Physical Activity Guidelines for Traumatic Brain Injury

Original Editor - Naomi O'Reilly

Top Contributors - Naomi O'Reilly, Rachael Lowe and Uchechukwu Chukwuemeka  


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

Barriers to Physical Activity

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]

Individual Level Barriers [6][9]

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]

  • Diminished Drive / Motivation
  • Feel Self-Conscious
  • Lack of Time
  • Lack of Interest
  • Lack of Energy
  • 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
  • Increased Fatigue
  • Decreased Mobility
  • Decreased Balance
  • Decreased Muscle Strength
  • Changes to Oxidative Metabolism
  • Pain limits Participation

Societal Level Barriers [6][9]

  • 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 [6][9]

  • Barriers in Outdoor Areas i.e. uneven pathways [10]
  • 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.

Benefits Physical Activity

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][15] 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.”


  • Increased Cardiorespiratory Fitness including Peak VO2, Anaerobic Threshold, Increased Work Rate and Time to Volitional Exhaustion [17][18][19]
  • Increased Muscle Strength including increased Power Output [20]
  • Improved Fatigue [17][21]
  • Increased Balance [22]
  • Increased Mobility [22]


Improved Cognitive Function including;

  • Improved Processing Speed [23][24]
  • Improved Executive Functioning [23][25]
  • Increased Learning Ability [23][26]
  • Improved Overall Cognitive Function [25][26][24]
  • Reduced Risk of Developing Cognitive Impairment, including Alzheimer's Disease [24]


Physical Activity Guidelines

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][35]

American College of Sports Medicine Physical Activity Guidelines for Traumatic Brain Injury

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. [10] 

Types of Exercise

An exercise program for an individual with a traumatic brian injury should be tailored to address an individual’s specific needs and abilities while also considering the impact of the brain injury on tone and spasticity, range of motion and flexibility, cardiovascular and muscular endurance, strength and cognitive impairments. Incorporating physical activity to improve these concerns can increase quality of life and ability to perform activities of daily living skills. Physiotherapists can play a large role in developing physical activity programs, in particular during the rehabilitation phase of treatment and following discharge into the community. Physiotherapist can also play a huge role in educating physical activity providers on the needs of individuals with a traumatic brian injury on accessing community based physical activity programs.


Aerobic exercise takes place in the presence of oxygen and involves aerobic metabolism of glucose. The exercise is low in intensity and sustained for a longer period than strength training. A decline in maximal aerobic capacity occurs across the adult age-span, accelerating later years. [36]

This sort of exercise is meant to increase the heart rate, which encourages the heart muscle to stay strong. Cardiovascular exercise also helps relax blood vessel walls, lower blood pressure, burn body fat, lower blood sugar levels, reduce inflammation, boost mood, and increase good HDL Cholesterol. Participation in cardiovascular exercise reduces the risk of heart disease, stroke, type 2 diabetes, breast and colon cancer, depression, and falls but more importantly for individuals with a traumatic brian injury building your endurance makes it easier to carry out many activities of daily living.

Aim for 150 minutes per week of moderate-intensity cardiovascular activity or 75 minutes a week of vigorous-intensity cardiovascular activity, or an equivalent combination of moderate and vigorous intensity cardiovascular activity, in episodes of at least 10 minutes, spread throughout the week. [15][37]

Examples of Cardiovascular Exercise include: Walking, Jogging, Swimming, Cycling, Dancing, or classes like Aerobics.


Strength training, or Progressive Resistance Training, is generally defined as training in which the resistance against which a muscle generates force is progressively increased over time [15]. The maximal weight or resistance a person can lift or move to complete the movement is defined as the one repetition maximum (1 RM). Prescriptions of repetitions at what repetition maximum vary depending on prior experience with Progressive Resistance Training and co-morbidities. One recommendation (Level IIA evidence) from the American College of Sports Medicine and the American Heart Association [31] suggests "8 - 10 exercises be performed on two or more nonconsecutive days per week using the major muscle groups". [31]

This sort of exercise is meant to challenge muscles by pushing or pulling against resistance. Strengthening your muscles not only makes you stronger, but also stimulates bone growth, bone density, lowers blood sugar, assists with weight control, improves balance and posture, and reduces stress and pain in the lower back and joints.

