In the world of seating and mobility, pressure injuries are a big deal. It is our job as clinicians and therapists to prevent peak pressure through the use of seating and positioning products, to minimize risk of pressure injuries. In today’s blog we’re taking a look at the mechanics of pressure injuries and will identify some scenarios in which a wheelchair user could benefit from a short-term positioning surface to safely perform daily tasks.
The Mechanics of Pressure Injuries: It’s Not Just Ischemia
Before we talk about the solutions, I’m going to speak first about the problem. As I’m sure you’ve heard before, ischemia was the most widely accepted and most researched cause of pressure injuries. Ischemia is a lack of blood flow. However, Stekelenburg, a well-known pressure injury researcher, in 2007 performed a study* in animals refuting that a lack of blood flow is the primary factor in tissue necrosis. In that study, they looked at cell death with ischemia and compared it to cell death with ischemia and force loading or pressure. They found that more damage was caused by a combination of ischemia and tissue distortion vs. ischemia by itself. This concept of sustained cellular deformation leading to cell death has become more well-known and increasingly researched mechanism of pressure injury ideology.
Simply put, under load large compressive and tensile strains induce large deformations at the cellular level. Large cellular deformations can stretch the plasma membrane of individual cells. This damage to the plasma membrane could disrupt cellular homeostasis and eventually cause cell death and result in tissue injury. Damage from deformation can occur not only at the organ and tissue level, but also at the cellular level, and this damage can even occur in situations where there is good blood flow.
We are not just worried about blood flow and circulation; we are now also concerned with cellular deformation. The two charts here compare and contrast what happens during ischemia and cellular deformation, but the end result of each pressure injury pathway is still cell death. And more importantly, the timeframes are quite different. Considering cellular deformation can happen in minutes to hours, it’s extremely important to address the wheelchair users’ skin protection needs beyond the wheelchair. This includes surfaces they are sitting on for bathing, toileting, driving, and beyond.
Scenarios for Short-Term Seating Surfaces
As we mentioned in the above paragraph, cellular deformation can happen in a matter of minutes. Taking this into consideration, our clients can minimize the risk of pressure injuries by using short-term seating solutions. Below is a chart of activities where ROHO short-term seating solutions can be utilized to minimize deformation, inflammation, and ischemia in these scenarios.
Skin protection in bed is vital. “Bed sores” have historically caused debilitating pressure injuries to wheelchair users. Our clients rest and sleep in bed at least eight hours a day. ROHO has a line of mattresses and overlays which offer the skin protection many clients need while supine and in a reclined position. See the chart below for a description of the ROHO mattress line.
Given what we know about cellular deformation and pressure injuries, we encourage clinicians to assess and address the skin protection needs for MRADLs in bed, the bathroom, and beyond. These short-term seating surfaces, mattresses, and overlays can be ordered through suppliers and/or through eCommerce. This gives a variety of access methods to these products which can make a world of difference in protecting skin and optimally preventing skin breakdown. By making it common practice to select appropriate skin protection products for use outside of the wheelchair, we can further reduce pressure injuries for the at-risk client population.
*Stekelenburg, A., Strijkers, G. J., Parusel, H., Bader, D. L., Nicolay, K., & Oomens, C. W. (2007). Role of ischemia and deformation in the onset of compression-induced deep tissue injury: MRI-based studies in a rat model. Journal of Applied Physiology, 102(5), 2002-2011.
Eleni Halkiotis, MOT, OTR/L, ATP
Eleni is a graduate of the master’s degree occupational therapy program at the University of the Sciences in Philadelphia. She has been practicing occupational therapy since 2005. Her specialization in seating began in 2009 in New York City at Bellevue Hospital and continued at Independence Care System (ICS). At ICS Eleni was the primary therapist for the multiple sclerosis (MS) team. She provided in-clinic and home visiting treatment in English and Spanish for manual and powered mobility and seating and positioning interventions to members with MS and a vast array of other physical disabilities and chronic conditions. Eleni has participated in clinical research in multiple practice settings and very much enjoys teaching. She served as an adjunct professor in the occupational therapy program at Thomas Jefferson University in 2006 and 2007, and since 2009 continues to teach biannually at New York University. She has presented professionally at the International Seating Symposium in 2013 and 2017, the European Seating Symposium in 2013, and the World Federation of Occupational Therapy Congress in 2018. She holds licenses to practice occupational therapy in the United States of America and in the United Kingdom.