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Journal of Exercise Physiologyonline 71 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 72 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
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