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Brain Injury
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ibij20
The effects of exercise to promote quality of life
in individuals with traumatic brain injuries: a
systematic review
Grace C. O’Carroll , Stephanie L. King , Sean Carroll , John L. Perry & Natalie
Vanicek
To cite this article: Grace C. O’Carroll , Stephanie L. King , Sean Carroll , John L. Perry & Natalie
Vanicek (2020): The effects of exercise to promote quality of life in individuals with traumatic brain
injuries: a systematic review, Brain Injury, DOI: 10.1080/02699052.2020.1812117
To link to this article: https://doi.org/10.1080/02699052.2020.1812117
Published online: 15 Nov 2020.
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The eects of exercise to promote quality of life in individuals with traumatic brain
injuries: a systematic review
Grace C. O’Carroll
a
, Stephanie L. King
a
, Sean Carroll
a
, John L. Perry
b
, and Natalie Vanicek
a
a
Department of Sport, Health and Exercise Science, University of Hull, Hull, UK;
b
Psychology Department, Mary Immaculate College, Limerick, Republic
of Ireland
ABSTRACT
Objective: To systematically review the eects of exercise interventions that may enhance quality of life
(QOL) in individuals with traumatic brain injury (TBI).
Methods: A systematic search was conducted using ve databases up to April 2018. Studies were
included if QOL was quantied following an exercise programme for people with a TBI. Methodological
quality was assessed using a validated scoring checklist. Two independent reviewers assessed study
inclusion and methodological quality.
Results: Thirteen studies met the inclusion criteria (seven RCTs, six non-RCTs). The median total scores for
the quality assessment tool were 26.1 (RCTs), and 21.3 (non-RCTs), out of 33. Eight out of the 13 studies
reported improved QOL following an exercise programme. The duration of the interventions varied from
8-12 weeks. The most common programmes involved moderate to vigorous exercise; with a frequency
and duration of 3–5 times/week for 30–60 minutes.
Conclusion: Due to the diversity of the exercise training interventions, heterogeneity of patient char-
acteristics, multitude of QOL instruments and outcome domains assessed, it was not possible to draw any
denitive conclusion about the eectiveness of exercise interventions. However, this review identied
positive trends to enhance various aspects of QOL measured using a range of assessment tools.
ARTICLE HISTORY
Received 22 March 2019
Revised 24 June 2020
Accepted 13 August 2020
KEYWORDS
Traumatic brain injury;
rehabilitation; exercise;
quality of life
Introduction
Traumatic brain injury (TBI) is a global health issue with at
least 10 million annual cases, and a major cause of disability,
morbidity and mortality (1,2). Following a head injury, long-
term consequences can affect the physical, cognitive, beha-
vioral, and emotional functions of the individual causing
reduced motor control/balance, sensation deficits, and issues
with speech (1). In addition, TBI individuals are significantly
more likely to report adverse lifestyles, including sedentary
behavior (3), binge drinking (4), and more vulnerable to
experiencing fatigue, depression (5), high levels of self-
reported anxiety, or generalized anxiety disorders, epilepsy
(4) and developing early Alzheimer’s (6). These issues can
result in relationship breakdowns (7), job losses (8) and home-
lessness (9), leading to significant social stigma and socioeco-
nomic consequences, with financial burdens on the healthcare
system.
Quality of life (QOL) is a subjective measure, taking into
consideration the individuals’ perception of their physical,
cognitive and affective states, interpersonal relationships and
social roles in their lives (10). The World Health Organization
QOL questionnaire also includes a spiritual dimension, which
examines an individual’s perception of ‘meaning of life’ and
overarching personal beliefs (10). Accordingly, QOL is a very
complex and broad-ranging concept, affected by physical
health, independence, psychological state of mind, beliefs,
and social relationships. However, in broad terms, QOL has
been defined as an “individuals’ perception of their position in
life in the context of the culture and value systems in which they
live and in relation to their goals, expectations, standards and
concerns”
(10,p1405)
. QOL outcome measures are important
within head injury research (11,12) as individuals with TBI
report a lower QOL compared with the general population
(13,14).
Regular physical activity is well known for promoting
a variety of health benefits including improvements to cardior-
espiratory fitness (15), lower mortality rates (16), reduced
depressive symptoms (17), and enhancing overall psychologi-
cal well-being (18) in healthy individuals. Regular exercise,
which is a planned, structured form of physical activity, has
also been shown to enhance cognitive functioning and facilitate
neuroplasticity (19). For these reasons, exercise training has
been suggested to play a key role in the rehabilitation of
individuals following a TBI.
Better physical functioning, and participation in fulfilling
activities, such as social interactions and returning to employ-
ment, has previously indicated QOL improvements following
a TBI (20,21). Additionally, physical activity is reportedly an
effective treatment modality for reducing anxiety and somatic
conditions in both healthy and TBI individuals (22). Due to the
positive effects of exercise and physical activity on an indivi-
duals’ QOL, it has been considered a health-promoting self-
care behavior.
Despite the extensive research in TBI rehabilitation, there is
still disagreement about the most effective exercise modality
CONTACT Stephanie L. King graceocarroll@yahoo.com Sport, Health and Exercise Science, University of Hull, Hull HU6 7RX
BRAIN INJURY
https://doi.org/10.1080/02699052.2020.1812117
© 2020 Taylor & Francis Group, LLC
and general exercise principles in terms of frequency, intensity,
time, and type (FITT) of exercise intervention and the impact
this could have on QOL outcomes.
Aim
The overarching aim of this systematic review was to evaluate
exercise training interventions that may enhance QOL in indi-
viduals following a TBI. The main objective was to report on
the effects of structured exercise training on QOL outcomes
within adults following TBI. Secondly, we reviewed the exercise
intervention characteristics (FITT principles) within published
studies with QOL as an outcome measure and the different
QOL tools used as study outcome variables. The overall quality
of the published exercise training studies in adults following
TBI were evaluated.
Methods
This systematic review was undertaken and reported in accor-
dance with the general principles recommended in the
Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) statement (23).
Search strategy
The evidence-based PICO model (24) was used to help for-
mulate the clinical question. The determinants are outlined in
Table 1.
All forms of study designs were included apart from sys-
tematic and narrative review articles, and guideline papers, to
maximize available data. Database searches were conducted in
PubMed, Web of Science, Scopus, Cochrane, and ProQuest.
The specific search terms used were “traumatic brain injury”,
“TBI”, “exercise”, “physical activity”, and “quality of life”. The
complete set of Boolean operators is outlined in Appendix 1.
