Original research| Volume 97, ISSUE 9, SUPPLEMENT , S194-S200, September 2016

Download started.


Evaluation of a Physical Activity Behavior Change Program for Individuals With a Brain Injury



      To investigate the effectiveness of a physical activity intervention for use within a comprehensive outpatient rehabilitation program for individuals with brain injury.


      Quasi-experimental comparison group design with 3-month follow-up.


      Comprehensive outpatient rehabilitation clinic that is a transitional setting between acute inpatient rehabilitation and community dwelling.


      Individuals (N=47) with a brain injury were enrolled into either the intervention (n=22; 8 women, 14 men; mean age, 48.68y) or control group (n=25; 9 women, 16 men; mean age, 46.23y).


      Consisted of an 8-week informational and social/behavioral program that focused on enabling individuals to become independently active. The control group completed the standard of care typically available to patients in comprehensive outpatient rehabilitation.

      Main Outcome Measures

      Behavioral Risk Factor Surveillance Survey self-report physical activity items, Exercise Self-Efficacy Scale, and Mayo-Portland Adaptability Inventory-4.


      The intervention group reported significantly (P<.001) greater weekly activity, self-efficacy, and rehabilitation outcomes at the completion of the program as well as at the 3-month follow-up when compared with the control group. Significantly, individuals in the experimental group reported increasing their weekly activity from 45 minutes preprogram to 72 minutes postprogram (d=2.12; 95% confidence interval, 1.78–2.52), and 67 minutes at 3-month follow-up.


      Findings suggest that the intervention may be effective in increasing the physical activity behaviors of individuals engaged in a comprehensive outpatient rehabilitation program after brain injury.


      List of abbreviations:

      CI (confidence interval), MPAI-4 (Mayo-Portland Adaptability Inventory-4), RR (relative risk), TBI (traumatic brain injury)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. Centers for Disease Control and Prevention. Report to Congress 2015– Traumatic Brain Injury–Injury Center. Available at: Accessed April 23, 2015.

