title: Integrated care improves risk-factor modification after stroke: initial results of the Integrated Care for the Reduction of Secondary Stroke model Effectiveness of a shared team approach between nurses and doctors for improved risk factor management in survivors of stroke: a cluster randomized controlled trial Preventive effects of multiple domain interventions on lifestyle and risk factor changes in stroke survivors: Evidence from a two-year randomized trial Does telephone follow-up improve blood pressure after minor stroke or TIA? A randomized controlled trial to assess the psychosocial effects of early exercise engagement in patients diagnosed with transient ischaemic attack and mild, non-disabling stroke Impact of enhanced secondary prevention on health behaviour in patients following minor stroke and transient ischaemic attack: a randomized controlled trial Secondary Prevention of New Vascular Events with Lifestyle Intervention in Patients with Noncardioembolic Mild Ischemic Stroke: A Single-Center Randomized Controlled Trial A randomized trial testing the superiority of a postdischarge care management model for stroke survivors. Utility of a Post-Hospitalization Stroke Prevention Program Managed by Nurses Efficacy of a Chronic Care–Based Intervention on Secondary Stroke Prevention Among Vulnerable Stroke Survivors: A Randomized Controlled Trial
abstract: Objective : Despite evidence demonstrating that risk-factor management is effective in reducing recurrent cerebrovascular disease , there are very few structured care programmes for stroke survivors . The aim was to implement and evaluate an integrated care programme in stroke . Methods : 186 patients with stroke were r and omised to either the treatment ( integrated care ) or control ( usual care ) group and were followed up over 12 months . The Integrated Care for the Reduction of Secondary Stroke ( ICARUSS ) model of integrated care involved collaboration between a specialist stroke service , a hospital coordinator and a patient ’s general practitioner . The primary aim was to promote the management of vascular risk factors through ongoing patient contact and education . Results : In the 12 months poststroke , systolic blood pressure ( sBP ) decreased in the treatment group but increased in controls . The group difference was significant , and remained so when age , sex , disability and sBP at discharge were accounted for ( p = 0.04 ) . Treatment patients also exhibited better modification of body mass index ( p = 0.007 ) and number of walks taken ( p<0.001 ) than controls . Rankin scores indicated significantly reduced disability in treatment patients relative to controls in the year poststroke ( p = 0.003 ) . Conclusions : Through an integrated system of education , advice and support to both patient and GP , the ICARUSS model was effective in modifying a variety of vascular risk factors and therefore should decrease the likelihood or recurrent stroke or vascular event BACKGROUND AND PURPOSE Limited evidence exists on the benefits of organized care for improving risk factor control in patients with stroke or transient ischaemic attack . The effectiveness of an individualized management programme in reducing absolute cardiovascular disease risk in this high-risk population was determined . METHODS This was a prospect i ve , multicentre , cluster-r and omized controlled trial with blinded assessment of outcomes and intention-to-treat analysis . Patients hospitalized for stroke/transient ischaemic attack and aged ≥18 years were recruited from four hospitals . General practice s treating recruited patients were r and omized to provide either usual care or an individualized management programme comprising nurse-led education and review of care plans by stroke specialists in addition to usual care . The primary outcome was a change in cardiovascular Framingham Risk Score between baseline and 12 months . RESULTS From January 2010 to November 2013 , 156 general practice s ( 280 patients ) were r and omly assigned to usual care ( control ) and 159 ( 283 patients ) to the intervention . The median age was 70.1 years ; 65 % were male . Overall , > 80 % of participants were prescribed recommended secondary prevention therapies at baseline . The primary efficacy analysis comprised 533 participants , with 30 either dying or lost to follow-up . In adjusted analyses , no significant between-group difference was found in the cardiovascular risk score at 12 months ( 0.04 , 