Invest Clin 64(2): 151 - 164, 2023 https://doi.org/10.54817/IC.v64n2a02
Corresponding author: Jianan Li. Center of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medi-
cal University, Nanjing, Jiangsu210029, China. Email: lijianan@carm.org.cn
Pre-stroke physical activity is related to
good functional outcomes in stroke patients
after endovascular thrombectomy.
Xiangbo Meng1,2, Haiyan Ding3, Congguo Yin4, Wenqing Xia4, Yan Wu2 and Jianan Li1
1Center of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical
University, Nanjing, Jiangsu, China.
2Department of Rehabilitation Medicine, Affiliated Hangzhou First People’s Hospital,
Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
3Department of Radiology, Huai’an Fifth People’s Hospital, Huai’an, Jiangsu, China.
4Department of Neurology, Affiliated Hangzhou First People’s Hospital, Zhejiang
University School of Medicine, Hangzhou, Zhejiang, China.
Keywords: physical activity; stroke; endovascular thrombectomy; prognosis; functional
outcome.
Abstract. Studies have shown that regular physical activity (PA) may re-
duce the risk of stroke. Nevertheless, the protective effect of pre-stroke PA on
the post-stroke functional status in patients treated with endovascular throm-
bectomy (EVT) is still uncertain. For this study, hospitalized patients with acute
ischemic stroke were selected, all of whom underwent EVT after occlusion of
the large vessels in the anterior circulation. The PA levels before the stroke were
assessed by the International Physical Activity Questionnaire, and the outcome
indicators (the modified Rankin scale score and the Barthel index) were evalu-
ated. A total of 144 patients were included in this study. Among the patients
with high PA levels before the stroke, men were more active than women, and
the proportion of patients with smoking and alcohol abuse was high before
admission. Also, the patients with a high PA level were more likely to have no
history of hypertension and atrial fibrillation, and had lower triglyceride levels
at admission. We determined that a high pre-stroke PA level is independently
related to a favorable functional outcome at three months. In addition, there
was no correlation between a high pre-stroke PA and a good functional outcome
at two weeks. A high pre-stroke PA level is independently associated with sat-
isfactory activities of daily living at three months. Regular PA before a stroke
is an independent predictor of a favorable functional outcome in patients with
anterior circulation strokes who receive EVT, and it has a protective effect on
the functional prognosis.
152 Meng et al.
Investigación Clínica 64(2): 2023
La actividad física previa al ictus se relaciona con
un buen resultado funcional en pacientes con ictus tras
una trombectomía endovascular.
Invest Clin 2023; 64 (2): 151 – 164
Palabras clave: actividad física; ictus o infarto cerebral; trombectomía indovascular;
pronóstico; resultado funcional.
Resumen. Diversos estudios han demostrado que la actividad física regu-
lar (AF) antes del ictus puede reducir su riesgo, pero el efecto protector fun-
cional de la AF previa al ictus sobre el estado funcional posterior al ictus, aún
no está claro en los pacientes tratados con trombectomía endovascular (TEV).
Se seleccionaron pacientes hospitalizados con ictus isquémico agudo, a todos
los cuales se les realizó TEV por una oclusión de los grandes vasos de la circu-
lación anterior. El nivel de la AF antes del infarto cerebral fue evaluado por el
Cuestionario Internacional de Actividad Física y se evaluaron los indicadores
de resultado de acuerdo a la puntuación de la escala de Rankin modificada y el
índice de Barthel. Un total de 144 pacientes fueron incluidos en este estudio.
Entre los pacientes con niveles elevados de AF antes del ictus, los hombres eran
más activos que las mujeres, y la proporción de pacientes con hábito tabáquico
y abuso de alcohol era alta antes del ingreso. Además, lo más probable es que
los pacientes con los niveles elevados de AF no tenían antecedentes de hiper-
tensión y fibrilación auricular, y los niveles de triglicéridos estaban más bajos
al momento de su ingreso. Se determinó que un nivel alto de AF previa al ictus
se relaciona de forma independiente con un buen resultado funcional a los 3
meses. Además, no hubo correlación entre la AF previa al ictus avanzado y un
buen resultado funcional a las 2 semanas. Un nivel alto de AF previa al infarto
cerebral se asocia de forma independiente con actividades satisfactorias de la
vida diaria a los 3 meses. Conclusión: La AF regular antes del ictus es un predic-
tor independiente de un buen resultado funcional en los pacientes con el ictus
de la circulación anterior que reciben TEV, y tiene un efecto protector sobre el
pronóstico funcional.
