Aerobic Exercise – Chronic

Evidence Reviewed as of before: 22-11-2011
Author(s): Adam Kagan, B.Sc.; Anita Petzold, BSc OT; Nathalie Serrat, BSC PT; Amanda Ischayek BSc PT; Sabrina Ianni, BSc, PT; Caroline Labelle, BSc PT; Sukhdeep Johal, Bsc PT; Monica Trozzo BSc. PT; Elissa Sitcoff, BA BSc; Annabel McDermott, OT; Nicol Korner-Bitensky, PhD OT
Expert Reviewer: Janice Eng, PhD PT; Pamela Duncan, PhD PT(C)
Patient/Family Information Table of contents

Introduction

It has been shown that patients with stroke have been shown to have low endurance during exercise, likely due to both the event and also as a secondary reaction to forced inactivity. It is also known that there is a positive connection between aerobic capacity and functional performance (Katz-Leurer et al. 2003). This module will focus on aerobic exercise for people who are in the chronic phase (longer than 6 months post stroke) of recovery.

  • Click here to view the AEROBICS 2019 Update Best Practice Recommendations.
  • Click here to access the CPSR 2013 Clinicians’ guide.
  • Click here to access the CPSR 2013 Patients’ guide.

Patient/Family Information

Authors: Erica Kader; Adam Kagan, B.Sc.; Nathalie Serrat, BSC PT; Amanda Ischayek BSc PT; Sabrina Ianni, BSc, PT; Caroline Labelle, BSc PT; Sukhdeep Johal, Bsc PT; Monica Trozzo BSc. PT; Elissa Sitcoff, BA BSc; Nicol Korner-Bitensky, PhD OT

What is aerobic exercise?

Aerobic exercise refers to physical activity that requires the body to use oxygen to generate energy. Participating in aerobic exercise is important to maintain a healthy body. A major benefit of aerobic exercise is that it conditions the heart and lungs. It does so by increasing the oxygen available to the body and enabling the heart to use oxygen more efficiently. In addition, aerobic exercise can also control body fat, increase energy, decrease tension, increase stamina, and improve mood. There are several different types of aerobic exercises that can be done at different levels of intensity for varying periods of time. Any activity that lasts longer than 3 minutes is considered aerobic (such as golf, biking, walking, and swimming). Note: While other forms of exercises (such as those focused on flexibility and muscles training) are equally important, only those focusing on aerobic exercise will be addressed in this module.

Why is exercise important after I have had a stroke?

After a stroke, it is common to experience continued difficulties in mobility, for example in walking. It is important to continue to exercise despite these challenges to avoid a vicious cycle, where difficulty in mobility leads to lack of exercise, and lack of exercise leads to further muscle weakening and reduced fitness. Inactivity can contribute to physical complications, including osteoporosis and decreased circulation. It can also lead to loss of independence, depression, and social isolation. The more inactive you are, the harder it is to maintain cardiovascular, mental, and neurological health.

Can exercise still be useful in the chronic phase?

While traditional belief was that most of an individual’s physical recovery occurred within the first several months after having a stroke, recent research has shown that an exercise program after this period, including in the chronic phase, can be beneficial as well. Research studies have shown that exercise during the chronic phase post stroke can lead to an improvement of one’s physical and mental well being, heart function, endurance, general quality of life, and movement. In addition, exercise can help to lower blood pressure, create a healthy balance of fats in the blood, help the body to maintain a healthy level of insulin, and minimize depression.

How do I begin to exercise after a stroke?

Before beginning an exercise program, it is recommended that you undergo a comprehensive medical evaluation to assess your specific needs. Your medical or rehabilitation team can work with you to develop an appropriate exercise regime (including types of activities, how often you should participate in activities and for how long) based on your individual needs and abilities.

What kind of activities should I do?

You should pick an activity that you will have fun doing. Examples of aerobic exercise activities include:

  • Golf
  • Walking
  • Dancing
    With permission of Dr. Patricia McKinley, McGill School of Physical and Occupational Therapy
  • Swimming
  • Cycling
  • Tennis
  • Bowling




Gardening and housework are also great forms of aerobic exercise. Try adding exercise to your daily routine, for example, parking your car further away from your destination. Any form of physical activity can be beneficial as long as it is done regularly and consistently. When it comes to bicycling, many people find it difficult or are afraid to fall. This problem can be solved by using a stationary bicycle. Stationary bicycles are a safe and effective means of low-impact, or light, aerobic exercise, so they are a good choice for people who have had a stroke. They can also be altered to fit your individual needs. Treadmills are also helpful for walking, providing that there is a bar to hold on to, and a way to modify speed and intensity. A treadmill is especially useful to retrain people who have had a stroke to walk again.

Can I participate in the same exercise as before?

After a stroke, it may be difficult to resume the same activities that you enjoyed before. You may need to change your previous exercise regime, which may mean discovering new exercise activities that are perhaps less physically demanding. Things that you may need to modify are:

  • The level of difficulty of exercise
  • Length of time you exercise
  • How often you exercise

These will depend on your needs and abilities and should be assessed by a rehabilitation team. Certain equipment can also be used to facilitate exercising, such as handrails and assistive devices. For example, you may enjoy swimming but may need to find a pool that has special safety equipment and adaptations.

Who can help me resume my exercise activities?

While rehabilitation staff, such as occupational therapists, physiotherapists, social workers, recreation therapists, and psychologists will start you on your new exercise program, your family and friends are an excellent source of support to help you continue with success. Exercising with a friend or family member is motivating, encouraging, and of course more fun.

How much exercise should I do?

According to the American Heart Association, the recommended frequency of training is 3 to 7 days a week, with a duration of 20 to 60 minutes per day, depending on the patient’s level of fitness. ** Once again, however, it is very important that you seek medical advice before beginning an exercise program and get advice on how often and for how long you should be doing the activities. Where can I participate in exercise? While in the hospital or rehabilitation centre, you will participate in exercise programs developed and assisted by your rehabilitation team. When you are ready to go home, the team may show you how to continue with this exercise on your own, may recommend that you join an exercise program, or a combination of the two. Day centers, local community centers, and gyms in your area may be able to provide appropriate programs and support that you need.

Here is a link to an online Stroke Class.

Is it effective after stroke?

Researchers have studied how aerobic exercise can help with stroke in the sub-acute phase and found the following:

  • Aerobic Capacity: this is the highest amount of oxygen consumed during maximal exercise. Studies showed that aerobic exercise improved aerobic capacity.
  • Heart rate: with aerobic exercise, heart rate did not increase in patients with chronic stroke. This is a positive outcome.
  • Walking: in some studies, aerobic exercise was shown to improve walking distance and speed.
  • Endurance: strong evidence has shown aerobic exercise improves endurance in people with sub-acute stroke.
  • Depression: studies have shown that aerobic exercise can improve depressive symptoms in individuals with sub-acute stroke, but only in the short term.
  • Quality of Life: performing aerobic exercise also seemed to improve the quality of life of people with sub-acute stroke.
  • Balance: aerobic exercise was shown to improve some aspects of balance in people with sub-acute stroke.