We searched the databases for article published between 1900
and April 2018.
Data extraction and synthesis
Following the database searches and the deletion of duplicates,
initially the article titles were screened against the inclusion
and exclusion criteria, followed by the abstracts and then a full-
text review of potentially included articles against the specific
criteria. The final selection of articles, where QOL was an
outcome measure, were analyzed independently by two
reviewers (GO, SK). No disagreements were encountered and
therefore a third reviewer was not required to act as an adju-
dicator. The data were extracted and organized by category:
study identification, aim, participant characteristics and sam-
ple size, intervention characteristics, QOL outcome measures,
and results.
Outcomes measures
The primary outcome of this systematic review was to report
on the effectiveness of the exercise training programmes in
improving QOL in adults following a TBI. Secondly, the
characteristics of the exercise interventions were reviewed.
Our review considered the setting where the exercise interven-
tion was delivered and detailed the FITT (Frequency, Intensity,
Time, and Type) principles of the structured exercise pro-
gramme. This review was conducted to evaluate whether the
FITT principles influenced QOL outcomes within TBI patients.
The different QOL tools utilized to evaluate the effects were
exercise interventions were reviewed.
To be considered for inclusion in this systematic
review, QOL assessment tools must have presented
information related to at least one of the following
domains: 1) physical functioning, 2) psychological or
mental function, 3) social and economic function, 4)
pain, 5) vitality, and 6) general health perceptions.
This included (but not limited to) tools that measured
depression, anxiety, stress, social interactions, sleep
quality, and functional independence. QOL was quanti-
fied using validated questionnaires, including a mixture
of generic or condition-specific scales developed to
measure overall QOL and domains of QOL.
Quality assessment
The methodological quality of the included studies was
assessed using a checklist developed by Downs & Black
(25) which is suitable for both randomized and non-
randomized studies of healthcare interventions. It consists
of several components including: 1) Reporting (ten items):
assessing whether the information provided is sufficient; 2)
External Validity (three items): addressing the extent to
which the findings could be generalized to the population;
3) Bias (seven items): addressing biases in the measure-
ment of intervention and outcomes; 4) Confounding (six
items): assessing bias in the selection of study subjects; and
5) Power (one item): assessing whether the negative find-
ings could be due to chance. Answers were scored 0–1,
except for one item in the Reporting component (scored
0–2) and the Power subscale (scored 0–5). The total max-
imum score was 33. Overall scoring can be categorized
into good (>20), moderate (11–20) and poor (<11) meth-
odological quality (25). The methodological quality was
assessed by two independent reviewers with any disagree-
ments being resolved before continuation of the analysis.
Table 1. PICO model for formulating the clinical question.
Criteria Determinants
Population Only human adults with a TBI (exclusively a TBI population, or TBI
participants within comparison groups).
Intervention Physical activity; or divided attention/dual-tasking rehabilitation;
or exercise training.
Comparison Treated with exercise intervention vs. untreated or participants
received alternative rehabilitation (e.g., relaxation); people
with TBI vs. healthy or individuals with other traumas;
comparisons made between different severities of TBI (e.g.,
mild, moderate, severe); or comparison based on pre- or post-
injury characteristics.
Outcomes QOL or health-related QOL (HRQOL) relating to at least one of the
following domains: physical functioning, mental functions,
socio-economic function, pain, vitality, overall life satisfaction
and/or general health perceptions
2G. C. O’CARROLL ET AL.
Results
Search results
The initial search returned 5128 articles (Web of Science: 1309,
PubMed: 1804, Scopus: 1581, Cochrane: 238 and ProQuest:
196). The duplicate articles (2023) were identified and
excluded, leaving 3105 studies for the initial stage of the review
(Figure 1). Both reviewers screened 43 full-text articles, with 30
articles being excluded (Figure 1). The remaining 13 studies
were included in the final analysis according to the unanimous
decision of the two reviewers.
Quality assessment
The quality of the methodologies reported within the primary
studies was assessed and analyzed separately for the RCT and
the non-RCTs (Table 2). All of the RCT studies (26–32) had
total scores >20, categorized as ‘good’, ranging from 22 (30) to
29 (29). All seven articles reported clear descriptions of their
main outcomes, interventions, principle confounders, exact
probabilities, and reported external validity. Of the seven
RCT studies, Bateman et al. (26), Bellon et al. (31), and
Hassett et al. (29) scored highest on internal validity (bias),
with Elsworth et al. (28) and Hassett et al. (29) scoring highest
for internal validity (confounding). The lowest ratings were for
internal validity (confounding) sub-sections, with only one
study using an assessor-blinded randomization design (29)
and only one study presenting confounding adjustment (28).
For the four non-RCTs, the total scores ranged from 18 (33,34)
to 25 (35). All six non-RCTs (33–38) reported clear descrip-
tions of their main outcomes, patient information, interven-
tion, findings, and presented the study group approached and
included. Damiano et al. (36) and Lee et al. (35) scored highest
on external validity, with Kleffelgaard et al. (33), Lee et al. (35),
Schwandt et al. (34), and Weinstein et al. (38) scoring highest
on internal validity (confounding) of all the six non-RCTs.
However, Kleffelgarrd et al. (33) scored the lowest for internal
validity (bias). Similar to the RCT studies, the lowest ratings
were for two of the internal validity (confounding) sub-
sections; hidden randomization and confounding adjustments.
Articles identified in initial search (n =
5,128)
Web of Science (n = 1,309)
PubMed (n = 1,804)
Scopus (n = 1,581)
Cochrane (n = 238)
ProQuest (n = 196)
Articles for initial review after
duplicates removed (n = 3,105)
Duplicate articles removed (n = 2,023)
Articles for full-text review
(n = 43)
Articles excluded following review of
titles and abstracts (n = 3,062)
Articles included after full-text review (n = 13)
Articles excluded following full text review (n = 30)
No access to full-text (n = 1)
Only virtual reality tasks (n = 2)
No QOL outcome measure (n = 12)
Participants mean age <18years (n = 1)
Intervention not including physical activity,
exercise or dual-tasking activities (n = 13)
Not peer-reviewed work (n = 1)
Figure 1. PRISMA flowchart of literature screening process.
BRAIN INJURY 3
Table 2. Methodological quality assessment scoring using an assessment tool for randomized and non-randomized trials (Downs & Black, 1998).
