Seating & Positioning 2012 Handbook

Time to Make a Change?

How Environment, Media & Everyday Living Impact Seat Cushion Life... & When It’s Time for a Replacement

Seat CushionWheelchair seat cushions are capable of doing some pretty amazing things.

At the very least, they’re supposed to be comfortable to end users who are seated on them for many hours, every day, for years in a row. Cushions with more complex designs and perhaps made with multiple media can also provide proper positioning to improve enduser function, and can help to evenly distribute the end-user’s body weight and resulting pressure, which ultimately can protect all-toovulnerable skin.

On top of that, cushions are called upon to be light in weight, especially for end users who propel their own chairs. They can’t add undue height, either, since that can make it difficult for chair and user to slide under desks or dining room tables.

They also have to deal with factors that would be their undoing, such as unwanted moisture or extreme temperatures.

All in all, seat cushions are superheroes in compact and comfortable packages that require little maintenance. But even superheroes have their kryptonite, and for cushions, it’s a simple one: use. Day-in, day-out use. And because cushion breakdown or failure can lead to major positioning and skin-protection issues, it’s critical to know when cushions need to be replaced. What are the warning signs? How can providers and clinicians teach consumers and caregivers to check for wear? And what factors can make cushions more susceptible to wear?

Making a Visual Inspection

Today’s wheelchair seat cushions — particularly those intended for complex rehab clients — are designed to withstand a lot of pressure and use. And today’s improved materials — from special types of foam and gels to honeycomb to air cells or combinations of media — can be used to create cushions that perform well for long periods of time.

But cushions aren’t invincible, especially if they’re exposed to certain elements or situations. That’s why it’s important for cushion users, caregivers and members of the end-user’s seating & mobility team to be on the lookout for signs of wear.

“A visual inspection of the cushion is important when assessing for wear,” says Susan Cwiertnia, PT, MS, clinical specialist, VARILITE. “The indications of wear that a clinician would look for vary depending on the materials and construction of the cushion, since they are designed to function differently.”

“Wear presents in many different ways, depending on the type of medium used,” says Steve Boucher, OTR/L, clinical education specialist, Sunrise Medical. “Some common visual cues include wearing of a cover (ripped, torn, severely thinned out); a foam cushion that resembles the shape of a pancake (in terms of cushion height); or a gel/fluid pad that no longer appears to be robust with material (flattening of a fluid pack in the well of a cushion).”

John Storie, eastern U.S. sales director for Quantum Rehab, starts his investigation by looking at the client.

“The first thing to look at is the position of the client sitting on the seat cushion,” he says. “If the client sitting on the seat cushion has a pelvic obliquity, then the clinician/ATP must be sure to examine the seat cushion for wear on the side of the cushion where the client’s pelvis is lower.”

After that, Storie adds, “Then they should look for a wear pattern in the cushion cover. For some materials, the color of the material will be different in this location, and for other materials, wear could be evident from pilling of the material. The clinician/ATP should place their hand on the seat cushion and feel if one side of the cushion is lower than the other or where the cushion’s material feels softer or more worn.”

Different Materials, Different Types of Wear

Visually and physically inspecting a cushion can help providers and clinicians to determine the extent of the cushion’s wear, but it’s important to note that all cushions do not show wear in the same ways.

“When assessing the condition of a cushion, keep in mind that different technologies wear differently,” says Dan Hill, president, EquaPressure LLC.

As an example, he says, “Foam can form a permanent sag or impression. This is a dead giveaway that the cushion is breaking down. Before an impression forms, it is my experience that foams soften first.”

“Open-cell foam will show wear and tear with signs of crumbling foam and/or a compression set,” Cwiertnia says. “When the foam is exposed to sunlight, it will degrade, causing discoloration and crumbling. Moisture can also cause problems with foam, such as mold.

“A compression set occurs when the open cells in the foam are no longer resilient and don’t spring back to their original height. Frequently, this is called ‘bottoming out’ in our industry. This also means that foam has lost some of its loadbearing properties and can affect pressure distribution.”

Hill suggests testing the foam for fitness: “The pelvic region of the cushion takes more weight, heat and moisture during use than the area near the front of the cushion, under the user’s knees. Compare the foam in these two areas by simultaneously squishing them. If the foam in the pelvic region is noticeably softer — and of the same piece of foam as the other area — then replacement should be considered, or the user is at greater risk for sores. Foam will turn a darker yellow as it ages, even if it is sitting unused the whole time. This isn’t a cause for concern. However, if the foam feels crumbly or crusty, then there is a problem.”

For fluid and gel cushions, Boucher says, “Check to see if there is enough fluid in the cushion — how easy is it to push your finger down into the fluid/gel and feel the base of the cushion? Check to see if the fluid or gel still migrates around the fluid/gel pack.”

In cushions that use both elastomer gel and foam, Cwiertnia says, “The covering of the elastomer gel can start to crack and peel off.” And in viscous fluid and foam cushions, she adds, “The seams of the fluid packs should be checked for cracks or punctures, which cause leaks. Also, the viscous fluid has potential to become nonhomogenous if it isn’t kneaded, which will result in hard lumps in the fluid that can interfere with skin protection.”

Polyurethane honeycomb cushions, Cwiertnia says, “have cells that are designed to absorb shock and pressure by the cells bending or deforming, but return back to their shape when the load is removed. Over time those cells can lose that ability and will remain flattened out. Clinicians should look for flattened areas on these cushions that don’t return to shape, especially with an active user who may be exposed to frequent shocks, such as dropping off curbs.”

