The Psychological Impact of Exercise-Based Neurorehabilitation in Stroke Survivor

Abstract

Stroke is a major cause of protracted disability everywhere and those who survived the stroke have severe physical, cognitive and mental impairments. One of the key interventions that have proved to be of great benefit to stroke recovery is exercise-based neuro rehabilitation that has proven to have significant benefit over and above the restoration of physical potential. The chapter offers a thorough review of the psychological consequences of neuro rehabilitation based on exercise among stroke survivors, the mechanisms by which physical exercise affects the outcome of mental health. It has been established that structured exercise programs have a big impact in reducing depression and anxiety, improving self-efficacy and quality of life and mediate neuroplasticity-related cognitive changes. The chapter is a synthesis of the existing studies on the dose-response relationships, the best features of interventions and personal differences in psychological reactions to exercise rehabilitation. The neurobiological mechanisms of these effects, such as neurotransmitter modulation, neurotransmitter-dependent changes in the expression and functional connectivity of brain-derived neurotrophic factor are given special attention. Discussed is the clinical implications and future research directions on the need to incorporate psychological assessment and support into exercise-based rehabilitation protocols.

Keywords: stroke rehabilitation, exercise therapy, psychological outcomes, depression, quality of life, neuroplasticity, mental health, post stroke recovery.

1. Introduction

Stroke is a catastrophic neurological phenomenon in that almost 15 million people worldwide experience a stroke every year, of which almost 6 million are killed, and 5 million are permanently disabled [1]. The impact of stroke is much bigger than the direct physical disabilities, including extensive psychological effects that may have a very strong influence on the recovery process and long-term results. Post stroke depression occurs to 30–50 percent of survivors, whereas anxiety disorders happen in about 25-percent of survivors that decreases rehabilitation participation, slower functional recovery and decreases the quality of life [2, 3].

The exercise-based neuro rehabilitation has been developed as a core aspect of the overall stroke recovery programs which were traditionally aimed to restore motor control and physical autonomy. Nevertheless, the growing body of research has shown that exercise has significant positive effects in the psychological sphere, and its therapeutic potential lies in the treatment of mental health problems of stroke survivors [4, 5]. The understanding that exercise is both a physical and psychological intervention has changed the paradigms of rehabilitation, placing a stress on the interdependence of physical and mental recovery.

The mechanisms by which the psychological effect of exercise in stroke rehabilitation works are multi-factorial and interrelated. The neurobiological mechanisms are exercise-related neuroplasticity, neurotransmitters regulation, and central nervous system anti-inflammatory influences [6]. Some of the mechanisms in psychology are increased self-efficacy, change in body image, social interaction and cognitive reorganization which have been made possible by accomplishment of milestones in the rehabilitation process [7]. These mechanisms play a significant role in understanding how to optimize the rehabilitation protocols and how specific interventions may be developed in order to achieve the maximum outcomes of physical and psychological recovery.

This chapter summarizes the available literature on the psychological effects of neuro rehabilitation based on exercises in stroke survivors. It explores the scale and effect of psychological disorders after stroke, evaluates the evidence behind exercise as a psychological treatment, outlines neurobiological and psychological mechanisms underlying it, discusses clinical and implementation issues and finds the way forward in future research. This is aimed at equipping clinicians, researchers and healthcare professionals with an in-depth knowledge on how exercise rehabilitation could be used to help in alleviating the multifaceted psychological needs of stroke survivors.

2. Psychological Stroke Repercussions

2.1 Post-Stroke Depression

Post-stroke depression (PSD) is one of the most prevalent and disabling psychological factors after stroke as it has an estimated prevalence of between 30% and 50% depending on the method of assessment and length elapsed after a stroke [8]. PSD is typified by sustained low mood, anhedonia, worthlessness and in severe instances, suicidal ideation. The condition usually occurs in the first three months after the stroke, but may occur at any stage of the recovery process [9]. In contrast with the situation with major depressive disorder among the general population, PSD has peculiarities associated with the neurological damage or impairment of functions caused by a stroke.

There are multifactorial etiological mechanisms of PSD, including biological and psychosocial factors. At the neurobiological level, it was found that the functional impairment of frontal-subcortical circuits, in particular, the ones that entail the left anterior hemisphere and basal ganglia, is involved in the development of depression [10]. Damage to ascending pathways causes the depletion of monoaminergic neurotransmitters such as serotonin and norepinephrine, as well as adds to depressive symptomatology. The abrupt loss of independence, alterations in social roles, diminished social engagement, and perceived burden on relatives put the person under the risk of depression psychosocially because of depression [11].

