Physical fitness training for stroke patients

David H Saunders; Carolyn A Greig; Gillian E Mead; Archie Young

doi:10.1002/14651858.CD003316.pub3

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Topics

Analysis 1.1

Comparison 1 Cardiorespiratory training versus control ‐ end of intervention, Outcome 1 Disability ‐ FIM Instrument.

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Analysis 1.2

Comparison 1 Cardiorespiratory training versus control ‐ end of intervention, Outcome 2 Disability ‐ Rivermead Mobility Index.

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Analysis 1.3

Comparison 1 Cardiorespiratory training versus control ‐ end of intervention, Outcome 3 Disability ‐ mixed FIM + Barthel scales.

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Analysis 1.4

Comparison 1 Cardiorespiratory training versus control ‐ end of intervention, Outcome 4 Adverse events and risk factors ‐ blood pressure, systolic.

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Analysis 1.5

Comparison 1 Cardiorespiratory training versus control ‐ end of intervention, Outcome 5 Adverse events and risk factors ‐ blood pressure, diastolic.

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Analysis 1.6

Comparison 1 Cardiorespiratory training versus control ‐ end of intervention, Outcome 6 Physical fitness ‐ cardiorespiratory, VO2 (ml/kg/min).

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Analysis 1.7

Comparison 1 Cardiorespiratory training versus control ‐ end of intervention, Outcome 7 Physical fitness ‐ cardiorespiratory, maximum cycling work rate (Watts).

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Analysis 1.8

Comparison 1 Cardiorespiratory training versus control ‐ end of intervention, Outcome 8 Mobility ‐ functional ambulation categories.

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Analysis 1.9

Comparison 1 Cardiorespiratory training versus control ‐ end of intervention, Outcome 9 Mobility ‐ gait speed, maximal (m/min over 5 to 10 metres).

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Analysis 1.10

Comparison 1 Cardiorespiratory training versus control ‐ end of intervention, Outcome 10 Mobility ‐ gait speed, maximal (m/min over 5 to 10 metres); subgroup: ACSM.

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Analysis 1.11

Comparison 1 Cardiorespiratory training versus control ‐ end of intervention, Outcome 11 Mobility ‐ gait speed, preferred (m/min).

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Analysis 1.12

Comparison 1 Cardiorespiratory training versus control ‐ end of intervention, Outcome 12 Mobility ‐ gait endurance (6‐MWT metres).

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Analysis 1.13

Comparison 1 Cardiorespiratory training versus control ‐ end of intervention, Outcome 13 Mobility ‐ gait endurance (m/min).

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Analysis 1.14

Comparison 1 Cardiorespiratory training versus control ‐ end of intervention, Outcome 14 Physical function ‐ Berg Balance scale.

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Analysis 2.1

Comparison 2 Cardiorespiratory training versus control ‐ end of retention follow up, Outcome 1 Disability ‐ Rivermead Mobility Index.

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Analysis 2.2

Comparison 2 Cardiorespiratory training versus control ‐ end of retention follow up, Outcome 2 Mobility ‐ gait speed, maximal (m/min).

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Analysis 2.3

Comparison 2 Cardiorespiratory training versus control ‐ end of retention follow up, Outcome 3 Mobility ‐ gait speed, maximal (m/min); subgroup: specificity.

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Analysis 2.4

Comparison 2 Cardiorespiratory training versus control ‐ end of retention follow up, Outcome 4 Mobility ‐ gait endurance (6‐MWT metres).

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Analysis 3.1

Comparison 3 Strength training versus control ‐ end of intervention, Outcome 1 Physical fitness ‐ muscle strength.

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Analysis 3.2

Comparison 3 Strength training versus control ‐ end of intervention, Outcome 2 Mobility ‐ gait speed, maximal (m/min).

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Analysis 3.3

Comparison 3 Strength training versus control ‐ end of intervention, Outcome 3 Mobility ‐ gait speed, preferred (m/min).

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Analysis 3.4

Comparison 3 Strength training versus control ‐ end of intervention, Outcome 4 Mobility ‐ gait endurance (6‐MWT metres).

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Analysis 3.5

Comparison 3 Strength training versus control ‐ end of intervention, Outcome 5 Physical function ‐ stair climbing, maximal (sec/step).

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Analysis 5.1

Comparison 5 Mixed training versus control ‐ end of intervention, Outcome 1 Disability ‐ Lawton IADL.

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Analysis 5.2

Comparison 5 Mixed training versus control ‐ end of intervention, Outcome 2 Disability ‐ Barthel ADL.

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Analysis 5.3

Comparison 5 Mixed training versus control ‐ end of intervention, Outcome 3 Disability ‐ Barthel ADL ambulation subscale.

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Analysis 5.4

Comparison 5 Mixed training versus control ‐ end of intervention, Outcome 4 Disability ‐ Barthel & FIM Instrument.

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Analysis 5.5

Comparison 5 Mixed training versus control ‐ end of intervention, Outcome 5 Physical fitness ‐ strength, ankle dorsiflexion*.

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Analysis 5.6

Comparison 5 Mixed training versus control ‐ end of intervention, Outcome 6 Physical fitness ‐ strength, knee extension*.

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Analysis 5.7

Comparison 5 Mixed training versus control ‐ end of intervention, Outcome 7 Mobility ‐ gait preferred speed (m/min).

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Analysis 5.8

Comparison 5 Mixed training versus control ‐ end of intervention, Outcome 8 Mobility ‐ gait preferred speed (m/min); subgroup: therapy time.