Received: 02-10-2022 Accepted: 21-11-2022
INTRODUCTION
Stroke is one of the most prevalent
clinical diseases in the cerebrovascular sys-
tem and compromises patients’ health and
quality of life 1,2. In this disease, cell death
happens because of an unexpected decrease
or stop of the local arterial blood flow to
the brain tissue. This leads to cell death and
damage to some parts of the brain, causing
its malfunction. It can cause the following
symptoms: paralysis, weakness or sensory
changes in one side of the body or face, ver-
tigo, understanding or speech disruption, or
low vision on one side 3,4. Stroke is divided
into two types: ischemic stroke, with high
morbidity, it can cause disability or death,
because of the loss of blood supply and hem-
Effects of pre-stroke physical activity in stroke patients 153
Vol. 64(2): 151 - 164, 2023
orrhagic stroke, caused by bleeding, with
high mortality, high disability rate and high
relapse speed 3,5,6. Ischemic stroke is the
main cause of death and disability. This dis-
ease almost always happens in people over
40 years-old. To date, recombinant tissue
plasminogen activator (rt-PA), endovascu-
lar thrombectomy (EVT) and antiplatelet
therapy are the only three well-documented
emergency treatment methods for ischemic
stroke 7. For patients with acute ischemic
stroke caused by an occlusion of the large
vessels in the anterior circulation, EVT
has become one of the standard treatment
methods when there is an indication for EVT
(within a specified time limit, based on the
mismatch between regional cerebral perfu-
sion and infarction) 8,9. Approximately two-
thirds of stroke survivors need some help in
their daily life 10, so it is very important for
them to have a reduced degree of functional
impairment.
Fors M et al. found that preoperative
exercise therapy was moderately correlated
with maintaining the postoperative physical
activity level of patients with degenerative
lumbar diseases 11. Moran et al. found that
preoperative exercise rehabilitation train-
ing can reduce all kinds of postoperative
complications after abdominal surgery 12.
In addition, there is strong evidence that
regular physical activity (PA), as a precon-
ditioning stimulus 13, has been consistently
shown to be associated with a reduced risk
of first stroke and its recurrence 14. Animal
studies have proven the beneficial effects of
preischemic exercise training on stroke, and
these beneficial effects include a prolonged
survival time, a reduction in neurological
deficits 15, a decreased infarct volume and an
improvement in the sensorimotor function
after stroke 13,16. The mechanism by which
exercise provides this protection may involve
a combination of highly interactive ways,
such as reducing the neurotoxicity through
the glutamate system 15, reducing oxidative
stress and apoptosis of nerve cells 17, in-
hibiting the inflammatory injury after cere-
bral ischemia/reperfusion 18, improving the
function of the blood–brain barrier after an
ischemic stroke 19, activating endothelial ni-
tric oxide synthase 16 to reduce the vascu-
lar injury after stroke, and promoting the
expression of heat shock protein in neurons
and glia 20. Therefore, the clinical guidelines
for stroke prevention recommends regular
PA (2014, Class IIa, Level of Evidence C) 21.
Regular PA is an important recommendation
in preventing stroke 22.
In this study, we intend to provide PA
advice to the public by investigating the PA
level before stroke and determining whether
it has a beneficial effect on the poststroke
functional status in patients who have had
EVT, for a stroke that was caused by an ante-
rior circulation large vessel occlusion.
METHODS
This study is a prospective cohort study
that was conducted from September 2018 to
May 2020. Patients with acute stroke consec-
utively admitted to the Department of Neu-
rology of the Affiliated Hangzhou First Peo-
ple’s Hospital of Zhejiang University School
of Medicine (Hangzhou, China, a first-class
tertiary hospital) were included. Stroke was
defined according to the World Health Or-
ganization (WHO) standard 23. In addition,
according to the diagnosis and treatment
standard that was currently used in the re-
spective stroke unit ward of the neurology
department, all patients received standard-
ized reperfusion therapy (EVT with or with-
out intravenous rt-PA).
