4.4 Exercise Interventions Post Acquired Brain Injury
Following an ABI, motor impairments in combination with cognitive impairment can have a significant impact on functional abilities (Boake et al., 2000). Unlike the more uniform focal deficits seen following stroke, the motor deficits following ABI tend to be diverse including impairment of force, endurance, coordination and balance (Boake et al., 2000). Frequently rehabilitation efforts are directed at specific motor impairments with the aim of improving overall functional ability.
4.4.1 Partial Body Weight Supported Gait Training
Movement disorders post-ABI decrease the ability of a person to remain independent due to a loss of ambulation. A lack of sufficient strength and balance to maintain an erect posture may prevent gait training which is necessary for the restoration of self-ambulation following brain injury. Partial body weight supported gait training is postulated to result in earlier gait rehabilitation, earlier weight-bearing to increase strength and reduce spasticity. Moreover, this gait intervention allows for the simulation of task-specific walking movements and enables rehabilitation therapist to assist patients in the components of gait rather than bearing their body weight. This type of gait training physically supports patients in a way that does not generate compensatory strategies for ambulation that may develop while using a cane or a walker (Seif-Naraghi & Herman, 1999) which may create undesirable motor habits. Partial body weight support also reduces the demands on muscles while the patient works on improving the coordination of the movement while gradually increasing muscular strength. Body weight support can be gradually adjusted as the patient improves to encourage postural control and balance.
Individual Studies
Table 4.12 Partial Body Weight Supported Gait Training Post ABI
| Author/Year/ Country/ Study design/ PEDro and D&B Score |
Methods |
Outcome |
|
Brown et al., (2005) |
N=20 Chronic TBI patients were randomly assigned to receive either body weight support treadmill training (BSSTT) or conventional over-ground gait training (COGT) for 15 minutes plus 30 minutes of exercise 2 days per week for 3 months. Outcome measures included Functional Ambulation Category (FAC), Functional Reach (FC), Timed Up and Go, Gait velocity, Stride Width, Left-Right Step Length differential. |
Step Length Differential improved significantly more for the COGT group than for the BWSTT group after 3-months of intervention (p=0.011). There were no other significant differences between groups at baseline or after 3-months of intervention on any of the outcome measures. |
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Wilson et al., (2006) |
N=40 TBI patients were randomized to either 8 weeks of standard physical therapy or physical therapy supplemented with partial weight-bearing gait training twice weekly. Outcomes included FIM, Functional Assessment Measure (FAM), Rivermead Mobility Index (RMI), Gross Motor Subscale (GMS), the Standing Balance Scale (SBC), and the Functional Ambulation Category (FAC). Outcomes were assessed at the beginning and conclusions of the 8-week training period (FIM, FAM) or on a weekly basis (RMI, GMS, SBS, FAC). |
Significant (p<0.05) improvements were detected in both groups over time on FAC, SBC, RMI, and FIM. However, there were no differences between the treatment groups on any of the measures. |
PEDro = Physiotherapy Evidence Database rating scale score. (Moseley et al. 2002).
D&B = Downs and Black (1998) quality assessment scale score.
Discussion
We identified two RCTs which evaluated the efficacy of partial body weight supported gait training following ABI. Brown et al. (2005) conducted an RCT in which 20 ABI patients were randomized to either body weight supported treadmill training or conventional over-ground gait training. They reported that body weight supported treadmill training provided no additional benefit over conventional gait training in measures of ambulation following 3 months of training. Similarly, in another RCT, Wilson et al. (2006) randomized 40 ABI patients to either standard physical therapy or physical therapy supplemented with partial body weight-bearing gait training. These authors also reported that there were no significant group differences on measures of balance, ambulation and mobility at the end of the 8-week training period (Wilson et al., 2006).
Conclusion
Based on two RCTs, there is Level 1 evidence that partial body weight supported gait training does not provide any added benefit over conventional gait training in ambulation, mobility or balance.
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Partial body weight supported gait training is not better than conventional gait training for improving ambulation, mobility or balance.
