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Journal of Exercise Physiologyonline

April 2020 Volume 23 Number 2

EditorOfficial-in Research-Chief Journal of JEPonline Tommythe American Boone, PhD Society, MBA of ReviewExercise Board Physiologists Therapeutic Exercise Protocols in Patients with Todd Astorino, PhD Julien Baker,ISSN 1097 PhD- 9751 Traumatic Brain Injury: A Systematic Review Steve Brock, PhD Lance Dalleck, PhD Carolina dos Santos Silva Borges1, Gabriel Rodrigues Eric Goulet, PhD 1,2,3 Robert Gotshall, PhD Neto Alexander Hutchison, PhD M. Knight-Maloney, PhD 1Professional Master's in Family Health, Nursing and Len Kravitz, PhD Medical Schools, Nova Esperança (FACENE/FAMENE), James Laskin, PhD João Pessoa, Paraíba, Brazil, 2Coordination of Physical Yit Aun Lim, PhD Lonnie Lowery, PhD Education, Nursing and Medical Schools, Nova Esperança Derek Marks, PhD (FACENE/FAMENE), 3Coordination of Physical Education, Cristine Mermier, PhD Center for Higher Education and Development (CESED - Robert Robergs, PhD UNIFACISA / FCM / ESAC), Campina Grande, Paraíba, Chantal Vella, PhD Brazil Dale Wagner, PhD Frank Wyatt, PhD Ben Zhou, PhD ABSTRACT Borges CSS, Neto GR. Therapeutic Exercise Protocols in Patients with Traumatic Brain Injury: A Systematic Review. JEPonline 2020;23(2):71-82. Individuals with traumatic

Official Research Journal brain injury (TBI) face obstacles that hinder equal of the American Society of participation in rehabilitation programs. Thus, the purpose of Exercise Physiologists this review was to systematize the therapeutic exercise protocols in patients with TBI. The review took place through ISSN 1097-9751 the database of the Virtual Health Library (VHL), Pubmed, Web of Science and Scopus considering studies from the period from January 1989 to April 2019. Based on the evidence in the literature about the rehabilitation protocols for individuals with TBI, it is clear that the interventions adopted by the scholars are diverse and 70.5% of the protocols used kinesiotherapy exercises in order to globally rehabilitate the sequelae from the TBI. However, exercise has benefits in reducing the post-injury inflammatory process. In addition, exercise has promoted neural plasticity and cognitive recovery in individuals with TBI.

Keywords: Exercise Therapy, Traumatic Brain Injury

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INTRODUCTION

It is estimated that 1.7 million cases of traumatic brain injury (TBI) occur annually in the United States, 52,000 people die and 275,000 people are hospitalized (17). Annually in Europe, 1.6 million people suffer from TBI, 70,000 do not survive and 100,000 have permanent disabilities (16). In Brazil annually, it is estimated that 500,000 cases of TBI occur and about 75,000 to 100,000 people die (7).

Generally, trauma survivors have temporary or permanent disabilities, making the individual in need of continuous and multidisciplinary assistance (36,37). After the injury, functional recovery can be gradually restored, but it is important to include the individual in a rehabilitation program. Neurological rehabilitation has shown benefits in neural plasticity. The deteriorated tissue may not recover its function, but other brain areas adapt and assume the lost function (2,25).

The structural and functional changes in the neural tissue resulting from neural plasticity, together with stimuli during the performance of repetitive exercises are capable of producing changes in the structures of the motor cortex (40). The evidence points out that in addition to the rehabilitation helping with the acute phase, the benefits are numerous years after the injury since the persistence of functional limitations is very common (6). Despite this expectation, many post- TBI patients are inactive and sedentary (30). Generally, after discharge from rehabilitation the TBI patients are rehospitalized for surgical and medical reasons that contribute to the formulation of incentive programs for exercising (20).

In addition, this population faces obstacles that hinder participation in exercise programs. The barriers identified range from a lack of motivation and willingness to financial difficulties due to a lack of resources to perform the exercises (29). The home exercise program is an effective alternative in these cases. The exercise protocols intended for the home environment are complementary to clinical rehabilitation and present satisfactory results in the patient's functional recovery (41).

