periodic leg movement

[sheepless]

sheepless, you wrote "... there are few flagged flow limitations between the sharp inhales.  otoh, there are lots of unflagged flow limitations throughout my nightly flows and both unflagged and flagged breaths between the larger inhales during plm are abbreviated in comparison" and I assume (correctly?) that you intended to use  "flow limits" rather than "breaths".

I meant: the breaths between the larger inhales are abbreviated (in amplitude) whether flagged or not flagged as flow limitations.  the implication (assumption) being that reduced volume may (maybe?) also be considered a flow limitation.  I've speculated, rightly or wrongly, that those intervening smaller breaths, flagged or unflagged, are flow limitations that trigger the machine to raise pressure.  

In any case, were it not for the plm factor and my ignorance about it, your comments about flagged (FL) and unflagged (fl) flow limit frequencies, and differing extents in plm and non-plm segments of sleep, I'd say your misshapen peaks are independent of plm and would impair your sleep to some extent, as you know. 

Of the deformations getting the most research I've seen (and getting 2018 ResMed patent attention), your "M" shaped inspiratory flow peak seems to be the most troubling of some 47 shapes that have been classified into 3 categories of sleep effects and seriousness.

scrolling through just the one night I see that the m shape is most prevalent whether in the midst of plm respiration or not so you may be right but I've assumed that the ones in between the sharp inhales, which I believe are in response to movement, are caused by my reaction to the movement, i.e., some kind of physical clenching, often expressed as a moan/groan

My other impression of your new FR views, in light of your comment above, was a wish to know if the density of deformed peaks within their space along the time line was the same in plm and non-plm sleep. I think you observed that in plm sleep either or both the scale and the duration of FL and fl instances were reduced vs. the same in non-plm sleep. If either lessening is true that tends to support my impression that (in my breathing, anyway) the "Norwegian sigh" could be a breathing defense against fl that have increased to near the critical level where, say, the VAuto will flag it. The sleep sigh is either a defensive respiratory design feature or a useful bystander on the breathing scene. 

not sure I follow but I'm attaching some screenshots of flagged and unflagged non-plm flow limitations and sighs. I have mostly ignored sighs so I'll have to pay more attention to these now as it may be that the sighs do in fact follow a bit after a flow limitation.

Unlike the M tips that are followed by a FL within the next breath not sure if this is relevant to your point but you've probably noticed as I have that the flow limitation marked in the graph always comes after the flow limited deformation in the flow rate waveform in the super majority of my many instances of it, the sigh is followed by a FL in about 1/3 or more of my many instances of it every 5 to 15 minutes. Wary of confirmation bias, I believe that within the 4-6 breaths that precede the sigh, I see greater deformation effects overall and in the first couple of breaths after the sigh there is a reduction in deformations--not always, but often. If I understand your observations, you are or may be seeing a similar fl-clearing effect from plm FR spikes--accordingly, my question about FL and fl density along their respective time lines. 

I find myself reading some of your post, the preceding paragraph in particular, more than one way.  perhaps you can clarify your meaning if I'm to respond. otherwise, maybe these additional screenshots will serve as my response.

This rather obscure topic is below the horizon of present machine flagging and medical treatment, but a lot of attention has been (Tero Aittokallio, et al. Finland, 2001 and  subsequently) and is being given to it and I would not be surprised to see/hear of some emerging help in new machine designs--even if it's hidden foundational stuff, for refinements and marketing strategies to build upon (stories about "jailbreak" come to mind).

For the here and now, it seems an AHI-like index, an M index, could well be useful as a guide to efficacies in making changes to whip fragmented or unrestful sleep of those who either never had SA or those who've reduced AHI below, say, 1.0. Until new machines or some DIY algorithm add-on, say, to OSCAR, comes along, the MI would be manual work, if worthwhile (and I'm not quite there yet).  

obscure perhaps, but interesting and potentially leading edge.  have you read or speculated how we might whip fragmented unrestful sleep using an m index?  would treatment be different than say raising pressure support against flow limitations as conventional wisdom currently instructs?

shots in this post (times are rough and intended only to help identify the pic): 23:23 - a sigh; 4:44 - a sigh ~1.5 minutes after a flagged flow limitation;  1:52 - flagged & unflagged non-plm flow limitations.

