http://academicdepartments.musc.edu/newscenter/2017/turan/
Research
shows moderate to vigorous physical activity is by far the strongest
predictor of an improved outcome in people who have suffered a stroke.
Vigorous
walking three to five times each week decreases the chance of recurrent
stroke by fivefold in patients with narrowed arteries in the brain,
report investigators at the Medical University of South Carolina in an
article in Neurology.
The
results, published in the January 24 issue, involved patients with
symptoms of intracranial stenosis, the narrowing of arteries in the
brain, which is the most common cause of stroke worldwide.
 | |
| Dr. Tanya Turan tells patients with intracranial stenosis that exercise can have a big impact on improving their health. |
The
investigators analyzed three-year follow-up data for 227 patients who
had been randomized to the intensive medical management arm of the
MUSC-led Sammpris or stenting versus aggressive medical therapy for
intracranial stenosis trial. Enrollment in the Sammpris trial, which was
designed to evaluate whether stenting plus intensive medical management
or intensive medical management alone was more effective at preventing
recurrent stroke in these patients, was stopped early, in 2011, for
safety reasons because patients in the stenting arm had a 2 ½ times
higher 30-day rate of stroke or death than those in the intensive
medical therapy arm.
Follow-up continued, however, to
evaluate the role of risk factor control in preventing recurrent stroke,
and those findings are presented in the Neurology article.
Reaching
targets for systolic blood pressure (<140 mmHg, < 130 mmHg for
diabetics) and low-density lipoprotein cholesterol (<70 mg/d)
significantly reduced the risk of secondary stroke, myocardial
infarction or a vascular event. Approximately half of the study
participants met these targets on average during the study. Those who
did not were about twice as likely to experience a recurrent stroke,
heart attack or vascular event.
However, moderate to
vigorous physical activity was by far the strongest predictor of an
improved outcome. Indeed, patients who did not regularly engage in
moderate to vigorous exercise were up to five times as likely to
experience a recurrent stroke or other vascular event.
How
much exercise was needed to attain benefit? “At least vigorous walking
for about 30 minutes, three to five times each week,” says Tanya Turan, M.D., director of the MUSC Stroke Division and lead author of the article.
Study
participants self-reported exercise using the 6-point Patient-Centered
Assessment and Counseling for Exercise, or PACE, score. Those who scored
above 3 met the target for physical activity and received benefit.
Moderate exercise was defined as brisk walking or slow cycling for at
least 10 minutes at a time, and vigorous activity as jogging or fast
cycling for at least 20 minutes at a time.
There was
evidence for a dose-dependent effect with exercise, with greater
protection from vascular events seen with more exercise. All study
participants were enrolled free of charge in a commercially available
lifestyle modification program, which included regular coaching on
healthy lifestyle behaviors.
Control of other risk
factors, such as smoking, body mass index and glycated hemoglobin, did
not significantly affect vascular outcomes.
This is the
first report showing an association between exercise and prevention of
recurrent stroke. The current American Heart guidelines for patients
with intracranial stenosis recommend lowering blood pressure and
cholesterol but do not mention exercise. Turan believes that, given
these findings, the next version of the guidelines may be more
supportive of exercise for secondary stroke prevention in patients with
intracranial stenosis.
“When I counsel my patients
with this condition, I talk with them about those two primary risk
factors, blood pressure and cholesterol, but also mention the impact of
exercise and tell them that they can do it without having to take an
extra pill and that it could have the biggest impact,” Turan says.
While
it is true that stroke patients can have physical or emotional barriers
to exercise, including stroke-related disability or depression, this
analysis demonstrates that access to a lifestyle modification program
can substantially increase their willingness to exercise. The percentage
of study participants who were at target for physical activity
increased from 32 percent at study entry to 56 percent by the four-month
follow-up visit.
Lifestyle modification programs, such
as the one used in the study, are commercially available and can be
used to help motivate stroke patients to meet exercise targets. These
programs can cost $400 to $500 annually and may be out of the reach of
some patients; however, insurance reimburses for these costs in some
cases. For patients who cannot afford to participate in a formal
lifestyle modification program, physicians and their health care staff
can work toward the same goal by consistently encouraging exercise in
order to prevent recurrent stroke. Many hospitals also offer cardiac and
stroke rehabilitation services that promote exercise.
Turan has a simple message for physicians.
“Tell your patients to exercise,” she says. “Think outside of the pillbox.”
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