The biomechanics of sitting‐acquired pressure ulcers in patients with spinal cord injury or lesions

Sitting‐acquired pressure ulcers (SAPU) in permanent wheelchair users with traumatic or non traumatic disorders of the central nervous system (CNS) are a great medical challenge. The purpose of this review is to summarise what is currently known concerning the aetiology of SAPU, particularly in its severe form, which may now be classified as a ‘deep tissue injury’ according to the US National Pressure Ulcer Advisory Panel. Specifically, this review focuses on biomechanical aspects of deep SAPU and describes the relevant bioengineering methodologies and research evidence. It discusses the unique biomechanical conditions in deep tissues, which are caused by chronic sitting associated with CNS disorders, and overall, the present review indicates that avoiding interface pressures above 32 mmHg in such patients is not necessarily a ‘pressure relief.’

[1]  J. Reuler,et al.  The pressure sore: pathophysiology and principles of management. , 1981, Annals of internal medicine.

[2]  G A Ksander,et al.  An In‐Depth Look at Pressure Sores Using Monolithic Silicon Pressure Sensors , 1984, Plastic and reconstructive surgery.

[3]  C. Oomens,et al.  The etiology of pressure ulcers: skin deep or muscle bound? , 2003, Archives of physical medicine and rehabilitation.

[4]  Cees W J Oomens,et al.  In vitro models to study compressive strain-induced muscle cell damage. , 2003, Biorheology.

[5]  M Meehan,et al.  National pressure ulcer prevalence survey. , 1994, Advances in wound care : the journal for prevention and healing.

[6]  Dan L. Bader,et al.  Effects of Compressive Loading Regimens on Tissue Viability , 1990 .

[7]  A. Gefen,et al.  Pressure-time cell death threshold for albino rat skeletal muscles as related to pressure sore biomechanics. , 2006, Journal of biomechanics.

[8]  C. Dangoisse,et al.  [Prevention and treatment of pressure ulcers]. , 1991, Revue medicale de Bruxelles.

[9]  J. B. Reswick,et al.  Experience at Rancho Los Amigos Hospital With Devices and Techniques to Prevent Pressure Sores , 1976 .

[10]  Amit Gefen,et al.  Stress relaxation of porcine gluteus muscle subjected to sudden transverse deformation as related to pressure sore modeling. , 2006, Journal of biomechanical engineering.

[11]  M. Versluysen.  How elderly patients with femoral fracture develop pressure sores in hospital. , 1986, British medical journal.

[12]  J. D. Shea.  Pressure sores: classification and management. , 1975, Clinical orthopaedics and related research.

[13]  M J Peterson,et al.  Measurement and redistribution of excessive pressures during wheelchair sitting. , 1982, Physical therapy.

[14]  Cwj Cees Oomens,et al.  Quantification and localisation of damage in rat muscles after controlled loading; a new approach to study the aetiology of pressure sores. , 2001, Medical engineering & physics.

[15]  M. Kosiak,et al.  Etiology and pathology of ischemic ulcers. , 1959, Archives of physical medicine and rehabilitation.

[16]  I. D. Swain,et al.  The effects of posture, body mass index and wheelchair adjustment on interface pressure , 1997 .

[17]  C. Oomens,et al.  Can Loaded Interface Characteristics Influence Strain Distributions in Muscle Adjacent to Bony Prominences? , 2003, Computer methods in biomechanics and biomedical engineering.

[18]  Robert Ragan,et al.  Seat-interface pressures on various thicknesses of foam wheelchair cushions: a finite modeling approach. , 2002, Archives of physical medicine and rehabilitation.

[19]  J. Bugaresti,et al.  A review of body mass index and waist circumference as markers of obesity and coronary heart disease risk in persons with chronic spinal cord injury , 2005, Spinal Cord.

[20]  A Gefen,et al.  Mechanical compression-induced pressure sores in rat hindlimb: muscle stiffness, histology, and computational models. , 2004, Journal of applied physiology.

[21]  R. Daniel,et al.  Etiologic factors in pressure sores: an experimental model. , 1981, Archives of physical medicine and rehabilitation.

[22]  Shuichi Kuroda,et al.  Finite element analysis of undermining of pressure ulcer with a simple cylinder model. , 2005, Journal of Nippon Medical School = Nippon Ika Daigaku zasshi.

[23]  M. Castro,et al.  Influence of complete spinal cord injury on skeletal muscle within 6 mo of injury. , 1999, Journal of applied physiology.

[24]  N P Reddy,et al.  Stress distribution in a physical buttock model: effect of simulated bone geometry. , 1992, Journal of biomechanics.

[25]  T. Husain,et al.  An experimental study of some pressure effects on tissues, with reference to the bed-sore problem. , 1953, The Journal of pathology and bacteriology.

