Exercise Injury

The "Hot" Injury

Most athletes know that the suffix itis is bad news: not fatal, but annoying and probably painful. Itis actually means "inflammation," which describes both the sensation and the physiology of the body's reaction to connective tissue damage.

Inflammation is swelling and pressure around an injury caused by blood cells rushing to the site. The process can help heal, but if the injury is ignored, it can build up scar tissue that will lead to chronic, lifelong pain. Repetitive motions, like pitching a baseball or rowing a boat, are most likely to be the source of an itis. Causes can range from improper motion to weak or imbalanced muscles.

A common inflammatory injury is tendinitis, an injury to the tendons, tough connective tissue between muscle and bone. Bursitis occurs around the hips, knees, feet, elbows, and shoulders due to the friction of a tendon repeatedly moving over the bursas, the small, fluid-filled sacs located there.

Because overuse is the single biggest cause of inflammation, and because inflammation occurs so gradually, it's easy to remedy if the underlying injury is diagnosed at an early stage. Medication, physical therapy, a change in mechanics, and rest are among the common treatments.

If the inflammation is in an early stage, reduce swelling and pain with ice packs three times a day for the first three days. If that seems to help, gradually begin exercis­ing the affected area again, keeping the ice handy for reapplication if pain returns.

Some inflammation (grades three and four on the 1-4 inflammation scale) takes longer to resolve. Don't despair. Your doctor can suggest exercises that will help prevent atrophy of the rest of your body, including cycling, swimming, and isometric workouts. As the injury begins to heal, start thinking about slowly increasing your use of the affected area, using appropriate support (tape, elastic bandages, cushioned surfaces).

How soon is too soon to return to action? Your body will tell you. If you have a 100 percent range of motion around the affected joint, and 80 to 90 percent of your former strength, you may be ready.

Bikes That Go Nowhere

Bikes That Go Nowhere

Home-exercise bikes are uniting fitness with the cocooning craze. As more people seek entertainment and leisure activities in the comfort of their homes, these bikes allow them to stay trim and healthy while avoiding overcrowded gyms and the familiar hazards of sharing the roads with motorists.

Depending on the features you need or desire, a bike will typically cost between $150 and $700. Although all exercise bikes help you tone the buttocks, upper legs, and to a lesser extent, the calves, certain bikes do even more:

Dual-action models allow you to pump the handle bars back and forth, toning the arms and shoulders.

Recumbent bikes, which have you sit and pedal with your legs stretched out in front of you, target the lower abdominals, and provide a workout less stressful on the knees and back.

Electronic bikes allow you to program resistance levels and various interval workouts.

Training stands let you transform your traditional bike into an indoor exerciser.

The Tufts Health Plan Health Journal notes some features of a safe, comfortable bike:

o Stability when you're seated on it.

o Covers over flywheels, chains, and other moving parts.

o Handlebars that adjust to a position comfortable throughout your workout.

o Smooth and consistent motion.

o A seat that's well-padded and easy to adjust.

Building Bone

Building Bone for Better Life

Much of what young women do for their bodies now will determine their health and mobility in old age. Research suggests that women can build bone mass throughout their early adult years, beyond the time their linear growth stops, which is important in preventing osteoporosis and its related problems later on.

A Creighton University School of Medicine in Omaha, Nebraska, study finds that through lifestyle changes such as regular exercise and increased calcium intake, women up to age 30 can increase their bone mass and thus reduce the risk of bone injury in their later years. The study found the risk of bone fracture by age 70 was far less for women who eat calcium-rich diets, at 39 percent, than the 77 percent risk for women who consumed too little calcium.

Dr. Robert Recker, who led the study, advises that women consume 1,400 to 1,500 milligrams, or approximately three servings, of calcium per day. Calcium-rich foods, such as eight ounces of milk, a cup of yogurt, or one ounce of cheese can fulfill the daily requirement. For women concerned about weight gain and cholesterol intake, low-fat, low-cholesterol varieties will do the job just as well as their high-fat counterparts.

Although calcium supplements are available, Dr. Recker does not favor them. Rather, he recommends eating a well-balanced diet that provides other essential nutrients in addition to calcium.

Bad Fat

Fat That Hurts You

How much fat you lose while dieting is not necessarily as important as what kind, according to researchers at the University of Washington. And dieting may not be the best way to lose it, either.

Authors of the study recommend worrying more about "central" fat, the kind that causes a large, round trunk, because that kind of fat has been linked to heart disease, hypertension, and diabetes. A fat rump and thighs may not look nice, but apparently they don't pose as much danger to your health.

To lose that central fat, the researchers recommend exercise over dieting, pointing to a study of older men that showed those who exercised had to lose only a quarter of the weight lost by those who dieted, in order to shed the same amount of central fat.

And if it's easier to lose, it's easier to keep off, especially since exercise increases the metabolic rate, letting the body burn calories faster. Dieting causes the body to burn calories more slowly, which is why dieters often regain weight so quickly.

The doctors caution that an exercise program needn't be particularly strenuous. Walking a few extra blocks to work every day or taking the steps instead of the elevator is probably a sufficient increase for people who don't exercise at all. The benefits of going from none to a little exercise, they say, far outweigh those of going from a little to a lot.

As always, it is recommended that you consult your physician before beginning any exercise regimen.

Health Con Artists and Scammers

Health Con Artists

They may no longer travel the countryside in wagons laden with bottles of miracle tonics, but health swindlers still prey on consumers. Pills, creams, and devices that supposedly allow you to lose weight easily, grow hair, or tone your body are especially prevalent. Convincing testimonials, incredible before-and-after pictures, and great "bargain" pricing lure health-conscious, youth-conscious, I-want-immediate-and-improbable-results spenders.

Deceptive claims abound for serious medical conditions as well. Unproven arthritis remedies like copper bracelets, special diets, and questionable drugs bilk sufferers out of millions of dollars annually. There are even medications and clinics that fraudulently offer "miracle cures" for cancer.

To detect a fraudulent product, you need to know the language of its maker. Many swindlers promote their products as being painless or working faster than conventional medicine, and they offer money-back guarantees (although they usually skip town by the time you find out you've been tricked). Most embellish their advertising with impressive-sounding, but bogus, ingredients, or claim that their products have exotic or ancient origins.

Before investing in such a product, check it out with a doctor, pharmacist, or other health expert. The Better Business Bureau, your state Attorney General's office, or the nearest Food and Drug Administration are other good sources to which you can refer.

Good New from the AHA

Heartening News from the AHA

Here's news straight from the heart: The American Heart Association (AHA), which for years singled out only smoking, high blood pressure, and high blood cholesterol as major risk factors for coronary disease, has added a fourth factor—physical inactivity—to those that can be controlled with changes in lifestyle.

For the 70 million Americans afflicted with coronary disease, and the 1.5 million who suffer a heart attack each year, this is definitely good news. Not only can exercise help prevent heart attacks, it can improve the chances of survival for people who have already suffered an attack. It also decreases the occurrence of second attacks. On the other hand, people who avoid all physical activity run a 30 percent higher than normal risk of heart disease, says the AHA.

