- Possible Medications and the Implications for Exercise
- Facilitators to Participation (Inclusive TIMES)
- ACSM Guidelines
- Key Questions to Ask the Client
- Further information
ABI is damage to the brain, occurring any time after birth. The injury can be traumatic (eg from a blow to the head) or non-traumatic (at the cellular level from seizure, stroke, multiple sclerosis, Parkinson’s disease, tumour, poisoning etc).
The brain is the control centre of the nervous system and different parts of the brain control the various voluntary and involuntary systems, senses and movements. This means that the effects vary depending on the affected part of the brain. There is still a lot to be learned about ABI and how to manage the symptoms, which can be complex. Knowing what part of the brain has been damaged and how (traumatic or non-traumatic) will help guide your research in informing you of the likely symptoms experienced by the client (see image 1). The client will also be able to tell you in collaboration with their allied professionals and support team. Here are some possible symptoms to give you an idea of what to look for:
- Cognitive/thinking – concentration/attention, planning ability, problem solving and/or memory;
- Physical – paralysis, balance, coordination or limb weakness;
- Communication – ability to speak clearly or quickly;
- Sensory – impaired sight, touch, smell, taste or body temperature control; and
- Behaviour – easily fatigued, lack of control over behaviour, impulsivity, initiative, motivation, mood changes and lack of acceptable social restraint (which can have social consequences)
- Social – difficulty creating and maintaining close relationships
If the cause was traumatic the client will very likely experience some or all of the following: muscle wastage (atrophy) and an increase in fat between the muscles (intramuscular); and the muscle fibres will change from oxidative to non-oxidative becoming resistant to insulin. These can lead to high blood pressure (hypertension), high cholesterol (dyslipidemia), diabetes type II; coronary heart disease (CHD) and/or hormone problems (ACSM, 2016). These clients may also experience exaggerated involuntary reflexes to sudden noises or other stimuli (startle response) and an inability to automatically adjust heart-rate in response to exercise, especially isometric contractions (pressor-chronotropic response).
Implications for Exercise #
Because of the variation of the injury and the associated impact and symptoms, collaboration with the individual and allied professionals is especially important during consultation to inform the client’s exercise session plan. For example, fitness goals could be rehabilitative of a body part or function, or for general health benefits.
Immediately following brain injury the brain will be inflamed. The client will require physical and cognitive rest until the inflammation has reduced significantly and a physician has given the client the green light to exercise.
Exercise has been shown to enhance memory, attention and cognitive recovery, and positively impact individuals experiencing depression. Some clients with ABI can safely participate in exercise, including cardio-vascular endurance training and muscular resistance training at the same regularity and intensity as people without ABI (see ACSM guidelines). For others it is recommended that they start with lighter intensities for example a pace that is comfortable for them with the aim of gradually progressing to moderate intensity activities. These will include clients with recent brain injuries who have been given the go-ahead to exercise from their rehabilitation specialist; are beginners to exercise; or have other conditions that may have implications for exercise (eg. CHD).
Clients with ABI will generally have a lower capacity for exercise than the general population, mostly due to the lack of exercise following their injury. For example, their submaximal heart rate is generally lower; they tend to breather more heavily during exertion (aerobic capacity is reduced by 67% – 74%); and they fatigue 2.5 times more quickly. Most clients with ABI will benefit from a fitness programme that develops physical functions (neuro-motor function) and balance. For example, walking lunges, sit-to-stand, squats (progress on a wobble board, one-legged – with eyes open, eyes closed, arms overhead).
Note: Clients with ABI (and any other CNS injury) generally have a greater risk of CHD mostly due to inactivity following their injury, if this is the case, see UFIT Explorer: Coronary Heart Disease for guidelines.
