Pre-stroke physical activity is associated with fewer post-stroke complications, lower mortality and a better long-term outcome

Molecular insights of exercise therapy in disease prevention and treatment

Despite substantial evidence emphasizing the pleiotropic benefits of exercise for the prevention and treatment of various diseases, the underlying biological mechanisms have not been fully elucidated. Several exercise benefits have been attributed to signaling molecules that are released in response to exercise by different tissues such as skeletal muscle, cardiac muscle, adipose, and liver tissue. These signaling molecules, which are collectively termed exerkines, form a heterogenous group of bioactive substances, mediating inter-organ crosstalk as well as structural and functional tissue adaption. Numerous scientific endeavors have focused on identifying and characterizing new biological mediators with such properties. Additionally, some investigations have focused on the molecular targets of exerkines and the cellular signaling cascades that trigger adaption processes. A detailed understanding of the tissue-specific downstream effects of exerkines is crucial to harness the health-related benefits mediated by exercise and improve targeted exercise programs in health and disease. Herein, we review the current in vivo evidence on exerkine-induced signal transduction across multiple target tissues and highlight the preventive and therapeutic value of exerkine signaling in various diseases. By emphasizing different aspects of exerkine research, we provide a comprehensive overview of (i) the molecular underpinnings of exerkine secretion, (ii) the receptor-dependent and receptor-independent signaling cascades mediating tissue adaption, and (iii) the clinical implications of these mechanisms in disease prevention and treatment.

Pre-stroke physical activity matters for functional limitations: A longitudinal case-control study of 12,860 participants

Objective

In the chronic phase after a stroke, limitations in activities of daily living (ADLs) and instrumental ADL (IADLs) initially plateau before steadily increasing. The benefits of pre-stroke physical activity on these limitations remain unclear. To clarify this relationship, we examined the effect of physical activity on the long-term evolution of functional limitations in a cohort of stroke survivors and compared it to a cohort of matched stroke-free adults.

Methods

Longitudinal data from 2,143 stroke survivors and 10,717 stroke-free adults aged 50 years and older were drawn from a prospective cohort study based on the Survey of Health, Ageing and Retirement in Europe (2004-2022; 8 data collection waves). Physical activity was assessed in the pre-stroke wave. Functional limitations were assessed in the post-stroke waves. Each stroke survivor was matched with 5 stroke-free adults who had similar propensity scores computed on the basis of key covariates, including baseline age, sex, body mass index, limitations in ADL and IADL, chronic conditions and country of residence, before any of the participants from either cohort had experienced a stroke.

Results

Results showed an interaction between stroke status and physical activity on ADL limitations (b = -0.076; 95% CI = -0.142 to -0.011), with the effect of physical activity being stronger in stroke survivors (b = -0.345, 95% CI = -0.438 to -0.252) than in stroke-free adults (b = -0.269, 95% CI = -0.269 to -0.241).

Conclusion

The beneficial effect of pre-stroke physical activity on ADL limitations after stroke is stronger than its effect in matched stroke-free adults followed for a similar number of years.

Impact

Physical activity, an intervention within the physical therapist's scope of practice, is effective in reducing the risk of functional dependence after stroke. Moreover, pre-stroke levels of physical activity can inform the prognosis of functional dependence in stroke survivors.

Primordial and Primary Prevention of Ischemic Stroke in Saudi Arabia: A Combination Approach and Evolving Concepts

Ischemic stroke is a considerable public health hazard and a significant cause of disability and mortality in Saudi Arabia. Primary prevention strategies in the country are currently limited. With the health sector transformation program that depends on the principles of value-based care and applying the new model of care in disease prevention, aggressive and serious steps for primary stroke prevention are expected to be implemented. This article reviews primordial and primary prevention of ischemic stroke in Saudi Arabia and suggests a combination approach and framework for implementation. We provide a pragmatic solution to implement primordial and primary stroke prevention in Saudi Arabia and specify the roles of the government, health professionals, policymakers, and the entire population. Currently, there are several key priorities for primordial and primary stroke prevention in Saudi Arabia that should target people at different levels of risk. These include an emphasis on a comprehensive approach that includes both individual and population-based strategies and establishing partnerships across health-care providers to share responsibility for developing and implementing both strategies. This is an urgent call for action to initiate different strategies suggested by experts for primary stroke prevention in Saudi Arabia.

