Physical fitness training for stroke patients

  • Conclusions changed
  • Review
  • Intervention

Authors

  • David H Saunders,

    Corresponding author
    1. Institute for Sport, Physical Education and Health Sciences (SPEHS), University of Edinburgh, Moray House School of Education, Edinburgh, Midlothian, UK
    • David H Saunders, Moray House School of Education, Institute for Sport, Physical Education and Health Sciences (SPEHS), University of Edinburgh, St Leonards Land, Holyrood Road, Edinburgh, Midlothian, EH8 2AZ, UK. Dave.Saunders@ed.ac.uk.

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  • Mark Sanderson,

    1. University of the West of Scotland, Institute of Clinical Exercise and Health Science, Hamilton, UK
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  • Miriam Brazzelli,

    1. University of Edinburgh, Division of Clinical Neurosciences, Edinburgh, UK
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  • Carolyn A Greig,

    1. University of Birmingham, School of Sport, Exercise and Rehabilitation Sciences, MRC-ARUK Centre for Musculoskeletal Ageing Research, Birmingham, UK
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  • Gillian E Mead

    1. University of Edinburgh, Centre for Clinical Brain Sciences, Edinburgh, UK
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Abstract

Background

Levels of physical fitness are low after stroke. It is unknown whether improving physical fitness after stroke reduces disability.

Objectives

To determine whether fitness training after stroke reduces death, dependence, and disability. The secondary aims were to determine the effects of training on physical fitness, mobility, physical function, quality of life, mood, and incidence of adverse events.

Search methods

We searched the Cochrane Stroke Group Trials Register (last searched January 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 12: searched January 2013), MEDLINE (1966 to January 2013), EMBASE (1980 to January 2013), CINAHL (1982 to January 2013), SPORTDiscus (1949 to January 2013), and five additional databases (January 2013). We also searched ongoing trials registers, handsearched relevant journals 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, with no intervention, a non-exercise intervention, or usual care in stroke survivors.

Data collection and analysis

Two review authors independently selected trials, assessed quality, and extracted data. We analysed data using random-effects meta-analyses. Diverse outcome measures limited the intended analyses.

Main results

We included 45 trials, involving 2188 participants, which comprised cardiorespiratory (22 trials, 995 participants), resistance (eight trials, 275 participants), and mixed training interventions (15 trials, 918 participants). Nine deaths occurred before the end of the intervention and a further seven at the end of follow-up. No dependence data were reported. Diverse outcome measures made data pooling difficult. Global indices of disability show a tendency to improve after cardiorespiratory training (standardised mean difference (SMD) 0.37, 95% confidence interval (CI) 0.10 to 0.64; P = 0.007); benefits at follow-up and after mixed training were unclear. There were insufficient data to assess the effects of resistance training.

Cardiorespiratory training involving walking improved maximum walking speed (mean difference (MD) 7.37 metres per minute, 95% CI 3.70 to 11.03), preferred gait speed (MD 4.63 metres per minute, 95% CI 1.84 to 7.43), walking capacity (MD 26.99 metres per six minutes, 95% CI 9.13 to 44.84), and Berg Balance scores (MD 3.14, 95% CI 0.56 to 5.73) at the end of the intervention. Mixed training, involving walking, increased preferred walking speed (MD 4.54 metres per minute, 95% CI 0.95 to 8.14), walking capacity (MD 41.60 metres per six minutes, 95% CI 25.25 to 57.95), and also pooled balance scores but the evidence is weaker (SMD 0.26 95% CI 0.04 to, 0.49). Some mobility benefits also persisted at the end of follow-up. The variability and trial quality hampered the assessment of the reliability and generalisability of the observed results.

Authors' conclusions

The effects of training on death and dependence after stroke are unclear. Cardiorespiratory training reduces disability after stroke and this may be mediated by improved mobility and balance. There is sufficient evidence to incorporate cardiorespiratory and mixed training, involving walking, within post-stroke rehabilitation programs to improve the speed and tolerance of walking; improvement in balance may also occur. There is insufficient evidence to support the use of resistance training. Further well-designed trials are needed to determine the optimal content of the exercise prescription and identify long-term benefits.

Résumé scientifique

Entraînement physique chez les patients victimes d'un AVC

Contexte

Les niveaux de forme physique sont faibles après un AVC. On ignore si l'amélioration de la forme physique après un AVC permet de réduire l'incapacité.

Objectifs

Déterminer si l'entraînement physique après un AVC réduit la mortalité, la dépendance et l'incapacité. Les objectifs secondaires visaient à déterminer les effets de l'entraînement physique, la mobilité, la fonction physique, la qualité de vie, l’humeur et l'incidence des événements indésirables.

Stratégie de recherche documentaire

Nous avons effectué des recherches dans le groupe Cochrane sur les accidents vasculaires cérébraux (dernière recherche en janvier 2013), le registre Cochrane des essais contrôlés (CENTRAL) ( La Bibliothèque Cochrane 2012, numéro 12: Recherche effectuée en janvier 2013), MEDLINE (de 1966 à janvier 2013), EMBASE (de 1980 à janvier 2013), CINAHL (de 1982 à janvier 2013), SPORTDiscus (de 1949 à janvier 2013) et cinq bases de données supplémentaires (de janvier 2013). Nous avons également effectué une recherche dans les registres d'essais cliniques en cours, une recherche manuelle dans les journaux et les actes de conférence pertinents, vérifié les références bibliographiques et contacté des experts du domaine.

Critères de sélection

Les essais randomisés comparant l'entraînement cardiorespiratoire ou l'entraînement de résistance, ou les deux, à l'absence d'intervention, à une intervention sans exercice physique ou à des soins courants chez les victimes d'AVC.

Recueil et analyse des données

Deux auteurs de revue ont sélectionné les essais, évalué la qualité et extrait les données de manière indépendante. Nous avons analysé les données à l'aide de méta-analyses à effets aléatoires. Des mesures différentes des critères de jugement ont limité les analyses prévues.

Résultats principaux

Nous avons inclus 45 essais comprenant 2 188 participants, qui comportaient des interventions cardiorespiratoires (22 essais, 995 participants), de résistance (huit essais, 275 participants) et d'entraînement combiné (15 essais, 918 participants). Neuf décès sont survenus avant la fin de l'intervention et sept autres à la fin du suivi. Aucune donnée sur la dépendance n'a été rapportée. Des mesures différentes des critères de jugement ont rendu la combinaison des données difficile. Les indices d'incapacité montrent une tendance vers l’amélioration après les entraînements cardiorespiratoires (différence moyenne standardisée (DMS) 0,37, intervalle de confiance (IC) à 95% 0,10 à 0,64; P =0,007); les bénéfices lors du suivi et après l'entraînement conjugué n'étaient pas clairs. Il n'y avait pas suffisamment de données pour pouvoir évaluer les effets des exercices de résistance.

L'entraînement cardiorespiratoire comportant de la marche a amélioré la vitesse de marche maximale (différence moyenne (DM) de 7,37 mètres par minute, IC à 95% 3,70 à 11,03), la vitesse de marche préférée (DM de 4,63 mètres par minute, IC à 95% 1,84 à de 7,43), la capacité de marche (DM 26,99 mètres par six minutes, IC à 95%, entre 9,13 44.84), et les scores de Berg Balance (DM de 3,14, IC à 95% 0,56 à 5,73) à la fin de l'intervention. L'entraînement conjugué, portant sur la marche, augmentait la vitesse de marche préférée (DM de 4,54 mètres par minute, IC à 95%, entre 0,95 et 8,14), la capacité de marche (DM 41,60 mètres par six minutes, IC à 95% 25,25 à 57,95) et l'équilibre, mais les preuves sont plus faibles (DMS de 0,26, IC à 95% 0,04 à 0,49). Certains effets bénéfiques sur la mobilité étaient également notables à la fin du suivi. La variabilité et la qualité des essais ont entravé la fiabilité et la généralisabilité des résultats observés.

Conclusions des auteurs

Les effets de l'entraînement sur la mortalité et la dépendance après un AVC ne sont pas clairs. Les entraînements cardiorespiratoires réduisent l'incapacité après un accident vasculaire cérébral (AVC) et cela peut être influencé par une amélioration de la mobilité et de l'équilibre. Il existe suffisamment de preuves pour intégrer l’entraînement cardiorespiratoire et conjugué, comportant de la marche, dans les programmes de rééducation post-AVC afin d'améliorer la vitesse et la tolérance de la marche; l’amélioration de l'équilibre peut également se produire. Il n'existe pas suffisamment de preuves pour recommander l'utilisation des exercices de résistance. Des essais complémentaires bien conçus doivent être réalisés afin de déterminer la prescription d'exercice physique optimale et identifier les bénéfices sur le long terme.

摘要

中風病患的體能訓練

背景

中風後體能變差。目前尚未知中風後改善體能是否降低失能情況。

目的

為了判定中風後的體能訓練能否減少死亡、依賴與失能。再來就是要判定訓練對體能、發病率、身體功能、生活品質、情緒與負面事件的效用。

搜尋策略

我們檢索考科藍中風試驗註冊小組(上次檢索時間為2010年四月)、考科藍對照試驗中心(The Cochrane Library,2010年七月)、MEDLINE (1966年 to 2010年三月),EMBASE(1980至2010年三月)、 CINAHL(1982至2010年三月)、SPORTDiscus(1949至2010年三月)、以及五個額外的資料庫(2010年三月)。我們也檢索持續進行的試驗註冊,手動檢索相關期刊與會議,篩選參考清單、並與該領域的專家接觸。

選擇標準

比較中風倖存者接受心肺訓練或阻力訓練,或兩者一起進行的隨機試驗與無介入措施,非運動介入或一般照護。

資料收集與分析

兩位審查作者獨立挑選試驗,評估其品質,並萃取資料。我們使用隨機效用後設分析資料。多種成果測量限制預期的分析。

主要結果

我們收錄32個試驗,共1414位參與者,內容涵蓋心肺(14項試驗,651位參與者)、阻力(7項試驗,246位參與者)、並混合介入措施(11項試驗,517位參與者)。五位樣本在介入結束時死亡,九位樣本在追蹤結束時死亡。沒有報告其他相關資料。多樣化的成果量測讓資料不易彙總。大多數效用的評估都不顯著。心肺訓練措施結束時,包含健走改善最快走路速度(平均差MD每分鐘8.66公尺,95%CI是2.98至14.34),喜好的步行速度(MD每分鐘4.68公尺,95%CI 是1.40至7.96),步行能力(MD每六分鐘 47.13公尺,95% CI是 19.39 to 74.88)。這些訓練的效果也維持至追蹤結束時。

包含走路的混合訓練增加喜好的步行速度(MD每分鐘2.93,95% CI是0.02至5.84),步走能力(MD每6分鐘30.59公尺,95% CI是 8.90至52.28),但果用較差,且試驗結果間有異質性。資料不足以評估阻力訓練的成效。收錄之試驗品質差異性影響觀察結果的可信度與普遍性。

作者結論

訓練對中風後的死亡、依賴、以及失能的效用尚未明朗。有充足的證據顯示綜合心肺訓練與中風後復建方案的步行,能提升步行中的速度、耐力及獨立性。進一步設計良好的試驗以決定最佳運動處方並確認長期效益是需要的。

Plain language summary

Physical fitness training for stroke patients

Physical fitness is important to allow people to carry out everyday activities such as walking and climbing stairs. However, physical fitness is often reduced in stroke patients and may limit their ability to perform everyday activities and also worsen any stroke-related disability. For this reason fitness training has been proposed as a beneficial approach for stroke patients. In January 2013 this review identified 45 trials involving 2188 participants, which tested different forms of fitness training after stroke.

Studies of fitness training can be difficult to carry out. This means most of the studies were small and of moderate quality. However, some consistent findings did emerge. We found that some types of fitness training, particularly those involving walking, can improve exercise ability, walking and balance after stroke. However, there was not enough information to draw reliable conclusions about the impact of fitness training on quality of life or mood.

There was no evidence that any of the different types of fitness training caused injuries or other health problems; exercise appears to be a safe intervention.

Résumé simplifié

Entraînement physique chez les patients victimes d'un AVC

La condition physique est importante pour permettre aux personnes de réaliser leurs activités quotidiennes telles que marcher et monter des marches. Cependant, la condition physique est souvent restreinte chez les patients victimes d'un AVC et peut limiter leur capacité à effectuer les activités quotidiennes et également aggraver l'incapacité liée à un AVC. Pour cette raison, l'entraînement physique a été proposé comme une approche bénéfique pour les patients victimes d'un AVC. En janvier 2013, cette revue a identifié 45 essais impliquant 2 188 patients, qui ont essayé différentes méthodes d'entraînement physique suite à un accident vasculaire cérébral (AVC).

Les études portant sur l'entraînement physique peuvent être difficiles à réaliser. Cela signifie que la plupart des études étaient de petite taille et de qualité modérée. Cependant, certains résultats constants ont émergé. Nous avons constaté que certaines méthodes d'entraînement physique, en particulier celles impliquant la marche, peuvent améliorer la capacité d'exercice, la marche et l'équilibre après un AVC. Cependant, il n'y avait pas suffisamment d'informations pour tirer des conclusions fiables concernant l'impact de l'entraînement physique sur la qualité de vie ou l'humeur.

Il n'y avait aucune preuve que toute méthode d'entraînement physique utilisée soit à l'origine de blessures ou d'autres problèmes de santé; l’exercice semble être une intervention sûre.

Notes de traduction

Traduit par: French Cochrane Centre 14th January, 2014
Traduction financée par: Ministère du Travail, de l'Emploi et de la Santé Français

Laički sažetak

Tjelovježba za poboljšanje tjelesne kondicije nakon moždanog udara

Dobra tjelesna kondicija važna je za obavljanje svakodnevnih aktivnosti kao što su hodanje i penjanje uz stepenice. Međutim, tjelesna je kondicija često oslabljena nakon moždanog udara i može bolesnicima ograničiti obavljanje svakodnevnih funkcija te pogoršati njihovu invalidnost. Stoga se preporučuje tjelovježba nakon moždanog udara. Cochrane sustavni pregled pronašao je 45 kliničkih istraživanja, s ukupno 2188 ispitanika, u kojima je istražen učinak različitih oblika tjelovježbe nakon moždanog udara. Dokazi se odnose na rezultate istraživanja dostupne do siječnja 2013.

Istraživanja o tjelovježbi može biti vrlo teško provesti. Većinu pronađenih istraživanja odlikuje malen broj ispitanika i umjerena kvaliteta. Međutim, uočeni su određeni dosljedni rezultati. Utvrđeno je da određeni oblici tjelovježbe, osobito oni koji uključuju hodanje, mogu povoljno djelovati na mogućnost dodatnog vježbanja, hodanje i ravnotežu nakon moždanog udara. Međutim, nije nađeno dovoljno informacija da bi se mogli donijeti zaključci o učinku tjelovježbe na kvalitetu života i raspoloženje bolesnika.

Nisu nađeni dokazi da različiti oblici tjelovježbe za poboljšanje kondicije uzrokuju ozljede ili druge zdravstvene probleme te se tjelovježba nakon moždanog udara doima kao sigurna intervencija.

Bilješke prijevoda

Hrvatski Cochrane
Prevela: Livia Puljak
Ovaj sažetak preveden je u okviru volonterskog projekta prevođenja Cochrane sažetaka. Uključite se u projekt i pomozite nam u prevođenju brojnih preostalih Cochrane sažetaka koji su još uvijek dostupni samo na engleskom jeziku. Kontakt: cochrane_croatia@mefst.hr

淺顯易懂的口語結論

能訓練對中風患者是有助益的。

體能對日常活動的表現是重要的。中風患者的體能在中風後受損,這可能會降低他們執行日常活動的能力,也加劇中風相關的失能

此次回顧有1414位參與者,共32個試驗,發現中風後的心肺體能訓練能改善步行的表現。

因資料過少,無法獲得其它結論。

譯註

翻譯: East Asian Cochrane Alliance
翻譯補助: 台灣衛生福利部/台北醫學大學實證醫學研究中心

எளியமொழிச் சுருக்கம்

பக்கவாத நோயாளிகளுக்கான உடற்திறன் பயிற்சி

நடப்பது மற்றும் மாடிப்படி ஏறுவது போன்ற அன்றாட நடவடிக்கைகளை மேற்கொள்ள மக்களை அனுமதிப்பதற்கு உடற்திறன் முக்கியமானதாகும். எனினும், பக்கவாத நோயாளிகளில் உடற்திறன் குறைந்து, அன்றாட நடவடிக்கைகளை செய்யக் கூடிய திறனைக் கட்டுப்படுத்தக் கூடும், மேலும் பக்கவாதம்-தொடர்பான இயலாமையை மோசமடைய செய்யும். இந்த காரணத்திற்காக பக்கவாத நோயாளிகளுக்கு உடற்திறன் பயிற்சி ஒரு நன்மையளிக்கக் கூடிய அணுகுமுறையாக முன்மொழியப்பட்டது. ஜனவரி 2013 ல், வெவ்வேறு முறையான உடற்திறன் பயிற்சிகளை, ​ பக்கவாதம் ஏற்பட்ட பின் சோதனை செய்த, 2188 பங்கேற்பாளர்கள் சம்பந்தப்பட்ட 45 சோதனைகளை இந்த திறனாய்வு அடையாளம் கண்டது.

உடற்திறன் பயிற்சி ஆய்வுகளை செயல்படுத்தி நடத்துவது கடினமாக இருக்க முடியும். இது என்னவென்றால், பெரும்பாலான ஆய்வுகள் சிறியதாகவும் ​ மிதமான தரத்தையுடையதாகவும் ​இருந்தன என்பதாகும். எனினும், சில சீரான கண்டுபிடிப்புகள் வெளிவந்தன. சில உடற்திறன் பயிற்சி வகைகள், குறிப்பாக, நடைபயிற்சி சம்மந்தப்பட்டவை உடற்பயிற்சி செய்யும் ​ திறன் மற்றும் பக்கவாதத்திற்கு பிறகான நடை, மற்றும் உடல் சமநிலையை மேம்படுத்த முடியும் என்று நாங்கள் கண்டுபிடித்தோம். எனினும், வாழ்க்கைத் தரம் அல்லது மனநிலையின் மேல் உடற்திறன் பயிற்சியின் தாக்கம் பற்றி நம்பகமான முடிவுகளுக்கு வர போதுமான தகவல் இல்லை.

எந்தவொரு பல்வேறு வகையான உடற்திறன் பயிற்சிகளும் காயங்களையோ அல்லது மற்ற ஆரோக்கிய பிரச்சினைகளையோ ஏற்படுத்தியது என்பதற்கு எந்த ஆதாரமும் இல்லை; உடற்பயிற்சி ஒரு பாதுகாப்பான சிகிச்சை தலையீடாக தோன்றுகிறது.

மொழிபெயர்ப்பு குறிப்புகள்

மொழி பெயர்ப்பாளர்கள்: சிந்தியா ஸ்வர்ணலதா ஸ்ரீகேசவன், தங்கமணி ராமலிங்கம், ப்ளசிங்டா விஜய், ஸ்ரீகேசவன் சபாபதி.

Background

Physical activity and exercise recommendations exist for a wide range of healthy, older, and patient populations (Nelson 2007; O'Donovan 2010) including those with specific health problems such as stroke (Gordon 2004). Although exercise and physical activity are promoted positively the evidence is still incomplete.

What is physical fitness training?

Exercise refers to a subset of physical activity which is planned, structured, repetitive, and deliberately performed to train (improve) one or more components of physical fitness (USDHHS 2008). Since the term 'exercise' is used more generically within stroke care we will refer to exercise as 'physical fitness training'.

What is physical fitness?

Physical fitness describes a set of physiological attributes that a person has or achieves, which confer the ability to perform physical activities without undue fatigue. Activities can range from day-to-day tasks to leisure activities (USDHHS 2008). The most important components of physical fitness are those responsible for muscular work, as follows.

  1. Cardiorespiratory fitness is the ability to transport and use oxygen and is usually expressed as maximal oxygen uptake (VO2 max). Cardiorespiratory fitness confers 'endurance', that is the ability to perform physical activity for an extended period.

  2. Muscle strength refers to the ability of a specific muscle or muscle group to exert force. Strength is associated with the ability to perform forceful movements such as pushing or lifting.

  3. Muscle power refers to the rate at which muscular work can be performed during a single explosive contraction. Power is associated with the ability to carry out forceful movements, in particular those that are dynamic.

In addition, other components of fitness can influence the ability to perform physical activities, including flexibility (range of motion about a specific joint), balance (ability to maintain stability and posture), and body composition (for example relative amounts of fat and fat-free mass).

Determinants of fitness

Physical fitness is lower in women compared with men and it deteriorates due to increasing age (1% to 4% in one year) (Young 2001), physical inactivity (12% to 14% in 10 days) (Kortebein 2008), and other secondary consequences of chronic disease such as inflammation (Degens 2006).

Functional importance of fitness

When the level of fitness is low (regardless of the reason) physical activities may either become limited by fatigue or impossible to perform (Young 2001). Levels of fitness below a threshold needed to perform instrumental activities of daily living (ADL) may mean loss of independence, for example cardiorespiratory fitness (Shephard 2009) and muscle strength (Hasegawa 2008).

Description of the condition

A common neurological consequence of stroke is unilateral loss or limitation of muscle function; the direct consequence can be limitation or loss of movement, mobility, and functional ability. In addition, a whole range of indirect complications occur after stroke (Indredavik 2008; Langhorne 2000). Low levels of physical activity are therefore common soon after stroke (Bernhardt 2004; Bernhardt 2007). In community-dwelling stroke patients cardiorespiratory fitness ranges from 26% to 87% of the value expected in age and gender-matched healthy people (Smith 2012). Muscle strength (Gerrits 2009; Horstman 2008) and muscle power (Saunders 2008) are also impaired with bilateral deficits, which suggest the influence of physical inactivity. The level of post-stoke fitness may be low due to a range of factors directly and indirectly connected to stroke.

  1. Pre-stroke fitness levels may already be low since physical inactivity (Lee 2002) and low levels of fitness (Kurl 2003) are both risk factors for stroke. In addition, most stroke patients are elderly (more than 70 years of age) so levels of fitness will be low due to the effects of age (Malbut 2002) and the presence of comorbid diseases.

  2. Direct neurological effects of stroke reduce the muscle mass available for activation (e.g. hemiparesis).

  3. Post-stroke physical inactivity (for whatever reason) will cause a longitudinal loss of fitness alongside the effects of comorbid diseases and increasing age. Limitation or loss of functional abilities after stroke (e.g. walking, stair climbing, chair rising) are associated with low cardiorespiratory fitness levels, muscle strength, and muscle power (Flansbjer 2006; Patterson 2007; Saunders 2008).

Therefore, inactivity, which commonly occurs after stroke, may result in low levels of physical fitness. This may exacerbate or cause some common post-stroke physical limitations. Restoration of motor function in order to improve functional ability is a key focus within stroke rehabilitation and a number of interventions have been investigated that involve physical activities and physical fitness training (Langhorne 2009).  

Description of the intervention

Although the design of physical fitness training interventions varies across healthy people, older people, and patient groups, the structure and content remains guided by a common set of well-established principles (ACSM 1998).  

Type of training

Most physical fitness training programs are classified as either: (1) cardiorespiratory training (to improve cardiorespiratory fitness), (2) resistance training (to improve muscular strength and muscle power), or (3) mixed training, which combines cardiorespiratory and resistance training. With regard to other aspects of fitness, all types of training programme have the potential to influence body composition (increase lean mass and reduce adiposity) and some may also incorporate elements which improve flexibility (stretching exercises) and balance.  

Mode of training

The type of fitness training influences the mode(s) of exercise. For example, cardiorespiratory training commonly employs walking and cycling, whilst resistance training employs activities involving muscle contractions resisted by weights, body mass, or elastic devices.  

Dose of training

The dose of training is controlled by influencing: (1) the amount of training (for example programme length (weeks, months), frequency (days/week), and duration (minutes) of sessions), and (2) the intensity of training (amount of work or effort).  

It is the manipulation of type, mode, and dose which defines an exercise prescription; however, the effectiveness is also influenced by some other critically important principles of training (ACSM 1998) including progression of training, whether training is task-related (specific), and the fact that training effects are reversible if training is reduced or stopped.  

Physical fitness training is, therefore, very much a complex intervention with numerous component parts and this can give rise to variation in plausible benefits. 

How the intervention might work

Regular physical activity is currently recommended where possible to people of all ages, including those with disabilities, in order to promote and maintain health (Haskell 2007; USDHHS 2008). The dose-response relationship means additional benefits exist if physical fitness training is employed, in particular with regard to physical function. Physical fitness training interventions improve physical function in healthy elderly people (Chodzko-Zajko 2009). 

Post-stroke physical activity and fitness levels are low, and these low levels are associated with common post-stroke functional limitations. Increased fitness and physical function could benefit a range of other common post-stroke problems, for example by reducing fatigue, reducing the incidence of falls and fractures, compensating for the increased energetic cost of a hemiparetic gait, reducing disability and improving independence, and improving quality of life and mood.

Physical therapies are known to promote structural brain remodelling (Gauthier 2008) and this can influence post-stroke motor deficits. There is systematic review evidence that repetitive practice of some common day-to-day activities produces some modest improvements in mobility and ADL in stroke patients (French 2010). Therefore, participation in repetitive, task-related fitness training may have functional benefits even if fitness is not improved.

Engagement with group training activities may have some psychosocial benefits in people with stroke (Carin-Levy 2009; Mead 2005; Patterson 2009). Therefore, simply participating in physical fitness training may be beneficial, particularly where group activities are involved.

Physical fitness training is known to be beneficial for people with a number of conditions that are comorbid conditions or risk factors for stroke. Systematic review evidence shows that exercise interventions can reduce blood pressure (Cornelissen 2013), improve vascular risk factors in obesity (Shaw 2006) and type II diabetes (Thomas 2006), reduce mortality in coronary heart disease (CHD) patients (Heran 2011), and improve depressive symptoms in patients diagnosed with depression (Rimer 2012). Therefore, post-stroke cardiorespiratory training, in particular, could reduce morbidity and mortality through secondary prevention of stroke and comorbid disease.  

In summary, physical fitness training does not simply provide a mechanism to increase fitness, it has multiple mechanisms of action and has a spectrum of plausible benefits that are relevant to many people with stroke. However, there may also be risks, such as training-induced soft tissue injuries, altered muscle tone, falls, and vascular events. 

Why it is important to do this review

Physical fitness training for stroke survivors remains under-investigated in two key areas.

  • Firstly, the range of possible benefits is not fully explored. The top 10 most important research priorities for 'life after stroke' have recently been defined by a partnership of patients, carers, and clinicians; exercise interventions may have a beneficial role in at least five of the top 10 research priorities (Pollock 2012).

  • Secondly, although enough evidence is available to implement fitness training for stroke, the optimal exercise prescription has yet to be defined (Mead 2011).

There has been sustained interest in physical fitness interventions for stroke evidenced by the trials included in previous updates of this review: Saunders 2004a (12 trials), Saunders 2009 (24 trials), and Brazzelli 2011 (32 trials). The previous version of this Cochrane Review was the fourth most cited Cochrane systematic review about stroke and the seventh most accessed Cochrane review (2164 full-text accesses during 2011) about stroke as a whole (source: The Cochrane Library Impact Data Pack, 2011). Considering the degree of incomplete knowledge and the high level of interest we believe it is essential to continue updating this review.

Objectives

To determine whether fitness training after stroke reduces death, dependence, and disability. The secondary aims were to determine the effects of training on physical fitness, mobility, physical function, quality of life, mood, and incidence of adverse events.

Methods

Criteria for considering studies for this review

Types of studies

All trials described as randomised controlled trials (RCTs), single-blinded or open, that examined the effects of cardiorespiratory, resistance, or mixed training using any of the following six comparisons.

  • Cardiorespiratory training versus control: (1) at the end of intervention, (2) at the end of follow-up.

  • Resistance training versus control: (3) at the end of intervention, (4) at the end of follow-up.

  • Mixed training (cardiorespiratory plus resistance training) versus control: (5) at the end of intervention, (6) at the end of follow-up.

In this review 'end of intervention' refers to the time point when a training programme finishes; 'end of follow-up' refers to any time point occurring after the end of the intervention. Measures at the end of follow-up allow us to examine whether training effects (if any) are retained after training is completed.

We included studies in which controls were exposed to either physical activity occurring during usual care or no training after usual care. By 'no training' we meant either no intervention or a non-exercise intervention (for example cognitive tasks or sham training). Therefore, we deemed the following comparisons suitable for inclusion where 'usual care' refers to inpatient hospital care or other standard rehabilitation given to all stroke patients delivered as a normal part of stroke care in the region in which the trials were performed:

  • training plus usual care versus usual care (during usual care);

  • training versus no training (after usual care).

We included only full-text reports of published and unpublished trials. We did not include conference proceedings alone (that is abstract and poster presentations) because usually they provide only limited data and do not allow full assessment of study quality. We did not exclude trials on the basis of their sample size. We included studies published in languages other than English only when a translation could be arranged. Where investigators published several reports based on data from a single study population, we selected the most recent or most complete report for data extraction and we listed the other reports as duplicate publications.

Types of participants

Adult stroke survivors who were considered suitable for fitness training by the trials' authors. Participants were considered eligible irrespective of the time since stroke onset.

Types of interventions

We assessed the following interventions.

Cardiorespiratory training

The aim of this type of training is to improve the cardiorespiratory component of physical fitness. It is typically performed for extended periods of time on devices or ergometers (for example treadmill, cycling, rowing) or by utilising modes of activity such as walking or climbing stairs.

Resistance training

This type of training is performed primarily to improve muscle strength and muscular endurance or muscle power output, or both. It is typically carried out by making repeated muscle contractions resisted by body weight, elastic devices, masses, free weights or specialised machine weights, and isokinetic devices.

Mixed training

This describes training interventions that comprise different activity components, some intended to improve cardiorespiratory fitness and others to improve strength, power or muscular endurance; for example, a training programme comprising both cycling and weight training.