Study
Reporting External validity
1 2 3 4 5 6 7 8 9 10 11 12 13
Participant
Blinding
Researcher
Blinding
Data
Dredging
Clear
Follow up
Adjustments
Appropriate
Statistics
Intervention
Compliance
Validity &
Reliability
Participant Groups
From Same
Population
Recruitment
Groups & Time
Periods
Randomization Hidden
Randomization
Confounding
Adjustment
Withdrawal Accounted for
RCTs Bateman (2001) 0 1 1 1 1 1 1 1 1 1 0 0 1
Bellon (2015) 0 1 1 1 1 1 1 1 1 1 0 0 1
Blake (2008) 0 1 0 1 1 1 1 1 1 1 0 0 1
Driver (2006) 0 0 1 1 1 0 1 1 1 1 0 0 0
Elsworth (2011) 0 1 1 1 1 0 1 1 1 1 0 1 1
Hassett (2009) 0 1 1 1 1 1 1 1 1 1 1 0 1
Hoffman (2010) 0 0 1 1 1 0 1 1 1 1 0 0 0
Non-RCTs Chin (2015) 0 0 1 1 1 1 1 1 1 0 0 0 0
Damiano (2016) 0 0 1 1 1 1 1 1 1 0 0 0 0
Kleffelgaard (2015) 0 0 0 1 0 1 1 1 1 0 0 0 1
Lee (2014) 0 0 0 1 1 1 1 1 1 0 0 0 1
Schwandt (2012) 0 0 1 1 0 1 1 1 1 0 0 0 1
Weinstein (2017) 0 0 0 1 1 1 1 1 1 0 0 0 1
Study
Internal Validity-Bias Internal Validity-Confounding
14 15 16 17 18 19 20 21 22 23 24 25 26 27
Participant
Blinding
Researcher
Blinding
Data
Dredging
Clear
Follow up
Adjustments
Appropriate
Statistics
Intervention
Compliance
Validity &
Reliability
Participant Groups
From Same
Population
Recruitment
Groups & Time
Periods
Randomization Hidden
Randomization
Confounding
Adjustment
Withdrawal
Accounted
for
Power Total
Score
RCTs Bateman (2001) 0 1 1 1 1 1 1 1 1 1 0 0 1 5 28
Bellon (2015) 0 1 1 1 1 1 1 1 1 1 0 0 1 5 27
Blake (2008) 0 1 0 1 1 1 1 1 1 1 0 0 1 5 27
Driver (2006) 0 0 1 1 1 0 1 1 1 1 0 0 0 5 23
Elsworth (2011) 0 1 1 1 1 0 1 1 1 1 0 1 1 5 27
Hassett (2009) 0 1 1 1 1 1 1 1 1 1 1 0 1 5 29
Hoffman (2010) 0 0 1 1 1 0 1 1 1 1 0 0 0 5 22
Non-RCTs Chin (2015) 0 0 1 1 1 1 1 1 1 0 0 0 0 4 21
Damiano (2016) 0 0 1 1 1 1 1 1 1 0 0 0 0 5 23
Kleffelgaard (2015) 0 0 0 1 0 1 1 1 1 0 0 0 1 2 18
Lee (2014) 0 0 0 1 1 1 1 1 1 0 0 0 1 5 25
Schwandt (2012) 0 0 1 1 0 1 1 1 1 0 0 0 1 2 18
Weinstein (2017) 0 0 0 1 1 1 1 1 1 0 0 0 1 5 23
1 = Yes, item addressed appropriately, 0 = No, item not addressed or unable to determine. Q5 1 = partially addressed, 2 = item addressed appropriately
4G. C. O’CARROLL ET AL.
By default, all non-RCTs scored zero (attributed ‘no’) for
randomization. Additionally, all 13 studies scored zero (attrib-
uted ‘no’) for blinding the participants to the intervention they
received. This aspect of research design is inherently challen-
ging as all the interventions involved structured exercise.
Study characteristics
Participants
The number of participants recruited to the primary studies
varied from 4 to 157 adult neurological patients; with 4 to 69
undertaking structured exercise across all 13 eligible studies
(Table 3). All 13 studies included both female and male parti-
cipants, with an age range between 24 and 65 years, and three
studies included more women than men (30,35,38). Ten out of
the 13 primary studies investigated the effects of exercise inter-
vention on adults following TBI exclusively (29–38), while the
remaining three articles grouped together a variety of brain-
related injuries that included TBI (26–28). One study (26)
included participants who had suffered strokes and hemor-
rhages, whereas another included various neurological disor-
ders, including Parkinson’s disease, multiple sclerosis, motor
neurone disorders, and cerebral palsy (28). One study (27) did
not specify the nature of the brain-injury amongst participants,
but specified that the majority of participants required
a wheelchair or walking frame/aid for mobility purposes. For
those studies reporting data, the severity of the TBI ranged
from mild to severe (Glasgow Coma Score of 13–15 for mild,
9–12 for moderate and 3–8 for severe) across the 13 studies.
Nine out of the 13 reported on cases where the time since
injury was 6 months or longer (27,30–32,34–38), with two
studies including participants who had sustained the injury in
under 6 months (26,29). Two studies did not specify the time
since injury (28,33). All the studies were conducted in coun-
tries with well-developed healthcare systems, including US,
Canada, Australia, Norway, and UK.
Interventions
The duration of the exercise interventions was short-term,
ranging from 8 to 12 weeks across all studies (Table 4).
Individual exercise sessions ranged from 30 to 90 minutes
duration with frequencies ranging from one to five times per
week. The most common exercise programme involved exer-
cise sessions lasting 30 minutes, performed three times weekly
(26,34,37,38). One study did not specify the duration or the
frequency of the sessions (31). Five studies demonstrated rela-
tively good completion rates of 77% (29), 78% (34), 93%
(37,38) and >80% (36) for the exercise interventions. Lee
et al. (35) reported an average attendance of 71% over the
8 week supervised IntenSati programme, with Blake et al.
(32) outlining their exercise group completed 58/80 sessions
(73%) over the 8 weeks. In one case series (33), the four
participants attended between 8 and 15 sessions out of the
maximum 16. During the supervised sessions in one study
(30), only 5.9 (from 10) sessions were attended over the
10 weeks. The RCT of Bateman and colleagues (26) outlined
that the average total minutes of exercise performed by the
exercise group were 552 minutes, which was only half of the
prescribed maximum. One study documented a considerably
lower number of exercise sessions performed per week, with
only 44% partaking in ≥1 session, 8% ≥2 sessions and 2% ≥3
sessions (28). Two studies did not present any adherence rates
(27,31).