Inclusion and exclusion criteria
The inclusion criteria of this study
were as follows: patients with acute isch-
emic stroke who were at least 18 years old
and were hospitalized within 24 hours after
symptoms had appeared; patients who had
a confirmed occlusion of the anterior circu-
lation large vessels on admission; patients
who were treated with emergency EVT; and
patients who had a modified Rankin scale
154 Meng et al.
Investigación Clínica 64(2): 2023
(mRs) score of ≤ 1 before the stroke. The
exclusion criteria were as follows: no reliable
information about the patient’s past physi-
cal activities; patients with pre-stroke cogni-
tive impairment; patients who were lost to
follow-up; and patients who were missing
information on their mRs at three months.
The Medical Ethics Committee of the
Affiliated Hangzhou First People’s Hospital
of Zhejiang University School of Medicine
approved this study. After fully informing
the patients of the condition assessment
and treatment methods in this study, the
patients or their legally authorized person
signed the informed consent form and par-
ticipated in the clinical trial. The patient had
the right to withdraw from the trial.
Observation and evaluation index
We recorded information including age,
sex, height, weight, body mass index, educa-
tion level, smoking (currently smoking more
than ten cigarettes a day), alcohol abuse,
on-going antiplatelet therapy, ongoing an-
ticoagulant therapy, hypertension, diabetes,
atrial fibrillation (persistent or paroxysmal),
the severity of stroke (the National Institute
of Health Stroke Scale, NIHSS) at admission,
hypertension, vascular occlusion, blood lip-
ids, blood glucose, fibrinogen and the PA
level before the stroke.
All patients had a CTP (computed to-
mography-guided perfusion scan), an emer-
gency computed tomography (CT) and/or a
magnetic resonance imaging scan. The pa-
tient’s baseline arterial occlusion was evalu-
ated by two methods: digital subtraction
angiography and computed tomography an-
giography. If the M2-MCA segment (middle
cerebral artery, MCA, the second segment of
the middle cerebral artery) was noted to be
occluded when evaluating the anterior cir-
culation of large vessels, then a distal occlu-
sion was considered. The M1 segment (the
first segment of the middle cerebral artery)
and intracranial carotid artery, ICA) were
considered proximal occlusions (proximal-
M1, proximal-ICA).
Our research group conducted quanti-
tative and qualitative interviews with each
patient by a questionnaire to determine the
patient’s regular PA level before the stroke.
When the patient could not answer be-
cause of aphasia, memory loss or any other
stroke-related reasons, we interviewed the
patient’s close relatives. In this study, we
used a standardized and validated question-
naire, the International Physical Activity
Questionnaire (IPAQ) 18, which recorded the
PA of the patients during the week before
admission. The participants were asked if
the activity level of that week actually repre-
sented the activities of the previous several
weeks. If not, the patients were excluded
from the study. The IPAQ quantified the level
of PA. The calculation of the total score of
the questionnaire was defined as the sum of
the daily cumulative time (in minutes) and
frequency (days) of all activities with differ-
ent intensities (low, medium, or intense) in
four fields (work, transportation, housework,
gardening, and leisure) that were performed
in a week. The level of physical activity (MET-
min/week) is expressed by the metabolic
equivalent (MET).
According to the criteria recommended
by the IPAQ working group, the patients were
divided into three groups based on their pre-
stroke PA levels. The details are as follows:
High PA was defined as meeting any one
of the following two standards: (a) the total
number of days that the patient engaged in
various types of vigorous-intensity physical
activity was ≥3 d/w, and the overall level of
physical activity was ≥1500 MET-min/week;
(b) the total number of days that the patient
engaged in physical activity at three inten-
sities was >5 d/w, and the overall level of
physical activity was ≥3000 MET-min/week.
Moderate PA was defined as meeting any
one of the following three standards: (a) en-
gaging in all kinds of vigorous physical activ-
ity for at least 20 min every day that totaled
≥3 d/w; (b) engaging in all kinds of moder-
ate intensity and/or walking activities for at
least 30 minutes every day that totaled ≥ 5
Effects of pre-stroke physical activity in stroke patients 155
Vol. 64(2): 151 - 164, 2023
d/w; (c) the total number of days of that the
patient engaged in physical activity at 3 in-
tensities was ≥ 5 d/w, and the overall level
of physical activity was ≥ 600 MET-min/week.
