Running head EXERCISE PROGRAMS TO PREVENT FALLS .docx

Running head: EXERCISE PROGRAMS TO PREVENT FALLS
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EXERCISE PROGRAMS TO PREVENT FALLS
5
Exercise Programs to Prevent
Fall Related Injuries in Older Adults
Student
Student
Gwynedd Mercy University
Abstract
The implementation of exercise programs was evaluated to

identify best-practice in fall-related injury prevention. This
paper incorporates information from four different studies to
identify the evidence that suggests best-practice protocol.
Evidence of these studies suggests that implementing exercise
programs helps to prevent fall-related injuries in long-term care
facilities for older adults. Incorporating exercise programs
increases patient safety, prevents further injury, and promotes
communication between patients and staff. By implementing
these programs, patients’ overall health improves and they’re
more satisfied by their ability to perform activities of daily
living on a more independent level.
Exercise Programs to Prevent Fall Related Injuries in Older
Adults
As individuals age through life, the risk for falls increase
immensely. This is due to the lack of strength as well as a lack
of balance in the human body. It is important for nurses to take
l precautions to help stop patient falls because in many
instances, falls are preventable (Ambutas, Lamb, & Quigley,
2017). Fall prevention includes important interventions that
stop subsequent injuries from happening to patients. Everyday,
nurses take precautions to prevent falls but additional actions

could be taken in order to make these interventions more
effective. Every patient is at risk of falling, especially older
adults because they lose muscle mass and balance as they age
(Taylor, Lillis, & Lynn, 2015, p. 142). After performing fall-
risk assessments on each patient, nurses implement suggested
best practice protocols for low-risk, moderate-risk, and high-
risk patients. Best practice includes educating patients and
families on fall risk, using bed or chair alarms, lowering the
beds, encouraging regular toileting and other precautions
(Taylor, et al., p. 145). Exercise programs act as another
important measure that nurses could implement, in order to help
patients improve their balance, strength and mobility while
performing activities of daily living, and reduce risk for falls
(Ambutas, Lamb & Quigley).
The following clinical question will be used to identify best
practice related to exercise programs in order to prevent falls in
older adults:
P: Older adults living in long-term care facilities
I: Exercise programs
C: (none)
O: Prevent fall-related injuries
T: (None)
In long-term care facilities for older adults, how do exercise
programs help prevent fall-related injuries?
Review of Literature
Dal Bello-Haas, Thorpe, Lix, Scudds, and Hadjistavropoulos
(2012) completed a quantitative research study that focused on
the implementation of a walking program in long-term care
facilities, in order to prevent falls. Risk for falling increases
with advancing age. The research question that these authors
asked was a to assess the effectiveness of an individualized,
progressive, walking program compared to usual care in
individuals residing in long-term care facilities. The study
participants were over the age of 60, resided in a long-term care
facility, and participated in several different walking programs.
The results of this study suggested increased activity and

participation in exercise contribute to prevention of falls in the
long-term. The researchers stated nurses and health care
providers working in long-term care environments should
implement exercise programs for residents to prevent falls.
Kato, Izumi, Hiramatsu, and Shogenji (2006) also investigated
the use of exercise to prevent falls in the older adult population,
who are at increased risk for falls. The participants in this
quantitative study completed stretching, muscle strengthening,
and toe exercises three times per week. Results of this study
showed older adults who participated in the exercise program
experienced less falls. The researchers suggested exercise
programs were effective in reducing falls in residents of long-
term care facilities and should be considered for use with this
patient population.
In addition to focusing on strength and balance, a quantitative
study by Gschwind, Kressig, Lacroix, Muehlbauer, Pfenninger,
and Granacher (2013) also investigated the effects of exercise
on improvement of psychosocial well-being. Preventing falls in
the older adult may require interventions to address more than
one focus area. The researchers designed a rehabilitation
program for older adults living at home in which patients
worked to improve everyday balance, strength, and psychosocial
well-being. The objective for this program is to prevent the risk
of falls in the older adult population. Older adults in the study
were taught balance and strength training exercises. Participants
were contacted by phone to encourage use of the exercises. The
results of this experiment showed improvement in strength,
balance, and an increase in daily living activities. The
researchers state that patient education is important for older
adults living in community settings to incorporate exercise into
daily activities.
Sherrington, Tiedemann, Fairhall, Close, and Lord (2011)
also investigated the use of exercise to prevent the risk of falls.
In addition to focusing on older adults, the researchers included
participants from other age groups in this quantitative study.
Study participants completed balance exercises and participated

in progressive walking activities. The results suggested exercise
can help lower the risk of falls in the older adult. In addition,
the researchers stated fall prevention exercise training should
not be confined to just the aging adult, but also offered and
implemented in the general population. In doing so, everyone
can increase their balance ability, which ultimately decreases
the risk of falls. The type of training should vary with each
individual. If the patient is healthy, the balance exercise along
with strength training and brisk walking is appropriate. On the
other hand, if the patient is at high risk for falls, balance
exercises should be the area of focus.
Summary
Results from the reviewed studies suggest that the
implementation of exercise programs is effective in preventing
fall-related injuries in older adults and can be effective for use
in long-term care environments. Exercise allows for the
strengthening of muscles in the lower extremities, which in turn
helps to prevent loss of balance and mobility. Ultimately, falls
are reduced when patients gain strength and ambulate regularly.
According to these authors, patient safety is increased with the
implementation of exercise programs that include walking,
muscle strengthening and balance routines. The findings
presented by these authors suggest that implementing exercise
programs for older adults in long-term care facilities would be
beneficial for safety and satisfaction of patients.
Barriers and Suggested Strategies
There are potential barriers to the implementation of the
recommendations in the reviewed studies. Patients with
decreased mobility or complete immobility would not be able to
complete these exercise programs. It would also be difficult to
implement the exercise protocol for patients with physical,
cognitive, or psychosocial impairments. Nurses should consider
variations in exercise regimens appropriatge for patients with
decrased mobility or other impariments. Nurse could provide
passive exercise activities for patients who are completely
immobile.

Implementation of the suggested interventions may be difficulty
for patients experiencing pain. Adequate and appropriate use of
pharmacological and nonpharmacological interventions for pain
management should be implemented before use of the suggested
exercise interventions. Nurses should assess patients’ pain and
collaborate with other health care providers to provide pain
relief.
It could be very costly to implement the recommended exercise
programs, as many of them would have to be individualized to
the patient which would require trained personnel. This could
be a potential barrier to implementation of the suggested
strategies. Nurses may have to work with managers and
administrators to find solutions for financial resources.
Lastly, patient interest is a potential barrier to the
recommendations because patients have to be willing to
exercise. Nurses should involve patients in exercise decisions
and provide patient education to support the patient’s treatment
decisions. Nurses should also be flexible and creative in
determining exercise regimens for patients, allowing the patient
input into desired activities and activities based on patient
interests.
Conclusion
Patient safety has always been a main concern in nursing
practice but further precautions to fall-related injuries can be
taken. Exercise is proven to have many positive outcomes on
the mind and body. Therefore, incorporating exercise programs
in long-term care facilities, nurses can increase patient safety
measures and promote improved overall quality of life.

References
Ambutas, S., Lamb, K.V., & Quigley, P. (2017). Fall reduction
and injury prevention toolkit: Implementation on two medical-
surgical units. MEDSURG Nursing, 26(3), 175-179.
Bello-Haas, V PM., Thorpe, L., Lix, L., Scudds, R., and
Hadjistavropoulos, T. (2012). The
effects of a long-term care walking program on balance, falls
and well-being. BMC
Geriatrics, 12(76), N.PAG. doi: 10.1186/1471-2318-12-76
Kato, M., Izumi, K., Hiramatsu, T., & Shogenji, M. (2006).
Development of an exercise
program for fall prevention for elderly persons in a long-term
care facility. Japan Journal
of Nursing Science, 3(2), 107–117. doi:10.1111/j.1742-
7924.2006.00057.x
Gschwind, Y. J., Kressig, R. W., Lacroix, A., Muehlbauer, T.,
Pfenninger, B., & Granacher, U.
(2013). A best practice fall prevention exercise program to
improve balance, strength / power, and psychosocial health in
older adults: Study protocol for a randomized controlled trial.
BMC Geriatrics, 1 (105), N.PAG. doi: 10.1186/1471-2318-13-
105
Sherrington, C., Tiedemann, A., Fairhall, N., Close, J., & Lord,
S. (2011), Exercise to prevent
falls in older adults: An updated meta-analysis and best practice
recommendations. New
South Wales Public Health Bulletin, 22(3-4), N.PAG. doi:
10.1071/NB10056
Taylor, C., Lillis, C., & Lynn, P. (2015). Fundamentals of
nursing: The art and science of
nursing care. (8th ed.). Philadelphia: Wolters Kluwer

