Associations between pre-stroke physical activity levels and health-related quality of life 3 months after stroke: A registry-based study (part of PAPSIGOT)

Abstract

Background:

Whether pre-stroke physical activity is associated with health-related quality of life after stroke has been sparsely investigated.

Aims:

To explore associations between pre-stroke physical activity and health-related quality of life 3 months after stroke onset.

Methods:

A consecutively collected cohort study with data from registries. Included were adult patients with first stroke in the period 2014–2018 who were hospitalized at any one of the three stroke units in Gothenburg, Sweden. Pre-stroke physical activity was assessed with the Saltin–Grimby Physical Activity Level Scale (SGPALS) after hospital admission for acute stroke. Health-related quality of life was assessed with the EuroQoL 5 Dimensions 5 Level Version (EQ-5D-5L) 3 months after stroke. Data were analyzed with the Kruskal–Wallis test and binary logistic regression.

Results:

Data were included from 2044 patients; 91% had ischemic stroke, 46% were female, and mean age was 73 years, with mild stroke severity median National Institute of Health Stroke Scale (NIHSS) of 2. Patients who were pre-stroke physically active reported better overall health-related quality of life by the EQ-5D-5L index value, all the domains in EQ-5D-5L, and the EuroQoL-Visual Analogue Scale (EQ-VAS) compared with pre-stroke physically inactive patients (all p < 0.001). Better health-related quality of life 3 months after stroke was associated with pre-stroke light and moderate physical activity: adjusted odds ratio (95% confidence interval), 1.9 (1.5–2.3) and 2.3 (1.5–3.4), respectively.

Conclusion:

Pre-stroke physical activity is associated with better health-related quality of life 3 months after stroke. For the domains of mobility, self-care, and pain/discomfort, physical activity with higher intensity is even more beneficial.

Keywords

Pre-stroke stroke exercise physical activity sedentary behavior health-related quality of life

Introduction

Stroke is a leading cause of disability, with an increasing number of people living with the consequences of stroke.¹ Stroke can have an impact on physical, cognitive, and psychological health.² In life after stroke, the well-being of a person is often affected with reduced health-related quality of life,^2,3 as reported by 25% of patients 3 months after stroke.⁴ Patient-reported outcomes such as health-related quality of life, defined as “how well a person functions in their life and his or her perceived well-being in physical, mental, and social domains of health,”⁵ provide important information from the patient’s perspective.⁶ There are many factors associated with health-related quality of life after stroke such as demographic factors, comorbidities, neurological deficits, functional disability, and psychosocial factors.⁷ Older age,^7–9 female sex,^10,11 lack of exercise,^9,11–14 and physical inactivity after stroke^9,12,14 are associated with poor health-related quality of life.

A lack of physical activity and sedentary behavior are associated with poor health-related quality of life and lower general health in a Swedish general population.¹⁵ A German study with 497 patients explored whether pre-stroke physical activity is associated with better health-related quality of life, and it found better physical quality of life in the domains of hand function, mobility, and activities of daily living when participants were pre-stroke physically active.¹⁶ However, the association with health-related quality of life needs to be confirmed with other studies on the topic. Furthermore, pre-stroke physical activity is positively associated with reduced stroke severity, functional disability, and activities of daily living.^17,18 The definition of physical activity is any movement of the body produced by muscles that produces energy, while exercise is a subset of physical activity that is planned, structured, and repeated to maintain or improve fitness or skills.¹⁹ The aim of this study was to identify associations between pre-stroke physical activity and health-related quality of life 3 months after stroke onset.

Methods

Study design and study sample

This is a consecutively collected cohort with retrospective data from two Swedish stroke registries, the national quality registry Riksstroke and the local quality registry Väststroke, with data from the acute setting and a 3-month follow-up. Data were merged by a statistician at Riksstroke, and thereafter the dataset was pseudonymized. Inclusion criteria were as follows: adult patients (⩾18 years) with first-ever stroke in the period 1 November 2014 to 31 August 2018. Stroke was diagnosed as ischemic stroke (I63) or intracerebral hemorrhage (I61) according to the International Classification of Diseases, Tenth Revision (ICD-10) and included patients who had registered 3-month follow-up data. Exclusion criteria were lack of registered information for pre-stroke physical activity or for health-related quality of life.