Low PA was defined as no activity had
been reported, or if there was some activity,
it was lower than 600 MET-min/week 19.
We used the mRS to evaluate the func-
tional results and the Barthel Index to eval-
uate the activities of daily living (ADL) re-
sults, and these data were obtained from in
person interviews or communication tools.
Evaluation at admission
Within 48 hours after admission, an in-
terview was conducted by a researcher (Yan
Wu) who did not participate in the clinical
treatment and was trained on how to con-
duct the clinical evaluation. The basic infor-
mation and clinical information of the pa-
tients were recorded in the case report form.
Follow-up endpoint
The primary outcome was a good func-
tional outcome defined as an mRs≤ 2 after
three months of stroke (90 days (within a win-
dow of ±7 days) after entering the study). The
secondary outcomes were the mRs score (Good
defined as ≤2) two weeks after stroke (14 days
and within a window of ±1 day after the study
entry) and the ADL l evel (Good defined as a
Barthel index score between 95 and 100) three
months after admission (90 days within a win-
dow of ±7 days after the study entry).
Statistical analysis
Data for continuous variables were re-
ported as the mean ± standard deviation
(SD) or median (interquartile range, IQR),
depending on whether the variables were
normally distributed. Categorical variables
are described as percentages. The χ2 test was
used to compare the categorical variables
between the groups, and Student’s t test or
ANOVA (normal distribution variables) and
the Kruskal–Wallis test (nonnormal distri-
bution variables) were used to compare the
continuous variables between the groups.
We used a multivariate logistic regres-
sion model to evaluate the correlation be-
tween the PA level before stroke and the
functional outcome. In the logistic regres-
sion model, the pre-stroke PA was evaluat-
ed in two different ways as an independent
variable: (1) as a categorical variable, it
was compared with the high, moderate and
low PA groups; (2) as a binary variable, we
used the receiver operating curve (ROC) to
determine the predictive value of the IPAQ
score for predicting a good functional out-
come in order to find the best cutoff point
for the total IPAQ score for the prediction of
a good functional outcome. The weekly ex-
ercise time corresponding to the IPAQ cut-
off point can be calculated by IPAQ score/
(days * METs assigned by different intensity
activities). The cutoff point was used to di-
vide the patients with different pre-stroke PA
levels into two groups, high and low PA, and
the differences between the two groups were
compared. The results are expressed as the
adjusted odds ratios (ORs) with correspond-
ing 95% confidence intervals (95% CIs).
All statistical analyses were conducted
using SPSS 20.0 for Windows (IBM Corp). A
two-sided P value of < 0.05 was considered
to be statistically significant.
RESULTS
Clinical characteristics of the population
During the trial, 945 patients with isch-
emic stroke were admitted to the research-
er’s hospital. Patients who did not meet the
inclusion criteria were excluded: six patients
whose PA in the last week before admission
did not represent the patient’s activity in the
weeks prior to stroke and four patients who
lacked reliable information on their previous
physical activity. No patients were lost to
follow-up. A total of 144 patients were finally
included in this study (Fig. 1). Table 1 sum-
marizes the baseline characteristics of the
cohort and the three groups of patients with
different PA levels, and this data included the
patients’ basic data and clinical information.
156 Meng et al.
Investigación Clínica 64(2): 2023
Fig. 1. Flow diagram of patients’ selection for the study (PA= Physical activity. EVT= Endovascular throm-
bectomy; mRs = modified Rankin scale.
Table 1
Socio-demographic of the patient.
Variables Total population
(n=144)
Low PA
(n=35)
Moderate PA
(n=65)
High PA
(n=44) p
Sex (males) 88(61.1%) 17(48.6%) 36(55.4%) 35(79.5%) 0.009
Age, years 69.6±11.3 69.3±13.0 71.0 ±10.3 67.9±11.3 0.375
Educa
tion level
Primary school
and below 98(68.1%) 24(68.6%) 43(66.2%) 31(70.5%)
0.972
Junior middle
school 32(22.2%) 7(20.0%) 16(24.6%) 9(20.5%)
Senior high school
or above 14(9.7%) 4(11.4%) 6(9.2%) 4(9.1%)
Smoking habit 45(31.2%) 12(34.3%) 13(20.0%) 20(45.5%) 0.017
Alcohol abuse 37(25.7%) 5(14.3%) 14(21.5%) 18(40.9%) 0.016
BMI, kg/m223.4±3.5 23.7±4.1 23.1±3.5 23.5±2.9 0.389
NIHSS at admission 16 [13-20.75] 17 [12.5-21.5] 16 [12.25-21] 16 [13-20] 0.894
Notes: Data are expressed as n (%), mean ± standard deviation or the median [interquartile ranges].
