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Don was injured in a motorcycle accident near the end of his college career. He experiences severe depression from the loss of future plans, which included the chance to become a professional hockey player. In addition, he has other losses in relationships with family and friends as well as marriage plans. Don is unable to carry out the responsibility of caring for himself because of delusional thoughts and the inability to begin or initiate even simple activities. He has spent almost all of his adult life in rehabilitation programs. Six years ago, he elected to move to a community-based assisted living program for persons with acquired brain injury. Don eats sparingly and drinks soda most of his waking hours. Unless going out for a leisure activity, he remains sedentary most of the day. Damage to his left knee from the motorcycle accident limits the exercises he can complete. He is not motivated to exercise, smokes two packs of cigarettes daily, and is sometimes overwhelmed by bouts of depression and anger.

All these men are on comprehensive medication programs for controlling seizures, problems with thinking, anxiety, depression, or other medical problems.

People working on the development of a fitness plan should consult with the participant's physician in order to avoid any negative impact from a medication program. Being familiar with the side effects of these medications will help prepare the coach for obstacles such as lowered motivation and balance problems.

Other emotional and behavioral impairments common to brain injury include: fatigue, mood swings, denial, anxiety, lowered self-esteem, lack of motivation, difficulty with emotional control and anger management, sexual dysfunction, inability to self-monitor, and difficulty in relating to others.

It is important to note that there is a great variation in impairments due to brain injury, because damage to different parts of the brain can affect a variety of aspects of functioning in the world: thinking, feeling, moving, or behavior.

Deficits of attention include the ability to focus on a particular matter, the ability to sustain attention over time, and the speed at which this information is processed. This affects Rob to a great degree in his ability to process information and focus on a task. Noisy, crowded environments make it difficult for Rob to focus his attention and be able to learn a new skill. Avoiding the gym at prime-time hours is helpful in keeping Rob focused.

Impairments of memory and learning affect Don. His ability to retain information takes repetition and clear direction. Don's short-term memory is almost nonexistent. Therefore, it is necessary to use schedules and verbal prompting for reminders.

Motor planning and goal-directed behavior affect Rob. Initiation is difficult for him unless prompting is given on specific tasks. Rob does display goal-directed behavior but is limited to a certain few tasks such as fishing, weight training, and, upon occasion, church.

Planning and problem-solving are areas in which all the men need assistance. After years of institutional life, their ability to do these tasks has diminished greatly. States of confusion such as disorientation are common to Sam and Don. Scheduling and being consistent in carrying out activities is helpful. Impaired short-term memory also plays a role in this confused behavior.

Judgment problems are common with Sam, who periodically tries to stick his finger in the equipment or licks items in the gym facility.

Combative and disruptive behavior affects Sam. Using the incorrect approach can elicit hostile responses. Sam can be self-abusive, combative, and disruptive to houseplants in demonstrating frustration.

Lack of inhibition affects Sam in the form of inappropriate sexual and social behavior. He blows kisses to strangers in the community and demonstrates inappropriate touch to males and females.

Irritability is common for Don. Communication can be difficult for this individual at times. Based on the day and/or mood, he may or may not be up to the task of training.

Anxiety does affect Rob, although to a much lesser degree since his participation in a fitness program. When experiencing anxiety, Rob will "zone out" periodically, only being able to respond verbally with yes or no. He will describe his body as getting "very stiff." Large groups, others with disabilities, and new people can trigger this response. Anxiety can be displayed by all the men at different levels for different reasons.

Detachment from reality affects Don in that he hears and responds to voices that are not there. Rob periodically thinks people are talking about him, whether in the community or on television, which results in an increase in anxiety and a decrease in participation.

Balance is a key issue for Sam and Don. Sam's balance varies from day to day based on his nutrition and the amount of sleep he receives. Don's balance issues come from the fact that he has a damaged left knee, which makes it difficult for him to move in and out of tight areas.

Reduced range of motion affects all the men due to many years of limited activity. Rob suffers from reduced range of motion due to muscle spasms and contractions as a by-product of his anxiety problems. Don's tightness comes from a sedentary lifestyle and involuntary muscle spasms.

Endurance problems are an issue for everyone from years of being sedentary and limited activities. Endurance problems for Sam and Don are exacerbated by the fact that they each smoke two packs of cigarettes each day and have poor nutrition habits.

Bowel and bladder dysfunction affects Sam and Don. Cues are given frequently to avoid mishaps. Sam and Don's incontinence is worsened by the huge amounts of caffeine beverages that they consume. It is not uncommon for Sam to make five trips to the restroom during a one-hour outing.

