LOW BACK PAIN

Low Back Pain

This article is also available in Spanish: Lumbalgia (Low Back Pain).

Almost everyone will experience low back pain at some point in their lives. This pain can vary from mild to severe. It can be short-lived or long-lasting. However it happens, low back pain can make many everyday activities difficult to do.

Anatomy

Your spine is made up of small bones, called vertebrae, which are stacked on top of one another. Muscles, ligaments, nerves, and intervertebral disks are additional parts of your spine.

Understanding your spine and how it works can help you better understand low back pain. 

Description

Back pain is different from one person to the next. The pain can have a slow onset or come on suddenly. The pain may be intermittent or constant. In most cases, back pain resolves on its own within a few weeks.

Cause

There are many causes of low back pain. It sometimes occurs after a specific movement such as lifting or bending. Just getting older also plays a role in many back conditions.

As we age, our spines age with us. Aging causes degenerative changes in the spine. These changes can start in our 30s — or even younger — and can make us prone to back pain, especially if we overdo our activities.

These aging changes, however, do not keep most people from leading productive, and generally, pain-free lives. We have all seen the 70-year-old marathon runner who, without a doubt, has degenerative changes in her back!

Over-activity

One of the more common causes of low back pain is muscle soreness from over-activity. Muscles and ligament fibers can be overstretched or injured.

This is often brought about by that first softball or golf game of the season, or too much yard work or snow shoveling in one day. We are all familiar with this "stiffness" and soreness in the low back — and other areas of the body — that usually goes away within a few days.

Disk Injury

Some people develop low back pain that does not go away within days. This may mean there is an injury to a disk.

Disk tear. Small tears to the outer part of the disk (annulus) sometimes occur with aging. Some people with disk tears have no pain at all. Others can have pain that lasts for weeks, months, or even longer. A small number of people may develop constant pain that lasts for years and is quite disabling. Why some people have pain and others do not is not well understood.

Disk herniation. Another common type of disk injury is a "slipped" or herniated disc.

Herniated disk.

A disk herniates when its jelly-like center (nucleus) pushes against its outer ring (annulus). If the disk is very worn or injured, the nucleus may squeeze all the way through. When the herniated disk bulges out toward the spinal canal, it puts pressure on the sensitive spinal nerves, causing pain.
Because a herniated disk in the low back often puts pressure on the nerve root leading to the leg and foot, pain often occurs in the buttock and down the leg. This is sciatica.
A herniated disk often occurs with lifting, pulling, bending, or twisting movements.

Disk Degeneration

With age, intevertebral disks begin to wear away and shrink. In some cases, they may collapse completely and cause the facet joints in the vertebrae to rub against one another. Pain and stiffness result.

Disk degeneration.

This "wear and tear" on the facet joints is referred to as osteoarthritis. It can lead to further back problems, including spinal stenosis.

Degenerative Spondylolisthesis

(Spon-dee-low-lis-THEE-sis). Changes from aging and general wear and tear make it hard for your joints and ligaments to keep your spine in the proper position. The vertebrae move more than they should, and one vertebra can slide forward on top of another. If too much slippage occurs, the bones may begin to press on the spinal nerves.

Spondylolisthesis.

Spinal Stenosis

Spinal stenosis occurs when the space around the spinal cord narrows and puts pressure on the cord and spinal nerves.

When intervertebral disks collapse and osteoarthritis develops, your body may respond by growing new bone in your facet joints to help support the vertebrae. Over time, this bone overgrowth (called spurs) can lead to a narrowing of the spinal canal. Osteoarthritis can also cause the ligaments that connect vertebrae to thicken, which can narrow the spinal canal.

Spinal stenosis.

Scoliosis

This is an abnormal curve of the spine that may develop in children, most often during their teenage years. It also may develop in older patients who have arthritis. This spinal deformity may cause back pain and possibly leg symptoms, if pressure on the nerves is involved.

Additional Causes

There are other causes of back pain, some of which can be serious. If you have vascular or arterial disease, a history of cancer, or pain that is always there despite your activity level or position, you should consult your primary care doctor.

Symptoms

Back pain varies. It may be sharp or stabbing. It can be dull, achy, or feel like a "charley horse" type cramp. The type of pain you have will depend on the underlying cause of your back pain.

Most people find that reclining or lying down will improve low back pain, no matter the underlying cause.

People with low back pain may experience some of the following:

• Back pain may be worse with bending and lifting.
• Sitting may worsen pain.
• Standing and walking may worsen pain
• Back pain comes and goes, and often follows an up and down course with good days and bad days.
• Pain may extend from the back into the buttock or outer hip area, but not down the leg.
• Sciatica is common with a herniated disk. This includes buttock and leg pain, and even numbness, tingling or weakness that goes down to the foot. It is possible to have sciatica without back pain.

Regardless of your age or symptoms, if your back pain does not get better within a few weeks, or is associated with fever, chills, or unexpected weight loss, you should call your doctor.

Tests and Diagnosis

Medical History and Physical Examination

After discussing your symptoms and medical history, your doctor will examine your back. This will include looking at your back and pushing on different areas to see if it hurts. Your doctor may have you bend forward, backward, and side to side to look for limitations or pain.

Your doctor may measure the nerve function in your legs. This includes checking your reflexes at your knees and ankles, as well as strength testing and sensation testing. This might tell your doctor if the nerves are seriously affected.

Imaging Tests

Other tests which may help your doctor confirm your diagnosis include:

X-rays. Although they only visualize bones, simple X-rays can help determine if you have the most obvious causes of back pain. It will show broken bones, aging changes, curves, or deformities. X-rays do not show disks, muscles, or nerves.

Magnetic resonance imaging (MRI). This study can create better images of soft tissues, such as muscles, nerves, and spinal disks. Conditions such as a herniated disk or an infection are more visible in an MRI scan.

Computerized axial tomography (CAT) scans. If your doctor suspects a bone problem, he or she may suggest a CAT scan. This study is like a three-dimensional X-ray and focuses on the bones.

Bone scan. A bone scan may be suggested if your doctor needs more information to evaluate your pain and to make sure that the pain is not from a rare problem like cancer or infection.

