Physical Activity Guidelines for Traumatic Brain Injury: Difference between revisions

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==== Health ====
==== Health ====
* Improved Cognitive Function including improved processing speed, executive functioning, learning ability and overall cognitive function <ref>Chin LM, Keyser RE, Dsurney J, Chan L. Improved cognitive performance following aerobic exercise training in people with traumatic brain injury. Archives of physical medicine and rehabilitation. 2015 Apr 1;96(4):754-9.</ref><ref>Grealy, M.A., Johnson, D.A., and Rushton, S.K. Improving cognitive function after brain injury: the use of exercise and virtual reality. Arch Phys Med Rehabil. 1999; 80: 661–667</ref>
* Increased Cardiorespiratory Fitness <ref name=":7">Chin, L.M.K.; Chan, L.; Woolstenhulme, J.G.; Christensen, E.J.; Shenouda, C.N.; Keyser, R.E. Improved Cardiorespiratory Fitness with Aerobic Exercise Training in Individuals With Traumatic Brain Injury. J. Head Trauma Rehabil. 2015, 30, 382–390. [CrossRef] [PubMed]</ref><ref name=":8">Lorenz, L.S.; Charrette, A.L.; O’Neil-Pirozzi, T.M.; Doucett, J.M.; Fong, J. Healthy body, healthy mind: A mixed methods study of outcomes, barriers and supports for exercise by people who have chronic moderate-to-severe acquired brain injury. Disabil. Health J. 2018, 11, 70–78. [CrossRef] [PubMed]</ref><ref name=":9">Hassett, L.; Moseley, A.M.; Harmer, A.R. Fitness training for cardiorespiratory conditioning after traumatic brain injury. Cochrane Database Syst. Rev. 2017, 12, CD006123. [PubMed]</ref>
* Increased Muscle Strength
* Improved Fatigue <ref name=":7" /><ref name=":10">Weinstein, A.A.; Chin, L.M.K.; Collins, J.; Goel, D.; Keyser, R.E.; Chan, L. Effect of Aerobic Exercise Training on Mood in People with Traumatic Brain Injury: A Pilot Study. J. Head Trauma Rehabil. 2017, 32, E49–E56. [CrossRef] [PubMed]</ref>
* Increased Balance
* Increased Mobility <ref name=":11">Chanpimol, S.; Seamon, B.; Hernandez, H.; Harris-Love, M.; Blackman, M.R. Using Xbox kinect motion capture technology to improve clinical rehabilitation outcomes for balance and cardiovascular health in an individual with chronic TBI. Arch. Physiother. 2017, 7. [CrossRef] [PubMed]</ref>
* Improved Cognitive Function including improved processing speed, executive functioning, learning ability and overall cognitive function <ref>Chin LM, Keyser RE, Dsurney J, Chan L. Improved cognitive performance following aerobic exercise training in people with traumatic brain injury. Archives of physical medicine and rehabilitation. 2015 Apr 1;96(4):754-9.</ref><ref>Grealy, M.A., Johnson, D.A., and Rushton, S.K. Improving cognitive function after brain injury: the use of exercise and virtual reality. Arch Phys Med Rehabil. 1999; 80: 661–667</ref><ref name=":12">Chin, L.M.; Keyser, R.E.; Dsurney, J.; Chan, L. Improved cognitive performance following aerobic exercise training in people with traumatic brain injury. Arch. Phys. Med. Rehabil. 2015, 96, 754–759.</ref><ref name=":13">Gordon, W.A.; Sliwinski, M.; Echo, J.; McLoughlin, M.; Sheerer, M.S.; Meili, T.E. The benefits of exercise in individuals with traumatic brain injury: A retrospective study. J. Head Trauma Rehabil. 1998, 13, 58–67. [CrossRef] [PubMed]</ref>
