Well said by Kofi Annan “It is my aspiration that health will finally be seen not as a blessing to be wished for, but as a human right to be fought for.” (Atlas Intellectual Disability 2007)
1. Introduction
Health care for majority of the Indians is considered as a blessing. There are huge differences in the distribution and access towards the healthcare facilities. Religions, castes, gender, regional, different systems of medicine, health System, economical bias3[1] are some of the major bias, towards the distribution of the health care facilities. India has 1.2 Billion populations out of which about 1/3rd is illiterate population. How do we create awareness to such huge mass with so much of diversity and so many different faiths? These days it has been observed a change in the distribution of diseases from the communicable to the Non-communicable (life style related disorders). This is the result of industrialization and the rapid migratory population to the cities.
2. International Scenario
Non-communicable diseases (NCDs), namely cancers, cardiovascular disease, chronic respiratory diseases and diabetes, are chronic, costly but largely preventable diseases. These four diseases share common modifiable risk factors and are a major cause of poverty, a barrier to economic development, and a serious threat to the achievement of the UN Millennium Development Goals (MDGs). In 2009, the UN Secretary General Ban Ki-moon described the
global NCD epidemic as a “public health emergency in slow emotion”.3
NCDs are the world’s number one killer, causing 60% of all deaths globally. A staggering 35 million people die every year from these silent killers, of which 18 million are women.1 NCDs represent the biggest threat to women’s health worldwide, increasingly impacting on women in developing countries in their most productive years. The costs of NCDs to families and societies are high and escalating, in terms of healthcare and lost productivity. For these reasons, NCDs have been identified as a global risk, and one of the most important threats to businesses and
economies.2
In the next 10 years it is expected that, India will add 120 million people in the working age category. Currently, India has about 2/3rd of the population below 35 years in age. Currently, 2/3rd of India lives in rural India and probably, in that category, healthcare does not figure in the list of priorities. 2/3rd of India does not have adequate access to healthcare. Awareness and sensitization about healthcare is missing. People will go and splurge money on dining outside, but will not spend a fraction in wellness. Indian’s believes more on religion, spirituality and charity than wellness. How do we make a transit from the role of religion, spirituality and beliefs on health to the reality of what health means? Healthcare professionals available are not willing to work in the so called rural India. At max, they are willing to work in semi urban India .The incidence of diseases is not vastly different in rural India from that of urban India for most of the ailments .Status of urban poor is deplorable when it comes to healthcare.
3. Indian Scenario
Only 20% of the healthcare in India is contributed by the government and reaming 80% of the healthcare is by the private sector/Public Private Partnership/NGO/National and International health organizations.
From the report by the Ministry of Health and Family welfare on the Burden of disease in India, it shows the leading cause of death in 2004 as 50.1 % of the deaths were from the Non-Communicable Diseases.
According Burden of disease in India by DALYSto
• Non-communicable diseases:
– Cardiovascular diseases (31%)
– Mental illnesses (26%)
– Cancer (10%)
• Communicable diseases:
– Acute respiratory infections (ARI, e.g. pneumonia) (18%)
– Perinatal illnesses (around childbirth) (17%)
– Diarrhoea (16%)
– Tuberculosis (6%)
– HIV (4%)
– Malaria (3%)
# Amongst the Non-Communicable Diseases- Cardiovascular diseases contributes (31%), Mental Illness (26%) and Cancer contributes (10%) . Whereas for communicable diseases Acute respiratory infections (ARI, e.g. pneumonia) contributes (18%), the second major contribution is by Perinatal illnesses (around childbirth) which contributes by (17%), Diarrhoea by (16%), followed by Tuberculosis (6%) and rest is 7 % is contributed by HIV (4 %) and Malaria (3%).
