Exercise After Stroke: How to Regain Strength, Balance, and Cardiovascular Health
In my years of experience as a clinical exercise physiologist, I have worked with hundreds of patients after they’ve had a stroke. One thing that consistently stands out is that while rehabilitation focuses heavily on regaining movement, which is absolutely essential, the exercise needed to build stamina, improve energy, and address cardiovascular risk factors is often left out.
Most stroke survivors receive excellent physiotherapy aimed at restoring function: walking, balance, and the ability to perform daily activities. But very few are provided with structured programs that challenge the cardiovascular system, improve endurance, or reduce the risk factors that contribute to another stroke.
This gap is important because in addition to being a neurological event, a stroke is also a cardiovascular condition. Without attention to fitness, blood pressure, glucose control, cholesterol, and overall stamina, patients remain vulnerable. Research now shows that including aerobic exercise and even interval training can improve cardiovascular health, reduce recurrence risk, and enhance quality of life — yet most patients leave rehab unsure of what’s safe, effective, and appropriate for them.
What is a stroke?
A stroke occurs when the blood supply to part of the brain is interrupted or reduced, depriving the brain of oxygen and nutrients. Within minutes, brain cells begin to die. Strokes are generally caused either by a blood clot blocking an artery (ischemic stroke, the most common type) or by a blood vessel bursting and causing bleeding into the brain (hemorrhagic stroke). The effects vary depending on the area of the brain affected but can include weakness or paralysis on one side of the body, difficulty with speech, vision impairments, or loss of balance and coordination.
Exercise After a Stroke - What the Evidence Shows
There are a number of systematic reviews, trials, and recent research findings that demonstrate the benefits of adding cardiovascular & high‐intensity interval training (HIIT) after stroke. HIIT includes multiple sets of short bursts of high-intensity exercise alternated with rest or low intensity exercise).
The impact HIIT is promising. In 9 trials including approximately 375 patients HIIT improved cardiorespiratory fitness (measured as peak VO₂) by ~3.8 ml/kg/min (95% CI: 2.62 to 5.01). It also improved balance and gait speed compared both to continuous aerobic training and usual care.
Saunders et al., 2020, Cochrane review “Physical fitness training for stroke survivors” found that exercise training, especially involving walking, improves fitness, balance, walking speed/capacity.
Systematic review of exercise effects after stroke or transient ischemic attack: shows reductions in resting systolic blood pressure (≈ −5.3 mm Hg), improvements in fasting glucose, insulin, and increases in HDL cholesterol. These are risk factors for future strokes / cardiovascular disease.
A study led by McMaster University (Moncion, Tang, etc., including “Stroke survivors may benefit from brief bursts of intense exercise …”) compared high‐intensity interval training (HIIT) vs moderate‐intensity continuous training (MICT) in stroke survivors (6 months to 5 years after stroke). HIIT (short bursts of high intensity, interspersed with rest/low intensity) produced greater improvements in cardiovascular fitness.
The protocol used: 3 sessions/week for 12 weeks; HIIT group did ten 1-minute intervals (high effort) with 1 minute low intensity rest between, total ~19 minutes per session. The continuous group did 20-30 minutes at steady moderate intensity. The HIIT group nearly doubled improvements in fitness compared to moderate intensity.
Another study “Locomotor training intensity after stroke: Effects of interval type and mode” explored comparing short vs long interval HIIT and over‐ground vs treadmill mode, showing that short‐interval bursts (30 seconds high effort / 30-60 sec rest) produced faster over-ground walking speeds during the sessions and good cardiovascular load.
What is less well covered / gaps
The average patient often gets little to no advice or programming aimed at improving aerobic capacity after standard physical therapy. Physical therapy often focuses on function (walking, transfers, balance) but less on pushing the cardiovascular system.
Sustainability of gains once structured exercise stops: many studies show benefits during the intervention, but fewer have long-term follow up to see how fitness, risk factors, and outcomes (e.g. second stroke risk) are impacted.
Optimal prescription (what type of HIIT, how intense, how frequent, how supervised) is still being refined. Also safety in people with comorbidities, severe mobility limitations, etc.
Although the research has yet to confirm the optimal exercise protocol, the importance of engaging in cardiovascular exercise is the common theme.
How Exercise Helps: Mechanisms & Outcomes
Improved cardiovascular fitness (VO₂peak or equivalent) means heart, lungs, and circulatory system can deliver oxygen more efficiently. Helps daily activity endurance.
Reduced risk factors: Lower resting blood pressure, improved glucose metabolism, improved lipid profile. These are critical for preventing another stroke.
Neuroplasticity and functional gains: Exercise can help promote brain recovery, improve walking capacity, balance, muscle strength. The meta-analyses show gains in gait speed, balance measures, etc.
