Level of physical activity in the week preceding an ischemic stroke

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1 Dnish University Colleges Level of physicl ctivity in the week preceding n ischemic stroke Lindhl, Mrinne Pi; Krrup LH, Truelsen T, Pedersen A, Lerke H, Lindhl M, Hnsen L, Schrling H, Boysen G. Published in: Cerebrovsculr Diseses Publiction dte: 2007 Document Version Pre-print: Det originle mnuskript indsendt til udgiveren. Artiklen hr endnu ikke gennemgået peer-review (fgfællebedømmelse) og redigering. Link to publiction Cittion for pulished version (APA): Krrup LH, Truelsen T, Pedersen A, Lerke H, Lindhl M, Hnsen L, Schrling H, Boysen G. (2007). Level of physicl ctivity in the week preceding n ischemic stroke. Cerebrovsculr Diseses, 24, Generl rights Copyright nd morl rights for the publictions mde ccessible in the public portl re retined by the uthors nd/or other copyright owners nd it is condition of ccessing publictions tht users recognise nd bide by the legl requirements ssocited with these rights. Users my downlod nd print one copy of ny publiction from the public portl for the purpose of privte study or reserch. You my not further distribute the mteril or use it for ny profit-mking ctivity or commercil gin You my freely distribute the URL identifying the publiction in the public portl Downlod policy If you believe tht this document breches copyright plese contct us providing detils, nd we will remove ccess to the work immeditely nd investigte your clim. Downlod dte: 23. Nov. 2017

2 Originl Pper Cerebrovsc Dis 2007;24: DOI: / Received: Jnury 22, 2007 Accepted: Mrch 22, 2007 Published online: July 17, 2007 Level of Physicl Activity in the Week Preceding n Ischemic Stroke Lrs-Henrik Krrup Thoms Truelsen Anders Pedersen Hnne Lerke Mrinne Lindhl Lotte Hnsen Peter Schnohr b Gudrun Boysen Deprtment of Neurology nd b The Copenhgen City Hert Study, Bispebjerg University Hospitl, Copenhgen, Denmrk Key Words Ischemic stroke Physicl Activity Scle for the Elderly Physicl ctivity Abstrct Bckground: Most observtionl studies investigting physicl ctivity s risk fctor for stroke hve concentrted on the yers preceding stroke event. In the present cse control study we compred the reported level of physicl ctivity performed during the week preceding n ischemic stroke with tht of community controls. Furthermore we clculted the odds rtio for stroke bsed on the level of physicl ctivity. Subjects nd Methods: Ptients with n ischemic stroke were recruited consecutively from hospitls covering Copenhgen City. Community controls were recruited mong prticipnts of the Copenhgen City Hert Study nd mtched ccording to ge nd gender. The level of physicl ctivity ws ssessed using The Physicl Activity Scle for the Elderly (PASE), which quntifies the mount of physicl ctivity done in the lst 7 dys. Results: A totl of 127 cses nd 301 control subjects were included in the study. Men ( 8 SD) PASE scores for cses were nd for controls (p! 0.001). For ech 1-point increse in PASE score the odds rtio for ischemic stroke ws 0.98 ( ), equivlent to n odds rtio of 0.86 (95% CI: ) for ech 10-point increse. Conclusion: Stroke ptients re less physiclly ctive in the week preceding n ischemic stroke when compred to ge- nd sex-mtched controls. Incresing PASE score ws inversely, log-linerly nd significntly ssocited with odds rtio for ischemic stroke. Copyright 2007 S. Krger AG, Bsel Introduction The beneficil effects of physicl ctivity on mjor stroke risk fctors re well documented. Physicl ctivity reduces hypertension, type 2 dibetes mellitus, improves metbolism, nd hs been linked to direct beneficil chnges of the vsculr system [1 6]. The impct on mjor stroke risk fctors my explin why physicl ctivity is ssocited with reduced occurrence of stroke nd other crdiovsculr diseses. Regulr exercise hs been recommended both for the prevention of crdiovsculr disese nd in stroke survivors [7, 8]. A newly published met-nlysis showed tht physicl inctivity is stroke risk fctor [9]. Most studies hve concentrted on physicl ctivity in the yers preceding n ischemic stroke event. One study exmined the level of physicl ctivity 2 weeks prior to n ischemic stroke event nd compred to community controls [10]. The results showed tht the percentges of stroke ptients tht were inctive were substntilly higher when compred to community controls [10]. The im of the present study ws to evlute Fx E-Mil krger@krger.ch S. Krger AG, Bsel /07/ $23.50/0 Accessible online t: Lrs-Henrik Krrup, MD Bispebjerg University Hospitl Bispebjerg Bkke 23 DK 2400 Copenhgen NV (Denmrk) Tel , Fx , E-Mil lh.krrup@gmil.com