Recent estimates,
# NCMH Background papers predicts that deaths due to CVD in 2015 would be as high as 6.4 crore. Deaths due to CVD would be more than double. Most of this increase will occur due to coronary heart disease (AMI,Angina,CHF and Inflammatory heart disease)
200
5 India’s Share in Non -communicable Diseases
Table 1. Health conditions and disability-adjusted life-years (DALYs) lost in India, 1998 Share in the total burden
DALYs lost of disease Disease/health condition ( x 1000) (%)
| Communicable diseases, maternal and perinatal conditions | |
| Tuberculosis | 7,577 2.8 |
| HIV/AIDS | 5,611 2.1 |
| Diarrhoeal diseases | 22,005 8.2 |
| Malaria and other vector-borne conditions | 4,200 1.6 |
| Leprosy | 208 0.1 |
| Childhood diseases | 14,463 5.4 |
| Otitis media | 475 0.1 |
| Maternal and perinatal conditions | 31,207 11.6 |
| Others | 49,517 18.4 |
| Non-communicable conditions | |
| Cancers | 8,992 3.4 |
| Diabetes | 1,981 0.7 |
| Mental illness | 22,944 8.5 |
| Blindness | 3,699 1.4 |
| Cardiovascular diseases | 26,932 10.0 |
| COPD and asthma | 4,061 1.5 |
| Oral diseases | 1,247 0.5 |
| Others | 18,801 7.0 |
| Injuries | 45,032 16.7 |
| All listed conditions | 200,634 74.6 |
| Others | 68,319 25.4 |
COPD: chronic obstructive pulmonary disease Source: Peters et al. 2001
4. The need of the hour
A challenge of epidemic proportions and its socio-economic and developmental impacts
14. Note with profound concern that, according to WHO, in 2008, an estimated 36 million of the 57 million global deaths were due to non-communicable diseases, principally cardiovascular diseases, cancers, chronic respiratory diseases and diabetes, including about 9 million before the age of 60, and that nearly 80 per cent of those deaths occurred in developing countries;
Life style related disorders/diseases are all the impact of the rapidly growing urbanization, where human beings are more treated as machines and they are less concerned with their individual wellness. Research shows that these diseases could be prevented if proper care was taken with diet, ergonomics, back care, exercises etc. If we calculate the loss due to the NCD’s d, it puts a lot of burden (financial, mental, and social) on the patients which could be prevented. More researches need to be done on how the preventive health care programs could be bringing down to the grass root level and also the involvement of the community.
Note with grave concern that non-communicable diseases and their risk factors lead to increased burdens on individuals, families and communities, including impoverishment from long-term treatment and care costs, and to a loss of productivity that threatens household income and leads to productivity loss for individuals and their families and to the economies of Member States, making non-communicable diseases a contributing factor to poverty and hunger, which may have a direct impact on the achievement of the internationally agreed development goals, including the Millennium Development Goals;
5. United Nations on NCD
All member countries assembled at the United Nations from 19 to 20 September 2011, to address the prevention and control of non-communicable diseases worldwide, with a particular focus on developmental and other challenges and social and economic impacts, particularly for developing countries. Finally they agreed upon a common a resolution in form of a declaration (Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases). Some of the major points about this declaration are:-
1. Global burden and threat of non-communicable diseases constitutes one of the major challenges for development in the twenty-first century, which undermines social and economic development throughout the world, and threatens the achievement of internationally agreed development goals;
2. Members recognize that non-communicable diseases are a threat to the economies of many Member States, and may lead to increasing inequalities between countries and populations;
3. Members recognize the primary role and responsibility of Governments in responding to the challenge of non communicable diseases and the essential need for the efforts and engagement of all sectors of society to generate effective responses for the prevention and control of non-communicable diseases;
4. Members recognize also the important role of the international community and international cooperation in assisting Member States, particularly developing countries, in complementing national efforts to generate an effective response to non-communicable diseases;
5. Members reaffirm the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.
Risk factors
There are numerous risk factors associated with the NCD and so it is hard to find the exact risk factor that is causing the disease. WHO identifies the six leading risk factors that are associated with non-communicable diseases as being the leading global risk factors for death today2:
The six leading risks factors associated with non-communicable diseases
1. Tobacco Use
2. Physical Inactivity
3. Overweight/Obesity
4. High Blood Pressure
5. High Cholesterol Levels
6. High Blood Glucose Levels
7. Children and NCD
“No child should die unnecessarily without care” and certainly “no child should suffer” if we have the means to prevent it.
