Intervention Review

You have free access to this content

Non-pharmacological interventions for preventing secondary vascular events after stroke or transient ischemic attack

  1. Marilyn MacKay-Lyons1,*,
  2. Marianne Thornton2,
  3. Tim Ruggles3,
  4. Marion Che1

Editorial Group: Cochrane Stroke Group

Published Online: 28 MAR 2013

Assessed as up-to-date: 11 DEC 2012

DOI: 10.1002/14651858.CD008656.pub2


How to Cite

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 of Systematic Reviews 2013, Issue 3. Art. No.: CD008656. DOI: 10.1002/14651858.CD008656.pub2.

Author Information

  1. 1

    School of Physiotherapy - Dalhousie University, Halifax, Nova Scotia, Canada

  2. 2

    Ottawa Hospital Rehabilitation Centre, Department of Physiotherapy, Ottawa, Ontario, Canada

  3. 3

    Dalhousie University, W.K. Kellog Health Sciences Library, Halifax, Nova Scotia, Canada

*Marilyn MacKay-Lyons, School of Physiotherapy - Dalhousie University, 4th Floor, Forrest Building, 5869 University Avenue, Halifax, Nova Scotia, B3H 3J5, Canada. M.MacKay-Lyons@Dal.Ca.

Publication History

  1. Publication Status: New
  2. Published Online: 28 MAR 2013

SEARCH

 

Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms
 

Description of the condition

Stroke is the fourth leading cause of disease burden and the second leading cause of death among adults worldwide (Lopez 2006). Individuals presenting with stroke typically have atherosclerotic lesions throughout their vascular system and manifest, or are at increased risk of, cardiovascular disease (CVD). Common risk factors for both stroke and CVD include hypertension, dyslipidemia, diabetes, physical inactivity, obesity, excessive alcohol consumption and tobacco use (Gordon 2004). People who have experienced a stroke or transient ischemic attack (TIA) are at heightened risk of subsequent vascular events, including myocardial infarction (MI) and second strokes (Touze 2005). Recurrent strokes have higher fatality rates than primary strokes, and for those who survive a second stroke, a greater proportion will experience long-term disability and institutionalization (Hankey 2005).

 

Description of the intervention

Interventions for stroke survivors are needed to avert further vascular events, including a second stroke, MI and vascular death. Non-pharmacological interventions, including exercise, dietary advice, lifestyle counselling and patient education, may have a role to play in secondary prevention after stroke. In terms of primary stroke prevention one epidemiological study reported that a combination of four health behaviors (i.e. physical activity, current non-smoking, moderate alcohol intake and adequate daily vitamin C intake) was associated with a two-fold reduction in stroke incidence (Myint 2009). Further, a meta-analysis of physical activity intervention studies concluded that moderate and high levels of physical activity were associated with reduced risk of total, ischemic and hemorrhagic strokes (Lee 2003).

The effects of individual non-pharmacological interventions on vascular risk factors in people with, or at risk of having, CVD have been explored through evidence-based reviews and meta-analyses. Exercise confers significant health benefits including lowering blood pressure (Fagard 2007; Kelley 2008; Whelton 2002), improving plasma lipoprotein status (Houston 2009; Kodama 2007), reducing body weight (Shaw 2006), and enhancing glycemic control (Boulé 2001; Gordon 2009). Nevertheless, one Cochrane review on the effects of exercise training after stroke concluded that, despite evidence of impaired cardiovascular fitness after stroke, the benefits of training alone on death, dependence and disability remain unclear (Brazzelli 2011). Dietary advice produces modest reductions in body weight (Dansinger 2007), total cholesterol, low-density lipoprotein cholesterol, and systolic and diastolic blood pressure (Brunner 2007). Education programs focusing on exercise and diet reduce fasting plasma glucose in individuals at high risk for type 2 diabetes (Yamaoka 2005). Lifestyle interventions leading to sustained moderate weight loss are effective in the prevention and treatment of hypertension, diabetes and dyslipidemia (Orzano 2004).

 

How the intervention might work

Reducing vascular risk factors is often a complex process that requires intervention at multiple levels. Thus, cardiac rehabilitation (CR) programs designed for people with CVD or diabetes tend to be multi-faceted, involving combinations of exercise, dietary advice, lifestyle counselling and patient education (Balady 2007). Although the components of CR programs vary, aerobic training is a common constituent. Exercise-based CR, with or without patient education and lifestyle counselling, has been shown to induce favourable effects on total cholesterol, triglycerides, systolic blood pressure and rates of self-reported smoking in people with coronary heart disease (Taylor 2004). A systematic review revealed reductions in total cholesterol and triglycerides with multi-modal CR but not exercise alone, whereas neither CR nor exercise alone affected high-density lipoprotein cholesterol or recurrence of non-fatal MI (Jolliffe 2001). A meta-analysis reported reduced recurrent MI and mortality with CR programs that incorporated supervised exercise alone, exercise plus risk reduction education, or risk reduction strategies without supervised exercise (Clark 2005). In terms of the type 2 diabetes population, systematic reviews have reported improvements in glycosylated hemoglobin, fasting blood glucose, systolic blood pressure and diabetes knowledge with group-based educational programs (Deakin 2005).

A modelling study based primarily on data from observational studies provided preliminary support for a multi-faceted approach to secondary stroke prevention (Hackam 2007). The authors concluded, "At least four-fifths of recurrent vascular events in patients with cerebrovascular disease might be prevented by application of a comprehensive, multifactorial approach." In addition, a pilot trial of a 10-week CR program for patients post-stroke showed greater improvement in cardiac risk score in the CR group compared with the usual care group (Lennon 2008).