[2SleepBetta]

sheepless, you wrote "... there are few flagged flow limitations between the sharp inhales.  otoh, there are lots of unflagged flow limitations throughout my nightly flows and both unflagged and flagged breaths between the larger inhales during plm are abbreviated in comparison" and I assume (correctly?) that you intended to use  "flow limits" rather than "breaths".

I meant: the breaths between the larger inhales are abbreviated (in amplitude) [by FL or fl effects] whether [those limiters are] flagged or not flagged as flow limitations.  the implication (assumption) being that reduced volume may (maybe?) also be considered [as being caused by] a flow limitation.  [I've speculated, rightly or wrongly, that those intervening smaller breaths, flagged or unflagged, are flow limitations that trigger the machine to raise pressure. FWIW, IMO, not so, but the "smallers" are your normal flow rate profiles which may reflect effects of FL or fl or may reflect some kind of perverse machine-algorithm response to the actual high-to-low-FR rhythm (Beethoven's 5th)].

In any case, were it not for the plm factor and my ignorance about it, your comments about flagged (FL) and unflagged (fl) flow limit frequencies, and differing extents in plm and non-plm segments of sleep, I'd say your misshapen peaks are independent of plm and would impair your sleep to some extent, as you know. 

Of the deformations getting the most research I've seen (and getting 2018 ResMed patent attention), your "M" shaped inspiratory flow peak seems to be the most troubling of some 47 shapes that have been classified into 3 categories of sleep effects and seriousness.

scrolling through just the one night I see that the m shape is most prevalent whether in the midst of plm respiration or not so you may be right but I've assumed that the ones [the m's] in between the sharp inhales, which [same sharp inhales] I believe are in response to movement, [and those sharp inhales] are caused by my reaction to the movement, i.e., some kind of physical clenching, often expressed [audibly] as a moan/groan  [and physically as a motion of my legs].

My other impression of your new FR views, in light of your comment above, was a wish to know if the density of deformed peaks within their space along the time line was the same in plm and non-plm sleep. I think you observed that in plm sleep either or both the scale and the duration of FL and fl instances were reduced vs. the same in non-plm sleep. If either lessening is true that tends to support my impression that (in my breathing, anyway) the "Norwegian sigh" could be a breathing defense against fl that have increased to near the critical level where, say, the VAuto will flag it. The sleep sigh is either a defensive respiratory design feature or a useful bystander on the breathing scene. 

not sure I follow but I'm attaching some screenshots of flagged and unflagged non-plm flow limitations and sighs. I have mostly ignored sighs so I'll have to pay more attention to these now as it may be that the sighs do in fact follow a bit after a flow limitation. [In my experience those sighs that have an accompanying FL have that FL within the time span of the next breath after the sigh.]

Unlike the M tips that are followed by a FL within the next breath not sure if this is relevant to your point but you've probably noticed as I have that the flow limitation marked in the graph always comes after the flow limited deformation in the flow rate waveform [yes, same here] in the super majority of my many instances of it, the sigh is followed by a FL in about 1/3 or more of my many instances of it every 5 to 15 minutes. Wary of confirmation bias, I believe that within the 4-6 [revision: no, say, 6-8] breaths that precede the sigh, I see greater deformation effects overall and in the first couple of breaths after the sigh there is a reduction in deformations--not always, but often. If I understand your observations, you are or may be seeing a similar fl-clearing effect from plm FR spikes--accordingly, my question about FL and fl density along their respective time lines. 

I find myself reading some of your post, the preceding paragraph in particular, more than one way.  perhaps you can clarify your meaning if I'm to respond. otherwise, maybe these additional screenshots will serve as my response. [Please consider replying in those and other confused or "contested"  areas using another color of font so I can work at being clearer and we can continue limiting  how much typing we need to do in this discussion, IF YOU CHOOSE TO CONTINUE I'd welcome that and these: Screen shots of context and more 1-2 minute views with FR and FL (mask pressure and even low level leak at FR spikes can help, too); all FR at least 1 inch amplitude on screen would be helpful with any commentary. The more breathing detail the better]

This rather obscure topic is below the horizon of present machine flagging and medical treatment, but a lot of attention has been (Tero Aittokallio, et al. Finland, 2001 and  subsequently) and is being given to it and I would not be surprised to see/hear of some emerging help in new machine designs--even if it's hidden foundational stuff, for refinements and marketing strategies to build upon (stories about "jailbreak" come to mind).