Bone density test. If osteoporosis is a concern, your doctor may order a bone density test. Osteoporosis weakens bone and makes it more likely to break. Osteoporosis by itself should not cause back pain, but spinal fractures due to osteoporosis can.

Treatment

In general, treatment for low back pain falls into one of three categories: medications, physical medicine, and surgery.

Nonsurgical Treatment

Medications. Several medications may be used to help relieve your pain.

• Aspirin or acetaminophen can relieve pain with few side effects.
• Non-steroidal anti-inflammatory medicines like ibuprofen and naproxen reduce pain and swelling.
• Narcotic pain medications, such as codeine or morphine, may help.
• Steroids, taken either orally or injected into your spine, deliver a high dose of anti-inflammatory medicine.

Physical medicine. Low back pain can be disabling. Medications and therapeutic treatments combined often relieve pain enough for you to do all the things you want to do.

• Physical therapy can include passive modalities such as heat, ice, massage, ultrasound, and electrical stimulation. Active therapy consists of stretching, weight lifting, and cardiovascular exercises. Exercising to restore motion and strength to your lower back can be very helpful in relieving pain.
• Braces are often used. The most common brace is a corset-type that can be wrapped around the back and stomach. Braces are not always helpful, but some people report feeling more comfortable and stable while wearing them.
• Chiropractic or manipulation therapy is provided in many different forms. Some patients have relief from low back pain with these treatments.
• Traction is often used, but without scientific evidence for effectiveness.
• Other exercise-based programs, such as Pilates or yoga are helpful for some patients.

Surgical Treatment

Surgery for low back pain should only be considered when nonsurgical treatment options have been tried and have failed. It is best to try nonsurgical options for 6 months to a year before considering surgery.

In addition, surgery should only be considered if you doctor can pinpoint the source of your pain.

Surgery is not a last resort treatment option "when all else fails." Some patients are not candidates for surgery, even though they have significant pain and other treatments have not worked. Some types of chronic low back pain simply cannot be treated with surgery.

Spinal Fusion. Spinal fusion is essentially a "welding" process. The basic idea is to fuse together the painful vertebrae so that they heal into a single, solid bone.
Spinal fusion eliminates motion between vertebral segments. It is an option when motion is the source of pain. For example, your doctor may recommend spinal fusion if you have spinal instability, a curvature (scoliosis), or severe degeneration of one or more of your disks. The theory is that if the painful spine segments do not move, they should not hurt.

Fusion of the vertebrae in the lower back has been performed for decades. A variety of surgical techniques have evolved. In most cases, a bone graft is used to fuse the vertebrae. Screws, rods, or a "cage" are used to keep your spine stable while the bone graft heals.

The surgery can be done through your abdomen, your side, your back, or a combination of these. There is even a procedure that is done through a small opening next to your tailbone. No one procedure has been proven better than another.
The results of spinal fusion for low back pain vary. It can be very effective at eliminating pain, not work at all, and everything in between. Full recovery can take more than a year.

Disk Replacement. This procedure involves removing the disk and replacing it with artificial parts, similar to replacements of the hip or knee.
The goal of disk replacement is to allow the spinal segment to keep some flexibility and maintain more normal motion.
The surgery is done through your abdomen, usually on the lower two disks of the spine.

Although no longer considered a new technology, the results of artificial disk replacement compared to fusion are controversial.

Prevention

It may not be possible to prevent low back pain. We cannot avoid the normal wear and tear on our spines that goes along with aging. But there are things we can do to lessen the impact of low back problems. Having a healthy lifestyle is a good start.

Exercise

Combine aerobic exercise, like walking or swimming, with specific exercises to keep the muscles in your back and abdomen strong and flexible.

Proper Lifting

Be sure to lift heavy items with your legs, not your back. Do not bend over to pick something up. Keep your back straight and bend at your knees.

Weight

Maintain a healthy weight. Being overweight puts added stress on your lower back.

Avoid Smoking

Both the smoke and the nicotine cause your spine to age faster than normal.

Proper Posture

Good posture is important for avoiding future problems. A therapist can teach you how to safely stand, sit, and lift.

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INSOMNIA

What are Different Types of Insomnia?

There are multiple ways to describe insomnia:

Acute insomnia

A brief episode of difficulty sleeping. Acute insomnia is usually caused by a life event, such as a stressful change in a person's job, receiving bad news, or travel. Often acute insomnia resolves without any treatment.

Chronic insomnia

A long-term pattern of difficulty sleeping. Insomnia is usually considered chronic if a person has trouble falling asleep or staying asleep at least three nights per week for three months or longer. Some people with chronic insomnia have a long-standing history of difficulty sleeping. Chronic insomnia has many causes.

Comorbid insomnia

Insomnia that occurs with another condition. Psychiatric symptoms — such as anxiety and depression — are known to be associated with changes in sleep. Certain medical conditions can either cause insomnia or make a person uncomfortable at night (as in the case of arthritis or back pain, which may make it hard to sleep.

Onset insomnia

Difficulty falling asleep at the beginning of the night.

Maintenance insomnia

The inability to stay asleep. People with maintenance insomnia wake up during the night and have difficulty returning to sleep.

What Causes Insomnia?

Insomnia can be caused by psychiatric and medical conditions, unhealthy sleep habits, specific substances, and/or certain biological factors. Recently, researchers have begun to think about insomnia as a problem of your brain being unable to stop being awake (your brain has a sleep cycle and a wake cycle—when one is turned on the other is turned off—insomnia can be a problem with either part of this cycle: too much wake drive or too little sleep drive). It's important to first understand what could be causing your sleep difficulties.

How Much Sleep Do You Need?

Medical Causes of Insomnia

There are many medical conditions (some mild and others more serious) that can lead to insomnia. In some cases, a medical condition itself causes insomnia, while in other cases, symptoms of the condition cause discomfort that can make it difficult for a person to sleep.

Examples of medical conditions that can cause insomnia are:

• Nasal/sinus allergies
• Gastrointestinal problems such as reflux
• Endocrine problems such as hyperthyroidism
• Arthritis
• Asthma
• Neurological conditions such as Parkinson's disease
• Chronic pain
• Low back pain

Medications such as those taken for the common cold and nasal allergies, high blood pressure, heart disease, thyroid disease, birth control, asthma, and depression can also cause insomnia.