In addition to increasing the strength of the heart, exercise aids in weight control, increases the benefits of a low-fat diet, and improves the "good" to "bad" cholesterol ratio. It has also been shown to deter diabetes (a disease linked to heart disease), and it sometimes lowers high blood pressure.

By exercise, the AHA is not talking about training for a marathon. Simply doing things that require a little extra exertion—taking the stairs rather than the elevator, pumping your own gas, enjoying a nice walk—can improve your cardiovascular health. To achieve optimal benefits, the AHA recommends 30 to 60 minutes of either vigorous or casual exercise, three to four times a week.

Childhood Obesity

Teen Obesity Lingers

Acne fades and voices deepen, but teen obesity hangs around. U.S. Department of Agriculture researchers at Tufts University tracked weight and health patterns over the course of subjects' lives. They found that whether or not people bring their weight under control during adulthood, having carried excess pounds during their teen years puts them at greater risk for certain cancers, circulatory problems, and mobility impairment in their elder years.

The study found that teen boys 20 pounds overweight were twice as likely as boys of normal weight to have died or contracted heart disease by the age of 70. Overweight girls were found not to be at higher risk of heart disease, but they were found to have great difficulty performing simple physical tasks during old age, and were at a higher risk of arthritis. Health risks were greatest for people remaining overweight from adolescence through adulthood.

Despite the findings, parents need not force their overweight teens into strict diets, advises Tufts researcher Aviva Must, Ph.D. They are unlikely to stick to them, which could make them feel like failures. And diets that bring quick weight loss may be detrimental to a growing teen's health, says Must. Instead, she recommends a more subtle, long-term strategy: serving family meals relatively low in fat, limiting TV time, and encouraging vigorous exercise. Parents who set an example by adopting healthy habits for themselves will be most successful in helping their children.

Biking

Time To Bike

Whether you bicycle for competition or just to stay in shape, one of your goals should be to maximize your results while minimizing the time you spend on the workout. According to Bicycling magazine, there are a few things you can do to get the most out of your time in the saddle.

One is to keep an eye on your heart rate. When you're not in your target training zone, you're not working as effectively as you could be. Check your heart rate frequently, either by feeling for your pulse at your wrist or neck, or by using one of the new wristband heart monitors.

Remember also that your heart has no idea how much ground you're covering—only how hard you're working. Leave the 150-mile workouts to the pros, and concentrate on quality, not quantity.

Sometimes, though, the longer ride is the better ride. If you use your bike as transportation, as many do, plan ahead to find the route with the least stop-and-start traffic, even if it's half again as long. After all, if you're going to sit still at traffic lights, what kind of workout is that?

Come rainy and icy days, cyclists have one big advantage over other athletes: They can get their workout indoors almost as easily as outdoors, and much more safely. Set up a stationary bike routine that simulates your usual outdoor ride: 10 minutes of warm-up, 20 to 30 minutes of hard riding, and five minutes spent cooling down.

I prefer mountain bikes to road bikes because they give you greater options, such as riding on the grass, a greater work load and thus a greater exercise. The most important factor in the price of the bike is the weight of the components. Go for the heavier bike! You are doing this to get in or stay in shape, and the harder you work the better. Make sure you wear a helmet, and stay away from traffic!

Too Much Advice

Too Much Advice

There is a dizzying amount of advice these days on what to eat. Published studies say broccoli fights cancer and fiber helps to control your appetite. Your doctor says cut down on fat. Your neighbor credits zinc for maintaining his sex drive. It's all enough to make an otherwise sane person seek comfort from a bag of potato chips or a triple-decker cheeseburger. To help clarify matters, Men's Fitness offers a nutritional strategy based on three goals:

1. Boost your energy. Eat beans for protein, complex carbohydrates, fiber, and important vitamins and minerals. For the functioning of your metabolism, nerves, and muscles, get magnesium from whole grains, green veggies, and bananas. Increase your stamina with wheat germ. Hydrate yourself daily with eight 12-ounce glasses of water to keep your system functioning efficiently.

2. Reduce fat. Choose lean meats flavored with low-fat ingredients such as chilis and tomatoes. Eat potatoes which are rich in vitamin C, potassium, fiber, and carbohydrates. For dessert, choose low-fat yogurt and low-fat toppings.

3. Live longer. Eat one or two seafood dishes every week (heart-friendly). Guard against cancer with beta-carotene (yellow-orange fruits and vegetables, broccoli, and spinach). Snack on nuts (high in fat—but the unsaturated kind).

I strongly recommend my partner Dr. Steve Schnurs' book, "The Reality Diet".

http://www.amazon.com/Reality-Diet-Steven-Schnur/dp/B00164CNSQ/ref=sr_1_1?ie=UTF8&s=books&qid=1246816070&sr=8-1

Well Rounded Workout

Well-Rounded Workout

The benefits of regular exercise continue to pile up. Reduced risk of heart disease, lower blood pressure, a better overall frame of mind, and fewer feelings of depression are but a few of the ways exercise can help us live longer, healthier, and happier lives.

According to the book Staying Healthy in a Risky Environment: The New York University Medical Center Family Guide, people who want all the benefits of exercise should make sure they plan their workouts around four key elements:

Cardiorespiratory endurance. Usually referred to as aerobic activity, this type of exercise increases the efficiency of your heart and lungs. It includes anything that makes you breathe hard for 20 minutes or more, such as basketball, vigorous tennis, running, brisk walking, and swimming.

Muscular strength. Muscle mass isn't just for the beach. Studies show that people who use weight machines or free weights along with their aerobic exercise have greater mobility—even into their 90s.

Muscular endurance. Think of endurance as strength over time. Gradually increasing the repetitions in your strength training regimen will help your muscles work longer at a single task.

Muscular flexibility. A good stretching routine can prevent stress injuries and increase your range of motion.

Binge Eating

Beware of the Binge

Successful dieters often reward themselves with an occasional "pig-out." For some, though, that kind of reward can kill within hours, according to one study.

The research shows that the risk of a heart attack for some middle-aged people may increase dramatically just six to seven hours after a single high-fat meal.

Blame Factor VII, a clot-forming protein in blood that normally does its work on damaged tissue. Sudden high-fat intake causes Factor VII to shift into overdrive. Those with a history of high-fat diets are most at risk from the clots because their coronary arteries may already be narrowed.

Exercise and Diabetes

Exercise and Diabetes

Exercise and live longer!

This is hardly late-breaking news for most people, but for patients with diabetes it may be the exact opposite of what they've always been told.

A recent study conducted at the Johns Hopkins School of Medicine suggests that people with diabetes who can exercise should—because burning as little as 2,000 calories a week can prolong their lives. Two thousand calories isn't much, either. An hour a day of gardening or walking should suffice, say researchers. Of course, blood-glucose levels should be watched carefully as part of any diabetic's exercise program.

Wine

For Wine Lovers at Heart

Does white or red wine go with veal? Or should I just have a beer? When in doubt, experts say, take the wine and make it white. It may be better for your heart.

