title: Integrated care improves risk-factor modification after stroke: initial results of the Integrated Care for the Reduction of Secondary Stroke model ExStroke Pilot Trial of the effect of repeated instructions to improve physical activity after ischaemic stroke: a multinational randomised controlled clinical trial Effects of a web-based stroke education program on recurrence prevention behaviors among stroke patients: a pilot study. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials Feasibility, safety and efficacy of an early aerobic rehabilitation program for patients after minor ischemic stroke: A pilot randomized controlled trial. A lifestyle intervention as supplement to a physical activity programme in rehabilitation after stroke: a randomized controlled trial The effectiveness of personalized coronary heart disease and stroke risk communication. A pilot randomized controlled trial to evaluate the benefit of the cardiac rehabilitation paradigm for the non-acute ischaemic stroke population Secondary prevention and health promotion after stroke: can it be enhanced? Does behaviour modification affect post-stroke risk factor control? Three-year follow-up of a randomized controlled trial The cardiac model of rehabilitation for reducing cardiovascular risk factors post transient ischaemic attack and stroke: a randomized controlled trial Effectiveness of a postdischarge care management model for stroke and transient ischemic attack: a randomized trial. A preliminary study to examine the effects of aerobic and therapeutic (nonaerobic) exercise on cardiorespiratory fitness and coronary risk reduction in stroke survivors. Impact of enhanced secondary prevention on health behaviour in patients following minor stroke and transient ischaemic attack: a randomized controlled trial Blood pressure 1 year after stroke: the need to optimize secondary prevention. Secondary Prevention of New Vascular Events with Lifestyle Intervention in Patients with Noncardioembolic Mild Ischemic Stroke: A Single-Center Randomized Controlled Trial Use of the six-minute walk test poststroke: is there a practice effect? Implementation of a stroke self-management program A randomized trial testing the superiority of a postdischarge care management model for stroke survivors. Effects of early exercise engagement on vascular risk in patients with transient ischemic attack and nondisabling stroke. Exercise capacity early after stroke. Effects of an individualized multimedia computer program for health education in patients with a recent minor stroke or transient ischemic attack – a randomized controlled trial Impact of Treadmill Exercise on Efficacy Expectations, Physical Activity, and Stroke Recovery Long-term survival and vascular event risk after transient ischaemic attack or minor ischaemic stroke: a cohort study The influence of early aerobic training on the functional capacity in patients with cerebrovascular accident at the subacute stage. Gait outcomes after acute stroke rehabilitation with supported treadmill ambulation training: a randomized controlled pilot study. Utility of a Post-Hospitalization Stroke Prevention Program Managed by Nurses The impact of stroke nurse specialist input on risk factor modification: a randomised controlled trial. Physiological outcomes of aerobic exercise training in hemiparetic stroke patients. Effects of an Aerobic Exercise Program on Aerobic Capacity, Spatiotemporal Gait Parameters, and Functional Capacity in Subacute Stroke
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 Objectives To investigate if repeated verbal instructions about physical activity to patients with ischaemic stroke could increase long term physical activity . Design Multicentre , multinational , r and omised clinical trial with masked outcome assessment . Setting Stroke units in Denmark , China , Pol and , and Estonia . Participants 314 patients with ischaemic stroke aged ≥40 years who were able to walk—157 ( mean age 69.7 years ) r and omised to the intervention , 157 ( mean age 69.4 years ) in the control group . Interventions Patients r and omised to the intervention were instructed in a detailed training programme before discharge and at five follow-up visits during 24 months . Control patients had follow-up visits with the same frequency but without instructions in physical activity . Main outcome measures Physical activity assessed with the Physical Activity Scale for the Elderly ( PASE ) at each visit . Secondary outcomes were clinical events . Results The estimated mean PASE scores were 69.1 in the intervention group and 64.0 in the control group ( difference 5.0 ( 95 % confidence interval −5.8 to 15.9 ) , P=0.36 . The intervention had no significant effect on mortality , recurrent stroke , myocardial infa rct ion , or falls and fractures . Conclusion Repeated encouragement and verbal instruction in being physically active did not lead to a significant increase in physical activity measured by the PASE score . More intensive strategies seem to be needed to promote physical activity after ischaemic stroke . Trial registration Clinical Trials The effectiveness of methods to prevent stroke recurrence and of education focusing on learners ' needs has not been fully explored . The aims of this study