Reducing pressure with the goal of improving outcomes: a retrospective chart review of cushion evaluations and recommendations at one seating clinic.

PURPOSE: To describe the current seating recommendations made by a seating clinic for wheelchair users who presented with a Pressure Injury (PrI) or history of PrI. METHODS: Retrospective review of electronic medical records of 133 adults who used a wheelchair as their primary means of mobility who had a cushion evaluation during which interface pressure mapping data was documented. RESULTS: Clinicians adjusted 71% of participants' wheelchair cushions, including 49% who received a new cushion, and 37% of participants' wheelchairs. The most common adjustments besides receiving a new cushion were: addition of an underlay, adjusting the inflation of a cushion, and adjustments to the foot or back support of the wheelchair. Forty-five participants only received adjustments (i.e. no new cushion), while 23 participants only received education and feedback rather than equipment modifications. Those 23 participants had significantly lower Peak Pressure Index (PPI) than those who received equipment modifications (mean [95% CI] 76.7 [59.1, 94.3] versus 111.6 [102.1, 121.2] respectively, p = 0.001). The PPI was reduced by an average of 22.5 mmHg from the initial to final seating system amongst those who received modifications ([13.9-31.0], p<.001). CONCLUSIONS: The seating clinicians considered interface pressure mapping in their decision-making and effectively reduced interface pressures with their interventions. Cushion replacement is important when someone presents with a PrI. However, adjusting an existing wheelchair cushion and/or seating system provides important additions and alternatives to consider for reducing interface pressure. There is also a role for education about proper use of equipment, weight shifts, and alternate seating surfaces.IMPLICATIONS FOR REHABILITATIONA cushion evaluation may involve evaluating more than one cushion configuration and using pressure mapping to compare the best options.To address perceived wheelchair cushion issues, posture and positioning should be evaluated and adjusted as necessary, in addition to evaluating the cushion itself.Common positioning modifications include: modifying/adding cushion underlays or inflation and foot and back supports in response to clients' changing postural needs and wheelchair components coming out of optimal position due to wear and tear.Adjustments to the wheelchair and cushion aim to distribute body weight over a larger surface area, reduce pressure at high-risk locations, improve posture, and increase function. These adjustments should consider individual's specific needs and goals, while also being mindful of funding barriers.

The participation and activity measurement system: an example application among people who use wheeled mobility devices.

PURPOSE: To present the Participation and Activity Measurement System (PAMS), a system designed to examine activity and participation among people who use wheeled mobility devices. METHODS: Description of PAMS' components and an example of its application among people who use tilt-in-space wheelchairs. RESULTS: PAMS combines objective and subjective descriptions of mobility-based activities within a person's home and community. By applying technologies such as wheel revolution counters, seat occupancy sensors and global positioning systems, PAMS captures diverse metrics of wheelchair use including destinations, wheeled distance, duration of occupancy and the use of specialised features such as tilt. These metrics also provide the basis for a prompted recall interview designed to elicit contextual data about wheelchair use within a person's home and community. A recent study among people who use tilt-in-space wheelchairs demonstrates the components and application of PAMS. CONCLUSIONS: The combination of objective and subjective data afforded by the application of PAMS reflects a complex relationship between wheelchair use and the role of mobility as people go about their daily home and community activities. PAMS can be adapted to a variety of research questions and may be used as an alternative or supplement to self-report assessments of activity and participation.

Use of power tilt systems in everyday life.

PURPOSE: The goal of this study was to monitor and describe the use of power tilt systems in everyday life. Additionally, tilt measurements were used to determine if participants performed regular pressure relieves. METHODS: Wheelchair occupancy and seat position of 16 fulltime power wheelchair users were monitored regularly for 1-2 weeks. Daily wheelchair occupancy, typical position, time spent at different tilt angles, tilt frequency and pressure relieving tilt (PRT) frequency were described. RESULTS: Participants used their tilt systems in many different ways, including subjects who typically sat at small (0-14 degrees) tilt angles and subjects who typically sat at medium (15-29 degrees) tilt angles. Few subjects tilted past 45 degrees. Almost all subjects tilted throughout the day, with the median subject performing >3 tilts per hour of wheelchair occupancy. Despite the regular use, few subjects performed regular PRTs (median = 0.13/h) CONCLUSION: Differences in tilt-use illustrated the variability in function and activity among users, as well as the diverse benefits of a tilt system for different users. Further study into why subjects did not regularly achieve PRT magnitudes would be valuable to inform improved training, education and follow-up.

Characterization of power wheelchair use in the home and community.

OBJECTIVE: To characterize the use of power wheelchairs and to determine if multiple measures of mobility and occupancy jointly provide a more comprehensive picture of wheelchair usage and daily activity in full-time power wheelchair users than daily distance alone. DESIGN: Prospective observational study. SETTING: Subjects' everyday mobility was measured in their homes and communities for 2 weeks, and prompted recall interviews were conducted by phone. PARTICIPANTS: A convenience sample (N=25) of nonambulatory, full-time power wheelchair users. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Wheelchair usage was logged electronically, and geolocation and interview data were used to isolate chair use to (1) in the home, (2) not in the home indoors, or (3) outdoors. Distance wheeled, time spent wheeling, number of bouts, time spent in the wheelchair, and the percentage of time in the wheelchair spent wheeling were measured to describe wheelchair use. RESULTS: The median wheelchair user spent 10.6 hours (range, 5.0-16.6h) in his/her wheelchair daily and wheeled 1.085 km (range, 0.238-10.585 km) over 58 minutes (range, 16-173 min) and 110 bouts (range, 36-282 bouts). Wheelchair use varied across subjects, within subjects from day to day, and between environments. Mobility bouts outdoors were longer and faster than those wheeled indoors. In a regression analysis, distance wheeled explained only 33% of the variation in the number of bouts and 75% in the time spent wheeling. CONCLUSIONS: Power wheelchair use varies widely both within and between users. Measuring distance, time, and number of bouts provides a clearer picture of mobility patterns than measuring distance alone, whereas occupancy helps to measure wheelchair function in daily activities.

Effect of seat inclination on seated pressures of individuals with spinal cord injury.

BACKGROUND AND PURPOSE: Manual wheelchair configurations commonly include "squeezing" the wheelchair frame to improve balance for users with spinal cord injuries. This squeezing is achieved by lowering the rear portion of the seat relative to the front of the seat while maintaining the same back angle. The study's purpose was to examine the effect of increasing posterior seat inclination on buttock interface pressures. SUBJECTS: Nine male and 5 female subjects (mean age=37 years, SD=11.2, range=19-55) with complete thoracic or lumbar spinal cord injury were tested. METHODS: Subjects sat on a pressure mat placed over a foam cushion. Pressure readings were taken at seat angles reflecting seat height decreases of 0, 5.1, 7.6, and 10.2 cm (0, 2, 3, and 4 in) of the rear of the seat relative to the front of the seat. An analysis of variance and a Duncan multiple range test were used for data analysis. RESULTS: No meaningful differences were found in measurements of interface pressure (dispersion index, contact area, and seat pressure index), total force on seat, or peak pressure index with posterior seat inclination. DISCUSSION AND CONCLUSION: The data indicate no meaningful evidence that squeezing a wheelchair frame increases seat interface pressures.