Disability and Rehabilitation

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Effects of aerobic exercise using cycle ergometry

on balance and functional capacity in post-stroke
patients: a systematic review and meta-analysis of
randomised clinical trials

Luigi Da Campo, Melina Hauck, Miriam Allein Zago Marcolino, Douglas

Pinheiro, Rodrigo Della Méa Plentz & Fernanda Cechetti

To cite this article: Luigi Da Campo, Melina Hauck, Miriam Allein Zago Marcolino, Douglas
Pinheiro, Rodrigo Della Méa Plentz & Fernanda Cechetti (2019): Effects of aerobic exercise using
cycle ergometry on balance and functional capacity in post-stroke patients: a systematic review and
meta-analysis of randomised clinical trials, Disability and Rehabilitation

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DISABILITY AND REHABILITATION
https://doi.org/10.1080/09638288.2019.1670272

REVIEW ARTICLE

Effects of aerobic exercise using cycle ergometry on balance and functional

capacity in post-stroke patients: a systematic review and meta-analysis of
randomised clinical trials
Luigi Da Campoa, Melina Hauckb, Miriam Allein Zago Marcolinoa, Douglas Pinheiroa ,
Rodrigo Della M

ea Plentza,b and Fernanda Cechettia
a
Graduate Program of Rehabilitation Sciences, Federal University of Health Sciences, Porto Alegre, Brazil; bGraduate Program of Health
Sciences, Federal University of Health Sciences, Porto Alegre, Brazil

ABSTRACT ARTICLE HISTORY

Background: Previous studies have shown that aerobic exercise with cycle ergometer improves motor Received 6 August 2018
control. Revised 16 September 2019
Purpose: The objective of this systematic review and meta-analysis are to evaluate evidence about the Accepted 17 September 2019
effects of aerobic exercise with cycle ergometer on the balance of post-stroke patients, evaluated by the
KEYWORDS
Berg Balance Scale (BBS), and functional capacity, evaluated by the maximal oxygen intake and six-minute Stroke; postural balance;
walk test (6MWT). exercise; cardiorespiratory
Methods: The research was conducted on MEDLINE, LILACS, Cochrane Library, EMBASE, Physiotherapy fitness; systematic review;
Evidence Database, and Google Scholar until March 2018 (CRD42015020146). Two independent reviewers meta-analysis
performed the article selection, data extraction, and methodological quality assessment. The main out-
come was balance assessed by the Berg scale and the secondary outcome was functional capacity of the
maximal oxygen intake and the 6MWT. Meta-analysis was conducted using a random-effects method, and
mean pre-post intervention difference with a 95% confidence interval (95%CI).
Results: The review included 5 papers and a total of 258 patients. It was observed that the cycle ergom-
eter did not improve balance in this population (0.03 [
0.57 to 0.64] p ¼ 0.91) or functional capacity in
maximal oxygen intake (2.40 [
0.24 to 5.04] p ¼ 0.07) and 6MWT (
40.49 [
131.70 to 50.72] p ¼ 0.38).
Conclusions: The cycle ergometer aerobic exercise did not seem to improve balance or functional cap-
acity in post-stroke patients.

ä IMPLICATIONS FOR REHABILITATION

 Aerobic exercise with cycle ergometer does not improve balance in patients after chronic stroke, but
the results for functional capacity are more promising.
 Beneficial changes in functional capacity can be seen after 12–4 weeks of training, and are depend-
ent on the initial level of physical fitness of each individual.
 The use of the cycle-ergometer to improve balance and functional capacity was not superior when
compared to conventional physiotherapy; therefore, a combination of therapeutic modalities would
be ideal for rehabilitation and post-stroke patients.