Are there any side effects or risks?

While exercise is mostly risk-free, it is important to stay within your own personal threshold. As mentioned before, it is best to consult with your doctor or therapist before beginning an exercise program. They will assist you in determining how often you should exercise, what activities you should participate in, and how intense they should be. If you were physically active before the stroke, you may or may not be able to continue with the same activities. You may simply need to modify those activities so they are easier for you. If you feel dizzy, have pain (especially in your chest) or have difficulty breathing, stop exercising immediately and tell your healthcare provider.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.
Note: Only studies that included at least one outcome measure for aerobic capacity (VO2, heart rate and/or workload during either a maximal stress test on a treadmill or a cycle ergometer) are included in this report. The only exception is when there is a follow-up of the study groups at a later date using other outcome measures such as depression, quality of life etc. All studies to date that have examined the effect of aerobic exercise on chronic stroke featured a “cocktail” of different types of treatment (e.g. strength training, flexibility training as well as a strong aerobic training component) so it is important to note that the effects of these interventions may be due in part to the combination of different treatments and not the aerobic component specifically. As well it should be noted that some of the studies contain small sample sizes, which can lead to inconclusive results. More studies with larger sample size are needed before conclusive result can be found.

The studies that meet the inclusion criteria (4 high quality RCTs, 5 fair quality RCTs, 2 quasi-experimental studies, 1 pre-post design study, 1 repeated measures study and 1 non-controlled intervention study) suggest that a sustained exercise program containing an aerobic component provided over a period of at least 8 weeks, 3 x per week, may improve aspects of physiological function, physical function, and emotional well-being in patients with chronic stroke.

Outcomes

Activity and participation
Not effective
1b

One high quality RCT (Pang et al., 2005) and one quasi-experimental non-randomized trial (Sunnerghagen, 2007) examined the effects of aerobic exercise on activity and participation in patients with chronic stroke.

One high quality RCT (Pang et al., 2005) investigated the effect of aerobic exercise on activity and participation in patients with chronic stroke. No significant difference in scores on the Physical Activity Scale for Individuals with Physical Disabilities was found between the intervention group who received 19 weeks of cardiorespiratory fitness, mobility, balance and leg muscle strength exercise (the FAME program), and the control group who received a 19-week seated upper extremity exercise program.

In the quasi-experimental non-randomized trial, Sunnerghagen (2007) investigated the effect of circuit training on strength, aerobic capacity, and activity and participation in community-living “young” males with chronic stroke. The experimental group trained for 45 minutes 3x/week for 8 weeks on strength, endurance and aerobic capacity whereas the controls received no treatments. At post treatment non-significant differences were found within the experimental group for activities of daily living (ADLs) as measured by the Functional Independence Measure and Instrumental Activity Measure and for physical activity level as assessed with the Physical Activity Scale for the Elderly.
Note: The quasi-experimental non randomized trial did not report between group differences and is therefore not included in determining level of evidence.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that aerobic exercise does not improve activity and participation in patients with chronic stroke.

Ambulation and transfers
Effective
1b

One high quality RCT (Quaney et al., 2009) found a significant improvement in ambulation and transfers (as measured by the Get Up and Go test) in favour of the intervention group immediately following an 8-week progressive, resistive stationary bicycle exercise program, compared to the control group that completed an 8-week upper and lower extremity stretching program.
Note: This difference between groups was not seen on follow-up assessment 8 weeks later.

Conclusion: There is moderate evidence (level 1b) from one high quality study that aerobic exercise improves ambulation and transfer skills in patients with chronic stroke versus a stretching program, in the short term.

Attention
Insufficient evidence
5

One pre-post design study (Kluding et al., 2011) investigated the effect of aerobic exercise on attention in patients with chronic stroke and found no significant improvement in attention (measured by the Flanker Test – recognition of congruent and incongruent stimuli), from baseline to post-intervention following a 12-week aerobic and strengthening exercise program.
Note: This study did not compare aerobic training to a non-aerobic control, therefore it was not used to determine the level of evidence for the effectiveness of aerobic training.

Conclusion: There is insufficient evidence (level 5) regarding the efficacy of aerobic exercise on attention. However, one non-controlled study reported no improvement in attention following an aerobic exercise program.

Balance
Not effective
1a

Three high quality RCTs (Chu et al., 2004, Pang et al., 2005, Quaney et al., 2009) and one fair quality RCTs (Janssen et al., (2008) investigated the effect of aerobic exercise on balance in patients with chronic stroke.

In the first high quality RCT, Chu et al., (2004) found no significant post-intervention difference for balance (measured by the Berg Balance Scale) between the intervention group who received an 8-week chest-deep water-aerobic program compared to the control group who received arm and hand exercises while sitting.
Note: The authors pointed out that the lack of significant improvements for balance may have been due to the buoyancy of the water during the training aiding the participants too much. As well pre-test scores on the Berg Balance Scale were quite high which may have led to a ceiling effect (inability to detect further improvement in those already scoring at the top of the Scale initially).

In the second high quality RCT, Pang et al., (2005) found no significant difference in balance (as measured by the Berg Balance Scale) between the intervention group who followed the FAME program (19 weeks of cardiorespiratory fitness, mobility, balance and leg muscle strength exercises), and the control group who followed a 19-week seated upper extremity exercise program.
Note: Pre-test scores on the Berg Balance Scale were quite high which may have led to a ceiling effect (inability to detect further improvement in those already scoring at the top of the Scale initially).

The third high quality RCT, Quaney et al., 2009 investigated the effects of aerobic exercise on balance (as measured by the Berg Balance Scale). Patients with chronic stroke were randomized to an intervention group that completed an 8-week progressive resistive stationary bicycle exercise program, or a control group that completed an 8-week upper and lower extremity stretching program. A trend towards a significant difference in balance scores was seen immediately following completion of the program (8 weeks) that reached significance at follow-up assessment (16 weeks), in favour of the intervention group.

In the fair quality RCT, Janssen et al., (2008) investigated the effectiveness of functional electrical stimulation FES- assisted leg cycling training on improving aerobic capacity, maximal power output, muscle strength and functional performance in patients with chronic stroke. Both groups received cycling training in conjunction with FES twice a week for 6 weeks. However, the treatment group received FES evoking muscle contractions while the control group received sensible FES which could be felt but did not evoke muscle contractions. At post treatment there was no statistically significant difference between groups in balance as measured by the Berg Balance Scale.