* Higher Perceptions of Global Health, Health Status and Quality of Life <ref name=":1">Gordon, W.A., Sliwinski, M., Echo, J., McLoughlin, M., Sheerer, M.S., and Meili, T.E. The benefits of exercise in individuals with traumatic brain injury: a retrospective study. J Head Trauma Rehabil. 1998; 13: 58–67</ref><ref name=":2">Wise EK, Hoffman JM, Powell JM, Bombardier CH, Bell KR. Benefits of exercise maintenance after traumatic brain injury. Archives of physical medicine and rehabilitation. 2012 Aug 1;93(8):1319-23.</ref>
* Higher Perceptions of Global Health, Health Status and Quality of Life <ref name=":1">Gordon, W.A., Sliwinski, M., Echo, J., McLoughlin, M., Sheerer, M.S., and Meili, T.E. The benefits of exercise in individuals with traumatic brain injury: a retrospective study. J Head Trauma Rehabil. 1998; 13: 58–67</ref><ref name=":2">Wise EK, Hoffman JM, Powell JM, Bombardier CH, Bell KR. Benefits of exercise maintenance after traumatic brain injury. Archives of physical medicine and rehabilitation. 2012 Aug 1;93(8):1319-23.</ref>
* Decreased Incidence of Depression <ref name=":1" /><ref name=":2" />
* Decreased Incidence of Depression <ref name=":1" /><ref name=":2" />
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==== Psycho-Social ====
==== Psycho-Social ====
* Improved Mood <ref name=":2" /><ref name=":3" />
* Improved Mood <ref name=":10" /><ref name=":14">Schwandt, M.; Harris, J.E.; Thomas, S.; Keightley, M.; Snaiderman, A.; Colantonio, A. Feasibility and effect of aerobic exercise for lowering depressive symptoms among individuals with traumatic brain injury: A pilot study. J. Head Trauma Rehabil. 2012, 27, 99–103. [CrossRef] [PubMed]</ref><ref name=":15">Blake, H.; Batson, M. Exercise intervention in brain injury: A pilot randomized study of Tai Chi Qigong. Clin. Rehabil. 2009, 23, 589–598. [CrossRef] [PubMed] </ref><ref name=":12" /><ref name=":13" /><ref name=":2" /><ref name=":3" />
* Increased Self Esteem <ref name=":4">Thornton, M., Marshall, S., McComas, J., Finestone, H., McCormick, A., and Sveistrup, H. Benefits of activity and virtual reality based balance exercise programmes for adults with traumatic brain injury: perceptions of participants and their caregivers. Brain Inj. 2005; 19: 989–1000</ref>
* Increased Self Esteem <ref name=":4">Thornton, M., Marshall, S., McComas, J., Finestone, H., McCormick, A., and Sveistrup, H. Benefits of activity and virtual reality based balance exercise programmes for adults with traumatic brain injury: perceptions of participants and their caregivers. Brain Inj. 2005; 19: 989–1000</ref>
* Increased Social Participation <ref name=":4" />
* Increased Social Participation <ref name=":4" />
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Exercise guidelines for individuals with a traumatic brain injury have been published by the American College of Sports Medicine, which recommend exercising at a frequency of three to five times per week, at an intensity of 40% to 70% of peak oxygen uptake, or a 13/20 Rating of Perceived Exertion (RPE), and for a duration of 20 to 60 minutes using an appropriate mode of exercise e.g. walking, swimming, cycling, that will depend upon the individual's physical ability. 
Exercise guidelines for individuals with a traumatic brain injury have been published by the American College of Sports Medicine, which recommend exercising at a frequency of three to five times per week, at an intensity of 40% to 70% of peak oxygen uptake, or a 13/20 Rating of Perceived Exertion (RPE), and for a duration of 20 to 60 minutes using an appropriate mode of exercise e.g. walking, swimming, cycling, that will depend upon the individual's physical ability. 


