This article is designed to help users and carers in the public domain to learn more about preventing pressure ulcers when sitting in a chair or wheelchair. It is not intended for clinicians. The article was put together by BHTA industry expert members.

What is a pressure ulcer?

A pressure ulcer is any area of localised damage to the skin and underlying soft tissue. There are a number of risk factors, including age, diagnosis, medication, continence, nutrition, mobility, and weight. There are also other factors not specific to the person, such as the support surface, temperature, and moisture. (1)

Whilst sitting, the skin and soft tissues get squeezed and deformed between the bone and the support surface. Over time this can cause the cells to die and the area of resulting dead tissue is called a pressure ulcer.

TIP: Everyone is potentially at risk of developing a pressure ulcer (2)

Why is sitting important in pressure ulcer prevention?

When sitting in an upright stable position, we still have localised high-pressure areas:

Therefore, posture and pressure are linked, with both affecting one another.

Why might someone be at risk of pressure ulcers?

• Neurological impairment
• Changes in body shape and size
• Little or no active movement
• Movements that are difficult to control
• Lack of body awareness and/or sensory impairments
• Difficulty communicating discomfort

What are the signs and symptoms to look out for?

Early symptoms of a pressure ulcer include:

• Persistent discolouration of the skin
• Discoloured patches not turning white when pressed
• A patch of skin that feels warm, spongy, or hard
• Pain or itchiness in the affected area
• The skin may not be broken at first, but if the pressure ulcer gets worse, it can form an open wound or blister
• A deep wound that reaches the deeper layers of the skin
• A very deep wound that may reach the muscle and bone (4)

How does a pressure ulcer affect a person?

• The impact of a pressure ulcer on a person is significant, with their being affected physically, psychologically, socially, emotionally, spiritually, and financially (5)
• Pressure ulcers are often painful and debilitating (6)
• Infected ulcers can cause an unpleasant odour and further health problems
• Healthcare professionals may advise keeping weight off the pressure ulcer to allow healing, which can impact on independence and interaction

TIP: With care, pressure ulcers are mostly preventable (7)

Prevention can not only improve a person’s outcomes, but it can also reduce the costs to the NHS and benefit the wider community:

Where can you get further information or advice?

Consult a general practitioner or healthcare professional for information and advice on:

• Ensuring a regular change of position: a person with a pressure ulcer, or at risk of developing a pressure ulcer, needs to change position frequently
• Considering pressure relieving and postural management equipment
• Applying special dressings that speed up the healing process
• Eating a healthy, balanced diet

TIP: Chair functions, such as tilt-in-space, can be effective in redistributing pressure

Case study:

• Mrs A, a 72-year-old lady diagnosed with dementia
• Mrs A is frail, generally weak, and not always aware of her position
• She struggles to sit upright and tends to slump with her head falling forward
• Without a chair that is set up to her body shape and size, she is at risk of discomfort, sliding out of the chair, not being able to eat or drink safely, and developing pressure ulcers
• With the appropriate chair, she is more comfortable, and her risk of pressure ulcers is reduced. She has a more stable upright position and her head is supported, making it easier for her to eat, drink and communicate
• Needs regular change of position
• Needs regular skin inspection to check if damage has started

References:

1. European Pressure Ulcer Advisory Panel (EPUAP), National Pressure Ulcer Advisory Panel (NPUAP), Pan Pacific Pressure Injury Alliance (PPPIA) (2014) Prevention and Treatment of Pressure Ulcers: Quick Reference Guide Available from: http://www.epuap.org/wp-content/uploads/2016/10/quick-reference-guide-digitalnpuap-epuap-pppia-jan2016.pdf
2. 2. National Institute for Health and Care Excellence (NICE) (2014) [CG179] Pressure ulcers: prevention and management. Available from: www.nice.org.uk/ guidance/cg179
3. Collins F (2001) Selecting cushions and armchairs: how to make an informed choice Journal of Wound Care / Therapy Weekly Supplement 13(5)
4. 4. NHS (2017) Pressure ulcers (pressure sores) Available from: https://www.nhs.uk/conditions/pressure-sores/#symptoms-ofpressure-ulcers
5. 5. Langemo DK (2005) Quality of Life and Pressure Ulcers: What is the Impact? Wounds 17(1)
6. 6. Moore ZE, Webster J, Samuriwo R (2015) Wound-care teams for preventing and treating pressure ulcers Cochrane Database Syst Rev 16(9)
7. 7. NHS Improvement (2018) Stop the Pressure Available from: http://nhs.stopthepressure.co.uk/
8. 8. Jan YK, Crane BA, Liao F, Woods JA, Ennis WJ (2013) Comparison of muscle and skin perfusion over the ischial tuberosities in response to wheelchair tilt-in-space and recline angles in people with spinal cord injury Archives of Physical Medicine and Rehabilitation 94(10):1990-6

This article is designed to help users and carers in the public domain to learn more about good posture when sitting in a chair or wheelchair. It is not intended for clinicians. This article was put together by BHTA industry expert members.

What is posture?

Posture is the way we hold ourselves or body segments in relation to one another and their orientation in space. Body positioning can be intentional or unintentional.

