International Journal of

Environmental Research
and Public Health

Systematic Review
Effectiveness of Rehabilitation Exercise in Improving Physical
Function of Stroke Patients: A Systematic Review
Kyung Eun Lee 1 , Muncheong Choi 2 and Bogja Jeoung 2, *

1 Department Sport Industry Studies, Yonsei University, Seoul 03722, Korea

2 Department Exercise Rehabilitation, Gachon University, Incheon 21936, Korea
* Correspondence: bogja05@gachon.ac.kr

Abstract: Rehabilitation is a crucial part of recovery for stroke survivors, and numerous studies have
examined various exercises and treatments of stroke. In addition, it is very important for patients
to choose the timing of rehabilitation and what kind of rehabilitation they will proceed with. The
purpose of the current study is to examine research investigating the effects of rehabilitation exercise
programs in recovery of physical function in patients with stroke, based on aspects of their physical
function, physical strength, and daily activities, and systematically examine their effects. Therefore,
through systematic review, we have investigated the effects of interventions in rehabilitation exercise
programs for recovery of physical function in patients with stroke. We collected relevant publications
through the databases MEDLINE/PubMed and Google scholar. Twenty-one articles were ultimately
selected for the analysis. We classified the rehabilitation programs and identified the trends of
treatment for stroke survivors. Our review indicated that task-oriented therapy is still dominant,
but various types of combined rehabilitations have been attempted. In addition, it was identified
that physical and active rehabilitation were required rather than unconditional rest, even at an early
stage. Home-based treatment was used for rapid recovery and adaptation to daily life during the
Citation: Lee, K.E.; Choi, M.; Jeoung, mid-term period.
B. Effectiveness of Rehabilitation
Exercise in Improving Physical Keywords: stroke rehabilitation; stroke exercise; stroke therapy; systematic review
Function of Stroke Patients: A
Systematic Review. Int. J. Environ.
Res. Public Health 2022, 19, 12739.
https://doi.org/10.3390/ 1. Introduction
ijerph191912739
Stroke is a cerebrovascular disease that occurs when blood supply to the brain is
Academic Editors: Joaquín Calatayud interrupted, or when bleeding occurs in brain tissue, resulting in loss of brain function [1].
and Rubén López-Bueno Stroke is a terrifying disease occurring every two seconds, with people dying every six
Received: 22 August 2022
seconds due to stroke worldwide, and 15 million new cases occurring yearly. Approxi-
Accepted: 29 September 2022
mately 40% of patients suffer from functional impairment after stroke onset, and 15–30%
Published: 5 October 2022
experience severe motor, sensory, cognitive, perceptual, and/or language impairments [2,3].
In particular, more than 85% of patients with stroke experience hemiplegia, which results in
Publisher’s Note: MDPI stays neutral
impaired upper limb function and decreased motor ability [4]. This impairment is a major
with regard to jurisdictional claims in
factor that affects the ability to balance, and the levels of daily and social activities [5].
published maps and institutional affil-
Rehabilitation is vital for minimizing sequelae after stroke, and patients who undergo
iations.
continuous professional and systematic rehabilitation following the acute phase tend to
recover rapidly [6,7]. Drug and rehabilitation therapy are currently practiced rehabilitation
treatments for stroke. Various interventions can be applied for recovery, such as bilateral
Copyright: © 2022 by the authors.
training, repetitive task training, constraint-induced movement therapy, electrical stimu-
Licensee MDPI, Basel, Switzerland. lation, robotic therapy, and exercise [8]. Among these, exercise is crucial because it helps
This article is an open access article patients return to activities of daily life by restoring the function of impaired muscles and
distributed under the terms and improving physical function. Exercise is also essential for preventing secondary complica-
conditions of the Creative Commons tions, as was reported in a study determining that continued exercise and physical activity
Attribution (CC BY) license (https:// after a stroke reduce the risk of recurrence of cardiovascular disease and mortality [9].
creativecommons.org/licenses/by/ Commonly used rehabilitation exercises include those for central nerve develop-
4.0/). ment, passive or active exercise, progressive resistance exercise, mat exercise, and balance,

Int. J. Environ. Res. Public Health 2022, 19, 12739. https://doi.org/10.3390/ijerph191912739 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2022, 19, 12739 2 of 17