Health/Lippincott Williams &
Wilkins.
Frequent manual repositioning and incidence of pressure
ulcers among bed-bound elderly hip fracture patients
Shayna E. Rich, MA, PhD1; David Margolis, MD, PhD2;
Michelle Shardell, PhD1; William G. Hawkes; PhD1;
Ram R. Miller, MD1; Sania Amr, MD1; Mona Baumgarten,
PhD1
1. Department of Epidemiology and Public Health, University of
Maryland School of Medicine, Baltimore, Maryland, and
2. Departments of Epidemiology & Biostatistics, and
Dermatology, University of Pennsylvania School of Medicine,
Philadelphia, Pennsylvania
Reprint requests:
Shayna Rich, MA, PhD, 121 South Fremont
Avenue, Apartment 431; Baltimore, MD
21201.
Tel: 11 443 604 6308;
Fax: 11 410 706 4433;
Email: [email protected]
Manuscript received: March 3, 2010
Accepted in final form: September 28, 2010

DOI:10.1111/j.1524-475X.2010.00644.x
ABSTRACT
Frequent manual repositioning is an established part of pressure
ulcer prevention,
but there is little evidence for its effectiveness. This study
examined the association
between repositioning and pressure ulcer incidence among bed-
bound elderly hip
fracture patients, using data from a 2004–2007 cohort study in
nine Maryland and
Pennsylvania hospitals. Eligible patients (n5269) were age�65
years, underwent hip
fracture surgery, and were bed-bound at index study visits
(during the first
5 days of hospitalization). Information about repositioning on
the days of index vis-
its was collected from patient charts; study nurses assessed
presence of stage 21
pressure ulcers 2 days later. The association between frequent
manual repositioning
and pressure ulcer incidence was estimated, adjusting for
pressure ulcer risk factors
using generalized estimating equations and weighted estimating
equations.
Patients were frequently repositioned (at least every 2 hours) on
only 53% (187/
354) of index visit days. New pressure ulcers developed at 12%
of visits following
frequent repositioning vs. 10% following less frequent
repositioning; the incidence
rate of pressure ulcers per person-day did not differ between the
two groups (inci-
dence rate ratio 1.1, 95% confidence interval 0.5–2.4). No
association was found be-

tween frequent repositioning of bed-bound patients and lower
pressure ulcer
incidence, calling into question the allocation of resources for
repositioning.
Pressure ulcers are a common complication of immobility
among the elderly, resulting in substantial pain and suffering
1
and excess hospital costs with charges for associated hospital
stays averaging > US$15,000.2 As of October 2008, Med-
icare no longer reimburses hospitals for treatment of hos-
pital-acquired stage 3 or 4 pressure ulcers.
3
This decision
was based on the designation of pressure ulcers as a ‘‘rea-
sonably preventable condition,’’ i.e., it is assumed that
pressure ulcers will generally not develop on patients re-
ceiving care according to current evidence-based guide-
lines. Unfortunately, although national and international
clinical guidelines for pressure ulcer prevention recom-
mend a wide range of measures, the evidence for the effec-
tiveness of many of these measures is fairly weak.
4–6
To
ensure that the measures recommended by clinical guide-
lines lead to a reduction in pressure ulcers, it is critical to
confirm both that these measures are effective and that
they are widely implemented.
One of the major methods for prevention of pressure

ulcers is the frequent manual repositioning of patients with
limited mobility. In particular, several clinical guidelines
recommend that bed-bound patients be repositioned every
2 hours.
5,6
This recommendation is based primarily on
expert opinion, with few epidemiological studies and in-
conclusive evidence that repositioning at this frequency is
effective in preventing the development of pressure ulcers.
Despite the dearth of evidence, repositioning bed-bound
patients every 2 hours has become firmly established as the
standard of care.
Confirming the effectiveness of frequent repositioning is
an important goal, to ensure that the standard of care is
appropriate and because the labor costs associated with
this intervention are considerable. Indeed, repositioning
and transferring patients take up the largest proportion of
the time devoted to pressure ulcer prevention,
7
and in one
study cost of repositioning accounted for 73% of the total
cost for pressure ulcer prevention.
8
Several studies have
also shown that manual repositioning increases health care
workers’ risk for back pain and musculoskeletal inju-
ries.
9,10

Given the shortage of both skilled and unskilled
nursing labor, the allocation of nursing time to patient re-
positioning every 2 hours is only justified if this interven-
tion is effective.
Furthermore, it is unclear to what degree the recom-
mendation for frequent manual repositioning is being im-
plemented in US health care facilities. A study published in
2001 by the Health Care Financing Administration (now
the Centers for Medicare and Medicaid Services) found
that, in 1996, only 66% of bed- and chair-bound patients
CI Confidence interval
GEE Generalized estimating equations
IRR Incidence rate ratio
MMSE Mini-Mental State Examination
OR Odds ratio
PRSS Pressure-redistributing support surfaces
Wound Rep Reg (2011) 19 10–18 c� 2010 by the Wound
Healing Society10
Wound Repair and Regeneration
mailto:[email protected]
were repositioned every 2 hours.
11

A study by Bates-Jen-
sen et al.
12
in nursing homes in 2003 found that only 18 of
58 such patients were repositioned at least every 2 hours.
No study since then has examined adherence to this rec-
ommendation, although a few studies have examined the
use of repositioning, but not its frequency, in preventing
pressure ulcers.
13–15
There is some evidence that the ap-
propriate frequency of repositioning should vary with the
support surface in use,
16
and guidelines differ in whether
patients using mattresses and overlays designed to redis-
tribute pressure (i.e., pressure-redistributing support sur-
faces, PRSS) can be repositioned less frequently than those
using standard support surfaces.
5,6
Yet no studies have ex-
amined if the frequency of repositioning for patients using
PRSS differs from that for patients using standard support
surfaces. Thus, it is of interest to examine the degree of
adherence to frequent manual repositioning recommenda-
tions in bed-bound patients, particularly when considering
the type of support surface in use.

Manual repositioning of bed-bound patients every
2 hours is an established part of the clinical guidelines for
pressure ulcer prevention, but there is little evidence for its
effectiveness and little is known about its implementation
in the hospital setting. Thus, it is unclear what effect the
recommendation for frequent manual repositioning has on
clinical outcomes. In this study, we aimed to determine if
manual repositioning every 2 hours is associated with a
lower incidence of pressure ulcers among bed-bound
elderly hip fracture patients and to examine the degree of
adherence to recommendations for manual repositioning
in these patients.
MATERIALS AND METHODS
Participants
Data for this study were collected as part of a prospective
cohort study of patients aged 65 years or older who un-
derwent surgery for hip fracture (ICD-9 code 820) between
2004 and 2007 in any of nine hospitals that participate in
the Baltimore Hip Studies network. The methods for the
parent study have been described previously.
17
Data for
the parent study were collected in the nine acute care hos-
pitals and the 105 postacute facilities to which patients
enrolled in this study were discharged; data for the current
analysis were collected in the nine admission hospitals. All
hospitals included in this analysis were voluntary non-
profit acute care facilities, including four teaching hospi-
tals. Seven of the study hospitals were in Maryland and
two in Pennsylvania. The number of beds in each hospital
ranged from 100 to 536 (median 253).

The parent study was approved by the Institutional
Review Boards of each of the participating hospitals and
the University of Maryland Baltimore; the latter also ap-
proved the current study. Permission to contact patients
for screening and recruitment was obtained from attending
physicians. If the patient had a Mini-Mental State Exam-
ination (MMSE)
18
score of 20 or greater, the patient’s writ-
ten consent was obtained; otherwise the patient’s verbal
assent and a proxy’s written consent were obtained. Proxy
consent was also obtained for patients who were uncon-
scious or noncommunicative. A total of 1,167 patients were
screened for eligibility, of whom 1,055 were eligible (90%
of screened), and 658 patients enrolled (62% of eligible).
Data about repositioning frequency were collected for
the first 5 days of each patient’s initial hospitalization.
Thus, patients who did not have any study visits during the
first 5 days of hospitalization (n5103) were excluded from
the current study. Because national clinical guidelines only
recommend repositioning for bed-bound patients, patients
were also excluded from the current study if they were not
bed-bound according to the activity item of the Braden
scale
19
during at least one study visit in the first 5 days of
hospitalization (n5286), leaving a sample of 269 patients.
Measures

