Lauren E. Rosen, PT, MPT, MSMS, ATP

Matching clients’ needs with the breadth of wheelchair cushion options on the market—air, gel/fluid, foam, honeycomb, and sculptured—can be daunting. We asked an expert to help demystify the process.

Lauren E. Rosen, PT, MPT, MSMS, ATP, a 14-year industry veteran, is the program coordinator for the Motion Analysis Center at St Joseph’s Children’s Hospital, Tampa, Fla. She performs 3-D gait analysis, and oversees a pediatric and adult seating and positioning clinic. Rosen works with clients of all ages and their impairments span the range of disabilities, from children who have cerebral palsy, spina bifida, or muscular dystrophy to adults who have muscular dystrophy, MS, spinal cord injuries, head injuries, or stroke, as well as orthopedic patients.

Judy O’Rourke How does choosing the proper cushion help prevent pressure sores from forming?

Lauren Rosen It’s everything—it’s knowing everything there is to know about the patient and what their needs are in coordination with picking the right cushion and thus helping to prevent pressure sores. For example, there are certain cushions that are better for people who have no sensation, for people who tend to slide in their chair, and for people with previous pressure sores.

JO How do you perform a mat evaluation and what anatomical aspects do you consider?

LR We perform a mat evaluation on everybody. What we’re looking at specific to cushions is pelvic position. So, is the pelvis tilted forward or backward, or does it sit in a good neutral position, do they have a pelvic obliquity, is one side higher than the other side, and also, is their pelvis rotated, so is one side rotated forward of the other side? The most commonly used technology nowadays to do that is pressure mapping. There are a number of different brands of pressure mapping systems, and they all generally work the same way: you put a cushion on a surface and you put the pressure mapping system over the cushion. The client then sits on the pressure map on top of the cushion, and after a good acclimation period, a reading is taken from the pressure map. It reads how much pressure there is between the patient and the cushion, so you’re able to tell if you’ve got too much pressure in one area or if a cushion is properly set up, as well.

For related articles, read “Preventing Pressure Ulcers” and “Striking a Balance” from previous issues.

JO How do you instruct clients to perform pressure relief?

LR It depends on whether they are cognitively intact and whether they have sensation. People who are cognitively intact and have sensation generally know when to do pressure relief because their butt hurts, and if they have the ability, they will shift their own position. If they don’t, they’ll ask their caregiver to shift them. Or if they have a power-tilt system, they’ll push a button and tilt themselves. If you have poor sensation or aren’t cognitively intact, then you don’t know you need to shift your position; in which case, generally, we tell people they should do some sort of pressure relief about every 30 minutes. When they are learning to perform pressure relief, we suggest setting an egg timer to remind them to tilt.

JO How do you determine optimal pressure distribution?

LR The cheap, easy way to do that is let somebody sit in a cushion a little bit and take them off it and look at their butt. You can tell if they’ve got a high pressure area because you’ve got redness in one area and not in the others.

JO How do you match the cushion type with clients’ needs?

LR Generally, foam cushions tend to be used for people who don’t need a lot of pressure relief and who may just need a little bit of positioning and comfort. Some foam cushions are made of multilayers of foam, with a softer foam near the skin and a harder foam underneath; they can provide pressure relief. This is not a cushion we use for somebody who has had skin issues. When the client sinks into it, and it’s contoured to them, the skin can’t breathe as well. But there are some foam cushions we use for clients who need pressure relief and positioning—just not with skin issues.

A lot of people use gel cushions. In most cases, it’s gel combined with foam. The gel provides pressure relief and the foam provides rigidity. Those are usually people who don’t have sensation and who aren’t moving themselves. If you live where it’s really cold and you’re outside for a while, the gel can get hard, and also it can migrate. Manufacturers try very hard to prevent the gel from moving, but I have yet to see one that’s 100% successful because gel by its nature will move. Gel cushions require upkeep, and some clients come into the clinic and are completely bottomed out in the cushion. We’ll say, “When was the last time you moved your gel?” and they (quizzically) say, “Huh?”

Some honeycomb cushions have a softer top in which clients tend to immerse a little bit more quickly. Some people find it more comfortable. With this type of cushion, you don’t get liquid pooling near the skin. If someone is incontinent, the liquid goes straight through the cushion, through the bottom. Honeycomb cushions tend to be a bit more breathable and you can get airflow underneath them. They can keep you a bit cooler and prevent moisture buildup, which is one of the causes of pressure sores.

There are air cushions with and without quadrants, which are for someone who has a pelvic obliquity and who has positioning needs. Generally, they’re designed to move. As you put more pressure in one area, the cells deflate, causing cells in another area to inflate. If you’ve got someone with an obliquity, then only the cells within each quadrant will inflate and deflate. The toughest thing about air cushions is inflating them properly. People tend to overinflate them so they feel more stable and then you’re basically sitting on a rock. Educating clients is very important. One manufacturer has a nice printout I give to clients and discuss, showing how to inflate the cushion and how to check it. Most people like to look at a cushion when they’re not sitting on it, and they say, “Oooo, that’s not right!” The only way to properly inflate and check an air cushion is with a client sitting on it. You have to put your hands in specific places.

