Measuring Pressure interface and shear on cushions fitted correctly versus upside down

Background

At a recent seating seminar therapists were asked if they had experienced a client sitting on their wheelchair cushion placed upside down? The answer was “Yes” 80% had experienced this more than once. Asked if, in their opinion, would this place their client at further risk the majority answered “Yes”!

The Problem

If the cushion is placed incorrectly in chair, how can we minimise risk for pressure & shear?
The following 3 cushion types had their data measured:

1. Vicair Aircell cushions
2. Flotation cushion
3. Gel cushion

The tools used were a pressure-map and an iShear. iShear is the world’s first tool to measure total shear force in the seat of a wheelchair. It is placed under the cushion and communicates the results to an app through a bluetooth connection.
The total shear force (TSF) in the seat plane measured by the iShear is the anterior-posterior force parallel to the seat plane. It’s measured between the cushion and the seat base interface.

Conclusion

The Vicair Aircell technology cushions performed significantly better than flotation and gel cushions for pressure and shear when used upside down. Further evaluation and clinical research is suggested.

The Research

We rely on the following statistics presented on the right of the pressure mapping image and interpreted in combination to help objectively contrast pressure care products and personal positioning. Comfort, fit, temperature, moisture, set up and posture are also important considerations.

Shear force

This indicates the total shear force in the seated plane. It is accepted that high shear force overtime is associated with deep tissue injury and tissue torsion. A reduction in this force reduces risk. Shear force or sliding force is often inversely proportional to peak pressure. It tends to increase with time and, when it is high, it can be considered there is some sliding on the seated surface. The rotational component of the Shear mapper can quantify some postural instability by measuring pelvic rotation.

Dispersion index (Regional distribution)

Under 50% is linked in literature to lower risk of pressure injury development. This is a measure of tissue load specifically over the vulnerable IT area.

Coefficient of variance or CoV

The measure of rate of change in a tissue’s weight bearing. If this is over 50% there is some risk for a tissue torsion/stress/strain/shear injury. COV can be misleadingly high if weight bearing is not immersive.

Peak pressure Index

Indicates the area of highest point pressures.

Sensing area

This is the size of the weight bearing area. The larger the area the better for pressure distribution.
Pressure mat is orientated with the front right of the cushion at the bottom right of the screen. Shear map is oriented as the icon indicates. Rotation depicted by arrow and figures indicate magnitude.

Reducing pressure ulcer incidents and saving money in staff maintenance time, by using Vicair cushions

By: Darrin Brooks, MS, PTA Director of Rehabilitation Solaris Senior Living, Naples, Florida

The Issue – Pressure Ulcers due to inappropriate seating

In a rehabilitative environment, improper sitting is the source of a slew of issues that lead to a bad quality of life, as well as medical complications and miseries for the client. Pressure injuries were reported at 9% of the residents at our institution. Furthermore, employees spend time everyday maintaining and monitoring equipment, resulting in a considerable amount of time spent on maintenance on a weekly basis, taking time away from patient care.

The Solution – Introducing Vicair Products

We presented Vicair products to multiple residents as the standard offering in an effort to save money on staff maintenance time, minimise the occurrence of pressure ulcers, and ultimately strengthen our institution’s reputation as a quality patient care institution. This appeared to be a dicey gamble at first, as I was investing about $300 per client, for a total annual commitment of $30,000. I was certain that the experiment would be successful based on my past experience with Vicair, but I couldn’t be certain until the data came in.

The Result – Quick Recover, prevention & time saving

Vicair wheelchair cushions seem to last a lot longer, which saves me time and money.

“After switching to a Vicair, residents who had developed a pressure spot on their regular cushion quickly healed.”

When I first showed the Vicair cushions to the nursing staff, they were immediately impressed by its comfort, pressure-relieving abilities, and adjustability. Residents who had acquired a pressure injury on their usual cushion swiftly recovered once they were moved to a Vicair, according to the nurse unit manager.

“It was clear right away that the Vicair cushions significantly sped up the healing process.”

We began an informal observational study of pressure sores with and without a Vicair cushion. The Vicair cushions rapidly became noticeable as having a significant impact on healing. We put all patients with pressure areas on a Vicair wheelchair cushion at that point, and we didn’t have to look any further to observe how much more successful the cushions are in the healing process. The number of residents suffering from pressure injuries has dropped from 9 percent to 1 percent. In every case, the patient appreciated the cushion’s comfort, and the therapist appreciated the option to adapt the cushions to the patient’s preferences.

Our financial situation improved once we switched to Vicair cushions. Despite the initial outlay, the nurse hourly rate, prescription costs, and treatment supply costs were decreased as a result of fewer pressure injuries. Now there are fewer injuries to attend to the nursing team can also spend more time on patient resident care.

Every administrator understands how much time, effort, and money a single acquired pressure injury contributes to a patient’s treatment. Not to mention the time and effort it takes to report an acquired pressure injury.

