Effects of circuit training on body composition and peak cardiorespiratory responses in patients with moderate to severe traumatic brain injury

Cardiorespiratory fitness assessment and training in the early sub-acute phase of recovery following traumatic brain injury: a systematic review

OBJECTIVES

To examine the safety of cardiorespiratory fitness (CRF) assessment and training in the early sub-acute phase of recovery (≤3 months) following moderate-to-extremely severe traumatic brain injury (TBI).

METHODS

A systematic review was completed in accordance with the PRISMA guidelines. Studies investigating adults and adolescents ≥15 years with moderate-to-extremely severe TBI were considered for inclusion. The methodological quality of the included studies was evaluated according to the McMaster Guidelines for Critical Review Form - Quantitative Studies.

RESULTS

Eleven studies with a total of 380 participants were included in the review. Adverse events (AEs) and symptom monitoring were poorly reported. Only four studies reported on the occurrence of AEs, with a total of eight AEs reported. Three of the reported AEs were concussion-like symptoms with no further exercise-induced symptom exacerbation reported. No serious AEs were reported.

CONCLUSION

There is no evidence to suggest that CRF assessment and training is unsafe in the early sub-acute phase of recovery following moderate-to-extremely severe TBI. However, despite the low AE and symptom exacerbation rates identified, a timeframe for safe commencement was unable to be established due to poor reporting and/or monitoring of exercise-induced symptoms and AEs in the current literature.

Brain changes: aerobic exercise for traumatic brain injury rehabilitation

Introduction

Traumatic Brain Injury (TBI) accounts for millions of hospitalizations and deaths worldwide. Aerobic exercise is an easily implementable, non-pharmacological intervention to treat TBI, however, there are no clear guidelines for how to best implement aerobic exercise treatment for TBI survivors across age and injury severity.

Methods

We conducted a PRISMA-ScR to examine research on exercise interventions following TBI in children, youth and adults, spanning mild to severe TBI. Three electronic databases (PubMed, PsycInfo, and Web of Science) were searched systematically by two authors, using keywords delineated from "Traumatic Brain Injury," "Aerobic Exercise," and "Intervention."

Results

Of the 415 papers originally identified from the search terms, 54 papers met the inclusion criteria and were included in this review. The papers were first grouped by participants' injury severity, and subdivided based on age at intervention, and time since injury where appropriate.

Discussion

Aerobic exercise is a promising intervention for adolescent and adult TBI survivors, regardless of injury severity. However, research examining the benefits of post-injury aerobic exercise for children and older adults is lacking.

The timeframe for safe resumption of high-level mobility following traumatic brain injury is currently unknown: a systematic review

PURPOSE

To examine the safety of high-level mobility (HLM) prescription in the early sub-acute phase of recovery following moderate-to-extremely severe traumatic brain injury (TBI) with specific focus on provocation of concussion-like symptoms.

DESIGN

Systematic review. PROSPERO ID: CRD42017069369.

MAIN MEASURES

Extracted data included study design, brain injury severity, time to commence HLM, type of HLM, physiological and symptom monitoring, and rate of adverse events.

RESULTS

Nineteen studies were included in the review. Fifteen studies included participants who commenced HLM within 6 weeks of injury, with the earliest time to commencement being 3 days. Overall, adverse events and symptom monitoring were poorly reported. A total of six adverse events were reported across three studies. One of the six adverse events was a concussion-like symptom. No falls were reported. No studies monitored concussion-like symptom provocation in direct relation to HLM.

CONCLUSION

A safe timeframe for return to HLM after moderate-to-extremely severe TBI could not be determined due to insufficient reporting of symptom monitoring and adverse events. Further research into the safety of HLM in the early sub-acute rehabilitative stage after moderate-to-extremely severe TBI is required in order to better understand potential sequelae in this population.IMPLICATIONS FOR REHABILITATIONHigh-level mobility assessment and training is commonly reported in the early sub-acute phase of recovery following moderate-to-extremely severe traumatic brain injury.There is no consensus on a safe timeframe to commence high-level mobility assessment or training after moderate-to-extremely severe traumatic brain injury.High-level mobility assessment and training appears to be safe in the early sub-acute phase following moderate-to-extremely severe traumatic brain injury, however, adverse events and symptoms are poorly reported.Clinicians should continue to proceed with caution when assessing and prescribing high-level mobility for patients with moderate-to-extremely severe traumatic brain injury in the early sub-acute phase of recovery and monitor for risks such as falls and exacerbation of concussion-like symptoms.

