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According to the Brain Injury Association:
  • 5.3 million Americans (a little more than 2% of the population) currently live with a disability resulting from a TBI
  • 1.5 million people sustain a TBI each year
  • 50,000 die due to TBI each year 
  • Every 21 seconds a person in the US sustains a TBI


Quotes from individuals who have had a TBI

“Maybe ten percent of the time people are willing to wait to hear me. The other 90% of the time, people are too busy.”

“For example, yesterday, I had a video in, then out, then in to test my ability to coordinate my hands. Just yesterday, I peeled an orange. I half peeled a banana too. For you it’s so easy to do, but me, I go, ‘hmmm how?’”

“My short term goals are just remembering to brush my teeth, take my pills, eat my breakfast. Just the simple things.”

These comments were quoted from individuals that have endured a traumatic brain injury (Hrenko, Rees, Lox, & O’Connor, 2003). The individuals, ranging in age from 25 to 45, were discussing either long and/or short-term goals and/or physical and cognitive struggles they deal with as a result of their injury. As a group, due to their brain injuries, these individuals have dealt with loss of some or all of the following: eyesight, clear speech, muscle strength, coordination, independent walking, and independent living, to name a few.


What is a traumatic brain injury?

A brain injury can be defined as a craniocerebral injury that results from initial sudden forces levied to the head and secondary brain damage (e.g., raised intracranial pressure, intracranial dematoma), which leaves residual disabilities (Zoerink & Lauener, 1991).

According to the Brain Injury Association, traumatic brain injury is an insult to the brain, not of a degenerative or congenital nature but caused by an external physical force, that may produce a diminished or altered state of consciousness, which results in an impairment of cognitive abilities or physical functioning. It can also result in the disturbance of behavioral or emotional functioning.  These impairments may be either temporary or permanent and cause partial or total functional disability or psychosocial maladjustment.

Adopted by the Brain Injury Association Board of Directors, February 22, 1986. This definition is not intended as an exclusive statement of the population served by the Brain Injury Association of America.

Most traumatic head injuries are caused by motor vehicle accidents and occur in males ages 15-24. Further, the injuries that result from these accidents are usually closed injuries, where the brain crashes against the skull causing diffuse damage. The complications that follow can be categorized under three headings: psychomotor (physical/movement), affective (emotion), and cognitive (thinking, reasoning) (Lepore, 1987).


Causes of brain injury can include, but are not limited to:

  • Airway obstruction
  • Near-drowning, throat swelling, choking, strangulation, crush injuries to the chest
  • Electrical shock or lightening strike
  • Trauma to the head and/or neck
  • Traumatic brain injury with or without skull fracture, blood loss from open wounds, artery impingement from forceful impact, shock
  • Vascular disruption
  • Heart attack, stroke, arteriovenous malformation (AVM), aneurysm, intracranial surgery
  • Infectious disease, intracranial tumors, metabolic disorders
  • Meningitis, certain venereal diseases, AIDS, insect-carried diseases, brain tumors, hypo/hyperglycemia, hepatic encephalopathy, uremic encephalopathy, seizure disorders
  • Toxic exposure- poisonous chemicals and gases, such as carbon monoxide poisoning
  • Asthma attack, loss of oxygen


Psychomotor impairments may include:

  • Slowness or confusion in the planning and sequencing of movements (ataxia, apraxia)
  • Muscle spasticity
  • Contractures, fatigue, & balance impairment (Lepore, 1987)
  • A variety of sensory impairments, including vision and hearing loss (Porretta, 2000)


Affective, social, emotional, and behavioral impairments may include:

  • Lowered self-esteem
  • Lack of motivation
  • Difficulty relating to others
  • Impulsivity, impatience, social dependency, irritability, apathy, inability to profit from experience, changes in personality, short temper, lack of awareness of physical and/or mental limitations (Lepore, 1987).

Cognitive impairments, which can affect both the physical and emotional self, often include:

  • Short and/or long term memory loss 
  • Poor concentration
  • Communication disorders related to speech, writing, and reading
  • Logical reasoning, organization skills, orientation (Lepore, 1987)


Aquatic Rehabilitation

As a result of the myriad of deficits that can occur following a TBI, rehabilitation specialists are presented with a challenging opportunity to devise appropriate rehabilitation programs and adapted physical activity specialists to provide lifelong physical activity and recreation programs (Driver, 2002).

Specifically, aquatic recreation therapy allows an individual with a TBI to attempt patterns of movement in the water without fear of falling or weakness (Driver, O'Connor, Lox, & Rees, 2003). Further, completing movements in the water leads to strengthened postural muscles and increased stability.  These benefits are particularly important to people with brain injuries whose balance may be compromised (Hrenko, Rees, Lox, & O’Connor, 2003).

Movement exploration in the water helps individuals understand their bodies, which is especially applicable to people with a brain injury who often lack feeling and knowledge of what their body is capable of doing (Lepore, Gayle, & Stevens, 1998).  Some therapeutic psychomotor effects of water exercise include muscle relaxation, relief of pain and muscle spasms, maintenance or increased range of motion in joints, and improvement in muscular strength and endurance. This may lead to an increase in enjoyment of life, self-esteem, and self-awareness, as individuals are able to complete tasks on their own (Lepore, Gayle, & Stevens, 1998).

Therefore, it is important to include recreation programs, such as adapted aquatics, that help to tackle the cognitive, physical, and social problems resulting from a brain injury (Zoerink & Lauener, 1991).