No disease is there which may not affect the children; children are at high risk for the NCD.
Why do we need to integrate children with NCD’s ?
1. NCD’s effect children
2. Children have right to health and life
3. A life course approach to NCD prevention and risk factors is vital
4. Strengthening paediatric health systems is important
8. Adults
The Indian Diabetes Epidemic
Diabetes is a life-long, incurable disease marked by high blood sugar levels. It is estimated that almost 41 million Indians are diabetic, and that figure is expected to reach 73.5 million by 2025. The total annual cost to treat India’s diabetic patients (including direct and indirect expenses) is estimated at $420 per capita. If that per capita expenditure were to remain constant, the total estimated cost of treating the disease would reach $30 billion by 2025.
Indians seem more vulnerable to Type 2 diabetes. This form of the disease can be caused by genetics but also obesity, and it can lead to amputations, heart failure and blindness. In addition to lifestyle changes that are
causing diabetes—the dietary excess, reduced physical activity and increased stress associated with more affluence—Indians have a strong genetic vulnerability to the disease.
“ Young people are entering the prime of their lives to discover that they are infected with a metabolic ‘virus’ that may lead to cardiovascular disease, diabetes, cancers. They acquired this virus through no real fault of their own, by being exposed to modern lifestyles and unhealthy urban environments. The only way to move forward is to reclaim ownership of how the world and our future are shaped. ”
Dr Amina Aitsi-Selmi, London33
9. Ageing
India will be reaching the expected nine billion mark around 2050. That is only one side of the story and the problem there off. Out of this 9 billion people in 2050, a large chunk of them would be from developing countries with India’s share being close to 2 billion. Secondly the “grandparents boom” would become clearly visible and pose a major problem to the countries concerned and to the world at large. This means a significant percentage (according to my rough estimate-10%) of this 9 billion people would be in the age bracket of 60 and above. More than 150 million of this global aging population will be from India. This demography is likely to bring up peculiar challenges including the national budgets for aged, health care problems, retirement policies, and utilization of the elderly and social management of the aged.
11. Women and NCD’s
‘Each year, millions of women and children die from preventable causes. These are not mere statistics. They are people with names and faces. Their suffering is unacceptable in the 21st century’,
Ban Ki-moon,
United Nations Secretary-General
Global Strategy for Women’s
and Children’s Health,
September 2010
Failure to act now on NCDs will undermine development gains made to date, including progress
made on women’s empowerment. Recognising the importance of women’s contribution to society in both their productive and reproductive roles as well as consumers and providers of healthcare, will enable real progress in turning back the global epidemic of NCDs. Together, with the political will and the right policies, we can stop the millions of preventable NCD-related deaths for women, men, girls, boys and future generations.
Rank Cause Number of deaths %
| 1 | Cardiovascular diseases | 9,127,416 | 33.2% |
| 2 | Infectious and parasitic diseases | 3,811,044 | 13.9% |
| 3 | Cancer | 3,566,128 | 13.0% |
| 4 | Respiratory diseases | 2,018,967 | 7.3% |
| 5 | Respiratory infections | 1,812,342 | 6.6% |
| 6 | Unintentional injuries | 1,408,698 | 5.1% |
| 7 | Perinatal conditions | 1,379,337 | 5.0% |
| 8 | Digestive diseases | 865,847 | 3.1% |
| 9 | Diabetes mellitus | 723,273 | 2.6% |
| 10 | Neuropsychiatric conditions | 640,406 | 2.3 % |
| | Total | | 27,501,236 |
Individual understanding of the health science, illness and disease would not enable me to reach the wider community for health care delivery, but it should also involve the understanding of the wider population, their needs, strengths and constraints along with an understanding of effective policies. The health of a nation is sum total of health of its citizens, communities and environment where the individuals are living. A healthy nation would only be possible if there is total participation of its citizens, communities and the government in this goal. In other words the barriers towards the health care access could be numerous, like- economical, geographical, cultural, policy, attitudes, education, gender etc. So just by learning best practices in clinical practice would not help in understanding of the health but it would also involve an understanding of health policy, management, health economy, planning, research, evaluation and survilliance.
