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Pressure cushions and tilt-in-space wheelchairs to prevent pressure areas

Last update: 13 Dec 2016

People with severe cerebral palsy who have low mobility can receive injuries to their skin called pressure areas if they sit in the same position for too long
A special cushion or a wheelchair that tilts to change a person’s body position are two pieces of equipment that are used to relieve pressure on the body parts put under regular pressure
Having good nutrition and skin care can also reduce the likelihood of pressure areas.

Who are these for?

Children and adults with cerebral palsy who stay seated for long periods of time can experience damage to their skin and underlying tissue because of tension, friction, and the fragile condition of their skin1, 2. This injury is known as a pressure area and can cause pain and discomfort. Pressure cushions and tilt-in-space wheelchairs are the equipment they use to avoid this problem. This equipment may be suitable for people with cerebral palsy with the following characteristics:
Type of cerebral palsy : Bilateral cerebral palsy, Diplegia, Hemiplegia, Quadriplegia, Triplegia, Unilateral cerebral palsy

More information about cerebral palsy is contained in the What is CP? section.

Mobility : GMFCS IV, GMFCS V

Gross Motor Function Classification System (GMFCS) – classifies severity of mobility difficulties of children and adolescents with CP.

GMFCS Level I
Walks without limitations in the home and community, climbs stairs and can run and jump, difficulties with speed and coordination.

GMFCS Level II
Walks with limitations, difficulties with long distances and uneven surfaces, uses a railing for climbing stairs, limited running and jumping.

GMFCS Level III
Walks using a hand-held mobility device such as crutches or walking frame, may use wheeled mobility for long distances.

GMFCS Level IV
Usually relies on wheeled mobility with assistance, may use powered mobility, usually needs special seating and assistance with transfers.

GMFCS Level V
Usually transported in a manual wheelchair, requires specialised seating and full assistance for transfers.

See full glossary

Arm ability : MACS I, MACS II, MACS III, MACS IV, MACS V

Manual Ability Classification System (MACS) – classifies severity of upper limb impairment: how children with cerebral palsy use their hands to handle objects in daily activities in the home, school, and community settings.

MACS Level I
Handles objects easily and successfully.

MACS Level II
Handles most objects but with somewhat reduced quality and/or speed of achievement.

MACS Level III
Handles objects with difficulty; needs help to prepare and/or modify activities.

MACS Level IV
Handles a limited selection of easily managed objects in adapted situations.

MACS Level V
Does not handle objects and has severely limited ability to perform even simple actions.

See full glossary

Communication ability : CFCS I, CFCS II, CFCS III, CFCS IV, CFCS V

Communication Function Classification System (CFCS) – classifies severity of everyday communication of people with cerebral palsy.

CFCS Level I
Effective Sender and Receiver with unfamiliar and familiar partners.

CFCS Level II
Effective but slower paced Sender and/or Receiver with unfamiliar and/or familiar partners.

CFCS Level III
Effective Sender and Receiver with familiar partners.

CFCS Level IV
Inconsistent Sender and/or Receiver with familiar partners.

CFCS Level V
Seldom effective Sender and Receiver even with familiar partners.

See full glossary

Movement disorder : Ataxia, Athetosis, Dystonia, Hypotonia, Spasticity

More information about movement disorders can be found on our websites.

Intellectual ability : No intellectual disability, Mild intellectual disability, Moderate intellectual disability, Severe intellectual disability

A person’s thinking skills – ability to understand ideas, learn and solve problems. People with intellectual disability have difficulty with intellectual functioning which may influence learning, communication, social and daily living skills. Intellectual disability may be mild to very severe.

See full glossary

Physiotherapists, occupational therapists and nurses can work with someone with cerebral palsy and their family to develop a comprehensive plan for preventing pressure areas.

Cerebral Palsy Alliance offers a service where our therapists can help a person decide on the best pressure prevention plan for them.

Find a Cerebral Palsy Alliance service

Therapy - Fees will apply for an assessment, recommendation of appropriate equipment and therapy. The cost will depend on the provider and the number of sessions a person needs. You should check with your provider to see if there will be additional costs to prepare pressure care prevention plans and funding applications, and for therapist’s travel to sessions.

