Physical activity and exercise recommendations for stroke survivors: an American Heart Association scientific statement from the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council.

Annually, 700 000 people in the United States suffer a stroke, or 1 person every 45 seconds, and nearly one third of these strokes are recurrent.1 More than half of men and women under the age of 65 years who have a stroke die within 8 years.1 Although the stroke death rate fell 12% from 1990 to 2000, the actual number of stroke deaths increased by 9.9%. This represents a leveling off of prior declines.2 Moreover, the incidence of stroke is likely to continue to escalate because of an expanding population of elderly Americans; a growing epidemic of diabetes, obesity, and physical inactivity among the general population; and a greater prevalence of heart failure patients.3 When considered independently from other cardiovascular diseases, stroke continues to be the third leading cause of death in the United States. Improved short-term survival after a stroke has resulted in a population of an estimated 4 700 000 stroke survivors in the United States.1 The majority of recurrent events in stroke survivors are recurrent strokes, at least for the first several years.4 Moreover, individuals presenting with stroke frequently have significant atherosclerotic lesions throughout their vascular system and are at heightened risk for, or have, associated comorbid cardiovascular disease.5,6 Accordingly, recurrent stroke and cardiac disease are the leading causes of mortality in stroke survivors. Both coronary artery disease (CAD) and ischemic stroke share links to many of the same predisposing, potentially modifiable risk factors (hypertension, abnormal blood lipids and lipoproteins, cigarette smoking, physical inactivity, obesity, and diabetes mellitus), which highlights the prominent role lifestyle plays in the origin of stroke and cardiovascular disease.5,7,8 Modification of multiple risk factors through a combination of comprehensive lifestyle interventions and appropriate pharmacological therapy is now recognized as the cornerstone of initiatives aimed at the prevention of recurrent stroke and acute cardiac events in stroke survivors.5,9 Several important factors underscore the potential value of exercise training and physical activity in stroke survivors. Previous studies have demonstrated the trainability of stroke survivors and documented beneficial physiological, psychological, sensorimotor, strength, endurance, and functional effects of various types of exercise.10–23 Moreover, data from studies involving stroke and able-bodied subjects have documented the beneficial impact of regular physical activity on multiple cardiovascular disease risk factors and provided evidence that such benefits are likely to translate into a reduced risk for mortality from stroke and cardiac events.24–28 Although they require additional validation by randomized clinical trials and other appropriately designed studies, these observations make recommendations for stroke survivors to participate in regular physical activity highly compelling at the present time. Unfortunately, stroke remains a leading cause of long-term disability in the United States.1 Consequently, stroke survivors are often deconditioned and predisposed to a sedentary lifestyle that limits performance of activities of daily living, increases the risk for falls, and may contribute to a heightened risk for recurrent stroke and cardiovascular disease. Clearly, stroke survivors can benefit from counseling on participation in physical activity and exercise training. However, most healthcare professionals have limited experience and guidance in exercise programming for this diverse and escalating