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10.1093 PTJ Pzac153
10.1093 PTJ Pzac153
https://doi.org/10.1093/ptj/pzac153
Advance access publication date November 7, 2022
Review
Abstract
Objective. The aims of this systematic review and meta-analyses were to evaluate the effects of exercise on the functional
capacity and quality of life (QoL) of people with acquired brain injury (ABI) and to analyze the influence of training variables.
Methods. Five electronic databases (MEDLINE, Cochrane Library, CINAHL, SportDiscus, and Web of Science) were searched
until October 2021 for clinical trials or experimental studies examining the effects of exercise on the functional capacity and
QoL in adults with ABI and comparing exercise interventions with non-exercise (usual care).
Results. Thirty-eight studies were evaluated. A total sample of 2219 people with ABI (exercise, n = 1572; control, n = 647)
were included in the quantitative analysis. A greater improvement was observed in walking endurance (z score = 2.84), gait
speed (z score = 2.01), QoL physical subscale (z score = 3.42), and QoL mental subscale (z score = 3.00) was observed in
the experimental group than in the control group. In addition, an improvement was also observed in the experimental group
in the “Timed Up and Go” Test scores and balance without differences from the control group. Significant interactions were
also observed between the rehabilitation phases, type, frequency and volume of training, and overall effects.
Conclusion. The results suggest that exercise improves functional capacity and QoL regardless of model training, highlighting
the effectiveness of long-term exercise that includes short sessions with components such as strength, balance, and aerobic
exercise.
Impact. The results shown in this systematic review with meta-analysis will allow physical therapists to better understand
the effects of training on people with ABI.
Keywords: Balance Physical Endurance, Quality of Life, Stroke, Traumatic Brain Injuries
Received: July 8, 2021. Revised: May 14, 2022. Accepted: August 29, 2022
© The Author(s) 2022. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved.
For permissions, please email: journals.permissions@oup.com
2 Exercise for People With Acquired Brain Injury
diagnosis of ABI in the subacute or chronic phase, considering In addition, the level of evidence was analyzed using the
a medically stable situation.25 On the other hand, studies Grading of Recommendations Assessment, Development and
were excluded if a sample population with advanced dementia Evaluation (GRADE) approach.18 The quality of the evidence
or noncontrolled delirium was used; the study was a review, was based on 5 factors—risk of bias, inconsistency, indirect
case study, or observational study; the study was not a fully evidence, imprecision, and potential for publication bias—
published original investigation; and numerical data on the resulting in 4 levels of evidence quality: high, moderate, low,
studied variables were not shown or reported. and very low. The evaluation was performed at https://grade
pro.org/.
Study Selection, Data Extraction, and Quality
Assessment Data Synthesis and Data Analysis
All retrieved articles were managed with Endnote X9 (Clari- The meta-analyses and statistical analysis were conducted
vate Analytics; Philadelphia, PA, USA), and duplicate studies using Review Manager software (RevMan 5.2; Cochrane Col-
were filtered. Two reviewer authors (M.P.R. and A.G.S.) laboration, Oxford, UK) and Jamovi Project software (Pack-
sources). After evaluation of 2158 abstracts and titles, 1925 However, a moderate increase on the Berg Balance Scale was
were excluded and 233 were assessed as full text. Finally, observed after the training program in the EG (SMD = 0.65;
38 studies fulfilled all criteria and were included in the 95% CI = 0.36–0.94; P < .001).
quantitative analysis.31,38–76 Furthermore, significant differences were observed in favor
The studies were published between 2004 and 2021 and of the EG compared with the UC (Fig. 4) on the physi-
included groups of both men and women. The age range cal (z = 3.42; P < .001) and mental (z = 3.00; P = .003) QoL
was between 37.4 and 79.2 years (mean = 61.13 years). The subscales. In this regard, a significant moderate increase on
interventions had a mean duration of 12.4 weeks (range = 4– the QoL physical subscale (SMD = 0.60; 95% CI = 0.37–0.97;
48 weeks) and were performed between 1 and 7 times per P = .001) and a small increase on the QoL mental subscale
week. Intervention sessions lasted between 30 and 120 min- (SMD = 0.40; 95% CI = 0.27–0.53; P < .001) were observed
utes. The main characteristics of the interventions featured in after the exercise program in the EG.
the articles are shown in Supplemental Tables 1 and 2.
Effects of Covariates
Risk of Bias and Level of Evidence
have determined a difference of 28% for the TUG, 44 m no significant difference was observed compared with UC
for the 6-Minute Walk Test, 0.22 m/s for the 10-m walk regarding this variable. Consistent with these results, several
test, or 10% for the Berg Balance Scale to be considered studies agree on the improvement of this functional capacity
detectable and clinically significant changes in individuals construct through exercise programs.17,22
with a neurological disorder.32–34 In our study, the changes in All types of the included training models (aerobic, strength,
the EG were 20.2% for the TUG, 44.73 m for the 6-Minute multicomponent, or stretching) have led to positive improve-
Walk Test, 0.14 m/s for the 10-m walk test, and 8.5% for the ments in at least 1 of the studied variables. Previous studies
Berg Balance Scale. In this sense, according to the results of our have shown the benefits of strength training on mobility
meta-analyses, it can be stated that the changes produced by and spasticity in people with ABI.77,78 Furthermore, aerobic
exercise on functional capacity were not clinically significant training has been demonstrated to be effective in improving
in the population with ABI except for the 6-Minute Walk Test. walking endurance.15,79 Although only 4 studies evaluated
Findings also showed that mobility outcome measured by balance, all have shown improvements, only in young par-
the TUG showed a small improvement in the EG; however, ticipants and regardless of their training model, in line with
Pérez-Rodríguez et al. 7
Figure 3. Differences on a balance test (Berg Balance Scale [BBS]) between the usual care group (UC) and the exercise group (EG). The forest plot shows
the results of a random-effects meta-analysis for EG compared with UC, shown as standardized mean differences with 95% CIs, on a balance test.