We only included trials that aimed at training stroke survivors. We defined 'training' as a systematic, progressive increase in the intensity or resistance, frequency, or duration of the physical activity throughout a scheduled programme. We categorised the 'dose' of the cardiorespiratory or resistance training components of a training programme as falling within or below the American College of Sports Medicine (ACSM) criteria for developing and maintaining fitness (ACSM 1998). We sought measures of adherence to training since this can modify the dose of training received by trial participants. For the purposes of this review, adherence included both: (1) attendance at training sessions, and (2) compliance with exercise instructions during training sessions.

We excluded trials that focused on different types of standard rehabilitation techniques but did not include a physical fitness component. We also excluded trials that combined fitness training with assistive technologies, such as robotic and electromechanical-assisted gait training devices during body weight-supported locomotor training, as well as trials investigating virtual reality approaches.

We excluded studies which compared upper and lower body training if an additional non-exercise control group was not considered.

If any description of a training regimen was unclear, we contacted the authors for further information.

Types of outcome measures

We anticipated that existing trials in the literature would use different measures to assess outcomes relevant to this review; in particular they would use a variety of rating scales. For each outcome of interest we tried, therefore, to list the most common and relevant measures or tools. We only included rating scales that had been described in peer-reviewed journals.

Primary outcomes
  1. Case fatality: numbers of deaths from all causes.

  2. Death or dependence: composite outcome where dependence is classified as having a Barthel Index score of less than 20 or modified Rankin Scale score of 3, 4, or 5 (Lindley 1994).

  3. Disability: assessed by functional scales such as the Functional Independence Measure (Hamilton 1994); Barthel Index (Collin 1988); Rivermead Mobility Index (Collen 1991); Functional Ambulation Category (Holden 1984); Nottingham Extended Activities of Daily Living Scale (Wade 1992); Lawton Index of Activities of Daily Living (Lawton 1969); and the Stroke Impact Scale (Duncan 1999).

Since the review protocol was originally written, the use of the International Classification of Functioning, Disability and Handicap (ICF) is becoming more widespread (WHO 2001). In the ICF classification the term 'disability' is an umbrella term for impairments and activity limitations. In this version of the review the primary outcome measure 'disability' refers to 'global indices of activity limitation'. Secondary outcome measures of mobility and physical function refer to 'specific activity limitations'.

Secondary outcomes
  • Adverse effects: recurrent non-fatal cardiovascular or cerebrovascular events; altered muscle tone; training-induced injury; incidence of falls; incidence of fractures.

  • Vascular risk factors: resting systolic and diastolic blood pressure; resting heart rate; total cholesterol.

  • Physical fitness: exercise heart rate and maximum or peak oxygen uptake (peak VO2); muscle strength and power output; body mass index (BMI).

  • Mobility: gait speed (maximum or preferred speed); gait capacity (e.g. six-minute walking test (6-MWT)).

  • Physical function: balance; stair climbing; weight bearing; 'timed up and go' test.

  • Health status and quality of life: any relevant scale such as the Short Form 36 Health Survey Questionnaire (http://www.sf-36.org) and the Nottingham Health Profile (Hunt 1980).

  • Mood: any relevant scale such as the Hospital Anxiety and Depression Scale (HADS) (Zigmond 1983); the Beck Depression Index (Beck 1961).

Search methods for identification of studies

See the 'Specialized register' section in the Cochrane Stroke Group module. We searched for trials in all languages and arranged translation of relevant papers published in languages other than English.

Electronic searches

We searched the Cochrane Stroke Group Trials Register, which was last searched by the Managing Editor in January 2013. In addition, we searched the following electronic bibliographic databases:

  • Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 12: searched January 2013) (Appendix 1);

  • MEDLINE (1966 to January 2013) in Ovid (Appendix 2);

  • EMBASE (1980 to January 2013) in Ovid (Appendix 3);

  • CINAHL (1982 to January 2013) in EBSCO (Appendix 4);

  • SPORTDiscus (1949 to January 2013) in EBSCO (Appendix 5).

We developed the search strategies for the electronic databases with the help of the Cochrane Stroke Group Trials Search Co-ordinator. The MEDLINE search strategy includes both MeSH controlled vocabulary (/) and free text terms (.tw.) for the relevant target condition (for example stroke, cerebrovascular diseases) and for specific interventions (for example fitness training, muscle strengthening, cycling, rowing, treadmill, circuit training). We limited the search to clinical trials and intervention studies carried out in humans. We did not apply any language restrictions. We adapted the MEDLINE search strategy, and accommodated differences in indexing and syntax, to search the other major electronic databases. We imported all citations identified by the electronic searches into a Reference Manager database and removed duplicate records.

We also searched the following electronic databases and websites using the terms 'stroke', 'exercise', and 'physical fitness' to identify additional relevant trials, ongoing trials, and thesis dissertations:

We performed citation tracking of all reports selected for inclusion using Google Scholar (http://scholar.google.co.uk/) (last searched June 2013).

Searching other resources

We scrutinised the proceedings of relevant stroke meetings listed on the Internet Stroke Centre's website (www.strokecenter.org/) including the European Stroke Conference (2000 to 2012), the International Stroke Conference (2000 to 2012), and the World Stroke Conference (2000 to 2012). Proceedings were used to identify ongoing studies and full publications that may have been missed in other searches. We did not consider potentially relevant completed studies for inclusion if they were available only as conference proceedings; instead we retained them as 'Studies Awaiting Classification'. We will consider these studies for inclusion in the next update of this review if a full publication has subsequently become available.

We handsearched relevant scientific journals that focus on exercise and physical fitness and are not currently included in the The Cochrane Collaboration handsearching programme:

  • Adapted Physical Activity Quarterly (1984 to January 2013);

  • British Journal of Sports Medicine (1974 to January 2013);

  • International Journal of Sports Medicine (1980 to January 2013);

  • Journal of Science and Medicine in Sport (1998 to January 2013);

  • Research Quarterly for Exercise and Sport (1985 to January 2013);

  • Sports Medicine (1984 to January 2013).

We examined the references lists of all relevant studies identified by the above methods and perused all relevant systematic reviews identified during the entire search process for further trials. We also checked all the references in both the studies awaiting classification and ongoing studies sections of the previous version of this review. We contacted experts in the field and principal investigators of relevant studies to enquire about unpublished and ongoing trials.

Data collection and analysis

Selection of studies

One review author (DS) read the titles and abstracts of all citations identified by the electronic searches and excluded obviously irrelevant reports. We retrieved the full text of the remaining papers and two review authors (DS and MS) independently assessed these and selected trials which met the pre-specified inclusion criteria. Any disagreements were resolved by discussion and if necessary in consultation with a third review author (GM or CG). One review author (DS) also screened the correspondence with experts and trial investigators for details of any additional published or unpublished trials.

Data extraction and management

Two review authors (MS and DS) independently extracted data from the selected studies. We recorded the following characteristics for each individual study.

  • Publication details: authors, year of publication, publication status (published, unpublished, or ongoing), citation of other relevant trials.

  • Details of study conduct: study design, method of recruitment, inclusion and exclusion criteria, number of participants enrolled, number of participants excluded, number of participants assessed, losses to follow-up, geographical location of the trial, setting in which the trial was conducted (e.g. hospital, community).

  • Characteristics of participants: total number, age, gender, stage of care, severity of stroke, time since stroke onset, co-morbidity, walking ability.

  • Details of intervention: total number of intervention groups, type of training (i.e. cardiorespiratory, resistance, or mixed), training mode (e.g. treadmill walking, weight training), dose (i.e. intensity, frequency of delivery), timing (i.e. during or after usual care), length of training (i.e. duration and programme length), adherence to intervention (i.e. attendance, compliance).

  • Details of outcome measures: choice of outcomes (i.e. death, dependence, disability, physical fitness measures, gait assessment, physical function measures, health status and quality of life, mood, adverse events, risk factors), outcome data, reported outcomes, missing outcomes.

We classified all outcome data as being from time points at either: (1) the end of intervention, or (2) the end of follow-up (that was defined as any period of time after the training intervention was completed). We resolved any disagreement by consensus or arbitration.

Assessment of risk of bias in included studies

Two review authors (MS and DS) assessed the risk of bias for the following items, as described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We included one extra item 'confounded by increased training time' where we recorded trials that did not include a balanced exposure to an attention control as being at 'high risk' of exaggerating effects.

  • Random sequence generation

  • Allocation concealment

  • Blinding of participants *

  • Blinding of outcome assessment

  • Incomplete outcome data

  • Selective reporting

  • Other bias

  • Confounded by increased training time

* For trials of physical interventions like exercise it is not possible to blind participants or those delivering interventions. However, some trials may incorporate a degree of blinding if the control group participates in an attention control intervention that allows the investigators to disguise the exact purpose of the two interventions; the trial could be described simply as a 'comparison of two interventions'.

Data synthesis

We carried out statistical analysis using RevMan 5.2 (RevMan 2012). We calculated a summary statistic for each outcome measure to describe the observed treatment effect. All summary statistics reported in this review refer to effects at either: (1) the end of intervention, or (2) the end of follow-up. We qualitatively assessed whether clinical heterogeneity was present among included studies and we combined studies in a meta-analysis only when we judged them reasonably homogeneous in terms of participants, interventions, and outcomes.

Continuous and dichotomous data

The data required for meta-analyses of continuous data in RevMan 2012 were mean and standard deviation (SD). When collecting continuous data we took some precautions to check whether standard error (SE) was mistakenly reported as SD. We used SE or 95% confidence interval (CI) to compute SD when missing. The included studies presented results of continuous data either as mean and SD of change from baseline for each intervention group or mean and SD of final measurement values, or both. We extracted change from baseline scores instead of final measurement values when possible. In our analyses we combined final measurement values with change from baselines scores using the mean difference (MD) method as we assumed that MDs based on changes from baseline scores addressed the same underlying treatment effects as MDs based on final measurements.

The data required for meta-analyses of dichotomous data in RevMan 2012 were number of events in each intervention group and total number of participants in each intervention group.

In the case of missing outcome data, we attempted to analyse data according to the intention-to-treat (ITT) approach. When individual patient data were available we used the 'last observation carried forward' (LOCF) approach (that is the most recently reported outcome was assumed to hold for all subsequent outcome assessments).

Measures of effect

For continuous data we calculated mean differences with 95% CIs if the studies used the same instrument to measure the same outcome (for example disability). However, if studies used a variety of instruments (for example rating scales), we calculated the standardised mean difference (SMD) with 95% CI.

For dichotomous data we calculated odds ratios (OR) with 95% CIs.

We assessed statistical homogeneity between trial results by means of the Chi2 test for heterogeneity, which is included in the forest plots in RevMan 5. Because the Chi2 test has notoriously low power in meta-analyses when studies have small sample size, or when the number of events is small, we decided: (1) to set the significance level at 0.10 rather than at the conventional level of 0.05, and (2) to analyse data using a random-effects model (a fixed-effect model would have given the same quantitative conclusions but with narrower CI).

To quantify inconsistency across studies we used the I2 statistic, which is included in the meta-analysis graphs in RevMan 5.

Where possible, we investigated publication bias by entering data from studies included in the relevant meta-analyses in funnel plots (treatment effect versus trial size).

Subgroup analysis and investigation of heterogeneity

When sufficient data were available, we planned to investigate heterogeneity between included studies (both clinical and statistical) by means of subgroup analyses. We attempted to compare effect estimates in the following main subgroups:

  • type of training (cardiorespiratory versus resistance training versus mixed training);

  • time of training (during usual care versus after usual care).

The complexity of exercise interventions and low numbers of studies in the meta-analyses mean that subgroup analyses are difficult to perform and difficult to interpret. We explored the following planned subgroups instead, where possible, using a sensitivity analysis approach:

  • training programs that met the ACSM guidelines (ACSM 1998) versus those that did not;

  • type of control interventions (no intervention versus non-exercise intervention versus other intervention);

  • duration of training (less than 12 weeks versus 12 weeks or more);

  • severity of stroke (mild symptoms versus severe symptoms).

Sensitivity analysis

When sufficient data were available we planned to explore the influence of some study characteristics by means of sensitivity analyses. We considered the effect of excluding studies in which the comparisons were confounded by increased training time and explored some of the factors originally intended for subgroup analyses.

Results

Description of studies

Results of the search

The previous version of this review (Brazzelli 2011) included 32 trials (total 1414 participants). In this updated version we repeated the previous electronic searches and other relevant searches (for example handsearching, screening of conference proceedings and relevant websites) in 2013. After removal of duplicates, we screened a total of 7508 citations. We identified 13 systematic reviews of exercise interventions and screened them for relevant trials (An 2011; Brogardh 2012; Chen 2011; English 2010; French 2010; Hancock 2012; Mehrholz 2011; Mehta 2012; Mehta 2012a; Meng 2012; States 2009; Timmermans 2010; van het Hoofd 2011).

The results of our searching activities are summarised in the study flow diagram (Figure 1). We identified and applied the inclusion criteria to a total of 75 potentially relevant new trials.

Figure 1.

Study flow diagram for the current update of this review.

Overall, the 17 potentially relevant studies in the Characteristics of studies awaiting classification table contain little new primary outcome data and few quality of life measures outcomes. The physical outcomes, including mobility, are unlikely to influence the existing pattern of findings in the review.

Included studies

The 13 new included studies bring the total number of studies in this review to 45 trials. Two trials are dissertations (Cuviello-Palmer 1988; James 2002) and 14 trials have secondary publications (Cooke 2010; da Cunha 2002; Donaldson 2009; Duncan 2003; Eich 2004; Flansbjer 2008; Katz-Leurer 2003; Langhammer 2007; Mead 2007; Salbach 2004; Sims 2009; Richards 1993; Teixeira 1999; Winstein 2004).

Participants
Characteristics

A total of 2188 stroke survivors (range 13 to 250 individuals, mean 44.5, median 42) were randomised to physical fitness training or control interventions in the 45 included clinical trials. The mean age of the patients was approximately 64 years. The mean time since onset of symptoms ranged from 8.8 days in trials assessing participants before discharge from hospital (Richards 1993) to 7.7 years in trials assessing participants after hospital discharge (Teixeira 1999).

One trial recruited non-ambulatory stroke survivors (Richards 1993), three trials recruited both ambulatory and non-ambulatory participants (Bateman 2001; Cooke 2010; Lennon 2008), two trials did not report this information (Donaldson 2009; Winstein 2004), and all the remaining trials recruited ambulatory stroke survivors.

Sample size

Of the 45 included trials:

Interventions
Cardiorespiratory training

Twenty-two trials with a total of 995 randomised participants (range 15 to 92 individuals) examined cardiorespiratory training (Ada 2013; Aidar 2007; Bateman 2001; Cuviello-Palmer 1988; da Cunha 2002; Eich 2004; Glasser 1986; Globas 2012; Ivey 2010; Ivey 2011; Kang 2012; Katz-Leurer 2003; Kuys 2011; Lennon 2008; Moore 2010; Mudge 2009; Park 2011; Pohl 2002; Potempa 1995; Salbach 2004; Smith 2008; Takami 2010). Details of the cardiorespiratory interventions are summarised in Table 1. Two of these trials assessed circuit training (Mudge 2009; Salbach 2004), one trial assessed aquatic training (Aidar 2007), four trials assessed cycle ergometry (Bateman 2001; Katz-Leurer 2003; Lennon 2008; Potempa 1995), and two assessed a 'Kinetron' ergometer (Cuviello-Palmer 1988; Glasser 1986). The majority of trials focused on walking using treadmills (da Cunha 2002; Eich 2004; Globas 2012; Ivey 2010; Ivey 2011; Kang 2012; Kuys 2011; Moore 2010; Pohl 2002; Smith 2008; Takami 2010), overground walking (Park 2011), or a combination of treadmill and overground walking (Ada 2013). The training programs comprised regular weekly sessions of sufficient duration (usually greater than 20 minutes) but the exercise intensity was described in only 10 of the included trials. In 12 trials (515 participants in total) the cardiorespiratory training started after usual care, while in 10 trials (480 participants in total) it started during usual care. In three of these trials participants were recruited in the acute phase of stroke, less than one month post-stroke (Cuviello-Palmer 1988; da Cunha 2002; Takami 2010).

Table 1. Outline of the studies which focused on cardiorespiratory training interventions
  1. ACSM: American College of Sports Medicine
    min: minute(s)

Study IDMode of trainingDuring or after usual careUpper or lower bodySpecific trainingIntensityDuration (minutes)

Frequency

(days)

Programme length (weeks)ACSM criteria met
Aidar 2007Water trainingAfterBothYesUnknown45 to 60212Unknown
Lennon 2008Cycle ergometer (cardiac rehabilitation programme)AfterBothNo50% to 60% maximum heart rate30210Yes
Moore 2010Treadmill gait training with overhead harnessAfterLower bodyYes80 to 85 age-predicted maximum heart rateUnknown2 to 54Yes
Mudge 2009Circuit trainingAfterLower bodyYesUnknown3034Unknown
Smith 2008Treadmill gait trainingAfterLower bodyYesRate perceived exertion ≤ 132034Yes
Glasser 1986KinetronDuringLower bodyNoUnknown20 to 6053Unknown
Cuviello-Palmer 1988KinetronDuringLower bodyNoHeart rate < resting + 20 beats/minute7 to 1753No
da Cunha 2002Treadmill gait training with body weight support (BWS)DuringLower bodyYesUnknown2052 to 3Unknown
Pohl 2002

Treadmill gait training

Group (1) STT (structured speed-dependent treadmill training)

Group (2) LTT (limited progressive treadmill training group)

DuringLower bodyYesUnknown3034Unknown
Eich 2004Treadmill gait trainingDuringLower bodyYes60% heart rate reserve3056Yes
Bateman 2001Cycle ergometerDuringLower bodyNo60% to 80% age-related heart rate maximum≤ 30312Yes
Katz-Leurer 2003Cycle ergometerAfterLower bodyNo≤ 60% heart rate reserve20 then 305 then 32 then 6
(total 8)
Yes
Potempa 1995Cycle ergometerAfterLower bodyNo30% to 50%
maximum effort
30310Yes
Salbach 2004Circuit trainingAfterLower bodyYesUnknown5536Unknown
Ada 2013Treadmill + overground walkingAfterLower bodyYesUnknown30min3

Group 1 = 16

Group 2 = 8

Unknown
Globas 2012TreadmillAfterLower bodyYes40% to 50% progressing to 60% to 80% heart rate reserve10 to 20 min increasing to 30 to 50 min312Yes
Ivey 2010TreadmillAfterLower bodyYes40% to 50% progressing to 60% to 70% heart rate reserve10 to 20 min increasing to 40 min3

24

(6 months)

Yes
Ivey 2011TreadmillAfterLower bodyYes40% to 50% progressing to 60% to 70% heart rate reserve10 to 20 min increasing to 40 min3

24

(6 months)

Yes
Kang 2012TreadmillAfterLower bodyYesUnknown3034Unknown
Kuys 2011TreadmillAfterLower bodyYes40% progressing to 60% heart rate reserve3036Yes
Park 2011Overground community-based walkingDuringLowerYesUnknown6034Unknown
Takami 2010

Treadmill gait training with body weight support (BWS)

Group (1) Backward walking group

Group (2) Forward walking group

DuringLower bodyYesUnknown1063Unknown

Three of the included cardiorespiratory training trials had more than one intervention group that met the eligibility criteria; these compare two different durations, intensities and modes of training. Each of these studies therefore has two entries when included in any meta-analyses, each sharing 50% of the number of participants in the single control group from each trial.

  • Ada 2013: Group 1 - duration four months training; Group 2 - duration two months training.

  • Pohl 2002: Group 1 - intensity high due to rapid progression; Group 2 - intensity lower due to limited progression.

  • Takami 2010: Group 1 - mode: backward walking on treadmill; Group 2 - mode: forward walking on treadmill.

Resistance training

Eight trials with a total of 275 randomised participants (range 18 to 54 individuals) assessed the effects of resistance training (Aidar 2012; Bale 2008; Flansbjer 2008; Inaba 1973; Kim 2001; Ouellette 2004; Sims 2009; Winstein 2004) (details of these trials are summarised in Table 2). All employed muscle contractions resisted by weights, exercise machines, or elastic devices. Five trials limited strength training to the lower limbs, one trial to the upper limbs (Winstein 2004), and two trials trained both the upper and lower limbs (Aidar 2012; Sims 2009). The training met or nearly met the ACSM 1998 criteria for strength training in five trials. Most programs were short (less than 12 weeks) apart from Aidar 2012 and Ouellette 2004 (12 weeks). In five trials resistance training started after usual care (Aidar 2012; Flansbjer 2008; Kim 2001; Ouellette 2004; Sims 2009), whilst in three trials it started during usual care (Bale 2008; Inaba 1973; Winstein 2004). In Winstein 2004 participants were recruited during the acute phase of stroke (less than one month post-onset).

Table 2. Outline of the studies which focused on resistance training interventions
  1. ACSM: American College of Sports Medicine

Study IDMode of trainingDuring/after usual careUpper or lower bodySpecific trainingIntensityDuration (minutes)Frequency (days)Programme length (weeks)ACSM criteria
Bale 2008Resistance training; weightsDuringLower bodyNo10 to 15 repetitions to achieve moderate fatigue5034Yes
Flansbjer 2008Dynamic and isokinetic resistance training (leg extension/curl rehab exercise machine)AfterLower bodyYes6 to 10 repetitions equivalent to 80% of maximum load90Unknown10Unclear (criteria nearly met)
Sims 2009Resistance training; machine weightsAfterBothYes3 x 8/10 repetitions at 80% one repetition maximumUnknown210Unclear (criteria nearly met)
Inaba 1973Resistance trainingDuringLower bodyNo50% and 100%
maximum weight
Unknown'Daily'4 to 8Yes
Winstein 2004Resistance training; weights;
Thera-band and grip devices
DuringUpper bodyNoUnknown603 high
2 slow
4 to 6 (target of 20 sessions)Unknown
Kim 2001Resistance training; isokinetic dynamometerAfterLower bodyNoMaximal effort
3 x 10 repetitions
3036Yes
Ouellette 2004Resistance training; weights and pneumatic resistance machinesAfterLower bodyNo70% one repetition maximum:
3 x 8 to 10 repetitions
Not applicable312Unclear (criteria nearly met)
Aidar 2012Resistance training; machine weightsAfterBothNoOMNI Resistance Exercise Scale45 to 60312Unclear
Mixed training

Fifteen trials with a total of 918 randomised participants (range 13 to 250 individuals) assessed the effects of mixed training (Cooke 2010; Donaldson 2009; Duncan 1998; Duncan 2003; Galvin 2011; James 2002; Langhammer 2007; Mead 2007; Richards 1993; Richards 2004; Teixeira 1999; Toledano-Zarhi 2011; van de Port 2012; Yang 2006; Zedlitz 2012) (details of these trials are summarised in Table 3). The mode of exercise was rather diverse (for example circuit training, walking or treadmill training, and resistance training). Eight trials focused on the training of the lower limbs, one trial on the training of the upper limbs, and six trials on the training of both the lower and the upper limbs. All interventions contained one or more functionally relevant activities (such as walking). Intensity of exercise was reported sufficiently to classify the cardiorespiratory component of three trials (James 2002; Langhammer 2007; Teixeira 1999) and the strength component of five trials (Duncan 1998; Duncan 2003; Langhammer 2007; Teixeira 1999; possibly Toledano-Zarhi 2011) as satisfying the ACSM 1998 criteria. In the majority of trials the duration of the intervention programme was less than 12 weeks. In eight trials training started after completion of usual care, whilst in four trials it started during usual care. Three trials recruited participants in the acute phase of stroke, less than one month post-onset (Galvin 2011; Richards 1993; Toledano-Zarhi 2011).

Table 3. Outline of the studies which focused on mixed training interventions
  1. ACSM: American College of Sports Medicine

Study IDMode of trainingDuring or after usual careUpper or lower bodySpecific trainingIntensityDuration (minutes)Frequency (days)Programme length (weeks)ACSM criteria
Cooke 2010Resistance training plus treadmill trainingDuringLower bodyYesUnknown6046Unknown
Donaldson 2009Paretic upper limb exercises and hand grip activitiesDuringUpper bodyYesUnknown6046Unknown
Langhammer 2007Walking, stationary bicycling, stair walking, treadmill, and resistance trainingAfterBothYes70% to 80% maximum pulse (cardiorespiratory component); 50% to 60% one repetition maximum (strength component)452/3Unclear. Minimum 20 hours every third month in the first year after strokeYes
Richards 1993Treadmill plus Kinetron plus tilt tableDuringLower bodyYesUnknown10455Unknown
Richards 2004Treadmill plus Kinetron plus limb load monitorDuringLower bodyYesUnknown6058Unknown
Duncan 1998Walking or cycle ergometry; elastic-resisted contractionsAfterBothYesUnknown90312

Cardio: no

Strength: yes

Teixeira 1999Walking and stepping or cycle ergometry;
resistance training body mass, weights, and elastic
AfterLower bodyYes50% to 70% maximum work rate (cardiorespiratory component) 50% to 80% one repetition maximum, 3 x 10 repetitions (strength component)60 to 90310

Cardio: yes

Strength: yes

Duncan 2003Circuit trainingAfterLower bodyYes50% to 60% heart rate reserve90 to 12034

Cardio: yes

Strength: unclear

James 2002Circuit trainingAfterBothYesUnknown90312 to 14 (total of 36 sessions)

Cardio: no

Strength: yes

Yang 2006Functional stepping and chair risingAfterLower bodyYesUnknown3034No
Mead 2007Circuit including walking, stepping, cycle ergometry; resistance training body mass, weights, and elasticAfterBothYesRating of perceived exertion: 13 to 1640 to 75312 to 14 (total of 36 sessions)Unknown
Galvin 2011Family mediated gait and strength trainingDuringLowerYesUnknown3578Unknown
Toledano-Zarhi 2011Treadmill, hand bike, cycle ergometer plus group exercise for strength, balance and co-ordination exerciseDuringBothYes (treadmill)Cardiorespiratory 50% to 70% of maximal heart rate

Cardiorespiratory 90 min

Group 45 to 55 min

Cardiorespiratory 2/wk

Group 1/wk

6

Cardio: yes

Strength: unknown

van de Port 2012Task-oriented circuit training. 8 workstations targeting balance, stair walking, turning, transfers, and speed walkingAfterLowerYes (task-oriented)Unknown90212Unknown
Zedlitz 2012Treadmill walking, strength training, and home exercise assignmentsAfterBothYes (walking)Cardiorespiratory and strength progressed from 40% to 70%120212

Cardio: yes

Strength: unknown

Adherence to training interventions

Adherence to the interventions was defined in terms of: (1) attendance at the planned training sessions, and (2) compliance with the planned content of the training sessions.

Attendance

Rate of attendance (%) could be clearly determined in 24 of the 45 included trials (Ada 2013; Aidar 2012; Bateman 2001; Duncan 1998; Duncan 2003; Eich 2004; Flansbjer 2008; Globas 2012; Kuys 2011; Langhammer 2007; Mead 2007; Mudge 2009; Park 2011; Ouellette 2004; Pohl 2002; Richards 1993; Richards 2004; Salbach 2004; Sims 2009; Toledano-Zarhi 2011; van de Port 2012; Winstein 2004; Yang 2006; Zedlitz 2012). The proportion of attended training sessions ranged from 65% up to 100%. Five trials measured attendance for the training and the control groups separately and showed similar rates between groups (Bateman 2001; Langhammer 2007; Mead 2007; Ouellette 2004; Salbach 2004). A few other trials described attempts to facilitate attendance and make up missed sessions, or reported that "attendance did not differ between intervention groups" but did not provide attendance rates (Bale 2008; Cooke 2010; Teixeira 1999). One trial specifically excluded those participants who attended fewer than nine training sessions from the statistical analyses (thus preventing an intention-to-treat assessment of results) (da Cunha 2002).

Compliance

Compliance with the scheduled exercise programme during training sessions was described in few trials. For cardiorespiratory training interventions, Langhammer 2007 stated that the compliance with the individualised training levels was 'high', Pohl 2002 and Globas 2012 reported that participants 'tolerated' training, and Salbach 2004 maintained that most of the participants completed nine out of 10 circuit training exercises. For mixed training, Duncan 1998 reported 'good compliance' with home-based training and Yang 2006 stated that mixed circuit training was 'performed as planned'. Mead 2007 reported 94% to 99% compliance with circuit training exercises 'tailored' to individual requirements. Information on compliance was not available for the remaining trials. Zedlitz 2012 described the compliance of participants with training as 'good'; they also examined the compliance of therapists in delivering the content of the planned protocol (more than 98%).

Comparisons

Training interventions were compared with control interventions in different ways in the included studies. We identified seven different types of comparison, which has implications for establishing the effects of fitness training.

  • Training plus a proportion of usual care versus usual care (eight out of 45 trials).

  • Training plus usual care versus usual care (nine out of 45 trials).

  • Training plus usual care versus non-exercise intervention plus usual care (two out of 45 trials).

  • Training versus non-exercise intervention - after usual care (nine out of 45 trials).

  • Training plus non-exercise intervention versus non-exercise intervention - after usual care (three out of 45 trials).

  • Training versus no intervention - after usual care (nine out of 45 trials).

  • Training versus usual outpatient care (six out of 45 trials).

The nature of some of these comparisons allows intervention and control groups to be comparable in terms of exposure time (both groups are exposed to an intervention, the frequency and duration of which is similar between groups) and the 'attention' received by the therapists. Therefore, these comparisons allow one to separate the specific effects of fitness training from those of usual rehabilitation interventions.

Other comparisons make it impossible to have a comparable intervention and control group exposure time (for example the 'training versus no intervention' comparison). We will describe these comparisons in the review as 'confounded by additional training time'. With regard to interventions involving physical exercise, a greater exposure to the intervention has a known effect on rehabilitation outcomes ('augmented therapy time') (Kwakkel 2004). Therefore, although these comparisons allow comment on the overall effect of training programs, they make it difficult to attribute any benefits to the content of the exercise prescription itself.

