Aerobic Exercise – Subacute

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 focuses on aerobic exercise as an intervention for people who are in the sub-acute phase (1-6 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 NOTE: *The authors have no direct financial interest in any tools, tests or interventions presented in StrokEngine.

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.

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.

Is it effective after stroke?

  • 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: It is often difficult to say with absolute certainty whether a particular exercise intervention is “aerobic” in nature. In this module we include only those studies that had a clear aerobic exercise intervention. Specifically only those that included an outcome examining the effect of exercise on aerobic capacity (peak VO2, peak workload and peak heart rate during some sort of maximal aerobic test) were considered. Many of these studies also examined functional, physical and emotional outcomes and these results are included. As well, all studies to date that have examined the effect of aerobic exercise on sub-acute 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.

The studies that meet the inclusion criteria (3 fair quality RCTs, 1 quasi-experimental study and 1 pilot study) suggest that a sustained exercise program containing an aerobic component provided over a period of at least 8 weeks, 3 times per week, may improve aspects of physiological function, physical function, and emotional well-being in patients with sub-acute stroke.

Outcomes

Anaerobic threshold VO2
Insufficient Evidence
5

One pre-post pilot study (Yang et al., 2007) investigated the effect of aerobic exercise on anaerobic threshold VO2 in patients with sub-acute stroke who also had a history of carotid artery disease (CAD) and remaining mild to moderate hemiparetic gait. The patients followed a program of moderate intensity treadmill training for 12 weeks. A significant pre-post improvement in anaerobic threshold VO2 was found.

Conclusion: There is insufficient evidence (level 5) that aerobic exercise has an effect on anaerobic threshold VO2 in patients with subacute stroke. However one pre-post pilot study found that aerobic exercise significantly improves anaerobic threshold VO2 in patients with sub-acute stroke.

Balance
Effective
1b

One high quality RCT (Duncan et al., 2003) studied the effect of aerobic exercise on balance in patients with sub-acute stroke. A significant improvement in balance, as measured by the Berg Balance Scale, was found in favour of the treatment group immediately following a 12-to-14 week endurance, strength, balance and upper extremity exercise program when compared to the control group who received usual care only. However no between group difference was found on functional reach.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that aerobic exercise improves some aspects of balance (but not functional reach) compared to usual care in individuals with subacute stroke. It is of note that the exercise program contained a balance component.

Blood lipid profile
Insufficient Evidence
5

One pre-post pilot study (Yang et al., 2007), investigated the effect of aerobic exercise on blood lipid profile in patients with sub-acute stroke who also had a history of carotid artery disease (CAD) and remaining mild to moderate hemiparetic gait. The patients followed a program of moderate intensity treadmill training for 12 weeks. A significant pre-post improvement in blood lipid profile was found, as indicated by a decrease in total cholesterol (TC), low density lipoprotein cholesterol (LDL), triglyceride and TC/high density lipoprotein cholesterol (HDL). As well, an increase in total HDL was found, however the increase was not significant.

Conclusion: There is insufficient evidence (level 5) that aerobic exercise has an effect on the blood lipid profile of patients with subacute stroke. However, one pre-post pilot study found that aerobic exercise improves the blood lipid profile of patients with sub-acute stroke.

Blood pressure
Not Effective
1B

One high quality RCT (Katz-Leurer et al., 2003a) studied the effect of aerobic exercise on blood pressure in patients who were in the sub-acute phase after a first stroke. No significant effect on resting or sub maximal blood pressure was found for the treatment group following an 8-week aerobic training program using a leg cycle ergometer when compared to the control group who received regular therapy only.

One pre-post pilot study (Yang et al., 2007), studied the effect of aerobic exercise on blood pressure in patients with sub-acute stroke who also had a history of carotid artery disease (CAD) and remaining mild to moderate hemiparetic gait. The patients followed a program of moderate intensity treadmill training for 12 weeks. A significant pre-post improvement in blood pressure was found, as indicated by a significant decrease in resting blood pressure and a significant increase in peak systolic blood pressure; however peak diastolic blood pressure did not change significantly.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that aerobic exercise does not improve resting or sub maximal blood pressure compared to usual care in patients with sub-acute stroke. However, one pre-post pilot study found that aerobic exercise does improve resting blood pressure as well as peak systolic (but not diastolic) blood pressure in patients with subacute stroke.