Conclusion: There is strong evidence (level 1a) from three high quality RCTs and one fair quality RCT that aerobic exercise does not improve balance in individuals with chronic stroke.
Note:
Pretest scores on the Berg Balance Scale were quite high which may have led to a ceiling effect (inability to detect further improvement in those already scoring at the top of the Scale initially).
Note: One high quality RCT found differences approaching significance on completion of the aerobic exercise program, which then became significant 8 weeks after completion of the program. Two high quality studies note that high pretest scores on the Berg Balance Scale may have led to a ceiling effect, influencing the results of the studies.

Blood lipid profile
Effective
2b

One quasi-experimental study (Rimmer et al., 2009) found an improvement in triglycerides (lowered) and low-density lipoprotein cholesterol (lowered) in favour of both moderate intensity shorter duration (MISD) exercise or low-intensity longer duration exercise (LILD) compared to conventional therapeutic exercise (TE) following 14 weeks of intervention.

Conclusion: There is limited evidence (level 2b) from one quasi-experimental study that aerobic exercise can improve the blood lipid profile of those with chronic stroke.

Blood pressure
Effective
2a

One fair quality RCT (Potempa et al., 1995) and one quasi-experimental study (Rimmer et al., 2009) investigated the effect of aerobic exercise on blood pressure in patients with chronic stroke.

One fair quality RCT (Potempa et al., 1995) investigated the effect of aerobic exercise on blood pressure in an intervention group that received a 10-week progressive aerobic training program on a bicycle ergometer, and a control group that received a 10-week range of motion training program. While no overall significant between group differences were found for resting and sub-maximal blood pressure, a significant between group differences in sub-maximal systolic blood pressure was found in favour of a subgroup of patients in the intervention group who were able to work at a peak workload of at least 40 watts.

One quasi-experimental study (Rimmer et al., 2009) found an improvement in diastolic blood pressure following moderate intensity shorter duration exercise compared to conventional therapeutic exercise (TE), but no difference between low-intensity longer duration exercise (LILD) and TE, following 14 weeks of intervention.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT demonstrating that aerobic exercise at a peak workload of at least 40 watts improves sub-maximal systolic blood pressure in patients with chronic stroke. However, no effect was found for resting blood pressure or sub-maximal blood pressure. Furthermore, one quasi-experimental study found that aerobic exercise (moderate intensity and short duration) can improve the blood pressure of patients with chronic stroke.

Body composition
Effective
2a

One fair quality RCT with a pre-post lag-control design (Rimmer et al., 2000) investigated the effect of aerobic exercise on body composition, defined as a combination of body weight, body mass index, and total skinfold, in predominantly African-American patients with chronic stroke. A significant reduction in body weight, body mass index, and total skinfold (indicating an improvement in body composition as most of the patients were considered overweight), was found in favor of the intervention group following a 12-week aerobic, strength and flexibility exercise training program, compared to the control group who received no intervention.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that aerobic exercise improves body composition by reducing body weight, body mass index, and total skinfold in patients with chronic stroke.

Bone mineral density
Effective
1b

One high quality RCT (Pang et al., 2005) investigated the effect of aerobic exercise on bone mineral density in patients with chronic stroke. A significant difference in femoral neck bone mineral density on the paretic side (as measured using dual-energy x-ray absorptiometry), was found in favour of the intervention group who followed the FAME program (19 weeks of cardiorespiratory fitness, mobility, balance and leg muscle strength exercises), compared to the control group who followed a 19-week seated upper extremity exercise program. No significant difference was found on the non-paretic side.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT reporting that aerobic exercise improves femoral neck bone mineral density on the paretic side, but not the non-paretic side, in patients with chronic stroke.

Carbon dioxide production
Effective
2a

One fair quality RCT (Potempa et al., 1995) investigated the effect of aerobic exercise on carbon dioxide production. A significant between group difference was found for peak VCO2 in favour of the intervention group that received a 10-week progressive aerobic training program on a bicycle ergometer, compared to the control group that received a 10-week range of motion training program.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT demonstrating that aerobic exercise increases VCO2 in patients with chronic stroke.

Depression
Insufficient evidence
5

One repeated measures study (Rand et al., 2010) investigated the effect of aerobic exercise on depression symptoms in patients with chronic stroke, as measured using the Geriatric Depression Scale. No significant change in depressive symptoms was seen at 3 or 6 months.

Conclusion: There is insufficient evidence (level 5) to indicate whether aerobic exercise is effective in improving depression in patients with chronic stroke. However, one repeated measures study found that aerobic exercise and recreation does not improve depression symptoms.

Disability related to mobility
Not effective
2a

One fair quality RCT (Macko et al., 2005) investigated the effect of aerobic exercise on disability related to bodily mobility in patients with chronic stroke. The intervention group received a 6-month progressive treadmill training program with a target of 35 minutes at 60-70% heart rate reserve, and the control group received a stretching program combined with 5-minutes of low-intensity treadmill training at 30-40% heart rate reserve. No significant between group difference was found on the Rivermead Mobility Index, indicating no effect on disability related to bodily mobility.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT indicating that aerobic exercise does not improve disability related to bodily mobility (as measured by the Rivermead Mobility Index) in patients with chronic stroke.

Endurance
Effective
2a

Two fair quality RCTs (Potempa et al., 1995, Rimmer et al., 2000) investigated the effect of aerobic exercise on endurance in patients with chronic stroke.

In the first fair quality RCT, Potempa et al. (1995) found a significant increase in exercise time (indicating an improvement in endurance) in favour of the intervention group who received a 10-week progressive aerobic training program on a bicycle ergometer, compared to the control group who received a 10-week range of motion training program.

In the second fair quality RCT, using a lag-control design, Rimmer et al. (2000) found a significant increase in time to exhaustion, (indicating an improvement in endurance) in favour of the intervention group following a 12-week aerobic, strength and flexibility training program, compared to the control group who received no intervention.

Conclusion: There is limited evidence (level 2a) from two fair quality RCTs that aerobic exercise improves endurance in patients with chronic stroke.

Executive function
Not effective
1b

One high quality RCT (Quaney et al., 2009) and one repeated measures study (Rand et al., 2010) investigated the effect of aerobic exercise on executive function in patients with chronic stroke.

The high quality RCT (Quaney et al., 2009) randomized patients with chronic stroke to an intervention group that completed an 8-week progressive, resistive stationary bicycle exercise program, or a control group that completed an 8-week upper and lower extremity stretching program. No significant between-group differences in executive function were found on completion of the program (8-weeks) or on follow-up assessment (16-weeks), as measured by the Wisconsin Card Sorting Task, Stroop task and Trail-Making task.

The repeated measures study (Rand et al., 2010) investigated the effect of a 6-month aerobic and recreation program on executive function, as measured by the Stroop Test, Verbal Digital Span Backward Test (VDSBT), Trail Making Test (Part B), Walking While Talking test (WWT), and Rey Auditory Verbal Learning Test (RAVLT). In comparison to baseline scores, significant improvements were seen on the Stroop Test, WWT and RAVLT – long delay at 3 months, and persisted on the Stroop Test at 6 months.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that aerobic exercise does not improve executive function in patients with chronic stroke, when compared with a stretching program.
NOTE: However, one repeated measures study found that participation in an exercise and recreation program can improve performance of dual tasks, response inhibition and memory in patients with chronic stroke.