Data on BMI were missing for four patients (1 in the low PA group, and 3 in the mderate PA group) Data on NIHSS
at admission were missing for 4 patients (2 in the low PA group, 1 in the moderate PA group, and 1 in the high PA
group).
Effects of pre-stroke physical activity in stroke patients 157
Vol. 64(2): 151 - 164, 2023
The average age of the enrolled popu-
lation was 69.6±11.3 years old, 61.1% of
the patients were male, and their average
baseline NIHSS was 16 (quartile 13, 20.75).
Cardiogenic stroke was the most common
subtype of stroke (46.50%). The median
total IPAQ score was 1680 MET-min/week
(quartile range 661.5, 3659.25). According
to the IPAQ grouping criteria, there were
44 (30.56%) patients with high PA levels,
65 (45.14%) patients with moderate levels,
and 35 (24.31%) patients with low activity
levels.
The differences between the groups
(patients classified according to the PA lev-
els before the stroke) are shown in Table 1
and Table 2. When the patients with high
pre-stroke PA levels were compared with the
patients with low and moderate PA levels,
men were more active than women, and
the proportion of patients with smoking
and alcohol abuse was high before admis-
sion. The patients with high pre-stroke PA
levels were more likely to have no history of
hypertension or atrial fibrillation and had
lower triglyceride levels at admission. The
baseline NIHSS scores did not differ among
the three groups of patients (p = 0.894).
Comparison of the primary neurological
outcomes
Seventy patients (48.61%) showed
good functional outcomes at three months
(Table 3). The proportion of functionally-
independent patients at three months was
significantly higher in the patients with high
PA levels (Table 3). The logistic regression
analysis showed that high pre-stroke PA lev-
els were independently associated with good
functional outcomes (OR=3.19, 95% CI:
1.07-9.47, p=0.037, Table 4, Model A).
Model A: PA of the patients during
the week before admission and Model B:
High PA was defined as meeting any one of
the following two standards: (a) the total
number of days that the patient engaged
in various types of vigorous-intensity phys-
ical activity was ≥3 d/w, and the overall
level of physical activity was ≥1500 MET-
min/week; (b) the total number of days
that the patient engaged in physical activ-
ity at three intensities was >5 d/w, and
the overall level of physical activity was
≥3000 MET-min/week.
Analysis of the ROC curve analysis
showed that the total IPAQ cutoff point
score of 3859.5 MET-min/week (the area
under the curve is 0.688, 95% CI 0.586-
0.789) has the highest predictive value
of functional independence, with a sensi-
tivity of 74.8% and a specificity of 68.8%
(p=0.001). Regarding the ROC curve, it is
necessary to mention that due to the sensi-
tivity of 68.8% and specificity of 74.8%, and
subsequently high false negative and false
positive values (FN= 25.2%; FP: 21.84%),
this test has limitations as a good indicator
to distinguish PA groups (Fig. 2).
The logistic regression analysis showed
that the pre-stroke high PA level group,
which was above the cutoff point (IPAQ >
3859.5 MET-min/week), was also indepen-
dently associated with good functional out-
comes (OR = 3.3, 95% CI: 1.25-8.71, p =
0.016, Table 4, model B).
Comparison of the secondary neurological
outcomes
Thirty-nine patients (27.08%) showed
good functionality at two weeks (Table 3).
The logistic regression analysis showed
no correlation between a high pre-stroke
PA and a good functional outcome at
two weeks (Table 4, Models A and B). Re-
garding the Barthel index, 71 patients
(49.30%) showed satisfactory activities in
daily living at three months (Table 3). The
proportion of patients with acceptable ac-
tivities of daily living at three months was
significantly higher in the patients with
high levels of PA (Table 3). The logistic re-
gression analysis showed that a high pre-
stroke PA was correlated independently
with good ADL (p <0.05, Table 4, Models
A and B). Pre-stroke PA is an independent
predictor of good ADL.
