Billinger Et Al 2014

AHA/ASA Scientific Statement
Physical Activity and Exercise Recommendations for

Stroke Survivors
A Statement for Healthcare Professionals From the American Heart
Association/American Stroke Association
The American Academy of Neurology affirms the value of this statement as an educational tool
for neurologists.
Sandra A. Billinger, PT, PhD, FAHA, Chair; Ross Arena, PT, PhD, FAHA, Co-Chair;
Julie Bernhardt, PT, PhD; Janice J. Eng, BSc, PT/OT, PhD; Barry A. Franklin, PhD, FAHA;
Cheryl Mortag Johnson, OTR; Marilyn MacKay-Lyons, BSc, MScPT, PhD;
Richard F. Macko, MD; Gillian E. Mead, MD, MA, FRCP; Elliot J. Roth, MD, FAHA;
Marianne Shaughnessy, PhD, RN, CRNP; Ada Tang, PT, PhD; on behalf of the American Heart
Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Lifestyle and
Cardiometabolic Health, Council on Epidemiology and Prevention, and Council on Clinical Cardiology
Purpose—This scientific statement provides an overview of the evidence on physical activity and exercise recommendations
for stroke survivors. Evidence suggests that stroke survivors experience physical deconditioning and lead sedentary
lifestyles. Therefore, this updated scientific statement serves as an overall guide for practitioners to gain a better
understanding of the benefits of physical activity and recommendations for prescribing exercise for stroke survivors
across all stages of recovery.
Methods—Members of the writing group were appointed by the American Heart Association Stroke Council’s Scientific
Statement Oversight Committee and the American Heart Association’s Manuscript Oversight Committee. The writers
used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality
reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize
Downloaded from http://ahajournals.org by on July 23, 2020
existing evidence and indicate gaps in current knowledge.

Results—Physical inactivity after stroke is highly prevalent. The assessed body of evidence clearly supports the use of
exercise training (both aerobic and strength training) for stroke survivors. Exercise training improves functional capacity,
the ability to perform activities of daily living, and quality of life, and it reduces the risk for subsequent cardiovascular
events. Physical activity goals and exercise prescription for stroke survivors need to be customized for the individual to
maximize long-term adherence.
Conclusions—The recommendation from this writing group is that physical activity and exercise prescription should be
incorporated into the management of stroke survivors. The promotion of physical activity in stroke survivors should
emphasize low- to moderate-intensity aerobic activity, muscle-strengthening activity, reduction of sedentary behavior,
and risk management for secondary prevention of stroke. (Stroke. 2014;45:2532-2553.)
Key Words: AHA Scientific Statements ◼ aerobic exercise ◼ exercise, physical ◼ physical activity ◼ rehabilitation
◼ strength training
The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship
or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete
and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.
This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on January 15, 2014. A copy of the
document is available at http://my.americanheart.org/statements by selecting either the “By Topic” link or the “By Publication Date” link. To purchase
additional reprints, call 843-216-2533 or e-mail [email protected].
The American Heart Association requests that this document be cited as follows: Billinger SA, Arena R, Bernhardt J, Eng JJ, Franklin BA, Johnson
CM, MacKay-Lyons M, Macko RF, Mead GE, Roth EJ, Shaughnessy M, Tang A; on behalf of the American Heart Association Stroke Council, Council
on Cardiovascular and Stroke Nursing, Council on Lifestyle and Cardiometabolic Health, Council on Epidemiology and Prevention, and Council on
Clinical Cardiology. Physical activity and exercise recommendations for stroke survivors: a statement for healthcare professionals from the American Heart
Association/American Stroke Association. Stroke. 2014;45:2532–2553.
Expert peer review of AHA Scientific Statements is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines
development, visit http://my.americanheart.org/statements and select the “Policies and Development” link.
Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express
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© 2014 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org DOI: 10.1161/STR.0000000000000022
2532
Billinger et al Exercise Recommendations for Stroke Survivors 2533
A nnually, 795 000 people in the United States experience

a stroke; or ≈1 person every 40 seconds, and nearly one
quarter of these strokes are recurrent.1 An estimated 7 million
appropriate prescription for exercise training. However, most
healthcare professionals have limited experience and guid-
ance in exercise programming for this diverse and escalating
American adults are living with a stroke,1 and it is projected patient population. The present scientific statement is intended
that an additional 4 million will have a stroke by 2030, which to help bridge the current knowledge gap in physical activity
is almost a 25% increase in prevalence from 2010.2 Data and exercise recommendations in the stroke population.
from the Framingham Study revealed a lifetime stroke risk
of 1 in 5 for women and 1 in 6 for men among those 55 to 75 Methods
years of age.3 Moreover, the incidence of stroke is likely to Writing group members were nominated by the committee
continue to escalate because of an expanding population of chair on the basis of their previous work in relevant topic areas
elderly Americans4 and the apparent epidemic in the general and were approved by the American Heart Association (AHA)
population regarding modifiable cardiovascular risk factors, Stroke Council’s Scientific Statement Oversight Committee
including diabetes mellitus, obesity, and physical inactivity. and the AHA’s Manuscript Oversight Committee. The writ-
American adults with disability are more likely to be obese, ers used systematic literature reviews, references to published
to smoke, and to be physically inactive,5 which leads to an clinical and epidemiology studies, morbidity and mortality
increased cardiovascular risk in an already functionally com- reports, clinical and public health guidelines, authoritative
promised population. When considered independently from statements, personal files, and expert opinion to summarize
other cardiovascular diseases (CVDs), stroke continues to be existing evidence and indicate gaps in current knowledge. All
the fourth-leading cause of death in the United States.1 members of the writing group had the opportunity to comment
Unfortunately, stroke remains a leading cause of long-term and approved the final version of this document. The document
disability in the United States.1 Consequently, stroke survi- underwent extensive AHA internal peer review, Stroke Council
vors are often deconditioned and predisposed to a sedentary Leadership review, and Scientific Statements Oversight
lifestyle that adversely impacts performance of activities of Committee review before consideration and approval by the
daily living, increases the risk for falls, and may contribute AHA Science Advisory and Coordinating Committee.
to a heightened risk for recurrent stroke and other CVDs. The
majority of studies have investigated ischemic stroke, although Results
stroke is often considered a broader term for a transient isch- Prestroke Disability, Poststroke Sequelae, and
emic attack (TIA), ischemic stroke, or intracerebral hemor- Comorbid Conditions
rhage. All 3 of these categories pose an increased risk for a
The World Health Organization’s International Classification

