Ming-De Chen and James H.

Rimmer
Effects of Exercise on Quality of Life in Stroke Survivors: A Meta-Analysis
Print ISSN: 0039-2499. Online ISSN: 1524-4628
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doi: 10.1161/STROKEAHA.110.607747
2011;42:832-837; originally published online February 3, 2011; Stroke.
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Progress Review
Effects of Exercise on Quality of Life in Stroke Survivors
A Meta-Analysis
Ming-De Chen, MS, OT; James H. Rimmer, PhD
Background and PurposeOne of the major consequences after stroke is the deterioration in health-related quality of life
(HRQOL). Three previous systematic reviews indicated that exercise has limited to no effect in improving HRQOL in
stroke survivors. The objective of this meta-analysis was to update the evidence on exercise and HRQOL in stroke
survivors with additional new information on randomized controlled trials that have been published since these 3
previous reviews.
MethodsMEDLINE, Cumulated Index to Nursing and Allied Health Literature, EMBASE, and SportsDiscus databases
were searched for randomized controlled trials reporting the effects of exercise on HRQOL in stroke survivors from
1950 to March 2010. The methodological quality of each study was appraised using the Physiotherapy Evidence
Database scale. Standardized mean difference was used to compute effect size and subgroup analysis was conducted to
test the consistency of results across the subgroups with different characteristics.
ResultsA total of 1101 citations was identified and 9 studies met all criteria for a total sample of 426 stroke survivors.
Eight studies were rated as good quality (ie, Physiotherapy Evidence Database scale 5). This meta-analysis provided
evidence that exercise can have a small to medium effect on HRQOL outcomes (standardized mean difference, 0.32,
P0.01) at postintervention but not at follow-up after exercise was terminated (standardized mean difference, 0.17,
P0.12). No adverse events related to exercise were reported.
ConclusionsThe results provide moderate support for the use of exercise to improve HRQOL in stroke survi-
vors. However, the challenge for researchers is identifying effective strategies for sustaining these effects
postintervention. (Stroke. 2011;42:832-837.)
Key Words: exercise

meta-analysis

quality of life

stroke

systematic review
S
troke survivors report a poorer health-related quality of
life (HRQOL) compared with the general population.
13
Although HRQOL is a multidimensional concept, it is usually
measured by physical or mental attributes associated with
overall health status.
4,5
For stroke survivors, the physical
attributes of HRQOL include the interference they perceive in
performing physical activities such as the ability to walk 1
block or by responses to pain levels associated with perform-
ing activities (eg, work outside the home and housework),
4,5
and mental attributes are often measured by the perception of
subjective feelings of interference in participating in social
activities.
4,5
Exercise may offset some of the decline in HRQOL in
stroke survivors by (1) reducing secondary conditions such
depression and pain; and/or (2) improving overall physical
fitness, which leads to higher levels of physical function (eg,
greater self-efficacy in performing activities of daily living).
6
The dozen or so systematic reviews that have been published
on the effects of exercise in stroke survivors
719
have focused
almost entirely on physiological changes such as walking
speed and duration,
714,16,17,19
cardiorespiratory fitness,
14,16,18
and muscle strength.
9,11,14,15,17,18
There have only been 3 systematic reviews
14,18,19
on the
effects of exercise on changes associated with HRQOL in
stroke survivors. All of these reviews concluded that the
evidence before 2007 for using exercise to improve HRQOL
in stroke survivors is limited or absent. However, since 2007,
several investigators have examined the effects of exercise on
HRQOL in stroke survivors.
2022
Given the importance of
HRQOL as a primary outcome of rehabilitation and exercise
training programs for stroke survivors,
6
the purpose of this
meta-analysis was to examine the effects of various doses and
types of exercise on HRQOL in stroke survivors that would
support or refute the findings from the 3 previous systematic
reviews.
Methods
Literature searches of 4 computer databases were performed.
MEDLINE (1950 to March 2010), Cumulated Index to Nursing and
Received November 2, 2010; final revision received December 13, 2010; accepted December 14, 2010.
From the Department of Disability and Human Development (M.D.C.), University of Illinois at Chicago and the Department of Disability and Human
Development (J.H.R.), University of Illinois at Chicago & Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL.