For air cushions, Hill says, “Leaks are an See us at ISS Booths #29, 30, 31 obvious sign of replacement needs. Usually happen on a seam and can be easily located by submerging the cushion or washing a seam with soapy water and looking for bubbles. Breaks off the seam are usually preceded by the formation of a stress line across the chamber. This is where the material of the chamber is being stretched too far. The material is starting to stretch, and that line will appear as a lighter shade across the chamber. This is a sign of potentially imminent failure.”

Says Cwiertnia: “If the bladder of an air cushion is made out of neoprene or a similar material, it may start to crack over time. Exposure to petroleum or lanolin will cause the rubber to degrade. When the material cracks, it will develop a slow leak.

“Clinicians should check the material near the valve of cushions for wear and tear because this can be a common area for cracking. If they are punctured, most air cushions can be repaired with a type of patch kit. If a cushion has too many patched areas near the seat surface, it has potential to interfere with skin protection performance.”

Anticipating Wear Factors

Just as different media wear differently, they can be susceptible to different factors and environments. Knowing the factors that can contribute to or accelerate the wear process can help providers and clinicians to anticipate how a cushion will age.

“Weather, climate, terrain and transfers definitely impact materials,” Storie says. “For example, I know of clients who live in environments where a lot of snow is found, and in the winter, outdoor use of a manual wheelchair can cause salt and sand from the road to get into the seat cushion cover. Once salt and sand are inside a cushion cover, they can damage the material containing the gel or air, which causes failure of the cushion.”

“Cold weather can affect both fluid cushions and air-filled cushions if not managed properly by the end user or caregiver,” Boucher says. “Cold temperatures can cause an air-filled cushion to lose air and potentially cause skin issues.”

Heat can also have an impact, Boucher notes: “Severe heat can increase the chances of fluid cushions to leak if or when seams of the fluid pack become unglued. Air cushions are affected by both cold and hot temperatures, as with heat, air expands. If not maintained properly, this leads to over inflation and possible damage.

“I have not seen foam be deeply impacted by weather conditions as much as fluid/gel and air.”

Everyday cushion use, of course, can also cause wear, especially among active wheelchair users.

“Activity of a user will definitely have an impact on cushion longevity,” Boucher says. “The more active a user, the more transfers take place, the more movement — side to side, as well as back and forth — occurs. More weight shifts are typically completed, which leads to increased unloading/loading of the cushion.”

Wheelchair users often develop transfer routines, which can also impact cushion wear, Boucher says: “If an end user consistently ‘plops’ onto their cushion, it can cause lots of issues with all cushions. Elasticity of foam can decrease quicker; fluid/gel and air cushions can potentially pop.”

“Slide board transfers can be tough on some cushions, causing wear from frequently placing the slide board on top of the cushion,” Cwiertnia says. “Cushion covers function to protect the cushion and can also wear out easily from frequent transfers and washing. The cushion cover is often designed to work with the cushion as part of the system for pressure distribution, moisture and temperature management. A worn cover should be replaced for optimum cushion performance.”

Moisture can also be a problem to watch for, she notes: “The foam cushion should be checked if the client is incontinent or it has been exposed to moisture from bathing or wet weather.”

Helping Consumers Help Themselves

Since consumers and their caregivers are the ones living with their cushions every day, teaching them to watch for signs of wear can be helpful.

Storie suggests advising cushion users to look for wear patterns in the cushion cover’s material and to check to see if one side of the cushion is lower than the other.

“The client may start developing pain from his or her seated position, may constantly feel positioned incorrectly, and may notice that the seat cushion feels hard after sitting on it for a short period of time,” he says. “He or she may also have red areas starting to develop, which can be an indicator of a pressure ulcer developing from poor positioning from a worn seat cushion.

“As soon as a client notices any of these indicators, he or she should make an appointment to see his or her seating specialist. These may be indicators that the seat cushion needs to be replaced or that another part of the seating system may be causing problems that can have long-term effects on the client’s body and functional life.”

Cwiertnia recommends informing consumers about how to maintain their cushions.

“The consumers should look for the same signs of wear and tear such as crumbling, cracks and leaks,” she says. “They should be aware of bottoming out on a foam cushion and especially air cushions. Most manufacturers have instructions on how to check the air level of the cushion.”

Wheelchair users should also continue to perform skin checks, Cwiertnia says, “looking for areas of redness to alert them that their cushion may not be functioning optimally, and they might be at risk of skin breakdown. Any signs of non-blanching redness, increased sitting discomfort, excessive cushion wear or a significant change in their medical condition warrants a consultation with a clinician to ensure that their equipment is meeting their needs.”

Of course, because of the hard work they do, even well-cared-for cushions need eventual replacement… which means working with consumers’ funding sources. Boucher says, “A new cushion can be justified with proper documentation when the cushion no longer meets the needs of the end user. This could be due to wear and tear after the manufacturer’s warranty, or a change in enduser medical status.”

Says Cwiertnia, “Medicare requires a 24-month manufacturer’s warranty on cushions, but ironically won’t replace the cushion unless it has met the five-year useful lifetime requirement for DME. Medicare will pay for a new cushion if there has been a medical change in the patient’s status that requires a new cushion and if a new order is received. If the five-year requirement has been met, the beneficiary doesn’t automatically qualify for a new cushion. They still must demonstrate that there has been excessive wear and receive a new order from the physician.”

Boucher recommends including detailed documentation including the consumer’s current cushion, diagnosis, changes in medical status, wear and tear of the cushion and what new cushions have been successfully trialed with the client.

“Diagnosis and successful trials are the most critical pieces of information required,” he says.

This article originally appeared in the March 2012 issue of Mobility Management.

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