were to assess the effects of such interventions among stroke patients and their primary caregivers and to evaluate the feasibility of a web-based stroke education program . The participants were 36 patients with a clinical diagnosis of ischemic stroke within 12 months post-stroke and their primary caregivers . The participants were r and omly assigned to either an experimental or a control group . The primary measures included blood chemistry , self-reported health behaviors , sense of control , and health motivation for stroke patients , and caregiver mastery for caregivers . To test the feasibility of the intervention program , the rates of participation and occurrence of technical problems were calculated . The experimental group tended to improve significantly more than the control group in terms of exercise , diet , sense of control and health motivation for the stroke patients and in terms of caregiver mastery for the primary caregivers . The rate of participation in the web-based program was 63.1 % . This program , which focuses on recurrence prevention in stroke patients and caregivers , has the potential to improve health behaviors for stroke patients Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more OBJECTIVE To examine the feasibility , safety and effectiveness of an early aerobic rehabilitation program for patients after minor ischemic stroke . DESIGN R and omized control trial . METHODS Twenty-eight patients , 1 - 3 weeks post minor ischemic stroke ( modified Rankin scale ; mRS ≤ 2 ) , were r and omly assigned to intervention or control groups . Measures were taken at weeks 1 and 6 . All participants were instructed in home practice to achieve strength and flexibility , and were asked to continue their normal community routine . Intervention group participants performed a supervised exercise training program twice a week for 6 weeks .  Exercise capacity was evaluated by the 6-minute walk distance test ( 6MWD ) , and the modified Bruce treadmill test . RESULTS Eight subjects out of 14 participated in all 12 training sessions , one at less than 50 % of the sessions , while five reached the highest stage of the program . No adverse events were noted during the intervention period . In the intention to treat analysis a significant improvement over time was seen for the functional parameters only . No interaction ( group*time ) was found . According to the per protocol analysis a significant interaction effect was found ; only the intervention group participants showed a significant clinical change in the 6MWD test ( 412 ± 178 meters to 472 ± 196 meters , vs the control group 459 ± 116 meters to 484 ± 122 meters , p < 0.01 ) . CONCLUSIONS An early supervised aerobic training after minor ischemic stroke is feasible and well tolerated and , in a per- protocol analysis , was associated with improved walking endurance . Further studies with a larger sample size are needed to assess the effect of such a program on functional abilities , prevention of risk factors , and recurrent stroke Objective : To evaluate the effectiveness of lifestyle group intervention on well-being , occupation and social participation . Design : A r and omized controlled trial . Setting : Senior centres in the community . Subjects : Of 204 stroke survivors screened , 99 ( 49 % ) were r and omized three months after stroke whereby 86 ( 87 % ) participants ( mean ( SD ) age 77.0 ( 7.1 ) years ) completed all assessment s ( 39 in the intervention group and 47 in the control group ) . Intervention : A lifestyle course in combination with physical activity ( intervention group ) compared with physical activity alone ( control group ) . Both programmes were held once a week for nine months . Main outcome measure : The Short Form Question naire ( SF-36 ) , addressing well-being and social participation . Assessment s were performed at baseline and at nine months follow-up . Results : We found no statistically significant differences between the groups at the nine months follow-up in the SF-36 . Adjusted mean differences in change scores in the eight subscales of SF-36 were ; ‘ mental health ’ ( + 1.8 , 95 % confidence interval ( CI ) –4.0 , + 7.6 ) , ‘ vitality ’ ( −3.0 , 95 % CI −9.6 , + 3.6 ) , ‘ bodily pain ’ ( + 3.3 , 95 % CI −7.8 , + 14.4 ) , ‘ general health ’ ( −1.6 , 95 % CI −8.4 , + 5.1 ) , ‘ social functioning ’ ( −2.5 , 95 % CI −12.8 , + 7.8 ) , ‘ physical functioning ’ ( + 1.0 , 95 % CI −6.7 , + 8.6 ) , ‘ role physical ’ ( −7.1 , 95 % CI −22.7 , + 8.4 ) , ‘ role emotional ’ ( + 11.8 , 95 % CI −4.4 , + 28.0 ) . Conclusions : Improvements were seen in both groups , but no statistically significant differences were found in the intervention group compared to controls . An intervention comprising regular group-based activity with peers may be sufficient in the long-term rehabilitation after stroke BACKGROUND Current guidelines recommend global risk assessment to guide vascular risk factor management ; however , most provider-patient communication focuses on individual risk factors in isolation . We sought to evaluate the impact of personalized coronary heart disease and stroke risk communication on patients ' knowledge , beliefs , and health behavior . METHODS We conducted a r and omized controlled trial