Flexibility
Effective
2a

One fair quality RCT with a pre-post lag-control design (Rimmer et al., 2000) investigated the effect of aerobic exercise on flexibility in patients with chronic stroke. A significant improvement in hamstring and low back flexibility (as assessed by the sit and reach test), was found in favour of the intervention group following a 12-week aerobic, strength and flexibility exercise training program, compared to the control group who received no intervention. No significant gain in shoulder flexibility of the affected and unaffected extremity was reported pre/post exercise.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that an aerobic exercise improves hamstring and low back flexibility, but does not improve shoulder flexibility in patients with chronic stroke.
Note:
The program included a flexibility component making it difficult to differentiate the effect of the aerobic exercise alone.

Gait speed
Conflicting
4

Two high quality RCT (Chu et al., 2004, Lee et al., 2008), two fai quality RCTs (Macko et al., 2005, Luft et al., 2008) and two non-controlled intervention studies (Rand et al., 2010, Kluding et al., 2011) examined the effect of aerobic exercise on gait speed.

One high quality RCT (Chu et al., 2004) investigated the effect of aerobic exercise on functional mobility as measured by walking speed in patients with chronic stroke. A significant increase in walking speed (measured by self-selected gait speed over 8 meters) was found in favour of the intervention group following an 8-week chest-deep water-aerobic program, compared to the control group who received arm and hand exercises while sitting.

The second high quality (Lee et al., 2008) found no significant improvement in walking speed following 10 to 12 weeks of aerobic cycling compared to sham cycling.

The first fair quality RCT (Macko et al., 2005) investigated the effect of aerobic exercise on gait speed in patients with chronic stroke. The intervention group received a 6-month progressive treadmill training program with a target of 35 minutes at 60-70% heart rate reserve, and the control group received a stretching program combined with 5-minutes of low-intensity treadmill training at 30-40% heart rate reserve. No significant between group difference was found for the 30-foot walking speed (at both usual pace or at fast pace), or the speed subscale of the Walking Impairment Questionnaire.

A second fair quality RCT (Luft et al., 2008) found a significant increase in peak effort treadmill walking velocity and average walking velocity over 6-minutes (over ground), for a group of patients who received 6 months of progressive task-repetitive treadmill training with a target of 40 minutes at 60% heart rate reserve, compared to a control group who received a therapist assisted stretching program for a comparable duration. No significant between group difference was found for fastest walking velocity over 10-meters (over ground).

One repeated measures study (Rand et al., 2010) investigated the effect of a 6-month aerobic and recreation program on gait speed in patients with chronic stroke, as measured by the 5-meter walk test. A significant improvement in gait speed was seen at 3 months and a non-significant trend was seen on re-assessment at 6 months, as compared to baseline measures.

A pre-post design study (Kluding et al., 2011) found no significant improvement in self-selected gait speed (measured by the 10-m walk test) from baseline to post-intervention following a 12-week aerobic and strengthening exercise program.
Note: This study did not compare aerobic training to a non-aerobic control, therefore it was not used to determine the level of evidence for the effectiveness of aerobic training.

Conclusion: There is conflicting evidence (level 4) as to whether aerobic exercise improves gait speed in patients with chronic stroke. While 1 high quality RCT and 1 fair quality RCT found that aerobic exercise improves aspects of gait speed, another high quality RCT and one fair quality RCT found no improvement in gait speed.
NOTE: The high quality RCT that found positive results provided chest-deep water-aerobic program as part of the intervention, while the high quality RCT that did not find positive results used aerobic cycling as the intervention.

Memory
Insufficient evidence
5

One pre-post design study (Kluding et al., 2011) investigated the effect of aerobic exercise on memory in patients with chronic stroke and found a significant improvement in working memory (measured by the Digit Span Backwards task) but no significant improvement in self-reported memory (measured by the Stroke Impact Scale memory component) from baseline to post-intervention following a 12-week aerobic and strengthening exercise program.
Note: This study did not compare aerobic training to a non-aerobic control, therefore it was not used to determine the level of evidence for the effectiveness of aerobic training.

Conclusion: There is insufficient evidence (level 5) regarding the efficacy of aerobic exercise on memory. However, one non-controlled study reported improved working memory following an aerobic exercise program.

Mobility
Insufficient evidence
5

One pre-post design study (Kluding et al., 2011) investigated the effect of aerobic exercise on mobility in patients with chronic stroke (measured by the Stroke Impact Scale mobility subscale) and found a strong trend toward significant improvement from baseline to post-intervention following a 12-week aerobic and strengthening exercise program.
Note: This study did not compare aerobic training to a non-aerobic control, therefore it was not used to determine the level of evidence for the effectiveness of aerobic training.

Conclusion: There is insufficient evidence (level 5) regarding the efficacy of aerobic exercise on mobility. However, one non-controlled study reported a strong trend towards improved mobility following an aerobic exercise program.

Motor learning
Effective
1b

One high quality RCT (Quaney et al., 2009) investigated the effect of an aerobic exercise program on conditional learning (as measured by predictive force accuracy using Predictive Grip Force Modulation tasks) and on implicit learning (as measured by sequence-specific and random-sequence reaction times on the Serial Reaction Timed Task). Patients with chronic stroke were randomized to an intervention group that completed an 8-week progressive resistive stationary bicycle exercise program, or a control group that completed an 8-week upper and lower extremity stretching program. Significant between-group differences in both predictive force accuracy (conditional learning) and sequence-specific reaction time (implicit learning) were found in favour of the intervention group immediately following completion of the exercise program (8 weeks) but these differences were not maintained at follow-up assessment (16 weeks). No significant group differences were seen for random-sequence reaction time (implicit learning).

Conclusion: There is moderate evidence (level 1b) from one high quality study that aerobic exercise improves conditional learning and some aspects of implicit learning (sequence-specific reaction times) in patients with chronic stroke in the short term, when compared with a stretching program.

Peak heart rate
Not effective
1b

One high quality RCT (Lee et al., 2008), one fair quality RCT (Potempa et al., 1995) and one quasi-experimental non-randomized trial (Sunnerghagen, 2007) investigated the effect of aerobic exercise on peak heart rate in patients with chronic stroke.

The high quality RCT (Lee et al., 2008) found no significant improvement in peak rate (during a test of maximal effort on a bicycle ergometer) following 10 to 12 weeks of aerobic cycling compared to sham aerobic cycling. However, it should be noted that a trend toward significance was found (p=.07) and that the non-significant result may be due to a small N.