== Conclusion   ==
== Summary   ==
<div class="row">
Physical activity, including exercise, sport and daily physical activity participation, may positively affect cardiorespiratory fitness <ref name=":8" /><ref name=":7" /><ref name=":9" />, strength, fatigue <ref name=":7" /><ref name=":10" />, balance and mobility <ref name=":11" />, mood <ref name=":14" /><ref name=":10" /><ref name=":15" /><ref name=":12" /><ref name=":13" />, and cognition <ref name=":12" /><ref name=":13" /> following traumatic brian injury. Physical activity should be considered an important adjunct to rehabilitation and is important for individuals with moderate to severe traumatic brian injury, both in those who are community dwelling and supported accommodation facilities during early recovery and long term. <ref name=":16">Palmer-McLean, K.; Harbst, K.B. Chapter 36: Stroke and Brain Injury. In ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities; Human Kinetics: Champaign, IL, USA, 2003.</ref>
   <div class="col-md-6">[[File:Infographic 970px.jpg|border|center]]</div>
 
   <div class="col-md-6">[[File:4-physical-activity-for-disabled-adults.jpeg|border|center]]</div>
Current guidelines by the American College of Sports Medicine recommend 20 min of aerobic physical activity at low to moderate intensity at least 3 to 5 sessions per week along with strength, flexibility, and balance training for community-dwelling adults with a history of traumatic brain injury, which are not met by most individuals with a traumatic brian injury. <ref name=":16" /> In fact research suggests that physical activity levels decline as early as one week following discharge from inpatient rehabilitation. <ref>Hamilton, M.; Williams, G.; Bryant, A.; Clark, R.; Spelman, T. Which factors influence the activity levels of individuals with traumatic brain injury when they are first discharged home from hospital? Brain Inj. 2015, 29, 1572–1580. [CrossRef] [PubMed]</ref><ref>Pinto S, Newman M, Hirsch M. Perceived Barriers to Exercise in Adults with Traumatic Brain Injury Vary by Age. Journal of Functional Morphology and Kinesiology. 2018 Sep;3(3):47.</ref><div class="row">
   <div class="col-md-6">[[File:Infographic 970px.jpg|border|center|Increasing Physical Activity among Adults with Disabilities <ref>Centres for Disease Control and Prevention. Increasing Physical Activity among Adults with Disabilities. https://www.cdc.gov/vitalsigns/disabilities/images/infographic_970px.jpg [Accessed 22 Sep 2019]</ref>]]</div>
   <div class="col-md-6">[[File:4-physical-activity-for-disabled-adults.jpeg|border|center|Physical Activity for Disabled Adults]]</div>
</div>
</div>


Revision as of 19:58, 29 September 2019

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Top Contributors - Naomi O'Reilly, Kim Jackson, Rachael Lowe, Simisola Ajeyalemi and Uchechukwu Chukwuemeka  

Introduction[edit | edit source]

Physical activity, defined as any bodily movement produced by skeletal muscles that requires energy expenditure, benefits every aspect of health and in daily life can be categorized into occupational, sports, conditioning, household, or other activities, including exercise, which is planned, structured, and repetitive and has as a final or an intermediate objective the improvement or maintenance of physical fitness. [1] Regular physical activity shows benefits for everyone including children, adolescents, adults, older adults, and people with a disability across all ethnic groups and most importantly has been shown to reduce the risk of non-communicable diseases, such as Coronary Heart Disease, Type 2 Diabetes, Stroke, Cancer, Osteoporosis and Depression. [2] Physical activity can also improve bone and functional health and as a key determinant of energy expenditure, is fundamental to energy balance and weight control.

