DME

Blog posts of '2021' 'April'


How to select wheelchair seating components for the prevention and treatment of pressure injury?

We would like to introduce a new resource, designed to assist in the multidisciplinary approach to selecting wheelchair seating components for pressure injury prevention and treatment.

We created this in collaboration with our Permobil Americas Education Team and the Pan Pacific Pressure Injury Alliance (PPPIA) to produce a Cobranded Guide.

Over the past few months we worked closely with Dr Emily Haesler the Methodologist & Editor-in-Chief of the 2019 International Guidelines and Professor Keryln Carville the PPPIA Chair, to produce this pocket guide and would like to thank both for their advice and expertise.

This new resource is called the Wheelchair Seating Pocket Guide and is available for download here.

It is based on the recommendations and best practice statements included in the 2019 International Guideline. It is intended as a brief overview and is best read in conjunction with the full 2019 International Guideline and the free abridged Quick Reference Guide which are available here.   

In this week’s blog, we would like to highlight some of the evidence-based recommendations from the International Guidelines in relation to the seated posture, along with providing some tips on selecting the appropriate components for seating. 


What type of individual should be using a high specification seating support surface?

The number one factor in common among all wheelchair users is impaired mobility. As stated in the introduction of 2019 International Guideline, “a number of contributing or compounding factors are associated with pressure injuries; the primary of which is impaired mobility.” 

Seating support surfaces specifically designed for tissue offloading should be used with individuals with certain risk factors, instead of “entry-level” surfaces. As outlined in the recommendations and good practice statements in the 2019 International Guideline, the following factors increase the risk of developing a pressure injury (PI).  

If any of these apply, refer the individual for a seating and wheelchair mobility evaluation: 

  • Limited mobility and limited activity
  • Previous/current pressure injury
  • Alterations to skin condition over pressure points
  • Pain at pressure points
  • Diabetes mellitus
  • Perfusion and circulation deficits 8
  • Oxygenation deficits
  • Impaired nutrition
  • Moist skin
  • Increased body temperature
  • Older age
  • Impaired sensory perception
  • Obesity 

What are the considerations with the seat support (cushion) when pressure injury prevention and treatment are the goals? 

Every surface in daily use needs to be taken into consideration. For individuals who use a wheelchair, a quality cushion with tissue offloading properties, is only as good as the system it is placed in. 

The ideal seating system consists of: 

  • The wheelchair base, correctly configured to match the individual’s measurements and range of motion limitations
  • The back support, which positions the trunk to optimise pelvic positioning, further aiding in the prevention and treatment of a pressure injury
  • The seat support (cushion) which will immerse and envelop or offload for optimal pressure redistribution and positioning
  • Any needed accessories to add stability, redistribute pressure, and allow for function 

Consider other seating support surfaces that the individual would utilise throughout the day such as, a shower commode, car seat, bed mattress and other seating surfaces. 

For this reason, when the need for tissue offloading has been identified, a referral to a specialised seating therapist is warranted. 


The Optimal Seating System Equation  

Experts in seating and positioning are successful in positioning their clients because they understand the critical interplay between the cushion, the back support, the wheelchair configuration and any needed accessories to create an optimal seating system. 

Positioning an individual optimally, will take much more than just a cushion. The trunk can never be addressed without considering the pelvis and the pelvis cannot be addressed without considering the trunk. With every seating referral, remember this simple seating equation as a reminder to think of all critical components of the SEATING SYSTEM.

Knowing when to refer your client for an assessment by another health professional is an important aspect of your role. It may be in regards to a seating assessment by a specialist, or in regards to another concern you have with your client which is outside your scope of practice, such as a newly identified skin lesion or significant weight loss. 


The Multidisciplinary Approach to Pressure Injury Prevention & Treatment

The recognition, treatment, and prevention of a pressure injury is a multidisciplinary, team effort. It is important to understand your role as a health professional in this process. Roles and responsibilities vary across clinical settings and geographic locations; however, an individual-centred approach to care is a gold standard. The primary focus for everyone involved is care delivery centred around the individual and meeting their wants, needs and goals.

Here is a diagram showing the main members of the multidisciplinary team for pressure injury prevention & treatment, however this is not an exhaustive list.

  

For more information, download your free copy of the Wheelchair Seating Pocket Guide  

If you are interested in more information in regard to Pressure Injury Treatment & Prevention, make sure you download the brand new Pressure Injury Guideline Mobile App launched in March 2021, called the InterPIP.  This International Pressure Injury Prevention and Treatment Quick Reference Guideline Mobile App is a joint creation between the Worlds 3 leading Pressure Injury Advisory Groups – NPIAP, EPUAP and PPPIA

 


 

 

Dee Smith
LTC / Aged Care Clinical Specialist
 

Dee is a Registered Nurse with almost 25 years’ experience in a variety of specialities.  

She graduated from Sydney University with a Bachelor of Nursing in 1997 and in 2001 gained a Post Graduate Certificate in Infection Control. She has Certificate IV in Training and Assessment. 