158 Meng et al.
Investigación Clínica 64(2): 2023
Table 2
Characteristics of the patients at baseline.
Variables Total
population
(n=144)
Low PA
(n=35)
Moderate PA
(n=65)
High PA
(n=44)
p
Etiology
of cerebral
infarction
Atherosclerosis 28(19.4%) 7(20.0%) 10(15.4%) 11(25.0%) 0.101
Cardiogenic 67(46.5%) 15(42.9%) 38(58.5%) 14(31.8%)
Undetermined 49(34.0%) 13(37.1%) 17(26.2%) 19(43.2%)
Site of
occlusion
Proximal-ICA 53(36.8%) 13(37.1%) 20(30.8%) 20(45.5%) 0.6
Proximal-M1 77(53.5%) 18(51.4%) 39(60.0%) 20(45.5%)
Distal-M2 14(9.7%) 4(11.4%) 6(9.2%) 4(9.1%)
Minutes from stroke
onset to admission
260
[185.5-363]
292
[169-402]
239
[182-332]
296
[213-403.75]
0.116
Reperfusion
therapies
EVT alone 102(70.8%) 26(74.3%) 44(67.7%) 32(72.7%) 0.745
Combined rt-PA
and EVT
42(29.2%) 9(25.7%) 21(32.3%) 12(27.3%)
On-going antiplatelet therapy 24(16.7%) 9(25.7%) 8(12.3%) 7(15.9%) 0.226
On-going anticoagulant
therapy
16(11.1%) 5(14.3%) 7(10.8%) 4(9.1%) 0.761
Hypertension 96(66.7%) 28(80.0%) 46(70.8%) 22(50.0%) 0.012
Diabetes 31(21.5%) 10(28.6%) 13(20.0%) 8(18.2%) 0.494
Glucose, mmol/L 7.2
[6.4-8.5]
7.7
[6.375-9.25]
7.2
[6.4-7.99]
6.985
[6.275-8.125]
0.470
Total cholesterol, mmol/L 3.69
[3.165-4.425]
3.78
[3.25-4.4125]
3.695
[3.1375-4.3025]
3.59
[3.13-4.87]
0.828
HDL cholesterol, mmol/L 1.13
[0.925-1.245]
1.045
[0.8975-1.18]
1.14
[0.955-1.25]
1.16
[0.93-1.25]
0.140
LDL cholesterol, mmol/L 1.97
[1.635-2.565]
2.13
[1.7375-2.4825]
1.99
[1.6325-2.5825]
1.9
[1.56-2.93]
0.902
Triglyceride, mmol/L 1.31
[0.8-1.74]
1.435
[1.1575-2.0525]
1.365
[0.8-2.2175]
1.01
[0.63-1.54]
0.018
Fibrinogen,g/L 2.57
[2.28-2.99]
2.65
[2.45-3.09]
2.45
[2.1425-2.99]
2.595
[2.2875-2.94]
0.269
Atrial fibrillation 79(54.9%) 20(57.1%) 42(64.6%) 17(38.6%) 0.027
CAD 15(10.4%) 4(11.4%) 6(9.2%) 5(11.4%) 0.915
Notes: Data are expressed as n (%), mean ± standard deviation or the median [interquartile ranges].
Proximal-ICA= Proximal- intracranial carotid artery; Proximal-M1= Proximal- the first segment of middle cerebral
artery; Distal-M2= Distal- the second segment of the middle cerebral artery; rt-PA = recombinant tissue plasmino-
gen activator; EVT= Endovascular thrombectomy; HDL= High density lipoprotein; LDL=Low density lipoprotein;
CAD= Coronary heart disease; PA= Physical activity.
Data on glucose was missing for 1 patient (in the low PA group)
Data on total cholesterol, HDL cholesterol, LDL cholesterol, triglyceride were missing for 3 patients respectively (1
in the low PA group, 1 in the moderate PA group, and 1 in the high PA group), Data on fibrinogen was missing for
1 patient (in the moderate PA group.
