An overview of the epidemiology of traumatic brain injury (TBI), along with the benefits of physical activity (PA) and general programming and planning considerations, is outlined in the accompanying Special Populations column. To receive the many health benefits associated with PA, it is recommended that individuals complete 150 minutes of moderate-intensity PA or 75 minutes of vigorous-intensity PA along with 2 days of strength training per week (17). This recommendation also allows for a combination of moderate- and vigorous-intensity exercises to meet the desired time goals. Despite this recommendation, a recent study found that a sample of outpatients with TBI completed only 46 minutes of PA per week (6). To help individuals with a TBI successfully increase their amount of PA and receive the resulting health benefits, it is critical to find activities that are enjoyable and adapt programs based on each individual's unique cognitive and motor skills.
With the variety of PA programs that have been associated with physical and psychosocial benefits for individuals with a TBI, practitioners should be able to find a type of activity that each individual can enjoy. Aquatics and tai chi are 2 examples of activities that may improve fitness and mood. Aquatics can develop vital capacity and oxidative capacity because of the increased pressure in the water forcing people to breathe deeper (9). Aquatic exercises also have positive effects on blood pressure and blood flow, and participation in an aquatics program has been shown to improve mood states for individuals with a TBI (7). Initial research on tai chi qigong has also demonstrated improved self-esteem and mood for this population (2). In addition to those activities, circuit training programs have demonstrated improvements in aerobic capacity, endurance, and muscle strength for this population (1,2,7,12). This column focuses on examples of specific guidelines that can be used to design a circuit training program enabling individuals with a TBI to complete the recommended amount of weekly PA.
To produce desired benefits, circuit programs should be performed 3 times per week and incorporate flexibility, aerobic, and resistance training components (1). Before beginning a program, exercise assessments can be used to determine a safe initial workload for individuals with a TBI (12) and can be repeated throughout the duration of the program to track an individual's progress. Research has shown that progressive exercise assessments using produce more accurate results with higher maximal oxygen consumption values than a bicycle ergometer assessment for individuals with a TBI (12). However, because many individuals may require assistive devices for mobility and balance purposes, treadmill walking may not be appropriate for all individuals. The type of assessment chosen should be based on what is most suitable and safe for each person.
SPECIFIC PROGRAM GUIDELINES
Before engaging an individual with a TBI in the circuit training program, a physician's approval and preliminary assessments for strength, flexibility, and coordination are necessary. While assessing for strength and flexibility, it is imperative to consider range of motion limitations. Strength assessment using manual muscle testing should be performed and documented in the available range of motion. During the flexibility assessments, while measuring the passive range of motion, care must be taken to perform the movement slowly to avoid discomfort or an increase in the muscle tone (for more information on manual muscle testing and flexibility assessment, please read Daniels and Worthingham's Muscle Testing: Techniques of Manual Examination (4) and Physiological Assessment of Human Fitness (14)).
Assessing coordination for individuals with limb ataxia is done using the finger-to-nose and heel-to-shin tests. In the finger-to-nose test, the individual is asked to touch his/her nose from an extended arm position. In the heel-to-shin test, the individual is asked to touch his/her knee with the opposite foot and then drag the foot all the way down and up the shin. It is not safe for individuals with limb ataxia to train with free weights or walk on a treadmill because their coordination is affected. These individuals should train using weight machines and walk on a track holding side rails gently—treadmills should be used with caution to consider hypotonia, ataxia, and quick fatigability.
Using the initial assessment to understand the individual's level of fitness, the circuit training program can be designed. The program begins with a 5- to 10-minute warm-up session, which includes walking on a treadmill or cycling on a recumbent bike. Also focusing on improving flexibility using flexibility exercises targeting major muscle groups is key for this population because spasticity can make it difficult for individuals to complete certain exercises (11).
