Aerobic exercise, an effective intervention for cognitive impairment after ischemic stroke

The problem with this is that first your doctor has to get you 100% recovered so you can do this aerobic workout.  And since you  lost 5 cognitive years from your stroke, how else is your doctor going to recover that cognition?

 Aerobic exercise, an effective intervention for cognitive impairment after ischemic stroke

Mingjin Zhu1, Wenjun Chen2 and Jie Zhang1*

1Department of Rehabilitation Medicine, Tongde Hospital of Zhejiang Province, Hangzhou, China

2Department of Pharmacy, Xixi Hospital of Hangzhou, Hangzhou, China

Edited by

Yu-zhang Liu, University of Pittsburgh, United States

Reviewed by

Cathy W. Levenson, Florida State University, United States

Kang Chen, Tianjin University of Sport, China

*Correspondence

Jie Zhang, zhangjie198781@163.com

Received 20 October 2024

Accepted 24 March 2025

Published 04 April 2025

Citation

Zhu M, Chen W and Zhang J (2025) Aerobic exercise, an effective intervention for cognitive impairment after ischemic stroke. Front. Aging Neurosci. 17:1514271. doi: 10.3389/fnagi.2025.1514271

Cognitive dysfunction is a common and debilitating complication following ischemic stroke, significantly impairing the quality of life of patients. In recent years, aerobic exercise has emerged as a promising non-pharmacological intervention to mitigate post-stroke cognitive impairment (PSCI). This review synthesizes current evidence on the efficacy and mechanisms of aerobic exercise in enhancing cognitive recovery after ischemic stroke. Key mechanisms include improved cerebral hemodynamics through enhanced cerebral blood flow (CBF), promotion of neuroplasticity via brain-derived neurotrophic factor (BDNF)-mediated pathways, suppression of neuroinflammation (e.g., NLRP3 inflammasome inhibition), and attenuation of oxidative stress. Preclinical and clinical studies demonstrate that aerobic exercise modalities such as gait training, cycling, and aquatic therapy enhance cognitive domains including memory, executive function, and attention, with optimal benefits observed at moderate-to-high intensity and a frequency of ≥3 sessions per week. Despite robust evidence, challenges remain in standardizing exercise protocols and addressing individual variability in treatment response. Future research should prioritize large-scale randomized controlled trials to validate long-term cognitive benefits and identify biomarkers for personalized rehabilitation strategies. This review underscores the imperative to integrate aerobic exercise into post-stroke rehabilitation paradigms, offering a dual therapeutic approach to improve both physical and cognitive outcomes.

Keywords

aerobic exercise, ischemic stroke, cognitive dysfunction, neuroplasticity, rehabilitation

1 Introduction

Ischemic stroke is a significant global health concern, characterized by the interruption of blood supply to the brain, leading to various neurological deficits. Its epidemiology reveals a high prevalence, particularly in populations with risk factors such as old age, hypertension, diabetes, and obesity (Wang et al., 2022). Reports indicate that stroke is a leading cause of long-term disability, with cognitive impairment being one of the most common sequelae following an ischemic event (Rochemont et al., 2020). Age-related physiological changes—such as hemodynamic dysfunction, loss of elasticity in the arterial walls, chronic neuroinflammation, and increased blood-brain barrier permeability—amplify vascular cognitive impairment severity (Iadecola et al., 2019). Post-stroke cognitive impairment is defined as a decline in cognitive function following a stroke, manifesting as difficulties in attention, memory, executive function, and visual-spatial abilities (Gray et al., 2021). This impairment profoundly affects the quality of life and can complicate rehabilitation efforts, emphasizing the need for effective interventions (Gallucci et al., 2024). The spectrum of cognitive impairment can range from mild cognitive dysfunction to more severe forms, such as vascular dementia (Inoue et al., 2023). Understanding the clinical presentation of these cognitive deficits is crucial for developing targeted rehabilitation strategies that can improve outcomes for stroke survivors.

Physical exercise, as a non-pharmacological intervention, can modulate neuroinflammatory pathways, enhance cognitive function, and improve brain health in Alzheimer's disease (Hu et al., 2024). Aerobic exercise, in particular, has emerged as a vital component in the rehabilitation of stroke patients, especially in addressing cognitive deficits, and plays a key role in improving recovery outcomes (Maeneja et al., 2023). Aerobic exercise, defined as physical activity that elevates heart rate and enhances cardiovascular fitness, includes activities such as walking, cycling, and swimming (Serra et al., 2022). Aerobic exercise has emerged as a promising intervention for mild cognitive impairment (MCI), while also enhancing cerebral blood flow, promoting neurogenesis, and improving cognitive function through molecular mechanisms such as modulating microglia and astrocytes, and promoting neuroprotective factors (Huang et al., 2023; Dao et al., 2024). Research indicates that engaging in regular aerobic exercise can mitigate the cognitive decline associated with ischemic stroke, making it a promising intervention for enhancing cognitive recovery and functional independence in affected individuals (Choi et al., 2024). A network meta-analysis of 29 RCTs with 1,507 participants found that aerobic exercise was the most effective for improving global cognition (MD = 2.83, 95% CI 0.66–4.85) in older adults with Alzheimer's disease (Hu et al., 2025). Another clinical study showed that one-year moderate-to-high intensity aerobic exercise intervention in sedentary older adults increased peak VO2 by 10% (p < 0.001), improved cognitive function, and showed a positive correlation between fitness gains and cognitive performance (r = 0.282, p = 0.042) (Tarumi et al., 2022).

Currently, the heterogeneity in aerobic exercise responses based on stroke subtype is unclear, and the mechanisms underlying the effects of aerobic exercise on cognitive recovery post-stroke remain insufficiently explored. This highlights a significant gap in stroke rehabilitation research, where a one-size-fits-all approach to aerobic exercise may not be universally effective. Different stroke subtypes can lead to distinct neurological impairments, which may influence the brain's response to physical activity. Additionally, the optimal exercise intensity, duration, and frequency for recovery may vary depending on the stroke subtype and individual patient characteristics. A deeper understanding of the relationship between ischemic stroke, cognitive dysfunction, and aerobic exercise is essential. Further investigation is needed to clarify how aerobic exercise improves cognitive outcomes in stroke survivors. This review integrates preclinical and clinical evidence, bridging fields such as epidemiology and molecular biology, to explore the potential mechanisms through which aerobic exercise improves cognitive impairment after ischemic stroke. The ai