Nordic Seating Symposium - Socialstyrelsen

Nordic Seating Symposium

Stockholm 2012

Are your preventive interventions related to pressure ulcers in fact rational at all?

Helle Dreier OT, MSI

A retrospective examination of ”activity based seating assessments”

2005 – 2010 Carried out at

Specialrådgivningen Holbæk

2012

From the retrospective examination of ABSA’s 2005 - 2010

• 89 individuals (+16)

1. with sitting problems &

2. suffering from 119 tissue damages:

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Tissue damages devided into diagnoses

With cognitive disability complications


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• 44 of these individuals were suffering from tissue damages very likely related to the seated position located:

– Spine, hollow of the knee, throchanter, scapula, feet/legs, heel, or the Crista Iliaca/Ribs.

• 28 of these individuals were not sufficiently documented in the present material to identify location and reason of tissue damages.

• +16 individuals were in serious, general

pain related to the seated position.

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• 69 tissue damages were related to the seated position in bed /chair

• 58 of these were Tuber Ischii related

• 11 of these were Os Coxygis related


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• 6 tissue damages were related to the lying position in bed and were

• Os Sacrum related


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The anatomical facts


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How to make a tissue damage in a lying position in bed on Os Coxygis?

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Discuss with your neighbour

Which assistive device strategy would you choose for this patient?


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Foto venligst stillet til rådighed af KvaliCare


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Foto venligst stillet til rådighed af ROS Dermatologisk afdeling


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Is it a rational strategi to open every pressure ulcer case with a pressure relieving mattress?


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Rational strategy to prevent tissue damages:

• As a therapist you are responsible for choosing the right assistive devices and for the individual adjustments

• And dependent upon:

• Access to wound-professional expertise: – able to analyze and identify

the location with accuracy

– Willing to reflect on the conclusions together with you – in a shared language


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Accuracy lead to rationality

• Inaccuracy – (fx by using the

location: Os Sacrum in general) might be fatal because:

• Tissue damages related to the Os Coxygis usually are related to the seated position

• Tissue damages related to the Os Sacrum usually are related to the lying position

• It might draw out the time untill managing the real problems related to the seated position can begin.

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Reflection lead to rationality • Interdisciplinary

reflection is the basis for a shared object

• Collaboration between:

• wound professional expertise/

• Assistive device expertise

• contribute with different but relevant and necessary knowledge for a shared job



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Shared language lead to rationality • Because it forms the basis

of your intervention choises and enable your reflections on the effects.

• Are you able to understand the meaning and consequences of words like:

• Fistula • Cavity • Granulation tissue? • If not: you need to know: is

the tissue healing or is it still under some kind of strain?

• Otherwise your intervention will be a number of random shots and most possibly a very risky business.


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You need deep assistive device knowledge

Remember the individual adjustments to make the

assistive devices fit the body and the individual ressources

(and not the opposite)

Mattresses for lying problems

Cushions and individual wheelchair adjustments for problems in being seated


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So rationality is about:

• Accuracy

• Interdisciplinarity

• Reflection

• Shared language

• Assistive device knowledge


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By the way….you need to know….




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A source to serious misunderstanding: • A pressure ulcer is not only a

matter of pressure

• But unfortunately the words make us associate exclusively to pressure-relief

• A pressure ulcer is very much a question of shear too

• The intervention practice need to catch both, which you can’t do with a cushion


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Another source to serious misunderstanding:

NPUAP •unclassified, •unstageable and •deep tissue injury

According to the EPUAP – Quick Reference Guide – 4 Categories


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And even one more source to serious misunderstanding:

• According to EPUAP/NPUAP Quick Reference Guide:

• Category I – non-blanchable erythema ”may indicate ”at risk” persons…..

• NO!! • It indicates an existing

tissue damage in an ”at risk” person.

• The assistive device intervention (ex. mattress) is too late then, to be named preventive.

• It might hopefully form a cure.


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Use of tissue damages as ressource

• Try to look upon existing

tissue damages as a

reprehensible definite proof of pressure and shear and

• An ultimative expression of the fatal consequences of an unsuitable relationship between the body and the assistive devices (ex. mattress, cushion,wheelchair)

This perspective gives you

the opportunity to use the

tissue damages as a guide

for doing it much better:

• Connect your own deep assistive device knowledge to the wound professionals knowledge

• Have interdisciplinary focus on analysis and reflections in common to draw up a shared object


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So – you might need to turn your perspective upside down to be rational:

• Forget the name: Pressure Ulcer. • It makes us forget in the clinical praxis that it’s all about: • tissue and not skin • pressure and shear (and not just pressure) • That we are too late to prevent as a

– Cat. I – (non blancable erythema) has emerged. It indicates a rise of damage meaning that now it’s a matter of cure strategy….(to prevent it from getting worse)

• That the serious damages are happening underneath the skin – in the tissue closest to the bones – deep tissue injury.

