Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 59

CLINICAL PRACTICE GUIDELINE



Full-time wheelchair users with pressure
ulcers located on a sitting surface should
limit sitting time and use a gel or air surface
that provides pressure redistribution



Maintain an offloaded position from the
seating surface for at least 1 to 2 minutes
every 30 minutes.

(Scientific evidence-I, II, III, IV IV; Grade of
,
recommendation-A; Strength of panel opinion-Strong)

An effective wheelchair and seating system
can help promote skin health, sitting balance
stability, symmetrical posture, greater upper limb
use, and enhanced functional performance.
Wheelchair features that optimize independence
in performing pressure redistribution,
transferring, and propelling, as well as providing
optimal postural support and minimizing the risk
of developing pressure ulcers, are recommended
(Garber and Krouskop, 1997). An individual
physical and functional assessment by a clinician
with specific expertise in all these areas and in
complex mobility equipment is necessary to
achieve the best outcomes (Beer, 1984; Lowthian,
1993; Rosenthal et al., 1996; Coggrave & Rose,
2003). In addition to an objective evaluation and
clinical judgment by the clinician, it is essential to
incorporate direct feedback from the individual
requiring the wheelchair into the decision making
process for determining what is the most
appropriate wheelchair and seating system
(Garber and Dyerly 1991; Garber 1985).
Sitting postures can significantly affect ischial
pressures, and lateral pelvic tilt can affect
pressure distribution over the buttocks; therefore,
postural management is crucial when selecting a
seating system (Koo et al., 1996). The loss of
innervation to muscles of the body results in
abnormal postures being assumed to achieve
sitting stability within wheelchairs and seating
systems. A common postural compensation seen
in persons with SCI is posterior rotation of the
pelvis, flattened lumbar curve, C-shaped
thoracolumbar spinal curve, and extended
cervical spine. Left unattended, these
asymmetrical postures can result in deformity,
excessive sitting pressures and shear, as well as
loss of function (Hobson, 1992; Koo et al., 1996).
Maintaining good postural alignment can facilitate
equal weight bearing over the bony prominences
of the buttocks (Krouskop et al., 1983). Unequal
or excessive pressure or shear over bony areas, as
well as impaired dynamic sitting stability can
contribute to pressure ulcers (Bergstrom et al.,
1992; Karatas et al., 2008). A "plumb line"
posture (alignment of the ear/shoulder/hip) keeps
normal spinal curves intact. Slouching forward or

leaning to one side places unequal pressure over
the buttocks.
An interface pressure-mapping device is an
array of sensors contained in a flexible mat that
measure interface pressure between the user and
the underlying support surface that can be used as
a tool to help determine the wheelchair cushion
and seating system to obtain that will best
minimize the risk of pressure ulcer development.
Most interface pressure-mapping devices provide
a value of relative peak pressure values at the
interface of the buttocks and the various
wheelchair cushions, a visual display of uniformity
of the weight-bearing surface, surface contact area
and an ability to compare these values in a static
and dynamic position (Bar, 1991; Salcido et al.,
1996; Barnett & Shelton, 1997). As there is no
absolute interface pressure that predicts the
development of pressure ulcers (Sprigle and
Sonenblum, 2011), interpretation of the data is
only one aspect of determining pressure
redistribution equipment. Interface pressuremapping can be used to rule out the least
desirable surface but cannot solely determine the
optimal cushion surface for a person. One of the
most beneficial applications of using a interfacepressure mapping system is to educate wheelchair
users through the use of imagery observed during
pressure relief techniques, the impact of posture
changes and functional movements, and set up of
the cushion, especially in the case of air floatation
cushions (Coggrave & Rose, 2003; Henderson et
al., 1994). There are multiple contributing factors
to pressure ulcer incidence, and they must be
taken into consideration additionally (Ho & Bogie,
2007; Makhsous et al., 2007). These factors
include skin moisture, friction, shear, nutrition,
age, and arterial pressure. Variability in body
habitus, such as weight, muscle tone, body fat
content, and skeletal frame size, also impact
interface pressure (Gefen, 2007; Henderson et al.,
1994, Hamanami et al., 2004; Barnett & Shelton,
1997). How people transfer into wheelchairs and
how they position and reposition themselves
within the seating system have a direct impact of
pressure or shear forces that occur to the buttocksurface interface (Barnett & Shelton, 1997). Even
the age, condition, and type of the cushion and
the surface it is placed upon can factor into the
development of pressure ulcers.
Wheelchairs not only provide mobility, but
they can also provide an independent means of
performing pressure redistribution (Nixon, 1985,
Sprigle and Sonenblum, 2011) for those persons
who are unable to physically lift their body from

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Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury

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