Repositioning
Data about repositioning were collected from the nursing
flowsheet by a specially trained chart abstractor or a reg-
istered nurse experienced in medical record review. This
information included the number of times that the patient
was manually repositioned on each of the first 5 days of the
patient’s initial hospital stay. If the nursing flowsheet indi-
cated only the frequency of turning rather than the number
of times the patient was turned (e.g., ‘‘q2h’’ to indicate
turning every 2 hours), the corresponding number of turns
was recorded in the daily total. Repositioning was classi-
fied as frequent if there were 12 or more turns per hospital
day, corresponding to an average frequency of every
2 hours, as recommended in several clinical guidelines for
the prevention of pressure ulcers.
5,6
Pressure ulcer status
Specially trained research nurses assessed pressure ulcer
status at study visits that occurred at baseline (as soon as
possible after hospital admission) and on alternating days
for 21 days. The presence and stage of pressure ulcers were
determined at each study visit by a whole-body skin exam-
ination conducted according to standard wound assess-
ment practice.
20
Standard definitions of pressure ulcer
stages
21

were used: stage 1 (alteration of intact skin with
persistent redness), stage 2 (partial thickness dermal loss or
serum-filled blister), and stages 3 and 4 (full-thickness tis-
sue loss without/with exposed bone, tendon, or muscle).
The study outcome was development of one or more new
pressure ulcers stage 2 or higher at the visit following the
day for which repositioning frequency was recorded. Re-
sults were similar when the study outcome was restricted
to stage 2 pressure ulcers. Because only 16 of the pressure
ulcers observed in the study ever reached stages 3 or 4, it
was not possible to perform an analysis restricting the
study outcome to stage 3 and 4 pressure ulcers. Patients
with pressure ulcers continued to be considered at risk for
additional pressure ulcers. Results were virtually identical
when patients with pressure ulcers present at hospital
admission were excluded from the analysis.
Covariates
At each assessment, the research nurse recorded the
patient’s Braden scale score,
19,22
based on observation
Healing Society 11
Frequent repositioning and pressure ulcer incidenceRich et al.
and discussion with clinical staff. The Braden scale com-
prises six items: mobility, activity, sensory perception, ex-
posure to friction and shear forces, skin moisture, and
nutritional status. The ‘‘friction and shear’’ item is rated

on a three-point scale; each of the other five items is rated
on a four-point scale. The values for each item are summed
to provide a score ranging from six to 23, with lower scores
indicating a higher risk for pressure ulcer development. A
cut-off point of 16 is commonly used to indicate ‘‘at-risk’’
patients.
23
Acute mental status was also assessed at each visit by
counting the number of orientations to person, place, and
time. Incontinence status was based primarily on the
research nurses’ observation of skin moisture and/or soil-
ing with stool during the skin assessment and secondarily
on the four-point incontinence item of the Norton scale of
pressure ulcer risk.
24
Information about use of PRSS was
recorded by the research nurses on a structured form at
each study visit. PRSS were considered to be in use if any
overlays were observed to be on the patient’s bed or if the
mattress on the patient’s bed was made of any materials
other than standard foam and spring. For pressure ulcer
preventive devices other than PRSS, cushions were con-
sidered in use if they were on the patient’s chair or wheel-
chair, even if the patient was not seated at the time of the
assessment, whereas heel protectors, elbow protectors, and
positioning pillows/wedges were only recorded as being in
use if they were observed to be on, or supporting, the
patient at the time of assessment.
Data about all other covariates were obtained by clini-
cal observation at the baseline study visit, by patient or
proxy interview, or by chart review. At the baseline visit,

research nurses used the Subjective Global Assessment of
Nutritional Status
25
to classify individuals as being at low,
moderate, or high risk of nutrition-associated complica-
tions. Arterial insufficiency, defined as absence of pedal
pulses or ankle brachial index < 1, was also determined at
the baseline visit. Weight and height were obtained from
the medical chart or, when missing, from patient or proxy
interview; this information was used to calculate the pa-
tient’s body mass index (weight [kg]/height[m]
2
). Standard
definitions
26
were used to define weight status: under-
weight (body mass index < 18.5), normal weight (body
mass index518.5–24.9), and overweight/obese (body mass
index�25.0). Severity of illness was measured on the Rand
Sickness at Admission Scale (hip fracture version)
27
and
comorbidity by the Charlson Comorbidity Index,
28
both
of which use information from the medical chart. The
number of days since hospital admission was determined
according to the information in the medical chart.

Analysis
To describe the study population, the distributions of the
patients’ characteristics noted at the baseline visit were
compared for those repositioned frequently (at least every
2 hours) on the day of the baseline visit and those reposi-
tioned less frequently. We used simple counts and propor-
tions for categorical variables, and means with standard
deviations for continuous variables. p-values were
obtained by chi-square test for categorical variables or by
two-sample t-test for continuous variables.
Study visits at which patients in the study sample were
bed-bound during the first 5 days of hospitalization
(354 person-visits) were designated as index visits. Because
some patients had multiple index visits, generalized esti-
mating equations (GEE) analysis
29
with an exchangeable
working correlation matrix was used to account for
within-patient correlation. GEE models with a log link,
Poisson working model, and offset of log number of
days between visits (to account for differing amounts of
patient follow-up) were fit to determine the association
between repositioning frequency on the day of an index
visit and incidence of pressure ulcers stage 2 or higher at
the following visit. Estimates of incidence rate ratios
(IRR) and 95% confidence intervals (CI) were reported,
both unadjusted and adjusted for covariates. The number
of days since hospital admission was included in the
adjusted model as a continuous variable using a linear
spline with a knot at hospital day 2, and some admission
hospitals with few outcomes were combined in the

adjusted model. To determine whether the association
between repositioning frequency and pressure ulcer
incidence was modified by pressure ulcer risk status,
another adjusted model was fit with additional covariates
for the patient’s Braden scale score (dichotomized at
the sample’s median) at the index visit and a term for the
interaction between Braden scale score and repositioning
frequency.
Because repositioning data and covariate data were
missing for 10% (37/354) and 9% (33/354) of index visits,
respectively, weighted estimating equations analysis
30
was
used to account for possible selection bias due to missing
data. To compute the weights for this analysis, the prob-
ability of having observed (nonmissing) repositioning data
was estimated using a GEE model with a logit link, bino-
mial working model, and predictor variables (admission
hospital, severity of illness, use of pressure ulcer preventive
devices other than PRSS, pressure ulcer incidence before
or at the index visit, linear spline of days since hospital
admission, and completeness of other covariate data). The
probability of having complete covariate data was esti-
mated in a similar way with admission hospital as the
predictor variable. Weights were then estimated as the
product of the inverse probability of having complete cov-
ariate data and the inverse probability of having observed
repositioning data.
GEE models were fit with a binomial distribution and
identity link to determine estimates and 95% CI for the
proportion of index visit days on which patients were fre-
quently repositioned, for the whole study sample, for sub-

groups of patients using each type of support surface, and
for subgroups of patients in each admission hospital. GEE
models with a logit link and binomial working model were
fit to determine whether PRSS use on a given day was
associated with frequent repositioning on the same day.
Estimates of prevalence odds ratios (OR) and 95% CI are
reported, both unadjusted and adjusted for covariates. To
avoid overfitting, age, sex, acute mental status, comorbid-
ity, arterial insufficiency, use of preventive devices other
than PRSS, and presence of a pressure ulcer at the index
visit were eliminated from the model, after it was deter-
mined that these variables did not change the estimate of
the coefficient of interest by > 10%. Because the use of
frequent repositioning and PRSS were expected to vary
Healing Society12
Frequent repositioning and pressure ulcer incidence Rich et al.
based on hospital policy and resources, it was expected
that there may be important clustering effects by admis-
sion hospital. To examine these effects, additional models
were fit that adjusted for admission hospital using indica-
tor variables. All analyses were performed using SAS 9.1
(SAS Institute Inc., Cary, NC).
RESULTS
Study sample
Patients’ baseline characteristics, by repositioning frequency
on the day of the baseline visit, are shown in Table 1.