Psychosocial benefits: Better mood, quality of life, reduced fatigue likely. Some evidence here, though more limited.
What an Exercise Program Might Look Like After Stroke
Warm-up
5–10 minutes of low-intensity activity (walking, gentle cycling, or range-of-motion exercises).
Prepares the cardiovascular system and reduces injury risk.
Aerobic Exercise (3-5 x/week; working up to accumulating 30 minutes per session)
Activities may include walking, treadmill, stationary cycling, recumbent stepper, or aquatic exercise.
Start at low intensity and progress gradually.
Choose the activity that best fits mobility and balance levels.
High-Intensity Interval Training (HIIT)
One option: 1 minute of higher-effort exercise followed by 1 minute of easy movement, repeated up to 10 times (~20 minutes).
Shorter intervals (30 seconds on / 30–60 seconds rest) can also be effective.
Needs medical clearance and ideally supervision, especially in the early stages.
Strength / Resistance Training (2-3x/week)
Use body weight, resistance bands, or machines to target major muscle groups.
Focus on lower limbs and core to support walking and balance.
Complements but does not replace aerobic exercise.
Balance & Neuromotor Training
Practice single-leg stance, tandem stance, obstacle stepping, or functional tasks like reaching and turning.
Improves fall prevention and walking safety.
Cool-down / Flexibility
Gentle walking or slow cycling to bring heart rate down.
Stretching and light mobility work to aid recovery.
Is is important to note that levels of physical impairment can vary significantly after a stroke and no one program fits all. An Exercise Physiologist can assist you to determine what exercise program is best for you considering your medical condition.
Many stroke survivors experience hemiparesis (weakness on one side of the body), poor coordination, or balance difficulties.
These deficits can limit what exercises feel safe or possible. For example:
Walking may require a cane, walker, or treadmill with handrails.
Free weights may be difficult to control safely if one arm is weaker.
Standing balance work may need to be adapted or supported.
Exercise choices should be tailored to each person’s abilities. Seated options (such as stationary cycling, recumbent stepper, or pool-based exercise) can provide cardiovascular benefits without overloading balance or mobility.
Intensity levels may need to start lower for those with significant weakness or fatigue, with gradual progression as strength and confidence build.
Importantly, these challenges don’t mean exercise isn’t possible — just that modification and creativity are key. Even with deficits, patients can safely improve cardiovascular health, strength, and balance with the right program.
Safety & Practical Issues
Always clear with physician / stroke rehab team, especially if there are comorbid conditions (heart disease, uncontrolled hypertension, arrhythmias, unstable joints).
Monitoring: HR (if possible), perceived exertion (e.g. Borg scale), watch for symptoms: chest discomfort, undue shortness of breath, dizziness.
Start slow and progress: both in duration and intensity.
Supervision possible: supervised sessions are safer, but community programs or home programs may be possible with proper guidance.
Accessibility: for people with limited mobility, hemiparesis, use assistive devices, seated or aquatic options.
Recommendations
Stroke survivors should ask their rehab team: “Is there a way to include aerobic / cardiovascular fitness training or interval training in my program?”
If your clinic or therapy doesn’t offer that, consider find supervised community programs (or cardiac rehabilitation programs) that are adapted for people post-stroke.
For home programs: starting with walking, or cycling, or seated aerobic machine; gradually increasing intensity; using interval-type bouts once capable.
Setting realistic goals: e.g. walking farther, reducing fatigue, being able to do daily tasks without getting winded.
Tracking progress: e.g. distance walked, time spent in higher intensity, heart rate if possible, perceived exertion.
Potential Outcomes From an Exercise Program
Improvements in endurance / cardiovascular fitness (appearance of greater ease with walking, less fatigue).
Increases in walking speed, walking capacity.
Better balance, fewer falls or increased confidence with mobility.
Reduction in resting blood pressure, better glucose control, improved lipid profile — lowering stroke recurrence risk.
Better quality of life, less depression, more social participation.
Conclusions
Exercise after stroke should not stop at restoring basic function. Cardiovascular training, and especially interval training, offers real chance to improve health, reduce future stroke risk, and improve overall quality of life.
Evidence increasingly supports that HIIT (in appropriately screened and supervised individuals) is more effective than moderate continuous training for some outcomes.
There remain gaps: more long-term data, better implementation, making training accessible. But the case is strong enough that stroke rehab programs should be considering better integration of cardiovascular / interval training.
If you have question about exercising after a stroke contact us. We are here to help you achieve your health and fitness goals.
The information in the blog is provided for informational and educational purposes only and does not constitute medical advice. The information is not a substitute for professional medical advice, diagnosis, or treatment. For questions please follow up with your healthcare professional.
