Effects of wheelchair cushions and pressure relief maneuvers on ischial interface pressure and blood flow in people with spinal cord injury

On the Move pad - a portable multipurpose pad: User feedback

CONTEXT/OBJECTIVE

Hard-shell toilet seats may compromise safety and hinder the participation of individuals at risk for pressure injuries (PIs) when using these facilities away from home in public, hotel, or family/friend restrooms. Moreover, people often add "wash-cloths" for additional padding for comfort, and to reduce the risk of PIs due to pressure or shearing on their wheelchairs surfaces. This study investigated the utilization of portable pads, initially designed for toilet use but adaptable to various places and contexts, while examining pad usability.

DESIGN

A cross-sectional descriptive survey design.

SETTING

Inpatient care, outpatient care, and community setting.

PARTICIPANTS

45 individuals at risk of PIs.

RESULTS

Participants extended the use of these pads beyond toilets, employing them as wheelchair armrest and leg rest pads in other settings. Feedback from a customized questionnaire indicated high levels of usefulness (8.5/10) and ease of use (9.1/10) attributed to the pads. Among the features, the top three favored were ease of use, comfort/cushioning, and function. Participants expressed a desire for a variety of sizes and colors to enable versatile usage and suggested incorporating a pocket for storing small items.

CONCLUSIONS AND RELEVANCE

Individuals at risk of PIs require cushioning not only on hard-shell toilet seats, but also for additional padding, protection and enhancing the use of wheelchairs. Rehabilitation professionals can play a crucial role in educating and training both clients and caregivers to understand PI prevention, enabling them to effectively leverage the pads in appropriate situations, thereby enhancing their comfort in their wheelchairs during social engagement.

Reducing pressure with the goal of improving outcomes: a retrospective chart review of cushion evaluations and recommendations at one seating clinic

PURPOSE

To describe the current seating recommendations made by a seating clinic for wheelchair users who presented with a Pressure Injury (PrI) or history of PrI.

METHODS

Retrospective review of electronic medical records of 133 adults who used a wheelchair as their primary means of mobility who had a cushion evaluation during which interface pressure mapping data was documented.

RESULTS

Clinicians adjusted 71% of participants' wheelchair cushions, including 49% who received a new cushion, and 37% of participants' wheelchairs. The most common adjustments besides receiving a new cushion were: addition of an underlay, adjusting the inflation of a cushion, and adjustments to the foot or back support of the wheelchair. Forty-five participants only received adjustments (i.e. no new cushion), while 23 participants only received education and feedback rather than equipment modifications. Those 23 participants had significantly lower Peak Pressure Index (PPI) than those who received equipment modifications (mean [95% CI] 76.7 [59.1, 94.3] versus 111.6 [102.1, 121.2] respectively, p = 0.001). The PPI was reduced by an average of 22.5 mmHg from the initial to final seating system amongst those who received modifications ([13.9-31.0], p<.001).

CONCLUSIONS

The seating clinicians considered interface pressure mapping in their decision-making and effectively reduced interface pressures with their interventions. Cushion replacement is important when someone presents with a PrI. However, adjusting an existing wheelchair cushion and/or seating system provides important additions and alternatives to consider for reducing interface pressure. There is also a role for education about proper use of equipment, weight shifts, and alternate seating surfaces.

Clinical Remote Monitoring of Individuals With Spinal Cord Injury at Risk for Pressure Injury Recurrence Using mHealth: Protocol for a Pilot, Pragmatic, Hybrid Implementation Trial

BACKGROUND

Pressure injuries are one of the most challenging secondary conditions for individuals with spinal cord injuries and related disorders (SCI/D) owing to inherent, lifelong risk factors that include a lack of sensory and motor function below the level of injury and reliance on a wheelchair for daily mobility, resulting in prolonged periods of sitting. Although many factors contribute to the development of pressure injuries, the pressure between the skin and a surface is always a factor and the development of injury is dependent on the magnitude and duration of the pressure. Clinically, broad recommendations for relieving pressure are used because we know very little about the unique day-to-day life patterns of the individual wheelchair user. Typically, it is after the occurrence of a pressure injury that the therapist will check equipment fit and the effectiveness of pressure offloading and ask about other surfaces they sit on in their home and community. This time-lapsed, largely self-reported data are fraught with recall bias and inaccuracies that the therapist incorporates into a plan of care.

OBJECTIVE

This study's objective is to pilot-test the implementation and clinical effectiveness of a telehealth model of care combined with our mobile health (mHealth) Assisted Weight-Shift device for remote monitoring of factors related to maintaining skin health and wheelchair setup. Our overall hypothesis is that this study will result in an effective implementation plan, and the enhanced connected model of care using remote monitoring of pressure management will result in pilot-level, improved clinical outcomes for adults with spinal cord injury at high risk for pressure injury recurrence.

METHODS

For all aims, we will use a mixed methods design using an exploratory, sequential approach to include the strengths of both qualitative and quantitative data. For aims 1 and 2, we will iteratively collect qualitative data from therapists, patients with SCI/D, and other stakeholders. For aim 3, we will perform a hybrid effectiveness-implementation randomized controlled trial to pilot-test the intervention. The projected results include an iteratively developed and tested implementation plan that meets moderate to high levels of acceptability, feasibility, and appropriateness. Additionally, the pilot trial results are expected to show positive trends in relevant clinical outcomes related to reduced pressure injury incidence, recurrence, and improved healing when compared with the standard of care.

RESULTS

Currently, 6 participants have been recruited for our aim-1 qualitative study.

CONCLUSIONS

This study will expand upon our previous study to move the Assisted Weight-Shift system into routine clinical care, which was a strong desire of adults with SCI/D for improved individualized care plans to prevent pressure injuries. The results of this study will guide the next steps in a full, hybrid effectiveness-implementation trial with the goal of improving care to prevent pressure injuries.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/51849.

The relationship between in-seat movement and pressure ulcers in wheelchair users with SCI/D

OBJECTIVE

To identify parameters that are associated with time at pressure, are most related to pressure ulcer outcomes, and that may be used to influence pressure ulcer (PrU) outcomes in future intervention studies.

DESIGN

Analysis used datasets from cross-sectional and longitudinal observational studies. Wheelchair-usage and in-seat metrics thresholds were optimized to differentiate individuals in PrU or No PrU groups. Logistic regression identified the demographics and in-seat activity metrics that impacted PrU outcomes.

SETTING

General Community.

PARTICIPANTS

Fifty individuals with spinal cord injuries and/or disorders (SCI/D) who use a wheelchair as their primary mobility device. 22 subjects were within the first year following injury and 28 had been using a wheelchair for over 2 years. Twenty-one participants reported PrU outcomes.