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4.4.2 Directed Therapy at Specific Deficits
Often within the rehabilitation setting, there is a need for patients to accomplish specific goals that will facilitate their integration back into their community setting. Accomplishing specific physical goals may serve as a foundation for improved functioning and safety such as improved balance or ability to stand independently.
Individual Studies
Table 4.13 Effects of Directed Therapy to Address Specific Deficits Post ABI
| Author/Year/ Country/Study design/ PEDro and D&B Score |
Methods |
Outcome |
|
Canning et al., (2003) |
N=22 Severe TBI patients (chronicity<12 months) with no orthopedic condition preventing training were divided randomly into a regular rehab program (control) group, and rehabilitation plus 4 weeks of intensive training of sit-to-stand and step-up exercises (treatment) group. Study measured pre/post sit-to-stand repetitions in 3 min (motor performance), peak oxygen consumption (exercise capacity), oxygen consumption workload test (exercise efficiency). |
Sit-to-stand training resulted in a 62% improvement in motor performance compared to control (18% increase) (p<0.05). There were no significant changes between groups in exercise capacity or efficiency. The increase in exercise capacity for the treatment group was significant (p<0.01). |
|
Dault and Dugas (2002) |
N=8 TBI patients (mean age 29.6, chronicity: 6-106 months) completed an individualized 12-week training program (TP) combining aerobic dance, and slide and step training for 30 minutes twice a week compared to traditional muscular training (TMT) for 60 minutes twice a week for 12 weeks. Postural imbalance was evaluated by using the Clinical Test for Sensory Interaction in Balance (CTSIB). Coordination deficits evaluated by using a jumping jack movement |
Significant pre- and post training differences for the TP group in wrist temporal delay (p < 0.01), knee improvement (p < 0.001), and sway area (p < 0.05), but not the TMT group. |
|
Sietsema et al., (1993) |
N=20 TBI subjects (mean age 31.6 yrs, chronicity: 6 years) experiencing upper limb spasticity received Occupational Embedded Intervention and rote exercise for two separate 20 minute sessions one week apart. Range of motion (trunk inclination, shoulder flexion, elbow extension and total movement (leaning forward and reaching) were measured by taking the maximum distance between the scapula and the wrist before and after treatment. |
No significant order effects. There was a significant increase in range of motion in the occupational embedded condition compared with exercise alone (p < 0.001). Subjects leaned forward and reached an average of 12.22 cm farther and their scapula-to-wrist measurement was an average of 3.52 cm greater than it was during the rote exercise. |
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Sveistrup et al., (2003) |
N=14 Preliminary data from 2 clinical trials using flat screen virtual reality technology (VR) compared to conventional exercise in three 1 hour sessions of balance retraining exercises per week for 6 weeks. Subjects experienced moderate to severe TBI, and were 2 months post-injury but no longer participating in acute inpatient rehabilitation. |
Clients in both groups showed significant improvements on the Community Balance and Mobility Scale (p value not provided). However, there were no differences in improvement between VR and conventional exercise groups. |
PEDro = Physiotherapy Evidence Database rating scale score (Moseley et al. 2002).
D&B = Downs and Black (1998) quality assessment scale score.
Discussion
Sit-to-Stand Training
Canning et al. (2003), in a single blinded RCT compared the addition of an intensive sit-to-stand training program to a traditional rehabilitation program. The experimental group demonstrated an increased ability to repeat sit-to-stand within a defined time frame.
Balance Training
Dault and Dugas (2002) compared the effect of a specific balance and coordination training program post-traumatic brain injury to traditional muscular training. This prospective cohort design demonstrated a significant improvement in balance and coordination within the specific therapy training group.
Reach Training
Siestma et al. (1993) explored the effect of an occupationally embedded intervention within a game setting to a traditional arm reaching exercise. The experimental condition of the game in fact showed a significantly increased range of motion of the upper extremity relative to the control intervention.
Siestma et al. (1993) showed significant benefit with the use of an occupationally embedded intervention compared to traditional therapy. Although this study was completed in 1992, there may be significant implications for demonstration of this effect when taking into account the potential for newer technologically enhanced interventions such as virtual reality incorporated into therapy.
