Aerobic conditioning in patients after stroke: a mapping of systematic reviews

Acondicionamiento aeróbico en pacientes pos-accidente cerebrovascular: un mapeo de revisiones sistemáticas

ABSTRACT

Most health professionals have limited experience and little scientific knowledge regarding aerobic exercise programming for post-stroke patients. These issues raise the need for highly reliable studies to contribute to clinical decision-making. Thus, this study analyzed in which contexts and levels of evidence aerobic conditioning in post-stroke patients has been investigated. It mapped systematic reviews and the search strategy was applied in the National Library of Medicine (MedLine) via PubMed, International Prospective Register of Systematic Reviews (PROSPERO), and Physiotherapy Evidence Database (PEDro) databases. The PRISMA and Amstar 2 instruments were used for article analysis and selection and methodological evaluation of the selected articles, respectively. In total, 15 systematic reviews that employed multiple forms of aerobic training were included, relating their effects to cognitive benefits, improved walking, self-care, cardiorespiratory fitness, mobility, and neuroplasticity. Of these, four were classified as high and moderately reliable based on the methodological analysis. The safest articles to be reproduced in clinical practice refer to aerobic training associated with functional capacity, using a combination of therapeutic modalities; cognitive training combined with aerobic exercises; and aerobic exercises associated with improved walking distance. Health professionals should seek methods and know how to distinguish them before making any decision.

Keywords:
Cardiac Rehabilitation; Exercise; Physical Conditioning, Human; Systematic Review

RESUMO

A maioria dos profissionais da saúde apresenta uma experiência limitada e pouco conhecimento científico a respeito da programação do exercício aeróbico em vítimas dessa doença. Tais problematizações trazem a necessidade de estudos altamente confiáveis a fim de contribuir na tomada de decisões clínicas. O objetivo deste trabalho é analisar em que contextos e níveis de evidência o condicionamento aeróbico em pacientes pós-AVC tem sido investigado. O estudo consistiu em um mapeamento de revisões sistemáticas, e a estratégia de busca da pesquisa foi realizada nas bases de dados Sistema Online de Busca e Análise de Literatura Médica (MedLine) via PubMed, International Prospective Register of Systematic Reviews (Prospero) e Physiotherapy Evidence Database (PEDro). Os instrumentos Prisma e Amstar 2 foram utilizados, respectivamente, para análise e seleção dos estudos e para avaliação metodológica dos artigos selecionados. Foram incluídas 15 revisões sistemáticas que utilizaram múltiplas formas de treinamento aeróbico, relacionando os seus efeitos com benefícios cognitivos, melhora da caminhada, autocuidado, aptidão cardiorrespiratória, mobilidade e neuroplasticidade. Quatro estudos foram classificados em alta e moderada confiabilidade a partir da análise metodológica. Os artigos mais seguros a serem reproduzidos na prática clínica são referentes ao treino aeróbico associado à capacidade funcional, utilizando uma combinação de modalidades terapêuticas; treino cognitivo combinado a exercícios aeróbicos e exercícios aeróbicos associados à melhora na distância de caminhada. Há necessidade de que os profissionais de saúde busquem métodos e saibam distinguir entre eles antes de qualquer tomada de decisão.

Descritores:
Reabilitação Cardíaca; Exercício; Condicionamento Físico, Humano; Revisão Sistemática

RESUMEN

La mayoría de los profesionales de la salud tienen una experiencia limitada y poco conocimiento científico acerca de la programación del ejercicio aeróbico en las víctimas de esta afección. Estas problematizaciones plantean la necesidad de estudios muy confiables con el fin de contribuir a la toma de decisiones clínicas. El objetivo de este trabajo es analizar en qué contextos y niveles de evidencia se evaluó el acondicionamiento aeróbico en pacientes pos-ACV. Este estudio consistió en un mapeo de revisiones sistemáticas, y la estrategia de búsqueda de la investigación se llevó a cabo en Medical Literature Analysis and Retrieval System Online (MedLine) mediante PubMed, International Prospective Register of Systematic Reviews (Prospero) y Physiotherapy Evidence Database (PEDro). Se utilizaron los instrumentos Prisma y Amstar 2, respectivamente en el análisis y selección de estudios, y en la evaluación metodológica de los artículos seleccionados. Se incluyeron 15 revisiones sistemáticas que utilizaron múltiples formas de entrenamiento aeróbico, relacionando sus efectos con beneficios cognitivos, mejora de la marcha, autocuidado, aptitud cardiorrespiratoria, movilidad y neuroplasticidad. Cuatro estudios se clasificaron como de alta y moderada confiabilidad según el análisis metodológico. Los artículos más seguros para reproducir en la práctica clínica están relacionados con el entrenamiento aeróbico asociado a la capacidad funcional, que hicieron uso de una combinación de modalidades terapéuticas; entrenamiento cognitivo combinado con ejercicios aeróbicos y ejercicios aeróbicos asociados a la mejora de la distancia de la marcha. Es necesario que los profesionales de la salud busquen métodos y sepan distinguirlos antes de la toma de decisiones.

Palabras clave:
Rehabilitación Cardíaca; Ejercicio; Acondicionamiento Físico Humano; Revisión Sistemática

INTRODUCTION

According to the World Health Organization (WHO), a stroke is a clinical syndrome of vascular origin that leads to focal brain damage caused by an interruption in the blood supply to the brain due to the rupture or blockage of one or more blood vessels; it has a rapid onset and lasts longer than 24 hours^1-3. According to its etiology, a stroke can be ischemic or hemorrhagic^4-7. Brain ischemia is characterized by the obstruction of a blood vessel, accounting for 87% of stroke cases. Intracranial hemorrhage represents 13% of stroke cases and involves the rupture of a blood vessel responsible for cerebral perfusion, culminating in blood accumulated in the intraparenchymal or subarachnoid space^3-5.

Stroke is most commonly caused by cardiovascular diseases, such as myocardial infarction, valvular heart disease, arrhythmias, congenital heart defects, and systemic diseases that can produce septic, fatty, or air emboli, leading to total or partial occlusion, which affects cerebral circulation^7,8. Both mechanisms of injury can result in brain tissue necrosis, leading to acute symptoms such as loss of neurological function, paresis, and coma^4,9.

Impairments and disabilities caused by stroke result from neuronal death and the loss or disruption of connections between the central nervous system (CNS) and the effector organs. Most common immediate limitations include difficulty walking, deficits in postural balance and proprioception, fatigue, and reduced aerobic endurance^10,11. These limitations can be seriously disabling, drastically interfering with the performance of activities of daily living (ADLs) and, therefore, with one’s functional independence and socialization, negatively altering their quality of life^4,11-14.

The Clinical Practice Guidelines For Managing Stroke In Rehabilitation¹⁵ strongly recommends that post-stroke rehabilitation therapy be initiated as soon as medical stability is achieved, as it is strongly associated with better functional outcomes. In discussing the rehabilitation of affected individuals, this guideline indicates that rehabilitation should prioritize preventing disease recurrence and secondary complications, recovering functioning and managing comorbidities.