It is common for clients with ABI to experience spasticity (causing stiff and tight muscles and possibly jerky movements) as both are caused by impairments to the central nervous system (brain and spinal cord). If the client is taking medication for this, see the notes below. Normally muscles work in pairs (agonist-antagonist pairs), when one muscle is contracted the opposing muscle is relaxed. When a client has spasticity, this balance is disrupted and certain muscles become tight, usually the muscles of the arms and legs, causing pain, reduced range of motion, contractures and/or reduced walking capacity. Spasticity is individual and can range from mild to severe. Clients with more severe spasticity will require more energy for movement and activities and so may fatigue more easily.
Exercising in water (hydrotherapy (30-35°C/98-95°F) is very beneficial for clients with spasticity and has been shown to reduce the need for medication as the properties of water reduce spasticity by helping the muscles to relax. If a client also experiences seizures and/or the startle reflex it is important that they are always under supervision while in the pool and that they learn to recognise the triggers, becoming aware of when a seizure is likely to occur.
Note: If a client has a seizure they should not swim or engage in water sports that day even if they seem to have recovered. If a client experiences a seizure in the water, support their head until the seizure has passed to ensure they do not ingest water, while alerting the lifeguard.
Brain injury is the primary cause of seizures in adults (ACSM, 2016). Approximately 30% of people with ABI experience seizures, 80% of the time within 2 years of the injury. Seizures are thought to be caused by abnormal electrical brain activity. There are different types of seizures outlined in table 1, see UFIT Explorer Epilepsy if your client has been diagnosed as having epilepsy. If your client experiences a there are steps you can take to support them safely and to protect them from injuring themselves.
*Take a note of the time the seizure started and:
1. If they are unconscious:
- Allow the person to jerk/convulse without restraint
- If they have a seizure in the water, support their head until the seizure has passed to ensure they do not ingest water
- If they are on the ground, cushion their head
- Place them in the recovery position once the seizure has finished and allow them to come around in their own time, staying with them until they have fully recovered
- Explain to them what happened
2. If they are conscious:
- Guide them away from danger and allow them to come around in their own time, staying with them until they have fully recovered
- Explain to them what happened
3. If they are in a wheelchair:
- Allow the person to remain in the chair and support them gently so that they do not fall out and to ensure they do not damage their head (eg place a cushion or rolled jacket behind their head)
- Put the brakes on
4. Call an ambulance if:
- It is their first seizure
- If the seizure lasts more than 5 minutes*
|Table 1 Types of Seizures|
|Primary Generalised Seizures||Grand-mal or tonic-clonic seizures
|The individual loses consciousness for up to a minute, followed by uncontrollable jerking for up to a minute after which the individual will often go into a deep sleep.|
|Absence seizures||A short loss of consciousness. Individual may stare blankly and not even realise they have had a seizure|
|Myoclonic seizures||People often compare theses seizures to electric shocks that cause sporadic jerks often on both sides of the body|
|Clonic seizures||Affect both sides of the body and consist of repetitive rhythmic jerks|
|Tonic seizures||Cause muscle stiffness|
|Atonic seizures||Causes a sudden loss of muscle tone (mostly in the arms and legs) which often causes the individual to fall.|
(produced by a small part of brain)
|Client maintains awareness||Simple Motor||Causes jerking, spasms, muscle rigidity and head turning|
|Simple Sensory||Causes unusual sensations which can affect vision, hearing, smell, touch and/or taste|
|Simple Psychological||Causes memory lapse or emotional turmoil|
|Client loses awareness||Complex||Causes involuntary movements like lip smacking, fidgeting etc|
|Partial with Secondary Generalisation||The individual may initially be conscious and then loses consciousness and may experience convulsions|
As already mentioned, lower intensity endurance aerobic training is best for most clients with ABI. In particular for clients with chronic heart failure it is most beneficial for improving their physical functioning. The client will most likely be working with other allied professionals, it is ideal for you as the fitness professional to work in collaboration with this team or professional. The client should start on a light-intensity walking programme where you (the fitness professional) observe their exercise responses and support them in learning to observe these responses also.