All of the studies delivered supervised, structured exercise
programmes with the exception of two, whereby one encour-
aged an unsupervised, but supported self-directed exercise
intervention at the local gymnasium (28). The other study
promoted a home-based walking programme with coaching
contact via telephone/e-mail (31). Three studies (29,30,33)
included both supervised and unsupervised (home-based)
exercise sessions. Eight of the 13 studies included different
types of aerobic-based exercises (aquatic aerobics/resisted exer-
cise, treadmill walking/running, stationary biking, stair-
stepping, rowing, track running) as part of the intervention
(26–28,30,31,34,37,38); with four studies concentrating on
motor control, balance, and strength and conditioning training
(32,33,35,36). The study by Hassett et al. (29) combined both
strength-based and aerobic exercise in their exercise sessions.
The prescribed intensity of the exercise sessions across the
primary studies was moderate to vigorous intensity, ranging
from 50% to 80% of maximum heart rate (HRmax) (39). One
article used RPM to gauge exercise intensity, where partici-
pants maintained 40–80 rpm against resistance on an elliptical
trainer (36). Another paper categorized intensity as a weekly
5% increase in number of steps, initiated from their baseline
data (31). Hassett et al. (29) categorized their cardiorespiratory
intensity as moderate (heavy breathing but could talk). Four
studies did not report exercise intensities (28,33,35,38). Nine of
the 13 studies included a control or usual care group (26–
32,35,37). Bateman et al. (26), Driver et al. (27), Hassett et al.
(29), Bellon et al. (31), and Blake et al. (32) provided their
control groups with alternative activities (relaxation therapy,
vocational rehabilitation classes, home-based exercises, nutri-
tional programme, and non-exercise social and leisure activ-
ities, respectively). Elsworth et al. (28), Hoffman et al. (30),
Damiano et al. (36), and Lee et al. (35) did not specify the
‘standard care’ provided to their control groups. However, the
remaining four studies only presented findings for the inter-
vention group (33,34,37,38).
Outcome measures
Quality of life
The primary outcomes were QOL assessment or related
domain-specific tools for 11 (26,27,30–38) of the 13 studies,
with the remaining two specifying QOL as their secondary
outcomes (28,29) (Table 5). A total of 28 different QOL-
related instruments were used across all 13 studies. There was
only one study that incorporated a tool measuring overall QOL
in relation to TBI specifically: the Quality of Life in Brain
Injuries questionnaire (QOLIBRI) (33). The remaining tools
that were used measured various domains affecting QOL (e.g.,
anxiety, depression, fatigue, mood, pain, etc.). The tools most
frequently assessed were the Pittsburg Sleep Quality Index
(PSQI) (n = 3 studies) (30,36,37), the Becks Depression Index
(BDI) (n = 3) (30,35,37) followed by the Profile of Mood States
questioannire (POMS) (n = 2) (29,38) and the Hospital Anxiety
and Depression Scale (HADS) (n = 2) (26,33). Nine out of the
BRAIN INJURY 5
Table 3. Study characteristics and population data for included studies.
Author
Country
of origin
Total
sample
size (n)
EX group
sample size
(n) Gender
Mean age
(years)
Diagnosis and physical status
Severity
(GCS)
Mean time
since injury
(months)
EX CON EX CON
RCTs Bateman (2001) UK 157 55 M & F 41.7 44.7 TBI (22% of total cohort), stroke, hemorrhage, other. Long-term inpatients with complex disability. Able to
sit on a cycle ergometer. No physical, cognitive, or behavioral impairments sufficiently severe to
prevent compliance/ participation in training.
NR 5.1 5.9
Bellon (2015) USA 69 69 M & F 43.7 TBI >6months, needing medical attention, able to walk unassisted or with aid, no participating in other PA
programme.
Mild to
severe
100.5
Blake (2008) UK 20 10 M & F 44.5 46.2 TBI > 1year Mild to
severe
196.8 178.8
Driver (2006) USA 18 9 M & F 37.8 35.3 Unspecified previous Brain Injury with varying levels of disability. 40.0% used wheelchairs for mobility;
30% required walking frame/aid.
NR 40.3 41.2
Elsworth (2011) UK 99 48 M & F 55 57 Unspecified subgroups of participants with neurological conditions (Parkinson’s, multiple sclerosis, motor
neurone disease, neuromuscular disorders, cerebral palsy, TBI, transverse myelitis). Able to engage
within an exercise facility and walk 10m with aid.
NR NR NR
Hassett (2009) Australia 62 32 M & F 35.4 33 TBI (able to walk independently). Severe to
very
severe
2.6 2.3
Hoffman (2010) USA 80 37 M & F 39.7 37.1 TBI (with at least mild depression, no physical barrier to use of standard exercise equipment). NR 6-60 6-60
Non-RCTs Chin (2015) USA 7 7 M & F 33.3 n/a TBI (able to walk independently on the treadmill without assistance or requiring support). Mild to
moderate
48 n/a
Damiano (2016) USA 24 10 M & F 31.3 32.5 TBI (ability to walk independently and safely without assistance; acceptable balance on Neurocom
testing).
NR 90 NR
Kleffelgaard (2015) Norway 4 4 M & F 36 n/a TBI (ongoing dizziness and balance problems). Mild NR n/a
Lee (2014) USA 21 9 M & F 48.2 44.5 TBI occuring >year, medically documented TBI, no contradicting medical conditions. NR 88.1 27.3
Schwandt (2012) Canada 4 4 M & F 29 n/a TBI (moderate to severe depression, no musculoskeletal impairments). Moderate to
severe
31.2 n/a
Weinstein (2017) USA 10 10 M & F 32.9 n/a TBI (non-penetrating), sedentary, walk unassisted. Mile to
severe
79.2 n/a
CON = Control, EX = Exercise, GCS = Glasgow Coma Scale, n/a = Not applicable, NR = Not Reported, RTC = Randomized Controlled Trial, TBI = Traumatic Brain Injury
6G. C. O’CARROLL ET AL.
Table 4. Intervention characteristics for included studies, detailing the exercise FITT principles (frequency, intensity, time, type), comparison groups, and the QOL outcome measures.
