Cognitive effects

Individuals with acquired brain injuries experience cognitive impairments that can impact them for the rest of their lives.

Topics in this section include:


Changes in cognitive abilities

Attention & concentration
Attention is being able to focus on something. There are several different types of attention, including:

  • Selective (focused) attention: This is being able to ignore distractions. Examples of challenges with selective focused attention may include being unable to focus when there are multiple people talking or being easily distracted while driving. Other examples include forgetting what you were going to get from the bedroom, or trouble preparing a meal.
  • Sustained attention: This is how long you can concentrate on an activity or task. Sustained attention depends on factors such as the task, how tired you are, and environmental distractions.
  • Spatial attention: This is your ability to be aware of specific locations in the environment.
  • Alternating (divided) attention: This lets you switch from one task to another without losing track of what you’re doing, and to keep track of several things at once. This may be difficult to do after a brain injury.
  • Attentional capacity (‘working memory’): This is how much information you can take in at once without getting overloaded and your ability to use that information. For example, the average adult can hear and repeat a 7-digit phone number but usually won’t remember it 5 minutes later. After a brain injury, you may not be able to take in as much information.
  • Prospective memory: This is the ability to plan, retain and retrieve an idea as planned. For example, if you need to run an errand, you need to plan to stop at the store, remember to stop at the store, and complete your errand. This memory can be challenging for someone with an acquired brain injury because planning can be difficult.

The changes in attention that can happen after a brain injury can make it hard to follow a conversation, hard to work, or make it unsafe to cook a meal or drive. In the early stages of recovery, you might not be alert enough to communicate or be fully aware of your environment. If you can focus on something, it may only be for a short amount of time.

At times, one small detail or focus on the wrong information may cause you to be distracted. These distractions could be internal: for example, you might be distracted because you need to go to the bathroom. The distraction could be external: for example, while talking, your attention may be on someone’s tone of voice or clothing rather than what they are saying. You could be trying to pay attention to words, how you look, noise from the street, and other activity in the room all at the same time.

If you can’t concentrate, it’s hard to finish a task. You might know what you need to do, but have trouble keeping track. We all have problems concentrating, especially when we’re tired or don’t feel well. For individuals with a brain injury, it can be so difficult to pay attention or concentrate that it’s hard to do even the simplest task like washing your hands or dressing.

Tips to help with concentration and attention

  • Ask people to repeat the things they say to you and break it up into small bits of conversation. This will help you absorb the information.
  • Break tasks into small steps.
  • Engage in hobbies or activities that you enjoy and can do. Card games, puzzles, and reading help develop concentration and are entertaining at the same time.
  • People who have trouble focusing may get tired quickly. Make sure you take short breaks to give your brain a rest.
  • Reduce distractions; have only one person in the room, turn off the TV or radio, and try to limit the number of things you’re doing at the same time.
  • Take away time pressures. Don’t rush through a task or expect it to be done perfectly.
Judgement and problem-solving
Problem-solving and judgment may be impaired after a brain injury. You might have trouble judging a situation, figuring out what the right response should be, or act on your first impulse. Your thinking style may not be flexible – in other words, once you make up your mind, it can be hard to change it.

Problem-solving skills are incredibly important for living independently and safely. You may need to work with specialists or caregivers to develop these skills.

Tips for judgment and problem-solving

  • Ask for feedback on your behaviour. You can ask your psychologist, occupational, or speech therapist for ideas on how to do this
  • Consider the possible reactions of people that would be affected by your decision
  • Make a list of choices – or ask your caregiver to give you choices – when it comes time to decide. For example, have your caregiver ask if you want to go for a walk, practice exercises or watch TV instead of asking what you want to do
  • Reduce distractions that could affect your decision-making process
  • Take extra time to clearly think about your decision
  • Try planning and reasoning out loud so you can more clearly think about your decisions. You can also have a caregiver listen to you and make suggestions
  • Work with a caregiver, friend, or family member on decisions whenever possible
  • Write down the important things to think about when making a decision. This gives you a guide to refer to during the process
  • Write down problems or situations from the past – they can help with decision-making in the future.
Language & communication
After a brain injury, it’s common to have trouble with speaking, understanding language, writing and reading. This includes:

  • Difficulty expressing yourself
  • Difficulty finding words
  • Difficulty understanding others
  • Trouble with conversation
  • Trouble with facial expressions or tone
  • Difficulty organizing your speech
  • Not being able to respond appropriately

These challenges can come from physical issues with control over your tongue, mouth and throat muscles. They can also arise from damage to the parts of the brain that control and understand language (this is called aphasia).

