Fitness training for cardiorespiratory conditioning after traumatic brain injury

Testosterone replacement in hypogonadal men during inpatient rehabilitation following traumatic brain injury: Results from a double-blind, placebo-controlled clinical pilot study

BACKGROUND

Endocrinopathy, including hypogonadism, is common following traumatic brain injury (TBI). Prior evidence suggests hypogonadism is associated with poorer function.

OBJECTIVE

Determine the feasibility, safety, and efficacy of testosterone (T) therapy in hypogonadal men following TBI in acute rehabilitation.

DESIGN

Randomized, double blind, placebo-controlled pilot trial.

SETTING

Inpatient rehabilitation brain injury unit.

PARTICIPANTS

Men ages 18 -65, post moderate to severe TBI receiving inpatient rehabilitation.

INTERVENTIONS

Transdermal T gel or placebo.

MAIN OUTCOME MEASURES

Revised FIM™ score, strength, adverse events.

RESULTS

Of 498 screened, 70 participants were enrolled, and 22 meeting all criteria were randomized into placebo (n = 10) or physiologic T therapy (n = 12). There was no significant difference between groups in rate of improvement on the FIM™ (intercepts t = -0.31, p = 0.7593, or slopes t = 0.61, p = 0.5472). The Treatment group demonstrated the greatest absolute improvement in FIM™ scores and grip strength compared to Placebo or Normal T groups. There was no difference in adverse events between groups. Percentage of time with agitation or aggression was highest in the Placebo group.

CONCLUSIONS

Although there were no significant differences in rates of recovery, treatment group subjects showed greater absolute functional and strength improvement compared to the Placebo or Normal T groups.

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.

Fitness training for cardiorespiratory conditioning after traumatic brain injury

BACKGROUND

Reduced cardiorespiratory fitness (cardiorespiratory deconditioning) is a common consequence of traumatic brain injury (TBI). Fitness training may be implemented to address this impairment.

OBJECTIVES

The primary objective of this updated review was to evaluate whether fitness training improves cardiorespiratory fitness in people who have sustained a TBI. The secondary objectives were to evaluate whether fitness training improves body function and structure (physical and cognitive impairments, psychological responses resulting from the injury), activity limitations and participation restrictions in people who have sustained a TBI as well as to evaluate its safety, acceptance, feasibility and suitability.

SEARCH METHODS

We searched 10 electronic databases (the Cochrane Injuries Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Embase; PubMed (MEDLINE); CINAHL; AMED; SPORTDiscus; PsycINFO; PEDro and PsycBITE) and the International Clinical Trials Registry Platform for relevant trials. In addition we screened reference lists from systematic reviews related to the topic that we identified from our search, and from the included studies, and contacted trialists to identify further studies. The search was run in August 2017.

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 results, extracted data and assessed bias. We contacted all trialists for additional information. We calculated mean difference (MD) or standardised mean difference (SMD) and 95% confidence intervals (CI) for continuous data, and odds ratio with 95% CI for dichotomous data. We pooled data when there were sufficient studies with homogeneity.

MAIN RESULTS

Two new studies incorporating 96 participants were identified in this update and were added to the six previously included studies. A total of eight studies incorporating 399 participants are included in the updated review. The participants were primarily men aged in their mid-thirties who had sustained a severe TBI. No studies included children. The studies were clinically diverse with regard to the interventions, time postinjury and the outcome measures used. At the end of intervention, the mean difference in peak power output was 35.47 watts (W) in favour of fitness training (MD 35.47 W, 95% CI 2.53 to 68.41 W; 3 studies, 67 participants; low-quality evidence). The CIs include both a possible clinically important effect and a possible negligible effect, and there was moderate heterogeneity among the studies.Five of the secondary outcomes had sufficient data at the end of intervention to enable meta-analysis: body composition (SMD 0.29 standard deviations (favouring control), 95% CI -0.22 to 0.79; 2 studies, 61 participants; low-quality evidence), strength (SMD -0.02 (favouring control), 95% CI -0.86 to 0.83; 2 studies, 23 participants; very low-quality evidence), fatigue (SMD -0.32 (favouring fitness training), 95% CI -0.90 to 0.26; 3 studies, 130 participants; very low-quality evidence), depression (SMD -0.43 (favouring fitness training), 95% CI -0.92 to 0.06; 4 studies, 220 participants; very low-quality evidence), and neuromotor function (MD 0.01 m (favouring fitness training), 95% CI -0.25 to 0.27; 2 studies, 109 participants; moderate-quality evidence). It was uncertain whether fitness training was more or less effective at improving these secondary outcomes compared to the control interventions. Quality of life was assessed in three trials, but we did not pool the data because of substantial heterogeneity. Five of the eight included studies had no dropouts from their intervention group and no adverse events were reported in any study.