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Analysis 5.9

Comparison 5 Mixed training versus control ‐ end of intervention, Outcome 9 Mobility ‐ gait endurance (6 MWT metres).

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Analysis 5.10

Comparison 5 Mixed training versus control ‐ end of intervention, Outcome 10 Physical function ‐ Fugl‐Meyer lower extremity.

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Analysis 5.11

Comparison 5 Mixed training versus control ‐ end of intervention, Outcome 11 Physical function ‐ Fugl‐Meyer upper extremity.

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Analysis 5.12

Comparison 5 Mixed training versus control ‐ end of intervention, Outcome 12 Physical function ‐ Berg Balance.

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Analysis 5.13

Comparison 5 Mixed training versus control ‐ end of intervention, Outcome 13 Physical function ‐ functional reach.

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Analysis 5.14

Comparison 5 Mixed training versus control ‐ end of intervention, Outcome 14 Physical function ‐ timed up and go (sec).

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Analysis 5.15

Comparison 5 Mixed training versus control ‐ end of intervention, Outcome 15 Physical function ‐ timed up and go (sec); sensitivity analysis: excluding Yang 2006.

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Analysis 5.16

Comparison 5 Mixed training versus control ‐ end of intervention, Outcome 16 Health related QoL ‐ SF‐36 role physical.

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Analysis 5.17

Comparison 5 Mixed training versus control ‐ end of intervention, Outcome 17 Health related QoL ‐ SF‐36 physical function.

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Analysis 5.18

Comparison 5 Mixed training versus control ‐ end of intervention, Outcome 18 Health related QoL ‐ SF‐36 social function.

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Analysis 5.19

Comparison 5 Mixed training versus control ‐ end of intervention, Outcome 19 Mobility ‐ Community Ambulation Speed (> 0.8 m/sec).

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Analysis 6.1

Comparison 6 Mixed training versus control ‐ end of retention follow up, Outcome 1 Disability ‐ Barthel & FIM combined.

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Analysis 6.2

Comparison 6 Mixed training versus control ‐ end of retention follow up, Outcome 2 Mobility ‐ gait preferred speed (m/min).

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Analysis 6.3

Comparison 6 Mixed training versus control ‐ end of retention follow up, Outcome 3 Physical function ‐ timed up and go (sec).

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Analysis 6.4

Comparison 6 Mixed training versus control ‐ end of retention follow up, Outcome 4 Health related QoL ‐ SF‐36 role physical.

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Analysis 6.5

Comparison 6 Mixed training versus control ‐ end of retention follow up, Outcome 5 Health related QoL ‐ SF‐36 physical function.

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Analysis 6.6

Comparison 6 Mixed training versus control ‐ end of retention follow up, Outcome 6 Case fatality.

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Analysis 6.7

Comparison 6 Mixed training versus control ‐ end of retention follow up, Outcome 7 Mobility ‐ Community Ambulation Speed (> 0.8 m/sec).

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Analysis 7.1

Comparison 7 Cardiorespiratory training versus strength training, Outcome 1 Mobility ‐ gait preferred speed (m/min).

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Analysis 7.2

Comparison 7 Cardiorespiratory training versus strength training, Outcome 2 Mobility ‐ gait preferred speed (m/min); sensitivity analysis: confounded studies removed.

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Table 1. Cardiorespiratory training: individual study data ‐ end of intervention

Outcome	Measure	Study	Participants	Method	Effect Size	Significance
Disability	FIM locomotor subscale	da Cunha 2002	12	MD (fixed), 95% CI	‐0.17 [‐2.46, 2.12]	NS
Disability	Barthel index	Pohl 2007	155	MD (fixed), 95% CI	13.6 [6.89, 20.31]	P < 0.0001
Disability	Barthel Index > 75	Pohl 2007	155	OR (fixed), 95% CI	3.62 [1.84, 7.10]	P = 0.0002
Disability	Motricity index	Pohl 2007	155	MD (fixed), 95% CI	11.60 [3.54, 19.66]	P = 0.005
Physical function	Timed up and go (seconds)	Salbach 2004	91	MD (fixed), 95% CI	‐3.90 [‐13.75, 5.95	NS
Physical function	Fugl‐Meyer score	Potempa 1995	42	MD (fixed), 95% CI	‐10.00 [‐15.68, ‐4.32]	NS
Mood	Anxiety ‐ HADS	Bateman 2001	60	MD (fixed), 95% CI	‐1.94 [‐3.80, ‐0.08	NS
Mood	Depression ‐ HADS	Bateman 2001	60	MD (fixed), 95% CI	‐1.40 [‐3.21, 0.41]	NS
Risk	Body mass (kg)	Bateman 2001	72	MD (fixed), 95% CI	5.38 [‐1.69, 12.45	NS
HADS: Hospital anxiety and depression scale NS: not significant

Table 1. Cardiorespiratory training: individual study data ‐ end of intervention

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Table 2. Mixed training: individual study data ‐ end of retention follow up

