10 1002@14651858 CD003316 Pub7
10 1002@14651858 CD003316 Pub7
10 1002@14651858 CD003316 Pub7
Library
Cochrane Database of Systematic Reviews
Saunders DH, Sanderson M, Hayes S, Johnson L, Kramer S, Carter DD, Jarvis H, Brazzelli M, Mead
GE
Saunders DH, Sanderson M, Hayes S, Johnson L, Kramer S, Carter DD, Jarvis H, Brazzelli M, Mead GE.
Physical fitness training for stroke patients.
Cochrane Database of Systematic Reviews 2020, Issue 3. Art. No.: CD003316.
DOI: 10.1002/14651858.CD003316.pub7.
www.cochranelibrary.com
TABLE OF CONTENTS
HEADER......................................................................................................................................................................................................... 1
ABSTRACT..................................................................................................................................................................................................... 1
PLAIN LANGUAGE SUMMARY....................................................................................................................................................................... 2
SUMMARY OF FINDINGS.............................................................................................................................................................................. 4
BACKGROUND.............................................................................................................................................................................................. 10
OBJECTIVES.................................................................................................................................................................................................. 12
METHODS..................................................................................................................................................................................................... 12
Figure 1.................................................................................................................................................................................................. 15
RESULTS........................................................................................................................................................................................................ 18
Figure 2.................................................................................................................................................................................................. 22
Figure 3.................................................................................................................................................................................................. 25
Figure 4.................................................................................................................................................................................................. 32
Figure 5.................................................................................................................................................................................................. 33
Figure 6.................................................................................................................................................................................................. 34
DISCUSSION.................................................................................................................................................................................................. 39
AUTHORS' CONCLUSIONS........................................................................................................................................................................... 45
ACKNOWLEDGEMENTS................................................................................................................................................................................ 46
REFERENCES................................................................................................................................................................................................ 47
CHARACTERISTICS OF STUDIES.................................................................................................................................................................. 71
DATA AND ANALYSES.................................................................................................................................................................................... 208
Analysis 1.1. Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 1 Death............................ 212
Analysis 1.2. Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 2 Disability - Functional 213
Independence Measure.........................................................................................................................................................................
Analysis 1.3. Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 3 Disability - Barthel 214
Index.......................................................................................................................................................................................................
Analysis 1.4. Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 4 Disability - Rivermead 214
Mobility Index (scale 0 to 15)...............................................................................................................................................................
Analysis 1.5. Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 5 Disability - combined 215
disability scales.....................................................................................................................................................................................
Analysis 1.6. Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 6 Risk factors - blood 216
pressure, systolic...................................................................................................................................................................................
Analysis 1.7. Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 7 Risk factors - blood 216
pressure, diastolic.................................................................................................................................................................................
Analysis 1.8. Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 8 Risk factors - body mass 217
index (BMI).............................................................................................................................................................................................
Analysis 1.9. Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 9 Physical fitness - peak 217
VO2.........................................................................................................................................................................................................
Analysis 1.10. Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 10 Physical fitness - 218
maximum cycling work rate.................................................................................................................................................................
Analysis 1.11. Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 11 Mobility - functional 218
ambulation categories..........................................................................................................................................................................
Analysis 1.12. Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 12 Mobility - walking 219
maximal speed (over 5 to 10 metres)..................................................................................................................................................
Analysis 1.13. Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 13 Mobility - walking 220
preferred speed.....................................................................................................................................................................................
Analysis 1.14. Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 14 Mobility - walking 220
capacity (6-MWT metres)......................................................................................................................................................................
Analysis 1.15. Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 15 Mobility - walking 221
capacity (m/min)...................................................................................................................................................................................
Analysis 1.16. Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 16 Mobility - community 222
walk (min)..............................................................................................................................................................................................
Analysis 1.17. Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 17 Physical function - 222
Berg Balance Scale (score 0 to 56)......................................................................................................................................................
Analysis 1.18. Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 18 Physical function - 223
Timed Up and Go (sec).........................................................................................................................................................................
Analysis 1.19. Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 19 Health-related QoL - 223
SF-36 & SF-12 Physical Health Component........................................................................................................................................
Analysis 1.20. Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 20 Health-related QoL - 224
SF-36 & SF-12 Mental Health Component...........................................................................................................................................
Analysis 1.21. Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 21 Health-related QoL - 224
EuroQol EQ-5D......................................................................................................................................................................................
Analysis 1.22. Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 22 Mood - Beck 225
Depression Index...................................................................................................................................................................................
Analysis 2.1. Comparison 2 Cardiorespiratory training versus control - end of retention follow-up, Outcome 1 Death................. 226
Analysis 2.2. Comparison 2 Cardiorespiratory training versus control - end of retention follow-up, Outcome 2 Disability - 227
combined disability scales...................................................................................................................................................................
Analysis 2.3. Comparison 2 Cardiorespiratory training versus control - end of retention follow-up, Outcome 3 Mobility - walking 228
maximal speed (m/min).......................................................................................................................................................................
Analysis 2.4. Comparison 2 Cardiorespiratory training versus control - end of retention follow-up, Outcome 4 Mobility - walking 228
preferred speed (m/min)......................................................................................................................................................................
Analysis 2.5. Comparison 2 Cardiorespiratory training versus control - end of retention follow-up, Outcome 5 Mobility - walking 229
capacity (6-MWT metres)......................................................................................................................................................................
Analysis 2.6. Comparison 2 Cardiorespiratory training versus control - end of retention follow-up, Outcome 6 Physical function 229
- Berg Balance scale..............................................................................................................................................................................
Analysis 2.7. Comparison 2 Cardiorespiratory training versus control - end of retention follow-up, Outcome 7 Health-related 230
QoL - EuroQol EQ-5D............................................................................................................................................................................
Analysis 3.1. Comparison 3 Resistance training versus control - end of intervention, Outcome 1 Death........................................ 233
Analysis 3.2. Comparison 3 Resistance training versus control - end of intervention, Outcome 2 Physical fitness - composite 233
measure of muscle strength.................................................................................................................................................................
Analysis 3.3. Comparison 3 Resistance training versus control - end of intervention, Outcome 3 Physical fitness - muscle 234
strength, paretic knee flexion..............................................................................................................................................................
Analysis 3.4. Comparison 3 Resistance training versus control - end of intervention, Outcome 4 Physical fitness - muscle 235
strength, paretic knee extension.........................................................................................................................................................
Analysis 3.5. Comparison 3 Resistance training versus control - end of intervention, Outcome 5 Mobility - walking maximal 235
speed (m/min).......................................................................................................................................................................................
Analysis 3.6. Comparison 3 Resistance training versus control - end of intervention, Outcome 6 Mobility - walking preferred 236
speed (m/min).......................................................................................................................................................................................
Analysis 3.7. Comparison 3 Resistance training versus control - end of intervention, Outcome 7 Mobility - walking capacity (6- 236
MWT metres)..........................................................................................................................................................................................
Analysis 3.8. Comparison 3 Resistance training versus control - end of intervention, Outcome 8 Physical function - Berg Balance 237
Scale (score 0 to 56).............................................................................................................................................................................
Analysis 3.9. Comparison 3 Resistance training versus control - end of intervention, Outcome 9 Physical function - stair climbing, 237
maximal (sec/step)................................................................................................................................................................................
Analysis 3.10. Comparison 3 Resistance training versus control - end of intervention, Outcome 10 Physical function - Timed Up 238
and Go (sec)..........................................................................................................................................................................................
Analysis 3.11. Comparison 3 Resistance training versus control - end of intervention, Outcome 11 Health-related QoL - SF-36 238
physical functioning (PF) scale............................................................................................................................................................
Analysis 3.12. Comparison 3 Resistance training versus control - end of intervention, Outcome 12 Health-related QoL - SF-36 239
mental health (MH) scale.....................................................................................................................................................................
Analysis 3.13. Comparison 3 Resistance training versus control - end of intervention, Outcome 13 Mood - Centre for 239
Epidemiologic Studies for Depression scale (CES-D).........................................................................................................................
Analysis 3.14. Comparison 3 Resistance training versus control - end of intervention, Outcome 14 Mood - combined depression 240
scales......................................................................................................................................................................................................
Analysis 4.1. Comparison 4 Resistance training versus control - end of retention follow-up, Outcome 1 Death............................. 241
Analysis 4.2. Comparison 4 Resistance training versus control - end of retention follow-up, Outcome 2 Mobility - walking 242
maximal speed (m/min).......................................................................................................................................................................
Analysis 4.3. Comparison 4 Resistance training versus control - end of retention follow-up, Outcome 3 Mobility - walking capacity 242
(6-MWT metres).....................................................................................................................................................................................
Analysis 4.4. Comparison 4 Resistance training versus control - end of retention follow-up, Outcome 4 Physical function - Timed 243
Up and Go (sec).....................................................................................................................................................................................
Analysis 5.1. Comparison 5 Mixed training versus control - end of intervention, Outcome 1 Death................................................ 248
Analysis 5.2. Comparison 5 Mixed training versus control - end of intervention, Outcome 2 Disability - Barthel Index (BI)........... 249
Analysis 5.3. Comparison 5 Mixed training versus control - end of intervention, Outcome 3 Disability - Lawton IADL................... 250
Analysis 5.4. Comparison 5 Mixed training versus control - end of intervention, Outcome 4 Disability - Rivermead Mobility Index 250
(RMI).......................................................................................................................................................................................................
Analysis 5.5. Comparison 5 Mixed training versus control - end of intervention, Outcome 5 Disability - combined disability 251
scales......................................................................................................................................................................................................
Analysis 5.6. Comparison 5 Mixed training versus control - end of intervention, Outcome 6 Risk factors - blood pressure, 251
systolic...................................................................................................................................................................................................
Analysis 5.7. Comparison 5 Mixed training versus control - end of intervention, Outcome 7 Risk factors - blood pressure, 252
diastolic..................................................................................................................................................................................................
Analysis 5.8. Comparison 5 Mixed training versus control - end of intervention, Outcome 8 Physical fitness - peak VO2 (mL/kg/ 252
min)........................................................................................................................................................................................................
Analysis 5.9. Comparison 5 Mixed training versus control - end of intervention, Outcome 9 Physical fitness - gait economy, VO2 253
(mL/kg/metre).......................................................................................................................................................................................
Analysis 5.10. Comparison 5 Mixed training versus control - end of intervention, Outcome 10 Physical fitness - muscle strength, 253
ankle dorsiflexion*................................................................................................................................................................................
Analysis 5.11. Comparison 5 Mixed training versus control - end of intervention, Outcome 11 Physical fitness - muscle strength, 254
knee extension*.....................................................................................................................................................................................
Analysis 5.12. Comparison 5 Mixed training versus control - end of intervention, Outcome 12 Physical fitness - muscle strength, 254
grip strength (paretic hand).................................................................................................................................................................
Analysis 5.13. Comparison 5 Mixed training versus control - end of intervention, Outcome 13 Mobility - walking maximum 255
speed......................................................................................................................................................................................................
Analysis 5.14. Comparison 5 Mixed training versus control - end of intervention, Outcome 14 Mobility - walking preferred speed 255
(m/min)..................................................................................................................................................................................................
Analysis 5.15. Comparison 5 Mixed training versus control - end of intervention, Outcome 15 Mobility - walking capacity (6-MWT 256
metres)...................................................................................................................................................................................................
Analysis 5.16. Comparison 5 Mixed training versus control - end of intervention, Outcome 16 Mobility - Community Ambulation 257
Speed (> 0.8 m/sec)..............................................................................................................................................................................
Analysis 5.17. Comparison 5 Mixed training versus control - end of intervention, Outcome 17 Physical function - balance - Berg 257
Balance scale.........................................................................................................................................................................................
Analysis 5.18. Comparison 5 Mixed training versus control - end of intervention, Outcome 18 Physical function - balance - 258
functional reach....................................................................................................................................................................................
Analysis 5.19. Comparison 5 Mixed training versus control - end of intervention, Outcome 19 Physical function - balance - 258
combined outcome data......................................................................................................................................................................
Analysis 5.20. Comparison 5 Mixed training versus control - end of intervention, Outcome 20 Physical function - Timed Up and 259
Go (sec)..................................................................................................................................................................................................
Analysis 5.21. Comparison 5 Mixed training versus control - end of intervention, Outcome 21 Health-related QoL - SF-36 physical 260
functioning.............................................................................................................................................................................................
Analysis 5.22. Comparison 5 Mixed training versus control - end of intervention, Outcome 22 Health-related QoL - SF-36 physical 260
role functioning.....................................................................................................................................................................................
Analysis 5.23. Comparison 5 Mixed training versus control - end of intervention, Outcome 23 Health-related QoL - SF-36 social 261
role functioning.....................................................................................................................................................................................
Analysis 5.24. Comparison 5 Mixed training versus control - end of intervention, Outcome 24 Mood - Hospital Anxiety and 261
Depression Scale (HADS) - anxiety score.............................................................................................................................................
Analysis 5.25. Comparison 5 Mixed training versus control - end of intervention, Outcome 25 Mood - Hospital Anxiety and 262
Depression Scale (HADS) - depression score......................................................................................................................................
Analysis 5.26. Comparison 5 Mixed training versus control - end of intervention, Outcome 26 Mood - Stroke Impact Scale 262
emotion score........................................................................................................................................................................................
Analysis 5.27. Comparison 5 Mixed training versus control - end of intervention, Outcome 27 Mood - combined depression 263
scales......................................................................................................................................................................................................
Analysis 5.28. Comparison 5 Mixed training versus control - end of intervention, Outcome 28 Cognitive function - FIM cognitive 263
score.......................................................................................................................................................................................................
Analysis 5.29. Comparison 5 Mixed training versus control - end of intervention, Outcome 29 Cognitive function - SIS memory 264
and thinking..........................................................................................................................................................................................
Analysis 5.30. Comparison 5 Mixed training versus control - end of intervention, Outcome 30 Cognitive function - SIS 264
communication.....................................................................................................................................................................................
Analysis 6.1. Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 1 Death.................................... 269
Analysis 6.2. Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 2 Disability - Barthel Index (BI).... 269
Analysis 6.3. Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 3 Disability - Nottingham 270
Extended ADL........................................................................................................................................................................................
Analysis 6.4. Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 4 Disability - Rivermead Mobility 270
Index (RMI).............................................................................................................................................................................................
Analysis 6.5. Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 5 Disability - combined disability 271
scales......................................................................................................................................................................................................
Analysis 6.6. Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 6 Mobility - Functional 271
Ambulation Categories.........................................................................................................................................................................
Analysis 6.7. Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 7 Mobility - walking preferred 272
speed (m/min).......................................................................................................................................................................................
Analysis 6.8. Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 8 Mobility - walking capacity 272
(6-MWT metres).....................................................................................................................................................................................
Analysis 6.9. Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 9 Mobility - community 273
ambulation speed (> 0.8 m/sec)..........................................................................................................................................................
Analysis 6.10. Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 10 Physical function - balance 273
- Berg Balance Scale.............................................................................................................................................................................
Analysis 6.11. Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 11 Physical function - balance 274
- functional reach..................................................................................................................................................................................
Analysis 6.12. Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 12 Physical function - Timed 274
Up and Go (sec).....................................................................................................................................................................................
Analysis 6.13. Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 13 Health-related QoL - SF-36 275
physical functioning..............................................................................................................................................................................
Analysis 6.14. Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 14 Health-related QoL - SF-36 275
physical role functioning......................................................................................................................................................................
Analysis 6.15. Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 15 Mood - Stroke Impact Scale 276
emotion score........................................................................................................................................................................................
Analysis 6.16. Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 16 Mood - Geriatric Depression 276
Scale.......................................................................................................................................................................................................
Analysis 6.17. Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 17 Mood - Hospital Anxiety 277
and Depression Scale (HADS) - anxiety score.....................................................................................................................................
Analysis 6.18. Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 18 Mood - Hospital Anxiety 277
and Depression Scale (HADS) - depression score...............................................................................................................................
Analysis 6.19. Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 19 Mood - combined 278
depression scales..................................................................................................................................................................................
Analysis 6.20. Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 20 Cognitive function - FIM 278
cognitive score......................................................................................................................................................................................
Analysis 6.21. Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 21 Cognitive function - SIS 279
memory and thinking...........................................................................................................................................................................
Analysis 6.22. Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 22 Cognitive function - SIS 279
communication.....................................................................................................................................................................................
Analysis 7.1. Comparison 7 Cardiorespiratory versus resistance versus mixed training, Outcome 1 Disability - combined 281
disability scales.....................................................................................................................................................................................
Analysis 7.2. Comparison 7 Cardiorespiratory versus resistance versus mixed training, Outcome 2 Mobility - walking maximal 282
speed......................................................................................................................................................................................................
Analysis 7.3. Comparison 7 Cardiorespiratory versus resistance versus mixed training, Outcome 3 Mobility - walking preferred 283
speed......................................................................................................................................................................................................
Analysis 7.4. Comparison 7 Cardiorespiratory versus resistance versus mixed training, Outcome 4 Mobility - walking capacity 284
(6-MWT distance)...................................................................................................................................................................................
Analysis 7.5. Comparison 7 Cardiorespiratory versus resistance versus mixed training, Outcome 5 Physical Function - Balance 286
- Berg Balance Scale.............................................................................................................................................................................
Analysis 7.6. Comparison 7 Cardiorespiratory versus resistance versus mixed training, Outcome 6 Physical function - Timed up 287
and go....................................................................................................................................................................................................
ADDITIONAL TABLES.................................................................................................................................................................................... 288
APPENDICES................................................................................................................................................................................................. 299
WHAT'S NEW................................................................................................................................................................................................. 303
HISTORY........................................................................................................................................................................................................ 304
CONTRIBUTIONS OF AUTHORS................................................................................................................................................................... 305
DECLARATIONS OF INTEREST..................................................................................................................................................................... 305
SOURCES OF SUPPORT............................................................................................................................................................................... 306
DIFFERENCES BETWEEN PROTOCOL AND REVIEW.................................................................................................................................... 306
INDEX TERMS............................................................................................................................................................................................... 306
[Intervention Review]
David H Saunders1, Mark Sanderson2, Sara Hayes3, Liam Johnson4, Sharon Kramer4, Daniel D Carter5, Hannah Jarvis6, Miriam Brazzelli7,
Gillian E Mead8
1Physical Activity for Health Research Centre (PAHRC), University of Edinburgh, Edinburgh, UK. 2Institute of Clinical Exercise and Health
Science, University of the West of Scotland, Hamilton, UK. 3School of Allied Health, Ageing Research Centre, Health Research Institute,
University of Limerick, Limerick, Ireland. 4The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg,
Australia. 5School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland. 6Research Centre
for Musculoskeletal Science and Sports Medicine, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester,
UK. 7Health Services Research Unit, University of Aberdeen, Aberdeen, UK. 8Centre for Clinical Brain Sciences, University of Edinburgh,
Edinburgh, UK
Contact address: David H Saunders, Physical Activity for Health Research Centre (PAHRC), University of Edinburgh, St Leonards Land,
Holyrood Road, Edinburgh, Midlothian, EH8 8AQ, UK. [email protected].
Citation: Saunders DH, Sanderson M, Hayes S, Johnson L, Kramer S, Carter DD, Jarvis H, Brazzelli M, Mead GE. Physical fitness training
for stroke patients. Cochrane Database of Systematic Reviews 2020, Issue 3. Art. No.: CD003316. DOI: 10.1002/14651858.CD003316.pub7.
Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
ABSTRACT
Background
Levels of physical activity and physical fitness are low after stroke. Interventions to increase physical fitness could reduce mortality and
reduce disability through increased function.
Objectives
The primary objectives of this updated review were to determine whether fitness training after stroke reduces death, death or dependence,
and disability. The secondary objectives were to determine the effects of training on adverse events, risk factors, physical fitness, mobility,
physical function, health status and quality of life, mood, and cognitive function.
Search methods
In July 2018 we searched the Cochrane Stroke Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, SPORTDiscus, PsycINFO, and four
additional databases. We also searched ongoing trials registers and conference proceedings, screened reference lists, and contacted
experts in the field.
Selection criteria
Randomised trials comparing either cardiorespiratory training or resistance training, or both (mixed training), with usual care, no
intervention, or a non-exercise intervention in stroke survivors.
Main results
We included 75 studies, involving 3017 mostly ambulatory participants, which comprised cardiorespiratory (32 studies, 1631 participants),
resistance (20 studies, 779 participants), and mixed training interventions (23 studies, 1207 participants).
Death was not influenced by any intervention; risk differences were all 0.00 (low-certainty evidence). There were few deaths overall
(19/3017 at end of intervention and 19/1469 at end of follow-up). None of the studies assessed death or dependence as a composite
outcome. Disability scores were improved at end of intervention by cardiorespiratory training (standardised mean difference (SMD) 0.52,
95% CI 0.19 to 0.84; 8 studies, 462 participants; P = 0.002; moderate-certainty evidence) and mixed training (SMD 0.23, 95% CI 0.03 to 0.42; 9
studies, 604 participants; P = 0.02; low-certainty evidence). There were too few data to assess the effects of resistance training on disability.
Secondary outcomes showed multiple benefits for physical fitness (VO2 peak and strength), mobility (walking speed) and physical function
(balance). These physical effects tended to be intervention-specific with the evidence mostly low or moderate certainty. Risk factor data
were limited or showed no effects apart from cardiorespiratory fitness (VO2 peak), which increased after cardiorespiratory training (mean
difference (MD) 3.40 mL/kg/min, 95% CI 2.98 to 3.83; 9 studies, 438 participants; moderate-certainty evidence). There was no evidence of
any serious adverse events. Lack of data prevents conclusions about effects of training on mood, quality of life, and cognition. Lack of data
also meant benefits at follow-up (i.e. after training had stopped) were unclear but some mobility benefits did persist. Risk of bias varied
across studies but imbalanced amounts of exposure in control and intervention groups was a common issue affecting many comparisons.
Authors' conclusions
Few deaths overall suggest exercise is a safe intervention but means we cannot determine whether exercise reduces mortality or the
chance of death or dependency. Cardiorespiratory training and, to a lesser extent mixed training, reduce disability during or after usual
stroke care; this could be mediated by improved mobility and balance. There is sufficient evidence to incorporate cardiorespiratory and
mixed training, involving walking, within post-stroke rehabilitation programmes to improve fitness, balance and the speed and capacity of
walking. The magnitude of VO2 peak increase after cardiorespiratory training has been suggested to reduce risk of stroke hospitalisation
by ˜7%. Cognitive function is under-investigated despite being a key outcome of interest for patients. Further well-designed randomised
trials are needed to determine the optimal exercise prescription, the range of benefits and any long-term benefits.
Review question
We reviewed the evidence that examines whether physical fitness training is beneficial for health and function in people who have had
a stroke.
Background
Physical fitness is important to allow people to carry out everyday activities such as walking and climbing stairs. Physical fitness varies
among everyone. For example, fitness in men tends to be a little higher than in women and everyone's fitness declines as we get older and
if we become less physically active. In particular, in stroke survivors' physical fitness is often low. This may limit their ability to perform
everyday activities and also worsen stroke-related disability. For this reason fitness training has been proposed as a beneficial approach
for people with stroke. However, taking part in fitness training could have a range of other benefits important to people with stroke such as
improving cognitive function (thinking skills), improving mood, and quality of life, and it could reduce the chance of having another stroke.
Study characteristics
In July 2018 we identified 75 studies for inclusion in the review. The studies involved a total of 3617 participants at all stages of care
including being in hospital or back living at home. Most of the people who took part were able to walk on their own. The studies tested
different forms of fitness training; these included cardiorespiratory or 'endurance' training, resistance or 'strength' training, or mixed
training, which is a combination of cardiorespiratory plus resistance training.
Key results
We found that cardiorespiratory fitness training, particularly involving walking, can improve fitness, balance and walking after stroke.
The improvements in cardiorespiratory fitness may reduce the chance of stroke hospitalisation by 7%. Mixed training improves walking
ability and improves balance. Strength training may have a role in improving balance. So, overall it seems likely that people with stroke
are likely to benefit the most from training that involves cardiorespiratory training and that involves some walking. However, there was
not enough information to draw reliable conclusions about the impact of fitness training on other areas such as quality of life, mood, or
cognitive function. Cognitive function is under-investigated despite being a key outcome of interest for stroke survivors. There was no
evidence that any of the different types of fitness training caused injuries or other health problems; exercise appears to be safe. We need
more studies to examine the benefits that are most important to stroke survivors, in particular for those with more severe stroke who may
be unable to walk.
Studies of fitness training can be difficult to carry out. We have the highest confidence in the estimates of benefit from cardiorespiratory
training (moderate/high). The evidence for other training types is moderate to low. However, some consistent findings emerged with
different studies all tending to show similar effects in different groups of participants.
Summary of findings for the main comparison. Cardiorespiratory training compared to control for people with stroke: end of intervention
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Cardiorespiratory training compared to control for people with stroke: end of intervention
Better health.
Informed decisions.
Trusted evidence.
Comparison: control; end of intervention
Death Risk difference 0.00 1631 ⊕⊕⊝⊝ Death is very uncommon, with only 4 deaths; 2 deaths in the con-
(−0.01 to 0.01) (32 RCTs) Lowa trol group and 2 in the intervention group of a single study (Gor-
Analysis 1.1 don 2013).
Dead or dependent - 0 (0 RCTs) - No studies reported the composite outcome of death or depen-
dency.
Disability Pooled functional SMD 0.52 higher 462 ⊕⊕⊕⊝ A SMD of global scales of disability is difficult to interpret. The
scales (0.19 higher to 0.84 high- (8 RCTs) Moderateb magnitude of increase observed (> 0.5) can generally be cate-
er) gorised as a 'moderate' effect. Any improvement may be reflect-
Analysis 1.5 ing improved mobility since mobility items are commonly includ-
ed in these assessment tools.
Physical fit- VO2 peak (mL/kg/ MD 3.4 mL/kg/min higher 438 ⊕⊕⊕⊝ An increase of 1 MET (3.3 mL/kg/min) is associated with a 7% risk
ness min) (2.98 higher to 3.83 high- (9 RCTs) Moderatec reduction in stroke hospitalisation (Pandey 2016). The effect here
er) is of similar magnitude and suggests secondary prevention tar-
Analysis 1.9 gets could be achieved within short periods of training.
Mobility Preferred gait speed MD 4.47 m/min faster 588 ⊕⊕⊕⊕ These increases in preferred walking speed and walking capaci-
(m/min) (2.07 faster to 6.87 faster) (12 RCTs) Highd ty are relevant to community ambulation. The interventions are
mostly those with a walking mode of exercise. These functional
Analysis 1.13 benefits are also maintained after the end of the training inter-
ventions. Maximal speed and other indices of gait also improve.
Gait endurance (6- MD 33.41 m further 882 ⊕⊕⊕⊕
MWT metres) (19.04 further to 47.78 fur- (16 RCTs) Highe
ther)
Analysis 1.14
4
Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Physical fitness training for stroke patients (Review)
Physical Berg Balance Scale MD 1.92 units higher 471 ⊕⊕⊕⊝ Both of these outcomes are indices of balance.
function (0.16 higher to 3.68 high- (8 RCTs) Moderatef
(0 to 56, best balance er)
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= 56)
Analysis 1.17
Better health.
Informed decisions.
Trusted evidence.
Analysis 1.18
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and
its 95% CI).
6-MWT: 6-Minute Walk Test; CI: confidence interval; MD: mean difference; MET: metabolic equivalent; RCT: randomised controlled trial; RR: risk ratio; SMD: standardised
mean difference
aMost participants were high-functioning; risk of death was low among this group. There is some risk of bias from imbalanced exposure in 13 of the 20 included studies and some
reporting uncertainties concerning reasons for dropouts in six of the 32 studies.
bThere is some heterogeneity (I2 = 61%); other issues with individual studies account for this heterogeneity.
cThere are some 'Risk of bias' items recorded as 'high' but these are among studies with a low weighting. There is uncertainty in the data of one study (Jin 2013). If we exclude
this study, a clear effect is still present (MD 2.80 mL/kg/min higher (1.66 higher to 3.95 higher) with high-certainty evidence).
dAlthough five out of 13 studies are confounded for exposure time the effect is still apparent when these are excluded.
eSome heterogeneity is present (I2 = 30%) but sensitivity analysis of confounded studies and those using non-walking (cycling) exercise modes reduces this and a similar beneficial
effect remains.
Summary of findings 2. Resistance training compared to control for people with stroke: end of intervention
Resistance training compared to control for people with stroke: end of intervention
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(95% CI) participants the evidence
(studies) (GRADE)
Death Risk difference 0.00 803 ⊕⊕⊝⊝ Death is very uncommon, with only 2 deaths; 1 in the control group
(−0.02 to 0.02) (20 RCTs) Lowa and 1 in the intervention group of a single study (Knox 2018).
Analysis 3.1
Better health.
Informed decisions.
Trusted evidence.
Dead or dependent - 0 (0 RCTs) - No studies reported the composite outcome of death or dependen-
cy.
Disability Pooled functional - - - Too few data reporting global indices of disability to establish any
scales consensus effects.
Physical Fit- VO2 peak (mL/kg/min) - - - The rationale for resistance training is to increase muscle strength
ness and not cardiorespiratory fitness therefore there is little rationale to
investigate this outcome. Only 1 study measured VO2 peak and this
indicated a 6% improvement.
Muscle strength - com- SMD 0.58 higher 60 (2 RCTs) ⊕⊕⊝⊝ Overall, 11 RCTs reported muscle strength outcomes. 10/11 studies,
posite measure (0.06 higher to 1.1 Lowb mostly examining lower limb fitness, demonstrated that resistance
higher) training can improve muscle strength and some studies also indicat-
Analysis 3.2 ed that indices such as local muscular endurance and power output
can be improved.
Muscle strength - SMD 0.72 higher 93 (3 RCTs) ⊕⊕⊕⊝
paretic knee flexion (0.10 higher to 1.34 Moderatec Variation in the method for measuring strength restricts the pooling
higher) of data however three small groups of outcomes could be pooled.
Analysis 3.3 These show medium-sized effects (SMD > 0.5) only for one outcome,
a composite measure of strength.
Muscle strength - SMD 1.09 higher 93 (3 RCTs) ⊕⊕⊝⊝
paretic knee extension (0.23 lower to 2.41 Lowd
higher)
Mobility Preferred gait speed MD 2.15 m/min faster 203 ⊕⊕⊕⊝ There was no statistically significant effect of training on preferred
(m/min) (3.57 slower to 7.87 (5 RCTs) Moderatee walking speed or on other indices of gait such as maximal walking
faster) speed. Only 6-MWT data showed a benefit but this and all other gait
Analysis 3.6 measures showed no statistically significant effect after a follow-up
period. These training interventions were not based on a walking
Gait endurance (6- MD 24.98 m further 238 ⊕⊕⊝⊝ mode of exercise.
MWT metres) (11.98 further to (5 RCTs) Lowf
37.98 further)
Analysis 3.7
6
Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Physical fitness training for stroke patients (Review)
Physical Berg Balance Scale MD 3.27 higher 220 ⊕⊕⊝⊝ Both of these outcomes are indices of balance.
Function (2.15 higher to 4.38 (5 RCTs) Lowg
(0 to 56, best balance = higher) The training only showed a statistically significant improvement in
Library
Cochrane
56) balance measured with the Berg Balance Scale.
Analysis 3.8
Better health.
Informed decisions.
Trusted evidence.
Analysis 3.10
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and
its 95% CI).
6-MWT: 6-Minute Walk Test; CI: confidence interval; MD: mean difference; RCT: randomised controlled trial; SMD: standardised mean difference
aMost participants were high-functioning; risk of death was low among this group. There is serious risk of bias from imbalanced exposure in 12 of the 20 included studies.
bOne of the two included studies has major risk of bias issues and the composite measure of muscle strength is indirect in nature.
cOne of the three included studies has risk of bias issues. There is some heterogeneity (I2 = 47%).
dOne of the three included studies has risk of bias issues. There is high heterogeneity (I2 = 87%).
eHigh degree of heterogeneity (I2 = 76%).
fVery serious risk of bias including three out of five studies confounded for exposure time; key 'Risk of bias' items affecting highest weighted studies.
gVery serious risk of bias including three out of five studies confounded for exposure time.
hHigh degree of heterogeneity (I2 = 89%) and four out of five studies confounded for exposure time.
Mixed training compared to control for people with stroke: end of intervention
Library
Cochrane
Death Risk difference 0.00 1231 ⊕⊕⊝⊝ Although there were more deaths in the control group
(23 RCTs) Lowa there was no statistically significant difference between the
Analysis 5.1 (−0.02 to 0.01) groups.
Dead or dependent - 0 (0 RCTs) - No studies reported the composite outcome of death or de-
Better health.
Informed decisions.
Trusted evidence.
pendency.
Disability Pooled functional scales SMD 0.23 higher 604 ⊕⊕⊝⊝ A SMD of global scales of disability is difficult to interpret.
(0.03 higher to 0.42 higher) (9 RCTs) Lowb The magnitude of increase observed (0.2 to 0.5) can gen-
Analysis 5.5 erally be categorised as a 'small' effect. Any improvement
may be reflecting improved mobility since mobility items
are commonly included in these assessment tools. 7/9 stud-
ies were confounded for exposure time so any effects may
be exaggerated. Any improvement may be connected to im-
proved mobility since mobility items are a common feature
of these scales.
Physical fit- VO2 peak (mL/kg/min) MD 1.4 mL/kg/min higher 140 ⊕⊕⊝⊝ There were too few cardiorespiratory fitness data reported
ness (-0.19 lower to 2.99 higher) (2 RCTs) Lowc to establish any consensus effects for mixed training.
Analysis 5.8
Muscle strength - ankle SMD 0.8 stronger (-0.82 148 (2 RCTs) ⊕⊝⊝⊝ Overall 6 RCTs reported muscle strength outcomes.
dorsiflexion weaker to 2.41 stronger) Very lowd
Variation in the method for measuring strength restrict-
Analysis 5.10 ed the pooling of data; however, 3 groups of strength out-
comes could be pooled.
Muscle strength - knee SMD 0.33 stronger (0.05 202 (3 RCTs) ⊕⊕⊝⊝
extension stronger to 0.61 stronger) Only knee extensor strength showed a small (> 0.2) benefi-
Lowe
cial effect on knee extension strength.
Analysis 5.11
Analysis 5.12
Mobility Preferred gait speed (m/ MD 4.71 m/min faster 738 ⊕⊕⊕⊝ These increases in preferred walking speed and walking ca-
min) (1.32 faster to 8.1 faster) (10 RCTs) Moderateg pacity are relevant to community ambulation. The inter-
ventions are mostly those with a walking mode of exercise.
Analysis 5.14 These functional benefits in the 6-MWT were also main-
tained after the end of the training interventions.
8
Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Physical fitness training for stroke patients (Review)
Gait endurance (6-MWT MD 35 m further 720 ⊕⊕⊝⊝
metres) (15.91 further to 54.09 fur- (10 RCTs) Lowh
ther)
Library
Cochrane
Analysis 5.15
Physical Berg Balance Scale MD 2.12 higher 419 ⊕⊕⊝⊝ Both of these outcomes are indices of balance, only the
function (0.82 higher to 3.41 higher) (9 RCTs) Lowi Berg Balance Scale demonstrated a statistically significant
(0 to 56, best balance = improvement.
56)
Better health.
Informed decisions.
Trusted evidence.
Analysis 5.17
Analysis 5.20
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and
its 95% CI).
6-MWT: 6-Minute Walk Test; CI: confidence interval; MD: mean difference; OR: odds ratio; RCT: randomised controlled trial; RR: risk ratio; SMD: standardised mean differ-
ence
aMost participants were high-functioning; risk of death was low among this group. There is serious risk of bias from imbalanced exposure in 16 of the 23 included studies.
bThere is heterogeneity (I2 = 21%) in addition to very serious risk of bias from imbalanced exposure in seven of the nine included studies.
cThere is heterogeneity (I2 = 35%) in addition to very serious risk of bias from imbalanced exposure in the study weighted 79.6%.
to elderly people; two-thirds of strokes are in people aged under related (specific), and the fact that training effects are reversible if
70 years (Feigin 2017); however, the effects of increasing age will training is reduced or stopped.
have a part to play as will the presence of comorbid conditions.
• Direct neurological effects of stroke reduce the muscle mass Physical fitness training is, therefore, very much a complex
available for activation (e.g. hemiparesis). intervention with numerous component parts and this can give rise
to variation in plausible benefits.
• Post-stroke physical inactivity will cause a longitudinal loss
of fitness alongside the effects of comorbid diseases and How the intervention might work
increasing age. Limitation or loss of functional abilities after
stroke (e.g. walking, stair climbing, chair rising) are associated Regular physical activity is currently recommended where possible
with low cardiorespiratory fitness levels, muscle strength, and to people of all ages, including those with disabilities, in order
muscle power (Flansbjer 2006; Patterson 2007; Saunders 2008). to promote and maintain health (Haskell 2007; USDHHS 2018).
The dose-response relationship means additional benefits exist if
Therefore, when levels of physical fitness are low after stroke (for physical fitness training is employed, in particular with regard to
whatever reason) this may exacerbate or cause some common physical function. Physical fitness training interventions improve
post-stroke physical limitations (Saunders 2013a). Restoration of physical function in healthy elderly people (Bangsbo 2019;
motor function in order to improve functional ability is a key Chodzko-Zajko 2009).
focus within stroke rehabilitation and a number of interventions
have been investigated that involve physical activities and physical Post-stroke physical activity and fitness levels are low, and these
fitness training (Langhorne 2009). low levels are associated with common post-stroke functional
limitations. Increased fitness and physical function could benefit
Description of the intervention a range of other common post-stroke problems, for example by
reducing fatigue, reducing the incidence of falls and fractures,
The basic structure and content of all physical fitness training
compensating for the increased energetic cost of a hemiparetic gait,
interventions are guided by a common set of well-established
reducing disability and improving independence, and improving
principles (ACSM 2011). The design of physical fitness training
quality of life and mood.
interventions varies across healthy people, older people, and
different patient groups. Physical therapies are known to promote structural brain
remodelling (Gauthier 2008), and this can influence post-stroke
Type of training
motor deficits. There is systematic review evidence that repetitive
Most physical fitness training programmes are classified as either: practice of some common day-to-day activities produces some
modest improvements in mobility and ADL in people with stroke
• cardiorespiratory training (to improve cardiorespiratory fitness); (French 2016). Fitness training is repetitive in nature and is
• resistance training (to improve muscular strength and muscle commonly task-related in nature, therefore participation in it may
power); or lead to functional benefits even when fitness is not improved.
• mixed training, which combines cardiorespiratory and
Engagement with group training activities may have some
resistance training.
psychosocial benefits in people with stroke (Carin-Levy 2009; Mead
With regard to other aspects of fitness, all types of training 2005; Patterson 2009). Fitness training is commonly delivered in a
programme have the potential to influence body composition group setting; therefore, in these instances simply participating in
(increase lean mass and reduce adiposity) and some may also physical fitness training may be beneficial, particularly when group
incorporate elements that improve flexibility (stretching exercises) activities are delivered in a non-medical environment (Young 2019).
and balance.
Cognitive function impairments are common after stroke and are
Mode of training predicted by low indices of physical fitness (Lee 2014). In older
adults (aged over 65 years) with cognitive impairment, exercise
The type of fitness training influences the mode(s) of exercise. For interventions have been shown to improve cognitive function
example, cardiorespiratory training commonly employs walking (Heyn 2004). Further, in people with stroke and traumatic brain
and cycling, whilst resistance training employs activities involving injury, systematic review evidence suggests that exercise exerts a
muscle contractions resisted by weights, body mass, or elastic positive effect on global cognitive function, though further studies
devices. are required (Vanderbeken 2017). Therefore, there is some rationale
that fitness training interventions could benefit cognition in people
Dose of training
with stroke.
The dose of training is controlled by influencing, firstly, the amount
of training (e.g. programme length (weeks, months), frequency Physical fitness training is known to be beneficial for people
(days/week), and duration (minutes) of sessions), and secondly, the with a number of conditions that are comorbid conditions or
intensity of training (rate of work or effort made). risk factors for stroke. Systematic review evidence shows that
exercise interventions can reduce blood pressure (Cornelissen
It is the manipulation of type, mode, and dose that defines an 2013; Smart 2019); improve vascular risk factors in obesity (Shaw
exercise prescription; however, the effectiveness is also influenced 2006), and type II diabetes (Thomas 2006); improve cardiovascular
by some other critically important principles of training (ACSM mortality (Anderson 2016); and improve depressive symptoms
2011), including progression of training, whether training is task- regardless of health status (Gordon 2018). Therefore, post-stroke
cardiorespiratory and resistance training could reduce morbidity
and mortality through secondary prevention of stroke and • cardiorespiratory training versus control: 1) at the end of
comorbid disease intervention, 2) at the end of follow-up;
• resistance training versus control: 3) at the end of intervention,
In summary, physical fitness training does not simply offer a 4) at the end of follow-up;
mechanism to increase fitness, it has multiple mechanisms of
action and has a spectrum of plausible benefits that are relevant • mixed training (cardiorespiratory plus resistance training)
versus control: 5) at the end of intervention, 6) at the end of
to many people with stroke. However, as well as benefits there
follow-up.
may also be risks associated with fitness training such as training-
induced soft tissue injuries, altered muscle tone, falls, and vascular In this review 'end of intervention' refers to the time point when
events. a training programme finishes; 'end of follow-up' refers to any
time point occurring after the end of the intervention. Measures
Why it is important to do this review
at the end of follow-up allow us to examine whether training
Physical fitness training for stroke survivors remains under- effects (if any) are retained after training is completed. For studies
investigated in three key areas. with multiple follow-up phases we analysed data from the longest
follow-up period.
• The range of possible benefits is not fully explored. The top
10 most important research priorities for 'life after stroke' have We included studies in which controls were exposed to either
been defined by a partnership of patients, carers, and clinicians physical activity occurring during usual care or no training after
(Pollock 2012). These include, in order of priority, the need usual care. By 'no training' we meant either no intervention or a
to identify interventions for 1) cognition, 2) coming to terms non-exercise intervention (e.g. cognitive tasks or sham training).
with long-term consequences, 3) aphasia, 4) arm function, 5) Therefore, we deemed the following comparisons suitable for
vision, 6) fatigue, 7) balance, gait and mobility, 8) speech, 9) inclusion where 'usual care' refers to inpatient hospital care or
confidence, and 10) exercise interventions for function, quality other standard rehabilitation given to all stroke patients delivered
of life, and secondary prevention. Exercise interventions may as a normal part of stroke care in the region in which the studies
have a beneficial role in at least four of these domains (1, 4, 7 and were performed:
10; Saunders 2014a).
• training plus usual care versus usual care (during usual care);
• Enough evidence is available to implement fitness training for
stroke, the optimal exercise prescription has yet to be defined • training versus no training (after usual care).
(Mead 2011).
We included full-text reports of published and unpublished studies.
• Fitness training has a plausible benefit for secondary stroke Studies communicated via conference proceedings alone or by
prevention but there still remains a lack of direct evidence about abstract alone provide only limited data and do not allow full
secondary stroke and cardiovascular risk. assessment of study quality. Therefore, we did not exclude any
studies that were potentially relevant but we retained them
There has been sustained interest in physical fitness interventions
as 'awaiting classification' pending further information or full
for stroke evidenced by the studies included in previous updates
publication. We did not exclude studies on the basis of their sample
of this review: Saunders 2004a (12 studies), Saunders 2009
size. We included studies published in languages other than English
(24 studies), Brazzelli 2011b (32 studies), Saunders 2013b (45
only when a translation could be arranged. Where investigators
studies), and Saunders 2016 (58 studies). Considering the degree of
published several reports based on data from a single study
incomplete knowledge, the high level of interest, and the clinical
population, we selected the most recent or most complete report
relevance of this review for improving patient care, we believe it is
for data extraction and we listed the other reports as additional
essential to continue updating the earlier version of this review.
publications.
OBJECTIVES
Types of participants
The primary objectives of this updated review were to determine Adult stroke survivors who were considered suitable for fitness
whether fitness training after stroke reduces death, death or training by the studies' authors; we used the study authors'
dependence, and disability. definition of stroke. Participants were considered eligible
irrespective of the time since stroke onset.
The secondary objectives were to determine the effects of training
on adverse events, risk factors, physical fitness, mobility, physical Types of interventions
function, health status and quality of life, mood, and cognitive
function. We included the following interventions.
• Cochrane Central Register of Controlled Trials (CENTRAL; 2018, • British Library EThOS (e-theses online service; www.bl.uk/
Issue 1; Appendix 1) in the Cochrane Library; ethos-and-theses);
• MEDLINE Ovid (from 1946 to July 2018; Appendix 2); • DART-Europe E-theses PortAL (www.dart-europe.eu/basic-
• Embase Ovid (from 1974 to July 2018; Appendix 3); search.php).
• CINAHL EBSCO (Cumulative Index to Nursing and Allied Health We searched grey literature using:
Literature; from 1937 to July 2018; Appendix 4);
• SPORTDiscus EBSCO (from 1949 to July 2018; Appendix 5); • Google Scholar
• PsycINFO Ovid (from 1806 to July 2018; Appendix 6);
We checked the bibliographies of included studies and performed
• Conference Proceedings Citation Index- Science (Web of
forward citation tracking of all included studies (and other relevant
Science; from 1990 to July 2018; Appendix 7);
studies) using Google Scholar (scholar.google.co.uk/) for further
• PEDro (Physiotherapy Evidence database references to relevant studies.
(www.pedro.fhs.usyd.edu.au/index.html) July 2018; Appendix
8). We contacted researchers in the field to obtain additional
information on relevant studies and contacted original authors for
The search strategy includes Cochrane Highly Sensitive Search clarification and further data if study reports were unclear.
Strategies for identification of RCTs, as described in the Cochrane
Handbook for Systematic Reviews of Interventions (Lefebvre 2011), Data collection and analysis
and Cochrane Stroke's search strategies for the identification of
'stroke' studies in respective databases and other resources. These Selection of studies
are supplemented with strategies to identify exercise interventions. Two review authors (DS or MS or SH or DC or SK or LJ or
We have added PsycINFO to the search resources in this update in HJ) independently screened titles and abstracts of the unique
recognition of the increasing interest in cognition outcomes. references obtained as a result of our searching activities. We
excluded studies that two review authors classified as 'exclude'; we
In order to identify other published, unpublished, and ongoing retained all other studies for full-text screening.
studies we searched for ongoing studies using the following
registries. We retrieved the full-text articles for the remaining references and
two review authors (DS or MS or SH or DC or SK or LJ or HJ)
• US National Institutes of Health Ongoing Trials Register independently screened the full-text articles to identify studies
ClinicalTrials.gov (clinicaltrials.gov/) for inclusion, and identify and record reasons for exclusion of
• World Health Organization International Clinical Trials Registry the ineligible studies. We resolved any disagreements through
Platform (ICTRP; apps.who.int/trialsearch) discussion or, if required, we consulted a third review author (GM
or MB). We collated multiple reports of the same study so that each
Searching other resources
study, not each reference, was the unit of interest in this review.
We searched for theses in the following (using the search terms in
Appendix 9): We used the Covidence tool to carry out the selection process and
to record this in sufficient detail to complete a PRISMA flow chart
• ProQuest Dissertations and Theses Global (www.proquest.com/ (Moher 2009; Figure 1), and the 'Characteristics of excluded studies'
products-services/pqdtglobal.html); table.
Figure 1. Study flow diagram for the current update of this review
Figure 1. (Continued)
We included studies irrespective of publication status providing quality of life, mood, adverse events, risk factors), outcome data,
available reports had sufficient detail to apply eligibility criteria and reported outcomes, missing outcomes.
perform quality assessment.
We classified all outcome data as being from time points at either
We retained potentially relevant studies with insufficient the end of intervention or the end of follow-up, which we defined
information to either include or exclude in the 'Characteristics of as any period of time after the training intervention was completed.
studies awaiting classification' table. We resolved any disagreement by consensus or arbitration.
• publication details: authors, year of publication, publication Participant blinding is often impossible to achieve in behavioural
status (published, unpublished, or ongoing), citation of other interventions. However, we considered studies to be at low risk
relevant studies; of bias if the study authors described some attempt to disguise
the true purpose of the comparisons being made (e.g. describing a
• details of study conduct: study design, method of recruitment,
study as a comparison of two different interventions or some kind
inclusion and exclusion criteria, number of participants
of 'sham' intervention). We considered studies to be at high risk of
enrolled, number of participants excluded, number of
bias if there was an imbalanced exposure such as would occur with
participants assessed, losses to follow-up, geographical location
no control intervention or a waiting-list control.
of the study, setting in which the study was conducted (e.g.
hospital, community); Incomplete outcome data (attrition bias)
• characteristics of participants: total number, age, gender, stage
of care, severity of stroke, time since stroke onset, co-morbidity, We assessed this domain twice, once at the end of intervention and
walking ability; once at the end of follow-up. We considered studies to be at high
risk of bias where we judged imbalanced losses to have occurred
• details of intervention: total number of intervention groups,
coupled with a per-protocol analysis. If overall participant attrition
type of training (i.e. cardiorespiratory, resistance, or mixed),
was 20% or greater of those randomised, we considered a study at
training mode (e.g. treadmill walking, weight training), dose (i.e.
high risk of bias (Schulz 2002), irrespective of distribution of losses,
intensity, frequency of delivery), timing (i.e. during or after usual
reasons given or analytical approach (e.g. imputations, intention-
care), length of training (i.e. duration and programme length),
to-treat).
adherence to intervention (i.e. attendance, compliance);
• details of outcome measures: choice of outcomes (i.e. Other bias
death, dependence, disability, physical fitness measures, gait
assessment, physical function measures, health status and We considered 'Risk of bias' items relevant to cluster-RCTs in this
domain.
Lag-control or waiting-list studies: we dealt with these in the same Summary of findings and assessment of the certainty of the
way as cross-over studies. We ignored the delayed or waiting-list evidence
iteration of the study because of the risk of carry-over effects.
We used GRADE to assess the evidence for the primary
In studies with more than one relevant control group, we used only outcomes death, death or dependence, and disability, plus the
one control group within a meta-analysis. We performed sensitivity secondary outcomes relating to physical fitness (cardiorespiratory
analysis to examine the relative influence of selecting each group fitness, muscle strength), mobility (preferred walking speed, gait
on meta-analysis results. Where data from multiple control groups endurance), and physical function (Berg balance scores, three-
were similar we considered combining the control group data using metre Timed Up and Go). We performed these analyses and
the methods described in section 16.5.4 of the Cochrane Handbook presented the results in a 'Summary of findings' table generated
for Systematic Reviews of Interventions (Higgins 2011). using GRADEpro GDT software.
In studies with more than one relevant intervention group, we Subgroup analysis and investigation of heterogeneity
included all intervention groups as separate comparisons within When sufficient data were available, we planned to investigate
a meta-analysis, with the control group data replicated across all heterogeneity between included studies (both clinical and
comparisons, but with the control group sample size divided evenly statistical) by means of subgroup analyses. We attempted to
compare effect estimates for all outcomes in the following main studies (Dean 2018; Ivey 2017; Sandberg 2016; Vanroy 2017). The
subgroups: remainder either completed but we excluded them as irrelevant,
were terminated, or the data were never published or made
• type of training (cardiorespiratory versus resistance training available;
versus mixed training); • of the nine abstract-only studies awaiting classification, one
• time of training (during usual care versus after usual care). is now included (Buyukvural 2015). The remainder have been
excluded or have no full-text paper published or made available;
The complexity of exercise interventions and low numbers of
studies in the meta-analyses meant that subgroup analyses were • of the three full publication studies awaiting classification that
difficult to perform and difficult to interpret. need further information to include or exclude, only one author
team responded and we were able to exclude the data.
Sensitivity analysis
Included studies
We planned to explore for all outcomes the influence of studies that
were confounded by increased training time. We included 17 new studies in this update (Arabzadeh 2018;
Buyukvural 2015; Coroian 2018; Dean 2018; Fernandez-Gonzalo
RESULTS 2016; Furnari 2014; Ivey 2017; Kim 2016a; Kim 2017a; Knox
2018; Mao 2015; Moore 2015; Sandberg 2016; Taylor-Pilliae 2014;
Description of studies Topcuoglu 2015; Vanroy 2017; Zou 2015).
Results of the search Two separate studies in the previous update (Saunders 2016), have
emerged as being the same study. These have now been conflated
The previous version of this review included 58 studies, involving
with a further recent publication and together these now form Aidar
2797 participants (Saunders 2016). In this updated version we used
2016.
the updated electronic searches and other relevant searches in
July 2018. We screened a total of 16,704 citations; this includes One of the 17 included studies (Knox 2018), includes a strength
duplicates. training intervention group and a mixed training intervention
group, both of which we included and analysed as two separate
We identified 29 new systematic reviews of exercise interventions
studies each sharing the same control group (effectively giving 18
and screened these for relevant studies (Abbasian 2018; Ammann
new studies). For clarity, we counted the control group (n = 48) once
2014; Austin 2014; Baldwin 2016; Bonini-Rocha 2018; Boyne 2017;
to calculate the total number of unique participants in the review
Chen 2016; Crozier 2018; D'Isabella 2017; Dorsch 2018; English
(n = 3617). We split the control participants across the resistance
2017; Hasan 2016; Iatridou 2018; Ilunga Tshiswaka 2018; Jeon
training (n = 24) and mixed training (n = 24) groups where we
2015; Kendall 2016; Mehrholz 2017; Oberlin 2017; Plummer 2018;
were comparing them in a meta-analysis. In other meta-analyses,
Salter 2016; Saltychev 2016; Tally 2017; Van Criekinge 2019; Van
we used all 48 control participants; we ensured that there was no
Duijnhoven 2016; Vanderbeken 2017; Vloothuis 2016; Wang 2018;
double counting at any point.
Wist 2016; Zheng 2016).
In summary, when these adjustments are reconciled, this update
The results of our searching activities are summarised in Figure 1.
includes a total of 75 studies comprising 3617 participants (see
We applied the eligibility criteria, with the following results.
Characteristics of included studies table).
• We excluded 86 studies that did not meet the eligibility criteria
Participants
(see Characteristics of excluded studies table).
• We identified 56 new ongoing studies (see Characteristics of Characteristics
ongoing studies table). A total of 3617 stroke survivors (sample range 13 to 250
• We identified 35 studies for which we require more information individuals) were randomised to physical fitness training or control
to establish eligibility, including those for which only the interventions in the 75 included clinical studies. The mean age
abstract is currently available (see Characteristics of studies of the participants was approximately 62 years. The mean time
awaiting classification table). since onset of symptoms ranged from 8.8 days in studies assessing
• We identified one study that was a secondary analysis of two participants before discharge from hospital (Richards 1993), to
studies already included in the previous update. These two 7.7 years in studies assessing participants after hospital discharge
previously included studies, authored by Aidar in 2012 and in (Teixeira 1999).