 

Why it is important to do this review

Recurrent strokes contribute significantly to the overall personal and economic burden associated with stroke (Spieler 2003). However, control of vascular risk factors has been noted to be inadequate for people post-stroke (Mouradian 2002). According to one meta-analysis, only 10.6% of American adults with a history of stroke or MI have achieved control of their vascular risk factors (Muntner 2006). Moreover, one study reported that 52% of stroke rehabilitation participants could not name a single risk factor for stroke (Koenig 2007), and another study found that over 75% of community-dwelling people post-stroke were not in a state of readiness to incorporate exercise into their lifestyle (Garner 2005). Thus, interventions to reduce risk factors after stroke should be given priority in health care. Despite gaps in our understanding of the role of non-pharmacological interventions in secondary stroke prevention, their use is being recommended (Lindsay 2008; Sacco 2006).  Evidence of effectiveness is critical to drive the development and uptake of secondary stroke prevention programs. This review aimed to appraise the current literature comprehensively regarding the effectiveness of multi-modal programs of non-pharmacological interventions that involve exercise together with dietary advice, lifestyle counselling, patient education, or a combination of these, in preventing secondary vascular events and reducing vascular risk factors after stroke or TIA.

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms

To determine the effectiveness of comprehensive programs of non-pharmacological interventions in preventing secondary vascular events (i.e. second stroke, MI, vascular death) and reducing vascular risk factors (e.g. hypertension, abdominal obesity, dyslipidemia) following stroke or TIA when compared with usual care.

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms
 

Criteria for considering studies for this review

 

Types of studies

We included randomized controlled trials (RCTs), as well as the first phase of cross-over studies in which the order of assignment was determined randomly.

 

Types of participants

We included male and female adults (aged over 18 years) with a clinical diagnosis of stroke or TIA, either ischemic or hemorrhagic in origin.  

 

Types of interventions

We included trials that compared non-pharmacological interventions that included components traditionally used in CR programs with usual care. We included a program if it consisted of:

  1. aerobic training designed to improve cardiorespiratory fitness by incorporating a systematic increase in exercise intensity over the course of the program. Typically, a minimum of 20 minutes of dynamic exercise is performed by walking, stair climbing or using an ergometer (e.g. stationary bicycle, treadmill). The training may be offered in a group or individual format, the latter being either supervised or unsupervised; and
  2. one or more of the following:
    1. dietary advice on nutritional strategies aimed at reducing vascular risk factors that is delivered by health professionals or other personnel in person, over the telephone, or in written instructions to individuals or small groups;
    2. verbal or written patient education addressing topics such as risk factor modification, cardiac medications, effects of exercise, and diabetes management, delivered by health professionals or other personnel, in person, over the telephone or in written format (e.g. pamphlets, manuals) to individuals or small groups;
    3. lifestyle counselling, delivered by health professionals or other personnel, in person or over the telephone, to individuals or small groups, regarding health behavioral issues associated with vascular risk factor modification (e.g. tobacco use, alcohol consumption, physical activity, medication adherence, psychosocial support, stress management). 

The intervention group was compared with those participants whose care involved:

  • routine or usual treatment (i.e. the standard of care recommended in that country, such as follow-up with the required health professionals); or
  • waiting list; or
  • no intervention.

We excluded trials if they involved exercise training alone because that topic has been the subject of a separate Cochrane review (Brazzelli 2011).

 

Types of outcome measures

We sought information on the following outcome measures for each trial.

 

Primary outcomes

  • A cluster of second stroke or MI or vascular death, whichever occurred first.

 

Secondary outcomes

  • Secondary vascular events: second stroke, MI, and vascular death.
  • Vascular risk factors: blood pressure (resting systolic and diastolic), body weight (body mass index, waist circumference), lipid profile (total cholesterol, low and high density lipoprotein cholesterol, ratio of total cholesterol to high density lipoprotein cholesterol, triglycerides), insulin resistance (fasting plasma glucose, hemoglobin A1c) and tobacco use. We will also record adverse events such as exercise-related musculoskeletal injuries or cardiovascular events.

 

Search methods for identification of studies

See the 'Specialized register' section in the Cochrane Stroke Group module. We searched for trials in all languages and arranged translation of reports published in languages other than English.

 

Electronic searches

 

Databases

We searched the Cochrane Stroke Group Trials Register (September 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 2), the Cochrane Database of Systematic Reviews (CDSR) (The Cochrane Library 2012, Issue 2), the Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library 2012, Issue 2), the Health Technology Assessments Database (HTA) (The Cochrane Library 2012, Issue 2) and the National Health Service (NHS) Economic Evaluations Database (NHS EED) (The Cochrane Library 2012, Issue 2). In addition, we searched: MEDLINE (1950 to February 2012) (Appendix 1), EMBASE (1974 to February 2012), CINAHL (1982 to February 2012), SPORTDiscus (1800 to February 2012), PsycINFO (1887 to February 2012), Web of Science (1900 to February 2012), PEDro (Physiotherapy Evidence Database) (www.pedro.fhs.usyd.edu.au/) (February 2012), OT Seeker (www.otseeker.com/search.aspx) (February 2012), OpenSIGLE (opensigle.inist.fr/) (February 2012), REHABDATA (www.naric.com/research/default.cfm) (February 2012) and Dissertation Abstracts (February 2012) (Appendix 2).

 

Search strategy

The structure of the searches comprised a generic 'stroke' component, supplemented with search terms for locating studies that relate to exercise, physical fitness, cardiorespiratory training or strength training and CR, nutrition, diet, patient education, smoking and stress. We limited studies to trials and intervention studies by a further subset of maximally sensitive search strings. The MEDLINE search strategy (Appendix 1) comprised both MeSH controlled vocabulary and free-text terms (i.e. text words or titles and abstracts). We generated an equivalent search strategy for the other databases using the same logic as the MEDLINE search strategy but modified to accommodate differences in indexing, syntax and search engine capabilities (Appendix 2). We searched all databases from inception and when using controlled vocabulary terms we used the explode facility. For databases and trials registers not sophisticated enough to support complex strategies, we used considerably shorter versions.

