DME

Preventing Pressure Injuries Outside the Wheelchair

Last week Australia was encouraged to create awareness around chronic wounds as part of Wounds Awareness week.

This week it’s New Zealand’s turn to promote awareness with their Wound Awareness week running this month. As such we will continue our theme of Pressure Injury (PI) prevention and redistribution surfaces in this week’s blog.

Good Pressure Injury (PI) risk reduction requires us to consider all the support surfaces being used. We can apply many of the same principles of design, forces, and materials science to multiple surfaces and positions to specifically address potential equipment risks. Today’s blog, whilst still addressing reduction of risk of PI, will look at some of the other positions and surfaces that we need to consider. 

Lying

End users that are dependant on carers for transfer assistance can spend increased time in bed based on the availability of support staff. Whilst this is not ideal it is the reality for many with mobility impairments. This can result in an increased need to complete functional tasks in bed and for the user to use the bed functions such as head raise to enable seated tasks.

Although this bed function can assist someone to complete tasks in bed, we need to acknowledge the shear forces that accompany this bed movement. Using a knee break in conjunction with head raise can reduce the amount of slide but not eliminate the risk of sustaining a shear sacral injury. We also need to consider the mattress surface and how it will interface with the user and the bed profiling.

As with sitting, those that have significant movement limitations will be at a higher risk of sustaining an injury due to lack of movement. For these users the mattress materials and design can be crucial.

A ROHO Mattress Overlay

When we think about the materials that provide the highest levels of redistribution the first thought is air. When air is used in a container that enables it to work as a fluid, we are considering hydrostatic forces rather than peak forces, this enables maximum immersion and envelopment. A benefit of a non-powered air mattress is that there are no power chords as potential trip hazards or risk of power outage impacting the usage.

Other commonly prescribed air mattress options include air alternating systems. These work on the concept of loading and off-loading. These systems usually consist of rows of tubes that inflate and deflate in sequence so that there are times when the depressed cells mean there is no contact on the corresponding area of the body. As such the peak pressure increases when the cells are inflated. This constant changing can make some users feel like they are on gentle waves like water. 

Talley Quattro Acute Mattress Replacement

When considering air alternating systems, you do need to check the minimum user weight requirements as this differs between manufacturer design as does the sequence or ratio of inflated cells. For some users the inflation of cells may not be tolerated. Another point frequently raised by users is the noise of the power unit; whilst most manufacturers have significantly reduced the noise we need to consider the impact even a small noise can make in the quiet silence of the middle of the night….many of us have experienced that dripping tap you may not hear until you lie awake trying to sleep!!

Consider the location of the users home, some areas are known for power cuts and a contingency plan may be required for what to do in the event of a power outage, this may include consideration of a generator in some remote locations.

With both types of air mattresses we do need to consider transfers. Generally the higher the pressure redistribution properties the harder bed mobility is. A foam mattress may not provide the same level of immersion and envelopment or offloading, however because it is a more static, solid option it also has less impact on independent movement. With an alternating mattress there is usually a “hard” or “transfer” mode but pressure risk will be increased if this isn’t returned to normal cycle for lying.

Like wise with the ROHO mattresses, transfers need to be considered. The mattress is available in sections and can be inserted into foam surrounds to assist with bed mobility and transfers.  

Bathroom and Personal Care Tasks

Independent self-care and ADLs can take longer for those with impairments and may be completed from surfaces we don’t consider. When assessing for pressure risk it is important to consider all the support surfaces that are being used.

Commodes come standard with a seat made of similar materials to a toilet seat. Although this is not an issue for someone with full sensation, the ability to move and for short periods of time, it is important to find out more about the tasks and time spent to ensure it is not a concerning risk factor. If risk is identified, consideration of the seat needs to be addressed with padding or a pressure redistribution surface. 

A ROHO Toilet Seat Cushion

Skin tears and injuries do not always come as a direct result of pressure forces, but they can become chronic wounds. Not having the strength to complete a side transfer or mis-judgement may result in the user landing on a surface not intended eg the wheelchair wheel, and sustain a skin injury. Transfer style and other assistive technology such as slide boards may need to be addressed to prevent injury.

Be aware of all surfaces! Be open and have discussions around PI risk, prevention strategies and equipment options. Pressure injuries are for the most part preventable. Chronic wounds can have significant negative impacts both physically and emotionally. Our education team can provide clinical support and education around pressure care and the clinical application to our equipment ranges.

You can contact us at education.au@permobil.com or reach out to your local Permobil Territory Sales Manager.  

Tracee-lee Maginnity
Clinical Education Specialist

Tracee-lee Maginnity joined Permobil Australia in July 2019, as a clinical education specialist. She graduated Auckland University of Technology with a BHSc (Occupational Therapy) in 2003 and has since worked in various roles related to seating and mobility including assessing, prescribing and educating.

