Original Contribution
Lifestyle Interventions to Prevent Cardiovascular Events
After Stroke and Transient Ischemic Attack
Systematic Review and Meta-Analysis
Inger A. Deijle, MSc; Sander M. Van Schaik, MD; Erwin E.H. Van Wegen, PhD;
Henry C. Weinstein, MD, PhD; Gert Kwakkel, PhD; Renske M. Van den Berg-Vos, MD, PhD
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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.
Methods—For this systematic review and meta-analysis, we systematically searched PubMed, Embase, PsycInfo, and the
Cochrane Library from the start of the database to May 7, 2015. Subgroup analyses were conducted to explore the
influence of therapy-related factors.
Results—Twenty-two randomized controlled trials were identified with a total of 2574 patients. Pooling showed a significant
reduction in systolic blood pressure by the lifestyle interventions applied, compared with usual care (mean difference,
−3.6 mm Hg; 95% confidence interval, −5.6 to −1.6, I2=33%). No significant effect was found on cardiovascular events,
mortality, diastolic blood pressure, or cholesterol. In the subgroup analyses, the trials with cardiovascular fitness
interventions, trials with an intervention that lasted longer than 4 months, and interventions that used >3 behavior change
techniques were more effective in reducing systolic blood pressure.
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. (Stroke. 2017;48:00-00. DOI: 10.1161/STROKEAHA.116.013794.)
Key Words: life style ◼ secondary prevention ◼ stroke
P
atients with a transient ischemic attack (TIA) or ischemic
stroke have an increased risk of recurrent stroke and other
cardiovascular events.1,2 Risk factors for recurrent cardiovascular events can be classified into 3 major groups: (1) nonmodifiable risk factors such as age, sex, and family history,
(2) medically modifiable risk factors, which can be altered
by medical interventions such as pharmacological therapy or
surgical procedures, and (3) behaviorally modifiable risk factors, which can be modulated by changes in lifestyle factors
such as physical inactivity and cigarette smoking.3 There is a
solid body of evidence on the efficacy of secondary prevention
measures that modify the medically modifiable risk factors in
preventing recurrent stroke, coronary heart disease (CHD),
and death.4,5 However, there is no solid evidence for interventions addressing behaviorally modifiable risk factors by
lifestyle interventions in the literature, and it remains unclear
which implementation strategy for lifestyle interventions is
most effective.5,6 Lifestyle interventions are usually complex
interventions with several interacting components,7 making it
challenging to adequately describe and compare them in systematic reviews.
To date, 2 systematic reviews of lifestyle interventions to
prevent recurrent stoke or cardiovascular events in patients
after a TIA or ischemic stroke have been published.8,9 The first
systematic review pooled 5 trials and found an overall significant increase in physical activity participation compared
with usual care. No significant effects were reported for mortality, cardiovascular event rates, cholesterol, blood pressure,
or cardiovascular risk factors. Unfortunately, this systematic
review also included studies with other patients besides those
with a TIA or ischemic stroke, such as patients with a lower
limb amputation.10 The second review focused on nonpharmacological lifestyle interventions that included components
from cardiac rehabilitation programs.9 One phase II trial was
Received June 15, 2016; final revision received October 25, 2016; accepted November 3, 2016.
From the Department of Physical (I.A.D.), Department of Neurology (S.M.V.S., H.C.W., R.M.V.d.B.-V.), OLVG West, Amsterdam, The Netherlands;
Department of Rehabilitation Medicine, Move Research Institute Amsterdam, VU Medical Center, The Netherlands (E.E.H.V.W., G.K.); and Reade Center
for Rehabilitation and Rheumatology, Amsterdam, The Netherlands (G.K.).
The online-only Data Supplement is available with this article at http://stroke.ahajournals.org/lookup/suppl/doi:10.1161/STROKEAHA.
116.013794/-/DC1.
Correspondence to Renske M. Van den Berg-Vos, MD, PhD, Department of Neurology, OLVG W, Jan Tooropstraat 164, 1061 AE Amsterdam, The
Netherlands. E-mail [email protected]
© 2016 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org
DOI: 10.1161/STROKEAHA.116.013794
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2 Stroke January 2017
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identified, in which patients were assigned to a 10-week exercise program or no intervention. A significant reduction in
cardiac risk score based on age, resting blood pressure, smoking status, diabetic status, total cholesterol, and high-density
lipoprotein levels was found in favor of the intervention group
when compared with usual care.10 Both reviews stem from
2013 (including trials up to 2012), thereafter several new
studies of lifestyle interventions with or without an exercise
program have been published.
The primary objective of the current systematic review
and meta-analysis of randomized controlled trials (RCTs)
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 TIA or ischemic stroke. The secondary
objective was to explore the influence of therapy-related factors such as timing of intervention, intensity, total duration,
and the use of behavior change techniques.
Materials and Methods
This systematic review was conducted according to the Preferred
Reporting Items for Systematic Reviews and Meta-Analysis
(PRISMA) statement.11 We searched PubMed, Embase, PsycInfo,
and the Cochrane Library from the start of the database to May 7,
2015. Definitions, study selection, and data extraction are available
in the Materials and Methods in the online-only Data Supplement. A
protocol for this systematic review was not published.
Results
Study Identification
The study selection process is summarized in Figure 1. The
search in electronic databases yielded a total of 19.148 titles.
After reviewing titles and abstracts, 37 full-text articles were
retrieved for possible inclusion, 15 studies were subsequently
excluded. The excluded articles can be found in the Result in
the online-only Data Supplement.
Study Description
Twenty-two RCTs met the inclusion criteria with a total of
2574 patients: 12 trials used a behavior change intervention
(n=552),14–25 5 trials used a cardiovascular fitness intervention (n=1800),26–30 and 5 trials used a combined intervention
(n=222).10,31–34 Table I in the online-only Data Supplement
summarizes the included studies.
Risk of Bias Assessment
Table II in the online-only Data Supplement illustrated the
result of the risk of bias assessment according to the Cochrane
guidelines.12 Nine studies had a low risk,10,16,18,24–26,32–34 8 had a
moderate risk,14,17,21,23,27–29,31 and 5 had a high risk of bias.15,19–
21,30
Three of the 5 studies with a high risk of bias had outcome
measures that were not suitable for pooling, whereas 2 of the
Quality Assessment
Two reviewers (I.D. and S.S.) independently assessed the risk of
bias, solving disagreements in a consensus meeting. The quality of
RCTs was assessed using the checklist developed by the Cochrane
Collaboration, which evaluates the presence of potential selection
bias, performance bias, detection bias, attrition, and reporting bias.12
Quantitative Analysis
Meta-analyses were performed for each intervention for which at
least 2 RCTs with comparable outcomes were identified. Statistical
analysis was performed using RevMan 2014 version 5.3 and was conducted according to the Cochrane handbook for systematic reviews
of interventions.13 See the Materials and Methods in the online-only
Data Supplement for detailed description of the quantitative analysis.
The separate effects of behavior change interventions, cardiovascular fitness interventions, and interventions involving both components
were pooled for meta-analysis. Subsequently, a subgroup analysis
investigated the effects of therapy-related factors. In addition, linear
regression analyses were used to determine associations between
individual mean differences (MD), on the one hand, and timing of the
intervention, total duration, intensity, and the use of behavior change
techniques, on the other. All analyses used 2-sided test and an α value
of 0.05, regression coefficients with their corresponding 95% confidence interval (CI) were calculated.
Subgroup Analyses
The cutoff points for the subgroup analyses were the median values for
the studies reporting the following variables: (1) timing of the intervention (within 3 months after onset of TIA or ischemic stroke or >3
months after onset of TIA or ischemic stroke), (2) total duration (≤4
versus >4 months), (3) intensity (≤8 versus >8 contact moments); and
(4) number of different behavior change techniques (≤3 versus >3).
These analyses are based on comparison of the subgroup effect and
their CIs. Nonoverlap of the CIs indicated statistical significance.13
Figure 1. Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) flow diagram. RCT indicates randomized controlled trial.
Deijle et al Lifestyle Interventions After TIA and Stroke 3
5 provided suitable data for pooling but were excluded in the
meta-analysis because of high risk of bias.15,19
Therapy-Related Factors
The timing of the intervention ranged from 2 weeks to >1 year
after the TIA or ischemic stroke.10,32 Intensity ranged from
no patient contact moments (2 interventions provided only a
personalized secondary prevention plan to the patient’s general practitioner)15,25 to 72 contact moments.28 Duration of the
intervention ranged from 1 contact moment23 to a 24-month
intervention.26 The number of behavior change techniques
used ranged from 123,25,27,29,30 to 7 described techniques.33 The
main therapy-related factors are summarized in Table I in the
online-only Data Supplement.
Effect of Interventions
Meta-Analysis
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Cardiovascular Event Rate and Mortality
Figure 2 shows cardiovascular event rates of 506 patients
after pooling.24,26,31,33 Lifestyle interventions were found to
have a heterogeneous nonsignificant effect on the risk ratio
when compared with usual care (risk ratio, 0.79; 95% CI,
0.30–2.06; I2=59% random-effect). Figure 3 shows the risk
of death summarized >5 trials (n=1492 patients).16,24–26,33 No
significant difference was found in the risk ratio of death (risk
ratio, 1.16; 95% CI, 0.82–1.63; I2=0% fixed-effect). Subgroup
analyses showed no significant difference between the effects
on the number of cardiovascular events (including mortality) between therapies focusing on behavior change interventions, cardiovascular fitness interventions, and combined
interventions.
Blood Pressure
Figure 4.1 shows data of 650 patients from 10 studies.10,14,18,24,27,29,31–34 Pooling showed a significant reduction in
systolic blood pressure (SBP) by the lifestyle interventions
applied compared with usual care (MD, −3.6 mm Hg; 95%
CI, −5.6 to −1.6; I2=33% fixed-effect). Figure 4.2 shows that
the behavior change intervention did not result in a significant
MD in blood pressure (behavior change interventions MD, 1.0
mm Hg; 95% CI, –4.5 to 6.5; I2=0% fixed-effect). Figure 4.3
and 4.4 shows subgroup analyses of the cardiovascular fitness interventions and the combined interventions. The MD in
SBP after the intervention was statistically significant in both
intervention groups (MD, −3.9 mm Hg; 95% CI, −6.5 to −1.3;
I2=19% fixed-effect and MD, −5.3 mm Hg; 95% CI, −9.0 to
−1.6; I2=46% fixed-effect, respectively).