The online-only Data Supplement is available at http://stroke.ahajournals.org/cgi/content/full/STROKEAHA.110.607747/DC1.
Correspondence to James H. Rimmer, PhD, Director, National Center on Physical Activity and Disability, Department of Disability and Human
Development, University of Illinois at Chicago. 1640 West Roosevelt Road, Chicago, IL 60608-6904. E-mail jrimmer@uic.edu
2011 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org DOI: 10.1161/STROKEAHA.110.607747
832 by guest on May 30, 2014 http://stroke.ahajournals.org/ Downloaded from
Allied Health Literature (CINAHL, 1982 to March 2010), EMBASE
(1980 to March 2010), and SportsDiscus (1968 to March 2010) were
searched by the combinations of subject headings and key words
related to stroke and exercise. Search terms are listed in Supplemen-
tal Table I (available at http://stroke.ahajournals.org). The reference
lists of relevant studies were also manually searched.
Studies were included if they met the following criteria: (1)
recruited only stroke survivors 19 years of age; (2) no other
disability groups were included in the study; (3) exercise was the
primary intervention exposure; (4) HRQOL was a targeted outcome;
(5) randomized controlled trial; (6) published in English; and (7)
published in a peer-reviewed journal. HRQOL was defined as 1
physical and/or mental attributes associated with overall health
status. Common examples of instruments that include HRQOL
measures are the Short Form-36 and Stroke Impact Scale.
4
Exclusion
criteria included: (1) therapy/rehabilitation interventions (eg, body
weight supported treadmill training); (2) nonexercise treatment
approaches (eg, psychotherapy); (3) no adequate data on effect size
estimation; and (4) qualitative or case study.
Methodological quality of each study was established with the
Physiotherapy Evidence Database Scale (PEDro scale)
23
(www.
pedro.org.au). The PEDro scale is a valid and reliable measurement
tool that is widely used in the exercise and rehabilitation research
literature to rate the quality of intervention research. It consists of 1
nonscored item for examining external validity (ie, eligibility crite-
ria) and 10 scored items for appraising internal validity and quality
of statistical reporting. The 10 items include random allocation,
concealed allocation, baseline similarity, blinding of participants,
therapists, assessors, dropout rate, intention-to-treat analysis,
between-group statistical comparisons, point measures, and mea-
sures of variability.
Statistical Analysis
The standardized mean difference was used to compute effect size
(ES). Standardized mean difference was calculated as the mean
change before and after the exercise intervention minus the mean
change for the control group divided by the preintervention pooled
standard deviation.
24
Because the standardized mean difference is
prone to overestimating ES for individual studies with small sam-
ples, Hedges g was used to correct this bias.
24
For studies with 1
ES (eg, multiple HRQOL outcomes), an average ES was calculated
that represented the general effect of the intervention.
25
An initial meta-analysis was performed to examine the overall
effects of the exercise exposure on HRQOL using Comprehensive
Meta-Analysis, Version 2.0. Separate meta-analyses were also con-
ducted under the 2 subdomains (physical and mental) of HRQOL.
The magnitude of the ES was classified as small (0.20), medium
(0.21 to 0.79), or large (0.80).
26
The Q statistic was used to determine heterogeneity among ESs,
and the I
2
statistic was used to measure the degree of variation.
27,28
When heterogeneity was identified, a random effects model was used
to aggregate the ESs to adjust for variance from subject-level
sampling error and random differences among studies.
25
Planned
subgroup analyses were conducted to test the consistency of results
across the subgroups with different time since stroke (6 months
versus 6 months) and intervention characteristics. The intervention
characteristics included mode of exercise, weekly amount of exercise
that met the US Physical Activity Guidelines (150 minutes/week
versus 150 minutes/week),
29
length of intervention (12 weeks
versus 12 weeks), intervention format (individual versus group),
and intervention setting (clinical versus community-based).
Results
Figure 1 summarizes the study selection process. The data-
base search resulted in the identification of 1101 citations. A
total of 9 randomized controlled trials met all
criteria.
2022,3035
The characteristics of the 9 studies are listed in Supple-
mental Table II. Eight studies were ranked as good quality
(ie, PEDro 5)
2022,3034
and 1 study was ranked as fair
quality (ie, PEDro 4).