Tracee-lee is passionate about maximising functional outcomes with end users and the importance of education within the industry.

This week is Wound Awareness week in Australia. Why is it important to be aware of wounds? Chronic wounds affect half a million Australians with an annual estimated cost of over 3 Billion dollars (Wound Aware website). The definition of a chronic wound encompasses any wound that is resistant to healing.

While Pressure Injuries (PIs) have a direct correlational-causation with peak pressure and shearing forces, the causation of a chronic wound may not be pressure related, however pressure injuries are  the most common causation of a chronic wound.

The impacts on those who experience chronic wounds can extend beyond the physical issues of the wound to affect quality of life and general well-being. It is essential that we consider equipment and best practice guidelines when working with people to assess and trial Assistive Technology options. For more information about wounds and ways to create awareness check out some of the resources at the official website here.

To acknowledge and promote the importance of wound awareness, this week’s blog is a reminder on some of the considerations when prescribing pressure redistribution surfaces for beds and wheelchairs.

Creating Awareness

A historical approach to education around PIs has often included graphic images to shock us into the serious consequences that can result. Although the serious nature of chronic wounds cannot be underestimated, it is important to understand the development of PIs.

Education should be around prevention and monitoring. Yes, an early stage PI usually presents itself as a red mark on the skin surface, but not all red marks on the skin develop into PIs. When prescribing new seating we need to not just tell someone to monitor for red marks, but also advise them on what to do if they get skin markings and what kind of information you may want. As a clinician, the first questions I want to know are the location, if the skin blanches and how long it takes for any red marks to appear and fade.

It is more important that a user is empowered to understand the risks of PI and understand how to decrease those risks. It should become second nature to routinely monitor skin integrity and to know who to contact and when. Open discussions and general awareness can help in breaking the stigma and embarrassment that prevents some people from seeking early intervention.

Post-discharge from your services, who should they contact if they have PI concerns? For those not involved with regular services, you may advise them to re-contact you or their GP.

Who is at risk of a PI?

When prescribing AT, we need to consider the risk factors for the individual. A good risk assessment will not predict who will sustain a pressure injury but can assist in identification of factors that can be addressed to reduce risk. Those at risk include:

• Individuals who are unable to independently adjust their posture or position
• Individuals who present with asymmetrical postures and or uneven tonal patterns
• Individuals who constantly “slide into PPT” (Posterior Pelvic Tilt)
• Individuals who have history of PIs – old scar tissue
• Individuals who are sitting or lying for prolonged periods
• Ageing population

Where do pressure injuries occur?

PIs related to sitting or lying occur around bony prominences, often where the layer of tissue between the bone and skin is minimal such as the sacrum when sitting in posterior pelvic tilt.

Positioning will contribute to the area at higher risk, so the list above indicates the most common areas for sitting and lying supine. When lying on the side however, the greater trochanter and ear are also vulnerable areas.

Seating considerations

During the clinical reasoning process, it is important to consider both the postural positioning and skin protection requirements of each individual. This should guide the identification of the type of seating requirements. The design and materials of the proposed seating options will differ depending on goals and what approach you are taking to pressure redistribution and positioning.

Are you trying to reduce an abnormal postural position or accommodate to increase area of loading? If so, you will need to consider the adjustability and modularity of the seating to achieve the required points of control and contours.

Are you wanting to offload the ITs by increasing the loading of the Greater Trochanters? Consider the types of foam used, the contour and the depth between the areas of the trochanter ledge and the Ischial well.

Are you trying to provide maximum pressure care for someone that doesn’t have complex postural issues but has a history of PI? The Dry Floatation Technology design of a ROHO High profile cushion offers maximum immersion and envelopment and allows individualised set up.

Or are you trying to find a cushion for intermittent use such as community outings or the user is at low risk of a pressure injury and has no postural issues? There are a range of basic foam cushions available on the market.

If you would like more information on potential seating solutions or want further clinical support you can contact the clinical education team education.au@permobil.com. If you want to know more about seating and positioning this week’s live webinar on 20 August focuses on Pelvic Obliquity. To Register

Tracee-lee Maginnity
Clinical Education Specialist

Tracee-lee Maginnity joined Permobil Australia in July 2019, as a clinical education specialist. She graduated Auckland University of Technology with a BHSc (Occupational Therapy) in 2003 and has since worked in various roles related to seating and mobility including assessing, prescribing and educating.

Tracee-lee is passionate about maximising functional outcomes with end users and the importance of education within the industry.