2014, have since been recognised as the being same trial and
are now conflated along with their more recent publication to be Two studies recruited non-ambulatory stroke survivors (Richards
collectively referred to as Aidar 2016. 1993; Wang 2014), three studies recruited both ambulatory and
non-ambulatory participants (Bateman 2001; Cooke 2010; Lennon
• We identified one study that was a secondary analysis of a study
2008), six studies did not report this information (Donaldson 2009;
included in the previous update (Aidar 2018).
Lee 2013a; Verheyden 2009; Winstein 2004; Topcuoglu 2015; Zou
• We identified 17 new studies that met the eligibility criteria. 2015), and all the remaining studies recruited ambulatory stroke
survivors.
With regard to ongoing studies and those awaiting classification in
the previous version of this review: Sample size
• of the 13 ongoing studies, four have been completed and met Of the 75 included studies:
the eligibility criteria and we have added them to the included
• 16 studies had 20 participants or fewer (Arabzadeh 2018; Bale • Ada 2013: Group 1 - duration four months' training; Group 2 -
2008; Coroian 2018; Cuviello-Palmer 1988; da Cunha 2002; duration two months' training
Donaldson 2009; Duncan 1998; Glasser 1986; James 2002; Kim • Pohl 2002: Group 1 - intensity high due to rapid progression;
2001; Kim 2016a; Letombe 2010; Moore 2010; Richards 1993; Group 2 - intensity lower due to limited progression
Smith 2008; Teixeira 1999); • Takami 2010: Group 1 - mode: backward walking on treadmill;
• four studies had over 100 participants (Ada 2013 102 Group 2 - mode: forward walking on treadmill
participants; Gordon 2013 128 participants; Jin 2013 128
participants; Van de Port 2012 250 participants); Resistance training
• one publication had over 100 participants (Knox 2018 144 Twenty studies with a total of 779 randomised participants (range
participants) but is counted as two studies in this review; 18 to 93 individuals) assessed the effects of resistance training
• 54 remaining studies recruited between 21 and 100 participants. (Aidar 2016; Arabzadeh 2018; Bale 2008; Buyukvural 2015; Coroian
2018; Fernandez-Gonzalo 2016; Flansbjer 2008; Inaba 1973; Ivey
Interventions 2017; Kim 2001; Knox 2018; Lee 2013a; Lee 2013b; Ouellette 2004;
Cardiorespiratory training Sims 2009; Son 2014; Taylor-Pilliae 2014; Verheyden 2009; Winstein
2004; Zou 2015). Details of the nature and dose of the resistance
Thirty-two studies with a total of 1631 randomised participants training intervention studies are summarised in Table 2.
(range 15 to 128 individuals) examined cardiorespiratory training
(Ada 2013; Aidar 2018; Bateman 2001; Cuviello-Palmer 1988; da All employed muscle contractions resisted by weights, exercise
Cunha 2002; Eich 2004; Glasser 1986; Globas 2012; Gordon 2013; machines, or elastic devices. One study trained the upper limbs
Ivey 2010; Ivey 2011; Jin 2013; Kang 2012; Katz-Leurer 2003; Kim (Winstein 2004), one trained the trunk (Verheyden 2009), two
2014; Kuys 2011; Lennon 2008; MacKay-Lyons 2013; Mao 2015; studies trained both the upper and lower limbs (Aidar 2016; Sims
Moore 2010; Mudge 2009; Park 2011; Pohl 2002; Potempa 1995; 2009), one was unclear (Taylor-Pilliae 2014), and the remaining
Salbach 2004; Sandberg 2016; Smith 2008; Takami 2010; Topcuoglu studies involved the lower limbs only. Most programmes were short
2015; Vanroy 2017; Wang 2014; Yang 2014). Details of the nature (less than 12 weeks) apart from Aidar 2016, Fernandez-Gonzalo
and dose of the cardiorespiratory interventions are summarised in 2016, Ivey 2017, Knox 2018, Ouellette 2004, and Taylor-Pilliae
Table 1. 2014 (12 weeks). Twelve studies started resistance training after
usual care (Aidar 2016; Fernandez-Gonzalo 2016; Flansbjer 2008;
Two of these studies assessed circuit training (Mudge 2009; Salbach Ivey 2017; Kim 2001; Knox 2018; Lee 2013a; Lee 2013b; Ouellette
2004). 2004; Sims 2009; Son 2014; Taylor-Pilliae 2014; Zou 2015), whilst
eight studies started it during usual care (Arabzadeh 2018; Bale
One study assessed aquatic training (Aidar 2018).
2008; Buyukvural 2015; Coroian 2018; Inaba 1973; Verheyden 2009;
Twelve studies used some form of ergometry: seven assessed cycle Winstein 2004). Only Winstein 2004 recruited participants during
ergometry (Bateman 2001; Jin 2013; Katz-Leurer 2003; Lennon the acute phase of stroke (less than one month post-onset).
2008; Potempa 1995; Sandberg 2016; Yang 2014), two assessed
Three of the studies appear similar in terms of participants and
seated/recumbent cycle ergometry (Vanroy 2017; Wang 2014), two
interventions and have a shared authorship (Lee 2013a; Lee 2013b;
assessed a 'Kinetron' ergometer (Cuviello-Palmer 1988; Glasser
Son 2014). Although the sample sizes are different there is a
1986), and one assessed arm cranking ergometer (Topcuoglu 2015).
possibility that these three publications share some of the same
Seventeen studies focused on walking using treadmills (da Cunha participants. We have not had a response to queries to establish
2002; Eich 2004; Globas 2012; Ivey 2010; Ivey 2011; Kang 2012; Kuys this.
2011; MacKay-Lyons 2013; Mao 2015; Moore 2010; Pohl 2002; Smith
Mixed training
2008; Takami 2010), overground walking (Gordon 2013; Kim 2014;
Park 2011), or a combination of treadmill and overground walking Twenty-three studies with a total of 1207 randomised participants
(Ada 2013). (range 13 to 250 individuals) assessed the effects of mixed training
(Cooke 2010; Dean 2018; Donaldson 2009; Duncan 1998; Duncan
The training programmes comprised regular weekly sessions of 2003; Furnari 2014; Galvin 2011; James 2002; Kim 2016a; Kim
sufficient duration (usually longer than 20 minutes), the exercise 2017a; Knox 2018; Langhammer 2007; Letombe 2010; Mead 2007;
intensity was clearly described in 20 of the 32 included studies. In Moore 2015; Richards 1993; Richards 2004; Shin 2011; Teixeira 1999;
16 studies the cardiorespiratory training started after usual care, Toledano-Zarhi 2011; Van de Port 2012; Yang 2006; Zedlitz 2012).
while in 16 studies it started during usual care. In five of these Details of the nature and dose of the mixed training interventions
studies participants were recruited in the acute phase of stroke, less are summarised in Table 3.
than one month post-stroke (Cuviello-Palmer 1988; da Cunha 2002;
MacKay-Lyons 2013; Sandberg 2016; Takami 2010). The modes of exercise are quite diverse since these comprise circuit
training or various combinations of walking, treadmill training,
Three of the included cardiorespiratory training studies had more and resistance training. All interventions contained one or more
than one intervention group that met the eligibility criteria; these functionally relevant activity (such as walking). Most programmes
compare two different durations, intensities, and modes of training. were short, with six studies meeting or exceeding 12 weeks (Duncan
Each of these studies therefore has two entries when included in 1998; Knox 2018; Mead 2007; Moore 2015; Van de Port 2012;
any meta-analyses, each sharing 50% of the number of participants Zedlitz 2012). Nine studies occurred during usual care; five of these
in the single control group from each study. recruited participants in the acute phase of stroke, less than one
month post-onset (Galvin 2011; Kim 2016a; Letombe 2010; Richards
1993; Toledano-Zarhi 2011), and four at a later stage of care (Furnari Balanced comparisons
2014; Kim 2017a; Richards 2004; Shin 2011). The nature of some of these comparisons allows intervention
Adherence to the intervention and control groups to be comparable in terms of exposure time
(both groups are exposed to an intervention, the frequency and
We defined adherence to the interventions in terms of: 1) duration of which is similar between groups) and the 'attention'
attendance at the planned training sessions, and 2) compliance received by the therapists. Therefore, these comparisons allow one
with the planned content of the training sessions. to separate the specific effects of fitness training from those of usual
rehabilitation interventions.
Attendance
Rate of attendance (%) could be clearly determined in 33 of the • Training plus a proportion of usual care versus usual care
75 included studies (Ada 2013; Aidar 2016; Bateman 2001; Duncan • Training plus usual care versus non-exercise intervention plus
1998; Duncan 2003; Eich 2004; Fernandez-Gonzalo 2016; Flansbjer usual care
2008; Globas 2012; Ivey 2017; Kim 2016a; Kuys 2011; Langhammer • Training versus non-exercise intervention - after usual care
2007; MacKay-Lyons 2013; Mead 2007; Moore 2015; Mudge 2009; • Training versus usual outpatient care
Park 2011; Ouellette 2004; Pohl 2002; Richards 1993; Richards
2004; Salbach 2004; Sandberg 2016; Sims 2009; Taylor-Pilliae 2014; Confounded comparisons
Toledano-Zarhi 2011; Van de Port 2012; Wang 2014; Winstein 2004;
Other comparisons make it impossible to have a comparable
Yang 2006; Zedlitz 2012; Zou 2015). The proportion of attended
intervention and control group exposure time (e.g. the 'training
training sessions ranged from 65% up to 100%. Seven studies
versus no intervention' comparison). We described these
measured attendance for the training and the control groups
comparisons in the review as 'confounded by additional training
separately and showed similar rates between groups (Bateman
time'. With regard to interventions involving physical exercise,
2001; Langhammer 2007; MacKay-Lyons 2013; Mead 2007; Ouellette
a greater exposure to the intervention has a known effect
2004; Salbach 2004; Taylor-Pilliae 2014). A few other studies
on rehabilitation outcomes ('augmented therapy time'; Kwakkel
described attempts to facilitate attendance and make up missed
2004). Therefore, although these comparisons allow comment on
sessions, or reported that "attendance did not differ between
the overall effect of training programmes, they make it difficult to
intervention groups" but did not provide attendance rates (Bale
attribute any benefits to the content of the exercise prescription
2008; Cooke 2010; Teixeira 1999). One study specifically excluded
itself.
those participants who attended fewer than nine training sessions
from the statistical analyses (da Cunha 2002); this prevents an • Training plus usual care versus usual care
intention-to-treat assessment of results.
• Training plus non-exercise intervention versus non-exercise
Compliance intervention - after usual care
• Training versus no intervention - after usual care
Compliance with the scheduled exercise programme during
training sessions was described in only a few studies. Outcome measures
For cardiorespiratory training interventions, Langhammer 2007 The included studies recorded outcome measures at the end of the
stated that the compliance with the individualised training levels training period (end of intervention), or at any other defined point
was 'high'; other studies reported that participants 'tolerated' either within the study duration or after completion of the training
training (Globas 2012; MacKay-Lyons 2013; Pohl 2002; Kim 2016a), programme, or both (scheduled end of follow-up).
or showed no discomfort (Jin 2013). Salbach 2004 maintained that
most of the participants completed nine out of 10 circuit training Some outcome measures involved continuous data (e.g.
exercises. Mao 2015 recorded compliance data but this was not assessment scales) with skewed distributions. Due to time and
reported. resource constraints we did not attempt to transform these data.
We therefore combined continuous skewed data and continuous
For mixed training, Duncan 1998 reported 'good compliance' normal-distributed data.
with home-based training, and Yang 2006 stated that mixed
circuit training was "performed as planned". Mead 2007 reported Excluded studies
94% to 99% compliance with circuit training exercises 'tailored' The most common reasons for exclusion were interventions
to individual requirements. Dean 2018 reported that 70% of that either did not meet the criteria for fitness training
the participants received an "appropriate dose" of training. ('wrong intervention') or were confounded by other intervention
Information on compliance was not available for the remaining components ('co-intervention') along with inappropriate control
studies. Zedlitz 2012 described the compliance of participants groups, such as those with an active physical intervention ('wrong
with training as 'good'. Two studies reported good compliance control'). These are documented in the Characteristics of excluded
of therapists in delivery of the content of the planned protocol studies table.
(MacKay-Lyons 2013; Zedlitz 2012).
Risk of bias in included studies
Comparisons
Details and justifications for 'Risk of bias' assessments in individual
The included studies compared training interventions with control studies are shown in the Characteristics of included studies table.
interventions in different ways. We identified seven different types For Knox 2018, the risk of bias scores are included twice as there are
of comparison, which has implications for establishing the effects two entirely separate classes of intervention in this study giving a
of fitness training. total of 75 studies. As this is a complex review we decided to apply
Physical fitness training for stroke patients (Review) 20
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the 'Risk of bias' assessments to 'all outcomes' for simplicity apart the end of the intervention and the end of follow-up. We present
from incomplete outcome data, for which we assessed bias at both the summary results in Figure 2 and Figure 3.
Figure 2. 'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included
study. In studies with no follow-up measurement we did not assess risk of bias for the item labelled 'Incomplete
outcome data (attrition bias): end of follow-up'; this results in some blank spaces
Figure 2. (Continued)
Figure 2. (Continued)
Figure 3. 'Risk of bias' graph: review authors' judgements about each 'Risk of bias' item presented as percentages
across all included studies. In studies with no follow-up measurement, we did not assess risk of bias for the item
labelled 'Incomplete outcome data (attrition bias): end of follow-up'; this results in some blank spaces
bias. However, some studies utilised an attention control or other 2012) and the remaining four out of 33 studies (12%) of studies
means to disguise the 'true nature' of the comparison. were assessed as unclear risk of bias because there was not enough
information to make a judgement based on the nature and extent
Investigator blinding of dropouts or on whether an intention-to-treat.
We assessed the outcome assessment to be at low risk of detection
One of the included studies did not analyse data for the participants
bias in 38 out of 75 (50%) of the included studies (Ada 2013; Aidar
who dropped out but we were able to impute sometimes large
2016; Bale 2008; Bateman 2001; Cooke 2010; Coroian 2018; Dean
numbers of missing values in individual participant data obtained
2018; Donaldson 2009; Duncan 2003; Furnari 2014; Gordon 2013;
from Bateman 2001. This did not influence any of the findings;
Kang 2012; Katz-Leurer 2003; Kim 2001; Kim 2014; Kim 2016a; Knox
therefore, we included only the imputed data in this review for
2018 (both comparisons); Kuys 2011; Langhammer 2007; MacKay-
simplicity.
Lyons 2013; Mao 2015; Mead 2007; Moore 2015; Ouellette 2004; Park
2011; Richards 1993; Richards 2004; Taylor-Pilliae 2014; Topcuoglu The bias assessment could not be applied to the 42 out of 75 (56%)
2015; Van de Port 2012; Vanroy 2017; Verheyden 2009; Wang 2014; studies with no end of follow-up measurement. Therefore, there are
Yang 2006; Yang 2014; Zedlitz 2012; Zou 2015). We assessed 11 out 42 blank spaces in Figure 2 since a 'Risk of bias' judgement was not
of 75 (15%) as being at high risk of detection bias because outcome possible.
assessment was not blinded (Arabzadeh 2018; Eich 2004; Flansbjer
2008; Galvin 2011; Globas 2012; Ivey 2010; Ivey 2017; Moore 2010; Selective reporting
Salbach 2004; Smith 2008; Winstein 2004) and the remaining 26 out
We assessed nine out of 75 (12%) studies as being at low risk of
of 75 (35%) were assessed as unclear risk of bias because there was
reporting bias (Ada 2013; Arabzadeh 2018; Cooke 2010; Fernandez-
not enough information to make a judgement. Among studies that
Gonzalo 2016; Galvin 2011; Kuys 2011; Mead 2007; Sandberg 2016;
used blinded outcome assessment some instructed participants
Zedlitz 2012). We assessed three out of 75 (4%) of studies as
not to reveal group assignments (Bateman 2001; Duncan 2003;
being at high risk of reporting bias (Coroian 2018; Knox 2018 both
Flansbjer 2008; Mead 2007). However, some degree of unmasking
comparisons). The remaining 63 out of 75 studies (84%) of studies
can easily occur and was documented in some studies (e.g. Eich
were assessed as unclear risk of bias because there was not enough
2004; Mudge 2009; Salbach 2004).
information to make a judgement. This is because the majority
Incomplete outcome data of studies did not have readily available protocols. In most cases,
where these were available, there was no evidence of selective
We assessed risk of attrition bias at the end of intervention (75 reporting of outcomes relevant to this review.
studies) and at the end of follow-up where data existed (33 studies
only). Other potential sources of bias
We assessed 55 out of 75 (73%) included studies as being at low We assessed 63 out of 75 (84%) studies as being at low risk of
risk of attrition bias at the end of intervention (Ada 2013; Bale 2008; other biases (Ada 2013; Aidar 2018; Arabzadeh 2018; Bale 2008;
Coroian 2018; Cuviello-Palmer 1988; da Cunha 2002; Dean 2018; Bateman 2001; Cooke 2010; Cuviello-Palmer 1988; da Cunha 2002;
Donaldson 2009; Duncan 1998; Eich 2004; Fernandez-Gonzalo 2016; Donaldson 2009; Duncan 1998; Duncan 2003; Eich 2004; Fernandez-
Flansbjer 2008; Galvin 2011; Glasser 1986; Globas 2012; Gordon Gonzalo 2016; Flansbjer 2008; Furnari 2014; Galvin 2011; Glasser
2013; James 2002; Kang 2012; Katz-Leurer 2003; Kim 2001; Kim 1986; Gordon 2013; Inaba 1973; Ivey 2010; Ivey 2011; Ivey 2017;
2016a; Kim 2017a; Knox 2018 (both comparisons); Kuys 2011; James 2002; Jin 2013; Kang 2012; Katz-Leurer 2003; Kim 2001;
Langhammer 2007; Lee 2013a; Lee 2013b; Lennon 2008; Letombe Kim 2014; Kim 2016a; Kim 2017a; Knox 2018 (both comparisons);
2010; MacKay-Lyons 2013; Mead 2007; Moore 2010; Moore 2015; Kuys 2011; Langhammer 2007; Lee 2013a; Lee 2013b; Lennon
Mudge 2009; Ouellette 2004; Park 2011; Pohl 2002; Potempa 1995; 2008; Letombe 2010; MacKay-Lyons 2013; Mao 2015; Mead 2007;
Richards 2004; Salbach 2004; Shin 2011; Sims 2009; Smith 2008; Moore 2010; Mudge 2009; Park 2011; Pohl 2002; Potempa 1995;
Son 2014; Taylor-Pilliae 2014; Teixeira 1999; Toledano-Zarhi 2011; Richards 1993; Richards 2004; Salbach 2004; Sandberg 2016; Shin
Topcuoglu 2015; Van de Port 2012; Vanroy 2017; Verheyden 2009; 2011; Smith 2008; Son 2014; Takami 2010; Toledano-Zarhi 2011;
Winstein 2004; Yang 2006; Yang 2014; Zou 2015). We assessed 11 out Topcuoglu 2015; Van de Port 2012; Vanroy 2017; Verheyden 2009;
of 75 (15%) studies as being at high risk of attrition bias at the end Wang 2014; Winstein 2004; Yang 2006; Yang 2014). We assessed 7
of intervention (Aidar 2016; Bateman 2001; Cooke 2010; Inaba 1973; out of 75 (9%) of studies as being at high risk of other biases. These
Ivey 2010; Ivey 2011; Ivey 2017; Kim 2014; Mao 2015; Richards 1993; included those that recruited via media advertisements (Globas
Wang 2014). The remaining 9 out of 75 studies (12%) were assessed 2012; Ouellette 2004; Teixeira 1999; Zedlitz 2012), involved different
as unclear risk of bias because there was not enough information travel demands between intervention and control exposures
to make a judgement based on the nature and extent of dropouts (Moore 2015), had baseline differences in outcomes of interest
or on whether an intention-to-treat approach was used or not. (Sims 2009), and reluctance to recruit some participants (Coroian
2018). The remaining 5 out of 75 studies (7%) of studies were
We assessed 18 out of 33 (55%) included studies as being at low risk assessed as unclear risk of bias because there was not enough
of attrition bias at the end of follow-up (Ada 2013; Arabzadeh 2018; information to make a judgement.
Dean 2018; Fernandez-Gonzalo 2016; Furnari 2014; Kim 2016a; Kim
2017a; Knox 2018 (both comparisons); Langhammer 2007; Mao Confounded by additional training time (imbalanced exposure)
2015; Mead 2007; Mudge 2009; Sandberg 2016; Sims 2009; Smith We judged studies in which the participants received an unequal
2008; Taylor-Pilliae 2014; Van de Port 2012). We assessed 11 out of amount of exposure to the intervention and comparison arms
33 (33%) as being at high risk of bias (Bateman 2001; Cooke 2010; of the study to be at high risk of bias. Technically this could be
Donaldson 2009; Duncan 2003; Flansbjer 2008; Inaba 1973; Kuys
2011; MacKay-Lyons 2013; Richards 2004; Winstein 2004; Zedlitz
Physical fitness training for stroke patients (Review) 26
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Cochrane Trusted evidence.
Informed decisions.
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Disability (21%) and therefore the data from Bateman 2001 should be treated
with caution; their exclusion does not change the findings.
Cardiorespiratory training (comparisons 1 and 2)
End of intervention Resistance training (comparisons 3 and 4)
Two studies assessed Rivermead Mobility Index (RMI) scores during Mixed training (comparisons 5 and 6)
usual care (Bateman 2001; Takami 2010), and one study after usual End of intervention
care (Globas 2012). There was a small overall improvement in
scores (MD 1.56, 95% CI 0.20 to 2.92; P = 0.02; Analysis 1.4). When we Nine studies assessed the effects of mixed training at the end of
excluded the data from Bateman 2001 (risk of bias) the effect was the treatment phase or at follow-up using a variety of scales that
strengthened (MD 2.18, 95% CI 0.99 to 3.37; P = 0.0003). measured disability outcomes: Lawton Instrumental Activities of
Daily Living (IADL) scores reported by Duncan 1998 and Duncan
• One study reported Physical Activity and Disability Scale scores 2003 at the end of intervention showed no statistically significant
(Mudge 2009). effect (MD 0.83, 95% CI −0.51 to 2.17; P = 0.22; Analysis 5.3).
• One study reported Older Americans Resources and Services
Six studies assessed the Barthel Index during usual care (Galvin
Questionnaire (Gordon 2013).
2011; Kim 2016a; Letombe 2010), and after usual care (Duncan 1998;
• One study reported that FIM scores were better than the control Duncan 2003; Langhammer 2007), at the end of intervention and
but no data were reported (Topcuoglu 2015). showed no statistically significant effect (MD 2.84, 95% CI −0.48 to
6.17; P = 0.09; Analysis 5.2). Barthel Index scores reached ceiling
We combined all the available disability scale data from these
level in five out of 20 participants at baseline and 10 out of 20
individual outcomes (using FIM data from Bateman 2001), and
participants at end of intervention (Duncan 1998); excluding this
can be moderately certain of an overall effect in favour of
cardiorespiratory training (SMD 0.52, 95% CI 0.19 to 0.84; P = study reduces heterogeneity (I2 statistic from 21% to 10%) and gives
0.002; 462 participants; moderate-certainty evidence; Analysis 1.5). a statistically significant beneficial effect (MD 4.02, 95% CI 0.16 to
Exclusion of the Bateman 2001 data made a trivial difference. One 7.88; P = 0.04).
of the included studies was confounded for exposure time and had RMI was assessed by three studies after usual care (Dean 2018;
multiple bias concerns (Wang 2014); if excluded, the heterogeneity Mead 2007; Van de Port 2012). The direction of benefit favoured
disappeared and the overall beneficial effect remained (SMD 0.35 training but the effect was not significant (MD 0.41, 95% CI −0.02,
0.15 to 0.55; P = 0.0007). This study, of non-ambulatory stroke 0.84; Analysis 5.4).
survivors, had the largest individual effect size.
• One study reported Nottingham Extended Activities of Daily
End of follow-up
Living (EADL; Mead 2007). In addition, Van de Port 2012
Studies reported a range of different global scales at follow- separately reported four subscales of the Nottingham EADL
up including RMI scores (Bateman 2001), Nottingham Extended scale; only one was significantly affected in favour of the usual
ADL (Bateman 2001), Physical Activity and Disability Scale scores care rather than mixed training; all other subscales showed no
(Mudge 2009), and the Frenchay Activities Index (FAI; Katz-Leurer statistically significant effect.
2003). When we combined all the disability scale data from • One study reported FIM data (Mead 2007), and showed no
these individual outcomes (Nottingham Extended ADL data from statistically significant effect at the end of intervention.
Bateman 2001), there was no statistically significant effect of • One study reported the Stroke Impact Scale (Duncan 2003),
cardiorespiratory training at the end of follow-up (SMD 0.20, 95% showing a marginal benefit. In addition, Van de Port 2012
CI −0.07 to 0.46; P = 0.14; Analysis 2.2). When the analysis was separately reported 11 subscales of the Stroke Impact Scale. One
repeated using RMI data from Bateman 2001 instead of Nottingham subscale was significantly affected in favour of the usual care
Extended ADL data there was still no statistically significant effect. rather than mixed training; all other subscales were unaffected.
There was a considerable proportion of interpolated missing data
• One study reported the Katz ADL scale (Letombe 2010), but there were enough data to compare cardiorespiratory training
and showed no statistically significant effect at the end of and mixed training. Both of these show beneficial effects although
intervention. there is some overall heterogeneity (I2 = 22%). In summary,
• One study reported the Modified Patient-Specific Functional cardiorespiratory training, with or without resistance training
Scale (Dean 2018), with no statistically significant effect shown included, improves scores of global disability.
at end of intervention.
Effect of training on secondary outcomes
We combined all available studies with disability scale data (nine
Adverse events
studies, 604 participants) from the end of intervention, including
the Barthel Index (Duncan 1998; Duncan 2003; Galvin 2011; Kim Adverse events were not typically sought (a priori) as an outcome
2016a; Langhammer 2007; Letombe 2010), FIM (Mead 2007), and measure but were instead reported in a more ad hoc fashion.
RMI (Dean 2018; Van de Port 2012). There was very low certainty However, a number of studies specifically reported no serious
in the small significant effect of mixed training at the end of the adverse events (Coroian 2018; Ivey 2017; Kim 2016a; Kim 2017a;
intervention (SMD 0.23, 95% CI 0.03 to 0.42; P = 0.02; Analysis Moore 2015; Sandberg 2016). One study reported serious adverse
5.5). There were several potential combinations of data that could events (n = 6) that were mostly considered unconnected to the
be included in this analysis as individual studies reported more intervention (Dean 2018). One study reported excessive fatigue
than one disability scale; we presented Barthel Index, FIM and among participants after strength training (Coroian 2018).
RMI data. We observed moderate inconsistency among studies'
heterogeneity: (I2 = 21%), and this may relate to the different The following studies reported falls.
specific domains each tool addresses. Seven of the nine studies
• Mead 2007 reported 11 falls in eight of the 32 participants
included in these analyses were confounded by increased training
allocated to mixed training and five falls in four of the 34
time whereby the amount of contact with therapists in the
participants in the control group (P = 0.21, non-significant). None
experimental groups was greater than in the control groups (Dean
of these falls occurred within training sessions.
2018; Duncan 1998; Duncan 2003; Galvin 2011; Kim 2016a; Letombe
2010; Van de Port 2012). The remaining two studies without this • Van de Port 2012 reported 29 falls in participants allocated to
source of confounding were among the smallest individual effects mixed training and 26 falls in those allocated to usual care (P =
(Langhammer 2007; Mead 2007). 0.93, non-significant); one fall occurred during exercise training.
• Dean 2018 reported 10 falls during the intervention; one fall
End of follow-up occurred at the training venue.
Two studies reported the Barthel Index (Galvin 2011; Langhammer • Taylor-Pilliae 2014 reported 29 falls; 14 in the intervention group
2007); there was no statistically significant effect at the end of and 15 in the control group.
follow-up (MD 1.82, 95% CI −13.69 to 17.33; P = 0.82; Analysis 6.2). • Vanroy 2017 reported one fall in the intervention and one in the
control group.
Two studies reported Nottingham EADL (Galvin 2011; Mead 2007);
there was no statistically significant effect at the end of follow-up With regard to secondary cerebrovascular events; 11 participants
(MD 3.10, 95% CI −5.20 to 11.40; P = 0.46; Analysis 6.3). (seven participants receiving the training intervention and four
control participants) were reported to have had a cerebrovascular
Three studies reported RMI (Dean 2018; Mead 2007; Van de Port event between baseline and the end of the training intervention. In
2012); there was a statistically significant benefit at the end of three the studies that included a follow-up assessment, 11 participants
to four months of follow-up (MD 0.35, 95% CI 0.02 to 0.69; P = 0.04; (five participants receiving the training intervention and six control
Analysis 6.4). However, two of the three studies were confounded participants) were reported to have had a cerebrovascular event
for increased training time (Dean 2018; Van de Port 2012). between the end of intervention and the end of follow-up.
When we combined all studies with disability scale data from With regard to cerebrovascular events, three participants (one
the end of follow-up, including Barthel Index (Galvin 2011; participant receiving the training intervention and two control
Langhammer 2007), Modified Patient-Specific Functional Scale participants) were reported to have suffered a cardiovascular event
(Dean 2018), FIM (Mead 2007), and RMI (Van de Port 2012), there was between baseline and the end of the training intervention.
no statistically significant effect (SMD 0.10, 95% CI −0.17 to 0.37; P =
0.45; Analysis 6.5). It is worth noting that three studies included in Cardiometabolic risk factors
these analyses were confounded by increased training time (Dean
2018; Galvin 2011; Van de Port 2012). There were several potential Few studies within each type of training reported cardiometabolic
combinations of data that could be included in this analysis as risk factor data so meta-analysis was limited. Cardiorespiratory
individual studies reported more than one disability scale; we fitness, discussed in the next section, is also a risk factor predictive
presented Barthel Index, FIM and RMI data of stroke.
(da Cunha 2002), had an unusually high systolic blood pressure in for the standard deviation (Jin 2013), and this study dominates the
the intervention group; this introduced heterogeneity but had little weighting (86%). If excluded, a slightly smaller effect occurs (MD
effect on the pooled effect size. One study stated that there was an 2.80 mL/kg/minute, 95% CI 1.66 to 3.95; I2 = 0%; P = 0.00001). If
effect of cardiorespiratory training on blood pressure but did not we assumed that the reported values were standard error values
provide data (Ivey 2011). incorrectly reported and we then converted them to SD, the effect
was again similar (MD 2.86 mL/kg/minute, 95% CI 1.77 to 3.96; I2
Two studies (174 participants) reported body mass index (BMI) = 0%; P = 0.00001) and the weighting becomes comparable to the
data at the end of cardiorespiratory training interventions with no other studies (8.8%).
evidence of effect (MD 1.19, 95% CI −0.38 to 2.76; Analysis 1.8).
• One study estimated peak VO2 indirectly from workload and
One study (Lennon 2008) reported waist girth measures but these
showed a beneficial effect of training at the end of intervention
were not affected by cardiorespiratory training.
(Lennon 2008).
One study of cardiorespiratory fitness training reported that • One study assessed peak VO2 after a 12-month follow-up and
glucose control (two-hour glucose), fasting insulin, insulin suggests a training-induced benefit still remained (MacKay-
sensitivity (HOMA: Homeostatic Model Assessment), and total Lyons 2013). This study is small (n = 50) but at low risk of bias.
triglycerides improved after training (Wang 2014). There was no • One study assessed VO2 cost during the 12-MWT and did not
statistically significant effect on cholesterol levels (high-density
show any significant training effect at the end of intervention
lipoprotein (HDL), low-density lipoprotein (LDL)) or fasting glucose
(Moore 2010).
levels.
• One study planned oxygen uptake measures but did not report
Resistance training (comparisons 3 and 4) them (Kuys 2011).
One study of resistance training (Zou 2015), reported post-training Six studies (336 participants) assessed maximum cycling work rate
improvements in glucose control (two-hour glucose), fasting at the end of intervention. This indicated that cardiorespiratory
insulin, insulin sensitivity (HOMA), and in cholesterol levels (total, fitness improved significantly in participants who received the
HDL, LDL). There was no statistically significant effect on fasting training intervention (MD 10.60 watts, 95% CI 1.88 to 19.33; I2 = 85%;
glucose or total triglycerides. P = 0.02; Analysis 1.10). The large number of dropouts in Bateman
2001 means these data are at risk of bias; if excluded, the overall
One resistance training study measured BMI; there was no
effect was strengthened and all the heterogeneity disappeared (MD
statistically significant effect (Zou 2015).
12.90 watts, 95% CI 8.39 to 17.42; I2 = 0%). Data from Bateman 2001
No resistance training studies reported blood pressure outcomes. suggested that the improvement measured by maximal cycling
work rate was not maintained at follow-up.
Mixed training (comparisons 5 and 6)
Musculoskeletal fitness
Two studies of mixed training examined blood pressure (Moore
2015; Toledano-Zarhi 2011), and meta-analysis showed no effects No studies reported indices of musculoskeletal fitness.
on systolic (Analysis 5.6), or diastolic blood pressure (Analysis 5.7).
Resistance training (comparisons 3 and 4)
One study reported no effect of mixed training on body composition Cardiorespiratory fitness
outcomes (body mass index and fat mass) (Moore 2015).
One study showed a small increase in cardiorespiratory fitness (VO2
One study of mixed training reported post-training improvements peak: 6%) after strength training (Ivey 2017).
in HDL cholesterol (representing a risk reduction) (Moore 2015).
There was no statistically significant effect on glucose control Musculoskeletal fitness
(two-hour glucose), insulin sensitivity (HOMA), and total and LDL Musculoskeletal fitness data, including muscle strength data,
cholesterol levels. were awkward to synthesise because data can be collected from
different muscle groups, using different equipment, different
Physical fitness
muscle contraction types (e.g. isometric, concentric), and reported
Cardiorespiratory training (comparisons 1 and 2) as different data dimensions (e.g. force, torque, power). A total of
11 studies examined the effects of resistance training on indices
Cardiorespiratory fitness
relating to muscle strength.
Nine studies (317 participants) assessed cardiorespiratory fitness
using directly measured peak VO2 (mL/kg/minute) at the end of Two studies with a total of 60 participants assessed the effects of
the intervention. Most of the studies took place after usual care resistance training on a composite measure of muscle strength at
and there was a consistent pattern of improvement in peak VO2 the end of intervention, during and after usual care (Kim 2001;
Winstein 2004). Kim 2001 used a composite measure (i.e. the sum of
measures. We can be moderately certain that cardiorespiratory
the percentage change in six muscle groups) to assess the strength
fitness increased significantly in the training groups (MD 3.40 mL/
of the lower limbs, while Winstein 2004 used a composite measure
kg/minute, 95% CI 2.98 to 3.83; I2 = 0%; P = 0.00001; Analysis 1.9).
(i.e. the sum of the torque of the extensors and flexors of the wrist,
Doses of training varied between four weeks and six months among
elbow, and shoulder) to assess the strength of the upper limbs.
the studies. All studies demonstrated the same beneficial direction
We have low certainty in the pooled estimate of effect in favour
of effect; the effect was similar for interventions delivered during
of the resistance training group (SMD 0.58, 95% CI 0.06 to 1.10; P
or after usual care. One study had unusually small values reported
= 0.03; Analysis 3.2). However, Winstein 2004 was biased by lack
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of blinding and the use of a dynamometer that was hand-held by bilateral extension of the whole lower limb; they presented the data
the investigator, and confounded by increased training time in the as graphs and we could not extracted them satisfactorily to pool in
intervention group. meta-analysis.
Three studies with a total of 93 participants showed that training Mixed training (comparisons 5 and 6)
could increase knee flexion strength in the affected leg; we have Cardiorespiratory fitness
moderate certainty in this effect (SMD 0.72, 95% CI 0.10 to 1.34; P
= 0.02; Analysis 3.3). The same studies showed no increase in knee Two studies (140 participants) reported cardiorespiratory fitness
extension strength of the affected leg; we have low certainty in this data as VO2 peak scores and showed effect of cardiorespiratory
effect (SMD 1.09, 95% CI −0.23 to 2.41; I2 = 87%; Analysis 3.4). Only fitness; we have low certainty in this effect (MD 1.40, 95% CI −0.19 to
one of these studies (Flansbjer 2008), included any follow-up data. 2.99; I2 = 35%; Analysis 5.8). Letombe 2010 also reported beneficial
differences in VO2 peak (+30%) but incomplete reporting prevented
• One study examined strength bilaterally in the lower limb incorporation in this meta-analysis.
extensors and unilaterally in the knee extensors and the ankle
flexors (plantar and dorsi; Ouellette 2004). They reported that • Two studies measured peak work rate (watts) as an index
all strength measures improved significantly after resistance of cardiorespiratory fitness: Moore 2015 reported that peak
training compared with the control group except for ankle work rate increased after training. Letombe 2010 also reported
dorsiflexion on the unaffected side. They presented the data as changes in peak work rate (watts: +20%) but incomplete
graphs and we could not extract them satisfactorily for further reporting prevented meta-analysis of these two studies.
analyses. • One study examined gait economy (net VO2 mL/kg per metre
• One study reported that participants allocated to resistance walked; Mead 2007). A small beneficial effect at the end of
training of the lower limbs achieved significantly greater intervention disappeared after a three-month follow-up.
gains in the 10-repetition maximum exercise compared with
• One study examined walking performance (time or metabolic
controls (12.18 versus 8.58 kg, P < 0.02) after one month of
equivalents (METS)) during a Modified Bruce treadmill protocol
intervention (Inaba 1973). No statistically significant differences
and reported no statistically significant effect of mixed training
were observed between groups after two months of training.
(Toledano-Zarhi 2011).
Inaba 1973 did not report any measures of variance and
therefore we were not able to include these data in our analyses. Musculoskeltal fitness
• One study reported significant gains in maximal strength
A total of six studies examined the effects of mixed training on
(bilateral one-repetition maximum (1-RM)) in a range of
indices relating to muscle strength.
upper and lower body muscle groups after resistance training
compared with the control group (Aidar 2016). Two studies (148 participants) assessed ankle dorsiflexion strength
• One study reported no statistically significant gains in elbow and but did not show any effect of training; we have very low certainty
wrist strength (3-RM; peak torque of flexors and extensors) at in this effect (SMD 0.80, 95% CI −0.82 to 2.41; I2 = 94%; Analysis
either the end of intervention (six weeks) or the end of follow-up 5.10). There was considerable heterogeneity between their results
(six months; Coroian 2018). and both studies were confounded by increased training time.
• One study reported increases in static and dynamic strength Yang 2006 also reported a range of other lower limb strength
(1-RM, Newtons) of the extensors of the whole lower limb (hip improvements, but all measurements were potentially biased as
and knee) in the trained (more affected) leg (Fernandez-Gonzalo they were obtained by means of a hand-held dynamometer, which
2016). This was accompanied by muscle hypertrophy (+9.4%). is not a reliable, objective method of measurement.
In addition, there were strength gains in the less affected
(untrained) leg. Three studies (202 participants) assessed knee extension strength.
• One study showed that maximum strength (1-RM, pounds) of We have moderate certainty in the small effect size in favour of the
extensors of the whole lower limb (hip and knee) improved in mixed training group at the end of intervention (SMD 0.33, 95% CI
the paretic leg (143%) and non-paretic leg (121%) plus there was 0.05 to 0.61; P = 0.02; Analysis 5.11). One of the studies showed that
a small increase in cardiorespiratory fitness (VO2 peak; 6%; Ivey this training effect was not retained at the end of the scheduled
follow-up (Cooke 2010).
2017).
Three studies (147 participants) that assessed grip strength of the
One study showed that submaximal muscular endurance (number
paretic hand did not show any significant improvement after mixed
of repetitions) of extensors of the whole lower limb (hip and knee)
training at the end of intervention; we have low certainty in this
increased after strength training with an increase in total number
effect (MD 0.32, 95% CI −0.88 to 1.52; I2 = 0%; Analysis 5.12). One
of repetitions in the paretic leg (178%) and non-paretic leg (161%;
other study reported grip strength data that we could not pool in
Ivey 2017).
this meta-analysis, and showed no statistically significant effect of
Two studies reported peak explosive power output measures. training at end of intervention or after a range of follow-up time
Fernandez-Gonzalo 2016 reported increases in power output points (Langhammer 2007).
(watts) of the extensors of the whole lower limb (hip and knee) in
• One study assessed knee flexion strength and showed no
the trained (more affected) leg. This was accompanied by muscle
statistically significant effect at the end of intervention or end of
hypertrophy (+9.4%). In addition there were power gains in the less
follow-up (Cooke 2010).
affected (untrained) leg. Ouellette 2004 suggested that peak power
was improved during unilateral knee extensions but not during • One study assessed the effect of mixed training on elbow
extension, elbow flexion, and pinch force at the end of
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intervention but did not detect any significant training effect Maximum walking speed (MWS)
(Donaldson 2009). Seventeen studies with 20 comparisons and a total of 782
• One study assessed the maximum explosive extensor power participants measured maximum walking speed (metres per
of the affected and unaffected lower limb and showed no minute) at the end of intervention. The pooled MD showed
statistically significant effect at the end of intervention or end of significant consensus in favour of the training group (MD +7.66
follow-up (Mead 2007). m/minute, 95% CI 3.65 to 11.68; P = 0.0002; Analysis 1.12). This
analysis also shows a consistent effect across the studies as a
Mobility
whole and a similar magnitude of effect arising from training
Cardiorespiratory training (comparisons 1 and 2) delivered during or after usual care. The mode of cardiorespiratory
training in all these studies was walking-specific apart from cycle
Functional Ambulation Category
ergometry (Bateman 2001; Sandberg 2016; Vanroy 2017), circuit
Two studies, which included three relevant comparisons and 73 type-training (Mudge 2009), and aquatic exercise (Aidar 2018). Nine
participants, measured the effect of treadmill gait training using the of the 20 comparisons were confounded for imbalanced exposure
Functional Ambulation Category (FAC) scale (da Cunha 2002; Pohl time. If the exposure-confounded studies and non-walking studies
2002). The pooled MD showed that the FAC score measured at the were excluded seven out of eight of the remaining studies show
end of intervention was significantly better in stroke survivors who a beneficial direction of effect and together show a substantial
received cardiorespiratory training during usual care (MD 0.53, 95% consensus of benefit (MD +12.49 m/minute, 95% CI 4.02 to 20.95). A
CI 0.21 to 0.85; P = 0.001; Analysis 1.11). We could not pool the FAC funnel plot of the complete data in this analysis showed a tendency
data reported by one study due to the way it was reported; there toward asymmetry, suggesting potential publication bias and this
was no evidence of an effect of training on FAC in this study (Vanroy is focused on those studies occurring during usual care (Figure 4).
2017).
Figure 4. Funnel plot of comparison 1. Cardiorespiratory training versus control - end of intervention, outcome:
1.12 mobility - walking maximal speed (over 5 to 10 metres; m/min)
Five studies with six comparisons (312 participants) also provided overall effect is consistent, the two comparisons of Ada 2013 show
follow-up data on maximum walking speed and observed a the smallest effect. Ada 2013 used a 12-month follow-up whilst all
significant training effect at the end of follow-up (MD 6.71 m/ the others used a three-month follow-up period. If we excluded
minute, 95% CI 2.40 to 11.02; P = 0.002; Analysis 2.3). Although the
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the data, heterogeneity was reduced and the confidence in the of effect among the studies taking place after usual care. The
treatment effect strengthened. mode of cardiorespiratory training in all these studies was walking-
specific, apart from three studies that used cycle ergometry (Katz-
Preferred walking speed (PWS) Leurer 2003; Vanroy 2017; Yang 2014). Five of the 13 comparisons
Twelve studies with 13 comparisons (588 participants) measured are confounded for exposure time. If confounded and non-walking
the preferred gait speed (metres per minute) at the end of studies are excluded, the consistent beneficial effect among the
intervention. We have high certainty in the pooled MD, which remaining six studies is still apparent (MD +5.83 m/minute, 95%CI
indicates a significant effect in favour of training (MD 4.47 m/ 2.32 to 9.34). A funnel plot of the complete data shows no evidence
minute, 95% CI 2.07 to 6.87; P = 0.0003; Analysis 1.13). This pooled of asymmetry (Figure 5).
effect is contributed to mostly by the consistent positive directions
Figure 5. Funnel plot of comparison 1. Cardiorespiratory training versus control - end of intervention, outcome:
1.13 mobility - walking preferred speed (m/min)
Three studies provided follow-up data at three months (Kuys demonstrated at all stages of care although some heterogeneity is
2011), and 12 months (Ada 2013; MacKay-Lyons 2013), after the present (I2 = 30%). Nine of the 17 comparisons are confounded for
intervention. Pooling these data showed no evidence of retention exposure time. All studies contained walking-specific interventions
(Analysis 2.4). apart from two that used cycle ergometry (Jin 2013; Yang 2014). If
studies confounded for exposure and those using cycle ergometry
Six-Minute Walk Test (6-MWT)
are excluded then six of the remaining seven studies each show
Sixteen studies with 17 comparisons (882 participants) assessed beneficial directions of effect and together these give a clear
walking endurance using the 6-MWT (total metres walked in consensus effect in favour of training (MD +40.30 metres/6 minutes,
six minutes). We have high certainty that cardiorespiratory 95% CI 13.24 to 67.37); this is dominated by studies occurring after
training significantly increased the walking capacity at the end of usual care. A funnel plot of the complete data shows no evidence of
intervention (MD +33.41 metres/6 minutes, 95% CI 19.04, 47.78; asymmetry (Figure 6).
P = 0.00001; Analysis 1.14). A consistent direction of effect was
Figure 6. Funnel plot of comparison 1. Cardiorespiratory training versus control - end of intervention, outcome:
1.14 mobility - walking capacity (6-Minute Walk Test (metres))
Five studies provided follow-up data at three months (Eich 2004; difference between participants who received Kinetron walking
Kuys 2011; Mudge 2009), and 12 months (Ada 2013; MacKay-Lyons training and controls (Glasser 1986).
2013), after the intervention. When pooled these data show some
evidence of retention (MD 38.29 metres, 95% CI 7.19 to 69.39; P = Resistance training (comparisons 3 and 4)
0.02; Analysis 2.5). Although overall heterogeneity is low, the effects Maximal walking speed (MWS)
are variable and not obviously associated to either the shorter or
longer follow-up periods. Six studies (274 participants) measured maximal walking speed
(metres per minute). Resistance training did not increase the
Other mobility outcomes walking velocity at the end of intervention (MD 2.83 m/minute,
95% CI −0.49 to 6.14; Analysis 3.5). There was some moderate
Similar to the 6-MWT data, three studies measured walking heterogeneity; studies showing positive directions of effect either
endurance (reported as metres per minute) in 154 stroke survivors involved walking-related exercise (Bale 2008), or were problematic
at the end of intervention, during (da Cunha 2002; Eich 2004), due to either use of interpolated data (Buyukvural 2015), or due to
and after (Salbach 2004), usual care. Walking capacity increased being confounded for exposure time (Buyukvural 2015; Knox 2018).
significantly in participants who received cardiorespiratory training Follow-up data pooled from two studies did not show any effect of
(MD 8.87 metres/minute, 95% CI 1.35 to 16.40; P = 0.02; Analysis retained training effects (Flansbjer 2008; Knox 2018; Analysis 4.2).
1.15).
Preferred walking speed (PWS)
Two studies reported time taken for the community walk test (Kim
2014; Park 2011). There was a small difference between participants Five studies (203 participants) measured preferred gait speed
who received community ambulation training and controls at the (metres per minute) but failed to demonstrate any effect of
end of intervention (MD −10.54 minutes, 95% CI −14.11 to −6.98; P resistance training at the end of intervention; we have moderate
= 0.00001; Analysis 1.16). certainty in this effect (MD 2.15 m/min, 95% CI −3.57 to 7.87;
Analysis 3.6). One study measured comfortable walking speed after
• One study measured the time taken by stroke participants follow-up; the intervention effect exceeded the control group (Knox
to walk a six-metre distance and did not find any significant 2018).
Five studies (238 participants) assessed walking capacity as metres Three studies (232 participants) measured community ambulation
walked in six minutes. We have low certainty in the effect of speed (the ability to walk at 0.8 metres per second or more) and did
resistance training at the end of intervention (MD 24.98 metres, not demonstrate any significant training effects either at the end of
95% CI 11.98 to 37.98; P = 0.0002; Analysis 3.7). Three of the five intervention (Analysis 5.16), or at follow-up (Analysis 6.9).
studies are confounded for exposure time, or have multiple risk of
bias concerns (Ivey 2017). Two studies provided follow-up data that • One study examined FAC scores and detected no statistically
showed no training effect on walking capacity at the end of follow- significant effect of training at the end of intervention or at end
up (Analysis 4.3). of three-month follow-up (Van de Port 2012).
Mixed training (comparisons 5 and 6) Comparison of cardiorespiratory, resistance training, and mixed
training (comparison 7)
Maximum walking speed (MWS)
Where sufficient data existed we performed a subgroup analysis to
Three studies (168 participants) reported an increase in maximum compare the effects of the different types combined with sensitivity
walking speed (MD +8.48 m/minute, 95% CI 1.76 to 15.20; Analysis analyses to examine combinations of training types on mobility
5.13). Two of the included studies are confounded for exposure outcomes at the end of intervention. The effect sizes described
time, which could exaggerate the response. below arise from the sensitivity analyses below and are not shown
in Analysis 7.2, Analysis 7.3, or Analysis 7.4.
• Only one included follow-up data and suggested that end of
intervention benefit was retained after 12 weeks of follow-up Maximal walking speed
(Knox 2018).
Maximal walking speed increased significantly after
Preferred walking speed (PWS) cardiorespiratory training and mixed training but not after
resistance training (Analysis 7.2). We examined pair-wise
Ten studies (738 participants) measured the effects of mixed
combination of these subgroups. Excluding the resistance training
training on preferred walking speed (metres per minute). We have
subgroup showed that cardiorespiratory training with or without
moderate certainty in the walking speed increase at the end of
a resistance training element (mixed) benefits maximal walking
intervention in stroke survivors who received mixed training (MD
speed (MD 7.77 m/min, 95% CI 4.11 to 11.44; P = 0.00001);
4.71 m/minute, 95% CI 1.32 to 8.10; P = 0.006; Analysis 5.14). The
the heterogeneity in this analysis was greatly reduced when we
effect is influenced mostly by data from interventions delivered
removed studies confounded for intervention exposure. Excluding
after usual care and there is significant heterogeneity within this
the cardiorespiratory training subgroup showed that resistance
subgroup as well as overall. Only the interventions in three of the
training with or without a cardiorespiratory training element
10 studies had balanced control and training exposures and these
(mixed) also appears to benefit maximal walking speed (MD 3.63 m/
show no statistically significant effect overall (Mead 2007; Richards
min, 95% CI 0.64 to 6.63; P = 0.02); however, this benefit is due to
1993; Richards 2004). A funnel plot of these data (not included) did
mixed training interventions not the resistance training.
not show any evidence of asymmetry.
Preferred walking speed (PWS)
Five studies (542 participants) that provided follow-up data for
preferred gait speed did not show a training effect at the end of the Preferred walking speed increased significantly after
scheduled follow-up (Analysis 6.7). cardiorespiratory and mixed training but not after resistance
training (Analysis 7.3). We examined pair-wise combination of these
• One study showed some indication of dose-response, where the subgroups. Excluding the resistance training subgroup showed that
improvement in preferred gait speed was positively associated cardiorespiratory training with or without a resistance training
with the amount of time spent on the gait training component element benefits preferred walking speed (MD 4.56 m/min, 95% CI
(Richards 1993). 2.35 to 6.77; P value < 0.0001); excluding studies confounded for
intervention time preserves a benefit whilst greatly reducing the
Six-Minute Walk Test (6-MWT)
heterogeneity. Excluding the cardiorespiratory training subgroup
Ten studies (720 participants) measured walking capacity (metres showed that resistance training with or without a cardiorespiratory
walked in six minutes). We have low certainty in the significant element benefits preferred walking speed (MD 3.80 m/min, 95% CI
increase shown after mixed training (MD 35.00 metres, 95% CI 1.07 to 6.53; P = 0.006). All this benefit arises from the mixed training
15.91 to 54.09; P < 0.0003; Analysis 5.15). All studies in this meta- subgroup; however, seven out of 10 studies were confounded for
analysis, apart from Moore 2015, were confounded for exposure intervention time.
time. A funnel plot of these data (not included) did not show any
Six-Minute Walk Test (6-MWT)
asymmetry.
Gait endurance increased significantly after cardiorespiratory and
Four studies (464 participants) included a follow-up and showed mixed training but not after resistance training (Analysis 7.4). We
that walking capacity remained significantly greater in the groups examined pair-wise combination of these subgroups. Excluding
who had participated in training (MD 47.48 metres, 95% CI 23.72 to the resistance training subgroup showed that cardiorespiratory
71.23; P = 0.0001; Analysis 6.8). It is worth noting, however, that in training, with or without a resistance training element, benefits
all studies in this analysis the intervention groups were confounded gait endurance (MD 33.97 metres, 95% CI 22.59 to 45.35; P value
by additional training time, which could exaggerate the effect. P < 0.00001). There is a similar contribution from both subgroups
but the majority of studies were confounded for intervention time.
Excluding the cardiorespiratory training subgroup showed that
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resistance training, with or without a cardiorespiratory element, • One study assessed the effect on antero-posterior and medio-
benefits gait endurance (29.53 metres 95% CI 18.87, 40.18; P value lateral sway velocity and showed a beneficial effect of training
< 0.00001); the majority of studies (12/15) were confounded for (Lee 2013a).
intervention time. • One study assessed the effect on antero-posterior and medio-
lateral sway distance and showed a beneficial effect of training
Physical function (Son 2014).
The included studies assessed participants' physical function using
Step tests
a variety of different measures including rating scales (e.g. Berg
Balance Scale) and specific measures of functional performance Four studies examined the effect of resistance training on stair
(e.g. functional reach, Timed Up and Go test, stair climbing). climbing speed using different protocols.