Flexibility exercises should be done using proprioceptive neuromuscular facilitation (PNF) techniques, which are manual stretching techniques. During PNF, muscles are first stretched passively, and then while maintaining the stretched position, the participant is instructed to contract the muscles isometrically (there should be no movement). Finally, this is followed by relaxation and further passive stretching in increased range of motion. A few flexibility exercise recommendations include the following:
- Muscles must be stretched slowly because vigorous movements can increase the muscle tone in the spastic muscles
- The stretch should be maintained for at least 30 seconds.
The aerobic component should last from 15 to 25 minutes, and successful programs have included the following guidelines (1):
- Complete activities such as treadmill walking, stationary cycling, and arm crank ergometers
- If unable to complete 15-25 minutes of continuous activity, participants should rest when needed but still complete total number of minutes
- Maintain intensity of 40-70% of o2peak (but can be lower because normative values are not available)
- Incorporate heart rate monitors because some individuals may have difficulty manually checking their own pulse rate
- Progress safely in intensity and duration throughout the program.
Resistance training should be conducted for the remainder of the session, followed by cool-down stretching. Although more research is needed on resistance training for this specific population, individuals who have experienced a stroke have demonstrated physiological improvements when strength and aerobic components are combined in a PA program (13). Recommendations for resistance training in a combined program include the following (13):
- 2 sets of 8 repetitions, progressing in intensity throughout the course of the program
- Begin with a resistance that is 50% of an individual's 1 repetition maximum and progress to 60-70% of an individual's 1 repetition maximum (16)
- Resistance exercises should be performed for all major muscle groups (10).
Adjust workloads so that individuals conduct resistance training at a safe level of intensity depending on secondary issues faced (e.g., seizures, severe spasticity, ataxia, low cognitive awareness to estimate intensity of exercise and ensure it is completed safely). On the original Borg rating of perceived exertion scale (ranging from 6 representing no exertion at all to 20 representing extremely maximal exertion) (13), the exercises should be individualized depending on secondary issues, contraindications, and individual's initial level of fitness. However, depending on an individual's level of cognitive impairment, it may be more appropriate to use a modified version of the scale, such as the Borg Category-Ratio 10 RPE scale, which includes a 1-10 general intensity scale using a ratio format (e.g., level 10 is twice as hard as level 5) to rate exertion during PA (3,5).
Depending on each individual's unique needs, specific motor impairments (e.g., hypotonia [decreased muscle tone], spasticity [certain muscles stay continuously contracted], apraxia [loss of the ability to carry out skilled movements and gestures], and ataxia [lack of balance and coordination or a disturbance of gait)] may require adaptations to the environment and PA program. The following are examples of considerations for exercise prescription:
- Perform exercises sitting down or holding on to a stationary object because many individuals have difficulty balancing (10)
- Because of hypotonia, individuals with a TBI may not be able to lift the same amounts of weight or may fatigue faster than others of a similar age or gender
- Incorporate weight machines instead of free weights when necessary because ataxia and apraxia make it difficult for individuals to coordinate and carry out desired movements (10)
- Spasticity in the limbs makes it difficult to perform each exercise through the full range of motion (11), and adding flexibility exercises may improve the individual's ability to carry out complete movements
- Some individuals with a TBI have difficulty walking, and it may be necessary to keep surroundings free from any obstructions (8)
- Cognitive impairments may require specific strategies to help individuals with communication or memory during the program (Table 1).
By following the guidelines outlined above, circuit training can be a safe and beneficial program for adults with a TBI. Although this column has focused on circuit training recommendations for adults, physical education teachers and coaches who work with children need to understand that children with a TBI are a group that requires additional considerations. It is important to be able to recognize certain negative behaviors that students may demonstrate. For example, a child who scores level VIII on the Ranchos Los Amigos Cognitive Functioning Scale (an evaluation tool used to describe the 8 stages of recovery observed after a brain injury, explained comprehensively in Table 2) may become angry and frustrated seemingly for no reason, which may continually frustrate the fitness professional. However, after consulting with the child's psychological and educational therapist, the teacher is made aware of the fact that the child may typically demonstrate these behaviors because of his/her injury. Professionals at the rehabilitation center are an important resource throughout the planning process to identify behaviors that could be a sign of problems and suggest modifications and special considerations to make the program a success.
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