Does washing a Vicair cushion affect the pressure redistribution characteristics of the cushion?

Proper cleaning of wheelchair cushions is not only important for maintaining the equipment’s performance and durability but also for promoting user health, comfort, and overall well-being. It plays a critical role in infection control, hygiene, and creating a safe and clean environment for wheelchair users 1.

Unlike many wheelchair cushions that can only be cleaned with a damp cloth, Vicair O2 cushions don’t need any setup or adjustments before and after washing, the cushion can be put in the washing machine entirely, making a convenient feature. Agidens conducted a study to evaluate the impact of washing on the bacterial load of Vicair O2 cushions 2. The study involved washing the cushions in a common household washing machine at 60°C using a standard detergent (Areal), which resulted in a remarkable 99.99% reduction in bacterial load across all areas of the cushion.

In addition to the study of Agidens and since the importance of cleaning wheelchair cushions, we did an inhouse study according to the ISO standard

16840-2, to investigate the influence of washing on Vicair O2 cushions. The effect of washing on the pressure redistribution of the SmartCellsTM is assessed during pressure mapping, the contact area and immersion are the characteristics of interest.

For the study, two Vicair Adjuster O2 cushions, with dimensions 40x45cm, were utilized. The two cushions had SmartCells from the same batch and were uniformly filled to the standard filling grade. The cushions were classified as follows:

  1. Cushion 1: ‘New cushion’, served as a control and was neither washed nor used.
  2. Cushion 2: ‘Washed & used cushion’, washed 24 times and subjected to simulated use between washes.



To simulate real-world conditions, a specialized setup involving SmartCell abrasion was employed. The abrasion procedure entails subjecting the SmartCells to grinding between two pressure-applied plates, which are encased in rubber material. This setup mimics the typical wear and tear that occurs with regular use of a wheelchair cushion.

The cushions underwent a total of 24 wash cycles and were evaluated after the 2nd, 8th, 16th and 24th cycle. To ensure uniformity, both cushions were preloaded 20 times prior to the washing process to facilitate a consistent SmartCell smoothing effect and reaction pattern.

In typical daily usage, cushions are used after washing, leading to SmartCell smoothing. This observation was confirmed by Cushion 2, the washed & used cushion, which exhibited no significant deviations from the new cushion. Contact area variations were limited to a maximum of 3% reduction in contact area for the washed & used cushion in comparison to the new cushion. Immersion levels fluctuated, ranging from a 1.8% increase for the new cushion to a 2.4% increase for the washed & used cushion.

The first time a Vicair cushion is used after washing it can be slightly less flexible (just like your freshly washed jeans), leading to a slightly decrease in contact area and immersion. But this effect is cancelled out by shortly using the cushion, using the washed cushion makes it perform comparable to a new cushion.


It is noteworthy to mention t hat the washing machine should be loaded to only half its capacity with Vicair cushions, as displayed by the symbol on the label, in order to prevent contact between the cushion and the washing machine door, as this interaction could potentially lead to liner damage.

In summary, our findings indicate that the process of washing a Vicair cushion and subsequent usage thereof does not exert adverse impacts on the pressure redistribution characteristics of the cushion. The cushion can be subjected to washing with confidence, a procedure that effectively eliminates 99.99% of bacterial presence.


  1. Conijn, N., Helming, T., Van Der Heyden, B., & Kramer, C. (2023). The importance of cleaning your wheelchair cushion 04.3REV8.23.
  2. Op De Beeck, J. (2023). Test Report Disinfection Wheelchair Cushion.


Is there a risk of bottoming out when using a Vicair cushion incorrectly?

1 Introduction

Vicair cushions provide optimal skin protection when used correctly. But we must also keep in mind that sometimes a cushion is inadvertently placed incorrectly in a wheelchair. The cushion can end up backwards or rotated in the wrong direction in the wheelchair. It is also conceivable that a cushion could end up upside down in the cover, for example after cleaning, and therefore end up unseen upside down in a wheelchair. Incorrect placement can also be due to the fact that a wheelchair is often measured with two fingers (4cm) of space between the user’s calves and the front of the cushion. Thus, the cushion may be placed so far forward that it touches the user’s calves. For wheelchairs with an open back support, the cushion may also be placed too far to the back of the wheelchair.