In addition, insomnia may be a symptom of underlying sleep disorders. For example, restless legs syndrome—a neurological condition in which a person has an uncomfortable sensation of needing to move his or her legs—can lead to insomnia. Patients with restless legs syndrome typically experience worse symptoms in the later part of the day, during periods of inactivity, and in the transition from wake to sleep, which means that falling asleep and staying asleep can be difficult. An estimated 10 percent of the population has restless legs syndrome.

Sleep apnea is another sleep disorder linked to insomnia. With sleep apnea, a person's airway becomes partially or completely obstructed during sleep, leading to pauses in breathing and a drop in oxygen levels. This causes a person to wake up briefly but repeatedly throughout the night. People with sleep apnea sometimes report experiencing insomnia.

If you have trouble sleeping on a regular basis, it's a good idea to review your health and think about whether any underlying medical issues or sleep disorders could be contributing to your sleep problems. In some cases, there are simple steps that can be taken to improve sleep (such as avoiding bright lighting while winding down and trying to limit possible distractions, such as a TV, computer, or pets). While in other cases, it's important to talk to your doctor to figure out a course of action. You should not simply accept poor sleep as a way of life—talk to your doctor or a sleep specialist for help.

Insomnia & Depression

Insomnia can be caused by psychiatric conditions such as depression. Psychological struggles can make it hard to sleep, insomnia itself can bring on changes in mood, and shifts in hormones and physiology can lead to both psychiatric issues and insomnia at the same time.

Sleep problems may represent a symptom of depression, and the risk of severe insomnia is much higher in patients with major depressive disorders. Studies show that insomnia can also trigger or worsen depression.

It's important to know that symptoms of depression (such as low energy, loss of interest or motivation, feelings of sadness or hopelessness) and insomnia can be linked, and one can make the other worse. The good news is that both are treatable regardless of which came first.

Insomnia & Anxiety

Most adults have had some trouble sleeping because they feel worried or nervous, but for some it's a pattern that interferes with sleep on a regular basis. Anxiety symptoms that can lead to insomnia include:

• Tension
• Getting caught up in thoughts about past events
• Excessive worrying about future events
• Feeling overwhelmed by responsibilities
• A general feeling of being revved up or overstimulated

It's not hard to see why these symptoms of general anxiety can make it difficult to sleep. Anxiety may be associated with onset insomnia (trouble falling asleep), or maintenance insomnia (waking up during the night and not being able to return to sleep). In either case, the quiet and inactivity of night often brings on stressful thoughts or even fears that keep a person awake.

When this happens for many nights (or many months), you might start to feel anxiousness, dread, or panic at just the prospect of not sleeping. This is how anxiety and insomnia can feed each other and become a cycle that should be interrupted through treatment. There are cognitive and mind-body techniques that help people with anxiety settle into sleep, and overall healthy sleep practices that can improve sleep for many people with anxiety and insomnia.

Insomnia & Lifestyle

Insomnia can be triggered or perpetuated by your behaviors and sleep patterns. Unhealthy lifestyles and sleep habits can create insomnia on their own (without any underlying psychiatric or medical problem), or they can make insomnia caused by another problem worse.

Examples of how specific lifestyles and sleep habits can lead to insomnia are:

• You work at home in the evenings. This can make it hard to unwind, and it can also make you feel preoccupied when it comes time to sleep. The light from your computer could also make your brain more alert.
• You take naps (even if they are short) in the afternoon. Short naps can be helpful for some people, but for others they make it difficult to fall asleep at night.
• You sometimes sleep in later to make up for lost sleep. This can confuse your body's clock and make it difficult to fall asleep again the following night.
• You are a shift worker (meaning that you work irregular hours). Non-traditional hours can confuse your body's clock, especially if you are trying to sleep during the day, or if your schedule changes periodically.

Some cases of insomnia start out with an acute episode but turn into a longer-term problem. For example, let's say a person can't sleep for a night or two after receiving bad news. In this case, if the person starts to adopt unhealthy sleep habits such as getting up in the middle of the night to work, or drinking alcohol before bed to compensate, the insomnia can continue and potentially turn into a more serious problem. Instead of passing, it can become chronic.

Once this happens, worry and thoughts such as, "I'll never sleep," become associated with bedtime, and every time the person can't sleep, it reinforces the pattern.

This is why it's important to address insomnia instead of letting it become the norm. If lifestyle and unhealthy sleep habits are the cause of insomnia, there are cognitive behavioral techniques and sleep hygiene tips that can help. If you have tried to change your sleep behaviors and it hasn't worked, it's important to take this seriously and talk to your doctor.

Insomnia & Food

Certain substances and activities, including eating patterns, can contribute to insomnia. If you can't sleep, review the following lifestyle factors to see if one or more could be affecting you:

Alcohol is a sedative. It can make you fall asleep initially, but may disrupt your sleep later in the night.

Caffeine is a stimulant. Most people understand the alerting power of caffeine and use it in the morning to help them start the day and feel productive. Caffeine in moderation is fine for most people, but excessive caffeine can cause insomnia. A 2005 National Sleep Foundation poll found that people who drank four or more cups/cans of caffeinated drinks a day were more likely than those who drank zero to one cups/cans daily to experience at least one symptom of insomnia at least a few nights each week.

Caffeine can stay in your system for as long as eight hours, so the effects are long lasting. If you have insomnia, do not consume food or drinks with caffeine too close to bedtime.

Nicotine is also a stimulant and can cause insomnia. Smoking cigarettes or tobacco products close to bedtime can make it hard to fall asleep and to sleep well through the night. Smoking is damaging to your health. If you smoke, you should stop.

Heavy meals close to bedtime can disrupt your sleep. The best practice is to eat lightly before bedtime. When you eat too much in the evening, it can cause discomfort and make it hard for your body to settle and relax. Spicy foods can also cause heartburn and interfere with your sleep.

Insomnia & The Brain 

In some cases, insomnia may be caused by certain neurotransmitters in the brain that are known to be involved with sleep and wakefulness.