AUTHORS' CONCLUSIONS

There is low-quality evidence that fitness training is effective at improving cardiorespiratory deconditioning after TBI; there is insufficient evidence to draw any definitive conclusions about the other outcomes. Whilst the intervention appears to be accepted by people with TBI, and there is no evidence of harm, more adequately powered and well-designed studies are required to determine a more precise estimate of the effect on cardiorespiratory fitness, as well as the effects across a range of important outcome measures and in people with different characteristics (e.g. children). In the absence of high quality evidence, clinicians may be guided by pre-exercise screening checklists to ensure the person with traumatic brain injury is safe to exercise, and set training parameters using guidelines established by the American College of Sports Medicine for people who have suffered a brain injury.

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

BACKGROUND

Few people with chronic moderate-to-severe brain injury are following recommended physical activity guidelines.

OBJECTIVE

Investigate effects of planned, systematic physical activity while cultivating social and emotional well-being of people with chronic moderate-to-severe brain injury.

HYPOTHESIS

Moderate-to-intensive physical activity would be associated with improvements in impairment and activity limitation measures (endurance, mobility, gait speed) immediately post-intervention and six weeks later (study week 12).

METHODS

The intervention was a single group pre-/post-intervention study with 14 people with chronic moderate-to-severe brain injury who live in brain injury group homes and exercised 60-90 min, 3 days per week for 6 weeks at a maximum heart rate of 50-80%. Pre-post measures (administered weeks 0, 6 and 12) were the 6 Minute Walk Test, High-level Mobility Assessment Tool and 10 Meter Walk Test. The qualitative component used a brief survey and semi-structured interview guide with participants, family members, and staff.

RESULTS

Following program completion, post-intervention group changes were noted on all outcome measures and greater than minimal detectable change for people with brain injury. Three transitioned from low to high ambulatory status and maintained this change at 12 weeks. During interviews, participants agreed the program was stimulating. More than eighty percent liked working out in a group and felt better being active.

CONCLUSIONS

Program impact included physical, cognitive and social/emotional aspects. Social aspects (group format, trainers) were highly motivating and supported by residents, family, and staff. Investments in transportation and recruiting and training interns to assist participants are critical to program sustainability and expansion.

Neurorehabilitation: applied neuroplasticity

The prevalence of disability due to neurological conditions is escalating worldwide. Neurological disorders have significant disability-burden with long-term functional and psychosocial issues, requiring specialized rehabilitation services for comprehensive management, especially treatments tapping into brain recovery 'neuroplastic' processes. Neurorehabilitation is interdisciplinary and cross-sectorial, requiring coordinated effort of diverse sectors, professions, patients and community to manage complex condition-related disability. This review provides evidence for a range of neurorehabilitation interventions for four common neurological conditions: multiple sclerosis (MS), stroke, traumatic brain injury and Parkinson's disease using the Grade of Recommendation, Assessment, Development and Evaluation tool for quality of evidence. Although, existing best-evidence for many interventions is still sparse, the overall findings suggest 'strong' evidence for physical therapy and psychological intervention for improved patient outcomes; and. 'moderate' evidence for multidisciplinary rehabilitation for longer term gains at the levels of activity (disability) and participation in MS and stroke population. The effect of other rehabilitation interventions is inconclusive, due to a paucity of methodologically robust studies. More research is needed to improve evidence-base for many promising rehabilitation interventions.

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.

Pilot study of intensive exercise on endurance, advanced mobility and gait speed in adults with chronic severe acquired brain injury

BACKGROUND AND PURPOSE

Effects of high-intensity exercise on endurance, mobility and gait speed of adults with chronic moderate-to-severe acquired brain injury (ABI) were investigated. It was hypothesized that intensive exercise would be associated with improvements in impairment and activity limitation measures.

PARTICIPANTS

Fourteen adults with chronic ABI in supported independent living who could stand with minimal or no assist and walk with or without ambulation device were studied. Eight presented with low ambulatory status.

METHODS

This was a single group pre- and post-intervention study. Participants received a 6-week exercise intervention for 60-90 minutes, 3 days/week assisted by personal trainers under physical therapist supervision. Measures (6MWT, HiMAT and 10MWT) were collected at baseline, post-intervention and 6 weeks later. Repeated measures T-test and Wilcoxon Signed Ranks test were used.

RESULTS

Post-intervention improvements were achieved on average on all three measures, greater than minimal detectable change (MDC) for this population. Three participants transitioned from low-to-high ambulatory status and maintained the change 6 weeks later.

DISCUSSION AND CONCLUSION

People with chronic ABI can improve endurance, demonstrate the ability to do advanced gait and improve ambulatory status with 6 weeks of intensive exercise. Challenges to sustainability of exercise programmes for this population remain.

Valsalva maneuver unveils central baroreflex dysfunction with altered blood pressure control in persons with a history of mild traumatic brain injury

Background

Patients with a history of mild TBI (post-mTBI-patients) have an unexplained increase in long-term mortality which might be related to central autonomic dysregulation (CAD). We investigated whether standardized baroreflex-loading, induced by a Valsalva maneuver (VM), unveils CAD in otherwise healthy post-mTBI-patients.

