Stroke and transient ischemic attack

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Stroke is highly prevalent and shares many of the same risk factors as cardiovascular disease. Physical activity and exercise is associated with a reduced incidence of stroke. Exercise can be used in both the rehabilitation of non-disabling and disabling stroke.

Guidelines recommend starting an exercise program as soon as medical stability is achieved and progressing to an optimal level of function for independence. Physical activity guidelines once exercise can be tolerated recommend the use of aerobic exercise, strength-training, and flexibility and balance training.

CONTENTS

What is stroke?

A stroke is the rapid loss of neurological function following a failure of the blood flow to the brain. This failure of the blood flow can result either from a blood flow restriction (ischemia) following an arterial blockage or from a hemorrhage following the rupture of a blood vessel. Strokes can lead to permanent damage as a result of infarction (tissue death). Strokes are commonly categorized as either ischemic and hemorrhagic in type. It is thought that the large majority of strokes are of the ischemic category. Ischemic strokes are similar in concept to heart attacks, which involve the failure of blood supply to the heart rather than to the brain. Common symptoms of stroke include the inability to move the legs or arms on one side of the body, an inability to understand speech, or a loss of vision.


What is a transient ischemic attack?

A transient ischemic attack (TIA) is very similar to an ischemic stroke in that involves neurological dysfunction following a failure of the blood flow to the brain (ischemia). However, TIAs do not involve infarction (tissue death) and symptoms typically resolve in a very short period of time. TIAs present very similar symptoms to strokes, including the inability to move the legs or arms on one side of the body, an inability to understand speech, and a loss of vision. TIAs are sometimes referred to as “mini-strokes” in the lay press.


What is the prevalence of stroke?

The following table sets out the prevalence of stroke in various different populations and geographies around the world:

Study Population Prevalence
Wu et al. Chinese island populations pre-2000 5.54 per 1,000
Wu et al. Chinese island populations post-2000 8.34 per 1,000
Sun et al. China 3.94 – 12.85 per 1,000
Mukhopadhyay et al. Mumbai in India 48.7 per 1,000
Centers for Disease Control and Prevention US 15 – 41 per 1,000

Based on these studies, it appears the prevalence of individuals with stroke in various populations ranges widely from around 4 – 50 per 1,000 people, which can be stated as 0.4 – 5.0%. The prevalence of stroke seems to be higher in developed countries.


What is the incidence of stroke?

The following table sets out the incidence of stroke in various different populations and geographies around the world:

Study Population Age Incidence
Tsai et al. Chinese populations aged 45 – 74 years 205 – 584 per 100,000
Tsai et al. White populations aged 45 – 74 years 170 – 335 per 100,000
Sudlow et al. Europe + Russia + Australasia + the US aged 45 – 84 years 300 – 500 per 100,000
Wolfe et al. Multiethnic population in South London average age 71.7 years 126 per 100,000
Kulshreshtha et al. South Asia undisclosed 145 – 262 per 100,000
Sun et al. China undisclosed 136 – 441 per 100,000

Based on these studies, it appears that the incidence of first-time stroke in various populations ranges from around 100 – 600 per 100,000 people, which can be stated as 0.1 – 0.6%.


What are the risk factors for stroke?

The following studies, which are set out in the table below, have investigated the risk factors for stroke in middle-aged and early old-aged people (predominantly of the ischemic type):

