The was an editorial in the journal of The Lancet published by Liqun Jiang, et al on March 5, 2026 titled “Optimal exercise modalities for enhancing motor function recovery after stroke: a Bayesian systematic review with pairwise and network meta-analyses.” The article is attached in PDF format for your information, and below is a summary for your convenience.
Introduction
Stroke is a leading cause of death and disability worldwide, with prevalence rising most rapidly in low and middle-income countries. Survivors frequently experience persistent motor dysfunction, gait instability, and balance impairments that diminish quality of life and impose a substantial healthcare burden. Identifying effective strategies to restore function therefore remains a critical challenge in rehabilitation medicine.
Exercise interventions are central to stroke rehabilitation, providing safe, flexible, and cost-effective strategies that enhance cardiopulmonary endurance, muscular strength, postural stability, and neuromotor control. Their efficacy is typically quantified through internationally recognized functional outcomes encompassing walking capacity, gait speed, balance, and motor recovery.
Background
This study aimed to compare the effectiveness of different exercise interventions in improving motor function recovery after stroke and to identify optimal rehabilitation strategies.
Methods
A comprehensive search of five databases was conducted for randomized controlled trials (RCTs) up to March 13, 2025. Primary outcomes included the 6-min walk test (6MWT), 10-m walk test (10MWT), Berg Balance Scale (BBS), and FMA (total, UE, LE). Pairwise and Bayesian network meta-analyses were performed to compare the relative effects of different exercise modalities. Risk of bias was assessed using the RoB 2 tool, and evidence certainty was rated using CINeMA. This systematic review was prospectively registered in PROSPERO (CRD420251091242).
Findings
A total of 317 RCTs involving 14,464 stroke patients were included. Network meta-analysis showed that, compared with routine care, electrical stimulation plus exercise (ESX) was associated with the largest improvement in walking endurance (MD = 53.4 m, 95% CI 14.27–92.58, p < 0.05, I 2 = 0%), while aerobic exercise (AE), functional training (FT), gait training (GT), and mind-body exercise (MBE) showed smaller effects. Lower limb training (LLT) demonstrated the greatest improvement in gait speed (MD = 0.18 m/s, 95% CI 0.14–0.23, p < 0.05, I 2 = 0%), with TCMEX, task-oriented training (TOT), and MBE also showing benefits. For balance (BBS), core stability training (CST) ranked highest (SMD = 0.77, 95% CI 0.30–1.24, p < 0.05, I 2 = 93.24%), followed by MBE and FT. FT showed the largest pooled effect for total FMA (SMD = 2.15, 95% CI 0.48–3.81, p < 0.05, I 2 = 93.86%), whereas MBE showed larger pooled effects for FMA-LE (SMD = 1.94, 95% CI 0.04–3.85, p < 0.05, I 2 = 97.54%) and FMA-UE (SMD = 1.85, 95% CI 1.08–2.63, p < 0.05, I 2 = 95.57%). Substantial heterogeneity was observed in several pooled comparisons. Meta-regression analyses identified multiple outcome-specific clinical and contextual factors (e.g., intervention duration, stroke phase, stroke severity, routine rehabilitation, age, sex distribution, and socioeconomic setting) that partially explained between-study variability, although no single factor accounted for heterogeneity across all outcomes. Importantly, global network diagnostics indicated acceptable overall model fit and consistency, supporting cautious interpretation of the comparative estimates at the network level.
Interpretation
Several structured exercise interventions were associated with improved motor outcomes after stroke. High heterogeneity was observed in some comparisons; however, meta-regression analyses suggested several potential sources of variability, and global network assessments indicated generally acceptable heterogeneity. These findings should therefore be interpreted cautiously, particularly for outcomes with substantial between study variation.
Evidence before this study
We searched PubMed, Embase, Web of Science, Scopus, and Cochrane Library to March 13, 2025, for RCTs on exercise after stroke. Prior reviews showed that structured exercise improves walking, balance, and motor function, but most were limited to pairwise comparisons, leaving uncertainty about the relative efficacy of modalities and the optimal dose. The dose-response relationship had not been systematically assessed.
Added value of this study
This review synthesized 317 RCTs (14,464 patients) evaluating 22 interventions. Using pairwise and network meta-analyses, we ranked exercise modalities across six validated outcomes, with the 6MWT as the primary endpoint. Additional model-based analyses were conducted to explore patterns of intervention effects.
Implications of all the available evidence
Structured exercise interventions improve post-stroke motor outcomes and provide a robust evidence base to support individualized, evidence-informed rehabilitation strategies. These findings help inform clinical decision-making by clarifying the relative effectiveness of commonly used exercise modalities, while emphasizing the need to tailor interventions to patient characteristics and rehabilitation context.
Conclusion
This study synthesized evidence from 317 RCTs using pairwise, network, and dose–response meta-analyses to compare 22 exercise interventions across six functional outcomes in stroke rehabilitation. The findings showed relatively favorable effects across multiple domains. Exercise prescriptions should not rely on fixed dose targets but instead be individualized according to stroke severity, clinical phase, safety, tolerability, and adherence, to ensure both effectiveness and feasibility in real-world rehabilitation practice.