Depression
Effective*
1B

One high quality RCT (Lai et al., 2006, based on the patient group studied by Duncan et al., 2003) studied the effect of aerobic exercise on depression in patients with sub-acute stroke. A significantly better outcome in depressive symptoms, as indicated by a lower mean score on the Geriatric Depression Scale and higher mean scores on the emotional subscales of both the Medical Outcome Short Form-36 and the Stroke Impact Scale, was found in favour of the intervention group immediately following a 12-to-14 week endurance, strength, balance and upper extremity exercise program when compared to the control group who received usual care only. However, when measured at 6 months post treatment, the between group differences were no longer significant. Significantly fewer patients in the intervention group, compared to the control group, scored in the “depressed range” of the GDS (GDS score ≥ 6) at both assessment times when compared to baseline. No significant difference in antidepressant medication use was reported between groups immediately post intervention or at 6 month follow up.

Note: It should be noted that no relation was found between depressive symptoms at baseline and effect of aerobic exercise on gains in physical function, however it was found that only patients in the intervention group with depressive symptoms at baseline showed improvements in measures of quality of life (measured by the Stroke Impact Scale and Medical Outcome Short Form-36).

Conclusion: There is moderate evidence (level 1b) from one* high quality RCT that aerobic exercise improves depressive symptoms in the short term, but not the long term (6-month follow up), and also results in significantly fewer scoring in the “depressed range” on the Geriatric Depression Scale (score ≥ 6) in both the short term and the long term (6-month follow up), compared to usual care for individuals with subacute stroke.

*It is important to note that along with finding an improvement for depressive symptoms, this study also found an improvement for aerobic capacity (as per Duncan et al., 2003 ).

Endurance
Effective
1A

Three high quality RCTs (Letombe et al., 2010, Katz-Leurer et al., 2003a, Duncan et al., 2003) studied the effect of aerobic exercise on endurance in patients with subacute stroke.

The first high quality RCT (Letombe et al., 2010) found an improvement at 4 weeks (post-treatment) in exercise duration in favour of aerobic exercise + conventional therapy compared to conventional therapy alone.

The second high quality RCT (Katz-Leurer et al., 2003a) found an improvement in endurance, as indicated by a significantly longer exercise time (higher stage reached during a multi-stage test on a leg cycle ergometer), in favour of the treatment group following an 8-week aerobic training program using a leg cycle ergometer, when compared to the control group who received regular therapy only.

The third high quality RCT (Duncan et al., 2003) found an improvement in endurance, as indicated by a significant increase in exercise duration, in favour of the treatment group immediately following a 12-to-14 week endurance, strength, balance and upper extremity exercise program when compared to the control group who received usual care only.

Conclusion: There is strong evidence (level 1a) from three high quality RCTs that aerobic exercise improves endurance compared to usual care in individuals with subacute stroke.

Functional independence
Not Effective
1B

One high quality RCT (Katz-Leurer et al., 2003a) and one fair quality RCT (Katz-Leurer & Shochina, 2007) investigated the effect of aerobic exercise on functional independence in patients with subacute stroke.

In the high quality RCT (Katz-Leurer et al., 2003a), patients were randomly assigned to one of two groups; the intervention group received regular rehabilitation therapy combined with an 8-week supervised aerobic exercise program, while the control group received regular therapy alone. No overall effect of aerobic exercise on level of functional independence was found, as indicated by a lack of significant between group difference on the Functional Independence Measure (FIM), measured at baseline and immediately post intervention.

The fair quality RCT (Katz-Leurer & Shochina, 2007) found no significant difference in Functional Independence Measure scores between a group of patients who received 8 weeks of aerobic exercise on a cycle ergometer (with a target of 30 minutes per session at 60% of HR reserve) combined with usual care and a group who received usual care only (control).

Conclusion: There is moderate evidence (level 1b) from one high quality RCT and one fair quality RCT that aerobic exercise does not improve functional independence compared to usual care in patients with subacute stroke.

Independence in daily and social activities
Not Effective
1B

One high quality RCT (Letombe et al., 2010) and one fair quality RCT (Katz-Leurer et al., 2003b) investigated the effect of aerobic exercise on independence in daily and social activities for patients with subacute stroke.

The first high quality RCT (Letombe et al., 2010) randomized patients with subacute stroke to receive aerobic exercise + conventional therapy or conventional therapy alone. At 4 weeks (post-treatment), no significant differences were observed between groups on independence in daily activities as measured with the Barthel Index and the Katz ADL Scale.

