Cochrane for Clinicians

Putting Evidence into Practice

Physical Fitness Training for Patients with Stroke


Am Fam Physician. 2017 Jun 1;95(11):701-702.

Author disclosure: No relevant financial affiliations.

Clinical Question

Does physical fitness training improve disability after stroke?

Evidence-Based Answer

There is moderate-quality evidence that physical fitness training improves disability after stroke. Cardiovascular training that includes only aerobic exercise has a moderate effect on disability (standard mean difference [SMD] = 0.52 on a pooled disability scale), although it is not clear whether this effect is sustained after patients stop training.1 (Strength of Recommendation [SOR]: A, based on consistent, good-quality patient-oriented evidence.) There is insufficient evidence to determine whether resistance training has a beneficial effect on disability. Mixed cardiovascular and resistance training has a small effect on disability and is of questionable clinical relevance.1 (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.) There is no evidence of reduced risk of stroke recurrence, nor is there risk of harm from physical fitness training in patients after a stroke.1

Practice Pointers

Stroke is the fifth most common cause of death and a primary cause of adult disability in the United States.2 Nearly 3% of U.S. adults are stroke survivors.3 Physical fitness levels in these patients are degraded because of the neurologic effects of stroke, tendency for physical inactivity, and predisposing poor baseline fitness.4 Exercise interventions may improve disability and decrease stroke recurrence, but evidence regarding the effect is limited to small trials with diverse functional measures.

This Cochrane review included 58 randomized trials and 2,797 patients.1 Training sessions were diverse in mode, intensity, duration, and proximity to stroke, limiting comparability of results. Some trials included nonambulatory participants, whereas others included only ambulatory patients. Meta-analysis showed no effect on mortality, independence, or stroke recurrence after physical fitness training.

The best evidence of benefit was found for cardiovascular training. Eight

Author disclosure: No relevant financial affiliations.


show all references

1. Saunders DH, Sanderson M, Hayes S, et al. Physical fitness training for stroke patients. Cochrane Database Syst Rev. 2016;(3):CD003316....

2. Benjamin EJ, Blaha MJ, Chiuve SE, et al.; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2017 update: a report from the American Heart Association [published correction appears in Circulation. 2017;135(10):e646]. Circulation. 2017;135(10):e146–e603.

3. Schiller JS, Lucas JW, Peregoy JA. Summary health statistics for U.S. adults: National Health Interview Survey, 2011. Vital Health Stat. 2012;10(256):1–218.

4. Billinger SA, Coughenour E, Mackay-Lyons MJ, Ivey FM. Reduced cardiorespiratory fitness after stroke: biological consequences and exercise-induced adaptations. Stroke Res Treat. 2012;2012:959120.

5. Ivey FM, Macko RF, Ryan AS, Hafer-Macko CE. Cardiovascular health and fitness after stroke. Top Stroke Rehabil. 2005;12(1):1–16.

6. National Institute for Health and Care Excellence. Stroke rehabilitation in adults. Clinical guideline CG162. June 2013. Accessed April 26, 2017.

These are summaries of reviews from the Cochrane Library.

This series is coordinated by Corey D. Fogleman, MD, Assistant Medical Editor.

A collection of Cochrane for Clinicians published in AFP is available at



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