35
A total of 426 stroke survivors were
included across the 9 studies, ranging from 13 to 93 subjects.
The mean age of participants was 66.93.4 years (range, 61
to 72 years), and the mean time since stroke was 26.735.8
months (range, 2.2 to 109 months).
Most of the researchers used a combination of aerobic,
strength, balance, and/or flexibility training (N6).
21,3135
Retrieved 1101 citations using four databases
MEDLINE N=250
CINAHL N=390
SportsDiscus N=158
EMBASE N=303
Reviewed title and abstract of studies
N=833
Excluded 268 duplicate studies
Reviewed studies in full -text level
N=100
Studies with outcomes on HRQOL
N=17
Excluded 83 Studies
No outcomes on HRQOL N=58
Therapeutic exercise N=9
Other non-exercise approach N=5
Case study N=3
Without randomization N=3
Not an intervention study N=2
Included people with other
disabilities N=1
Not a full article N=1
Review article N=1
Studies included for meta-analysis
N=9
Excluded 733 irrelevant studies
Excluded 8 Studies
without data on ES
No between-group contrast
data N=4
Not compared to non-exercise
control group N=4
Figure 1. Flow chart depicting the num-
ber of included and excluded studies.
Chen and Rimmer Exercise on Quality of LifeMeta-Analysis 833
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The mean length of the exercise interventions was 10.42.6
weeks (range, 4 to 12 weeks). Most of the interventions were
implemented 3 times per week (N7) and the average
duration per session was 67.925.1 minutes (range, 30 to 90
minutes). Researchers associated with 4 of the studies
21,22,33,35
monitored adverse events during the intervention and none
were reported.
Five different HRQOL instruments were used across
studies. Five studies
21,3134
used the Short Form-36 and 4
studies
20,22,32,34
used the Stroke Impact Scale. Additional
instruments included the Nottingham Health Profile,
35
Stroke-Adapted Sickness Impact Profile,
30
and Recovery
Locus of Control Scale.
22
Six studies
20,22,30,3234
examined
intervention effects at follow-up, which ranged from 12 to
24 weeks postintervention.
Effects on HRQOL
Figure 2 shows the 9 studies
2022,3035
that examined the
effects of exercise at postintervention. The results from a
fixed effect model showed a significant small to medium ES
on overall HRQOL outcomes (grand ES, 0.32; 95% CI, 0.12
to 0.51; P0.01; I
2
0%).
Figure 3 highlights the 6 studies
20,22,30,3234
that examined
intervention effects at follow-up (12 to 24 weeks postinter-
vention). A fixed effect model showed a nonsignificant small
ES at follow-up on HRQOL outcomes (grand ES, 0.17; 95%
CI, 0.05 to 0.39; P0.12; I
2
8.36%).
Figure 4 presents the results of separate meta-analyses on
the physical and mental subdomains of HRQOL. There was a
significant positive ES (grand ES, 0.33; P0.02) on the
physical subdomain at postintervention (ie, self-reported
changes on strength, bodily pain, and activities of daily
living). A similar significant ES (grand ES, 0.23; P0.04)
was found on the mental subdomain at postintervention (ie,
self-reported changes on mood and social participation). At
follow-up, the effects of exercise declined and there were no
significant ESs on both subdomains of HRQOL (grand ES,
0.01; P0.98 for physical subdomain; 0.19; P0.11 for
mental subdomain).
Subgroup Analysis
Figure 5 shows the results of planned subgroup analyses for
exercise effects on HRQOL at postintervention. Strength
training and interventions that combined aerobic and strength
training protocols achieved significant effects, whereas the
interventions that used aerobic training only did not result in
significant changes on HRQOL. There was a significant
effect for the exercise interventions implemented in
community-based settings (N5) and for studies with dura-
tions 150 minutes per week (N5). There was a nonsig-
nificant effect for the exercise interventions conducted in
clinical settings and for those 150 minutes per week.
However, the differences did not reach statistical significance
for mode of exercise, weekly amount of exercise, and setting.
Chronic stroke survivors (ie, time since stroke 6 months)
experienced greater benefits than subacute stroke survivors
(ie, 6 months) but the difference was not significant
(P0.64). Nonsignificant differences in effects were also
found for intervention length (12 weeks versus 12 weeks;
P0.46) and format (individual versus group; P0.92).