previous studies.80,81 Regarding exercise dosage, the covariate repetition and continuity of training. Furthermore, results
analysis indicated that a frequency of 1 training session per show the importance of adjusting the training variables cor-
week could increase the benefits on gait speed and the TUG. rectly to achieve the proposed objectives in the rehabilitation
In addition, metraregression showed that training programs process of people with ABI.82 In this context, although in our
of longer duration in weeks led to greater improvements in meta-analyses we carried out a comparison between the differ-
gait speed. These results are consistent with the principles of ent types of training (strength, aerobic, and multicomponent)
8 Exercise for People With Acquired Brain Injury
without finding differences in functional capacity between diferences between both groups. These improvements could
training modes, more experimental studies are needed, includ- be explained by the improvements in functional capacity and
ing to analyze the effects of different types of training such balance. Previous systematic reviews have concluded that
as strength versus endurance. In addition, more randomized exercise may be a key factor in maintaining and/or improving
controlled trials are also needed to compare the effects in the QoL after ABI, especially during the chronic phase. In the
different phases of ABI and determine if there is a sensitive literature, we found studies that evidenced exercise as a
phase of improvement. determinant to maintain a good QoL after ABI,9 especially
Our results show that gait speed as well as mobility (TUG) during the chronic phase.16,70 We also agree with authors who
improve more in patients in the subacute phase of the disease indicate the importance of adherence to exercise programs
compared with those in the chronic phase. However, most of because the longer the intervention lasted, more adherence
the studies included in this review were performed during the and positive effects were associated.83 In addition, it should
chronic phase of the disease. This factor may be distorting be mentioned that, despite significant changes, the level of
the results, so more studies are needed to analyze the benefits evidence measured by GRADE on these variables reflected
of physical exercise on functional capacity in the subacute low evidence. Thus, our results can confirm that performing
phase of the disease, which would allow us to perform a more exercise programs can exert moderate improvements in
powerful analysis of the results. QoL when proposing short-time sessions and long program
Finally, it was found that time per session had no interaction durations, highlighting positive health effects of those mainly
on the effects of training on functional capacity, except for gait based on the aerobic training model. Previous research has
speed, which was found to have a moderate interaction, show- shown that a change of 19% in the SF-36 is considered to be
ing that those sessions with shorter durations (approximately the minimum detectable change in people with neurological
30 minutes) could improve the benefits on this variable. From disorders.84 In our meta-analyses, we found changes of 11%
the studies included in our meta-analyses, it can be noted in the physical subcomponent of the SF-36 and 10% in the
that those who used long-duration sessions (>60 minutes) mental subcomponent. The type of exercise seems not to be
found less benefit in gait speed. One of the reasons that could as decisive, given the heterogeneity observed in the training
explain these results, according to Hotting et al,14 is that models of the included studies.
short training sessions as the aforementioned may prevent the
onset of high rates of fatigue, a component that can delay Type of Exercise and Intervention Characteristics
adaptations to training and which is a common characteristic
of people with ABI. Due to the high heterogeneity of both types of training and
the sample present in the studies, we must be cautious in
interpreting the results of our meta-analyses in relation to the
Quality of Life type and dose of exercise that provides the greatest benefits for
Exercise programs also led to an improvement on the the variables analyzed. For example, according to our results,
QoL variable (SF-36) compared with UC, with significant those patients in the subacute phase of the disease have an
Pérez-Rodríguez et al. 9
increased ability to improve variables such as gait speed or the versus usual care but also versus different types of interven-
TUG. These results underline the importance of incorporating tions. In addition, the measurement of neuromuscular vari-
physical exercise in ABI disease, especially in the subacute ables such as rate of force development or central activation
phase. ratio should be analyzed in future studies, because they would
This systematic review has highlighted the effectiveness of give us more in-depth information on the underlying mech-
specifically designed physical exercise programs for people anisms that explain the changes in strength and functional
with ABI. In this context, this systemac review highlighted capacity in this population.
the effectiveness and importance of specifically designed exer-
cise programs for people with ABI, taking into account the
functional capacities and special needs of this population.45 Study Limitations
In addition, data also showed that the SMDs of the stud- Despite the standardized protocol used to guide and structure
ied programs were small to moderate in most of the cases, the search strategy, study selection, extraction of data, and
resulting in the inability to generate potential long-term health statistical analysis, some limitations of this review should
changes in these populations.85 Additional high-quality, ran- be noted. First, this review considered populations with all
domized controlled trials are urgently needed to investigate etiologies of ABI; nevertheless, 26 of the 30 articles selected
the real effects of exercise programs in individuals with ABI post-stroke participants, 2 articles focused on TBI only, and
during rehabilitation phases. In this context, more randomized 2 articles focused on ABI (involving different etiologies). For
controlled trials are also needed comparing not only exercise this reason, 1 of the limitations of the study is not having been
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