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Movement and Cognition

How our ability to maintain balance, walk, and move is directly reflective of our higher human functions (A brief overview and case study)

Balance and cognition are inextricably linked. Quantification of improvement in key performance indicators of cognition is directly related to precisely measured improvements in balance and postural stability. A thorough understanding of this relationship is paramount to the understanding of conditions related to cognitive impairment, leaning and behavioral struggles, brain injury, and so much more.

At the time of presentation to APEX Brain Centers, Roger was a 70-year-old male struggling with severe balance problems, clumsiness, fatigue, and a general disinterest in life. He used to enjoy life as a family man, successful entrepreneur and golfer. Just over 10 years prior he had undergone radiation therapy for cancer that damaged his 8th cranial nerve (the balance and hearing nerve). He had also undergone prism therapies and surgery for eye position abnormalities, which have caused further insult to his ability to maintain good balance and to learn effectively. Although not listed as a primary complaint, he also suffered from significant cognitive decline in several areas as evidenced by very low to low average scores on standardized cognitive testing.

Roger sought care at APEX Brain Centers in Asheville, NC in May of 2015 and underwent an intensive course of brain/body rehabilitation. He was admitted into an individualized program directed by extensive diagnostic testing and led by clinicians highly experienced in functional neurology. What follows is a sampling of some of the leading-edge clinical interventions and significant functional gains Roger experienced during his program.

Intervention for balance and cognitive decline

Roger underwent comprehensive brain/body rehabilitation at a frequency of 3 times per day over the course of 15 days (with 2 days off between each for much needed rest and recovery). His brain function was carefully monitored throughout the training process with measurement of EEG, vital signs, eye movements, balance, mental and physical timing, and more to ensure he was receiving the proper amount therapy to be effective, but not too much so as to be counter-productive. Modalities implemented included, but were not limited to: neurofeedback, Interactive Metronome, vestibular rehabilitation, metabolic and nutritional therapies, eye movement and neurological rehabilitation, whole body vibration, electrical stimulation, breathing exercises, and home care recommendations.

Outcomes after Brain Training

Subsequent to his rehabilitative program, Roger reported subjective improvements in the vast majority of his pre-intensive complaints. More profound than that, his wife was quoted as saying, “it’s like I have my old husband back.” She noted that he used to be the life of the party and had been slowly deteriorating over time to the point of sitting in his chair all day and sleeping more and more often. He was finally plugging back into life, putting an end to his isolation and apathy. As is demonstrated by his balance testing, he is also experiencing a renewed ability to maintain balance, allowing him to be safer and more efficient in navigating his physical environment and getting back on the golf course.

Actual, measurable objective improvements recorded with post-intensive diagnostic testing include:

  • Cognitive Testing: Increase in his Neurocognition Index of 48%. This is a standardized overall score of cognitive performance. Increases in various aspects of memory, attention, processing speed and more as great as 21%.
  • Interactive Metronome: 56% improvement in task average with motor timing, and normalization of hyper-anticipatory timing tendency with motor tasks (i.e. responding prematurely to a pre-set reference tone).
  • Computerized Assessment of Postural Stability (CAPS): 20.5% improvement in balance on an unstable surface with eyes closed – bringing him from severe to mild reduction in balance compared to his peers. Elimination of a posterior center of pressure (CoP); significantly reducing his risk of falling backwards.
  • Video Oculography (VOG): Significant improvements in numerous aspects of oculomotor (eye movement) functionality including: gaze holding, slow and fast eye movements, optokinetic responses, and spontaneous/involuntary eye movements.

Better Movement Equals Better Cognition

With an alarming increase in the number of baby boomers and seniors experiencing balance issues and cognitive decline (that are in fact related and measurable), it is important to recognize the symptoms of these potentially debilitating disorders and, more importantly, that something can be done about them. Early intervention is key, as the longer one waits and the more function is lost, the more difficult it is to recover and have full engagement with life. These same concepts apply to all areas of cognitive and mental health.

Learn more on this topic… join Dr. Trayford for his MedFit webinar, Movement and Cognition.


Dr. Michael S. Trayford is a Board Certified in Chiropractic Neurology and Neurofeedback; and is the Founder and Director of Clinical Operations at APEX Brain Centers in Asheville, NC. His primary areas of focus in clinical practice, associated research, and teaching are learning and behavioral disorders of adulthood (with a focus on addictive and compulsive behaviors), brain injury, and cognitive impairment.

std-gehm

Save the Date: Global Employee Health and Fitness Month is May 1-31

Employers and Employees everywhere can show their support for healthy living and well-being by participating in Global Employee Health and Fitness Month (GEHFM) sponsored by the National Association for Health and Fitness (NAHF).

