Welcome to Open Airwaves, a podcast brought to you by the American Academy of Dental Sleep Medicine, where we have clinical discussions on dental sleep medicine-related topics. I am your host, Dr. Tanya DeSanto. I am joined today by our guest, Colonel Philip Neal. Dr. Neal is an Army dentist stationed at Fort Cavajos, Texas. He created a DSM short course that produced over 1,100 graduates between 2016 and 2023. The course ensured every Army installation and GDE program had trained dental sleep medicine providers. More importantly, those providers increased the delivery of oral appliances from less than three a month in 2015 to over 3,500 in a year in 2022. He co-authored the first Veterans Association Department of Defense Clinical Practice Guideline on OSA and insomnia management in 2019 and the recent update for 2025. He serves as Deputy Sleep Medicine Consultant to the Surgeon General and is the primary investigator on a military operational medicine research grant focused on accelerating worldwide deployment and ideal management of service members with OSA. He has pioneered methods to incorporate mindfulness concepts and positional therapy to reduce insomnia and optimize OSA therapy outcomes. Upon military retirement, he hopes to continue his research and treatment supporting veterans and their families. In this episode, we'll explore how Colonel Neal's military experience sparked a deep commitment to sleep health advocacy, transforming the lives of countless soldiers along the way. It's my great pleasure to welcome Colonel Neal, and thank you so much for joining us. I'd like to dive right in. Welcome. Thank you. Thanks so much for having me, Dr. Stanton. I think your story is fascinating, and I continue to be fascinated by it. I think we can start off. I'd like you to tell our audience a little bit about yourself. Tell us your story, if you could sum that up for us. Sure. You know, I was just a normal kid. I had a great family and friends and parents and grandparents that raised me. And I decided to join the Army because I went directly into college, and I just didn't have the focus and discipline that I thought was going to take me somewhere. So I enlisted six months after high school, and the rest of the story is just me walking into incredible opportunities and being exposed to mentors and leaders that gave me the chance to make an impact and taught me the way to help others. I always say when people thank me for my service, I thank them for their taxes, and I thank them for everything they've done for me. I continue to do all I can. I'll probably retire next year. I've been saying that for about 10 years, but I don't think I'll ever be able to repay what the Army's done for my family and for me. So after some time enlisted, I applied for a scholarship for dental school, and the Army paid for both my undergrad through GI Bill and dental school. And then I came back on active duty. I deployed a few times and went through a clinical residency and had a normal career. I'd been teaching a leadership school in San Antonio where dentists and physicians, PAs, go before they're promoted to major, captain's career course. And I was preparing to take command in Italy, and there was a small unit that had a little flat overlooking the Mediterranean. I'd been tracking it for several years, and then my wife was accepted to law school. She was a nurse and had been a warrior transition unit nurse and supported military active duty and veterans, but I didn't even know she was applying to law school. I knew that she took the LSAT, but I didn't know really what that meant. I was just being supportive. And she told me she was accepted to law school, so I needed to find a way to stay in San Antonio. And so we checked to see what jobs were available, and they sent me to be deputy director of operations and policy for MedCom. And so I began writing policy, and one of the policies they assigned was sleep apnea. And the policy at that time was that during residencies, dentists could make two for resident benefit to learn how to do it, but the rest of them were referred to the network. And so I started studying more and more about the appliances, and I had sleep apnea at the time, and I did not know what their efficacy was or what they could do. I went to an AADSM essentials course, and that really lit the fire when I saw how we could reduce veteran suicide, improve cognitive function, improve overall health, and how sleep apnea was the number one medical deployment waiver requested to go to the Gulf War. And so all these soldiers that were going over and didn't have a good option. And so that kind of opened the door for me to get involved with sleep medicine. That was in 2014, and it's been my primary focus since. So, Colonel Leo, can you just explain that for the non-military person like myself? So it was impeding the ability of soldiers to go overseas if they had sleep apnea? Is that what you're saying? Yes. So when we go into a new location, then the soldiers just sleep on the ground. They're in a tent, they're on the move, structures of opportunity. So distilled water and electricity are not a guarantee. And so when someone has sleep apnea, then if they're well managed with a PAP, then they can request a waiver to deploy. And so the surgeon that's in charge of that theater, the medical provider that's in charge of that theater will then analyze what they think the mission and the surroundings will be. And if they believe that distilled water and electricity and sleeping at the same place is likely to happen, then they'll approve the waiver to go. And so early on in conflicts, then we do not approve those waivers very often. But once we've been somewhere for a while and gotten established and electrical grid set up and containerized housing units and people are going back to the same place, then we do approve those waivers. But there's so many people that even if they get the waiver approved to go over there, the complications with operational sleep where our soldiers average about four hours of sleep a night is what the studies show. And so any sleep problem becomes magnified when they're not getting a sufficient quantity. So was there a shortage of soldiers then? Because if they had sleep apnea and needed a CPAP, they weren't able to get deployed overseas? Right. So sometimes that means that the person who's deployed over there doesn't get to come back. They need to stay longer until someone can be qualified to replace them, find a replacement. And sometimes what the most common thing that's happening right now is commanders have something called a commander's override. So I was in command and whenever we needed to deploy someone, we look at their medical readiness. And that's one of the things that we need to make sure is OK. But the commander, in order to meet the mission, they're allowed to override a non-deployable condition and say that they're