postural, mobility, and gait training. According to previous studies, the approaches to
rehabilitation exercises are different depending on the stage of the stroke and the types of
exercise (passive, isometric, isokinetic, and isotonic) [10]. In particular, studies show that
applying rehabilitation exercise early after stroke is effective [11]. However, as physical or
occupational rehabilitation therapy is mainly focused on the early-onset stage, essential
exercise is rarely applied in the early stages of rehabilitation. In addition, rehabilitation
exercise is effective if it is utilized at the appropriate time in accordance with individual
functional suitability [12].
Therefore, guidelines for each type of exercise (passive/isometric/isokinetic/isotonic)
are necessary, as well as programs tailored to the individual functional levels of patients,
such as the time since the injury occurrence. This customized approach will help patients
with stroke recover quickly even after discharge, which will save time and cost. While there
are numerous studies on restoring function in patients with stroke, systematic comparative
analysis studies on the effectiveness of rehabilitation exercise interventions that consider
the timing of the occurrence of impairment and the type of exercise in the clinical field are
difficult to find. Therefore, a systematic analysis of studies applying rehabilitation exercises
for physical function recovery in patients with stroke is necessary.
This study aims to examine research investigating the effects of rehabilitation exercise
programs in recovery of physical function in patients with stroke, based on aspects of their
physical function, physical strength, and daily activities, and systematically examine their
effects. Based on the study findings, we will present the types and programs of exercises
optimized for the phase of injury in patients with stroke.

2. Materials and Methods

The systematic review protocol was conducted based on the Preferred Reporting Items
for Systematic reviews and Meta-Analysis (PRISMA) 2020 [13].

2.1. Systematic Data Resource

A systematic search of relevant publications was conducted in the following electronic
databases: MEDLINE/PubMed and Google Scholar, from May 2022 to June 2022. We
focused on articles published between 2012 to 2022, and English articles only were involved.
The main keywords were “stroke rehabilitation”, “stroke exercise”, and “stroke therapy”,
and the Boolean operator “AND/OR” was applied for additional search.

2.2. Eligibility and Exclusion Criteria

The eligibility criteria were established according to PICO strategy including patients,
intervention, comparison, and outcome, as follows:
• Patients (P): Patients with a stroke (except where a person without disabilities acts as
a person with disabilities)
• Interventions (I): Rehabilitation, exercise, and/or treatment for stroke survivors
• Comparisons (C): No rehabilitation or other intervention
• Outcomes (O): The results after intervention regarding functional improvement, pain
reduction, and effectiveness of treatment
Meanwhile, the exclusion criteria included meta-analysis, reviews, letters, and pro-
ceedings. Further, the articles that did not target stroke survivors were removed. In
addition, publications where intervention, results, case report, or full text were unavailable
were not included for review.

2.3. Screening, Selection, and Exrtraction Process

This review paper selected samples based on PRISMA 2020, and three researchers were
involved in the selection and extraction process. Each researcher collected publications
through a search engine and conducted synthesis and exclusion. As a result, duplicated
and irrelevant records were excluded in the identification stage. We identified the related
Int. J. Environ. Res. Public Health 2022, 19, 12739 3 of 17

publications by screening the titles and abstracts. The researchers read and assessed the
full text articles, and finally selected samples suitable for the study purpose.

2.4. Assessment of Quality

The selected publications were evaluated using the physiotherapy evidence database
(PEDro) scale to identify the methodological quality [14]. The PEDro scale is an appropriate
method for rating the quality of clinical treatment or intervention which assesses 11 items,
including specified eligibility criteria, random allocation, concealed allocation, groups
similar at baseline, subject–therapist–assessor blinding, less than 15% drop-out, intention-to-
treat analysis, between-group statistical comparisons, point measures, and variability data.

3. Results
3.1. Study Selection
Through the database search, 675 articles were identified as potential publications
for review. Once the titles and abstracts of the remaining 95 articles were analyzed, we
retained 52 papers for assessing eligibility. Of these, 31 publications were excluded through
full-text review. Subsequently, 21 articles were ultimately selected for the current review.
The PRISMA flow diagram are presented in Figure 1.

Figure 1. PRISMA flow diagram of the systematic review.

3.2. Quality Assessment and Risk of Bias

To evaluate the quality of the selected articles, the PEDro scale was used. Thirteen of
the articles in the review were of high quality (score 9–11 points), while eight demonstrated
good qualities (score 6–8 points). The result of PEDro is presented in detail in Appendix A.

3.3. Study Characteristics

Twenty-one papers related to rehabilitation and/or exercise in stroke patients were
finally analyzed, summarizing characteristics such as intervention, exercise type, control
group, assessment, and results. The results can be seen in Table 1.
Int. J. Environ. Res. Public Health 2022, 19, 12739 4 of 17

Table 1. Characteristics of the studies included in the systematic review.