Tips to improve communication skills

A speech-language pathologist can help identify the best strategies for successful communication when a person has a brain injury, but there are a few general guidelines that can help you communicate:

  • Find a place where you feel comfortable talking and listening, where you don’t feel pressured or distracted
  • Don’t turn on a TV, radio, or other noisy items when you want to communicate with someone
  • Talk and listen to one person at a time. Group conversations can be overwhelming and hard to follow
  • If you don’t understand someone, ask them to repeat themselves or use different wording
  • Take your time to think and speak – there’s no rush

It is also important to show patience and understanding. This is an adjustment for everyone and tempers and frustration can run high. It’s normal to experience those feelings, but it’s important to make sure you are doing what you can to address those feelings appropriately.

Memory
Memory is generally divided into two categories: declarative and non-declarative. Declarative memory is things that can be clearly remembered such as specific past events (episodic memory) or knowledge and facts (semantic memory). Non-declarative procedural memory is memory that is retained as a skill or a motor response.

How memory is affected depends on the brain injury. Some individuals lose their memories of time before or immediately after the injury. Others are unable to make new memories, while still others forget skills or motor responses that used to be second-nature, although this is less common.

The most common types of memory loss after a brain injury are:

  • Short-term memory loss: This means you can’t remember things that just happened and are often influenced by problems with attention.
  • Amnesia: This most commonly refers to loss of declarative (episodic) memory after damage to specific areas of your brain’s memory system. Amnesia can be divided into anterograde and retrograde.
    • Anterograde amnesia: This means the inability to form new memories, after the time of injury, and is often the result of short-term memory loss.
    • Retrograde amnesia: This means you’ve forgotten what happened before your brain injury.

On rare occasions, a person with memory loss may remember things that did not happen or twist events. This is called confabulation, and it’s done automatically without the person realizing it: they don’t know that they are making up information and tend to not fully recognize the impact of their brain injury.

Problems with memory can affect progress in all areas. If memories fade quickly, you won’t be able to learn from new experiences, remember that you’re making changes or remember that you’re improving. This can have a huge impact on rehabilitation. In therapy, you’re learning mobility skills, how to use assistive devices, how to communicate and how to process information. If you have trouble remembering what you learned from one day to the next, progress may be slower.

During the assessment stage of therapy, therapists will test memory for events that happened:

  • Before the accident (remote or retrograde memory)
  • In the past few minutes (immediate memory)
  • In the past few minutes, hours, or days (recent or anterograde memory)

Immediate and recent memory tends to be more affected by a brain injury than remote memory.

Memory recovery is often slow, and in some cases a person may never fully recover. This can be incredibly frustrating and upsetting for both you and family/friends. It’s important to be gentle with yourself, and as you cope with the changes surrounding your brain injury that you do what you can to take care of your mental and emotional health.

There are steps you can take to help with any memory changes you may be experiencing.

Tips to help with memory

  • Be patient with yourself. It’s frustrating to not be able to remember things, but you’re working hard. Take the time you need, ask people to repeat themselves if needed, and be kind to yourself when you’re working on your memory
  • Choose activities that are familiar to you – this will help you form memories, and create enjoyable experiences
  • Having routines helps all of us remember, so consider creating routines for events that are repeated everyday, like when you have meals or where you put the housekeys
  • Try to use one calendar system for keeping track of events, rather than several different systems in different rooms or situations
  • Use any calendar or routine consistently – consistency helps make habits and avoids confusion
  • It’s a good general rule to write things down if you need to remember them. Have paper and a pen or pencil with you so that you can write down important points, or ask the person with whom you’re speaking to write down what they want you to remember
  • You can buy devices that shut off stoves and other appliances automatically. This can help to prevent safety hazards
Planning skills
Many people with a brain injury find it hard to plan, begin, and finish an activity. You may not be able to think ahead or lack follow-through to finish a task. Your thinking may be disorganized and incomplete. This may show up as repetitive movements or comments. You might act impulsively by doing something quickly without thinking or need a lot of time to understand information and respond the right way.

Planning is an important part of building independence. For example, you need to be able to do laundry, so you have clean clothes. This means you need to know when to add soap, how to set your washing cycle, and how to set your drying cycle. You may not be able to plan out all the steps right away, but by setting goals and working with rehabilitation specialists, you can develop your planning skills.