Body segments (1):

Posture has two main purposes:

1. Antigravity – to provide the rigidity needed to maintain an erect posture against gravity
2. Interface with the outside world – to orientate body segments to interact with the environment

The body structure is a very complex system. It is naturally unstable but highly flexible, which allows for a wide variety of postures but also makes it very vulnerable to damage.

TIP: Posture is influenced by body shape and size, the supporting surface, and even health or emotional state

Why is good posture important?

• Enables independence
• Encourages interaction
• Promotes physiological function
• Manages comfort levels and quality of life

When poor seated posture is adopted over prolonged periods of time, a person can experience:

• Muscle fatigue and associated pains e.g. lower back pain or neck pain
• Organ dysfunction e.g. breathing and digestion
• Limitations in activity e.g. difficulty with eating and drinking
• Limited range of movement in joints and/or altered body shape
• Other health issues e.g. pressure ulcers, bowel and/or bladder problems

What is good posture?

Good posture (2):

• Facilitates effective functional performance
• Is energy efficient
• Does not harm the body systems

TIP: Failure to manage posture can result in many health complications

What is postural management?

Postural management is the use of any technique to minimise postural problems and enhance health (3). It must be individualised, targeting all body segments. It must also take into consideration the full 24-hour period.

How might someone who is having difficulty with their posture sit?

TIP: Select a chair to suit body shape and size

Why might someone have difficulty managing their posture?

• Neurological impairment
• Changes in body shape and size
• Little or no active movement
• Movements that are difficult to control
• Lack of body awareness and/or sensory impairments
• Difficulty communicating discomfort

Where can you get further information or advice?

Contact a healthcare professional for advice on postural management.

Case study:

• Mr. A, a 35-year-old gentleman diagnosed with cerebral palsy
• Mr. A has muscle spasms and stiffness
• He has a curved spine and struggles to sit upright
• Without a chair that is set up to his body shape and size, he is at risk of pain, not being able to eat or drink safely, and developing pressure ulcers
• With the appropriate chair, he is more comfortable, and his risk of pressure ulcers is reduced. He has a more stable upright position, making it safer for him to eat, drink and communicate, and manage his muscle problems

References:

1. Pope PM (2002) Posture management and special seating In Edwards S (Ed) Neurological Physiotherapy London: Churchill Livingstone
2. Pope PM (2007) Severe and Complex Neurological Disabilities: Management of the Physical Condition London: Butterworth-Heinmann
3. Farley R, Clark J, Davidson C, Evans G, MacLennan K, Michael S, Morrow M, Thorpe S (2003) What is the evidence for the effectiveness of postural management? International Journal of Therapy and Rehabilitation 10(10):449-455

The BHTA has produced this guidance to ensure families and carers understand what an assessment is and what outcomes should be achieved.

Assessments can be face to face or virtual, depending on the type of equipment being assessed for. Regardless of whether the assessment is online or in person, there are certain things you can do to make sure you and your family get the most out of the process.

A health professional will carry out the assessment. They must be qualified, trained, and experienced in identifying needs and offering suitable solutions for disabled children.

If your child has an education, health and care plan (EHCP) in place, it is important that any needs identified in the assessment are included and specified in the plan. There are legal obligations for the EHCP to cover all needs identified in relation to education, health, and care, including equipment provision (as stated in the Children & Young People’s Act 2014).

Before the virtual or face-to-face assessment

Questions to ask before the assessment:

• Why does my child need an assessment?
• What equipment is my child being assessed for?
• Who will attend the assessment and how long will it take?
• What information should I receive before the meeting, and who will provide this?
• Does my child need to be off school?
• Does my child need to be well on the day of the assessment?

It’s important to know where the assessment will take place. If your child’s needs are such that you would prefer the assessment to take place at home, you can request this. However, some assessments may need to take place in a clinic for practical reasons, in order to achieve the best outcome for your child. An example of this might be when the equipment being considered needs to be tried out.

If your assessment is virtual, it is important to know how the call will be accessed and which platform it will be on (Zoom or Teams, for example). Any reputable organisation will be happy to take you through a trial call so any technical difficulties can be ironed out.

If the assessment is for larger pieces of equipment, it can be helpful to see the room where it will be used. It can also be useful to have a tape measure to hand to give dimensions, if needed. There may be further questions which will be asked on the day, and sometimes a physical assessment may be necessary following a virtual one.

If the assessment is virtual, it is important to check your internet connection to make sure it is working correctly.

On the day of the assessment

Prepare your child for the assessment by explaining what will happen.

Follow the “Nothing about me, without me” approach.

It’s important that the assessment does not feel rushed. If you are concerned that your child is uncomfortable during the assessment and that it won’t be possible to get an accurate picture of their needs, ask to reschedule.

If you have concerns about the equipment being discussed, you can raise them during the assessment.

If the therapist believes a specific piece of equipment is needed, they need to ensure that either you or the family understand why and how it will contribute to your child’s wellbeing.

Before the assessment is completed, there should be time to ask questions. You may want to know:

• What’s going to happen next?
• How long will it be until I hear the outcome of the assessment?
• Who can I contact if I have any questions or concerns?
• Who will make a decision?
• How will I be informed?