going to deploy the soldier anyway. And so they can make that decision, including sleep apnea. That's the most common thing that happens right now because so many people have it and so few have oral appliances that unfortunately we have to send them. And they do the best they can. We get battery backups and sometimes they can recharge those. But it's big and it's bulky. It's hard to move. It's a great therapy in the right situations. But in a deployed environment, it's usually not a good solution. Wow. And I would imagine that like their daily activities, I mean, they can't function well because they're not sleeping well. And even if they're all in the same barracks, I don't even know if I'm using the right word, but if they're all in the same sleeping quarters, the people that don't have sleep apnea also struggle because the snoring of the partner next to them, like sleeping is disrupted everywhere. Exactly, exactly. And how was that soldier that snored? And when we went to the field, my first assignment was in Central America. So when we would go out, we were in the jungle. And so we didn't have tents. We slept in hammocks. And it's impossible to sleep any other way except on your back in a hammock. So I was out and on my hammock and I had a mosquito net hanging over me. And I woke up the next morning and I was bit up by mosquitoes. And there was a boot in my mosquito net. And someone had thrown it at me during the night to try to get me to stop snoring. I don't mean to laugh. I really understand it now that now that I treat sleep and I constantly, you know, record other people with SnoreLab and they do. And they listen to themselves and see how bad it is. They all apologize. And when I was deployed and actually providing sleep apnea care in Iraq, the people who lived with the people that I was treating would come in and thank me and talk about how I changed their lives because everything was set up around getting back to their their chew where they slept before the other person and getting asleep before they fell asleep, because once they went to sleep, no one else could. And, you know, we had fights break out because of that. We had soldiers that had to be moved to different houses. And when early, when I deployed as an enlisted guy, I stayed in a hangar. So there were there were 500 of us sleeping in this in this big hangar. And we took the snores and put them over in the corner of the hangar. And it sounded like an outboard motor going across a lake when you when you when you walk through, you can hear all those stores over there. And because they snore a lot and they were more used to the sound, they did better around other snores. But the people that were not used to being around snoring, it was really disruptive. So even then, we tried to we tried to change it. And we know that when they have those. Arousals in their sleep is disruptive, that it's going to harm their cognitive function. So those are but it's important, it's a safety issue, they're going to make bad decisions. And, you know, the the reaction time of decision making when you're when you only get four hours of sleep, if you get less than four hours sleep, it's equivalent to legal intoxication. And if that is harmed by fragmented sleep due to snoring or sleep apnea, then it's magnified. And, you know, our soldiers, if they if they drive under the influence, that's something that will court martial or separate a leader for. But unfortunately, you know, we'll send an 18 year old into a firefight on four hours of sleep every single day. And so that really motivated me to try to get them the best quality sleep that we could get them because it's difficult to get the quantity that they need. So when you were deployed your three times, were you you weren't a dentist at that point, though, correct? So at two times as a as an enlisted guy and two times as a as an officer. So then when you are not the point that first two times you were not a dentist yet, you were on the other side of the fence, like you were part of the people that suffered with sleep apnea. So then when you were a dentist, you probably could take everything you've learned, you know, your first two times that you were deployed and really make a difference. I can see where you'd really want to make that change because you were on both sides of that. You know, it seems like to me, it was really fortunate to have that perspective, to be able to communicate it to people. And yeah, I think I think it's an advantage. But once you start briefing this to our leaders, like military leaders know how important sleep is, but they also have to accomplish the mission. And so you're constantly balancing your resources and doing the best that you can. You can never you never have enough time. And so sleep is compressed a lot. So leaders do what they can to try to improve sleep of their of their soldiers. But it's difficult. So is this what is this how your wheels were spinning? Is this how you started developing this protocol for soldiers with sleep apnea? Is this the spark that drove you? It did. A big piece of it was that even on when I was enlisted, I was part of forensics team. And once I became a dentist, I was part of our forensic postmortem identification team. And so I've been part of the identification of around 70 soldiers. And only two of those were combat related deaths. The rest of them were all motor vehicle accidents, a few helicopter crashes and a lot of suicides. And so when you dive into the manifestations of poor sleep, cognitive function, those people that are committing suicide, a lot of times there's a sleep breakdown there. And that's why they make that decision to seek a permanent solution to a temporary problem. And drowsy driving is so much more dangerous than drunk driving for us. When they're under the influence of alcohol, they'll break late, they'll turn late. But a micro sleep where they just nod off for a second, they don't turn at all. They don't break at all. And it's really damaging. It puts others at risk as well as them. And these accidents that we saw, a lot of them were when they were coming, they were on their way into PT or they were to physical training early in the morning. And just nodding off at the wheel. A lot of the same things happened while they were in Iraq, where they would nod off at the wheel and overcorrect. And when we were first adjusting to armored vehicles, they had a higher center of gravity and they would roll over. And so when they would roll, the turret would spin and it would cut the fingers off of the gunner that was up out of the top of the turret. And so while I was at a combat support hospital in 2008, we had a lot of those soldiers evacuated to us that had lost their fingers. And it wasn't due to combat. They weren't in action. They were just on a convoy moving the vehicle somewhere. And then a lot of times they would say, oh, I thought that I saw