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.”