testing personalized risk communication based on Framingham stroke and coronary heart disease risk scores compared with a st and ard risk factor education . A total of 89 patients were recruited from primary care clinics and followed up for 3 months . Outcomes included the following : risk perception and worry , risk factor knowledge , risk reduction preferences and decision conflict , medication adherence , health behaviors , and blood pressure . RESULTS Participants had a very low underst and ing of numeric information , high perceived risk for stroke or myocardial infa rct ion , and high proportion of medication nonadherence . Patients ' ability to identify vascular risk factors increased with personalized risk communication ( mean 1.8 additional risk factors , 95 % CI 1.3 - 2.2 ) and st and ard risk factor education ( mean 1.6 additional risk factors , 95 % CI 1.1 - 2.1 ) immediately after the intervention but was not sustained at 3 months . Patients in the personalized group had less decision conflict than the st and ard risk factor education group over intended risk reduction strategies ( 5.9 vs 10.1 , P = .003 ) . There was no appreciable impact of either communication strategy on medication adherence , exercise , smoking cessation , or blood pressure . CONCLUSIONS Personalized risk communication was preferred by patients and had a small impact on risk reduction preferences and decision conflict but had no impact on patient beliefs or behavior compared with st and ard risk factor education Objective : To evaluate risk factor reduction and health-related quality of life following a 10-week cardiac rehabilitation programme in non-acute ischaemic stroke subjects . Design : Single-blinded r and omized control trial . Setting : Outpatient rehabilitation . Subjects : Forty-eight community-dwelling ischaemic stroke patients ( 38 independently mobile , 9 requiring assistance , 1 non-ambulatory ) were r and omly assigned to intervention or control groups by concealed allocation . Intervention : The trial consisted of a 10-week schedule with measures taken at weeks 1 and 10 . Both groups continued usual care ( excluding aerobic exercise ) ; intervention subjects attended 16 cycle ergometry sessions of aerobic-training intensity and two stress-management classes . Main outcome measures : Cardiac risk score ( CRS ) ; VO2 ( mL O2/kg per minute ) and Borg Rate of Perceived Exertion ( RPE ) assessed during a st and ardized ergometry test ; Hospital Anxiety and Depression Scale ( HADS ) ; Frenchay Activity Index ; Fasting Lipid Profiles and Resting Blood Pressure . Results : Group comparison with independent t-tests showed significantly greater improvement at follow-up by intervention subjects than controls in VO2 ( intervention 10.6 ±1.6 to 12.0 ± 2.2 , control 11.1 ±1.8 to 11.1 ±1.9 t=4.734 , P<0.001 ) and CRS ( intervention 13.4 ±10.1 to 12.4 ±10.5 , control 9.4 ±6.7 to 15.0 ±6.1 t=-2.537 , P<0.05 ) . RPE rating decreased in intervention subjects ( 13.4 ±12.2 to 12.4 ±2.0 ) and increased in controls ( 13.8 ±1.8 to 14.4 ±1.6 ) ; Mann — Whitney U ( U = 173.5 , P<0.05 ) . Within-group comparison showed significant decrease in the HADS depression subscale in the intervention group alone ( 5.1 ±3.4 to 3.0 ±2.8 ) ( Wilcoxon signed ranks test Z=-3.278 , P<0.001 ) . Conclusion : Preliminary findings suggest non-acute ischaemic stroke patients can improve their cardiovascular fitness and reduce their CRS with a cardiac rehabilitation programme . The intervention was associated with improvement in self-reported depression The aim was to study if health outcome and secondary prevention were satisfactory 1 year after stroke and if nurse-led interventions 3 months after stroke could have impact . Design was a r and omized controlled open trial in a 1-year population . Primary outcome was health status 1 year after stroke . One month after stroke , survivors were r and omized into  intervention group ( IG ) with follow-up by a specialist nurse ( SN ) after 3 months ( n = 232 ) , and control group ( CG ) with st and ard care ( n = 227 ) , all to be followed up 1 year after stroke . At the first follow-up , patients grade d their health , replied to the EuroQol-5 Dimensions ( EQ-5D ) health outcome questions , health problems were assessed , and supportive counseling was provided in the IG . Health problems requiring medical interventions were primarily referred to a general practitioner ( GP ) . One year after stroke , 391 survivors were followed up . Systolic blood pressure ( BP ) had decreased in IG ( n = 194 ) from median 140 to 135 ( P = .05 ) , but about half were above the limit 139 in both groups . A larger proportion ( 22 % ) had systolic BP > 155 in the CG ( n = 197 ) than in the IG ( 14 % ; P = .05 ) . In the IG , 62 % needed referrals compared with the 75 % in the CG ( P = .009 ) . Forty percent in the IG and 52.5 % in the CG ( P = .04 ) reported anxiety/depression . In the IG , 75 % and 67 % in the CG rated their general health as fairly good or very good ( P = .05 ) . Although nurse-led interventions could have some effect , the results were not optimal . A more powerful strategy could be closer collaboration between the SN and a stroke clinician , before referring to primary care Objective : Little is