Outcome measures

Outcome measures were recorded at the end of the training period (end of intervention), or at any other defined point either within the trial duration or after completion of the training programme, or both (scheduled end of follow-up).

A variety of outcome measures were used in the included studies but few trials shared the same outcome measures. This limited the opportunity to combine outcome measures in the meta-analyses.

Some outcome measures involved continuous data (for example assessment scales) with skewed distributions. Due to time and resources constraints we did not attempt to transform these data (Higgins 2008). We therefore combined continuous skewed data and continuous normal-distributed data.

Excluded studies

The most common reasons for exclusion were: a controlled trial in which the intervention did not meet the criteria for fitness training or did not include a suitable comparison, or a confounding of training with another active physical intervention.

Risk of bias in included studies

Details and justifications for 'Risk of bias' assessments in individual studies are shown in the Characteristics of included studies table. As this is a complicated review we decided to apply the 'Risk of bias' assessments to 'all outcomes' for simplicity apart from incomplete outcome data, for which bias was assessed at (1) the end of the intervention, and (2) the end of follow-up. We present 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.

Figure 3.

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Allocation

Randomisation

We assessed less than half (20/45, 44%) of the included studies as having a low risk of selection bias. All studies did identify that randomisation had occurred but many did not describe the actual mechanism of how this was achieved. Therefore, uncertainties remain among a number of trials. Most trials of fitness training are small; therefore, the use of techniques to balance participant numbers (e.g. block randomisation) and participant characteristics (e.g. stratification or minimisation based on age, gender, or outcomes of interest recorded at baseline) is quite common.

Allocation concealment

Mechanisms of allocation concealment were poorly reported in nine of the included trials (20%). There are instances when centralised assignment mechanisms are used where allocation concealment is automatic (e.g. Mead 2007) in which case the risk of bias is rated as low. In other trials where allocation concealment mechanisms are needed envelopes were frequently used. Numbered, sealed, opaque envelopes (e.g. Cooke 2010; Donaldson 2009) are appropriate. However, many trials reporting the use of 'sealed envelopes' did not specify whether they were sequentially numbered or opaque therefore we were unable to exclude potential selection bias with certainty.

Blinding

Participant blinding

Participants cannot be blinded to physical interventions like fitness training and in most circumstances (43 of the 45 trials (96%)) the risk of bias is automatically 'high'. However, some trials utilised an attention control where the trialists attempted to blind participants to the 'true nature' of the comparison. In two trials, the participants were informed that they would receive one of two different, potentially beneficial interventions (Kim 2001; Mead 2007) without being given information on the types of interventions. Similarly, in another trial (Donaldson 2009) participants allocated to the experimental group were advised that they were to be offered extra therapy but were not told which type of therapy. In these three instances we reported the judgement on risk of bias as 'unclear'.

Investigator blinding

We considered the outcome assessment to be at low risk of detection bias in 19 of the included trials (42%). Among trials that used blinded outcome assessment some instructed participants not to reveal group assignments (Bateman 2001; Duncan 2003; Flansbjer 2008; Mead 2007). However, some degree of unmasking can easily occur and was documented in some trials (e.g. Eich 2004; Mudge 2009; Salbach 2004). Outcome assessment was not blinded in six trials (Galvin 2011; Globas 2012; Ivey 2010; Moore 2010; Smith 2008; Winstein 2004).

Incomplete outcome data

Intention-to-treat (ITT) analysis

Twenty-one trials reported the use of an ITT approach for their analyses although one of these trials (Bateman 2001) did not analyse data for the participants who dropped out. In the previous version of this review (Brazzelli 2011) we included sensitivity analyses examining the effect of imputing sometimes large numbers of missing values in data obtained from Bateman 2001; this did not influence any of the findings, therefore only the imputed data are included in this review for simplicity.

Of the 24 trials that did not mention ITT, 15 did not have any missing data (Aidar 2012; Bale 2008; Cuviello-Palmer 1988; Glasser 1986; Ivey 2010; Ivey 2011; Kang 2012; Kim 2001; Moore 2010; Park 2011; Potempa 1995; Smith 2008; Takami 2010; Teixeira 1999; Yang 2006).

Incomplete outcome data

Incomplete outcome data arose from participant attrition meaning all outcomes were affected. At the end of intervention 38 included studies reported an attrition rate of 10% or less. Five trials reported an attrition rate between 10% and 20% (Aidar 2012; da Cunha 2002; Langhammer 2007; Richards 1993; Zedlitz 2012). Two trials exceeded an attrition rate of 20% (Ivey 2010 (25%) and Ivey 2011 (51%)).

At the end of follow-up the attrition rate increased for 11 of the 20 trials that followed participants after completion of the intervention (Bateman 2001; Cooke 2010; Donaldson 2009; Duncan 2003; Galvin 2011; Katz-Leurer 2003; Kuys 2011; Mudge 2009; Richards 2004; Winstein 2004; Zedlitz 2012) and ranged from 14% to 40%. Overall, the proportion of withdrawals was similar for the intervention and control groups. The bias assessment could not be applied when no end of follow-up measurement was included in trial designs. Therefore, some blank spaces occur in Figure 2.

Overall, we judged 33 trials (73%) trials as being at low risk of attrition bias at the end of intervention and seven of 20 trials at the end of follow-up (35%).

Selective reporting

The majority of studies, particularly the older trials, do not have readily available protocols. In most cases, where these were available, there was no evidence of selective reporting of outcomes relevant to this review.

Other potential sources of bias

Most of the included trials recruited participants during hospital or community stroke care. In a few trials, however, participants' recruitment involved media advertisements (Ouellette 2004; Teixeira 1999) or databases of potential volunteers (Kim 2001; Lennon 2008; Mudge 2009; Sims 2009; Yang 2006). These methods of recruitment render these trials more prone to self selection bias and hamper the generalisability of their findings.

Confounded by additional training time (imbalanced exposure)

Trials in which the participants received an unequal amount of exposure to the intervention and comparison arms of the trial are judged to be at high risk of bias. Technically this could be described as a source of confounding rather than bias but it is appropriate to record it here. The design of more than half of the trials in this review mean that in 23 trials (51%) the effects of fitness training could be exaggerated because the training intervention groups received greater time of exposure irrespective of the content of the training programme.

Effects of interventions

Effect of training on primary outcome measures

Case fatality
Cardiorespiratory training (Comparisons 1 and 2)
End of intervention

None of the 22 trials of cardiorespiratory training (1020 participants) reported death as a reason for participant losses (Analysis 1.1). Three of the 22 trials in this analysis did report dropouts but could either not contact participants (Kuys 2011: n = 1) or did not fully describe reasons for dropouts (Bateman 2001; Ivey 2011).

End of follow-up

One out of five trials (Katz-Leurer 2003) (304 participants) reported that one participant died in the cardiorespiratory training group (1/46) compared with one participant in the control group (1/46) (Analysis 2.1).

Resistance training (Comparisons 3 and 4)
End of intervention

None of the eight trials (274 participants) reported deaths (Analysis 3.1), although one had a large number of undocumented dropouts (Inaba 1973).

End of follow-up

None of the three trials (138 participants) reported deaths (Analysis 4.1), although one had a large number of undocumented dropouts (Inaba 1973).

Mixed training (Comparisons 5 and 6)
End of intervention

Two of the 15 trials (918 participants) reported nine deaths between the baseline and the end of intervention assessments of Langhammer 2007 (6/35 control, 1/32 training) and van de Port 2012 (2/124 control, 0/126 training). Odds of death from all causes whilst participating in mixed training showed a weak tendency favouring training (odds ratio (OR) 0.18, 95% confidence interval (CI) 0.03 to 1.03; P = 0.05; Analysis 5.1). However, in the Langhammer 2007 trial, three of the six deaths in the control and the one death in the training group occurred before discharge and before the intervention began; after excluding these data, the odds of dying was OR 0.19, 95% CI 0.01 to 4.08 (P = 0.29). The other 13 trials reported no deaths. However, two trials described undocumented losses: Richards 1993 (two control) and Richards 2004 (five training, seven control) mentioning only that some participants were not available.

End of follow-up

Four of the 11 trials (762 participants) reported a total of nine deaths (Cooke 2010; Duncan 2003; Galvin 2011; van de Port 2012). These data are cumulative and include both those occurring in the follow-up period along with those deaths occurring before the end of intervention (van de Port 2012: n = 2). Odds of death from all causes at the end of the follow-up period showed a tendency favouring the mixed training although this only approaches borderline significance (OR 0.27, 95% CI 0.06 to 1.11; P = 0.07; Analysis 6.1). The other seven mixed trials reported that no losses to follow-up were attributable to death apart from Richards 1993 (two control), Richards 2004 (five training, seven control), and Zedlitz 2012 (four control), which describe only that some participants were lost or not available for follow-up.

Death or dependence

The composite outcome of death or dependence was not reported by any trial.

Disability
Cardiorespiratory training (Comparisons 1 and 2)
End of intervention

The Functional Independence Measure (FIM) was assessed by three trials during usual care (Bateman 2001) and after usual care (Cuviello-Palmer 1988; Katz-Leurer 2003). Overall, there was no effect of training (standardised mean difference (SMD) 0.21, 95% CI -0.10 to 0.52; P = 0.18; Analysis 1.2). However, the Bateman 2001 data are problematic because the procedures for obtaining FIM data at the end of intervention were not uniform and there was a high proportion of missing FIM data at the end of intervention (38%); exclusion of this trial does not change the result (SMD 0.17, 95% CI -0.29 to 0.63; P = 0.46).

Rivermead Mobility Index (RMI) scores were assessed by three trials during usual care (Bateman 2001; Takami 2010) and after usual care (Globas 2012). There was a small overall improvement in scores (mean difference (MD) 1.56, 95% CI 0.20 to 2.92; P = 0.02; Analysis 1.3). If the problematic data of Bateman 2001 are excluded the effect is strengthened (MD 2.18, 95% CI 0.99 to 3.37; P = 0.0003).

Physical Activity and Disability scale scores were reported by Mudge 2009. Overall, there was no effect (MD 16.90, 95% CI -15.15 to 48.95; P = 0.3; Analysis 1.4).

If all the disability scale data from these individual outcomes are combined (using FIM data from Bateman 2001) there is a significant overall effect in favour of cardiorespiratory training (SMD 0.37, 95% CI 0.10 to 0.64; P = 0.007; Analysis 1.5). If the analysis is repeated using RMI data from Bateman 2001 instead of FIM, an overall effect is still evident (SMD 0.33, 95% CI 0.04 to 0.62; P = 0.03).

End of follow-up

RMI scores were assessed by Bateman 2001; there was no effect at the end of follow-up (Analysis 2.2).

Nottingham Extended ADL was assessed by Bateman 2001 at the end of follow-up (Analysis 2.3). Although no effect was shown the considerable proportion of missing data (21%) means that the analysis should be treated with caution.

Physical Activity and Disability scale scores were reported by Mudge 2009. There was no effect at the end of follow-up (MD 19.90, 95% CI -17.58 to 57.38; P = 0.3; Analysis 2.4).

The Frenchay Activities Index (FAI) was reported by Katz-Leurer 2003. There was no effect at the end of follow-up (MD 1.00, 95% CI -1.55 to 3.55; P = 0.44; Analysis 2.5).

If all the disability scale data from these individual outcomes are combined (Nottingham Extended ADL data from Bateman 2001) there is no effect of cardiorespiratory training at the end of follow-up (SMD 0.20, 95% CI -0.07 to 0.46; P = 0.14; Analysis 2.6). If the analysis is repeated using RMI data from Bateman 2001 instead of Nottingham Extended ADL data there is still no effect.

Resistance training (Comparisons 3 and 4)

Ouellette 2004 assessed participants' functional abilities and disability outcomes by means of the Late Life Function and Disability Instrument (LLFD). This scale, however, has not been validated in stroke survivors and we have not included it in the analyses. The remaining trials either did not measure disability outcomes or used sub-scales or specific dimensions of existing functional scales (Inaba 1973; Winstein 2004), which we did not deem suitable for inclusion.

Mixed training (Comparisons 5 and 6)
End of intervention

Six trials assessed the effects of mixed training at the end of the treatment phase or at follow-up using a variety of scales which measured disability outcomes: Lawton Instrumental Activities of Daily Living (IADL) scores reported by Duncan 1998 and Duncan 2003 at the end of intervention showed no significant effect (MD 0.83, 95% CI -0.51 to 2.17; P = 0.22; Analysis 5.2).

The Barthel Index was assessed by four trials during usual care (Galvin 2011) and after usual care (Duncan 1998; Duncan 2003; Langhammer 2007) at the end of intervention (MD 2.65, 95% CI -0.95 to 6.25; P = 0.15; Analysis 5.3). Barthel Index scores reached ceiling level in five out of 20 participants at baseline and 10 out of 20 participants at follow-up (Duncan 1998).

RMI was assessed by two trials after usual care (Mead 2007; van de Port 2012). These data showed a significant improvement at the end of intervention (MD 0.48, 95% CI 0.05 to 0.91; P = 0.03; Analysis 5.4).

Nottingham Extended Activities of Daily Living (EADL) was reported by Mead 2007 and showed no significant effects at the end of intervention (MD -0.20, 95% CI -1.08 to 0.68; P = 0.66; Analysis 5.5). In addition, van de Port 2012 reported separately four sub-scales of the Nottingham EADL scale; only one was significantly affected in favour of the usual care rather than mixed training; all other sub-scales were unaffected.

FIM was reported by Mead 2007 and showed no significant effects at the end of intervention (Analysis 5.6).

The Stroke Impact Scale was reported by one study (Duncan 2003) showing a marginal benefit (Analysis 5.7). In addition, van de Port 2012 reported separately 11 sub-scales of the Stroke Impact Scale. One sub-scale was significantly affected in favour of the usual care rather than mixed training; all other sub-scales were unaffected.

If disability scale data from the end of intervention are combined including the Barthel Index (Duncan 1998; Duncan 2003; Galvin 2011; Langhammer 2007), FIM (Mead 2007), and RMI (van de Port 2012), there is a tendency for an effect of mixed training at the end of the intervention (SMD 0.24 (0 to 100), 95% CI 0.00 to 0.47; P = 0.05; Analysis 5.8). There are many potential combinations of data which could be included in this analysis as individual studies report more than one disability scale; therefore, we included Barthel Index data and FIM data as these relate more to overall, 'global' disability. There is heterogeneity among these results too (Chi² = 7.62, df = 5 (P = 0.18); I² = 34%) and this may relate to the different domains each tool addresses. Another explanation could be that four out of the six trials included in these analyses (Duncan 1998; Duncan 2003; Galvin 2011; van de Port 2012) were confounded by increased training time (amount of contact with therapists in the experimental groups was greater than in the control groups). When these trials were excluded from Analysis 5.8 there was no effect in the remaining subgroup (Langhammer 2007; Mead 2007: MD -0.11, 95% CI -0.45 to 0.23; P = 0.53).

End of follow-up

The Barthel Index was assessed by two trials (Galvin 2011; Langhammer 2007); there was no significant effect at the end of follow-up (MD 1.82, 95% CI -13.69 to 17.33; P = 0.82; Analysis 6.2).

The FIM was reported by Mead 2007 and showed no significant effect at the end of follow-up (MD 0.20, 95% CI -1.88 to 2.28; P = 0.85; Analysis 6.3).

Nottingham EADL was reported by Mead 2007 and Galvin 2011 and showed no significant effects at the end of follow-up (MD 3.10, 95% CI -5.20 to 11.40; P = 0.46; Analysis 6.4).

RMI was assessed by Mead 2007 and van de Port 2012; there was a significant benefit at the end of three to four months of follow-up (MD 0.39, 95% CI 0.04 to 0.73; P = 0.03; Analysis 6.5). The large trial of van de Port 2012 is confounded by increased training in the intervention group compared with the control group; when these data were excluded there was no effect.

If disability scale data from the end of follow-up are combined including Barthel Index (Galvin 2011; Langhammer 2007), FIM (Mead 2007), and RMI (van de Port 2012), there is no effect (SMD 0.16, 95% CI -0.12 to 0.44; P = 0.26; Analysis 6.6).

It is worth noting that two trials included in these analyses (Galvin 2011; van de Port 2012) were confounded by increased training time.

Comparison of cardiorespiratory training, resistance training, and mixed training (Comparison 7)

We performed a subgroup analysis to directly compare the effects of the different types of training (cardiorespiratory training versus mixed training versus resistance training) on pooled disability outcomes at the end of the intervention (Analysis 7.1). Cardiorespiratory and mixed training together showed an overall beneficial effect. Although the cardiorespiratory training effect was more convincing than the mixed training, which is of borderline significance, the overall magnitude of effect is very similar between the two interventions and there is no statistically significant difference between these subgroups.

Effect of training on secondary outcomes

Adverse events

Adverse events were not reported systematically in the included trials.

Mead 2007 reported 11 falls in eight of the 32 participants allocated mixed training and five falls in four of the 34 participants in the control group (P = 0.21, non-significant). None of these falls occurred within training sessions.

van de Port 2012 reported 29 falls in 126 participants allocated mixed training and 26 falls in those allocated usual care (P = 0.93 non-significant); one fall occurred during exercise training.

Ten of the included trials provided some comments on participant tolerance of the training programme and did not report any adverse events such as falls, fractures, or injuries arising during the intervention.

Considering all included trials, 10 participants (seven participants receiving the training intervention and three control participants) were reported to have suffered a cerebrovascular event between baseline and the end of the training intervention.

In the 17 trials that included a follow-up assessment, 10 participants (four participants receiving the training intervention and six control participants) were reported to have suffered a stroke or cerebrovascular event between the end of intervention and the end of follow-up.

Three participants (one participant receiving the training intervention and two control participants) were also reported to have suffered a cardiovascular event between baseline and the end of the training intervention.

Vascular risk factors

Few data regarding modification of risk factors for cardiovascular and cerebrovascular events were available in the included trials. Four trials, with a total of 267 participants, showed no significant training effects on systolic (MD 0.40 mmHg, 95% CI -8.38 to 9.18; 0.93; Analysis 1.6) or diastolic blood pressure (MD -0.33 mmHg, 95% CI -2.97 to 2.31; P = 0.81; Analysis 1.7) at the end of intervention (da Cunha 2002; Katz-Leurer 2003; Lennon 2008; Potempa 1995).

One trial stated that there was an effect of cardiorespiratory training on blood pressure but did not present data (Ivey 2011).

It should be noted that the peak VO2 values are discussed in the next section as a cardiorespiratory fitness outcome; however, low values of peak VO2 are also a vascular risk factor (for cardiovascular and cerebrovascular events) and are therefore also relevant to this section.

Physical fitness
Cardiorespiratory training (Comparisons 1 and 2)

Cardiorespiratory fitness was assessed in seven trials (247 participants) using measures of peak VO2 (ml/kg/minute) at the end of the intervention. Most of the studies took place after usual care and there was a consistent pattern of improvement in measures of peak VO2 showing that cardiorespiratory fitness increased significantly in the training group (MD 2.46 ml/kg/minute, 95% CI 1.12 to 3.80; P = 0.0003; Analysis 1.8). Doses of training vary between four weeks and six months among the trials.

VO2 cost assessed during the 12-minute walking test in Moore 2010 did not show any significant training effect at the end of intervention (Analysis 1.9).

Similarly, in four trials that measured maximal cycling work rate at the end of intervention during (Bateman 2001; da Cunha 2002) and after (Katz-Leurer 2003; Potempa 1995) usual care, cardiorespiratory fitness improved significantly in participants who received the training intervention (SMD 0.60, 95% CI 0.18 to 1.02; P = 0.005; Analysis 1.10). The large number of dropouts in Bateman 2001 means these data are at risk of bias. When it is excluded all statistical heterogeneity disappears and the overall effect is strengthened (SMD 0.84, 95% CI 0.49 to 1.18; P < 0.00001).

Results from Bateman 2001 showed that the improvement measured by maximal cycling work rate was not maintained at follow-up (MD 5.11, 95% CI -18.93 to 29.15; Analysis 2.7).

Resistance training (Comparisons 3 and 4)

Two trials with a total of 30 participants assessed the effects of resistance training on a composite measure of muscle strength at the end of intervention, during and after usual care (Kim 2001; Winstein 2004). Kim 2001 used a composite measure (that is the sum of the percentage change in six muscle groups) to assess the strength of the lower limbs, while Winstein 2004 used a composite measure (that is the sum of the torque of the extensors and flexors of the wrist, elbow, and shoulder) to assess the strength of the upper limbs. The pooled estimate of effect was only marginally in favour of the resistance training group (SMD 0.58, 95% CI 0.06 to 1.10; P = 0.03; Analysis 3.2). However, Winstein 2004 was biased by the lack of blinding and the use of a dynamometer which was hand-held by the investigator, and confounded by increased training time in the intervention group.

Two trials with a total of 42 participants assessed the effects of training on knee muscle strength measured with a dynamometer at the end of intervention during (Bale 2008) and after (Flansbjer 2008) usual care but did not detect any significant training effect on either knee extension (Analysis 3.3) or knee flexion (Analysis 3.4). Follow-up data were available for only one of these two trials (Flansbjer 2008) and did not show any significant training effect over time (Analysis 4.2; Analysis 4.3).

Ouellette 2004 examined strength bilaterally in the lower limb extensors and unilaterally in the knee extensors and the ankle flexors (plantar and dorsi). All strength measures were reported to improve significantly after resistance training compared with the control group except for ankle dorsiflexion on the unaffected side. This study also suggested that peak power was improved during unilateral knee extensions but not during bilateral extension of the whole lower limb. However, as strength and power data were presented as graphs, we were not able to extrapolate them satisfactorily for further analyses.

Inaba 1973 reported that participants allocated to resistance training of the lower limbs achieved significantly greater gains in the 10-repetition maximum exercise compared with controls (12.18 versus 8.58 kg, P < 0.02) after one month of intervention. No significant differences were observed between groups after two months of training. No measures of variance were reported by this trial and therefore we were not able to include these data in our analyses.

Aidar 2012 reported significant gains in maximal strength (1-repetition maximum) in a range of upper and lower body muscle groups after resistance training compared with the control group.

Overall, meta-analysis of muscle strength data is awkward because so many different muscles groups can be assessed using a range of different equipment and muscle contraction types.

Mixed training (Comparisons 5 and 6)

Based on the results of two individual trials a small significant difference was observed in VO2 peak (Duncan 2003) and in gait economy (Mead 2007: net VO2 mL/kg per metre) at the end of intervention in participants who received mixed training (Analysis 5.11; Analysis 5.12). The benefit in gait economy, however, disappeared after a three-month follow-up (Analysis 6.7).

Toledano-Zarhi 2011 reported no effect of mixed training on walking performance (time or METS) during a Modified Bruce treadmill protocol.

Two trials with a total of 148 participants (Duncan 2003; Yang 2006) did not show any significant improvement in ankle dorsiflexion strength after mixed training (Analysis 5.13) but there was considerable heterogeneity between their results (Chi2 17.67, df = 1) and both trials were confounded by increased training time. Yang 2006 also reported a range of lower limb strength improvements, but all measurements were potentially biased as they were obtained by means of a hand-held dynamometer, which is not a reliable, objective method of measurement.

The same two trials also assessed the effect of mixed training on knee extension strength. Data for knee extension strength were also available from the Cooke 2010 trial. The pooled SMD indicated a small effect size in favour of the mixed training group at the end of intervention (SMD 0.33, 95% CI 0.05 to 0.61; P = 0.02; Analysis 5.14). Cooke 2010 showed that this training effect was not retained at the end of the scheduled follow-up (Analysis 6.9). Cooke 2010 also assessed knee flexion strength but no significant training effect was observed either at the end of intervention or at follow-up (Analysis 5.15; Analysis 6.8).

Donaldson 2009 assessed the effect of mixed training on elbow extension, elbow flexion, and grip force at the end of intervention but did not detect any significant training effect (Analysis 5.16; Analysis 5.17; Analysis 5.18).

Mead 2007 assessed the extensor power of the lower affected limb at the end of the training period and at follow-up but found no differences between mixed training and a 'non-exercise' control intervention (Analysis 5.20; Analysis 6.10).

The pooled results of two trials assessing grip strength of the paretic hand (Duncan 2003; Langhammer 2007) did not show any significant improvement after mixed training at the end of the intervention phase (SMD -0.05, 95% CI -0.36 to 0.26; P = 0.75; Analysis 5.19). Langhammer 2007 also provided follow-up data for grip strength, which failed to demonstrate any training effect over time (Analysis 6.11).

Mobility
Cardiorespiratory training (Comparisons 1 and 2)
Functional Ambulation Category

Two trials, which included three relevant comparisons and 73 participants, measured the effect of treadmill gait training using the Functional Ambulation Category (FAC) scale (da Cunha 2002; Pohl 2002). The pooled MD showed that the FAC score measured at the end of intervention was significantly better in stroke survivors who received cardiorespiratory training during usual care (MD 0.53, 95% CI 0.21 to 0.85; P = 0.001; Analysis 1.11).

Maximum walking speed (MWS)

Thirteen trials with a total of 709 participants measured maximum walking speed (metres per minute) at the end of intervention. The mode of cardiorespiratory training in all these trials was walking-specific apart from two trials that used cycle ergometry (Bateman 2001) and circuit type-training (Mudge 2009) respectively. The pooled mean difference was significantly in favour of the training group (MD 7.37 m/min 95% CI 3.70 to 11.03; P < 0.0001; Analysis 1.12). This analysis also shows a consistent effect across the studies as a whole and a similar magnitude of effect arising from training delivered during or after usual care. The Bateman 2001 data are not walking-specific and are problematic due to high dropout rates; if the data are excluded heterogeneity is reduced and the confidence in the treatment effect strengthened. If the longer trials are also excluded (longer than 12 weeks; Ada 2013; Globas 2012) there is little change.

A funnel plot of the 13 studies (including 16 relevant comparisons) that measured maximum walking speed showed a tendency toward asymmetry, suggesting potential publication bias during but not after usual care (Figure 4).

Figure 4.

Funnel plot of comparison: 1 Cardiorespiratory training versus control - end of intervention, outcome: 1.12 Mobility - maximal gait speed (m/min over 5 to 10 metres).

Five trials (312 participants) also provided follow-up data on maximum walking speed and a significant training effect was observed at the end of follow-up (MD 6.71 m/min 95% CI 2.40 to 11.02; P = 0.002; Analysis 2.8). Although the overall effect is consistent the two comparisons of Ada 2013 show the smallest effect. Ada 2013 used a 12-month follow-up whilst all the others used a three-month follow-up period. If the data are excluded heterogeneity is reduced and the confidence in the treatment effect strengthened.

Preferred walking speed (PWS)

Eight trials measured the preferred gait speed (metres per minute) in a total of 425 stroke survivors at the end of the training period during and after usual care. The mode of cardiorespiratory training in all these trials was walking-specific apart from one trial (Katz-Leurer 2003) which used cycle ergometry. The pooled mean difference indicated a significant training effect (MD 4.63 m/min 95% CI 1.84 to 7.43; P = 0.001; Analysis 1.13). The majority of the interventions contributing to this effect took place after usual care. There is a consistent effect even though dose of training varies.

Two trials provided follow-up data three months (Kuys 2011) and 12 months (Ada 2013) after the intervention. Pooling these data shows no evidence of retention (Analysis 2.9).

Six-Minute Walking Test (6-MWT)

Ten trials assessed walking endurance using the six-minute walking test (total metres walked in six minutes: 6-MWT) in a total of 468 stroke survivors. Cardiorespiratory training significantly increased the walking capacity at the end of intervention (MD 26.99 metres, 95% CI 9.13 to 44.84; P = 0.003; Analysis 1.14). The majority of the interventions contributing to this effect took place after usual care and these include longer interventions (longer than 12 weeks). The subgroup of trials before usual care were shorter (four to six weeks) and show no significant effect.

A funnel plot of the 10 studies (including 11 relevant comparisons) that measured 6-MWT showed no evidence of asymmetry, suggesting no publication bias (Figure 5).

Figure 5.

Funnel plot of comparison: 1 Cardiorespiratory training versus control - end of intervention, outcome: 1.14 Mobility - gait endurance (6-MWT metres).

Four trials provided follow-up data three months (Eich 2004; Kuys 2011; Mudge 2009) and 12 months (Ada 2013) after the intervention. When pooled these data show no evidence of retention (MD 33.37 metres, 95% CI -8.25 to 74.99; P = 0.12; Analysis 2.10). However, exclusion of the 12-month follow-up data of Ada 2013 reveals consistent retention among the three trials with a three-month follow-up (MD 64.60 metres, 95% CI 29.87 to 99.32; P = 0.0003).

Other mobility outcomes

Similar to the 6-MWT data, three trials measured walking endurance (reported as metres per minute) in 154 stroke survivors at the end of intervention, during (da Cunha 2002; Eich 2004) and after (Salbach 2004) usual care. Walking capacity increased significantly in participants who received cardiorespiratory training (MD 8.87 metres/min, 95% CI 1.35 to 16.40; P = 0.02; Analysis 1.15).

Glasser 1986 measured the time taken by stroke participants to walk a six metre distance and did not find any significant difference between participants who received Kinetron walking training and controls (Analysis 1.16).

Park 2011 reported time taken for the community walk test. There was no difference between participants who received community ambulation training and controls at the end of intervention (Analysis 1.18).

Smith 2008 assessed the effect of cardiorespiratory training using the mobility domain of the Stroke Impact Scale (SIS). SIS scores were similar between intervention groups at the end of the intervention and at follow-up (Analysis 1.17; Analysis 2.13).

It is worth noting that six trials, which assessed walking outcomes, were confounded by additional training time in the intervention groups (Ada 2013; Katz-Leurer 2003; Kuys 2011; Moore 2010; Park 2011; Smith 2008).

