In 2020, the World Health Organization published its guidelines on physical activity and sedentary behaviour, with its now-familiar message that regular physical activity is good for hearts, bodies and minds, and its recommendation that adults do at least 150 minutes to 300 minutes of moderate aerobic activity weekly as well as muscle strengthening activities (World Health Organization 2020). 

While the guidelines included recommendations for both children and adults with disabilities, they didn’t specifically address many forms of disability, including those resulting from traumatic brain injuries (TBI). 

‘It was such a great step forward having the WHO guidelines but one of the challenges is that they looked at eight different health conditions but that didn’t include TBI. 

‘In addition, because they’re public health guidelines, when they were looking for the evidence they excluded anything that was conducted in rehab. 

‘So although they were a fantastic step for promoting physical activity, they still didn’t really provide any guidance for health professionals working with people with TBI along that rehab journey,’ says Associate Professor Leanne Hassett APAM, a physiotherapy researcher with the Institute for Musculoskeletal Health at the University of Sydney and Conjoint Associate Professor of Allied Health at Western Sydney Local Health District. 

Around the same time, the Medical Research Future Fund announced that it would fund TBI research through its Traumatic Brain Injury Mission and Leanne and her collaborator Professor Gavin Williams saw this as an opportunity to fund a project looking at physical activity for people living with TBI. 

Along with a team of colleagues from the University of Sydney, the University of Melbourne and a number of other institutions, Leanne and the team applied for and were awarded a $406,506 grant to adapt the WHO guidelines into a clinical practice guideline for TBI. 

The resulting Australian physical activity clinical practice guideline for people with moderate to severe traumatic brain injury (Hassett & Johnson, on behalf of the BRIDGES Guideline Development Group 2024) was completed and published in 2024, with a research paper published in Clinical and Public Health Guidelines (Hassett et al 2025). 

Developing the new clinical guideline 

Associate Professor Leanne Hassett led the project to design the new physical activity guidelines.

Leanne says the team looked at two aspects of physical activity for the guideline—first, how to deliver it (that is, what sort of physical activity was needed by people with TBI) and second, how to promote physical activity to these patients and clients. 

‘In our delivery we were thinking about fitness training, strength training, functional mobility training and getting back to sport and recreation. Then we looked at the overall promotion of physical activity as necessary for health.’ 

The guideline development process sought to determine whether the following interventions— structured aerobic exercise; muscle strengthening; gait, balance and functional exercise; sport and physical recreation; and promotion of physical activity—could be used for people with moderate to severe TBI in two populations, children and adolescents and adults including older adults. 

To develop the guideline the team used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) ADOLOPMENT approach (Schünemann et al 2017) and used an overarching implementation science framework to ensure that the guideline was developed with future implementation in mind. 

As with most current guideline development projects, the team conducted a systematic review to look at the research that had been done on physical activity for people living with TBI (Johnson et al 2023). 

They also undertook an audit of 26 paediatric and adult brain injury services across Australia to understand current practice, barriers to and facilitators of the promotion and delivery of physical activity programs (publication in progress). 

‘That helped us to understand what was currently going on, both to inform the guideline and to assist with its implementation at the other end.’ 

Another early step in developing the guideline was to identify the evidence for physical activity in people with TBI and, more importantly, to identify the gaps. 

‘I knew there were a lot of gaps in the evidence for TBI and that we would need to be a bit creative in how we thought about developing this guideline. 

Even though there’s not strong evidence for everything in TBI, I think a guideline is still a worthwhile thing to do to start moving the research priorities forward. 

The way I built up the project to develop the guideline was to build a lot of little studies into it to help fill those gaps.’ 

In addition to looking at the evidence base, the researchers spent time gathering information from people living with TBI to understand what their experiences and preferences for physical activity were (Haynes et al 2025). 

They also held focus groups with different interest-holders, including health professionals, people with TBI, family members and support workers, the organisations that fund physical activity and community providers of physical activity to better understand the challenges. 

‘Those pieces of work were important in informing the value of physical activity, the acceptability, the feasibility, the resource requirements—all those bits you have to fill in when you’re doing the guideline work that weren’t necessarily available in the literature.’ 

Having contributors with lived experience of TBI was particularly important, Leanne says, and made the guideline a stronger document. 

