Table 13.
Studies examining the relationship between physical activity and stroke.
| Publication Country Study Design Quality Score | Objective | Population | Methods | Outcome | Comments and Conclusions |
|---|---|---|---|---|---|
| Wisloff et al 2006 [58] | To assess exercise amount and intensity in relation to subsequent CVD mortality (including stroke). | • n = 27,143 men, 28,929 women | 16 year follow up | Multivariate adjusted RR (95% CI) Men | Both high and low- intensity exercise may be associated with a reduced risk of stroke in both men and women. |
| Norway | • Sex: Men and women | PA Assessment: Questionnaire | G1 = 1.00 (referent) | ||
| • Age: ≥ 20 yr | G2 = 0.90 (0.70-1.17) | ||||
| • Characteristics: free from CVD | PA | G3a = 0.90 (0.64-1.26) | |||
| • HUNT Study | G1 = None | G3b = 0.59 (0.27-1.27) | |||
| G2 = <1/wk | G3c = 0.62 (0.40-0.95) | ||||
| G3a = 1/wk ≤ 30 min low | G3d = 0.51 (0.31-0.86) | ||||
| G3b = 1/wk ≤ 30 min high | G4a = 0.72 (0.49-1.05) | ||||
| G3c = 1/wk > 30 min low | G4b = 0.63 (0.31-1.30) | ||||
| Prospective cohort | G3d = 1/wk > 30 min high | G4c = 1.02 (0.72-1.44) | |||
| G4a = 2-3/wk ≤ 30 min low | G4d = 0.59 (0.37-0.92) | ||||
| G4b = 2-3/wk ≤ 30 min high | G5a = 0.97 (0.70-1.36) | ||||
| D & B score = 12 | G4c = 2-3/wk > 30 min low | G5b = 0.68 (0.27-1.66) | |||
| G4d = 2-3/wk > 30 min high | G5c = 0.81 (0.65-1.20) | ||||
| G5a = ≥ 4/wk ≤ 30 min low | G5d = 0.67 (0.49-1.11) | ||||
| G5b = ≥ 4/wk ≤ 30 min high | |||||
| G5c = ≥ 4wk > 30 min low | RR (95% CI) Women | ||||
| G5d = ≥ 4/wk > 30 min high | G1 = 1.00 (referent) | ||||
| Outcome Measure: IHD mortality | G2 = 1.01 (0.81-1.25) | ||||
| Cox proportional HR | G3a = 0.88 (0.68-1.15) | ||||
| G3b = 0.98 (0.46-2.10) | |||||
| G3c = 0.63 (0.42-0.94) | |||||
| G3d = 1.00 (0.50-1.98) | |||||
| G4a = 0.91 (0.70-1.17) | |||||
| G4b = 1.44 (0.78-2.65) | |||||
| G4c = 0.62 (0.44-0.88) | |||||
| G4d = 0.77 (0.36-1.66) | |||||
| G5a = 0.74 (0.56-0.99) | |||||
| G5b = 0.40 (0.10-1.62) | |||||
| G5c = 0.63 (0.45-0.89) | |||||
| G5d = 0.51 (0.21-1.26) | |||||
| Abbott et al 2003 [69] | To examine the way in which risk factor effects on the incidence of thromboembolic and hemorrhagic stroke can change over a broad range of ages. | • n = 7,589 | 6, 15 and 26 year follow up | Incidence rates per 1000 of stroke: | The protective effect of PA on reducing risk of stroke increased with age. |
| USA | • Sex: Men | • G1 = 9.0 (49) | |||
| • Age: 45-93 yr | PA assessment: Using PA index over a 24 hour period PA information collected at study enrolment 1965-1968 and updated at physical examinations that occurred at 6, 15 and 26 years into follow-up. | • G2 = 17.8 (124) | |||
| Prospective cohort | • Characteristics: Free from CHD and stroke at enrolment; Japanese ancestry living on the island of Oahu, Hawaii. | Grouped into 4 age groups, yr: | • G3 = 33.4 (112) | ||
| D & B score = 14 | • Honolulu Heart Program | G1 = 45-54 | • G4 = 48.1 (111) | ||
| G2 = 55-64 | Incidence of stroke event increased with advancing age p <0.001 | ||||
| G3 = 65-74 | There appeared to be a small protective effect within each age group. Inverse relations increased with age (p = 0.046). The protective effect of PA became significant in men >77 years (p = 0.032) | ||||
| G4 = 75-93 | |||||
| Outcome Measure: diagnosis of fatal and non fatal stroke during 26 years of follow-up | |||||
| Cox proportional HR | |||||
| Gillium et al 1996 [70] | To examine the relationship between recreational and non-recreational PA and risk of stroke. | • n = 2,368 men, 2,713 women | 11.6 year follow up | Number of Cases: 249 white women, 270 white men, 104 black | Sedentary behaviour was found to be associated with increased risk of stroke. |
| USA | • Sex: Men and women | PA assessment: Questionnaire divided into tertiles: | |||
| • Age: 45-74 yr | T1 = Low | RR (95% CI) Black men and women Recreational PA | |||
| Prospective cohort | • Ethnicity: Black and white | T2 = Medium | • T1 = 1.33 (0.67-2.63) | ||
| D & B score = 12 | • NHANES I | T3 = High | • T2 = 1.33 (0.63-2.79) | ||
| • T3 = 1.00 (referent) | |||||
| Outcome Measure: Total Stroke | Non-recreational PA | ||||
| Cox proportional HR | • T1 = 1.40 (0.90-2.16) | ||||