The subgroup analyses showed a significant effect of treatment duration, a difference in effect was found in favor of
trials with interventions that lasted longer than 4 months compared with those lasting ≤4 months (MD, −2.6 mm Hg; 95%
CI, −4.7 to −0.4, I2= 0% fixed-effect and MD, −10.1; 95% CI,
−15.4 to −4.8; I2 0% fixed-effect, respectively). For the use
of behavior change techniques, a significant effect was also
found in favor of trials with interventions that used 3 behavior
change techniques or less and those using >3 behavior change
techniques (MD, −2.6 mm Hg; 95% CI, −4.7 to −0.4; I2=0%
fixed-effect and MD, −10.1 mm Hg; 95% CI, −15.4 to −4.8;
I2= 0% fixed-effect, respectively). With regards to the timing
of the treatment, no difference in effect was found between
trials starting within 3 months or trials starting after 3 months
(MD, −3.7 mm Hg; 95% CI, −6.8 to −0.5; I2=38% fixed-effect
and MD −2.2 mm Hg; 95% CI, −8.2 to 3.8; I2= 52% randomeffect, respectively). We found no significant effect of trials
that used ≤8 patient contacts for their intervention and trials
that used >8 patient contacts (MD, 1.0 mm Hg; 95% CI, −4.5
to 6.5; I2=0% fixed-effect and MD, −4.3 mm Hg; 95% CI, −6.5
to −2.2; I2=33% fixed-effect, respectively).
In linear regression analysis, a significant negative association is found in both the number of contact moments and SBP
(regression coefficient, −2.5; 95% CI, −4.3 to −0.6) and number of behavior change techniques applied and SBP (regression coefficient, −0.5; 95% CI, −0.5 to −0.03).
Changes in diastolic blood pressure (DBP) from baseline to
postintervention were pooled for a total of 648 patients from 8
studies.10,14,18,24,27,29,31–34 A nonsignificant heterogeneous MD in
DBP reduction was found (MD, −0.2 mm Hg; 95% CI, −2.2 to
1.9; I2=55% random-effect). Figure I in the online-only Data
Supplement shows the meta-analysis for DBP.
Cholesterol
Three trials (n=126) were pooled, showing a nonsignificant
MD for total cholesterol level (MD=0.09 mmol/L; 95% CI,
−0.30 to 0.48; I2=0% fixed-effect).10,14,34
Physical Activity and Cardiorespiratory Fitness
Thirteen studies reported physical activity as an outcome
measure: 8 studies (n=874) using a behavior change intervention,14,16,17,19–23 2 studies (n=427) using a cardiovascular fitness intervention,26,28 and 3 studies (n=154) using a combined
intervention.32–34 The heterogeneity of the outcome measures
prevented pooling. The outcome measures of these studies varied from change in self-reported minutes spent on exercise per
week14 to maintaining an exercise program.19 Six interventions
led to a significant increase of the physical activity level,19–22,33,34
whereas 6 interventions yielded no significant changes in the
Figure 2. Risk ratios with 95% confidence interval (CI) estimates for cardiovascular events (lifestyle interventions vs usual care) among
patients with transient ischemic attack or ischemic stroke. M–H indicates Mantel–Haenszel statistic.
4 Stroke January 2017
Figure 3. Risk ratio with 95% confidence interval (CI) estimates for death (lifestyle interventions vs usual care) among patients with transient ischemic attack or ischemic stroke. M–H indicates Mantel–Haenszel statistic.
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level of physical activity,14,16,17,26,28,32 and one study did not
report the outcome of the measure.23 Four studies (n=170) found
a significant increase in cardiorespiratory fitness in the intervention group as measured by VO2max or maximal oxygen
uptake.8,27,31,32 One study (n=28)29 used a 6-minute walking test
to measure cardiorespiratory fitness and reported a significant
and clinically relevant change in the intervention group (412±178
to 472±196 m versus 459±116 to 484±122 m in the control
group; P<0.01; minimal clinically important difference, 29 m).35
Discussion
The main finding of this meta-analysis was a significant 3.6mm Hg reduction in SBP by lifestyle interventions compared
with usual care. In the subgroup analyses, the trials with a cardiovascular fitness intervention and a combined intervention showed
a significant reduction in SBP, whereas trials with a behavior
change intervention showed no significant effect. About other
end points, this systematic review found no effect of lifestyle
interventions on cardiovascular events, mortality, DBP, or total
cholesterol. The lack of positive effects for these end points may
be explained by the fact that the study samples were small and
the follow-up was short, with a median duration of 5.5 months.
The secondary aim of the present review was to investigate
which therapy-related factors have an impact on the intervention effect. Our subgroup analyses indicated that interventions
involving a cardiovascular fitness program result in a significant reduction in SBP. This may be explained by the fact
that endurance training decreases blood pressure by reducing
systemic vascular resistance.36 Furthermore, our subgroup
analyses showed that trials with an intervention that lasted
longer than 4 months and interventions that used >3 behavior
change techniques were more effective in reducing SBP. In
this analysis, the same trials lasted longer than 4 months and
used >3 behavior change techniques, this makes it difficult
Figure 4. Meta-analysis and subgroup analysis for mean difference in systolic blood pressure with 95% confidence interval (CI; lifestyle
interventions vs usual care) among patients with transient ischemic attack or ischemic stroke. IV indicates inverse variance.
Deijle et al Lifestyle Interventions After TIA and Stroke 5
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to disentangle whether the effect modification is because of
duration of the number of behavior change techniques. Linear
regression analyses suggested that there is a positive association between the number of contact moments and number of
behavior change techniques used and change in SBP.
Blood pressure is the most consistent and powerful predictor of stroke, in both primary and secondary prevention.37,38 It is
debatable whether the 3.6-mm Hg reduction in SBP found in this
systematic review and meta-analysis is clinically relevant. The
PROGRESS trial (The Perindopril Protection Against Recurrent
Stroke Study) found no difference in the risk of stroke or major
vascular events in the group treated by perindopril alone and for
whom the SBP was on average 5 mm Hg lower than in the placebo group.38 Despite this uncertainty on clinical relevance, it is
at least remarkable that it was achieved by offering patients lifestyle interventions and not prescribing antihypertensive drugs
or by performing a strictly pharmacologically based intervention. Furthermore, it might be relevant from an epidemiological
perspective, as it presumably reduces the cardiovascular event
rates in the population of TIA and patients with ischemic stroke.
Therefore, as a complement to antihypertensive drugs, lifestyle
interventions may be effective in lowering blood pressure and
reducing recurrent TIA or stroke rates.
The results on SBP in our systematic review are consistent
with those of other systematic reviews, which investigated the
effect of exercise-based cardiac rehabilitation programs in
patients with CHD. For example, the review by Taylor et al39
reported a significant 3.2-mm Hg decrease in SBP in patients
with CHD, but no significant difference in DBP after an exercise-based cardiac rehabilitation program was observed. In
contrast to our systematic review, Taylor et al39 found a significant reduction in all-cause mortality (odds ratio, 0.8; 95% CI,
0.68–0.93), cardiac mortality (OR, 0.74; 95% CI, 0.61–0.96),
and cholesterol levels (MD, −0.37 mmol/L; 95% CI, -0.63 to
−0.11). However, the total number of patients in their metaanalyses was larger than that in the current review (8432 versus
1492), and it is not clear whether mortality rates are comparable between patients with CHD and patients with stroke.
Parallels between comorbidities and risk factors in stroke
and CHD suggest that a cardiac rehabilitation model of care
may provide patients after a TIA or ischemic stroke with much
needed improvement in both secondary prevention and cardiorespiratory fitness. The latter is important because evidence from
several trials consistently shows a significant decline in cardiorespiratory fitness and physical functioning after both TIA and
stroke.40,41 However, more knowledge is needed about the similarities and differences between patients after a TIA or stroke
and CHD, about both psychosocial characteristics (cognition,
depression, anxiety, and fatigue) and physical performance.
The present review has some limitations. First, despite the
inclusion criteria, there was substantial heterogeneity in the
interventions applied, with regards to content, intensity, and
duration, especially for the behavior change interventions.
This is a well-known difficulty when comparing complex
lifestyle interventions, where heterogeneity of intervention
content and mode of delivery is likely to be large.42 Second,
because no biologically determined cutoff points are known,
the cutoff points in the subgroup analyses for the timing of
the intervention, its intensity, patient contacts, duration, and
use of behavior change techniques were determined using the
median value. Third, because of our language restrictions,
we may have missed trials published in other languages than
English and studies published in non–peer-reviewed journals.
Fourth, because of the large variety in outcome measures, a
limited number of studies were suitable for pooling. Finally,
the limited number of trials that we found preclude the use of
funnel plots to determine small-study effects.
We suggest that future high-quality RCTs investigating the
effects of lifestyle interventions on preventing cardiovascular events, mortality, and modifiable risk factors should meet
the following criteria: (1) complete description of all therapyrelated characteristics of the intervention: the timing of the
intervention, the intensity, the duration of the intervention, and
the use of behavior change techniques, with the aim to improve
replicability and comparability between studies; (2) the lifestyle
intervention should preferably consist of >8 contact moments,
distributed over a treatment period of at least 4 months; (3) the
lifestyle intervention should use >3 behavior techniques; (4)
the lifestyle intervention should include a guided cardiovascular fitness intervention with behavior change interventions,
ie, guidance on how to achieve and maintain an active lifestyle, in combination with guidance on medication adherence,
smoking cessation, alcohol intake, and diet; (5) use a theoretical framework in developing lifestyle interventions. Because
changing lifestyles is known to be difficult, the development of
a lifestyle intervention can be facilitated by taking into account
all factors that might influence the change in health behavior.43
These factors include cognitive factors, such as self-efficacy,
knowledge, and attitude, as well as environmental factors. A
theoretical framework, such as the Transtheoretical Model,44
can be used as an approach to understand these factors.
Obviously, a large phase III trial of high methodological quality is needed to answer the question whether lifestyle interventions are effective in preventing recurrent cardiovascular events,
reducing mortality, and influencing modifiable risk factors.
Disclosures
None.
References
1. Touzé E, Varenne O, Chatellier G, Peyrard S, Rothwell PM, Mas JL.
Risk of myocardial infarction and vascular death after transient ischemic
attack and ischemic stroke: a systematic review and meta-analysis. Stroke.
2005;36:2748–2755. doi: 10.1161/01.STR.0000190118.02275.33.
2. van Wijk I, Kappelle LJ, van Gijn J, Koudstaal PJ, Franke CL, Vermeulen
M, et al.; LiLAC study group. Long-term survival and vascular event risk
after transient ischaemic attack or minor ischaemic stroke: a cohort study.
Lancet. 2005;365:2098–2104. doi: 10.1016/S0140-6736(05)66734-7.
