Professional Documents
Culture Documents
Background and Purpose—In studies enrolling patients with stroke, higher levels of prestroke physical activity are
associated with better functional outcomes. However, prospective studies evaluating this association are sparse. Using
a cohort of initially healthy men, we aimed to prospectively assess the association between physical activity and
functional outcomes from cerebral vascular events.
Methods—We conducted a prospective cohort study among 21 794 men enrolled in the Physician’s Health Study who
provided information on physical activity at baseline and who did not have a history of stroke or transient ischemic
attack (TIA). Baseline levels of physical activity were categorized as: vigorous exercise ⬍1, 1, 2 to 4, and ⱖ5
times/week. Possible functional outcomes included TIA and stroke with modified Rankin Scale score of 0 to 1, 2 to 3,
Downloaded from http://stroke.ahajournals.org/ by guest on October 12, 2017
or 5 to 6. Multinomial logistic regression was used to determine the association between physical activity and functional
outcomes from cerebral vascular events.
Results—After a mean of 20.2 years of follow-up, 761 TIAs, 1146 ischemic strokes, 221 hemorrhagic strokes, and 11
strokes of unknown type occurred. Compared with men who did not experience a stroke or TIA and who exercise
vigorously ⬍1 time/week, men who exercise vigorously ⱖ5 times/week had adjusted relative risk (95% CIs) of 0.67
(0.53– 0.86) for TIA, 0.84 (0.61–1.14) for stroke with modified Rankin Scale score 0 to 1, 0.85 (0.67–1.08) for modified
Rankin Scale score 2 to 3, and 1.12 (0.78 –1.60) for modified Rankin Scale score 5 to 6 after total stroke. Other levels
of physical activity did not have a significant impact on the risk of our outcomes.
Conclusions—Physical activity before TIA or stroke does not appear to influence functional outcomes after cerebral
vascular events. (Stroke. 2011;42:3352-3356.)
Key Words: epidemiology 䡲 physical activity 䡲 stroke
Received March 3, 2011; final revision received June 9, 2011; accepted June 21, 2011.
Bruce Ovbiagele, MD, MSc, was the Guest Editor for this paper.
From the Division of Preventive Medicine (P.M.R., I-M.L., J.M.G., T.K.) and the Division of Aging (J.M.G.), Department of Medicine, Brigham and
Women’s Hospital, Harvard Medical School, Boston, MA; the Department of Epidemiology (P.M.R., I-M.L., T.K.), Harvard School of Public Health, Boston,
MA; the Department of Neurology (C.S.K.), Boston University School of Medicine, Boston, MA; Massachusetts Veterans Epidemiology and Research
Information Center (J.M.G.), Boston Veterans Affairs Healthcare System, Boston, MA; and INSERM Unit 708-Neuroepidemiology (T.K.), Paris, France.
The online-only Data Supplement is available at http://stroke.ahajournals.org/lookup/suppl/doi:10.1161/STROKEAHA.111.619544/-/DC1.
Correspondence to Tobias Kurth, MD, ScD, INSERM U708 –Neuroepidemiology, Hôpital de la Pitié-Salpêtrière, 47 boulevard de l’Hôpital, 75651
Paris, France. E-mail tkurth@rics.bwh.harvard.edu
© 2011 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org DOI: 10.1161/STROKEAHA.111.619544
3352
Rist et al Physical Activity and Stroke Outcomes 3353
have been previously described.7–9 Briefly, in 1982, 22 071 US male each functional outcome according to level of physical activity.
physicians between the ages of 40 and 84 years were randomized to When examining the relationship between physical activity and
receive aspirin, -carotene, both placebo, or both active agents. functional outcome after hemorrhagic stroke, TIA was not included.
Participants were free of a history of stroke, transient ischemic attack We distinguished 2 multivariable models: I (confounder model)
(TIA), myocardial infarction, and other major diseases at baseline. included age (continuous), smoking status (never, past, or currently
All men provided written informed consent and this study has been smoking ⬍20 or ⱖ20 cigarettes daily), alcohol consumption (rarely,
approved by the Institutional Review Board at Brigham and Wom- monthly, weekly, or daily), and parental history of myocardial
en’s Hospital. Since the completion of the trial,7,8 follow-up is infarction before age 60 years (yes/no). We also adjusted for
ongoing.10 This analysis included data available as of March 2008 randomized treatment assignments. II (intermediate model) addition-
when morbidity and mortality follow-up was ⬎99%. ally controlled for body mass index (continuous), history of hyper-
tension (yes/no), history of high cholesterol (yes/no/missing), and
Assessment of Exposure history of diabetes (yes/no).
