Clinical Remote Monitoring of Individuals With Spinal Cord Injury at Risk for Pressure Injury Recurrence Using mHealth: Protocol for a Pilot, Pragmatic, Hybrid Implementation Trial.

BACKGROUND: Pressure injuries are one of the most challenging secondary conditions for individuals with spinal cord injuries and related disorders (SCI/D) owing to inherent, lifelong risk factors that include a lack of sensory and motor function below the level of injury and reliance on a wheelchair for daily mobility, resulting in prolonged periods of sitting. Although many factors contribute to the development of pressure injuries, the pressure between the skin and a surface is always a factor and the development of injury is dependent on the magnitude and duration of the pressure. Clinically, broad recommendations for relieving pressure are used because we know very little about the unique day-to-day life patterns of the individual wheelchair user. Typically, it is after the occurrence of a pressure injury that the therapist will check equipment fit and the effectiveness of pressure offloading and ask about other surfaces they sit on in their home and community. This time-lapsed, largely self-reported data are fraught with recall bias and inaccuracies that the therapist incorporates into a plan of care. OBJECTIVE: This study's objective is to pilot-test the implementation and clinical effectiveness of a telehealth model of care combined with our mobile health (mHealth) Assisted Weight-Shift device for remote monitoring of factors related to maintaining skin health and wheelchair setup. Our overall hypothesis is that this study will result in an effective implementation plan, and the enhanced connected model of care using remote monitoring of pressure management will result in pilot-level, improved clinical outcomes for adults with spinal cord injury at high risk for pressure injury recurrence. METHODS: For all aims, we will use a mixed methods design using an exploratory, sequential approach to include the strengths of both qualitative and quantitative data. For aims 1 and 2, we will iteratively collect qualitative data from therapists, patients with SCI/D, and other stakeholders. For aim 3, we will perform a hybrid effectiveness-implementation randomized controlled trial to pilot-test the intervention. The projected results include an iteratively developed and tested implementation plan that meets moderate to high levels of acceptability, feasibility, and appropriateness. Additionally, the pilot trial results are expected to show positive trends in relevant clinical outcomes related to reduced pressure injury incidence, recurrence, and improved healing when compared with the standard of care. RESULTS: Currently, 6 participants have been recruited for our aim-1 qualitative study. CONCLUSIONS: This study will expand upon our previous study to move the Assisted Weight-Shift system into routine clinical care, which was a strong desire of adults with SCI/D for improved individualized care plans to prevent pressure injuries. The results of this study will guide the next steps in a full, hybrid effectiveness-implementation trial with the goal of improving care to prevent pressure injuries. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/51849.

Effects of Real-Time Pressure Map Feedback on Confidence in Pressure Management in Wheelchair Users With Spinal Cord Injury: Pilot Intervention Study.

BACKGROUND: Wheelchair users with a spinal cord injury (SCI) are at a high risk for developing pressure injuries (PIs). Performing weight shifts is a primary method of pressure management for PI prevention; however, individuals with SCI may lack confidence in their abilities to perform adequate pressure relief due to their lack of sensation. Real-time seat interface pressure mapping feedback may provide partial substitution for sensory feedback such that an individual's confidence is improved. OBJECTIVE: We aim to examine how confidence for pressure management by wheelchair users with SCI was impacted by providing access to real-time, on-demand seat interface pressure mapping feedback. METHODS: Adults with SCI (N=23) completed self-efficacy questions addressing confidence around 4 factors related to performing weight shifts in this longitudinal, repeated-measures study. We evaluated the impact of providing standard PI prevention education and access to live pressure map feedback on confidence levels for performing weight shifts. RESULTS: Access to live pressure map feedback while learning how to perform weight shifts resulted in significantly higher confidence about moving far enough to relieve pressure at high-risk areas. Confidence for adhering to the recommended weight shift frequency and duration was not significantly impacted by in-clinic education or use of pressure map feedback. Confidence that performing weight shifts reduces PI risk increased most following education, with slight additional increase when pressure map feedback was added. CONCLUSIONS: Access to live pressure mapping feedback improves confidence about performing weight shifts that relieve pressure when provided in the clinical setting and demonstrates potential for the same in the home. This preliminary exploration of a smartphone-based pressure mapping intervention highlights the value of access to continuous pressure mapping feedback to improve awareness and confidence for managing pressure. TRIAL REGISTRATION: ClinicalTrials.gov NCT03987243; https://clinicaltrials.gov/study/NCT03987243.

Visualization of user interactions with a pressure mapping mobile application for wheelchair users at risk for pressure injuries.