Programs in rehabilitation are usually planned around the level of cognitive functioning a person exhibits (Lepore, 1987). The Adult Head Trauma service at Rancho Los Amigos Hospital (Downey, CA) has formulated a description of the levels of cognitive functioning at each stage of recovery:

  • Level 1 No response
  • Level 2 Generalized Response
  • Level 3 Localized Response
  • Level 4 Confused - Agitated
  • Level 5 Confused – Inappropriate – Non-agitated
  • Level 6 Confused – Appropriate
  • Level 7 Automatic - Appropriate
  • Level 8 Purposeful and Appropriate

The revised 10 level scale includes:

  • Level 9 Purposeful, Appropriate - Stand-By Assistance on Request
  • Level 10 Purposeful, Appropriate - Modified Independent

Individuals in levels 1-4 are not appropriate for community aquatics (level one – person is comatose; level 2 & 3 – person shows inconsistent stimulus response; level 4 – person is confused, and exhibits bizarre behavior, often aggressive) (Lepore, 1987).


Individuals at Level 5 can be slowly reintroduced to aquatics, however, keep the following points in mind.  These individuals:

  • Can respond to simple commands fairly consistently
  • Need very structured environments (limited number of other people in the pool)
  • Need one-to-one instruction
  • Need frequent redirection of attention
  • Benefit from repetition
  • Instruction required for use of kickboard, kickstick, etc.
  • Should participate in aquatic sessions lasting only 15 minutes


When developing an aquatics program for individuals at Level 6, 7, & 8, keep the following points in mind:

Level 6

  • Gradually decrease structure, offer simple choices for activities
  • Increase time in pool to 20-30 minutes
  • Introduce activities where success and failure can be experienced
  • Use activities that improve cognitive skills, perceptual motor skills, spatial relationships and awareness

Level 7

  • Involve participants in activity planning and goal setting
  • Introduce activities with more complex directions
  • Emphasize problem solving, judgment, and flexibility in thought

Level 8

  • Re-teach and continue with swimming skills previously performed (prior to injury)
  • Provide opportunities to socialize (promotes community re-entry: Community re-entry programs generally focus on developing higher level motor, social, and cognitive skills in order to prepare the person with a brain injury to return to independent living and potentially to work Brain Injury Association of America)
  • Teach personal safety, survival skills, strokes
  • Integrate participants into the regular swim program

(Lepore, 1987)


Common issues associated with TBI and suggestions for instruction in the aquatics environment:

Contractures, spasticity and high muscle tone

  • Perform aquatic activities in warm water
  • Perform activities and swim strokes under water to increase ROM and decrease pain
  • Perform activities slowly in warm-up phases (gentle stretches; never force a joint)
  • Tactile teaching may be needed – tell individual what you are going to do prior to touching them
  • For spasticity problems, spot individual near head, as spastic movements may cause head to submerge


  • Model desired activities
  • Be consistent in activities and instruction
  • Keep instruction to a few words – simplify, demonstrate, repeat
  • Ask swimmer to repeat instructions
  • Use orientation questions at the beginning of each session, for example: “Where is the best place to enter the shallow end of the pool?”


  • Streamline body for floating
  • Hand paddles and fins may help with propulsion
  • Utilize weight belts for lower body muscle atrophy to keep head above water
  • Fatigue is common, as well as decreased sensation (check for abrasions)
  • Be aware of muscle spasms
  • Be knowledgeable of assistance in orthotic devices
  • Promote independence
  • Modify strokes and entries depending on each individual


  • Obtain medical clearance
  • Medicines may reduce concentration, coordination, reaction time
  • Be aware of factors that cause seizures – stress, caffeine, illness
  • Close supervision
  • Discourage long periods of breath holding
  • Devise emergency plan
  • Pull individual on back and keep head above water

Blind & visual impairment

  • Encourage those with any sight to use it – wear bright colors
  • Manipulate or place individual’s hand on you for demonstration
  • Keep directions concise with specific cues – use right, left, number of strokes
  • Avoid gestures
  • Describe surroundings and what others are doing
  • Use lane lines, and auditory and/or tactile signals
  • Allow environment exploration with buddy

(Lepore, Gayle, & Steven,1998)


Helpful Organizations / Websites



Lepore, G. (1987). Teaching aquatic activities to persons with head injuries. National Aquatics Journal, 8-9.

Lepore, M., Gayle, G.W., & Stevens, S. (1998). Adapted aquatics programming:  A professional guide.  Champaign, IL:  Human Kinetics.

Driver, S., O'Connor, J., Lox, C., & Rees, K. (2003). Effect of an aquatics program on psychol/social experiences of individuals with brain injuries: A pilot study. Journal of Cognitive Rehabilitation, 21(1), 22-31.

Driver, S. (2002). Effects of aquatics program on the physiological and psychological parameters of individuals with brain injuries.  Manuscript submitted for publication.

Hrenko, B. (2003). The effects of aquatic and land exercise on activities of daily living among individuals with traumatic brain injury. Unpublished master’s thesis, Southern Illinois University Edwardsville, Edwardsville, Illinois, United States.

Porretta, D. (2000). Cerebral Palsy, Stroke, and Traumatic Brain Injury. In J. P. Winnick (Ed.), Adapted Physical Education and Sport (pp. 187-196).Champaign: Human Kinetics.

Traumatic brain injury definition recommended by the Brain Injury Association of America. (2004, June 19). Retrieved June 19, 2004, from

Zoerink, D.D., Lauener, K. (1991). Effects of a leisure education program on adults with traumatic brain injury. Therapeutic Recreation Journal, 25(3), 19-28.



This content was created by
Betsy Hrenko-Keigher, a Ph.D. Student in Adapted Physical Education,
at Texas Woman’s University for
“Aquatics for Special Populations”,
Summer, 2004

page last updated 1/3/2017 1:00 PM