Introduction
Stroke is characterised by a decrease or complete discontinuation
of blood supply to brain tissue, causing transient or permanent
deficits in cerebral areas and in the functional status of individuals
[1]. The ischemic type is 80% more frequent than the haemor-
rhagic type [1] and, currently, stroke is considered a public health
problem [1,2]. Stroke is the second leading cause of death in the
world, behind only ischemic heart disease, and the leading cause
of disability in adults, affecting almost 700 000 individuals per
year worldwide, from which 500 000 are new stroke events and
200 000 are recurring events [1–3]. In Brazil, cerebrovascular dis-
eases led to 160 621 hospitalisations with a mortality rate of 51.8/
100 000 inhabitants in 2009 [1,2]. Also, there were more than
100 000 deaths due to cerebrovascular diseases in 2012 showing
a correlation between old age and the increasing of stroke inci-
dence [4].
Balance control is critical to maintaining orthostatic posture
and dynamic posture, such as ambulation [5]. After injury, patients
show significant balance deficits, which is a complex process that
depends on the integration of the visual, vestibular and central
and peripheral nervous systems [5]. In dynamic activities, such as
gait, the weight transfer from the paretic limb during the posture
phase is difficult, and changes in the space-time variables, includ-
ing velocity [6]. Functional capacity can be defined as the possibil-
ity of autonomously maintaining mental and physical abilities for
the maintenance of life [7]. Functional incapacity is defined by the
presence of impairment in the performance of certain gestures
and certain activities of daily living or even by the impossibility of

CONTACT Fernanda Cechetti nandacechetti@gmail.com Post-Graduation Program in Rehabilitation Sciences, Federal University of Health Sciences of Porto
Alegre, Porto Alegre, Rio Grande do Sul, Brazil
Supplemental data for this article can be accessed here.
ß 2019 Informa UK Limited, trading as Taylor & Francis Group
2 L. DA CAMPO ET AL.
performing them [8]. Basic activity of daily living skills (ABVDs),
such as dressing, eating, bathing alone, and even wandering small
distances independently are strongly impaired, predisposing the
individual to a functional disability. Likewise, instrumental activ-
ities of daily living (AIVDs), which refer to the more complex activ-
ities of everyday life, such as walking, shopping, cleaning the
house, among others are also impaired [9].
A recent meta-analysis with 729 post-stroke patients showed
that interventions with physical exercises appear to be effective in
improving balance self-efficacy in this population [10]. The cycle
ergometer is one of the therapeutic alternatives used in physical
therapy which allows passive, active, and resisted exercises by
mechanical or electrical systems [11]. In a recent systematic
review, cycle ergometer training was the most commonly used
form of aerobic training, and conventional physiotherapy (based
on stretching, strengthening, balance, coordination, and gait train-
ing) was the most frequent control therapy [12].
Studies have demonstrated that aerobic exercise with a cycle
ergometer for the lower limbs improves muscle function, trunk
control, and gait speed in post-stroke patients [13]. Others
reported an improvement in functional and aerobic capacity
[14,15], motor function, distance travelled, muscle tone [16],
muscle strength [17], and gait performance [15]. According to pre-
vious studies, cycle ergometer therapy in post-stroke patients has
shown significant gains in static and dynamic balance when
measured by the Berg Balance Scale (BBS) when compared to
conventional exercise [18].
Although cycling is not the most obvious intervention when
seeking balance improvement, the patient even in the sitting pos-
ition performs upper and lower limb movements that will radiate
to the trunk, and good trunk control may be considered a
requirement important for the control of more complex and func-
tional activities such as maintaining balance; in this context,
cycling treatment seems to be a good option [13]. Therefore, this
study aims to systematically review randomised clinical trials (RCT)
which applied aerobic exercise with cycle ergometer alone, com-
pared to conventional therapy or other interventions on balance