In the fair fair quality RCT (Katz-Leurer et al., 2003b using the group studied in Katz-Leurer et al., 2003a) patients were randomly assigned to one of two groups; the intervention group received regular rehabilitation therapy combined with an 8-week supervised aerobic exercise program, and the control group received regular therapy alone. No overall effect of aerobic exercise on level of independence in daily and social activities was found, as indicated by a lack of significant between group difference on the Frenchay Activities Index (FAI), measured at baseline (to assess pre-stroke levels) and at 6 months post stroke. However, a significant effect was found for a subgroup of patients who had higher severity of stroke (Stroke Severity Scale [SSS] > 30 at baseline), as indicated by significantly less decline in scores on the FAI for the intervention group compared to the control group.

Conclusion: There is moderate evidence (level 1b) from one* high quality RCT and one* fair quality RCT that aerobic exercise does not improve independence in daily and social activities compared to usual care in patients with acute/subacute stroke.

*It is important to note that along with finding an effect of aerobic exercise on independence in patients with severe stroke, these studies also found an improvement in aerobic capacity (please see Katz-Leurer et al., 2003a).

Lactic acid
Insufficient Evidence
5

One pre-post pilot study (Yang et al., 2007), studied the effect of aerobic exercise on resting and peak lactic acid levels in patients with subacute stroke who also had a history of carotid artery disease (CAD) and remaining mild to moderate hemiparetic gait. The patients followed a program of moderate intensity treadmill training for 12 weeks. A significant pre-post increase in peak lactate (indicating an improvement) was found while no significant pre-post difference was noted for resting lactate.

Conclusion: There is insufficient evidence (level 5) that aerobic exercise has an effect on lactic acid in patients with sub-acute stroke. However, one pre-post pilot study found that aerobic exercise improves peak lactate but does not improve resting lactate, in patients with subacute stroke who have CAD.

Motor control (Upper and lower extremity)
Not Effective
1B

One high quality RCT (Duncan et al., 2003) studied the effect of aerobic exercise on upper and lower extremity motor control in patients with subacute stroke. No significant difference in motor control for the upper and lower extremities, as measured by the Fugl-Meyer Motor Score, was found between the treatment group immediately following a 12- to-14 week endurance, strength, balance and upper extremity exercise program and the control group who received usual care only.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that aerobic exercise does not improve upper and lower extremity motor control compared to usual care in patients with subacute stroke.

Peak heart rate
Not Effective
1B

One high quality RCT (Katz-Leurer et al., 2003a), one quasi-experimental study (Tang et al., 2008) and one pre-post pilot study (Yang et al., 2007), investigated the effect of aerobic exercise on peak heart rate in patients with subacute stroke.

One high quality RCT (Katz-Leurer et al., 2003a) studied the effect of aerobic exercise on peak heart rate in patients who had a first stroke and were in the sub-acute phase. The treatment group received regular therapy combined with an 8-week aerobic training program using a leg cycle ergometer and the control group received regular therapy only. No significant between group difference was found for peak heart rate.

The quasi-experimental study (Tang et al., 2008) found no significant difference in peak heart rate between a group of patients who received cycle ergometry sessions until discharge combined with standard rehabilitation, compared to the control group who received standard rehabilitation only.

One pre-post pilot study (Yang et al., 2007), investigated the effect of aerobic exercise on aerobic capacity in patients with sub-acute stroke who also had a history of carotid artery disease (CAD) and remaining mild to moderate hemiparetic gait. The patients followed a program of moderate intensity treadmill training for 12 weeks. A significant pre-post increase in peak heart rate during a treadmill stress test was found, indicating an improvement in aerobic capacity.

Conclusion: There is moderate evidence (level 1b) from one highquality RCTand one quasi-experimental study that aerobic exercise does not significantly increase peak heart rate compared to usual care in patients with subacute stroke. It is of note, however, that one pre-post pilot study found that aerobic exercise does significantly increase peak heart rate – indicating an improvement in aerobic capacity – in patients with subacute stroke.

Peak VO2
Effective
1A

Two high quality RCTs (Letombe et al., 2010, Duncan et al., 2003), one quasi-experimental study (Tang et al., 2008) and one pre-post pilot study (Yang et al., 2007) studied the effect of aerobic exercise on peak VO2 in patients with subacute stroke.