At baseline, all physicians filled out a questionnaire asking about We examined whether age, randomized treatment assignment to
health and lifestyle characteristics, including physical activity. Spe- aspirin, smoking status, history of hypertension, or obesity modified
cially, the men were asked, “How often do you exercise vigorously the association between physical activity at baseline and functional
enough to work up a sweat?” Possible responses were rarely/never, outcomes from total stroke by including an interaction term between
1 to 3 times/month, 1 time/week, 2 to 4 times/week, 5 to 6 physical activity and each variable in separate age-adjusted models.
times/week, or daily.3 Previous studies have shown that this method In secondary analyses, we used updated physical activity infor-
of assessing physical activity correlates well with physical fitness mation at 36 and 108 months to determine the relationship between
measures.11,12 To be consistent with a prior study,3 we combined the physical activity and risk of our functional outcomes from stroke.
2 lowest categories into ⬍1 time/week and the 2 highest into ⱖ5 Due to differences in the response categories, we a priori decided to
dichotomize physical activity into ⬍1 time/week and ⱖ1 time/week,
Downloaded from http://stroke.ahajournals.org/ by guest on October 12, 2017
time/week and who did not experience a stroke or TIA, We found no evidence of effect modification by age,
although this reduction in risk was not statistically significant. history of hypertension, smoking status, randomized aspi-
Adjusting for potential intermediates did not impact our rin assignment, or obesity on the association between
results (data not shown). Results when examining only physical activity and functional outcome from total stroke
ischemic stroke outcomes were similar to those seen for total (all Pinteraction ⬎0.16).
stroke outcomes (Table 3). When examining hemorrhagic When we dichotomized physical activity (⬍1 time/week
stroke, there was some suggestion that exercising 2 to 4 versus ⱖ1 time/week) to perform analyses updated over time,
times/week reduces one’s risk of any of our functional results were essentially unchanged (Supplemental Tables;
outcomes from stroke (Table 3). http://stroke.ahajournals.org).
Table 2. Multivariable-Adjusted Relative Risk of Total Stroke, TIA, and Ischemic or Hemorrhagic Stroke According to Level of
Physical Activity (Nⴝ21 794)*
TIA Total Stroke Ischemic Stroke Hemorrhagic Stroke
Table 3. Multivariable-Adjusted ORs of Functional Outcomes After Cerebral Vascular Events According to Level of Physical
Activity (Nⴝ21 794)*
No TIA/stroke TIA mRS 0 –1 mRS 2–3 mRS 5– 6
No. Percent No. Percent RR (95% CI)† No. Percent RR (95% CI)† No. Percent RR (95% CI)† No. Percent RR (95% CI)†
Total stroke (n⫽761) (n⫽429) (n⫽708) (n⫽241)
⬍1 time/wk 5380 27.4 239 31.4 1.00 127 29.6 1.00 225 31.8 1.00 77 32.0 1.00
1 time/wk 3608 18.4 150 19.7 1.04 (0.84–1.28) 78 18.2 1.04 (0.78–1.38) 135 19.1 1.01 (0.81–1.26) 36 14.9 0.83 (0.56–1.24)
2–4 times/wk 7436 37.8 276 36.3 0.91 (0.76–1.09) 162 37.8 1.03 (0.82–1.31) 236 33.3 0.85 (0.70–1.03) 77 32.0 0.84 (0.61–1.16)
ⱖ5 times/wk 3231 16.4 96 12.6 0.67 (0.53–0.86) 62 14.5 0.84 (0.61–1.14) 112 15.8 0.85 (0.67–1.08) 51 21.2 1.12 (0.78–1.60)
Ischemic stroke (n⫽761) (n⫽396) (n⫽634) (n⫽116)
⬍1 time/wk 5380 27.4 239 31.4 1.00 115 29.0 1.00 200 31.6 1.00 35 30.2 1.00
1 time/wk 3608 18.4 150 19.7 1.04 (0.84–1.28) 69 17.4 1.02 (0.75–1.38) 121 19.1 1.03 (0.81–1.30) 17 14.7 0.88 (0.49–1.57)
2–4 times/wk 7436 37.8 276 36.3 0.91 (0.76–1.09) 152 38.4 1.07 (0.84–1.37) 213 33.6 0.87 (0.71–1.06) 39 33.6 0.96 (0.60–1.52)
ⱖ5 times/wk 3231 16.4 96 12.6 0.67 (0.53–0.86) 60 15.2 0.89 (0.65–1.22) 100 15.8 0.86 (0.67–1.10) 25 21.6 1.22 (0.73–2.06)
Hemorrhagic stroke (n⫽30) (n⫽73) (n⫽118)
⬍1 time/wk 5380 27.4 NA NA NA 10 33.3 1.00 24 32.9 1.00 39 33.1 1.00
1 time/wk 3608 18.4 NA NA NA 9 30.0 1.40 (0.57–3.47) 14 19.2 0.92 (0.47–1.79) 18 15.3 0.81 (0.46–1.41)
Downloaded from http://stroke.ahajournals.org/ by guest on October 12, 2017
2–4 times/wk 7436 37.8 NA NA NA 9 30.0 0.72 (0.29–1.78) 23 31.5 0.74 (0.42–1.32) 37 31.4 0.78 (0.50–1.23)
ⱖ5 times/wk 3231 16.4 NA NA NA 2 6.7 0.37 (0.08–1.70) 12 16.4 0.85 (0.42–1.70) 24 20.3 1.03 (0.62–1.73)
TIA indicates ischemic attack; mRS, modified Rankin Scale; RR, relative risk; CI, confidence interval; OR, odds ratio; NA, not applicable.
