Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 22

22

PRESSURE ULCER PREVENTION AND TREATMENT FOLLOWING SPINAL CORD INJURY

potential for significant blood flow increases and
pressure relief at the ischial tuberosities
(Sonenblum and Sprigle, 2011). When this
movement is provided by a powered mechanism,
the individual acquires the ability to perform
pressure redistribution independently (Henderson
et al., 1994).
Traditionally, a weight shift every 15 to 30
minutes has been recommended to allow the skin
and underlying tissues to be replenished with
oxygen (Bergstrom et al., 1992; Nixon, 1985;
Ho and Bogie, 2007). Analyzing subcutaneous
tissue oxygen measurements of newly injured and
individuals with chronic SCI (n=46), Coggrave
and Rose (2003) found that the mean duration of
pressure relief required to raise tissue oxygen to
unloaded levels was 1 minute and 51 seconds.
This duration of pressure relief was more
successfully accomplished by the subjects leaning
forward, side to side or having the wheelchair
tilted back at greater than 65 degrees compared
to performing a push-up lift (Coggrave and Rose,
2003). This duration of time is much longer
than the previously recommended 15-30 seconds.
Individualized attention must be given to
determine the method of weight shifting that
allows the person to consistently perform the
maneuver and sustain the off-loaded pressure
for the duration of time recommended. Each
individual must be assessed for the weight
shifting method that is optimal for their
performance. Re-education regarding this
significant change in duration of off-loaded
pressure is important to communicate during
out-patient visits to medical personnel who are
providing care to the person who has been
living with SCI and when reassessing seating
and mobility equipment. Retraining in alternative
methods or a change in mobility equipment
may be necessary if the person cannot sustain
the increased off-loading time. A referral to an
occupational or physical therapist may be
necessary for this re-assessment and training
to learn a new weight shift method.
Henderson (1994) studied average ischial
tuberosity pressures for different postures,
including upright resting posture, tilting back to
35 and 65 degrees, and 45 degree forward lean.
Forward leaning demonstrated a significant
reduction of ischial tuberosity pressures.
Hobson (1992) found that an ischial pressure
reduction could be obtained by forward leaning
but that an increase in ischial tuberosity pressure
was noted with up to 30 degrees of forward
flexion prior to when any reduction began to
occur. Henderson (1994) studied average ischial

tuberosity pressures for different postures,
including upright resting posture, tilting back to
35 and 65 degrees, and 45 degree forward lean.
Forward leaning demonstrated a significant
reduction of ischial tuberosity pressures. During
lateral leaning, a 32% to 38% decrease in average
pressure on the opposite side was found to occur
yet no indication of the pressures seen on the
weighted side were noted. Lateral trunk leaning
to 15 degrees reduced pressure on the
unweighted side, but the impact on the weighted
side was not reported (Henderson et al., 1994).
Sonenblum and Sprigle (2011) showed that the
seated tilt of power wheelchairs creates pressure
redistribution and increased blood flow during
maximum tilts at 45 to 60 degrees in more than
80% of subjects.
A study which compared the efficacy of a
dynamic wheelchair cushion and a tilt-in-space
wheelchair with conventional cushion in providing
pressure redistribution for patients with
tetraplegia showed that both a dynamic cushion
wheelchair and a tilt-in-space wheelchair with
conventional cushion provided similar pressure
redistribution over the ischial tuberosities (Burns
and Betz, 1999).
For individuals with SCI who are dependent
on a wheelchair for all mobility, it is crucial that
they use a wheelchair and seating system that has
been customized for their unique physical and
functional needs. This wheelchair and seating
system is essential to contributing to positive
health maintenance as well as unencumbered
participation in life by providing optimal mobility.
An individualized prescribed wheelchair chosen
specifically for the user can facilitate healthy
tissue viability, symmetrical and balanced posture,
and optimal mobility, allowing for mobility-related
activities of daily living.
A specially selected wheelchair seat cushion
and back support should be used at all times
when persons are out of bed. Pressure ulcers
occurring at the ischial tuberosities and the
sacrum are likely to be a result of being seated in
a wheelchair. A seat cushion and solid back that
relieves and redistributes pressure and reduces
risk of pressure ulcer formation is an important
aspect of prevention (Bogie et al., 1995).
In meeting the complex seating needs of
persons with SCI, it is advisable to obtain an
evaluation from a specialized seating clinic that
employs a comprehensive approach (Coggrave
and Rose, 2003). This approach should include
a review of medical history, postural and
functional assessment, skin history assessment,
visual inspection of skin of sitting surfaces,
Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury

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