved only for bipolar disorder and schizophrenia, Quetiapine (Seroquel) and Olanzapine (Zyprexa), are sometimes used off-label for treatment of insomnia. Self-reported outcomes and sleep studies suggest they are effective with increased total sleep time, slow wave restorative sleep, and decreasing sleep latency. At low doses, quetiapine primarily has antihistiminergic properties and is weakly pro-serotonergic . It has been known to decrease anxiety and enhance the effectiveness of antidepressant medications.

 

Potential Concerns

These medications may cause significant weight gain and cardiac conduction abnormalities, such as prolonged QT interval. Of additional and significant concern is their risk (low) of movement disorders, including tardive dyskinesia. Tardive dyskinesia is a very undesirable condition of uncontrollable movements of the mouth, tongue and/or neck that sometimes resembles a cow chewing its cud. It is an unpredictable side effect usually associated with only long term use, but not always, and one that does not always resolve when the drug is stopped. For this reason, the use of these medications for sleep should be weighed carefully for risks vs. benefits and in most cases avoided for use in uncomplicated insomnia.

 

 

References

Sleep – Overviews

  1. Healthy Sleep
  2. Sleep complaints: Whenever possible, avoid the use of sleeping pills. – PubMed – NCBI

 

Sleep – Why is Sleep Needed?

  1. Brain Basics: Understanding Sleep : National Institute of Neurological Disorders and Stroke (NINDS)
  2. Sleep
  3. Sleep Drives Metabolite Clearance from the Adult Brain – 2013
  4. Dopaminergic Neurogenetics of Sleep Disorders in Reward Deficiency Syndrome (RDS) – 2014

 

Sleep – Deficiency

  1. Sleep Deprivation and Deficiency
  2. Are you getting enough sleep

 

Sleep – Strategies for Sleep

  1. Seven Strategies for Sleep
  2. Ten Mistaken Beliefs About Sleep
  3. Sleep Restriction Therapy instructions

 

Sleep – Circadian rhythm sleep disorders, Shift Work

  1. Circadian rhythm sleep disorders
  2. Shift work: Improving daytime sleep – Mayo Clinic

 

Sleep – Insomnia

  1. Insomnia
  2. Pain-related Insomnia Versus Primary Insomnia
  3. Sleep disorders and depression
  4. Problem-Solving Therapy Compared to Cognitive Therapy for the Treatment of Insomnia

 

Sleep – Nightmares

  1. Nightmare disorder – Mayo Clinic
  2. Sleep terrors (night terrors) – Mayo Clinic
  3. Imagery rehearsal therapy – An emerging treatment for posttraumatic nightmares in veterans
  4.  Putative dopamine agonist (KB220Z) attenuates lucid nightmares in PTSD patients – Role of enhanced brain reward functional connectivity and homeostasis redeeming joy – 2015

 

Sleep – Pain

  1. Sleep Disturbance and Chronic Pain
  2. Relationship among Chronic Pain, Opiates, and Sleep -Thesis
  3. sleep deprivation in patients with chronic neck and back pain
  4. The Effects of Sleep Deprivation on Pain Inhibition and Spontaneous Pain in Women
  5. Pain-related Insomnia Versus Primary Insomnia
  6. Sleep, Chronic Pain, and Inflammation- Integrative Approaches

 

Sleep – Sleep Studies (Polysomnograms – PSG)

  1. Sleep Studies
  2. Polysomnography (sleep study) – Mayo Clinic

 

Sleep – Opioids Effect on Sleep

  1. Relationship among Chronic Pain, Opiates, and Sleep -Thesis
  2. Sleep-Disordered Breathing and Chronic Opioid Therapy
  3. Opioid-induced respiratory depression: ABCB1 transporter pharmacogenetics. – PubMed – NCBI
  4. the-effect-of-opioids-on-sleep-architecture-2007

 

Sleep – Natural and Herbal Preparations for Sleep

 

Natural and Herbal Preparations Overview

  1. Updates on Nutraceutical Sleep Therapeutics and Investigational Research – 2015
  2. Herbal Insomnia Medications that Target GABAergic Systems – A Review of the Psychopharmacological Evidence – 2014
  3. Herbal triple combination: An effective alternative to benzodiazepines
  4. Efficacy and safety of a polyherbal sedative-hypnotic formulation compared to Ambien

 

Natural and Herbal Preparations Melatonin

  1. Melatonin for the Treatment of Primary Sleep Disorders – 2013
  2. The effectiveness of melatonin for promoting healthy sleep – a rapid evidence assessment of the literature – 2014
  3. Insomnia associated with valerian and melatonin usage in the 2002 National Health Interview Survey. – 2007
  4. Ramelteon: MedlinePlus Drug Information
  5. Melatonin hypothesizing-that-putative-dopaminergic-melatonin-benzodiazepine-reward-circuitry-receptors – 2013
  6. Melatonin therapy in fibromyalgia. – PubMed – NCBI

 

