What are the benefits and risks of aerobic exercise programmes for people after stroke?

Key messages

• People with stroke can safely take part in programmes of exercise that involve aerobic fitness training.

• Aerobic fitness training may improve fitness, reduce disability, increase walking speed, and improve balance at the end of the programme, but it is unclear if these are noticeable improvements.

• There is not enough evidence about the effects of aerobic training and further research is needed.

What is stroke?

A stroke occurs when the blood supply to part of the brain is interrupted, leading to damage in specific areas of the brain. The impact of stroke can be life-changing and varies depending on the severity of damage and where it occurs in the brain. As well as affecting the ability to move, stroke can impact thinking, feeling, and behaviour. These effects can persist throughout life after stroke. One physical impact of stroke is reduced aerobic fitness and muscle strength, which make physical activity and getting back to everyday activities more difficult. Low aerobic fitness could also be a risk for having another stroke.

What happens during rehabilitation after stroke?

After a stroke, many patients receive rehabilitation, for example, from a physiotherapist or other health professional, to help them overcome difficulties with everyday activities. Rehabilitation often includes different types of exercise. One type is aerobic (or 'cardiorespiratory') training, which involves continuous exercise that increases heart rate, which may increase the stamina needed for repetitive activities like walking.

What did we want to find out?

We wanted to find out if aerobic fitness training is beneficial at any time after stroke (whether in hospital or after going home). Specifically, we wanted to know whether aerobic training after stroke:

• is safe;

• improves physical fitness and movement (including walking and balance);

• changes how people feel (including depression and quality of life); and

• reduces the risk of another stroke.

What did we do?

We searched for studies that tested an aerobic training exercise programme for people after a stroke compared to usual care, no programme or a non-exercise programme. We only included studies if the exercise programme being tested was based only on aerobic training; we excluded studies that involved other types of exercise, such as muscle strength training.

We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors like study methods and the number of people involved.

What did we find?

We found 53 studies involving 2672 people with stroke. Most of the study participants could walk. Thirty-seven of the studies were conducted in high-income countries. The average age of study participants was 61.9 years. Most studies took place either within three months of a stroke (19 studies) or at least six months after a stroke (29 studies). In 28 studies, the people in the aerobic exercise groups received more attention than those in the control groups.

In 49 studies, exercise sessions lasted between 20 and 60 minutes; in 48 studies, exercise frequency was 3 to 5 days a week. The programme was less than 12 weeks in 37 studies. Exercise intensity was reported as maximal heart rate, heart rate reserve (based on resting heart rate), or participants' ratings of perceived exertion.

Sixteen of the 53 studies followed up the people taking part in the studies. The length of follow-up ranged between 12 weeks and 12 months after the programme started. One study planned a six-month follow-up but did not report it.

Main results

• Aerobic exercise does not affect the number of deaths at the end of the programme (36 studies, 1563 participants) or at follow-up (10 studies, 713 participants).

• Aerobic exercise does not affect the number of second strokes at the end of the programme (8 studies, 544 participants) and probably does not affect them at follow-up (4 studies, 412 participants).

• We are very uncertain about the results for blood pressure at the end of the programme (9 studies, 535 participants) or at follow-up (3 studies, 155 participants).

• Aerobic exercise may cause small improvements in balance (18 studies, 772 participants), disability (17 studies, 1073 participants), aerobic fitness (13 studies, 608 participants) and comfortable walking speed (16 studies, 647 participants) at the end of the programme, but it is unclear if these changes are large enough to be meaningful for people with stroke. The results at follow-up are unclear; the aerobic fitness benefit may continue but may not be large enough to be meaningful for people with stroke (5 studies, 237 participants).

What are the limitations of the evidence?

• Most studies involved people who could walk; little is known about the many people with stroke who have more limited mobility.

• Most studies took place in high-income countries; little is known about people with stroke in other countries.

• There are many uncertainties and not enough evidence about the effects of aerobic training. Further research is needed.

How up to date is this evidence?

This review is one of three that update a previous single review on fitness training for stroke. The evidence is based on searches run up to April 2025.