You are leaving Medscape Education
Cancel Continue
Log in to save activities Your saved activities will show here so that you can easily access them whenever you're ready. Log in here CME & Education Log in to keep track of your credits.


What Is the Effect of Exercise on Stroke Patients?

  • Authors: News Author: Pauline Anderson; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 12/16/2022
  • Valid for credit through: 12/16/2023
Start Activity

  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for primary care physicians, neurologists, nurses/nurse practitioners, physician assistants, and other members of the healthcare team who treat and manage adults with a history of stroke.

The goal of this activity is for the healthcare team to be better able to evaluate how exercise can affect cognitive function among adults with a history of stroke.

Upon completion of this activity, participants will:

  • Analyze the effect of exercise on cognition
  • Evaluate how exercise can affect cognitive function among adults with a history of stroke
  • Outline implications for the healthcare team


Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.

News Author

  • Pauline Anderson

    Freelance writer, Medscape


    Pauline Anderson has no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine


    Charles P. Vega, MD, has the following relevant financial relationships:
    Consultant or advisor for: GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.

Editor/Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC


    Amanda Jett, PharmD, BCACP, has no relevant financial relationships.

Compliance Reviewer

  • Yaisanet Oyola, MD

    Associate Director, Accreditation and Compliance, Medscape, LLC


    Yaisanet Oyola, MD, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.

Accreditation Statements

In support of improving patient care, Medscape, LLC is jointly accredited with commendation by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

    For Physicians

  • Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

    Contact This Provider

    For Nurses

  • Awarded 0.25 contact hour(s) of nursing continuing professional development for RNs and APNs; 0.00 contact hours are in the area of pharmacology.

    Contact This Provider

  • For Physician Assistants

    Medscape, LLC has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 0.25 AAPA Category 1 CME credits. Approval is valid until 12/16/2023. PAs should only claim credit commensurate with the extent of their participation.

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]

Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 75% on the post-test.

Follow these steps to earn CME/CE credit*:

  1. Read the target audience, learning objectives, and author disclosures.
  2. Study the educational content online or printed out.
  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates from the CME/CE Tracker.

*The credit that you receive is based on your user profile.


What Is the Effect of Exercise on Stroke Patients?

Authors: News Author: Pauline Anderson; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 12/16/2022

Valid for credit through: 12/16/2023


Clinical Context

Exercise can have a positive effect on cognitive function. A previous meta-analysis by Northey and colleagues, published in the February 2018 issue of the British Journal of Sports Medicine, summarized the results of 39 randomized trials of exercise among adults older than 50 years.

Researchers found moderate-quality evidence that exercise significantly improved cognitive function. Moreover, different forms of exercise, including aerobic exercise, resistance training, multicomponent training, and tai chi, were all associated with improved cognitive outcomes. In contrast, yoga did not affect cognitive function. The research also suggested that exercise was most beneficial to cognition when it was at least moderate intensity and lasted at least 45 minutes per session.

Patients with stroke are at high risk for cognitive decline. A new randomized trial examines the potential benefit of exercise on their cognitive function.

Study Synopsis and Perspective

Results of a new proof-of-concept trial suggest that exercise had a positive effect on cognitive domains specifically affected by stroke, including memory, attention, and executive function.

The results indicate that exercise is not only physically beneficial but also has a clinically important effect on cognition in patients who have had a stroke, study investigator Teresa Liu-Ambrose, PhD, PT, associate professor and Canada Research Chair in Physical Activity, Faculty of Medicine, University of British Columbia, Vancouver, Canada, told Medscape Medical News.

"At the start of our trial, subjects had at least mild to moderate cognitive impairment, and after 6 months of training, those in the exercise group, on average, were reverting to what would be seen more as a normal state of cognition," she added.

The findings were published online October 13 in JAMA Network Open.[2]

First Study to Target Cognition

Research shows that stroke doubles dementia risk, but poststroke rehabilitation tends to focus on improving motor function rather than cognition, said Dr Liu-Ambrose.