Physical inactivity has been identified as the fourth leading risk factor for global mortality causing an estimated 3.2 million deaths globally or 6% of deaths. [3] Globally 23 percent of adults 18+ and 80 percent of adolescents are insufficiently active, and this number is higher among individuals with a disability. Current evidence suggests that inactivity has negative effects on everyone, but the effects appear to be worse for people with disability, particularly for those with a traumatic brain injury. [4]

Physical Activity and Traumatic Brain Injury[edit | edit source]

Barriers to Physical Activity[edit | edit source]

Common Barriers Experienced by People with a Disabilities [5]
Given that individuals with a disability have decreased levels of physical activity, there has been a major focus by researchers on identifying the barriers they experience in relation to physical activity participation. A broad spectrum of researchers have identified many barriers to participation, some that are shared across all individuals both with and without a disability eg. perceptions of limited time to engage in physical activity, while others relate more specifically to certain groups of individuals with a disability e.g. lack of wheelchair access. [6] In much of the research available the barriers identified have not distinguished whether the barriers relate to active versus inactive people, and generally reflect the barriers encountered by inactive individuals. As such we need to consider that the barriers preventing inactive people from initiating physical activity may differ from the barriers that active individuals face and learn to manage successfully on an ongoing basis to remain active. [6] We also need to consider the barriers for those with a traumatic brain injury on an individual level, relating to how their disability impacts on their physical activity participation, while also considering societal and environmental level barriers.

A wide range of barriers exist that limit and in some cases prevent individuals with a traumatic brian injury from being active, which increases the risk of developing further secondary and chronic health conditions. Barriers to participation in physical activity vary depending on age, severity of the traumatic brain injury, type of impairment and length of time since initial injury. [7]

[8]

Individual Level Barriers[edit | edit source]

Research highlights that physical activity levels decrease from pre-injury to post-injury periods, which may be suggestive that disability and disability related factors contribute to lower levels of physical activity engagement, with severity of the disability having a major impact on return to physical activity. [6]

Psychosocial[edit | edit source]
  • Diminished Drive / Motivation
  • Feel Self-Conscious
  • Lack of Time
  • Lack of Interest
  • Lack of Energy
Knowledge[edit | edit source]
  • Lack of Knowledge regarding Benefits of Physical Activity
  • Lack of Knowledge of Where to Exercise
  • Lack of Knowledge of Types of Physical Activity
Physical Impairment[edit | edit source]
  • Increased Fatigue
  • Decreased Mobility
  • Decreased Balance
  • Decreased Muscle Strength
  • Changes to Oxidative Metabolism
  • Pain limits Participation

Societal Level Barriers[edit | edit source]

  • Lack of Support
  • Poor Community Integration
  • Lack of Counselling by a Physician on role of Physical Activity
  • Lack of Adapted Physical Activity Opportunities
  • Poor Trainer / Coach Knowledge Awareness of Traumatic Brain injury
  • Trainer / Coach and Therapists Perceive Individuals with a Traumatic Brain injury as Lacking Adequate Skills and Underestimate Physical Abilities

Environmental Level Barriers[edit | edit source]

  • Barriers in Outdoor Areas i.e. uneven pathways [9]
  • Lack of Accessible Facilities e.g. limited adaptive equipment or space between equipment, no ramps or elevators, poor signage
  • Lack of Transportation
  • Cost of the Program

You can view the following Breaking Barriers Series, which explores in detail the main barriers to people with a disability leading more active lifestyles.

[10]
[11]
[12]
[13]

Benefits Physical Activity[edit | edit source]

There is strong evidence demonstrating that being physically active is beneficial to individuals in terms of their physical and mental health, well-being, cognitive function, and increased longevity with positive outcomes for the community and wider society through health savings, social engagement, and greater productivity. [2][14] Physical activity not only promotes good health and functioning and helps prevent and manage disease; it also contributes to a range of wider social benefits for individuals and communities. The relevance and importance of the wider benefits of physical activity for individuals vary according to life stage and various other factors but include: improved learning and attainment; managing stress; self-efficacy; improved sleep; the development of social skills; and better social interaction. According to the Expert Committee that developed the US Guidelines on Physical Activity in 2008, “the health benefits of being habitually physically active appear to apply to all people regardless of age, sex, race/ethnicity, socioeconomic status and...people with physical or cognitive disabilities.”