something and then I overcorrected. But you talk to the people that were behind them and they said, oh, they started drifting off to the side and then they rolled. And so these vehicles don't have air conditioning. It's hot over there. They don't have enough sleep. It's easy to nod off like that. And after the fact, I think that was what was happening a lot. And so being exposed to those type of things, it just, I felt so lucky to be able to find something that could really save lives of soldiers. The two biggest things that kill our service members are suicide and motor vehicle accident and improving sleep touches both of those things. And so I feel really fortunate. That's so moving. I can see why you're so driven to do this. I mean, it's so empowering. I get goosebumps listening to you, to be honest. That's amazing. What can you tell us, like how you started developing this? Like, what did you have to go through? What was your seed? You knew there was a problem. You knew you had to do something. You felt compelled to do something. Like, what was the first step to getting this going? So I was assigned the policy. And this is another part where my enlisted experience really came in to help me. So I wrote the policy. The policy was assigned to me in 2014, but it was kind of back burner. There were other policies that needed to be done first or prioritized. And so this one took a little while longer after I'd been to the sleep essentials course with ADSM. And I started reaching out to people that did it and learning more about it. Then I understood what needed to be done, and I wrote the policy fairly quickly. But the problem was we didn't have anyone in the military that knew how to provide modern oral appliance therapy. We had one specific type of appliance we started using in 1989, and it was great. And it's still great, but it was before we hit the digital revolution where we had seamless digital workflows and things that we could scale. And so writing a policy is great, but if you push it out and no one knows how to execute it, then nothing's going to happen. So I knew that I'd seen policies be pushed out where they asked me to do something I had no idea what to do, and I would put that policy inside and keep doing my job because there was nothing I could do. So I knew that we needed to create a course to help. And at the time, there were many residencies, I think, around Tufts and UNC, University of the Pacific. And I started talking to everyone that I could, the current president of ADSM. Then I had a meeting with him to start it, former president, Rod Rogers. And I started asking people if you could set up a course to teach. And I only have one week. If you could teach people in a week to come in not knowing anything about doing sleep medicine, and then when they leave the course, they go back to their installation and they stand up a sleep program where they can go talk to the physician, set up the referrals, do everything. And so that was the intent of it. And so it turned out to require about 30 hours of online training ahead of time. And then we call it a 40-hour week. It was Monday through Friday, but we worked later than that. And we got it all in. They developed a good scientific understanding of sleep apnea. And then we had skills assessments where we didn't just tell them, like a lot of courses, you watch a few PowerPoints and you take notes. And if you're really diligent, you learn it. But the Army performance-oriented training methods mean that when we teach you something, we evaluate to see if you can do it. And so with this course, everything hands-on. They had a skills checklist to make sure they knew how to take the proper records, take the proper bite. We had 100-question tests at the end on all the science and everything that we'd done. And these guys went out and they were just stars. We taught the first course in 2017. Several of those guys are now out in the civilian world with 100% sleep and TMD practices doing really well. and those guys from those courses became the champions that took it out to the rest of the enterprise. So the sleep course, I think, was the biggest impact, being able to teach those guys. And by writing the policy and creating the course, it put me in contact with all these amazing sleep medicine experts who were really gracious with their time and their knowledge and helping get that established, both civilian experts and military experts. And that opened the door for me to be involved with the clinical practice guideline working group, become a deputy consultant to the Surgeon General on this. They mainly just bring me in for oil appliance related things, but there was never a dentist associated with it before. And so I think that's what really helped. Once we created true champions and taught them how to do it, then they went out. And that's why we saw the big growth. And the most important thing I did was bring all those experts together to help train our guys, and our guys went out and really made the difference. That's amazing, because that program is just still growing and thriving today, correct? Well, it's not in the same format anymore. Whenever we lost, Army Medicine lost full authority and we fell under the Defense Health Organization that brought the Army, Navy, and Air Force together, the funding stream was no longer available because it was from a Department of the Army program. And now we were DHA civilians that were included in our clinics instead of Department of Army clinics. Army clinics. So we have a form of it and we've still done it, and we hope to stand it back up again. But now it's regressed back to a two-day didactic online program. But we've trained mentors at all of our graduate education programs with the hands-on 40-hour course, and many of them have become diplomats, AADSM, and they're able to mentor the people that go through the two-year. But the real value that's out there now that endures is that I could never have created the course without the help of all the AADSM leaders. And so when Dr. Braga was creating the mastery program, she came and helped taught our course, and we sat and talked at length about ways that it could be improved and what we had done and what we'd learned. And so she took those things and really improved on most of them and created the mastery program. And so they give a really gracious discount to military to go through the mastery program. And I really see what I started there as being something that helped the mastery program go. And so I'm really glad to see that that's helping so many people now. That's awesome. That's so awesome. To develop the protocol for how I would treat, I think we all find reasons to change our protocols as we learn and get more experience. And what I was finding was that in dentistry, we expect 98% to 100% success. Everything we do should work. We have good protocols, and it's clear what to do. But