Equipment – The price of a cushion or tilt-in-space wheelchair will vary considerably depending on the needs of the individual. You can ask your health care provider if you are eligible for funding to assist with the fees, cushion and wheelchair costs. Accessing this support will involve completing and submitting a funding application.

People with disability living in Australia may also be eligible for a health care rebate through Medicare or funding from the National Disability Insurance Scheme.

It may take multiple sessions to try out the different cushions and tilt-in-space wheelchairs that are on the market to find the right option. Making the best choice will involve the client, their family members and carers who will be assisting with the equipment, along with wheelchair suppliers and the person’s medical support team.

Prevention of pressure areas

Preventing pressure areas is very important. Pressure areas usually develop on the bony areas of a person’s body. For someone in a wheelchair, this means the areas at greatest risk are the buttocks (ischial tuberosities) and tailbone (sacrum and coccyx). For a person with cerebral palsy who sits for long periods in a wheelchair, there are two common strategies to minimise pressure and friction on the skin:

These specialised cushions are placed on the seat of a wheelchair to help reduce the pressure on the bony areas of the buttocks and tailbone. They are also used to support deformities of the hips and regulate heat and moisture. The cushions are made of one or more materials, most commonly foam, gel and air. There are many types available. Choosing the right cushion will depend on the person’s living environment, weight, mobility level, skin condition, posture in their wheelchair and the level of support they need.

Considerations: The cushions need to properly fit both the person and their wheelchair and other seating. All pressure cushions require a cover. The cushion cover will need to be carefully selected to ensure it fits properly and does not create forces that increase stress on the skin and the risk of developing pressure areas. They should be washable, especially for people who sweat, are incontinent, or eat and drink in their chairs. A second cushion cover is suggested to allow one to be washed while the other is in use. Placing towels, plastic sheets and other fabric over the cushion may reduce the benefits of the cushion and should be avoided.

With a tilt-in-space wheelchair, the entire seat and backrest tilt backwards within the wheelchair. The angle between the seat and backrest remains the same. As the angle of tilt increases, the pressure between the seat cushion and buttocks is reduced and redistributed to the backrest.

A person who uses a tilt-in-space wheelchair will stay in the upright position for most of the day, but move the seat and backrest into the tilted position for several short periods to reduce the pressure on their buttocks and help prevent pressure areas1. By reducing pressure on the buttocks pressure areas can be prevented.

A tilted position is also often used to help hold an individual’s pelvis correctly in a wheelchair and to support the head and neck during everyday activities like eating, using eye-gaze control devices, communicating and school activities.

Considerations: Tilt-in-space seating can make a wheelchair larger, heavier and more expensive. Care must also be taken if someone is propelling their own tilt-in-space wheelchair in the tilted position as this can reduce the person’s vision and arm positioning, impacting on mobility and safety.

People with cerebral palsy are at greater risk of experiencing pressure areas if they are:

  • Sitting or lying still for long periods
  • Under- or over-weight
  • Poorly nourished
  • Incontinent
  • Unable to feel pain or discomfort in the areas where pressure areas commonly develop2

Pressure areas are also more likely to develop when:

  • Moisture is present
  • Skin is dry or fragile
  • Infection is present
  • A person has trouble controlling their own temperature
  • They have spine or hip deformities
  • There is a change in health status or medication

Pressure areas are also known as pressure injuries, pressure sores, pressure ulcers and bedsores.

Two additional strategies are used to reduce pressure areas. They are not often used by people with cerebral palsy and are not included in this topic. One involves shifting weight in the wheelchair (called repositioning) and the other involves reclining the back rest of the wheelchair to redistribute pressures to different areas of skin.

Pressure cushions and wheelchairs will come with instructions and product information. It is very important to keep this information for future reference.

Assessments

Before selecting equipment, a therapist will assess a person’s risk factors for developing pressure areas and create an appropriate prevention plan. This can involve mapping the risks and grading them on a scale based on the severity of existing pressure areas. The therapist will recommend regular monitoring of the person’s skin to help identify pressure areas early and ensure prevention wherever possible.