known about the long-term effectiveness after stroke of interventions for behaviour modification and ensuring concordance with therapies . We describe a follow-up study of a previous r and omized controlled trial of a brief period of behaviour modification . The aim of this study was to determine outcomes three years after the initial intervention . Design : Survivors of the original cohort were contacted and asked to attend for follow-up interview , within a geriatric day hospital . This study was carried out in the Geriatric Day Hospital at Stobhill Hospital , Balornock Road , Glasgow . Interventions : Details of risk factor control , including blood pressure , cholesterol levels and diabetic control , were assessed . Question naires used in the initial study were repeated including the Geriatric Depression Scale score , Euroqol Perceived Health Status and Stroke Services Satisfaction Question naire . Main measures : Primary outcome was collective risk factor control . Clinical outcomes including recurrent cerebrovascular events , medication persistence and perceived health status were also recorded . Results : Mean length of follow-up was 3.6 years ( SD 0.43 ) . Of the 205 patients enrolled in the initial study , 102 patients attended for repeat interview ( 49 intervention/53 control ) . There were no significant differences in the percentage of controlled risk factors between groups ( intervention 51.7 % versus control 55.9 % , P = 0.53 ) . Similarities were observed in the number of recurrent clinical events and medication persistence between groups . No overall difference was observed in perceived health status , satisfaction with care or depression scores . Conclusions : Brief intervention with respect to behaviour modification and risk factor control does not appear to have any long-term benefit . These results must be cautiously interpreted in light of the small study number and further research is required Objective : To evaluate the feasibility and effectiveness of a st and ard National Health Service cardiac rehabilitation programme on risk factor reduction for patients after a minor stroke and transient ischaemic attack . Design : Single-blind r and omized controlled trial . Setting : Cardiac rehabilitation classes . Subjects : Twenty-four patients . Intervention : All participants received st and ard care . In addition , the intervention group undertook an eight-week cardiac rehabilitation programme consisting of weekly exercise and education classes . Outcome measures : Cardiovascular disease risk score ; lipid profiles ; resting blood pressure ; C-reactive protein ( measured with a high sensitive assay ) and fibrinogen levels ; blood glucose ; obesity ; physical activity levels ; subjective health status ( SF-36 ) ; Hospital Anxiety and Depression Scale . Results : Group comparison with independent t-tests showed a significantly greater improvement in the cardiovascular disease risk score for participants in the intervention group compared to st and ard care ( intervention 25.7 ± 22.8 to 23.15 ± 18.3 , control 25.03 ± 15.4 to 27.12 ± 16.1 , t = −1.81 , P < 0.05 ) . There were also significant improvements for the intervention group in activity levels ( intervention 9.41 ± 7.7 to 8.08 ± 5.7 , control 14.50 ± 5.5 to 9.83 ± 6.6 , t = −2.00 , P < 0.05 ) and the SF-36 domains of physical functioning ( intervention 70 ± 24.6 to 75.4 ± 11.1 , control 90.00 ± 12.4 to 83.16 ± 17.3 , t = −2.72 , P < 0.05 ) and mental health ( intervention 84 ± 40 to 92 ± 40 , control 88.00 ± 60 to 84 ± 44 , z = −2.06 , P < 0.05 ) . Conclusion : The results suggest that st and ard cardiac rehabilitation programmes are a feasible and effective means of reducing the risk of future cardiovascular events for patients after minor stroke and transient ischaemic attack BACKGROUND This r and omized controlled trial tested the effectiveness of comprehensive , interdisciplinary postdischarge care management in improving a profile of indicators of health recovery and secondary prevention ( profile of health and prevention ) in stroke and transient ischemic attack ( TIA ) patients . METHODS Ninety-six stroke/TIA patients were r and omized to usual care or intervention at discharge from our acute stroke unit . The intervention group received an in-home biopsychosocial assessment by an advanced practice nurse at 1 month . A care plan was developed by an interdisciplinary team and implemented in collaboration with the patient 's primary care physician . The profile of health and prevention , measured at 3 months , was comprised of 5 domains : ( 1 ) Neuromotor Function , ( 2 ) Severe Complications , ( 3 ) Quality of Life , ( 4 ) Management of Risk for common poststroke complications and recurrent stroke , and ( 5 ) Stroke Knowledge . A single global hypothesis test across multiple end points was used to compare the 2 groups . RESULTS The intervention significantly improved the profile of health and prevention ( P < .0001 ) . In addition , each domain showed a positive effect of the intervention . Effect sizes ( in st and ard deviation units ) of the intervention on domains were .1 for Neuromotor Function ( 90 % confidence interval [ CI ] = -.3 to .5 ) ; .4 for Severe Complications ( 90 % CI = .1 to .8 ) ; .5 for Quality of