The effect of PSD on stroke recovery is extensive and two-fold. The depressed stroke survivors show low participation in the rehabilitation activities, slower motor recovery, poorer functional outcomes, and high mortality rates [12]. Depression reduces the cognitive ability especially the executive and attention ability, which is important in the learning process of new compensatory strategies in rehabilitation. Moreover, PSD considerably affects the reduction of life quality and intensifies care burden, which begins its cycle of promoting psychological distress and preventing recovery [13].

2.2 Anxiety Disorders and Fears

Stroke survivors were found to have anxiety disorders in about 2025 per cent in the form of a generalized anxiety disorder, panic disorder or specific phobias about falling or a recur [14] stroke. Although it has a strong influence on the participation in rehabilitation and functional recovery, post-stroke anxiety is often under-recognized and under-treated. The survivors are often overwhelmed with excessive concern over the incidents of future illnesses, anxiety that they will fall during mobility processes and having social anxiety over impairments in communication or a physical disability that is noticeable [15].

Fear of falling is a highly common and dysfunctional manifestation of anxiety in stroke survivors, occurring in 40–73 percent of stroke patients during the rehabilitation process [16]. The resultant effect of this fear, which may be avoidance of activities, less practice in mobility and lowered levels of physical activity are a self-perpetuating cycle of deconditioning and fall risk. The interaction between anxiety and physical rehabilitation is not straightforward; on one hand, the anxiety can promote the cautiousness and safety consciousness, but on the other hand, anxiety can inhibit learning and limit the severity of practice that is required to achieve the best motor recovery [17].

Dysfunction in the structures of the limbic system, especially, the amygdala and hippocampus, and cortex-subcortical circuits pertaining to emotion regulation are some of our neurobiological underpinnings of post-stroke anxiety [18]. Damages to the right hemisphere, especially the parietal and the temporal lobes have been linked to increased anxiety. Also, persistent stimulation of the hypothalamic-pituitary-adrenal axis and an increase in cortisol levels are responsible not only to persistent anxiety symptoms but can also disrupt the recovery processes in the neural system [19].

2.3 Decreased Self-Efficacy and Quality of Life

Stroke has a severe effect on self-efficacy of the survivor their belief in their capacity to perform actions that would help them to meet certain goals. The abrupt physical, cognitive and communicative impairments impose on the previously formed beliefs and abilities about oneself [20]. Low self-efficacy is found to be a strong prognosis or predictor of poor rehabilitation outcome as low self-efficacy individuals have lower chances of engaging in challenging activities, persisting during challenges or setting challenging goals of recovery [21].

The health related quality of life (HRQoL) is significantly impaired after the stroke and those who attended stroke show lower satisfaction level of physical, psychological, social and environmental levels [22]. Physical impairment has a direct relationship with HRQoL because of less physical autonomy in activities of everyday living and psychological elements such as depression, anxiety, and low self-efficacy intermediation of the interaction between physical impairment and subjective well-being [23]. Loss of employment and altered roles in the family, social isolation also adds to the low quality of life, which supports the multidimensional character of post stroke psychological consequences.

The interdependence of depression and anxiety on self-efficacy and quality of life results in the development of complex psychological images, which should be evaluated and treated as a whole. The studies have shown that the psychological aspects tend to explain variance in the quality of life that cannot be attributed to the physical impairment alone, which is why it is so important to consider the issue of mental health in stroke rehabilitation [24]. This knowledge has propelled the growing concern on interventions especially exercise-based interventions that can simultaneously address physical and psychological recovery domains.

3. Mechanisms and Evidence of Exercise-Based Neuro Rehabilitation

3.1 Types of Exercise Interventions in Stroke Rehabilitation

The exercise-based neuro rehabilitation is a set of varied intervention modalities which are aimed at achieving motor recovery, cardiovascular fitness and functional independence. Treadmill training, cycling and arm ergometry are aerobic exercises used to enhance cardiovascular endurance and also gives a repetitive task-oriented practice [25]. These interventions are usually moderate to vigorous intensity activity that is carried out over the period of 20–60 minutes, 3–5 times a week, and intensity is determined by heart rate, perceived exertion or metabolic equivalents [26].