Natural and Herbal Preparations Valerian

  1. Valerian-HealthProfessional
  2. Valerian | University of Maryland Medical Center
  3. Valerian – No Evidence for Clinically Relevant Interactions 2014
  4. Can valerian improve the sleep of insomniacs after benzodiazepine withdrawal? – PubMed – NCBI
  5. Critical evaluation of the effect of valerian extract on sleep structure and sleep quality. – PubMed – NCBI
  6. Insomnia associated with valerian and melatonin usage in the 2002 National Health Interview Survey. – 2007

 

Sleep – Prescription Medications for Sleep

  1. Understanding the relationships of medications on sleep
  2. Hypnotics-MedlinePlus

 

Sleep Medications – Benzodiazepines

  1. Chronic benzodiazepine usage and withdrawal in insomnia patients. – PubMed – NCBI
  2. Correlates of benzodiazepine use in individuals with insomnia. – PubMed – NCBI
  3. Efficacy of two interventions on the discontinuation of benzodiazepines in long-term users: 36-month follow-up of a cluster randomised trial in pri… – PubMed – NCBI
  4. Benzodiazepine use and risk of Alzheimer’s disease – case-control study

 

Sleep Medications – Doxepin

  1. Treatment-resistant insomnia treated with pregabalinEfficacy and Safety of Doxepin 3 and 6 mg in a 35-day Sleep Laboratory Trial in Adults with Chronic Primary Insomnia
  2. Doxepin – up-to-date – a review of its pharmacological properties and therapeutic efficacy with particular reference to depression
  3. Doxepin for insomnia: a systematic review of randomized placebo-controlled trials. – PubMed – NCBI

 

Sleep Medications – Gabapentin (Neurontin)

  1. Gabapentin increases slow-wave sleep in normal adults – 2002
  2. Gabapentin improves sleep in the presence of alcohol. – PubMed – NCBI
  3. A Randomized, Double-Blind, Single-Dose, Placebo-Controlled, Multicenter, Polysomnographic Study of Gabapentin in Transient Insomnia Induced by Sleep Phase Advance – 2014
  4. Treatment effects of gabapentin for primary insomnia. – PubMed – NCBI
  5. An Open Pilot Study of Gabapentin vs. Trazodone to Treat Insomnia in Alcoholic Outpatients – 2003

Sleep Medications – Pregabalin (Lyrica)

  1. Treatment-resistant insomnia treated with pregabalin

 

Sleep Medications – Suvorexant (Belsomra)

  1. Belsomra Prescribing Information
  2. Kinetic properties of “dual” orexin receptor antagonists at OX1R and OX2R orexin receptors

 

Sleep Medications – Trazadone

  1. Trazodone: a review of its pharmacological properties … [Drugs. 1981] – PubMed – NCBI
  2. Cognitive, psychomotor and polysomnographic effects of trazodone in primary insomniacs
  3. An Open Pilot Study of Gabapentin vs. Trazodone to Treat Insomnia in Alcoholic Outpatients – 2003

 

 

Sleep Medications – “Z-Drugs”

  1. Hypnotic hazards – adverse effects of zolpidem and other z-drugs – 2008
  2. Effectiveness of non-benzodiazepine hypnotics in treatment of adult insomnia: meta-analysis of data submitted to the Food and Drug Administration – 2012

 

Sleep Medications – Zolpidem (Ambien)

  1. Zolpidem-Induced Sleepwalking, Sleep Related Eating Disorder
  2. Two Cases of Zolpidem-Associated Homicide
  3. Ambien (Zolpidem) Associated Homicide
  4. Ambien (Zolpidem)-Induced Sleepwalking, Sleep Related Eating Disorder

  

Sleep – Sleep Disorders

 

Sleep Apnea

(see Sleep Apnea)

 

Periodic Limb Movement Disorder

  1. Periodic Limb Movement Disorder
  2. Periodic Limb Movement Disorder Causes and Treatments on MedicineNet.com

Restless Leg Syndrome

  1. Restless Legs Syndrome:Periodic Limb Movement Disorder : National Sleep Disorders Research Plan, 2003

 

Sleep Walking

  1. Sleepwalking – Mayo Clinic
  2. Seroquel (Quetiapine)-induced Sleep-related Eating Disorder-like Behavior

 

 

Emphasis on Education

 

Accurate Clinic promotes patient education as the foundation of it’s medical care. In Dr. Ehlenberger’s integrative approach to patient care, including conventional and complementary and alternative medical (CAM) treatments, he may encourage or provide advice about the use of supplements. However, the specifics of choice of supplement, dosing and duration of treatment should be individualized through discussion with Dr. Ehlenberger. The following information and reference articles are presented to provide the reader with some of the latest research to facilitate evidence-based, informed decisions regarding the use of conventional as well as CAM treatments.

 

For medical-legal reasons, access to these links is limited to patients enrolled in an Accurate Clinic medical program.

 

Should you wish more information regarding any of the subjects listed – or not listed –  here, please contact Dr. Ehlenberger. He has literally thousands of published articles to share on hundreds of topics associated with pain management, weight loss, nutrition, addiction recovery and emergency medicine. It would take years for you to read them, as it did him.

 

For more information, please contact Accurate Clinic.

 

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