PTJ: Physical Therapy & Rehabilitation Journal | Physical Therapy, 2023;103:1–13

https://doi.org/10.1093/ptj/pzac153
Advance access publication date November 7, 2022
Review

Effects of Exercise Programs on Functional Capacity and

Quality of Life in People With Acquired Brain Injury:
A Systematic Review and Meta-Analysis
Marta Pérez-Rodríguez , PhD1 ,* , Andrea Gutiérrez-Suárez, MSc2 ,
Jacobo Ángel Rubio Arias , PhD3 ,4 , Luis Andreu-Caravaca , MSc5 ,6 , Javier Pérez-Tejero, PhD1

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1 Department of Health and Human Performance, Faculty of Physical Activity and Sport Science-INEF, Universidad Politécnica de Madrid,
Madrid, Spain
2 Department of Physiotherapy, Medicine and Biomedical Sciences, Faculty of Physiotherapy, Universidad de A Coruña, A Coruña, Spain
3 LFE Research Group, Department of Health and Human Performance, Faculty of Physical Activity and Sport Science-INEF, Universidad
Politécnica de Madrid, Madrid, Spain
4 Health Research Centre, Department of Education, Faculty of Educational Sciences, University of Almería, Almería, Spain
5 International Chair of Sports Medicine, Faculty of Medicine, UCAM, Universidad Catolica de Murcia, Murcia, Spain
6 Facultad de Deporte, UCAM, Universidad Católica de Murcia, Murcia, Spain

*Address all correspondence to Dr Pérez Rodríguez at: marta.pr@fundacionsegundaparte.org