Table 1. Baseline characteristics of study participants, by
repositioning frequency on day of baseline visit
Characteristics
Patients repositioned at
least every 2 hours
(N5139)
Patients repositioned less
frequently than every 2 hours
(N5130)n
All patients
(N5269)
w
p-value
z
n (%)
Age �85 years 68 (48.9) 71 (54.6) 139 (51.7) 0.35
Male sex 36 (25.9) 32 (24.6) 68 (25.3) 0.81
White race 137 (98.6) 128 (98.5) 265 (98.5) 0.95
Community resident before
admission
83 (59.7) 86 (66.2) 169 (62.8) 0.27

Medicaid payor 12 (8.6) 6 (4.6) 18 (6.7) 0.19
Trochanteric fracture 53 (38.1) 57 (43.9) 110 (40.9) 0.34
Partial or total arthroplasty 58 (41.7) 56 (43.1) 114 (42.4) 0.82
Albumin < 3.0 g/dL 48 (34.5) 45 (34.6) 93 (34.6) 0.99
Not fully oriented to person,
place, and time
61 (45.9) 46 (36.2) 107 (41.2) 0.11
High risk of nutrition-related
complications
22 (16.3) 11 (8.5) 33 (12.5) 0.06
Incontinence 0.97
None 95 (68.8) 91 (70.0) 186 (69.4)
Urinary only 28 (20.3) 26 (20.0) 54 (20.2)
Fecal with or without urinary 15 (10.9) 13 (10.0) 28 (10.5)
Arterial insufficiency 56 (40.3) 62 (47.7) 118 (43.9) 0.22
Braden scale score �16 129 (94.9) 119 (93.7) 248 (94.3) 0.69
Pressure ulcers present at
baseline visit

25 (20.2) 9 (7.8) 34 (14.2) 0.006
Mean (standard deviation)
Mean age (years) 83.9 (6.4) 84.0 (6.5) 84.0 (6.5) 0.90
Mean Rand Sickness at
Admission score
13.6 (7.5) 12.9 (6.3) 13.3 (6.9) 0.40
Mean Charlson Comorbidity
Index
1.5 (1.5) 1.5 (1.5) 1.5 (1.5) 0.67
Mean MMSE score 15.8 (11.1) 17.5 (10.8) 16.6 (11.0) 0.21
Mean BMI (weight [kg]/height
[m]
2
)
23.4 (5.3) 24.2 (4.7) 23.8 (5.0) 0.24
Mean Braden scale score 13.8 (1.7) 14.2 (1.6) 14.0 (1.7) 0.07
Mean length of hospital stay
(days)
6.0 (2.7) 5.7 (3.1) 5.9 (2.9) 0.35

Mean interval between admission
and baseline visit (days)
1.8 (1.1) 1.6 (1.1) 1.7 (1.1) 0.15
nIncludes patients with missing repositioning data and two
study participants who did not have a baseline visit in the first 5
days of
hospitalization at which the patient was bed-bound.
w
Because of missing data, N for individual items ranges from 240
to 269.
z
p-value determined by two-sample t-test for continuous
variables or chi-square for categorical variables.
MMSE, Mini-Mental State Examination. BMI, body mass index.
Healing Society 13
Patients repositioned frequently (at least 12 times/day or
every 2 hours on average) were more likely than those repo-
sitioned less frequently to have a pressure ulcer at the base-
line visit (p50.006). Those repositioned frequently were also
more likely to have a high risk of nutrition-related compli-
cations (p50.06) and to have a lower mean Braden scale
score (p50.07) than patients repositioned less frequently.
Effect of frequent repositioning on incidence of

pressure ulcers
Patients in the study sample had an incident pressure ulcer
stage 2 or higher at 11% (38/354) of visits following an
index visit; the proportion was 12% (22/187) for visits
following days on which patients were frequently reposi-
tioned and 10% (16/167) following days on which patients
were repositioned less frequently (Table 2). The rate of
incident pressure ulcers stage 2 or higher at the visit
following an index visit per person-day of follow-up was
similar whether or not the patient was repositioned
frequently on the day of the index visit (unadjusted IRR
1.22, 95% CI 0.65–2.30; covariate-adjusted IRR 1.12,
95% CI 0.52–2.42).
The effect of frequent repositioning on pressure ulcer
incidence varied somewhat (p for the interaction50.07 in
adjusted model) according to whether or not the patient was
at high risk of pressure ulcers, as indicated by a Braden scale
score less than the study sample median value of 14. Among
the higher risk patients, the incidence rate of pressure ulcers
per person-day of follow-up was lower for those frequently
repositioned on the day of the index visit compared with
those repositioned less frequently (adjusted IRR 0.39, 95%
CI 0.08–1.84), whereas in lower risk patients, the incidence
rate of pressure ulcers for those repositioned frequently was
higher than for those repositioned less frequently (adjusted
IRR 2.19, 95% CI 0.73–6.60).
Relationship between use of PRSS and frequent
repositioning
Patients were repositioned frequently on 53% of the days
on which an index visit occurred (95% CI 47–58%); the
proportion was 54% (78/145) among patients using PRSS
and 52% (106/204) among patients using standard mat-

tresses. The proportion of days with frequent repositioning
according to type of support surface ranged from 42 to
66% (Figure 1). The use of frequent repositioning also
differed substantially by admission hospital; the hospital-
specific proportion of days on which frequent repositioning
was in use ranged from 23 to 77%. Examining the role of
admission hospital in detail, we found that hospitals with
more PRSS use tended to have less use of frequent reposi-
tioning and vice versa, indicating that admission hospital
was a negative confounder of the association between
PRSS use and frequent repositioning. Thus, although there
was no association between using PRSS and frequent
repositioning in models not accounting for admission hos-
pital (unadjusted OR 1.14, 95% CI 0.74–1.75; covariate-
adjusted OR 1.06, 95% CI 0.67–1.70), the odds of frequent
repositioning in patients using PRSS were more than twice
as high as the odds in patients using standard mattresses
in models accounting for admission hospital (hospital-
adjusted OR 2.08, 95% CI 1.10–3.92; fully adjusted OR
2.28, 95% CI 1.15–4.54).
DISCUSSION
In this study of bed-bound elderly hip fracture patients, we
did not find that repositioning patients at least every 2
hours is associated with a decreased incidence of pressure
ulcers, suggesting that manual repositioning at this fre-
quency may not effectively prevent pressure ulcers. Previ-
ous studies of frequent repositioning for pressure ulcer
prevention have yielded inconsistent results. Although a
Table 2. Unadjusted and adjusted incidence rate ratios for
developing a pressure ulcer stage 2 or higher at the following
visit, by
frequency of repositioning on the day of an index visit

Repositioning frequency Number of visits
% who developed �1 IPU
at following visit
Unadjusted
IRR (95% CI)
Fully adjustedn
IRR (95% CI)
Among all patients
Less than every 2 hours 167 10 Reference —
At least every 2 hours 187 12 1.22 (0.65, 2.30) 1.12 (0.52, 2.42)
Among patients at higher risk of pressure ulcers (Braden scale
score <14)
Among patients at lower risk of pressure ulcers (Braden scale
score �14)
All models account for within-patient correlation by generalized
estimating equations using an exchangeable structure for the
work-

ing correlation matrix.
nAccounts for missing repositioning and missing covariate data
using weighted estimating equations, and adjusts for age, sex,
acute
mental status, risk of nutrition-related complications, weight
status, incontinence status, arterial insufficiency, severity of
illness,
comorbidity, use of pressure-redistributing support surfaces, use
of any other pressure ulcer preventive device, admission
hospital,
prior pressure ulcer of any stage, and number of days since
hospital admission.
IPU, incident pressure ulcer stage 2 or higher; IRR, incidence
rate ratio; CI, confidence interval.
Healing Society14
randomized trial
16
found a lower incidence of pressure
ulcers for patients repositioned every 2 hours than for
those repositioned every 3 hours among patients using a
standard mattress, the same group
31

found no significant
difference in pressure ulcer incidence when they compared
groups under two repositioning-interval regimens (2 hours
in a lateral position and 4 hours in a supine position vs.
4 hours in each position). Observational studies in humans
have only shown that the duration of pressure likely to
result in pressure ulcers falls within a range of 1–6
hours.
32,33
Finally, studies in humans using surrogate
endpoints (skin temperature and redness, and contact
pressure) and animal studies and in vitro tissue studies
suggest that even a 2-hour interval of repositioning might
be insufficient to prevent tissue damage.
34–36
Thus, the
evidence for an optimal repositioning interval is inconclu-
sive, with biological plausibility for an interval < 2 hours
but little difference in clinical outcomes between this inter-
val and longer intervals. Taken together, the published
literature and the present study findings suggest that the
clinical recommendations for manual repositioning with a
specified interval are not well-founded.
Recent guidelines have recognized the limitations of the
evidence for manual repositioning, and these guidelines
have recommended that frequency of manual reposition-
ing should be tailored to each patient based on character-
istics such as mobility and general medical condition.
37