Therefore the aim of this research was to find out what the risks are for the user when a cushion is used incorrectly. It is important to research whether there is bottoming out and how well the risk zones are protected against high-pressure forces. Bottoming out is defined as the state of support surface deformation beyond critical immersion whereby effective pressure redistribution is lost (EPUAP/ NPIAP guideline).


  1. Method

To answer the research question 6 different cushions are tested with the ISO indenter and skinny indenter. The following cushions were tested for this study: Vicair Adjuster O2 10cm, Vicair Vector O2 10cm, Vicair Active O2 9cm, Vicair 4 8cm, Jay J3 and ROHO Quadtro Select High Profile. These cushions were 40x45cm or the size closest to that. The Vicair cushions and Jay J3 are tested out of the box, the ROHO is adjusted to the corresponding testing weight. After loading 65kg with the ISO indenter, for 5 minutes, pressure distribution and immersion was measured in the positions:



  • Correct;
  • Rotated 90 degrees clockwise;
  • Backwards;
  • 4cm forward;
  • 4cm backwards;
  • Cushion upside down in cover;
  • Cushion & cover upside down is only tested for Vicair Active O2 and Vicair 4.



The immersion was also measured in all positions with the skinny indenter with a load of 130 kg to simulate a worst case scenario.

The pressures were measured (Xsensor pressure sensor mat) at five locations. These places correspond to the position of the tuberosities ischii left (LIT) and right (RIT), the trochanter major of the femur left (LGT) and right (RGT) and the coccyx bone.




3.1 Results

For the overview of all the results see table 1 and 2, this section discusses the most striking and important results.

3.1.1 Immersion at 65kg (ISO indenter)

The immersion generally decreases somewhat in improperly placed cushions compared to the correct position. This can be explained by the fact that the indenter does not enter the cushion at the correct position. The exception to this, is the test in which the cushion was placed 4cm too far back. With the Vicair Adjuster O2 and Vector O2, there was 1 to 2 mm more immersion but no bottoming out with at least 41mm of space below the lowest point of the indenter (table 1).

3.1.2 Immersion at 130kg (skinny indenter)

To simulate the worst case scenario the skinny indenter is loaded with 130kg, at this high load the limit of 25mm (stated by the Vicair Manual) below the lowest point of the indenter is exceeded in all Vicair cushions, except the Vector. To assure safe use of the cushion the Vicair manual states that the lowest bony prominence should be supported by at least 2,5cm/1” of SmartCells. This prevents the risk that the bony prominence touches the wheelchair seat.

Although the Adjuster and Vector have less than 25mm left (table 2) the pressure does not increase significantly, indicating that the definition of the EPUAP/NPIAP for bottoming out is not yet fulfilled. The Vicair 4 has the lowest immersion space left, 11mm (table 2), this is about the height of 1 SmartCell, increasing the risk of bottoming out. But according to the user manual of the Vicair 4, bottoming out is: “touching the bottom of the cushion with a bony prominence”, this is not the case yet, since there is still a SmartCell below the bony prominence.

3.2 Dispersion index and coefficient of variation

The dispersion index and coefficient of variation give an impression of the pressure distribution on the cushion. The dispersion index looks at the ratio between the high-risk zones that have been chosen and the pressure on the rest of the surface. The coefficient of variation looks at the distribution of pressure across the entire surface.

In almost all measurements, these values worsened when the cushion was not positioned correctly. When this was not the case, for example, when the cushion was placed too far back, this was offset by a decrease in contact area and an increase in average pressure. So it is important to assess all values in the whole context.

  1. Conclusion

With loads appropriate to the size of the cushion, there is no chance of bottoming out with improper placement of the cushion. With extreme loads, it is more important that the cushion is placed correctly in the wheelchair.