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
Introduction
Acquired brain injury (ABI) is a broad health term that
involves different etiological conditions, of which the most
common are stroke, traumatic brain injury (TBI), and non-
traumatic brain injury.1 ABI is one of the main causes of
death and disability in adults, and its incidence has increased
over the last 20 years.2 People with ABI may present persis-
tent and disabling deficits in physical, cognitive, behavioral,
socioaffective, and sensory areas. The indicated sequelae can
range from a mild to severe level of impairment and might
vary according to characteristics such as age, sex, preinjury
lifestyle, type of injury, and quality of the neurorehabilitation
process as well as other contextual and personal factors.3
People with ABI present muscle weakness due to neuro-
muscular disturbances (mainly due to incorrect activation
of upper motor neuron syndrome).4 It is also common to
detect deficits along different dimensions of the quality of
life (QoL) status in this population. This health-related QoL
deterioration may involve physical health, psychological state,
level of independence, and social and personal dimension.5
With the aim of improving the QoL, ABI patients receive
neurorehabilitation therapy to improve functional capacity
and achieve the highest level of autonomy and participation.6
The QoL of people with ABI is lower than that of individuals
without diseases, mainly due to lower autonomy and func-
tional capacity, which makes it difficult for them to perform
daily living tasks in a satisfactory manner. In addition, the ABI
population presents higher levels of depression, lower self-
esteem levels, and higher sedentary behaviors, which leads
to a poorer QoL.7 These characteristics act as predictors of
physical functioning recovery and maintenance of QoL levels8
and are determining factors of physical activity participation.9
The most usual impairment after ABI is hemiparesis on 1
side of the body. In addition, ABI may be associated with
hypertonia, hypotonia, dyskinesia, and ataxia, mainly in the
lower limbs, which mainly result in balance problems, gait
impairments, and decreased functional independence.10
As a consequence of deficits in physical capacity resulting
from the disease, physical activity levels are lower in people
with ABI than in the rest of the population.11,12 Because
physical exercise has been proven as an effective noninvasive
therapy to improve neural integrity, engage mechanisms for
cerebrovascular control, and promote neurotrophic factors
important for neuroplasticity,13,14 the inclusion of people
with ABI in physical exercise programs should be a funda-
mental pillar in their rehabilitation process. In general, there
are numerous studies that have shown the benefits of different
types of exercise on balance, gait speed, or walking endurance,
among others, in people with ABI.15–18 In this context, aero-
bic exercise demonstrated the ability to positively impact neu-
rological function after an ABI19 as well as improve physical,
cognitive, and socioaffective functions. In addition, exercise
intervention may improve both the physical and mental com-
ponents of QoL (both of which may be compromised as a
consequence of an ABI), that are essential for the performance
of daily life activities.7 However, previous systematic reviews
do not analyze the effects of exercise programs on functional
capacity and QoL in patients with ABI, nor do they explore the
differences between types of exercise and possible variables
that could modify the results.20 Therefore, to maximize the
benefits derived from physical exercise, the exercise modality
that has the greatest impact on this population should be
investigated.21
Although evidence exists of the positive effects of exercise
on the health of people with ABI of different etiologies, most
review studies focused only on patients after stroke.16,20,22
Therefore, it seems necessary to carry out this study to pro-
mote an investigation of the effects of exercise in this popula-
tion and its use as part of rehabilitation, defining its type and
dosage from the exercise interventions considered.
To the best of our knowledge, no previous studies have
conducted a systematic review with meta-analysis regarding
the effects of physical exercise programs on the functional
capacity and QoL in individuals with ABI. The meta-analysis
carried out by Perry et al16 differ from the present study
in that they analyzed the effect of exercise on depression
and not on the variables mentioned above. Therefore, given
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the wide variety of exercise programs in the literature with
heterogeneous samples, it is important to determine the effects
and optimal dosage of physical exercise programs to ensure
the benefits for individuals with ABI. Therefore, the aims of
this study were to evaluate the benefits of exercise programs
on functional capacity and QoL in people with ABI; and
to determine the type of exercise, phase of the disease, and
frequency that are most beneficial for people with ABI via a
systematic review with meta-analysis.
Methods
Design
This systematic review and meta-analysis study was regis-
tered in the International Prospective Register of Systematic
Review with the registration number CRD42020144588 and
developed in accordance with the Preferred Reporting Items
for Systematic Reviews and Meta-Analyses Protocols 2021
statement. The study design was strictly guided by the PICO-
S framework (P = population, I = intervention, C = control,
O = outcome, S = study). The protocol for this systematic
review was previously published.23
Data Sources and Searches
A comprehensive search was conducted in the following elec-
tronic databases: MEDLINE, the Cochrane Library, CINAHL,
SportDiscus, and Web of Science (science and social science
citation indexes) from study inception through October 25,
2021, and no restrictions were applied to the search dates. To
identify articles missed in the database search, backward cita-
tion searching was conducted by hand-searching the reference
lists of all articles from the full-text review. The systematic
search strategy (Suppl. Material) was conducted by 2 reviewer
authors (M.P.R. and A.G.S.) and carried out a combination
of medical subject headings and broad-range search terms
related to exercise interventions and the studied population
with ABI.
Selection Criteria
We included randomized and nonrandomized trials that per-
formed structured and supervised exercise programs (physical
activity that is planned, structured, and repetitive and that
has as a final or intermediate objective the improvement