Cardiorespiratory training (comparisons 1 and 2) Two studies (91 participants) reported time needed to ascend
Balance outcomes stairs using similar protocols (10 steps; Ouellette 2004; 11 steps
Buyukvural 2015), and showed a beneficial effect of intervention at
Seven studies with eight comparisons (471 participants) assessed the end of the training period (MD −2.07 sec, 95% CI −3.18 to −0.96;
the effects of cardiorespiratory training on balance using the Berg P value 0.0003; Analysis 3.9).
Balance Scale. We have moderate certainty in the increase in
balance scores (MD 1.92, 95% CI 0.16 to 3.68; P = 0.03; Analysis Two other studies reported data not suitable to pool due to protocol
1.17). All studies except Bateman 2001 and Jin 2013 included a differences. We could not use SMD as there would be a mix of end-
walking component; when we excluded these two studies the effect score and change-score data.
was strengthened (MD 2.99, 95% CI 0.95 to 5.02: P = 0.004). The
backwards-walking group of Takami 2010 appeared to produce a • One study reported time to climb four steps. Change scores
larger benefit compared with the forwards-walking group from the showed no statistically significant effect on maximal or chosen
same study. Bateman 2001 and MacKay-Lyons 2013 also assessed speed (Kim 2001).
participants at the end of the follow-up period but did not show any • One study used a two-minute step test and showed beneficial
effect (Analysis 2.6). effect on stair climbing (Taylor-Pilliae 2014).
• One study assessed balance using a single leg stance test (left Timed Up and Go
and right legs, with and without eyes closed) and demonstrated
Five studies (224 participants) examined the effect of resistance
a beneficial direction of effect in all (Sandberg 2016).
training on the Timed Up and Go test. There was no benefit
• One study showed Brunel Balance Scores did not change after and we have low certainty in the estimate (MD −3.46 sec, 95%
training (Mao 2015). CI −6.94 to 0.02; I2 = 89%; Analysis 3.10). The during- and after-
Other outcomes
usual-care subgroups did each show a beneficial effect; however,
four out of five studies were confounded for intervention time,
Five studies (223 participants) showed that performance of the there is substantial heterogeneity, and Buyukvural 2015 is based on
Timed Up and Go test improved; we have moderate certainty in this variance data interpolated from published P values.
effect (MD −3.42 sec, 95% CI −4.78 to −2.05; P value 0.00001; Analysis
1.18). Two studies (117 participants) examined Timed Up and Go data
at follow-up and this shows no statistically significant effect of
• One study showed that functional reach was higher after training retained benefits (Analysis 4.4)
(Kang 2012).
• One study showed that Fugl-Meyer scores did not change after Other outcomes
training (Mao 2015). • One study examined the effect of resistance training on the
• One study demonstrated a medium beneficial effect of training Trunk Impairment Scale; there was no statistically significant
on time taken to rise from a chair (Aidar 2018). effect size (Verheyden 2009).
• One study concluded there was no benefit of isokinetic upper
Resistance training (comparisons 3 and 4)
limb training to upper limb function (upper limb Fugl-Meyer
Balance outcomes scores and Box and Block tests; Coroian 2018).
Five studies (220 participants) assessed balance using the Berg • One study showed trivial direction benefit from lower limb
Balance scale. We have low certainty in the pooled after training training on lower limb and total Fugl-Meyer scores (Zou 2015).
(MD 3.27, 95% CI 2.15 to 4.38; P = 0.00001; Analysis 3.8). Only Knox • One study showed no beneficial effect of training on the Short
2018 reported Berg Balance data again after follow-up (at three Physical Performance Battery score; only the 'strength' subscale
months) and showed a small positive direction of benefit. showed a beneficial direction of change (Taylor-Pilliae 2014).
• One study assessed the maximum weight-bearing on the Mixed training (comparisons 5 and 6)
affected leg (% body weight) and showed a beneficial change Balance outcomes
after training (Bale 2008).
Nine studies (419 participants) assessed balance using the Berg
• One study examined the effect on indices of postural sway
Balance Scale. We have low certainty in the beneficial effect (MD
(centre of pressure). This could not be pooled but suggested a
2.12, 95% CI 0.82 to 3.41; P = 0.001; Analysis 5.17). Heterogeneity
beneficial effect of training (Arabzadeh 2018).
is low in this meta-analysis; however, five of the nine studies were
confounded for increased exposure time in the intervention groups; Comparison of cardiorespiratory, resistance training, and mixed
excluding these studies extinguishes the beneficial effect. Follow- training (comparison 7)
up data from three studies (201 participants) did not show any Where sufficient data existed we performed a subgroup analysis to
significant retention of training effects (Analysis 6.10). compare the effects of the different types combined with sensitivity
analyses to examine combinations of training types on the Berg
Two studies with a total of 166 participants measured balance
Balance Scale and Timed Up and Go data at the end of intervention.
using the functional reach test but did not show any benefit of
The effect sizes described below arise from the sensitivity analyses
mixed training at the end of intervention (Duncan 2003; Mead 2007;
below and are not shown in Analysis 7.5 or Analysis 7.6.
Analysis 5.18). One study provided follow-up data (Mead 2007); this
did not show any retention effects. Balance
Other study balance data included; Excluding the resistance training subgroup showed that
cardiorespiratory training with or without a resistance training
• One study measured the Four Square Step Test; however, these element benefits balance (MD 1.87, 95% CI 0.76 to 2.99; P
data were very different at baseline in a way that benefited the = 0.0009; Analysis 7.5); this is contributed to similarly for
control group (Toledano-Zarhi 2011). both training types but exclusion of the studies confounded
• One study measured balance using the timed balance test for intervention time cancels out evidence of beneficial effect.
after intervention and after three-month follow-up (Van de Port Excluding the cardiorespiratory training subgroup showed that
2012). resistance training with or without a cardiorespiratory training
• One study measured postural sway (static balance) in a range of element benefits balance (MD 2.75, 95% CI 1.92 to 3.58; P value
conditions and planes of movement; however, the study authors < 0.00001). Both intervention types contribute in a similar and
concluded there was no statistically significant effect of mixed consistent way and the benefit is still evident when the studies
training (Shin 2011). confounded for intervention time are excluded (MD 2.81, 95% CI
1.47 to 4.15; P value < 0.0001).
• One study reported multiple benefits of aquatic exercise to
a range of balance and stance outcomes measured using a Timed Up and Go
'baropodometric' system (Furnari 2014).
Excluding the resistance training subgroup showed that
There were sufficient data among the all different measures of cardiorespiratory training with or without a resistance training
balance described above to justify pooling using SMD meta-analysis element benefits Timed Up and Go (MD −2.61 sec, 95% CI
(12 studies, 755 participants). This showed an overall beneficial −3.93 to −1.29; P value < 0.0001; Analysis 7.6). Excluding
improvement in balance at the end of intervention (SMD 0.28, the cardiorespiratory training subgroup showed that resistance
95% CI 0.11 to 0.45; P = 0.001; Analysis 5.19). However, seven of training with or without a cardiorespiratory training element
the 12 included studies were confounded by additional training benefits Timed Up and Go (MD −2.88 sec, 95% CI −5.02 to −0.75;
time; when we excluded these data there was no statistically P value < 0.00001). Taking into account these data as a whole
significant effect of training on balance. A funnel plot of these data the magnitude of effect across the three training types was very
(not included) appears asymmetrical; however, the asymmetry is similar and was consistent, with 15 out of 17 studies showing a
caused by two small studies each showing negative effects (Kim positive direction of benefit. However, many of the studies (12/17)
2016a; Toledano-Zarhi 2011). are confounded for intervention time.
training at the end of intervention (Analysis 5.27), or the end of The observed numbers of deaths in this review may be low because
follow-up (Analysis 6.19). the included participants were at lower risk of death compared
with the wider stroke population. This may occur, first, because
Cognitive function the inclusion criteria of the studies of exercise select participants
Cardiorespiratory training (comparisons 1 and 2) with milder strokes (most were ambulatory), and reduced risk
factors (such as blood pressure ceiling criteria). In other words,
One study of cardiorespiratory training showed no statistically those at higher risk of dying were probably systematically excluded
significant effect on FIM cognitive score (memory, problem-solving due to contraindications to exercise. Second, there may be self-
questions) at the end of intervention (Bateman 2001). We did not selection by participants who are physically active with higher
consider end of follow-up data due to the considerable proportions fitness. Higher physical activity and cardiorespiratory fitness are
of missing data. known to be associated with reduced stroke risk and stroke
mortality (Hooker 2019). In addition, the majority of the training
Resistance training (comparisons 3 and 4)
programmes in this review were of short duration (12 weeks or
One study showed benefits of short intense training on attention, less). A systematic review of the effect of exercise-based cardiac
working memory, information processing, and executive function rehabilitation showed reduced cardiovascular mortality in people
(Fernandez-Gonzalo 2016). Some cognition data is incomplete in with coronary heart disease (Anderson 2016), but the training
this study for participants with expressive aphasia or upper limb programmes were longer (median six months) than those in
spasticity. this review. Since many stroke patients have coexisting heart
disease, training might influence post-stroke mortality if it contains
Mixed training (comparisons 5 and 6) cardiorespiratory training delivered over long periods of time. With
Two studies (159 participants) showed no statistically significant regard to longer-term interventions, currently two small studies of
effect on FIM cognitive score (memory, problem-solving questions) cardiorespiratory training (Ivey 2010; Ivey 2011), and one of mixed
at the end of intervention (Analysis 5.28), or end of follow-up training (Dean 2018), exist; these used a six-month intervention
(Analysis 6.20). duration. Current evidence lacks the interventions most likely to
influence mortality.
Two studies (133 participants) used SIS domains of
'communication' and 'memory and thinking' to assess cognitive Although higher physical activity and higher cardiorespiratory
function. The meta-analyses showed no statistically significant fitness are linked to the primary prevention of stroke, there is a lack
effects at the end of intervention (Analysis 5.29; Analysis 5.30), or of data on the role of fitness training interventions in the secondary
the end of the six-month follow-up (Analysis 6.21; Analysis 6.22). prevention of stroke. This gap in knowledge is currently a research
priority and requires investigation (Pollock 2012).
• One study showed that mixed training benefited cognitive
function assessed by the Korean version of the Montreal Death or dependence
Cognitive Assessment but not the Trail Making Test or Stroop test There were no data available to allow us to draw conclusions
(Kim 2017a). about the influence of training on the composite outcome of death
• One study showed that mixed training improved cognition or dependence after stroke. Death is infrequent and measures of
measured using the ACE-R tool (Moore 2015). dependency, such as those based on simple questions, a Barthel
Index score of less than 20, or a modified Rankin Scale score of 3,
'Summary of findings' tables
4, or 5, are lacking (Lindley 1994). Both elements of this composite
We have presented the results for the primary outcome measures outcome are likely to be rare in stroke survivors who are eligible for
'Summary of findings' tables for cardiorespiratory training physical fitness training.
(Summary of findings for the main comparison), resistance training
(Summary of findings 2), and mixed training (Summary of findings Disability
3). In addition we made a post-hoc decision to include domains We assessed a number of different global indices of disability. Data
relating to physical fitness, mobility, and physical function. using the same scales were limited, which restricted the meta-
analyses to the use of standardised mean differences. In addition,
DISCUSSION a number of methodological issues weakened and biased the
available data.
Summary of main results
Effect of training on primary outcome measures After cardiorespiratory training there was no improvement
in Functional Independence Instrument scores (Analysis 1.2),
Death Barthel Index scores (Analysis 1.3), or other individually-reported
There were no statistically significant effects on mortality, which outcomes. However, there was an improvement in Rivermead
suggests that there were no benefits but also that there were no Mobility Index scores (Analysis 1.4). Pooling all available disability
adverse effects on mortality. Although there is low certainty in scale data from different scales showed a moderate beneficial
these analyses, death from any cause was a very uncommon event effect (SMD; Analysis 1.5). This pattern of findings could occur
among the participants. At the end of intervention only 19 out of the because training influences the physical/mobility items of these
total 3617 participants had died and these were restricted to five various scales; such items dominate the scoring in tools like
out of 75 studies. At the end of follow-up 19 out of 1469 participants the Rivermead Mobility Index (eight out of 15 items) whereas
had died; these were restricted to seven out of 24 studies with they are less influential in more 'global' tools like the Functional
follow-up time points. Independence Measure (two out of 18 items). Since walking is a
common mode of cardiorespiratory exercise, these findings could
Physical fitness training for stroke patients (Review) 39
Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cochrane Trusted evidence.
Informed decisions.
Library Better health. Cochrane Database of Systematic Reviews
be precipitated by improvements in walking and mobility rather 2016). We have moderate certainty that our observed effect of +3.40
than more 'global' effects on disability. mL/kg/min (95% CI 2.98 to 3.83) is of similar magnitude to this and
this indicates that meaningful risk reduction may be achievable
There were too few data to allow for any comment on the effect with short cardiorespiratory training interventions either during or
of resistance training and there was no evidence of intervention after usual care.
effects at the end of follow-up where data existed.
Physical fitness
Studies of mixed training used various disability measurement
instruments, which individually showed no clear consensus Cardiorespiratory fitness
effects. Pooling all available data from different scales showed Cardiorespiratory training significantly improved physiological
a small effect at the end of intervention (Analysis 5.5). Like indicators (VO2 peak), and performance indicators (exercise
cardiorespiratory training these significant effects could be driven tolerance) of cardiorespiratory fitness. This improvement may be
principally by changes in mobility. Most pooled studies were beneficial because a low VO2 peak is associated with functional
confounded by additional training time; when these were excluded
limitation in elderly people (Young 2001). In people with stroke the
the benefits vanished. This means that participation in mixed
functional benefits are, however, less clear (see for example the
training appeared effective but it is impossible to attribute any
contradictory data by Michael 2007 and Patterson 2007).
benefits to the actual content of the mixed training programmes.
A limited 'fitness reserve' caused by a low VO2 peak coupled with
The effects of cardiorespiratory training (moderate-certainty
evidence) and mixed training (low-certainty evidence) are similar poor walking economy (high oxygen cost of walking) is a common
in magnitude at the end of intervention (Analysis 7.1). Overall, post-stroke problem (Blokland 2018; Macko 2001). Training to
the findings show that interventions containing cardiorespiratory improve either component (VO2 peak and/or walking economy)
training, with or without resistance training content (i.e. mixed could benefit walking performance and exercise tolerance after
training), improve global measures of disability after stroke. These stroke. Although there were too few data to determine whether
effects may be driven by improvements in mobility rather than economy can be improved, there is clear consensus that VO2 peak
being indicative of a change in more 'global' disability status. This can be improved. This increases the 'fitness reserve', meaning that
would agree with the findings among the secondary outcomes walking at a given speed is less demanding. Our consensus effect
(mobility). (+3.40 mL/kg/min 95% CI 2.98 to 3.83) is very similar to other recent
systematic reviews (+2.2 mL/kg/min 95% CI 1.3 to 3.1; Boyne 2017).
Effect of training on secondary outcome measures
There were too few other data to draw conclusions on the
Adverse events effects of the other training types or the post-training retention of
There was no evidence of any serious adverse events arising from cardiorespiratory fitness.
training in people who participated in physical fitness training
Musculoskeletal fitness
programmes. However, this finding cannot be generalised to the
wider stroke population as only a few studies specifically recorded Consensus effects using meta-analysis measures of
or reported adverse events. There is a clear need to improve the musculoskeletal fitness (muscle strength and power) are difficult to
reporting of adverse events in physical fitness training studies. achieve in a meaningful way because there are so many different
testing approaches, protocols, outcome dimensions, and muscle
Risk factors groups that can be used. Resistance training and mixed training
Few studies reported vascular risk factors, and the variety of studies included in this review that measured musculoskeletal
outcomes restricted meta-analysis. There were no consensus fitness did so via a range of outcomes, including not just maximal
effects on blood pressure. In individual studies, which reported strength but also other dimensions such as local muscular
metabolic measures (glucose tolerance, insulin sensitivity, lipids), endurance and maximal explosive power output.
there were some beneficial directions of effect but no consensus
Most resistance training studies individually showed improvements
can be reached. Blood pressure remained an uncommon outcome
in musculoskeletal fitness and in some cases these were substantial
reported in studies of exercise after stroke and yet it could be
in magnitude and dominated by lower limb muscle groups.
an important, plausible benefit. Other recent systematic reviews
have examined the effect of exercise on cardiovascular risk Mixed training studies reported a range of outcomes with most of
factors and reported beneficial effects on systolic blood pressure, the examples of a beneficial direction of effect within lower limb
fasting glucose and insulin, and HDL cholesterol (D'Isabella 2017); rather than upper limb musculature.
however, this included a number of studies that did not meet our
eligibility criteria. The review of D'Isabella 2017 did not include In this review update there is evidence of increased interest in
cardiorespiratory fitness as an outcome. resistance training and thus musculoskeletal fitness measures
occur more commonly. However, the certainty of the evidence is
There was an increase in cardiorespiratory fitness after still low to moderate.
cardiorespiratory training; this is discussed in the next section
below from a functional perspective. However, as well as having Several studies examine dynamic expressions of musculoskeletal
functional implications, low VO2 peak values are associated with fitness such as explosive power output (Fernandez-Gonzalo 2016;
increased stroke risk and stroke mortality (Hooker 2019). An Mead 2007; Ouellette 2004). In people with stroke, explosive power
increase in VO2 peak of 1 MET (equivalent to +3.3 mL/kg/min) is associated with function and disability after stroke (Saunders
equates to a 7% risk reduction in stroke hospitalisation (Pandey 2008), and in elderly people explosive power output may be more
important than strength for function and disability (Puthoff 2007). Walking speed improvements after training could be connected
Interventions to improve explosive power after stroke remain to an increased fitness reserve (arising from an increased VO2
under-investigated. peak and/or improved gait economy). Walking-based training
interventions dominate the effects of both cardiorespiratory and
Mobility mixed training and these are by definition task-related and
All the meta-analyses of walking performance outcomes are repetitive in nature. These elements by themselves may facilitate
summarised in Table 4 and this shows a clear pattern of findings. motor learning and benefit gait performance even in the absence of
an obvious improvement in physical fitness parameters.
Cardiorespiratory training increased maximal walking speed,
preferred walking speed, and walking capacity (6-MWT) at the Therefore, on the whole, there is consistent evidence that measures
end of the training period (Analysis 1.12; Analysis 1.13; Analysis of walking performance improve after both cardiorespiratory
1.14). When these analyses are restricted to studies that have training and mixed training, but not after resistance training alone.
a balanced control group exposure, and that use walking as a Although the improvements are clear, one could still question
mode of exercise, all three magnitudes of beneficial effect increase, whether they are clinically important. For example, Fulk 2011
suggesting the importance of exercise being task-related. Benefits concluded that a clinically important increase in preferred walking
were retained in both maximum walking speed (Analysis 2.3), speed after stroke would be 10.5 m/minute; this is greater than the
and 6-MWT (Analysis 2.5). Benefits to walking performance also upper 95% confidence interval (CI) margin of the effect sizes for
emerge when walking in a community setting outside the research preferred walking speed in this review. Fulk 2018 suggested that the
environment (Analysis 1.16). There is evidence that suggests that minimum clinically important difference for 6-MWT is +71 to +130
cardiorespiratory training, as well as improving walking speed, may metres based on patients who are initially fast walkers (≥ 0.4m/
reduce the reliance of stroke survivors on other people to assist sec); these exceed the effects in this review. Baseline gait speed will
with ambulation (Functional Ambulation Categories score; Analysis remain an important consideration for making judgements about
1.11). There is high certainty of the evidence for cardiorespiratory magnitude of effects in walking speed outcomes.
training.
Physical function
Resistance training benefited only walking capacity (6-MWT) and A variety of measures to assess motor function were used in the
not maximal or preferred walking speed. It is worth noting that included studies; balance data and Timed Up and Go data could
most of the resistance training interventions did not incorporate each be pooled and were recorded across all training types.
walking as a mode of exercise. Improvements noted in muscle
strength may not necessarily produce functional benefits (Kim All three main intervention types collected Berg Balance score data
2001), which translate into a better walking performance. The and each showed beneficial effect sizes. Most cardiorespiratory
relationships between 'fitness' and 'function' is indeed very training studies involved walking, and these contributed most
complex and may arise from factors such as non-linear associations of the beneficial effect (moderate certainty). Mixed training data
(Buchner 1991), or the interaction of 'co-impairments' such as were less trustworthy and possibly affected by confounding
lack of balance and low muscle strength (Rantanen 2001). In (low certainty). Resistance training interventions demonstrated
this review it could also be that the intramuscular metabolic the largest overall effect but were of low certainty. Taken all
adaptations arising from resistance training increased the tolerance together interventions involving cardiorespiratory training with or
of participants to any fatiguing effects of the performance-based without resistance training (mixed) improved balance. Likewise
6-MWT. However, there is low certainty of the evidence for this resistance training with or without cardiorespiratory training
outcome. (mixed) improved balance. These data suggest that there is more to
training balance that just specific 'balance training' interventions
Mixed training increased maximal walking speed, preferred walking as demonstrated by the similar effects of resistance training and
speed, and walking capacity (6-MWT) at the end of the training of walking-type exercise. Other systematic reviews have examined
period (Analysis 5.14; Analysis 5.15). These effect sizes are all cardiorespiratory training effects (Pang 2013), and trunk training
similar in magnitude to those for cardiorespiratory training and effects (Cabanas-Valdés 2013; Sorinola 2014), on balance after
they are also of lower certainty (low to moderate). However, these stroke. Although Sorinola 2014 reported a significant effect of trunk
consensus effects are more tenuous because of heterogeneity, exercise on standing balance (SMD 0.72, 95% CI −0.01 to 1.45; P
some of which can be explained by the fact that all are dominated = 0.05) the balance data as a whole are not convincing and these
by imbalanced exposures, which could exaggerate the effects. reviews have different eligibility criteria to the current review. The
Benefits were retained only in the 6-MWT performance (Analysis systematic review of Van Duijnhoven 2016 examined the effects
6.8). Moreover, all studies, except Yang 2006, included specific of different exercise therapy interventions and showed that these
walking training. benefited balance; the overall effect size on the Berg Balance scale
was 2.22 points (95% CI 1.26 to 3.17), which is very similar to our
When comparing the effects of the different interventions
data. In addition, Van Duijnhoven 2016 noted that it was specific
(comparison 7) it is cardiorespiratory training with or without
balance and/or weight-shifting training that gave the largest effect
resistance training (mixed training) that benefits walking speed
size (3.75 points 95% CI 1.71 to 5.78), whereas in this review, the
outcomes. Within this analysis it is clear that the cardiorespiratory
largest effect was after resistance training and this is of similar
element is key and this is most effective when presented via a
magnitude (MD 3.27, 95% CI 2.15 to 4.38).
walking mode of exercise. Resistance training with or without a
cardiorespiratory element (mixed) also benefits walking speed but All three training types appear to give a similar overall effect on
these data are dominated by the effect of mixed training and they Timed Up and Go performance. While there is no clear minimum
are less trustworthy. clinically-important difference established for this outcome, it does
relates to mobility, balance and risk of falls and is therefore relevant There is a rationale as to why cognitive function may be improved
to people with stroke. by fitness training (Heyn 2004), and interventions to improve
cognitive function have emerged as the highest rated research
Health status and quality of life priority with regard to life after stroke (Pollock 2012). There are still
Data do exist that examine quality-of-life measures; however, very few data to determine whether exercise is beneficial, therefore
studies use a range of different tools to report different subscales this remains an important knowledge gap.
and summary statistics, which makes meaningful pooling of these
Factors influencing primary and secondary outcome measures
data difficult. Therefore, few conclusions can be drawn on whether
training can improve self-perceived health status and quality of Performing subgroup analyses is challenging when the number
life after stroke. Taking into account all the data, there is also no of studies is small; the consequences are reduced power and the
discernible pattern in terms of studies showing or not showing a influence of characteristics unrelated to the grouping factors.
beneficial direction of effect across physical, mental, or emotional
domains of the scales used. In addition, 14 out of 19 studies that Dose of training
included quality-of-life outcomes were confounded for additional All the training interventions in this review occurred regularly and
intervention time, which means it is difficult to attribute any effects were progressive in nature. The interventions differed in the dose
to the content of training. A systematic review of exercise after of training, quantified in terms of the intensity of the exercise, and
stroke included quality of life outcomes and also concluded that overall volume of training time.
there was no consistent effect (Pang 2013).
With regard to cardiorespiratory training interventions (Table
Mood 1), and studies that together reported a clear improvement in
Few studies of variable methodological quality were available to cardiorespiratory fitness (Analysis 1.9), nine out of the 10 studies
assess the effects of training on mood. There is no consistent reported exercise intensity as 60% to 80% heart rate reserve, 50%
pattern of effects and the pool of studies are at risk of bias due to to 85% maximum heart rate, or 30% to 50% maximum effort; rate
attrition and confounding due to imbalanced exposures. of perceived exertion was reported as 13 to 15 in two of 10 studies;
there is some variation. Likewise, programme length varied from
A recent systematic review of exercise for depressive symptoms less than 12 weeks in four out of 10 studies to 12 weeks or longer
after stroke combined data from 13 studies, with a total of 1022 in six out of 10 studies. There is heterogeneity in the analysis
participants, and showed a small effect at the end of exercise (SMD of cardiorespiratory fitness but this gives no obvious explanation
−0.13, 95% CI −0.26 to 0.01; P = 0.03), but not follow-up (Eng 2014). to magnitude of effects. It is worth noting that all these studies
These findings may differ from the current review, since Eng 2014 involved cardiorespiratory training, which was regular (mostly 3
pooled different exercise types; only five out of 13 RCTs met our to 5 days/week) and progressive. The undeniable tendency is for
eligibility criteria, and we made a methodological decision not an improved fitness response across all the studies irrespective of
to pool the data from Lennon 2008 in our meta-analyses (as this dose, so perhaps precise prescription of intensity is less important
would have involved estimating mean and standard deviation from compared to being able to engage with exercise, which is regular
median and range). and progressive; this elicits a physiological adaptation.
In both reviews small benefits could be exaggerated due to With regard to resistance training interventions (Table 2), eight out
confounded exposure. Also, any lack of effect could arise from the of 20 studies reported intensity of 70% to 80% maximal strength,
fact that the symptoms of depression are relatively mild; this could and five out of 20 studies stated that a maximum effort was required
be due to confounding by antidepressant medications, which were over a target number of repetitions. Overall, 12 out of 20 studies
not reported. required six to 15 repetitions of each exercise used; nine out of
20 studies reported that three to six sets of each exercise were
Cognitive function performed. Programme length varied from less than 12 weeks in
Only six studies have examined the effect of fitness training 14 out of 20 studies to 12 weeks or longer in six out of 10 studies.
interventions on cognitive function outcomes; currently no Like cardiorespiratory training, there is variation in overall dose
conclusions can be drawn. There are other systematic reviews and some studies activated more muscle groups/used differing
that have examined the effects of exercise on cognitive function numbers of exercises than others. Although we synthesised data
(Cumming 2012; Garcia-Soto 2013; Zheng 2016). The review without meta-analysis, there is a clear pattern of improved muscle
of Cumming 2012 showed that physical activity and exercise strength arising from resistance training interventions. Regular
interventions produced significant improvements in cognitive resistance training can stimulate musculoskeletal adaptations in
function at the end of the intervention (SMD 0.20, 95% CI 0.04 to relatively short exercise programmes, and although these vary,
0.36; P = 0.015; nine studies, 716 participants). Although six out they are regular and progressive.
of 13 of the studies involved exercise interventions only three out
With regard to mixed training interventions (Table 3), where the
of 13 included studies meet our inclusion criteria (Bateman 2001;
dose parameters for the cardiorespiratory and resistance training
Duncan 2003 (cited as Studentski); Mead 2007). Garcia-Soto 2013
components are reported, these are similar in nature to those
reviewed the effects of cardiorespiratory and resistance training
described above.
interventions on cognitive function after stroke. None of the five
included studies met our criteria for inclusion. Likewise, Zheng With regard to dose, the reality of progression is that dose is not
2016 examined the effect of cardiorespiratory exercises and none fixed and should constantly change to drive adaptations. In those
of the 10 included studies met our eligibility criteria. who respond more, progression may occur faster whilst being more
conservative in those who adapt slower. A 'one-size-fits-all' dose,
particularly in terms of intensity and progression, does not seem different stimuli and adaptations reflect the multi-dimensional
realistic and should be instead be personalised. With regard to a nature of balance.
starting dose, perhaps this is less important because progression
will move things on quickly; just doing something will be a good Overall, there is no one 'optimal' training type. Most patients are
start and help familiarise patients with what is involved. likely to benefit from a mixed programme of cardiorespiratory plus
resistance training for secondary prevention, to improve fitness,
Underestimation of benefits may arise if interventions are poorly improve mobility, and improve balance.
attended or complied with. Few included studies had full
attendance, where interventions occurred partly or completely Timing of training
during inpatient care, were home-based, or were of very short All our meta-analyses were divided into 'during usual care' and
duration (four weeks). Overall, there were no real threats to 'after usual care' subgroups. However, these analyses should be
planned dose among the included studies as a whole. This is a interpreted with caution as for many comparisons only a limited
reflection of there being few adverse events and indicates that number of studies was available.
these interventions are acceptable to those who participated.
However, the patient mix of included participants may have Overall completeness and applicability of evidence
restricted generalisability the wider stroke population.
We include patient-centred outcomes: still a lack of key
Overestimation of benefits may arise in studies where the outcomes
intervention group is potentially confounded by increased training
A priority-setting exercise undertaken in 2012 identified the top 10
time compared with the control group; this is adding an undefined
research priorities for life after stroke (Pollock 2012). Among the
element of 'dose', which may involve physical activity. In these
priorities identified by people with stroke and those who care for
studies with no attention control, additional benefits could arise
them are a substantial proportion of areas for which fitness training
from non-specific effects of therapist input, psychosocial effects of
could be beneficial:
contact with other participants, and factors such as travel to and
from a training location that could amount to a substantial dose of • cognitive function;
physical activity from which a real training effect could arise.
• upper limb function;
Although benefits have emerged in programmes less than 12 weeks • mobility, balance and gait; and
in length, there is some evidence to suggesting that four- to six- • the role of exercise in physical function, quality of life, and
week programmes of physical rehabilitation are less effective than secondary stroke prevention (Saunders 2014a).
those of eight to 14 weeks (Pollock 2014). There is no reason why
longer programmes of fitness training would not be more effective, Apart from mobility, balance, and some aspects of function, there is
likewise increased physical activity during the whole of life after little evidence relating to the other areas, which patients identified
stroke could achieve or maintain some of the same benefits as as relevant. In particular, cognitive function lacks investigation
exercise. despite being ranked the most important research priority.
Overall, the findings of this systematic review indicate that stroke To measure disability and dependence in stroke is problematic. A
survivors may successfully participate in, and complete, a variety variety of disability and assessment scales are usually reported in
of short-term training interventions. An 'optimal' dose for the studies of physical rehabilitation and fitness training. These scales
content of training for people with stroke has yet to be established. do not always assess the same functional domain and therefore
In reality, this is likely to be highly individual and therefore a pose the problem of the validity and reliability of combining their
personalised, stratified approach to physical fitness training seems results in a meta-analysis. Furthermore, some of these scales
more appropriate. are not validated in stroke survivors and, therefore, may lack
specificity. Rating scales are also prone to a 'ceiling effect' and
Type of training to skewed distributions. It would be useful if only well-known,
validated scales were used in future studies for the assessment
We were able to compare the effects of the different types of
of participants' functional performance and if study investigators
training on gait speed. Walking speed increased significantly
would clearly address the problems related to the use of these
after cardiorespiratory training and mixed training, but not
scales.
after resistance training. Both cardiorespiratory interventions and
mixed interventions comprised specific gait-related training, which Stroke survivors who are eligible for fitness training have typically
resulted in positive training effects. mild levels of disability. Mild impairments may be difficult to
assess and many of the existing disability scales may fail to detect
Overall, the findings of this review show that benefits reflect
them. However, functional decline over time that is simply due
the concept of specificity, the task-related nature of the training
to increasing age and inactivity could mean that mild disability
response. In particular, cardiorespiratory fitness (VO2 peak)
may progress quickly to more serious levels. Therefore, it would be
improved after interventions including cardiorespiratory training; useful to assess long-term outcomes in mild stroke survivors using
muscle strength improved after interventions including resistance pre-clinical disability measures (e.g. Fried 1996).
training; walking performance improved in particular after training
interventions based on walking or walking-like modes of exercise. Some lack of follow-up data
Balance was improved by gait-containing cardiorespiratory Both improvements in physical fitness after training and
training content but also by resistance training content; the improvements in physical function after rehabilitation are
transient. Since physical fitness may be linked to functional status,
Physical fitness training for stroke patients (Review) 43
Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cochrane Trusted evidence.
Informed decisions.
Library Better health. Cochrane Database of Systematic Reviews
the long-term retention of benefit should be routinely examined in Increase in studies including resistance training elements
studies assessing the effects of fitness training. Fitness and function
Compared with previous updates of this systematic review, we have
parameters are known to deteriorate with physical inactivity and to
observed an increase in studies with a resistance training element.
decrease with increasing age. Therefore, it is plausible that short-
This means the data about fitness training are now more complete.
term effects of training only emerge as being beneficial after a
The increase in interest mirrors that in other areas of public health
period of functional decline. There is a need to examine strategies
(Steele 2017).
aimed at promoting physical activity (including reduction of
sedentary behaviour) and maintaining physical fitness in the long Nature of control groups: confounding
term after stroke.
More than half of the included studies (41/75 studies; 55%) have
Functional advantages observed at the end of rehabilitation a design without attention control, meaning that the exposure
interventions are known to be transient, disappearing at a time is not equivalent. This confounds these data such that the
later stage (Kwakkel 2002). This is probably due to continued benefits can only be attributed to the whole exposure rather than
improvements in the control group rather than deterioration in the content and design of the fitness training itself.
function (Langhorne 2002). Fitness improvements observed at
the end of training interventions are also known to deteriorate. Quality of the evidence
Few studies included in this systematic review assessed possible
All the data we have reviewed are from RCTs. The main
retention of benefits over time. Those that did were at increased
threat concerning conclusions about the content and design of
risk of attrition bias. Most of the functional improvements observed
the exercise programmes is due to imbalanced exposure. Our
at the end of the training period were not sustained at later
sensitivity analyses identify where this may be happening.
assessments. We found, however, that cardiorespiratory and mixed
training effects on some measures of walking performance were Potential biases in the review process
retained at the end of the follow-up period. This retention effect
could have arisen from an increase in habitual levels of physical At the search stage it is possible that some relevant studies were
activity (including walking) facilitated by participation in a training missed. However, we used a very comprehensive search strategy
intervention. The extent to which short-term fitness training and ensured that every stage of inclusion involved an independent
influences longer-term, habitual physical activity after stroke is consensus decision by two review authors.
still unknown. Currently, there are no data examining either long-
term fitness training interventions or interventions to facilitate At the study selection stage it is possible that the interventions
continued exercise after the training intervention is completed. were misclassified resulting in either exclusion or resulting
Long-term assessments should be incorporated into future studies in misclassification of primary subgroup (cardiorespiratory,
of physical fitness training. Long-term uptake of exercise could resistance, or mixed training). However, we used well-known
benefit from additional behaviour change support rather than just definitions for fitness training that allowed clear criteria to be used
a finite exercise intervention (e.g. eight-week programme). (USDHHS 2018).
Interventions are typically short At the data extraction stage most included studies did not formally
include adverse events as a pre-planned outcome. However, we
While programmes of exercise may be finite, patients are likely to screened all studies for adverse and serious adverse events.
benefit from activity (including exercise) during the whole of life
after stroke. Other interventions, such as being more physically At the data extraction stage two review authors extracted all study
active and being less sedentary, are, like exercise, also 'energy characteristics and 'Risk of bias' items independently and reached
expending' in nature and may provide some similar benefits to a consensus. One review author extracted outcome data but all the
exercise. It is plausible that these approaches may contribute analysed data in Review Manager 2014 were double checked by a
to what exercise can offer and facilitate long-term retention and second review author.
benefits.
At the data analysis stage missing data from one included
Participant characteristics study were interpolated before analysis (Bateman 2001). Where
heterogeneity was introduced we tested the effect of including this
Most participants were ambulatory and were higher functioning.
study with a sensitivity analysis.
Only five out of 75 studies included participants who were non-
ambulatory, so there are difficulties in generalising the review At the data analysis stage there could be publication bias and small-
findings to people with stroke who cannot walk. Included studies study biases that affected the conclusions. We did test for evidence
used eligibility criteria relating to contraindications to exercise; of publication bias where a meta-analysis included 10 or more
this means that participants are more likely have better function studies. There was no evidence of problematic publication biases.
and health status. Although this restricts the population, the
data are still generalisable to people who are screened as being At the data analysis stage we examined a range of different classes
able to safely participate in exercise interventions. The average of outcomes; this is a broad review with that aim. However, small
age of participants was approximately 62 years. The findings are feasibility or pilot studies with high risk of bias and multiple
considered generalisable since two-thirds of all strokes are among outcomes may be more 'visible' in this review as the data
those aged under 70 years (Feigin 2017). may appear in multiple meta-analyses of different outcomes.
Conversely, large studies focused on limited numbers of outcomes
may be less 'visible'. Small studies with multiple outcome measures
are also more vulnerable to showing positive effects by chance if largest effects relate to resistance training. These effects may
not adjusted for multiple comparisons. reduce risk of falls.
At the reporting stage we made post hoc decisions about which Therefore, for people with stroke who are able to take part in
outcomes to include in the tables of studies. We included the exercise there are good reasons to want to combine different
findings for the primary outcomes and we did this for all three training types in order to maximise benefits directly relating to
training types irrespective of effect. Secondary outcomes that were physical fitness and mobility, and indirectly relating to reduction of
not included are clearly stated as being incomplete data on which risk of falls and secondary prevention.
a consensus cannot be reached.
A range of initiatives including practitioner training, best
Agreements and disagreements with other studies or practice guidelines, and recommendations have been developed
reviews worldwide that help facilitate the flow of research information into
practice. For example:
We retrieved 29 systematic reviews relating to exercise after stroke
during the searches for this update. On the whole these differ from • UK (Exercise and Fitness Training after Stroke
the architecture of this broad review because most tend to focus on Instructor course; www.laterlifetraining.co.uk/courses/exercise-
one type of exercise (e.g. cardiorespiratory or resistance training), for-stroke-instructor/);
one mode of exercise (e.g. walking/treadmill), or report a restricted • Canada (Canadian Best Practice Recommendations for Stroke
range of types of outcome measures. Therefore, this review is much Care; www.strokebestpractices.ca/);
more comprehensive in terms of capturing both the complexity of
• USA (APA Physical Activity and Exercise Recommendations for
intervention and also the range of potential benefits from exercise Stroke Survivors; Billinger 2014).
as a whole.
These initiatives are based on existing evidence about the benefits
Outcome by outcome there are some patterns of similarity. These of exercise after stroke and the needs of stroke survivors to have
include that cardiorespiratory fitness can be improved (Baldwin ongoing access to rehabilitation after discharge from hospital; they
2016; Boyne 2017; Saltychev 2016); balance can be improved by can inform service delivery.
cardiorespiratory, resistance, and mixed training (Chen 2016; Hasan
2016; Iatridou 2018; Tally 2017; Van Duijnhoven 2016; Vloothuis There are now a range of service delivery models in place in
2016; Wist 2016); and walking/mobility can be improved by mixed different countries around the world (Australia, Brazil, Canada,
and cardiorespiratory training (Baldwin 2016; Bonini-Rocha 2018; India, Nigeria, Singapore, Sweden, UK, and USA; Van Wijck 2019).
Boyne 2017; English 2017; Ilunga Tshiswaka 2018; Jeon 2015; The European Stroke Action Plan 2018-2030 gives a clear mandate
Kendall 2016; Mehrholz 2017), particularly if walking is used as an for implementation of services including fitness training, stating
exercise mode. There are also some shared concerns among other a target for 2030 of "Offering physical fitness programmes to all
systematic reviews about the benefits of resistance training alone in stroke survivors living in the community" (Norrving 2018).
terms of carry over of functional benefits (Dorsch 2018; Salter 2016;
Wist 2016). The findings of this systematic review update will contribute to
evidence-based pathways aimed at improving life after stroke.
There are some differences, with several reviews showing
positive effects on cognitive outcomes (Hasan 2016; Oberlin Implications for research
2017; Vanderbeken 2017; Zheng 2016), whereas our analyses
were inconclusive. One reason why our findings and those of Larger, well-designed clinical studies are needed to assess the
other reviews may differ is that some reviews included other co- effects of physical fitness training after stroke and to determine the
intervention elements that we would automatically exclude, and optimal regimen for improving fitness.
they may also have included studies that do not meet our criteria Future studies should:
for being defined as exercise. One review author team shared our
concerns about inadequate reporting, and the nature and dose of • comply with the current CONSORT guidelines for reporting of
exercise interventions (Ammann 2014). randomised clinical studies (CONSORT 2010);
• report exercise and control interventions more clearly;
AUTHORS' CONCLUSIONS
intervention reporting guidelines do exist (TIDiER; Hoffmann
Implications for practice 2014) including some specific to exercise (CERT Consensus
Exercise Reporting Template; Slade 2014);
Cardiorespiratory training alone can improve cardiorespiratory • include a broader population of stroke survivors (including non-
fitness. As well as benefiting functional capacity this may have a risk ambulatory stroke survivors) to allow stratification by gender,
reduction effect for secondary events. level of impairment, and functional ability;
Cardiorespiratory training alone or combined with a resistance • assess the effects of physical fitness training in people
training element (mixed training) improves the speed and capacity with specific post-stroke problems, for example people with
of walking when a walking mode of exercise is used; some of these depression or post-stroke fatigue;
effects are retained • be of longer duration (12 weeks or longer);
• have a long-term follow-up; and
Cardiorespiratory training or resistance training alone or in
• have some type of attention control to reduce confounding.
combination (mixed training) improves indices of balance. The
ACKNOWLEDGEMENTS We thank the Cochrane Stroke editorial team for their assistance
in preparing the protocol. We are grateful to Josh Cheyne for
Parts of the Background and Methods sections of this review his assistance in developing the search strategies. We also thank
include sections of verbatim template text because the approaches all investigators who provided further information about existing
used correspond to the protocol of a connected review by some studies.
of the same author team investigating interventions to reduce
sedentary behaviour after stroke (Saunders 2018). The approach is We would be grateful if people who are aware of studies potentially
permitted by The Cochrane Publication Policy. relevant for this review could contact David Saunders.
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of circuit training as alternative to usual physiotherapy after biofeedback cycling training on functional recovery and walking
stroke: randomised controlled trial. BMJ 2012;344:e2672. ability of lower extremity in patients with stroke. Kaohsiung
Journal of Medical Sciences 2014;30(1):35-42.
Van der Port IG, Wevers L, Roelse H, Van Kats L, Lindeman E,
Kwakkel G. Cost-effectiveness of a structured progressive task- Zedlitz 2012 {published data only}
oriented circuit class training programme to enhance walking Zedlitz AM, Rietveld TC, Geurts AC, Fasotti L. Cognitive
competency after stroke: the protocol of the FIT-Stroke trial. and graded activity training can alleviate persistent
BMC Neurology 2009;9:43. fatigue after stroke: a randomized, controlled trial. Stroke
2012;43(4):1046-51.
Vanroy 2017 {published data only}
* Vanroy C, Feys H, Swinnen A, Vanlandewijck Y, Truijen S, Zou 2015 {published data only}
Vissers D, et al. Effectiveness of active cycling in subacute stroke Zou J, Wang Z, Qu Q, Wang L. Resistance training improves
rehabilitation: a randomized controlled trial. Archives of Physical hyperglycemia and dyslipidemia, highly prevalent among
Medicine and Rehabilitation 2017;98(8):1576-85. nonelderly, nondiabetic, chronically disabled stroke patients.
Archives of Physical Medicine and Rehabilitation 2015; Vol. 96,
Vanroy C, Vanlandewijck Y, Cras P, Truijen S, Vissers D, issue 7:1291-6.
Swinnen A, et al. Does a cycling program combined with
education and followed by coaching promote physical activity
in subacute stroke patients? A randomized controlled trial. References to studies excluded from this review
Disability and Rehabilitation 2019;41(4):413-21.
Alabdulwahab 2015 {published data only}
Verheyden 2009 {published data only} Alabdulwahab SS, Ahmad F, Singh H. Effects of functional limb
Verheyden G, Vereeck L, Truijen S, Troch M, Lafosse C, Saeys W, overloading on symmetrical weight bearing, walking speed,
et al. Additional exercises improve trunk performance after perceived mobility, and community participation among
stroke: a pilot randomized controlled trial. Neurorehabilitation patients with chronic stroke. Rehabilitation Research and
and Neural Repair 2009;23(3):281-6. Practice 2015;2015:241519. [DOI: 10.1155/2015/241519]
Wang 2014 {published data only} Askim 2018 {published data only}
Wang Z, Wang L, Fan H, Lu X, Wang T. Effect of low-intensity Askim T, Langhammer B, Gunnes M, Ihle-Hansen H,
ergometer aerobic training on glucose tolerance in severely Indredavik B. Life after stroke-the LAST study. International
Journal of Stroke 2015;10 Suppl 2:419. [DOI: http:// after transient ischemic attack and minor ischemic stroke:
dx.doi.org/10.1111/ijs.12479] baseline data of the MoveIT study. Journal of Stroke and
Cerebrovascular Diseases 2017;26(5):1114-20. [DOI: 10.1016/
* Askim T, Langhammer B, Ihle-Hansen H, Gunnes M, j.jstrokecerebrovasdis.2016.12.029]
Lydersen St, Indredavik B. Efficacy and safety of
individualized coaching after stroke: the LAST study (Life Boss HM, Schaik MS, Deijle IA, Melker EC, Berg BT, Scherder EJA,
After Stroke): a pragmatic randomized controlled trial. Stroke et al. A randomised controlled trial of aerobic exercise
2018;49(2):426-32. after transient ischaemic attack or minor stroke to prevent
cognitive decline: the MoveIt study protocol. BMJ Open
Askim T, Langhammer B, Ihle-Hansen H, Lydersen S, Gunnes M, 2015;4(12):e007065. [DOI: 10.1136/bmjopen-2014-007065]
Indredavik B. Effect of an individualized prolonged follow up
programme for maintenance of motor function after stroke- Boss HM, Van Schaik SM, Deijle IA, De Melker EC, Van
the LAST study. A multisite randomised controlled trial. den Berg BT, Scherder EJ, et al. A randomised control trial of
International Journal of Stroke 2016;11 Suppl 3:21. [DOI: http:// aerobic exercise after transient ischaemic attack or minor stroke
dx.doi.org/10.1177/1747493016670567] to prevent cognitive decline: the MOVEIT study protocol. BMJ
Open 2014;4(12):e007065.
Askim T, Langhammer B, Ihle-Hansen H, Mari G, Stian L, Bent I.
A randomized controlled trial assessing the effect of a long- Boss HM, Van Schaik SM, Deijle IA, De Melker EC, Van
term follow-up programme aiming to maintain motor function den Berg BT, Scherder EJ, et al. A randomised controlled trial of
after stroke: the life after stroke (LAST) study. European Stroke aerobic exercise after transient ischaemic attack or minor stroke
Journal 2016;1 Suppl 1:727. [DOI: 10.1177/2396987316642910] to prevent cognitive decline: the MoveIT study. European Stroke
Journal 2018;3 Suppl 1:91. [DOI: 10.1177/2396987318770127]
Gunnes M, Langhammer B, Aamot IL, Lydersen S, Schroeter W,
Reneflot K, et al. How well do stroke survivors adhere to an 18- Boss HM, Van Schaik SM, Deijle IA, De Melker EC, Van
month physical activity and exercise programme? secondary den Berg BT, Scherder EJ, et al. Safety and feasibility of post-
results from a randomised controlled trial. Gait and Posture stroke care and exercise after minor ischemic stroke or transient
2017;57 Suppl 1:166. [DOI: 10.1016/j.gaitpost.2017.06.367] ischemic attack: MotiveS & MoveIT. NeuroRehabilitation
2014;34:401-7.
Awad 2015 {published data only}
Awad A, Shaker H, Shendy W. Effect of shoulder girdle Brauer 2018 {published data only}
strengthening on trunk alignment in patients with stroke. * Brauer SG, Kuys SS, Paratz JD, Ada L. Improving physical
Physiotherapy 2015;101 Suppl 1:eS1378-eS1379. [DOI: 10.1016/ activity after stroke via treadmill training and self management
j.physio.2015.03.1320] (IMPACT): a protocol for a randomised controlled trial. BMC
Neurology 2018;18:1-8. [DOI: 10.1186/s12883-018-1015-6]
Baer 2018 {published data only}
Baer GD, Salisbury LG, Smith MT, Pitman J, Dennis M. Brauer SG, Kuys SS, Waters L, Paratz JD, Ada L. The stroke-
Treadmill training to improve mobility for people with sub- IMPACT trial (improving physical activity via treadmill training):
acute stroke: a phase II feasibility randomized controlled a single blinded randomised controlled trial protocol.
trial. Clinical Rehabilitation 2018;32(2):201-12. [DOI: International Journal of Stroke 2014;9 Suppl 1:46.
10.1177/0269215517720486]
Brouwer 2018 {published data only}
Bang 2014 {published data only} Brouwer B, Bryant D, Garland JS. Effectiveness of client-
Bang D-H, Shin W-S, Noh H-J, Song M-S. Effect of unstable centered "tune-ups" on community reintegration, mobility,
surface training on walking ability in stroke patients. Journal of and quality of life after stroke: a randomized controlled
Physical Therapy Science 2014;26(11):1689-91. trial. Archives of Physical Medicine and Rehabilitation
2018;99(7):1325-32.
Bernhardt 2018 {published data only}
Buyukavci 2016 {published data only}
* Bernhardt J, Churilov L, Langhorne P, Pandian J, Dewey H,
Shrikanth V, et al. Determining optimal early rehabilitation after Buyukavci R, Sahin F, Sag S, Dogu B, Kuran B. The impact of
stroke (avertdose): a multi-arm covariate-adjusted, response- additional trunk balance exercises on balance, functional
adaptive randomised controlled trial. European Stroke Journal condition and ambulation in early stroke patients: randomized
2018;3 Suppl 1:612. [DOI: 10.1177/2396987318773967] controlled trial. Turkiye Fiziksel Tip ve Rehabilitasyon Dergisi
2016;62(3):248-56. [DOI: 10.5606/tftrd.2016.84770]
Bernhardt J, Dewey H, Langhorne P, Pandian J, Thijs V,
Churilov L, et al. Avert-dose (determining optimal early Cabanas-Valdés 2017 {published data only}
rehabilitation after stroke): a planned international randomised Cabanas Valdes R, German Romero A, Girabent Farres M,
controlled trial. International Journal of Stroke 2016;11 Suppl Bagur Calafat C, Caballero Gomez MF, Gerard UC. Long-term
3:226-7. [DOI: 10.1177/1747493016670567] follow-up effects of additional core stability exercises training
on improving dynamic sitting balance for stroke patients. A
Boss 2017 {published data only} randomized controlled trial. European Stroke Journal 2016;1
* Boss HM, Deijle IA, Van Schaik SM, De Melker EC, Van Suppl 1:341. [DOI: 10.1177/2396987316642909]
den Berg BT, Weinstein HC, et al. Cardiorespiratory fitness
Cabanas-Valdés R, Bagur-Calafat C, Girabent-Farrés M, analysis of the CIRCIT trial. Cerebrovascular Diseases 2016;42
Caballero-Gómez FM, Hernández-Valiño M, Urrutia Cuchi G. Suppl 1:6. [DOI: 10.1159/000447732]
The effect of additional core stability exercises on improving
dynamic sitting balance and trunk control for subacute stroke Faulkner 2014 {published data only}
patients: a randomized controlled trial. Clinical Rehabilitation Faulkner J, Lanford J, Lambrick D, Stoner L, Woolley B,
2016;30(10):1024-33. Donnell T, et al. The efficacy of early exercise engagement
as a secondary prevention strategy for stroke and TIA: study
* Cabanas-Valdés R, Bagur-Calafat C, Girabent-Farrés M, protocol and recruitment feasibility. International Journal of
Caballero-Gómez FM, du Port de Pontcharra-Serra H, German- Stroke 2014;9 Suppl 1:36.
Romero A, et al. Long-term follow-up of a randomized
controlled trial on additional core stability exercises training Faulkner 2015 {published data only}
for improving dynamic sitting balance and trunk control in Faulkner J, McGonigal G, Woolley B, Stoner L, Wong L,
stroke patients. Clinical Rehabilitation 2017;31(11):1492-9. [DOI: Lambrick D. A randomized controlled trial to assess the
10.1177/026921551770180] psychosocial effects of early exercise engagement in patients
diagnosed with transient ischaemic attack and mild, non-
NCT01864382. "Core stability" exercises to improve sitting
disabling stroke. Clinical Rehabilitation 2015;29(8):783-94. [DOI:
balance in stroke patients (Fisionet) [Effects of the inclusion
10.1177/0269215514555729]
of exercises "Core Stability" in the treatment of inpatient
physiotherapy to improve balance in post-stroke patients sitting Faulkner 2017a {published data only}
in subacute phase. Randomized clinical trial]. clinicaltrials.gov/
ct2/show/NCT01864382 (first received 29 May 2013). Faulkner J, Stoner L, Lanford J, Jolliffe E, Mitchelmore A,
Lambrick D. Long-term effect of participation in an early
Choi 2015 {published data only} exercise and education program on clinical outcomes and cost
implications, in patients with TIA and minor, non-disabling
Choi JU, Kang SH. The effects of patient-centered task-
stroke. Translational Stroke Research 2017;8(3):220-7. [DOI:
oriented training on balance activities of daily living and self-
10.1007/s12975-016-0510-6]
efficacy following stroke. Journal of Physical Therapy Science
2015;27(9):2985-8. [DOI: 10.1589/jpts.27.2985] Graef 2016 {published data only}
Choi 2017 {published data only} Graef P, Michaelsen SM, Dadalt ML, Rodrigues DA, Pereira F,
Pagnussat AS. Effects of functional and analytical strength
Choi YK, Kim K, Choi, JU. Effects of stair task training on walking
training on upper-extremity activity after stroke: a randomized
ability in stroke patients. Journal of Physical Therapy Science
controlled trial. Brazilian Journal of Physical Therapy
2017;29(2):235-7. [DOI: 10.1589/jpts.29.235]
2016;20(6):543-52. [DOI: 10.1590/bjpt-rbf.2014.0187]
Chua 2016 {published data only}
Gunnes 2017 {published data only}
Chua J, Culpan J, Menon E. Efficacy of an electromechanical
Gunnes M, Langhammer B, Aamot IL, Lydersen S, Schroeter W,
gait trainer poststroke in Singapore: a randomized controlled
Reneflot K, et al. How well do stroke survivors adhere to an 18-
trial. Archives of Physical Medicine and Rehabilitation
month physical activity and exercise programme? Secondary
2016;97(5):683-90. [DOI: 10.1016/j.apmr.2015.12.025]
results from a randomised controlled trial. Gait and Posture
Dong Hyun 2016 {published data only} 2017;57 Suppl 1:199.