There is need for the improvement in the areas of - Urban Health, Rural Health, Tribal Health, Health in hilly areas, Health for private sector, Work Place wellness, Healthcare amongst Minorities, Geriatric care in urban & rural health , Health care in disaster and healthcare for refuges, Mother and Child care. It is shocking to note that According to International Institute of Population Sciences, Mumbai, 56 % of the Indian women in the age group of 15-49 suffer from anemia.
10. Effective policy making, evaluation and surveillance
NCD surveillance
− Monitor outcomes (morbidity and mortality)
− Monitor exposures (risk factors)
− Monitor health system capacity and response
(interventions)
Multisectoral partnerships and health-in-all-policies
approaches that involve all government departments
− Develop national multisectoral plans
− Establish an effective multisectoral coordination mechanisms
− Establish cross-cluster action teams, in particular with Ministries of Agriculture, Education, Finance, Planning,
Social Affairs and Welfare, Trade, and Transport
− Engage with the private sector not affiliated with the tobacco industry, and partner with civil society
Multisectoral partnerships and health-in-all-policies
approaches that involve all government departments
− Develop national multisectoral plans
− Establish an effective multisectoral coordination mechanisms
− Establish cross-cluster action teams, in particular with Ministries of Agriculture, Education, Finance, Planning,
Social Affairs and Welfare, Trade, and Transport
− Engage with the private sector not affiliated with the tobacco industry, and partner with civil society
6.Prevention and control of NCD’s
There is clear evidence that preventive interventions work and that improved access to
health care can reduce the burden of morbidity, disability and premature mortality1
Physical inactivity
Physical activity reduces the risk of NCDs. It also promotes wellbeing, physical and mental
health, and can sustain independent living in older adults as well as social connectedness. Promoting physical activity through the media (in combination with a healthy diet) has been estimated to be a cost-effective, low-cost and highly feasible option7. The cost-effectiveness of other potential strategies is being assessed.
Reduce risk factors and create health-promoting environments
Advance the implementation of multisectoral, cost-effective, population-wide interventions in order to reduce the impact of the common non-communicable disease risk factors, namely tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol, through the implementation of relevant international agreements and strategies, and education, legislative, regulatory and fiscal measures, without prejudice to the right of sovereign Nations to determine and establish their taxation policies, other policies, where appropriate, by involving all
relevant sectors, civil society and communities as appropriate and by taking the following actions:
(a) Encourage the development of multisectoral public policies that create equitable health-promoting environments that empower individuals, families and communities to make healthy choices and lead healthy lives;
(b) Develop, strengthen and implement, as appropriate, multisectoral public policies and action plans to promote health education and health literacy, including through evidence-based education and information strategies and programmes in and out of schools, and through public awareness campaigns, as important factors in
furthering the prevention and control of non-communicable diseases, recognizing that a strong focus on health literacy is at an early stage in many countries;
Role of PT
Health Promotion
Health Promotion in Physical Therapy- Many health care professionals, including physical therapists, are needed to lead and develop health promotion plans and strategies in the work forces in order to assist the nation in achieving Healthy People 2010 and 2020 goals (Rea, Marshak, Neish and Davis, 2004).
Physical therapists’ educational and practice guidelines currently emphasize inclusion of health promotion (Martin and Fell, 1999).
Education/Advocacy
Educate to restore movement and reduce pain
Encourage patients/patient to take charge of their health by teaching techniques for recovery, pain relief, injury prevention and improved physical movement, with emphasis on what the patient can do for her/himself
Promote independence and facilitate patients assuming responsibility for their rehabilitation and self-care social interaction enabling safe community access and participation.