Corroborating these recommendation priorities, research findings reveal that aerobic conditioning positively interferes with cardiovascular risk factors, helping to reduce systemic blood pressure (BP), weight, and low-density lipoprotein (LDL). These benefits help minimize sequelae, promoting independence and recovery from functional damage. All these changes can improve patients’ physiological and metabolic functions, increasing high-density lipoprotein (HDL) and tolerance to exertion, with improved gait performance and blood properties. In turn, these effects help to reduce the recurrence risk, thus constituting an important resource for managing the various comorbidities frequently exhibited by stroke survivors^7,15,16.

However, most health professionals have limited experience and little scientific knowledge regarding the programming of aerobic exercise for stroke victims. Such problematizations underscore the need for highly reliable studies to obtain knowledge, as to contribute to clinical and political decision-making. A goal achieved by using guidelines from studies on health interventions which come from systematic reviews (SR), published to be widely used during clinical practice¹⁷.

Systematic reviews offer a valuable tool to inform decisions based on accurate, succinct, reliable, and comprehensive summaries of the best available evidence on a given topic. They help in updating knowledge and providing concrete information for policymakers to assess risks, benefits, and potential harms of health behaviors and interventions. They also contribute by gathering and synthesizing research relevant to patients and caregivers, serving as a starting point for developers of clinical practice guidelines, and providing a structured foundation that allows funders to identify gaps and set priorities for new research investments^16,18-20.

But despite strict protocols for SR reporting, they can differ in quality and analysis. Consequently, readers of systematic reviews should be critical and carefully evaluate their methodological quality^19,20, as it is a prerequisite for the valid and appropriate interpretation of review results.

Given this context, adding research evidence to guide clinical practice is one of the main reasons for developing studies that synthesize the literature. Based on these important questions, this study analyzed in which contexts and levels of evidence aerobic fitness in post-stroke patients have been investigated.

METHODOLOGY

This study mapped systematic reviews and carefully complied with the following steps: selection of the guiding question; definition of the characteristics of the sample’s surveys; selection of the research included in the review sample; analysis of the findings of the systematic reviews included in the review; interpretation of the results; and a report of the review providing a critical examination of the findings.

Research question formulation used the Pico strategy (P: population/patients; I: intervention; C: comparison/control; O: outcome), according to Chart 1.

Chart 1
Pico strategy for formulating the research question

Population	Post-stroke patients
Intervention	Aerobic exercise
Comparator	No comparison
Outcome	Contexts and levels of evidence of systematic reviews

• Source: Prepared by the authors.

“In what contexts and levels of evidence has aerobic exercise in post-stroke patients been investigated in systematic reviews?” acted as the study guiding question.

Bibliographic search was conducted in the following databases: the National Library of Medicine (MedLine) via PubMed, the International Prospective Register of Systematic Reviews (Prospero) and the Physiotherapy Evidence Database (PEDro). The search strategy used descriptors and correlates found in the Medical Subject Headings (MeSH)-“Rehabilitation stroke,” “Exercise,” “Physical Conditioning” and “Systematic Review”-, as well as descriptors and related terms found in the Health Science Descriptors (DeCS): “Stroke Rehabilitation,” “Exercise,” “Physical Conditioning, Human,” “Systematic Review.”

Each term was combined with one another using the Boolean operators “AND” and “OR” according to the search strategy in MedLine, PEDro and Prospero. The entire search process employed advanced search strategies and full-text search to avoid the loss of potential studies, applying the following filters: publication time (2010-2022), type of study (systematic reviews), and language (English and Portuguese).

Study identification was divided into phases:

• Phase 1 - Identification: Search in the databases using descriptors and filters. To be included in this phase, the publications had to be available in Portuguese or English and accessible for reading in full. Relevant studies were found in the references of the selected articles. Duplicate articles were excluded.

• Phase 2 - Selection: Reading titles and abstracts thoroughly to ensure that they met the previously defined criteria. Studies addressing interventions unrelated to aerobic fitness, such as resistance training, medication use, or other post-stroke rehabilitation approaches, were excluded. Narrative reviews, case studies, comments, letters to the editor, and articles with inadequate study design were disregarded. Main issues were recorded in a separate table, along with the characteristics of the selected articles, the reasons for and identification of the excluded articles.

• Phase 3 - Eligibility: Selection of studies included in phase 2 based on detailed full-text reading, thus ensuring an evaluation based on the established inclusion criteria. Articles lacking clear presentation of outcomes related to aerobic exercise, studies whose target audience included conditions other than stroke or that were not specific to this population were excluded.

• Phase 4 - Inclusion: Data extraction by outcomes and separated by study. Relevant characteristics of each article-authors, year, sample size, study objective, and main results of the studies-were described in a specific spreadsheet.

The Rayyan QCRI online software from the Qatar Computer Research Institute for Data Analysis was used in phases 1 and 2 to remove duplicates and read the titles and abstracts. Two researchers identified and selected the studies independently. Each researcher analyzed the titles and abstracts separately, categorizing the studies as “eligible,” “ineligible,” or “undecided.” Disagreements regarding eligibility were solved by a third evaluator. The final decisions were duly recorded in the software.

STUDY RESULTS

Bibliographic search was performed between January 5 and February 20, 2022, and identified a total of 483 articles in the databases. During analysis, 53 duplicates were identified and excluded, and 383 articles were disregarded after reading the title and abstract as they did not meet the previously established inclusion criteria. Finally, 30 studies remained for full-text reading, of which 15 met all the inclusion criteria and were included in the review.

The review followed the 27-item Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Figure 1 presents a detailed description of the studies identified according to the Prisma method.

Figure 1
PRISMA Flowchart

Risk of bias and methodological quality

Assessing the Methodological Quality of Systematic Reviews (Amstar) consists of an instrument for assessing the quality of systematic reviews. Its original version was published in 2007, built upon the analysis and updating of other instruments, empirically validated and generic, meaning it is suitable for assessing SR in all areas²¹. In its first version, Amstar had 37 items, 29 of which were selected by factor analysis, comprising 11 factors. Amstar underwent another modification, being named Amstar 2. This change was made by a group of experts to value Amstar as a comprehensive critical appraisal tool designed primarily for systematic reviews of health intervention studies. Its final version was externally validated, performing well in relation to the overall assessments of a panel of content experts¹⁷.