Participants
Study ID (Number, Intervention Exercise Type Control Assessment Results
Intervention, Control)
Structured Progressive Temporo-spatial gait: + (p < 0.05), except
SPCCT + Health
Circuit Class Therapy Temporo-spatial gait: for the step length of the unaffected limb
40 participants (20, 20) Education Duration:
Bovonsunthonchai (SPCCT) + MI (Motor FDM (p = 0.063).
Age: 49.9 Functional 90 min
et al. (2020) imagery) Strength: Step length: + (p < 0.001)
Time since stroke Aerobic Frequency:
[15] Duration: 90 min dynamometer Step time: X (p > 0.05)
: 3–12 months 3 times/week (4
Frequency: Step length, time: SI Hip flexor: + (p = 0.002)
weeks)
3 times/week (4 weeks) Knee extensor: + (p = 0.014)
APA-Strokes
Gait velocity: 6 MWT
(progressive exercise Sittercise (performed
BBS (Berg balance Gait speed: + (p = 0.004)
76 participants (43, 33) with gait, standing and in a seated position)
scale), SPPB (Short 30-foot walk: + (p = 0.02)
Stuart et al. (2019) Age: 63.9 seated coordination Duration: 60 min
Aerobic Physical Performance SPPB: X (p = 0.54)
[16] Time since stroke exercises) Frequency:
Battery), the 30-foot BBS: X (p = 0.23)
: 5.1 years Duration: 60 min 3 times/week
timed walk, the Stroke SIS: X (p = 0.90)
Frequency: (6 weeks)
Impact Scale (SIS)
3 times/week (6 weeks)
Constraint-induced
movement therapy
(CIMT): treadmill Treadmill training
Ground reaction force
38 participants (19, 19) training with load (5% of without load
Ribeiro et al. (GRF) from static and Static GRF of the paretic limb: + (p = 0.037)
Age: 57 body weight) on the Duration: 30 min
(2020) Aerobic dynamic trials Control group’s dynamic GRF: + (p = 0.021)
Time since stroke nonparetic limb Frequency:
[17] Swing time symmetry Swing time: X (p = 0.190)
: 3 months Duration: 30 min 2 times/week
ratio
Frequency: (9 sessions)
2 times/week
(9 sessions)
Int. J. Environ. Res. Public Health 2022, 19, 12739 5 of 17

Table 1. Cont.

Participants
Study ID (Number, Intervention Exercise Type Control Assessment Results
Intervention, Control)
Transcranial direct
current stimulation
(tDCS) + body
weight-supported
* Crossover design
treadmill training Gait speed: 10 MWT
30 participants (15, 15) G1: tDCS + BWSTT →
(BWSTT) → Sham stim + Walking ability: Timed G10 s Gait speed: + (p < 0.005)
Manji et al. (2018) Age: 62.2 Sham stim + BWSTT
body weight-supported Aerobic Up and Go (TUG) G10 s Walking ability: + (p < 0.005)
[18] Time since stroke G2: Sham stim +
treadmill training Lower limb: FMA-LE, Effect with the groups or interaction: X
: at least 4 months BWSTT → tDCS +
(BWSTT) TCT, POMA
BWSTT
Duration: 20 min
Frequency:
7 times/week
(2 sessions)
Robotic rehabilitation +
224 participants (113, conventional Task-oriented
Cecchi et al. 111) physiotherapy exercises) + Age-FMA-UE: X (p = 0.603)
Functional
(2021) Age: 68.5 (6 times/week) Conventional FMA-UE * Age is associated with the outcome after
(passive)
[19] Time since stroke Duration: 45 min physiotherapy conventional but not robotic rehabilitation.
: 46.5 days Frequency: 5 days/week (6 times/week)
(30 sessions)
Repetitive facilitative
exercise (elicit movement
of the shoulder, elbow,
49rticipants (26, 23) wrist, and fingers +
Conventional ARAT(Action Research
Shimodozono Age: 65 passive stretching) + Functional ARAT: + (p = 0.009)
upper-extremity Arm Test)
et al. (2012) [20] Time since stroke dexterity-related training (passive) FMA: + (p = 0.019)
rehabilitation program FMA
: 6.8 weeks (30 min)
Duration: 40 min
Frequency: 5 days/week
(20 sessions)
Int. J. Environ. Res. Public Health 2022, 19, 12739 6 of 17

Table 1. Cont.