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

Time in chair, pressure relief frequency, weight shift frequency, percentage of seated time that the subject is active (CoP Percent Active), frequency of in-seat movement, unloading event frequency, maximum time between events, and number of transfers.

RESULTS

Optimal cutoff thresholds for the most significant in-seat movement metrics included: unloading event frequency of 3.1 times per hour (OR 0.353, 95% CI [0.110, 1.137]), maximum time between events of 155.4 min (OR 2.888, 95% CI [0.886, 9.413]), and CoP Percent Active of 2.6% (OR 0.221, 95% CI [0.063, 0.767]). When individuals were more active than these cutoffs, significantly more individuals were in the no pressure ulcer group. In predictive modeling, CoP Percent Active was the in-seat movement metric that significantly predicted PrU outcomes. The model was improved by adding age, occupation, and injury completeness.

CONCLUSION

Of the 4 significant predictors in the model, only CoP Percent Active was modifiable. Therefore, an opportunity exists to design approaches to modify behavior. However, the results illustrate that the key to preventative movement may be through functional movement as opposed to scheduled, routine pressure reliefs.

OFF-LOADING PRESSURE RELIEF WITH FOAM CUT OUT CUSHIONS: EXPERIENCES FROM RANCHO LOS AMIGOS NATIONAL REHABILITATION CENTER

This paper explores the efficacy of the cushion fitting technique using foam cut out cushions for off-loading bony prominences in the sitting position, with a particular focus on reducing the high risk of developing pressure injuries among aging wheelchair users. This technique, historically employed at Rancho Los Amigos National Rehabilitation Center, has shown promising results in reducing pressure injuries for patients with spinal cord injuries. However, its widespread adoption remains limited. This manuscript aims to raise awareness about foam cut out cushions, its historical context, and its contemporary relevance by presenting customized solutions for individual patients with specific deformities. Key clinical points are highlighted, emphasizing the importance of skilled clinicians in the fitting process and the need to consider foam cut out cushions alongside other preventive measures. Case examples illustrate successful outcomes, demonstrating improved pelvic stability, posture, and off-loading of bony prominences. By promoting foam cut out cushions as a valuable cushioning option, this manuscript equips clinicians with knowledge to utilize this technique effectively.

Steering-by-leaning facilitates intuitive movement control and improved efficiency in manual wheelchairs

BACKGROUND

Manual wheelchair propulsion is widely accepted to be biomechanically inefficient, with a high prevalence of shoulder pain and injuries among users. Directional control during wheelchair movement is a major, yet largely overlooked source of energy loss: changing direction or maintaining straightforward motion on tilted surfaces requires unilateral braking. This study evaluates the efficiency of a novel steering-by-leaning mechanism that guides wheelchair turning through upper body leaning.

METHODS

16 full-time wheelchair users and 15 able-bodied novices each completed 12 circuits of an adapted Illinois Agility Test-course that included tilted, straight, slalom, and 180° turning sections in a prototype wheelchair at a self-selected functional speed. Trials were alternated between conventional and steering-by-leaning modes while propulsion forces were recorded via instrumented wheelchair wheels. Time to completion, travelled distance, positive/negative power, and work done, were all calculated to allow comparison of the control modes using repeated measures analysis of variance.

RESULTS

Substantial average energy reductions of 51% (able-bodied group) and 35% (wheelchair user group) to complete the task were observed when using the steering-by-leaning system. Simultaneously, able-bodied subjects were approximately 23% faster whereby completion times did not differ for wheelchair users. Participants in both groups wheeled some 10% further with the novel system. Differences were most pronounced during turning and on tilted surfaces where the steering-by-leaning system removed the need for braking for directional control.

CONCLUSIONS

Backrest-actuated steering systems on manual wheelchairs can make a meaningful contribution towards reducing shoulder usage while contributing to independent living. Optimisation of propulsion techniques could further improve functional outcomes.

Effects of Real-Time Pressure Map Feedback on Confidence in Pressure Management in Wheelchair Users With Spinal Cord Injury: Pilot Intervention Study

BACKGROUND

Wheelchair users with a spinal cord injury (SCI) are at a high risk for developing pressure injuries (PIs). Performing weight shifts is a primary method of pressure management for PI prevention; however, individuals with SCI may lack confidence in their abilities to perform adequate pressure relief due to their lack of sensation. Real-time seat interface pressure mapping feedback may provide partial substitution for sensory feedback such that an individual's confidence is improved.

OBJECTIVE

We aim to examine how confidence for pressure management by wheelchair users with SCI was impacted by providing access to real-time, on-demand seat interface pressure mapping feedback.

METHODS

Adults with SCI (N=23) completed self-efficacy questions addressing confidence around 4 factors related to performing weight shifts in this longitudinal, repeated-measures study. We evaluated the impact of providing standard PI prevention education and access to live pressure map feedback on confidence levels for performing weight shifts.

RESULTS

Access to live pressure map feedback while learning how to perform weight shifts resulted in significantly higher confidence about moving far enough to relieve pressure at high-risk areas. Confidence for adhering to the recommended weight shift frequency and duration was not significantly impacted by in-clinic education or use of pressure map feedback. Confidence that performing weight shifts reduces PI risk increased most following education, with slight additional increase when pressure map feedback was added.

CONCLUSIONS

Access to live pressure mapping feedback improves confidence about performing weight shifts that relieve pressure when provided in the clinical setting and demonstrates potential for the same in the home. This preliminary exploration of a smartphone-based pressure mapping intervention highlights the value of access to continuous pressure mapping feedback to improve awareness and confidence for managing pressure.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03987243; https://clinicaltrials.gov/study/NCT03987243.

Measure It: Proper Wheelchair Fit Is Key to Ensuring Function while Protecting Skin Integrity

GENERAL PURPOSE

To review the biomechanics of posture, appropriate means to configure a wheelchair to permit proper postural support, and common problems arising from improper wheelchair fit.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will:1. Synthesize the concepts influencing proper wheelchair fit.2. Identify the biomechanics of posture as they apply to wheelchair fit.3. Summarize the appropriate assessment guidelines for determining and preparing to adjust wheelchair fit.