Resistance training (Comparisons 3 and 4)
Maximal walking speed (MWS)

Four trials with a total of 104 participants measured maximal walking speed (metres per minute) during (Bale 2008) and after (Flansbjer 2008; Kim 2001; Ouellette 2004) usual care. Overall, resistance training did not increase the walking velocity at the end of intervention (MD 1.92 m/min, 95% CI -3.50 to 7.35; Analysis 3.5). There was, however, definite heterogeneity between trial results (Chi2 = 7.76, df = 3, P = 0.05). The heterogeneity was mainly due to the results of one trial (Bale 2008) that involved specific walking-related exercises and, in contrast to the results of the other three trials, showed a significant training effect during usual care (MD 8.40 m/min, 95% CI 2.82 to 13.98). Follow-up data were available from one trial only (Flansbjer 2008) and did not show any significant training effect (Analysis 4.4).

Preferred walking speed (PWS)

Three trials with a total of 80 participants also measured preferred gait speed (metres per minute) during (Bale 2008) and after (Kim 2001; Ouellette 2004) usual care but failed to demonstrate any effect of resistance training on walking speed at the end of intervention (MD 2.34 m/min, 95% CI -6.77 to 11.45; Analysis 3.6). Heterogeneity between results (Chi2 = 9.18, df = 2, P = 0.01) was again attributable to the results of the Bale 2008 trial.

Six-Minute Walking Test (6-MWT)

Two trials assessed the walking capacity (metres walked in six minutes) in a total of 66 stroke survivors (Flansbjer 2008; Ouellette 2004). Resistance training did not have any significant effect on walking capacity at the end of intervention (MD 3.78, 95% CI -68.56 to 76.11; level of heterogeneity Chi2 = 0.00, df = 1, P = 0.99; Analysis 3.7). One trial (Flansbjer 2008) provided follow-up data that confirmed the lack of training effect on walking capacity at the end of follow-up (Analysis 4.5).

Mixed training (Comparisons 5 and 6)
Functional ambulation categories

One trial (van de Port 2012) examined the effects of mixed training on Functional Ambulation Category scores and showed no effect at the end of intervention (Analysis 5.21) and borderline beneficial effect after a follow-up of three months (MD 0.11, 95% CI 0.00 to 0.22; P = 0.05; Analysis 6.12).

Preferred walking speed (PWS)

Nine studies with a total of 639 participants measured the effects of mixed training on preferred walking speed (metres per minute). The walking speed increased at the end of intervention in stroke survivors who received mixed training (MD 4.54 m/min, 95% CI 0.95 to 8.14; P = 0.01; Analysis 5.22). The effect is influenced mostly by data from interventions delivered after usual care and there is significant heterogeneity within the after usual care subgroup (Chi² = 34.39, df = 5, P < 0.00001). Only the interventions in three of the nine studies (Mead 2007; Richards 1993; Richards 2004) are not confounded by additional training time and show no effect.

Subgroup analysis of trials in which the experimental group was confounded by additional training time showed a significant difference in favour of mixed training (MD 6.32 metres/min, 95% CI 1.08 to 11.55; P = 0.02; Analysis 5.23) whilst those not confounded by additional training time did not (MD 0.49 metres/min, 95% CI -2.96 to 3.94; P = 0.78). The confounded data show significant heterogeneity (I2 = 85%; P < 0.001) whilst the unconfounded data do not (I2 = 8%; P = 0.34).

A funnel plot that was generated using continuous measures for preferred walking speed at the end of intervention did not suggest the presence of publication bias as its shape did not show gross asymmetry (Figure 6).

Figure 6.

Funnel plot of comparison: 5 Mixed training versus control - end of intervention, outcome: 5.22 Mobility - preferred gait speed (m/min).

Four trials that provided follow-up data for preferred gait speed did not show a significant training effect at the end of the scheduled follow-up (Analysis 6.13).

One study showed some indication of dose-response, where the improvement in preferred gait speed was positively associated with the amount of time spent on the gait training component (R2 = 0.63; Richards 1993).

Six-Minute Walking Test (6-MWT)

Seven trials measured the walking capacity (metres walked in six minutes) in a total of 561 participants. Walking capacity increased significantly in the mixed training group (MD 41.60 metres, 95% CI 25.25 to 57.95; P < 0.00001; Analysis 5.24). Two trials included a follow-up and showed that walking capacity remained significantly greater in the groups who had participated in training (MD 51.62 metres, 95% CI 25.20 to 78.03; P = 0.0001; Analysis 6.14).

It is worth noting, however, that in all trials in this analysis the intervention groups were confounded by additional training time, which could exaggerate the effect.

Other mobility outcomes

Three trials measured community ambulation speed (the ability to walk at 0.8 metres per second or more) in a total of 232 participants during (Cooke 2010) and after (Duncan 2003; Mead 2007) usual care. No significant training effects were observed either at the end of intervention (Analysis 5.25) or at follow-up (Analysis 6.15).

Comparison of cardiorespiratory, resistance training, and mixed training (Comparison 7)

We performed a subgroup analysis to compare the effects of the different types of training (cardiorespiratory training versus mixed training versus resistance training) on mobility outcomes at the end of intervention.

  • Maximal walking speed increased significantly after cardiorespiratory training but not after resistance training (Analysis 7.2). No mixed training data are available for this outcome.

  • Preferred walking speed increased significantly after cardiorespiratory and mixed training but not after resistance (Analysis 7.3). Excluding trials that were potentially confounded by additional training time; only cardiorespiratory training showed a significant training effect.

  • Gait endurance (6-MWT) increased significantly after cardiorespiratory, and particularly mixed training, but not after resistance training (Analysis 7.4). All mixed training trials are confounded by additional training time.

Physical function

The included trials assessed participants' physical function using a variety of different measures including rating scales (for example Berg Balance Scale) and specific measures of functional performance (for example functional reach, timed up and go test, stair climbing).

Cardiorespiratory training (Comparisons 1 and 2)

Six trials with a total of 257 participants assessed the effects of cardiorespiratory training on balance using the Berg Balance Scale. There was a significant improvement in the scores (MD 3.14, 95% CI 0.56 to 5.73; P = 0.02; Analysis 1.20). All trials except Bateman 2001 (no effect) involved walking. The Bateman 2001 data are also at risk of bias; if the data are excluded the effect is strengthened (MD 4.26, 95% CI 1.29 to 7.24; P = 0.005). The backwards walking group of Takami 2010 appeared to produce a larger (non-significant) benefit compared with the forwards walking group from the same trial. One trial (Bateman 2001) also assessed participants at the end of the follow-up period but did not show any training effect over time (Analysis 2.14).

Three trials (Kang 2012; Moore 2010; Salbach 2004) that measured the performance of a total of 131 participants during the timed up and go test did not show any specific benefits of training at the end of the intervention after usual care (Analysis 1.21).

Resistance training (Comparisons 3 and 4)

One trial (Bale 2008) assessed the maximum weight-bearing on the affected leg (% body weight). A small training effect was observed in the resistance training group compared with the usual rehabilitation group (MD 11.80, 95% CI 0.89 to 22.71; Analysis 3.8).

Two trials (Kim 2001; Ouellette 2004) did not find any significant differences between intervention groups in the time needed to ascend a 10-stair flight at the end of the training period (MD -0.04, 95% CI -0.86 to 0.77; Analysis 3.9).

Another trial (Flansbjer 2008) measured the participants' performance of the timed up and go test but failed to demonstrate any significant training effect either at the end of intervention (Analysis 3.10) or at follow-up (Analysis 4.6).

Mixed training (Comparisons 5 and 6)
Balance outcomes

Five trials with a total of 239 participants assessed the participants' balance using the Berg Balance Scale. Scores show a tendency for beneficial improvements in balance at the borderline of statistical significance (MD 0.32, 95% CI 0.00 to 0.65; P = 0.05; Analysis 5.26). Follow-up data from two trials did not show any significant training effect (Analysis 6.16).

Two trials (Duncan 2003; Mead 2007) with a total of 166 participants measured balance using the functional reach test but did not show any benefit of mixed training at the end of intervention (Analysis 5.27). One trial also provided follow-up data (Mead 2007), which did not show persistence of any training effect beyond the duration of intervention.

One trial measured balance using the Four Square Step Test (Toledano-Zarhi 2011) and found no significant effect at the end of intervention (Analysis 5.28); however these data are very different at baseline in a way which benefits the control group.

One trial measured balance using the timed balance test (van de Port 2012) and showed a beneficial effect of training at the end of intervention (MD 0.32, 95% CI 0.06 to 0.58; P = 0.02; Analysis 5.29) and after a three-month follow-up (MD 0.46, 95% CI 0.09 to 0.83; P = 0.02; Analysis 6.18).

There were sufficient data among the different measures of balance used (eight trials, 575 participants) to be legitimately pooled. This showed an overall beneficial improvement in balance at the end of intervention (SMD 0.26, 95% CI 0.04 to 0.49; P = 0.02; Analysis 5.30). If the problematic data of Toledano-Zarhi 2011 are excluded the effect strengthens and any evidence of heterogeneity disappears (SMD 0.33, 95% CI 0.16 to 0.50; P = 0.0001). However, five of the eight included trials were confounded by additional training time; when these data are excluded, leaving only Mead 2007, Richards 1993 and Richards 2004, there is no effect of training on balance.

Other outcomes

Four trials measured the time to complete the timed up and go test in a total of 418 participants (Mead 2007; Richards 2004; van de Port 2012; Yang 2006). Participants in the training group were faster than those in the control group (MD -1.37 sec, 95% CI -2.26 to -0.47; P = 0.003; Analysis 5.32) at the end of the mixed training phase. The Yang 2006 and van de Port 2012 data were, however, confounded by additional training time. After removal of these data from the analysis no significant training effect was evident (MD -1.13 seconds, 95% CI -2.91 to 0.65; Analysis 5.33). Follow-up data in three trials (Mead 2007; Richards 2004; van de Port 2012) did not show a significant retention of mixed training benefits (Analysis 6.19).

One trial assessed upper extremity functional performance using the Action Research Arm test (Donaldson 2009). No significant training effects were observed (Analysis 5.31).

Comparison of cardiorespiratory, resistance training, and mixed training (Comparison 7)

We performed a subgroup analysis to directly compare the effects of the different types of training (cardiorespiratory training versus mixed training versus resistance training) on the Berg Balance Scale at the end of intervention (Analysis 7.5). There was an overall beneficial effect of cardiorespiratory and mixed training on balance and whilst the significant effect is within the cardiorespiratory subgroup, the magnitude of effect was similar with no statistically significant difference between the subgroups.

Health status and quality of life
Cardiorespiratory training (Comparisons 1 and 2)

One trial assessed the effects of cardiorespiratory training on measures of quality of life, in 28 participants (Aidar 2007). Both the SF-36 physical component score and the SF-36 emotion score were significantly better at the end of the training period in participants who underwent cardiorespiratory training (Analysis 1.24; Analysis 1.25).

One trial (Globas 2012) examined effects of cardiorespiratory training on the SF-12 and showed a significant improvement in the mental health domain (MD 9.30, 95% CI 4.31 to 14.29; P = 0.0003; Analysis 1.26) but not the physical health domain (Analysis 1.27).

One trial (Ada 2013) examined effects on EuroQoL scores showing no effect at the end of intervention (Analysis 1.28). There was also no effect after a 12-month follow-up although the effect approaches statistical significance (Analysis 2.15).

Resistance training (Comparisons 3 and 4)

One small trial of 20 participants (Kim 2001) did not show any significant differences between the resistance training group and the control group in either the physical health or mental health component of the SF-36 at the end of intervention (Analysis 3.11; Analysis 3.12).

Mixed training (Comparisons 5 and 6)

One trial (Cooke 2010) measured the effects of mixed training on quality of life in 50 participants using two components of the EuroQol scale. Scores were not significantly different between intervention groups at the end of the training phase (Analysis 5.34; Analysis 5.35) or at follow-up (Analysis 6.20; Analysis 6.21).

A few trials assessed the effects of mixed training on quality of life using different components of the SF-36 survey questionnaire. In two trials with a total of 112 participants (Duncan 2003; James 2002) significantly better scores were obtained in the SF-36 physical functioning component in the mixed training group at the end of intervention (SMD 0.48, 95% CI 0.10 to 0.85) (Analysis 5.36) but not in the social role functioning component (Analysis 5.37). Three trials with a total of 178 participants (Duncan 2003; James 2002; Mead 2007) showed significantly better scores in the SF-36 physical role functioning component for the mixed training group at the end of intervention (SMD 0.56, 95% CI 0.26 to 0.86; Analysis 5.38). This effect was retained at follow-up (Analysis 6.23).

One trial (Duncan 2003) showed that participants receiving mixed training had significantly better results in the emotional role functioning component of the SF-36 compared with controls at the end of the training period (Analysis 5.39) but not at follow-up (Analysis 6.24).

One trial (Zedlitz 2012) assessed the effect of mixed training on the Stroke-Adapted Sickness Impact profile and showed no effect at the end of intervention (Analysis 5.40) or end of six-month follow-up (Analysis 6.25).

It is worth noting that in the Duncan 2003, James 2002 and Zedlitz 2012 trials the intervention group was potentially confounded by additional training time.

Mood
Cardiorespiratory training (Comparisons 1 and 2)

One trial (Smith 2008) assessed the potential benefits of cardiorespiratory training on depression symptoms using the Beck Depression Index. No significant differences were found between intervention groups at the end of intervention (Analysis 1.29) and at follow-up (Analysis 2.16).

One trial (Bateman 2001) assessed participants using the anxiety and depression components of the Hospital Anxiety and Depression Scale (HADS). The anxiety score decreased immediately after cardiorespiratory training (MD -1.94, 95% CI -3.80 to -0.08; Analysis 1.30) but this small benefit was not retained at the follow-up assessment (Analysis 2.17). In contrast, the depression score was not significantly different between groups at the end of the training phase (Analysis 1.31) but decreased significantly in the cardiorespiratory group at the end of the follow-up period (MD -2.70, 95% CI -4.40 to -1.00; Analysis 2.18). This trial had, however, substantial missing values at the end of intervention (29%) and end of follow-up (37%) and therefore these findings should be interpreted with caution. Another trial (Lennon 2008), which measured participants' mood using the HADS, reported that the depression score improved in the intervention group but not in the control group. We were, however, unable to include these trial data in our analyses as they were presented in a format not suitable for RevMan 2012.

Resistance training (Comparisons 3 and 4)

One trial (Sims 2009) assessed 88 participants using the Centre for Epidemiological Studies for Depression scale (CES-D). The mood in the resistance training group was significantly better at the end of intervention (MD -5.49, 95% CI -9.78 to -1.20; Analysis 3.13) and at follow-up (MD -8.92, 95% CI -13.03 to -4.81; Analysis 4.7).

One trial (Aidar 2012) used the Brazilian translation of the State-Trait Anxiety Inventory and showed no effect on either trait anxiety (Analysis 3.14) or state anxiety (Analysis 3.15) at the end of intervention.

Mixed training (Comparisons 5 and 6)

Two trials (Duncan 2003; van de Port 2012) assessed mood in 335 participants using the emotion domain of the Stroke Impact Scale (SIS) and showed no significant effect at the end of intervention (Analysis 5.41) or after three-month follow-up (Analysis 6.26).

One trial (Duncan 2003) showed improvements in Geriatric Depression Scale scores at the end of intervention (MD -1.90, 95% CI -3.10 to -0.70; P = 0.002; Analysis 5.42) but not the end of follow-up (Analysis 6.27).

Three trials (Mead 2007; van de Port 2012; Zedlitz 2012) assessed 391 participants using the anxiety and depression components of the Hospital Anxiety and Depression Scale (HADS). No immediate training effects were observed on either HADS component at the end of the intervention (Analysis 5.43; Analysis 5.44). However the effect size for depression showed a tendency to favour the control group which approached statistical significance (P = 0.08). No retained training effects were observed on either HADS component at the end of follow-up (Analysis 6.28; Analysis 6.29).

Discussion

The included trials encompassed a variety of outcome measures. This has been a typical drawback of stroke rehabilitation trials for some time (Greener 2002) and continues to be a problem when summarising and combining data in a systematic review.

Effect of training on primary outcome measures

Case fatality

Death, from any cause, is not a common event among the participants of the trials included in this review. Only nine out of the total 2215 participants died before the end of the intervention period and nine out of 1206 died before the end of follow-up.

Where deaths did occur there may be a tendency toward these being more common among the control groups rather than the intervention groups of mixed training trials. However, there are still too few data to draw any conclusions about the effect of fitness training on case fatality.

The observed numbers of deaths in this review may be low because the included participants were at lower risk of death compared with the wider stroke population. This may occur firstly because the inclusion criteria of the trials of exercise select participants with milder strokes (most were ambulatory) and reduced risk factors (such as blood pressure ceiling criteria). Secondly, there may be self selection by participants who are physically active with increased fitness. Higher physical activity is known to be associated with reduced risk of stroke (Lee 2003; Wendel-Vos 2004) and higher VO2 peak is associated with reduced risk of stroke (Kurl 2003) and mortality (Lee 2002). In addition, the majority of the training programs in this review were of short duration (12 weeks or less). A Cochrane Review of the effect of exercise-based cardiac rehabilitation showed reduced mortality in people with coronary heart disease in the longer term (12 months follow-up and more; Heran 2011); the training programs tended to be much longer than those in this review. Since many stroke patients have coexisting heart disease, training might influence post-stroke mortality provided it comprises cardiorespiratory training delivered over long periods of time. This requires investigation.

Although higher physical activity and cardiorespiratory fitness are linked to the primary prevention of stroke, there is a lack of data on the role of fitness training in the secondary prevention of stroke. This requires further investigation.

Death or dependence

There were no data available to allow us to draw conclusions about the influence of training on the composite outcome of death or dependence after stroke. Death is infrequent and measures of dependency such as those based on simple questions, a Barthel Index score of less than 20, or modified Rankin Scale score of 3, 4, or 5, are lacking (Lindley 1994). Both elements of this composite outcome are likely to be rare in stroke survivors who are eligible for physical fitness training.

Disability

We assessed a number of different global indices of disability. Data using the same scales were limited and this restricted the meta-analyses, and a number of methodological issues weakened and biased the available data.

After cardiorespiratory training there was no improvement in FIM scores (Analysis 1.2) but there was an improvement in Rivermead Mobility Index scores (Analysis 1.3). Pooling all available disability scale data from different scales showed a small beneficial effect (SMD; Analysis 1.5). This pattern of findings could occur because training influences the physical/mobility items of these various scales; such items dominate the scoring in tools like the Rivermead Mobility Index (eight out of 15 items) whereas they are less influential in more 'global' tools like the FIM (two out of 18 items). Use of walking as a mode of cardiorespiratory exercise is common, therefore these findings could be driven by improvements in walking and mobility.

In trials of mixed training various disability measurement instruments were used. Among these the only significant improvements were in Rivermead Mobility Index scores, both at the end of training (Analysis 5.4) and retained after a period of follow-up (Analysis 6.5). Pooling all available data from different scales shows a hint of benefit at the end of intervention (Analysis 5.8). Like cardiorespiratory training these significant effects could be driven principally by changes in mobility. The study designs of several of the mixed training trials were confounded by additional training time; when these were excluded the benefits vanish. This means that although participation in mixed training appeared effective it is impossible to attribute any benefits to the actual content of the mixed training programs.

The overall effects of cardiorespiratory training and mixed training at the end of intervention are similar in magnitude (Analysis 7.1).

There are too few data to allow for any comment on the effect of resistance training.

Lack of benefits among many of the disability tools may arise from a lack of sensitivity due to the recruitment of people typically presenting with milder strokes. There was evidence of ceiling effects in the Barthel Index data from two trials (Bateman 2001; Duncan 1998). Similarly, the Functional Independence Instrument, which was assessed in some of the included studies, is known to be prone to ceiling effects, particularly in community-living patients (Hall 1996). Thirdly, a lack of effect on disability measures despite functional benefits has been reported in trials of exercise for healthy elderly people (Keysor 2001).

It is worth pointing out that a lack of an immediate effect does not necessarily preclude longer-term benefits. Increased fitness may provide some 'reserve capacity' to cope with the deterioration of function that will occur with increasing age and thus postpone crossing 'thresholds of independence' (Young 2001). Therefore, indicators of pre-clinical disability (Fried 1996) coupled with long-term follow-up may be a more useful approach for assessing outcomes in trials of fitness training after stroke.

Overall, the small benefits after cardiorespiratory and mixed training detected using scale-based measures of disability may be driven by improvements in mobility rather than being indicative of a change in more 'global' disability status. This would agree with the findings among the secondary outcomes (mobility).

Effect of training on secondary outcome measures

Adverse events

There was no evidence of any serious adverse event arising from training in people who participated in physical fitness training programs. However, this finding cannot be generalisable to the wider stroke population as only a few trials specifically recorded or reported adverse events. There is a clear need to improve the reporting of adverse events in physical fitness training trials.

Vascular risk factors

A few trials reported vascular risk factors. There was no effect on blood pressure but there was an increase in peak VO2. As well as indicating poor cardiorespiratory fitness, low values of peak VO2 peak are associated with an increased risk of stroke (Kurl 2003) and stroke mortality (Lee 2002). Limited data meant that no conclusions could be drawn. Blood pressure is rarely reported among trials of fitness training and yet it could be an important, plausible benefit.

Physical fitness

Cardiorespiratory fitness

Cardiorespiratory training, and to a smaller degree mixed training, significantly improved VO2 peak and exercise tolerance during continuous exercise. This improvement may be beneficial because a low VO2 peak is associated with functional limitation in elderly people (Young 2001). In people with stroke the functional benefits are, however, less clear (see for example the contradictory data by Patterson 2007 and Michael 2007).

Gait economy may improve in response to training that contains walking activity. A limited 'fitness reserve' caused by a low VO2 peak coupled with poor walking economy is a common post-stroke problem (Macko 2001). Therefore, training to improve walking economy and increase the peak may be beneficial for walking performance and exercise tolerance after stroke. Only few, inconsistent data were available for the assessment of gait economy. Data from one individual trial (Mead 2007) suggested that mixed training may improve gait economy at the end of the training period even though this training effect appeared to disappear at follow-up. On the whole, the data were insufficient to draw reliable conclusions on the effect of training on gait economy as well as on the post-training retention of cardiorespiratory fitness.

Musculoskeletal fitness

The few trials that assessed whether resistance training or mixed training improved muscle strength after stroke show inconsistent results. Most of the trials that showed positive training effects were either methodologically biased or confounded by additional training time.

One individual trial (Mead 2007) measured explosive lower limb extensor power but showed no immediate or retained effect of mixed training. Non-response could be due to a lack of explosive, fast movements during resistance training. In people with stroke, explosive power is associated with function and disability after stroke (Saunders 2008), and in elderly people explosive power output may be more important than strength for function and disability (Puthoff 2007). Interventions to improve explosive power after stroke remain under-investigated; however, one ongoing trial does include training with fast movements (NCT01573585 trial; Ongoing studies).

Mobility

All the meta-analyses of walking performance outcomes are summarised in Table 4 and this shows a clear pattern of findings.

Table 4. Pooled walking data for cardiorespiratory training, resistance training, and mixed training at the end of the training period and at follow-up
  1. CI: confidence interval
    m: metre
    MD: mean difference
    min: minutes
    NS: non-significant

End of intervention End of follow-up
Intervention Walking outcome

Trials

(number of participants)

MD

(95% CI)

Significance level

Trials

(number of participants)

MD

(95% CI)

Significance level

Cardiorespiratory

training

Maximal gait speed13 (609)7.37 m/min (3.70 to 11.03)P < 0.00015 (312)

6.71 m/min

(2.40 to 11.02)

P = 0.002
Preferred gait speed8 (425)4.63 m/min (1.84 to 7.43)P = 0.0012 (126)

0.72 m/min

(-6.78 to 8.22)

NS
6-Minute Walking Test10 (468)26.99 metres (9.13 to 44.84)P = 0.0034 (233)

33.37 metres

(-8.25 to 74.99)

NS
Resistance trainingMaximal gait speed4 (104)1.92 m/min
(-3.50 to 7.35)
NS1 (24)-19.8 m/min
(-95.77 to 56.17)
NS
Preferred gait speed3 (80)2.34 m/min
(-6.77 to 11.45)
NS---
6-Minute Walking Test2 (66)3.78 metres
(-68.56 to 76.11)
NS1 (24)11.0 m/min
(-105.95 to 127.95)
NS

Mixed

training

Maximal gait speed------
Preferred gait speed9 (639)4.54 m/min (0.95 to 8.14)P = 0.014 (443)

1.60 m/min

(-5.62 to 8.82)

NS
6-Minute Walking Test7 (561)41.60 metres (25.25 to 57.95)P < 0.000013 (365)51.62 metres (25.20 to 78.03)P = 0.0001

Cardiorespiratory training increased preferred and maximal walking speed and walking capacity (6-MWT) at the end of the training period (Analysis 1.12; Analysis 1.13; Analysis 1.14). Benefits were retained after follow-up only in maximum walking speed (Analysis 2.8). Gait improvements in stroke survivors after cardiorespiratory training may occur due to an increased fitness reserve (arising from an increased VO2 peak or improved gait economy, or both). Cardiorespiratory walking training is, however, also task-related and repetitive in nature. These elements by themselves may facilitate motor learning and benefit gait performance even in the absence of an obvious improvement in physical fitness parameters. There is evidence that suggests cardiorespiratory training, as well as improving walking speed, may reduce the reliance of stroke survivors on other people to assist with ambulation (Functional Ambulation Categories score; Analysis 1.11).

Mixed training increased preferred walking speed and walking capacity at the end of the training period (Analysis 5.22; Analysis 5.24). Benefits were retained only in the 6-MWT performance (Analysis 6.14). These findings were based, however, on trials that were heterogeneous and potentially confounded by additional training time. When we looked only at the results of the 'unconfounded' trials, we did not find any significant training effect (Analysis 5.23). Moreover, all trials except one (Yang 2006) included specific walking training. Therefore, benefits may be explained by the additional walking practice and treatment 'attention'.

Meta-analyses revealed no significant effects of resistance training on walking outcomes. It is worth noting that most of the resistance training interventions did not incorporate walking as a mode of exercise. Improvements in muscle strength may not necessarily produce functional benefits (Kim 2001), which translate into a better walking performance. The relationships between 'fitness' and 'function' is indeed very complex and may arise from factors such as non-linear associations (Buchner 1991) or the interaction of 'co-impairments' such as lack of balance and low muscle strength (Rantanen 2001).

Therefore, on the whole, there is consistent evidence that measures of walking performance improve after both cardiorespiratory training and mixed training but not after resistance training. Although the improvements are clear one could still question whether they are clinically important. For example Fulk 2011 concluded that a clinically important increase in preferred walking speed after stroke would be 10.5 m/min; this is greater than the upper 95% CI margin of the effect sizes for preferred walking speed in this review.

Physical function

A variety of measures to assess functional limitations were used in the included trials. A number of balance outcomes were reported and data could be pooled.

Berg Balance scores improved after both cardiorespiratory (Analysis 1.20) and mixed training (Analysis 5.26) by a similar magnitude (Analysis 7.5). When balance data using other measurement tools are also combined (SMD; Analysis 5.30) a beneficial effect is shown for mixed training. All of the mixed training interventions involve weight bearing and walking and some specifically include balance training; these components of the training could improve balance. However, this overall effect is difficult to attribute to the content of the mixed training because many of the studies were confounded by increased training time. A sensitivity analysis showed the benefit disappeared when confounded studies were excluded.

The timed up and go measure improved after mixed training (Analysis 5.32) but, like the balance scores, when confounded trials were excluded the effect was no longer significant.

Health status and quality of life

Only a limited number of trials, with inconsistent results, included relevant quality of life measures. Therefore, few conclusions can be drawn on whether training can improve self perceived health status and quality of life after stroke.

One small trial (Aidar 2007) showed that both the physical functioning and the emotional role functioning of the SF-36 survey were significantly better after cardiorespiratory training.

Two trials, confounded by additional training time, showed better results on the physical functioning but not the social role functioning of the SF-36 survey after mixed training. Similarly, three trials demonstrated both immediate and long-term benefits of mixed training on the 'physical role functioning' of the SF-36 survey. The scoring of this domain is, however, problematic in people - such as stroke survivors - who are not engaged in employment (Johnson 1999). Furthermore, various elements of the SF-36 survey are prone to ceiling effects (Hobart 2002).

A small individual trial did not show any significant effect on the physical functioning and mental health components of the SF-36 health survey after resistance training.

Mood

Only data from individual trials of variable methodological quality were available to assess the effects of training on mood. Results were not consistent amongst trials and no conclusions can be drawn.

Factors influencing primary and secondary outcome measures

Performing subgroup analyses is problematic when the number of trials is small; the consequences are reduced power and the influence of characteristics unrelated to the grouping factors.

Dose of training

All the training interventions occurred regularly and were progressive in nature. The interventions differed in the dose of training, quantified in terms of (1) overall volume of training time, and (2) the intensity of the exercise used.

The ACSM 1998 criteria were used to define an effective overall 'dose' of fitness training as defined by the parameters of intensity, duration, and frequency. Some study interventions may have provided a sufficient dose of training but failure to record or report intensity meant they could not be assigned to a category. Conversely, interventions meeting the criteria may have provided a low dose of training because they were of short duration (for example Kwakkel 2004).

Underestimation of benefits may arise if interventions are poorly attended or complied with. Full attendance was found in few included trials, where interventions occurred partly or completely during inpatient care, were home-based, or were of very short duration (four weeks).

Overestimation of benefits may arise in trials where the intervention group is potentially confounded by increased training time compared with the control group. In these trials with no attention control additional benefits could arise from non-specific effects of therapist input, psychosocial effects of contact with other participants and factors such as travel to and from a training location that could amount to a substantial dose of physical activity from which a real training effect could arise.

A further exaggeration of this simple 'dose' effect in confounded trials would also be expected for trials with a long duration or large volumes of training, or both. In most confounded trials the total volume of training was 20 hours or more, whilst only few unconfounded trials exceeded 20 hours of training. Published meta-analyses have shown that augmented stroke rehabilitation may result in improvements in activities of daily living (Kwakkel 2004). This source of confounding may influence the outcome in trials of physical fitness training. For example, in a number of instances when we excluded confounded trials in sensitivity analyses, the effect sizes became smaller. The data of Richards 1993 supported these observations, showing that longer gait training was associated with improved mobility outcomes (this may also be indicative of a dose-response effect).