• Look at tissue damages as a ressource of importance and as a guide for your intervention strategy to cure.

• Follow the story of the tissue damage – is it healing or is it still under serious strain? – and do it in interdisciplinarity?


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From the retrospective examination of ABSA’s 2005 - 2010 Considerable recovery documented in the record during the

years 2008 - 2010


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And now we focus on the seated position


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Realize the differences Tissue damages related to the lying position – mostly pressure

• Supportive surface large • Stability level high (except if

the head of the bed is elevated)

• Activity level and expectations low

Tissue damages related to the seated position – pressure & shear

• Supportive surface small • Stability level low (shear risk

high) • Pressure distribution area low • Activity level and expectations

high


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Realize the different consequences of your interventions

This is a passive situation: • Neither the patient nor you

expect activity on high level • OK to think pressure relief

This is an active situation:

• The wheelchair user will be

expecting a continuing active life and might be dependant on it

• That is why it is NOT OK to think pressure relief

• You must be thinking bigger because it is possible to do so


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Think quality of the seated position

A: Think STABILITY and be in control

of the shear factor

B: Think PRESSURE DISTRIBUTION

(NB!! in contrast to pressure relief)

and be in control of the pressure factor

C: Think DAILY OCCUPATIONS and be in control of

shear and pressure factors during performance of actions in everyday life


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And

• Thinking traditionally - (meaning pressure relief)

• Because if you do so you forsake a wheelchair user in need

• Evidence of the effects of immobilization and repositioning is limited – no RCT’s exists .

• And immobilization can have detrimental adverse effects on every organ system of the body and may cause muscle loss, joint contractures, deprivation of environmental and social stimulation and might even impede wound healing .

• Thinking bigger means you offer the wheelchair user comprehensible, manageable and meaningful interventions to prevent, to cure and to avoid serious losses of experience of coherence and quality of life.


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A: Keep your attention on to stability To be in control of the shear factor you must – if possible at all - make use of an other third support surface than os coxygis

Use the SIPS as the third point of support.

Spina Illiaca posterior superior (SIPS)


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B: Keep your attention on to pressure distribution

You can make use of the body contact area to distribute pressure up till: •10 % using arm rests •10 % using foot rests •30 % using the wheel chair back • Then what is left for the vulnerable buttocks? Roughly 50 % on the seat • So! Use the assistive devices in contact with the body


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C: Keep your attention on to daily occupations

• Consider which of the actions in everyday life is meaningfull and essential to the individual (you can be sure that the actions will be performed whether you have forbidden them or not – as they seriously are meaningfull and essential).

• Be the partner of the wheelchair user in identification of the ”risky” actions and participate seriously in the invention of alternatives.

• Be sure to see the relevant and concrete actions in the domestic context. (you can not do with just talking !)


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Daily occupations

• Florence Clark et al…(2006) Databased Models of How Pressure Ulcers Develop in Daily-living Contexts of Adults With Spinal Cord Injury. Archives of Physical Medicine and Rehabilitation. 87; 1516 – 63

• Florence Clark (ongoing study) Lifestyle Redesign ® for Pressure Ulcer Prevention in Spinal Cord Injury. http://ot.usc.edu/faculty/directory/florenceclark

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http://ot.usc.edu/faculty/directory/florenceclark

From the retrospective examination of ABSA’s 2005 – 2010

Elements of the ABSA: home visits and try-outs


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Elements in the activity based seating assessment process


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Keep your attention on to the object which is to optimize the ability to remain seated without damage

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• To control pressure – use SIPS as the third point of support to create pressure distribution and stability

• To control shear – use SIPS as the third point of support to create pressure distribution and stability

Rational interventions related to sitting acquired tissue damages

• Which are emerging because of pressure as well as shear

• That’s why a cushion can’t solve the problem alone!

• You definitely must: – make use of the SIPS and a

stable contact to this - if possible at all - to stabilize and pressure distribute

– And at the same time optimize the cushion


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Focus on target and act preventive • Focus on every

wheelchair user being seated for more than 15 minutes .

• Particularly focus on new, permanent wheelchair users (to prevent contractures which may reduce the sitting ability – over time

• Focus on fakta you are able to assess with your own eyes and hands and forget your beliefs

• Concentrate on: 1. Wheelchair users

suffering from absent or disturbed sensibility

2. Wheelchair users suffering from reduced sitting ability

• Play down: • The focus on other

possible reasons for pressure ulcers described in the litterature as it takes out your focus – concentrate on the quality of the seated pos.