For the here and now, it seems an AHI-like index, an M index, could well be useful as a guide to efficacies in making changes to whip fragmented or unrestful sleep of those who either never had SA or those who've reduced AHI below, say, 1.0. Until new machines or some DIY algorithm add-on, say, to OSCAR, comes along, the MI would be manual work, if worthwhile (and I'm not quite there yet).  

obscure perhaps, but interesting and potentially leading edge.  have you read or speculated how we might whip fragmented unrestful sleep using an m index?  would treatment be different than say raising pressure support against flow limitations as conventional wisdom currently instructs? [In my case and in addition to continued use of PS, I'd use the counts over selected reasonable periods of time to assess efficacy of a change of life style or other plausible factor (e.g., exercise type, level and timing; foods, beverages, supplements; sleep hygiene; sleeping position; preoccupations/committments, attitudinal and relationship matters (news listening, watching); matters of faith--any one of these (or a combination) at one time and without immediate thought (in my case) of new meds.

When machine, algorithm, sleep science, medical insurance converge on a solution, its likely there will be a new line of attack on fl-aggravating and causal factors, if not simply a broader category of scoreable disturbances.

More immediate and focused feedback, say from m-counts, on limited changes would fit this old guy better, a person who has turned over a new leaf or a few, but turning over a whole tree is not something I'll do soon except in extremis. And, yes, to other kind readers, at my advanced age I know, for example, that beneficial results of improved sleep hygiene, exercise and diet are not immediate. But at my age, I am, (and many of us are) reluctant to give up remaining pleasures and debatable habits.] 



shots in this post (times are rough and intended only to help identify the pic): 23:23 - a sigh; 4:44 - a sigh ~1.5 minutes after a flagged flow limitation;  1:52 - flagged & unflagged non-plm flow limitations.

[mper6794]

Hi, sheepless, dear folks

_ As you might know am on this OSCAR/BPAP realms for some 2.5 years, trying to tame properly my UARS and RLS drawbacks. Currently, happy on no medication, except for experiencing successfuly? CBD oil (7 to 15 mg a day);

_ Still learning a great deal, even though I consider I have success on my therapy at a certain level of 80-95% most of the time. However, I have been experiencing kind of unusall change of sleep pattern for last couple of months, which I would like to share and ask for similar experiences and insights:

_ Intrigued thing is: from somewhere on August 10th, before I started up CBD oil for RLS (August 13th and slightly later) my sleep pattern have changed from kind of (1) "not planned, segmented-later-to-get up sleep", in two phases (first phase followed by readings, meditations, energy therapies) to more (2) "solid 4.5-6 hrs, higher sleep effiency" (please, see attached);

_matters of the fact (taking into account my How You Feel daily index; no intention to be precised here, but it works by averaging some 6 times a day) is that I have been feeling worse with this latter sleep pattern;

_ These days, I am kind of stuck on what sleep pattern to pursue, that is, would be better keep on trying to get up later on (2), or, weird decision, get back to (1) "segmented two-phase style", stopping CBD oil, and so on. For reason I have not undertood yet, it appears later-than-6:00 morning hour sleep would be crucial for me;

_ worth mentioning that with Clonazepam 0.5mg (up to may, 15th this year), I used to have improved (2) style, with higher How You Feel Index than sometimes happens these later days. I would never return to, though;

_ some time ago, SleepRider posted something on poliphasic sleep pattern, which had called my attention at that time. On account of what I am facing these days, quite recently I researched on the so-called "segmented sleep" (you might want to google this: https://www.mattressnerd.com/polyphasic ... ted-sleep/). There are claims it could be more natural and would work better, at least used to be so in pre-industrial times.