In this new update, the domains became more detailed, now encompassing: selection of duplicate studies, data extraction, funding sources, and risk of bias. The final version of the scale consisted of 16 items, which comprise the minimum requirements for a systematic review: (1) Did the research questions and inclusion criteria for the review include the components of PICO?; (2) Did the report of the review contain an explicit statement that the review methods were established prior to the conduct of the review and did the report justify any significant deviations from the protocol?; (3) Did the review authors explain their selection of the study designs for inclusion in the review?; (4) Did the review authors use a comprehensive literature search strategy?; (5) Did the review authors perform study selection in duplicate?; (6) Did the review authors perform data extraction in duplicate?; (7) Did the review authors provide a list of excluded studies and justify the exclusions?; (8) Did the review authors describe the included studies in adequate detail?; (9) Did the review authors use a satisfactory technique for assessing the risk of bias (RoB) in individual studies that were included in the review?; (10) Did the review authors report on the sources of funding for the studies included in the review?; (11) If meta-analysis was performed did the review authors use appropriate methods for statistical combination of results?; (12) If meta-analysis was performed, did the review authors assess the potential impact of RoB in individual studies on the results of the meta-analysis or other evidence synthesis?; (13) Did the review authors account for RoB in individual studies when interpreting/ discussing the results of the review?; (14) Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?; (15) If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?; and (16) Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?

Each item includes the following answer options: (1) “yes,” if the review explicitly includes the criterion; (2) “no,” if it does not include it; and (3) “partial yes,” in cases of partial adherence to the standard. Responses to the Amstar 2 items are not used to obtain an overall score because, according to experts, scores can mask critical weaknesses that should diminish confidence in the results of a systematic review. Thus, the evaluation performed with this instrument must follow a classification process based on identifying critical domains¹⁷.

RESULTS

The studies included in this SR employed multiple types of aerobic training, relating its effects to cognitive benefits, improved walking, self-care, cardiorespiratory fitness, mobility, and neuroplasticity.

Hasan et al.²² and Aguilar et al.²³ analyzed the effect of aerobic interventions in improving cognitive functions after stroke. Hasan et al.²² observed beneficial effects related to working memory, spatial memory and executive function when aerobic exercise (AE) was performed at low and moderate intensity, whereas Aguilar et al.²³ obtained positive cognitive responses during walking, showing good scores on cognitive tests.

A methodological evaluation of the critical and non-critical points of the review evinced that the study by Hasan et al.²² met six of the 16 items, corresponding to only 37.5% of the Amstar 2 questions. Of the ten items not selected, four were excluded as this review is not a meta-analysis. Disregarded items met the criteria for the following components: PICO, risk of bias, rationale for excluding articles, satisfactory detailed description of the studies, funding sources, and satisfactory methods for assessing risk of bias. Three of these items correspond to non-critical domains, and the other three to critical domains. Hence the critically low overall confidence rating of the study by Hasan et al.²², as it presents more than one critical flaw and has reduced reliability due to not providing a comprehensive summary of the available studies.

The study by Aguilar et al.²³ met 12 items on the checklist, about 75%. Failure to comply with three of the four remaining items does not impact the critical analysis since such issues are specific to meta-analyses, which this study is not, and thus not applicable. One disregarded item corresponds to a non-critical domain. Hence the high overall confidence rating of the review, as it offers an accurate analysis and comprehensive summary of the available studies that address the question of interest.

Four systematic reviews evaluated the effect of AE on functional capacity. Luo et al.²⁴ observed favorable results regarding peak VO₂ improvement using high-intensity aerobic exercise. Cardiorespiratory fitness improved after eight weeks of training at 70% to 85% intensity. Evaluation of methodological quality showed that the study met 11 of the 16 items on the checklist, covering 68.7% of the items. This article did not adhere to four items related to the selection of study designs, research strategies, funding sources, and risk of bias. Of these, two are considered critical items and the other two non-critical, classifying the study as low reliability, which indicates a high risk of bias.

Marsden et al.²⁵ found that peak VO2 improved by 10% to 15% compared to baseline when aerobic exercise is performed in programs lasting over three months. This review met only eight of the 16 items in Amstar 2, totaling 50% of applicable items. Disregarded items met the criteria for the following components: PICO, study design, detailed description of the included studies, risk of bias, funding sources, and adequate methods for statistical combination. Of these, four items are considered critical, and the other four are non-critical. According to the instrument used, the review by Marsden et al.²⁵ presents critically low reliability.

Still on this topic, Lee et al.²⁶ analyzed AEs performed for over 12 weeks, which resulted in significantly greater cardiorespiratory fitness during daily activities. In turn, Campo et al.²⁷ found that AE performed on a cycle ergometer had no significant results in improving peak VO₂ among post-stroke patients.

Chart 2
Characteristics of the selected studies

Authors	Year of publication	Sample size	Study objective	Main results
Polese et al.28	2013	9	To analyze whether mechanically assisted walking results in immediate improvements in walking speed and distance compared to no intervention or to no-gait intervention.	Treadmill training increased walking speed by 0.14 m/s, more than no intervention/intervention without walking. Treadmill training increased walking distance by 40m, more than no intervention/intervention without walking.
Peurala et al.29	2014	44	To investigate the evidence of the effect of walking training on gait and self-care in patients at different stroke stages.	Walking training consisting of 12 to 36 sessions over four to 12 weeks was required for effective improvements in walking speed and distance in stroke patients. The level of evidence seems to increase with longer walking times, three to five times a week, for 20 to 60 minutes.
Ploughman et al.30	2014	30	To determine the extent to which aerobic exercise influences post-stroke neuroplasticity markers.	Strength training at moderate or high intensity increases BDNF, IGF-I, NGF, and synaptogenesis in various brain regions.
Francica et al.31	2014	15	To conduct a survey of techniques and procedures applied in stroke rehabilitation.	Improvements in cardiorespiratory fitness, walking speed, functional capacity, balance, and muscle strength were observed with total training durations ranging from 4 weeks to 6 months, three to five times a week, using progressive loads of 50%-80%, with treadmill, cycle ergometer, upper body cycling, and cycling.
Hasan et al.22	2015	25	To test the effects of aerobic training on complex cognitive and motor performance post-stroke.	Studies indicate that early initiation of low- to moderate-intensity AE improves coordination and complex locomotor tasks. Recovery of lower limb balance and functional capacity improved after four weeks of cycling for 20 to 30 minutes. Low- and moderate-intensity AEs improved spatial memory, working memory, and executive function.
Charalambos et al.32	2015	15	To examine the available RCTs of treadmill-based interventions in stroke patients and to evaluate the efficacy of TT by assessing final walking speed (post-speed), speed, and changes in walking speed.	Mean pre-velocity was 0.47 m/s for GC (control group) and 0.23 m/s for ExG (experimental group). Weighted mean post-velocity was 0.67 m/s for GC, whereas the weighted mean speed was 0.22 m/s for ExG and 0.16 m/s for GC. Speed varied from 0.08 m/s in the ExG group and from 0.06 to 0.31 m/s in the GC group, showing that the individuals improved statistically from baseline as a result of the intervention.
Marsden et al.25	2015	12	To determine the efficacy of exercise interventions in improving cardiorespiratory fitness after stroke.	AT can increase cardiorespiratory fitness in people with mild to moderate post-stroke impairment after 19 weeks of varying training, reducing the percentage of VO required during daily activities.
Kendall et al.33	2016	9	To analyze studies that examined the efficacy of various EA intervention modalities in long-term stroke survivors and to assess the impact of these interventions on long-term mobility outcomes.	Aerobic exercise can improve mobility, ranging from an average minimum of six months after a stroke to a maximum of 70 months, improving walking and gait ability.
Tshiswaka et al.34	2017	29	To evaluate the available literature that highlights the impact of walking training on improving walking ability for stroke survivors.	Walking training improved walking performance for stroke survivors, specifically with different training mechanisms for 30 minutes on the ground or treadmill. Ground and treadmill gait training improved gait, function, gait cycle duration, and swing phase speed. High-intensity aerobic training significantly improved gait and peak O² consumption rate.
Luo et al.24	2020	22	To evaluate the evidence and safety of high-intensity interventions related to improving functional walking outcomes after stroke.	High-intensity exercise is a safe and powerful stimulus for increasing walking competence in stroke survivors, improving walking distance, comfortable walking speed, stride length, and TUG compared with low- and moderate-intensity exercise.
Luo et al.35	2019	17	To explore the effect of different intensities, types, and durations on cardiorespiratory fitness gains and walking capacity, and whether the effects of high-intensity exercise differ between post-stroke stages.	High-intensity exercise (70%-85% of peak VO2), three to five times per week for 30 to 40 minutes over eight to 12 weeks, may be beneficial in improving peak VO2 and 6MWT in subacute and chronic stroke survivors.
Lee et al.26	2019	18	To evaluate the effects of combined AT and RT on CRF, muscle strength, and walking ability in ambulatory stroke patients.	AT improved cardiorespiratory fitness in stroke patients, suggesting that moderate intensity of 40% to 60% three days a week for 20 weeks should be considered for the greatest effect on all outcomes.
Campo et al.27	2019	5	To review RCTs that applied AE using only a cycle ergometer, in comparison with conventional therapy or other interventions on the functional capacity outcomes of post-stroke patients.	The cycle ergometer did not appear to improve peak VO2 when compared with traditional therapy, such as physiotherapy and ergotherapeutic interventions, stretching activities, and exercise series for upper and lower extremities.
Limaye et al.36	2021	9	To provide an overview of serum biomarkers relevant to neuroplasticity and brain repair and the association between aortic stenosis and serum neuroplasticity in stroke survivors.	AE may potentially increase serum biomarkers of neuroplasticity in stroke survivors. Studies are needed to obtain the modality, intensity, type, frequency, and duration of aerobic exercise at different stages of stroke recovery.
Aguilar et al.23	2021	5	To determine whether the combination of supervised AE and structured cognitive training results in better cognitive performance compared with AE or training involving other strategies.	AE interventions + cognitive treatment improved the Stroop and mental rotation tests, spatial extension, and cognitive responses during walking. Moreover, the combined intervention led to greater improvement compared with motor training + unstructured mental activities.