future vascular event6,7; however, this risk is further elevated
of Functioning, Disability, and Health organizes the effects
in patients with cerebrovascular disease and comorbid CVD.6,7
of conditions such as stroke into problems of “body functions
Although stroke survivors vary in their level of participation in and structure” (impairments), “activity,” and “participation”
physical activity, hospital- and community-based studies have dimensions.25 The majority of stroke survivors have resid-
consistently found low levels of activity.8,9 On a population ual impairments caused by the stroke, such as hemiparesis,
basis, the physical activity of community-living stroke survi- spasticity, cognitive dysfunction, and aphasia. Full recovery
vors is lower than that of older adults with other chronic health is achieved in only a small proportion of stroke survivors.
conditions of the musculoskeletal or cardiovascular system.10 Activity limitations are manifested by reduced ability to per-
Physical activity and exercise have the potential to posi- form daily tasks, and at 6 months after stroke, 40% of stroke
tively influence multiple physical and psychosocial domains survivors have difficulties with basic self-care (eg, dressing,
after stroke. We define physical activity as “any bodily move- feeding).26 More than 30% of stroke survivors report partici-
ment produced by skeletal muscles that results in energy pation restrictions (eg, difficulty with autonomy, engagement,
expenditure,” whereas exercise is “a subset of physical activ- or fulfilling societal roles) even at 4 years after stroke.27
ity that is planned, structured, and repetitive and has as a final One of the major consequences of these impairments,
or an intermediate objective the improvement or maintenance activity limitations, and participation restrictions is a chronic
of physical fitness.”11 There is strong evidence that exercise sedentary lifestyle.28 What is particularly disconcerting is
after stroke can improve cardiovascular fitness,12 walking that many of these stroke survivors have the ability to under-
ability,13 and upper-extremity muscle strength.14 There are less take higher levels of physical activity but choose not to do
consistent reports of lower-extremity muscle strength gains.15 so.29 Likely reasons for limited exercise participation by peo-
Although exercise has been shown to reduce falls in older ple with stroke include a lack of (1) awareness that exercise
adults,16 this finding has not been confirmed in stroke,17 likely is feasible or desirable, (2) access to resources to support
a consequence of too few studies with relatively small sample exercise, and (3) structured exercise sessions whereby exer-
sizes. Although exercise has primarily been used to improve cises could be demonstrated by a rehabilitation specialist or
physical function after stroke, emerging research suggests that exercise leader.30 These sedentary behaviors cause further
exercise may improve depressive symptoms,18 some aspects declines in cardiorespiratory fitness, which compounds the
of executive functioning and memory,19–21 and health-related deleterious impact on functional capacity after a stroke. After
quality of life22 after stroke and poststroke fatigue.23 6 to 12 months after stroke, stroke survivors with ambula-
Therefore, stroke survivors can benefit from counseling on tory ability have substantially diminished cardiorespiratory
.
increasing participation in physical activity,24 as well as the fitness, measured by peak oxygen consumption (Vo2).31,32
2534 Stroke August 2014
In addition to being far below age- and sex-predicted nor- have moderate to severe disability45 and10% have dementia46
mative levels, these . values fall below or scarcely surpass before the stroke event. Poorer preexisting function measured
the minimal peak Vo2 values (≈15 to 18 mL·kg−1·min−1) by greater disability45 or low physical activity47 has been
necessary for independent living.33 The concomitant pres- associated with greater stroke severity and poorer long-term
ence of other CVDs in the majority of stroke survivors is a outcomes. Obese patients with stroke who are referred to
major explanatory factor of poor cardiorespiratory fitness; rehabilitation demonstrate less improvement in motor recov-
however, there are other physiological consequences from ery and functional outcomes48,49 but may have decreased mor-
the stroke that also contribute to compromised function. In tality rates compared with those who are underweight.50
terms of skeletal muscle on the stroke-affected side, there is Collectively, the above-mentioned variables can create
severe muscle wasting, increased intramuscular fat, a shift a vicious circle of decreased activity and greater exercise
from slow-twitch toward fast-twitch “fatigable” muscle fiber intolerance, which leads to secondary complications such
characteristics, greater expression of inflammatory cytokines as reduced cardiorespiratory fitness, increased fatigability,
involved in muscle atrophy, and reduction of capillaries per muscle atrophy/weakness, osteoporosis, and impaired circu-
muscle fiber.34 Other biological changes that may negatively lation to the lower extremities in stroke survivors. In addi-
affect cardiorespiratory health after stroke are elevated sys- tion, diminished self-efficacy, greater dependence on others
temic levels of proinflammatory markers, abnormal glucose for activities of daily living, and reduced ability for normal
and insulin metabolism, impaired autonomic control, and societal interactions can have a profound negative psycho-
respiratory dysfunction.34 logical impact. This situation has several important implica-
Elevated energy costs of movement after stroke also con- tions for individuals with stroke and the professionals who
tribute to a sedentary lifestyle, especially in physically decon- counsel them. Coexisting cardiovascular conditions, whether
.
ditioned older patients. The oxygen cost of walking (ie, Vo2 they develop before or after stroke, can delay or inhibit par-
per distance walked) is 2-fold higher than values reported for ticipation in an exercise program, complicate the rehabilita-
able-bodied subjects.35 Poststroke fatigue is common, with a tion and long-term course of care, and limit the ability of
prevalence rate from 35% to 92%,36 and may also contribute to the patient to perform functional activities independently.51
and be aggravated by a sedentary lifestyle. Fatigue may have In fact, poststroke patients with CAD have 3 times as many
different constructs in which exertional fatigue is related to cardiac complications during rehabilitation.52 A study char-
cardiorespiratory and skeletal muscle fitness, whereas chronic acterizing patients at the time of recurrent stroke found that
fatigue is related to depression.37 Appropriate screening and 75% had hypertension, 37% had ischemic heart disease,
treatment of fatigue and depression are paramount to the initi- 56% had hyperlipidemia, 29% had atrial fibrillation, and
ation of exercise and long-term compliance in this population. 24% had diabetes mellitus.53 Given the heightened risk of
Although impairments may limit daily activities to some secondary cardiac complications and recurrent stroke, the
extent, they reduce participation to a lesser extent.38,39 For poststroke period is a particularly important time to imple-
example, participation in physical activity may be influenced ment stroke secondary prevention interventions (eg, a post-
by a wide range of individual factors, such as stroke sever- stroke exercise program).41
ity, preexisting and comorbid conditions, motivation, fatigue,
depression, adaptability and coping skill, cognition, and learn- Importance of Comprehensive Stroke Care and
ing ability. In addition, societal and environmental influences CVD Risk Reduction
such as program costs, means of transportation, accessibility, The primary objectives of comprehensive care are stroke are to
family support, social policies, and social stigmas can have a (1) reverse the deficits caused by the stroke and minimize their
substantial influence on physical activity participation.40 impact; (2) prevent, recognize, and manage secondary medical
Stroke does not usually occur in isolation. Patients with conditions, including recurrent stroke; (3) maximize indepen-
stroke have a high prevalence of associated medical prob- dence in ability to perform activities of daily living; (4) facili-
lems. These conditions may predate the stroke (“preexisting tate psychological and social adaptation and coping by the
conditions”), occur for the first time after stroke (“poststroke patient and family; (5) optimize the resumption of prior life
sequelae”), or present as manifestations of preexisting medi- roles and reintegration into the community; and (6) enhance
cal conditions after stroke (eg, poststroke angina in patients quality of life.54 Although maximizing functional recovery
with a history of coronary artery disease [CAD]). Other and facilitating physical independence are often the defining
preexisting CVDs are present in the majority of poststroke goals of formal rehabilitation and long-term care, they are not
individuals: high rates of CAD, chronic hypertension, atrial the only focus areas of the poststroke care process. Preventing
fibrillation, hyperlipidemia, metabolic syndrome, and diabe- secondary conditions such as subsequent stroke and other car-
tes mellitus.41,42 Although traditionally, stroke has not been diovascular events also constitutes an important function for
considered a CVD, vascular health appears to have important stroke care professionals. This is particularly compelling in
implications for recovery from stroke, with low aortic stiff- view of the fact that stroke is the fourth-leading cause of death
ness being a biomarker of vascular integrity that is associated and the leading cause of severe disability in the United States.1
with favorable neurological outcomes at hospital discharge.43 Overall, ≈30% of stroke survivors will have recurrent stroke
There is strong evidence for a clear inverse relation between within their lifetimes, 18% of which will be fatal. Rates of
physical activity and cardiovascular health.44 There have recurrence are thought to differ between the sexes; within 5
been reports that 20% of patients admitted for stroke already years of a stroke, 24% of women and 42% of men can be
expected to experience a secondary stroke.55,56 Even young Furthermore, in formal recommendations of measures
adults (aged <50 years) have a >10% recurrence rate of stroke designed to prevent stroke and other CVDs, the promotion of
within 5 years after a first-ever ischemic stroke, with athero- increased physical activity and the implementation of physi-
thrombotic, cardioembolic, or lacunar subtypes having the cal exercise training are prominent as key components of a
highest risk.57 Recurrent strokes have higher rates of mortality comprehensive stroke risk-reduction program.41 This recom-
and are usually associated with increased severity of disabil- mendation is not only important in primary stroke prevention
ity because of the reduced resilience of the remaining injured but is also valuable for people who have sustained a prior
brain. Additionally, recurrent stroke is not the only concern; stroke. A formal recommendation was developed in a prior
5% will have a myocardial infarction within the first year after AHA statement41 that suggested that after an ischemic stroke
stroke, and 3% per year thereafter.58 Manifestations of periph- or TIA, these individuals should engage in moderate-inten-
eral artery disease comprise additional complications, such as sity physical activity on a regular basis. The effective dose
intermittent claudication, and other signs of leg ischemia may and timing of physical activity are described in subsequent
also occur. After stroke, healthcare professionals and stroke sections of the present statement. Proposed mechanisms by
survivors tend to focus most of their rehabilitation on recov- which exercise might lead to risk reduction are through its
ery, but the prevention of a subsequent stroke, as well as CAD effects on lowering blood pressure and weight, increasing glu-
and peripheral artery disease, is also an important task. cose tolerance, improving lipid levels, and reducing arterial
Understanding the epidemiology of ischemic stroke and inflammation. Aerobic exercise has been shown to improve
its risk factors can facilitate the implementation of evidence- glucose tolerance in people with stroke.64 Reductions in blood
based measures to prevent subsequent strokes and other pressure66,67 and improvements in total cholesterol66 have been
CVDs. Risk factors for ischemic stroke can be classified into reported after moderate-intensity aerobic exercise in stroke
3 major groups: (1) nonmodifiable risk factors (including age, survivors. The use of a comprehensive exercise and lifestyle
race, sex, and family history); (2) medically modifiable risk program modeled after cardiac rehabilitation in people after a
factors that can be altered by medical interventions such as TIA and mild stroke was shown to yield improvements in total
pharmacological therapy or surgical procedures as indicated cholesterol, body composition, blood pressure, and behavior
(including previous TIA, carotid artery disease, atrial fibrilla- change toward nonsmoking.68
tion, CAD, other types of cardiac disease, hypertension, ciga- Physical activity can be effective only if it is done con-
rette smoking, hyperlipidemia, hypercoagulability, diabetes sistently. Unfortunately, although physical activity is clearly
mellitus, hormone replacement, inflammatory processes, and established and widely recognized as a means to reduce the
sickle cell disease); and (3) behaviorally modified risk fac- risk of stroke and other CVDs in virtually all individuals,
tors that may be modulated by changes in lifestyle (including sedentary behaviors remain a persistent and significant prob-
physical inactivity, obesity, alcohol abuse, drug abuse, oral lem for the general population, and even more so for chronic
contraceptive use, diabetes mellitus, cigarette smoking, hyper- disease populations, including those with stroke.8,9 Therefore,
lipidemia, and hypertension).41,59,60 Because both CAD and healthcare professionals should consider ways to educate
ischemic stroke share links to many of the same predisposing, stroke survivors and caregivers on the importance of cardio-
potentially modifiable risk factors (ie, hypertension, abnor- vascular risk reduction and help set goals for their continued
mal blood lipids and lipoproteins, cigarette smoking, physi- participation in physical activity and exercise.
cal inactivity, obesity, and diabetes mellitus), it is clear that
lifestyle choices play a prominent role in the origin of stroke Goals of Prescribed Physical Activity
and CVD.59 Modification of risk factors through a combina- and Exercise
tion of comprehensive lifestyle interventions and appropriate After a stroke, the physical activity goals and exercise pre-
pharmacological therapy is now recognized as the cornerstone scription for the patient need to be customized to the toler-
of initiatives aimed at the prevention of recurrent stroke and ance of the patient, stage of recovery, environment, available
acute cardiac events in stroke survivors.61 social support, physical activity preferences, and their specific
Physical activity is particularly important for the prevention impairments, activity limitations, and participation restric-
of secondary complications related to recurrent stroke and tions. Immediately after an acute stroke, the first goals dur-
other CVDs. There is emerging evidence (albeit from small ing poststroke rehabilitation relevant to physical activity and