There are many possible chemical interactions in the brain that could interfere with sleep and may explain why some people are biologically prone to insomnia and seem to struggle with sleep for many years without any identifiable cause—even when they follow healthy sleep advice.

Symptoms

Insomnia is difficulty falling asleep or staying asleep and is often considered chronic if it happens at least three nights per week for three months or longer.

Most of us have experienced brief periods of insomnia (also called acute insomnia). Almost everyone knows what it feels like to still be awake staring at the ceiling and wishing for sleep—this can happen when you travel and experience jet lag, or when you're anxious and overwhelmed by life circumstances.

So how do you distinguish a normal, passing sleep problem from a more serious form of insomnia that requires treatment?

Symptoms of Insomnia

According to guidelines from a physician group, people with insomnia have one or more of the following symptoms:

• Difficulty falling asleep
• Difficulty staying asleep (waking up during the night and having trouble returning to sleep)
• Waking up too early in the morning
• Unrefreshing sleep (also called "non-restorative sleep")
• Fatigue or low energy
• Cognitive impairment, such as difficulty concentrating
• Mood disturbance, such as irritability
• Behavior problems, such as feeling impulsive or aggression
• Difficulty at work or school
• Difficulty in personal relationships, including family, friends and caregivers

The duration of insomnia is important. Doctors consider insomnia chronic if it occurs at least three nights per week for three months or longer. At this point, your insomnia may be a behavioral pattern (for example, your nighttime routines do not cue your body for sleep, or your sleep schedule is out of sync with your biological clock), or it could be comorbid, meaning it is linked to another medical or psychiatric issue that needs to be addressed. Recently, researchers have begun to think about insomnia as a problem of your brain being unable to stop being awake. Your brain has a sleep cycle and a wake cycle—when one is turned on the other is turned off. Insomnia can be a problem with either part of this cycle: too much wake drive or too little sleep drive. Regardless of its cause, if insomnia has become a regular occurrence, talking to your doctor about treatment may be a good idea.

You may also want to consider whether and to what degree insomnia is affecting your life. If you feel fatigued or have low energy during the day and it gets in the way of your productivity and enjoyment of friends, family, or hobbies, that probably means you could benefit from talking to your doctor. If you've tried on your own to make adjustments to your sleep routines and it hasn't worked, you may want to enlist the help of a sleep specialist.

Diagnosis

Doctors use a number of approaches to diagnose insomnia and understand a person's unique symptoms. Some of these measures can be done at home, while others require an office visit or an appointment at a sleep clinic.

Here you'll find information on when, where, and how to seek help if you have difficulty sleeping, as well as tips for talking to your doctor and a list of questions you may want to think about before your visit to be better prepared.

There are many ways to improve your sleep that involve psychological and behavioral steps. Cognitive behavioral treatments for insomnia (CBTi), relaxation techniques, and general sleep hygiene guidelines can help many people with sleep difficulties.

Diagnosing Insomnia

There is no definitive test for insomnia. Doctors use many different tools to diagnose and measure insomnia symptoms, some of which involve asking you questions in the office, having you fill out logs and questionnaires, performing certain blood tests, or doing an overnight sleep study. All of these tests help your doctor understand your personal experience with insomnia and create the right treatment plan.

Sleep log: A sleep log is a simple diary that keeps track of details about your sleep. In a sleep log, you’ll record details like your bedtime, wake up time, how sleepy you feel at various times during the day, and more. A sleep log can also help your doctor figure out what might be causing insomnia. Here is a sample sleep log.

A sleep inventory is an extensive questionnaire that gathers information about your personal health, medical history, and sleep patterns.

Blood tests: Your doctor may perform certain blood tests to rule out medical conditions such as thyroid problems, which can disrupt sleep in some people.

Sleep study: Your doctor may suggest that you do an overnight sleep study, or polysomnography, to gather information about your nighttime sleep. In this exam, you sleep overnight in a lab set up with a comfortable bed. During the exam you will be connected to an EEG, which monitors the stages of your sleep. A sleep study also measures things like oxygen levels, body movements, and heart and breathing patterns. A sleep study is a non-invasive test.

How to Talk to Your Doctor About Insomnia 

You can talk to your doctor at one of your regular visits, or make a special appointment to go in and discuss your sleep. Many people think sleep troubles are just a normal part of life, but it's important to take sleep as seriously as you would other aspects of your health. Sleep isn't routinely addressed in annual well visits, so often patients are the ones to bring up the topic. You can ask your doctor if there is anything in your medical history that could indicate the cause of your sleep difficulty.

You may want to think about the following questions beforehand to get the most out of your conversation. You may even want to jot down notes to take with you:

• Exactly what do your sleep difficulties look like: do you have trouble falling asleep, staying asleep, or do you wake up too early? How many times a week do you have trouble sleeping like this?
• What is your sleep schedule: what time do you go to bed, wake up, and nap during the day? (even short naps count)
• Is your weekend sleep schedule different from your weekday schedule? Does your work schedule require you to adjust your sleep at all?
• What do you do when you can't sleep—get out of bed, read, watch TV, work on your laptop? Is there anything you've done in the past that has helped you sleep?
• Do you lie awake feeling anxious or worrying about responsibilities and tasks?
• What is your sleep environment like: Do you sleep alone or with a partner? Is your room dark and quiet? Is your bed comfortable? Do you have any sleep disruptions during the night, for example, young children in the house?
• How long have you had trouble sleeping? Have you had trouble sleeping on and off for as long as you can remember, or is this a new issue?
• Have you had any major changes (a move, a new job), or any stressful circumstances in your life recently (a breakup, financial troubles)?
• Do you have any medical conditions?

Treatment

You should seek help if your insomnia has become a pattern, or if you often feel fatigued or unrefreshed during the day and it interferes with your daily life. Many people have brief periods of difficulty sleeping (for example, a few days after starting a new job), but if insomnia lasts longer or has become a regular occurrence, you should ask for help.

