Mobility

Every brain injury is different and will require its own treatment plan and timeline. It’s important the person with a brain injury works with medical professionals, including physiotherapists and occupational therapists to address mobility issues and create a rehabilitation plan. This plan may include your involvement as a caregiver.

Topics in this section include:

In some cases, a brain injury will have physical effects on a person with a brain injury. These effects include:

  • Ataxia (jerkiness) and coordination
  • Balance problems
  • Chronic (consistent) pain
  • Fatigue, difficulties with sleeping, and insomnia
  • Headaches
  • Impaired motor control and motor planning
  • Muscle tone
    • Spasticity (increased tone, tightly flexed)
    • Flaccid (reduced tone, limp)
  • Paralysis or weakness
  • Perception and receiving sensory information (for example, phantom pain) and figuring out how to act on it
  • Sensory problems
    • Dizziness
    • Vision (double vision, loss of vision) may cause significant mobility/balance issues Trouble with hand-eye coordination
    • Hearing loss, tinnitus, equilibrium, ringing in the ears
    • Taste
    • Touch and sense of position of the limbs
    • Smell
    • Sensations on the skin like tingling, pain, or itching

Many of these 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.

How the brain 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

In some cases, individuals experience visible effects after their brain injury. For example, stroke survivors often experience increase in muscle tone, meaning parts of their body are tightly flexed. Many people with traumatic brain injury may have additional temporary injuries like broken bones which will impact mobility.

In many cases, physical deficits of brain injury are ‘invisible’ to others most of the time (such as balance issues or hand-eye coordination). It is also more common for people with a brain injury to experience cognitive and behavioural changes. These are only noticed by people who know the person. This is why brain injury is often referred to as an ‘invisible’ injury.

Common mobility issues after brain injury

Balance
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 requires functional muscle strength, intact vision, intact vestibular function (inner ear), intact sensation in the skin, muscles, tendons and joints. It also requires an intact brainstem cognitive function and motor planning. When you have normal balance, your brain is continually processing inputs and information from multiple senses and body parts. The brain then immediately sends directions out to the body’s motor system (arms, legs, trunk/core, eyes, ears, skin) to keep you centered.

Balance problems after a brain injury are common: 30-65% of survivors have reported some sort of issue with balance [1]. This is because there are so many systems involved in keeping proper balance, and damage to one area of the brain can impact those functions.

Common causes of balance problems after an acquired brain injury include:

  • Changes in blood pressure
  • Injury to the brainstem
  • Medications
  • Mental health issues like depression, anxiety, fear of falling, or fear of moving
  • Problems with vision or the vestibular system
  • Sensory impairments

People living with a brain injury can also experience dizziness. Dizziness is a sensation of lightheadedness, spinning, or nausea.

Balance is important not only for walking. Poor balance can keep someone 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 a person’s mental health and well-being.

A survivor may be referred to a physiotherapist or other specialist who can recommend appropriate activities and exercises. Balance usually improves over time, but every individual is different. While most 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.

How to help with balance problems

If a survivor is having issues with balance, there are some ways you can help.

  • Make sure they have good shoes, appropriate eyewear, and walking aids
  • Offer your arm when they are moving. You should stand on the side that is weakest or their non-dominant side to offer the most support.
  • Inspect mobility aids before each use, and make sure brakes and moving parts are in working order
  • If stairs are unavoidable, install railings on stairs, and encourage the person to use them
  • If stairs are unavoidable in your home and walking up them is exceptionally difficult, an electronic stair lift could be beneficial
  • Get rid of rugs to eliminate potential tripping hazards
  • Clear traffic areas in the home of furniture and other obstructions
  • Use appropriate lighting and nightlights

Another way to provide assistance is to help the survivor avoid alcohol and substance use, which can impair faculties involved with balance.

Endurance
Endurance is having the strength and ability to perform an action over an extended period. It can be measured by how well you perform an activity or an increase in the activity. For example, first you walk further, then you walk faster.

For most of us, we have the endurance necessary to go about our daily lives with ease – we don’t even think about it. But after a brain injury, a person may lose some of their endurance. They may get tired more easily/quickly and no longer have the ability to complete tasks the way they did before their injury.

