stroke connection

Staff and Consultants:

Dennis Milne, Vice President, American Stroke Association

Wendy Segrest, Director, American Stroke Association Operations

Debi McGill, Editor-in-Chief

Jon Caswell, Lead Editor

Mike Mills, Writer

Sam Gaines, Writer

Pierce Goetz, Art Director

Michelle Neighbors, Advertising Sales

Copyright 2005 American Heart Association ISSN 1047-014X

Stroke Connection Magazine is published six times a year by the American Stroke Association, a division of the American Heart Association. Material may be reproduced only with appropriate acknowledgment of the source and written permission from the American Heart Association. Please address inquiries to the Editor-in-Chief. The information contained in this publication is provided by the American Stroke Association as a resource. The services or products listed are not owned or provided by the American Stroke Association. Additionally, the products or services have not been evaluated and their listing should not be construed as a recommendation or endorsement of these products or services.1-888-4STROKE (1-888-478-7653) StrokeAssociation.org

contents November/December 2005

20

26 30Stroke Connection Magazine is underwritten

in part by Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership, makers of Plavix.

Feature StoryPaying for Long-Term Care 20

Alternatives for funding the ongoing needs of survivors

ArticlesMaximizing Insurance Benefits for

Physical Therapy 18More physical therapy, more independence —

one expert’s thoughts on how to get the most from your insurance

Other Measures 26“‘Train To End Stroke’ helped me prove to myself

that stroke survivors can set lofty goals and achieve them, just like anybody else.”

The Risky Business of Lighting Up 28Smoking is still the No. 1 cause of preventable deaths in this country.

Papa’s Choice 30Because her father could no longer speak for himself,

Doris Thurston made sure his voice was heard.

Ropin’ Recovery 33Survivor Larry Pemberton knows what to do with the horns of a dilemma — lasso them!

DepartmentsLetters to the Editor 4

Stroke Notes 7 Readers Room 12

Life at the Curb 32 Everyday Survival 34

a division of

Produced and distributed in cooperation with Vitality Communications

November/December 2005 �

Item No: B1-K0197 Trim Size: 8 1/4" x 10 3/4" Publication: Stroke Connection

YOU DON’T WANT ANOTHERHEART ATTACK OR ANOTHERSTROKE TO SNEAK UP ON YOU.

PLAVIX HELPS KEEP BLOOD PLATELETSFROM STICKING TOGETHER AND FORMINGCLOTS, WHICH HELPS PROTECT YOU FROMANOTHER HEART ATTACK OR STROKE.If you’ve had a heart attack or stroke, the last thing youneed is another one sneaking up on you. PLAVIX mayhelp. PLAVIX is a prescription medication for peoplewho have had a recent heart attack or recent stroke, orwho have poor circulation in the legs, causing pain(peripheral artery disease).

PLAVIX OFFERS PROTECTION.PLAVIX is proven to help keep blood platelets fromsticking together and forming clots, which helps keepyour blood flowing. This can help protect you fromanother heart attack or stroke.

IMPORTANT INFORMATION: If you have a stomachulcer or other condition that causes bleeding, youshouldn't use Plavix. When taking Plavix alone or withsome medicines including aspirin, the risk of bleedingmay increase.To minimize this risk, talk to your doctorbefore taking aspirin or other medicines with Plavix.Additional rare but serious side effects could occur.

WITHOUT PLAVIX WITH PLAVIX

PROVEN TO HELP PROTECT FROM ANOTHER HEART ATTACK OR STROKE

TALK TO YOUR DOCTOR ABOUT PLAVIX.For more information, visit www.plavix.com or call1-877-700-0701


© 2005 Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership.USA.CLO.05.08.12/September 2005 B1-K0197/09-05

B1K0197_StrokeConnectionAd 9/27/05 1:19 PM Page 1

November/December 2005�

Item No: B1-K0206 Trim Size: 8 1/4" x 10 3/4" Publication: Stroke Connection_IBC

PLAVIX®clopidogrel bisulfate tabletsRx onlyBrief Summary of Prescribing Information Rev. November 2004 INDICATIONS AND USAGEPLAVIX (clopidogrel bisulfate) is indicated for the reduction of thrombotic events asfollows:

• Recent MI, Recent Stroke or Established Peripheral Arterial DiseaseFor patients with a history of recent myocardial infarction (MI), recent stroke, orestablished peripheral arterial disease, PLAVIX has been shown to reduce therate of a combined endpoint of new ischemic stroke (fatal or not), new MI (fatalor not), and other vascular death.

• Acute Coronary SyndromeFor patients with acute coronary syndrome (unstable angina/non-Q-wave MI)including patients who are to be managed medically and those who are to bemanaged with percutaneous coronary intervention (with or without stent) orCABG, PLAVIX has been shown to decrease the rate of a combined endpoint ofcardiovascular death, MI, or stroke as well as the rate of a combined endpoint ofcardiovascular death, MI, stroke, or refractory ischemia.

CONTRAINDICATIONSThe use of PLAVIX is contraindicated in the following conditions:

• Hypersensitivity to the drug substance or any component of the product.• Active pathological bleeding such as peptic ulcer or intracranial hemorrhage.

WARNINGSThrombotic thrombocytopenic purpura (TTP): TTP has been reported rarely followinguse of PLAVIX, sometimes after a short exposure (<2 weeks). TTP is a serious condition and requires urgent referral to a hematologist for prompt treatment. It ischaracterized by thrombocytopenia, microangiopathic hemolytic anemia (schistocytes[fragmented RBCs] seen on peripheral smear), neurological findings, renal dysfunc-tion, and fever. TTP was not seen during clopidogrel's clinical trials, which includedover 17,500 clopidogrel-treated patients. In world-wide postmarketing experience,however, TTP has been reported at a rate of about four cases per million patientsexposed, or about 11 cases per million patient-years. The background rate is thoughtto be about four cases per million person-years. (See ADVERSE REACTIONS.)PRECAUTIONSGeneralAs with other antiplatelet agents, PLAVIX prolongs the bleeding time and thereforeshould be used with caution in patients who may be at risk of increased bleeding fromtrauma, surgery, or other pathological conditions (particularly gastrointestinal andintraocular). If a patient is to undergo elective surgery and an antiplatelet effect is notdesired, PLAVIX should be discontinued 5 days prior to surgery.

Due to the risk of bleeding and undesirable hematological effects, blood cell countdetermination and/or other appropriate testing should be promptly considered, when-ever such suspected clinical symptoms arise during the course of treatment (seeADVERSE REACTIONS).

GI Bleeding: In CAPRIE, PLAVIX was associated with a rate of gastrointestinal bleed-ing of 2.0%, vs. 2.7% on aspirin. In CURE, the incidence of major gastrointestinalbleeding was 1.3% vs. 0.7% (PLAVIX + aspirin vs. placebo + aspirin, respectively).PLAVIX should be used with caution in patients who have lesions with a propensity tobleed (such as ulcers). Drugs that might induce such lesions should be used with caution in patients taking PLAVIX.

Use in Hepatically Impaired Patients: Experience is limited in patients with severehepatic disease, who may have bleeding diatheses. PLAVIX should be used with caution in this population.

Use in Renally-impaired Patients: Experience is limited in patients with severe renalimpairment. PLAVIX should be used with caution in this population.Information for PatientsPatients should be told that they may bleed more easily and it may take them longer thanusual to stop bleeding when they take PLAVIX or PLAVIX combined with aspirin, and thatthey should report any unusual bleeding to their physician. Patients should inform physi-cians and dentists that they are taking PLAVIX and/or any other product known to affectbleeding before any surgery is scheduled and before any new drug is taken.Drug InteractionsStudy of specific drug interactions yielded the following results:

Aspirin: Aspirin did not modify the clopidogrel-mediated inhibition of ADP-inducedplatelet aggregation. Concomitant administration of 500 mg of aspirin twice a day for 1day did not significantly increase the prolongation of bleeding time induced by PLAVIX.PLAVIX potentiated the effect of aspirin on collagen-induced platelet aggregation. PLAVIX and aspirin have been administered together for up to one year.

Heparin: In a study in healthy volunteers, PLAVIX did not necessitate modificationof the heparin dose or alter the effect of heparin on coagulation. Coadministration ofheparin had no effect on inhibition of platelet aggregation induced by PLAVIX.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): In healthy volunteers receivingnaproxen, concomitant administration of PLAVIX was associated with increased occultgastrointestinal blood loss. NSAIDs and PLAVIX should be coadministered with caution.

Warfarin: Because of the increased risk of bleeding, the concomitant administration ofwarfarin with PLAVIX should be undertaken with caution. (See PRECAUTIONS–General.)

Other Concomitant Therapy: No clinically significant pharmacodynamic interactionswere observed when PLAVIX was coadministered with atenolol, nifedipine, or bothatenolol and nifedipine. The pharmacodynamic activity of PLAVIX was also not signifi-cantly influenced by the coadministration of phenobarbital, cimetidine or estrogen.

The pharmacokinetics of digoxin or theophylline were not modified by the coad-ministration of PLAVIX (clopidogrel bisulfate).

At high concentrations in vitro, clopidogrel inhibits P450 (2C9). Accordingly, PLAVIXmay interfere with the metabolism of phenytoin, tamoxifen, tolbutamide, warfarin,torsemide, fluvastatin, and many non-steroidal anti-inflammatory agents, but thereare no data with which to predict the magnitude of these interactions. Caution should beused when any of these drugs is coadministered with PLAVIX.

In addition to the above specific interaction studies, patients entered into clinical trials with PLAVIX received a variety of concomitant medications including diuretics,beta-blocking agents, angiotensin converting enzyme inhibitors, calcium antago-nists, cholesterol lowering agents, coronary vasodilators, antidiabetic agents(including insulin), antiepileptic agents, hormone replacement therapy, heparins(unfractionated and LMWH) and GPIIb/IIIa antagonists without evidence of clinicallysignificant adverse interactions. The use of oral anticoagulants, non-study anti-plateletdrug and chronic NSAIDs was not allowed in CURE and there are no data on their concomitant use with clopidogrel.Drug/Laboratory Test InteractionsNone known.Carcinogenesis, Mutagenesis, Impairment of FertilityThere was no evidence of tumorigenicity when clopidogrel was administered for 78 weeksto mice and 104 weeks to rats at dosages up to 77 mg/kg per day, which afforded plasma exposures >25 times that in humans at the recommended daily dose of 75 mg.

Clopidogrel was not genotoxic in four in vitro tests (Ames test, DNA-repair test inrat hepatocytes, gene mutation assay in Chinese hamster fibroblasts, and metaphasechromosome analysis of human lymphocytes) and in one in vivo test (micronucleustest by oral route in mice).

Clopidogrel was found to have no effect on fertility of male and female rats at oral doses up to 400 mg/kg per day (52 times the recommended human dose on amg/m2 basis).PregnancyPregnancy Category B. Reproduction studies performed in rats and rabbits at doses upto 500 and 300 mg/kg/day (respectively, 65 and 78 times the recommended dailyhuman dose on a mg/m2 basis), revealed no evidence of impaired fertility or fetotoxic-ity due to clopidogrel. There are, however, no adequate and well-controlled studies inpregnant women. Because animal reproduction studies are not always predictive of ahuman response, PLAVIX should be used during pregnancy only if clearly needed.Nursing MothersStudies in rats have shown that clopidogrel and/or its metabolites are excreted in themilk. It is not known whether this drug is excreted in human milk. Because many drugsare excreted in human milk and because of the potential for serious adverse reactions innursing infants, a decision should be made whether to discontinue nursing or to dis-continue the drug, taking into account the importance of the drug to the nursing woman.Pediatric UseSafety and effectiveness in the pediatric population have not been established.Geriatric UseOf the total number of subjects in controlled clinical studies, approximately 50% ofpatients treated with PLAVIX were 65 years of age and over. Approximately 16% ofpatients treated with PLAVIX were 75 years of age and over. The observed difference in risk of bleeding events with clopidogrel plus aspirin versusplacebo plus aspirin by age category is provided in the following table (see ADVERSEREACTIONS).

ADVERSE REACTIONSPLAVIX has been evaluated for safety in more than 17,500 patients, including over 9,000patients treated for 1 year or more. The overall tolerability of PLAVIX in CAPRIE was sim-ilar to that of aspirin regardless of age, gender and race, with an approximately equal inci-dence (13%) of patients withdrawing from treatment because of adverse reactions. Theclinically important adverse events observed in CAPRIE and CURE are discussed below.

Hemorrhagic: In CAPRIE patients receiving PLAVIX, gastrointestinal hemorrhageoccurred at a rate of 2.0%, and required hospitalization in 0.7%. In patients receivingaspirin, the corresponding rates were 2.7% and 1.1%, respectively. The incidence ofintracranial hemorrhage was 0.4% for PLAVIX compared to 0.5% for aspirin.

In CURE, PLAVIX use with aspirin was associated with an increase in bleeding com-pared to placebo with aspirin (see table below). There was an excess in major bleed-ing in patients receiving PLAVIX plus aspirin compared with placebo plus aspirin, pri-marily gastrointestinal and at puncture sites. The incidence of intracranial hemorrhage(0.1%), and fatal bleeding (0.2%), were the same in both groups.

The overall incidence of bleeding is described in the table below for patients receiv-ing both PLAVIX and aspirin in CURE, CURE Incidence of bleeding complications (% patients)Event PLAVIX Placebo P-value

(+ aspirin)* (+ aspirin)*(n=6259) (n=6303)

Major bleeding † 3.7 ‡ 2.7 § 0.001Life-threatening bleeding 2.2 1.8 0.13

Fatal 0.2 0.25 g/dL hemoglobin drop 0.9 0.9Requiring surgical intervention 0.7 0.7Hemorrhagic strokes 0.1 0.1Requiring inotropes 0.5 0.5Requiring transfusion ( 4 units) 1.2 1.0

Other major bleeding 1.6 1.0 0.005Significantly disabling 0.4 0.3Intraocular bleeding with

significant loss of vision 0.05 0.03Requiring 2-3 units of blood 1.3 0.9

Minor bleeding ¶ 5.1 2.4 <0.001* Other standard therapies were used as appropriate.† Life threatening and other major bleeding.‡ Major bleeding event rate for PLAVIX + aspirin was dose-dependent on aspirin:

<100 mg=2.6%; 100-200 mg= 3.5%; >200 mg=4.9%Major bleeding event rates for PLAVIX + aspirin by age were: <65 years = 2.5%, 65 to <75 years = 4.1%, 75 years 5.9%

§ Major bleeding event rate for placebo + aspirin was dose-dependent on aspirin: <100 mg=2.0%; 100-200 mg= 2.3%; >200 mg=4.0%Major bleeding event rates for placebo + aspirin by age were: <65 years = 2.1%, 65 to <75 years = 3.1%, 75 years 3.6%

¶ Led to interruption of study medication.

Ninety-two percent (92%) of the patients in the CURE study received heparin/LMWH, and the rate of bleeding in these patients was similar to the overall results.

There was no excess in major bleeds within seven days after coronary bypass graftsurgery in patients who stopped therapy more than five days prior to surgery (eventrate 4.4% PLAVIX + aspirin; 5.3% placebo + aspirin). In patients who remained on ther-apy within five days of bypass graft surgery, the event rate was 9.6% for PLAVIX +aspirin, and 6.3% for placebo + aspirin.