The first high quality RCT (Letombe et al., 2010) found a significant difference in peak VO2 during a stationary bike stress test, at 4 weeks (immediately post-treatment) in favour of aerobic focused exercise + conventional rehabilitation compared to conventional rehabilitation alone.

The second high quality RCT (Duncan et al., 2003) found a significant increase in peak VO2 during a bicycle stress test, indicating an improvement in aerobic capacity, in favour of the treatment group immediately following a 12-to-14 week endurance, strength, balance and upper extremity exercise program when compared to the control group who received usual care only.

The quasi-experimental study (Tang et al., 2008) found a trend toward improvement for peak VO2 in favour of the exercise group, who received cycle ergometry sessions until discharge combined with standard rehabilitation, compared to the control group who received standard rehabilitation only. However no significant between group differences were found.

One pre-post pilot study (Yang et al., 2007) investigated the effect of aerobic exercise on peak VO2 in patients with sub-acute stroke who also had a history of carotid artery disease (CAD) and remaining mild to moderate hemiparetic gait. The patients followed a program of moderate intensity treadmill training for 12 weeks. A significant pre-post improvement in peak VO2 during a treadmill stress test was found indicating an improvement in aerobic capacity.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs that aerobic exercise significantly increases peak VO2 compared to usual care in patients with subacute stroke. In addition, one pre-post pilot study found an improvement following treatment. While one quasi-experimental study found a trend toward improvement in peak VO2 following aerobic exercise compared to the non-exercise control, no significant between-group differences were found.

Peak workload
Effective
1A

Two high quality RCTs (Letombe et al., 2010, Katz-Leurer et al., 2003a), one fair quality RCT (Katz-Leurer & Shochina, 2007) and one quasi-experimental study (Tang et al., 2008) studied the effect of aerobic exercise on peak workload in patients with subacute stroke.

The first high quality RCT (Letombe et al., 2010) found a significant increase in peak workload (Watts), at 4 weeks (immediately post-treatment), in favour of aerobic exercise combined with conventional therapy compared to conventional therapy alone.

The second high quality RCT (Katz-Leurer et al., 2003a), the treatment group received regular therapy combined with an 8-week aerobic training program using a leg cycle ergometer and the control group received regular therapy only. A significant increase in peak workload during a test on a leg cycle ergometer, indicating an improvement in aerobic capacity, was found in favour of the treatment group compared to the control group immediately following intervention.

The fair quality study by Katz-Leurer & Shochina (2007) found a significant increase in peak workload following 8 weeks of aerobic exercise on a cycle ergometer (with a target of 30 minutes per session at 60% of HR reserve) combined with usual care compared to usual care only (control).

The quasi-experimental study (Tang et al., 2008) found no significant difference in peak work rate (Watts) between a group of patients who received cycle ergometry sessions until discharge combined with standard rehabilitation, compared to the control group who received standard rehabilitation only.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs and one fair quality RCT that aerobic exercise significantly increases peak workload compared to usual care in patients with subacute stroke. However, it should be noted that one quasi-experimental study found no improvement.

Quality of life
Effective*
1B

One high quality RCT (Lai et al., 2006, using the patient population indicated in Duncan et al., 2003) studied the effect of aerobic exercise on quality of life in patients with subacute stroke. No significant difference for quality of life as measured by the Stroke Impact Scale (SIS) and the Medical Outcome Short Form-36 (SF-36) was found between the intervention group who followed a 12-to-14 week endurance, strength, balance and upper extremity exercise program, and the control group who received usual care. It was found, however, that patients in the intervention group with significant depressive symptoms at baseline showed significantly greater improvement in most of the subscales of the SIS and SF-36 when compared to the control group.

Conclusion: There is moderate evidence (level 1b) from one* high quality RCT that patients with sub-acute stroke who also have significant depressive symptoms may improve their quality of life, compared to usual care, by performing aerobic exercise.

*It is important to note that along with finding an improvement for quality of life in patients with baseline depressive symptoms, this study (based on Duncan et al., 2003) also found an improvement for aerobic capacity.

Resting heart rate
Effective
1B

One high quality RCT (Katz-Leurer et al., 2003a), one fair quality RCT (Katz-Leurer & Shochina, 2007) and one pre-post pilot study (Yang et al., 2007) studied the effect of aerobic exercise on resting heart rate in patients with subacute stroke.