        • Bhambhani Y.
        • Rowland G.
        • Farag M.
        Effects of circuit training on body composition and peak cardiorespiratory responses in patients with moderate to severe traumatic brain injury.
        Arch Phys Med Rehabil. 2005; 86: 268-276
        • Mossberg K.A.
        • Orlander E.E.
        • Norcross J.L.
        Cardiorespiratory capacity after weight-supported treadmill training in patients with traumatic brain injury.
        Phys Ther. 2008; 88: 77-87
        • Ada L.
        • Dorsch S.
        • Canning C.G.
        Strengthening interventions increase strength and improve activity after stroke: a systematic review.
        Aust J Physiother. 2006; 52: 241-248
        • Cooke E.V.
        • Mares K.
        • Clark A.
        • Tallis R.C.
        • Pomeroy V.M.
        The effects of increased dose of exercise-based therapies to enhance motor recovery after stroke: a systematic review and meta-analysis.
        BMC Med. 2010; 8: 60-70
        • Driver S.
        • O'Connor J.
        • Lox C.
        • Rees K.
        Evaluation of an aquatics programme on fitness parameters of individuals with a brain injury.
        Brain Inj. 2004; 18: 847-859
        • Grealy M.A.
        • Johnson D.A.
        • Rushton S.K.
        Improving cognitive function after brain injury: the use of exercise and virtual reality.
        Arch Phys Med Rehabil. 1999; 80: 661-667
        • Marzolini S.
        • Oh P.
        • McIlroy W.
        • Brooks D.
        The effects of an aerobic and resistance exercise training program on cognition following stroke.
        Neurorehabil Neural Repair. 2013; 27: 392-402
        • Rand D.
        • Eng J.J.
        • Tang P.F.
        • Hung C.
        • Jeng J.S.
        Daily physical activity and its contribution to the health-related quality of life of ambulatory individuals with chronic stroke.
        Health Qual Life Outcomes. 2010; 8: 80
        • Eng J.J.
        • Reime B.
        Exercise for depressive symptoms in stroke patients: a systematic review and meta-analysis.
        Clin Rehabil. 2014; 28: 731-739
        • Driver S.
        • Ede A.
        Impact of physical activity on mood after TBI.
        Brain Inj. 2009; 23: 203-212
        • Driver S.
        • Rees K.
        • O'Connor J.
        • Lox C.
        Aquatics, health-promoting self-care behaviours and adults with brain injuries.
        Brain Inj. 2006; 20: 133-141
        • Gordon N.F.
        • Gulanick M.
        • Costa F.
        • et al.
        Physical activity and exercise recommendations for stroke survivors.
        Stroke. 2004; 35: 1230-1240
        • Mossberg K.A.
        • Amonette W.E.
        • Masel B.E.
        Endurance training and cardiorespiratory conditioning after traumatic brain injury.
        J Head Trauma Rehabil. 2010; 25: 173-183
        • Haskell W.L.
        • Lee I.
        • Pate R.R.
        • et al.
        Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association.
        Med Sci Sports Exerc. 2007; 39: 1423-1434
        • Driver S.
        • Ede A.
        • Dodd Z.
        • Stevens L.
        • Warren A.
        What barriers to physical activity do individuals with a recent brain injury face?.
        Disabil Health J. 2012; 5: 117-125
        • Driver S.
        Development of a conceptual model to predict physical activity participation in adults with brain injuries.
        Adapt Phys Activ Q. 2008; 25: 289-307
        • Driver S.
        What barriers to physical activity do outpatients with a traumatic brain injury face?.
        J Cogn Rehabil. 2009; 33: 4-10
        • De Wit L.
        • Putman K.
        • Dejaeger E.
        • et al.
        Use of time by stroke patients: a comparison of four European rehabilitation centers.
        Stroke. 2005; 36: 1977-1983
        • Alzahrani M.A.
        • Ada L.
        • Dean C.M.
        Duration of physical activity is normal but frequency is reduced after stroke: an observational study.
        J Physiother. 2011; 57: 47-51
        • Billinger S.A.
        • Arena R.
        • Bernhardt J.
        • et al.
        Physical activity and exercise recommendations for stroke survivors: a statement for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2014; 45: 2532-2553
        • Damush T.M.
        • Plue L.
        • Bakas T.
        • Schmid A.
        • Williams L.S.
        Barriers and facilitators to exercise among stroke survivors.
        Rehabil Nurs. 2007; 32: 253-262
        • Rimmer J.H.
        • Wang E.
        • Smith D.
        Barriers associated with exercise and community access for individuals with stroke.
        J Rehabil Res Dev. 2008; 45: 315-322
        • Billinger S.A.
        • Coughenour E.
        • MacKay-Lyons M.
        • Ivey F.M.
        Reduced cardiorespiratory fitness after stroke: biological consequences and exercise-induced adaptations.
        Stroke Res Treat. 2012; : 1-11
        • Mossberg K.A.
        • Ayala D.
        • Baker T.
        • Heard J.
        • Masel B.
        Aerobic capacity after traumatic brain injury: comparison with a nondisabled cohort.
        Arch Phys Med Rehabil. 2007; 88: 315-320
        • Prajapati S.K.
        • Mansfield A.
        • Gage W.H.
        • Brooks D.
        • McIlroy W.E.
        Cardiovascular responses associated with daily walking in subacute stroke.
        Stroke Res Treat. 2013; : 1-7
        • Rimmer J.H.
        • Rowland J.L.
        Health promotion for people with disabilities: implications for empowering the person and promoting disability-friendly environments.
        Am J Lifestyle Med. 2008; 2: 409-420
        • McDermott S.
        • Moran R.
        • Platt T.
        • Isaac T.
        • Wood H.
        • Dasari S.
        Risk for onset of health conditions among community-living adults with spinal cord and traumatic brain injuries.
        Prim Health Care Res Dev. 2007; 8: 36-43
        • Selassie A.W.
        • Cao Y.
        • Church E.C.
        • Saunders L.L.
        • Krause J.
        Accelerated death rate in population-based cohort of persons with traumatic brain injury.
        J Head Trauma Rehabil. 2014; 29: E8-E19
        • Kumar S.
        • Selim M.H.
        • Caplan L.R.
        Medical complications after stroke.
        Lancet Neurol. 2010; 9: 105-118
        • Davenport R.J.
        • Dennis M.S.
        • Wellwood I.
        • Warlow C.P.
        Complications after acute stroke.
        Stroke. 1996; 27: 415-420
        • Meschia J.
        • Bruno A.
        Post-stroke complications.
        CNS Drugs. 1998; 9: 357-370
        • Go A.S.
        • Mozaffarian D.
        • Roger V.L.
        • et al.
        Executive summary: heart disease and stroke statistics—2014 update: a report from the American Heart Association.
        Circulation. 2014; 129: 399-410
        • Driver S.
        • Irwin K.
        • Woolsey A.
        • Pawlowski J.
        Creating an effective physical activity-based health promotion programme for adults with a brain injury.
        Brain Inj. 2012; 26: 1482-1492
        • Driver S.
        • Irwin K.
        • Woolsey A.
        • Warren A.M.
        Piloting a physical activity centred education programme for adults with a brain injury.
        Brain Inj. 2013; 27: 1173-1180
        • Pawlowski J.
        • Dixon-Ibarra A.
        • Driver S.
        Review of the status of physical activity research for individuals with traumatic brain injury.
        Arch Phys Med Rehabil. 2013; 94: 1184-1189
        • Cleveland S.
        • Driver S.
        • Swank C.
        • Shearin S.
        Classifying physical activity research following stroke using the behavioral epidemiologic framework.
        Top Stroke Rehabil. 2015; 22: 289-298
      2. Glenn M. The Apathy Evaluation Scale. The Center for Outcome Measurement in Brain Injury. Available at: Accessed April 23, 2015.

