An assistive technology clinician or professional is almost never able to focus exclusively on one physical condition when working with a seating & wheeled mobility client. The consumers who work with OTs, PTs and ATPs often have complex medical histories that too often include surgeries and pressure ulcers.
Even after stitches have been removed and wounds have closed, the challenges aren’t over. Resulting scar tissue can continue to have a profound and potentially debilitating impact on the wheelchair user’s activity level and quality of life. That’s why having clinical strategies to deal with them can make such a difference.
Strategic Step 1: Know Your Enemy
The first step is simple, but critical: Know what you’re dealing with, and where.
Stacey Mullis, OTR/L, ATP, director of clinical education for Comfort Company, says, “First, be aware of the presence of scar tissue and where it’s located. Then the goal becomes pressure redistribution away from that area.”
The adjustability of today’s seating & positioning technology, as well as the wide range of product choices, can help. “For example, consider a person with a closed pressure ulcer at the ischial tuberosities (ITs),” Mullis says. “If your seating system has legrests that are set too high, or even elevating legrests, there is increased pressure on the ITs. It would be important to set the height of the legrests to allow for pressure redistribution through the femurs. Another consideration for this example would be back angle. A reclined back can result in increased pressure on the ITs. Closing the back angle will redistribute pressure through a larger surface area.”
Strategic Step 2: Know How Scars Change
Scars don’t go away (see sidebar), but they do mature and change. Understanding that process can help clinicians to advise clients about what to expect, and can help all seating professionals who are making technology choices.
W. Darren Hammond, MPT, CWS, senior director of The ROHO Institute for Education, says that while scar tissue evolves, it never achieves the capabilities that original tissue had. “Scar tissue progresses,” he says. “When the scar originally starts to fill up the dead space, it’s laid down kind of like [the game of] pickup sticks. It’s haphazardly thrown into the area. It will be a different color, and it doesn’t have the strength. But as that collagen matures and that scar matures, it almost looks like scaffolding. Things are a lot better aligned, and it has greater strength and resiliency. A lot of times, the scar will flatten. So the scar does increase in strength and resiliency, but it never progresses to [equal] the tissue that was there.”
Mullis says, “After a year of remodeling, scar tissue will only have approximately 75 percent of its original tensile strength. When a pressure ulcer closes, lost muscle, subcutaneous fat or dermis are not replaced, which can result in a thinner layer. Scar tissue is not as flexible as normal skin, and does not have a normal blood supply, sweat glands or hair.”
Strategic Step 3: Know Why a Past Pressure Ulcer Raises the Risk for Another One
One of seating’s best-known bits of wisdom is that having a pressure ulcer raises the risk for having another one in the future. Is it true?
“An approximate 13 to 56 percent of adults will have a recurrent pressure ulcer at the same site,” Mullis says. “This is due to the compromised tensile strength of the tissue, decreased depth of tissue, in areas that had high pressure to begin with. When I think about the thickness of normal tissue at bony prominences such as the ITs, it’s already thin. Consider compromised tissue with decreased tensile strength there, and it accentuates the risk of breakdown.”
Another common axiom in the industry is that the wheelchair seat cushion is always considered the primary suspect when a wheelchair user breaks down. But Hammond points out that other factors may be to blame instead. Once a client has a pressure ulcer, Hammond says, “I always tell people, ‘This tissue’s not the same any longer, so you probably won’t be able to sit as long. You may have to do more frequent weight shifts. Hydration is even more important now, that you continue to maintain your hydration and drink water because when your tissue is not hydrated, it’s less pliable and will be at greater risk for breakdown. Every single thing that increases the risk [for breakdown] will put you at greater risk if you have scar tissue.”
When a client insists that nothing has changed — a common claim among wheelchair users who develop their first pressure ulcers years after being in their chairs — Hammond asks them about situations, even seemingly benign ones, that are new.
“They’ll say, ‘I had this cushion for 10 years without any breakdown. And then all of a sudden, I had a urinary tract infection and I was really moist,’” he says as an example. “Your normal skin could tolerate that pressure, shear and friction, so you’ve been sitting for 10 years with no problem. But as soon as it was moist, it started to break down. It would be the same thing with scars. You could sit for 12 hours for the past 10 years with no problem, but then for whatever reason — maybe you got a pressure ulcer in bed and it’s on a sitting surface — and people think they can go back to sitting 12 hours. No, you can’t. It has nothing to do with the cushion. It has to do with that tissue not being the same tissue that was there before.