Discussion
Among the 3 previous systematic reviews that were con-
ducted on exercise and HRQOL in stroke survivors before
2007, 2 reviews
14,19
concluded that there was limited evi-
dence and 1 review
18
found no evidence to support the use of
exercise in improving HRQOL in this population. Since
2007, there have been 3 additional randomized controlled
trials
2022
that examined the effects of exercise in improving
HRQOL in stroke survivors. The results of our meta-analysis
include these 3 more recent studies and provide new evidence
that exercise training has a small to medium statistically
Study name Hedges g and 95% CI Hedges g
Lower Upper Relative
limit limit Weight(%)
Ada, 2003 -0.27 -1.04 0.50 6.45
Duncan, 1998 0.28 -0.57 1.13 5.36
Flansbjer, 2008 0.39 -0.41 1.20 5.90
Lai, 2006 0.36 -0.05 0.77 22.75
Lee, 2008 0.14 -0.63 0.92 6.37
Mead, 2007 0.24 -0.24 0.72 16.60
Sims, 2009 0.72 0.12 1.32 10.62
Studenski, 2005 0.24 -0.17 0.65 22.75
Teixeira-Salmela, 1999 1.05 -0.04 2.14 3.22
0.32 0.12 0.51
-2.00 -1.00 0.00 1.00 2.00
Favours Control Favours Exercise
Study name Hedges g and 95% CI Hedges g
Lower Upper Relative
limit limit Weight(%)
Ada, 2003 -0.27 -1.04 0.50 6.45
Duncan, 1998 0.28 -0.57 1.13 5.36
Flansbjer, 2008 0.39 -0.41 1.20 5.90
Lai, 2006 0.36 -0.05 0.77 22.75
Lee, 2008 0.14 -0.63 0.92 6.37
Mead, 2007 0.24 -0.24 0.72 16.60
Sims, 2009 0.72 0.12 1.32 10.62
Studenski, 2005 0.24 -0.17 0.65 22.75
Teixeira-Salmela, 1999 1.05 -0.04 2.14 3.22
0.32 0.12 0.51
-2.00 -1.00 0.00 1.00 2.00
Favours Control Favours Exercise
Study name Hedges g and 95% CI Hedges g
Lower Upper Relative
limit limit Weight(%)
Ada, 2003 -0.27 -1.04 0.50 6.45
Duncan, 1998 0.28 -0.57 1.13 5.36
Flansbjer, 2008 0.39 -0.41 1.20 5.90
Lai, 2006 0.36 -0.05 0.77 22.75
Lee, 2008 0.14 -0.63 0.92 6.37
Mead, 2007 0.24 -0.24 0.72 16.60
Sims, 2009 0.72 0.12 1.32 10.62
Studenski, 2005 0.24 -0.17 0.65 22.75
Teixeira-Salmela, 1999 1.05 -0.04 2.14 3.22
0.32 0.12 0.51
-2.00 -1.00 0.00 1.00 2.00
Favours Control Favours Exercise
Figure 2. Meta-analysis of exercise interventions
on HRQOL at postintervention. Heterogeneity: Q
value6.22; df(Q)8 (P0.62); I
2
0%, indicating
the presence of homogeneity.
Study name Hedges g and 95% CI
Lower Upper Relative
Hedges g limit limit Weight (%)
Ada, 2003 0.05 -0.69 0.80 8.62
Flansbjer, 2008 0.58 -0.24 1.39 7.20
Lai, 2006 0.09 -0.35 0.52 25.28
Mead, 2007 0.01 -0.47 0.49 20.76
Sims, 2009 0.74 0.13 1.35 12.86
Studenski, 2005 0.02 -0.41 0.46 25.28
0.17 -0.05 0.39
-2.00 -1.00 0.00 1.00 2.00
Favours Control Favours Exercise
Study name Hedges g and 95% CI
Lower Upper Relative
Hedges g limit limit Weight (%)
Ada, 2003 0.05 -0.69 0.80 8.62
Flansbjer, 2008 0.58 -0.24 1.39 7.20
Lai, 2006 0.09 -0.35 0.52 25.28
Mead, 2007 0.01 -0.47 0.49 20.76
Sims, 2009 0.74 0.13 1.35 12.86
Studenski, 2005 0.02 -0.41 0.46 25.28
0.17 -0.05 0.39
-2.00 -1.00 0.00 1.00 2.00
Favours Control Favours Exercise
Study name Hedges g and 95% CI
Lower Upper Relative
Hedges g limit limit Weight (%)
Ada, 2003 0.05 -0.69 0.80 8.62
Flansbjer, 2008 0.58 -0.24 1.39 7.20
Lai, 2006 0.09 -0.35 0.52 25.28
Mead, 2007 0.01 -0.47 0.49 20.76
Sims, 2009 0.74 0.13 1.35 12.86
Studenski, 2005 0.02 -0.41 0.46 25.28
0.17 -0.05 0.39
-2.00 -1.00 0.00 1.00 2.00
Favours Control Favours Exercise
Figure 3. Meta-analysis of exercise interventions
on HRQOL at follow-up. Heterogeneity: Q val-
ue5.46; df (Q)5 (P0.36); I
2
8.36%, indicating
the presence of homogeneity.