Effect of Wheels, Casters and Forks on Vibration Attenuation and Propulsion Cost of Manual Wheelchairs

Manual wheelchair users are exposed to whole-body vibrations as a direct result of using their wheelchair. Wheels, tires, and caster forks have been developed to reduce or attenuate the vibration that transmits through the frame and reaches the user. Five of these components with energy-absorbing characteristics were compared to standard pneumatic drive wheels and casters. This study used a robotic wheelchair propulsion system to repeatedly drive an ultra-lightweight wheelchair over four common indoor and outdoor surfaces: linoleum tile, decorative brick, poured concrete sidewalk, and expanded aluminum grates. Data from the propulsion system and a seat-mounted accelerometer were used to evaluate the energetic efficiency and vibration exposure of each configuration. Equivalence test results identified meaningful differences in both propulsion cost and seat vibration. LoopWheels and SoftWheels both increased propulsion costs by 12-16% over the default configuration without reducing vibration at the seat. Frog Legs suspension caster forks increased vibration exposure by 16-97% across all four surfaces. Softroll casters reduced vibration by 11% over metal grates. Wide pneumatic 'mountain' tires showed no difference from the default configuration. All vibration measurements were within acceptable ranges compared to health guidance standards. Out of the component options, softroll casters show the most promising results for ease of efficiency and effectiveness at reducing vibrations through the wheelchair frame and seat cushion. These results suggest some components with built-in suspension systems are ineffective at reducing vibration exposure beyond standard components, and often introduce mechanical inefficiencies that the user would have to overcome with every propulsion stroke.

Validating a wheelchair in-seat activity tracker

Wheelchair users often experience prolonged periods of stationary sitting. Such periods are accompanied with increased loading of the ischial tuberosities. This can lead to the development of pressure ulcers which can cause complications such as sepsis. Periodic pressure offloading is recommended to reduce the onset of pressure ulcers. Experts recommend the periodic execution of different movements to provide the needed pressure offloading. Wheelchair users, however, might not remember to perform these recommended movements in terms of both quality and quantity. A system that can detect such movements could provide valuable feedback to both wheelchair users as well as clinicians. The objective of this study was to present and validate the WiSAT - a system for characterizing in-seat activity for wheelchair users. WiSAT is designed to detect two kinds of movements - weight shifts and in-seat movements. Weight shifts are movements that offload pressure on ischial tuberosities by 30% as compared to upright sitting and are maintained for 15 seconds. In-seat movements are shorter transient movements that involve either a change in the center of pressure on the sitting buttocks or a transient reduction in total load by 30%. This study validates the use of WiSAT in manual wheelchairs. WiSAT has a sensor mat which was inserted beneath a wheelchair cushion. Readings from these sensors were used by WiSAT algorithms to predict weight shifts and in-seat movements. These weight shifts and in-seat movements were validated against a high-resolution interface pressure mat in a dataset that resembles real-world usage. The proposed system achieved weight shift precision and recall scores of 81% and 80%, respectively, while in-seat movement scores were predicted with a mean absolute error of 22%. Results showed that WiSAT provides sufficient accuracy in characterizing in-seat activity in terms of weight shifts and in-seat movement.

Visualization of user interactions with a pressure mapping mobile application for wheelchair users at risk for pressure injuries

Pressure injuries for individuals with spinal cord injuries (SCI) are correlated with mortality and are a leading cause for rehospitalizations. The Assisted Weight Shift (AW-Shift©) is a mobile pressure mapping application designed to provide users with a live map view and reminders to perform weight shifts. Novel visualization techniques were used to understand daily distributions of user interaction wit h AW-Shift©. The date and time of system interactions were recorded for six participants with SCI over 7 days (five males/one female, five manual users/one power user, 55.3 ± 17.3 years old, 10.6 ± 6.5 years since injury). Circular frequency plots were created to visualize the time and frequency participants brought the app to the foreground of their phone and received alerts and reminders to complete weight shifts. While some participants used the system regularly throughout the day, others primarily used it before 8am; highlighting the system's importance for regular spot checks and morning wheelchair setup. Participant adherence to weight shift reminders was low suggesting the live pressure map may be more useful. Circular frequency plots can be used by clinicians to more easily review large amounts of patient data. Future work will investigate raw pressure mat data and create a closed-loop weight shift detection algorithm.

Interface pressure reduction effects of wheelchair cushions in individuals with spinal cord injury: a rapid review

OBJECTIVE

Wheelchair cushion is routinely used to manage the sitting acquired pressure for an individual with spinal cord injury, but which kind of wheelchair cushion performs better in terms of interface pressure management is unclear. This review aims to compare different kinds of wheelchair cushions on their effect of interface pressure reduction in individuals with spinal cord injury.

METHODS AND RESULTS

The databases of MEDLINE, CINAHL, EMBASE and Web of Science were searched. Totally 10 studies were included in this review. Seven of the included studies indicated that air cushions were superior to gel cushions in interface pressure reduction. Three of the included studies reported that gel cushions were superior to polyurethane foam cushions in interface pressure reduction. The variables of measurement duration, measurement focus, measurement devices, cushion covering, sample variations and body positioning of patients may confound the comparison of interface pressure reduction effect of different wheelchair cushions among studies.

CONCLUSIONS

Air cushion was reported more consistently effective in interface pressure reduction than gel and foam cushions. While the variable parameters (measurement duration, focus, devices) and individual conditions (BMI, body positioning) may interfere the comparison among studies. Researches disseminating consistent parameters and clinical prescriptions with individualized evaluation are suggested for the establishment of an evidence-based practice in clinic.Implications for rehabilitationWheelchair cushion is routinely used for an individual post spinal cord injury to manage the sitting acquired pressure.Which kind of wheelchair cushion performs better in terms of interface pressure management is unclear.Air cushion is found more consistently effective in interface pressure reduction than gel cushion and foam cushion.Individualized evaluation of the interface pressure is suggested for the prescription of wheelchair cushion in clinic.

Sensor Cell Network for Pressure, Temperature and Position Detection on Wheelchair Users

This work proposes an optical sensing network to monitor pressure and temperature in specific areas of a wheelchair to prevent pressure ulcers and to monitor the position of the wheelchair user by analyzing its pressure distribution. The sensing network is composed of six optical fiber Bragg grating (FBG)-based sensor cells. Each sensor cell is built from a polylactic acid (PLA) base and has two FBGs, one embedded in epoxy resin to monitor pressure variations (FBG_P) and another without resin to monitor temperature (FBG_T). Once produced, all sensor cells were experimentally characterized for pressure and temperature variations, resulting in an average pressure sensitivity of 81 ± 5 pm/kPa (FBG_P) and −5.0 ± 0.4 pm/kPa (FBG_T), and an average temperature sensitivity of 25 ± 1 pm/°C (FBG_P) and 47.7 ± 0.7 pm/°C (FBG_T). The sensor cells were then placed in six specific areas of a wheelchair (four in the seat area and two in the shoulder blade area) to carry out experimental tests, wherein the response of the sensors to a specific sequence of relief positions was tested. During the execution of the test, the optical signal of all sensors was monitored, in real time, with the pressure and temperature values detected in each zone of the wheelchair. In addition, random position changes were performed in order to evaluate the precision of the proposed sensing network in the identification of such positions.