Physical Activity Intolerance and Cardiorespiratory Dysfunction in Patients with Moderate-to-Severe Traumatic Brain Injury

Moderate-to-severe traumatic brain injury (TBI) is a chronic health condition with multi-systemic effects. Survivors face significant long-term functional limitations, including physical activity intolerance and disordered sleep. Persistent cardiorespiratory dysfunction is a potentially modifiable yet often overlooked major contributor to the alarmingly high long-term morbidity and mortality rates in these patients. This narrative review was developed through systematic and non-systematic searches for research relating cardiorespiratory function to moderate-to-severe TBI. The literature reveals patients who have survived moderate-to-severe TBI have ~ 25-35% reduction in maximal aerobic capacity 6-18 months post-injury, resting pulmonary capacity parameters that are reduced 25-40% for weeks to years post-injury, increased sedentary behavior, and elevated risk of cardiorespiratory-related morbidity and mortality. Synthesis of data from other patient populations reveals that cardiorespiratory dysfunction is likely a consequence of ventilator-induced diaphragmatic dysfunction (VIDD), which is not currently addressed in TBI management. Thus, cardiopulmonary exercise testing should be routinely performed in this patient population and those with cardiorespiratory deficits should be further evaluated for diaphragmatic dysfunction. Lack of targeted treatment for underlying cardiorespiratory dysfunction, including VIDD, likely contributes to physical activity intolerance and poor functional outcomes in these patients. Interventional studies have demonstrated that short-term exercise training programs are effective in patients with moderate-to-severe TBI, though improvement is variable. Inspiratory muscle training is beneficial in other patient populations with diaphragmatic dysfunction, and may be valuable for patients with TBI who have been mechanically ventilated. Thus, clinicians with expertise in cardiorespiratory fitness assessment and exercise training interventions should be included in patient management for individuals with moderate-to-severe TBI.

Oxygen uptake on-kinetics before and after aerobic exercise training in individuals with traumatic brain injury

Objective: The high prevalence of fatigue among persons with traumatic brain injury (TBI) may be related to poor cardiorespiratory fitness observed in this population. Oxygen uptake on-kinetics is a method of assessing cardiorespiratory fitness and may be used to examine performance fatigability (decline in performance during a given activity) in persons with TBI.Purpose: To examine the effect of aerobic exercise training on oxygen uptake on-kinetics during treadmill walking in individuals with TBI.Methods: Seven ambulatory adults with chronic non-penetrating TBI performed short moderate-intensity (3-6 metabolic equivalents) walking bouts on a treadmill, prior to and following an aerobic exercise training program (clinicaltrials.gov: NCT01294332). The 12-week training program consisted of vigorous-intensity exercise on a treadmill for 30 min, 3 times a week. Breath-by-breath pulmonary gas exchange was measured throughout the bouts, and oxygen uptake on-kinetics described the time taken to achieve a steady-state response.Results: Faster oxygen uptake on-kinetics was observed after exercise training, for both the absolute and relative intensity as pre-training.Conclusions: Faster oxygen uptake on-kinetics following aerobic exercise training suggests an attenuated decline in physical performance during a standardized walking bout and improved performance fatigability in these individuals with TBI.Implications for rehabilitationSevere fatigue is a common complaint among persons with traumatic brain injury (TBI).Oxygen uptake on-kinetics may be used as an objective physiological measure of performance fatigability in persons with TBI.Faster oxygen uptake on-kinetics following aerobic exercise training suggests improved performance fatigability in these individuals with TBI.Aerobic exercise training appeared beneficial for reducing performance fatigability and may be considered as part of the rehabilitative strategy for those living with TBI.

Effect of Aerobic Exercise Training on Mood in People With Traumatic Brain Injury: A Pilot Study

BACKGROUND

Exercise training is associated with elevations in mood in patients with various chronic illnesses and disabilities. However, little is known regarding the effect of exercise training on short and long-term mood changes in those with traumatic brain injury (TBI).

OBJECTIVE

The purpose of this study was to examine the time course of mood alterations in response to a vigorous, 12-week aerobic exercise training regimen in ambulatory individuals with chronic TBI (>6 months postinjury).

METHODS

Short and long-term mood changes were measured using the Profile of Mood States-Short Form, before and after specific aerobic exercise bouts performed during the 12-week training regimen.

RESULTS

Ten subjects with nonpenetrating TBI (6.6 ± 6.8 years after injury) completed the training regimen. A significant improvement in overall mood was observed following 12 weeks of aerobic exercise training (P = .04), with moderate to large effect sizes observed for short-term mood improvements following individual bouts of exercise.