In terms of people with brain injuries, as with others with disabilities, more attention and opportunities are needed. Currently, few fitness programs are offered and/or available for persons with brain injury. At best, fitness for an individual with a brain injury takes the form of recreational activities and outings with no clear structure and no evaluation format. A proper evaluation format provides safety precautions for the participant while recording valuable information that is helpful in determining future progress and goals.

Persons with brain injuries face the same dilemma as persons with developmental disabilities. James Rimmer, Ph.D., at the University of Illinois at Chicago, argues that the number of people with developmental disabilities participating in organized fitness activities is very limited. Rimmer also says: "There is a pressing need to convey the message to the community of professionals, staff, and families who work in this field that fitness is not a luxury, but rather, an essential prerequisite for maintaining optimal health and well-being throughout the lifespan."

It has been observed that most professionals either lack the expertise in this area to provide adequate programming, or are simply unaware of the need for this component to be added to the current program structure in which they work.

Studies are limited in the area of persons with brain injuries in relation to exercise, health, and activity patterns. In a paper entitled, "The Benefits of Exercise in Individuals with Traumatic Brain Injury," Gordon et al., 1998 note: "The results of this study point to the need for a prospective study in which the effects of exercise in individuals with TBI are rigorously evaluated. In such a study, factors such as length of time since injury; severity of injury; and the potential benefits in terms of cognitive function, physical capacity, and mood need to be more precisely measured and controlled." Gordon et al. also contend that the credibility of their results argue strongly for additional research.

It has been observed that people with brain injuries generally have a greater propensity towards poor health habits as well as having poor health profiles. As in other special needs populations, the benefits of a proper exercise program can be helpful in the avoidance of secondary health problems. Health-risking habits and behaviors that have been observed:

• Smoking
• Dietary problems or habits
• Lack of exercise
• Prolonged inactivity
• Medications that may be debilitating over time
• Sedentary lifestyle
• Indifference
• Lack of initiation
• Depression

Many individuals who are either in clinical rehabilitative settings or have made the transition from these programs into community-based settings have had their fitness levels seriously compromised. A proper medical referral and health evaluation screening should be made before implementing any fitness regimen. Any current health or physical limitation should be dealt with under the supervision of a medical professional. Individuals based in the community with brain injuries should also follow the same approach.

All successful fitness programs incorporate the three most important elements of physical conditioning: strength training, cardiovascular conditioning, and flexibility conditioning. Although the needs of an individual with a brain injury are the same as those of a non-injured person with regards to physical fitness, steps must be taken with each individual to ensure that the specific functional disabilities are addressed to ensure the success of the program. Each person has different needs based on health profiles and specific preferences in the activities chosen. Approaches to motivation, communication, and the individual's capacity to understand and follow a fitness program must be individualized. Information profiles from the person's rehabilitation case, team meetings, and consultations with professional resources such as neuro-psychologists, neuro-psychiatrists, and physical therapists can be very important in developing this individualized approach.

There may be other obstacles common to all individuals that should be identified and considered in the development of a fitness program. These include:

• Disabilities present prior to injury
• Embarrassment about appearance
• Mood-altering medications
• Poor nutrition contributing to lack of energy and motivation
• Allergies or allergy medications causing energy problems
• Misaligned joints or joint pain
• Orthopedic injuries

In developing a fitness plan for an individual with an acquired brain injury, six common dimensions should be considered:

1. Fatigue remains a common yet often complex and multi-factoral problem for persons with brain injuries. There are many conditions that produce fatigue, including chronic pain, sleep disturbances, hypothyroidism, and depression, among others. Among the common benefits of a fitness regimen are improved stamina and strength, which will lower the fatigue factor.
2. Depression may accompany traumatic brain injury at all levels of severity. Exercise is a cost-effective treatment of mild to moderate depression and enhances mood and intellectual function.
3. Memory problems may be combatable by using repetition and constant review of the exercises and program.
4. Slowed thinking - the individual cannot process information at the same rate as prior to the injury. By giving one-step directions in a clear and concise form, you help the participant to understand each instruction.
5. Executive function problems, which are responsible for initiation and motivation, goal-oriented behavior, planning, orientation, and memory and learning, will be a factor when developing the fitness program. The coach should develop a clear understanding of each participant's impairments in order to properly structure the participant's training program.
6. Physical impairments may be sustained at the time of injury or may develop later from a complexity of problems, including lack of use, sedentary lifestyle, and effects of long-term medication use. These problems may include visual impairments, sensory deficits, motor disturbances, and bowel and bladder dysfunction. Balance is a complex, integrative function involving not only the production and reception of adequate sensory information, but the appropriate interpretation of that information as well. Balance issues are very important when developing a program that is safe as well as effective.