or maintenance of physical fitness).24 Studies that included
virtual formats or home-based interventions were excluded.
No language or publication date restrictions were imposed,
and only peer-reviewed journal articles were included. Partic-
ipants (>18 years old) had to meet the criteria for a clinical
Pérez-Rodríguez et al.
diagnosis of ABI in the subacute or chronic phase, considering
a medically stable situation.25 On the other hand, studies
were excluded if a sample population with advanced dementia
or noncontrolled delirium was used; the study was a review,
case study, or observational study; the study was not a fully
published original investigation; and numerical data on the
studied variables were not shown or reported.
Study Selection, Data Extraction, and Quality
Assessment
All retrieved articles were managed with Endnote X9 (Clari-
vate Analytics; Philadelphia, PA, USA), and duplicate studies
were filtered. Two reviewer authors (M.P.R. and A.G.S.)
independently screened the titles and abstracts of all retrieved
articles. Abstracts that met the initial screening criteria as
well as relevant PICO-S information were retrieved as full-
text articles. Disagreements were solved by discussion with
a third reviewer author (J.A.R.A.). In follow-up studies with
multiple time points, only the data closest to the end of
the intervention were included. Data were extracted and
entered a standardized recording data extraction form. The
following information was extracted with a predesigned data
extraction form: author(s), year of publication, participant
characteristics (sample size, mean age, sex, stage after stroke
or TBI, additional impairments), exercise intervention charac-
teristics (type, frequency, duration), comparators, outcomes,
and adverse events. When necessary, manuscript authors were
contacted for more information on missing data.
Outcomes
Regarding functional capacity, the following variables were
considered: walking endurance test (6-Minute Walk Test),26
gait speed (10-meter walk test), and mobility (Timed “Up &
Go” Test [TUG]).27 The effects of intervention on variable
balance was measured with the Berg Balance Scale.28 To assess
QoL, the mental and physical subscales of the 36-Item Short
Form Survey (SF-36) assessment tool was selected for use.26
Risk of Bias Assessment and Level of Evidence
The study quality of the selected references was evaluated
with the Cochrane Collaboration tool29 for assessment of
risk of bias. The tool evaluated the randomness of the allo-
cation sequence (selection bias); concealment of the alloca-
tion sequence (selection bias); masking of participants and
personnel to outcome assessment (performance and detection
bias, respectively); incomplete outcome data (attrition bias);
selective outcome reporting (reporting bias); and any other
potential sources of bias. The possible risks of bias in each
of the 6 indicated domains were categorized as high risk,
low risk, or unclear according to the information reported in
the study. Two researchers (M.P.R. and A.G.S.) independently
evaluated each eligible study according to these criteria, and
a consensus was reached by discussion of the discrepancies
in the risk of bias assessment of these studies. In contrast,
publication bias was evaluated using the funnel plot and
analyzed with the Egger test,30 which allowed the detection
of the symmetry in the funnel plot of the training effects
on the exercise group (EG). The minimum level of statistical
significance was set at P < .05. Two independent reviewers
(M.P.R. and A.G.S.) assessed each study for risk of bias.
Disagreements during the quality assessment were resolved by
discussion between the two by a third author (J.A.R.A.).
3
In addition, the level of evidence was analyzed using the
Grading of Recommendations Assessment, Development and
Evaluation (GRADE) approach.18 The quality of the evidence
was based on 5 factors—risk of bias, inconsistency, indirect
evidence, imprecision, and potential for publication bias—
resulting in 4 levels of evidence quality: high, moderate, low,
and very low. The evaluation was performed at https://grade
pro.org/.
Data Synthesis and Data Analysis
The meta-analyses and statistical analysis were conducted
using Review Manager software (RevMan 5.2; Cochrane Col-
laboration, Oxford, UK) and Jamovi Project software (Pack-
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age for R, 2018, Version 1.0.7; retrieved from https://www.
jamovi.org). A random-effects meta-analysis was performed
to determine the summary effect of exercise on functional
capacity, balance, and QoL. The effects on outcomes between
postintervention and preintervention times and between exer-
cise and usual care arms were expressed as mean differences
(MDs) and standardized mean differences (SMDs) when mea-
sured with different instruments and scales that were not com-
parable or to calculate the effect size (adjusted Hedges g) of
the intervention and 95% CIs. Threshold values for effect size
were 0.2 (small effect), 0.5 (moderate effect), and 0.8 (large
effect).31 In addition, the increases for the experimental group
were contrasted with the values considered to be minimal
clinically important differences for the TUG (an improvement
of 28%),32 the 6-Minute Walk Test (44 m),33 and the 10-m
walk test (0.22 m·s−1 ).34 Heterogeneity among the studies
was evaluated using the I2 test and the Cochrane χ-square
test. The between-study variance was evaluated using the τ -
square test,35,36 in which I2 values of 30% to 60% showed
a moderate level of heterogeneity; a P value <0.1 for the χ-
square test was defined as an indicator of heterogeneity, and
a τ -square test value >1 suggested the presence of substantial
statistical heterogeneity.
Effects of Covariates: Meta-Regression
and Sub-Analysis
A subgroup analysis was applied using Review Manager
software (RevMan 5.2). The studies were coded according
to the following criteria: phase of the etiology (subacute
or chronic), type of exercises performed in the intervention
(aerobic, strength, multicomponent, or other), and training
sessions per week (frequency: 1, 2, 3, or >3 sessions). In each
EG, the MD and SMD (95% CI) were calculated before
and after exercise. The estimation of the effect was con-
ducted using the inverse variance random-effects method.37
The difference between the groups was estimated using the
χ-square statistical test. In addition, a meta-regression model
was applied in a residual restricted maximum likelihood to
analyze variance between the studies (τ -square test) using
Jamovi Project software (Package for R) to explore the impact
of duration of intervention (weeks), total number of sessions,
and length of sessions (time, in minutes). Significance was
