Home     |     News     |     Buyer's Guide     |     Features     |     Products     |     Education     |     Archives

August/September 2003


Cushion Conclusions

By Sharon Kurfuerst, MEd, OTR/L, ABD, and Felicia Chew, MS, OTR/L
For the older client, wheelchair cushion selection must be based on a thorough knowledge of the pluses and minuses of each cushion type.

The ability to position the body and change body position is often taken for granted. In many instances, these skills and abilities may decline or be lost, especially in the elderly patient, due to injury, illness, or even the normal aging process. As a result, the patient may experience medical complications and a rapid decrease in functional abilities. It is critical to identify impaired mobility and/or function and provide the patient with the means to be positioned comfortably in a wheelchair to allow optimal function, maintain health, and promote quality of life.

Impaired function or mobility puts the elderly patient at risk for experiencing one or more of the following: contractures; falls; skin breakdown; muscle atrophy; decline in activity tolerance; pain; aspiration; impaired peristalsis, digestion, and elimination; impaired circulation; difficulty supporting adequate respiration; altered sensation; and social/behavioral issues. Proper positioning can assist in meeting quality of care requirements and enhance patient quality of life and functional performance. An integral part of any positioning intervention is the selection of a proper cushion that meets the individual medical and functional needs of the patient.

General Considerations
When selecting a wheelchair cushion for the elderly patient, there are several general areas that need to be considered to ensure that the cushion meets the needs of the patient and does not result in harm or an increased risk of medical or functional impairment. Attention to the following considerations may help promote a positive outcome:
  • The degree to which the patient is continent
  • The ease with which the cushion can be cleaned by the patient or the caregivers
  • The degree of maintenance required for the cushion—an important consideration for the institutionalized elder
  • The weight of the cushion
  • Cost
  • •Durability.1

It is important to ensure that a comprehensive individualized assessment of the patient’s needs, functional abilities, and desired goals is completed by a skilled occupational therapist. The rehab professional can match the patient with an optimal seating system, including selection of the proper cushion, while considering the proper pressure medium for the patient. Additionally, the setting in which the patient will primarily use the cushion and the level of expected activity play important roles in the selection process.

There are several important considerations that should be kept in mind by the occupational therapist responsible for addressing positioning needs and cushion selection prior to choosing a seating system. These include determining whether the seating system will be for short-term or long-term use, the impact the seating system will have on the patient’s ability to complete functional activities, who will be responsible for managing the seating system (patient, caregivers), and the patient’s and caregivers’ ability to understand and be compliant with the recommended seating system. Finally, it is important to consider the requirements necessary for facilitating reimbursement of the seating system, including the selected cushion and the willingness of the wheelchair vendor to assist with this process.

In addition to these considerations, the occupational therapist should have a solid working knowledge of the properties of the various types of cushions that are available and their expected clinical outcomes. In a long-term care setting, where cushions can often be switched or misplaced, it is important to consider that a cushion improperly used can cause greater harm than good.

There are four primary categories of cushions: air, flotation (which includes gel and water filled), foam, and combination. A newer type of cushion, the honeycomb cushion, is also available and will be discussed as a separate category. Each type of cushion possesses unique advantages and disadvantages that must be considered prior to selection.

The selection process should also include assessing patient-specific factors often found in the elderly patient, including the presence of fixed versus flexible deformities, the amount of time anticipated sitting on the cushion, the activities that will be completed while seated, history of skin breakdown and the potential risk for further skin compromise, functional mobility status including sitting balance, and endurance for upright positioning.

Air and flotation cushions
Air cushions, when optimally used, can provide significant pressure relief to the elderly patient who may be unable to independently shift his or her weight due to physical and/or cognitive impairments. Advantages of an air cushion include features such as being lightweight, providing more even distribution of pressure (an important feature in the elderly patient who may have decreased body mass), and the ability to modify the cushion to assist in pressure sore relief. Air cushions are also suitable for incontinent patients as they are waterproof, and if the cushion has various compartments or chambers for the air, varying inflation pressures can be achieved.

However, consistent monitoring of optimal air inflation is required in this type of cushion. If the seal on the cushion is not maintained and air is able to escape, the leakage can cause the loss of pressure relief properties. The risk of leakage, increased cost, and the need for higher maintenance are the disadvantages of using air cushions.

Flotation cushions are filled with a fluid such as gel or water. There are many advantages to using a flotation cushion. First, it allows the fluid to be distributed into smaller compartments within the cushion and the cushion can conform to bony prominences in order to address a specific concern in an elderly patient. Flotation cushions can also contour to the patient, providing maximum postural support, excellent pressure distribution, and enhanced thermal properties for increased comfort during prolonged sitting. Disadvantages of flotation cushions include increased weight, chance of leakage, increased cost, an inability to return to baseline shape without requiring kneading or manual redistribution of the fluid, and the need for ongoing maintenance to ensure proper functioning.