Neutropenia/agranulocytosis: Ticlopidine, a drug chemically similar to PLAVIX, isassociated with a 0.8% rate of severe neutropenia (less than 450 neutrophils/µL). InCAPRIE severe neutropenia was observed in six patients, four on PLAVIX and two onaspirin. Two of the 9599 patients who received PLAVIX and none of the 9586 patientswho received aspirin had neutrophil counts of zero. One of the four PLAVIX patients inCAPRIE was receiving cytotoxic chemotherapy, and another recovered and returned tothe trial after only temporarily interrupting treatment with PLAVIX (clopidogrel bisul-fate). In CURE, the numbers of patients with thrombocytopenia (19 PLAVIX + aspirinvs. 24 placebo + aspirin) or neutropenia (3 vs. 3) were similar.

Although the risk of myelotoxicity with PLAVIX (clopidogrel bisulfate) thus appearsto be quite low, this possibility should be considered when a patient receiving PLAVIXdemonstrates fever or other sign of infection.

Gastrointestinal: Overall, the incidence of gastrointestinal events (e.g. abdominalpain, dyspepsia, gastritis and constipation) in patients receiving PLAVIX (clopidogrelbisulfate) was 27.1%, compared to 29.8% in those receiving aspirin in the CAPRIE trial.In the CURE trial the incidence of these gastrointestinal events for patients receivingPLAVIX + aspirin was 11.7% compared to 12.5% for those receiving placebo + aspirin.

In the CAPRIE trial, the incidence of peptic, gastric or duodenal ulcers was 0.7% forPLAVIX and 1.2% for aspirin. In the CURE trial the incidence of peptic, gastric or duo-denal ulcers was 0.4% for PLAVIX + aspirin and 0.3% for placebo + aspirin.

Cases of diarrhea were reported in the CAPRIE trial in 4.5% of patients in the PLAVIX group compared to 3.4% in the aspirin group. However, these were rarelysevere (PLAVIX=0.2% and aspirin=0.1%). In the CURE trial, the incidence of diarrheafor patients receiving PLAVIX + aspirin was 2.1% compared to 2.2% for those receiv-ing placebo + aspirin.

In the CAPRIE trial, the incidence of patients withdrawing from treatment becauseof gastrointestinal adverse reactions was 3.2% for PLAVIX (clopidogrel bisulfate) and4.0% for aspirin. In the CURE trial, the incidence of patients withdrawing from treatment because of gastrointestinal adverse reactions was 0.9% for PLAVIX + aspirincompared with 0.8% for placebo + aspirin.

Rash and Other Skin Disorders: In the CAPRIE trial, the incidence of skin andappendage disorders in patients receiving PLAVIX was 15.8% (0.7% serious); the cor-responding rate in aspirin patients was 13.1% (0.5% serious). In the CURE trial theincidence of rash or other skin disorders in patients receiving PLAVIX + aspirin was4.0% compared to 3.5% for those receiving placebo + aspirin.

In the CAPRIE trial, the overall incidence of patients withdrawing from treatmentbecause of skin and appendage disorders adverse reactions was 1.5% for PLAVIX and 0.8% for aspirin. In the CURE trial, the incidence of patients withdrawing becauseof skin and appendage disorders adverse reactions was 0.7% for PLAVIX + aspirin compared with 0.3% for placebo + aspirin.

Adverse events occurring in 2.5% of patients on PLAVIX in the CAPRIE controlledclinical trial are shown below regardless of relationship to PLAVIX. The median dura-tion of therapy was 20 months, with a maximum of 3 years.Adverse Events Occurring in 2.5% of PLAVIX Patients in CAPRIE

% Incidence (% Discontinuation)Body System PLAVIX AspirinEvent [n=9599] [n=9586]Body as a Whole- general disorders

Chest Pain 8.3 (0.2) 8.3 (0.3)Accidental/Inflicted Injury 7.9 (0.1) 7.3 (0.1)Influenza-like symptoms 7.5 (<0.1) 7.0 (<0.1)Pain 6.4 (0.1) 6.3 (0.1)Fatigue 3.3 (0.1) 3.4 (0.1)

Cardiovascular disorders, generalEdema 4.1 (<0.1) 4.5 (<0.1)Hypertension 4.3 (<0.1) 5.1 (<0.1)

Central & peripheral nervous system disorders

Headache 7.6 (0.3) 7.2 (0.2)Dizziness 6.2 (0.2) 6.7 (0.3)

Gastrointestinal system disordersAbdominal pain 5.6 (0.7) 7.1 (1.0)Dyspepsia 5.2 (0.6) 6.1 (0.7)Diarrhea 4.5 (0.4) 3.4 (0.3)Nausea 3.4 (0.5) 3.8 (0.4)

Metabolic & nutritional disordersHypercholesterolemia 4.0 (0) 4.4 (<0.1)

Musculo-skeletal system disordersArthralgia 6.3 (0.1) 6.2 (0.1)Back Pain 5.8 (0.1) 5.3 (<0.1)

Platelet, bleeding, & clotting disordersPurpura/Bruise 5.3 (0.3) 3.7 (0.1)Epistaxis 2.9 (0.2) 2.5 (0.1)

Psychiatric disordersDepression 3.6 (0.1) 3.9 (0.2)

Respiratory system disordersUpper resp tract infection 8.7 (<0.1) 8.3 (<0.1)Dyspnea 4.5 (0.1) 4.7 (0.1)Rhinitis 4.2 (0.1) 4.2 (<0.1)Bronchitis 3.7 (0.1) 3.7 (0)Coughing 3.1 (<0.1) 2.7(<0.1)

Adverse Events Occurring in 2.5% of PLAVIX Patients in CAPRIE (continued)% Incidence (% Discontinuation)

Body System PLAVIX AspirinEvent [n=9599] [n=9586]Skin & appendage disorders

Rash 4.2 (0.5) 3.5 (0.2)Pruritus 3.3 (0.3) 1.6 (0.1)

Urinary system disordersUrinary tract infection 3.1 (0) 3.5 (0.1)

Incidence of discontinuation, regardless of relationship to therapy, is shown in parentheses.

Adverse events occurring in 2.0% of patients on PLAVIX in the CURE controlledclinical trial are shown below regardless of relationship to PLAVIX.Adverse Events Occurring in 2.0% of PLAVIX Patients in CURE

% Incidence (% Discontinuation)Body System PLAVIX Placebo

(+ aspirin)* (+ aspirin)*Event [n=6259] [n=6303]Body as a Whole- general disorders

Chest Pain 2.7 (<0.1) 2.8 (0.0)Central & peripheral nervous system disorders

Headache 3.1 (0.1) 3.2 (0.1)Dizziness 2.4 (0.1) 2.0 (<0.1)

Gastrointestinal system disordersAbdominal pain 2.3 (0.3) 2.8 (0.3)Dyspepsia 2.0 (0.1) 1.9 (<0.1)Diarrhea 2.1 (0.1) 2.2 (0.1)

*Other standard therapies were used as appropriate.

Other adverse experiences of potential importance occurring in 1% to 2.5% ofpatients receiving PLAVIX (clopidogrel bisulfate) in the CAPRIE or CURE controlledclinical trials are listed below regardless of relationship to PLAVIX. In general, the inci-dence of these events was similar to that in patients receiving aspirin (in CAPRIE) orplacebo + aspirin (in CURE).

Autonomic Nervous System Disorders: Syncope, Palpitation. Body as a Whole-general disorders: Asthenia, Fever, Hernia. Cardiovascular disorders: Cardiac failure.Central and peripheral nervous system disorders: Cramps legs, Hypoaesthesia,Neuralgia, Paraesthesia, Vertigo. Gastrointestinal system disorders: Constipation,Vomiting. Heart rate and rhythm disorders: Fibrillation atrial. Liver and biliary systemdisorders: Hepatic enzymes increased. Metabolic and nutritional disorders: Gout,hyperuricemia, non-protein nitrogen (NPN) increased. Musculo-skeletal system disor-ders: Arthritis, Arthrosis. Platelet, bleeding & clotting disorders: GI hemorrhage,hematoma, platelets decreased. Psychiatric disorders: Anxiety, Insomnia. Red bloodcell disorders: Anemia. Respiratory system disorders: Pneumonia, Sinusitis. Skin andappendage disorders: Eczema, Skin ulceration. Urinary system disorders: Cystitis.Vision disorders: Cataract, Conjunctivitis.

Other potentially serious adverse events which may be of clinical interest but wererarely reported (<1%) in patients who received PLAVIX in the CAPRIE or CURE con-trolled clinical trials are listed below regardless of relationship to PLAVIX. In general,the incidence of these events was similar to that in patients receiving aspirin (inCAPRIE) or placebo + aspirin (in CURE).

Body as a whole: Allergic reaction, necrosis ischemic. Cardiovascular disorders:Edema generalized. Gastrointestinal system disorders: Gastric ulcer perforated, gastri-tis hemorrhagic, upper GI ulcer hemorrhagic. Liver and Biliary system disorders:Bilirubinemia, hepatitis infectious, liver fatty. Platelet, bleeding and clotting disorders:hemarthrosis, hematuria, hemoptysis, hemorrhage intracranial, hemorrhage retroperi-toneal, hemorrhage of operative wound, ocular hemorrhage, pulmonary hemorrhage,purpura allergic, thrombocytopenia. Red blood cell disorders: Anemia aplastic, anemiahypochromic. Reproductive disorders, female: Menorrhagia. Respiratory system disorders: Hemothorax. Skin and appendage disorders: Bullous eruption, rash erythe-matous, rash maculopapular, urticaria. Urinary system disorders: Abnormal renal function, acute renal failure. White cell and reticuloendothelial system disorders:Agranulocytosis, granulocytopenia, leukemia, leukopenia, neutrophils decreased.Postmarketing ExperienceThe following events have been reported spontaneously from worldwide postmarket-ing experience:

• Body as a whole:- hypersensitivity reactions, anaphylactoid reactions

• Central and Peripheral Nervous System disorders:- confusion, hallucinations, taste disorders

• Hepato-biliary disorders:- abnormal liver function test, hepatitis (non-infectious)

• Platelet, Bleeding and Clotting disorders:- cases of bleeding with fatal outcome (especially intracranial, gastrointestinal

and retroperitoneal hemorrhage)- agranulocytosis, aplastic anemia/pancytopenia, thrombotic thrombocytopenic

purpura (TTP) - some cases with fatal outcome – (see WARNINGS).- conjunctival, ocular and retinal bleeding

• Respiratory, thoracic and mediastinal disorders:- bronchospasm

• Skin and subcutaneous tissue disorders:- angioedema, erythema multiforme, Stevens-Johnson syndrome, lichen planus

• Renal and urinary disorders:- glomerulopathy, increased creatinine levels

• Vascular disorders:- vasculitis, hypotension

• Gastrointestinal disorders:- colitis (including ulcerative or lymphocytic colitis), pancreatitis

• Musculoskeletal, connective tissue and bone disorders:- myalgia

OVERDOSAGEOverdose following clopidogrel administration may lead to prolonged bleeding timeand subsequent bleeding complications. Appropriate therapy should be considered ifbleeding is observed. A single oral dose of clopidogrel at 1500 or 2000 mg/kg waslethal to mice and to rats and at 3000 mg/kg to baboons. Symptoms of acute toxicitywere vomiting (in baboons), prostration, difficult breathing, and gastrointestinal hem-orrhage in all species.Recommendations About Specific Treatment:Based on biological plausibility, platelet transfusion may be appropriate to reverse thepharmacological effects of PLAVIX if quick reversal is required.DOSAGE AND ADMINISTRATIONRecent MI, Recent Stroke, or Established Peripheral Arterial DiseaseThe recommended daily dose of PLAVIX is 75 mg once daily.Acute Coronary SyndromeFor patients with acute coronary syndrome (unstable angina/non-Q-wave MI), PLAVIXshould be initiated with a single 300 mg loading dose and then continued at 75 mgonce daily. Aspirin (75 mg-325 mg once daily) should be initiated and continued incombination with PLAVIX. In CURE, most patients with Acute Coronary Syndrome alsoreceived heparin acutely (see CLINICAL STUDIES).

PLAVIX can be administered with or without food.No dosage adjustment is necessary for elderly patients or patients with renal dis-

ease. (See Clinical Pharmacology: Special Populations.)Distributed by:Bristol-Myers Squibb/Sanofi Pharmaceuticals PartnershipNew York, NY 10016

PLAVIX® is a registered trademark of Sanofi-Synthelabo.

Brief Summary of Prescribing Information Rev. November 2004

B1K0206_IBC 9/27/05 1:25 PM Page 1


mail: c/oEditor-in-ChiefStroke Connection Magazine 7272GreenvilleAve.Dallas,TX75231

fax: 214-706-5231

e-mail: [email protected]

We Want To Hear From You

Letters may be edited for length and scientific integrity. The opinions presented are those of the individual and do not reflect those of the American Stroke Association.

L E T T E R S

My 78-year-old wife has little use of her left eye after two strokes. I’m told it’s physical damage that’s unfixable. She can hardly read at all — black print on white paper, that is.

The other day Time magazine had a story that began with white print on a black background, reverse of the usual printing. She was able to read it well. The typeface was no larger than usual.

This was a surprise to us, and we wondered if such information has any application for others with eye defects.

My wife also came out of dementia in which she spoke gibberish of names, numbers and colors for days on end. Somehow she rewired her brain back to normal. Switched lobes, they say. A miracle!

Bob Roop, CaregiverWest Monroe, New York

I had been struggling for years, juggling a high-demand job and home, and in June 2004, after an argument at home, I had problems breathing. It wasn’t until the next morning that I realized my arm and leg were not usable. Since I was only 38, I didn’t know those were stroke symptoms. I had always thought I was too young even though I had been on high blood pressure medications for years.

It took me months of therapy to use my left side again. It is still somewhat weak. I run out of energy easily and dare not go too many places by myself. I can’t seem to handle simple situations. I blank out and forget easily. Sometimes my mind feels like a blank sheet of paper. I miss my old, independent self very much.

It’s hard for others to understand how I struggle on a daily basis because I look normal. I am still trying to figure out what works and how I can adapt. Reading your magazine gives me comfort and lots of encouragement. I know I’m not alone in my symptoms. Donna Isaacs’ “Eight Simple Rules” (May/June 2005) will help me get through tough and discouraging days.

Sun-sun Lin, SurvivorLa Palma, California

I recently received your magazine and read the fantastic article, “Eight Simple Rules,” by stroke survivor Donna Isaacs of Tyler, Texas (May/June 2005). I am also a stroke survivor (2½ years ago), and found Donna’s eight rules very inspiring. It’s so nice when you can find positive folks to talk to about your stroke.

Dawn McHugh, SurvivorVia e-mail

Blessings for an outstanding publication that was better than any support group. I read your magazine cover to cover and find so many articles that have made my journey so much better. I had a stroke Jan. 6, 2004, and it has been a difficult journey, but Donna Isaacs’ eight rules (May/June 2005) have made a difference. The stroke does not define me.

Rosemary Henley, SurvivorSpringfield, Missouri

Upon receiving my May/June 2005 Stroke Connection Magazine, I was delighted to see Shelley Cushing’s article, “Striving May Be Required.”

My husband Ken, also a stroke survivor, and I had the pleasure of meeting this remarkable young woman at DisneyWorld in December 1998. Shelley’s mom, Fran, noticed my husband’s AFO and came over and struck up a conversation and a friendship that has continued via the mail since then. She, too, is a woman of great strength and resilience. The wonderful support Shelley had and continues to receive from her family has undeniably played a large part in her miraculous recovery.

Shelley has attained goals that doctors thought were not possible. It seems they forgot to factor in Shelley’s inner strength and determination. I have Shelley’s picture on my refrigerator as a daily inspiration to me.

God bless you, Shelley, and don’t let anyone tell you what you can’t do!