Fatigue in stroke survivors: a 5-year follow-up of the Fall study of Gothenburg

Longer term knowledge of post-stroke fatigue (PSF) is limited. Our aim was to describe the prevalence of, and to identify baseline predictors associated with, PSF 5 years after stroke. We undertook a follow-up of stroke survivors from the 504 consecutively recruited participants in the observational "The Fall Study of Gothenburg", conducted between 2014 and 2016. The dependent variable, PSF, was assessed using the Swedish version of the Fatigue Assessment Scale (S-FAS) and defined as having a S-FAS score ≥ 24. The S-FAS questionnaire was mailed to potential participants in August 2020. The independent variables, previously obtained from medical records, included age; sex; comorbidities; stroke severity; hospital length of stay; body mass index (BMI); number of medications and lifestyle factors at index stroke. To identify predictors of PSF, univariable and multivariable logistic regression analyses were performed. Of the 305 eligible participants, 119 (39%) responded with complete S-FAS. Mean age at index stroke was 71 (SD 10.4) years and 41% were female. After a mean of 4.9 years after stroke, the prevalence of PSF was 52%. Among those with PSF, almost two thirds were classified as having both physical and mental PSF. In the multivariable analysis, only high BMI predicted PSF with an odds ratio of 1.25 (95% CI 1.11-1.41, p < 0.01). In conclusion, half of the participants reported PSF 5 years after index stroke and higher body mass index was identified as a predictor. The findings from this study are important for healthcare professionals, for planning health-related efforts and rehabilitation of stroke survivors.ClinicalTrials.gov, Identifier NCT02264470.

Death and ADL Dependency After Scoring Zero on the NIHSS: A Swedish Retrospective Registry-Based Study

Background and Objectives

Of all strokes, mild strokes (defined as 5 points or less on the National Institutes of Health Stroke Scale [NIHSS]) are in the majority. However, up to one-third of patients with mild strokes still exhibit significant deficits 3 months after the stroke. Studies on the presumably mildest strokes, defined by zero points on the NIHSS (0-NIHSS) at admission, are scarce. Hence, we aimed to study patient characteristics and outcomes among patients with 0-NIHSS strokes.

Methods

Our retrospective registry-based study included a total of 6,491 adult patients with stroke admitted to 3 different stroke units in Gothenburg, Sweden, from November 2014 to June 2019. Our main outcome was a composite measure including death and activities of daily living (ADL) dependency 3 months after the stroke. Analyses of patient characteristics were followed by adjusted analyses including multiple confounders.

Results

In total, 5,945 patients had data on NIHSS at admission, of whom 1,412 (24%) presented with a 0-NIHSS stroke. Among these, the median age was 72 years, 600 (42%) were female, and 86 (6%) had a hemorrhagic stroke. Among previously ADL-independent patients, 65 (6%) were either dead or ADL-dependent 3 months after the stroke. Prestroke physical inactivity (OR 2.48, 95% CI 1.40-4.38) and age (OR 1.05 per gained year, 95% CI 1.02-1.08) significantly increased the risk of death and ADL dependency.

Discussion

One of 17 patients has either died or become ADL-dependent 3 months after a 0-NIHSS stroke, stressing that these strokes are not always benign. Older and physically inactive patients are at greater risk of an adverse outcome.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Exercise Preconditioning Ameliorates Cognitive Impairment in Mice with Ischemic Stroke by Alleviating Inflammation and Modulating Gut Microbiota

Several studies have demonstrated that exercise preconditioning is an effective means of alleviating poststroke cognitive impairment (PSCI). Mechanisms of regulating cognitive function have not been fully elucidated. Herein, the present study is aimed at exploring the effect of the microbiota-gut-inflammasome-brain axis in the process of exercise preconditioning moderating cognitive impairment after ischemic stroke. We observed that exercise preconditioning decreased infarct size, reduced the degree of neuronal damage, and alleviated cognitive impairment in mice with ischemic stroke. In addition, exercise preconditioning also reduced the expression of inflammatory cytokines, as well as NLRP3, Caspase-1, IL-18, and IL-1β protein expressions. Ischemic stroke could downregulate the abundance of Roseburia while increasing the abundance of the Helicobacter at the level of genus. As a comparison, exercise preconditioning increased the abundance of the Lactobacillus, which was beneficial for mice at the genus level. In conclusion, exercise preconditioning can improve cognitive dysfunction after ischemic stroke through alleviating inflammation and regulating the composition and diversity of the gut microbiota, which might provide a new strategy for the prevention of PSCI.

Incidence, early case fatality and determinants of stroke in Iran: Golestan Cohort Study

OBJECTIVES

While few studies investigated the incidence of stroke in Iran, no Iranian cohort has estimated the standardized-incidence rate and early fatality of first-ever-stroke subtypes along with associated factors.

