Seating & Positioning 2012 Handbook

Traumatic Brain Injury & Seating

The Challenges of Creating Mobility Solutions for Clients with Brain Injuries

Traumatic Brain InjuryRecent 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 somewhat different.”

The Anatomy of a Brain Injury

The lasting impact of a brain injury, Komotar says, depends on several factors.

“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 in recovery.

“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 equipment choices.

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 for them.”

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 different equipment.

“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.

About the Author

Laurie Watanabe is the editor of Mobility Management. She can be reached at lwatanabe@1105media.com.

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