| • T2 = 1.41 (0.74-2.70) | |||||
| • T3 = 1.00 (referent) | |||||
| RR (95% CI) White men age 45-64 Recreational PA | |||||
| • T1 = 1.24 (0.63-2.41) | |||||
| • T2 = 1.17 (0.61-2.27 | |||||
| • T3 = 1.00 (referent) | |||||
| Non-recreational PA | |||||
| • T1 = 1.07 (0.40-2.86) | |||||
| • T2 = 1.75 (1.04-2.96) | |||||
| • T3 = 1.00 (referent) | |||||
| RR (95% CI) White women age 45-64 Recreational PA | |||||
| • T1 = 3.13 (0.95-10.32) | |||||
| • T2 = 1.80 (0.52-6.22) | |||||
| • T3 = 1.00 (referent) | |||||
| Non-recreational PA | |||||
| • T1 = 3.51 (1.66-7.46) | |||||
| • T2 = 1.07 (0.57-1.99) | |||||
| • T3 = 1.00 (referent) | |||||
| RR (95% CI) White men age 65-74 Recreational PA | |||||
| • T1 = 1.29 (0.58-1.88) | |||||
| • T2 = 0.86 (0.58-1.28) | |||||
| • T3 = 1.00 (referent) | |||||
| Non-recreational | |||||
| • T1 = 1.82 (1.15-2.88) | |||||
| • T2 = 1.20 (0.88-1.64) | |||||
| • T3 = 1.00 (referent) | |||||
| RR (95% CI) White women age 65-75 Recreational PA | |||||
| • T1 = 1.55 (0.95-2.53) | |||||
| • T2 = 1.27 (0.76-2.12) | |||||
| • T3 = 1.00 (referent) | |||||
| Non-recreational PA | |||||
| • T1 = 1.82 (1.10-3.02) | |||||
| • T2 = 1.42 (1.01-2.00) | |||||
| • T3 = 1.00 (referent) | |||||
| Lee and Blair 2002 [71] | To examine the association between PF and stroke mortality in men. | • n = 16,878 | Baseline medical evaluation between 1971 and 1994 with average follow up period of 10 years | Average estimated maximal METs | Moderate and high levels of PF were associated with lower risk of stroke mortality in men. |
| • Sex: Men | • T1 = 8.5 MET | ||||
| • Age: 40-87 yrs | • T2 = 10.5 MET | ||||
| USA | • Aerobics Center Longitudinal Study | • T3 = 13.1 MET | |||
| Prospective cohort | PF assessment: Maximal exercise tolerance test, divided into tertiles | RR (95% CI) adjusted for age and exam year | |||
| • T1 = 1.00 (referent) | |||||
| D & B score = 13 | T1 = Low | • T2 = 0.35 (0.16-0.77) | |||
| T2 = Moderate | • T3 = 0.28 (0.11-0.71) | ||||
| T3 = High | Trend p = 0.005 | ||||
| Cox proportional HR | |||||
| Hu et al 2000 [72] | To examine the association between PA and risk of total stroke and stroke sub- types in women. | • n = 72,488 | Baseline measurement in 1986 with follow-up questionnaire in 1988 and 1992 | • 407 cases of stroke (258 ischemic strokes, 67 subarachnoid hemorrhages, 42 intracerebral hemorrhages, and 40 strokes of unknown type) | PA, including moderate-intensity exercise such as walking, is associated with a substantial reduction in risk of total and ischemic stroke in a dose- response manner. |
| • Sex: Women | |||||
| • Age:40-65 yr | |||||
| USA | • Characteristics: Nurses | ||||
| Prospective cohort | • Nurses' Health Study | PA assessment: Questionnaire for total PA (MET h/wk), divided into quintiles, walking activity (MET h/wk), divided into quintiles and walking pace | Multivariate RR (95% CI) for total stroke by total PA level | ||
| • Q1 = 1.00 (referent) | |||||
| D & B score = 13 | • Q2 = 0.98 | ||||
| • Q3 = 0.82 | |||||
| • Q4 = 0.74 | |||||
| • Q5 = 0.66 | |||||
| Total PA (MET h/wk) | |||||
| p = 0.005 | |||||
| Q1 = 0 - 2.0 | |||||
| Q2 = 2.1 - 4.6 | |||||
| Multivariate RR (95% CI) for ischemic Stroke by total PA level | |||||
| Q3 = 4.7 - 10.4 | |||||
| Q4 = 10.5-21.7 | |||||
| • Q1 = 1.00 (referent) | |||||
| Q5 = > 21.7 | |||||
| • Q2 = 0.87 | |||||
| Walking activity (MET h/wk) | • Q3 = 0.83 | ||||
| Q1 = 0.5 | • Q4 = 0.76 | ||||
| Q2 = 0.6 - 2.0 | • Q5 = 0.52 | ||||
| Q3 = 2.1 - 3.8 | p = 0.003 | ||||
| Q4 = 3.9 - 10 | |||||
| Q5 = 10 | Multivariate RR (95% CI) for total stroke by walking activity | ||||
| Walking pace (mph) | • Q1 = 1.00 (referent) | ||||
| G1 < 2.0 | • Q2 = 0.76 | ||||
| G2 = 2-2.9 | • Q3 = 0.78 | ||||
| G3 3.0 | • Q4 = 0.70 | ||||
| • Q5 = 0.66 | |||||
| Outcome measure: Stroke incidence | p = 0.01 | ||||
| Multivariate RR (95% CI) for ischemic stroke by walking activity | |||||
| Pooled logistic regression | |||||
| Cox proportional HR | • Q1 = 1.00 (referent) | ||||
| • Q2 = 0.77 | |||||
| • Q3 = 0.75 | |||||
| • Q4 = 0.69 | |||||
| • Q5 = 0.60 | |||||
| p = 0.02 | |||||
| Multivariate RR (95% CI) for total stroke by usual Walking Pace | |||||
