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 Featuring United Spinal Association and the National Organization on Disability.