3. Billinger SA, Arena R, Bernhardt J, Eng JJ, Franklin BA, Johnson
CM, et al.; American Heart Association Stroke Council; Council
on Cardiovascular and Stroke Nursing; Council on Lifestyle and
Cardiometabolic Health; Council on Epidemiology and Prevention;
Council on Clinical Cardiology. Physical activity and exercise recommendations for stroke survivors: a statement for healthcare professionals from the American Heart Association/American Stroke Association.
Stroke. 2014;45:2532–2553. doi: 10.1161/STR.0000000000000022.
4.European Stroke Organisation (ESO) Executive Committee, ESO
Writing Committee. Guidelines for management of ischaemic stroke and
transient ischaemic attack 2008. Cerebrovasc Dis. 2008;25:457–507.
5. Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI,
Ezekowitz MD, et al.; American Heart Association Stroke Council,
Council on Cardiovascular and Stroke Nursing, Council on Clinical
6 Stroke January 2017
Downloaded from http://stroke.ahajournals.org/ by guest on June 15, 2017
Cardiology, and Council on Peripheral Vascular Disease. Guidelines for
the prevention of stroke in patients with stroke and transient ischemic
attack: a guideline for healthcare professionals from the American Heart
Association/American Stroke Association. Stroke. 2014;45:2160–2236.
doi: 10.1161/STR.0000000000000024.
6. Di Legge S, Koch G, Diomedi M, Stanzione P, Sallustio F. Stroke
prevention: managing modifiable risk factors. StrokeRes Treat.
2012;2012:391538. doi: 10.1155/2012/391538.
7. Michie S, Ashford S, Sniehotta FF, Dombrowski SU, Bishop A, French
DP. A refined taxonomy of behaviour change techniques to help people change their physical activity and healthy eating behaviours: the
CALO-RE taxonomy. Psychol Health. 2011;26:1479–1498. doi:
10.1080/08870446.2010.540664.
8. Lennon O, Galvin R, Smith K, Doody C, Blake C. Lifestyle interventions for secondary disease prevention in stroke and transient ischaemic
attack: a systematic review. Eur J Prev Cardiol. 2014;21:1026–1039.
doi: 10.1177/2047487313481756.
9. Mackay-Lyons M, Thornton M, Ruggles T, Che M. Non-pharmacological
interventions for preventing secondary vascular events after stroke or transient ischemic attack. Cochrane Database Syst Rev. 2013;3:CD008656.
10. Lennon O, Carey A, Gaffney N, Stephenson J, Blake C. A pilot randomized controlled trial to evaluate the benefit of the cardiac rehabilitation
paradigm for the non-acute ischaemic stroke population. Clin Rehabil.
2008;22:125–133. doi: 10.1177/0269215507081580.
11. PRISMA Group. Preferred reporting items for systematic reviews and
meta-analyses: the PRISMA statement. BMJ. 2009; 339:b2535.
12. Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD,
et al.; Cochrane Bias Methods Group; Cochrane Statistical Methods
Group. The Cochrane Collaboration’s tool for assessing risk of bias in
randomised trials. BMJ. 2011;343:d5928.
13. Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of
Interventions version 5.1.0. The Cochrane Collaboration, 2011. www.
cochrane-handbook.org. Accessed September 10, 2015.
14. Adie K, James MA. Does telephone follow-up improve blood pressure
after minor stroke or TIA? Age Ageing. 2010;39:598–603. doi: 10.1093/
ageing/afq085.
15. Allen KR, Hazelett S, Jarjoura D, Wickstrom GC, Hua K, Weinhardt J,
et al. Effectiveness of a postdischarge care management model for stroke
and transient ischemic attack: a randomized trial. J Stroke Cerebrovasc
Dis. 2002;11:88–98. doi: 10.1053/jscd.2002.127106.
16. Allen K, Hazelett S, Jarjoura D, Hua K, Wright K, Weinhardt J, et
al. A randomized trial testing the superiority of a postdischarge care
management model for stroke survivors. J Stroke Cerebrovasc Dis.
2009;18:443–452. doi: 10.1016/j.jstrokecerebrovasdis.2009.02.002.
17.Damush TM, Ofner S, Yu Z, Plue L, Nicholas G, Williams LS.
Implementation of a stroke self-management program: A randomized controlled pilot study of veterans with stroke. Transl Behav Med.
2011;1:561–572. doi: 10.1007/s13142-011-0070-y.
18. Ellis G, Rodger J, McAlpine C, Langhorne P. The impact of stroke nurse
specialist input on risk factor modification: a randomised controlled trial.
Age Ageing. 2005;34:389–392. doi: 10.1093/ageing/afi075.
19. Flemming KD, Allison TG, Covalt JL, Herzig DE, Brown RD. Utility
of a post-hospitalization stroke prevention program managed by nurses.
Hosp Pract (1995). 2013;41:70–79. doi: 10.3810/hp.2013.08.1070.
20. Gillham S, Endacott R. Impact of enhanced secondary prevention on
health behaviour in patients following minor stroke and transient ischaemic attack: a randomized controlled trial. Clin Rehabil. 2010;24:822–
830. doi: 10.1177/0269215510367970.
21. Green T, Haley E, Eliasziw M, Hoyte K. Education in stroke prevention:
efficacy of an educational counselling intervention to increase knowledge in stroke survivors. Can J Neurosci Nurs. 2007;29:13–20.
22. Kim JI, Lee S, Kim JH. Effects of a web-based stroke education program
on recurrence prevention behaviors among stroke patients: a pilot study.
Health Educ Res. 2013;28:488–501. doi: 10.1093/her/cyt044.
23. Maasland E, Koudstaal PJ, Habbema JD, Dippel DW. 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. Acta Neurol Scand. 2007;115:41–48. doi:
10.1111/j.1600-0404.2006.00722.x.
24. McManus JA, Craig A, McAlpine C, Langhorne P, Ellis G. Does behaviour modification affect post-stroke risk factor control? Three-year follow-up of a randomized controlled trial. Clin Rehabil. 2009;23:99–105.
doi: 10.1177/0269215508095874.
25. Wolfe CD, Redfern J, Rudd AG, Grieve AP, Heuschmann PU, McKevitt
C. Cluster randomized controlled trial of a patient and general
practitioner intervention to improve the management of multiple risk factors after stroke: stop stroke. Stroke. 2010;41:2470–2476. doi: 10.1161/
STROKEAHA.110.588046.
26. Boysen G, Krarup LH, Zeng X, Oskedra A, Kõrv J, Andersen G, et al.;
ExStroke Pilot Trial Group. ExStroke Pilot Trial of the effect of repeated
instructions to improve physical activity after ischaemic stroke: a multinational randomised controlled clinical trial. BMJ. 2009;339:b2810.
27.Potempa K, Lopez M, Braun LT, Szidon JP, Fogg L, Tincknell T.
Physiological outcomes of aerobic exercise training in hemiparetic
stroke patients. Stroke. 1995;26:101–105.
28. Shaughnessy M, Michael K, Resnick B. Impact of treadmill exercise on
efficacy expectations, physical activity, and stroke recovery. J Neurosci
Nurs. 2012;44:27–35. doi: 10.1097/JNN.0b013e31823ae4b5.
29. Toledano-Zarhi A, Tanne D, Carmeli E, Katz-Leurer M. Feasibility,
safety and efficacy of an early aerobic rehabilitation program for patients
after minor ischemic stroke: A pilot randomized controlled trial. Neuro
Rehabilitation. 2011;28:85–90. doi: 10.3233/NRE-2011-0636.
30. Rimmer JH, Rauworth AE, Wang EC, Nicola TL, Hill B. A preliminary study to examine the effects of aerobic and therapeutic (nonaerobic) exercise on cardiorespiratory fitness and coronary risk reduction
in stroke survivors. Arch Phys Med Rehabil. 2009;90:407–412. doi:
10.1016/j.apmr.2008.07.032.
31. Boss HM, Van Schaik SM, Deijle IA, de Melker EC, van den Berg BT,
Scherder EJ, et al. Safety and feasibility of post-stroke care and exercise after minor ischemic stroke or transient ischemic attack: MotiveS
& MoveIT. Neuro Rehabilitation. 2014;34:401–407. doi: 10.3233/
NRE-141049.
32. Faulkner J, Lambrick D, Woolley B, Stoner L, Wong LK, McGonigal G.
Effects of early exercise engagement on vascular risk in patients with transient ischemic attack and nondisabling stroke. J Stroke Cerebrovasc Dis.
2013;22:e388–e396. doi: 10.1016/j.jstrokecerebrovasdis.2013.04.014.
33. Kono Y, Yamada S, Yamaguchi J, Hagiwara Y, Iritani N, Ishida S, et al.
Secondary prevention of new vascular events with lifestyle intervention
in patients with noncardioembolic mild ischemic stroke: a single-center randomized controlled trial. Cerebrovasc Dis. 2013;36:88–97. doi:
10.1159/000352052.
34. Kirk H, Kersten P, Crawford P, Keens A, Ashburn A, Conway J. The
cardiac model of rehabilitation for reducing cardiovascular risk factors
post transient ischaemic attack and stroke: a randomized controlled trial.
Clin Rehabil. 2014;28:339–349. doi: 10.1177/0269215513502211.
35. Liu J, Drutz C, Kumar R, McVicar L, Weinberger R, Brooks D, et al. Use
of the six-minute walk test poststroke: is there a practice effect? Arch Phys
Med Rehabil. 2008;89:1686–1692. doi: 10.1016/j.apmr.2008.02.026.
36. Fagard RH, Cornelissen VA. Effect of exercise on blood pressure control
in hypertensive patients. Eur J Cardiovasc Prev Rehabil. 2007;14:12–17.
doi: 10.1097/HJR.0b013e3280128bbb.
37.Rothwell PM, Algra A, Amarenco P. Medical treatment in acute
and long-term secondary prevention after transient ischaemic attack
and ischaemic stroke. Lancet. 2011;377:1681–1692. doi: 10.1016/
S0140-6736(11)60516-3.
38.PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack. Lancet.
2001;358:1033–1041.
39. Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K, et al.
Exercise-based rehabilitation for patients with coronary heart disease:
systematic review and meta-analysis of randomized controlled trials. Am
J Med. 2004;116:682–692. doi: 10.1016/j.amjmed.2004.01.009.
40. Mackay-Lyons MJ, Makrides L. Exercise capacity early after stroke. Arch
Phys Med Rehabil. 2002;83:1697–1702. doi: 10.1053/apmr.2002.36395.
41.Baert I, Daly D, Dejaeger E, Vanroy C, Vanlandewijck Y, Feys H.
