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. These deficits include: 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.
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 and 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 therapists 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). Partial body weight support also reduces the demands on muscles while the patient works on improving the coordination of the movement. Body weight support can be gradually adjusted, as the patient improves, to encourage postural control and balance.
We identified several studies that evaluated the efficacy of partial body weight supported gait training following ABI. Brown et al. (2005) conducted a 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 three 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 although each group made functional improvements, there were no significant between-group differences on measures of balance, ambulation and mobility at the end of the eight week training period (Wilson et al. 2006). Once again, Esquenazi et al. (2013) compared robotic assisted treadmill training to manually assisted treadmill training for individuals with TBI and found no difference between the two interventions for gait velocity, endurance or the mobility. However, both interventions resulted in significant improvement in gait parameters. From these studies, it appears that body weight supported treadmill training is not superior to more conventional methods.
Clark et al. (2012) demonstrated that using body-weight-support treadmill training with handrail support reduces the amount of center of mass displacement and postural instability. However, they also noted that support alters timing and variability components of gait patterns. Although the study explored seven gait training methods, Clark et al. (2012) concluded that no one method provides the optimal stimulus and that combining various methods may be the most beneficial. Peters et al. (2014) identified that with intensive therapy using body-weight-support treadmill training, balance activities, strength coordination, and range of motion activities, individuals can significantly improve their walking speed and Timed Up and Go test scores. The benefits lasting up to three months post intervention.
There is Level 1b evidence that partial body weight supported gait training does not provide any added benefit over conventional gait training in ambulation, mobility or balance.
Partial body weight supported gait training is not better than conventional gait training for improving ambulation, mobility or balance.
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.
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.
Dault and Dugas (2002) compared the effect of a specific balance and coordination training program post TBI to traditional muscular training. This prospective cohort design demonstrated a significant improvement in balance and coordination within the specific therapy training group. Similar elements were studied by Ustinova et al. (2015) in a therapeutic exercise program that was geared towards full-body coordination, posture and gait. This intervention improved postural stability, gait and coordination (Ustinova et al. 2015).
Virtual reality interventions have also been shown to be beneficial in improving balance. Ustinova et al. (2014) had participants complete 15 sessions of virtual reality therapy and found that this intervention targeted the recovery of postural and co-ordination abnormalities, with significant improvements shown for balance and dynamic stability. Cuthbert et al. (2014) also demonstrated a significant improvement on balance using virtual reality therapy; however, the gains made using this intervention were not significantly different than those made with standard therapy. Finally, during static balance tasks, visual feedback provided using a Wii Balance board helped reduce weight-bearing asymmetry (Foo et al. 2013).
Mumford et al. (2012) used virtual reality therapy with an interactive LCD surface and tracking cameras over 12 1-hour sessions. They found that accuracy and dexterity improved significantly in both upper extremities, but speed and efficiency only improved significantly for the right arms. Schafer and Ustinova (2013) compared reaches in the physical environment after having participants with TBI and controls practice reaches in a virtual environment. Reaching distances in the physical environment increased for both groups, but a greater effect was noted among those with TBI.
In a study by Lorentzen et al. (2012), participants received either Neural Tension Technique (NTT) treatment or random passive movement (RPM) therapy on knee joints. No significant changes in muscle stiffness were observed for either group with objective measures. Range of motion may be improved to the same effect by NTT and RPM therapies.
Hirose et al. (2013) compared a group receiving electrical muscle stimulation (EMS) and a control group to determine the effects of EMS on muscle atrophy in the lower limbs. The use of EMS resulted in significantly reduced amounts of atrophy.
There is Level 1b 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.
Many ABI patients have gone through a period of prolonged bed rest as a result of comorbid injuries or a prolonged loss of consciousness; consequently, cardiovascular changes, muscular atrophy and loss of lean body mass commonly occur (Boake et al. 2000). 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).
It appears that the introduction of an aerobic training program can have a positive influence on individuals post injury. When comparing individuals with TBI that exercise to those that do not, the exercisers were less depressed, had less symptoms and better self-reported health status than non-exercising brain injury survivors (Gordon et al. 1998). Other studies have shown additional benefits. For example, Mossberg et al. (2002) found a rehabilitation program that included calisthenics and a treadmill training program resulted in significant improvement in total ambulation time. Similarly, Chin et al. (2015) reported that supervised treadmill training resulted in increased oxygen uptake, work rate and a decrease in fatigue.