95 % confidence interval -1.7 , 1.8 ) . CONCLUSIONS The effectiveness of an organized secondary prevention programme for stroke may be limited in patients from high-performing hospitals with regular post-discharge follow-up and communication with general practice Background and aim Behavioral and lifestyle interventions in stroke patients need to be intense enough to result in sustainable treatment differences among groups of a r and omized trial . Therefore , we report the effects of multidomain interventions on lifestyle and laboratory parameters after 12 and 24 months from a trial that examined whether intensive risk factor management can prevent cognitive decline in ischemic stroke patients . Methods This prospect i ve r and omized , open-label , blinded endpoint trial recruited patients within three months after acute stroke in five Austrian neurological clinics during June 2010 and November 2012 . One hundred and one patients were r and omized into multidomain intervention and 101 into st and ard care . Lifestyle interventions were individualized to match predefined targets of regular physical activity , healthy diet , and adequate physiological risk factor control . Results A total of 167 participants ( 80 intervention , 87 control ) completed the 12-month visit and 155 ( 76 intervention , 79 control ) the 24-month visit . During the first 12 months , adherence to healthy lifestyle and adequately controlled physiological parameters ( measured by summary scores ) improved significantly in the intervention group compared to controls ( p < 0.01 ) . The consumption of reduced-fat milk ( p = 0.031 ) , reduced-fat spreads ( p = 0.007 ) , and fish ( p = 0.021 ) increased in the intervention group from baseline to 12 months but not in controls . After 24 months , the group difference was significant for the lifestyle summary score but no longer for the combined laboratory lifestyle score . Conclusions These results demonstrate that intensified individualized multidomain lifestyle interventions in stroke patients are effective in promoting healthy lifestyle in stroke care BACKGROUND hypertension is a common risk factor for stroke/transient ischaemic attack ( TIA ) and there is good evidence that blood pressure ( BP ) control prevents recurrent stroke . We investigated whether telephone follow-up ( TFU ) improved risk factor management in hypertensive patients after stroke/TIA . METHODS we conducted a r and omised controlled trial and assigned hypertensive patients within 1 month of stroke or TIA to receive usual care ( n = 27 ) or usual care plus regular TFU ( n = 29 ) . Primary outcome was the difference in 12 h ambulatory systolic BP change from baseline to 6 months ( DeltaSBP ) in both groups . TFU at 7 days , 1 , 2 and 4 months included patient-focussed education and goal setting . RESULTS mean baseline BP was 145/83 mm Hg ( st and ard deviation ( SD ) 21/14 ) . There was no significant difference in DeltaSBP over 6 months with TFU . Median DeltaSBP was 0 mm Hg ( interquartile range 19.5 ) in the TFU group and 3.0 mm Hg ( 20 ) fall in the usual care group ( P = 0.29 ) . Post hoc analysis showed that statin use increased from baseline to 6 months ( P = 0.02 ) and cholesterol was significantly lower at 6 months in all patients ( mean reduction 0.95 mmol/l ; P < 0.001 ) . CONCLUSION our study found TFU that promoted patient-led management of risk factors did not improve BP control over 6-month follow-up in primary care after stroke/TIA Objective : To examine the effect of an early exercise and education programme on psychosocial health of transient ischaemic attack ( TIA ) and mild , non-disabling stroke patients . Design : R and omized , parallel-group , clinical trial . Setting : Hospital and academic institution . Participants : A total of 55 newly diagnosed transient ischaemic attack/mild stroke patients ( Mean[SD ] ; 69[11]y ) . Intervention : Participants were r and omized to either an eight-week , twice weekly , 90-minute exercise and education programme ( experimental group ) or to a usual care control group . Main measures : Psychosocial measures ( SF-36 , Hospital Anxiety and Depression Scale , Profile of Mood States , International Physical Activity Question naire , Stroke Awareness Question naire ) were assessed at baseline and eight-week and 12-month follow-up . Results : The experimental group demonstrated improvements in the Physical Component Score ( Mean[SD ] ; 44.1[11.7 ] to 47.4[11.3]% ) , Vitality ( 46.5[12.4 ] to 54.2[14.2]% ) , Physical Functioning ( 45.6[10.7 ] to 51.9[14.7]% ) , Role Physical ( 38.7[10.8 ] to 43.1[13.6]% ) and Global Health ( 49.1[10.3 ] to 54.4[13.6]% ) from the SF-36 , at the eight-week follow-up assessment ( P < 0.05 ) . There were no further changes in these measures between the eight-week and 12-month follow-up assessment ( P > 0.05 ) . The experimental group demonstrated a greater awareness of the signs and symptoms associated with stroke ( P < 0.05 ) . There were no differences in the Mental Component Score ( SF-36 ) , the Hospital Anxiety and Depression Scale or the International Physical Activity Question naire between treatment groups ( P > 0.05 ) . Conclusion : Early engagement in an exercise and education programme may improve physical health perceptions in transient ischaemic attack/mild stroke patients . However , secondary prevention exercise and education programmes warrant further research with regards to their effects on perceptions of mental health in this population group Objective : To evaluate whether enhanced secondary prevention more significantly influences readiness to change health behaviour after minor stroke/transient ischaemic attack , compared with conventional stroke secondary prevention . Design : Single-blind r and omized control trial . Setting : Rural district general hospital outpatient clinic . Subjects : Fifteen women and 37 men with a mean age of 68.3 years with first minor stroke or transient ischaemic attack . Interventions : The intervention group received ‘ enhanced secondary prevention ’ ( additional advice , motivational interviewing and telephone support ) to change health behaviour . Both groups received ‘ conventional care ’ which included advice given during routine care . Main measures : The primary outcome was ‘ readiness to change behaviour ’ measured using a vali date d stroke specific score based on the transtheoretical model . Secondary outcomes were the Hospital Anxiety and Depression Scale , and self-reported alcohol consumption , smoking behaviour , exercise frequency , and fruit and vegetable consumption . Results : Analysis of the data for the 52 participants showed no statistical difference in the groups for the primary outcome of readiness to change behaviour . Statistically significant improvements for change in self-reported exercise were demonstrated ( P = 0.007 ) ; to 2—3 times per week in the intervention group compared to 0—1 times per week in the control group , and in fruit and vegetable consumption ( P = 0.033 ) ; to 10 portions of fruit and vegetables consumed per week in the intervention group compared to 1 or 2 portions a week for the control group . No evidence of a difference between groups was seen for alcohol consumption or Hospital Anxiety and Depression Scale . Conclusions : While no difference was demonstrated between the groups for readiness to change behaviour , a clinical ly significant effect in reported exercise behaviour and diet were demonstrated in the intervention group . This interesting finding indicates a dissonance between the behaviour scale and actual behaviour change , potentially indicating a lack of sensitivity of the scale to detect a change in this patient group Background : Lifestyle modification is associated with a substantially decreased risk of cardiovascular events . However , the role of lifestyle intervention for secondary prevention in patients with noncardioembolic ischemic stroke is inadequately defined . We assessed the hypothesis that lifestyle intervention can reduce the onset of new vascular events in patients with noncardioembolic mild ischemic stroke . Methods : We conducted an observer-blind r and omized controlled trial that enrolled 70 patients ( 48 men , mean age 63.5 years ) with acute noncardioembolic mild ischemic stroke . The patients were allocated in equal numbers to a lifestyle intervention group or a control group . We performed lifestyle interventions , which comprised exercise training , salt restriction and nutrition advice for 24 weeks . Then all patients were prospect ively followed up for occurrence of the primary endpoints , including hospitalization due to stroke recurrence and the onset of other vascular events . We also evaluated systolic blood pressure ( SBP ) at the clinic and at home , low-density lipoprotein cholesterol ( LDL-C ) , high-density lipoprotein cholesterol ( HDL-C ) , hemoglobin A1c ( HbA1c ) and high-sensitivity C-reactive protein ( hs-CRP ) to compare