Study Approach Finding
Gronewold et al. The researchers investigated whether the ankle-brachial index could be used as a simple non-invasive marker of stroke. They therefore recruited 4,299 subjects from the population-based Heinz Nixdorf Recall study (subjects aged 45 – 75 years and 47.3% men) who were without previous stroke, coronary heart disease or myocardial infarcts. The researchers followed up these subjects for ischemic and hemorrhagic stroke events over 109.0 ± 23.3 months. The researchers reported that those subjects suffering stroke displayed significantly lower ankle-brachial index values at baseline than the other subjects (1.03 ± 0.22 vs. 1.13 ± 0.14).
Ratanakorn et al. The researchers investigated whether an abnormal  ankle-brachial index was associated with stroke in 747 Thai patients with a history of ischemic stroke or transient ischemic attack (TIA). The researchers found that the incidence of an abnormally low ankle-brachial index (≤0.9) in ischemic stroke patients was 18.1%. They noted that an abnormally low ankle-brachial index was significantly associated with female gender, age ≥ 60 years and previous (non-stroke) ischemic events such as coronary artery disease, cerebrovascular disease, and atrial fibrillation.
Jokela et al. The researchers assessed whether personality traits are risk factors for stroke. They therefore recruited subjects from three prospective cohort studies (Health and Retirement Study, Wisconsin Longitudinal Study graduate and sibling samples) including a total of 24,543 males and females with an average age of 61.4 years. The researchers followed-up over 3 – 15 years. The researchers reported that the personality trait of extraversion was associated with an increased risk of stroke mortality while the personality trait of conscientiousness was associated with lower mortality risk from stroke.
Hyun et al. The researchers investigated the associations between major risk factors and stroke risk, comparing Asian with non-Asian men using data from the Asia Pacific Cohort Studies Collaboration, which is a pooled analysis of individual participant data from 44 studies involving 386,411 men with 9.4 years of follow-up. The researchers reported that there were significant, positive associations between the risk of stroke and all of the major risk factors investigated, which included: body mass index (BMI), smoking, diabetes, systolic blood pressure and total cholesterol. They found that in most cases the risk factors were similar for males in both Asia and in Australia/New Zealand. They therefore suggested that reducing systolic blood pressure, total cholesterol, BMI, smoking, and diabetes would probably help reduce stroke risk.
Alkali et al. The researchers investigated stroke risk factors, imaging subtypes and 30-day outcomes in adult Nigerians. They therefore recruited all patients presenting with acute stroke at the National Hospital Abuja between January 2010 and June 2012. The researchers studied 272 patients, of which 168 (61.8%) were males, with a mean age at presentation of 56.4 ± 12.7 years in males and 52.9 ± 14.8 years in females. The researchers reported that the incidence of known stroke risk factors included hypertension (82.7%), obesity (32.6%), diabetes (23.5%), hyperlipidemia (18.4%), atrial fibrillation (9.2%), and cigarette smoking (7.7%).
Onwuchekwa et al. The researchers performed a door-to-door stroke prevalence study in 2008 in randomly selected adults aged >18 years in south Nigeria. This study included a physical/neurological examination. The researchers found that although stroke prevalence was high and increased with age the incidence of conventional risk factors was not similarly high. On the one hand, they noted that hypertension (blood pressure ≥140/90mmHg) was present in all stroke cases. However, they observed that diabetes mellitus (fasting blood sugar >126 mg/dL) was only present in 1 person and none had hypercholesterolemia, obesity (body mass index >30 kg/m2), or a history of alcohol intake or smoking.
Mierzecki et al. The researchers assessed metabolic risk factors and their interaction with family history of premature ischemic stroke. They recruited 344 healthy individuals, including 143 with family history of premature ischemic stroke and 201 without family history of premature ischemic stroke (control group). The researchers found that in the group with family history of premature ischemic stroke, there was also a significantly higher mean body mass index (BMI), higher systolic and diastolic blood pressure, and higher low-density lipoprotein cholesterol (LDL-C) in both males and females. Males also displayed significantly higher total cholesterol. The researchers concluded that both males and females with family history of premature ischemic stroke display an unfavorable shift in various major risk factors, which may be the underlying cause of family history being a risk factor for premature ischemic stroke.
Copstein et al. The researchers assessed the prevalence of stroke and its risk factors in a population of 3,391 subjects aged >20 years in vulnerable communities in southern Brazil. The researchers reported that 285 individuals (8.4%) had incurred a stroke previously. They found that the risk factors for stroke included: age from 40 to 59, age from 60 to 79, widowhood, present smoking, previous smoking, hypertension, and ischemic heart disease.
Kastorini et al. The researchers compared the classic cardiovascular disease risk factors with those of ischemic stroke. They enrolled 1,000 subjects over 2009 – 2010, including 250 consecutive patients with a first acute coronary syndrome, 250 consecutive patients with a first ischemic stroke, and 500 population-based, control subjects. The researchers investigated the following risk factors: smoking/passive smoking, family history of cardiovascular disease, physical inactivity, hypertension, hypercholesterolemia, diabetes mellitus, presence of overweight and obesity, trait anxiety, and adherence to the Mediterranean diet. The researchers reported that the risk factors with the highest effect size for acute coronary syndrome were smoking and hypercholesterolemia but for stroke, they were anxiety and family history of cardiovascular disease. Nevertheless, when the researchers compared the odds ratios for each of the risk factors between acute coronary syndrome and ischemic stroke, there were no significant differences. The researchers therefore concluded that simultaneous primary prevention measures are likely appropriate for these diseases.
Von Sarnowski et al. The researchers prospectively recruited a large, multi-national European cohort of patients with cerebrovascular events aged 18 – 55 years primarily in order to establish their prevalence of Fabry disease. However, in a secondary analysis of 4,467 patients with a mean age of 47 years with ischemic stroke or transient ischemic attack, they also investigated various risk factors. The researchers reported that the most frequently reported potential risk factors were smoking (55.5%), physical inactivity (48.2%), arterial hypertension (46.6%), dyslipidemia (34.9%), and obesity (22.3%). They noted that other less-frequently reported potential risk factors included high-risk alcohol consumption (33.0%) and short sleep duration (20.6%), particularly in males, and migraine (26.5%) in women.
Fahimfar et al. The researchers investigated the risk factors and their population attributable fraction for stroke in cohort from the Iranian population comprising of 1,089 men and 1,289 women, with average ages of 61.1 ± 7.6 and 59.0 ± 6.7 years, respectively. The researchers found that over a 9.3-year period of follow-up, the following risk factors were independently associated with increased risk of stroke events in the total population: age ≥ 65 years, male gender, hypertension, diabetes mellitus and chronic kidney disease.