In a study performed on adolescent traumatic brain injury subjects 16 months after injury, it was observed that there was a significant reduction in the performance of running speed, balance, strength, and bilateral coordination. Weaknesses in movement abilities can be addressed through an active range of motion and progressive resistance exercises.

From a previous study, it should be noted that exercise in individuals with brain injuries has been associated with less impairment, elevated mood, and perceptions of better health.

Careful organization and sequencing is critical when delivering the program. By conducting one step at a time, the level of frustration experienced by the participant will be decreased.

In administering these programs, it is important to distinguish whether they should be delivered sequentially, or if each program should be treated as a separate unit delivered randomly. Limitations should not be placed on individuals wanting to participate in a fitness program because he or she prefers one activity to another. Rob and Sam prefer strength training to cardiovascular work, and their participation in the program would be limited if they felt that they had to participate in the other aspects of the program. The best fitness program, however, does combine all three aspects of the fitness regimen: stretching, strength, and cardiovascular training.

Typically, persons with a brain injury have been sedentary for long periods of time. Muscles are tight and atrophied from inactivity. Stretching is an easy and economical way to start a fitness program while ensuring suppleness and flexibility for the muscle groups so as to prevent injury. This phase of training may be used to prepare the muscle groups for the added stress that will be placed on them from strength and cardiovascular training. There is no cost involved, and stretching can be performed on location at any site.

Strength training is a way for a participant to see quick results, which can be a powerful motivation for those who need to see progress quickly. Because strength training shows more noticeable progress through advances in weight or resistance, it becomes a popular phase of the training cycle. Changes are more quickly noted in body composition and dimensions than in any other aspect of training. Strength training helps the individual develop muscular strength for participating in cardiovascular activities.

Cardiovascular training is an equally important phase of the fitness program, and can be the most important element. Aerobic work is key for improving the efficiency of the heart and lungs and is the best way to reduce body fat. However, a program based on cardiovascular training alone has little effect on muscular strength and endurance. To promote interest in a cardiovascular program, it may be helpful to initially choose activities such as walking outdoors, dancing, or swimming. These activities will add flavor to the program and will be less monotonous for the participant.

The three major types of stretching used in fitness and conditioning regimens are static, ballistic, and proprioceptive neuromuscular facilitation (PNF).

• Static stretching, the most popular method of gaining flexibility, involves slowly stretching a muscle to mild discomfort and holding that position for a period of 20 to 30 seconds.
• Ballistic stretching uses the momentum of bouncing to produce the stretching effect. This is a flexibility movement that produces a high risk of injury.
• PNF stretching refers to any of several post-isometric relaxation stretching techniques in which a muscle group is passively stretched, then contracts isometrically against resistance while in the stretched position, and then is passively stretched again through the resulting increased range of motion.

For participants who suffer from coordination problems and have difficulty completing stretches on their own, a knowledgeable trainer may administer PNF stretching. PNF was initially developed as a method of rehabilitating stroke survivors. Only a well-trained individual should administer this technique. Rob is very athletic and does have good coordination, but because of the extent of his limited range of motion, he benefits from this technique.

It is important in all aspects of exercise prescription with acquired brain injury not to push beyond excessive limits. The trainer must know his or her client. He must be aware of psychological limitations as well as physical limitations.

Although there are standards of time and intensity for all people involved in a fitness program, the trainer must relax these elements when working with individuals with a brain injury. For some individuals, completion of the simplest task can spell success. In time, by using accurate documentation and displaying patience, the coach can gradually increase the progression of exercises to avoid discouraging the participant.

A successful stretching program will incorporate flexibility exercises for all body parts and musculature by taking into account all restrictions that may apply. Flexibility exercises should be performed each day to provide optimum results, but the frequency will be determined by the level at which the participant can perform.

Using a multi-modal approach, the trainer should demonstrate each stretch and explain its effect on the area worked. It may be helpful to have the client identify a number of stretches he or she prefers doing and find pictures to correlate with each stretch. These may be posted where the client has access for reference and as a reminder.

