Skip to main content

Advertisement

Table 13 Studies examining the relationship between physical activity and stroke.

From: A systematic review of the evidence for Canada's Physical Activity Guidelines for Adults

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   
  1. 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.