“This amazing, new and improved GEHFM is truly historic in the arena of workplace wellness. Business and industry can encourage positive behavior change in the supportive context of workplace policies and culture and provide support that assists today’s workforce with their daily struggles.  Through GEHFM we will achieve the optimum result of a more physically active and healthier population…one healthy moment and one healthy group at a time,” said Diane H. Hart, President and Executive Director of the National Association for Health and Fitness.

All you have to do is create and share “Moments, Groups and Projects for Health” – such as preparing a healthy meal, organizing a recurring walk or bike ride with colleagues or participating in a clean-up day in your community.  Employers will challenge their employees to continue to do so throughout the month, concluding the month with a culminating project.  It is time to make healthy the norm in America and we believe GEHFM is a powerful effort toward the realization of this goal.

Since the founding of Employee Health and Fitness celebration in May of l989, there have been significant strides in documenting the evidence of the value of investing in employee health.  Employee health is a powerful, strategic component of an organization’s human capital management.  Progressive employers understand that their greatest asset is their employees, and an investment in their employees’ health is essential to managing health care costs, improving organizational productivity and employee morale.  We hope this event plants a seed that the small choices you make each day can have a big impact on long term health.

It’s simple to show your support for a healthy, active workplace.  Sign up at healthandfitnessmonth.org

Join Diane Hart for her free webinar, “Your Voice, Capitol Hill and America’s Health”.
Click here to sign up.

exercise-fitness-at-home

Managing Your Exercise In a Pandemic: 10 Easy Exercises to Build a Strong Core Without Leaving the House

Just in time for the novel coronavirus (COVID-19) social distancing and closures of gyms and fitness centers in many areas, here’s a revisit of many important core exercises you can do at home to keep yourself strong and healthy. Download the free illustrated PDF (Chapter 21 of Diabetes & Keeping Fit For Dummies) for illustrations of the exercise listed below. (You can also find a variety of other at-home exercises on Diabetes Motion Academy Resources for free download.)

Many people are stuck at home for one reason or another think they can’t work on staying fit, but the truth is that you can get a stronger core and stay fitter without leaving home. You’d be amazed at how easy it is to get your fit on.

Remember: Your body core — the muscles around your trunk and pelvis — is particularly important to keep strong so that you can go about your normal daily activities and prevent falls and injuries, particularly as you age. Having a strong body core makes you better able to handle your daily life, even if that’s just doing grocery shopping or playing a round of golf.

Core exercises are an important part of a well-rounded fitness program, and they’re easy to do at home on your own. To get started on your body core workout, you don’t need to purchase anything. (Some of the advanced variations do call for equipment like a gym ball or dumbbells.)

Tip: Include all 10 of these easy core exercises in your workouts, doing at least one set of 15 repetitions of each one to start (where appropriate). Work up to doing two to three sets of each per workout, or even more repetitions if you can. For best results, do these exercises at least two or three nonconsecutive days per week; muscles need a day or two off to fully recover and get stronger. Just don’t do them right before you do another physical activity (because a fatigued core increases your risk of injury).

#1: Abdominal Squeezes

This exercise (Figure 21-1) is great for working your abdominals and getting your body core as strong as possible. If you’re female and have had gone through a pregnancy at some point, getting these muscles in shape doing these squeezes is a must.

  1. Put one of your hands against your upper stomach and the other facing the other direction below your belly button.
  2. Inhale to expand your stomach.
  3. Exhale and try to pull your abdominal muscles halfway toward your spine.

This is your starting position.

  1. Contract your abdominal muscles more deeply in toward your spine while counting to two.
  2. Return to the starting position from Step 3 for another count of two.

Work up to doing 100 repetitions per workout session.

#2: Planks or Modified Planks

Nobody likes doing planks, but they get the job done when it comes to boosting the strength of your core. Both planks and modified planks (Figure 21-2) work multiple areas, including your abdominals, lower back, and shoulders.

  1. Start on the floor on your stomach and bend your elbows 90 degrees, resting your weight on your forearms.
  2. Place your elbows directly beneath your shoulders and form a straight line from your head to your feet.
  3. Hold this position as long as you can.