Exercise programme intensity is one of the most important fitness training variables. The Pohl 2002 trial demonstrated that higher intensity walking increased maximal walking speed compared with lower intensity walking. However, the training programme in the Pohl 2002 trial was also the most rapidly progressing. So it is somewhat difficult to disentangle the effect derived from an increase in progression from the effect due to the intensity of the intervention.

The findings of this review indicate that stroke survivors may successfully complete a variety of short-term training interventions. However, the optimal dose of training for people with stroke has yet to be established.

Type of training

None of the included trials directly compared cardiorespiratory, resistance, and mixed training. We were able to compare the effects of the different types of training on gait speed. Walking speed increased significantly after cardiorespiratory training and mixed training, but not after resistance training. Both cardiorespiratory interventions and mixed interventions comprised specific gait-related training, which resulted in positive training effects.

Overall, the findings of this review show that benefits reflect the concept of the specificity of the training response. In particular, cardiorespiratory fitness (VO2 peak) improved after cardiorespiratory training; muscle strength improved after resistance training; walking performance improved after training interventions based on walking or walking-like modes of exercise; walking and physical function outcomes did not improve after resistance training interventions, probably because functionally relevant movements are difficult to incorporate into resistance training interventions.

Timing of training

All our meta-analyses were divided into 'during usual care' and 'after usual care' subgroups. However, this still does not have much value for a subgroup analysis since there are generally too few trials and too many other influential confounding factors. For instance, trial design tends to differ among these groups, interventions tend to be longer after usual care, etc.

Retention of benefits

Functional advantages observed at the end of rehabilitation interventions are known to be transient, disappearing at a later stage (Kwakkel 1999; Kwakkel 2002). This is probably due to continued improvements in the control group rather than deterioration in function (Langhorne 2002). Fitness improvements observed at the end of training interventions are also known to deteriorate.

Few trials included in this review assessed possible retention of benefits over time. Those that did were at increased risk of attrition bias. Most of the functional improvements observed at the end of the training period were not sustained at later assessments. We found, however, that cardiorespiratory and mixed training effects on some measures of walking performance were retained at the end of the follow-up period. This retention effect could have arisen from an increase in habitual levels of physical activity (including walking) facilitated by participation in a training intervention. The extent to which short-term fitness training influences longer-term habitual physical activity after stroke is still unknown. Currently, there are no data examining either long-term fitness training interventions or interventions to facilitate continued exercise after the training intervention is completed. Long-term assessments should be incorporated into future trials of physical fitness training.

Effect of physical activity performed by control groups

Training effects arising from physical activity in the control group could partly explain the lack of effect observed in some of the included trials.

Effect of risk of bias

There are insufficient data to reliably examine the effects of risk of bias on estimates of effect. Overall, the methodological quality of most of the 45 included trials was modest. Only two trials enrolled more than 100 participants. Only 20 trials reported adequate methods of sequence generation and 19 trials had blinded outcome assessors (but some degree of unmasking occurred in three of these trials). The rate of attendance could only be determined in half of the included trials.

Summary of review findings

  • Most available data relate to ambulatory people in the chronic phase (more than one month) post-stroke.

  • It is feasible for stroke survivors to participate in a variety of short-term fitness training regimens presented in a range of settings, either during usual stroke care or after hospital discharge.

  • There were insufficient data to assess death and dependence outcomes reliably.     

  • From the limited data reported in the included trials, there is an indication that participation in fitness training programs is safe and does not result in serious adverse events.

  • There is some evidence that global indices of disability are reduced after training and that this is mediated largely by mobility improvements.

  • There is some evidence that cardiorespiratory training may improve cardiorespiratory fitness.

  • There is clear evidence that cardiorespiratory training improves measures of walking performance (e.g. walking speed and walking capacity) and reduces dependence on others for ambulation during usual care. Some training effects were retained at follow-up.

  • There is some evidence that mixed training may improve measures of walking performance. Some training effects were retained at follow-up.

  • There are insufficient data to assess reliably the effects of resistance training.

  • There is an indication that the training effect may be greater when fitness training is specific or 'task-related'.

  • There is some evidence that balance improves after mixed and cardiorespiratory training.

  • There are few data relating to quality of life and mood outcomes.

  • There are insufficient data to conduct meaningful subgroup analyses to explore the effects of the type, 'dose', and timing of training on outcome measures.

  • Limited methodological quality of included trials and relatively small sample sizes hamper the generalisability of findings.

Issues for research

Control groups

In terms of trial design, there should be a concerted effort to balance total contact time across all arms in order to avoid confounded results. Preferably, the control intervention should be a non-exercise intervention to avoid training effects. In reality this may be difficult to achieve since even performing activities of daily living may be sufficient to cause training effects in elderly people (Young 2001). However, a comparison of two different doses of training would be a robust way of clarifying whether the content of the training itself is beneficial.

Interventions

Currently there are few well-controlled trials examining interventions to improve muscle force production. Trials of resistance training often focus on pre-specified movements that bear little resemblance to those relevant to everyday life and, even though muscle strength may improve, no functional benefits arise. The nature of the association between physical fitness and functional benefits is complex, and this suggests that training interventions should also address other co-impairments such as balance.

Outcome measures

To measure disability and dependence in stroke is problematic. A variety of disability and assessment scales are usually reported in trials of physical rehabilitation and fitness training. These scales do not always assess the same functional domain and therefore pose the problem of the validity and reliability of combining their results in a meta-analysis. Furthermore, some of these scales are not validated in stroke survivors and, therefore, may lack specificity. Rating scales are also prone to 'ceiling effect' and to skewed distributions. It would be useful if only well-known, validated scales are used in future trials for the assessment of participants' functional performance and if trial investigators would clearly address the problems related to the use of these assessment scales.

Stroke survivors who are eligible for fitness training have typically mild levels of disability. Mild impairments may be difficult to assess and many of the existing disability scales may fail to detect them. However, functional decline over time that is simply due to increasing age and inactivity could mean that mild disability may progress quickly to more serious levels. Therefore, it would be useful to assess long-term outcomes in mild stroke survivors using pre-clinical disability measures (for example Fried 1996).

Long-term studies

Both improvements in physical fitness after training and improvements in physical function after rehabilitation are transient. Since physical fitness may be linked to functional status, the long-term retention of benefit should be routinely examined in trials of fitness training. Fitness and function parameters are known to deteriorate with physical inactivity and to decrease with increasing age. Therefore, it is plausible that short-term effects of training only emerge as being beneficial after a period of functional decline.

There is a need to examine strategies aimed at promoting physical activity and maintaining physical fitness in the long term after stroke.

In conclusion, there is a clear need for larger well-designed trials of physical fitness training. Future trials should include participants with a greater spectrum of stroke severity that includes non-ambulatory patients, have adequate control interventions, and use relevant outcome measures.

Authors' conclusions

Implications for practice

Cardiorespiratory training and mixed training during or after usual stroke care is effective in increasing walking speed and walking capacity in stroke survivors. It is likely that improvements in fitness, mobility, and physical function outcomes are associated with 'task-related' training. Guidance and services for exercise after stroke are developing worldwide, including:

These initiatives are based on existing evidence about the benefits of exercise after stroke and the needs of stroke survivors to have ongoing access to rehabilitation after discharge from hospital. The findings of this review will inform the content of such services.

Implications for research

Larger, well-designed clinical trials are needed to assess the effects of physical fitness training after stroke and to determine the optimal regimen for improving fitness.

Future trials should:

  • comply with the current CONSORT guidelines for reporting of randomised clinical trials (CONSORT 2010);

  • include a broader population of stroke survivors (including non-ambulatory stroke survivors) to allow stratification by gender, level of impairment, and functional ability;

  • assess the effects of physical fitness training in people with specific post-stroke problems, such as people with depression or post-stroke fatigue;

  • be of longer duration (12 weeks or longer);

  • comprise a long-term follow-up.

The training intervention and the control intervention should be comparable in terms of duration to prevent overestimation of training effects. The content of an attention control intervention should be chosen carefully to prevent underestimation of treatment effects caused by confounded physical activity in the control group.

Implications for future updates

The literature on physical fitness training interventions is constantly growing. Complex reviews such as this do attract suggestions to 'split' findings in some way. However, for ease of updating and to allow direct comparison of a range of different fitness interventions the current architecture should remain. It may be desirable to revise some of the inclusion criteria to allow more potentially relevant comparisons to be assessed especially where these are not covered by existing Cochrane Reviews.

Acknowledgements

We thank the Cochrane Stroke Group editorial team for their assistance in preparing the protocol. We are grateful to Brenda Thomas for her assistance in developing the search strategies. We would also thank all investigators who provided further information about existing trials.

We would be grateful if people who are aware of trials potentially relevant for this review could contact David Saunders.

Data and analyses

Download statistical data

Comparison 1. Cardiorespiratory training versus control - end of intervention
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Case fatality221020Odds Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]
1.1 During usual care9414Odds Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]
1.2 After usual care13606Odds Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]
2 Disability - Functional Independence Measure3162Std. Mean Difference (IV, Random, 95% CI)0.21 [-0.10, 0.52]
2.1 During usual care152Std. Mean Difference (IV, Random, 95% CI)0.23 [-0.32, 0.78]
2.2 After usual care2110Std. Mean Difference (IV, Random, 95% CI)0.17 [-0.29, 0.63]
3 Disability - Rivermead Mobility Index (scale 0 to 15)3146Mean Difference (IV, Random, 95% CI)1.56 [0.20, 2.92]
3.1 During usual care2110Mean Difference (IV, Random, 95% CI)1.43 [-0.62, 3.49]
3.2 After usual care136Mean Difference (IV, Random, 95% CI)2.0 [0.53, 3.47]
4 Disability - Physical Activity and Disability Scale158Mean Difference (IV, Random, 95% CI)16.9 [-15.15, 48.95]
4.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
4.2 After usual care158Mean Difference (IV, Random, 95% CI)16.9 [-15.15, 48.95]
5 Disability - combined disability scales6289Std. Mean Difference (IV, Random, 95% CI)0.37 [0.10, 0.64]
5.1 During usual care285Std. Mean Difference (IV, Random, 95% CI)0.51 [-0.10, 1.12]
5.2 After usual care4204Std. Mean Difference (IV, Random, 95% CI)0.33 [-0.00, 0.67]
6 Risk factors - blood pressure, systolic4190Mean Difference (IV, Random, 95% CI)0.40 [-8.38, 9.18]
6.1 During usual care112Mean Difference (IV, Random, 95% CI)26.33 [1.95, 50.71]
6.2 After usual care3178Mean Difference (IV, Random, 95% CI)-2.69 [-8.03, 2.66]
7 Risk factors - blood pressure, diastolic4190Mean Difference (IV, Random, 95% CI)-0.33 [-2.97, 2.31]
7.1 During usual care112Mean Difference (IV, Random, 95% CI)1.0 [-10.46, 12.46]
7.2 After usual care3178Mean Difference (IV, Random, 95% CI)-0.41 [-3.12, 2.31]
8 Physical fitness - peak VO2 (ml/kg/min)7247Mean Difference (IV, Random, 95% CI)2.46 [1.12, 3.80]
8.1 During usual care112Mean Difference (IV, Random, 95% CI)3.43 [0.56, 6.30]
8.2 After usual care6235Mean Difference (IV, Random, 95% CI)2.32 [0.81, 3.84]
9 Physical fitness - gait economy, VO2 (ml/kg/metre)120Mean Difference (IV, Random, 95% CI)-0.08 [-0.28, 0.12]
9.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
9.2 After usual care120Mean Difference (IV, Random, 95% CI)-0.08 [-0.28, 0.12]
10 Physical fitness - maximum cycling work rate (Watts)4221Std. Mean Difference (IV, Random, 95% CI)0.60 [0.18, 1.02]
10.1 During usual care289Std. Mean Difference (IV, Random, 95% CI)0.32 [-0.34, 0.98]
10.2 After usual care2132Std. Mean Difference (IV, Random, 95% CI)0.83 [0.47, 1.18]
11 Mobility - functional ambulation categories273Mean Difference (IV, Random, 95% CI)0.53 [0.21, 0.85]
11.1 During usual care273Mean Difference (IV, Random, 95% CI)0.53 [0.21, 0.85]
11.2 After usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
12 Mobility - maximal gait speed (m/min over 5 to 10 metres)13609Mean Difference (IV, Random, 95% CI)7.37 [3.70, 11.03]
12.1 During usual care8302Mean Difference (IV, Random, 95% CI)8.16 [2.07, 14.25]
12.2 After usual care5307Mean Difference (IV, Random, 95% CI)8.93 [3.54, 14.33]
13 Mobility - preferred gait speed (m/min)8425Mean Difference (IV, Random, 95% CI)4.63 [1.84, 7.43]
13.1 During usual care248Mean Difference (IV, Random, 95% CI)4.02 [-3.36, 11.40]
13.2 After usual care6377Mean Difference (IV, Random, 95% CI)4.69 [1.57, 7.80]
14 Mobility - gait endurance (6-MWT metres)10468Mean Difference (IV, Random, 95% CI)26.99 [9.13, 44.84]
14.1 During usual care4123Mean Difference (IV, Random, 95% CI)17.20 [-7.76, 42.17]
14.2 After usual care6345Mean Difference (IV, Random, 95% CI)44.09 [17.20, 70.98]
15 Mobility - gait endurance (m/min)3154Mean Difference (IV, Random, 95% CI)8.87 [1.35, 16.40]
15.1 During usual care263Mean Difference (IV, Random, 95% CI)12.24 [-3.41, 27.89]
15.2 After usual care191Mean Difference (IV, Random, 95% CI)6.60 [-2.66, 15.86]
16 Mobility - 6 metre walking time (sec)120Mean Difference (IV, Random, 95% CI)-3.32 [-8.52, 1.88]
16.1 During usual care120Mean Difference (IV, Random, 95% CI)-3.32 [-8.52, 1.88]
16.2 After usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
17 Mobility - Stroke Impact Scale (mobility domain)120Mean Difference (IV, Random, 95% CI)-3.20 [-17.14, 10.74]
17.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
17.2 After usual care120Mean Difference (IV, Random, 95% CI)-3.20 [-17.14, 10.74]
18 Mobility - Community walk test (min)125Mean Difference (IV, Random, 95% CI)-10.68 [-35.22, 13.86]
18.1 During usual care125Mean Difference (IV, Random, 95% CI)-10.68 [-35.22, 13.86]
18.2 After usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
19 Mobility - Walking ability questionnaire (score 0 to 76)125Mean Difference (IV, Random, 95% CI)1.04 [-6.71, 8.79]
19.1 During usual care125Mean Difference (IV, Random, 95% CI)1.04 [-6.71, 8.79]
19.2 After usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
20 Physical function - Berg Balance Scale (score 0 to 56)5257Mean Difference (IV, Random, 95% CI)3.14 [0.56, 5.73]
20.1 During usual care2110Mean Difference (IV, Random, 95% CI)2.22 [-1.86, 6.31]
20.2 After usual care3147Mean Difference (IV, Random, 95% CI)4.06 [0.52, 7.60]
21 Physical function - Timed Up and Go (sec)3131Mean Difference (IV, Random, 95% CI)-2.52 [-6.18, 1.15]
21.1 During usual care120Mean Difference (IV, Random, 95% CI)-2.10 [-6.27, 2.07]
21.2 After usual care2111Mean Difference (IV, Random, 95% CI)-3.94 [-11.65, 3.77]
22 Physical function - Functional Reach120Mean Difference (IV, Random, 95% CI)2.20 [0.09, 4.31]
22.1 During usual care120Mean Difference (IV, Random, 95% CI)2.20 [0.09, 4.31]
22.2 After usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
23 Mobility - Activities-Specific Balance Confidence scale (scores 0 to 100)125Mean Difference (IV, Random, 95% CI)10.66 [-4.66, 25.98]
23.1 During usual care125Mean Difference (IV, Random, 95% CI)10.66 [-4.66, 25.98]
23.2 After usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
24 Health-related QoL - SF-36 emotional role functioning128Mean Difference (IV, Random, 95% CI)11.0 [6.15, 15.85]
24.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
24.2 After usual care128Mean Difference (IV, Random, 95% CI)11.0 [6.15, 15.85]
25 Health-related QoL - SF-36 physical functioning128Mean Difference (IV, Random, 95% CI)10.60 [6.51, 14.69]
25.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
25.2 After usual care128Mean Difference (IV, Random, 95% CI)10.60 [6.51, 14.69]
26 Health-related QoL - SF-12 Mental136Mean Difference (IV, Random, 95% CI)9.30 [4.31, 14.29]
26.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
26.2 After usual care136Mean Difference (IV, Random, 95% CI)9.30 [4.31, 14.29]
27 Health-related QoL - SF-12 physical136Mean Difference (IV, Random, 95% CI)2.80 [-1.68, 7.28]
27.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
27.2 After usual care136Mean Difference (IV, Random, 95% CI)2.80 [-1.68, 7.28]
28 Health-related QoL - EuroQol EQ-5D1102Mean Difference (IV, Random, 95% CI)2.59 [-4.47, 9.65]
28.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
28.2 After usual care1102Mean Difference (IV, Random, 95% CI)2.59 [-4.47, 9.65]
29 Mood - Beck Depression Index120Mean Difference (IV, Random, 95% CI)0.60 [-1.60, 2.80]
29.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
29.2 After usual care120Mean Difference (IV, Random, 95% CI)0.60 [-1.60, 2.80]
30 Mood - Hospital Anxiety and Depression Scale (HADS) - anxiety score160Mean Difference (IV, Random, 95% CI)-1.94 [-3.80, -0.08]
30.1 During usual care160Mean Difference (IV, Random, 95% CI)-1.94 [-3.80, -0.08]
30.2 After usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
31 Mood - Hospital Anxiety and Depression Scale (HADS) - depression score160Mean Difference (IV, Random, 95% CI)-1.40 [-3.21, 0.41]
31.1 During usual care160Mean Difference (IV, Random, 95% CI)-1.40 [-3.21, 0.41]
31.2 After usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
Analysis 1.1.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 1 Case fatality.

Analysis 1.2.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 2 Disability - Functional Independence Measure.

Analysis 1.3.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 3 Disability - Rivermead Mobility Index (scale 0 to 15).

Analysis 1.4.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 4 Disability - Physical Activity and Disability Scale.

Analysis 1.5.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 5 Disability - combined disability scales.

Analysis 1.6.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 6 Risk factors - blood pressure, systolic.

Analysis 1.7.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 7 Risk factors - blood pressure, diastolic.

Analysis 1.8.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 8 Physical fitness - peak VO2 (ml/kg/min).

Analysis 1.9.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 9 Physical fitness - gait economy, VO2 (ml/kg/metre).

Analysis 1.10.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 10 Physical fitness - maximum cycling work rate (Watts).

Analysis 1.11.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 11 Mobility - functional ambulation categories.

Analysis 1.12.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 12 Mobility - maximal gait speed (m/min over 5 to 10 metres).

Analysis 1.13.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 13 Mobility - preferred gait speed (m/min).

Analysis 1.14.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 14 Mobility - gait endurance (6-MWT metres).

Analysis 1.15.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 15 Mobility - gait endurance (m/min).

Analysis 1.16.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 16 Mobility - 6 metre walking time (sec).

Analysis 1.17.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 17 Mobility - Stroke Impact Scale (mobility domain).

Analysis 1.18.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 18 Mobility - Community walk test (min).

Analysis 1.19.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 19 Mobility - Walking ability questionnaire (score 0 to 76).

Analysis 1.20.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 20 Physical function - Berg Balance Scale (score 0 to 56).

Analysis 1.21.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 21 Physical function - Timed Up and Go (sec).

Analysis 1.22.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 22 Physical function - Functional Reach.

Analysis 1.23.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 23 Mobility - Activities-Specific Balance Confidence scale (scores 0 to 100).

Analysis 1.24.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 24 Health-related QoL - SF-36 emotional role functioning.

Analysis 1.25.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 25 Health-related QoL - SF-36 physical functioning.

Analysis 1.26.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 26 Health-related QoL - SF-12 Mental.

Analysis 1.27.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 27 Health-related QoL - SF-12 physical.

Analysis 1.28.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 28 Health-related QoL - EuroQol EQ-5D.

Analysis 1.29.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 29 Mood - Beck Depression Index.

Analysis 1.30.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 30 Mood - Hospital Anxiety and Depression Scale (HADS) - anxiety score.

Analysis 1.31.

Comparison 1 Cardiorespiratory training versus control - end of intervention, Outcome 31 Mood - Hospital Anxiety and Depression Scale (HADS) - depression score.

Comparison 2. Cardiorespiratory training versus control - end of retention follow-up
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Case fatality5304Odds Ratio (M-H, Random, 95% CI)1.0 [0.06, 16.48]
1.1 During usual care3226Odds Ratio (M-H, Random, 95% CI)1.0 [0.06, 16.48]
1.2 After usual care278Odds Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]
2 Disability - Rivermead Mobility Index1 Mean Difference (IV, Random, 95% CI)Subtotals only
2.1 During usual care166Mean Difference (IV, Random, 95% CI)-0.25 [-1.85, 1.35]
2.2 During usual care - ITT analysis using 'last observation carried forward' approach184Mean Difference (IV, Random, 95% CI)0.04 [-1.47, 1.55]
2.3 After usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
3 Disability - Nottingham Extended ADL1147Mean Difference (IV, Random, 95% CI)2.90 [-2.68, 8.48]
3.1 During usual care164Mean Difference (IV, Random, 95% CI)2.64 [-5.57, 10.85]
3.2 During usual care - ITT analysis using 'last observation carried forward' approach183Mean Difference (IV, Random, 95% CI)3.13 [-4.48, 10.74]
3.3 After usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
4 Disability - Physical Activity and Disability Scale158Mean Difference (IV, Random, 95% CI)19.90 [-17.58, 57.38]
4.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
4.2 After usual care158Mean Difference (IV, Random, 95% CI)19.90 [-17.58, 57.38]
5 Disability - Frenchay Activities Index (FAI)179Mean Difference (IV, Random, 95% CI)1.0 [-1.55, 3.55]
5.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
5.2 After usual care179Mean Difference (IV, Random, 95% CI)1.0 [-1.55, 3.55]
6 Disability - Combined disability scales3220Std. Mean Difference (IV, Random, 95% CI)0.20 [-0.07, 0.46]
6.1 During usual care - ITT analysis using 'last observation carried forward' approach183Std. Mean Difference (IV, Random, 95% CI)0.18 [-0.26, 0.61]
6.2 After usual care2137Std. Mean Difference (IV, Random, 95% CI)0.21 [-0.12, 0.55]
7 Physical fitness - maximum cycling work rate (Watts)184Mean Difference (IV, Random, 95% CI)5.11 [-18.93, 29.15]
7.1 During usual care184Mean Difference (IV, Random, 95% CI)5.11 [-18.93, 29.15]
7.2 After usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
8 Mobility - maximal gait speed (m/min)5312Mean Difference (IV, Random, 95% CI)6.71 [2.40, 11.02]
8.1 During usual care3152Mean Difference (IV, Random, 95% CI)7.92 [2.01, 13.83]
8.2 After usual care2160Mean Difference (IV, Random, 95% CI)5.33 [-0.96, 11.63]
9 Mobility - preferred gait speed (m/min)2126Mean Difference (IV, Random, 95% CI)0.72 [-6.78, 8.22]
9.1 During usual care124Mean Difference (IV, Random, 95% CI)3.60 [-14.70, 21.90]
9.2 After usual care1102Mean Difference (IV, Random, 95% CI)0.14 [-8.08, 8.37]
10 Mobility - gait endurance (6-MWT metres)4233Mean Difference (IV, Random, 95% CI)33.37 [-8.25, 74.99]
10.1 During usual care273Mean Difference (IV, Random, 95% CI)55.35 [12.38, 98.32]
10.2 After usual care2160Mean Difference (IV, Random, 95% CI)22.34 [-44.02, 88.69]
11 Mobility - peak activity index (steps/min)158Mean Difference (IV, Random, 95% CI)12.20 [1.38, 23.02]
11.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
11.2 After usual care158Mean Difference (IV, Random, 95% CI)12.20 [1.38, 23.02]
12 Mobility - max step rate in 1 min158Mean Difference (IV, Random, 95% CI)12.10 [0.93, 23.27]
12.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
12.2 After usual care158Mean Difference (IV, Random, 95% CI)12.10 [0.93, 23.27]
13 Mobility - Stroke Impact Scale (mobility domain)120Mean Difference (IV, Random, 95% CI)5.90 [-7.97, 19.77]
13.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
13.2 After usual care120Mean Difference (IV, Random, 95% CI)5.90 [-7.97, 19.77]
14 Physical function - Berg Balance scale184Mean Difference (IV, Random, 95% CI)-0.79 [-5.93, 4.35]
14.1 During usual care184Mean Difference (IV, Random, 95% CI)-0.79 [-5.93, 4.35]
14.2 After usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
15 Health-related QoL - EuroQol EQ-5D1102Mean Difference (IV, Random, 95% CI)-6.96 [-14.86, 0.93]
15.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
15.2 After usual care1102Mean Difference (IV, Random, 95% CI)-6.96 [-14.86, 0.93]
16 Mood - Beck Depression Index120Mean Difference (IV, Random, 95% CI)-1.30 [-3.67, 1.07]
16.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
16.2 After usual care120Mean Difference (IV, Random, 95% CI)-1.30 [-3.67, 1.07]
17 Mood - Hospital Anxiety and Depression Scale (HADS) - anxiety score153Mean Difference (IV, Random, 95% CI)-1.6 [-3.58, 0.38]
17.1 During usual care153Mean Difference (IV, Random, 95% CI)-1.6 [-3.58, 0.38]
17.2 After usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
18 Mood - Hospital Anxiety and Depression Scale (HADS) - depression score153Mean Difference (IV, Random, 95% CI)-2.7 [-4.40, 1.00]
18.1 During usual care153Mean Difference (IV, Random, 95% CI)-2.7 [-4.40, 1.00]
18.2 After usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
Analysis 2.1.

Comparison 2 Cardiorespiratory training versus control - end of retention follow-up, Outcome 1 Case fatality.

Analysis 2.2.

Comparison 2 Cardiorespiratory training versus control - end of retention follow-up, Outcome 2 Disability - Rivermead Mobility Index.

Analysis 2.3.

Comparison 2 Cardiorespiratory training versus control - end of retention follow-up, Outcome 3 Disability - Nottingham Extended ADL.

Analysis 2.4.

Comparison 2 Cardiorespiratory training versus control - end of retention follow-up, Outcome 4 Disability - Physical Activity and Disability Scale.

Analysis 2.5.

Comparison 2 Cardiorespiratory training versus control - end of retention follow-up, Outcome 5 Disability - Frenchay Activities Index (FAI).

Analysis 2.6.

Comparison 2 Cardiorespiratory training versus control - end of retention follow-up, Outcome 6 Disability - Combined disability scales.

Analysis 2.7.

Comparison 2 Cardiorespiratory training versus control - end of retention follow-up, Outcome 7 Physical fitness - maximum cycling work rate (Watts).

Analysis 2.8.

Comparison 2 Cardiorespiratory training versus control - end of retention follow-up, Outcome 8 Mobility - maximal gait speed (m/min).

Analysis 2.9.

Comparison 2 Cardiorespiratory training versus control - end of retention follow-up, Outcome 9 Mobility - preferred gait speed (m/min).

Analysis 2.10.

Comparison 2 Cardiorespiratory training versus control - end of retention follow-up, Outcome 10 Mobility - gait endurance (6-MWT metres).

Analysis 2.11.

Comparison 2 Cardiorespiratory training versus control - end of retention follow-up, Outcome 11 Mobility - peak activity index (steps/min).

Analysis 2.12.

Comparison 2 Cardiorespiratory training versus control - end of retention follow-up, Outcome 12 Mobility - max step rate in 1 min.

Analysis 2.13.

Comparison 2 Cardiorespiratory training versus control - end of retention follow-up, Outcome 13 Mobility - Stroke Impact Scale (mobility domain).

Analysis 2.14.

Comparison 2 Cardiorespiratory training versus control - end of retention follow-up, Outcome 14 Physical function - Berg Balance scale.

Analysis 2.15.

Comparison 2 Cardiorespiratory training versus control - end of retention follow-up, Outcome 15 Health-related QoL - EuroQol EQ-5D.

Analysis 2.16.

Comparison 2 Cardiorespiratory training versus control - end of retention follow-up, Outcome 16 Mood - Beck Depression Index.

Analysis 2.17.

Comparison 2 Cardiorespiratory training versus control - end of retention follow-up, Outcome 17 Mood - Hospital Anxiety and Depression Scale (HADS) - anxiety score.

Analysis 2.18.

Comparison 2 Cardiorespiratory training versus control - end of retention follow-up, Outcome 18 Mood - Hospital Anxiety and Depression Scale (HADS) - depression score.

