The Wheelchair cushion is a common fall guy when wheelchair users develop pressure sores. At times they are guilty as hell. At other times they may not be.
An unfortunate fact of life for many wheelchair users is the potential for acquiring pressure sores. These sores are the criminal element of the wheeled world. An encounter with these felons can rob a victim of their health, independence, quality of life, and yes, in extreme cases even their life. In these cases justice is myopic, the victim always does the time.
These robbers work alone or may work in gangs, often striking the same victim several times. They are extremely patient, taking their time and casing out the site. At other times they strike quickly and quietly. They are often repeat offenders who will return to the same crime site to work their mischief over again. The culprits are known, the clinical detectives have identified them, yet the long arm of clinical retribution often reaches out and grabs the wrong suspect.
Through profiling we are able to determine who the potential victims may be. They are identified as “at risk”. It doesn’t matter how they got there, rating scale, history, clinical observations, or just bad luck. The at risk list includes paraplegics, quadriplegics and tetraplegics, most people with a spinal cord injury or disease or a long list of others that include people who have difficulty changing positions while sitting and/or have loss of sensation in certain parts of the body (they are unable to feel pressure building up).
The causes are also known and include: pressure build up on body parts, inappropriate wheelchair or wheelchair cushion technology, poor nutrition, incontinence, lifestyle issues, stress, poor hygiene, poor care, aging, and a roster of physiological bad guys that would easily confound Sherlock Holmes. Yet, when the suspects are tossed into a lineup, the wheelchair cushion is always the first to be fingered.
In defense of the cushion, there are other possible contributing factors that need to be looked at. Pressure sores on or near the seating contact area (your butt, back and thighs) do not necessarily begin or end with the cushion. The cushion may be a convenient fall guy who is taking a guilt by association rap. While the wheelchair cushion should always be suspect, it should not be so at the risk of letting the other suspects go free. There is some detective work that needs to be done here. It should start with checking out the cushion’s alibis.
Was the cushion in the vicinity of the crime? A good upright sitter, with a sacral sore (lower back), who does not go into a sacral sitting position (slouching) probably did not get the sore from the cushion. The cushion was probably nowhere near the area while the individual was seated in the chair. Look to one of the other suspects such as a bed surface, recliner chair, gurney, stretcher, turning frequency, shower/commode equipment with seat cutouts, lift slings and lumbar pads for some clues. How often does the victim use these devices and for what period of time? Is the equipment being used properly and is it in good shape?
When it comes to ischial sores count on a rigged jury (pointy bone on bottom of each buttock). The cushion will most certainly be found guilty. But is it? The ischials of most wheelchair users are regularly in contact with more than just a wheelchair cushion. Some prior offenders that need to be investigated are car seats, airplane seats, unpadded shower benches and chairs, transfer boards, and anything that the victim sits in regularly other than the wheelchair and wheelchair cushion. Sitting up in bed with the hips flexed more than 30 degrees will load the ischials. Dragging the ischials across a transfer board, or hard landing transfers, sitting on a transfer sling all day, not doing weight lifts or shifts (changing position), over extending sitting times, should qualify as accessories to the crime.
Be thorough in your investigation. Make sure that the cushion was not framed or set up. Check the cushion, make sure it is in good condition and adjusted and placed properly. Pummels are effective, but not when the cushion is placed on the chair backwards. Cushions with air cells are great pressure reducers, but not when cells are facing down instead of up. Over or under inflation of air flotation cushions can cause problems. Under inflate and the user will bottom out. Over inflate and it is like sitting on bricks. Worn out cushion bases and seat hammock (sagging seat upholstery) can inhibit pressure reducing characteristics of the wheelchair cushion. Make sure that reliefs, buildups and cut outs are the right size and in the right place. Confirm that the user is actually able to place themselves in proper alignment with reliefs and contours.
Inspect the cushion. Some cushions have been known to disguise themselves by wearing their covers backwards. Take a peek under the wrapper and confirm that the cushion and cover are in sync. Frisk the cushion. Some strange accomplices have been known to hide under the cushion or cover. Some disclosures have been; wallets, keys, books, assorted supplies and meds, bunched up pads, fruit, a can of beer, another cushion, a small tool kit, phones, a tennis ball, a baby bottle, hair brushes, and any combination of these items. When these items are under the cushion they change the cushion dynamics, when they are under the cover they become a point of increased pressure.
It should be clear by now that wound prevention and pressure management involves more than just swapping cushions. The contributing factors and circumstances can be varied and complex and changing. In most cases it may be impossible to single out one element in the event and pronounce it as the primary offender. It is a multi-dimensional problem. The solution is also multi-dimensional and should be approached that way. Deal with cushion issues, but don’t forget the other issues.