Aerobic Exercise

Evidence Reviewed as of before: 30-05-2021
Author(s)*: Tatiana Ogourtsova, PhD OT; 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).

Click here to view the AEROBICS 2019 Update Best Practice Recommendations.

Click here to access the Canadian Partnership for stroke Recovery (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?

Experts have done some experiments to compare aerobic exercise with other treatments to see whether it helps people who have had a stroke.

In individuals with ACUTE stroke (< 4 weeks after stroke)

Studies found that aerobic exercise:

  • Was more helpful than the other treatments for improving awareness about stroke and walking endurance (i.e. your physical tolerance when walking).
  • Was as helpful as other treatments for improving cardiovascular fitness parameters (e.g. your blood pressure); quality of life; mood and affect (e.g. symptoms of depression and/or anxiety); and physical activity.

In individuals with CHRONIC stroke (> 6 months after stroke)

Studies found that aerobic exercise:

  • Was more helpful than the other treatments for improving cognitive function (e.g. memory, attention); grip strength; quality of life; walking endurance (i.e. physical tolerance when walking); and walking speed.
  • Was as helpful as other treatments for improving balance; cardiovascular fitness parameters (e.g. your blood pressure); executive functions (e.g. your ability to plan and sequence tasks); functional independence (i.e. your ability to perform tasks of daily life such as dressing and washing); mobility (walking, going up/down the stairs); mood and affect (e.g. symptoms of depression and/or anxiety); the strength of your leg muscles; and physical activity.

In individuals with stroke (unspecified time period post-stroke)

Studies found that aerobic exercise:

  • Was more helpful than the other treatments for improving balance; cardiovascular fitness parameters (e.g. your blood pressure); functional independence (your ability to perform tasks of everyday life such as dressing and washing); quality of life; the function of your legs and overall function of your body; spasticity (the tone of your muscles); walking endurance (your physical tolerance when walking); and walking speed.
  • Was as helpful as other treatments for improving cognitive abilities (e.g. memory, attention); dexterity (ability to manipulate small objects with your fingers); capacity to exercise; executive function (e.g. your ability to plan and sequence tasks); depression; fatigue; mobility (ability to move around); muscle strength; and the quality of sleep.

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, many studies to date that have examined the effect of aerobic exercise 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.

This module focuses on aerobic exercise for people who have had a stroke. This module contains 16 studies, where 11 of them are of high quality. Three studies report effects of aerobic exercise for individuals early in their stroke recovery period (1 month or less after stroke). Nine studies report effects of aerobic exercise for individuals in their chronic stroke period (6 months or more after stroke). Four studies report effects of aerobic exercise for individuals after stroke with unspecified period.

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Results Table

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Outcomes

Acute phase

Cardiovascular fitness parameters
Not effective
1b

One high quality RCT (Wijkman et al., 2017) investigated the effect of aerobic exercise on cardiovascular fitness parameters in the acute phase of stroke recovery. This high quality RCT randomized patients to receive aerobic exercise or no scheduled physical exercise. Cardiovascular fitness parameters [Resting diastolic blood pressure, Resting systolic blood pressure (SBP), Peak SBP, Difference in SBP (peak – resting), Resting heart rate, Peak heart rate, Difference in heart rate (peak – resting), Aerobic capacity work rate] were measured by ergometer exercise test at post-treatment (12 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that aerobic exercise is not more effective than a comparison intervention (usual care without scheduled physical exercise) in improving cardiovascular fitness parameters in the acute phase of stroke recovery.

Health-related quality of life
Conflicting
4

Two high quality RCTs (Faulkner et al., 2015; Moren et al., 2016) investigated the effect of aerobic exercise on health-related quality of life (HRQoL) in the acute phase of stroke recovery.

The first high quality RCT (Faulkner et al., 2015) randomized patients to receive a resistance exercise and education program or written information. HRQoL was measured by the Short-Form 36 (SF-36: Physical component score, Mental component score, Mental health, Social functioning, Global health, Role physical, Role emotional, Vitality, Bodily pain, Physical functioning) at post-treatment (8 weeks) and follow-up (12 months). Significant between-group differences were found in change scores from baseline to post-treatment in some components of HRQoL (Physical component score, Global health, Role physical, Vitality, Physical Functioning), favouring exercise + education vs. written information. Differences did not remain significant at follow-up.

The second high quality RCT (Moren et al., 2016) randomized patients to receive physical activity or no treatment; both groups received usual care. HRQoL was measured by the EuroQoL 5 Dimension Visual Analogue Scale at follow-up (3 and 6 months). No significant between-group difference was found at either time point.

Conclusion: There is conflicting evidence (Level 4) regarding the effect of aerobic exercise on HRQoL in the acute phase of stroke recovery. While one high quality RCT found that an exercise + education program was more effective than written information alone, another high quality RCT found that physical activity was not more effective than no treatment.
Note:
Differences in outcome measures may explain the conflicting findings.

Mood and affect
Not effective
1b

One high quality RCT (Faulkner et al., 2015) investigated the effect of aerobic exercise on mood and affect in the acute phase of stroke recovery. This high quality RCT randomized patients to receive a resistance exercise and education program or written information. Mood and effect were measured by the Hospital Anxiety and Depression Scale (HADS: Anxiety, Depression) and the Profile and Mood States (PMS: Vigour, Depression, Confusion, Tension, Anger, Fatigue) at post-treatment (8 weeks) and follow-up (12 months). A significant between-group difference was found in change scores from post-treatment to follow-up in one measure (PMS: Fatigue), favouring exercise + education vs. written information. No other significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that aerobic exercise is not more effective than a comparison intervention (written information) in improving mood and affect in the acute phase of stroke recovery.

Physical activity
Not Effective
1a

Two high quality RCTs (Faulkner et al., 2015; Moren et al., 2016) investigated the effect of aerobic exercise on physical activity in the acute phase of stroke recovery.

The first high quality RCT (Faulkner et al., 2015) randomized patients to receive a resistance exercise and education program or written information. Physical activity was measured by the International Physical Activity Questionnaire (IPAQ: Leisure time walk activity, Leisure time moderate activity, Leisure time vigorous activity, Total leisure time activity, Sitting time) at post-treatment (8 weeks) and follow-up (12 months). No significant between-group difference was found at either time point.

