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It's Not Always the Cushion

When Pressure Injuries Occur, Seat Cushions Are Often Blamed. But Truly, It's Complicated

• By Laurie Watanabe
• Apr 01, 2021

Perhaps because they’re so conspicuous, seat cushions are often blamed when wheelchair users develop pressure injuries.

But the real answers to why and how pressure injuries develop are much more complicated.

Linda Norton, M.Sc.CH, Ph.D., OT Reg. (ONT), is the Manager, Learning & Development for Motion [formerly known as Motion Specialties].

“I think it’s a lot of things,” Norton said when asked about the cause of pressure injuries. “I’m not seeing patients clinically right now; I’m a non-clinical OT, but involved more in education and research. We do know that having an appropriately fitted wheelchair and cushion tends to reduce the incidence of pressure injuries. There was a great article by [David] Brienza that actually talked about that in long-term care. It’s one of the few random control trial studies about seating and pressure injuries in an elderly population.

“I think people jump to that conclusion that it’s the chair. But the reality is that pressure, friction, shear can happen anywhere. So it could be a slip during a transfer that caused it, it could be a change in the client’s commode, it could be a change in their bed surface, it could be a number of different things. You really need to do a holistic assessment to look at the situation.”

Subtle Contributors to Pressure Injury Risk

Those different causes can be far less obvious than the often-accused seat cushion.

“One of the studies that got me interested in doing my Ph.D. was by [Jeanne] Jackson [and colleagues],” Norton said. “They did a really interesting longitudinal study out of the University of Southern California, and they looked [at]: What were the things that contributed to skin breakdown in the population that they saw?”

The first factor was perpetual danger: “There’s always a threat of a pressure ulcer occurring, so people live with that threat, and it doesn’t seem like so much of a threat anymore,” Norton explained. “It’s no different than if you’re living in a dangerous neighborhood and you avoid a certain alleyway, but the longer you live in that neighborhood, the more accustomed you get, and you start to go down that alleyway because it’s faster.”

The second factor is change or disruption of routine. “People may be coping really well with managing their pressure, friction and shear,” Norton said. “Then there’s a change in caregiver. Or somebody has a routine when they’re traveling, and all of a sudden, their flight gets delayed.

There’s something that happens, and they don’t necessarily have a way to address the situation, or the knowledge to address that particular scenario.”

Another factor: Changes in prevention behaviors. “The longer you’re doing a prevention behavior like shifting your weight, and the further you are away from a medical appointment, the [more] the behavior deteriorates,” Norton said. “The focus on it becomes less. It happens with medication, it happens with all kinds of things, not just in this domain.”

Jackson also identified the “lifestyle risk ratio,” which Norton described as “the balance of how many liabilities are in that person’s life around developing a pressure injury versus the things that buffer it. A liability might be not having the right bed surface, but the buffer can be a caregiver who does consistent repositioning.”

The factor most closely related to her own research, Norton said, is “how well does the healthcare provider individualize the treatment? Do we just hand people a sheet that says, ‘Shift your weight every 20 minutes?’ Do we move alongside the patient and help them figure out how they integrate weight shifting into their day, rather than just giving them a task to do?”

Norton compared the current pandemic to the constant pressure injury vigilance wheelchair users and caregivers need to practice: “We’re seeing it now in terms of what people are calling COVID fatigue. People who are at risk for pressure injuries probably have pressure injury prevention fatigue, too.

“Preventing a pressure injury is a long-term goal, but in the short term, you have the opportunity to go to a wedding or do something really fun and exciting. You might recognize you’re at risk, but you don’t want to miss that activity. When you’re in a healthcare setting, one of the dangers is you [as the healthcare professional] are focused on whatever the medical issue is. But as the patient, that’s only one of the things [they’re] focused on.”

The final factor in the Jackson report, Norton said, is access to needed care, services and support. “Sometimes people who are in wheelchairs who have issues with pressure injuries or are at risk of developing them don’t have wheelchair-accessible healthcare. So that also contributes to skin breakdown.”