Participants
Study ID (Number, Intervention Exercise Type Control Assessment Results
Intervention, Control)
Cardiorespiratory
Fitness, Body
Aerobic and resistance Body lean mass: + (p = 0.039)
Composition and
training (AT + RT) Predominantly trunk: + (p = 0.02)
Dietary Assessment.
Duration: 20–60 min affected-side limbs: + (p = 0.04), VO2VT: +
Maximal Isometric
Frequency:5 times/wk (p = 0.046)
68 participants (35, 33) Strength
Marzolini et al. (6 months) Aerobic Muscular strength: + (p < 0.03)
Age: 63.7 6 MWT, Sit-to-Stand
(2018) (duration or intensity Resistance AT Both groups yielded similar and significant
Time since stroke and Stair Climb
[21] was increased)-2 sessions (isotonic) improvements:
: 11.5 months Performance
(AT) 6 MWT: X (p = 0.8)
Exercise Logs,
8weeks-2 sessions (RT) VO2peak: X (p = 0.9)
Adherence to Exercise,
(1 to 2 sets of 10 to 11 Sit-to-stand time: X (p = 0.05),
Exercise Performance,
exercises) Stair climb performance: X (p = 0.97)
and Adverse Event
Reporting
Multidisciplinary stroke
rehabilitation (Cyclic
46 participants (23, 23) Sham stretch
neuromuscular electrical ROM Passive range of motion: X (p = 0.217)
Jong et al. (2013) Age: 57.2 Functional positioning procedure
stimulation (NMES)) Pain in the hemiplegic No significant difference between the
[22] Time since stroke (passive) + simultaneous sham
Duration: 45 min shoulder: Shoulder Q groups (r2 = 1.53, p = 0.217)
: 43 days conventional TENS
Frequency: 2 times/wk
(16 sessions)
FMA-UE: IMT > BMT (p < 0.01)
MAS: IMT + (p = 0.01),
FMA-UE
Robot-assisted therapy BMT X (p = 0.55)
Muscle spasticity:
68 participants (20, 10) (RT) CT X (p = 0.44)
MAS
Hung et al. (2019) Age: 55.54 BMT robot vs. IMT robot Functional Individualized MAL: IMT + (p = 0.01)
Quality of movement:
[23] Time since stroke Duration: 90–100 min (passive) occupational therapy BMT X (p = 0.55)
MAL
: 23 months Frequency: 5 times/wk CT X (p = 0.44)
Muscle strength of the
(20 sessions) MRC: IMT X (p = 0.27)
affected arm: MRC
BMT + (p = 0.01)
CT: X (p = 0.3)
Int. J. Environ. Res. Public Health 2022, 19, 12739 7 of 17

Table 1. Cont.

Participants
Study ID (Number, Intervention Exercise Type Control Assessment Results
Intervention, Control)
FMA-UE
Total MRC: D-IMT > P-IMT, CT (p = 0.04,
Muscle spasticity:
Robot-assisted therapy p = 0.04)
MAS
44 participants (32, 12) (RT) FMA:X (p = 0.77),
Quality of movement:
Hsieh et al. (2018) Age: 54 P-IMT vs. D-IMT Functional Conventional proximal FMA: X (p = 0.97),
MAL
[24] Time since stroke Duration: 90–100 min (passive) rehabilitation +FTP proximal MRC: X (p = 0.12)
Muscle strength of the
: 21 months Frequency: 5 times/wk * Distal upper-limb robotic rehabilitation
affected arm: MRC
(20 sessions) using the D-IMT had superior effects on
Wrist-worn
distal muscle strengthen
accelerometers
HYBRID (combined
FMA-UE
Functional Training WMFT-FAS: HYBRID > FTP (p < 0.05)
19 participants (9, 10) the Ashworth Scale
Patten et al. Practice + Power Resistance * Crossover design Treatment order: X (p = 0.43)
Age: 68 WMFT-FAS
(2013) training) (isokinetic) G1: FTP→HYBRID FMA: X (p > 0.05)
Time since stroke Functional
[25] Duration: 75 min Functional G2: HYBRID→FTP FIM: + (HYB > FTP, p < 0.05)
: 12 months Independence
Frequency: 5 times/wk Ashworth score: X (p > 0.05)
Measure: FIM
(24 sessions)
WMAFT: + (p = 0.02)
FMA-UE
Smart watch based Grip power: X (p = 0.46)
23 participants (17, 6) WMFT-FAS
Home-based FMA-UE: X (p = 0.34)
Chae et al. (2020) Age: 61.4 Tele-rehabilitation Grip power
rehabilitation Functional ROM: flexion: + (p < 0.001)
[26] Time since stroke service ROM
Duration: 30 min Extension: X (p = 0.16)
: at least 6 months BDI: Beck Depression
Frequency: 12 weeks Internal rotation: + (p = 0.001)
Inventory
External rotation: X (p = 0.2)
Treatment effect (FTP vs. POWER): X (both
Dynamic resistance UEFMMS
groups improved without differential
training (POWER) vs. the Ashworth Scale
14 participants (14) * Crossover design treatment effects)
Functional task practice Resistance European Stroke Scale
Corti et al. (2012) Age: 59.8 (10 week+10 week) Treatment order: X (p > 0.05)
(FTP) (isokinetic) CMHAI
[27] Time since stroke Order1: FTP→POWER Period effect: X (p > 0.05)
Duration: 90 min Functional Kinematics of
: 15 weeks Order2: POWER→FTP Kinematic:
Frequency: 3 days/wk functional reach to
Treatment effect: POWER > FTP
(30 sessions) grasp
Treatment order: G2 > G1
Int. J. Environ. Res. Public Health 2022, 19, 12739 8 of 17

Table 1. Cont.