Joshi et al. The researchers performed a retrospective cross-sectional study between January 2007 and December 2009 in 418 Pakistani male and female patients with a mean age of  65 ± 0.8 years in order to assess the risk factors for ischemic stroke. The researchers found that the most frequent risk factors were: hypertension (86.8%), type II diabetes mellitus (59.8%), dyslipidemia (59.1%), and smoking (18.1%).
Ashkanani et al. The researchers performed a retrospective chart review of all patients admitted to the Amiri Hospital, Kuwait, who either were discharged or passed away with a diagnosis of stroke in order to assess the risk factors for stroke in this cohort. The researchers reported that common risk factors included type II diabetes mellitus (56.3%), hyperlipidemia (57.0%), hypertension (68.9%), and a history of ischemic heart disease (28.5%).
Yong et al. The reviewers performed a systematic review of the effect of 5 well-known risk factors (hypertension, dyslipidemia, obesity, diabetes, and smoking) on the risk of stroke in the Chinese population by reference to literature published to December 2010. The reviewers reported that the association between hypertension and stroke was the strongest of these 5 well-known risk factors reported in studies, with adjusted odds ratios ranging between 2.75 – 5.47 times. However, they also noted that there were also strong associations between stroke risk and the other risk factors.
Deoke et al. The researchers performed a case-control study between patients with stroke admitted in a tertiary care center in central India and age- and sex-matched controls. The researchers investigated risk factors including education, socioeconomic status, level of physical activity, alcohol intake, smoking, tobacco chewing, family history of stroke, history of systemic hypertension, and history of transient ischemic attack or ischemic heart disease. The researchers reported that a sedentary life-style, a history of transient ischemic attack, a history of coronary artery disease, a family history of stroke, systemic hypertension, and ECG abnormalities were significant risk factors. On the other hand, the researchers found that low socio-economic status, smoking, tobacco chewing, alcohol consumption, obesity and type II diabetes mellitus were not significant risk factors. The researchers observed that the most significant risk factors were as follows: systemic hypertension with an odds ratio of 15.92 times, followed by coronary artery disease with an odds ratio of 3.86, times, abnormal ECG with an odds ratio of 2.49 times, and a sedentary life-style with an odds ratio of 2.41 times.
Maskey et al. The researchers investigated the risk factors for stroke using a hospital-based, prospective, cross-sectional study in 160 stroke patients with a mean age of 65.98 ± 10.69 years, admitted to Manipal Teaching Hospital, Pokhara from November 2007 – October 2010. The researchers reported that risk factors were observed in the following proportion of cases: hypertension (61.2%), smoking (59.4%), alcohol (26.9%), left ventricular hypertrophy (27.5%), atrial fibrillation 37(23%), elevated triglycerides (23%), type II diabetes mellitus (9.3%) and elevated total cholesterol (7.5%).
Chen et al. The researchers investigated chronic kidney disease (CKD) as a risk factor for stroke. To do this, they conducted a nationwide retrospective cohort study based on the Taiwan National Health Insurance Research Database from 2004 – 2007 in 1,393 patients hospitalized for CKD but with no traditional cardiovascular risk factors at baseline and followed-up each subject over a 3-year period. An age-matched control cohort was used of patients hospitalized for appendectomies. The researchers found that after adjusting for covariates, patients with primary CKD had a 1.94 times greater risk of incurring a stroke than the age-matched controls.
Lindner et al. The researchers assessed the correlation between the risk of stroke and an increased incidence of periodic limb movements in sleep (PLMS) among dialyzed patients, which has previously been associated with an increased risk of mortality. They therefore subjected 100 transplanted and 50 waiting-list patients to sleep testing using polysomnography. They used the Periodic Limb Movements in Sleep Index (PLMSI) to define moderate and severe cases as those with >15 and >25 events per hour, respectively. The researchers found that those subjects with severe PLMS had a higher 10-year risk of stroke as well as a higher 10-year coronary heart disease risk. The researchers therefore concluded that PLMS is an independent predictor of stroke risk in patients with chronic kidney disease.
Miah et al. The researchers performed a cross-sectional study at Mymensingh Medical College Hospital in Bangladesh from November 2009 – October 2010 to assess variations in types of stroke (ischemic stroke and hemorrhagic stroke) during summer and winter as well as to explore variations in the risk factors for stroke. The researchers reported that the frequency of ischaemic stroke was greater in the summer than in the winter but for hemorrhagic stroke the reverse was the case. In terms of risk factors, the researchers found that hypertension was the most important risk factor. Other risk factors included: age, smoking, type II diabetes mellitus, tobacco chewing, ischemic heart disease, dyslipidemia, oral contraceptive pill, alcohol, atrial fibrillation, and history of stroke.
Howard et al. The researchers investigated the effect of ethnicity on the risk of stroke. They recruited a total of 25,714 black and white males and females, aged ≥45 years and stroke-free at baseline and followed-up after an average of 4.4 years. The researchers reported that the unadjusted risk of stroke was 2.90 times greater in blacks than in whites at 45 years old and 1.66 times greater at age 65 years old. However, adjusting for other well-known risk factors (particularly hypertension) reduced the differences by 40% and 45%, respectively to 2.14 and 1.35 times.
Hamer et al. The researchers explored the risk factors for stroke and ischemic heart disease prospectively in a cohort of 82,380 subjects with a mean age of 55.4 ± 14.2 years with no known history of cardiovascular disease at baseline, based on the Health Survey for England. The subjects were followed-up after an average of 8 years for cause-specific mortality. The researchers reported that the major risk factors for stroke were: age (1.15 times), smoking (1.71 times), type II diabetes (1.75 times), total cholesterol (0.78 times), and systolic blood pressure (1.22 times per standard deviation).
Aquil et al. The researchers performed a cross-sectional study in Ziauddin Hospital, Karachi from January to December 2007 to assess the risk factors in 100 patients with various subtypes of acute ischemic stroke and a mean age of 63.5 years. The researchers reported that the main risk factors were present as follows: hypertension (85%), type II diabetes mellitus (49%), ischemic heart disease (30%), dyslipidemia (22%), smoking (9%), atrial fibrillation (5%), and previous history of stroke (29%).
Lin et al. The researchers investigated the risk factors of ischemic stroke in 7,920 Taiwanese individuals with atrial fibrillation by reference to the universal national health insurance database. The researchers found that the risk factors for ischemic stroke in individuals with atrial fibrillation were age, hypertension, type II diabetes mellitus, heart failure, previous ischemic stroke or transient ischemic accident, and peripheral arterial disease. However, the researchers found that in individuals with atrial fibrillation gender, coronary artery disease, history of myocardial infarction, and chronic kidney disease were not associated with ischemic stroke.