controlled trials) of the beneficial impact of regular physical exercise are aimed at preventing complications of prolonged
activity and exercise in stroke survivors on CVD risk fac- inactivity, regaining voluntary movement, and recovering
tors, including hypertension,62 arterial function,63 and insulin basic activities of daily living. Detrimental effects of bed rest
response.64 Whether such benefits translate into a reduced risk include diuresis with significant losses of sodium and potas-
for recurrent stroke and cardiac events is unknown; however, sium, decreased volume of blood plasma, reduced cardiac
there is compelling evidence from large prospective cohorts output, depressed immune function, increased resting heart
that physical activity has a protective effect on CAD or first rate (0.5 bpm for each bed rest day), loss of muscle strength
stroke, with a dose-response relationship.65 After stroke, exer- (eg, 25% loss of. plantar flexor muscle strength over 5 weeks),
cise integrated into a comprehensive plan of care that includes reduced peak Vo2 (0.8% daily loss), orthostatic intolerance,
diet modification and use of cholesterol-lowering medica- and increased risk of joint contractures and deep venous
tions, antihypertensive medications, and aspirin could lower thromboembolism.69 Thus, during acute and inpatient reha-
the risk of a second stroke by 80%.61 bilitation, minimization of bed rest is critical, and simple
exposure to orthostatic or gravitational stress (ie, intermittent program facilitated stroke survivors to choose suitable types
sitting or standing) has been shown to obviate much of the of physical activity (1 predischarge session, 5 individual ses-
deterioration in exercise tolerance that normally follows an sions, and 5 phone calls) but did not demonstrate any effect on
acute hospital stay. Early mobilization (within 24 hours after physical activity over a 24-month period.74 As well, 8 weekly
stroke, and at regular intervals afterward) has been shown to 2-hour facilitated group meetings on self-management and
result in earlier walking and improved functional recovery.70 secondary stroke prevention did not increase walking activity
Once the patient is medically stable, the next goal is to initi- after 3 months.75 The critical elements (number of sessions,
ate an exercise training regimen designed to regain (or exceed) mode of delivery, type of follow-up, and monitoring) of a suc-
prestroke levels of activity as early and as much as possible. cessful physical activity counseling intervention have not been
Such activities typically occur within inpatient rehabilitation identified definitively. A system that requires the patient to be
units or supervised community or home settings. Physical accountable for their health behavior appears to be promising.
and occupational therapy is initiated to improve motor recov- This integrated care model includes discussion of stroke pre-
ery (ie, gait, upper extremity function, balance, and muscle vention guidelines, predischarge education on modifiable risk
strength), motor skills, efficiency in self-care, and occupa- factors, 4 telephone interviews to determine health behavior
tional and leisure-time activities. Emphasis is on progres- profile, 5 prescheduled visits to the healthcare provider along
sive task difficulty, repetition, and functional practice.71 It is with faxing of health profiles before each visit, and follow-up
recommended that interventions for motor recovery include phone calls after each visit to review recommendations. The
cardiovascular and strengthening exercises.71 Consequently, results of this integrated care model resulted in lower systolic
rehabilitation exercise programs designed to optimize func- blood pressure, lower body mass index, and a greater num-
tional motor performance in stroke survivors increasingly ber of walks after 12 months.76 Regular physical activity and
have incorporated aerobic exercise training that uses a variety exercise can improve mobility15 and may help maintain bone
of modalities (eg, treadmill, cycle ergometer, recumbent step- density in individuals with chronic stroke.32 Low bone den-
per, chest-deep water, functional exercises) to improve cardio- sity, impaired balance, and frequent falls all contribute to the
respiratory fitness, muscle strength, and functional mobility.15 2- to 7-fold increase in fracture risk within the first year of
Improving cardiorespiratory fitness increases submaximal stroke.77,78 Whether initiation of exercise early after stroke can
exercise tolerance and endurance and consequently the ability prevent the loss of bone mineral density and deterioration of
to execute activities of daily living. Aerobic treadmill exer- bone structure commonly seen after stroke or reduce fracture
.
cise has been shown to increase peak Vo2 while lowering the risk is currently unknown.79
energy cost of walking after stroke.72 Recent research stud- Cardiorespiratory exercise training in individuals many years
ies have shown that early aerobic exercise is feasible (stud- after stroke can result in improvements in aerobic capacity and
ies commencing within 6 days to 6. months after stroke)73 and sensorimotor function.80 Furthermore, there is a strong associa-
results in improvements in peak Vo2 and walking distance.73 tion between physical activity and risk of first stroke.81 An aero-
It is in this supportive environment that patients (with their bic exercise program after stroke has been shown to enhance
families and caregivers) can also learn to self-monitor their glucose regulation,64 improve blood pressure,66 and improve
exertion and track physical activity in hospital, home, or com- arterial function.63 These findings are consistent with the grow-
munity settings. It is critical for the patient to develop the ing body of evidence that interventions that promote plaque sta-
skills and confidence for eventual self-management of physi- bility, favorable changes in vascular wall function, or both have
cal activity and an exercise training program. important implications for the management of patients after
The third set of goals after stroke rehabilitation is designed a stroke or other vascular events.82 Although extrapolation of
to facilitate the stroke survivor to develop and maintain an these data to the prevention of secondary strokes is unproven,
active lifestyle that meets recommended physical activity mounting evidence suggests it is likely that improving cardio-
and exercise guidelines for prevention of recurrent stroke respiratory fitness and engaging in regular physical activity or
and cardiac events, as well as to maintain or improve physi- exercise after stroke has broad health benefits.
cal function. Physical activities must consider the individual’s
functional limitations and comorbidities, as well as the indi- Preexercise Evaluation
vidual’s personal preferences, environment, and resources, Exercise is a normal human function that can be undertaken
and could range from an exercise program at home to an with a high level of safety by most people, including those with
appropriate community or sport program. Partnerships with stroke. However, exercise is not without risks, and although
healthcare professionals and community support groups may adverse events are not reported systematically in the literature,
facilitate health promotion and long-term adherence to physi- the recommendation that individuals with stroke participate in
cal activity. The use of education or personalized, tailored an exercise program is based on the premise that the benefits
counseling interventions has demonstrated mixed results on outweigh these risks. As is the case for the general population,
improving adherence to an exercise program and increasing the major potential health hazards of exercise for stroke survi-
physical activity after stroke. A physical activity counseling vors are also likely to include musculoskeletal injury and, in
intervention (2 predischarge individual sessions and 4 phone rare cases, sudden cardiac death. Perhaps more pertinent to the
follow-up sessions) resulted in greater physical activity 9 and stroke population is an increased fall risk with mobility. Falls
52 weeks after the event in a sample of rehabilitation patients, may occur with exercise training, and when reported, they
of whom 20% were stroke patients.24 In contrast, a similar occurred in 13%32 to 25%83 of intervention-group participants
with stroke. Although habitual physical activity is associated ability, however, other modalities and special protocols are
with an overall reduction in the risk of sudden cardiac death in needed that consider stroke-related issues such as hemiparesis
the general adult population, and the likelihood of experienc- and balance impairment and use small increments of workload
ing a fatal cardiac event during exercise training is extremely increases to maintain reasonable test duration.96,97 Upright and
small, it is well established that exercise can precipitate malig- semirecumbent cycle ergometry may be more applicable to
nant ventricular arrhythmias.84–86 Moreover, several studies a greater subset of the stroke survivor population, because
have now shown that the transiently increased risk of cardiac these offer the advantage of seated support for individuals
arrest that occurs during exercise results primarily from the with impaired postural control, permit the feet to be affixed
presence of preexisting CAD, especially in habitually seden- to the pedals to accommodate lower-limb dysfunction,97 and
tary adults.87,88 Because up to 75% of stroke survivors have increase safety for those with cognitive or behavioral issues.
coexisting cardiac disease, and 20% to 40% of cases present Clinically relevant abnormalities indicative of elevated risk
with silent cardiac ischemia,89–91 the foremost priority in for- for acute cardiac events and mortality, such as ST-segment
mulating the exercise prescription is to minimize the potential depression, angina pectoris, ventricular arrhythmias, ventricu-
adverse effects of exercise via appropriate screening, program lar tachycardia, or bundle-branch block, have been observed
design, monitoring, and education. in ≈11% of exercise tests in stroke survivors, although despite
Before embarking on a physical conditioning regimen after these abnormalities, the frequency of serious adverse events
stroke, all participants should undergo a complete medical his- remains low, and thus, such testing provides important infor-
tory, usually the most important part of the preexercise evalu- mation for establishing safe and individualized exercise pre-
ation, and a physical examination aimed at the identification scriptions.93 There are, however, limitations to graded maximal
of neurological complications and medical comorbidities that exercise testing after stroke that should be considered. Firstly,
require special consideration or constitute a contraindication to unlike the standard care pathway for individuals attending car-
exercise. These may include assessment of neurological com- diac rehabilitation programs, there is limited availability and
plications or other medical comorbidities and conditions and access to cardiopulmonary exercise testing in most stroke clin-
stroke-specific issues such as weakness or balance impairment, ical and community settings. Furthermore, tests performed on
cognitive or behavioral issues, and communication issues. cycle ergometry are often subject to termination from local-
It is recommended that individuals with stroke undergo ized muscle fatigue rather .than from attainment of maximal
graded exercise testing with ECG monitoring as part of a aerobic capacity, and peak Vo2 values are typically 5% to 10%
medical evaluation before beginning an exercise program.86,92 lower than those achieved via treadmill testing.98. Whether
If the physician overseeing the patient’s care determines an individuals with stroke achieve “true” maximal Vo2 during
exercise test is not indicated or such an assessment in a given graded exercise tests is not clear. After stroke, exercise tests
facility is not possible, the initiation of an exercise training are often terminated for noncardiopulmonary reasons,97 and
program, individually tailored to a patient’s physical capabili- the ability to achieve maximal effort is associated with greater
ties, should not be delayed. Although there are limited data on cognitive and motor impairment.99 Total-body recumbent
the safety of graded exercise testing after a stroke,91 available steppers that engage both the upper and lower limbs appear
evidence suggests that graded exercise testing is likely to be to be a possible alternative to traditional ergometers, and .
associated with an acceptably low risk of serious cardiovas- stroke survivors have been found to achieve higher peak Vo2
cular complications in stroke survivors.91,93 Such testing helps and heart rate values using this modality.100
determine participants’ exercise capacity and identify associ- In lieu of graded maximal exercise tests, submaximal tests
ated adverse signs or symptoms that may affect the safety of may be considered for stroke survivors. Walk tests, such as
an exercise program. the commonly used 6-minute walk test (6MWT), have been
Generally, graded exercise testing after stroke should be designed and used as surrogate measures of cardiorespiratory
conducted in accordance with contemporary guidelines as fitness in other populations, but associations between distance
.
detailed elsewhere.92,94 Briefly, the exercise test modality/ walked and peak Vo2 are low to moderate.101–104 Given the
protocol for stroke survivors is selected to optimally assess presence of neuromotor and walking limitations after stroke
functional capacity and the cardiovascular response to exer- that may confound test performance, results should be inter-
cise. The test should evaluate the heart rate, rhythm, and ECG preted with caution. Predictive submaximal tests have also
response to exercise, as well as the systolic and diastolic been studied after stroke, but clear recommendations regard-
blood pressure response. Careful assessment of the subjective ing specific protocols are not yet available. Although a mod-
response (especially cardiac symptoms) should be performed. est correlation with maximal tests has been reported, there
Ratings of perceived exertion should be collected. The test- were also nonsignificant associations with hemodynamic
ing mode should be selected or adapted to the needs of the responses (heart rate, rate pressure product).102 Studies using
individual. A standard treadmill walking protocol can be used, cycle ergometry after stroke have been unable
. to demonstrate
with the aid of handrails if needed. The progressive workload accurate predictive equations of peak Vo2 based on exercise
of the Bruce protocol (3-minute stages commencing from test performance,105,106 but a recent study that used total-body
stage 1, 1.7 mph at 10% incline, to stage 7, 6.0 mph at 22% recumbent steppers found
. strong associations between actual
incline) or its modified version (starting at a lower intensity of and predicted peak Vo2.107
1.7 mph at 0% incline) is appropriate for some participants, No studies have specifically addressed the issue of how
with a progressive workload achieved by increasing the speed soon after a stroke graded exercise testing can be performed
and grade of the treadmill.95 For those with limited walking safely. Until such data become available, good clinical
judgment should be foremost in deciding the timing of graded In practice, early physical (out of bed) activity prescription is
exercise testing after stroke and whether to use a submaxi- dependent on a range of factors that include patient stability
mal or symptom-limited maximal test protocol. In the absence (although what constitutes stability is not well defined), level