Ethics

Research was conducted in accordance with the Declaration of Helsinki. Ethical approval (registration number 346-16 with approval 4/5 2016) from the Regional Ethical Review Board in Gothenburg, Sweden. An amendment (registration number T807-18) was made with an approval on 14 September 2018. Data from quality registries are excluded from the rule of patient consent by the Data Inspection Board in Sweden according to the Personal Data Act, Swedish law No. SFS 1998:204, as the purposes of the registries are to improve quality of care, treatment, and rehabilitation. The patients receive information about stroke registries at the stroke units with an opt-out option. Data were pseudonymized so that it was not possible to identify individuals in the research dataset.

Usual care

Patients receive care and rehabilitation at the Sahlgrenska University Hospital in Gothenburg, in the west of Sweden. The catchment area is 750, 000 inhabitants for acute and basic care. The hospital consists of three sites, each with a comprehensive stroke unit where multidisciplinary teamwork is performed. Physiotherapists and occupational therapists assess all patients with stroke.

Measurements and variables

Variables

Information on the following variables were retrieved from the Väststroke registry: sex, pre-stroke physical activity assessed with the Saltin–Grimby Physical Activity Level Scale (SGPALS), stroke type, and stroke severity assessed with the National Institute of Health Stroke Scale (NIHSS) at admission; and from the Riksstroke registry: age, reperfusion therapies, length of hospital stay, and discharge destination. Specially trained nurses at the stroke units collect the data from the charts and register information in the two quality registries. Physiotherapists assess pre-stroke physical activity at first encounter in the stroke unit and register the information in the Väststroke registry. Information on health-related quality of life assessed with the EuroQoL 5 Dimensions 5 Level Version (EQ-5D-5L) questionnaire was retrieved from the 3-month follow-up in Väststroke. The 3-month follow-up is a postal questionnaire; if a patient does not respond, the information is collected by telephone by trained nurses. The EQ-5D-5L could be reported by proxy, and information about assisted or non-assisted response was collected from the registry.

Dependent variable

The EQ-5D-5L is a generic self-reported scale for health-related quality of life in mobility, self-care, usual activities, pain or discomfort, and anxiety or depression. An index value can be calculated from a value set with answers from each domain of the EQ-5D-5L. In this study, the index value was calculated with an index calculator with values from the United Kingdom. The EQ-5D-5L index value has a maximum value of 1 for full health and an anchor of 0 for a state equivalent to being dead, where values less than 0 are regarded as worse than being dead.^20–22 Perceived general health is collected from the EuroQoL-Visual Analogue Scale (EQ-VAS) with a scale from 0 to 100; the higher value, the better.²¹ The EQ-5D is reliable and validated for stroke.^23,24 The EQ-VAS and the EQ-5D-5L (domains and index value) were used in this study. The Väststroke registry has a license to use the EQ-5D-5L.

Assessment scales

The SGPALS²⁵ is a generic self-reported assessment tool of physical activity in four levels used in this study to assess pre-stroke physical activity. The patients were asked “How much time do you spend being physically active or exercising during your leisure time?” Information about physical activity was taken by the physiotherapists within the first days and when needed confirmed by next of kin in dialogue with patient and relatives. The questions refer to the past year. The answer levels are “1. Physically inactive,” “2. Some light physical activity for at least 4 hours/week,” “3. Regular physical activity and training for at least 2-3 hours/week,” and “4. Regular hard physical training for competitive sports several times per week.” Stroke severity was assessed with the NIHSS²⁶ on a scale ranging from 0 to 42, where a lower value indicates lesser stroke severity.²⁷ The Montreal Cognitive Assessment (MoCA) is a screening tool to detect mild cognitive impairment. The score ranges from 0 to 30 where a value below 26 can indicate cognitive impairment.²⁸

Statistics

Descriptive statistics

Nominal variables are presented with frequencies and percentages, ordinal variables with medians (Md) and interquartile range (IQR), and continuous variables with means and standard deviations (SDs). For data analyses, the IBM SPSS Statistics for Windows was used (Version 28.0., IBM Corp., Armonk, NY, 2019). The p-value for significance was set at <0.05.