*Men who exercised ⬍1 time/wk and who did not experience a stroke or TIA, served as the reference category.
†Values have also been adjusted for age, smoking status, alcohol consumption, parental history of myocardial infarction before age 60 y, and randomized treatment
assignments.
Several limitations should be considered when interpreting 6. Stroud N, Mazwi TM, Case LD, Brown RD Jr, Brott TG, Worrall BB, et
our results. Although we have updated information on phys- al. Prestroke physical activity and early functional status after stroke.
J Neurol Neurosurg Psychiatry. 2009;80:1019 –1022.
ical activity during follow-up, we only could dichotomize 7. Final report on the aspirin component of the ongoing Physicians’ Health
activity levels, which may lead to some misclassification. Study. Steering committee of the Physicians’ Health Study research
Additionally, we did not have information on the types and group. N Engl J Med. 1989;321:129 –135.
intensities of physical activity. Because this is an observa- 8. Hennekens CH, Buring JE, Manson JE, Stampfer M, Rosner B, Cook NR,
et al. Lack of effect of long-term supplementation with beta carotene on
tional study, residual confounding may be present. Finally, the incidence of malignant neoplasms and cardiovascular disease. N Engl
although the homogeneity of the cohort improves our internal J Med. 1996;334:1145–1149.
validity, it may limit the generalizability of our results to 9. Manson JE, Buring JE, Satterfield S, Hennekens CH. Baseline charac-
other male populations or women. teristics of participants in the Physicians’ Health Study: a randomized
trial of aspirin and beta-carotene in US physicians. Am J Prev Med.
In conclusion, results of this large prospective study in men
1991;7:150 –154.
suggest that physical activity may help to reduce the risk of 10. Sesso HD, Buring JE, Christen WG, Kurth T, Belanger C, MacFadyen J,
incident stroke, but there is little evidence that prestroke et al. Vitamins E and C in the prevention of cardiovascular disease in
physical activity influences functional outcomes after stroke. men: the Physicians’ Health Study II randomized controlled trial. JAMA.
2008;300:2123–2133.
Future research is warranted to explore whether specific types
11. Siconolfi SF, Lasater TM, Snow RC, Carleton RA. Self-reported physical
of physical activity or other lifestyle factors influence func- activity compared with maximal oxygen uptake. Am J Epidemiol. 1985;
tional outcomes from stroke. 122:101–105.
12. Kohl HW, Blair SN, Paffenbarger RS Jr, Macera CA, Kronenfeld JJ. A
Downloaded from http://stroke.ahajournals.org/ by guest on October 12, 2017
Sources of Funding mail survey of physical activity habits as related to measured physical
fitness. Am J Epidemiol. 1988;127:1228 –1239.
The Physician’s Health Study is supported by grants CA-34944,
13. Berger K, Kase CS, Buring JE. Interobserver agreement in the classifi-
CA-40360, and CA-097193 from the National Cancer Institute and
cation of stroke in the Physicians’ Health Study. Stroke. 1996;27:
grants HL-26490 and HL-34595 from the National Heart, Lung, and
238 –242.
Blood Institute, Bethesda, MD. P.M.R. is funded by a training grant
14. Uyttenboogaart M, Stewart RE, Vroomen PC, De Keyser J, Luijckx GJ.
from the National Institute of Aging (AG-00158). Optimizing cutoff scores for the Barthel Index and the modified Rankin
Scale for defining outcome in acute stroke trials. Stroke. 2005;36:
Disclosures 1984 –1987.
None. 15. van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J. Inter-
observer agreement for the assessment of handicap in stroke patients.
References Stroke. 1988;19:604 – 607.