Given the substantial costs and burden of repositioning
every 2 hours, it is important to target this intervention to
patients who are most likely to benefit. In this study, there
was some suggestion that the effect of repositioning was
modified by the patient’s pressure ulcer risk status. Among
patients at high risk of pressure ulcers (as indicated by low
Braden scale scores), those repositioned at least every
2 hours had a lower rate of incident pressure ulcers than
those repositioned less frequently; among patients at low
risk of pressure ulcers, those repositioned at least every
2 hours had a higher rate of incident pressure ulcers than
those repositioned less frequently, although neither differ-
ence was statistically significant. If confirmed in future
studies, these findings suggest that, even among bed-
bound patients, repositioning may only be effective as a
prevention measure for those at particularly high risk of
pressure ulcers, and patients at high risk according to
Braden scale score may be a population of particular in-
terest. Additional studies should examine if frequent repo-
sitioning is only effective in this patient population.
We found limited adherence to the recommendation for
frequent manual repositioning despite the fact that the
study population, bed-bound elderly hip fracture patients,
is recognized as being at high risk of pressure ulcers.
7,38
It
is reassuring that patients who were repositioned fre-
quently were more likely than those who were repositioned
less frequently to have a lower Braden scale score. Overall,
though, patients were repositioned at least every 2 hours
on only 53% of days. This finding is consistent with several

previous studies showing a low prevalence of reposition-
ing, although the prevalence may vary substantially by
hospital unit.
11,13
In one study, staff members did not
reposition patients as regularly as prescribed despite
knowledge that repositioning should be done,
39
and sev-
eral studies have found that the main reasons cited for not
regularly repositioning patients include lack of time and
lack of staff, rather than a lack of knowledge of turning
protocols.
40
Thus, despite indications that repositioning
is widely accepted as standard care for pressure ulcer
prevention, repositioning does not appear to be fully
implemented.
The prevalence of frequent repositioning was higher
among patients using PRSS when compared with patients
on standard support surfaces, allaying concerns that use of
a PRSS reduces frequent repositioning. These results sug-
gest that providers are using these preventive measures
together for high-risk patients, as is appropriate under
43%
53%

42%
55%
66%
52%
0%
25%
50%
75%
100%
Standard
(n=206)
Static air
overlay (n=52)
Alternating
pressure
overlay (n=26)
Static air
mattress
(n=28)
Alternating
pressure
mattress

(n=18)
Other PRSS
(n=23)
Type of Support Surface
P
ro
p
o
rt
io
n
o
f
d
a
y
s
(
%
)
45%
64%
22%

77%
29%
62%
22%
79%
59%
52%
35%
75%
Figure 1. Proportion of days (and 95% confidence intervals) on
which patients were repositioned at least every 2 hours (�12
times/
day), by type of support surface.
Healing Society 15
current guidelines, rather than using PRSS alone. The
presence of a PRSS may also be a cue to remind providers
to frequently reposition patients. However, we found sub-
stantial variation in the prevalence of frequent reposition-
ing and PRSS use by hospital, indicating that differences
in resource availability or facility policies, such as the pres-

ence of quality improvement initiatives, may play major
roles in the implementation of pressure ulcer prevention
guidelines.
An important limitation of this study is its observational
design; randomized studies are required to provide strong
evidence regarding the effectiveness of this intervention.
However, given that repositioning every 2 hours is the cur-
rent standard of care, it would be difficult and possibly
unethical to perform experimental studies where patients
are randomized to less frequent intervals of repositioning.
To strengthen the inferences drawn from this study, we
adjusted for many known confounders of the association
of interest, but bias due to unmeasured confounders can-
not be excluded. Also, there may be errors in the informa-
tion about frequency of repositioning obtained from
medical records. This limitation is particularly salient as
the prior study by Bates-Jensen et al.
12
found a wide dis-
crepancy between actual repositioning practices and med-
ical record documentation, with documentation rates
much higher than repositioning rates measured by thigh
monitors. As such errors are probably equally likely
among patients who do and do not develop pressure
ulcers, the errors tend to bias results toward the null. An-
other limitation of this study was the relatively small sam-
ple size which limited the power to test the associations of
interest. Finally, our study population was limited to hip
fracture patients age 65 years or older, and results may not
be generalizable to other patients at risk for pressure
ulcers. However, because hip fracture patients are fre-
quently bed-bound for long periods of time in the periop-
erative period, pressure ulcers are a common complication

of immobility among these patients.
17
Thus, elderly hip
fracture patients represent an excellent population in
which to examine repositioning as an intervention to pre-
vent pressure ulcers, and there is no known reason that the
effect of frequent repositioning in this population would
differ from that in other populations at risk for pressure
ulcers. The high incidence of pressure ulcers seen in this
study may be due to the choice of elderly hip fracture
patients (a particularly high-risk group) as the study sam-
ple, but it may also be linked to infrequent repositioning
practices in study facilities. Unfortunately, data were not
available to examine facility polices, practices, or resources
related to repositioning; the contribution of these factors
to pressure ulcer incidence may be an important future
area of study.
Pressure ulcers have been recognized as an important
indicator of quality of care, particularly since the identifi-
cation of stage 3 or 4 pressure ulcers as one of the hospital-
acquired conditions for which the Centers for Medicare
and Medicaid Services will not provide reimbursement.
Clinical practice guidelines for pressure ulcer prevention
recommend the use of frequent manual repositioning in
bed-bound patients, but this study found that the imple-
mentation of this intervention was suboptimal. The imple-
mentation also varied substantially by hospital, indicating
that factors other than patient need influence the choice of
pressure ulcer prevention methods and that the quality of
care for pressure ulcer prevention may differ by facility.
However, the results of this study and others indicate that
we do not yet have evidence for the efficacy of frequent re-

positioning for pressure ulcer prevention. Additional
study is needed to determine if there is a standard interval
at which manual repositioning is effective at preventing
pressure ulcers, or if manual repositioning is only effective
in a subpopulation of bed-bound patients. In the absence
of this information, it is unclear if the variations in care
demonstrated in this study translate into a difference in
patient outcomes, or if decreasing the frequency of reposi-
tioning might reduce the cost and burden of this interven-
tion without increasing the incidence of pressure ulcers.
The current findings call into question the efficacy of turn-
ing as a pressure ulcer prevention strategy, but it is pre-
mature to suggest that frequent manual repositioning is
unnecessary. Repositioning may be more important for
patients at higher risk (i.e., lower scores) by the Braden
scale, but further research is required.
ACKNOWLEDGMENTS
Supported by grants from the National Institute on Aging
(T32 AG000262 and F30 AG034008); National Institute
of Arthritis and Musculoskeletal and Skin Diseases (R01
AR47711); University of Maryland General Clinical Re-
search Center Grant, General Clinical Research Centers
Program, National Center for Research Resources (M01
RR16500); National Institute on Aging Claude D. Pepper
Older Americans Independence Center (P30 AG028747);
and National Institute of Child Health and Human Devel-
opment (K12 HD043489).
Preliminary results from this study were presented as a
poster at the 2009 Annual Scientific Meeting of the Amer-
ican Geriatrics Society, Chicago, IL, April 30, 2009, and at
the 61st Annual Meeting of the Gerontological Society of
America, National Harbor, MD, November 19, 2008. Fi-
nal results from this study were presented at the 137th An-

nual Meeting of the American Public Health Association,
Philadelphia, PA, November 10, 2009.
Data from this study have been the subject of other
analyses, the results of which have been previously pub-
lished. The publications are as follows: (a) Baumgarten,
M., Margolis, D.J., Orwig, D.L., Shardell, M.D., Hawkes,
W.G., Langenberg, P., Palmer, M.H., Jones, P.S., McAr-
dle, P.F., Sterling, R., Kinosian, B.P., Rich, S.E., Sowin-
ski, J., and Magaziner, J. 2009. ‘‘Pressure Ulcers in Elderly
Patients with Hip Fracture Across the Continuum of
Care.’’ Journal of the American Geriatrics Society. 57(5):
863–70. (b) Baumgarten, M., Margolis, D., Orwig, D.,
Hawkes, W., Rich, S., Langenberg, P., Shardell, M.,
Palmer, M.H., McArdle, P., Sterling, R., Jones, P.S., and
Magaziner, J. 2010. ‘‘Use of Pressure-Redistributing Sup-
port Surfaces Among Elderly Hip Fracture Patients
Across the Continuum of Care: Adherence to Pressure Ul-
cer Prevention Guidelines.’’ Gerontologist. 50:253–62. Nei-
ther of these previously published articles have examined
the hypotheses that are addressed in this article.
The authors have no potential conflicts of interest. Dr.
Rich had full access of the data in the study and takes
Healing Society16
responsibility for the integrity of the data and the accuracy
of the data analysis.
Author contributions: Study concept and design: Rich,