Comparison 3. Resistance training versus control - end of intervention
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Case fatality8274Odds Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]
1.1 During usual care3113Odds Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]
1.2 After usual care5161Odds Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]
2 Physical fitness - composite measure of muscle strength260Std. Mean Difference (IV, Random, 95% CI)0.58 [0.06, 1.10]
2.1 During usual care00Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
2.2 During and after usual care140Std. Mean Difference (IV, Random, 95% CI)0.47 [-0.16, 1.10]
2.3 After usual care120Std. Mean Difference (IV, Random, 95% CI)0.84 [-0.09, 1.76]
3 Physical fitness - muscle strength, knee extension (Nm)242Mean Difference (IV, Random, 95% CI)12.01 [-4.46, 28.47]
3.1 During usual care118Mean Difference (IV, Random, 95% CI)4.80 [-5.98, 15.58]
3.2 After usual care124Mean Difference (IV, Random, 95% CI)21.80 [4.92, 38.68]
4 Physical fitness - muscle strength, knee flexion (Nm)242Mean Difference (IV, Random, 95% CI)9.61 [-5.01, 24.24]
4.1 During usual care118Mean Difference (IV, Random, 95% CI)4.5 [-1.13, 10.13]
4.2 After usual care124Mean Difference (IV, Random, 95% CI)20.5 [0.84, 40.16]
5 Mobility - maximal gait speed (m/min)4104Mean Difference (IV, Random, 95% CI)1.92 [-3.50, 7.35]
5.1 During usual care118Mean Difference (IV, Random, 95% CI)8.40 [2.82, 13.98]
5.2 After usual care386Mean Difference (IV, Random, 95% CI)1.00 [-4.57, 2.57]
6 Mobility - preferred gait speed (m/min)380Mean Difference (IV, Random, 95% CI)2.34 [-6.77, 11.45]
6.1 During usual care118Mean Difference (IV, Random, 95% CI)9.0 [3.42, 14.58]
6.2 After usual care262Mean Difference (IV, Random, 95% CI)-2.61 [-7.73, 2.51]
7 Mobility - gait endurance (6-MWT metres)266Mean Difference (IV, Random, 95% CI)3.78 [-68.56, 76.11]
7.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
7.2 After usual care266Mean Difference (IV, Random, 95% CI)3.78 [-68.56, 76.11]
8 Physical function - weight-bearing (% body weight - affected side)118Mean Difference (IV, Random, 95% CI)11.80 [0.89, 22.71]
8.1 During usual care118Mean Difference (IV, Random, 95% CI)11.80 [0.89, 22.71]
8.2 After usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
9 Physical function - stair climbing, maximal (sec/step)261Std. Mean Difference (IV, Random, 95% CI)-0.04 [-0.86, 0.77]
9.1 During usual care00Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
9.2 After usual care261Std. Mean Difference (IV, Random, 95% CI)-0.04 [-0.86, 0.77]
10 Physical function - Timed Up and Go (sec)124Mean Difference (IV, Random, 95% CI)-1.20 [-11.84, 9.44]
10.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
10.2 After usual care124Mean Difference (IV, Random, 95% CI)-1.20 [-11.84, 9.44]
11 Health-related QoL - SF-36 mental health120Mean Difference (IV, Random, 95% CI)2.8 [-4.95, 10.55]
11.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
11.2 After usual care120Mean Difference (IV, Random, 95% CI)2.8 [-4.95, 10.55]
12 Health-related QoL - SF-36 physical functioning120Mean Difference (IV, Random, 95% CI)1.47 [-4.24, 7.18]
12.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
12.2 After usual care120Mean Difference (IV, Random, 95% CI)1.47 [-4.24, 7.18]
13 Mood - Centre for Epidemiologic Studies for Depression scale (CES-D)188Mean Difference (IV, Random, 95% CI)-5.49 [-9.78, -1.20]
13.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
13.2 After usual care188Mean Difference (IV, Random, 95% CI)-5.49 [-9.78, -1.20]
14 Mood - State Trait Anxiety Inventory - Trait Anxiety (score 20 to 80)124Mean Difference (IV, Random, 95% CI)-2.70 [-10.57, 5.17]
14.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
14.2 After usual care124Mean Difference (IV, Random, 95% CI)-2.70 [-10.57, 5.17]
15 Mood - State Trait Anxiety Inventory - State Anxiety (score 20 to 80)124Mean Difference (IV, Random, 95% CI)-2.60 [-8.89, 3.69]
15.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
15.2 After usual care124Mean Difference (IV, Random, 95% CI)-2.60 [-8.89, 3.69]
Analysis 3.1.

Comparison 3 Resistance training versus control - end of intervention, Outcome 1 Case fatality.

Analysis 3.2.

Comparison 3 Resistance training versus control - end of intervention, Outcome 2 Physical fitness - composite measure of muscle strength.

Analysis 3.3.

Comparison 3 Resistance training versus control - end of intervention, Outcome 3 Physical fitness - muscle strength, knee extension (Nm).

Analysis 3.4.

Comparison 3 Resistance training versus control - end of intervention, Outcome 4 Physical fitness - muscle strength, knee flexion (Nm).

Analysis 3.5.

Comparison 3 Resistance training versus control - end of intervention, Outcome 5 Mobility - maximal gait speed (m/min).

Analysis 3.6.

Comparison 3 Resistance training versus control - end of intervention, Outcome 6 Mobility - preferred gait speed (m/min).

Analysis 3.7.

Comparison 3 Resistance training versus control - end of intervention, Outcome 7 Mobility - gait endurance (6-MWT metres).

Analysis 3.8.

Comparison 3 Resistance training versus control - end of intervention, Outcome 8 Physical function - weight-bearing (% body weight - affected side).

Analysis 3.9.

Comparison 3 Resistance training versus control - end of intervention, Outcome 9 Physical function - stair climbing, maximal (sec/step).

Analysis 3.10.

Comparison 3 Resistance training versus control - end of intervention, Outcome 10 Physical function - Timed Up and Go (sec).

Analysis 3.11.

Comparison 3 Resistance training versus control - end of intervention, Outcome 11 Health-related QoL - SF-36 mental health.

Analysis 3.12.

Comparison 3 Resistance training versus control - end of intervention, Outcome 12 Health-related QoL - SF-36 physical functioning.

Analysis 3.13.

Comparison 3 Resistance training versus control - end of intervention, Outcome 13 Mood - Centre for Epidemiologic Studies for Depression scale (CES-D).

Analysis 3.14.

Comparison 3 Resistance training versus control - end of intervention, Outcome 14 Mood - State Trait Anxiety Inventory - Trait Anxiety (score 20 to 80).

Analysis 3.15.

Comparison 3 Resistance training versus control - end of intervention, Outcome 15 Mood - State Trait Anxiety Inventory - State Anxiety (score 20 to 80).

Comparison 4. Resistance training versus control - end of retention follow-up
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Case fatality3138Odds Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]
1.1 During usual care295Odds Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]
1.2 After usual care143Odds Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]
2 Physical fitness - muscle strength, knee extension (Nm)124Mean Difference (IV, Random, 95% CI)17.4 [-0.01, 34.81]
2.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
2.2 After usual care124Mean Difference (IV, Random, 95% CI)17.4 [-0.01, 34.81]
3 Physical fitness - muscle strength, knee flexion (Nm)124Mean Difference (IV, Random, 95% CI)17.60 [-2.17, 37.37]
3.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
3.2 After usual care124Mean Difference (IV, Random, 95% CI)17.60 [-2.17, 37.37]
4 Mobility - maximal gait speed (m/min)124Mean Difference (IV, Random, 95% CI)-19.80 [-95.77, 56.17]
4.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
4.2 After usual care124Mean Difference (IV, Random, 95% CI)-19.80 [-95.77, 56.17]
5 Mobility - gait endurance (6-MWT metres)124Mean Difference (IV, Random, 95% CI)11.0 [-105.95, 127.95]
5.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
5.2 After usual care124Mean Difference (IV, Random, 95% CI)11.0 [-105.95, 127.95]
6 Physical function - Timed Up and Go (sec)124Mean Difference (IV, Random, 95% CI)-3.10 [-16.67, 10.47]
6.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
6.2 After usual care124Mean Difference (IV, Random, 95% CI)-3.10 [-16.67, 10.47]
7 Mood - Centre for Epidemiologic Studies for Depression scale (CES-D)186Mean Difference (IV, Random, 95% CI)-8.92 [-13.03, -4.81]
7.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
7.2 After usual care186Mean Difference (IV, Random, 95% CI)-8.92 [-13.03, -4.81]
Analysis 4.1.

Comparison 4 Resistance training versus control - end of retention follow-up, Outcome 1 Case fatality.

Analysis 4.2.

Comparison 4 Resistance training versus control - end of retention follow-up, Outcome 2 Physical fitness - muscle strength, knee extension (Nm).

Analysis 4.3.

Comparison 4 Resistance training versus control - end of retention follow-up, Outcome 3 Physical fitness - muscle strength, knee flexion (Nm).

Analysis 4.4.

Comparison 4 Resistance training versus control - end of retention follow-up, Outcome 4 Mobility - maximal gait speed (m/min).

Analysis 4.5.

Comparison 4 Resistance training versus control - end of retention follow-up, Outcome 5 Mobility - gait endurance (6-MWT metres).

Analysis 4.6.

Comparison 4 Resistance training versus control - end of retention follow-up, Outcome 6 Physical function - Timed Up and Go (sec).

Analysis 4.7.

Comparison 4 Resistance training versus control - end of retention follow-up, Outcome 7 Mood - Centre for Epidemiologic Studies for Depression scale (CES-D).

Comparison 5. Mixed training versus control - end of intervention
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Case fatality15918Odds Ratio (M-H, Random, 95% CI)0.18 [0.03, 1.03]
1.1 During usual care5215Odds Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]
1.2 After usual care10703Odds Ratio (M-H, Random, 95% CI)0.18 [0.03, 1.03]
2 Disability - Lawton IADL2113Mean Difference (IV, Random, 95% CI)0.83 [-0.51, 2.17]
2.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
2.2 After usual care2113Mean Difference (IV, Random, 95% CI)0.83 [-0.51, 2.17]
3 Disability - Barthel Index (BI)4218Mean Difference (IV, Random, 95% CI)2.65 [-0.95, 6.25]
3.1 During usual care140Mean Difference (IV, Random, 95% CI)6.70 [-3.97, 17.37]
3.2 After usual care3178Mean Difference (IV, Random, 95% CI)1.99 [-2.32, 6.29]
4 Disability - Rivermead Mobility Index (RMI)2308Mean Difference (IV, Random, 95% CI)0.48 [0.05, 0.91]
4.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
4.2 After usual care2308Mean Difference (IV, Random, 95% CI)0.48 [0.05, 0.91]
5 Disability - Nottingham Extended ADL166Mean Difference (IV, Random, 95% CI)-0.20 [-1.08, 0.68]
5.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
5.2 After usual care166Mean Difference (IV, Random, 95% CI)-0.20 [-1.08, 0.68]
6 Disability - Functional Independence Measure (FIM)166Mean Difference (IV, Random, 95% CI)-0.10 [-1.70, 1.50]
6.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
6.2 After usual care166Mean Difference (IV, Random, 95% CI)-0.10 [-1.70, 1.50]
7 Disability - Stroke Impact Scale (SIS-16)194Mean Difference (IV, Random, 95% CI)6.0 [0.19, 11.81]
7.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
7.2 After usual care194Mean Difference (IV, Random, 95% CI)6.0 [0.19, 11.81]
8 Disability - Combined disability scales6526Std. Mean Difference (IV, Random, 95% CI)0.24 [0.00, 0.47]
8.1 During usual care140Std. Mean Difference (IV, Random, 95% CI)0.38 [-0.24, 1.01]
8.2 After usual care5486Std. Mean Difference (IV, Random, 95% CI)0.21 [-0.06, 0.48]
9 Risk factors - blood pressure, systolic128Mean Difference (IV, Random, 95% CI)3.20 [-9.55, 15.95]
9.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
9.2 After usual care128Mean Difference (IV, Random, 95% CI)3.20 [-9.55, 15.95]
10 Risk factors - blood pressure, diastolic128Mean Difference (IV, Random, 95% CI)-0.80 [-5.59, 3.99]
10.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
10.2 After usual care128Mean Difference (IV, Random, 95% CI)-0.80 [-5.59, 3.99]
11 Physical fitness - peak VO2 (ml/kg/min)1100Mean Difference (IV, Random, 95% CI)0.99 [0.35, 1.63]
11.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
11.2 After usual care1100Mean Difference (IV, Random, 95% CI)0.99 [0.35, 1.63]
12 Physical fitness - gait economy, VO2 (ml/kg/metre)166Mean Difference (IV, Random, 95% CI)-0.01 [-0.03, -0.00]
12.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
12.2 After usual care166Mean Difference (IV, Random, 95% CI)-0.01 [-0.03, -0.00]
13 Physical fitness - muscle strength, ankle dorsiflexion*2148Std. Mean Difference (IV, Random, 95% CI)0.80 [-0.82, 2.41]
13.1 During usual care00Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
13.2 After usual care2148Std. Mean Difference (IV, Random, 95% CI)0.80 [-0.82, 2.41]
14 Physical fitness - muscle strength, knee extension*3202Std. Mean Difference (IV, Random, 95% CI)0.33 [0.05, 0.61]
14.1 During usual care154Std. Mean Difference (IV, Random, 95% CI)0.29 [-0.25, 0.83]
14.2 After usual care2148Std. Mean Difference (IV, Random, 95% CI)0.36 [-0.02, 0.73]
15 Physical fitness - muscle strength, knee flexion154Mean Difference (IV, Random, 95% CI)6.40 [-3.76, 16.56]
15.1 During usual care154Mean Difference (IV, Random, 95% CI)6.40 [-3.76, 16.56]
15.2 After usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
16 Physical fitness - muscle strength, elbow extension force (N)118Mean Difference (IV, Random, 95% CI)-19.43 [-54.11, 15.25]
16.1 During usual care118Mean Difference (IV, Random, 95% CI)-19.43 [-54.11, 15.25]
16.2 After usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
17 Physical fitness - muscle strength, elbow flexion force (N)118Mean Difference (IV, Random, 95% CI)-15.50 [-54.04, 23.04]
17.1 During usual care118Mean Difference (IV, Random, 95% CI)-15.50 [-54.04, 23.04]
17.2 After usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
18 Physical fitness - muscle strength, grip force (N)118Mean Difference (IV, Random, 95% CI)-6.25 [-52.41, 39.91]
18.1 During usual care118Mean Difference (IV, Random, 95% CI)-6.25 [-52.41, 39.91]
18.2 After usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
19 Physical fitness - muscle strength, grip strength (paretic hand)2165Std. Mean Difference (IV, Random, 95% CI)-0.05 [-0.36, 0.26]
19.1 During usual care00Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
19.2 After usual care2165Std. Mean Difference (IV, Random, 95% CI)-0.05 [-0.36, 0.26]
20 Physical fitness - muscle strength, leg extensor power (affected leg) W/Kg166Mean Difference (IV, Random, 95% CI)0.07 [-0.08, 0.22]
20.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
20.2 After usual care166Mean Difference (IV, Random, 95% CI)0.07 [-0.08, 0.22]
21 Mobility - Functional Ambulation Categories1242Mean Difference (IV, Random, 95% CI)0.10 [-0.02, 0.22]
21.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
21.2 After usual care1242Mean Difference (IV, Random, 95% CI)0.10 [-0.02, 0.22]
22 Mobility - preferred gait speed (m/min)9639Mean Difference (IV, Random, 95% CI)4.54 [0.95, 8.14]
22.1 During usual care3153Mean Difference (IV, Random, 95% CI)3.37 [-2.63, 9.37]
22.2 After usual care6486Mean Difference (IV, Random, 95% CI)4.97 [0.68, 9.26]
23 Mobility - preferred gait speed (m/min); subgroup: therapy time9639Mean Difference (IV, Random, 95% CI)4.54 [0.95, 8.14]
23.1 Confounded6438Mean Difference (IV, Random, 95% CI)6.32 [1.08, 11.55]
23.2 Unconfounded3201Mean Difference (IV, Random, 95% CI)0.49 [-2.96, 3.94]
24 Mobility - gait endurance (6 MWT metres)7561Mean Difference (IV, Random, 95% CI)41.60 [25.25, 57.95]
24.1 During usual care140Mean Difference (IV, Random, 95% CI)66.30 [-19.79, 152.39]
24.2 After usual care6521Mean Difference (IV, Random, 95% CI)40.68 [24.03, 57.33]
25 Mobility - Community Ambulation Speed (> 0.8 m/sec)3232Odds Ratio (M-H, Random, 95% CI)1.38 [0.78, 2.42]
25.1 During usual care167Odds Ratio (M-H, Random, 95% CI)1.75 [0.46, 6.65]
25.2 After usual care2165Odds Ratio (M-H, Random, 95% CI)1.31 [0.70, 2.44]
26 Physical function - Balance - Berg Balance scale5239Std. Mean Difference (IV, Random, 95% CI)0.32 [0.00, 0.65]
26.1 During usual care3119Std. Mean Difference (IV, Random, 95% CI)0.18 [-0.28, 0.64]
26.2 After usual care2120Std. Mean Difference (IV, Random, 95% CI)0.54 [0.17, 0.90]
27 Physical function - Balance - Functional reach2166Std. Mean Difference (IV, Random, 95% CI)0.14 [-0.22, 0.50]
27.1 During usual care00Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
27.2 After usual care2166Std. Mean Difference (IV, Random, 95% CI)0.14 [-0.22, 0.50]
28 Physical function - Balance - Four Square Step Test128Mean Difference (IV, Random, 95% CI)3.00 [-1.21, 7.21]
28.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
28.2 After usual care128Mean Difference (IV, Random, 95% CI)3.00 [-1.21, 7.21]
29 Physical function - Balance - Timed balance test1242Mean Difference (IV, Random, 95% CI)0.32 [0.06, 0.58]
29.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
29.2 After usual care1242Mean Difference (IV, Random, 95% CI)0.32 [0.06, 0.58]
30 Physical function - Balance - combined outcome data8575Std. Mean Difference (IV, Random, 95% CI)0.26 [0.04, 0.49]
30.1 During usual care3119Std. Mean Difference (IV, Random, 95% CI)0.18 [-0.28, 0.64]
30.2 After usual care5456Std. Mean Difference (IV, Random, 95% CI)0.30 [0.02, 0.57]
31 Physical function - Action Research Arm Test118Mean Difference (IV, Random, 95% CI)-1.40 [-16.58, 13.78]
31.1 During usual care118Mean Difference (IV, Random, 95% CI)-1.40 [-16.58, 13.78]
31.2 After usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
32 Physical function - Timed Up and Go (sec)4418Mean Difference (IV, Random, 95% CI)-1.37 [-2.26, -0.47]
32.1 During usual care162Mean Difference (IV, Random, 95% CI)-2.0 [-11.24, 7.24]
32.2 After usual care3356Mean Difference (IV, Random, 95% CI)-1.75 [-3.37, -0.12]
33 Physical function - Timed Up and Go (sec) - sensitivity analysis - unconfounded trials2128Mean Difference (IV, Random, 95% CI)-1.13 [-2.91, 0.65]
33.1 During usual care162Mean Difference (IV, Random, 95% CI)-2.0 [-11.24, 7.24]
33.2 After usual care166Mean Difference (IV, Random, 95% CI)-1.10 [-2.91, 0.71]
34 Health-related QoL - EuroQol (Health State)167Mean Difference (IV, Random, 95% CI)0.12 [-0.03, 0.27]
34.1 During usual care167Mean Difference (IV, Random, 95% CI)0.12 [-0.03, 0.27]
34.2 After usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
35 Health-related QoL - EuroQol (self perceived health)167Mean Difference (IV, Random, 95% CI)9.10 [-0.14, 18.34]
35.1 During usual care167Mean Difference (IV, Random, 95% CI)9.10 [-0.14, 18.34]
35.2 After usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
36 Health-related QoL - SF-36 physical functioning2112Std. Mean Difference (IV, Random, 95% CI)0.48 [0.10, 0.85]
36.1 During usual care00Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
36.2 After usual care2112Std. Mean Difference (IV, Random, 95% CI)0.48 [0.10, 0.85]
37 Health-related QoL - SF-36 social role functioning2112Std. Mean Difference (IV, Random, 95% CI)0.48 [-0.22, 1.17]
37.1 During usual care00Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
37.2 After usual care2112Std. Mean Difference (IV, Random, 95% CI)0.48 [-0.22, 1.17]
38 Health-related QoL - SF-36 physical role functioning3178Std. Mean Difference (IV, Random, 95% CI)0.56 [0.26, 0.86]
38.1 During usual care00Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
38.2 After usual care3178Std. Mean Difference (IV, Random, 95% CI)0.56 [0.26, 0.86]
39 Health-related QoL - SF-36 emotional role functioning193Mean Difference (IV, Random, 95% CI)15.5 [2.98, 28.02]
39.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
39.2 After usual care193Mean Difference (IV, Random, 95% CI)15.5 [2.98, 28.02]
40 Health-related QoL - Stroke-Adapted Sickness Impact profile183Mean Difference (IV, Random, 95% CI)-2.70 [-7.81, 2.41]
40.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
40.2 After usual care183Mean Difference (IV, Random, 95% CI)-2.70 [-7.81, 2.41]
41 Mood - Stroke Impact Scale emotion score2335Mean Difference (IV, Random, 95% CI)2.87 [-3.40, 9.14]
41.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
41.2 After usual care2335Mean Difference (IV, Random, 95% CI)2.87 [-3.40, 9.14]
42 Mood - Geriatric Depression Scale193Mean Difference (IV, Random, 95% CI)-1.90 [-3.10, -0.70]
42.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
42.2 After usual care193Mean Difference (IV, Random, 95% CI)-1.90 [-3.10, -0.70]
43 Mood - Hospital Anxiety and Depression Scale (HADS)- anxiety score3391Mean Difference (IV, Random, 95% CI)-0.28 [-0.95, 0.40]
43.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
43.2 After usual care3391Mean Difference (IV, Random, 95% CI)-0.28 [-0.95, 0.40]
44 Mood - Hospital Anxiety and Depression Scale (HADS) - depression score3391Mean Difference (IV, Random, 95% CI)0.59 [-0.08, 1.26]
44.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
44.2 After usual care3391Mean Difference (IV, Random, 95% CI)0.59 [-0.08, 1.26]
Analysis 5.1.

Comparison 5 Mixed training versus control - end of intervention, Outcome 1 Case fatality.

Analysis 5.2.

Comparison 5 Mixed training versus control - end of intervention, Outcome 2 Disability - Lawton IADL.

Analysis 5.3.

Comparison 5 Mixed training versus control - end of intervention, Outcome 3 Disability - Barthel Index (BI).

Analysis 5.4.

Comparison 5 Mixed training versus control - end of intervention, Outcome 4 Disability - Rivermead Mobility Index (RMI).

Analysis 5.5.

Comparison 5 Mixed training versus control - end of intervention, Outcome 5 Disability - Nottingham Extended ADL.

Analysis 5.6.

Comparison 5 Mixed training versus control - end of intervention, Outcome 6 Disability - Functional Independence Measure (FIM).

Analysis 5.7.

Comparison 5 Mixed training versus control - end of intervention, Outcome 7 Disability - Stroke Impact Scale (SIS-16).

Analysis 5.8.

Comparison 5 Mixed training versus control - end of intervention, Outcome 8 Disability - Combined disability scales.

Analysis 5.9.

Comparison 5 Mixed training versus control - end of intervention, Outcome 9 Risk factors - blood pressure, systolic.

Analysis 5.10.

Comparison 5 Mixed training versus control - end of intervention, Outcome 10 Risk factors - blood pressure, diastolic.

Analysis 5.11.

Comparison 5 Mixed training versus control - end of intervention, Outcome 11 Physical fitness - peak VO2 (ml/kg/min).

Analysis 5.12.

Comparison 5 Mixed training versus control - end of intervention, Outcome 12 Physical fitness - gait economy, VO2 (ml/kg/metre).

Analysis 5.13.

Comparison 5 Mixed training versus control - end of intervention, Outcome 13 Physical fitness - muscle strength, ankle dorsiflexion*.

Analysis 5.14.

Comparison 5 Mixed training versus control - end of intervention, Outcome 14 Physical fitness - muscle strength, knee extension*.

Analysis 5.15.

Comparison 5 Mixed training versus control - end of intervention, Outcome 15 Physical fitness - muscle strength, knee flexion.

Analysis 5.16.

Comparison 5 Mixed training versus control - end of intervention, Outcome 16 Physical fitness - muscle strength, elbow extension force (N).

Analysis 5.17.

Comparison 5 Mixed training versus control - end of intervention, Outcome 17 Physical fitness - muscle strength, elbow flexion force (N).

Analysis 5.18.

Comparison 5 Mixed training versus control - end of intervention, Outcome 18 Physical fitness - muscle strength, grip force (N).

Analysis 5.19.

Comparison 5 Mixed training versus control - end of intervention, Outcome 19 Physical fitness - muscle strength, grip strength (paretic hand).

Analysis 5.20.

Comparison 5 Mixed training versus control - end of intervention, Outcome 20 Physical fitness - muscle strength, leg extensor power (affected leg) W/Kg.

Analysis 5.21.

Comparison 5 Mixed training versus control - end of intervention, Outcome 21 Mobility - Functional Ambulation Categories.

Analysis 5.22.

Comparison 5 Mixed training versus control - end of intervention, Outcome 22 Mobility - preferred gait speed (m/min).

Analysis 5.23.

Comparison 5 Mixed training versus control - end of intervention, Outcome 23 Mobility - preferred gait speed (m/min); subgroup: therapy time.

Analysis 5.24.

Comparison 5 Mixed training versus control - end of intervention, Outcome 24 Mobility - gait endurance (6 MWT metres).

Analysis 5.25.

Comparison 5 Mixed training versus control - end of intervention, Outcome 25 Mobility - Community Ambulation Speed (> 0.8 m/sec).

Analysis 5.26.

Comparison 5 Mixed training versus control - end of intervention, Outcome 26 Physical function - Balance - Berg Balance scale.

Analysis 5.27.

Comparison 5 Mixed training versus control - end of intervention, Outcome 27 Physical function - Balance - Functional reach.

Analysis 5.28.

Comparison 5 Mixed training versus control - end of intervention, Outcome 28 Physical function - Balance - Four Square Step Test.

Analysis 5.29.

Comparison 5 Mixed training versus control - end of intervention, Outcome 29 Physical function - Balance - Timed balance test.

Analysis 5.30.

Comparison 5 Mixed training versus control - end of intervention, Outcome 30 Physical function - Balance - combined outcome data.

Analysis 5.31.

Comparison 5 Mixed training versus control - end of intervention, Outcome 31 Physical function - Action Research Arm Test.

Analysis 5.32.

Comparison 5 Mixed training versus control - end of intervention, Outcome 32 Physical function - Timed Up and Go (sec).

Analysis 5.33.

Comparison 5 Mixed training versus control - end of intervention, Outcome 33 Physical function - Timed Up and Go (sec) - sensitivity analysis - unconfounded trials.

Analysis 5.34.

Comparison 5 Mixed training versus control - end of intervention, Outcome 34 Health-related QoL - EuroQol (Health State).

Analysis 5.35.

Comparison 5 Mixed training versus control - end of intervention, Outcome 35 Health-related QoL - EuroQol (self perceived health).

Analysis 5.36.

Comparison 5 Mixed training versus control - end of intervention, Outcome 36 Health-related QoL - SF-36 physical functioning.

Analysis 5.37.

Comparison 5 Mixed training versus control - end of intervention, Outcome 37 Health-related QoL - SF-36 social role functioning.

Analysis 5.38.

Comparison 5 Mixed training versus control - end of intervention, Outcome 38 Health-related QoL - SF-36 physical role functioning.

Analysis 5.39.

Comparison 5 Mixed training versus control - end of intervention, Outcome 39 Health-related QoL - SF-36 emotional role functioning.

Analysis 5.40.

Comparison 5 Mixed training versus control - end of intervention, Outcome 40 Health-related QoL - Stroke-Adapted Sickness Impact profile.

Analysis 5.41.

Comparison 5 Mixed training versus control - end of intervention, Outcome 41 Mood - Stroke Impact Scale emotion score.

Analysis 5.42.

Comparison 5 Mixed training versus control - end of intervention, Outcome 42 Mood - Geriatric Depression Scale.

Analysis 5.43.

Comparison 5 Mixed training versus control - end of intervention, Outcome 43 Mood - Hospital Anxiety and Depression Scale (HADS)- anxiety score.

Analysis 5.44.

Comparison 5 Mixed training versus control - end of intervention, Outcome 44 Mood - Hospital Anxiety and Depression Scale (HADS) - depression score.