Resistance training is aimed towards enhancing muscle power, strength and endurance by subjecting a particular group of muscle fibers to progressive loads. Functional activities and resistance training has been proven to be effective in ameliorating both strength and functional outcomes in post-stroke weakness, which is a major limitation to functional activities [27]. Common programs include 2–3 sessions a week, with the major muscles being 1–3 sets of 8–15 repetitions at 50–80 percent one-repetition maximum [28].

Task-based training focuses on drilling of functional activities that are important in everyday living including sit-to-stand transfer, reaching and grasping, and walking. This methodology is consistent with the principles of motor learning because it offers problem-specific training to enable neural reorganization and the acquisition of skills [29]. The use of circuit training programs is a trendy method of training that incorporates various types of exercises that incorporate aerobic, resistance and task-oriented activities [30].

Some of the new exercise options are aquatic therapy, where the buoyancy of water is used to eliminate weight-bearing stresses and provide resistance with which strengthening can occur; robotic assisted training, which allows high-intensity and repetitive practice, real-time feedback; and virtual reality enhanced exercises, which make exercises seem more engaging and motivating through gamification [31, 32]. Although these innovative methods have a future, classic forms of exercise are the basis of evidence-based stroke rehabilitation, and time-tested procedures and proved efficacy in various groups are established.

3.2 Neurobiological Processes of Psychological Benefits

Working out has profound actions on the central nervous system, which has a variety of neurobiological mechanisms, which directly impact mood, cognition, and emotional regulation. Acute exercise elevates the secretion of endorphins, enkephalins and endocannabinoids, which leads to instant mood elevation and perception of less pain [33]. Exercise training also produces lasting neurochemical modifications that have been shown to stimulate serotonin, dopamine and norepinephrine production and receptor sensitivity in areas of the brain that regulate mood e.g., prefrontal cortex, hippocampus and amygdala [34].

The brain-derived neurotrophic factor (BDNF) is a central mediator of the exercise induced neuroplasticity and psychological gains. Exercise enhances BDNF levels in the hippocampus and cortex leading to neurogenesis, synaptic and neuronal survival [35]. Exercise-induced increase in BDNF has been linked to better motor learning, higher cognitive abilities and less depression in stroke survivors [36]. The BDNF Val66Met polymorphism has an effect on personal responses to exercise where the Met carriers have reduced responses to BDNF and may need tailored exercise regimens in order to gain the maximum however [37].

Physical activity stimulates post-stroke neuroplasticity of the brain in its structure and functions. Neuroimaging researches indicate that cortical thickness, hippocampal volume and white matter integrity are enhanced with aerobic exercise among stroke survivors [38]. The elements of the operation connectivity show that there is normalization of broken neural networks by exercise, especially in default mode, attention, and motor networks [39]. Such structural and functional modifications are associated with cognitive, mood and general psychological wellbeing enhancement.

Exercise has psychological advantages that include its anti-inflammatory properties. The neuroinflammatory cascade due to stroke is chronic and leads to secondary brain damage and mood alterations [40]. Exercise decreases the pro-inflammatory cytokine levels (IL-6, TNF-a, IL-1b) and increases the anti-inflammatory markers (IL-10, IL-4), which forms a neuroprotective environment that facilitates recovery and mental health [41]. Also, exercise has the effect of regulating the activity of the hypothalamic pituitary adrenal axis by lowering cortisol levels and enhancing resilience to stress in stroke survivors [42].

3.3 Psychological Mediators and Mechanisms

And in addition to neurobiological impacts, exercise also has psychological outcomes by way of cognitive, behavioral and social impact. One of the major psychological channels in which exercise has an influence on the mental health is self-efficacy enhancement. Effective accomplishment of increasingly demanding exercise activities brings mastery experiences that reinforce self-efficacy beliefs [43]. Because the self-efficacy that stroke survivors gain through exercise translates to other areas of their lives, further boosting their readiness to participate in social life, the self-efficacy is generalized to other life areas [44].

Working out offers socialization and support especially when it is a group oriented program. Rehabilitation encourages social interaction, which overcomes the isolation most stroke survivors feel after their stroke, supports the provision of peer support, normalized social roles and belonging [45]. Group activity generates common experiences, encouragement and learning activities that complement motivation and compliance. It has also been found that social elements of the exercise programs play a significant role in psychological gains, regardless of the impact of the physical exercise [46].

The restructuring of the cognition happens when the stroke survivors are involved in the rehabilitation exercises. This goal setting, progress checking, surmounting difficulties and meeting milestones helps to think in patterns of adaptation and to fight against catastrophic or helpless thinking that are typical of depression [47]. Exercise provides behavioral activation disrupting withdrawal and inactivity patterns that sustain depressive symptoms. The routine and order created by the routine exercise plans also assist in setting healthy daily rhythms that assist in the regulation of mood [48].