Study Intervention setting and exercise type
Duration
(week)
Frequency (per
week)
Time
(min/
session) Intensity
Control/ compari-
son group
QOL outcome
measures
RCTs Bateman (2001) Rehabilitation Centre Inpatients. Aerobic exercise programme (stationary cycling) 12 3 30 60-80% HRmax Relaxation
exercises - TBI
BBS, RMI, Barthel
index, FIM, NEADL,
HADS
Bellon (2015) Home-based walking programme. Pedometer measuring steps 12 NR NR 5% weekly step
increase
Nutrition
programme - TBI
CES-D, PSS
Blake (2008) Supervised Tai Chi (Qigong - integrating posture, movement, breathing
techniques)
8 1 60 NR Non-exercise social
and leisure
activities
GHQ-12, PSDQ
Driver (2006) Community-based exercise programme. Unspecified Aerobic and resistance
programme (aquatic -based)
8 3 60 50-70% HRmax Vocational rehab
classes - TBI
HPLP-II, PSDQ
Elsworth (2011) Cardiovascular, strength and flexibility training (Community-based gymnasium
exercise)
12 At least one
session
NR NR Standard treatment
– TBI
SF-36, FSS,
Hassett (2009) Cardiorespiratory (primarily walking/jogging) and strength training (community-
based gymnasium exercise with personal trainer supervision)
12 3 60 Moderate to vigorous
intensity (heavy
breathing but able to
talk)
Unsupervised,
usual care -
Home-based
exercise
programme - TBI
DASS, POMS, BICRO-
39
Hoffman (2010) Aerobic-based exercise (running, steps, rowing, cycling) Partly supervised,
community, gymnasium- based.
10 5 sessions
(1 x supervised
session)
30 60% HRmax Continued daily
routine - TBI
BDI, BPI, PSQI, Head
injury symptom
checklist, SF-36,
PQOL.
Non-RCTs Chin (2015) Supervised Aerobic exercise (treadmill walking). Medical research Centre. 12 3 30 70-80% HRR n/a PSQI, BDI-II
Damiano (2016) Unsupervised, home-based exercise programme. Motor control (training (elliptical
trainer)
8 5 30 40-80 rpm Continued daily
routine - healthy
HAMD, PSQI, BAI,
PTSD (PCL-C)
Kleffelgaard
(2015)
Hospital outpatient rehabilitation. Supervised, group-based, modified vestibular
rehabilitation with some strength and conditioning activities (circuits) and
home-based aerobic exercise programme (walking, jogging, aquatics)
8 2 1 x 90 1
x 60
NR n/a RPQ, QOLIBRI, HADS
Lee
(2014)
Group supervised. IntenSati workout (fusing high-energy aerobics, martial arts,
dance, yoga, and strength conditioning)
8 2 60 NR NR PNAS, BDI, LIFE-3
Schwandt
(2012)
Outpatient medical rehabilitation unit. Aerobic (cycling, recumbent step, treadmill) 12 3 30 60-75% HRmax n/a HAMD, RSES
Weinstein
(2017)
Supervised aerobic exercise on treadmill 12 3 30 70-80% HRR n/a POMS
BAI = Beck Anxiety Inventory, BBS = Berg Balance Scale, BDI-II = Beck Depression Index version 2, BICRO-39 = Brain Injury Community Rehabilitation Outcome, BPI = Brief Pain Inventory, CES_D = Centre of Epidemiological Studies-
Depression, DASS = Depression Anxiety Stress Scale, FIM = Functional Independence Measure, FSS = Fatigue Severity Scale, GHQ-12 = General Health Questionnaire, HADS = Hospital and Anxiety Scale, HAMD = Hamilton Depression
inventory, HPLP_II = Health Promoting Lifestyle Profile, HRmax = Maximum Heart Rate, HRR = Heart Rate Reserve, n/a = Not applicable, NEADLI = Nottingham Extended Activities of Daily Living scale, NR = Not Reported, PNAS = Positive
and Negative Affect Scale, POMS = Profile of Mood States, PQOL = Perceived Quality Of Life scale, PSDQ = Physical Self-Description Questionnaire, PSS = Perceived Stress Scale, PSQI = Pittsburg Sleep Quality Index, PTSD (PCL-C) = Post-
Traumatic Stress Disorder (checklist-civilian version), QOLIBRI = Quality Of Life after Brain Injury, RMI = Rivermead mobility index, RPQ = Rivermead Post-concussion symptoms Questionnaire, RSES = Rosenburg Self-Esteem Scale, SF-36 =
Short Form questionnaire 36, TBI = Traumatic Brain Injury.
BRAIN INJURY 7
Table 5. The effects of the exercise interventions on overall QOL specific to TBI (in bold) and QOL domain outcome measures for each study.
