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Sonenblum SE, McDonald A, Maurer CL, Bass A, Watson M, Zellner H. Reducing pressure with the goal of improving outcomes: a retrospective chart review of cushion evaluations and recommendations at one seating clinic. Disabil Rehabil Assist Technol 2024; 19:1552-1560. [PMID: 37177785 DOI: 10.1080/17483107.2023.2212012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/04/2023] [Indexed: 05/15/2023]
Abstract
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.
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Affiliation(s)
- Sharon Eve Sonenblum
- George W. Woodruff School of Mechanical Engineering, GA Institute of Technology, Atlanta, GA, USA
| | | | | | - Amber Bass
- Division of Physical Therapy, Emory School of Medicine, Atlanta, GA, USA
| | - Marigny Watson
- Division of Physical Therapy, Emory School of Medicine, Atlanta, GA, USA
| | - Haley Zellner
- Division of Physical Therapy, Emory School of Medicine, Atlanta, GA, USA
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Sonenblum SE, Feng C, Sprigle S. The relationship between in-seat movement and pressure ulcers in wheelchair users with SCI/D. J Spinal Cord Med 2024; 47:91-99. [PMID: 36260494 PMCID: PMC10795617 DOI: 10.1080/10790268.2022.2122340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
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.
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Affiliation(s)
- Sharon Eve Sonenblum
- George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Chen Feng
- H. Milton Stewart School of Industrial & Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Stephen Sprigle
- Rehabilitation Engineering and Applied Research Lab, Georgia Institute of Technology, Atlanta, Georgia, USA
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Portoghese C, Deppisch M, Sonenblum S, Samson B, Munro C, Capasso V, Call E, Black J, Brienza D. The Role of Shear Stress and Shear Strain in Pressure Injury Development. Adv Skin Wound Care 2024; 37:20-25. [PMID: 38117167 DOI: 10.1097/asw.0000000000000075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
ABSTRACT Although other patient safety indicators have seen a decline, pressure injury (PI) incidence has continued to rise. In this article, the authors discuss the role of shear stress and shear strain in PI development and describe how accurate assessment and management can reduce PI risk. They provide explanations of shear stress, shear strain, friction, and tissue deformation to support a better clinical understanding of how damaging these forces are for soft tissue. Clinicians must carefully assess each patient's risk factors regarding shear forces within the contexts of activity and mobility. The authors also provide a toolbox of mitigation strategies, including support surface selection, selection of materials that contact the individual, management of immobility using positioning techniques, and the use of safe patient handling techniques. With a clear understanding of how shear forces affect PI risk and mitigation strategies, clinicians will more accurately assess PI risk and improve PI prevention care plans, ultimately reducing PI incidence to become more aligned with other patient safety indicators.
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Affiliation(s)
- Caroline Portoghese
- Caroline Portoghese, OTR/L, ATP/SMS, is Assistive Technology Professional and Rehabilitation Consultant, Handi Medical, Saint Paul, Minnesota. Michelle Deppisch, PT, CWS, is Wound Care Consultant, Michele Deppisch PT, CWS, LLC, Hertford, North Carolina. Sharon Sonenblum, PhD, is Principal Research Scientist, George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, Georgia. Barbara Samson, OTR/L, MBA, CWS, CSPHC, is Executive Clinical Specialist, Mölnlycke Health Care, Peachtree Corners, Georgia. Cassendra Munro, PhD, RN, RNFA, CNOR, Nurse Scientist, Stanford Health Care, Office of Research, Patient Care Services, Menlo Park, California. Virginia Capasso, PhD, ANP-BC, ACNS-BC, CWS, is Advanced Practice Nurse and Nurse Scientist, Massachusetts General Hospital, Boston, Massachusetts, and Instructor in Surgery, Harvard Medical School, Boston. Evan Call, MS, CSM-NRM, is Adjunct Faculty, Weber State University, Ogden, Utah. Joyce Black, PhD, RN, FAAN, is Florence Neidfelt Professor of Nursing, University of Nebraska Medical Center, College of Nursing, Omaha, Nebraska. David Brienza, PhD, is Professor, University of Pittsburgh, Pittsburgh, Pennsylvania. The authors have disclosed no financial relationships related to this article. Submitted March 12, 2023; accepted in revised form July 5, 2023
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Kottner J, Coleman S. The theory and practice of pressure ulcer/injury risk assessment: a critical discussion. J Wound Care 2023; 32:560-569. [PMID: 37682783 DOI: 10.12968/jowc.2023.32.9.560] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