Based on these studies, it seems that in addition to the usual suspects (hypertension, hypercholesterolemia, atrial fibrillation, obesity, type II diabetescoronary artery disease, increasing age and smoking), there are other risk factors, including a sedentary life-style, alcohol intake, chronic kidney disease, low ankle-brachial index, and certain personality types (e.g. extraversion and non-conscientious behaviour).


What are the risk factors for stroke in the very old?

The following studies, which are set out in the table below, have investigated the risk factors for stroke in the very old (predominantly of the ischemic type):

Study Approach Finding
Auriel et al. The researchers investigated the epidemiological, clinical and rehabilitation features of patients aged ≥85 years with a first-ever ischemic stroke based on a hospital-based stroke registry. Additionally, they compared these features with similar first-time ischemic stroke patients aged 65 – 84 years. The researchers reported that in those subjects aged >85 years, there was a significantly higher proportion of a history of atrial fibrillation and large artery atherosclerosis than in the younger patients but a lower prevalence of hypertension, type II diabetes mellitus, hyperlipidemia, and smoking.
Shimizu et al. The researchers carried out analyses of clinical data on 426 patients registered at a Japanese tertiary emergency hospital in respect of their risk factors for stroke. The subjects were stratified into two groups by age-at-onset (>75 years and <75 years). The researchers reported that common risk factors for stroke such as hypertension except atrial fibrillation were not prominent in the group <75 years.
Béjot et al. The researchers analysed the risk factors associated with first-ever strokes in the population of Dijon, France from 1985 to 2006 in individuals aged >80 years and in younger individuals. The researchers reported that in the individuals experiencing a first-ever stroke aged >80 years, there was a lower prevalence of type II diabetes, hypercholesterolemia and alcohol intake but a higher prevalence of hypertension, atrial fibrillation, previous myocardial infarction and use of pre-stroke antiplatelet agents.
Lee et al. The researchers retrospectively reviewed the risk factors associated with first-ever ischemic stroke patients admitted to the Chiayi Chang Gung Memorial Hospital in Taiwan from January 2002 to December 2005 in individuals aged >80 years and in younger individuals. The researchers reported that in the individuals experiencing a first-ever stroke aged >80 years, there was a lower frequency of lacunar infarct, atrial fibrillation, type II diabetes mellitus, hyperlipidemia and smoking, but a higher incidence of total anterior circulation infarct, pneumonia, urinary tract infection and upper gastrointestinal bleeding.
Arboix et al. The researchers assessed the risk factors in very old patients with ischemic stroke using a prospective hospital-based stroke registry, dividing individuals into two groups, with one group comprising 303 patients aged >85 years another group comprising 1,537 patients aged <85 years. The researchers found that type II diabetes, hypertension, hyperlipidemia and heavy smoking occurred more frequently in the stroke patients <85 years than in the stroke patients aged >85 years.
Rojas et al. The researchers examine the risk factor profile and stroke subtype in 179 patients with ischemic stroke aged >80 years and 356 patients with ischemic stroke aged <80 years. The researchers reported that the older group tended to display the risk factors to a greater extent than the younger group: female gender, hypertension, and atrial fibrillation. In contrast, they reported that the younger group tended to display type II diabetes, hyperlipidemia, smoking, and obesity.
Hornsten et al. The researchers investigated the association between stroke and depression in a population-based study performed between 2005 – 2007. The subjects were 601 individuals aged >85 years from eight urban and rural municipalities in northern Sweden and Finland. The researchers reported that the prevalence of depression was 50.4% in those individuals with stroke but only 34.3% in those without stroke. The researchers concluded that stroke displayed a strong association with depression in the very old.

Based on these studies, it seems that many of the usual suspects (hypertensionhypercholesterolemiaobesitytype II diabetescoronary artery disease, increasing age and smoking) are not common risk factors in the very old. However, atrial fibrillation seems to remain a significant risk factor and depression may also be an important risk factor.


What are the risk factors for recurrent stroke?

The following studies, which are set out in the table below, have investigated the risk factors for recurrent stroke (predominantly of the ischemic type):

Study Approach Finding
Laloux et al. The researchers examined the risk factors for recurrent stroke in 168 patients who had been admitted for either recurrent stroke or transient ischemic attack (TIA). The researchers reported that the recurrent stroke was not associated with a particular subtype of stroke. The most frequent risk factors were hypertension (79%), hypercholesterolemia (43%), smoking (25%), and type II diabetes (22%) and most of the patients had more than 1 risk factor (84%).
Ois et al. The researchers examined the risk factors associated with 7-day and 90-day stroke recurrence after an initial minor stroke or transient ischemic attack (TIA) in a prospective hospital-series of 689 patients. The researchers reported that 90-day recurrence occurred in 16.1% of patients and 7-day recurrence in 9% of patients. The researchers reported that the independent variables associated with 90-day recurrence included: severe symptomatic extra or intracranial arterial disease, weakness, speech impairment, severe alcohol intake, heart failure, previous transient ischemic attack (TIA) and vertebrobasilar events.
Suanprasert et al. The researchers investigated the risk factors of recurrent ischemic stroke in 67 patients with recurrent ischemic stroke and 167 patients without recurrent ischemic stroke. The researchers found that patients who did not incur a recurrent ischemic stroke had lower systolic and diastolic blood pressure levels, and higher high-density lipoprotein (HDL) levels than patients who did incur a recurrent ischemic stroke.
Liou et al. The researchers performed a 1-year, hospital-based study in 587 first-ever stroke patients and 475 recurrent ischemic stroke patients. The researchers reported that the main risk factors for recurrent ischemic stroke were: hypertension, type II diabetes mellitus, low high-density lipoprotein (LDL) levels, and older age. However, they also noted that metabolic syndrome was significantly more common in the recurrent stroke group than in the first-ever stroke group.
Leoo et al. The researchers assessed the risk factors of 889 patients with recurrent stroke and a mean age of 77 years who were admitted to 23 Swedish stroke centers. The researchers reported that the most frequent vascular risk factors were: hypertension (75%) and hyperlipidemia (56%) although a minority also had atrial fibrillation (29%).
Moroney et al. The researchers prospectively examined 297 patients with a mean age of 72.0 ± 8.4 years who had been hospitalized with ischemic stroke in order to assess the risk factors associated with recurrent strokes within 90 days. The researchers found that stroke recurrence rate within 90 days was 7.4%. They found that the main independent predictors of recurrent stroke were: major hemispheric stroke syndrome, atherothrombotic stroke mechanism, and atrial fibrillation.