Overall Impact Sport & PA.jpeg
[15]

Health[edit | edit source]

  • Increased Cardiorespiratory Fitness [16][17][18]
  • Increased Muscle Strength
  • Improved Fatigue [16][19]
  • Increased Balance
  • Increased Mobility [20]
  • Improved Cognitive Function including improved processing speed, executive functioning, learning ability and overall cognitive function [21][22][23][24]
  • Higher Perceptions of Global Health, Health Status and Quality of Life [25][26]
  • Decreased Incidence of Depression [25][26]
  • Improved Sleep [27]

Psycho-Social[edit | edit source]

Physical Activity Guidelines[edit | edit source]

The World Health Organisation developed Global Recommendations on Physical Activity for Health with the overall aim of providing national and regional level policy makers with guidance on the dose-response relationship between the frequency, duration, intensity, type and total amount of physical activity needed for the prevention of Non Communicable Diseases. While these guidelines were not specifically tailored to the traumatic brain injury population, the World Health Organization suggest that the recommendations could be applied to adults with a disability with adjustment to the guidelines for each individual based on their exercise capacity and specific health risks or limitations. [4][31]

American College of Sports Medicine Physical Activity Guidelines for Traumatic Brain Injury[edit | edit source]

Exercise guidelines for individuals with a traumatic brain injury have been published by the American College of Sports Medicine, which recommend exercising at a frequency of three to five times per week, at an intensity of 40% to 70% of peak oxygen uptake, or a 13/20 Rating of Perceived Exertion (RPE), and for a duration of 20 to 60 minutes using an appropriate mode of exercise e.g. walking, swimming, cycling, that will depend upon the individual's physical ability. 

Summary[edit | edit source]

Physical activity, including exercise, sport and daily physical activity participation, may positively affect cardiorespiratory fitness [17][16][18], strength, fatigue [16][19], balance and mobility [20], mood [28][19][29][23][24], and cognition [23][24] following traumatic brian injury. Physical activity should be considered an important adjunct to rehabilitation and is important for individuals with moderate to severe traumatic brian injury, both in those who are community dwelling and supported accommodation facilities during early recovery and long term. [32]

Current guidelines by the American College of Sports Medicine recommend 20 min of aerobic physical activity at low to moderate intensity at least 3 to 5 sessions per week along with strength, flexibility, and balance training for community-dwelling adults with a history of traumatic brain injury, which are not met by most individuals with a traumatic brian injury. [32] In fact research suggests that physical activity levels decline as early as one week following discharge from inpatient rehabilitation. [33][34]
Increasing Physical Activity among Adults with Disabilities [35]
Physical Activity for Disabled Adults

References[edit | edit source]

