The review concluded that cardiovascular exercise early after stroke enhances aerobic capacity and walking endurance in patients with moderate to mild motor deficits following stroke. The authors’ conclusions were based on the evidence and appear reasonable, although the fact that many outcomes could not be pooled and the uncertain clinical significance of outcomes should be considered.

To determine the effectiveness of early cardiovascular exercise after stroke.

EMBASE, MEDLINE/PREMEDLINE, CINAHL, The Cochrane Library and Web of Science were searched to November 2011 for articles in English, French or German. Search terms were reported. Reference lists of identified articles were searched.

Randomised and non-randomised controlled studies of cardiovascular exercise in the subacute stage after stoke were eligible for inclusion. Patients had to be over 18 years of age and medically stable enough to participate in an exercise programme. All types and severity of stroke were considered. The subacute stage was defined as between seven days and six months post-stroke. Any type of objective or subjective outcome was considered but the primary outcome was physical functioning and/or physical performance using validated parameters or scales.

Trials were published between 1998 and 2011 and conducted during in-patient rehabilitation in various countries that included USA, Germany and Israel. The most common forms of cardiovascular training were leg cycle ergometry and treadmill training. Training protocols involved continuous exercise for 20 to 90 minutes for two to five sessions per week. The control group was generally usual care. Patients had mild to moderate deficits in motor function. Mean start of intervention was 34 days after stroke; one study enrolled patients after six days. A range of exercise and functional outcomes were reported including functional ability, balance and peak oxygen uptake.

Two reviewers undertook study selection in a blinded fashion. Disagreements were resolved by consensus or discussion with a third reviewer.

Quality assessment was undertaken using the PEDro scale to appraise 11 quality items including randomisation, blinding and withdrawals and drop-outs to give a maximum score of 10 (one item assessed external validity). Studies that scored 9 or 10 were deemed excellent, 6 to 8 were good, 4 or 5 were fair and less than 4 were deemed poor quality.

Two reviewers independently assessed study quality. Disagreements were resolved by consensus or discussion with a third reviewer.

Data were extracted on fitness, functional and quality of life outcomes and used to calculate mean differences and 95% confidence intervals (CI).

One reviewer extracted data which were checked by a second reviewer. Disagreements between reviewers were resolved by consensus or discussion with a third reviewer. Study authors were contacted for missing/unclear data.

Random-effects meta-analysis was used to calculate pooled standardised mean differences (SMD) with 95% CI. The Ι² and Χ² statistics were used to assess statistical heterogeneity. Publication bias was assessed using funnel plots.

Eleven studies (423 patients, range 15 to 100) were included in the review: 10 randomised controlled trials or pilot trials and one prospective controlled matched study. Seven trials were deemed good quality and four trials were deemed fair quality.

Compared with control, cardiovascular exercise was associated with a statistically significantly increased aerobic capacity (SMD 0.83, 95% CI 0.50 to 1.16; three studies; Ι²=0%) and walking endurance (SMD 0.69, 95% CI 0.45 to 0.94; six studies; Ι²=0%). There was no statistically significant difference in gait speed. Results for other outcomes were presented.

There was a low risk of publication bias.

Cardiovascular exercise early after stroke enhances aerobic capacity and walking endurance in patients with moderate to mild motor deficits following stroke.

Inclusion criteria for the review were clearly defined and several relevant data sources were searched. Articles in English, French or German were considered, although there could still be some risk for language bias. There was a low risk of publication bias. Attempts were made to reduce reviewer error and bias during the review.

Quality assessment was undertaken using a standard checklist, which indicated that the quality of the included studies was fair to good. Data were combined using meta-analysis and statistical heterogeneity was assessed, which was appropriate. The authors noted that the included studies did not describe concomitant medication usage, which may have confounded the results. Many outcomes could not be quantitatively pooled, which hindered interpretation of the results. The clinical significance of the outcomes was also not mentioned, and the justification for using standardised mean differences over weighted mean differences was not given.

Overall, the authors’ conclusions were based on the evidence and appear reasonable, although the fact that many outcomes could not be pooled and the uncertain clinical significance of outcomes should be considered.

Practice: The authors stated that cardiovascular exercise interventions and exercise testing protocols using leg cycle ergometry have the potential for implementation in subacute stroke rehabilitation.

Research: The authors stated that further research is needed to evaluate the long-term effects of cardiovascular exercise on aerobic capacity, physical functioning, and quality-of-life. Appropriate methods for cardiovascular rehabilitation early after stroke (before 7 days) need to be developed. Cardiovascular exercise protocols for severely affected stroke individuals also need to be developed.

Not stated.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.