Kim DH, Jang SH. Effects of an upper-limb exercise program Hahn 2015 {published data only}
for improving muscular strength and range of movement on
Hahn J, Shin S, Lee W. The effect of modified trampoline
respiratory function of stroke patients. Journal of Physical
training on balance, gait, and falls efficacy of stroke patients.
Therapy Science 2016;28(10):2785-8.
Journal of Physical Therapy Science 2015;27(11):3351-4. [DOI:
Dubey 2018 {published data only} 10.1589/jpts.27.3351]
Dubey L, Karthikbabu S, Mohan, D. Effects of pelvic stability Haruyama 2017 {published data only}
training on movement control, hip muscles strength,
Haruyama K, Kawakami M, Otsuka T. Effect of core
walking speed and daily activities after stroke: a randomized
stability training on trunk function, standing balance, and
controlled trial. Annals of Neurosciences 2018;25:80-9. [DOI:
mobility in stroke patients: a randomized controlled trial.
10.1159/000486273]
Neurorehabilitation and Neural Repair 2017;31(3):240-9.
English 2015 {published data only}
Hendrey 2018 {published data only}
* English C, Bernhardt J, Crotty M, Esterman A, Segal L, Hillier S.
Hendrey G, Clark RA, Holland AE, Mentiplay BF, Davis C,
Circuit class therapy or seven-day week therapy for increasing
Windfeld-Lund C, et al. Feasibility of ballistic strength training
rehabilitation intensity of therapy after stroke (CIRCIT): a
in sub-acute stroke: a randomized, controlled, assessor-blinded
randomized controlled trial. International Journal of Stroke
pilot study. Archives of Physical Medicine and Rehabilitation
2015;10(4):594-602. [DOI: 10.1111/ijs.12470]
2018;99(12):2430-46. [DOI: 10.1016/j.apmr.2018.04.032]
English C, Bernhardt J, Crotty M, Esterman A, Segal L, Watts J,
et al. Circuit class therapy reduces length of rehabilitation
stay, but weekend therapy does not. An exploratory secondary
Heron 2017 {published data only} Kim 2017b {published data only}
Heron N, Kee F, Mant J, Reilly PM, Cupples M, Tully M, et al. Kim CY, Lee JS, Kim HD. Comparison of the effect of lateral
Stroke Prevention Rehabilitation Intervention Trial of Exercise and backward walking training on walking function in patients
(SPRITE) - a randomised feasibility study. BMC Cardiovascular with poststroke hemiplegia: a pilot randomized controlled
Disorders 2017;17(1):290. [DOI: 10.1186/s12872-017-0717-9] trial. American Journal of Physical Medicine and Rehabilitation
2017;96(2):61-7. [DOI: 10.1097/PHM.0000000000000541]
Hillier 2014 {published data only}
Hillier S, English C, Bernhardt J, Crotty M, Esterman A, Kwon 2015 {published data only}
Segal L. Circuit class and 7-day week therapy for increasing Kwon OH, Woo Y, Lee JS, Kim KH. Effects of task-oriented
rehabilitation intensity of therapy after stroke (CIRCIT): treadmill-walking training on walking ability of stroke patients.
six month follow-up and cost analysis of the CIRCIT RCT. Topics in Stroke Rehabilitation 2015;22(6):444-52. [DOI:
International Journal of Stroke 2014;9 Suppl 3:22. 10.1179/1074935715Z.00000000057]
Hornby 2016 {published data only} Lee 2015 {published data only}
* Hornby TG, Holleran CL, Hennessy PW, Leddy AL, Connolly M, Lee YH, Park SH, Yoon ES, Lee CD, Wee SO, Fernhall B, et
Camardo J, et al. Variable Intensive Early Walking postStroke al. Effects of combined aerobic and resistance exercise on
(VIEWS): a randomized controlled trial. Neurorehabilitation and central arterial stiffness and gait velocity in patients with
Neural Repair 2016;30(5):440-50. chronic poststroke hemiparesis. American Journal of Physical
Medicine and Rehabilitation 2015;94(9):687-95. [DOI: 10.1097/
Leddy AL, Connolly M, Holleran CL, Hennessy PW, Woodward J, PHM.0000000000000233]
Arena RA, et al. Alterations in aerobic exercise performance
and gait economy following high-intensity dynamic Lee 2016 {published data only}
stepping training in persons with subacute stroke. Journal of Lee MM, Shin DC, Song CH. Canoe game-based virtual reality
Neurologic Physical Therapy 2016;40(4):239-48. [DOI: 10.1097/ training to improve trunk postural stability, balance, and upper
NPT.0000000000000147] limb motor function in subacute stroke patients: a randomized
controlled pilot study. Journal of Physical Therapy Science
Mahtani GB, Kinnaird CR, Connolly M, Holleran CL,
2016;28(7):2019-24. [DOI: doi.org/10.1589/jpts.28.2019]
Hennessy PW, Woodward J, et al. Altered sagittal- and frontal-
plane kinematics following high-intensity stepping training Lee 2017a {published data only}
versus conventional interventions in subacute stroke. Physical
Lee DH, Park SH, Han JW. Effect of bilateral upper extremity
Therapy 2017;97(3):320-9. [DOI: 10.2522/ptj.20160281]
exercise on trunk performance in patients with stroke. Journal
Hubbard 2015 {published data only} of Physical Therapy Science 2017;29(4):625-8. [DOI: 10.1589/
jpts.29.625]
Hubbard IJ, Carey LM, Budd TW, Levi C, McElduff P, Hudson S,
et al. A randomized controlled trial of the effect of early Lee 2017b {published data only}
upper-limb training on stroke recovery and brain activation.
Lee MJ, Lee JH, Koo HM, Lee SM. Effectiveness of bilateral arm
Neurorehabilitation and Neural Repair 2015;29(8):703-13. [DOI:
training for improving extremity function and activities of daily
10.1177/1545968314562647]
living performance in hemiplegic patients. Journal of Stroke
Hunter 2018 {published data only} and Cerebrovascular Diseases 2017;26(5):1020-5. [DOI: 10.1016/
j.jstrokecerebrovasdis.2016.12.008]
Hunter SM, Johansen-Berg H, Ward N, Kennedy NC, Chandler E,
Weir CJ, et al. Functional strength training and movement Lee 2018a {published data only}
performance therapy for upper limb recovery early poststroke-
Lee MJ, Yoon S, Kang JJ, Kim J, Kim JM, Han JY. Efficacy
efficacy, neural correlates, predictive markers, and cost-
and safety of caregiver-mediated exercise in post-
effectiveness: FAST-INdiCATE trial. Frontiers in Neurology
stroke rehabilitation. Annals of Rehabilitation Medicine
2018;25(8):733. [DOI: 10.3389/fneur.2017.00733]
2018;42(3):406-15. [DOI: 10.5535/arm.2018.42.3.406]
Immink 2014 {published data only}
Lee 2018b {published data only}
Immink MA, Hillier S, Petkov J. Randomized controlled trial
Lee MM, Lee KJ, Song CH. Game-based virtual reality canoe
of yoga for chronic poststroke hemiparesis: motor function,
paddling training to improve postural balance and upper
mental health, and quality of life outcomes. Topics in Stroke
extremity function: a preliminary randomized controlled study
Rehabilitation 2014;21(3):256-71. [DOI: 10.1310/tsr2103-256]
of 30 patients with subacute stroke. Medical Science Monitor
Kim 2016b {published data only} 2018;24:2590-8. [DOI: 10.12659/MSM.906451]
Kim N, Lee B, Kim Y, Min W. Effects of virtual reality treadmill Lim 2016 {published data only}
training on community balance confidence and gait in
Lim HS, Kim YL, Lee SM. The effects of Pilates exercise training
people post-stroke: a randomized controlled trial. Journal of
on static and dynamic balance in chronic stroke patients: a
Experimental Stroke and Translational Medicine 2016;9(1):1-7.
randomized controlled trial. Journal of Physical Therapy Science
2016;28(6):1819-24. [DOI: 10.1589/jpts.28.1819]
Lim 2017 {published data only} controlled trial. Physical Therapy 2017;97(6):640-8. [DOI:
Lim HS, Yoon S. The effects of Pilates exercise on 10.1093/physth/pzx032]
cardiopulmonary function in the chronic stroke patients: a
McDonnell 2017 {published data only}
randomized controlled trials. Journal of Physical Therapy
Science 2017;29(5):959-63. McDonnell MN, Serranda I, Hiller SL. Increasing the amount of
upper extremity rehabilitation in the first four weeks following
Lin 2015 {published data only} stroke: a feasibility study. Stroke 2017;48 Suppl 1:ATMP39.
Lin CH, Chou LW, Luo HJ, Tsai PY, Lieu FK, Chiang SL, et al.
Meng 2018 {published data only}
Effects of computer-aided interlimb force coupling training on
paretic hand and arm motor control following chronic stroke: Meng G, Meng X, Tan Y, Yu J, Jin A, Zhao Y, et al. Short-term
a randomized controlled trial. PloS One 2015;10(7):e0131048. efficacy of hand-arm bimanual intensive training on upper
[DOI: 10.1371/journal.pone.0131048] arm function in acute stroke patients: a randomized controlled
trial. Frontiers in Neurology 2018;8:726. [DOI: 10.3389/
Linder 2017 {published data only} fneur.2017.00726]
Linder S, Rosenfeldt A, Alberts J. Forced aerobic exercise
Ordahan 2015 {published data only}
enhances upper extremity task practice in patients with stroke.
Stroke 2015;46 Suppl 1:A144. Ordahan B, Karahan AY, Basaran A, Turkoglu G, Kucuksarac S,
Cubukcu M, et al. Impact of exercises administered to stroke
Linder S, Rosenfeldt A, Bazyk A, Lee J, Blohm M, Penko A, et al. patients with balance trainer on rehabilitation results: a
Forced- and voluntary-rate aerobic exercise training improve randomized controlled study. Hippokratia 2015;19(2):125-30.
cardiovascular function in individuals with chronic stroke.
Stroke 2017;48 Suppl 1:AWP154. Pandian 2015 {published data only}
Pandian S, Arya KN, Kumar D. Effect of motor training involving
Linder S, Rosenfeldt A, Penko A, Alberts J. The utilization of the less-affected side (MTLA) in post-stroke subjects: a pilot
forced aerobic exercise to augment the recovery of motor randomized controlled trial. Topics in Stroke Rehabilitation
function following stroke: a randomized clinical trial. Neurology 2015;22(5):357-67. [DOI: 10.1179/1074935714Z.0000000022]
2014;82 Suppl 10:P2.016.
Park 2015a {published data only}
* Linder SM, Rosenfeldt AB, Dey T, Alberts JL. Forced aerobic
Park BS, Noh JW, Kim MY, Lee LK, Yang SM, Lee WD, et al. The
exercise preceding task practice improves motor recovery
effects of aquatic trunk exercise on gait and muscle activity in
poststroke. American Journal of Occupational Therapy
stroke patients: a randomized controlled pilot study. Journal of
2017;71(2):1-9. [DOI: 10.5014/ajot.2017.020297]
Physical Therapy Science 2015;27(11):3549-53. [DOI: 10.1589/
Lund 2018 {published data only} jpts.27.3549]
Lund C, Dalgas U, Grønborg TK, Andersen H, Severinsen K, Park 2015b {published data only}
Riemenschneider M, et al. Balance and walking performance
Park BS, Kim MY, Lee LK, Yang SM, Lee WD, Noh JW, et al. Effects
are improved after resistance and aerobic training in
of conventional overground gait training and a gait trainer with
persons with chronic stroke. Disability and Rehabilitation
partial body weight support on spatiotemporal gait parameters
2018;40(20):2408-15. [DOI: 10.1080/09638288.2017.1336646]
of patients after stroke. Journal of Physical Therapy Science
Malagoni 2016 {published data only} 2015;27(5):1603-7. [DOI: 10.1589/jpts.27.1603]
Malagoni AM, Cavazza S, Ferraresi G, Grassi G, Felisatti M, Park 2015c {published data only}
Lamberti N, et al. Effects of a "test in-train out" walking
Park KH, Kim DY, Kim TH. The effect of step climbing exercise
program versus supervised standard rehabilitation in chronic
on balance and step length in chronic stroke patients. Journal
stroke patients: a feasibility and pilot randomized study.
of Physical Therapy Science 2015;27(11):3515-8. [DOI: 10.1589/
European Journal of Physical and Rehabilitation Medicine
jpts.27.3515]
2016;52(3):279-87.
Park 2016a {published data only}
Malik 2018 {published data only}
Park KH, Lim JY, Kim TH. The effects of ankle strategy exercises
Malik AN, Amjad I, ul-Ain Q. Effect of circuit gait training vs
on unstable surfaces on dynamic balance and changes in the
traditional gait training on mobility performance in stroke.
COP. Journal of Physical Therapy Science 2016;28(2):456-9. [DOI:
Journal of the Pakistan Medical Association 2018;68(3):455-8.
10.1589/jpts.28.456]
Marryam 2017 {published data only}
Park 2016b {published data only}
Marryam M, Umar M. Effectiveness of task oriented training
Park GD, Choi JU, Kim YM. The effects of multidirectional
in improving upper limb function after stroke. Rawal Medical
stepping training on balance, gait ability, and falls efficacy
Journal 2017;42(3):341-3.
following stroke. Journal of Physical Therapy Science
Martins 2017 {published data only} 2016;28(1):82-6. [DOI: 10.1589/jpts.28.82]
Martins JC, Aguiar LT, Nadeau S, Scianni AA, Teixeira-Salmela LF,
Faria CD. Efficacy of task-specific training on physical activity
levels of people with stroke: protocol for a randomized
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Park 2016c {published data only} Roh 2016 {published data only}
Park KT, Kim HJ. Effect of the a circuit training program using Roh S, Gil HJ, Yoon S. Effects of 8 weeks of mat-based Pilates
obstacles on the walking and balance abilities of stroke exercise on gait in chronic stroke patients. Journal of Physical
patients. Journal of Physical Therapy Science 2016;28(4):1194-8. Therapy Science 2016;28(9):2615-9. [DOI: 10.1589/jpts.28.2615]
[DOI: 10.1589/jpts.28.1194]
Rose 2017 {published data only}
Park 2016d {published data only} Rose DK, Nadeau SE, Wu SS, Tilson JK, Dobkin BH, Pei Q, et
Park T-Y, Cha Y-J, Son S-M. Comparison of body composition al. Locomotor training and strength and balance exercises for
of trunk and extremities of affected sides at different aerobic walking recovery after stroke: response to number of training
exercise intensities in chronic stroke patients: a randomized sessions. Physical Therapy 2017;97(11):1066-74. [DOI: 10.1093/
controlled preliminary report. Iranian Journal of Public Health ptj/pzx079]
2016;45(8):1085-6.
Rose 2018 {published data only}
Park 2017a {published data only} Rose DK, DeMark L, Fox EJ, Clark DJ, Wludyka P. A backward
Park J, Gong J, Yim J. Effects of a sitting boxing program on walking training program to improve balance and mobility in
upper limb function, balance, gait, and quality of life in stroke acute stroke: a pilot randomized controlled trial. Journal of
patients. NeuroRehabilitation 2017;40(1):77-86. [DOI: 10.3233/ Neurologic Physical Therapy 2018;42(1):12-21. [DOI: 10.1097/
NRE-161392] NPT.0000000000000210]
Vahlberg 2017 {published data only} Vasileva 2017 {published data only}
Vahlberg B, Cederholm T, Hellström K, Zetterberg L, Lindmark B. Vasileva D, Izov N, Maznev I, Lubenova D, Mihova M, Markovski V,
Body composition and training after stroke. European et al. Changes in kinetic parameters of gait in patients with
Geriatric Medicine 2015;6 Suppl 1:S112-S113. [DOI: 10.1016/ supratentorial unilateral stroke in chronic period. Open Access
S1878-7649(15)30402-2] Macedonian Journal of Medical Sciences 2017;5(2):201-6. [DOI:
10.3889/oamjms.2017.053]
Vahlberg B, Cederholm T, Lindmark B, Zetterberg L, Hellstrom K.
Progressive resistance and balance training in circuit classes Wang 2015 {published data only}
about a year after stroke: a randomized controlled trial. Wang TC, Tsai AC, Wang JY, Lin YT, Lin KL, Chen JJ, et al.
Cerebrovascular Diseases 2014;37 Suppl 1:428. Caregiver-mediated intervention can improve physical
functional recovery of patients with chronic stroke: a
Vahlberg B, Cederholm T, Lindmark B, Zetterberg L, Hellström K.
randomized controlled trial. Neurorehabilitation and Neural
Effects of progressive resistance and balance training 1-3 years
Repair 2015;29(1):3-12. [DOI: 10.1177/1545968314532030]
after stroke: a randomized controlled trial. FASEB Journal
2014;28 Suppl 1:706.14. Wright 2018 {published data only}
* Vahlberg B, Cederholm T, Lindmark B, Zetterberg L, Wright H, Wright T, Pohlig RT, Kasner SE, Raser-Schramm J,
Hellström K. Short-term and long-term effects of a Reisman D. Protocol for promoting recovery optimization
progressive resistance and balance exercise program in of walking activity in stroke (PROWALKS): a randomized
individuals with chronic stroke: a randomized controlled controlled trial. BMC Neurology 2018;18(1):39. [DOI: 10.1186/
trial. Disability and Rehabilitation 2017;39(16):1615-22. [DOI: s12883-018-1044-1]
10.1080/09638288.2016.1206631]
Zhang 2016 {published data only}
Vahlberg B, Cederholm T, Zetterberg L, Lindmark B, Hellstrom K. Zhang Y, Wang YZ, Huang LP, Bai B, Zhou S, Yin MM, et al.
Progressive resistance and balance training in circuit classes Aquatic therapy improves outcomes for subacute stroke
about one year after stroke: a randomized controlled trial. patients by enhancing muscular strength of paretic lower
Cerebrovascular Diseases 2014;37 Suppl 1:334. limbs without increasing spasticity: a randomized controlled
trial. American Journal of Physical Medicine and Rehabilitation
Vahlberg B, Lindmark B, Zetterberg L, Hellström K, Cederholm T. 2016;95(11):840-9. [DOI: 10.1097/PHM.0000000000000512]
Body composition and physical function after progressive
resistance and balance training among older adults Zhiyan 2017 {published data only}
after stroke: an exploratory randomized controlled trial. Zhiyan H, Li NI, Baoyun C, Zunke G, Qinghong W, Lange F.
Disability and Rehabilitation 2017;39(12):1207-14. [DOI: Rehabilitation nursing for cerebral stroke patients within a
10.1080/09638288.2016.1191551] suitable recovery empty period. Iranian Journal of Public Health
2017;46(2):180-5.
Valkenborghs 2016 {published data only}
Valkenborghs S, Callister R, Nilsson M, Erickson K, Visser M, Zhu 2016 {published data only}
Dunn A, et al. Aerobic exercise to increase efficacy of task- Zhu Z, Cui L, Yin M, Yu Y, Zhou X, Wang H, et al. Hydrotherapy
specific training for the upper limb after stroke: a pilot study. vs. conventional land-based exercise for improving
International Journal of Stroke 2016;11 Suppl 1:12. walking and balance after stroke: a randomized controlled
trial. Clinical Rehabilitation 2016;30(6):587-93. [DOI:
* Valkenborghs S, Callister R, Nilsson M, Erickson K, Visser M,
10.1177/0269215515593392]
Dunn A, et al. Aerobic exercise to increase efficacy of task-
specific training for the upper limb after stroke: a pilot study
protocol. Cerebrovascular Diseases 2016;42 Suppl 1:113-4. References to studies awaiting assessment
Valkenborghs 2017 {published data only} Brands Guendling 2017 {published data only}
Valkenborghs SR, Visser MM, Dunn A, Erickson KI, Nilsson M, Brands-Guendling N, Guendling PW. Equipment-
Callister R, et al. AExaCTT - Aerobic Exercise and Consecutive based movement therapy in stroke rehabilitation. BMC
Task-specific Training for the upper limb after stroke: protocol Complementary and Alternative Medicine 2017;17 Suppl 1:P22.
for a randomised controlled pilot study. Contemporary [DOI: 10.1186/s12906-017-1782-4]
Clinical Trials Communications 2017;7:179-85. [DOI: 10.1016/
j.conctc.2017.07.009] Chan 2017 {published data only}
Chan K, Phadke CP, Stremler D, Suter L, Pauley T, Ismail F,
Van Criekinge 2017 {published data only} et al. The effect of water-based exercises on balance
Van Criekinge T, Saeys W, Hallemans A, Vereeck L, De Hertogh W, in persons post-stroke: a randomized controlled trial.
Van de Walle P, et al. Effectiveness of additional trunk exercises Topics in Stroke Rehabilitation 2017;24(4):228-35. [DOI:
on gait performance: study protocol for a randomized 10.1080/10749357.2016.1251742]
controlled trial. Trials 2017;18(1):1-12. [DOI: 10.1186/
s13063-017-1989-1] Chan 2018 {published data only}
Chan WN, Tsang WW. Effect of Tai Chi training on dual-tasking
performance that involves stepping down among stroke
survivors: a pilot study. Evidence-based Complementary and Frimpong 2014 {published data only}
Alternative Medicine : ECAM 2017;2017:Article ID 9134173. [DOI: Frimpong E, Olawale OA, Antwi DA, Antwi-Boasiako C,
10.1155/2017/9134173] Dzudzor B. Task-oriented circuit training improves ambulatory
functions in acute stroke: a randomized controlled trial. Journal
* Chan WN, Tsang WW. The effect of Tai Chi training on the
of Medicine and Medical Sciences 2014;5(8):169-75.
dual-tasking performance of stroke survivors: a randomized
controlled trial. Clinical Rehabilitation 2018;32(8):1076-85. [DOI: Gezer 2018 {published data only}
10.1177/0269215518777872]
Gezer H, Karaahmet OZ, Gurcay E, Dulgeroglu D, Cakci A. The
Chen 2014 {published data only} effect of aerobic exercise on stroke rehabilitation. Irish Journal
of Medical Science 2018:1-5.
Chen YJ, Huang HC, Tasi SY, Lin CW, Lin SY. Exercise
interventions increase lower extremity muscle strength in Hwang 2015 {published data only}
patients with stroke. Cerebrovascular Diseases 2014;38 Suppl
Hwang G-Y. The Effects of Aquatic Exercise Program on
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Cardiorespiratory Function, Motor Fitness, and Physical Activity
Deshpande 2018 {published data only} Affect for Poststroke Adults [PhD Thesis]. Denton, Texas USA:
Texas Womens University, 2015.
CTRI/2017/05/008482. The effect of task oriented circuit
training on hand function in people with one-sided weakness Jeon 2016 {published data only}
living in the society [Influence of task oriented circuit
Jeon HJ, An S, Yoo J, Park NH, Lee KH. The effect of monkey
training on upper limb function in community dwelling
chair and band exercise system on shoulder range of motion
stroke survivors]. ctri.nic.in/Clinicaltrials/pmaindet2.php?
and pain in post-stroke patients with hemiplegia. Journal of
trialid=17978&EncHid=&userName=CTRI/2017/05/008482 (first
Physical Therapy Science 2016;28(8):2232-7. [DOI: 10.1589/
received 4 May 2017).
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* Deshpande SA, Girish N, Mohapatra S. Influence
Kim 2015 {published data only}
of task oriented circuit training on upper limb
function among community dwelling stroke survivors. Kim SJ, Cho HY, Kim YL, Lee SM. Effects of stationary
Neurorehabilitation and Neural Repair 2018;32(4-5):408-9. [DOI: cycling exercise on the balance and gait abilities of chronic
10.1177/1545968318765498] stroke patients. Journal of Physical Therapy Science
2015;27(11):3529-31. [DOI: 10.1589/jpts.27.3529]
Ellis 2018 {published data only}
Kim 2017c {published data only}
* Ellis MD, Carmona C, Drogos J, Dewald J. Progressive
abduction loading therapy with horizontal-plane viscous Kim K, Jung SI, Lee DK. Effects of task-oriented circuit training
resistance targeting weakness and flexion synergy to on balance and gait ability in subacute stroke patients: a
treat upper limb function in chronic hemiparetic stroke: a randomized controlled trial. Journal of Physical Therapy Science
randomized clinical trial. Frontiers in Neurology 2018;9:71. [DOI: 2017;29(6):989-92. [DOI: 10.1589/jpts.29.989]
10.3389/fneur.2018.00071]
Koç 2015 {published data only}
Ellis MD, Carmona C, Drogos J, Traxel S, Dewald JP. Progressive Koç A. Exercise in patients with subacute stroke: a randomized,
abduction loading therapy targeting flexion synergy to regain controlled pilot study of home-based exercise in subacute
reaching function in chronic stroke: preliminary results from stroke. Work 2015;52(3):541-7. [DOI: 10.3233/WOR-152156]
an RCT. Conference Proceedings - IEEE Engineering in Medicine
and Biology Society 2016:5837-40. Kumaran 2016 {published data only}
Kumaran DS, Rao BK, Rao SN, Kamath A. Effect of a task and
Faulkner 2017b {published data only} context based exercise program (TCEP) on improving walking
Faulkner J, Tzeng YC, Lambrick D, Woolley B, Allan PD, function in community dwelling stroke survivors: a randomized
O'Donnell T, et al. A randomized controlled trial to assess the controlled trial. International Journal of Stroke 2016;11:59. [DOI:
central hemodynamic response to exercise in patients with 10.1177/1747493016670567]
transient ischaemic attack and minor stroke. Journal of Human
Hypertension 2017;31(3):172-7. [DOI: 10.1038/jhh.2016.72] Lawal 2016 {published data only}
* Lawal I, Hillier S, Hamzat T, Rhoda A. Augmented duration
Floel 2018 {published data only} of circuit class therapy in the rehabilitation of muscle strength
* Flöel A, Nave A, Rackoll T, Grittner U, Blasing H, Gorsler A, and spasticity post stroke: a randomized controlled trial.
et al. Physical activity in subacute stroke - phys-stroke. International Journal of Stroke 2016;11 Suppl 3:188. [DOI:
European Stroke Journal 2018;3 Suppl 1:593. [DOI: 10.1177/1747493016670567]
10.1177/2396987318773967]
Lawal IU, Hillier SL, Hamzat TK, Rhoda A. Effectiveness of a
Rackoll T, Nave A, Grittner U, Meisel A, Endres M, Ebinger M, structured circuit class therapy model in stroke rehabilitation:
et al. A heart for running-safety considerations on aerobic a protocol for a randomised controlled trial. BMC Neurology
exercise in the subacute phase of stroke-data from the phys- 2015;15:88. [DOI: 10.1186/s12883-015-0348-7]
stroke trial. European Stroke Journal 2018;3(Suppl 1):129. [DOI:
10.1177/2396987318770127]
Lawal IU, Lawal I. Effectiveness of augmenting therapy Song 2015a {published data only}
time in circuit class therapy on mobility of upper/lower Song GB, Hwangbo G. The effect of a rehabilitational sliding
extremity post stroke: a randomized pilot study. Physiotherapy machine and conventional neurological physical therapy on the
2015;101:eS840-eS841. [DOI: 10.1016/j.physio.2015.03.1658] balance of patients with hemiplegia. Journal of Physical Therapy
Science 2015;27(1):171-3. [DOI: 10.1589/jpts.27.171]
Maheshwari 2018 {published data only}
Maheshwari PK, Kaushik S, Vishwas K. Comparison of strength Song 2015b {published data only}
training and task specific exercises to improve upper limb * Song HS, Kim JY, Park SD. Effect of the class and individual
function in stroke patients. Neurorehabilitation and Neural applications of task-oriented circuit training on gait ability in
Repair 2018;32(4-5):491-2. [DOI: 10.1177/1545968318765498] patients with chronic stroke. Journal of Physical Therapy Science
2015;27(1):187-9. [DOI: 10.1589/jpts.27.187]
Matsumoto 2016 {published data only}
Matsumoto S, Uema T, Ikeda K, Miyara K, Nishi T, Noma T, et Song HS, Kim JY, Park SD. The effect of class-based task-
al. Effect of underwater exercise on lower-extremity function oriented circuit training on the self-satisfaction of patients
and quality of life in post-stroke patients: a pilot controlled with chronic stroke. Journal of Physical Therapy Science
clinical trial. Journal of Alternative and Complementary Medicine 2015;27(1):127-9. [DOI: 10.1589/jpts.27.127]
2016;22(8):635-41. [DOI: 10.1089/acm.2015.0387]
Szczygiel 2015 {published data only}
Oh 2016 {published data only} Szczygiel J, Opara J. Effects of treadmill training with partial
Oh DS, Park SE. The effect of lumbar stabilization exercise body-weight support on biomechanical parameters of gait after
on the pulmonary function of stroke patients. Journal of stroke. Physiotherapy 2015;101 Suppl 1:eS1151. [DOI: 10.1016/
Physical Therapy Science 2016;28(6):1896-900. [DOI: 10.1589/ j.physio.2015.03.2062]
jpts.28.1896]
Van den Berg 2016 {published data only}
Opara 2016 {published data only} * Van Den Berg M, Crotty M, Liu E, Killington M, Kwakkel G,
Opara J, Szczygiel J. Effects of treadmill training with partial Van Wegen E. Early supported discharge by caregiver-mediated
body-weight support on clinical parameters of GAIT early after exercises and e-Health support after stroke: a proof-of-
stroke-preliminary results. Cerebrovascular Diseases 2016;41 concept trial. Stroke 2016;47(7):1885-92. [DOI: 10.1161/
Suppl 1:113. STROKEAHA.116.013431]
Ploughman 2017 {published data only} Vloothuis J, Mulder M, Nijland RH, Konijnenbelt M, Mulder H,
Ploughman M, Eskes GA, Kelly LP, Kirkland MC, Hertogh CM, et al. Caregiver-mediated exercises with
Devasayaham AJ, Wallack EM, et al. Aerobic exercise enhances e-health support for early supported discharge after
the beneficial effects of cognitive training and reopens the stroke (CARE4STROKE): study protocol for a randomized
'window of recovery' in chronic stroke via neurotrophins. controlled trial. BMC Neurology 2015;15(1):193. [DOI: 10.1186/
International Journal of Stroke 2017;12(4 Suppl 1):18-9. [DOI: s12883-015-0440-z]
10.1177/1747493017721569]
Vij 2015 {published data only}
Pudipeddi 2016 {published data only} Vij JS, Multani NK. NDT based gait training as compared to lower
Pudipeddi BK. Effect of strength training on normalizing limb strengthening in correction of gait pattern of post-stroke
the tone and strength of spastic elbow flexors in hemiparetic patients. Physiotherapy 2015;101:eS1591-eS1592.
subjects with stroke with isokinetic analyser [BIODEX]. [DOI: 10.1016/j.physio.2015.03.1599]
International Journal of Stroke 2016;11 Suppl 3:135. [DOI:
Wu 2017 {published data only}
10.1177/1747493016670567]
Wu X-L. Effect of Qi-cultivating and mood-soothing
Ruescas-Nicolau 2015 {published data only} bodybuilding exercise on psychological mood and degree of
Ruescas-Nicolau MA, Sanchez-Sanchez ML, Espi-Lopez GV, satisfaction with care in stroke patients with gastrointestinal
Marques-Sule E, Perez-Miralles JA. Effect of a combined bleeding. Shi Jie Hua Ren Xiao Hua Za Zhi 2017;25(9):837-40.
cardiovascular /task-oriented interval training programme on
Xu 2015 {published data only}
walking capacity in chronic stroke subjects. Cerebrovascular
Diseases 2015;39 Suppl 2:322. Xu CW, Liu HL, Zhao D. Effect of acupuncture and exercise
rehabilitation on motor function and activity of daily life among
Sanchez Sanchez 2015 {published data only} hemiplegia patients after stroke. Journal of Clinical Acupuncture
Sanchez-Sanchez ML, Ruescas-Nicolau MA, Espi-Lopez GV, and Moxibustion 2015;31(3):11-3.
Perez-Miralles JA, Morcillo-Fores JA, Marques-Sule E, et al.
Yang 2018 {published data only}
Effects on the upper limb sensoriomotor function of a circuit
class strength training with elastic bands. Cerebrovascular Yang ZH, Wu HY, Shen MY, Yang JQ, Cao LM. Clinical analysis
Diseases 2015;39 Suppl 2:323. of three kinds of exercise therapy on knee control in
hemiplegic patients. Neurorehabilitation and Neural Repair
2018;32(4-5):392. [DOI: 10.1177/1545968318765498]
Klassen TD, Eng JJ, Bayley M, Benavente O, Bennett J, Fraser J, NCT02619110 {published data only}
et al. Implementing an extra hour of intensive, task-specific, NCT02619110. The effect of backward walking treadmill training
physical therapy daily for individuals post-stroke during on balance in patient with chronic stroke [The purpose of
inpatient rehabilitation: feasibility data from the DOSE study. this study was to discuss on the effects of backward walking
International Journal of Stroke 2015;10 Suppl 4:86. [DOI: treadmill training on balance ability, speed of walking and
10.1111/ijs.12633-2] cardiopulmonary fitness for patient with chronic stroke].
clinicaltrials.gov/ct2/show/NCT02619110 (first received 2
* NCT01915368. Determining Optimal post-Stroke Exercise December 2015).
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2 August 2013).
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Van Criekinge 2019
Schulz 2002 Van Criekinge T, Truijen S, Verbruggen C, Van de Venis L,
Schulz KF, Grimes DA. Sample size slippages in randomised Saeys W. The effect of trunk training on muscle thickness
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2002;359(9308):781-5. Rehabilitation 2019;41(15):1751-9.
CHARACTERISTICS OF STUDIES
Ada 2013
Methods Design: randomised trial of cardiorespiratory training vs no intervention – after UC
Withdrawals: 2 months treadmill training group: 1 participant withdrew; control group: 3 participants
withdrew - reasons unclear
Intervention: treadmill training 2-month group: 34 participants: 28 men and 6 women; mean age 64
years (SD 12); 20 months post-stroke (SD 15). Treadmill training 4-month group: 34 participants; 24 men
and 10 women; mean age 70 years (SD 11); 22 months post-stroke (SD 16)
Control: 34 participants; 19 men and 15 women; mean age 63 years (SD 13); 19 months post-stroke (SD
13)
Inclusion criteria: within first 5 years post-stroke; MMSE score of > 23; discharged from rehabilitation;
community-dwelling; 10-m unaided walking speed > 9 seconds
Interventions Invention group: both 2-month and 4-month treadmill training group received 30 min treadmill walk-
ing 3 times/week for 8 or 16 weeks respectively
Progressive in nature. Both groups also received overground walking training (20% of intervention dur-
ing week 1, increasing to 50% at week 8; for those in 4-month group, overground walking reduced to
20% of intervention increasing again to 50% at week 16)
Outcomes Included outcomes: 6-MWT; EuroQol Health Status; Adelaide Activities Profile; walking and falls self-ef-
ficacy
Notes There were 2 intervention groups. The extracted data correspond to:
• group 1 (4-month intervention) end of intervention data were compared with control group data avail-
able at 4 months only
• group 2 (2-month intervention) end of intervention data were compared with control group data avail-
able at 2 months only
A subgroup analysis was performed (Dean 2014) to examine the effects of the intervention on slower (≤
4 m/sec) and faster (> 4 m/sec) walkers at baseline
Risk of bias
Random sequence genera- Low risk Computer-generated randomisation stratified on walking disability by inde-
tion (selection bias) pendent researcher
Allocation concealment Low risk Allocation concealment ensured because all available participants allocated in
(selection bias) groups of 15 to blocks of 3 after baseline measures recorded
Selective reporting (re- Low risk Reported outcomes correspond to trial registry ACTRN12607000227493
porting bias)
Aidar 2016
Methods Design: randomised trial of resistance training vs no intervention after UC
Withdrawals: 3 participants from intervention group during 2nd week of intervention and 2 participants
from control group were not assessed at the end of the intervention
Intervention: 11 participants; 6 men and 5 women; mean age 51.7 years (SD 8.0); days after stroke un-
known (> 1 year)
Control: 13 participants; 9 men and 4 women; mean age 52.5 years (SD 7.7); days after stroke unknown
(> 1 year)
Inclusion criteria: below 'per-capita' income, below minimum wage, medical authorisation 'clinically
healthy people', stroke > 1 year ago, clinically stable, presence of hemiplegia or hemiparesis
Exclusion criteria: aphasia, no recurrent strokes, asymptomatic with a non-disabling deficit or with se-
vere disabilities
Interventions Intervention group: resistance training; 12-week intervention, 3 times/week, each session lasting 60
min - conducted in the morning. Minimum of 48 h rest between sessions. Warm-up including 10-15 min
walking followed by upper and lower body strengthening exercises: bar-guided squat, machine bench
press, horizontal leg press, military press machine, abdominal crunch, front lateral pull downs and bar-
guided lunges. 3 sets of 8-10 reps with 2-min rest between sets
• 2012 paper: State-Trait Anxiety Inventory; muscle strength (1-RM kg for various lifts; squat, bench
press, leg press, military press, lateral pull downs, lunges)
• 2014 paper: depression (BDI), muscle strength
• 2016 paper: SF-36
Risk of bias
Random sequence genera- Unclear risk "Lottery" allocation into groups; still unclear exactly what was done
tion (selection bias)
Incomplete outcome data High risk 2/13 control group not analysed in 2016 paper; no ITT analysis
(attrition bias)
End of intervention
Other bias Unclear risk Self-selection bias may occur as advertisements were used
Aidar 2018
Methods Design: randomised trial of cardiorespiratory training (aquatic physical exercises) vs no intervention -
after UC
ITT: no
Withdrawals: (2007) 1 intervention group participant refused training programme; 2 control partici-
pants were not assessed at the end of the intervention
Intervention: (2007) 15 participants; 10 men and 5 women; mean age 50.3 years (SD 9.1)
Intervention: (2018) 19 participants; 10 men and 9 women; mean age 51.8 years (SD 8.5)
Control: (2007) 13 participants; 9 men and 4 women; mean age 52.5 years (SD 7.7)
Control: (2018) 17 participants; 9 men and 8 women; mean age 52.7 years (SD 6.7)
Interventions Intervention group: aquatic physical sessions (e.g. walking activity and physical exercises in the water;
swimming) 45-60 min each session; 2 times/week for 12 weeks
Notes Content of the intervention not very detailed. It appears that the Aidar 2018 paper is an extension of
this same study published in 2007 with 8 new women participants added and different outcome report-
ed
Risk of bias
Random sequence genera- Unclear risk Stated 'random' but no further details provided
tion (selection bias)
Incomplete outcome data Unclear risk 1/16 lost from intervention and 2/15 from control group. No ITT analysis
(attrition bias)
End of intervention
Arabzadeh 2018
Methods Design: open-label, randomised clinical trial; task-orientated resistance training (and balance) vs CPT
during UC
Randomisation: unclear; states that the randomisation procedure was performed by a person who was
not involved in the assessment
Allocation concealment: independent person prepared sealed envelopes, which were picked up by par-
ticipants in the order in which they entered the study
Blinding: participants in both groups were treated and assessed by the same physiotherapist; bias due
to “non blinding" was noted in the studies limitations; participants and assessors may have under-
stood nature of group assignments
Intervention: 10 participants; 8 men (80%) and 2 women (20%); mean age: 58.9 (SD 26.8); time since
stroke onset: 32.80 days (SD 16.71)
Control: 10 participants; 7 men (70%) and 3 women (30%); mean age: 59.6 (SD 7.16); time since stroke
onset: 32.5 days (SD 15.78)
Inclusion criteria: hemiplegia following stroke within 3 months, observational clear asymmetry in
weight bearing, ability to walk 10 m independently without an assistive device, and BBS in the range of
30-40
Exclusion criteria: impaired vision, neurological or orthopaedic diseases affecting postural function,
and other diseases preventing participation
Interventions Intervention: 10 task-oriented exercises aimed at promoting balance, some of which incorporated
strengthening. Progression was achieved by increasing repetitions, height of exercise step and adding
weights around ankles; and somatosensory and vision manipulations (open/closed eyes and hard/soft
surface). Frequency of intervention: 50 min/session 3 days/week for 4 weeks
Control: CPT (mat exercises, range of motion exercises, and walking education). The control group
matched the intervention group in terms of time and number of exercises. Frequency of intervention:
50 min/session 3 days/week for 4 weeks
Other outcomes: plantar pressure distribution, centre of pressure path length, and the centre of pres-
sure confidence ellipse area
Risk of bias
Random sequence genera- Unclear risk Report states "randomisation procedure" but no further details provided on
tion (selection bias) how order of envelopes was achieved
Allocation concealment Unclear risk Performed by an independent person but unclear whether envelopes were
(selection bias) opaque and sequentially numbered
Blinding (performance Unclear risk Comparison of 2 different interventions (task-oriented exercise program vs
bias and detection bias) CPT)
All outcomes
Blinding of outcome as- High risk Both the article and trial registry indicate that blinding was not used
sessment (detection bias)
All outcomes
Incomplete outcome data Unclear risk ITT not reported and no information about extent of dropouts or retention
(attrition bias)
End of intervention
Selective reporting (re- Low risk Included outcomes correspond with protocol IRCT2015100224297N1
porting bias)
Bale 2008
Methods Design: randomised trial of resistance training plus % UC vs UC - during UC
Withdrawals: none
Intervention: 8 participants; 3 men and 5 women; mean age 68.0 years (SD 13); time since stroke 49.4
(SD 22.1) days
Control: 10 participants; 4 men and 6 women; mean age 64.9 years (SD 8.8); time since stroke 32.0 (SD
18.5) days
Inclusion criteria: first onset of stroke with reduced muscle strength in the affected leg; ability to under-
stand verbal information; ability to sit without support
Interventions Intervention group: resistance training 50 min/day 3 days/week for 4 weeks. 8 individually tailored ex-
ercises for the affected lower limb involving weight bearing, stepping, sit-to-stand, heel/toe raising, and
bridging. Tailored progression included using weights, reducing speed, adding more sets, etc. Other
functional activities sometimes included too (walking, stair climbing, sit-to-stand). 1 set of 10-15 reps to
moderate fatigue
Control group: UC (Bobath) 50 min/day 3 days/week for 4 weeks, plus UC (other) 50 min/day, 2 days/
week for 4 weeks. Total training: 50 min/day 5 days/week for 4 weeks
Outcomes Included outcomes: isometric muscle strength; preferred walking speed; maximal walking speed
Other outcomes: maximum weight bearing; 2 items of the MAS; Patient Global Impression of Change
tool
Risk of bias
Random sequence genera- Unclear risk Drawing lots - not clearly described
tion (selection bias)
Bateman 2001
Methods Design: multicentre randomised trial of cardiorespiratory training plus UC vs non-exercise intervention
plus UC - during UC
Interventions Intervention: cardiorespiratory training; cycle ergometry at 60% -80% of age-related HR maximum for
up to 30 min/day 3 days/week for 12 weeks
Control: relaxation - programme individualised: included breathing exercises, progressive muscle re-
laxation, autogenic exercises, visualisation techniques
Setting: multicentre, 4 rehabilitation units
Outcomes Included outcomes: FIM; BI (0-20 scale); NEADL; RMI; HADS; BBS; gait maximum speed; maximum cy-
cling workload (data transformed to Log base e); BMI
Other outcomes: fatigue questionnaire
Notes Mixed brain injury data provided by study authors; stroke-only data retained and re-analysed. High rate
of missing data made statistical analyses difficult
Risk of bias
Blinding of outcome as- Low risk Investigator blinded; participants encouraged to maintain blinding; efficacy
sessment (detection bias) unknown
All outcomes
Reasons for losses not clear but included exclusion after recruitment and
baseline assessments due to discharge
Buyukvural 2015
Methods Design: prospective RCT; resistance training + conventional rehabilitation (isokinetic group) vs conven-
tional rehabilitation alone (control group) - during UC
A group of healthy controls performed the isokinetic test protocol (healthy controls) only for compari-
son of healthy vs non-paretic side peak torque measurements pre-treatment (not discussed in this re-
view)
Participants Randomised: 50 stroke participants. 25 participants were randomised to resistance training, and 25 to
the control group
Intervention: 25 participants; 17 men (68%) and 8 women (32%); mean age: 51.3 (SD 12.0); mean
months post-stroke: 3 (range 2-8)
Control: 25 participants; 16 men (64%) and 9 women (36%); mean age: 55.4 (SD 10.5); mean months
post-stroke: 3 (range 2-9)
Exclusion criteria: not co-operative, with a previous history of stroke, concomitant disorders preventing
rehabilitation programme such as severe cardiovascular and pulmonary diseases, uncontrolled hyper-
tension, stroke due to tumour or trauma, major sensorimotor aphasia, orthopaedic disorders can affect
isokinetic assessments, musculoskeletal pain of lower limbs, and vestibular disorders
Ankle exercise protocol: 5 repetitions at 60°/s, 90°/s, 120°/s angular velocities; 10 s rest period; 10 repe-
titions at 150°/s angular velocity. Frequency of intervention: 5 days/week for 3 weeks
Setting: hospital
Outcomes Included outcomes: muscle strength; paretic and non-paretic knee peak torque (at 60°/s and 180°/s)
and ankle peak torque (at 60°/s and 120°/s), Stroke Specific QoL Scale, timed 10-metre walk test, 6-
MWT, stair-climbing test, TUG test, BBI, and RMI
Notes It is unclear what the conventional rehabilitation consisted of, in terms of content and dose
No variance/SD data available for outcomes; requested from author. SD of change scores interpolated
from P values
Risk of bias
Random sequence genera- Unclear risk No information on randomisation procedure. Groups appear balanced
tion (selection bias)
Blinding (performance High risk Not attention control for amount of exposure therefore no opportunity to con-
bias and detection bias) ceal purpose etc
All outcomes
Incomplete outcome data Unclear risk Extent of missing outcome data not reported
(attrition bias)
End of intervention
Other bias Unclear risk Inadequate reporting makes it difficult to assess other potential biases in this
study
Cooke 2010
Methods Design: phase I multicentre trial; 4 centres; mixed training plus UC vs UC - during UC - i.e. FST + CPT vs
CPT alone and vs CPT + CPT
Randomisation: computer-generated random allocation in blocks of 9 per study centre (stratified allo-
cation by baseline scores for visual spatial neglect)
ITT: attempt to measure participants at outcome and follow-up even if they withdrew but analyses
were not performed according to ITT principle
Participants Randomised: total 109 participants. 38 participants were randomised to CPT, 35 to CPT + CPT, and 36 to
FST + CPT (only the results from the CPT and the CPT + FST groups were included in this review)
Intervention: FST + CPT = 36 participants; 22 men (61%) and 14 women (39%); mean age: 71.17 (SD
10.6); 33.86 (SD 16.50) days after stroke
Control: CPT = 38 participants; 21 men (55%) and 17 women (45%); mean age: 66.37 (SD 13.7); 36.76 (SD
22.41) days after stroke
Inclusion criteria: inpatients between 1 and 13 weeks after anterior circulation stroke (ischaemic and
haemorrhagic); independently mobile; some voluntary contraction in the lower affected limb; no or-
thopaedic surgery or trauma affecting the lower limb in the last 8 weeks; no previous history of neuro-
logical diseases; able to follow a 1-stage command
Interventions Intervention: FST/mixed training + CPT. FST consisted of increasing the amount of body weight the par-
ticipants needed to move; increasing movement resistance; reducing amount of body weight support
during treadmill training. Frequency of intervention: 1 h for 4 days/week for 6 weeks
Control: CPT included soft tissue mobilisation, facilitation of muscle activity, facilitation of co-ordinat-
ed multi-joint movement; tactile and proprioceptive input, resistive exercise, and functional retraining.
Frequency of intervention: 1 h for 4 days/week for 6 weeks
Setting: hospital
Other outcomes: gait parameters; paretic knee torque force analysis; modified RMI
Notes Study authors stated 'strength training' but intervention was actually mixed training
Risk of bias
Random sequence genera- Low risk Computer-generated random allocation in blocks of 9 per study centre (strati-
tion (selection bias) fied allocation by baseline scores for visual spatial neglect)
Incomplete outcome data High risk Attempt to measure participants at outcome and follow-up even if they with-
(attrition bias) drew but analyses were not performed according to ITT principle. Imbalanced
End of intervention losses at the end of intervention
Incomplete outcome data High risk Attempt to measure participants at outcome and follow-up even if they with-
(attrition bias) drew but analyses were not performed according to ITT principle. Imbalanced
End of follow-up large losses at the end of follow-up
28/74 (38%) total losses: 14 participants were lost from the CPT group (5 un-
well, 4 withdrew, 1 moved abroad, 2 housebound, 2 died) and 7 in the inter-
vention group CPT + FST group (5 unwell, 2 withdrew)
Selective reporting (re- Low risk Reported outcome correspond with those in trial register NCT00322192
porting bias)
Imbalanced exposure High risk Imbalanced exposure (CPT + CPT group although balanced does not meet in-
clusion criteria)
Coroian 2018
Methods Design: RCT; resistance training plus UC vs non-exercise (sham) intervention plus UC to compare isoki-
netic strengthening of elbow and wrist muscles to passive mobilisation of the same joints in a popula-
tion of chronic stroke
Randomisation: randomly assigned in a 1:1 ratio. Randomisation sequence was centralised and com-
puted in permuted blocks of 4 participants by a statistician (using Talena)
Blinding: physiotherapists and occupational therapists were blinded as to which participants had been
included in which group. Provision of upper limb strengthening exercises was provided by a therapist
not involved with participant’s care
Measurements: baseline, end of intervention (variable, between 45 days and 60 days) and follow-up at
3 months and 6 months
Withdrawals: intervention group: 2/10 (20%) discontinued after the end of the intervention (2 moved to
another region). Control group: 2/10 (20%) discontinued after the 3-month follow-up (gastric ulcer = 1;
lost to follow up n = 1)
Participants Randomised: 20 participants (20 reported in study, intervention n = 10, control n = 10)
Intervention: 10 participants; 8 men (80%); mean age 63.6 years; time since stroke 32.2 months
Control: 10 participants; 8 men (80%); 63.6 years; time since stroke 29.1 months
Inclusion criteria: > 18 years, time since stroke > 6 months, flexion/extension manual muscle testing of
the elbow and wrist > 2/5, Modified Ashworth Scale score < 3/5 for the wrist and elbow muscles, no limi-
tations in upper limb range of motion (at shoulder, elbow, metatarsophalangeal joint)
Exclusion criteria: cognitive impairment (Boston Aphasia Quotient Score < 4/5), Catherine Bergego
Scale > 14/20, MMSE < 22 and participant (or their legal team) refusal to take part in the study
Interventions Intervention: 18-day rehabilitation programme spread over 6 consecutive weeks (3 days/week). Each
day: 2 x 30 min of PT (passive and active mobilisation of upper and lower limbs, balance exercises,
manual strengthening of weak muscles, global motor reinforcement, task training, cardiorespirato-
ry and walking training. Plus 1 x 45 min OT (focused on hand grasp). Upper limb isokinetic muscle
Physical fitness training for stroke patients (Review) 83
Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cochrane Trusted evidence.
Informed decisions.