CONCLUSIONS

Specific improvements in long-term mood state and short-term mood responses following individual exercise sessions were observed in these individuals with TBI. The largest improvement in overall mood was observed at 12 weeks of exercise training, with improvements emerging as early as 4 weeks into the training regimen.

Home-based circuit training program for an adolescent female with severe traumatic brain injury: A case report

Adolescents with traumatic brain injury (TBI) are often discharged from physical therapy (PT) services without transitioning into exertional conditioning programs. Active participation in physical activities with peers at school is essential to achieve a sense of accomplishment and acceptance. Factors such as reduced aerobic fitness and residual gait impairments can lead to limited participation and peer interaction. The purpose of this case report was to describe the impact of home-based circuit training (HBCT) focusing on strength and balance on gait speed (GS), energy expenditure, and functional performance in a 17-year-old female with severe TBI. The participant sustained a TBI from a motor vehicle crash. Although she was ambulatory and independent with the basic activities of daily living following two years of rehabilitation, she presented with activity limitations and participation restrictions at school. The participant performed a 4-week HBCT program developed by a school physical therapist that focused on strength and balance. At the end of 4 weeks, improvements were observed in 6 MWT (change = 79.7 m), GS (change = 0.22 m/s), and the COPM scores (performance score change = 2.8, satisfaction score change = 2.2, MCID = 2). Improvements in functional performance, gait speed, and self-perception of occupational performance were observed following 4-week HBCT. Future clinical trials on short duration, HBCT program for children and young adults with TBI are recommended in order to establish effectiveness of HBCT.

Improved Cardiorespiratory Fitness With Aerobic Exercise Training in Individuals With Traumatic Brain Injury

OBJECTIVE

To examine cardiorespiratory fitness in individuals with traumatic brain injury (TBI), before and following participation in a supervised 12-week aerobic exercise training program.

METHODS

Ten subjects with nonpenetrating TBI (TBI severity: mild, 50%; moderate, 40%; severe, 10%; time since injury [mean ± SD]: 6.6 ± 6.8 years) performed exercise training on a treadmill 3 times a week for 30 minutes at vigorous intensity (70%-80% of heart rate reserve). All subjects completed a cardiopulmonary exercise test, with pulmonary gas exchange measured and a questionnaire related to fatigue (Fatigue Severity Scale) at baseline and following exercise training.

RESULTS

After training, increases (P < .01) in peak oxygen consumption ((Equation is included in full-text article.); +3.1 ± 2.4 mL/min/kg), time to volitional fatigue (+1.4 ± 0.8 minutes), and peak work rate (+59 ± 43 W) were observed. At the anaerobic threshold, (Equation is included in full-text article.)(+3.6 ± 2.1 mL/kg/min), treadmill time (+1.8 ± 1.1 minutes), and work rate (+37 ± 39 W) were higher (P < .01) following exercise training. Subjects also reported significantly lower (P < .05) Fatigue Severity Scale composite scores (-0.9 ± 1.3) following exercise training.

CONCLUSION

These findings suggest that individuals with TBI may benefit from participation in vigorous aerobic exercise training with improved cardiorespiratory fitness and diminished fatigue.

Model Programs to Address Obesity and Cardiometabolic Disease: Interventions for Suboptimal Nutrition and Sedentary Lifestyles

Problems posed by obesity-related endocrine diseases embody a national health crisis. Caloric excess and sedentary lifestyle from which they develop also pose significant challenges for rehabilitation providers. Almost two thirds of the U.S. population are currently overweight or obese, a number that has increased by >10% within the last decade and is expected to grow. An overweight body habitus is strongly associated with clinical hazards, including cardiometabolic syndrome, diabetes hypertension, and coronary artery disease. The component health risks of the cardiometabolic syndrome include coalescing of risk factors that predict a health calamity unless effective interventions can be developed and widely adopted. Obesity by itself is now considered an American Diabetes Association-qualified disability, but it is also disturbingly prevalent in other physical disability groupings of adults and children. This monograph describes successes of the Diabetes Prevention Program (DPP), a National Institutes of Health multisite randomized controlled trial that reported significant weight reduction and a 58% decreased incidence of type-2 diabetes accompanying 1 year of structured lifestyle intervention. This treatment benefit (1) exceeded that of metformin pharmacotherapy, (2) was so powerful that the trial was closed before reaching endpoints, and (3) was judged cost-effective for the patient and society. The DPP roadmap incorporating physical activity, diet, and behavioral approaches has been widely adapted to specific community, faith, racial, ethnic, school, and national populations with excellent outcomes success. The lockstep physical activity approach, activity prescription, and long-term success of the program are described and compared with other programs to illustrate effective countermeasures for the pandemics of obesity and obesity-related cardioendocrine disease. We will illustrate adaptation of the DPP for a cohort of persons with disability from spinal cord injury and the benefits observed.