The Proper Motor Control Model Revealed by Wheelchair Curling Quantification of Elite Athletes

Simple Summary

This is the first study to quantitatively explore the motor control of elite wheelchair curling athletes. It is known that, psychologically, wheelchair users are often not comfortable with their wheelchair motor skills and, therefore, hesitate to participate in sports/physical activities. For increasing exercise of this population, an effective learning/training program should firstly be developed. This study has chosen a suitable sport, i.e., wheelchair curling, and identified and described generalizable characteristics or “markers” among elite athletes. Such markers could provide effective ways of accurately identifying, evaluating, and communicating when learning the skill. Due to this being an under-investigated area, this study also shed new light on how to scientifically promote physical participation of wheelchair users.

Abstract

Background: Wheelchair users are disadvantaged when it comes to accruing the benefits of physical activities. Hence, promoting various sports is crucial for keeping this population healthy. Since wheelchair curling can be played by individuals from a wide range of ages, strengths, and endurance levels, it has potential to improve wheelchair users’ well-being. Yet, hardly any motion studies exist. This study aimed to facilitate understanding of optimized control of wheelchair curling for promoting wheelchair users’ participation. Methods: Using motion capture technology, nine national-level athletes were tested. Kinematic parameters related to segment/joint control and their coordination were quantified for both slow and fast curling. Descriptive statistics (means and standard deviations) and correlation analysis were applied for characterizing the skill. Results: (1) Curling control consists of an acceleration phase and a stabilizing delivery phase; (2) the control of trunk, shoulder, and wrist are responsible for accelerating the rock; (3) elbow control is accountable for the accurate delivery of the rock; and (4) during the slow curling, a synchronized effort of trunk, shoulder, and wrist is used for accelerating the rock, while a sequential control among the segment/joints is applied in fast curling. Conclusions: The results supply valuable motor learning markers that could have a significant positive impact on the teaching and learning of wheelchair curling, as such, the findings have great potential for the health promotion of wheelchair users.

Modelling, design and control of a new seat-cushion for pressure ulcers prevention

Pressure ulcers are a frequent complication in patients having limited activity and mobility (e.g., elderly people, spinal cord injury patients, people with disabilities, etc.). The aim of this work is the conceptual design, modelling and control of a new seat cushion for pressure ulcers prevention. The whole system (constituted by the seat cushion equipped with a real-time pressure mapping with closed-loop control) is designed to identify the critical points on the human skin, before pressure ulcers creation, and to be able to distribute the contact pressure between the human and cushion avoiding wound creation. The seat cushion is constituted by soft air-cells actuated by air flow. To define the shape and size of the soft air-cells, finite element simulations are carried out, analysing the internal volume reduction with external loads application to reproduce the variable stiffness. The data obtained by finite element analysis are used to simulate inflation and deflation of the soft bubble air-cells. Finally, the control systems of a single air-cell and of the whole cushion are designed and simulated. The novelty of our work consists in the conception of a seat cushion able to recognise higher and lower risk zones of pressure ulcer generation on the human skin and to provide compensation automatically. This work can therefore be considered in line with the sustainable development goals recently launched by the EU Commission.

Relationship between ultrasonographically low-echoic lesions under the skin, wheelchair sitting time, and interface pressure on ischial region in individuals with chronic spinal cord injury

Objective: To determine the relationship between physical findings, wheelchair sitting time, and interface pressure on ischial region in subjects with spinal cord injury (SCI).Design: Cross-sectional study.Setting: Rehabilitation center in Japan.Participants: Manual wheelchair users with chronic SCI (n = 45).Interventions: Pressure ulcers (PU) were diagnosed by inspection, palpation, and ultrasonography. Self-reports were obtained on wheelchair sitting time and pressure mapping was recorded while the subject was seated on the wheelchair.Outcome measures: Subjects were divided into those with ultrasonographically low-echoic lesions (PU-positive group, n = 11) and no such lesions (PU-negative group, n = 34). Outcome measures included wheelchair sitting time and interface pressure at bilateral ischial regions.Results: Using ultrasonography, 13 low-echoic lesions were identified in 11 subjects of the PU-positive group. The pressure duration was longer and interface pressure was significantly higher in subjects of the PU-positive group compared with those of the PU-negative group (P < 0.05 and P < 0.001, respectively).Conclusions: This is the first study to evaluate the interrelationship between physical findings, sitting time, and ultrasonographically measured interface pressure on ischial region area in subjects with spinal cord injury. To prevent pressure ulcers, we recommend avoidance of prolonged wheelchair sitting and measures that can reduce the interface pressure. These variables should be carefully tailored to the needs of the individual subjects with SCI.

CLINICAL EFFECTIVENESS OF 3D-MODELING-BASED CUSTOMIZED OFF-LOADING PRESSURE-RELIEF CUSHIONS FOR SPINAL CORD INJURY

This study aimed to investigate the effectiveness of a 3D-modeling-based customized off-loading cushion to prevent pressure ulcers in people with spinal cord injury (SCI) using wheelchairs. The study included five people with SCI who use the traditionally manufactured customized off-loading cushions. As part of the test, each subject sat on three types of pressure-relief cushions, and the pressure between the seating surface and cushion was measured for 60[Formula: see text]min. The average measured pressure values were compared, and the change in pressure with time was analyzed to verify the clinical effect. The results showed that the CAD/CAM-based customized off-loading cushion exhibited a better decrease in pressure and pressure distribution effect on the ischial tuberosity and coccyx than the adjustable air cushion but did not differ much from the traditionally manufactured customized off-loading cushion. The clinical and economic effectiveness of the customized off-loading cushion based on the computer-aided design and manufacturing (CAD/CAM) technology was analyzed and tested on people with SCI. An occupational therapist evaluating the client followed by designing the customized off-loading strategy has no difference in terms of clinical effect compared to the traditional manufacturing method. However, time, effort, and cost should be considered when choosing an intervention strategy.

Design and development of a wheelchair seating pressure relief reminder system for pressure ulcer prevention among paraplegics

Individuals with paraplegia spend their time on the wheelchair for life. Adapting to prolonged wheelchair seating for almost all activities of daily living is challenging. The loss of abilities to sense any pain or excessive seating pressure cause them to remain seated on the wheelchair without any pressure relief activities. This situation leads to secondary complications including pressure ulcer which further degrades the individual's health. To overcome this, a wheelchair seating pressure relief training system (WSETs) was developed. Optimal placement of the force sensitive resistors (FSR) as seating pressure sensors on the cushion were determined, and their responses were investigated with 5 paraplegics. Two different FSR orientations, A and B, were compared. Each paraplegic sat in resting position and then performed pressure relief activities (PRA) which included whole body push-up, left and right lean and forward lean, before returning to resting position. Orientation B, with more forward positioned FSRs, showed higher sensitivity, implying better capture of high-risk area of pressure ulcer development. The FSR sensor readings were significantly different among pressure relief activities in all subjects (p < 0.05) indicating the validity of FSR measures for the intended application. In conclusion, the WSETs system was proven suitable as a training tool for new paraplegics to habituate themselves in performing PRA.