Repeat this exercise as many times as possible during each workout.

#3: Side Planks

A modification of regular planks, this side plank exercise (Figure 21-3) works some of the same and some slightly different muscles that include your abdominals, oblique abdominal muscles, sides of hips, gluteals, and shoulders. Try doing some of both types for the best results.

  1. Start out on the floor on your side with your feet together and one forearm directly below your shoulder.
  2. Contract your core muscles and raise your hips until your body is in a straight line from head to feet.
  3. Hold this position without letting your hips drop for as long as you can.
  4. Repeat Steps 1 through 3 on the other side.

Switch back and forth between sides as many times as you can.

Tip: Try these plank variations to mix things up a bit:

* Raised side plank: Lifting both your top arm and your leg upward brings other muscles into play and makes your core work harder to maintain balance, but don’t let your hips sag.

* Gym ball side plank: Resting your supporting arm on a gym ball, use your core muscles to control the wobble to further strengthen your side muscles.

* Side plank with lateral raise: While holding the side plank position, slowly raise and lower a light dumbbell or other weight with your top arm to improve your coordination and strength.

* Side plank pulse: From the side plank position, add a vertical hip drive by lowering your hips until they’re just off the floor and then driving them up as far as you can with each repetition of this move.

#4: Bridging

If you work on your abdominal strength, you also need to build the strength in your lower back to keep things balanced. Bridging (Figure 21-4) is a good exercise to do that as it works your buttocks (including gluteals), low back, and hip extensors. Remember to breathe in and out throughout this exercise.

  1. Slowly raise your buttocks from the floor, keeping your stomach tight.
  2. Gently lower your back to the ground.
  3. Repeat Steps 1 and 2.

Tip: Try the bridging with straight leg raise variation: With your legs bent, lift your buttocks up off the floor. Slowly extend your left knee, keeping your stomach tight. Repeat with the other leg. Do as many repetitions as possible.

#5: Pelvic Tilt

An easy exercise to do, the pelvic tilt (Figure 21-5) works your lower back and
lower part of your abdominals.

  1. Lie on your back on the floor with your knees bent and feet flat on the floor.
  2. Place your hands either by your sides or supporting your head.
  3. Tighten your bottom, forcing your lower back flat against the floor, and then relax.
  4. Repeat Steps 2 and 3 as many times as you can.

#6: Superhero Pose

Whether you want to leap a tall building with a single bound or not, try doing this superhero pose exercise (Figure 21-6) to get a stronger core. It works many areas, including your  lower back, upper back, back of shoulders, and gluteals.

  1. Lie on your stomach with your arms straight over your head.
  2. Rest your chin on the floor between your arms.
  3. Keeping your arms and legs straight, simultaneously lift your feet and your hands as high off the floor as you can.

Aim for at least three inches.

  1. Hold that position (sort of a superhero flying position) for 10 seconds if possible, and then relax your arms and legs back onto the floor.

Tip: If this exercise is too difficult, try lifting just your legs or arms off the floor separately — or even just one limb at a time.

#7: Knee Push-Ups

Push-ups are hard to do if you haven’t built up the strength in your shoulders yet, so this knee version (Figure (21-7) is an easier way to start for most people. This exercise works your chest, front of shoulders, and back of upper arms.

  1. Get on your hands and knees on the floor or a mat.
  2. Place your hands shoulder-width apart on the floor.
  3. Tighten your abdominal muscles to straighten your lower back and lower yourself down toward the floor as far as you can without touching.
  4. Push yourself back up until your arms are extended, but don’t lock your elbows.

Tip: If knee push-ups are too hard for you, try doing wall push-ups to start instead. Stand facing a wall at an arm’s length and place your palms against it at shoulder height and with your feet about a foot apart. Do your push-ups off the wall.

#8: Suitcase Lift

This exercise (Figure 21-8) is the proper way to lift items from the floor. Before you begin, place dumbbells or household items slightly forward and between your feet on the floor. You work the same muscles used in doing squats (lower back and lower body) with this activity.

  1. Stand in an upright position with your back and arms straight, with your hands in front of your abdomen.
  2. Bending only your knees, reach down to pick up the dumbbells.
  3. Grab the dumbbells or items in both hands and then push up with your legs and stand upright, keeping your back straight.