Evaluation of a Physical Activity Intervention for Adults With Brain Impairment

Background. Individuals with brain impairment (BI) are less active than the general population and have increased risk of chronic disease. Objective. This controlled trial evaluated the efficacy of a physical activity (PA) intervention for community-dwelling adults with BI. Methods. A total of 43 adults with BI (27 male, 16 female; age 38.1 ± 11.9 years; stage of change 1-3) who walked as their primary means of locomotion were allocated to an intervention (n = 23) or control (n = 20) condition. The intervention comprised 10 face-to-face home visits over 12 weeks, including a tailored combination of stage-matched behavior change activities, exercise prescription, community access facilitation, and relapse prevention strategies. The control group received 10 face-to-face visits over 12 weeks to promote sun safety, healthy sleep, and oral health. Primary outcomes were daily activity counts and minutes of moderate-to-vigorous-intensity PA (MVPA) measured with the ActiGraph GT1M at baseline (0 weeks), postintervention (12 weeks) and follow-up (24 weeks). Between-group differences were evaluated for statistical significance using repeated-measures ANOVA. Results. MVPA for the intervention group increased significantly from baseline to 12 weeks (20.8 ± 3.1 to 31.2 ± 3.1 min/d; P = .01), but differences between baseline and 24 weeks were nonsignificant (20.8 ± 3.1 to 25.3 ± 3.2 min/d; P = .28). MVPA changes for the control group were negligible and nonsignificant. Between-group differences for change in MVPA were significant at 12 weeks ( P = .03) but not at 24 weeks ( P = .49). Conclusion. The 12-week intervention effectively increased adoption of PA in a sample of community-dwelling adults with BI immediately after the intervention but not at follow-up. Future studies should explore strategies to foster maintenance of PA participation.

The reliability, validity, and feasibility of physical activity measurement in adults with traumatic brain injury: an observational study

OBJECTIVE

To determine the reliability and validity of the Physical Activity Scale for Individuals with a Physical Disability (PASIPD) in adults with severe traumatic brain injury (TBI) and estimate the proportion of the sample participants who fail to meet the World Health Organization guidelines for physical activity.

DESIGN AND PARTICIPANTS

A single-center observational study recruited a convenience sample of 30 community-based ambulant adults with severe TBI.

PROTOCOL

Participants completed the PASIPD on 2 occasions, 1 week apart, and wore an accelerometer (ActiGraph GT3X; ActiGraph LLC, Pensacola, Florida) for the 7 days between these 2 assessments.

RESULTS

The PASIPD test-retest reliability was substantial (intraclass correlation coefficient = 0.85; 95% confidence interval, 0.70-0.92), and the correlation with the accelerometer ranged from too low to be meaningful (R = 0.09) to moderate (R = 0.57). From device-based measurement of physical activity, 56% of participants failed to meet the World Health Organization physical activity guidelines.

CONCLUSION

The PASIPD is a reliable measure of the type of physical activity people with severe TBI participate in, but it is not a valid measure of the amount of moderate to vigorous physical activity in which they engage. Accelerometers should be used to quantify moderate to vigorous physical activity in people with TBI.

The Aetiology of Reduced Cardiorespiratory Fitness Among Adults with Severe Traumatic Brain Injury and the Relationship with Physical Activity: A Narrative Review

Reduced cardiorespiratory fitness or cardiorespiratory deconditioning is a secondary physical impairment commonly reported to affect people after traumatic brain injury (TBI), both in the short- and long-term. Eleven studies have measured peak oxygen uptake${\rm ({\dot V}O}_{{\rm 2peak}} )$to evaluate fitness in this population. The mean (SD)${\rm \dot VO}_{{\rm 2peak}}$from these studies was 27.2 (6.7) mL.kg−1·min−1, which is markedly below the average fitness level of age-matched healthy individuals. The aetiology of cardiorespiratory deconditioning has not been well evaluated among people with TBI; however, studies on prolonged bed rest and studies on the acute consequences of TBI inform our current understanding. The primary aim of this paper is to present a model to describe the physiological factors contributing to the development of cardiorespiratory deconditioning among people with severe TBI. We propose that both central and peripheral factors contribute to reduced fitness, and that these changes occur because of both the initial brain damage and trauma sustained and the prolonged and initially extreme physical inactivity that is commonly experienced after this type of injury. Reduced fitness can significantly affect the ability to return to pre-injury activities. Given that reintegration into the community is a key goal of rehabilitation among people with TBI, interventions that can prevent or reverse reduced fitness need to be implemented.