Aim for 2 Sessions per week of Strength Training activity of moderate or high intensity that involve all major muscle groups with 1 - 2 Sets of 8 - 12 Repetitions [15][20]

Examples of Strength Training include: Body Weight Exercise ie. Squats, Lunges, Resistance Bands, Resistance Training Machines, Free Weights.


A performance-related component of physical fitness that involves the maintenance of the body’s equilibrium while stationary or moving. Balance training includes static and dynamic exercises that are designed to improve individuals’ ability to withstand challenges from postural sway or destabilizing stimuli caused by self-motion, the environment, or other objects.

This sort of exercise is meant to make you feel steadier on your feet and helps prevent falls. It is particularly import following a traumatic brian injury and as we get older as the systems that help us maintain balance, our vision, our inner ear, and our muscles and tendons are impacted.

Aim for 2 Sessions per week of Balance Training, where possible combined with Strength Training

Examples of Balance Exercises include standing on one foot, tandem stance, walking heel to toe, standing on an unstable surface and all can be done with eyes open or closed. Other Balance Activities include Tai Chi, and Yoga.


Flexibility is range of motion possible at a joint. It is specific to each joint and depends on a number of specific variables, including but not limited to the tightness of specific ligaments and tendons. Flexibility exercises enhance the ability of a joint to move through its full range of motion. Stretching helps maintain flexibility.

This sort of exercise is meant to increase muscle length and allow an individual to move their joints through a greater range of motion and prevent contractors. Improved flexibility may make it easier to get into positions such as squatting, bending, or reaching.

Aim for a program of stretching at least three or four times per week.

Examples of Flexibility Training include: Stretching, Tai Chi, and Yoga


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. [38] In fact research suggests that physical activity levels decline as early as one week following discharge from inpatient rehabilitation. [39][40]

Physical activity, including exercise, sport and daily physical activity participation, may positively affect cardiorespiratory fitness [18][17][19], strength [20], fatigue [17][21], balance and mobility [22], mood [27][21][28][26][29], and cognition [26][29] 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. [38] Individuals with a traumatic brian injury who participate in some form of physical activity were more independent in activities of daily living, had greater self-efficacy for exercise and were more likely to be educated than those who were currently inactive. Encouragement, tailored education and support from health care professionals regarding safety and appropriateness of physical activities could help in addressing such barriers directly, and this in turn may increase confidence to be more active for those who are physically able.

Educating individuals with a traumatic brain injury about the benefits of physical activity may increase their motivation to be more active, alleviate their concerns regarding their own physical health and highlight the forms of physical activity that may be most suitable for them to start with. Similalrilty informing and educating service providers of physical activity about the barriers and determinants specific to traumatic brian injury may assist in the development of community physical activity interventions. This way, rehabilitation professionals such as physiotherapists and community support workers may encourage participants who have the potential to be physically active, while providing a safe environment to exercise to maintain high self-efficacy. [41] The following resource below outlines the key steps to increasing physical activity levels among individuals with a disability, and are relevant when working with individuals after a traumatic brian injury. [15][42]

Remember some activity is better than no activity. When individuals with a traumatic brian injury are not able to meet the guidelines, they should engage in some form of regular physical activity according to their abilities and should avoid inactivity.

Increasing Physical Activity among Adults with Disabilities [42]
Physical Activity for Disabled Adults


ACSM Increasing Physical Activity for Adults with a Disability Brochure

The purpose of this American College of Sports Medicine brochure is to highlight meaningful health facts and activity barriers facing adults with a disability. Several strategies and ideas to overcome these barriers are recommended. 

Accessibility Instruments Measuring Fitness and Recreation Environments Manuals

These manuals are a validated series of questionnaire measures that can be used by persons with mobility limitations and professionals i.e., fitness and recreation center staff, and/or owners of fitness centers to assess the accessibility of recreation and fitness facilities, including fitness centers and swimming pools.

The National Center on Physical Activity and Disability 14 Weeks to a Healthier You

The National Center on Physical Activity and Disability (NCPAD) is an information center concerned with physical activity and disability. NCPAD offers publications, online tools, and information and consultation services to people with disabilities, families, caregivers, policy makers, organizations, healthcare practitioners, and the fitness community on health promotion, physical activity, and weight management for people with disabilities. They also have the 14 Weeks to a Healthier You Program, a free, web-based, personalized physical activity and nutrition program targeted to people with chronic conditions, mobility limitations, and physical disabilities.