The second high quality RCT (Moren et al., 2016) randomized patients to receive physical activity or no treatment; both groups received usual care. Physical activity was measured by the Physical Activity of Moderate to Higher Intensity (MVPA) and number of steps per day at follow-up (3 and 6 months). No significant between-group differences were found at either time point.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that aerobic exercise is not more effective than a comparison intervention (written information) or no treatment in improving physical activity in the acute phase of stroke recovery.

Sroke awareness
Effective
1b

One high quality RCT (Faulkner et al., 2015) investigated the effect of aerobic exercise on stroke awareness in the acute phase of stroke recovery. This high quality RCT randomized patients to receive a resistance exercise and education program or written educational material. stroke awareness was measured by the Stanford Medical Centre stroke Awareness Questionnaire (SMCSAQ) at post-treatment (8 weeks) and follow-up (12 months). A significant between-group difference was found in change scores from baseline to post-treatment, favouring exercise + education vs. written educational material. Differences did not remain significant at follow-up.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that aerobic exercise is more effective than a comparison intervention (written educational material) in improving stroke awareness in the acute phase of stroke recovery.

Walking endurance
Effective
1b

One high quality RCT (Moren et al., 2016) investigated the effect of aerobic exercise on walking endurance in the acute phase of stroke recovery. This high quality RCT randomized patients to receive physical activity or no treatment; both groups received usual care. Walking endurance was measured by the 6 Minute Walk Test at follow-up (3 and 6 months). A significant between-group difference was found at 6-month follow-up, favouring physical activity vs. no treatment.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that physical activity is more effective than no treatment in improving long-term walking endurance of patients in the acute phase of stroke recovery.

Chronic phase

Balance
Conflicting
4

Four high quality RCTs (Pang et al., 2005; Liu-Ambrose & Eng, 2015; Lee et al., 2015; Moore et al., 2015) and one fair quality RCT (Lund et al., 2018) investigated the effect of aerobic exercise on balance in the chronic stage of stroke recovery.

The first high quality RCT (Pang et al., 2005) randomized patients to receive a community-based fitness and mobility exercise program (FAME) or a seated upper extremity program. Balance was measured by the Berg Balance Scale (BBS) at post-treatment (19 weeks). No significant between group difference was found.

The second high quality RCT (Liu-Ambrose & Eng, 2015) randomized patients to receive the FAME program or usual care. Balance was measured by the BBS at mid-treatment (3 months) and post-treatment (6 months). No significant between group difference was found at either time point.

The third high quality RCT (Lee et al., 2015) randomized patients to receive aerobic + resistance exercise training or light physical activity. Balance was measured by the Chair Sit and Reach Test and the Functional Reach Test at post-treatment (16 weeks). Significant between-group differences were found in both measures of balance, favouring aerobic + resistance exercise training vs. light physical activity.

The fourth high quality RCT (Moore et al., 2015) randomized patients to receive a fitness and mobility exercise program (adapted from the FAME program) or time-matched stretching. Balance was measured by the BBS at post-treatment (19 weeks). A significant between-group difference was found, favouring the fitness and mobility exercise program vs. stretching.

The fair quality RCT (Lund et al., 2018) randomized patients to receive aerobic training, resistance training or upper extremity training. Balance was measured by the BBS at post-treatment (12 weeks). No significant between-group differences were found.

Conclusion: There is conflicting evidence (Level 4) regarding the effectiveness of aerobic exercise in improving balance in the chronic stage of stroke recovery. While two high quality RCTs found that the FAME exercise program was not more effective than comparison interventions (seated upper extremity program, usual care), two high quality RCTs found that other aerobic exercise programs (aerobic + resistance exercise training, exercises adapted from the FAME program) were more effective than comparison interventions (light physical activity, stretching).

Cardiovascular fitness parameters
Conflicting
4

Five high quality RCTs (Pang et al., 2005; Gordon, Wilks & McCaw-Binns, 2013; Tang et al., 2014 and 2016; Lee et al., 2015; Moore et al., 2015) and two fair quality RCTs (Severinsen et al., 2014; Lund et al., 2018) investigated the effect of aerobic exercise on cardiovascular fitness parameters in the chronic stage of stroke recovery.

The first high quality RCT (Pang et al., 2005) randomized patients to receive a community-based fitness and mobility exercise program (FAME) or a seated upper extremity program. Maximal oxygen consumption was measured by the maximal exercise test on the Excalibur cycle ergometer at post-treatment (19 weeks). A significant between-group difference was found, favouring the FAME program vs. seated upper extremity exercises.

The second high quality RCT (Gordon, Wilks & McCaw-Binns, 2013) randomized patients to receive aerobic exercise or massage. Resting heart rate was measured by heart monitor at post-treatment (12 weeks) and follow-up (3 months). A significant between-group difference was found at follow-up only, favouring aerobic exercise vs. massage.

The third high quality RCT (Tang et al., 2014; 2016) randomized patients to receive aerobic training or balance/flexibility training. Peak oxygen consumption was measured by graded maximal exercise test using a leg cycle ergometer at post-treatment (6 months). No significant between-group difference was found.

The fourth high quality RCT (Lee et al., 2015) randomized patients to receive aerobic + resistance exercise training or light physical activity. Cardiovascular parameters (peripheral systolic blood pressure (SBP) / diastolic blood pressure (DBP), central SBP / DBP, Pulse Wave Velocity (PWV), Augmentation Index – AIx@75) were measured at post-treatment (16 weeks). Significant between-group differences were found for three cardiovascular fitness parameters (central DBP, PWV, AIx@75), favouring aerobic + resistance training vs. light physical activity.

The fifth high quality RCT (Moore et al., 2015) randomized patients to receive a fitness and mobility exercise program or time-matched stretching. Cardiovascular parameters (Peak oxygen consumption, Peak work rate, SBP, DBP) were measured by the maximal progressive recumbent bicycle exercise test and the semi-automated sphygmomanometer at post-treatment (19 weeks). Significant between-group differences were found for three cardiovascular fitness parameters (Peak oxygen consumption, Peak work rate, DBP), favouring the fitness and mobility exercise program vs. stretching.

The first fair quality RCT (Severinsen et al., 2014) randomized patients to receive aerobic training, resistance training or upper extremity training. Peak aerobic capacity (VO2 peak) was measured by the maximal progressive stepwise cycle ergometer test at post-treatment (12 weeks) and at follow-up (6 months). Significant between-group differences were found at post-treatment, favouring aerobic training vs. resistance training and aerobic training vs. upper extremity training; differences were not maintained at follow-up.