Studies have shown that any kind of moderate alcohol intake, say two drinks a day, can reduce coronary artery disease. But researchers from Kaiser Permanente Medical Center in Oakland, California, found that among imbibers with a preference, those who favored wine were least at risk for heart trouble, and those who drank white wine were even better off.

The study also found that even three or more glasses of wine daily can be beneficial.

Weight Lifting

Weight Lifting: Less is More

Who's getting the better workout? The woman who quietly does her three sets each of lighter weight lifts? Or the man who piles on the weight and grunts and strains to hoist one enormously heavy set? According to a study reported in the Journal of Applied Sport Science Research involving subjects doing deadlifts, squats, crunches, bench presses, and bent-over rows, the woman would win.

Lifting less weight with more repetitions is better for building muscles and high-intensity endurance, the study found. The advantage of low-weight, high-repetition training was particularly apparent after just seven weeks of exercising, and the benefits intensify when extended over months and years.

Senior Strenght

Senior Strength

Think of weightlifting and you think of Arnold Schwarzenegger, not Grandma. But mounting evidence seems to show that older people—even those in their 90s—can get important benefits from strength training, according to the Harvard Health Letter.

Most people's muscle strength peaks around age 30 or 40, and then declines to about 60 to 70 percent of peak by age 80. The result is increasing risk of health problems, such as the dangerous falls that cause half of all injuries in seniors and rob them of their independence.

Muscle atrophy, though, isn't caused by age itself, but by the inactivity that usually accompanies advancing age. Research shows that with proper training, a decline in muscle strength can be reversed by people at almost any age, so they can remain self-reliant much longer than otherwise possible. For instance, Tufts University researchers found that in a group of frail seniors aged 86 to 96, the power of their knee extensors was increased by 174 percent in a program of high-intensity workouts over a two-month period. And their heel-to-toe walking speed, important as an indicator of the balance needed to prevent falls, increased 48 percent.

Specific muscle strength isn't the only benefit of strength training for seniors, researchers say. The risk of certain metabolic disorders related to body composition, such as Type II (non-insulin dependent) diabetes, increases over the years as fat replaces muscle. Altering the body composition through strength training has the potential to hold off or prevent these disorders. It also increases bone density, and therefore can help prevent osteoporosis.

Arthritis, while it cannot be reversed, can be slowed by strengthening the muscles, ligaments, and tendons around a joint, thus reducing friction and stress. In addition, strength training, like aerobics, is often touted as an anti-depressant.

It's becoming easier for seniors to begin working with weights. Many fitness centers and YMCAs and YWCAs now have weightlifting programs for seniors, providing appropriate equipment, guidance, and companionship.

With seniors more than anyone, a strength training regimen should have the blessing of a qualified physician.

Nitroglycerin Use Instructions

NITROLINGUAL 0.4 MG SPRAY or Tablets (Form of NITROGLYCERIN)

This is a brand name form of NITROGLYCERIN. USES: Nitroglycerin relaxes blood vessels allowing more blood to flow through. This reduces the workload on the heart and improves blood flow to the heart. Lingual nitroglycerin acts quickly to relieve angina (chest pain).

HOW TO TAKE THIS MEDICATION: At the first sign of chest pain, sit down and spray one or two metered doses on or under the tongue. Close mouth immediately after each dose. The drug is absorbed directly through the lining of the mouth. Spray should not be inhaled and swallowing should be avoided. Do not eat, drink or smoke while spray is in your mouth. Effects should begin within 1 to 3 minutes. If after 5 minutes, there is no relief of chest pain, use another metered dose. If there is no relief after 3 applications, call 911. However, if you use NTG and have relief notify me. Nitroglycerin spray may be used prophylactically 5 to 10 minutes before engaging in activities that may precipitate an attack.

SIDE EFFECTS: Headache, dizziness, flushing, and rapid heartbeat may occur. These effects may subside as your body adjusts to the medication.

PRECAUTIONS: This drug appears to be safe when used during pregnancy, but should be used only if clearly needed. It is not known if nitroglycerin appears in breast milk. Consult your doctor before breast-feeding. Avoid excessive amounts of alcohol as this may worsen side effects. Do not smoke!

DRUG INTERACTIONS: Inform your doctor about all the medicines you use especially if you take medicine to treat high blood pressure, drugs to dilate your blood vessels or drugs to treat migraines (ergot alkaloids) as your dose may need to be adjusted.

NOTES: Carry this medication with you at all times. Do not shake container. Aerosol container should not be punctured, exposed to heat, fire or incinerator.

MISSED DOSE: This medication is used only at the onset of an attack of chest pain or 10 to 15 minutes before engaging in an activity that may cause chest pain. This medication is not for routine use.

STORAGE: Store at room temperature away from heat and direct sunlight.

MEDICAL ALERT: Your condition can cause complications in a medical emergency. For information on enrollment call Medic Alert(TM) at 1-800-854-1166.

Carpal Tunnel Syndrome

Carpal Tunnel Syndrome or CTS

Copyright 1995 Health ResponseAbility Systems, Inc.

Carpal tunnel syndrome is a type of repetitive motion injury.

This hand condition primarily results from performing the same

motions for hours at a time, as when a VDT (video display

terminal) operator types continuously. The syndrome is named for

the narrow tunnel in the wrist formed by ligament and bone.

Tendons that enable the hand to close pass through the carpal

tunnel.

Carpal tunnel syndrome isn't always an medical problem, but

is sometimes accompanied by other diseases or conditions. Some

disorders such as diabetes, hypothyroidism, and rheumatoid

arthritis sometimes contribute to the syndrome.

What Are The Symptoms Of Carpal Tunnel Syndrome?

Symptoms of carpal tunnel syndrome may include:

1. Numbness in the fingers or hands

2. Weakness in the fingers or hands

3. Pain from the wrist, that may seem to shoot up into the

forearm

or down into the palm of the hand or surface of the fingers

4. Tingling in the fingers or hands

5. Burning in the fingers and hands

6. Difficulty opening and closing hands.

If the condition is not treated, carpal tunnel syndrome may

result in permanent injury and loss of the use of the hand.

Prevention And Self-Care Techniques

The American Physical Therapy Association recommends several

steps to prevent or alleviate the symptoms of carpal tunnel

syndrome caused by keyboard work:

1. Keep wrists relaxed and straight, using only finger movements

to strike the keys. Your typing table should be slightly higher

than your elbows when your arms are held relaxed by your sides.

Rest your elbows by your sides or support them with special arm

rests now available on some office chairs. Relax your shoulders

and keep them level.

2. Press keys with the minimum pressure necessary. Make sure the

keyboard is kept clean and in good working order to minimize

resistance.

3. Move your entire hand to press hard-to-reach keys rather than

overextending your fingers. Use two hands if necessary to execute

combination keystrokes, such as shifting to upper case.

4. Break up typing tasks with other activities--such as

proofreading, filing, or telephone work--to rest fatigued

muscles.

Others report that:

1. Elevation of extremity may help relieve symptoms, when soft

tissue swelling is the cause.