1. Lee CD, Folsom AR, Blair SN. Physical activity and stroke risk: a 16. Banks JL, Marotta CA. Outcomes validity and reliability of the modified
meta-analysis. Stroke. 2003;34:2475–2481. Rankin Scale: implications for stroke clinical trials: a literature review
2. Wendel-Vos GC, Schuit AJ, Feskens EJ, Boshuizen HC, Verschuren and synthesis. Stroke. 2007;38:1091–1096.
WM, Saris WH, et al. Physical activity and stroke. A meta-analysis of 17. Farrell B, Godwin J, Richards S, Warlow C. The United Kingdom
observational data. Int J Epidemiol. 2004;33:787–798. Transient Ischaemic Attack (UK-TIA) aspirin trial: final results. J Neurol
3. Lee IM, Hennekens CH, Berger K, Buring JE, Manson JE. Exercise and Neurosurg Psychiatry. 1991;54:1044 –1054.
risk of stroke in male physicians. Stroke. 1999;30:1– 6. 18. Hacke W, Kaste M, Fieschi C, Toni D, Lesaffre E, von Kummer R, et al.
4. Deplanque D, Masse I, Lefebvre C, Libersa C, Leys D, Bordet R. Prior Intravenous thrombolysis with recombinant tissue plasminogen activator
TIA, lipid-lowering drug use, and physical activity decrease ischemic for acute hemispheric stroke. The European Cooperative Acute Stroke
stroke severity. Neurology. 2006;67:1403–1410. Study (ECASS). JAMA. 1995;274:1017–1025.
5. Krarup LH, Truelsen T, Gluud C, Andersen G, Zeng X, Korv J, et al. 19. Weimar C, Kurth T, Kraywinkel K, Wagner M, Busse O, Haberl RL, et
Prestroke physical activity is associated with severity and long-term al. Assessment of functioning and disability after ischemic stroke. Stroke.
outcome from first-ever stroke. Neurology. 2008;71:1313–1318. 2002;33:2053–2059.
Physical Activity and Functional Outcomes From Cerebral Vascular Events in Men
Pamela M. Rist, I-Min Lee, Carlos S. Kase, J. Michael Gaziano and Tobias Kurth
doi: 10.1161/STROKEAHA.111.619544
Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 2011 American Heart Association, Inc. All rights reserved.
Print ISSN: 0039-2499. Online ISSN: 1524-4628
The online version of this article, along with updated information and services, is located on the
World Wide Web at:
http://stroke.ahajournals.org/content/42/12/3352
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published
in Stroke can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office.
Once the online version of the published article for which permission is being requested is located, click
Request Permissions in the middle column of the Web page under Services. Further information about this
process is available in the Permissions and Rights Question and Answer document.
1 time/wk 14275 72.6 522 68.6 0.88 302 70.4 0.99 483 68.2 0.89 164 68.1 0.91
(0.75, 1.04) (0.80, 1.22) (0.76, 1.05) (0.69, 1.20)
1 time/wk 10933 57.3 345 51.2 0.86 193 52.9 0.95 354 53.9 1.00 107 48.9 0.83
(0.73, 1.00) (0.77, 1.17) (0.85, 1.17) (0.64, 1.09)
Ischemic Stroke
Ischemic Stroke (n=674) (n=339) (n=590) (n=108)
<1 time/wk 8149 42.7 329 48.8 1.00 160 47.2 1.00 271 45.9 1.00 53 49.1 1.00
1 time/wk 10933 57.3 345 51.2 0.86 179 52.8 0.95 319 54.1 1.02 55 50.9 0.94
(0.73, 1.00) (0.76, 1.18) (0.86, 1.20) (0.64, 1.38)
Hemorrhagic Stroke
Hemorrhagic Stroke (n=25) (n=66) (n=107)
<1 time/wk 8149 42.7 NA NA NA 11 44.0 1.00 31 47.0 1.00 57 53.3 1.00
1 time/wk 10933 57.3 NA NA NA 14 56.0 1.04 35 53.0 0.91 50 46.7 0.75
(0.47, 2.32) (0.56, 1.49) (0.51, 1.10)
* CI denotes confidence interval. Men who exercised less than one time per week served as the reference category.
† Values have also been adjusted for age, smoking status, alcohol consumption, parental history of myocardial infarction before age
60, and randomized treatment assignment to aspirin and/or beta-carotene.
Online Table. Multivariable-adjusted odds ratios of functional outcomes after cerebral vascular events according to 108
month level of physical activity (N=19735). *
No TIA or TIA MRS 0-1 MRS 2-3 MRS 5-6
stroke
N % N % RR N % RR N % RR N % RR
(95% CI)† (95% CI)† (95% CI)† (95% CI)†
Total Stroke (n=542) (n=239) (n=524) (n=165)
<1 time/wk 7510 41.1 252 46.5 1.00 96 40.2 1.00 219 41.8 1.00 80 48.5 1.00
1 time/wk 10755 58.9 290 53.5 0.90 143 59.8 1.17 305 58.2 1.14 85 51.5 0.92
(0.75, 1.07) (0.90, 1.53) (0.95, 1.36) (0.67, 1.26)