Evolution of cardiorespiratory fitness after stroke: a 1-year follow-up
study. Influence of prestroke patients’ characteristics and stroke-related
factors. Arch Phys Med Rehabil. 2012;93:669–676. doi: 10.1016/j.
apmr.2011.09.022.
42. Glasziou PP, Chalmers I, Green S, Michie S. Intervention synthesis: a
missing link between a systematic review and practical treatment(s).
PLoS Med. 2014;11:e1001690. doi: 10.1371/journal.pmed.1001690.
43. French SD, Green SE, O’Connor DA, McKenzie JE, Francis JJ, Michie
S, et al. Developing theory-informed behaviour change interventions
to implement evidence into practice: a systematic approach using the
Theoretical Domains Framework. Implement Sci. 2012;7:38. doi:
10.1186/1748-5908-7-38.
44. Prochaska JO, Velicer WF. The transtheoretical model of health behavior
change. Am J Health Promot. 1997;12:38–48.
Lifestyle Interventions to Prevent Cardiovascular Events After Stroke and Transient
Ischemic Attack: Systematic Review and Meta-Analysis
Inger A. Deijle, Sander M. Van Schaik, Erwin E.H. Van Wegen, Henry C. Weinstein, Gert
Kwakkel and Renske M. Van den Berg-Vos
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SUPPLEMENTAL MATERIAL
Effects of lifestyle interventions to prevent recurrent cardiovascular events after transient
ischemic attack and ischemic stroke: a systematic review and meta-analysis.
Inger A. Deijle1, MSc; Sander M. Van Schaik2, MD; Erwin E.H. Van Wegen3, PhD; Henry C.
Weinstein2, MD PhD; Gert Kwakkel4, PhD; Renske M. Van den Berg-Vos2, MD PhD
1
Department of Physical Therapy, OLVG, Amsterdam, The Netherlands
Department of Neurology, OLVG, West, Amsterdam, The Netherlands
3
Department of Rehabilitation Medicine, Move Research Institute Amsterdam, VU Medical
Center, Amsterdam, The Netherlands.
4
Department of Rehabilitation Medicine, Move Research Institute Amsterdam, VU Medical
Center and Amsterdam Rehabilitation Research Center, Reade Center for Rehabilitation and
Rheumatology, Amsterdam, Netherlands
2
Corresponding author:
R.M. Van den Berg-Vos, M.D., Ph.D.
Department of Neurology, OLVG, West
Jan Tooropstraat 164, 1061 AE Amsterdam, The Netherlands
e-mail: [email protected]
tel: +31 205108780, fax: +31 206837198
1
TABLE OF CONTENTS
1. Material and methods
a. Definitions
b. Study selection
c. Data extraction
d. Quantitative analysis
2. Results, excluded studies
3. Table I: Included studies and therapy related factors
4. Table II: Risk of bias assessment
5. Figure I: Meta-analysis and subgroup analysis for mean difference in diastolic blood
pressure
6. Literature search strategy
7. References supplemental material
2
1. MATERIALS AND METHODS
1a. Definitions
In accordance with the definition used by the American Heart Association/American Stroke
Association (AHA/ASA), transient ischemic attack (TIA) was defined as “a transient episode
of neurological dysfunction caused by focal brain, or retinal ischemia, without acute
infarction”.1 Ischemic stroke was defined as “an episode of neurological dysfunction caused
by focal cerebral, or retinal infarction”.2 Minor stroke was not defined in a consensus
definition, but it is generally assumed that minor stroke is “an ischemic stroke with a shortterm good functional outcome”.3A study was considered an RCT when ‘‘the individuals
followed in the trial were definitely or possibly assigned prospectively to one of two (or
more) alternative forms of health care using random allocation’.4
At this moment there is no consensus on the classification of lifestyle interventions. In this
systematic review we use the following three categories: 1) behavior change interventions, 2)
cardiovascular fitness interventions or 3) a combination of both of these. Behavior change
interventions aim to change health behavior of patients, and thereby the behaviorally
modifiable risk factors.5,6 Behavior change interventions can be defined as “coordinated sets
of activities designed to change specified behavior patterns”.7 They address one or more of
the following aspects: physical inactivity, overweight or obesity, cigarette smoking, heavy
alcohol use, hypertension, lipid profile, medication adherence.8 There are various forms of
behavior change interventions. Widely used is education to improve knowledge about health
behavior. Other forms are counseling programs to improve self-management or selfregulation, and specific techniques such as motivational interviewing.9 Cardiovascular fitness
interventions are defined as “interventions with the aim to improve the level of physical
activity and/or cardiorespiratory fitness and to influence modifiable risk factors, for example
blood pressure and cholesterol”.5 The third type lifestyle intervention is a combination of a
behavior change intervention and a cardiovascular fitness intervention. In clinical practice the
combination of exercise training with psychosocial education is implemented at large scale in
so called cardiac rehabilitation programs for patients with CHD, which are effective in
reducing total and cardiovascular mortality and hospital admissions.10
In the subgroup analysis we explored if components of lifestyle interventions were
significantly associated with the prevention of recurrent cardiovascular events, reduced
mortality and improved modifiable risk factors. For this purpose the following therapy related
factors are explored: start of intervention relative to TIA or ischemic stroke onset, intensity,
total duration, use of behavior change techniques. The start of intervention was described as
the time from onset TIA or ischemic stroke until start of the intervention, and was described
in months. The intensity was defined as the amount of patient contacts, which can be done
face-to-face, via telephone or online. The total duration of the intervention was described in
months. To describe the use of behavior change techniques in this review, we used the
CALO-RE taxonomy from Michie et al.11 This taxonomy comprises 40 behavior change
techniques, and can be used to identify potential active ingredients in studies.
1b. Study selection
We searched Pubmed, Embase, PsycInfo and the Cochrane Library from the start of the
database up until May 7, 2015. An experienced librarian assisted in developing the search
strategy. The search was performed with an extensive string, including American/English
spelling and singular/plural terms. Keywords focused on TIA, stroke and synonyms, risk
reduction behavior, lifestyle interventions, exercise therapy, secondary prevention, diet,
smoking cessation and health knowledge (supplement 1). Studies were included if they met
the following inclusion criteria: 1) were Randomized Controlled Trials (RCT), 2) involved
3
patients older than 18 years, with a history of TIA or ischemic stroke, 3) compared the effect
of lifestyle interventions with usual care or no intervention, and 4) aimed to improve
cardiovascular risk profile, recurrence of cardiovascular events and mortality for TIA or
ischemic stroke survivors. The types of interventions included were behavior change
interventions, cardiovascular fitness interventions or a combination of both. Studies were
included when they used one of the following outcomes measures: risk of recurrent
cardiovascular disease (CHD, recurrent TIA or ischemic strokes, vascular death), blood
pressure (resting systolic and DBP), lipid profiles (total cholesterol, low and high density
lipoprotein cholesterol), physical activity measures (questionnaires and activity monitors),
cardiorespiratory fitness measured by maximal exercise capacity test (VO2max) or by
submaximal cycling, or walking capacity tests such as the 6 minutes walking distance
(6MWD), body weight (body mass index, waist circumference), dietary behavior, alcohol
use, and tobacco use. Studies with pharmacological interventions alone are excluded in this
systematic review.
1c. Data extraction
One review author (I.D) conducted the first search on titles based on the inclusion and
exclusion criteria. Two review authors scanned the extracted titles and abstracts
independently (I.D and S.S), they discussed differences and reached consensus. In the next
stage, the same two authors scanned full-text articles independently and they discussed their
selection for inclusion and reached consensus. Recorded data variables were trial name, year
of publication, country of origin, patient characteristics, start of intervention, intensity, total
duration, mode of delivery, use of behavior change techniques, setting, health care provider,
use of theoretical framework, outcome measures, duration of follow-up, and number of
patients for each group. Corresponding authors were contacted if data was unclear or missing.
1d. Quantitative analysis
The data required for meta-analyses of continuous data were numbers of patients, outcome
measures, means, and standard deviations (SD) of post-intervention scores on outcome
measures for both the experimental and control group means. For continuous data, mean
differences (MD) with 95% confidence intervals (CIs) were calculated if the studies used the
same instrument to measure an outcome (for example blood pressure). If studies used
different instruments (for example different maximal exercise capacity tests), the
standardized mean difference (SMD) with 95% CI was calculated. When the standard
deviation (SD) was missing, standard error or 95% CI was used to calculate the SD. For
dichotomous data, risk ratios (RR) with 95% CIs were calculated using the Mantel-Haenszel
statistical method. We assume in our meta-analysis that the effects of lifestyle interventions
have the same quantity or impact on stroke patients irrespective of age, gender, ethnicity or
having risk factors for stroke. With that, we theoretically assumed that the effects of lifestyle
interventions are the more or less the same among different stroke phenotypes and chose for a
fixed-effects model and subsequently, verified the model by using the I2 ratio test with a cut
off of 50% or less. In case of significant heterogeneity, a random effects model was used in
line with the guidelines of the Cochrane Handbook (version5.1.0). We assessed the
possibility of publication bias by evaluating a funnel plot of the trial mean differences for
asymmetry, which can result from the nonpublication of small trials with negative results.
When a protocol of an individual study was available, the outcomes in the protocol and the
published report was compared.
4
2. RESULTS, EXCLUDED STUDIES
15 studies were subsequently excluded: two studies because the reported outcome was other
than the aforementioned outcome measure,12,13 six studies were no RCTs14-19 and seven
studies included other patients than patients with TIA or ischemic stroke. 20-26
5
3. Table I: Included studies and therapy related factors
Author, year of publication,
country
Patient characteristics
(patient condition, N,
age, % men)
Description intervention
Follow-up
Start of
intervention
Intervention: intensity &
total duration
Adie et al. (2010) UK
Minor stroke or TIA
N=56
Age= 74.7
Men = 54%
Intervention group: telephone
follow-up and educational
material.
6 months
< 1 month after Intensity: 4 patient contacts
minor
Total duration: 4 months
stroke/TIA
2. Provide information on
consequences of behavior to the
individual
27. Use of follow up prompts
37. Motivational interviewing
< 1 month post
discharge
Intensity: 0 patient contacts
Total duration: 3 months
2. Provide information on
consequences of behavior to the
individual
27. Use of follow up prompts
6 months
< 2 months
post discharge
Intensity: 12 patient contacts 2. Provide information on
Total duration: 6 months
consequences of behavior to the
individual
16. Prompt self-monitoring of
behavior
27. Use of follow up prompts
6 months
< 1 month post
discharge
Intensity: 7 patient contacts
Total duration: 4.5 months
2. Provide information on
consequences of behavior to the
individual
5. Goal setting (behavior)
16. Self-monitoring of behavior
18. Prompting focus on past
success
27. Use of follow up prompts
28. Facilitate social comparison
5 months
< 3 months
after
stroke/TIA
Intensity: 3 patient contacts
Total duration: 3 months
2. Provide information on
consequences of behavior to the
individual
27. Use of follow up prompts
Control group: usual care.
