BACKGROUND: Resistance exercise shows potential for improving swallowing function in post-stroke dysphagia (PSD), though optimal dose-response parameters remain unclear. While the American College of Sports Medicine (ACSM) framework effectively guides exercise prescriptions in healthy populations, its application to PSD rehabilitation lacks meta-analytical validation. This study evaluates varying resistance exercise dosages on swallowing outcomes in PSD patients. METHODS: We systematically searched PubMed, Embase, Web of Science, and Cochrane for randomized controlled trials (RCTs) investigating resistance training in PSD. Interventions were stratified using ACSM compliance criteria (6/8 and 7/8 thresholds) into high-adherence versus low/uncertain-adherence groups. Subgroup analyses employed random-effects meta-analyses. RESULTS: Analysis included 19 RCTs (n = 566). Using 6/8 ACSM criteria, 11 studies comprised the high-adherence group and eight the low/uncertain group. High-adherence interventions demonstrated improved positively oriented scores (SMD -1.72 (95% CI -3.26 to -0.18)), enhanced safety (SMD -0.93 (95% CI -1.54 to -0.32)), and worsened negatively oriented scores (SMD 2.27 (95% CI 0.66 to 3.87)). Low-adherence groups showed non-significant improvements in positively oriented scores (SMD -0.47 (95% CI -1.02 to 0.09)), negatively oriented scores (SMD 0.43 (95% CI -0.09 to 0.94)), and safety (MD -1.85 (95% CI -3.83 to 0.13)). Applying stricter 7/8 criteria reclassified nine studies as high-adherence and 10 as low/uncertain. High-adherence groups exhibited greater positively oriented scores improvement (SMD -2.15 (95% CI -4.11 to -0.20)), safety enhancement (MD -1.05 (95% CI -1.58 to -0.51)), and negatively oriented scores decline (SMD 2.85 (95% CI 0.82 to 4.89)). Low-adherence groups maintained non-significant outcomes: positively oriented scores (SMD -0.33 (95% CI -0.75 to 0.10)), negatively oriented scores (SMD 0.32 (95% CI -0.09 to 0.74)), and safety (MD -1.39 (95% CI -2.84 to 0.07)). CONCLUSION: Resistance exercise demonstrates superior therapeutic effects over non-resistance interventions for PSD. High adherence to ACSM-recommended dosages yields significantly greater improvements in swallowing function and safety compared to low/uncertain adherence regimens. These findings validate the clinical utility of ACSM guidelines for optimizing resistance exercise prescriptions in PSD rehabilitation. SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD420251041450.

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