Comparison 6. Mixed training versus control - end of retention follow-up
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Case fatality11762Odds Ratio (M-H, Random, 95% CI)0.27 [0.06, 1.11]
1.1 During usual care6243Odds Ratio (M-H, Random, 95% CI)0.19 [0.02, 1.68]
1.2 After usual care5519Odds Ratio (M-H, Random, 95% CI)0.34 [0.05, 2.28]
2 Disability - Barthel Index (BI)2103Mean Difference (IV, Random, 95% CI)1.82 [-13.69, 17.33]
2.1 During usual care140Mean Difference (IV, Random, 95% CI)9.0 [-1.29, 19.29]
2.2 After usual care163Mean Difference (IV, Random, 95% CI)-6.90 [-21.05, 7.25]
3 Disability - Functional Independence Measure (FIM)166Mean Difference (IV, Random, 95% CI)0.20 [-1.88, 2.28]
3.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
3.2 After usual care166Mean Difference (IV, Random, 95% CI)0.20 [-1.88, 2.28]
4 Disability - Nottingham Extended ADL2106Mean Difference (IV, Random, 95% CI)3.10 [-5.20, 11.40]
4.1 During usual care140Mean Difference (IV, Random, 95% CI)9.5 [-1.83, 20.83]
4.2 After usual care166Mean Difference (IV, Random, 95% CI)0.30 [-0.93, 1.53]
5 Disability - Rivermead Mobility Index (RMI)2308Mean Difference (IV, Random, 95% CI)0.39 [0.04, 0.73]
5.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
5.2 After usual care2308Mean Difference (IV, Random, 95% CI)0.39 [0.04, 0.73]
6 Disability - Combined disability scales4411Std. Mean Difference (IV, Random, 95% CI)0.16 [-0.12, 0.44]
6.1 During usual care140Std. Mean Difference (IV, Random, 95% CI)0.53 [-0.10, 1.16]
6.2 After usual care3371Std. Mean Difference (IV, Random, 95% CI)0.09 [-0.22, 0.40]
7 Physical fitness - gait economy, VO2 (ml/kg/metre)166Mean Difference (IV, Random, 95% CI)-0.00 [-0.02, 0.01]
7.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
7.2 After usual care166Mean Difference (IV, Random, 95% CI)-0.00 [-0.02, 0.01]
8 Physical fitness - muscle strength, knee flexion142Mean Difference (IV, Random, 95% CI)4.20 [-9.36, 17.76]
8.1 During usual care142Mean Difference (IV, Random, 95% CI)4.20 [-9.36, 17.76]
8.2 After usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
9 Physical fitness - muscle strength, knee extension142Mean Difference (IV, Random, 95% CI)4.20 [-12.71, 21.11]
9.1 During usual care142Mean Difference (IV, Random, 95% CI)4.20 [-12.71, 21.11]
9.2 After usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
10 Physical fitness - muscle strength, leg extensor power (affected leg) W/Kg166Mean Difference (IV, Random, 95% CI)0.02 [-0.13, 0.17]
10.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
10.2 After usual care166Mean Difference (IV, Random, 95% CI)0.02 [-0.13, 0.17]
11 Physical fitness - grip strength (paretic hand)163Mean Difference (IV, Random, 95% CI)-0.04 [-0.26, 0.18]
11.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
11.2 After usual care163Mean Difference (IV, Random, 95% CI)-0.04 [-0.26, 0.18]
12 Mobility - Functional Ambulation Categories1242Mean Difference (IV, Random, 95% CI)0.11 [0.00, 0.22]
12.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
12.2 After usual care1242Mean Difference (IV, Random, 95% CI)0.11 [0.00, 0.22]
13 Mobility - preferred gait speed (m/min)4443Mean Difference (IV, Random, 95% CI)1.60 [-5.62, 8.82]
13.1 During usual care2136Mean Difference (IV, Random, 95% CI)-1.02 [-8.64, 6.60]
13.2 After usual care2307Mean Difference (IV, Random, 95% CI)3.45 [-8.19, 15.08]
14 Mobility - gait endurance (6-MWT metres)3365Mean Difference (IV, Random, 95% CI)51.62 [25.20, 78.03]
14.1 During usual care140Mean Difference (IV, Random, 95% CI)109.50 [17.12, 201.88]
14.2 After usual care2325Mean Difference (IV, Random, 95% CI)46.46 [18.89, 74.03]
15 Mobility - community ambulation speed (> 0.8 m/sec)3217Odds Ratio (M-H, Random, 95% CI)1.33 [0.70, 2.53]
15.1 During usual care152Odds Ratio (M-H, Random, 95% CI)2.14 [0.56, 8.12]
15.2 After usual care2165Odds Ratio (M-H, Random, 95% CI)1.15 [0.48, 2.76]
16 Physical function - Balance - Berg Balance scale2102Mean Difference (IV, Random, 95% CI)2.22 [-7.79, 12.22]
16.1 During usual care2102Mean Difference (IV, Random, 95% CI)2.22 [-7.79, 12.22]
16.2 After usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
17 Physical function - Balance - Functional reach166Mean Difference (IV, Random, 95% CI)2.5 [-0.97, 5.97]
17.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
17.2 After usual care166Mean Difference (IV, Random, 95% CI)2.5 [-0.97, 5.97]
18 Physical function - Balance - Timed balance test1242Mean Difference (IV, Random, 95% CI)0.46 [0.09, 0.83]
18.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
18.2 After usual care1242Mean Difference (IV, Random, 95% CI)0.46 [0.09, 0.83]
19 Physical function - Timed Up and Go (sec)3370Mean Difference (IV, Random, 95% CI)-1.37 [-3.86, 1.12]
19.1 During usual care162Mean Difference (IV, Random, 95% CI)0.0 [-6.97, 6.97]
19.2 After usual care2308Mean Difference (IV, Random, 95% CI)-1.65 [-4.84, 1.53]
20 Health-related QoL - EuroQol (Health State)150Mean Difference (IV, Random, 95% CI)0.04 [-0.12, 0.20]
20.1 During usual care150Mean Difference (IV, Random, 95% CI)0.04 [-0.12, 0.20]
20.2 After usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
21 Health-related QoL - EuroQol (self perceived health)149Mean Difference (IV, Random, 95% CI)3.40 [-7.31, 14.11]
21.1 During usual care149Mean Difference (IV, Random, 95% CI)3.40 [-7.31, 14.11]
21.2 After usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
22 Health-related QoL - SF-36 physical functioning2146Mean Difference (IV, Random, 95% CI)2.46 [-7.20, 12.11]
22.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
22.2 After usual care2146Mean Difference (IV, Random, 95% CI)2.46 [-7.20, 12.11]
23 Health-related QoL - SF-36 physical role functioning2146Mean Difference (IV, Random, 95% CI)11.61 [2.38, 20.84]
23.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
23.2 After usual care2146Mean Difference (IV, Random, 95% CI)11.61 [2.38, 20.84]
24 Health-related QoL - SF-36 emotional role functioning180Mean Difference (IV, Random, 95% CI)10.0 [-2.28, 22.28]
24.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
24.2 After usual care180Mean Difference (IV, Random, 95% CI)10.0 [-2.28, 22.28]
25 Health-related QoL - Stroke-Adapted Sickness Impact profile183Mean Difference (IV, Random, 95% CI)-0.70 [-6.16, 4.76]
25.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
25.2 After usual care183Mean Difference (IV, Random, 95% CI)-0.70 [-6.16, 4.76]
26 Mood - Stroke Impact Scale emotion score2322Mean Difference (IV, Random, 95% CI)0.13 [-3.26, 3.51]
26.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
26.2 After usual care2322Mean Difference (IV, Random, 95% CI)0.13 [-3.26, 3.51]
27 Mood - Geriatric Depression Scale180Mean Difference (IV, Random, 95% CI)-1.4 [-2.54, -0.26]
27.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
27.2 After usual care180Mean Difference (IV, Random, 95% CI)-1.4 [-2.54, -0.26]
28 Mood - Hospital Anxiety and Depression Scale (HADS) - anxiety score3391Mean Difference (IV, Random, 95% CI)-0.11 [-0.78, 0.57]
28.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
28.2 After usual care3391Mean Difference (IV, Random, 95% CI)-0.11 [-0.78, 0.57]
29 Mood - Hospital Anxiety and Depression Scale (HADS) - depression score3391Mean Difference (IV, Random, 95% CI)0.26 [-0.43, 0.96]
29.1 During usual care00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
29.2 After usual care3391Mean Difference (IV, Random, 95% CI)0.26 [-0.43, 0.96]
Analysis 6.1.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 1 Case fatality.

Analysis 6.2.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 2 Disability - Barthel Index (BI).

Analysis 6.3.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 3 Disability - Functional Independence Measure (FIM).

Analysis 6.4.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 4 Disability - Nottingham Extended ADL.

Analysis 6.5.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 5 Disability - Rivermead Mobility Index (RMI).

Analysis 6.6.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 6 Disability - Combined disability scales.

Analysis 6.7.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 7 Physical fitness - gait economy, VO2 (ml/kg/metre).

Analysis 6.8.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 8 Physical fitness - muscle strength, knee flexion.

Analysis 6.9.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 9 Physical fitness - muscle strength, knee extension.

Analysis 6.10.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 10 Physical fitness - muscle strength, leg extensor power (affected leg) W/Kg.

Analysis 6.11.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 11 Physical fitness - grip strength (paretic hand).

Analysis 6.12.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 12 Mobility - Functional Ambulation Categories.

Analysis 6.13.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 13 Mobility - preferred gait speed (m/min).

Analysis 6.14.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 14 Mobility - gait endurance (6-MWT metres).

Analysis 6.15.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 15 Mobility - community ambulation speed (> 0.8 m/sec).

Analysis 6.16.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 16 Physical function - Balance - Berg Balance scale.

Analysis 6.17.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 17 Physical function - Balance - Functional reach.

Analysis 6.18.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 18 Physical function - Balance - Timed balance test.

Analysis 6.19.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 19 Physical function - Timed Up and Go (sec).

Analysis 6.20.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 20 Health-related QoL - EuroQol (Health State).

Analysis 6.21.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 21 Health-related QoL - EuroQol (self perceived health).

Analysis 6.22.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 22 Health-related QoL - SF-36 physical functioning.

Analysis 6.23.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 23 Health-related QoL - SF-36 physical role functioning.

Analysis 6.24.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 24 Health-related QoL - SF-36 emotional role functioning.

Analysis 6.25.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 25 Health-related QoL - Stroke-Adapted Sickness Impact profile.

Analysis 6.26.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 26 Mood - Stroke Impact Scale emotion score.

Analysis 6.27.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 27 Mood - Geriatric Depression Scale.

Analysis 6.28.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 28 Mood - Hospital Anxiety and Depression Scale (HADS) - anxiety score.

Analysis 6.29.

Comparison 6 Mixed training versus control - end of retention follow-up, Outcome 29 Mood - Hospital Anxiety and Depression Scale (HADS) - depression score.

Comparison 7. Cardiorespiratory versus resistance versus mixed training
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Disability - combined disability scales12815Std. Mean Difference (IV, Random, 95% CI)0.30 [0.13, 0.46]
1.1 Cardiorespiratory training6289Std. Mean Difference (IV, Random, 95% CI)0.37 [0.10, 0.64]
1.2 Resistance training00Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
1.3 Mixed training6526Std. Mean Difference (IV, Random, 95% CI)0.24 [0.00, 0.47]
2 Mobility - maximal walking speed17 Mean Difference (IV, Random, 95% CI)Subtotals only
2.1 Cardiorespiratory training13609Mean Difference (IV, Random, 95% CI)7.37 [3.70, 11.03]
2.2 Resistance training4104Mean Difference (IV, Random, 95% CI)1.92 [-3.50, 7.35]
2.3 Mixed training00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
3 Mobility - preferred walking speed (m/min)20 Mean Difference (IV, Random, 95% CI)Subtotals only
3.1 Cardiorespiratory training8425Mean Difference (IV, Random, 95% CI)4.63 [1.84, 7.43]
3.2 Resistance training380Mean Difference (IV, Random, 95% CI)2.34 [-6.77, 11.45]
3.3 Mixed training9639Mean Difference (IV, Random, 95% CI)4.54 [0.95, 8.14]
4 Mobility - gait endurance (6-MWT metres)19 Mean Difference (IV, Random, 95% CI)Subtotals only
4.1 Cardiorespiratory training10468Mean Difference (IV, Random, 95% CI)26.99 [9.13, 44.84]
4.2 Resistance training266Mean Difference (IV, Random, 95% CI)3.78 [-68.56, 76.11]
4.3 Mixed training7561Mean Difference (IV, Random, 95% CI)41.60 [25.25, 57.95]
5 Balance - Berg Balance Scale10496Mean Difference (IV, Random, 95% CI)2.32 [1.07, 3.58]
5.1 Cardiorespiratory training5257Mean Difference (IV, Random, 95% CI)3.14 [0.56, 5.73]
5.2 Resistance training00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
5.3 Mixed training5239Mean Difference (IV, Random, 95% CI)1.82 [-0.31, 3.95]
Analysis 7.1.

Comparison 7 Cardiorespiratory versus resistance versus mixed training, Outcome 1 Disability - combined disability scales.

Analysis 7.2.

Comparison 7 Cardiorespiratory versus resistance versus mixed training, Outcome 2 Mobility - maximal walking speed.

Analysis 7.3.

Comparison 7 Cardiorespiratory versus resistance versus mixed training, Outcome 3 Mobility - preferred walking speed (m/min).

Analysis 7.4.

Comparison 7 Cardiorespiratory versus resistance versus mixed training, Outcome 4 Mobility - gait endurance (6-MWT metres).

Analysis 7.5.

Comparison 7 Cardiorespiratory versus resistance versus mixed training, Outcome 5 Balance - Berg Balance Scale.

Appendices

Appendix 1. CENTRAL search strategy (The Cochrane Library)

#1        MeSH descriptor: [Cerebrovascular Disorders] explode all trees
#2        MeSH descriptor: [Brain Injuries] this term only
#3        MeSH descriptor: [Brain Injury, Chronic] this term only
#4        stroke or poststroke or post-stroke or cerebrovasc* or brain vasc* or cerebral vasc* or cva* or apoplex* or SAH:ti,ab,kw 
#5        (brain* or cerebr* or cerebell* or intracran* or intracerebral) near/5 (isch?emi* or infarct* or thrombo* or emboli* or occlus*):ti,ab,kw 
#6        (brain* or cerebr* or cerebell* or intracerebral or intracranial or subarachnoid) near/5 (haemorrhage* or hemorrhage* or haematoma* or hematoma* or bleed*):ti,ab,kw 
#7        MeSH descriptor: [Hemiplegia] this term only
#8        MeSH descriptor: [Paresis] explode all trees
#9        hempar* or hemipleg* or brain injur*:ti,ab,kw 
#10      MeSH descriptor: [Gait Disorders, Neurologic] explode all trees
#11      #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10
#12      MeSH descriptor: [Exercise] this term only
#13      MeSH descriptor: [Exercise Test] this term only
#14      MeSH descriptor: [Physical Exertion] this term only
#15      MeSH descriptor: [Exercise Therapy] this term only
#16      MeSH descriptor: [Physical Fitness] this term only
#17      MeSH descriptor: [Muscle Stretching Exercises] this term only
#18      MeSH descriptor: [Resistance Training] this term only
#19      MeSH descriptor: [Isometric Contraction] this term only
#20      MeSH descriptor: [Isotonic Contraction] this term only
#21      MeSH descriptor: [Sports] explode all trees
#22      MeSH descriptor: [Physical Endurance] explode all trees
#23      MeSH descriptor: [Locomotion] explode all trees
#24      MeSH descriptor: [Early Ambulation] this term only
#25      MeSH descriptor: [Sports Equipment] this term only
#26      MeSH descriptor: [Tai Ji] this term only
#27      MeSH descriptor: [Yoga] this term only
#28      MeSH descriptor: [Dance Therapy] this term only
#29      MeSH descriptor: [Exercise Movement Techniques] this term only
#30      MeSH descriptor: [Fitness Centers] this term only
#31      MeSH descriptor: [Leisure Activities] this term only
#32      MeSH descriptor: [Recreation] this term only
#33      physical near/3 (exercise* or exertion or endurance or therap* or conditioning or activit* or fitness):ti,ab,kw 
#34      exercise near/3 (train* or intervention* or protocol* or program* or therap* or activit* or regim*):ti,ab,kw 
#35      fitness near/3 (train* or intervention* or protocol* or program* or therap* or activit* or regim* or centre* or center*):ti,ab,kw 
#36      (training or conditioning) near/3 (intervention* or protocol* or program* or activit* or regim*):ti,ab,kw 
#37      sport* or recreation* or leisure or cycling or bicycl* or rowing or treadmill* or running or circuit training or swim* or walk* or dance* or dancing or tai ji or tai chi or yoga:ti,ab,kw 
#38      (endurance or aerobic or cardio*) near/3 (fitness or train* or intervention* or protocol* or program* or therap* or activit* or regim*):ti,ab,kw 
#39      muscle strengthening or progressive resist*:ti,ab,kw 
#40      (weight or strength* or resistance) next (train* or lift* or exercise*):ti,ab,kw 
#41      (isometric or isotonic or eccentric or concentric) next (action* or contraction* or exercise*):ti,ab,kw 
#42      {or #12-#41}
#43      #11 and #42
#44      "SR-STROKE*" 
#45      #43 not #44

Appendix 2. MEDLINE (Ovid) search strategy

1. cerebrovascular disorders/ or exp basal ganglia cerebrovascular disease/ or exp brain ischemia/ or exp carotid artery diseases/ or exp intracranial arterial diseases/ or exp intracranial arteriovenous malformations/ or exp "intracranial embolism and thrombosis"/ or exp intracranial hemorrhages/ or stroke/ or exp brain infarction/ or vasospasm, intracranial/ or vertebral artery dissection/ or brain injuries/ or brain injury, chronic/
2. (stroke or poststroke or post-stroke or cerebrovasc$ or brain vasc$ or cerebral vasc$ or cva$ or apoplex$ or SAH).tw.
3. ((brain$ or cerebr$ or cerebell$ or intracran$ or intracerebral) adj5 (isch?emi$ or infarct$ or thrombo$ or emboli$ or occlus$)).tw.
4. ((brain$ or cerebr$ or cerebell$ or intracerebral or intracranial or subarachnoid) adj5 (haemorrhage$ or hemorrhage$ or haematoma$ or hematoma$ or bleed$)).tw.
5. hemiplegia/ or exp paresis/
6. (hempar$ or hemipleg$ or brain injur$).tw.
7. Gait Disorders, Neurologic/
8. or/1-7
9. exercise/
10. exercise test/
11. physical exertion/
12. exercise therapy/
13. physical fitness/
14. muscle stretching exercises/ or resistance training/
15. isometric contraction/
16. isotonic contraction/
17. exp sports/
18. exp physical endurance/
19. exp locomotion/
20. early ambulation/
21. sports equipment/
22. tai ji/ or yoga/ or dance therapy/
23. exercise movement techniques/
24. fitness centers/
25. leisure activities/
26. recreation/
27. (physical adj3 (exercise$ or exertion or endurance or therap$ or conditioning or activit$ or fitness)).tw.
28. (exercise adj3 (train$ or intervention$ or protocol$ or program$ or therap$ or activit$ or regim$)).tw.
29. (fitness adj3 (train$ or intervention$ or protocol$ or program$ or therap$ or activit$ or regim$ or centre$ or center$)).tw.
30. ((training or conditioning) adj3 (intervention$ or protocol$ or program$ or activit$ or regim$)).tw.
31. (sport$ or recreation$ or leisure or cycling or bicycl$ or rowing or treadmill$ or running or circuit training or swim$ or walk$ or dance$ or dancing or tai ji or tai chi or yoga).tw.
32. ((endurance or aerobic or cardio$) adj3 (fitness or train$ or intervention$ or protocol$ or program$ or therap$ or activit$ or regim$)).tw.
33. (muscle strengthening or progressive resist$).tw.
34. ((weight or strength$ or resistance) adj (train$ or lift$ or exercise$)).tw.
35. ((isometric or isotonic or eccentric or concentric) adj (action$ or contraction$ or exercise$)).tw.
36. or/9-35
37. Randomized Controlled Trials as Topic/
38. random allocation/
39. Controlled Clinical Trials as Topic/
40. control groups/
41. clinical trials as topic/
42. double-blind method/ or single-blind method/
43. Placebos/ or placebo effect/
44. cross-over studies/
45. Multicenter Studies as Topic/
46. Therapies, Investigational/
47. Research Design/
48. Program Evaluation/
49. evaluation studies as topic/
50. randomized controlled trial.pt.
51. controlled clinical trial.pt.
52. clinical trial.pt.
53. multicenter study.pt.
54. (evaluation studies or comparative study).pt.
55. random$.tw.
56. (controlled adj5 (trial$ or stud$)).tw.
57. (clinical$ adj5 trial$).tw.
58. ((control or treatment or experiment$ or intervention) adj5 (group$ or subject$ or patient$)).tw.
59. (quasi-random$ or quasi random$ or pseudo-random$ or pseudo random$).tw.
60. ((multicenter or multicentre or therapeutic) adj5 (trial$ or stud$)).tw.
61. ((control or experiment$ or conservative) adj5 (treatment or therapy or procedure or manage$)).tw.
62. ((singl$ or doubl$ or tripl$ or trebl$) adj5 (blind$ or mask$)).tw.
63. (coin adj5 (flip or flipped or toss$)).tw.
64. versus.tw.
65. (cross-over or cross over or crossover).tw.
66. (placebo$ or sham).tw.
67. (assign$ or alternate or allocat$ or counterbalance$ or multiple baseline).tw.
68. controls.tw.
69. (treatment$ adj6 order).tw.
70. or/37-69
71. 8 and 36 and 70
72.  limit 71 to humans

Appendix 3. EMBASE (Ovid) search strategy

1. cerebrovascular disease/ or basal ganglion hemorrhage/ or brain hemorrhage/ or brain infarction/ or brain ischemia/ or carotid artery disease/ or cerebral artery disease/ or cerebrovascular accident/ or intracranial aneurysm/ or occlusive cerebrovascular disease/ or stroke/
2. stroke patient/ or stroke unit/
3. (stroke or poststroke or post-stroke or cerebrovasc$ or brain vasc$ or cerebral vasc$ or cva$ or apoplex$ or SAH).tw.
4. ((brain$ or cerebr$ or cerebell$ or intracran$ or intracerebral) adj5 (isch?emi$ or infarct$ or thrombo$ or emboli$ or occlus$)).tw
5. ((brain$ or cerebr$ or cerebell$ or intracerebral or intracranial or subarachnoid) adj5 (haemorrhage$ or hemorrhage$ or haematoma$ or hematoma$ or bleed$)).tw.
6. brain injury/
7. hemiparesis/ or hemiplegia/ or paresis/
8. (hempar$ or hemipleg$ or brain injur$).tw.
9. or/1-8
10. exercise/ or aerobic exercise/ or aquatic exercise/ or arm exercise/ or athletic performance/ or dynamic exercise/ or exercise intensity/ or isokinetic exercise/ or muscle exercise/ or pilates/ or static exercise/
11. exercise test
12. kinesiotherapy/ or isometric exercise/ or movement therapy/ or muscle training/ or neuromuscular facilitation/ or stretching exercise/ or tai chi/ or yoga/
13. muscle strength/
14. muscle isometric contraction/ or muscle isotonic contraction/
15. mobilization/
16. locomotion/ or swimming/ or walking/ or dancing/
17. physical activity/ or jumping/ or lifting effort/ or stretching/ or weight lifting/
18. fitness/ or exp training/ or endurance/
19. exp sport/ or recreation/ or leisure/
20. (physical adj3 (exercise$ or exertion or endurance or therap$ or conditioning or activit$ or fitness)).tw.
21. (exercise adj3 (train$ or intervention$ or protocol$ or program$ or therap$ or activit$ or regim$)).tw.
22. (fitness adj3 (train$ or intervention$ or protocol$ or program$ or therap$ or activit$ or regim$ or centre$ or center$)).tw.
23. ((training or conditioning) adj3 (intervention$ or protocol$ or program$ or activit$ or regim$)).tw.
24. (sport$ or recreation$ or leisure or cycling or bicycl$ or rowing or treadmill$ or running or circuit training or swim$ or walk$ or dance$ or dancing or tai ji or tai chi or yoga).tw.
25. ((endurance or aerobic or cardio$) adj3 (fitness or train$ or intervention$ or protocol$ or program$ or therap$ or activit$ or regim$)).tw.
26. (muscle strengthening or progressive resist$).tw.
27. ((weight or strength$ or resistance) adj (train$ or lift$ or exercise$)).tw.
28. ((isometric or isotonic or eccentric or concentric) adj (action$ or contraction$ or exercise$)).tw.
29. or/10-28
30. Randomized Controlled Trial/
31. Randomization/
32. Controlled Study/
33. control group/
34. clinical trial/ or controlled clinical trial/
35. Crossover Procedure/
36. Double Blind Procedure/
37. Single Blind Procedure/ or triple blind procedure/
38. Parallel Design/
39. placebo/
40. Multicenter Study/
41. experimental design/ or experimental study/ or quasi experimental study/
42. experimental therapy/
43. evaluation/ or "evaluation and follow up"/ or evaluation research/ or clinical evaluation/
44. methodology/
45. "types of study"/
46. research subject/
47. Comparative Study/
48. random$.tw.
49. (controlled adj5 (trial$ or stud$)).tw.
50. (clinical$ adj5 trial$).tw.
51. ((control or treatment or experiment$ or intervention) adj5 (group$ or subject$ or patient$)).tw.
52. (quasi-random$ or quasi random$ or pseudo-random$ or pseudo random$).tw.
53. ((multicenter or multicentre or therapeutic) adj5 (trial$ or stud$)).tw.
54. ((control or experiment$ or conservative) adj5 (treatment or therapy or procedure or manage$)).tw.
55. ((singl$ or doubl$ or tripl$ or trebl$) adj5 (blind$ or mask$)).tw.
56. (coin adj5 (flip or flipped or toss$)).tw.
57. versus.tw.
58. (cross-over or cross over or crossover).tw.
59. placebo$.tw.
60. sham.tw.
61. (assign$ or alternate or allocat$ or counterbalance$ or multiple baseline).tw.
62. controls.tw.
63. (treatment$ adj6 order).tw.
64. or/30-63
65. 9 and 29 and 64
66. limit 65 to human

Appendix 4. CINAHL (EBSCO) search strategy

S78.  S57 and S77
S77.  S58 or S59 or S60 or S61 or S62 or S63 or S64 or S65 or S66 or S67 or S70 or S71. or S74 or S75 or S76
S76.  TI ( meta analysis* or metaanlaysis or meta-anlaysis or systematic review* ) or AB ( meta analysis* or metaanlaysis or meta-anlaysis or systematic review* )
S75.  TI ( counterbalance* or multiple baseline* or ABAB design ) or AB ( counterbalance* or multiple baseline* or ABAB design )
S74.  S72 and S73
S73.  TI trial* or AB trial*
S72.  TI ( clin* or intervention* or compar* or experiment* or preventive or therapeutic ) or AB ( clin* or intervention* or compar* or experiment* or preventive or therapeutic )
S71.  TI ( crossover or cross-over or placebo* or control* or factorial or sham ) or AB ( crossover or cross-over or placebo* or control* or factorial or sham )
S70.  S68 and S69
S69.  TI ( blind* or mask*) or AB ( blind* or mask* )
S68.  TI ( singl* or doubl* or tripl* or trebl* ) or AB ( singl* or doubl* or tripl* or trebl* )
S67.  TI random* or AB random*
S66.  PT systematic review
S65.  PT clinical trial
S64.  (MH "Community Trials") or (MH "Experimental Studies") or (MH "One-Shot Case Study") or (MH "Pretest-Posttest Design+") or (MH "Solomon Four-Group Design") or (MH "Static Group Comparison") or (MH "Study Design")
S63.  (MH "Clinical Research") or (MH "Clinical Nursing Research")
S62.  (MH "Placebo Effect") or (MH "Placebos") or (MH "Meta Analysis")
S61.  (MH "Factorial Design") or (MH "Quasi-Experimental Studies") or (MH "Nonrandomized Trials")
S60.  (MH "Control (Research)") or (MH "Control Group")
S59.  (MH "Crossover Design") or (MH "Clinical Trials+") or (MH "Comparative Studies")
S58.  (MH "Random Assignment") or (MH "Random Sample+")
S57.  S12 and S56
S56.  S13 or S14 or S15 or S16 or S17 or S18 or S19 or S20 or S21 or S22 or S23 or S24 or S25 or S26 or S27 or S28 or S29 or S30 or S31 or S32 or S35 or S38 or S41 or S44 or S45 or S48 or S49 or S52 or S55
S55.  S53 and S54
S54.  TI (action* or contraction* or exercise*) or AB (action* or contraction* or exercise*)
S53.  TI (isometric or isotonic or eccentric or concentric) or AB (isometric or isotonic or eccentric or concentric)
S52.  S50 and S51
S51.  TI (train* or lift* or exercise*) or AB (train* or lift* or exercise*)
S50.  TI (weight or strength* or resistance) or AB (weight or strength* or resistance)
S49.  TI (muscle strengthening or progressive resist*) or AB (muscle strengthening or progressive resist*)
S48.  S46 and S47
S47.  TI (fitness or train* or intervention* or protocol* or program* or therap* or activit* or regim*) or AB (fitness or train* or intervention* or protocol* or program* or therap* or activit* or regim*)
S46.  TI (endurance or aerobic or cardio*) or AB (endurance or aerobic or cardio*)
S45.  TI (sport* or recreation* or leisure or cycling or bicycl* or rowing or treadmill* or running or circuit training or swim* or walk* or dance* or dancing or tai ji or tai chi or yoga) or AB (sport* or recreation* or leisure or cycling or bicycl* or rowing or treadmill* or running or circuit training or swim* or walk* or dance* or dancing or tai ji or tai chi or yoga)
S44.  S42 and S43
S43.  TI (intervention* or protocol* or program* or activit* or regim*) or AB (intervention* or protocol* or program* or activit* or regim*)
S42.  TI (training or conditioning) or AB (training or conditioning)
S41.  S39 and S40
S40.  TI (train* or intervention* or protocol* or program* or therap* or activit* or regim* or centre* or center*) or AB (train* or intervention* or protocol* or program* or therap* or activit* or regim* or centre* or center*)
S39.  TI fitness or AB fitness
S38.  S36 and S37
S37.  TI (train* or intervention* or protocol* or program* or therap* or activit* or regim*) or AB (train* or intervention* or protocol* or program* or therap* or activit* or regim*)
S36.  TI exercise or AB exercise
S35.  S33 and S34
S34.  TI ( exercise* or exertion or endurance or therap* or conditioning or activit* or fitness ) or AB ( exercise* or exertion or endurance or therap* or conditioning or activit* or fitness )
S33.  TI physical or AB physical
S32.  (MH "Treadmills")
S31.  (MH "Recreation+") or (MH "Recreational Therapists") or (MH "Recreational Therapy") or (MH "Recreation Therapy (Iowa NIC)")
S30.  (MH "Leisure Activities+")
S29.  (MH "Fitness Centers")
S28.  (MH "Tai Chi")
S27.  (MH "Dancing+") or (MH "Aerobic Dancing") or (MH "Dance Therapy")
S26.  (MH "Yoga")
S25.  (MH "Sports Equipment and Supplies+")
S24.  (MH "Ambulation Therapy (Saba CCC)") or (MH "Early Ambulation") or (MH "Exercise Therapy: Ambulation (Iowa NIC)") or (MH "Ambulation: Walking (Iowa NOC)") or (MH "Walking+")
S23.  (MH "Locomotion+")
S22.  (MH "Sports+")
S21.  (MH "Isometric Contraction") or (MH "Isotonic Contraction")
S20.  (MH "Muscle Strengthening+") or (MH "Athletic Training+") or (MH "Athletic Training Programs")
S19.  (MH "Stretching")
S18.  (MH "Physical Endurance+") or (MH "Endurance Sports") or (MH "Endurance (Iowa NOC)")
S17.  (MH "Physical Fitness+")
S16.  (MH "Therapeutic Exercise+")
S15.  (MH "Exertion+")
S14.  (MH "Exercise Test+") or (MH "Exercise Test, Cardiopulmonary") or (MH "Exercise Test, Muscular+")
S13.  (MH "Exercise+")
S12.  S1 or S2 or S5 or S8 or S9 or S10 or S11
S11.  (MH "Gait Disorders, Neurologic+")
S10.  TI ( hemipleg* or hemipar* or paresis or paretic ) or AB ( hemipleg* or hemipar* or paresis or paretic )
S9.  (MH "Hemiplegia")
S8.  S6 and S7
S7.  TI ( haemorrhage* or hemorrhage* or haematoma* or hematoma* or bleed* ) or AB ( haemorrhage* or hemorrhage* or haematoma* or hematoma* or bleed* )
S6.  TI ( brain* or cerebr* or cerebell* or intracerebral or intracranial or subarachnoid ) or AB ( brain* or cerebr* or cerebell* or intracerebral or intracranial or subarachnoid )
S5.  S3 and S4
S4.  TI ( ischemi* or ischaemi* or infarct* or thrombo* or emboli* or occlus* ) or AB ( ischemi* or ischaemi* or infarct* or thrombo* or emboli* or occlus* )
S3.  TI ( brain* or cerebr* or cerebell* or intracran* or intracerebral ) or AB ( brain* or cerebr* or cerebell* or intracran* or intracerebral )
S2.  TI ( 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 )
S1.  (MH "Cerebrovascular Disorders+") or (MH "stroke patients") or (MH "stroke units")

Appendix 5. SPORTDiscus (EBSCO) search strategy

S16. (S7 and S15)
S15. S8 or S9 or S10 or S11 or S12 or S13 or S14
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* )  
S13. TI ( meta analysis* or metaanlaysis or meta-anlaysis or systematic review* ) or AB ( meta analysis* or metaanlaysis or meta-anlaysis or systematic review* )
S12. TI ( counterbalance* or multiple baseline* or ABAB design ) or AB ( counterbalance* or multiple baseline* or ABAB design )
S11. ( TI ( clin* or intervention* or compar* or experiment* or preventive or therapeutic ) or AB ( clin* or intervention* or compar* or experiment* or preventive or therapeutic ) ) and ( TI trial* or AB trial* )
S10. TI ( crossover or cross-over or placebo* or control* or factorial or sham ) or AB ( crossover or cross-over or placebo* or control* or factorial or sham )
S9. ( TI ( singl* or doubl* or tripl* or trebl* ) or AB ( singl* or doubl* or tripl* or trebl* ) ) and ( TI ( blind* or mask*) or AB ( blind* or mask* ) )
S8. TI random* or AB random*
S7. S1 or S2 or S3 or S4 or S5 or S6
S6. TI ( hemipleg* or hemipar* or paresis or paretic ) or AB ( hemipleg* or hemipar* or paresis or paretic )
S5. DE "HEMIPLEGIA"
S4. ( TI ( brain* or cerebr* or cerebell* or intracerebral or intracranial or subarachnoid ) or AB ( brain* or cerebr* or cerebell* or intracerebral or intracranial or subarachnoid ) ) and ( TI ( haemorrhage* or hemorrhage* or haematoma* or hematoma* or bleed* ) or AB ( haemorrhage* or hemorrhage* or haematoma* or hematoma* or bleed* ) )
S3. ( TI ( brain* or cerebr* or cerebell* or intracran* or intracerebral ) or AB ( brain* or cerebr* or cerebell* or intracran* or intracerebral ) ) and ( TI ( ischemi* or ischaemi* or infarct* or thrombo* or emboli* or occlus* ) or AB ( ischemi* or ischaemi* or infarct* or thrombo* or emboli* or occlus* ) )
S2. TI ( 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 )
S1. DE "CEREBROVASCULAR disease" or DE "BRAIN Hemorrhage" or DE "CEREBRAL embolism & thrombosis"

What's new

DateEventDescription
5 July 2013New citation required and conclusions have changedAdditional co-author. We have revised the main text and conclusions of the review according to the findings of the new included trials.
28 January 2013New search has been performedWe 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.