834 Stroke March 2011
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significant positive effect in improving HRQOL in stroke
survivors. Furthermore, this study is the first meta-analysis to
examine the effects of exercise on both the physical and
mental subdomains of HRQOL in stroke survivors.
The 3 previous reviews found that strength training-only
intervention did not change HRQOL significantly. The effect
on HRQOL for combined exercise (aerobic plus strength)
was inconclusive. One review
18
found that combined exercise
did not have a significant effect on HRQOL, but another
review
14
found that combined exercise resulted in a signifi-
cant effect in improving basic and instrumental activities of
daily living. This meta-analysis found that both strength
training only and combined exercise had a significant effect
on HRQOL. Furthermore, the positive effect covered several
physical subdomain outcomes of HRQOL, including
strength, bodily pain, hand function, mobility, and general
physical health.
The 3 previous reviews did not report outcomes associated
with the mental subdomain. In the present meta-analysis, we
were able to identify 5 studies that examined the effects of
exercise on HRQOL and demonstrated a small but statisti-
cally significant positive ES on the mental subdomain at
postintervention, which included self-reported changes in
mood, memory, vitality, and social participation.
In the 6 studies that measured HRQOL at postintervention
and follow-up, gains identified at postintervention diminished
after 12 to 24 weeks at follow-up. This finding raises an
important issue related to the sustainability of exercise
participation in stroke survivors. Elimination of structured,
supervised support may reduce access or motivation to
continue to engage in exercise after these supports are
removed. Future research must determine if participants stop
exercising after the study ends because there is less structure,
supervision, or availability of exercise equipment or if the
type of exercise they continue to engage in has different
elements (eg, less structure, social support, staff expertise,
etc) that may not be as socially, emotionally, or physically
reinforcing.
Subgroup analyses did not show significant differences
between patients with chronic versus those with subacute
stroke, but relatively greater benefits were observed for
chronic patients. Exercise interventions implemented in
community-based settings reported a significant positive ES
compared with nonsignificant ES in clinical settings. How-
ever, more studies are needed to better understand the effects
of exercise on HRQOL by time since stroke and setting. Our
findings reinforce the need for identifying effective strategies
for supporting exercise after subacute stroke rehabilitation
ends. The length of stay in inpatient medical rehabilitation
has been declining over the past 2 decades
36
and healthcare
providers need to provide a means for their patients with
Subdomain
(No. of study)
Hedges g and 95% CI
Hedges g
Lower Upper
limit limit
P-value
Physical (N=4) 0.33 0.05 0.60 0.02
Mental (N=5) 0.23 0.01 0.46 0.04
Physical (N=2) 0.01 -0.32 0.33 0.98
Mental (N=5) 0.19 -0.04 0.42 0.11
-2.00 -1.00 0.00 1.00 2.00
Favours Control Favours Exercise
Time
Post-
intervention
Follow-up

v
)
-
-
- - 2.00

v
)
-
-
- -
-
-
Figure 4. Grand effect size on physical and mental
subdomain of HRQOL using a xed effect model.