WCPT on NCD
For physical therapists, the official recognition that a global strategy is required to reduce this burden of disability and deaths is highly significant. The profession of physical therapy, known in some countries as physiotherapy, helps millions of people every year to prevent these conditions and their risk factors – most importantly obesity. They also manage their effects, along with the effects of aging, illness, accidents, and the stresses and strains of life. Physical therapists specialize in human movement and physical activity, promoting health, fitness, and wellness. They identify physical impairments, limitations, and disabilities that prevent people from being as active and independent as they might be, and then they find ways of overcoming them. They maximize people’s movement potential.
So when the World Health Organization points out that physical inactivity is one of the leading risk factors for global mortality, causing 3.2 deaths annually, and that physical activity can reduce non-communicable diseases, it is clear that the profession has a major part to play.
Dr Marilyn Moffat, President of WCPT (2011).
Prevention and management of diabetes: the role of the physiotherapist
As the diabetes epidemic grows in size and complexity, there is an increasing realization that physicians alone are unable to provide the care required by people with diabetes. To help them live life to the fullest, people with the condition need the services of a range of healthcare personnel, including diabetes nurses, dietitians, podiatrists, psychologists and eye specialists. The role of most of these is well defined; the multi-disciplinary team approach benefits increasing numbers of people with diabetes worldwide.
Preventing diabetes
The Diabetes Prevention Project done by Sanjay Kalra, Bharti Kalra, Naresh Kumar it clearly showed that lifestyle modification, including intensive exercise, is more effective in preventing diabetes than pharmacological therapy, and highlighted the role of trained professionals in motivating people to follow lifestyle interventions.1 physiotherapy leads to metabolic improvements even in the absence of weight loss, reducing the frequency of cardiovascular events and improving life expectancy. Effective exercise counseling ensures both cardio-respiratory and musculoskeletal fitness.1 Physiotherapists, with their knowledge of physiology and anatomy, can suggest specific exercises for people with coexisting complications, cautioning against certain movements that might be detrimental to their health. For example, an isotonic exercise like jogging will benefit a person with high blood pressure and diabetes, but the repeated foot trauma associated with jogging may harm someone with peripheral sensory neuropathy or Charcot foot. Physiotherapy can play an important role in preventing and managing foot problems. TENS and IFT are considered gold-standard therapies for the relief of neuropathic pain, and have proven benefits in the management of painful diabetic neuropathy, oedema (build-up of fluid in tissue) and resistant foot ulcers. In people who are unfortunate enough to undergo an amputation, the physiotherapist helps with post-operative pain relief, rehabilitation, limitation of disability, and the optimum use of prostheses.
Benefits of supervised group program for women being treated for early stages of Breast cancer: Pragmatic Randomized control trial. Supervised group exercise provided functional and psychological benefit after a 12 week intervention and 6 months later. Clinicians should encourage activity for their patients. (BMJ)
GUIDELINES ON PREVENTION IN LOW BACK PAIN
Summary of the concepts of prevention in low back pain (LBP):
• The general nature and course of commonly experienced LBP means that there is limited scope for preventing its incidence (first-time onset). Prevention, in the context of this guideline, is focused primarily on reduction of the impact and consequences of LBP.
• Primary causative mechanisms remain largely undetermined: risk factor modification will not necessarily achieve prevention.
• There is considerable scope, in principle, for prevention of the consequences of LBP – e.g. episodes (recurrence), care seeking, disability, and workloss.
• Different interventions and outcomes will be appropriate for different target populations (general population, workers, and children) yet inevitably there is overlap.
• Interventions that are essentially treatments in the clinical environment, focused on management of current symptoms, are not considered as ‘prevention’ for the purposes of this guideline: they are covered in the accompanying clinical guidelines
Overarching comments:
• Overall, there is limited robust evidence for numerous aspects of prevention in LBP.
• Nevertheless, there is evidence suggesting that prevention of various consequences of LBP is feasible.
• However, for those interventions where there is acceptable evidence, the effect sizes are rather modest.
• The most promising approaches seem to involve physical activity/exercise and appropriate (biopsychosocial) education, at least for adults.