  1. ↑ Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public health reports. 1985 Mar;100(2):126.
  2. ↑ 2.0 2.1 Physical Activity Guidelines Advisory Committee. Physical Activity Guidelines Advisory Committee Report, 2008. Washington, DC: U.S. Department of Health and Human Services, 2008. 
  3. ↑ Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT, Lancet Physical Activity Series Working Group. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. The lancet. 2012 Jul 27;380(9838):219-29.
  4. ↑ 4.0 4.1 World Health Organisation. Physical Activity. Available at: http://www.who.int/topics/physical_activity/en/ [accessed 20 May 2016]
  5. ↑ National Center on Health, Physical Activity and Disability (NCHPAD). (2019). Addressing Barriers. Available at: https://www.nchpad.org/1246/5928/A~Proactive~Approach~to~Inclusive~Fitness [Accessed 17 September 2019].
  6. ↑ 6.0 6.1 6.2 Martin JJ. Benefits and barriers to physical activity for individuals with disabilities: a social-relational model of disability perspective. Disability and rehabilitation. 2013 Dec 1;35(24):2030-7.
  7. ↑ Jaarsma EA, Dijkstra PU, Geertzen JHB, Dekker R. Barriers to and facilitators of sports participation for people with physical disabilities: A systematic review. 2014. Scandinavian Journal of Medicine </nowiki>&Science in Sports, 24 (6), 871-881
  8. ↑ Empower. Disability and Health Inequalities - Introduction to the Breaking Barriers Series. Available from: http://www.youtube.com/watch?v=5lfUiH77BxA[last accessed 30/09/19]
  9. ↑ Hassett L, Moseley AM, Harmer AR. Fitness training for cardiorespiratory conditioning after traumatic brain injury. Cochrane Database of Systematic Reviews. 2017(12).
  10. ↑ Empower. Breaking Barriers - Transport as a barrier to an active lifestyle for disabled people. Available from: https://youtu.be/5lfUiH77BxA[last accessed 30/09/19]
  11. ↑ Empower. Breaking Barrier - Inaccessible Venues. Available from: https://youtu.be/Ck_962U741c[last accessed 30/09/19]
  12. ↑ Empower. Breaking Barriers - Equipment as a barrier to disabled people keeping active. Available from: https://youtu.be/CfcZgprOnIk[last accessed 30/09/19]
  13. ↑ Empower. Breaking Barriers - lack of knowledgeable staff as a barrier to disabled people keeping active. Available from: https://youtu.be/psAv4dKSGPo[last accessed 30/09/19]
  14. ↑ Institute,UK Chief Medical Officers' Physical Activity Guidelines, 7 September 2019, Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/832868/uk-chief-medical-officers-physical-activity-guidelines.pdf, [Accessed 27th September 2019]
  15. ↑ Brainline. How Exercise Can Heal the Brain after a Traumatic Brain Injury. Available from: http://www.youtube.com/watch?v=BUevLwJGMlQ[last accessed 30/09/19]
  16. ↑ 16.0 16.1 16.2 16.3 Chin, L.M.K.; Chan, L.; Woolstenhulme, J.G.; Christensen, E.J.; Shenouda, C.N.; Keyser, R.E. Improved Cardiorespiratory Fitness with Aerobic Exercise Training in Individuals With Traumatic Brain Injury. J. Head Trauma Rehabil. 2015, 30, 382–390. [CrossRef] [PubMed]
  17. ↑ 17.0 17.1 Lorenz, L.S.; Charrette, A.L.; O’Neil-Pirozzi, T.M.; Doucett, J.M.; Fong, J. Healthy body, healthy mind: A mixed methods study of outcomes, barriers and supports for exercise by people who have chronic moderate-to-severe acquired brain injury. Disabil. Health J. 2018, 11, 70–78. [CrossRef] [PubMed]
  18. ↑ 18.0 18.1 Hassett, L.; Moseley, A.M.; Harmer, A.R. Fitness training for cardiorespiratory conditioning after traumatic brain injury. Cochrane Database Syst. Rev. 2017, 12, CD006123. [PubMed]
  19. ↑ 19.0 19.1 19.2 19.3 Weinstein, A.A.; Chin, L.M.K.; Collins, J.; Goel, D.; Keyser, R.E.; Chan, L. Effect of Aerobic Exercise Training on Mood in People with Traumatic Brain Injury: A Pilot Study. J. Head Trauma Rehabil. 2017, 32, E49–E56. [CrossRef] [PubMed]