Pressure ulcer/injury (PU) risk assessment is widely considered an essential component in clinical practice. It is a complex and broad concept that includes different approaches, such as clinical judgement, using standardised risk assessment instruments, skin assessments, or using devices to measure skin or tissue properties. A distinction between PU risk assessment and early detection is important. PU risk measures the individual's susceptibility to developing a PU under a specific exposure (primary prevention), and early detection includes the assessment of early (sub)clinical signs and symptoms to prevent progression and to support healing (secondary prevention). PU risk is measured using prognostic/risk factors or prognostic models. Every risk estimate is a probability statement containing varying degrees of uncertainty. It therefore follows that every clinical decision based on risk estimates also contains uncertainty. PU risk assessment and prevention is a complex intervention, where delivery contains several interacting components. There is a huge body of evidence indicating that risk assessment and its outcomes, the selection of preventive interventions and PU incidence are not well connected. Methods for prognostic model development and testing in PU risk research must be improved and follow state-of-the-art methodological standards. Despite these challenges, we do have substantial knowledge about PU risk factors that helps us to make better clinical decisions. An important next step in the development of PU risk prediction might be the combination of clinical and other predictors for more individualised care. Any prognostic test or procedure must lead to better prevention at an acceptable cost.
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Affiliation(s)
- Jan Kottner
- Charité-Universitätsmedizin Berlin, Institute of Clinical Nursing Science, Berlin, Germany
| | - Susanne Coleman
- Leeds Institute of Clinical Trials Research, University of Leeds, UK
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Arnold N, Scott J, Bush TR. A review of the characterizations of soft tissues used in human body modeling: Scope, limitations, and the path forward. J Tissue Viability 2023; 32:286-304. [PMID: 36878737 DOI: 10.1016/j.jtv.2023.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 02/06/2023] [Accepted: 02/10/2023] [Indexed: 02/27/2023]
Abstract
Soft tissue material properties are vital to human body models that evaluate interactions between the human body and its environment. Such models evaluate internal stress/strain responses in soft tissues to investigate issues like pressure injuries. Numerous constitutive models and parameters have been used to represent mechanical behavior of soft tissues in biomechanical models under quasi-static loading. However, researchers reported that generic material properties cannot accurately represent specific target populations due to large inter-individual variability. Two challenges that exist are experimental mechanical characterization and constitutive modeling of biological soft tissues and personalization of constitutive parameters using non-invasive, non-destructive bedside testing methods. It is imperative to understand the scope and appropriate applications for reported material properties. Thus, the goal of this paper was to compile studies from which soft tissue material properties were obtained and categorize them by source of tissue samples, methods used to quantify deformation, and material models used to describe tissues. The collected studies displayed wide ranges of material properties, and factors that affected the properties included whether tissue samples were in vivo or ex vivo, from humans or animals, the body region tested, body position during in vivo studies, deformation measurements, and material models used to describe tissues. Because of the factors that affected reported material properties, it is clear that much progress has been made in understanding soft tissue responses to loading, yet there is a need to broaden the scope of reported soft tissue material properties and better match reported properties to appropriate human body models.
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Affiliation(s)
- Nicole Arnold
- Department of Mechanical Engineering, Michigan State University, 428 S Shaw Lane, Rm. 2555 Engineering Building, East Lansing, MI, 48824-1226, USA
| | - Justin Scott
- Department of Mechanical Engineering, Michigan State University, 428 S Shaw Lane, Rm. 2555 Engineering Building, East Lansing, MI, 48824-1226, USA
| | - Tamara Reid Bush
- Department of Mechanical Engineering, Michigan State University, 428 S Shaw Lane, Rm. 2555 Engineering Building, East Lansing, MI, 48824-1226, USA.