Outcome	Measure	Study	Participants	Method	Effect Size	Significance
Disability	FIM Instrument	Mead 2007	66	MD (fixed), 95% CI	0.20 [‐1.88, 2.28]	NS
Disability	Nottingham EADL	Mead 2007	66	MD (fixed), 95% CI	0.30 [‐0.93, 1.53]	NS
Disability	Rivermead Motor Index	Mead 2007	66	MD (fixed), 95% CI	0.20 [‐0.41, 0.81]	NS
Disability	Lawton IADL	Duncan 2003	80	MD (fixed), 95% CI	0.80 [‐0.96, 2.56]	NS
Disability	Barthel ADL	Duncan 2003	80	MD (fixed), 95% CI	‐1.70 [‐5.51, 2.11]	NS
Disability	Barthel ambulation subscale	Richards 2004	62	MD (fixed), 95% CI	‐2.00 [‐5.13, 1.13]	NS
Disability	FIM cognitive subscale	Duncan 2003	80	MD (fixed), 95% CI	0.40 [‐0.25, 1.05]	NS
Disability	FIM motor subscale	Duncan 2003	80	MD (fixed), 95% CI	1.90 [‐1.88, 5.68]	NS
Physical fitness	Net gait economy ml/kg/10 metre	Mead 2007	65	MD (fixed), 95% CI	0.00 [‐0.02, 0.02]	NS
Physical fitness	Power, LLEP, affected (w/kg)	Mead 2007	65	MD (fixed), 95% CI	0.02 [‐0.13, 0.17]	NS
Mobility	Gait endurance (6‐MWT)	Dean 2000	9	MD (fixed), 95% CI	16.20 [‐175.76, 208.16]	NS
Physical function	Berg Balance	Richards 2004	62	MD (fixed), 95% CI	‐2.00 [‐5.48, 1.48]	NS
Physical function	Functional reach	Mead 2007	66	MD (fixed), 95% CI	2.50 [‐0.97, 5.97]	NS
Health and QoL	SF‐36 social function	Duncan 2003	80	MD (fixed), 95% CI	10.60 [0.53, 20.67]	P = 0.04
Mood	Anxiety (HADS)	Mead 2007	66	MD (fixed), 95% CI	‐0.25 [‐1.79, 1.29]	NS
Mood	Depression (HADS)	Mead 2007	66	MD (fixed), 95% CI	0.18 [‐1.27, 1.63]	NS
6‐MWT: 6‐Minute Walk Test EADL: extended activities of daily living FIM: Functional Independence Measure HADS: Hospital anxiety and depression scale Lawton IADL: Lawton instrumental activities of daily living LLEP: Lower limb extensor power NS: not significant QoL: quality of life SF‐36: Short Form 36 questionnaire

Table 2. Mixed training: individual study data ‐ end of retention follow up

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Table 3. Cardiorespiratory training interventions

Study	Training mode	During/after usual care	Upper/lower body	Specific training	Intensity	Duration	Frequency	Programme length	ACSM criteria met
Glasser 1986	Kinetron	During	Lower	No	UN	20 to 60	5	3	UN
Cuveillo‐Palmer 1988	Kinetron	During	Lower	No	HR < resting + 20 beats/minute	7 to 17	5	3	No
da Cunha 2002	BWS treadmill	During	Lower	Yes	UN	20	5	2 to 3	UN
Pohl 2002a	Treadmill	During	Lower	Yes	UN	30	3	4	UN
Pohl 2002b	Treadmill	During	Lower	Yes	UN	30	3	4	UN
Eich 2004b	Treadmill	During	Lower	Yes	60% HRR	30	5	6	Yes
Pohl 2007	BWS gait trainer	During	Lower	Yes	UN	20	5	4	UN
Bateman 2001	Cycle ergometer	Both	Lower	No	60% to 80% ARHRM	≤ 30	3	12	Yes
Katz‐Leurer 2003a	Cycle ergometer	Both	Lower	No	≤ 60% HRR	20 then 30	5 then 3	2 then 6 (total 8)	Yes
Potempa 1995	Cycle ergometer	After	Lower	No	30% to 50% max effort	30	3	10	Yes
Salbach 2004	Circuit training	After	Lower	Yes	UN	55	3	6	UN
ARHRM: age‐related heart rate maximum BWS: body weight supported HR: heart rate HRR: heart rate reserve UN: unknown

Table 3. Cardiorespiratory training interventions

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Table 4. Strength training interventions

Study	Mode	During/after usual care	Upper/lower body	Specific training	Intensity	Duration	Frequency	Programme length	ACSM criteria
Inaba 1973	Resistance training	During	Lower	No	50% and 100% maximum weight	UN	'Daily'	4 to 8	Yes
Winstein 2004	Resistance training; weights; Thera‐band and grip devices	Both	Upper	No	UN	60	3 high 2 slow	4 to 6 (target of 20 sessions)	UN
Kim 2001	Resistance training; isokinetic dynamometer	After	Lower	No	Maximal effort 3 x 10 repititions	30	3	6	Yes
Ouellette 2004	Resistance training; weights and pneumatic resistance machines	After	Lower	No	70% 1‐RM 3 x 8 to 10 repititions	N/A	3	12	No (almost achieves criteria)
1‐RM: one repetition maximum UN: unknown

Table 4. Strength training interventions

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Table 5. Mixed training interventions

