P ressureulcersrepresentasignificanthealthcarecostaswellasasignificantrisk

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1 Evaluating the Pressure-Reducing Capabilities of the Gel Pad in Supine Sarah Thorne, Katrine Sauvé, Christine Yacoub, Paulette Guitard KEY WORDS gels pressure pressure ulcer supine position OBJECTIVE. Gel pads are commonly used by occupational therapists in acute care settings to reduce pressure on the coccyx and sacrum in supine. The purpose of this study was to determine the pressure-reducing capabilities of gel pads used in supine and the resultant potential impact on pressure ulcer management. METHOD. A pressure-mapping system was used to measure interface pressures between the participant s buttocks and the mattress, with and without the gel pad. RESULTS. The gel pad did not have a significant effect on interface pressure for most participants. No obvious clinical indicators were identified. CONCLUSION. Use of the gel pad is not recommended to decrease pressure in supine. Because potential adverse effects may result from using the gel pad in supine and no clinical indicators were identified to direct practice, use of the gel pad in supine is not recommended as an intervention for decreasing interface pressure. Thorne, S., Sauve, K., Yacoub, C., & Guitard, P. (2009). Evaluating the pressure-reducing capabilities of the gel pad in supine. American Journal of Occupational Therapy, 63, Sarah Thorne, OT Reg, is Occupational Therapist, Southlake Regional Health Centre, 893 Dales Avenue, Newmarket, Ontario L3Y5Z6 Canada; sarahathorne@ hotmail.com Katrine Sauvé is Occupational Therapist, completing a Master s of Public Health at Hamburg University of Applied Sciences, Hamburg, Germany. Christine Yacoub, OT Reg (Ont.), is Occupational Therapist, The Ottawa Hospital, Ottawa, Ontario. Paulette Guitard, PhD, OT Reg OT(C), is Associate Professor, Occupational Therapy Program, University of Ottawa, Ontario. P ressureulcersrepresentasignificanthealthcarecostaswellasasignificantrisk ofincreasedmorbidityandmortalityduringandafterahospitaladmission.in the United States alone, >60,000 people die each year from pressure ulcers or sequelaethereof,andthecostinhealthcaredollarsexceeds$1billion(allamounts inu.s.dollars)peryear(bansal,scott,stewart,&cockerell,2005).inaustralia, pressureulcertreatmentisestimatedtoadd$350millionannuallytohealthcare costs(lewis,pearson,&ward,2003).interventionsaimedatpreventionaresignificantly lower in cost than treatment of pressure ulcers(schectman, Hanson, Garrett,&Dunn,2001).Pressureulcersresultfromincreased,sustainedpressure onanareaoftheskin,theriskofwhichincreaseswhenconcomitantconditions compromiseskinintegrityorbloodflow.skincareprogramscommonlyinvolvea varietyofinterventionstopreventthedevelopmentofpressureulcersthroughthe reductionoreliminationofthispressure. Occupationaltherapistsareinvolvedinmanyinterventionssuchasthedevelopmentofpositioningschedulesandmobilizationoftheperson,asappropriate, topreventthedevelopmentoraggravationofpressureulcers(bansaletal.,2005). Inmanysettings,itistheresponsibilityoftheoccupationaltherapisttorecommend pressure reduction or relief surfaces both in seated and supine positions (Griesbrecht,2006). Inanenvironmentofmanagedhealthcareresources,occupationaltherapists areoftenobligatedtouseavailableequipmentinunconventionalways.onecommonpracticeintheacutecaresettingistoprovideasquaregelpadtoreducethe pressureonthecoccygealregioninsupine.thus,acushiondesignedforusein seatingisoftenusedinsupine.dataexisttosupporttheuseofgelsurfacesina 744 November/December 2009, Volume 63, Number 6

