Cardiorespiratory Training for Poststroke Cognition—Targeting the Mind Through the Body

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aerobic exercise (65 posts to February 2016)

Cardiorespiratory Training for Poststroke Cognition—Targeting the Mind Through the Body

Zafer Keser, MD¹

1. Author Affiliations 
2. Article Information

 Published Online: August 26, 2025 2025;8;(8):e2528921. doi:10.1001/jamanetworkopen.2025.28921 

Although the benefits of aerobic exercise for overall cardiovascular health and both primary and secondary stroke prevention are well established—and cognitive decline is known to occur in the context of recurrent strokes and poor overall health ²—the role of aerobic exercise in supporting cognitive function independent of these factors remains unclear. The well-designed randomized clinical trial by Brodtmann et al³ tested a biologically plausible but previously undersupported theory⁴: that an intense structured cardiorespiratory exercise (CRX) program may be protective against stroke-related cognitive impairment. In this study, patients with subacute ischemic stroke (within 2 months of onset) participated in an 8-week, high-intensity intervention (180 minutes per week). Participants were randomized to receive either progressive aerobic and resistance training (the CRX group—active intervention) or a control regimen consisting of balance and stretching exercises. The primary outcome, change in hippocampal volume, did not differ significantly between the groups (effect size: −0.10; 95% CI, −0.01 to 0.87). However, notable benefits emerged in the cognitive domains commonly affected in patients who survive stroke.⁵ Patients in the CRX group demonstrated superior performance on executive function, measured by the Trail Making Test, part B (effect size: −3.75; 95% CI, −5.02 to −2.49), as well as global cognition—including memory, language, and praxis—assessed by the Alzheimer Disease Assessment Scale–Cognition subscale (effect size: −1.00; 95% CI, −1.35 to −0.65). These secondary and exploratory outcomes highlight an essential message: that supervised, intensity-tailored aerobic and resistance training programs can yield meaningful cognitive improvements after stroke.

At first glance, the lack of significant change in the primary imaging outcome—hippocampal volume—might suggest a “negative” trial. However, from a clinical standpoint, the findings are both positive and actionable. The study demonstrated that aerobic exercise confers tangible clinical benefits, reinforcing the idea that it should be regarded not just as a tool for improving mobility and cardiovascular health but also as a potentially viable intervention for cognitive recovery after stroke. This shifts the narrative from offering generic advice to stay active toward recommending structured aerobic exercise programs delivered by trained professionals. Notably, the slower-than-expected rate of hippocampal atrophy in the control group—likely due to higher-than-standard activity levels across both groups²—may have limited the ability to detect between-group differences. The authors also acknowledged that structural brain changes may require longer intervention durations to become measurable, suggesting that future studies could further elucidate the full potential of aerobic exercise in neurorehabilitation.

It is also important to consider the generalizability of these findings. The study cohort had a median National Institute of Health Stroke Scale score of 0 to 1 at the time of enrollment and a low burden of cardiovascular comorbidities, reflecting a population with relatively mild strokes and higher functional capacity. This likely contributed to their ability to adhere to the demanding exercise protocol. Future trials should aim to include more representative stroke populations, including individuals with moderate to severe strokes, those with significant cardiovascular risk, and patients with hemorrhagic strokes. Expanding the scope of study populations will be critical for informing clinical guidelines and ensuring equitable access to evidence-based poststroke interventions.

Of note, the authors deserve particular commendation for their determination to complete the trial amid the challenges posed by the COVID-19 pandemic. Their creative adaptation, including the design and deployment of the virtual platform to deliver the intervention remotely, ensured that enrollment targets were met and underscored the feasibility of scalable models of poststroke rehabilitation.

In summary, this randomized clinical trial provides convincing evidence that structured, supervised CRX can enhance cognitive outcomes following ischemic stroke. While no significant structural brain changes were observed during the study duration, the cognitive improvements suggest that neural function—and potentially, neuroplasticity—can be influenced through targeted exercise interventions. It is time for stroke care to embrace a more integrated approach, one that recognizes cardiorespiratory fitness not only as a cardiovascular or motor imperative⁶ but also as a cornerstone of cognitive recovery. This trial marks a pivotal step toward embedding personalized, intensity-guided exercise programs into the core of poststroke care.