The Conclusion on Vicair wheelchair cushions

I’ve never seen how much difference one type of cushion can make on so many facets of patient and staff wellbeing in my 30+ years of expertise. I can’t say enough good things about Vicair cushions and all of their other items. They are a brand that I am pleased to have as a resource for my patients’ requirements. Beyond merely making a sale, I’ve personally witnessed their dedication to the patient’s well-being. They make my patients happy, and everyone is pleased when the patient is pleased.

“I cannot speak highly enough of Vicair cushions and all of their products.”

– Darrin Brooks, MS, Director of Rehabilitation

VIEW OUR SELECTION OF VICAIR WHEELCHAIR CUSHIONS

Clinical Case: Preventing sliding and creating stability with a Vicair Adjuster O2

By: Carlos Kramer, Head of Education Vicair

Background

Diagnosed with congenital spinal muscular atrophy at only 11 months old, Mrs. C – now 60 years old -has lived with this challenging disability for quite some time now. Throughout all her life her dependability on others has been what bothers her the most. As a teenager she couldn’t just go out for a night with friends, she was depending on her parents for all her movements. Other than that she however never got any ‘special’ treatment growing up, she went to a normal school and participated to the best of her abilities.
Mrs C. was able to walk until she was about 30 years old, after which she started using a manual wheelchair. After five years she switched to a power wheelchair, overtime transfers became more difficult as her limb and trunk muscles started to fail. She is now dependant on lifts for all her transfers. The arrival of an adjustable power wheelchair, an ETAC Balder in combination with Focal arm supports changed a lot as she regained her freedom to do things more independently.
In her initial set-up Mrs. C developed a category II pressure sore in the area of her IT’s. This was eventually remedied when she received a ROHO contour select cushion.

The problem

Despite having contributed a great deal to the healing of the pressure sore, Mrs C. is not happy with her ROHO cushion. Her biggest objection is that she feels like she is constantly sliding out of her chair. Her partner and caregiver confirms this as he indicates that he needs to reposition her frequently on a daily basis. Apart from the sliding, she also indicates that on her current cushion she doesn’t feel comfortable going outside independently. Every ledge she has to go up or down she feels her position shift, unable to reposition herself this creates uncertainty and fear. During the positioning Mrs C’s hip limitation also needs to be taken into account, her wheelchair back and seat are positioned in a larger angle than 90 degrees in order to facilitate this.


In order to assess her situation two measurements were conducted: an iShear measurement and a pressure mapping. The pressure map shows the ideal pressure redistribution qualities of the Roho cushion. Through the iShear measurement we can see that Total Shear Forces play a role and that the shear force is almost equally distributed.

Actions taken before Vicair

To prevent the sliding from happening, Mrs C. tried using a positioning belt. To her disappointment this did not help, the sensation of sliding and the actual sliding was not prevented. Besides this the belt needed to be positioned extremely tight also causing discomfort. Before starting the trial with Vicair, Mrs C. had one last meeting with a Roho consultant to optimize her positioning. This expert optimized her position at the event mrs C. attended by making some adjustments, it turned out however that on a daily basis this optimal position could not be maintained. Partially because neither her caregiver nor home care knew how to maintain the set up on a daily basis.

Implementing Vicair into the seating system

When Mrs C. first came into contact with Vicair at the Supportbeurs 2018 (rehabilitation exhibition) in Utrecht two cushions were suggested as possible solution: the Vector O2 and Adjuster O2. The Adjuster O2 turned out to be the most optimal solution, this due to its superior immersion and pressure redistribution qualities. Additionally the Adjuster O2 is extremely good in situations where the lines of the body need to be followed and the pre-ischial bar would minimize any sliding. Hence the clinical trial was started with the Vicair Adjuster O2, 10cm high. The initial set up of the cushion was not ideal so during the trial the cushion was adjusted into the optimal position. The figure below shows the adjustments that were made to the filling grade of the Adjuster so that Mrs C. was deemed to be positioned correctly.

Again a pressure mapping measurement was conducted and an iShear measurement. When we compare the pressure map to the earlier situation, we can see that the pressure redistribution qualities of both cushions can be considered equally good. It’s noteworthy however that we almost see no trace of the legs on the pressure mapping of the Roho cushion. The Vicair Adjuster O2 pressure map shows in light grey a contour of the legs, indicating more support of the legs. The iShear measurement also favours the Vicair Adjuster O2 as it reduces total shear by 20%.

Conclusion

After a trial of several weeks, the results are very positive: Mrs C. is delighted with her Adjuster O2. She no longer experiences the sensation of sliding forward and indicates a great amount of stability. The first is confirmed by her partner as he no longer needs to reposition her, the correct position she’s being put into in the morning lasts all day. Mrs. C shows us that the gained stability on her new cushion allows her to have more function in her upper body: she demonstrates a movement of leaning forward that she was beforehand unable to do independently. There has been no record of pressure sores, demonstrating the AD qualities of the cushion. She also shows us that she has now changed the positioning of her feet, old pictures show her feet completely on the edge or half outside of her feet support. She shares that she took this position to sort of brace herself, trying to work against the sliding. Now her feet are normally positioned on the support. Summing up her story she tells us that she has regained her confidence to move around outside. The increased stability has returned her self-confidence to move onto, off and over ledges without ever fearing the consequences.

