ATP Series

Wound Care & Seating

How Collaboration Can Reap Better Outcomes

Pressure injuries are dangerously common among people who use wheelchairs. But the professionals who treat those injuries and the ones who recommend and configure wheelchairs and seating don’t routinely cross paths. A Venn diagram of wound care specialists and seating specialists would typically show little overlap.

Could clients benefit if there were more collaboration — more overlap — between the two fields?

Collaborating with Wound Care Professionals

Daniella Giles, PT, DPT, ATP/SMS, is the Clinical Educator at Ride Designs and has been a physical therapist (PT) for 20 years. Though nurses are often associated with wound care, Giles said PTs “do have scope of practice, including wound care, that is actually greater than nursing.

“An RN [Registered Nurse] does not do debridement — removal or cleaning out of tissues. And therapists do several different kinds of it. Sharps debridement we’re allowed to do. We do mechanical debridement, which is basically scrubbing it, whether it be with a machine and water or different lavage water systems.”

Giles noted her background in acute rehab: “That was my first job, and we did wound [care]. You had to debride anything that had orders for debridement. That was 20 years ago, so I haven’t been doing that for a long time. But it’s within our scope, and it’s something that we’re familiar with.”

Though Giles said she couldn’t specifically recall, as a seating clinician, collaborating with a wound care professional, she acknowledged that sharing information could be helpful in determining wheelchair seating strategies.

“I went from [acute rehab] into [seating] equipment, and of course, wounds are always part of what we’re doing with equipment,” she said. “I have asked extensive [wound care] questions of the caregivers and the patient: ‘Exactly what are you doing? Show me the supplies. What is the routine? When is the last time the doctor made a change? Who is coming out? How often?’

“I would love it if we could communicate with [wound care professionals] when we’re doing a certain intervention or equipment wise. Then we could say, ‘Did you see anything good last week?’ or ‘Inadvertently, did you see something bad? Is there a new [affected] area? How are things doing?’”

Telehealth could facilitate these collaborations. “I think that would be fabulous if, now that we’re doing so much videoconferencing, we could just get a snippet of what they’re doing,” Giles said. “I know they’re busy, but could we get a five-minute report or contact with them? Could we say, ‘Hey, can you send us notes or advice? What would you like to see? How are you going to determine healing? When are there positive signs?’

“I’m sure that would only benefit the patient.”

Why Wound Histories Are Important

Knowing a wheelchair user’s history of pressure injuries is important, Giles said, because wounds permanently impact skin.

Even after the patient has recovered from an injury, Giles explained, “We never say, ‘There’s no wound there.’ We say, ‘There’s a healed [Stage] 4’ or ‘There’s a healed [Stage] 3.’

“You never backstage. The depth that [the injury] is to begin with is then a healed [injury] of that depth. You never say it’s a zero. It cannot be; it’s never going to be the same.”

That’s because skin and tissues never fully regain the function they had before injury. “It is not elastic,” Giles said of that skin. “It does not release oils.”

Giles said she also needs to know about Stage 1 and 2 injuries: “Those are documented wounds; those are areas of skin that are showing signs of lower life. Some cells are dying. The metabolic systems of those cells are different than the ones around them, and I want to know about that.”

Giles said she routinely asks seating clients, “‘Is there an area that you worry about? Is there an area that your caregiver says ‘ugh’ about?’ Those are [Stage] 1’s and 2’s, and those are often not classified professionally. The patient doesn’t know that’s a wound. So I’ll say, ‘Are there any areas that you carefully watch or that are sometimes iffy?’”

She also pointed out that if, for example, a client has had flap surgery, orthopaedic interventions might have occurred. “[The patient has infection, so they’ll shave the IT [ischial tuberosity],” Giles said as a surgical example. “The IT should not be this shape; this is like a dagger. So I want to see it, and I want to feel it. I don’t trust the charts.”

Sitting Upright While Healing

If a wheelchair user has a wound in an area that would be in contact with the seat cushion — can the client sit in a wheelchair while healing?

Yes, if the right precautions are taken, Giles said, adding that physicians she’s worked with have even prescribed upright sitting as part of the healing course.