| • G1 = 1.00 (referent) | |||||
| • G2 = 0.81 | |||||
| • G3 = 0.49 | |||||
| p < 0.001 | |||||
| Multivariate RR (95% CI) for ischemic stroke by usual walking pace | |||||
| • G1 = 1.00 (referent) | |||||
| • G2 = 0.71 | |||||
| • G3 = 0.47 | |||||
| p < 0.001 | |||||
| Lee et al 1999 [74] | To examine the association between exercise and stroke risk. | • n = 21,823 | 11.1 year follow up | Number of Cases: 533 | VPA is associated with a decreased risk of stroke in men. |
| • Sex: Men | |||||
| • Age: 40-84 yr | PA assessment: Questionnaire for frequency of VPA, divided into 4 groups | Multivariate RR1 (95% CI) for total stroke by VPA | |||
| USA | |||||
| • G1 = 1.00 (referent) | |||||
| Prospective cohort | • G2 = 0.79 (0.61-1.03) | Inverse association with PA seemed to be mediated through beneficial effects on body weight, BP, cholesterol and glucose tolerance. | |||
| G1 < 1 time/week | • G3 = 0.80 (0.65-0.99) | ||||
| G2 = 1 time/week | • G4 = 0.79 (0.61-1.03) | ||||
| D & B score = 13 | G3 = 2-4 times/week | p = 0.04 | |||
| G4 ≥ 5 times/week | RR2 (95% CI) for total stroke by VPA | ||||
| • G1 = 1.00 (referent) | |||||
| RR1 = adjusted for smoking, alcohol consumption, history of angina and parental history of MI at <60 years | • G2 = 0.81 (0.61-1.07) | ||||
| • G3 = 0.88 (0.70-1.10) | |||||
| • G4 = 0.86 (0.65-1.13) | |||||
| p = 0.25 | |||||
| RR2 (95% CI) for ischemic stroke by | |||||
| RR2 = adjusted for all of the above plus, BMI, history of, hypertension, high cholesterol and diabetes | |||||
| VPA | |||||
| • G1 = 1.00 (referent) | |||||
| • G2 = 0.90 (0.66-1.22) | |||||
| • G3 = 0.95 (0.74-1.22) | |||||
| • G4 = 0.97 (0.71-1.32) | |||||
| Outcome Measure: Total Stroke (Ischemic and Hemorrhagic) | p = 0.81 | ||||
| RR2 (95% CI) for hemorrhagic stroke by VPA | |||||
| Cox proportional HR | • G1 = 1.00 (referent) | ||||
| • G2 = 0.54 (0.25-1.13) | |||||
| • G3 = 0.71 (0.41-1.23) | |||||
| • G4 = 0.54 (0.26-1.15) | |||||
| p = 0.10 | |||||
| Bijnen et al 1998 [166] | To describe the association between the PA patterns of elderly men and stroke mortality. | • n = 802 | 10 year follow up | Number of Cases: 47 | No significant finding |
| • Sex: Men | |||||
| • Age:64-84 yr | PA assessment: | Multivariate adjusted RR (95% CI) | |||
| Denmark | • Characteristics: Not all free from previous stroke | Questionnaire for LTPA, divided into tertiles | • T1= 1. 00 (referent) | ||
| • T2 = 0.65 (0.33-1.25) | |||||
| Prospective cohort | T1 = Lowest | • T3 = 0.55 (0.24-1.26) | |||
| T2 | p = 0.12 | ||||
| T3 = Highest | |||||
| D & B score = 15 | |||||
| Outcome Measure: Stroke Mortality | |||||
| Cox proportional HR | |||||
| Schnohr et al 2006 [214] | To describe the association between different levels of LTPA and subsequent causes of death (stroke). | • n = 2136 men, 2,758 women | 5 year follow up | RR (95% CI), univariate | Although RR for of death from stroke was below 1 for both moderate and high compared with low PA, this association did not reach the level of statistical significance. |
| • G1 = 1.00 (referent) | |||||
| • Sex: Men and women | PA assessment: | • G2 = 0.64 (0.39-1.05) | |||
| Copenhagen | • Age: 20 -- 79 yr | Questionnaire for LTPA, | • G3 = 0.70 (0.41-1.21) | ||
| • Characteristics: Healthy, PA level did not change between 2 examinations, 5 years apart | divided into 3 groups | Trend p = 0.4 | |||
| Prospective cohort | G1 = Low PA (<4 METS) | ||||
| G2 = Moderate PA (4-6 | RR (95% CI), multivariate: | ||||
| METS) | • G1 = 1.00 (referent) | ||||
| D & B score = 13 | G3 = High PA (>6 METS) | • G2 = 0.67 (0.40-1.12) | |||
| • Copenhagen City Heart Study | • G3 = 0.76 (0.43-1.34) | ||||
| Multivariate Analysis Kaplan-Meier Plots | Trend p = 0.6 | ||||
| Linear, Logistical and Cox Regression. | |||||
| Vatten et al 2006 [253] | To investigate whether obesity- related CV mortality could be modified by PA. | • n = 26,515 men, 27,769 women | 16 year follow up | Number of Cases: 994 women, 771 men | Lower levels of TPA are associated with an increased risk of stroke. |
| • Sex: Men and women | PA assessment: Questionnaire for total amount of PA, divided into 4 groups | ||||
| Norway | • Age: 20 yr | Multivariate HR (95% CI), men | |||