METHODS

Golestan Cohort Study is a prospective study launched in northeastern Iran in 2004, including 50,045 individuals aged 40-75 at baseline. Age-standardized incidence rate of first-ever-stroke was calculated per 100,000 person-years, according to World Standard Population. The 28-day case fatality was calculated by dividing the number of fatal first-ever-stroke during the first 28 days by total events. Cox proportional hazard models were conducted to assess incidence and fatality risk factors. We used Population Attributable Fractions to estimate the incidence and early fatality proportions reduced by ideal risk factor control.

RESULTS

1,135 first-ever-strokes were observed during 8.6 (median) years follow-up. First-ever-stroke standardized incidence rate was estimated 185.2 (95% CI: 173.2-197.2) per 100,000 person-years. The 28-day case fatality was 44.1% (95% CI: 40.4-48.2). Hypertension and pre-stroke physical activity were the strongest risk factors associated with first-ever-stroke incidence (Hazard ratio: 2.83; 2.47-3.23) and 28-day case fatality (Hazard ratio: 0.59; 0.44-0.78), respectively. Remarkably, opium consumption was strongly associated with hemorrhagic stroke incidence (Hazard ratio: 1.52; 1.04-2.23) and ischemic stroke fatality (Hazard ratio: 1.44; 1.01-2.09). Overall, modifiable risk factors contributed to 83% and 61% of first-ever-stroke incidence and early fatality, respectively.

CONCLUSION

Efficient risk factor control can considerably reduce stroke occurrence and fatality in our study. Establishing awareness campaigns and 24-hour stroke units seem necessary for improving the stroke management in this area.

Associations between pre-stroke physical activity and physical quality of life three months after stroke in patients with mild disability

Background

Much is known about the association between physical activity and the occurrence of stroke. However, the evidence about the correlation between pre-stroke physical activity and post-stroke quality of life remains inconsistent. Thus, there is a high public health relevance to the topic.

Aim

The aim of this study was to investigate the association between pre-stroke physical activity and physical quality of life after three months.

Methods

Data arises from 858 patients with stroke included a prospective single-centre observational cohort study in Augsburg, Germany, between September 2018 and November 2019. The participants were recruited at the Department of Neurology and Clinical Neurophysiology, University Hospital of Augsburg after their stroke event. The level of physical activity was determined following the short form of the International Physical Activity Questionnaire at baseline. Physical quality of life was assessed three months after hospital discharge using the German version of the Stroke Impact Scale (SIS). A multiple linear regression model and a quantile regression were carried out.

Results

A total of 497 patients were included in the analysis (mean age 69.6, 58.8% male), 26.2% had a high, 18.9% a moderate and 54.9% a low level of pre-stroke physical activity. Patients with high pre-stroke physical activity had a significantly better physical quality of life three months after stroke in the SIS physical domain (beta = 4.1) and in the SIS subdomains hand function (beta = 5.6), mobility (beta = 4.1) and activities of daily living (beta = 3.7). In the physical domain and the subdomain mobility, the effect was especially strong for persons with low physical quality of life after three months.

Conclusion

Pre-stroke physical activity seems to have an important and positive association with physical quality of life after three months in patients with mild disability. Further studies are needed to confirm these results.

Pre-stroke Physical Activity and Cerebral Collateral Circulation in Ischemic Stroke: A Potential Therapeutic Relationship?

Favorable cerebral collateral circulation contributes to hindering penumbral tissue from progressing to infarction and is associated with positive clinical outcomes after stroke. Given its clinical importance, improving cerebral collateral circulation is considered a therapeutic target to reduce burden after stroke. We provide a hypothesis-generating discussion on the potential association between pre-stroke physical activity and cerebral collateral circulation in ischemic stroke. The recruitment of cerebral collaterals in acute ischemic stroke may depend on anatomical variations, capacity of collateral vessels to vasodilate, and individual risk factors. Physical activity is associated with improved cerebral endothelial and vascular function related to vasodilation and angiogenic adaptations, and risk reduction in individual risk factors. More research is needed to understand association between cerebral collateral circulation and physical activity. A presentation of different methodological considerations for measuring cerebral collateral circulation and pre-stroke physical activity in the context of acute ischemic stroke is included. Opportunities for future research into cerebral collateral circulation, physical activity, and stroke recovery is presented.

Low-Density Lipoprotein Cholesterol and Mortality in Patients With Intracerebral Hemorrhage in Taiwan

Objective: Lower serum low-density lipoprotein cholesterol (LDL-C) levels are associated with increased intracerebral hemorrhage (ICH) risk. However, reverse causality and residual confounding has not attracted public attention. Therefore, we assessed whether people with LDL-C have increased risk of mortality adjusting for potential confounders using two large Taiwan cohorts.