• But, no single intervention is likely to be effective to prevent the overall problem of LBP, owing to its multidimensional nature.
• Prevention in LBP is a societal as well as an individual concern.
• So, optimal progress on prevention in LBP will likely require a cultural shift in the way LBP is viewed, its relationship with activity and work, how it might best be tackled, and just what is reasonable to expect from preventive strategies.
• It is important to get all the players onside, but innovative studies are required to understand better the mechanisms and delivery of prevention in LBP.
• Anecdotally, individuals may report that various strategies work for them, but in the absence of scientific evidence that does not mean they can be generally recommended for prevention; it is not known whether some of these strategies have disadvantageous long-term effects.
WCPT on CBR
CBR is a means of improving equitable access to rehabilitation and ensuring effective use of scarce resources. In partnership with CBR workers and disabled people, physical therapists have a range of key roles to play(6).Some of these roles may provide new challenges for education and practice. Physical therapists may be project initiators. Alternatively they may be external facilitators invited to support services established and owned by DPOs. Roles will also be shaped by:
• the level of commitment to CBR within the health care system
• the current pattern of deployment of physical therapists and their numbers
• the potential for gaining community experience relevant to PHC and CBR during physical therapy qualifying education
• the level of community awareness about the potential of physical therapy to effect positive change in health status and social participation of disabled people.
It is to expand and improve early childhood care and education;
• achieve free, compulsory and quality primary education for all;
• ensure equal access to appropriate learning, life skills programmes and basic and continuing education for all adults;
• promote gender equality;
• facilitate inclusion of marginalized, vulnerable and discriminated groups at all levels.
The main focus of prevention in health care is to stop health conditions from occurring (primary prevention). However, prevention also involves early detection and treatment to stop the progression of a health condition (secondary prevention) and management to reduce the consequences of an existing health condition (tertiary prevention). This element mainly focuses on primary prevention.
• Rehabilitation for a young girl born with cerebral palsy might include play activities to encourage her motor, sensory and language development, an exercise programme to prevent muscle tightness and development of deformities and provision of a wheelchair with a specialized insert to enable proper positioning for functional activities.
• Rehabilitation for a young boy who is deaf blind might include working with his parents to ensure they provide stimulating activities to encourage development, functional mobility training to enable him to negotiate his home and community environments and teaching appropriate communication methods such as touch and signs.
• Rehabilitation for an adolescent girl with an intellectual impairment might include teaching her personal hygiene activities, e.g. menstrual care, developing strategies with the family to address behavioral problems and providing opportunities.
Take home message.
Prevention is better than cure.
1.Ageing- Should India Promote Scientific Research on Aging?
Prof Kalluri Subba Rao. *Hon. Coordinator for Center for Research and Education in Aging (CREA)
University of Hyderabad
Hyderabad- 500046. India
ksrsl@yahoo.com
Women-
2. World Economic Forum (2010) Global Risks Report Cologny/Geneva
3.Non-Communicable Diseases: PRIORITY FORWOMEN’S HEALTH AND DEVELOPMENT; The NCD Alliance, Putting non-communicable diseases on the global agenda.
Ban Ki-moon,
United Nations Secretary-General
Global Strategy for Women’s
and Children’s Health,
September 2010
4. Surrvilance,POLICY, PLAN
Combating Noncommunicable Diseases Leadership agenda for action, WHO(2010)
5.Prevention and control of NCD
7.Cecchini M, Sassi F, Lauer JA, Lee YY, Guajardo-Barron V, Chisholm D (2010). Tackling of unhealthy diets, physical inactivity, and obesity: health effects and cost-effectiveness. Lancet, 376: 1775-84.
6.PREVENTION
1. Resolution WHA53.14. Global strategy for the prevention and control of non-communicable diseases. In: Fifty-third
World Health Assembly, Geneva, 22 March 2000. Geneva, World Health Organization, 2000.