The one high quality RCT (Katz-Leurer et al., 2003a) found a significant decrease in resting heart rate (indicating an improvement) in favour of the treatment group, who received regular therapy combined with an 8-week aerobic training program using a leg cycle ergometer, compared to the control group, who received regular therapy, immediately following intervention.

The fair quality RCT (Katz-Leurer & Shochina, 2007) found no significant difference in resting heart rate post intervention between a group of patients who received 8 weeks of aerobic exercise on a cycle ergometer (with a target of 30 minutes per session at 60% of HR reserve) combined with usual care and a group who received usual care only (control).

One pre-post pilot study (Yang et al., 2007) investigated the effect of aerobic exercise on resting heart rate in patients with sub-acute stroke who also had a history of carotid artery disease (CAD) and remaining mild to moderate hemiparetic gait. The patients followed a program of moderate intensity treadmill training for 12 weeks. A significant pre-post reduction in resting heart rate was found, indicating an improvement.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT and one pre-post pilot study that aerobic exercise improves resting heart rate compared to usual care in patients with subacute stroke. However one fair quality RCT found no improvement compared to usual care.

Stair climbing
Effective
1B

One high quality RCT (Katz-Leurer et al., 2003a) and one fair quality RCT (Katz-Leurer & Shochina, 2007) looked at the effect of aerobic exercise on stair climbing in patients with subacute stroke.

The high quality RCT (Katz-Leurer et al., 2003a) found a significant improvement in the number of stairs climbed was found for the intervention group, immediately following an 8-week aerobic training program using a leg cycle ergometer, compared to the control group who did not receive aerobic training.

The fair quality RCT by Katz-Leurer & Shochina (2007) found a significant improvement in number of stairs climbed in favour of a group of patients who received 8 weeks of aerobic exercise on a cycle ergometer (with a target of 30 minutes per session at 60% of HR reserve) combined with usual care and a group who received usual care only (control).

Conclusion: There is moderate evidence (level 1b) from one high quality RCT and one fair quality RCT that aerobic exercise improves stair climbing, specifically the number of stairs climbed, compared to usual care, in patients with subacute stroke.

Strength
Not Effective
1B

One high quality RCT (Duncan et al., 2003) studied the effect of aerobic exercise on strength in patients with subacute stroke. No significant improvement in grip strength, as measured by a JAMAR dynamometer, or in ankle dorsiflexion and knee extension isometric strength, as measured by a Cybex dynamometer, was found for the treatment group who received a 12 to 14-week endurance, strength, balance and upper extremity exercise program, compared to the control group who received usual care only.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that aerobic exercise does not improve strength compared to usual care in patients with subacute stoke.

Upper extremity function
Not Effective
1B

One high quality RCT (Duncan et al., 2003) studied the effect of aerobic exercise on upper extremity function in patients with sub-acute stroke. No significant difference in upper extremity function, as measured by the Wolf Motor Function Test, was found between the treatment group immediately following a 12-to-14 week endurance, strength, balance and upper extremity exercise program and the control group who received usual care only.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that aerobic exercise does not improve upper extremity function compared to usual care in patients with subacute stroke.

Walking distance
Conflicting
4

Two high quality RCTs (Duncan et al., 2003, Katz-Leurer et al., 2003a), one fair quality RCT (Katz-Leurer & Shochina, 2007) and one quasi-experimental study (Tang et al., 2008) investigated the effect of aerobic exercise on walking distance in patients with subacute stroke.

The high quality RCT (Duncan et al., 2003) found a significant increase in 6-minute walking distance in favour of the treatment group immediately following a 12- to-14 week endurance, strength, balance and upper extremity exercise program compared to the control group who received usual care only. In contrast, a second high quality RCT (Katz-Leurer et al., 2003a) found no significant between-group difference in distance (measured by a subjective test of walking distance) immediately following an 8-week aerobic training program using a leg cycle ergometer, when compared to the control group who did not receive aerobic training.

The fair quality RCT (Katz-Leurer & Shochina, 2007) found no significant difference in walking distance post intervention between a group of patients who received 8 weeks of aerobic exercise on a cycle ergometer (with a target of 30 minutes per session at 60% of HR reserve) combined with usual care and a group who received usual care only (control).