Start by calling your primary care physician or bringing up the topic of sleep at your next well visit if you have one scheduled. If your doctor is knowledgeable about sleep disorders, he or she will guide you through the next steps, which may involve an assessment and further testing, or a referral to a sleep specialist. Your doctor may also start by giving you some basic information and resources about healthy sleep habits—these behavioral tips may help certain people with insomnia—or discussing potential medical treatment options to consider. Your doctor could refer you to a psychotherapist if your sleep struggles seem connected to anxiety, depression, or a major life adjustment.

If you don't feel satisfied after your conversation with your primary care physician, ask for a referral to a doctor who specializes in sleep medicine or consult other available resources. It's important to find a doctor who has the proper knowledge and training to treat your insomnia.

Many cities also have sleep centers and clinics (sometimes connected to a hospital) that offer assessments, testing, and treatment. An Internet search will help you locate the nearest center.

Non-Medical (Cognitive & Behavioral) Treatments for Insomnia

There are psychological and behavioral techniques that can be helpful for treating insomnia. Relaxation training, stimulus control, sleep restriction, and cognitive behavioral therapy are some examples.

Some of these techniques can be self-taught, while for others it's better to enlist the help of a therapist or sleep specialist. 

Relaxation training, or progressive muscle relaxation, teaches the person to systematically tense and relax muscles in different areas of the body. This helps to calm the body and induce sleep. Other relaxation techniques that help many people sleep involve breathing exercises, mindfulness, meditation techniques, and guided imagery. Many people listen to audio recordings to guide them in learning these techniques. They can work to help you fall asleep and also return to sleep in the middle of the night.

Stimulus control helps to build an association between the bedroom and sleep by limiting the type of activities allowed in the bedroom. An example of stimulus control is going to bed only when you are sleepy, and getting out of bed if you've been awake for 20 minutes or more. This helps to break an unhealthy association between the bedroom and wakefulness. Sleep restriction involves a strict schedule of bedtimes and wake times and limits time in bed to only when a person is sleeping.

Cognitive behavioral therapy (CBT) includes behavioral changes (such as keeping a regular bedtime and wake up time, getting out of bed after being awake for 20 minutes or so, and eliminating afternoon naps) but it adds a cognitive or "thinking" component. CBT works to challenge unhealthy beliefs and fears around sleep and teach rational, positive thinking. There is a good amount of research supporting the use of CBT for insomnia. For example, in one study, patients with insomnia attended one CBT session via the internet per week for 6 weeks. After the treatment, these people had improved sleep quality.

Medical Treatments for Insomnia

There are many different types of sleep aids for insomnia, including over-the-counter (non-prescription) and prescription medications.

Determining which medication may be right for you depends on your insomnia symptoms and many different health factors. This is why it's important to consult with a doctor before taking a sleep aid.

Major classes of prescription insomnia medications include benzodiazepine hypnotics, non-benzodiazepine hypnotics, and melatonin receptor agonists.

Alternative Medicine

There are alternative medicines that may help certain people sleep. It's important to know that these products are not required to pass through the same safety tests as medications, so their side effects and effectiveness are not as well understood.

Insomnia & You

Insomnia can have a significant impact. Some of the effects of insomnia are obvious, while others can be subtle and increase over time. Either way, it's important to address insomnia.

If you have insomnia, you may feel as though you're alone. Many people don't talk about sleep troubles—either because the problem is so long-standing it has become an accepted part of life, or because they believe they should cope with it on their own. Chances are, though, if you talk to people you know, you'll find someone else with similar sleep troubles.

As anyone who has insomnia will tell you, the very act of lying awake while the rest of the house sleeps can also feel very lonely and frustrating. Tucking into bed with your partner and then tossing and turning, staring at the ceiling or your clock, or getting back up on your own to mull around the living room can be a solitary experience. Whether you live by yourself or in a full household, insomnia can make you feel like you're the only one still awake while the rest of the world sleeps.

If you can't sleep, over time, the lack of control and unpredictability you experience can become a source of tension and worry. Not only do people with insomnia feel the effects of insufficient sleep on their mental and physical health, they also tend to feel anxiety or even dread as the evening progresses and the prospect of lying awake again looms. If this cycle sounds familiar, don't resign yourself to night after night of sub-par sleep and do not blame yourself. Know that insomnia is a sleep problem experienced by many adults and could be caused by something happening in your body that is beyond your control. There are many different treatment options for insomnia available, so talk to your doctor about what might be best for you.

Insomnia Side Effects

Insomnia is difficult in its own right, but it may also cause other issues, both psychological and physical. Many people with insomnia feel more refreshed when they get proper treatment and finally begin to sleep well again.

Chronic insomnia (difficulty sleeping for three months or longer) may also lead to changes in mood, lack of motivation and energy, irritability, and more. When you're drowsy, it may make you feel tense and preoccupied, and the worry over your inability to sleep can add to this.

For those who take care of small children or have a lot of family and work responsibilities to balance, insomnia can make these tasks feel even more overwhelming when you are tired.

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HIPERCHOLESTEROLEMIA

Hypercholesterolemia, or high cholesterol, occurs when there is too much cholesterol in the body. Cholesterol is a soft, waxy, fat-like substance that is a natural component of all the cells in the body. Your body makes all the cholesterol it needs. Added cholesterol, which comes from the foods you eat, may cause harm.

High cholesterol raises your risk for heart disease, heart attack, and stroke. When there is too much cholesterol circulating in the blood, it can create sticky deposits (called plaque) along the artery walls. Plaque can eventually narrow or block the flow of blood to the brain, heart, and other organs. Blood cells that get caught on the plaque form clots, which can break loose and completely block blood flow through an artery, causing heart attack or stroke.

The normal range for total blood cholesterol is between 140 to 200 mg per decilitre (mg/dL) of blood (usually just expressed as a number). However, the total number doesn't tell the whole story: There are two types of cholesterol, HDL (high density lipoproteins, or "good" cholesterol) and LDL (low density lipoproteins, or "bad" cholesterol). The amount of HDL relative to LDL is considered a more important indicator of heart disease risk. There is a third kind of fatty material called triglycerides found in the blood. They also play a role (generally as triglyceride levels rise, "good" HDL cholesterol falls). In fact, there is a subset of physicians who believe that trigylcerides are the only fats in the body that increase heart disease risk. When you have high cholesterol, it usually means you have high levels of LDL cholesterol, normal or low levels of HDL cholesterol, and normal or high levels of triglycerides.