< 6 months (N=4) 0.28 0.05 0.52
> 6 months (N=5) 0.38 0.04 0.72
Aerobic (N=1) -0.27 -1.04 0.50
Strength (N=2) 0.60 0.12 1.08
Combined (N=5) 0.32 0.09 0.55
<150 min (N=2) 0.10 -0.31 0.51
>150 min (N=5) 0.31 0.02 0.61
<12 weeks (N=4) 0.44 0.06 0.82
>12 weeks (N=5) 0.27 0.05 0.50
Individual (N=4) 0.31 0.05 0.56
Group (N=5) 0.33 0.03 0.62
Clinic-based (N=4) 0.33 -0.01 0.68
Community-based(N=5) 0.31 0.07 0.54
-2.00 -1.00 0.00 1.00 2.00
Favours Control Favours Exercise
Category
(No. of study) Variable
Time since
stroke
Mode of
exercise
Weekly amount
of exercise
Intervenon
length
Format
Seng
Hedges g and 95% CI Hedges g
Lower
limit
Upper
limit
Q
B,
p-value
3.59,
p=0.17
0.21,
p=0.64
0.55,
p=0.46
0.01,
p=0.91
0.01,
p=0.92
0.69,
p=0.41
< 6 months (N=4) 0.28 0.05 0.52
> 6 months (N=5) 0.38 0.04 0.72
Aerobic (N=1) -0.27 -1.04 0.50
Strength (N=2) 0.60 0.12 1.08
Combined (N=5) 0.32 0.09 0.55
<150 min (N=2) 0.10 -0.31 0.51
>150 min (N=5) 0.31 0.02 0.61
<12 weeks (N=4) 0.44 0.06 0.82
>12 weeks (N=5) 0.27 0.05 0.50
Individual (N=4) 0.31 0.05 0.56
Group (N=5) 0.33 0.03 0.62
Clinic-based (N=4) 0.33 -0.01 0.68
Community-based(N=5) 0.31 0.07 0.54
-2.00 -1.00 0.00 1.00 2.00
Favours Control Favours Exercise
< 6 months (N=4) 0.28 0.05 0.52
> 6 months (N=5) 0.38 0.04 0.72
Aerobic (N=1) -0.27 -1.04 0.50
Strength (N=2) 0.60 0.12 1.08
Combined (N=5) 0.32 0.09 0.55
<150 min (N=2) 0.10 -0.31 0.51
>150 min (N=5) 0.31 0.02 0.61
<12 weeks (N=4) 0.44 0.06 0.82
>12 weeks (N=5) 0.27 0.05 0.50
Individual (N=4) 0.31 0.05 0.56
Group (N=5) 0.33 0.03 0.62
Clinic-based (N=4) 0.33 -0.01 0.68
Community-based(N=5) 0.31 0.07 0.54
-2.00 -1.00 0.00 1.00 2.00
Favours Control Favours Exercise
Category
(No. of study) Variable
Time since
stroke
Mode of
exercise
Weekly amount
of exercise
Intervenon
length
Format
Seng
Hedges g and 95% CI Hedges g
Lower
limit
Upper
limit
Q
B,
P-value
3.59,
P=0.17
0.21,
P=0.64
0.55,
P=0.46
0.01,
P=0.91
0.01,
P=0.92
0.69,
P=0.41
Figure 5. Subgroup analysis for effects on
HRQOL at postintervention. Q
B
indicates
Q statistic between groups.
Chen and Rimmer Exercise on Quality of LifeMeta-Analysis 835
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stroke to exercise in community-based settings. Stroke sur-
vivors experience many barriers to exercise
37,38
and an
important research need is finding effective ways for people
with stroke to engage in community exercise.
The study has several limitations. First, although the
meta-analysis demonstrated evidence that exercise had a
positive effect on HRQOL in patients with stroke, there was
substantial heterogeneity in subject characteristics (eg, age,
severity of disability, baseline physical or mental status),
which may limit findings to the entire population of stroke
survivors. Second, although we attempted to estimate sepa-
rate ESs for the physical and mental subdomains of HRQOL,
most of the reviewed studies only reported an aggregate score
for overall HRQOL, which limited our ability to better
estimate the effects on each of these subdomains. Third, the
improvements in self-reported HRQOL in some participants
in the exercise group could be due to the social attention
received by research staff (ie, Hawthorne effect) and the
possibility that staff gave more encouragement/attention to
subjects in the exercise versus control groups. Fourth, we
may have missed some relevant studies that were published in
other languages besides English.
