Advertisement

Effects of Wheelchair Cushions and Pressure Relief Maneuvers on Ischial Interface Pressure and Blood Flow in People With Spinal Cord Injury

Published:January 30, 2014DOI:https://doi.org/10.1016/j.apmr.2014.01.007

      Abstract

      Objective

      To investigate the effectiveness and interactions of 2 methods of pressure ulcer prevention, wheelchair cushions and pressure relief maneuvers, on interface pressure (IP) and blood flow of the buttocks.

      Design

      Within-subject repeated measures.

      Setting

      Rehabilitation center.

      Participants

      Wheelchair users with a spinal cord injury or disorder (N=17).

      Interventions

      Participants performed 3 forward leans and 2 sideward leans with different degrees of lean while seated on each of 3 different wheelchair cushions.

      Main Outcome Measures

      IP measured with a custom sensor and blood flow measured with laser Doppler flowmetry were collected at the ischial tuberosity.

      Results

      Pressure relief maneuvers had a significant main effect on the ischial IP (P<.001); all maneuvers except for the small frontward lean resulted in a significant reduction in IP compared with upright sitting. Blood flow significantly varied across postures (P<.001) with flow during upright sitting and small forward leans being significantly lower than during the full and intermediate leans in both the forward and sideward directions.

      Conclusions

      The results of the study highlight the importance of positioning wheelchair users in a manner that facilitates in-seat movement. Regardless of the cushion being used, the pressure relief maneuvers resulted in very large reductions in IPs and significant increases in buttock blood flow. Only the small frontward lean was shown to be ineffective in reducing pressure or increasing blood flow. Because these pressure relief maneuvers involved postural changes that can occur during functional activities, these pressure relief maneuvers can become a part of volitional pressure relief and functional weight shifts. Therefore, clinical instruction should cover both as a means to impart sitting behaviors that may lead to better tissue health.

      Keywords

      List of abbreviations:

      IP (interface pressure), LDPM (Laser Doppler Perfusion Monitoring), SCI (spinal cord injury)
      To read this article in full you will need to make a payment

      Subscribe:

