Combined Aerobic and Strength Training Delivers Small but Real Gains for Stroke Survivors

Stroke survivors face chronically reduced cardiorespiratory fitness and muscle strength, compounding disability and increasing risk of secondary cardiovascular events. Multicomponent exercise that targets both aerobic capacity and muscular strength simultaneously could address these deficits more efficiently than single-modality programs, yet the evidence base has remained fragmented. This Cochrane review provides the most comprehensive synthesis to date of combined training interventions for stroke.

Researchers searched nine major databases and two trial registries through January 2024, identifying 30 RCTs with 1,519 participants (mean age 63.7 years). Most participants were ambulatory, recruited during early subacute (within 6 months) or chronic (beyond 6 months) recovery stages. Interventions typically combined walking or ergometer-based aerobic exercise with resistance training using weights, machines, bodyweight, or elastic bands, usually delivered in a circuit format two to five days per week for four weeks to one year. Twenty-three of thirty studies lacked a balanced dose of control exposure, introducing significant risk of bias.

On the primary safety outcomes, combined training had no effect on mortality at end of intervention (RD −0.00, 95% CI −0.02 to 0.01; high certainty) or follow-up, nor on secondary cardiovascular or cerebrovascular events (RD −0.00, 95% CI −0.02 to 0.01; high certainty). For efficacy, combined training produced a small improvement in disability at end of intervention (SMD 0.20, 95% CI 0.04 to 0.36; low certainty) that was not maintained at follow-up. Walking speed improved modestly at end of intervention (MD 0.09 m/s, 95% CI 0.04 to 0.14; very low certainty) but not at follow-up. Balance showed small improvements at end of intervention (SMD 0.25; low certainty) with some signal of persistence at follow-up (SMD 0.24; low certainty). Effects on systolic blood pressure, cardiorespiratory fitness, and lower-limb strength were directionally positive but evidence was very uncertain.

Combinedtraining interventions were well adhered to and no serious adverse events or concerning patterns of dropout were attributed to the exercise programs, affirming their tolerability across a broad post-stroke population. Eleven studies included a follow-up period averaging 7.3 months, but sparse data at these timepoints limits conclusions about long-term benefit retention.

The review's principal caveat is that overall certainty is low to very low for most outcomes, driven by imprecision (small study counts and participant numbers), inconsistency across interventions, and systematic bias from unbalanced control conditions. Most evidence comes from high-income countries and ambulatory patients, leaving non-ambulatory survivors and lower-income settings poorly represented. Larger, rigorously designed trials with adequate control conditions and extended follow-up are essential to resolve these uncertainties and define optimal exercise prescriptions.