Study Outcome measure Intervention Control Between group diff. p values (95% CI)
Pre Post Change Pre Post Change
RCTs Bateman (2001) BSS 39.6 46.5 ↑37.7 44.7 ↑p > 0.05
RMI 8.2 10.9 ↑8.2 10.6 ↑p > 0.05
Barthel index 14.2 17.0 ↑13.8 17.3 ↑p > 0.05
FIM (total) 88.9 105.6 ↑85.7 101.4 ↑p > 0.05
NEADL 43.4 32.1 ↑44.1 32.5 ↑p > 0.05
HADS (anxiety) 5.6 5.0 ↑6.1 5.5 ↑p > 0.05
HADS (depression) 5.7 5.5 ↑6.6 5.8 ↑p > 0.05
Bellon
(2005)
CES-D 16.1 12.0 ↑16.0 15.2 ↑NR
PSS 25.6 20.8 ↑23.1 24.3 ↓NR
Blake
(2008)
GHQ-12 1.5 0.0* ↑3.5 2.5 ↑p = 0.03 (U = 22)*
PSDQ (self-esteem) 2.8 3.4* ↑2.6 2.9 ↑p = 0.34 (U = 37.5)
Driver
(2006)
HPLP-II
-HR 3.4 2.9* ↓2.4 2.4 = NR
-PA 2.3 2.9* ↑2.4 2.3 ↓NR
-Nutrition 2.4 0.6* ↓2.5 2.5 = NR
-SG 2.5 2.9* ↓2.6 2.6 = NR
-IPR 2.6 3.0* ↑2.6 2.6 = NR
-SM 2.8 2.8 = 2.7 2.7 = NR
PSDQ (self-esteem) 3.7 4.4* ↑3.8 3.8 = NR
Elsworth (2011) SF-36
-Mental 51.4 5.3 ↑50.5 51.6 ↑p = 0.47 (5.3,5.8)
-Physical 28.9 33.0 ↑28.6 29.3 ↑p = 0.05 (-7.7,0.8) *
FSS 4.4 4.1 ↑4.4 4.2 ↑p = 0.38 (-0.4,0.5)
Hassett
(2009)
DASS
-Depression 1.0 5.0 ↓1.0 1.0 = p = 0.24 (-6,2)
-Anxiety 2.0 2.0 = 2.0 1.0 ↑p = 0.13 (-3,0)
-Stress 3.0 4.0 ↓3.0 2.0 ↑p = 0.13 (-5,1)
POMS
-Vigor 58.0 56.0 ↓60.0 61.0 ↑p = 0.06 (-8,0)
-Tension 37.0 38.0 ↓36.0 37.0 ↓p = 0.62 (-2,4)
-Depression 40.0 41.0 ↓39.0 39.0 = p = 0.33 (-2,5)
-Anger 44.0 47.0 ↓43.0 43.0 = p = 0.26 (-2,7)
-Fatigue 46.0 47.0 ↓44.0 43.0 p = 0.07 (-0,6)
-Confusion 40.0 45.0 ↓41.0 41.0 = p = 0.007 (1,7) *
BICRO-39
-Socializing 14.0 14.0 = 12.0 14.0 ↑p = 0.12 (-1,5)
-Psychological 7.0 10.0 ↓7 7 = p = 0.14 (-5,1)
Hoffman (2010) BDI 21.5 16.4 ↑24.7 21.2 ↓p = 0.25
BPI 3.8 3.1 ↑3.5 3.5 = p = 0.03*
PSQI 10.0 9.0 ↑10.6 10.9 ↑p = 0.11
HISC 11.0 11.8 ↓11.4 11.4 = p = 0.68
SF-12
-Mental 31.8 38.3 ↑28.2 32.5 ↑p = 0.24
-Physical 41.6 42.0 ↑41.4 39.5 ↓p = 0.22
PQOL 54 58.0 ↑45 49 ↑p = 0.39
(Continued)
8G. C. O’CARROLL ET AL.
Table 5. (Continued).
Study Outcome measure Intervention Control Between group diff. p values (95% CI)
Non-RCTs Chin
(2015)
PSQI 4.6 3.7 ↑n/a n/a
BDI-II 7.7 4.6 ↑n/a n/a
Damiano (2016) HAMD 4.9 3.4 ↑1.1 NR p = 0.35
PSQI 5.2 3.5 ↑NR NR p = 0.04*
BAI 7.3 5.6 ↑NR NR p = 0.09
PTSD (PCL-C) 30.1 25.5 ↑9.6 NR p = 0.14
Kleffelgaard (2015) Patient 1 HADS 20 14 ↑n/a n/a
RPQ-3 9 2 ↑n/a n/a
RPQ-13 13 12 ↑n/a n/a
QOLIBRI 40 43 ↑n/a n/a
Patient 2 HADS 20 10 ↑n/a n/a
RPQ-3 5 0 ↑n/a n/a
RPQ-13 27 4 ↑n/a n/a
QOLIBRI 41 67 ↑n/a n/a
Patient 3 HADS 19 11 ↑n/a n/a
RPQ-3 10 10 = n/a n/a
RPQ-13 36 24 ↑n/a n/a
QOLIBRI 38 68 ↑n/a n/a
Patient 4 HADS 20 23 ↓n/a n/a
RPQ-3 5 5 = n/a n/a
RPQ-13 40 28 ↑n/a n/a
QOLIBRI 43 54 ↑n/a n/a
Lee
(2014)
PNAS
Positive 44.3 69.5* ↑16.9 34.5 ↑p > 0.05
Negative 84.9 56.9 ↑57.3 50.7 ↑p > 0.05
BDI 29.6 16.6* ↑19.1 10.4 ↑p = 0.01*
Life-5 3.6 4.2* ↑3.6 5.3 p > 0.05
Schwandt (2012) HAMD 23.8 12.5 ↑n/a n/a
RSES 13.3 21.3 ↑n/a n/a
Weinstein (2017) POMS -6.9* ↑n/a n/a NR
Upward arrow indicates improvement, downward arrow indicates detriment, equal sign indicates no change
* indicates significant change (p<0.05)
BAI = Beck Anxiety Inventory, BBS = Berg Balance Scale, BDI-II = Beck Depression Index version 2, BICRO = Brain Injury Community Rehabilitation Outcome, BPI = Brief Pain Inventory, CES_D = Centre of Epidemiological Studies-Depression,
DASS = Depression Anxiety Stress Scale, FIM = Functional Independence Measure, FSS = Fatigue Severity Scale, GHQ-12 = General Health Questionnaire, HADS = Hospital and Anxiety Scale, HAMD = Hamilton Depression inventory, HISC
= Head Injury Symptoms Checklist, HR = Health Responsibility, HRmax = Maximum Heart Rate, HRR = Heart Rate Reserve, IPR = Inter-personal Relationships, n/a = Not Applicable, NEADLI = Nottingham Extended Activities of Daily
Living scale, NR = Not Reported, PA = Physical Activity, PNAS = Positive and Negative Affect Scale, POMS = Profile of Mood States, PQOL = Perceived Quality Of Life scale, PSDQ = Physical Self-Description Questionnaire, PSQI = Pittsburg
Sleep Quality Index, PSS = Perceived Stress Scale, PTSD (PCL-C) = Post-Traumatic Stress Disorder (checklist-civilian version), QOLIBRI = Quality Of Life after Brain Injury, RMI = Rivermead mobility index, RPQ = Rivermead Post-concussion
symptoms Questionnaire, RSES = Rosenburg Self-Esteem Scale, SF-36 = Short Form questionnaire 36, SG = Spiritual Growth, SM = Stress Management, TBI = Traumatic Brain Injury,
BRAIN INJURY 9
13 studies measured their outcomes at baseline and post-
intervention (two testing points). Four studies had additional
follow-up assessments that included QOL tools (26,29,31,38).
Five articles (28–30,32,35) outlined significant improve-
ments in the intervention group compared to the control
group using the Short Form-36 (SF-36), POMS, Brief Pain
Inventory (BPI), General Health Questionnaire-15 (GHQ-
15), and the Positive and Negative Affect Scale (PNAS) tools.