Tips to help with planning

  • Break down the task into small steps. For example, when making a salad, first prepare the lettuce. When this is done, proceed to the next step, and so on
  • Have a caregiver, friend, or family member clearly and briefly explain the activity before you start
  • Read instructions or have directions read to you slowly so you have time to understand and respond
  • Reduce distractions, reduce the demands, and give yourself extra time to problem-solve
  • Routines and schedules outlining future events help with better organization
  • Use a checklist so that you can check off each step of a task as you do it
  • Use a calendar or whiteboard to provide visual cues and reminders
  • When possible, help with household chores (as much as you can do). Things like setting the table, washing the dishes, or preparing a salad need planning but may be familiar enough that you can do them easily. These kinds of activities will help you practice step-by-step planning
  • Daily activities tracker
Self-awareness
It’s common after a brain injury for a person not to be as self-aware as they were before. For example, an injured person may not be aware of what they can’t do anymore. They may not notice or remember the changes in themselves, be in denial, or grieving those changes, which are emotional responses. Or they feel pressure to return home or return to work even if they are not completely ready. This may lead to the person overestimating their abilities and underestimating their problems.

Self-awareness is difficult to spot in yourself. This is when you need the help of therapists, caregivers, family, and friends. Your support team will help you figure out the best ways to receive feedback and identify ways to improve self-awareness. For example, perhaps you’re more likely to listen to a sibling vs. a parent, or a doctor over a family member when receiving feedback.

It’s important to note that these symptoms of cognitive changes after a brain injury won’t happen in everyone. They can also happen for people with mental health disorders, the aging population, and people with different illnesses. People who experience cognitive symptoms following an acquired brain injury (ABI) should be referred to a neuropsychologist for formal neuropsychological testing that can provide insight into the root cause of the symptoms. These results and the profile of your cognitive needs will be used to create individualized treatment plans.

Cognitive rehabilitation and recovery

Every person is unique, and so is each brain injury. For that reason, it is impossible to predict how recovery will impact your cognition (thinking skills). Cognitive rehabilitation is a tool that can have a positive impact. Cognitive rehabilitation is a collection of treatments that work to improve a person’s cognitive functioning in everyday life after injury. A variety of different professionals are involved in cognitive rehabilitation, but the most common therapists are licensed Speech-Language Pathologists (SLPs) or Occupational Therapists (OTs). Sometimes therapy is delivered by a person called a “cognitive rehabilitation therapist” (CRT).

For cognitive rehabilitation to be effective, it must be designed specifically for your needs and your goals, with a focus on both your cognitive strengths and areas you find challenging.  Each person is different, which means rehabilitation plans needs to be as well.

Cognitive rehabilitation can be helpful even years after injury. It’s never too late to seek support to develop cognitive skills and address challenges you may be facing.


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Tips for aging with a brain injury

There are steps you can take to keep yourself as healthy and safe as possible as you age.

Do activities that are engaging and enjoyable

Keeping yourself engaged and entertained is good for your emotional well-being and your brain. This includes hobbies you enjoy, meeting with friends, and anything else that brings you joy. It’s also helpful to complete activities that pose a bit of a challenge. It stimulates your cognitive process, can have physical benefits, and can give you goals to work towards.

Have regular medical checkups

It’s important as we age to have regular medical checkups. Individuals often spend a lot of time in rehabilitation and treatment for brain injury, but the rest of the body needs checkups too. Medical professionals will give you advice on exercise, diet, and other parts of your overall health.

Make sure you’re in an appropriate living situation

In some cases, seniors are not able to live alone or at home. In these cases, long-term care homes may be the most appropriate option. Many long-term care homes are specifically equipped for seniors, making them a safe, and comfortable choice. Many are also equipped for individuals with specific needs, including the effects of brain injury.

If you are moving into a long-term care home or are completing rehabilitation while in a long-term care home, there may be some adjustments you need to make.

  • Establish new routines. Routines are a great way to reinforce memory, familiarize yourself with new places, and stay organized.
  • Create a plan for adjusting to the new environment.
  • Work with healthcare professionals on rehabilitation plans. You may have to complete activities and therapies a little differently in long-term care.

Make sure you’re well-rested

Fatigue is a common effect of brain injury. It’s also common in seniors; it takes more energy to complete actions or tasks. That’s why it’s incredibly important to prioritize a good night’s sleep and listen to your body. Take rests when you need to, and don’t overwork yourself.