and functional capacity outcomes in post-stroke patients.
Methods
Design and search strategy
This systematic review was reported according to the PRISMA
Statement [19] and the Cochrane Collaboration [20]. Its protocol
was registered in the International Prospective Register of
Systematic Reviews (PROSPERO: CRD42017060748) and can be
fully assessed online at http://www.crd.york.ac.uk/PROSPERO/dis-
play_record.php?ID=CRD42017060748.
Specifically, the following PICO question was formulated:
“Amongst post-stroke patients, to what extent do structured aer-
obic exercise interventions performed on a cycle ergometer, in
comparison to non-training controls, active controls or to another
exercise intervention, impact balance in terms of the BBS and
functional capacity in terms of the VO2max and 6MWT.”
Literature searches were conducted using electronic databases
(no year restriction, but up to May 2019), MEDLINE (accessed by
PubMed), LILACS, Physiotherapy Evidence Database (PEDro),
EMBASE, Cochrane Central Register of Controlled Trials (Cochrane
CENTRAL), and Google Scholar. The search strategy used the indi-
vidual or combined indexed terms “stroke,” “exercise,” “exercise
therapy,” and “physical exertion,” non-indexed words related to
the intervention such as “stationary cycling” and its variations
added to a previously proposed sequence of words with high
sensitivity in the search for RCTs [21]. Words related to outcomes
of interest were not included to enhance the sensitivity of our
search. Search terms were adjusted to fit the requirements of
each electronic database. The search strategy used in MEDLINE is
shown in Supplementary Appendix S1.
Eligibility criteria, intervention, and participants
Only RCTs with at least one intervention group by aerobic exer-
cise with a cycle ergometer and one comparator group were
included, which assessed the effects of interventions on balance
in post-stroke patients. The comparisons were made between aer-
obic exercise with a cycle ergometer and placebo, control or
other treatment. Editorial comments, reviews, and meta-analyses
were excluded. The languages were restricted to English,
Portuguese, and Spanish. RCTs included adult patients, men, and
women, of any race or ethnic background, with a diagnosis of
ischemic or haemorrhagic stroke. Post-stroke patients in the acute
period (until three months) were not included.
Outcome measures
The primary outcome was balance assessed by the BBS. The
secondary outcome was functional capacity assessed by the
six-minute walk test (6MWT) and/or maximum oxygen consump-
tion (VO2max).
Study selection and data extraction
Two independent reviewers assessed the titles and abstracts of all
articles identified by the search strategy. Potentially eligible but
uncertain studies were retrieved for full-text evaluation. The same
reviewers independently assessed the full text to perform selec-
tion according to pre-specified eligibility criteria. Data extraction
was done by two reviewers independently using a standardised
form and included the methodological design, number of sub-
jects, comparison groups, intervention protocol, and results of
outcomes of interest. Extracted outcomes were related to balance
and functional capacity.
Disagreements between authors during the selection of
articles were evaluated by a third reviewer when it was not pos-
sible to reach a consensus. The authors of incomplete papers
were contacted by email, and in the impossibility of obtaining
more information about the research, the study was excluded
from the analysis.
Assessment of risk of bias
The assessment of methodological quality was made descriptively,
according to the method proposed by the Cochrane
Collaboration, considering the following characteristics of the
studies: random sequence generation, concealed allocation, blind-
ing of participants and investigators (professional who adminis-
tered the training), blinding of outcome assessors, incomplete
outcome data, selective reporting, and other bias. The judgment
was categorised as low, high, or unclear risk of bias [16].
Data analysis
The meta-analysis was performed using the random-effect model.
Effect size was calculated using the difference between the mean
and standard deviation before and after the intervention, compar-
ing the intervention group and control group. Statistical
 EFFECTS OF AEROBIC EXERCISE WITH CYCLE-ERGOMETER 3