of definitive evidence, it may be prudent to follow guidelines of impairment, staff attitudes, and hospital protocols and pro-
similar to those recommended for individuals after myocar- cesses. In the first 24 to 48 hours of stroke, simply getting out
dial infarction and use submaximal protocols (with a prede- of bed has been shown to significantly increase heart rate,
termined end point, often defined as a peak heart rate of 120 blood pressure, and oxygen saturation and improve conscious
bpm, or 70% of the age-predicted maximum heart rate, or a state.111 However, not all acute stroke survivors can tolerate
peak metabolic equivalent [MET] level of 5).92 In the absence activity this early. Current clinical trials in this early time point
of definitive evidence, it also appears prudent to consider a should help refine safety criteria for early commencement and
systolic blood pressure >250 mm Hg or diastolic blood pres- protocols for exercise in the first weeks after stroke.108,112
sure >115 mm Hg an absolute (rather than relative) indication
to terminate a graded exercise test after stroke.92 As is recom- When Should Physical Activity Begin After Stroke?
mended for those with CAD, the upper limit of the target heart The consensus view throughout the world is that physical
rate range for subsequent exercise training should generally activity should begin early after stroke; however, how early
be at least 10 bpm below the heart rate associated with blood remains controversial,113 and there are no specific protocols to
pressure responses of this magnitude.86 guide the frequency, intensity, time, or type of physical activ-
From a practical standpoint, it may not be possible, for a ity in this early time frame. Recent small clinical trials have
variety of reasons, for many stroke survivors to perform an tested protocols promoting physical activity that commence
exercise test before they begin an exercise program. For those within 24 to 72 hours of stroke onset, but results have been
with significant impairments or activity limitations that pre- inconclusive.70,112,114–116 These data have important implica-
clude exercise testing, pharmacological stress testing may be tions for inpatients and early post–hospital discharge activity
considered.91 For those for whom an exercise ECG is recom- recommendations, yet many studies have demonstrated low
mended but not performed, lower-intensity exercise should levels of physical activity among individuals in the early post-
be prescribed. The reduced exercise intensity may be com- stroke phase.94,117–120
pensated for by increasing the training frequency, duration, or
both. Depending on the severity of disability and other coex- Rationale for Physical Activity/Structured Exercise
isting medical conditions, certain people may need to partici- In 2008, the US Department of Health and Human Services
pate in a medically supervised exercise program. published physical activity guidelines for all Americans121
In summary, evaluation of the stroke survivor for an exer- based, in part, on the Physical Activity Guidelines Advisory
cise program is multidimensional and includes a careful Committee Report,44 which included a section on the relation-
medical history and physical examination. If flexibility and ship between physical activity and cerebrovascular disease
adaptability are used in the selection of testing protocols, most and stroke. The research review concluded that “physically
stroke survivors who are deemed stable for physical activity active men and women generally have a lower risk of stroke
can undergo exercise testing. Consideration regarding the incidence or mortality than the least active, with more active
individual’s medical and functional status should be given people demonstrating a 25% to 30% lower risk for all strokes.”
when the testing protocol and modality are being selected. Moreover, the benefits appear to be derived from a variety of
Results from submaximal exercise tests may need to be inter- activity types, including activity during leisure time, occupa-
preted with caution. If the evaluation is conducted with the tional activity, and structured exercise (eg, walking).
aforementioned considerations, an exercise program can be Several clinical guidelines now recommend increased life-
highly beneficial and safe for stroke survivors. style physical activity and a structured exercise program after
stroke.122–124 These recommendations are based on several
Early Physical Activity and Rationale for Exercise- lines of clinical evidence, including the extrapolation of data
Based Rehabilitation from other nonstroke populations. One study reported that
Given its detrimental impact on many body systems, prolonged 40% of stroke survivors believed that fatigue was either their
bed rest, as advocated before the 1950s, is no longer recom- worst symptom or one of their most debilitating symptoms,
mended in the care of uncomplicated and clinically stable impairing their performance of activities of daily living and
patients with acute coronary and other CVD. events.108 Nearly negatively affecting psychological functioning and quality
3 decades ago, researchers measured peak Vo2 in healthy sub- of life.125 It has been suggested that fatigue after stroke may
jects before and after 14 days of bed rest using daily treatments be triggered by physical deconditioning, which precipitates a
with a reverse-gradient garment that simulated the effects of vicious, self-perpetuating cycle of fatigue, avoidance of mod-
standing. Aerobic capacity remained essentially unchanged erate to vigorous physical activity, decreased aerobic reserves,
in subjects who received treatment with reverse-gradient gar- further deconditioning, and more fatigue.36 Indeed, a recent
ments, whereas there was a significant decrease (14%) in systematic review of relevant studies found that measured
.
nontreated (control) subjects.109 Accordingly, simple expo- peak Vo2 among selected samples of stroke survivors ranged
sure to orthostatic or gravitational stress appears to obviate a from 8 to 22 mL·kg−1·min−1, which was 26% to 87% (≈53%
significant portion of the deterioration in functional capacity overall) lower than that of age- and sex-matched healthy con-
that normally follows an acute coronary or vascular event.110 trol subjects.80 Time since stroke ranged from 10 days to >7
years, which indicates that a reduced level of cardiorespira- support and unweighting devices such as harnesses that lift
tory fitness may well persist years after stroke. patients, effectively decreasing their weight, allows patients
On the basis of the available evidence, it is recommended that who might otherwise be unable to exercise to walk on a
stroke survivors undertake regular aerobic exercise to increase treadmill. Finally, in patients with residual gait and balance
aerobic capacity and improve gait efficiency, thereby reduc- limitations that preclude walking at faster speeds, exercise
ing fall risk and enhancing functional independence, as well intensity can be augmented by increasing the treadmill
as reducing the risk of recurrent cardiovascular events.126 In grade. Because most stroke survivors may prefer to walk
addition, resistance (strength) training is advocated to increase at moderate intensities, it is helpful to recognize that walk-
independence in activities of daily living, flexibility training to ing on level ground at 2 or 3 mph corresponds to ≈2 and 3
increase range of movement and prevent deformities, and neu- METs, respectively.135 At a 2-mph walking speed, each 3.5%
romuscular training to enhance balance and coordination.124 increase in treadmill grade adds ≈1 MET to the gross energy
The prescription of exercise for the stroke survivor is cost. For patients who can negotiate a 3-mph walking speed,
comparable in many ways to the prescription of medica- each 2.5% increase in treadmill grade adds ≈1 MET to gross
tions; that is, one recommends a safe and effective dosage energy expenditure.135
(ie, frequency, intensity, time, type) according to individual To maximize the specificity of training adaptations to
functional capacity and limitations, while simultaneously daily activities, adjunctive muscular strength and endurance
attempting to avoid underdosing or overdosing.127 Stroke exercises are also advocated for clinically stable stroke sur-
survivors who may be at risk for exertion-related cardio- vivors, by use of resistance-training programs.124,127 Because
vascular events should be considered for peak or symptom- the hemodynamic response to resistance exercise is largely
limited exercise testing124 before they begin a vigorous proportional to the percentage of maximal voluntary contrac-
exercise
. training program (ie, 60%–89% .of heart rate reserve tion,136 increased muscle strength results in an attenuated heart
or Vo2 reserve or. ≥6.0 METs,. where Vo2 reserve=percent
. rate and blood pressure response to any given load, because
intensity×[peak Vo2−resting Vo2]+resting Vo2).128 On the the load now represents a lower percentage of maximal vol-
other hand, empirical experience and previous studies have untary contraction.137 Thus, resistance training can decrease
demonstrated the safety and effectiveness of early outpa- cardiac demands during daily activities such as carrying gro-
tient, medically supervised exercise rehabilitation using ceries or lifting moderate-weight to heavy objects.138 Although
adjunctive intensity modulators (ie, rating of perceived exer- there are no research-based guidelines for determining when
tion [11–12 on the 6–20 scale] or the patient’s resting heart and how to initiate resistance training after ischemic or hem-
rate plus 20 bpm) and continuous ECG monitoring, without orrhagic stroke, it may be prudent to prescribe 10 to 15 rep-
a preliminary peak exercise test.129 Joo et al130 reported that. etitions for each set of exercises (eg, higher repetitions with
on average, this methodology corresponded to ≈42% Vo2 reduced loads), similar to that recommended for patients after
reserve among patients entering a phase 2 cardiac rehabilita- myocardial infarction.124,127 Such regimens should be per-
tion program, an intensity that approximates the minimum or formed 2 to 3 days per week and include a minimum of 1 set
threshold intensity for improving cardiorespiratory fitness in of 8 to 10 different exercises that involve the major muscle
this patient subset.131 Such reduced exercise intensities may groups of the torso, as well as the upper and lower extremities.
be compensated for in part by increasing the training fre- Adjunctive flexibility and neuromuscular training, including
quency, duration, or both. yoga139 and tai chi,140 have also been reported to be beneficial
Aerobic training modes for stroke survivors may include in improving balance, quality of life, and mental health while
leg, arm, or combined arm-leg ergometry at the appropriate reducing the fear of falling.
intensity, as described previously.127 Because symptomatic or Few data are available regarding the effectiveness of suit-
silent myocardial ischemia may be highly arrhythmogenic,132 ably modified exercise programs for patients who are unable
the target heart rate for endurance exercise should be set safely to walk after stroke and those with difficulties in communi-
below (≥10 bpm) the ischemic ECG or anginal threshold.133 cating, because these patients have been underrepresented in
The recommended frequency of training is ≥3 days per week, previous trials.141 The role of complex interventions, such as
with a duration of 20 to 60 minutes per session depending on interactive computer and active-play video games,142,143 should
the patient’s functional capacity. However, for many stroke be evaluated in stroke survivors. Laver et al143 reviewed the
survivors, multiple short bouts of moderate-intensity physical role of virtual reality and interactive video gaming as new
exercise (eg, three 10- or 15 minute exercise bouts), repeated treatment approaches in stroke rehabilitation. Although there
throughout the day, may be better tolerated (eg, interval train- was insufficient evidence regarding the impact of these poten-
ing, a work-rest approach) than a single long session. Structured tial therapies on gait speed, some studies suggested that these
exercise interventions should be complemented by an increase may be beneficial in improving arm function and in the per-
in daily lifestyle activities (eg, walking breaks at work, garden- formance of activities of daily living. Active-play video games
ing, household chores) to improve fitness and move patients require both upper- and lower-limb movement, which has the
out of the least fit, least active high-risk cohort.134 potential to allow players to reach moderate to vigorous levels
Treadmill walking appears to offer 3 distinct advantages of physical activity.144 One study in healthy adults that used
in the exercise rehabilitation of stroke survivors.124 First, it an open-circuit indirect metabolic chamber reported a wide
requires the performance of a task required for everyday range of energy expenditures (1.3 to 5.6 METs) during Wii
living, namely, walking, which should enhance the gener- Sports and Wii Fit Plus game activities.145 Exercise program-
alizability of training effects. Second, the use of handrail ming recommendations for stroke survivors are summarized
in the Table. Structured treadmill or cycle ergometer exercise stroke, as assessed by preconditioning versus postconditioning
regimens should be complemented by muscular strength/ improvements in brachial artery vasomotor reactivity (flow-
endurance and flexibility training, as well as increased daily mediated dilation) and physical performance on a 6MWT.67
lifestyle activities (eg, walking breaks at work, gardening, Physical activity reduces the risk of cognitive impairment,
self-care, and household chores).146 Additional neuromuscular mainly vascular dementia, in older people living indepen-
activities that may be beneficial for stroke survivors include dently.148 There is also evidence that exercise has positive
tai chi, yoga, modified recreational activities with paddles/bal- effects on depression149 and cognition150 in adults without
loons or sport balls, and active-play video/computer gaming. stroke, and there are preliminary findings that exercise may
confer similar effects after stroke.18,21 Although few studies
Cardiovascular, Cognitive, and Functional have investigated the impact of fitness training on cognition
Outcome Measures and mood after stroke, a recent report21,151 using combined
A recent review that summarized the reported outcomes of aerobic and resistance training noted improvements in overall
numerous randomized controlled trials of structured aerobic cognition and in the subdomains of attention/concentration and
exercise and muscle resistance training after stroke concluded visuospatial/executive function. Moreover, there was a 44.5%
that cycle ergometry and intensive treadmill training can reduction in the proportion of patients meeting the threshold
increase aerobic capacity and improve walking performance.147 criteria for mild cognitive impairment at posttraining compared
Resistance training enhanced muscular strength but had only with baseline assessments. Collectively, these data and other
modest or no transfer in bettering gait performance. A struc- recent comprehensive reviews15 suggest that structured aerobic
tured aerobic exercise intervention has been found to be benefi- exercise, including walking, is beneficial for stroke survivors,
cial for enhancing the vascular health of people with subacute improving ambulatory ability and the performance of daily
Table. Summary of Exercise/Physical Activity Recommendations for Stroke Survivors