accepted at an alpha level ≤.05.
Results
Study Selection
Figure 1 summarizes the study selection process. The
electronic database search identified 6834 studies (4 other
4 Exercise for People With Acquired Brain Injury
sources). After evaluation of 2158 abstracts and titles, 1925
were excluded and 233 were assessed as full text. Finally,
38 studies fulfilled all criteria and were included in the
quantitative analysis.31,38–76
The studies were published between 2004 and 2021 and
included groups of both men and women. The age range
was between 37.4 and 79.2 years (mean = 61.13 years). The
interventions had a mean duration of 12.4 weeks (range = 4–
48 weeks) and were performed between 1 and 7 times per
week. Intervention sessions lasted between 30 and 120 min-
utes. The main characteristics of the interventions featured in
the articles are shown in Supplemental Tables 1 and 2.
Risk of Bias and Level of Evidence
The participants involved in the selected studies received
supervised and structured exercise training; hence, it was dif-
ficult to design research with a credible placebo-control arm.
As shown in Supplemental Figure 1, most of the studies were
judged to have a low risk of bias in each component in the
cited Cochrane risk of bias tool. Eight articles were not ran-
domized,31,49,54,63–65 and 3 did not mask participants.43,49
Five studies presented high risk in all items.49,54,55,58,64 Most
studies did not report attrition bias, but reporting bias was
difficult to contrast because only 13 articles presented inter-
vention protocols and no other evidence was found to report
bias (Suppl. Fig. 1).
According to the GRADE, a very low level of evidence was
obtained for the balance test, a low level of evidence was
obtained for the QoL variables, a moderate level of evidence
was obtained for the TUG, and a high level of evidence
was obtained for walking endurance and gait speed (Suppl.
Tab. 3).
Funnel Plot and Egger Test
The funnel plots showed asymmetry in the effects of the inter-
ventions on the EG. In addition, the results of the Egger test
showed significant heterogeneity for the TUG (z = −2.375;
P = .018) and Berg Balance Scale (z = 1.867; P = .062) and no
significance for the walking endurance test, gait speed, or
QoL (physical and mental subscales). No significant asymme-
try was observed when differences between the EG and the
usual care group (UC) were analyzed, except for QoL (phys-
ical: z = 2.707 [P = .007]; mental: z = 1.933 [P = .053]) (Suppl.
Fig. 2).
Meta-Analysis
The effects of exercise and usual care are shown in the Table.
Regarding functional capacity, the change in the EG was
significantly greater than the change shown by the UC on
the walking endurance test (z = 2.84; P = .005) and gait speed
(z = 2.01; P = .040). However, no significant difference was
observed on the TUG between the UC and the EG (Fig. 2).
In addition, only the minimal clinically important difference
was observed for the walking endurance test, in which an
increment of 44.73 m was observed (Table).
Furthermore, when the change within the EG was ana-
lyzed, the exercise program evoked a small significant increase
in walking endurance (SMD = 0.40; 95% CI = 0.26–0.53;
P < .001) and gait speed (SMD = 0.36; 95% CI = 0.22–0.50;
P < .001). The UC showed no significant improvement after
training.
Regarding the Berg Balance Scale, no statistically significant
differences were observed between the UC and the EG (Fig. 3).
However, a moderate increase on the Berg Balance Scale was
observed after the training program in the EG (SMD = 0.65;
95% CI = 0.36–0.94; P < .001).
Furthermore, significant differences were observed in favor
of the EG compared with the UC (Fig. 4) on the physi-
cal (z = 3.42; P < .001) and mental (z = 3.00; P = .003) QoL
subscales. In this regard, a significant moderate increase on
the QoL physical subscale (SMD = 0.60; 95% CI = 0.37–0.97;
P = .001) and a small increase on the QoL mental subscale
(SMD = 0.40; 95% CI = 0.27–0.53; P < .001) were observed
after the exercise program in the EG.
Effects of Covariates
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An analysis of the covariates was conducted in the EG of the
included articles that involved only people with stroke and
the difference between postintervention and preintervention
times due to the low number of studies developing physical
exercise programs in people with ABI or TBI. Subgroup
analysis (Suppl. Tabs. 4 and 5) showed the differences between
the groups according to the phase of etiology (subacute or
chronic) for gait speed (χ 2 = 10.18; P = .001) and the QoL
physical subscale (χ 2 = 5.50; P = .020) in favor of studies that
included people in the subacute phase. In addition, significant
differences in training frequency were observed in the TUG
(χ 2 = 18.15; P < .001) outcomes in favor of once per week.
Likewise, there were significant differences between partici-
pants who performed an aerobic intervention and those who
carried out a multicomponent training intervention in favor of
aerobic training in the QoL physical (MD = 2.01; χ 2 = 3.60;
P = .060) and QoL mental (MD = 3.21; χ 2 = 5.94; P = .010)
subscales.
The meta-regression analysis (Suppl. Tabs. 6 and 7) showed
a negative significant interaction in gait speed (Fig. 5) with
duration in weeks (omnibus test; P = .005) and total sessions
(P = .004). In addition, a negative interaction was observed
between the TUG and session time (P = .039). Furthermore,
a significant negative relationship was observed in the change
of the Berg Balance Scale and age (P = .018). Finally, a negative
interaction effect was observed between the QoL physical
subscale and session time (P = .006), and a positive interaction
effect was observed between the total number of sessions and
the QoL physical subscale (P = .022).
Discussion
The main finding of this study was that exercise programs
lead to significant positive changes in functional capacity and
QoL compared with the UC regardless of the type of inter-
vention or exercise program (aerobic, strength, stretching, or
multicomponent).
Functional Capacity: Walking Endurance, Gait
Speed, Mobility, and Balance
Exercise programs may lead to an improvement in functional
capacity in people with ABI. Walking endurance (measured
with the 6-Minute Walk Test), gait speed (measured with the
10-m walk test), and balance (measured with the Berg Balance
Scale) showed improvement after exercise programs, evincing
significant differences with respect to the UC. In addition,
walking endurance and gait speed showed a high level of
evidence. It should be noted that, although improvement was
evident in the EG, the effects were small. Previous studies
 Pérez-Rodríguez et al.