#9: Squats with Knee Squeezes

These squats (Figure 21-9) are not your normal squats. They’re more like a combination of squatting and wall sitting with a twist. You work the front and back of thighs, inner thighs (adductors), hip flexors and extensors all with this one exercise.

  1. Stand with your back against the wall, with your feet aligned with your knees and straight out in front of you.
  2. Place a ball or pillow between your knees and hold it there with your legs.
  3. Inhale to expand your stomach and then exhale and contract your abdominal muscles.
  4. Bend your knees and lower yourself into a squat.

Warning: To avoid injuring your knees, don’t bend them more than 90 degrees.

  1. Squeeze the ball with your thighs, drawing your stomach muscles more deeply toward your spine.
  2. Do as many squeezes as you can up to 20 and then return to the starting position.

#10: Lunges

Lunges (Figure 21-10) are a common activity to work on the front and back of thighs, hip flexors and extensors, abdominals, and lower back all with one exercise. Do them with proper form to avoid aggravating your knees, though.

  1. Keep your upper body straight, with your shoulders back and relaxed and chin up.
  2. Pick a point to stare at in front of you so you don’t keep looking down, and engage your core.
  3. Step forward with one leg, lowering your hips until both knees are bent at about a 90-degree angle.

Make sure your front knee is directly above your ankle, not pushed out too far, and don’t let your back knee touch the floor.

  1. Focus on keeping your weight on your heels as you push back up to the starting position.

Tip: To prevent injuries, if you feel any pain in your knees or hips when you do a lunge, do the following instead:

* Take smaller steps out with your front leg.

* Slowly increase your lunge distance as your pain gets better.

* Try doing a reverse lunge (stepping backward rather than forward) to help reduce knee strain.


Reprinted from Colberg, Sheri R., Chapter 21, “Ten Easy Exercises to Build a Strong Core Without Leaving the House” in Diabetes & Keeping Fit for Dummies. Wiley, 2018.

Sheri R. Colberg, PhD, FACSM, is the author of The Athlete’s Guide to Diabetes: Expert Advice for 165 Sports and Activities (the newest edition of Diabetic Athlete’s Handbook). She is also the author of Diabetes & Keeping Fit for Dummies, co-published by Wiley and the ADA. A professor emerita of exercise science from Old Dominion University and an internationally recognized diabetes motion expert, she is the author of 12 books, 30 book chapters, and over 420 articles. She was honored with the 2016 American Diabetes Association Outstanding Educator in Diabetes Award. Contact her via her websites (SheriColberg.com, DiabetesMotion.com, or DMAcademy.com).

woman-video-chatting

Social Distancing – Not Social Isolation: Coaching for Connectedness

We all still need each other. Even in the age of COVID-19, our health continues to depend upon healthy supportive relationships. Our coach training company, Real Balance 1 has always stressed what we call Coaching for Connectedness.  We‘ve seen lifestyle improvement occur and last more often when people receive support for the changes they are making to live healthier lives.  When a coaching client sets up an action step we ask “Who/what else can help support you in this?”. Research on what makes health behavior last points primarily to two factors: a shift in self-concept and community support. (2)   It’s also a well-established fact that people who are more socially isolated have significantly higher rates of all major chronic illnesses. (3)

Our challenge in the midst of a pandemic situation is how we distance from each other while remaining connected to each other. Yes, follow the CDC guidelines for social distancing. We can still greet each other with elbow bumps, and then go for a walk, a bike ride, a cruise in kayaks, etc., and continue to avoid the proximity that puts us at any risk. We can connect via phone and receive the nourishment of live, interactive conversation that texting and e-mail don’t quite match. We can climb on board a web-based platform such as Zoom and Skype where we are face-to-face for our conversation. We also have all sorts of apps such as Facetime, WeChat, and many more that allow us to have face-to-face interaction for live conversations.

As coaches we can continue to work remotely with our clients, as the majority of coaching is already done. As we do, explore the feelings that the changes brought about by social distancing are bringing out in your clients. Empathize. Explore. When people talk about their fears, the intensity of those fears almost always lessens. As people become less afraid, their thinking improves. They aren’t so quick to jump into dismissive all-or-none thinking. They are then able to engage in strategic thinking with their coach to find unique solutions to staying healthy.