Margolis, Amr, Miller, Baumgarten. Data acquisition:
Rich, Shardell, Hawkes, Margolis, Baumgarten. Data
management and analysis: Rich, Shardell, Hawkes. Data
interpretation and preparation of manuscript: Rich,
Shardell, Hawkes, Margolis, Amr, Miller, Baumgarten.
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203
JRRDJRRD Volume 48, Number 3, 2011Pages 203–214
Journal of Rehabilitation Research & Development
Assessing evidence supporting redistribution of pressure for
pressure
ulcer prevention: A review
Stephen Sprigle, PhD, PT;* Sharon Sonenblum, PhD
Rehabilitation Engineering and Applied Research Lab, Georgia
Institute of Technology, Atlanta, GA
Abstract—The formation and underlying causes of p ressure
ulcers (PUs) are qu ite complex, with multiple influencing fac-
tors. However, by definition pressure ulcers cannot form with-
out loading, or pressure, on tissue. Clinical interventions
typically target the magnitude and/or duration of loading. Pres-
sure magnitude is managed by the selection of support surfaces
and postural supports as well as body posture on supporting
surfaces. Duration is addressed via turning and weight shifting
frequency as well as with th e use of dynamic s urfaces that
actively redistribute pressure on the body surfaces. This article
shows that preventative interventions must be targeted to both
magnitude and duration and addresses the rationale behind sev-
eral common clinical interventions—some with more scientific
evidence than others.
Key words: body posture, clinical interventions, postural sup-
ports, pressure magnitude, pressure ulcers, prevention inter-
ventions, support surface, tissue loading, turning frequency,
weight shifting frequency, wheelchair.
INTRODUCTION

The formation a nd underlying c auses of pressure
ulcers (PUs) are quite complex, with multiple influencing
factors. However, by definition PUs cannot form without
forces, or press ure, on tissue. Because tissue loading is
the defining characteristic of PU formation, i t naturally
garners significant attention in research in PU prevention
strategies.
Research has clearly demonstrated that the damaging
effects of pressure are related to both its magnitude and
duration. Simply stated, tissues can withstand higher
loads for shorter periods of time. Kosiak first demon -
strated this characteristic 50 years ago by applying vary-
ing loads to the trochanters and ischial tuberosities of
dogs for varying periods of time [1]. High loads for short
durations and low loads for long durations induced
ulcers, with the time-at-pre ssure curve following an
inverse parabola. Reswick and Rogers tried to extend this
animal research into clinica lly relevant i nformation, and
using combinations of interviews and interface pressure
measurements (IPMs), de termined a pressure-time rela -
tionship that was similar to that of Kosiak [2].
Using the premise that both the ma gnitude and dura-
tion of loading are important, we c an diagram a simple
model of PU development (Figure 1) that illustrates the
reasoning behind certain clin ical interventions. Pressure
magnitude is managed by the selection of support sur-
faces and postural supports as well as body posture upon
supporting surfaces. Duration is a ddressed via turning
and weight shifting frequency as well as with the use of
dynamic surfaces that a ctively redistribute pressure on
the body surfaces.

Abbreviations: IPM = interface pressure measurement, Mobil-
ity RERC = Rehabili tation Engineering Research Center on
Wheeled Mobility, PU = pressure ulcer, SCI = spinal cord
injury.
*Address all correspondence to Stephen Sprigle, PhD, PT;
Georgia Tech–Applied Physiology, 490 Tenth St NW,
Atlanta, GA 30032-0156; 404-385-4302; fax: 404-894-9320.
Email: [email protected]
DOI:10.1682/JRRD.2010.05.0102
mailto:[email protected]
204
JRRD, Volume 48, Number 3, 2011
This article reviews the evidence supporting clinical
interventions that address the magnitude of pressure and
the duration of that pressure. Within this article, “support
surfaces” will refer to devices designed for horizont al
(mattresses, overlays) and s eated (wheelchair cushions)
postures. The ter m “pressure” will refer to the force or
load exerted over an area of the body or on a lo calized
area of the body surface.
LOADING
A fairly extensive amount of re search has applied
loads to tissues and monitored physiological outcomes.
For obvious re asons, research with animal models uses
controlled loading to create PUs or tissue necrosis,
whereas human studies are limited to indirect measures,
such as the effect of loading on blood flow.

Tissue Response to Loading in Animal Models
As mentioned previously, Kosiak u ndertook seminal
research by applying load s to the trochan ters and isch ial
tuberosities of dogs [1]. Load s ranged from 100 to
500 mmHg, and durations ranged from 1 to 1 2 hours.
Kosiak monitored animals for 14 days postischemia to
determine the occurrence of PUs. Dinsdale applied pres-
sures between 45 and 1,500 mmHg for 3 hours to swine
with and without paraplegia [3]. Normal pressure was com-
bined with friction in half the specimens. The results indi-
cated that no necrosis occurred with normal pressures
below 150 mmHg, but in combination with friction, tissue
changes could be seen after loading with 45 mmHg. Daniel
et al. also studied swine with and without paraplegia [4].
Using an indenter to apply load at the greater troch anter,
they found that application of 200 mmHg for 15 hours did
not induce a PU. Ulcers were obtained by applyin g
500 mmHg for 4 hours and 800 mmHg for 8 hours.
Linder-Ganz and Gefen exposed rat hind limbs to
pressure magnitudes of 86, 262, and 525 mmHg for 2, 4,
and 6 hours, respectively [5]. They used finite ele ment
modeling to calculate internal stresses and concluded that
tissue damage occurred with 13 kPa o f internal stress
applied for 6 hours and 40 kPa of interna l stress applied
for 2 ho urs. Both conditions represent an approximate
stress application rate of 80 kPa/h.
While this is not a comprehensive list of animal PU
etiology research, collectiv ely the studies illustrat e
results obtained by applying different loads over different
durations (Table). The use of different sizes and shapes
of indenters, dif ferent loading parameters , and different
animal models explains why a range of mag nitudes and

durations are linked to PU development. Despite these
differences, the evidence suggests that both magnitude
and duration of loa ds must be considered in PU preven -
tion and validates the simple intervention model in
Figure 1.
Blood Flow Response to Loading in Humans
While research has clearly shown a rela tionship
between pressure magnitude and duration and tissue
damage, these studies have not de fined a critical ma gni-
tude above whic h ischemia occurs. Many studies have
used controlled experimental approaches for determining
the pressure at whic h blood flow to tissue cea ses with
significantly varying results. Lassen and Holste in found
that the pressure required for vascular occlusion approxi-
mated diastolic pressures when the measured skin
approached heart level [6]. Holloway et al. loaded the
forearm and found that blood flow decreased as external
pressure approached mean arterial pressure and that
occlusion was reached at ~120 mmHg [7]. Ek et al. found
“weak positive correlations” between blood flow during
Figure 1.
Rationale for redistribution of pressure.
205
SPRIGLE and SONENBLUM. Redistributing pressure to
prevent pressure ulcers
loading at the heel and systolic blood pressure [8]. Load-
ing at the sac rum did not resu lt in the same relationship
with blood pressure. Sangeorzan et al. de termined that

71 mmHg was need ed to occl ude flow over the tibialis
anterior (a “soft” site) but only 42 mmHg occluded flow
over the tibia (a “hard” site ) [9]. Bennett et al. measured
occlusion pressure at the thenar eminences of nondis -
abled subjects and found that 100 to 120 mmHg was nec-
essary to occlude v essels in “low shear” conditions and
60 to 80 mmHg was needed in the pre sence of “high
shear” conditions [10]. Bar re viewed the literature and
concluded that a critical pressure is necessary to occlude
blood flow and that while this threshold is related to ves-
sel pressure, it appears to vary widely [11].
The animal and human studies contribute important
information to the field of PU research by identifying tis-
sue’s response to external loads. However, the results are
very hard to apply clinically. Controlled loading at specific
anatomical sites simply doe s not generalize to the person
lying in bed or sitting in a wheelchair. For exa mple, the
magnitudes and durations of loading used to induce dam -
age in animals greatly exceed those deemed a cceptable in
clinical environments. This apparent discrepancy does not
invalidate either the research or the clinical interpretation
of the findings. Rather, these animal tests inform us about
the mechanism of injury and the complex relationships
between the variables involved when supporting the
human body in sitting or lying positions.
To date, research has not identified a specific thresh-
old at which loads can be d eemed harmful across people
or sites on the body. Tissue’s tolerance to load varies
according to the condition of the tissue and its location,
age, hydration, and metabolism. All the factors common
to PU risk assessment tools tend to influence how the tis-
sue distributes the loading and its ability to wi thstand
load.