Participants
Study ID (Number, Intervention Exercise Type Control Assessment Results
Intervention, Control)
Supervised physical
Barthel index (BI)
therapy + Segmental
37 participants (19, 18) the Ashworth Scale Both groups improved in BI, Elbow ROM,
Annino et al. muscle vibration
Age: 68.6 Functional Supervised physical (MAS) Elbow muscles strength
(2019) (SPT-SMV)
Time since stroke (passive) therapy (SPT) Manual muscle testing Muscle tone in elbow joint improved only
[28] Duration: 30 min
: null (MMT) in SPT-SMV (p = 0.008)
Frequency: 3 days/wk
ROM
(24 sessions)
Different intensities of
arm rehabilitation
training
(correct positioning and
carrying of the arm;
32 participants (11, 10,
passive, assisted and Resistance FMA-UE
11) 1 h (group A)
Han et al. (2012) active movements; (isotonic) ARAT (Action FMA and ARAT: Group C > A, B (p < 0.05)
Age: 50.2 2 h (group B)
[29] strength training; Functional Research Arm Test) BI: X (p > 0.05).
Time since stroke 3 h (group C)
practice of functional (passive) Barthel index (BI)
: 38–42 days
activities)
Duration: G1: 1 h/G2:
2 h/G3: 3 h
Frequency: 5 days/wk
(30 sessions)
G1: Forced aerobic
exercise (60% to 80% of
their heartrate reserve) +
43 participants (16, 14, repetitive task practice
6 MWT:
Linder et al. 13) (FE + RTP) Aerobic
G1: + (p < 0.001)
(2020) Age: 56 G2: Voluntary aerobic Functional G3: RTP only 6 MWT
G2: + (p < 0.001)
[30] Time since stroke exercise + RTP (VE + (passive)
G3: X (p = 0.21)
: 13 months RTP)
Duration: 90 min
Frequency: 3 times/wk
(24 sessions)
Int. J. Environ. Res. Public Health 2022, 19, 12739 9 of 17

Table 1. Cont.

Participants
Study ID (Number, Intervention Exercise Type Control Assessment Results
Intervention, Control)
Home exercise video on
smart technology and
automated reminders
Adherence: X (p > 0.05)
62 participants (30, 32) (stretching,
Emmerson et al. Adherence WMFT: X (p > 0.05)
Age: 66 strengthening, fine Functional Paper-based home
(2017) WMFT Satisfaction: X (p > 0.05)
Time since stroke motor/coordination) (passive) exercise program
[31] Satisfaction * smart technology was not superior to
: 4 months Duration & Frequency
standard paper-based
depended on the
participants
(average 38 min/day)
CPRS clinical
determinants
Upper extremity aerobic FIM sub scores (motor and cognitive): +
Functional
40 participants (20, 20) exercise (UEAE) (p > 0.05)
Topcuoglu et al. independence measure
Age: 65.95 (arm crank ergometry) Conventional NHP: + (p > 0.005)
(2015) Aerobic (FIM)
Time since stroke Duration: 30 min physiotherapy BDS: + (p = 0.005)
[32] Nottingham Health
: 3.5 months Frequency: 5 days/wk Clinical determinants: significant pain
Profile (NHP)
(20 sessions) relief and decline in signs and symptom
Beck Depression Scale
scores (BDS)
Shoulder subluxation
Active shoulder exercise
distance
36 participants (18, 18) with a sling suspension Subluxation: + (p = 0.001)
Shoulder
Jung et al. (2019) Age: 58.5 system Resistance Proprioception: + (p = 0.046)
Bilateral arm training proprioception
[33] Time since stroke Duration: 40 min (isometric) FMA: + (p = 0.002)
FMA-UE
: 28.65 days Frequency: 5 days/wk MFT: + (p = 0.007)
the manual function
(20 sessions)
test (MFT)
Int. J. Environ. Res. Public Health 2022, 19, 12739 10 of 17

Table 1. Cont.

Participants
Study ID (Number, Intervention Exercise Type Control Assessment Results
Intervention, Control)
Isokinetic peak torque
SIS: isokinetic group had higher scores on
FMA-UE
nearly every domain
Isokinetic training in Stroke Impact Scale
24 participants (12, 12) Extensor peak torque at 60◦ : + (p = 0.007)
Kerimov et al. paretic upper extremity Tailored strengthening (SIS)
Age: 54.3 Resistance Extensor peak isometric muscle strength: +
(2021) Duration: 40 min exercises with exercise Disabilities of the Arm,
Time since stroke (isokinetic) (p = 0.007)
[34] Frequency: 3 days/wk bands Shoulder and Hand
: at least 6 months DASH after 4weeks after the end of
(12 sessions) (DASH) questionnaire
treatment: + (p = 0.014)
Grip strength
Grip strength: X (p > 0.05)
Peak isometric strength
Upper limb strength
Upper limb cycle and grip
20 participants (10, 10) ULCE: all variables showed Superior
Pinheiro et al. ergometer (ULCE) Trunk impairment
Age: 66.2 Conventional (p = 0.005)
(2021) Duration: 20 min Aerobic scale (TIS)
Time since stroke physiotherapy TIS: + (p < 0.001)
[35] Frequency: 5 days/wk Level of independence:
: null (Acute) MRS: + (p < 0.001)
(20 sessions) Modified Rankin scale
(MRS)
Int. J. Environ. Res. Public Health 2022, 19, 12739 11 of 17

