RATIONALE: Levels of physical activity and physical fitness, including both cardiorespiratory fitness and muscle strength, are often low after stroke and are associated with post-stroke disability. Multicomponent exercise interventions that increase muscle strength and cardiorespiratory fitness could be effective for improving physical function and disability, and for secondary prevention.
OBJECTIVES: The primary objective of this review is to determine whether combined cardiorespiratory fitness and resistance training after stroke has any effects on death, disability, adverse events, risk factors, fitness, walking, and indices of physical function when compared to a non-exercise control.
SEARCH METHODS: In January 2024, we searched nine databases (CENTRAL, MEDLINE, Embase, CINAHL, SPORTDiscus, PsycINFO, WoS, PEDro, and DORIS) and two trial registers (ClinicalTrials.gov and ICTRP). We also undertook reference checking, citation tracking, and contact with experts in the field, in order to identify eligible studies.
ELIGIBILITY CRITERIA: We included randomised controlled trials (RCTs) that compared combined cardiorespiratory fitness and muscle strength training against usual care, no intervention, or a non-exercise intervention for people with stroke.
OUTCOMES: Our critical outcome domains were death, disability, adverse events, risk factors, fitness, walking, and indices of physical function. We assessed outcomes at the end of intervention and at the end of follow-up. Our other important outcome domains were indices of quality of life, mood, cognition, and fatigue.
RISK OF BIAS: We used the Cochrane tool RoB 1 to assess bias in the included studies.
SYNTHESIS METHODS: Where possible, we synthesised results for each outcome at the end of intervention and end of follow-up using random-effects meta-analyses on arm-level data. For dichotomous outcomes, we calculated the risk difference (RD) and 95% confidence interval (CI). For continuous outcomes, we calculated a mean difference (MD) or standardised mean difference (SMD), and 95% CI. We used GRADE to assess certainty of evidence for critical outcomes.
INCLUDED STUDIES: We included 30 studies with 1519 participants, who had an average age of 63.7 years. Most studies recruited ambulatory participants (28 of the 30 studies) during the early subacute (14 studies) and chronic (14 studies) stages of recovery. Most studies (26) took place in high-income countries. Most study interventions lacked a balanced dose of control exposure (23 studies). Eleven studies included a follow-up period (mean 7.3 months; range 3 to 12 months). Most interventions combined cardiorespiratory training (usually walking or ergometer-based) and resistance training (weights, machines, bodyweight or elastic resistance) in a circuit-type format. Training occurred two to five days a week for between four weeks and one year.
SYNTHESIS OF RESULTS: Combined training does not increase or decrease deaths at the end of intervention (risk difference RD -0.00, 95% CI -0.02 to 0.01; 26 studies, 1352 participants; high certainty) or end of follow-up (RD -0.01, 95% CI -0.04 to 0.02; 8 studies, 531 participants; high certainty). Combined training may improve indices of disability slightly at the end of intervention (standardised mean difference SMD 0.20, 95% CI 0.04 to 0.36; 13 studies, 789 participants; low certainty) but has little or no effect at the end of follow-up (SMD 0.10, 95% CI -0.07 to 0.28; 8 studies, 614 participants; low certainty). Combined training does not increase or reduce the incidence of secondary cardiovascular or cerebrovascular events at the end of intervention (RD -0.00, 95% CI -0.02 to 0.01; 8 studies, 684 participants; high certainty) or end of follow-up (RD 0.01, 95% CI -0.06 to 0.09; 4 studies, 285 participants; high certainty). Combined training may have little or no effect on systolic blood pressure (mmHg) at the end of intervention, but the evidence is very uncertain (mean difference MD -1.83, 95% CI -9.60 to 5.95; 5 studies, 140 participants; very low certainty); there were no follow-up data. Combined training may improve indices of cardiorespiratory fitness and musculoskeletal fitness (lower limb strength), but the evidence is very uncertain. Few data were available at follow-up. Combined training may improve comfortable walking speed (metres per second) at the end of intervention (MD 0.09, 95% CI 0.04 to 0.14; 13 studies, participants not available; very low certainty) but may have little or no effect at the end of follow-up (MD 0.03, 95% CI -0.07 to 0.13; 7 studies, 605 participants; very low certainty), although the evidence is very uncertain for both time points. Combined training may improve balance slightly at the end of intervention (SMD 0.25, 95% CI 0.11 to 0.39; 16 studies, 839 participants; low certainty) and end of follow-up (SMD 0.24, 95% CI -0.00 to 0.49; 6 studies, 535 participants; low certainty). In terms of acceptability and tolerability, interventions were closely adhered to, with no pattern of concerning adverse effects or participant losses attributable to combined training. Overall, our certainty about the evidence is limited by imprecision (small number of studies and participants) and risks of bias (e.g. from imbalanced exposure doses).
AUTHORS' CONCLUSIONS: Combined training after stroke does not affect mortality or the incidence of secondary events at the end of intervention or end of follow-up. Since these events are infrequent, conclusions cannot be drawn about any protective effect on mortality or secondary events. Small beneficial effects on physical fitness and blood pressure at the end of intervention may represent a reduced risk of secondary events, but this is very uncertain. Combined training may cause small improvements in fitness, disability, walking speed, and balance at the end of intervention. The small benefit observed for balance may be preserved after a follow-up period. The evidence for these effects is of low or very low certainty. Combined training interventions were adhered to successfully without serious adverse events or adverse effects; the interventions were acceptable to and well tolerated by participants. Limited data at follow-up restricts the conclusions we can draw about the retention of any benefits observed. Larger, well-designed trials are needed to determine the optimal regimen for exercise prescription, the benefits, and long-term effects.
FUNDING: This Cochrane review had no dedicated funding.
REGISTRATION: Protocol (and previous versions) available via DOI 10.1002/14651858.CD003316 (DOI/10.1002/14651858.CD003316.pub7, DOI/10.1002/14651858.CD003316.pub6, DOI/10.1002/14651858.CD003316.pub5, DOI/10.1002/14651858.CD003316.pub4, DOI/10.1002/14651858.CD003316.pub3, DOI/10.1002/14651858.CD003316.pub2).