heterogeneity was assessed using the Cochrane’s Q test and the
inconsistency test (I2), which values above 25% and 50% were
considered indicative of moderate and high heterogeneity,
respectively. An alpha value 0.05 and a confidence interval of
95% (95% CI) were considered statistically significant. All meta-
analyses with forest plots were performed with R language in the
RStudio software. The risk of bias graphic was generated in
Review Manager version 5.3.5.
Results
Flow of studies
In the search strategy, 12 636 papers were found, but 729 were
duplicates. After reviewing the titles and abstracts, 20 papers
were selected for full-text evaluation. From those, ten were
excluded because of method of intervention, four articles were
not RCTs, and one was Chinese. Finally, five papers were included
in the systematic review and meta-analysis (Figure 1).
Descriptions of studies
All studies included in this systematic review and meta-analysis
evaluated balance through the BBS [17,22–24]; three studies eval-
uated VO2max [17,23,24], while three studies evaluated 6MWT
[17,22,24]. Table 1 shows the characteristics of the studies with
author, year, number of patients, training protocol, comparator
group, measured outcomes, and features. There was great vari-
ability between the training protocols regarding the intervention
time, at 6 weeks [18], 8 weeks [23], 12 weeks [17,24], and up to
four months [22].
The number of protocol days during the week and the inter-
vention time was also varied, two times a day for at least 10 min
[22], three times a week for 45 min [23], three times a week for
36 min with a rest interval of 5–10 min [24], five times a week for
30 min [18], and five times a week for 40 min [17]. Comparison
groups were conventional therapy [17,18] physio and ergothera-
peutic interventions [22], stretching activities for upper and lower
extremities [23], and series of exercises for the upper extrem-
ities [24].
Risk of bias
In the random sequence generation, two studies presented a low
risk of bias [17,24], one study presented a high risk of bias [23]
and two studies presented an unclear risk of bias [22,23] (selec-
tion bias); all studies presented an unclear risk of allocation con-
cealment (selection bias). Only one of the studies presented
adequate blinding of participants and personnel [16], while two
studies presented a high risk of bias [23,24] and two presented an
unclear risk of bias [17,22] (performance bias). In the blinding of
outcome assessment, three studies presented a low risk of bias
[18,23,24] and two presented an unclear risk of bias [17,22]
(detection bias). Three studies presented a low risk of bias for
incomplete outcome data [17,18,23] (attrition bias). Three studies
presented low risk of bias for selective reporting [17,18,23] and
two studies presented high risk of bias (reporting bias) (Figure 2).