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Mechanical analysis of deep tissue injury during sitting in patients with spinal cord injury via parametric finite element model. Biomech Model Mechanobiol 2022; 21:1573-1584. [PMID: 35931860 DOI: 10.1007/s10237-022-01607-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 06/24/2022] [Indexed: 11/02/2022]
Abstract
Spinal cord injury patients are prone to develop deep tissue injury because of long-term mechanical load. However, there is a lack of statistical research on the influence of tissue characteristics on the internal mechanical state of soft tissue. This study aimed to investigate the influence of tissue characteristics on the internal mechanical state of buttock in spinal cord injury patients. A three-dimensional reference buttock model was established and a visualization program was generated to modify the parameter values. Through changing the muscle atrophy, body mass index and the radius of curvature of the ischial tuberosity, 96 different model variants were simulated and validated in this study. With body mass index increasing from 16 to 40, the principal shear stress was 10.4 times principal compressive stress, the maximum shear strain and the max cluster volume increased by 1.2 (P < 0.001) and 8.8 times (P < 0.001), respectively. The interaction between BMI and muscle atrophy was significant when BMI was greater than or equal to 22.5 kg/m2. In all BMI stages, when the radius of curvature of the ischial tuberosity was 19 mm, the internal stress of the tissue always occupies the highest value. The results demonstrate that body mass index is the most important factor affecting the risk of buttock deep tissue injury. This study provides insights into investigation of inter-individual factors influencing the soft tissue response and assessment of deep tissue injury risk during sitting.
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Gefen A, Brienza DM, Cuddigan J, Haesler E, Kottner J. Our contemporary understanding of the aetiology of pressure ulcers/pressure injuries. Int Wound J 2021; 19:692-704. [PMID: 34382331 PMCID: PMC8874092 DOI: 10.1111/iwj.13667] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/02/2021] [Accepted: 07/25/2021] [Indexed: 12/25/2022] Open
Abstract
In 2019, the third and updated edition of the Clinical Practice Guideline (CPG) on Prevention and Treatment of Pressure Ulcers/Injuries has been published. In addition to this most up‐to‐date evidence‐based guidance for clinicians, related topics such as pressure ulcers (PUs)/pressure injuries (PIs) aetiology, classification, and future research needs were considered by the teams of experts. To elaborate on these topics, this is the third paper of a series of the CPG articles, which summarises the latest understanding of the aetiology of PUs/PIs with a special focus on the effects of soft tissue deformation. Sustained deformations of soft tissues cause initial cell death and tissue damage that ultimately may result in the formation of PUs/PIs. High tissue deformations result in cell damage on a microscopic level within just a few minutes, although it may take hours of sustained loading for the damage to become clinically visible. Superficial skin damage seems to be primarily caused by excessive shear strain/stress exposures, deeper PUs/PIs predominantly result from high pressures in combination with shear at the surface over bony prominences, or under stiff medical devices. Therefore, primary PU/PI prevention should aim for minimising deformations by either reducing the peak strain/stress values in tissues or decreasing the exposure time.