Table. Effects of Programmed Exercise and Usual Care (Control)

No. of No. of Effect (Lower to Upper

Variable Measure Overall Effect, z (P) Heterogeneity
Groups Participants 95% CI)a
τ2 χ2 P I2 (%)
Functional Walking endurance, mean
capacity difference
Exercise 31 1076 44.73 (28.47 to 60.99) 5.39 (<.001) 1192.47 99.22 <.001 70
Usual care 12 557 5.53 (−5.74 to 16.80) 0.96 (.340) 114.78 19.41 .050 43
Gait speed
Exercise 20 452 0.14 (0.07 to 0.20) 4.21 (<.001) 0.01 31.83 .030 40
Usual care 5 166 0.05 (−0.03 to 0.13) 1.16 (.250) 0.00 3.22 .520 0
Timed “Up & Go” Test
Exercise 15 354 −3.69 (−5.65 to −1.72) 3.68 (<.001) 5.22 24.64 .040 43
Usual care 5 162 −1.34 (−3.70 to 1.02) 1.11 (.270) 1.94 5.45 .240 27
Balance Berg Balance Test
Exercise 24 803 3.67 (2.16 to 5.18) 4.43 (<.001) 10.78 267.2 <.001 92
Usual care 6 260 1.01 (−0.56 to 2.58) 1.26 (.210) 0.48 5.69 .340 12
Quality of life Physical
Exercise 20 498 4.90 (3.73 to 6.07) 8.21 (<.001) 1.87 28.28 .080 33
Usual care 8 277 0.51 (−0.89 to 1.91) 0.72 (.470) 0.00 0.85 1.000 0
Mental
Exercise 18 448 2.88 (1.70 to 4.06) 4.80 (<.001) 1.17 22.60 .160 25
Usual care 8 277 0.16 (−0.72 to 1.04) 0.36 (.720) 0.09 7.18 .410 3
a Determined by the inverse variance random-effects method.
5

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6 Exercise for People With Acquired Brain Injury

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Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart of the search process. Adapted from: Moher D,
Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA
Statement. PLoS Med 6: e1000097. doi:10.1371/journal.pmed1000097.