Library Better health. Cochrane Database of Systematic Reviews
Control: 18-day rehabilitation programme spread over 6 consecutive weeks (3 days/week). Each day:
2 x 30 min of PT (passive and active mobilisation of upper and lower limbs, balance exercises, manual
strengthening of weak muscles, global motor reinforcement, task training, cardiorespiratory and walk-
ing training. Plus 1 x 45 min OT (focused on hand grasp). Performed only passive mobilisation of the el-
bow and wrist in the allowed range of motion
Outcomes Included outcomes: upper limb Fugl-Meyer Assessment (sensorimotor impairment), Box and Block test
(grasping capacities), Modified Ashworth scale (spasticity), muscle strength of wrist and elbow flex-
ors and extensors (maximum isokinetic reciprocal flexion/extension contractions, plus highest peak
torques)
Risk of bias
Allocation concealment Low risk Centralised system; randomisation sequence likely to be secure
(selection bias)
Blinding (performance Unclear risk Attempts to blind those involved in delivering and receiving the interventions
bias and detection bias) and care, to the exact nature of the overall exposures
All outcomes
Incomplete outcome data Low risk No dropouts at end intervention (45d). ITT analysis performed
(attrition bias)
End of intervention
Incomplete outcome data Unclear risk 2/10 (20%) lost from intervention at 3 months and 2/10 lost from control at 6
(attrition bias) months. Therefore, at final follow-up (6 months) both groups lost 2/10 but ITT
End of follow-up analysis used
Selective reporting (re- High risk Only the Fugl Meyer outcome measure was reported on the NCT01554137 trial
porting bias) registry
Other bias High risk Anecdotal assessment of fatigue resulted in changes and reluctance to recruit
participants
Cuviello-Palmer 1988
Methods Design: randomised trial of cardiorespiratory training plus % UC vs UC - after UC
Randomisation: unknown
Allocation concealment: unknown
Interventions Intervention: cardiorespiratory training: isokinetic ergometer allowing resisted reciprocal leg move-
ments (Kinetron II); commencing at 2 x 7 min/day for 5 days/week and 1 x 7 min/day for 1 day/week (to-
tal 6 days/week) for 3 weeks progressing to 10 min/session in week 2 and 12 min in week 3
Exercise intensity maintained at a HR of < 20 bpm above resting
Control: UC: 2 x 45 min/day for 5 days/week and 1 x 45 min/day for 1 day/week (total 6 days/week) for 3
weeks
Gait training, mat exercises, and transfer training achieved via strengthening exercises, post neuro-
muscular facilitation (PNF), functional electrical stimulation (FES), Brunnstrom, Rood, and neurodevel-
opment techniques
Setting: rehabilitation centre
Outcomes Included outcomes: FIM (old version); preferred gait speed (7 seconds)
Other outcomes: stance symmetry; contact time (seconds); stride cadence steps/min and other biome-
chanical gait parameters
Notes —
Risk of bias
da Cunha 2002
Methods Design: randomised trial of cardiorespiratory training plus % UC vs UC - during UC
Randomisation mechanism: random number table
Allocation concealment: unknown
Blinding: unknown
ITT: no
Interventions Intervention: cardiorespiratory training: treadmill walking with body weight support 20 min/day 6
days/week for 2-3 weeks (until discharge); intensity unknown but rapid progression imposed by in-
creasing speed and reducing body weight support; the 20-min training replaced the 20-min gait train-
ing component of the control
Control: UC 3 h/day for 6 days/week for 2-3 weeks until discharge; included kinesitherapy (1 h/day), OT
(1 h/day), and physical therapy (1 h/day): the physical therapist included 20 min of gait training com-
prising stepping, standing, turning, etc, but not continuous walking
Setting: rehabilitation centre
Outcomes Included outcomes: cycle performance work rate (watts); VO2 peak; BP; FAC; FIM (lower limb); gait
speed maximal (5 m); gait endurance (5 min); gait economy
Other outcomes: stance symmetry; contact time (s); stride cadence steps/min and other biomechani-
cal gait parameters
Notes —
Risk of bias
Random sequence genera- Low risk Randomisation by using random numbers to pre-assign participants based on
tion (selection bias) recruitment order
Dean 2018
Methods Design: 2-group, assessor-blinded, RCT with parallel mixed methods process and economic evalua-
tions. 2 centres in community setting
ReTRAIN i.e. mixed training plus UC vs UC alone - after UC (> 1 month post-discharge)
Randomisation: the random sequence was computer-generated with minimisation for time since
stroke (≤ 3 months vs > 3 months) and level of functional disability (mRS score ≤ 2 vs > 2)
Blinding: assessor blinded to group allocation; participants were reminded not to reveal their alloca-
tion to assessors but any unblinding was recorded; after assessments assessors were asked to guess
participant allocation
Participants, trainers providing the intervention and researchers conducting the process and economic
evaluations could not be blinded to allocation
ITT: missing data were reported but no attempts were made to analyse according to ITT
Withdrawals: before start of intervention 2/23 allocated to ReTRAIN withdrew (1 unwell, 1 family crisis);
2/22 control withdrew before intervention (1 unwell, 1 wanted to be in the experimental group). At 6-
month follow-up there were missing data for 1 participant in the control group; none in the experimen-
tal group. At 9 months there were no missing data (ReTRAIN n = 21; control n = 20)
Intervention: ReTRAIN + UC 23 participants; 16 men (70%) and 7 women (30%); mean age: 70 (SD 12);
time since stroke ≤ 3 months n = 1 (4%), > 3 months n = 22 (96%)
Control: UC 22 participants; 14 men (67%) and 8 women (33%); mean age: 71 (SD 10); time since stroke
≤ 3 months n = 0 (0%), >3 months n = 22 (100%)
Inclusion criteria: diagnosis of stroke, any time since stroke but at least 1 month since discharge from
NHS physical rehabilitation services, able to walk independently indoors with or without mobility aids,
but with self-reported difficulty with stairs, slopes or uneven surfaces, willingness to be randomised
and attend the training venue and cognitive capacity and communication ability sufficient to partici-
pate
Exclusion criteria: < 18 years old, currently (or within 1 month of) receiving ARNI training or have con-
traindications to moderate to vigorous physical activity (adapted from ACSM guidelines)
Control: all participants received treatment as usual. The control group received a UK Stroke Associa-
tion booklet on exercise after stroke.
Outcomes Included outcomes: RMI, TUG Test, modified Patient-Specific Functional Scale, Stroke QoL, adverse
events at 6 and 9 months, SF12, EQ-5D-5L, EQ5 (QoL)
Other outcomes: feasibility, acceptability and process outcome, acceptability of randomisation, out-
come measurement burden and the intervention assessments). Intervention fidelity, physical activ-
ity subjective and objective (accelerometry and a physical activity diary). Stroke Self-Efficacy Ques-
tionnaire, Fatigue Assessment Scale, Exercise Beliefs and Self-questionnaires, Carer Burden Index and
Health and Social Service use through a Service Receipt Inventory
NCT02429180
Risk of bias
Blinding (performance High risk The control group did not receive an active or sham treatment
bias and detection bias)
All outcomes
Blinding of outcome as- Low risk Outcomes were assessed by independent researchers who were blinded to
sessment (detection bias) group allocation. Participants were also reminded not to reveal their alloca-
All outcomes tion
Incomplete outcome data Low risk Very few dropouts: 2 in each group. Intervention (2/23): reasons 1 unwell, 1
(attrition bias) family crisis; control (2/22): 1 unwell, 1 wanted ReTRAIN intervention. At end of
End of intervention intervention data was available for 21/21 in the intervention group and 19/22
in the control. ITT not mentioned
Incomplete outcome data Low risk Outcome data available at 12-month follow-up for 21/23 in the intervention
(attrition bias) and 20/22 in the control group. ITT not mentioned
End of follow-up
Selective reporting (re- Low risk The primary outcomes as reported in the study registration, feasibility, accept-
porting bias) ability and fidelity were not mentioned in the study registration (outcomes not
included in review)
Other bias Unclear risk Exercise after stroke booklet given to control group
Imbalanced exposure High risk The intervention received active 'treatment' whereas the control group re-
ceived UC and this could vary from nothing or could meet or exceed that pro-
vided in the intervention
Donaldson 2009
Methods Design: phase II randomised multicentre trial; 3 centres; mixed training plus UC vs UC - during UC - i.e.
FST + CPT vs CPT alone and vs CPT plus CPT
Allocation concealment: sequentially numbered, sealed, opaque envelopes held by an independent in-
vestigator
ITT: yes
Withdrawals: 2 participants were lost at outcome in the CPT group (new stroke = 1; dropped out = 1).
A further 11 participants were lost at follow-up. 5 participants in the CPT group (3 unwell, 1 moved
abroad, 1 dropped out) and 2 in the CPT + FST group (1 unwell, 1 moved abroad)
Participants Randomised: total 30 participants. 10 participants were randomised to CPT, 10 to CPT + CPT, and 10 to
CPT + FST (only the results from the CPT and the CPT + FST groups were included in this review, total
20)
Intervention: CPT + FST = 10 participants, 3 men and 7 women; mean age: 72.6
Inclusion criteria: inpatients; infarction of the anterior cerebral circulation between 1 week and 3
months after stroke; some voluntary contraction in the upper affected limb; no obvious unilateral visu-
ospatial neglect; ability, prior to the stroke, to use the paretic upper limb to lift a cup and drink; ability
to follow a 1-stage command
Interventions Intervention: CPT + FST. FST = repetition and goal-directed functional activity of the upper limb; hand
positioning; hand grip activities; hand manipulation involving objects; improving power of shoulder/el-
bow muscles to enable appropriate hand position. Frequency of intervention: 1 h for 4 days/week for 6
weeks
Control: CPT included soft issue mobilisation, facilitation of muscle activity/movement, positioning;
joint alignment; tactile and proprioceptive input. Frequency of intervention: 1 h for 4 days/week for 6
weeks
Outcomes Included outcomes: upper limb strength (hand grip force, pinch grip force; isometric elbow flexion and
extension force); upper limb function (ARAT)
Risk of bias
Allocation concealment Low risk Sequentially numbered, sealed, opaque envelopes held by an independent in-
(selection bias) vestigator
Blinding of outcome as- Low risk Assessor blinded to group allocation; efficacy unknown
sessment (detection bias)
All outcomes
Selective reporting (re- Unclear risk Unclear how the study relates to NCT00322192; outcomes do not correspond
porting bias)
Imbalanced exposure High risk Imbalanced exposure in comparison used CPT vs CPT + FST
Duncan 1998
Methods Design: randomised trial of mixed training vs UC - after UC (outpatient)
Randomisation mechanism: unknown; method: blocks of 10
Allocation concealment: third party involvement
Blinding: unclear
ITT: yes
Interventions Intervention: mixed training, performed approximately 90 min/day 3 days/week for 12 weeks (8 weeks
supervised 1:1 with therapist and 4 weeks alone), functional exercises comprising assistive/resistive ex-
ercise, balance exercises, upper limb functional activities, walking or cycling; apart from some resisted
exercise the training intensity was not quantified
Control: usual outpatient care, physical and OT as advised by the patient's physician, averaging 44
min/day, 3.25 days/week for 12 weeks, therapeutic interventions were during home or outpatient visits
and comprised balance training (60%), strength training (40%), bimanual activities (50%), and facilita-
tive exercise (30%); cardiorespiratory training was not provided (0%)
Setting: home-based, therapist-supervised for first 8 weeks
Outcomes Included outcomes: BI; Lawton ADL; gait endurance (6-MWT); BBS; gait preferred speed (data lack vari-
ance measures)
Other outcomes: SF-36 (non-standard pooling of data), Jebsen Hand Test; Fugl Meyer (upper and lower
extremity)
Notes —
Risk of bias
Random sequence genera- Unclear risk Block randomisation used (blocks of 10), method unknown
tion (selection bias)
Duncan 2003
Methods Design: randomised trial of mixed training vs UC - after UC (outpatient)
Randomisation mechanism: unknown; method: blocks of 6
Allocation concealment: sealed envelopes
Blinding: investigator; participants asked to maintain blinding
ITT: yes
Interventions Intervention: mixed training, performed approximately 90 min/day 3 days/week for 12-14 weeks (36
sessions); training included range of motion and flexibility, strength training, balance, functional upper
extremity practice, endurance training via interval training on cycle ergometer. All elements progres-
sive but intensity not quantified
Control: usual outpatient care including PT and OT for participants who needed. All controls received
30-min visit every 2 weeks including provision of health promotion information
Setting: home-based, therapist-supervised for first 8 weeks
Outcomes Included outcomes: cognitive and motor subscales of the FIM; SF-36 subscales; ankle dorsiflexion and
knee extension isometric strength (Nm); isometric grip strength (N); BBS; functional reach; VO2 peak;
gait speed preferred (10 metre); 6-MWT; community ambulation (> 0.8 m/s)
Other outcomes: Stroke Impact Scale; cycle duration; Fugl Meyer scores
Notes Some outcomes reported as change from baseline scores, others reported as means at the end of 6-
month follow-up
Risk of bias
Random sequence genera- Unclear risk Block randomisation used (blocks of 6), method unknown
tion (selection bias)
Blinding of outcome as- Low risk Investigator blinded; participants asked to maintain blinding
sessment (detection bias)
All outcomes
Eich 2004
Methods Design: randomised trial of cardiorespiratory training plus UC vs UC - during UC
Randomisation mechanism: picking envelopes; method: restricted
Allocation concealment: sealed envelopes
Blinding: investigator; efficacy was compromised
ITT: yes
Interventions Intervention: cardiorespiratory training, performed 30 min/day 5 days/week for 6 weeks; progressive
treadmill training with either no or minimal support of body weight; intensity was 60% of HR reserve
Control: both groups received UC comprising individual PT based on Bobath concept plus occupation-
al and speech therapy, and neuropsychology as required
Setting: rehabilitation unit - inpatient care
Outcomes Included outcomes: gait speed maximal (10 m); gait endurance (6-MWT)
Other outcomes: RMA (non-normal data); walking quality scale (non-normal data)
Notes —
Risk of bias
Random sequence genera- Low risk Restricted randomisation; independent person picking one of (initially) 50
tion (selection bias) sealed envelopes
Allocation concealment Unclear risk Sealed envelopes; opaque and numbered unknown
(selection bias)
Blinding of outcome as- High risk Quote: "one could not fully exclude the possibility that the outcome observers
sessment (detection bias) were not totally blind"
All outcomes
Fernandez-Gonzalo 2016
Methods Design: RCT of resistance training vs no intervention (usual routines). Study commenced after UC
Blinding: blinded outcome assessment for MRI and cognitive function; no blinded outcome assessment
stated for force, power, function and dual task outcomes
Withdrawals: intervention group n = 2 (unrelated medical issue); control group n = 1 (unrelated medical
issue)
Participants Randomised: total 32 participants (n = 29 reported in study; intervention n = 14; control n = 15)
Intervention: 14 participants; 11 men (79%) and 3 women (21%); mean age 61.2 (SD 9.8) years; 3.5 (SD
3.6) years after stroke
Control: 15 participants; 11 men (73%) and 4 women (27%); mean age 65.7 (SD 12.7) years; 4.3 (SD 4.9)
years after stroke
Inclusion criteria: stroke confirmed by CT or MRI, age > 40 years, ≥ 6 months post-stroke, able to walk 20
m with/without assistive device, ability to perform closed-chain exercise using the prescribed training
device
Exclusion criteria: unstable angina, congestive heart failure, severe arterial disease, major depression,
dementia (< 24 on the MMSE), failure to understand instructions, chronic pain
Interventions Intervention: unilateral explosive resistance training of the more affected leg; real time feedback was
given to participants. 4 sets of 7 maximal repetitions of the hip and leg extensors whilst seated on a fly-
wheel-resisted leg press device. Each repetition included a resisted concentric and eccentric phase.
Training occurred 2 days/week for 12 weeks
Setting: unclear
Outcomes Included outcomes: muscle volume and cross-sectional area (MRI); maximal unilateral isometric force,
maximal unilateral dynamic force, peak power output; BBS; TUG; cognitive function; QoL SF-36 'physi-
cal functioning (PF) and 'mental health' (MH) scales
Notes NCT02120846
Risk of bias
Random sequence genera- Low risk Computerised block randomisation to either a training group or control group
tion (selection bias)
Blinding of outcome as- Unclear risk Mix of blind (MRI and cognition) and unblinded assessment (strength and pow-
sessment (detection bias) er)
All outcomes
Incomplete outcome data Low risk No ITT analysis (per protocol analysis) but only 2/14 and 1/15 losses
(attrition bias)
End of intervention
Imbalanced exposure High risk Control group followed their usual routines; no attention control
Flansbjer 2008
Methods Design: randomised trial of resistance training vs no training - after UC
Blinding: physiotherapists who assessed isokinetic strength and gait performance outcomes were
blinded to group assignment but the physiotherapist who assessed dynamic strength and muscle tone
outcomes was not blinded; participants were not blinded but were told not to disclose group assign-
ment
Measurements: at the end of intervention (10 weeks), 5-month follow-up, and a 4-year follow-up
Withdrawals: 1 participant dropped out from the intervention group due to an accident unrelated to
strength training. 2 participants were unable to perform follow-up assessments due to new illness, 4
participants did not wish to continue at follow-up stage (but were reported in general good health)
Intervention: 15 participants (16 randomised), 9 men and 6 women; mean age 61 (SD 5) years; time
since stroke 18.9 (SD 7.9) months
Control: 9 participants, 5 men and 4 women; mean age 60 (SD 5) years; time since stroke 20.0 (SD 11.6)
months
Inclusion criteria: age 40-70 years; 6 months post-stroke; able to perform isolated extension and flexion
movements of the knee; at least 15% reduction in muscle strength in the paretic limb (mean isokinetic
peak torque at 60º/s); walk unsupervised for 200 m with or without walking aid; no medication, physi-
cal, cognitive, or mental dysfunction that could impact upon knee muscle strength, gait performance,
or perceived participation; able to understand verbal and written information
Interventions Intervention group: 10 weeks of dynamic and isokinetic knee muscle strength training. Each training
session started with a warm-up of 5 min of stationary cycling, 5 repetitions without resistance and 5
repetitions at 25% of maximum load. The participants then performed 6-8 repetitions at about 80% of
their maximum load with a 2-min rest between each set. The participants performed as many repeti-
tions as possible. The load was adjusted every 2 weeks to remain at 80% of their maximum load. Each
training session lasted about 90 min but the actual progressive strength training time was < 6 min
Control group: participants were encouraged to continue daily activities and training but not to en-
gage in any progressive strength training
Outcomes Included outcomes: dynamic and isokinetic muscle strength; 3 m TUG; maximum walking speed; 6-
MWT; SIS - Swedish version; muscle tone assessed with the MAS
Notes Maximum walking speed data obtained from study authors. The physiotherapist that supervised the re-
sistance training was the same that assessed dynamic strength and muscle tone outcomes
Risk of bias
Random sequence genera- Low risk Stratified by gender unequal randomisation (2:1)
tion (selection bias)
Blinding of outcome as- High risk Physiotherapists who assessed isokinetic strength and gait performance out-
sessment (detection bias) comes were blinded to group assignment but the physiotherapist who as-
Incomplete outcome data High risk 1/25 (4%) total losses at the end of 5-month follow-up, ITT analysis used
(attrition bias)
End of follow-up 7/25 (28%) total losses at the end of 4-year follow-up and no ITT analysis used.
2 participants were unable to perform follow-up assessments due to new ill-
ness, 4 participants did not wish to continue at follow-up stage (but were re-
ported in general good health)
Furnari 2014
Methods Design: single-blinded RCT; mixed training (aquatic exercise) plus conventional physical therapy vs
conventional physical therapy alone - during UC
Blinding: assessor blinded to group allocation; participants may have understood nature of group as-
signments
ITT: not stated, withdrawals not outlined - unclear if analyses were performed according to ITT princi-
ple
Intervention: 8-week hydrokinesitherapy (aquatic therapy) and conventional physical therapy = 20 par-
ticipants; 10 men (50%) and 10 women (50%); mean age: 68 (SD 3); time since stroke onset: 7 months
(SD 1.6)
Control: 8-week conventional physical therapy = 20 participants; 10 men (50%) and 10 women (50%);
mean age: 72 (SD 5); time since stroke onset: 6 months (SD 1.4)
Inclusion criteria: paresis and spasticity secondary to a first stroke, clinically stable, absence of previ-
ous MI, ability to stand up without assistance for at least 51.2 s with closed eyes, ability to walk 10 m
(with or without assistive device), time since stroke of at least 30 days, serological negativity to hepati-
tis B, hepatitis C and HIV, absence of infectious diseases, absence of pressure ulcers, absence of urinary
and/or faecal incontinence, and MMSE ≥ 24
Exclusion criteria: previous vascular accident, muscle contractures of the lower limb joints, previous
treatment with botulinum toxin, phenol or alcohol nerve blocks tor motor point injections for low-
Interventions Intervention: aquatic therapy consisted of a 10-min light warming up in the water 15 min of Halliwick
method (sagittal rotation control; transverse rotation control) and combined rotation control (a com-
bination of transverse sagittal and longitudinal rotations), 15 min of rounding and balancing exercis-
es according to the Ai Chi method focused on weight bearing on the more affected side, 10 min of low-
er-limb strength exercises using water resistance and 10 min of light cooling down (walking). Degree of
difficulty was reviewed weekly to ensure participants made progress at their own pace. Frequency of
intervention: aquatic therapy: 1 h, 3 times/week for 8 weeks and conventional physical therapy: 1 h, 3
times/ week for 8 weeks
Control: conventional physical therapy programme consisting of general conditioning exercises, in-
cluding 10 min of warming up (e.g. calf, shoulder and hand passive range of motion exercises), 20 min
of lower and upper extremity strengthening, 20 min of postural control exercise, including mainte-
nance of standing and shifting the weight loads to the paretic side, and 10 min of gait training for the
same amount of time as the aquatic therapy group spent in the pool. Exercises in this programme were
designed with gradual increments to meet the capabilities of each participant. Frequency of interven-
tion: 1 h, 6 times/week for 8 weeks
Setting: hospital
Outcomes Included outcomes: baropodometric outcomes: postural stability and spatio-temporal gait parameters
Other outcomes: clinical data for baseline only (Modified Ashworth Scale, BI, FIM, Tinetti Test)
Risk of bias
Random sequence genera- Unclear risk Stated 'randomised' but no further details provided
tion (selection bias)
Incomplete outcome data Unclear risk No indication of whether dropouts occurred or what analytical approach to
(attrition bias) this was used
End of intervention
Imbalanced exposure Low risk Control group received conventional physical therapy of equal time, frequency
and duration
Galvin 2011
Methods Design: randomised trial of mixed FAME plus UC vs UC - during (and after UC)
Withdrawals: 2 participants in the intervention group before outcome assessment (MI and stroke). In
the control group 1 withdrew before outcome assessment (1 unwell), 2 died before follow-up assess-
ment
Intervention: 19 participants; 7 men and 13 women; mean age 69.95 years (SD 11.7)
Control: 18 participants; 13 men and 7 women; mean age 63.15 years (SD 13.3)
Inclusion criteria: 2 weeks after stroke onset; diagnosed as first unilateral stroke; > 18 years of age; par-
ticipating in a PT programme; medically stable family member willing to participate in the programme
Interventions Invention group: individualised FAME programmes daily for 35 min for 8 weeks aiming to improve sta-
bility, gait velocity, and lower limb strength plus UC (CPT)
Outcomes Included outcome: lower limb Fugl-Meyer Assessment; MAS; BBS; 6-MWT
Notes —
Risk of bias
Random sequence genera- Low risk Independent person using computer-generated random numbers
tion (selection bias)
Allocation concealment Unclear risk Sealed envelope; whether opaque and numbered unknown
(selection bias)
Blinding of outcome as- High risk Assessor not blinded to group allocation
sessment (detection bias)
All outcomes
Incomplete outcome data Low risk ITT used; all randomised participants analysed using LOCF
(attrition bias)
End of intervention 3/37 (8%) lost from intervention group 2 (MI and stroke); control group 1 (1 un-
well), 2 died before follow-up assessment
Incomplete outcome data Unclear risk ITT used; all randomised participants analysed using LOCF
(attrition bias)
End of follow-up 5/37 (14%) total losses; control group 2 (died)
Selective reporting (re- Low risk Reported outcomes correspond to protocol NCT00666744
porting bias)
Glasser 1986
Methods Design: randomised trial of cardiorespiratory training plus % UC vs UC - during UC
Randomisation: unknown
Allocation concealment: unknown
Blinding: unknown
ITT: no withdrawals
Interventions Intervention: cardiorespiratory training: isokinetic ergometer (Kinetron) training twice a day 5 days/
week for 10 weeks; the intensity was maintained at 50-100 psi and duration of each session progressed
from 10-30 min over the first 5 weeks
Control: therapeutic exercise and gait training 1 h/session 2 sessions/day, 5 days/week for 5 weeks
Setting: physical therapy department
Notes —
Risk of bias
Imbalanced exposure Unclear risk Some attention control; may be a balanced exposure
Globas 2012
Methods Design: randomised, cross-over, controlled trial of high-intensity cardiorespiratory training plus UC vs
UC - after UC
Measurements: end of intervention (3 months); follow-up data (12 months) not used
Withdrawals: 2 participants in the intervention group, 1 due to recurrent stroke, 1 due to transport
problems. Other dropouts were reported but these occurred after the cross-over part of the study be-
gan and are therefore uncontrolled
Intervention: 18 participants; 14 men and 4 women; mean age 68.6 years (SD 6.7)
Control: 18 participants; 15 men and 3 women; mean age 68.7 years (SD 6.1)
Inclusion criteria: > 6 months post-stroke, confirmed diagnosis of ischaemic stroke via CT and/or MRI
scans; hemiparetic gait as evaluated by a neurologist; at least 1 clinical sign for paresis, spasticity, or
circumduction during gait; ability to treadmill walk at > 0.3 km/h for 3 min
Exclusion criteria: unstable angina pectoris; heart failure; haemodynamically significant valvular dys-
function; peripheral arterial occlusive disease; dementia; aphasia; major depression; already perform-
ing aerobic exercise training (> 20 min/day, > 1 day/week)
Interventions Invention group: 39 sessions of 30-50 min of treadmill training 3 times/week for 3 months. Training in-
tensity was 60%-80% maximum HR. Treadmill training was progressed as tolerated by 1-5 min/week
and by 0.1-0.3 km/h every 1-2 weeks. Treadmill inclination was 0°
Control group: UC PT included passive, muscle tone-regulating exercises for upper and lower limbs
with element of balance training. Performed for 1 h for 1-3 times/week. Control group also completed
cross-over period of treadmill training, which was similar in protocol except for 2° inclination
Outcomes Included outcome: peak exercise capacity (VO2 peak); 6-MWT; 10 m timed walks; 5-chair rise test; BBS;
RMI; SF-12
Risk of bias
Other bias High risk May be self-selection bias due to use of newspaper adverts
Imbalanced exposure Unclear risk Some attention control but time appears not to be balanced
Gordon 2013
Methods Design: RCT of aerobic (walking) training vs massage - after UC
Randomisation: block randomised
Allocation concealment: unclear
Blinding: blinded assessor
ITT: completed
Measurements: 6 weeks and 12 weeks (end of intervention)
Withdrawals: 7 participants from the intervention and 5 participants from the control dropped out
Participants Randomised: total 128 participants; 64 participants were randomised to intervention, 64 to control
Intervention: 64 participants; 29 men (45.3%) and 35 women (54.7%); mean age: 63.4 (SD 9.4); 384 (SD
108) days after stroke
Control: 64 participants; 29 men (45.3%) and 35 women (54.7%); mean age: 64.9 (SD 11.1); 354 (SD 108)
days after stroke
Inclusion criteria: ≥ 40 years of age, community-dwelling, 6-24 months post-stroke, able to walk with or
without an assistive device
Exclusion criteria: not currently in rehabilitation or regular exercise programme, not having any disor-
der that would compromise exercise training such as unstable cardiovascular diseases, not having any
cognitive deficits
Interventions Intervention: cardiorespiratory walking training. Participants were supervised by trained instructors to
walk briskly along a prescribed course for 15 min, 3 times/week, for 12 weeks, initially progressing by
5 min over week up to 30 min in their home or community. Target HR was 60%-85% of age-predicted
maximum HR (220-age). Training progression was also carried out by increasing speed
Control: light massage to the affected limbs for 25 min, 3 times/week, for 12 weeks, at home
Setting: community/home
Outcomes Included outcomes: Physical and Mental Component Summary scores of the Medical Outcomes Survey,
SF-36, BI, Instrumental ADL dimension of the Older Americans Resources and Services Questionnaire;
6-MWT
Other outcomes: resting HR, lower limb Motricity Index
Risk of bias
Random sequence genera- Unclear risk Described as "block randomised" but with no further information on how this
tion (selection bias) was achieved
Blinding (performance High risk No blinding of participants or deliverers of intervention or control pro-
bias and detection bias) grammes
All outcomes
Incomplete outcome data Low risk Missing data have been imputed using appropriate methods
(attrition bias) 12/128 (9.4%) total losses:
End of intervention
• 7 participants were lost from the intervention group; death (2), recurrent
stroke (2), intervening comorbidity (1), programme too difficult (1), did not
like group assignment (1)
• 5 in the control group; death (2), intervening comorbidity (2), or violence in
community (1)
Selective reporting (re- Unclear risk Trial register or protocol not available. "Trial was not registered as enrolment
porting bias) commenced before 2005"
Imbalanced exposure Low risk Balanced exposure: intervention and control groups were exposed to the same
frequency and duration of treatment
Inaba 1973
Methods Design: randomised trial of resistance training plus UC vs UC - during UC
Randomisation: unknown
Allocation concealment: unknown
Blinding: outcome assessor - unclear
ITT: no
Interventions Intervention: progressive resistive exercise once/day for 4-8 weeks; extension of the affected lower limb
from 90º to full-knee extension whilst in the supine position on an Elgin table (machine weights), 5 rep-
etitions at 50% maximum weight, and 10 at maximum
Control: UC: conventional functional training, including stretching, 4-8 weeks until discharge
Setting: rehabilitation centre
Outcomes Included outcomes: leg strength (10-RM) lacked variance measures number of participants able to per-
form 10 ADL
Notes —
Risk of bias
Incomplete outcome data High risk Large numbers of undocumented losses and no ITT analysis
(attrition bias)
End of intervention Unclear: 101/177 participants lost to follow-up across the control and both in-
tervention groups; 54 participants completed the control vs strength training
comparison; estimated dropouts approximately 60
1 reason given for dropouts was discharge before end of the study
Incomplete outcome data High risk Large numbers of undocumented losses and no ITT analysis
(attrition bias)
End of follow-up Unclear: 101/177 participants lost to follow-up across the control and both in-
tervention groups; 54 participants completed the control vs strength training
comparison; estimated dropouts approximately 60
1 reason given for dropouts was discharge before end of the study
Ivey 2010
Methods Design: randomised trial of cardiorespiratory training vs UC - after UC
ITT: no
Withdrawals: intervention group 10 participants and control group 17 participants lost to follow-up, 7
in both groups due to medical reasons unrelated to study procedures; 3 and 10 respectively due to gen-
eral compliance issues
Inclusion criteria: chronic hemiparetic stroke (> 6 months); completed all conventional UC
Exclusion criteria: history of vascular surgery; vascular disorders of the lower limb; symptomatic pe-
ripheral arterial occlusive disease
Interventions Invention group: treadmill training for 40 min 3 times/week for 6 months at a target intensity of
60%-70% HR reserve, initially started with discontinuous training, which progressed to continuous
Control group: UC: 13 targeted active and passive supervised stretching movements of the upper and
lower body for 30-40 min 3 times/week for 6 months
Notes —
Risk of bias
Random sequence genera- Low risk Blocked allocation schema and computer-based pseudo-random number gen-
tion (selection bias) erator
Blinding (performance High risk Participants described as not blinded, although there was matched exposure
bias and detection bias) to staff
All outcomes
Selective reporting (re- Unclear risk Relationship to trial register entries unclear
porting bias)
Ivey 2011
Methods Design: randomised trial of cardiorespiratory training vs UC - after UC
Blinding: unknown
ITT: no
Inclusion criteria: chronic hemiparetic stroke with mild to moderate hemiparetic gait; completed all
conventional UC; still present with residual hemiparetic gait deficits > 6 months post-stroke
Physical fitness training for stroke patients (Review) 106
Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cochrane Trusted evidence.
Informed decisions.
Library Better health. Cochrane Database of Systematic Reviews
Interventions Invention group: treadmill training for 40 min 3 times/week for 6 months at a target intensity of
60%-70% HR reserve, initially started with discontinuous training, which progressed to continuous
Control group: UC: 13 targeted active and passive supervised stretching movements of the upper and
lower body for 30-40 min 3 times/week for 6 months
Outcomes Included outcomes: 6-MWT, peak aerobic capacity during treadmill protocol
Other outcomes: middle cerebral artery blood flow velocity bilaterally during normocapnia and hyper-
capnia (6% CO2)
Notes —
Risk of bias
Random sequence genera- High risk Mechanism not described, number randomised not clear
tion (selection bias)
Selective reporting (re- Unclear risk Relationship to trial register entries unclear
porting bias)
Ivey 2017
Methods Design: prospective RCT; resistance training (intervention group) vs stretching (control group) - after
UC
Participants Randomised: 38 stroke participants. 22 participants were randomised to resistance training, and 16 to
the control group
Number analysed = 30
Intervention: 14 participants; 10 men (71%) and 4 women (29%); mean age: 57 (SD 14) years; mean
years post-stroke: 5 (SD 4)
Control: 16 participants; 11 men (69%) and 5 women (31%); mean age: 55 (SD 9); mean years post-
stroke: 6 (SD 5)
Exclusion criteria: participants with signs indicating myocardial ischaemia during baseline exercise
testing or other contraindications for participating in exercise training
Interventions Intervention: bilateral resistance training of the lower extremities, 45 min/day for 3 days/week for 12
weeks. Leg extension, leg curl and leg press were trained on a pneumatic resistance device. Partici-
pants performed 2 sets of 20 repetitions on each leg and each machine (20 x 2 x 3 = 120 repetitions/ses-
sion). Resistance was initially set at 10-15-RM and then incrementally lowered within each set such that
the full set of 20 repetitions could be completed
Control: 45 min of supervised, passive and active stretching primarily aimed at the lower extremity
musculature. Frequency of intervention: not reported, but the control and intervention groups were
matched for level of research staff attention
Setting: outpatient
Outcomes Included outcomes: muscle endurance; maximum number of paretic and non-paretic leg press rep-
etitions at 70% 1-RM at a fixed cadence (60 bpm, 0°-90°). Muscle strength; paretic and non-paretic
leg press 1-RM. 6-MWT, peak oxygen consumption (VO2 peak) during a graded treadmill exercise text,
Timed 10-metre walking speed test (self-selected walking speed and fastest comfortable walking
speed)
Notes It is unclear what the conventional rehabilitation consisted of, in terms of content and dose
Risk of bias
Random sequence genera- High risk Computer-based block pseudo-randomisation; unpredictable enough to be
tion (selection bias) considered random. Non-random allocation of 4/38 participants to interven-
tion group to compensate for dropouts; 4/14 of the intervention group
Allocation concealment Low risk Randomisation based on baseline data so allocation concealment not an issue
(selection bias)
Blinding (performance Unclear risk Attention control will compensate for the fact that blinding participants not
bias and detection bias) possible
All outcomes
Incomplete outcome data High risk 8/22 (36%) dropout rate from intervention group; no dropouts from control
(attrition bias) group.
End of intervention
No ITT analysis
Selective reporting (re- Unclear risk No available pre-published protocol or trial registry entry
porting bias)
James 2002
Methods Design: randomised trial of mixed training vs no intervention - after UC
Randomisation mechanism: computer; method: blocks of 4
Allocation concealment: sealed envelopes
Blinding: investigator
ITT: yes
Interventions Intervention: mixed training, performed 90-120 min/day 3 days/week for 4 weeks
Warm-up followed by half squats; chair squats; small knee bends; standing on affected leg; single-leg
half squat on affected leg; standing on unaffected leg and bending affected hip and knee; stair step-
ping; stepping on spot; walking indoors and outdoors; stepping forwards, backwards and sideways;
opening and closing doors; walking and placing/lifting objects; placing objects on shelves. Finished
with a cool down; progression achieved increasing pulse rate from 50% (first 2 weeks) to 60% (last 2
weeks) of HR reserve, increasing total distance walked, and increasing step height and repetition num-
ber
Control: no intervention
Setting: participants' homes
Outcomes Included outcomes: gait speed preferred (5 m with mixed surfaces and a dead turn at 2.5 m)
Other outcomes: functional walking ability questionnaire; upright motor control test; SF-36 - older ver-
sion
Risk of bias
Random sequence genera- Low risk Block randomisation (groups of 4) using computer software
tion (selection bias)
Allocation concealment Unclear risk Sealed envelopes; opaque and numbered unknown
(selection bias)
Jin 2013
Methods Design: RCT of progressive aerobic cycling training vs control
Randomisation: stratified randomisation; stratification based on age, gender and deficit severity
Allocation concealment: information not included
Blinding: "single blind" but does not outline in the paper who was blinded
ITT: not completed
Measurements: 12 weeks (end of intervention)
Withdrawals: before randomisation
Participants Randomised: total 128 participants. 65 participants were randomised to intervention, 63 to control
Intervention: 65 participants; 46 men (71%) and 19 women (29%); mean age: 57.6 (SD 6.6); 561 (SD 156)
days after stroke
Control: 63 participants; 45 men (71%) and 18 women (29%); mean age: 56.3 (SD 6.5); 537 (SD 144) days
after stroke
Inclusion criteria: 42-68 years, Chinese Han population, first ischaemic stroke (< 6 months), indepen-
dent mobility with or without an assistive device
Exclusion criteria: haemorrhagic stroke, brainstem lesions and/or bilateral signs, diabetes mellitus or
other concomitant nervous system disorders, cardiac or pulmonary disease possibly affecting the auto-
nomic nervous system, any clinically relevant arrhythmia, heart failure, renal failure, unstable angina,
uncontrolled hypertension, peripheral arterial occlusive disease, aphasia, dementia, untreated major
depression, and other medical conditions that precluded participation in exercise training and conven-
tional treatment
Interventions Intervention: cardiorespiratory training: cycling training for 40 min/day, 5 times/week, target intensi-
ty of 50%-70% for 12 weeks. The training was started at a low intensity (40%-50% HR reserve) for 10-20
min and increased by approximately 5 min every 2 weeks as tolerated. Aerobic intensity was similarly
progressed by 5% HR reserve every 2 weeks. Participants pedaled for 6-10 min in each task condition,
and 2-3 min of rest were provided between each task
Control: matched duration of conventional therapy including supervised stretching movements lasting
35 min and 5-min low-intensity over-ground walking training at 20%-30% HR reserve, 5 times/week
Outcomes Included outcomes: peak VO2 (L/min), peak VO2, mL/kg/min, resting SBP, resting DBP, BMI, 6 min Walk
Distance, BBS, spasticity (modified Ashworth Scale), paretic knee strength, non-paretic knee strength
Other outcomes: resting HR, peak HR, peak SBP, peak DBP
Notes —
Risk of bias
Random sequence genera- Low risk Quote: "After baseline testing, the subjects were stratified according to age,
tion (selection bias) gender and deficit severity, then, randomly assigned to either an aerobic cy-
cling training group or a control group by drawing lots."
Blinding (performance Unclear risk Not clear who was blinded; exposure was balanced
bias and detection bias)
All outcomes
Incomplete outcome data Unclear risk No information on dropouts or incomplete outcome data after randomisation
(attrition bias) and at end of intervention. ITT not carried out
End of intervention
Selective reporting (re- Unclear risk Trial register or protocol not available
porting bias)
Imbalanced exposure Low risk Balanced exposure: matched duration of treatment exposure between inter-
vention and control groups
Kang 2012
Methods Design: randomised trial of cardiorespiratory training plus UC vs non-exercise intervention plus UC - af-
ter UC
Intervention: 10 participants; 6 men and 4 women, mean age 56.3 (SD 7.6); 13.5 days post-stroke (SD
4.0)
Control: 10 participants; 6 men and 4 women, mean age 56.1 (SD 7.8); 15.1 days post-stroke (SD 7.4)
Inclusion criteria: hemiparetic stroke 6 months after diagnosis; ability to walk for 15 min; without visual
disabilities; MMSE score of ≥ 21; Brunnstrom stage > 4
Exclusion criteria: cardiovascular problems, orthopaedic, and other neurological diseases except
stroke for influencing gait
Interventions Invention group: treadmill training for 30 min/day 3 times/week for 4 weeks, progressed by 0.1 km/h
each time stable walking for 20 s was achieved
Control group: non-exercise intervention of general stretching added range of motion exercises plus UC
Outcomes Included outcomes: TUG; Functional Reach Test; 10-metre maximal walk test; 6-MWT
Notes 1 arm of this 3-group RCT was not used (treadmill with optic flow intervention)
10-metre maximal walk test data converted from m/sec into m/min
Risk of bias
Random sequence genera- Low risk Independent person picking sealed envelopes
tion (selection bias)
Allocation concealment Unclear risk Sealed envelopes; whether opaque or numbered unknown
(selection bias)
Katz-Leurer 2003
Methods Design: randomised trial of cardiorespiratory training plus UC vs UC - during UC
Randomisation mechanism: unknown; method: blocks based on side of lesion
Allocation concealment: not reported
Blinding: investigator; efficacy unknown
ITT: unknown
Interventions Intervention: cardiorespiratory training: cycle ergometer; 8-week programme: (1) 20 min/day 5 days/
week for 2 weeks of intermittent (10 x 1 min) exercise progressing to 20 min continuous exercise by end
of week 2; (2) 30 min/day 3 days/week for 6 weeks not exceeding 60% HR reserve; ACSM criteria for car-
diorespiratory training met
Control: CPT, OT, speech therapy, and group activity/exercise
Setting: rehabilitation centre
Outcomes Included outcomes: FIM; BP; maximum cycle workload (watts); comfortable walking speed (10 m) gait
endurance; distance until fatigue; FAI; stair climbing
Other outcomes: SSS
Notes —
Risk of bias
Random sequence genera- Unclear risk Block randomisation based on side of lesion; mechanism not reported
tion (selection bias)
Kim 2001
Methods Design: randomised trial of resistance training vs non-exercise intervention - after UC
Randomisation mechanism: unknown; method: stratified based on gender, age (50-59 or 60+ years),
and time since onset of stroke (6 months-2 years/2+ years)
Allocation concealment: unknown
Blinding: investigator; participants blinded to purpose of interventions
ITT: unknown
Interventions Intervention: isokinetic dynamometer (Kin-Com); 45 min/day, 3 days/week for 6 weeks; after a warm-
up this comprised 30 min of 3 x 10 resisted repetitions of maximal effort concentric hip flexion/exten-
sion, knee flexion/extension and ankle dorsiflexion/plantarflexion of the affected lower limb; progres-
sion in the resistance was achieved by increasing the preload on the Kin-Com device; ACSM criteria for
resistance training met
Control: exactly the same as intervention except the resisted contractions replaced with passive range
of motion movements
Setting: rehabilitation centre
Outcomes Included outcomes: gait preferred speed (m/min over 8 m); gait maximum speed (m/min); stair climb-
ing speed (stairs/s); composite strength score for the affected (trained) lower limb; stair walking perfor-
mance (4 x 18 cm steps) self-selected and maximal; 'physical functioning' and 'mental health' scales of
the SF-36
Risk of bias
Random sequence genera- Low risk Mechanism unknown; method stratified based on gender, age (50 to 59 or 60+
tion (selection bias) years), and time since onset of stroke (6 months to 2 years/2+ years). Likely
that software was used to achieve this complexity.
Blinding (performance Unclear risk Attention control used; participants blinded to purpose of interventions
bias and detection bias)
All outcomes
Kim 2014
Methods Design: randomised trial of community walking training programme plus UC vs UC (conventional PT
and OT) during UC
Interventions Intervention: cardiorespiratory training, walking programme, 30 min/day 5 times/week for 4 weeks
Week 3 – 400 m route, uneven ground, gradual slope, unpaved road, obstacles
Outcomes Included outcomes: walking function measured using 10-metre walk test, 6-MWT and 'community
walking assessment' (300 m route, different terrains and gradients)
Risk of bias
Random sequence genera- Unclear risk Sealed envelopes marked on the inside with an "O or X". Unclear how this was
tion (selection bias) administered
Allocation concealment High risk Unclear whether sealed envelopes were numbered, opaque, or opened se-
(selection bias) quentially. Also the envelopes were "… marked on the inside with an O or X".
Therefore concealment may be threatened
Blinding of outcome as- Low risk "… the assessor was blinded"
sessment (detection bias)
All outcomes
Kim 2016a
Methods Design: single-centre randomised trial: mixed circuit training plus % UC (excluding PT) to conventional
PT based on neurodevelopmental treatment plus UC (excluding PT) - during UC (inpatient)
Randomisation: participants were randomised allocated in a 1:1 ratio, no further details were provided
regarding methods of randomisation
ITT: 20 patients were randomised and analysed; the study authors did not explicitly report on dropouts,
or missing data or ITT
Intervention: circuit training 10 participants; 6 men (60%) and 4 women (40%); mean age: 65.2 (SD
10.1); 30.1 (SD 21.8) days after stroke
Control: CPT 10 participants; 7 men (70%) and 3 women (30%); mean age: 66.0 (SD 8.8); 29.9 (SD 20.3)
days after stroke
Inclusion criteria: a clinical diagnosis of a first stroke confirmed by neuroimaging (CT or MRI); a hemi-
paresis; a time interval between stroke and recruitment of ≤ 3 months; the ability to comprehend the
instructions for the testing procedures; and mild to moderate walking deficit, as indicated by FAC be-
tween 3 and 4
Exclusion criteria: a severe cognitive impairment (Korean-MMSE ≤ 10) or aphasia; previous stroke his-
tory; not independent 'sit to stand' activity (BBS score < 18); acute systemic illness or infection; a sig-
nificant orthopaedic condition or pain that limited participation in exercise; and visual impairment or
vestibular system deficit that caused balance impairment
Interventions Intervention: circuit training; mixed training plus UC 90-min circuit-training classes, 5 times/week for
4 weeks. Training consisted of a 5-min warm-up period, 5 classes of 15-min duration of complex exer-
cises interspersed by 1-min rest, and a 5-min cool-down period. The 5 categories were: trunk exercise
and active sitting practice, sit-to-stand practice, standing and walking practice, aerobic treadmill train-
ing and lower-limb strength training (TheraBand). Treadmill speed and gradient were progressed and
TherBand repetitions and resistance progressed
Control: individual CPT for 30 min twice a day (total 60 min), 5 days a week for the 4 weeks. The content
of the individual PT sessions was based on neurodevelopmental treatment for motor recovery
Outcomes Included outcomes: motor function lower limb (lower limb score Fugl-Meyer assessment), gait en-
durance (6-MWT), balance (BBS), ADL function (Korean version of the Modified BI)
Notes
Risk of bias
Random sequence genera- Unclear risk Randomised in a 1:1 ratio, evenly matched via sealed envelope technique but
tion (selection bias) no further information provided
Allocation concealment Unclear risk Randomisation was performed using a sealed envelope technique, unclear if
(selection bias) envelopes were opaque
Blinding (performance High risk There was no description provided regarding information participants re-
bias and detection bias) ceived about the aim of the study and no sham control was provided
All outcomes
Blinding of outcome as- Low risk The outcome assessor was blinded to allocation
sessment (detection bias)
All outcomes
Incomplete outcome data Low risk All participants who were randomised were analysed no details on dropouts or
(attrition bias) missing data was reported
End of intervention
Selective reporting (re- Unclear risk All outcomes specified in the methods were reported in detail, the study proto-
porting bias) col was not published and no reference was made to registration of the study
Kim 2017a
Methods Design: randomised trial of mixed training plus UC vs UC only - during UC
Intervention: 14 participants (9 men), mean age 50.71 years (14.81) and time since stroke 12.79 (7.34)
months
Control: 15 participants (10 men), mean age 51.87 years (17.42) and time since stroke 11.73 (8.02)
months
Inclusion criteria: at least 3 months post-stroke, cognitive ability allowed research instructions to be
followed, Korean-MMSE score ≥ 10 points, ability to walk ≥ 10 m independently, and adequate vision for
study tests
Exclusion criteria: bilateral stroke or previous stroke affecting the other side, insufficient gait ability for
using treadmill, risk of epilepsy, and use of anti-epileptics
Interventions Intervention: handgrip strength training; progressive 15 min grasping training with power web exercis-
er and digi-flex devices. Walking speed cardiorespiratory treadmill training (15 min) with 5% body mass
Physical fitness training for stroke patients (Review) 118
Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cochrane Trusted evidence.
Informed decisions.
Library Better health. Cochrane Database of Systematic Reviews
Conventional therapy alone. Involved joint movements, mat movements and walking exercises 10 min
each. 60 min/session, 2 sessions/day, 5 days/week for 6 weeks
Control: conventional therapy alone. Involved joint movements, mat movements and walking exercis-
es 10 min each. 60 min/session, 2 sessions/day, 5 days/week for 6 weeks
Setting: hospital
Outcomes Included outcomes: cognitive function test (Korean version of Montreal Cognitive Assessment, trail
making test and Stroop test, handgrip strength test, 10 metre walking test, TUG
Risk of bias
Blinding (performance High risk No description of who ran the intervention, unbalanced intervention between
bias and detection bias) groups
All outcomes
Incomplete outcome data Low risk Analysed per protocol but only 1/15 dropped out in intervention group
(attrition bias)
End of intervention
Other bias Low risk Muscle strength should be maximum value not an average of triplicate mea-
sures; but overall no substantive issues noted
Knox 2018
Methods Design: single-blinded, RCT with 2 intervention groups
Blinding: outcome assessor blinded; participants may have understood nature of group assignments
Withdrawals: 12 weeks post-intervention: task group: 6/51 (11%) participants from task group (3 de-
ceased, 2 moved away, 1 return to work), 5/45 (11%) participants from strength group (1 deceased, 2 no
transport, 2 moved away), 5/48 (10%) participants from control group (1 deceased, 2 no transport, 1 re-
turn to work, 1 private healthcare)
Follow-up after a further 12 weeks: 10/51 (20%) participants from task group (2 moved away, 1 second
stroke, 1 no transport), 6/45 (13%) participants from strength group (1 deceased), 8/48 (17%) partici-
pants from control group (1 returned to work, 1 deceased, 1 no transport)
Mixed training group 51 participants; 25 men (49%) and 26 women (51%); mean age: 51 (SD 15); time
since stroke: 10 weeks (SD 8)
Resistance training group = 45 participants, 25 men (56%) and 20 women (44%); mean age: 51 (SD 12);
time since stroke: 9 weeks (SD 7)
Control: 48 participants, 22 men (46%) and 26 women (54%); mean age: 48 (SD 14); time since stroke 8
weeks (SD 7)
Inclusion criteria: between 20–79 years of age, < 6 months after the onset of a first stroke, medically sta-
ble (people who were HIV+ but on antiretroviral treatment and stable), and who could walk at least 10
m at < 1.1 m/s without assistance but with the use of assistive devices or supervision, if needed, able
to understand and follow instructions, and live near enough to attend sessions in the hospital with the
help of caregivers
Exclusion criteria: medical, neurological, or orthopaedic conditions that could interfere with their post-
stroke recovery such as active HIV status, neurological disorders, or musculoskeletal injuries interfering
with gait rehabilitation
Interventions Mixed training group: (task group) 6 exercises focused on improving strength, balance, and task per-
formance while standing and walking, and included an endurance walking station. Exercises were pro-
gressed by reducing the use of supports and increasing the complexity of the tasks. Participants’ care-
givers attended to give the correct assistance to the participant in the execution of the tasks and were
directed to assist the participant in working on a progressively more difficult structured walking pro-
gramme at home between the formal therapy sessions. Frequency of intervention: 6 sessions of 1 h
each over a 12-week period
Resistance training group: (strength group) 3 sets of 10 repetitions; 10 exercises performed while sit-
ting and lying, which targeted the major muscles in the lower extremities. Exercise progressed as per
the participants’ performance and feedback. Resistance was provided with gravity, free weights, elastic
bands, and balls. Frequency of intervention: 6 sessions of 1 h each over a 12-week period
Control: 90-min educational session on stroke management that included 20 min of exercises, provid-
ed by an occupational or physiotherapist. Frequency of intervention: one 90-min session. Single ses-
sion so not a training intervention
Setting: hospital
Outcomes Included outcomes: walking endurance- six-min walk test, comfortable and fast gait speeds, 10 m gait
speed, balance function, mobility
Notes Trial registered retrospectively (9 years after study start date): PACTR201802003054396
Risk of bias
Random sequence genera- Low risk Stratified by comfortable gait speed and randomised with computer-generat-
tion (selection bias) ed random numbers
Allocation concealment Unclear risk Computer-generated sequence was used by a physiotherapist blinded to
(selection bias) group allocation. However, the study authors outline that "stratification en-
velopes" were used but it is unclear whether they were sequentially num-
bered, sealed or opaque
Blinding (performance High risk No attempt was made to blind participants to group assignment.
bias and detection bias)
All outcomes
Incomplete outcome data Low risk Participants with missing outcome data were not excluded. Participants
(attrition bias) with missing follow-up data were not excluded. Small, balanced number of
End of intervention dropouts (11% task group, 11% strength group, and 10% control group).
Incomplete outcome data Low risk Balanced attrition across 3 groups post-intervention, ≤ 20% attrition in all
(attrition bias) groups
End of follow-up
Selective reporting (re- High risk Reported outcomes correspond to protocol PACTR201802003054396; howev-
porting bias) er, protocol published retrospectively
Imbalanced exposure High risk No attempt to account for imbalanced exposure in experimental arms (both
6 x 1-h sessions over 12 weeks) and control arm (1 x 90-min session over 12
weeks)
Kuys 2011
Methods Design: randomised, single-blind trial of cardiorespiratory plus UC vs UC - during UC
ITT: yes
Intervention: 15 participants; 7 men and 8 women; mean age 63 years (SD 14); 52 days post-stroke (SD
32)
Control: 15 participants; 7 men and 8 women; mean age 72 years (SD 17); 49 days post-stroke (SD 30)
Inclusion criteria: first stroke diagnosed via CT; referred for PT rehabilitation; scored ≤ 2 MAS; medically
stable; MMSE score of at least 24
Exclusion criteria: normal gait speed (> 1.2 m/s); cardiovascular problems
Interventions Invention group: treadmill walking for 30 min 3 times/week for 6 weeks at 40%-60% HR reserve (initially
starting at 40% HR reserve, progressing by 5%-10% increase each week until 60% reached)
Outcomes Included outcomes: 10-metre walk test; comfortable walking speed; 6-MWT
Notes —
Risk of bias
Random sequence genera- Low risk Independent researcher generated random sequence in blocks of 4 using com-
tion (selection bias) puter-generated random number sequence
Allocation concealment Unclear risk Consecutively numbered envelopes; not reported whether these were sealed
(selection bias) and opaque
Selective reporting (re- Low risk All included outcomes were described in trial registry ACTRN12607000412437.
porting bias) Planned oxygen uptake measures not reported
Langhammer 2007
Methods Design: randomised trial of mixed training vs UC - after UC - i.e. intensive exercise (with emphasis on
endurance, strength, and balance) vs regular exercise (no specific treatment was recommended) at dis-
charge. Sample size calculation reported
Allocation concealment: unclear. Protocol was sealed for 1.5 years from the start of the study
Withdrawals: 3 participants in the intensive group at discharge (1 dead and 2 withdrawals) and 5 (3
dead and 2 withdrawals) in the regular exercise group at discharge. 1 dead and 1 withdrawal at 3
months and 2 dead at 6 months in the regular exercise control group
Intervention: 35 participants, gender not reported; mean age 76 years (SD 12.7)
Control: 40 participants, gender not reported; mean age 72 years (SD 13.6)
Exclusion criteria: > 1 stroke event, subarachnoid bleeding, tumour, other serious illness, brainstem, or
cerebellar stroke
Control: rehabilitation and follow-up treatments according to participants' needs but not on regular
basis. No specific treatment was recommended. Participants were, however, encouraged to maintain
high activity level
Outcomes Included outcomes: MAS; BI; grip strength measured with a Martin Vigorimeter; occurrences of falls and
pain
Notes —
Risk of bias
Random sequence genera- Low risk Use of dice (uneven numbers vs even numbers). In addition, randomisation
tion (selection bias) was stratified according to gender and hemisphere lesion (minimisation) Ran-
domisation was performed by an investigator not involved with the partici-
pants or the treatment
Allocation concealment Unclear risk Unclear; protocol was sealed for 1.5 years from the start of the study
(selection bias)
Blinding (performance High risk Some unstructured attention control "The amount of training was equal in the
bias and detection bias) two groups". However, the control intervention was not given on a regular ba-
All outcomes sis
Blinding of outcome as- Low risk Experienced investigator, blinded to group allocation
sessment (detection bias)
All outcomes
Lee 2013a
Methods Design: randomised trial of close kinetic chain resistance exercise vs open kinetic chain resistance exer-
cise vs no intervention
Randomisation: unclear
Allocation concealment: information not included
Blinding: information not included
ITT: no ITT but no losses
Withdrawals: none
Participants Randomised: total 33 participants. 11 to close kinetic chain exercise (CKC), 11 to open kinetic chain ex-
ercise (OKC) and 11 to control
Intervention 1 CKC: 11 participants; 7 men, 4 women; mean age: 59.3 (SD 8.87); months post-stroke
19.9 (SD 7.59)
Intervention 2 OKC 11 participants; 7 men, 4 women; mean age 58.8 (SD 6.81); months post-stroke 20.3
(SD 8.13)
Control: 11 participants: 6 men, 5 women; mean age 60.10 (SD 7.01); months post-stroke 19.70 (SD 9.42)
Physical fitness training for stroke patients (Review) 124
Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cochrane Trusted evidence.