[26]  Dan L. Bader,et al.  Pressure sores : clinical practice and scientific approach , 1990 .

[27]  Roland R Roy,et al.  Mechanical properties of rat soleus after long-term spinal cord transection. , 2002, Journal of applied physiology.

[28]  D. Berlowitz,et al.  Pressure‐Related Deep Tissue Injury under Intact Skin and the Current Pressure Ulcer Staging Systems , 2005, Advances in skin & wound care.

[29]  M. Bliss.  Acute pressure area care: Sir James Paget's legacy , 1992, The Lancet.

[30]  Michael M. Priebe,et al.  The Medical Management of Pressure Ulcers , 2003 .

[31]  M Arcan,et al.  Modeling the body/chair interaction - an integrative experimental-numerical approach. , 2000, Clinical biomechanics.

[32]  Pierre A Guertin,et al.  Body weight, limb size, and muscular properties of early paraplegic mice. , 2004, Journal of neurotrauma.

[33]  D S Drummond,et al.  A study of pressure distributions measured during balanced and unbalanced sitting. , 1982, The Journal of bone and joint surgery. American volume.

[34]  J A de Guise,et al.  Analysis of pressure distribution at the body-seat interface in able-bodied and paraplegic subjects using a deformable active contour algorithm. , 2001, Medical engineering & physics.

[35]  L. Giangregorio,et al.  Musculoskeletal changes in women with spinal cord injury: a twin study. , 2005, Journal of clinical densitometry : the official journal of the International Society for Clinical Densitometry.

[36]  Folke Sjöberg,et al.  Sitting Pressure and Perfusion of Buttock Skin in Paraplegic and Tetraplegic Patients, and in Healthy Subjects: A Comparative Study , 2002, Scandinavian journal of plastic and reconstructive surgery and hand surgery.

[37]  D. Thomas,et al.  Prevention and treatment of pressure ulcers: what works? what doesn't? , 2001, Cleveland Clinic journal of medicine.

[38]  S M Peirce,et al.  Ischemia‐reperfusion injury in chronic pressure ulcer formation: A skin model in the rat , 2008, Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society.

[39]  Helena Saraste,et al.  Measuring seating pressure, area, and asymmetry in persons with spinal cord injury , 2004, European Spine Journal.

[40]  Clay J Cockerell,et al.  Decubitus ulcers: A review of the literature , 2005, International journal of dermatology.

[41]  Qunli Sun,et al.  Finite element modeling of human buttock-thigh tissue in a seated posture , 2005 .

[42]  L. Bennett,et al.  Skin blood flow in seated geriatric patients. , 1981, Archives of physical medicine and rehabilitation.

[43]  A Gefen,et al.  In vivo muscle stiffening under bone compression promotes deep pressure sores. , 2005, Journal of biomechanical engineering.

[44]  K. Berecek,et al.  Etiology of decubitus ulcers. , 1975, The Nursing clinics of North America.

[45]  T. G. Cooney,et al.  Pressure sores. , 1984, The Western journal of medicine.

[46]  G Gustavsson,et al.  Skin blood flow in relation to external pressure and temperature in the supine position on a standard hospital mattress. , 2020, Scandinavian journal of rehabilitation medicine.

[47]  P. J. Atkinson,et al.  Bone and soft tissue changes in paraplegic patients , 1979, Paraplegia.

[48]  E. Landis,et al.  Micro-injection studies of capillary blood pressure in human skin , 1930 .

[49]  M R Drost,et al.  Passive transverse mechanical properties of skeletal muscle under in vivo compression. , 2001, Journal of biomechanics.

[50]  L. Edsberg,et al.  Microstructural and mechanical characterization of human tissue at and adjacent to pressure ulcers. , 2000, Journal of rehabilitation research and development.

[51]  Y. C. Fung,et al.  BIOMECHANICS OF INJURY AND HEALING , 2001 .

[52]  G V Cochran,et al.  Model experiments to study the stress distributions in a seated buttock. , 1982, Journal of biomechanics.

[53]  G. Sethi,et al.  Suppurative diseases of the lungs. Pleurae and pericardium. , 1977, Current problems in surgery.

[54]  E F Wywialowski,et al.  Tissue perfusion as a key underlying concept of pressure ulcer development and treatment. , 1999, Journal of vascular nursing : official publication of the Society for Peripheral Vascular Nursing.

[55]  C. S. Bickel,et al.  Assessment of skeletal muscle mass in men with spinal cord injury using dual-energy X-ray absorptiometry and magnetic resonance imaging. , 2004, Journal of applied physiology.

[56]  E. Landis,et al.  THE EFFECT OF EXTERNAL PRESSURE ON THE VASCULAR VOLUME OF THE FOREARM AND ITS RELATION TO CAPILLARY BLOOD PRESSURE AND VENOUS PRESSURE. , 1942, The Journal of clinical investigation.