Dietary Considerations #
Protein is especially important for clients with neurological impairments and should be consumed within 20 minutes of exercising. 3g carbohydrates to 1 g protein can reduce muscle injury and improve adaptive response (amino acid uptake by muscle) (ACSM, 2016, pg 246).
Clients who experienced a traumatic brain injury are more likely to develop Coronary Heart Disease (CHD) and so would benefit greatly from adopting health-enhancing lifestyle choices for example, working towards reaching the recommended amount of physical activity; transforming their diet (see Harvard’s Healthy Eating Pyramid and Healthy Eating Plate). They may also be prescribed medication to return their functioning to optimal which may have implications for exercise (see medications in UFIT Explorer: Coronary Heart Disease).
Possible Medications and the Implications for Exercise #
Prescribed medication can vary greatly depending on the cause of the brain injury and is most likely to be prescribed to prevent the cause from recurring. Once you have identified the cause of the client’s injury, please see the associated condition for guidelines that will support you both in designing a safe and effective fitness programme for the client. For example, a client whose injury is due to stroke may be on medication for high blood pressure, or to prevent blood clots.
There are many medications prescribed for spasticity and they each work in different ways and have varying side effects. They can be oral or in the form of intra-muscular injections. Some clients may choose more complementary or alternative methods for example, hydrotherapy, biofeedback, surgery etc.
Baclofen is an oral prescription that works within the spinal cord by depressing the nervous system, relaxing the muscles. It has many frequent adverse side-effects like fatigue, muscle weakness (especially in non-affected muscles), loss of muscle tone. Large doses are required yet is frequently used as its tolerance remains constant meaning increased dosages are not required over time and typically doesn’t cause sedation (only fatigue). Suddenly stopping this prescription can cause hallucinations, psychoses and/or seizures. Because the client may fatigue easily, short and frequent duration activities with plenty of rest periods are ideal.
Tizanidine (often known as Zanaflex) is another oral prescription that relaxes muscle spasms and tightened muscles. Common side effects include sedation and a dry mouth, however this prescription does not cause muscle weakness.
Diazepam (often known as Valium) is also prescribed for spasticity at bed-time as it frequently causes drowsiness, unsteadiness and short-term memory issues. It can also be addictive and require increased dosages over time yet is often prescribed as the effects last longer than other medications.
Intramuscular Injections (Botulinum toxin or Botox) are sometimes used when individuals experience pain and/or impairments in functioning. Botox is injected directly into the affected muscles block the nerve impulses that tell the muscles to contract, relieving spasticity. It can take up to a month to take full effect, lasting up to three months. Only the injected muscles are affected and side-effects are minimal (discomfort at the injection site). Clients who have been injected with Botox should be encouraged to start on lighter intensities until they become familiar with their body’s response to both the Botox and physical exercise.
Anticonvulsants are prescribed to prevent the rapid firing of neurons that trigger a seizure. They can prevent the spread of a seizure and prevent damage to the brain. Different medications are prescribed for the various types of seizures. Common anticonvulsants for grand-mal seizures include: valproic acid (often known as Depakene or Depakote), topiramate (often known as Topamax) and lamotrigine (often known as Lamictal). For partial seizures common medications include: carbamazepine (often known as Tegretol), phenytoin (known as Dilantin) and Oxcarbazepine (known as Trileptal).
Most anticonvulsant medication causes some drowsiness or dizziness and can trigger depression and suicidal thoughts. Because there are so many medications, each with various potential side-effects it is best to ask the client to bring their medication information with them and to explore with the client the side-effects that they experience. There may be implications relating to fatigue, the time of day the client exercises, hydration etc.
Weight loss of 4.5 kg (10lbs) can increase the risk of side effects due to the increased bioavailability of the medication. A review of the client’s prescription is recommended in this case.