Life ( 90 % CI = .1 to .9 ) ; .6 for Management of Risk for common poststroke complications and recurrent stroke ( 90 % CI = .3 to 1 . ) ; and 1.0 for Stroke Knowledge ( 90 % CI = .6 to 1.4 ) . CONCLUSIONS This model of care management result ed in a significantly better profile of health and prevention for stroke/TIA patients 3 months postdischarge OBJECTIVES To compare the effects of 3 different exercise training regimens on cardiorespiratory fitness and coronary risk factor reduction in subjects with unilateral stroke . DESIGN A cluster assignment by residential location repeated- measures design . SETTING University-based medical center . PARTICIPANTS Fifty-five subjects with unilateral ischemic stroke were assigned to the following groups : intensity ( n=18 ) , duration ( n=19 ) , and therapeutic exercise ( n=18 ) . INTERVENTION A 14-week intervention with subjects r and omized to 1 of 3 interventions : ( 1 ) moderate intensity , shorter duration ( MISD ) exercise ( gradually increasing exercise intensity while keeping exercise duration constant at 30 min ) , ( 2 ) low-intensity , longer duration ( LILD ) exercise ( gradually increasing duration to 60 min while keeping exercise intensity constant ) , or ( 3 ) conventional therapeutic exercise ( TE ) consisting mainly of strength , balance , and range of motion activities . All groups exercised 3 days per week . MAIN OUTCOME MEASURES Peak oxygen consumption ( VO2peak ) , submaximal oxygen consumption ( VO2 ) , lipid panel , and resting blood pressure . RESULTS The MISD group attained more favorable effects on systolic ( P<.04 ) and diastolic blood pressure ( P<.002 ) and total cholesterol ( TC ) ( P<.036 ) compared with LILD and TE groups . Both MISD ( P<.029 ) and LILD ( P<.045 ) showed significant reductions in triglycerides compared with TE ( P<.029 ) . There was no significant change in VO2peak and submaximal VO2 in any of the groups . CONCLUSIONS Overall , both MISD and LILD conditions achieved greater clinical and significant gains in coronary risk reduction compared with TE 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 Lowering blood pressure ( BP ) in stroke survivors reduces the risk of recurrent stroke . We tested the hypothesis that a nurse-led nonpharmacologic intervention would lower the BP of participants in an intervention group compared with a control group . A total of 349 patients who had sustained acute stroke or transient ischemic attack were r and omly assigned to either usual care or to 4 home visits by a nurse . During the visits , the nurse measured and recorded BP and provided individually tailored counseling on a healthy lifestyle . A total of 303 patients completed the 1-year follow up . No change in systolic BP was noted in either the intervention group or the control group . Because of an increase in diastolic BP in the control group ( P = .03 ) , a difference in mean diastolic BP between the 2 groups was found at follow-up ( P = .007 ) . Mean BP at follow-up was 139/82 mm Hg in the intervention group and 142/86 mm Hg in the control group . Linear regression analysis demonstrated that BP at the point of discharge was the strongest predictor of BP 1 year later ( P < .0001 ) . The proportion of patients on antihypertensive medication increased in the intervention group ( P = .002 ) . Patients were compliant with antihypertensive therapy , and 92 % of the hypertensive patients in the intervention group followed the advice to see a general practitioner ( GP ) for BP checkups . At follow-up , 187 patients ( 62 % ) were hypertensive , with no difference in the rate of hypertension seen between the groups . Our data indicate that home visits by nurses did not result in a lowering of BP . Patients complied with antihypertensive therapy and GP visits in the case of hypertension . Nonetheless , the majority of patients were hypertensive at the 1-year follow up 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 OBJECTIVES To determine whether a practice effect occurs across 2 trials of the six-minute walk test ( 6MWT ) among community-dwelling people within 1 year poststroke and to identify characteristics distinguishing people who show a practice effect from those who do not . DESIGN Secondary analysis of scores on 2 trials of the 6MWT administered approximately 30 minutes apart at baseline in a r and omized controlled trial . SETTING General community . PARTICIPANTS People ( N=91 ) living in the community with a residual walking deficit within the first year of a first or recurrent stroke . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURE Distance walked on the 6MWT .  