TL;DR: A network meta-analysis of 47 trials found that resistance training combined with electrical stimulation therapy produced the largest improvements in balance and lower-limb motor function after stroke, while resistance training plus stretching training was most effective for walking ability.
Stroke ranks among the leading causes of disability globally, and lower-limb dysfunction after stroke directly undermines independence and quality of life. Rehabilitation strategies vary widely in their combinations and intensities. This systematic review and network meta-analysis set out to establish which combinations of resistance training with adjunctive therapies produced the strongest evidence for functional recovery.
Researchers analyzed 47 randomized controlled trials involving 2448 total participants. The trials compared three approaches: resistance training alone, resistance training combined with other modalities (electrical stimulation therapy, stretching training, aerobic exercise, functional training, or other interventions), and control conditions (standard daily care or no additional treatment). The primary outcomes measured were balance (using tests like the Berg Balance Scale), lower-limb motor function (strength and coordination measures), and walking ability (gait speed and endurance).
The results showed a clear hierarchy. For balance and lower-limb motor function, resistance training combined with electrical stimulation therapy outperformed all other combinations. Using the Surface Under the Cumulative Ranking Curve (SUCRA) method, which ranks interventions based on their probability of being most effective, electrical stimulation combined with resistance training scored 91.13% for balance improvements and 79.70% for motor function. For walking ability, however, the pattern shifted: resistance training combined with stretching training emerged as most effective, ranking 96.34% on the SUCRA scale. This suggests that different functional outcomes may benefit from different adjunctive approaches.
The findings underscore that resistance training itself remains a cornerstone of post-stroke rehabilitation, but the addition of targeted complementary therapies amplifies outcomes. The data did not support resistance training combined with aerobic exercise alone as superior to resistance training with electrical stimulation or stretching for these specific lower-limb outcomes. This specificity matters: rehabilitation protocols appear to work best when matched to functional goals, rather than using one-size-fits-all combinations.
If you are recovering from stroke or working with someone who is, these findings have practical implications:
Electrical stimulation for strength and balance gains. If your rehabilitation team recommends electrical stimulation therapy (neuromuscular electrical stimulation, or NMES) alongside resistance training, the evidence supports this pairing for rebuilding leg strength and stability. Electrical stimulation activates muscle fibers that may be partially denervated or weak, complementing voluntary resistance efforts.
Stretching for walking. If walking speed or distance is your primary goal, combining resistance training with stretching training appears to offer the strongest evidence base. This combination addresses both the strength needed to propel yourself forward and the flexibility required for a functional gait pattern.
Resistance training is non-negotiable. All effective combinations included resistance training. This remains the foundation. The question is not whether to do it, but what to add alongside it.
Individualization matters. Your specific deficits should guide your protocol. Balance problems, weakness, and walking speed are interconnected but distinct outcomes. A therapist should assess which limitation most constrains your independence and weight the rehabilitation plan accordingly.
Timing and intensity are not detailed here. This meta-analysis identifies effective combinations but does not deeply address how many sessions per week, how much load, or how long each session should be. Work with your rehabilitation team to establish dosing aligned with these findings.
| Attribute | Details |
|---|---|
| Study type | Systematic review and Bayesian network meta-analysis |
| Sample size | 2448 participants across 47 randomized controlled trials |
| Primary outcomes | Balance, lower-limb motor function, walking ability |
| Journal | American Journal of Physical Medicine and Rehabilitation |
| Publication year | 2025 |
| PubMed ID | 42020998 |
| Evidence tier | |
| Key finding | Resistance training plus electrical stimulation therapy most effective for balance and motor function; resistance training plus stretching training most effective for walking ability |
| Limitations | Heterogeneity in trial designs, outcome measurement tools, and intervention protocols; some trials had small sample sizes; publication bias cannot be excluded |
Optimal Strategy of Resistance Training Combined With Other Rehabilitation Interventions for Lower-Limb Dysfunction in Stroke Patients: A Systematic Review and Network Meta-Analysis. *American Journal of Physical Medicine and Rehabilitation*. https://pubmed.ncbi.nlm.nih.gov/42020998/
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