Methods: The Mei-Jhao (MJ) cohort has 414,372 adults participating in a medical screening program with 378 ICH deaths within 15 years of follow-up (1994–2008). Cox proportional hazards regressions estimated hazard death ratios according to LDL-C levels. We identified 4,606 ICH patients from the Taiwan Stroke Registry (TSR) and analyzed the impact of LDL-C on 3-month mortality.

Results: Low cholesterol (LDL-C <100 mg/dL), found in 1/4 of the MJ cohort, was highly prevalent (36%) among young adults (age 20–39). There was a graded relationship between cholesterol and mortality for ICH [Hazard ratio, 1.56; 95% confidence interval (CI), 1.13–2.16]. Compared with patients with an LDL-C of 110–129 mg/dL in TSR, the risk for mortality was 1.84 (95% CI, 1.28–2.63) with an LDL-C of <100 mg/dL.

Conclusion: Lower serum LDL-C level independently predicts higher mortality after acute ICH. While its causative role may vary, low cholesterol may pose potential harms in Taiwan.

Prestroke physical activity and outcomes after intracerebral haemorrhage in comparison to ischaemic stroke: protocol for a matched cohort study (part of PAPSIGOT)

INTRODUCTION

Piling evidence suggests that a higher level of prestroke physical activity can decrease stroke severity, and reduce the risk of poststroke mortality. However, prior studies have only included ischaemic stroke cases, or a majority of such. We aim to investigate how premorbid physical activity influences admission stroke severity and poststroke mortality in patients with intracerebral haemorrhage, compared with ischaemic stroke. A prespecified analysis plan counteract some inherent biases in observational studies, and promotes transparency.

METHODS AND ANALYSIS

This is a statistical analysis protocol for a matched cohort study, including all adult patients with intracerebral haemorrhage, and matched ischaemic stroke controls, treated at Sahlgrenska University Hospital in Sweden between 1 November 2014 and 30 June 2019. All patients have been identified in the Väststroke register, and the data file has been sent for merging with national registries. The follow-up of time for survival will be approximately 2-7 years. The sample size calculation indicates that a minimum of 628 patients with intracerebral haemorrhage is needed for power of 80% at an alpha level of 0.01. Multiple imputation by chained equations will be used to handle missing data. The entire cohort of patients with intracerebral haemorrhage will be matched with consecutive ischaemic stroke controls (1:3 ratio) using nearest neighbour propensity score matching. The association between prestroke physical activity and admission stroke severity will be evaluated using multivariable ordinal regression models, and risk for all-cause mortality will be analysed using multivariable Cox proportional-hazards models. Potential confounders include age, ethnicity, income, educational level, comorbidity, medical treatments, alcohol-related disorders, drug abuse and smoking.

ETHICS

Data collection for the Physical Activity Pre-Stroke In GOThenburg project was approved by the Regional Ethical Board on 4 May 2016. An additional application was approved by the National Ethical Review Authority on 7 July 2021.

Mechanisms of Preconditioning Exercise-Induced Neurovascular Protection in Stroke

Ischemic stroke is a leading cause of death and disability. Tissue plasminogen activator is the only U.S. Food and Drug Administration approved thrombolytic therapy for ischemic stroke patients till date. However, its use is limited due to increased risk of bleeding and narrow therapeutic window. Most of the preclinically tested pharmacological agents failed to be translated to the clinic. This drives the need for alternative therapeutic approaches that not only provide enhanced neuroprotection, but also reduce the risk of stroke. Physical exercise is a sort of preconditioning that provides the body with brief ischemic episodes that can protect the body from subsequent severe ischemic attacks like stroke. Physical exercise is known to improve cardiovascular health. However, its role in providing neuroprotection in stroke is not clear. Clinical observational studies showed a correlation between regular physical exercise and reduced risk and severity of ischemic stroke and better outcomes after stroke. However, the underlying mechanisms through which prestroke exercise can reduce the stroke injury and improve the outcomes are not completely understood. The purpose of this review is to: demonstrate the impact of exercise on stroke outcomes and show the potential role of exercise in stroke prevention and recovery; uncover the underlying mechanisms through which exercise reduces the neurovascular injury and improves stroke outcomes aiming to develop novel therapeutic approaches.