• BDNF: brain-derived neurotrophic factor; BWSTT: combined with body weight support; CRF: cardiorespiratory fitness; AE: aerobic exercise; IGF-I: insulin-like growth factor I; NGF: nerve growth factor; Speed: retention of changes in walking speed; AT: aerobic training; RT: resistance training; TT: treadmill training; TUG: timed up and go; peak VO₂: peak oxygen consumption; WS: walking speed on the ground.

The review by Lee et al.²⁶ met 13 of the 16 items, corresponding to approximately 81.2%. Disregarded items included the selection of study designs, duplicate data extraction, and funding sources; however, these items do not correspond to critical domains. Thus, the review can be classified as having moderate confidence, since the unfulfilled items present only three non-critical domains and no critical domains. Notably, the review by Campo et al.²⁷ was one of the two studies that rigorously complied with the instrument items, showing high confidence. It addressed 15 of the 16 items on the checklist, totaling 93.7%, omitting only one item related to funding sources of the included studies, which is not considered a critical domain. According to Amstar 2, therefore, the review presents high confidence.

Five studies conducted reviews covering the effects of walking training, with positive results involving gait competence, walking distance, peak VO₂ rate, gait speed, and stride length in moderate- to high-intensity exercise performed on a treadmill or on the ground. Tshiswaka et al.³⁴ observed that training improved walking performance when performed for 30 minutes on the ground or treadmill with body weight support, also using biofeedback, which improved function, gait cycle and swing phase. When performed at high intensity, they improved gait and peak VO₂ rate in post-stroke patients.

According to the methodological evaluation, the study fulfilled only 56.2% of the items, disregarding nine out of 16, which include review methods, risk of bias assessment, selection of duplicate studies, funding sources, and heterogeneity assessment. Of these nine items, three were excluded since the review is not a meta-analysis. Thus, the study by Tshiswaka et al.³⁴ may present critically low confidence, as it fails to address three critical items and three non-critical items.

Another study involving walking competence in post-stroke patients was that of Luo et al.³⁵, with positive results for high-intensity treadmill walking lasting over 12 weeks for at least six months after the stroke, improving distance covered, walking speed, and increasing stride length. Evaluation of methodological quality showed that the study complied with 12 items on Amstar 2, about 75%. Unfulfilled parameters included funding sources, the impact of risk of bias and conflict of interest. Of these, three are considered non-critical items and one critical, thus the study presents low confidence.

Peurala et al.³⁰ and Charalambos et al.³² also addressed aerobic interventions to improve walking in post-stroke patients. Peurala et al.²⁹ reviewed studies that compared walking training with no treatment and walking training with general physiotherapy in chronic stroke patients. Results related to walking training versus no training proved beneficial, with an increase in distance covered by the patients after 12 to 18 sessions, each lasting 30 to 60 minutes. Charalambos et al.³² observed an improved walking speed when interventions were performed up to 16 sessions.

Methodological quality assessment showed that the study by Peurala et al.²⁹ met 11 items, which is equivalent to 68.7% of the total, disregarding funding sources, assessment of bias in individual studies, discussion of observed heterogeneity, investigation of publication bias and conflict of interest, and therefore presents critically low confidence, with three critical items and two non-critical items among those not met.

Charalambos et al.³² met 12 items on the checklist, corresponding to about 75%. However, they failed to consider aspects such as duplicate data extraction, presentation list of excluded studies with respective reasons, funding sources, and assessment of the impact of risk of bias in individual studies on the results. Thus, confidence in the review was assessed as critically low, since two of the unfulfilled items are considered critical, and other two are non-critical.

Regarding improving walking function, Polese et al.²⁸ evaluated the efficacy of treadmill training in immediately improving walking speed and distance. Results indicated a mean increase in walking speed of 0.14 m/s and an increase of 40 meters in the distance covered, with no significant differences between training on land and training on a treadmill.

Regarding methodological evaluation, the study met 10 of the 16 items, corresponding to 62.5%. Overlooked items included duplicate data extraction, funding sources, and conflict of interest. The remaining three items did not apply because the study did not perform a meta-analysis. Thus, the review can be classified as having moderate confidence since there are no critical domains among the non-compliant items.