Study	Mode	During/after usual care	Upper/lower body	Specific training	Intensity	Duration	Frequency	Programme length	ACSM criteria
Richards 1993	Treadmill + Kinetron + tilt table	During	Lower	Yes	UN	104	5	5	UN
Richards 2004	Treadmill + Kinetron + limb load monitor	During	Lower	Yes	UN	60	5	8	UN
Duncan 1998	Walking or cycle ergometry; elastic resisted contractions	After	Both	Yes	UN	90	3	12	cardio no, strength yes
Teixeira‐Salmela 1999	Walking and stepping or cycle ergometry; resistance training body mass, weights and elastic	After	Lower	Yes	50% to 70% maximum work rate (CR) 50% to 80% 1‐RM 3 x 10 repetitions (STR)	60 to 90	3	10	cardio yes, strength yes
Dean 2000	Walking and circuit training	After	Lower	Yes	UN	60	3	4	No
Duncan 2003	Circuit training	After	Lower	Yes	50% to 60% HRR	90 to 120	3	4	Cardio yes, strength UC
James 2002	Circuit training	After	Both	Yes	UN	90	3	12 to 14 (total of 36 sessions)	Cardio no, strength yes
Yang 2006	Functional stepping and chair rising	After	Lower	Yes	UN	30	3	4	No
Mead 2007	Circuit including walking, stepping, cycle ergometry; resistance training body mass, weights and elastic	After	Both	Yes	RPE 13 to 16	40 to 75	3	12 to 14 (total of 36 sessions)	UN
1‐RM: one repetition maximum CR: cardiorespiratory component HRR: heart rate reserve RPE: rating of perceived exertion STR: strength component UN: unknown

Table 5. Mixed training interventions

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Table 6. Cardiorespiratory training: individual study data ‐ end of retention follow up

Outcome	Measure	Study	Participants	Method	Effect Size	Significance
Disability	Nottingham EADL	Bateman 2001	64	MD (fixed), 95% CI	2.64 [‐5.57, 10.85]	NS
Disability	Barthel index	Pohl 2007	155	MD (fixed), 95% CI	12.40 [4.32, 20.48]	P = 0.003
Disability	Frenchay Activities Index	Katz‐Leurer 2003	79	MD (fixed), 95% CI	1.00 [‐1.55, 3.55]	NS
Disability	Barthel Index > 75	Pohl 2007	155	OR (fixed), 95% CI	1.64 [0.87, 3.10]	NS
Physical fitness	Maximum cycling work (Watts)	Bateman 2001	66	MD (fixed), 95% CI	2.59 [1.69, 3.49]	P < 0.00001
Mobility	Functional Ambulation Categories	Pohl 2007	155	MD (fixed), 95% CI	1.20 [0.65, 1.75	P < 0.0001
Physical function	Berg Balance scale	Bateman 2001	66	MD (fixed), 95% CI	‐2.90 [‐7.88, 2.08]	NS
Physical function	Motricity index	Pohl 2007	155	MD (fixed), 95% CI	11.90 [3.63, 20.17	P = 0.005
Mood	Anxiety ‐ HADS	Bateman 2001	53	MD (fixed), 95% CI	‐1.60 [‐3.58, 0.38]	NS
Mood	Depression ‐ HADS	Bateman 2001	53	MD (fixed), 95% CI	‐2.70 [‐4.40, ‐1.00]	P = 0.002
Risk	Body mass (kg)	Bateman 2001	64	MD (fixed), 95% CI	2.81 [‐4.63, 10.25]	NS
EADL: extended activities of daily living HADS: Hospital anxiety and depression scale NS: not significant

Table 6. Cardiorespiratory training: individual study data ‐ end of retention follow up

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Table 7. Strength training: individual study data ‐ end of intervention

Outcome	Measure	Study	Participants	Method	Effect Size	Significance
Disability	LLFDI (frequency dimension)	Ouellette 2004	41	MD (fixed), 95% CI	0.10 [‐4.65, 4.85]	NS
Disability	LLFDI (limitation dimension)	Ouellette 2004	41	MD (fixed), 95% CI	1.30 [‐5.02, 7.62]	NS
Disability	FIM Mobility	Winstein 2004	40	MD (fixed), 95% CI	0.90 [‐3.66, 5.46]	NS
Disability	FIM Self‐care	Winstein 2004	40	MD (fixed), 95% CI	‐0.85 [‐4.26, 2.56]	NS
Disability	Improvement in 10 ADL	Inaba 1973	54	OR (fixed), 95% CI	2.88 [0.95,8.70]	NS
Physical function	Timed up and go (seconds)	Yang 2006	48	MD (fixed), 95% CI	‐1.50 [‐5.23, 2.23]	NS
Health and QoL	SF‐36 Physical Health	Kim 2001	20	MD (fixed), 95% CI	1.47 [‐4.24, 7.18]	NS
Health and QoL	SF‐36 Mental Health	Kim 2001	20	MD (fixed), 95% CI	2.80 [‐4.95, 10.55]	NS
FIM: Functional Independence Measure LLFDI: late life function and disability NS: not significant QoL: quality of life SF‐36: Short Form 36 questionnaire

Table 7. Strength training: individual study data ‐ end of intervention

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Table 8. Strength training: individual study data ‐ end of retention follow up

Outcome	Measure	Study	Participants	Method	Effect size	Significance
Disability	FIM Mobility	Winstein 2004	31	MD (fixed), 95% CI	‐3.23 [‐6.14, ‐3.32]	P = 0.03
Disability	FIM Self‐care	Winstein 2004	31	MD (fixed), 95% CI	‐3.32 [‐6.48, ‐0.16]	P = 0.04
FIM: Functional Independence Measure

Table 8. Strength training: individual study data ‐ end of retention follow up

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Table 9. Mixed training: individual study data ‐ end of intervention