Protect yourself from falls

If you struggle with balance or mobility or want to take extra precautions against falls:

  • Arrange furniture so you have plenty of space to walk
  • Avoid putting frequently used items on high shelves
  • Avoid wet, slippery floors, and don’t let water build up on walkways or driveways
  • Clean up any spills or dropped food right away
  • Have plenty of light so you can easily see where you’re going
  • Install gates and handrails on staircases
  • Keep drawers and cabinet doors closed
  • Never stand on a chair, a table, or any surface that has wheels
  • Remove clutter from your walkways outside, and keep the paths inside your home free from tripping hazards (boxes, books, clothes, toys, shoes, unsecured rugs)
  • Secure any cords safely out of the way
  • Wear shoes with good support and slip-resistant bottoms

Stay active within your community

Keep in touch with your friends, family, and community. Go for lunches, participate in community activities, volunteer, and stay in touch through phone calls, emails, and in-person get-togethers. You will reduce your risk of social isolation and cultivate a strong support system.

Take care of your mental and physical health

Staying healthy and active is an important part of aging. This includes eating well, exercising, and taking care of your mental health and wellbeing. There are many ways you can create a healthy lifestyle as you age.

  • Learning new, easy meals to make at home
  • Keep a journal to share your thoughts and feelings
  • Taking daily walks
  • Use appropriate correction equipment for hearing and vision loss. I.e. hearing aids and glasses
  • Use mindful meditation to help clear your mind

These ideas are just the tip of the iceberg. Find practices or activities that make you feel happy and fulfilled and work them into your routines.

Ways to find help after an opioid overdose

Meeting with a counsellor

Counselling is a positive step towards overcoming problematic substance use. Licensed therapists can provide one-on-one help and give concrete advice and practical tips towards change. Counselling is also beneficial for individuals with a brain injury who are learning to cope with the changes in their lives.

Help groups

Many cities have local help groups for substance use. These groups are designed to offer a supportive environment for people with living experience of substance use. Local healthcare professionals should be able to provide more information about support in a specific area and whether they can support specific needs post-injury.

There are also many brain injury associations across Canada that offer programs and resources specific to the area.

Residential rehabilitation

For those who need a different environment, residential rehabilitation centres are available. There are both private and public addiction centres in Canada. While public centres are free, they have long wait times. Private centres involve out-of-pocket expenses.

Please remember: not every centre will be equipped to meet the needs of a person with problematic substance use and brain injury. It’s important to work with a medical team to find the best course of treatment.

Supervised consumption sites

Problematic drug use is a complex issue with no easy solution. Many people struggle to stop. This is where supervised consumption sites can be useful. They are a place for people looking to stop or reduce their drug use, and research shows they are effective at improving health and saving lives.

Along with offering a safe place for consumption, many supervised consumption sites have screening services to catch potential contaminants, access to emergency services, testing for diseases/infections, and referrals/information on treatment (Source: Government of Canada).

Resources

Disclaimer: We cannot guarantee the accessibility of any resources not located on our website.There are no quick and easy answers to substance use problems, but there are resources for individuals looking for help.


Disclaimer: There is no shortage of web-based online medical diagnostic tools, self-help or support groups, or sites that make unsubstantiated claims around diagnosis, treatment and recovery. Please note these sources may not be evidence-based, regulated or moderated properly and it is encouraged individuals seek advice and recommendations regarding diagnosis, treatment and symptom management from a regulated healthcare professional such as a physician or nurse practitioner. Individuals should be cautioned about sites that make any of the following statements or claims that:

  • The product or service promises a quick fix
  • Sound too good to be true
  • Are dramatic or sweeping and are not supported by reputable medical and scientific organizations.
  • Use of terminology such as “research is currently underway” or “preliminary research results” which indicate there is no current research.
  • The results or recommendations of product or treatment are based on a single or small number of case studies and has not been peer-reviewed by external experts
  • Use of testimonials from celebrities or previous clients/patients that are anecdotal and not evidence-based 

Always proceed with caution and with the advice of your medical team. 

Opioid overdose

Opioid overdoses can have catastrophic results, including brain injury. Brain injuries present new challenges and changes that can be difficult to cope with, particularly if the survivor is also trying to cope with substance use. It takes a long time to figure out the extent of the changes they have experienced and establish a continuing care plan that will help them with rehabilitation and the recovery process. The effects of the brain injury will change them as well. It’s a scary experience that can be hard to put into words or share with others and can have a huge impact on mental health and wellbeing.