RESULTS Mean 6MWT scores + /- SD for trials 1 and 2 were 196+/-119 m and 197+/-126 m , respectively ( n=83 ) . The mean difference in 6MWT performance across trials was 0+/-35 m ( 95 % confidence interval [ CI ] , -7 to 8 m ) . The Pearson correlation coefficient between 6MWT distances was .96 ( P<.001 ) , and the intraclass correlation coefficient was .98 ( 95 % CI , .97-.99 ) . The Bl and -Altman plot showed no clear pattern . Participants whose improvement was equal to or greater than the minimal detectable change of 29 m between trials ( 14 % ) did not significantly differ from those in the rest of the study sample ; however , they tended to be younger ( P=.05 ) and more likely to have a mild or moderate gait deficit ( P=.06 ) . CONCLUSIONS Findings do not support a practice effect across 2 trials of the 6MWT in individuals within 1 year poststroke . Thus , a practice walk does not appear necessary . Further research is recommended to evaluate the influence of young age , acute stroke , and mild-to-moderate gait deficit on practice effects ABSTRACT Secondary stroke prevention is championed as guideline care ; yet there are no systematic programs offered . We developed a stroke self-management program to address this gap and pilot test the program . We conducted a r and omized controlled trial at two Veterans Administration ( VA ) hospital sites where we recruited patients with an acute stroke to receive either the stroke program or an attention-control protocol over a 12-week period following hospital discharge . The stroke program included six sessions that facilitated stroke self management focusing on increasing self-efficacy to recover from stroke and engage in secondary stroke risk factor management . We surveyed outcomes at baseline , 3 and 6 months . We conducted an intention to treat analysis comparing the intervention to the control group on changes of outcomes between baseline and follow-up modeled by a linear model with fixed effects for treatment , visit , and the treatment by visit interaction adjusting for baseline . We recruited 63 participants ( 33 control and 30 intervention ) who were hospitalized with a primary diagnosis of ischemic stroke . We found trends in differences between groups on self-efficacy to communicate with physicians , weekly minutes spent in aerobic exercise , and on dimensions of stroke-specific quality of life . This pilot study demonstrated the feasibility of delivering a  stroke self-management program to recent stroke survivors in a healthcare organization . The program also demonstrated improvements in patient self-efficacy , self-management behaviors , specific dimensions of stroke-specific quality of life compared to a group that received an attention placebo program 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 The objective of this study was to conduct a r and omized , parallel-group clinical trial assessed the efficacy of a health-enhancing physical activity program ( exercise and education ) on vascular risk factors and aerobic fitness in patients who have experienced a transient ischemic attack ( TIA ) or nondisabling stroke . Sixty patients ( 69±11 years ) completed a baseline ( BL ) vascular risk stratification and aerobic fitness examination ( cycle test ) within 2 weeks of symptom onset . Subjects were then r and omized to either an 8-week , twice weekly exercise program or to a usual-care control ( CON ) group . Postintervention ( PI ) assessment s were completed immediately after the intervention and at 3-month follow-up . A series of primary ( systolic blood pressure [ SBP ] ) and secondary ( vascular risk factors like total cholesterol [ TC ] , high-density lipoproteins , etc . ; Framingham risk score ; peak oxygen uptake ) outcome measures were assessed . Significantly greater reductions in SBP ( mean change±SD ; -10.4±9.2 mm Hg ) and TC ( -.53±.90 mmol/L ) were observed between BL and PI assessment s for the exercise group compared with the CON group ( -1.9±15.4 mm Hg and -.08±.59 mmol/L , respectively ) ( P<.05 ) . These improvements were maintained between the PI and the 3-month follow-up assessment ( P>.05 ) . Significant improvements in aerobic fitness were also observed and maintained at the 3-month follow-up assessment after regular exercise participation ( P<.05 ) . The early engagement in exercise result ed in significant improvements in vascular risk factors and fitness in those diagnosed with TIA . As these beneficial effects were maintained up to 3 months after completing the exercise program , exercise should be considered a useful additive treatment strategy for newly diagnosed TIA patients . Future research should examine the long-term efficacy of such programs OBJECTIVE To evaluate exercise capacity of patients with a poststroke interval of less than 1 month . DESIGN Prospect i ve , cohort , observational study . SETTING Exercise testing laboratory in a tertiary care hospital . PARTICIPANTS Twenty-nine patients ( mean age + /- st and ard deviation , 64.9+/-13.5 y ) with a poststroke interval of 26.0+/-8.8 days . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Peak exercise capacity ( VO(2)peak ) was measured by  open-circuit spirometry  during maximal effort treadmill walking with 15 % body-weight support . RESULTS Mean VO(2)peak was 14.4+/-5.1 mL. kg(-1 ) . min(-1 ) or 60%+/-16 % of age- and sex-related normative values for sedentary healthy adults . CONCLUSIONS Exercise capacity approximately 1 month after stroke was compromised . Further research is needed to eluci date the physiologic basis of this low capacity Background – Transient ischemic attack ( TIA ) and stroke patients often show a striking lack of knowledge about their disease . We developed a computer program that provided health education fitting the educational level , risk profile and symptoms of patients and evaluated it in a r and omized controlled trial ABSTRACT Stroke survivors are at high risk for cardiovascular mortality which can be in part mitigated by increasing physical activity . Self-efficacy for exercise is known to play a role in adoption of exercise behaviors . This study examines self-reported psychological outcomes in a group of 64 stroke survivors r and omized to either a 6-month treadmill training program or a stretching program .  