3 the level of physicl ctivity in the week preceding n ischemic stroke nd to compre it with ge- nd sexmtched community controls. In ddition we clculted odds rtio for ischemic stroke bsed on the level of physicl ctivity. Subjects nd Methods Selection of Cses nd Control Subjects Ptients were recruited consecutively when dmitted to stroke units t one of the five hospitls covering centrl Copenhgen, Denmrk. These deprtments receive ll subjects dmitted with suspected cute stroke living in the ctchment re. The inclusion period lsted from August 12th, 2003 to April 1st, Inclusion criteri were s follows: ischemic stroke comptible with CT scns in ptients ged 40 yers or older. Ptients with trnsient ischemic ttck in whom the scn showed signs of infrction were not included in the study. Ptients were excluded if they hd other types of stroke thn ischemic, if they could not cooperte with the exmintions, or if they hd previously been enrolled. Verbl nd written informed consent ws obtined from the ptient. This study ws pproved by the locl ethic committee, (KF) /04. Community control subjects were rndomly recruited mong prticipnts in the Copenhgen City Hert Study, which hs been described in detil elsewhere [11]. Briefly, 19,698 people living in the Copenhgen res Østerbro nd Nørrebro were chosen rndomly within ge nd sex strt, nd invited by letter to four helth exmintions held in , , , nd Prticipnts t the fourth exmintion were gend sex-mtched to cses in the present study. As reported, level of physicl ctivity vries ccording to seson; controls were selected for every 50 cses enrolled. Questionnires were sent by mil within 1 week from the dte of selection. A totl of 510 subjects were contcted nd response ws received from 335 (65.6%). Physicl Activity Assessment The subjects physicl ctivity level ws mesured using the Physicl Activity Scle for the Elderly (PASE) [12, 13]. The PASE questionnire ws developed with the purpose of ssessing level of physicl ctivity in middle-ged nd elderly individuls. The questionnire is 12-item scle tht mesures the verge number of hours per dy spent on prticipting in sports, occuptionl ctivity, household ctivities, nd leisure time ctivities over 1- week period. The PASE scoring lgorithm ws derived from physicl ctivity mesured by movement counts from n electronic physicl ctivity monitor, ctivity diries, nd self-ssessed ctivity levels in generl popultion of noninstitutionlized persons. PASE hs been vlidted in helthy subjects [14, 15], people with disbilities [16] nd sedentry subjects [12, 17]. Men PASE score rnged from in the vlidting studies. The PASE questionnire hs vlidity in line with other physicl ctivity questionnires [18]. Physicl ctivity in ptients referred to the week before onset of stroke symptoms, wheres in controls it referred to the week before responding to the questionnire. S t t i s t i c s Due to incomplete questionnires 34 control subjects nd 17 cse subjects were excluded from the finl nlyses. Comprison of ctegoricl vribles ws done using 2 sttistics nd ordinl vribles were nlyzed using Kruskl-Wllis sttistics corrected for ties. Continuous vribles were trnsformed to presumed normlity nd compred using the two-smple t test. Subjects were divided into four ctegories ccording to their totl PASE score: 0 49; 50 99; nd Multivrite conditionl logistic regression for mtched dt ws used to clculte the odds rtio nd 95% confidence intervls for the ssocition between physicl ctivity nd ischemic stroke. Interctions nd tests for linerity of continuous vribles were done using log likelihood rtio tests in the multivrite model. The difference in men PASE score for ssessing interview