History

Protocol first published: Issue 4, 2001
Review first published: Issue 1, 2004

DateEventDescription
22 November 2010New citation required and conclusions have changedNew first author. We have revised the main text and conclusions of the review according to the findings of the new included trials.
22 November 2010New search has been performedWe 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 criteria and objectives.
2 March 2009New search has been performedWe updated the search of the Cochrane Stroke Group Trials Register in March 2009.
3 November 2008New citation required and conclusions have changedThere is sufficient evidence to incorporate cardiorespiratory training, using walking as a mode of exercise, into the rehabilitation 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 2008New search has been performedWe 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 revised throughout.
23 October 2008AmendedConverted to new review format.

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.

For this update

DH Saunders developed and ran searches, selected studies, extracted and interpreted data, performed the analyses, and wrote the review.
MF Sanderson selected studies, extracted and interpreted data, and contributed to writing the review.
M Brazzelli advised on the methodology and analyses and provided comments on a draft version of the review.
GE Mead and CA Greig helped select studies and provided comments on a draft version of the review.

Declarations of interest

DH Saunders and CA Greig were co-authors of one included study (Mead 2007).
MF Sanderson and DH Saunders received NIHR research funding to complete this update.
GE Mead has received research funding for exercise after stroke. She has received honoraria from Later Life Training to develop an educational course of exercise after stroke for exercise professionals. She has also received honoraria and expenses to present work on exercise after stroke at conferences. She has led a trial of exercise after stroke that is included in the review (Mead 2007).
M Brazzelli has no declarations of interest.

Sources of support

Internal sources

  • No sources of support supplied

External sources

  • National Institute for Health Research (NIHR), UK.

    Cochrane Review Incentive Scheme 2012

Differences between protocol and review

Subgroup analyses were on the whole not possible as there were too few trials within the meta-analyses and too many other influential factors.

In this update we have changed the approach from one where we discussed various elements of trial quality to adoption of the Cochrane 'Risk of bias' tool.

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Ada 2013

Methods

Design: randomised trial of cardiorespiratory training versus no intervention – after usual care

Randomised: computer-generated randomisation stratified on walking disability by independent researcher

Allocation concealment: not applicable

Blinding: assessors blind to group allocation

ITT: yes

Measurements: end of interventions (2 and 4 months) and 6 and 12 months follow-up

Withdrawals: 2 months treadmill training group: 1 participant withdrew; control group: 3 participants withdrew - reasons unclear

Participants

Randomised: 102 participants

Intervention: treadmill training 2 months group: 34 participants; 28 males and 6 females; mean age 64 years (SD 12); 20 months post-stroke (SD 15). Treadmill training 4 months group: 34 participants; 24 males and 10 females; mean age 70 years (SD 11); 22 months post-stroke (SD 16)

Control: 34 participants; 19 males and 15 females; 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 metre unaided walking speed > 9 seconds

Exclusion criteria: unstable cardiac status; severe cognitive and/or asphasia

Interventions

Invention group: both 2 months and 4 months treadmill training group received 30 minutes treadmill walking 3 times/week for 8 or 16 weeks respectively
Progressive in nature. Both groups also received overground walking training (20% of intervention during 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)

Control group: no intervention

Setting: rehabilitation centre

OutcomesIncluded outcomes: 6-MWT; EuroQol Health Status; Adelaide Activities Profile; walking and falls self efficacy
Notes

There were 2 intervention groups. The extracted data correspond to:

Exp 1 (4-month intervention) end of intervention data were compared with control group data available at 4 months only

Exp 2 (2-month intervention) end of intervention data were compared with control group data available at 2 months only

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskComputer-generated randomisation stratified on walking disability by independent researcher
Allocation concealment (selection bias)Low riskAllocation concealment ensured because all available participants allocated in groups of 15 to blocks of 3 after baseline measures recorded
Blinding (performance bias and detection bias)
All outcomes
High riskNo attention control
Blinding of outcome assessment (detection bias)
All outcomes
Low riskAssessor blinded
Incomplete outcome data (attrition bias)
End of intervention
Low risk

ITT analysis performed

Few (2/102) losses; 2-month treadmill training group: 1 participant withdrew; control group: 3 participants withdrew

Reasons and timing unclear

Incomplete outcome data (attrition bias)
End of follow-up
Low risk

ITT analysis performed

Few losses (2/102); 2-month treadmill training group: 1 participant withdrew; control group: 3 participants withdrew

Reasons and timing unclear

Selective reporting (reporting bias)Low riskReported outcomes correspond to trial registry ACTRN12607000227493
Other biasUnclear riskUnclear
Imbalanced exposureHigh riskIntervention group has uncontrolled exposure

Aidar 2007

Methods

Design: randomised trial of cardiorespiratory training (aquatic physical exercises) versus no intervention - after usual care

Randomisation: stated 'random' but no further details provided

Allocation concealment: not reported

Blinding: not reported

ITT: no

Measurements: at the end of intervention (12 weeks)

Withdrawals: 1 participant in the intervention group refused the training - at the beginning of the programme; 2 participants in the control group were not assessed at the end of the intervention

Participants

Randomised: 31 participants, assessed 28 (15 participants in the intervention group and 13 in the control group)

Intervention: 15 participants: 10 males and 5 females; mean age 50.3 years (SD 9.1)

Control: 13 participants; 9 males and 4 females; mean age 52.5 years (SD 7.7)

Inclusion criteria: ischaemic cerebrovascular accident; hemiplegia or hemiparesis

Exclusion criteria: cognitive impairment; significant co-morbidities

Interventions

Intervention group: aquatic physical sessions (e.g. walking activity and physical exercises in the water; swimming) 45 to 60 minutes each session; 2 times/week for 12 weeks

Control group: no intervention - delayed started of the same programme

Setting: community setting

OutcomesIncluded outcome: SF-36
NotesContent of the intervention not very detailed. Unclear whether the trial met the ACSM criteria for fitness training
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskStated 'random' but no further details provided
Allocation concealment (selection bias)Unclear riskNot reported
Blinding (performance bias and detection bias)
All outcomes
High riskNo attention control
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot reported
Incomplete outcome data (attrition bias)
End of intervention
Unclear risk1/16 lost from intervention and 2/15 from control group. No ITT analysis
Selective reporting (reporting bias)Unclear riskNo protocol available
Other biasUnclear riskUnclear
Imbalanced exposureHigh riskImbalanced exposure

Aidar 2012

Methods

Design: randomised trial of strength training versus usual care

Randomised mechanism: lottery allocation into groups

Allocation concealment: not reported

Blinding: assessor blinded to group allocation

Measurements: end of intervention (12 weeks)

Withdrawals: 3 participants from intervention group during second week of intervention and 2 participants from control group were not assessed at the end of the intervention

Participants

Randomised: 24 participants

Intervention: 11 participants: 6 males and 5 females; mean age 51.7 years (SD 8.0)

Control: 13 participants: 9 males and 4 females; mean age 52.5 years (SD 7.7)

Inclusion criteria: ischaemic stroke at least 1 year prior to testing; hemiplegia or hemiparesis

Exclusion criteria: aphasia

Interventions

Intervention group: strength training sessions (3 sets of 8 to 10 repetitions, leg press, front pulley and bench press) 45 to 60 minutes each session; 3 times/week for 12 weeks

Control group: no intervention

Setting: indoor basketball court

OutcomesIncluded outcomes: State-Trait Anxiety Inventory; muscle strength
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk"Lottery" allocation into groups; still unclear exactly what was done
Allocation concealment (selection bias)Unclear riskAllocation concealment: not reported
Blinding (performance bias and detection bias)
All outcomes
High riskNo attention control
Blinding of outcome assessment (detection bias)
All outcomes
Low riskBlinded outcome assessors
Incomplete outcome data (attrition bias)
End of intervention
High risk5/29 dropouts (17%) with no ITT analysis
Selective reporting (reporting bias)Unclear riskNo protocol available
Other biasUnclear riskSelf selection bias may occur as advertisements were used
Imbalanced exposureHigh riskIntervention group has uncontrolled exposure

Bale 2008

Methods

Design: randomised trial of resistance training plus % usual care versus usual care - during usual care

Sample size calculation reported

Randomisation: drawing lots - not clearly described

Allocation concealment: unclear

Blinding: outcome assessors blinded

ITT: planned but no withdrawals

Measurements: at the end of intervention (4 weeks)

Withdrawals: none

Participants

Randomised: 18 participants

Intervention: 8 participants; 3 males and 5 females; mean age 68.0 years (SD 13); time since stroke  49.4 (SD 22.1) days

Control: 10 participants; 4 males and 6 females; 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 understand verbal information; ability to sit without support

Exclusion criteria: significant sensory or cognitive sequels; arrhythmia; uncontrolled angina pectoris or hypertension; co-morbidities that could mask the sequels from the stroke; lack of motor control of the affected leg

Interventions

Intervention group: resistance training 50 minutes a day 3 days per week for 4 weeks. 8 individually tailored exercises 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). One set of 10 to 15 repetitions to moderate fatigue.

Control group: usual care (Bobath) 50 minutes a day 3 days per week for 4 weeks, plus usual care (other) 50 minutes/day, 2 days per week for 4 weeks. Total training: 50 minutes a day 5 days per week for 4 weeks

Setting: 2 rehabilitation units

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

Notes

Very small sample size

Poor external validity

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskDrawing lots - not clearly described
Allocation concealment (selection bias)Unclear riskPoorly reported
Blinding (performance bias and detection bias)
All outcomes
High riskAttention control exposure
Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessor
Incomplete outcome data (attrition bias)
End of intervention
Low riskITT planned but no withdrawals
Selective reporting (reporting bias)Unclear riskNo protocol available
Other biasUnclear riskUnclear
Imbalanced exposureLow riskBalanced exposure

Bateman 2001

Methods

Design: multi-centre randomised trial of cardiorespiratory training plus usual care versus non-exercise intervention plus usual care - during usual care
Randomisation: mechanism - computer; method - blocks size of 10 participants
Allocation concealment: numbered, sealed envelopes
Blinding: investigator blinded; participants encouraged to maintain blinding; efficacy unknown
ITT: yes, but participants were excluded after recruitment and baseline assessments due to discharge

Measurements: end of intervention (12 weeks) and at follow-up
Withdrawals: intervention group (12 participants: 4 before and 8 after the 12-week assessment); control group (12 participants: 2 before and 10 after the 12-week assessment)
Reasons unclear but included early discharge

ParticipantsRandomised: 84 participants
Intervention: 40 participants; males 20, females 20; age 47.0 years (SD 13.1); 144 days (SD 84) post-stroke
Control: 44 participants; males 29, females 14; age 50.3 years (SD 10.1); 184 days (SD 127) day post-stroke
Inclusion criteria: single stroke; could comply with planned interventions; could sit on a cycle ergometer
Exclusion criteria: likely to be inpatient for < 3 months; impairments severe enough to limit training compliance and participation; cardiac disease; co-morbidities contraindicated for exercise
InterventionsIntervention: cardiorespiratory training; cycle ergometry at 60% to 80% of age-related heart rate maximum for up to 30 minutes per day 3 days per week for 12 weeks
Control: relaxation - programme individualised: included breathing exercises, progressive muscle relaxation, autogenic exercises, visualisation techniques
Setting: multicentre, 4 rehabilitation units
OutcomesIncluded outcomes: FIM; BI (0 to 20 scale); NEADL; RMI; HADS; BBS; gait maximum speed; maximum cycling workload (data transformed to Log base e); BMI
Other outcomes: fatigue questionnaire
NotesMixed brain injury data provided by authors; stroke-only data retained and re-analysed. High rate of missing data made statistical analyses difficult
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskComputer based block (n = 10) randomisation
Allocation concealment (selection bias)Low riskNumbered, sealed envelopes
Blinding (performance bias and detection bias)
All outcomes
High riskAttention control
Blinding of outcome assessment (detection bias)
All outcomes
Low riskInvestigator blinded; participants encouraged to maintain blinding; efficacy unknown
Incomplete outcome data (attrition bias)
End of intervention
High risk

ITT employed

6/84 (7%) lost: intervention group 4; control group 2

Reasons for losses not clear but included exclusion after recruitment and baseline assessments due to discharge

Large amounts of missing outcome data

Incomplete outcome data (attrition bias)
End of follow-up
High risk

ITT employed

24/85 (29%) total losses; intervention group 8; control group 10

Selective reporting (reporting bias)Unclear riskProtocol not available
Other biasUnclear riskUnclear
Imbalanced exposureLow riskBalanced exposure

Cooke 2010

Methods

Design: phase I multicentre trial; 4 centres; mixed training plus usual care versus usual care - during usual care - i.e. functional strength training (FST) plus conventional physiotherapy (CPT) versus conventional physiotherapy alone and versus conventional physiotherapy plus conventional physiotherapy (CPT + CPT)

Randomisation: computer-generated random allocation in blocks of 9 per trial centre (stratified allocation by baseline scores for visual spatial neglect)               

Allocation concealment: sequentially numbered, sealed, opaque envelopes

Blinding: assessor blinded to group allocation

ITT: attempt to measure participants at outcome and follow-up even if they withdraw but analyses were not performed according to ITT principle

Measurements: at the end of intervention (6 weeks) and 12 weeks later (follow-up)   

Withdrawals: at outcome 7/74 (9%) participants were lost at outcome in the control CPT group (3 unwell, 3 withdrew, 1 moved abroad). At follow-up, a further 21 participants had withdrawn (total 28/74 26%). 14 participants were lost in the CPT group (5 unwell, 4 withdrew, 1 moved abroad, 2 housebound, 2 died) and 7 in the CPT + FST group (5 unwell, 2 withdrew)

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)

Number randomised in comparisons used in this review this review = 74

Intervention: FST + CPT = 36 participants: 22 males (61%) and 14 females (39%); mean age: 71.17 (SD 10.6); 33.86 (SD 16.50) days after stroke

Control: CPT = 38 participants: 21 males (55%) and 17 females (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 orthopaedic surgery or trauma affecting the lower limb in the last 8 weeks; no previous history of neurological diseases; able to follow a 1-stage command

Exclusion criteria: not reported    

Interventions

Intervention: FST/mixed training plus CPT. FST consisted of increasing the amount of body weight the patients needed to move; increasing movements resistance; reducing amount of body weight support during treadmill training. Frequency of intervention: 1 hour for 4 days/week for 6 weeks

Control: CPT included soft issue mobilisation, facilitation of muscle activity, facilitation of co-ordinated multi-joint movement; tactile and proprioceptive input, resistive exercise, and functional retraining. Frequency of intervention: 1 hour for 4 days/week for 6 weeks

Setting: hospital

Outcomes

Included outcomes: walking speed; health-related quality of life measures (e.g. EuroQol)    

Other outcomes: gait parameters; paretic knee torque force analysis; modified RMI       

NotesTrial authors stated 'strength training' but intervention was actually mixed training
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskComputer-generated random allocation in blocks of 9 per trial centre (stratified allocation by baseline scores for visual spatial neglect)
Allocation concealment (selection bias)Low riskSequentially numbered sealed opaque envelopes
Blinding (performance bias and detection bias)
All outcomes
High riskComparison used means no attention control
Blinding of outcome assessment (detection bias)
All outcomes
Low riskAssessor blinded to group allocation
Incomplete outcome data (attrition bias)
End of intervention
High risk

Attempt to measure participants at outcome and follow-up even if they withdraw but analyses were not performed according to ITT principle. Imbalanced losses at the end of intervention

7/74 (9%) participants were lost from the control CPT group (3 unwell, 3 withdrew, 1 moved abroad)

Incomplete outcome data (attrition bias)
End of follow-up
High risk

Attempt to measure participants at outcome and follow-up even if they withdraw but analyses were not performed according to ITT principle. Imbalanced large losses at the end of follow-up

28/74 (38%) total losses: 14 participants were lost from the CPT group (5 unwell, 4 withdrew, 1 moved abroad, 2 housebound, 2 died) and 7 in the intervention group CPT + FST group (5 unwell, 2 withdrew)

Selective reporting (reporting bias)Low riskReported outcome correspond with those in trial register NCT00322192
Other biasUnclear riskUnclear
Imbalanced exposureHigh riskImbalanced exposure (CPT + CPT group although balanced does not meet inclusion criteria)

Cuviello-Palmer 1988

Methods

Design: randomised trial of cardiorespiratory training plus % usual care versus usual care - after usual care
Randomisation: unknown
Allocation concealment: unknown
Blinding: unknown
ITT: no

Measurements: end of intervention (3 weeks)
Withdrawals: none

ParticipantsRandomised: 20 participants
Intervention: 10 participants; 6 males and 4 females; age 69.5 years (SD 14.1); 20.7 days post-stroke (SD 13.2)
Control: 10 participants; 7 males and 3 females; age 71.8 years (SD 12.0); 12.0 days post-stroke (SD 16.8)
Inclusion criteria: unknown
Exclusion criteria: unknown
InterventionsIntervention: cardiorespiratory training: isokinetic ergometer allowing resisted reciprocal leg movements (Kinetron II); commencing at 2 x 7 minutes/day for 5 days/week and 1 x 7 minutes/day for 1 day/week (total 6 days/week) for 3 weeks progressing to 10 minutes per session in week 2 and 12 minutes in week 3
Exercise intensity maintained at a heart rate of < 20 beats/minute above resting
Control: usual care: 2 x 45 minutes/day for 5 days/week and 1 x 45 minutes/day for 1 day/week (total 6 days/week) for 3 weeks
Gait training, mat exercises, and transfer training achieved via strengthening exercises, post neuromuscular facilitation (PNF), functional electrical stimulation (FES), Brunnstrom, Rood, and neurodevelopment techniques
Setting: rehabilitation centre
OutcomesIncluded outcomes: FIM (old version); preferred gait speed (7 seconds)
Other outcomes: stance symmetry; contact time (seconds); stride cadence steps/minute and other biomechanical gait parameters
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNot reported
Allocation concealment (selection bias)Unclear riskNot reported
Blinding (performance bias and detection bias)
All outcomes
High riskSome degree of attention control
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot reported
Incomplete outcome data (attrition bias)
End of intervention
Low riskNo withdrawals, no planned ITT
Selective reporting (reporting bias)Unclear riskNo protocol available
Other biasUnclear riskUnclear
Imbalanced exposureLow riskExposure balanced

da Cunha 2002

Methods

Design: randomised trial of cardiorespiratory training plus % usual care versus usual care - during usual care
Randomisation mechanism: random number table
Allocation concealment: unknown
Blinding: unknown
ITT: no

Measurements: end of intervention (2/3 weeks - until discharge)
Withdrawals: none

ParticipantsRandomised: 15 participants
Intervention: 7 participants; 6 males and 1 females; age 57.8 years (SD 5.5); 15.7 days post-stroke (SD 7.7)
Control: 8 participants; 7 males and 1 female; age 58.9 years (SD 12.9); 19.0 days post-stroke (SD 12.7)
Inclusion criteria: recent stroke (onset < 6 weeks); significant gait deficit (< 36 metres/minute; FAC score of 0, 1 or 2); sufficient cognition to participate in training (Mini Mental State Examination - MMSE ≥ 21); able to stand and take 1 or more steps without assistance
Exclusion criteria: co-morbidity or disability other than hemiparesis; recent myocardial infarct; any uncontrolled health condition; joint disease or rheumatoid arthritis; obesity (> 110 kg); cognitive impairment (MMSE < 21)
InterventionsIntervention: cardiorespiratory training: treadmill walking with body weight support 20 minutes/day 6 days/week for 2 to 3 weeks (until discharge); intensity unknown but rapid progression imposed by increasing speed and reducing body weight support; the 20-minute training replaced the 20-minute gait training component of the control
Control: usual care 3 hours per day for 6 days per week for 2 to 3 weeks until discharge; included kinesitherapy (1 hour per day), occupational therapy (1 hour per day) and physical therapy (1 hour per day): the physical therapist included 20 minutes of gait training comprising stepping, standing, turning, etc, but not continuous walking
Setting: rehabilitation centre
OutcomesIncluded outcomes: cycle performance work rate (Watts); VO2 peak; blood pressure; FAC; FIM (lower limb); gait speed maximal (5 metres); gait endurance (5 minutes); gait economy
Other outcomes: stance symmetry; contact time (seconds); stride cadence steps/minute and other biomechanical gait parameters
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskRandomisation by using random numbers to pre-assign participants based on recruitment order
Allocation concealment (selection bias)Unclear riskNot reported
Blinding (performance bias and detection bias)
All outcomes
High riskSome degree of attention control
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot reported
Incomplete outcome data (attrition bias)
End of intervention
Low riskNo withdrawals, no planned ITT
Selective reporting (reporting bias)Unclear riskNo protocol available
Other biasUnclear riskUnclear
Imbalanced exposureLow riskBalanced exposure

Donaldson 2009

Methods

Design: phase II randomised multicentre trial; 3 centres; mixed training plus usual care versus usual care - during usual care - i.e. functional strength training (FST) plus conventional physiotherapy (CPT) versus CPT alone and versus CPT plus CPT

Randomisation: computer-generated random allocation. Allocation was stratified by baseline Action Research Arm Test score in blocks of 3 within each stratum

Allocation concealment: sequentially numbered sealed opaque envelopes held by an independent investigator

Blinding: assessor blinded to group allocation

ITT: yes 

Measurements: at the end of intervention (6 weeks) and 12 weeks after (follow-up)           

Withdrawals: 2 participants were lost at outcome in the CPT group (new stroke = 1; bail = 1). A further 11 participants were lost at follow-up. 5 participants in the CPT group (3 unwell, 1 moved abroad, 1 bail) 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 males and 7 females; mean age: 72.6

Control: CPT = 10 participants, 5 males and 5 females; mean age: 72.6                                                

Inclusion criteria: inpatients; infarction of the anterior cerebral circulation between 1 weeks and 3 months after stroke; some voluntary contraction in the upper affected limb; no obvious unilateral visuospatial 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

Exclusion criteria: not reported   

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/elbow muscles to enable appropriate hand position. Frequency of intervention: 1 hour 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 hour for 4 days/week for 6 weeks

Setting: hospital setting

Outcomes

Included outcomes: upper limb strength (hand grip force, pinch grip force; isometric elbow flexion and extension force); upper limb function (ARAT)

Other outcomes: dexterity (i.e. 9-HPT)

NotesNot clear how this relates to NCT00322192
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskComputer-generated random allocation
Allocation was stratified by baseline ARAT score in blocks of 3 within each stratum
Allocation concealment (selection bias)Low riskSequentially numbered, sealed, opaque envelopes held by an independent investigator
Blinding (performance bias and detection bias)
All outcomes
Unclear risk

No attention control in the comparison, however:

Quote: "The majority of subjects (68%) who completed outcome measures were unsure as to which group they had been allocated (CPT 75%, CPT + CPT 60%, CPT + FST 70%; Table 3). Only 4 of the 28 subjects (14%) correctly identified the treatment they received. Even in the CPT group who had been told that they would receive no extra therapy, only 1 person correctly identified their grouping."

Blinding of outcome assessment (detection bias)
All outcomes
Low riskAssessor blinded to group allocation; efficacy unknown
Incomplete outcome data (attrition bias)
End of intervention
Low risk

ITT analysis planned

2/20 (10%) lost at the end of intervention: control CPT group (new stroke = 1; bail = 1)

Incomplete outcome data (attrition bias)
End of follow-up
High risk

ITT analysis planned

9/20 (45%) total losses at the end of follow-up: additional 5 participants in the control CPT group (3 unwell, 1 moved abroad, 1 bail) and 2 in the intervention CPT + FST group (1 unwell, 1 moved abroad)

Selective reporting (reporting bias)Unclear riskUnclear how the trial relates to NCT00322192; outcomes do not correspond
Other biasUnclear riskUnclear
Imbalanced exposureHigh riskImbalanced exposure in comparison used CPT versus CPT + FST

Duncan 1998

Methods

Design: randomised trial of mixed training versus usual care - after usual care (outpatient)
Randomisation mechanism: unknown; method: blocks of 10
Allocation concealment: third party involvement
Blinding: unclear
ITT: yes

Measurements: end of intervention (12 weeks)
Withdrawals: none

ParticipantsRandomised: 20 participants
Intervention: 10 participants; number of males and females unknown; age 67.3 years (SD 9.6); 66 days post-stroke
Control: 10 participants; number of males and females unknown; age 67.8 years (SD 7.2); 56 days post-stroke
Inclusion criteria: 30 to 90 days post-stroke; minimal/moderately impaired sensorimotor function; available to attend all training sessions; ambulatory with or without supervision or walking aids; living at home within 50 miles
Exclusion criteria: medical condition which compromised outcome assessment or prevented fitness training; MMSE score < 18 or receptive aphasia
InterventionsIntervention: mixed training, performed approximately 90 minutes/day 3 days/week for 12 weeks (8 weeks supervised 1:1 with therapist and 4 weeks alone), functional exercises comprising assistive/resistive exercise, 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 occupational therapy as advised by the patient's physician, averaging 44 minutes per day, 3.25 days per week for 12 weeks, therapeutic interventions were during home or outpatient visits and comprised balance training (60%), strength training (40%), bimanual activities (50%) and facilitative exercise (30%); cardiorespiratory training was not provided (0%)
Setting: home-based, therapist-supervised for first 8 weeks
OutcomesIncluded outcomes: BI; Lawton Activities of Daily Living; gait endurance (6-MWT); BBS; gait preferred speed (data lack variance measures)
Other outcomes: SF-36 (non-standard pooling of data), Jebsen Hand Test; Fugl Meyer (upper and lower extremity)
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskBlock randomisation used (blocks of 10), method unknown
Allocation concealment (selection bias)Unclear riskThird party involvement
Blinding (performance bias and detection bias)
All outcomes
High riskDegree of attention control
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot reported
Incomplete outcome data (attrition bias)
End of intervention
Low riskPlanned ITT; no losses
Selective reporting (reporting bias)Unclear riskProtocol not available
Other biasUnclear riskUnclear