Results indicated that , regardless of group , all study participants experienced increased self-efficacy ( F = 2.95 , p = .09 ) and outcome expectations for exercise ( F = 13.23 , p < 0.001 ) and improvements in activities of daily living as reported on the Stroke Impact Scale ( F = 10.97 , p = .002 ) . No statistically significant between-group differences were noted , possibly because of the fact that specific interventions design ed to enhance efficacy beliefs were not part of the study . Theoretically based interventions should be tested to clarify the role of motivation and potential influence on exercise and physical activity in the stroke survivor population BACKGROUND Determinants of survival and of risk of vascular events after transient ischaemic attack ( TIA ) or minor ischaemic stroke are not well defined in the long term . We aim ed to re study these risks in a prospect i ve cohort of patients after TIA or minor ischaemic stroke ( Rankin grade < or = 3 ) , after 10 years or more . METHODS We assessed the survival status and occurrence of vascular events in 2473 participants of the Dutch TIA Trial ( recruitment in 1986 - 89 ; arterial cause of cerebral ischaemia ) . We included 24 hospitals in the Netherl and s that recruited at least 50 patients . Primary outcomes were all-cause mortality and the composite event of death from all vascular causes , non-fatal stroke , and non-fatal myocardial infa rct ion . We assessed cumulative risks by Kaplan-Meier analysis and prognostic factors with Cox univariate and multivariate analysis . FINDINGS Follow-up was complete in 2447 ( 99 % ) patients . After a mean follow-up of 10.1 years , 1489 ( 60 % ) patients had died and 1336 ( 54 % ) had had at least one vascular event . 10-year risk of death was 42.7 % ( 95 % CI 40.8 - 44.7 ) . Age and sex-adjusted hazard ratios were 3.33 ( 2.97 - 3.73 ) for age over 65 years , 2.10 ( 1.79 - 2.48 ) for diabetes , 1.77 ( 1.45 - 2.15 ) for claudication , 1.94 ( 1.42 - 2.65 ) for previous peripheral vascular surgery , and 1.50 ( 1.31 - 1.71 ) for pathological Q waves on baseline electrocardiogram . 10-year risk of a vascular event was 44.1 % ( 42.0 - 46.1 ) . After falling in the first 3 years , yearly risk of a vascular event increased over time . Predictive factors for risk of vascular events were similar to those for risk of death . INTERPRETATION Long-term secondary prevention in patients with cerebral ischaemia still has room for further improvement OBJECTIVE To investigate the effect of early aerobic training on the aerobic and functional abilities of patients in the subacute stage of cerebrovascular accident ( CVA ) . DESIGN R and omized controlled trial . SETTING Rehabilitation unit in Israel . PARTICIPANTS Ninety-two patients who had a first CVA were r and omly assigned to an exercise-training group or to a control group . INTERVENTION Aerobic training with a leg cycle ergometer for 8 weeks . MAIN OUTCOME MEASURES Workload , exercise time , resting and submaximal blood pressure and heart rate , and functional abilities . RESULTS A trend toward improvement was found in all aerobic parameters for the experimental group , but only heart rate at rest ( P=.02 ) , workload , and work time ( P<.01 ) improved significantly . A trend for improvement was also found in all parameters of function for the experimental group , but only stair climbing was significantly better ( P<.01 ) . An interaction ( 95 % confidence interval , 1.7 - 17.21 ) was found between age and aerobic training on walking distance . Although no significant effect was found in the group of younger patients ( aged < 65y ) , a significant difference in favor of training was noted in the group of older patients . CONCLUSIONS Patients with CVA in the subacute stage improved some of their aerobic and functional abilities after submaximal aerobic training OBJECTIVE To investigate gait outcomes with supported treadmill ambulation training ( STAT ) associated with regular rehabilitation in acute stroke survivors . DESIGN R and omized controlled trial , pilot study . SETTING Rehabilitation medicine service at a Veterans Affairs medical center . PARTICIPANTS Seven acute stroke survivors assigned to regular intervention group and 6 patients assigned to STAT intervention .  