Better physical competence and body image lead to psychological wellbeing. The body related self-perceptions of stroke survivors improve as they become stronger, more mobile as well as functional through exercise [49]. This body image boost is associated with decreased stress and anxiety, high self-esteem and increased life satisfaction. The feeling of reclaiming the control over his own body, once having lost it as a result of stroke, is a strong psychological value of exercise rehabilitation [50].

4. Evidence for Psychological Effects of Exercise Rehabilitation

4.1 Impact on Depression and Mood

Systematic reviews and meta-analyses have all shown that exercise-based interventions have a great deal to alleviate depressive symptoms in stroke survivors. Eng and colleagues (2021) performed a comprehensive meta-analysis of 23 randomized controlled trials and discovered that exercise interventions decreased the level of depression with a standardized mean difference of -0.52 (95% CI: -0.71 to -0.33), which is a moderate-to-large effect size [51]. Such advantages are found in a variety of exercise modes which include aerobic training, resistance training, and mixed exercises indicating that antidepressant effects are strong and do not hinge on the type of exercises.

The relationship between the parameters of exercises and the results of depression have been studied as dose-response relationships, but the optimal prescriptions are yet to be developed. Research indicates that at least 12 weeks of a duration exercise program, undertaken 3–5 times per week, and 30–60 minutes per session, have the most significant and long-term antidepressant effects [52]. It seems that a higher intensity exercise is more effective in reducing depression compared to a lower intensity activity, but the correlation is not necessarily linear and the level of individual tolerance should be considered [53]. Notably, exercise has shown similar effectiveness in mild-to-moderate depression treatment as pharmacological antidepressants in stroke survivors with fewer side effects and other added physical outcomes [54].

The long-term follow up studies have shown that the antidepressant effects of exercise are not only on the course of intervention but also on the post-intervention period when regular body exercise is sustained by the individuals [55]. Nevertheless, exercise interruption also results in a slow reappearance of depression symptoms, which underscores the need to encourage continuous exercise practices as a lifestyle change other than a time-limited intervention. Long term compliance, such as home-based ecclesiastical programs, community exercise programs and incorporating the activity to normal medical treatment are key in sustaining psychological benefits [56].

4.2 Effects on Anxiety and Quality of Life

Although the evidence base of exercise impacts on anxiety among stroke survivors is not as strong as that of depression, the existing studies show the presence of anxiolytic effects. A meta-analysis conducted by Oberlin and colleagues (2020) revealed that the effect of the exercise interventions on anxiety symptoms had an intermediate effect size (SMD = -0.45, 95% CI: -0.68 to -0.22) [57]. Remarkably, task oriented and balance training exercises seem specifically useful in fear of falling reduction, which is a direct and frequently used anxiety related issue in this population [58].

Rehabilitation through exercise has continued to enhance health related quality of life in various aspects. The physical domain gains are also firmly developed, where exercise improves mobility, strength and functional independence [59]. The benefits of psychological domain are less emotional distress, elevated mood and self-perception. Social functioning is enhanced by participation in the community, re-involvement in leisure activities and enhanced social relationship [60]. The improvements in environmental domain are associated with a high degree of independence and less dependency, which allows more significant involvement in the home and community settings.

Systematic reviews and meta-analytic studies have shown that exercise interventions are effective in overall quality of life with small to moderate effect sizes (SMD = 0.30 to 0.55) when comparing according to the particular measure of quality of life and exercise regimen [61]. The extent of the quality of life improvements is associated with both the physical increase of the function and the decreasing of the psychological symptoms, which confirms the concept of the physical and mental health interdependence of the stroke recovery. Interestingly, quality of life can be improved in excess of what physical functionality changes would predict on its own, implying that exercise may have independent psychological mechanisms which can improve well-being [62].

4.3 Self-Efficacy Improvement and Cognitive Payoff

Exercise intervention continues to prove to have a positive effect on self-efficacy in stroke survivors. Research that has used validated self-efficacy instruments, including the Stroke Self-Efficacy Questionnaire and the Self-Efficacy for exercise scale, have found that there was significant change after exercise programs [63]. The self-efficacy gains mediate the effect of these gains to other outcomes such as reduced depression, higher physical activity levels and functional independence. Interventions that include goal-setting, performance feedback, and graded task progression seem to be the most effective to be used to improve self-efficacy [64].

