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Am Fam Physician. 2017;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 trials showed that cardiovascular training reduced disability at the end of the intervention (SMD = 0.52; 95% confidence interval [CI], 0.19 to 0.84; an SMD greater than 0.5 represents a moderate effect). Measures of mobility were significantly improved, including maximal walking speed (mean difference [MD] = 6.71 meters per minute; 95% CI, 2.73 to 10.69), preferred gait speed (MD = 4.28 meters per minute; 95% CI, 1.71 to 6.84), and walking distance (MD = 30.29 meters in six minutes; 95% CI, 16.19 to 44.39). These mobility effects may have contributed to the disability improvement. Three trials included follow-up assessment at three to six months. There was no evidence of sustained disability improvement; however, some mobility improvements were sustained.

Neither resistance training nor mixed resistance and cardiovascular training conferred the benefits of cardiovascular training alone. There was insufficient evidence to show that resistance training resulted in a sustained effect on disability. Mixed training reduced disability at the end of the intervention (SMD = 0.26; 95% CI, 0.04 to 0.49; an SMD of 0.2 to 0.5 represents a small effect). However, it is unclear whether this represents a clinically important outcome. Mixed training, which included walking, showed some of the same mobility benefits as cardiovascular training alone, including preferred gait speed (MD = 4.54 meters per minute; 95% CI, 0.95 to 8.14) and walking distance (MD = 41.60 meters in six minutes; 95% CI, 25.25 to 57.95). The actual effect on mobility was uncertain because benefit was demonstrated only if exercise was initiated after usual care.

A previous evidence review that did not include a meta-analysis suggested that exercise interventions benefit patients who have had a stroke.5 Guidelines from the U.K.'s National Institute for Health and Care Excellence recommend cardiovascular and resistance exercise training for these patients.6

The practice recommendations in this activity are available at http://www.cochrane.org/CD003316.

The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. government.

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