Clinical Case: Pressure redistribution and stability through immersion on an Adjuster 12

By: Fiona Smith, Occupational therapist HBDHB & Megan Ransley, Sales Area Manager, Physiotherapist Morton & Perry

Background

This case describes the situation of a 46-year old male: Mr. S. Mr. S suffers from end-stage kidney disease (not palliative) and is on hemodialysis three times a week. He underwent a right below-knee and left below-knee amputation in subsequent years. Furthermore he is diagnosed with peripheral neuropathy, hypertension, type two diabetes that is poorly controlled and diabetic retinopathy. Mr. S. lives alone in his own home. Despite being unable to work, he was mobile, independent and active. His first amputation concerned his right toe as a consequence of gangrene. His right lower leg was later amputated due to an infection and non-healing of the toe wound.
In the subsequent year his left leg was amputated below the knee due to a non-healing and necrotic left heel ulcer. Mr. S. was in considerable pain due to the ulcer. Due to significant small vessel foot disease and no revascularization options he chose to have the second amputation. Mr. S. was fitted with a basic self-propelling manual wheelchair with a basic flat foam cushion following his first amputation. It was hoped that Mr. S. would be fitted with a prosthesis after healing of the stump and that he would return to independent mobility. This goal was however not achieved due to the very slow healing of the wound.

The Problem

Mr. S.’s problem situation consists of a threefold of things:

  • The manual wheelchair he was issued did not meet his physical and functional needs. He was unable to self-propel effectively due to poor configuration of the wheelchair.
  • He demonstrated a poor sitting posture in the wheelchair. He was positioned in a posterior pelvic tilt causing him to slide forward. In further assessment it was established that his posture was fully flexible and that the canvas back support and seat had become slung and were making his posture even worse.
  • The wheelchair cushion did not afford Mr. S. sufficient pressure redistribution as he indicated a sitting tolerance of approximately an hour. After which he would experience pain under both ischial tuberosities (Its) and in his sacral region. Despite being able to weight shift independently he could not sit in his wheelchair comfortably all day and needed to switch to different surfaces to reduce discomfort.

Actions taken before using Vicair

In an attempt to improve his positioning and try to meet his needs, the wheelchair was reconfigured. The rear wheels were brought forward, to improve access to the push rims. The front-and-rear-seat-to-floor-height was adjusted to enable safe transfers. The changes however turned out to be insufficient to assist Mr. S. in his daily functioning and position him comfortably.

Implementing Vicair into the seating solution

A trial was started with the Vicair Active (9cm) and a Vicair Adjuster 12, of which we will discuss the details shortly, however, two other adjustments were made to the seating system that are relevant to the situational assessment:

  • S. was issued a TA-iQ front-wheel drive power wheelchair with tilt and HiLow. This enabled him to access his him and the community independently without experiencing the fatigue that was caused by self-propelling. This new wheelchair configuration would also allow for future-proofing of foot placement prosthetics.
  • A firm contoured back support was fitted to his wheelchair: nxt Active Contour height-adjustable backrest. This back system assisted in facilitating an upright position and prevent slumping.

Pressure mapping comparisons

Pressure mapping was undertaken on all three cushions: a foam cushion, the Vicair Active (9cm) and the Vicair Adjuster 12. Single peak pressures seen over the ITs sitting on the foam
cushion were eliminated as the legs could be used as weight-bearing surfaces.

Foam cushion

Pressure mapping of the foam cushion demonstrated that Mr. S. was weight-bearing significantly through both ITs, but in particular the right with a peak of pressure seen there. It also demonstrated that Mr. S.’s weight was unevenly distributed with almost no weight being taken through the thighs. The picture showed a small surface area of weight-bearing. This cushion allowed only one hour of sitting before pain was experienced in the ITs. It is likely that over time the foam was compressing and the cushion’s pressure redistribution properties were diminishing.

Vicair Active (9cm)

It was thought that the firm front of the Vicair Active 9 would enable safer and easier transfers while affording the pressure redistribution Mr. S. required. As can be seen from the pressure mapping images, significant improvement was made in relation to the pressure redistribution with a much larger surface area taking weight. This cushion was adjusted by removing 5 cells from both the left and right compartment to allow immersion. Mr. S. commented that the cushion felt comfortable and supportive. He sat well with an improved upright posture. He managed to transfer with ease.

Vicair Adjuster 12

Trial of the Vicair Adjuster 12 cushion was carried out as a comparison. Mr. S. immediately commented that this cushion felt even more comfortable. This is likely because of the depth of
the cushion. Mr. S. is a heavy man and could immerse deeply into the Adjuster 12 cushion without the need for cells to be removed. This deep immersion afforded a greater surface area over which his weight was distributed, giving even pressure redistribution and the feeling of greater comfort. The greater immersion available from the Vicair Adjuster 12 cushion also enabled Mr. S. to feel more stable within his wheelchair. The pre-ischial bar provided a barrier to the pelvis sliding forward.