Group comparisons

Dropout analyses were analyzed as differences between the study sample and the excluded group with chi-square used for nominal variables and the Mann–Whitney U test for ordinal and continuous variables. Differences between groups of patients with three physical activity levels (SGPALS: 1, 2, and 3–4) were analyzed with the Kruskal–Wallis’ test and the Independent-Samples Jonckheere–Terpstra Test for Ordered Alternatives on the following outcomes: the EQ-5D-5L’s five domains, the EQ-5D-5L index value, and the EQ-VAS. SGPALS levels 3 and 4 were merged in the dataset due to there being few observations on level 4 and are together referred to as “regular physical activity and training.”

Selection of independent variables

The primary independent variable was pre-stroke physical activity, with patients divided into three groups with the SGPALS. The independent variables were sex, age divided into four groups (18–64, 65–74, 75–84, and 85–100 years), stroke severity in three groups (NIHSS: 0, 1–5, and 6–42), reperfusion therapy (yes/no), length of hospital stay (days), and discharge destination dichotomized to own home or healthcare facility (nursing home or hospital ward). The divisions in age and NIHSS groups were based on balanced groups for the regression analyses.

Regression analyses

The association between pre-stroke physical activity and health-related quality of life was analyzed with binary logistic regression.²⁹ Assumptions were checked with cross tabs to secure >10 events per variable and checked for multicollinearity (defined as >±0.70) with correlation and chi-square analyses. The dependent variable was dichotomized and divided by the Md of the EQ-5D-5L index value, where a value equal or above the Md (>0.736) referred to a better outcome, while a value ⩽Md was considered as a poor outcome. A univariable analysis analyzed unadjusted values of odds ratios (ORs) and 95% confidence intervals (CIs), where variables with p < 0.25 were included in a multivariable analysis.²⁹ A regression model was performed to calculate adjusted values analyzed with multivariable analysis including all independent variables. In the regression analyses, the reference groups were physical inactivity (SGPALS1), male sex, age group 18–64 years, no symptoms on NIHSS (zero), no reperfusion treatment, and discharge to healthcare facility.

The model fit was evaluated with the Hosmer–Lemeshow test (a good fit >0.05), the Omnibus test (a good fit is p ⩽ 0.05), and area under the receiver operating characteristic curve (AUC, where ⩽0.5 is interpreted as poor performance), and the explained variance with the Cox and Snell and Nagelkerke tests (the higher values, the better). The model was internally validated with bootstrapping where 2000 smaller samples (bootstrap samples) from the original dataset were analyzed and presented as bootstrap standard errors, bias-corrected, and accelerated 95% CI and p-values.

Results

In total, 2044 patients were included in the analyses (Figure 1). In the study sample, 91.1% had ischemic stroke, 45.7% were females, the mean age was 72.6 years (SD: 13.4 years) with a range from 19 to 100 years, and the patients had mild stroke, with a Md NIHSS score of 2 (IQR = 5; see Table 1). Dropout analyses between the study sample (n = 2044) and the group of excluded patients (n = 1695) showed differences in sex, age, and stroke severity. The chi-square test showed more females in the study sample (45.7% females) compared with the excluded group (51.5% females), p < 0.001. The Mann–Whitney U test revealed a difference in age with younger patients in the study sample (Md = 74 years, IQR = 18) and older patients in the excluded group (Md = 77 years, IQR = 20), p < 0.001. Patients in the study sample had milder stroke assessed with NIHSS (Md = 2, IQR = 5) compared with the excluded group (NIHSS Md = 6, IQR = 12), p < 0.001.