Although our subgroup analyses results provide further
understanding on the effects of exercise on HRQOL in stroke
survivors, future research must examine the precise doses of
exercise (ie, intensity, frequency, duration, pattern, and mo-
dality) tailored to specific HRQOL outcomes (eg, physical
versus mental). Exercise that has an element of social
participation (eg, performed in groups versus individually)
should be explored because there may be additive benefits
exercising in socially engaging settings with participants
experiencing similar health issues.
Conclusions
The results of this meta-analysis provide moderate support
for the use of exercise in improving HRQOL in stroke
survivors. However, more research is needed to identify
precise changes in HRQOL based on specific doses of
exercise being targeted to specific outcomes (eg, physical
versus mental). In responding to the poorer HRQOL reported
by many stroke survivors, exercise participation may be an
important modifiable behavior that can lead to improvements
in HRQOL. Future research is needed to determine if short-
term improvements in HRQOL can be sustained over a longer
period by providing some level of continued exercise support
to stroke survivors after the interventions ends.
Acknowledgments
We thank Christine Pellegrini, PhD, for her comments and editing
during the development stages of the manuscript.
Sources of Funding
This work was supported by the National Institute on Disability and
Rehabilitation Research, Rehabilitation Engineering Center on Inter-
active Exercise Technologies and Exercise Physiology for People
with Disabilities (RecTech), Grant H133E070029.
Disclosures
None.
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ONLINE SUPPLEMENT
S1. Search Terms Related to Stroke and Exercise
Stroke-related Exercise-related
Brain hemorrhage
Cerebral embolism &
thrombosis
Cerebrovascular disease
Hemiplegia
Hemiplegic
Stroke

Abdominal exercise
Aerobic exercise
Aerobic training
Anaerobic exercise
Aquatic exercise
Arm exercise
Balance training
Exercise
Exercise movement
techniques
Exercise therapy
Functional exercise
Functional training
Muscle strengthening
Physical activity
Physical fitness
Resistance training
Strength exercise
Strength training
Therapeutic exercise

ONLINE SUPPLEMENT
S2. Study Characteristics of 9 Included Studies and Instrument
Study
Study
Characteristics
Participant
Characteristics
Intervention
Instrument and
Measure
Ada, 2003
1
RCT
PEDro: 7
N, E/C: 11/14
Age: 66
Time since stroke: 28
mo
Mode: aerobic
Intensity: NR
Volume: 30 min, 3x/wk, for 4 wk
Format, setting: group, community
Control: placebo low-intensity home exercise
Stroke-Adapted
Sickness Impact
Profile
MTP: 0,4,16 wk
Duncan, 1998
2
RCT
PEDro: 7
N, E/C: 10/10
Age: 67.3
Time since stroke: 2.2
mo
Mode: combined
Intensity: NR
Volume: 90 min, 3 x/wk, for 12 wk
Format, setting: individual, home
Control: usual care
SF-36
MTP: 0,12 wk
Flansbjer,
2008
3

RCT
PEDro: 6
N, E/C: 15/9
Age: 61
Time since stroke: 18.9
mo
Mode: strengthening
Intensity: 80% of 1-RM
Volume: 2 sets of 6-8 rep., 90 min, 2 x/wk, for 10
wk
Format, setting: individual, hospital
Control: continue their usual daily activities
SIS
MTP: 0,10, 30 wk
Lai, 2006
4
RCT
PEDro: 6
N, E/C: 44/49
Age: 69.8
Time since stroke: 2.6
mo
Mode: combined
Intensity: NR
Volume: NR min, 3 x/wk, for 12 wk
Format, setting: individual, home
Control: usual care
SIS
SF-36
MTP: 0,12, 36 wk
Lee, 2008
5
RCT
PEDro: 8
N, E/C: 36/12
Age: 63.2
Time since stroke: 57
mo
Mode: 3 groups aerobic, strength, and combined
Intensity: aerobic: 50-70% of VO
2peak
,