Allen et al. (2002) USA
Ischemic stroke or TIA
N=96
Age= 70.5
Men = 44.5 %
Intervention group: an individual 3 months
treatment plan for patients and
GP.
Behavior change techniques*
Control group: usual care.
Allen et al. (2009) USA
Ischemic stroke
N= 360
Age= 68.5
Men= 50%
Intervention group: home visit
with standard education.
Personalized health record and
periodic phone calls. A copy of
the care plans was send to GP.
Control group: usual care +
written patient summary.
Damush et al. (2011) USA
Ischemic stroke
N= 63
Age= 65.7
Men= 98.4%
Intervention group: stroke selfmanagement program with a 2
weekly telephone sessions, and
at 4.5 months a booster call.
Control group: written patient
education materials, placebo
telephone calls.
Ellis et al. (2005) UK
Stroke or TIA
N=205
Age=65.1
Men=53%
Intervention group: individual
advice on lifestyle changes and
written information.
Control group: usual care.
Flemming et al (2013) USA
Gillham et al. (2010) UK
Atherosclerotic ischemic
stroke
N=42
Age= 70.1
Men= 58.5 %
Intervention group: a physiciandirected nurse-case-management
program.
Minor stroke or TIA
N= 52
Age=68.3
Men=71 %
Intervention group: information
from the nurse practitioner. Two
times telephone support to
discuss progress.
12 months
< 3 months
after stroke
Intensity: 5 patient contacts
Total duration: 1 year
2. Provide information on
consequences of behavior to the
individual
5. Goal setting (behavior)
27. Use of follow up prompts
37. Motivational Interviewing
3 months
Patient were
recruited from
stroke clinic
Intensity: 3 patient contacts
Total duration: 1.5 months
2. Provide information on
consequences of behavior to the
individual
27. Use of follow up prompts
37. Motivational Interviewing
3 months
Direct after
minor stroke/
TIA
Intensity: 2 patient contacts
Total duration: 2 months
2. Provide information on
consequences of behavior to the
individual
27. Use of follow up prompts
37. Motivational Interviewing
3 months
< 12 months
post stroke
Intensity: 9 patient contacts
Total duration: 9 weeks
2. Provide information on
consequences of behavior to the
individual
16. Prompt self-monitoring of
target behavior
19. Provide feedback on
performance
27. Use of follow up prompts
caregivers, web based, selfefficacy
29. Plan social support /social
change
3 months
< 3 months
after
stroke/TIA
Intensity: 1 patient contact
Total duration: 1
intervention of 20 to 25
minutes
2. Provide information on
consequences of behavior to the
individual
Control group: usual care.
Control group: usual care.
Green et al. (2007) Canada
Stroke
N= 200
Age=66.8
Men= 58.5 %
Intervention group: nursemediated motivational
counseling intervention and a 3hour lifestyle group class.
Control group: usual care.
Kim et al.(2013) Republic of
Korea)
Maasland et al. (2007) The
Netherlands
Ischemic stroke
N=36
Age=65.6 years
Men= 63.9 %
Intervention group: web-based
stoke education program.
Minor stroke or TIA
N= 65
Age=64
Men= 60%
Intervention group: information
from the physician, health
information by an individualized
multimedia computer program,
printed summary.
Control group: usual care.
Control group: usual care.
7
McManus et al. (2007) UK
Stroke or TIA
N= 102
Age= unclear
Men= unclear
Intervention group: three times
written and verbal about
lifestyle. Risk factors were
assessed at each visit.
43 months
< 3 months
after stroke
Intensity: 3 patient contacts
Total duration: 3 months
2. Provide information on
consequences of behavior to the
individual
27. Use of follow up prompts
8 months
< 6 months
after stroke
Intensity: 0 patient contacts
Total duration: 8 months
2. Provide information on
consequences of behavior to the
individual
< 90 days after
stroke
Intensity: 5 patient contacts
Total duration: 24 months
2. Provide information on
consequences of behavior to the
individual
5. Goal setting (behavior)
25. Agree behavior contract
27. Use of follow up prompts
< 6 months
after stroke
Intensity: 30 patient contacts 21. Provide instruction on how
Total duration: 2.5 months
to perform the behavior
Control group: usual care.
Wolfe et al. ( 2010) UK
Stroke
N= 523
Age= 21.29% >80 years
Men= 53%
Intervention group: Tailored
evidence-based management
advice was provided on paper to
patients, their GP, and
caregivers. At 3 and 6 months
keeping well plan was modified.
Control group: usual care.
Exercise interventions
Boysen et al. (2009) Denmark
Ischemic stroke
N= 314
Age= 69.5
Men=31.5 %
Intervention group: repeated
24 months
individual instruction to improve
physical activity. Follow-up
visits with repeated instruction
and readjustment physical
activity plan.
Control group: patients receive
information on the possible
benefits of physical benefits but
no specific instruction.
Potempa et al. (1995) USA
Hemiplegic stroke
N= 42
Age= 43 to 72 years
Men= 54.8 %
Intervention group: patients
received exercise training on an
adapted cycle ergometer.
2.5 months
Control group: 10 weeks
program of passive range of
motion exercise.
8
Rimmer et al. (2009) USA
Unilateral ischemic stroke
N=55
Age= 59.6 years
Men= 40%
Intervention group 1: moderate
intensity, shorter duration
exercise
3.5 months
< 6 months
after stroke
Intensity:
MISD group: 24 patient
contacts
LILD group: 24 patient
contacts
Total duration: 3.5 months
6 months
Chronic phase
Intensity: 72 patient contacts 5. Goal setting (behavior)
Total duration: 6 months
21. Provide instruction on how
to perform the behavior
2.5 months
1-3 weeks after Intensity: 12 patient contacts 21. Provide instruction on how
minor stroke
Total duration: 2.5 months
to perform the behavior
12 months
< 3 months
after minor
stroke/TIA
2 months
< 2 weeks after Intensity: 32 patient contacts 2. Provide information on
NDS/TIA
Total duration: 8 weeks
consequences of behavior to the
individual
Intervention group 2: lowintensity, longer duration
exercise.
21. Provide instruction on how
to perform the behavior
Control group: conventional
therapeutic exercise.
Shaughnessy et al. (2012)
Ischemic stroke
N= 113
Age= 64.4
Men= 44 %
Intervention group: treadmill
training focused on an ultimate
goal of engaging the patients in
three 40-minute exercise
sessions weekly.
Control group: stretching
program.
Toledano-Zarhi et al. (2011)
Israel
Minor stroke
N= 28
Age= 65
Men= 75 %
Intervention group: exercise
program on a treadmill, bike
machine. Group practice for
strength, flexibility and
coordination performances. A
home exercise booklet was
provided.
Control group: instructions in
home practice to achieve
strength and flexibility and
continue with normal routine.
Combined interventions
Boss & van Schaik et al. (2014 Minor stroke and TIA
) The Netherlands
N=20
Age: 62.7
Men: 70%
Intervention group: 8 weeks
exercise program and individual
lifestyle guidance.
Control group: usual care.
Faulker et al. (2013) New
Zealand
TIA and nondisabling
stroke (NDS)
N=60
Intervention group: exercise and
education sessions.
Intensity: 28 patient contacts 2. Provide information on
Total duration: 1 year
consequences of behavior to the
individual
21. Provide instruction on how
to perform the behavior
27. Use of follow up prompts
37. Motivational Interviewing
9
Kirk et al. (2014) UK
Age=68.5 years
Men= 51,7 %
Control group: usual care.
21. Provide instruction on how
to perform the behavior
27. Use of follow up prompts
TIA and minor stroke
N=24
Age=67.2 years
Men= 79.2 %
Intervention group: cardiac
6 months
rehabilitation program consisting
of weekly exercise and
education classes
< 1month after
TIA/minor
stroke
Intensity: 24 patient contacts 2. Provide information on
Total duration: 8 weeks
consequences of behavior to the
individual
21. Provide instruction on how
to perform the behavior
27. Use of follow up prompts
35 months
Acute mild
non cardio
embolic
ischemic
stroke
Intensity: 51 patient contacts 2. Provide information on
Total duration: 6 months
consequences of behavior to the
individual
5. Goal setting (behavior)
10. Prompt review of behavior
goals
17. Prompt self-monitoring of
behavior
21. Provide instruction on how
to perform the behavior
26. Prompt practice
27. Use of follow up prompts
2.5 months
> 1 year after
stroke
Intensity: 20 patient contacts 19. Provide feedback on
Total duration: 2.5 months
performance
21. Provide instruction on how
to perform the behavior
36. Stress management /
emotional control training
Control group: usual care.
Kono et al. (2013) Japan
Mild ischemic stroke
N=70
Age=63.5 years
Men= 68.6 %
Intervention group: exercise
training, salt restriction and
nutrition advice.
Control group: 3 times lifestyle
modification + usual medical
care.
Lennon et al. (2008) Ireland
Ischemic stroke
N= 48
Age= 59.8
Men= 58%
Intervention group: 30-minute
cycle ergometer exercise.
Patients received two life skills
classes addressing stress
management, relaxation and life
balance.
Control group: usual care.
*The behavior change techniques are numbered according to the Taxonomy from Michie 2011.11
10
4. Table II: Risk of bias assessment (Cochrane handbook) (yes, no, unclear)
Study
Sequence
generation
Allocation
concealment
Blinding of
personnel
and
outcome
assessors
Incomplete
outcome
data
addressed
Free of
selective
reporting
Free of other
risk of bias
Risk of
bias
Behaviour change
interventions
Adie et al. (2010)
Unclear
Yes
Unclear
Yes
Yes
Yes
Moderate
Allen et al. (2002)
Allen et al. (2009)
Damush et al. (2011)
Ellis et al. (2005)
Yes
Yes
Yes
Yes
Yes
Yes
Unclear
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
High
Low
Moderate
Low
Flemming et al. (2013)
Gillham et al. (2010)
Green et al. (2007)
Kim et al. 2013
Maasland et al. (2007)
McManus et al. (2007)
Wolfe et al. ( 2010)
Exercise interventions
Boysen et al. (2009)
Potempa et al. (1995)
Rimmer et al. (2009)
Shaughnessy et al. (2012)
Toledano-Zarhi et al. (2011)
Combined interventions
Boss & van Schaik et al. (2014)
Faulkner et al. (2013)
Kirk et al. (2014) UK
Unclear
Yes
Unclear
Yes
Yes
Yes
Yes
Unclear
Yes
Yes
Unclear
Unclear
Yes
Yes
No
No
Yes
Unclear
Unclear
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
High
High
High
Moderate
Moderate
Low
Low
Yes
Unclear
No
Unclear
Unclear
Yes
Unclear
Unclear
Unclear
Unclear
Yes
Unclear
Yes
Unclear
Unclear
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Low
Moderate
High
Moderate
Moderate
Unclear
Yes
Yes
Unclear
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Moderate
Low
Low
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Low
Low
Kono et al. (2013)
Lennon et al. (2008)
11
5. Figure I: Meta-analysis and subgroup analysis for mean difference in diastolic blood
pressure with 95% confidence interval (CI) (lifestyle interventions vs usual care) among
patients with TIA or ischemic stroke.