The quasi-experimental study (Tang et al., 2008) found a trend toward improvement for patients who received 30 minutes on a cycle ergometer, 3 times per week, until discharge, compared to the control group who received standard rehabilitation only. However, no significant between group differences were found.

Conclusion: There is conflicting evidence (level 4) as to whether aerobic exercise improves walking distance, with one high quality RCT showing that aerobic exercise does improve walking distance compared to usual care, and one high quality RCT along with one fair quality RCT reporting that aerobic exercise does not improve walking distance compared to usual care. However, it is to be noted that the high quality RCT that found an improvement (Duncan et al., 2003) had a longer treatment period and included a more varied treatment intervention.

Walking speed
Conflicting
4

Two high quality RCTs (Duncan et al., 2003, Katz-Leurer et al., 2003a) and one quasi-experimental study (Tang et al., 2008) investigated the effect of aerobic exercise on walking speed in patients with subacute stroke.

The high quality RCT (Duncan et al., 2003) found a significant increase in 10-meter walking velocity in favour of the treatment group who received a 12-to-14 week endurance, strength, balance and upper extremity exercise program when compared to the control group who received usual care only. In contrast, a second high quality RCT (Katz-Leurer et al., 2003a) found no significant between-group difference in 10-m walking velocity, immediately following an 8-week aerobic training program using a leg cycle ergometer, when compared to the control group who did not receive aerobic training.

The quasi-experimental study (Tang et al., 2008) found no improvement in walking speed following 30 minutes on a cycle ergometer, 3 times per week, until discharge, compared to the control group who received standard rehabilitation only.

Conclusion: There is conflicting evidence (level 4) as to whether aerobic exercise improves walking speed, with one high quality RCT showing that aerobic exercise does improve walking speed compared to usual care, and one high quality RCT reporting that aerobic exercise does not improve walking speed compared to usual care. However, it is to be noted that the high quality RCT that found an improvement (Duncan et al., 2003) had a longer treatment period and included a more varied treatment intervention.

References

Cooke, E. V., Mares, K., Clark, A., Tallis, R. C. & Pomeroy, V. M. (2010). The effects of increased dose of exercise-based therapies to enhance motor recovery after stroke: a systematic review and meta-analysis. BMC Medicine, 8:60. Doi:10.1186/1741-7015-8-60.

Duncan P., Studenski S., Richards L., Gollub S., Lai S.M., Reker D., Perera S., Yates J., Koch V., Rigler S., & Johnson D. (2003). Randomized clinical trial of therapeutic exercise in sub-acute stroke. Stroke, 34, 2173-2180.

Katz-Leurer M., Shochina M., Carmeli E., & Friedlander Y. (2003a). The influence of early aerobic training on the functional capacity in patients with cerebrovascular accident at the subacute stage. Archives of American Journal of Physical Medicine & Rehabilitation, 84, 1609-1614.

Katz-Leurer M., Carmeli E., & Shochina M. (2003b). The effect of early aerobic training on independence six months post stroke. Journal of Clinical Rehabilitation, 17, 735-741.

Katz-Leurer M. & Shochina M. (2007). The influence of autonomic impairment on aerobic exercise outcome in stroke patients. NeuroRehabilitation, 22, 267-72.

Lai S.M., Studenski S., Richards L., Pereram S., Reker D., Rigler S., & Duncan P.W. (2006). Therapeutic exercise and depressive symptoms after stroke. Journal of the American Geriatrics Society, 54, 240-247.

Letombe, A., Cornille, C., Delahaye, H., Khaled, A., Morice, O., Tomaszewski, A., & Olivier, N. (2010). Early post-stroke physical conditioning in hemiplegic patients: A preliminary study. Annals of Physical and Rehabilitation Medicine, 53, 632–642.

Tang A, Sibley K, Thomas S, Bayley M, Richardson D, McIlroy W & Brooks D. (2008). Effects of an aerobic exercise program on aerobic capacity, spatiotemporal gait parameters, and functional capacity in subacute stroke. Neurorehabilitation & Neural Repair OnlineFirst, DOI:10.1177/1545968308326426

Yang A.L., Lee S.D., Su C.T., Wang J.L., & Lin K.L. (2007). Effects of exercise intervention on patients with stroke with prior coronary artery disease: aerobic capacity, functional ability and lipid profile: a pilot study. Journal of Rehabilitation Medicine, 39, 88-90.

We need your feedback