Shear forces

As Mr. S. indicated the sensation of sliding forward in his initial seating system a shear force assessment was made by using iShear. This demonstrated that Mr. S. was experiencing not only downward pressure but also dangerous forward shearing forces (sliding force). Shear forces were reduced from 125.5N on the foam cushion, to 83.2N on the Active 9 cushion, then to 62.2N on the Adjuster 12 cushion. This demonstrates that Mr. S. was able to sit more upright, with less sliding forward. The reduction in shear force is likely contributing to the preference towards the Adjuster 12 cushion the increased comfort and to improved sitting tolerance.

The Conclusion

Mr. S. is now comfortably using his new powered wheelchair with the Vicair Adjuster 12 and nxt backrest. He is able to remain in his wheelchair comfortably for the duration of the day. He can now use his wheelchair without the risk of pressure and shear related injuries. The new configuration allows him to safely and independently access his home and community.
The Adjuster 12 provides Mr. S. with high-pressure distribution properties that are needed to enable him to sit safely and comfortably all day. The pre-ischial bar prevents him from sliding forward, whilst deep immersion provides stability. Furthermore the cushion is low maintenance and easy to understand. The Vicair Adjuster 12 turned out to be the ideal product choice and solution for Mr. S.

Clinical Case: Pain relief through pressure redistribution on a Vicair Adjuster O2

By: Carlos Kramer, Head of Education Vicair

Background

In this case we will discuss the situation of a 53-year old male: Mr. R. He was diagnosed with small fibre neuropathy in 2014 which displays itself in nerve pain from the fingertips to the toes. It also affects the autonomic nervous system, which causes gut, bladder, stomach problems and reduces muscle tone. Mr. R. suffers from chronic pain and fatigue in addition to spasms that show in his fingers and legs, especially when he’s sitting on a couch or laying in bed (resting position). He also catheterizes, but is still able to urinate normally.
A medication cocktail is used to help ease Mr. R’s situation, it consists of anti-depressants, anti-epileptica that need to assist in falling asleep in addition to pain killers. Mr. R. makes use of a manual wheelchair and tries to walk as much as possible. He has no history of skin breakdown. Lastly, Mr. R. has an ankle flexion limitation.

The Problem

In his current seating solution Mr. R. suffers from pain in his buttocks, due to atrophy. He experiences the pain mostly under his sitting bones (IT’s). He experiences neuropathy pain when areas are pressured. A very basic example of this is when drying his legs with a towel after a shower, 30 minutes after the activity he still suffers from pain.

The situation before Vicair

Mr. R. makes use of a Quickie Helium wheelchair that was fitted with a Jay basic cushion. His back is a tension adjustable system. He experienced pain from the seat cushion and felt like a lot of pressure was being caused by the cushion. In order to assess the current situation a pressure measurement was done via pressure mapping (figure 1). The pressure map confirmed the sensation described by Mr. R. as a lot of pressure is shown in the IT area.

Implementing Vicair into the seating solution

In order to redistribute pressure the Vicair Adjuster O2 (6cm) was introduced. This model’s known quality for equal pressure distribution was thought to solve the pressure spikes shown in
the pressure map. Another pressure measurement was conducted when the wheelchair cushion was implemented into the seating system. The measurement (figure 2) shows a significant decrease in spiked pressure points and an overall redistribution of pressure, which would hopefully in time result in less pain.

The Conclusion

After three weeks of testing his new Vicair Adjuster O2 (6cm) cushion in his manual wheelchair, Mr. R. experienced a significant improvement. He no longer had the sensation of sensitively painful sitting bones. Overall the pain that he experiences has been reduced, hence the Adjuster O2 was a welcome change.

Clinical Case: Addressing a positioning challenge and handling shear forces involved

By: Carlos Kramer, Head of Education Vicair

Background

At the age of 12 a series of medical procedures started for Mr. C as he was diagnosed with epiphysiolysis. This meant that due to an accelerated growth process in puberty a deformation of the hip and hip socket was starting to form. As a result there was also hardly any cartilage left in his hip joints. He underwent a series of surgeries from his 12th year onwards in an attempt to slow down the accelerated growth process. This involved placing and removing metal pins in his hips. Now at the age of 25 his opinion is that the surgeries had divergent effects and that he is still looking for a real solution. The deformity in his hips initially caused Mr. C.’s legs to be positioned outwards (V-shape). In his last surgery doctors attempted to reposition his legs more inwards by vertically cutting one of his femurs. According to Mr. C. this had devastating results causing only more discomfort and he therefore refused further surgery on his other leg.
Mr. C. has no history of skin breakdown or pressure ulcers whilst using his custom made manual wheelchair. He also does not make use of any medication. In his leisure time, Mr. C. loves to swim and he cycles with an high-end handbike – he is a young active individual. Due to his fixed hip rotation as a result of his epiphysiolysis, he makes use of his wheelchair in almost all daily activities.

The problem

This case mainly revolves around a positioning and stability challenge. His adjusted manual wheelchair is set up to fit the negative anterior wedge in his hips. This in practice means that the seating surface is set up in a downward angle towards the front of the wheelchair. The wheelchair has almost no back support, has a hip belt positioned around the sias, features foam knee blocksand a 3D space fibre cushion that facilitates breathability and microclimate control.


