ATP Series

Under Pressure: Q&A with Denise Harmon, ATP/CRTS

Mobility Management: When wheelchair users develop pressure injuries, the seat cushion often gets the blame. Is that fair?

Denise Harmon: It’s complicated (sometimes, the path to discovery of a simple causal factor is the complication!). The cushion is the first cause to be suspected, but often we find that other factors have contributed.

MM: It’s natural to think about pressure injuries as weight that stays in one place for too long. But how much impact do other factors have?

DH: I think often if the consumer comes into the evaluation with a bias (either from personal observation or physician commentary, etc.) that the cushion has caused a pressure injury, we often jump to the conclusion that the seat cushion needs to be re-considered.

It’s important to develop and follow a practice of thorough risk assessment, which includes both physical evaluation and interview of activities of daily living. There are a number of other causal factors: type of transfer, appropriate seating dimensions (seat depth, seat-back angle, knee-heel angle, footrest height), weight loss, microclimate, incontinence, comorbidities, etc.

It’s sometimes more difficult to determine, but often providing education and resources regarding effects of, for example, microclimate can go a long way in affecting pressure. Undergarments can have an impact on pressure: There are very lightweight, stretchy, seamless undergarments available in department stores or online that can have positive effects in protecting bony areas.

I worked with an individual who, in spite of our recommendations, continued to wear heavy jeans with heavy pockets and seaming, which put pressure directly on his stage IV wounds. Multiple appointments, re-educating with the same words consistently regarding his selection of garments (you can look just as good in a pair of stretch athletic pants with no pockets) helped to change his “wardrobe approach.”

MM: Weight-shifting requires the client (plus maybe a caregiver) to perform weight shifts according to recommendations from the seating team. How much do we need to examine whether the client is following recommendations?

DH: 100 percent! Client education and compliance are key. Our approach should be one of interview, education and review, each and every time we are with the client. The emerging “connected chair” technology for power chairs allows clinicians to review the client’s history in utilization of tilt, recline/power seat functions. This is an extremely useful tool and important for us to expand on, to enhance our individual practices.

MM: Can non-compliance come from a lack of education?

DH: Yes. As we learn more and more about the key contributing issues to risk/cause of pressure injury, we need to make sure we continue to share the information with our clients. So many individuals we see, in spite of best intentions, have a lot going on in their daily lives, and the message can get lost over time.

Messaging to the client should be consistent and ongoing. Being proactive is key: In working with high-risk individuals, it’s important to schedule continued appointments for monitoring of their skin/situation and hopefully progressively building into both their own knowledge base as well as daily habits (versus waiting for a call after the problem arises or has escalated).

MM: Let’s say a client has developed a pressure injury and you are assessing for new seating. What questions do you ask?

DH: If there is a report available from the physician or wound care specialist, this is important to access. Inspect the pressure injury: Visual inspection informs us. Observe seated posture both in the mobility base, as well as on a mat table: Seeing the individual in both seated environments is critical in looking at postural asymmetries, etc. Of course, physical assessment with the clinician is key: measuring balance, body angles and shapes, points of support needed for off-loading pressure, etc. Often you will spot a very subtle postural asymmetry that has a huge impact on pelvic position/pressure to a bony prominence. When interview and physical assessment don’t result in informing to cause of pressure, pressure mapping is a key tool to utilize.

This article originally appeared in the March/April 2021 issue of Mobility Management.

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