Forward and backward placement has a strikingly large influence on immersion and pressure distribution. It is therefore important that users and therapists are aware that the cushion is placed correctly in the wheelchair. With a correctly fitted wheelchair and an appropriate cushion, there is the possibility that the user will place the cushion too far forward in the wheelchair, thus resulting in inferior pressure distribution and immersion, but without creating any risk for the user.

If the cushion ends up upside down in the cover, this has a major impact on the performance of the cushion. The contact area decreases and the average pressure increases. It is therefore important that the risk of this is properly addressed with communication in the manual, quick installation guide and on the cushion itself. However, the risk of bottoming out is really small, and with that the risk of any damage to the user as a result of the misuse of the cushion.

How effective is washing your Vicair wheelchair cushion?


vicair washable cushions

Washing Vicair products at 60°C with a mild detergent reduces the bacterial load by 99.99%, as demonstrated in recent tests conducted by Agidens, and an independent test centre in Belgium specializing in process and cleaning validation (Agidens test report disinfection wheelchair cushions – 2023, written by (Op De Beeck, 2023))1.

Three Vicair cushions, namely the Vicair Adjuster O2, Vector O2, and Vicair 4, were tested by Agidens for bacterial load reduction after washing. To demonstrate disinfection capabilities using a washing program on a common household washing machine together with laundry detergent (Areal Colour).

The Vicair 4 cushion was included due to its “hidden” zippers, which may be more prone to contamination. As opposed to the two other cushions, the top and bottom sides of the Vicair 4 are both made of the same polyester fabric with a polyurethane coating, and there are no Velcro strips on the bottom side.

Eleven different test locations on the cushion, including difficult-to-reach areas, were identified as worst-case scenarios. After washing the cushions for one hour at 60°C, there was on average a remarkable 99.99% reduction in bacterial load across all test locations.

While the zipper and Velcro of the Adjuster O2 and Vector O2 cushions posed slightly more challenge for disinfection, they still achieved at least a 99.99% reduction in bacterial load. Except for the zipper of the Adjuster during run 3, with a bacterial load reduction of 99.988%, this was the location with the lowest reduction. At 2/3th of the locations (Liner [top, bottom, grooves, outside, and inside], SmartCells, and compartment walls), the bacterial count after washing was less than <10 CFU/ml (colony-forming units per ml), indicating no countable residual bacterial load.

Notably, the test showed no significant difference in disinfection efficacy between professional detergent and common household detergent.

The effectiveness of cleaning products is expressed in a log reduction. This means that the difference in the amount of bacteria load before and after cleaning or disinfection is considered. Log 1 indicates that 90% of the bacteria have been killed, log 2 represents 99%, log 3 is 99.9%, log 4 is 99.99%, and so on.

The log reduction achieved during all three runs was similar across all test locations. On average, the disinfection phase lasted 10 minutes, with temperatures ranging between 57°C and 61°C. A log reduction of 4 (equivalent to a 99.99% reduction in microbes) is generally considered sufficient for Class 1 medical devices. Except for the zipper of the Adjuster O2 cushion during run 3, the desired reduction was achieved at every test location of all cushions during the three runs.

The literature review “the importance of cleaning your wheelchair cushion” showed that a log 3 or 4 reduction is generally considered as being sufficient for Class 1 (low risk) medical devices.2 This indicates that a common household washing machine, in combination with laundry detergent, effectively cleans even the most challenging-to-disinfect areas of the cushions, making it suitable for this type of medical device. The open design of the cushion facilitates the easy penetration of water and detergent into the compartments and SmartCells 1, which is why the cushions can be cleaned effectively.


  1. Conijn, N., Helming, T., Van Der Heyden, B., & Kramer, C. (2023). The importance of cleaning your wheelchair cushion 04.3REV8.23. 2. Op De Beeck, J. (2023). Test Report Disinfection Wheelchair Cushion.

The effects of misuse of your wheelchair cushion


It is estimated that 10% of the population are people with disabilities. About 10% of the people with a disability require a wheelchair.

