James is a jovial, 64-year-old Alabama native who owns his own small engine repair business and has been a T12 paraplegic for nearly 40 years. Lying in bed after his most recent myocutaneous flap repair, he relates that he really should be more careful and stop sliding off his cushion and onto the concrete while working. Five months ago, James developed a stage IV full thickness pressure ulcer, which had little chance of healing without having the circulation and padding a muscle would give to the exposed bony prominence. He reports that in his three past flap repairs, he had been put on long-term bed rest. He recalls extended hospitalizations of between 2 and 4 months for the first flaps, only to have one of them dehisce once he was allowed to sit. The last flap repair had him lying in bed at home for nearly 8 months, waiting for it to heal sufficiently. He did his research when this latest sore occurred, hoping to avoid such long downtimes but still have a successful closure to his debilitating problem.
James is in a newly renovated 18-bed unit dedicated entirely to medical-surgical patients at the Shepherd Center in Atlanta. He sought out the services of a plastic surgeon who has 23 years of experience with myocutaneous flap repairs for pressure ulcers, and the team of nurses and therapists who are following a long-developed program of postoperative recovery and therapy. The Shepherd Center is a 152-bed rehabilitation hospital that specializes in medical treatment, research, and rehabilitation for individuals with spinal cord and brain injuries. Although James has been coping with his spinal cord injury (SCI) for many years, some of the other flap patients at the facility are newly injured spinal cord and/or acquired brain injury patients whose pressure ulcers developed during their initial hospitalization period, before they were able to begin their rehab at Shepherd Center. It can be especially difficult for newly injured patients and their families to endure this extra period of bed rest and healing. Once the ulcers are repaired, their energy and participation in therapy often greatly improve.
2 WEEKS POST-SURGERY
James has been on bed rest now for 2 weeks, waiting for his Jackson-Pratt drains to be removed as the initial bleeding and inflammation resolved, and his staples were finally removed. He has been on a low air loss specialty mattress and has been encouraged to learn how to prone. He tries this position twice a day, initially with help from his therapist and now from nursing. He is instructed about the benefits of proning in avoiding future recurrences and in speeding healing of the flap. Fortunately, James has had no issues with healing after this latest surgery. The incision is intact without bruising or dehiscence, and the muscle lies directly over his ischium. If there were issues, his physical therapist would have had many choices of modalities to enhance and speed up the healing process.
High voltage galvanic stimulation has considerable laboratory and clinical evidence for being helpful in healing chronic wounds and accelerating healing by facilitating galvanotaxic attraction of cells to the wound, as well as restoring sympathetic tone and vascular resistance in the SCI population. Some electrical stimulation units can have additional uses, including neuromuscular stimulation to encourage motor recovery in incomplete SCI patients and TENS for pain relief. Pulsed radio-frequency emission technology has replaced our diathermy in the past few years and has shown to be beneficial in reducing openings on dusky, edematous, and/or bruised flaps. Light therapy also is utilized on an as-needed basis to enhance healing properties. Within the past year, Shepherd Center has been using ultrasonic assisted debridement (UAD) via a rental unit. Using low-frequency ultrasonic waves, the cold cavitation effect debrides dead tissues while leaving the healthy granulation tissue undisturbed and may even reduce bacterial biofilm. Two to three times weekly, UAD for 3-minute to 10-minute sessions has shown to be beneficial in speeding up the process for debriding eschar, slough, and tunneling areas, thereby shortening the time that traditional autolytic and chemical debridement are required and reducing time to closure/granulation of dehiscence. This technology is being utilized currently on a rental by the minute basis, with possible purchase in the near future given its usefulness. Finally, physical therapists at Shepherd Center are trained in vacuum assisted closure and serve as trouble-shooting specialists to back up a nursing staff trained in the application of these dressings, as they are often used in areas where they are difficult to apply.
STRETCH, SIT, AND TRANSFER
After being on complete bed rest the past 2 weeks with minimal leg motion so not to disturb the newly transplanted muscle, James is now reaching the stretching phase of his recovery. Physical therapists visit daily to progressively stretch the newly transferred muscle slowly over his ischium, looking and feeling carefully for any separation or pulling. The therapists also give a progressively more aggressive soft tissue massage to the muscle and incision line as well as myofascial release for tension in the surrounding regions. The incision should be able to tolerate a moderate amount of cross friction massage without showing signs of stress prior to sitting. This massage is completed during the 5 days to 12 days of stretching needed so the hip can flex to a safe angle for sitting (about 110 degrees). Once the incision is strong and flexible, sitting resumes, not all at once, but for half an hour more each day, until patients can sit a safe number of hours in order to get home. Typically, patients return home 1 week after they have begun sitting.