many thanks

[sheepless]

mper,

idk the answer but can tell you a little about my experience, with the caveat that the answer probably varies from person to person.

anyway, I was so happy a while back to be getting 7 to 9 hour sleeps without naps even though I continued to wake frequently. (way back before pap & then while using apap it took all night & several daytime naps to get close to 8 hours of sleep. I used to say I needed 18 hours to get 8 hours sleep.)

recently that's changed. now I'm only sleeping 5 to 6 hours at night. still waking too often so I'm more inclined to nap now but only 10 to 20 minutes, sometimes at in early morning, sometimes in the afternoon. just enough to take the edge of sleepiness off. it bothers me to wake up for the day as early as 3:30am & rarely later than 5:30am. otoh, while fewer hours is psychologically disturbing, I think I feel physically better.

I can only guess that my sleep quality is improved, perhaps getting more deep sleep now. plus I've lost some weight & reduced my pressure settings. last almost 2 weeks with fewer disturbing leaks & flow limitations & ahi under 1.0.

things have a way of changing so we'll see how long this pattern lasts.

frankly I wonder how much control you have to choose but my gut response to your charts is that the shorter duration ones toward the bottom look better.

the goal for most of us is 8 continuous hours of undisturbed sleep so neither pattern may be ideal. in the meantime, I'd say your how you feel index is all you need go on.

switching gears, I've been noticing a recent pattern with my plm. I take 2mg ropinirole at 7:30 & again at 9:30 pm. the early one because it takes time for it start working & in the apparently vain hope it'll stave off before bed rls; the later one to make it last longer (half life of 6 hours if I remember correctly).

the pattern is: rls before bed, worsening in bed while trying to go to sleep, followed by 2 short sessions with flow rate clearly showing plm. after that, most nights, longer sessions & little or no further plm. can't explain it but speculate that a) the ropinirole is helping and b) maybe that's why I'm feeling better with fewer hours of sleep.

[mper6794]

_ hi, sheepless. Thanks for the inputs.

_ quickly revisiting your thread, while sharing something I think I learnt with my case:

.... this thing of respiration and RLS/PLMS looks an intricated one, indeed. See, for instance, Barry Krakow's experience on this, in his book Sound Sleep;

.... one thing, for sure, though: either Clonazepam 0.5 mg (this, much better in terms of action and lesser side-effects) or Pregabalin were able to improve my sleep, by bringing more stable respiration, more stable REM, quick back-to-sleep transitions, and so on. Side effects, in particular from the second, would prevent me from never come back;

.... RLS (not PLMS, I think; no signals like yours) since kid used to be one thing that bothered my nights for some 50 years. However, it only severely attacked (used to get me crazy, actually) when I arousal/awake at night by respiratory effort (all kind of ridiculous minor things are able to do this);

.... should I don't awake up by respiratory effort, maybe I would not have had problems with RLS, eventually. It appears RLS had a preferred time to attack, in my case, from bed time to some 4;00 in the morning;

.... This will might look weird for you. However, even before the CBD oil, after my midnight wake ups (see upper pictures above), I had learnt by using some relaxation techniques to tame my RLS for the rest of the night; in particular, so-called EFT- emotion freedom technique, by tapping accupoints and rolling-eye moves, like in EMDR - Eye Movement Desensitization and Reprocessing); I am on this for the last 7 months or so;

..... as a miracle, it appears that CBD oil has definitively solved 50 years of RLS since August 13th, this year. Finger crossed!

all the best

[sheepless]

mper, your progress is great news! interesting that relieving anxiety appears to be the general purpose of EFT and I presume cbd oil. no doubt that anxiety is bad for sleep and maybe it aggravates rls, idk. I have no idea what plm feels like but for me, waking rls feels quite physical. it can be either a) like an electrical shock that starts in the legs and nearly instantaneously shoots up somewhere in my torso, making me twitch just once with each shock, or b) a more constant sensation I can't really describe that makes me want to move my legs, and really most of my body, to try to alleviate it. even with the latter I find myself grunting sporadically, which to me implies a stimulus, like the electrical shock in a). otoh, we often hear about links between mental and physical states so worth thinking a bit about anxiety. idk if I'm anxious. maybe that would explain my sweaty hands and feet, the constantly jiggling legs, drumming fingers, etc. I may have been anxious for so long it feels normal. I've tried very small quantities of cbd without noting any benefit but based on your experience will try again with a larger dose. the thc oil I use helps me sleep through plm but I have a sneaking suspicion it aggravates the rls. if cbd oil works, it would eliminate the possibility that the psychoactive effects of thc are detrimental to sleep, in the way sleeping pills always leave me feeling lousy; too much thc does the same to a lesser degree. I've also had some exposure to EMDR so I might try EFT as well.