Based on these studies, it seems that the main risk factors for recurrent strokes include the usual suspects (hypertensionhypercholesterolemiatype II diabetesatrial fibrillation, and alcohol) as well as metabolic syndrome.


Does exercise reduce stroke incidence and stroke risk factors?

A number of studies have investigated the use of exercise interventions for the reduction of stroke incidence and for decreasing the extent of stroke risk factors, as follows:

Study Approach Finding
Silva-Smith et al. The researchers investigated the effects of a physical activity and healthy eating intervention on the reduction of stroke risk factors in overweight/obese and sedentary older adults. They recruited 69 subjects and randomly assigned them to either an 8-week group motivational intervention or bi-weekly newsletters by mail. Before and after the intervention, the researchers recorded physical activity levels using  a blinded pedometer as well as 7-day physical activity self-report, body composition, and dietary habits using 24-hour recall. The researchers found that there were significantly greater levels of activity in the 7-day physical activity self-report in the intervention group post-intervention.
Jefferis et al. The researchers investigated how in older age is associated with the incidence of stroke in males. They recruited 4,252 men from a UK population-based cohort who reported usual physical activity, of whom 3,435 were ambulatory and free from cardiovascular disease and heart failure at baseline, over a 2-year period from 1998 to 2000 and followed them for 11 years, during which period 195 first strokes occurred. The researchers reported that walking for a greater number of hours per week was associated with lower heart rate, D-dimer (a fibrin degradation product that is found in the blood after a blood clot is degraded and which may indicate thrombosis), and higher 1-second forced expiratory volume. The researchers reported that in comparison with men walking <3 hours/week, men walking >22 hours per week had a 36% relative risk of stroke (age- and region-adjusted). However, no effect of walking pace was observed.
Hu et al. The researchers investigated the association between physical activity and risk of total stroke and stroke subtypes in females. They recruited total of 72,488 female nurses aged 40 – 65 years who did not have cardiovascular disease or cancer at baseline in 1986 and followed-up over an 8-year period during which time there were 407 incident cases of stroke. The researchers found that increasing physical activity was strongly inversely associated with risk of total stroke. In comparison with the lowest quintile of physical activity, they found that individuals in the highest quintile had a 34% relative risk of stroke. Also, they reported that a brisk walking pace was associated with lower risk of total and ischemic stroke compared with a slower pace.
Abbott et al. The researchers performed a prospective study of cardiovascular disease known as the Honolulu Heart Program, which began following 8,006 males in 1965. At baseline, the researchers classified all subjects as inactive, partially active, or active and then assessed the association between this designation and the incidence of stroke over 22 years of follow-up in younger (45 – 54 years) and older (55 – 68 years) subjects. The researchers reported that in the older men, those who were inactive or partially active displayed a 3 – 4 times greater incidence of hemorrhagic stroke compared to active men, and a 2 – 3 times greater incidence of intra-cerebral hemorrhage compared to active men. The researchers therefore concluded that physical activity may be important for reducing stroke risk.
Gillum et al. The researchers assessed whether physical inactivity is associated with increased stroke risk in both males and females using a longitudinal cohort study taken from the Nation Health and Nutrition Examination Survey I (NHANES I). The researchers followed-up with 7,895 subjects aged 45 – 74 years including 5,852 subjects without a history of stroke, over an average period of 11.6 years. The researchers assessed the correlations between self-reported physical activity levels and stroke risk. The researchers reported that low non-recreational activity was associated with significantly greater risk of stroke, even after adjusting known major risk factors such as hypertension.
Sattelmair et al. The researchers assessed the association between physical activity and stroke risk in 39,315 healthy females aged >45 years from the Women's Health Study. The researchers recorded self-reported physical activity at baseline and at 36, 72, 96, 125, and 149 months of follow-up. The researchers found that individuals partaking in >1500 kcal/week of leisure-time physical activity were 17% less likely to incur a stroke than individuals partaking in <200kcal/week of leisure-time physical activity.
Lee et al. The researchers carried out a prospective cohort study, which was part of the Physicians' Health Study, a cohort of 21,823 male physicians aged 40 – 84 years, who were followed for an average of 11.1 years. The researchers recorded at baseline the self-reported frequency of exercise vigorous enough to work up a sweat. The researchers assessed the association between self-reported vigorous exercise and stroke occurrence. The researchers reported that those individuals performing vigorous exercise >5 times per week at baseline were 21% less likely to incur a stroke over the follow-up period than those performing no such exercise at baseline.

Based on these studies, it seems that physical activity and exercise is correlated with a reduced stroke risk in both male and female populations of various ages.


Can exercise be used in the treatment of non-disabling stroke?

A number of studies have investigated the use of exercise interventions for the treatment and rehabilitation of non-disabling stroke, as follows:

