permobil-gefen-conference-image-finalIncidence of pressure associated injuries in hospital settings and care facilities are around one to two out 10.  Speaking to F2L in Sydney at a conference on pressure injuries hosted by Permobil Australia, Amit Gefen professor of Biomedical Engineering at Tel Aviv University, said treatment options can depend on many things, for example equipment that is prescribed and the level of monitoring of the equipment, particularly seating support.  “How often adjustments are made to wheelchair cushions along with any changes to lifestyle or routine.”

He said there was a strong connection between the level of risk, the usage patterns of equipment and the type of equipment being used.  “You can control the level of risk by prescribing the right equipment and making sure the equipment stays right.”

Adjustability is a key component when it comes to adequate design and selection of wheelchair cushions with literature showing that external and internal anatomy, as well as tissue structure and function change considerably over time, which increases the risk for pressure injuries.

“An ideal cushion should be carefully tailored to the individual and be adequately adjustable to accommodate the physical changes that occur over time. This can be influenced by numerous factors, including the wardrobe.”

Cushions also wear out, so people should be assessed and the cushions evaluated and replaced regularly to protect from pressure injuries, he said.

According to Professor Gefen it was also important that the cushion be able to ‘wrap around’ the buttocks for greater side loading that disperses bodyweight. Durability was another factor to consider when it comes to choosing a good cushion. “The cushion should maintain its structure, properties, function and performance over time, especially when it is subject to prolonged use and environmental conditions.”

Air cell based cushions are generally more effective in protecting patients with a history of severe pressure injuries, compared to flat foam cushions which appear to lack sufficient envelopment.

Those most at risk from pressure injuries are: bed-bound patients with impaired mobility/sensation; patients post spinal cord injury, brain trauma or stroke; those with degenerative neuromuscular diseases and people undergoing prolonged surgery and prosthetic users.

“For spinal cord injury patients living in the community pressure injuries are very common, and unfortunately one in 10 patients will end their lives as a result, which is a general number for western countries,”   he said.

 “Much of our research work is focused on protecting the relatively young people who are more likely to be in car or sporting accidents, from pressure injuries. These people often need to use a wheelchair for decades and in most cases lack the discomfort/pain ‘alarm’ mechanism that enforces continuous micro-movements in the healthy. Because most people with spinal cord injury undergo dramatic body and tissue changes this substantially increases their risk of developing pressure injuries. If you cannot move or respond you are at high risk.”  

Risk assessment tools need to be updated for dealing with the risk of deep tissue injury and technologies developed to enable a better idea of internal tissue conditions for improving risk assessment and early diagnosis

“Once you understand the injury does not necessarily start on the skin you need to develop risk assessment tools that look under the skin.  We have MRI’s but these are less feasible for clinical practice.

“Pressure mapping is currently widely used and is rather inexpensive and technologically straightforward to measure as opposed to the more sophisticated MRI.  I expect that will change over time with tools that will show what is going on internally, for example portable or even hand-held ultrasound based imaging systems.  You need to remember that while pressure mapping offers some advantages it is only providing a partial picture (of what is happening on the skin, and even that without the shear component) and trying to show a very complex situation with partial information.” 

Most of the research in pressure injury is coming from Europe with much less from the United States. “I am not sure what is the driving force in the US but it probably has to do with funding mechanisms. While funding policies vary in different countries, funding streams from the US seem to be more focused on traditional diseases like cancer, AIDS, cardiovascular diseases and diabetes.” Pressure injuries definitely require more attention from governmental funding bodies in the US, but also in Europe and Asia.

Professor Gefen said because the implications from pressure injuries are less well known and obvious other diseases and conditions tend to have greater prominence when it comes to funding. “Because firstly we are lacking the understanding and the technology but the gap is closing and I can see light at the end of tunnel.  International guidelines have changed substantially as we adapt to the new knowledge about pressure injury and a lot of research is being put into clinical practice nowadays. In medicine generally it’s very difficult to change concepts within short times, and I think it happening for pressure injuries, which is very encouraging.”

Pictured: Amy Darvall clinical nurse consultant, Professor Amit Gefen and Permobil managing director, Owen Dawes