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
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
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
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.
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.
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
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.
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
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
-Maintain impeccable hygiene, keeping risk areas clean and dry of perspiration or
-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
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, WheelchairJunkie.com