IV: Inverse Variance; SD: standard deviation.
6. LITERATURE SEARCH STRATEGY
#1 Search ((("Stroke"[Mesh] OR stroke*[tiab] OR cerebrovascular accident*[tiab] OR brain
vascular accident*[tiab] OR apoplex*[tiab] OR cva[tiab] OR cvas[tiab])) AND ("Secondary
Prevention"[Mesh] OR "Life Style"[Mesh] OR "Exercise"[Mesh] OR "Exercise
Therapy"[Mesh] OR "Tobacco Use Cessation"[Mesh] OR risk reduction behavior*[tiab] OR
risk reduction behaviour*[tiab] OR secondary preventi*[tiab] OR lifestyle*[tiab] OR life
style*[tiab] OR exercis*[tiab] OR smoking cessati*[tiab] OR walking*[tiab])) AND
(((((randomized controlled trial[pt] OR controlled clinical trial[pt] OR randomized[tiab] OR
placebo[tiab] OR drug therapy[sh] OR randomly[tiab] OR trial[tiab] OR groups[tiab]))) OR
((((review[tiab] OR "Review"[Publication Type] OR "Meta-Analysis as Topic"[Mesh] OR
meta-analysis[tiab] OR "Meta-Analysis "[Publication Type]) NOT ("Letter"[Publication
Type] OR "Editorial"[Publication Type] OR "Comment"[Publication Type])) NOT
("Animals"[Mesh] NOT ("Animals"[Mesh] AND "Humans"[Mesh]))))) OR ("Epidemiologic
Studies"[Mesh] OR cohort[tiab] OR longitudinal[tiab] OR prospective[tiab] OR
retrospective[tiab] OR follow up[tiab] OR followup[tiab]))
#2 Search (((("Stroke"[Mesh] OR "Ischemic Attack, Transient"[Mesh]) AND ("Secondary
Prevention"[Mesh] OR "Tertiary Prevention"[Mesh])))) OR ((("Secondary Prevention"[Mesh]
OR "Tertiary Prevention"[Mesh] OR "Risk Reduction Behavior"[Mesh:NoExp] OR "Life
Style"[Mesh] OR "Rehabilitation Nursing"[Mesh] OR "rehabilitation" [Subheading] OR
"Rehabilitation"[Mesh] OR "Exercise"[Mesh] OR "Exercise Therapy"[Mesh] OR "Health
Behavior"[Mesh] OR "Tobacco Use Cessation"[Mesh] OR "Diet"[Mesh] OR "Diet
Therapy"[Mesh] OR "Health Knowledge, Attitudes, Practice"[Mesh] OR risk reduction
behavior*[tiab] OR risk reduction behaviour*[tiab] OR secondary preventi*[tiab] OR tertiary
preventi*[tiab] OR lifestyle*[tiab] OR life style*[tiab] OR rehabilitati*[tiab] OR
exercis*[tiab] OR health behavior*[tiab] OR health behaviour*[tiab] OR training*[tiab] OR
walking*[tiab] OR smoking cessati*[tiab] OR tobacco[tiab] OR diet[tiab] OR diets[tiab] OR
dietary[tiab] OR health knowledge[tiab] OR aerobic*[tiab] OR "Health Education"[Mesh]
OR health educati*[tiab] OR "Exercise"[Mesh])) AND (("Ischemic Attack, Transient"[Mesh]
OR tia[tiab] OR tias[tiab] OR transient ischemic attack*[tiab] OR transient ischaemic
attack*[tiab] OR minor stroke*[tiab]))) OR (("Stroke"[Mesh] OR stroke*[tiab] OR
cerebrovascular accident*[tiab] OR brain vascular accident*[tiab] OR apoplex*[tiab] OR
cva[tiab] OR cvas[tiab]) AND (("Secondary Prevention"[Mesh] OR "Tertiary
Prevention"[Mesh] OR secondary preventi*[tiab] OR tertiary preventi*[tiab])) AND (("Risk
Reduction Behavior"[Mesh:NoExp] OR "Life Style"[Mesh] OR "Rehabilitation
Nursing"[Mesh] OR "rehabilitation" [Subheading] OR "Rehabilitation"[Mesh] OR
"Exercise"[Mesh] OR "Exercise Therapy"[Mesh] OR "Health Behavior"[Mesh] OR "Tobacco
Use Cessation"[Mesh] OR "Diet"[Mesh] OR "Diet Therapy"[Mesh] OR "Health Knowledge,
Attitudes, Practice"[Mesh] OR risk reduction behavior*[tiab] OR risk reduction
behaviour*[tiab] OR lifestyle*[tiab] OR life style*[tiab] OR rehabilitati*[tiab] OR
exercis*[tiab] OR health behavior*[tiab] OR health behaviour*[tiab] OR training*[tiab] OR
walking*[tiab] OR smoking cessati*[tiab] OR tobacco[tiab] OR diet[tiab] OR diets[tiab] OR
dietary[tiab] OR health knowledge[tiab] OR aerobic*[tiab] OR "Health Education"[Mesh]
OR health educati*[tiab] OR "Exercise"[Mesh])))
#3 Search (((("Stroke"[Mesh] OR stroke*[tiab] OR cerebrovascular accident*[tiab] OR brain
vascular accident*[tiab] OR apoplex*[tiab] OR cva[tiab] OR cvas[tiab])) AND (("Secondary
Prevention"[Mesh] OR "Life Style"[Mesh] OR "Exercise"[Mesh] OR "Exercise
Therapy"[Mesh] OR "Tobacco Use Cessation"[Mesh] OR risk reduction behavior*[tiab] OR
risk reduction behaviour*[tiab] OR secondary preventi*[tiab] OR lifestyle*[tiab] OR life
style*[tiab] OR exercis*[tiab] OR smoking cessati*[tiab] OR "Exercise"[Mesh])))) AND
((((randomized controlled trial[pt] OR controlled clinical trial[pt] OR randomized[tiab] OR
placebo[tiab] OR drug therapy[sh] OR randomly[tiab] OR trial[tiab] OR groups[tiab]))) AND
((((review[tiab] OR "Review"[Publication Type] OR "Meta-Analysis as Topic"[Mesh] OR
meta-analysis[tiab] OR "Meta-Analysis "[Publication Type]) NOT ("Letter"[Publication
Type] OR "Editorial"[Publication Type] OR "Comment"[Publication Type])) NOT
("Animals"[Mesh] NOT ("Animals"[Mesh] AND "Humans"[Mesh])))))
#4 Search (((((("Stroke"[Mesh] OR stroke*[tiab] OR cerebrovascular accident*[tiab] OR
brain vascular accident*[tiab] OR apoplex*[tiab] OR cva[tiab] OR cvas[tiab])) AND
("Secondary Prevention"[Mesh] OR "Life Style"[Mesh] OR "Exercise"[Mesh] OR "Exercise
Therapy"[Mesh] OR "Tobacco Use Cessation"[Mesh] OR risk reduction behavior*[tiab] OR
risk reduction behaviour*[tiab] OR secondary preventi*[tiab] OR lifestyle*[tiab] OR life
style*[tiab] OR exercis*[tiab] OR smoking cessati*[tiab] OR walking*[tiab])) AND
(((((randomized controlled trial[pt] OR controlled clinical trial[pt] OR randomized[tiab] OR
placebo[tiab] OR drug therapy[sh] OR randomly[tiab] OR trial[tiab] OR groups[tiab]))) OR
((((review[tiab] OR "Review"[Publication Type] OR "Meta-Analysis as Topic"[Mesh] OR
meta-analysis[tiab] OR "Meta-Analysis "[Publication Type]) NOT ("Letter"[Publication
Type] OR "Editorial"[Publication Type] OR "Comment"[Publication Type])) NOT
("Animals"[Mesh] NOT ("Animals"[Mesh] AND "Humans"[Mesh]))))) OR ("Epidemiologic
Studies"[Mesh] OR cohort[tiab] OR longitudinal[tiab] OR prospective[tiab] OR
retrospective[tiab] OR follow up[tiab] OR followup[tiab])))) OR ((((("Stroke"[Mesh] OR
"Ischemic Attack, Transient"[Mesh]) AND ("Secondary Prevention"[Mesh] OR "Tertiary
Prevention"[Mesh])))) OR ((("Secondary Prevention"[Mesh] OR "Tertiary Prevention"[Mesh]
OR "Risk Reduction Behavior"[Mesh:NoExp] OR "Life Style"[Mesh] OR "Rehabilitation
Nursing"[Mesh] OR "rehabilitation" [Subheading] OR "Rehabilitation"[Mesh] OR
"Exercise"[Mesh] OR "Exercise Therapy"[Mesh] OR "Health Behavior"[Mesh] OR "Tobacco
Use Cessation"[Mesh] OR "Diet"[Mesh] OR "Diet Therapy"[Mesh] OR "Health Knowledge,
Attitudes, Practice"[Mesh] OR risk reduction behavior*[tiab] OR risk reduction
13
behaviour*[tiab] OR secondary preventi*[tiab] OR tertiary preventi*[tiab] OR lifestyle*[tiab]
OR life style*[tiab] OR rehabilitati*[tiab] OR exercis*[tiab] OR health behavior*[tiab] OR
health behaviour*[tiab] OR training*[tiab] OR walking*[tiab] OR smoking cessati*[tiab] OR
tobacco[tiab] OR diet[tiab] OR diets[tiab] OR dietary[tiab] OR health knowledge[tiab] OR
aerobic*[tiab] OR "Health Education"[Mesh] OR health educati*[tiab] OR
"Exercise"[Mesh])) AND (("Ischemic Attack, Transient"[Mesh] OR tia[tiab] OR tias[tiab]
OR transient ischemic attack*[tiab] OR transient ischaemic attack*[tiab] OR minor
stroke*[tiab]))) OR (("Stroke"[Mesh] OR stroke*[tiab] OR cerebrovascular accident*[tiab]
OR brain vascular accident*[tiab] OR apoplex*[tiab] OR cva[tiab] OR cvas[tiab]) AND
(("Secondary Prevention"[Mesh] OR "Tertiary Prevention"[Mesh] OR secondary
preventi*[tiab] OR tertiary preventi*[tiab])) AND (("Risk Reduction
Behavior"[Mesh:NoExp] OR "Life Style"[Mesh] OR "Rehabilitation Nursing"[Mesh] OR
"rehabilitation" [Subheading] OR "Rehabilitation"[Mesh] OR "Exercise"[Mesh] OR
"Exercise Therapy"[Mesh] OR "Health Behavior"[Mesh] OR "Tobacco Use
Cessation"[Mesh] OR "Diet"[Mesh] OR "Diet Therapy"[Mesh] OR "Health Knowledge,
Attitudes, Practice"[Mesh] OR risk reduction behavior*[tiab] OR risk reduction
behaviour*[tiab] OR lifestyle*[tiab] OR life style*[tiab] OR rehabilitati*[tiab] OR
exercis*[tiab] OR health behavior*[tiab] OR health behaviour*[tiab] OR training*[tiab] OR