Although James has been exercising regularly with therapy bands, he may have unsafe transfers. Use of a manual lift is recommended for home if patients bump or shear their sitting bones despite transfer training. Shepherd Center has overhead ceiling lifts in all rooms. Often these devices are used for the first several days while the patient adjusts once again to being up. Transfer training is begun with therapists once the patient’s strength and endurance will tolerate it. While sliding boards are occasionally used to increase safety, patients are encouraged to avoid sliding (and therefore potential shearing) on the board. Sometimes all that is needed is a few sessions to recall how to lean shoulders and head opposite the direction the hips need to move. A gel-filled pad, or even a piece of a foam noodle (the kind children often use when swimming), is laid on top of the wheel to protect the ischia (sitting bones) from potential shearing. Therapists are able to utilize modern tablet technology in their everyday interventions. In conjunction with the Wireless Rehabilitation Engineering Research Center (RERC) at Georgia Institute of Technology, the “Side by Side” skill trainer enables therapists to give immediate visual feedback when teaching patients to do functional tasks such as transferring and wheelchair skills. They also can compare their technique to expert videos. “The device allows patients to self-assess their skill development in real time,” explains Jennith Bernstein, PT, ATP, coordinator for this venture at Shepherd Center.
SCI patients, as a result of their impaired or absent sensation, are dependent on having good and well-maintained equipment to maintain healthy skin. Once sitting has resumed, all flap repair patients have an opportunity to visit with physical therapists such as Bernstein, who specialize in seating and mobility. While at the seating clinic, therapists assess the patient’s wheelchair and cushion for appropriate fit and function. When a patient presents with skin injury (or post-flap), their sitting pressures are closely assessed via a pressure mapping device.
OPTIMIZING FOR MOBILITY
James has an air cushion, which can provide some of the best pressure redistribution, but air cushions also are one of the most poorly understood pieces of equipment for patients. Both overinflation and underinflation can cause skin injury. Many times these cushions can therefore worsen the situation, and the new chair may even cause new problems. James admits to not knowing how to properly inflate his cushion despite using it for several years. While on the pressure mapping system, James will be able to see in quantitative terms how much pressure he is getting, and how it changes when air is added or removed.
Effective redistribution of pressures while sitting is a very important component of the patients’ long-term success. “There is no one cushion that will work for all patients, and pressure mapping can give us valuable feedback,” says David Kreutz, PT, ATP, director of the seating clinic. “It provides information on relative pressure changes as we adjust and change cushions and other wheelchair components. But, unfortunately, the only way to truly tell what is too much pressure is by how their skin reacts.” In addition, pressure mapping is a great tool for giving the patients themselves visual feedback. They can easily see how too much air in the cushion changes their pressures, how effective their weight shift is, and how postural changes like leaning on the armrests a bit or leaning forward can reduce pressure.
While at the seating clinic, backrests can be changed to solid and/ or contoured styles to add support and improve posture and balance. Furthermore, chairs can have the angle of seating adjusted to reduce sliding out, and several types of cushions may be trialed. Gel/foam combinations, ischial cutout cushions, and air cushions are the most common for post-flap repair. Something as simple as a legrest that is too high can contribute to higher ischial pressures, and poor trunk support can raise sacral or unilateral ischial pressures. “We always recommend that patients return to the therapist who prescribed the new wheelchair or cushion and have it assessed before accepting it,” says Kreutz. Power chairs with tilt functions are sometimes recommended to those clients needing a more effective and independent weight shift. Tetraplegics who have been satisfied for many years with manual chairs may no longer be able to safely transfer and/or weight shift due to shoulder dysfunction or skin injury and are educated about the benefits of power seating, as well as using manual lifts rather than doing more independent transfers. Often these patients begin to realize that their equipment will need to change as they age in order to maximize their health and long-term independence.
Home equipment needs also are reviewed prior to discharge. Showering is an important part of James’ daily routine and maintaining good hygiene. Padded equipment is always recommended for flap patients, as well as anyone who has impaired sensation. Roll-in shower chairs are recommended for individuals with severely impaired balance to shower more safely or for individuals needing limited transfers. A general rule after myocutaneous flap repair is to avoid cutout seats for 6 months to 12 months, so roll-in shower chairs are ordered with solid seats, and toilets are initially avoided. Padded tub benches are usually safe for paraplegics who have reasonably easy transfers. James is educated about the benefits of the padded bench for his shoulders as it prevents the low transfers that can strain these joints and will be less of a strain on his new flap repair than sliding into a low tub. Transfer training to a padded, solid seat for showering is completed as appropriate once patients are transferring easily enough to the wheelchair. Padded, elevated toilet seats are ordered for use after the initial recovery period. Mattress choice also is discussed and prescribed as appropriate. While powered specialty mattresses are beneficial, patients who have closed skin at discharge are usually safe on an orthopedic style mattress, especially if they can prone for all or part of the night. If a hospital bed frame is required, a group I foam mattress is recommended at minimum.
Before James goes home, he completes key classes designed to re-educate about skin and wound basics as well as problem solving. To avoid future skin injury, it is important for patients to know how to advocate for themselves to get the recommended equipment (now and in the future when it wears out), make smart decisions, and follow the “do’s and don’ts” after surgery. For most patients, if they go home and do exactly as they did prior to undergoing this surgery, they will come back sooner or later with the same problem. To prevent this cycle, it is vital to understand what contributed to getting a pressure ulcer in the first place. “You know, I think it just might be time to retire,” James says. Whether he does or not, he hopefully will remember that the condition of his skin has to come first. Right now, he will simply be happy to be home with no dressing changes for the first time in half a year, all within 30 days of his surgery.
Julie Hill, PT, CWS, is a physical therapist and wound specialist at the Shepherd Center, Atlanta. For more information, contact .