2. Splinting of the hand and forearm at night may also help.

Diagnosing Carpal Tunnel Syndrome

In addition to a physical evaluation by a physician that may

include a Tinel sign test, an electomyogram may be recommended to

diagnosis carpal tunnel syndrome or to rule out other possible

causes of the symptoms.

Treatment Options For Carpal Tunnel Syndrome

Treatments options for carpal tunnel syndrome may include wearing

a splint, resting the joint, immobilization of the wrist,

medications (such as corticosteroids), and in some cases surgery.

The benefits, risks and costs of all treatment options should be

discussed with a qualified physician.

Document ID: lhf00223
These stretches can be done at your desk and can help ease strain for folks who use keyboards or who write for extended periods of time. They can help prevent repetitive motion injuries involving the wrist, such as carpal tunnel syndrome:

1. Spread your fingers, and place the tips on the palm side (including your thumb) against the side of your desk, your other hand or other surface. Gently push against the surface, bending at the joints where your fingers join your hand and at your wrist. This helps to stretch the tendons and muscles in your wrist and forearm. Hold for about five seconds, and repeat three to six times for each hand.

2. With your palm facing the floor, bend your wrist downward and push on the backs of your fingers with the other hand. Push the fingers of the first hand against this resistance until you feel it in your upper forearm muscles.

Hold each move for about five seconds with your wrist bent as far as it will go in each direction. Repeat each move several times.

3. Sit straight in your chair. Place your palms onto the chair, under your thighs, with fingers pointing inward. Slowly extend your arms and feel the stretch in your forearms. Hold for 15 seconds, relax, then repeat three times.

Want to talk with others who have repetitive strain injury? Check out Better Health's mutual support chats (Keyword: Better Health > Events, Chats button > Repetitive Strain Injury).

Copyright 1997, Health ResponseAbility Systems, Inc.

Cholesterol

Cholesterol{kuh-les'-tur-awl}

Overview

Cholesterol is a white, waxy, fatty substance that occurs in the tissues of all vertebrates in the animal kingdom. Excess cholesterol can build up in the bloodstream and accumulate on the walls of arteries, forming "plaques," which can clog the blood vessels and lead to heart attacks and strokes. Because of its role in heart disease in humans, cholesterol has been the focus of much debate over what constitutes healthy or unhealthy levels of cholesterol in the blood and how to reduce cholesterol in the diet.

Function

In higher animals cholesterol has a number of functions. It is a structural component of CELL membranes. They serve primarily in synthetic and degradative reactions and in energy production. The outer membranes of most cells have intermediate cholesterol-polar lipid ratios and have both protective and metabolite-transport functions. In addition to its role in membrane structure cholesterol has other important functions. Cholesterol is stored in the adrenals, testes, and ovaries, chiefly as the fatty acid ester, and converted to STEROID hormones. These hormones include the male and female SEX HORMONES (androgens and estrogens) as well as the adrenal corticoids (cortisol, corticosterone, aldosterone, and others). In the liver cholesterol is the precursor of bile acids that aid in the digestion of foods.

Metabolism

In the average American adult, the total amount of lipoprotein- bound cholesterol circulating in the blood is about 200 mg per 100 ml of serum. Cholesterol is obtained from foods having saturated fatty acids and is also synthesized from acetate, primarily in the liver. Normally the total amount of cholesterol from these two sources remains constant because the rate of cholesterol synthesis in the liver is under feedback control. When the dietary intake is high, liver synthesis is low; when intake is low, synthesis increases. Dietary cholesterol is transported in the blood from the intestine to the liver by means of large lipoprotein molecules. The liver then secretes Very Low Density Lipoprotein (VLDL)-- containing cholesterol and cholesterol ester among other compounds--into the blood. VLDL is partially converted in adipose tissue (fat) to Low Density Lipoprotein (LDL). LDL is the major transport protein for cholesterol, supplying both free and esterified cholesterol to body tissues. High Density Lipoprotein (HDL) is involved in the transport of cholesterol to the liver to be broken down and excreted, and in removing some LDL cholesterol from artery walls. If a person's intake of dietary fat is high, many experts consider that levels of serum cholesterol will also increase, causing greater risk of HEART DISEASE and especially ATHEROSCLEROSIS. Studies have shown that high levels of HDL cholesterol reduce that risk, and high levels in other lipoproteins, particularly LDL, have the opposite effect. Hence the terms “good cholesterol” for HDL, and “bad cholesterol” for LDL. A 1984 report indicated that reduction of LDL ratios would lower the risk of heart disease, and a 1987 report provided evidence that reduction of cholesterol could have a positive effect in some persons with high cholesterol levels. Various drugs can help lower cholesterol levels for persons with very high cholesterol levels. Studies recommend that adults try to limit their cholesterol intake, to reduce the risk of coronary disease. Controversy has surrounded the suggestion that mass screening for high cholesterol levels should begin in childhood.

Adapted from an article by Armand J. Fulco

Bibliography

Bibliography: Cooper, K. H., Controlling Cholesterol (1989);Kwiterovich, P. O.,

Jr., Beyond Cholesterol (1989); Yeagle, Philip L., ed., The Biology of

Cholesterol (1988).

Insomnia or Sleeplessness

INSOMNIA

Despite the traditional belief that eight hours comprise a good night's sleep, healthy individuals vary widely in the quantity of sleep they need. While the average is about seven to eight hours, others need as few as three or as many as ten hours of sleep each night to feel refreshed. Because there is no standard daily sleep requirement, insomnia or sleeplessness is considered to be of medical importance only when it compromises a persons's ability to function in everyday life. One of the three most common disorders that primary care physicians are asked to evaluate, it affects about one out of every three adults.

Major Causes

Situational/Psychological -- Emotional disturbances are the most common reasons for an inability to sleep. The stresses of modern life, financial insecurity, job worries, family discord, health concerns, excitement, etc. all may contribute to insomnia. In addition, sleeplessness is a cardinal symptom of deprssion and anxiety disorders. Classically, depressed persons have insomnia and fitful sleep, yet they awaken early in the morning. Also, an inability to sleep may be a result of major psychoses such as schizophrenia and manic-depressive illness.

Altered Sleep-Wake Cycle -- Most of us have a stable pattern of activities that relate to the solar day. If we work days, we sleep nights and vice versa. When this cycle is disrupted, insomnia can occur. Disturbances in the sleep-wake cycle may be seen in frequent travelers to distant time zones and in employees who rotate day-night/night-day work schedules.

Medical Illness -- A number of health problems produce symptoms that can disturb sleep. Ulcer pain, asthma attacks, croup and itching tend to be more frequent at night. Congestive heart failure, heartburn and sinus congestion may be aggravated when a horizontal postion is assumed. In addition, intestinal and urinary disorders which require frequent trips to the commode, and any condition that causes severe pain, can disrupt the sleep pattern.