While heredity may be a factor for some people, the main culprits are lack of exercise and diets high in saturated fat. High cholesterol can be prevented, sometimes with lifestyle changes (diet and exercise) alone. If these do not work, your doctor may recommend medications to lower your cholesterol levels.

Signs and Symptoms

In the early stages, there usually aren't any symptoms of high cholesterol. The only way to tell if your cholesterol is high is through a blood test.

Causes

In some cases, high cholesterol levels may be inherited, your liver may make too much cholesterol, or your body may not remove LDL from your blood efficiently. High cholesterol and elevated triglycerides can also be associated with other diseases, such as diabetes. But most often high cholesterol is caused by eating foods high in saturated fat and not getting enough exercise. High cholesterol is more common in people who are overweight or obese, a condition that affects almost half of U.S. adults.

Risk Factors

Some factors increase a person's risk of having high cholesterol. While some of these cannot be changed, many can be. The most important risk factors for high cholesterol are:

• Being overweight or obese
• Eating a diet high in saturated fat and trans fatty acids (found in processed and fried foods)
• Not getting enough exercise
• Family history of heart disease
• High blood pressure
• Smoking
• Diabetes

Diagnosis

Most people do not have any symptoms of high cholesterol. A blood test is the only way to check levels of cholesterol in your blood. If your levels are above 200 mg/dL, or your HDL is below 40, your doctor may do a fasting lipid profile, a test performed after you abstain from food for 12 hours.

Although cholesterol levels above 200 are generally considered high, what is considered safe for each person depends on whether you are at risk for, or have, heart disease.

Total cholesterol levels:

• Desirable: Below 200 mg/dL
• Borderline high: 200 to 239
• High: Above 240

LDL cholesterol levels:

• Optimal for people with heart disease or who are at high risk: Below 70 mg/dL
• Optimal for people at risk of heart disease: Below 100
• Optimal: 100 to 129
• Borderline high: 130 to 159
• High: 160 to 189

HDL cholesterol levels:

• Poor: Below 40 mg/dL
• Acceptable: 40 to 59
• Optimal: 60 or above

Triglyceride levels:

• Optimal: Below 150 mg/dL
• Borderline high: 150 to 199
• High: Above 200

Adults with normal total and HDL cholesterol levels should have their cholesterol checked every 5 years. If you have high cholesterol, you should be checked every 2 to 6 months. You should have liver function tests as well if you are on cholesterol-lowering medication.

Preventive Care

Most people can lower cholesterol levels by eating a well balanced diet, getting regular exercise, and losing excess weight.

Diet

A healthy diet can help you lose weight. Losing just 5 or 10 pounds may help lower your cholesterol. To eat a healthy diet:

• Cut down on saturated fats and trans fats. No more than 10% of your daily calories should come from saturated fat, and you should avoid trans fats completely. Based on data from 4 studies, it is estimated that a 2% increase in energy intake from trans fats increases the incidence of heart disease by 23%. Choose unsaturated fats, such as olive oil and canola oil, instead.
• Eat whole grains, whole wheat bread and pasta, oatmeal, oat bran, and brown rice.
• Eat more fruits and vegetables, which are high in fiber and can help lower cholesterol levels. Studies show that plant-based diets are associated with decreases in total cholesterol and LDL cholesterol of up to 15%.
• Limit cholesterol in your diet. The highest amounts are found in egg yolks, whole milk products, and organ meats.
• Eat fatty fish. The American Heart Association (AHA) recommends that people eat at least 2 servings of fatty fish (such as salmon or herring) each week.
• Eat phytosterols and stanols found in nuts, seeds, vegetable oils, and fortified food products, such as orange juice, yogurt, and salad dressing. Studies show that eating 2 to 3 grams of phytosterols daily reduces total cholesterol by up to 11% and LDL cholesterol by up to 15%.
• Increase your intake of high fiber foods, especially oats, barley, and legumes, as well as fruits, vegetables, and other whole grains.

The AHA has developed dietary guidelines that help lower fat and cholesterol intake and reduce the risk of heart disease. The AHA does not recommend very low-fat diets, because new research shows that people benefit from unsaturated ("good") fats, such as those found in olive oil, avocados, and nuts.

Many fad diets are popular, but they may not help you lose weight and keep it off. In some cases, they may not even be healthy. A healthy diet includes a variety of foods. If a diet bans an entire food group (such as carbohydrates), it is probably not healthy.

Experts recommend eating a balanced diet that emphasizes fruit and vegetables:

• Grains: 6 to 8 servings per day (half should be whole grains)
• Vegetables: 3 to 5 servings per day
• Fruits: 4 to 5 servings per day
• Fat-free or low-fat dairy: 2 to 3 servings per day
• Lean meat, poultry, seafood: 3 to 6 oz. per day (about the size of a deck of cards)
• Fats and oils: 2 to 3 tbsp. per day (use unsaturated fats such as olive oil or canola oil)
• Nuts, seeds, legumes: 3 to 5 servings per week
• Sweets, sugars: 5 or fewer servings per week (the fewer, the better)

In addition, the AHA also recommends eating 2 servings of fatty fish (such as salmon, herring, or lake trout) per week; restricting sodium (salt, including salt already added to food) to less than 2,400 mg per day; and limiting alcohol intake to 1 drink a day for women and 2 for men. However, moderate alcohol consumption may help lower triglyceride levels and increase HDL levels.

The TLC (therapeutic lifestyle changes) diet is recommended for people who have high cholesterol. With the TLC diet, less than 7% of your daily total calories should come from saturated fat, and only 25% to 35% of your daily calories should come from fat, overall. Sodium should be limited to 2,400 mg per day. If these steps do not lower your cholesterol, your doctor may suggest adding more soluble fiber to your diet, along with plant sterols (found in cholesterol-lowering margarines and salad dressings).

The Mediterranean style diet concentrates on whole grains, fresh fruits and vegetables, fish, olive oil, and moderate, daily wine consumption. This diet is not low fat. It is low in saturated fat but high in monounsaturated fat. This diet is naturally rich in fiber, antioxidants, and omega-3 fatty acids. It appears to be heart healthy: In a long-term study of 423 people who had a heart attack, those who followed a Mediterranean style diet had a 50 to 70% lower risk of recurrent heart disease compared with people who received no special dietary counseling.