Informed decisions.
Library Better health. Cochrane Database of Systematic Reviews
Exclusion criteria: severe cognitive, communicative, perceptual or sensory problems preventing under-
standing of study purpose; other neurologic or psychiatric problems causing difficulties in following
programme; unstable cardiovascular/ventilatory problems
Warm-up – 4 reps at 25% of 1-RM followed by 3 sets (8-10 reps) at 70% of 1-RM adjusted weekly
Intervention 1 CKC: seated, paretic foot on pedal of a leg press machine with pneumatic resistance, ex-
tend leg and slowly flex
Intervention 2 OKC: sat in chair, back facing leg press exercise machine, knee maintained at 90° of flex-
ion with free distal extremity. Extend and slowly flex knee
Setting: unclear
Risk of bias
Imbalanced exposure High risk Imbalanced exposure between control group and both intervention groups
Lee 2013b
Methods Design: randomised trial of close kinetic chain resistance exercise vs open kinetic chain resistance exer-
cise vs no intervention
Randomisation: unclear
Allocation concealment: information not included
Blinding: information not included
ITT: no ITT but no losses
Withdrawals: none
Participants Randomised: total 39 participants. 13 to close kinetic chain exercise (CKC), 13 to open kinetic chain ex-
ercise (OKC) and 13 to control
Intervention 1 CKC: 13 participants; 8 men, 5 women; mean age: 49.3 (SD 8.87); months after stroke
14.9 (SD 9.59)
Intervention 2 (OKC): 13 participants; 8 men, 5 women; mean age 50.8 (SD 6.81); months post-stroke
15.7 (SD 8.13)
Control: 13 participants; 9 men, 4 women; mean age 49.10 (SD 7.01); months after stroke 15.10 (SD 8.73)
Inclusion criteria: hemiparesis secondary to single onset unilateral stroke; ability to ambulate inde-
pendently over 10 m (with/without device); absence of significant lower extremity joint pain and major
sensory deficits; absence of significant lower limb contractures; no significant cardiovascular or respi-
ratory symptoms contradictive to walking
Warm-up – 4 reps at 25% of 1-RM followed by 3 sets (8-10 reps) at 70% of 1-RM adjusted weekly
Intervention 1 CKC: seated, paretic foot on pedal of a leg press machine with pneumatic resistance, ex-
tend leg and slowly flex
Intervention 2 OKC: sat in chair, back facing leg press exercise machine, knee maintained at 90° of flex-
ion with free distal extremity. Extend and slowly flex knee
Setting: unclear
Risk of bias
Imbalanced exposure High risk Imbalanced exposure between control group and both intervention groups
Lennon 2008
Methods Design: pilot randomised study of cardiorespiratory training vs UC - after UC. Sample size calculation
reported
Randomisation: stratified randomisation (by age and sex) into 4 blocks of 6 using a sequence generator
by an independent party
Participants Randomised: total 48 participants. Participants were recruited from the Stroke Rehabilitation Database
(Dublin). Volunteers contacted the research team for initial screening
Intervention: 24 participants; 14 men (58%) and 10 women (42%); mean age 59.0 years (SD 10.3); mean
number of weeks from stroke 237.3 (SD 110.7)
Control: 24 participants; 14 men (58%) and 10 women (42%); mean age 60.5 years (SD 10.0); mean num-
ber of weeks from stroke 245.3 (SD 169.8)
Inclusion criteria: > 1 year post-ischaemic stroke and > 18 years of age; participants were recruited irre-
spective of their ability to ambulate independently
Exclusion criteria: O2 dependence, angina, unstable cardiac conditions, uncontrolled diabetes mellitus,
major medical conditions, claudication, cognitive impairment, or beta blocker medication
Interventions Intervention: the Cardiac Rehabilitation Programme consisted of cycle ergometry training using either
the upper or lower limbs. Exercise load was set at 50%-60% of the participants' maximal HR. Resistance
and speed were adjusted daily to ensure progression. Frequency: participants trained twice weekly for
30 min each time, for 10 weeks. Measurements performed at week 1 and re-assessment at week 10. All
sessions were supervised by a physiotherapist
Control: CPT and OT; no therapy contained an aerobic exercise component; measurements at week 1
and re-assessment at week 10. No further details provided
Outcomes Included outcomes: VO2; BMI; maximum cycle workload; resting SBP; resting DBP; total cholesterol;
FAI; HADS
Other outcomes: resting HR; cardiac risk score; RPE
Notes The study authors maintained that their pilot study was too small for detecting functional benefits (a
minimum of 120 participants in each group would have been required to show expected change in all
primary outcomes); possible Hawthorn effect due to the fact that the control group did not receive the
comparable non-exercise related attention to the intervention group
Risk of bias
Random sequence genera- Low risk Stratified randomisation (by age and sex) into 4 blocks of 6 using a sequence
tion (selection bias) generator by an independent party
Allocation concealment Unclear risk Opaque envelopes; sealed and numbered unknown
(selection bias)
Blinding (performance High risk Control group did not receive the comparable non-exercise related attention
bias and detection bias) to the intervention group
All outcomes
Letombe 2010
Methods Design: randomised trial of mixed training plus UC vs UC
Randomisation: information not included
Allocation concealment: information not included
Blinding: information not included
ITT: not completed
Measurements: before and end of intervention (4 weeks)
Withdrawals: none reported
Exclusion criteria: existence of disorders associated with hemiplegic motor damage, such as cogni-
tive and memory disorders; hemisensory neglect; the existence of an intercurrent affection or unstable
brain lesions
Interventions Intervention: participants in the training group (n = 9) received conservative physical therapy for 3 h/
day, 5 days/week, for a period of 4 weeks. Conservative physical therapy consisted of gait exercises,
stance exercises, the treatment of orthopaedic disorders, balance work (with a view to subsequently
withdrawing gait aids), use of support stockings and braces and maintenance of the freedom of move-
ment of the proximal-distal limb joints. In addition general exercise training was implemented, with
cardiorespiratory exercise (monitored by a HR monitor), muscle strengthening, gait exercises, and work
focused on executive functions, lasting for between 40 and 60 min/day, 4 times a week. Aerobic exer-
cise was included in the form of steady exercise on a semi-recumbent cycle ergometer (with both feet
pedaling) was performed at between 70% and 80% of maximum power
Control: participants in the control group (n = 9) received conservative physical therapy for 3 h/day, 5
days/week, for a period of 4 weeks. Conservative physical therapy consisted of gait exercises, stance ex-
ercises, the treatment of orthopaedic disorders, balance work (with a view to subsequently withdraw-
ing gait aids), use of support stockings and braces and maintenance of the freedom of movement of the
proximal-distal limb joints
Outcomes Included outcomes: triangular maximal aerobic power test using a cycle ergometer
Notes —
Risk of bias
Random sequence genera- Unclear risk Described only as "randomized into two groups"
tion (selection bias)
Selective reporting (re- Unclear risk Trial register or protocol not available
porting bias)
MacKay-Lyons 2013
Methods Design: randomised trial of BWSTT (cardiorespiratory) vs control (UC)
Blinding: yes
ITT: yes
Measurements: end of intervention (12 weeks), 6 months, 12 months
Withdrawals: 5 withdrawals by end of intervention - 3 from intervention and 2 from control; 3 more
withdrawals by 6-month follow-up - 1 from intervention, 2 from control; 5 more withdrawals by 12-
month follow-up – 3 from intervention, 2 from control
Interventions Intervention: 60 min, 5 days/week for 6 weeks then 3 days/week for 6 weeks
5-10 min active/passive stretching; 10-15 min upper extremity training (active exercises and stretch-
ing); 10-15 min lower extremity training (active exercises and stretching)
25-30 min treadmill gait training (initially treadmill speed 80%-90% of self-paced overground speed
with 20%-30% body weight supported for ambulatory-independent participants and 70%-80% of over-
ground speed with 40% body weight supported for ambulatory-dependent participants)
5-10 min active/passive stretching; 10-15 min upper extremity training (active exercises and stretch-
ing); 10-15 min lower extremity training (active exercises and stretching)
5-10 min of pre-gait activities in standing followed by 20-25 min overground walking at comfortable
self-selected speeds
Outcomes Included outcomes: cardiovascular fitness (VO2 peak); 6-MWT; comfortable walking speed; BBS
Other outcomes: Chedoke-McMaster stages of Recovery Leg and Foot; participant satisfaction with pro-
gramme
Risk of bias
Random sequence genera- Low risk Computer-generated, permuted block randomisation stratified by ambulatory
tion (selection bias) status
Allocation concealment Low risk Quote: "A person not involved in the study prepared and safeguarded individ-
(selection bias) ual, opaque sealed envelopes containing group and physiotherapist alloca-
tion, which were opened after completion of the baseline assessment"
Blinding (performance Unclear risk There was a similar dose of exposure across both groups. Participants were
bias and detection bias) informed they would be allocated to 1 of 2 'intervention' groups. The groups
All outcomes were kept separate
Blinding of outcome as- Low risk Blinded outcome assessment. Participants instructed not to discuss their in-
sessment (detection bias) tervention with outcome assessor. A test of blinding was also performed and
All outcomes analysed statistically to demonstrate no significant unblinding
Selective reporting (re- Unclear risk Not clear whether a protocol exists
porting bias)
Mao 2015
Methods Design: single hospital centre RCT. Cardiorespiratory training (BWSTT) plus UC vs conventional over-
ground walking training plus UC (BWSTT replaces part of UC) - during UC
Blinding: baseline and end of intervention outcome measures completed by examiner blinded to group
allocation
Participants Randomised: total 29 participants. 15 participants were randomised to intervention, data from 12 were
presented and analysed. 14 participants were randomised to control group, data from 12 were present-
ed and analysed
Intervention: BWSTT plus UC = 12 participants; 2 men (17%) and 10 women (83%); mean age: 59.55 (SD
9.23) years; mean body mass 65.17 (SD 10.26) kg; 49.25 (SD 19.51) days after stroke
Control: conventional overground walking training plus UC = 12 participants; 3 men (25%) and 9
women (75%); mean age: 60.82 (SD 10.7) years; mean body mass 65.25 (SD 11.42) kg; 47.67 (SD 16.78)
days after stroke
Inclusion criteria: stroke confirmed by CT or MRI; unilateral hemiparesis for no more than 3 months re-
sulting from first stroke; residual gait impairment, defined by an abnormal 10 m walk time according to
age (age < 60 = ≥ 10 s or 1 m/s; age 60-69: ≥ 12.5 s or 0.8 m/s; age ≥ 70: ≥ 16.6 s, < 0.6 m/s); and adequate
mental and physical capacity to attempt the tasks as instructed (MMSE score ≥ 27, average modified
Ashworth Scale score at hip, knee, and ankle ≤ 2)
Exclusion criteria: presence of significant medical complications or unstable vital signs that precluded
participation in the study
Interventions Intervention: BWSTT plus UC. Standardised BWSTT consisted of 30%-40% assisted body support tread-
mill walking. Progressive programme in which assisted body support was decreased and treadmill
speed increased separately. No further detail for percentage assisted body support was provided. Fre-
quency of intervention: initial at 0.5 miles per hour (0.8 km/h) treadmill speed for 20 min, 5 days/week
for 3 weeks progressing to 2.5 miles per hour (4 km/h) for 40 min, 5 days/week for 3 weeks
Control: conventional overground walking training plus UC. Individualised overground gait training
based on the principles of neurodevelopmental therapy (Bobath method). Frequency of control: 30
min, 5 days/week for 3 weeks
UC for both intervention and control groups consisted of 20-40 min, 5 days/week for 3 weeks of thera-
peutic exercises (range of movement; strengthening exercises; as well as facilitation techniques to re-
cruit muscle activity on the paretic extremity. UC also consisted of 60 min, 5 days/week for 3 weeks of
OT session (functional stimulation and self-exercise programme). No further specific details were pro-
vided
Setting: hospital
Outcomes Included outcomes: Brunel Balance Assessment; Fugl-Meyer Lower Extremity Assessment; self-selected
walking speed
Other outcomes: 3-D motion analysis at self-selected walking speed (cadence, stride time and length,
step time and length; kinematic and kinetic data included joint angles and moments)
Notes
Risk of bias
Random sequence genera- Unclear risk Randomly assigned to the groups, no further details provided
tion (selection bias)
Blinding (performance Unclear risk Active attention control compensates for lack of blinding
bias and detection bias)
All outcomes
Incomplete outcome data High risk Overall dropout rate 20% in intervention and 14% in control groups. No ITT
(attrition bias) analysis
End of intervention
Mead 2007
Methods Design: explanatory randomised trial of mixed training vs non-exercise intervention - after UC
Randomisation mechanism: internet application; minimisation dichotomised on sex; FIM score (120);
age (70 years)
Allocation concealment: sequence generation and allocation occurred simultaneously
Blinding: investigator; participants encouraged to maintain blinding
ITT: yes
Interventions Intervention: mixed training: group circuit training performed 40-75 min/day 3 days/week for 12-14
weeks (36 sessions); after a warm-up the training comprised 2 components: (1) a cardiorespiratory cir-
cuit (cycle ergometry, raising and lowering an exercise ball, shuttle walking, standing chest press, and
stair climbing and descending); (2) resistance training circuit (upper back exercise and triceps exten-
sion using TheraBand, lifting a weighted pole, a sit-to-stand exercise); progression in duration, repeti-
tion number, speed, mass of objects and resistance of TheraBand whilst maintaining a RPE (6-20 scale)
of 13-60
Control: non-exercise intervention; seated relaxation involving deep breathing and progressive muscu-
lar relaxation; no muscle contractions were involved
Setting: rehabilitation hospital
Outcomes Included outcomes: FIM; NEADL; RMI; functional reach; TUG; sit-to-stand time; SF-36 - version 2; HADS;
gait preferred speed; gait economy (VO2 mL/kg/m); lower limb extensor explosive power (W/kg)
Other outcomes: EMS (ceiling effect); FAC (ceiling effect)
Notes —
Risk of bias
Random sequence genera- Low risk Internet software-based minimisation dichotomised on sex; FIM score (120);
tion (selection bias) age (70 years)
Allocation concealment Low risk Not applicable; sequence generation and allocation occurred simultaneously
(selection bias)
Selective reporting (re- Low risk Reported outcome correspond to proposal; Chief Scientist Office of the Scot-
porting bias) tish Executive (CZB/4/46)
Moore 2010
Methods Design: randomised, cross-over trial of cardiorespiratory training vs no intervention - after UC - (i.e. in-
tensive locomotor training - including treadmill training - vs delayed cardiovascular training)
Participants Randomised: 20 participants; mean age 50 years (SD 15); men 14, women 6; duration of post-stroke
symptoms 13 months (SD 8); moderate/severe gait limitations 13/7
Intervention: the number of participants randomised to the immediate locomotor training group was
not clearly reported
Control: the number of participants randomised to the delayed locomotor training group was not clear-
ly reported
Inclusion criteria: patients with hemiparesis of > 6 months' duration who were attending physical ther-
apy after unilateral supratentorial stroke; all patients were required to walk > 10 m overground without
physical assistance and medical clearance
Interventions Intervention: the immediate locomotor training group received 4 weeks of intensive locomotor train-
ing after discharge from clinical physical therapy, which consisted of high-intensity stepping practice
on a motorised treadmill while wearing an overhead harness attached to a safety system. Frequency:
2-5 days/week for 4 weeks. Intensity: highest tolerable speed with velocity increased in 0.5 km/h incre-
ments until participants reached 80%-85% of predicted maximum HR or until the participants' RPE in-
creased to 17 on the Borg scale. Partial weighted support was reduced in 10% increments as tolerated
by participants who needed partial weighted support. Measurements were performed: 4 weeks before
termination of usual physical therapy; soon after termination of usual physical therapy; after comple-
tion of the 4-week locomotor training; and again after a delay of 4 weeks after termination of locomo-
tor training
Control: delayed locomotor training group. The delayed group was also assessed 4 weeks before and
after termination of usual physical therapy, but did not receive locomotor training or any other inter-
ventions for 4 weeks after termination of usual physical therapy. After this 4-week delay the partici-
pants received locomotor training as described above
Outcomes Included outcomes: preferred gait speed; fastest gait speed; 12-MWT; O2 cost; peak treadmill speed;
VO2 peak, TUG; BBS
Notes We used only data at the end of the first cross-over period for analyses
Risk of bias
Random sequence genera- Low risk Stratified randomisation according to severity of gait impairment
tion (selection bias)
Moore 2015
Methods Design: single-blind RCT. Mixed training vs attention control - after UC
Withdrawals: 0 withdrawals
Intervention: 20 participants; 18 men (90%) and 2 women (10%); mean age: 68 (SD 8); 21 (SD 34)
months after stroke
Control: 20 participants; 16 men (80%) and 4 women (20%); mean age: 70 (SD 11); 16 (SD 12) months af-
ter stroke
Inclusion criteria: age > 50 years, > 6 months after stroke onset, could complete 6-MWT, living at home,
completed CPT and were not undertaking moderate exercise ≥ 3 days/week
Interventions Intervention: mixed training. Group classes including warm-up, stretching, functional strengthening
(increasing load and repetitions; 2 sets of 5 to 3 sets of 10), balance, agility and cardiorespiratory train-
ing (40% -50% maximum HR increasing to 70%-80%). Frequency of intervention: 40-60 min/day for 3
days/week for 19 weeks
Control: home-based stretching. 10 seated stretches for the upper and lower body. Frequency of inter-
vention: 40-60 min/day for 3 days/week for 19 weeks
Outcomes Included outcomes: risk factors (BP, glucose control, lipid profile, body composition), cognition, mobili-
ty (10-MWT, 6-MWT), balance, QoL, physical fitness (peak oxygen consumption and peak work rate)
Notes ISRCTN41026907
Risk of bias
Random sequence genera- Low risk Online tool used by independent administrator; method unknown
tion (selection bias)
Allocation concealment Low risk Randomisation and allocation performed independently and remotely after
(selection bias) consent
Blinding of outcome as- Low risk Outcome assessors were blinded to the study hypotheses and group assign-
sessment (detection bias) ment
All outcomes
Selective reporting (re- Unclear risk Trial registry mentions a physical activity and a stroke impairment outcome
porting bias) which are not present in the publications
Other bias High risk Intervention is leisure-centre based, the control is home-based - there would
be 3 x 2 x 19 = 114 journeys to and from the intervention which is potentially a
lot of un-quantified physical activity
Imbalanced exposure Low risk Stretching was provided to the control - study authors list that stretching does
not lower metabolic factors while other such as yoga does
Mudge 2009
Methods Design: randomised trial of cardiorespiratory training vs non-exercise intervention training - after UC
(circuit-based rehabilitation vs social and educational sessions); power calculation reported
Randomisation: computer-generated random numbers by an individual not associated with the study
Blinding: assessor blinded (unmasking of the independent assessor occurred in 3 cases who inadver-
tently stated or implied their group allocation)
ITT: yes
Withdrawals: 1 participant in the intervention group (disinterest) and 2 participants in the control
group (too busy) withdrew at the end of intervention. 3 further participants withdrew from the inter-
vention group (health problems = 2; another stroke = 1) and 2 from the control group (health problems
= 1; another stroke = 1) before the end of follow-up
Participants Randomised: 58 participants; median age 71.5 years (range 39.0-89.0 years); median 3.9 years af-
ter stroke (range 0.5-18.7 years); participants were recruited through the Stroke Foundation of New
Zealand, stroke clubs, and the local hospital stroke service. Potential candidates were invited to con-
tact the investigators if they wished to participate. All participants walked independently and 26 (45%)
used an assistive device. 55 participants completed the study
Physical fitness training for stroke patients (Review) 137
Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cochrane Trusted evidence.
Informed decisions.
Library Better health. Cochrane Database of Systematic Reviews
Control: 27 participants were randomised to social and educational sessions; 13 men and 14 women;
median age 71.0 (range 44.0-86.0); median onset of stroke 5.8 years (range 0.5-18.7)
Inclusion criteria: participants with ≥ 1 strokes > 6 months earlier, had been discharged from rehabili-
tation and were able to walk independently (with an aid if necessary). Some residual gait difficulty was
required, as defined by a score of < 2 on at least 1 of the walking items of the physical functioning scale
of the SF-36
Exclusion criteria: participants were excluded if they had progressive neurological diseases or signifi-
cant health problems, > 2 falls in the previous 6 months, unstable cardiac conditions, uncontrolled hy-
pertension, or congestive heart failure
Interventions Intervention: participants in the intervention group attended 12 group circuit sessions 3 times/week
for 4 weeks. Groups were led by 1 of the principal investigators assisted by 2 physiotherapist students.
There were 15 stations in the circuit that were graded to each participant's ability and progressed as
tolerated. Each station contained either a task-oriented gait or standing balance activity (e.g. step-
ups, balance beam, marching in place) or strengthening of a lower extremity muscle with the purpose
to improve gait (e.g. lunges, Swiss ball squats, side leg lifts). Total exercise time was 30 min including
stretching. Measurements performed post-intervention and at 3-month follow-up
Control: participants in the control group attended 8 sessions - 4 social and 4 educational sessions (e.g.
provide participants with relevant and useful information for everyday activities; provide intellectual
stimulation and enjoyment sessions; play a game; cafe outing). Each session lasted 90 min. The con-
trol group was led by an occupational therapist. Measurements performed post-intervention and at 3-
month follow-up
Outcomes Included outcomes: mean number of steps a day measured by the StepWatch Activity Monitor; walking
speed and walking endurance
Other outcomes: self-reported confidence during ADL and self-reported mobility assessed by the ABCS,
the RMI, and the PADS
Notes Randomisation was revealed to each participant by the principal investigator after the second baseline
assessment. The study was limited by the small number of participants. Participants volunteered to
participate and were likely to be highly motivated. The sample appeared in fact to be higher function-
ing in terms of gait speed. A gait endurance component was not included in the training circuit
Risk of bias
Random sequence genera- Low risk Computer-generated random numbers by an individual not associated with
tion (selection bias) the study
Blinding (performance Unclear risk Attention control incorporated but not equivalent
bias and detection bias)
All outcomes
Blinding of outcome as- Unclear risk Assessor blinded; unmasking of the independent assessor occurred in 3 cases,
sessment (detection bias) who inadvertently stated or implied their group allocation
All outcomes
Imbalanced exposure Unclear risk Attention control used but there is not an equivalent exposure
Ouellette 2004
Methods Design: randomised trial of resistance training vs non-exercise intervention - after UC
Randomisation: unknown
Allocation concealment: unknown
Blinding: investigator
ITT: yes
Interventions Intervention: progressive resistance training of both lower limbs performed 3 days/week for 12 weeks
comprising 3 sets of 8-10 repetitions at 70% of 1-RM); exercises were (1) seated bilateral leg press, and
(2) unilateral knee extension, both using pneumatic resistance, and unilateral ankle; dorsiflexion; plan-
tarflexion, both using weights; progression achieved via weekly assessment of 1-RM; warm-up for each
exercise was 4 repetitions of 25% 1-RM
Control: non-exercise: bilateral range of motion and upper body flexibility exercises 3 days/week for 12
weeks
Setting: exercise laboratory
Outcomes Included outcomes: muscle strength (bilateral lower limb extension force); muscle strength (unilat-
eral knee extension, ankle dorsiflexion and ankle plantarflexion); gait endurance (6-MWT), preferred
speed (10 m) and maximal speed (10 m); chair rise time (5 repetitions); stair climb time (10 steps); late
life function and disability instrument scale; SF-36 physical function subscale
Other outcomes: muscle power - bilateral lower limb extension and unilateral knee extension; geriatric
depression scale (data not reported); sickness impact profile; Ewarts self efficacy scale
Risk of bias
Park 2011
Methods Design: randomised, single-blind trial of cardiorespiratory training plus UC vs UC - during UC
Withdrawals: 2 participants (1 from both intervention and control groups) not regularly participating
Intervention: 14 participants; 7 men and 6 women; mean age 59.4 years (SD 8.5)
Control: 13 participants; 5 men and 7 women; mean age 56.9 years (SD 7.8)
Inclusion criteria: 6 months to 5 years post-first stroke; walking speed < 0.7 m/s
Interventions Invention group: 4-phased walking training programme (progressing 150 m-200 m-300 m-500 m) 1 h 3
times/week for 4 weeks
Outcomes Included outcomes: 10-metre walk test; 6-MWT; Community Walk test
Notes —
Risk of bias
Random sequence genera- Unclear risk Participants drew 1 of 2 cards from an envelope
tion (selection bias)
Blinding of outcome as- Low risk Person assessing outcome and analysing data blinded
sessment (detection bias)
All outcomes
Pohl 2002
Methods Design: randomised trial of cardiorespiratory training plus % UC vs UC - during UC
Randomisation mechanism: unknown; method: equal block based on gait speed
Allocation concealment: unknown
Blinding: investigator; efficacy unknown
ITT: no
Participants Randomised: 60 participants. 20 participants were randomised to the speed-dependent treadmill train-
ing group (STT); 20 participants to the limited progressive treadmill training group (LTT) and 20 partici-
pants to a conventional gait training group (CGT)
Intervention: STT group = 20 participants; 14 men, 6 women; age 57.1 years (SD 13.9); 16.8 (20.5) weeks
post-stroke. LTT group = 20 participants; 16 men, 4 women; age 58.2 years (SD 10.5); 16.2 (16.4) weeks
post-stroke
Control: 20 participants; 13 men, 7 women; age 61.6 years (SD 10.6); 16.10 (SD 18.5) weeks post-stroke
Inclusion criteria: left or right hemiparesis for > 4 weeks; impaired gait; no or slight abnormal muscle
tone (Ashworth Score 0 and 1); walk without assistance (FAC = 3); 10 m walk time > 5 s and < 60 s; class
B exercise risk (ACSM 1998); absence of known heart disease; no evidence of heart failure, ischaemia or
angina at rest or exercise; appropriate rise in SBP and absence of ventricular tachycardia during exer-
cise
Exclusion criteria: previous treadmill training; class C or D exercise risk (ACSM 1998); cognitive deficits
(MMSE < 26 of 30); movement disorders; orthopaedic or gait-influencing diseases
Interventions Intervention:
Group 1: STT; 30 min/day 3 days/week for 4 weeks; minimal body weight support (10%) for first 3 ses-
sions; speed was increased progressively to the highest speed at which the participant could walk safe-
ly. The maximum-achieved speed was held for 10 s followed by a recovery period. Each time the partic-
ipant successfully completed 10 s of walking at the set speed, the speed was increased during the next
phase by 10%. Treadmill was run at 0% incline
Group 2: LTT; 30 min/day 3 days/week for 4 weeks; minimal body weight support for first 3 sessions;
speed was increased by no more than 5% of the maximum initial speed each week (20% over 4 weeks);
treadmill was run at 0% incline
Both intervention groups also received CPT 45 min/day 2 days/week for 4 weeks (included some gait
training); total 12 h of treatment
Control: conventional gait training that comprised post neuromuscular facilitation and Bobath tech-
niques; 30 min/day 3 days/week for 4 weeks. The control group also received CPT 45 min/day 2 days/
week for 4 weeks (included some gait training); total 15 h of treatment
Notes The control group (20 participants) was divided between the 2 relevant comparisons to avoid exaggera-
tion of overall participant numbers in the analyses
Risk of bias
Random sequence genera- Unclear risk Mechanism unknown; randomised to equal blocks based on gait speed
tion (selection bias)
Blinding (performance Unclear risk Attention control used, but not equivalent
bias and detection bias)
All outcomes
Imbalanced exposure Unclear risk Imbalanced exposure favouring training (control 15 h > intervention 12 h)
Potempa 1995
Methods Design: randomised trial of cardiorespiratory training vs non-exercise intervention - after UC
Randomisation: unknown
Allocation concealment: unknown
Blinding: unknown
ITT: no
All participants aged 43-70 years and were 216 days post-stroke (SD 43)
All participants had upper and lower limb hemiparesis
Inclusion criteria: medically stable; at least 6 months post-stroke; completed formal rehabilitation
Exclusion criteria: patients with brain stem lesions; any clinical evidence that would preclude maximal
exercise testing
Interventions Intervention: cardiorespiratory training: cycle ergometer training for 30 min/day 3 days/week for 10
weeks; intensity 30%-50% of maximal effort increasing to maximum sustainable over first 4 weeks
Control: non-exercise intervention: passive range of motion exercises for 30 min/day 3 days/week for
10 weeks
Setting: unknown
Risk of bias
Richards 1993
Methods Design: randomised trial of mixed training plus UC vs UC - during UC
Randomisation mechanism: unknown; method: stratified on BI scores
Allocation concealment: unknown
Blinding: investigator; efficacy unknown
ITT: no
Interventions Intervention: mixed training: task-oriented gait-training programme that used a tilt table, resisted ex-
ercises using a Kinetron, and treadmill walking, 104 min/day 5 days/week for 5 weeks; progression
achieved via velocity and resistance (Kinetron) increments
Control: traditional neurophysical techniques 109 min/day 5 days/week for 5 weeks
Setting: hospital
Other outcomes: Fugl-Meyer balance; Fugl-Meyer upper and lower extremity scores
Notes We did not use a second control group of early conventional therapy for comparison since it differed
from the institution UC; it commenced earlier than usual during hospital care and had substantially
longer contact time.
Risk of bias
Richards 2004
Methods Design: randomised trial of mixed training plus % UC vs UC - during UC
Randomisation mechanism: unknown; method: variable blocks stratified on time since stroke, disabili-
ty, and age
Allocation concealment: unknown
Blinding: investigator; efficacy unknown
ITT: yes
Interventions Intervention: mixed training: task-oriented gait training programme that used a limb-load monitor, re-
sisted exercises using a Kinetron, and treadmill walking, intervention occurred during PT sessions of
60 min/day 5 days/week for 8 weeks, progression achieved via velocity and resistance (Kinetron) incre-
ments
Control: PT sessions of 60 min/day 5 days/week for 8 weeks not including the task-oriented gait train-
ing content above
Setting: 2 rehabilitation units
Outcomes Included outcomes: preferred walking speed; TUG; BI (ambulation subscore); BBS
Other outcomes: kinematic gait analysis weakened by missing data in 50% participants; Fugl-Meyer leg
and arm scores
Notes A second control group of conventional therapy was not used for comparison since (1) it was much
shorter in duration, and (2) started later than the training intervention
Outcome data imputed from graphs in publication
Risk of bias
Random sequence genera- Unclear risk Unclear; randomisation based on variable blocks stratified on time since
tion (selection bias) stroke, disability, and age
Salbach 2004
Methods Design: randomised trial of cardiorespiratory training vs non-exercise intervention - after UC
Randomisation mechanism: computer; method: stratified on gait speed
Allocation concealment: unknown
Blinding: investigator blinded (unblinded during assessment of intervention group 18/42 and control
group 16/43)
ITT: yes
Interventions Intervention: cardiorespiratory training: task-oriented circuit training, performed 55 min/day 3 days/
week for 6 weeks, comprising a warm-up followed by 10 walking-related tasks (step ups, balance beam,
kicking ball, stand up and walk, obstacle course, treadmill, walk and carry, speed walk, backward walk-
ing, stairs); progression of speed, load and degree of assistance
Control: functional practice, whilst seated, of writing, keyboard use, and manipulating cards; some
practice encouraged at home. 3 days/week for 6 weeks
Setting: 2 rehabilitation centres or hospitals
Outcomes Included outcomes: gait endurance 6-MWT; gait comfortable speed; gait maximal speed; TUG; BBS
Other outcomes: activity-specific balance confidence scale
Notes —
Risk of bias
Random sequence genera- Low risk Computer-based randomisation stratified on gait speed
tion (selection bias)
Sandberg 2016
Methods Design: RCT. Cardiorespiratory training vs no intervention - after UC
Blinding: cycle ergometer test stated as blind at baseline but blinding unclear for other outcome
Withdrawals: 2/27 (7%) withdrew from control group; 1 due to recurrent stroke, 1 unknown reason
Intervention: 29 participants; 14 men (52%) and 15 women (52%); mean age: 73.1 (SD 7); 22.2 (SD 10.1)
days after stroke (earlier for some outcomes)
Control: 27 participants; 14 men (52%) and 13 women (48%); mean age: 70.4 (SD 8.1); 22.8 (SD 10.8)
days after stroke (earlier for some outcomes)
Inclusion criteria: age ≥ 50 years, could walk > 5 m, understand instructions, stroke diagnosis
Exclusion criteria: medical or neurological diseases that were a risk or prevented delivery of training
programme
Control: only advice about exercise and physical activity (usual practice in this setting)
Setting: unclear
Outcomes Included outcomes: peak work rate (watts), 6-MWT, 10-metre walk test, TUG, balance (single leg stance
test), QoL (EQ-5D)
Notes NCT02107768
Risk of bias
Allocation concealment Unclear risk Not clear whether envelopes had sufficient safeguards (opaque etc)
(selection bias)
Blinding (performance High risk No attention control and intervention delivered by 2 of the study authors
bias and detection bias)
All outcomes
Blinding of outcome as- Unclear risk Some outcomes were not assessed by blind personnel and blinding seemed to
sessment (detection bias) be applied differently at baseline and follow-up
All outcomes
Incomplete outcome data Unclear risk 2/27 (7%) dropouts in 2016 paper (n = 56 total) from control group plus no ITT
(attrition bias) analysis. Partner paper (2017) indicated 3 participants in the control group (re-
End of intervention ducing this to n = 24) were missing BP data and were not included. Exact ef-
fects uncertain
Incomplete outcome data Low risk 2/27 lost in control group due to unknown reasons and recurrent stroke. Not
(attrition bias) likely attributed to intervention received
End of follow-up
Selective reporting (re- Low risk BP (2017 paper) was not in the pre-published protocol so might be questioned
porting bias)
Shin 2011
Methods Design: randomised trial of mixed training vs UC
Randomisation: information not included
Allocation concealment: information not included
Blinding: information not included
ITT: not completed
Measurements: before and end of intervention (4 weeks)
Withdrawals: none reported
Exclusion criteria: unable to ride a bicycle or perform functional exercise due to arthritis, low-back pain
or degenerative joint disease; receiving treatment for other symptoms; unable to follow instructions
due to low perceptive abilities, cognitive or communication disorder
Interventions Intervention: participants in the training group (n = 11) received a total of 60 min/day combined exer-
cise training, consisting of 30 min of functional strength training and 30 min of aerobic exercise 5 days/
week for 4 weeks. Functional strength training included bridging, stepping and stair exercises. Aero-
bic exercise was completed using a cycle ergometer and treadmill for 15 min each at < 40% HR reserve
based on age matched maximum HR
Outcomes Included outcomes: static and dynamic balance (force platform measurements), BBS (eyes open and
eyes closed)
Notes —
Risk of bias
Blinding (performance Unclear risk Not reported but there was an attention control
bias and detection bias)
All outcomes
Selective reporting (re- Unclear risk Trial register or protocol not available
porting bias)
Sims 2009
Methods Design: pilot randomised study of resistance training vs no intervention (i.e. a waiting list comparison
group) - after UC. Sample size calculation reported
Blinding: unclear
ITT: yes
Measurements: at the end of the training programme (10 weeks) and at 6-month follow-up
Participants Randomised: 45 participants; 27 men and 18 women; mean age 67.13 years (SD 15.23), average time
since stroke 13.2 months (SD 4.95)
Intervention: 23 participants were allocated to the progressive resistance training group. 21 partici-
pants completed the 10-week programme (2 people became medically ineligible)
Exclusion criteria: < 18 years; stroke < 6 months ago; inability to walk a distance of at least 20 m inde-
pendently with or without a gait assistive device; Prime-MD Patients Health Questionnaire score < 5;
depression with psychotic features; alcohol or drug-related depression, schizophrenia; bipolar disor-
der; other psychiatric diagnoses; suicidal ideation; dementia; terminally ill; uncontrolled hypertension;
unstable angina; and unstable insulin-dependent diabetes
Interventions Intervention: participants in the intervention group attended a community gymnasium twice/week for
10 weeks and trained under the supervision of an accredited fitness trainer. The training programme
entailed moderate strengthening exercises (3 sets of 8/10 repetitions at a resistance of 80% of 1-RM)
using machine weights for the major upper and lower limb muscle groups. Resistance was increased
when participants were able to complete 3 sets of 10 repetitions of an exercise
Control: the waiting list controls received UC and were asked not to do any resistance-type exercise
(content of the 'usual care' intervention not specified)
Notes Sample size calculation performed but sample obtained was smaller than that of the calculation (45
participants instead of 60). Small sample size. At baseline the intervention group had significantly low-
er depression scores than the comparison group. Impact of social interaction was not assessed
The participants in the control group received more attention than simply UC as they received a 10-
week strength assessment
Risk of bias
Random sequence genera- Low risk Quote: "Following the baseline assessments participants were randomly allo-
tion (selection bias) cated to the intervention or comparison group by a centrally located indepen-
dent person using a computer generated block randomisation list, with blocks
of six, stratified by gender."
Allocation concealment Low risk Not applicable as participants allocated in blocks after recruitment and base-
(selection bias) line assessment
Selective reporting (re- Unclear risk Included outcomes correspond with protocol ACTRN12605000613606
porting bias)
Other bias High risk At baseline the intervention group had significantly lower depression scores
than the comparison group
Smith 2008
Methods Design: randomised trial of cardiorespiratory training vs non-exercise intervention - after UC (i.e. tread-
mill gait training vs weekly telephone calls - the main purpose of the study was to explore the potential
additional benefits of treadmill training)
Randomisation: random matched-pair assignment. The investigator assigned a number to suitable par-
ticipants and placed them in 1 of the intervention groups by 'the roll of a dice' (odd control, even treat-
ment), or systematically allocated a participant to match a randomly assigned participant in the alter-
nate group (minimisation?)
Measurements: at the end of the intervention (4 weeks) and then 6 weeks later
Withdrawals: none
Intervention: 10 participants, 8 men and 2 women; mean age 57.8 years (SD 7.0); time from stroke: 8
participants < 1 year and 2 participants ≥ 1 year < 2 years
Control: 10 participants, 4 men and 6 women; mean age 56 years (SD 8.3); time from stroke: 8 partici-
pants < 1 year and 2 participants ≥ 1 year < 2 years
Inclusion criteria: stroke in the middle cerebral artery territory > 3 months but < 2 years prior to en-
rolling in the study; walking slower than pre-stroke
Exclusion criteria: cognitive impairment; unable to ambulate; concomitant pathology that prevented
walking on a treadmill
Interventions Intervention: participants in the intervention group received 12 sessions of treadmill training (20 min
each session) over 4 weeks plus weekly calls from the investigator enquiring about the quality of their
week and encouraging them to keep a QoL log. They wore a standard gait belt on the treadmill and had
a practice session prior to the start of the study. The starting speed on the treadmill was the speed at
which the participant could walk during the practice session for 5 min with a RPE ≤ 13. The speed was
increased by 0.2 mph each time the participant walked for 10 consecutive min with a RPE ≤ 13
Risk of bias
Random sequence genera- Unclear risk Random matched-pair assignment. The investigator assigned a number to
tion (selection bias) suitable participants and placed them in 1 of the intervention groups by 'the
roll of a dice' (odd control, even treatment), or systematically allocated a par-
ticipant to match a randomly assigned participant in the alternate group (min-
imisation?)
Son 2014
Methods Design: randomised trial of resistance training plus UC vs sham training (no resistance) plus UC (most
likely after discharge from usual hospital care approximately 18 months post-stroke)
Randomisation: software used to randomise participants
Allocation concealment: information not included
Blinding: information not included
ITT: not completed but no losses
Measurements: before and end of intervention (6 weeks)
Exclusion criteria: joint contracture, pain, or fracture of the musculoskeletal system, and hemianopia
Interventions Intervention: participants in the training group (n = 14) received lower-limb resistance training for 30
min, 5 times/week for 6 weeks. Warm-up included 1 set of 4 reps of resisted knee extension at 25% 1-
RM, followed by 3 sets of 8-10 reps of resisted knee extension at 70% 1-RM. Resistance load was pro-
gressed weekly via reassessment of 1-RM
Control: participants in the control group (n = 14) received sham lower limb training with no resistance
for 30 min, 5 times/week for 6 weeks. Warm-up included 1 set of 4 reps of knee extension at no resis-
tance, followed by 3 sets of 8-10 reps of knee extension at no resistance
All participants received conservative physical therapy for 30 min/day, 5 days/week, for a period of 6
weeks. Conservative physical therapy consisted of joint mobilisation, muscle strengthening, and bal-
ance training
Outcomes Included outcomes: balance outcomes including antero-posterior (A-P), medio-lateral (M-L) sway dis-
tances, and the BBS; TUG times
Notes —
Risk of bias
Blinding (performance Unclear risk Not reported although there was a suitable attention control
bias and detection bias)
All outcomes
Incomplete outcome data Low risk All 3 criteria for ITT analysis have not been met - methods suggest a per-proto-
(attrition bias) col analysis; however there were no losses
End of intervention
Selective reporting (re- Unclear risk Trial register or protocol not available
porting bias)
Takami 2010
Methods Design: randomised trial of cardiorespiratory training plus % UC vs UC - during UC
Blinding: unknown
Withdrawals: 2 participants from backward walking group and 1 participant from forward walking
group due to family reasons
Intervention 1: 12 participants in backward walking group; 6 men and 6 women; mean age 66.1 years
(SD 6.3); 13.2 days post-stroke (SD 8.4)
Intervention 2: 12 participants in forward walking group; 9 men and 3 women; mean age 71.1 years (SD
10.6); 14.7 days post-stroke (SD 8.1)
Control: 12 participants; 5 men and 7 women; mean age 66.9 years (SD 10.6); 13.7 days post-stroke (SD
8.9)
Inclusion criteria: ability to walk 10 m using aids; post-stroke period of < 5 weeks; FIM-Locomotion
score of ≤ 5; perfect BBS and RMI scores
Interventions Invention groups: BWSTT for 30 min then 10 min of either: backward or forward walking 6 times/week
for 3 weeks
Treadmill speed was progressed each week (0.8, 1.0, and 1.3 km/h)
Control group: conventional training overground walking (150-200 m) for 40 min 6 times/week for 3
weeks
Outcomes Included outcomes: BBS; RMI; 10-metre maximum walking speed; walking ratios during 10 metre for-
ward walking and 5 metre backward walking; Motricity Index; FIM-Locomotion
Notes —
Risk of bias
Taylor-Pilliae 2014
Methods Design: community-based RCT, 3 groups; Tai Chi, 'SilverSneakers' group exercise, or non-exercise inter-
vention
Only Silversneakers and control groups were included giving strength training vs non-exercise interven-
tion - after UC
Randomisation: simple randomisation; participants drew a slip of paper from a non-transparent con-
tainer
Allocation concealment: allocation was concealed; participants were handed an opaque, sealed enve-
lope matching the slip of paper taken from the container, and instructed to open the envelope when
they returned home
Withdrawals: intervention n = 6 (refuse group allocation n = 5, lack of time n = 1); control n = 3 (refuse
group allocation n = 3)
Participants Randomised: n = 92: intervention (Silversneakers mixed training) n = 44; control group n = 48. N = 145
randomised to study as a whole
Intervention: 44 participants; 20 men (45.5%) and 24 women (54.5%); mean age: 69.6 (SD 9.4); days af-
ter stroke not reported
Control: 48 participants; 23 men (47.9%) and 25 women (52.1%); mean age: 68.2 (SD 10.3); days after
stroke not reported
Inclusion criteria: based on pre-screening using standardised tests: functional disability (mRS), physical
function (Short Physical Performance Battery), cognitive impairment (MMSE)
Interventions Intervention: SilverSneakers is a national fitness programme for older adults offering different types of
group-based exercise classes (e.g. aerobics, strength and range of movement, water aerobics, yoga).
In this particular intervention muscular strength and range of movement classes were taught by a cer-
tified instructor at local community fitness centres. 1 h/day, 3 days/week for 12 weeks. Each class ap-
proximately consisted of a 10-min warm-up period, 40-min of exercise, and a 10-min cool-down period
Outcomes Included outcomes: physical function (SPBB including balance using timed balance test, gait speed us-
ing 4-metre walk test, lower body strength using chair stand test), patient-reported fall rates, aerobic
endurance (2-min step test), QoL (SF-36) physical health and mental health composite scores, depres-
sive symptoms (Center for Epidemiologic Studies Depression Scale)
Notes The study author indicated that the 'SilverSneakers Classic' intervention was used, which is focused on
muscular strength and range of motion exercises, and this has no substantive cardiorespiratory train-
ing
Risk of bias
Random sequence genera- Unclear risk Simple randomisation; the study authors reference Taylor-Pilliae 2012 in
tion (selection bias) which the following was reported "subjects drew a slip of paper from a non-
transparent container"
Allocation concealment Unclear risk Concealed allocation identified, no further details provided
(selection bias)
Blinding (performance High risk No specific details provided. Study staff supervised intervention groups. Un-
bias and detection bias) likely blinding for performance bias. Participants dropped out after knowing
All outcomes group allocation; no participant blinding as such and no balanced attention
control dose
Incomplete outcome data Low risk Dropouts; Intervention 6/44 (14%) control 3/48 (7%) , ITT analysis employed
(attrition bias)
End of intervention
Other bias Unclear risk Range of motion (passive) exercises included in strength intervention
Imbalanced exposure High risk Attention control exposure not matched for dose
Teixeira 1999
Methods Design: randomised trial of mixed training vs no intervention - after UC
First iteration only of a lag control design; participants randomly allocated to immediate or delayed -
participants allocated delayed intervention initially received no intervention
Randomisation mechanism: unknown; method: unclear ("balanced blocks")
Allocation concealment: unknown
Blinding: unknown
ITT: no
Interventions Intervention: mixed training: cardiorespiratory and lower extremity strength training 60-90 min/day 3
days/week for 10 weeks; cardiorespiratory training: graded walking plus stepping or cycling progress-
ing from 10-20 min/day and from 50%-70% of maximal cycling work rate over first 5 weeks; strength
training: 7 exercises involving use of body weight and progressive resistive exercise using different
masses and elastic bands (TheraBand), each performed as 3 x 10 repetitions and progressing from
50%-80% of 1-RM; warm-up and warm-down 10-20 min/day
Control: no intervention
Setting: unclear
Outcomes Included outcomes: gait preferred speed (22 m); Adjusted Activity Score; NHP
Other outcomes: insufficient data to compare lower limb muscle strength (peak torque Nm); muscle
tone assessment; and stair climbing
Notes —
Risk of bias
Toledano-Zarhi 2011
Methods Design: mixed training plus non-exercise intervention vs non-exercise intervention after UC
Exclusion criteria: SBP > 200 mmHg; DBP > 110 mmHg; unstable angina; arrhythmia; congestive heart
failure; ST depression ≥ 2 mm on resting ECG; arterioventricular block with no pacemaker; severe pe-
ripheral vascular disease; severe lung disease; orthopaedic or neurological disability; dementia or ma-
jor depression
Interventions Intervention: mixed training; 2 days/week for total of 3 h/week for 6 weeks. Twice/week 35-55 min of
treadmill, hand bike, and cycle ergometer at 50%-70% HR maximum. Once/week 45-55 min of group
strength, flexibility, and co-ordination
Control: home-based booklet with guidance on strength and flexibility and encouragement to contin-
ue with usual community routine
Setting: hospital
Outcomes Included outcomes: 6-MWT; Four Square Step Test; stair ascending and descending; treadmill perfor-
mance (Bruce protocol); BP
Risk of bias
Topcuoglu 2015
Methods Design: RCT of cardiorespiratory upper limb exercise plus UC vs UC - during UC
Randomisation: computer-generated numbers and the treatment group was assigned by the system
Withdrawals: none
Participants Randomised: 52 participants randomised with only 40 participants included; intervention 20 and con-
trol 20
Intervention: 20, mean age 65.95 years (SD 8.7), men 11 and time since stroke 75.3 (SD 29.3) days
Control: 20, mean age 67.5 years (SD 11.2), men 11 and time since stroke 81.40 (36.3) days
Inclusion criteria: hemiplegic stroke within ≥ 1 and ≤ 6 months post-stroke, diagnosed with complex re-
gional pain syndrome
Exclusion criteria: aphasia, serious mental disorder, a disease that could hinder the aerobic exercise
programme to be carried out with upper-arm ergometry, a history of fracture accounting for CRPS,
those with whom no cooperation could be established, and those without sitting balance for 20 min
Interventions Intervention: received standard rehabilitation programme for CRPS and stroke and aerobic exercise
programme accompanied by arm crank ergometry for 5 days/week for 30 min/day for 4 weeks. Stan-
dardised CPT for CRPS type 1 and comprehensive stroke physio programme, which included therapeu-
tic exercises, neurological exercises, postural exercises, balance and co-ordination exercises
Control: standardised CPT for complex regional pain syndrome type 1 and comprehensive stroke
physio programme, which included therapeutic exercises, neurological exercises, postural exercises,
balance and co-ordination exercises
Setting: hospital
Risk of bias
Random sequence genera- Low risk Computer-generated numbers, treatment group assigned by the system
tion (selection bias)
Blinding (performance High risk No attention control and no description of blinding of other study personnel
bias and detection bias)
All outcomes
Blinding of outcome as- Low risk Assessment provided by same physician pre- and post- who were not aware of
sessment (detection bias) participants' group assignment
All outcomes
Incomplete outcome data Low risk ITT not described but no dropouts
(attrition bias)
End of intervention
ITT: yes
Withdrawals: intervention group (4 participants did not start intervention, 1 participant withdrew with-
out reason); control (1 participant at the end of intervention missing assessment, 2 participants died
from cancer, 2 participants had recurrent stroke, 2 participants withdrew without reason)
Intervention: 124 participants; 82 men and 42 women; mean age 56 years (SD 10); time post-stroke 80.9
days (SD 13.0)
Inclusion criteria: verified stroke (according to WHO definition); able to walk a minimum of 10 m unas-
sisted; discharged home from rehabilitation centre; requirement to continue PT during outpatient care
Exclusion criteria: cognitive deficits (MMSE < 24 score); unable to communicate; lived > 30 km from re-
habilitation centre
Interventions Invention group: circuit training programme for 90 min twice/week for 12 weeks. Training included 8
stations intended to improve walking competency. Each station exercise was performed for 3 min with
3 min recovery
Control group: outpatient CPT care, no restriction or detail given regarding time or duration of these
sessions
Outcomes Included outcomes: mobility domain of SIS; RMI; falls efficacy scale; NEADL; HADS; fatigue severity
scale; Motricity index; 6-MWT; 5-metre comfortable walking speed test; timed balance test; TUG; modi-
fied stair test
Notes —
Risk of bias
Random sequence genera- Low risk Participants stratified by rehabilitation centre using an online minimisation
tion (selection bias) procedure
Allocation concealment Low risk Risk removed due to online dynamic allocation mechanism: i.e. there is no al-
(selection bias) location list to conceal
Blinding of outcome as- Low risk Blinded outcome assessment. The efficacy of blinding was confirmed through
sessment (detection bias) statistical analysis of guesses of allocation
All outcomes
Selective reporting (re- Unclear risk Some planned secondary outcomes in the trial register (Dutch Trial Register
porting bias) NTR1534) were not reported or not followed up beyond baseline (chair rise,
Motricity index). Other unplanned outcomes appear in report including func-
Quote: "The circuit training group received 4461 treatment sessions compared
with 4378 for the UC group. The average treatment time/session was 72 (SD
39) mins for the intervention group compared with 34 (SD 10) mins for the con-
trol group (P < 0.05)."
Vanroy 2017
Methods Design: randomised trial. Cardiorespiratory training (cycling) plus UC vs non-exercise intervention plus
UC – commenced during UC with some participants discharged home. A second phase in which the in-
tervention group were allocated to 2 different exposures will be excluded from this review
Randomisation: permuted block randomisation using computer. Stratified on stroke type, motor func-
tion and cardiorespiratory fitness
Measurements: at the end of intervention (3 months). We excluded data at 6- and 12-month follow-up
as other exposures started at the end of the 3-month exercise intervention
Withdrawals: 2/33 (6%) lost at 3 months in the intervention group (1 high BP, 1 refusal). 1/26 (4%) lost at
3 months in the control group (discharged home)
Participants Randomised: total 59 participants. 33 participants were randomised to intervention group, 26 to con-
trol group
Intervention: 33 participants; 20 men (61%) and 13 women (39%); mean age: 66.7 (SD 8.8); 50.5 (SD
19.8) days after stroke
Control: 26 participants; 18 men (69%) and 8 women (31%); mean age: 63.8 (SD 11.8); 48.5 (SD 19.2)
days after stroke
Inclusion criteria: first-ever stroke; age ≤ 80 years; 3-10 weeks post stroke; able to carry out simple in-
structions; able to pedal a MOTOmed cycling leg trainer at 50 revolutions/min
Exclusion criteria: pre-existing neurologic disorders with impaired functionality; existing pre-stroke;
pre-stroke BI < 50; absolute contraindications for exercise testing
Interventions Intervention: cardiorespiratory cycling exercise using a MOTOmed seated cycling ergometer. Sessions
were in intervals weeks 1-8, and continuous weeks 9-12 all performed at 50 pedal revolutions/min
or at a self-chosen frequency but maintaining the target HR training zone. Intensity progressed from
60%-75% HR reserve. Frequency of intervention: 30 min/day for 3 days/week for 3 months. Total ses-
sion time starting at 51 min reduced to 40 min as intensity increased.
