Hello, welcome back to Training Course One. This is Lesson Six, the final lesson, focused on prescribing fitness training.
The learning objectives for this lesson are to understand how to use fitness test results to develop FITT training parameters, and to understand additional considerations when designing a fitness training program for adults with moderate to severe traumatic brain injury.
The FITT parameters refer to frequency, intensity, time, and type (or mode) of exercise. The recommendations presented here are based on the American College of Sports Medicine guidelines specific to stroke and traumatic brain injury. Although these guidelines are older, they remain clearer and more applicable to people with moderate to severe TBI than more recent guidelines, which tend to focus primarily on mild TBI or concussion.
The recommended exercise frequency is three to five sessions per week. Exercise intensity should range between 40% and 85% of heart rate reserve using the heart rate reserve method. This intensity range is equivalent to approximately 40% to 70% of VO₂ peak or a rating of perceived exertion of around 13 on the Borg 6–20 scale. Session duration should range from 20 to 60 minutes, progressing from intermittent to continuous exercise as tolerance improves.
Energy expenditure is another useful way to prescribe exercise, as it combines intensity and time. The target is at least 300 kilocalories per session. This can be achieved through lower-intensity, longer-duration exercise or higher-intensity, shorter-duration exercise. Intensity and time can therefore be adjusted to suit an individual’s abilities and tolerance.
The final FITT parameter is type of exercise. Ideally, exercise should use large muscle groups in a rhythmical and continuous manner. It is important to consider the person’s exercise history and preferences, as selecting activities they previously enjoyed may improve engagement. Exercise specificity is also important, as fitness improvements tend to occur in the mode of exercise being trained.
For example, if a patient is still in rehabilitation and working to improve walking ability, treadmill-based fitness training may be a good option. This allows improvements in cardiovascular fitness to translate more directly into functional walking improvements. There are many possible exercise modes that involve large muscle groups, including those shown in the examples provided.
Another useful option is circuit-based training. Circuit classes can improve mobility and provide increased practice dosage during rehabilitation, while also delivering a fitness training stimulus. This approach was investigated in a study conducted at Liverpool Hospital’s brain injury unit in Sydney, where circuit classes were run three times per week.
In that study, 53 participants with severe TBI, predominantly males in their mid-30s, participated in the circuit class. Heart rate monitoring showed that participants spent only about 12 minutes of a 52‑minute class working above 50% of heart rate reserve. The mean heart rate during the class was 121 beats per minute, equivalent to approximately 37% of heart rate reserve—slightly below the recommended 40% threshold.
However, total energy expenditure exceeded the ACSM-recommended 300 kilocalories per session. This was achieved through low-intensity, long-duration continuous exercise, as participants moved continuously between stations without rest. This demonstrates that circuit classes may provide both rehabilitative practice and a meaningful fitness stimulus in inpatient settings.
Using fitness test results to prescribe exercise involves several steps. The first is to calculate the target training heart rate zone using the Karvonen equation, or heart rate reserve method. The recommended range of 40% to 85% heart rate reserve can be adjusted according to individual tolerance and clinical judgment.
The next step is to identify the exercise parameters from the fitness test that correspond to the target heart rate range. For example, using a treadmill test, 40% heart rate reserve may correspond to a heart rate of 137 beats per minute. Reviewing test data may show that this intensity is achieved when walking at 6.5 km/h with a 5% incline.
Similarly, 85% heart rate reserve may correspond to a heart rate of approximately 185 beats per minute, which may occur at a speed of 7.5 km/h and a 15% incline later in the test. These data help define the training prescription, such as treadmill speeds between 6.5 and 7.5 km/h, inclines between 5% and 15%, and durations of at least 20 minutes.
Exercise duration can be adjusted depending on intensity. Lower-intensity sessions should generally be longer, while higher-intensity sessions may be shorter. Interval training may be needed initially, alternating between higher and lower intensities, before progressing toward continuous training. Wearing a heart rate monitor during training is essential, as it allows clinicians to confirm whether the person is working within their prescribed training zone and to adjust parameters accordingly.