Besides the motor learning, cognitive function improvements with exercise rehabilitation include executive, processing speed, attention and memory improvements. Systematic review by Ploughman and colleagues (2022) has shown that exercise-related differences cause significant changes in global cognitive function (SMD = 0.39) and individual cognitive domains such as executive functioning (SMD = 0.35) and attention (SMD = 0.42) [65]. All these enhancements in cognition lead to better quality of life and functional independence and ensure more successful engagement in cognitive rehabilitation and everyday activities.

Exercise intervention timing is related to cognitive outcomes, and new data indicate that the time of intervention (before 3 months after a stroke) can be even more beneficial in terms of cognitive effects, which could be explained by the higher neuroplasticity of acute recovery stages [66]. Cognitive gains are however also evident in exercise that is initiated at chronic stages of stroke implying that the neuroplastic potential is persistent, which may be utilized with the help of suitable interventions [67]. The best exercise parameters that lead to cognitive enhancement have not been studied so well yet, but moderate-vigorous intensity aerobic exercise seems the most effective in repetitive studies.

5. Practice and Clinical Implementation

5.1 Psychological Evaluation during Exercise Rehabilitation

During exercise-based rehabilitation, comprehensive psychological assessment must be incorporated in order to recognize the mental health requirements, monitor intervention responses and maximize the use of intervention approaches. Screeners used to assess depression, which include Patient Health Questionnaire-9 (PHQ-9) or Hospital Anxiety and Depression Scale (HADS), and are validated, should be employed at baseline, through the intervention and after the program ends [68]. The measurement of anxiety through such instruments as the Generalized Anxiety Disorder-7 (GAD-7) or the HADS anxiety subscale is the valuable supplementary data [69].

This significant mediator of rehabilitation outcomes can be tracked using self-efficacy measurement with the help of stroke specific instruments. Multidimensional well-being shifts are measured by quality of life assessment using elaborate measures such as the Stroke Impact Scale, or the Short Form-36 Health Survey [70]. Constant psychological surveillance enables one to identify those people who do not respond well to exercise alone and who can respond to adjunctive psychological interventions like cognitive behavioral therapy or pharmacotherapy [71].

Exercise prescription must take into consideration physical abilities and mental condition. Patients who have acute depression or anxiety might need alternative management, such as reduced initial intensities, reduced time of session, increased supervision and encouragement [72]. On the other hand, psychological preparedness and motivation have an impact on the right intensity and progress rates of exercises. Teamwork in goal-setting including physical and psychological goals increase engagement and consideration of holistic needs of the stroke survivors [73].

5.2 Psychological Outcome Improvement Strategies

The psychological benefits of exercise rehabilitation can be maximized by a number of evidence-based strategies. Group based exercise programs use social support and group interaction to improve mood and motivation [74]. Formal programs which include education elements dealing with mood regulation, stress management and health behavior offer other psychological instruments on top of the exercise itself [75]. Mindfulness or relaxation activities can be incorporated in exercise sessions to increase anxiety reduction and stress management capacity.

The psychological experience of the exercise rehabilitation can be improved with environmental changes. Green exercise Outdoor exercise programs in the natural environment show better mood benefits than indoor exercise, potentially as a result of other stress reducing effects of exposure to nature [76]. Integration in music with exercise improves joy, lessens the perceived efforts and could result in greater mood elevations [77]. The psychological comfort and involvement may be improved by creating favorable and supportive settings with proper aesthetic concerns and reducing clinical settings.

Exercise programs should be individualized according to the personal preferences, the previous experience and the present psychological condition to maximize the adherence and psychological gains [78]. Choice in exercise modalities, autonomy in goal-setting and programs that reflect personal values and interests increase intrinsic motivation and long-term involvement [79]. Frequent review of progress, in both physical performance and psychological achievements, promotes the importance of further involvement and bolsters self efficacy.

5.3 Addressing Barriers to Exercise Participation

There are many psychological barriers that do influence exercise in stroke survivors. Symptoms that involve depression such as lack of energy, anhedonia and hopelessness decrease the desire to start exercise programs and persist with them [80]. Activity avoidance is caused by anxiety and fear of falling or fear of worsening of health. The management of these psychological obstacles must be done through specific approaches such as motivational interviewing, restructuring of catastrophic thoughts in the mind, and graduated exposure to activities they fear [81].