The current seating system however lacks stability for the ideal position. Mr. C. needs to reposition every 5 to 10 minutes in order to be comfortable. He feels like he is constantly sliding forward despite his belt, resulting in a lot of pressure on his lower legs just below the knees (on the kneepads). This results in redness of the skin in the knee/lower leg area. He is bothered mostly by the lack of stability when he is actively moving around in his wheelchair and often chooses to keep moving in the uncomfortable position and reposition when he reaches his ‘destination’. Repositioning in itself is a tardy process in which he always needs to release the belt, reposition and fasten the belt.

Expressing the problem in numbers

Due to his wheelchair being set in a permanent angle to better fit his fixed hip rotation, there would naturally be a tendency to slide – as in confirmed by Mr. C. in describing his problem. An iShear measurement could therefore provide a lot of insight into the shear forces created by his set up that cause the pressure on his knees. Three different situations were measured with iShear: positioned in the wheelchair without knee blocks or belt; with knee blocks and with knee blocks and belt.
iShear shows an off-the-charts measurement of shear forces when Mr. C. is positioned in his wheelchair without any aids. When the knee blocks are applied an overall reduction of 7kg in shear forces is observed. This means that the kneepads hold a force of 3,5kg per knee.


Even though the knee pads provide a reduction in shear forces, the amount of force that is left over shows that there must be a significant amount of pressure put on the knee pads. This corresponds with the indication Mr. C. gave about redness of skin in this area. Surprisingly the shear force measurements by iShear show mixed results when the hip belt is applied. Depending on how Mr. C. (re)positions himself the belt can have a positive, negative, or no effect at all on the amount of shear force. Seeing that he repositions himself very often, there’s a chance that he repositions himself into an even worse position (more shear force, more pressure on the pads) and locks this with the belt. In such a “wrong” position the belt forces Mr. C. down his seat even more, increasing the sliding effect down the fixed seating surface.

Actions taken before Vicair

Over the years, Mr. C. had several wheelchairs and cushions in an attempt to better suit his needs and make him more comfortable. None of the changes succeeded in offering a solution to his seating challenge. The current set up was the best achievable result so far.

Implementing Vicair into the seating system

It was obvious that the sliding effect (and thus shear forces) were created by the fixed angle of the wheelchair set up, the inability to immersion into the 3D space fibre cushion only further amplified the situation. The texture of the cushion in place even felt like it would stimulate sliding and create friction.
Theoretically speaking this sliding on the fixed, angled seating surface could be decreased or stopped by positioning Mr.C’s IT’s on a flat seating surface. A flat foam piece under his IT’s however feels very hard and uncomfortable. Therefore a different solution was chosen: the combination of a wedge – that would cancel-out the sliding angle – and a Vicair cushion. The image below displays the plan in a simplified way.

Keeping in mind Mr. C’s request for stability, the Vicair Vector O2 (6cm) was chosen as the preferred cushion to fix the problem at hand. It’s the most stable cushion in the Vicair range and is known for ‘forcing’ people into a correct position. The front compartments of the Vector would also support leg alignment. A foam wedge was placed under the two middle compartments in the back of the Vicair Vector O2. It was fixed into the right position by making use of Velcro in the Vector’s cover.
The foam wedge created the flat seating surface under his IT’s where the two SmartCell filled compartments above it would provide the comfort that foam alone couldn’t offer. In addition to changing Mr. C’s wheelchair seat cushion, Vicair knee pads were made to fit his knee blocks. Implementing the SmartCell technology into the knee pads would hopefully redistribute the pressure created by the shear forces on the knee blocks, resulting in less redness and discomfort. Because the Vicair Vector O2 (6cm) was higher than the original 3D space fibre cushion the filling grade was adjusted to facilitate a comfortable position with regards to the distance to the wheels of the chair and manual movement.

Conclusion

During the fitting process of the clinical assessment an immediate change was already noticeable. In testing and adjusting his new cushion, Mr. C. no longer felt the need to fasten his hip belt. On top of that he made several test rounds around the facility in his wheelchair and he did not feel the need to reposition. A definitive conclusion about the solution offered could only really be made after a longer period of testing.

After two weeks of testing his new set up, Mr. C. indicates that he barely uses his positioning belt anymore. This in itself for him is a great achievement as after previous changes he was never able to do this. Mr. C describes his new Vicair knee pads as being ‘perfect’, he experiences less pressure or better distributed pressure and clearly observes less redness of his knees.
Ideally, Mr. C. would like to be positioned a little bit lower for easier reach to the wheels whilst moving around. Despite the reduced amount of cells in the Vector O2, the cushion is still a little bit higher than the old one. Together with Vicair product specialists, Mr. C. is now exploring the options to further optimise his positioning on a Vicair wheelchair cushion. Meanwhile, he is very satisfied with the improvements so far and moves around without any restraints.