The second fair quality RCT (Lund et al., 2018) randomized patients to receive aerobic training, resistance training or upper extremity training. Cardiovascular fitness parameters (peak oxygen update, resting HR, maximal HR) were measured by the maximal progressive cycle ergometer test and a heart rate monitor at post-treatment (12 weeks). No significant between-group differences were found.

Conclusion: There is conflicting evidence (Level 4) regarding the effectiveness of aerobic exercise programs on cardiovascular fitness in the chronic phase of stroke recovery. While three high quality RCTs and one fair quality RCT found that aerobic exercise programs were more effective than comparison interventions (seated upper extremity exercises, light physical activity, stretching, resistance training, upper extremity training), two high quality RCTs* and one fair quality RCT found that aerobic exercise programs were not more effective than comparison interventions (massage, balance/flexibility training, upper extremity training).
*Note:
One of the high quality RCTs found that aerobic exercises were more effective than massage in the long-term.

Cognition
Effective
1b

One high quality RCT (Moore et al., 2015) investigated the effect of aerobic exercise on cognition in the chronic stage of stroke recovery. This high quality RCT randomized patients to receive a fitness and mobility exercise program or stretching. Cognition was measured by the Addenbrooke’s Cognitive Examination Revised at post-treatment (19 weeks). A significant between-group difference was found, favouring the fitness and mobility exercise program vs. stretching.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that aerobic exercise is more effective than a comparison intervention (stretching) in improving cognition in the chronic stage of stroke recovery.

Executive functions
Conflicting
4

Two high quality RCTs (Tang et al., 2014 & 2016; Liu-Ambrose & Eng, 2015) investigated the effect of aerobic exercise on executive functions in the chronic stage of stroke recovery.

The first high quality RCT (Tang et al., 2014 & 2016) randomized patients to receive aerobic training or balance/flexibility training. Executive functions were measured by the Verbal Digit Span Test Forward & Backward (working memory), Trail Making Test B (set shifting), and Colour-Word Stroop Test (selective attention and conflict resolution) at post-treatment (6 months). No significant between-group differences were found.

The second high quality RCT (Liu-Ambrose & Eng, 2015) randomized patients to receive a community-based Fitness and Mobility Exercise (FAME) program or usual care. Executive functions were measured by the Stroop Test (selective attention and conflict resolution), Trail Making Tests – Part A and B (set shifting) and verbal digit span forward/backward test (working memory) at mid-treatment (3 months) and post-treatment (6 months). At mid-treatment a significant between-group difference was found in one measure of executive functions (Trail Making Tests), favouring the FAME program vs. usual care. At post-treatment significant between-group differences were found in two measures of executive functions (Stroop Test; verbal digit span forward/backward test), favouring the FAME program vs. usual care.

Conclusion: There is conflicting evidence (Level 4) regarding the effectiveness of aerobic exercise in improving executive functions in the chronic stage of stroke recovery. One high quality RCT found that aerobic training was not more effective than a balance/flexibility program, whereas another high quality RCT found that aerobic exercise was more effective than usual care.

Functional independence
Not effective
1b

One high quality RCT (Gordon, Wilks & McCaw-Binns, 2013) investigated the effect of aerobic exercise on functional independence in the chronic stage of stroke recovery. This high quality RCT randomized patients to receive aerobic exercise or massage. Functional independence was measured by the Barthel Index at post-treatment (12 weeks) and follow-up (3 months). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that aerobic exercise is not more effective than a comparison intervention (massage) in improving functional independence in the chronic stage of stroke recovery.

Functional status and service use
Not effective
1b

One high quality RCT (Gordon, Wilks & McCaw-Binns, 2013) investigated the effect of aerobic exercise on functional status and service use in the chronic stage of stroke recovery. This high quality RCT randomized patients to receive aerobic exercise or massage. Functional status and service use were measured by the Older Americans Resources and Services at post-treatment (12 weeks) and follow-up (3 months). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that aerobic exercise is not more effective than a comparison intervention (massage) in improving functional status and service use in the chronic stage of stroke recovery.

Grip strength
Effective
1b

One high quality RCT (Lee et al., 2015) investigated the effect of aerobic exercise on grip strength in the chronic stage of stroke recovery. This high quality RCT randomized patients to receive aerobic + resistance exercise training or light physical activity. Grip strength of the unaffected hand was measured by handheld dynamometer at post-treatment (16 weeks). A significant between-group difference was found, favouring aerobic + resistance exercise training vs. light physical activity.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that aerobic exercise with resistance training is more effective than a comparison intervention (light physical activity) in improving grip strength of the unaffected hand in the chronic stage of stroke recovery.

Health-related quality of life
Effective
1b

One high quality RCTs (Gordon, Wilks & McCaw-Binns, 2013) investigated the effect of aerobic exercise on health-related quality of life (HRQoL) in the chronic stage of stroke recovery. This high quality RCT randomized patients to receive aerobic exercise or massage. HRQoL was measured by the Short-Form-36 (SF-36: Physical health component, Mental health component) at post-treatment (12 weeks) and follow-up (3 months). A significant between-group difference was found at post-treatment (SF-36: Physical health component), favouring aerobic exercise vs. massage.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that aerobic exercise is more effective than a comparison intervention (massage) in improving health-related quality of life in the chronic stage of stroke recovery.
Note:
Between-group differences were only significant for one measure of health-related quality of life.

Mobility
Not effective
1b

One high quality RCT (Lee et al., 2015) investigated the effect of aerobic exercise on mobility in the chronic stage of stroke recovery. This high quality RCT randomized patients to receive aerobic and resistance exercise training or light physical activity. Mobility was measured by the Timed Up and Go Test at post-treatment (16 weeks). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that aerobic exercise is not more effective than a comparison intervention (light physical activity) in improving mobility in the chronic stage of stroke recovery.

Mood and affect
Not effective
1b

One high quality RCT (Liu-Ambrose & Eng, 2015) investigated the effect of aerobic exercise on mood and affect in the chronic stage of stroke recovery. This high quality RCT randomized patients to receive a community-based Fitness and Mobility Exercise (FAME) program or usual care. Mood and affect were measured by the 17-item stroke Specific Geriatric Depression Scale at mid-treatment (3 months) and post-treatment (6 months). No significant between-group difference was found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that aerobic exercise is not more effective than a comparison intervention (usual care) in improving mood and affect in the chronic stage of stroke recovery.