2 seatedposition;however,wefoundnoresearchthatdemonstratestheefficacyofthegelpadinsupinewhenusedin conjunctionwithatraditionalhospitalmattress.moreover, studiesofbedpositioningfailtoexaminetheuseofthegel padasanoptioninanacutecaresetting.inthisstudy,the pressure-reducingcapabilitiesofthegelpadinasupineposition were explored. Findings presented in this article will provideoccupationaltherapistsandotherhospitalstaffwith additionalinformationtodevelopeffectivepolicyandpracticeguidelinestopreventandtreatpressureulcers. Etiology and Prevalence of Pressure Ulcers Pressure ulcers representareasofsuperficialordeepdamaged tissueassociatedwithfourcauses:pressure,shear,friction, and moisture(arnold, 2003). Pressure ulcers and tissue necrosiscanbecausedbysustainedpressureof>32mmhg (acceptedcapillaryfillingpressure)foraperioduptoand exceeding2hr(bansaletal.,2005).thedegreeoftissue damage can be exacerbated by intrinsic(chronic medical conditions, contractures) and extrinsic(pressure, friction, shear,ormoisture)factors(bansaletal.,2005).infact,the presence of significant shear forces can further lower the thresholdofpressurerequiredtocausetissuedamageby50% (Bonomini,2003). Evidencehassuggestedthatcriticallyillpatientsadmittedtothehospitalfrequentlyareexperiencingpressureulcers orareatahighriskfordevelopingthemduringhospitalization(coats-bennet,2002).moreover,incidenceofpressure ulcers in hospitalized patients ranges from 2% to 29% (Arnold, 2003). This problem persists in long-term care facilities,whereprevalencerangesfrom3%to35%(abelet al.,2005).dataindicatethatthemostcommonareaswhere pressure ulcers develop are the sacrum/coccyx(36%), followedbythegreatertrochanters,ischialtuberosities,andheels andankles(geyer,brienza,karg,trefler,&kelsey,2001). Manyfactorscontributetothedevelopmentofpressure ulcersinhospitalizedpatients,includingimmobility,incontinence,alteredmentalstatus,severityofdisease,poornutritionalstatus,historyofpreviouspressureulcers,andincreased age(hornetal.,2004).decreasedmobilityhasbeenshown tobeofsignificantimportance(bonomini,2003).inaddition,manychronicdiseaseprocessescandecreasecirculation andreducebloodoxygenation,renderingtissuesmoresusceptibletoinjuryatlowerthresholdsofpressure(arnold, 2003;Griffiths&Gallimore,2005). Determining the risk level of developing a pressure ulcerisacrucialfirststepinprevention.thebradenscale for Predicting Pressure Sore Risk (Bergstrom, Braden, Laguzza,&Holman,1987)isoneofmanytoolsthathave been developed to identify people at risk for developing pressureulcers.itisfrequentlyusedandhasbeenadopted bymanyacutecarefacilities(griesbrecht,2006;thomas Hess, 2004) because it has shown the highest validity (Pancorbo-Hidalgo,Garcia-Fernandez,Lopez-Medina,& Alvarez-Nieto, 2006) of the tools available. The Braden Scaleidentifiesriskusingsixsubscalesandprovidesascore outof23.accordingtothisscale,ascorerangingfrom15 to18indicatesalowriskandascoreof 12indicatesavery highrisk(ayello,baranoski,lyder,&cuddigan,2004). Courtney, Ruppman, and Cooper(2006) recommended theimplementationofaskincareprogramforpeoplewith ascore<16onthebradenscale. Regularskinchecksshouldbecompletedonclientswith lowerbradenscalescores.skinchecksincludeablanching test,whichcandetectapressureulcerinitsinitialstages.the blanchingtestdetectsthepresenceorabsenceofcapillary refill by applying light pressure to the reddened area. A changeinskincolorindicatesthepresenceofcapillaryrefill butissuggestiveofunderlyingtissuedamageandistherefore identified as a Stage I ulcer(national Research Council InstituteforBiodiagnostics,2006). Interventions Used to Reduce Pressure Ulcer Incidence Manyinterventionsareusedinhospitalstoreduceinterface pressure(thepressurebetweenasurfaceandabonyprominence)topreventthedevelopmentoraggravationofpressuresores(coats-bennet,2002).accordingtoschoonhoven etal.