One fair quality RCT (Potempa et al., 1995) found no significant difference was found for peak heart rate during a maximal test on a bicycle ergometer between the intervention group, who received a 10-week training program on an adjusted bicycle ergometer and the control group who received a passive range of motion exercise program.

In the quasi-experimental non-randomized trial, Sunnerghagen (2007) investigated the effect of circuit training on strength, aerobic capacity, and activity and participation in community-living “young” males with chronic stroke. The experimental group trained for 45 minutes 3x/week for 8 weeks on strength, endurance and aerobic capacity whereas the controls received no treatments. At post treatment non-significant differences were found within the experimental group for peak heart rate as tested while on the electrical bicycle ergonometer.
Note: The quasi-experimental non randomized trial did not report between group differences and is therefore not included in determining level of evidence.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT and one fair quality RCT that aerobic exercise does not increase peak heart rate in patients with chronic stroke.

Peak VO2
Effective
1a

Four high quality RCTs (Chu et al., 2004, Pang et al., 2005, Lee et al., 2008, Quaney et al., 2009), five fair quality RCTs (Potempa et al., 1995, Rimmer et al., 2000, Macko et al., 2005, Janssen et al., 2008, Luft et al., 2008), two quasi-experimental non-randomized trial (Sunnerghagen, 2007, Rimmer et al., 2009) and two non-controlled intervention studies (Macko et al., 2001, Kluding et al, 2011) investigated the effect of aerobic exercise on peak VO2 in patients with chronic stroke.

In the first high quality RCT, Chu et al. (2004) found a significant increase in peak VO2 during a test of maximal effort on a bicycle ergometer (indicating an improvement in aerobic capacity) in favour of the intervention group following an 8-week chest-deep water-aerobic program, compared to the control group who received 8 weeks of arm and hand exercises while sitting.

In the second high quality RCT, Pang et al. (2005) found a significant increase in peak VO2 during a test of maximal effort on a bicycle ergometer (indicating an improvement in aerobic capacity) in favour of the intervention group immediately following a 19-week program of cardiorespiratory fitness, mobility, balance and leg muscle strength exercises (the FAME program), compared to the control group who followed a 19-week seated upper extremity exercise program.

The third high quality RCT (Lee et al., 2008) showed a significant improvement in peak VO2 (during a test of maximal effort on a bicycle ergometer) following 10 to 12 weeks of aerobic cycling compared to sham aerobic cycling.

The fourth high quality RCT (Quaney et al., 2009) found a significant improvement in peak VO2 on metabolic stress testing in favour of the intervention group immediately following an 8-week progressive, resistive stationary bicycle exercise program, compared to the control group that completed an 8-week upper and lower extremity stretching program.
Note: This difference between groups was not seen on follow-up assessment 8 weeks later.

The first fair quality RCT (Potempa et al. (1995) found a significant increase in peak VO2 during a test at maximal effort on a bicycle ergometer (indicating an improvement in aerobic capacity) in favour of the intervention group following a 10-week training program on an adjusted bicycle ergometer compared to the control group who received a passive range of motion exercise program.

The second fair quality study (Rimmer et al. (2000) – using a lag-control design – found a significant increase in peak VO2 during a test of maximum effort on a bicycle ergometer (indicating an improvement in aerobic capacity) in favour of the intervention group following a 12-week aerobic, strength and flexibility training program, compared to the control group who received no intervention.
Note: The control group then went on to receive the intervention as indicated by the “lag-control” study design.

The third fair quality RCT (Macko et al. (2005) found a significant increase in peak VO2 during a treadmill stress test (indicating an improvement in aerobic capacity) in favour of the intervention group following a 6-month progressive treadmill training program with a target length of 35 minutes at 60-70% heart rate reserve, compared to the control group who received a stretching program combined with 5-minutes of low-intensity treadmill training at 30-40% heart rate reserve.

A fourth fair quality study, Janssen et al. (2008) investigated the effectiveness of FES-assisted leg cycling training on improving aerobic capacity, maximal power output, muscle strength and functional performance in patients with chronic stroke. Both groups received cycling training in conjunction with FES twice a week for 6 weeks. However, the treatment group received FES evoking muscle contractions while the control group received sensible FES, which could be felt but did not evoke muscle contractions. At post treatment there was no statistically significant difference between groups in aerobic capacity as measured by VO2 max.
Note: This study did not compare aerobic training to a non-aerobic control, therefore it was not used to determine the level of evidence for the effectiveness of aerobic training.

In the fifth fair quality RCT, Luft et al. (2008) found a significant increase in peak VO2 during a treadmill stress test, for a group of patients who received 6 months of progressive task-repetitive treadmill training with a target of 40 minutes at 60% heart rate reserve, compared to the control group who received a therapist assisted stretching program for a comparable duration.

In the quasi-experimental non-randomized trial, Sunnerghagen (2007) investigated the effect of circuit training on strength, aerobic capacity, and activity and participation in community-living “young” males with chronic stroke. The experimental group trained for 45 minutes 3x/week for 8 weeks on strength, endurance and aerobic capacity whereas the controls received no treatments. At post treatment non-significant differences were found within the experimental group for peak VO2.
Note: The quasi-experimental non-randomized trial did not report between group differences and is therefore not included in determining level of evidence.

The second quasi-experimental (Rimmer et al., 2009) found no difference in peak VO2 between moderate intensity, shorter duration (MISD) exercise or low-intensity longer duration exercise (LILD) compared to conventional therapeutic exercise (TE) following 14 weeks of intervention.

One non-controlled intervention study (Macko et al., 2001) investigated the effect of aerobic exercise on peak VO2 in patients with chronic stroke. A significant increase in peak VO2 during a treadmill stress test, indicating an improvement in aerobic capacity, was found for 23 patients who received a 6-month progressive treadmill training program with a target of approximately 40 minutes at 60-70% heart rate reserve.

A pre-post design study (Kluding et al., 2011) found a strong trend toward significantly improved peak VO2 from baseline to post-intervention following a 12-week aerobic and strengthening exercise program.
Note: This study did not compare aerobic training to a non-aerobic control, therefore it was not used to determine the level of evidence for the effectiveness of aerobic training.

Conclusion: There is strong evidence (level 1a) from four high quality RCTs, four fair quality RCTs, and one non-controlled intervention study that aerobic exercise significantly increases peak VO2 (indicating an improvement in aerobic capacity) in patients with chronic stroke when compared with a range of control therapies including stretching exercises, sham aerobic activity, conventional therapy and no intervention.

Peak volume of total exhalation
Effective
2a

One fair quality RCT (Potempa et al., 1995) investigated the effect of aerobic exercise on volume of exhalation (VE). A significant between group difference was found for peak VE in favour of the intervention group that received a 10-week progressive aerobic training program on a bicycle ergometer, compared to the control group that received a 10-week range of motion training program.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT demonstrating that aerobic exercise increases peak VE in patients with chronic stroke.