Outcome	Measure	Study	Participants	Method	Effect size	Significance
Disability	FIM Instrument	Mead 2007	66	MD (fixed), 95% CI	‐0.10 [‐1.70, 1.50]	NS
Disability	Nottingham EADL	Mead 2007	66	MD (fixed), 95% CI	‐0.20 [‐1.08, 0.68]	NS
Disability	Rivermead Motor Index	Mead 2007	66	MD (fixed), 95% CI	‐0.41 [‐6.14, 0.81	NS
Disability	FIM motor subscale	Duncan 2003	93	MD (fixed), 95% CI	2.60 [‐0.29, 5.49]	NS
Disability	FIM cognitive subscale	Duncan 2003	93	MD (fixed), 95% CI	0.10 [‐0.37, 0.57]	NS
Physical fitness	VO₂peak	Duncan 2003	100	MD (fixed), 95% CI	0.99 [0.35, 1.63]	P = 0.002
Physical fitness	Net gait economy ml/kg/10 metre	Mead 2007	65	MD (fixed), 95% CI	‐0.14 [‐0.27, ‐0.01]	P = 0.03
Physical fitness	Strength, handgrip	Duncan 2003	100	MD (fixed), 95% CI	0.32 [‐1.85, 2.49]	NS
Physical fitness	Power, LLEP, affected (W/kg)	Mead 2007	65	MD (fixed), 95% CI	0.07 [‐0.07, 0.21]	NS
Physical function	Adjusted Activity Score	Teixeira 1999	13	MD (fixed), 95% CI	13.79 [2.11, 25.47]	P = 0.02
Health and QoL	Nottingham Health Profile	Teixeira 1999	13	MD (fixed), 95% CI	‐8.97 [‐12.84, ‐5.10]	P = 0.00001
Mood	Anxiety (HADS)	Mead 2007	66	MD (fixed), 95% CI	‐0.34 [‐1.84, 1.16]	NS
Mood	Depression (HADS)	Mead 2007	66	MD (fixed), 95% CI	0.54 [‐0.93, 2.01]	NS
EADL: extended activities of daily living FIM: Functional Independence Measure HADS: Hospital anxiety and depression scale LLEP: Lower limb extensor power NS: not significant QoL: quality of life

Table 9. Mixed training: individual study data ‐ end of intervention

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Comparison 1. Cardiorespiratory training versus control ‐ end of intervention

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Disability ‐ FIM Instrument Show forest plot	3	162	Std. Mean Difference (IV, Fixed, 95% CI)	0.21 [‐0.10, 0.52]

1.1 During usual care	1	52	Std. Mean Difference (IV, Fixed, 95% CI)	0.23 [‐0.32, 0.78]
1.2 After usual care	2	110	Std. Mean Difference (IV, Fixed, 95% CI)	0.20 [‐0.17, 0.58]
2 Disability ‐ Rivermead Mobility Index Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 During usual care	2	232	Mean Difference (IV, Random, 95% CI)	1.25 [‐0.74, 3.25]
2.2 During usual care ‐ LOCF	2	238	Mean Difference (IV, Random, 95% CI)	1.18 [‐0.92, 3.29]
2.3 After usual care	0	0	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3 Disability ‐ mixed FIM + Barthel scales Show forest plot	4	317	Std. Mean Difference (IV, Fixed, 95% CI)	0.42 [0.19, 0.64]

3.1 During usual care	2	207	Std. Mean Difference (IV, Fixed, 95% CI)	0.53 [0.25, 0.81]
3.2 After usual care	2	110	Std. Mean Difference (IV, Fixed, 95% CI)	0.20 [‐0.17, 0.58]
4 Adverse events and risk factors ‐ blood pressure, systolic Show forest plot	3	144	Mean Difference (IV, Random, 95% CI)	0.83 [‐12.50, 14.17]

4.1 During usual care	1	12	Mean Difference (IV, Random, 95% CI)	26.33 [1.95, 50.71]
4.2 After usual care	2	132	Mean Difference (IV, Random, 95% CI)	‐5.46 [‐11.76, 0.85]
5 Adverse events and risk factors ‐ blood pressure, diastolic Show forest plot	3	144	Mean Difference (IV, Fixed, 95% CI)	‐0.23 [‐3.33, 2.87]

5.1 During usual care	1	12	Mean Difference (IV, Fixed, 95% CI)	1.0 [‐10.46, 12.46]
5.2 After usual care	2	132	Mean Difference (IV, Fixed, 95% CI)	‐0.33 [‐3.55, 2.89]
6 Physical fitness ‐ cardiorespiratory, VO2 (ml/kg/min) Show forest plot	2	54	Mean Difference (IV, Random, 95% CI)	3.52 [1.52, 5.52]

6.1 During usual care	1	12	Mean Difference (IV, Random, 95% CI)	3.43 [0.56, 6.30]
6.2 After usual care	1	42	Mean Difference (IV, Random, 95% CI)	3.60 [0.82, 6.38]
7 Physical fitness ‐ cardiorespiratory, maximum cycling work rate (Watts) Show forest plot	4	221	Std. Mean Difference (IV, Random, 95% CI)	0.60 [0.18, 1.02]

7.1 During usual care	2	89	Std. Mean Difference (IV, Random, 95% CI)	0.32 [‐0.34, 0.98]
7.2 After usual care	2	132	Std. Mean Difference (IV, Random, 95% CI)	0.83 [0.47, 1.18]
8 Mobility ‐ functional ambulation categories Show forest plot	4		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

8.1 During usual care	4	228	Mean Difference (IV, Fixed, 95% CI)	0.72 [0.46, 0.98]
8.2 After usual care	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
9 Mobility ‐ gait speed, maximal (m/min over 5 to 10 metres) Show forest plot	8	462	Mean Difference (IV, Fixed, 95% CI)	6.47 [2.37, 10.57]

