Saunders David H, Carstairs Sharon A, Cheyne Joshua D, Fileman Megan, Morris Jacqui, Morton Sarah, Wylie Gavin, Mead Gillian E
Physical Activity for Health Research Centre (PAHRC), University of Edinburgh, Edinburgh, UK.
School of Health Sciences, University of Dundee, Dundee, UK.
Cochrane Database Syst Rev. 2025 Sep 24;9(9):CD016002. doi: 10.1002/14651858.CD016002.
Levels of physical activity and physical fitness, including both cardiorespiratory fitness and muscle strength, are often low after stroke and are associated with post-stroke disability. Multicomponent exercise interventions that increase muscle strength and cardiorespiratory fitness could be effective for improving physical function and disability, and for secondary prevention.
The primary objective of this review is to determine whether combined cardiorespiratory fitness and resistance training after stroke has any effects on death, disability, adverse events, risk factors, fitness, walking, and indices of physical function when compared to a non-exercise control.
In January 2024, we searched nine databases (CENTRAL, MEDLINE, Embase, CINAHL, SPORTDiscus, PsycINFO, WoS, PEDro, and DORIS) and two trial registers (ClinicalTrials.gov and ICTRP). We also undertook reference checking, citation tracking, and contact with experts in the field, in order to identify eligible studies.
We included randomised controlled trials (RCTs) that compared combined cardiorespiratory fitness and muscle strength training against usual care, no intervention, or a non-exercise intervention for people with stroke.
Our critical outcome domains were death, disability, adverse events, risk factors, fitness, walking, and indices of physical function. We assessed outcomes at the end of intervention and at the end of follow-up. Our other important outcome domains were indices of quality of life, mood, cognition, and fatigue.
We used the Cochrane tool RoB 1 to assess bias in the included studies.
Where possible, we synthesised results for each outcome at the end of intervention and end of follow-up using random-effects meta-analyses on arm-level data. For dichotomous outcomes, we calculated the risk difference (RD) and 95% confidence interval (CI). For continuous outcomes, we calculated a mean difference (MD) or standardised mean difference (SMD), and 95% CI. We used GRADE to assess certainty of evidence for critical outcomes.
We included 30 studies with 1519 participants, who had an average age of 63.7 years. Most studies recruited ambulatory participants (28 of the 30 studies) during the early subacute (14 studies) and chronic (14 studies) stages of recovery. Most studies (26) took place in high-income countries. Most study interventions lacked a balanced dose of control exposure (23 studies). Eleven studies included a follow-up period (mean 7.3 months; range 3 to 12 months). Most interventions combined cardiorespiratory training (usually walking or ergometer-based) and resistance training (weights, machines, bodyweight or elastic resistance) in a circuit-type format. Training occurred two to five days a week for between four weeks and one year.
Combined training does not increase or decrease deaths at the end of intervention (risk difference RD -0.00, 95% CI -0.02 to 0.01; 26 studies, 1352 participants; high certainty) or end of follow-up (RD -0.01, 95% CI -0.04 to 0.02; 8 studies, 531 participants; high certainty). Combined training may improve indices of disability slightly at the end of intervention (standardised mean difference SMD 0.20, 95% CI 0.04 to 0.36; 13 studies, 789 participants; low certainty) but has little or no effect at the end of follow-up (SMD 0.10, 95% CI -0.07 to 0.28; 8 studies, 614 participants; low certainty). Combined training does not increase or reduce the incidence of secondary cardiovascular or cerebrovascular events at the end of intervention (RD -0.00, 95% CI -0.02 to 0.01; 8 studies, 684 participants; high certainty) or end of follow-up (RD 0.01, 95% CI -0.06 to 0.09; 4 studies, 285 participants; high certainty). Combined training may have little or no effect on systolic blood pressure (mmHg) at the end of intervention, but the evidence is very uncertain (mean difference MD -1.83, 95% CI -9.60 to 5.95; 5 studies, 140 participants; very low certainty); there were no follow-up data. Combined training may improve indices of cardiorespiratory fitness and musculoskeletal fitness (lower limb strength), but the evidence is very uncertain. Few data were available at follow-up. Combined training may improve comfortable walking speed (metres per second) at the end of intervention (MD 0.09, 95% CI 0.04 to 0.14; 13 studies, participants not available; very low certainty) but may have little or no effect at the end of follow-up (MD 0.03, 95% CI -0.07 to 0.13; 7 studies, 605 participants; very low certainty), although the evidence is very uncertain for both time points. Combined training may improve balance slightly at the end of intervention (SMD 0.25, 95% CI 0.11 to 0.39; 16 studies, 839 participants; low certainty) and end of follow-up (SMD 0.24, 95% CI -0.00 to 0.49; 6 studies, 535 participants; low certainty). In terms of acceptability and tolerability, interventions were closely adhered to, with no pattern of concerning adverse effects or participant losses attributable to combined training. Overall, our certainty about the evidence is limited by imprecision (small number of studies and participants) and risks of bias (e.g. from imbalanced exposure doses).