Figure 1.

Flow chart of the study sample where pre-stroke physical activity was assessed with the Saltin–Grimby Physical Activity Level Scale (SGPALS) and health-related quality of life with the EQ-5D-5L.

Table 1.

Characteristics presented as groups of patients with different levels of pre-stroke PA assessed with Saltin–Grimby Physical Activity Level Scale (SGPALS).

Median (IQR)	Physical inactivity	Light PA	Regular PA and training	Total number
n (%)	978 (47.8%)	914 (44.7%)	152 (7.4%)	2044 (100%)
Age, years	77 (18)	73 (15)	65 (19)	74 (18)
Age groups, years:
18–64	199 (20.3)	226 (24.7)	74 (48.7)	499 (24.4)
65–74	215 (22.0)	276 (30.2)	44 (28.9)	535 (26.2)
75–84	293 (30.0)	292 (31.9)	28 (18.4)	613 (30.0)
85–100	271 (27.7)	120 (13.1)	6 (3.9)	397 (19.4)
Sex, females	509 (52.0)	385 (42.1)	41 (27.0)	935 (45.7)
Sex, males	469 (48.0)	529 (57.9)	111 (73.0)	1109 (54.3)
Stroke type:
Ischemic stroke	889 (90.9)	829 (90.7)	144 (94.7)	1862 (91.1)
Intracerebral hemorrhage	89 (9.1)	85 (9.3)	8 (5.3)	182 (8.9)
Acute stroke severity^a:
NIHSS	2 (6)	1 (3)	1 (3)	2 (5)
Reperfusion therapies:
Thrombolysis^b	96 (9.8)	107 (11.7)	28 (18.5)	231 (11.3)
Thrombectomy^c	52 (5.7)	54 (6.3)	9 (6.1)	115 (6.0)
Cognition:
MoCA^d	24 (7)	25 (5)	27 (3)	25 (5)
Cognitive impairment	260 (61.3)	273 (52.5)	29 (32.2)	562 (54.4)
Length of hospital stay, days	10 (15)	7 (9)	6 (5)	8 (12)
Discharge destination^e:
Own home	675 (69.5)	790 (86.6)	142 (93.4)	1607 (79.0)
Nursing home	220 (22.7)	52 (5.7)	0 (0.0)	272 (13.4)
Another ward	76 (7.8)	70 (7.7)	10 (6.6)	156 (7.7)

IQR: interquartile range; n: numbers; PA: physical activity; NIHSS: National Institute of Health Stroke Scale; MoCA: Montreal Cognitive Assessment.

MoCA < 26 indicates cognitive impairment. Proportions presented as valid percentage.

Missing: ^aNIHSS (n = 2). ^bThrombolysis (n = 6). ^cThrombectomy (n = 130). ^dMoCA (n = 1010). ^eDischarge destination (n = 9).

The mean value of the EQ-5D-5L was 0.66 (SD: 0.32) with a range from −0.59 to 1.00, while the EQ-VAS value measuring self-reported overall health was 65.0 (SD: 22.8, range: 0–100). Outcomes of the domains of EQ-5D-5L, the EQ-5D-5L index value, and the EQ5 VAS are presented in Supplementary Table S1. In the study sample, 50.3% of the patients reported no problems with mobility, 70.5% no problems with self-care, 40.9% no problems with usual activities, 43.7% no problems with pain/discomfort, and 41.8% no problems with anxiety/depression. However, 124 patients (6.1%) had an index value below 0, indicating a state of feeling worse than dead. Patients who were pre-stroke physically active (SGPALS > 1) reported significantly better health-related quality of life in all five domains of EQ-5D-5L (Figure 2), as well as in the EQ-5D-5L index value (p = 0.003 to <0.001) and EQ-VAS (p < 0.001) compared with physically inactive patients (SGPALS 1) presented in Supplementary Table S1. Furthermore, patients who exercised with higher intensity (SGPALS 3–4) reported better health-related quality of life compared with patients with light physical activity (SGPALS 2), in the domains of mobility, self-care, and pain/discomfort as well as in the EQ-VAS and the EQ-5D-5L index value. Patients need of help responding the EQ-5D-5L was reported as 1172 (59.2%) patients who answered the questionnaire unassisted, 463 (23.4%) with relatives, 59 (3.0%) with caregivers, and 287 (14.5%) with a trained nurse by telephone.