This can feel incredibly lonely, but it’s important to remember that there are people and places that can provide support. Whether this is a family member, a friend, a support worker or even a local brain injury association , there are resources available to help a survivor succeed in their next steps.

Topics in this section include:


What are opioids?

Opioids are a drug used to manage pain, typically after surgery. They induce feelings of euphoria (happiness or ‘feeling high’). When prescribed by a doctor and taken in the recommended dosages, opioids can be safe. These prescriptions are often made with codeine, fentanyl, morphine, oxycodone, hydromorphone, or medical heroin.

Opioids can also be produced and obtained illegally and in a variety of forms. When obtained on the black market, opioid production is not controlled. Often these opioids contain unsafe doses of fentanyl or carfentanil. Carfentanil is specifically for large animals (like elephants), not humans. It’s approximately 100 times more toxic than fentanyl and 10,000 times more toxic than morphine. The smallest amount could cause an overdose.

How do opioid overdoses cause a brain injury?

An opioid overdose can cause damaging effects such as slowing breathing/heart rate and starving the brain of oxygen. The parts of the brain that use the most energy and oxygen are the most vulnerable. When loss of oxygen is more severe it can also damage areas of the brain that are fed by the smallest blood vessels that are furthest from the heart.  The medical term for partial oxygen deprivation is hypoxia. Hypoxia can worsen into anoxia when a person completely stops breathing.

Opioids have their effect by causing the brain to release dopamine, the brain’s natural opioid, in greater amounts. When used over a long period of time, the brain adapts by reducing the number of receptors, a process known as tolerance. Opioids alter the brain and how a person responds to normal rewards in the environment. Things that would normally make someone feel good and happy may no longer be motivating. That is why some people may, use drugs in a dangerous way, even though they know their opioid use is causing problems. This leads to a greater risk of overdose. Approximately 12 people die from opioid overdoses in Canada every day, having the biggest impact on Canadians aged 15-24 [1].

Currently there isn’t much research on individuals who acquire a brain injury through an opioid overdose. What is evident is that those who do survive an overdose from opioids can be left with catastrophic brain injuries that deeply affect the survivor and those close to them.

Substance use can continue to be a concern after a brain injury. The difficulties with attention, memory and judgment may make it more difficult to benefit from care. Substance use after brain injury can often interfere with the brain’s natural recovery and participation in treatment.

Effects of an opioid overdose

Depending on what parts of the brain are damaged and how long the brain was without oxygen, the survivor may experience [2]:

  • Limb weakness
  • Balance and coordination issues
  • Spasticity or rigidity in muscle tone
  • Abnormal, involuntary movements
  • Loss of vision
  • Memory loss
  • Speech and language challenges
  • Changes in cognitive abilities related to thinking and decision-making – this can affect future planning, work and social interactions
  • Changes in personality – this includes irritability, impulsiveness, and social impairments

The impact of overdose can range from subtle to severe. Some people may notice that they are more forgetful, less coordinated or have more trouble getting and staying organized. For survivors of many episodes of overdose, or longer and more severe anoxia, they may experience fundamental changes to their personality and abilities. Recovery does occur, but many changes may be lasting and require rehabilitation.

If you have had an opioid overdose and are experiencing subtle challenges, see the section below on ways to find help after an opioid overdose and brain injury

Substance use rehabilitation and brain injury

One of the existing challenges with treatment for substance use and brain injury at the same time is that current facilities/programs are not equipped to handle both. The majority of brain injury rehabilitation, community, and support programs require participants to be sober. Similarly, centres and programs that specialize in addiction support are not able to handle the complex needs of someone with a brain injury.

This does not mean that a support plan can’t be created – it just means that the survivor will need to work with caregivers and medical professionals with knowledge of what services are available.


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Mobility aids

You may find that you need help navigating the world after your injury. There are several mobility and environmental aids that can make moving around easier. You should only use a mobility aid if it is recommended by a physiotherapist or occupational therapist. The therapist will make sure the aid fits you and will show you how to use it properly. Using an ill-fitting aid or using an aid improperly can increase the risk of injury (e.g., due to falls or repetitive strain).

Canes

Canes are an excellent aid that offer support if you have a deficit on one side of your body and only require a small amount of help moving. They are meant to help with balance and should be used when a person can mostly walk on their own.