Records idenfied through database

Idenficaon

searching (n = 12.636): MEDLINE (11.080), Addional records idenfied

EMBASE (458) COCHRANE (341), PEDRO through other sources
(133), Scielo (93), Google Scholar (530), (n = 1)
LILACS (1)

Duplicates removed (n =729)

Screening

Records excluded in tle

Records screened
and abstract
(n = 10.907)
(n =10.887)

Full-text arcles assessed Full-text articles excluded

for eligibility
Eligibility

because of (n = 15):
(n = 20)

10 article another method

of intervention
Studies included in 1 article in chinese
qualitave synthesis 4 article were not
(n =5) randomized clinical trial
Included

Studies included in quantave

synthesis (meta-analysis)
(n =5 )

Figure 1. Flow diagram of study selection process.

 4 L. DA CAMPO ET AL.

Effects of interventions
pre- and post-training outcome on

pre- and post-training outcome on

pre- and post-training outcome on

pre- and post-training outcome on

pre- and post-training outcome on

There was no significant difference in

There was no significant difference in

There was no significant difference in

There was no significant difference in

There was no significant difference in

balance and 6MWT, but improved
Balance

balance and functional capacity.

balance and functional capacity.

Five studies evaluated balance through the BBS [17,18,22–24],
significantly peak of VO2.
totalling 258 patients. It was observed that the cycle ergometer
Features

did not seem to improve balance when compared traditional

therapy [17,18] physio and ergotherapeutic interventions [22],
stretching activities for upper and lower extremities [23], and ser-
ies of exercises for the upper extremities [24].
balance.

balance.
(MD ¼ 0.03 [95%CI ¼
0.57 to 0.64]; I2 0%; p ¼ 0.91 –
Figure 3).

Functional capacity
A meta-analysis for functional capacity included three studies
[17,23,24] evaluated VO2max, totalling 195 patients. The interven-
Measured outcomes

Balance with BBS and

tion did not improve the peak VO2 when compared conventional
therapy [17,18] physio and ergotherapeutic interventions [22],
Balance with BBS.
Balance with BBS
Balance, VO2max

Balance, VO2max

stretching activities for upper and lower extremities [23], and ser-
and 6MWT.

and 6MWT.

and 6MWT.

VO2max. ies of exercises for the upper extremities [24], and also showed
high heterogeneity (MD ¼ 2.40 [95%CI ¼
0.24 to 5.04]; I2 77%;
p ¼ 0.07 – Figure 4).
A meta-analysis for functional capacity included three studies
[17,22,24] that evaluated functional capacity through 6MWT, total-
Physio and ergotherapeutic

45 min of upper and lower

during the same period

ling 188 patients. It was observed that the intervention did not
Seven different exercises

week for 8 weeks (24

activities, 3 times per
30 min per session, 5

increase functional capacity when compared traditional therapy

extremity stretching
Traditional therapy for
Conventional therapy

sessions) at home.
times a week for
Comparator

[17,18] physio and ergotherapeutic interventions [22], stretching

for the upper

activities for upper and lower extremities [23], and series of exer-
interventions

extremities.

cises for the upper extremities [24] with high heterogeneity

4 weeks.
of time.