Facilitators to Participation (Inclusive TIMES) #
Facilitators will vary greatly, depending on the client’s particular circumstances. Clients with minor ABI may not need any more facilitators than someone without ABI, while a client with a more severe impairment may need adaptations across all elements of the inclusive TIMES model. This is where a client-centred approach and collaboration with allied professionals is key.
If a client has been affected cognitively they may require assistance with remembering their appointments (a text reminder the day and hour before), transport and personal-care which may be time and support considerations.
The client may fatigue easily so shorter sessions &/ regular rest periods may be ideal (Plan for breaks in activities).
Regular and consistent routines are often supportive for clients for example, the same time and days each week.
Each client will be individual, yet most clients with severe symptoms will benefit from starting with shorter duration and lower intensity activities, progressing gradually to moderate intensity.
Cool-down should always be long and gradual to allow the client’s blood pressure to return to normal and to prevent blood pooling in the legs. Especially if they are taking ACE inhibitors and/or diuretics for hypertension. (5-10mins low intensity aerobic activity and stretch)
In warm climates the client should exercise at cooler times of the day
- To support the client in maintaining an appropriate blood pressure rate.
- Especially if the client is taking statins to avoid ER (exertional rhabbdomyolysis)
Cognitive effects will be supported by patient, clear, simple instruction in more than one format (eg verbal and visual) Break complicated activities into three simple segments while providing plenty of visual cues and time to practice each segment before moving on to the next one.
Do not pretend to understand if you do not.
It may help to write down the sequence of an activity or have visual cue cards ready.
For memory impairments photos can be supportive to recall and write down events.
Create a lanyard with images of each activity.
Plan for lack of motivation that may sometimes be evident, remember that establishing a regular routine is the initial priority.
Discuss why some behaviour is inappropriate, provide clear consequences of misbehaviour and be consistent and clear.
Time out is an effective strategy that allows them to think about their behaviour
If you can get to know something about the participant prior to the start of the programme this will help build rapport which will encourage participation and help you get to know what they like or dislike.
All clients should be encouraged to become familiar with the RPE Scale, teaching them to learn their body’s response to various intensities so that they can learn to know what intensity is appropriate for the body on any given day.
Deconditioned clients should start with lighter intensities (see training guidelines)
A slow warm-up can assist clients with spasticity as this increases the blood flow allowing the muscles to soften.
It is ideal for you as the fitness professional and the client to keep a diary of neurological symptoms triggered by exercise. This will help guide exercise intensity and identify other triggers. This could be attached to the client’s fitness programme/session plan.
If light intensity exercise triggers or worsens the client’s neurological symptoms; if the client has a high risk of cardiopulmonary decompensation during lighter intensities (eg. 50% of heart rate reserve), for example their heart rate and blood pressure don’t adjust to exercise; or if they experience pain or autonomic dysfunction stop exercising immediately and wait until the client receives clearance from their doctor or rehabilitation team (allied professionals) before exercising further. Note the intensity at which the client was exercising and work below this threshold once they have clearance and until the client’s endurance increases.
The client should always breathe consistently throughout all activities, in particular resistance training – throughout the entire range of motion, as holding the breath raises blood pressure considerably.
Clients with affected limbs eg reduced arm function and range of motion in those who experienced a stroke, benefit from repetitive, functional movement (or shaping) of the affected limb to create new neural pathways in the brain while limiting the use of the non-affected limb during that activity.
Most clients with ABI will benefit from a fitness programme that develops neuromotor function and balance. For example, sit-to-stand exercises, walking lunges, work on a wobble board, one-legged squats; with eyes open, closed, arm over-head etc. The client may feel anxious about activities that require balance (cycling, surfing, skate-boarding etc.) so improving their balance and proprioception (sense of self-movement in relation to the environment) will build their self-efficacy in relation to balance.
It is important that the client feels safe and supported in their fitness programme. This environment of safety and trust can be supported by working with allied professionals (eg. A member of their rehabilitation team; their physician or direct support staff) to reassure the client that their programme is safe.