“And even without scar tissue, as we get older, our skin is at greater risk, just with age.”
Strategic Step 4: Consider the Other Surfaces in Your Clients’ Lives
Wheelchair seating systems get the brunt of the discussion among seating clinicians and professionals who are trying to help clients avoid pressure ulcers. But Hammond says the many other possible sitting surfaces in your clients’ everyday lives also need consideration.
“Quite often we as seating therapists and seating professionals only think that it’s an area of concern when someone’s sitting in their wheelchair on their wheelchair cushion,” he says. “But the reality is they could potentially have a continuum of sitting throughout the day. They could sit in the car, they may sit in a movie theatre seat. If they do sit in other areas, they still need to protect their skin accordingly.
“I think that’s one of the things that sometimes we as seating professionals don’t think about. We are only cognizant of the power or manual wheelchair, and quite often nurses will just be cognizant of the bed, of the mattress. It’s always good when the PTs and OTs and seating professionals start to think about the mattress, and it’s really good when the nursing professionals start to think about the seating.”
Strategic Step 5: Understand Offloading vs. Redistributing Pressure
Asked about best practices for clients with scar tissue, Mullis says, “The first goal is to redistribute pressure away from the area. Typically if the scar tissue is at the ITs, an offloading-style cushion will be effective to remove pressure from the area and also prevent the effects of shear on the weakened tissue. This style of cushion loads the trochanters and redistributes pressure across the femurs. If a person has scar tissue on the trochanter, an immersion-style cushion may be more appropriate, as you don’t want the loading on that area. It can redistribute the pressure over a larger surface area to decrease the amount on the weakened area.”
The terms offloading and pressure redistribution are often used in tandem when managing pressure ulcer and scar tissue, but Hammond says understanding the differences between them is crucial.
“What we try to say is ‘load redistribution’,” he explains. “Some people use the term ‘offloading’ to describe what all cushions do. But there are really two different technologies to manage load redistribution. With an immersion or envelopment technology — like ROHO, but also like JAY and like VARILITE — any time you sink into a cushion, you’re managing that force by spreading that force over a larger area. An offloading design — like Ride Designs — uses an offloading technique to manage the load redistribution. A lot of people say, ‘We have a scar or a wound, so we need offloading.’ Offloading is just a method to manage that load, but there is also the theory that you can manage loads by increasing the surface area, and you can redistribute the load well enough by that immersion technique.”
So which technique is better?
“They’re literally two different philosophies,” Hammond says. “Both work. It’s matching the philosophy with the risk and with the patient. You can’t say one is better than the other.”
But Hammond adds that small amounts of pressure can be beneficial for scar tissue that’s maturing.
“What makes that collagen mature is controlled stress,” he explains. “It’s stress that the tissue, when it’s healing, can tolerate. If it’s too much stress, it’ll break down again. If it’s not enough stress, it actually won’t heal as well.”
Post-surgical patients, Hammond notes, may be advised to lightly massage developing scar tissue after some healing has begun: “That’s done for a couple of reasons: to prevent adhesion, because the scar sometimes will [adhere] to bone and other tissue, and also that light massage actually matures the collagen and helps realign it. There’s a theory that low, controlled stress is actually a really good thing that will progress the scar in healing. An offloading type of product totally offloads, so it doesn’t necessarily apply controlled stress to the area.”
The practice of applying controlled stress to healing scars can be compared to how bones are now known to heal after fractures.
“That’s just the foundational science of how the collagen matures,” Hammond says. “That’s actually how all tissue matures; it matures with controlled stress. That’s why 20 or 30 years ago, somebody with a hairline fracture would be non-weight bearing. But then all those non-compliant patients started walking on their casts, and orthopaedic surgeons saw greater healing with that controlled stress, because the controlled stress was still in the cast. So now when people have bone healing, typically after a week or two, it’s weight bearing as tolerated, or partial weight bearing. And that’s because bone heals better with a controlled stress environment. And so does tissue.”
Strategic Step 6: Some Parts of the Body Are Trickier to Manage than Others
That being said, not all pressure ulcers are equal when it comes to the clinician’s or ATP’s ability to redistribute pressure. When there’s less surface area near the pressure ulcer, redistributing weight can be difficult.