Study Approach Finding
Prior et al. The researchers performed a prospective cohort study in order to assess the feasibility and effectiveness of a 6-month outpatient comprehensive cardiac rehabilitation program for secondary prevention after transient ischemic attack (TIA) or mild, non-disabling stroke. They recruited 110 subjects with a mean age of 64.9 years who had sustained a TIA or mild, non-disabling stroke within <12 months with >1 vascular risk factor from a stroke prevention clinic providing usual care. The researchers reported that the following outcomes improved significantly: aerobic capacity, total cholesterol, total cholesterol-to-high-density lipoprotein (HDL-C) ratio, triglycerides, waist circumference, body mass index (BMI), and bodyweight. They also noted non-significant but favorable changes in low-density lipoprotein (LDL-C) levels, high-density lipoprotein (HDL-C) levels, systolic and diastolic blood pressure and smoking status.
Eng and Reime The reviewers performed a systematic review and meta-analysis of randomized controlled trials exploring the effects of structured exercise (e.g. functional, resistance, or aerobic training) on depressive symptoms in stroke patients. The researchers included 13 studies with a total of 1,022 subjects in the meta-analysis. The reviewers reported that structured exercise resulted in significantly reduced depressive symptoms immediately post-exercise intervention but these effects were not retained at long-term follow-up. The reviewers therefore recommend that exercise may be an effective treatment to prevent or reduce depressive symptoms following stroke.
Pang et al. The reviewers performed a systematic review and meta-analysis of randomized controlled trials exploring whether aerobic exercise can improve aerobic capacity in individuals with stroke. They found 9 articles covering 7 trials with 480 subjects, in which exercise intensity ranged from 50 – 80% of heart rate reserve and exercise duration ranged from 20 – 40 minutes, 3 – 5 days per week. The reviewers reported that there was a significant effect size of aerobic exercise for improving VO2-max and peak workload, walking velocity and walking endurance. This indicates that aerobic exercise is effective for improving cardiovascular fitness and functional ability in stroke patients.
Boss et al. The researchers performed a randomised controlled trial to investigate the safety and feasibility of a post-stroke care including an exercise program after minor ischemic stroke or transient ischemic attack (TIA). They recruited 20 patients with a recent minor stroke or TIA without cardiac contraindications and randomly assigned them to one of two interventions: post-stroke care without exercise or post-stroke care with exercise. The researchers carried out exercises tests on the subjects before and after the intervention. The researchers reported that no adverse events occurred during any of the exercise tests no during the exercise program. After one year, the researchers reported that significantly more patients in the post-stroke care with exercise group achieved the desired outcomes in comparison with the post-stroke care group without exercise.
Kamm et al. The researchers performed a prospective, interventional single-center cohort study in order to evaluate the feasibility and effectiveness of a 3-month, comprehensive outpatient rehabilitation program in 105 patients surviving a transient ischemic attack (TIA) or stroke with minor or no residual deficits. The researchers reported that exercise capacity, smoking status, systolic and diastolic blood pressure, body mass index (BMI), low-density lipoprotein cholesterol (LDL-C), triglycerides, performance in the 9-Hole-Peg-Test, 6-minute Walking Test, and One Leg Stand Test, and health-related quality of life all improved significantly as a result of the exercise program.  The researchers concluded that the program was both feasible and accepted by patients.
Tanne et al. The researchers assessed the tolerability, safety and effect of a 3-month, outpatient supervised exercise training program performed twice weekly in 52 patients after a non-disabling ischemic stroke. The  subjects were assigned to either an exercise group or a non-training control group. The researchers evaluated exercise capacity using the 6-minute walk test and the modified Bruce exercise test before and after the intervention. The researchers reported that post-intervention, the exercise group displayed a significant improvement in 6-minute walk test performance and in exercise duration achieved in the modified Bruce test but the control group did not improve. The researchers concluded that an outpatient supervised exercise training program after a minor ischemic stroke is feasible, well-tolerated and is associated with improvement in exercise capacity and functional ability.
Faulkner et al. The researchers performed a randomized, parallel-group clinical trial in order to assess the efficacy of a physical activity program on vascular risk factors and aerobic fitness in 60 patients aged 69 ± 11 years who had experienced a transient ischemic attack (TIA) or non-disabling stroke. The researchers randomly allocated the subjects to either an 8-week, twice weekly exercise program or to a usual-care control. The researchers observed significantly greater reductions in systolic blood pressure and aerobic fitness for the exercise group than the control group, both of which were maintained from post-intervention to 3-month follow-up.
Morris et al. The reviewers performed a systematic review of randomized controlled trials or comparison studies that investigated the effects of interventions to promote long-term participation in physical activity on measures of frequency, duration, or intensity after >3 months in community-dwelling stroke survivors. The reviewers found 11 studies involving 1,704 subjects in which two intervention types were identified: individualized tailored counseling with or without supervised exercise (6 studies) and supervised exercise with advice (5 studies). The researchers found that only tailored home exercise led to higher physical activity participation at 12 months.

Based on these studies, it appears that exercise programs are feasible, well-tolerated and is associated with improvement in exercise capacity and functional ability in individuals suffering non-disabling stroke. It also appears effective for reducing depressive symptoms post-stroke. Tailored home exercise seems optimal for increasing physical activity levels in stroke survivors.


What are rehabilitation needs after mild-disabling stroke?

Several studies have investigated the rehabilitation needs of individuals following mild-disabling stroke and the ability of physiotherapy to meet these needs, as follows:

Study Approach Finding
DePaul et al. The researchers carried out a survey-based study in order to assess the physiotherapy-related needs of 241 individuals with stroke at discharge, 6 months post-discharge, and 1 year post-discharge from hospital. The researchers found that the individuals reported needs and barriers related to motor control, walking, stairs, fatigue, prevention of falls, and access to physiotherapy services.
Askim et al. The researchers carried out a survey-based study in 19 physiotherapists treating 46 patients suffering from mild-to-moderate stroke in order to assess to what extent task-specific training is part of conventional physiotherapy practice for stroke patients post-discharge from hospital. The researchers found that the most commonly selected task-specific activities were sit-to-stand (60.9%), balance in standing position (65.2%), walking on even ground (78.3%), and stair climbing (56.5%).
Kuys et al. The researchers assessed whether usual-care physiotherapy has a cardiorespiratory training effect by means of an observational study, using heart rate monitoring and video-recording in 30 consecutive stroke patients from a geriatric and rehabilitation unit. The researchers found that the stroke patients spent an average of 21 minutes participating in standing and walking activities deemed capable of having a cardiorespiratory training effect but the average intensity of 24% heart rate reserve was considered to be insufficient.