Clinical Case: Enhancing positioning and maintaining skin integrity, by using Vicair cushions

By: Erin Davis, Occupational Therapist, Southern Rehab

Background

In this study we will be describing a case of a 31 year old female, Miss Y. Miss Y was diagnosed with an anoxic brain injury post anaesthetic which resulted in spastic quadriplegia and severe cognitive impairment. Additionally there is bilateral acetabular dysplagia with complete dislocation. The anoxic brain injury followed from a cardiorespiratory arrest during an eye surgery that Miss Y underwent at an age of
18 months old. Presently she has a high level of tetraplegia and is non-communitive. She requires a wheelchair (tilt-in-space) for mobility and is dependent on full assistance for mobilising, transfers (predominantly made by ceiling track hoist) and all self-care and daily activities.

Miss Y lives in her own home, just next door to her parents and has two main caretakers who support her in her daily activities. She enjoys getting out in the community in her wheelchair or by driving along in one of the vans of her carers. She enjoys shopping, meeting her mother at work and many other community activities. She loves the spa in her home, enjoys sitting outdoors in the delightful garden and loves being involved in tasks around the home. She enjoys watching television and listening to the recordings of her favourite music and television series.

The Problem

The problem she faced was that Miss Y’s seating no longer met her postural needs and did not support her pelvis, trunk or legs. She was mobilised in planar seating (with no contouring) and the attached flat lateral trunk supports were too small and not positioned correctly. In detail this meant that a number of things needed to be taken into account when addressing her positioning, when lying down the following was noted:

  • Her pelvis has an anterior tilt, obliquity (left 1½” lower) and rotation (right forward). With a T-roll institu the tilt moves to posterior and her obliquity reduces by ¼”
  • Her trunk shows significant scoliosis (convex to the left) which has its apex at the lumbar/thoracic junction. There’s a rotation through the thoracic spine (left forward) and lumbar lordosis.
  • Her left hip is internally rotated and adducted over the midline and her right hip is in external rotation.
  • Her left knee has a flexion contracture of approximately 30 degrees.
  • There is minimal movement through the joints that enables corrections.

When sitting in a supported seating on a plinth miss Y had the same postural anomalies as when lying down, though her obliquity was increased to 2½” discrepancy.
An x-ray revealed further details about Miss Y’s situation and it was noted that her thoracic alignment is normal apart from mild rotational deformity in the lower thoracic. Her lumbar spine has marked rotoscoliotic deformity, convex left with a Cobb angle of approximately 46 degrees. Her pelvis is distorted with mild subluxation pubic symphysis and bilateral acetabular dysplasia. It also showed that there is complete bilateral dislocation of both hips, with superior displacement of the proximal femora. Furthermore her right leg is internally rotated.

Actions taken before using Vicair

Modifications to Miss Y’s existing seating was considered but deemed not an option because more contouring was required than the seating could sustain. After several trials her wheelchair was set up with the following things to attempt to address the problem at hand:

  • A multi-layer contoured foam cushion with additional custom contouring was placed at the pelvis and medial thigh area to support her pelvic obliquity, dislocated hips and her thigh position.
  • A dual foam back support with a contouring cube system on a solid shell was used. The system was custom contoured in the lumbar and thoracic spine area to support her lumbar lordosis and trunk rotation.
  • D-shaped, curved lateral trunk supports (medium on right, large of left) offset were used to support her scoliosis.
  • A contoured headrest.
  • A centre point anterior support harness and a 2 point hip support belt were used.

This seating system needed to be reviewed and adjusted every 6 to 12 months and prior to starting the clinical trial it was found that it wasn’t supporting her accurately. Limited further contouring was achieved but she was starting to get reddening of her skin over her left ischial tuberosity. In exploring more options Miss Y attended the local spasticity clinic and had reviews with Orthopaedic Consultants to determine what medical input could assist the management of her dislocated hips and left knee contracture. Surgery, however, is not an option as the family declined any further general anesthetic due to this being the initial cause of her diagnosis. It was determined that she could perhaps benefit from botox in her left hamstring and alternative seating.

Implementing Vicair into the seating solution

It was determined that Miss Y required a system that she could immerse into to accommodate and support her rather than the system being moulded to her. Vicair cushions have immersive qualities and it was therefore decided to trial a Vicair Vector of 6cm high with an increased amount of Smartcells in the medial thigh support and right rear greater trochanter areas.
It was found that further depth was required, therefore the Vicair Vector of 10cm high was introduced. It was found to be successful at capturing Miss Y’s pelvis and maintaining her skin integrity. Shortly after, the Vicair Vector O2 became available on the market and it was agreed to trial the 10cm high Vicair O2 version as well to see the difference between this and the standard Vicair Vector cushion.
The Vicair Multifunctional back support cushion was also trialled, replacing the foam contouring on the existing back shell. It was set up with an increase in cells in the lower three compartments. It was found that Miss Y now had contact with her entire trunk and therefore gained the support in the lumbar region that she required.

The Conclusion

Instead of sitting on top of her seating and being pushed forward, Miss Y is immersed into it, therefore cradling her dislocated hips and filling all the gaps at her spine to give improved support. There’s no longer a case of reddened areas as aggressively as before on her left ischial tuberosity and when it occurs it is resolved after an evening in bed. With her new seating solution she is also able to mobilise longer in her wheelchair without the same degree of concern for her skin integrity. The Vicair Vector O2 has also been a welcome change for the standard 10 cm high cushion as it offers the ability to be washed off by machine washing. After food or drink was spilled the Vicair Vector O2 cleaned off easier. Additionally the Vector O2 was easier and faster to dry out if they happened to be out in wet weather. There was one concern raised regarding where the liquid would go if spilled on the cushion, but this was rectified by the use of a Kylie pad tucked in the cover under the cushion. Due to the success of the Vicair Vector O2 and Multifunctional back in her wheelchair, Miss Y’s car seat was stripped back and set up with the same products to give the same support when she is using this chair.

