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
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
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.