Effects of pre-stroke physical activity in stroke patients 159
Vol. 64(2): 151 - 164, 2023
DISCUSSION
This prospective study on patients with
an acute anterior circulation large vessel oc-
clusion shows that a high level of regular PA
before stroke was significantly related to a
good functional outcome and better activi-
ties of daily living after an EVT.
To the best of our knowledge, there is
no report on the influence of the PA on the
functional prognosis of stroke in patients
who have received an EVT for a stroke caused
by an anterior circulation occlusion.
For people who are relatively inactive,
such as the elderly (who had an average age
of 69 years old in this study), the necessi-
ty of physical activity in their daily life and
work has been confirmed in this research.
As a benefit for the patients themselves and
society, PA before a stroke can play a neuro-
protective role, which is helpful to improve
significantly the outcome of a stroke, reduce
the social burden and achieve a healthy and
disability-free life.
As shown in Table 1, PA may play a dose-
dependent role. The ROC curve indicated a
Table 3
Comparison of primary and secondary neurological outcomes in different groups.
Variables Total population
(n = 144)
Low PA
(n = 35)
Moderate PA
(n = 65)
High PA
(n = 44) p
mRs(≤2) at 3 months 70(48.61%) 10(28.57%) 31(47.69%) 29(65.91%) 0.004
mRs(≤2) at 2 weeks 39(27.08%) 4(11.43%) 18(27.69%) 17(38.64%) 0.026
Barthel index (95~100)
at 3 months
71(49.30%) 10(28.57%) 30(46.15%) 31(70.45%) 0.001
Notes: Data are expressed as n (%); PA= Physical activity. mRs= modified Rankin scale
Table 4
Multivariate regression analyses of the association between pre-stroke physical
activity level and outcome variables.
Level of PA mRs 0–2 at 3
months a
Odds ratio
p-value mRs ≤2 at
2 weeks a
Odds ratio
p-value Barthel Index of 95
or 100 at 3 months a
p
Model A Low 1.0 0.096 1.0 0.163 1.0 0.03
Moderate 2.34(0.89,6.15) 0.086 3.18(0.92, 11.03) 0.068 2.07(0.81, 5.28) 0.13
High 3.19(1.07,9.47) 0.037 3.12(0.84, 11.58) 0.089 4.25(1.45,12.41) 0.008
Model B High PA group:
IPAQ≥ cutoff
point
3.3(1.25, 8.71) 0.016 1.91(0.77, 4.78) 0.166 3.32 (1.29, 8.56) 0.013
Notes:
In model A, the relationship between pre-stroke PA and prognosis in high, moderate and low level groups was com-
pared.
In model B, the IPAQ cutoff point was 3859.5 MET-min/week.
Patients were divided into high level and low level PA groups with this cutoff point.
The relationship between these two groups and good functional outcomes was compared. PA= Physical activity;
IPAQ= International Physical Activity Questionnaire. mRs= modified Rankin scale
a Adjustment for sex, smoking, alcohol abuse, hypertension, atrial fibrillation and triglyceride levels.
160 Meng et al.
Investigación Clínica 64(2): 2023
beneficial effect of PA before a stroke on the
stroke outcome and that the cutoff point
was 3,859.5 MET-min/week. The required PA
level can be reached by walking for approxi-
mately three hours (180 minutes) every day
for seven days or by intense physical activ-
ity (such as lifting heavy objects, digging,
jogging or fast cycling) for approximately
69 minutes every day. Among the above ac-
tivities, walking is common, convenient, and
cheap. Walking requires the use of large skel-
etal muscles of the whole body, with almost
no side effects; therefore, it is worthy of pro-
motion.
Previous studies that evaluated pa-
tients who did not receive rt-PA and EVT
20,21, a study that did not mention throm-
bolysis 24, and other retrospective observa-
tional study that evaluated patients who
received rt-PA 25, showed that pre-stroke
PA could benefit patients with ischemic
stroke in terms of its severity at admis-
sion, the final infarct area size reduction
and the prognosis. In contrast, other stud-
ies that evaluated patients with intrave-
nous rt-PA thrombolytic therapy 26, or only
conventional drug therapy 27, showed that
PA had no significant effects on the stroke
severity and functional outcome.