Objective Assessment of Activity in Inpatients with Traumatic Brain Injury: Initial Findings

Purpose:Use accelerometers to examine the physical activity behaviours of individuals following TBI undergoing inpatient rehabilitation.

Method:Twenty-one individuals with Traumatic brain injury (TBI) undergoing inpatient rehabilitation (9 females, 12 males;Mage = 43.8 ± 14.7 years;MGCS = 9.1 ± 4.3;Mtime since injury = 40.8 ± 22.1 days;Mlength of stay (LOS) = 30 ± 14 days) wore accelerometers for an average of 8.4 ± 2.0 consecutive days (1440 minutes/day). Activity counts (AC) were collected at 1 minute epochs and descriptive statistics were calculated to assess intensity of activity and time spent being active and sedentary.

Results:During scheduled therapy, time individuals completed an average of 161.4 ± 65.5 AC/minute, which decreased to 114.5 ± 51.3 during non-therapy time and 22.2 ± 10 when sleeping. Using population level cut points, individuals were on average considered inactive during therapy, inactive or sedentary during non-therapy time, and only one participant spent >1 minute in moderate intensity activity. The mean length of active and sedentary bouts was 9 minutes.

Discussion:Findings indicate that the amount and intensity of activity completed is low amongst individuals completing inpatient rehabilitation after TBI, with the majority considered sedentary or inactive. While the sample is small, it is important to develop and implement safe and effective strategies to increase activity levels during rehabilitation.

Ventilatory anaerobic thresholds of individuals recovering from traumatic brain injury compared with noninjured controls

OBJECTIVE

The purpose of this study was to compare the peak aerobic capacities and ventilatory anaerobic thresholds (VAT) of individuals with a traumatic brain injury (TBI) to age- and gender-matched controls.

METHODS

Nineteen participants that previously suffered a mild to moderate TBI and 19 apparently healthy controls volunteered as subjects. Traumatic brain injury and healthy controls were matched for age and gender and were similar in weight and body mass index. Volunteers performed a maximal graded treadmill test to volitional failure where oxygen consumption ((Equation is included in full-text article.)O2), carbon dioxide production ((Equation is included in full-text article.)CO2, ventilation ((Equation is included in full-text article.)E, and heart rate were measured continuously. From metabolic and ventilatory data, VAT was measured using a previously described method. VAT and peak exercise responses of participants with a TBI were compared with healthy controls.

RESULTS

The (Equation is included in full-text article.)O2, and (Equation is included in full-text article.)CO2 at VAT and peak exercise were lower for TBI compared with healthy controls. (Equation is included in full-text article.)E was also lower for TBI at VAT and peak exercise. Heart rate was lower for TBI at VAT; however, TBI had similar heart rate to healthy controls at peak exercise.

CONCLUSIONS

The VAT and peak exercise capacities of participants with a TBI were below the metabolic demands of many routine daily activities. The data suggest that therapeutic interventions for individuals with a TBI should include targeted exercise prescriptions to improve cardiorespiratory fitness.

Circuit class therapy can provide a fitness training stimulus for adults with severe traumatic brain injury: a randomised trial within an observational study

QUESTIONS

Can circuit class therapy provide sufficient exercise dosage (at least 20 minutes at ≥ 50% heart rate reserve or total caloric expenditure ≥ 300 kilocalories) to induce a cardiorespiratory fitness effect in adults with traumatic brain injury? Can feedback from heart rate monitors influence exercise intensity?

DESIGN

Randomised controlled trial within an observational study.

PARTICIPANTS

Fifty-three people with severe traumatic brain injury, of whom 40 progressed into the trial.

INTERVENTION

All participants undertook circuit class therapy. Participants allocated to the experimental group received exercise intensity feedback from a heart rate monitor and the control group received no feedback.

OUTCOME MEASURES

Proportion of participants exercising at ≥ 50% heart rate reserve for at least 20 minutes or expending ≥ 300 kilocalories during circuit class therapy. The primary outcome measure for the trial was the time spent in the heart rate training zone (ie, at ≥ 50% heart rate reserve) during the intervention and re-assessment periods.