      3. Sherer M. The Awareness Questionnaire. The Center for Outcome Measurement in Brain Injury. Available at: Accessed April 23, 2015.

        • Benedict R.H.
        • Schretlen D.
        • Groninger L.
        • et al.
        Hopkins Verbal Learning Test–Revised.
        Clin Neuropsychol. 1998; 12: 43-55
      4. Reitan R.M. Wolfson D. The Halstead-Reitan Neuropsychological Test Battery: theory and clinical interpretation. 2nd ed. Neuropsychology Pr, Tucson1993
        • Jackson W.T.
        • Novack T.A.
        • Dowler R.N.
        Effective serial measurement of cognitive orientation in rehabilitation: the Orientation Log.
        Arch Phys Med Rehabil. 1998; 79: 718-720
      5. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance Survey—questionnaires. Available at: Accessed April 23, 2015.

        • Brown W.J.
        • Trost S.G.
        • Bauman A.
        • Mummery K.
        • Owen N.
        Test-retest reliability of four physical activity measures used in population surveys.
        J Sci Med Sport. 2004; 7: 205-215
        • Marcus B.H.
        • Selby V.C.
        • Niaura R.S.
        • Rossi J.S.
        Self-efficacy and the stages of exercise behavior change.
        Res Q Exerc Sport. 1992; 63: 60-66
        • Kean J.
        • Malec J.F.
        • Altman I.M.
        • Swick S.
        Rasch measurement analysis of the Mayo-Portland Adaptability Inventory (MPAI-4) in a community-based rehabilitation sample.
        J Neurotrauma. 2011; 28: 745-753
        • Bohac D.L.
        • Malec J.F.
        • Moessner A.M.
        Factor analysis of the Mayo-Portland Adaptability Inventory: structure and validity.
        Brain Inj. 1997; 11: 469-482
        • Maas A.I.
        • Steyerberg E.W.
        • Marmarou A.
        • et al.
        IMPACT recommendations for improving the design and analysis of clinical trials in moderate to severe traumatic brain injury.
        Neurotherapeutics. 2010; 7: 127-134
        • Craig L.E.
        • Wu O.
        • Bernhardt J.
        • Langhorne P.
        Predictors of poststroke mobility: systematic review.
        Int J Stroke. 2011; 6: 321-327
        • Sheffler L.R.
        • Knutson J.S.
        • Gunzler D.
        • Chae J.
        Relationship between body mass index and rehabilitation outcomes in chronic stroke.
        Am J Phys Med Rehabil. 2012; 91: 951-956
        • Lohse K.R.
        • Lang C.E.
        • Boyd L.A.
        Is more better? Using metadata to explore dose-response relationships in stroke rehabilitation.
        Stroke. 2014; 45: 2053-2058
        • Yang S.Y.
        • Kong K.H.
        Level and predictors of participation in patients with stroke undergoing inpatient rehabilitation.
        Singapore Med J. 2013; 54: 564-568
        • Wise E.K.
        • Hoffman J.M.
        • Powell J.M.
        • Bombardier C.H.
        • Bell K.R.
        Benefits of exercise maintenance after traumatic brain injury.
        Arch Phys Med Rehabil. 2012; 93: 1319-1323
        • Bellon K.
        • Kolakowsky-Hayner S.
        • Wright J.
        • et al.
        A home-based walking study to ameliorate perceived stress and depressive symptoms in people with a traumatic brain injury.
        Brain Inj. 2015; 29: 313-319
        • Mitchell E.J.
        • Veitch C.
        • Passey M.
        Efficacy of leisure intervention groups in rehabilitation of people with an acquired brain injury.
        Disabil Rehabil. 2014; 36: 1474-1482
        • Schwandt M.
        • Harris J.E.
        • Thomas S.
        • Keightley M.
        • Snaiderman A.
        • Colantonio A.
        Feasibility and effect of aerobic exercise for lowering depressive symptoms among individuals with traumatic brain injury: a pilot study.
        J Head Trauma Rehabil. 2012; 27: 99-103
        • Martelli M.F.
        • Zasler N.D.
        • Tiernan P.