The average age of participants was 60.1 years, and most publications focused on
middle-aged and older adults. Most of the studies were randomized controlled trials, and
three studies were of cross-over design [18,25,27]. In the case of the outcome measures,
resistance and functional exercise mainly used Fugl-Meyer scale, the Wolf Motor Function
Test, and Range of Motion. In terms of aerobics, the most commonly used were gait
parameters and Six-Minute Walking Test.

3.4. Exercise Type

The exercises or rehabilitation for stroke patients were classified into resistance, aerobic,
or functional (occupational). Each type was reported in detail.
In two of these studies, resistance exercise was used as an intervention [33,34]. Jung
et al. [33] used an active shoulder exercise with a sling, which applied shoulder joint
isometric contraction. In comparison with the control group that received bilateral arm
training, researchers found the sling system decreased shoulder subluxation, and improved
proprioception and upper extremity function. Kerimov et al. [34] investigated the effects
of isokinetic strengthening in post-stroke patients. The participants conducted a wrist
strengthening program with an isokinetic dynamometer, and the control group performed
customized home-based exercises using resistance bands. The findings showed that isoki-
netic exercise improves motor function of upper limbs.
Five articles researched aerobic exercise [16–18,32,35]: three for lower extremities [16–18],
and two for the upper body [32,35]. Stuart et al. [16]’s adaptive physical activity exercise
program (APA), and Manji et al. [18]’s combined therapy showed improvement in gait
speed. In addition, Ribeiro et al. [17] examined the effects of treadmill training with load.
Although application of load did not indicate extra benefits, they found a minimization of
weight-bearing asymmetry. In terms of upper extremity aerobic exercise, two publications
used arm ergometers. Both articles reported that aerobic exercise is an effective program
for stroke patients.
Functional rehabilitation was used in eight papers [19,20,22–24,26,28,31]. Several
of them [19,23,24] implemented robot-assisted therapy, such as Bi-Manu-Track and In-
Motion robots. In a similar vein, two articles used electrical stimulation [22,28], and
some researchers used smart devices for home care of chronic survivors [26,31]. In
summary, publications researching functional therapy mainly dealt with equipment or
technical treatments.
The remaining six papers applied combined rehabilitation [15,21,25,27,29,30]. Func-
tional, resistance, and aerobic exercises were blended in these papers. Regarding combi-
nation of functional with aerobic treatment [15,30], Bovonsunthonchai et al. [15] applied
both circuit class and training with motor imagery. Liner et al. [30] also conducted aerobic
exercise and repetitive task practice. The results of these articles showed that there were
significant therapeutic improvements in gait and walking capacity when aerobic exercise
and occupational therapy were performed in parallel. In the case of functional and re-
sistance exercises being combined [25,27,29], functional task practice was implemented
with strength or power training. Of such studies, two articles [25,27] conducted isokinetic
exercise in resistance training. Patten et al. [25] carried out both multi- and single-joint
exercises such as lunges, squats, bicep curls (dumbbell), and supine triceps extensions
(dumbbell). Corti et al. [27] also performed isokinetic movements of the upper extremity
using a dynamometer. Both studies found more effective results in programs combined
with resistance exercises than in single functional training. In terms of methodology es-
pecially, these publications used a cross-over design to validate the effectiveness of the
treatment order. However, it was found that the order was not statistically significant. The
last paper, Han et al. [29], provided stroke survivors with functional activities and strength
training as an isotonic exercise. For resistance and aerobic exercise programs [21], Mazolini
et al. [21] conducted two sessions for each program and found significant improvement in
cardiorespiratory capacity compared with single-method therapy.
Int. J. Environ. Res. Public Health 2022, 19, 12739 12 of 17