[mper6794]

_ Anxiety: you have touched an important, understimated aspect;

_ CBD oil for beating anxiety or boosting dopamine in RLS? there are claims for both;

_ I would suspect in my case, CBD would be working on both fronts. Concerning anxiety, it looks it has been working similar to Clonazepam.

good luck

[sheepless]

recently I quoted a rls/plm related article in another thread to answer a question about plm severity thresholds. looking at the article again I see some interesting commentary that is news to me. the whole thing is worth a read if interested. from

http://www.jpgmonline.com/article.asp?is...s%20severe

this part speaks to a relationship between plm and apnea. PaulaO2, OpalRose and others have already referred to this connection; I haven't paid it much attention because it happens to be contrary to my own experience as apap, asv and vauto machines have had no impact on my plm. however, it might apply to and interest others.

"There are two types of PLMs. Type I (spontaneous) has peak frequency between midnight and 3 a.m. followed by decrease in late morning hours. Type II, which is associated with Sleep-related Breathing Disorders (SRBD), REM Behavioral Disorder (RBD) and narcolepsy has a more even distribution throughout the night.

With the improvements in polysomnographic technology and respiratory monitoring, it has been recognized recently that PLMS may occur in the setting of Upper Airways Resistance Syndrome (UARS), and appear to be caused by it. [4] It is also clear now that in some cases a diagnosis of PLMS is made when actually the underlying problem is either UARS or a mild obstructive sleep apnea. In these cases, Continuous Positive Airway P ressure treatment results in a significant improvement in the PLMS. [5] Interestingly, severe Obstructive Sleep Apnea (OSA) can mask underlying PLMS and they merely become more noticeable during CPAP treatment. [6] Adding to the confusion is the observation that CPAP in and of itself can cause PLMs. [5],[6],[7]"

[mper6794]

_ hi, sheeppless, Interesting paper....

_ I would follow it up with this one, and some questions for you: https://academic.oup.com/sleep/article/4...63/2731733
_ with this extracts from the paper, to make my point:

…""Patients were 15 men and 2 women with a median age of 66 (range: 48–77) years.
…..abnormal sleep behaviors that were suggestive of rapid eye movement (REM) sleep behavior disorder (RBD) in whom video-polysomnography ruled out RBD and showed the reported behaviors associated with vigorous periodic limb movements during sleep (PLMS).
…Reported sleep behaviors were kicking (n = 17), punching (n = 16), gesticulating (n = 8), falling out of bed (n = 5), assaulting the bed partner (n = 2), talking (n = 15), and shouting (n = 10). Behaviors resulted in injuries in 3 bed partners and 1 patient. 
….stereotyped PLMS involving the lower limbs, upper limbs, and trunk (median PLMS index 61.2; median PLMS index in NREM sleep 61.9; during REM sleep only 8 patients had PLMS and their median PLMS index in REM sleep was 39.5)
….In these cases, video-polysomnography ruled out RBD and identified prominent PLMS followed by arousals containing abnormal behaviors.
….Sleep history also revealed sleep-onset insomnia (n = 8), fragmented sleep (n = 8), nonrestorative sleep (n = 7), and hypersomnia (n = 12). The median Epworth Sleepiness Scale score was 12 (range: 0–19), with 10 patients scoring higher than 10…..
…Six patients had restless legs syndrome (RLS) of mild intensity occurring less than 3 nights per week that was only reported when we specifically asked for it. None had sought medical advice for RLS
….Two patients had a previous diagnosis of obstructive sleep apnea syndrome and both were treated successfully with continuous positive airway pressure for several years..
……During REM sleep, there were no vocalizations or semi-purposeful behaviors following PLMS, probably because the intensity of PLMS in REM sleep was less severe than in NREM sleep. 
……PLMS occurred intermittently during the entire night except in 3 subjects in whom PLMS were found only in the first third of the night. PLMS occurred in NREM sleep in all subjects (median PLMS index in NREM sleep 61.9) and in REM sleep in 8 (in these 8 patients the median PLMS index in REM sleep was 39.5) (Table 2). Nine patients had PLMS only in NREM sleep, 8 had PLMS in both NREM and REM sleep, and none had PLMS only in REM sleep. When compared with PLMS in NREM sleep, those PLMS in REM sleep were less severe and less frequent but showed the same stereotyped motor pattern…
….Sleep efficiency (%)           79 (58–91)       84 (74–90)
….PLMS–arousal index/hr      43.8 (11.5–58.9)         4.4 (0.7–17.3)
….PLMS are stereotyped repetitive episodes consisting in extension of the great toe and ankle, and flexion of the knee and hip sometimes coincident with arm movements.5 PLMS are thought to result from dopaminergic dysfunction, and dopaminergic agonists decrease the PLMS number and related arousals…
…..In these settings, treatment of PLMS with dopaminergic agents can improve in some instances the severity and frequency of these problems.10–12
….PLMS were associated with arousals that contained motor behaviors and vocalizations and resulted in sleep fragmentation leading to insomnia, nonrestorative sleep, and hypersomnia. Dopaminergic agents reduced the number of PLMS, restored sleep continuity, and improved dramatically all symptoms....""

my points: 

____ then, maybe certain PLMS could exist independent of respiratory efforts in disorder breathing.

____I may have this stereotyped PLMS, maybe of the groaning type, as audio-recorded a few times (in particular during NREM; not driven by respiratory efforts);

____ however, contrary I used to think, my sterotyped PLMS/arousals (did not subside with Clonazepam, diminishing througout time, and less than 01/hour currently), after some 650 days of observation on OSCAR,  suggest me this does not bring me significant drawbacks to my sleep (back to sleep quickly usually), as compared with arousals due to respiratory effort (absolute majority, non-flagged events). Theses days, I don’t even pay much attention on those PLMS arousals;

 Sheepless, just a curiosity (and, eventually, it could  add some insight for your therapy), as far as I remembered your case, do you think you would be able to discriminate your arousals/awakenings (and deleterious significance) in terms of respiratory-driven and, say, clean-not respiratory effort driven, independent PLMS ?

....” this part speaks to a relationship between plm and apnea. PaulaO2, OpalRose and others have already referred to this connection; I haven't paid it much attention because it happens to be contrary to my own experience as apap, asv and vauto machines have had no impact on my plm”…. 
I am aware you have been interpreting this way for a quite sometime. Just to see whether I have already got your point, I was wondering if you are meaning here that PLMS would lead to respiratory effort and arousal/awakening, and not the other way around?

all the best

[sheepless]

mper, there's a lot to respond to but a couple brief comments for now.

as I'm sure you know, the point of my last post is that unlike my case there may be a close association between plm & apnea in other cases.

now, responding generally to some of your comments, I don't think there's any association between my plm & my apnea. I believe my plm precedes & triggers the respiratory reaction to movement I see in my flow rate. absent ropinirole, my plm has been present at a wide range of settings throughout my 4 years of apap, asv & vauto.

idk how to see & measure effects of plm sleep disturbances. otoh, plm is clearly present in some but not all full awakenings that result in a mask off end of session. making up a number, maybe half of my mask off's are not clearly related to plm.

it's easy to discriminate between plm & other arousals; not so easy to determine the cause(s) of non plm arousals. obviously I can see them in my flow rate, but I am unable to identify a reason for waking in many/most of them.

several members are using movement sensing devices & scrutinizing flows looking for connections between how they feel, movement, flow limitations, sighs & spikes indicating arousals.

maybe eventually that will help identify causes of some arousals & suggest treatments for them.

if you have ideas about how to discriminate arousals let me know. I'm just not sure many of mine are respiratory driven.