INTERVENTIONS
Support Surfaces
Support surfaces attempt to redistribute forces away
from bony prominences, thereby reducing the magnitude
of loading at these at-risk sites. In general, creating suc -
cessful support surfaces is challenging because of the dif-
ferences in ind ividual risk factors, as well as the
complicated nature by which force is distributed through-
out tissue. For example, when a person sits on a cushion,
normal loading works in combination with shear and fric-
tional forces to induce complex tissue distortion. Conse-
quently, myriad support surface designs ex ist that have
benefit for some p eople, but for the most part, no single
surface is optimal for all persons. Two very general cate -
gories of support surfaces can be defined: reactive sur-
faces that respond to the load placed upon them and active
surfaces that dynamically a lter the body–support-surface
interface. Although active surfaces serve as a duration
intervention, their primary role as a supp ort surface (thus
affecting magnitude of loading) makes it natural to
present them together with reactive support surfaces.
Table.
Examples of animal pressure ulcer models highlighting different
loading parameters.
Author Animal Model Loading Conditions Outcome
ischial tuberosity
100–500 mmHg over 1–12 h Proposed inverse magnitude-
duration

relationship.
Dinsdale [2] Swine with and w
spinal injury
45–
and without friction
Loading at 45 mmHg in the presence
of friction-induced damage.
spinal injury
200 mmHg for 15 h, 500 mmHg
for 4 h, 800 mmHg for 8 h
No damage at 200 mmHg for 15 h,
but damage under other conditions.
Linder-Ganz & Gefen [4] Rat hind limbs 86, 262, and 525
mmHg for 2, 4,
and 6 h, respectively
Tissue damage occurred with loading
rate of 80 kPa/h.
1. Kosiak M. Etiology and pathology of ischemic ulcers. Arch
Phys Med Rehabil. 1959;40(2):62–69. [PMID: 13618101]
2. Dinsdale SM. Decubitus ulcers in swine: Light and electron
microscopy study of pathogenesis. Arch Phys Med Rehabil.
1973;54(2):51–56. [PMID: 4692634]
3. Daniel RK, Wheatley D, Priest D. Pressure sores and
paraplegia: An experimental model. Ann Plast Surg.
1985;15(1):41–

DOI:10.1097/00000637-198507000-00005
4. Linder-Ganz E, Gefen A. Mechanical compression-induced
pressure sores in rat hindlimb: Muscle stiffness, histology, and
computational models. J Appl Phys-
iol. 2004;96(6):2034–
DOI:10.1152/japplphysiol.00888.2003
http://www.ncbi.nlm.nih.gov/pubmed/13618101
http://dx.doi.org/10.1097/00000637-198507000-00005
http://dx.doi.org/10.1152/japplphysiol.00888.2003
206
Judging the effectiveness of support surfaces is done
with both direct and indirect methods. Indirect methods
use physiological means such as blood flow , tissue oxy-
genation, and interface pressure to judge performance.
Direct methods follow a group of patients over time to
determine PU occurrence. Direct methods are more valu-
able but are harder to adminis ter and are limited in the
number of interventions that can be inve stigated (i.e.,
types of surfaces).
In their systematic review focused on randomiz ed
controlled trials with PU development as an outcome,
Cullum et al. used the term “constant low-pressure sup-
port surfaces” to describe the myriad foam, air , water,

and elastomeric mattresses, overlays, and cushions [12].
Their review of the literature concluded that these sur-
faces outperform standard hospital mattresses in prevent-
ing PU formation. Comparisons between dif ferent
constant low-pressure surfaces did not result in definitive
outcomes. In othe r words, differences across the more
common reactive surfaces have not been demonstrated in
terms of PU outcomes.
Studies on wheelchair cushions are not as common as
those on mattresses, but informative evidence is still
available. Indirect measures, specifically interface pres-
sures, comprise the bulk of studies on cushions [13–16].
Researchers have shown tha t high s eated interface pres-
sures were associated with PU occurrence [17–19].
Therefore, despite the limita tions in IPM as a less accu-
rate representation of localized loading [5,20–22], it can
be useful in selecting cushions.
Because active surfaces vary loading of pa rticular
regions of the body, they intend to alter both the magni-
tude and duration of loading. Active surfa ces are avail-
able for both mattresses and wheelchair cushions, with
mattresses being use d and studie d more freque ntly. In
part, this is the result of a funding decision in the United
States by the Ce nters for Me dicare and Medic aid Ser-
vices to not pay for powered wheelchair cushions for PU
prevention. Evidence on commercially available a ctive
cushions is limited to seco ndary outcomes [16,23].
Because the secondary measurements vary throughout
the cycle of ac tive cushions, the results of such studies
are hard to apply clinically.
Studies of active mattresses and overlays a re more
common than those of cushions and have used both direct
and indirect outcomes. Two recent systematic reviews do

a very thorough job of covering the literature on alternat-
ing pressure mattresses so the details will not be repeated
here [12,24]. Cullum et al. focused exclusively on direct
outcomes (PU development), while Vanderwee et al.
extended their review to include studies with indirect out-
come measurements and a lternative study designs. But
both groups reached the same conclusions: alternating
pressure air mattres ses are better than standard hospital
mattresses but their bene fit over constant low -pressure
mattresses is unclear. Furthermore, differences across
types of alternating pressure air mattresses were not dem-
onstrated. Active surfaces also provide inc reased poten-
tial for mechanical problems and user error compared
with some alternatives. One major limitation of most of
the reviewed studies, as pointed out by Cullum et al., was
that turning schedules were not controlled. Therefore, it
is possible that nurses made a point to turn patients on the
standard mattresses more frequently than those on the
active surfaces because of a perceived need for increased
intervention. If true, than comparable outcomes could
come with the benefit of re duced clinical intervention
time for the active surfa ce, but research to evaluate this
possibility is needed.
Interventions for Reducing Duration of Loading
The body’s motor and sensory systems are responsi-
ble for ensuring that we move periodically to change our
posture. This may be in the form of discomfort eliciting
movement or subconscious postural shifts or fidgeting.
Many studies over the years have monitored movements
in chairs a s metrics of co mfort and function [25–28],
thereby establishing a base of knowledge about sitting as
a dynamic activity. Many people at risk of dev eloping
PUs are either unable to effectively reposition themselves

or are not provided with the sensory feedback that elicits
movements. Therefore, that loss of mobility and sensa-
tion are identified as risk fa ctors within every PU risk
assessment scale is not surprising.
We use this information to tar get movement as a
means of redistributing pressure and altering the duration
of loading on tissues. Cli nically, this includes turning
schedules for patients who are in bed and weight shifting
strategies for those who are seated.
Turning Frequency
In a st udy on PU prev ention interventions, Richard -
son et al. found that manual repositioning was the most
commonly used intervention and that it was also the most
expensive [29]. The idea of necessary repositioning has
appeared throughout literature and textbooks since the
207
1800s [30]. Evidence that some repositioning is neces-
sary can be found across decades of literature.
In the United S tates, common practice requires that
at-risk patients be repositioned at least every 2 hours if
consistent with overall patient goals [31]. Despite efforts
by a number of researchers to identify the origins of this
practice, or at the very least identify evidence supporting
the 2-hour turning practice, no strong scientific support
exists [30,32–33]. In fact, earlier texts often included

suggestions that the turning schedule depend on the mag-
nitude of loading and condition of the patient.
Therefore, the s tandard practice of using the sa me
turning schedules independent of support surface is not
reflective of earlier work. Re cent evidence demonstrates
the need to account for the support surface in determining
the optimal turning schedule. Defloor et a l. showed that
2- and 3-hour turning schedules resulted in the develop-
ment of PUs in 14 to 24 percent of patients lying on
standard mattresses. A 6-hour turning sc hedule for
patients lying on a viscoelastic mattress resulted in simi -
lar outcomes, but a 4-hour turning schedule for patie nts
lying on a visc oelastic mattress signific antly reduced
stage II PUs . Other research suggests that turning ma y
need to occur more frequently than every 2 hours and that
sufficient pressure reduction surfaces are needed in addi -
tion to turning [32,34–36]. Recently, Vanderwee et al.,
using a pressu re-reducing mattress, found no difference
between repositioning patient s every 4 hours and alter -
nating between 2 hours in late ral and 4 h ours in supine
[36]. In both interventions, more than 16 percent of parti-
cipants developed a PU. Additionally, two studies of sec-
ondary outcomes demonstrated that redness and ox ygen
reduction while lying in bed occurred in less than 2 hours
[37]. Furthermore, in studies on turning, patients who are
able will change posture between scheduled reposition-
ings. As a result, these subjects are exposed to more posi-
tion changes than offered by the intervention, which may
mask a need for more frequent repositioning in those
unable to reposition themselves [36]. The necessary repo-
sitioning frequency may be so high that implementation
is impractical for immobile patients [32].
Positioning Devices and Posture
The entire premise behind turning is obviously to

reduce the amount of time di fferent body surfaces are
exposed to loading. Operati onally, many facilities
sequence between supine and two side-lying postures.
The loading at specific body surfaces is highly dependent
on the resulting postures an d any positioning devices
used. For example, side lyin g may expose a malleolus to
damaging loading but proper positioning of the lower
limbs and judicious use of positioning devices can effec-
tively reduce loa ds from this bony prominence ( Figure
2(a)). Adopting a supine posture with the head of the bed
elevated alters loading on the buttocks, which is why it is
a controversial posture. Elevating only the head of the
bed increases both the normal and frictional forces on the
sacrum [38–39]. Mechanics suggests that as the head ele-
vates, more of the upper-body weight will be transmitted
through the buttocks to the supporting surface. In addi-
tion, the tendency to slide is increased as the trunk sup -
port is inclined. The complication is that it is a functional
posture, adopted so people can converse with others ,
read, and eat, to name a fe w activities. Some of the fric -
tional forces can be counteracted by raising the foot of
Figure 2.
(a) Use of positioning devices to redistribute pressure and (b)
raising
foot of bed counteracts sliding tendency.
208
the bed, but this will not reduce the normal forces on the