Smoking Status and Functional Outcomes in Young Stroke

Objective: Stroke in young adults is uncommon, and the etiologies and risk factors of stroke in young adults differ from those in older populations. Smoker's paradox is an unexpected favorable outcome, and age difference is used to explain the association between smoking and the favorable functional outcome. This study aimed to investigate the existence of this phenomenon in young stroke patients. Methods: We analyzed a total of 9,087 young stroke cases registered in the nationwide stroke registry system of Taiwan between 2006 and 2016. Smoking criteria included having a current history of smoking more than one cigarette per day for more than 6 months. After matching for sex and age, a Cox model was used to compare mortality and function outcomes between smokers and non-smokers. Results: Compared with the non-smoker group, smoking was associated with older age, higher comorbidities, and higher alcohol consumption. Patients who report smoking with National Institutes of Health Stroke Scale scores of 11-15 had a worse functional outcome (adjusted odds ratio, 0.81; 95% confidence interval, 0.76 - 0.87). Conclusion: Smokers had a higher risk of unfavorable functional outcomes at 3 months after stroke, and therefore, we continue to strongly advocate the importance of smoking cessation.

Association of Primary Hypertension and Risk of Cerebrovascular Diseases with Overweight and Physical Activity in Korean Women: A Longitudinal Study

Cerebrovascular diseases include stroke, intracranial stenosis, aneurysms, and vascular malformations; primary hypertension is typically associated with cerebrovascular disease. The incidence of these diseases is higher in men than in women, and low physical activity and obesity are known to increase the risk of cerebrovascular disease. This study aimed to longitudinally analyze the adjusted relative risk (ARR) of primary hypertension and cerebrovascular diseases, in relation to body mass index (BMI) and physical activity (PA), in Korean women. The study retrieved the data of 1,464,377 adult Korean women (aged 50–79 years), who participated in the national health screening program from 2002 to 2003. The participants had no history of primary hypertension or cerebrovascular diseases, and were followed up by the International Statistical Classification of Diseases and Related Health Problems (ICD) until 2013. The participants were divided into the following groups: normal weight (18.5–24.9), overweight (25.0–29.9), and obese (≥30.0) kg/m², based on the World Health Organization (WHO) classification. The frequency of PA (days) was determined using a physical activity questionnaire, and defined as low (0–2), medium (3–4), and high (5–7) days. The RR was calculated using Cox regression. Three models were created based on the adjusted variables. The ARR for hypertension was 0.933 (95% CI; 0.920–0.955, p < 0.001) in obese patients with medium PA. Primary hypertension was lower (ARR: 0.943; 95% CI; 0.928–0.961, p < 0.001) in overweight participants with medium PA, than in those with low PA. The incidence of cerebrovascular disease was lower in overweight individuals with medium PA (ARR: 0.945, 95% CI; 0.925–0.976, p < 0.001), than in those with low PA. The risk of cerebrovascular disease was reduced in normal-weight participants with medium PA (ARR: 0.889; 95% CI: 0.854–0.919; p < 0.001), than in those with high PA (ARR 0.913; 95% CI; 0.889–0.953, p < 0.001). In the obese group, there was no significant difference in the risk of cerebrovascular disease, based on the frequency of PA. In conclusion, the relative risk of primary hypertension in women was lower with moderate activity than with low activity, in the normal-weight and overweight groups. The relative risk of cerebrovascular disease was lower in the participants with moderate and high activity than in those with low activity, even at normal weight. In obese individuals, moderate and high activity reduced cerebrovascular disease compared to low activity. Therefore, regardless of obesity, PA may contribute to the prevention of primary hypertension and cerebrovascular disease in adult women.

Prestroke Physical Activity and Adverse Health Outcomes After Stroke in the Atherosclerosis Risk in Communities Study

BACKGROUND AND PURPOSE

The association of physical activity (PA) before stroke (prestroke PA) with long-term prognosis after stroke is still unclear. We examined the association of prestroke PA with adverse health outcomes in the ARIC study (Atherosclerosis Risk in Communities).

METHODS

We included 881 participants with incident stroke occurring between 1993 and 1995 (visit 3) and December 31, 2016. Follow-up continued until December 31, 2017 to allow for at least 1-year after incident stroke. Prestroke PA was assessed using a modified version of the Baecke questionnaire in 1987 to 1989 (visit 1) and 1993 to 1995 (visit 3), evaluating PA domains (work, leisure, and sports) and total PA. We used Cox proportional hazards models to quantify the association between tertiles of accumulated prestroke PA levels over the 6-year period between visits 1 and 3 and mortality, risk of cardiovascular disease, and recurrent stroke after incident stroke.

RESULTS

During a median follow-up of 3.1 years after incident stroke, 676 (77%) participants had adverse outcomes. Highest prestroke total PA was associated with decreased risks of all-cause mortality (hazard ratio, 0.78 [95% CI, 0.63-0.97]) compared with lowest tertile. In the analysis by domain-specific PA, highest levels of work PA were associated with lower risk for all-cause (hazard ratio, 0.77 [95% CI, 0.62-0.96]) and cardiovascular mortality (hazard ratio, 0.45 [95% CI, 0.29-0.70]), and highest levels of leisure PA were associated with lower all-cause mortality (hazard ratio, 0.72 [95% CI, 0.58-0.89]) compared with lowest tertile of PA. No significant associations for sports PA were observed.