3.5. Exercise Type Based on the Stage of Stroke

Rehabilitation programs required by stroke patients are different according to the
stage of stroke. Previous studies defined early subacute as less than three months, late
subacute as three to six months, and chronic as more than six months [14]. According to
this time frame, the results are as follows, except for the study of Annino (2019), without
the description of the phase.
Six papers [19,20,22,29,33,35] dealt with the early subacute stage. Cecchi et al. [19]
and Jong et al. [22] used electrical stimulation or robotic rehabilitation focusing on patients
diagnosed with stroke 43–46 days previously. Conducting a study on patients at a similar
stage, Han et al. [29] and Jung et al. [33] used resistance-combined exercises. A study by
Shimodozono et al. [20] applied functional exercises for participants who were diagnosed
six weeks prior. The papers reviewed relating to the early subacute phase mainly used
equipment for treatment, or passive exercise.
Five papers dealt with the late acute period [17,18,27,31,32] for three to six months
after occurrence. Three of them [17,18,32] conducted aerobic rehabilitation using treadmill
or ergometry. Emmerson et al. [31] identified the effect of home-based exercise for stroke
patients in the late acute phase. Corti et al. (2012) [27] compared resistance training and
functional task practice.
The chronic stage was dealt with in nine articles [15,16,21,23–26,30,34]. Four of these
used complex exercise [15,21,25,30] which is the combination of functional, aerobic, and
resistance exercises. In the case of single rehabilitation, there are three articles [16,26,34] for
chronic patients. Stuart et al. [14] used APA-stroke, which contains progressive exercises
and coordination trainings necessary for daily activities. Chae et al. [26] studied the effect of
home-based functional therapy using smart watches to help chronic patients train steadily.
Further, Kerimov et al. [34] conducted isokinetic training in the paretic upper body. Hung
et al. [23] and Hsieh et al. [34] both examined robot-assisted therapy, which is relevant to
functional therapy.

4. Discussion
The goal of stroke rehabilitation is to minimize patients’ impairment and recover daily
activities [36]. The therapy and training for stroke have been studied for a long time, but
the results of the various interventions are too sporadic to be chosen efficiently for practical
aspects. To the best of our knowledge, research regarding the classification of exercise
types and exercise types according to stroke stage are still insufficient. Therefore, this study
attempted to classify the effects of intervention for stroke patients through a systematic
literature review based on exercise type and the phase of stroke.

4.1. Exercise Type

While previous research investigated the application of only single exercises, complex
and/or combined exercises have recently been approached for effective rehabilitation and
therapy [37]. Through the six articles investigating combined exercises, we found they
were effective in improving upper limb and walking ability compared to the performance
of a single exercise. Veerbeek et al. [38] also suggested that new rehabilitation access in the
form of physical activity combined with novel treatments is considered very promising.
In addition, regarding exercise-based rehabilitation, specifically three types of contraction
movements are conducted: isometric, isokinetic, and isotonic training.
Despite these diverse programs, it can be seen from the guidelines and previous
articles that task-oriented therapy is still dominant in rehabilitation for patients with
stroke [39,40]. However, our outcomes and some previous studies showed that the trends
of intervention-applying technologies included robot-assisted, electrical stimulation, and
virtual reality [41–43]. It has been transformed from the passive help of therapists and
simple repetitive forms to a relatively systematic rehabilitation by adopting additional
methods. This can be the salient approach in stroke treatment, where continuity of partici-
pation is the most important. Moreover, the reason why tele-medication and home-based
Int. J. Environ. Res. Public Health 2022, 19, 12739 13 of 17

treatment related studies are increasing can be interpreted in a similar context. In addition,
it was found that studies of cross-over design are being conducted in the field of stroke
rehabilitation, which confirmed the importance of the effectiveness based on the order of
intervention [25,27]. Although task-oriented therapies are still predominantly used for
stroke survivors, various forms of combined exercise have recently been attempted.

4.2. Exercise Type Based on the Stage of Stroke

Prior publications regarding post stroke rehabilitation indicated that future studies
should consider the optimal timing, type, and frequency of treatment [40,44]. According to
our findings, in the early stages, therapy using electrical/robotic aid or passive types of
exercises were mainly performed for impairment. The guidelines for adult stroke written
by Winstein et al. [40] also agreed on the use of assistive technologies in early post-onset. In
Kim et al.’s literature review [45], initial treatment was important to prevent complications.
According to their review, there were many studies on exercises using instruments for
spasticity. Therefore, it was confirmed that many studies partially supported the results
of this study. Stroke survivors generally have a strong preference for rest periods over
exercise-based rehabilitation [46], and to our knowledge, bed rest is considered the best
solution, at least in the early stages. However, from the results of the current study, it
was found that motor activities and mobilization were required from the initial phase.
Askim et al. [47] agreed that the time of bed rest in the early stages of stroke was related
to negative functional effects three months later. The results indicate that physical and
active rehabilitation is required even during the acute stages following stroke rather than
unconditional rest.
The program of late acute phase mostly consists of aerobic and home-based exercises.
The second stage of rehabilitation, late acute period, requires adaptation and recovery to
daily life. Similar outcomes were identified in a systematic review conducted by Kendall
et al. [48], which found that continuous aerobic exercise after two to six months of stroke
improved walking ability. Oliver et al. [49] also stated the beneficial effects of cardiovascular
exercise in subacute stages. In terms of home-based rehabilitation, the severity of illness and
comorbidities [40] should be considered. Chi et al. [50] demonstrated that stroke patients
in both the acute (less than six months after stroke onset) and chronic periods (more than
six months) experienced improvement in physical function. In addition, the survivors
in the acute level showed greater improvement. These results are partially related to the
results of the current study, in that home-based treatment is effective in the acute stage.
We confirmed that the late acute period is a step for adaptation and recovery for stroke
patients, and the focus here is on self-treatment and/or home-based therapy. However,
further studies are required to clearly distinguish the rehabilitation based on the specific
acute phase.
In the chronic stage of six months or more, our review found that combined exercise
programs and tele-rehabilitation using smart devices were mainly conducted. Functional
independence and autonomy may be important in this period [51]. From this point of view,
computerized alert systems and mobile devices might be effective for stroke survivors in the
chronic phase. However, Nam et al. [52] postulated mobile applications and smart devices
are beneficial tools for treatment of stroke patients in the acute phase, which shows the
opposite outcome from this study. Research related to tele-rehabilitation is increasing, but
studies examining the effects of timing are insufficient. More research is therefore required
regarding at which phase internet-based intervention is appropriate. Although it is not
clearly distinguished by stage, it was found to be partially consistent with the guidelines
in previous studies. In future studies, it is necessary to select specific rehabilitation by
subdividing the stages. This study has several limitations. First, it does not include articles
written in English. Previous articles on related topics written in Spanish and German might
have been excluded. Second, this study did not distinguish the type of stroke, such as
ischemic or hemorrhagic stroke, because it was not mentioned in the selected papers.
Int. J. Environ. Res. Public Health 2022, 19, 12739 14 of 17