Circuit Training Recommendations for Individuals with a Traumatic Brain Injury [43]

Provides Circuit Training Recommendations for Individuals with Traumatic Brain Injury including specific programme guidelines and modifications to make.


  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: [accessed 20 May 2016]
  5. National Center on Health, Physical Activity and Disability (NCHPAD). (2019). Addressing Barriers. Available at: [Accessed 17 September 2019].
  6. 6.0 6.1 6.2 6.3 6.4 6.5 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:[last accessed 30/09/19]
  9. 9.0 9.1 9.2 Driver S, Ede A, Dodd Z, Stevens L, Warren AM. What barriers to physical activity do individuals with a recent brain injury face?. Disability and health journal. 2012 Apr 1;5(2):117-25.
  10. 10.0 10.1 Hassett L, Moseley AM, Harmer AR. Fitness training for cardiorespiratory conditioning after traumatic brain injury. Cochrane Database of Systematic Reviews. 2017(12).
  11. Empower. Breaking Barriers - Transport as a barrier to an active lifestyle for disabled people. Available from:[last accessed 30/09/19]
  12. Empower. Breaking Barrier - Inaccessible Venues. Available from:[last accessed 30/09/19]
  13. Empower. Breaking Barriers - Equipment as a barrier to disabled people keeping active. Available from:[last accessed 30/09/19]
  14. Empower. Breaking Barriers - lack of knowledgeable staff as a barrier to disabled people keeping active. Available from:[last accessed 30/09/19]
  15. 15.0 15.1 15.2 15.3 15.4 Institute,UK Chief Medical Officers' Physical Activity Guidelines, 7 September 2019, Available from:, [Accessed 27th September 2019]
  16. Brainline. How Exercise Can Heal the Brain after a Traumatic Brain Injury. Available from:[last accessed 30/09/19]
  17. 17.0 17.1 17.2 17.3 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]
  18. 18.0 18.1 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]
  19. 19.0 19.1 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]
  20. 20.0 20.1 20.2 Irwin K, Ede A, Buddhadev H, Driver S, Ronai P. Physical activity and traumatic brain injury. Strength & Conditioning Journal. 2011 Aug 1;33(4):43-7.
  21. 21.0 21.1 21.2 21.3 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]
  22. 22.0 22.1 22.2 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]
  23. 23.0 23.1 23.2 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.
  24. 24.0 24.1 24.2 Erickson KI, Hillman C, Stillman CM, Ballard RM, Bloodgood B, Conroy DE, Macko R, Marquez DX, Petruzzello SJ, Powell KE. Physical Activity, Cognition, and Brain Outcomes: A Review of the 2018 Physical Activity Guidelines. Medicine and science in sports and exercise. 2019 Jun;51(6):1242-51.
  25. 25.0 25.1 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
  26. 26.0 26.1 26.2 26.3 26.4 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.
  27. 27.0 27.1 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]
  28. 28.0 28.1 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]
  29. 29.0 29.1 29.2 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]
  30. 30.0 30.1 30.2 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.
  31. 31.0 31.1 31.2 31.3 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
  32. 32.0 32.1 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
  33. 33.0 33.1 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
  34. Morris TP, Muñoz JM, Cattaneo G, Solana-Sánchez J, Bartrés-Faz D, Pascual-Leone A. Traumatic brain injury modifies the relationship between physical activity and global and cognitive health: results from the Barcelona Brain Health Initiative. Frontiers in behavioral neuroscience. 2019;13.
  35. World Health Organization. Global recommendations on physical activity for health. World Health Organization; 2010.
  36. Fleg JL. Aerobic exercise in the elderly: a key to successful aging. Discovery Medicine [Internet]. 2012. Available at: Accessed 26 June 2018.
  37. US Dept of Health and Human Services. 2008 Physical Activity Guidelines for Americans. Available from [Last accessed 15 Set 2019]
  38. 38.0 38.1 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.
  39. 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]
  40. 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.
  41. Reavenall S, Blake H. Determinants of physical activity participation following traumatic brain injury. International Journal of Therapy and Rehabilitation. 2010 Jul;17(7):360-9.
  42. 42.0 42.1 Centres for Disease Control and Prevention. Increasing Physical Activity among Adults with Disabilities. [Accessed 22 Sep 2019]
  43. Ede A, Buddhadev H, Irwin K, Driver S, Sorace P. Circuit training recommendations for individuals with a traumatic brain injury. Strength & Conditioning Journal. 2011 Aug 1;33(4):48-51.