A wheelchair is appropriate when it meets the individual’s needs and environmental conditions; provides a proper fit and postural support based on sound biomechanical



One element of postural support is the wheelchair cushion. Wheelchair seat cushions are designed to provide comfort and aid against pressure injury development. To aid against pressure injuries, cushions are designed to reduce extrinsic risk factors known to increase the risk of pressure injuries, such as pressure and shear.


Manufacturers of wheelchair cushions should specify the an exact description of the intended purpose in the device’s instructions for use and should specify contraindications, warnings, and precautions.


Four commonly used wheelchair cushions are foam, foam/gel, interconnected air cell, and compartmented air cell cushions. Their instructions for use differ based on intended use/indications, expected lifetime, and precautions.

However, despite the clear instructions in the instructions for use of wheelchair cushions, there is still a risk that a wheelchair cushion can be misused with all the detrimental consequences that can result from misuse, primarily pressure injuries (PI’s), skeletal deformation, and loss of function.


 Risks of misuse of a wheelchair cushion

Healthcare professionals, clinical educators, carers, but also patients must be aware of how to apply a medical device in accordance with the instructions for use and the potential risk of developing a Device Related Pressure

Injury (DRPI) if medical devices are not applied correctly. This is particularly important in the community setting. Devices should be carefully selected to ensure a good fit with the user’s anatomy and contours. It should also

be possible to be able to adjust them in response to changes in tissue characteristics, volume, and contours.


Misuse of a wheelchair cushion could also lead to accelerated aging or failure of the cushion.


 Factors influencing misuse of a wheelchair cushion – disregarding the instructions for use

Wheelchair cushion manufacturers disclose in their instructions for use the maintenance of the cushion and when there is potential cushion failure. When an individual does not adhere to the instructions in the instructions

for use, this is considered to be misuse. Furthermore, these instructions for use instruct when and how to check for bottoming out, if an individual continues to use the cushion when bottoming out has occurred, this is also

considered as misuse and discouraged by wheelchair cushion manufacturers.


 Continuing use while cushion shows fatigue

After 6 month of use, 70% of foam wheelchair cushions show signs of fatigue. When a foam cushion ages, interface pressure magnitudes tend to rise over time.

If a cushion is used after the cushion has started to show material fatigue, the user is at a higher risk of developing pressure injuries since the cushion age has an inverse

relationship with cushion performance.

One study found a PI incidence of 26.4% in wheelchair users with chronic Spinal Cord Injury (SCI) and reasoned that this might be due to prolonged use of a foam cushion.

Foam cushions are not durable and deteriorate over time, even without use, and therefore should be changed more frequently (e.g. every six months instead of yearly).

The study by Kovindha et al. is not the only study that found prolonged use of a foam cushion. A study by Sumiya et al. found that foam cushions can be used upwards of 4 years before being replaced. This means

that cushions that are profoundly deteriorated, are still being used, which could lead to unacceptably high interface pressures.


 Over- or underinflation of air-filled cushions

Air-filled cushions, specifically rubber designed cushions with multiple air bladders, are at risk of over- or underinflation. When a wheelchair cushion is over-inflated, there is less immersion and envelopment, which

can lead to stability issues, higher interface pressures, and an increased risk of pressure injuries. When a wheelchair cushion is underinflated, this can lead to bottoming out, which also puts the user at a higher risk

of developing pressure injuries because tissue is not suspended in the material and hits the bottom of the wheelchair. Furthermore, the bladders of these cushions can be punctured or burned, rendering them useless.11 12



Unfortunately, there was very little literature on misuse. Therefore, we had to rely heavily on other search engines such as google scholar, but also on experts in

the fields. Despite all our efforts, we could include only seven studies in this review.

When we asked experts in the field for possible relevant literature, we were able to include fourteen articles to assess for eligibility based on the text.


Assess the incidence of misuse of a wheelchair cushion 

Only one of the seven studies (Key et al.6) reported the incidence of misuse during a visit at the seating clinic. Of the 166 patients included and followed-up by Key et al., 4

patients were reported to misuse their cushion.