How to help a survivor improve endurance

It takes time, patience, and practice to build up endurance. Your role in the process is as a motivator and supporter. As they work on endurance building and strengthening exercises set by physiotherapists, kinesiologists, or occupational therapists, they will need someone to encourage them. You may also have to help them with some of the exercises by watching their form and gait to make sure they are doing it correctly outside of appointments.

One of the ways you can provide motivation is to help keep track of their progress for each activity. For example, if their goal is to walk 100 metres in a set amount of time, track that progress. Then help them set their next goal. Goal-setting is something the therapists can help with, and it can help both of you see how much progress they’re making.

Gross and fine motor skills
Mobility refers to one’s ability to move their limbs/extremities. This includes gross motor skills such as walking and larger movements and fine motor skills such as picking things up. This is an incredibly challenging effect of brain injury. Survivors who lose parts of their mobility have to cope with major lifestyle changes. Physiotherapy and occupational therapy can help with strengthening or re-learning 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 the survivor’s normal control of muscle tone. This may cause decreased muscle tone – the limbs feel floppy and heavy (also called hypotonicity or flaccid). It could also cause an increase in muscle tone – the 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. The survivor may experience hemiparesis – muscle weakness on one side of the body only. Some may experience 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. The treatment plan will need to be adapted as mobility changes. They may never fully regain the mobility they had before the injury.

How to help improve muscle tone and strength

Ways to improve muscle tone depend on whether the person with a brain injury is experiencing spasticity or flaccid muscles. If they are experiencing spasticity, their healthcare provider may recommend medication along with stretching and range of motion (ROM) exercises overseen by a therapist. If they are experiencing flaccid muscle tone, treatment can include working on proper positioning, exercises, and joint-positioning devices [2].

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.

Your role as the caregiver is to provide the motivation and support their needs. This is difficult physically, emotionally and mentally for the person with a brain injury, who in the past was able to be mobile without assistance. As difficult as it may be, they will appreciate having you in their corner. It will also be difficult for you to watch them go through this process. You will also need a support system to take care of yourself and your mental health.

How to help 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 for the survivor will vary, they will contain several key components, including but not limited to:

  • Repetition
  • Goal of increasing speed and accuracy
  • Proper form
  • Inclusion of sensory cues
Posture
The head and neck give the eyes, mouth, and tongue a stable base. The area of your body between the shoulders and hips – also known as the trunk – 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, the person with a brain injury may be leaning left or right because the muscles that hold their 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 abnormal or poor, the person may need a list of visual checks to use when they’re sitting or standing. (looking for hip tilt, shoulders back, head up). You can help them by reminding them what to do to sit correctly. This list will depend on what posture problems they are having.

Physical rehabilitation can be useful in helping the survivor work on their posture when sitting and standing through developing muscle strength, exercises and gait training.

You can help by reminding them or assisting them with:

  • Rolling their shoulders back
  • Using a wall to help straighten their posture. Their ears should line up with the middle of their shoulders
  • When they sit, have them sit all the way back in their chairs, and choose chairs with high backs
  • Wearing shoes that provide proper support
  • Using a mattress that properly supports the spine

There are also some simple yoga stretches and positions to help with posture and flexibility. The survivor should first consult with their therapists and doctors about whether they should perform yoga. This is an activity you could both do together.

Sensations
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 the person with a brain injury experiences sensation can affect their 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.

Losing sensation can be a serious safety issue because they may not be able to feel an injury or be aware of that part of their body anymore. It’s important to know what types of sensations have changed to help keep them safe. For example, if they can’t feel hot or cold temperatures in a part of their body, get them to use an unaffected body part to check the water temperature before a shower.

Managing changes in sensations can be challenging, but the healthcare team can help both of you learn ways to cope with this change. The treatment plan will depend on the sensation changes they are experiencing.

How to assist a survivor with mobility issues

If you are providing mobility assistance to a brain injury survivor, it’s important that you are trained to do so safely. Helping someone with mobility can involve transferring them from a bed to a chair, helping them use the facilities, and walking. Caregivers need to know how to safely lift, position, and move the person to reduce the risk of injury for both of you.