(2006),70%ofstageiulcersdidnotprogresswhen preventative measures were used, reinforcing the importanceofearlyintervention(nixonetal., 2006).Themost commonpreventionmethodisacombinationofmanual repositioningoftheclientandtheuseofatherapeuticsurface(arnold,2003).therapeuticsurfacesareusedprimarily to lower the interface pressure, thus limiting the risk of developing pressure ulcers (Kernozek & Lewin, 1998; Shechtmanetal.,2001). Interfacepressurecanbeaccuratelymeasuredwiththe useofapressure-mappingsystem.pressuremappingprovidesaquantitativemeasureoftheefficacyofvarioustherapeutic surfaces and can therefore guide clinical decisions (Schmeler&Buning,1999).Thissystemconsistsofamat containingnumeroussensors,whichisplacedbetweenthe individualandthesurface.thismatmeasurestheinterface pressureandprovidesacomputer-generatedpictorialrepresentation of pressure points between the surface and the body,aswellastherelativedegreeofseverityofsuchareas (Stinson, Porter-Armstrong, & Eakin, 2003). Pressure- mappingsystemsmeasureonlyuniaxialpressure(vertical) anddonotmeasureshearforces(schmeler&buning,1999). The American Journal of Occupational Therapy 745

3 Pressuremappingdoesallowforbefore-and-aftercomparisonratherthanproductcomparisonandhelpswithvalidatingclinicaljudgment.Inonestudy,pressuremapsdemonstratedthat25%ofparticipantswereseatedoninappropriate surfaces (Crawford, Strain, Gregg, Walsh, & Porter- Armstrong,2005).Thirty-twommHgisthetheoretically identifiedcapillaryclosingpressure;however,accordingto Bar(1998),noexistingsurfacehasbeenfoundtoconsistentlymaintainpressures<32mmHg.Thus,Barsuggested that60mmhgisamorerealisticandattainabletargetfor pressure relief surfaces. Schmeler and Buning s (1999) researchrecommendedthatpressure-mappingreadingsof 80to120mmHgnecessitateachangeinsurfaceandrepresentasignificantriskfordevelopmentofpressureulcersin aseatedposition.theystressthepotentialforserioussequelae ifpressurereadingsexceed120mmhg. Role of Occupational Therapy in Pressure Ulcer Prevention Occupationaltherapistsmakerecommendationsrelatingto positioningtorelieveorreducepressure;onesuchcommon suggestionisthepositioningoftheheadofthebedat30 to improvecirculationoverthesacrumandtheischialtuberosities(lewisetal.,2003). Occupational therapists also make recommendations regardingpressure-reliefsurfacesonthebasisofskinstatus, thepatient sdegreeofmobility,andadditionalriskfactors. Mosttherapeuticsurfacescontainfoam,gel,orair.Gelsurfacesarecommonlyusedforpressurereliefbecausethisallows for immersion in the viscous surface, thus limiting shear (Coats-Bennet,2002).Cushionsandothersurfacesvaryin theirabilitytoreduceinterfacepressureonacase-by-casebasis (Pellow,1999).Inprinciple,freelyflowinggelevenlydistributes the pressure throughout the supporting surface(bar, 1991).Inpractice,however,Barstipulatedthatthecoveron gelsurfacesmayconstrainthegel,which,inturn,limitsthe efficacyofpressurereductionbythissurface.therapistsshould takethisconstraintintoconsiderationwhenmakingrecommendationspertainingtoselectionofsupportsurfaces. The current study focused on the pressure-relieving capabilitiesofthegelpadinthesupinepositionwiththe headofthebedat30 elevationandattemptedtovalidate thiscommonoccupationaltherapyintervention. Method Weusedaquantitativecross-overdesigninwhicheachparticipantservedashisorherowncontrolfortreatmentcomparison.Themethodologyandprotocolwereapprovedby therelevantinstitutionalethicsreviewboards. Sixtyparticipantswererecruitedfromtheacutefloors (medical and surgical) of a Canadian urban tertiary care teaching hospital. Participants were required to meet the followinginclusioncriteria: Age 18years Atlowtomoderateriskofskinbreakdown(scoreof10 18ontheBradenScale) Able to tolerate the required test position in bed(30 anglefor20min) Between75and250lb. Potentialparticipantswereexcludedifanyofthefollowingconditionswerepresent: Agitation Incontinence of bowel or bladder (without Foley catheter) Needforpalliative/comfortmeasures Diagnosisofcellulitisaffectingbuttocks,lowerback,or upperthighs Existing non-pressure-related ulcers in pressure-prone