Posterior Pelvic Tilt    

Last weeks live webinar looked at the very common posture that comes from a posteriorly tilted pelvis. Whilst we often discuss the pelvis as the foundation, it is important to appreciate that to support the pelvis back to a neutral position, the primary point of control comes from the backrest. Yes the cushion features will certainly assist as will a pelvic support belt, however we can’t overlook the crucial role the backrest plays. Today’s blog will take a closer look at pelvic blocks as a point of control for reducible posterior pelvic tilt (PPT)  

Pelvic Block

A pelvic block refers to the provision of an insert or contouring in the back support to adjust the force at the pelvis.  Providing an increased force at the posterior aspect of the pelvis can assist in both reducing a PPT and maintaining a neutral pelvis.

There are various ways we can create this force, lets take a closer look at some of the potential options. 

Tension Adjustable Backrests

If clinical reasoning identifies an upholstery back rest, I will always consider a tension adjustable option first. A tension adjustable backrest uses horizontal straps under the front upholstery. By adjusting these straps you can increase or decrease the force as required. Next time you have an opportunity I recommend you try it out. First sit in the wheelchair without adjusting it so you can feel the difference. Next loosen off ALL the straps. Now tighten the lower straps of the backrest from the seat base to the Posterior Superior Iliac Spine (PSIS)as much as you can. Now gently work your way up the straps doing each one above the tightened straps to follow the contours of the trunk position wanted. By having the lower straps tightened you will feel a more upright trunk posture coming from the increased force at the pelvis.

Another Back rest that uses a similar concept to a tension adjustability, is the Acta Relief. This is a unique backrest. Equipped with an oversized aluminum shell cut-out to allow deeper immersion into the back. It has adjustable Boa system that can be tightened and loosed off at different areas. Whilst a similar concept to tension adjustable straps, the Acta back can provide stronger points of control that maintain and do not slip as webbing straps can, but it has to be removed if chair is regularly folded.

Aftermarket Off The Shelf Back Supports

Most after market or ridged backrests consist of a shell and foam interface. Mounting brackets may provide adjustment for active seat depth and STB angle. You need to understand what you are trying to achieve before identifying appropriate equipment. There may be a standard adjustment such as a dual or hinged shell which enables the shell to be opened at a hinge joint usually just above the PSIS.

Some aftermarket back rests are supplied with dense foam wedges that can be placed between the shell and the foam interface, image 6  shows inserts provided with the  Dreamline contour back rest.

Adjustable Backrests

There are several adjustable backrests on the market that allow you to adjust the contouring of the support surface to create individualised support. These tend to work well with significant complex and asymmetrical postures, and for those with ongoing changing postural needs such as those with aggressive progressive conditions. I am frequently surprised when I see clients with these types of backrest with NO adjustment to the contour…it is as flat as the day it was packed at the manufacturers. Whilst we could consider these types of backrests for ongoing needs, they still need to be appropriately selected and individualised to the users current needs. I have had significant success in even minor adjustments through the trunk contour when the point of control has been set up appropriately and is proving the support required. Materials of the backrest are crucial when working with these adjustable backrests. Think critically with the clinical reasoning process, how much force do you want compared to how much immersion. What are you trying to achieve? With  a back support, it is essential to simulate the map findings and identify the impact of gravity and how you can achieve the required support for the end user. An adjustable back is easy to create a pelvic block in as you can adjust the contours to meet the users needs by taking out or adding in foam pieces. When you apply good contouring that provides the appropriate level of support you can create an appropriate solution for the user. 

These BAC pads made of a dense closed cell foam and are designed to be moved and overlapped so you can easily build up a pelvic block and other contouring as it is required. Pictured are the standard BAC. 

Making a Pelvic Block  

Not sure if a pelvic block would make a difference with a clients existing seating? Consider doing the towel trial.  Taking a small washcloth or hand towel fold it into several layers and place it at the pelvis area where you want support (seat surface to PSIS height), what I like about this method which I first saw over 15 years ago when Bengt Engstrom facilitated a workshop, was the ease in which to get further information. Most households will have a small towel to fold up and use. I could change the thickness and height to see the impact it could have just as I could place it in front of or behind the foam interface depending on the materials of the backrest.  Bengt is a Swedish Physiotherapist, author and original designer of our Corpus Seating System in the Permobil power bases.  I will use the towel as part of the assessment process, however it can be trialled if wanting to trial different thicknesses etc. I have made multiple pelvic blocks. I find an electric bread knife is a cost effective tool for these kinds of projects so keep one in my tool kit for these purposes.

Step 1 – Take a piece of foam in required density, it should be the thickness you are wanting, I often use a dense 1 or 2 inch.

Step 2 - cut a rectangle, approximately as wide as inner back rest (A)and height of seated surface to PSIS (B)

Step 3 - Chamfer off the top corner edge to create transition from pelvis to back support with knife

Step 4 - Attach between the shell and foam interface 

A individualised custom pelvic block to provide the force for a reducible posterior tilt…..now don’t forget the cushion and supports to complete the solution! If you have questions about any of the concepts or products featured please contact us at Education.Au@permobil.com

Tracee-lee Maginnity
Clinical Education Specialist

Tracee-lee Maginnity joined Permobil Australia in July 2019, as a clinical education specialist. She graduated Auckland University of Technology with a BHSc (Occupational Therapy) in 2003 and has since worked in various roles related to seating and mobility including assessing, prescribing and educating.