• Increased range of motion in musculature and joints
• For some, there will be an increase in muscular strength
• Reduced occurrence of injury
• Promoted relaxation
• Stretched facial tissue
• Positive effects on balance
• Less delayed muscle soreness

• Explain the stretching process and its benefits.
• Perform in a slow, controlled manner.
• Gradually increase range of motion.
• Demonstrate and post photos.
• Stretch frequently (before, during, and after cardiovascular and strength exercises).
• Hold each stretch for 15 to 20 seconds.
• Breathe normally (do not hold breath).
• Be aware of any discomfort (some individuals with a brain injury may experience a dampened sense of pain).
• Provide positive feedback.

Problem: For Don, stretching presents a major problem. He has exceptionally poor balance and offers resistance to most types of training. It is very difficult for Don to lie on the floor in order to complete basic flexibility exercises. Because he also often does not allow others to enter his personal space, physical contact, such as assisted stretches, is difficult.

Solution: Finding an individual who has established a solid relationship with Don will be helpful in introducing a fitness plan. Talking about a fitness proposal, including its benefits, time allotments, and content, will allow Don to be at greater ease with the program. Choosing an appropriate site will help Don to be less self-conscious and lower his anxiety. Discussing his expectations and concerns, and allowing him to voice what he would like to achieve, will provide him with a motive for participating. Stretching can be accomplished through assisted stretches with a coach.

As in all other aspects of an effective program, it must be simple and easy. For some participants, the completion of one set of one exercise may be a success. Here, the use of a multi-modal system is key for proper performance of each exercise and safety. Progression will be based on each individual and his or her fitness levels. It is counterproductive to push beyond reasonable limits for each client.

Developing a game plan with the client and reviewing it each time before starting will help to reinforce what is accomplished.

Listing the benefits of strength training, posting this list, and reviewing it frequently may help to motivate participants with short-term memory problems. Because of common short-term memory problems, all aspects of the fitness program should be methodical and repetitive.

• Increased strength
• Increased muscle endurance
• Reduction of body fat
• Increased metabolic rate
• Increased muscle mass
• Improved self esteem
• Increased body awareness
• Stress reduction
• Self-confidence
• Integration into the community and social benefits

For clients who are limited in resources or have extensive physical limitations, the use of therapeutic bands can be an effective training tool. Exercises can be performed for all muscle groups using this apparatus. Thera-bands, a brand name, come in different thicknesses that will determine the amount of tension delivered. Most fitness retailers sell these bands, which include information on use. The cost: $12 to $18.

• Know your client and his/her capabilities, limitations, and needs.
• Identify the facility or place where you will perform the program.
• Keep proper documentation on everything performed.
• Start slowly and progress gradually.
• Do not set up your client for failure *.
• If your participant attempts an exercise that cannot be completed, let him or her know that this is normal and part of the process.
• Use machines for clients with balance issues if training at a facility.
• Schedule breaks to boost energy whenever needed.
• Do not allow the client to determine his or her own weights.
• Always start with minimal weight or tension.

*There are a few ways to avoid setting up your participant for failure: Select an activity or an apparatus that the individual will be able to complete. Always start with the lightest weights or shortest distance possible. Do not set unrealistic goals or expectations. Carefully plan out your strategy and game plan before each session. Re-enforce the fact that what may seem to be an unsuccessful attempt at exceeding a boundary is actually a success in itself.

Problem: Sam exhibits narcissistic behavior in which he seeks out constant positive reassurance in relation to his appearance and body. He is very conscious of the development of his body, but he needs consistent motivation to train. He sometimes exhibits inappropriate social behaviors in public.
Solution: This narcissistic behavior works in the favor of the coach in persuading Sam to start training. The key with Sam is to be consistent and not vary from the schedule once it is in place, and he has begun training. Sam is very aware that he keeps a very rigid schedule of activities, and that he plans new activities around this schedule. Therefore, once the schedule is in place, it is very important to be consistent. For Sam, going to a community facility provides some of the motivation for his participation. It would be helpful to review proper social skills prior to entering the facility.

One of the most challenging aspects of a physical fitness program for persons with developmental disabilities is improving cardiovascular fitness. As Dr. Rimmer points out, the achievement of aerobic fitness is associated with moderate to vigorous exercise. This can be a difficult level of exertion to attain for people with a head injury, because of their sedentary history. Finding an activity that holds the interest of the participant is helpful in maintaining a consistent program.

Typically, individuals with a head injury lead a sedentary lifestyle. Therefore, precautions must be taken when developing the aerobic program. For some clients, something as simple as walking down a 30-foot corridor may be taxing. Before starting your program, consult with primary care physicians and physical therapists to identify the abilities and fitness levels of each participant.

