Patricia Karg

A randomized control trial to evaluate pressure-reducing seat cushions for elderly wheelchair users.

OBJECTIVE To determine if the use of pressure-reducing wheelchair cushions for elderly nursing home resident wheelchair users who are at high risk for developing sitting-acquired pressure ulcers would result in a lower incidence rate of pressure ulcers, a greater number of days until ulceration, and lower peak interface pressures compared with the use of convoluted foam cushions over a 12-month period. To determine the feasibility of conducting a subsequent full-scale definitive trial to evaluate the use of pressure-reducing seat cushions for elderly nursing home resident wheelchair users. DESIGN Randomized control trial SETTING 2200-bed skilled nursing facilities (1 suburban and 1 urban academic medical center) PATIENTS 32 male and female at-risk nursing home residents who were wheelchair users > or = 65 years of age. Participants had Braden Scale scores < or = 18, Braden Activity and Mobilitysubscale scores < or = 5, no sitting surface pressure ulcers, and a daily wheelchair sitting tolerance of more than 6 hours. All met criteria for using the ETAC Twin wheelchair. INTERVENTIONS Seating evaluation with pressure-mapping and subsequent seating prescription. Subjects were assigned to either a foam (n=17) or pressure-reducing cushion (n=15) group and weekly assessments of skin and pressure ulcer risk were made. MAIN OUTCOME MEASURES Incidence of pressure ulcers, days to ulceration, and peak interface pressure. MAIN RESULTS At a 95% confidence interval, a 2-tailed analysis showed no differences between the FOAM and pressure-reducing cushion groups for pressure ulcer incidence, total days to pressure ulcer, or initial peak interface pressure. Pressure-reducing cushions were more effective in preventing sitting-acquired (ischial) pressure ulcers (P<.005). Higher interface pressures were associated with a higher incidence of pressure ulcers (P<.001). CONCLUSIONS A definitive randomized control multicenter cushion trial is feasible with a sample size of 50 to 100 per study group. In the definitive trial, the definition of sitting-acquired pressure ulcers should be limited to lesions occurring over the ischial tuberosities.

A randomized clinical trial on preventing pressure ulcers with wheelchair seat cushions.

OBJECTIVES: To determine the efficacy of skin protection wheelchair seat cushions in preventing pressure ulcers in the elderly nursing home population.

Wavelet-Based Spectrum Analysis of Sacral Skin Blood Flow Response to Alternating Pressure

OBJECTIVES To provide insight into the physiologic mechanisms associated with alternating pressure, using wavelet analysis of skin blood flow (SBF) oscillations, and to determine whether the application of alternating pressure induces myogenic responses, thereby enhancing SBF as compared with constant loading. DESIGN Repeated-measures design. SETTING University research laboratory. PARTICIPANTS Healthy, young adults (N=10; 5 men, 5 women; mean age +/- standard deviation, 30.0+/-3.1 y). INTERVENTION Alternating pressure for 20 minutes (four 5-min cycles with either 60 mmHg or 3 mmHg) and constant loading for 20 minutes at 30 mmHg on the skin over the sacrum. MAIN OUTCOME MEASURES A laser Doppler flowmeter was used to measure sacral SBF response to both alternating pressure and constant loading. Wavelet-based spectrum analysis of SBF oscillations was used to assess underlying physiologic mechanisms including endothelium-related metabolic (.008-.02 Hz), neurogenic (.02-.05 Hz), and myogenic (.05-.15 Hz) controls. RESULTS Alternating pressure stimulated an increase in sacral SBF of compressed soft tissues as compared with constant loading (P<.01). SBF during the high-pressure phase of 4 alternating pressure cycles showed an increasing trend. An increase in power in metabolic frequency range and a decrease in power in the myogenic frequency range during alternating pressure were observed compared with SBF prior to loading. Power increased in the myogenic frequency range during the low-pressure phase of alternating pressure and decreased during the high-pressure phase. CONCLUSIONS SBF control mechanisms, as assessed by the characteristic frequencies embedded in SBF oscillations, show different responses to 2 loading pressures with the same average pressure but different patterns. Our study suggests that optimization of operating parameters and configurations of alternating pressure support surfaces to compensate for impaired SBF control mechanisms in pathologic populations may be possible using wavelet analysis of blood flow oscillations.

