A TBI can affect one’s movement, balance, cognition, and emotions. The following physical considerations should be taken into account when designing an exercise program. Paralysis may be present in two or all four extremities. Impairments in motor control and coordination as well as limited range of motion and spasticity can occur. Individuals with TBI may have balance issues that affect sitting or standing as well as seizures that result from an abnormality in electric activity in the brain. Cognition is often affected resulting in the potential for mental confusion, memory loss, and impaired ability to learn and process new information. Lastly, emotions may be impacted resulting in mood swings, depression, anxiety, apathy, aggression, and irritable behavior.

 An exercise program for a person with TBI should be tailored to address concerns of excessive tone, spasticity, decreased range of motion, decreased cardiovascular and muscular endurance, loss of flexibility, over-use injury, and affected side neglect⁴.  Incorporating physical activity to improve these concerns can increase one’s quality of life and ability to perform activities of daily living skills (ADLS). There are a variety of additional considerations that must be taken into account when creating an effective exercise program for individuals with TBI, including:

• A typical standing exercise may need to be performed seated or standing while using a fixed-support structured to ensure safety when balance issues are present⁴. The NCHPAD video series on balance training can aid in selecting appropriate exercises to perform.
• When cognition issues are present, incorporating multi-joint exercises are beneficial in developing retention of complex movement or muscle memory⁴. To maintain consistency and proper form throughout an exercise cueing from a fitness professional or exercise partner may be necessary. 
• Affected side neglect can be addressed with resistive ROM exercises where the individual is actively performing an exercise and the fitness professional is resisting the movement they are performing. This type of exercise allows for the incorporation of strength training into the passive joint or muscle group.
• Aerobic activity options can include upper and/or lower body ergometers and treadmills. The goal for aerobic exercise is to increase independence in ADLS and decrease risk of cardiovascular disease. Individuals with TBI should focus on intensity of 40 to 70 percent VO2 peak and 13 to 20 on the Borg Rate of Perceived Exertion (RPE) Scale⁴. Activity should be performed on three to five days per week with 20 to 60 minutes per session.
• Strength training should include isometric exercises, weight machines, and free weights. The goal is increased independence in ADLS by improving muscular strength and function. Training should be performed on at least two days per week with three sets of eight to 12 repetitions⁴.   
• Flexibility training should include stretching and ROM exercises. The goal is to increase ROM of involved extremities and prevent contractures. These exercises should be performed at least two days per week ideally after aerobic and/or strength training⁴.
• Neuromuscular training should include coordination and balance activities. The goal is to improve level of safety of ADLS. These exercises should be performed on at least two days per week ideally on the same days as strength training⁴.
• Warm water pool training is beneficial in individuals with TBI as is provides a weightless environment for the development of functional movement⁴. 
• Individuals with TBI have lower oxidative capacities and faster fatigue rates.  During physical activity make sure to incorporate proper rest between exercises and consider exercise during a time of the day that does not further promote fatigue.
• Circuit training has been found effective in improving cardiorespiratory fitness of individuals with TBI². This type of training combines resistance exercise with aerobic exercise through a variety of different types of movements. A combination of alternating upper and lower body work with high resistance, short duration exercise with low resistance, longer duration aerobic exercise, and upper body ergometry has been effective in persons with TBI².

When working with people with disability and chronic conditions it is important that fitness professionals are knowledgeable about how certain common medications affect and are affected by exercise, and where to go to find more information. For individuals with TBI, the following common medications and side effects are listed below⁴. For more information on medications, disability, and exercise please refer to this NCHPAD factsheet. 

•    Anti-seizure medication: fatigue, drowsiness, dizziness, double vision, lack of coordination
•    Anti-parkinsonian medication: dizziness, agitation, low blood pressure, nausea, confusion
•    Anti-spasticity medication: drowsiness, weakness, dizziness, nausea, lightheadedness
•    Antidepressants: headaches, nausea, dizziness, agitation, aggressiveness, increased heart rate, drowsiness
•    Antipsychotics: low blood pressure, seizures, muscle spasms
•    Anti-anxiety medication: nausea, drowsiness, dizziness
•    Psychostimulants: agitation, weight loss, insomnia