Walkers or rollators

A person uses a walker when they require more stability. A walker has four legs. Rollators are like walkers but have wheels for ease of use. Walkers and rollators are sturdier than canes and allow people with more significant balance problems to continue walking, building up their strength and stability over time. In some cases, a person may need to use a walker or rollator permanently for safety.

Wheelchairs

In some cases, a person with a brain injury may not be able to walk. This could be temporary or permanent depending on the cause. Some people may find that they can walk short distances or indoors but need a wheelchair to travel longer distances or outdoors. When a person is unable to walk, they use a wheelchair. There are several different kinds of wheelchairs ranging from basic manual models to more advanced motorized chairs. Wheelchairs can provide you with the ability to move around, but it does mean that some places may be inaccessible, and your home environment will need to be adapted.

Walking poles

For some people, walking on uneven ground (typically outside) can still pose a challenge, even if they are able to walk indoors with no trouble. This is where walking poles can come in handy. Also called urban poles, these walking poles can be used for increased activity and for balance by people in rehabilitation. Some sticks even come with special ‘feet’ or ‘grips’ that can be changed depending on the environment and purpose of the walk. Many models are also collapsible for easy storage. If you would like to try using walking poles, you should consult with your doctor first, particularly if you are currently using a walker or cane. You should also be aware that if you have joint pain or are unable to grip the poles that they may not work for you.

Orthotics and proper shoes

When a person experiences mobility issues, there is the possibility that the way they walk, and their posture will change as a result. This can cause additional health problems, including pain. Doctors may recommend orthotics or special shoes that provide more foot and arch support in order to alleviate related pain, correct skeletal positioning/posture, and overall help improve balance [1].

Some people with brain injury have ‘drop foot’. These people will have difficulty flexing the foot when swinging the leg forward during walking. The toes may drag on the ground and increase the risk of tripping. An ankle-foot orthosis is a device that fits around the ankle and helps to keep the toes from dragging while walking. Alternatively, a functional electrical stimulation device can activate the muscle at the front of the shin during the swing phase of walking to flex the foot. If you think you have drop foot, you should speak to your doctor or physiotherapist about getting an ankle-foot orthosis or functional electrical stimulation.

Stair lifts

Stairs can be difficult to use if you are experiencing problems with walking, lifting your legs, and balance. If your home has stairs and you are not able to live entirely on one floor, a stair lift is a safe alternative. These are mechanical chairs that move up and down on a track. They can be installed in your home to make the environment more user-friendly.

Ramps

If you have a wheelchair, you will need to use ramps to access places, including your home. There are companies that make these modifications and will be able to recommend appropriate ramps for you.

Wider doors

If you are using a walker or in a wheelchair, you may need wider doors to navigate easily. This is an additional renovation you may need to complete.

Bathroom adaptations

Using the washroom with mobility issues can be frustrating and unsafe. There are several modifications that can be made to make it easier, including:

  • Grab bars
  • Higher toilets
  • Walk or wheel-in showers
  • Shower seats

Your bathroom is just one area that may need some modifications. An occupational therapist will be able to help you identify problem areas in your home and how best to adapt them to suit your mobility needs.

There are renovation grants available if you need to adjust your living environment. Available funds depend on provincial programs.


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Mobility

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
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 [1].

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
  • Medications
  • 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
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 [2]. 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:

  • 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 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
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.

Physical rehabilitation

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.


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Tips for coping with hearing loss

Avoid noisy environments

If you have some hearing, avoiding noisy environments can make it easier for you to hear and understand conversation. The more background noise there is, the harder it is for your auditory systems to filter out what’s important, making it harder for you to communicate.

Hearing aids

Some hearing loss is permanent, but can be helped with hearing aids. There are a few different types of hearing aids your audiologist may recommend [1].

In-the-ear (ITE)
This type of hearing aid fits inside the ear canal and on the outer portion of the ear. This type is best for mild hearing loss.
Behind-the-ear (BTE)
This type fits behind the ear. This hearing aid works for all degrees of hearing loss, including severe. Behind-the-ear aids work with other assistive devices including FM systems, telephone adaptors, and television amplifiers. This is a good option for people who have small ear canals or get ear infections.
Open fit hearing aids
These are similar to the behind-the-ear aids because the amplifier and electronics sit behind the ear. There is a slim tube and tip that sit inside the ear canal. This is a more comfortable option for people with small canals. Open fit hearing aids work for severe hearing losses and are best for persons with mild to moderate high frequency hearing loss.
CROS (Contralateral Routing of Signal)
This system is for people with one ear that is unable to be helped by a hearing aid. A microphone on the ear with a deficit can feed sound to the stronger ear.