Pat Aites, CaregiverVerona, Pennsylvania

Connecting You to Us

“ My muscle stiffness made it impossible for me to do a lot. Now I think anything is possible”

A few years back, Ed suffered a stroke that affected the right side of his brain—leaving him with severe spasticity (tight, stiff muscles) on the left side of his body.

Ed tried injections and physical therapy to help ease his pain and increase his mobility, but nothing worked. Then Ed’s doctor suggested Medtronic ITB TherapySM (Intrathecal Baclofen Therapy).

“ It was exciting to finally feel like I was getting better. . .like I could do this.”

ITB Therapy helped reduce his spasticity which gave Ed the functional improvement he needed to accomplish more at his physical therapy sessions.

The results? Ed can do more at home and take care of himself again. He’s even back to doing a little cooking, which is something he’s always loved to do. His wife, Andrea, loves that, too.

Results vary; not every individual will receive the same benefi ts. Side effects can occur. For more information, please refer to the accompanying patient information.

Ed R., stroke survivor. Ed has been receiving Medtronic ITB TherapySM since 2004.

Talk to your doctor about Medtronic ITB TherapySM or call 1-800-856-3823 ext. 103 Find out more at www.spasticity.com.

Embrace the possibilities

My wife and I take

walks in the park.

I can apply myselfmore during therapy.

e”

A357 Medtronic 1 10/6/05 2:43:08 PM

Completely read this information before you start using Medtronic ITB TherapySM (Intrathecal Baclofen Therapy). This information does not take the place of thorough discussions with your doctor. You and your doctor should discuss ITB Therapy before you begin receiving the therapy and at regular refill appointments.

Q: What is Lioresal® Intrathecal (baclofen injection)?

A: Lioresal Intrathecal is a liquid form of baclofen, and is commonly used to treat severe spasticity. Liquid baclofen is used for injections and infusion into the intrathecal space (the fluid-filled area surrounding the spinal cord), using an implantable drug delivery system.

Q: What is severe spasticity?

A: Severe spasticity is tight, stiff muscles that make movements – especially of the arms and legs – difficult or uncontrollable. Severe spasticity can interfere with an individual’s function and/or comfort.

Q: Who is a candidate for Lioresal Intrathecal?

A: People who suffer from severe spasticity resulting from cerebral palsy, multiple sclerosis, stroke, traumatic brain injury, or spinal cord injury, and who suffer intolerable side effects from oral baclofen (pills), may be a candidate for Lioresal Intrathecal. A screening test will help determine if you will respond to the intrathecal medication. Talk with your doctor about whether Lioresal Intrathecal may be an option for you.

Q: Who is not a candidate for Lioresal Intrathecal?

A: People who are hypersensitive (extremely sensitive) to oral baclofen should not take Lioresal Intrathecal.

Q: What are the most common side effects of Lioresal Intrathecal?

A: The side effects of intrathecal baclofen include loose muscles, sleepiness, upset stomach, vomiting, headaches, and dizziness. As with most medications, overdose (drug dose is too high) or under dose (drug dose is too low) can occur. Talk with your doctor about the side effects you may experience from your treatment.

Q: What do I need to know if I am using Lioresal Intrathecal?

A: Abruptly stopping intrathecal baclofen can result in serious medical problems and in rare cases has been fatal. It is important to keep your pump filled with medication by attending regularly scheduled refill appointments.

Q: What are the signs of rapid or abrupt withdrawal fromintrathecal baclofen?

A: Increase or return in spasticity, itching, low blood pressure, lightheadedness, and tingling sensation are often early indications of baclofen withdrawal. It is very important that your doctor be called right away if you experience any of the above symptoms.

In rare cases, severe symptoms may occur. These symptoms include high fever, altered mental status, spasticity worse than before you started ITB Therapy, and muscle rigidity. It is very important that your doctor be called right away if you experience any of the above symptoms.

Q: What can I do to prevent baclofen underdose or abruptdiscontinuation of intrathecal baclofen?

A: It is very important that you keep all of your refill appointments. This may require some planning prior to traveling. Maintaining a regular refill schedule will ensure the pump does not run out of medication and that any potential problems with the infusion system are diagnosed and corrected. Additionally, you should be aware of what your pump alarms sound like. If you hear an alarm, contact your doctor immediately.

Furthermore, it is very important that you know and understand the signs of baclofen underdose. Also be sure to tell your doctor right away if you experience any unusual symptoms, side effects, or changes in your condition.

Q: What are the symptoms of baclofen overdose?

A: Although rare, it is possible for you to receive too muchmedication (overdose). A baclofen overdose may cause drowsiness, lightheadedness, respiratory depression (difficulty breathing),seizures, loss of consciousness and coma. If you experience anyof the above symptoms, it is very important that you or your caregiver contact your doctor right away.

This provides a summary of the most important information about Lioresal Intrathecal. If you would like more information, talk with your doctor. You can ask for information about Lioresal Intrathecal that is written for healthcare professionals. You also can get more information by visiting www.spasticity.com.

Rx only.

Lioresal® is a registered trademark of Novartis Pharmaceuticals Corporation.

PATIENT INFORMATIONLIORESAL® INTRATHECAL (baclofen injection 40 mg/20 mL, 10 mg/5 mL, 10 mg/20 mL, 0.05 mg/1 mL)

Medtronic, Inc., 710 Medtronic Parkway NE, Minneapolis, MN 55432-5604, USAInternet: www.medtronic.comTel. 763-505-5000, Toll-free: 1-800-328-0810, Fax 763-505-1000 200601888 EN NP6975 ©Medtronic, Inc. 2005 All Rights Reserved

fere with

A357 Medtronic 2 10/6/05 2:43:17 PM


S T R O K E Connecting You to the World

Two cholesterol-lowering drugs have been found to reduce the rate of cerebral vasospasm, a deadly complication that can follow a brain hemorrhage.

Subarachnoid hemorrhage (SAH) occurs when a blood vessel on the brain’s surface ruptures and bleeds into the space between the brain and the skull. Vasospasm, a prolonged contraction of blood vessels, sometimes occurs after the hemorrhage and may lead to another stroke, increasing the risk of disability and death.

Two small studies investigated the effectiveness of using statins a few days after an SAH to prevent vasospasm. In a U.S. study, the statin drug simvastatin reduced vasospasm associated with brain injury. In a larger British study, pravastatin not only lowered markers of brain injury, it also reduced the risk of disability and death.

“Thirty-five percent of people with SAH die in the first 24 hours,” said John R. Lynch, M.D., an author of the U.S. report. Lynch is an assistant professor of neurology and medicine at Duke University Medical Center in Durham, N.C. “In addition, after surgical repair of the vessel, it has been observed that up to two-thirds of patients have vasospasm one to two weeks later. Vasospasm is a major cause of morbidity and mortality and there is essentially no treatment to prevent it.”

The British researchers studied 80 SAH patients, ages 18 to 84 years. Patients who received pravastatin were 32 percent less likely to develop vasospasm and 42 percent less likely to develop severe vasospasm, compared with those who took placebo.

Also, the incidence of vasospasm-related disability was decreased by 83 percent in the statin group. These patients were also 75 percent less likely to die while in the hospital than those on placebo.

In the U.S. study, which involved 39 patients with SAH, 26 percent of the patients treated with simvastatin had evidence of brain vasospasm during the study period compared with 60 percent of those on placebo.

Both teams of researchers said they believe that other statin drugs also may reduce vasospasm. “There is some evidence that statins can increase levels of nitric oxide, a chemical that helps blood vessels to dilate. This may prevent the blood vessels from squeezing up on themselves,” said neurosurgeon Peter Kirkpatrick of the University of Cambridge, U.K., and lead author of the English study. “The drugs also appear to have beneficial anti-clotting and anti-inflammatory effects.”

“Larger, longer studies are now needed to find the most effective dose and determine if the statins reduce disability and death over time,” Lynch said.

Statins Reduce Vasospasm in SAH



Stroke survivors with aphasia showed improvement through the use of short-term, intense language retraining called Constraint-Induced Aphasia Therapy (CIAT). The improvement occurred regardless of the survivor’s age or the severity or

duration of the aphasia.“About 38 percent of stroke survivors have aphasia after

suffering a stroke on the left side of their brain,” said lead author Marcus Meinzer, Ph.D., of the Unversität Konstanz in Konstanz, Germany. Many survivors improve spontaneously during the first six months after stroke, but as many as 60 percent still have language difficulty more than six months after stroke. This is called chronic aphasia.

“Usually patients in the chronic stage of aphasia received about two hours of therapy a week over the course of a year, but we found that it is better to give the therapy within a shorter period of time,” Meinzer said. “This is supported by

the fact that patients did not further improve on a less intensive schedule when reassessed six months later, even though on average they received about the same amount of therapy compared to a two-week intensive training period.”

Researchers enrolled 27 survivors who had had aphasia for about four years. They were given 30 hours of language training — three hours a day for 10 days. CIAT requires intense training of verbal communication along with language games that progress from simple communication to more complex language skills. CIAT encourages patients to speak rather than use gestures or other nonverbal forms of expression.

Twelve patients were assigned to a basic CIAT program that relied on the 30 hours of training, and 15 were assigned to “CIAT plus,” which added a written module and was reinforced by family members at home.

Language functions were assessed with a standardized measure of aphasia at baseline (the beginning of the study), immediately after the CIAT training and again at six months.

“We found that language skills improved in 85 percent of the patients and those improvements lasted for six months,” Meinzer said. The improvements were even more pronounced among patients assigned to the CIAT plus group.

“Survivors and their families said that both the amount and the quality of everyday communication improved with CIAT training,” Meinzer said.

Based on their previous work, the researchers speculated that CIAT training and intensive traditional language therapy may allow the brain to reassign language function to an area of the brain not affected by stroke.

“Any well-founded intervention might profit from an intensive schedule,” Meinzer said.

Intense Therapy Pays Off

November/December 2005�0


More than 1,300 households receiving Stroke Connection Magazine are in the areas of Louisiana, Mississippi and Alabama where Katrina did enormous damage. Our hearts and prayers go out to each and every one — and to all who have suffered because of this hurricane.

The American Cancer Society, American Diabetes Association and the American Heart Association jointly contributed $1 million to the Bush Clinton Katrina Fund to help hospitals, healthcare systems and patient support services in the devastated areas get up and running again. We hope our combined support will help ensure that stroke patients — as well as people with cancer, diabetes and heart disease — will receive the quality healthcare they need during this crisis and beyond.

“During a crisis like this, people who have a chronic disease like stroke, heart disease, diabetes or cancer are among the most vulnerable, said M. Cass Wheeler, CEO, American Heart Association. “We want to be sure that every patient in the devastated areas gets the care that they need and deserve.

“Mississippi, Louisiana and Alabama already face death rates from cardiovascular disease that are significantly higher than most other states in the U.S. And in a situation like this, it can be difficult or even impossible to get the immediate care you need if you have a heart attack or stroke. We need to do everything we can to ensure that the problems caused by Katrina don’t edge those death rates even higher.”

The three health organizations ordinarily do not fund natural disaster relief efforts, but the devastation Hurricane Katrina brought to individuals, communities and healthcare systems is unprecedented in recent history. We felt compelled to provide immediate assistance.

To mark National Family Caregivers Month, the National

Family Caregivers Association (NFCA) is launching The Caring Every Day Campaign. The campaign acknowledges the one in five American adults who serve as family caregivers.

As stroke families know, caregiving is an important and time-consuming part of daily life.

Unfortunately, the burdens and stress that are a part of family caregiving can take their toll: family caregivers are known to have much higher rates of depression than the rest of the population.

The NFCA Web site highlights the campaign and its messages and provides easy access to information and ideas. They have also added a special “Prescription Assistance” section providing information about the new Medicare drug benefit with links to helpful decision-making tools.

The Caring Every Day Campaign is sponsored by Adventist HealthCare, AstraZeneca, Eisai Inc., Novartis,

Brooks and Eckerd Pharmacy, GlaxoSmithKline, Johnson & Johnson Consumer Products Company, MetLife Foundation, Pfizer and Living Independently Group, Inc.

For more information on The Caring Every Day Campaign contact:

National Family Caregivers Association

10400 Connecticut AvenueSuite 500Kensington, MD 20895301 942 6430 or 800/896-3650 [email protected]

$1 Million Contributed to Bush Clinton Katrina Fund

November Is Family Caregivers Month

November/December 2005 ��

Lingraphica®

Call to arrange a free trial.

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+A361_Northstar Neuro 1 10/7/05 11:07:25 AM

November/December 2005��

Prior to my stroke, I could depend on my sense of direction in most driving situations. Driving the streets in unfamiliar cities

presented no problems. We would drive our car from our hotel to find new restaurants and shops and return without a moment’s hesitation.

Now, six years after my stroke, I quite often find myself wondering and wandering. Don’t misunderstand, I am extremely grateful to be able to drive; many of my stroke survivor friends no longer can. It is just that I zig more now when I should have zagged and in the process, get farther off the intended course. I think the correct terminology is “directionally challenged.”

The first clue to the loss of my sense of direction was when I got lost as a patient driving my wheelchair around in Moses Cone Hospital (in Greensboro, N.C.). I remember the relief I felt as I wheeled up to the rehab nurses station and asked my nurse, “Becky, where is my room?” This experience reminds me of Moses wandering around in the desert for 40 years. My wife Charlotte tells me that it was because he wouldn’t stop and ask for directions. Must be a man thing.

The loss of my sense of direction became painfully obvious on a trip around the block from our hotel to a mall in Charlotte, N.C. My bride had attended a meeting in the hotel that morning, and since walking at that stage of my recovery required quite an effort, I decided to drive to the mall located in the next block. One-way streets directed me around the block occupied by our hotel. I thought just going around the block would surely be something I could handle with minimum confusion.

How a building as large as our hotel could disappear while I shopped in the mall really puzzled me. I came out of the mall, and suddenly I was in the Twilight Zone. Admittedly, Charlotte is

a big city, but I had only gone one block! My first thought was that I had exited the mall on a different side from my entry. That would explain how I had lost the hotel, but that would not explain how, after the normal and customary search, I found my car in the space where I had left it! After a little more zigging and zagging, I drove my car and myself safely back to the hotel.

Without going into too much detail about the many other places I have gotten lost (Waynesville, Manteo, Hendersonville, Mt. Airy, Summerfield, Colfax and Browns Summit – all in North Carolina), let me simply say that my sense of direction, like so many other things affected by the stroke, is improving with time and effort. Each new venture gets a little easier, so I keep a full tank of gas and keep trying.

David P. Layton, SurvivorGreensboro, North Carolina

Directionally Challenged

R E A D E R S Connecting You to Others

“I zig more now when I should

have zagged and in the process,

get farther off the intended course.”

David and Charlotte Layton

November/December 2005 �3



“Old activities now limited by lack of balance and stamina have reshaped themselves and become

enjoyable again.”

Four years ago I had a stroke. As many of you know, stroke changes everything and presents new realities every day. Survival demands learning to live in the new situation. Everything becomes therapy.

Old activities now limited by lack of balance and stamina have reshaped themselves and become enjoyable again. For instance, after two stretches of physical therapy, I was playing golf again in three months, taking a 9 on the first hole of a par three course. But it was great to be outdoors again. I pushed myself to learn to run again, now I can sprint 40 meters in 12 seconds — it isn’t pretty, but I can do it.

A pastor asked me to substitute for him in the pulpit, which I did with great fear and trembling. As the old adage says, “To live without risk is to risk not living.” I can no longer play baseball, but I volunteer in our local little league and help kids with disabilities. I make regular visits to the wellness center for half-workouts. I still serve on committees, and I’m typing this article! So I’m finding a new “normal” suited to the new me, and that’s good.