CONCLUSIONS

Higher levels of total prestroke PA as well as work and leisure PA were associated with lower risk of mortality after incident stroke. Public health strategies to increase lifetime PA should be encouraged to decrease long-term mortality after stroke.

Levels of physical activity before and after stroke in relation to early cognitive function

Regular physical activity is widely recommended in the primary and secondary prevention of stroke. Physical activity may enhance cognitive performance after stroke, but cognitive impairments could also hinder a person to take part in physical activity. However, a majority of previous studies have not found any association between post-stroke cognitive impairments and a person’s subsequent level of activity. In this explorative, longitudinal study, we describe the intraindividual change in physical activity from before to 6 months after stroke, in relation to early screening of post-stroke cognitive impairments. Participants were recruited at 2 to 15 days after stroke, and screened for cognitive impairments using the Montreal Cognitive Assessment tool. Information on pre-stroke physical activity was retrospectively collected at hospital admittance by physiotherapists. Post-stroke physical activity was evaluated after 6 months. Of 49 participants included, 44 were followed up. The level of physical activity changed in more than half of all participants after stroke. Participants who were physically active 6 months after stroke presented with significantly less cognitive impairments. These results highlight that many stroke survivors experience a change in their physical activity level following stroke, and that unimpaired cognition may be important for a stroke survivors’ ability to be physically active.

Association between trunk core muscle thickness and functional ability in subacute hemiplegic stroke patients: an exploratory cross-sectional study

BACK GROUND

Balance impairment could occur due to weakness of the core muscles in stroke patients.

OBJECTIVE

To investigate the association between functional ability, including trunk balance and core muscle thickness using ultrasonography in subacute hemiplegic stroke patients.

METHODS

The muscle thickness of the anterior and posterior trunk muscles was measured using ultrasonography. For the evaluation of trunk balance, trunk impairment scale and Berg balance scale (BBS) were used. The functional ambulatory scale (FAS), timed up-and-go test, 10 m gait velocity, functional reach (FR), and functional independence measure were also assessed for functional ability.

RESULTS

Overall, 41 patients with subacute hemiplegic stroke were included. Partial correlation analysis showed that posterior trunk muscle thickness was significantly correlated with BBS, FAS, and FR. As for the paralytic side, the posterior trunk muscle thickness of both paretic and nonparetic sides presented a significant relationship with BBS, FAS, and FR. The quadratus lumborum (QL) thickness of both sides showed a significant relationship with BBS, FAS, and FR.

CONCLUSIONS

The thickness of the posterior trunk muscles, especially the QL, on both the paretic and nonparetic sides, was significantly related with the functional ability after stroke. The exercise program of core posterior trunk muscles closely related with functional ability would be helpful to improve trunk balance and ambulatory function in subacute stroke patients.

Pre-stroke physical activity and admission stroke severity: A systematic review

BACKGROUND

Admission stroke severity is an important clinical predictor of stroke outcomes. Pre-stroke physical activity contributes to stroke prevention and may also be associated with reduced stroke severity. Summarizing the evidence to date will inform strategies to reduce burden after stroke.

AIMS

To summarize the published evidence for the relationship between pre-stroke physical activity and admission stroke severity and to provide recommendations for future research.

SUMMARY OF REVIEW

MEDLINE, Embase, Emcare, CENTRAL, and gray literature databases were searched on 14 February 2020 using search terms related to stroke and pre-stroke physical activity in adult stroke survivors. We screened 8,152 references and assessed 172 full-text references for eligibility. We included seven studies (n = 41,800 stroke survivors). All studies were observational, assessed pre-stroke physical activity using self-reported questionnaires, and assessed admission stroke severity using the National Institute of Health Stroke Scale. Analyses were categorized as the presence of pre-stroke physical activity (four studies) or dose-response (five studies). In three studies, presence of pre-stroke physical activity was associated with milder stroke severity, and no association in one study. Greater pre-stroke physical activity duration and intensity (two studies) or amount (three studies) were associated with milder stroke severity. Studies ranged between moderate to critical risk of bias, primarily due to confounding factors. Pre-stroke physical activity may be associated with reduced risk factors for severe stroke, distal occlusion, smaller infarcts, and shorter time-to-treatment delivery.

CONCLUSION

Pre-stroke physical activity may be associated with reduced admission stroke severity. Lack of randomized controlled trials limited causality conclusions. Future research recommendations were provided.