Lip reading

Lip reading is a difficult skill to learn, but it can come in handy for communicating with others on a daily basis, particularly since the majority of people don’t know sign language.

Subtitles for videos

Subtitles for videos and films make it possible to still enjoy visual content without having to rely on audio to understand what is happening.

Use American Sign Language

American Sign Language (ASL) is an effective way for people with hearing deficits to communicate. Like learning any new language, it will take a lot of time, hard work, and patience to learn. It may also require other members of your household or close community to learn it as well so that they can communicate with you in a way that’s easy for you. There are courses you can take.

Use writing as a communication tool

Reading and writing are effective tools of communication. You can have others write out what they want to say if you’re having quick conversations. There are also dictation programs available that generate words based on what a person is saying. This can be an effective tool if you aren’t using sign language or are communicating with someone who does not know sign language.


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Disclaimer: There is no shortage of web-based online medical diagnostic tools, self-help or support groups, or sites that make unsubstantiated claims around diagnosis, treatment and recovery. Please note these sources may not be evidence-based, regulated or moderated properly and it is encouraged individuals seek advice and recommendations regarding diagnosis, treatment and symptom management from a regulated healthcare professional such as a physician or nurse practitioner. Individuals should be cautioned about sites that make any of the following statements or claims that:

  • The product or service promises a quick fix
  • Sound too good to be true
  • Are dramatic or sweeping and are not supported by reputable medical and scientific organizations.
  • Use of terminology such as “research is currently underway” or “preliminary research results” which indicate there is no current research.
  • The results or recommendations of product or treatment are based on a single or small number of case studies and has not been peer-reviewed by external experts
  • Use of testimonials from celebrities or previous clients/patients that are anecdotal and not evidence-based 

Always proceed with caution and with the advice of your medical team. 

Tips to manage fatigue

There are some actions you can take to help manage your fatigue.

Ask for help

Fatigue can make it difficult to complete daily tasks, travel, or go to appointments. A caregiver, family member or personal support worker can assist with tasks that may leave you fatigued, and work with you as you build up your endurance.

Cognitive behaviour therapy (CBT) and occupational therapy (OT)

One of the leading causes of fatigue is the extra mental and physical efforts it takes a person with a brain injury to complete tasks.

Cognitive behaviour therapy is designed to help survivors coping with mental and cognitive changes. For fatigue stemming from cognitive changes, cognitive behaviour therapy can be helpful in building endurance and understanding what’s causing fatigue and how to manage it.

Occupational therapy is available to help people living with brain injury relearn skills or find new ways to complete activities of daily living (ADLs). When you practice these skills consistently, it will take less and less energy for you to complete them – this leads to less instances of fatigue.

Remember: the effects of rehabilitation happen over time and recovery is based on several factors. You won’t notice significant changes right away but that doesn’t mean the rehabilitation isn’t helping you. It’s like tracking fitness goals: you notice changes and improvements week to week, not day to day.

These therapies are available both privately and publicly. Private therapy is paid for by you. Publicly funded therapy is available at no additional cost: however, availability of public therapy is limited and differs from province to province based on the services available. Your doctor will be able to provide you with more accurate local information or recommendations.

Depending on your private or work insurance plan, occupational therapy and cognitive behaviour therapy may be partially or fully covered under psychotherapy services. It is always best to check directly with your insurance provider about your coverage.

Communicate your experience with fatigue

Your loved ones and friends may not understand how deeply fatigue can impact your daily life.  They may see you at a family gathering or event and make comments like “glad to see you are feeling better” or “great to see you back to normal”. They don’t know that you have had to sleep leading up to the event and will have to sleep for hours after it, just so you could have the energy to attend.

It’s okay to tell them you struggle with fatigue and you are always recovering. Openness and honesty will help educate others on the experience of living with a brain injury.

Create schedules to manage your day and your fatigue

Set out a schedule and plan your activities, appointments, and tasks for each day. You only have so much time and energy, and you want to make sure it will get you through the day. Chances are your energy levels before your injury were a lot different than your energy levels now. This means you will have to practice pacing – taking a bit more time and spreading out your schedule.