 

Ongoing trials and research registers

In addition, we searched the following ongoing trials and research registers (February 2012):

  1. ClinicalTrials.gov (clinicaltrials.gov/ct/gui);
  2. Current Controlled Trials Register (www.controlled-trials.com/);
  3. Internet Stroke Center Stroke Trials Registry (www.strokecenter.org/trials/);
  4. CenterWatch (www.centerwatch.com/).

 

Searching other resources

To identify other published, unpublished and ongoing trials we:

  1. checked reference lists of all relevant articles;
  2. contacted authors of key papers and investigators known to be involved in research on the topic of the review.

 

Data collection and analysis

Two review authors independently screened the titles and abstracts of the citations produced by the electronic searches and excluded obviously irrelevant studies. We then obtained the full text of the remaining studies and the same two authors selected trials meeting the review inclusion criteria. These two review authors resolved any disagreements through negotiation, with a third review author serving as an arbitrator if necessary. We obtained translations of possibly relevant trials published in languages other than English.

 

Data extraction and management

Two review authors independently extracted data from the included trials using a standard data extraction form. We extracted the immediate post-intervention assessment findings along with any follow-up assessment findings if the latter were available. The two review authors resolved any discrepancy between the data extracted by negotiation, arbitrated by a third review author as necessary. We considered the following:

  1. direction of the treatment effect;
  2. size of the treatment effect;
  3. treatment effect consistent across studies;
  4. strength of evidence for the treatment effect.

 

Assessment of risk of bias in included studies

We conducted a risk of bias assessment of included studies using the Cochrane tool for assessing risk of bias (Higgins 2011). We made a judgement on each of these criteria relating to the risk of bias of 'low risk', 'high risk' or 'unclear risk'. We resolved differences through discussion with a third review author serving as an arbitrator as necessary. We considered the results of the risk of bias assessment in the interpretation of the findings of the review. We also took into account potential bias resulting from heterogeneity of the interventions received by control groups.

 

Measures of treatment effect

Primary outcome data were counts of rare events, the number of times vascular events occurred. We planned to use the rate ratio as the summary statistic in the meta-analysis to compare the rate of events in the two groups. For secondary outcome data that were continuous, we planned to calculate the difference in means and 95% confidence interval (CI) for trials using outcome measurements made on the same scale. Our intention was to use the standardized mean difference (SMD) and 95% CI for trials assessing the same outcome but measuring it in a variety of ways. For ordinal scales summarized using methods for binary data, we proposed to describe the treatment effects using risk ratios, odds ratios or risk differences; and for ordinal scales summarized using methods for continuous data, we would describe treatment effects as a difference in means or SMD.

 

Unit of analysis issues

If trials included in the review report follow-up assessment findings, we planned to perform two separate analyses based on time frame: short-term (immediate post-intervention) and long-term (follow-up). Otherwise, we planned to include the immediate post-intervention assessment findings in the analysis. For cross-over trials, we planned to include data from the first period since there is a strong possibility of a carry-over effect. We planned to combine cluster-randomized trials with individually randomized trials in the same meta-analysis by using a summary measurement from each cluster.

 

Dealing with missing data

We planned to document missing data for each trial and contact the trial authors to request data that were not missing at randomization. We addressed the potential impact of missing data on the findings of the review in the Discussion.

 

Assessment of heterogeneity

We planned to assess statistical heterogeneity using the I2 statistic, which describes the percentage of variability in effect estimates due to heterogeneity. If we found heterogeneity, we planned to address possible causes in the Discussion.

 

Assessment of reporting biases

We planned to use funnel plots to assess reporting bias; we limited analysis of the plots to visual interpretation.

 

Data synthesis

If there were high-quality data without publication or reporting bias but the outcomes were diverse, we planned to answer the four questions descriptively. If there were sufficient high-quality studies with sufficiently similar outcomes we would carry out a quantitative meta-analysis (Deeks 2011). Given the likelihood of heterogeneity of the study populations, interventions and outcomes, we planned to conduct a random-effects meta-analysis (i.e. the trials are not all estimating the same intervention effect). 

In the analyses we also planned to examine features of the trials that could have an influence on outcomes including diagnoses studied (stroke, TIA, or both), severity of stroke, time post-stroke, interventions used in addition to exercise (e.g. dietary advice, patient education, lifestyle counselling), length of intervention and length of follow-up.

 

Subgroup analysis and investigation of heterogeneity

We did not plan to conduct any subgroup analyses.

 

Sensitivity analysis

We identified issues deemed appropriate for a sensitivity analysis (method of randomization, blinding of outcome assessor, intention-to-treat analysis, type of study) during the review process. We planned to conduct sensitivity analyses if there were sufficient data. If an analysis revealed that a particular decision made in the process of study identification or data extraction influenced the results of the review, we planned to interpret the findings with caution in the Discussion

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms
 

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies; Characteristics of ongoing studies.

See: Characteristics of included studies; Characteristics of excluded studies; Characteristics of ongoing studies.

 

Results of the search

We identified eight studies for possible inclusion in this review (Figure 1). For more information see Characteristics of included studies, Characteristics of excluded studies, and Characteristics of ongoing studies. Of the eight trials, we included one (Lennon 2008), excluded two (Prior 2011; Tang 2010) and five are ongoing (Kirk ongoing; Lennon 2009; MacKay-Lyons 2010; NCT00536562; NCT00929994).

 FigureFigure 1. Flowchart of search results.

 

Included studies

We found only one RCT (Lennon 2008) on the effects of a non-pharmacological intervention strategy for people post-stroke or TIA that involved aerobic exercise and one or more of dietary advice, patient education and lifestyle counselling. Details of this study are outlined in Characteristics of included studies.

 

Excluded studies

We excluded two studies because they were not RCTs and focused on feasibility of a CR programme (Prior 2011; Tang 2010).

