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NOTE: This article is for informative purposes only, and is not medical advice. If you're at risk of pressure sores, please work with your in-person physician and rehabilitation clinician to fully address the issue.

According to a study by the University of Alabama, 80% of full-time wheelchair users will experience a pressure sore during their lifetime, and 30% will have two or more occurrences. Yet, it's also estimated that 95% of all pressure sores experienced by wheelchair users are preventable. As wheelchair users, then, it's vital that we understand pressure sore dynamics and their risk factors – and focus on preventative measures.

What Is a Pressure Sore?
Pressure sores (also known as a decubitis ulcers or bed sores), are a wound that develops from pressure between a bone and the skin, effectively cutting off the blood supply to the area, killing and eroding the tissue. Imagine rolling out a thick layer of dough on a table. Now, picture taking your knuckle and pressing it into the dough until your knuckle digs through to the table. This is the dynamic of a pressure sore, where the skin and underlying tissue is compressed between the bone and a hard surface till it becomes a wound.

Pressure sore symptoms are categorized by stages:

Stage I – The skin is not broken, but appears red on those of lighter skin color (may not be visibly discolored on those of darker skin), maybe painful, softer, or of a notably different temperature than surrounding skin.

Stage II – Pressure sore area may appear as a swollen blister or an open wound, with a slight dish to it.

Stage III – The area is a deep, crater-like wound, often yellowish at its depth.

Stage IV – The wound exposes muscle, tendons or bone, representing the most severe case.

Primary Causes
For wheelchair users, the most common areas for pressure sores – namely because of extreme, continuous seated forces – are the tail bone, buttocks, spine, shoulder blades, heels, and the backs of one's arms and legs. However, sustained pressure isn't the only cause. Friction (as in a “dragging” of the skin during transfers), and shear forces (as in sliding forward in one's seat and “tugging” the skin), are likewise risk factors, contributing to pressure sores.

Secondary Factors
Besides direct pressure, other factors contribute to pressure sores. Weight loss and atrophy lead to less protective tissue; malnutrition and dehydration lessens tissue integrity; incontinence leads to moisture and bacteria that breaks down the skin; excessive moisture (most commonly, perspiration), or dryness of the skin, in general, can increase friction; poor circulation inhibits blood flow to vital areas (which is why proper positioning is so important); smoking reduces oxygen in the blood, decreasing needed circulation; and, muscle spasms and tone increase friction and shear forces. All of these increase the risk of pressure sores, as well as negatively impact the severity of sores, and can delay or prevent healing.

Many don't realize that pressure sores aren't an isolated wound, that in their severe forms, they can effect the entire body, right down to resulting in death. Sepsis is when a pressure sore allows bacteria to enter the bloodstream, leading to organ failure. Cellulitis is an infection of the skin's connective tissue brought about by a pressure sore, and can lead to meningitis. When a pressure sore is deep enough, bone infections can occur. And, a type of cell carcinoma can lead to an aggressive form of cancer in non-healing wounds. Therefore, pressure sores aren't isolated to single symptoms, but can lead to very dangerous health complications.

Unfortunately, once signs of a pressure sore are found, damage has already occurred and must be treated immediately. In the simplest of cases, a Stage I, changes to an individual's daily routine, such as increased or prolonged routines of pressure relief (including bed rest), may heal the damaged tissue. However, for more severe cases, medical intervention is required, ranging from wound dressing to antibiotics to surgery (including removing dead tissue, or using one's own skin and tissue to help close the wound, called “skin flap reconstruction”). All of these treatments require major lifestyle changes, where bed confinement – often for months – is required.

Again, 95% of pressure sores are preventable, and adjusting one's lifestyle toward optimal health is key. Firstly, using proper seating – from pressure-management cushions to full power tilt seating – is vital. Secondly, one should perform weight shifts, either manually or through power seating, every 15 to 20 minutes. Thirdly, proper intake of fluids (8 to 10 glasses of water per day), and proper nutrition by maintaining an appropriate level of calories, protein, vitamins, and minerals will bolster one's tissue resilience. Lastly, proper hygiene toward keeping one's skin clean increases skin integrity. By taking these actions – which are very practical in everyday life – one dramatically reduces the risk of pressure sores.

Recipe for Reducing Risks
-Use dedicated pressure-management cushions, with low-shear covers (do not use pillows or sheepskin)

-For power wheelchair users, tilt, recline, and elevating legrests – individually or combined, based on need – dramatically reduce pressure risks when used correctly

-Shift weight every 15 to 20 minutes, either manually or via power seating

-Maintain impeccable hygiene, keeping risk areas clean and dry of perspiration or incontinence

-Drink at least 72oz. of water per day

-Maintain a high-protein diet, of appropriate calories to sustain healthy weight

-Have a diet of appropriate vitamins and minerals, taking supplements if needed (vitamin C and Zinc are especially important in this area)

-Avoid cigarettes, alcohol, and caffeine (all of which adversely effects skin tissue)

A Personal Story
Being slender, with asymmetrical posture that puts extreme pressure on my left ischial tuberosity (buttocks cheek bone), and adding in spasticity and tone that causes shear and friction, I've long been at extreme risk for seated pressure sores. In college, due to not following proper health preventative measures for someone at my risk level, I developed a Stage II pressure sore. Despite having the proper cushion and power tilt seating, I continued struggling with pressure sore risks for years – exemplified by obvious pain in my case of having full body sensation. However, it wasn't until my late 30s, a time when many with disabilities become more at risk, that I truly addressed the issue. I dramatically increased my caloric intake, sustaining a 17lb. weight increase; I began drinking a minimum of 72oz. of water per day, cutting out caffieinated beverages; I assumed a high-protein diet; and, I balanced-out my nutrition with applicable vitamin and mineral supplements. The cumulative result is that I've dramatically increased my tissue's tolerance to seated pressure – that is, reduced my risk of pressure sores – where I'm not just healthier, but more comfortable and active.

Not Inevitable, But Preventable
As we know, wheelchair users are at extreme risks for pressure sores. Yet, with proper preventative measures – seating solutions, pressure relief, hygiene, hydration, and nutrition – the risks are minimized, if not eliminated. Therefore, for those at risk, pressure sores shouldn't be viewed as inevitable, but as preventable.  

Published 4/2011, Copyright 2011,