Figure 2.

Patients divided in groups with different pre-stroke physical activity (PA) levels and their distribution in the five domains of health-related quality of life (EQ-5D-5L) 3 months after stroke.

The binary logistic regression analyses showed that pre-stroke physical activity was associated with better health-related quality of life assessed as a dichotomized EQ-5D-5L index value in the univariable analysis, for both light physical activity (OR: 2.56, 95% CI: 2.13–3.08) and regular physical activity and training (OR: 4.18, 95% CI: 2.87–6.07). This association was also found in the multivariable analysis, for light physical activity (OR: 1.86, 95% CI: 1.52–2.29) and regular physical activity and training (OR: 2.25, 95% CI: 1.51–3.36; Figure 3, Supplementary Table S2). Furthermore, beside physical activity, discharge to own home and shorter length of hospital stay were associated with better health-related quality of life, while female sex, older age (>85 years), and more severe strokes (NIHSS > 5) were associated with poor health-related quality of life.

Figure 3.

Associations between pre-stroke physical activity (PA) and other independent variables and better health-related quality of life as the dependent variable (dichotomized) analyzed with multivariable binary logistic regression. The reference groups were physical inactivity, male sex, age 18–64 years, no symptoms on the NIH Stroke Scale, and discharge to healthcare facility, while length of stay is a continuous scale (per day).

Discussion

This study shows that pre-stroke physical activity is associated with better health-related quality of life 3 months after stroke onset. Besides physical activity discharge to own home and shorter length of hospital stay are associated with better health-related quality of life, while female sex, older age (>85 years), and more severe strokes (NIHSS > 5) are associated with decreased health-related quality of life. Groups of patients with higher levels of pre-stroke physical activity have better health-related quality of life compared with physically inactive patients in overall health-related quality of life as well as in all the five domains: mobility, self-care, everyday activities, pain/discomfort, and anxiety/depression. In addition, a higher intensity of physical activity was even more beneficial in the domains of mobility, self-care, and pain/discomfort.

The results of this study that associate pre-stroke physical activity with better health-related quality of life confirm the results of a recent smaller study.¹⁶ This is in line with the reported association of post-stroke physical inactivity on reduced health-related quality of life after stroke reported in several other studies.^9,11–14 Furthermore, physical inactivity is associated with decreased health-related quality of life in a Swedish general population.¹⁵ In the present study, female sex, older age, and severe stroke were also associated with decreased health-related quality of life, as seen previously in several studies.^7–11 More patients had thrombolysis in the pre-stroke physically active group compared to the inactive patients. This could be because of their younger age but may also be a result of faster door-to-needle times and less prevalent contraindications in physically active and younger patients. In this study, the final model also included both pre-stroke physical activity and less stroke severity to be associated with better health-related quality of life. Previous studies have reported pre-stroke physical activity and younger age to be associated with reduced stroke severity.^18,30 Hence, our results suggest that pre-stroke physical activity remains an important factor for better health-related quality of life when adjusted for age and stroke severity.