walking*[tiab] OR smoking cessati*[tiab] OR tobacco[tiab] OR diet[tiab] OR diets[tiab] OR
dietary[tiab] OR health knowledge[tiab] OR aerobic*[tiab] OR "Health Education"[Mesh]
OR health educati*[tiab] OR "Exercise"[Mesh]))))) OR ((((("Stroke"[Mesh] OR stroke*[tiab]
OR cerebrovascular accident*[tiab] OR brain vascular accident*[tiab] OR apoplex*[tiab] OR
cva[tiab] OR cvas[tiab])) AND (("Secondary Prevention"[Mesh] OR "Life Style"[Mesh] OR
"Exercise"[Mesh] OR "Exercise Therapy"[Mesh] OR "Tobacco Use Cessation"[Mesh] OR
risk reduction behavior*[tiab] OR risk reduction behaviour*[tiab] OR secondary
preventi*[tiab] OR lifestyle*[tiab] OR life style*[tiab] OR exercis*[tiab] OR smoking
cessati*[tiab] OR "Exercise"[Mesh])))) AND ((((randomized controlled trial[pt] OR
controlled clinical trial[pt] OR randomized[tiab] OR placebo[tiab] OR drug therapy[sh] OR
randomly[tiab] OR trial[tiab] OR groups[tiab]))) AND ((((review[tiab] OR
"Review"[Publication Type] OR "Meta-Analysis as Topic"[Mesh] OR meta-analysis[tiab] OR
"Meta-Analysis "[Publication Type]) NOT ("Letter"[Publication Type] OR
"Editorial"[Publication Type] OR "Comment"[Publication Type])) NOT ("Animals"[Mesh]
NOT ("Animals"[Mesh] AND "Humans"[Mesh]))))))
# 5 Search (((((("Stroke"[Mesh] OR stroke*[tiab] OR cerebrovascular accident*[tiab] OR
brain vascular accident*[tiab] OR apoplex*[tiab] OR cva[tiab] OR cvas[tiab])) AND
("Secondary Prevention"[Mesh] OR "Life Style"[Mesh] OR "Exercise"[Mesh] OR "Exercise
Therapy"[Mesh] OR "Tobacco Use Cessation"[Mesh] OR risk reduction behavior*[tiab] OR
risk reduction behaviour*[tiab] OR secondary preventi*[tiab] OR lifestyle*[tiab] OR life
style*[tiab] OR exercis*[tiab] OR smoking cessati*[tiab] OR walking*[tiab])) AND
(((((randomized controlled trial[pt] OR controlled clinical trial[pt] OR randomized[tiab] OR
placebo[tiab] OR drug therapy[sh] OR randomly[tiab] OR trial[tiab] OR groups[tiab]))) OR
((((review[tiab] OR "Review"[Publication Type] OR "Meta-Analysis as Topic"[Mesh] OR
meta-analysis[tiab] OR "Meta-Analysis "[Publication Type]) NOT ("Letter"[Publication
Type] OR "Editorial"[Publication Type] OR "Comment"[Publication Type])) NOT
("Animals"[Mesh] NOT ("Animals"[Mesh] AND "Humans"[Mesh]))))) OR ("Epidemiologic
Studies"[Mesh] OR cohort[tiab] OR longitudinal[tiab] OR prospective[tiab] OR
retrospective[tiab] OR follow up[tiab] OR followup[tiab])))) OR ((((("Stroke"[Mesh] OR
"Ischemic Attack, Transient"[Mesh]) AND ("Secondary Prevention"[Mesh] OR "Tertiary
Prevention"[Mesh])))) OR ((("Secondary Prevention"[Mesh] OR "Tertiary Prevention"[Mesh]
14
OR "Risk Reduction Behavior"[Mesh:NoExp] OR "Life Style"[Mesh] OR "Rehabilitation
Nursing"[Mesh] OR "rehabilitation" [Subheading] OR "Rehabilitation"[Mesh] OR
"Exercise"[Mesh] OR "Exercise Therapy"[Mesh] OR "Health Behavior"[Mesh] OR "Tobacco
Use Cessation"[Mesh] OR "Diet"[Mesh] OR "Diet Therapy"[Mesh] OR "Health Knowledge,
Attitudes, Practice"[Mesh] OR risk reduction behavior*[tiab] OR risk reduction
behaviour*[tiab] OR secondary preventi*[tiab] OR tertiary preventi*[tiab] OR lifestyle*[tiab]
OR life style*[tiab] OR rehabilitati*[tiab] OR exercis*[tiab] OR health behavior*[tiab] OR
health behaviour*[tiab] OR training*[tiab] OR walking*[tiab] OR smoking cessati*[tiab] OR
tobacco[tiab] OR diet[tiab] OR diets[tiab] OR dietary[tiab] OR health knowledge[tiab] OR
aerobic*[tiab] OR "Health Education"[Mesh] OR health educati*[tiab] OR
"Exercise"[Mesh])) AND (("Ischemic Attack, Transient"[Mesh] OR tia[tiab] OR tias[tiab]
OR transient ischemic attack*[tiab] OR transient ischaemic attack*[tiab] OR minor
stroke*[tiab]))) OR (("Stroke"[Mesh] OR stroke*[tiab] OR cerebrovascular accident*[tiab]
OR brain vascular accident*[tiab] OR apoplex*[tiab] OR cva[tiab] OR cvas[tiab]) AND
(("Secondary Prevention"[Mesh] OR "Tertiary Prevention"[Mesh] OR secondary
preventi*[tiab] OR tertiary preventi*[tiab])) AND (("Risk Reduction
Behavior"[Mesh:NoExp] OR "Life Style"[Mesh] OR "Rehabilitation Nursing"[Mesh] OR
"rehabilitation" [Subheading] OR "Rehabilitation"[Mesh] OR "Exercise"[Mesh] OR
"Exercise Therapy"[Mesh] OR "Health Behavior"[Mesh] OR "Tobacco Use
Cessation"[Mesh] OR "Diet"[Mesh] OR "Diet Therapy"[Mesh] OR "Health Knowledge,
Attitudes, Practice"[Mesh] OR risk reduction behavior*[tiab] OR risk reduction
behaviour*[tiab] OR lifestyle*[tiab] OR life style*[tiab] OR rehabilitati*[tiab] OR
exercis*[tiab] OR health behavior*[tiab] OR health behaviour*[tiab] OR training*[tiab] OR
walking*[tiab] OR smoking cessati*[tiab] OR tobacco[tiab] OR diet[tiab] OR diets[tiab] OR
dietary[tiab] OR health knowledge[tiab] OR aerobic*[tiab] OR "Health Education"[Mesh]
OR health educati*[tiab] OR "Exercise"[Mesh]))))) OR ((((("Stroke"[Mesh] OR stroke*[tiab]
OR cerebrovascular accident*[tiab] OR brain vascular accident*[tiab] OR apoplex*[tiab] OR
cva[tiab] OR cvas[tiab])) AND (("Secondary Prevention"[Mesh] OR "Life Style"[Mesh] OR
"Exercise"[Mesh] OR "Exercise Therapy"[Mesh] OR "Tobacco Use Cessation"[Mesh] OR
risk reduction behavior*[tiab] OR risk reduction behaviour*[tiab] OR secondary
preventi*[tiab] OR lifestyle*[tiab] OR life style*[tiab] OR exercis*[tiab] OR smoking
cessati*[tiab] OR "Exercise"[Mesh])))) AND ((((randomized controlled trial[pt] OR
controlled clinical trial[pt] OR randomized[tiab] OR placebo[tiab] OR drug therapy[sh] OR
randomly[tiab] OR trial[tiab] OR groups[tiab]))) AND ((((review[tiab] OR
"Review"[Publication Type] OR "Meta-Analysis as Topic"[Mesh] OR meta-analysis[tiab] OR
"Meta-Analysis "[Publication Type]) NOT ("Letter"[Publication Type] OR
"Editorial"[Publication Type] OR "Comment"[Publication Type])) NOT ("Animals"[Mesh]
NOT ("Animals"[Mesh] AND "Humans"[Mesh])))))) Filters: Publication date from
2012/02/01
#6 Search (((((("Stroke"[Mesh] OR stroke*[tiab] OR cerebrovascular accident*[tiab] OR
brain vascular accident*[tiab] OR apoplex*[tiab] OR cva[tiab] OR cvas[tiab])) AND
("Secondary Prevention"[Mesh] OR "Life Style"[Mesh] OR "Exercise"[Mesh] OR "Exercise
Therapy"[Mesh] OR "Tobacco Use Cessation"[Mesh] OR risk reduction behavior*[tiab] OR
risk reduction behaviour*[tiab] OR secondary preventi*[tiab] OR lifestyle*[tiab] OR life
style*[tiab] OR exercis*[tiab] OR smoking cessati*[tiab] OR walking*[tiab])) AND
(((((randomized controlled trial[pt] OR controlled clinical trial[pt] OR randomized[tiab] OR
placebo[tiab] OR drug therapy[sh] OR randomly[tiab] OR trial[tiab] OR groups[tiab]))) OR
((((review[tiab] OR "Review"[Publication Type] OR "Meta-Analysis as Topic"[Mesh] OR
meta-analysis[tiab] OR "Meta-Analysis "[Publication Type]) NOT ("Letter"[Publication
15
Type] OR "Editorial"[Publication Type] OR "Comment"[Publication Type])) NOT
("Animals"[Mesh] NOT ("Animals"[Mesh] AND "Humans"[Mesh]))))) OR ("Epidemiologic
Studies"[Mesh] OR cohort[tiab] OR longitudinal[tiab] OR prospective[tiab] OR
retrospective[tiab] OR follow up[tiab] OR followup[tiab])))) OR ((((("Stroke"[Mesh] OR
"Ischemic Attack, Transient"[Mesh]) AND ("Secondary Prevention"[Mesh] OR "Tertiary
Prevention"[Mesh])))) OR ((("Secondary Prevention"[Mesh] OR "Tertiary Prevention"[Mesh]
OR "Risk Reduction Behavior"[Mesh:NoExp] OR "Life Style"[Mesh] OR "Rehabilitation
Nursing"[Mesh] OR "rehabilitation" [Subheading] OR "Rehabilitation"[Mesh] OR
"Exercise"[Mesh] OR "Exercise Therapy"[Mesh] OR "Health Behavior"[Mesh] OR "Tobacco
Use Cessation"[Mesh] OR "Diet"[Mesh] OR "Diet Therapy"[Mesh] OR "Health Knowledge,
Attitudes, Practice"[Mesh] OR risk reduction behavior*[tiab] OR risk reduction
behaviour*[tiab] OR secondary preventi*[tiab] OR tertiary preventi*[tiab] OR lifestyle*[tiab]
OR life style*[tiab] OR rehabilitati*[tiab] OR exercis*[tiab] OR health behavior*[tiab] OR
health behaviour*[tiab] OR training*[tiab] OR walking*[tiab] OR smoking cessati*[tiab] OR