Foam and combined Cushions
Foam cushions are often the preferred option for elderly patients in long-term care centers and skilled nursing facilities due to their low-cost, minimal maintenance, and lightweight properties. Occupational therapists designing seating systems for elderly patients are able to customize foam cushions by cutting them to fit the contour of the individual patient. However, there are also several disadvantages to using foam cushions, especially for the elderly patient with limited functional abilities. As foam ages, it can become compressed, and can promote pressure sores when the original pressure distribution qualities are no longer available. Additionally, the durability of foam is limited, and thus the cushions may need to be replaced more frequently with prolonged usage. Finally, foam does not resist moisture, and therefore is not suggested for patients who are incontinent.

Combined cushions utilize more than one of the properties (gel, water, air, and foam) described above. Combined cushions allow the occupational therapist to bring together the best properties of the selected cushions in customizing a cushion to the individual needs of the patient. The occupational therapist should work closely with a reputable product vendor to select the best combination of materials to accommodate all of the clinical and functional needs of the patient.

Honeycomb Cushions
Honeycomb cushions are a recent development and are gaining popularity. These cushions, made of thermoplastic urethane, are able to distribute weight evenly without the risk of leaking or puncture common with gel and air cushions. The beehive structure of the honeycomb cushion allows air to flow more effectively, thus keeping skin cooler and drier, which reduces the risk of skin breakdown. In addition, these cushions are lightweight, do a fair job of absorbing shock, and provide postural support. Another advantage for patients who use the cushion frequently is that the cushion can be cleaned in a washing machine and dryer. The limitations of the honeycomb cushion are twofold—first, some users, especially those who are lighter, may find the cushions to be too firm and thus uncomfortable. Second, over time, the cushion can become compressed and cause problems with adequate pressure distribution, resulting in the need for more frequent replacement. Since these cushions are relatively new to the market, additional information is needed regarding their optimal applicability.

Cushion Covers
A discussion of cushion selection would not be complete without a brief mention of the need to also select the appropriate cushion cover. Cushion covers serve a variety of purposes. They help to prolong the life of the cushion, resulting in less frequent replacement; ensure optimal pressure distribution; and assist in achieving conformity of the cushion to the patient. A well-made cover promotes air exchange, responds to changes in both external and body temperature, reduces friction and risk for shearing, and positively influences postural stability. Conversely, poorly fitted or improper cushion covers can result in a negative change to the conformity and pressure distribution achieved by the cushion itself.

Conclusions
Wheelchair cushions are prescribed for a variety of reasons for the elderly patient including comfort, proper positioning, pressure relief and the maintenance of skin integrity, and postural management. Proper cushion selection is a dynamic process that requires in-depth assessment and individualized treatment planning to meld the specific properties of the cushion with the unique needs of the patient.

Ideally, an occupational therapist, with a strong knowledge of positioning techniques and products combined with comprehensive patient assessment skills, should be part of the interdisciplinary team choosing seating recommendations and cushion selections. The evaluating occupational therapist should have access to several different types and sizes of cushions, as well as other positioning devices that may be used in conjunction with the cushion to facilitate successful seating and positioning intervention. The ability of a patient to trial a cushion for a few days while performing functional activities helps the occupational therapist to determine the cushion’s overall suitability for function, comfort, and manageability by the patient and caregivers. Without an inventory of cushions and positioning devices, the intervention process may lengthen, thus possibly further contributing to the medical and functional decline of the elderly patient. Ultimately, the proper cushion combined with other devices determined to be necessary for a patient’s optimum seating and positioning can maximize the functional abilities, safety, and quality of life of elders in a variety of settings.

Reference
  • Mayall JK, Desharnais G. Positioning in a Wheelchair: A Guide for Professional Caregivers of the Disabled Adult. 2nd ed. Thorofare, NJ: Slack Inc; 1995.


Sharon Kurfuerst, MEd, OTR/L, ABD, is director, clinical services, and Felicia Chew, MS, OTR/L, is a clinical specialist for Genesis Rehabilitation Services in Kennett Square, Pa. They can be contacted via email at Sharon.Kurfuerst@ghv.com and Felicia.Chew@ghv.com.

LOOKING FOR EXPERT ADVICE?

Experts here are available to answer all your questions!
Please contact us for more information about this feature, or to become an expert.

MEDIA CENTER

Interactive Media
Resources
Classifieds
Calendar
Consumer Resources
Media Kit
Advertiser Index
EAB
Reprints
Submit an Article
Home     |     News     |     Buyer's Guide     |     Features     |     Products     |     Education     |     Archives

ADDITIONAL ONLINE RESOURCES

Allied Healthcare
Medical Education
24X7mag
Clinical Lab Products (CLP)
Orthodontic Products
The Hearing Industry Resource
Rehab Management 		Physical Therapy Products
Plastic Surgery Products
Imaging Economics
RT Magazine
Sleep Review 		medCME
Practice Growth
Practice Builders
powered by:
Copyright © 2009 Ascend Media LLC | Rehab Management | All Rights Reserved.
Privacy Policy | Terms of Service