9.1 During usual care	7	371	Mean Difference (IV, Fixed, 95% CI)	5.93 [1.61, 10.24]
9.2 After usual care	1	91	Mean Difference (IV, Fixed, 95% CI)	11.40 [‐1.61, 24.41]
10 Mobility ‐ gait speed, maximal (m/min over 5 to 10 metres); subgroup: ACSM Show forest plot	8	462	Mean Difference (IV, Fixed, 95% CI)	6.47 [2.37, 10.57]

10.1 ACSM criteria met	2	123	Mean Difference (IV, Fixed, 95% CI)	2.55 [‐3.03, 8.13]
10.2 ACSM criteria unknown	4	235	Mean Difference (IV, Fixed, 95% CI)	9.44 [2.02, 16.86]
10.3 ACSM criteria not met	2	104	Mean Difference (IV, Fixed, 95% CI)	14.22 [3.83, 24.61]
11 Mobility ‐ gait speed, preferred (m/min) Show forest plot	4	356	Mean Difference (IV, Fixed, 95% CI)	5.15 [2.05, 8.25]

11.1 During usual care	2	175	Mean Difference (IV, Fixed, 95% CI)	6.55 [1.32, 11.77]
11.2 After usual care	2	181	Mean Difference (IV, Fixed, 95% CI)	4.39 [0.53, 8.24]
12 Mobility ‐ gait endurance (6‐MWT metres) Show forest plot	3	296	Mean Difference (IV, Fixed, 95% CI)	38.93 [14.34, 63.52]

12.1 During usual care	2	205	Mean Difference (IV, Fixed, 95% CI)	38.66 [11.19, 66.13]
12.2 After usual care	1	91	Mean Difference (IV, Fixed, 95% CI)	40.0 [‐15.13, 95.13]
13 Mobility ‐ gait endurance (m/min) Show forest plot	4	309	Mean Difference (IV, Fixed, 95% CI)	7.44 [3.47, 11.42]

13.1 During usual care	3	218	Mean Difference (IV, Fixed, 95% CI)	7.63 [3.23, 12.03]
13.2 After usual care	1	91	Mean Difference (IV, Fixed, 95% CI)	6.60 [‐2.66, 15.86]
14 Physical function ‐ Berg Balance scale Show forest plot	2	168	Mean Difference (IV, Fixed, 95% CI)	1.44 [‐2.15, 5.03]

14.1 During usual care	1	77	Mean Difference (IV, Fixed, 95% CI)	‐0.30 [‐5.52, 4.92]
14.2 After usual care	1	91	Mean Difference (IV, Fixed, 95% CI)	3.0 [‐1.94, 7.94]

Comparison 1. Cardiorespiratory training versus control ‐ end of intervention

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Comparison 2. Cardiorespiratory training versus control ‐ end of retention follow up

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Disability ‐ Rivermead Mobility Index Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 During usual care	2	221	Mean Difference (IV, Random, 95% CI)	1.01 [‐1.39, 3.41]
1.2 During usual care ‐ LOCF Bateman	2	239	Mean Difference (IV, Random, 95% CI)	1.14 [‐0.98, 3.26]
1.3 After usual care	0	0	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Mobility ‐ gait speed, maximal (m/min) Show forest plot	3	283	Mean Difference (IV, Fixed, 95% CI)	9.01 [4.42, 13.61]

2.1 During usual care	3	283	Mean Difference (IV, Fixed, 95% CI)	9.01 [4.42, 13.61]
2.2 After usual care	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Mobility ‐ gait speed, maximal (m/min); subgroup: specificity Show forest plot	3	268	Mean Difference (IV, Fixed, 95% CI)	7.53 [2.59, 12.48]

3.1 Gait specific training	2	204	Mean Difference (IV, Fixed, 95% CI)	10.60 [4.91, 16.29]
3.2 Cycle ergometry training	1	64	Mean Difference (IV, Fixed, 95% CI)	‐1.90 [‐11.89, 8.09]
4 Mobility ‐ gait endurance (6‐MWT metres) Show forest plot	2	204	Mean Difference (IV, Fixed, 95% CI)	57.51 [25.82, 89.19]

4.1 During usual care	2	204	Mean Difference (IV, Fixed, 95% CI)	57.51 [25.82, 89.19]
4.2 After usual care	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 2. Cardiorespiratory training versus control ‐ end of retention follow up

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Comparison 3. Strength training versus control ‐ end of intervention

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Physical fitness ‐ muscle strength Show forest plot	2	60	Std. Mean Difference (IV, Fixed, 95% CI)	0.58 [0.06, 1.10]

1.1 During usual care	0	0	Std. Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 During and after usual care	1	40	Std. Mean Difference (IV, Fixed, 95% CI)	0.47 [‐0.16, 1.10]
1.3 After usual care	1	20	Std. Mean Difference (IV, Fixed, 95% CI)	0.84 [‐0.09, 1.76]
2 Mobility ‐ gait speed, maximal (m/min) Show forest plot	2	62	Mean Difference (IV, Fixed, 95% CI)	‐1.17 [‐5.53, 3.19]

2.1 During usual care	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.2 After usual care	2	62	Mean Difference (IV, Fixed, 95% CI)	‐1.17 [‐5.53, 3.19]
3 Mobility ‐ gait speed, preferred (m/min) Show forest plot	3		Mean Difference (IV, Random, 95% CI)	Subtotals only

3.1 During usual care	0	0	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3.2 After usual care	2	62	Mean Difference (IV, Random, 95% CI)	‐2.61 [‐7.73, 2.51]
3.3 After usual care ‐ sensitivity analysis	3	110	Mean Difference (IV, Random, 95% CI)	2.37 [‐6.80, 11.53]
4 Mobility ‐ gait endurance (6‐MWT metres) Show forest plot	2	90	Mean Difference (IV, Fixed, 95% CI)	39.33 [‐8.20, 86.85]