Interface shear and pressure characteristics of wheelchair seat cushions

Pressure ulcer incidence rates have remained constant despite advances in support surface technology. Interface shear stress is recognized as a risk factor for pressure ulcer development and is the focus of many shear reduction technologies incorporated into wheelchair cushions; however, shear reduction has not been quantified in the literature. We evaluated 21 commercial wheelchair seat cushions using a new methodology developed to quantify interface shear stress, interface pressure, and horizontal stiffness. Interface shear stress increased significantly with applied horizontal indenter displacement, while no significant difference was found for interface pressure. Material of construction resulted in significant differences in interface shear stress, interface pressure, and horizontal stiffness. This study shows that the existing International Organization for Standardization (ISO) 16840-2 horizontal stiffness measure provides similar information to the new horizontal stiffness measure. The lack of a relationship between interface shear stress and the overall horizontal stiffness measure, however, suggests that a pressure and shear force sensor should be used with the ISO 16840-2 horizontal stiffness measure to fully quantify a cushions ability to reduce interface shear stress at the patients bony prominences.

Seat cushion optimization: A comparison of interface pressure and tissue stiffness characteristics for spinal cord injured and elderly patients☆☆☆

OBJECTIVE A method for designing tissue deformation minimizing seat surfaces was evaluated. Pressure and stiffness criteria were used to optimize surface shape. The methods efficacy for patients with spinal cord injuries (SCI) and a comparison of cushion performance and interface characteristics with a group of 30 elderly patients are presented. DESIGN Repeated measures, prospective study. SETTING University medical center. PATIENTS SCI (n=12), elderly (age 65 + years) [n=30]. INTERVENTIONS One flat and two custom foam seat cushions. MAIN OUTCOME MEASURES Interface pressure measured using a pressure sensing pad; tissue stiffness and pressure recorded on a rigid programmable seat surface. RESULTS Pressure distributions on contoured cushions for the SCI group contained lower values than distributions on flat cushions. A comparison of the pressure data between the elderly and SCI showed that significant differences exist between interface characteristics. The SCI group had higher peak interface pressures for all cushions tested. Tissue stiffness measurements were similar for each group. CONCLUSIONS Results showed improved effectiveness of custom contoured foam seat cushions versus flat foam cushions. The results suggest that pressure distributions for SCI are more sensitive to support cushion characteristics than for the elderly. Further research is needed to determine the extent of the difference between the populations represented by these groups.

Effects of local cooling on sacral skin perfusion response to pressure: Implications for pressure ulcer prevention

People with spinal cord injuries are at high risk for developing pressure ulcers. Increased skin temperature is one of the extrinsic causative factors for this multi-factorial disease. Previous animal studies revealed that local skin cooling reduced the severity of ulceration, and cooling is widely used in plastic surgery and organ transplants for tissue preservation. The objectives of this pilot study were to develop test protocols and instrumentation and to investigate the effect of local cooling on skin perfusion response to pressure on young healthy human subjects. Reactive hyperemia was quantified in this study to compare the effects of pressure with and without cooling. Reactive hyperemia is a normal physiological response occurring after vessel occlusion. Laser Doppler flowmetry was used to measure skin blood flow. Time-dependent spectral analysis was used to analyze and decompose the blood flow data into frequency ranges associated with specific blood flow control mechanisms. The study used a repeated measures design with two test conditions: 8 kPa of pressure with and without cooling to 25 degrees C. We hypothesized that local cooling would reduce the post-ischemic reactive hyperemic response induced by the rigid indenter. Time series results showed that normalized peak perfusion response was significantly lower with cooling (p=0.019). Time-dependent spectral analysis results suggested that both metabolic and myogenic responses contribute to this protective effect. Findings from our study on humans were consistent with previous animal studies. Additional studies on individuals with spinal cord injury are planned to further evaluate the cooling effect in a high-risk population.