areas(e.g.,vascular,trauma) Dermatologicalconditioninterferingwithpressureulcer stagingorvisualization Needforrestraints Inabilitytolieinsupine(i.e.,respiratorycomplications, hiatalhernia,bilevelpositiveairwaypressure,inabilityto managesecretions,tracheotomy) Presenceofchesttubes,nephrostomytubes,ornasogastric tubes(continuous). Participantswererecruitedbytheprimaryoccupational therapistduringtheinitialassessmentifthepreviouslymentioned inclusion/exclusion criteria were met; names were forwardedtotheresearchteamwithconsentfrompotential participants.researchassistants,trainedtofollowtheprotocol and to use the clinical tests, performed all data collection. Data Collection Datawereobtainedfromthreesources.Themedicalchart providedmedicalhistory,demographicdata,andabraden Scalescore.Askinintegrityassessmentconsistingofavisual scanofskinandablanchingtestprovidedqualitativeinformation.finally,theforcesensitiveapplications(fsa)pressure-mappingsystemdistributedbyvistamedical(andrew Frank,MedcareIT,Winnipeg,Manitoba)wasusedasthe primarytooltocollectquantitativedatainthisstudy.the pressure-mappingsystemmeasuredtheamountofpressure appliedtotheskinofanindividual,thusidentifyingareas at risk for pressure ulcer development. Pressure-mapping equipment consisted of an in. vinyl mat, of approximately1/16in.thicknessandconnectedtoalaptop 746 November/December 2009, Volume 63, Number 6

4 computer.the256sensorswithinthematcouldreadpressureatdiscretelocations;resultantreadingswereinterpreted bythecomputersystem. Onceinformedconsentwasobtainedfromtheparticipant or guardian, the medical chart was reviewed by the researchassistant.participantswereseenovertwosessions lastingapproximately20mineach,withaminimumdelay of 2 h between sessions. The first data collection session commencedwithanassessmentofskinintegrity,inwhich existingpressureareasweredocumentedifpresent.thefsa pressure-mappingmatwasthenplacedunderthebuttocks ofthesupineparticipantwiththeheadofthebedelevated to30.pressurereadingsweretakenat5-minintervalscommencingattimezerofor20minandrecordedforlaterstatistical analysis. At the end of this period, the pressure- mappingmatwasremoved,skinintegritywasreassessed,and participantswerepositionedinsidelying.aftera2-hrrest period, the previously mentioned procedure was repeated withtheadditionofan in.gelpadbetween the mattress surface and the pressure-mapping mat. The equipmentwascleanedbetweeneachuse. Results Sixty-eighteligiblepatientswererecruitedtoparticipatein thisstudyfromacutecaremedicalandsurgicalunits;60 patientscompletedbothsessionsofthestudy.eightparticipantsdeclinedasaresultofdifficultycoordinatingtest sessionswithmedicalappointmentsorashorthospitalizationlength.ofthe60patientswhocompletedthestudy, themajorityweremale(57%).theaverageageoftheparticipantswas72.6years.forsubsequentdemographicand dataanalysis,menandwomenwereconsideredseparately. Theaverageheightandweightofmaleparticipantswere 69.12in.(standarddeviation[SD]=4.10)and173.38lb (SD=35.91),respectively,withanaveragebodymassindex (BMI)of25.68kg/m 2 (SD=5.80).Similarly,theaverage heightandweightoffemaleparticipantswere64.03in.(sd =2.04)and142.67lb(SD=33.01),withanaverageBMI of24.52kg/m 2 (SD=5.81). Duringthetwostudysessions,withandwithoutthegel pad,themaximumpressurereadingswererecordedat5-min intervals,beginningattimezero.themeanmaximumpressure(pmax) was calculated for each participant using the recordedmaximumpressuresforthefinalfourintervals.the readingsattimezerowereexcludedfromthecalculationsto allow time for maximal submersion into the gel pad and stabilization of potential fluctuations in pressure. Mean maximuminterfacepressurewiththegelpad(pmaxg)was 51.64mmHg,witha95%confidenceintervalof42.29to Meanmaximuminterfacepressurewithoutthegel Table 1. Spearman s Correlation Calculations Pmaxg/Pmaxng BMI Height Weight Female (n = 33) Male (n = 26) Combined (n = 59) Note. Pmaxg = maximum interface pressure with gel pad; Pmaxng = maximum interface pressure without gel pad; BMI = body mass index. pad(pmaxng)wascalculatedas54.03mmhgwithalower andupperconfidenceintervalof45.57and62.49.using thesedata,thedifferencebetweenthemeanmaximumpressurewiththegel(pmaxg)andthemeanmaximumpressure withoutthegel(pmaxng)wascalculatedforeachparticipant (Pmaxg Pmaxng).Withthisinformation,theoverallaveragemeandifferencewascalculatedtobe 2.39mmHg(SD =35.58).Thisindicatesthat,onaverage,amongallparticipants,aslightlygreatermeanpressurewasobservedwithout thegelpadbutalsothatthemeandifferencewithandwithoutthegelpadvariedwidelyamongparticipants. ThenonparametricWilcoxonsigned-ranktestwasused tocalculatethedifferencebetweenthemediansofthetwo setsofobservations.thetwo-tailedpvaluewascalculatedat.54.thisfindingindicatesthatthereisnosignificantdifferencebetweenthemediansofpmaxngandpmaxg;therefore, theadditionofagelpaddoesnotchangeinterfacepressure inastatisticallysignificantway. Inaposthocexaminationoftheindividualmeandifferences,threedistinctgroupsemerged.Inthisanalysis,a significant differencewasdefinedasbeing2standarddeviationsfromtheaveragemeandifference.foronegroup(n= 3),theadditionofthegelpadprovidedasignificantreductionininterfacepressure;thiscorrespondstoanindividual mean difference larger than mmhg. In a second group (n = 2), the addition of the gel pad significantly increasedtheinterfacepressure:anindividualmeandifferenceofmorethan68.77mmhgwasmeasured.however, forthemajorityofparticipants(n=55),theadditionofthe gelpaddidnotsignificantlyincreaseordecreaseinterface pressure. Individual results of the skin integrity assessment showedthattherewerenochangesbeforeandaftereach session,withorwithoutthegelpad.forexample,people withrednessbeforethebeginningofsessionshadredness throughoutwithoutimprovementorexacerbation;people withnosignsofcompromisedskinintegritybeforecommencing the sessions remained as such throughout. We shouldnotethatalthoughchangeswerenotobservedduring The American Journal of Occupational Therapy 747

5 the short sessions, skin integrity changes may occur with longerperiodsoftimeinsupine. Correlationswerecalculatedinanattempttoelucidate therelationshipbetweenthemeanindividualdifferencein pressure(pmaxg Pmaxng)andheight,weight,andBMI. For this nonparametric data, Spearman s rank correlation testwasusedtocalculatethecorrelationsformenandwomen combinedorseparately(table1).correlationswerecalculatedfor59participants;datawerenotavailablefor1participantbecausetheindividualdeclinedtoprovidethisinformationtotheresearchteam.themeanindividualdifference inpressurewasfoundtohaveatendencytoincreasetogether withbmiandweightofmenseparatelyandalsowithbmi andweightofmenandwomencombined.inotherwords, withtheadditionofthegelpad,interfacepressurehada tendency to increase as an individual s weight or BMI increased.thecorrelationrelationshipswereconsideredof weakstrength(ρ=0.33)forweightwiththecombined maleandfemalegroupandofmediumstrength(ρ=.34.66)forbmiandweightwiththemalegroupseparately.in addition,thecorrelationrelationshipbetweentheindividual differenceinpressureandbmiforthecombinedgroupwas consideredofmediumstrength.datawerealsoanalyzedfor a relationship between the mean individual difference in pressureandadmissiondiagnosis;nonewasfound. Discussion Thestudyresultssuggestthatthepressure-relievingcapabilitiesofthegelpadinsupineareuncertain.Forthemajorityofparticipants,thepresenceofthegelpaddidnotsignificantly affect interface pressure; therefore, there is no indication for its use. In fact, the gel pad significantly reducedthepressureforonly3participants.morealarmingly,itspresenceconsiderablyincreasedthepressurefor2 participants; for these participants, use of the gel pad is clearlycontraindicated.theseresultsmaybeexplainedin