Prescriptive Guidelines:
Setting/Mode of Exercise Goals/Objectives Frequency/Intensity/Time
Hospitalization and early convalescence (acute phase) • Prevent deconditioning, hypostatic pneumonia, • ≈10- to 20-bpm increases in resting HR; RPE
• Low-level walking, self-care activities orthostatic intolerance, and depression ≤11 (6–20 scale); frequency and duration
• Intermittent sitting or standing • Evaluate cognitive and motor deficits as tolerated, using an interval or work-rest
• Seated activities • Stimulate balance and coordination approach
• Range of motion activities, motor challenges
Inpatient and outpatient exercise therapy or

“rehabilitation”
Aerobic .
• Large-muscle activities (eg, walking, graded • Increase walking speed and efficiency • 40%–70% V o2 reserve or HR reserve; 55%–80%
walking, stationary cycle ergometry, arm • Improve exercise tolerance (functional capacity) HR max; RPE 11–14 (6–20 scale)
ergometry, arm-leg ergometry, functional • Increase independence in ADLs • 3–5 d/wk
activities seated exercises, if appropriate • Reduce motor impairment and improve cognition • 20–60 min/session (or multiple 10-min sessions)
• Improve vascular health and induce other • 5–10 min of warm-up and cool-down activities
cardioprotective benefits (eg, vasomotor • Complement with pedometers to increase lifestyle
reactivity, decrease risk factor) physical activity
Muscular strength/endurance • Increase muscle strength and endurance • 1–3 sets of 10–15 repetitions of 8–10 exercises
• Resistance training of U/L extremities, trunk • Increase ability to perform leisure-time and involving the major muscle groups at 50%–80%
using free weights, weight-bearing or occupational activities and ADLs of 1RM
partial weight-bearing activities, elastic • Reduce cardiac demands (ie, RPP) during lifting • 2–3 d/wk
bands, spring coils, pulleys or carrying objects by increasing muscular • Resistance gradually increased over time as
• Circuit training strength, thereby decreasing the % MVC that a tolerance permits
• Functional mobility given load now represents
Flexibility • Increase ROM of involved segments • Static stretches: hold for 10–30 s
• Stretching (trunk, upper and lower • Prevent contractures • 2–3 d/wk (before or after aerobic or strength
extremities) • Decrease risk of injury training)
• Increase ADLs
Neuromuscular • Improve balance, skill reacquisition, quality of life, • Use as a complement to aerobic, muscular
• Balance and coordination activities and mobility strength/endurance training, and stretching
• Tai chi • Decrease fear of falling activities
• Yoga • Improve level of safety during ADLs • 2–3 d/wk
• Recreational activities using paddles/sport
balls to challenge hand-eye coordination
• Active-play video gaming and interactive
computer games
1RM indicates 1 repetition maximum; ADLs, activities of daily living; HR, heart rate; MVC,. maximal voluntary contraction; ROM, range of motion; RPE, rating of
perceived exertion (6–20 category scale); RPP, rate-pressure product; U/L, upper/lower; and V o2, oxygen uptake.
Modified with permission from Gordon et al.124 Copyright © 2004, American Heart Association, Inc.
activities. This is highly relevant given that the prevalence of stroke recovery to establish whether the use of higher doses of
depression among stroke survivors is ≥30%152 whereas a stroke physical activity commenced early after stroke slows or pre-
doubles an individual’s risk for dementia (including Alzheimer vents loss of cardiorespiratory fitness and to develop detailed
disease).153 Well-designed trials are needed to clarify optimal recommendations for frequency, intensity, time, and type of
exercise programming and long-term outcomes of physical exercise to be prescribed to this population.
conditioning in this patient population, including morbidity,
mortality, dependence, and disability. Subacute Phase of Stroke Recovery
Evidence continues to support exercise training for improve-
Exercise Across the Continuum of Stroke Care ment of cardiorespiratory fitness during subacute stroke.12,73,163
Individuals in the subacute stage of recovery demonstrate
Cardiorespiratory Response to Acute Exercise in low cardiorespiratory fitness levels similar to those findings
Stroke Survivors in chronic stroke.67,164–166 Routine physical therapy appears
The cardiac response to acute exercise (primarily during exer- to provide a mean of only 3 minutes of low-intensity aero-
cise testing) among stroke survivors has been documented in bic training (≥40% of heart rate reserve) per session, which
a small number of studies.154–156 Stroke survivors have been defines a gap in exercise provision across the subacute stroke
shown to achieve significantly lower maximal workloads, phase.164 Few randomized studies are available to guide exer-
heart rate, and blood pressure responses than control subjects cise recommendations across the subacute recovery period.
during progressive exercise testing to volitional fatigue.157,158 Cycle ergometers have been used in several studies to exam-
Other earlier studies, which used various adapted ergome- ine the effect of aerobic exercise interventions on functional
try devices or exercise protocols with smaller . sample sizes, capacity, such as the 6MWT and stair climbing in stroke survi-
yielded similar findings.159–162 In general, Vo2 at a given vors.167,168 A supervised home-based exercise program .using a
submaximal workload in stroke survivors is greater than in cycle ergometer demonstrated improvements in peak Vo2 and
healthy subjects, possibly because of reduced mechanical effi-. walking speed (using the Timed Up and Go test) and endur-
ciency, the effects of spasticity, or both. In contrast, peak Vo2 ance (using the 6MWT).169 Tang et al168 assigned stroke survi-
is reduced in these stroke survivors. However, a recent study vors to either an exercise group using a cycle ergometer plus
demonstrated that stroke survivors can exercise at or above standard stroke rehabilitation or standard rehabilitation alone.
target minutes and the intensity necessary for cardiac reha- Both groups improved from baseline measures during an aver-
bilitation.93 To improve the cardiorespiratory response and age length of stay of only 9 days, but the exercise intervention
acquire health benefits from exercise, more research is needed .
group demonstrated greater improvements in peak Vo2 and
regarding stroke-adapted cardiac rehabilitation models.
6MWT distance.
Treadmill training is another option for participating in
Acute Phase of Stroke Recovery aerobic exercise. A randomized controlled trial compared stan-
Little to no information is available for aerobic exercise dur- dard of care in rehabilitation to a group receiving standard of
ing the acute stage of stroke recovery; however, evidence is care plus body weight–supported treadmill training.170 A more
starting to emerge that supports early physical activity with recent study used a novel method for a walking exercise inter-
a focus on mobility, often termed early mobilization. A pilot vention. The authors tested whether robot-assisted gait training
study (A Very Early Rehabilitation Trial for Stroke [AVERT]) may be a potential avenue to facilitate improvements in cardio-
assessing the feasibility and safety of a frequent mobiliza- respiratory function early after stroke. Chang et al165 performed
tion program commencing within 24 hours after stroke was a study in which participants assigned to the intervention group
performed.114 Seventy-one patients during the first 24 hours received 40 minutes of gait training along with 60 minutes
after stroke were randomized to either receive standard of of standard physical therapy every day for 2 weeks. Control
care or very early mobilization. Those in the early mobiliza- patients received 100 minutes of standard physical therapy
tion group started out-of-bed or upright activity, including for the 2-week period. The robot-assisted gait-training
. group
standing and walking, at frequent intervals within 24 hours of demonstrated a 12.8% improvement in peak Vo2 compared
stroke onset. There was no significant difference in the num- with the control group. Furthermore, patients who received
ber of deaths between the 2 groups. Furthermore, secondary the robot-assisted gait training increased their lower-extremity
safety measurements were similar between the standard-of- Fugl-Meyer assessment score and strength compared with con-
care group and the very early mobilization group. Therefore, trol subjects. Hence, robot-assisted gait training may offer new
starting physical activity within the first 24 hours of stroke inroads toward improving functional motor and cardiorespira-
symptoms was observed to be safe and feasible. This trial70 tory health in subacute stroke, in conjunction with conventional
suggests that early and frequent mobilization starting within physical therapy. Treadmill training can be used to increase car-
24 hours of first onset of stroke symptoms is independently diovascular fitness and improve walking in subacute stroke sur-
associated with improved functional outcomes as measured vivors. For balance and safety concerns, a body-weight support
by the Barthel Index and the Rivermead Motor Assessment system can be used in conjunction with the treadmill.
at 3 months after stroke and may improve the rate of walking An 8-week aerobic exercise intervention reported positive
recovery. Confirmation of these preliminary findings is nec- findings on cardiorespiratory health and physical function
essary in a larger randomized controlled trial (under way).151 of patients in the subacute phase after stroke.67 During an
Furthermore, there remains a great need for additional experi- 8-week aerobic exercise intervention, 9 participants exercised
mental studies to be performed during the acute stages of at 50% to 59% of heart rate reserve for 4 weeks followed by
60% to 69% of heart rate reserve for the remaining 4 weeks. the intensity of training directly correlated
. with the degree. of
However, at 50% to 59% of heart rate reserve, only 70% of improvements observed in peak Vo2. After 1 year, peak Vo2
the exercise time was spent in the prescribed range. Only 63% continued to be significantly higher than baseline measures in
of the exercise time was spent in the higher-intensity range the treadmill training group.
(60%–69% of heart rate reserve). Baseline and postinterven- A recent single-cohort study examined high-intensity
tion assessments included the 6MWT, a peak exercise test, (85%–95% of peak heart rate from an exercise test) uphill
and flow-mediated dilation of the brachial artery for vascular treadmill walking in four 4-minute work periods, with a
health. At baseline, there were between-limb differences in 3-minute active recovery between . each bout.174 Primary
brachial artery vasomotor reactivity through flow-mediated outcome measures were peak Vo2 and walking economy.
.
dilation, and participants had low peak Vo2. After the inter- Despite . a small sample size (n=8), significant gains in
vention, improvements were noted in resting systolic blood peak Vo2 were found that were maintained at a 1-year fol-
pressure, flow-mediated dilation in bilateral brachial arteries, low up. However, the improvement in walking economy
.
6MWT distance, and peak Vo2. Aerobic exercise in subacute immediately after the intervention was not maintained at
stroke survivors facilitated improvements in cardiorespira- the 1-year follow-up.
tory and vascular health and improved the risk factor profile. Strength training also has been found to have beneficial
Although this is 1 study, more research is needed to examine effects in stroke survivors. Several observational studies have
exercise prescription parameters (frequency, intensity, time) shown strong associations between paretic knee-extension
in the subacute stage of stroke recovery, for example, shorter torque and locomotion ability and between both hip flexor and
bouts versus longer bouts of exercise time and exercise inten- ankle plantar flexor strength of the paretic limb and walking
sity (high intensity versus moderate intensity). speed after stroke.175–177
On the basis of the available literature, aerobic exercise in Results from prospective trials suggest benefit may be
the subacute stages of stroke recovery has beneficial effects accrued through poststroke resistance-training programs.
on cardiorespiratory health, functional outcomes, and cardiac A 12-week, twice per week, progressive resistance-training
risk reduction.67,73,169 program demonstrated positive improvements in muscle
strength, gait, and balance in stroke subjects.178 Lower-limb
strength increased 68% on the affected side and less so on the
Chronic Phase of Stroke Recovery intact side. Transfer time, motor performance, and static and
It has been well established that aerobic exercise initiated dynamic balance also showed improvements. These results
during the chronic stage of stroke recovery has beneficial confirmed those of a previous study that showed benefits of
effects on cardiorespiratory health. Seminal aerobic exercise
strength training of the hemiparetic knee.179 More recently, a