5. Conclusions
This systematic review examines the effects of interventions and types of rehabilitation
based on the stroke phase. We confirmed that task-oriented therapy is still dominant,
but various types of combined rehabilitations have been attempted academically. In
addition, it was identified that during the initial stage, physically active rehabilitation
was required rather than unconditional bed rest. In terms of the mid-term period, home-
based treatment was applied for recovery and adaptation to daily life. According to
this approach, we provide an overview of applicable guidelines and the specific types
and programs of exercises optimized to the period of injury in patients with stroke. The
patient’s stage and period after stroke onset do not completely represent the severity of
their impairment. However, by establishing guidelines based on period, it will be possible
to suggest post-stroke care suitable for each patient. Therefore, this study attempted to
analyze the rehabilitation program for stroke survivors and provide appropriate exercises
according to the patient’s stage. Future studies can consider a rehabilitation program suited
to patient characteristics by further subdividing the stages.

Author Contributions: Conceptualization, K.E.L., M.C. and B.J.; methodology, K.E.L.; software,
K.E.L.; validation, K.E.L., M.C. and B.J.; formal analysis, K.E.L. and M.C.; investigation, K.E.L., M.C.
and B.J.; resources, M.C.; data curation, K.E.L., M.C. and B.J.; writing—original draft preparation,
K.E.L.; writing—review and editing, K.E.L. and M.C.; visualization, K.E.L.; supervision, B.J.; project
administration, B.J.; funding acquisition, B.J. All authors have read and agreed to the published
version of the manuscript.
Funding: This study was supported by the Translational R&D Program on Smart Rehabilitation Exer-
cises (NCR-TRSRE-Eq01A), National Rehabilitation Center, Ministry of Health and
Welfare, Korea.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Acknowledgments: This study was supported by the Translational R&D Program on Smart Reha-
bilitation Exercises (NCR-TRSRE-Eq01A), National Rehabilitation Center, Ministry of Health and
Welfare, Korea.
Conflicts of Interest: The authors declare no conflict of interest.

Appendix A

Table A1. Assessment of Methodological quality by PEDro scale.

Selected
1 2 3 4 5 6 7 8 9 10 11 Score
Paper
1 Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes 10
2 Yes Yes Yes Yes Yes No No No Yes Yes Yes 8
3 Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes 10
4 Yes Yes No Yes No No Yes Yes Yes Yes Yes 8
5 Yes No No Yes No No No Yes Yes Yes Yes 6
6 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 11
7 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 11
8 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 11
9 Yes Yes No Yes Yes No Yes Yes Yes Yes Yes 9
10 Yes No No Yes Yes Yes Yes Yes Yes Yes Yes 9
Int. J. Environ. Res. Public Health 2022, 19, 12739 15 of 17

Table A1. Cont.

Selected
1 2 3 4 5 6 7 8 9 10 11 Score
Paper
11 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 11
12 Yes Yes No Yes No No No Yes Yes Yes Yes 7
13 Yes Yes No Yes Yes Yes Yes Yes No Yes Yes 10
14 Yes Yes Yes Yes Yes No No Yes Yes No Yes 7
15 Yes Yes No No No Yes No Yes Yes Yes Yes 6
16 Yes Yes Yes Yes Yes No No Yes Yes No Yes 8
17 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 11
18 Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes 11
19 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 11
20 Yes Yes No Yes No No No Yes Yes Yes Yes 8
21 Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes 10

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