AUTHORS' CONCLUSIONS: Combined training after stroke does not affect mortality or the incidence of secondary events at the end of intervention or end of follow-up. Since these events are infrequent, conclusions cannot be drawn about any protective effect on mortality or secondary events. Small beneficial effects on physical fitness and blood pressure at the end of intervention may represent a reduced risk of secondary events, but this is very uncertain. Combined training may cause small improvements in fitness, disability, walking speed, and balance at the end of intervention. The small benefit observed for balance may be preserved after a follow-up period. The evidence for these effects is of low or very low certainty. Combined training interventions were adhered to successfully without serious adverse events or adverse effects; the interventions were acceptable to and well tolerated by participants. Limited data at follow-up restricts the conclusions we can draw about the retention of any benefits observed. Larger, well-designed trials are needed to determine the optimal regimen for exercise prescription, the benefits, and long-term effects.
This Cochrane review had no dedicated funding.
Protocol (and previous versions) available via DOI 10.1002/14651858.CD003316 (DOI/10.1002/14651858.CD003316.pub7, DOI/10.1002/14651858.CD003316.pub6, DOI/10.1002/14651858.CD003316.pub5, DOI/10.1002/14651858.CD003316.pub4, DOI/10.1002/14651858.CD003316.pub3, DOI/10.1002/14651858.CD003316.pub2).
中风后身体活动水平和身体素质，包括心肺功能和肌肉力量，通常较低，且与中风后残疾相关。增加肌肉力量和心肺功能的多组分运动干预可能对改善身体功能和残疾以及二级预防有效。
本综述的主要目的是确定与非运动对照组相比，中风后心肺功能和阻力训练相结合对死亡、残疾、不良事件、风险因素、身体素质、步行和身体功能指标是否有任何影响。
2024年1月，我们检索了九个数据库（CENTRAL、MEDLINE、Embase、CINAHL、SPORTDiscus、PsycINFO、WoS、PEDro和DORIS）以及两个试验注册库（ClinicalTrials.gov和ICTRP）。我们还进行了参考文献核对、引文追踪，并与该领域的专家联系，以确定符合条件的研究。
我们纳入了随机对照试验（RCT），这些试验比较了中风患者心肺功能和肌肉力量联合训练与常规护理、无干预或非运动干预的效果。
我们的关键结局领域是死亡、残疾、不良事件、风险因素、身体素质、步行和身体功能指标。我们在干预结束时和随访结束时评估结局。我们的其他重要结局领域是生活质量、情绪、认知和疲劳指标。