training studies in chronic stroke survivors demonstrated pre-post study design tested whether strength training the lower
cardiovascular improvements (blood pressure response), extremities at 85% to 95% of 1 repetition for a maximum of 3
reduced energy . expenditure at submaximal efforts, and days per
. week would improve muscle strength, walking, and
increased peak Vo2.12,72,171 These data suggest that aerobic peak Vo2 The authors reported that lower-extremity strength
exercise training and improved cardiovascular fitness might significantly improved, as did walking. (6MWT distance and
enable activities of daily living to be performed at a lower Timed Up and Go test), but not peak Vo2.180
percentage of aerobic capacity. There are few studies that have examined the long-term
Lennon and colleagues172 implemented a 10-week pro- benefits of exercise after stroke. A recent study reported on
gram either consisting of standard of care or standard of a 4-year follow-up after a 10-week randomized, controlled
care plus cycle ergometry sessions and 2 stress management resistance exercise training program using 80% of 1 repeti-
sessions. Those who participated in aerobic exercise in the tion a maximum of twice weekly. Four years after interven-
form of cycle ergometry . exhibited significantly greater tion, the resistance-training group continued to demonstrate
improvements in peak Vo2 and cardiac risk at follow-up significant differences in muscle strength compared with the
than those who only received standard of care. These find- control group; however, no between-group differences were
ings suggest that aerobic exercise implemented during the found for walking performance on the Timed Up and Go test
chronic stages of stroke facilitates improvements in cardio- or 6-MWT.181
respiratory parameters. Collectively, these findings support the use of regular exer-
Although most studies have used traditional exercise pre- cise to improve overall health after stroke, which is consis-
scription parameters, recent studies have begun to examine tent with consensus statements on exercise for able-bodied
high-intensity training. Two randomized controlled studies individuals.121 Because increased levels of physical activity
using high-intensity training at 60%. to 80% of heart rate are associated with a reduced risk for stroke and CAD and
reserve reported improved peak Vo2 at the end of the train- enhanced physical and psychosocial performance, such inter-
ing intervention compared with the control group. Globas and ventions performed in a stroke rehabilitation program and in
colleagues173 compared a 3-month progressive, high-intensity the community may have a favorable effect on the prevention
aerobic treadmill exercise intervention (n=18) with a con- of recurrent stroke and cardiovascular events. Accordingly,
ventional care physical therapy group (n=18). Results sug- professionals who design and conduct stroke rehabilitation
gested that high-intensity .treadmill training facilitates greater programs should consider allocating more time to aero-
improvements in peak Vo2, with the experimental group bic exercise training and muscle strengthening to optimize
improving whereas control subjects did not. Furthermore, patient outcomes.
Motivators and Barriers to Physical Activity The perceived barriers identified in the systematic review
and Exercise Training included those likely to reduce self-efficacy, that is, individu-
Most of the current evidence concerning the benefits of physi- als’ beliefs that they can engage in the activity. In a survey of
cal activity and exercise after stroke is from trials that recruited 312 stroke survivors, self-efficacy, outcome expectations, and
ambulatory stroke survivors. Implementation of this evidence, physician recommendations all influenced self-reported activ-
even for ambulatory stroke survivors, is not straightforward, ity after stroke,183 although these factors accounted for only
because simple advice in and of itself does not increase physi- 30% of the variance in exercise behavior. Theory can be used to
cal activity after stroke.74 By understanding the barriers and develop an intervention to improve self-efficacy and outcome
motivators to physical activity after stroke, we may be better expectations for exercise and, by extension, improve exercise
able to advise stroke survivors to participate in physical activ- behavior.191 It is possible to change health beliefs about suscep-
ity.141 The promotion of physical activity in more disabled tibility to stroke and the perceived benefit of exercise to reduce
stroke survivors is likely to be even more challenging. risk using a psychological intervention designed to modify
There are several reasons why exercise might not be per- stroke survivors’ readiness to exercise and beliefs about physi-
formed with adequate frequencies or intensities to facilitate risk cal activity.192 Whether this increases the amount of exercise in
reduction,83,182–184 including patient-related factors (eg, depres- stroke survivors will need to be explored further.
sion, fatigue, lack of interest or motivation, lack of perceived How might we put this evidence into practice? Physical
self-efficacy, negative belief systems concerning exercise, and barriers such as costs and lack of transportation should ide-
fear [of falling, subsequent stroke, and other adverse events]), ally be removed, and stroke survivors should have access
practical reasons (eg, lack of family or other social supports, to exercise guidance delivered by instructors with suitable
lack of availability of fitness resources, lack of transportation, knowledge and training.182 The provision of social support
lack of awareness of the availability of fitness services amongst appears important; adherence to exercise may be better if it is
health professionals), and cost. A systematic review of 6 arti- done in a group.30 Professional advice to increase activity is
cles reported on perceived barriers and motivators to exercise perceived to be important, but professional advice on its own
in 174 stroke survivors, most of whom were already taking part is unlikely to increase physical activity.74 Health and exercise
in physical activity research.185 The most commonly reported professionals should understand that enhancement of self-
barriers were environmental (access, transport, cost), health efficacy and outcome expectations and allowing patients to
problems, stroke-related impairments, embarrassment, and fear establish goals might all help with the uptake of exercise; and
of recurrent strokes.40,62,186–188 Lack of knowledge about how and stroke survivors should be reassured that exercise is likely to
where to exercise and about the potential benefits of exercise40 reduce (rather than increase) the risk of a recurrent stroke61
and lack of motivation were also found to be barriers.40,186 and may improve fatigue.23
The most commonly reported motivator was the possibility Healthcare professionals are in a position to help establish
of meeting other stroke survivors, thus providing psychological appropriate exercise prescription and programming in the lon-
and social support,62,186–188 and the benefit of professional support ger term. For example, if a stroke survivor had already started
in guiding and facilitating physical activity.62,187,188 Other moti- exercise training in the hospital, information about the mode
vators included (1) the use of group exercise classes, because of training, duration, and intensity achieved in the hospital is
participants did not want to let class members down by not highly relevant to fitness instructors who will work with the
attending186,188; (2) the desire to carry out normal daily tasks186–188; stroke survivor after discharge from hospital.
and (3) for male participants, the self-reported functional benefit, In summary, several barriers and motivators to physical
including a resumption of driving.188 A subsequent study sug- activity have been identified in the literature. Addressing these
gested that fitness instructors working in the community should barriers and building on the motivators may increase partici-
be properly trained to deliver exercise to stroke survivors. These pation with physical activity.
barriers and motivators appear to be different in older people;
a large European survey found that the 3 most frequently cited Treatment Gaps and Future
barriers with advanced age were poor health (57.7%), lack of Research Directions
company (43.0%), and lack of interest (36.7%).189 Adherence to physical activity and exercise recommendations
Since this systematic review by Carroll et al,185 several rele- is critical to promote effectiveness but difficult to achieve in
vant studies have been published. In a quantitative study of 14 practice. Despite the availability of national guidelines for
stroke survivors, the most common motivating factors were to risk factor management, there remain large treatment gaps.
improve overall health, improve functional capacity, enhance These gaps exist between the practices recommended by the
confidence and reduce musculoskeletal issues, whereas lack of guidelines for clinicians to provide to stroke survivors and the
motivation, musculoskeletal issues, and fatigue were the most actual physical activity– and exercise-prescribing behaviors
commonly reported barriers.190 In a qualitative study with 11 practiced by clinicians. Historically, the intensity of stroke
community-dwelling stroke survivors, good balance and qual- rehabilitation interventions was insufficient to induce aerobic
ified personnel to deliver the intervention were important.182 In challenge.94 Although the importance of implementing exer-
a survey of exercise preferences in 23 stroke survivors and 42 cise training into neurological rehabilitation programs is now
healthy control participants,30 some preferred organized group recognized, intensity is still primarily determined on the basis
sessions, whereas others preferred to exercise with family or of observation and subjective reports rather . than objective
to incorporate exercise into their daily routine. measures such as peak heart rate or peak Vo2.193
There also are significant gaps between the recommendations training-related improvements in blood pressure and heart
made to patients by clinicians who adhere to the guidelines and rate has been conflicting.66,167,171,172 To date, we lack prospec-
the actual behaviors performed by the patients. Lack of adher- tive studies with long-term follow-up evaluating the effects
ence to stated guidelines by clinicians and patients accounts for of poststroke physical activity levels or exercise on the hard
a great deal of the failure by patients at heightened risk for stroke end points of all-cause or cardiovascular-related mortality or
and other cardiovascular events to achieve health lifestyles.194 the incidence of recurrent events. Such studies would signifi-
Clearly, there is an urgent need to bridge these treatment gaps cantly improve the evidence base for exercise prescription to
by developing and implementing approaches that provide all reduce cardiovascular risk.
stroke survivors with access to effective, comprehensive stroke
risk-reduction interventions, including exercise.195 It is also Exploring Effective Models of Care
important to ensure that health professionals and the clients What is the best model to support an overall increase in physi-
they serve follow the recommendations provided. cal activity and exercise training as a key component of sec-
Since the original recommendations were published in ondary prevention? Behavioral interventions are effective in
2004, there has been steady growth in the body of research changing lifestyle behaviors after stroke.200 In noncontrolled
examining the effects of physical activity and structured exer- studies, hospital treatment utilization rates (medications, edu-
cise programs after stroke. There is now a solid foundation cation on lifestyle factors) were increased when secondary
of evidence regarding the benefits of such interventions on stroke prevention strategies were initiated early201 and contin-
improving aerobic capacity and walking ability in this popula- ued through outpatient care and after discharge,202 and a ran-
tion,12,15 but gaps remain in our knowledge, and there are many domized controlled trial is currently under way to compare
areas yet to explore through ongoing research. the effectiveness of usual care versus in-hospital and ongo-
ing education through stroke community health workers on
Examining the Influence of Exercise on Free-Living control of stroke risk factors and knowledge of stroke and
Physical Activity lifestyle modification.203
Although the effectiveness of exercise interventions in Secondary prevention programs may also be modeled after
improving gait speed and ambulatory capacity is well estab- comprehensive risk factor modification programs such as car-
lished,12,15 whether and to what extent these changes translate diac rehabilitation. Core components of this model of care
to actual increases in free-living physical activity is not yet include participant assessment, exercise training, nutritional
known. Self-report questionnaires may be used to capture this counseling, management of risk factors (blood pressure, lip-