Several core principles of fitness training should be considered. Overload is necessary to promote physiological adaptation, meaning the person must be challenged sufficiently. With repeated training over time, this leads to measurable adaptations such as increased muscle mass and cardiac structural changes.
Progression is a critical principle. Training parameters must be regularly adjusted to maintain overload as fitness improves. In inpatient settings, progression may be required every few days rather than every few weeks. Heart rate monitoring helps identify when an individual is no longer working within their training zone, indicating a need to increase intensity, duration, or frequency.
Specificity of training reinforces the importance of matching the exercise mode to the desired outcome. Recovery is equally important. High-intensity sessions should be followed by appropriate rest or lighter sessions. Overtraining can reduce capacity and increase the risk of injury, while insufficient training frequency can lead to detraining. A frequency of three to five sessions per week generally balances training and recovery well.
Individual responsiveness must always be considered. Clinicians should ask how the person feels after each session and the following day, adjusting the program based on fatigue, soreness, or reduced tolerance.
Several special considerations apply to individuals with TBI. Physical, cognitive, and behavioral impairments should guide the choice of exercise. For those with cognitive or behavioral impairments, externally paced exercise may be helpful. If the goal is to improve walking and the individual can ambulate, treadmill training may be preferable to cycling.
Orthopedic injuries require close collaboration with the medical team. Individuals recovering from fractures may not tolerate impact or jolting forces, such as running, until healing is complete. Seizure risk should also be considered. Fitness training is generally safe, but it is important to ensure medications are taken as prescribed and that the individual is well on the day of training.
For individuals who have undergone a craniotomy, medical clearance is essential. Some individuals may need to wear a helmet or avoid high-impact activities until the skull defect is repaired. Medications such as beta blockers can also affect heart rate responses and must be considered when interpreting training intensity.
Finally, broader considerations include ensuring appropriate assessment, screening, medical clearance, exercise testing, and goal setting before starting a training program. The setting and environment should be chosen based on the individual’s impairments and preferences, whether at home, in hospital rehabilitation, or in the community.
Supervision requirements should be carefully considered. Some individuals may train independently, while others may require one-on-one or supervised support from a physiotherapist, family member, support worker, or personal trainer. Supervision may be needed for safety or to ensure training intensity is appropriate.
Adherence is often the greatest challenge. Selecting enjoyable activities, supportive environments, and appropriate supervision helps build self-efficacy and long-term engagement. Understanding barriers and facilitators is essential, and it may take several attempts to identify the best combination of exercise type, setting, and support.
Monitoring during training is crucial. Ratings of perceived exertion are useful, but heart rate monitoring provides objective data to guide progression or regression of training parameters. This ensures ongoing improvement in fitness while maintaining safety.
This concludes Lesson Six. Please complete the final quiz, then proceed to Module Three, which includes post-course learning materials, case studies, and a final course quiz. Thank you.
- National Assistance Card
- Kai’s Story
- Fred’s Story
- Technical report (pages 25-60)
- Compendium of Physical Activities
Garber CE, Blissmer B, Deschenes MR, et al. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334-59. https://doi.org/10.1249/MSS.0b013e318213fefb.
Hassett LM, Moseley AM, Whiteside B, Barry S, Jones T. Circuit class therapy can provide a fitness training stimulus for adults with severe traumatic brain injury: a randomised trial within an observational study. J Physiother. 2012;58(2):105-12. https://doi.org/10.1016/s1836-9553(12)70090-5.
Ozemek C, Bonikowske A, Christle J, Gallo P. ACSM’s Guidelines for Exercise Testing and Prescription (12th Edition). Baltimore: Walters Kluwer, 2025. ISBN: 978-1-9752-1920-8.
Palmer-McLean K, Harbst K. Stroke and brain injury (chapter 38). In: Durstine J, Moore G, Painter PL, et al., eds. ACSM’s Exercise Management For Persons With Chronic Diseases and Disabilities (3rd Edition). Champaign IL: Human Kinetics, 2009:287-97. ISBN: 0736074333.