Over the past few years Dee has been working within the Aged Care Industry as a Clinical Nurse Consultant in Infection Prevention & Control, to assist Residential AgeCare Facilities in meeting the requirements for the Aged Care Quality StandardsDee developed and delivered education and training of evidenced-based practice in Infection Prevention and Control, Wound Care and Pressure Injury Management. 

Dee joined Permobil in 2020 as the Seating and Positioning BDM and in 2021, joined the Asia Pacific Clinical Education team as Long Term Care/Aged Care Clinical Specialist. Dee is passionate about mentoring, educating and empowering health care professionals to provide safe and quality care. 


 


When prescribing a wheelchair and seating system there is usually discussion on what are blanket branded as accessories When we look to the definition of an “accessory” we find:

NOUN - a thing which can be added to something else in order to make it more useful, versatile, or attractive. "a range of bathroom accessories"

synonyms:     attachment · extra · addition · add-on · retrofit · adjunct · appendage · appurtenance · (additional) component · fitment · supplement.

By definition we could consider headrests and laterals as accessories, but how well will the seating system work with asymmetrical postural needs without these components? Whilst a cup holder is an addition that is useful and potentially versatile it’s not part of the seating outcome so much as an accessory that aids functional independence. There is an array of solutions that could assist in the task of carrying a drink from different accessories through to task adaptation. However, when we consider seating requirements it can create confusion when we use this wording accessory - especially when we are justifying equipment applications for a reader that may have little or no clinical experience. It is important to consider the language we use when articulating needs and using clear clinical justification for all the essential components of the solution.

Postural supports should not be seen as merely useful add ons but as a fundamental part of the overall solution. 


The seating system

With the increased images of end users in new equipment flooding some social media platforms we often see some unique and amazing modifications and configurations of AT solutions, but it also highlights some frequent and common configurations that have a cookie cutter feel to them. Of course you cannot know the background, history, assessment findings or goals for these images, they are just moments in time caught on camera but it does highlight some fundamental oversights commonly seen in the prescription process. Let us take the backrest for example. Most manufacturers offer a selection of back heights within the selected style, this can be further configured with how and where it is mounted onto the wheelchair. The back height is particularly crucial when identifying functional use such as for an active self-propeller or in a tilt in space chair.  I have seen numerous images of children in active user style manual wheelchairs with back rests at shoulder height or higher. This configuration can have a negative impact on the child’s functional ability and the development of an effective push stroke. We want to provide support when required but also enable freedom for function. Some of these set ups are also utilising shoulder harnesses and when the back height is not inline with the shoulder you cannot achieve the appropriate line of pull. In NSW Australia I have seen many backrests set up and integrated into the function of the headrest. It was a common solution with some population groups through various custom seating clinics. However from my experience these were only as effective as the contouring and materials used, for individuals with postural positioning requirements the ability to provide angulation and appropriate support it is tricky to achieve when extending a back support to integrate occipital support.  And this brings us back to Accessories vs Postural supports…is a head support an accessory or a crucial part of the solution? 


Headrests

When prescribing any seating component, we are essentially matching needs identified from the assessment to product parameters that provide points of control or forces that will support those needs. As such, identification of a headrest should be part of the initial postural solution rather than viewed as an extra add on at the end. What do we need to consider when identifying a potential head support?

A properly configured and positioned head support is an essential component of wheelchair. The position of the head can affect common activities and daily functions such as:

  •          Socialization and communication
  •          Safe Swallowing
  •          Respiration
  •          Attention to Task
  •          Mobility

The first question to address is around the intended use. Is there a postural requirement to provide support, is it for resting when in tilted position or is it too meet safety recommendations when using the chair as an occupant seat in transport? Each of these reasons will guide the potential solution. 


Head Support for postural support

The head position will affect posture and balance just as posture and balance affect head positioning. Poor seating positioning, unbalanced musculature, decreased innervation and neural disruptions can all contribute to head position. Understanding where the head needs to be supported is crucial for best outcomes. 

When considering a head support, a posterior head support is usually the simplest and least restrictive, as such this is likely to be an initial consideration. The pad is designed to be positioned in the suboccipital area with the goal to prevent excessive extension, rotation, or lateral flexion.

Other considerations include:

  •          Address pelvis head and trunk alignment before trying to fit for a head support.
  •          Remember that head position changes constantly with the slightest body movement.
  •          Aim to position the pad in the suboccipital area posteriorly and avoid resting on the ear if positioned laterally.
  •          Consider a head support with lateral, anterior/posterior, height, and angle adjustability, that can support the head                     posteriorly and laterally.
  •          Choose head support hardware that has offset capabilities to accommodate a head position out of midline.

 


Head Support in tilt n Space  

 It is considered best practice to prescribe a headrest for mobility bases with tilt in space or recline features. It is important to consider the different impact that movement of the users centre of gravity will have on head positioning when utilising these chair features. Ensure it has been set to maximise support in positions required without impeding function in a neutral position.

The head support should not be seen as just an add on; clinical consideration, function and seating principals need to be applied to the clinical reasoning process. A head support should not be a prop for poor positioning or a last minute add on but an integrated consideration. 


 

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.