The intervention group also received 4 educational sessions (weeks 3, 6, 8, 12) about stroke and risk
factors, importance of an active lifestyle, how to increase physical activity and cardiorespiratory capac-
ity during and after the study
Control: passive, supine mobilisation therapy of paretic hip and knee: 30 min/day for 3 days/week for 3
months
Outcomes Included outcomes: cardiorespiratory fitness (peak workload and oxygen uptake), mobility (FAC, pre-
ferred walking speed (10 m), maximum walking speed (10 m)
Other outcomes: knee extension strength (omitted as a handheld dynamometer was used). In second
paper measures of physical activity (steps, energy expenditure SenseWear) and also self-reported phys-
ical activity (diary, Physical Activity Scale for Individuals with Physical Disabilities). Also Baecke Ques-
tionnaire of Habitual Physical Activity only used at 12 months which is not end of intervention
Risk of bias
Blinding (performance High risk Attention control balances the groups however participants were aware of the
bias and detection bias) different intervention programmes
All outcomes
Blinding of outcome as- Low risk The outcome assessors were blinded. Participants were aware of different pro-
sessment (detection bias) grammes but instructed not to inform the assessor
All outcomes
Incomplete outcome data Low risk ITT not described but very low attrition
(attrition bias)
End of intervention
Selective reporting (re- Unclear risk All outcomes specified in the methods were reported, however no pre-pub-
porting bias) lished protocol documents or trial registry entries
Other bias Low risk The intervention group also received 4 educational sessions (weeks 3, 6, 8,
12) relating to continuing the intervention after it had finished, since this is fo-
cused on the period after our outcome of interest at the end of the interven-
tion it is unlikely that it led to bias
Verheyden 2009
Methods Design: randomised trial of functional strength training plus UC vs UC
Randomisation: simple randomisation
Allocation concealment: information not included
Blinding: assessor blinded
ITT: not completed
Measurements: before and end of intervention (5 weeks)
Withdrawals: none, however 2 participants received fewer hours of intervention therapy due to ear-
ly discharge. In the control group, 3 participants were discharged early and therefore received fewer
hours of UC. All participants were evaluated before discharge and included in analysis
Exclusion criteria: an age of ≥ 80 years; unable to understand instructions; other disorders that could af-
fect motor performance or an ability to obtain maximum trunk performance
Interventions Intervention: participants in the training group (n = 17) received resistance training for the trunk for 30
min, 4 times/week for 5 weeks. Seated exercises included selective movements of the upper and low-
er part of the trunk in supine and in sitting. In addition conventional multidisciplinary stroke rehabili-
tation, such as neuro-developmental treatment and motor learning strategies, was provided. No other
details were reported.
Control: participants in the control group (n = 16) received conventional multidisciplinary stroke re-
habilitation, such as neuro-developmental treatment and motor learning strategies. No other details
were reported
Notes —
Risk of bias
Random sequence genera- Unclear risk Method described only as simple randomisation by personnel not involved in
tion (selection bias) the study
Blinding (performance High risk "...patients nor the physiotherapists who delivered the interventions were
bias and detection bias) blinded"
All outcomes
Incomplete outcome data Low risk A total of 2 participants from the intervention group completed 3 and 4 h fewer
(attrition bias) of additional therapy due to early discharge. The participants were evaluated
End of intervention before discharge and included in the analysis. A total of 3 participants from the
control group were discharged early after 21, 23, and 25 days respectively and
therefore received fewer h of CPT (number of fewer h not reported)
Although ITT was not referred to specifically there were "no dropouts during
the course" of the study, and "... all participants were evaluated before dis-
charge."
Selective reporting (re- Unclear risk Trial register or protocol not available
porting bias)
Wang 2014
Methods Design: randomised trial of cardiovascular training plus UC vs UC - during UC
Randomisation: sealed card selection by participants
Inclusion criteria: time since stroke onset of 1-6 months; age > 45 years; severely impaired with the af-
fected leg marked ≤ 3 on the 7-point Chedoke–McMaster Stroke Assessment scale; unable to walk even
with walk aids; the unaffected leg can move against normal resistance; fasting glucose < 7 mmol/L; no
physician diagnosed diabetes; never using medications that may significantly alter HR and blood glu-
cose level; and able to understand the purpose and content of the study
Exclusion criteria: signs and symptoms of subarachnoid haemorrhage, transient ischaemic attack, se-
vere cerebral oedema, O2 dependence, angina, unstable cardiac conditions, peripheral arterial occlu-
sive disease, abnormal high fever, severe pneumonia, high BP > 200/110 mmHg, dementia, aphasia op-
erationally defined as incapacity to follow 2-point commands, untreated major depression, and other
medical conditions that precluded participation in exercise training
Interventions Intervention: participants in the training group (n = 23) received conventional stroke rehabilitation
5 days/week for 6 weeks, (3 x 40-min physical therapy sessions; 2 x 15-min OT sessions; 1 x 30-min
acupuncture or traditional Chinese manipulation session; and 1 x 30-min physical agents therapy ses-
sion). 1 x 40-min physical training session was replaced by low-intensity aerobic cardiovascular train-
ing 3 days a week for 6 weeks using a cycle ergometer. Cycling training consisted of 30 min sessions in-
cluding: 5 min warm-up; 30 min active pedaling at an intensity based on an incremental graded exer-
cise test (2.5 W ramp every 3 min maintaining 50 rpm until exhaustion); followed by 5-min cool down.
Target HR was calculated as ((peak HR in graded exercise test – resting HR) x 50% to 70%) + resting HR
Control: participants in the training group (n = 27) received conventional stroke rehabilitation 5 days/
week for 6 weeks, (3 x 40-min physical therapy sessions; 2 x 15-min OT sessions; 1 x 30-min acupunc-
ture or traditional Chinese manipulation session; and 1 x 30-min physical agents therapy session)
Outcomes Included outcomes: BI; exercise test time; glucose tolerance variables (fasting glucose; fasting insulin;
2-h plasma glucose; homeostasis model assessment–insulin resistance index), and serum lipid profiles
(total triglycerides, HDL cholesterol, LDL cholesterol)
Notes —
Risk of bias
Random sequence genera- Unclear risk 1 of 2 cards selected from a sealed envelope by participants
tion (selection bias)
Blinding (performance High risk Therapists blinded but there was imbalanced intervention exposure
bias and detection bias)
All outcomes
Blinding of outcome as- Low risk Outcome measures administered by a blinded rater
sessment (detection bias)
All outcomes
All 3 criteria for ITT analysis have not been met - methods suggest a per-proto-
col analysis
Selective reporting (re- Unclear risk Trial register or protocol not available
porting bias)
Imbalanced exposure High risk Intervention group was exposed to an additional exposure volume on top of
UC PT
Winstein 2004
Methods Design: randomised trial of resistance training plus UC vs UC - during and after UC
Randomisation mechanism: unknown; method: stratified on Orpington Prognostic Scale (1.6-1.4 and
4.2-6.8)
Allocation concealment: sealed envelopes
Blinding: principal investigator but not outcome assessor
ITT: no
Interventions Intervention: upper limb movements resisted by gravity, free weights, TheraBand and grip devices for
fingers, 60 min/day 5 days/week for 4-6 weeks, high-intensity for 3 days/week and low-intensity higher
velocity for 2 days/week, training target 20 h total
Control: standard care delivered by OT, included muscle facilitation exercises using neuro-develop-
mental approach, electrical stimulation, stretching, ADL and caregiver training; activities included use
of upper limbs
Setting: inpatient rehabilitation hospital and outpatient clinic
Outcomes Included outcomes: FIM (mobility and self-care scores); FTHUE; composite measure of strength (sum of
torque from extension and flexion of the wrist elbow and shoulder); grip and pinch force
Risk of bias
Random sequence genera- Unclear risk Mechanism unknown; stratification based on Orpington Prognostic Scale
tion (selection bias) (1.6-1.4 and 4.2-6.8)
Yang 2006
Methods Design: randomised trial of mixed training vs no intervention - after UC
Randomisation mechanism: picking envelopes
Allocation concealment: sealed envelopes
Blinding: investigator
Interventions Intervention: mixed training performed as a circuit 30 min/day 3 days/week for 4 weeks; circuit com-
prised 6 x 5-min lower extremity workstations (standing and reaching, sit-to-stand from chair, stepping
forwards and backwards onto blocks, stepping sideways onto blocks, forward step-up onto blocks),
participants encouraged to work hard, progression achieved by increasing number of repetitions in
each 5-min block, and increasing step and chair height, and the complexity of task; extended periods
(5-min) warrant acknowledgement of a cardiorespiratory component despite the author's title (pro-
gressive resistance strength training)
Control: no intervention
Outcomes Included outcomes: gait endurance (6-MWT - outcome assessor not blinded); gait speed preferred (10
m); 3 metre TUG; step test; isometric strength of knee and hip ankle extension and flexion; and ankle
dorsi-flexion and plantar-flexion (using handheld dynamometer)
Other outcomes: gait cadence and stride length
Notes Study authors stated "strength training" but intervention was actually mixed training. Data reported as
absolute and change scores
Risk of bias
Random sequence genera- Unclear risk Quote: "...independent person who picked one of the sealed envelopes 30 min
tion (selection bias) before the start of the intervention."
Allocation concealment Unclear risk Sealed envelopes; opaque and numbered not reported
(selection bias)
Yang 2014
Methods Design: randomised cross-over trial of cardiorespiratory training plus UC (outpatient) vs UC (outpa-
tient)
Exclusion criteria: patients with aphasia who were unable to follow instructions; blindness or visual im-
pairment; musculoskeletal disorders; cardiac disorders and peripheral neuropathy
Interventions Intervention: 15 participants in the training group received conventional stroke rehabilitation (1 h PT;
1 h OT). In addition extra cardiovascular training was given for 30 min, 5 times/week for 4 weeks. Cy-
cling training consisted of 15 min sessions each of forward and backward cycling including: 150-s pas-
sive warm-up; 10-min active pedaling at 50-70 rpm at an intensity of stage 13 of the Borg scale; 150 sec-
onds of passive cool-down
Control: 15 participants in the control group received conventional stroke rehabilitation (1 h PT; 1 h OT)
Outcomes Included outcomes: 6-MWT; comfortable walking speed using 10-metre walk test
Other outcomes: lower limb subscale of Fugl-Meyer assessment (LE-FMA); modified Ashworth scale
Authors indicate the 10-MWT was at a comfortable speed not a maximal speed
Risk of bias
Random sequence genera- Low risk Quote: "... computer-generated random numbers"
tion (selection bias)
Allocation concealment Unclear risk Some evidence of concealment but the description is inadequate; only report-
(selection bias) ed as Quote: "... held in sealed envelopes by an independent individual"
All 3 criteria for ITT analysis have not been met - methods suggest a per-proto-
col analysis, however only 1 participant affected
Selective reporting (re- Unclear risk Trial register or protocol not available
porting bias)
Zedlitz 2012
Methods Design: multicentre randomised trial of mixed training plus non-exercise intervention vs non-exercise
intervention - after UC
Randomised: block randomisation; implemented individually but also as a cluster when numbers were
low
ITT: yes
Withdrawals: 1 participant withdrew consent before allocation into group; intervention group (5 par-
ticipants, 3 withdrew consent before end of intervention, 1 participant withdrew due to poor health
before end of intervention; 1 participant withdrew due to recurrent stroke before follow-up); control
group (6 participants, 3 withdrew consent, 1 got new job; 1 family emergency, 1 participant recurrent
stroke all before end of intervention; 4 participants lost to follow-up)
Intervention: 38 participants (1 withdrew consent); 22 men and 23 women; mean age 54.8 years (SD
9.1); 4.4 years post-stroke (SD 4.2)
Control: 45 participants; 21 men and 17 women; mean age 55.6 years (SD 8.8); 3.3 years post-stroke (SD
3.9)
Inclusion criteria: sustained stroke > 4 months; reported severe fatigue; between ages 18-70 years; able
to walk independently
Exclusion criteria: severe cognitive deficits; severe comorbidity (cardiac disease, pulmonary disease);
depression
Interventions Invention group: treadmill walking and strength training ranging from 40%-70% maximum HR for 2 h
twice/week for 12 weeks
Outcomes Included outcomes: Checklist Individual Strength-subscale Fatigue; HADS; SIS; 6-MWT
Notes —
Risk of bias
Random sequence genera- Unclear risk Randomisation implemented (individually) in groups of 8 in each centre by
tion (selection bias) picking 1 of 8 sealed envelopes. If only 4 participants were available in 1 centre
then they were allocated as a group (cluster)
Allocation concealment Unclear risk Full nature and use of envelopes is unclear
(selection bias)
Selective reporting (re- Low risk Included outcomes correspond to trial registry NTR2704. Some proposed cog-
porting bias) nitive outcomes not present in publication
Zou 2015
Methods Design: RCT. Resistance training vs attention control - after UC
Randomisation: randomised by selection of sealed envelopes. Block sampling to ensure similar group
sizes
Allocation concealment: sealed envelopes used (not clear if sequentially numbered or opaque)
Blinding: study investigators not blinded, outcome assessors blinded, participants may have under-
stood nature of group assignments
Withdrawals: 2/28 (7%) participants from the intervention group (2 withdrew due to muscle fatigue).
3/28 (11%) participants from the control group (3 due to moving to another location)
Intervention: 28 participants; 13 men (46%) and 15 women (54%); mean age: 52.3 (SD 6.9); 15 (SD 6.2)
months after stroke
Control: 28 participants; 9 men (32%) and 19 women (68%); mean age: 51.4 (SD 7.2); 8 (SD 5.1) months
after stroke
Inclusion criteria: age < 60 years, nondiabetic, > 6 months after stroke onset disabled stroke patients
who had completed CPT. Baseline characteristics indicate at least 3 weeks of rehabilitation training and
BI score > 60
Exclusion criteria: diabetes, heart failure, unstable angina, dementia, and aphasia
Interventions Intervention: resistance training; 3 sets of 15 repetitions of leg press, leg extension and leg curl using re-
sistance training machines. Legs were trained unilaterally and alternately. Resistance was progressed
every 2 weeks. Frequency of intervention: 40 min/day for 3 days/week for 8 weeks
Control: active and passive upper and lower body stretching exercises. Frequency of intervention: 40
min/day for 3 days/week for 8 weeks
Outcomes Included outcomes: risk factors (blood glucose control indices, serum lipids, BMI); muscle strength;
Fugl-Meyer scores
Risk of bias
Random sequence genera- Unclear risk Physical method suggested but no mechanism actually described
tion (selection bias)
Allocation concealment High risk Sealed envelopes not stated as opaque (or numbered) plus unblinded investi-
(selection bias) gators could make this vulnerable
Blinding (performance Unclear risk Those delivering intervention were blinded to baseline data and group assign-
bias and detection bias) ment. Attention control was used but study authors indicated participants
All outcomes may have known which group they belonged to
Blinding of outcome as- Low risk Outcome assessors and therapists were blinded to baseline data and group as-
sessment (detection bias) signment
All outcomes
Incomplete outcome data Low risk ITT analysis not used. Few withdrawals, but those in the intervention group
(attrition bias) were due to muscle fatigue, 2/28 (7%), whereas those in the control group all
End of intervention withdrew due to moving to another location, 3/28 (11%)
Selective reporting (re- Unclear risk Trial registry or protocol not available
porting bias)
Other bias Unclear risk Not all participants completed all training content some of the stretches were
active as well as passive
6-MWT: 6-Minute Walk Test; 9-HPT: 9-Hole Peg Test; 12-MWT: 12-minute walk test; ABCS: Activities-Specific Balance Confidence Scale;
ACSM: American College of Sports Medicine; ADL: activities of daily living; AQoL: Assessment of Quality of Life Instrument; ARAT: Action
Research Arm Test; BBS: Berg Balance scale; BDI: Beck Depression Inventory; BI: Barthel Index; BMI: body mass index; BP: blood pressure;
bpm: beats per minute;BWSTT: body weight supported treadmill training; CES-D: Centre for Epidemiological Studies Depression scale;
CRPS: complex regional pain syndrome; CT: computerised tomography; CPT: conventional physiotherapy; DBP: diastolic blood pressure;
ECG: electrocardiogram; EMS: Elderly Mobility Scale; FAC: Functional Ambulation Classification; FAI: Frenchay Activity Index; FAME: family-
mediated exercise; FAPS: Functional Ambulation Profile Score; FIM: Functional Independence Measure; FST: functional strength training;
FTHUE: Functional Test of the Hemiparetic Upper Extremity; HADS: Hospital Anxiety and Depression Scale; HDL: high-density lipoprotein;
HR: heart rate; HRQoL: health-related quality of life; IQR: interquartile range; ITT: intention-to-treat; LDL: low-density lipoprotein;
LOCF: last observation carried forward; LOT-R: Life Orientation Test - Revised; MAS: Motor Assessment Scale; MI: myocardial infarction;
MMSE: Mini Mental State Examination; MRI: magnetic resonance imaging; mRS: modified Rankin Scale; NEADL: Nottingham Extended
Activities of Daily Living; NHP: Nottingham Health Profile; NHS: National Health Service; OT: occupational therapy; PADS: Peripheral
Arterial Diseases Walking Impairment questionnaire; PT: physiotherapy; QoL: quality of life; RCT: randomised controlled trial; RLOC:
Recovery Locus of Control Scale; RM: repetition maximum; RMA: Rivermead Motor Assessment; RMI: Rivermead Mobility Index; RPE: rate
of perceived exertion; RPM: revolutions per minute; SBP: systolic blood pressure; SD: standard deviation; SF-12: Short Form-12 Health
Survey Questionnaire; SF-36: Short Form 36 Health Survey; SIS: Stroke Impact Scale; SSS: Scandinavian Stroke Scale; SWLS: Satisfaction
with Life Scale; TUG: timed up and go test; UC: usual care; WHO: World Health Organization
Ru 2017 Co-intervention
Participants Stroke n = 20
Outcomes PT
Chan 2017
Methods RCT
Participants Stroke n = 32
Chan 2018
Methods RCT
Interventions Conventional training arm of study (Tai Chi arm excluded) vs no intervention
Notes Conventional training unclear on content and progression; 2 connected studies with different re-
ported sample sizes
Chen 2014
Methods RCT
Participants Stroke n = 77
Deshpande 2018
Methods RCT
Ellis 2018
Methods RCT
Participants Stroke n = 32
Notes Robot device involved; unclear if this represents physical fitness training
Faulkner 2017b
Methods RCT
Floel 2018
Methods RCT
Frimpong 2014
Methods RCT
Participants Stroke n = 20
Gezer 2018
Methods RCT
Participants Stroke n = 42
Outcomes Exercise tolerance, respiratory function, 6-MWT, FIM, NHP, BDI, and Pittsburgh Sleep Quality Index
Hwang 2015
Methods Randomised cross-over study
Participants Stroke n = 11
Outcomes Resting HR, mean arterial pressure, respiratory variables, normal gait speed, TUG, psychological
variables relating to affect
Notes Need cross-over data from first iteration; study author contacted
Jeon 2016
Methods RCT
Participants Stroke n = 12
Kim 2015
Methods RCT
Participants Stroke n = 27
Kim 2017c
Methods RCT
Participants Stroke n = 30
Notes The control group may incorporate an exercise co-intervention that is not UC
Koç 2015
Methods RCT
Outcomes BI
Notes Progression and intervention content unclear; sought from study authors
Kumaran 2016
Methods RCT
Participants Stroke n = 62
Lawal 2016
Methods RCT
Participants Stroke n = 91
Maheshwari 2018
Methods RCT
Participants Stroke n = 47
Matsumoto 2016
Methods RCT
Oh 2016
Methods RCT
Participants Stroke n = 40
Opara 2016
Methods RCT
Participants Stroke n = 60
Interventions BWSTT
Ploughman 2017
Methods RCT
Participants Stroke n = 60
Pudipeddi 2016
Methods Controlled study; randomisation unclear
Participants Stroke n = 30
Ruescas-Nicolau 2015
Methods RCT
Participants Stroke n = 13
Participants Stroke n = 12
Song 2015a
Methods RCT
Participants Stroke n = 40
Outcomes Balance
Song 2015b
Methods RCT
Participants Stroke n = 30
Szczygiel 2015
Methods RCT
Participants Stroke n = 60
Participants Stroke n = 63
Outcomes Mobility section of the SIS; other sections of the SIS; mobility, RMI, BI, NEADL, TUG test, mRS, Fugl
Meyer lower extremity, Motricity Index, BBS, HADS
Vij 2015
Methods RCT
Participants Stroke n = 40
Outcomes Step length, stride length, cadence, gait velocity, spasticity, foot pressure, Wisconsin Gait Scale
Wu 2017
Methods RCT
Participants Stroke, n = 60
Xu 2015
Methods RCT
Yang 2018
Methods RCT
Participants Stroke n = 60
Yelnik 2017
Methods RCT
Outcomes Fugl-Meyer Score, number of days to walking 10 m unassisted, balance, autonomy, QoL, unexpect-
ed medical events
Zhang 2015
Methods RCT
Participants Stroke n = 40
2-MWT: 2 minute walk test; 5-MWT: 5-Metre Walk Test; 6-MWT: 6-Minute Walk Test; 10-MWT: 10-Metre Walking Test; ARAT: Action Research
Arm Test; BBS: Berg Balance Scale; BI: Barthel Index; BDI: Beck Depression Inventory; BWSTT: body weight supported treadmill training;
FAC: Functional Ambulation Classification; FIM: Functional Independence Measure; HADS: Hospital Anxiety and Depression Scale; HR:
heart rate; MAL: Motor Activity Log; MMT: Manual Muscle Test; mRS: modified Rankin Scale; NEADL: Nottingham Extended Activities of
Daily Living; NHP: Nottingham Health Profile; NIHSS: National Institutes of Health Stroke Scale; PT: physiotherapy; QoL: quality of life;
RCT: randomised controlled trial; RMI: Rivermead Mobility Index; SIS: Stroke Impact Scale; TIA: transient ischaemic attack; TUG: Timed
Up-and Go Test; UC: usual care; WMFT: Wolf Motor Function Test
ACTRN12615000728538
Trial name or title Home-based, tailored intervention for reducing falls after stroke: the Falls After Stroke Trial (FAST)
Methods RCT
Participants N = 270
ACTRN12615000728538 (Continued)
Outcomes Self-report falls incidence, BBS, 6MWT, self-report and accelerometer-measured physical activity,
community participation (Later-Life Function and Disability Instrument), HRQoL, Step test, Health
care utilisation and costs, gait speed
Contact information Prof Catherine Dean, Ground Floor 75 Talavera Road, Macquarie University, NSW 2109, Australia;
+61 2 9850 6620; [email protected]
Notes
ACTRN12616000391471
Trial name or title A study on benefit of circuit class therapy on mobility, balance, reintegration into normal life and
quality of life of people with stroke
Methods RCT
Participants N = 40
Contact information Dr Nor Azlin Mohd. Nordin, Physiotherapy Programme, School of Rehabilitation Sciences, Facul-
ty of Health Sciences, Jalan Raja Muda Aziz, Universiti Kebangsaan Malaysia, 50300 Kuala Lumpur,
Malaysia; +6019 359 4418, +603 26878038; [email protected]
ACTRN12616001288415
Trial name or title A comparison of two forms of physiotherapy on functional performance after acquired brain injury:
a pilot randomised controlled trial
Methods RCT
Participants N = 30
Outcomes Global Impression of Change scale, STS item of the Mobility Scale for Acute Stroke Patients (MSAS),
muscle strength, goal attainment, subjective ranking of functional task performance
Contact information Mr Davide de Sousa, Physiotherapy Department, Graythwaite Rehabilitation Centre, Ryde Hospi-
tal, Denistone Road, Eastwood NSW 2122, Australia; +61298587144; [email protected]
sw.gov.au
ACTRN12616001288415 (Continued)
Notes Details of functional tasks and strategies used in the intervention are not presented
ACTRN12617000452392
Trial name or title Core muscles strengthening for balance and gait performance in individuals with
chronic stroke
Methods RCT
Participants Stroke
Starting date
Contact information
ACTRN12617000746336
Trial name or title Walking away fatigue and disease after stroke
Methods RCT
Participants N = 30
Outcomes Fatigue Severity Scale, feasibility, daily step count, fasting glucose, resting BP, BMI, gait speed,
blood lipids, daily time spent in moderate intensity activity, gait endurance, MAS
Contact information Dr Niru Mahendran, 12D47, Faculty of Health, University of Canberra, 1 University Drive, Bruce ACT
2617, Australia; +612 6206 8302; [email protected]
Notes
Methods RCT
Participants N = 42
Outcomes BI, FAC scale, Frequency Activities Index, Fugl-Meyer motor score, exercise test duration, peak heart
rate
Contact information Huaping Pan, 168 Gushan Rd, Jiangning District, Nanjing, Jiangsu, +86 18901588339, heap-
[email protected]
Notes
ChiCTR-IOR-17010821
Trial name or title Effect of sling exercise training on the balance function of stroke patients with hemiplegia
Participants N = 50
CTRI/2016/09/007258
Trial name or title Exercise using all four limbs in half-side paralysis
Methods RCT
Participants N = 50
Contact information Dr Kamal Narayan Arya, Pt. Deendayal Upadhyaya Intitute for the Physically Handicapped, 4 VD
Marg, New Delhi, Central, DELHI 110002 India; 9899897408; [email protected]
Notes
CTRI/2016/10/007337
Trial name or title Effectiveness of physiotherapy training to improve control of sitting on floor
Methods RCT
Participants N = 50
Outcomes Attainment of squatting and sitting on the floor using goal attainment scale, lower limb strength
using Motricity Index (lower limb strength), Fugl Meyer Scale (lower limb motor recovery), short fall
efficacy scale (fear of falling, Neuro QoL-Short form (ability to participate in social roles and activi-
ties))
Notes
CTRI/2017/03/008061
Trial name or title Comparison of home exercises verses exercises given in hospital set up in improving functional re-
covery of upper limbs in post stroke patients
Methods RCT
Participants N = 60
Interventions Home-based exercises by care givers with routine therapy given at hospital setup
Outcomes Fugl-Meyer MAS (upper extremity level of impairment), WMFT (upper extremity function), SIS (par-
ticipation level)
Notes
CTRI/2018/01/011543
Trial name or title Efficacy of task-oriented training approach on trunk and hip musculature to improve balance in
stroke subjects: a randomised controlled trial
Methods RCT
Participants N = 40
CTRI/2018/01/011543 (Continued)
Outcomes Trunk Impairment Scale, Brunel Balance Assessment, Tinetti performance oriented mobility as-
sessment scale, stroke rehabilitation assessment of movement measures
Notes
IRCT20150721023277N2
Trial name or title The efficacy of occupation-based and exercise-based interventions on performance components
and areas of occupation in subjects with chronic stroke
Methods RCT
Participants N = 45
Interventions Structured exercise protocol including the range of motion and strengthening exercises, balance
and endurance training and functional use of the upper extremity
Outcomes Participation in occupational areas 2. Performance components including upper limb function,
balance and functional mobility and cognition
Notes
IRCT2016102430477N1
Trial name or title Effect of rehabilitation in stroke recovery
Methods RCT
Participants N = 20
Outcomes Neurophysiological parameters (rest motor threshold, active motor threshold, recruitment curve,
cortical silent period and ipsilateral silent period) recorded by transcranial magnetic stimulation,
Modified BI, Modified Ashworth Scale, Fugl-Meyer
IRCT20171105037256N4
Trial name or title The effect of dual-task exercises on balance, falling and activities of daily living in stroke
patients
Participants Unknown
Outcomes TUG
JPRN-UMIN000019380
Trial name or title The effect of walking exercise by Nordic pole on the aerobic performance for stroke patients
Methods RCT
Participants N = 40
Interventions Cardiorespiratory
Notes
Miller 2014
Trial name or title Protocol for a randomised controlled clinical trial investigating the effectiveness of Fast muscle Ac-
tivation and Stepping Training (FAST) for improving balance and mobility in sub-acute stroke
Methods RCT
Participants N = 60
Outcomes Chedoke-McMaster Stroke Assessment, BBS, 10-MWT, maximum voluntary contraction, gait speed,
Physiological Balance Test
Notes
NCT01161329
Trial name or title Description of physical and psychosocial problems one year after stroke and the effect of intensi-
fied physical activity for patients with stroke - a combined physical and behavioural approach
Methods RCT
Participants N = 67
Outcomes BBS
Notes
NCT01915368
Trial name or title Determining Optimal post-Stroke Exercise (DOSE)
Methods RCT
Participants N = 75
Outcomes Ambulatory function measured by the 6-MWT, ambulatory function from the 5-Meter Walk Test, bal-
ance function from the BBS, ambulatory function from the FAC, QoL measured with EuroQol, cog-
nition measured by the Montreal Cognitive Assessment, cognition measured by the Digit Symbols
Substitution Test, cognition measured by the Trail Making Test, depression measured by Patient
Health Questionnaire-9, HR measured during the intervention sessions, step count measured dur-
ing the intervention sessions
Notes
NCT01916486
Trial name or title Vitality: promoting cognitive function in older adults with chronic stroke (Vitality)
Methods RCT
Participants N = 119
Outcomes Alzheimer's Disease Assessment Scale Cognitive Subscale Plus, IADL Scale, Fatigue Severity Scale,
Short Physical Performance Battery, 6-MWT, TUG, quadriceps strength, grip strength, European
QoL
Notes
NCT02272426
Trial name or title The safety and tolerability of an aerobic and resistance exercise program with cognitive training
post-stroke
Methods RCT
Participants N = 132
Outcomes Adverse events related to interventions, training programme adherence, Cognitive Assessment
Battery, Depression Scale, QoL
NCT02437006
Trial name or title Early intervention with a low-intensity leg cycling exercise program for individuals after
stroke
Methods RCT
Participants N = 120
NCT02437006 (Continued)
Notes
NCT02494518
Trial name or title Forced aerobic exercise for stroke rehabilitation
Methods RCT
Participants N = 34
Outcomes Fugl Meyer Assessment, WMFT, SIS, Metabolic Stress Test, ARAT, 6-MWT
Notes
NCT02550015
Trial name or title High intensity interval training after stroke
Methods RCT
Participants N = 70
Outcomes Maximal Oxygen Uptake, change in BP, 10-MWT, TUG, BBS, FIM, International Physical Activity
Questionnaire, Montreal Cognitive Assessment, 6-MWT
Notes
NCT02550990
Trial name or title Synergistic effects of aerobic exercise and cognitive training on cognition in stroke patients with
cognitive decline
NCT02550990 (Continued)
Methods RCT
Participants N = 75
Outcomes Montreal Cognitive Assessment, Wechsler Memory Scale, Wechsler Adult Intelligence Scale, FIM,
Lawton IADL Scale, SIS, TUG, 6-MWT, mobility, Fugl-Meyer Assessment, RMI, Geriatric Depression
Scale, MVC knee extension strength
Notes
NCT02619110
Trial name or title The effect of backward walking treadmill training on balance in patient with chronic
stroke
Methods RCT
Participants N = 30
Notes
NCT02703805
Trial name or title FIT for FUNCTION
Methods RCT
Participants N = 216
Outcomes Reintegration to Normal Living Index, Rapid Assessment of Physical Activity, BBS, Short Physical
Performance Battery, 6-MWT, grip and knee strength, European QoL 5-Dimension Questionnaire,
cardiovascular risk factors, self-efficacy for physical activity (Stanford 6-item Scale), level of par-
ticipant knowledge, skill, and confidence for self-management (Patient Activation Measure) and
healthcare utilisation and cost evaluation
NCT02703805 (Continued)
Notes NCT02703805
NCT02710773
Trial name or title Backward treadmill training in patients with chronic stroke
Methods RCT
Participants N = 20
Notes
NCT02717715
Trial name or title SunRISe Study - Stroke Rehabilitation In Suriname
Methods RCT
Participants N = 20
NCT02731235
Trial name or title The effect of aerobic exercise in patients with minor stroke
Methods RCT
NCT02731235 (Continued)
Participants N = 84
Outcomes Graded Cycling Test with Talk Test, Physical Activity Scale, Short time activity measurements, WHO-
five Well-being Index, Montreal Cognitive Assessment, Major Depression Inventory, Multidimen-
sional Fatigue Inventory
Notes
NCT02753322
Trial name or title Training dual-task balance and walking in people with stroke
Methods RCT
Participants N = 84
Outcomes Degree of the dual-task interference, standing balance (with eyes open and closed), 10-MWT, ob-
stacle crossing, Chinese version of Activities-specific Balance Confidence Scale, Chedoke Arm and
Hand Activity Inventory, incidence of falls
Email: [email protected]
Notes
NCT02855424
Trial name or title The effect of leg cycling exercise program at low or moderate intensity for individuals with suba-
cute stroke
Methods RCT
Participants N = 90
Outcomes Symptom-limit exercise tolerance tests, changed activity of autonomic nervous system, 10-MWT,
BI, Stroke-Specific QoL Scale, Fugl-Meyer (lower extremity), Multi-dimensional Fatigue Inventory,
performance of cycling
NCT02855424 (Continued)
Email: [email protected]
Notes
NCT02902367
Trial name or title SMS-guided training after acute stroke or transient ischemic attack - a randomised controlled trial
(SMS/TIA)
Methods RCT
Participants N = 80
Outcomes 6-MWT, Short Physical Performance Battery, 10-MWT, hand-dynamometer, body composition, car-
diometabolic risk markers, mortality, health-related QoL
Email: [email protected]
Notes
NCT02923765
Trial name or title Stepper aerobic training on fitness, disability, inflammation and thrombosis in stroke patients
Methods RCT
Participants N = 170
Outcomes Cardiopulmonary Exercise Test, FIM, thrombosis and coagulation activities of blood samples by
flow cytometry, dynamic TG assay, and enzyme-linked Immunosorbent assay
Email: [email protected]
Notes
NCT02937480
Trial name or title Efficacy of task-specific training in physical activity level post-stroke
Methods RCT
Participants N = 38
Outcomes Physical activity levels (physical activity monitor, Human Activity Profile), gait speed, TUG, Upper
Extremity Performance Test (TEMPA), handgrip strength, 6-MWT, SS-QOL
Email: [email protected]
Notes
NCT02938000
Trial name or title E-rehabilitation: aerobic resistance training for stroke survivors
Methods RCT
Participants N=3
Outcomes Peak VO2 using 6-MWT, BBS, adherence to exercise programme, Patient Health Questionnaire - 9
(PHQ 9)
Email: [email protected]
NCT02948725
Trial name or title Clinical application of cross-education during stroke rehabilitation (X-Ed-Stroke01)
Methods RCT
Participants N = 24
Outcomes Fugl-Meyer Assessment, grip and wrist strength, volume of motor cortex activation
NCT02948725 (Continued)
Email: [email protected]
Notes
NCT03122626
Trial name or title Does participation in a group, task-oriented community-based exercise program improve the abili-
ty to do everyday activities among people with stroke?
Methods RCT
Participants N = 60
Interventions Together In Movement and Exercise (TIME) Program vs wait-listed control group
Outcomes Subjective Index of Physical and Social Outcome, NEADL (multiple secondary outcomes)
Email: [email protected]
Notes
NCT03259932
Trial name or title Comparison of fatigue and recovery after stroke depending on the usual management with or with-
out physical training (FRAM)
Methods RCT
Participants N = 160
Interventions Physical activity – aerobic exercise, muscle building in circuit training, balance and flexibility exer-
cises
Notes
NCT03425890
Trial name or title Effect of self-empowered upper limb repetitive engagement (SURE) program on upper limb recov-
ery after stroke
Methods RCT
Participants N = 20
Interventions SURE Program – individualised daily self exercise and functional use of the arm and hand on their
own outside of therapy 60 min a day 6 days a week for 4 weeks. Strengthening and exercise exercis-
es. Control group received no program, only an educational booklet on stroke
Outcomes Upper limb Fugl Meyer Scale (primary outcome), ARAT, rating of everyday arm-use in the communi-
ty and home, Stanford Fatigue Visual Numeric Scale, VAS scale for pain, Modified Ashworth Scale,
duration of affected upper limb activity in h, bilateral motor cortex brain activation
Notes
NCT03458884
Trial name or title Does cardiorespiratory interval training improve post-stroke fatigue?
Methods RCT
Participants N = 50
Outcomes Post-stroke fatigue, peak o2 consumption, VO2 peak, feasibility (fidelity, adherence and adverse
events)
Notes
NCT03479632
Trial name or title Aerobic exercise for non-ambulatory stroke survivors
Methods RCT
Participants N = 40
Interventions Aerobic walking programme using a treadmill with body-weight support system. Control receive
only standard care
Outcomes Resting heart rate, resting BP, change in vital capacity and change in forced vital capacity
NCT03479632 (Continued)
Notes
NCT03528148
Trial name or title The effect of elliptical cross training bike for stroke patients
Methods RCT
Participants N = 50
Notes
NCT03548090
Trial name or title The effect of plantarflexion training in people with chronic stroke
Methods RCT
Participants N = 50
Interventions Skateboard exercise at an incline angle with different bodyweight (50%, 75%, 90%)
Outcomes Step length asymmetry ratio, EMG of gastrocnemius, soleus, plantarflexion torque, walking speed,
SIS
Notes
PACTR201511001359344
Trial name or title The Nigerian stroke aerobic study (NISAS)
Methods RCT
Participants N = 56
PACTR201511001359344 (Continued)
Outcomes VO2 max, gait speed, motor function, balance, lipid profile, fasting blood sugar, red and white
blood count, packed cell volume, anthropometric (e.g. BMI), biochemical (e.g. urea), cardiovascular
(BP etc)
Notes
PACTR201712002689193
Trial name or title Effect of 6 weeks task-orientated circuit training on balance and quality of life of stroke
Methods RCT
Participants N = 30
Interventions Task-orientated circuit training (balance training, double leg standing, tandem walking, standing
and walking, squat exercises
Notes
RBR-26q4z9
Trial name or title Effect of exercises with action observation and aquatic physical therapy in arm recov-
ery after stroke
Participants N = 60
Notes
RBR-2mf595
Trial name or title Serious game for evaluation and treatment in stroke
Methods RCT
Participants N = 24
Outcomes MVC, TUG, gait speed, Modified Ashworth Scale, Fugl Meyer, Modified BI, NHP, motor con-
trol
RBR-4g6fhf
Trial name or title The effects of exercise with cycle ergometer in patients after acute stroke
Methods RCT
Participants N = 24
Outcomes Dynamometry for assessment of upper and lower limb muscle strength, Ordinal Scale of Muscle
Tone Assessment in Adults for evaluation of muscle tone, 10-MWT for gait evaluation, BBS for bal-
ance evaluation, Manovacuometry, Spirometry, Mental State Minisease for Cognitive Assessment,
mRS, and Scandinavian Stroke Scale
Notes
RBR-4wk4b3
Trial name or title Influence of an exercise program on cardiac remodeling and functional capacity of patients with
stroke
Methods RCT
Participants N = 40
RBR-4wk4b3 (Continued)
Notes
RBR-4wz3w3
Trial name or title Task-oriented group therapy and home-based exercise increase in the amount of practice in the
subacute phase after Stroke - randomised clinical trial
Methods RCT
Participants N = 110
Outcomes Fugl-Meyer, grip strength, box and block test, 6-MWT, TUG test
Notes
RBR-5thjgv
Trial name or title Effects of physical training on metabolic, hemodynamic, autonomic and inflammatory parameters
of post-stroke individuals
Methods RCT
Participants N = 30
Outcomes Muscle strength, 10-MWT, TUG test, HR variability, haemodynamic and inflammatory markers
Notes RBR-5thjgv
RBR-7699xz
Trial name or title Multidisciplinary analysis of a motor rehabilitation protocol with partial weight support for
post stroke patients: a randomised clinical trial
Methods RCT
RBR-7699xz (Continued)
Participants N = 50
Notes
RBR-7hqk8t
Trial name or title Efficacy of task-specific training in changing neurotrophic factors and impact on clinical out-
comes in individuals with stroke: a randomised controlled trial
Methods RCT
Participants N = 36
Notes
TCTR20160601005
Trial name or title Effectiveness of antigravity treadmill training in improving walking capacity and balance in hemi-
paretic ischemic stroke patients
Methods RCT
Participants N = 34
Outcomes 6-MWT, FAC, balance, muscle EMG, satisfaction after antigravity treadmill training
Notes
TCTR20170615002
Trial name or title Effects of task-oriented training on upper extremity functional performance in patients with sub-
acute stroke: a randomised controlled trial
Methods RCT
Participants N = 28
Notes
Vahlberg 2018
Trial name or title Protocol and pilot study of a short message service-guided training after acute stroke/transient is-
chemic attack to increase walking capacity and physical activity
Methods RCT
Participants N = 80
Outcomes 6-MWT, chair-rising, mobility, gait speed, handgrip strength, body composition (fat mass and mus-
cle mass), biochemical risk-markers, health-related QoL, and cardiovascular events
Notes NCT02720276
10-MWT: 10-Metre Walk Test; 6-MWT: 6-Minute Walk Test; ARAT: Action Research Arm Test; BBS: Berg Balance Scale; BMI: body mass index;
BI: Barthel Index; BP: blood pressure; EMG: electromyography; FAC: Functional Ambulation Classification; FIM: Functional Independence
Measure; HRQoL: health-related quality of life; IADL: Instrumental Activities of Daily Living; MAS: Motor Assessment Scale; mRS: modified
Rankin Scale; MVC: maximal voluntary contraction; NEADL: Nottingham Extended Activities of Daily Living Scale; NHP: Nottingham Health
Profile; QoL: quality of life; RCT: randomised controlled trial; RMI: Rivermead Mobility Index; RVGA: Rivermead Visual Gait Assessment;
SIS: Stroke Impact Scale; SS-QoL: Stroke Specific Quality of Life Scale; STS: sit to stand; TIA: transient ischaemic attack; TUG: Timed Up
and Go Test; UC: usual care; VAS: Visual Analogue Scale; WHO: World Health Organization; WMFT: Wolf Motor Function Test
1.1 During usual care 16 698 Risk Difference (M-H, Random, 0.0 [-0.02, 0.02]
95% CI)
1.2 After usual care 16 933 Risk Difference (M-H, Random, 0.0 [-0.02, 0.02]
95% CI)
2 Disability - Functional Independence 3 162 Std. Mean Difference (IV, Random, 0.21 [-0.10, 0.52]
Measure 95% CI)
2.1 During usual care 1 52 Std. Mean Difference (IV, Random, 0.23 [-0.32, 0.78]
95% CI)
2.2 After usual care 2 110 Std. Mean Difference (IV, Random, 0.17 [-0.29, 0.63]
95% CI)
3 Disability - Barthel Index 3 243 Mean Difference (IV, Random, 6.65 [-0.67, 13.98]
95% CI)
3.1 During usual care 2 115 Mean Difference (IV, Random, 10.48 [-11.83, 32.80]
95% CI)
3.2 After usual care 1 128 Mean Difference (IV, Random, 2.60 [-0.15, 5.35]
95% CI)
4 Disability - Rivermead Mobility Index 3 146 Mean Difference (IV, Random, 1.56 [0.20, 2.92]
(scale 0 to 15) 95% CI)
4.1 During usual care 2 110 Mean Difference (IV, Random, 1.43 [-0.62, 3.49]
95% CI)
4.2 After usual care 1 36 Mean Difference (IV, Random, 2.0 [0.53, 3.47]
95% CI)
5 Disability - combined disability scales 8 462 Std. Mean Difference (IV, Random, 0.52 [0.19, 0.84]
95% CI)
5.1 During usual care 3 130 Std. Mean Difference (IV, Random, 0.88 [0.08, 1.68]
95% CI)
5.2 After usual care 5 332 Std. Mean Difference (IV, Random, 0.33 [0.11, 0.55]
95% CI)
6 Risk factors - blood pressure, systolic 5 318 Mean Difference (IV, Random, -0.20 [-4.00, 5.60]
95% CI)
6.1 During usual care 1 12 Mean Difference (IV, Random, 26.33 [1.95, 50.71]
95% CI)
6.2 After usual care 4 306 Mean Difference (IV, Random, -1.41 [-5.25, 2.43]
95% CI)
7 Risk factors - blood pressure, diastolic 5 318 Mean Difference (IV, Random, -0.15 [-2.28, 1.98]
95% CI)
7.1 During usual care 1 12 Mean Difference (IV, Random, 1.0 [-10.46, 12.46]
95% CI)
7.2 After usual care 4 306 Mean Difference (IV, Random, -0.19 [-2.35, 1.98]
95% CI)
8 Risk factors - body mass index (BMI) 2 174 Mean Difference (IV, Random, 1.19 [-0.38, 2.76]
95% CI)
8.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
8.2 After usual care 2 174 Mean Difference (IV, Random, 1.19 [-0.38, 2.76]
95% CI)
9 Physical fitness - peak VO2 9 438 Mean Difference (IV, Random, 3.40 [2.98, 3.83]
95% CI)
9.1 During usual care 3 121 Mean Difference (IV, Random, 2.28 [0.75, 3.81]
95% CI)
9.2 After usual care 6 317 Mean Difference (IV, Random, 3.51 [3.06, 3.96]
95% CI)
10 Physical fitness - maximum cycling 6 336 Mean Difference (IV, Random, 10.60 [1.88, 19.33]
work rate 95% CI)
10.1 During usual care 3 148 Mean Difference (IV, Random, 3.48 [-5.23, 12.19]
95% CI)
10.2 After usual care 3 188 Mean Difference (IV, Random, 13.37 [8.55, 18.19]
95% CI)
11 Mobility - functional ambulation cat- 2 73 Mean Difference (IV, Random, 0.53 [0.21, 0.85]
egories 95% CI)
11.1 During usual care 2 73 Mean Difference (IV, Random, 0.53 [0.21, 0.85]
95% CI)
11.2 After usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
12 Mobility - walking maximal speed 17 782 Mean Difference (IV, Random, 7.66 [3.65, 11.68]
(over 5 to 10 metres) 95% CI)
12.1 During usual care 10 383 Mean Difference (IV, Random, 5.20 [0.48, 9.92]
95% CI)
12.2 After usual care 7 399 Mean Difference (IV, Random, 10.94 [7.13, 14.76]
95% CI)
13 Mobility - walking preferred speed 12 588 Mean Difference (IV, Random, 4.47 [2.07, 6.87]
95% CI)
13.1 During usual care 6 211 Mean Difference (IV, Random, 3.90 [-1.25, 9.05]
95% CI)
13.2 After usual care 6 377 Mean Difference (IV, Random, 4.69 [1.57, 7.80]
95% CI)
14 Mobility - walking capacity (6-MWT 16 882 Mean Difference (IV, Random, 33.41 [19.04, 47.78]
metres) 95% CI)
14.1 During usual care 7 225 Mean Difference (IV, Random, 32.10 [10.11, 54.10]
95% CI)
14.2 After usual care 9 657 Mean Difference (IV, Random, 37.03 [15.54, 58.51]
95% CI)
15 Mobility - walking capacity (m/min) 3 154 Mean Difference (IV, Random, 8.87 [1.35, 16.40]
95% CI)
15.1 During usual care 2 63 Mean Difference (IV, Random, 12.24 [-3.41, 27.89]
95% CI)
15.2 After usual care 1 91 Mean Difference (IV, Random, 6.60 [-2.66, 15.86]
95% CI)
16 Mobility - community walk (min) 2 47 Mean Difference (IV, Random, -10.54 [-14.11, -6.98]
95% CI)
16.1 During usual care 2 47 Mean Difference (IV, Random, -10.54 [-14.11, -6.98]
95% CI)
16.2 After usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
17 Physical function - Berg Balance 8 471 Mean Difference (IV, Random, 1.92 [0.16, 3.68]
Scale (score 0 to 56) 95% CI)
17.1 During usual care 3 160 Mean Difference (IV, Random, 0.79 [-2.01, 3.59]
95% CI)
17.2 After usual care 5 311 Mean Difference (IV, Random, 2.67 [0.07, 5.26]
95% CI)
18 Physical function - Timed Up and Go 5 223 Mean Difference (IV, Random, -3.42 [-4.78, -2.05]
(sec) 95% CI)
18.1 During usual care 1 20 Mean Difference (IV, Random, -2.10 [-6.27, 2.07]
95% CI)
18.2 After usual care 4 203 Mean Difference (IV, Random, -3.58 [-5.02, -2.13]
95% CI)
19 Health-related QoL - SF-36 & SF-12 2 164 Std. Mean Difference (IV, Random, 0.51 [0.20, 0.82]
Physical Health Component 95% CI)
19.1 During usual care 0 0 Std. Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
19.2 After usual care 2 164 Std. Mean Difference (IV, Random, 0.51 [0.20, 0.82]
95% CI)
20 Health-related QoL - SF-36 & SF-12 2 164 Std. Mean Difference (IV, Random, 0.58 [-0.52, 1.68]
Mental Health Component 95% CI)
20.1 During usual care 0 0 Std. Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
20.2 After usual care 2 164 Std. Mean Difference (IV, Random, 0.58 [-0.52, 1.68]
95% CI)
21 Health-related QoL - EuroQol EQ-5D 2 158 Mean Difference (IV, Random, 6.55 [-1.36, 14.47]
95% CI)
21.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
21.2 After usual care 2 158 Mean Difference (IV, Random, 6.55 [-1.36, 14.47]
95% CI)
22 Mood - Beck Depression Index 2 56 Mean Difference (IV, Random, -1.22 [-5.62, 3.19]
95% CI)
22.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
22.2 After usual care 2 56 Mean Difference (IV, Random, -1.22 [-5.62, 3.19]
95% CI)
Analysis 1.1. Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 1 Death.
Study or subgroup Training Control Risk Difference Weight Risk Difference
n/N n/N M-H, Random, 95% CI M-H, Random, 95% CI
1.1.1 During usual care
Bateman 2001 0/40 0/44 7.19% 0[-0.05,0.05]
da Cunha 2002 0/7 0/8 0.29% 0[-0.22,0.22]
Eich 2004 0/25 0/25 2.67% 0[-0.07,0.07]
Glasser 1986 0/10 0/10 0.49% 0[-0.17,0.17]
Katz-Leurer 2003 0/46 0/46 8.64% 0[-0.04,0.04]
Kim 2014 0/13 0/13 0.79% 0[-0.14,0.14]
Kuys 2011 0/15 0/15 1.02% 0[-0.12,0.12]
MacKay-Lyons 2013 0/24 0/26 2.65% 0[-0.07,0.07]
Study or subgroup Training Control Std. Mean Difference Weight Std. Mean Difference
N Mean(SD) N Mean(SD) Random, 95% CI Random, 95% CI
Subtotal *** 23 29 31.91% 0.23[-0.32,0.78]
Heterogeneity: Not applicable
Test for overall effect: Z=0.83(P=0.4)
1.1 During usual care 3 226 Risk Difference (M-H, Random, 0.0 [-0.03, 0.03]
95% CI)
1.2 After usual care 3 134 Risk Difference (M-H, Random, 0.0 [-0.05, 0.05]
95% CI)
2 Disability - combined disability scales 3 220 Std. Mean Difference (IV, Random, 0.20 [-0.07, 0.46]
95% CI)
2.1 During usual care 1 83 Std. Mean Difference (IV, Random, 0.18 [-0.26, 0.61]
95% CI)
2.2 After usual care 2 137 Std. Mean Difference (IV, Random, 0.21 [-0.12, 0.55]
95% CI)
3 Mobility - walking maximal speed (m/ 5 312 Mean Difference (IV, Random, 95% 6.71 [2.40, 11.02]
min) CI)
3.1 During usual care 3 152 Mean Difference (IV, Random, 95% 7.92 [2.01, 13.83]
CI)
3.2 After usual care 2 160 Mean Difference (IV, Random, 95% 5.33 [-0.96, 11.63]
CI)
4 Mobility - walking preferred speed 3 176 Mean Difference (IV, Random, 95% 1.67 [-3.27, 6.62]
(m/min) CI)
4.1 During usual care 2 74 Mean Difference (IV, Random, 95% 2.54 [-3.65, 8.73]
CI)
4.2 After usual care 1 102 Mean Difference (IV, Random, 95% 0.14 [-8.08, 8.37]
CI)
5 Mobility - walking capacity (6-MWT 5 283 Mean Difference (IV, Random, 95% 38.29 [7.19, 69.39]
metres) CI)
5.1 During usual care 3 123 Mean Difference (IV, Random, 95% 50.76 [19.09, 82.43]
CI)
5.2 After usual care 2 160 Mean Difference (IV, Random, 95% 22.34 [-44.02, 88.69]
CI)
6 Physical function - Berg Balance 2 134 Mean Difference (IV, Random, 95% 0.04 [-2.48, 2.56]
scale CI)
6.1 During usual care 2 134 Mean Difference (IV, Random, 95% 0.04 [-2.48, 2.56]
CI)
6.2 After usual care 0 0 Mean Difference (IV, Random, 95% 0.0 [0.0, 0.0]
CI)
7 Health-related QoL - EuroQol EQ-5D 2 150 Mean Difference (IV, Random, 95% -4.25 [-8.00, 1.49]
CI)
7.1 During usual care 0 0 Mean Difference (IV, Random, 95% 0.0 [0.0, 0.0]
CI)
7.2 After usual care 2 150 Mean Difference (IV, Random, 95% -4.25 [-8.00, 1.49]
CI)
Analysis 2.1. Comparison 2 Cardiorespiratory training versus control - end of retention follow-up, Outcome 1 Death.