Personally I experienced almost no depression and only momentary anger, which surfaced in the question “Why me?” Calling on my inner resources to answer that, I discovered again that life is filled with awe and is itself the experience of grace. To watch my thumb strive to touch my other four fingers as I labor for rebirth and wholeness is a taste of holiness. And on and on, life is without end.

We are not alone in the universe. We do not live or die by ourselves. Here are a few ways love and care have incarnated in my life since the stroke:

• A caring, supportive community

• Dozens of cards and countless visits from friends, each carrying a prayer or a wish for well-being

• A hospital staff whose 26 days of care left me without complaint, except for the daily dose of Metamucil and broiled fish on Friday

• A therapist who unbendingly made her demands but coupled them with saving laughter that was both inspiring and healing

• A sensitive pastor who helped me articulate my own faith rather than mouthing an easy optimism

• And lastly, because it is most important, a wife and family of undying love and loyalty.

I have thought much about wellness these past years. I have concluded that many people are healed that are not completely cured; that true wellness is much more than physical health; that when I remember where I was that first morning compared to where I have come, I feel extremely lucky and blessed. Though residue of the stroke remains, I can say that life is good and is something to be cherished, shared and celebrated.

J. Wayne Judd, SurvivorBridgewater, Virginia

Wayne Judd and granddaughter Denali


The date was April 4, 1996. It was the day my life changed. One moment I wasn’t doing anything in particular, and the next thing I knew I was paralyzed on one side and couldn’t

do anything if I wanted to. I know that thousands have experienced the same thing. Let that be a lesson to me for not paying attention when my doctor spoke, or not reading your magazine cover to cover. Now, of course, it’s the only thing that I read cover to cover. We get smart so late.

In my case, I was quickly admitted to an excellent rest home with terrific therapists. From not being able even to sit up without falling over to being able to walk out of there was a memorable experience. I called my therapist “the little girl that could fly” because she was taking stunt-flying lessons; she insisted that I could not use any walking aids because she didn’t want me to learn any bad habits. Theoretically I already had enough.

As I learned how to walk again, she led me over the roots of a big tree, and then she would trip me to see if

I could regain my balance. She also taught me a lot of respect for her efforts.

I subsequently experienced four more strokes. They may have affected my brain, but fortunately not my mind. It has been an ongoing battle, but with God’s help, I know who’s going to win. My doctor wisely told me not to show up in his office without a cane, and believe me, I took his advice. Now when I travel, the security personnel are quick to provide me with a wheelchair, which I do accept.

Jim Fisher, SurvivorHayward, California

This is my 9th anniversary of a very bad stroke. (All strokes are bad.) I was completely paralyzed on the right side: leg, arm, speech, tongue and shoulder; couldn’t swallow. I was fed by a tube in my stomach for three months. Since then I have

recovered almost to normal. At 75 I still go to strength training twice a week at our senior center. They call me the poster boy because I could not lift my arm over my head when I first started.

Learned the computer — that kept me occupied. No tPA at that time, but there were no doctors in the hospital anyway because it was a long weekend. It took a doctor 4½ hours to see me late in the afternoon (after his barbecue, I guess). I was admitted with a slight stroke (could not walk). I was put to bed with no medication and that is when I had a very bad stroke — in the hospital, at night.

But the reason I am sending you this message is for you to please tell all your readers not to believe anyone (including the DOCTORS) that tells them there will be no recovery after the first year. This is not true as I have been getting better all these years since 1996. It is very slow, and sometimes it is not noticed. Believing what others say will only cause them to stop moving and working out. (I should have kept a diary.)

I could have given you all the details of my stroke, but I wanted to keep it short and to the point. Keep pushing yourself, keep moving.

Joseph R. Markowski, SurvivorOyster Bay, New York

Be Careful Who You Listen To

Moving Right Along, Slowly

Jim Fisher in his garden

Joseph Markowski and friends keeping it moving



On Sept. 22, 2001, a stroke shut down my entire left side, and I spent three weeks in intensive care. My blood pressure was

very low because of atrial fibrillation. I was one month in the hospital in super-critical condition. Then one day I woke up and my heart rate and EKG were normal, apparently for no reason. I was able to sit up without passing out and spent 10 minutes in a chair.

On to six weeks of rehab. I had to retrain every function I retained: reading, swallowing, etc. I was

extremely grateful for all we take for granted. Now that has changed. I value my relationships with my family and friends and patients, and I feel extremely blessed. After three years of rehab, I can drive, work as a dentist and play golf and tennis again. I may not win any golf tournaments, but my home life is less stressful — not a bad trade.

My wife Roberta has been a marvelous caregiver, helping me while keeping the family going. After not practicing dentistry for three years, I now know how much I missed it and what a big part of my life my profession is. As a result, my work is much more rewarding. My goal of getting everything back to “normal” seems realistic at this point.

In one second my life changed dramatically, but for the better in many ways. Survivors must remain positive and patient. Handle your depression with psychiatric care and as many antidepressants as you need. You can recover. It takes time. Stroke Connection Magazine is a tremendous help; you can read it over and over to inspire you to go on. Just do what you have to do — meds, rehab, etc. — just do it!

I am much better being an alive 24-handicap golfer than a dead 6-handicap golfer. It took three years of therapy to realize this. To my friends and patients who stuck with me, I am deeply grateful. To those that did not, I respect that choice. Life goes on. Look forward, don’t look back.

Dr. Stanley Sirgutz, SurvivorNew York City, New York

Notes from an Alive

24-handicap Golfer

“In one second my life changed dramatically, but for the better in

many ways.”

Dr. Stan Sirgutz with wife Roberta and son Nathan


Every thoughtful husband and wife knows the time eventually will come when one of them will have to carry on alone, and perhaps spend many years as a widow or widower. The American Stroke Association has prepared a practical, supportive brochure to help spouses prepare for life without their marriage partner. It will help you be ready “when the time comes” not only to handle the details and decisions that follow a spouse’s death, but also to deal with financial and practical matters – in short, to resume life as effectively as possible.

For more information, please visit us at strokeassociation.org/plannedgiving or e-mail us at [email protected].

Please send to: American Stroke Association Planned Giving Department 7272 Greenville Avenue Dallas, TX 75231-4596

Please send me the free booklet When the TimeComes. (CCA)

Please have a representative contact me to discuss how charitable estate planning can benefit me. (CCD)

I am considering a gift to the American Stroke Association through my estate plan. (CCC)

I have already included the American Stroke Association in my will/estate plan. (CCB)

When the time comes for one of you to carry on.

Name

Address

City

State ZIP

Phone

Birthdate E-mail

LS-0370 ©2005 American Heart Association

06EPGEA IAD SC 11/05

• Sudden numbness or weakness of the face, arm or leg, especially on one side of the body

• Sudden confusion, trouble speaking or understanding

• Sudden trouble seeing in one or both eyes

• Sudden trouble walking, dizziness, loss of balance or coordination

• Sudden, severe headache with no known cause

Know...the warning signs of stroke:

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irst, let’s be clear: The rehabilitation goal for stroke survivors is to return to normal functioning as quickly and to the greatest extent possible. Physical therapy is often part of the recovery process. However, there is little benefit to the patient if the therapy doesn’t work or is less effective than it could be — or worse yet, causes a decline in functioning.

The first rule of thumb in maximizing insurance benefits is to make sure the patient gets the best therapy possible. Frankly, insurance restrictions and limitations on physical therapy came about precisely because common physical therapy practices were not based on scientific

evidence of what works best. Now, insurance policies often limit the first course of physical therapy treatment and then approve additional therapy only if the patient continues to show improvement.

Better results are achieved when stroke patients receive coordinated, multidisciplinary evaluation and rehabilitation treatment. The team determining and coordinating care should include the patient’s physician, a nurse who specializes in rehabilitation care, a physical therapist, an occupational therapist, a speech/language pathologist, a psychologist, a recreational therapist, the patient, the family and any other caregivers. This team approach is standard in rehabilitation facilities accredited by the Commission on the Accreditation of Rehabilitation Facilities. See www.carf.org or call (520) 325-1044.

How To Get the Best Care

1. Ideally, the patient would have received their initial stroke care in a Certified Primary Stroke Center, a hospital certified to provide the best care as quickly as possible when a stroke occurs. In these “best care” facilities, rehabilitation needs are comprehensively evaluated and therapy is begun as soon as the patient is medically stabilized — as soon as 24 hours after the stroke.

2. When the patient is discharged from the hospital after initial stroke treatment, where and how they receive follow-up care should be determined by the care team — including the family, physician and hospital social workers — based on an initial comprehensive rehabilitation evaluation that has already been completed.

Insurance Benefits for Physical Therapy

Maximizing

by Pamela Armstrong, MPH, MBA

Things You Can Do To Get Additional Therapy

Therapy improves the lives of survivors and caregivers alike, and the more the

better. Here are some things that will help you maximize your benefits.

• Get your physical therapy from a licensed facility. Insurance companies are less likely to approve additional therapy if you are getting it from either the local gym or an expensive health spa in an exotic location. Neither place is likely to provide the best medically sound therapy at the most cost-effective price.

• Choose a facility that is used to dealing with stroke survivors who have the same recovery challenges you have, and that treated them successfully. Ask your potential physical therapist how many patients with your specific disabilities he or she has treated, how many improved their independence as a result, and how much average improvement each patient gained. Ask how many patients have had their physical therapy benefits extended because their therapy resulted in continuous improvement. Compare the responses of more than one therapist you might choose, and, of course, find a therapist with good answers to these questions.

• Choose a therapist who will create a written plan of reasonable expectations for your therapy. The plan should be based on medical necessity, as specified by your physician. The results of your therapy, based on the therapist’s written plan, should then be documented thoroughly. A report in your patient chart, written by your therapist, should state whether the goals of your therapy were achieved — and if not, why not. The written plan and the report documenting the results should be submitted to the insurance company when requesting approval for additional therapy.

3. Rehabilitation services, including physical therapy, can be provided in:

• an inpatient setting (special hospital unit).

• a hospital or other facility but on an outpatient basis (the patient usually comes several days a week for therapy).

• a nursing facility where the patient stays full-time.

• their home.

The best overall care is usually provided in an inpatient or outpatient setting at a facility that specializes in stroke rehab care.

4. Make sure the physical therapist continually coordinates with the patient’s physician as well as all other members of the rehabilitation team.

5. Good therapists listen carefully to the patient and to home caregivers to determine adjustments that need to be made in treatments. They also thoroughly explain what is being done and why. Good communication and partnering are essential to good care. Do not accept anything less.

How to Maximize Insurance Coverage for Physical Therapy and Other Types of Rehabilitation Treatment

1. Thoroughly check your insurance Evidence of Coverage or Certificate of Coverage to find out what your policy states regarding physical therapy benefits and other types of rehabilitation care.

2. Call the member services phone number for your insurance plan and ask for clarification of anything you read in the policy that you do not understand. Also ask about the best way to maximize your benefits for the rehabilitation treatments needed.

3. Once you are clear about your insurance coverage, ask your therapist and your doctor to work with you to maximize the benefits. For example, the therapist may have additional exercises that a family member could assist the patient with between visits that might speed up the healing process. To ensure that the patient is benefiting from the therapy as much as possible, and to convince the insurance company of the ongoing improvements resulting from the therapy (so that additional therapy visits might be approved), be sure to comply with the daily exercise and other treatment recommendations of the therapist.

Pamela Armstrong, MPH, MBA, is the author of Surviving Healthcare, recently named “Health Book of the Year” by Foreword Magazine. Visit www.SurvivingHealthcare.com for more information.

To read about stroke rehabilitation care guidelines that are based on scientifically evaluated clinical trial results, go to www.guidelines.gov and enter the search term “Stroke Rehabilitation” in the upper left corner of the Home page.


F E A T U R E

Paying for Long-Term Careby Jon Caswell

any stroke families don’t

know how to care for a

family member who can’t

handle a few activities of daily living

(ADLs) but isn’t so compromised that

they require a nursing home. Does

another family member sacrifice their

life so that the survivor can live at

home, or do they arrange for home

healthcare assistance? Whatever you

decide, you have to figure out how to

pay for it. At that point, you really are

on the horns of a dilemma.


Families in this situation quickly discover that there is a big hole in the safety net of Medicare, Medicaid and private health insurance. Medicare or private insurance only covers long-term care if it is “skilled care” (see “Skilled vs. Unskilled”). “Even then, Medicare only pays for 100 days,” said long-term care expert Phyllis Shelton. “And the average number of days paid by Medicare is less than 25 days, because most people don’t meet the skilled-care qualification

longer. Medicare doesn’t pay for assisted living. It doesn’t pay for nursing home care for people with chronic conditions, like Alzheimer’s disease.”

Shelton is the author of Long-Term Care: Your Financial Planning Guide. Long-term care is generally defined as needing assistance with two or more activities of daily living for at least 90 days.

The Medicaid OptionMedicaid does pay for nursing home care, but it’s only part of

the answer. “Medicaid is the federal and state welfare program for the poor,” Shelton said. “It currently pays for about half of all nursing home care in the United States, but it is fast being overspent. And many states are exercising asset recovery, so in those cases it is not much more than a loan program.”

There are significant problems with relying on Medicaid. First, most Medicaid programs don’t pay for extended home health care, such as 8- to 10-hour shifts. Second, many nursing home facilities don’t accept Medicaid patients because they represent a financial loss for the facility. Third, Medicaid patients are at the mercy of the system. They must go wherever there’s a bed for them, and a private room is usually not an option.

“In my book, I relate the story of an Ohio family who spent all their assets paying for two years of nursing home care for the aging father,” Shelton said. “Then the mother had to go into a nursing home, at which time the family home was sold to pay for her care for 18 months. Both parents ended up on Medicaid, but because there are so few Medicaid beds in Ohio, the mother is in Cleveland, and the father is two hours away in Toledo, and the children live in Canton. So visiting is difficult.”

Since Medicaid is a program for people with limited resources, most states require that most assets be depleted before patients can qualify. “About a quarter of nursing home patients currently paid by Medicaid did not enter the nursing home on Medicaid,” Shelton said. “In other words, they had to ‘spend down’ or exhaust their resources before they became Medicaid patients.” (See “Transferring Assets to Qualify for Medicaid,” p. 23.)

Generally, if keeping independence and staying in control is important to a family, Medicaid appears to be a solution of last resort because choices for care are so limited.

Skilled vs. Unskilled“It’s the skilled/unskilled aspect that the

average person has no idea about,” said Phyllis Shelton, author of Long-Term Care: Your Financial Planning Guide. “Skilled care is paid for by Medicare or health insurance, but neither one pays for unskilled care, and long-term care is considered unskilled.”

Skilled care

Skilled care has nothing to do with how sick a person is. It is determined by the services the patient receives, and those services have to be getting the patient better.

Examples of “skilled care” services include:

• Speech and physical therapy, which is paid for by Medicare or private insurance until the patient stops showing progress (or until the payment cap is met).

• Care for a bedsore is covered only until it is under control, not until it’s healed.

• Extended IVs or tube feeding.

Unskilled care

Unskilled care has nothing to do with how sick a person is but with what services they receive. Once progress stops, the care is considered “chronic” or “maintenance” and traditional insurance payment stops.

Examples of “unskilled care” services include:

• Daily cleaning of a colostomy drain or a catheter.

• Respiratory therapy for an emphysema patient (while this helps them stay alive, they are not getting better).

• Help with activities of daily living such as bathing or dressing.