Regular physical activity postpones age of occurrence of first-ever stroke and improves long-term outcomes

OBJECTIVE

Few data are available on the associations between the level of pre-stroke physical activity and long-term outcomes in patients with stroke. This study is designed to assess the associations between pre-stroke physical activity and age of first-ever stroke occurrence and long-term outcomes.

METHODS

Six hundred twenty-four cases with first-ever stroke were recruited from the Mashhad Stroke Incidence Study a prospective population-based cohort in Iran. Data on Physical Activity Level (PAL) were collected retrospectively and were available in 395 cases. According to the PAL values, subjects were classified as inactive (PAL < 1.70) and active (PAL ≥ 1.70). Age at onset of stroke was compared between active and inactive groups. Using logistic model, we assessed association between pre-stroke physical activity and long-term (5-year) mortality, recurrence, disability, and functional dependency rates. We used multiple imputation to analyze missing data.

RESULTS

Inactive patients (PAL < 1.70) were more than 6 years younger at their age of first-ever-stroke occurrence (60.7 ± 15.5) than active patients (67.0 ± 13.2; p < 0.001). Patients with PAL< 1.7 also had a greater risk of mortality at 1 year [adjusted odds ratio (aOR) = 2.31; 95%CI: 1.14-4.67, p = 0.02] and 5 years after stroke (aOR = 1.81; 95%CI: 1.05-3.14, p = 0.03) than patients who were more physically active. Recurrence rate, disability, and functional dependency were not statistically different between two groups. Missing data analysis also showed a higher odds of death at one and 5 years for inactive patients.

CONCLUSIONS

In our cohort, we observed a younger age of stroke and a higher odds of 1- and 5-year mortality among those with less physical activity. This is an important health promotion strategy to encourage people to remain physically active.

Increasing time spent engaging in moderate-to-vigorous physical activity by community-dwelling adults following a transient ischemic attack or non-disabling stroke: a systematic review

Purpose: The risk of recurrent stroke following a transient ischaemic attack (TIA) or non-disabling stroke is high. Clinical guidelines recommend this patient population accumulate at least 150 minutes of moderate-to-vigorous physical activity each week to reduce the risk of recurrent stroke. We aimed to identify interventions that increase time adults spend in moderate-to-vigorous physical activity following TIA or non-disabling stroke.Method: We searched thirteen databases for articles of secondary prevention interventions reporting outcomes for duration in moderate-to-vigorous physical activity or exercise capacity.Results: Eight trials were identified (n = 2653). Of these, three (n = 198) reported changes in time spent in moderate-to-vigorous physical activity. Only one trial (n = 70), reported significant change in time spent engaging in moderate-to-vigorous physical activity (between-group difference: 11.7 min/day [95% CI 4.07-19.33]) when comparing participation in a six-month exercise education intervention to usual care. No trial measured moderate-to-vigorous physical activity after intervention end.Conclusion: Despite recommendations to participate in regular physical activity at moderate-to-vigorous intensity for secondary stroke prevention, there is very little evidence for effective interventions for this patient population. There is need for clinically feasible interventions that result in long-term participation in physical activity in line with clinical guidelines. Trial registration: Protocol registration: PROSPERO CRD42018092840Implications for rehabilitationThere is limited evidence of the effectiveness of interventions that aim to increase time spent engaging in moderate-to-vigorous physical activity (MVPA) for people following a TIA or non-disabling stroke.A program comprising aerobic and resistance exercises ≥2 per week, supervised by a health professional (supplemented with a home program) over at least 24 weeks appears to be effective in assisting people adhere to recommended levels of moderate to vigorous physical activity after TIA or non-disabling stroke.Secondary prevention programs which include health professional supervised exercise sessions contribute to better adherence to physical activity guidelines; didactic sessions alone outlining frequency and intensity are unlikely to be sufficient.

Smoking Paradox in Stroke Survivors?: Uncovering the Truth by Interpreting 2 Sets of Data