 

Risk of bias in included studies

The risk of bias for each study may be seen under Characteristics of included studies. The baseline characteristics were reported to be no different between the CR program and control group. An independent party randomly assigned participants using a sequence generator to either intervention or control groups. After initial testing, a clerical staff member unrelated to the trial gave the participants an opaque envelope containing the details of their allocation. However, it was not stated if the envelope was sealed. Dropouts, losses to follow-up and intention to treat were not reported.

 

Allocation

We deemed random sequence generation and allocation concealment to be adequate for the one trial.

 

Blinding

We deemed blinding to avoid performance or detection bias to be adequate, as the outcomes were assessed either by monitoring equipment or by an independent assessor blinded to group allocation.

 

Incomplete outcome data

Incomplete outcome data was low risk in the study.

 

Selective reporting

We found reporting to be adequate in the study.

 

Other potential sources of bias

There were no other concerns regarding risk of bias.

 

Effects of interventions

Only one study of 48 participants met the inclusion criteria for this review. Therefore, we were unable to perform the planned meta-analyses.

 

Discussion

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms
 

Summary of main results

The aim of this review was to examine the effectiveness of non-pharmacological interventions for secondary stroke prevention. We identified one completed trial, involving 48 participants, for inclusion in the review. The results of this trial show small amounts of improvement in the intervention group in blood pressure lowering, and few vascular events along with other indicators of stroke/TIA survivors' health recovery and secondary prevention compared with usual care.

 

Overall completeness and applicability of evidence

There is limited applicable evidence. No studies reported any adverse events. Several studies are underway that will add to the completeness of the evidence. See Characteristics of ongoing studies for more information.

 

Quality of the evidence

The one included RCT used valid and reliable outcome measures but reported substantial attrition, resulting in large amounts of missing data.

 

Potential biases in the review process

With only one trial included in the review, the results can only be interpreted as preliminary and no recommendations can be drawn with respect to practice.

 

Agreements and disagreements with other studies or reviews

We found no studies or reviews that disagreed.

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms

 

Implications for practice

No implications for practice can be drawn due to limited evidence.

 
Implications for research

Further evidence is required. Several trials are under way that will add to the body of knowledge.

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms

The authors would like to acknowledge editors and staff of the Cochrane Stroke Group for advice and helpful comments on this review.

 

Data and analyses

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms

This review has no analyses.

 

Appendices

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms
 

Appendix 1. MEDLINE search strategy

1. "Cerebrovascular Disorders" [Mesh]
2. Stroke* [tiab]
3. poststroke* [tiab]
4. post-stroke [tiab]
5. cerebrovasc* [tiab]
6. cerebral vasc* [tiab]
7. brain vasc* [tiab]
8. CVA [tiab]
9. transient ischemic attack* [tiab]
10. transient ischaemic attack* [tiab]
11. TIA [tiab]
12. brain infarct* [tiab]
13. brain ischemi* [tiab]
14. brain ischaemi* [tiab]
15. ischemic attack* [tiab]
16. ischaemic attack* [tiab]
17. "ischaemic stroke" [tiab]
18. "ischemic stroke" [tiab]
19. "haemorrhagic stroke" [tiab]
20. "hemorrhagic stroke" [tiab]
21. apoplexy  [tiab]
22. 1-21/OR
23. Exercise [Mesh]
24. Exercise Therapy [Mesh]
25. Exercise Tolerance [Mesh]
26. Exercise Test [Mesh]
27. Exertion [Mesh]
28. Physical Fitness [Mesh]
29. Exercise Movement Techniques [Mesh]
30. Physical Therapy Modalities [Mesh]
31. Physical Therapy (Specialty) [Mesh]
32. physiotherapy*
33. physical therapy
34. physical therapies
35. Locomotion [Mesh]
36. Early Ambulation [Mesh]
37. Sports [Mesh]
38. Weight Lifting [Mesh]
39. Bicycling [Mesh]
40. Running [Mesh]
41. Swimming [Mesh]
42. Walking [Mesh]
43. Sports Equipment [Mesh]
44. Leisure Activities [Mesh]
45. Recreation [Mesh]
46. Isometric Contraction [Mesh]
47. Isotonic Contraction [Mesh]
48. physical exercise* [tiab]
49. physical activity [tiab]
50. physical activities [tiab]
51. exercise [tiab]
52. fitness [tiab]
53. training [tiab]
54. conditioning [tiab]
55. recreation [tiab]
56. leisure [tiab]
57. sport [tiab]
58. sports [tiab]
59. cycle [tiab]
60. cycling [tiab]
61. bicycl* [tiab]
62. treadmill* [tiab]
63. run [tiab]
64. running [tiab]
65. swim* [tiab]
66. walk* [tiab]
67. muscle strength* [tiab]
68. progressive resist* [tiab]
69. weight training [tiab]
70. weight lift* [tiab]
71. isometric [tiab]
72. isotonic [tiab]
73. Nutrition Assessment [Mesh]
74. Nutrition Therapy [Mesh]
75. Diet [Mesh]
76. Diet, Sodium-Restricted [Mesh]
77. Diet, Fat-Restricted [Mesh]
78. Diet Therapy [Mesh]
79. Diet, Mediterranean [Mesh]
80. Diet, Reducing [Mesh]
81. Diabetic Diet" [Mesh]
82. Food Habits [Mesh]
83. nutrition [tiab]
84. diet [tiab]
85. diets [tiab]
86. dietary [tiab]
87. Smoking Cessation [Mesh]
88. smoking cessation [tiab]
89. Tobacco Use Disorder [Mesh]
90. Stress [Mesh]
91. Stress, Psychological [Mesh]
92. Education [Mesh]
93. Health Education [Mesh]
94. Patient Education [Mesh]
95. Health Promotion [Mesh]
96. Patient-Centered Care [Mesh]
97. Telephone [Mesh]
98. "cardiac rehabilitation" [tiab]
99. "cardiac rehab" [tiab]
100. 23-99/OR
101. Secondary Prevention [Mesh]
102. second* [tw]
103. recurren* [tw]
104. subsequen* [tw]
105. sequel* [tw]
106. Risk Factors [Mesh]
107. 101-106/OR
108. randomized controlled trial[pt]
109. controlled clinical trial[pt]
110. randomized controlled trials[mesh]
111. random allocation[mesh]
112. double-blind method[mesh]
113. single-blind method[mesh]
114. clinical trial[pt]
115. clinical trials[mesh]
116. clinical trial [tw]
117. (singl*[tw] or doubl*[tw] or trebl*[tw] or tripl*[tw]) AND (mask*[tw] OR blind*[tw])
118. placebos[mesh]
119. placebo*[tw]
120. random*[tw]
121. research design[mesh:noexp]
122. comparative study[pt]
123. evaluation studies[pt]
124. Evaluation Studies as Topic[mesh]
125. follow-up studies[mesh]
126. prospective studies[mesh]
127. control*[tw]
128. prospectiv*[tw]
129. volunteer*[tw]
130. 108-129/OR
131. 22 and 100 and 107 and 130
132. animal/ not (human/ and animal/)
133. 131 NOT 132