(MD ¼
40.49 [95%CI ¼
131.70 to 50.72], I2 93%; p ¼ 0.38 –

Figure 5).

Discussion
day, 5 times a week for 12 week. Intensity
Progressive aerobic cycling training 40 min a

training for 45 min, 3 times per week for

periods of 5–10 min, 3 times a week for

This systematic review with a meta-analysis of RCTs showed that

12 weeks. Target exercise intensity was
Cycling exercise at least 10 min, 2 times a

reasons, 9 patients dropped out of the

Because of sanitary and/or organisational

study so that we were able to receive

Cycling exercise 3  12 min with resting

day, for 4 months in addition to their

Cycling exercise 30 min a day, 5 times a

aerobic exercise with a cycle ergometer does not improve bal-

Progressive resistive stationary bicycle

ance, assessed with BBS, and functional capacity, assessed with

set at 75% of heart rate reserve.
of 50–70% heart rate reserve.

6MWT, or VO2max in post-stroke patients when compared to con-

Training Protocol

BBS: Berg Balance Scale; VO2max: the maximal oxygen intake; 6MWT: six minute walk test.

ventional physical therapy. To the best of our knowledge, this is

data from 31 patients.

the first systematic review to verify the effect of aerobic training

conventional therapy.

with a cycle ergometer on the balance of post-stroke patients.

week for 6 weeks.

The balance can be defined as the ability of the individual to

maintain the body mass centre on the support base or to return
8 weeks.
Table 1. Characteristics of the studies included in the systematic review.

the body mass centre on it after the application of an internal or

Drop out

external disordered force. Another definition, also quite adequate,

refers to balance as an ability of the nervous system to perceive
instability in advance and/or momentary, producing coordinated
responses, with the goal of bringing the body mass centre into
32 chronic stroke patients.

29 chronic stroke patients.

38 chronic stroke patients.

the support base, avoiding, thus, the fall [25]. Some authors
31 stroke patients with

reported that a cycle ergometer may have more positive effects

Patients (n)

on balance when assessed differently. Kim et al. [18] and Kamps

Intervention: 65

Intervention: 16

Intervention: 16

Intervention: 13
128 chronic stroke

Intervention:19

and Schu €le [22] reported a positive effect of intervention with a

hemiparesis.
Control: 63

Control: 15

Control: 16

Control: 16

Control: 19

cycle ergometer on functional variables, like dynamic balance

patients.

assessed by TUG. This result is similar to that of the study of

Kopczynski [25], which compared training with a cycle ergometer
to a treadmill and observed a significant improvement in both
groups. Even though the difference between groups was not sig-
Quaney et al. 2009 [23]

nificant, it is possible that the TUG is a more sensitive scale for

Kamps et al. 2005 [22]

Lund et al. 2017 [24]

Kim et al. 2015 [18]

detecting changes in the balance in post-stroke patients. In add-

Jin et al. 2013 [17]

ition, the BBS scale may be not an enough sensitive instrument to

evaluate balance in patients after stroke, because it is an evalu-
Author, year

ator-dependent and a quantitative scale with values are expressed

by the evaluator after qualitative visualisation of the individual’s
movement [22].
 EFFECTS OF AEROBIC EXERCISE WITH CYCLE-ERGOMETER 5