Drugs -- Among the prescribed, non-prescription and illicit drugs that can cause insomnia are stimulants such as caffeine, diet pills and speed; tranquilizers; hormones; cancer chemotherapy; blood pressure medications; alcohol; and thyroid medicines. Sudden withdrawal of depressants (downers), alcohol, sleeping pills, narcotics, psychiatric medication and most recreational drugs can produce abstinence syndromes manifested, at least in part, by sleeplessness.

Sleep Disorders -- Three primary sleep disorders are implicated. Myoclonic syndrome refers to an involuntary nocturnal jerking of the leg muscles. The restless leg syndrome is manifested by an ill-defined nighttime discomfort in the legs that is relieved by walking. Finally, sleep apnea includes a variety of conditions characterized by repetitive episodes of sleep-induced cessation of breathing. In severe cases, heart disease and sudden death can occur.

Hospitalization -- Persons who are admitted to the hospital often have multiple reasons for insomnia: illness, medication, anxiety, noise level, environmental stress, etc.

Aging -- Sleep requirements diminish only slightly with advancing age, but the elderly may sleep less soundly. Daytime inactivity and napping may contribute to insomnia in this population.

Evaluation

The initial step is a detailed medical history and examination. Attention is paid to psychosocial problems and stress-related health complaints. Usually the diagnosis is readily apparent, but blood tests may be required. Referral to a psychiatrist, sleep center or specialist in sleep disorders may be appropriate for difficult cases which do not respond to treatment.

Treatment

The therapy must be tailored to the diagnosis, e.g. medication change, pain control, improvement in life situation. General measures include stopping caffeine and alcohol, regular exercise, relaxing before bedtime, avoidance of daytime naps and developing a sleeping routine. Use of the bedroom should be reserved only for sleeping. Specific measures include relaxation training and sleeping pills. The benzodiazepine class of hypnotic medications is commonly prescribed. In general, sleeping pills are addicting, have side effects and are ineffective after long-term use. And withdrawal syndromes may actually aggravate insomnia. These medications should be used with discretion and close medical supervision.

Mitral Regurgitation

MITRAL REGURGITATION

As opposed to mitral stenosis, regurgitation is more common in males, and is often noted more rapidly after the rheumatic fever episode. In this disorder, the valve opening is unable to be closed fully by the leaflets of the valve, and when the ventricle (lower chamber) contracts, the blood flows right back into the atrium from where it came, instead of into the aorta, where it belongs. This is a partial phenomenon, and symptoms are related to its severity. The ventricle must work overtime to compensate, and often hypertrophies or enlarges to impressive proportions in the process.

Symptoms

Fatigue is often the earliest symptom, but later shortness of breath occur. Fluid accumulation, sometimes noted as ankle swelling or edema may occur. Arrhythmias such as atrial fibrillation are sometimes noted. Finally, heart failure, shock and death may occur. It is noteable that many cases progress very slowly and never require intensive treatment. Survivals which are normal or near normal are commonplace.

Diagnosis

First suspected by its murmur on exam, mitral regurgitation is evaluated much like mitral stenosis, as described above.

Treatment

No treatment is necessary in many cases. The careful addition of appropriate drugs such as digoxin may be useful to control rhythm irregularities. Although restraint is indicated, in some cases the extent of symptoms warrants surgical valve replacement as discussed above. This is best done when symptoms are severe, but not so severe that the heart muscle is permanently damaged, as assessed by the cardiologist.

Mitral Stenosis

MITRAL STENOSIS

This is the most common single valve disorder to follow rheumatic fever, and about 65% of cases occur in females. The valves become thickened and stiff, and ultimately calcium deposits form on the valve leaflets. Since the function of the mitral valve is to direct and control blood flow from the left atrium to the left ventricle, eventually, this flow becomes markedly restricted.

Ten or more years may elapse between the original case of rheumatic fever and the development of symptoms from mitral stenosis, although a physician may suspect the disease much earlier from its characteristic, if sometimes subtle, murmur. Thus, young adults are the typical patients.

Symptoms

Over a period of 4 to 8 years, the patient notes shortness of breath as the heart is unable to drain the lungs adequately through the narrowed mitral opening. First noted only after exercise, this later becomes evident even at rest. As pressure builds in the lungs, blood vessels burst, and coughing of blood may occur. Finally all the symptoms of congestive heart failure may ensue.

During the process, the left atrium enlarges markedly, visible on x-ray, and noted on exam. Rhythm disturbances, notably atrial fibrillation, occur. Finally, shock may ensue, leading to death if untreated.

Diagnosis

A combination of history, typical or worrisome murmur, signs of heart enlargement and irregular rhythm are usually the first clues, and echocardiography confirms the diagnosis. Cardiac catheterization is often done prior to treatment to better quantify the situation.

Treatment

In the early stages, avoidance of heavy exertion, and the use of salt restriction are important; the latter avoids fluid accumulations which may further strain the struggling heart. Diuretics such as hydrochlorothiazide, furosemide, and others are added as needed. Heart rhythm stabilizing drugs are useful in some cases, including quinidine, propranolol, and others. In some cases, blood clots form on the rough and thickened valve, and break off, lodging in the arteries of the body; anticoagulants such as warfarin are useful in these cases.

Surgical treatment of the diseased valve is indicated when the symptoms become dangerous or severely impair the daily life of the patient. This may involve simple stretching of the narrowed orifice, or total replacement of the valve with an artificial device. In major centers, such surgery has a mortality of under 2%. Current thinking suggests that the survival long-term is better if replacement is done before the occurrence of severe symptoms. This is a highly specialized area where the surgeon, cardiologist, and patient must consider many variables. Over two thirds of patients operated upon are alive 10 years later, and the mean age is in the 50's at the time of surgery. Thus there is a reasonably good expectation for such patients who previously had almost no chance for survival.

Pacemakers

PACEMAKERS

The heart has an intrinsic system of electrical activity which accounts for its orderly and regular contraction. The rate and rhythm of the heart beat are modified by heart diseases and medications as well as psychological, neurological, chemical and hormonal factors.

When certain abnormal heart rhythms (arrhythmia’s) occur, the heart may be unable to pump enough blood to maintain either a normal blood pressure or an adequate supply of oxygen to body tissues. Blackouts and/or sudden death may result.

If arrhythmia’s cannot be reversed and prevented by medication, a pacemaker is often required. The vast majority of arrhythmia’s that necessitate pacemaker insertion are manifested by extremely slow heart rates (less than 50 beats per minute). Occasionally, pacers are used to shock abnormally fast heart rates back into a normal rhythm.

Types of Pacemakers

Pacemakers are comprised of a hockey puck-sized electrical impulse generator connected to one (unipolar) or two (bipolar) wire leads which are attached to the heart muscle. Although there are many power sources available--from nuclear to a variety of power cells--lithium batteries are most commonly employed.

Temporary pacers are utilized when the heart abnormality or disorder is reversible or short-lived, e.g. heart attack, chemical imbalance, or drug overdose. They are also used to treat certain fast heart rhythms, evaluate the effects of heart medications, and to tide the patient over until arrangements can be made for placement of a permanent pacemaker. Permanent pacers are designed to work indefinitely, limited only by the lifetime of their power source (about eight years for lithium batteries).