“Historically, all we’ve had is side-lying in bed,” Giles said, describing previous recovery strategies. “That’s the ideal situation, where we remove all the pressure from pressure injuries. That’s how they heal. You have a reduction in the forces acting upon those cells. Cellular metabolism is restored, and they stay alive. But if you put them back into the same environment, you can expect the same result.

“So once the physicians learned the orthotic concept of the loading and offloading, they would not only send them to us for assessment and molding — but once that cushion was in place, they would prescribe sitting as part of the healing protocol.”

Sitting upright has a number of benefits, not just for bodily functions, but also for overall well-being. “When a person is upright and engaged in life, they’re going to do better than if they’re in bed,” Giles said. But being able to sit upright requires careful consideration of how pressure will be distributed.

How to Distribute Weight Safely

While it’s common to hear about the need to offload weight from injured areas, Giles said, “The best thing about offloading is obviously, there’s no contact. But I can’t offload until I appropriately load. Loading is the answer. So now we really focus on strategic loading, and the application of pressures, force isolation, strategic loading, applied pressure points at tolerant areas. That’s really where our [Ride Designs] science is focused: Looking at that body, looking at where the scars are, where the history is, where the current wear patterns are.”

Just as she used to check wear on the bottoms of shoes while assessing gait, Giles now checks for evidence of how weight is distributed. “I look at the seat, the seat cushion, and the body in that context,” she said “I’ll look at their skin and say, ‘What’s the likely place these people are sitting?’ I see the wear, I see the history. I can identify areas of high pressures, high friction, high shear strains and forces. So the real science and the real beauty of what we do is finding a place to put all the pressure where the skin can handle it.”

Finding enough safe areas to bear weight can be difficult for clients with a history of wounds.

Giles described Ride Designs cushions as a kind of orthotic: “So cutting the hole [in the cushion] is very easy once I have figured all that out. I could just carve away, once I have strategically come up with where to apply all forces. It’s an orthotic and prosthetic concept; an orthotist created this concept.

“So it’s strategic loading, and not applying force where it can’t be tolerated. And oftentimes that includes the bony prominences, but it would also include scar tissue because of all the things we know about scar tissue. Not only is the chemical makeup different, but there are also adhesions and skin contractures, and adhesions that happen under the skin. So as that scar is making all of those connections on the outside that we see, it’s also on that underside surface, and those can become very adhered to the other tissues. Even if that area could have handled pressure before, it’s different now. That’s where knowing the [patient’s] history comes in. That will tell us the makeup of [the affected skin and tissues], but also how they relate to the other tissues. The tissues are not as mobile. Our skin is made to flex and move and shift, and it can’t do that anymore.”

Giles said she has contacted physicians before flap surgeries to emphasize the importance of maintaining weight-bearing areas. “If I’ve got somewhere where I normally want to apply a lot of pressure [but that area is compromised], we might apply pressure to the posterior buttocks area, above those landmarks,” she said. “A lot of times in the old days, flap surgeries would include this arch, kind of up over the hips. That was very dangerous for us, because we want to load there. So we might have to look at, again, avoiding that, even though it’s not a bony prominence. It’s now part of the scar tissue area. And that would be much less tolerant to load before it would break down. [Compromised skin] may be in one of our traditional, more tolerant areas, and we really have to watch out for that.

“I’ve told physicians, ‘Please, we’re at a place where this guy is barely able to sit. We’ve had multiple scar tissues, multiple episodes, years in bed. The only treatment strategy we have left to safely sit is an orthotic concept. And if I’ve got a scar in these two places, I’m not going to be able to use that strategy either.’ So we have worked with them to strategically bring those scars elsewhere, to preserve the surfaces of our orthotic kind of concept.”

Giles also advocates for tissue mobility after surgery. “Physical therapists do soft tissue mobility,” she noted. “We do scar mobilization. It’s important that once it’s healed and once the physician says it’s fine, there is a place and time in the healing process where we should be making sure that tissue moves to its best ability. Because that’s like how the skin used to be, and where it functions the best. And so we can make a difference [by incorporating soft tissue mobility strategies].

“We could have a much better relationship with wound care professionals in order to address some of those things that could make the situation much better for our sitting population.”

This article originally appeared in the Jul/Aug 2022 issue of Mobility Management.

In Support of Upper-Extremity Positioning