The strength of this study is the large study sample with consecutively collected patients. All patients admitted to the stroke units were included in the registries regardless of stroke severity, communication skill, and cognitive impairment, which can explain internal missing on some variables. The patient-reported outcome measures provide valuable information and are useful in addition to other assessments in healthcare.³¹ The study is limited by the internal missing data, a common occurrence in registry-based studies with data from a clinical setting. To reduce missing data for the 3-month follow-up and health-related quality of life, the postal questionnaires were followed by reminders and a telephone call with a trained nurse. Still, about a quarter of the patients failed to answer the 3-month follow-up questionnaire. The excluded patients without follow-up data had more severe strokes and were probably more often discharged to nursing homes, possibly introducing a risk of selection bias. Physical activity was self-reported and assessed retrospectively, which is a limitation because the answers can be unreliable due to recall bias. To reduce recall bias, the activity levels were assessed by physiotherapists, and relatives could confirm the physical activity levels. In addition, self-reported assessments are not as reliable as objective measurements like accelerometer data, although the former is more feasible in large cohorts.¹⁸ The SGPALS is a generic instrument not validated for patients with stroke, although with good predictive validity for general health, morbidity, and mortality.²⁵ Cardiovascular risk factors and comorbidity could be associated with lower physical activity levels, and the lack of this information is also a limitation since the pre-stroke health-related quality of life could already have been reduced.

This study adds to knowledge about the benefits of physical activity in relation to stroke. Not only does physical activity reduce the risk of stroke, but it can also have a positive influence on the consequences of stroke such as better health-related quality of life. Objective measurements and assessments are often used in stroke research, but patient-reported outcome measures are needed as a complement. Health-related quality of life is complex and depends on many factors, and therefore future research could investigate the association with pre-stroke physical activity with adjustment for additional factors such as functional abilities, cardiovascular risk factors and comorbidity. The results are generalizable in similar contexts, with similar populations with predominately mild stroke. Furthermore, research is needed to promote physical activity after stroke as secondary prevention and a modifier of outcome.

In conclusion, pre-stroke physical activity is associated with better health-related quality of life 3 months after stroke. This was reported for the EQ-5D-5L index value as well as the EQ-VAS. For the domains of mobility, self-care, and pain/discomfort, higher-intensity physical activity was even more beneficial.

Supplemental Material

sj-docx-1-wso-10.1177_17474930231184367 – Supplemental material for Associations between pre-stroke physical activity levels and health-related quality of life 3 months after stroke: A registry-based study (part of PAPSIGOT)

Supplemental material, sj-docx-1-wso-10.1177_17474930231184367 for Associations between pre-stroke physical activity levels and health-related quality of life 3 months after stroke: A registry-based study (part of PAPSIGOT) by Malin Reinholdsson, Annie Palstam, Katarina Jood and Katharina S Sunnerhagen in International Journal of Stroke

Footnotes

Acknowledgements

The authors thank the participating patients and the staff at the stroke units for assistance with data acquisition. They also thank the Väststroke Collaboration for data from the Väststroke Registry and the members of the Riksstroke Collaboration for data from the Swedish Stroke Registry, Riksstroke ().

Author contributions

M.R. and K.S.S. conceived the study. K.S.S. and A.P. supervised the project. M.R. applied for ethical approval, performed data acquisition, prepared and analyzed the data, and wrote the draft manuscript. K.J. had a major role in data acquisition. All authors critically revised the manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was funded by the Swedish Heart and Lung Foundation, the Swedish Brain Foundation, Promobilia, Local Research and Development Board for Gothenburg and Södra Bohuslän, the Swedish Stroke Association, and the Trust funds from: Greta and Einar Asker, Hjalmar Svensson, Renée Eander and Rune and Ulla Almlöv. This work was supported by the Swedish state under an agreement between the Swedish government and the county councils (grant number: ALFGBG-942914).

ORCID iDs

Malin Reinholdsson

Katharina S Sunnerhagen

Data access statement

Permission to use data is regulated and requires application and approval from the Swedish Ethical Review Authority. After a confidentiality review, data may be available to researchers upon request by professor K.S.S.

Supplemental material

Supplemental material for this article is available online.

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