In this study, we found that there was
no significant association between the
physical activity level before stroke and the
severity of the stroke. However, we found a
significant association between the PA level
before the stroke and obtaining a satisfac-
tory functional outcome at three months,
consistent with some of the abovemen-
tioned research results. The inconsistency
of the results may be caused by the inclu-
sion population and the research design.
The patients in this study had a high degree
of stroke (NIHSS score was 16 at admis-
sion), which was why they were willing to
undergo EVT.
The operation itself may also affect the
functional outcome. Another reason may
Fig 2. Receiver operating characteristics (ROC) curve analysis for predictive power of International Physical
Activity Questionnaire (IPAQ) score on functional outcome in stroke patients who were treated with
EVT(= Endovascular thrombectomy). Area under curve (95%CI) =0.688(0.586-0.789).
Effects of pre-stroke physical activity in stroke patients 161
Vol. 64(2): 151 - 164, 2023
be that we used the IPAQ to evaluate PA.
This questionaire is currently recognized
as an effective and worldwide used method
for measuring the physical activity levels of
adults. It has been used in Chinese popu-
lation research and has excellent validity
and reliability 28,29. The IPAQ involves ask-
ing about the patient’s physical activities
in various fields of daily life, so the esti-
mated level of the patient’s physical activ-
ity is higher than the other survey results
(in some of above mentioned studies) that
simply asked about the patient’s physical
activity that was undertaken in their leisure
time 25,26,30. The IPAQ will not classify the
patients with high-intensity professional
sports activities and lack of leisure time
for physical activities into the moderate or
low PA group. In addition, compared with
the effective drugs for treating stroke, the
physical activity level is more likely to be
only a surrogate marker of the patient’s
past health status 31.
Our research has some limitations.
First, we used a cohort study. The nature
of this type of observational study makes
us unable to determine the causality. There
may also be residual confounding factors,
such as the different surgical times and
smoothing degrees for each patient, the
degree of professional rehabilitation inter-
vention during the postoperative recovery,
and psychological factors, such as depres-
sion and anxiety symptoms that affect the
patient’s physical function and stroke prog-
nosis. Second, because the patients entered
the study based on their will and compli-
ance with the inclusion criteria, research-
ers could not select the participants in a
targeted way, which resulted in the incon-
sistency in some of the baseline data levels
in the different groups of patients. How-
ever, we believe that these inconsistencies
are due to the characteristics of the differ-
ent level of PA groups and the results of the
study. Third, the severities of the strokes
in the patients enrolled in this study were
high. For patients with severe disability and
aphasia, most of their PA levels before onset
were determined by questioning their fami-
lies. Moreover, we used self-reports for ret-
rospective registration to assess the level
of physical activity before stroke. All these
may lead to bias in the results of pre-stroke
activity.
In conclusion, this study confirms that
regular PA before stroke is an independent
predictor of a good functional outcome in
patients with an anterior circulation stroke
who receive EVT, and PA can play a protec-
tive role in the functional prognosis. In fu-
ture research, we can expand the sample
size to determine whether pre-stroke ex-
ercise plays a beneficial role in the stroke
outcome.
Limitation
According to the cut off obtained from
the ROC curve and the values of FN and FP,
the test used had limitations for distinguis-
hing groups, and it is necessary and impor-
tant to pay attention to this point in future
studies.
Funding
This research was supported by the Zhe-
jiang Provincial Medical and Health Technol-
ogy Project under Grant number 2020KY701.
Competing Interests
The authors declared that they have no
competing interests.
Authors’ Orcid Number
• Xiangbo Meng: 0000-0002-5329-8459
• Haiyan Ding: 0000-0002-6126-278X
• Congguo Yin: 0000-0002-8026-4174
• Wenqing Xia: 0000-0002-1373-3567
• Yan Wu: 0000-0002-2829-047
• Jianan Li: 0000-0003-3177-4335
162 Meng et al.
Investigación Clínica 64(2): 2023
Authors’ Contribution
XM, CY, WX, and JL contributed to the
conception of the study. XM, HD, and WX
performed the experiment. YW contributed
significantly to the analysis and manuscript
preparation. XM, HD, CY and YW performed
the data analyses and wrote the manuscript.
JL helped perform the analysis with con-
structive discussions.
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