| • Characteristics: Free from CVD at baseline | • Q1 = 1.00 (referent) | ||||
| Prospective cohort | • Q2 = 1.05 (0.85-1.30) | ||||
| • HUNT study | G1 = High | • Q3 = 1.21 (0.95-1.54) | |||
| G2 = medium | • Q4 = 1.35 (1.05-1.74) | ||||
| D & B score = 14 | G3 = low | p = 0.009 | |||
| G4 = never | |||||
| Multivariate HR (95% CI), women | |||||
| Outcome Measure: Stroke mortality | • Q1 = 1.00 (referent) | ||||
| • Q2 = 1.16 (0.93-1.45) | |||||
| • Q3 = 1.45 (1.14-1.86) | |||||
| Cox proportional HR | |||||
| • Q4 = 1.45 (1.14-1.83) | |||||
| p < 0.001 | |||||
| Agnarsson et al 1999 [255] | To examine the association of LTPA and pulmonary function with the risk of stroke. | • n = 4,484 | Length of Follow-up: 10.6 ± 3.6 years | Number of Cases: 249 | Apparent protective effect of regular continued LTPA in middle age men on the risk of ischemic stroke. |
| • Sex: Men | |||||
| • Age: 45-80 | Adjusted for age and smoking RR (95% CI) for total stroke by LTPA level | ||||
| Iceland | • Characteristics: no history of Stroke | PA assessment: Questionnaire for LTPA (h/wk) and type of activity (intensity), each divided into 3 groups | |||
| Prospective cohort | • Reykjavik Study | • G1 = 1.00 (referent) | |||
| • G2 = 0.84 (0.63-1.13) | |||||
| • G3 = 0.73 (0.40-1.35) | |||||
| D & B score = 13 | LTPA summer/winter | ||||
| G1 = none | Adjusted for age and smoking RR (95% CI) for ischemic stroke by LTPA level | ||||
| G2 = ≤ 5 h/wk | |||||
| G3 = ≥ 6 h/wk | |||||
| • G1 = 1.00 (referent) | |||||
| Type of Activity | • G2 = 0.72 (0.51-1.01) | ||||
| G1 = none | |||||
| • G3 = 0.78 (0.41-1.48) | |||||
| G2 = low intensity | |||||
| G3 = high Intensity | |||||
| RR (95% CI) for total stroke by type of activity | |||||
| Outcome Measure: Total and ischemic Stroke | • G1 = 1.0,0 (referent) | ||||
| • G2 = 0.75 (0.53-1.08) | |||||
| • G3 = 1.10 (0.78-1.57) | |||||
| Cox proportional HR | |||||
| RR (95% CI) for ischemic stroke by type of activity | |||||
| • G1 = 1.00 (referent) | |||||
| • G2 = 0.72 (0.44-1.07) | |||||
| • G3 = 0.96 (0.64-1.44) | |||||
| Ellekjaer et al 2000 [256] | To examine the association between different levels of LTPA and stroke mortality in middle-aged and elderly women. | • n = 14,101 | Baseline 1984-1986: 2 self administered questionnaires and clinical measurements included in the screening program. | Number of cases: 457 | This study demonstrates a consistent, negative association between PA and stroke mortality in women. |
| • Sex: Women | |||||
| • Age: 50 yr | Multivariate RR (95% CI), all age groups | ||||
| Norway | • Characteristics: free from stroke at baseline | ||||
| • G1 = 1.00 (referent) | |||||
| Prospective cohort | • G2 = 0.77 | ||||
| PA assessment: Questionnaire for LTPA, divided into 3 groups | • G3 = 0.52 | ||||
| D & B score = 14 | Multivariate RR (95% CI), age 50--69 years | ||||
| G1 = low | The most active women had approx. 50% lower risk of death from stroke compare to inactive women. | ||||
| G2 = medium | • G1 = 1.00 (referent) | ||||
| G3 = high | • G2 = 0.57 | ||||
| • G3 = 0.42 | |||||
| Outcome Measure: Death from stroke | p = 0.0021 | ||||
| Multivariate RR (95% CI), age 70-79 years | |||||
| Cox proportional HR | |||||
| • G1 = 1.00 (referent) | |||||
| • G2 = 0.79 | |||||
| • G3 = 0.56 | |||||
| p = 0.0093 | |||||
| Multivariate RR (95% CI), age 80-101 years | |||||
| • G1 = 1.00 (referent) | |||||
| • G2 = 0.91 | |||||
| • G3 = 0.57 | |||||
| p = 0.1089 | |||||
| Evenson et al 1999 [257] | To examine the relationship between PA and ischemic stroke risk. | • n = 14,575 | 7.2 year follow up | Number of Cases: 189 | PA was weakly associated with a reduced risk of ischemic stroke among middle aged adults. |
| • Sex: Men and women | Number of Dropouts: 0% | ||||
| • Age: 45-64 yr | PA assessment: Questionnaire (Baecke questionnaire) | ||||
| USA | • Atherosclerosis Risk in Communities Study | Sport, Incidence of Ischemic Stroke | |||
| Prospective cohort | Multivariate adjusted RR (95% CI) by sport | ||||
| Outcome Measure: | |||||
| Ischemic Stroke | • Q1 = 1.00 (referent) | ||||
| D & B score = 14 | • Q3= 0.83 (0.52-1.32) | ||||
| Multivariate Poisson and Cox proportional HR | |||||
| Multivariate adjusted RR (95% CI) by LTPA | |||||