Peak workload
Effective
1a

Two high quality RCTs (Chu et al., 2004, Lee et al., 2008), three fair quality RCTs (Potempa et al., 1995, Rimmer et al., 2000, Janssen et al., 2008), one quasi-experimental non-randomized trial, (Sunnerghagen, 2007) and one non-controlled intervention study (Macko et al., 2001) investigated the effect of aerobic exercise on peak workload in patients with chronic stroke.

One high quality RCT (Chu et al., 2004) investigated the effect of aerobic exercise on peak workload in patients with chronic stroke. A significant increase in peak workload during a test of maximal effort on a bicycle ergometer, indicating an improvement in aerobic capacity, was found in favour of the intervention group following an 8-week chest-deep water-aerobic program, compared to the control group who received arm and hand exercises while sitting.

A second high quality RCT (Lee et al., 2008) showed a significant improvement in peak power output (during a test of maximal effort on a bicycle ergometer) following 10 to 12 weeks of aerobic cycling compared to sham aerobic cycling.

The first fair quality RCT (Potempa et al. 1995) found a significant increase in peak workload during a maximal test on a bicycle ergometer (indicating an improvement in aerobic capacity) in favour of the intervention group following a 10-week training program on an adjusted bicycle ergometer compared to the control group that received a passive range of motion exercise program.

The second fair quality RCT (Rimmer et al. (2000), using a lag-control design, also found a significant increase in peak workload (indicating an improvement) in favour of the intervention group following a 12-week aerobic, strength and flexibility exercise training program, compared to the control group which received no intervention.

In the third fair quality study, Janssen et al. (2008) investigated the effectiveness of FES- assisted leg cycling training on improving aerobic capacity, maximal power output, muscle strength and functional performance in patients with chronic stroke. Both groups received cycling training in conjunction with FES twice a week for 6 weeks. However, the treatment group received FES evoking muscle contractions while the control group received sensible FES which could be felt but did not evoke muscle contractions. At post treatment there was no statistically significant difference between groups in maximal power output as measured by PO max.
Note: This study did not compare aerobic training to a control of non-aerobic training, therefore it was not used in determining level of evidence.

In the quasi-experimental non-randomized trial, Sunnerghagen (2007) investigated the effect of circuit training on strength, aerobic capacity, and activity and participation in community-living “young” males with chronic stroke. The experimental group trained for 45 minutes 3x/week for 8 weeks on strength, endurance and aerobic capacity whereas the controls received no treatments. At post treatment non-significant differences were found within the experimental group for peak workload as tested while on the electrical bicycle ergometer.
Note: The quasi-experimental non randomized trial did not report between group differences and is therefore not included in determining level of evidence.

One non-controlled intervention study (Macko et al., 2001) investigated the effect of aerobic exercise on peak workload in patients with chronic stroke. A significant increase in peak workload during a treadmill stress test, indicating an improvement in aerobic capacity, was found for 23 patients who received a 6-month progressive treadmill training program with a target of approximately 40 minutes at 60-70% heart rate reserve.

Conclusion: There is strong evidence (level 1a) from two high quality RCT, 2 fair quality RCTs, and one non-controlled intervention study, that aerobic exercise significantly increases peak workload – indicating an improvement in aerobic capacity – in patients with chronic stroke. However, one fair quality RCT found that the use of FES- assisted cycling training compared to cycling training alone does not improve maximal power output in patients with chronic stroke. Note that in this study, both groups performed cycling on a bicycle ergometer.

Perceived self-efficacy in functional mobility
Not effective
1b

One high quality RCT (Lee et al., 2008) investigated the effect of aerobic exercise on perceived self-efficacy in functional mobility and found no improvement following 10 to 12 weeks of aerobic cycling compared to sham cycling.

Conclusion: There is moderate evidence (level 1b) from one high quality study that aerobic exercise does not improve perceived self-efficacy in functional mobility when compared to sham activity.

Quality of life
Not effective
1b

One high quality RCT (Lee et al. 2008) investigated the effect of aerobic exercise on quality of life and found no improvement following 10 to 12 weeks of aerobic cycling compared to sham cycling.

Conclusion: There is moderate evidence (level 1b) from one high quality study that aerobic exercise does not improve quality of life.

Respiratory exchange ratio
Not effective
1b

One high quality RCT (Pang et al., 2005) and one fair quality RCT (Potempa et al., 1995) and one quasi-experimental non-randomized trial (Sunnerghagen, 2007) examined the effect of aerobic exercise on respiratory exchange ratio in patients with chronic stroke.

The high quality RCT (Pang et al., 2005), investigated the effect of aerobic exercise on respiratory exchange ratio in patients with chronic stroke. No significant difference was found for respiratory exchange ratio between the intervention group who followed the FAME program (19 weeks of cardiorespiratory fitness, mobility, balance and leg muscle strength exercises), and the control group who followed a 19-week seated upper extremity exercise program.

The fair quality RCT (Potempa et al., 1995), investigated the effect of aerobic exercise on respiratory exchange ratio. No significant between group differences were found between the intervention group who received a 10-week progressive aerobic training program on a bicycle ergometer, and the control group who received a 10-week range of motion training program.

In the quasi-experimental non-randomized trial, Sunnerghagen (2007) investigated the effect of circuit training on strength, aerobic capacity, and activity and participation in community-living “young” males with chronic stroke. The experimental group trained for 45 minutes 3x/week for 8 weeks on strength, endurance and aerobic capacity whereas the controls received no treatments. At post treatment non-significant differences were found within the experimental group for respiratory exchange ratio.
Note: The quasi-experimental non randomized trial did not report between group differences and is therefore not included in determining level of evidence.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT and one fair quality RCT demonstrating that aerobic exercise has no significant effect on respiratory exchange ratio in patients with chronic stroke.

Resting heart rate
Not effective
2a

One fair quality RCT (Potempa et al., 1995) investigated the effect of aerobic exercise on resting heart rate. No significant between group differences in resting heart rate were found between the intervention group who received a 10-week progressive aerobic training program on a bicycle ergometer, and the control group who received a 10-week range of motion training program.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that aerobic exercise has no significant effect on resting heart rate in patients with chronic stroke.

Sensorimotor function
Not effective
1b

One high quality RCT (Quaney et al., 2009), one fair quality RCT (Potempa et al., 1995) and one non-controlled study (Kluding et al., 2011) investigated the effect of aerobic exercise on sensorimotor function in patients with chronic stroke.

The high quality RCT (Quaney et al., 2009) investigated the effects of aerobic exercise on motor function (as measured by the Fugl-Meyer sensorimotor test). Patients with chronic stroke were randomized to an intervention group that completed an 8-week progressive, resistive stationary bicycle exercise program, or a control group that completed an 8-week upper and lower extremity stretching program. No significant between-group difference in sensorimotor function was found on completion of the program (8-weeks) or on follow-up assessment (16-weeks).