In view of the alarming number of cases of TBI and the complexity of the sequelae that limit the individual's life, it is important to formulate rehabilitation strategies that provide a better quality of life. This means it necessary to conduct a data survey to analyze how patients with TBI are being treated. Hence, the purpose of this review was to systematize the therapeutic exercise protocols in patients with TBI.

METHODS

This study is a review of evidence in the literature that used the databases: Virtual Health Library (VHL), Pubmed, Web of Science and Scopus during the period from January 1989 to April 2019. For the search, the keywords in the Portuguese, English, and Spanish languages were used in the Health Sciences Descriptors (DeCS) and interlaced with the Boolean operators "OR" and "AND".

The descriptors and keywords used were: "exercise therapy" OR rehabilitation OR physiotherapy OR kinesiotherapy OR "motor relearning" AND "traumatic brain injury" OR hemiplegia OR "neural plasticity" OR "muscle spasticity" OR "head trauma" AND "home care” OR caregivers. 73

In addition, the following inclusion criteria were used: studies made available in full text in Portuguese, English, and Spanish languages. Priority was given to the insertion of studies related to the research theme, with interventions that used therapeutic or home exercises for patients who suffer from a TBI.

As exclusion criteria, it was decided to discard: (a) studies from systematic and literature reviews; (b) research that used aerobic exercises as an intervention; and (c) studies that did not correspond to the research topic, but were also unavailable in full text.

This proposed study is in accordance with the standard of the prism scale (Figure 1). The systematic analysis of the studies was careful and observed the title, the summary, the methodological aspects, the results and the discussion, as well as the conclusion of the study.

Searches on Electronic Databases (January 1989 to April 2019)

Selection Identified Studies (n=139)

Studies Excluded Based

on Title, Summary and Elegibility Methodology

(n=122)

Inclusion Studies Included in the Research (n=17)

Figure 1. Description of Study Selection. 74

RESULTS

The general description of the studies considered the following components: (a) author (year); (b) methodology (population and instruments used); and (c) the conclusion(s) of the study. The selected studies are described in Table 1. Thus, during the search 139 studies were identified and after the systematic reading of the title and abstracts, 122 studies were excluded from the research. In total, only 14 articles, 2 monographs, and 1 dissertation were included, which were in accordance with the established criteria.

Based on the evidence in the literature about the rehabilitation protocols for individuals with TBI, it was observed that the interventions adopted by the scholars were diverse. In 70.5% of the studies, kinesiotherapy exercises were used and both corroborate with satisfactory results (3,8,9, 11,14,24,28,31-35).

In addition to kinesiotherapy, it is possible to observe that the protocols presented some exercises based on the Bobath method, Brunnstrom method, and the Car and Shepherd method. The Bobath method consists of therapeutic movement through the inhibition of primitive postures in order to rehabilitate individuals with neurological disorders (1). Bobath is commonly used to treat children with cerebral palsy and adults with an acute cerebrovascular accident (AVE) and TBI (5).

The Brunnstrom method seeks to acquire voluntary movements through the control of primitive movements (19). The Carr and Shepherd method seeks to relearn the motor movements by performing exercises with functional tasks (12). In relation to studies that included therapeutic methods, 17.64% of the studies used the Bobath method (8,14,34), and only 5.88% of the studies used Kabat as an intervention (34). However, all other studies used at least one exercise with the premises of each therapeutic method.

Gait training was performed in several ways. The conventional gait training in parallel bar without obstacles corresponded to 23.52% of the studies (3,9,28,33), with obstacles present in 5.88% (31), as well as 5.88% of the studies used gait training with help and assistants (14). Only one protocol used aerobic exercises (24) and the stationary bicycle (3,34) as a complement to the treatment. The static and dynamic bipedal balance training corresponded to 17.64% of the studies (9,32,33), and only 11.76% of the studies performed up and down stairs training (steps) (31,34).

Regarding the modalities of therapeutic exercises used, 11.76% of the studies used the passive form (9,32), active exercises (24,33) and active-resistive exercises in the intervention (3,9). In relation to the other kinesiotherapy techniques, 64% of the protocols used the techniques of respiratory kinesiotherapy (9,14,24) and 5.88% underwent ocular motor rehabilitation (3).

