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I just came to the end of my hope. I felt depressed and I cut myself with scissors and I got desperate for things to go right for once. Everything in my life at the time was wrong. When you’re in it, you don’t see a way out.

Kelly Holmes, before becoming the Olympic 800 m and 1500 m champion

The role of exercise and physical activity as a means of either preventing or treating neurological disease has received little interest from physicians in spite of decades of research showing clear benefits to this treatment approach. Some areas, such as stroke and depression, are well studied whereas other areas, such as multiple sclerosis, have lower levels of evidence. Unfortunately, as is also the case in other areas of clinical care, exercise is underprescribed for neurological conditions and for those with impaired mental health.

In this chapter we discuss exercise prescription in stroke, Parkinson’s disease, multiple sclerosis, cognitive impairment/dementia and epilepsy, as well as in depression and anxiety. Also refer to Chapter 1 to review the importance of exercise for health and Chapter 16 for more instruction as to how to prescribe exercise.


The population health physical activity guidelines of approximately 150 minutes per week of aerobic activity and one to two sessions of strength-based training are an appropriate foundation for patients with all the conditions discussed in this chapter. Flexibility and functional training (e.g. balance, transfers) are also important. Determining the correct type of aerobic activity (e.g. walking, arm cycling, water exercises) will depend on the neurological deficit and other factors such as balance.


Stroke is a condition characterized by rapidly developing neurological symptoms that last for more than 24 hours or lead to death, with no apparent cause other than that of vascular origin. The two main causes of stroke are brain infarction (which is thromboembolic) and hemorrhage.

Effects of physical activity on stroke mortality

Physically active men and women have a 25–30% reduced risk of stroke when compared with inactive men and women. Various physical activities provide benefits—leisure time activity, occupational movement, and walking. The benefits are not influenced by age or gender.

Key data come from observational studies as well as two meta-analyses of physical activity and stroke.1, 2 The magnitude of the effect of those studies is shown in Table 54.1. The beneficial effects of higher levels of occupational physical activity are similar in extent to those seen in general physical activities, such as walking.

Table 54.1

Dose-response for the benefit of exercise in stroke. Relative risks below 1.0 reflect relative protection against stroke

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