Two included systematic reviews cover AE effects on neuroplasticity and brain repair post-stroke. Ploughman et al.³⁰ observed an increase in brain-derived neurotrophic factor (BDNF), insulin-like growth factor I (IGF-I), nerve growth factor (NGF), and synaptogenesis in various brain regions when moderate- or high-intensity exercise is performed. Methodological evaluation showed that this article met four of the 16 items, equivalent to only 25% of the total. Overlooked requirements relate to PICO components, review methods, selection of study designs, reasons for excluding articles, detailed characteristics of the included studies, use of a satisfactory technique to assess risk of bias, funding sources, heterogeneity, and items that are not applicable because this is not a meta-analysis. The other three unfulfilled items relate to meta-analyses, and thus were not considered. Thus, this article presents a critically low confidence level since among the unrealized items, five are non-critical and four are critical.

Another study on neuroplasticity is that of Limaye et al.³⁶, who analyzed AE programs that resulted in a significant decrease in the BDNF alteration score (serum biomarkers) after 36 continuous treatment sessions performed for 30 minutes at moderate intensity on a stationary bicycle. Moreover, an AE program performed on a stationary bicycle for 24 sessions, lasting up to 45 minutes, also proved to significantly increase the BDNF change score. IGF-I and vascular endothelial growth factor (VEGF) scores increased in studies comparing different AE groups after 20 minutes of moderate-intensity treadmill exercise.

Regarding the methodological quality review, the article met approximately 50% of the requirements, only eight out of 16 items. Issues that were overlooked include study designs, funding sources, discussion of the impact of bias in individual studies, and reporting of conflicts of interest. Four of the unmatched items are specific to meta-analyses and were therefore disregarded, since the article did not perform a meta-analysis. According to Amstar 2, the study by Limaye et al.³⁶ can be considered of low confidence, as it has three non-critical items and one critical item among those not fulfilled.

SR by Francica et al.³¹ and Kendall et al.³³, which analyzed post-stroke AE protocols, involved treatments performed on a treadmill and cycle ergometer. Both investigated studies whose results showed improvements in cardiorespiratory fitness, walking speed, and overall functional improvement.

Francica et al.³¹ reviewed training programs ranging from four weeks to six months, three to five times a week, using a progressive load of 50%-80%. According to the Amstar checklist, the review met seven of the 16 items, about 43.7%. Disregarded items include risk of bias assessment, inclusion of detailed characteristics of the included studies, satisfactory technique for assessing risk of bias, funding sources, and discussion of possible heterogeneities. Three items were excluded, as the study is not a meta-analysis. As per confidence assessment, the review by Francica et al.³¹ presents a critically low grade as the authors failed to fulfill three critical items and three non-critical items.

Finally, Kendall et al.³³ analyzed the mobility of post-stroke patients undergoing aerobic training, observing beneficial results when treatment ranged from a minimum average of six months to a maximum of 70 months after the stroke, with improvements in walking and gait ability. According to the quality analysis, the review fulfilled only 10 of the 16 items on the checklist, corresponding to 62.5%. Disregarded items refer to funding sources, discussion about the risk of bias in individual studies, analysis of possible heterogeneities, and three non-applicable items since the study is not a meta-analysis. Thus, the study presents a low degree of confidence since, among the unfulfilled items features two non-critical and one critical.

Chart 3
Analysis of Amstar 2 criteria.

	D1	D2	D3	D4	D5	D6	D7	D8	D9	D10	D11	D12	D13	D14	D15	D16	RESULTS
Polese et al. (2013)	+	+	+	-	+	x	-	+	+	x	▲	▲	+	+	▲	x	Moderate
Peruala et al. (2014)	+	-	+	-	+	+	+	-	+	x	+	+	x	x	x	x	Critically low
Ploughman et al. (2014)	X	X	X	-	+	+	x	x	x	x	▲	▲	x	x	▲	+	Critically low
Francica et al. (2014)	+	X	+	-	+	+	+	x	x	x	▲	▲	x	x	▲	+	Critically low
Hasan et al. (2015)	+	X	+	-	+	+	x	x	x	x	▲	▲	x	+	▲	+	Critically low
Charalambos et al. (2015)	+	-	+	-	+	x	x	+	+	x	▲	▲	▲	x	▲	+	Critically low
Mardsen et al. (2015)	X	+	X	-	+	+	+	x	x	x	x	x	x	+	x	+	Critically low
Kendall et al. (2016)	+	+	+	-	+	+	-	x	+	x	▲	▲	x	+	▲	+	Low
Tshiswaka et al. (2017)	+	X	+	-	x	+	+	+	x	x	▲	▲	x	x	▲	+	Critically low
Luo et al. (2020)	+	+	+	+	+	+	+	-	+	x	+	x	x	+	+	x	Low
Luo et al. (2019)	+	+	X	X	+	+	+	+	+	x	+	x	+	+	x	+	Critically low
Lee et al. (2019)	+	+	X	-	+	x	-	+	+	x	+	x	+	+	+	+	Moderate
Campo et al. (2019)	+	+	+	-	+	+	-	-	+	x	+	+	+	+	+	+	High
Limaye et al. (2021)	+	+	X	-	+	+	-	-	+	x	▲	▲	x	x	▲	x	Low
Aguilar et al. (2021)	+	+	+	-	+	+	+	-	-	x	▲	▲	+	+	▲	+	High

• Note: D: Amstar 2 domains; + (positive) in green: yes; − (negative) in yellow: partial; X in red: no; triangle in gray: not applicable.

Chart 4
Overall confidence rating of the review results.

Article	Critical/Non-Critical Domains	Overall confidence rating
Polese et al.28 (2013)	0 / 3	Moderate
Peurala et al.29 (2014)	3 / 2	Critically Low
Ploughman et al.30	4 / 5	Critically Low
Francica et al.31 (2014)	3 / 3	Critically Low
Hasan et al.22 (2015)	3 / 3	Critically Low
Charalambos et al.32 (2015)	2 / 2	Critically Low
Marsden et al.25 (2015)	4 / 5	Critically Low
Kendall et al.33 (2016)	1 / 2	Low
Tshiswaka et al.34 (2017)	3 / 3	Critically Low
Luo et al.24 (2020)	1 / 3	Low
Luo et al.35 (2019)	2 / 3	Critically Low
Lee et al.26 (2019)	0 / 3	Moderate
Campo et al.27 (2019)	0 / 1	High
Limaye et al.36	1 / 3	Low
Aguilar et al.23 (2021)	1 / 0	High

DISCUSSION

We mapped systematic reviews to analyze in which contexts and levels of evidence aerobic exercise among post-stroke patients has been investigated. After critically analyzing the 15 selected studies, the results revealed that over half present poor methodological quality. Only two showed high reliability^23,27 and two, moderate reliability^26,32, according to the Amstar 2 criteria. The remaining 11 articles scored low or critically low reliability.