Assessing the severity

The damage pressure areas cause can range from mild to severe.

  • Mild - appears as red skin
  • Severe – appears as deep, open wounds which can be painful and restrict a person’s daily activities.

Careful assessment will also be required to ensure the correct pressure cushion and tilt-in-space wheelchair is trialled and selected.

A therapist will regularly review pressure cushions and wheelchairs to check they fit correctly, are comfortable and meet the needs of the individual with cerebral palsy.

Best available research evidence

We searched the medical and allied health literature to find research, published since 1995, evaluating the effects of pressure cushions and tilt-in-space wheelchairs.

The search aimed to find the best available evidence to answer two questions for children and adults with cerebral palsy.

  1. What are the best cushions for preventing pressure areas?
    We included only articles involving longer term use of pressure cushions in day-to-day life.
    We did not include research measuring the pressure exerted on the buttocks and upper legs from short periods of sitting. This is because these research conditions do not take into consideration the other factors which may impact on pressure area development over time.
  2. Does tilt-in-space reduce pressure areas on the buttocks, legs and lower back?

1 - Pressure cushions for preventing pressure areas

We didn’t find any research completed with people with cerebral palsy. We then drew on the best available evidence in other diagnostic groups. There was one good quality randomised controlled trial of 232 elderly people with limited mobility living in a nursing home3. The study compared a basic foam cushion with skin protection cushions (specifically designed to reduce pressures near bony areas). The overall incidence of pressure areas was lower than expected over the six-month study period, probably because all study participants had expert seating assessments and properly fitted wheelchairs, incontinence covers fitted to the cushions and a weekly skin review. There were, however, significantly fewer pressure areas in the group of participants who used the skin protection cushions.

We found two additional and related systematic reviews of studies which investigated pressure area prevention in a range of diagnoses4,5. One review suggested that custom-fit air cushions, followed by gel cushions were more effective than water or foam cushions4. The other systematic review concluded that there was insufficient good quality research to draw conclusions about the most effective type of cushions5.

2 - Wheelchair tilt-in-space

We did not find any research which evaluated a reduction of pressure areas. We did locate many studies which measured short term pressures under the legs, buttocks and lower back when a seat was tilted in space at varying angles. The most informative evidence was from three systematic reviews of adults and/or children at risk of pressure areas4,6,7 and three additional studies not included in these reviews8,9,10. There were no studies with children or adults with cerebral palsy. Most studies included adults with spinal cord injury.

The findings from these studies are summarised below:

  • As more angle of tilt-in-space is used, the pressures applied to the bony prominences in the buttocks when sitting are progressively reduced4,8,9,10.
  • Reducing pressures on the buttocks - Although researchers report it is difficult to identify a minimum amount of tilt-in-space to recommend4,7, some authors suggest that 20° to 35° 6,11 may be the minimum requirement for unloading pressures from the buttocks.
  • Reducing pressures on the tailbone - Studies exploring the impact of tilt-in-space on pressures on the lower back suggest that at least 30° to 35° tilt is needed to minimise the displacement of pressure from the buttocks to the tailbone (sacrum and coccyx)10,11.
  • There are no guidelines about how often, or for how long, tilt-in-space should be applied over the course of the day to prevent pressure areas.
  • Reclining the backrest in addition to tilt-in-space may further reduce the pressures exerted11,12.