Evaluation of interface pressure and temperature management in five wheelchair seat cushions and their effects on user satisfaction

BACKGROUND

Factors such as the manufacturing materials, shape or even the mechanical and thermal response of sitting Pressure Redistribution Support Surfaces (PRSS) can be potential contributors to pressure ulcers. However, few studies have compared a number of characteristics of the most frequently used devices.

OBJECTIVE

To compare three potential contributors to pressure ulcers in five commercial PRSS: pressure redistribution, temperature and perceived comfort.

METHOD

Study with a cross-over randomized design in healthy volunteer participants. Data was collected in a temperature and relative humidity controlled environment. To assess thermal response, the temperature (Flir-E60) of the region of interest was captured before and after use of each PRSS for further analysis. The region of interest was the gluteal zone. To assess the pressure redistribution a pressure mat (XSensor®) was used between the 5 cushion and each study participant using a standardized method. Finally, a subjective perception questionnaire recorded comfort, adaptability and thermal sensation parameters. Data analysis levels of significance were set at 0.05.

RESULTS

A total of 22 participants completed the assessments. There were no statistically significant differences in baseline temperatures between PRSS (>0.05). Pressure redistribution analysis showed significant differences between all PRSS in all variables evaluated except in the maximum and peak pressure index al sacrum. The subjective assessment suggested no major user-perceived differences between PRSS.

CONCLUSION

Seat cushions made of open cell polyurethane foam blocks of variable hardness and the horseshoe cushion (also open cell polyurethane foam) seem to provide a more effective pressure relief characteristic than those injected with polyurethane foam and gel in most of the studied pressure variables. However, the cushions provide similar thermal response and perceived comfort.

Wheelchair Pressure Ulcer Prevention Using FBG Based Sensing Devices

In this work, a fiber Bragg grating (FBG) based sensing system for wheelchair pressure ulcer prevention was developed. Six FBGs were strategically positioned in a wheelchair to monitor the more prominent bone areas, namely scapulas (right (SR) and left (SL)), ischiatic zone (right (IR) and left (IL)), and heels (right (HR) and left (HL)). The sensing architecture was tested by a female user during pressure relief exercises, to verify its effectiveness on pressure monitoring. The proposed system proves to be a compact and reliable solution for wheelchair pressure ulcer prevention, making it a suitable alternative to existing conventional electronic sensors, with the advantage of being immune to electromagnetic interferences and usable in humid environments. In addition to the pressure, the breathing rate was also monitored. By combining the proposed sensing architecture with a wheelchair user detection software, it is possible to create alerts for the user to know when a new position should be adopted, in order to relieve the pressure in a specific area, thus avoiding one of the biggest problems for such patients, pressure ulcers.

Pressure distribution analysis in three wheelchairs cushions of subjects with spinal cord injury

Purpose: Pressure injuries are a complication due to spinal cord injury. The objective of the study is to compare the pressure distribution in the wheelchair seat of subjects with spinal cord injury using 3 pads (Roho^®, Varilite^® and Jay^®). Methods: Pressure analysis was performed on 10 participants in two situations: (a) the participant sitting in static posture and (b) with the wheelchair being used for locomotion. Results: In the static position: Jay^® showed the best rates for average pressure and also the contact area, the Roho^® had the lowest average for the peak pressure. During the wheelchair moving, Jay^® showed the best average pressure, Roho^® had a lower average for peak pressure and Varilite^® provided a highest means for the contact area of the buttocks and thighs. Conclusions: The use of appropriate cushion is an effective measure in people with spinal cord injury. Implications for Rehabilitation Pressure injuries are a complication due to spinal cord injury. Study to compare the pressure distribution in the wheelchair seat of subjects with spinal cord injury is important to minimize the injuries resulting from pressure injuries. The comfort resulting from the use of the cushion suited to the demands of the subjects with spinal cord injury is fundamental for the process of rehabilitation and social participation of the people affected. Understanding and minimizing pressure points can contribute to the appropriate rehabilitation process.

Pattern detection from seating pressure distribution during wheelchair motion using deep embedded clustering

To minimize the occurrence of ulcers in high-risk mobile individuals such as wheelchair users, it is necessary to detect all typical distribution patterns and to indentify the patterns that may be associated with pressure ulcers. However, pattern detection is difficult because the pressure distribution during motion includes a variety of patterns compared to those of static postures. Thus, the establishment of a method to detect typical patterns based on distribution patterns is important. We utilized deep embedded clustering for identification purposes. This clustering technique extracts features using auto-encoder and simultaneously optimizes data points into the clusters, which might realize good clustering performance due to the detected optimal features. We used a pressure distribution dataset that was pre-labeled by nursing experts. The dataset consisted of a total of 26944 distribution images with ten class annotations. The clustering method including traditional approaches (k-means and principal component analysis plus k-means) were compared with deep embedded clustering while the threshold to noise reduction was changing. The deep embedded clustering with 80 mmHg threshold achieved the best performance. This approach also tended to be less dependent on the threshold values.

The effectiveness of curvilinear supine position on the incidence of pressure injuries and interface pressure among surgical patients

BACKGROUND

Intraoperative pressure injury is still a major problem of perioperative nursing. Reducing the peak interface pressure is a valid clinical intervention for reducing the incidence of intraoperative pressure injuries. However, studies of repositioning and pressure-redistributing for surgical patients are still lacking. In this context we aimed to evaluate the effect of a curvilinear supine position on incidence of pressure injury with surgical patients in a hospital setting.

METHODS

This was a prospective, randomized, controlled study, carried out from May to December 2016, included 104 surgical patients from a university hospital in China (experimental group, n = 52; control group, n = 52). Incidence of pressure injury, interface pressure, comfort and satisfaction scores from surgeons, anesthesiologists, OR nurses were recorded. Mann-Whitney U Chi-square test was used for difference of pressure injury's incidence and mixed linear model was used for interface pressure.

RESULTS

Overall the intervention group had significant fewer intraoperative pressure injuries than the control group (0 patients [0%] vs. 9 patients [17.65%], p = 0.002). Compared with control group, the experimental group had significantly lower interface pressures in the sacrum and heel regions (F = 23.81, p < 0.001; F = 60.71, p < 0.001). The subjects felt comfortable in two groups were 40(80%) vs. 3(5.88%) (experimental group vs. control group), respectively (p < 0.001).

