Many physical effects impact a person’s mobility, or the ability to move. Examples of this include, but are not limited to:
- Being unable to walk (limps, poor posture, poor endurance, not able to walk and complete activities at the same time, poor balance, needing to use a walking aid like a cane or rollator).
- Being unable to work, play or drive
- Being unable to sit or get dressed
- Pressure sores from staying in the same position for too long
- Contractures (permanently stiff joints and/or tight muscles)
- Loss of muscle mass from disuse
- Experiencing impaired movement control
- Increased dependency on others
- Increased risk of falls
- Poor bed and wheelchair positioning
When a person experiences changes in their mobility after a brain injury, it can be difficult to adjust to their new reality. This can lead to increased risks of mental health challenges, such as anxiety and depression.
It’s important to work with medical professionals, including physiotherapists, occupational therapists and kinesiologists, to address mobility issues and create a goal-oriented rehabilitation plan.
Topics in this section include:
How the brain perceives the environment & controls mobility
Our brain controls our ability to move, our physical responses and our ability to use and move objects. While the location and size of the brain injury doesn’t always mean there will be mobility challenges, certain areas of the brain do control specific aspects of mobility, such as:
- Basic body functions such as heart rate, blood pressure, respiration, sweating, consciousness, and alertness.
- Coordination and balance, including smoothness of movement.
- Information related to sight, touch, and spatial awareness. If the brain is having trouble determining where and what things are, it can make it difficult to perform movements like reaching for and picking up objects and moving in the environment.
- Planning movements and putting them in order, and strength and coordination of muscles. This means that a person may be able to walk but have difficulty planning their movements or may move impulsively.
- The vestibular system. Everyone has a vestibular system which is made up of organs in the inner ear and the vestibular nerve. The vestibular system provides the brain with information about motion, head position, and where you are in a space. It also helps with balance by stabilizing the head and body during movement and maintaining good posture.
- Vision. Movements can become more difficult if there are visual deficits that make it more difficult to see.
Many survivors with traumatic brain injury will not have significant visible physical limitations because of the brain injury (although they may have additional temporary injuries like broken bones which will impact mobility). In many cases, physical deficits are ‘invisible’ to others. This is true of cognitive and behavioural effects as well. This is why brain injury is often referred to as an invisible injury.
Effects on mobility after brain injury
- Balance is the ability to keep yourself centered as you walk, sit, and engage in other movements. It allows you to control and adjust your body before, during and after movement to keep from falling. Balance problems after a brain injury are common: 30-65% of survivors have reported some sort of issue with balance .
Balance requires functional muscle strength, vision, vestibular function (inner ear), sensation in the skin, muscles, tendons and joints (known as proprioception). It also requires cognitive function and movement planning. When you are keeping your balance, your brain is continually processing inputs and information from multiple senses and body parts. The brain then sends directions out to the body’s motor and sensory system (muscles in the arms, legs, core, and eyes) to keep you centered.
Common causes of balance problems after an acquired brain injury include:
- Changes in blood pressure
- The actual injury to the brain
- Mental health issues like depression, anxiety, fear of falling, or fear of moving
- Sensory impairments
- Impairments in motor control
- Dizziness, which is a sensation of light-headedness, spinning, or nausea.
Balance is important not only for walking but for doing all daily activities. Poor balance can keep you from taking part in activities such as sports, driving and work. Issues with balance and dizziness can increase the risk of falls and injuries, including another head injury. It can have an impact on your abilities and your mental health and well-being.
How can I improve my balance?
Balance problems will usually improve over time with activity and exercises. The more you move, the more you improve. You may be referred to a physiotherapist or other specialist who can help you with your balance. While many people with an acquired brain injury can walk or move independently within a few months of their injury, many will have problems with quick movements, running, sports and high-level balance activities. Some people will recover completely while others may have lasting deficits that change their daily lives.
If one or more of your balance systems is not working well, you can try to improve your balance by focusing on areas that are working. For example, if you have poor vision, make sure you have good shoes, optimal lighting, and vision aids
Other ways to cope with balance problems include:
- Use mobility aids such as canes and walkers, if recommended by a healthcare professional.
- Hold onto a family member or caregiver’s arm if you feel unsteady
- Wear proper footwear (closed toe and heel, well fitting, flat-heeled)
- Work with an occupational therapist to make changes to your home environment such as railings on stairs, installing railings and safety chairs in the bathroom, and removing rugs or other tripping hazards.
- Clear high-traffic areas in your home
- Use adequate lighting and nightlights (for example, smart lights that can be controlled by voice or by phone).
- Avoid alcohol or other substances that can impair your sense of balance
- Endurance is having the strength, energy and ability to perform an action over an extended period of time. It can be measured by how well you perform an activity or how much you can increase the intensity or duration of the activity. For example, first you walk further, then you walk faster.
How to improve my endurance
It takes time, patience, and practice to build up your endurance. This will be regulated by your physiotherapist and occupational therapists, healthcare providers, and caregivers. Your therapist may give you strengthening exercises like using small weights or resistance bands. They may also recommend focusing on form and repetition to help your endurance and other aspects of mobility such as posture and gait.
One of the ways you can keep track of your progress is by keeping a record of the activities you are doing. For example, if your goal is to walk 100 metres on the treadmill in a set time, track that progress. Then set your next goal. Goal-setting is something your therapists can help with, and it can help you see how much progress you’re making.