| • Q1 = 1.00 (referent) | |||||
| • Q2 = | |||||
| • Q3 = 0.89 (0.57-1.37) | |||||
| Multivariate adjusted RR (95% CI) by OPA | |||||
| • Q1 = 1.00 (referent) | |||||
| • Q2 = | |||||
| • Q3 = 0.69 (0.47-1.00) | |||||
| Haheim et al 1993 [258] | To determine the risk factors of stroke incidence and mortality. | • n = 14,403 | Baseline Screening from May 1972- December 1973. | HR (95% CI) for stroke incidence | Increased LTPA is associated with a reduced risk of stroke incidence but not mortality. |
| • Sex: Men | • G1 = 1.00 (referent) | ||||
| • Age: 40-49 yr | • G2 = 0.64 (0.38-1.08) | ||||
| Norway | PA assessment: Questionnaire for LTPA, divided into groups | • G3 = 0.36 (0.15-0.80) | |||
| Prospective cohort | HR (95% CI) for stroke mortality | ||||
| G1 = Sedentary | • G1 = 1.00, (referent) | ||||
| G2 = Moderate | • G2 = 0.82 (0.33-2.35) | ||||
| D & B score = 14 | G3 = Intermediate or Great | • G3 = 0.29 (0.03-1.51) | |||
| Outcome Measure: Incidence of stroke morbidity and mortality until study end date, December 31, 1984. | |||||
| Cox proportional HR | |||||
| Hu et al 2005 [259] | To assess the relationship of different types of PA with total and type-specific stroke risk. | • n = 47,721 | PA assessement: Mailed questionnaire for LTPA, OPA and commuting PA, divided into groups as follows: | RR (95% CI) by LTPA, men | A high level of LTPA reduces the risk of all subtypes of stroke. Daily active commuting also reduces the risk of ischemic stroke. |
| • Sex: Men and women | • G1 = 1.00 (referent) | ||||
| • G2 = 0.83 | |||||
| Finland | • Age: 25-64 | • G3 = 0.72 | |||
| • Characteristics: Healthy at baseline | p < 0.001 | ||||
| Prospective cohort | |||||
| LTPA levels: | RR (95% CI) by LTPA, women | ||||
| G1 = Low | • G1 = 1.00 (referent) | ||||
| D & B score = 13 | G2 = Moderate | • G2 = 0.86 | |||
| G3 = High | • G3 = 0.75 | ||||
| p = 0.007 | |||||
| OPA: | |||||
| G1 = Light | RR (95% CI) by LTPA, men and women | ||||
| G2 = Moderate | |||||
| G3 = Hard | |||||
| • G1 = 1.00 (referent) | |||||
| • G2 = 0.85 | |||||
| Commuting PA: | |||||
| G1 = Motorized or no work, | • G3 = 0.73 | ||||
| G2 = walking or cycling 1-29 min G3 = walking or cycling ≥ 30 min. | p <0.001 | ||||
| RR (95% CI) by OPA, men | |||||
| • Not significant | |||||
| Outcome Measure: Incidence of fatal or non-fatal stroke occurring during follow-up until end of 2003. Mean follow-up of 19 years. | |||||
| RR (95% CI) by OPA, women | |||||
| • Not significant | |||||
| RR (95% CI) by OPA, men and women | |||||
| • G1 = 1.00 (referent) | |||||
| Cox proportional hazard | • G2 = 0.90 | ||||
| • G3 = 0.87 | |||||
| p = 0.007 | |||||
| RR (95% CI) by commuting PA, men | |||||
| • G1 = 1.00 (referent) | |||||
| • G2 = 0.91 | |||||
| • G3 = 0.85 | |||||
| p = 0.047 | |||||
| RR (95% CI) by commuting PA, women | |||||
| • G1 = 1.00 (referent) | |||||
| • G2 = 0.86 | |||||
| • G3 = 0.85 | |||||
| p = 0.018 | |||||
| RR (95% CI) by commuting PA, men and women | |||||
| • G1 = 1.00 (referent) | |||||
| • G2 = 0.89 | |||||
| • G3 = 0.85 | |||||
| p = 0.002 | |||||
| Kiely et al 1994 [260] | To examine the influence of increased PA on stroke risk in members of the Framingham study cohort. | • n = 1,897 men 2,299 women | Baseline measurement in 1954-1955 and follow up in either 1968-1969 or 1971- 1972 | Multivariate adjusted RR (95% CI) at first examination, men (mean age 50 years) | Medium and high levels of PA among men are protective against stroke relative to low levels. |
| • Sex: Men and women | |||||
| USA | • G1 = 1.00 (referent) | ||||
| • Age: 28-62 yr | • G2 = 0.90 (0.62-1.31) p = 0.59 | ||||
| Prospective cohort | • Characteristics: Free from stroke | PA assessment: Questionnaire for metabolic work done during a typical 24 hr period, divided into 3 groups | • G3 = 0.84 (0.59-1.18) p = 0.31 | ||
| Multivariate adjusted RR (95% CI) at first examination, women (mean age 50 years) | Protective effect of PA was slightly less for high levels of PA compared to medium levels for older men. | ||||
| D & B score = 12 | |||||
| G1 = Low | • G1 = 1.00 (referent) | ||||
| G2 = Medium | • G2 = 1.21 (0.89-1.63) p = 0.23 | ||||
| G3 = High | • G3 = 0.89 (0.60-1.31) p = 0.54 | ||||