have determined a difference of 28% for the TUG, 44 m
for the 6-Minute Walk Test, 0.22 m/s for the 10-m walk
test, or 10% for the Berg Balance Scale to be considered
detectable and clinically significant changes in individuals
with a neurological disorder.32–34 In our study, the changes in
the EG were 20.2% for the TUG, 44.73 m for the 6-Minute
Walk Test, 0.14 m/s for the 10-m walk test, and 8.5% for the
Berg Balance Scale. In this sense, according to the results of our
meta-analyses, it can be stated that the changes produced by
exercise on functional capacity were not clinically significant
in the population with ABI except for the 6-Minute Walk Test.
Findings also showed that mobility outcome measured by
the TUG showed a small improvement in the EG; however,
no significant difference was observed compared with UC
regarding this variable. Consistent with these results, several
studies agree on the improvement of this functional capacity
construct through exercise programs.17,22
All types of the included training models (aerobic, strength,
multicomponent, or stretching) have led to positive improve-
ments in at least 1 of the studied variables. Previous studies
have shown the benefits of strength training on mobility
and spasticity in people with ABI.77,78 Furthermore, aerobic
training has been demonstrated to be effective in improving
walking endurance.15,79 Although only 4 studies evaluated
balance, all have shown improvements, only in young par-
ticipants and regardless of their training model, in line with
Pérez-Rodríguez et al. 7

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Figure 2. Differences in functional capacity (walking endurance, gait speed, and Timed “Up & Go” Test) between the usual care group (UC) and the
programmed exercise group (EG). The forest plot shows the results of a random-effects meta-analysis for EG compared with UC, shown as mean
differences with 95% CIs, on a walking test.