RESULTS

Circuit class therapy provided sufficient cardiorespiratory exercise dosage for 28% (95% CI 18 to 42) of the cohort according to the heart rate reserve criteria and 62% (95% CI 49 to 74) according to the caloric criteria. Feedback did not increase the time in the training zone during the intervention (mean difference 4.8 minutes, 95% CI -1.4 to 10.9) or re-assessment (1.9 minutes, -4.4 to 8.3) periods.

CONCLUSION

The low intensity, long duration structure of circuit class therapy can provide sufficient exercise dosage for a fitness training effect for 62% of people with traumatic brain injury. Feedback from heart rate monitors does not necessarily influence exercise intensity.

TRIAL REGISTRATION

ACTRN12607000522415.

Physiologic responses of competitive Canadian cross-country skiers with disabilities

OBJECTIVE

To examine the acute cardiorespiratory and metabolic responses in competitive cross-country skiers with disabilities.

DESIGN

Cross-sectional comparisons using a select group of Canadian athletes training for the Vancouver 2010 Paralympic Winter Games.

SETTING

Canmore Nordic Centre Provincial Park, Canmore, Alberta.

PARTICIPANTS

Nine competitive cross-country skiers (4 with visual impairment, 1 with traumatic brain injury, 3 with spinal cord injury, and 1 with cerebral palsy).

INTERVENTIONS

Three-minute and 12-minute exercise tests in the standing or sitting skiing position to voluntary fatigue.

MAIN OUTCOME MEASURES

Cardiorespiratory responses using a telemetric system to compare the physiologic responses among the athletes with different disabilities. Heart rate (HR) and capillary lactate were measured at 2, 5, and 10 minutes of recovery.

RESULTS

The t test results indicated that the peak values of the absolute and relative oxygen uptake (VO2peak), HR, and ventilation rate were significantly higher during the 12-minute compared with the 3-minute protocol during standing skiing. However, the oxygen pulse and ventilatory equivalent for oxygen ratio were not significantly (P > 0.05) different between the 2 protocols. Analysis of variance revealed no significant (P > 0.05) differences among the 3 trials for these peak physiologic responses during sitting skiing. Cross-sectional comparisons of the peak physiologic responses between the standing and sitting skiers indicated significantly (P < 0.05) higher values in the standing compared with the sitting position. Cardiorespiratory respiratory efficiency was significantly (P < 0.05) lower in the sitting compared with the standing position. HR during 10 minutes of recovery was significantly correlated with VO2peak. Pearson correlations were not significant between VO2peak and lactate removal during recovery.

CONCLUSION

These descriptive findings during the standing and sitting skiing protocols provide preliminary data that would be useful in testing, training, and classification of competitive skiers with disabilities.

Endurance training and cardiorespiratory conditioning after traumatic brain injury

OBJECTIVE

To examine the importance of cardiorespiratory conditioning after traumatic brain injury (TBI) and provide recommendations for patients recovering from TBI.

METHOD

Review of literature assessing the effectiveness of endurance training programs.

MAIN OUTCOMES AND RESULTS

A sedentary lifestyle and lack of endurance are common characteristics of individuals with TBI who have a reduction in peak aerobic capacity of 25% to 30% compared with healthy sedentary persons. Increased physical activity and exercise training improves cardiorespiratory fitness in many populations with physical and cognitive impairments. Therefore, increasing the endurance and cardiorespiratory fitness of persons with TBI would seem to have important health implications. However, review of the TBI literature reveals that there have been few well-designed, well-controlled studies of physiologic and psychological adaptations of fitness training. Also lacking are long-term follow-up studies of persons with TBI.

CONCLUSIONS

Assessing endurance capacity and cardiorespiratory fitness early in the TBI rehabilitation process merits consideration as a standard of care by professional rehabilitation societies. Also, providing effective, safe, and accessible training modalities would seem to be an important consideration for persons with TBI, given the mobility impairments many possess. Long-term follow-up studies are needed to assess the effectiveness of cardiorespiratory training programs on overall morbidity and mortality.

Physical exercise and cognitive recovery in acquired brain injury: a review of the literature

OBJECTIVE

Physical exercise has been shown to play an ever-broadening role in the maintenance of overall health and has been implicated in the preservation of cognitive function in both healthy elderly and demented populations. Animal and human studies of acquired brain injury (ABI) from trauma or vascular causes also suggest a possible role for physical exercise in enhancing cognitive recovery.

DATA SOURCES

A review of the literature was conducted to explore the current understanding of how physical exercise impacts the molecular, functional, and neuroanatomic status of both intact and brain-injured animals and humans.

