Key messages

• People with stroke can complete programmes of exercise that target both aerobic fitness and muscle strength (this is called 'combined training').

• By engaging in combined training, people with stroke may experience small improvements in some aspects of fitness, balance, and walking speed.

What is stroke?

Stroke occurs when the blood supply to part of the brain is interrupted, and this leads to damage in some areas of the brain. The impact of stroke can be life-changing and vary depending on the severity of damage and where this occurs in the brain. The effects can be both physical and psychological, not only affecting the ability to move, but also the way someone thinks, behaves, and feels. These effects can persist throughout life after stroke. A physical impact of stroke is that aerobic fitness and muscle strength can be low; this makes physical movement more difficult, which may restrict a return to meaningful everyday activities.

What happens during rehabilitation after stroke?

After a stroke, many patients will receive rehabilitation, for example from a physiotherapist or other health professional, to help overcome physical problems with everyday activities. This therapy may involve different types of exercise, including aerobic training and strength training. Aerobic training (also called ‘cardiorespiratory training’) involves continuous exercise. It can increase aerobic fitness, which improves the endurance needed for repetitive activities like walking. Strength training (also called ‘resistance training’) can involve lifting weights or pulling against elastic resistance. It can improve fitness by strengthening muscles, which can help with activities like lifting objects, standing up, or walking. Patients may also be advised to do exercises at home. Therefore, the normal process of rehabilitation after a stroke may include elements of both aerobic training and muscle strength training.

What did we want to find out?

Since both aerobic fitness and muscle strength can be low after a stroke, combined exercise could improve both of these elements of fitness and the post-stroke physical problems arising from them.

We wanted to find out whether programmes of exercise that combine both an aerobic fitness training element and muscle strength training are beneficial at any time after stroke (whether in hospital, or later, after going home).

Specifically, we wanted to determine whether combined training after a stroke is safe, whether it improves physical fitness, improves movement (including walking and balance), changes the way people feel (including depression, quality of life) and whether it reduces the chance of having another stroke.

What did we do?

We searched for studies that tested exercise programmes in people after stroke. We only included studies where the exercise programme contained both an aerobic training element and a muscle strengthening element. We summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and number of people included.

What did we find?

We found 30 studies that involved 1519 people with stroke; most participants were able to walk. Some exercise programmes were delivered in the first few months after a stroke, and others were delivered later on, more than six months after the stroke. Most combined training programmes lasted less than 12 weeks, were safe, and combined several types of activities, including walking and lifting weights.

Main results

Combined training does not affect the number of deaths or second strokes at the end of the training programme or after a period of follow-up. Since deaths and second strokes were uncommon, we cannot determine whether combined training reduces the chance of death or secondary events. Small beneficial effects on blood pressure at the end of the intervention may suggest there is a reduced risk of secondary events, but this is very uncertain.

Combined training may cause small improvements in fitness (aerobic fitness and muscle strength of the legs), disability, walking speed, and balance at the end of a combined training programme. These are important outcomes for people with stroke, but the evidence has many uncertainties. Twelve studies measured the effects again 3 to 12 months after the combined training had finished; there was some limited evidence that the positive effect on balance may be retained.

Combined training interventions were adhered to without serious adverse events or effects; the interventions were acceptable to participants and well tolerated. Larger trials are needed to determine the best approach to exercise prescription, and its benefits and long-term effects.

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, industrialised countries; little is known about people with stroke in other countries.

There are lots of uncertainties and not enough evidence about the effects of combined aerobic training and strength training.

How up to date is this evidence?

This review updates evidence from a previous review (which was in a different format combining three separate programmes). The evidence is based on searches run up to January 2024.