partbythefactthatthegelpadwasdesignedtobeusedin asittingposition. Previousresearchusingpressuremappinghashelpedto developguidelinestofacilitateselectionofappropriatesupport surfaces. As previously mentioned, Schmeler and Buning s (1999) research recommended that pressure- mappingreadingsof80to120mmhgnecessitateachange insurfaceandrepresentasignificantriskfordevelopmentof pressure ulcers in a seated position. In a supine position, pressureisdistributedovertheentireposterioraspectofthe body; as a result, one would anticipate lower acceptable interfacepressuresatthecoccygealregion.contrarytothe previously stated expectation, for 9 participants, pressure exceeded80mmhgaftertheadditionofthegelpad,indicatingthatthepressure-reliefsurfacewasnotadequate.for5 participants,interfacepressurewiththeadditionofthegel padexceeded120mmhg,avaluethatindicatesthepotential forserioussequelae.conversely,withoutthegelpad,only7 participantsrecordedinterfacepressures>80mmhg,with only 4 people in this group exceeding 120 mmhg. This findingfurthersuggeststhatforsomepeopletheadditionof thegelpadispotentiallymoredetrimentalthantheuseof thetraditionalhospitalmattressalone. ComparedwiththefindingsofShechtmanetal.(2001), wefoundacorrelationbetweenthepressure-reducingcapabilitiesofthegelpadandtheweightandbmiofmaleparticipants.althoughstatisticallysignificant,thesecorrelations arenotstrongenoughtobeusedtoestablishreliableguidelines for use in a clinical setting. The difference in the strengthoftherelationshipmaybeexplainedbyparticipants position in the studies. The former study was conducted withparticipantsintheseatedposition;insupine,pressure maybedispersedoveralargersurfacearearatherthanprimarilyoverthecoccygealregion.thisstudysupportsfindingsfromgarberandkrouskop(1982):theprovisionofa therapeuticsurfacesuchasacushionoragelpaddoesnot eliminatetheriskofapressuresoreformation.resultsalso supportpreviousstudiesthathaveconcludedthatnoone pressure-reliefsurfaceisbestsuitedforallpeopleandthat individualandongoingassessmentisessentialtoprovidethe besttherapeuticsurface(pellow,1999). Giventhatnoclearindicatorswereidentifiedtosupporttheuseofthegelpad,thatthereexistspotentiallydetrimentalconsequencesofincreasedpressurewiththisintervention,andthatfor>80%ofparticipantsnosignificant changewasnoted,itisnotadvisabletousethe18-18-in. gelpadinsupine. Limitations Asinmostquantitativeresearchcarriedoutinclinicalsettings,challengesexisted.Theequipmentprovidedaquantitativecomputerizedmeasurebutcouldnotaccountfor transientchangesinpostureandappropriatepositioning onthemat.fourresearchassistantscollecteddata;however,theeffectofthisvariationwasmitigatedbyextensive trainingbeforedatacollectionandtheconsistentuseofthe same pressure-mapping system. In the hospital setting, participantsoftenpresentedindifferenttypesofattireand wereincludedregardlessofwhetherclothingorincontinenceprotectionwasworn.thismayhaveaffectedpressurereadingsbutshouldnothaveaffectedthefinalcalculations (Pmaxg and Pmaxng). Because different attire is representativeofthishospitalpopulation,itallowedinvestigatorstodrawrealisticandrelevantconclusions.finally, becauseofdocumentationchallengeswithinanacutecare 748 November/December 2009, Volume 63, Number 6

6 setting, several estimations were made regarding height, weight,andresultantbmi. Future Study Infuturestudies,itwouldbeinterestingtofurtherinvestigatecorrelationsbetweenweight,BMI,andtheroleofmorphologyascorrelatedtogelpadefficacy.Thisinformation couldbeusedtoclarifypotentialindicationsforgelpaduse in the clinical setting. Because the gel pad is intended to decreasepressureunderthecoccygealregion,thefsasystem provided readings only in that area. Future investigations shouldreproducethestudyusingthefullfsamattresssystemtoevaluatetheeffectofthegelpadoninterfacepressure atotherpressure-proneareas. Conclusions Thiscross-overdesignstudyexaminedtheefficacyofthegel