Prepared by Danielle Collins and Victoria Sim
Occupational Therapists
Prince of Wales Hospital
Seating Clinic
September 20...
Outline
What is Seating Clinic?
How & what do we assess?
Interventions & seating options for pressure
management
Case Stud...
What is Seating Clinic?
Our Clients
People with ‘complex seating’ problems –
have or are at risk of developing postural
problems or pressure sores...
4
Seating Clinic Process:
Assessment and goals
setting with client
Fabrication / fitting of
seating solutions,
Trials
Revi...
Seating Anatomy 101
IT = Ischial tuberosity
GT= Greater
Trochanter
Sacrum
Coccyx
ASIS = anterior
superior iliac spine
The initial assessment –2 hrs
History- whole of day approach
Discussion of problems identified by client and
referrer
Disc...
7
Postural Assessment
Hands on assessment
– In wheelchair
– Lying on plinth
– Sitting on edge of plinth
– Reflex / spasm p...
Pressure Ax- More than just a chair!
Seating system-
cushion and backrest
Commode
Other seating surfaces
Posture and postu...
Intervention
Cushions- commercial and customised
Backrests- commercial and customised
Education on pressure relieving tech...
Solutions- Commercial Cushion
Off the shelf Modified
11
Solutions- Commercial Backrests
Off the shelf Modified
12
Examples of customised mods
Case Study- Trish
T4 AIS A paraplegic since 2000 following a fall
PMHx: diabetes, chronic back pain
Lives rurally with daughter, carer and c...
Presenting problems
Sacrum- stage 2Left GT- stage 4
Problems identified
History of poor skin integrity, scar tissue and tethered areas
Multiple pressure injuries- no safe lyi...
Bedrest positioning
Skin post procedures- ready for seating!
Once healed- equipment explored
No more manual wheelchair seating
Power wheelchair trials- problems!
Cushion trials and pr...
Thinking beyond the chair….
Neuro psych involvement to ensure safe to make decisions
Specialised wheelchair set up- PWC wi...
Prone Options
Prone wheelchair Prone shower trolley
Interface Pressure
Mapping
Interface Pressure Mapping
What is Interface Pressure Mapping?
How do we use it?
What are the limitations of IPM?
What are...
What is Interface Pressure Mapping?
Pressure mapping is used to show the
distribution of pressure across a surface.
It mea...
How do we use it?
We look at the distribution of
pressure across the surface
aiming for even dispersion
throughout the ima...
Now to see what we are talking
about!
Limitations of Pressure Mapping
Provides a “snap shot” in time
Does not measure shear or contour forces
Pressure mat and c...
Clinical Applications
Objective representation of Peak
Pressure
Differential comparison of Support
Surfaces
Frame 1: RGK
Foam cushion
Frame 2: Roho
Frame 3: Jay 2
Deep Contour
Frame 4: J...
Effectiveness of Weight Shifting
Interventions
Effectiveness of Weight Shifting
Interventions (Cont)
Effectiveness of Weight Shifting
Interventions (Cont)
Fabricating Custom Seating
Measure Postural Abnormality &
Correction
Initial Cushion Set-up (open valve) Cushion adjusted using Quadtro Valve
Documentation and funding
E.g to Justify 45 degrees tilt in space (over
standard 27 degrees)
No Tilt 45 ˚ Tilt27˚ Tilt
Case Study- Trent
Background
33year old T4 AIS A paraplegic
Injury sustained when he was 18
Lives with 2 brothers, mother lives nearby and
a...
Problem list upon Referral
• Stage 3 pressure area – right GT. Developed
approximately 3 months ago.
• Normally sits on fo...
Between Referral & Seating Clinic
Intervention
Spent 3 weeks on bed rest then returned to work 12
hours /day
Taking rest b...
Assessment
Transfers: Self transfers without sliding board.
Good lift & clearance from wheels
Clothing: Wearing 4 way stre...
Seating Clinic Intervention –
Pressure Mapping
Frame 1: Trinova (All inflated)
Frame 2: Trinova cycle 1
Frame 3: Trinova C...
More than just a Chair – Car seat
Frame 1: Action Pilot (foot clear of brakes)
Frame 2: Action Pilot (normal position)
Fra...
More than just a chair – Seating Clinic
Holistic approach to assessment and
management
Multidisciplinary approach critical...
References
Bar, C. (1998). Pressure: Why measure it and how.
A presentation at the 14th International Seating
Symposium. V...
Seating Clinic
Prince of Wales Hospital
Email“: rehabeng@sesiahs.health.nsw.gov.au
Ph: (02) 9382 5286
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Danielle Collins, Prince of Wales Hospital - Interventions & seating options for pressure management

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Danielle Collins, Occupational Therapist, Seating Clinic, Prince of Wales Hospital delivered the presentation at 2013 Reducing Avoidable Pressure Injuries Conference.