Losing Weight

Being overweight increases the risk of high cholesterol and heart disease. Even a 5 to 10 pound weight loss can lower LDL twice as much as diet alone. Weight loss often results in lower triglyceride levels and increased HDL, too. To maintain a healthy diet, you should aim for a gradual, weekly weight loss of 1/2 to 1 pound.

Getting Exercise

Regular exercise reduces the risk of death from heart disease and helps lower LDL cholesterol levels, especially when combined with a healthy diet. Just 30 minutes of moderate exercise 5 times per week can help you lose weight or maintain a proper weight, reduce LDL and triglyceride levels, and increase levels of HDL. Studies show that every 10 minutes of added exercise per session is associated with a 1.4 mg/dL increase in HDL cholesterol. Exercise may also lower blood pressure. Talk with your doctor before starting a new exercise program.

Treatment Approach

Lowering your cholesterol level reduces your risk of heart disease and stroke. Studies show that for every 1% reduction in cholesterol levels there is a 2% reduction in the rate of heart disease. People who already have heart disease or are at higher risk benefit most from lowering their cholesterol.

Changes in lifestyle, improved diet and more exercise, are the most effective means of both preventing and, in less severe cases, treating high LDL cholesterol levels. In addition to recommending lifestyle changes, doctors often prescribe specific cholesterol-lowering medications.

Medications

If your LDL cholesterol remains high, after changing your diet and exercise habits, your doctor may prescribe medications to lower it. If your cholesterol is very high (more than 200 mg/dL), you may start drug therapy at the same time you improve your diet and exercise habits. Drugs commonly used to treat high cholesterol include:

Statins: These are usually the drugs of choice as they are easy to take and have few interactions with other drugs. Side effects can include myositis (inflammation of the muscles), joint pain, stomach upset, and liver damage. People who are pregnant or have liver disease should not take statins. Statins include:

• Lovastatin (Mevachor)
• Pravastatin (Pravachol)
• Rosuvastatin (Crestor)
• Simvastatin (Zocor)
• Atorvastatin (Lipitor)
• Fluvastatin (Lescor)

Niacin (nicotinic acid): In prescription form, niacin is sometimes used to lower LDL cholesterol. It can be more effective in raising HDL cholesterol than other medications. Side effects may include redness or flushing of the skin (which can be reduced by taking aspirin 30 minutes before the niacin), stomach upset (which usually subsides in a few weeks), headache, dizziness, blurred vision, and liver damage. Dietary supplements of niacin should not be used instead of prescription niacin, as it can cause side effects. Only take niacin for high cholesterol under a doctor's supervision.

Bile acid sequestrants: These are used to treat high levels of LDL. Common side effects include bloating, constipation, heartburn, and elevated triglycerides. People who have high levels of triglycerides (fats in the blood) should not take bile acid sequestrants. These drugs include:

• Cholestyramine (Prevalite, Questran)
• Colestipol (Colestid)
• Colesevelam (WelChol)

Cholesterol absorption inhibitors: The medication ezetimibe (Zetia) limits how much LDL cholesterol can be absorbed in the small intestine. Side effects include headaches, nausea, muscle weakness. Ezetimibe is combined with simvastatin in the drug Vytorin.

Fibric acid derivatives: These medicines are effective at lowering triglyceride levels, and moderately effective at lowering LDL. They are used to treat high triglycerides and low HDL in people who cannot take niacin. Side effects include myositis, stomach upset, sun sensitivity, gallstones, irregular heartbeat, and liver damage.

• Gemfibrozil (Lopid)
• Fenofibrate (Tricor, Lofibra)

If you do not respond to one class of drugs, you doctor may use a combination of drugs from 2 classes.

Nutrition and Dietary Supplements

In addition to eating a healthy diet, low in saturated fat, with plenty of whole grains, fruits, and vegetables, some specific foods and supplements may help lower cholesterol.

Fiber: Several studies show that soluble fiber (found in beans, oat bran, barley, apples, psyllium, flaxseed, and glucomannan) lowers LDL cholesterol and triglycerides. Fiber can also help you lose weight because it makes you feel full. Your doctor will encourage you to get more fiber in your diet. You may also take a fiber supplement. Men should get 30 to 38 g of fiber per day. Women should get 21 to 25 g per day.

Beta-glucan is a type of soluble fiber found in oat bran and other plants. It slightly reduces LDL cholesterol, which is why oat bran is touted as a cholesterol-lowering food.

Soy: Many studies have shown that eating soy protein (tofu, tempeh, and miso), rather than animal meat, helps lower blood cholesterol levels, especially when you eat a diet low in saturated fat. One study found that as little as 20 g of soy protein per day is effective in reducing total cholesterol, and that 40 to 50 g shows faster effects (in 3 weeks instead of 6). Another study found that soy can help reduce triglyceride levels. The AHA recommends that people with elevated total and LDL cholesterol add soy to their daily diet, and that soy is safe when consumed as part of your regular diet. But talk to your doctor before you take soy supplements. Soy isoflavones may have estrogen-like effects in the body, which might lead to an increased risk of breast and other cancers.

Omega-3 fatty acids, found in fish oil: There is good evidence that omega-3 fatty acids (namely EPA and DHA) found in fish oil can help prevent heart disease, lower blood pressure, and reduce the level of triglycerides in the blood. However, fish oil can also raise levels of both HDL and LDL slightly. When taken as a supplement, it can also act as a blood thinner, so people who already take blood-thinning medication should only take a fish oil supplement under their doctor's supervision. One preliminary study found that people with high cholesterol who took fish oil and red yeast rice lowered cholesterol levels about as much as people who took simvastatin (Zocor). The AHA recommends that people eat at least 2 servings of fatty fish (such as salmon) per week, and that fish is safe when consumed as part of your regular diet. If you have high cholesterol, talk to your doctor before taking a fish oil supplement.