 

Appendix 2. Examples of other search strategies

 

EMBASE

('cerebrovascular disease'/exp OR (stroke* OR poststroke* OR 'post stroke' OR cerebrovasc* OR 'brain'/exp OR 'brain' AND vasc* OR 'transient ischemic attack'/exp OR 'transient ischemic attack' OR 'transient ischaemic attack' OR 'brain'/exp OR 'brain' AND infarct* OR 'brain'/exp OR 'brain' AND ischemi* OR 'brain'/exp OR 'brain' AND ischaemi* OR ischemic AND attack* OR ischaemic AND attack*) OR 'apoplexy'/exp OR 'apoplexy' OR cva:ab,ti OR tia:ab,ti AND ('kinesiotherapy'/exp OR 'exercise tolerance'/exp OR 'exercise test'/exp OR 'physiotherapy'/exp OR 'mobilization'/exp OR 'bicycle'/exp OR 'swimming'/exp OR 'walking'/exp OR 'treadmill exercise'/exp OR 'muscle isometric contraction'/exp OR 'muscle isotonic contraction'/exp OR 'physical exercise'/exp OR 'physical exercise' OR 'physical activity'/exp OR 'physical activity' OR 'physical activites' OR 'exercise'/exp OR 'exercise' OR 'fitness'/exp OR 'fitness' OR 'training'/exp OR 'training' OR 'conditioning'/exp OR 'conditioning' OR 'recreation'/exp OR 'recreation' OR 'leisure'/exp OR 'leisure' OR 'sport'/exp OR 'sport' OR 'sports'/exp OR 'sports' OR cycle OR 'cycling'/exp OR 'cycling' OR bicycl* OR treadmill* OR run OR 'running'/exp OR 'running' OR swim* OR walk* OR 'muscle strength'/exp OR 'muscle strength' OR 'progressive resistance' OR 'weight lifting'/exp OR 'weight lifting' OR isometric OR isotonic OR 'nutritional assessment'/exp OR 'nutrition'/exp OR 'diet therapy'/exp OR 'sodium restriction'/exp OR 'low fat diet'/exp OR 'mediterranean diet'/exp OR 'low calory diet'/exp OR 'diabetic diet'/exp OR 'feeding behavior'/exp OR 'diet'/exp OR 'diet' OR diets OR nutrition* OR 'smoking cessation'/exp OR 'tobacco dependence'/exp OR 'stress'/exp OR 'mental stress'/exp OR 'education'/exp OR 'education' OR 'health education'/exp OR 'health education' OR 'patient education'/exp OR 'patient education' OR 'health promotion'/exp OR 'health promotion' OR 'patient care'/exp OR 'patient care' OR 'telephone'/exp OR 'telephone' OR ‘cardiac rehabilitation’ or ‘cardiac rehab’) AND (second* OR recurren* OR subsequen* OR sequel* OR 'risk factor'/exp) AND (random* OR 'clinical trial'/exp OR 'clinical trial' OR 'clinical trials'/exp OR 'clinical trials' OR 'double blind' OR 'single blind' OR 'triple blind' OR placebo* OR 'evaluation study' OR 'evaluation studies'/exp OR 'evaluation studies' OR 'comparative study'/exp OR 'comparative study' OR 'comparative studies'/exp OR 'comparative studies' OR 'follow-up study'/exp OR 'follow-up study' OR 'follow-up studies'/exp OR 'follow-up studies' OR 'prospective study'/exp OR 'prospective study' OR 'prospective studies'/exp OR 'prospective studies' OR 'research design'/exp OR 'research design'))

 

CINAHL


S47S35 and S38 and S39 and S46 

S46S34 or S40 or S45 

S45S43 or S44 

S44TI "cardiac rehab" or AB "cardiac rehab" 

S43TI "cardiac rehabilitation" or AB "cardiac rehabilitation" 

S42S35 and S38 and S39 and S41 

S41S34 or S40 

S40(MH "Education") or (MH "Health Education") or (MH "Patient Education") or (MH "Health Promotion") or (MH "Patient Centered Care") or (MH "Telephone") 

S39random* or blind* or trial* or research or evaluation or prospective or "follow-up" 

S38S37 or S36 

S37second* or recurren* or subsequen* or sequel* 

S36(MH "Risk Factors") or (MH "Cardiovascular Risk Factors") 

S35S4 or S3 or S2 or S1 

S34S33 or S32 or S31 or S30 or S29 or S28 or S27 or S26 or S25 or S24 or S23 or S22 or S21 or S20 or S19 or S18 or S17 or S16 or S15 or S14 or S13 or S12 or S11 or S10 or S9 or S8 or S7 or S6 or S5 

S33(MH "Stress+") 

S32(MH "Tobacco") 

S31(MH "Smoking Cessation") 

S30nutrition or diet or diets 

S29(MH "Food Habits") 

S28(MH "Diabetic Diet") 

S27(MH "Mediterranean Diet") 

