Seating & Positioning 2012 Handbook
Traumatic Brain Injury & Seating
The Challenges of Creating Mobility Solutions for Clients with Brain Injuries
- By Laurie Watanabe
- Mar 01, 2012
Recent mainstream media headlines have made brain injury a
trending topic far beyond clinical circles. We’re learning that
the kinds of repeated concussions commonly sustained by football
players and other contact-sport athletes can have lifelong, devastating
impacts. That brain injuries to today’s soldiers can challenge
their efforts to move forward after returning home. And that
sometimes, as with the heartwarming continuing recovery of Rep.
Gabrielle Giffords, who was severely injured in an assassination
attempt last year, an injured brain can learn to adapt so well that
even leading neurologists are joyously impressed.
Indeed, the complexity of the human brain makes any injury to
it equally complex. Clients who have brain injuries may therefore
have among the most complex and challenging conditions a seating& mobility professional will face.
The Newness of Neurology
The medical community is learning more information all the time
about how the human brain functions and how injuries impact
those functions. In that respect, neurology is still a relatively new
and unfolding field of medicine.
Ricardo Komotar, M.D., is the assistant professor of clinical
neurosurgery and the director of surgical neuro-oncology at the
University of Miami (Fla).
He says about brain injuries, “We don’t really have enough experience
to make predictions. If someone breaks their leg, you know
how long they’re going to be on crutches or in a cast. If someone
has pneumonia, you know how long they have to be on antibiotics
before they’re back to baseline. But when it comes to brain injury,
it’s nearly impossible, especially early on after injury, to know what
the final outcome is going to be. It’s almost always a watch-and-wait
type of experience, where early on, you don’t know, and then as
time goes on, it starts to become clearer.”
In addition, Komotar notes, “The issue is that everyone’s brain is
The Anatomy of a Brain Injury
The lasting impact of a brain injury, Komotar says, depends on
“There are several different parts of the brain,” he explains, “and
it depends on how severe the brain injury is, how old the patient is,
and what part of the brain is injured.”
Patients can recover function for quite a long time after an
injury, he adds: “The early period after an injury, the first few
weeks, can be very telling. So if someone rapidly recovers in the
first few weeks, that’s obviously a great prognostic sign. But even if
they don’t recover in the first couple of weeks, typically long-term recovery can occur for months — not so much years, but months.”
While we commonly speak of patients “healing” after a brain
injury, Komotar points out, “There is no ‘healing’ in the brain. The
brain isn’t like bones or muscles or the skin, where the cells regenerate
and they heal. Other parts of the brain need to compensate;
you form new connections, which in older people is more
limited. In a head injury in a younger person, there’s more leeway
“With anyone less than 20 (years old), let’s say, there’s more plasticity
in the brain.”
Clients needing seating & mobility from ATPs may have experienced
injury to multiple parts of their brains, Komotar says.
“Problems with balance can be (caused by injury to) the cerebellum;
problems with walking can be in the cerebellum or the
motor regions, the parts of the brain that control movement. It’s not
one specific part, really.”
If speech and language are also impacted, he says, that’s usually
caused by injury to the left temporal lobe of the brain. Emotional
changes in clients — such as increased impatience or becoming
more emotional more quickly than before — can be caused by
injury to the medial left temporal lobe.
Different Mobility Presentations
Mobility is one of many functions that can be affected by an injury
to the brain.
Jay Brislin, MSPT, is director of Quantum products & clinical
development for Quantum Rehab.
“Anytime somebody has a brain injury, any part of their movement
can be affected,” he says. “It is common for people to have
increased muscle tone, which can directly affect balance, gait
and muscle control, as well as motor planning and the vestibular
system. For instance, a person’s balance can be affected significantly based on the muscle control perspective. So if somebody’s
leg doesn’t move smoothly, it can directly affect the person’s
ability to remain upright on their feet and make them more
susceptible to falls.”
But knowing that a client has been diagnosed with a brain injury
doesn’t automatically give the clinician or provider a complete
picture of the client’s symptoms.