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Affiliation(s)
- Amit Gefen
- The Herbert J. Berman Chair in Vascular Bioengineering, Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel
| | - David M Brienza
- Departments of Rehabilitation Science and Technology & Bioengineering and the McGowan Institute of Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Janet Cuddigan
- College of Nursing, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Emily Haesler
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Australia.,Australian Centre for Evidence Based Aged Care, School of Nursing and Midwifery, LaTrobe University, Melbourne, Victoria, Australia.,Australian National University Medical School, Academic Unit of General Practice, Australian National University, Canberra, ACT, Australia
| | - Jan Kottner
- Charité Center 1 for Health and Human Sciences, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Tissue matters: In-vivo tissue properties of persons with spinal cord injuries to inform clinical models for pressure ulcer prevention. J Biomech 2021; 120:110389. [PMID: 33780812 DOI: 10.1016/j.jbiomech.2021.110389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 03/09/2021] [Accepted: 03/13/2021] [Indexed: 01/01/2023]
Abstract
The prevalence of pressure ulcers in patients with spinal cord injuries has been estimated to be between 30% and 47%. Individuals with spinal cord injuries sit for a majority of the time, increasing the risk of developing pressure ulcers in the buttocks and thighs due to large internal stresses. Human body models have been developed to study the formation of pressure ulcers, yet a persistent limitation in these models has been the material properties used to represent the soft tissues in the buttocks and thighs. Specifically, soft tissue material property data have not included wheelchair users, such as those with spinal cord injuries. The goals of this research were 1) to determine the in-vivo material properties of soft tissue in the thighs and buttocks of individuals with spinal cord injuries and 2) compare these to properties obtained from able-bodied people. Results indicated that the proximal and middle thigh regions of those who had a spinal cord injury were softer than the same regions as able-bodied individuals, while the distal thigh regions were stiffer. These findings are vital because they indicate that models developed using properties from able-bodied individuals will not produce internal stress or strain magnitudes that represent individuals who have a spinal cord injury. This information suggests that models should obtain material property data sets from their desired population. Human body models must represent the population being studied if they are to inform clinical assessments and make accurate patient predictions.
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Sonenblum SE, Seol D, Sprigle SH, Cathcart JM. Seated buttocks anatomy and its impact on biomechanical risk. J Tissue Viability 2020; 29:69-75. [PMID: 32008891 DOI: 10.1016/j.jtv.2020.01.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 01/13/2020] [Accepted: 01/20/2020] [Indexed: 11/28/2022]
Abstract
AIM The objective of this study was to describe the amount, types, and shapes of tissue present in the buttocks during sitting (i.e., seated buttocks soft tissue anatomy), and the impact of seated buttocks soft tissue anatomy on biomechanical risk. MATERIALS AND METHODS The buttocks of 35 people, including 29 full-time wheelchair users with and without a history of pelvic pressure ulcers were scanned sitting upright on 3" of flat HR45 foam in a FONAR Upright MRI. Multi-planar scans were analyzed to calculate bulk tissue thickness, tissue composition, gluteus maximus coverage at the ischium, the contour of the skin, and pelvic tilt. RESULTS Bulk tissue thickness varied from 5.6 to 32.1 mm, was composed mostly of adipose tissue, and was greatest in the able-bodied cohort. Skin contours varied significantly across status group, with wheelchair users with a history of pressure ulcers having tissue with a peaked contour with a radius of curvature of 65.9 mm that wrapped more closely to the ischium (thickness at the apex = 8.2 mm) as compared to wheelchair users with no pressure ulcer history (radius of curvature = 91.5 mm and apex thickness = 14.5 mm). Finally, the majority of participants presented with little to no gluteus coverage over their ischial tuberosity, regardless of status group. CONCLUSIONS This study provides quantitative evidence that Biomechanical Risk, or the intrinsic characteristic of an individual's soft tissues to deform in response to extrinsic applied forces, is greater in individuals at greater risk for pressure ulcers.
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Affiliation(s)
- Sharon E Sonenblum
- Rehabilitation Engineering and Applied Research Laboratory, The George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, 801 Atlantic Dr. Office 026, Atlanta, Georgia.
| | - Davin Seol
- Rehabilitation Engineering and Applied Research Laboratory, The George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, 801 Atlantic Dr. Office 026, Atlanta, Georgia.
| | - Stephen H Sprigle
- Rehabilitation Engineering and Applied Research Laboratory, College of Design and The George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, 801 Atlantic Dr., Lab 027, Atlanta, Georgia.
| | - John McKay Cathcart
- Lecturer in Diagnostic Radiography, Room 17J10, School of Health Sciences Ulster University, Shore Road, Jordanstown, Newtownabbey, Antrim, Ireland.
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Sonenblum SE, Ma J, Sprigle SH, Hetzel TR, McKay Cathcart J. Measuring the impact of cushion design on buttocks tissue deformation: An MRI approach. J Tissue Viability 2018; 27:162-172. [DOI: 10.1016/j.jtv.2018.04.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 04/06/2018] [Accepted: 04/23/2018] [Indexed: 12/17/2022]
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