The variation in exercises during constant practice can improve

muscular strength and motor control in physically active individu-
als [26], as it promotes a process of memory consolidation involv-
ing the prefrontal cortex, which is associated with a higher level
of planning. In the practice of a single exercise, the part of the
brain that is involved in the primary motor cortex, which is associ-
ated with simple motor learning [27]. Two studies that employed
exercise variation in the control group showed greater gains in
balance in comparison to aerobic exercise with a cycle ergometer
[17,24]. Jin et al. [17] showed a greater improvement in the con-
ventional physiotherapy group without significant superiority to
the intervention group with a cycle ergometer. Lund et al. [24]
showed superiority to improving balance, performing seven upper
limb exercises during the same period (36-min-a-day, 3 times a
week) compared to intervention with a cycle ergometer [24].
Possibly, the variation in upper limb exercises may have been the
positive influence on the control group. As it is known that prac-
ticing motor acts induce plasticity in the central nervous system.
The repeated practice of a new motor skill for days or weeks
expands the focus representation in the primary motor area to
create some new synaptic connections [28,29].
The aerobic capacity is reduced in advanced age, mainly due
to cardiac and peripheral alterations, and a significant reduction
in skeletal muscle mass. In sedentary elderly subjects undergoing
regular and intense physical training, VO2max may increase from
30% to 40%. However, beneficial changes can be seen after
12–14 weeks of training, and are dependent on the initial level of
physical fitness of each individual [30]. A recent systematic review
with a meta-analysis including 15 studies, and a total of 598 par-
ticipants, pointed out that moderate and vigorous aerobic exer-
cise with a cycle ergometer and treadmill can increase the
VO2max scores in post-stroke patients, and that higher intensities
would be associated with better results [31]. In a meta-analysis by
Pascual-Leone et al. [32], aerobic training with a cycle ergometer,
Figure 2. Bias risk analysis. treadmill, exercises in water, and functional exercises were

Figure 3. Meta-analysis of balance. It was observed that the cycle ergometer did not increase the balance (MD ¼ 0.03 [95%CI ¼
0.57 to 0.64]; I2 0%; p ¼ 0.91).

Figure 4. Meta-analysis of (VO2max), demonstrated that the intervention does not improved peak VO2, also with high heterogeneity (MD ¼ 2.40 [95%CI ¼
0.24 to
5.04]; I2 77%; p ¼ 0.07).
6 L. DA CAMPO ET AL.
Figure 5. Meta-analysis of 6MWT, demonstrated that the intervention does not improve this variable, also with high heterogeneity (MD ¼
40.49 [95%CI ¼
131.70
to 50.72], I2 93%; p ¼ 0.38).
demonstrated to be effective at improving VO2max in patients
after stroke. However, the review of Pascual-Leone et al. [32], the
only study that failed to demonstrate significant effect of aerobic
training involved a 4-week intervention. It is possible that this
period was not sufficient to cause substantial cardiovascular
changes in post-stroke patients. Our meta-analysis showed that
aerobic exercise with a cycle ergometer was not able to cause sig-
nificant improvements in the VO2max scores. Two studies
included in our meta-analysis performed the intervention protocol
for 12 weeks [12,17], while one study performed the intervention
for only 8 weeks [15]. It is believed that time may not have been
sufficient to promote significant gains in groups after the inter-
vention. Therefore, increasing aerobic capacity may be associated
with intervention time, and the employment of a cycle ergometer
during longer periods may provide better results for VO2max.
Our meta-analysis showed that aerobic exercise with a cycle
ergometer was not able to cause significant improvements in the
6MWT scores. In the study of Kamps et al. [21], the intervention
protocol was 4 months, while in the studies of Jin et al. [17] and
Lund et al. [24] it was 12 weeks. Two studies [17,22] demonstrated
a significant increase in the cycle ergometer group compared to
the control group with conventional therapy. The study by Lund
et al. [24] showed that the intervention group retained the same
values for the 6MWT in the pre- and post-intervention compari-
son, whereas the control group had a significant increase in this
outcome. The author does not explain the reason for the better
performance in 6MWT, but it is possibly because of an exercise
series. Exercises are more dynamic and involve multiple joints,
while aerobic exercise with a cycle ergometer is a static activity
with cyclic movements of the lower or upper limbs and does not
exercise the gait. Curiously, only Lund et al. [24] described the
population included in their sample in detail, including age in
years (40–80) and months post-stroke (between 6 and 36), which
may have influenced these results.
An important bias that may influence the results of the meta-
analysis is the time since the stroke. While some of the patients
included in the studies had only a few months of injury, there
were other cases which the injury time was greater than
18 months [14,17,22]. Such variations in injury time can signifi-
cantly compromise patients’ evolution, because motor physical
therapy seeks to improve the patient’s potential for functional
recovery when started early [33]. Another important limitation is
that all studies included in the meta-analysis using balance as a
secondary outcome and did not consider strictly as an initial
problem of the individuals, which could make aerobic training
with cycle ergometer less effective, considering that some
patients may have had an equilibrium value considered normal at
the beginning of the study.
BBS is probably not enough sensitive instrument to detect
changes in this population, mainly because it is an evaluator-
dependent scale, it is possible that the Time up and go test is a
more sensitive scale to detect changes in balance in post-stroke
patients, as it is an exclusively quantitative analysis of the
patient’s performance in the test [22]. Thus, it was inferred that
there was no increase in patient cases, there was hardly any
improvement of the balance, that there was a failure in the task
and that the small changes were not informed about the relevant
information [24].
Conclusion
This systematic review with meta-analysis suggests that aerobic
exercise in rehabilitation with a cycle ergometer did seem not to
improve balance or functional capacity in post-stroke patients.
However, as only a few studies were found, with a high risk of
bias and very heterogeneous results, further RCTs with better
methodological quality are required to provide more conclusive
evidence about the subject.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
We would like to thank Coordenaç~ao de Aperfeiçoamento de
Pessoal de N
ıvel Superior (CAPES) for financial support.
ORCID
Douglas Pinheiro http://orcid.org/0000-0002-6411-1389
References
[1] Almeida S. An
alise epidemiolo
gica do acidente vascular
cerebral no Brasil [Epidemiological analysis of stroke in
Brazil]. RNC. 2012;20(4):481–482.
[2] Lima LGC, Oliveira PSD, Silva VS, et al. Acidente vascular
encef
alico, um problema de sau
de pu
blica: uma revis~ao de
literatura [Stroke, a public health problem: a literature
review]. EFDeportes Com. 2014;19:196.
[3] American Heart Association. Heart disease and stroke statis-
tics. Dallas (TX): American Heart Association; 2005.
[4] DATASUS. Sistemas de informaç~ao sobre mortalidade (SIM).
Minist
erio da Sa
ude [Mortality Information Systems (SIM).
Ministry of Health]. 2012 [cited 2017 Nov 5]. Available
from: http://tabnet.datasus.gov.br/
[5] Britto H, Mendes L, Silva E, et al. Correlation between bal-
ance, speed, and walking ability in individuals with chronic
hemiparesis. Fisioter Mov. 2016;29(1):87–94.