4.1 During usual care	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.2 After usual care	2	90	Mean Difference (IV, Fixed, 95% CI)	39.33 [‐8.20, 86.85]
5 Physical function ‐ stair climbing, maximal (sec/step) Show forest plot	2	61	Std. Mean Difference (IV, Fixed, 95% CI)	0.04 [‐0.47, 0.55]

5.1 During usual care	0	0	Std. Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.2 After usual care	2	61	Std. Mean Difference (IV, Fixed, 95% CI)	0.04 [‐0.47, 0.55]

Comparison 3. Strength training versus control ‐ end of intervention

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Comparison 5. Mixed training versus control ‐ end of intervention

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Disability ‐ Lawton IADL Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

1.1 During usual care	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 After usual care	2	113	Mean Difference (IV, Fixed, 95% CI)	0.83 [‐0.51, 2.17]
2 Disability ‐ Barthel ADL Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 During usual care	0	0	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 After usual care	2	113	Mean Difference (IV, Random, 95% CI)	2.87 [‐1.37, 7.12]
3 Disability ‐ Barthel ADL ambulation subscale Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

3.1 During usual care	2	79	Mean Difference (IV, Fixed, 95% CI)	‐1.94 [‐5.92, 2.04]
3.2 After usual care	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 Disability ‐ Barthel & FIM Instrument Show forest plot	3	179	Std. Mean Difference (IV, Fixed, 95% CI)	0.27 [‐0.02, 0.57]

4.1 During usual care	0	0	Std. Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.2 After usual care	3	179	Std. Mean Difference (IV, Fixed, 95% CI)	0.27 [‐0.02, 0.57]
5 Physical fitness ‐ strength, ankle dorsiflexion* Show forest plot	2		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

5.1 During usual care	0	0	Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
5.2 After usual care	2	148	Std. Mean Difference (IV, Random, 95% CI)	0.80 [‐0.82, 2.41]
6 Physical fitness ‐ strength, knee extension* Show forest plot	2		Std. Mean Difference (IV, Fixed, 95% CI)	Subtotals only

6.1 During usual care	0	0	Std. Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.2 After usual care	2	148	Std. Mean Difference (IV, Fixed, 95% CI)	0.34 [0.02, 0.67]
7 Mobility ‐ gait preferred speed (m/min) Show forest plot	8	332	Std. Mean Difference (IV, Fixed, 95% CI)	0.27 [0.05, 0.49]

7.1 During usual care	2	79	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.01 [‐0.45, 0.43]
7.2 After usual care	6	253	Std. Mean Difference (IV, Fixed, 95% CI)	0.36 [0.11, 0.61]
8 Mobility ‐ gait preferred speed (m/min); subgroup: therapy time Show forest plot	8	332	Std. Mean Difference (IV, Fixed, 95% CI)	0.27 [0.05, 0.49]

8.1 Confounded	5	196	Std. Mean Difference (IV, Fixed, 95% CI)	0.51 [0.23, 0.80]
8.2 Unconfounded	3	136	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.07 [‐0.41, 0.27]
9 Mobility ‐ gait endurance (6 MWT metres) Show forest plot	4	177	Std. Mean Difference (IV, Fixed, 95% CI)	0.39 [0.09, 0.69]

9.1 During usual care	0	0	Std. Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
9.2 After usual care	4	177	Std. Mean Difference (IV, Fixed, 95% CI)	0.39 [0.09, 0.69]
10 Physical function ‐ Fugl‐Meyer lower extremity Show forest plot	4	199	Std. Mean Difference (IV, Fixed, 95% CI)	0.25 [‐0.03, 0.53]

10.1 During usual care	2	79	Std. Mean Difference (IV, Fixed, 95% CI)	0.08 [‐0.36, 0.53]
10.2 After usual care	2	120	Std. Mean Difference (IV, Fixed, 95% CI)	0.36 [0.00, 0.73]
11 Physical function ‐ Fugl‐Meyer upper extremity Show forest plot	4	199	Std. Mean Difference (IV, Fixed, 95% CI)	0.07 [‐0.21, 0.35]

11.1 During usual care	2	79	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.04 [‐0.48, 0.40]
11.2 After usual care	2	120	Std. Mean Difference (IV, Fixed, 95% CI)	0.14 [‐0.22, 0.50]
12 Physical function ‐ Berg Balance Show forest plot	4	199	Std. Mean Difference (IV, Random, 95% CI)	0.21 [‐0.27, 0.69]

12.1 During usual care	2	79	Std. Mean Difference (IV, Random, 95% CI)	‐0.15 [‐0.60, 0.29]
12.2 After usual care	2	120	Std. Mean Difference (IV, Random, 95% CI)	0.54 [0.17, 0.90]
13 Physical function ‐ functional reach Show forest plot	2		Std. Mean Difference (IV, Fixed, 95% CI)	Subtotals only

13.1 During usual care	0	0	Std. Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
13.2 After usual care	2	166	Std. Mean Difference (IV, Fixed, 95% CI)	0.13 [‐0.18, 0.43]
14 Physical function ‐ timed up and go (sec) Show forest plot	4	185	Mean Difference (IV, Fixed, 95% CI)	‐1.14 [‐2.06, ‐0.22]