The fair quality RCT (Potempa et al., 1995) found no significant overall difference in sensorimotor function (as measured by the Fugl-Meyer Index (FMI) between the intervention group, who received a 10-week progressive aerobic training program on a bicycle ergometer, and the control group, who received a 10-week range of motion training program. It is of note, however, that a significant correlation was found between improvement in aerobic capacity (as evaluated by peak VO2) and improvement in sensorimotor function, indicating that exercise training may benefit those who can train at an intensity that improves aerobic capacity.

A pre-post design study (Kluding et al., 2011) found a significant improvement in motor function (as measured by the Fugl-Meyer test and Stroke Impact Scale) from baseline to post-intervention following a 12-week aerobic and strengthening exercise program.
Note: This study did not compare aerobic training to a non-aerobic control, therefore it was not used to determine the level of evidence for the effectiveness of aerobic training.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT and one fair quality RCT that aerobic exercise does not significantly improve sensorimotor function in patients with chronic stroke when compared with range of motion therapy.

Stair climbing
Not effective
2a

One fair quality RCT (Macko et al., 2005) investigated the effect of aerobic exercise on stair climbing in patients with chronic stroke. The intervention group received a 6-month progressive treadmill training program with a target of 35 minutes at 60-70% heart rate reserve, and the control group received a stretching program combined with 5-minutes of low-intensity treadmill training at 30-40% heart rate reserve. No significant between group difference was found for the stair climbing subscales of the Walking Impairment Questionnaire.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT indicating that aerobic exercise does not improve stair climbing in patients with chronic stroke.

Strength (Lower extremity)
Conflicting
4

Three high quality RCTs (Chu et al., 2004, Pang et al., 2005, Lee et al., 2008), two fair quality RCT (Rimmer et al., 2000, Janssen et al., 2008), one quasi-experimental non-randomized trial (Sunnerghagen, 2007) and one repeated measures study (Rand et al., 2010) investigated the effect of aerobic exercise on lower extremity muscle strength in patients with chronic stroke.

In the first high quality RCT, Chu et al. (2004) found a significant increase in strength on the paretic lower limb (measured with a dynamometer for isokinetic flexor and extensor muscle strength) in favour of the intervention group following an 8-week chest-deep water-aerobic program, compared to the control group who received arm and hand exercises while sitting. However, no significant between group difference was found for the non-paretic side.

In the second high quality RCT, Pang et al. (2005) found a significant difference in leg muscle strength as measured by a hand-held dynamometer for isometric knee extension, in favour of the intervention group following 19 weeks of cardiorespiratory fitness, mobility, balance and leg muscle strength exercises (the FAME program), compared to the control group who followed a 19-week seated upper extremity exercise program.

The third high quality RCT (Lee et al., 2008) found no significant improvement in lower extremity strength (measured by stair climbing power and lower limb weight lifting ability) following 10 to 12 weeks of aerobic cycling compared to sham aerobic cycling.

In one fair quality RCT, using a pre-post lag-control design, Rimmer et al. (2000) investigated the effect of aerobic exercise on strength in predominantly African-American patients with chronic stroke. A significant increase in the amount of weight the patients were able to lift during a bench press and a leg press, indicating an improvement in strength, was found in favour of the intervention group following a 12-week aerobic, strength and flexibility exercise training program, compared to the control group who received no intervention.

In the second fair quality RCT, Janssen et al., (2008) investigated the effectiveness of FES- assisted leg cycling training on improving aerobic capacity, maximal power output, muscle strength and functional performance in patients with chronic stroke. Both groups received cycling training in conjunction with FES twice a week for 6 weeks. However, the treatment group received FES evoking muscle contractions while the control group received sensible FES which could be felt but did not evoke muscle contractions. At post treatment there was no statistically significant difference between groups in strength as measured by Maximum Voluntary Contraction.
Note: This study did not compare aerobic training to a control of non-aerobic training, therefore it was not used in determining level of evidence.

In the quasi-experimental non-randomized trial, Sunnerghagen (2007) investigated the effect of circuit training on strength, aerobic capacity, and activity and participation in community-living “young” males with chronic stroke. The experimental group trained for 45 minutes 3x/week for 8 weeks on strength, endurance and aerobic capacity whereas the controls received no treatments. Strength was measure pre and post intervention using a dynamometer to assess isometric knee extension and flexion. At post treatment there was a significant improvement for strength in the paretic leg but not for the non-paretic leg as measured by a dynamometer.
Note: The quasi-experimental non randomized trial did not report between group differences and is therefore not included in determining level of evidence.

In the repeated measures study, Rand et al., 2010 investigated the effect of a 6-month aerobic and recreation program on isometric muscle knee strength in patients with chronic stroke, as measured by a dynamometer. Significant improvement in strength was seen at 3 months and a non-significant trend was seen on re-assessment at 6 months, as compared to baseline data.
Note: This study did not specify whether muscle strength was measured on the paretic side only or on both the paretic and non-paretic limbs.

Conclusion: There is conflicting evidence (level 4) as to whether aerobic exercise improves lower extremity strength in patients with chronic stroke. While 1 high quality RCT found no improvement in strength, 2 high quality RCTs and 1 fair quality RCT found that aerobic exercise improves lower extremity strength.
Note: The two high quality RCTs and the fair quality RCT that found an improvement in strength involved a strength-training component.

Strength (Upper extremity)
Effective
2a

In one fair quality RCT, using a pre-post lag-control design, Rimmer et al. (2000) investigated the effect of aerobic exercise on strength in predominantly African-American patients with chronic stroke. A significant increase in the amount of weight the patients were able to lift during a bench press, indicating an improvement in strength, was found in favour of the intervention group following a 12-week aerobic, strength and flexibility exercise training program, compared to the control group who received no intervention. No significant between group differences in hand grip strength in the affected and unaffected extremity was reported.

Conclusion: There is limited evidence (level 2a) from 1 fair quality RCT that aerobic exercise is effective in improving upper extremity strength but not hand grip strength in patients with chronic stroke.

Submaximal VO2
Not effective
2b

One quasi-experimental (Rimmer et al., 2009) found no difference in submaximal VO2 between moderate intensity, shorter duration (MISD) exercise or low-intensity longer duration exercise (LILD) compared to conventional therapeutic exercise (TE) following 14 weeks of intervention.

Conclusion: There is limited evidence (level 2b) from one quasi-experimental study that aerobic exercise does not improve submaximal VO2 in patients with chronic stroke.

Walking distance
Conflicting
4

Two high quality RCTs (Pang et al., 2005, Lee et al., 2008) and two fair quality RCTs (Macko et al., 2005, Janssen et al., 2008) examined the effect of aerobic exercise on walking distance.