What are the key recommendations for Australian physiotherapists? 

The Australian physical activity clinical practice guideline consists of five recommendations each for the adult population and the child and adolescent group, with information on whether the recommendation was strong or conditional, a rating of the certainty of the evidence and the criteria used to justify the recommendation. 

Good and precautionary practice points were also developed to further guide clinical decision-making alongside the guideline recommendations. 

The recommendations can be found in Table 1 (below):

Implementation of the guideline recommendations 

A second Medical Research Future Fund grant worth $2.3 million was awarded to Leanne and her team in 2023 to continue filling the gaps in the evidence base as well as implement the guideline in health services across Australia. 

Initial work is looking at some specific groups including culturally and linguistically diverse communities, Aboriginal and Torres Strait Islander communities, rural and regional populations, those with higher support needs and young children—all groups that were not engaged in the initial studies to develop the guideline. 

‘We’re doing that bit first just to learn a little more to help inform the guideline implementation—we want to make sure that our guideline is going to improve equity, not cause inequity.’ 

Studies to fill some of the gaps in the evidence base are underway and as results become available, the guideline will be updated. 

The team is also gearing up to start a two-year randomised cluster trial at 20 sites across Australia to support wider implementation. 

'We’re supporting the health professionals to work out what guideline recommendations they’re not currently meeting in their service and what’s stopping them.

‘Then we’ll help them to make that change, whether it’s education and training, building up new resources for them or connecting them with community services—whatever is needed.’ 

An important part of the study is the development of a resource hub including videos and other resources informed by the work that the team has done to develop the guideline.

 While it will initially be accessible only by trial participants, Leanne says it will eventually be opened to the wider rehabilitation community. 

Some recommendations will be easier to implement than others. 

Mobility training, for example, is already widely used in rehabilitation. 

On the other hand, Leanne says that the availability of strength and fitness training in rehabilitation settings can vary. 

‘Although most people have some sort of fitness training, when we did the audit of the services we found that less than half actually do a fitness test to measure how fit someone is to set the training baseline. 

‘So there’s a lot of work that we can do in that area and it’s the same with strength training.’ 

It’s trickier when it comes to supporting people with TBI to return to sport and recreational physical activities, which can come with an increased risk of another TBI. 

‘It’s a tough one and there is still definitely some more research needed in that space. 

‘Different people have different views and there’s no clear guidance so people are told all sorts of different things—eg, that they can never return to any type of sport. 

‘It just depends who they speak to along their journey so it’s going to be really hard getting everyone on board for that one.’ 

There’s also a psychological challenge that comes with the return to sport, particularly for people who were participating at a high level prior to their injury, something that was highlighted during the qualitative studies and focus groups held during the guideline development stage. 

‘When we were developing the recommendations, the most heated discussions were about return to sport and recreation. 

'Some people might have been competing at a high level in a sport but they’ve now got impairments that make it hard for them to get back to the level that they were at before. 

‘As health professionals, we’re trying to navigate that with them but psychologically it can be very challenging.’ 

A further challenge comes when patients with TBI move from inpatient and outpatient rehabilitation services back into the community, where they might join community programs or go to private rehabilitation services or clinics for ongoing care. 

Leanne hopes that the guideline will help to ensure consistent, evidence-based care for people with TBI no matter where they are in Australia and what services they use. 

‘These people with TBI have had a team of health professionals that they’ve been working with for weeks, months, years sometimes and the transition to a different setting and different people working with them is really challenging. 

‘It can take a lot of time to find suitable programs and facilities and to find the right person to work with them and then you might need to help get things set up. 

‘But we don’t want to keep them in health; we want them to get out into the community and be physically active.’ 

The final recommendation has to do with promoting physical activity and increased participation at all levels to avoid negative health consequences due to physical inactivity. 

‘It’s not just the physical benefits; it’s the mental, psychological and societal benefits of physical activity.’ 

The last part of the project will be to ensure that the guideline is updated with new evidence from ongoing studies completed both within Australia and overseas. 

‘Within the five-year funding, we have to implement and review and, where needed, update the guideline recommendations because this guideline has National Health and Medical Research Council approval, which is valid for five years.’ 

Click here for more information about the Australian physical activity clinical practice guideline for people with moderate to severe traumatic brain injury. 

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