| Outcome Measure: Incidence of stroke, as defined by the first occurrence of atherothrombotic brain infarctions, cerebral embolism or other type of stroke, during 32 years of follow-up. | |||||
| Multivariate adjusted RR (95% CI) at second examination, men (mean age 63 years) | |||||
| • G1 = 1.00 (referent) | |||||
| • G2 = 0.41 (0.24-0.89) p = 0.0007 | |||||
| • G3 = 0.53 (0.34-0.84) p = 0.007 | |||||
| Multivariate adjusted RR (95% CI) at second examination, women (mean age 64 years) | |||||
| Cox proportional HR | |||||
| • G1 = 1.00 (referent) | |||||
| • G2 = 0.97 (0.64-1.47) p = 0.67 | |||||
| • G3 = 1.21 (0.75-1.96) p = 0.43 | |||||
| Krarup et al 2007 [261] | To compare the reported level of PA performed during the week preceding an ischemic stroke with that of community controls. | • n = 127 cases 301 controls | PA assessment: | Univariate OR (95% CI) | Stroke patients are less physically active in the week preceding an ischemic stroke when compared to age and sex-matched controls. Increasing PASE score was inversly, log-linearly and significantly associated with OR for ischemic stroke. |
| Questionnaire about PA 1 week prior to stroke (cases) and 1 week prior to questionnaire (controls), divided into PASE scores and quartiles | PASE Score | ||||
| • Sex: Men and women | • Q1 = 1.00 (referent) | ||||
| Denmark | • Q2 = 0.51 (0.28-0.95) | ||||
| • Age: ≥ 40 yr | • Q3 = 0.27 (0.14-0.54) | ||||
| Case control | • Characteristics: Case: Stroke Patients (20% had history of Stroke), Controls: 4% had history of stroke | • Q4 = 0.08 (0.03-0.20) | |||
| D & B score = 14 | Q1 = 0-49 | Multivariate OR (95% CI) PASE Score | |||
| Q2 = 50-99 | |||||
| Q3 = 100-149 | • Q1 = 1.00 (referent) | ||||
| Q4 = 150+ | • Q2 = 0.53 (0.26-1.08) | ||||
| • Q3 = 0.27 (0.12-0.59) | |||||
| Outcome measure: | |||||
| Ischemic stroke | • Q4 = 0.09 (0.03-0.25) | ||||
| Chi squared Kruskal-Wallis Statistics Multivariate conditional logistic regression | |||||
| Kurl et al 2003 [262] | To examine the relationship of PF with subsequent incidence of stroke. Also to compare PF with conventional risk factors as a predictor for future stroke. | • n = 2,011 | Baseline examinations conducted between March 1984 and December 1989 with average follow up period of 11 years | Multivariate HR (95% CI), any stroke | Low PF was associated with an increased risk of any stroke and ischemic stroke. |
| • Sex: Men | • Q1 = 1.00 (referent) | ||||
| • Age: 42, 48, 54 or 60 yrs | • Q2 = 1.39 (0.70-2.77) | ||||
| Finland | • Q3 = 1.32 (0.66-2.65) | ||||
| • Characteristics: Free from stroke or pulmonary disease • Kuopio Ischaemic Heart Disease Risk Factor Study |
• Q4 = 2.30 (1.18-4.06) | ||||
| Prospective cohort | Trend p = 0.01 | ||||
| PF assessment: Maximal exercise test on cycle ergometer. VO2 max (ml/kg/min) divided into quartiles | |||||
| Multivariate HR (95% CI), ischemic stroke | |||||
| D & B score = 14 | |||||
| • Q1 = 1.00 (referent) | |||||
| • Q2 = 1.28 (0.56-2.94) | |||||
| • Q3 = 1.64 (0.74-3.65) | |||||
| Q1 = >35.3 | |||||
| • Q4 = 2.40 (1.09-5.25) | |||||
| Q2 = 30.3-35.3 | |||||
| Trend p = 0.01 | |||||
| Q3 = 25.2-30.2 | |||||
| Q4 = <25.2 | |||||
| Outcome Measure: Stroke incidence | |||||
| Cox proportional HR | |||||
| Myint et al 2006 [263] | To examine the association between a combination of OPA and LTPA with risk of subsequent stroke. | • n = 22,602 | Baseline measurement in | Model A: Used all 4 categories of PA | Higher levels of PA assessed using a single simple pragmatic tool based on both OPA and LTPA is associated with reduced stroke risk. |
| • Sex: Men | 1993-1997 | HR (95% CI), men and women | |||
| • Age: 40-79 yr | • G1 = 1.00 (referent) | ||||
| UK | • Characteristics: Healthy at baseline | PA assessment: Questionnaire for PA (includes LTPA and OPA) divided into 4 groups | • G2 = 0.78 (0.61-1.00) | ||
| • G3 = 0.66 (0.49-0.91) | |||||
| Prospective cohort | • European Prospective Investigation in Cancer-Norfolk | • G4 = 0.70 (0.49-0.99) | |||
| p = 0.024 | |||||
| D & B score = 11 | G1 = Inactive | HR (95% CI), men | |||
| G2 = moderately inactive | • G1 = 1.00 (referent) | ||||
| G3 = moderately active | • G2 = 0.75 (0.52-1.09) | ||||