Fixed-rate pacers generate impulses without regard for the intrinsic heart beat. Once the pacer is turned on and the rate is set, it fires continually at regular intervals. Because it can be dangerous for the pacer to fire at certain points during the heart beat, fixed-rate pacers have been replaced, for the most part, by demand pacers. The demand feature refers to the ability of the pacer to sense the heart's intrinsic beat and transmit an impulse only when necessary. Demand pacers, therefore, function intermittently depending upon the heart's ability to beat on its own.

Programmable pacers are adjustable for a variety of parameters. While they are not truly programmable in the computer sense of the word, changes in the rate, electrical output, sensitivity, mode, etc. can be made without removing the device. The two techniques of

effecting alterations in generator function are radio-frequency signals and pulsating magnetic fields. The former is preferable and can be adapted to receive information from the pacer as well as transmit.

The two methods of pacemaker placement are described below. Endocardial leads are those attached to the inner lining of the heart; epicardial leads are attached to the outside lining.

Endocardial Lead Placement

Also known as transvenous pacing, about 90 percent of all pacemakers are placed by this method using either local or general anesthesia. First the wire lead(s) is inserted into a vein in the neck, beneath the collarbone or near the shoulder. Then, using fluoroscopic X-rays as a guide, the surgeon advances the lead(s) into the chambers on the right side of the heart where it becomes lodged in the muscular fibers. Some leads have hooks, tines or screws to facilitate attachment to the inner wall (endocardium) of the heart. Which chamber (atrium or ventricle) is used to anchor the lead(s) depends on the type of arrhythmia and the pacemaker used. For permanent pacing, the generator is connected and placed beneath a pocket of skin on the chest or near the shoulder. Temporary pacers utilize an external generator at the bedside.

Epicardial Lead Placement

An operation under general anesthesia is required. Either the chest cavity is opened through a small incision beneath the left breast or, more commonly, an incision is placed below the breastbone. The heart is visualized directly, and the lead(s) is screwed into its outer wall (epicardium). The generator may be placed inside the chest cavity or under the skin in the upper abdomen of flank. Although this method assures more accurate and secure lead placement, it involves a bigger operation at greater risk to the patient.

Postoperative Care

The placement of the pacer leads can be checked with X-rays. The average length of hospitalization is about one day for insertion of a permanent pacing device. Most patients are followed-up by their cardiologists for regular pacemaker checks.

Complications

Among the operative problems are the risks of anesthesia, infection, bleeding, damage to blood vessels, perforation of the heart, blood clots in the veins, life-threatening arrhythmia’s and death. Long-term complications include lead dislodgement and erosion, pacer malfunction, migration of the generator, broken wires, damage to heart valves and pacemaker stimulation of the diaphragm muscle.

Results

About 80 percent of pacemaker patients are alive at two years, 65 percent at five years, and 40 percent at ten years. These figures do not differ remarkably from those for the general population matched for age.

Sleep Apnea

MayoClinic.com reprints

This single copy is for your personal, noncommercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, use the reprints link below.

· Order reprints of this article now.

Sleep apnea

By Mayo Clinic staff

Original Article:http://www.mayoclinic.com/health/sleep-apnea/DS00148

Definition

Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops and starts. You may have sleep apnea if you snore loudly and you feel tired even after a full night's sleep?

Sleep apnea occurs in two main types: obstructive sleep apnea, the more common form that occurs when throat muscles relax, and central sleep apnea, which occurs when your brain doesn't send proper signals to the muscles that control breathing. Additionally, some people have complex sleep apnea, which is a combination of both.

If you think you might have sleep apnea, see your doctor. Treatment is necessary to avoid heart problems and other complications.

Symptoms

The signs and symptoms of obstructive and central sleep apneas overlap, sometimes making the type of sleep apnea more difficult to determine. The most common signs and symptoms of obstructive and central sleep apneas include:

Excessive daytime sleepiness (hypersomnia)

Loud snoring, which is usually more prominent in obstructive sleep apnea

Observed episodes of breathing cessation during sleep

Abrupt awakenings accompanied by shortness of breath, which more likely indicates central sleep apnea

Awakening with a dry mouth or sore throat

Morning headache

Difficulty staying asleep (insomnia)

When to see a doctor 
Consult a medical professional if you experience, or if your partner observes, the following:

Snoring loud enough to disturb the sleep of others or yourself

Shortness of breath that awakens you from sleep

Intermittent pauses in your breathing during sleep

Excessive daytime drowsiness, which may cause you to fall asleep while you're working, watching television or even driving

Many people don't think of snoring as a sign of something potentially serious, and not everyone who has sleep apnea snores. But be sure to talk to your doctor if you experience loud snoring, especially snoring that's punctuated by periods of silence.

Ask your doctor about any sleep problem that leaves you chronically fatigued, sleepy and irritable. Excessive daytime drowsiness (hypersomnia) may be due to other disorders, such as narcolepsy.

Causes

http://www.mayoclinic.com/health/medical/IM04014

Obstructive sleep apnea

Causes of obstructive sleep apnea
Obstructive sleep apnea occurs when the muscles in the back of your throat relax. These muscles support the soft palate, the triangular piece of tissue hanging from the soft palate (uvula), the tonsils and the tongue.

When the muscles relax, your airway narrows or closes as you breathe in, and breathing momentarily stops. This may lower the level of oxygen in your blood. Your brain senses this inability to breathe and briefly rouses you from sleep so that you can reopen your airway. This awakening is usually so brief that you don't remember it.

You can awaken with a transient shortness of breath that corrects itself quickly, within one or two deep breaths, although this is rare. You may make a snorting, choking or gasping sound. This pattern can repeat itself five to 30 times or more each hour, all night long. These disruptions impair your ability to reach the desired deep, restful phases of sleep, and you'll probably feel sleepy during your waking hours.

People with obstructive sleep apnea may not be aware that their sleep was interrupted. In fact, many people with this type of sleep apnea think they sleep well all night.

Causes of central sleep apnea
Central sleep apnea, which is far less common, occurs when your brain fails to transmit signals to your breathing muscles. You may awaken with shortness of breath or have a difficult time getting or staying asleep. Like obstructive sleep apnea, snoring and daytime sleepiness can occur. The most common cause of central sleep apnea is heart disease, and less commonly, stroke. People with central sleep apnea may be more likely to remember awakening than people with obstructive sleep apnea are.

Causes of complex sleep apnea
People with complex sleep apnea have upper airway obstruction just like those with obstructive sleep apnea, but they also have a problem with the rhythm of breathing and occasional lapses of breathing effort.

Risk factors

Sleep apnea may occur if you're young or old, male or female. Even children can have sleep apnea. But certain factors put you at increased risk:

Obstructive sleep apnea

Excess weight. Fat deposits around your upper airway may obstruct your breathing. However, not everyone who has sleep apnea is overweight. Thin people develop the disorder, too.