In addition, significant pre-post improvements for the inter-
vention group were demonstrated with the Health-Promoting
Lifestyle Profile (HPLP-II) (27), the Pittsburg Sleep Quality
Index (PSQI) (36), PNAS (35), Life-3 (35), POMS (38),
GHQ-12 (32), and the Physical Self-Description
Questionnaire (PSDQ) (32) tools.
Discussion
This review has highlighted that exercise interventions can
illicit positive improvements on several domains of QOL,
such as sleep quality, mood, engaging in health-promoting
lifestyles, pain, self-esteem, and community re-engagement.
However, we found that only one non-randomized, uncon-
trolled series study (33) utilized a QOL tool specifically for
a TBI population (QOLIBRI). Overall, there was inconsistent
and limited evidence from RCTs and other studies to confirm
that structured, supervised outpatient exercise, combining
aerobic exercise and resisted exercise components promoted
positive changes in various indices related to QOL when per-
formed for at least 90 to 180 minutes/week, and working at
a prescribed moderate to vigorous intensity of 50–80% of age-
predicted HRmax or equivalent (26,27,30,31,34,37,38). In con-
trast, QOL domains and recovery of functional independence
were reported to occur independently of inpatient aerobic
training (28).
The Downs and Black (25) checklist presented ‘good’ overall
scores for the majority of the exercise intervention studies
included in this systematic review. Notably, only two of the
eligible RCTs of exercise interventions recruited exclusively
post-TBI participants but addressed very different research
questions related to their exercise interventions. Specifically,
Hassett et al. (29) recruited 62 predominantly male (85%)
participants in their mid-thirties (recently discharged from
inpatient neurological rehabilitation units following a very
severe TBI), and randomized participants to a supervised, com-
munity-based exercise intervention, or home-based ‘usual care’
exercise programme. Their aim was to compare the effects of
a supervised fitness center-based exercise program with an
unsupervised home-based exercise programme. In contrast,
within a single-center study, Hoffman et al. (30) looked to
test the hypothesis that a structured aerobic exercise pro-
gramme would decrease the severity of depressive symptoms
following a TBI. They randomized 84 adult TBI participants,
(predominantly females exhibiting at least mild depressive
symptoms), to a combined supervised community gymna-
sium/home-based aerobic exercise intervention compared to
a delayed-start control group. Furthermore, within the largest
eligible multi-center RCT of neurological patients, Bateman
et al. (26) conducted a post-hoc analysis investigating the
impact of pathology, comparing TBI versus non-TBI patients
within inpatient exercise rehabilitation. Together, these dis-
tinct RCTs represent the best quality evidence of the effective-
ness of supervised inpatient, community, or home-based, and
structured exercise training interventions on QOL outcomes
following a TBI. Regarding the smaller non-RCTs, failure to
report confounding adjustments contributed to a low-quality
score. These lower scores were entirely expected for exercise-
related interventions due to a default zero score allocated to the
randomization process and provided justification for our sepa-
rate comparison of the methodological quality for the RCT and
non-RCTs. For all 13 studies, it was impossible to blind parti-
cipants to their allocated interventions (exercise treatments),
although relaxation classes, vocational rehabilitation, delayed-
start and home-based exercise served as alternative group
comparisons.
Within their multi-center study, Hassett et al. (29) was
the only investigation that reported conducting their exer-
cise programme (combined aerobic and strengthening exer-
cise) according to professional body (40) guidelines for
post-brain injury patients. Across all studies, the overall
intervention periods were short, ranging from 8–12 weeks
(30–60 min/session), with four out of the five programmes
incorporating structured aerobic training, with supervised
components.
Hassett et al. (29) reported no differences in supervised
compared to home-based exercise interventions for cardior-
espiratory fitness, or psychological functioning outcomes
post-intervention or at follow-up. Likewise, significant
group differences in community reintegration outcomes
were not maintained at longer follow-up. Hoffman et al.
(30) reported lower pain outcomes amongst mainly female
post-TBI participants, but no significant differences in
depression scores (BDI), general health status or perceived
QOL between the exercise intervention and the delayed-start
control group at 10 weeks. However, a subsequent report by
Wise and colleagues (41) showed exercise intervention parti-
cipants maintained improvements in BDI scores over time.
Approximately half (48%) of their participants demonstrated
increased physical activity at 6 months compared with base-
line and those who exercised more than 90 minutes/week had
lower scores on the BDI at the 10-week and 6-month assess-
ments and reported higher perceived QOL and mental health
outcomes (41).
Eight of the 13 studies (26–28,30,31,34,37,38) incorpo-
rated different forms of aerobic exercise training, eviden-
cing that a range of exercise modalities can promote
positive changes to an individuals’ QOL. Individuals who
have suffered a TBI generally have a lower aerobic capacity
compared with age- and gender-matched controls (42,43);
therefore, a targeted exercise programme that includes
aerobic training could enhance cardiorespiratory fitness
outcomes (44) and improve QOL domains concomitantly
(26,27,30,33,34,36).
However, due to the small number of studies that elicited
significant changes, and the broad range of exercise modalities
that were described, we were unable to reach a consensus on
the optimum FITT principles, as described in our second
objective, or to establish a clear and definitive exercise pre-
scription. In addition, there was a lack of robust study designs;
10 G. C. O’CARROLL ET AL.
RCT designs are required to quantify and evaluate the effec-
tiveness of different exercise interventions clinically. The
effects of different exercise interventions following a TBI are
widely researched (41,45–48), but there remain contrasting
views on the most appropriate exercise modality and exercise
dose, highlighting the complexity of prescribing an individua-
lized exercise programme following a TBI. Nevertheless, this
systematic review has identified a range of exercise prescrip-
tions that can enhance QOL and/or its related domains.
A further objective of this systematic review was to
examine the different QOL tools used within the included
studies. All the significant improvements were identified by
tools that explored individuals’ perceptions of different
domains of QOL (HPLP-II, PSDQ, POMS, SF-36, BPI,
BDI, PNAS, Life-3, GHQ-12). Bergquist and colleagues
(49) asked brain-injured individuals to define their views
on QOL. Three major dimensions emerged: 1) achieving
a sense of productivity; 2) establishing a sense of self-
control, self-efficacy, and self-competency; 3) experiencing
a sense of community among self, and others. The percep-
tion of QOL can differ greatly between individuals follow-
ing a TBI, so measuring domains of QOL could be as
important as overall QOL tools. Quality of life is
a complex issue to discuss due to the many indicators
that influence it, including material living conditions, gov-
ernance, and basic rights (50). This current review concep-
tualized QOL definitions by looking at the persons’
physical, mental, social and economic functioning as well
as pain, vitality and general health perceptions.