        Community based rehabilitation: special issues.
        NeuroRehabilitation. 2012; 31: 3-18
        • Archer T.
        • Svensson K.
        • Alricsson M.
        Physical exercise ameliorates deficits induced by traumatic brain injury.
        Acta Neurol Scand. 2012; 125: 293-302
        • Haworth J.
        • Young C.
        • Thornton E.
        The effects of an 'exercise and education' programme on exercise self-efficacy and levels of independent activity in adults with acquired neurological pathologies: an exploratory, randomized study.
        Clin Rehabil. 2009; 23: 371-383
        • Reuter T.
        • Ziegelmann J.P.
        • Wiedemann A.U.
        • et al.
        Changes in intentions, planning, and self-efficacy predict changes in behaviors.
        J Health Psychol. 2010; 15: 935-947
        • Bandura A.
        Social foundations of thought and action: a social cognitive theory.
        Prentice-Hall, Englewood Cliffs1986
        • Altman I.M.
        • Swick S.
        • Parrot D.
        • Malec J.F.
        Effectiveness of community-based rehabilitation after traumatic brain injury for 489 program completers compared with those precipitously discharged.
        Arch Phys Med Rehabil. 2010; 91: 1697-1704
        • Brown M.
        • Gordon W.A.
        • Spielman L.
        Participation in social and recreational activity in the community by individuals with traumatic brain injury.
        Rehabil Psychol. 2003; 48: 266-274
        • Davies Hallett J.
        • Zasler N.D.
        • Maurer P.
        • Cash S.
        Role change after traumatic brain injury in adults.
        Am J Occup Ther. 1994; 48: 241-246
        • Sloan S.
        • Winkler D.
        • Anson K.
        Long-term outcome following traumatic brain injury.
        Brain Impair. 2007; 8: 251-261
        • Winkler D.
        • Unsworth C.
        • Sloan S.
        Time use following a severe traumatic brain injury.
        J Occup Sci. 2005; 12: 69-81
        • Huebner R.A.
        • Johnson K.
        • Bennett C.M.
        • Schneck C.
        Community participation and quality of life outcomes after adult traumatic brain injury.
        Am J Occup Ther. 2003; 57: 177-185
        • Dunton G.F.
        • Atienza A.A.
        • Castro C.M.
        • King A.C.
        Using ecological momentary assessment to examine antecedents and correlates of physical activity bouts in adults age 50+ years: a pilot study.
        Ann Behav Med. 2009; 38: 249-255
        • Dunton G.F.
        • Dzubur E.
        • Kawabata K.
        • Yanez B.
        • Bo B.
        • Intille S.
        Development of a smartphone application to measure physical activity using sensor-assisted self-report.
        Front Public Health. 2014; 2: 12
        • Dunton G.F.
        • Liao Y.
        • Kawabata K.
        • Intille S.
        Momentary assessment of adults' physical activity and sedentary behavior: feasibility and validity.
        Front Psychol. 2012; 3: 260
        • Heron K.E.
        • Smyth J.M.
        Ecological momentary interventions: incorporating mobile technology into psychosocial and health behaviour treatments.
        Br J Health Psychol. 2010; 15: 1-39
        • Liao Y.
        • Intille S.S.
        • Dunton G.F.
        Using ecological momentary assessment to understand where and with whom adults' physical and sedentary activity occur.
        Int J Behav Med. 2015; 22: 51-61
        • Marszalek J.
        • Morgulec-Adamowicz N.
        • Rutkowska I.
        • Kosmol A.
        Using ecological momentary assessment to evaluate current physical activity.
        Biomed Res Int. 2014; 2014: 915172
        • Godwin M.
        • Ruhland L.
        • Casson I.
        • et al.
        Pragmatic controlled clinical trials in primary care: the struggle between external and internal validity.
        BMC Med Res Methodol. 2003; 3: 28