Some clients with ABI may benefit from safety equipment to prevent falls for example, wearing a safety harness while on the treadmill, additional hand-rails by equipment etc
It is important that the client exercises in a well-ventilated space as high temperatures and humidity can increase blood pressure, especially affecting those with thermoregulation impairments.
Seats for resting should be available for clients who need regular rest periods.
If a client needs assistance with personal care and toileting and is taking diuretics (which increase urination), they should be encouraged to use the toilet before exercising to ensure that their exercise session doesn’t have to be interrupted by a bathroom break.
Bring the client on a tour of the facility and provide a basic map.
If the client’s verbal communication has been affected they may use another form of communication, for example picto-charts, a communication device or equipment, or a personalised system that may be known by their family, friends and support staff.
If the client is new to a fitness environment, as with any client they will most likely benefit more using resistance machines as opposed to free weights to assist them in learning correct form.
Protective headgear should be worn during activities that have a high risk of damage to the head to prevent further brain damage.
A quiet environment might suit some individuals if distractions within the environment affect concentration or anxiety levels or if a client has an exaggerated startle response.
The client may use assistive technology for ambulation for example, a walking cane; a quad cane; a walker; a wheelchair etc)
Again the level of support required will depend on the effects of the injury and will be client specific. Some clients may have support staff or family members or use assistive technology, others may not require such support. This will be clarified in consultation.
Working with rehabilitation team (allied professionals) is beneficial as neuromotor gains can be assessed before and during the programme. Ideally there will be no ‘after programme’ as a sustained programme will reap greater health benefits for the client.
If the client has or is at risk of CHD, work closely with their rehabilitation staff or physician/ general practitioner, especially in the beginning to ensure that the client is exercising at an appropriate and safe intensity (see also UFIT Explorer: Coronary Heart Disease for more details).
Be aware that clients may also have undiagnosed cardiometabolic conditions (eg. diabetes) for example, a client with hypertension may also have undiagnosed for example, diabetes or kidney disease etc. Some possible signs and symptoms include frequent thirst and hunger, frequent urination, unexplained weight loss, fatigue, blurred vision.
Social support is very important for promoting a healthy lifestyle after ABI.
If a client experiences behaviour issues, work with them and their allied professionals to identify triggers and co-create a plan to avoid or overcome these triggers.
The client’s motivation and discipline may be affected and additional motivation strategies may be required, like a healthy reward system etc.
Protein is especially important for clients with neurological impairments and should be consumed within 20 minutes of exercising. 3g carbohydrates to 1 g protein can reduce muscle injury and improve adaptive response (amino acid uptake by muscle) (ACSM, 2016, pg 246)
Some Programme Goals to consider as well as the client’s individual short-term and long-term goals:
Client learns to become familiar with the RPE scale and how their body responds to the intensities at which they are exercising.
Client gradually progresses towards moderate intensities.
Develop balance and motor-neuro functioning.
If the client is obese, weight loss should be a programme goal. Even 5-10% weight reduction improves blood pressure, blood lipid levels and factors that are related to the onset of type II diabetes. Remember that not all people with CHD are obese.
ACSM Guidelines #
|Recommendations for Cardiorespiratory Endurance|
|· Mode: using large muscle groups
· Frequency: 3-5 days per week
· Duration: 20-60 min most days
· Intensity: 40-50-85% of VO2R
|Table 4 Classification of Exercise Intensity for Cardiorespiratory Endurance|
|RPE||Intensity||% MHR*||% of HRR or VO2R|
|only engage in higher intensities if they have no/very few ABI symptoms and have clearance||10||Max effort activity
Feels almost impossible to keep going
Completely out of breath, unable to talk
|9||Very hard activity
Very difficult to maintain exercise intensity
Can barely breath and speak and single word
On the verge of becoming uncomfortable
Short of breath, can speak a sentence
|Client with ABI should start with lighter intensities and progress gradually||4-6||Moderate activity
Feels like you can exercise for hours
Breathing heavily, can hold short conversation
Feels like you can maintain for hours
Easy to breathe and carry a conversation
|1||Very light activity
Anything other than sleeping, watching TV, riding in a car etc
|*not always accurate, certain medications may interfere with heart rate
HRR= heart rate reserve; VO2R= oxygen uptake reserve; HRmax= maximum heart rate; RPE= rate of perceived exertion
|ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription, 7th Ed. (2014)|
Aerobic Training Guidelines #
Deconditioned clients should start with 3 x 10 mins aerobic activity at light intensity, progressing to 1 x 30 mins of light intensity aerobic activities that engage large muscle groups in repetitive activity, eg walking, rowing, cycling etc. It is important the increase the duration gradually. The ACSM (2016, pg 245) recommends increasing the duration by 5 mins every 2 weeks.