Clinical Case: Treatment of a category II pressure ulcer and improved asymmetric positioning through Vicair

Background

Wheelchair users automatically have a high risk of developing skin breakdown. When there are additional positioning aids involved, the risk increases. This clinical case describes the treatment of an 8-month-old category II pressure ulcer and solving asymmetry for Mr. de L (Spina Bifida patient). Mr. de L is a 73-year-old male who generally uses an office chair at home. Outside he uses a manual wheelchair: an active Quicky
Argon without arm support that is fitted with a Jay Easy Visco cushion. Mr. de L mainly walks therapeutically and to make transfers, using elbow crutches.

The Problem

Mr. de L. has a sensation disturbance in the buttocks and lower extremities. At the start of the treatment in the Seating Clinic the client suffered from a superficial pressure ulcer, category 2, with wound edge maceration. In general the pressure ulcer does not cause pain. The ulcer does not show signs of shear force or friction. Additionally Mr. de L. experiences pain in the left side of his body at the height of thoracic spinal cord segments 6-8 and in the left side of his torso. Treatment with pain medication has not been sufficient. The pain in his torso occurs after sitting for half an hour: the VAS score varies strongly. Once a week he goes to bed when the pain becomes unbearable and he wants to change his position. Further assessment shows that Mr. de L’s left leg has a different bony structure and size than his right leg. He uses a corrective left shoe because of the shorter left leg. This left leg also has reduced muscle mass. While seated and laying down the abdominal mass is positioned to the left side. He also uses a urine stoma. Once in a while, he is facing incontinent. This did not affect
the pressure ulcer.

Implementing Vicair into the seating solution

In an attempt to solve the problem at hand it was chosen to conduct pressure mapping of the current situation and of all cushions tested in the process.

All pressure maps show pressure on the ischial tuberosities (IT). When using the Jay Easy Visco cushion there is very significant pressure on the left buttock and the centre of gravity of the body
shifts to the left. It was found that when using a Vicair cushion that can be set up asymmetrically the pressure is redistributed more equally across the entire surface of the buttocks. The asymmetric setup is accomplished by relatively increasing the height of the cushion’s left side because there is less buttock/leg mass on this side.
After the pressure mapping, we chose to try out a cushion that can be adjusted to an asymmetric setup: a Vicair Positioner. By setting up this cushion asymmetrically (more volume on the left side, less volume on the right) the smaller leg/buttock mass is supported and the client experiences improved pelvic stability while seated. This cushion was tried for two weeks. At that point, the pressure ulcer had healed, but the client showed more tendency to slide. In order to provide more stability and prevention of sliding, we decided to try out a Vicair Active for the next two weeks. The cushion was set up in the following way in order to cater to Mr. de L. asymmetric needs: 7 SmartCells were removed from the cushion’s right rear compartment, 3 SmartCells were added to the left rear compartment and the centre compartment kept its standard filling. A solid seat was installed on top of the wheelchair’s sling seat to prevent it from hammocking. Due to the asymmetric setup, future risk of a pressure ulcer was reduced as the pressure was more equally redistributed on the adjusted Vicair Active.

The Conclusion

Mr. de L’s pressure ulcer was healed due to the switch to the Vicair Positioner. Afterwards, his desired seating positioning and stability were achieved by using the Vicair Active with an asymmetrical setup. He now experiences a high level of seating comfort. Mr de L. has started to stand up and sit down more often. He tries to walk two times a day in a functional manner, for instance in combination with a toilet visit or for transfers. He is more aware of the positive effect of alternating his position. In sum, the Vicair Active was able to provide skin protection and it met Mr. de L’s positioning needs for a cushion that provides stability and can be set up asymmetrically. It was however noted that ideally, Mr. de L needed extra back support (lower lumbar and lateral support) and that it was important to improve overall lateral support.

Clinical Case: Accommodating differences in mass with a Vicair Vector O2

By: Carlos Kramer, Head of Education Vicair, The Netherlands

Background

In 1943 Mr. R’s parents noticed something was amiss with their young son, at barely 3 years old his right leg started bothering him and after a doctor’s visit they were told their son probably had flatfeet or suffered from short term paralysis in his right leg. As time passed, the problems however only got worse to the point of being unable to walk. His parents pressed for a second opinion from the Sint Maartenskliniek in Nijmegen, the Netherlands, and quickly a relatively rare diagnosis was established: polio. His right leg had been affected and as a consequence had lagged in growth and muscle strength.
Now aged 78, Mr. R has a rich medical history with a number of key points that played a primary part in the condition of his health and mobility. Throughout most of his life he made due with orthopedic shoes to assist him in walking. In ’99 he broke his right hip after stepping off a ledge, losing his balance and as a consequence falling. It’s very likely that the imbalance and fall were caused by the limitation in his right leg. The head of his hip was broken and via surgery reattached with a metal pin.

