Levels of physical activity and physical fitness are low after stroke. Interventions
to increase physical fitness could reduce mortality and reduce disability through
increased function. The primary objectives of this updated review were to determine
whether fitness training after stroke reduces death, death or dependence, and disability.
The secondary objectives were to determine the effects of training on adverse events,
risk factors, physical fitness, mobility, physical function, health status and quality
of life, mood, and cognitive function. In July 2018 we searched the Cochrane Stroke
Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, SPORTDiscus, PsycINFO, and four
additional databases. We also searched ongoing trials registers and conference proceedings,
screened reference lists, and contacted experts in the field. Randomised trials comparing
either cardiorespiratory training or resistance training, or both (mixed training),
with usual care, no intervention, or a non‐exercise intervention in stroke survivors.
Two review authors independently selected studies, assessed quality and risk of bias,
and extracted data. We analysed data using random‐effects meta‐analyses and assessed
the quality of the evidence using the GRADE approach. Diverse outcome measures limited
the intended analyses. We included 75 studies, involving 3017 mostly ambulatory participants,
which comprised cardiorespiratory (32 studies, 1631 participants), resistance (20
studies, 779 participants), and mixed training interventions (23 studies, 1207 participants).
Death was not influenced by any intervention; risk differences were all 0.00 (low‐certainty
evidence). There were few deaths overall (19/3017 at end of intervention and 19/1469
at end of follow‐up). None of the studies assessed death or dependence as a composite
outcome. Disability scores were improved at end of intervention by cardiorespiratory
training (standardised mean difference (SMD) 0.52, 95% CI 0.19 to 0.84; 8 studies,
462 participants; P = 0.002; moderate‐certainty evidence) and mixed training (SMD
0.23, 95% CI 0.03 to 0.42; 9 studies, 604 participants; P = 0.02; low‐certainty evidence).
There were too few data to assess the effects of resistance training on disability.
Secondary outcomes showed multiple benefits for physical fitness (VO 2 peak and strength),
mobility (walking speed) and physical function (balance). These physical effects tended
to be intervention‐specific with the evidence mostly low or moderate certainty. Risk
factor data were limited or showed no effects apart from cardiorespiratory fitness
(VO 2 peak), which increased after cardiorespiratory training (mean difference (MD)
3.40 mL/kg/min, 95% CI 2.98 to 3.83; 9 studies, 438 participants; moderate‐certainty
evidence). There was no evidence of any serious adverse events. Lack of data prevents
conclusions about effects of training on mood, quality of life, and cognition. Lack
of data also meant benefits at follow‐up (i.e. after training had stopped) were unclear
but some mobility benefits did persist. Risk of bias varied across studies but imbalanced
amounts of exposure in control and intervention groups was a common issue affecting
many comparisons. Few deaths overall suggest exercise is a safe intervention but means
we cannot determine whether exercise reduces mortality or the chance of death or dependency.
Cardiorespiratory training and, to a lesser extent mixed training, reduce disability
during or after usual stroke care; this could be mediated by improved mobility and
balance. There is sufficient evidence to incorporate cardiorespiratory and mixed training,
involving walking, within post‐stroke rehabilitation programmes to improve fitness,
balance and the speed and capacity of walking. The magnitude of VO 2 peak increase
after cardiorespiratory training has been suggested to reduce risk of stroke hospitalisation
by ˜7%. Cognitive function is under‐investigated despite being a key outcome of interest
for patients. Further well‐designed randomised trials are needed to determine the
optimal exercise prescription, the range of benefits and any long‐term benefits. Physical
fitness training for stroke survivors Review question
We reviewed the evidence that examines whether physical fitness training is beneficial
for health and function in people who have had a stroke. Background
Physical fitness is important to allow people to carry out everyday activities such
as walking and climbing stairs. Physical fitness varies among everyone. For example,
fitness in men tends to be a little higher than in women and everyone's fitness declines
as we get older and if we become less physically active. In particular, in stroke
survivors' physical fitness is often low. This may limit their ability to perform
everyday activities and also worsen stroke‐related disability. For this reason fitness
training has been proposed as a beneficial approach for people with stroke. However,
taking part in fitness training could have a range of other benefits important to
people with stroke such as improving cognitive function (thinking skills), improving
mood, and quality of life, and it could reduce the chance of having another stroke.
Study characteristics
In July 2018 we identified 75 studies for inclusion in the review. The studies involved
a total of 3617 participants at all stages of care including being in hospital or
back living at home. Most of the people who took part were able to walk on their own.
The studies tested different forms of fitness training; these included cardiorespiratory
or 'endurance' training, resistance or 'strength' training, or mixed training, which
is a combination of cardiorespiratory plus resistance training. Key results
We found that cardiorespiratory fitness training, particularly involving walking,
can improve fitness, balance and walking after stroke. The improvements in cardiorespiratory
fitness may reduce the chance of stroke hospitalisation by 7%. Mixed training improves
walking ability and improves balance. Strength training may have a role in improving
balance. So, overall it seems likely that people with stroke are likely to benefit
the most from training that involves cardiorespiratory training and that involves
some walking. However, there was not enough information to draw reliable conclusions
about the impact of fitness training on other areas such as quality of life, mood,
or cognitive function. Cognitive function is under‐investigated despite being a key
outcome of interest for stroke survivors. There was no evidence that any of the different
types of fitness training caused injuries or other health problems; exercise appears
to be safe. We need more studies to examine the benefits that are most important to
stroke survivors, in particular for those with more severe stroke who may be unable
to walk. Quality of the evidence
Studies of fitness training can be difficult to carry out. We have the highest confidence
in the estimates of benefit from cardiorespiratory training (moderate/high). The evidence
for other training types is moderate to low. However, some consistent findings emerged
with different studies all tending to show similar effects in different groups of
participants.