Combined Cardiorespiratory and Resistance Training After Stroke: Small Gains, Big Questions

Highlight

• Combined aerobic and resistance training post-stroke does not affect mortality or secondary cardiovascular events.
• Small, short-term benefits in disability, walking speed, cardiorespiratory fitness, and balance were observed.
• Interventions were well tolerated without concerning adverse events, but long-term effects remain uncertain.
• Evidence quality is limited by small study sizes, imprecision, and risk of bias.

Background

Stroke remains a leading cause of long-term disability worldwide. Survivors often face diminished cardiorespiratory fitness and muscle strength, which contribute to reduced mobility, independence, and quality of life. These impairments are also linked to a higher risk of secondary cardiovascular or cerebrovascular events. The development of targeted exercise programs — integrating both aerobic and resistance elements — offers the potential to improve functional outcomes, promote recovery, and enhance overall health in the post-stroke population.

However, while individual components such as treadmill walking or resistance machine training have supportive evidence, the additive or synergistic effects of combining them are not fully understood. This Cochrane review sought to critically evaluate whether such multicomponent exercise designs yield meaningful improvements in survival, functional capacity, and secondary prevention outcomes.

Study Design

This systematic review and meta-analysis included randomized controlled trials comparing combined cardiorespiratory and muscle strength training to non-exercise controls (usual care, no intervention, or alternative therapy) in people with stroke. Comprehensive searches of nine bibliographic databases and two trial registries were completed in January 2024, supplemented by reference checking, citation tracking, and expert contact.

Thirty RCTs involving 1,519 participants (mean age 63.7 years) were included. The majority of studies recruited ambulatory individuals in the early subacute or chronic recovery phases and were conducted in high-income countries. Intervention programs typically combined aerobic modalities (walking or ergometer-based work) with strength training (free weights, machines, bodyweight, or elastic bands) in a circuit format. Frequencies ranged from 2–5 sessions/week over 4 weeks to 1 year.

Primary outcomes included mortality, disability, adverse events, incidence of secondary cardiovascular/cerebrovascular events, risk factors, physical fitness indices, walking performance, and other physical function measures. Secondary outcomes encompassed quality of life, mood, cognition, and fatigue.

Key Findings

Mortality and Secondary Events

No difference in mortality was observed at either end-of-intervention (RD -0.00, 95% CI -0.02 to 0.01) or follow-up (RD -0.01, 95% CI -0.04 to 0.02), with high certainty evidence. Similarly, combined training had no effect on the incidence of secondary cardiovascular or cerebrovascular events during intervention or follow-up periods.

Disability

At the end of intervention, there was a small reduction in disability (SMD 0.20, 95% CI 0.04 to 0.36; low certainty). This effect diminished at follow-up (SMD 0.10, 95% CI -0.07 to 0.28), indicating limited durability of functional benefit.

Blood Pressure

Mean systolic blood pressure changes were small and statistically uncertain at end of intervention (MD -1.83 mmHg, 95% CI -9.60 to 5.95; very low certainty). No follow-up data were reported on blood pressure outcomes.

Fitness Measures

Indices of cardiorespiratory fitness and lower limb strength showed possible improvements following intervention, but the small sample sizes and methodological limitations render the evidence very uncertain. Comfortable walking speed improved slightly at intervention end (MD 0.09 m/s, 95% CI 0.04 to 0.14), but gains were smaller and non-significant at follow-up (MD 0.03 m/s, 95% CI -0.07 to 0.13).

Balance

Balance gains were modest yet consistent: SMD 0.25 (95% CI 0.11 to 0.39; low certainty) at end of intervention and SMD 0.24 (95% CI -0.00 to 0.49; low certainty) at follow-up, suggesting potential persistence of benefit in postural control.

Safety and Tolerability

Interventions were well tolerated, with high adherence rates and no serious adverse events reported. Withdrawal rates did not show a concerning pattern relative to controls.

Expert Commentary

From a clinical rehabilitation perspective, even modest improvements in walking speed and balance can translate into meaningful enhancements in daily living. However, the small effect sizes, limited statistical certainty, and diminished retention of benefit raise questions about clinical significance and scalability. The absence of mortality or secondary event reduction is unsurprising given the low frequency of these outcomes within study horizons and sample sizes; nonetheless, the cardiovascular risk factor modulation potential of combined training warrants further exploration.

Methodological quality varied substantially across studies, with notable risks of bias from imbalanced control exposure, lack of blinding, and incomplete follow-up data. To advance the field, future large-scale RCTs should employ standardized exercise prescriptions, longer intervention durations, and robust monitoring to clarify optimal regimens for sustained outcomes.

Conclusion

Current evidence supports that combined cardiorespiratory and resistance training after stroke produces small, short-term improvements in functional measures such as disability, walking speed, fitness, and balance, with no impact on mortality or secondary event incidence. These interventions are safe and well tolerated, offering a viable option for enhancing recovery in ambulatory stroke survivors. However, long-term benefits remain uncertain due to limited and low-certainty data. Clinicians should approach exercise prescription with individualized goals, and researchers should prioritize high-quality, adequately powered trials to inform future guidelines.

Funding and ClinicalTrials.gov

No dedicated funding was received for this Cochrane review. Protocol registered under DOI 10.1002/14651858.CD003316.

References

Saunders DH, Carstairs SA, Cheyne JD, Fileman M, Morris J, Morton S, Wylie G, Mead GE. Combined cardiorespiratory and resistance training for people with stroke. Cochrane Database Syst Rev. 2025 Sep 24;9(9):CD016002. doi: 10.1002/14651858.CD016002. PMID: 40990157; PMCID: PMC12458986.