Sveistrup et al. (2003) demonstrated that balance improved for both conventional and virtual reality based balance retraining for patients who had completed their acute rehabilitation.
Conclusions
There is Level 1 evidence based on a single RCT that specific sit-to-stand training results in improved abilities.
There is Level 2 evidence that reach training with an embedded intervention is more effective than a traditional reaching exercise program.
There is Level 2 evidence that a specific balance and coordination training program is significantly more effective for improving balance and coordination compared to a traditional muscular training program.
There is Level 2 evidence that a virtual reality based balance retraining program is as effective at improving balance through a conventional balance retraining program.
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Specific training interventions post acquired brain injury are effective.
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4.4.3 Aerobic Training
General fitness training following ABI has the potential to influence multiple outcomes beyond the mere direct physical benefits such as improved aerobic capacity (Bushbacher & Porter, 2000). Many ABI patients have gone through a period of prolonged bedrest as a result of comorbid injuries or a prolonged loss of conciousness. Cardiovascular changes as well as muscular atrophy and loss of lean body mass commonly occur post traumatic brain injury (Boake et al., 2000). Potential benefits relevant post brain injury could include improved ambulation, endurance, fatigue levels or functional abilities. Even the potential for improved community integration and mood may result from overall improved physical fitness.
A total of 8 studies including one randomized controlled trial evaluating the effects of aerobic training programs were identified.
Individual Studies
Table 4.14 Effects of Aerobic Training to Influence Aerobic Capacity Post ABI.
| Author/ Year/ Country/ Study design/ PEDro and D&B Score |
Methods |
Outcome |
|
Bateman et al., (2001) |
N=175 Single incident ABI inpatients able to comply with intervention were divided into exercise (treatment) and relaxation (control) training groups for 3, 30 minute individual sessions per week for 12 weeks. Measures of exercise capacity (peak work rate, peak heart rate) body mass index, domains of mobility (modified Ashworth scale, Berg balance scale, Rivermead Mobility index, 10m walk velocity), functional disability and independence (Barthel Index, FIM, Nottingham Extended Activities of Daily Living(NEDLI)), fatigue questionnaire, and psychological well being (Hospital Anxiety and Depression scale) at baseline, end of training (week 12) and follow up (week 24) were taken. |
Baseline significance between work rate and Barthel Index (p<.000), FIM motor p<.000) and NEDLI (p<.000). 6 patients (3 exercise, 3 relaxation) had elbow flexor Ashworth scores greater than 2. Participation in exercise was not associated with increased spasticity. |
|
Bhambhani et al., (2005) |
N=14 Supbjects with moderate to severe ABI (GCS 4.6+/-1.4, chronicity: 17.2+/-17 months) participated in a 5 trial, 12 week circuit training program (mean 2.3, 60 minute sessions/week) designed to enhance muscular strength and aerobic fitness. |
No significant changes were observed in the body mass or percentage body fat during the study. Peak values of power output, oxygen uptake and ventilation rate increased significantly due to training (p<0.05). |
|
Hunter et al., |
N=12 consecutive ABI admissions to the Transitional Learning Community (Range 26-48 yrs; chronicity > 1yr) participated in an exercise protocol (flexibility, muscle & aerobic performance) for 50 minute sessions, 5 days / week for 3 months. Estimated oxygen consumption (VO2) and power output slopes to determine if a physical conditioning program was associated with a change in efficiency of exercise. |
VO2, maximum power output and maximum VO2 improved significantly after conditioning program (p<0.05). Treadmill tests showed the greatest improvement (compared to bicycle ergometer and mechanical stairs). |
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Jackson et al., (2001) |
N=55 Subjects consecutively admitted between 1 June 1996 and 30 September 1998 capable of sitting on a cycle ergometer participated in an aerobic exercise program (30 minutes 3x / week for 12 weeks). Main Outcomes were the number of sessions taken to achieve a cycling time of 30 minutes, overall mean cycling time per session over 24 sessions and mean time per session spent at over 60% of HR max over 24 sessions. |
46 achieved 30 minutes of training in at least one session over 60% HR max on at least one occasion. 91% increased their training time from 3 to 30 minutes. Mean time spent in cycling per session ranged from 8.2 to 30 minutes. 80% trained for an average 20 minutes per session |