Muscle strength - lower extremities
Conflicting
4

Three high quality RCTs (Pang et al., 2005; Gordon, Wilks & McCaw-Binns, 2013; Lee et al., 2015) and two fair quality RCTs (Severinsen et al., 2014; Lund et al., 2018) investigated the effect of aerobic exercise on lower extremities muscle strength in the chronic stage of stroke recovery.

The first high quality RCT (Pang et al., 2005) randomized patients to receive a community-based fitness and mobility exercise program (FAME) or a seated upper extremity program. Isometric knee extension (paretic, non-paretic) was measured by dynamometer at post-treatment (19 weeks). A significant between group difference was found, favouring the FAME program vs. seated upper extremity exercises.

The second high quality RCT (Gordon, Wilks & McCaw-Binns, 2013) randomized patients to receive aerobic exercise or massage. Lower extremity strength (paretic, non-paretic) was measured by the Motricity Index at post-treatment (12 weeks) and follow-up (3 months). No significant between-group difference was found at either time point.

The third high quality RCT (Lee et al., 2015) randomized patients to receive aerobic + resistance exercise training or light physical activity. Lower extremity strength was measured by the 30-sec Chair Stand Test at post-treatment (16 weeks). A significant between-group difference was found, favouring aerobic + resistance exercise training vs. light physical activity.

The first fair quality RCT (Severinsen et al., 2014) randomized patients to receive aerobic training, resistance training or upper extremity training. Maximal isometric knee strength (paretic, non-paretic) was measured by dynamometer at post-treatment (12 weeks) and follow-up (6 weeks). A significant between-group difference in knee strength (paretic, non-paretic) was found at post-treatment, favouring resistance training vs. aerobic training; this between-group difference was maintained at follow-up. There was no significant difference in knee strength between aerobic training vs. upper extremity training.
Note: A significant between-group difference in knee strength (non-paretic only) was found at post-treatment, favouring resistance training vs. upper extremity exercises; this difference was maintained at follow-up.

The second fair quality RCT (Lund et al., 2018) randomized patients to receive aerobic training, resistance training or upper extremity training. Knee strength (paretic, non-paretic) was measured by dynamometer at post-treatment (12 weeks). No significant between-group differences were found.

Conclusion: There is conflicting evidence (Level 4) regarding the effectiveness of aerobic exercise on lower extremity strength in the chronic stage of stroke recovery. While two high quality RCTs found that aerobic exercise was more effective than comparison interventions (seated upper extremity program, light physical activity), one high quality RCT and two fair quality RCTs found that aerobic exercise was not more effective than comparison interventions (massage, upper extremity training, resistance training).
Note
: In fact, one of the fair quality RCTs found that resistance training was more effective than aerobic training for improving knee strength.

Physical activity
Not effective
1b

One high quality RCT (Pang et al., 2005) and one fair quality RCT (Shaughnessy, Michael & Resnick, 2012) investigated the effect of aerobic exercise on physical activity in the chronic stage of stroke recovery.

The high quality RCT (Pang et al., 2005) randomized patients to receive a community-based fitness and mobility exercise program (FAME) or a seated upper extremity program. Physical activity was measured by the Physical Activity Scale for Individuals with Physical Disabilities at post-treatment (19 weeks). No significant between group difference was found.

The fair quality RCT (Shaughnessy, Michael & Resnick, 2012) randomized patients to receive aerobic treadmill training or stretching. Physical activity was measured by the Yale Physical Activity Survey (YPAS: Housework, Yard work, Caretaking, Moderate physical activity, Recreational activities) at post-treatment (6 months). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one fair quality RCT that aerobic exercise is not more effective than comparison interventions (seated upper extremity program, stretching) in improving physical activity in the chronic stage of stroke recovery.

Self-efficacy and expectations
Not effective
2a

One fair quality RCT (Shaughnessy, Michael & Resnick, 2012) investigated the effect of aerobic exercise on self-efficacy & expectations in the chronic stage of stroke recovery. This fair quality RCT randomized patients to receive aerobic treadmill training or stretching. Self-efficacy & expectations were measured by Short Self-Efficacy and Outcomes Expectations for Exercises (Outcome expectations; Self-efficacy) at post-treatment (6 months). No significant between-group difference was found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that aerobic exercise is not more effective than a comparison intervention (stretching) in improving self-efficacy & expectations in the chronic stage of stroke recovery.

Stroke outcomes
Not effective
1b

One high quality RCT (Moore et al., 2015) and one fair quality RCT (Shaughnessy, Michael & Resnick, 2012) investigated the effect of aerobic exercise on stroke outcomes in the chronic stage of stroke recovery.

The high quality RCT (Moore et al., 2015) randomized patients to receive a fitness and mobility exercise program or time-matched stretching. stroke outcomes were measured by the stroke Impact Scale (SIS: stroke recovery, Mood, Strength, Memory, Communication, Activities of daily living, Community mobility, Hand function, Participation, Physical total) at post-treatment (19 weeks). A significant between-group difference was found in only one measure (SIS: Mood), favouring the fitness and mobility exercise program vs. stretching.

The fair quality RCT (Shaughnessy, Michael & Resnick, 2012) randomized patients to receive aerobic treadmill training or stretching. stroke outcomes were measure by the SIS (Strength, Hand function, Activities of daily living, Mobility, Communication, Emotion, Memory and thinking, Participation, Overall sum, Recovery visual analogue scale) at post-treatment (6 months). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one fair quality RCT that aerobic exercise is not more effective than a comparison intervention (stretching) in reducing stroke outcomes in the chronic stage of stroke recovery.

Walking endurance
Effective
1a

Six high quality RCTs (Pang et al., 2005; Gordon, Wilks & McCaw-Binns, 2013; Tang et al., 2014 & 2016; Lee et al., 2015; Liu-Ambrose & Eng, 2015; Moore et al., 2015) and 2 fair quality RCTs (Severinsen et al., 2014; Lund et al., 2018) investigated the effect of aerobic exercise on walking endurance in the chronic stage of stroke recovery.

The first high quality RCT (Pang et al., 2005) randomized patients to receive a community-based fitness and mobility exercise program (FAME) or a seated upper extremity program. Walking endurance was measured by the 6-Minute Walk Test (6MWT) at post-treatment (19 weeks). A significant between-group difference was found, favouring the FAME program vs. seated upper extremity exercises.