medicine is not like that. We have failures. There are things that we do the best therapy that's available, but it's not always successful. And I was struggling with that because I was having these non responders. And so I dove into the literature to find out why those things were happening. And what I noticed was that positional therapy was very common and that there were other types of apnea that were not impacted well by oral appliances. We could help with collapsibility. We really didn't help much with loop gain. And you know the story, control, low arousals. So I wanted to see how we could impact those. So when I started looking at what was the most common phenotype, most common type of sleep apnea, you know, upper airway collapsibility was the one and positional apnea was just so prominent. You know, some of the numbers that we found, I think the readers should really look at the article by Landry that came out in 2023. It's a really good article that goes in depth, but that showed that, you know, 50 to 75% of sleep apnea is impacted by position and, you know, 20 to 35%, depending on which of the major studies you're looking at, will be completely managed just with positional therapy. So, you know, so I really wanted to understand what positional therapy means. And just like mandibular advancement devices are called mandibular advancement splints and oral appliance therapy, and a lot of different terms are used, you find the same thing when you're looking at research on positional therapy. But just for this conversation, I think it's best to divide it. There are three groups of people that I think are the most important ones. There are three groups of sleep apnea that are related when you're looking at position. So there's supine isolated, which means they only have clinical sleep apnea when they're on their back, when they're in the supine position. If they're in the lateral position, they're having fewer than five minutes an hour. The other type is supine predominant sleep apnea. And that means that they'll have twice as many events in supine position as they have in lateral position, but they still have clinical sleep apnea in the lateral position. We're still having five events for an hour in lateral. And then the third type is non-positional apnea. So it looks like that number is going to be around 20% of patients will have non-positional apnea and, you know, 75%, 25% break down from there. So then I want to see, well, who is impacted the most by positional therapy? And it's the same patients that we are treating. When I say we, I mean active duty, but I also include everyone using oral appliance therapy because oral appliance therapy is most effective in mild and moderate sleep apnea. That is where positional therapy is most effective. Positional therapy is most impactful in younger patients and in patients with lower BMI. So that was a lot of my patients. So I was excited to look at it. We have a lot of focus on, you know, how gender impacts this. And I found that supine isolated sleep apnea was slightly more prevalent in males, but supine predominant sleep apnea was equally impacted males and females. So this was going to help all of my soldiers that I was treating. So basically the Landry article is stating that almost 75% of this study group, this meta-analysis, that positional therapy, 70% of these patients with positional therapy, that's a huge number. The positional therapy is 70% of that group. That's big. So do you think then along those lines, I mean, is there a thought process that you think that maybe positional therapy could replace or augment oral appliance therapy? Can you keep thinking deeper into that? Right. I mean, that's a really, really good question. I think that positional therapy should be viewed as an adjunct. And on the VA DOD clinical practice guideline, we made the recommendation for people with positional apnea, they should receive positional therapy, but we did not recommend it as a standalone therapy or a first-line therapy. And we can talk, we'll talk a little later about it. I think on why we made that decision, but it is just going to be very impactful people using oral appliance therapy. If you're using oral appliance therapy, you're really impacting sleep apnea in two ways. You're protruding the mandible and that's going to increase the area of the airway, the size of the airway, and it's going to decrease collapsibility. And so, but when you combine a positional therapy to it, positional therapy is also going to reduce collapsibility, but it's also going to increase lung volume. That's going to significantly aid snoring is really significantly reduced whenever they're in lateral positions. That's going to reduce arousals, even if they're short of apneas or hypopneas, snoring related arousals are significant. And a lot of our patients are, that's their chief complaint. They came to us because their snoring is bothering them or is bothering someone else. So helping them to do that was good. And I'm always looking for a reason to help influence, to inspire people, to try to do things to be more healthy, to help them live better. And so when I found out that positional apnea became more effective, more impactful with weight loss over time. So there was another reason to try to convince people, you know, if they were, if they had a BMI or were healthy, that if they could lose a little bit away, it would not only help independently, but it would help with their positional apnea also. And that's one of the, that's one of the weaknesses of positional therapy. We see that patients will transition as they age. If they're, if they're significant weight gain and increase in severity that they'll transition from supine predominant sleep apnea to non-positional sleep apnea. But if we can, if we can help them maintain a lower severity and lower BMI, then they never reach that point. I can see where that would really, really be helpful to the soldiers too. You know, that, because they, you know, that group would have a lower BMI in general, you would assume, and positional therapy could be a huge adjunct to oral appliance therapy. What, so along those lines, so what if a sleep dentist is having relatively good results with mandibular advancement devices alone? Why would it be important for them to include positional therapy with their patients or the soldiers? That's a, that's a, that's a great question because we're, we're, we're working fast. You know, we don't have a lot of time and if we're getting good results, it's hard to find time to make those changes. So I think the first thing that I would say is to take, make sure that the sleep dentists understand the four main endotypes of sleep apnea. And, you know, we know that airway collapsibility, that that's our bread and butter. That's the most common endotype. But, but it does not, oral appliance therapy does not impact the other three endotypes. And