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Jankowski et al., (1990) |
N=14 CH-ABI individuals completed formal therapy and discharged from a rehabilitation centre received exercise training. Study measured peak oxygen consumption (V02pk), energy cost of walking (ECW), grip strength index (GSI), 60 second sit-up score (sit60) and Index of Physiologic Fatigability |
Significant increase in peak VO2 (31.3 mL/kg/min to 36.0 mL/kg/min); sit60 (15.4 to 29.6) and decrease in IPF (2.62 to 2.18. Average fatigability decreased 17%. No statistically significant changes in GSI or ECW |
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Mossberg et al., (2002) |
N=40 Ambulatory ABI subjects consecutively recruited for an individualized occupational, physical, speech and neuropsychotherapy program. Consider how 1 hr of individual PT 3x / week, and 1 hr of group PT 3x / week impacted gross motor-coordination, flexibility, strength and endurance. EKG, oxygen consumption, CO2 exhalation, Total Ambulation time (TAT), sub-maximal and peak HR, VO2 (oxygen pulse, respiratory quotient). |
Measures taken before admission and after discharge. TAT increased significantly (p<.01). HR, VO2 remained unchanged (p=0.09). |
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Wolman et al., (1994) |
N=6 Single incident brain injury subjects at Homerton Hospital performed graded exercise tests on a stationary bicycle in three, 30-minute sessions per week for twelve weeks. Heart rate measured to assess aerobic fitness. Spasticity assessed using modified Ashworth Scale. |
Exercise test duration (mean) improved from 8 to 12.5 minutes (p< 0.01). Mean Maximum workload increased from 52 to 95 watts (p<0.025). Spasticity increased post session (Max. Ashworth grade 2) but not overall. |
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Gordon et al., (1998) |
N=379 (TBI=240, non-TBI=139) TBI individuals completing the Quality of Life and Health Interviews (Research and Training Center – New York), and living in a community setting were classified as exercise and non-exercise groups. Beck Depression Inventory (BDI), The Institute for Rehabilitation Research (TIRR) Symptom Checklist, SF-36 Health Survey, Community Integration Questionnaire (CIQ), Craig Handicap Assessment Capacity Technique (CHART) were taken. |
TIRR checklist revealed fewer symptoms found among TBI exercisers (p<.0004). Individuals without disability were less depressed (BDI: p<.0001). TBI exercisers less depressed (p<.01) |
PEDro = Physiotherapy Evidence Database rating scale score (Moseley et al.2002),
D&B = Downs and Black (1998) quality assessment scale score.
Discussion
Bateman et al. (2001) in an RCT of exercise versus relaxation training found significant improvement in exercise capacity for the experimental group; however, there was no significant differences between the groups with regards to functional psychological status.
Similar achievements were noted in the studies completed by Jankowski et al. (1990), Wolman et al. (1994), and Hunter et al. (1990), where an intervention administered to a single group demonstrated improvements in aerobic capacity.
However, Mossberg et al. (2002) did not demonstrate improved aerobic capacity following a rehabilitation program that included calisthenics and a treadmill training program. The results did show a significant improvement in total ambulation time comparing the pre and post-intervention results.
Gordon et al (1998) in retrospective comparative study found that individuals following traumatic brain injury who exercised were less depressed, had less symptoms and better self-reported health status than non-exercising brain injury survivors.
Jackson et al (2001) evaluated the introduction of a cycle ergometer within an acute brain injury rehabilitation program. The results suggest that patients have the ability to participate in an exercise program during inpatient rehabilitation.
It appears that the introduction of an aerobic training program significantly impacts the aerobic capacity following acquired brain injury. Although the study by Mossberg et al. (2002), did not show a significant improvement in aerobic capacity specifically, the intervention itself which was described as “low aerobic exercise” which along with the small sample size and weak study design may have influenced this contradictory result. The conclusions of the studies by Bateman et al. (2001) and Gordon et al. (1998) re conflicting with regards to the effects of exercise and psychological status. Gordon et al. (1998) found that patients who exercised were less depressed than non-exercising patients; however, given that the design was a retrospective comparative design versus the prospective RCT conducted by Bateman et al. (2001), the likelihood of confounding factors is high. Specifically, one might anticipate that patients who are more depressed are less likely to spontaneously engage in exercise.