None of the research we located was carried out with people with cerebral palsy. We can, however, cautiously generalise the findings to children and adults with cerebral palsy as follows:

  • Specialised cushions which are designed to protect skin and reduce pressure on the bony prominences are recommended for people with cerebral palsy at risk of pressure areas2. Air and gel cushions are recommended over foam cushions3,4.
  • Pressure care should not be limited to use of a cushion. Tilt-in-space can be used, when appropriate, to provide short-term reduction of pressures on the bony prominences to reduce the risk of pressure areas. At least 30° to 35° degrees of tilt-in-space appears to be required to achieve pressure relief for the buttocks (ischial tuberosities) and tailbone (sacrum and coccyx)10,11.
  • Other components of prevention of pressure areas and discomfort are provision and maintenance of well-fitting wheelchairs and seating, with correctly adjusted armrests and leg rests, regular skin checks and care3, consideration of incontinence, and the appropriate use of cushion covers which minimise shearing effects.
  • Other equipment such as commode chairs and splints need to be well fitting and checked regularly. Education is necessary to ensure carers transfer people with cerebral palsy carefully between equipment (e.g., bed to wheelchair) to minimise stress to skin.
  • Maintaining a healthy weight and good nutrition are also important to reducing the risk of pressure areas.

Date of literature searches: May 2016

  1. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Australia; 2014.
  2. Australian Wound Management Association. Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury. Cambridge Media Osborne Park, WA: 2012. ISBN Print: 978-0-9807842-5-1, ISBN Online: 978-0-9807842-3-7.
  3. Brienza, D., Kelsey, S., Karg, P., Allegretti, A., Olson, M., Schmeler, M., Zanca, J., Geyer, M. J., Kusturiss, M., & Holm, M. (2010). A randomized clinical trial on preventing pressure ulcers with wheelchair seat cushions. Journal of the American Geriatrics Society, 58(12), 2308-2314. See abstract
  4. Groah, S., Schladen, M., Pineda, C., & Hsieh, J. (2015). Prevention of pressure ulcers among people with spinal cord injury: A systematic review. American Academy of Physical Medicine and Rehabilitation, 7(6), 613-636. See abstract
  5. McInnes, E., Jammali-Blasi, A., Bell-Syer, S. E. M., Dumville, J. C., Cullum, N. (2011). Support surfaces for pressure ulcer prevention. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD001735. DOI: 10.1002/14651858.CD001735.pub4.
  6. Michael, S. M., Porter, D., & Pountney, T. E. (2007). Tilted seat position for non-ambulant individuals with neurological and neuromuscular impairment: a systematic review. Clinical Rehabilitation, 21(12), 1063-1074.
  7. Casey, J., & Gittins, J. (2013). Use of tilt-in-space in seating systems for adults with physical disabilities. Physical Therapy Reviews, 18(4), 285-299. See abstract
  8. Sprigle, S., Maurer, C., & Sonenblum, S. e. (2009). Load redistribution in variable position wheelchairs in people with spinal cord injury. Journal of Spinal Cord Medicine, 33(1), 58-64.
  9. Sonenblum, S. E., & Sprigle, S. H. (2011). The impact of tilting on blood flow and localized tissue loading. Journal of Tissue Viability, 20(1), 3-13. See abstract
  10. Giesbrecht, E. M., Ethans, K. D., & Staley, D. (2011). Measuring the effect of incremental angles of wheelchair tilt on interface pressure among individuals with spinal cord injury. Spinal Cord, 49(7), 827-831. See abstract
  11. Chen, Y., Wang, J., Lung, C. W., Yang, T.D., Crane, B. A., & Jan, Y. K. (2014). Effect of tilt and recline on ischial and coccygeal interface pressures in people with spinal cord injury. American journal of physical medicine & rehabilitation, 93(12), 1019-1030. See abstract
  12. Jan, Y., & Crane, B., A. (2013). Wheelchair Tilt-in-Space and Recline Does Not Reduce Sacral Skin Perfusion as Changing From the Upright to the Tilted and Reclined Position in People With Spinal Cord Injury. Archives of Physical Medicine and Rehabilitation, 94, 1207-1210.
Find out about CP Check-Up™

Cerebral Palsy Alliance offers a service called CP Check-Up™ which provides ongoing surveillance of the health and well-being of our clients aged 0-18 years.
The information on this page was developed using the best research evidence combined with the expertise of clinicians and people with cerebral palsy and their families. It is provided to help people with cerebral palsy, their families and caregivers, clinicians and service providers make decisions about suitable interventions. This information is intended to support, but not replace, information exchanged, and decisions made, between people with cerebral palsy, their families and health professionals.