information but lack the accuracy of more objective methods ids, weight, diabetes mellitus, smoking, physical activity),
of collecting physical activity data in real time. Given that and psychosocial interventions,204 all of which are also rel-
stroke survivors often present with slower gait speeds and evant to individuals with stroke. The effectiveness of these
asymmetrical patterns, triaxial accelerometers are superior to exercise-based programs in reducing mortality and hospital
standard pedometers or uniaxial accelerometers in measuring admissions for individuals with CAD are well established.205
physical activity in this population.8,29 To date, these devices Moreover, behavioral interventions focused on education,
have largely been used to measure physical activity under self-management, and goal setting have been shown to be
research conditions. As devices have become more comfort- more effective than traditional cardiac rehabilitation inter-
able to wear, cheaper, and more robust, with longer battery ventions for individuals with cardiac disease.206 The applica-
life, we are seeing them used more broadly. In the future, tion of cardiac rehabilitation models to stroke has been the
accelerometry may be used as a primary outcome in clinical focus of recent work. Studies have established the feasibility
trials to measure changes in free-living physical activity as a and effectiveness of adapting exercise-based cardiac reha-
result of participation in exercise programs, as a method of bilitation interventions for individuals with mild to moderate
tracking intervention compliance in programs, or even as a disability from stroke,172,207 and comprehensive models that
motivational or self-management tool for participants. integrate exercise, lifestyle modification, and medications
have been shown to be beneficial for individuals after TIA
Benefits to Cardiovascular Health and Lowered or stroke with little to no residual deficits.68,208 Larger clini-
Risk for Secondary Events cal trials are currently under way to examine whether similar
We need to better understand the influence of physical activity models of care involving exercise and risk factor modification
and exercise training on the long-term cardiovascular health can be adapted and implemented among individuals with TIA
of stroke survivors. The inverse association between aerobic or a broader range of clinical presentation after stroke.209,210
capacity and CVD risk is well established in healthy popu- These trials represent important steps toward the develop-
lations,196 as is the association between sedentary behavior ment of optimal secondary prevention strategies that integrate
and cardiovascular risk.197–199 As discussed in previous sec- exercise interventions into a comprehensive risk-reduction
tions, for stroke survivors, the effects of exercise on reduc- program for stroke survivors.
ing occurrence of secondary events, or on outcomes related to
cardiovascular health (eg, mortality, vascular risk factors), are Concurrent Benefits to Markers of Vascular Health
either not known or not well established.15 Aerobic exercise Silent ischemic strokes resulting from vascular disease are
training after stroke has been shown to improve insulin sen- also an important consideration, given their high prevalence
sitivity64 but not lipid profiles,172 and the evidence regarding and significant clinical and public health impact.211,212 These
subclinical events manifest as cognitive decline and demen- There is also potential to develop Web-, mobile-, and tablet-
tia and are associated with cardiovascular risk factors such based applications (“apps”) for a variety of uses.225 Fitness-
as hypertension, dyslipidemia, and diabetes mellitus213,214 based applications are already widely used by the general
that may be mediated through exercise and physical activity. public to track and measure progress related to fitness and
Indeed, higher physical activity levels were associated with nutrition goals. Similar applications may be developed for
lower risk of silent brain infarcts among older adults with- people with disabilities, including stroke, that provide clini-
out history of stroke,215 and enhanced physical activity and cians with the means to enter customized exercise programs
fitness can improve cognitive function in older adults with- on their clients’ devices and remotely track and monitor exer-
out known impairment.150 Among stroke survivors, there is cise activities and progress. Web sites or mobile applications
some evidence demonstrating improved cognition after exer- for knowledge uptake may also be designed for health profes-
cise,19–21,216 but the mechanisms that underlie these changes are sionals that synthesize the current state of research and facili-
not known. Future clinical trials may build on the evidence tate implementation into clinical practice.
concerning the effects of exercise on neuroplastic changes Other new technologies may also provide novel ways of
in animal models217 to bridge the gap between basic science monitoring and delivering interventions with cardiovascular
and human stroke research. Ongoing work may examine the challenge. Through miniaturization, wearable technologies
effects of exercise on cognition concurrent with changes in are advancing rapidly and allow individuals to monitor and
cardiovascular health, including vascular risk factors such track physiological responses and progress over time. As the
as blood pressure, lipid profiles, glucose control and insulin market for such devices as smart watches, bracelets, sen-
sensitivity, and markers of brain health, such as white matter sors, or interactive glasses continues to grow, scientists and
hyperintensity volume, brain-derived neurotrophic factor lev- health professionals may turn to these technologies for use in
els, and Β-amyloid plaque formation. research and clinical practice. Video-based interactive gam-
ing platforms have gained recent popularity for their potential
Economic Analyses application in older adult and clinical populations. These sys-
There are significant economic costs associated with stroke. tems are commercially available; designed to be fun, moti-
Direct and indirect costs of stroke are $65.5 billion in the vational, and incrementally challenging; and provide visual
United States alone and €27 billion in the European Union.218 and auditory feedback to participants during repetitive, high-
The potential for exercise and physical activity as a second- intensity, and task-specific activities. Active video games have
ary prevention strategy would also have economic benefits. been shown to elicit cardiorespiratory responses of light (<3
Intervention-related cost-benefit analyses may include mor- METs)226,227 to moderate (3–6 METs) intensity among older
bidity, mortality, and hospitalization rates; productivity; and adults226 and moderate-level intensity among stroke survi-
quality of life-years.219 Economic evaluations related to exer- vors.228 Future work may examine the cardiovascular benefit
cise interventions will provide additional evidence to support derived from engaging in these activities over a period of time.
their use as a secondary prevention strategy.
Interventions for Individuals With Severe Stroke
Capitalizing on Technology To date, the majority of research has focused on individuals with
Novel methods of supporting exercise and physical activity mild to moderate disability from stroke, but a large gap remains
in stroke survivors should also be explored and developed. regarding how those with severe stroke may be supported to
Information and communication technologies have already increase physical activity patterns and engage in an exercise
been used successfully with other chronic disease popula- program. One potential area for this subset of the stroke popu-
tions, including CAD, hypertension, and diabetes mellitus.220 lation is the application of electromechanical-assisted walking
Mobile phone telemonitoring was effective for maintenance interventions. Historically, these interventions have focused
of regular exercise among individuals with chronic obstructive on the recovery of walking function and thus typically target
pulmonary disease,221 and telemedicine-based cardiac rehabil- changes in gait and mobility outcomes.229 New research, how-
itation programs have derived comparable benefit compared ever, is emerging regarding the potential aerobic benefits of
with conventional on-site programs with respect to improved such training among individuals with limited ambulatory capac-
risk factors, physical activity levels, anthropometric measures, ity. Treadmill training with a robotic exoskeleton after incom-
and dietary intake.222 Studies are currently under way to estab- plete spinal cord injury resulted in improved left ventricular
lish mobile- and Internet-based support for cardiac rehabili- and endothelial function.230 For stroke survivors, robot-assisted
tation interventions,223,224 and future work may extend these treadmill training combined with conventional inpatient reha-
remote-monitoring programs for stroke survivors. Although bilitation
short-term behavior change using these approaches is indi- . physical therapy was more effective in increasing
peak Vo2 than conventional physical therapy alone.165 Ongoing
cated, whether these models result in longer-term benefits is work may explore the broader application and effectiveness of
yet to be demonstrated. Historically, key practical challenges interactive gaming systems or electromechanical-assisted gait
with implementing technology-based programs for stroke sur- training to induce cardiovascular benefit after stroke.
vivors have included that technology solutions have not been Other areas of future research are likely to include the
easy to use, nor are they reliable, and that some older adults following:
have lacked confidence in using technology. Rapid changes
in both access and usability of technology will lead to these • Identifying factors (eg, stroke characteristics, clinical
kinds of programs becoming increasingly relevant. presentation, and personal or social factors) that influence
the degree to which a stroke survivor can respond to an The measurement of exercise capacity has been shown
exercise program,184,231 gaining a better understanding to improve risk discrimination and classification of all-
of the barriers and facilitators to exercise, including the cause and cardiovascular mortality among individuals
exercise preferences of these individuals,30 and iden- without history of CVD,232 but whether it is a similarly
tifying effective models of behavior change related to powerful predictor of CVD risk in the stroke population
exercise and secondary prevention.74 The results of such is not yet known.
research will help to establish optimal protocols to max- • Establishing effective strategies to facilitate long-term
imize benefit for various patient subgroups, including adherence to regular exercise and physical activity after
those with limited mobility, and will aid in the develop- stroke.
ment of programs that embed physical activity and exer- • Establishing effective interventions that take place
cise into the daily lives of stroke survivors. in both healthcare and home settings to optimize out-
• Understanding whether sedentary behaviors are just as comes, maximize adherence, and facilitate involvement
important as exercise behaviors in maintaining health of caregivers.
after stroke.
• Determining the effectiveness of different types of train- Conclusions
ing (ie, aerobic, resistance, and combined aerobic and As an important sentinel event, the stroke can serve as an
resistance training) on cardiovascular health and func- “alert” or “wake-up call” to the individual. The care and ser-
tional outcomes. vices that are provided to the individual after the stroke, which
• Determining whether and to what extent standard post- should include exercise training recommendations and physi-
stroke functional rehabilitation programs result in increased cal activity programs, can serve as important opportunities to
aerobic fitness and improved cardiovascular health.
implement effective and lasting behavioral and medical inter-
• Exploring the cost-effectiveness of different models of ventions that would improve overall health and might prevent
exercise participation for stroke survivors across a range
the future occurrence of cardiovascular events such as subse-
of settings (institution, community, home), including
quent stroke or myocardial infarction.
integration of individuals into community programs.
This will likely include tracking long-term engagement Exercise is a very valuable yet underused component of
and health outcomes. poststroke care. The evidence strongly supports the benefits of
• Analyzing the cost-benefit ratio of vigorous physical physical activity exercise for stroke survivors. With education
activity across various patient subsets, with specific ref- in and encouragement for the benefits and safety of exercise
erence to cerebrovascular, cardiovascular, and musculo- after stroke, and with development of appropriate programs in
hospitals and in communities, the ability to recruit patients to
skeletal benefit and complications.