  • The fitness center is shut down. How can you shift to working out at home? Use stretch bands. Modify a spare room into a place to do Yoga, floor exercises, etc. Spring brings better weather allowing more cardio outdoors.
  • Do more outdoor exercise/activity with other people – just keep your proper distance.
  • Encourage clients to find new ways to electronically visit their friends, grandchildren, and others. Play online games together.
  • Check in with your clients to make sure they have CDC information/WHO information about how to stay safe during the COVID-19 pandemic. (5,6)

Take heart at how people are showing concern for each other during this time. Younger people who are at somewhat less risk are engaging in social distancing, handwashing, etc. not only for themselves, but for the older and more vulnerable people who could be affected by the contact they are having. People in neighborhood chatlines are volunteering to go pick up groceries and prescriptions for older or more sickly neighbors. Hopefully what will come out of all of this is a greater sense of how we are all in this together. Distancing does not mean isolating. The truism of wellness pioneer Jack Travis is still valid: Connection is the Currency of Wellness.

Be well and stay well!


Michael Arloski, Ph.D., PCC, NBW-HWC – A psychologist with over twenty-five years of clinical work, and more than 23 years as a professional wellness coach, Dr. Arloski is one of the key developers of the field of health & wellness coaching. He is the author of Wellness Coaching For Lasting Lifestyle Change, 2nd Ed., and Masterful Health & Wellness Coaching: Deepening Your Craft.  His company, Real Balance Global Wellness Services, Inc., has trained over 9,000 health & wellness coaches worldwide www.realbalance.com.

References

  1. https://realbalance.com
  2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3753403/  
  3. https://www.apa.org/monitor/2019/05/ce-corner-isolation
  4. https://www.cdc.gov/coronavirus/2019-ncov/index.html
  5. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public

This article was published on Dr. Arloski’s blog. Reprinted with permission.

stretch_2

Did You Hear? Stretching is Back in Fashion, Part 2

For any person, a regular stretching routine can bring some surprising benefits. While you might think that stretching right before activity is beneficial, it needs to be done on a regular basis for a minimum of 10 minutes in order to bring some major changes to muscles and tendons. Research shows that people with the least flexibility have increased chances of injury…

Seniors-on-bikes

Turning Back the Clock on Aging

Consistent exercise and physical activity may be the closest thing we have to the “fountain of youth” in our society today. Dr. Michael Roizen, author of “The RealAge Workout”, cites studies on identical twins that show genetic inheritance influences only about 30% of the rate and way one ages – the rest is up to you!

Senior Man On Cross Trainer In Gym

Exercise and Cardiovascular Disease

Regular exercise has a favorable effect on many of the established risk factors for cardiovascular disease. For example, exercise promotes weight reduction and can help reduce blood pressure. Exercise can reduce “bad” cholesterol levels in the blood (the low-density lipoprotein [LDL] level), as well as total cholesterol, and can raise the “good” cholesterol (the high-density lipoprotein level [HDL]). In diabetic patients, regular activity favorably affects the body’s ability to use insulin to control glucose levels in the blood. Although the effect of an exercise program on any single risk factor may generally be small, the effect of continued, moderate exercise on overall cardiovascular risk, when combined with other lifestyle modifications (such as proper nutrition, smoking cessation, and medication use), can be dramatic.

Benefits of Regular Exercise

  • Increase in aerobic capacity
  • Decrease in blood pressure at rest
  • Decrease in blood pressure while exercising
  • Reduction in weight and body fat
  • Reduction in total cholesterol
  • Reduction in LDL (bad) cholesterol
  • Increase in HDL (good) cholesterol
  • Increased insulin sensitivity (lower blood glucose)
  • Improved self-esteem

Physiological Effects of Exercise

There are a number of physiological benefits of exercise. Regular aerobic exercise causes improvements in muscular function and strength and improvement in the body’s ability to take in and use oxygen (maximal oxygen consumption or aerobic capacity). As one’s ability to transport and use oxygen improves, regular daily activities can be performed with less fatigue. This is particularly important for patients with cardiovascular disease, whose exercise capacity is typically lower than that of healthy individuals. There is also evidence that exercise training improves the capacity of the blood vessels to dilate in response to exercise or hormones, consistent with better vascular wall function and an improved ability to provide oxygen to the muscles during exercise. Studies measuring muscular strength and flexibility before and after exercise programs suggest that there are improvements in bone health and ability to perform daily activities, as well as a lower likelihood of developing back pain and of disability, particularly in older age groups.