Both client and the exercise professional observe client’s RPE, especially as the client begins to gradually increase their exercise intensity.
Resistance Training Guidelines #
Choose a mode of exercise (free weights, bands or machines) that is comfortable throughout the full range of motion.
Perform between 3 and 20 repetitions (eg. 3-5, 18-20 depending on client’s individual appropriate intensity and capacity) of a combination of resistance training exercises that strengthen the major muscles of the hips, thighs, legs, back, chest, shoulders, arms and abdomen.
Repetitions can be performed at a moderate repetition duration (3 seconds concentric – pause – 3 seconds eccentric) in a controlled manner. For people with high cardiovascular risk or those with chronic disease (hypertension, diabetes) complete each exercise as the concentric portion becomes difficult (RPE 15-16).
Exercise each muscle group 2-3 non-consecutive days per week.
Allow enough time between sets to perform the next exercise in proper form.
Ensure normal, consistent breathing.
Clients with high blood pressure (hypertension) should avoid isometric contractions as they cause an exaggerated increase in blood pressure.
|Summary of General Exercise Programming|
There is such a variation in ABI so each client’s intensity will have to be evaluated independently. It is be ideal to start all clients out on lighter intensities, with gradual progression depending on the severity of their symptoms, condition and response to exercise.
Keeping a diary of neurological symptoms will help guide the client’s exercise intensity.
|Components of Training Programme||Frequency (sessions per week)||Intensity||Duration||Activity|
|Cardiorespiratory||3-5||40/50-85% HRR or VO2R 64/70-94% HR max
|20-60 min||Large muscle groups
|Resistance||2-3||Or Volitional fatigue (19-20 RPE)||1 set of 3-20 repetitions (eg 3-5, 8-10, 12-15)||Include all major muscle groups|
|Stretch to tightness at the end of the range of motion but not pain||15-30 seconds
|Static stretch all major muscle groups|
|HRR= heart rate reserve; VO2R= oxygen uptake reserve; HRmax= maximum heart rate; RPE= rate of perceived exertion|
|ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription, 7th Ed. (2014)|
Key Questions to Ask the Client #
if a client’s cognition and/or communication has been severely impacted by a brain injury they may use a communication device or a family member or support staff may be able to support the client in answering these questions – it is important to discern this before the initial consultation to ensure that the time together is maximised and to always ensure that the client is centre of the conversation
- When did the injury occur? If recently, has your doctor given you permission to exercise? (has the inflammation reduced?)
- What part of the brain was and is affected?
- How are your body functions and/or structures affected by your brain injury?
- Seizures? If yes? What type? How often? Duration? When was the last one?
- Limb weakness?
- Body temperature control?
- Do you fatigue easily?
- Do you have a sensitive response to loud and/or sudden noises etc?
- Have you noticed that your behaviour has been affected in any way? Eg Your motivation or moods?
- Do you find it easy to make new friends? And to keep old friends?
- Do you have any other long-term (chronic) health concerns that may affect your capacity to participate in certain physical activities (physically, mentally or socially)?