so if you can increase lung volume, then you can have an impact on loop gain. And, and you can have impact in those other areas. And so there's a, it goes into a pretty well in the Landry article, actually also there's limited evidence at least that positional therapy will impact the other three endotypes ineffective pharyngeal dilator response is one and loop gain and the low arousal respiratory arousal threshold is the other. And so if you can get them into positional therapy there's good evidence that you lower the increased arousal threshold and they stop being disturbed and that you, you can prevent loop gain by increasing lung volume, see about a 10% increase in lung volume in awake patients. When you transition from the supine to the lateral position, and that gives more residual lung volume, which is going to decrease the loop gain. And so we see that in the most recent studies as being a similar impact, see a 10% increase in lung volume and see a 10% decrease in loop gain and don't, or not sorry, control. Yeah. I don't want to go too deep into that. I know that's too much, but I think that's it. If they can, they can understand that the patients that are being referred back to them as non-responders they may have another simple way to help them, especially for, for the, for the practices that are mainly treating patients that have been unable to adopt pap therapy or unable to adhere to it. So if they, if they're unsuccessful with our appliances, then surgery is going to be their next option. And many can't afford that, or don't want to go through the invasive procedure. Excellent answer. So I have another question for you. When you look into positional therapy in the literature, you commonly come across current devices and they, some of the articles will name products that are used for, for supine sleep avoidance. Like for instance, in the Landry article, they talk about bumpers. One of the articles talked about tennis balls, bolsters, and vibrotactile devices. So all of those, all of that being said, I wondered what, Philip, what you thought, what is different about the positional therapy you provide to soldiers versus therapy, therapy historically provided by others? And what's your opinion on the devices and, and your thoughts on the recommendations? It's kind of a loaded question, but it's really interesting because it's brought up, these are brought up in many of the literature articles on devices and adjunct therapy, if you will. Yes. And that's a, there's a lot to impact there. That's a great, that's a great question. So the, the thing with the, with the, with the adjuncts that you're talking about, the tennis ball, slumber bumps, and the vibroactive devices, those are all specifically to enhance supine avoidance. So the therapy, therapy that I teach goes deeper into, into, and I'll explain that a little later, but if we're only looking at supine avoidance, then in the short term, all of those adjuncts work, work really well. You'll see a 50% reduction in HI, you'll see them adopted really quickly. And so I like them to help develop a habit of a comfortable lateral sleep position. I don't like them long-term as a solution because the long-term data is not very good on people. People will revert back to supine sleeping, or they'll become sensitized to the, to that adjunct and have a lot of arousals and stop using it because they're aroused. Of those options, and like everything, you know, there are a million oral appliances on the, on the market, and if you've been doing it long enough, you will find someone that loves every single one of them. I will pick the ones that we think are best, but oddly people love every single one that I've seen on the market. I've found someone that really liked it. And so we see, I see the same things with these, with, with the adjuncts that people use to avoid supine. When I was, when I was deployed, it was really simple. We had lacrosse balls that were at the tent just across from me that the physical therapy guys gave to help people massage their own backs. And so we had a supply of those and rubber bands, and we would tell them to, to put it in their t-shirt and twist it, put the rubber band on, and it was helpful with keeping them off their back. And we would do that while we were waiting on their appliance to be fabricated and delivered to us. So it was a great interim step. I just wonder, because how would you be out in the field and have all these devices in the middle of wherever you're stationed at? You know, really difficult, really difficult. And the other thing about those adjuncts is that I view them as a stick. Right. And so when you're trying to influence and change behavior, that's everything about the military's leadership and influencing behavior. You know, we know we've got the stick or the carrot. We can, we can, we can punish you for doing the wrong thing, or we can reward you for doing the right thing. And everything that I saw out there for positional therapy, it was stick. Everything was stick. And all of those things that were strapping to us at some level, they're causing arousals, you know, and people, some people adjust to them better than others. But when you try to go to a supine sleep, it's going to stop you and, and, and push you back. And so a lot of people were, were aroused by those. And I think that's why they, the long-term data may not be as good. And so when I was trying to understand how to best deliver positional therapy, I wanted it to be carrot. I wanted to make it good for the, for them, something that they wanted to do and something that they didn't need a lot of extra, they didn't need to spend money to, to be able to do it. And so the methods that we teach, we teach people to use the gear that they take to the field with them, or the pillows and the blankets, the things that they have at home and shape those into what they, to what they need to be able to get into the position. So that's, you know, I'm not against those adjuncts. And if, if, if dentists are out there right now and they're trying to get into doing more positional therapy, I think that's one of the easier things to do. Just have a, a handout with a few QR codes on a few options that they could, that they can look at. They can, there is just, Amazon is littered with, with next day delivery, anti-snoring and sleep apnea adjuncts like that. So I think that's a good way to start. But now to go, did, does that answer the questions on those adjuncts? Yeah, I think they're, I think they're great. I just don't see them as great standalone therapies or long-term therapies. And so now as far as what's different with, with the therapy that I, that we use in the military now is that it's more than supine avoidance. And at this point, well, shortly we'll go, we'll go and show some, some pictures. But when we, when we do the therapy, it's not just staying off your back. We're trying to, I