Phyllis Shelton


Alternatives for Paying for Long-Term Care

There are several ways to finance long-term care, according to Shelton, and some are better than others.

Long-Term Care Insurance

It is clear that the states (through Medicaid) can no longer afford to be the funder of last resort for care of the chronically ill and disabled. Using tax incentives and other legislative and policy measures, the federal government has made it clear that it wants the private insurance market to pay for most long-term care (LTC).

For instance, a portion of the premium for LTC insurance counts as a medical expense. Since medical expenses beyond 7.5 percent of your income are tax deductible, a portion of the premium for LTC insurance helps meet that threshold. At the other end, benefits paid are not considered taxable income, nor are premiums paid by employers considered taxable income for employees.

Congress has also standardized benefits to protect consumers. For example, a qualified policy must offer inflation and non-forfeiture benefits, and a qualified healthcare professional (physician, registered nurse, social worker) must certify that two or more activities of daily living will be compromised for at least 90 days.

“The message from the government is loud and clear,” Shelton said. “‘Take care of your long-term needs with private insurance.’ There simply isn’t enough money to create another entitlement program for long-term care. According to the comptroller general of the United States, just keeping Social Security, Medicare and Medicaid afloat could require a doubling of taxes.”

Linked Benefit Plans

Linked benefit plans are hybrids that combine long-term care benefits with life insurance or an annuity.

If a linked benefit plan is combined with life insurance, two times the death benefit may be available for LTC. “If you need the benefit for LTC almost immediately,” Shelton said, “the policy could pay as much as 2 percent a month for four years, or 4 percent for two years. The longer you have the policy without filing a claim, the more accumulation and the longer the benefit period.” Payment of a $100,000 lump-sum premium provides a monthly benefit of about $5,000 for four years.

You can also use an annuity to fund LTC. (An annuity is an investment that returns fixed annual

payments for a lifetime or a specified number of years.) Using this method, your lump-sum payment is put into

two funds: an LTC fund, which grows at a higher interest rate for five years, and a regular cash fund that grows at a smaller rate.

“The purpose of the separate LTC account is to allow you immediate access to the money for services from a licensed home healthcare agency, adult day care center, assisted living facility or nursing home care,” Shelton said. “Otherwise, early withdrawals from an annuity mean limitations on the amount you can withdraw, usually 10 percent, without a penalty.”

Medically Underwritten Annuity

Sometimes stroke survivors can’t qualify for LTC insurance. A long-term care immediate annuity is available to people who are already receiving LTC and may be a way to maximize financial resources to pay for it. This product involves paying a single, lump-sum premium that is converted into a monthly payment guaranteed for the life of the policyholder. This type of annuity is available to people with certain diseases or conditions (“medically underwritten”) and uses different life-expectancy tables than regular annuities.

For example, an 82-year-old man with advanced Parkinson’s who wanted a monthly benefit of $3,500 would normally have to pay about $300,000 in a single premium. However, because of the Parkinson’s, he would need only $134,000 to gain the same $3,500 monthly lifetime benefit. It can even be structured so that a beneficiary receives part of the money if the policyholder dies earlier than the insurance company expected.

Accelerated Death Benefits

An alternative to purchasing LTC insurance is to buy life insurance that provides cash advances against the death benefit to pay for LTC expenses of the policyholder.


Transferring Assets to Qualify for Medicaid

Medicaid was designed to help the poorest citizens pay for medical expenses. It has grown enormously since its inception in 1965. Much of this growth has come from increased use and cost of nursing home care for the “aged and disabled,” which now consumes two-thirds of Medicaid dollars.

To qualify for Medicaid, a person must have few assets and, in some states, very limited income. The most the healthy spouse can keep in 2005 is about $95,000 plus a house and car. Most people qualify for the program by “spending down” their assets. They exhaust their resources by paying for long-term care out-of-pocket. Others attempt to qualify by transferring assets to loved ones.

“This can be very tricky,” said Phyllis Shelton, a long-term care insurance expert. “First, because you must give up control of the asset and become dependent. And second, because it is not always looked on favorably by authorities.” Here are some of the reasons for not transferring assets:

• Divorce: If you sign over your assets to an adult child, half your assets may go to their spouse in a divorce settlement.

• Lawsuit: The child holding the assets is sued. The court will consider your assets theirs.

• College Financial Aid: Your grandchild no longer qualifies for financial aid because you transferred your assets to your child.

• Early Death of an Adult Child: Your child dies before you. Now you are at the mercy of a son- or daughter-in-law.

• Misuse of Funds: Your child makes disastrous investments with your money.

Because of program changes that will be required because of the aging of baby boomers, there are no guarantees that current benefits will continue. And states are also becoming more aggressive about estate recovery after the beneficiary dies. Estate recovery turns Medicaid into a loan, not an entitlement.

Source: “10 Reasons Why It Might Be a Bad Idea to Transfer Assets to Qualify for Medicaid” (See “LTC Reports” at www.ltcconsultants.com for a sample brochure.)

Because the benefit is paid while they are still alive, it is referred to as an “accelerated death benefit.”

A few of these policies pay for home care or assisted living. Typically, monthly benefits equal 2 percent of the face value of the policy for nursing home care and 1 percent for home health care. Benefit payments are not taxable income.

Some insurance companies include an LTC benefit at no extra charge. Check with your insurance professional to see if your life insurance policy has this feature.

“A big pitfall to this alternative is that inflation may not be addressed,” Shelton said, “so the benefit doesn’t increase as costs increase as it would with LTC insurance with an inflation rider.”

Viatical Settlements

“Viatica” were the supplies needed to provide last rites to Roman troops sent into battle. The word has come to mean any supplies for a journey. The “viatical” insurance alternative allows a terminally or chronically ill patient to “sell” a life insurance policy to a third party. The idea is that the money from this sale would provide money for a dying person’s final journey. The third-party purchaser becomes the owner and beneficiary of the life insurance policy. “Terminally or chronically ill” can be anyone with a life expectancy of two to three years. Remember, once you’ve done a viatical settlement, the life insurance policy is gone, and any expenses you were planning to settle with that money, such as medical bills or funeral expenses, will have to come from somewhere else.

Life Settlements

Life settlements are much like viatical settlements. In this case, a person with life insurance sells the policy to a third-party investor who then becomes the beneficiary. There is no terminal or chronic-illness requirement. Because of this the payout is at a lower rate, no more than 50 percent of the policy’s face value, compared to up to 80 percent in a viatical settlement.

Reverse Mortgages

“Since many older people own their homes free and clear, they find themselves ‘house rich and cash poor’,” Shelton said. “Reverse mortgages allow a family to tap into this wealth without giving up their home.”


www.ahca.org This is the Web site of the American Health Care Association, a consumer advocate on long-term care issues.

www.longtermcareliving.com This Web site can help you assess your needs and explore alternatives.

www.fpanet.org/public/tools/healthcare.cfm The Web site of the Financial Planning Association has helpful information on long-term care.

Reverse mortgages are also called “home equity conversion loans.” They allow people over 62 to convert part of their home equity into income without having to sell the house, give up title or take on a second mortgage payment. The income from this loan is generally paid in monthly installments. It’s tax-free and doesn’t count as income for Social Security eligibility purposes. The balance due the purchaser grows as cash is paid to the homeowner.

The homeowner still owns the home and can live in it until they die, no matter how much time passes. If they decide to sell in order to move, the loan is paid off from the proceeds of the sale. The older the patient is and the more valuable their home, the more they can borrow. Someone in their 60s can get about 38 percent of the home’s equity; a 75-year-old would get about 58 percent; and someone in their 80s would get about 60 percent.

Critical Illness Insurance

Introduced in the United States in the 1990s, critical illness insurance pays a lump sum upon diagnosis of one of a dozen or so diseases. Among the conditions covered are stroke, heart disease, Alzheimer’s, multiple sclerosis,

kidney failure and major organ transplants. Some policies return any part of the premium not paid out in benefits upon the death of the policyholder. You can purchase the policy at any age, but benefits are typically reduced by 50 percent at age 65 if you were older than 60 when you bought the policy.

A major benefit of such a policy is that the lump-sum payment allows the beneficiary to use the money however they want. When buying such a policy, if your parent had a condition (say, Alzheimer’s) covered by the policy, you might have to pay a higher premium.

The odds are greater than 50 percent that everyone in the United States will need some form of long-term care, and for stroke survivors the odds are probably even higher. Planning ahead can head off a tragedy, but for those who don’t have that option, investigating some of the alternatives mentioned here may help pay for the care your loved ones need.

Phyllis Shelton’s book, Long-Term Care: Your Financial Planning Guide, is available at bookstores, through www.amazon.com or at www.ltcconsultants.com.

LTC Resourceswww.aarp.org At the AARP homepage, type long-term care in the search window. It will take you directly to a great deal of up-to-date information on the subject. For information on contacting your state’s ombudsman if you have a problem with a care facility, type ombudsman into the search window.


I deserved a break after finishing our taxes on April 14, 2003, but the break I got was a massive stroke. When I tried standing up to stretch, I couldn’t. I knew something was wrong, and Uli, a foreign exchange student staying with us at the time, called 9-1-1. My

wife Nancy returned home from errands just in time to follow the ambulance to the helicopter.

Inside the chopper, the EMT asked if I had any allergies. “Helicopters,” I said. Having spent my life as a fixed-wing pilot, I just don’t trust helicopters. “If the good Lord had meant our wings to go around and around over our heads, he’d have made them that way to start with,” I said, trying hard to hold on to my sense of humor.

At the hospital, I chatted easily with everyone, not aware of the gravity of my situation. I’d been told that I’d had a stroke, but I did not know what that meant. As the first days of hospitalization passed, I learned that, for me, a stroke meant I could neither move nor feel anything in my left arm, hand or leg.

To say I was frightened is like saying King Kong was a big monkey. I was absolutely terrified.

All I could do was focus on learning to control a wheelchair, following the hospital routine and doing the small exercises the therapists had given me. The rest I left to providence.

During the first week of rehab, my friend Chip Whitaker assured me that he planned on doing the Maggie Valley (North Carolina) Moonlight Race with me the following August. At that time, I had not yet taken any steps.

My most precious memory had always been my first solo flight, but that has been replaced by my first parallel-bar, therapist-assisted, post-stroke steps. As I stumbled like a baby, I had tears streaming down my face. After weeks of not knowing if I would ever walk, those first steps were overwhelming.

During five weeks of rehab, I began to walk, at first slowly with a cane and knee brace, then gradually, without the cane. It was slow, tedious and painful. My right leg and lower back were in constant pain because my gait was

far from normal. Every step was agony, especially on the hills. Nancy and I had a lot of doubt and fear at that time. Should I even hope to walk the distance of the Moonlight Race? Progress was slow, but eventually I developed enough stamina to walk the 3.2 miles at the event, just four months post-stroke. Nancy, Chip and another friend, Joe Outcalt, and their wives plus two more couples accompanied us, with enough food to feed my rehab unit. We had a marvelous time, and it reinforced the notion that while life was different, it certainly was not over.

[undertaking a marathon]Almost a year later, in July 2004, my son Stephen took

me to a meeting about Train To End Stroke (TTES) in Memphis. Caught up in the enthusiasm of the moment, I signed up to complete a marathon the following January. Notice I said complete, not run. I still couldn’t run 26 yards, let alone 26 miles, but I was walking much better and had faith that, in five months, I could walk that far. In addition to the marathon, I committed to raise $3,500 for the American Stroke Association.

My training was vastly aided by therapy at a facility called “The Therapy Center,” in Knoxville. They have a marvelous treadmill called a “Pneu-Weight.” It suspends the patient in a hoist above the treadmill, which allows a disabled person to be balanced and supported while walking on the treadmill. As you improve, you can adjust the machine so that you carry more of your own weight.

I used this machine at least twice a week. The first couple of months of therapy were paid with what remained of the year’s allotment of insurance-covered therapy visits. Unfortunately, my remaining insurance benefits would not cover enough therapy to train for TTES. In stepped Kelly Cook.

other measures[by Rick Davis, Survivor • Ten Mile, Tennessee]

At the finish line at Disney World — Chip Whitaker, Kelly Cook, Rick Davis and Joe Outcalt


[solution to a problem]

Kelly came up with a plan for us to switch to a “training membership” at The Therapy Center, which would allow me to use their equipment. With this modification, I could afford to continue. Kelly even volunteered to oversee my workouts on the treadmill two or three days a week. Though not a physical therapist, she designed other exercises to help me regain strength and balance in my legs and back. On days when I didn’t go to therapy, I either walked outside or put miles on our home treadmill.

I would be less than honest if I did not admit the despair that tugged at me much of the time. It was greatest on days with little or no progress, then I would be full of self-pity — how much better for everyone, especially me, if I had just died! Then we wouldn’t have to endure this crap! I fantasized about cutting off my left hand with my power saw.

But I walked despite those thoughts. I kept a daily log, and from August to December, I walked nearly 180 miles. Though I gradually became stronger, I still wore a special knee brace to guard against permanent knee damage.

In addition to Stephen, other friends and family joined TTES. Our youngest son Shawn, an aspiring actor in New York, began training there, and my friends Joe and Chip also became involved. Chip is an experienced runner, but not so, Joe. He volunteered to walk the marathon with me. Then Kelly Cook signed up, too, and committed to raise $3,500 for ASA!

[a new challenge]During August, I began to experience extreme

fatigue when walking uphill. On a follow-up visit, my cardiologist, Dr. Piana, who had repaired the hole in my heart that most likely caused my stroke, ordered a stress test. Though the test showed everything normal, Dr. Piana was suspicious. An angiogram in September

2004 showed I had 95 percent blockage of a major heart artery, one known as “The Widowmaker.”

A stent was inserted to help the artery remain open. Following that, Dr. Piana and I compromised on a half marathon (13.1 miles). Though I was disappointed — a marathon sounds so much better than a half marathon — Joe was immensely relieved.

On January 9, 2005, I walked the half marathon in Orlando. Joe, Chip and Kelly were with me. I turned in a stunning time of 3 hours, 50 minutes. My son Shawn ran the full thing in about 3 minutes less! Still, the time was not all that far from the time it had taken me to complete just 3.2 miles 18 months before. Plus we raised almost

$14,000 for stroke research.I’m still working at getting better.

While I can walk a long way, I still don’t walk correctly, which results in considerable back pain. My left hand is still largely paralyzed, but I’m determined to keep trying. I may well go to my grave with a limp and a lousy left hand, but it won’t be because I’ve accepted it.

I now believe in miracles, and if that isn’t a blessing, what is? During my recovery, I have learned that sometimes you can’t make it alone, no matter how smart or strong you think you are. I’ve gotten plenty of help from family and friends, but most of all from my wife Nancy, who

had to suffer through recovery even though she didn’t have the stroke. I’ve gotten strength from the conviction that there must be something greater than myself. Now that I’ve discovered this source of strength, I hope to keep it the rest of my life. If that’s the case, I’ll be better off on the whole than I was before.

TTES helped me prove to myself that stroke survivors can set lofty goals and achieve them, just like anybody else. During the months of recovery, I learned that there are other measures of strength besides how much weight you can lift, and other measures of endurance than the miles you can run. I can tell you this much: Recovery is not only possible; with perseverance, it is inevitable.

“I now believe in miracles, and if that isn’t a blessing, what is?”


If you smoke, you are taking a deadly risk.

According to the American Heart Association (AHA), smoking is the “single most preventable risk factor” contributing to early death in the United States. This means quitting is the best thing you can do to avoid an early death. And early, preventable deaths from smoking-related illnesses — about 442,000 a year — make up nearly one-fifth of all deaths.