我们使用Cochrane工具RoB 1评估纳入研究中的偏倚。
在可能的情况下，我们使用随机效应荟萃分析对每组数据在干预结束时和随访结束时的每个结局进行合成。对于二分结局，我们计算风险差（RD）和95%置信区间（CI）。对于连续结局，我们计算平均差（MD）或标准化平均差（SMD）以及95%CI。我们使用GRADE评估关键结局证据的确定性。
我们纳入了30项研究，共1519名参与者，平均年龄为63.7岁。大多数研究在恢复的早期亚急性（14项研究）和慢性（14项研究）阶段招募了能够行走的参与者（30项研究中的28项）。大多数研究（26项）在高收入国家进行。大多数研究干预缺乏均衡的对照暴露剂量（23项研究）。11项研究包括随访期（平均7.3个月；范围3至12个月）。大多数干预措施采用循环训练的形式，将心肺训练（通常是步行或基于测力计）和阻力训练（重量训练、器械训练、自重训练或弹性阻力训练）相结合。训练每周进行两到五天，持续四周至一年。
联合训练在干预结束时（风险差RD -0.00，95%CI -0.02至0.01；26项研究，1352名参与者；高确定性）或随访结束时（RD -0.01，95%CI -0.04至0.02；8项研究，531名参与者；高确定性）均不会增加或减少死亡人数。联合训练在干预结束时可能会轻微改善残疾指标（标准化平均差SMD 0.20，95%CI 0.04至0.36；13项研究，789名参与者；低确定性），但在随访结束时几乎没有影响（SMD 0.10，95%CI -0.07至0.28；8项研究，614名参与者；低确定性）。联合训练在干预结束时不会增加或降低继发性心血管或脑血管事件的发生率（RD -0.00，95%CI -0.02至0.01；8项研究，684名参与者；高确定性）或随访结束时（RD 0.01，95%CI -0.06至0.09；4项研究，285名参与者；高确定性）。联合训练在干预结束时对收缩压（mmHg）可能几乎没有影响，但证据非常不确定（平均差MD -1.83，95%CI -9.60至5.95；5项研究，140名参与者；极低确定性）；没有随访数据。联合训练可能会改善心肺功能和肌肉骨骼功能指标（下肢力量），但证据非常不确定。随访时可用的数据很少。联合训练在干预结束时可能会提高舒适步行速度（米/秒）（MD 0.09，95%CI 0.04至0.14；13项研究，参与者人数未提供；极低确定性），但在随访结束时可能几乎没有影响（MD 0.03，95%CI -0.07至0.13；7项研究，605名参与者；极低确定性），尽管两个时间点的证据都非常不确定。联合训练在干预结束时可能会轻微改善平衡（SMD 0.25，95%CI 0.11至0.39；16项研究，839名参与者；低确定性）和随访结束时（SMD 0.24，95%CI -0.00至0.49；6项研究，535名参与者；低确定性）。在可接受性和耐受性方面，干预措施得到了严格遵守，没有因联合训练导致的不良影响或参与者流失的模式。总体而言，我们对证据的确定性受到不精确性（研究和参与者数量少）和偏倚风险（例如来自不均衡暴露剂量）的限制。
中风后的联合训练在干预结束时或随访结束时不会影响死亡率或继发性事件的发生率。由于这些事件很少见，因此无法得出关于对死亡率或继发性事件的任何保护作用的结论。干预结束时对身体素质和血压的微小有益影响可能代表继发性事件风险的降低，但这非常不确定。联合训练在干预结束时可能会使身体素质、残疾、步行速度和平衡略有改善。观察到的平衡方面的微小益处可能在随访期后得以保留。这些影响的证据确定性低或极低。联合训练干预措施成功实施，没有严重不良事件或不良反应；干预措施为参与者所接受且耐受性良好。随访时有限的数据限制了我们对观察到的任何益处的持续性得出结论。需要更大规模、设计良好的试验来确定运动处方的最佳方案、益处和长期效果。
本Cochrane综述没有专门的资金。
方案（及以前版本）可通过DOI 10.1002/14651858.CD003316获取（DOI/10.1002/14651858.CD003316.pub7、DOI/10.1002/14651858.CD003316.pub6、DOI/10.1002/14651858.CD003316.pub5、DOI/10.1002/14651858.CD003316.pub4、DOI/10.1002/14651858.CD003316.pub3、DOI/10.1002/14651858.CD003316.pub2）。