INTERVENTIONS Regular intervention consisted of 3 hours daily of physical therapy , kinesiotherapy , and occupational therapy . STAT group received regular rehabilitation with STAT substituted for usual gait training . Participants were tested at baseline , treated for an average of 3 weeks , and retested on discharge . The analysis of covariance procedure was used to test for differences between the 2 approaches . MAIN OUTCOME MEASURES Functional Ambulation Category Scale , gait speed , walking distance , gait energy expenditure , and gait energy cost . RESULTS The small sample size did not generate enough power to detect significant differences in any variable . However , medium to large effect sizes of 0.7 and 1.16 st and ard deviation units were observed for gait energy cost and walk distance , respectively . CONCLUSIONS This pilot study indicated that STAT is a safe , feasible , and promising intervention for acute stroke survivors . A larger trial is warranted for statistical relevance 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 SIR— Interventions with an educational or counselling component have been reported to be effective in a variety of patient groups to encourage smoking cessation [ 1 ] , lower blood pressure ( BP ) [ 2 , 3 ] , achieve modest reductions in cholesterol [ 4 ] , and promote weight loss [ 5 ] . Evaluation of the impact of education on physical outcomes is lacking in stroke disease , despite evidence that inadequate provision of information may adversely affect compliance with secondary prevention and psychosocial outcomes [ 6 ] . We describe a single-blind r and omised controlled trial of health education and counselling for patients with stroke or transient ischaemic attack ( TIA ) , and its effects on risk factors , satisfaction , mood and perceived health status BACKGROUND AND PURPOSE In hemiparetic individuals , low endurance to exercise may compound the increased energy cost of movement and contribute to poor rehabilitation outcomes . The purpose of this investigation was to describe how hemiparetic stroke patients responded to intense exercise and aerobic training . METHODS Forty-two subjects were r and omly assigned to an exercise training group or to a control group . Treatments were given three times per week for 10 weeks in similar laboratory setting s. Baseline and posttest measurements were made of maximal oxygen consumption , heart rate , workload , exercise time , resting and submaximal blood pressures , and sensorimotor function . RESULTS Only experimental subjects showed significant improvement in maximal oxygen consumption , workload , and exercise time . Improvement in sensorimotor function was significantly related to the improvement in aerobic capacity . After treatment , experimental subjects showed significantly lower systolic blood pressure at submaximal workloads during the grade d exercise test . CONCLUSIONS We conclude that hemiparetic stroke patients may improve their aerobic capacity and submaximal exercise systolic blood pressure response with training . Sensorimotor improvement is related to the improvement in aerobic capacity Background and objective . In spite of the challenges , engaging in exercise programs very early after stroke may positively influence aerobic capacity and stroke-related outcomes , including walking ability . The objective of this study was to evaluate the feasibility of adding aerobic cycle ergometer training to conventional rehabilitation early after stroke and to determine effects on aerobic capacity , walking ability , and health-related quality of life . Methods . A prospect i ve matched control design was used . All participants performed a grade d maximal exercise test on a semi-recumbent cycle ergometer , spatiotemporal gait assessment s , 6-Minute Walk Test , and Stroke Impact Scale . The Exercise group added 30 minutes of aerobic cycle ergometry to conventional inpatient rehabilitation 3 days/week until discharge ; the Control group received conventional rehabilitation only . Results . All Exercise participants ( n = 23 ) completed the training without adverse effects . In the 18 matched pairs , both groups demonstrated improvements over time with a trend toward greater aerobic benefit in the Exercise group with 13 % and 23 % increases in peak VO2 and work rate respectively , compared to 8 % and 16 % in the Control group ( group-time interaction P = .71 and .62 ) . A similar trend toward improved 6-Minute Walk Test distance ( Exercise 53 % vs Controls 23 % , P = .23 ) was observed . Conclusion . Early aerobic training can be safely implemented without deleterious effects on stroke rehabilitation . A trend toward greater improvement in aerobic capacity and walking capacity suggests that such training may have an early beneficial effect and should be considered for inclusion in rehabilitation programs
target: No significant effect was found on cardiovascular events , mortality , diastolic blood pressure , or cholesterol .
  Conclusions — We found that lifestyle interventions are effective in lowering systolic blood pressure .
  About other end points , this systematic review found no effect of lifestyle interventions on cardiovascular event rate mortality , diastolic blood pressure , or total cholesterol
background: Background and Purpose — Patients with a transient ischemic attack or ischemic stroke have an increased risk of subsequent cardiovascular events .
  The purpose of this systematic review and meta- analysis was to determine whether lifestyle interventions focusing on behaviorally modifiable risk factors with or without an exercise program are effective in terms of ( 1 ) preventing recurrent cardiovascular events , ( 2 ) reducing mortality , and ( 3 ) improving modifiable risk factors associated with cardiovascular disease in patients after a transient ischemic attack or ischemic stroke .