Motor Vehicle Transportation Use and Related Adverse Events Among Persons Who Use Wheelchairs

For the 2.2 million people who use wheelchairs in the United States, transportation is often needed for independence in the community. The purpose of this study was to investigate the characteristics of transportation use in a population of wheelchair users and to examine the motor vehicle crash involvement and injury frequency of these users. Responses were collected from 596 individuals from June 2002 to November 2003. Approximately 20% of the sample population was involved in a motor vehicle crash in the previous 3 years, resulting in a rate of 3.6 accidents/incidents per 100,000 miles traveled. Crashes were defined as any motor vehicle accident that the person was involved in during the previous 3 years. Persons who did not transfer from their wheelchair were more likely to be involved in a crash than those individuals who transferred to vehicle seats. Eighteen percent of the population reported involvement in a non–crash-related incident during the previous 3 years. Passengers reported a greater frequency of non–crash-related injuries than did drivers. The results of this study provide documentation of transportation use and safety in people who use wheelchairs. It provides insight into the risk of crash and injury in this population.

A method for custom-contoured cushion design using interface pressure measurements

The interface pressure distributions between flat foam cushions and the buttocks of seated test subjects were compared to custom-contoured cushion surface shapes generated with a seated-buttock contour gauge. Our hypothesis was that pressure measurements could be used to generate a contour equivalent to that obtained with a force-deflection contour gauge. The study was performed in a university medical center using spinal cord injured (SCI) (12) and elderly (30) test subjects. Interface pressure was measured using a pressure mapping pad. Contour shape was measured using an electronic force-deflection contour gauge. Pressure and contour information were reduced prior to analysis using singular value decomposition. Polynomial regressions were performed on the values in the first singular vectors of the corresponding pressure and contour decompositions. Relationships best described by cubic polynomials were detected between pressure and contour shape suggesting that interface pressure predicts optimal contour shape.

Effect of wheelchair headrest use on pediatric head and neck injury risk outcomes during rear impact

Comparative risks or benefits to wheelchair-seated pediatric occupants in motor vehicles associated with wheelchair headrest use during rear impact were evaluated using pediatric head and neck injury outcome measures. A Hybrid III 6-year-old anthropomorphic test device (ATD), seated in identical WC19-compliant pediatric manual wheelchairs, was used to measure head and neck response during a 25 km/h (16 mph), 11 g rear impact. ATD responses were evaluated across two test scenarios: three sled tests conducted without headrests, and three with slightly modified commercial headrests. Head and neck injury outcomes measures included: linear head acceleration, head injury criteria (HIC) values, neck injury criteria (N(ij)) values, and combined rotational head velocity and acceleration. Neck and head injury outcome measures improved by 34-70% in sled tests conducted with headrests compared to tests without headrests. Headrest use reduced N(ij) values and the likelihood of concussion from values above established injury thresholds to values below injury thresholds. Injury measure outcome reductions suggest lower head and neck injury risks for wheelchair-seated children using wheelchair-mounted headrests as compared to non-headrest users in rear impact. Use of relative comparisons across two test scenarios served to minimize effects of ATD biofidelity limitations.

Wheelchair Seating: A State of the Science Report

Regardless of the field, agenda-setting processes are integral to establishing research and development priorities. Beginning in 1998, the National Institute on Disability and Rehabilitation Research mandated that each newly funded Rehabilitation Engineering and Research Center (RERC) hold a state-of-the-science consensus forum during the third year of its 5-year funding cycle. NIDRRs aim in formalizing this agenda-setting process was to facilitate the formulation of future research and development priorities for each respective RERC. In February 2001, the RERC on Wheeled Mobility, University of Pittsburgh, conducted one of the first such forums. The scope encompassed both current scientific knowledge and clinical issues. In preparation, expert interviews were carried out to establish the focus for the forum. Because a stakeholder forum on wheelchair technology had recently been held, opinion favored wheelchair seating as the focus and included the following core areas: seating for use in wheelchair transportation, seated postural control, seating discomfort, and tissue integrity management. The aim of this report is to present a summary of the workshop outcomes, describe the process, and increase awareness of this agenda-setting process in order to enhance future participation in a process that critically influences the field of wheeled mobility.