strengthening: 50-80% of 1-RM
Volume: aerobic: 30 min, strengthening: 2 sets of
8 rep., combined: 60 min, 3x/wk, for 12 wk
Format, setting: group, laboratory
Control: combined low-intensity cycling and
strength exercise
SF-36
MTP: 0,12 wk
Mead, 2007
6
RCT
PEDro: 7
N, E/C: 32/34
Age: 72
Time since stroke: 5.9
mo
Mode: combined
Intensity: 13-16 out of 22, RPE
Volume: 40 min, 3x/wk, for 12 wk
Format, setting: group, hospital
Control: relaxation
SF-36
MTP: 0,12, 28 wk

Sims, 2009
7
RCT
PEDro: 6
N, E/C: 23/21
Age: 67.1
Time since stroke: 13.2
mo
Mode: strengthening
Intensity: 80% of 1-RM
Volume: 3 sets of 8-10 rep., 2 x/wk, for 10 wk
Format, setting: group, community-based
gymnasium
Control: usual care
SIS
Recovery Locus
of Control Scale
MTP: 0, 10, 26 wk
Studenski,
2005
8

RCT
PEDro: 6
N, E/C: 44/49
Age: 69.5
Time since stroke: 2.5
mo
Mode: combined
Intensity: 40 revolutions per minute (rpm)
Volume: 90 min, 3 x/wk, for 12 wk
Format, setting: individual, home
Control: usual care
SF-36
SIS
MTP: 0, 12, 36 wk
Teixeira-Salm RCT N, E/C: 7/6 Mode: combined Nottingham
ela, 1999
9
PEDro: 3 Age: 65.9
Time since stroke: 109.8
mo
Intensity: aerobic: 50-70% of HR
max
;
strengthening: 50-80% of 1-RM
Volume: 60-90 min, 3x/wk, for 10 wk
Format, setting: group, supervised setting
Control: no exercise intervention
Health Profile
MTP: 0, 10 wk
RCT, randomized controlled trial; E, exercise group; C, control group; NR, not reported; RM, repetition maximum; RPE, ratings of perceived
exertion; MTP, measurement time point; SF-36, Short Form-36; SIS, Stroke Impact Scale;


References

1. Ada L, Dean CM, Hall J M, Bampton J , Crompton S. A treadmill and overground walking program improves walking in persons residing
in the community after stroke: a placebo-controlled, randomized trial. Arch Phys Med Rehabil. 2003;84:1486-1491.
2. Duncan P, Richards L, Wallace D, Stoker-Yates J , Pohl P, Luchies C, Ogle A, Studenski S. A randomized, controlled pilot study of a
home-based exercise program for individuals with mild and moderate stroke. Stroke. 1998;29:2055-2060.
3. Flansbjer UB, Miller M, Downham D, Lexell J . Progressive resistance training after stroke: effects on muscle strength, muscle tone, gait
performance and perceived participation. J Rehabil Med. 2008;40:42-48.
4. Lai SM, Studenski S, Richards L, Perera S, Reker D, Rigler S, Duncan PW. Therapeutic exercise and depressive symptoms after stroke. J
Am Geriatr Soc. . 2006;54:240-247.
5. Lee M-J , Kilbreath SL, Singh MF, Zeman B, Lord SR, Raymond J , Davis GM. Comparison of effect of aerobic cycle training and
progressive resistance training on walking ability after stroke: a randomized sham exercise-controlled study. J Am Geriatr Soc.
2008;56:976-985.
6. Mead GE, Greig CA, Cunningham I, Lewis SJ , Dinn S, Saunders DH, Fitzsimons C, Young A. Stroke: a randomized trial of exercise or
relaxation. J Am Geriatr Soc. 2007;55:892-899.
7. Sims J , Galea M, Taylor N, Dodd K, J espersen S, J oubert L, J oubert J . Regenerate: assessing the feasibility of a strength-training
program to enhance the physical and mental health of chronic post stroke patients with depression. Int J Geriatr Psychiatry.
2009;24:76-83.
8. Studenski S, Duncan PW, Perera S, Reker D, Lai SM, Richards L. Daily functioning and quality of life in a randomized controlled trial
of therapeutic exercise for subacute stroke survivors. Stroke. 2005;36:1764-1770.
9. Teixeira-Salmela LF, Olney SJ , Nadeau S, Brouwer B. Muscle strengthening and physical conditioning to reduce impairment and
disability in chronic stroke survivors. Arch Phys Med Rehabil. 1999;80:1211-1218.