| G4 = active | |||||
| • G3 = 0.55 (0.35-0.86) | |||||
| • G4 = 0.67 (0.43-1.05) | |||||
| Outcome Measure: Incidence of fatal and non fatal stroke. | |||||
| p = 0.41 | |||||
| Women not significant p = 0.50 | |||||
| Cox proportional HR | |||||
| Model B: Used 3 categories of PA (G3 and G4 combined combined) | |||||
| HR (95% CI), men and women | |||||
| • G1 = 1.00 (referent) | |||||
| • G2 = 0.78 (0.61-1.00) | |||||
| • G3 = 0.68 (0.52-0.88) | |||||
| p = 0.009 | |||||
| HR (95% CI), men | |||||
| • G1 = 1.00 (referent) | |||||
| • G2 = 0.75 (0.52-1.09), | |||||
| • G3 = 0.61 (0.43-0.86) | |||||
| p = 0.019 | |||||
| Women not significant p = 0.34 | |||||
| Noda et al 2005 [264] | To examine the impact of exercise on CVD (stroke) mortality in Asian populations. | • n = 31,023 men, 42,242 women | 9.7 year follow up | Number of Cases: 186 men, 141 women | PA through walking and sports participation may reduce the risk of mortality from ischemic stroke |
| • Sex: Men and women | PA assessment: Questionnaire for PA (walking and sports participation (h/day), divided into quartiles: | Number of Dropouts: 3.4% | |||
| Japan | • Age: 40 -79 yr | ||||
| • Ethnicity: Asian | Multivariate adjusted HR (95% CI) by duration of walking PA, men | ||||
| Prospective cohort | |||||
| • Q1 = 1.03 (0.63-1.69) | |||||
| Q1 = <0.5 | • Q2 = 1.00 (referent) | ||||
| D & B score = 13 | Q2 = 0.5 | • Q3 = 0.56 (0.35-0.91) | |||
| Q3 = 0.6-0.9 | • Q4 = 0.71 (0.49-1.02) | ||||
| Q4 = >1.0 | |||||
| Multivariate adjusted HR (95% CI) by duration of walking PA, women | |||||
| Outcome Measure: Death from ischemic stroke | |||||
| • Q1 = 1.38 (0.82-2.33) | |||||
| • Q2 = 1.00 (referent) | |||||
| Cox proportional HR | |||||
| • Q3 = 0.56 (0.32-0.97) | |||||
| • Q4 = 0.73 (0.48-1.13) | |||||
| Multivariate adjusted HR (95% CI) by sport PA, men | |||||
| • Q1 = 1.34 (0.86-2.08) | |||||
| • Q2 = 1.00 (referent) | |||||
| • Q3 = 1.22 (0.66-2.25) | |||||
| • Q4 = 0.84 (0.45-1.57) | |||||
| Multivariate adjusted HR (95% CI) by sport PA, women | |||||
| • Q1 = 1.07 (0.64-1.77) | |||||
| • Q2 = 1.00 (referent) | |||||
| • Q3 = 0.62 (0.25-1.58) | |||||
| • Q4 = 0.73 (0.31-1.70) | |||||
| Paganini-Hill and Barreto 2001 [265] | To identify risk factors and preventative measures for stroke in elderly men and women. | • n = 4,722 men, 8,532 women | Baseline survey in 1981- 1982. | Multivariate adjusted RR (95% CI) for total hemorrhagic occlusion by exercise, men | Emphasized role of lifestyle modification in the primary prevention of stroke. |
| • Sex: Men and women | |||||
| PA assessment: Questionnaire on amount of hours per day of exercise | • Q1 = 1.00 (referent) | ||||
| USA | Age: 44-101 yr | • Q2 = 0.88 | |||
| • Characteristics: no previous history of stroke. Residence of a retirement community in Southern California | Q3 = 0.83 | ||||
| Prospective cohort | G1 = <0.5 | ||||
| G2 = <0.1 | Multivariate adjusted RR (95% CI) for total hemorrhagic occlusion by exercise, women | ||||
| G3 = 1+ | |||||
| D & B score = 13 | |||||
| Outcome Measure: Incidence of hemorrhagic occlusion strokes up until December 31, 1998. | • Q1 = 1.00 (referent) | ||||
| • Q2 = 0.91 | |||||
| • Q3 = 0.85 | |||||
| Poisson Regression 40 year follow up | |||||
| Pitsavos et al 2004 [266] | To investigate the interaction between PA in men with LVH on stroke mortality. | • n = 489 | Number of cases: 67 | PA reduced the risk of stroke in men without LVH. | |
| • Sex: Men | |||||
| PA assessment: Questionnaire | RR (95% CI) | ||||
| USA | • Age: 40-59 yr | • G1 = 1.00 (referent) | |||
| • Characteristics: Those without LVH | G1 = Sedentary | • G2 = 0.64 (0.45-0.91) | |||
| Prospective cohort | G2 = Moderate | • G3 = 0.72 (0.51-1.02) | |||
| • Corfu Cohort (Greece) from Seven Countries Study | G3 = Hard | ||||
| D & B score = 12 | Outcome Measure: Stroke mortality | ||||
| Cox proportional HR | |||||
| Sacco et al 1998 [267] | To investigate the association between LTPA and ischemic stroke. | • n = 369 case, 678 control | Case Subjects were recruited during hospitalization, self referral or from monitoring non hospitalized stroke. Controls were eligible if they had never been diagnosed with stroke and were >39 years. | LTPA was related to a decreased occurrence of ischemic stroke in elderly, multiethnic, urban subjects. | |