Neck circumference. The size of your neck may indicate whether or not you have an increased risk of sleep apnea. That's because a thick neck may narrow the airway and may be an indication of excess weight. A neck circumference greater than 17.5 inches (44 centimeters) is associated with an increased risk of obstructive sleep apnea.

High blood pressure (hypertension). Sleep apnea is not uncommon in people with hypertension.

A narrowed airway. You may inherit a naturally narrow throat. Or, your tonsils or adenoids may become enlarged, which can block your airway.

Being male. Men are twice as likely to have sleep apnea as women are. However, women increase their risk if they're overweight, and the risk also appears to rise after menopause.

Being older. Sleep apnea occurs two to three times more often in adults older than 65.

Family history. If you have family members with sleep apnea, you may be at increased risk.

Use of alcohol, sedatives or tranquilizers. These substances relax the muscles in your throat.

Smoking. Smokers are three times as likely to have obstructive sleep apnea than are people who've never smoked. Smoking may increase the amount of inflammation and fluid retention in the upper airway. This risk likely drops after you quit smoking.

Central sleep apnea

Being male. Males are more likely to develop central sleep apnea than are females.

Heart disorders. People with atrial fibrillation or congestive heart failure are more at risk of central sleep apnea.

Stroke or brain tumor. These conditions can impair the brain's ability to regulate breathing.

Complex sleep apnea
The same risk factors for obstructive sleep apnea are also risk factors for complex sleep apnea. In addition, complex sleep apnea may be more common in people who have heart disorders.

Complications

Sleep apnea is considered a serious medical condition. Complications may include:

Cardiovascular problems. Sudden drops in blood oxygen levels that occur during sleep apnea increase blood pressure and strain the cardiovascular system. If you have obstructive sleep apnea, your risk of high blood pressure (hypertension) can be up to two to three times greater than if you don't. The more severe your sleep apnea, the greater the risk of high blood pressure. If there's underlying heart disease, these multiple episodes of low blood oxygen (hypoxia or hypoxemia) can lead to sudden death from a cardiac event.
In contrast, central sleep apnea usually is the result, rather than the cause, of heart disease.
Obstructive sleep apnea also increases the risk of stroke, regardless of whether you have high blood pressure.

Daytime fatigue. The repeated awakenings associated with sleep apnea make normal, restorative sleep impossible. People with sleep apnea often experience severe daytime drowsiness, fatigue and irritability. You may have difficulty concentrating and find yourself falling asleep at work, while watching TV or even when driving. You may also feel irritable, moody or depressed. Children and adolescents with sleep apnea may do poorly in school or have behavior problems.

Complications with medications and surgery. Obstructive sleep apnea is also a concern with certain medications and general anesthesia. People with sleep apnea may be more likely to experience complications following major surgery because they're prone to breathing problems, especially when sedated and lying on their backs. Before you have surgery, tell your doctor that you have sleep apnea. Undiagnosed sleep apnea is especially risky in this situation.

Sleep-deprived partners. Loud snoring can keep those around you from getting good rest and eventually disrupt your relationships. It's not uncommon for a partner to go to another room, or even on another floor of the house, to be able to sleep. Many bed partners of people who snore are sleep deprived as well.

People with sleep apnea may also complain of memory problems, morning headaches, mood swings or feelings of depression, a need to urinate frequently at night (nocturia), and impotence. Gastroesophageal reflux disease (GERD) may be more prevalent in people with sleep apnea. Children with untreated sleep apnea may be hyperactive and may be diagnosed with attention-deficit/hyperactivity disorder (ADHD).

Preparing for your appointment

If it's suspected that you have sleep apnea, you're likely to start by first seeing your family doctor or a general practitioner. However, in some cases when you call to set up an appointment, you may be referred immediately to a sleep specialist.

Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be well prepared for your appointment. Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as restrict your diet.

Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.

Write down key personal information, including any major stresses or recent life changes.

Bring a list of all medications, as well as any vitamins or supplements, that you're taking.

Bring a family member or friend along, if possible. Sometimes it can be difficult to soak up all the information provided during an appointment. Someone who accompanies you may remember something that you missed or forgot. And because your bed partner may be more aware of your symptoms than you are, it may help to have him or her along.

Write down questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions ahead of time will help you make the most of your visit. List your questions from most important to least important in case time runs out. For sleep apnea, some basic questions to ask your doctor include:

What is likely causing my symptoms or condition?

Other than the most likely cause, what are other possible causes for my symptoms or condition?

What kinds of tests do I need?

Is my condition likely temporary or chronic?

What is the best course of action?

What are the alternatives to the primary approach that you're suggesting?

I have these other health conditions. How can I best manage them together?

Are there any restrictions that I need to follow?

Should I see a specialist? What will that cost, and will my insurance cover seeing a specialist?

Is there a generic alternative to the medicine or product you're prescribing me?

Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Your doctor may ask:

When did you first begin experiencing symptoms?

Have your symptoms been continuous, or occasional?

How severe are your symptoms?

What, if anything, seems to improve your symptoms?

What, if anything, appears to worsen your symptoms?

What you can do in the meantime

Try to sleep on your side. Most forms of sleep apnea are milder when you sleep on your side.

Avoid alcohol close to bedtime. Alcohol worsens obstructive and complex sleep apnea.

If you're drowsy, avoid driving. If you have sleep apnea you may be abnormally sleepy, which can put you at higher risk of motor vehicle accidents. At times, a close friend or family member might tell you that you appear sleepier than you feel. If this is true, try to avoid driving at all.

Tests and diagnosis

Your doctor may make an evaluation based on your signs and symptoms or may refer you to a sleep disorder center. There, a sleep specialist can help you decide on your need for further evaluation. Such an evaluation often involves overnight monitoring of your breathing and other body functions during sleep. Tests to detect sleep apnea may include:

Nocturnal polysomnography. During this test, you're hooked up to equipment that monitors your heart, lung and brain activity, breathing patterns, arm and leg movements, and blood oxygen levels while you sleep.

Oximetry. This screening method involves using a small machine that monitors and records the oxygen level in your blood while you're asleep. A simple sleeve fits painlessly over one of your fingers to collect the information overnight at home. If you have sleep apnea, the results of this test will show drops in your oxygen level during apneas and subsequent rises with awakenings. If the results are abnormal, your doctor may have you undergo polysomnography to confirm the diagnosis. Oximetry doesn't detect all cases of sleep apnea, so your doctor may still recommend a polysomnogram even if the oximetry results are normal.

Portable cardiorespiratory testing. Under certain circumstances, your doctor may provide you with simplified tests to be used at home to diagnose sleep apnea. These tests usually involve oximetry, measurement of airflow and measurement of breathing patterns.

If you have obstructive sleep apnea, your doctor may refer you to an ear, nose and throat doctor (otolaryngologist) to rule out any blockage in your nose or throat. An evaluation by a heart doctor (cardiologist) or a doctor who specializes in the nervous system (neurologist) may be necessary to look for causes of central sleep apnea.

