Stroke Awareness Month Highlights Research Exploring Cardiovascular Rehabilitation in Stroke Recovery: Part 2

Beyond clinical consequences, stroke remains one of the most economically burdensome neurologic conditions in the United States, with costs extending well beyond acute hospitalization to include long-term disability, rehabilitation needs, lost productivity, and informal caregiving. As the population ages and more individuals survive stroke, the cumulative financial impact on patients, caregivers, and health systems is projected to rise substantially in the coming decades, underscoring the need for sustainable models of poststroke care and recovery support.¹ To explore these challenges further, NeurologyLive® sat down with stroke expert Sara Cuccurullo, MD, chair, vice president, and medical director at Hackensack Meridian JFK Johnson Rehabilitation Institute.

In the second part of this discussion, Cuccurullo examined emerging evidence on structured cardiovascular rehabilitation after stroke, including its potential effects on functional recovery, mortality, hospital readmissions, and long-term health care costs. She also discussed how these findings have drawn interest from Medicare policymakers, what additional evidence is needed for broader adoption, and the implications for expanding access to poststroke rehabilitation programs nationwide.

What is the clinical relevance of these findings?

That article got Medicare's attention. The Medicare Innovation Center reached out and invited us to come speak with them about the program in Washington. So we went to the Innovation Center at the end of 2019, just before COVID.

They told us that with 795,000 strokes happening every year in the United States, and with people living longer and having more strokes, the financial impact on Medicare by the year 2030 would be enormous. They said that unless preventative programs are developed — either to prevent first strokes or to prevent recurrent strokes, since a first stroke is often more mild — it would be financially unsustainable for Medicare. And it's not good for patients either, because once you have a stroke, you have about a 12 to 25% chance of having another stroke that same year.

They wanted to look at programs that would keep stroke patients healthier. When we went to the Innovation Center, they loved the presentation. They asked us to prove three things: first, that there are cost savings with this program for Medicare; second, that we could bring this existing research project to its full statistical power; and third, that we could replicate it at other sites nationally.

What was the largest impact of the program and it’s findings?

On cost savings: we showed that patients who completed the Stroke CORE program — 36 sessions of aerobic exercise over four months, plus ancillary services, in addition to their standard rehab — had a 22% reduction in all-cause readmissions compared to the control group that received neuro-rehabilitation alone. We demonstrated a tremendous cost savings associated with that. Because 56% of stroke patients face readmission in the first year, and with 795,000 strokes annually, the average readmission cost of approximately $14,400 means readmissions alone cost Medicare roughly $1 billion — with a B — per year.

We also noted that a large portion of Medicare expenditures go toward long-term care for patients who are not functionally independent. We showed that the function of patients who completed this program improved substantially. We're essentially training them like athletes — getting them on these machines three times a week, ensuring their diet is sound, providing rehab psychology, and helping them manage all their risk factors: hypertension, diabetes, nutrition, medication adherence. They become overall healthier and more independent. And when patients are at a higher functional level, they tend to live with their families rather than entering long-term care facilities. So there are multiple ways this program can save Medicare money.

The second thing Medicare asked us to do was bring the study to its full power to determine the true impact on one-year all-cause mortality. We did complete the study, and found a 76% reduction in all-cause mortality for patients who completed this program — which is even greater than what we see with cardiac rehab. We also saw a 78% improvement in cardiac capacity — from where patients started to where they finished. Their endurance was significantly higher. Functional status improved across all three domains of the AM-PAC testing: mobility, ADLs, and cognition.

To give a concrete example: both groups started at matched functional levels. But by the end of the study, the control group — those who did not complete the program — were largely household ambulators, needing walkers and unable to get around in the community independently. The patients who did complete the program and exercised three times a week for four months, doing interval aerobic exercise with their heart rates elevated to target levels, were able to ambulate independently out in the community.

How did this program approach the personalized recovery for survivors?

I also want to note that every person who enters this program receives cardiac clearance. Every patient is seen by a cardiologist to assess their cardiac status, because the vascular system is one system. If you have plaque formation in the brain, you may also have it in the heart. We want to identify that before beginning interval cardiovascular conditioning on these bikes. Once patients are cleared by cardiology, we risk-stratify them — placing them in a low-, moderate-, or high-risk group — and push them at appropriately differentiated levels to complete the interval cardiovascular training.

Medicare also asked was whether we could replicate this study at other sites nationally. As the lead site and primary coordinating center for this research, we currently have grant funding pending to conduct a multi-site study with national partners who also care for stroke patients and have extensive experience in cardiac rehab. Some of the key partners involved include Mayo Clinic — Carmen Terzic, who is the director of cardiac rehab there, is working with us — as well as Preeti Raghavan at Johns Hopkins, medical director of the Sheikh Khalifa Stroke Institute, and Mooyeon Oh-Park who oversees cardiac rehab at Burke Rehabilitation.

We are working with several other facilities as well. We have presented updates of our data to the CMS Coverage and Analysis Group in 2023 and again more recently in 2025. They are very eager to access the data from our multi-site study, and we are awaiting the grant funding. That data will be critical in changing health care policy — specifically, to add stroke to the list of covered diagnostic categories for which Medicare would fund cardiac rehabilitation. Just as they did for cardiac rehab, peripheral vascular disease, and chronic heart failure, they have indicated that if the data can be replicated nationally, they will work to change policy and issue a national coverage determination so that stroke patients can benefit from this same comprehensive program.

We're very excited about that. We received a Clinical and Translational Science Award and are working closely with Hopkins to submit grant applications for this project. Our goal is to take the CORE Trials to the national level — establish proof of concept, and then achieve policy change so that stroke patients across the country can benefit from this program we feel so strongly about. We've published multiple articles covering much of what I've discussed. That's an overview.

Looking ahead, what excites you most about the future of stroke care?

What excites me most is the prospect of this becoming a service available to patients all over the country, not just here at JFK Johnson. Right now, stroke patients who want to participate have to pay out of pocket because there is no funding for them.

We're also currently running the pilot for the larger study, which Medicare wants to be a randomized controlled trial. Patients who are randomized in are thrilled to get to do the full program. Patients who are randomized out are very upset, because they know how beneficial it is and they want to participate. We need to collect the data before Medicare will pay for it. Our goal is to make this program available to any patient who is motivated enough to do it.

Transcript was edited for clarity.

REFERENCES
1. American Heart Association forecast on cardiovascular disease and stroke burden. Updated June 4, 2024. Accessed May 21, 2026.