There are a number of different ways to improve cardiovascular fitness levels. These include:

• Walking
• Bicycling
• Treadmill walking
• Dancing
• Swimming
• Jumping rope
• Rowing
• Calisthenics
• Aerobic classes

From the perspective of an individual with a brain injury, unless limited by physical disability, the easiest way to achieve aerobic fitness is walking. It is efficient, relatively safe, and progress can be measured easily. Start slowly and gradually increase your distance. As in all other aspects of your program, make this as enjoyable as possible. Go to areas of interest such as parks and beaches during good weather and malls or inside facilities during inclement weather.

Bicycling is another great exercise for improving aerobic fitness. Because some individuals suffer from balance and coordination problems, the use of a regular bicycle and stationary bikes may not be practical. The best machine for this purpose would be the stationary recumbent bike, which provides chair-like support for the back in a low, seated position. This is also a good choice for individuals with lower back problems.

Treadmills can be risky. They provide a great cardiovascular workout, especially in bad weather conditions. Be aware of your client's balance, concentration, and attention at all times. Even for the client who does have favorable balance, you must closely monitor the activity. Distractions may cause your client to lose focus from the task at hand. Safety is always the key issue.

Dancing is another great activity and one that most people enjoy. Let your participants choose the music they enjoy and have some fun. Dancing may also be used as a group activity.

As with all other activities, choose safe and effective exercises. Any increase of current activity levels will promote an increase in fitness levels and therefore will be effective.

Benefits of a Cardiovascular Program

• Reduction of specific risk factors for conditions, i.e., heart disease, stroke, etc.
• Increased heart efficiency
• Increased lung efficiency
• More calories burned (weight loss)
• Improved circulation
• Decreased harmful cholesterol

Target Heart Rate is the norm for determining heart rate during exercise and the range in which one must work for better health and greater endurance. To achieve optimum results, target heart rate should be between 55% to 90% of the maximum heart rate. In unfit individuals, the American College of Sports Medicine recommends that heart rates be between 55% to 64%. The equation for determining this value for a 40-year-old man with a resting heart rate of 60 is as follows:

220 (-) your age (-) resting heart rate x 55%(.55) to 90%(.90) (+) resting heart rate = Target Heart Rate

220
-40 (Age)
160
-60 (Resting heart rate)*
100
x.55 (% of exercise intensity)
55
+60 (Resting heart rate)
115 (Target heart rate)

* Resting heart rate is determined by taking the pulse for 60 seconds before getting out of bed

Additional Guidelines for a Cardiovascular Program:

• Medical referrals and evaluation
• Capabilities, limitations, and needs
• Proper documentation
• Start slowly, progress gradually
• Assist participant
• Be familiar with warning signs of overexertion
• Positive feedback
• Proper fluid intake
• Choose activities that provide incentives

1. Proper Spotting Techniques

   The spotting process is very important in maintaining the safety of the participant. Never turn attention away from the client. When using free weights, be alert at all times; the client may give up at any moment when experiencing discomfort or fatigue, and may not understand the consequences of simply letting the weight go. Give positive feedback throughout the exercise but keep directions minimal. If the client is using free weight exercises, always spot closest to the weight for better control. For example, if a bench press is being performed, hold onto the bar. If a dumbbell bench press is being performed, hold on to the participant's wrists, and do not grab under the elbow. When assisting during an exercise, use a motion that is identical to the speed of performance.

2. Health Monitoring
   • Medical, PT evaluations and releases*
   • Monitor heart rate, blood pressure, and periodically, body weight and body composition
   • CPR/first aid certification
   • Watch for excessive fatigue
   • Identify risk factors**
   • Awareness of individual's pain tolerance
   • Develop a plan for complications, including emergency numbers and contacts
   • Encourage the consumption of fluids
   • Keep accurate performance records
   • Medication cautions or effects

   *Medical and PT evaluations will be needed when dealing with individuals with physical impairments. Because Don had badly damaged his knee in his accident, a PT evaluation was needed before starting his program. The evaluation revealed that he was not able to perform routine leg exercises such as leg extensions, leg curls, or leg presses. Doing these exercises would have further damaged his knee.

   ** A risk factor is a specific condition or behavior associated with the development of cardiovascular disease. The more risk factors, the greater chance you have of developing secondary health problems such as heart disease.