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It is my experience that rational prevention is:

• A highly specialized job characterized by great complexity

• You need a team: – Well qualified

– Representing interdisciplinarity

– Experienced or under supervision of experienced colleagues

– Ability to reflect upon real prevention – and not just to prevent tissue damages from worsening

– Ability to see and foresee

Activities and assistive devices

Bodypositions lying - sitting

Knowledge of wound healing


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And it is my experience too, that rational prevention is:

• Too serious a job to hand over responsibility of decisions and implementation to:

– Members of the staff with fx technical competences or drivers

– Consultants being a part in the solution as to the economy

– The wheelchair user himself or the relatives

– The front health professional staff 6/25/2012 49


IS IT a rational prevention strategy to

minimize complexity? • How to choose ”the right assistive device”? • In Denmark we have seen a tendency: • Trying to minimize the complexity in the field by:

– Simplified choises implemented by standardization and price-agreements)

– Agreements of procedures trying to minimize the face-to-face-time concerning fx analysis, prescription and delivery (meaning virtual-delivery)

– The choises are very often dependant upon the responses from front staff to the therapists describing a Category I damage – meaning that we are already too late and meaning that prevention has in fact failed!


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On the opposite it is a rational prevention strategy to minimize riskfactors!

• To make the right choises concerning ”the right assistive device” need a strategy of:

• Trying to minimize riskfactors instead: – Having focus on quality of the seated positions in

permanent seated wheelchair users and especially the new ones – and to do it yourself. – Interdisciplinary accuracy, reflection and shared language

in co-operation with the individual, the relatives and the front staff in the daily occupation context.

– Elimination of the serious risk factors that we ourselves as health professionals constitute by over time loosing specialized competences behind a computer far from the lived life and by possible misinterpretations as well as old myths about pressure ulcers.

– We need to see, feel, try out and listen to the key figures in the daily occupational context and to make reasonable and sensible decisions ourselves using our own common sense.


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No – because:

• Pressure relieving matresses only reaches lying problems – and not sitting problems

• Pressure ulcers are considered to be a one and common problem – and are not usually separated from each other (sitting/lying)with serious consequences to the wheelchair user

• The meaning of ”prevention” is often limited to: ”to prevent it from worsening”


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No – because: • We expect pressure ulcers to be chronical or

uncureable – which leaves us with no serious ambitions on a quick cure

• We do not respect and include the wheelchair users personal expectations, ressources and comptences in our interventions

• We act as if we still believe it is all about pressure and are totally forgetting the shear-dimension in our intervention strategies

• We have too much focus on how to avoid the seated position in stead of having focus on how to create a less-risky seated position


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No – because:

• We are still thinking ”pressure relief” in stead of ”pressure distribution”

• It is common practice to highlight ”function” and underestimate the ”contextual daily occupations” though several studies has shown a potential in showing interest in that

• Therapists are considered to be a group of professionals with no share in cure of

pressure ulcers - and it may turn out to be a interdisciplinary power struggle. 6/25/2012 54



No – because: • 200 other possible riskfactors apart from sensibility

and reduced sitting-ability are disturbing our perspective and creative thinking: solutions

• We try to organize pressure ulcer strategies having focus on complexity and low costs in stead of having focus on those riskfactors that we ourselves as health professionals happens to perform by: not seeing, not feeling, not listening to the key figures and no trying outs

• We are missing golden opportunities to therapeutic reflections upon competences of the individual, the potential of assistive devices, possibilities to empowerment of the wheelchair user to take care of himself in the future.


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Expenses • Equipment-prices gives plenty of room for saving

money by using homevisits to make the right assistive device choises.

• According to Journal of Wound Care, May 2010 a current estimation of municipal wound care in Denmark is 735 mill d.kr. each year (pop. 5 mill.)and is expected to grow to 1,5 billion d.kr. in 2020.

• At the same time it is worth noticing

that one third of all Danish hospitalized

patiens seem to be suffering from some

kind of tissue damage .


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Looking 10 years back….

• Has any important changes emerged during the last 10 years as to the prevalence of pressure ulcers?

• Let me ask you one thing before I stop:

• What does it take for you to change behavior?

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Do you have any questions?

Thank you for your attention Read more: www.tryksaar.dk Where you find my references and other relevant stuff www.hjaelpemidler.com 6/25/2012 58


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Nordic Seating Symposium - Socialstyrelsen