The Need for Pressure Injury Education

Even among healthcare professionals, pressure injuries aren’t uniformly understood.

Norton said, “Years ago, we tried to do a study on bedrest and whether it was an effective treatment for pressure injuries. We were looking for people who had stage 1 or stage 2 pressure injuries, but in the phone calls, people were saying, ‘How big does the hole have to be before it’s considered a pressure injury?’

“So by the time somebody identifies that they have a pressure injury, it’s a 911 complete, ‘We’ve got to do something.’ If we could identify issues much more quickly, right at the development of redness, for example, then we would have more of an opportunity to intervene. We also know that it’s much easier to close a pressure injury the less time somebody’s had it, or the smaller or more shallow it is. But we’re not necessarily identifying them.”

Pressure injuries can also be mis-diagnosed. “Sometimes pressure injuries get confused with moisture-associated dermatitis or incontinence-associated dermatitis, which is a different thing,” Norton said. “And the treatments are different.

“The other thing worth making a note of is nutrition. One of the things that has been associated with closure is people’s nutritional status. It makes sense: If you don’t have the nutrients to use to repair your skin, then it’s going to take longer.” Norton added that a study found that 45 percent of medical and surgical patients admitted to hospitals across Canada were malnourished.

Where Clinical Practice Actually Happens

Ideally, wheelchair users, caregivers and healthcare professionals would quickly identify pressure injuries so patients could heal under optimal circumstances, with all the support they needed.

Then there’s pressure injury care in the real world.

“Donald Schon described medical research and best practices as a high ground, where all the needed resources are available, and the client sample may be limited to those without other complicating factors,” Norton said. “Unfortunately, that’s not always the case in clinical practice. Resources may be limited, and the clients may have other factors that could impact their treatment plan.

“That was the whole interesting thing when I started doing my research. I looked at how do healthcare providers identify and address lifestyle factors for their clients with chronic wounds? I didn’t just focus on pressure ulcers, but people with pressure ulcers are certainly a large proportion of who the clinicians I worked with treated. I spent six years studying this to basically draw the conclusion that there’s no common definition of what lifestyle factors are, there’s no common approach of how to manage them. And so what happens is it’s almost like we’re having two different conversations.”

Norton advocates for creating relationships in which wheelchair users and caregivers can be honest with seating teams. “The healthcare provider is telling you [the client] what the best practices are. You [as the client] want to be liked, so you’re telling the healthcare provider that’s what you’re doing, and if it turns out you’re not, you’re labeled non-compliant,” she said.

“We really need to be having the conversation ‘This is what best practice is. How do we implement prevention of pressure injuries into what you do day to day? What are the strategies that will work for you in your current settings?’ Even saying, ‘Some clients find it really difficult to follow these recommendations. Is that going to be an issue for you?’ Make it okay to not be perfect.”

Norton ties pressure management to activities clients are already doing. “If the person likes TV, I tie weight shifting to commercials: Every time there’s a commercial, you’re weight shifting. Or for somebody who is a gamer, every time they change a level or ‘die,’ that’s time for a weight shift.”

These strategies reflect Norton’s view of how to improve compliance. “The way I explain it in my head comes from a work of Donald Schon. He talks about best practices being this ivory tower on a mountain, but it overlooks a swamp. In the swamp is where clinical practice actually happens. You don’t have the perfect patient, you don’t have the perfect system like they often do when they’re doing research studies. Because a lot of that stuff is controlled. You have to do the best you can for that patient, applying those best practices, but it’s not necessarily realistic for them to follow all the best practices perfectly.”

Norton’s suggestions include weight-shifting adapted to real life. “Teaching a client to weight shift in different ways is also important,” she said. “It might not always be a full tilt back. Even small, frequent changes in weight shifting make a huge difference. We don’t always teach all the strategies.

“I think that’s where we need to focus, because we’re not living in a perfect system. It’s messy because there are so many contributing factors, and the person still needs to live their life, and that’s something that’s of value.”

For the studies referenced here, the resources are available here.

This article originally appeared in the Mar/Apr 2021 issue of Mobility Management.