Campo et al.’s²⁷ systematic review, which included five articles, showed high reliability. The authors analyzed aerobic interventions to improve OV₂ peak using cycle ergometer compared with conventional physical therapy, stretching activities for the lower limbs and exercise series for the upper limbs. All interventions were applied to chronic stroke patients, involving aerobic exercise sessions lasting 10 to 40 minutes at 50% to 70% intensity. This review sample totaled 188 patients, and the results of the six-minute walk test (6MWT) evinced that the exercise bike intervention did not improve functional capacity when compared with other therapeutic modalities. Moreover, beneficial changes in functional capacity can be observed after four to 12 weeks of training and depend on each individual’s initial level of physical fitness.

Three reviews also discuss the correlation between aerobic exercise and functional capacity in post-stroke patients. Lee et al.²⁶, who produced a RS of moderate reliability, evaluated 18 articles and a total sample of 602 participants. All interventions had an average training period of 15 weeks. According to the review findings, after a series of aerobic exercises, participants’ cardiorespiratory fitness increased by 12%, showing a significantly greater improvement in groups under 65. Post-stroke groups with less than two years since onset showed an increase in cardiorespiratory fitness compared with individuals who had been diagnosed with stroke over two years. Training for over 12 weeks resulted in a higher functional capacity when performed at moderate intensity, from 40% to 60%, three times a week, with no differences between supervised and unsupervised interventions.

Marsden et al.²⁵ and Luo et al.²⁴ also analyzed the functional capacity of individuals submitted to aerobic exercises and, compared with Campo et al.²⁷ and Lee et al.²⁶, present low reliability. According to Luo et al.²⁴, post-stroke patients exhibit improved functional capacity when aerobic training is performed at high intensity; they reported no significant differences between stroke phases, exercise mode, or duration, contradicting the findings of Campo et al.²⁷ and Lee et al.²⁶. Marsden et al.²⁵ observed an improvement of about 10% to 15% in functional capacity after mixed aerobic exercise, but did not clarify the intensity, frequency or duration of the interventions, thus scoring as critically low reliability.

Evidence suggests that post-stroke patients present decreased cardiorespiratory fitness due to physical limitations and the adoption of a sedentary lifestyle³⁷. As such, aerobic exercise has been included in the rehabilitation process of these individuals to improve functional capacity, gait and physical conditioning. As reduced levels of cardiovascular fitness are related to functional performance, it is imperative to emphasize moderate to high-intensity aerobic exercise in rehabilitation programs³⁸.

Another SR that showed good methodological quality was that of Polese et al.²⁸, who analyzed the effectiveness of treadmill training in improving walking speed and distance in post-stroke individuals, involving 275 participants and comparing between treadmill training versus no intervention. Their results showed that treadmill training increased walking speed by 0.12m/s. The immediate effect of short-distance treadmill training was an increase in walking distance of 40 meters compared with interventions that did not involve walking. Participants were aged between 50 and 74 years, with a post-stroke period ranging from 10 to 27 months. All interventions lasted from three to 26 weeks.

Research shows that the functional walking performance of post-stroke individuals improves significantly in terms of increased walking distance and walking speed following aerobic treadmill interventions consisting of up to 35 sessions, three times a week, lasting 70 minutes³⁹. Another study found that combining aerobic exercises with gait training brings positive results in terms of quality of life, gait speed, and better performance in climbing stairs when the exercises are performed for 60 to 90 minutes, three times a week⁴⁰.

In contrast to these findings, Charalambos et al.³² examined improvements in walking ability among post-stroke individuals following treadmill-based interventions and found evidence of increased walking speed in those who had suffered a stroke less than six months prior and had completed fewer than 30 sessions; however, this study has critically low reliability.

According to the RS of Aguilar et al.²³, which is characterized by high methodological reliability and analyzed interventions involving aerobic exercise and cognitive training in post-stroke patients, the combined intervention yielded better results in terms of mental flexibility compared with aerobic training alone.

Penna et al.⁴¹ corroborate that aerobic exercise associated with cognitive training presents beneficial results in relation to cognitive assessment, promoting neuroplasticity. Another study also reports that aerobic training can increase serum levels of neurotrophic factors. In post-stroke animal models, this change was observed when exercises were performed at moderate to high intensity in interventions involving eight weeks of aerobic training, three times a week, leading to cognitive benefits, including improved motor learning³⁸.

in a random-sample study, Wen et al.³⁹ point to considerable evidence that key information is often misreported in systematic reviews, thereby diminishing their potential usefulness. Thus, systematic reviews should be reported in a comprehensive and transparent manner to allow readers to assess the strengths and weaknesses of the research.

The overview provided by this mapping is essential for clinical practice, since most of the included studies showed poor methodological quality, as assessed by the AMSTAR 2 checklist. Although these studies have been published and can serve as references, their low quality may compromise the effectiveness of interventions, leading to the inefficient use of resources, the adoption of inappropriate therapeutic approaches, and, most importantly, adverse health outcomes for patients undergoing rehabilitation focused on post-stroke aerobic conditioning.

CONCLUSION

From this study, we conclude that aerobic exercise represents a promising rehabilitation resource for post-stroke patients. Based on the methodological analysis, the articles considered the most reliable and safe for application in clinical practice refer to aerobic training associated with improved functional capacity by combining different therapeutic modalities; cognitive training combined with aerobic exercises; and aerobic exercises aimed at improving walking distance. These reviews showed relevant benefits according to the individuals’ limitations, presenting reliability levels classified as moderate and high according to the methodological criteria. Considering that systematic reviews are subject to bias, researchers and health professionals should adopt rigorous strategies to identify and evaluate high-quality reviews, being able to distinguish them appropriately before supporting any clinical decision-making.

ACKNOWLEDGMENTS

We sincerely thank everyone who, directly or indirectly, contributed to this work by offering intellectual support, encouragement and listening throughout the process. We also express our gratitude to the Fisioterapia e Pesquisa journal for welcoming and publicizing a topic that captivates and inspires us as researchers and professionals in the area.

DATA AVAILABILITY

The data underlying this study are available in the published article.