14.1 During usual care	1	62	Mean Difference (IV, Fixed, 95% CI)	‐2.0 [‐11.24, 7.24]
14.2 After usual care	3	123	Mean Difference (IV, Fixed, 95% CI)	‐1.13 [‐2.05, ‐0.21]
15 Physical function ‐ timed up and go (sec); sensitivity analysis: excluding Yang 2006 Show forest plot	3	137	Mean Difference (IV, Fixed, 95% CI)	‐1.16 [‐2.93, 0.62]

15.1 During usual care	1	62	Mean Difference (IV, Fixed, 95% CI)	‐2.0 [‐11.24, 7.24]
15.2 After usual care	2	75	Mean Difference (IV, Fixed, 95% CI)	‐1.12 [‐2.93, 0.69]
16 Health related QoL ‐ SF‐36 role physical Show forest plot	3	178	Std. Mean Difference (IV, Fixed, 95% CI)	0.56 [0.26, 0.86]

16.1 During usual care	0	0	Std. Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
16.2 After usual care	3	178	Std. Mean Difference (IV, Fixed, 95% CI)	0.56 [0.26, 0.86]
17 Health related QoL ‐ SF‐36 physical function Show forest plot	2	112	Std. Mean Difference (IV, Fixed, 95% CI)	0.48 [0.10, 0.85]

17.1 During usual care	0	0	Std. Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
17.2 After usual care	2	112	Std. Mean Difference (IV, Fixed, 95% CI)	0.48 [0.10, 0.85]
18 Health related QoL ‐ SF‐36 social function Show forest plot	2	112	Std. Mean Difference (IV, Random, 95% CI)	0.48 [‐0.22, 1.17]

18.1 During usual care	0	0	Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
18.2 After usual care	2	112	Std. Mean Difference (IV, Random, 95% CI)	0.48 [‐0.22, 1.17]
19 Mobility ‐ Community Ambulation Speed (> 0.8 m/sec) Show forest plot	2	165	Odds Ratio (M‐H, Fixed, 95% CI)	1.31 [0.70, 2.44]

19.1 During usual care	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
19.2 After usual care	2	165	Odds Ratio (M‐H, Fixed, 95% CI)	1.31 [0.70, 2.44]

Comparison 5. Mixed training versus control ‐ end of intervention

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Comparison 6. Mixed training versus control ‐ end of retention follow up

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Disability ‐ Barthel & FIM combined Show forest plot	2		Std. Mean Difference (IV, Fixed, 95% CI)	Subtotals only

1.1 During usual care	0	0	Std. Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 After usual care	2	146	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.09 [‐0.41, 0.24]
2 Mobility ‐ gait preferred speed (m/min) Show forest plot	3	135	Mean Difference (IV, Fixed, 95% CI)	‐2.34 [‐5.17, 0.49]

2.1 During usual care	1	62	Mean Difference (IV, Fixed, 95% CI)	‐3.60 [‐14.80, 7.60]
2.2 After usual care	2	73	Mean Difference (IV, Fixed, 95% CI)	‐2.26 [‐5.18, 0.67]
3 Physical function ‐ timed up and go (sec) Show forest plot	3	136	Mean Difference (IV, Fixed, 95% CI)	‐0.30 [‐1.14, 0.55]

3.1 During usual care	1	62	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐6.97, 6.97]
3.2 After usual care	2	74	Mean Difference (IV, Fixed, 95% CI)	‐0.30 [‐1.15, 0.55]
4 Health related QoL ‐ SF‐36 role physical Show forest plot	2	146	Mean Difference (IV, Fixed, 95% CI)	11.61 [2.38, 20.84]

4.1 During usual care	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.2 After usual care	2	146	Mean Difference (IV, Fixed, 95% CI)	11.61 [2.38, 20.84]
5 Health related QoL ‐ SF‐36 physical function Show forest plot	2	146	Mean Difference (IV, Random, 95% CI)	2.46 [‐7.20, 12.11]

5.1 During usual care	0	0	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
5.2 After usual care	2	146	Mean Difference (IV, Random, 95% CI)	2.46 [‐7.20, 12.11]
6 Case fatality Show forest plot	3	211	Odds Ratio (M‐H, Fixed, 95% CI)	0.48 [0.04, 5.47]

6.1 During usual care	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.2 After usual care	3	211	Odds Ratio (M‐H, Fixed, 95% CI)	0.48 [0.04, 5.47]
7 Mobility ‐ Community Ambulation Speed (> 0.8 m/sec) Show forest plot	2	165	Odds Ratio (M‐H, Fixed, 95% CI)	1.19 [0.63, 2.26]

7.1 During usual care	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.2 After usual care	2	165	Odds Ratio (M‐H, Fixed, 95% CI)	1.19 [0.63, 2.26]

Comparison 6. Mixed training versus control ‐ end of retention follow up

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Comparison 7. Cardiorespiratory training versus strength training

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mobility ‐ gait preferred speed (m/min) Show forest plot	12		Std. Mean Difference (IV, Fixed, 95% CI)	Subtotals only

1.1 Cardiorespiratory training	4	356	Std. Mean Difference (IV, Fixed, 95% CI)	0.34 [0.13, 0.55]
1.2 Mixed training	8	332	Std. Mean Difference (IV, Fixed, 95% CI)	0.27 [0.05, 0.49]
2 Mobility ‐ gait preferred speed (m/min); sensitivity analysis: confounded studies removed Show forest plot	6		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

2.1 Cardiorespiratory training	3	266	Mean Difference (IV, Fixed, 95% CI)	6.98 [2.39, 11.56]
2.2 Mixed training	3	136	Mean Difference (IV, Fixed, 95% CI)	‐0.25 [‐3.21, 2.71]

Comparison 7. Cardiorespiratory training versus strength training

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