Treatments and drugs

http://www.mayoclinic.com/health/medical/IM00045

Continuous positive airway pressure (CPAP)

For milder cases of sleep apnea, your doctor may recommend lifestyle changes such as losing weight or quitting smoking. If these measures don't improve your signs and symptoms or if your apnea is moderate to severe, a number of other treatments are available. Certain devices can help open up a blocked airway. In other cases, surgery may be necessary.

Treatments for obstructive sleep apnea may include:

Therapies

Continuous positive airway pressure (CPAP). If you have moderate to severe sleep apnea, you may benefit from a machine that delivers air pressure through a mask placed over your nose while you sleep. With CPAP (SEE-pap), the air pressure is somewhat greater than that of the surrounding air, and is just enough to keep your upper airway passages open, preventing apnea and snoring.
Although CPAP is a preferred method of treating sleep apnea, some people find it cumbersome or uncomfortable. With some practice, most people learn to adjust the tension of the straps to obtain a comfortable and secure fit. You may need to try more than one type of mask to find one that's comfortable. Some people benefit from also using a humidifier along with their CPAP system.
Don't just stop using the CPAP machine if you experience problems. Check with your doctor to see what modifications can be made to make you more comfortable. Additionally, contact your doctor if you are still snoring despite treatment or begin snoring again. If your weight changes, the pressure settings may need to be adjusted.

Adjustable airway pressure devices. If CPAP continues to be a problem for you, you may be able to use a different type of airway pressure device that automatically adjusts the pressure while you're sleeping. For example, units that supply bilevel positive airway pressure (BiPAP) are available. These provide more pressure when you inhale and less when you exhale.

Oral appliances. Another option is wearing an oral appliance designed to keep your throat open. CPAP is more effective than oral appliances, but oral appliances may be easier for you to use. Some are designed to open your throat by bringing your jaw forward, which can sometimes relieve snoring and mild obstructive sleep apnea.
A number of devices are available from your dentist. You may need to try different devices before finding one that works for you. Once you find the right fit, you'll still need to follow up with your dentist at least every six months during the first year and then at least once a year after that to ensure that the fit is still good and to reassess your signs and symptoms.

Surgery 
The goal of surgery for sleep apnea is to remove excess tissue from your nose or throat that may be vibrating and causing you to snore, or that may be blocking your upper air passages and causing sleep apnea. Surgical options may include:

Uvulopalatopharyngoplasty (UPPP). During this procedure, your doctor removes tissue from the rear of your mouth and top of your throat. Your tonsils and adenoids usually are removed as well. This type of surgery may be successful in stopping throat structures from vibrating and causing snoring. However, it may be less successful in treating sleep apnea because tissue farther down your throat may still block your air passage. UPPP usually is performed in a hospital and requires a general anesthetic.

Maxillomandibular advancement. In this procedure, the upper and lower part of your jaw is moved forward from the remainder of your face bones. This enlarges the space behind the tongue and soft palate, making obstruction less likely. This procedure may require the cooperation of an oral surgeon and an orthodontist, and at times may be combined with another procedure to improve the likelihood of success.

Tracheostomy. You may need this form of surgery if other treatments have failed and you have severe, life-threatening sleep apnea. In this procedure, your surgeon makes an opening in your neck and inserts a metal or plastic tube through which you breathe. You keep the opening covered during the day. But at night you uncover it to allow air to pass in and out of your lungs, bypassing the blocked air passage in your throat.

Removing tissues in the back of your throat with a laser (laser-assisted uvulopalatoplasty) or with radiofrequency energy (radiofrequency ablation) are procedures that doctors sometimes use to treat snoring. Although sometimes these procedures are combined with others, they aren't usually recommended as sole treatments for obstructive sleep apnea.

Other types of surgery may help reduce snoring and contribute to the treatment of sleep apnea by clearing or enlarging air passages:

Nasal surgery to remove polyps or straighten a crooked partition between your nostrils (deviated nasal septum)

Surgery to remove enlarged tonsils or adenoids

Treatments for central and complex sleep apnea may include:

Therapies

Treatment for associated medical problems. Possible causes of central sleep apnea include heart or neuromuscular disorders, and treating those conditions may help. For example, optimizing therapy for heart failure may eliminate central sleep apnea.

Supplemental oxygen. Using supplemental oxygen while you sleep may help if you have central sleep apnea. Various forms of oxygen are available as well as different devices to deliver oxygen to your lungs.

Continuous positive airway pressure. This method, also used in obstructive sleep apnea, involves wearing a pressurized mask over your nose while you sleep. The mask is attached to a small pump that forces air through your airway to keep it from collapsing. CPAP may eliminate snoring and prevent sleep apnea. As with obstructive sleep apnea, it's important that you use the device as directed. If your mask is uncomfortable or the pressure feels too strong, talk with your doctor so that adjustments can be made.

Bilevel positive airway pressure (BiPAP). Unlike CPAP, which supplies steady, constant pressure to your upper airway as you breathe in and out, BiPAP builds to a higher pressure when you inhale and decreases to a lower pressure when you exhale. The goal of this treatment is to assist the weak breathing pattern of central sleep apnea. Some BiPAP devices can be set to automatically deliver a breath if the device detects you haven't taken one after so many seconds.

Adaptive servo-ventilation (ASV). This more recently approved airflow device learns your normal breathing pattern and stores the information in a built-in computer. After you fall asleep, the machine uses pressure to normalize your breathing pattern and prevent pauses in your breathing. ASV may be more successful than CPAP at treating central sleep apnea. However, more study is needed.

Along with these treatments, you may read or hear about different treatments for sleep apnea, such as implants. Although a number of medical devices and procedures have received Food and Drug Administration clearance, there's limited published research regarding how useful they are, and they aren't generally recommended as sole therapies.

Lifestyle and home remedies

In many cases, self-care may be the most appropriate way for you to deal with obstructive sleep apnea and possibly central sleep apnea. Try these tips:

Lose excess weight. Even a slight loss in excess weight may help relieve constriction of your throat. Sleep apnea may be cured in some cases by a return to a healthy weight. If you don't already have a weight-loss program, talk to your doctor about the best course of action for weight loss.

Avoid alcohol and medications such as tranquilizers and sleeping pills. These relax the muscles in the back of your throat, interfering with breathing.

Sleep on your side or abdomen rather than on your back. Sleeping on your back can cause your tongue and soft palate to rest against the back of your throat and block your airway. To prevent sleeping on your back, try sewing a tennis ball in the back of your pajama top.

Keep your nasal passages open at night. Use a saline nasal spray to help keep your nasal passages open. Talk to your doctor about using nasal decongestants or antihistamines because these medications are generally recommended only for short-term use.

Alternative medicine

Most alternative medicines for sleep apnea have not been well studied. Acupuncture has shown some benefit, but also needs more study. Although it may be used in conjunction with standard treatments, acupuncture should not replace them. Talk to your doctor about any alternative treatment approaches you're considering.

DS00148

June 28, 2008

© 1998-2009 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. A single copy of these materials may be reprinted for noncommercial personal use only. "Mayo," "Mayo Clinic," "MayoClinic.com," "EmbodyHealth," "Reliable tools for healthier lives," "Enhance your life," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research.