Weight Shifting and Pressure Management 2.0

Hello all!

I first wrote about Weight Shifting and Pressure Management in November 2013. Weight shifting and repositioning are important parts of pressure management to prevent pressure ulcer formation for individuals who use wheelchairs. Click here for the November 2013 Clinical Corner article, which contains information on what occurs internally to the tissue surrounding the pelvis during sitting.

Since the article was written, two of the clinical practice guidelines referenced in the article have been revised. The Prevention and Treatment of Pressure Ulcers: Quick Reference Guide¹ and Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury_² have had second editions published to incorporate new evidence-based recommendations. Let's take a look at the recommendations related to repositioning for pressure ulcer prevention and sitting or wheelchair use.

The Prevention and Treatment of Pressure Ulcers: Quick Reference Guide (hereafter called the Guide) addresses general repositioning for all individuals, which includes repositioning while in bed. The Guide recommends repositioning all individuals at risk of developing pressure ulcers, or those with existing pressure ulcers, unless contra-indicated, as repositioning reduces the length of time and the amount of pressure over the bony prominences.¹ The frequency of repositioning required remains dependent upon individual factors, including tissue tolerance, level of activity, general medical and skin condition, comfort and overall treatment objectives.

With respect to individuals who are seated, the Guide recommends:

1. "Position the individual so as to maintain stability and his or her full range of activities."^{1 (p. 24)}
2. "Select a seated posture that is acceptable for the individual and minimizes the pressure and shear exerted on the skin and soft tissues"^{1 (p. 25)}
3. "Ensure that the feet are properly supported either directly on the floor, on a footstool, or on footrests when sitting (upright) in a bedside chair or wheelchair."^{1 (p. 25)}
4. The second edition of the Guide continues to recommend to "Limit the time an individual spends seated in a chair without pressure relief".^{1 (p. 25)}

If the seated individual has an existing pressure ulcer, the Guide recommends minimizing sitting time and consulting a seating specialist if the pressure ulcer worsens when sitting. Consideration should be given to periods of bed rest for healing of sacral and ischial ulcers, while balancing the physical and emotional benefits of sitting. The Guide specifies:

"If sitting in a chair is necessary for individuals with pressure ulcers on the sacrum/coccyx or ischia, limit sitting to three times a day in periods of 60 minutes or less. Consult a seating specialist to prescribe an appropriate seating surface and/or positioning techniques to avoid or minimize pressure on the ulcer."^{1 (p. 26)}

A schedule of increased activity and progressive sitting as tolerated should be developed, taking into account the pressure ulcer response. Sitting schedules should be modified and the seated surface and posture should be re-evaluated if the ulcer worsens or does not improve.¹

Let's look now at the recommendations for wheelchair seating and positioning found in the second edition of the Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals (hereafter called the guideline). The guideline recommends the following:

"Prescribe wheelchairs and seating systems specific to the individual that allow that individual to redistribute pressure sufficiently to prevent the development of pressure ulcers.

• Obtain specific body measurements for optimal selection of seating system dimensions (postural alignment, weight distribution, balance, stability, and pressure redistribution capabilities).
• Prescribe a power weight-shifting wheelchair system for individuals who are unable to independently perform an effective pressure relief.
• Use wheelchair tilt-in-space and/or recline devices effective enough to offload tissue pressure.
• Use standing wheelchairs to remobilize individuals with existing pelvic pressure ulcers.
• Full-time wheelchair users with pressure ulcers located on a sitting surface should limit sitting time and use a gel or air surface that provides pressure redistribution.
• Maintain an offloaded position from the seating surface for at least 1 to 2 minutes every 30 minutes."^{2 (p. 58-59)}

The last point is worth emphasizing. Whereas the previous recommendation from the guideline was to weight shift every 30 minutes for 30 seconds or every 60 minutes for 1 minute, the new recommendation is to weight shift to offload bony prominences for a longer duration of time – at least for one to two minutes – every 30 minutes. The recommendation no longer recommends weight shifting every hour. Thus, we must encourage offloading on a more frequent basis and for a longer duration of time to allow for reoxygenation of the tissues under the bony prominences for pressure ulcer prevention.

Lastly, let's look at the recommendation for wheelchair support surfaces, or seating, found in the guideline. The Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury guideline recommends the following:

"Prescribe wheelchair seating systems for each person with a spinal cord injury individualized to anthropometric fit, to provide optimal ergonomics, and to provide maximal function.

• Prescribe wheelchair seating systems that
  • Redistribute pressure
  • Minimize shear
  • Provide comfort and stability
  • Reduce heat and moisture
  • Enhance functional activity
• Inspect and maintain all wheelchair cushions at regular scheduled intervals.
• Replace wheelchair seating systems that are no longer effective."^{2 (p. 62)}

In order to understand the wheelchair seating systems that redistribute pressure, minimize shear and reduce heat and moisture, it is important to have an understanding regarding generic materials and product design related to seating. For more information on this, please refer to past Clinical Corner articles related to wheelchair seating. For articles related to the materials, design and covers of wheelchair cushions and skin protection, please see Skin Protection and Cushion Materials, Skin protection and cushion design, Skin protection and Cushion Covers, respectively. Please refer here for an article related to Wear in Wheelchair Cushions.

This month, we reviewed some of the recommendations from current clinical practice guidelines with respect to weight shifting and repositioning for individuals who use wheelchairs. We also reviewed some of the recommendations related to the seating system for individuals with spinal cord injury. As with any guideline, it is important to use clinical reasoning to determine the most appropriate recommendations for individual clients.

References

1. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. (2014). Prevention and treatment of pressure ulcers: quick reference guide (2nd Ed). Cambridge Media: Perth, Australia.
2. Consortium for Spinal Cord Medicine. (2014). Pressure ulcer prevention and treatment following spinal cord injury: a clinical practice guideline for health-care professionals(2nd Ed). Paralyzed Veterans of America.