However, these incidents of misuse were only caught during a visit at the seating clinic. Therefore, incidents of misuse outside of the seating clinic were not caught, which could mean that the true incidence of misuse is

higher than Key et al. reported.

Anecdotal evidence corroborates this suggestion.


Several experts in the field reported about wheelchair users they met whose cushions were placed in the wrong orientation or even upside down and came to them complaining about discomfort. Therefore, the true

incidence of misuse remains unknown.


 Assess the risk of misuse of a wheelchair cushion

We found one extensive review on device related pressure injuries (DRPI) which, although it was not specifically on wheelchair cushions, provided extensive evidence on increased risk of development of pressure injuries

when a device provides pressure and/or shear at the skin-device surface.7 We feel comfortable extrapolating these results to misused wheelchair cushions, since an offloading cushion that is sat upon whilst in the wrong

orientation, can possibly increase shear and compressive forces, leading to an increased risk of pressure injuries.

However, it can also lead to minor complications such as discomfort and backpain or neck pain resulting from poor posture.


Assess factors influencing misuse of a wheelchair cushion

This was the only aim that was somewhat satisfactorily met since we found the most literature on factors influencing misuse. Although the factors identified by these studies are very important and should be taken seriously, due to the low amount of data, this is probably not the complete picture. Experts in the field might be able to add factors to the list that are not identified in this review, but are encountered in their work.

All factors influencing misuse boil down to the same thing, not following the instructions for use as specified by the manufacturer



Therefore, this implies that a lot of incidents of misuse can be prevented by a sufficient understanding and following the instructions for use, especially the ‘use’ and ‘caution’sections of instructions for use, and in the case of foam cushions also the ‘expected lifetime’ section. However, there could be several reasons why an individual does not adhere to the instructions for use. Firstly, the instructions for use could have not been provided with the cushion. Secondly, the wheelchair user is unable to understand the instructions for use due to language barriers, intellectual disabilities, or learning disabilities. These reasons are very serious, and action should be undertaken to decrease the risk of misuse. Possible solutions could be graphic presentation of the steps one needs to undertake to correctly use the cushion, short video’s explaining how to use the cushion, or 1-on-1 instruction of the wheelchair user and/or caregiver.


Future directions

There is very little literature regarding misuse of a wheelchair cushion. Since proper use is needed to achieve pressure and shear reducing properties, more scrutiny is needed regarding misuse.




Misuse or improper use of a wheelchair cushion can be a cause of the development of pressure injuries. Especially when the wheelchair user has both physical and intellectual disabilities. All Vicair cushions are provided with a Quick Installation Guide which depicts the installation steps, skin checks with pictures and a QR code linking to the user manual.

The Vicair 4 wheelchair cushion consists of four compartments of equal size. This cushion can be placed in the wheelchair in any orientation, even upside down, without affecting the pressure redistributing, positioning,

and microclimate control properties. Therefore, a Vicair 4 should be considered when there is a risk that the user will misuse their wheelchair cushion.


Larissa de Groot | 04-2021 | 02.12REV4.21


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


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.


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


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

By: Carlos Kramer, Head of Education Vicair


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 dependent 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 ITs. 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 confirm 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.

On 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 at 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 solutions: the Vector O2 and Adjuster O2.

The Adjuster O2 turned out to be the most optimal solution, 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%.


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 which 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 foot 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


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


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


At the age of 12, a series of medical procedures started for Mr C as he was diagnosed with epiphysiodesis. 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 a 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, and features foam knee blocks and 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. He 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 at a permanent angle to better fit his fixed hip rotation, there would naturally be a tendency to slide – as 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-chart 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 the 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 ITs on a flat seating surface. A flat foam piece under his ITs 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 on the Vector’s cover.

The foam wedge created the flat seating surface under his ITs 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.


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.

Mr C describes his new Vicair knee pads as being ‘perfect’, he experiences less pressure or better-distributed pressure and clearly observes less redness in 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.

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