CONCLUSIONS

Curvilinear supine position could significantly decrease the incidence of perioperative pressure injuries in surgical patients with surgery duration more than three hours. Considering these results, we recommend that curvilinear supine position use as effective interventions to inform perioperative care delivery, reducing perioperative pressure injuries. These findings may serve to guide the application of pressure redistribution in the surgical positioning of patients during prolonged surgery.

Pressure redistributing in-seat movement activities by persons with spinal cord injury over multiple epochs

Pressure ulcers, by definition, are caused by external forces on the tissues, often in the regions of bony prominences. Wheelchair users are at risk to develop sitting-acquired pressure ulcers, which occur in the regions of the ischial tuberosities, sacrum/coccyx or greater trochanters. As a means to prevent pressure ulcers, instruction on performing pressure reliefs or weight shifts are a part of the rehabilitation process. The objective of this study was to monitor the weight shift activity of full-time wheelchair users with acute spinal cord injury over multiple epochs of time in order to determine consistency or routine within and across epochs. A second objective was to evaluate the accuracy of self-reported pressure relief frequency within each measurement epoch. A wheelchair in-seat activity monitor was used to measure weight shifts and other in-seat movement. The data was classified into multiple in-seat activity metrics using machine learning. Seventeen full-time wheelchair users with spinal cord injury were measured within multiple epochs, each lasting more than 1 week. Across all in-seat activity metrics, no consistent pattern of activity changes emerged. None of the in-seat activity metric changed in any one direction across a majority of subjects. Subjects tended to over-estimate their frequency of performing pressure reliefs. Self-reported pressure relief behaviors are not reliable, and therefore, cannot be used to evaluate preventative behaviors either clinically or within research. This study had the capability of fully investigating in-seat movements of wheelchair users. The results indicated that in-seat movement does not reflect a routine, either in pressure reliefs, weight shifts or other functional in-seat movements. This study has illustrated the complexity of assigning causation of pressure ulcer occurrence to seated behaviors of wheelchair users and identifies the need for improved clinical techniques designed to develop routine behaviors to prevent pressure ulcers.

A Survey of Canadian Occupational Therapy Practices to Prevent Pressure Injuries Among Wheelchair Users via Weight Shifting

PURPOSE

The purpose of this study was to describe occupational therapy weight-shifting practices and explore recommended strategies for patients, healthcare staff, and family/caregivers across healthcare settings.

DESIGN

Cross-sectional survey.

SUBJECTS AND SETTING

Respondents included 97 currently practicing occupational therapists working in 5 main practice settings (ie, acute care, inpatient rehabilitation, outpatient rehabilitation, home and community care, and residential) from 9 out of 10 Canadian provinces.

METHODS

We created a 25-item questionnaire that included forced choice and open-ended queries. Items queried demographic information, weight-shifting techniques taught to patients, frequency and duration of weight shifting recommended, educational approaches used to teach weight shifting, and resources used to guide decision making. Participants were recruited via professional organizations and health authorities across Canada. Participants were excluded if they were not currently working with manual or power wheelchair users. Descriptive statistics were used to analyze quantitative data, and content analysis was used for qualitative data (responses to open-ended queries).

RESULTS

The most frequently recommended weight-shifting techniques were tilt (83.3%-92.8%), leaning to one side (47.9%-87.5%), and forward leaning (46.9%-83.3%). Study findings revealed a wide range of recommendations regarding frequency (every 10 minutes or less to >2 to 3 hours) and duration (≤30 seconds to as long as tolerated) of weight shifting. Weight-shifting interventions were most commonly guided by clinical experience (81.7%), practice guidelines (62.4%), and expertise of other team members (54.8%).

CONCLUSIONS

Results from this study highlight the need for further research to inform weight-shifting techniques and to build a more comprehensive understanding of weight-shifting education practices.

Pressure Relieving Effect of Adding a Pelvic Well Pad to a Wheelchair Cushion in Individuals With Spinal Cord Injury

Objective

To identify the pressure relieving effect of adding a pelvic well pad, a firm pad that is cut in the ischial area, to a wheelchair cushion on the ischium.

Methods

Medical records of 77 individuals with SCI, who underwent interface pressure mapping of the buttock-thigh area, were retrospectively reviewed. The pelvic well pad is a 2.5-cm thick firm pad and has a cut in the ischial area. Expecting additional pressure relief, it can be inserted under a wheelchair cushion. Subjects underwent interface pressure mapping in the subject's wheelchair utilizing the subject's pre-existing pressure relieving cushion and subsequently on a combination of a pelvic well pad and the cushion. The average pressure, peak pressure, and contact area of the buttock-thigh were evaluated.

Results

Adding a pelvic well pad, under the pressure relieving cushion, resulted in a decrease in the average and peak pressures and increase in the contact area of the buttock-thigh area when compared with applying only pressure relieving cushions (p<0.05). The mean of the average pressure decreased from 46.10±10.26 to 44.09±9.92 mmHg and peak pressure decreased from 155.03±48.02 to 131.42±45.86 mmHg when adding a pelvic well pad. The mean of the contact area increased from 1,136.44±262.46 to 1,216.99±255.29 cm².

Conclusion

When a pelvic well pad was applied, in addition to a pre-existing pressure relieving cushion, the average and peak pressures of the buttock-thigh area decreased and the contact area increased. These results suggest that adding a pelvic well pad to wheelchair cushion may be effective in preventing a pressure ulcer of the buttock area.

Passive limb movement intervals results in repeated hyperemic responses in those with paraplegia

STUDY DESIGN

Repeated measures.

OBJECTIVES

Reports suggest passive limb movement (PLM) could be used as a therapy to increase blood flow and tissue perfusion in the paralyzed lower limbs of those with spinal cord injuries. However, the hyperemic response to PLM appears to be transient, lasting only 30-45 s despite continued limb movement. The purpose of this investigation was to determine whether the hyperemic response is repeatable across multiple short bouts of passive limb movement.

SETTING

Cleveland Veterans Affairs Medical Center.

METHODS

Nine individuals with paraplegia 46 ± 6 years of age, 17 ± 12 years post injury (range: 3-33 years) with complete T3-T11 injuries were subject to 5 × 1 min bouts of passive knee extension/flexion at 1 Hz with a 1 min recovery period between each bout. Heart rate (HR), mean arterial pressure (MAP), femoral artery blood flow (FABF), skin blood flow (SBF), and tissue perfusion in the lower limb were recorded during baseline and throughout each bout of PLM.

RESULTS

Despite no increase in HR (p ≥ 0.8) or MAP (p ≥ 0.40) across all four bouts of PLM, the average increase in FABF during each bout ranged from 71 ± 87% to 88 ± 93% greater than baseline (p ≤ 0.043). SBF also increased between 465 ± 302% and 582 ± 309% across the five bouts of PLM (p ≤ 0.005).