The practical barriers such as transport problems, program costs, and unavailable facilities do not favor stroke survivors of limited resources. Solutions to barriers to accessibility include telerehabilitation and home-based exercise programs that are therapeutically beneficial [82]. The means of delivering evidence based interventions remotely such as video conferencing in order to facilitate supervision, mobile applications in order to provide guidance to exercise and wearable sensors in order to monitor are made possible by technology [83].

The social barriers such as no exercise partners, unavailability of care givers to be driven and stigma associated with disability also demand creative solutions. The practical assistance and psychological motivation of stroke survivors are supported by the peer support programs that link stroke survivors with the experience [84]. Increasing adherence can be achieved by education and participation in exercise programs by caregivers, who can also benefit by having the benefits of respite and stress reduction [85]. Programs that are organized within the community to specifically address persons with disabilities provide an inclusive set up that will lessen the stigma and lead to improved social integration among people.

6. Future Perspectives and Research Requirements

Although there have been great advancements on conceptualizing the psychological effects of exercise rehabilitation among survivors of stroke, there are still enormous research gaps. The parameters of optimal exercise prescription with specific outcomes (psychological outcomes) need to be investigated further. Although there are general principles, the individual difference in the response also requires the use of personal strategies depending on genetic variables, stroke type, comorbidities and initial mental conditions [86]. Making research into predictors of exercise response and developing algorithms to make exercise interventions tailored is a priority area.

Reductions in the psychological benefits and prolonged adherence to exercise participation are to be attended to. Majority of studies are carried out on the short-to-medium term results (3–6 months) but there are few long-term results obtained past one year [87]. Research into effective measures to enhance the adherence of long-term exercise, transition between supervised and independent exercise, and the ways to incorporate exercise into the habitual life would inform clinical practice and policy. Learning to adhere to psychological gains not only in months, but years, is the key to chronic disease management.

Combination of exercises and other treatment modalities has potential of improving psychological results even better. Integrated interventions that involve exercise, cognitive behavioral therapy, mindfulness-based interventions or pharmacotherapy can have synergies that are more effective than individual interventions [88]. Studies on the best combinations, sequencing and integration of various approaches to treatment would move treatment regimes forward. Moreover, exploring exercise as a preventive measure to prevent psychological complications, which should be started as early as after a stroke before the occurrence of symptoms, is also a significant preventive measure [89].

The importance of mechanistic research remains to be applied in learning how exercise can have psychological effects and determining where intervention can be optimized. The treatment strategies will be informed by advanced neuroimaging researches that explain the neural systems and the neurotransmitter mechanisms that are involved in exercise-related mood enhancement [90]. Precision medicine may be possible with the help of genetic and epigenetic studies of individual differences in response to exercise. Knowledge of the temporal dynamics of neurobiological changes in comparison to psychological improvements in symptoms can be used to determine timing and duration of intervention.

There is a need to implement research on implementation science that focuses on the way that psychological assessment and exercise interventions may be incorporated into the routine stroke practice. Even when there is a good body of evidence to support exercise benefits, this has not yet been translated into clinical practice of widespread use [91]. Studies on the impediments and facilitators to implementation, cost benefit analysis, policy implications and integration strategies to the healthcare system would enhance increased access to evidence based exercise rehabilitation to stroke survivors globally.

7. Conclusion

Neuro rehabilitation through exercise is an effective intervention in the context of dealing with the complex psychological issues of stroke survivors. The evidence has proven that structured exercise programs have a great impact in depression and anxiety reduction, self efficacy and quality of life, and cognitive functioning either neurobiologically or psychologically. These effects surpass the same that is being produced by ordinary pharmaceutical or psychological intervention, but at the same time enhances the physical functioning and health.

Psychological assessment and support should be integrated into the exercise rehabilitation programs in order to maximize the results. The acknowledgement of exercise as a physical and psychological intervention involves the clinicians embracing holistic methods, which consider the interrelationship between the body and the mind in the recovery process of stroke. Although the issue of access is still problematic, as long as the problem of adherence and the long-term benefits are promoted, the evidence base on the subject is quite significant, which is why exercise can be discussed as a cornerstone intervention in comprehensive stroke rehabilitation.

The further development of individualized exercise prescription, its combination with complementary therapies and inclusion in the regular care will be likely to improve the psychological advantages of exercise rehabilitation. Due to increasing knowledge of mechanisms behind, and strategies of implementation, exercise-based interventions can increasingly realize their potential in changing not only physical recovery but overall well-being and quality of life of stroke survivors across the globe.

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