tobacco[tiab] OR diet[tiab] OR diets[tiab] OR dietary[tiab] OR health knowledge[tiab] OR
aerobic*[tiab] OR "Health Education"[Mesh] OR health educati*[tiab] OR
"Exercise"[Mesh])) AND (("Ischemic Attack, Transient"[Mesh] OR tia[tiab] OR tias[tiab]
OR transient ischemic attack*[tiab] OR transient ischaemic attack*[tiab] OR minor
stroke*[tiab]))) OR (("Stroke"[Mesh] OR stroke*[tiab] OR cerebrovascular accident*[tiab]
OR brain vascular accident*[tiab] OR apoplex*[tiab] OR cva[tiab] OR cvas[tiab]) AND
(("Secondary Prevention"[Mesh] OR "Tertiary Prevention"[Mesh] OR secondary
preventi*[tiab] OR tertiary preventi*[tiab])) AND (("Risk Reduction
Behavior"[Mesh:NoExp] OR "Life Style"[Mesh] OR "Rehabilitation Nursing"[Mesh] OR
"rehabilitation" [Subheading] OR "Rehabilitation"[Mesh] OR "Exercise"[Mesh] OR
"Exercise Therapy"[Mesh] OR "Health Behavior"[Mesh] OR "Tobacco Use
Cessation"[Mesh] OR "Diet"[Mesh] OR "Diet Therapy"[Mesh] OR "Health Knowledge,
Attitudes, Practice"[Mesh] OR risk reduction behavior*[tiab] OR risk reduction
behaviour*[tiab] OR lifestyle*[tiab] OR life style*[tiab] OR rehabilitati*[tiab] OR
exercis*[tiab] OR health behavior*[tiab] OR health behaviour*[tiab] OR training*[tiab] OR
walking*[tiab] OR smoking cessati*[tiab] OR tobacco[tiab] OR diet[tiab] OR diets[tiab] OR
dietary[tiab] OR health knowledge[tiab] OR aerobic*[tiab] OR "Health Education"[Mesh]
OR health educati*[tiab] OR "Exercise"[Mesh]))))) OR ((((("Stroke"[Mesh] OR stroke*[tiab]
OR cerebrovascular accident*[tiab] OR brain vascular accident*[tiab] OR apoplex*[tiab] OR
cva[tiab] OR cvas[tiab])) AND (("Secondary Prevention"[Mesh] OR "Life Style"[Mesh] OR
"Exercise"[Mesh] OR "Exercise Therapy"[Mesh] OR "Tobacco Use Cessation"[Mesh] OR
risk reduction behavior*[tiab] OR risk reduction behaviour*[tiab] OR secondary
preventi*[tiab] OR lifestyle*[tiab] OR life style*[tiab] OR exercis*[tiab] OR smoking
cessati*[tiab] OR "Exercise"[Mesh])))) AND ((((randomized controlled trial[pt] OR
controlled clinical trial[pt] OR randomized[tiab] OR placebo[tiab] OR drug therapy[sh] OR
randomly[tiab] OR trial[tiab] OR groups[tiab]))) AND ((((review[tiab] OR
"Review"[Publication Type] OR "Meta-Analysis as Topic"[Mesh] OR meta-analysis[tiab] OR
"Meta-Analysis "[Publication Type]) NOT ("Letter"[Publication Type] OR
"Editorial"[Publication Type] OR "Comment"[Publication Type])) NOT ("Animals"[Mesh]
NOT ("Animals"[Mesh] AND "Humans"[Mesh])))))) Filters: Publication date from
2014/02/01
16
7. REFERENCES ONLINE-ONLY DATA SUPPLEMENT
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Easton JD, Saver JL, Albers GW, Alberts MJ, Chaturvedi S, Feldmann E, et al.
Definition and evaluation of transient ischemic attack: a scientific statement for
healthcare professionals from the American Heart Association/American Stroke
Association Stroke Council. Stroke. 2009;40:2276–2293.
Sacco RL, Kasner SE, Broderick JP, Caplan LR, Connors JJB, Culebras A, et al. An
updated definition of stroke for the 21st century: a statement for healthcare
professionals from the American Heart Association/American Stroke Association.
Stroke. 2013;44:2064–2089.
Crespi V, Braga M, Beretta S, Carolei A, Bignamini A, Sacco S. A practical definition
of minor stroke. Neurol Sci. 2013;3:1083–1086.
Higgins JPT, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The
Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ.
2011;343:d5928.
Billinger SA, Arena R, Bernhardt J, Eng JJ, Franklin BA, Johnson CM, et al. Physical
activity and exercise recommendations for stroke survivors: a statement for healthcare
professionals from the American Heart Association/American Stroke Association.
Stroke. 2014;45:2532–2553.
Michie S. Designing and implementing behaviour change interventions to improve
population health. J Health Serv Res Policy. 2008;13:64–69.
Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for
characterising and designing behaviour change interventions. Implement Sci. BioMed;
2011;6:42.
Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, et
al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic
attack: a guideline for healthcare professionals from the American Heart
Association/American Stroke Association. Stroke. 2014;45:2160–2236.
Rollnick S, Butler CC, Kinnersley P, Gregory J, Mash B. Motivational interviewing.
BMJ. 2010;340:c1900–c1900.
Heran BS, Chen JM, Ebrahim S, et al. Exercise-based cardiac rehabilitation for
coronary heart disease. Taylor RS. Cochrane Database Syst Rev;2011:CD001800.
Michie S, Ashford S, Sniehotta FF, Dombrowski SU, Bishop A, French DP. A refined
taxonomy of behaviour change techniques to help people change their physical activity
and healthy eating behaviours: the CALO-RE taxonomy. Psychol Health.
2011;26:1479–1498.
da Cunha IT, Lim PA, Qureshy H, Henson H, Monga T, Protas EJ. Gait outcomes after
acute stroke rehabilitation with supported treadmill ambulation training: a randomized
controlled pilot study. Arch Phys Med Rehabil. 2002;83:1258–1265.
Lund A, Michelet M, Sandvik L, Wyller T, Sveen U. A lifestyle intervention as
supplement to a physical activity programme in rehabilitation after stroke: a
randomized controlled trial. Clin Rehabil. 2012;26:502–512.
Tanne D, Tsabari R, Chechik O, Toledano A, Orion D, Schwammenthal Y, et al.
Improved exercise capacity in patients after minor ischemic stroke undergoing a
supervised exercise training program. Isr Med Assoc J. 2008 ;10:113–116.
Rimmer JH, Braunschweig C, Silverman K, Riley B, Creviston T, Nicola T. Effects of
a short-term health promotion intervention for a predominantly African-American
group of stroke survivors. Am J Prev Med. 2000;18:332–338.
Marzolini S, Oh P, McIlroy W, Brooks D. The effects of an aerobic and resistance
exercise training program on cognition following stroke. Neurorehabil Neural Repair.
17
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
2013;27:392–402.
Ireland S, MacKenzie G, Gould L, Dassinger D, Koper A, LeBlanc K. Nurse case
management to improve risk reduction outcomes in a stroke prevention clinic. Can J
Neurosci Nurs. 2010;32:7–13.
Cohen SN. Preventing recurrent ischemic stroke: a 3-step plan. J Fam Pract.
2005;54:412–422.
Denby F, Harvey RL. An educational intervention for stroke rehabilitation patients and
their families: healthy living after stroke. Top Stroke Rehabil. 2003;9:34–45.
Jönsson A-C, Höglund P, Brizzi M, Pessah-Rasmussen H. Secondary prevention and
health promotion after stroke: can it be enhanced? J Stroke Cerebrovasc Dis.
2014;23:2287–2295.
Hornnes N, Larsen K, Boysen G. Blood pressure 1 year after stroke: the need to
optimize secondary prevention. J Stroke Cerebrovasc Dis. 2011;20:16–23.
Joubert J, Reid C, Barton D, et al. Integrated care improves risk-factor modification
after stroke: initial results of the Integrated Care for the Reduction of Secondary Stroke
model. J Neurol Neurosurg Psychiatry. 2009;80:279–284.
Moore SA, Hallsworth K, Jakovljevic DG, Blamire AM, He J, Ford GA, et al. Effects
of Community Exercise Therapy on Metabolic, Brain, Physical, and Cognitive
Function Following Stroke: A Randomized Controlled Pilot Trial. Neurorehabil
Neural Repair. 2014;29:623–635.
Katz-Leurer M, Shochina M, Carmeli E, Friedlander Y. The influence of early aerobic
training on the functional capacity in patients with cerebrovascular accident at the
subacute stage. Arch Phys Med Rehabil. 2003;84:1609–1614.
Powers BJ, Danus S, Grubber JM, Olsen MK, Oddone EZ, Bosworth HB. The
effectiveness of personalized coronary heart disease and stroke risk communication.
Am Heart J. 2011;161:673–680.
Tang A, Sibley KM, Thomas SG, et al. Effects of an Aerobic Exercise Program on
Aerobic Capacity, Spatiotemporal Gait Parameters, and Functional Capacity in
Subacute Stroke. Neurorehabil Neural Repair. 2008 ;23:398–406.
18