Tracee-lee is passionate about maximising functional outcomes with end users and the importance of education within the industry.

Reducing Barriers to ROHO Cushion

Set Up    

ROHO have been manufacturing pressure redistribution surfaces to assist wheelchair users and those at high risk of pressure injury for the past 49 years. This week’s blog looks at how and when the SmartCheck may be used to assist in cushion set up and ongoing use.  

SETTING UP A ROHO CUSHION

Historically, initial set up of a ROHO air cushion involves over-inflating the cushion and then releasing air in relation to the individual user. As air is released, the user is immersed and enveloped leaving a layer of air between the user and the seat interface. Palpation of the lowest bony prominence (in most cases the ITs or Sacrum) is part of the process in guiding both the seated posture and the optimal air levels.

Research and EBP has repeatedly shown that a well-set up air cushion provides a high level of pressure redistribution and many facilities and services will provide an interim ROHO cushion when a pressure injury or high risk of injury has been identified. The main barriers to this type of cushion meeting a user’s needs is in establishing correct air inflation levels.

TOO MUCH AIR

When an air cushion is over-inflated we are not able to immerse in it effectively. Many users that find an air cushion unstable are actually sitting on an over-inflated cushion, rather than immersing into it as designed. When over-inflated, there is also increased peak pressure at the lowest bony points. Let’s think about a tyre, a tyre is filled with air. They are usually highly inflated and the more air that goes in the ‘harder’ they become.

The material of the cushion that contains the air will also impact the immersion and envelopment capacity of the cushion. Which is why ROHO is very particular about what their cushions are made of, hence why they make all their neoprene on-site.

NOT ENOUGH AIR

When a cushion is under-inflated and there is no layer of air between the user and the seat base, there is a risk of bottoming out and increased pressure. The cushion is designed to have a layer of air under the user, however we find that air cushions incorrectly set up are more likely to have too much air rather than too little.

WHEN THE SET UP GOES WRONG

I like to set up an air cushion with a user consciously. What I mean by that is I tend to talk through the process before and during the set up. I want them to be aware of the changes in how they are sitting as the air is released. If there is a wall mirror in the room we will often do the set up in front of it and talk about how they are immersing (or sinking) into it as the air is adjusted.

Many long term ROHO users know straight away if their cushion is correctly inflated by how they sit and feel. Others may need more consistent monitoring of the inflation level and assistance in checking and setting up. The set up and maintenance of inflation has been a barrier in some settings. Initial set up is often completed by a therapist but the user may need to adjust the inflation levels over time. I had one client who reported that her carer always added more air to the cushion even though she knew it required less.

Sometimes therapists arrange hire of an air cushion and it is sent directly to the end user. I once went to visit a client who was hospitalised for a pressure injury. The custom cushion had been removed and she was sitting on a ROHO. It was so over-inflated it was difficult to press down on the fully expanded cells, when I queried who had set it up for her she advised it was a maintenance worker.

So how do we overcome or reduce some of these barriers? For some, it is about education and training but others may need a more concrete cue. How can someone who has experienced a pressure injury and is anxious about their cushion set up feel more confident that it’s configured to meet their needs? For those that don’t know about the SmartCheck, it is a tool that can assist in checking the inflation level of a ROHO Single Compartment Cushion.

ROHO SMARTCHECK 

At a simplistic level, the Smart Check uses sensors to guide the appropriate level of inflation for the user. The SmartCheck is separate to the cushion and attaches as required to any Sensor-ready cushion. All single valve, single compartment ROHO cushions sold in New Zealand and Australia are Sensor Ready. This enables a SmartCheck device to be added at any stage even if not identified as a need until after someone has purchased the cushion. 

Once attached to the cushion, the SmartCheck uses illumination and arrows to enable you to set up and check the inflation level. 

SmartCheck is easy to use and can provide peace of mind to those at risk of pressure injuries and to those supporting them. It is a good idea to learn how to set up, override and reset to factory default settings. We have a great set up guide which is available HERE that walks you through the steps. 

If you want more information on the set up and use of SmartCheck, you can reach out to your local Territory Sales Mannager or contact us at education.au@permobil.com

Tracee-lee Maginnity
Clinical Education Specialist

Tracee-lee Maginnity joined Permobil Australia in July 2019, as a clinical education specialist. She graduated Auckland University of Technology with a BHSc (Occupational Therapy) in 2003 and has since worked in various roles related to seating and mobility including assessing, prescribing and educating.

Tracee-lee is passionate about maximising functional outcomes with end users and the importance of education within the industry.