Pressure injuries for individuals with spinal cord injuries (SCI) are correlated with mortality and are a leading cause for rehospitalizations. The Assisted Weight Shift (AW-Shift©) is a mobile pressure mapping application designed to provide users with a live map view and reminders to perform weight shifts. Novel visualization techniques were used to understand daily distributions of user interaction wit h AW-Shift©. The date and time of system interactions were recorded for six participants with SCI over 7 days (five males/one female, five manual users/one power user, 55.3 ± 17.3 years old, 10.6 ± 6.5 years since injury). Circular frequency plots were created to visualize the time and frequency participants brought the app to the foreground of their phone and received alerts and reminders to complete weight shifts. While some participants used the system regularly throughout the day, others primarily used it before 8am; highlighting the system's importance for regular spot checks and morning wheelchair setup. Participant adherence to weight shift reminders was low suggesting the live pressure map may be more useful. Circular frequency plots can be used by clinicians to more easily review large amounts of patient data. Future work will investigate raw pressure mat data and create a closed-loop weight shift detection algorithm.

Effect of chair types on work-related musculoskeletal discomfort during vaginal surgery.

BACKGROUND: Evidence supports that surgeons are at high risk for work-related musculoskeletal disorders. OBJECTIVE: The objective of the study was to compare the effect of different chairs on work-related musculoskeletal discomfort for surgeons during vaginal operations. STUDY DESIGN: This crossover study randomly assigned 4 surgeons to 4 chair types using a 4 × 4 Latin square model: a conventional round stool, a round stool with a backrest, a saddle chair with a backrest, and a Capisco chair. Subjective assessments of surgeon discomfort were performed with a validated body discomfort survey, and workload was assessed with the surgical task load index. The objective postural load was quantified with inertial measurement units of the modified rapid upper limb assessment limits. Subjective and objective assessments of chair comfort were performed with an 11 point scale and seat interface pressure-mapped distributions, respectively. The primary outcome was the difference in body discomfort scores between pre- and postsurgery measurements. Secondary outcomes were the differences in chair comfort scores, postural load, and seating interface pressure-mapped distribution. For each outcome, comparisons among the chair types were based on fitting a linear mixed model that handled the surgeon as a random effect and the chair type as a fixed effect. RESULTS: Data were collected for 48 vaginal procedures performed for pelvic organ prolapse. Mean (SD) duration of surgery was 122.3 (25.1) minutes. Surgeons reported body discomfort during 31 procedures (67.4%). Subjective increase in discomfort from the preoperative state was noted most commonly in the lower back (n = 14, 30.4%), followed by right shoulder (n = 12, 26.1%), upper back (n = 8, 17.4%), hips and buttocks (n = 7, 15.2%), left shoulder (n = 6, 13.0%), right or left thigh (n = 6, 13.0%), and neck (n = 6, 13.0%). Pre- and postsurgery body discomfort scores did not differ with respect to chair type. Chair discomfort scores for the round stool and the saddle chair were significantly higher than the round stool with backrest and the Capisco chair (P < .001). Although the average modified rapid upper limb assessment postural scores showed moderate to high musculoskeletal risk of neck and shoulder discomfort across the 4 surgeons; chair type did not affect postural scores. The saddle chair had significantly reduced dispersion of seated pressure vs the round stool with backrest (P ≤ .001), depicted by the number of cells with pressure values >5 mm Hg. An increased dispersion of pressure across the chair surface was associated with increased comfort (Spearman correlation, 0.40, P = .006). CONCLUSION: Musculoskeletal strain and associated discomfort for surgeons are very high during vaginal operations. Chair type can affect comfort, and chairs with more uniform distribution and fewer pressure points are more comfortable. However, the chair type used in surgery did not influence the musculoskeletal postural load findings.

Seating-Related Pressure Injury Prevention in Spinal Cord Injury: A Review of Compensatory Technologies to Improve In-Seat Movement Behavior.

A PURPOSE OF REVIEW: The purpose of this review was to (1) assess the factors related to the occurrence of pressure injuries in people with a spinal cord injury (SCI), (2) review methods of pressure injury prevention, and (3) examine compensatory technologies developed to promote in-seat movement to reduce the risk of pressure injuries. B RECENT FINDINGS: Risk factors for seating-related pressure injuries are well documented, yet, ulceration remains a daily concern for individuals with SCI. While prompts and alarms have been shown to be effective at increasing in-seat movement, the devices thus far were not designed for long-term use. Wheelchair users will benefit from continued development of novel technologies designed to help them self-manage pressure injury prevention. C SUMMARY: Optimized feedback about pressure and movement will help wheelchair users with SCI perform more effective movements to relieve pressure, perform movements more frequently and consistently, and maintain effective and frequent movement behaviors over time while feedback is available.