Regarding the other workouts, 41% used sit-up training (11,22,31-33), 11.76% used Step Up training (11,22), 23.52% of the studies performed daily life activity training (4,14,22,39), 11.76% used bed to chair transfer training (10,14) and decubitus change training. In addition, 5.88% performed functional training (14) and 64% used proprioceptive stimulation (9,32,34), as well as 75

11.76% of the protocols introduced playful activity (9,23), motor coordination training (23,33) and thin and thick motor skills (9,10).

Regarding the strengthening exercises used, 23.52% performed a pelvic elevation (bridge) (9,24, 28,31), 5.88% performed the trunk elevation exercise (24) and strengthened extremities (33), 11.76% used abdominal strengthening in protocols (24,28), and 17.64% performed strengthening exercises for upper limbs and lower limbs (3,24,31). The passive stretches of the upper limbs, lower limbs and trunk were inserted in 23, 52% (3,14,28,31). In addition, only 5.88% of the studies performed memory exercise (4) and 11.76% performed waist dissociation (9,31). Regarding the resources used in the exercise execution protocols, it is possible to observe the use of 1 kg dumbbells (9,31), 1 kg shin guards (9,28), stick (9,28), Swiss ball (9,28,31), pulleys (33), hula hoop (23), other balls (33).

With regard to the assessment instruments in the pre and post protocol: 17.64% of the studies used the Functional Independence Measure (FIM) (10,33,39), 11.76% the Tinetti Test (4,8), the Modified Ashworth Scale (24,32), and the Barthel Scale (14,32), and only 23.52% used the Sit- to-Stand (4,8,11,22). The other studies used instruments, such as the electromyography (24), the Psychomotor examination of Prcq evayer of second childhood and the adapted Rivermead Mobility Lndex (35), the Modified Rankin Scale, the Mini Mental state Examination, the Quality of Life Scale, the Glasgow Outcome Scale, and the Walking Category Scale (10), the Berg Balance Scale (3,4), the Godin and Shepard Questionnaire and Functional Reach Test (22), the Lawton and Brody Test (8), the Motor Development Scale (23), the Comunithy Integration Questionnaire (CIQ) and the Westmead Post-Traumatic Amnesia (39).

Table 1. Description of Selected Studies from Years 2003-2018.

Authors Methods Conclusion

Aguilera-Rúbio et al. * Subjects: 7 patients with acquired The rehabilitation program using (2018) brain injury, of these, 4 with AVE; 2 the treadmill and cognitive tasks with TBI, and 1 with anoxia. provided an improvement in balance and gait parameters. * Instrument: Timed Up and Go test.

Bailã et al. (2018) * Subjects: 1 male patient aged 46 yrs The neurorehabilitation program with TBI and TRM produced a marked improvement in the reduction of the patient's * Instruments: Mini mental and degree of dependence and Glasgow Coma Scale. disability.

Trevena-Peters et al. * Subjects: 104 patients with severe Training in activities of daily life (2017) TBI. during the post amnesia phase produced improvements in * Instruments: Functional functional independence. Independence Measure (MIF) 76

Adams e Moore (2017) * Subjects: 6 post concussion athlete The study described that the Patients. home program has the potential to improve post concussion * Instruments: Rivermed Post symptoms. Concussion Symptoms Questionnaire (RPCQ)

Pinheiro et al. (2016) * Subjects: 1 male patient with TBI. The interventions provided a satisfactory evolution in ROM for knee extension and flexion and in the shoulder abduction movement, as well as, improvement in the muscular strength of the lower limbs and postural alignment, and there was a reduction in the pain and shortening resistance.

Cihuelo (2016) * Subjects: 25 yr old patient with The results show that the severe TBI and secondary lesion intervention based on the Bobath subarachnoid hemorrhage. method is effective and provides an improvement in functional * Instruments: Barthel Scale. capacity and consequently improves the patient’s quality of life.

Rosa, Oliveira e Freire * Subjects: a 42 yr old male patient After the intervention, the authors (2015) with TBI and complaint of not be able observed an improvement in the to walk. patient’s cognitive status, as well as an improvement in the balance * Instruments; Muscle Strength Test. and strength of the upper limbs and lower limbs, and the patient started to walk without assistants.

Maronesi et al. (2015) * Subjects: one 4 yr old child with TBI, The proposed program was meningitis and hydrocephalus. effective in improving overall thin motor skills and balance. * Instruments: Motor Development Scale.