Table 4.15 Effects of Aerobic Training to Influence Aerobic Capacity Post ABI
| Author/Year |
n |
Intervention |
Result |
|
Bateman et al., (2001) |
175 |
Aerobic (treatment) vs relaxation program (control) to examine the impact of fitness training on exercise capacity, functional and psychologic measures |
Exercise group work rate (+) |
|
Jankowski et al., (2001) |
14 |
Experimental training program using various exercise modalities over several months |
Peak Oxygen Consumption (+) |
|
Mossberg et al., (2002) |
40 |
Individualized physical therapy treatment program to assess changes in cardiorespiratory responses to treadmill ambulation |
Ambulation Speed (+ from admission) |
|
Gordon et al., (1998) |
240 |
Retrospective study comparing a community sample of TBI individuals who exercise and those who do not. |
Beck's Depression Inventory (+ exercisers) |
|
Jackson et al., (2001) |
55 |
Retrospective analysis of the effect of an aerobic exercise program (using a cycle ergometer) early after injury. |
Patients with a range of disabilities have the capacity to participate in an exercise program early in rehabilitation, though some may take longer to achieve adequate intensity of aerobic exercise. |
|
Bhambhani et al., (2005) |
14 |
12 week circuit training program designed to enhance muscular strength, endurance and aerobic fitness |
Basal Metabolic Rate (-) |
|
Wolman et al., (1994) |
6 |
Assessed the impact of aerobic training on spasticity and aerobic capacity as part of rehabilitation program |
Mean Maximum Workload (+) |
|
Hunter et al., (1990) |
12 |
Progressive exercise tests conducted to determine whether results differed when performed on a treadmill, bicycle ergometer or mechanical stairs and whether such a program effects exercise performance |
Maximum Power Output (+) |
(+) Indicates statistically significant differences between treatment groups
(-) Indicates non-statistically significant differences between treatment groups
Conclusion
Based on a single RCT, there is Level 1 evidence that aerobic exercise improves aerobic capacity following ABI.
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Aerobic exercise post acquired brain injury is effective for improving general fitness.
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4.4.4 Exercise to Encourage Health-Promotion and Self-Esteem post-ABI
Research has shown that there is an increase in depression, decreased self-esteem, and decreased social contacts post-ABI. Physical activity or exercise has been repeatedly shown to positively impact health promoting behaviour. Exercise is associated with a number of health benefits including lower mortality rates, improved cardiovascular fitness, and enhanced psychological well being. This would be especially applicable to ABI survivors, as exercise could provide individuals with an opportunity to positively impact physical, cognitive and psychosocial deficits with the ultimate goal of improving functional capacity and quality of life. A further implication of exercise for brain injuries survivors is the role that exercise meets in fulfilling the frequent goal of becoming involved in meaningful, productive activity.