- Gross & fine motor skills
- Mobility refers to the ability to move your limbs. This includes gross motor skills such as walking and larger movements and fine motor skills such as picking things up and writing. These skills are incredibly altered by brain injury. If you lose parts of your mobility, you have to cope with major lifestyle changes. Physiotherapy and occupational therapy can help with strengthening or re-gaining mobility as well as learning new ways to accomplish tasks. This could include activities such as:
- Working with your fingers on small, detailed tasks such as writing or crafting
- Range of motion and strengthening exercises
Certain exercises and activities will be recommended based on your needs.
- Muscle tone, strength, and coordination
- Muscle tone is the amount of tension in a muscle when it’s in the resting position (not being actively used). When muscle tone is normal, the limbs and body feel easy to move. A brain injury may damage your normal control of muscle tone. This may cause decreased muscle tone – your limbs feel floppy and heavy (also called hypotonicity or flaccid). It could also cause an increase in muscle tone – your limbs feel stiff and tight (also called hypertonicity or spasticity). Both affect the ability to control movement.
After a brain injury, muscles may show different degrees of weakness. Some muscles may be stronger in one limb than another. Damage to certain parts of the brain may result in slow, jerky, or uncontrolled movements. You may hear the terms:
- Hemiparesis: muscle weakness on one side of the body only
- Hemiplegia: muscle paralysis (no movement) on one side of the body only
Physiotherapy and occupational therapy can assist with working on muscle tone. This is a process that requires patience as it can take a long time. Your treatment plan will need to be adapted as your mobility changes, and you may never fully regain the mobility that you had before the injury.
How to improve muscle tone and strength
Ways to improve muscle tone depend on whether you are experiencing spasticity or flaccid muscles. If you are experiencing spasticity, your doctor may recommend medication along with stretching and range of motion (ROM) exercises overseen by a therapist. If you are experiencing flaccid muscle tone, treatment can include working on proper positioning, exercises, and joint-positioning devices . Improving muscle tone requires time and patience.
Improving strength involves focusing on which muscle areas need the most help. Exercises such as resistance training can help increase strength over time and with a lot of practice and patience.
How to improve coordination
You need coordination for every movement you make. Improving coordination involves a lot of time and patience, like improving muscle tone and strength. While exercises will vary, they will contain several key components, including but not limited to:
- Goal of increasing speed and accuracy
- Proper form
- Inclusion of sensory cues
- The head and neck give the eyes, mouth, and tongue a stable base. The trunk (the area of your body between the shoulders and hips) gives us a stable base so we can use our arms and legs. To move normally, the head, neck, and trunk need to be properly positioned when standing and sitting.
A brain injury can affect the muscles that control head, neck, and trunk positions. It can also affect the sense of what is upright and what is straight. For example, you may be leaning left or right because the muscles that hold your posture are affected. This may be caused by wrong information coming from the senses about position, limited range of motion, abnormal muscle tone or pain. If posture is poor, you can create a list of visual checks to make when you are sitting or standing. You can also ask for a caregiver to help.
Physiotherapy can be useful in helping you work on your posture when sitting and standing. Therapists will use specific exercises and gait training to help make improvements. Along with these exercises, you can work on your posture by:
- Rolling your shoulders back
- Use a wall to help straighten your posture. Your ears should line up with the middle of your shoulders
- Sit all the way back in your chairs, and choose chairs with high backs
- Wear shoes that provide proper support
- Use a mattress that properly supports the spine
There are also some simple yoga stretches and positions to help with your posture and your flexibility. You should first consult with your therapists and doctors about whether you should perform yoga. If you are coping with balance issues, there are some forms of chair yoga that can be done from a seated position.
- Sensations tell us how we are moving, what we are feeling, and what’s going on around us. Forms of sensation include light touch, pain, temperature, moving joints and muscles, vision and hearing.
Changes to the way you experience sensation can affect your ability to sense movement or position, to feel changes in temperature, or to feel touch to the affected part of the body. It can also make it harder to re-learn movement since movement information must be sensed by thinking about the movement first. Loss of sensation can also make walking and balance more difficult.
Losing sensation can be a very serious safety issue because you may not be able to feel an injury or be aware of that part of your body anymore. It is important to know what types of sensations have changed to help keep yourself safe. For example, if you cannot feel hot or cold temperatures in a part of your body, use an unaffected body part to check the water temperature before a shower.
Managing changes in sensations can be challenging, but your healthcare team can help you learn ways to cope. Your treatment plan will depend on the sensation changes you are experiencing.
Assistance from caregivers
If you require mobility assistance, it is important that your caregivers are trained to provide it. Mobility assistance can include transferring you from a bed to a chair, helping you use the facilities, and walking. Caregivers need to know how to safely lift, position, and move you. This is important for everyone’s safety – proper training reduces the risk of injury for both of you. Caregivers will commonly receive this training from healthcare professionals involved in your care.
When a brain injury causes damage that affects mobility and movement, a physiotherapist will assess your physical status and abilities. After the assessment, a treatment program is created that fits your needs. Rehabilitation programs are goal-oriented, meaning the therapists work with you to develop a treatment plan that not only addresses areas of need, but will help you reach your goals. These goals and plans require ongoing re-assessment and modification as the treatment progresses and your goals change. Physical rehabilitation may consist of activities such as:
- Strengthening exercises focused on building endurance and muscle
- Range of motion (ROM) stretches, which often focus on specific joints
- Balance exercises which will target areas of deficit
- Gait training to improve walking
- Dizziness/vestibular retraining
- Visual/perception re-training
Physiotherapy can be short or long term and requires active participation. You may be given activities or exercises to do between appointments. Doctors may also recommend that you work with an occupational therapist to help meet goals surrounding activities of daily living (ADLs) and work. This could include cooking, typing, using public transportation independently, and more.