REFERENCES

• ¹ Schmidt MH, Selau CM, Soares PS, Franchi EF, Piber VD, Quatrin LB. Acidente vascular cerebral e diferentes limitações: uma análise interdisciplinar. Arq Ciênc Saúde UNIPAR. 2019;23(2):139-44. doi: 10.25110/arqsaude.v23i2.2019.6404
  » https://doi.org/10.25110/arqsaude.v23i2.2019.6404
• ² Santos LB, Waters C. Perfil epidemiológico dos pacientes acometidos por acidente vascular cerebral: revisão integrativa. Braz J Develop. 2020;6(1):2749-75. doi: 10.34117/bjdv6n1-198
  » https://doi.org/10.34117/bjdv6n1-198
• ³ Pompermaier C, Ferreira AP, Boiani LE, Pereira YCLV. Fatores de risco para o acidente vascular cerebral (AVC). APExxe [Internet]. 2020 [cited 2026 Mar 3];5:e24365. Available from: https://periodicos.unoesc.edu.br/apeux/article/view/24365
  » https://periodicos.unoesc.edu.br/apeux/article/view/24365
• ⁴ Pauli E, Leite MT, Bornholdt L, Hildebrandt LM, Kinalski SS, Beuter M. O viver de idosos após o acidente vascular cerebral. Rev Enferm UFSM. 2020;10:e29. doi: 10.5902/2179769239070
  » https://doi.org/10.5902/2179769239070
• ⁵ Vaz DWN, Evangelista HI, Pontes LC, Silva JB, Rezende RWS, et al. Epidemiological profile of stroke in the State of Amapá, Brazil. Res Soc Develop. 2020;9(8):e938986642. doi: 10.33448/rsd-v9i8.6642
  » https://doi.org/10.33448/rsd-v9i8.6642
• ⁶ Psaty BM, Koepsell TD, Manolio TA, Longstreth WT, Wagner EH, et al. Risk ratios and risk differences in estimating the effect of risk factors for cardiovascular disease in the elderly. J Clin Epidemiol. 1990;43(9):961-70. doi: 10.1016/0895-4356(90)90079-5
  » https://doi.org/10.1016/0895-4356(90)90079-5
• ⁷ Ovando AC, Michaelsen SM, Dias JA, Herber V. Treinamento de marcha, cardiorrespiratório e muscular após acidente vascular encefálico: estratégias, dosagens e desfechos. Fisioter Mov. 2010;23(2):253-69. doi: 10.1590/S0103-51502010000200009
  » https://doi.org/10.1590/S0103-51502010000200009
• ⁸ Barros AS, Santos SG, Medeiros GFR, Melo LPS. Análise de intervenções fisioterapêuticas na qualidade de vida de pacientes pós-AVC. Rev Neurocienc. 2014;22(2):308-14. doi: 10.34024/rnc.2014.v22.8107
  » https://doi.org/10.34024/rnc.2014.v22.8107
• ⁹ Ada L, Dean CM, Morris ME. Supported treadmill training to establish walking in non-ambulatory patients early after stroke. BMC Neurol. 2007;7(1):29. doi: 10.1186/1471-2377-7-29
  » https://doi.org/10.1186/1471-2377-7-29
• ¹⁰ Carmo SH, Paiva LDS, Adami F, Leitao FNC, Rebougas CMDP, et al. Relationship between motor-cognitive functions and hemodynamic response of individuals with chronic stroke during and after an acute bout of aerobic exercise. J Hum Growth Develop. 2022;31(2):267-82. doi: 10.36311/jhgd.v31.12223
  » https://doi.org/10.36311/jhgd.v31.12223
• ¹¹ Coelho VM, Silva KMR, Ferreira LRNB, Santos RCCS. Alterações cardiorrespiratórias em indivíduos hemiparéticos crônicos pós-acidente vascular cerebral. Rev Soc Bras Clín Méd. 2020 [cited 2026 Mar 3];18(3):130-3. Available from: https://www.sbcm.org.br/ojs3/index.php/rsbcm/article/view/755/416
  » https://www.sbcm.org.br/ojs3/index.php/rsbcm/article/view/755/416
• ¹² Ministério da Saúde (BR). Diretrizes de Atenção à Reabilitação da Pessoa com Acidente Vascular Cerebral [Internet]. Brasília, DF: Ministério da Saúde; 2013 [cited 2026 Mar 3]. Available from: https://www.gov.br/saude/pt-br/assuntos/saude-de-a-a-z/s/saude-da-pessoa-com-deficiencia/publicacoes/diretrizes-de-atencao-a-reabilitacao-da-pessoa-com-acidente-vascular-cerebral.pdf
  » https://www.gov.br/saude/pt-br/assuntos/saude-de-a-a-z/s/saude-da-pessoa-com-deficiencia/publicacoes/diretrizes-de-atencao-a-reabilitacao-da-pessoa-com-acidente-vascular-cerebral.pdf
• ¹³ Zaqueline FG, Eduardo CM, Vieira Júnior PRM, Soares PA. Avaliação da capacidade funcional pós acidente vascular cerebral (AVC). Rev Bras Ciênc Méd Saúde. 2017;5(5):1-5. doi: 10.5935/2674-7960.v5-0001
  » https://doi.org/10.5935/2674-7960.v5-0001
• ¹⁴ Moreira NRTL, Andrade AS, Ribeiro KSQS, Nascimento JA, Brito GEG. Qualidade de vida em indivíduos acometidos por acidente vascular cerebral. Rev Neurocienc. 2015;23(4):530-7. doi: 10.4181/RNC.2015.23.04.1036.08p
  » https://doi.org/10.4181/RNC.2015.23.04.1036.08p
• ¹⁵ Wendel-Vos GCW, Schuit AJ, Feskens E, Boshuizen HC, Verschuren W, et al. Physical activity and stroke. A meta-analysis of observational data. Int J Epidemiol. 2004;33(4):787-98. doi: 10.1093/ije/dyh168
  » https://doi.org/10.1093/ije/dyh168
• ¹⁶ Mota RS, Benvenuto MC, Klautau AV, Silva IL, Cardoso FB, et al. Avaliação da eficácia do exercício aeróbico na reabilitação de pacientes com marcha hemiparética. Fisioter Bras. 2010;11(4):1-6. doi: 10.33233/fb.v11i4.1397
  » https://doi.org/10.33233/fb.v11i4.1397
• ¹⁷ Shea BJ, Reeves BC, Wells G, Thuku1 M, Hamel C, et al. Amstar 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ. 2017(358):j4008. doi: 10.1136/bmj.j4008
  » https://doi.org/10.1136/bmj.j4008
• ¹⁸ Donato H, Donato M. Stages for undertaking a systematic review. Acta Med Port. 2019;32(3):227-35. doi: 10.20344/amp.11923
  » https://doi.org/10.20344/amp.11923
• ¹⁹ Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, et al, editors. Manual Cochrane para revisões sistemáticas de intervenções, versão 6.3 (atualizado em fevereiro de 2022). London: Cochrane; 2022.
• ²⁰ Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, et al. A declaração PRISMA 2020: diretriz atualizada para relatar revisões sistemáticas. Rev Panam Salud Publica. 2022;30(46):e112. doi: 10.26633/RPSP.2022.112
  » https://doi.org/10.26633/RPSP.2022.112
• ²¹ Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, et al. Development of Amstar: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol. 2007;7(1):1-7. doi: 10.1186/1471-2288-7-10
  » https://doi.org/10.1186/1471-2288-7-10
• ²² Hasan SMM, Rancourt SN, Austin MW, Ploughman M. Defining optimal aerobic exercise parameters to affect complex motor and cognitive outcomes after stroke: a systematic review and synthesis. Neural Plast. 2016;2016(6):2961573. doi: 10.1155/2016/2961573