Because smoking damages the cardiovascular system, it can quadruple the risk of getting coronary heart disease (CHD), the No. 1 single cause of death in the United States. Smoking is a major cause of stroke, the No. 3 killer.

CardiovascularDamage

The nicotine and carbon monoxide in cigarette smoke do most of the damage to the cardiovascular system. Nicotine, an addictive drug, acutely increases blood pressure and heart rate. It also narrows arteries and damages their lining.

Carbon monoxide binds to hemoglobin, which carries oxygen in the bloodstream. The binding effect reduces the amount of oxygen transported to your body’s tissues.

Over time this combination of assaults on the cardiovascular system from nicotine, carbon monoxide and other substances can speed up the process of atherosclerosis, or hardening of the arteries. Fatty deposits build up inside the arteries, resulting in chronic high blood pressure, narrowing of the arteries, restricting the flow of blood and increasing its tendency to clot. All these factors lead to an increased risk of heart attack and stroke.

Artery damage that restricts blood flow to other parts of the body — kidneys, stomach, arms, legs and feet – is called peripheral artery disease (PAD). PAD is 10 times more likely to develop in a smoker than in a nonsmoker.

Smoking can also promote heart disease by reducing HDL (good) cholesterol, which can lead to atherosclerosis. As soon as you quit smoking, your HDL cholesterol levels improve.

SecondhandSmoke

Breathing someone else’s smoke can also cause disease, according to the American Heart Association.

Smoking can quadruple the risk of getting coronary heart disease.

The Risky Business of Lighting Up by Mike Mills


Cigarette prices have risen considerably in recent years, largely because of federal and

state tax increases. The federal tax on a pack of cigarettes has risen from 16 cents in the 1990s to 39 cents today.

State excise taxes have taken an even larger leap. At least 37 states, along with the District of Columbia and Puerto Rico, have raised taxes since 2002, lifting the national average from 44.6 cents a pack to 84.5 cents today.

In 1997, the average price for a pack of cigarettes was about $2.10. A year later, 46 states and several major tobacco companies signed the $246 billion Master Settlement Agreement, which paid states to help cover the cost of smoking-related illnesses and anti-smoking programs.

Since the settlement, rising wholesale prices and federal and state taxes have pushed the price of cigarettes to an average of about $4.10 a pack.

Following are other facts about cigarette prices and taxes:

• Rhode Island has the highest tax per pack at $2.46.

• North Carolina had the lowest tax at 5 cents until September 1, when it rose to 30 cents.

• The highest per-pack retail price is $5.80 in New Jersey (Rhode Island’s wholesale prices are discounted).

• The lowest retail price is $3.21 in Colorado, which has no sales tax.

Secondhand smoke, a mixture of smoke given off by the cigarette and exhaled smoke, is a factor in about 35,000 deaths a year from cardiovascular disease. In fact, studies show that the risk of dying from heart disease brought on by secondhand smoke is about 10 times greater than the risk for dying from lung cancer.

Secondhand smoke contains more than 4,000 chemicals, of which at least 69 can cause cancer. Other chemicals found in cigarette smoke can do additional damage:

• Ammonia — Irritates and damages eyes, nose and airways. Unlikely to cause cancer.

• Benzene — Causes drowsiness, dizziness or headache. Causes leukemia and other cancers of the blood.

• Cadmium — Damages lungs. Causes shortness of breath, chest pain or cough. Causes cancer.

• Formaldehyde — Produces watery eyes; burning eyes, nose and throat; and skin rashes. Causes cancer.

• Lead — Causes learning disabilities, memory loss and decreased IQ. Likely to cause cancer.

• Polycyclicaromatichydrocarbons — A group of 100 chemicals that can cause skin rashes, sensitivity to sunlight, eye irritation and cataracts. Likely to cause cancer.

When Smokers Quit

After a person stops smoking, the body starts to recover almost immediately:

20minutes: Blood pressure drops to a level close to that before the last cigarette.

24hours: The chance of a heart attack decreases.

2weeksto3months: Circulation improves, and lung function increases up to 30 percent.

1to9months: Coughing, sinus congestion, fatigue and shortness of breath decrease.

1year: The excess risk of coronary heart disease is half that of a smoker.

5to15years: Stroke risk is reduced to that of a nonsmoker.

15years: Risk of coronary heart disease is that of a nonsmoker.

Editor’s Note: The American Heart Association supports federal legislation granting the Food and Drug Administration full authority to regulate the manufacture, distribution, sale, labeling, advertising and promotion of tobacco products to protect the public health — especially the elimination of advertising, marketing, or availability of tobacco products for children. If you would like to work on this issue, join You’re the Cure. At www.americanheart.org, enter You’re the Cure in the search window.

After a person stops smoking, the body starts to recover immediately.

The Rising Cost of Smoking

November/December 200530

salesmen have visited the house to show Dad a new car. He has not approved any of them, thank God, as Mother ordered two doors and our old Chrysler is a four-door. I don’t know why Mom wants a two-door, as we already have a two-door Anglia Ford to run around in.

Dad has been very upset and is often rude to the smiling salesmen. He roars and shakes his head no. Often he will not step into the offending car without a great deal of persuasion. I think I agree with him that we need a four-door, which I can drive to Maine if the parents fly up to our cottage in South Brooksville. I want to be able to carry passengers and luggage, and sleep on the road when necessary. Besides, the little cars are difficult for Dad to sit in comfortably. He is over six feet tall.

Perhaps Dad resents our putting him in the back seat while Mom and the driver sit up front. Whatever, I am unable to get Dad to communicate why he is so adamant against buying a new car.

Today the three of us drove to a Chrysler-Plymouth dealer in town. As we walked into the showroom, I noticed a beautiful beige and blue four-door. Charlie, the redheaded salesman who has served us for years, gave Mom a big smile and ignored Dad. I guided my father to a seat, as he limped along with his cane.

Charlie began to point out the two-door at Mother’s request. Dad sat on the edge of his chair, wobbling his cane and shaking his head, “No.” He obviously wanted to go home even though we had just arrived. Charlie’s smile soon diminished when he saw that Dad wanted to leave, and he led Mom into a hallway. I followed and overheard his words.

“Mrs. Thurston, I would suggest you pay no attention to your husband. He probably doesn’t understand anyway. After all, he isn’t going to be driving; you will.”

“But I do want him to like it,” she protested.

I stepped in to defend Dad. “Charlie, no way am I going to let Mom buy a car Dad doesn’t like. He knows what he wants and it’s a four-door. Dad is perfectly sane. He has aphasia and he is unable to talk, but we just haven’t found the right car yet. It’s important to encourage stroke patients to make decisions and to include them in family decisions.

Papa’s Choiceby Doris Thurston, Caregiver

Stuart, Florida

For several months now,

November/December 2005 3�

“We’re really looking for a bucket swivel seat so we can get him in and out of the car easily,” I continued. “Dad is tall and needs lots of leg room. Mom is short and needs to sit farther forward to drive.”

Charlie’s face brightened. “Then why not look at the new 1978 Plymouth Fury. You can push both seats back because they move separately.”

“Let’s try it, Mother,” I urged. “It’s important to please Dad. Just because he can’t talk doesn’t mean he can’t reason or decide. It seems to me he is still head of the house, and we should let him have a choice in the matter.”

I returned to Dad and began helping him up. “We’re going to look at a four-door, Dad. Let’s see if you like it. We’ll all go for a ride and then we can decide.”

He grunted “Huh-huh-huh,” nodding in agreement, and we shuffled towards the door. Dad looked pleased as he paused to take in the sleek car I had admired as we entered. Charlie helped him into the front, adjusting the seat so his legs would fit comfortably. Mom and I sat in the back, enjoying the plush blue-gray upholstery as Charlie stepped on the gas to take us for a drive.

The atmosphere gradually brightened as each of us fell in love with the car. Dad laughed at the air conditioner, a feature Mom had never been allowed to have in the past 25 years of Florida heat. He used to shake his head at “Polly’s frivolity” in even suggesting it. What a difference a stroke makes, I thought.

The Fury had all the trimmings, but what was more important, it had separate seats so Dad could move back and Mom could move forward. And it had a radio for me! We were all ecstatic and it was a sale. Charlie beamed as he helped Papa out of our new car.

This time his broad smile was for Dad.

This story was excerpted from Stroke: A Daughter’s Story, Doris Thurston’s book, available soon through Trafford Publishing.

“It’s important to please Dad. Just because he can’t talk doesn’t

mean he can’t reason or decide. It

seems to me he is still head of the

house, and we should let him have a

choice in the matter.”

Photos on these pages: Doris Thurston and her parents, Bob and Polly Thurston, from the 1970s; bottom right: Doris in 1996

Lifeat the

curb

When I was recovering in a certain New York hospital, I would be awakened every morning at 4 a.m. to a needle drawing blood (Note: medical vampires) or to someone yelling from the door “GOT ANY URINE?” (Note: medical weirdo). I know there are some people that actually wake up at that hour, but for me waking up at 4 a.m. like this after having a stroke would make the rack feel like a tanning salon.

I never had any urine to give because fortunately my room was right across the hall from the bathroom. (Note: old inner city hospitals don’t have private bathrooms.) I could just “hop” in my wheelchair and use a real toilet. No matter how good you think you feel, if you can’t get out of bed to go, you’re sick. Nothing says normal like using a toilet. Of course, I never wanted to use the urine bottle, but in my first week in ICU I had no choice, for two good reasons. One, at that time, I couldn’t get out of bed to go to the bathroom. And two, Nurse Ratchet threatened me by holding up what looked like a large garden hose and said it would be inserted if I didn’t start using that bottle NOW! Nothing like a little motivation.

One advantage of getting up that early is that I had time to prepare for physical therapy. I learned a few simple rules. Most important, never wear a hospital gown to physical therapy. As soon as I saw an 80-year-old guy down on his hands and knees in his hospital gown, I knew this was not a good wardrobe choice. I’m sure he was enjoying the breeze, but I just didn’t want to see that, so I made up my mind. Garment bag? Maybe, but never a hospital gown. Never! I wore sweats, sneakers and a T-shirt. I showered and shaved every day. This was my way of saying, “Up yours” to the stroke and “Bite me” to the hospital – I may be here, but I’m not one of you!

The PT room was the epicenter of physical therapy in the hospital. This was a very strange place. There were ramps and stairs for patients to practice on. They didn’t actually lead anywhere — a cruel metaphor for my life at the time. Everyone was

walking around with a glazed look in their eyes not sure where they were. There were these big red, yellow and orange exercise balls, the kind those Russian bears used to balance on. The room was a cross between “The Night of the Living Dead” and “The Big Apple Circus.”

All the therapists were young girls, and as they led me up and down those ramps and stairs I pretended I was Gunta the Good Bear. I imagined I was wearing a diamond-studded collar, a chain leash, and of course, in my mind they were naked. Nothing like a little more motivation.

I did all the therapy they threw at me. I figured it was my ticket out. The only time I didn’t do PT was when I had an MRI. Apparently I moved my head a lot, so the radiologist gave me five (yes five) Adivans to relax me. I not only fell out of my wheelchair, which is not easy to do, I began to dig that 80-year-old guy’s outfit. Nothing like a little medication.

Editor’s Note: Read John’s personal stroke story, “Life is at the Curb,” from the September/October 2003 issue of Stroke Connection at strokeassociation.org/strokeconnection, or book his one-man show about stroke recovery, “Brain Freeze,” by contacting him at [email protected].

John Kawie’s

comedian and stroke survivor john kawie Finds motivation in some strange and interesting places

On Motivation and Medication

“As soon as I saw an 80-year-old guy down on his hands and knees in his hospital gown,

I knew this was not a good wardrobe choice.”

My name is Larry Pemberton. I am 56 years old, and I have been roping steers since I was 15. I’m a member of three different team-roping associations and used to compete in 30–40 competitions a year. That is, before I had a stroke on Sept. 11, 2004. The stroke left me unable to use my right side. My first day at rehab I could only move my right index finger.

I was scared and mad. “Why me?!” I wanted to know. Then I cried and prayed and thought to myself, “I can beat this!” And with faith, family support and strong will, my recovery began.

In rehab I went to fighting this stroke. Lying in bed, I’d just kick my right leg off and try to get it back on the bed. Once I got something to move, I just wore it out working it. My therapists were angels with names like D’Linn, Jen, Otis, Evelyn, Gary and Suzie, and with all our combined efforts, I began to see more movement daily. I made enough progress that I went home, in a wheelchair, after only 10 days.

My brothers, son and daughter had redone my bathroom while I was in the hospital. It had a new shower, taller toilet, wider door, and it worked great.

When my therapist D’Linn Nichols came to the house, she asked me what my goal was, and I said I wanted to get back to roping. I started feeding and brushing my horses from the wheelchair. I still

went to therapy three days a week and to the weight room at our local high school, five nights a week. My wife Karen and my brother helped me get on and off the treadmill and exercise bike. And I started doing squats on my porch where I could hold onto the rail.

Just two months after my stroke, on Nov. 8, I walked eight-tenths of a mile on the road in front of our house. I also worked the cattle chute at the practice pen for my son Jake and my younger brother Tommy and I went to rodeo competitions on the weekends. Then I started roping a

practice dummy until I was too tired to swing the rope. My desire to rope again burned deep in my gut.

Team-roping is a team sport, and I rope with Jake and Tommy. I’m the header on our team, which means I rope the horns and then pull the slack out of the rope on my saddle horn, which allows the heeler to rope the steer’s feet. We practice all the time. In fact, the day of my stroke I’d played 18 holes of golf and roped 15 steers.

I worked hard at my recovery, progressing from the wheelchair to a quad cane to a regular cane. I was still going to therapy three days a week, and by mid-November I felt I was ready to get on a horse. D’Linn said she wanted to be there to supervise things, but I couldn’t wait.

Jake came over and saddled my horse and pushed me into the saddle, so by the time she got there, I was already on the horse. She asked if I could ride, so I rode around the corral. A couple of weeks later, on Dec. 11, I roped my first steer. It was exactly 90 days after my stroke. A week after that I was released from rehab, and on Dec. 20 I went back to work as a supervisor of roads and bridges for Taylor County in West Texas. I drive big machinery. Sometimes it was a challenge to get into the cabs, but I wouldn’t let anybody help me.

I haven’t returned to competitive team-roping yet, but I continue practicing, building up the strength and coordination in my right side. I still go to ropings on the weekends, and it won’t be long before I’m competing again. In addition to going to work and practicing, I babysit my grandkids, and I visit new stroke patients at the hospital every Wednesday. I get all sorts of questions, but mostly they want to know, “Will I ever get over this?” And I tell them, “Sure, but you can’t do it just sitting there.”

November/December 2005 33

Ropin’Recovery

by Larry PembertonSurvivor • Ovato, Texas

Brothers Tommy and Larry Pemberton

Larry back on the job


e sometimes find it difficult to ask for help, but learning to say “yes” when someone offers is really a gift you can give to both yourself and the person who offers. It’s simple: People feel good when they do something nice for someone else.

Caregivers may be reluctant to accept help because they feel they should handle everything. They may feel that a loved one is their responsibility — and theirs alone. They may think their loved one can’t get along without them. Or perhaps they’re afraid something will happen while they’re away.

Some think that accepting help is a sign of failure or selfishness — that they’re enjoying themselves when their loved one can’t. Or they don’t want to burden others.

But taking breaks and accepting support are a must. They reduce burnout, help you to be more patient and can even prevent premature placement of your loved one in a nursing home.

When you do approach your relatives and friends, remember it’s better to ask for help directly than to hint. And it’s much better to ask before you are desperate and hearing “no” could be hard to take.