- What is the cause of your brain injury? Traumatic (injury to the head) or non-traumatic (stroke, Parkinson’s disease, tumour etc), if the cause is non-traumatic, see the notes specific to that condition.
- How is your participation in activities of daily living affected?
- Are there any specific activities (of daily living or otherwise) that you have difficulty with and would like to work towards improving?
- Is support with any activities of daily living required? If yes, what level of support?
- What medication are you taking to address this health concern? (find out the dosage, frequency, time of day, side effects, long-term or short-term?)
- Are you taking any other medication for any other health concern? If yes, what is the name of it and what is it for? What side effects (if any) do you experience)?
- What other professionals do you work with that can feed in to any stage of your fitness programme (eg. preparation, action, maintenance) to make it more effective, safe and beneficial for you? (eg. rehabilitation team, physician, occupational therapist etc)
- Have they recommended a fitness or rehabilitation programme for you? If yes, did they provide a programme or any other guidelines?
- Why have you decided to start a fitness programme?
- Do you have any concerns about starting a fitness programme?
- What would you like to achieve from your fitness programme? SMART goals (specific, measurable, 100% achievable, realistic, time-frame)
- Short term:
- Long term:
- Have you exercised in the past?
- If yes, in what manner (type of activity, time span, length of activities etc)?
- How did you find it?
- What did you enjoy?
- Did you experience any barriers? If yes, what did you do to overcome these?
- Did you have support from your social circle? If yes, in what way?
- What types of fitness activities do you think you will enjoy or would you like to try?
- Are there certain times of the day that you feel more energetic or are more likely to fatigue easily?
- Have you ever changed a behaviour in the past (given up something or taken up something new)?
- If yes, what motivated you and helped you adhere to this behaviour change? (eg. reward system, buddy system, social support etc)?
- Have you ever engaged in any type of behaviour change in the past? If yes, what worked for you (motivation/adherence)?
Further information #
DASH diet, available at: http://dashdiet.org/default.asp [accessed 3rd April 2016]
Exercise is Medicine, ‘Your Prescription for Health Series’, available at: http://exerciseismedicine.org/assets/page_documents/YPH_All.pdf [accessed 6th April 2016]
Harvard School of Public Health, ‘Healthy Eating Plate & Healthy Eating Pyramid’, available at: https://www.hsph.harvard.edu/nutritionsource/healthy-eating-plate/ [accessed 9th May 2016]
Hadassah Medical Center, Botulinum Toxin (Botox) Injection for Spasticity, available at: http://www.hadassah-med.com/medical-care/departments/physical-medicine-and-rehabilitation/botulinum-toxin-(botox)-injection-for-spasticity [accessed 10th May 2016]
Kesiktas, N., Paker, N., Erdogan, N., Guelsen, G., Bicki, D. and Yilmaz, H., (2004), ‘The Use of Hydrotherapy for the Management of Spasticity’, The American Society of Neurohabilitation, 18, 268-273
Lava, N., (2016), Types of Seizures, available at: http://www.webmd.com/epilepsy/guide/types-of-seizures-their-symptoms [accessed 10th May 2016]
Moore, G., Durstine, L., and Painter, P., eds. (2016) American College of Sports Medicine: Exercise Management for Persons with Chronic Diseases and Disabilities, 5th Edition, Human Kinetics, Champaign
Noorbhai, H., Gabriels, G., and Noorbhai, A., (2014), ‘the effects of common medications in response to exercise and training’, Adv Pharmacoepidemiol Drug Saf, 3, 1, 146
Pescatello, L., Arena, R., Riebe, D., Thompson, P., eds. (2014), ACSM’s guidelines for exercise testing and prescription, 9th Edition, Baltimore: Lippincott Williams & Wilkins
Swain, D., Brawner, C., Chambliss, H., Nagelkirk, P., Paternostro Bayles, M. and Swank, A., eds. (2014), ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription, 7th Edition, Baltimore: Lippincott Williams & Wilkins