Pharmacologic Agents in Stroke Prevention, Acute Stroke Therapy, and Interventional Procedures J.J. Connors, III, MD Pharmaceutical agents have moved far beyond just the aspirin and heparin that were the mainstays of stroke and interventional therapy as recently as 10 to 15 years ago. Our understanding of the mechanisms of thrombus formation and vascular response to damage as well as our ar
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LayoutGlobal Health Care Declaration
Physical inactivity is the
biggest global public health
problem of the 21st century.
“Physical inactivity is the fourth leading risk factor for all global
deaths, with 31% of the world’s population not physically active,”
according to the World Health Organization (2010). A 2009 study
that directly measured physical activity levels rather than relying
on self-reported data shows physical inactivity to be the leading
cause of death in the U.S.
Physical inactivity is associated with: • 3.2 million deaths per year, including 2.6 million in low- and • Over 670,000 premature deaths (people 60 years and under); and• 30% of diabetes and ischemic heart disease burdens.
Cardiovascular disease, diabetes, cancer and chronic respiratory • Reduces the incidence of high blood pressure by almost 50%.
disease are four priority noncommunicable diseases identified by • Can reduce mortality and the risk of recurrent breast cancer by the World Health Organization (WHO) as costly and increasing, but largely preventable. In the U.S., more than 90 million people live • Can lower the risk of colon cancer by more than 60%.
with chronic illnesses. Chronic illnesses account for 70% of all • Can reduce the risk of developing Alzheimer’s disease by deaths in the U.S. and more than 60% of the nation’s medical care costs. Chronic diseases account for one-third of the years of • Can decrease depression as effectively as Prozac® or behavioral potential life lost before age 65. Globally, these diseases represent 60% of all deaths globally, 80% of which are in low- andmiddle-income countries (LMICS).
Cardiorespiratory fitness significantly increases length of life,whether you are in your 60s, 70s or 80s! The life expectancy of amoderately fit person in their 80s is as long as an unfit person intheir 60s.
Exercise is Medicine® Global
Health Care Declaration
Exercise is Medicine® encourages health care providers to includeexercise when designing treatment plans for patients. Exercise isMedicine is committed to the belief that exercise and physicalactivity are integral to the prevention and treatment of chronicdisease and should be regularly assessed as part of all medicalcare. The Exercise is Medicine Global Health Care Declaration is a tool to Physical activity reduces the
help bring the importance of physical activity and exercise to thehealth care setting to significantly reduce the global risk of dying prematurely.
noncommunicable disease burden. It represents a consensusamong government officials, public health, exercise and sports medicine experts and physical activity advocates from around the • Reduces the risk of heart disease by 40%.
world, who are committed to improving health and well-being • Lowers the risk of stroke by 27%.
through an Exercise is Medicine prevention, treatment and • Reduces the incidence of diabetes by almost 50%.
The Declaration outlines targets to be achieved by 2020, including: evidence-based prevention and diagnosis and treatment of • making physical activity a vital sign that all health care providers • Encourage more focused engagement with medical and nursing • including fields for tracking patients’ physical activity in schools to educate trainee doctors and nurse practitioners about the link between noncommunicable disease and physical activity • including physical activity education in the training of all health • Add physical activity education to accreditation criteria and • developing a referral database where health care providers can refer patients to allied health and fitness professionals for • Include physical activity in continuing education professional development programs, using the recommended WHO Physical • encouraging health care systems and payors to prioritize physical activity and develop comprehensive approaches to physical • Increase the number of health professionals with expertise in physical activity of at-risk and underserved populations to • developing an adult Health Care Effectiveness and Data enhance health promotion effectiveness.
Information Set (HEDIS) measure for physical activity.
• Ensure that all services include culturally salient patient education materials and counseling for physical activity.
• Disseminate current best-practice guidelines for promoting Exercise is Medicine Global
physical activity in high-risk subpopulations. • Include approaches relevant to primary, secondary and tertiary Health Care Targets
• Offer provider incentives to attend continuing education on Nearly 65% of patients would be more interested in exercising to effective population physical activity promotion approaches.
stay healthy if advised by their doctors or health care • Establish a payment system for physical inactivity diagnosis and professionals. Currently, only four out of ten physicians in the treatment with International Classification of Disease (CD) and U.S. talk to their patients about exercise. Current Procedural Terminology (CPT) codes.
• Develop new service codes with National Health Care Centers. In the U.S., develop codes with Centers for Medicare and Medicaid • Develop a Health Care Effectiveness and Data Information Set • Make physical activity a patient “vital sign” and advocate for (HEDIS) measure for physical activity.
physical activity screening and referral systems that all health • Include fields for tracking patients’ physical activity in electronic care providers assess and discuss with their patients.
• Include physical activity education in the training of all health • Encourage health care systems and payors to prioritize physical care professionals by ensuring that all health care professional activity and develop comprehensive approaches to physical organizations encourage their members to assess patients’ physical activity and discuss ways to make progress toward • Create Regional Centers with National Task Forces responsible meeting the WHO Recommendations on Diet, Physical Activity for developing policies and programs that address physical activity interventions that work in treating, preventing and • Make low-cost, evidence-based cognitive and behavioral managing critical noncommunicable disease problems within a interventions widely available for referral by health care providers • Ensure sufficient, appropriate referral to qualified physical activity counselors and providers based on each individual patient’sneeds. • Encourage referral services to catalog community-based physical PRACTICE
• Encourage health care professionals to be role models of active • Include physical activity as a health system intervention that includes risk factor surveillance, disease monitoring, • Raise awareness for culturally salient physical activity health • Ensure that physical activity and other noncommunicable disease prevention and management interventions are reframed as adevelopment issue and that increased funding by thegovernment, medical research centers and development agenciesis allocated through a multi-sectoral approach which supports“embedded health” and encourages the prevention and control ofnoncommunicable diseases through funding in multipleministries.