STUDY SELECTION

Searches of the MEDLINE, CINHAL, and PsychInfo databases yielded an extensive collection of animal studies of physical exercise in ABI. Animal studies strongly tie physical exercise to the upregulation of multiple neural growth factor pathways in brain-injured animals, resulting in both hippocampal neurogenesis and functional improvements in memory.

DATA EXTRACTION

A search of the same databases for publications involving physical exercise in human subjects with ABI yielded 24 prospective and retrospective studies.

DATA SYNTHESIS

Four of these evaluated cognitive outcomes in persons with ABI who were involved in physical exercise. Three studies cited a positive association between exercise and improvements in cognitive function, whereas one observed no effect. Human exercise interventions varied greatly in duration, intensity, and level of subject supervision, and tools for assessing neurocognitive changes were inconsistent.

CONCLUSIONS

There is strong evidence in animal ABI models that physical exercise facilitates neurocognitive recovery. Physical exercise interventions are safe in the subacute and rehabilitative phases of recovery for humans with ABI. In light of strong evidence of positive effects in animal studies, more controlled, prospective human interventions are warranted to better explore the neurocognitive effects of physical exercise on persons with ABI.

Validity of the modified 20-metre shuttle test: Assessment of cardiorespiratory fitness in people who have sustained a traumatic brain injury

PRIMARY OBJECTIVE

To validate the modified 20-metre shuttle test in adults who have sustained a traumatic brain injury (TBI).

DESIGN

Single-sample validity study.

SETTING

Brain injury rehabilitation unit.

PARTICIPANTS

Twenty-four adults with severe TBI, discharged from hospital for at least 6-months.

PROTOCOL

Participants attended the facility for a familiarization session, followed by a symptom-limited treadmill test and a modified shuttle test on two separate days. The treadmill test was based on an individualised protocol which used a physiotherapist-selected speed and increments in gradient every minute until volitional fatigue. The modified shuttle test was externally-paced and commenced with a speed of 2.4 km h(-1) which increased every minute until volitional fatigue.

MAIN MEASURES

Four primary measures were taken from both tests: peak oxygen uptake, peak heart rate, maximal velocity and rating of perceived exertion.

RESULTS

All participants completed the study. There were no adverse events. A high correlation was observed between the modified shuttle test and the treadmill test for peak oxygen uptake, peak heart rate and maximal velocity (r = 0.96, r = 0.80, r = 0.82, respectively; p < 0.001), but not for rating of perceived exertion (r = 0.013, p = 0.952).

CONCLUSION

The modified shuttle test is a valid measure of cardiorespiratory fitness in people who have sustained a TBI.

Exercise intervention in brain injury: a pilot randomized study of Tai Chi Qigong

OBJECTIVE

To examine the effects of a brief Tai Chi Chuan Qigong ('Qigong') exercise intervention on individuals with traumatic brain injury.

DESIGN

A single-centre randomized controlled trial pilot study.

SETTING

A registered charity day centre in the community.

SUBJECTS

Twenty individuals with traumatic brain injury.

INTERVENTION

Intervention participants attended a Qigong exercise session for one hour per week over eight weeks. Control participants engaged in non-exercise-based social and leisure activities for the same intervention period.

MEASURES

Outcome was assessed at baseline and post intervention using the General Health Questionnaire-12, the Physical Self-Description Questionnaire and the Social Support for Exercise Habits Scale, to measure perceived mood, self-esteem, flexibility, coordination, physical activity and social support.

RESULTS

Groups were comparable at baseline. After the intervention, mood was improved in the exercise group when compared with controls (U = 22.0, P =0.02). Improvements in self-esteem (Z = 2.397, P =0.01) and mood (Z = -2.032, P =0.04) across the study period were also evident in the exercise group only. There were no significant differences in physical functioning between groups. In view of the sample size, these findings are inconclusive.

CONCLUSIONS

This study provides preliminary evidence that a brief Qigong exercise intervention programme may improve mood and self-esteem for individuals with traumatic brain injury. This needs to be tested in a large-scale randomized trial.

Fitness training for cardiorespiratory conditioning after traumatic brain injury

BACKGROUND

Cardiorespiratory deconditioning is a common sequelae after traumatic brain injury (TBI). Clinically, fitness training is implemented to address this impairment, however this intervention has not been subject to rigorous review.

OBJECTIVES

The primary objective was to evaluate whether fitness training improves cardiorespiratory fitness in people who have sustained a TBI.

SEARCH STRATEGY

We searched ten electronic databases (Cochrane Injuries Group Trials Register; Cochrane Central Register of Controlled Trials (CENTRAL); EMBASE; PubMed (MEDLINE); CINAHL; AMED; SPORTDiscus; PsycINFO; PEDro and PsycBITE) and two clinical trials registers (TrialsCentral and Current Controlled Trials). The last search was August 2007. In addition we screened reference lists from included studies and contacted trialists to identify further studies.