Individual Studies
Table 4.16 Exercise to Improve Health Promotion and Self-Esteem post-ABI
| Author/Year/ Country/ Study design/ PEDro/D&B Score |
Methods |
Outcome |
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Hoffman et al., (2010) USA RCT D&B = 15 PEDro = 5 |
N=80 Subjects post-TBI were randomly assigned to either the exercise intervention or the control group. The 10 week exercise intervention consisted of supervised aerobic exercise once a week at a community gymnasium. They completed a 15 min warm-up, 30 mins of aerobic exercise using a target intensity of 12 on the Borg Scale of Perceived Exertion and 60% of estimated maximal heart rate, and then a 15 min cool-down. At home, the intervention subjects were instructed to complete 30 mins of aerobic exercise at least 4 times a week in addition to the supervised session. The control group received no instructions to abstain from exercise. | The exercise intervention group reported exercising more days of the week than the control group (p=.004). The exercise group also reported less pain interference (p=.021) and greater improvement on the Brief Pain Inventory (p=.031) in comparison to the control group. Post-hoc analyses compared highly active participants (90 mins or more of exercise per week) and low active participants (less than 90 mins of exercise per week). The high active group scored lower on the Beck Depression Inventory after the 10 week intervention than the low active group (p=.033). The high active subjects also reported more community activity (p=.028), better quality of life (p=.034) and better general mental health (p= .024). |
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Blake and Batson (2009) |
N=20 individuals with a TBI, of which 13 were moderate to severe TBI. Time since injury was 2 to 40 years. The mean age of the groups was 46.20 for the control group and 44.5 yrs for the treatment group. The treatment group participated in Tai Chi Chuan Qigong 1 hr/week for 8 weeks. Those in the control group participated in non exercise/social activities. |
In all there was a possible 80 attendances for each group, (10 individuals x 8 sessions). For those in the exercise group there was 58 of 80 attendances, compared to the intervention group where there was 64 of 80. At the 8 week follow-up significant differences on the General Health Questionnaire-12 seen between the two groups (p=0.026). Those in the intervention group showed improved mood, (Z=-2.032, P=0.042) and self-esteem scores on the Physical self Description Questionnaire were also improved (Z=2.397, P=0>017). |
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Driver et al., (2006) |
N=18 chronic ABI patients (time since injury ranged from 17-65 months) were randomly assigned to an 8-week aquatic exercise program (1 hour sessions 3x/week involving both aerobic and resistance training during which heart rate was kept within 50-70% of individual maximum) or to a control group (vocational rehabilitation class to improve reading and writing skills). The Health Promoting Lifestyle Profile II (HPLP-II) and the Physical Self Description Questionnaire (PSDQ) were used to assess health promoting self-care behaviours and self-esteem respectively before and after the completion of the 8-week program. |
The aquatic exercise group experienced significant improvements in the health responsibility (p<0.05), physical activity (p<0.05), nutrition (p<0.01), spiritual growth (p<0.01), and inter-personal relationships (p<0.001) subscales of the HPLP-II post-treatment. At the end of the program, the aquatic exercise group also showed significant improvements for the self esteem, co-ordination, body fat, strength, flexibility and endurance portions of the PSDQ (all p values <0.001). In both cases the control group experienced no significant differences across all variables of the HPLP-II or the PSDQ post-treatment. |
PEDro = Physiotherapy Evidence Database rating scale score (Moseley et al. 2002).
D&B = Downs and Black (1998) quality assessment scale score.
Discussion
Blake and Batson (2009) and the Driver et al. (2006) suggest participation in an exercise program improves self-esteem and health promoting behaviours compared with a conventional vocational rehabilitation program. However, both studies were conducted using small samples (n=20 and n=18) and thus extrapolation to the general ABI population cannot be easily made. Blake and Batson (2009) indicated that due to the small sample size the results are not conclusive, even though they did show improvement in mood and to some degree self-esteem. The Driver et al. (2006) study suggests that participation in group exercise should be encouraged as an adjunct of the rehabilitation process for ABI patients as it can foster feelings of well-being and self-esteem which could have a positive impact upon other rehabilitation strategies. In a much larger sample, Hoffman et al. (2010) reported physical benefits of exercise but did not find a significant difference between the exercise and control groups in mood. They did, however, find that mood was significantly higher in the participants who were exercising for more than 90 minutes each week. These results were based on post-hoc analyses; therefore, a cause-effect relationship has not been established. Since the other studies are based on small samples, further research needs to be conducted with a much larger sample which looks specifically at the dose-dependent relationship between mood changes and exercise. The Schwandt et al. (2011) study demonstrated the feasibility of aerobic exercises for individuals post-TBI and an association between exercise and a reduction in depressive symptoms, improved self-esteem and improved aerobic capacity.
Conclusions
There is Level 1 evidence that participation in an exercise program improves health promotion and self-esteem post-ABI.
There is Level two evidence from 2 studies, to suggest the exercise does help improve mood and overall general mental health.
There is Level 4 evidence suggesting that participating in exercise does reduce depressive symptoms and improve self-esteem.
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Exercise helps to improve mood, overall general mental health, health promotion and self-esteem post-ABI.
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