• Expand research that identifies and evaluates best practices for physical activity in health care, particularly those effective inpopulation segments at high risk of physical inactivity.
• Encourage sport and exercise science university research organizations in different countries to collaborate, share data anddefine complementary research objectives to optimize the use ofthe limited funds available and reduce duplication of effort.
Systemic integration of physical activity into health care cannothappen without changes in health care policy. Current policy inmany countries does not account for the value of physical activityas a means of health and wellness. Policy must be adapted tosupport health care providers in their efforts to integrate physicalactivity prescription/counseling and referral. COMMUNICATION AND PARTNERSHIP
• Develop action guides specifically for physicians, nurses and nurse practitioners, dieticians, fitness and child careprofessionals and for colleges and universities.
• Build upon successful programs already in place to create a • Evaluate and promote effective practices and programs that encourage physical activity in partnership with insurers. Forexample, create patient incentives for demonstrating increasedphysical activity and fitness, such as co-payment waivers duringchronic disease management visits.
• Encourage health care systems and payors to prioritize physical activity and develop comprehensive approaches to physicalactivity promotion and sharing of best practices and successfulmodels across regions.
• Establish a network of programs, providers and advocates for physical activity as a key component of the U.S. and global healthsystems.
• Create “twinning research centers” between university schools of exercise science and population health to support physicalactivity risk factor surveillance, disease monitoring,evidence-based prevention and diagnosis of noncommunicablediseases.
Economic Impact of Physical
Inactivity results in loss of muscle strength and balance andincreases the risk of falls. Every year, fall-related injuries in older Inactivity
adults cost the U.S. more than $20.2 billion. By 2020, the totalannual cost of fall-related injuries is expected to reach $32.4billion. The impact of a lack of physical activity on medical care costs islikely to grow as a result of an aging population, unless trends inphysical activity change. One study (CDC) has shown that thedirect medical costs of inactive adults are substantially higher thanthose of active adults.
Physical activity must play an
important role in global
health care delivery systems.
The WHO estimates that between 2005 and 2015, income loss (ininternational dollars) could rise to as much as $558 billion inChina, $27 billion in India, $303 billion in Russia and $33 billion in To reverse the current epidemic of non communicable diseases, the United Kingdom as a consequence of losses in productivity in the health care delivery system must implement policies and the workforce and increases in workforce costs due to chronic cost-effective programs to make physical activity and exercise a diseases. It was estimated that physical inactivity, in 1989, cost standard part of a global disease prevention and treatment medical the U.S. $5.7 billion due to hospitalizations and other related health care costs. According toKatzmarzyk and Janssen, about 2.6% assessment, counseling) helpinghealth professionals improve the older adults (over age 65). Health careexpenditures for people age 65 or Harvard researchers calculated thatthe direct medical costs attributable to expenditures in the U.S. (Colditz, 1999). At an American College of interventions that address education, behavior change, community Sports Medicine scientific session, Dr. Michael Pratt of the Centers for Disease Control and Prevention, estimated that direct medicalcosts related to physical inactivity were about $76 billion in 2000, Investments in primary care health systems must play a pivotal representing about 16% of GDP, and were expected to reach 20% role in creating sustainable patient-centered, cost-effective Call to Action
—Talk with your health care provider about including exercise as ACSM encourages priority actions to achieve the Declaration’s targets locally and nationally and promotes a comprehensive —Write to your local policy makers in support of physical activity counseling and referral as part of the health caresystem.
Exercise is Medicine calls on each person and all partners —Tell your family, friends and colleagues about Exercise is dedicated to the idea that exercise truly is medicine to continue to build, support and advocate for physical activity as essential forglobal health and well-being by committing to action.
Policymakers are called to change policy to support physical EIM resources available at
activity as a vital sign for health. Health care providers and fitness www.ExerciseIsMedicine.org.
professionals are called to integrate exercise into every patient andclient interaction. Communities, workplaces and schools are calledto promote physical activity as an essential part of health andwell-being.
commitment to the EIM
Declaration is as easy as:
Supporting the EIM Global Health Care
• Sign up at www.exerciseismedicine.org to become an EIM • Encourage other individuals and organizations to sign up and • Encourage local and national media coverage on the Declaration. • Develop advocacy campaigns focused on the Declaration. Implementing the action steps outlined
to work toward achieving 2020 targets
and priority actions:
—begin prescribing exercise to your patients.
—build a referral network of fitness professionals to whom you —distribute information about the importance of exercise (available at www.exerciseismedicine.org) to your patients.
• If you are a fitness or allied health professional: —Build a network of health care providers that will refer patients —Counsel your clients on the importance of physical activity as —Visit www.exerciseismedicine.org to learn what you need to know about physical activity as an integral part of the healthcare.
Chiropractic Neurology Research Brief A Quarterly Newsletter for Health Care Professionals by Mark Saracino, DC, DACAN Volume two Issue two Chiropractic’s Effectiveness for Headaches A Review of Randomized Controlled Trials Chiropractic is the most common alternative-medical treatment for headaches in the United States (1). There are a number of randomized controlled tr