Based on these studies, it seems that the physical qualities required by individuals who experience a stroke that leads to some disablement include: motor control, prevention of falls, walking, stairs, fatigue,. It seems that physiotherapists often prescribe exercises to help improve motor control and prevention of falls (i.e. balance in standing position), walking (i.e. walking on even ground), stairs (i.e. stair climbing) but they do not provide an exercise stimulus sufficient to develop resistance to fatigue, such as might occur with extended exercise training.

Can exercise be used for rehabilitation in mild-disabling stroke?

A small number of studies and reviews have investigated the use of specific exercise interventions for rehabilitation of mild-disabling stroke, as follows:

Study Approach Finding
Van de Port et al. The researchers performed a randomised controlled trial with follow-up to 24 weeks to investigate the effect of task-specific circuit training in comparison with usual physiotherapy on self-reported walking ability in patients with stroke post-discharge. The researchers recruited 250 subjects who were discharged patients with stroke and who could walk >10m without physical assistance. They randomly allocated them to either a circuit-training group, which performed two 90-minute sessions per week for 12 weeks, or to usual physiotherapy. The researchers reported that no adverse events occurred in either group and there were no significant differences between groups for the stroke impact scale mobility domain at 12 weeks. However, the circuit training group displayed significantly higher scores for gait speed, walking distance and the modified stairs test. At the 24-week follow-up, the circuit training group still displayed a superior improvement to the usual care group in respect of gait speed.
Wevers et al. The reviewers carried out a systematic review and meta-analysis of randomized, controlled trials of task-specific circuit training on gait in patients with stroke. They found 6 studies with 307 subjects. The reviewers reported that there were significant homogeneous effect sizes in favor of task-specific circuit training on walking distance, gait speed, and Timed Up-and-Go Test. They therefore concluded that there is evidence to support the use of task-specific circuit training for improving gait speed and distance in patients with chronic stroke.
Van de Port et al. The reviewers carried out a systematic review of randomized controlled trials in order to assess the effects of structured exercise programs involving lower-body strength-training, aerobic exercise, or gait-specific tasks for improving gait and health-related quality of life in patients with stroke. The reviewers found 21 trials were included, of which 5 involved on lower-body strength-training, 2 involved aerobic exercise and 14 involved gait-specific training. The reviewers reported that their meta-analysis displayed a significant effect of gait-specific training on both gait speed and walking distance. However, neither aerobic exercise nor lower-body strength-training had any significant effect on gait speed. They found strong evidence to support the use of aerobic exercise for enhancing stair-climbing ability. The reviewers concluded that gait-specific training is effective in improving walking in patients with stroke.
Kwakkel et al. The reviewers performed a systematic review and meta-analysis to assess the effects of augmented exercise time or greater exercise intensity on activities of daily living (ADL), walking, and dexterity in patients with stroke. The reviewers found 20 suitable studies that included 2,686 patients. The reviewers found that their meta-analysis displayed in a significant effect of augmented exercise time (>16 hours over 6 months) on ADL when measured post-intervention. There was also a significant effect of increased exercise intensity on both ADL and walking speed in the first 6 months after stroke. However, no effect of either augmented exercise time or greater exercise intensity was found for dexterity.
Veerbeek et al. The reviewers performed a systematic review and meta-analysis to assess the effects of augmented exercise on gait, gait-related activities, and both basic and extended activities of daily living (basic ADL and extended ADL) in patients with stroke within the first 6 months. The reviewers found 14 trials including 725 subjects. The reviewers reported that they found significant, small-to-moderate effect sizes in favor of augmented exercise time for walking ability, comfortable- and maximum-walking speed, and extended ADL. However, they did not find any significant effects for basic ADL.
Van Peppen et al. The reviewers performed a systematic review and meta-analysis to assess the effects physical therapy interventions for improving functional outcome after stroke. The reviewers found 151 studies of which 123 were randomized controlled trials and 28 were controlled clinical trials. The reviewers reported that there was strong evidence for the use of task-specific exercise training for improving balance and gait, as well as for strengthening a lower paretic limb.
Rensink et al. The reviewers performed an overview of the evidence relating to task-specific training in stroke patients with a particular focus on the implications for nursing practice. They identified 42 papers, including 9 systematic reviews. The reviewers reported that task-specific training displayed benefits for functional outcomes and health-related quality of life in comparison with traditional therapies. They noted that many of the interventions are feasible for nurses and can be performed in a ward or at home.
An and Shaughnessy The reviewers assessed the recent literature in relation to the effects of either balance or gait exercise interventions in stroke patients. They found 17 randomized clinical trials. The reviewers found that early exercise rehabilitation in acute-to-sub-acute stroke recovery can lead to improvements in balance and walking capacity. They suggest performing balance training for >1 hour, 3 – 5 times per week. They also suggest performing gait-specific exercises for 30 minutes, 3 – 5 times per week.

Based on these studies, there appears to be evidence for using task-specific circuit training to improve walking ability post-stroke (even more than for physiotherapy), for using aerobic exercise to increase stair-climbing ability, for using task-specific exercises for improving balance and gait and for strengthening a lower paretic limb, where mild disablement has occurred following a stroke.


