Pressure Sores, Part 1: "An Incurable Malady?"

Reprinted from PN June 2002
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Andrew R., 65, sustained a T4-5 spinal-cord injury (SCI) in an automobile accident in 1955. However, his first pressure-sore experience was not until 21 years later, when he developed an abscess on his hip. After surgery for the sore, he spent six weeks in the hospital.

"I went for ten years before the next one," he says. He estimates he's had only four pressure sores since 1955. His most recent one was this past year, when a blister formed on his tailbone.

He's fortunate to have had so few in all these years. Is he just "lucky?"

"I used to exercise regularly," he says. "And I've always used a foam cushion."

Andrew regularly relieves pressure on high-risk areas. "I take a nap daily. This gets me out of the seated position, takes the pressure off, and lets my skin breathe," he explains.

He also watches for problems. "I inspect my skin daily, or my wife does it for me," he says. "If anything doesn't look right, I see my doctor immediately."

At-risk individuals should be careful, Andrew says, and stay away from hard surfaces. However, he says, you can give people advice, but you can't make them follow it.

Pressure sores have plagued mankind since antiquity. In sixteenth-century Europe, the French surgeon Ambrose Par described pressure ulcers as "an incurable malady" that could be helped only with rest, exercise, and a good diet.

At the end of World War II, the first rehab programs specifically for people with SCI were developed. Improved medical care, new technologies, and the development of antibiotics provided innovative interventions for preventing and treating pressure ulcers.

Pressure Sores 101, taken from the University of Alabama-Birmingham's Department of Physical Medicine and Rehabilitation's Spinal Cord Injury InfoSheet #13: "Preventing Pressure Sores" and UAB's "Prevention of Pressure Sores Through Skin Care" CD (part of the SCI Health Education Multimedia Series), provides a crash course in the condition's basics, including risk factors, stages, prevention, and care and treatment. To learn more about these resources, contact Medical RRTC in Secondary Complications in SCI, University of Alabama-Birmingham Department of Physical Medicine and Rehabilitation, Research Services, SRC 506, 619 19th Street South, Birmingham, AL 35249-7330. (205) 934-3283 / 934-4642 (TTD) /

An Orthotic Approach

by Jeffrey J. Beaton, J.D., and Andrew C. Black III

Custom orthotic seating may reduce the risk of decubiti and promote healing of existing ulcers due to sitting conditions—but it also has difficulties and risks.

People with diminished sensation and movement, such as those with spinal-cord injury (SCI), are constantly on guard against decubitus ulcers. As at-risk individuals know, decubiti may lead to serious and costly medical consequences.

Among the primary factors causing ulcers are pressure and friction—natural consequences of sitting. Sophisticated seating techniques to deal with these issues are currently used by at least one facility.

Investigators at Tamarack Habilitation Technologies (Blaine, Minn.) are developing seating standards designed to decrease ulcer-producing factors. Using design features and custom manufacturing techniques called seating orthotics, Tamarack researchers have had excellent results decreasing the incidence of decubitus ulcers. The facility?s orthotists also have been able to help several dozen people sit safely and comfortably, despite their previous inability to do so because of decubiti.

It is fairly common for young adults to be able to sit safely on one of the standard (pneumatic or gel) cushions for 5-10 years after injury. However, without functional paraspinal and abdominal musculature, posture and spine alignment slowly degrade with time. In people without operational musculature, the pelvis tends to tilt and the spine curves, sometimes to the point of severe scoliosis.

Other physiologic symptoms, such as skin elasticity and circulation, progressively worsen with aging. The margin of safe sitting function becomes narrower each year, increasing the likelihood of something triggering a skin breakdown. Scarring, adhesions, and tissue loss in the wake of a decubitus ulcer significantly increase future risk. Intervention must occur as early and as actively as possible to prevent spiraling costs and suffering.

Although many contributing factors exist in addition to those listed above, decubiti are usually preventable with proper care and equipment that addresses these ulcer-generating factors. Sitting-surface materials that have some absorbency and promote air circulation will not only help reduce moisture at the skin surface but also reduce temperature by allowing that moisture to evaporate. Tamarack researchers and engineers have found that a custom orthotic-seat design may be the most reliable means to reduce the risk of decubitus ulcers.

This articles describes Tamarack's methods for achieving optimal seating for each individual they serve. The authors caution that anyone contemplating traveling far to obtain services from Tamarack must keep the difficulties and risks in mind. You must be willing and able to return to the facility to solve problems that may not show up until after you return home. Maintenance visits (at least every two years) should also be anticipated.

Tamarack tries to schedule a block of time ranging from five days in a row up to three to four weeks to have time for trial and follow-up modifications. For nonlocal clients, orthotists must duplicate the most critical system components and spend more time to "prove out" the orthosis before individuals return home. Therefore, the price of Tamarack orthotic services may be inflated, especially for long-distance travelers.

Custom orthotic seating reportedly effectively reduces the risk of decubiti formation and can promote healing of existing ulcers due to sitting conditions. Helping people heal or avoid decubitus ulcers over the long term, however, requires more than effective technology. It also calls for a program of education, monitoring, follow-up, and advocacy.

Jeffrey J. Beaton received his B.A. and J.D. from the University of Virginia. He was spinal-cord injured at C4 in 1977. A former board chairman of Virginia's Department of Rehabilitative Services and numerous disability advocacy groups, he currently practices law and mediation in Virginia Beach, Va. Andrew C. Black III, a native of Chesapeake, Va., is studying exercise physiology and kinesiology at Old Dominion University. He plans to pursue his master's degree in physical therapy. He works part-time with Beaton and is also associated with the Physical Therapy Department of Riverside Hospital, Newport News, Va.


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Pressure Sores, Part 1: "An Incurable Malady?"


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