Lesson 3: Pre-fitness test screening in adults after msTBI

Hello, welcome back to Training Course One.

This is Lesson 3: Pre-Fitness Test Screening in Adults After Moderate to Severe Traumatic Brain Injury.

The learning outcomes for this lesson are to know when to conduct a formal fitness test in this population; to understand why and how to complete a pre-fitness test screening; to guide the choice of fitness testing and training; and to understand the key preparations for conducting a fitness test.

First, we will cover some key terms used within the ACSM guidelines that are referred to in this section. Exercise participation is considered to occur when an individual performs planned, structured physical activity for more than 30 minutes at a moderate intensity, on at least three days per week, for a minimum of three months.

In our setting, if we are seeing someone a year or more after their traumatic brain injury in a community setting, we focus on what they have been doing in the past three months. If this is their initial rehabilitation period after their TBI, particularly in an inpatient setting, then we are interested in their physical activity participation prior to the injury.

Physical activity is classified into light, moderate, and vigorous intensities, each with different percentage ranges. Light intensity is 30–39%, moderate intensity is 40–59%, and vigorous intensity is greater than 60% of training intensity. These classifications also correspond to different ratings of perceived exertion and subjective symptoms. For example, moderate-intensity activity causes a noticeable increase in heart rate and breathing.

A common question is when it is the right time to start formal fitness training after a moderate to severe TBI. There is no clear guidance in the literature beyond the recommendation that training should not begin until the inflammatory process has settled, which is an acute process. By the time someone is admitted to rehabilitation after a severe TBI, they are generally clear to start from this perspective, although this depends on how quickly they reach rehabilitation. In practice, this is likely to be at least two weeks after a severe TBI.

A recent study from Epworth Hospital, led by Sara Gallo, investigated submaximal fitness testing in 138 adults with moderate, severe, and very severe TBI. The study examined whether testing caused concussion-like symptoms or adverse events. Participants were tested less than three months after injury, with the earliest test occurring nine days post-injury. The results showed the testing to be safe and feasible. Only one participant experienced a temporary increase in concussion symptoms, which resolved within an hour, and no adverse events occurred. These findings suggest that early fitness testing and training are safe.

Other important considerations include ensuring that the individual is medically stable, able to follow instructions, and able to actively use large muscle groups to achieve a fitness effect. Different rehabilitation sites may also have specific procedures agreed upon with medical teams, including requirements for medical approval.

Before conducting a fitness test and starting fitness training, pre-fitness test screening is essential to ensure safety and suitability. A pre-fitness test screening sheet has been developed and should be downloaded and adapted in collaboration with the local medical team to suit site-specific requirements.

Consent must be obtained before testing. Pre-injury physical activity history should be collected, focusing on activity participation in the three months before injury. This includes understanding how the individual participated, how important activity was to them, what benefits they experienced, whether they competed, the importance of competition, and who they were active with. This information helps guide fitness training and long-term return to physical activity.

Post-injury screening should assess impairments and injuries, including medical conditions, cognitive, language, or behavioral impairments, orthopedic injuries, and neuromotor impairments. These areas are included in the screening sheet to help determine relevance for fitness testing and training.

Standard screening recommended by the ACSM guidelines should also be completed. This includes a health screening questionnaire to identify signs or symptoms of cardiac conditions, such as chest discomfort during exercise. If signs or symptoms are present, medical clearance is recommended.

Next, current physical activity participation is assessed, using the definition of regular exercise as more than 30 minutes of moderate-intensity activity, three times per week, for at least three months. For individuals in initial inpatient rehabilitation, this should be considered pre-injury. It is also important to document the presence of cardiac, metabolic, diabetes, or renal disease, as these factors determine whether medical clearance is required.

The screening sheet includes a flowchart to assist decision-making. For individuals who did not participate in regular exercise and have no cardiovascular, metabolic, or renal disease and no symptoms, medical clearance is not required, and they can begin with light to moderate activity, progressing gradually. If disease or symptoms are present, medical clearance is recommended.

Individuals who previously engaged in regular exercise and have no disease or symptoms can begin at moderate to vigorous intensity without medical clearance. If they have known disease but are asymptomatic, moderate-intensity activity is permitted without clearance, while clearance is recommended for vigorous activity.

Overall, pre-fitness test screening allows clinicians to determine whether medical clearance or cardiac monitoring is required, whether a peak or submaximal exercise test is appropriate, and what heart rate targets should be used. Peak tests should ideally last eight to twelve minutes to avoid fatigue limiting true peak performance.

Screening information also helps determine the most appropriate test mode, considering impairments and training specificity. For example, treadmill testing may be preferred for someone with walking limitations, while cycling or field tests may be suitable alternatives. Protocols may be standardized or TBI-specific, with further detail provided in the next lesson.
Preparation for fitness testing includes measuring resting heart rate, ideally in the morning after the person has been seated quietly for five minutes, using the average of the last two minutes. Predicted maximum heart rate and target heart rate ranges should be calculated using the Karvonen (heart rate reserve) equation.

For some patients, a familiarization session may be helpful, particularly for treadmill testing. Appropriate clothing and footwear should be worn, patients should be well rested and medically well, and they should be taking their usual medications. Retesting should be conducted under similar conditions to allow meaningful comparison.

This concludes Lesson Three. Please complete the quiz. Thank you.