The best way to get this training is to work with doctors and therapists to learn safe procedures for lifting, moving and positioning. This is particularly important if they are unable to assist you during these processes.

Lifting

Lifting a person is a common caregiver duty that presents a unique challenge for people who are not used to it. It is difficult to do, and it’s something that must be done properly and safely to prevent injury.

Proper lifting should be practiced a few times before you attempt to do it unsupervised to minimize the risk of injury to yourself and the person you’re lifting. Caregivers who are lifting – especially on a daily basis – are at risk of injuring their back, neck and/or shoulders. In order to protect your body, you should take care of yourself through:

  • Exercise
  • Proper posture
  • Asking someone (for example, another caregiver) to assist you
  • Having the environment properly set up
  • Using proper lifting and moving tools like boards and chairs
  • Motivating the person with a brain injury to help with moving (if they are able)
If you are lifting someone, adhere to the following steps
  1. Tell the person you are going to lift them. Explain the process, and if they are mentally/physically able to, ask them to help you as much as possible
  2. Following proper lifting techniques, create a balanced base with one foot slightly behind you. Assume a squat-like position, keep your spine aligned and your shoulders squared
  3. Keep your elbows slightly bent and use your abdominal muscles, hips and legs; do not use your back to lift
  4. Keep the person as close as possible to the center of your body
  5. Shift your feet towards the location you will be lowering the person
  6. Bend your knees as you lower

Remember: if you are lifting someone out of a wheeled device, make sure the device brakes are engaged.

Helping someone out of a chair
This is most appropriate for someone who can still walk in some capacity. When sitting, the survivor should choose a sturdy chair with armrests if possible.

  • Ensure that the mobility aids are at the correct height and placement
  • Ask them to move forward in the chair
  • Help them slide their feet back until they are positioned under them, so they can rise to a standing position
  • They should use both hands to push on the chair’s armrests. Alternatively, if the survivor has one weaker arm, this could go on the mobility device. They should not put both hands on the mobility device – for example, a walker – when trying to stand
  • Ask them to lean slightly forward as they stand
Sitting up in bed
  • Show the survivor how to roll to the side of the bed
  • Have them slide their legs off the side of the bed
  • Have them push up from their forearm into a sitting position
During a car transfer
  • The survivor should push off the sear, not the car door, during transfers
  • They should be fully in their seat before their feet leave the ground
  • Have mobility aids ready if necessary
During shower and bathtub transfers
  • Use grab bars if available. Make sure the survivor knows not to use the towel bars as grab bars. They are not designed to provide that kind of support, and could lead to an accident
  • Ask them to sit on a transfer bench or shower safety seat (recommended) and carefully lift their legs over the edge of the tub [3]

If the person requires special tools or moving techniques, work with doctors and therapists to learn and practice how to move them safely.

Physical rehabilitation

When a brain injury causes damage that affects mobility and movement, a physiotherapist or kinesiologist – or in the case of fine motor skills, an occupational therapist – will assess the person’s physical status and abilities. After the assessment, a treatment program is created that fits the person’s needs. The rehabilitation program is tailored to the survivor and requires ongoing re-assessment and modification to make sure that it is optimized for positive progress. Rehabilitation may consist of activities such as:

  • Strengthening exercises focused on building endurance and muscle
  • Range of motion (ROM) stretches focusing on specific joints
  • Balance exercises which will target areas of deficit
  • Gait training to improve posture and walking
  • Dizziness/vestibular retraining
  • Visual/perception re-training

Physical therapy can be short or long term and requires active participation. The survivor may also be given activities or exercises to do at home between appointments under the supervision or with the assistance of caregivers. If this is the case, you will be shown how to help the person with these activities, including knowing when the exercise is being performed correctly.

Resources/studies

Factors That Influence Functional Mobility Outcomes of Patients After Traumatic Brain Injury

Can robot-assisted movement training (Lokomat) improve functional recovery and psychological well-being in chronic stroke? Promising findings from a case study

See sources