S26(MH "Diet") or (MH "Diet, Fat-Restricted") or (MH "Diet, Low Carbohydrate") or (MH "Diabetic Diet") 

S25(MH "Diet Therapy") 

S24(MH "Nutritional Assessment") 

S23(MH "Nutrition") 

S22physiotherapy or "physical therapy" or "physical therapies" or "physical exercise*" or "physical activity" or "physical activities" or exercise or fitness or training or conditioning or recreation or leisure or sport or sports or cycle or cycling or bicycl* or treadmill* or run or running or swim* or walk* or "muscle strength" or "progressive resistance" or "weight training" or "weight lift*" or isometric or isotonic 

S21(MH "Isometric Contraction") or (MH "Isotonic Contraction") or (MH "Isometric Exercises") 

S20(MH "Recreation") 

S19(MH "Leisure Activities") 

S18(MH "Sports Equipment and Supplies") 

S17(MH "Walking") 

S16(MH "Swimming") 

S15(MH "Running") 

S14(MH "Cycling") 

S13(MH "Weight Lifting") or (MH "Anaerobic Exercises") 

S12(MH "Sports") 

S11(MH "Early Ambulation") 

S10(MH "Locomotion") 

S9("physical therapy modalities") or (MH "Physical Therapy") 

S8(MH "Therapeutic Exercise") 

S7(MH "Physical Fitness") or (MH "Physical Activity") 

S6(MH "Exertion") 

S5(MH "Exercise") or (MH "Therapeutic Exercise") or (MH "Aerobic Exercises") or (MH "Anaerobic Exercises") or (MH "Aquatic Exercises") or (MH "Exercise Intensity") or (MH "Exercise Test") or (MH "Exercise Tolerance") or (MH "Isokinetic Exercises") or (MH "Isometric Exercises") or (MH "Isotonic Exercises") 

S4AB cva or tia 

S3stroke* or post stroke or "post stroke" or cerebrovasc* or "cerebral vascular" or "brain vasc*" or "transient ischemic attack*" or "transient ischemic attack*" or brain infarct* or brain ischemi* or brain ischaemi* or ischemic attack* or ischemic attack* or apoplexy 

S2stroke* or poststroke or "post stroke" or cerebrovasc* or "cerebral vascular" or "brain vasc*" or "transient ischemic attack*" or "transient ischaemic attack*" or brain infarct* or brain ischemi* or brain ischaemi* or ischemic attack* or ischaemic attack* or apoplexy 

S1(MH "Cerebrovascular Disorders+") 



 

Web of Science


#8#7 AND #3

#7#6 AND #2 AND #1

#6#5 OR #4

#5ts=(physical or physio* or exercise* or fitness or training or conditioning or recreation or leisure or sport* or cycl* or bicycl* or treadmill* or run* or swim* or walk* or isometric or isotonic or diet* or nutrition* or food or smoking or tobacco or stress or "cardiac rehab" or "cardiac rehabilitation")

#4ts=(educat* or "health promotion" or "patient centered care" or "patient centred care" or telephone)

#3ts=(Random* or trial* or blind* or evaluation or follow-up or prospective or research design)

#2ts=(stroke* or poststroke or "post stroke" or cerebrovasc* or "cerebral vascular" or "brain vasc*" or "transient isch?emic attack*" or brain infarct* or brain isch?emi* or isch?emic attack* or ischaemic attack* or "cerebralvascular disorders" or tia)

#1ts=(second* or recurren* or subsequen* or sequel* or risk)



 

Proquest Dissertations and Theses Database

(stroke or cva or cerebrovasc* or ischemi* or ischaemi* or infarct* or tia or apoplexy) AND (physical or physio* or exercise* or fitness or training or conditioning or recreation or leisure or sport* or diet* or nutrition* or food or smoking or tobacco or stress or education or "Patient-Centered Care" or telephone or "cardiac rehab" or "cardiac rehabilitation") AND (second* or recurren* or subsequen* or sequel* or risk)

 

ClinicalTrials.gov

(Stroke* OR poststroke* OR post-stroke OR cerebrovasc* OR cerebral vasc*) AND (Exercise OR Exertion OR physiotherapy* OR physical OR fitness OR training OR education or "Patient-Centered Care" or telephone or cardiac*)

 

CenterWatch and Current Controlled Trials

("Cerebrovascular Disorders" OR Stroke* OR poststroke* OR post-stroke OR cerebrovasc* OR cerebral vasc* OR brain vasc* OR CVA OR transient ischemic attack* OR transient ischaemic attack* OR TIA brain infarct* OR brain ischemi* OR brain ischaemi*)

 

Open SIGLE

(stroke or cva or cerebrovasc* or ischemi* or ischaemi* or infarct* or tia or apoplexy) AND (physical or physio* or exercise* or fitness or training or conditioning or recreation or leisure or sport* or diet* or nutrition* or food or smoking or tobacco or stress or education or "Patient-Centered Care" or telephone or "cardiac rehab" or "cardiac rehabilitation") AND (second* or recurren* or subsequen* or sequel* or risk)

 

OT Seeker

stroke or cva or cerebrovasc* or ischemi* or ischaemi* or infarct* or tia or apoplexy

Note: Fuzzy logic search used to broaden retrieval

 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms

Conceiving the review: Marilyn MacKay-Lyons.
Designing the review: Marilyn MacKay-Lyons, Tim Ruggles.
Co-ordinating the review: Marilyn MacKay-Lyons.
Data collection for the review:

  • designing search strategies: Tim Ruggles;
  • undertaking searches: Tim Ruggles;
  • screening search results: Marianne Thornton, Marion Che;
  • organizing retrieval of papers: Marianne Thornton;
  • screening retrieved papers against inclusion criteria: Marianne Thornton, Marion Che;
  • appraising quality of papers: Marianne Thornton, Marilyn MacKay-Lyons, Marion Che;
  • extracting data from papers: Marianne Thornton, Marilyn MacKay-Lyons, Marion Che;
  • writing to authors of papers for additional information: Marianne Thornton, Marion Che;
  • providing additional data about papers: Marianne Thornton, Marion Che;
  • obtaining and screening data on unpublished studies: Marianne Thornton.