bis ws tested using pired t test. The sttisticl softwre progrm STATA version 9.2 ws used for ll clcultions. The level of 5% ws considered sttisticlly significnt. R e s u l t s A totl of 127 ptients nd 301 control subjects were included in the finl nlyses. Women ccounted for 48% of cses nd 45% of controls. Men ge for cses ws 71.8 yers nd 71.5 yers for controls. Men ( 8 SD) PASE score ws for cses nd for controls (p! 0.001, tble 1 ). Cses hd significntly higher incidence of history of stroke, history of tril fibrilltion nd higher body mss index but not of history of myocrdil infrction or history of dibetes mellitus. Cses hd lower level of eduction nd were more often current smokers thn controls. Men ( 8 SD) PASE score for cses (n = 81) nd controls (n = 246) without ny of the following risk fctors history of stroke, history of myocrdil infrction, history of dibetes mellitus nd history of tril fibrilltion ws nd (p! 0.001), respectively. Subgroup nlyses of men nd women seprtely did not lter results significntly. The ssocition between PASE score nd ischemic stroke is presented in tble 2. Both in univrite nd multivrite nlyses incresing PASE score ws inversely ssocited with odds rtio for ischemic stroke. The ssocition ws significnt in ll ctegories except for PASE scores from 50 to 99 in the multivrite nlysis. There ws no significnt difference between the nlyses with PASE score entered either in four ctegories or s continuous vrible ( 2 = 0.81, 2 d.f.; p = 0.67). When entered s continuous vrible odds rtio for ech 1-score increse in PASE ws 0.98 (95% confidence intervl: ) equivlent to 0.86 (95% confidence intervl: ) for ech 10-point increse. There were only minor differences in the estimtes for Level of Physicl Activity before Ischemic Stroke Cerebrovsc Dis 2007;24:

4 Tble 1. Bseline chrcteristics for ptients with ischemic stroke nd control subjects Chrcteristics Cses (n = 127) Controls (n = 301) p vlue Age, yers NS Gender Men 66 (52.0%) 164 (54.5%) NS PASE score <0.001 PASE (ctegoricl) < (24%) 30 (10%) (46%) 103 (34%) (24%) 92 (31%) (6%) 76 (25%) Yers of eduction < yers 67 (53%) 138 (46%) 9 12 yers 47 (37%) 93 (31%) 13 yers 13 (10%) 70 (23%) Body mss index <0.01 <20 10 (8%) 9 (3%) (48%) 110 (37%) (32%) 133 (44%) >30 15 (12%) 49 (16%) Smoking <0.05 Never 30 (24%) 83 (28%) Ex-smoker 46 (36%) 137 (46%) Current smoker 51 (40%) 81 (27%) Dibetes mellitus 0.20 Yes 14 (11%) 19 (6%) No 113 (89%) 282 (94%) History of stroke <0.001 Yes 26 (20%) 12 (4%) No 101 (80%) 289 (96%) History of myocrdil infrction 0.60 Yes 9 (7%) 27 (9%) No 118 (93%) 274 (91%) Atril fibrilltion <0.01 Yes 12 (9%) 9 (3%) No 115 (91%) 292 (97%) Intke of lcohol units 0.98 Not drinking 24 (19%) 58 (19%) 1 14(women)/1 21 (men) 83 (65%) 196 (65%) >14 (women)/>21 men 20 (16%) 47 (16%) Systolic blood pressure, mm Hg <0.001 Number nd percent of subjects re given except for ge, PASE score nd systolic blood pressure (men 8 SD). p vlues re clculted for overll dt. men nd women nd interction nlyses were insignificnt ( 2 = 0.45, 1 d.f.; p = 0.50). Bi s A previous study hs shown tht the PASE score is often higher when subjects provide informtion on physicl ctivity by self-dministered questionnires compred to being interviewed [13]. We therefore exmined the possible bis due to differences in interview methods by contcting subsmple of 72 rndomly selected controls by telephone nd sked them the sme physicl ctivity questions. The men PASE score ws ccording to the self-reported dt nd when the sme subjects where interviewed by telephone (p = 0.13). As the difference ws not significnt, nd the difference ws only 7%, the originl dt derived from the control subjects were used without further djustment. Physiclly ctive subjects my be more likely to respond to questionnire 298 Cerebrovsc Dis 2007;24: Krrup /Truelsen /Pedersen /Lerke / Lindhl /Hnsen /Schnohr /Boysen