The second high quality RCT (Gordon, Wilks & McCaw-Binns, 2013) randomized patients to receive aerobic exercise or massage. Walking endurance was measured by the 6MWT at post-treatment (12 weeks) and follow-up (3 months). No significant between-group differences were found at either time point.

The third high quality RCT (Tang et al., 2014; 2016) randomized patients to receive aerobic training or balance/flexibility training. Walking endurance was measured by the 6MWT at post-treatment (6 months). No significant between-group difference was found.

The fourth high quality RCT (Lee et al., 2015) randomized patients to receive aerobic + resistance exercise training or light physical activity. Walking endurance was measured by the 6MWT at post-treatment (16 weeks). A significant between-group difference was found, favouring aerobic + resistance exercise training vs. light physical activity.

The fifth high quality RCT (Liu-Ambrose & Eng, 2015) randomized patients to receive the FAME program or usual care. Walking endurance was measured by the 6MWT at mid-treatment (3 months) and post-treatment (6 months). A significant between-group difference was found at post-treatment, favouring the FAME program vs. usual care.

The sixth high quality RCT (Moore et al., 2015) randomized patients to receive a fitness and mobility exercise program or time-matched stretching. Walking endurance was measured by the 6MWT at post-treatment (19 weeks). A significant between-group difference was found, favouring the fitness and mobility exercise program vs. stretching.

The first fair quality RCT (Severinsen et al., 2014) randomized patients to receive aerobic training, resistance training or upper extremity training. Walking endurance was measured by the 6MWT at post-treatment (12 weeks) and at follow-up (6 months). No significant between-group differences were found.

The second fair quality RCT (Lund et al., 2018) randomized patients to receive aerobic training, resistance training or upper extremity training. Walking endurance was measured by the 6MWT at post-treatment (12 weeks). No significant between-group differences were found.

Conclusion: There is strong evidence (Level 1a) from four high quality RCTs that aerobic exercise is more effective than comparison interventions (seated upper extremity program, light physical activity, usual care, stretching) in improving walking endurance in the chronic stage of stroke recovery.
Note
: However, two high quality RCTs and two fair quality RCTs found that aerobic exercise was not more effective than comparison interventions (massage, balance/flexibility training, resistance training, upper extremity training).

Walking speed
Effective
1a

Two high quality RCTs (Lee et al., 2015; Moore et al., 2015) and two fair quality RCTs (Severinsen et al., 2014; Lund et al., 2018) investigated the effect of aerobic exercise on walking speed in the chronic stage of stroke recovery.

The first high quality RCT (Lee et al., 2015) randomized patients to receive aerobic + resistance exercise training or light physical activity. Walking speed was measured by the 10 Meter Walk Test (10mWT) at post-treatment (16 weeks). A significant between-group difference was found, favouring aerobic + resistance exercise training vs. light physical activity.

The second high quality RCT (Moore et al., 2015) randomized patients to receive a fitness and mobility exercise program or time-matched stretching. Walking speed was measured by the 10mWT at post-treatment (19 weeks). A significant between-group difference was found, favouring the fitness and mobility exercise program vs. stretching.

The first fair quality RCT (Severinsen et al., 2014) randomized patients to receive aerobic training, resistance training or upper extremity training. Walking speed was measured by the 10mWT at post-treatment (12 weeks) and at follow-up (6 months). No significant between-group differences were found at post-treatment. Significant between-group differences were found at follow-up, favouring resistance training vs. aerobic training, and upper extremity training vs. aerobic training.

The second fair quality RCT (Lund et al., 2018) randomized patients to receive aerobic training, resistance training or upper extremity training. Walking speed was measured by the 10mWT at post-treatment (12 weeks). No significant between-group differences were found.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that aerobic exercise is more effective than comparison interventions (light physical activity, stretching) in improving walking speed in the chronic stage of stroke recovery.
Note: Two fair quality RCTs found that aerobic exercise was not more effective than comparison interventions (resistance training, upper extremity training). In fact, one fair quality RCT found that both resistance training and upper extremity training were more effective than aerobic exercise for improving walking speed.

Phase not specific to one period

Balance
Effective
1b

One high quality RCT (Sandberg et al., 2016) and one quasi-experimental design study (Marsden et al., 2016) investigated the effect of aerobic exercise on balance in patients with stroke.

The high quality RCT (Sandberg et al., 2016) randomized patients with acute/subacute stroke to receive an aerobic exercise program or no exercise program. Balance was measured by the Single Leg Stance Test (SLST: Right/left with eyes closed/open) at post-treatment (12 weeks). A significant between-group difference was found for three measures of balance (SLST: Right leg eyes open, Right leg eyes closed, Left leg eyes open), favouring aerobic exercise program vs. no exercise program.

The quasi-experimental design study (Marsden et al., 2016) assigned patients with acute, subacute or chronic stroke to receive a home- and community-based exercise program with aerobic content or usual care. Balance was measured by the Step Test (Right, Left) at post-treatment (12 weeks). A significant between-group difference was found on both measures of balance, favouring the aerobic exercise program vs. usual care.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one quasi-experimental study that aerobic exercise is more effective than comparison interventions (no exercise program, usual care) in improving balance in patients with stroke.

Cardiovascular fitness parameters
Effective
1a

Two high-quality RCTs (Wang et al., 2014; Sandberg et al., 2016) and one quasi-experimental design study (Marsden et al., 2016) investigated the effect of aerobic exercise on cardiovascular fitness parameters in patients with stroke.

The first high quality RCT (Wang et al., 2014) randomized patients with subacute/chronic stroke to receive low-intensity aerobic training or no training; both groups received conventional rehabilitation. Cardiovascular fitness parameters (Resting heart rate (RHR), Peak heart rate (PHR), Exercise test time) were measured at post-treatment (6 weeks). A significant between-group difference was found on one measure (exercise test time), in favour of aerobic training vs. no aerobic training.

The second high quality RCT (Sandberg et al., 2016) randomized patients with acute/subacute stroke to receive an aerobic exercise program or no exercise program. A cardiovascular fitness parameter (Peak work rate) was measured by the symptom-limited graded cycle ergometer test at post-treatment (12 weeks). A significant between-group difference was found, favouring aerobic exercise program vs. no exercise program.