Data management for the review:

  • entering data into RevMan: Marianne Thornton, Marion Che;
  • analysis of data: Marianne Thornton, Marilyn MacKay-Lyons.

Interpretation of data:

  • providing a methodological perspective: Marilyn MacKay-Lyons, Tim Ruggles;
  • providing a clinical perspective: Marilyn MacKay-Lyons, Marianne Thornton.

Writing the review: Marilyn MacKay-Lyons, Marianne Thornton, Marion Che.

Updating the review: Marilyn MacKay-Lyons, Marianne Thornton, Marion Che.

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms

Marilyn MacKay-Lyons is the principal investigator in a clinical trial that is a potentially eligible study for this Cochrane review. The trial is entitled 'Program of rehabilitative exercise and education to avert vascular events after non-disabling stroke or transient ischemic attack: a multi-centred RCT (PREVENT Trial)' (MacKay-Lyons 2010).

 

Sources of support

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms
 

Internal sources

  • No sources of support supplied

 

External sources

  • Nova Scotia Health Research Foundation, Canada.
    Knowledge Translation Research Grant

 

Differences between protocol and review

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms

None.

References

References to studies included in this review

  1. Top of page
  2. AbstractRésumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Characteristics of studies
  17. References to studies included in this review
  18. References to studies excluded from this review
  19. References to ongoing studies
  20. Additional references
Lennon 2008 {published data only}
  • Lennon O, Carey A, Gaffney N, Stephenson J. A pilot randomized controlled trial to evaluate the benefit of the cardiac rehabilitation paradigm for the non-acute ischaemic stroke population. Clinical Rehabilitation 2008;22:125-33.

References to studies excluded from this review

  1. Top of page
  2. AbstractRésumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Characteristics of studies
  17. References to studies included in this review
  18. References to studies excluded from this review
  19. References to ongoing studies
  20. Additional references
Allen 2002 {published data only}
  • 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. Journal of Stroke and Cerebrovascular Disease 2002;11:88-98.
Battersby 2009 {published data only}
  • Battersby M, Hoffmann S, Cadilhac D, Osborne R, Lalor E, Lindley R. 'Getting your life back on track after stroke': a Phase II multi-centered, single-blind, randomized, controlled trial of the Stroke Self-Management Program vs. the Stanford Chronic Condition Self-Management Program or standard care in stroke survivors. International Journal of Stroke 2009;4:137-44.
Boysen 2009 {published data only}
  • Boysen G, Krarup LH, Zeng X, Oskedra A, Kırv J, Andersen G, et al. 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.
Brazzelli 2011 {published data only}
Ellis 2005 {published data only}
  • Ellis G, Rodger J, McAlpine C, Langhorne P. The impact of a stroke nurse specialist input on risk factor modification: a randomised controlled trial. Clinical Rehabilitation 2005;23:99-105.
Gillham 2010 {published data only}
  • 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. Clinical Rehabilitation 2010;24:822-30.
Harrington 2010 {published data only}
  • Harrington R, Taylor G, Hollinghurst S, Reed M, Kay H, Wood VA. A community-based exercise and education scheme for stroke survivors: a randomized controlled trial and economic evaluation. Clinical Rehabilitation 2010;24:3-15.
Holmgren 2010 {published data only}
  • Holmgren E, Gosman-Hedström G, Lindström B, Wester P. What is the benefit of a high-intensive exercise program on health-related quality of life and depression after stroke? A randomized controlled trial. Advanced Physiotherapy 2010;12:125-33.
Marsden 2010 {published data only}
  • Marsden D, Quinn R, Pond N, Goledge R, Neilson C, White J, et al. A multidisciplinary group programme in rural settings for community-dwelling chronic stroke survivors and their carers: a pilot randomized controlled trial. Clinical Rehabilitation 2010;24:328-41.
Ovbiagele 2004 {published data only}
  • Ovbiagele B, Saver JL, Fredieu A, Suzuki S, McNair N, Dandekar A, et al. Protect: a coordinated stroke treatment program to prevent recurrent thromboembolic events. Neurology 2004;63:1217-22.
Prior 2011 {published data only}
  • Prior PL, Hachinski V, Unsworth K, Chan R, Mytka S, O'Callaghan C, et al. Comprehensive cardiac rehabilitation for secondary prevention after transient ischemic attack or mild stroke: I: feasibility and risk factors. Stroke 2011;42(11):3207-13.
Robinson 2005 {published data only}
  • Robinson JR, Maheshwari N. A "poly-portfolio" for secondary prevention: a strategy to reduce subsequent events by up to 97% over five years. American Journal of Cardiology 2005;95:373-8.
Strandberg 2006 {published data only}
  • Strandberg T, Pitkala K, Berglind S, Nieminen M, Tilvis R. Multifactorial intervention to prevent recurrent cardiovascular events in patients 75 years or older: The Drugs and Evidence-Based Medicine in the Elderly (DEBATE) study: a randomized, controlled trial. American Heart Journal 2006;152:585-92.
Tang 2010 {published data only}

References to ongoing studies

  1. Top of page
  2. AbstractRésumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Characteristics of studies
  17. References to studies included in this review
  18. References to studies excluded from this review
  19. References to ongoing studies
  20. Additional references
Kirk ongoing {unpublished data only}
  • Kirk H. Is the cardiac model of rehabilitation is more effective than standard care in reducing cerebrovascular risk factors post-transient ischaemic attack?. www.suht.nhs.uk/home.aspx (accessed 24 January 2013).
Lennon 2009 {unpublished data only}
MacKay-Lyons 2010 {unpublished data only}
  • MacKay-Lyons M, Gubitz G, Giacomantonio N, Wightman H, Marsters D, Thompson K, et al. Program of Rehabilitative Exercise and education to avert Vascular Events after Non-disabling stroke or TIA: a multi-site, RCT (PREVENT). BMC Neurology 2010;10:122.
NCT00536562 {unpublished data only}
  • Suskin N. Comprehensive cardiac rehabilitation programming for patients following transient ischemic attack. www.clinicaltrials.gov/ct2/show/NCT00536562 (accessed 24 January 2013).
NCT00929994 {unpublished data only}
  • Brooks D, Oh Paul, Black S, McIllroy WE. Effects of cardiac rehabilitation for individuals with transient ischemic attack. www.clinicaltrials.gov/ct2/show/NCT00929994 (accessed 24 January 2013).