[6] Hsu AL, Tang PF, Jan MH. Analysis of impairments influenc-
ing gait velocity and asymmetry of hemiplegic patients
after mild to moderate stroke. Arch Phys Med Rehabil.
2003;84:118–593.
[7] Dutra MOM, Coura AS, França ISX, et al. Sociodemographic
factors and functional capacity of elderly affected by
stroke. Rev Bras Epidemiol. 2017;20(1):124–135.
[8] Rosa TEC, Benicio MHD, Latorre M, et al. Fatores determi-
nantes da capacidade funcional entre idosos. Rev Sa
ude
Pu
blica. 2003;37(1):40–48.
[9] Rizzetti DA, Trevisan CM. Functional ability assessment in
patients with sequelae of stroke participants of the Project
Hidro-kinetic therapy applied to neurological pathologies
of the aging. Sau
de. 2008;34a(1–2):32–36.
[10] Tang A, Tao A, Soh M, et al. The effect of interventions on
balance self-efficacy in the stroke population: a systematic
review and meta-analysis. Clin Rehabil. 2015;29(12):
1168–1177. Dec
[11] Needham D, Truong A, Fan E. Technology to enhance
physical rehabilitation of critically ill patients. Crit Care Med
Mount Prospect. 2009;37(15):S436–S41.
[12] Francica J, Bigongiari A, Mochizuki L, et al. Aerobic pro-
gram in persons with stroke: a systematic review. Acta Med
Port. 2014;27(1):108–115.
[13] Ambrosini E, Ferrante S, Pedrocchi A, et al. Cycling induced
by electrical stimulation improves motor recovery in post-
acute hemiparetic patients: a randomised controlled trial.
Stroke J Cerebral Circ. 2011;42(4):1068–1073.
[14] Janssen TW, Beltman JM, Elich P, et al. Effects of electric
stimulation-assisted cycling training in people with chronic
stroke. Arch Phys Med Rehabil. 2008;89(3):463.
[15] Sandberg K, Kleist M, Falk L, et al. Effects of twice-weekly
intense aerobic exercise in early sub-acute stroke: a rando-
mised controlled trial. Arch Phys Med Rehabil. 2016;97(8):
1244–1253.
[16] Yang HC, Lee CL, Lin R, et al. Effect of biofeedback cycling
training on functional recovery and walking ability of lower
extremity in patients with stroke. Kaohsiung J Med Sci.
2014;30(1):35–42.
[17] Jin H, Jiang Y, Wei Q, et al. Effects of aerobic cycling train-
ing on cardiovascular fitness and heart rate recovery in
patients with chronic stroke. NeuroRehabilitation. 2013;
23(2):327–335.
[18] Kim SJ, Hwi-Young C, You KL, et al. Effects of stationary
cycling exercise on the balance and gait abilities of chronic
stroke patients. J Phys Ther Sci. 2015;27(11):3529–3531.
[19] Liberati A, et al. The PRISMA statement for reporting sys-
tematic reviews and meta-analyses of studies that evaluate
health care interventions: explanation and elaboration. Ann
Intern Med. 2009;62(10):1–34.
EFFECTS OF AEROBIC EXERCISE WITH CYCLE-ERGOMETER 7
[20] Green S, Higgins J, editors. 2005. Glossary. Cochrane hand-
book for systematic reviews of interventions 4.2.5. [cited
2017 Nov 19]. Available from: http://www.cochrane.org/
resources/glossary.htm
[21] Robinson KA, Dickersin K. Development of a highly sensi-
tive search strategy for the retrieval of reports of controlled
trials using PubMed. Int J Epidemiol. 2002;31(1):150–153.
[22] Kamps A, Schule K. Cyclic movement training of the lower
limb in stroke rehabilitation. Neurol Rehabil. 2005;11(5):
1–12.
[23] Quaney B, Lara A, Joan M, et al. Aerobic exercise improves
cognition and motor function post-stroke. Neuro Rehab
Neural Repair. 2009;23(9):879–885.
[24] Lund C, Dalgas U, Gronborg TK, et al. Balance and walking
performance are improved after resistance and aerobic
training in persons with chronic stroke. Disabil Rehabil.
2017;40:2408–2415.
[25] Kopczynski MC. Fisioterapia em neurologia. (Coleç~ao man-
uais de especializaç~ao Albert Einstein) [Physical therapy in
neurology. (Albert Einstein Specialization Manuals
Collection)]. Barueri (Brazil): Manole; 2012.
[26] Kim KS, Kim JY, Jeong IG, et al. The comparison of effect of
treadmill and ergometer training on gait and balance in
stroke. J Korean Med Sci. 2010;25(3):435–443.
[27] Fonseca RM, et al. Changes in exercises are more effective
than in loading schemes to improve muscle strength.
J Strength Cond. 2014;28:3085–3092.
[28] Shailesh S, Katherine JS ,Beth EF, et al. Neural substrates of
motor memory consolidation depend on practice structure.
Nat Neurosci. 2010;13:923–925.
[29] Karni A, Meyer G, Jezzard P, et al. Functional MRI evidence
for adult motor cortex plasticity during motor skill learning.
Nature. 1995;377(6545):155–158.
[30] Pang MYC, Charlesworth SA, Lau RWK, et al. Using aerobic
exercise to improve health outcomes and quality of life in
stroke: evidence-based exercise prescription recommenda-
tions. Cerebrovasc Dis. 2013;35(1):7–22.
[31] Cohen M, Abdalla RJ. Leso ~es nos esportes: diagno
stico, pre-
venç~ao e tratamento [Sports injuries: diagnosis, prevention
and treatment]. S~ao Paulo (Brazil): Revinter; 2003.
[32] Pascual-Leone A, Nguyet D, Cohen LG, et al. Modulation of
muscle responses evoked by transcranial magnetic stimula-
tion during the acquisition of new fine motor skills.
J Neurophysiol. 1995;74(3):1037–1045.
[33] Arthur AM, Vanini TM, Lima NM, et al. Tratamentos
Fisioterap^euticos em pacientes po
s-AVC: uma revis~ao do
papel da neuroimagem no estudo da plasticidade neural
[Physiotherapeutic treatments in post stroke patients: a
review of the role of neuroimaging in study of neural plas-
ticity]. Rev Ci^enc Biol Agr
ar Sau

de. 2010;14(1):187–208.