The quasi-experimental design study (Marsden et al., 2016) assigned patients with acute, subacute or chronic stroke to receive a home- and community-based exercise program with aerobic content or usual care. Cardiovascular fitness parameters (Vo2peak absolute, Vo2peak relative, HR, R-value) were measured during the 6 Minute Walk Test (6MWT), Shuttle Walk Test and Cycle Progressive Exercise Test (also Duration, Workload measures) at post-treatment (12 weeks). A significant between-group difference was found in one parameter (6MWT: Vo2peak absolute, relative), favouring an aerobic exercise program vs. usual care.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs and one quasi-experimental study that aerobic exercise is more effective than no treatment for improving some cardiovascular fitness parameters (e.g. exercise test time, peak work rate, peak oxygen uptake) in patients with stroke.

Cognition
Not effective
2b

One fair quality RCT (Nave et al., 2019) investigated the effect of aerobic exercise on cognition in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive aerobic physical fitness training using the PHYS-STROKE program or relaxation. Cognition was measured by the Montreal Cognitive Assessment at post-treatment (4 weeks) and follow-up (3, 6 months). No significant between group difference was found at any time point.

Conclusion: There is limited evidence (Level 2b) from one fair quality RCT that aerobic exercise is not more effective than a comparison intervention (relaxation) in improving cognition in patients with stroke.

Depression
Not effective
2b

One fair quality RCT (Nave et al., 2019) and one quasi-experimental design study (Marsden et al., 2016) investigated the effect of aerobic exercise on depression in patients with stroke.

The fair quality RCT (Nave et al., 2019) randomized patients with acute/subacute stroke to receive aerobic physical fitness training using the PHYS-STROKE program or relaxation. depression was measured by the Centre for Epidemiological Studies depression at post-treatment (4 weeks) and follow-up (3, 6 months). No significant between-group differences were found at any time points.

The quasi-experimental design study (Marsden et al., 2016) assigned patients with acute, subacute or chronic stroke to receive a home- and community-based exercise program with aerobic content or usual care. depression was measured by the Patient Health Questionnaire-9 at post-treatment (12 weeks). No significant between-group difference was found.

Conclusion: There is limited evidence (Level 2b) from one fair quality RCT and one quasi-experimental study that aerobic exercise is not more effective than comparison interventions (relaxation, usual care) in reducing depression in patients with stroke.

Dexterity
Not effective
2b

One fair quality RCT (Nave et al., 2019) investigated the effect of aerobic exercise on dexterity in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive aerobic physical fitness training using the PHYS-STROKE program or relaxation. Dexterity was measured by the Box and Block Test at post-treatment (4 weeks) and follow-up (3, 6 months). No significant between-group differences were found at any time points.

Conclusion: There is limited evidence (Level 2b) from one fair quality RCT that aerobic exercise is not more effective than a comparison intervention (relaxation) in improving dexterity in patients with stroke.

Executive functions
Not effective
2b

One fair quality RCT (Nave et al., 2019) investigated the effect of aerobic exercise on executive functions in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive aerobic physical fitness training using the PHYS-STROKE program or relaxation. Executive functions were measured by the Trail Making Test (TMT – A, B) at post-treatment (4 weeks) and follow-up (3, 6 months) and the Regensburger Wort-Flüssigkeits-Test at follow-up (3 months). No significant between group differences were found on any of the measures at any time point.

Conclusion: There is limited evidence (Level 2b) from one fair quality RCT that aerobic exercise is not more effective than a comparison intervention (relaxation) in improving executive functions in patients with stroke.

Exercise capacity
Not effective
2b

One quasi-experimental design study (Marsden et al., 2016) investigated the effect of aerobic exercise on exercise capacity in patients with stroke. This quasi-experimental design study assigned patients with acute, subacute or chronic stroke to receive a home- and community-based exercise program with aerobic content or usual care. Exercise capacity was measured by the Shuttle Walk Test at post-treatment (12 weeks). No significant between-group difference was found.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental study that aerobic exercise is not more effective than a comparison intervention (usual care) in improving exercise capacity in patients with stroke.

Fatigue
Not effective
2b

One quasi-experimental design study (Marsden et al., 2016) investigated the effect of aerobic exercise on fatigue in patients with stroke. This quasi-experimental study assigned patients with acute, subacute or chronic stroke to receive a home- and community-based exercise program with aerobic content or usual care. Fatigue was measured by the Fatigue Assessment Scale at post-treatment (12 weeks). No significant between-group difference was found.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental study that aerobic exercise is not more effective than a comparison intervention (usual care) in reducing fatigue in patients with stroke.

Functional independence
Effective
1b

One high quality RCT (Wang et al., 2014) and one fair quality RCT (Nave et al., 2019) investigated the effect of aerobic exercise on functional independence in patients with stroke.

The high quality RCT (Wang et al., 2014) randomized patients with subacute/chronic stroke to receive low-intensity aerobic training or no training; both groups received conventional rehabilitation. Functional independence was measured by the Barthel Index at post-treatment (6 weeks). A significant between-group difference was found in favour of aerobic training vs. no training.

The fair quality RCT (Nave et al., 2019) randomized patients with acute/subacute stroke to receive aerobic physical fitness training using the PHYS-STROKE program or relaxation. Functional independence was measured by the Barthel Index (change scores) and the modified Rankin Scale at post-treatment (4 weeks) and follow-up (3, 6 months). No significant between-group differences were found at any time points.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that aerobic exercise is more effective than no training in improving functional independence in patients with stroke.

Gait parameters
Not effective
2a

One fair quality RCT (Nave et al., 2019) investigated the effects of aerobic exercise in improving gait parameters in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive aerobic physical fitness training using the PHYS-STROKE program or relaxation. gait parameters (Number of steps/day, Step length, Step Cadence, gait Energy Cost) were measured at post-treatment (4 weeks) and follow-up (3, 6 months). No significant between-group differences were found at any time points.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that aerobic exercise is not more effective than a comparison intervention (relaxation) in improving gait parameters in patients with stroke.

Health-related quality of life
Effective
1b

One high quality RCT (Sandberg et al., 2016), one fair quality RCT (Nave et al., 2019) and one quasi-experimental design study (Marsden et al., 2016) investigated the effect of aerobic exercise on health-related quality of life (HRQoL) in patients with stroke.

The high quality RCT (Sandberg et al., 2016) randomized patients with acute/subacute stroke to receive an aerobic exercise program or no exercise program. HRQoL was measured by the European Quality of Life Scale (EQ-5D: Total score; Visual analogue Scale) at post-treatment (12 weeks). A significant between-group difference was found for one measure of HRQoL (EQ-5D: Visual analogue scale), favouring aerobic exercise program vs. no exercise program.