Evidence suggests that exercise is beneficial in patients who have had a stroke, but these studies were not specifically designed to explore the role of exercise, said Dr Liu-Ambrose. "To my knowledge, this new study is the only one directly aimed at cognition."

The new single-center, single-blinded study included 120 community-dwelling patients who had had an ischemic or hemorrhagic stroke. They were a mean age of 70 years, and 62% were men.

The researchers randomly allocated participants to 1 of 3 groups: an exercise training (EX) program that included progressively more difficult strength, aerobic, agility, and balance exercises; a cognitive and social enrichment (ENRICH) group that involved computerized cognitive training and social activities; and a control group that did balance and toning (BAT) exercises.

The 6-month intervention included twice-weekly 60-minute supervised classes. There was then a 6-month follow-up.

The mean baseline Montreal Cognitive Assessment and Alzheimer Disease Assessment Scale-Cognitive-Plus (ADAS-Cog-Plus) scores were 21.89 and 0.22, respectively, indicating cognitive impairment. The mean baseline Fugl-Meyer Assessment Motor score was 81.21, indicating moderate to mild motor impairment.

The primary outcome was the ADAS-Cog-Plus, which assesses memory, attention, and executive function. At the end of the intervention, participants in the EX group had significantly better ADAS-Cog-Plus performance compared with the BAT group (estimated mean difference, −0.24; 95% CI, −0.43 to 0.04; P=.02).

This difference did not persist at the end of follow-up (estimated mean difference, −0.08; 95% CI, −0.29 to 0.12).

Use It or Lose It

"It's intuitive and biologically sound to say that if you're not going to continue to do the exercises, the benefits over time will disappear; it's the notion of use it or lose it," said Dr Liu-Ambrose.

There were no cognitive differences between the ENRICH and BAT groups at the end of the intervention or at the end of follow-up. The evidence suggests that people improve only on the computerized training component they train for, and not on other cognitive performance measures, said Dr Liu-Ambrose.

As for secondary outcomes, the BAT group performed significantly better on the 6-minute walk test compared with the ENRICH group at the end of the intervention (estimated mean difference, −25.70 meters; 95% CI, −50.70 to −0.73 meters; P=.04). The BAT group also reported significantly higher physical activity participation outside the study compared with the EX group at the end of the intervention and at the end of follow-up.

Dr Liu-Ambrose noted that the BAT group included fundamental balance exercises, although these were not progressive.

"The takeaway here is that any basic exercise could be beneficial for people in the chronic phase of stroke, and improving some of the most basic motor functions such as balance, etc, could translate to people's capacity and willingness to engage in further physical activity."

The EX group significantly and meaningfully improved in terms of 4-meter gait speed (by 0.16 m/second) and 6-minute walk test (by 68.72 m) during the 6-month intervention.

A post hoc analysis showed that participants in the exercise group improved on the 13-item ADAS-Cog by 5.65 points. A change of 3.0 points on this scale is a minimally significant difference.

Dr Liu-Ambrose noted that such a change could translate into, for example, patients who have had a stroke being able to cook, plan, and remember to take their medication. "It allows them to live independently and with quality."

There were 42 adverse events (19 in the EX group, 2 in the ENRICH group, and 21 in the BAT group), and 35 of these were deemed not related or most likely not related to the study. No events were serious, with many stemming from muscle soreness, said Dr Liu-Ambrose.

The findings reflect the shifting perspective on what is possible during the chronic phase of stroke, said Dr Liu-Ambrose. "In the past, the notion was that once in the chronic phase, you can't reap much gain from intervening, but the evidence now would suggest there's still the potential from a neuroplasticity perspective."

Counterintuitive Findings

Commenting for Medscape Medical News, Robert J. Adams, MD, distinguished professor of neurology, director, South Carolina Stroke Center of Economic Excellence, Department of Neurology, Medical University of South Carolina, Charleston, and an American Stroke Association national volunteer expert, found the results "surprising."