buttocks [38] (Figure 2(b)).
The seated posture also affects how loads are re distrib-
uted. Sitting on a sling seat with a pelvic obliquity induces
asymmetric loading on the isch ial tuberosities, not to men-
tion contributing to postural instability (Figure 3(a)). A
slouched, kyphotic posture is typ ified by p osterior pelvic
tilt, a posture that loads the sacrum and coccyx while seated
(Figure 3(b)) [40–41].
In summary, body posture and positioning have a
direct relationship to loads on specific body sites, which
is why posture must be co nsidered when devising PU
prevention strategies.
Weight Shifting
Wheelchair users are often at high risk of developing
sitting-acquired PUs. Persons with absent or diminished
sensation and/or mobility are always at high risk of PUs
[42–43]. A variety of maneuvers to shift body weight off
the buttocks are taught to wheelchair users at risk of PUs.
They can push down on the seat or armrests to lift the
buttocks off the cushion s urface (Figure 4(a)), lean for -
ward to rest t heir trunk upon the lower limbs (Figure
4(b)), or lean to one side and then lean to the opposite
side (Figure 4(c)). Persons who use power wheelchairs
and cannot independently perform these maneuvers are
sometimes prescribed variable position wheelchairs that
incorporate powered tilt and/or recline to redistribute
weight off the buttock area (Figure 5).
Most guidelines that suggest weight shift or pressure
relief frequency have been developed for p ersons with
spinal cord injury (SCI) because of the effect of SCI on
sensation and mobility. For the SCI po pulation, recom-

mendations for weight shift frequency have typically
ranged from 15 to 30 seconds every 15 to 30 minutes to
60 seconds every hour [44–47]. Based on the wide range
of these guidelines, one can infer that they were based on
a combination of clinical experience, clinical insight, and
research findings.
In addition to weight shift frequency, one must also
consider the duration for which a weight shift is held . In
other words, not only do wheelchair users have to perform
weight shifts regularly, they must attend to the duration of
these maneuvers. The ability to sustain a weight shift is
dependent on myriad factors, including functional ability,
strength, flexibility, and postural control [46]. A 2003 study
measured tissue perfusion to investigate the length of time
required for tissue to rep erfuse in an SCI cohort ( n = 46)
[48]. The mean duration of weight shift required to return
transcutaneous partial pressure of oxygen to unloaded lev-
els following upright sitting was 1 minu te 51 seconds
(range = 42– 210 seconds). This fin ding suggests that the
Figure 3.
(a) Pelvic obliquity from sitting on sling seat and (b) posterior
pelvic
tilt loads sacrum and coccyx.
209
duration of weight shifts currently recommended (i.e., 15–
30 seconds) is inadequ ate. Further, this suggests that th e

common practice of sitting push-ups is not sustainable for
many to achieve reperfusio n. Consequently, the authors
supported the use o f alternate, sustainab le methods of
weight shift, namely fo rward lean, lateral lean, and rear -
ward tilt. Partial weight shifts may also allow for better sus-
tainability by persons with SCI.
Figure 4.
(a) Push-up weight shift, (b) forward-lean weight shift, and (c)
side-
lean weight shift.
Figure 5.
(a) Manual Tilt-in-Space wheelchair and (b) Power T ilt-in-
Space
wheelchair. Images used with permission. ©Invacare
Corporation.
210
Three recent studies inve stigating PU prevalence in
an SCI cohort considered weight shift behavior as a
potential risk factor [49–51]. None of the st udies found
weight shift behavior or frequency of weight shifts to be
associated with PU occ urrence. However, each of the
studies used self-report to measure weight shift practices.
Further objective analyses ar e needed to determine the
role of weight shifts in PU prevention.
CONCLUSIONS
The review of res earch corroborated the clinical

interventions commonly used for load redistribution but
also identified areas of uncertainty. As with all means of
prevention, some interventions are better supported than
others and some interventions have a legacy quality to
them and little el se. Nonetheless, several clinically ori-
ented suggestions can be made.
Support Surface Assessment
Selections of mattre sses, overlays, and cushions
should be based upon as sessment. Research is cle ar that
individual factors can contribute to PU susceptibility, and
all the PU risk assessment scales are based upon indi -
vidualized evaluation. Research has also shown that indi-
vidualized evaluation improves the selection of mattress
[52] and wheelchair cus hions [53]. Long-standing evi-
dence supports the use of seating clinics to select and pre-
scribe wheelchair cushions [54]. One of the benefits of
this type of individuali zed evaluation is its educational
aspect in informing patients and clients about skin health
and proper equipment use.
Interface Pressure
Interface pressure can be used to identify a reas of
unacceptably high pressures and to ensure a s ite is a de-
quately off-loaded during posture changes or a weight
shift. We advocate for use of pressure mapping to rule out
products rather than as a sole means to presc ribe a par-
ticular product [21]. For exa mple, if the interface pres-
sure under the ischial tuberosity is deemed too high for a
particular person by a clinician, then the clinician should
deem that p roduct unacceptable. That said, one cannot
infer that published IPM va lues will generalize to other
clients or patients. Another useful role for IPM is as sess-
ing how posture or position changes influence loading on

tissue. Repositioning in bed or while seated is necessary
to unweight different parts of the body. IPM can offer
visual feedback to clinicians, patients, and clients as they
sequence through different postures.
Weight Shift and Turning Frequency
Periodic repositioning is an important preventative
measure. Patients and clients who can independently
redistribute pressure should be educated to do so and
taught strategies to ensure compliance. Persons who can-
not reposition must rely on others to set and follow a rou-
tine. Evidence on how often a weight shi ft should be
performed and evidence behind turning schedules is lim-
ited. The odds are that repositioning frequency is not the
same for all people and surfaces. This can be inferred by
the wealth of evidence in dicating the individualized
nature of PU ris k and supports the approach that reposi-
tioning frequency should reflect the person, his or her
equipment, and the environment of use.
• Standard hospital beds are poor support surfaces.
Ample evidence has show n that standard ma ttresses
are inadequate to prevent PU s. Even relati vely “low
tech” mattresses and overlays offer better prevention
[12].
• Increasing activity has many health benefits, includ-
ing tissue health. In a study of more than 600 persons
with SCI with and without a history of recurrent PUs,
Krause and Broderick identif ied behaviors that were
shown to be protective [50]. These behaviors included
a healthy lifestyle, fitness, and exercise. Putting peo-
ple into equipment and postures that permit functional
activity addresses the key PU risk fac tor of immobil-

ity. We should promote reaching, leaning, and moving
as a means of promoting functional independence and
maintaining skin integrity.
• The European and U.S. National Pressure Ulcer Advi-
sory panels have recently released their joi nt Interna-
tional Pressure Ulcer Guidelines for Prevention and
Treatment. The document addresses both PU preven-
tion and PU trea tment by assessing many clinical
interventions.
• When reviewing conflicting literature, pay close atten-
tion to external validity. Literature regarding pressure
redistribution and support surfaces is o ften equivocal
and may be contradictory. This can oc cur because of
differences in methods, measurements, and subjects.
When reviewing literature, pay attention to how the
studies reflect your clinical situation. P erhaps some
studies better reflect your patient mix or techniques.
211
ACKNOWLEDGMENTS
Study concept and design: S. Sprigle, S. Sonenblum.
Analysis and interpretation of data: S. Sprigle, S. Sonenblum.
Drafting of manuscript: S. Sprigle, S. Sonenblum.
Critical revision of manuscript for important intellectual
S. Sprigle, S. Sonenblum.

Administrative, technical, or materia
S. Sonenblum.
Financial Disclosures: The authors have declared that no
competing
interests exist.
Funding/Support: This material was based on work supported by
the
Rehabilitation Engineering Research Center on Wheeled
Mobility
(Mobility RERC) and the Georgia Institute of Technology. The
Mobil-
ity RERC is funded by the National Institute on Disability and
Reha-
bilitation Research of the U.S. Department of Education (grant
H133E080003).
Additional Contributions: We thank Dr. Kath Bogie for her
guid-
ance in outlining the manuscript and offering important
feedback.
Disclaimer: The opinions contained in this article are those of
the
authors and do not necessarily reflect those of the U.S.
Department of
Education or the Georgia Institute of Technology.
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