With few papers looking specifically at the effects of exercise
on QOL in people with TBI, it is problematic for clinicians to
make evidence-based decisions when prescribing exercise pro-
grammes. The effectiveness of exercise on QOL needs to be
evaluated with adequately powered RCTs and by measuring
the feasibility of implementation, acceptability, and effective-
ness of exercise interventions on recognized QOL outcome
measures. Future research should consider and address the
methodological limitations of the published research to
improve research quality. Specifically, estimating random
variability when reporting methodology, and ensuring that
group allocations are randomized.
Limitations
Due to the limited literature available in this area, the broad
inclusion criteria allowed for three (26–28) studies which
included not solely TBI populations. As such there were
some neurological disorder groups that included TBI but it
was not possible to separate these data. The heterogeneity of
the control groups across the included studies was another
limitation, which could affect the reported improvements
when between-group analyses were conducted. In addition,
four studies (27,28,35,36) failed to present the injury severity,
so we were unable to distinguish between the sub-categories of
brain injuries in the results. Another limitation of this review
was that not all included studies were RCTs; hence, it was not
possible to draw definitive conclusions on effectiveness. During
this review it became apparent that defining QOL was a more
challenging task than first anticipated, and the tools used to
assess QOL were very broad throughout the studies. This firstly
led to the broad inclusion of what constituted as QOL or QOL
domain and the divergence of QOL tools administered across
all 13 studies. This made it difficult to accurately compare
effects of QOL because of exercise interventions and diverse
recommendations to the optimum QOL tools. Ideally, the
included studies would have all used the same QOL tools
allowing a more accurate comparison of interventions. Future
studies could explore QOL by breaking it down into distinct
sub-categories.
Selection bias should also be considered which can occur
when the probability of programme adoption or evaluation is
correlated to the impact (51). For the non-RCTs in this review,
the allocation of participants to the exercise treatments can
depend on an arbitrary decision made by the investigator
rather than by chance. Because of this, treatment outcomes
cannot be compared for relevant prognostic factors at baseline
without generating bias. In addition, as all the participants
were volunteers, self-selection bias may be present. This is
when the individuals that volunteer for a study differ from
those who do not volunteer in terms of relevant clinical char-
acteristics (51). So, for example, individuals who volunteer may
possess higher levels of motivation to recover, or to undertake
moderately vigorous exercise, which in turn could lead to
greater attendance rates and better QOL outcomes. However,
this may not be generalizable to the whole TBI population.
Therefore, this should be considered when analyzing data and
interpreting the outcomes of this review. Selection bias does
not occur in RCTs as participants are randomized into treat-
ment arms, emphasizing the need for more robust RCTs to
establish reliable comparisons between studies.
Conclusion
The findings from this review highlight that there appear to
be some modest improvements in QOL domains, including
self-esteem, pain, personal relationships and better psycho-
social reintegration, following structured exercise interven-
tions. The certainty of these findings is limited due to the
small number of relevant studies, plus the marked hetero-
geneity of study groups recruited and the diversity of exer-
cise-based interventions. Nonetheless, some commonality
findings emerged, such as the benefits of short-term, super-
vised combined aerobic and strengthening exercise inter-
ventions, performed at a moderate/vigorous intensity, least
three times weekly for up to 60 minutes. These findings are
preliminary and further studies, specifically longer term,
community-based RCTs, are required to improve study
quality and to build the evidence base for the effectiveness
of exercise on QOL.
Declaration of interest
There are no conflicts of interest to declare. The authors did not receive
any funding in the preparation of this review.
ORCID
Natalie Vanicek http://orcid.org/0000-0002-9602-3172
BRAIN INJURY 11
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Appendix 1. Search terms used for all ve databases
highlighting the Boolean operators ‘OR’, ‘AND’ and
‘NOT’
Database Search Terms
PubMed (“traumatic brain injury” OR “brain trauma” OR tbi OR “brain
injury” OR “concussion” OR “head injury” OR “traumatic
encephalopathy”)) AND (“physical therapy” OR “exercise
training” OR “physical activit*” OR “dual-task*” OR “divided
attention” OR “rehabilitation”)) AND (“quality of life” OR
“psychometric” OR “depression” OR “health-related quality of
life” OR “QoL” OR “life quality”)) NOT “stroke”))
Web of
Science
TOPIC: (“traumatic brain injury” OR “brain trauma” OR “tbi” OR
“brain injury” OR “concussion” OR “head injury” OR “traumatic
encephalopathy”) ANDTOPIC: (“physical therapy” OR “exercise
training” OR “physical activit*” OR “dual-task*” OR “divided
attention” OR “rehabilitation”) ANDTOPIC: (“quality of life” OR
“psychometric” OR “depression” OR “health-related quality of
life” OR “QoL” OR “life quality”) NOT TOPIC: (“stroke”)
Scopus (TITLE-ABS-KEY(“traumatic brain injury” OR “brain trauma” OR tbi
OR “brain injury” Or “concussion” Or “head injury” OR
“traumatic encephalopathy”)) AND (TITLE-ABS-KEY(“physical
therapy” OR “exercise training” OR “physical activit*” OR “dual
task*” OR “divided attention” OR “rehabilitation”)) AND (TITLE-
ABS-KEY(“quality of life” OR “psychometric” OR “depression”
OR “health related quality of life” OR “QoL” OR “life quality”))
AND NOT (TITLE-ABS-KEY(“stroke”))
Cochrane “traumatic brain injury” OR “brain trauma” OR tbi OR “brain
injury” OR “concussion” OR “head injury” OR “traumatic
encephalopathy” and “physical therapy” OR “exercise training”
OR “physical activit*” OR “dual task*” OR “divided attention”
OR “rehabilitation” and “quality of life” OR “psychometric” OR
“depression” OR “health related quality of life” Or “QoL” OR
“life quality” not “stroke”
ProQuest all(“traumatic brain injury” OR “brain trauma” OR “tbi” OR “brain
injury” OR “concussion” OR “head injury” OR “traumatic
encephalopathy”) AND all(“physical therapy” OR “exercise
training” OR “physical activit*” OR “dual task*” OR “divided
attention” OR “rehabilitation”) AND all(“quality of life” OR
“psychometric” OR “depression” OR “health related quality of
life” OR “QoL” OR “life quality”) NOT all(“stroke”)
BRAIN INJURY 13