Azcárate (2014) * Subjects: one 59 yr old patient with It can been seen that the concept TBI (intraparenchymal hematoma and of Bobath is very effective for subarachnoid hemorrhage). recovering the functionality of the person with hemiparesis by TBI. * Instruments: Tinetti Test and Sit-to- Stand.

Silva (2014) * Subjects: one 15 yr old patient with Neuromotor rehabilitation showed penetrating TBI. benefits in neural plasticity. 77

Sartor-Glittenberg e * Subjects: 3 patients with TBI and Patients with severe ataxia after Brickner (2014) severe ataxia. TBI improved balance, coordination and gait. * Instruments: Berg Scale and Functional Independence Measure.

Sanchez (2013) Subjects: 102 TBI patients aged 43. The protocol provided satisfactory results in reacquiring the motor and sensory patterns in the standing position.

Baia et al. (2012) * Subjects: 2 yr old male patient with The protocol provided functional polytrauma. gains in the patient’s ADLs.

* Instruments: Muscle Strength Test.

Martinez- Gramage et al. * Subjects: 7 patients (5 with cerebral The 3-month program provided an (2010) palsy and 2 with TBI). increase in ROM in ankle dorsiflexion as well as an * Instruments: Modified Ashworth improvement in the results of the Scale and electromyographic record. Ashworth scale.

Katz-Leurer et al. (2009) * Subjects: 15 children with severe The task-oriented exercise TBI. program can improve performance and balance. * Instruments: Sit-to-Stand.

Soares e Lucena (2007) * Subjects: Patients with TBI (right The intervention provided an hemiparesis). improvement in the body scheme and functional capacity of patients. * Instruments: Psychomotor examination of Prcq evayer of second childhood and the adapted Rivermead Mobility Index.

Canning et al. (2003) * Subjects: 24 individuals with TBI Intensive sit-up training is Instruments: Sit-to-Stand. recommended and very important in the rehabilitation of severe TBI.

DISCUSSION

Based on the evidence in the literature, one can observe the scarcity in studies containing protocols of therapeutic exercises directed to TBI. Nevertheless, the literature shows that exercise protocols are important in the physical rehabilitation of neurological patients, especially in TBI. The protocols directed to neurological patients should present differentiated approaches in order to cover all types of lesions (18). According to Andelic (6), even after years, functional limitations are persistent in the TBI, which denotes the importance of developing rehabilitation programs that continuously accompany the TBI patient. 78

There are many divergences regarding the time that the post-TBI patient will be able to participate in a rehabilitation program. In the study by Thomas et al. (38), the authors observed that rest after brain injury causes persistence and slow resolution of post-injury symptoms. These findings confirm the evidence of other studies that report the benefits of early rehabilitation, ranging from improvement and reduction of disability to the promotion of functional independence (13,15,21,26,27). However, exercise and physical activity have a prophylactic effect on the inflammatory process and on reducing the volume of the lesion, through the increase of the anti- inflammatory endogenous and the inhibition of neutrophils, thus facilitating the functional recovery of the region affected (26,27). In addition, the practice of exercises promotes neural plasticity that is a contributing factor for cognitive recovery (26), as well as, physical exercises are effective therapeutic methods in neonatal brain lesions, which can mitigate possible neurological deficiencies.

Despite the benefits pointed out, the physiotherapist should track and monitor the entire rehabilitation process since the symptoms are persistent and recovery is slow (21). The scarcity of studies was a limiting factor for the deepening of the proposed theme. Thus, it is necessary that more studies containing protocols of therapeutic exercises directed to this population be performed, especially since it is a lesion that presents varied and permanent sequelae.

CONCLUSIONS

The practice of exercises after traumatic brain injury has numerous benefits in the recovery of functionality. Despite the persistence of clinical signs and symptoms, the formulation of exercise protocols directed to this public is an effective strategy to promote functional independence. In addition, exercises contribute to the resolution of the post-injury inflammatory process.

However, there is a scarcity of studies with these characteristics. Thus, the present study emphasizes the importance and need for further studies on the theme being conducted so as to promote quality of life for individuals with TBI, as well as the continuity of rehabilitation since it is important to include this patient in rehabilitation and physical activity programs.

Address for correspondence: Carolina dos Santos Silva Borges, Avenida: Frei Galvão, 12- Gramame. CEP: 58067698, Facene/Famene- João Pessoa-Brasil. Phone: 21064777 Webmail: http://www.facene.com.br

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