Sculpted cushions are used for people with significant deformities, such as scoliosis or a pelvic obliquity. In most cases, if you’re using a sculptured cushion, you’re using a sculptured back in coordination with it, and you’re molding both at the same time so you’re getting the best correction you can get overall for their posture. If a client has a significant obliquity or prominent bony areas, in those areas we’ll use gel or some sort of soft spot to provide extra relief. There’s a sculptured cushion on the market that works well for people who’ve had recurrent pressure sores on their ischial tuberosities. The design is sculpted such that you do not end up having any pressure through your ischial tuberosities. It distributes the pressure through your thighs and your greater trochanters. People who have had trouble sitting on a cushion due to recurrent sores have had a lot of success sitting on that kind of cushion.

JO How does the length of time a client spends in a wheelchair—or the means of transfer—help determine the type of cushion needed?

LR Most people who are full-time wheelchair users, who have a neurologic injury, spend all day in the chair. Those kinds of people tend to have decreased sensation and problems with pressure. The woman who just uses the chair for a little bit during the day because she can’t walk all day usually has pretty good sensation. The longer you sit in one position and don’t move yourself, the more risk you have of developing pressure sores.

JO Describe some common forms of pressure relief.

LR Some people do a depression or a push-up. If they have strong arms, they can lift themselves up and their behind comes all the way off of the cushion. Some people will do a side lean. They lean all of the way over—if they lean to the right, they lean till their left cheek is off the cushion. They stay there for a little bit, then lean to the left, till the right cheek is off the cushion. There are power and manual tilt systems for wheelchairs, so either clients do it themselves or someone else tilts them back and they get pressure relief that way. People who can’t do any of those things, whose caregiver cannot lift them, will stay in the chair for a limited time and then they will transfer into bed.

JO How do cushion type and cushion covers affect transfers?

LR The texture and type of cushion can really affect a transfer for people who do lateral-scoot transfers by themselves. In terms of the covering on the cushion—I’ve had clients who, when they’ve switched cushions because of pressure issues, get caught on the cover in their transferring. We’ve had to change out the cover. Some cushions, when you push on them, by nature of the way the cushion is designed, either the person’s hand sinks into the foam, or the air goes out of the cell where they’re pushing. So it’s kind of a moving surface, and some people who have a decreased ability to transfer by themselves can’t transfer off that type of cushion. With somebody who does do a stand-pivot transfer, the thickness of the cushion affects the transfer. Sometimes if the cushion is too thick, a short person can’t quite get to the height of the cushion when they’re transferring into the chair—it actually raises the height up. Sometimes we’re better off doing a shorter cushion.

JO How do prior skin sores and skin integrity overall influence the type of cushion needed?

LR Once you’ve had a skin sore and it’s completely healed, your skin returns to about 80% of the strength it had before. That’s one of the big questions to ask clients—“Have you had a prior skin sore?” Somebody who has, even though their skin may be good right now, is still at higher risk of getting another one. With somebody who has never had a pressure sore and has always had good skin, we might consider one type of cushion. For somebody who doesn’t currently have a pressure sore but has had one in the past, we may consider a cushion that provides more pressure relief. It’s a very important question to ask clients and it’s something that often gets missed.

JO How often should cushions be inspected?

LR It depends on the type of cushion. Generally, for air cushions, I tell people once a week or once every couple of weeks. Gel, every day. You need to be sure the gel isn’t migrating. Honeycomb needs almost zero inspection, because there is no maintenance to it, as is the case with foam cushions.

JO Could you discuss funding issues?

LR It depends on the payor source, but some things are pretty straightforward. Medicare has pretty specific guidelines, so it’s very easy to know what type of cushion someone qualifies for based on those guidelines. The codes are all ICD-9 driven—for Medicare and some of the insurance companies. Other funding sources vary. Every state Medicaid is completely different. In some states it is a moving target.

JO Any other thoughts you’d like to share?

LR No cushion, in a vacuum, is going to prevent pressure sores. People have to do pressure relief, no matter what. They have to do skin checks to be sure their skin is staying healthy. We also need to look at the chair as a whole. I can have the perfect cushion for a client, but if I’ve got their legrests adjusted too high, I’ve put too much pressure onto their ischial tuberosities and there’s not a lot of pressure under their thigh—all of the pressure’s going right on their butt. Even if the cushion was appropriate, the whole seating system itself wasn’t. The armrest height, the back support, everything has to be done properly. A cushion, in and of itself, cannot prevent pressure sores.

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