CONCLUSIONS

Repeated bouts of PLM in those with SCI while in an upright position resulted in a robust and steady increase in FABF and SBF which could have implications for improving vascular health and tissue perfusion in the lower limbs of those with paraplegia.

Buttock tissue response to loading in men with spinal cord injury

OBJECTIVE/BACKGROUND

Despite the fact that most people with a spinal cord injury who use a wheelchair for mobility are considered at-risk for pressure ulcer (PrU) development, there still exists a spectrum of risk amongst this group. Efforts to differentiate risk level would benefit from clinical tools that can measure or predict the buttocks response to loading. Therefore, the goal of this study was to identify how tissue compliance and blood flow were impacted by clinically-measurable risk factors in young men with SCI.

METHODS

Blood flow at the ischial tuberosity was measured using laser Doppler flowmetry while the seated buttock was unloaded, and loaded at lower (40-60 mmHg) and high (>200 mmHg) loads. Tissue compliance of the buttock was measured using the Myotonometer while subject were lifted in a Guldmann Net.

RESULTS

Across 28 participants, blood flow was significantly reduced at high loads, while no consistent, significant changes were found at lower loads. At 40-60 mmHg, blood flow decreased in participants with a pressure ulcer history and lower BMI, but stayed the same or increased in most other participants. The buttock displaced an average of 9.3 mm (2.7 mm) at 4.2 N, which represented 82% (7%) of maximum displacement. BMI was related to the amount of buttock tissue displacement while smoking status explained some of the variation in the percent of max displacement.

CONCLUSION

Wide variability in tissue compliance and blood flow responses across a relatively homogeneous population indicate that differences in biomechanical risk may provide an explanation for the spectrum of PrU risk among persons with SCI.

Some people move it, move it… for pressure injury prevention

OBJECTIVE

To describe differences in in-seat behavior observed between individuals with a spinal cord injury (SCI) with and without a history of recurrent pressure injuries.

DESIGN

Cross-sectional cohort study.

SETTING

General community.

PARTICIPANTS

Twenty-nine adults more than 2 years post SCI, who used a wheelchair as their primary mobility device and had the ability to independently perform weight shift maneuvers. Participants were grouped according to whether or not they had a history of recurrent pressure injuries (PrIs), with 12 subjects having had two or more pressure injuries in the pelvic area (PrI Group).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Daily time in wheelchair, number of transfers, and frequency of pressure reliefs (full unloading), weight shifts (30% load reduction), and in-seat movements (transient center of pressure movements or unloading).

RESULTS

The median participant spent 10.3 hours in his wheelchair and performed 16 transfers to or from the wheelchair daily. Pressure reliefs were performed less than once every 3 hours in both groups. Weight shifts were performed significantly more often by the No PrI Group (median (interquartile range) 2.5 (1.0-3.6) per hour) than the PrI Group (1.0 (0.4-1.9), with P = 0.037 and effect size r = 0.39). In-seat movements were performed 46.5 (28.7-76.7) times per hour by the No PrI group and 39.6 (24.3-49.7) times per hour for the PrI group (P = 0.352, effect size r = 0.17).

CONCLUSION

Weight shifts that can be produced by functional activities and that partially unload the buttocks should be considered as an important addition to individuals' PrI prevention regimen.

Exploring repositioning movements in sitting with 'at risk' groups using accelerometry and interface pressure mapping technologies

BACKGROUND

Despite high quality guidelines underpinning pressure ulcer care (NPUAP/EPUAP/PPPIA, 2014), pressure ulceration still poses a significant financial impact on health care services in treatment and staff costs as well as having a profound effect on the health and quality of life of individuals experiencing them. Repositioning is a key preventative technique recommended by occupational therapists and other health care professionals. The frequency and quality of repositioning movements performed by individuals, however, can be difficult to determine. This paper explores the use of technology in monitoring repositioning movements in sitting.

OBJECTIVE

To explore the outputs of technologies such as interface pressure mapping systems and accelerometers in enabling the therapist to accurately monitor seated behaviour and enhance practice through targeted interventions to prevent sitting acquired pressure ulceration.

METHOD

Reviewing the findings of two recent research studies with 'at risk' cohorts (spinal cord injury; elderly orthopaedic), using accelerometry and seated interface pressures, this paper will highlight how useful this technology is in clinical practice to monitor weight shifts and repositioning behaviours.

RESULT

Both studies illustrated that the majority of individuals did not adhere to the frequency or magnitude of movements currently recommended to redistribute seating interface pressures. When repositioning was performed it was ineffective in reducing seated pressures.

CONCLUSION

In an era of personalised medicine, technology has an important role to play in providing the service user, caregivers and healthcare staff with important biofeedback information about seated behaviours, particularly those that minimise the risk of developing sitting acquired pressure ulcers. This information can augment occupational therapists' clinical decision-making in maximising active pressure ulcer prevention.

Trunk Function and Ischial Pressure Offloading in Individuals with Spinal Cord Injury

OBJECTIVE

To determine if there is a relationship between trunk function and offloading of the ischial tuberosities in individuals with Spinal Cord Injury (SCI).

DESIGN

Prospective cross-sectional evaluation.

SETTING

Sub-acute rehabilitation hospital.

PARTICIPANTS

Fifteen non-ambulatory participants with complete or incomplete traumatic and non-traumatic SCI, American Spinal Injury Association Impairment Scale (AIS), Classification A-D.

OUTCOME MEASURES

Isometric trunk strength using a hand held dynamometer, the ability to reach using the multidirectional reach test and offloading times of the ischial tuberosities using a customized pressure mat.

RESULTS

Participants who were able to engage in the multidirectional reach test were defined as "Reachers", whereas individuals who were unable to engage in the multidirectional reach test were defined as "Non-Reachers". Trunk strength was significantly higher in Reachers compared with Non-Reachers (P < 0.05). Offloading times over the left and right ischial tuberosities were lower in Non-Reachers when compared with Reachers, however the results were statistically significant only for offloading over the right ischial tuberosity (P < 0.05). There was no correlation between trunk strength and pressure offloading times for both groups.

CONCLUSIONS

Regardless of an individual's ability to engage in a reaching task, participants with spinal cord injury spent more time offloading the left ischial tuberosity compared with the right ischial tuberosity. The study highlights the need to identify factors that may contribute to offloading behavior in individuals with spinal cord injury who lack sufficient trunk strength.

Developing the tissue viability seating guidelines

BACKGROUND

Costs for the prevention and management of pressure ulcers have increased significantly with limited published advice from health and social care organisations on seating and preventing pressure ulcers. At the request of the UK Tissue Viability Society the aim of the publication was to develop a practical guide for people, carers and health and social care professionals on how the research and evidence base on pressure ulcer prevention and management can be applied to those who remain seated for extended periods of time.

