Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 61

CLINICAL PRACTICE GUIDELINE

was obtained when varying both seat tilt and
recline as compared to initial values. In another
study, 11 wheelchair users with SCI were assigned
to one of six protocols of various wheelchair tiltin-space and recline angles, and it was found that
the greatest increase in skin perfusion and
decrease in interface pressure over the ischial
tuberosity was obtained when a wheelchair tilt-inspace was 35 degrees combined with a 100
degree recline and when a tilt-in-space was at
least 25 degrees combined with a recline at 120
degrees (Jan et al., 2010).
Karatas et al. (2008) evaluated the center of
pressure displacement and the dynamic sitting
stability of SCI patients and their relation to
pressure ulcer development. They found that the
center of pressure displacement during dynamic
unsupported right, left, forward, and backward
leaning was smaller than in individuals without
SCI participating in the study as controls. This
difference can be explained by the loss of muscle
function in individuals with cervical and thoracic
SCI compared to individuals without SCI who
had fully functional trunk, abdominal, hip and
lower extremity muscles required to perform
dynamic sitting.
Significant reduction in sitting force can be
obtained by using armrests. The armrests support
10% of the body weight (combined weight of arm
and hand), thereby relieving seating forces over
the buttocks (Gilsdorf et al., 1991). Wheelchair
footplate position needs to be addressed when
adjusting the wheelchair. Foot-plate height should
be adjusted to ensure that peak pressures over
the pelvis are minimized. Footplates that are too
high can result in a suboptimal sitting pressure
distribution between the thighs and the ischial
tuberosities (i.e., pressure that is increased over
the ischial tuberosities). Footplates that are too
low can result in the body sliding forward on the
seat contributing to excessive shear and pressure
to the ischial tuberosities (Gilsdorf et al., 1990).
Excessive pressure of the posterior thighs can
result in lower body edema. However when
positioned in the chair with slight forward pelvic
rotation, some pressure is usually shifted to the
posterior thighs, which offloads the ischial
tuberosities. Stable trunk support will prevent
excessive shearing over the scapulae or sacral
areas, which can occur if the person is not
adequately supported in the wheelchair.
Standing wheelchairs, manual or power, are
available for independent mobility. Standing
systems can be utilized to allow for extended
pressure redistribution over the seat and backrest
areas, therefore allowing mobilization of persons

with or without existing pressure ulcers. Careful
consideration must be used when determining the
viability of using a standing wheelchair, such as
orthopedic status, cardiovascular stability,
spasticity, range of motion, and balance. In a
small study of load distribution in a standing
position, Sprigle et al. (2010) determined that a
61% reduction in seat force could be attained
with a standing position of 75 degrees or full
recline, as compared to 46% decrease in seat load
at full tilt. Standing to achieve pressure
redistribution may be seen as more socially
acceptable than tilting or reclining back in
community settings and therefore may be more
likely to be utilized in such environments. The
physical space needed for a wheelchair to assume
a standing position as compared to tilting/
reclining is less, thus can be performed in smaller
areas where accessibility is an issue. ADLs
performed in the standing position allow for
pressure redistribution to be built into normal
daily routines, resulting in a greater frequency of
performance.
It is suggested that having power wheelchair
features, such as power tilt/recline/standing, is not
enough to facilitate use to prevent pressure
ulcers. Consumers must be specifically educated
on how to best utilize these features in order that
they be used in the optimal manner. One study
indicated that even though 97.5% of individuals
had power tilt and/or recline on their wheelchairs
and used these functions daily, less than 35% used
them for the purpose of pressure redistribution
rather using them to reduce pain and increase
comfort (Lacoste et al., 2003).
Spasticity should be monitored and managed
so as to prevent the effects of skin shearing when
the body rubs against firm surfaces. Some of
these surfaces may be bed linens, wheelchair
parts, shoes, or braces and splints. After
discharge to home or community, the individual
with SCI must monitor the level of spasticity and
seek medical guidance when it becomes
detrimental to adequate skin care and function.
Sitting-acquired pressure ulcers occur within
the soft tissues compressed between weight
bearing bony prominences and the supporting
surface of the wheelchair. More than 65% of
sitting-acquired pressure ulcers occur on the
ischial tuberosities, sacrum, coccyx, and
trochanters (Gefen, 2007).
Reenalda et al. (2009) analyzed the sitting
position interface pressure distribution and
subcutaneous tissue oxygenation of 25 persons
without SCI. They found that their subjects shifted
posture an average of 7.8 times an hour in the

Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury

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