That there was improvement in cognitive function with the physical exercise regimen but not the cognitive and social enrichment intervention "seems counterintuitive and is what makes the report interesting," said Dr Adams.

"It suggests that more attention needs to be paid to this part of therapy."

He noted that the study participants were at least 5 years out from their stroke and had cognitive impairment and moderate physical deficits. "Right now, basically nothing much at all is done--either in the physical, social, or cognitive domains--this long after stroke, for sure not rigorous physical exercise."

The data might support the idea of periodic "booster" programs in the chronic phase after stroke, said Dr Adams.

However, he said, the study "does not provide evidence for an enduring benefit, nor does it reduce the progression from cognitive impairment to dementia."

Dr Liu-Ambrose and Dr Adams have reported no relevant financial relationships.

JAMA Netw Open. Published online October 13, 2022.

Study Highlights

  • The study design was a single-blind, randomized, 3-group trial. Study participants were community-dwelling adults who had survived a stroke at least 12 months before study enrollment. All participants were at least 55 years old and had no significant neurodegenerative disease or dementia at baseline. Patients receiving medications that could affect cognition were also excluded.
  • Participants were randomly assigned to 1 of 3 interventions. All interventions featured 2 weekly classes of 60 minutes' duration over the course of 6 months:
    • Exercise group, which included strength, agility, aerobic, and balance training
    • Cognitive and social enrichment group
    • Stretching and toning group, which included light exercise only
  • The primary outcome was the ADAS-Cog-Plus at 6 and 12 months after randomization. The ADAS-Cog-Plus is a 13-item assessment of different cognitive domains. It is scored from −3.46 to 4.31, with higher scores indicating worse cognitive function. The threshold for clinically meaningful change in ADAS-Cog-Plus is 3 points.
  • Participants also underwent other cognitive testing, as well as measurements of quality of life and physical function.
  • 120 participants enrolled in the study; 62% were men and the mean age of the cohort was 70 years. The average time since stroke at enrollment exceeded 5 years. The mean ADAS-Cog-Plus score at baseline was 0.22.
  • 86% of participants completed the 6-month intervention, and 80% attended repeat testing at 12 months.
  • At 6 months the exercise group had a significant positive change in the ADAS-Cog-Plus score compared with the stretching and toning cohort, but this difference did not persist at 12 months. There was no difference in ADAS-Cog-Plus scores between the cognitive and social enrichment and stretching at toning cohorts at 6 or 12 months.
  • The exercise group improved by a mean of 5.65 points on the ADAD-Cog-Plus from baseline to 6 months, satisfying the criteria for a clinically significant improvement. However, cognitive scores did not correlate with quality-of-life outcomes.
  • Stretching and toning were associated with more time in exercise outside of class compared with the exercise intervention. Stretching and toning were also associated with better 6-minute walk performance vs the social enrichment intervention.
  • The exercise group experienced improvements in walking speed and endurance from baseline at 6 months.
  • There were 4 adverse events related to the exercise study intervention, but they all resolved without clinical intervention.

Clinical Implications

  • A previous meta-analysis found that exercise was associated with significant improvements in cognitive function. Different forms of exercise, including aerobic exercise, resistance training, and tai chi, were associated with improved cognitive outcomes, and the best results were found for exercise of at least moderate intensity that lasted at least 45 minutes per session.
  • In the current study, an exercise program resulted in clinically significant improvements in cognitive function from baseline among a cohort of older adults with a history of stroke. Exercise was associated with better cognitive function compared with stretching and toning alone, but this advantage was not maintained 6 months after the intervention. There were no serious adverse events related to the exercise intervention.
  • Implications for the healthcare team: The healthcare team should routinely encourage exercise as tolerated among patients with a history of stroke, even years after their stroke.


Earn Credit

  • Print