The first high quality RCT (Pang et al., 2005) investigated the effect of aerobic exercise on walking distance in patients with chronic stroke. A significant increase in walking distance, measured by the 6-minute walk test, was found in favour of the intervention group who followed the FAME program (19 weeks of cardiorespiratory fitness, mobility, balance and leg muscle strength exercises), compared to the control group who received a 19-week seated upper extremity exercise program.

The second high quality (Lee et al., 2008) found no significant improvement in walking distance following 10 to 12 weeks of aerobic cycling compared to sham cycling.

In the first fair quality RCT, Macko et al. (2005) investigated the effect of aerobic exercise on walking distance in patients with chronic stroke. The intervention group received a 6-month progressive treadmill training program with a target of 35 minutes at 60-70% heart rate reserve, and the control group received a stretching program combined with 5-minutes of low-intensity treadmill training at 30-40% heart rate reserve. A significant difference was found in favour of the intervention group for 6-minute walking distance and the distance subscale of the Walking Impairment Questionnaire compared to the control group.

In the second fair quality RCT, Janssen et al., (2008) investigated the effectiveness of FES- assisted leg cycling training on improving aerobic capacity, maximal power output, muscle strength and functional performance in patients with chronic stroke. Both groups received cycling training in conjunction with FES twice a week for 6 weeks. However, the treatment group received FES evoking muscle contractions while the control group received sensible FES which could be felt but did not evoke muscle contractions. At post treatment there was no statistically significant difference between groups in walking distance as measured by the 6-minute walking test.
Note: This study did not compare aerobic training to a control of non-aerobic training, therefore it was not used in determining level of evidence.

Conclusion: There is conflicting evidence (level 4) between 1 high quality RCT and one fair quality RCT that found aerobic exercise improves walking distance and 1 high quality RCT that found no improvement in walking distance following aerobic exercise, in patients with chronic stroke. It should be noted that the high quality RCT that found no improvement involved aerobic cycling, whereas the other studies involved more gait related aerobic activities.

Walking economy
Effective
2b

One non-controlled intervention exercise study (Macko et al., 2001) investigated the effect of aerobic exercise on walking economy in patients with chronic stroke. A significant increase in VO2 during sub-maximal walking, indicating an improvement, was found for 23 patients following a 6-month progressive treadmill training program with a target of approximately 40 minutes at 60-70% heart rate reserve.

Conclusion: There is limited evidence (level 2b) from one non-controlled exercise study reporting that aerobic exercise improves walking economy in patients with chronic stroke.

Walking endurance
Insufficient evidence
5

Two non-controlled studies (Rand et al., 2010, Kluding et al., 2011) investigated the effect of aerobic exercise on walking endurance in patients with chronic stroke.

One repeated measures study (Rand et al., 2010) found a significant improvement in walking endurance, as measured by the 6 Minute Walk Test at 3 and 6 months, as compared to baseline, following a 6-month aerobic and recreation program.

A pre-post design study (Kluding et al., 2011) found a strong trend toward significantly improved aerobic fitness (measured by the 6 Minute Walk Test) from baseline to post-intervention following a 12-week aerobic and strengthening exercise program.
Note: This study did not compare aerobic training to a non-aerobic control, therefore it was not used to determine the level of evidence for the effectiveness of aerobic training.

Conclusion: There is insufficient evidence (level 5) to indicate whether aerobic exercise is effective in improving walking endurance in patients with chronic stroke. However, two non-controlled studies found that aerobic exercise may be effective in improving walking endurance.

References

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Janssen TW, Beltman JM, Elich P, Koppe PA, Konijnenbelt H, de Haan A, Gerrits KH. (2008). Effects of electric stimulation-assisted cycling training in people with chronic stroke. Arch Phys Med Rehabil , 89:463-469.

Kluding, P. M., Tsen, B. Y., & Billinger, S. A. (2011). Exercise and executive function in individuals with chronic study: A pilot study. Journal of Neurologic Physical Therapy, 35, 11-17.

Lee M., Kilbreath S.L., Singh M.F., Zeman B., Lord S.R., Raymond J., & Davis G.M. (2008). Comparison of Effect of Aerobic Cycle Training and Progressive Resistance Training on Walking Ability After Stroke: A Randomized Sham Exercise-Controlled Study. J Am Geriatr Soc, 56, 976-985.

Luft AR, Macko RF, Forrester LW, Villagra F, Ivey F, Sorkin JD, Whitall J, McCombe-Waller S, Katzel L, Goldberg AP, Hanley DF. (2008). Treadmill exercise activates subcortical neural networks and improves walking after stroke: a randomized controlled trial. Stroke, 39(12), 3341-3350.

Macko R, Smith G, Dobrovolny L, Sorkin J, Goldberg A & Silver K (2001). Treadmill Training Improves Fitness Reserve in Chronic Stroke Patients. Archives of Physical Medicine & Rehabilitation, 82, 879-84.

Macko RF, Ivey FM, Forrester LM, Hanley D, Sorkin JD, Katzel LI, Silver KH & Goldberg AP (2005). Treadmill exercise rehabilitation improves ambulatory function and cardiovascular fitness in patients with chronic stroke: A randomized, controlled trial. Stroke, 36, 2206- 2211.

Pang MYC, Eng JJ, Dawson AS, McKay HA & Harris JE (2005). A community-based fitness and mobility exercise program for older adults with chronic stroke: a randomized, controlled trial. Journal of American Geriatrics Society, 53(10), 1667-1674.

Potempa K, Lopez M, Braun LT, Szidon P, Fogg L & Tincknell T (1995). Physiological outcomes of aerobic exercise training in hemiparetic stroke patients. Stroke, 26(1), 101-105.

Rand, D., Eng, J. J., Liu-Ambrose, T., & Tawashy, A. E. (2010). Feasability of a 6-month exercise and recreation program to improve executive functioning and memory in individuals with chronic stroke. Neurorehabilitation and Neural Repair, 24, 722-729.

Rimmer JH, Riley B, Creviston T & Nicola T (2000). Exercise training in a predominantly African-American group of stroke survivors. Medicine & Science in Sports & Exercise, 32(12), 1990-1996.

Rimmer J, Rauworth A, Wang E, Nicola T & Hill B. (2009). A Preliminary Study to Examine the Effects of Aerobic and Therapeutic (Nonaerobic) Exercise on cardiorespiratory Fitness and Coronary Risk Reduction in Stroke Survivors. Arch Phys Med Rehabil, 90, 407-12.

Quaney, B. M., Boyd, L. A., McDowd, J. M., Zahner, L. H., He, J., Mayo, M. S., & Macko, R. F. (2009). Aerobic exercise improves cognition and motor function. Neurorehabilitation and Neural Repair, 23, 879-885.

Sunnerghagen KS (2007). Circuit Training in Community-Living “Younger” Men After Stroke. Journal of Stroke and Cerebrovascular Diseases, 16, 122-129.

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