When building your schedule, try to do it the night before or in the morning after you wake up. When making a schedule, make sure to do the following things:

  • Build in rest periods. One of the best ways to manage fatigue is to give yourself time to rest. Listen to your body and don’t “push through” if you’re feeling fatigued. If you know you need multiple rest periods a day, schedule them before you schedule anything else. Having a schedule with time set aside to rest will help ensure you take the time you need.
  • Schedule activities when you have the most energy. Depending on when you experience fatigue, there will be periods of time during the day that make the most sense to schedule activities. For example, many individuals have the most energy after they wake up in the morning and much less energy in the evenings. By scheduling activities and appointments during the times you have the most energy, you will minimize the risk that fatigue will interfere.

Exercise and physical activity

This should be undertaken on doctor recommendations. Exercise and physical activity have all-over health benefits but should be reintroduced slowly and under supervision. Overtime you will build up your skills and endurance, meaning you can do more and feel less fatigued.

Have plans in place for unexpected fatigue

Fatigue can be debilitating and leave a person unable to complete tasks. It can also occur unexpectedly, especially immediately following your injury. For example, you could become fatigued in a public place, at a social event, or at work.

When this happens, having coping strategies can help manage the situation. This could include having hand signals with your caregivers or having an emergency contact come get you. If you’re worried about fatigue catching you off guard, try the following aids:

  • Keep a journal to track when you commonly feel fatigued
  • Speak with your rehabilitation therapists about strategies for coping with fatigue and public outings
  • Share your feelings with caregivers or employers – they can help you come up with a plan

Manage stress

Elevated stress levels can increase fatigue, particularly for individuals with brain injury who have cognitive and problem-solving challenges. When you identify what causes you stress, you can either remove those stressors or start dealing with them on a gradual basis. Giving yourself this time to process and respond to stressors will help manage feelings of fatigue.

Manage your expectations

A brain injury is a major life change, and that means abilities have changed. It’s important during recovery to manage your expectations and focus on what you can do. Don’t always compare where you are today with where you were before the injury. That will lead to negative feelings and fatigue because you’re trying to push yourself to hard. Instead, focus on setting weekly or monthly goals and prioritizing your health and well-being.

Track your fatigue

What causes fatigue for you may not cause fatigue in someone else. It is dependent on the person, their injury, and the environment. While it can be difficult to identify triggers, it’s important that you and your caregivers learn what makes you feel fatigued: if you don’t, you may experience extended periods of fatigue or feel like you have no control over your energy levels.

It can be difficult to track your fatigue through the course of a day, especially if you’re experiencing memory issues. By keeping a journal of your activities and your feelings, you can more accurately identify periods of time where you feel fatigued.

Record all medications you’re taking

Some medications can have increased feelings of fatigue as a side effect. Keep a list of what medications you’re taking, when you’re taking them, and their side effects. This will help you identify when you may feel more tired.

Create a rating system

One way to check in with yourself and how fatigued you’re feeling is to create a rating system. Make a scale from 1-10 and measure your fatigue on that scale. For example, a 1 is not fatigued at all while a 7 or 8 is strong feelings of fatigue.

You should rate your fatigue levels before and after you complete an activity – for example, doing the dishes. If you find that doing the dishes takes you from a 1 to a 5 on your fatigue scale, perhaps take breaks or ask for help with dishes.

This rating system will not only help you identify what makes you feel fatigued; it will help you identify when to take breaks and improvements you make over time [1].

Understand what environments work for you

Some environments can increase a person’s fatigue. This includes places with loud noises, bright lights, overcrowding or that require a lot of travel. By understanding what environments cause fatigue and what environments work best for you, you can more easily participate in activities. Over time, you can reintroduce yourself to other environments for short periods of time. Wear sunglasses if it will help you deal with bright lights and ear plugs to deal with noise if it does not jeopardize your safety. Look for places that offer sensory-friendly settings – for examples, some grocery stores have specific sensory-friendly shopping days.

Remember: take breaks as often as you need. You don’t have to stay out for a full day if you’re experiencing fatigue or other symptoms. It’s important to listen to your body.

Use assistive technology and tools

Assistive technology and tools help individuals with acquired brain injury manage their symptoms and complete activities of daily living [2]. There are ways to use assistive devices to cope with fatigue. For example:

  • Wheelchairs during walking rehabilitation
  • Checklists to help manage tasks and minimize stress
  • A sleep journal to track sleep disturbances

Occupational therapists and cognitive behavioural therapists can assist in developing coping methods or introduce you to tools that manage fatigue.

If you need financial support to obtain assistive devices you can explore this assistive devices program. This program assists adults with physical disabilities who are in financial need to purchase assistive devices that increase their mobility and functional independence.


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