The 2013 Reducing Avoidable Pressure Injuries Conference featured a comprehensive case study led program covering topics such as prevention of pressure injuries during the surgical patient journey and in people with Spinal Cord Injuries, meeting Standard 8, translating research into clinical practice and more.

For more information about the event, please visit: http://www.informa.com.au/pressureinjuries13

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Danielle Collins, Prince of Wales Hospital - Interventions & seating options for pressure management

  1. 1. Prepared by Danielle Collins and Victoria Sim Occupational Therapists Prince of Wales Hospital Seating Clinic September 2013 More than just a chair: The role of a seating clinic in pressure injury prevention and management
  2. 2. Outline What is Seating Clinic? How & what do we assess? Interventions & seating options for pressure management Case Studies
  3. 3. What is Seating Clinic?
  4. 4. Our Clients People with ‘complex seating’ problems – have or are at risk of developing postural problems or pressure sores. People from any diagnostic group eg.MS, Spinal Injury, Stroke, Cerebral Palsy People from any geographical area – but we are a hospital based service
  5. 5. 4 Seating Clinic Process: Assessment and goals setting with client Fabrication / fitting of seating solutions, Trials Review, Modification, Ongoing review, application for funding. Client centred goals
  6. 6. Seating Anatomy 101 IT = Ischial tuberosity GT= Greater Trochanter Sacrum Coccyx ASIS = anterior superior iliac spine
  7. 7. The initial assessment –2 hrs History- whole of day approach Discussion of problems identified by client and referrer Discuss pressure injury history Postural assessment Pressure mapping if appropriate
  8. 8. 7 Postural Assessment Hands on assessment – In wheelchair – Lying on plinth – Sitting on edge of plinth – Reflex / spasm pattern – Pain – Functional seating needs
  9. 9. Pressure Ax- More than just a chair! Seating system- cushion and backrest Commode Other seating surfaces Posture and postural changes Transfers Sitting time- total Clothing choices Pressure relief techniques Spasm Moisture
  10. 10. Intervention Cushions- commercial and customised Backrests- commercial and customised Education on pressure relieving techniques Pressure mapping
  11. 11. Solutions- Commercial Cushion Off the shelf Modified
  12. 12. 11 Solutions- Commercial Backrests Off the shelf Modified
  13. 13. 12 Examples of customised mods
  14. 14. Case Study- Trish
  15. 15. T4 AIS A paraplegic since 2000 following a fall PMHx: diabetes, chronic back pain Lives rurally with daughter, carer and carer’s partner Previously independent with manual wheelchair mobility History of pressure injuries to left IT and GT Previous surgical intervention(2008)- debridement, VAC dressing and skin graft- 1year hospital admission Background
  16. 16. Presenting problems Sacrum- stage 2Left GT- stage 4
  17. 17. Problems identified History of poor skin integrity, scar tissue and tethered areas Multiple pressure injuries- no safe lying surface but prone Variable compliance with bedrest secondary to shoulder and neck pain and difficult due to hip contracture Conservative management vs surgical management Difficult home situation Risk of further skin breakdown if return to seating in manual wheelchair
  18. 18. Bedrest positioning
  19. 19. Skin post procedures- ready for seating!
  20. 20. Once healed- equipment explored No more manual wheelchair seating Power wheelchair trials- problems! Cushion trials and pressure mapping Education around pressure relieving techniques Seating options
  21. 21. Thinking beyond the chair…. Neuro psych involvement to ensure safe to make decisions Specialised wheelchair set up- PWC with tilt, seat to back angle on chair set to maintain skin integrity Sitting times monitored and capped at 2 hours at a time Not to sit everyday- continue with prone bedrest Pressure relieving regime- using tilt in PWC Safe transfer methods- sling, slide sheets, patslide Mattress upgrade Prone trolley options
  22. 22. Prone Options Prone wheelchair Prone shower trolley
  23. 23. Interface Pressure Mapping
  24. 24. Interface Pressure Mapping What is Interface Pressure Mapping? How do we use it? What are the limitations of IPM? What are the Clinical Applications of IPM? (Lipka, 1997) – Case study from POWH Seating Service