Study or subgroup Training Control Risk Difference Weight Risk Difference
n/N n/N M-H, Random, 95% CI M-H, Random, 95% CI
2.1.1 During usual care
Bateman 2001 0/40 0/44 33.72% 0[-0.05,0.05]
Eich 2004 0/25 0/25 12.5% 0[-0.07,0.07]
Katz-Leurer 2003 1/46 1/46 19.62% 0[-0.06,0.06]
Subtotal (95% CI) 111 115 65.84% 0[-0.03,0.03]
Total events: 1 (Training), 1 (Control)
Heterogeneity: Tau2=0; Chi2=0, df=2(P=1); I2=0%
1.1 During usual care 7 236 Risk Difference (M-H, Random, 0.0 [-0.04, 0.04]
95% CI)
1.2 After usual care 13 567 Risk Difference (M-H, Random, 0.00 [-0.02, 0.02]
95% CI)
2 Physical fitness - composite measure of 2 60 Std. Mean Difference (IV, Ran- 0.58 [0.06, 1.10]
muscle strength dom, 95% CI)
2.1 During usual care 0 0 Std. Mean Difference (IV, Ran- 0.0 [0.0, 0.0]
dom, 95% CI)
2.2 During and after usual care 1 40 Std. Mean Difference (IV, Ran- 0.47 [-0.16, 1.10]
dom, 95% CI)
2.3 After usual care 1 20 Std. Mean Difference (IV, Ran- 0.84 [-0.09, 1.76]
dom, 95% CI)
3 Physical fitness - muscle strength, paretic 3 93 Std. Mean Difference (IV, Ran- 0.72 [0.10, 1.34]
knee flexion dom, 95% CI)
3.1 During usual care 1 18 Std. Mean Difference (IV, Ran- 0.03 [-0.90, 0.96]
dom, 95% CI)
3.2 After usual care 2 75 Std. Mean Difference (IV, Ran- 1.01 [0.52, 1.50]
dom, 95% CI)
4 Physical fitness - muscle strength, paretic 3 93 Std. Mean Difference (IV, Ran- 1.09 [-0.23, 2.41]
knee extension dom, 95% CI)
4.1 During usual care 1 18 Std. Mean Difference (IV, Ran- -0.06 [-0.99, 0.87]
dom, 95% CI)
4.2 After usual care 2 75 Std. Mean Difference (IV, Ran- 1.66 [0.53, 2.79]
dom, 95% CI)
5 Mobility - walking maximal speed (m/ 7 274 Mean Difference (IV, Random, 2.83 [-0.49, 6.14]
min) 95% CI)
5.1 During usual care 1 18 Mean Difference (IV, Random, 8.40 [2.82, 13.98]
95% CI)
5.2 After usual care 6 256 Mean Difference (IV, Random, 1.80 [-1.52, 5.12]
95% CI)
6 Mobility - walking preferred speed (m/ 5 203 Mean Difference (IV, Random, 2.15 [-3.57, 7.87]
min) 95% CI)
6.1 During usual care 1 18 Mean Difference (IV, Random, 9.0 [3.42, 14.58]
95% CI)
6.2 After usual care 4 185 Mean Difference (IV, Random, -0.18 [-4.99, 4.63]
95% CI)
7 Mobility - walking capacity (6-MWT me- 5 238 Mean Difference (IV, Random, 24.98 [11.98, 37.98]
tres) 95% CI)
7.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
7.2 After usual care 5 238 Mean Difference (IV, Random, 24.98 [11.98, 37.98]
95% CI)
8 Physical function - Berg Balance Scale 5 220 Mean Difference (IV, Random, 3.27 [2.15, 4.38]
(score 0 to 56) 95% CI)
8.1 During usual care 1 20 Mean Difference (IV, Random, 3.70 [0.11, 7.29]
95% CI)
8.2 After usual care 4 200 Mean Difference (IV, Random, 3.22 [2.04, 4.39]
95% CI)
9 Physical function - stair climbing, maxi- 2 91 Mean Difference (IV, Random, -2.07 [-3.18, -0.96]
mal (sec/step) 95% CI)
9.1 During usual care 1 50 Mean Difference (IV, Random, -2.0 [-3.12, -0.88]
95% CI)
9.2 After usual care 1 41 Mean Difference (IV, Random, -5.36 [-13.13, 2.41]
95% CI)
10 Physical function - Timed Up and Go 5 224 Mean Difference (IV, Random, -3.46 [-6.94, 0.02]
(sec) 95% CI)
10.1 During usual care 1 50 Mean Difference (IV, Random, -2.0 [-3.12, -0.88]
95% CI)
10.2 After usual care 4 174 Mean Difference (IV, Random, -5.72 [-7.92, -3.52]
95% CI)
11 Health-related QoL - SF-36 physical 3 70 Mean Difference (IV, Random, 5.72 [-5.26, 16.70]
functioning (PF) scale 95% CI)
11.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
11.2 After usual care 3 70 Mean Difference (IV, Random, 5.72 [-5.26, 16.70]
95% CI)
12 Health-related QoL - SF-36 mental 3 70 Mean Difference (IV, Random, 7.69 [1.56, 13.83]
health (MH) scale 95% CI)
12.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
12.2 After usual care 3 70 Mean Difference (IV, Random, 7.69 [1.56, 13.83]
95% CI)
13 Mood - Centre for Epidemiologic Studies 2 180 Mean Difference (IV, Random, -3.76 [-6.98, -0.54]
for Depression scale (CES-D) 95% CI)
13.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
13.2 After usual care 2 180 Mean Difference (IV, Random, -3.76 [-6.98, -0.54]
95% CI)
14 Mood - combined depression scales 3 209 Std. Mean Difference (IV, Ran- -0.36 [-0.64, -0.09]
dom, 95% CI)
14.1 During usual care 0 0 Std. Mean Difference (IV, Ran- 0.0 [0.0, 0.0]
dom, 95% CI)
14.2 After usual care 3 209 Std. Mean Difference (IV, Ran- -0.36 [-0.64, -0.09]
dom, 95% CI)
Analysis 3.1. Comparison 3 Resistance training versus control - end of intervention, Outcome 1 Death.
Study or subgroup Training Control Risk Difference Weight Risk Difference
n/N n/N M-H, Random, 95% CI M-H, Random, 95% CI
3.1.1 During usual care
Arabzadeh 2018 0/10 0/10 1.3% 0[-0.17,0.17]
Bale 2008 0/8 0/10 1.05% 0[-0.19,0.19]
Buyukvural 2015 0/25 0/25 7.04% 0[-0.07,0.07]
Coroian 2018 0/10 0/10 1.3% 0[-0.17,0.17]
Inaba 1973 0/28 0/26 8.12% 0[-0.07,0.07]
Verheyden 2009 0/17 0/16 3.21% 0[-0.11,0.11]
Winstein 2004 0/21 0/20 4.83% 0[-0.09,0.09]
Subtotal (95% CI) 119 117 26.84% 0[-0.04,0.04]
Total events: 0 (Training), 0 (Control)
Heterogeneity: Tau2=0; Chi2=0, df=6(P=1); I2=0%
Test for overall effect: Not applicable
Study or subgroup Training Control Std. Mean Difference Weight Std. Mean Difference
N Mean(SD) N Mean(SD) Random, 95% CI Random, 95% CI
1 Death 5 251 Risk Difference (M-H, Random, 95% 0.00 [-0.04, 0.04]
CI)
1.1 During usual care 3 115 Risk Difference (M-H, Random, 95% 0.0 [-0.05, 0.05]
CI)
1.2 After usual care 2 136 Risk Difference (M-H, Random, 95% 0.00 [-0.06, 0.06]
CI)
2 Mobility - walking maximal speed 2 117 Mean Difference (IV, Random, 95% 7.80 [-3.32, 18.91]
(m/min) CI)
2.1 During usual care 0 0 Mean Difference (IV, Random, 95% 0.0 [0.0, 0.0]
CI)
2.2 After usual care 2 117 Mean Difference (IV, Random, 95% 7.80 [-3.32, 18.91]
CI)
3 Mobility - walking capacity (6-MWT 2 117 Mean Difference (IV, Random, 95% 22.41 [-27.87, 72.69]
metres) CI)
3.1 During usual care 0 0 Mean Difference (IV, Random, 95% 0.0 [0.0, 0.0]
CI)
3.2 After usual care 2 117 Mean Difference (IV, Random, 95% 22.41 [-27.87, 72.69]
CI)
4 Physical function - Timed Up and 2 117 Mean Difference (IV, Random, 95% -2.64 [-9.24, 3.95]
Go (sec) CI)
4.1 During usual care 0 0 Mean Difference (IV, Random, 95% 0.0 [0.0, 0.0]
CI)
4.2 After usual care 2 117 Mean Difference (IV, Random, 95% -2.64 [-9.24, 3.95]
CI)
Analysis 4.1. Comparison 4 Resistance training versus control - end of retention follow-up, Outcome 1 Death.
Study or subgroup Training Control Risk Difference Weight Risk Difference
n/N n/N M-H, Random, 95% CI M-H, Random, 95% CI
4.1.1 During usual care
Coroian 2018 0/10 0/10 5.12% 0[-0.17,0.17]
Inaba 1973 0/28 0/26 32.14% 0[-0.07,0.07]
Winstein 2004 0/21 0/20 19.09% 0[-0.09,0.09]
Subtotal (95% CI) 59 56 56.35% 0[-0.05,0.05]
Total events: 0 (Training), 0 (Control)
Heterogeneity: Tau2=0; Chi2=0, df=2(P=1); I2=0%
Test for overall effect: Not applicable
1.1 During usual care 10 344 Risk Difference (M-H, Random, 0.0 [-0.03, 0.03]
95% CI)
1.2 After usual care 13 887 Risk Difference (M-H, Random, -0.01 [-0.02, 0.01]
95% CI)
2 Disability - Barthel Index (BI) 6 256 Mean Difference (IV, Random, 2.84 [-0.48, 6.17]
95% CI)
2.1 During usual care 3 78 Mean Difference (IV, Random, 5.44 [-2.12, 13.00]
95% CI)
2.2 After usual care 3 178 Mean Difference (IV, Random, 1.99 [-2.32, 6.29]
95% CI)
3 Disability - Lawton IADL 2 113 Mean Difference (IV, Random, 0.83 [-0.51, 2.17]
95% CI)
3.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
3.2 After usual care 2 113 Mean Difference (IV, Random, 0.83 [-0.51, 2.17]
95% CI)
4 Disability - Rivermead Mobility Index 3 348 Mean Difference (IV, Random, 0.41 [-0.02, 0.84]
(RMI) 95% CI)
4.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
4.2 After usual care 3 348 Mean Difference (IV, Random, 0.41 [-0.02, 0.84]
95% CI)
5 Disability - combined disability scales 9 604 Std. Mean Difference (IV, Ran- 0.23 [0.03, 0.42]
dom, 95% CI)
5.1 During usual care 3 78 Std. Mean Difference (IV, Ran- 0.39 [-0.06, 0.84]
dom, 95% CI)
5.2 After usual care 6 526 Std. Mean Difference (IV, Ran- 0.17 [-0.09, 0.43]
dom, 95% CI)
6 Risk factors - blood pressure, systolic 2 68 Mean Difference (IV, Random, 4.98 [-2.70, 12.66]
95% CI)
6.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
6.2 After usual care 2 68 Mean Difference (IV, Random, 4.98 [-2.70, 12.66]
95% CI)
7 Risk factors - blood pressure, diastolic 2 68 Mean Difference (IV, Random, -3.49 [-9.51, 2.53]
95% CI)
7.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
7.2 After usual care 2 68 Mean Difference (IV, Random, -3.49 [-9.51, 2.53]
95% CI)
8 Physical fitness - peak VO2 (mL/kg/min) 2 140 Mean Difference (IV, Random, 1.40 [-0.19, 2.99]
95% CI)
8.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
8.2 After usual care 2 140 Mean Difference (IV, Random, 1.40 [-0.19, 2.99]
95% CI)
9 Physical fitness - gait economy, VO2 (mL/ 1 66 Mean Difference (IV, Random, -0.01 [-0.03, -0.00]
kg/metre) 95% CI)
9.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
9.2 After usual care 1 66 Mean Difference (IV, Random, -0.01 [-0.03, -0.00]
95% CI)
10 Physical fitness - muscle strength, ankle 2 148 Std. Mean Difference (IV, Ran- 0.80 [-0.82, 2.41]
dorsiflexion* dom, 95% CI)
10.1 During usual care 0 0 Std. Mean Difference (IV, Ran- 0.0 [0.0, 0.0]
dom, 95% CI)
10.2 After usual care 2 148 Std. Mean Difference (IV, Ran- 0.80 [-0.82, 2.41]
dom, 95% CI)
11 Physical fitness - muscle strength, knee 3 202 Std. Mean Difference (IV, Ran- 0.33 [0.05, 0.61]
extension* dom, 95% CI)
11.1 During usual care 1 54 Std. Mean Difference (IV, Ran- 0.29 [-0.25, 0.83]
dom, 95% CI)
11.2 After usual care 2 148 Std. Mean Difference (IV, Ran- 0.36 [-0.02, 0.73]
dom, 95% CI)
12 Physical fitness - muscle strength, grip 3 147 Mean Difference (IV, Random, 0.32 [-0.88, 1.52]
strength (paretic hand) 95% CI)
12.1 During usual care 2 47 Mean Difference (IV, Random, 0.32 [-1.12, 1.76]
95% CI)
12.2 After usual care 1 100 Mean Difference (IV, Random, 0.32 [-1.85, 2.49]
95% CI)
13 Mobility - walking maximum speed 3 168 Mean Difference (IV, Random, 8.48 [1.76, 15.20]
95% CI)
13.1 During usual care 1 29 Mean Difference (IV, Random, 8.00 [-5.06, 21.06]
95% CI)
13.2 After usual care 2 139 Mean Difference (IV, Random, 8.65 [0.82, 16.48]
95% CI)
14 Mobility - walking preferred speed (m/ 10 738 Mean Difference (IV, Random, 4.71 [1.32, 8.10]
min) 95% CI)
14.1 During usual care 3 153 Mean Difference (IV, Random, 3.37 [-2.63, 9.37]
95% CI)
14.2 After usual care 7 585 Mean Difference (IV, Random, 5.13 [1.16, 9.10]
95% CI)
15 Mobility - walking capacity (6-MWT me- 10 720 Mean Difference (IV, Random, 35.00 [15.91, 54.09]
tres) 95% CI)
15.1 During usual care 2 60 Mean Difference (IV, Random, 13.21 [-75.07, 101.49]
95% CI)
15.2 After usual care 8 660 Mean Difference (IV, Random, 40.37 [24.82, 55.92]
95% CI)
16 Mobility - Community Ambulation 3 232 Odds Ratio (M-H, Random, 95% 1.38 [0.78, 2.42]
Speed (> 0.8 m/sec) CI)
16.1 During usual care 1 67 Odds Ratio (M-H, Random, 95% 1.75 [0.46, 6.65]
CI)
16.2 After usual care 2 165 Odds Ratio (M-H, Random, 95% 1.31 [0.70, 2.44]
CI)
17 Physical function - balance - Berg Bal- 9 419 Mean Difference (IV, Random, 2.12 [0.82, 3.41]
ance scale 95% CI)
17.1 During usual care 5 160 Mean Difference (IV, Random, 0.50 [-3.00, 4.01]
95% CI)
17.2 After usual care 4 259 Mean Difference (IV, Random, 2.64 [1.34, 3.95]
95% CI)
18 Physical function - balance - functional 2 166 Std. Mean Difference (IV, Ran- 0.14 [-0.22, 0.50]
reach dom, 95% CI)
18.1 During usual care 0 0 Std. Mean Difference (IV, Ran- 0.0 [0.0, 0.0]
dom, 95% CI)
18.2 After usual care 2 166 Std. Mean Difference (IV, Ran- 0.14 [-0.22, 0.50]
dom, 95% CI)
19 Physical function - balance - combined 12 755 Std. Mean Difference (IV, Ran- 0.28 [0.11, 0.45]
outcome data dom, 95% CI)
19.1 During usual care 5 160 Std. Mean Difference (IV, Ran- 0.10 [-0.23, 0.43]
dom, 95% CI)
19.2 After usual care 7 595 Std. Mean Difference (IV, Ran- 0.35 [0.15, 0.54]
dom, 95% CI)
20 Physical function - Timed Up and Go 7 586 Mean Difference (IV, Random, -2.21 [-4.43, 0.02]
(sec) 95% CI)
20.1 During usual care 2 91 Mean Difference (IV, Random, -8.17 [-20.66, 4.33]
95% CI)
20.2 After usual care 5 495 Mean Difference (IV, Random, -1.45 [-2.66, -0.24]
95% CI)
21 Health-related QoL - SF-36 physical 2 112 Std. Mean Difference (IV, Ran- 0.48 [0.10, 0.85]
functioning dom, 95% CI)
21.1 During usual care 0 0 Std. Mean Difference (IV, Ran- 0.0 [0.0, 0.0]
dom, 95% CI)
21.2 After usual care 2 112 Std. Mean Difference (IV, Ran- 0.48 [0.10, 0.85]
dom, 95% CI)
22 Health-related QoL - SF-36 physical role 3 178 Std. Mean Difference (IV, Ran- 0.56 [0.26, 0.86]
functioning dom, 95% CI)
22.1 During usual care 0 0 Std. Mean Difference (IV, Ran- 0.0 [0.0, 0.0]
dom, 95% CI)
22.2 After usual care 3 178 Std. Mean Difference (IV, Ran- 0.56 [0.26, 0.86]
dom, 95% CI)
23 Health-related QoL - SF-36 social role 2 112 Std. Mean Difference (IV, Ran- 0.48 [-0.22, 1.17]
functioning dom, 95% CI)
23.1 During usual care 0 0 Std. Mean Difference (IV, Ran- 0.0 [0.0, 0.0]
dom, 95% CI)
23.2 After usual care 2 112 Std. Mean Difference (IV, Ran- 0.48 [-0.22, 1.17]
dom, 95% CI)
24 Mood - Hospital Anxiety and Depression 3 391 Mean Difference (IV, Random, -0.28 [-0.95, 0.40]
Scale (HADS) - anxiety score 95% CI)
24.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
24.2 After usual care 3 391 Mean Difference (IV, Random, -0.28 [-0.95, 0.40]
95% CI)
25 Mood - Hospital Anxiety and Depression 3 391 Mean Difference (IV, Random, 0.59 [-0.08, 1.26]
Scale (HADS) - depression score 95% CI)
25.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
25.2 After usual care 3 391 Mean Difference (IV, Random, 0.59 [-0.08, 1.26]
95% CI)
26 Mood - Stroke Impact Scale emotion 2 335 Mean Difference (IV, Random, 2.87 [-3.40, 9.14]
score 95% CI)
26.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
26.2 After usual care 2 335 Mean Difference (IV, Random, 2.87 [-3.40, 9.14]
95% CI)
27 Mood - combined depression scales 4 484 Std. Mean Difference (IV, Ran- -0.01 [-0.39, 0.37]
dom, 95% CI)
27.1 During usual care 0 0 Std. Mean Difference (IV, Ran- 0.0 [0.0, 0.0]
dom, 95% CI)
27.2 After usual care 4 484 Std. Mean Difference (IV, Ran- -0.01 [-0.39, 0.37]
dom, 95% CI)
28 Cognitive function - FIM cognitive score 2 159 Mean Difference (IV, Random, -0.08 [-0.47, 0.31]
95% CI)
28.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
28.2 After usual care 2 159 Mean Difference (IV, Random, -0.08 [-0.47, 0.31]
95% CI)
29 Cognitive function - SIS memory and 2 133 Mean Difference (IV, Random, 1.57 [-10.56, 13.70]
thinking 95% CI)
29.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
29.2 After usual care 2 133 Mean Difference (IV, Random, 1.57 [-10.56, 13.70]
95% CI)
30 Cognitive function - SIS communication 2 133 Mean Difference (IV, Random, -1.19 [-12.06, 9.67]
95% CI)
30.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
30.2 After usual care 2 133 Mean Difference (IV, Random, -1.19 [-12.06, 9.67]
95% CI)
Analysis 5.1. Comparison 5 Mixed training versus control - end of intervention, Outcome 1 Death.
Study or subgroup Training Control Risk Difference Weight Risk Difference
n/N n/N M-H, Random, 95% CI M-H, Random, 95% CI
5.1.1 During usual care
Cooke 2010 0/36 0/38 7.97% 0[-0.05,0.05]
Donaldson 2009 0/10 0/10 0.69% 0[-0.17,0.17]
Furnari 2014 0/20 0/20 2.46% 0[-0.09,0.09]
Galvin 2011 0/20 0/20 2.46% 0[-0.09,0.09]
Kim 2016a 0/10 0/10 0.69% 0[-0.17,0.17]
Kim 2017a 0/15 0/15 1.44% 0[-0.12,0.12]
Letombe 2010 0/9 0/9 0.57% 0[-0.19,0.19]
Richards 1993 0/10 0/8 0.56% 0[-0.19,0.19]
Analysis 5.3. Comparison 5 Mixed training versus control - end of intervention, Outcome 3 Disability - Lawton IADL.
Study or subgroup Training Control Mean Difference Weight Mean Difference
N Mean(SD) N Mean(SD) Random, 95% CI Random, 95% CI
5.3.1 During usual care
Subtotal *** 0 0 Not estimable
Heterogeneity: Not applicable
Test for overall effect: Not applicable
Study or subgroup Training Control Std. Mean Difference Weight Std. Mean Difference
N Mean(SD) N Mean(SD) Random, 95% CI Random, 95% CI
Test for overall effect: Not applicable
Study or subgroup Training Control Std. Mean Difference Weight Std. Mean Difference
N Mean(SD) N Mean(SD) Random, 95% CI Random, 95% CI
Galvin 2011 20 45.1 (14.9) 20 35.8 (17.2) 6.41% 0.57[-0.07,1.2]
Kim 2016a 10 46.7 (9.4) 10 49.8 (4.6) 3.51% -0.4[-1.29,0.49]
Richards 1993 9 33.2 (18.2) 8 28.4 (19.7) 3.06% 0.24[-0.72,1.2]
Richards 2004 31 46 (7) 31 47 (8) 9.51% -0.13[-0.63,0.37]
Shin 2011 11 45.6 (7.5) 10 43.4 (8.5) 3.72% 0.26[-0.6,1.13]
Subtotal *** 81 79 26.21% 0.1[-0.23,0.43]
Heterogeneity: Tau2=0.01; Chi2=4.36, df=4(P=0.36); I2=8.24%
Test for overall effect: Z=0.6(P=0.55)
Study or subgroup Training Control Std. Mean Difference Weight Std. Mean Difference
N Mean(SD) N Mean(SD) Random, 95% CI Random, 95% CI
Total *** 86 92 100% 0.56[0.26,0.86]
Heterogeneity: Tau2=0; Chi2=1.86, df=2(P=0.39); I2=0%
Test for overall effect: Z=3.66(P=0)
Test for subgroup differences: Not applicable
1.1 During usual care 6 243 Risk Difference (M-H, Random, -0.02 [-0.06, 0.02]
95% CI)
1.2 After usual care 7 663 Risk Difference (M-H, Random, -0.01 [-0.03, 0.01]
95% CI)
2 Disability - Barthel Index (BI) 2 103 Mean Difference (IV, Random, 1.82 [-13.69, 17.33]
95% CI)
2.1 During usual care 1 40 Mean Difference (IV, Random, 9.0 [-1.29, 19.29]
95% CI)
2.2 After usual care 1 63 Mean Difference (IV, Random, -6.90 [-21.05, 7.25]
95% CI)
3 Disability - Nottingham Extended ADL 2 106 Mean Difference (IV, Random, 3.10 [-5.20, 11.40]
95% CI)
3.1 During usual care 1 40 Mean Difference (IV, Random, 9.5 [-1.83, 20.83]
95% CI)
3.2 After usual care 1 66 Mean Difference (IV, Random, 0.30 [-0.93, 1.53]
95% CI)
4 Disability - Rivermead Mobility Index 3 349 Mean Difference (IV, Random, 0.35 [0.02, 0.69]
(RMI) 95% CI)
4.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
4.2 After usual care 3 349 Mean Difference (IV, Random, 0.35 [0.02, 0.69]
95% CI)
5 Disability - combined disability scales 5 452 Std. Mean Difference (IV, Ran- 0.10 [-0.17, 0.37]
dom, 95% CI)
5.1 During usual care 1 40 Std. Mean Difference (IV, Ran- 0.53 [-0.10, 1.16]
dom, 95% CI)
5.2 After usual care 4 412 Std. Mean Difference (IV, Ran- 0.04 [-0.25, 0.32]
dom, 95% CI)
6 Mobility - Functional Ambulation Cate- 1 242 Mean Difference (IV, Random, 0.11 [0.00, 0.22]
gories 95% CI)
6.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
6.2 After usual care 1 242 Mean Difference (IV, Random, 0.11 [0.00, 0.22]
95% CI)
7 Mobility - walking preferred speed (m/ 5 542 Mean Difference (IV, Random, 2.54 [-3.65, 8.72]
min) 95% CI)
7.1 During usual care 2 136 Mean Difference (IV, Random, -1.02 [-8.64, 6.60]
95% CI)
7.2 After usual care 3 406 Mean Difference (IV, Random, 4.29 [-4.46, 13.05]
95% CI)
8 Mobility - walking capacity (6-MWT me- 4 464 Mean Difference (IV, Random, 47.48 [23.72, 71.23]
tres) 95% CI)
8.1 During usual care 1 40 Mean Difference (IV, Random, 109.50 [17.12, 201.88]
95% CI)
8.2 After usual care 3 424 Mean Difference (IV, Random, 43.09 [18.50, 67.67]
95% CI)
9 Mobility - community ambulation speed 3 217 Odds Ratio (M-H, Random, 95% 1.33 [0.70, 2.53]
(> 0.8 m/sec) CI)
9.1 During usual care 1 52 Odds Ratio (M-H, Random, 95% 2.14 [0.56, 8.12]
CI)
9.2 After usual care 2 165 Odds Ratio (M-H, Random, 95% 1.15 [0.48, 2.76]
CI)
10 Physical function - balance - Berg Bal- 3 201 Mean Difference (IV, Random, 1.86 [-3.05, 6.78]
ance Scale 95% CI)
10.1 During usual care 2 102 Mean Difference (IV, Random, 2.22 [-7.79, 12.22]
95% CI)
10.2 After usual care 1 99 Mean Difference (IV, Random, 3.0 [-0.54, 6.54]
95% CI)
11 Physical function - balance - functional 1 66 Mean Difference (IV, Random, 2.5 [-0.97, 5.97]
reach 95% CI)
11.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
11.2 After usual care 1 66 Mean Difference (IV, Random, 2.5 [-0.97, 5.97]
95% CI)
12 Physical function - Timed Up and Go 5 510 Mean Difference (IV, Random, -1.41 [-3.74, 0.92]
(sec) 95% CI)
12.1 During usual care 1 62 Mean Difference (IV, Random, 0.0 [-6.97, 6.97]
95% CI)
12.2 After usual care 4 448 Mean Difference (IV, Random, -1.61 [-4.39, 1.17]
95% CI)
13 Health-related QoL - SF-36 physical 2 146 Mean Difference (IV, Random, 2.46 [-7.20, 12.11]
functioning 95% CI)
13.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
13.2 After usual care 2 146 Mean Difference (IV, Random, 2.46 [-7.20, 12.11]
95% CI)
14 Health-related QoL - SF-36 physical role 2 146 Mean Difference (IV, Random, 11.61 [2.38, 20.84]
functioning 95% CI)
14.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
14.2 After usual care 2 146 Mean Difference (IV, Random, 11.61 [2.38, 20.84]
95% CI)
15 Mood - Stroke Impact Scale emotion 2 322 Mean Difference (IV, Random, 0.13 [-3.26, 3.51]
score 95% CI)
15.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
15.2 After usual care 2 322 Mean Difference (IV, Random, 0.13 [-3.26, 3.51]
95% CI)
16 Mood - Geriatric Depression Scale 1 80 Mean Difference (IV, Random, -1.4 [-2.54, -0.26]
95% CI)
16.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
16.2 After usual care 1 80 Mean Difference (IV, Random, -1.4 [-2.54, -0.26]
95% CI)
17 Mood - Hospital Anxiety and Depression 3 391 Mean Difference (IV, Random, -0.11 [-0.78, 0.57]
Scale (HADS) - anxiety score 95% CI)
17.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
17.2 After usual care 3 391 Mean Difference (IV, Random, -0.11 [-0.78, 0.57]
95% CI)
18 Mood - Hospital Anxiety and Depression 3 391 Mean Difference (IV, Random, 0.26 [-0.43, 0.96]
Scale (HADS) - depression score 95% CI)
18.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
18.2 After usual care 3 391 Mean Difference (IV, Random, 0.26 [-0.43, 0.96]
95% CI)
19 Mood - combined depression scales 4 471 Std. Mean Difference (IV, Ran- -0.06 [-0.33, 0.22]
dom, 95% CI)
19.1 During usual care 0 0 Std. Mean Difference (IV, Ran- 0.0 [0.0, 0.0]
dom, 95% CI)
19.2 After usual care 4 471 Std. Mean Difference (IV, Ran- -0.06 [-0.33, 0.22]
dom, 95% CI)
20 Cognitive function - FIM cognitive score 1 93 Mean Difference (IV, Random, 0.40 [-0.19, 0.99]
95% CI)
20.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
20.2 After usual care 1 93 Mean Difference (IV, Random, 0.40 [-0.19, 0.99]
95% CI)
21 Cognitive function - SIS memory and 1 93 Mean Difference (IV, Random, 4.30 [-3.32, 11.92]
thinking 95% CI)
21.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
21.2 After usual care 1 93 Mean Difference (IV, Random, 4.30 [-3.32, 11.92]
95% CI)
22 Cognitive function - SIS communication 1 93 Mean Difference (IV, Random, 2.90 [-4.16, 9.96]
95% CI)
22.1 During usual care 0 0 Mean Difference (IV, Random, 0.0 [0.0, 0.0]
95% CI)
22.2 After usual care 1 93 Mean Difference (IV, Random, 2.90 [-4.16, 9.96]
95% CI)
Analysis 6.1. Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 1 Death.
Study or subgroup Training Control Risk Difference Weight Risk Difference
n/N n/N M-H, Random, 95% CI M-H, Random, 95% CI
6.1.1 During usual care
Cooke 2010 0/36 2/38 4.18% -0.05[-0.14,0.03]
Donaldson 2009 0/10 0/10 1.01% 0[-0.17,0.17]
Galvin 2011 0/20 2/20 1.3% -0.1[-0.25,0.05]
Richards 1993 0/10 0/8 0.81% 0[-0.19,0.19]
Richards 2004 0/32 0/31 8.52% 0[-0.06,0.06]
Toledano-Zarhi 2011 0/14 0/14 1.85% 0[-0.13,0.13]
Subtotal (95% CI) 122 121 17.67% -0.02[-0.06,0.02]
Total events: 0 (Training), 4 (Control)
Heterogeneity: Tau2=0; Chi2=2.58, df=5(P=0.76); I2=0%
Test for overall effect: Z=0.94(P=0.35)
Analysis 6.17. Comparison 6 Mixed training versus control - end of retention follow-
up, Outcome 17 Mood - Hospital Anxiety and Depression Scale (HADS) - anxiety score.
Study or subgroup Training Control Mean Difference Weight Mean Difference
N Mean(SD) N Mean(SD) Random, 95% CI Random, 95% CI
6.17.1 During usual care
Subtotal *** 0 0 Not estimable
Heterogeneity: Not applicable
Test for overall effect: Not applicable
Analysis 6.18. Comparison 6 Mixed training versus control - end of retention follow-
up, Outcome 18 Mood - Hospital Anxiety and Depression Scale (HADS) - depression score.
Study or subgroup Training Control Mean Difference Weight Mean Difference
N Mean(SD) N Mean(SD) Random, 95% CI Random, 95% CI
6.18.1 During usual care
Subtotal *** 0 0 Not estimable
Heterogeneity: Not applicable
1 Disability - combined disability scales 18 Std. Mean Difference (IV, Random, Subtotals only
95% CI)
1.1 Cardiorespiratory training 8 462 Std. Mean Difference (IV, Random, 0.52 [0.19, 0.84]
95% CI)
1.2 Resistance training 1 42 Std. Mean Difference (IV, Random, 0.12 [-0.48, 0.73]
95% CI)
1.3 Mixed training 9 604 Std. Mean Difference (IV, Random, 0.23 [0.03, 0.42]
95% CI)
2 Mobility - walking maximal speed 26 1176 Mean Difference (IV, Random, 95% 5.60 [3.11, 8.08]
CI)
2.1 Cardiorespiratory training 17 782 Mean Difference (IV, Random, 95% 7.66 [3.65, 11.68]
CI)
2.2 Resistance training 7 250 Mean Difference (IV, Random, 95% 2.75 [-0.61, 6.12]
CI)
2.3 Mixed training 3 144 Mean Difference (IV, Random, 95% 8.92 [1.74, 16.10]
CI)
3 Mobility - walking preferred speed 26 1481 Mean Difference (IV, Random, 95% 3.98 [1.96, 6.01]
CI)
3.1 Cardiorespiratory training 12 588 Mean Difference (IV, Random, 95% 4.47 [2.07, 6.87]
CI)
3.2 Resistance training 5 179 Mean Difference (IV, Random, 95% 1.97 [-3.76, 7.71]
CI)
3.3 Mixed training 10 714 Mean Difference (IV, Random, 95% 4.68 [1.26, 8.09]
CI)
4 Mobility - walking capacity (6-MWT dis- 30 1792 Mean Difference (IV, Random, 95% 30.14 [21.27, 39.00]
tance) CI)
4.1 Cardiorespiratory training 16 882 Mean Difference (IV, Random, 95% 33.41 [19.04, 47.78]
CI)
4.2 Resistance training 5 214 Mean Difference (IV, Random, 95% 24.83 [11.68, 37.97]
CI)
4.3 Mixed training 10 696 Mean Difference (IV, Random, 95% 35.30 [15.88, 54.71]
CI)
5 Physical Function - Balance - Berg Bal- 21 1062 Mean Difference (IV, Random, 95% 2.29 [1.42, 3.17]
ance Scale CI)
5.1 Cardiorespiratory training 8 471 Mean Difference (IV, Random, 95% 1.92 [0.16, 3.68]
CI)
5.2 Resistance training 5 196 Mean Difference (IV, Random, 95% 3.24 [2.11, 4.38]
CI)
5.3 Mixed training 9 395 Mean Difference (IV, Random, 95% 2.10 [0.73, 3.48]
CI)
6 Physical function - Timed up and go 16 1033 Mean Difference (IV, Random, 95% -3.04 [-4.62, -1.45]
CI)
6.1 Cardiorespiratory training 5 223 Mean Difference (IV, Random, 95% -3.42 [-4.78, -2.05]
CI)
6.2 Resistance training 5 224 Mean Difference (IV, Random, 95% -3.46 [-6.94, 0.02]
CI)
6.3 Mixed training 7 586 Mean Difference (IV, Random, 95% -2.21 [-4.43, 0.02]
CI)
Study or subgroup Training Control Std. Mean Difference Weight Std. Mean Difference
N Mean(SD) N Mean(SD) Random, 95% CI Random, 95% CI
Mudge 2009 31 77.8 (55.7) 27 60.9 (67.2) 13.38% 0.27[-0.25,0.79]
Takami 2010 10 11.9 (2.1) 6 8.4 (2.9) 5.75% 1.37[0.22,2.52]
Takami 2010 11 9.6 (3.4) 6 8.4 (2.9) 6.93% 0.35[-0.65,1.36]
Wang 2014 23 78.2 (12.1) 22 56 (14.1) 10.66% 1.66[0.98,2.35]
Subtotal *** 236 226 100% 0.52[0.19,0.84]
Heterogeneity: Tau2=0.14; Chi2=20.31, df=8(P=0.01); I2=60.61%
Test for overall effect: Z=3.12(P=0)
ADDITIONAL TABLES
Library
Cochrane
al care body (days) length
(weeks)
Ada 2013 Treadmill + overground walking After Lower Yes Unknown 30 min 3 Group 1 =
body 16
Group 2 =
Better health.
Informed decisions.
Trusted evidence.
8
Cuviel- Kinetron During Lower No Heart rate < resting + 20 beats/min 7-17 5 3
lo-Palmer body
1988
da Cunha Treadmill gait training with body During Lower Yes Unknown 20 5 2-3
2002 weight support body
Eich 2004 Treadmill gait training During Lower Yes 60% heart rate reserve 30 5 6
body
Globas Treadmill After Lower Yes 40%-50% progressing to 60%-80% 10-20 min 3 12
2012 body heart rate reserve increasing
to 30-50
Gordon Overground community-based After Lower Yes Target heart rate was 60%-85% of 15min 3 12
2013 walking body age-predicted maximum heart rate progress-
(220-age). ing by +5
min per
week
Ivey 2010 Treadmill After Lower Yes 40%-50% progressing to 60%-70% 10-20 min 3 24
body heart rate reserve increasing
to 40 min (6 months)
289
Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Physical fitness training for stroke patients (Review)
Table 1. Outline of the studies that focused on cardiorespiratory training interventions (Continued)
Ivey 2011 Treadmill After Lower Yes 40%-50% progressing to 60%-70% 10-20 min 3 24
body heart rate reserve increasing
Library
Cochrane
to 40 min (6 months)
Jin 2013 Cycle ergometry During Lower No Commencing at 40%-50% heart rate 40 5 12
reserve progressing 5% heart rate re-
serve every 2 weeks up to 70% heart
rate reserve
Better health.
Informed decisions.
Trusted evidence.
Kang 2012 Treadmill After Lower Yes Unknown 30 3 4
body
Katz-Leur- Cycle ergometer After Lower No ≤ 60% heart rate reserve 20 then 30 5 then 3 2 then 6
er 2003 body (total 8)
Kuys 2011 Treadmill After Lower Yes 40% progressing to 60% heart rate 30 3 6
body reserve
Lennon Cycle ergometer (cardiac rehabil- After Both No 50%-60% maximum heart rate 30 2 10
2008 itation programme)
MacK- Body weight supported treadmill During Both Yes Target heart rates corresponding to 60 5/week for 12
ay-Lyons training 60%-75% of baseline VO2peak 6 weeks
2013 then 3/
Initially treadmill speed 80%-90% of week for 6
Mao 2015 Body weight supported treadmill During Lower Yes Treadmill walking with 30%-40% 20 up to 40 5 3
training body weight support. Body support
was decreased and treadmill speed
increased. No further detail for per-
290
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Physical fitness training for stroke patients (Review)
Table 1. Outline of the studies that focused on cardiorespiratory training interventions (Continued)
centage assisted body support was
provided. Speed initially 0.5 miles/h
Library
Cochrane
(0.8 km/h) for 20 min progressing to
2.5 miles/h (4.0 km/h) for 40 min
Moore Treadmill gait training with over- After Lower Yes 80%-85% age-predicted maximum Unknown 2-5 4
2010 head harness body heart rate
Better health.
Informed decisions.
Trusted evidence.
2009 body
Sandberg Cycling (main exercise element) After Lower No Class included 2 x 8-min periods of 60 2 12
2016 high-intensity exercise (14-15 RPE;
75% maximum oxygen consumption;
80% maximum heart rate)
Takami Treadmill gait training with body During Lower Yes Unknown 10 6 3
2010 weight support body
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Cochrane
Vanroy MOTOmed seated cycling er- Com- Lower No Intensity progressed from 60%-75% 30 3 12 (3
2017 gometer menced heart rate reserve months)
during (Total ses-
(some dis- sion 51
charged min reduc-
ing to 40
Better health.
Informed decisions.
Trusted evidence.
home)
min)
Wang 2014 Wheelchair-seated pedaling er- During Lower Yes Cycling training consisted of 30-min 30 3 6
gometry sessions including: 5-min warm-up;
30-min active pedaling at an intensi-
ty based on an incremental graded
exercise test (2.5 W ramp every 3 min
maintaining 50 rpm until exhaus-
tion); followed by 5-min cool down.
Target heart rate was calculated as
((peak heart rate in graded exercise
test – resting heart rate) x 50%-70%)
+ resting heart rate
Yang 2014 Cycle ergometer During Lower Yes Cycling training consisted of 15-min 30 5 4
sessions each of forward and back-
ward cycling including: 150-s passive
warm-up; 10-min active pedaling at
50-70 rpm at an intensity of stage
13 of the Borg scale; 150 s of passive
cool-down
mph: miles per hour; RPE: rate of perceived exertion;RPM: revolutions per minute
Aidar 2016 Resistance training; machine weights After Both No OMNI Resistance 45-60 3 12
Exercise Scale
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Cochrane
Arabzadeh Task-oriented circuit with added weights and some During Lower Yes Unknown; tailored 50 3 4
2018 balance activities to individual ca-
pacity
Better health.
Informed decisions.
Trusted evidence.
body achieve moderate
fatigue
Fernan- Unilateral explosive resistance training of the more After Lower No Maximal effort Unclear 2 12
dez-Gon- affected leg
zalo 2016
Flansbjer Dynamic and isokinetic resistance training (leg ex- After Lower Yes 6-10 repetitions 90 Unknown 10
2008 tension/curl rehab exercise machine) body equivalent to 80%
of maximum load
Inaba 1973 Resistance training During Lower No 50% and 100% Unknown 'Daily' 4-8
body maximum weight
Ivey 2017 Pneumatic resistance machines After Lower No 10-15, decreasing Unclear 3 12
Kim 2001 Resistance training; isokinetic dynamometer After Lower No Maximal effort 30 3 6
body 3 x 10 repetitions
Knox 2018 Gravity, free weights, elastic bands and balls After Lower No 3 set of 10 repeti- 60 6 sessions 12
tions; progressed
individually
293
Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Physical fitness training for stroke patients (Review)
Table 2. Outline of the studies that focused on resistance training interventions (Continued)
(average
0.5 per
Library
Cochrane
week)
Lee 2013a Closed chain and open chain progressive resis- After Lower No 3 sets of 8-10 repe- Unclear 5 6
tance training titions (duration
based on
70% of 1 repetition repeti-
maximum tions)
Better health.
Informed decisions.
Trusted evidence.
Lee 2013b Closed-chain and open-chain progressive resis- After Lower No 3 sets of 8-10 repe- Unclear 5 6
tance training titions (duration
based on
70% of 1 repetition repeti-
maximum tions)
Ouellette Resistance training; weights and pneumatic resis- After Lower No 70% 1 repetition Not ap- 3 12
2004 tance machines body maximum: plicable
3 x 8-10 repetitions
Sims 2009 Resistance training; machine weights After Both Yes 3 x 8/10 repetitions Unknown 2 10
at 80% 1 repetition
maximum
Son 2014 Pneumatic leg press machine Probably Lower No 3 sets of 8-10 repe- 30 5 6
after titions
70% of 1 repetition
maximum
Taylor-Pil- Silversneakers national programme (strength and After Unclear Unclear Unclear 40 3 12
liae 2014 range of movement)
Library
Cochrane
Winstein Resistance training; weights; During Upper No Unknown 60 3 high 4-6 (target
2004 TheraBand and grip devices body 2 slow of 20 ses-
sions)
Better health.
Informed decisions.
Trusted evidence.
sity causing failure
10-12 repetitions,
then reduce to al-
low completion of
15
Dean 2018 Group circuit training (0-3 After Both Yes Unclear Unclear 2 classes 6
months) + home training (+ home
(0-6 months) exercise (0-3
months
group ex-
ercise; 0-6
Duncan Circuit training After Lower Yes 50%-60% heart rate reserve 90-120 3 4
2003 body
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Cochrane
Furnari Aquatic exercise During Upper Yes Unclear; difficulty progressed weekly 60 3 8
2014 or lower
body
Better health.
Informed decisions.
Trusted evidence.
2011 strength training
Kim 2017a Handgrip resistance train- During Both Yes Resistance increase 30 3 6
ing + treadmill walking
with some added load to Treadmill speed increase
unaffected leg
Knox 2018 Task-oriented circuit train- After Lower Yes (walk- Reduced support and increased complexity 60 6 sessions 12
ing (+ home-based walk- (+upper?) ing) and more demanding home-based walking
ing) (average
0.5 per
week)
Langham- Walking, stationary bicy- After Both Yes 70%-80% maximum pulse (cardiorespira- 45 2/3 Unclear.
mer 2007 cling, stair walking, tread- tory component); 50%-60% one repetition Minimum
mill, and resistance train- maximum (strength component) 20 hours
ing every third
Letombe Cycle ergometry, treadmill During Both in- Yes (walk- Cardiorespiratory training: 70%-80% maxi- 40-60 4 4
2010 walking, and isokinetic re- cluding ing) mal cycling power
sistance training trunk
Strength training; 6 x 10 repetitions at
50%-60% maximum
296
Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Physical fitness training for stroke patients (Review)
Table 3. Outline of the studies that focused on mixed training interventions (Continued)
Mead 2007 Circuit including walking, After Both Yes Rating of perceived exertion: 13-16 40-75 3 12-14 (to-
stepping, cycle ergometry; tal of 36
Library
Cochrane
resistance training body sessions)
mass, weights, and elastic
Moore Community-based group After Both Yes Increasing load and repetitions 40-60 3 19
2015 classes including warm-
up, stretching, functional 40%-50% maximum heart rate increasing to
70%-80%
Better health.
Informed decisions.
Trusted evidence.
strengthening, balance,
agility and cardiorespira-
tory training
Shin 2011 Functional strength train- During Lower Yes (walk- Cardiorespiratory progressive but < 40% 60 5 4
ing (bridging and step- ing and heart rate reserve
ping) + treadmill and cycle stepping)
ergometry Strength training described only as 'medi-
um intensity' of 5-15 repetitions
Teixeira Walking and stepping or After Lower Yes 50%-70% maximum work rate (cardiores- 60-90 3 10
1999 cycle ergometry; body piratory component) 50%-80% 1 repetition
resistance training body maximum, 3 x 10 repetitions (strength com-
mass, weights and elastic ponent)
Toledano- Treadmill, hand bike, cy- During Both Yes (tread- Cardiorespiratory 50%-70% of maximal Cardiores- Cardiores- 6
Zarhi 2011 cle ergometer + group ex- mill) heart rate piratory 90 piratory 2/
ercise for strength, bal- min week
ance and co-ordination
Zedlitz Treadmill walking, After Both Yes (walk- Cardiorespiratory and strength progressed 120 2 12
2012 strength training, and ing) from 40%-70%
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Cochrane
home exercise assign-
ments
Table 4. Pooled walking data for cardiorespiratory training, resistance training, and mixed training at the end of the training period and at follow-up
Better health.
Informed decisions.
Trusted evidence.
End of intervention End of follow-up
Cardiores- Maximal gait speed 17 (782) 7.66 m/min (3.65 to P = 0.0002 5 (312) 6.71 m/min ( 2.40 to 11.02) P = 0.002
piratory 11.68)
training Preferred gait speed 12 (588) 4.47 m/min (2.07 to 6.87) P = 0.0003 3 (176) 1.67 m/min (−3.27 to 6.62) NS
6-Minute Walk Test 16 (882) 33.41 m (19.04 to 47.78) P = 0.00001 5 (283) 38.29 m (7.19 to 69.39) P = 0.02
Resistance Maximal gait speed 6 (274) 2.83 m/min (−0.49 to NS 2 (117) 7.80 m/min (−3.32 to 18.91) NS
training 6.14)
6-Minute Walk Test 5 (238) 24.98 m (11.98 to 37.98) P value 0.0002 2 (117) 22.41 m (−27.87 to 72.69) NS
6-Minute Walk Test 10 (720) 35.00 m (15.91 to 54.09) P value < 4 (464) 47.48 m (23.72 to 71.23) P = 0.0001
0.0003
CI: confidence interval; MD: mean difference; NS: no statistically significant difference
298
Cochrane Trusted evidence.
Informed decisions.
Library Better health. Cochrane Database of Systematic Reviews
APPENDICES
S2TI ( stroke or poststroke or post-stroke or cerebrovasc* or brain vasc* or cerebral vasc or cva or apoplex or SAH ) or AB ( stroke or
poststroke or post-stroke or cerebrovasc* or brain vasc* or cerebral vasc or cva or apoplex or SAH )
S3TI ( brain* or cerebr* or cerebell* or intracran* or intracerebral ) or AB ( brain* or cerebr* or cerebell* or intracran* or intracerebral )
S4TI ( ischemi* or ischaemi* or infarct* or thrombo* or emboli* or occlus* ) or AB ( ischemi* or ischaemi* or infarct* or thrombo* or emboli*
or occlus* )
S5S3 and S4
S6TI ( brain* or cerebr* or cerebell* or intracerebral or intracranial or subarachnoid ) or AB ( brain* or cerebr* or cerebell* or intracerebral
or intracranial or subarachnoid )
S7TI ( haemorrhage* or hemorrhage* or haematoma* or hematoma* or bleed* ) or AB ( haemorrhage* or hemorrhage* or haematoma*
or hematoma* or bleed* )
S8S6 and S7
S9(MH "Hemiplegia")
S10TI ( hemipleg* or hemipar* or paresis or paretic ) or AB ( hemipleg* or hemipar* or paresis or paretic )
S11(MH "Gait Disorders, Neurologic+")
S12S1 or S2 or S5 or S8 or S9 or S10 or S11
S13(MH "Exercise+")
S14(MH "Therapeutic Exercise+")
S15(MH "Sports+")
S16(MH "Physical Endurance+") OR (MH "Exertion+") OR (MH "Muscle Strengthening+")
S17TI exercis* OR AB exercis*
S18TI train* OR AB train*
S19TI conditioning OR AB conditioning
S20TI strengthen* OR AB strengthen*
S21S13 OR S14 OR S15 OR S16 OR S17 OR S18 OR S19 OR S20
S22MH Random Assignment or MH Single-blind Studies or MH Double-blind Studies or MH Triple-blind Studies or MH Crossover design
or MH Factorial Design
S23TI ("multicentre study" or "multicenter study" or "multi-centre study" or "multi-center study") or AB ("multicentre study" or
"multicenter study" or "multi-centre study" or "multi-center study") or SU ("multicentre study" or "multicenter study" or "multi-centre
study" or "multi-center study")
S24TI random* or AB random*
S25AB "latin square" or TI "latin square"
S26TI (crossover or cross-over) or AB (crossover or cross-over) or SU (crossover or cross-over)
S27MH Placebos
S28TI ( ((singl* or doubl* or trebl* or tripl*) N3 (blind* or mask*)) ) OR AB ( ((singl* or doubl* or trebl* or tripl*) N3 (blind* or mask*)) )
S29TI Placebo* or AB Placebo* or SU Placebo*
S30MH Clinical Trials
S31TI (Clinical AND Trial) or AB (Clinical AND Trial) or SU (Clinical AND Trial)
S32S22 OR S23 OR S24 OR S25 OR S26 OR S27 OR S28 OR S29 OR S30 OR S31
S14. SU ( random* or trial or crossover or cross-over or placebo* or control* or factorial or sham or counterbalance* or multiple baseline*
or ABAB design or meta analysis* or metaanlaysis or meta-anlaysis or systematic review* ) or KW ( random* or trial or crossover or cross-
over or placebo* or control* or factorial or sham or counterbalance* or multiple baseline* or ABAB design or meta analysis* or metaanlaysis
or meta-anlaysis or systematic review* )
S15. S8 or S9 or S10 or S11 or S12 or S13 or S14
S16. (S7 and S15)
Search #1
Search #2
WHAT'S NEW
7 July 2019 New citation required and conclusions In this update there are now more studies containing resistance
have changed training either as a standalone intervention or as part of mixed
training (resistance plus cardiorespiratory). This has clarified
that resistance training content within programmes of training
can benefit balance after stroke.
7 July 2019 New search has been performed We have updated all main electronic search strategies to July
2018; we have rewritten the syntax of all the search strategies in-
cluding the addition of new resources (PsycINFO). Layout of the
methods now mirrors that in a related review (Interventions to
reduce sedentary behaviour after stroke).
HISTORY
Protocol first published: Issue 4, 2001
Review first published: Issue 1, 2004
12 November 2015 New citation required and conclusions New trials have changed where significant benefits emerge. Im-
have changed provements in global indices of disability are apparent now for
mixed training as well as cardiorespiratory training. Improve-
ments in balance are now only apparent among trials of mixed
training. We have added a new patient-important outcome (cog-
nitive function) but there is a lack of evidence and this highlights
an important knowledge gap.
29 October 2015 New search has been performed We have updated all main electronic search strategies to Febru-
ary 2015. We have included 13 additional randomised controlled
trials, bringing the total number of included trials to 58, involving
2797 participants. We have added a cognitive function outcome
to the review because this has been identified as a research pri-
ority. Secondly an application to carry out a Cochrane review of
exercise interventions for cognition after stroke was judged to
overlap and to be more efficiently combined with this review of
fitness training interventions after stroke. We checked all previ-
ously included trials for cognitive outcomes as well as those in
the updated searches. We have added two new co-authors.
5 July 2013 New citation required and conclusions Additional co-author. We have revised the main text and conclu-
have changed sions of the review according to the findings of the new included
trials.
28 January 2013 New search has been performed We have updated all main electronic search strategies to January
2013. We have included 13 additional randomised clinical trials,
bringing the total number of included trials to 45, involving 2188
participants. We have incorporated 'Risk of bias' tables.
22 November 2010 New search has been performed We have updated all main electronic search strategies to March
2010. We have included 11 additional randomised clinical trials
and 7 ongoing trials. We have better clarified our inclusion crite-
ria and objectives.
22 November 2010 New citation required and conclusions New first author. We have revised the main text and conclusions
have changed of the review according to the findings of the new included trials.
2 March 2009 New search has been performed We updated the search of the Cochrane Stroke Group Trials Reg-
ister in March 2009.
3 November 2008 New citation required and conclusions There is sufficient evidence to incorporate cardiorespiratory
have changed training, using walking as a mode of exercise, into the rehabilita-
tion of patients with stroke in order to improve speed, tolerance,
and independence during walking, but further trials are needed
to determine the optimal exercise prescription after stroke and
to establish whether any long-term benefits exist.
3 November 2008 New search has been performed We updated the searches to March 2007. There are now 24 trials,
involving 1147 participants, included in the review; 12 more trials
than in the previous version. The text of the review has been re-
vised throughout.
CONTRIBUTIONS OF AUTHORS
Original review
DH Saunders, CA Greig, GE Mead, and A Young contributed to writing the review protocol.
DH Saunders developed and ran searches, selected studies, extracted and interpreted data, performed the analyses, and co-wrote the
review.
CA Greig and GE Mead selected studies, extracted and interpreted data, performed the analyses, and co-wrote the review.
A Young provided comments on interim drafts of the review.
DECLARATIONS OF INTEREST
DH Saunders was a co-author of one included study (Mead 2007).
GE Mead receives royalties (about GBP 100 a year) for a book about fitness training after stroke (Exercise and Fitness Training after stroke)
a handbook for evidence-based practice. Ed Gillian Mead and Frederike van Wijck. These royalties are used to support further research.
She has led a study of exercise after stroke that is included in the review (Mead 2007).
SOURCES OF SUPPORT
Internal sources
• No sources of support supplied
External sources
• National Institute for Health Research (NIHR), UK.
• type of control interventions (no intervention versus non-exercise intervention versus other intervention); no intervention is explored
in depth anyway (studies confounded for exposure time);
• duration of training (less than 12 weeks versus 12 weeks or more); duration is still discussed in the current results;
• severity of stroke (mild symptoms versus severe symptoms); most participants recruited in exercise studies are high-functioning.
INDEX TERMS