Sometimes caregivers don’t know what to say when someone offers help. To start, you’ll increase your chances of getting specific help you need if you match the request with a particular talent or interest of the person offering. For example, if someone likes to cook, suggest preparing meals.

Post a task list on the refrigerator, calendar or another easily visible location. When someone offers to help, let them choose a task they want to do.

You don’t need to feel indebted to those who help. Your sincere appreciation is thanks enough. People understand that you may not be able to return the favor. Learning to receive graciously is a skill we all need to develop.

To make it easier to say “yes,” here’s some language to use and a list of things to say “yes” to:

• Read a book to my loved one, watch TV, listen to music or entertain them so I can have a break.

• Mow the lawn, rake leaves, pull weeds.

• Go shopping for me, or pick up a few items for me when you’re at the grocery store.

• Run errands.

• Drive to an appointment.

• Be available for talking. Help me laugh and get some perspective about my situation.

• Call once a week and let’s talk about anything but caregiving.

• Help me complete a project.

• Stay with my loved one so I can go to church, take a nap, attend a support group, go to the doctor, get a haircut or massage.

• Go to lunch or a movie with me, take a walk or help me get some exercise.

• Research new treatments on the Internet.

• Research local resources.

• Sort the mail and throw away the junk.

• Wash the car or get some gas.

• Give my loved one a haircut or a manicure.

• Help me fill out forms, deal with medical insurance issues.

Used with permission of Family Caregiver Alliance/National Center on Caregiving. For more information, visit www.caregiver.org or call 1-800-445-8106. ©2005 Family Caregiver Alliance.

E V E R Y D A Y Connecting You to Helpful Ideas

Message to Caregivers:Ask for and Accept Help

November/December 2005 35

Able! How One Company’s Disabled Workforce Became the Key to Extraordinary Success

By Nancy Henderson Wurst

BenBella Books: Dallas, Texas ISBN 1-932100-44-X

In a time when companies are outsourcing abroad, Habitat International, a Tennessee-based carpet manufacturer, has managed to achieve superior levels of productivity at home, often two to three times greater than its competition. Their secret: Hire the people no one else will. At Habitat, three of every four workers have a physical or mental disability. They earn normal wages and are cross-trained on every job. They work harder, with less supervision, lower turnover and an unparalleled level of loyalty.

Short Circuit: Biography of a Stroke

By Gilbert Good

Trafford: Victoria, B.C., Canada ISBN 1-41204295-X

Author Gilbert Good is the husband of survivor Reggie Good. This book is a chronicle of her stroke and near-complete recovery. It covers all the bases — persistence, perseverance, positive attitude, depression and dedication. It is also about the inseparable love of her husband, children and grandchildren, as well as the professionalism and passion of her caregivers.

The Aphasia Handbook

Edited by Martha Taylor Sarno, M.D., and Joan Peters, executive director of the National Aphasia Association

National Aphasia Association: New York, N.Y. ISBN 0-9758539-0-2

The Aphasia Handbook is designed to help, support and guide people with aphasia and their caregivers. Survivors with aphasia will find answers to everyday questions and gain a new understanding of living with this often frustrating and misunderstood condition. This book provides rich information about aphasia and its management in clear and accessible language. The user-friendly format uses tip boxes and cartoons to good effect and covers the gamut from an explanation of aphasia to patient rights.

The Meaning of Stroke — Mending the Mind

By Patton Howell

Saybrook Publishing: San Francisco, Calif. ISBN 0-933071-36-1

Dr. Patton Howell is a forensic psycho-physiologist specializing in stroke and other mind/brain problems. He is also a stroke survivor. His book recognizes that healing from stroke is not like healing from other diseases. It requires the survivor to figure out the stroke’s unique meaning. It details how both survivor and caregiver must mend their minds together; it is a healing concurrence like that of a mother and child. This concurrence helps to neutralize anger, a great danger to recovery.

These book summaries are provided as a resource to our readers. These books have not been reviewed or endorsed by the American Stroke Association.

Helpful Books

November/December 200536

Easy Medicare Help

New Medicare changes take effect in 2006. You can find out what those changes are and how they’ll affect you through the National Council on Aging’s BenefitsCheckUp® Web site. This site offers links to more than 1,300 government programs in all 50 states and the District of Columbia. It directs you to possible financial resources for prescription drugs, health care, rent and utilities, and other necessary living expenses. It provides easy-to-follow questionnaires that help determine what you’re qualified for. Be sure to have your personal information (e.g., name, address, Social Security number, insurance information) handy so you can answer the questions accurately.

BenefitsCheckUp.com

American Stroke Association

1-888-4-STROKE (478-7653)Fax: (214) 706-5231www.StrokeAssociation.org

National Family Caregivers Association

Voice: (800) 896-3650Fax: (301) 942-2302www.thefamilycaregiver.org

Americans With Disabilities Act (ADA)

Voice: (800) 514-0301TTY: (800) 514-0383www.usdoj.gov/crt/ada/adahom1.htm

National Aphasia Association

Voice: (800) 922-4622Fax: (410) 729-5724www.aphasia.org

National Rehabilitation Information Center (NARIC)

(800) 346-2742www.naric.com

Connect with the Federal Government

Need to renew your driver’s license? Apply for Social Security? Bid in a government auction? Get a passport application? Register to vote? FirstGov.gov is the federal government’s Web site for these and many other basic needs for government services, documents, opportunities and answers to your questions.

FirstGov.gov

1-800-FED-INFO

R e s o u r c e s

E V E R Y D A Y Connecting You to Helpful Ideas

Item No: B1-K0206 Trim Size: 8 1/4" x 10 3/4" Publication: Stroke Connection_IBC

PLAVIX®clopidogrel bisulfate tabletsRx onlyBrief Summary of Prescribing Information Rev. November 2004 INDICATIONS AND USAGEPLAVIX (clopidogrel bisulfate) is indicated for the reduction of thrombotic events asfollows:

• Recent MI, Recent Stroke or Established Peripheral Arterial DiseaseFor patients with a history of recent myocardial infarction (MI), recent stroke, orestablished peripheral arterial disease, PLAVIX has been shown to reduce therate of a combined endpoint of new ischemic stroke (fatal or not), new MI (fatalor not), and other vascular death.

• Acute Coronary SyndromeFor patients with acute coronary syndrome (unstable angina/non-Q-wave MI)including patients who are to be managed medically and those who are to bemanaged with percutaneous coronary intervention (with or without stent) orCABG, PLAVIX has been shown to decrease the rate of a combined endpoint ofcardiovascular death, MI, or stroke as well as the rate of a combined endpoint ofcardiovascular death, MI, stroke, or refractory ischemia.

CONTRAINDICATIONSThe use of PLAVIX is contraindicated in the following conditions:

• Hypersensitivity to the drug substance or any component of the product.• Active pathological bleeding such as peptic ulcer or intracranial hemorrhage.

WARNINGSThrombotic thrombocytopenic purpura (TTP): TTP has been reported rarely followinguse of PLAVIX, sometimes after a short exposure (<2 weeks). TTP is a serious condition and requires urgent referral to a hematologist for prompt treatment. It ischaracterized by thrombocytopenia, microangiopathic hemolytic anemia (schistocytes[fragmented RBCs] seen on peripheral smear), neurological findings, renal dysfunc-tion, and fever. TTP was not seen during clopidogrel's clinical trials, which includedover 17,500 clopidogrel-treated patients. In world-wide postmarketing experience,however, TTP has been reported at a rate of about four cases per million patientsexposed, or about 11 cases per million patient-years. The background rate is thoughtto be about four cases per million person-years. (See ADVERSE REACTIONS.)PRECAUTIONSGeneralAs with other antiplatelet agents, PLAVIX prolongs the bleeding time and thereforeshould be used with caution in patients who may be at risk of increased bleeding fromtrauma, surgery, or other pathological conditions (particularly gastrointestinal andintraocular). If a patient is to undergo elective surgery and an antiplatelet effect is notdesired, PLAVIX should be discontinued 5 days prior to surgery.

Due to the risk of bleeding and undesirable hematological effects, blood cell countdetermination and/or other appropriate testing should be promptly considered, when-ever such suspected clinical symptoms arise during the course of treatment (seeADVERSE REACTIONS).

GI Bleeding: In CAPRIE, PLAVIX was associated with a rate of gastrointestinal bleed-ing of 2.0%, vs. 2.7% on aspirin. In CURE, the incidence of major gastrointestinalbleeding was 1.3% vs. 0.7% (PLAVIX + aspirin vs. placebo + aspirin, respectively).PLAVIX should be used with caution in patients who have lesions with a propensity tobleed (such as ulcers). Drugs that might induce such lesions should be used with caution in patients taking PLAVIX.

Use in Hepatically Impaired Patients: Experience is limited in patients with severehepatic disease, who may have bleeding diatheses. PLAVIX should be used with caution in this population.

Use in Renally-impaired Patients: Experience is limited in patients with severe renalimpairment. PLAVIX should be used with caution in this population.Information for PatientsPatients should be told that they may bleed more easily and it may take them longer thanusual to stop bleeding when they take PLAVIX or PLAVIX combined with aspirin, and thatthey should report any unusual bleeding to their physician. Patients should inform physi-cians and dentists that they are taking PLAVIX and/or any other product known to affectbleeding before any surgery is scheduled and before any new drug is taken.Drug InteractionsStudy of specific drug interactions yielded the following results:

Aspirin: Aspirin did not modify the clopidogrel-mediated inhibition of ADP-inducedplatelet aggregation. Concomitant administration of 500 mg of aspirin twice a day for 1day did not significantly increase the prolongation of bleeding time induced by PLAVIX.PLAVIX potentiated the effect of aspirin on collagen-induced platelet aggregation. PLAVIX and aspirin have been administered together for up to one year.

Heparin: In a study in healthy volunteers, PLAVIX did not necessitate modificationof the heparin dose or alter the effect of heparin on coagulation. Coadministration ofheparin had no effect on inhibition of platelet aggregation induced by PLAVIX.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): In healthy volunteers receivingnaproxen, concomitant administration of PLAVIX was associated with increased occultgastrointestinal blood loss. NSAIDs and PLAVIX should be coadministered with caution.

Warfarin: Because of the increased risk of bleeding, the concomitant administration ofwarfarin with PLAVIX should be undertaken with caution. (See PRECAUTIONS–General.)

Other Concomitant Therapy: No clinically significant pharmacodynamic interactionswere observed when PLAVIX was coadministered with atenolol, nifedipine, or bothatenolol and nifedipine. The pharmacodynamic activity of PLAVIX was also not signifi-cantly influenced by the coadministration of phenobarbital, cimetidine or estrogen.

The pharmacokinetics of digoxin or theophylline were not modified by the coad-ministration of PLAVIX (clopidogrel bisulfate).

At high concentrations in vitro, clopidogrel inhibits P450 (2C9). Accordingly, PLAVIXmay interfere with the metabolism of phenytoin, tamoxifen, tolbutamide, warfarin,torsemide, fluvastatin, and many non-steroidal anti-inflammatory agents, but thereare no data with which to predict the magnitude of these interactions. Caution should beused when any of these drugs is coadministered with PLAVIX.

In addition to the above specific interaction studies, patients entered into clinical trials with PLAVIX received a variety of concomitant medications including diuretics,beta-blocking agents, angiotensin converting enzyme inhibitors, calcium antago-nists, cholesterol lowering agents, coronary vasodilators, antidiabetic agents(including insulin), antiepileptic agents, hormone replacement therapy, heparins(unfractionated and LMWH) and GPIIb/IIIa antagonists without evidence of clinicallysignificant adverse interactions. The use of oral anticoagulants, non-study anti-plateletdrug and chronic NSAIDs was not allowed in CURE and there are no data on their concomitant use with clopidogrel.Drug/Laboratory Test InteractionsNone known.Carcinogenesis, Mutagenesis, Impairment of FertilityThere was no evidence of tumorigenicity when clopidogrel was administered for 78 weeksto mice and 104 weeks to rats at dosages up to 77 mg/kg per day, which afforded plasma exposures >25 times that in humans at the recommended daily dose of 75 mg.

Clopidogrel was not genotoxic in four in vitro tests (Ames test, DNA-repair test inrat hepatocytes, gene mutation assay in Chinese hamster fibroblasts, and metaphasechromosome analysis of human lymphocytes) and in one in vivo test (micronucleustest by oral route in mice).

Clopidogrel was found to have no effect on fertility of male and female rats at oral doses up to 400 mg/kg per day (52 times the recommended human dose on amg/m2 basis).PregnancyPregnancy Category B. Reproduction studies performed in rats and rabbits at doses upto 500 and 300 mg/kg/day (respectively, 65 and 78 times the recommended dailyhuman dose on a mg/m2 basis), revealed no evidence of impaired fertility or fetotoxic-ity due to clopidogrel. There are, however, no adequate and well-controlled studies inpregnant women. Because animal reproduction studies are not always predictive of ahuman response, PLAVIX should be used during pregnancy only if clearly needed.Nursing MothersStudies in rats have shown that clopidogrel and/or its metabolites are excreted in themilk. It is not known whether this drug is excreted in human milk. Because many drugsare excreted in human milk and because of the potential for serious adverse reactions innursing infants, a decision should be made whether to discontinue nursing or to dis-continue the drug, taking into account the importance of the drug to the nursing woman.Pediatric UseSafety and effectiveness in the pediatric population have not been established.Geriatric UseOf the total number of subjects in controlled clinical studies, approximately 50% ofpatients treated with PLAVIX were 65 years of age and over. Approximately 16% ofpatients treated with PLAVIX were 75 years of age and over. The observed difference in risk of bleeding events with clopidogrel plus aspirin versusplacebo plus aspirin by age category is provided in the following table (see ADVERSEREACTIONS).

ADVERSE REACTIONSPLAVIX has been evaluated for safety in more than 17,500 patients, including over 9,000patients treated for 1 year or more. The overall tolerability of PLAVIX in CAPRIE was sim-ilar to that of aspirin regardless of age, gender and race, with an approximately equal inci-dence (13%) of patients withdrawing from treatment because of adverse reactions. Theclinically important adverse events observed in CAPRIE and CURE are discussed below.

Hemorrhagic: In CAPRIE patients receiving PLAVIX, gastrointestinal hemorrhageoccurred at a rate of 2.0%, and required hospitalization in 0.7%. In patients receivingaspirin, the corresponding rates were 2.7% and 1.1%, respectively. The incidence ofintracranial hemorrhage was 0.4% for PLAVIX compared to 0.5% for aspirin.

In CURE, PLAVIX use with aspirin was associated with an increase in bleeding com-pared to placebo with aspirin (see table below). There was an excess in major bleed-ing in patients receiving PLAVIX plus aspirin compared with placebo plus aspirin, pri-marily gastrointestinal and at puncture sites. The incidence of intracranial hemorrhage(0.1%), and fatal bleeding (0.2%), were the same in both groups.