Evidence-based recommendations for exercise

Some reviews have made evidence-based recommendations for the prevention and treatment of stroke that include non-pharmacological treatments, as follows:

Study Recommendation
An and Shaughnessy The reviewers assessed the recent literature in relation to the effects of either balance or gait exercise interventions in stroke patients. They found 17 randomized clinical trials. The reviewers found that early exercise rehabilitation in acute-to-sub-acute stroke recovery can lead to improvements in balance and walking capacity. They suggest performing balance training for >1 hour, 3 – 5 times per week. They also suggest performing gait-specific exercises for 30 minutes, 3 – 5 times per week.
Duncan et al. The reviewers provided an extremely detailed guideline, which is ideal for further reading. In respect of exercise therapy and physiotherapy, the reviewers strongly recommend starting rehabilitation therapy as soon as possible after medical stability is reached. Also, they recommend providing as much therapy as required in order to reestablish functional independence.
Bates et al. The reviewers provided a detailed guideline. They observed that research is in support of early mobilization of the patient with an acute stroke in order to avoid complications. They recommend the use of progressive activity as soon as medically tolerated.
Quinn et al. The reviewers performed an analysis of the literature in order to provide evidence-based guidelines for rehabilitation post-stroke. They noted that there is evidence to support the proposal that current rehabilitative therapies are well-tolerated in medically stable patients and that early treatment appears reasonable, although whether timing of treatment has a significant effect is uncertain. They noted that a longer duration and a higher intensity of rehabilitation predicts superior functional improvement and they propose that there is likely a dose-response relationship. They noted that physiotherapy is popular with patients and improves outcomes post-stroke but no specific therapeutic model has emerged as superior. They observed that aerobic exercise has been demonstrated to improve exercise capacity post-stroke.
Gordon et al. The reviewers provided physical activity and exercise recommendations for stroke survivors. They recommended the use of aerobic, strength, flexibility and balance training. For aerobic exercise, they recommended the use of exercise involving large-muscle groups (e.g. walking, cycling or stepping) at 50 – 80% of maximal heart rate (or an RPE of 11 – 14 on the Borg scale), 3 – 7 days per week for 20 – 60 minutes per session. For strength training, they recommended performing 3 sets of 10 – 15 repetitions of 8 – 10 exercises with major muscle groups, 2 – 3 days per week. For flexibility training, they recommended performing 10 – 30-second stretches of the major muscles 2 – 3 days per week. Similarly, for balance training, they recommended performing these tasks 2 – 3 days per week.

Based on these guidelines, it appears that current guidelines recommend that rehabilitation therapy start as early as possible post-stroke, once medical stability is reached and should be directed towards reestablishing an optimal level of functional independence. Once exercise is well-tolerated, current guidelines recommend the use of aerobic exercise (3 – 7 days per week for 20 – 60 minutes), strength-training (2 – 3 days per week for 3 sets of 10 – 15 repetitions of 8 – 10 exercises), and flexibility and balance training (2 – 3 days per week).


Conclusions

On the basis of these studies and reviews, the following conclusions might be drawn:

Area Conclusion
Prevalence of stroke The prevalence of individuals with stroke in various populations ranges widely from around 4 – 50 per 1,000 people, which can be stated as 0.4 – 5.0%.
Incidence of stroke The incidence of first-time stroke in various populations ranges from around 100 – 600 per 100,000 people, which can be stated as 0.1 – 0.6%.
Risk factors for stroke In addition to the usual suspects (coronary artery disease, hypertension, hypercholesterolemia, atrial fibrillation, obesity, type II diabetes, increasing age and smoking), there are other risk factors, including a sedentary life-style, alcohol intake, chronic kidney disease, low ankle-brachial index, and certain personality types (e.g. extraversion and non-conscientious behaviour).
Risk factors for stroke in the very old The usual suspects (coronary artery disease, hypertension, hypercholesterolemia, obesity, type II diabetes, and smoking), may not be as common risk factors in the very old as in younger people. On the other hand, it seems that atrial fibrillation remains a significant risk factor and depression may also be an important risk factor.
Risk factors for recurrent stroke The main risk factors for recurrent strokes include the usual suspects (hypertension, hypercholesterolemia, type II diabetes, and alcohol) as well as atrial fibrillation and metabolic syndrome.
Physical activity and exercise to prevent stroke Physical activity and exercise is correlated with a reduced stroke risk in both male and female populations of various ages.
Exercise in non-disabling stroke Exercise programs are feasible, well-tolerated and is associated with improvement in exercise capacity and functional ability in individuals suffering non-disabling stroke. It also appears effective for reducing depressive symptoms post-stroke. Tailored home exercise seems optimal for increasing physical activity levels in stroke survivors.
Rehabilitation needs after mild-disabling stroke The physical qualities required by individuals who experience a stroke that leads to some disablement include: motor control, prevention of falls, walking, stairs, fatigue,. It seems that physiotherapists often prescribe exercises to help improve motor control and prevention of falls (i.e. balance in standing position), walking (i.e. walking on even ground), stairs (i.e. stair climbing) but they do not provide an exercise stimulus sufficient to develop resistance to fatigue, such as might occur with extended exercise training.
Exercise for rehabilitation in mild-disabling stroke There appears to be evidence for using task-specific circuit training to improve walking ability post-stroke (even more than for physiotherapy), for using aerobic exercise to increase stair-climbing ability, for using task-specific exercises for improving balance and gait and for strengthening a lower paretic limb, where mild disablement has occurred following a stroke.
Recommendations for exercise post-stroke Current guidelines recommend that rehabilitation therapy start as early as possible post-stroke, once medical stability is reached and should be directed towards reestablishing an optimal level of functional independence. Once exercise is well-tolerated, current guidelines recommend the use of aerobic exercise (3 – 7 days per week for 20 – 60 minutes), strength-training (2 – 3 days per week for 3 sets of 10 – 15 repetitions of 8 – 10 exercises), and flexibility and balance training (2 – 3 days per week).

Based on these findings, stroke is highly prevalent and shares many of the same risk factors as cardiovascular disease. Physical activity and exercise is associated with a reduced incidence of stroke. Also, exercise can be used in both the rehabilitation of non-disabling and disabling stroke. Guidelines recommend starting an exercise program as soon as medical stability is achieved and progressing this through to an optimal level of function for independence to be achieved. Physical activity guidelines once exercise can be tolerated recommend the use of aerobic exercise (3 – 7 days per week for 20 – 60 minutes), strength-training (2 – 3 days per week for 3 sets of 10 – 15 repetitions of 8 – 10 exercises), and flexibility and balance training (2 – 3 days per week).


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