| • Sex: Men and women | O R (95% CI) for duration of LTPA and stroke | ||||
| USA | |||||
| • Age: > 39 yr | • G1 = 1.00 (referent) | ||||
| Case control | • Characteristics: Case Subjects: Diagnosed with first cerebral infarction after July 1, 1993. Control Subjects: Never diagnosed with stroke | • G2 = 0.42 | |||
| • G3 = 0.35 | |||||
| D & B score = 14 | • G4 = 0.31 | ||||
| PA assessment: | |||||
| Questionnaire | |||||
| Divided into duration of LTPA (h/wk) | |||||
| • Northern Manhattan Stroke Study | |||||
| G1 = 0 | |||||
| G2 = <2 | |||||
| G3 = 2-<5 | |||||
| G4 = ≥ 5 | |||||
| Multivariate conditional logistic regression Baseline data collection from 1982-1983 in East Boston (MA), New Haven (CT) and Iowa and Washington counties (IA). | |||||
| Simonsick et al 1993 [268] | To examine the association between recreational PA among physically capable older adults and incidence of selected chronic diseases and mortality over 3 and 6 years. | • n = 1,815 | After 3 years Iowa | No consistent relationship between PA and stroke was found after 3 or 6 years across all 3 population cohorts. | |
| • Sex: Men and women | |||||
| • Age: ≥ 65 yrs | OR (95% CI) Stroke and activity level | ||||
| USA | • Characteristics: Physically capable to do heavy work around the house, walk up and down a flight of stairs and walk a half mile without help. | • T1 = 0.22 (0.08-0.61) | |||
| • T2 = 1.05 (0.60-1.84) | |||||
| Prospective cohort | • T3 = 1.00 (Referent) | ||||
| PA assessment: Questionnaire | |||||
| New Haven | |||||
| D & B score = 12 | T1 = High | OR (95% CI) Stroke and activity level | |||
| T2 = Moderate and | • T1 = 1.06 (0.38-2.95) | ||||
| T3 = Inactive | • T2 = 1.26 (0.54-2.92) | ||||
| • Established Populations for Epidemiologic Studies of the Elderly | • T3 = 1.00 (Referent) | ||||
| Outcome Measure: Stroke incidence during 3 and 6 year follow-ups. | |||||
| East Boston | |||||
| OR (95% CI) Stroke and activity level | |||||
| • T1 = 0.59 (0.17-1.95) | |||||
| Logistic Regression | |||||
| • T2 = 1.08 (0.52-2.27) | |||||
| • T3 = 1.00 (Referent) | |||||
| After 6 years | |||||
| Iowa | |||||
| OR (95% CI) Stroke and activity level | |||||
| • T1 = 0.56 (0.31-1.00) | |||||
| • T2 = 0.97 (0.64-1.48) | |||||
| • T3 = 1.00 (Referent) | |||||
| New Haven | |||||
| OR (95% CI) Stroke and activity level | |||||
| • T1 = 1.05 (0.52-2.12) | |||||
| • T2 = 1.29 (0.72-2.32) | |||||
| • T3 = 1.00 (Referent) | |||||
| East Boston | |||||
| OR (95% CI) Stroke and activity level | |||||
| • T1 = 1.21 (0.56-2.61) | |||||
| • T2 = 1.73 (0.98-3.06) | |||||
| • T3 = 1.00 (Referent) | |||||
| Thrift et al 2002 [269] | To examine whether intracerebral hemorrhage is associated with dynamic or static exercise. | • n = 662 | PA assessment: Interview, divided into 3 groups: frequency of vigorous activity | Number of Cases: 331 | Findings not significant after multivariate analysis. |
| • Sex: Men and women | |||||
| • Age: 18-80 yr | Multivariate OR (95% CI) by frequency of VPA | ||||
| Australia | • Characteristics: Cases: first episode ofintracerebral hemorrhage Controls: Neighbours of cases | ||||
| G1 = Never | • G1 = 1.00 (referent) | ||||
| Case control | G2 = Rarely | • G2 = 0.68 (0.36-1.27) | |||
| G3 = Once or more per month | • G3 = 0.66 (0.39-1.11) | ||||
| D & B score = 14 | p = 0.094 | ||||
| OPA level | Multivariate OR (95% CI) by OPA level | ||||
| G1 = Sedentary | • G1 = 1.00 (referent) | ||||
| G2 = Light to moderate | • G2 = 0.94 (0.59-1.48), p = 0.773 | ||||
| G3 = Heavy | • G3 = 1.18 (0.57-2.46), p = 0.650 | ||||
| Outcome Measure: Intracerebral hemorrhage | |||||
| Multiple logistic regression | |||||
D & B score, Downs and Black quality score; YR, years; wk, week; CVD, cardiovascular disease; G, groups; PA, physical activity; CHD, coronary heart disease; RR, risk ratio; 95% CI, 95% confidence interval; T, tertile; PF, physical fitness; MET, metabolic equivalent; Q, quartile or quintile; OPA, occupational physical activity; LTPA, leisure-time physical activity; HR, hazard ratio; VPA, vigorous physical activity; LVH, left ventricular hypertrophy.