Background and Purpose- The observation that smokers with stroke could have better outcome than nonsmokers led to the term "smoking paradox." The controversy of such a complex claim has not been fully settled, even though different case mix was noted. Analyses were conducted on 2 independent data sets to evaluate and determine whether such a paradox truly exists. Methods- Taiwan Stroke Registry with 88 925 stroke cases, and MJ cohort with 541 047 adults participating in a medical screening program with 1630 stroke deaths developed during 15 years of follow-up (1994-2008). Primary outcome for stroke registry was functional independence at 3 months by modified Rankin Scale score ≤2, for individuals classified by National Institutes of Health Stroke Scale score at admission. For MJ cohort, mortality risk by smoking status or by stroke history was assessed by hazard ratio. Results- A >11-year age difference in stroke incidence was found between smokers and nonsmokers, with a median age of 60.2 years for current smokers and 71.6 years for nonsmokers. For smokers, favorable outcome in mortality and in functional assessment in 3 months with modified Rankin Scale score ≤2 stratified by the National Institutes of Health Stroke Scale score was present but disappeared when age and sex were matched. Smokers without stroke history had a ≈2-fold increase in stroke deaths (2.05 for ischemic stroke and 1.53 for hemorrhagic stroke) but smokers with stroke history, 7.83-fold increase, overshadowing smoking risk. Quitting smoking at earlier age reversed or improved outcome. Conclusions- "The more you smoke, the earlier you stroke, and the longer sufferings you have to cope." Smokers had 2-fold mortality from stroke but endured stroke disability 11 years longer. Quitting early reduced or reversed the harms.

The Impact of Physical Activity Before and After Stroke on Stroke Risk and Recovery: a Narrative Review

PURPOSE OF THE REVIEW

Summarising the evidence for pre- and post-stroke physical activity (PA) and exercise to reduce stroke risk, and improve recovery and brain health.

RECENT FINDINGS

Pre-stroke PA reduces the risk of stroke, and post-stroke PA and exercise reduce cardiovascular risk factors, which can moderate the risk of recurrent strokes. Pre-clinical evidence indicates that exercise enhances neuroplasticity. The results from clinical studies showed that exercise changes brain activity patterns in stroke survivors, which can be a signal neuroplasticity. The intensity of pre- and post-stroke PA and exercise is a key factor with higher intensities leading to greater benefits, including improvement in fitness. Having low fitness levels is an independent predictor for increased risk of stroke. Higher intensity leads to greater benefits; however, the optimum intensity of PA and exercise is yet unknown and needs to be further investigated. Strategies to decrease sedentary behaviour and improve fitness need to be considered.

Prestroke physical activity could influence acute stroke severity (part of PAPSIGOT)

Objective

To investigate the influence of prestroke physical activity (PA) on acute stroke severity.

Methods

Data from patients with first stroke were retrieved from registries with a cross-sectional design. The variables were PA, age, sex, smoking, diabetes, hypertension and statin treatment, stroke severity, myocardial infarction, new stroke during hospital stay, and duration of inpatient care at stroke unit. PA was assessed with Saltin-Grimby's 4-level Physical Activity Level Scale, and stroke severity was assessed with the National Institutes of Health Stroke Scale (NIHSS). Logistic regression was used to predict stroke severity, and negative binomial regression was used to compare the level of PA and stroke severity.

Results

The study included 925 patients with a mean age of 73.1 years, and 45.2% were women. Patients who reported light or moderate PA levels were more likely to present a mild stroke (NIHSS score 0 to 5) compared with physically inactive patients in a model that also included younger age as a predictor (odds ratio = 2.02 for PA and odds ratio = 0.97 for age). The explanatory value was limited at 6.8%. Prestroke PA was associated with less severe stroke, and both light PA such as walking at least 4 h/wk and moderate PA 2–3 h/wk appear to be beneficial. Physical inactivity was associated with increased stroke severity.

Conclusions

This study suggests that PA and younger age could result in a less severe stroke. Both light PA such as walking at least 4 h/wk and moderate PA 2–3 h/wk appear to be beneficial.

Registry-based stroke research in Taiwan: past and future

Stroke registries are observational databases focusing on the clinical information and outcomes of stroke patients. They play an important role in the cycle of quality improvement. Registry data are collected from real-world experiences of stroke care and are suitable for measuring quality of care. By exposing inadequacies in performance measures of stroke care, research from stroke registries has changed how we manage stroke patients in Taiwan. With the success of various quality improvement campaigns, mortality from stroke and recurrence of stroke have decreased in the past decade. After the implementation of a nationwide stroke registry, researchers have been creatively expanding how they use and collect registry data for research. Through the use of the nationwide stroke registry as a common data model, researchers from many hospitals have built their own stroke registries with extended data elements to meet the needs of research. In collaboration with information technology professionals, stroke registry systems have changed from web-based, manual submission systems to automated fill-in systems in some hospitals. Furthermore, record linkage between stroke registries and administrative claims databases or other existing databases has widened the utility of registry data in research. Using stroke registry data as the reference standard, researchers have validated several algorithms for ascertaining the diagnosis of stroke and its risk factors from claims data, and have also developed a claims-based index to estimate stroke severity. By making better use of registry data, we believe that we will provide better care to patients with stroke.