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
analysis indicated that a frequency of 1 training session per
week could increase the benefits on gait speed and the TUG.
In addition, metraregression showed that training programs
of longer duration in weeks led to greater improvements in
gait speed. These results are consistent with the principles of
repetition and continuity of training. Furthermore, results
show the importance of adjusting the training variables cor-
rectly to achieve the proposed objectives in the rehabilitation
process of people with ABI.82 In this context, although in our
meta-analyses we carried out a comparison between the differ-
ent types of training (strength, aerobic, and multicomponent)
8 Exercise for People With Acquired Brain Injury
Figure 4. Differences on a Quality-Of-Life Questionnaire 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 Quality-Of-Life
Questionnaire.
without finding differences in functional capacity between
training modes, more experimental studies are needed, includ-
ing to analyze the effects of different types of training such
as strength versus endurance. In addition, more randomized
controlled trials are also needed to compare the effects in the
different phases of ABI and determine if there is a sensitive
phase of improvement.
Our results show that gait speed as well as mobility (TUG)
improve more in patients in the subacute phase of the disease
compared with those in the chronic phase. However, most of
the studies included in this review were performed during the
chronic phase of the disease. This factor may be distorting
the results, so more studies are needed to analyze the benefits
of physical exercise on functional capacity in the subacute
phase of the disease, which would allow us to perform a more
powerful analysis of the results.
Finally, it was found that time per session had no interaction
on the effects of training on functional capacity, except for gait
speed, which was found to have a moderate interaction, show-
ing that those sessions with shorter durations (approximately
30 minutes) could improve the benefits on this variable. From
the studies included in our meta-analyses, it can be noted
that those who used long-duration sessions (>60 minutes)
found less benefit in gait speed. One of the reasons that could
explain these results, according to Hotting et al,14 is that
short training sessions as the aforementioned may prevent the
onset of high rates of fatigue, a component that can delay
adaptations to training and which is a common characteristic
of people with ABI.
Quality of Life
Exercise programs also led to an improvement on the
QoL variable (SF-36) compared with UC, with significant
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diferences between both groups. These improvements could
be explained by the improvements in functional capacity and
balance. Previous systematic reviews have concluded that
exercise may be a key factor in maintaining and/or improving
QoL after ABI, especially during the chronic phase. In the
literature, we found studies that evidenced exercise as a
determinant to maintain a good QoL after ABI,9 especially
during the chronic phase.16,70 We also agree with authors who
indicate the importance of adherence to exercise programs
because the longer the intervention lasted, more adherence
and positive effects were associated.83 In addition, it should
be mentioned that, despite significant changes, the level of
evidence measured by GRADE on these variables reflected
low evidence. Thus, our results can confirm that performing
exercise programs can exert moderate improvements in
QoL when proposing short-time sessions and long program
durations, highlighting positive health effects of those mainly
based on the aerobic training model. Previous research has
shown that a change of 19% in the SF-36 is considered to be
the minimum detectable change in people with neurological
disorders.84 In our meta-analyses, we found changes of 11%
in the physical subcomponent of the SF-36 and 10% in the
mental subcomponent. The type of exercise seems not to be
as decisive, given the heterogeneity observed in the training
models of the included studies.
Type of Exercise and Intervention Characteristics
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
type and dose of exercise that provides the greatest benefits for
the variables analyzed. For example, according to our results,
those patients in the subacute phase of the disease have an
Pérez-Rodríguez et al.
Figure 5. Univariate meta-regression chart of random effects. Each circle represents a study, and the size of the circle reflects the influence of that study
on the model. (A) Gait speed. (B) Timed “Up & Go” Test. (C) Balance. (D) Quality of life physical subscale.
increased ability to improve variables such as gait speed or the
TUG. These results underline the importance of incorporating
physical exercise in ABI disease, especially in the subacute
phase.
This systematic review has highlighted the effectiveness of
specifically designed physical exercise programs for people
with ABI. In this context, this systemac review highlighted
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
In addition, data also showed that the SMDs of the stud-
ied programs were small to moderate in most of the cases,
resulting in the inability to generate potential long-term health
changes in these populations.85 Additional high-quality, ran-
domized controlled trials are urgently needed to investigate
the real effects of exercise programs in individuals with ABI
during rehabilitation phases. In this context, more randomized
controlled trials are also needed comparing not only exercise
9
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versus usual care but also versus different types of interven-
tions. In addition, the measurement of neuromuscular vari-
ables such as rate of force development or central activation
ratio should be analyzed in future studies, because they would
give us more in-depth information on the underlying mech-
anisms that explain the changes in strength and functional
capacity in this population.
Study Limitations
Despite the standardized protocol used to guide and structure
the search strategy, study selection, extraction of data, and
statistical analysis, some limitations of this review should
be noted. First, this review considered populations with all
etiologies of ABI; nevertheless, 26 of the 30 articles selected
post-stroke participants, 2 articles focused on TBI only, and
2 articles focused on ABI (involving different etiologies). For
this reason, 1 of the limitations of the study is not having been
10
able to make a comparison between post stroke and TBI. Sec-
ond, although these meta-analyses demonstrated evidence that
exercise has a positive effect on the studied variables in people
with ABI, there was substantial heterogeneity regarding the
characteristics of individuals (eg, time from impairment onset,
etiology, rehabilitation phase, among others) and type of inter-
ventions, which may limit the application of the findings to the
entire population. On the other hand, another limitation of the
study is the limited inclusion of outcome measures. Addition-
ally, home-based or virtual interventions were not included in
the present study, which could be considered as a limitation
because currently there are exercise programs designed in
those formats for the studied population. On the other hand,
another limitation of the study is the restricted inclusion of
outcome measures, such as the upper limb related variables,
which were not considered. The inclusion of a greater number
of tests and variables would have provided a more global
view of the effects of training in this population. However,
after reviewing the literature, the most used tests were those
included in this study. Moreover, none of the authors indicated
allocation concealment in the studies included in these meta-
analyses; therefore, the possible existence of a high risk of
selection bias cannot be ruled out.
The findings of this review suggest that aerobic and mul-
ticomponent training may increase functional capacity and
QoL of people with ABI. It is hypothesized that the results
of this study may help establish the optimal type of phys-
ical exercise programs to rehabilitate individuals with ABI
and provide reliable evidence for wide application in this
population.
Author Contributions
M.P. and A.G. conceived the idea for the review, and performed the
searches, data extraction, L.A-C participated in methodological quality
assessment, as well as drafted the manuscript; J.Á.R.A. and L.A-C
analyzed the data and critically revised the manuscript content; and J.P.
conceived the idea for the review and critically revised the manuscript
content. All authors approved the final version of the manuscript and
agree with the order of presentation of the authors.
Funding
There are no funders to report for this study.
Ethics Approval
This study does not involve collection of primary data; therefore, ethical
approval was not required.
Systematic Review Registration
This study was preregistered in the International Prospective Register
of Systematic Review (PROSPERO: CRD42020144588).
Disclosures
The authors completed the ICMJE Form for Disclosure of Potential
Conflicts of Interest and reported no conflicts of interest.
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