the efficacy of the lifestyle interventions . Results : This trial was terminated earlier than expected because of the prespecified early stopping rule for efficacy . After the 24-week intervention period , the intervention group showed a significant increase in daily physical activity and a significant decrease in salt intake ( physical activity , p = 0.012 ; salt intake , p < 0.001 ) , with a significant difference between the r and omized groups ( physical activity , p < 0.001 ; salt intake , p = 0.018 ) . Similarly , blood pressure was decreased and the HDL-C levels were increased in the intervention group ( SBP , p < 0.001 ; HDL-C , p = 0.018 ) , with significant differences between the r and omized groups ( SBP , p < 0.001 ; HDL-C , p = 0.022 ) . In contrast , LDL-C , HbA1c and hs-CRP tended to decrease in the intervention group , but this decrease did not achieve significance . After a median follow-up period of 2.9 years , 12 patients allocated to the control group and 1 patient in the lifestyle intervention group experienced at least 1 vascular event . A sequential plans analysis indicated the superiority of the lifestyle intervention in interim analysis . Kaplan-Meier survival curves after the log-rank test showed a significant prognostic difference between the r and omized groups ( p = 0.005 ) . Conclusions : Lifestyle intervention with appropriate medication is beneficial for reducing the incidence of new vascular events and improving vascular risk factors in patients with noncardioembolic mild ischemic stroke OBJECTIVE We sought to evaluate whether comprehensive postdischarge care management for stroke survivors is superior to organized acute stroke department care with enhanced discharge planning in improving a profile of health and well-being . METHODS This was a r and omized trial of a comprehensive postdischarge care management intervention for patients with ischemic stroke and National Institutes of Health Stroke Scale scores greater than or equal to 1 discharged from an acute stroke department . An advanced practice nurse performed an in-home assessment for the intervention group from which an interdisciplinary team developed patient-specific care plans . The advanced practice nurse worked with the primary care physician and patient to implement the plan during the next 6 months . The intervention and usual care groups were compared using a global and closed hypothesis testing strategy . Outcomes fell into 5 domains : ( 1 ) neuromotor function , ( 2 ) institution time or death , ( 3 ) quality of life , ( 4 ) management of risk , and ( 5 ) stroke knowledge and lifestyle . RESULTS Treatment effect was near 0 SD for all except the stroke knowledge and lifestyle domain , which showed a significant effect of the intervention ( P = .0003 ) . CONCLUSIONS Postdischarge care management was not more effective than organized stroke department care with enhanced discharge planning in most domains in this population . The intervention did , however , fill a postdischarge knowledge gap Abstract Goal : Evidence -based guidelines exist for the prevention and treatment of patients with cerebral ischemia . Despite these guidelines , there are gaps in clinical practice . Our study aim ed to determine if a physician-directed , nurse-case-management program could reduce individual patient vascular risk factors . Methods : Patients hospitalized with atherosclerotic cerebral ischemia with ≥ 1 major uncontrolled risk factor for stroke ( hypertension , tobacco use , dyslipidemia , diabetes ) were eligible to enroll in our study . Patients were r and omized to management by the nurse-prevention program or usual care .  Patients in the usual-care group received their initial risk-factor assessment and a scheduled follow-up at 1 year . Patients in the usual-care group underwent further follow-up by primary care and /or neurology as recommended during their hospitalization or outpatient visit . Patients assigned to the prevention group received individualized education , motivational interviewing , and were aided in setting up their risk-factor modification goal plan . Additional education was tailored to each patient based on individualized risk factors . Prevention-group patients also underwent consultation with a registered dietitian and an exercise physiologist . The primary endpoint of the study was improvement of ≥ 1 major patient risk factor for occurrence of stroke to goal at 1 year . Results : At 1-year post-hospitalization , patients in the nurse-care-management group were 42 % more likely to have met the primary endpoint ( n = 18 ; 61 % nurse-managed patients ) compared with 33 % ( n = 18 ) of patients undergoing usual care ( P = 0.09 ) . There was no significant reduction in minor risk factors for either patient group . Patients in the prevention group had greater reductions in low-density lipoprotein cholesterol levels ( −38 vs −4 ; P = 0.0083 ) , changes in cardiovascular risk score ( −5.2 vs 1.3 ; P = 0.0033 ) , and had a greater reductions in systolic blood pressure ( −12.2 vs −0.105 ; P = 0.07 ) than their usual-care counterparts ( changes shown respectively ) . Patients in the prevention group were more likely to follow a prescribed diet than those in the usual-care group ( 50 % ) vs 7 % , respectively ; P = 0.0070 ) and maintain an exercise program ( 83 % vs 33 % , respectively ; P = 0.0018 ) . Summary : A physician-directed , nurse case-management system for patients post-hospitalization for cerebral ischemia is feasible and may help improve long-term control of major patient risk factors for stroke . A larger trial is needed to verify trends noted in our study Background : Disparities of care among stroke survivors are well documented . Effective interventions to improve recurrent stroke preventative care in vulnerable population s are lacking . Methods and Results : In a r and omized controlled trial , we tested the efficacy of components of a chronic care model – based intervention versus usual care among 404 subjects having an ischemic stroke or transient ischemic attack within 90 days of enrollment and receiving care within the Los Angeles public healthcare system . Subjects had baseline systolic blood pressure ( SBP ) ≥120 mm Hg .  The intervention included a nurse practitioner/physician assistant care manager , group clinics , self-management support , report cards , decision support , and ongoing care coordination . Outcomes were collected at 3 , 8 , and 12 months , analyzed as intention-to-treat , and used repeated- measures mixed-effects models . Change in SBP was the primary outcome . Low-density lipoprotein reduction , antithrombotic medication use , smoking cessation , and physical activity were secondary outcomes . Average age was 57 years ; 18 % were of black race ; 69 % were of Hispanic ethnicity . Mean baseline SBP was 150 mm Hg in both arms . SBP decreased to 17 mm Hg in the intervention arm and 14 mm Hg in the usual care arm ; the between-arm difference was not significant ( −3.6 mm Hg ; 95 % confidence interval , −9.2 to 2.2 ) . Among secondary outcomes , the only significant difference was that persons in the intervention arm were more likely to lower their low-density lipoprotein < 100 md/dL ( 2.0 odds ratio ; 95 % confidence interval , 1.1–3.5 ) . Conclusions : This intervention did not improve SBP control beyond that attained in usual care among vulnerable stroke survivors . A community-centered component could strengthen the intervention impact . Clinical Trial Registration : URL : https:// clinical trials.gov . Unique identifier : NCT00861081
target: The overall best evidence syntheses showed moderate quality evidence that lifestyle interventions do not lead to significant improvements in the physical activity level of people with stroke or TIA .
  There is low quality evidence that lifestyle interventions that specifically target physical activity are effective at improving the levels of physical activity of people with stroke or TIA .
  Based on the results of this review , general lifestyle interventions on their own seem insufficient in improving physical activity levels after stroke or TIA .
  Lifestyle interventions that specifically encourage increasing physical activity may be more effective .
background: Insufficient amounts of physical activity is a risk factor for ( recurrent ) stroke .
  People with a stroke or transient ischemic attack ( TIA ) have a high risk of recurrent stroke and have lower levels of physical activity than their healthy peers .
  Though several review s have looked at the effects of lifestyle interventions on a number of risk factors of recurrent stroke , the effectiveness of these interventions to increase the amounts of physical activity performed by people with stroke or TIA are still unclear .
  Therefore , the research question of this study was : what is the effect of lifestyle interventions on the level of physical activity performed by people with stroke or TIA ?