• Establishing the effectiveness of exercise training on these programs should increase. These programs, developed
quality of life in individuals with residual impairments by trained exercise professionals, should be offered early after
from stroke. stroke, when change can often make an impact, and should
• Establishing exercise testing protocols that provide continue to be monitored throughout chronic stages to impact
high sensitivity and specificity for concomitant CAD. lifestyle-changing behaviors and improve overall health.
Disclosures
Writing Group Disclosures

Other
Writing Group Research Speakers’ Expert Ownership Consultant/
Member Employment Research Grant Support Bureau/Honoraria Witness Interest Advisory Board Other
Sandra A. Kansas University NIH† None None None None None None
Billinger Medical Center
Ross Arena University of None None None None None None None
Illinois at Chicago
Julie Bernhardt Florey Institute of National Health and Medical None None None None None None
Neuroscience and Research Council*; National
Mental Health Stroke Foundation Australia*
Janice J. Eng University of Canadian Institutes None None None None None None
British Columbia of Health Research
(CIHR)†; Heart and Stroke
Foundation of Canada†
Barry A. Beaumont Health None None None None None None None
Franklin System, Royal
Oak, MI
Cheryl Mortag UW Hospital and NIH† None None None None None None
Johnson Clinics
Marilyn Dalhousie Canadian Institutes None None None None Canadian Stroke None
MacKay-Lyons University of Health Research Network (board of
(CIHR)†; Canadian Stroke directors)*;
Network†; Heart and Stroke Institute of
Foundation of Canada† Circulatory and
Respiratory Health,
Canadian Institutes
of Health Research
(advisory board)*
Richard F. VA Maryland/ NIH† None None None Interactive IKKOS Inc (unpaid None
Macko University of Motion to date)*
Maryland School of Technologies*
Medicine
Gillian E. Mead University of Chief Scientist, Office of None Elsevier (annual royalties for a book on None None None
Edinburgh Scottish Government†; exercise after stroke)*;
Welsh Stroke Organisation Late Life Training (not-for-profit
(paid to University company; annual royalties paid to
Edinburgh; research for University of Edinburgh)*; World Stroke
exercise after stroke)† Organisation (single royalty payment
to University Edinburgh in 2013 for an
education module to support research
on exercise after stroke)*
Elliot J. Roth Northwestern Kiwanis Foundation of None None None None None None
University Feinberg Illinois and Eastern Iowa*;
School of Medicine/ NIDRR†; NIH/NINDS†
Rehabilitation
Institute of Chicago
Marianne Baltimore VA None None None None None None None
Shaughnessy Geriatric Research
Education and
Clinical Centers/
University of
Maryland School
of Nursing
Ada Tang McMaster University Canadian Institutes of None None None None None None
Health Research†
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the
Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person
receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the
entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.
Reviewer Disclosures
Other Speakers’
Research Bureau/ Ownership Consultant/
Reviewer Employment Research Grant Support Honoraria Expert Witness Interest Advisory Board Other
Janet Fulton Centers for Disease Control and None None None None None None None
Prevention
Barbara Lutz University of Florida None None None None None None None
This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure
Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10 000 or more during
any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more
of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
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AHA/ASA Scientific Statement

Physical Activity and Exercise Recommendations for

existing evidence and indicate gaps in current knowledge.

A nnually, 795 000 people in the United States experience

The World Health Organization’s International Classification

Table. Summary of Exercise/Physical Activity Recommendations for Stroke Survivors

Inpatient and outpatient exercise therapy or

strength training of the hemiparetic knee.179 More recently, a

skeletal benefit and complications.

Writing Group Disclosures

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