But Mullis says, “The seating system goals should be to redistribute pressure away from the compromised areas, even heels or elbows. For example, with scar tissue on the elbow, the height and angle of the armrest needs to be adjusted to allow for maximum pressure redistribution across the arm, to prevent it from being solely on the elbow. This may mean adding a padded arm trough with articulating hardware to allow for repositioning of the arm and achieving the proper angles. It may even mean that a patient requires lateral postural supports to absorb some of the force leaning onto that elbow. Whatever is required to redistribute pressure away from the compromised area should be done, while attaining maximum function and comfort for the patient.”
“When someone has a scar on their sitting surface, you have a pretty good-sized area to redistribute the force over,” Hammond notes. “But when someone has a scar on their elbow or their head or their heels — and heels are a really huge problem — we don’t have the surface area to load around that bony prominence. There just isn’t much surface area there; for the elbow, all I’ve got is my forearm [to redistribute the weight to]. So that’s sometimes the problem, and that’s a problem with high immersion loading because you have to have other surface areas [for it to work]. Physiologically, everything would be the same, but in some instances you just don’t have the areas to offload force to, and that may be one of the problems.”
Pressure ulcers on heels can be especially tricky to work with.
“It’s changing a little bit with some different types of dressings,” Hammond says, “but the practice guidelines right now are you do offload the heels. The heels are different for many reasons: the anatomical structure, the fat deposition. It’s really complex, and one of the reasons we offload the heel is we just don’t have a lot of surface area around the heel to load.”
Strategic Step 7: Every Client Is Different
Because preventing future pressure ulcers is so critical to maintaining a client’s health and quality of life, it’s understandable that healthcare professionals, wheelchair users and their families and caregivers all want “best practice” standards to follow — a checklist, for instance, that dictates exactly how long a wheelchair user can safely sit without risking skin and tissue breakdown.
The problem is that clients are so different, with varying diagnoses, co-morbidities, medical histories and everyday activities, that creating a single successful standard is impossible.
Education for all stakeholders, therefore, is the best strategy available.
“It’s very important to make a wheelchair client and/or their caregivers aware of the risks of recurrence when they have a closed pressure ulcer,” Mullis says. “An optimal seating system alone will not prevent recurrence of a pressure ulcer. Effective pressure-relieving techniques should be identified for the individual consistent with the ability of the individual. A schedule can then be created that describes the frequency and duration of the weight shifts. For example, a client in a power chair can be taught to tilt for at least two minutes every 30 minutes to allow blood flow and oxygenation to the compromised tissue. One strategy I’ve used with folks who watch television during the day is to recommend tilting every time there is a commercial. This gives them a cue to perform frequent tilting, and it’s not disruptive to their routine.”
Hammond says he once worked with a surgeon who performed numerous flap surgeries at a rehabilitation hospital.
“We had a sitting protocol, and sometimes when we got to a certain point, the only way we could tell if they could sit was if we started to see some signs of breakdown,” he says. “If they were sitting four hours and five hours with good results, but then we bumped them up to six or seven, and we saw maybe a little opening or a little redness over that scar, we would say, ‘OK, that’s your level right there. You can’t sit more than four or five hours for five or six weeks, and then we’ll re-evaluate you.’”
While many clients would like to have specific guidelines on what’s safe and what isn’t, Hammond says, “Everybody heals differently. If someone has a pressure ulcer or flap surgery, maybe after four weeks, they can sit for two or three hours. In some people that two or three hours may be too much stress.”
Healing clients who may only be able to tolerate short periods of sitting might be able to sit multiple times per day if they change positions in between. “Incremental or small bouts of sitting is usually a good recommendation,” Hammond says, “while checking the skin quite frequently. Let’s say their wound can really only tolerate two hours of sitting. Well, sit in the morning for a couple of hours, then go back to bed or go prone or stand a little bit or do other activities, and then reintegrate seating later in the day.”
Hammond says a healed pressure ulcer isn’t a chronic condition, but it should be considered a chronic concern. “I think it begins with the thought process that as someone gets a pressure ulcer, they always have a pressure ulcer,” he says. “It’s a lifetime concern or it’s a continuum of concern, that once they have it, even though it may not be open, though it may not require dressing, it is always an area of concern as they move forward in their lives and as they age.”