Additional references

  1. Top of page
  2. AbstractRésumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Characteristics of studies
  17. References to studies included in this review
  18. References to studies excluded from this review
  19. References to ongoing studies
  20. Additional references
Balady 2007
  • Balady GJ, Williams MA, Ades PA, Bittner V, Comoss P, Foody JM, et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update. A scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2007;115:2675-82.
Boulé 2001
  • Boulé NG, Haddad E, Kenny GP, Wells GA, Sigal RJ. Effects of exercise on glycemic control and body mass in type 2 diabetes mellitus. A meta-analysis of controlled clinical trials. JAMA 2001;286:1218-27.
Brunner 2007
Clark 2005
  • Clark AM, Hartling L, Vandermeer B, McAlister FA. Meta-analysis: secondary prevention programs for patients with coronary artery disease. Annals of Internal Medicine 2005;143:659-72.
Dansinger 2007
  • Dansinger M, Tatsioni A, Wong JB, Chung M, Balk EM. Meta-analysis: the effect of dietary counselling for weight loss. Annals of Internal Medicine 2007;147:41-50.
Deakin 2005
Deeks 2011
  • Deeks JJ, Higgins JPT, Altman DG. Chapter 9: Analysing data and undertaking meta-analyses. In: Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane-handbook.org.
Fagard 2007
Garner 2005
  • Garner C, Page S. Applying the transtheoretical model to exercise behaviors of stroke patients. Topics in Stroke Rehabilitation 2005;12:69-75.
Gordon 2004
  • Gordon NF, Gulanick M, Costa F, Fletcher GF, Franklin BA, Roth EJ, et al. Physical activity and exercise recommendations for stroke survivors. An American Heart Association Scientific Statement from the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council. Circulation 2004;109:2031-41.
Gordon 2009
Hackam 2007
Hankey 2005
Higgins 2011
  • Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane-handbook.org.
Houston 2009
  • Houston MC, Fazio S, Chilton FH, Wise DE, Jones KB, Barringer TA, et al. Nonpharmacologic treatment of dyslipidemia. Progress in Cardiovascular Diseases 2009;52:61-94.
Jolliffe 2001
  • Jolliffe JA, Rees K, Taylor RS, Thompson D, Oldridge N, Ebrahim S. Exercise-based rehabilitation for coronary heart disease. Cochrane Database of Systematic Reviews 2001, Issue 1. [DOI: 10.1002/14651858.CD001800]
Kelley 2008
Kodama 2007
  • Kodama S, Tanaka S, Saito, K, Shu M, Sone Y, Onitake F, et al. Effect of aerobic exercise training on serum levels of high-density lipoprotein cholesterol. A meta-analysis. Archives of Internal Medicine 2007;167:999-1008.
Koenig 2007
  • Koenig KL, Whyte EM, Munin MC, O'Donnell L, Skidmore ER, Penrod LE, et al. Stroke-related knowledge and health behaviors among poststroke patients in inpatient rehabilitation. Archives of Physical Medicine and Rehabilitation 2007;88:1214-6.
Lee 2003
Lindsay 2008
  • Lindsay P, Bayley M, Hellings C, Hill MD, Woodbury E, Philips S. Canadian best practice recommendations for stroke care (updated 2008). Canadian Medical Association Journal 2008;179:S1-S25.
Lopez 2006
  • Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet 2006;367:1747-57.
Mouradian 2002
  • Mouradian MS, Majumdar SR, Senthilselvan A, Khan K, Shuaib A. How well are hypertension, hyperlipidemia, diabetes, and smoking managed after a stroke or transient ischemic attack?. Stroke 2002;33:1656-9.
Muntner 2006
  • Muntner P, DeSalvo KB, Wildman RP, Raggi P, He J, Whelton P. Trends in the prevalence, awareness, treatment, and control of cardiovascular disease risk factors among noninstitutionalized patients with a history of myocardial infarction and stroke. American Journal of Epidemiology 2006;163:913-20.
Myint 2009
  • Myint PK, Luben RN, Wareham NJ, Bingham SA, Khaw K-T. Combined effect of health behaviours and risk of first ever stroke in 20 040 men and women over 11 years' follow-up in Norfolk cohort of European Prospective Investigation of Cancer (EPIC Norfolk): prospective population study. BMJ 2009;338:b349.
Orzano 2004
  • Orzano AJ, Scott JG. Diagnosis and treatment of obesity in adults: an applied evidence-based review. Journal of the American Board of Family Practice 2004;17:359-69.
Sacco 2006
  • Sacco RL, Adams R, Albers G, Alberts MJ, Benavente O, Furie K, et al. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline. Circulation 2006;113:e409-49.
Shaw 2006
Spieler 2003
Taylor 2004
  • 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. America Journal of Medicine 2004;116:682-92.
Touze 2005
  • Touze 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;36:2748-55.
Whelton 2002
  • Whelton SP, Chin A, Xin X, He J. Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials. Annals of Internal Medicine 2002;136:493-503.
Yamaoka 2005
  • Yamaoka K, Tango T. Efficacy of lifestyle education to prevent type 2 diabetes. A meta-analysis of randomized controlled trials. Diabetes 2005;28:2780-6.