  » https://doi.org/10.1155/2016/2961573
• ²³ Aguilar LA, Quiroga ER, Santolaya SS, Coll-Andreu M, Paolucci S, et al. Effects of combined interventions with aerobic physical exercise and cognitive training on cognitive function in stroke patients: a systematic review. Brain Sci. 2021;11(4):473. doi: 10.3390/brainsci11040473
  » https://doi.org/10.3390/brainsci11040473
• ²⁴ Luo L, Meng H, Wang Z, Zhu S, Yuan S, et al. Effect of high-intensity exercise on cardiorespiratory fitness in stroke survivors: A systematic review and meta-analysis. Ann Phys Rehabil Med. 2020;63(1):59-68. doi: 10.1016/j.rehab.2019.07.006
  » https://doi.org/10.1016/j.rehab.2019.07.006
• ²⁵ Marsden DL, Dunn A, Callister R, Levi CR, Spratt NJ. Characteristics of exercise training interventions to improve cardiorespiratory fitness after stroke: a systematic review with meta-analysis. Neurorehabil Neural Repair. 2013;27(9):775-88. doi: 10.1177/1545968313496329
  » https://doi.org/10.1177/1545968313496329
• ²⁶ Lee J, Stone AJ. Combined aerobic and resistance training for cardiorespiratory fitness, muscle strength, and walking capacity after stroke: a systematic review and meta-analysis. J Stroke Cerebrovasc Dis. 2020;29(1):104498. doi: 10.1016/j.jstrokecerebrovasdis.2019.104498
  » https://doi.org/10.1016/j.jstrokecerebrovasdis.2019.104498
• ²⁷ Campo L, Hauck M, Allein M, Marcolino Z, Pinheiro D, et al. Effects of aerobic exercise using cycle ergometry on balance and functional capacity in post-stroke patients: a systematic review and meta-analysis of randomised clinical trials. Disabil Rehabil. 2021;43(11):1558-64. doi: 10.1080/09638288.2019.1670272
  » https://doi.org/10.1080/09638288.2019.1670272
• ²⁸ Polese JC, Ada L, Dean CM, Nascimento LR, Teixeira-Salmela LF. Treadmill training is effective for ambulatory adults with stroke: a systematic review. J Physiother. 2013;59(2):73-80. doi: 10.1016/S1836-9553(13)70159-0
  » https://doi.org/10.1016/S1836-9553(13)70159-0
• ²⁹ Peurala SH, Karttunen AH, Sjögren T, Paltamaa J, Heinonen A. Evidence for the effectiveness of walking training on walking and self-care after stroke: a systematic review and meta-analysis of randomized controlled trials. J Rehabil Med. 2014;46(5):387-99. doi: 10.2340/16501977-1805
  » https://doi.org/10.2340/16501977-1805
• ³⁰ Ploughman M, Austin MW, Glynn L, Corbett D. The effects of poststroke aerobic exercise on neuroplasticity: a systematic review of animal and clinical studies. Transl Stroke Res. 2015;6(1):13-28. doi: 10.1007/s12975-014-0357-7
  » https://doi.org/10.1007/s12975-014-0357-7
• ³¹ Francica JV, Bigongiari A, Mochizuki L, Miranda MLJ, Rodrigues B. Aerobic program in persons with stroke: a systematic review. Acta Med Port. 2014;27(1):108-15. doi: 10.20344/amp.4900
  » https://doi.org/10.20344/amp.4900
• ³² Charalambos CC, Bonilha HS, Kautz SA, Gregory CM, Bowden MG. Rehabilitating walking speed poststroke with treadmill-based interventions: a systematic review of randomized controlled trials. Neurorehabil Neural Repair. 2013;27(8):709-21. doi: 10.1177/1545968313491005
  » https://doi.org/10.1177/1545968313491005
• ³³ Kendall BJ, Gothe NP. Effect of aerobic exercise interventions on mobility among stroke patients: a systematic review. Am J Phys Med Rehabil. 2016;95(3):214-24. doi: 10.1097/PHM.0000000000000416
  » https://doi.org/10.1097/PHM.0000000000000416
• ³⁴ Tshiswaka DI, Bennett C, Franklin C. Effects of walking trainings on walking function among stroke survivors: a systematic review. Int J Rehabil Res. 2017;41(1):1-13. doi: 10.1097/MRR.0000000000000250
  » https://doi.org/10.1097/MRR.0000000000000250
• ³⁵ Luo L, Zhu S, Shi L, Wang P, Li M, et al. High intensity exercise for walking competency in individuals with stroke: a systematic review and meta-analysis. J Stroke Cerebrovasc Dis. 2019;28(12):104414. doi: 10.1016/j.jstrokecerebrovasdis.2019.104414
  » https://doi.org/10.1016/j.jstrokecerebrovasdis.2019.104414
• ³⁶ Limaye NS, Carvalho LB, Kramer S. Effects of aerobic exercise on serum biomarkers of neuroplasticity and brain repair in stroke: a systematic review. Arch Phys Med Rehabil. 2021;102(8):1633-44. doi: 10.1016/j.apmr.2021.04.010
  » https://doi.org/10.1016/j.apmr.2021.04.010
• ³⁷ Barros AFS, Santos SG, Medeiros GFR, Melo LP. Análise de intervenções fisioterapêuticas na qualidade de vida de pacientes pós-AVC. Rev Neurociênc. 2014;22(2):308-14. doi: 10.34024/rnc.2014.v22.8107
  » https://doi.org/10.34024/rnc.2014.v22.8107
• ³⁸ Mota RS, Bitencourt JS, Conceição TMA, Cardoso FB, Silva IL, et al. Avaliação do efeito do exercício aeróbico na marcha de indivíduos hemiparéticos. R Bras Cienc Mov. 2011;19(2):45-51. doi: 10.18511/rbcm.v19i2.1096
  » https://doi.org/10.18511/rbcm.v19i2.1096
• ³⁹ Wen J, Ren Y, Wang L, Li Y, Liu Y, et al. The reporting quality of meta-analyses improves: a random sampling study. J Clin Epidemiol. 2008;61(8):770-5. doi: 10.1016/j.jclinepi.2007.10.008
  » https://doi.org/10.1016/j.jclinepi.2007.10.008
• ⁴⁰ Merege Filho CAA, Alves CRR, Sepúlveda CA, Costa AS, Lancha Junior AH, et al. Influência do exercício físico na cognição: uma atualização sobre mecanismos fisiológicos. Rev Bras Med Esporte. 2014;20(3):237-41. doi: 10.1590/1517-86922014200301930
  » https://doi.org/10.1590/1517-86922014200301930
• ⁴¹ Penna LG, Pinheiro JP, Ramalho SHR, Ribeiro CF. Effects of aerobic physical exercise on neuroplasticity after stroke: systematic review. Arq Neuropsiquiatr. 2021;79(9):832-43. doi: 10.1590/0004-282X-ANP-2020-0551
  » https://doi.org/10.1590/0004-282X-ANP-2020-0551

• Financing source:
  nothing to declare

Edited by

• Responsible editor:
  Sônia LP Pacheco de Toledo

Publication Dates

• Publication in this collection
  22 June 2026
• Date of issue
  2026

History

• Received
  28 Sept 2023
• Accepted
  05 Aug 2025