SELECTION CRITERIA

Randomised controlled studies with TBI participants were eligible if they compared an exercise programme incorporating cardiorespiratory fitness training to usual care, a non-exercise intervention or no intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently screened the search output, extracted data and assessed quality. All trialists were contacted for additional information. Mean difference and 95% confidence intervals (CI) were calculated for continuous data and risk difference or odds ratio and 95% CI were calculated for dichotomous data. Data were pooled when there were sufficient studies with clinical and statistical homogeneity.

MAIN RESULTS

Six studies, incorporating 303 participants, were included. The participants were primarily males, in their mid thirties who had sustained a severe TBI. The studies were clinically diverse with regard to the interventions, time post-injury and the outcome measures used; therefore, the primary outcome could not be pooled. Three of the six studies indirectly assessed change in cardiorespiratory fitness after fitness training using the peak power output obtained during cycle ergometry (either at volitional fatigue or at a predetermined endpoint, that is, a percentage of predicted heart rate maximum). Cardiorespiratory fitness was improved after fitness training in one study (mean difference 59 watts, 95% CI 24 to 94), whilst there was no significant improvement in the other two studies. Four of the six studies had no drop-outs from their intervention group and no adverse events were reported in any study.

AUTHORS' CONCLUSIONS

There is insufficient evidence to draw any definitive conclusions about the effects of fitness training on cardiorespiratory fitness. Whilst it appears to be a safe and accepted intervention for people with TBI, more adequately powered and well-designed studies are required to determine the effects across a range of outcome measures.

Patterns of fatigue and its correlates over the first 2 years after traumatic brain injury

This study used a prospective longitudinal design to quantify fatigue and associated factors during the first 2 years after traumatic brain injury (TBI). Fifty-one individuals were assessed at 3 time points: within the first 6, 12, and 18-24 months after TBI. Self-reported fatigue improved during the first year, as did pain, sleep quality, cognitive independence, and involvement in productive activity. Further changes up to 2 years after TBI were not observed. The subset of individuals who reported significant increases in fatigue over the first 2 years demonstrated poorer outcomes in cognition, motor symptoms, and general functioning than those with decreased or stable fatigue.

Hand-held dynamometry in children with traumatic brain injury: within-session reliability

PURPOSE

To determine the within-session reliability of a standardized protocol for using a hand-held dynamometer (HHD) to measure lower-extremity (LE) strength in children with traumatic brain injury (TBI) and to assess any differences in reliability measures when compared with children with typical development (TD) matched for age and sex.

METHOD

A convenience sample of 24 children with TBI and 24 age- and sex-matched controls with TD. The strength of 4 LE muscle groups in each of the lower limbs was tested twice.

RESULTS

The within-session intrarater reliability ranged from 0.91 to 0.99 for children with TBI and for children with TD. For children with TBI, the standard error of measurement varied from 0.51 to 1.52 kg.

CONCLUSION

By using an HHD and a standardized measurement protocol, a novice tester can obtain reliable LE strength values in children with TBI.

Aerobic capacity after traumatic brain injury: comparison with a nondisabled cohort

OBJECTIVE

To compare aerobic capacity of people recovering from traumatic brain injury (TBI) with an age- and sex-matched group of nondisabled sedentary people.

DESIGN

Descriptive comparative study of peak and submaximal physiologic responses.

SETTING

Residential postacute treatment center.

PARTICIPANTS

Convenience sample of 13 people with TBI and 13 age- and sex-matched nondisabled subjects. All subjects could walk 5.3 kph (3.3 mph), follow 2-step commands, and comply with testing using the gas collection apparatus.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Subjects performed a graded maximal treadmill test during which heart rate, minute ventilation (VE), oxygen consumption (VO2), carbon dioxide production, and respiratory exchange ratio (RER) were measured every minute until exhaustion. Ventilatory equivalents for oxygen (VE/VO2) and oxygen pulse were calculated.

RESULTS

Subjects recovering from TBI had significantly lower peak responses for heart rate, VO2, VE, and oxygen pulse TBI (P<.01). Peak RER and VE/VO2 were similar. There were significant differences in submaximal responses for VE/VO2 and oxygen pulse.

CONCLUSIONS

Patients with TBI were significantly more deconditioned than a comparable group of sedentary people without disability. Participation in cardiorespiratory fitness programs after TBI should be encouraged to prevent secondary disability.