The fair quality RCT (Nave et al., 2019) randomized patients with acute/subacute stroke to receive aerobic physical fitness training using the PHYS-STROKE program or relaxation. HRQoL was measured by the EuroQoL Quality of Life Questionnaire 5D-5L at post-treatment (4 weeks) and follow-up (3, 6 months). No significant between-group differences were found at any time points.

The quasi-experimental study (Marsden et al., 2016) assigned patients with acute, subacute or chronic stroke to receive a home- and community-based exercise program with aerobic content or usual care. HRQoL was measured by the stroke and Aphasia Quality of Life-39 at post-treatment (12 weeks). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that aerobic exercise is more effective than a comparison intervention (no exercise program) in improving health-related quality of life in patients with stroke.

Mobility
Not effective
1b

One high quality RCT (Sandberg et al., 2016) and one fair quality RCT (Nave et al., 2019) investigated the effect of aerobic exercise on mobility in patients with stroke.

The high quality RCT (Sandberg et al., 2016) randomized patients with acute/subacute stroke to receive an aerobic exercise program or no exercise program. Mobility was measured by the Timed Up and Go test at post-treatment (12 weeks). A significant between-group difference was found, favouring aerobic exercise program vs. no exercise program.

The fair quality RCT (Nave et al., 2019) randomized patients with acute/subacute stroke to receive aerobic physical fitness training using the PHYS-STROKE program or relaxation. Mobility was measured by the Rivermead Mobility Index, Use of walking aids and Functional Ambulation Category, at post-treatment (4 weeks) and follow-up (3, 6 months). No significant between group differences were found on any of the measures at any time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that aerobic exercise is more effective than a comparison intervention (no exercise program) in improving mobility in patients with stroke.

Motor function
Effective
1b

One high quality RCT (Wang et al., 2014) investigated the effect of aerobic exercise on motor function in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive low-intensity aerobic training or no training; both groups received conventional rehabilitation. Motor function was measured by the Fugl Meyer Assessment (FMA: Total motor score) at post-treatment (6 weeks). A significant between-group difference was found, favouring aerobic exercise vs. no training.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that aerobic exercise is more effective than no training (conventional rehabilitation alone) in improving motor function in patients with stroke.

Motor function - lower extremity
Effective
1b

One high quality RCT (Wang et al., 2014) investigated the effect of aerobic exercise on lower extremity motor function in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive low-intensity aerobic training or no training; both groups received conventional rehabilitation. Lower extremity motor function was measured by the Fugl Meyer Assessment (FMA: Lower extremity score) at post-treatment (6 weeks). A significant between-group difference was found, favouring aerobic exercise vs. no training.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that aerobic exercise is more effective than no training in improving lower extremity motor function in patients with stroke.

Motor function - upper extremity
Not effective
1b

One high quality RCT (Wang et al., 2014) and one fair quality RCT (Nave et al., 2019) investigated the effect of aerobic exercise on upper extremity motor function in patients with stroke.

The high quality RCT (Wang et al., 2014) randomized patients with subacute/chronic stroke to receive low-intensity aerobic training or no training; both groups received conventional rehabilitation. Upper extremity motor function was measured by the Fugl Meyer Assessment (FMA: Upper extremity score) at post-treatment (6 weeks). No significant between-group difference was found.

The fair quality RCT (Nave et al., 2019) randomized patients with acute/subacute stroke to receive aerobic physical fitness training using the PHYS-STROKE program or relaxation. Upper extremity motor function was measured by the Rivermead Mobility Index (RMI – arm score) at post-treatment (4 weeks) and follow-up (3, 6 months). A significant between-group differences was found at 6-month follow up only, favouring aerobic physical fitness training vs. relaxation.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one fair quality RCT that aerobic exercise is not more effective than comparison interventions (no training, relaxation) in improving upper extremity motor function in patients with stroke.

Muscle strength
Not effective
2b

One fair quality RCT (Nave et al., 2019) investigated the effect of aerobic exercise on muscle strength in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive aerobic physical fitness training using the PHYS-STROKE program or relaxation. Muscle strength was measured by the Medical Research Council (MRC) Scale at post-treatment (4 weeks) and follow-up (3, 6 months). No significant between-group difference was found at any time points.

Conclusion: There is limited evidence (Level 2b) from one fair quality RCT that aerobic exercise is not more effective than a comparison intervention (relaxation) in improving muscle strength in patients with stroke.

Sleep quality
Not effective
2b

One fair quality RCT (Nave et al., 2019) investigated the effect of aerobic exercise on sleep quality in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive aerobic physical fitness training using the PHYS-STROKE program or relaxation. Sleep quality was measured by the Pittsburgh Sleep Quality Score at post-treatment (4 weeks) and follow-up (3, 6 months). No significant between-group difference was found at any time point.

Conclusion: There is limited evidence (Level 2b) from one fair quality RCT that aerobic exercise is not more effective than a comparison intervention (relaxation) in improving sleep quality in patients with stroke.

Spasticity
Effective*
2b

One fair quality RCT (Nave et al., 2019) investigated the effect of aerobic exercise on spasticity in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive aerobic physical fitness training using the PHYS-STROKE program or relaxation. spasticity was measured by the Resistance to Passive Movement Scale (REPAS) at post-treatment (4 weeks) and follow-up (3, 6 months). A significant between-group differences was found at follow up (6 months), favouring aerobic physical fitness training vs. relaxation.

Conclusion: There is limited evidence (Level 2b) from one fair quality RCT that aerobic exercise is more effective, in the long term*, than a comparison intervention (relaxation) in reducing spasticity in patients with stroke.

Stroke outcomes
Effective
1b

One high quality RCT (Sandberg et al., 2016) investigated the effect of aerobic exercise on stroke outcomes in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive an aerobic exercise program or no exercise program. stroke outcomes were measured by the stroke Impact Scale (SIS: Daily activities, Recovery) at post-treatment (12 weeks). A significant between-group difference was found in one measure (SIS: Recovery), favouring aerobic exercise program vs. no exercise.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that aerobic exercise is more effective than a comparison intervention (usual care) in reducing some stroke outcomes in patients with stroke.

Walking endurance
Effective
1b

One high-quality RCT (Sandberg et al., 2016), one fair quality RCT (Nave et al., 2019) and one quasi-experimental study (Marsden et al., 2016) investigated the effect of aerobic exercise on walking endurance in patients with stroke.