      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Allman R.M.
        • Goode P.S.
        • Burst N.
        • Bartolucci A.A.
        • Thomas D.R.
        Pressure ulcers, hospital complications, and disease severity: impact on hospital costs and length of stay.
        Adv Wound Care. 1999; 12: 22-30
        • Krause J.S.
        • Broderick L.
        Patterns of recurrent pressure ulcers after spinal cord injury: identification of risk and protective factors 5 or more years after onset.
        Arch Phys Med Rehabil. 2004; 85: 1257-1264
        • Raghavan P.
        • Raza W.A.
        • Ahmed Y.S.
        • Chamberlain M.A.
        Prevalence of pressure sores in a community sample of spinal injury patients.
        Clin Rehabil. 2003; 17: 879-884
        • Bouten C.V.
        • Oomens C.W.
        • Baaijens F.P.
        • Bader D.L.
        The etiology of pressure ulcers: skin deep or muscle bound?.
        Arch Phys Med Rehabil. 2003; 84: 616-619
        • Thomas D.R.
        Are all pressure ulcers avoidable?.
        JAMA. 2001; 2: 297-301
        • Gefen A.
        Reswick and Rogers pressure-time curve for pressure ulcer risk. Part 2.
        Nurs Stand. 2009; 23: 40-44
        • Aissaoui R.
        • Lacoste M.
        • Dansereau J.
        Analysis of sliding and pressure distribution during a repositioning of persons in a simulator chair.
        IEEE Trans Neural Syst Rehabil Eng. 2001; 9: 215-224
        • Consortium for Spinal Cord Medicine
        Pressure ulcer prevention and treatment following spinal cord injury: a clinical practice guideline for health-care professionals.
        Paralyzed Veterans of America, Washington (DC)2000
        • Moore Z.E.
        • Cowman S.
        Repositioning for treating pressure ulcers.
        Cochrane Database Syst Rev. 2009; : CD006898
        • Nixon V.
        Pressure relief.
        in: Spinal cord injury: a guide to functional outcomes in physical therapy management. Aspen Publishers, Rockville1985: 67-75
        • Makhsous M.
        • Rowles D.M.
        • Rymer W.Z.
        • et al.
        Periodically relieving ischial sitting load to decrease the risk of pressure ulcers.
        Arch Phys Med Rehabil. 2007; 88: 862-870
        • Coggrave M.J.
        • Rose L.S.
        A specialist seating assessment clinic: changing pressure relief practice.
        Spinal Cord. 2003; 41: 692-695
        • Bader D.L.
        The recovery characteristics of soft tissues following repeated loading.
        J Rehabil Res Dev. 1990; 27: 141-150
        • Nawoczenski D.A.
        • Clobes S.M.
        • Gore S.L.
        • et al.
        Three-dimensional shoulder kinematics during a pressure relief technique and wheelchair transfer.
        Arch Phys Med Rehabil. 2003; 84: 1293-1300
        • McInnes E.
        • Jammali-Blasi A.
        • Bell-Syer S.E.
        • Dumville J.C.
        • Cullum N.
        Support surfaces for pressure ulcer prevention.
        Cochrane Database Syst Rev. 2011; : CD001735
        • Regan M.A.
        • Teasell R.W.
        • Wolfe D.L.
        • et al.
        A systematic review of therapeutic interventions for pressure ulcers after spinal cord injury.
        Arch Phys Med Rehabil. 2009; 90: 213-231
        • Sanada H.
        • Nagakawa T.
        • Yamamoto M.
        • Higashidani K.
        • Tsuru H.
        • Sugama J.
        The role of skin blood flow in pressure ulcer development during surgery.
        Adv Wound Care. 1997; 10: 29-34
        • van Marum R.J.
        • Meijer J.H.
        • Ooms M.E.
        • Kostense P.J.
        • van Eijk J.T.
        • Ribbe M.W.
        Relationship between internal risk factors for development of decubitus ulcers and the blood flow response following pressure load.
        Angiology. 2001; 52: 409-416
        • Sprigle S.
        • Sonenblum S.
        Assessing evidence supporting redistribution of pressure for pressure ulcer prevention: a review.
        J Rehabil Res Dev. 2011; 48: 203-213
        • Brienza D.M.
        • Karg P.E.
        • Geyer M.J.
        • Kelsey S.
        • Trefler E.
        The relationship between pressure ulcer incidence and buttock-seat cushion interface pressure in at-risk elderly wheelchair users.
        Arch Phys Med Rehabil. 2001; 82: 529-533
        • van Marum R.J.
        • Meijer J.H.
        • Ribbe M.W.
        The relationship between pressure ulcers and skin blood flow response after a local cold provocation.
        Arch Phys Med Rehabil. 2002; 83: 40-43
        • Sonenblum S.E.
        • Sprigle S.H.
        • Cathcart J.M.
        • Winder R.J.
        3-dimensional buttocks response to sitting: a case report.
        J Tissue Viability. 2013; 22: 12-18
        • Ek A.C.
        • Gustavsson G.
        • Lewis D.H.
        Skin blood-flow in relation to external-pressure and temperature in the supine position on a standard hospital mattress.
        Scand J Rehabil Med. 1987; 19: 121-126
        • Smit C.A.
        • Zwinkels M.
        • van Dijk T.
        • de Groot S.
        • Stolwijk-Swuste J.M.
        • Janssen T.W.
        Gluteal blood flow and oxygenation during electrical stimulation-induced muscle activation versus pressure relief movements in wheelchair users with a spinal cord injury.
        Spinal Cord. 2013; 51: 694-699
        • Sonenblum S.E.
        • Sprigle S.H.
        The impact of tilting on blood flow and localized tissue loading.
        J Tissue Viability. 2011; 20: 3-13
        • Jan Y.K.
        • Jones M.A.
        • Rabadi M.H.
        • Foreman R.D.
        • Thiessen A.
        Effect of wheelchair tilt-in-space and recline angles on skin perfusion over the ischial tuberosity in people with spinal cord injury.
        Arch Phys Med Rehabil. 2010; 91: 1758-1764
        • Storey J.D.
        The positive false discovery rate: a Bayesian interpretation and the q-value.
        Ann Stat. 2003; 31: 2013-2035
        • Koo T.K.
        • Mak A.F.
        • Lee Y.L.
        Posture effect on seating interface biomechanics: comparison between two seating cushions.
        Arch Phys Med Rehabil. 1996; 77: 40-47
        • Gefen A.
        Reswick and Rogers pressure-time curve for pressure ulcer risk. Part 1.
        Nurs Stand. 2009; 23 (6, 8 passim): 64
        • Pipkin L.
        • Sprigle S.
        Effect of model design, cushion construction, and interface pressure mats on interface pressure and immersion.
        J Rehabil Res Dev. 2008; 45: 875-882
        • Bouten C.V.
        • Breuls R.G.
        • Peeters E.A.
        • Oomens C.W.
        • Baaijens F.P.
        In vitro models to study compressive strain-induced muscle cell damage.
        Biorheology. 2003; 40: 383-388
        • Breuls R.G.
        • Bouten C.V.
        • Oomens C.W.
        • Bader D.L.
        • Baaijens F.P.
        Compression induced cell damage in engineered muscle tissue: an in vitro model to study pressure ulcer aetiology.
        Ann Biomed Eng. 2003; 31: 1357-1364
        • Slomka N.
        • Or-Tzadikario S.
        • Sassun D.
        • Gefen A.
        Membrane-stretch-induced cell death in deep tissue injury: computer model studies.
        Cell Mol Bioeng. 2009; 2: 118-132
        • Lassen N.A.
        • Holstein P.
        Use of radioisotopes in assessment of distal blood flow and distal blood pressure in arterial insufficiency.
        Surg Clin North Am. 1974; 54: 39-55
        • Bergstrand S.
        • Lindberg L.G.
        • Ek A.C.
        • Linden M.
        • Lindgren M.
        Blood flow measurements at different depths using photoplethysmography and laser Doppler techniques.
        Skin Res Technol. 2009; 15: 139-147
        • Bar C.
        The response of tissue to applied pressure.
        Univ of Wales, Cardiff1988
        • Sprigle S.
        • Maurer C.
        • Sorenblum S.E.
        Load redistribution in variable position wheelchairs in people with spinal cord injury.
        J Spinal Cord Med. 2010; 33: 58-64
        • Reswick J.B.
        • Rogers J.
        Experience at Rancho Los Amigos Hospital with devices and techniques to prevent pressure sores.
        in: Kenedi R.M. Cowden J.M. Scales J.T. Bedsore biomechanics. Univ Park Pr, Baltimore1976: 301-310