   There are risk factors that cannot be controlled, such as gender, age, and family history. Risk factors that can be controlled or changed are smoking, blood cholesterol, weight and diet, blood pressure, and stress. Identifying the risk factors associated with each individual participating in the fitness program is necessary to promote a safe and healthy program.

Before implementing a series of goals, most people will identify their motivation for starting the fitness process. By virtue of the complications from changes in behavior and personality, and the impairments to cognition in individuals with a head injury, you may suggest ideas and provide knowledge in order to instill and maintain this motivation.

There are many parallels that can be drawn from comparing individuals with developmental disabilities to those who have acquired brain injuries. Dr. Rimmer points out the following regarding persons with developmental disabilities:

It will be extremely difficult to change the lifestyle patterns of persons with developmental disabilities if staff or family members are not proactive in encouraging physical activity participation.

The first step is to start with a very basic goal. For some people, that may be starting the program. For others, it may be walking the first 100 yards or mile.

There are two types of goals that will be helpful in allowing the participant to attain a higher level of physical fitness:

1. Short-term goals are realistic and attainable. They should be set to allow for easy and timely completion. When Rob had his first training session, his goal was set in 20-pound increments on the bench press, which he met each week in the gym.
2. Long-term goals may encompass two different categories. While some goals involve a dream for the future, other goals are more relevant to the immediate short-term goals. On Rob's first trip to the gym, he benched 100 pounds. He then set his long-term goal to bench 300 pounds, which he accomplished in six months. His other long-term goal was to be more presentable to the opposite sex in his quest for involvement in an intimate relationship.

One of the most effective ways to support an individual with a head injury is to work out a plan of action that is realistic and that can foster more motivation.

Another effective way to instill motivation is to encourage the participant to "buy into" the program so he or she "owns" the program. Re-enforce that the regimen developed is specifically for him or her and that the time designated for fitness training assists in accomplishing goals. Frequently discuss the positive changes taking place as a result of the training. After each training session, Rob was told what accomplishments he had made. He was so enthused that he wanted to go to the gym daily to strive for more progress.

Periodically challenge the participant without promoting discouragement. Emphasize that this is part of the process and that not being able to walk a certain distance or lift a specific weight does not mean failure.

After a few months of consistent training under his belt, Rob became more at ease with his fitness program. Increases in self-confidence and lowered anxiety made it possible to challenge him on various exercises when he was not challenging himself. Frequently provide encouragement. Praise can be a powerful motivator for anyone participating in a fitness program. Simply phrases such as, "I enjoy sharing this experience with you", "excellent job", and "I cannot believe how well you are doing", may provide your participant with the motivation he/she needs to continue the schedule.

Sam responds very positively to encouragement while training. He is very sensitive to others noting his progress and at times will ask for this confirmation.

Provide honest and positive feedback whenever possible. Rob becomes enthralled with the challenge of lifting higher weight totals. Periodically he becomes discouraged if he fails to lift a certain poundage. Reminders are given to Rob to realize how far he has come and how well he is doing. Progressing from 100-lb to 300-lb bench presses in six months is a wonderful accomplishment.

Consistency is important in maintaining an individual's interest and providing an activity to look forward to. A consistent schedule will allow the program to be successful. When necessary, prepare the participant for times that must be missed by scheduling for the next day or having a qualified coach take over for the day.

This consistency is key to Sam's continued participation. Once out of a regular schedule, he will balk at attempts to restart a fitness program. The same holds true for all the men participating.

Make the program a fun experience. Choose settings that are enjoyable for the participant, i.e., home, residential setting, public facility. Develop and offer a reward system for a task completed, i.e., lunch out, a movie, a shopping trip.

Sam, Don, and Rob all enjoy receiving little incentives for making it to the gym. Supplemental outings will usually revolve around light lunches, renting a movie, or another activity of their choosing.

The ability of the trainer to use adaptation is a great asset. It is necessary to use all possible resources at his or her disposal to deliver a successful program. Adaptation to physical limitations and behaviors is important.

Because Don experienced anxiety, it was necessary to start the fitness program in his domain, his room. By purchasing some handheld dumbbells, it was possible for him to participate within the security of his room.

Patience plays a large role in the success of the program. Acknowledge that each day presents new challenges and that success will be measured in small increments. Behaviors may change from day to day. Consequently, the trainer must be prepared with the right game plan to avoid discouragement. After Sam had missed only a few workouts, it took three months to get him back on a regular schedule.

In designing a support plan, it is helpful for the trainer to understand the methods by which success is measured in training individuals with acquired brain injury.