looked at what, so, so someone just tells me, you need to sleep on your side and not on your back. And so people will naturally try to go to their, to their side. And there's a very specific position that at least 90% of soldiers go to. And it's a, it's a field position where both, both knees are up, their hands are in front of them and they're, and they're exactly on their side. And that's the way a lot of us sleep, you know, and I'm sure a lot of the listeners sleep, but they go camping or somewhere that to sleep on the ground, try to sleep on our sides that way. And so the soldiers especially understand that and why they have a hard time sleeping on their, on their side. There is because of the pain that comes with their shoulders and their, and their back and their neck. And so they end up moving around. So pain's the number one reason why people fail at lateral sleep. So pain is the biggest arousal that my patients will report. Pain on their hips, pain on their shoulders, and when they're sleeping on their back, pain on their ribs, and that's from the bed partner's elbow that's hearing their snoring and is making sure that they roll back over to their side again. We call that a positive elbow sign. Or the boot in the hammock. Yeah, the boot in the mosquito net. And so, the therapy that we use, it wants you to focus on every part of your body. From head to toe, everything is important. Starting with the head, head position is very significant. It is very significant. How much, if you tuck your chin, how much that is going to harm what we're doing. With the older clients, we're protruding the mandible so that we can increase the distance between the genital tubercles and the hyoid, you know, the muscles that connect. That's what's gonna help keep the airway open. And so, we put the appliance in to do that, but then we manually put our chin closer to our hyoid and we're losing that impact. And so, I found that some of my patients were going back for efficacy tests and at home, they were doing well, they weren't snoring, and they were feeling better. When they went back into the lab and they only had one pillow, they were less comfortable and they rolled up in a ball more and tucked their chin and then they would fail. And when they extended their chin and were neutral or extended, they would pass. I wanted to intervene because there was in the literature with Landry and Beatty, they specifically talk about that in the study. They specifically talk about the significant difference in the AHI resulting from head position, you know, relative to the body position from a rotational perspective and how there was such a great improvement in AHI when the head was considered. And that they talked about early polysomnograms, they didn't incorporate head positioning at all. And once they started doing that, you know, fast forward, started to do that, they would see a huge difference in results. So, I think you're onto something. I mean, that's what I was reading in the research too. So, head position is huge. There was a great few studies by Isano and colleagues that looked at the head position, two things specifically at neck flexion or extension and at mouth opening. And so, what they did was these patients were under general anesthesia and they moved the head and tracked the airway and specifically the critical closing pressure. And so, for those using oral appliance therapy, the critical closing pressure, that's what we're after. And what we're trying to do is decrease that closing pressure, which is when you're reading the lid on it, it can be a little bit confusing because by decreasing the closing pressure, you're making it more negative. And so, normal closing pressure is gonna be around zero and you start having problems when it's above, but you're trying to, what we saw, the closing pressures would decrease significantly with neck extension. So, as long as we're talking about images, I just wanted to remind our listeners that there is a video component to this podcast that you can obtain when we're finished. So, as I was analyzing what the problems were with people being able to maintain a lateral position, I just wanted to dive in and see what makes the position, what positions do we already have that would help? And, you know, when I thought about the position, I knew that it needed to be comfortable because people are constantly aroused by discomfort and it needed to be stable. People get in a position to go to sleep, but then they'll roll out of it and end up in a poor position to sleep. And I wanted it to be precise because I wanted them to go back to that position and have a fundamental base position that they could go to to begin to go to sleep every night, every day of the week, and begin to go to sleep every night so that it wasn't random. It would be, they would find the exact way that worked best for them and then they'd be able to perfect that as they went. And so, you know, a good sleeping position should always improve their breathing. That's what we're trying to do, but it should also reduce arousals. It should reduce their mouth breathing. And if possible, it should help manage their insomnia. And it turns out that these positions did, and we may talk about that a little later also. But so I went and I had already read a hundred articles at least on positional therapy, everything that had to do with body position that impacted sleep. And then I did what I tell my children to do. If you have a problem, go to the internet and someone has probably already solved it. If something goes wrong with your vehicle, then go to YouTube and some person there is gonna tell you how to fix it. And so I started looking at the things we'd done with body position, things that we do laying on the ground and what could translate to sleep. And what I found was that the first position that we go to is the recovery position, trauma recovery position. So if all soldiers are taught this in basic training and it's what we do after basic life support. So if someone just had a, was just revived with CPR or if there's been a trauma and they have, you know, shrapnel or a wound in one lung, then we'll put them down on that side, on the wounded side. We'll pull their bottom leg straight. We'll push their top knee up. We'll stabilize their head with their lower arm and then put one arm in front of them to keep them from falling all the way to the prone position. And that works. We know that that works for years of combat medicine. And even with one destroyed lung, as long as they stay in that position, they'll bleed out of that position, that lung a little bit. It may fill with blood and become compromised, but the top lung will continue to ventilate them and they'll stay alive. If they roll to their back while the medics are checking everyone else, then they'll probably not survive as both lungs will fill with blood. So we know that position works to