7. Children
NCD Alliance briefing paper on children and NCD AND NCD’s children in every policy :Reccomendation for a lifecourse approach to NCDS.May2011
8. 4,6,5) Prevention,UN need of the hour Draft resolution submitted by the President of the UN General Assembly,Political declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases ;( 66 Session) 16 September 2011
9. ROLE OF PT
Dr. Barry P. Hunt Ed D
Professor of Health Promotion
Department of Food Science, Nutrition and Health Promotion
P.O. 9805
Mississippi State University
MSU, MS 39762
E-Mail: bhunt@fsnhp.msstate.edu
10.Role of PT
American Physical Therapy Association (2009). About APTA. Retrieved on June 1, 2009
From
11.Education advocacy- Guide to Interdisciplinary Team Roles and Responsibilities July 4, 2005
Physiotherapy Act, 1991, S.O. 1991, c.37, available at:
http://www.e-laws.gov.on.ca/DBLaws/Statutes/English/91p37_e.htm (Canada)
12.Diabetes Voice: September 2007 | Volume 52 | Issue 3Prevention and treatment of Diabetes : Sanjay Kalra, Bharti Kalra, Naresh Kumar
References
13. 1 Holman R. Should we treat impaired glucose tolerance and impaired fasting glycemia? In: DeFronzo RA, Ferrannini E, Keen H, Zimmet P, eds. International Textbook of Diabetes Mellitus, 3rd ed. John Wiley. Chichester, 2004: 771-94.
2 Kalra S, Kalra B, Nanda G. Transcutaneous electric nerve stimulation (TENS) in diabetic neuropathy. Diabetologia 2006; 49(Suppl 1): 121
Supervised exercise program women breast cancer : (Nanette Mutrie: Proffesor of exercise and sports psychology,Anna M Campbell, etal)www.bmj.com
Primary Health care :A resource guide for Physical Therapist: Canadian Physiotherapist Association, Alberta Physiotherapy Association, Canadian Physiotherapy association (2007)
Low back pain
14. EUROPEAN GUIDELINES FOR PREVENTION IN LOW BACK PAIN November 2004,
AK Burton F Balagué G Cardon, HR Eriksen Y Henrotin A Lahad, A Leclerc G Müller AJ van der Beek
Child
15. Convention on the Rights of Persons with Disabilities. New York, United Nations, 2006 (www.un.org/
disabilities/, accessed 30 March 2010).
1. Constitution of the World Health Organization. Geneva, 2006 (www.who.int/governance/eb/who_
constitution_en.pdf, accessed 30 May 2010).
2. Convention on the Rights of Persons with Disabilities. New York, United Nations, 2006 (www.un.org/
disabilities/, accessed 30 March 2010).
4. The right to health (Fact Sheet No. 31). Geneva, Office of the United Nations High Commissioner
for Human Rights/World Health Organization, 2008 (www.ohchr.org/Documents/Publications/
Factsheet31.pdf, accessed 30 May 2010).
16.A Focus on Children and Non-Communicable Diseases (NCDs), REMEMBERING OUR FUTURE AT THE UN SUMMIT ON NCDs, SEPTEMBER 2011
CVD INDIA
17.Cardiovascular Disease Trends in India 11/16/06 Naresh Trehan,Escorts Heart Institute and Research Centre, New Delhi, India
18. Global health risks: mortality and burden of disease attributable to selected major risks. Geneva: World Health Organization, December
2009. (Accessed September 2, 2010, at http://www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf.)
19. . World Confederation for Physical Therapy. Primary Health Care and Community Based Rehabilitation: Implications for physical therapy based on a survey of WCPT’s Member Organisations and a literature review. WCPT Briefing Paper 1. London, WCPT, 2001.
20.World Confederation for Physical Therapy 2011Dr Marilyn Moffat, President of WCPT.
21.Emerging Market Report: Health in India 2007 PricewaterhouseCoopers – India Diabetes
22.Burden Of Disease in INDIA: MINISTRY OF HEALTH AND FAMILY WELFARE
GOVERNMENT OF INDIA, 2005
No comments:
Post a Comment