  25. 25. What is Interface Pressure Mapping? Pressure mapping is used to show the distribution of pressure across a surface. It measures the INTERFACE pressure distributed by a subject across a support surface (e.g. cushion, mattress, backrest) It is helpful in assessing a single person on various surfaces using the same device and scale.
  26. 26. How do we use it? We look at the distribution of pressure across the surface aiming for even dispersion throughout the image When high peak pressures are identified (“red” areas) the clinician uses their clinical judgement to determine appropriate intervention Useful as an education tool for pressure relieving and re- assurance
  27. 27. Now to see what we are talking about!
  28. 28. Limitations of Pressure Mapping Provides a “snap shot” in time Does not measure shear or contour forces Pressure mat and cover can provide a “false” read due to hammocking effect or bunching Confusion between Interface Pressure and Capillary closing pressure Results not transferable between clients Requires clinical judgement to interpret results Clients can become reliant on it
  29. 29. Clinical Applications
  30. 30. Objective representation of Peak Pressure
  31. 31. Differential comparison of Support Surfaces Frame 1: RGK Foam cushion Frame 2: Roho Frame 3: Jay 2 Deep Contour Frame 4: Jay 2 with different well Size
  32. 32. Effectiveness of Weight Shifting Interventions
  33. 33. Effectiveness of Weight Shifting Interventions (Cont)
  34. 34. Effectiveness of Weight Shifting Interventions (Cont)
  35. 35. Fabricating Custom Seating
  36. 36. Measure Postural Abnormality & Correction Initial Cushion Set-up (open valve) Cushion adjusted using Quadtro Valve
  37. 37. Documentation and funding E.g to Justify 45 degrees tilt in space (over standard 27 degrees) No Tilt 45 ˚ Tilt27˚ Tilt
  38. 38. Case Study- Trent
  39. 39. Background 33year old T4 AIS A paraplegic Injury sustained when he was 18 Lives with 2 brothers, mother lives nearby and assists with wound dressings Utilises a manual wheelchair for all mobility needs Plays wheelchair basketball
  40. 40. Problem list upon Referral • Stage 3 pressure area – right GT. Developed approximately 3 months ago. • Normally sits on foam in manual wheelchair. Seating position has changed since sitting on low profile roho • Pressure area believed to be caused by toilet seat – sits on padded toilet seat • Works as Office Manager–recommended 3/52 weeks bedrest to heal pressure area
  41. 41. Between Referral & Seating Clinic Intervention Spent 3 weeks on bed rest then returned to work 12 hours /day Taking rest breaks every 2 hours at work Trial of electrical stim to heal wound Purchased alternative toiletting equipment Hired Trinova alternating air cushion on wheelchair (funded trough CRS)
  42. 42. Assessment Transfers: Self transfers without sliding board. Good lift & clearance from wheels Clothing: Wearing 4 way stretch lower body garments Toileting & shower equipment – reluctant to change Mattress: Sleeping prone or on left side Had been seen via MDT who had reviewed nutrition risk factors Workstation set-up
  43. 43. Seating Clinic Intervention – Pressure Mapping Frame 1: Trinova (All inflated) Frame 2: Trinova cycle 1 Frame 3: Trinova Cycle 2 Frame 4: Roho HP
  44. 44. More than just a Chair – Car seat Frame 1: Action Pilot (foot clear of brakes) Frame 2: Action Pilot (normal position) Frame 3: Roho LP (foot clear of brakes) Frame 4: Roho LP normal position)
  45. 45. More than just a chair – Seating Clinic Holistic approach to assessment and management Multidisciplinary approach critical to good outcomes Skilled intervention with equipment selection, prescription and set-up can assist with management of avoidable pressure injuries
  46. 46. References Bar, C. (1998). Pressure: Why measure it and how. A presentation at the 14th International Seating Symposium. Vancouver, BC. Lipka, D. (1997). An overview of pressure mapping systems. Technology SIS Quarterly. American Occupational Therapy Association. (7) 4. Schlemer, MR & Bunning, ME (1999) www.wheelchairnet.org/wcn_wcu/SlideLectures/MS/3PressureMapping.pdf Rappl, L. Poster Presentation at RESNA 2005
  47. 47. Seating Clinic Prince of Wales Hospital Email“: rehabeng@sesiahs.health.nsw.gov.au Ph: (02) 9382 5286
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