The high quality RCT (Sandberg et al., 2016) randomized patients with acute/subacute stroke to receive an aerobic exercise program or no exercise program. Walking endurance was measured by the  6 Minute Walk Test (6MWT) at post-treatment (12 weeks). A significant between-group difference was found, favouring aerobic exercise vs. no exercise.

The fair quality RCT (Nave et al., 2019) randomized patients with acute/subacute stroke to receive aerobic physical fitness training using the PHYS-STROKE program or relaxation. Walking endurance was measured by the 6MWT at post-treatment (4 weeks) and follow-up (3, 6 months). No significant between-group difference was found at any time points.

The quasi-experimental study design (Marsden et al., 2016) assigned patients with acute, subacute or chronic stroke to receive a home- and community-based exercise program with aerobic content or usual care. Walking endurance was measured by the 6MWT at post-treatment (12 weeks). A significant between-group difference was found, favouring aerobic exercise vs. usual care.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one quasi-experimental study design that aerobic exercise is more effective than comparison interventions (no exercise, usual care) in improving walking endurance in patients with stroke.

Walking speed
Effective
1b

One high quality RCT (Sandberg et al., 2016), one fair quality RCT (Nave et al., 2019) and one quasi-experimental study design (Marsden et al., 2016) investigated the effect of aerobic exercise on walking speed in patients with stroke.

The high quality RCT (Sandberg et al., 2016) randomized patients with acute/subacute stroke to receive an aerobic exercise program or no exercise program. Walking speed was measured by the  10 Minute Walk Test (10MWT) at post-treatment (12 weeks). A significant between-group difference was found, favouring aerobic exercise vs. no exercise.

The fair quality RCT (Nave et al., 2019) randomized patients with acute/subacute stroke to receive aerobic physical fitness training using the PHYS-STROKE program or relaxation. Walking speed was measured by the 10MWT post-treatment (4 weeks) and follow-up (3, 6 months). No significant between group difference was found at any time point.

The quasi-experimental study design (Marsden et al., 2016) assigned patients with acute, subacute or chronic stroke to receive a home- and community-based exercise program with aerobic content or usual care. Walking speed was measured by the 10MWT (Fast, Self-selected speed) at post-treatment (12 weeks). No significant between-group difference was found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that aerobic exercise is more effective than no exercise in improving walking speed in patients with stroke.

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Severinsen, K., Jakobsen, J. K., Pedersen, A. R., Overgaard, K., & Andersen, H. (2014). Effects of resistance training and aerobic training on ambulation in chronic stroke. American journal of physical medicine & rehabilitation, 93(1), 29-42.
https://journals.lww.com/ajpmr/Fulltext/2014/01000/Effects_of_Resistance_Training_and_Aerobic.3.aspx?casa_token=mB1Gwq9fLDgAAAAA:pLqqIJFYJWzoq_bAd4de_t5rgAHqgYHuSe4BZCikntkwsUv9dggoHkMiquX7UiX-DuDiVa0ltkg3WSoaL3jKxJa1ah8

Shaughnessy, M., Michael, K., & Resnick, B. (2012). Impact of treadmill exercise on efficacy expectations, physical activity, and stroke recovery. The Journal of neuroscience nursing: journal of the American Association of Neuroscience Nurses, 44(1), 27.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3249605/

Tang, A., Eng, J. J., Krassioukov, A. V., Madden, K. M., Mohammadi, A., Tsang, M. Y., & Tsang, T. S. (2014). Exercise-induced changes in cardiovascular function after stroke: a randomized controlled trial. International Journal of stroke, 9(7), 883-889.
https://journals.sagepub.com/doi/full/10.1111/ijs.12156?casa_token=BaEy8XeTLe8AAAAA%3AV1kHt11rKpBMnXOn1Vf4lap-4YXYAs8qECRbWkmOzU8eDZCSggtA4_buQjMTW3G_btKsnTGjZbkK_g

Tang, A., Eng, J. J., Tsang, T. S., & Liu-Ambrose, T. (2016). High-and low-intensity exercise do not improve cognitive function after stroke: A randomized controlled trial. Journal of rehabilitation medicine, 48(10), 841-846.
https://www.ingentaconnect.com/contentone/mjl/sreh/2016/00000048/00000010/art00002

Wijkman, M. O., Sandberg, K., Kleist, M., Falk, L., & Enthoven, P. (2018). The exaggerated blood pressure response to exercise in the sub‐acute phase after stroke is not affected by aerobic exercise. The Journal of Clinical Hypertension20(1), 56-64.
https://onlinelibrary.wiley.com/doi/full/10.1111/jch.13157

Wang, Z., Wang, L., Fan, H., Lu, X., & Wang, T. (2014). Effect of low-intensity ergometer aerobic training on glucose tolerance in severely impaired nondiabetic stroke patients. Journal of stroke and Cerebrovascular Diseases, 23(3), e187-e193.
https://www.sciencedirect.com/science/article/pii/S1052305713003959?casa_token=GoBcYRstDJ8AAAAA:IJo9a1F9CwFK_YLGBHuYDi0q-ca7d6CUdht3OvsR6hI-MgDQIxyJV2khbzTwrKl5f4bSVQZR1N4

Excluded studies:

Bo, W., Lei, M., Tao, S., Jie, L. T., Qian, L., Lin, F. Q., & Ping, W. X. (2019). Effects of combined intervention of physical exercise and cognitive training on cognitive function in stroke survivors with vascular cognitive impairment: a randomized controlled trial. Clinical Rehabilitation, 33(1), 54-63.
Reason for exclusion: The main part of the treatment focused on endurance, strength and balance (30-35 minutes) and aerobic exercise was provided only for the first 5 minutes as warm-up (cycling, jogging).

Jin, H., Jiang, Y., Wei, Q., Chen, L., & Ma, G. (2013). Effects of aerobic cycling training on cardiovascular fitness and heart rate recovery in patients with chronic strokeNeuroRehabilitation32(2), 327-335.
Reason for exclusion: Included in treadmill module.

Jin, H., Jiang, Y., Wei, Q., Wang, B., & Ma, G. (2012). Intensive aerobic cycling training with lower limb weights in Chinese patients with chronic stroke: discordance between improved cardiovascular fitness and walking ability. Disability and Rehabilitation34(19), 1665-1671.
Reason for exclusion: Included in treadmill module.

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