keep people on their side, but it's not completely comfortable. The other position is the prone firing position or a sniper position. So also you're laying on the ground, you have one straight leg, one bent leg, but you're set up more for comfort and you can stay in that position for hours at a time if needed, hopefully to never have to pull the trigger, but in a stable position that's comfortable. And so we combine those two positions and came up with what we call the base position, breathing and sleep enhancing sleeping position. And so what I do is I take people through this position from head to toe. And as you said, there'll be some images available but what I do to teach it in the clinic is where they're given a handout that shows the position and describes it. We actually have a bed in the delivery room where I deliver in group environment. So we'll have six to eight soldiers in there that are receiving their appliances and they're taught this as well. And we talk them through the entire position. And so I can go through the principles of it, but everything is important from their feet to their knees, to their hips, to their shoulders, to the angle. There's no, nothing is random about it. There's a variance and people will adapt these principles to be comfortable for them, but they have to observe all of these principles. I actually talk the patient through the position from head to toe. We've got an image of it and the listeners could go and see this image, but you'll see that the first part of this position that's a little different from others that I've seen is that your foot of your bottom leg, your straight leg is hanging off the bed just a bit so that your toes can point directly at the ground. What we find is when people go to the fetal position, they stack their hips and they stack their shoulders. And so they end up with pain on that lower hip and that's what causes them to toss and turn. Could be pain other places that we'll address, but to prevent that, we allow the toes to point directly at the ground and that puts the quadriceps muscle, the thigh, front of the thigh in contact with the sleeping surface, the mattress and prevents the hip from being in contact. So then we move on to the other leg. The trick with the top leg is it just needs a bend in the knee. We bend the knee so that we have a weight forward of the spine as a counterbalance to make it difficult to transition to supine sleep. So that bent leg for most people that are over 30, they're gonna want a little support there. A lot of people that are sleeping in that fetal position now they'll put a pillow between their knees that helps prevent low back pain. And so they're not gonna keep their hips stacked, they're gonna rotate a little bit farther forward so they may not need as much support, but most people would like a little support under their knee and so we do that with a body pillow, usually a king size pillow, but the ideal size of the pillow is just it goes from your chin to mid thigh when you're standing, that's about the right size. You don't have to have a certain pillow. I tell the soldiers just use the gear that they have with them in the field or pillows or blankets that they have at home just to get the right length, not necessary to buy anything at the beginning. So they have that knee bent. That leg can be a lot different. Some people like for their feet to touch, some people like for their knee to be really bent and up high, as long as there's a little bend in the knee and it's forward, then that's okay. So then we move up to the arms. So I tell them they're gonna be able to put their arms a lot of different ways, but they need to get both elbows out away from their bodies. Most people when they're sleeping on their side are gonna tuck their arms in tight to their bodies because if they hold their arms away from their bodies, that's gonna generate pain from unsupported body weight. So they hold their arms in tight, but that makes it difficult to use that weight of their arms as a counterbalance to make it difficult to transition back. So the pillow that's supporting their knee runs up and they pull it to their chest. The purpose of that pillow is a few things. One, it stops them from rolling all the way to the prone position because they're not staying on their side. They're in a hybrid position that's between their stomach or prone and fully lateral. That's what they need to do to take the pressure off their hip and the pressure off their shoulder is to rotate a little that direction. So that pillow is gonna be pulled to their chest so they don't roll. They're gonna have one arm under the pillow, the bottom arm, and the top arm is gonna be out away also. That they're resting their arm on that front pillow to prevent shoulder and neck pain from unsupported weight of that other arm. That pillow is then gonna run up and they'll be able to rest their chin on that pillow to help induce nasal breathing, prevent habitual mouth breathing. So we want people's mouth to stay closed. The studies are clear. If they open their mouth, it's easier to collapse the airway. And so that's one of the things that we're trying to do. Now, their bottom arm, what I find is a lot of these guys are swimming their arm under their pillow. So they're putting their arm under their pillow. And the reason they do that is because they're trying to get more lift out of their pillow to keep their head straight, keep it from sinking down too low. So they're swimming their arm under. That will manifest as shoulder and neck pain later on. It's not a healthy sleeping position. So getting the person to roll their arm under and to just have their elbow away from their body and their palm facing up from the bed, that's the position of that lower arm. We call it an underhook is the way I describe it to them. They've got an overhook and an underhook around that pillow. And that's gonna keep them comfortable. You've got to get that elbow away from the body so that the arm doesn't go to sleep. It doesn't have tingling or cause other issues. And now we're gonna move up to the head. So the problem with most lateral sleepers is that their pillow is too flat and too short. A standard pillow is gonna be 24 inches wide and about three inches high. And that's not enough. When you lay your head down on a normal pillow, your head's gonna sink down into it and your shoulder's gonna have to carry some of the weight of your head and that's gonna lead to shoulder pain. If it's a flat pillow going all the way across, you also have a good chance of it closing a nostril. That's gonna make it more difficult to breathe through your nose and that will cause you to roll back to your back to be able to breathe better. If you're wearing a mask, a pet mask, then staying on your side with a pillow out ahead is gonna disrupt that mask and make it difficult to keep a seal. And so a lot of pet users will roll to