  20. ↑ 20.0 20.1 Chanpimol, S.; Seamon, B.; Hernandez, H.; Harris-Love, M.; Blackman, M.R. Using Xbox kinect motion capture technology to improve clinical rehabilitation outcomes for balance and cardiovascular health in an individual with chronic TBI. Arch. Physiother. 2017, 7. [CrossRef] [PubMed]
  21. ↑ Chin LM, Keyser RE, Dsurney J, Chan L. Improved cognitive performance following aerobic exercise training in people with traumatic brain injury. Archives of physical medicine and rehabilitation. 2015 Apr 1;96(4):754-9.
  22. ↑ Grealy, M.A., Johnson, D.A., and Rushton, S.K. Improving cognitive function after brain injury: the use of exercise and virtual reality. Arch Phys Med Rehabil. 1999; 80: 661–667
  23. ↑ 23.0 23.1 23.2 23.3 Chin, L.M.; Keyser, R.E.; Dsurney, J.; Chan, L. Improved cognitive performance following aerobic exercise training in people with traumatic brain injury. Arch. Phys. Med. Rehabil. 2015, 96, 754–759.
  24. ↑ 24.0 24.1 24.2 24.3 Gordon, W.A.; Sliwinski, M.; Echo, J.; McLoughlin, M.; Sheerer, M.S.; Meili, T.E. The benefits of exercise in individuals with traumatic brain injury: A retrospective study. J. Head Trauma Rehabil. 1998, 13, 58–67. [CrossRef] [PubMed]
  25. ↑ 25.0 25.1 Gordon, W.A., Sliwinski, M., Echo, J., McLoughlin, M., Sheerer, M.S., and Meili, T.E. The benefits of exercise in individuals with traumatic brain injury: a retrospective study. J Head Trauma Rehabil. 1998; 13: 58–67
  26. ↑ 26.0 26.1 26.2 Wise EK, Hoffman JM, Powell JM, Bombardier CH, Bell KR. Benefits of exercise maintenance after traumatic brain injury. Archives of physical medicine and rehabilitation. 2012 Aug 1;93(8):1319-23.
  27. ↑ 27.0 27.1 Hoffman, J.M., Bell, K.R., Powell, J.M. et al. A randomized controlled trial of exercise to improve mood after traumatic brain injury. PM R. 2010; 2: 911–919
  28. ↑ 28.0 28.1 Schwandt, M.; Harris, J.E.; Thomas, S.; Keightley, M.; Snaiderman, A.; Colantonio, A. Feasibility and effect of aerobic exercise for lowering depressive symptoms among individuals with traumatic brain injury: A pilot study. J. Head Trauma Rehabil. 2012, 27, 99–103. [CrossRef] [PubMed]
  29. ↑ 29.0 29.1 Blake, H.; Batson, M. Exercise intervention in brain injury: A pilot randomized study of Tai Chi Qigong. Clin. Rehabil. 2009, 23, 589–598. [CrossRef] [PubMed]
  30. ↑ 30.0 30.1 Thornton, M., Marshall, S., McComas, J., Finestone, H., McCormick, A., and Sveistrup, H. Benefits of activity and virtual reality based balance exercise programmes for adults with traumatic brain injury: perceptions of participants and their caregivers. Brain Inj. 2005; 19: 989–1000
  31. ↑ World Health Organization. Global recommendations on physical activity for health. World Health Organization; 2010.
  32. ↑ 32.0 32.1 Palmer-McLean, K.; Harbst, K.B. Chapter 36: Stroke and Brain Injury. In ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities; Human Kinetics: Champaign, IL, USA, 2003.
  33. ↑ Hamilton, M.; Williams, G.; Bryant, A.; Clark, R.; Spelman, T. Which factors influence the activity levels of individuals with traumatic brain injury when they are first discharged home from hospital? Brain Inj. 2015, 29, 1572–1580. [CrossRef] [PubMed]
  34. ↑ Pinto S, Newman M, Hirsch M. Perceived Barriers to Exercise in Adults with Traumatic Brain Injury Vary by Age. Journal of Functional Morphology and Kinesiology. 2018 Sep;3(3):47.
  35. ↑ Centres for Disease Control and Prevention. Increasing Physical Activity among Adults with Disabilities. https://www.cdc.gov/vitalsigns/disabilities/images/infographic_970px.jpg [Accessed 22 Sep 2019]
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