METHODS AND FINDINGS

The evidence base informing the guidelines was obtained by applying a triangulation of methods: a literature review, listening event and stakeholder group consultation. The purpose was to engage users and carers, academics, clinicians, inspectorate and charities, with an interest in seating, positioning and pressure management to: gather views, feedback, stories, and evidence of the current practices in the field to create a greater awareness of the issue.

CONCLUSION

The new guidelines are inclusive of all people with short and long-term mobility issues to include all population groups. The document includes evidence on where pressure ulcers develop when seated, risk factors, best possible seated position and what seat adjustments are required, the ideal seating assessment, interventions, self-help suggestions and key seating outcomes. The updated TVS CPGs have been informed by the best available evidence, the insights and wisdom of experts, stakeholders and people who spend extended periods of time sitting.

Comparing the interface pressure redistribution after applying three different types of cushions: differences according to cushion type

[Purpose] The purpose of this study was to compare the interface pressure redistribution when sitting after applying three different types of cushions and on a firm surface in individuals in their 20s and those older than 60 years old. [Subjects and Methods] Healthy 100 elderly (60 years and older) subjects and 111 college students participated in this study. Interface pressure redistribution while sitting on a firm surface or honeycomb, air, and memory foam cushions, examined in that order. [Results] For all groups, significant differences were found in the total pressure mean among sitting states. When the hip and thigh interface pressure among sitting states were compared within each group, significant differences were found in the mean right hip pressure, mean left hip pressure, peak right hip pressure, peak left hip pressure, right hip pressure ratio, and left hip pressure ratio. [Conclusion] Our data indicated that the type of cushion should be considered and fit for individuals when recommending appropriate interface pressure redistribution cushions.

Seating-Related Pressure Injury Prevention in Spinal Cord Injury: A Review of Compensatory Technologies to Improve In-Seat Movement Behavior

A PURPOSE OF REVIEW

The purpose of this review was to (1) assess the factors related to the occurrence of pressure injuries in people with a spinal cord injury (SCI), (2) review methods of pressure injury prevention, and (3) examine compensatory technologies developed to promote in-seat movement to reduce the risk of pressure injuries.

B RECENT FINDINGS

Risk factors for seating-related pressure injuries are well documented, yet, ulceration remains a daily concern for individuals with SCI. While prompts and alarms have been shown to be effective at increasing in-seat movement, the devices thus far were not designed for long-term use. Wheelchair users will benefit from continued development of novel technologies designed to help them self-manage pressure injury prevention.

C SUMMARY

Optimized feedback about pressure and movement will help wheelchair users with SCI perform more effective movements to relieve pressure, perform movements more frequently and consistently, and maintain effective and frequent movement behaviors over time while feedback is available.

Measure it: proper wheelchair fit is key to ensuring function while protecting skin integrity

The objectives of this article are to help the clinician to better recognize the basic biomechanics of posture, describe the appropriate means to configure a wheelchair to permit proper postural support, and to identify common problems arising from improper wheelchair fit.

Systematic review of behavioral and educational interventions to prevent pressure ulcers in adults with spinal cord injury

OBJECTIVE

To investigate the efficacy of behavioral or educational interventions in preventing pressure ulcers in community-dwelling adults with spinal cord injury (SCI).

DATA SOURCES

Cochrane, Clinical Trials, PubMed, and Web of Science were searched in June 2016. The search combined related terms for pressure ulcers, spinal cord injury, and behavioral intervention. Each database was searched from its inception with no restrictions on year of publication.

REVIEW METHODS

Inclusion criteria required that articles were (a) published in a peer-reviewed journal in English, (b) evaluated a behavioral or educational intervention for pressure ulcer prevention, (c) included community-dwelling adult participants aged 18 years and older with SCI, (d) measured pressure ulcer occurrence, recurrence, or skin breakdown as an outcome, and (e) had a minimum of 10 participants. All study designs were considered. Two reviewers independently screened titles and abstracts. Extracted information included study design, sample size, description of the intervention and control condition, pressure ulcer outcome measures, and corresponding results.

RESULTS

The search strategy yielded 444 unique articles of which five met inclusion criteria. Three were randomized trials and two were quasi-experimental designs. A total of 513 participants were represented. The method of pressure ulcer or skin breakdown measurement varied widely among studies. Results on pressure ulcer outcomes were null in all studies. Considerable methodological problems with recruitment, intervention fidelity, and participant adherence were reported.

CONCLUSIONS

At present, there is no positive evidence to support the efficacy of behavioral or educational interventions in preventing pressure ulcer occurrence in adults with SCI.

A drive system to add standing mobility to a manual standing wheelchair

Current manual standing wheelchairs are not mobile in the standing position. The addition of standing mobility may lead to improved health and function for the user and may increase utilization of standing wheelchairs. In this project, a chain drive system was fitted to a manual standing wheelchair, adding mobility in the standing position. The hand rims are accessible from both seated and standing positions. The prototype uses 16-inch drive wheels in front with casters in the rear. Additional anterior casters are elevated when seated for navigating obstacles and then descend when standing to create a six-wheeled base with extended anterior support. Stability testing shows the center of pressure remains within the base of support when leaning to the sides or front in both seated and standing positions. Four veterans with spinal cord injury provided feedback on the design and reported that mobility during standing was very important or extremely important to them. The veterans liked the perceived stability and mobility of the prototype and provided feedback for future refinements. For example, reducing the overall width (width from hand rim to hand rim) and weight could make this system more functional for users.

Real-time strap pressure sensor system for powered exoskeletons

Assistive and rehabilitative powered exoskeletons for spinal cord injury (SCI) and stroke subjects have recently reached the clinic. Proper tension and joint alignment are critical to ensuring safety. Challenges still exist in adjustment and fitting, with most current systems depending on personnel experience for appropriate individual fastening. Paraplegia and tetraplegia patients using these devices have impaired sensation and cannot signal if straps are uncomfortable or painful. Excessive pressure and blood-flow restriction can lead to skin ulcers, necrotic tissue and infections. Tension must be just enough to prevent slipping and maintain posture. Research in pressure dynamics is extensive for wheelchairs and mattresses, but little research has been done on exoskeleton straps. We present a system to monitor pressure exerted by physical human-machine interfaces and provide data about levels of skin/body pressure in fastening straps. The system consists of sensing arrays, signal processing hardware with wireless transmission, and an interactive GUI. For validation, a lower-body powered exoskeleton carrying the full weight of users was used. Experimental trials were conducted with one SCI and one able-bodied subject. The system can help prevent skin injuries related to excessive pressure in mobility-impaired patients using powered exoskeletons, supporting functionality, independence and better overall quality of life.