Methods

In 29 healthy persons (31.3 ± 12.2 years; 9 women) and 25 post-mTBI-patients (35.0 ± 13.2 years, 7 women, 4–98 months post-injury), we monitored respiration (RESP), RR-intervals (RRI) and systolic blood pressure (BP) at rest and during three VMs. At rest, we calculated parameters of total autonomic modulation [RRI-coefficient-of-variation (CV), RRI-standard-deviation (RRI-SD), RRI-total-powers], of sympathetic [RRI-low-frequency-powers (LF), BP-LF-powers] and parasympathetic modulation [square-root-of-mean-squared-differences-of-successive-RRIs (RMSSD), RRI-high-frequency-powers (HF)], the index of sympatho-vagal balance (RRI LF/HF-ratios), and baroreflex sensitivity (BRS). We calculated Valsalva-ratios (VR) and times from lowest to highest RRIs after strain (VR-time) as indices of parasympathetic activation, intervals from highest systolic BP-values after strain-release to the time when systolic BP had fallen by 90 % of the differences between peak-phase-IV-BP and baseline-BP (90 %-BP-normalization-times), and velocities of BP-normalization (90 %-BP-normalization-velocities) as indices of sympathetic withdrawal.

We compared patient- and control-parameters before and during VM (Mann-Whitney-U-tests or t-tests; significance: P < 0.05).

Results

At rest, RRI-CVs, RRI-SDs, RRI-total-powers, RRI-LF-powers, BP-LF-powers, RRI-RMSSDs, RRI-HF-powers, and BRS were lower in patients than controls. During VMs, 90 %-BP-normalization-times were longer, and 90 %-BP-normalization-velocities were lower in patients than controls (P < 0.05).

Conclusions

Reduced autonomic modulation at rest and delayed BP-decrease after VM-induced baroreflex-loading indicate subtle CAD with altered baroreflex adjustment to challenge. More severe autonomic challenge might trigger more prominent cardiovascular dysregulation and thus contribute to increased mortality risk in post-mTBI-patients.

Physical activity and cognitive function in individuals over 60 years of age: a systematic review

BACKGROUND

It is unclear whether physical activity in later life is beneficial for maintenance of cognitive function. We performed a systematic review examining the effects of exercise on cognitive function in older individuals, and present possible mechanisms whereby physical activity may improve cognition.

METHODS

Sources consisted of PubMed, Medline, CINAHL, the Cochrane Controlled Trials Register, and the University of Washington, School of Medicine Library Database, with a search conducted on August 15, 2012 for publications limited to the English language starting January 1, 2000. Randomized controlled trials including at least 30 participants and lasting at least 6 months, and all observational studies including a minimum of 100 participants for one year, were evaluated. All subjects included were at least 60 years of age.

RESULTS

Twenty-seven studies met the inclusion criteria. Twenty-six studies reported a positive correlation between physical activity and maintenance or enhancement of cognitive function. Five studies reported a dose-response relationship between physical activity and cognition. One study showed a nonsignificant correlation.

CONCLUSION

The preponderance of evidence suggests that physical activity is beneficial for cognitive function in the elderly. However, the majority of the evidence is of medium quality with a moderate risk of bias. Larger randomized controlled trials are needed to clarify the association between exercise and cognitive function and to determine which types of exercise have the greatest benefit on specific cognitive domains. Despite these caveats, the current evidence suggests that physical activity may help to improve cognitive function and, consequently, delay the progression of cognitive impairment in the elderly.

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.

Effect of Physical Inactivity on Cognitive Performance after 2.5 Years of Follow-Up

Objective: To examine the association between physical activity and cognitive performance in a longitudinal study. Methods: We analyzed data from 17.333 noninstitutionalized persons aged 50 years or older in 11 European countries who participated in Wave 1 (2004/2005) and Wave 2 (2006/2007) of the Survey of Heath, Ageing, and Retirement in Europe (SHARE). Physical activity at baseline was measured as self-reported frequency of sports or activities requiring vigorous activity, and frequency of activities demanding a moderate level of activity. Cognitive function was measured at baseline and after a mean of 2.5 years of follow-up by delayed word recall and verbal fluency tests. The effects of physical activity at baseline on cognitive performance at follow-up were assessed in hierarchical multilevel random effects models adjusted for sociodemographic variables (age, education), somatic comorbidities, functional impairment (basic and instrumental activities of daily living, maximum grip strength), depressive symptoms, and body mass index. Results: After adjusting for potential confounders, we found physical inactivity (neither moderate nor vigorous) to be associated with a higher rate of cognitive decline over a mean follow-up of 2.5 years (β = –1.79 (SE = 0.17) for verbal fluency; β = –0.35 (SE = 0.04) for delayed word recall). Further analyses showed that vigorous activities more than once a week were especially related to change in cognition over time. Conclusion: Engagement in moderate and vigorous physical activities protects against cognitive decline in older age. Participation in physical activities may be of particular importance when other risk factors for cognitive decline are present.

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.