Bateman et al. (2001) compared cycling training (experimental group) to relaxation training (control group) and found significant improvement in exercise capacity for the experimental group; however, there was no significant difference between the groups in regards to functional independence (Bateman et al. 2001). This suggests that although exercise programs may improve physical fitness, gains in functional status often occur independently of aerobic exercise training (Bateman et al. 2001). Corral et al. (2014) also concluded that cycling training resulted in increased oxygen uptake capacity.
Hassett et al. (2012) examined the benefits of encouragement from a physiotherapist and heart rate monitor feedback during circuit training with a group of individuals with severe TBI. More specifically, the intervention group had their heart rate monitor uncovered and it beeped when they did not reach their target heart rate, whereas the control group had their monitors covered and muted.
Results indicate there was no significant difference between the two groups in terms of the amount of time spent in the heart rate target zone. Participants, although they spent <20 minutes in their heart rate target zone, did expend >300 kcal. Study authors did find that participants did benefit from the low intensity, long duration circuit class training. Earlier Hassett et al. (2009) found individuals assigned to exercise programs showed significant improvement in their cardiorespiratory levels regardless of where they worked out (in a gym or at home) or how often (2.4 sessions per week versus 0.5 sessions per week). However, adherence to the program was higher among those attending a fitness center. When compliance was explored further, those who adhered were found to be older and had exercised before the injury (Hassett et al. 2011).
Charrette et al. (2016) conducted a study of intensive exercise, consisting of endurance and full body strength training, for adults with chronic severe ABI. Results suggest that intensive combination of interventions improves gait distance and velocity, as well as mobility (Charrette et al. 2016).
There is Level 1a evidence that exercise programs improve cardiorespiratory output post ABI.
There is Level 2 evidence indicating that engaging in exercise prior to sustaining an ABI has a positive impact on exercise compliance post ABI.
There is Level 4 evidence that exercise improves gait, mobility and individual’s perception of their social, physical and mental health post ABI.
Exercise programs, both aerobic and weight training post AB, are effective for improving general fitness.
Engaging in exercise programs prior to injury increases the likelihood of continuing to exercise post ABI.
Adherence to an exercise program may be higher when done at a fitness center compared to at home.
Exercise to Encourage Health-Promotion and Self-Esteem post-ABI
Research has shown that there is an often an increase in depression and a decrease in self-esteem and social contacts post ABI. Exercise is a meaningful and productive activity that is associated with a number of health benefits including lower mortality rates, improved cardiovascular fitness, and enhanced psychological well-being. For the ABI population, exercise provides an opportunity to positively impact one’s physical, cognitive and psychosocial deficits with the ultimate goal of improving functional capacity and quality of life.
All studies in this section explore the use of exercise to improve well-being post ABI. Aquatic exercise was found to improve almost all subscales on the Health Promoting Lifestyle Profile, including interpersonal relationships, and also improved self-esteem as measured by the Physical Self-Description Questionnaire (Driver et al. 2006). This study suggests that participation in group exercise should be encouraged as an adjunct of the rehabilitation process for patients with ABI as it can foster feelings of well-being and self-esteem which could have a positive impact upon other rehabilitation strategies (Driver et al. 2006). Another type of exercise studied was Tai Chi Chuan Qigong. Although Tai Chi did improve mood and self-esteem scores for participants, the results were not significantly different from those who participated in non-exercise social and leisure activities. Hence, perhaps the social aspect of exercise programs is what helps to increase mood and self-esteem. Unfortunately both studies had a small sample size. 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.
In a much larger sampled study, Hoffman et al. (2010) compared individuals who exercised in a community-based program to individuals who did not participate in this program; however, the controls were able to exercise on their own. Although the intervention group was working out more days per week than controls, the amount of time in total per week was similar between groups making comparisons challenging. When the groups were ignored and those who were active (more than 90 minutes of activity per week) were compared to those who were not as active, the authors found that mood was significantly higher in the participants who were exercising for more than 90 minutes each week. Thus, any physical exercise is beneficial to patients post ABI. The former is reinforced by Schwandt et al. (2012b) who demonstrated that aerobic exercises (ergometer, treadmill, or recumbent step machine) all lead to a reduction in depressive symptoms, improved self-esteem and improved aerobic capacity. Furthermore, aerobic exercise programs in combination with a self-affirmation program (Lee et al. 2014) and home-based exercise programs (Bellon et al. 2015) have shown to improve depressive symptoms following intervention.
There is Level 1b evidence that participation in an exercise program improves health promotion and self-esteem post ABI.
There is Level 2 evidence to suggest that exercise does help improve mood and overall general mental health (i.e., depressive symptoms, quality of life and stress).
Exercise helps to improve mood, overall general mental health, health promotion and self-esteem post ABI.