their back to try to go to sleep with the pet, especially dangerous for the ones that take the mask off in the middle of the night because you're gonna have more deep sleep, more REM sleep later in the night. So you have more severe apnea, but they've learned to go to sleep on their back and stay on their back, which is gonna be harmful for them without a therapy in. So I don't recommend people to buy a pillow at the beginning, but for the head, I just ask them to take their pillow out of the pillowcase, the standard one, fold it in half and push it back into the pillowcase and just fold the extra part of the case in that doubles the size of their pillow. And that's usually enough to support their head well. When they're in this position, they should be able to roll that bottom shoulder a little and make sure that it's not supporting weight. So that's generally the position. There's a lot of variants to it. Everyone will adjust to different injuries that they've had, different things about their sleep, but those general principles are the same. We try to elevate the head just a little. So there's an incline going from the hips to the heart, to the head, keeping the head a little bit elevated, especially with people that have compromised nasal breathing because if you lay flat, I tell them to treat their head like it's a sprained ankle or a sprained wrist. You just wanna keep it elevated a little bit because if it's flat and the fluids pull there, they'll have more swelling. It's more likely to compromise their nasal breathing. So they'll get an advantage out of a slight elevation. So I'll share everything with all the listeners, all the details about it. I know it's gotta be hard to listen to the position without being able to see all the pictures and going through the slides, but everything in this position has a purpose. We talk about how people now have electric beds and they can sense snoring. And if they're snoring, it will elevate their head. And we talk about why that stops snoring. Yes, there's an upper airway impact from that, but likely the most significant impact of elevating the head in that position is the impact on the diaphragm. So they really relate to either the soldiers themselves or the soldier's spouses through pregnancy. So once someone's into the third trimester, they can no longer sleep on their back because of the weight of the baby compressing down bad for circulation, but it also traps the diaphragm and presses it into the lungs, takes away lung space. That's gonna cause poor ventilatory control, anxiety, and they're not gonna be able to breathe well. So shorter, faster breaths, that's gonna cause more arousals and make it more difficult to sleep. So if they can stay in this lateral position, it does the same thing. It allows the contents of their abdominal cavity, the weight that's there, to relax in a forward position, and it brings the diaphragm with it, which increases lung space. That is the phenomenon that increases lung space whenever you transition from supine to lateral. It's what's happening with the abdominal cavity and the effects of the rest of the body on lung space. So that's the advantage, and we talk about that, and when they get ready to go to sleep, they can take a big breath, a diaphragm breath, and make sure that they have room between the pillow there so it's not trapped, and they'll go. So that whole position, head to toe, is what we talk them through. I'll take just a... I wanna make sure that that's clear and see if anything needs to be cleared up with that, and then I'd like to speak a second on how we found that that impacted insomnia, if we get time. Well, I think that's amazing because I think we could all benefit from that in our practices, too, not just soldiers, but when we're struggling to get results, we're struggling to have snoring under control and increase lung space. I really feel like this is something we should be advocating all the time with our patients, just as standard of care. I can see such value in this. Thank you so much for sharing. Thanks. I really hope that we move to the point where at some point they're helping these patients of ours receive pillows to help them do this for it to be covered. If you think about the cost of other replacement arch, if it's broken, or pap supplies, sustainment supplies as they go, I mean, that's a lot of money that's involved with DME, and for pillows, people don't worry about spending $150 or $200 on a pillow, which when you look at it on scale, the money that we spend on improving sleep, breathing, and sleep, it's not very expensive. Right. Thank you so much, Dr. Neal, for all of the information you've shared with us today. Is there anything else you'd like to discuss as we get ready to close for our podcast here today? Yes. Thank you so much for having me. I really appreciate this. I know you love sleep as much as I do, and I would talk about it all day, every day, but I really appreciate you giving me the time. I want to thank the listeners for taking the time to listen to this, and thank them for all they're doing to help improve and extend the lives of their patients. We won't have time to get into it, but I think it's important to look for the impact, and maybe to dive in on another episode. We found that by doing positional therapy, giving them so much to think about, about having their foot in the right position, their knee in the right position, everything as they're making sure their position is correct, it works very similar to other mindfulness concepts that keeps their mind on the moment, and they fall asleep really quickly. I didn't know why that happened, but it was reported back to me by the patients, and I had to go talk to other behavioral health specialists about it, and that's the thing. As soon as they feel frustration, or they're worried about tomorrow, or yesterday, or worried that they're not asleep, that's when insomnia can really start to take hold, and I think it's one of the big reasons that people fail oral quietness therapy and PATH therapy, because they focus their anger on whatever is around. That's so interesting. The last thing I'll say is, I know this is daunting to try to start a new thing for your practice, but if you can just start with giving them a few QR codes, just letting them know there's some different options to think about, just find a way to start, and I think most of you will evolve as we all do to improve what we're doing for our patients. Awesome. Thank you so much for your time. This has really packed a lot in, in this podcast, and it's such valuable information. It's quite a game changer, so thank you so much. I appreciate it on behalf of the AADSM. We appreciate you. Thank you.

sleep health

military personnel

dental sleep medicine

obstructive sleep apnea

oral appliance delivery

DSM course

positional therapy

veteran support

cognitive functions

mindfulness strategies