Patients with newly diagnosed heart disease who participate in an exercise program report an earlier return to work and improvements in other measures of quality of life, such as more self-confidence, lower stress, and less anxiety. Importantly, by combining controlled studies, researchers have found that for heart attack patients who participated in a formal exercise program, the death rate is reduced by 20% to 25%. This is strong evidence in support of physical activity for patients with heart disease.

How Much Exercise is Enough?

Unfortunately, most Americans do not meet the minimum recommended guidelines for daily exercise. In 1996, the release of the Surgeon General’s Report on Physical Activity and Health provided a springboard for the largest government effort to date to promote physical activity among Americans. This redefined exercise as a key component to health promotion and disease prevention, and on the basis of this report, the Federal government mounted a multi-year educational campaign. The Surgeon General’s Report, a joint CDC/ACSM consensus statement, and a National Institutes of Health report agreed that the benefits mentioned above will generally occur by engaging in at least 30 minutes of modest activity on most, if not all, days of the week. Modest activity is defined as any activity that is similar in intensity to brisk walking at a rate of about 3 to 4 miles per hour.

These activities can include any other form of occupational or recreational activity that is dynamic in nature and of similar intensity, such as cycling, yard work, and swimming. This amount of exercise equates to approximately five to seven 30-minute sessions per week at an intensity equivalent to 3 to 6 METs (multiples of the resting metabolic rate*), or approximately 600 to 1200 calories expended per week.

How Can a Personal Trainer Help?

If you have cardiovascular disease or are at risk for developing disease, you may be apprehensive at starting an exercise program. You may have questions such as:

  • Is exercise safe for me?
  • How long should I exercise?
  • How frequently should I exercise?
  • Do I stretch before or after exercise?
  • Can I do strength training and lift weights?
  • How do I know if I’m exercising at the right intensity?
  •  What if I develop symptoms such as dizziness, light-headedness, or nausea?

A personal trainer or exercise professional can answer all of these questions for you and establish a well-rounded exercise program that is safe and effective.

A personal trainer will tell you what types of aerobic exercise are most appropriate for you and devise an exercise program tailored towards your needs. This will include guidelines for frequency (how many times per week), intensity (how hard you should exercise), and duration (how long each exercise session should last). A well-designed exercise routine will start with a warm-up that includes dynamic movements designed to raise the heart rate, increase core temperature, mobilize the major joints in the body, and prepare the body for more intense exercise. Warm-up can be followed by either aerobic exercise or weight training. Your trainer can monitor your heart rate and blood pressure during both activities to make sure you are exercising at the proper intensity. If heart rate and blood pressure get too high, your trainer will have you decrease the intensity of exercise or stop. If you develop any symptoms while exercising, your trainer will be right there to advise you and check your vital signs. Weight training is very safe as long as it is performed with proper supervision. Your trainer will recommend the most appropriate exercises for you to do and emphasize proper breathing and technique. Under the guidance of an exercise professional, you can help to improve aerobic capacity, decrease blood pressure and cholesterol, improve good cholesterol, lower blood glucose, improve muscular strength, increase joint range of motion, and lower weight and body fat. All of these will result in a lower risk for developing cardiovascular disease or if you already have disease, it will decrease the chances of subsequent cardiovascular events. Most importantly, working with an exercise professional will extend your lifespan and greatly improve the quality of your life.


Eric Lemkin is a certified personal trainer, strength & conditioning specialist, corrective exercise specialist and founder of Functionally Active Fitness. Lemkin has been a certified personal trainer for 17 years and has helped people ages 8-80 reach their fitness goals through customized personal training – specializing in exercise for the elderly or handicapped. 

References

  • Kochanek KD, Xu JQ, Murphy SL, Miniño AM, Kung HC. Deaths: final data for 2009 [PDF-2M]. National vital statistics reports. 2011;60(3).
  • Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB, et al. Heart disease and stroke statistics—2012 update: a report from the American Heart Association . Circulation. 2012;125(1):e2–220.
  • Heron M. Deaths: Leading causes for 2008 [PDF-2.7M]. National vital statistics reports. 2012;60(6).
  • Heidenriech PA, Trogdon JG, Khavjou OA, Butler J, Dracup K, Ezekowitz MD, et al. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation. 2011;123(8):933–44.
  • CDC. Million Hearts™: strategies to reduce the prevalence of leading cardiovascular disease risk factors. United States, 2011. MMWR 2011;60(36):1248–51.