“In many cases, they present very differently,” Brislin says about
brain-injured clients. “Sometimes there are similarities, but it’s
really a client-by-client basis. With a spinal cord injury, clients
typically present with an absence of movement. A brain injury can
present with absence of movement, but it often presents more with
a change in muscle tone — mostly, increased muscle tone.”
The client’s ability to speak and clearly communicate with
members of the seating & mobility team — and to understand what
the team is expressing — can also be affected.
All of those factors need to be considered by the ATP making
For instance, operating mobility equipment requires the ability
to successfully remember and perform a number of actions — such
as turning on a power chair and moving the joystick. That can be a
challenge, Brislin said, for brain-injured clients.
“When you’re dealing with a client that has a brain injury, there
are significant cognitive issues going on most of the time,” he notes.
“You want to look at repetitive movement that needs to be consistent
and also needs to be understood by the client. There may be
one day in the morning when they totally understand how to do
that repetitive movement, whatever it may be — reaching for some thing, grabbing for something, doing a task. By the afternoon, they
might have lost that; there may not be that memory. Those things
certainly make it difficult when you’re looking for mobility products
The versatility of today’s electronics, which can remember the
degree of tilt needed or give the client an audible alarm, can be
helpful for these clients. Whatever the case, Brislin says, “Our job
is to make sure they can (perform the actions) on a regular basis.
They need to be able to do it consistently and over a period of time.”
If that isn’t possible, Brislin says, ATPs may need to choose
“Sometimes, it would be awesome to be able to put somebody
into a power mobility device to increase their independence, but
based on cognition and safety factors, you may need to move to a
manual tilt-in-space or a K0005 that’s in need of a caregiver just
based on the fact that you’re not sure their cognition is going to
provide consistent safety and consistent use.”
To improve a client’s chances of success, Brislin also recommends
evaluating the environment in which the equipment will be used.
“The brain injury doesn’t just impact the person’s physical capabilities,”
Brislin says. “It also interferes with
other cognitive skills, like perceptually, where
they are in a room. If they’re not 100-percent
safe in their mobility product, you might need
to make that environment safe. You don’t want to
deny somebody a mobility product that they can
really get some positive effects from. But maybe
there are things within that person’s environment
that need to change — such as the fact
that stairs are there. You would hope they’re not
going to drive too close to those stairs, but somebody
with a brain injury with cognitive issues
could certainly do that by accident.”
Follow-Up & Teamwork
Follow-up is critical with these clients, because
while brain injuries themselves don’t progress,
their effects can cause other conditions to
worsen or change.
“You may have somebody who is able to
understand that they need to do a weight shift,
may even attempt to do a weight shift, but
cannot necessarily communicate to the muscles
to do that weight shift,” Brislin says. “If that
happens, you can get more postural issues, more
skin issues, etc., because that brain injury is
not necessarily allowing that communication
between the brain and the muscles.
Or perhaps the brain injury caused weakness
in the extremities.
“(Clients) may not think they’re weak there,”
he says. “They may not even realize what’s going
on. But it can end up making postural concerns
get worse quickly.”
Clients with brain injury also can benefit
when all members of the healthcare team —
caregivers, physicians, nurses in the rehab care
setting, speech therapists, etc. — keep in touch
with each other.
“This diagnosis needs to have that team that’s
constantly in communication,” Brislin says. “You end up having a lot of trial and error when it comes to finding the
appropriate mobility equipment for these clients.
“Someone with a brain injury may fully think they performed
the task that you asked them to perform, but they didn’t. A nurse
may say, ‘He thinks he lifts himself out of bed to get to the bathroom
every day, but we’re actually doing a dependent transfer.’”
Getting input from seating & mobility team members can give
ATPs a fuller, more accurate picture of the interventions that could
work to give clients with brain injury the best opportunities for
independent, safe mobility.
“Once you get those evaluations, your product choices can
change drastically depending on the results,” Brislin says.
This article originally appeared in the March 2012 issue of Mobility Management.
Laurie Watanabe is the editor of Mobility Management. She can be reached at firstname.lastname@example.org.