Alpha-linolenic acid (ALA): ALA is another omega-3 fatty acid that may protect the heart. However, studies have shown conflicting results about its ability to lower LDL, and it does not appear to lower triglyceride levels.

Vitamin C (100 to 200 mg per day): Several studies suggest that eating a diet high in vitamin C can help lower cholesterol levels, but there is no evidence that taking extra vitamin C through a supplement will help.

Beta-sitosterol (800 mg to 1 g per day in divided doses about 30 minutes before meals 3 times daily): Beta-sitosterol is a plant sterol, a compound that can stop cholesterol from being absorbed by the intestines. Several well-designed scientific studies have shown that beta-sitosterol does lower "bad" LDL cholesterol levels in the body. Beta-sitosterol may lower the amount of vitamin E and beta-carotene absorbed by the body, so you may want to ask your doctor if you need to take extra vitamin E or carotene.

Policosanol (5 to 10 mg 2 times per day): Policosanol is a mix of waxy alcohols usually derived from sugar cane and yams. Several studies have indicated it may lower "bad" LDL cholesterol and maybe even raise "good" HDL cholesterol. One study found that policosanol was equivalent to fluvastatin (Lescol) and simvastatin (Zocor) in lowering cholesterol levels. It may also inhibit blood clots from forming. However, almost all of the studies have been conducted in Cuba or Latin America using a proprietary form of policosanol, so it is hard to evaluate the evidence. Policosanol may increase the risk of bleeding, and should not be taken by people who also take blood-thinning medication.

Coenzyme Q10 (CoQ10): Researchers believe that CoQ10 may boost levels of antioxidants. One study found that people who received daily CoQ10 supplements within 3 days of a heart attack were much less likely to experience subsequent heart attacks and chest pain. They were also less likely to die of the condition than those who did not receive the supplements. Still, more research is needed to say whether CoQ10 has any role in preventing or treating atherosclerosis. People who take statins may have low levels of CoQ10. If you take statins, you may want to ask your doctor about taking a CoQ10 supplement. CoQ10 can interfere with anticoagulant / antiplatelet drugs.

Polyphenols: Polyphenols are chemical substances found in plants that have antioxidant properties. Test tube, animal, and some population-based studies suggest that the flavonoids quercetin, resveratrol, and catechins (all found in high concentration in red wine, and in grape juice) may help reduce the risk of atherosclerosis by protecting against the damage caused by LDL cholesterol. However, more studies in humans are needed to confirm these findings.

Resveratrol: A study in mice found that resveratrol protected against age-related damage to vital organs, including the heart and liver, even when the mice ate a high-fat diet. Although this study is promising, more studies are needed to determine whether resveratrol would have the same effect in humans. No one is sure how much resveratrol is needed to see a benefit. In addition, resveratrol may have estrogen-like effects, and researchers don't yet know whether it would pose the same risks as estrogen supplements. Resveratrol can potentially interact with a number of medications, including medications that are used to slow blood clotting, such as warfarin (Coumadin) and aspirin. If you take any prescription medications, check with your doctor before adding resveratrol to your regimen.

Herbs

The use of herbs is a time honored approach to strengthening the body and treating disease. However, herbs can trigger side effects and can interact with other herbs, supplements, or medications. For these reasons, you should take herbs with care and under the supervision of a health care provider.

Hawthorn (Crataegus monogyna, 900 to 1,800 mg per day in 2 to 3 divided doses): Hawthorn contains the polyphenols rutin and quercetin, and was traditionally used to treat cardiovascular diseases. Animal and laboratory studies show that hawthorn has antioxidant properties that may help lower high cholesterol and high blood pressure. Talk to your doctor before taking hawthorn, as it can interact with other drugs taken for heart disease and high blood pressure.

Garlic (Allium sativum, 900 mg per day of garlic powder, standardized to 0.6% allicin): Previous clinical trials have shown that fresh garlic and garlic supplements may lower cholesterol levels, prevent blood clots, and destroy plaque. However, more recent studies show no effect on cholesterol. Garlic can increase the risk of bleeding and should not be taken if you are also taking blood-thinning medication. Garlic may interact with Isoniazidand medications used to treat HIV/AIDS. Speak with your doctor.

Olive leaf extract (Olea europaea, 1000 mg per day): One study found that people with mild high blood pressure (hypertension) lowered cholesterol and blood pressure by taking olive leaf extract, compared to those who took placebo. More research is needed to confirm these findings.

Red yeast or red yeast rice (Monascus purpureus, 1,200 mg 2 times per day with meals): Several studies indicate that a proprietary form of red yeast (Cholestin) can lower cholesterol levels, and that the herb acts like prescription statin drugs (See "Medications" section). For that reason, you should not take red yeast without a doctor's supervision, especially if you already take statins to lower cholesterol.

Psyllium (Plantago psyllium, 10 to 30 g per day in divided doses taken 30 to 60 minutes after meals): Taking psyllium, a type of fiber, helps lower cholesterol levels, as well as blood sugar levels. If you take medicine for diabetes, talk to your doctor before taking psyllium.

Guggul (Commiphora mukul, 75 to 100 mg per day divided into 3 doses): Guggul is used in Ayurvedic medicine to treat high cholesterol levels. Scientific studies have found mixed results, guggul appears to work in Indian populations, but not in people who eat high-fat Western diets. Guggul may have estrogen-like properties. Take caution if you have a history of estrogen-sensitive cancers or if you're taking medications. Guggul can also affect thyroid function and therefore interact with thyroid medications. Speak with your doctor.

Other Considerations

Pregnancy

Cholesterol-lowering medications should be avoided during pregnancy.

Prognosis and Complications

Several complications may occur if high cholesterol is left untreated. These include:

• Heart disease. High cholesterol levels more than double the risk of heart attack. Lowering cholesterol by 1% reduces the risk of coronary artery disease by 2%.
• Stroke. Low levels of HDL ("good") cholesterol have been associated with an increased risk of stroke.
• Insulin resistance. 88% of people with low HDL and 84% with high triglycerides also have insulin resistance (which leads to high blood sugar levels). Many people with insulin resistance go on to develop diabetes.

Maintaining a proper weight, eating a diet low in saturated fat, and exercising can lower cholesterol levels and improve long-term prognosis.

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