5 Tble 2. Odds rtio for the risk of ischemic stroke relted to physicl ctivity PASE score Univrite Multivrite reference group reference group ( ) 0.53 ( ) ( ) 0.27 ( ) ( ) 0.09 ( ) 1 Multivrite nlyses djusted for systolic blood pressure, history of stroke, history of myocrdil infrction, tril fibrilltion, dibetes mellitus, lcohol consumption, yers of eduction, body mss index nd tobcco smoking. bout exercise thn less physiclly ctive subjects. A totl of 510 control subjects were contcted nd we received response from 335 (65.6%), lthough only 301 were included in the finl nlyses due to missing vlues. Discussion The present study showed tht physicl ctivity in the week preceding n ischemic stroke is significntly lower thn in community controls nd tht physicl ctivity ws inversely nd log-linerly ssocited with odds rtio for ischemic stroke. Our results my reflect tht stroke ptients re prone to sedentry lifestyle or tht stroke ptients hve incpcitting comorbidities prior to stroke. In fvor of the former is tht subgroup nlyses excluding cses nd controls with risk fctors still showed significntly higher PASE score in controls. In fvor of the ltter is the higher rte of history of stroke, tril fibrilltion, smoking, higher body mss index nd higher blood pressure observed in cses. A lower level of eduction might lso contribute. Physicl inctivity is well-estblished risk fctor for crdiovsculr disese nd stroke. A met-nlysis hs shown tht physicl exercise cn reduce mortlity in ptients with coronry hert disese (odds rtio: 0.80; 95% confidence intervl: ) [19]. After nondisbling stroke it is common to see fluctution nd sustined decline in physicl performnce [20]. Physicl ctivity is recommended for stroke survivors but so fr it hs not been studied if physicl ctivity reduces mortlity or the risk of recurrent stroke in stroke survivors. In review of 38 rndomized studies, ll with the gol of getting older people to exercise, it ws not possible to identify which interventions were most effective [21]. The chnges in physicl ctivity were smll nd short-lived. In order to decrese the risk of recurrent stroke through exercise stroke survivors need to continue to exercise fter initil rehbilittion. Therefore specific intervention progrms need to be developed nd tested in rndomized settings in order to demonstrte the presumed beneficil effects of physicl ctivity. The level of physicl ctivity differs ccording to seson [13]. To ccount for this possible bis control subjects were interviewed within few weeks fter the cse subjects were enrolled in the study. We lso ssessed the difference in PASE score between self-reported PASE score nd PASE score obtined by interview in subsmple of controls. This nlysis showed tht the score ws mrginlly lower when the person ws interviewed s compred to self-reported physicl ctivity. Although the difference ws mrginl nd not significnt the interview method is likely to hve bised the results towrds higher level of physicl ctivity in control subjects compred with cse subjects. However, the difference in men PASE score fr exceeded the difference due to interview method. There is evidence to suggest tht prestroke dementi is present in 15% of stroke popultion [22]. In the present study we hve not ssessed cognitive function. A decline in cognitive performnce is likely to reduce the level of physicl ctivity performed by the individul. We cnnot exclude tht some of the difference in PASE score found in this study might be due to difference in cognitive function. Controls were recruited mong prticipnts in the fourth exmintion of the Copenhgen City Hert Study, nd two thirds responded. It is possible tht some selection bis ws introduced, s helthier subjects re more likely to respond thn nonhelthy subjects. Recll bis will most likely ffect the results towrds higher scores but s both cses nd controls were sked to remember week bck in time recll bis is thought to ply similr role in the two groups. In conclusion our findings suggest tht ptients prior to stroke hve low level of physicl ctivity nd tht the level of physicl ctivity ws inversely nd log-linerly ssocited with odds rtio for ischemic stroke. Subgroup nlyses of men nd women seprtely nd in cses nd controls without ny prespecified risk fctors did not lter results significntly. Level of Physicl Activity before Ischemic Stroke Cerebrovsc Dis 2007;24:

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