After a long rehabilitation process at several institutions Mr. R. ended up seeing one of the country’s experts in post-polio at the Amsterdam Medical Centre (AMC) and was assigned an AFO (Ankle Foot Orthesis). After several measurements and try-outs, he became more mobile again. At the request of the AMC, he participated in a study researching the effects of an AFO for post-polio patients.
In Mr. R’s individual case a significant increase in the development of muscles was observed. For the study, he went through a general health check which he passed with flying colours apart from a minor deviation in his bladder which could be fixed. As doctors examined further, they found something else and in 2011 Mr. R. was diagnosed with prostate cancer. Signalling the beginning of a further deterioration of his health and quality of life. Even though Mr. R has now officially been declared cured of cancer, it greatly affected his physical wellbeing. Radiotherapy affected his intestines and as a result he is now dependant on catheterisation and flushing his intestines. Due to the illness he also lost a significant amount of muscle strength and is now for two years dependent on his wheelchair for most of his daily activities.

The problem

This case focuses on the importance of proper positioning and creating stability when there needs to be dealt with a difference in body mass in the seating surface, even pressure distribution is also of importance to safeguard skin integrity in an asymmetric position. Polio affected Mr. R’s right leg which can both be observed in the difference in length and muscle mass. There’s a 4cm difference in circumference between the right and the left leg just above the knee. Due to this difference in muscle mass, Mr. R is always positioned slightly crooked. In his current set up he also feels that he slides forward in his chair, indicating unstable positioning.
In addition he indicates being uncomfortable and not being able to sit in his chair all day and feels fatigued. The crooked position is confirmed when we conduct a pressure mapping measurement. As can be seen in figure 4 there’s a clear difference in pressure between the two sides. More pressure on his left leg could possibly also be the cause of the discomfort that he describes.

Existing set-up before Vicair seating system.

Mr. R. showed us two cushions, one that was a standard cushion delivered with the wheelchair that has never really been used. This to the fact that this was never prescribed as a flat cushion could never support the asymmetry in his body. In response to this demand Mr. R received an Jay Easy Visco to better fit his needs for a contoured cushion. The pressure map displayed in figure 1 shows the situation when Mr. R was seated on the Jay Easy Visco, hence his problem was not solved with this contoured cushion.

Implementing the Vicair seating system

The difference in mass along his right leg creates an asymmetry in his seating position. In a case with asymmetry, you could normally expect to make use of the Vicair Adjuster O2. However, in this case the choice fell upon the Vicair Vector O2 for precision positioning and accommodating the difference in mass along the entire leg rather than just supporting the asymmetry it causes in the hip area.
The extra compartments in the Vector O2 allow for precision positioning along the entire leg. The front compartments in the Vector O2 would also support his legs, improving leg alignment and stability of his legs whilst seated. First Mr. R’s position was assessed in an unadjusted Vicair Vector O2. This in order to make a proper judgement of where adjustments needed to be made. The assessment showed that, as expected, some adjustments needed to be made. The images show the differences in pressure between the Vicair Vector O2 in its standard configuration and the adjusted version.
The pressure maps show that the pressure has been significantly been decreased. The unadjusted Vector O2 was already an improvement in comparison to the Jay Easy Visco. The adjusted VectorO2, however, shows even more pressure improvement and we can now also see the leg support the cushion provides represented on the pressure map. Cells were added on the right side of the cushion to accommodate for the missing mass and a number of cells were taken out on the left where the normal leg is positioned. Figure 7 shows the adjust filling grade of Mr. R’s Vector O2.

Conclusion

Immediately after the adjustment, we can observe an improvement in Mr. R’s position. It was easily spotted by the line of his shoulders that is now positioned straight. He also immediately indicates that he feels more supported. A longer testing period should point out of the cushion also delivers the desired results for the long term. After about a month of testing Mr. R is still positioned nicely straight in his wheelchair on the adjusted cushion. He, however, indicates that he has a new fitting shoe for his AFO and received new leg supports for his wheelchair. His seating set up has therefore changed a bit but he has easily adjusted the cushion with adding and removing a number of single cells in compartments. This does, however, indicate that a different AFO has an influence on his positioning and therefore new shoes in the future might further affect his position
in the wheelchair. The combination of his new shoes and feet supports created a higher positioning of the thighs and it was therefore decided to create a foam wedge under the front of the cushion to make up for the distance that has been created and re-establish the support on the legs fully. This would be a temporary solution as the arrival of his new AFO might change the situation again.
In addition Mr. R tells us that he no longer experiences the sensation of sliding forward. A very positive change is that he now also prefers to stay in his wheelchair for daily activities. In restaurants, for example, he used to transfer to another chair but now prefers to stay in his wheelchair. It shows a high level of comfort that he now can remain in his chair all day. Last he indicates using his new Vector O2 on holiday this summer during very warm weather and confirms that the cushion’s breathability really supported temperature control – his old cushion was a lot warmer.

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