The overall incidence of bleeding is described in the table below for patients receiv-ing both PLAVIX and aspirin in CURE, CURE Incidence of bleeding complications (% patients)Event PLAVIX Placebo P-value

(+ aspirin)* (+ aspirin)*(n=6259) (n=6303)

Major bleeding † 3.7 ‡ 2.7 § 0.001Life-threatening bleeding 2.2 1.8 0.13

Fatal 0.2 0.25 g/dL hemoglobin drop 0.9 0.9Requiring surgical intervention 0.7 0.7Hemorrhagic strokes 0.1 0.1Requiring inotropes 0.5 0.5Requiring transfusion ( 4 units) 1.2 1.0

Other major bleeding 1.6 1.0 0.005Significantly disabling 0.4 0.3Intraocular bleeding with

significant loss of vision 0.05 0.03Requiring 2-3 units of blood 1.3 0.9

Minor bleeding ¶ 5.1 2.4 <0.001* Other standard therapies were used as appropriate.† Life threatening and other major bleeding.‡ Major bleeding event rate for PLAVIX + aspirin was dose-dependent on aspirin:

<100 mg=2.6%; 100-200 mg= 3.5%; >200 mg=4.9%Major bleeding event rates for PLAVIX + aspirin by age were: <65 years = 2.5%, 65 to <75 years = 4.1%, 75 years 5.9%

§ Major bleeding event rate for placebo + aspirin was dose-dependent on aspirin: <100 mg=2.0%; 100-200 mg= 2.3%; >200 mg=4.0%Major bleeding event rates for placebo + aspirin by age were: <65 years = 2.1%, 65 to <75 years = 3.1%, 75 years 3.6%

¶ Led to interruption of study medication.

Ninety-two percent (92%) of the patients in the CURE study received heparin/LMWH, and the rate of bleeding in these patients was similar to the overall results.

There was no excess in major bleeds within seven days after coronary bypass graftsurgery in patients who stopped therapy more than five days prior to surgery (eventrate 4.4% PLAVIX + aspirin; 5.3% placebo + aspirin). In patients who remained on ther-apy within five days of bypass graft surgery, the event rate was 9.6% for PLAVIX +aspirin, and 6.3% for placebo + aspirin.

Neutropenia/agranulocytosis: Ticlopidine, a drug chemically similar to PLAVIX, isassociated with a 0.8% rate of severe neutropenia (less than 450 neutrophils/µL). InCAPRIE severe neutropenia was observed in six patients, four on PLAVIX and two onaspirin. Two of the 9599 patients who received PLAVIX and none of the 9586 patientswho received aspirin had neutrophil counts of zero. One of the four PLAVIX patients inCAPRIE was receiving cytotoxic chemotherapy, and another recovered and returned tothe trial after only temporarily interrupting treatment with PLAVIX (clopidogrel bisul-fate). In CURE, the numbers of patients with thrombocytopenia (19 PLAVIX + aspirinvs. 24 placebo + aspirin) or neutropenia (3 vs. 3) were similar.

Although the risk of myelotoxicity with PLAVIX (clopidogrel bisulfate) thus appearsto be quite low, this possibility should be considered when a patient receiving PLAVIXdemonstrates fever or other sign of infection.

Gastrointestinal: Overall, the incidence of gastrointestinal events (e.g. abdominalpain, dyspepsia, gastritis and constipation) in patients receiving PLAVIX (clopidogrelbisulfate) was 27.1%, compared to 29.8% in those receiving aspirin in the CAPRIE trial.In the CURE trial the incidence of these gastrointestinal events for patients receivingPLAVIX + aspirin was 11.7% compared to 12.5% for those receiving placebo + aspirin.

In the CAPRIE trial, the incidence of peptic, gastric or duodenal ulcers was 0.7% forPLAVIX and 1.2% for aspirin. In the CURE trial the incidence of peptic, gastric or duo-denal ulcers was 0.4% for PLAVIX + aspirin and 0.3% for placebo + aspirin.

Cases of diarrhea were reported in the CAPRIE trial in 4.5% of patients in the PLAVIX group compared to 3.4% in the aspirin group. However, these were rarelysevere (PLAVIX=0.2% and aspirin=0.1%). In the CURE trial, the incidence of diarrheafor patients receiving PLAVIX + aspirin was 2.1% compared to 2.2% for those receiv-ing placebo + aspirin.

In the CAPRIE trial, the incidence of patients withdrawing from treatment becauseof gastrointestinal adverse reactions was 3.2% for PLAVIX (clopidogrel bisulfate) and4.0% for aspirin. In the CURE trial, the incidence of patients withdrawing from treatment because of gastrointestinal adverse reactions was 0.9% for PLAVIX + aspirincompared with 0.8% for placebo + aspirin.

Rash and Other Skin Disorders: In the CAPRIE trial, the incidence of skin andappendage disorders in patients receiving PLAVIX was 15.8% (0.7% serious); the cor-responding rate in aspirin patients was 13.1% (0.5% serious). In the CURE trial theincidence of rash or other skin disorders in patients receiving PLAVIX + aspirin was4.0% compared to 3.5% for those receiving placebo + aspirin.

In the CAPRIE trial, the overall incidence of patients withdrawing from treatmentbecause of skin and appendage disorders adverse reactions was 1.5% for PLAVIX and 0.8% for aspirin. In the CURE trial, the incidence of patients withdrawing becauseof skin and appendage disorders adverse reactions was 0.7% for PLAVIX + aspirin compared with 0.3% for placebo + aspirin.

Adverse events occurring in 2.5% of patients on PLAVIX in the CAPRIE controlledclinical trial are shown below regardless of relationship to PLAVIX. The median dura-tion of therapy was 20 months, with a maximum of 3 years.Adverse Events Occurring in 2.5% of PLAVIX Patients in CAPRIE

% Incidence (% Discontinuation)Body System PLAVIX AspirinEvent [n=9599] [n=9586]Body as a Whole- general disorders

Chest Pain 8.3 (0.2) 8.3 (0.3)Accidental/Inflicted Injury 7.9 (0.1) 7.3 (0.1)Influenza-like symptoms 7.5 (<0.1) 7.0 (<0.1)Pain 6.4 (0.1) 6.3 (0.1)Fatigue 3.3 (0.1) 3.4 (0.1)

Cardiovascular disorders, generalEdema 4.1 (<0.1) 4.5 (<0.1)Hypertension 4.3 (<0.1) 5.1 (<0.1)

Central & peripheral nervous system disorders

Headache 7.6 (0.3) 7.2 (0.2)Dizziness 6.2 (0.2) 6.7 (0.3)

Gastrointestinal system disordersAbdominal pain 5.6 (0.7) 7.1 (1.0)Dyspepsia 5.2 (0.6) 6.1 (0.7)Diarrhea 4.5 (0.4) 3.4 (0.3)Nausea 3.4 (0.5) 3.8 (0.4)

Metabolic & nutritional disordersHypercholesterolemia 4.0 (0) 4.4 (<0.1)

Musculo-skeletal system disordersArthralgia 6.3 (0.1) 6.2 (0.1)Back Pain 5.8 (0.1) 5.3 (<0.1)

Platelet, bleeding, & clotting disordersPurpura/Bruise 5.3 (0.3) 3.7 (0.1)Epistaxis 2.9 (0.2) 2.5 (0.1)

Psychiatric disordersDepression 3.6 (0.1) 3.9 (0.2)

Respiratory system disordersUpper resp tract infection 8.7 (<0.1) 8.3 (<0.1)Dyspnea 4.5 (0.1) 4.7 (0.1)Rhinitis 4.2 (0.1) 4.2 (<0.1)Bronchitis 3.7 (0.1) 3.7 (0)Coughing 3.1 (<0.1) 2.7(<0.1)

Adverse Events Occurring in 2.5% of PLAVIX Patients in CAPRIE (continued)% Incidence (% Discontinuation)

Body System PLAVIX AspirinEvent [n=9599] [n=9586]Skin & appendage disorders

Rash 4.2 (0.5) 3.5 (0.2)Pruritus 3.3 (0.3) 1.6 (0.1)

Urinary system disordersUrinary tract infection 3.1 (0) 3.5 (0.1)

Incidence of discontinuation, regardless of relationship to therapy, is shown in parentheses.

Adverse events occurring in 2.0% of patients on PLAVIX in the CURE controlledclinical trial are shown below regardless of relationship to PLAVIX.Adverse Events Occurring in 2.0% of PLAVIX Patients in CURE

% Incidence (% Discontinuation)Body System PLAVIX Placebo

(+ aspirin)* (+ aspirin)*Event [n=6259] [n=6303]Body as a Whole- general disorders

Chest Pain 2.7 (<0.1) 2.8 (0.0)Central & peripheral nervous system disorders

Headache 3.1 (0.1) 3.2 (0.1)Dizziness 2.4 (0.1) 2.0 (<0.1)

Gastrointestinal system disordersAbdominal pain 2.3 (0.3) 2.8 (0.3)Dyspepsia 2.0 (0.1) 1.9 (<0.1)Diarrhea 2.1 (0.1) 2.2 (0.1)

*Other standard therapies were used as appropriate.

Other adverse experiences of potential importance occurring in 1% to 2.5% ofpatients receiving PLAVIX (clopidogrel bisulfate) in the CAPRIE or CURE controlledclinical trials are listed below regardless of relationship to PLAVIX. In general, the inci-dence of these events was similar to that in patients receiving aspirin (in CAPRIE) orplacebo + aspirin (in CURE).

Autonomic Nervous System Disorders: Syncope, Palpitation. Body as a Whole-general disorders: Asthenia, Fever, Hernia. Cardiovascular disorders: Cardiac failure.Central and peripheral nervous system disorders: Cramps legs, Hypoaesthesia,Neuralgia, Paraesthesia, Vertigo. Gastrointestinal system disorders: Constipation,Vomiting. Heart rate and rhythm disorders: Fibrillation atrial. Liver and biliary systemdisorders: Hepatic enzymes increased. Metabolic and nutritional disorders: Gout,hyperuricemia, non-protein nitrogen (NPN) increased. Musculo-skeletal system disor-ders: Arthritis, Arthrosis. Platelet, bleeding & clotting disorders: GI hemorrhage,hematoma, platelets decreased. Psychiatric disorders: Anxiety, Insomnia. Red bloodcell disorders: Anemia. Respiratory system disorders: Pneumonia, Sinusitis. Skin andappendage disorders: Eczema, Skin ulceration. Urinary system disorders: Cystitis.Vision disorders: Cataract, Conjunctivitis.

Other potentially serious adverse events which may be of clinical interest but wererarely reported (<1%) in patients who received PLAVIX in the CAPRIE or CURE con-trolled clinical trials are listed below regardless of relationship to PLAVIX. In general,the incidence of these events was similar to that in patients receiving aspirin (inCAPRIE) or placebo + aspirin (in CURE).

Body as a whole: Allergic reaction, necrosis ischemic. Cardiovascular disorders:Edema generalized. Gastrointestinal system disorders: Gastric ulcer perforated, gastri-tis hemorrhagic, upper GI ulcer hemorrhagic. Liver and Biliary system disorders:Bilirubinemia, hepatitis infectious, liver fatty. Platelet, bleeding and clotting disorders:hemarthrosis, hematuria, hemoptysis, hemorrhage intracranial, hemorrhage retroperi-toneal, hemorrhage of operative wound, ocular hemorrhage, pulmonary hemorrhage,purpura allergic, thrombocytopenia. Red blood cell disorders: Anemia aplastic, anemiahypochromic. Reproductive disorders, female: Menorrhagia. Respiratory system disorders: Hemothorax. Skin and appendage disorders: Bullous eruption, rash erythe-matous, rash maculopapular, urticaria. Urinary system disorders: Abnormal renal function, acute renal failure. White cell and reticuloendothelial system disorders:Agranulocytosis, granulocytopenia, leukemia, leukopenia, neutrophils decreased.Postmarketing ExperienceThe following events have been reported spontaneously from worldwide postmarket-ing experience:

• Body as a whole:- hypersensitivity reactions, anaphylactoid reactions

• Central and Peripheral Nervous System disorders:- confusion, hallucinations, taste disorders

• Hepato-biliary disorders:- abnormal liver function test, hepatitis (non-infectious)

• Platelet, Bleeding and Clotting disorders:- cases of bleeding with fatal outcome (especially intracranial, gastrointestinal

and retroperitoneal hemorrhage)- agranulocytosis, aplastic anemia/pancytopenia, thrombotic thrombocytopenic

purpura (TTP) - some cases with fatal outcome – (see WARNINGS).- conjunctival, ocular and retinal bleeding

• Respiratory, thoracic and mediastinal disorders:- bronchospasm

• Skin and subcutaneous tissue disorders:- angioedema, erythema multiforme, Stevens-Johnson syndrome, lichen planus

• Renal and urinary disorders:- glomerulopathy, increased creatinine levels

• Vascular disorders:- vasculitis, hypotension

• Gastrointestinal disorders:- colitis (including ulcerative or lymphocytic colitis), pancreatitis

• Musculoskeletal, connective tissue and bone disorders:- myalgia

OVERDOSAGEOverdose following clopidogrel administration may lead to prolonged bleeding timeand subsequent bleeding complications. Appropriate therapy should be considered ifbleeding is observed. A single oral dose of clopidogrel at 1500 or 2000 mg/kg waslethal to mice and to rats and at 3000 mg/kg to baboons. Symptoms of acute toxicitywere vomiting (in baboons), prostration, difficult breathing, and gastrointestinal hem-orrhage in all species.Recommendations About Specific Treatment:Based on biological plausibility, platelet transfusion may be appropriate to reverse thepharmacological effects of PLAVIX if quick reversal is required.DOSAGE AND ADMINISTRATIONRecent MI, Recent Stroke, or Established Peripheral Arterial DiseaseThe recommended daily dose of PLAVIX is 75 mg once daily.Acute Coronary SyndromeFor patients with acute coronary syndrome (unstable angina/non-Q-wave MI), PLAVIXshould be initiated with a single 300 mg loading dose and then continued at 75 mgonce daily. Aspirin (75 mg-325 mg once daily) should be initiated and continued incombination with PLAVIX. In CURE, most patients with Acute Coronary Syndrome alsoreceived heparin acutely (see CLINICAL STUDIES).

PLAVIX can be administered with or without food.No dosage adjustment is necessary for elderly patients or patients with renal dis-

ease. (See Clinical Pharmacology: Special Populations.)Distributed by:Bristol-Myers Squibb/Sanofi Pharmaceuticals PartnershipNew York, NY 10016

PLAVIX® is a registered trademark of Sanofi-Synthelabo.

Brief Summary of Prescribing Information Rev. November 2004

B1K0206_IBC 9/27/05 1:25 PM Page 1

Item No: B1-K0206 Trim Size: 7 3/4" x 10 3/4" Publication: Stroke Connection_BackCover


PLAVIX HELPS KEEP BLOOD PLATELETSFROM STICKING TOGETHER AND FORMINGCLOTS, WHICH HELPS PROTECT YOU FROMANOTHER HEART ATTACK OR STROKE.If you’ve had a heart attack or stroke, the last thing youneed is another one sneaking up on you. PLAVIX mayhelp. PLAVIX is a prescription medication for people whohave had a recent heart attack or recent stroke, or whohave poor circulation in the legs, causing pain(peripheral artery disease).

PLAVIX OFFERS PROTECTION.PLAVIX is proven to help keep blood platelets fromsticking together and forming clots, which helps keepyour blood flowing. This can help protect you fromanother heart attack or stroke.

IMPORTANT INFORMATION: If you have a stomachulcer or other condition that causes bleeding, youshouldn't use Plavix. When taking Plavix alone or withsome medicines including aspirin, the risk of bleedingmay increase.To minimize this risk, talk to your doctorbefore taking aspirin or other medicines with Plavix.Additional rare but serious side effects could occur.

WITHOUT PLAVIX WITH PLAVIX

PROVEN TO HELP PROTECT FROM ANOTHER HEART ATTACK OR STROKE

TALK TO YOUR DOCTOR ABOUT PLAVIX.For more information, visit www.plavix.com or call1-877-700-0701


© 2005 Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership.

USA.CLO.05.08.156/September 2005 B1-K0206/09-05

B1K0206_StrokeConnectionAd BCvr 9/27/05 1:24 PM Page 1

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