padwhenusedtodecreaseinterfacepressureinasupinepositionforpatientsinanacutecaresetting.the18-18-in.gel padisroutinelyprovidedwiththegoalofdecreasinginterface pressures and thus reducing the risk of pressure ulcers. However,studyresultsindicatethatthisisseldomthecase; onlyasmallsubsetofparticipantsderivedsignificantbenefit fromthegelpad.forthemajorityofparticipants,theeffect ofthegelpadwasnegligible(i.e.,neithersignificantlyincreased nordecreasedtheinterfacepressureonthecoccygealregion). Finally,andofgreaterclinicalconcern,aretheparticipants forwhomtheinterfacepressurewasincreasedtoanalarming levelwiththeadditionofthegelpad.onfurtherexamination ofthedata,wefoundcorrelationsbetweentheefficacyofthe gel pad and BMI and weight of men. These correlations, however,werenotstrongenoughtoestablishclinicalguidelinesortopredictthoseparticipantswhowouldhaveanegativeoutcomewithgelpaduse.therefore,becausenoobvious indicatorsweredetermined,itisnotrecommendedtousethe in. gel pad in supine to alleviate pressure or to decreasetheriskofdevelopingpressuresores. s Acknowledgments Weextendsincerethankstothefollowingpeople:theparticipants;theresearchassistantswhodiligentlycollecteddata; AndrewFrankfromVistaMedicalforsupplyingtheFAS pressure-mappingsystem;rachelgervais,chiefofoccupational Therapy at The Ottawa Hospital; and our colleaguesattheciviccampusoftheottawahospitalfor ongoing support and participation. Partial results of this study were presented at the Canadian Association of OccupationalTherapists snationalconferenceinst.john s, Newfoundland,inJuly2007. References Abel, R. L., Warren, K., Bean, G., Gabbard, B., Lyder, C. H., Bing,M., et al. (2005). Quality improvement in nursing homes in Texas: Results from a pressure ulcer prevention project.journal of the American Medical Directors Association, 6, Arnold,M.C.(2003).Pressureulcerpreventionandmanagement: Thecurrentevidenceforcare.Advanced Practice in Acute and Critical Nursing Clinical Issues,14, Ayello,E.A.,Baranoski,S.,Lyder,C.H.,&Cuddigan,J.(2004). Bythenumbers:BradenScoreInterventions.Advances in Skin and Wound Care,17,150. Bansal, C., Scott, R., Stewart, D., & Cockerell, C. (2005) Decubitusulcers:Areviewoftheliterature.International Journal of Dermatology,44, Bar,C.(1991).Evaluationofcushionsusingdynamicpressure measurement[review].prosthetics and Orthotics International, 15, Bar,C.(1998,February).Pressure: Why measure it and how. Paper presented at the 14th International Seating Symposium, Vancouver,BC. Bergstrom,N.,Braden,B.,Laguzza,A.,&Holman,V.(1987). TheBradenScaleforPredictingPressureSoreRisk.Nursing Research, 36, Bonomini, J.(2003). Effective interventions for pressure ulcer prevention.nursing Standards, 17(52), Coats-Bennet,U.(2002).Woundandskinmanagementinthe ICU.Critical Care Nursing Quarterly,25, Courtney, A. B., Ruppman, B. J.,& Cooper, M. H.(2006). Saveourskin:Initiativecutspressureulcerincidenceinhalf. Nursing Management,37(4), Crawford,S.A.,Strain,B.,Gregg,B.,Walsh,D.M.,&Porter- Armstrong,A.P.(2005).Aninvestigationoftheimpactofthe ForceSensingArraypressuremappingsystemontheclinical judgmentofoccupationaltherapists.clinical Rehabilitation, 19, Garber,S.L.,&Krouskop,T.A.(1982).Bodyfluidanditsrelationshiptopressuredistributionintheseatedwheelchairpatient. Archives of Physical Medicine and Rehabilitation,63, Geyer,M.J.,Brienza,D.M.,Karg,P.,Trefler,E.,&Kelsey,S. (2001). A randomized control trial to evaluate pressure- reducingseatcushionsforelderlywheelchairusers.advances in Skin and Wound Care,14, Griesbrecht, E.(2006). Pressure ulcers and occupational therapypractice:acanadianperspective.canadian Journal of Occupational Therapy,73, Griffiths,H.,&Gallimore,D.(2005).Positioningcriticallyill patientsinhospital. Nursing Standards,19(42), Horn,S.,Bender,S.A.,Ferguson,M.L.,Smout,R.J.,Bergstrom,N., Taler,G.,etal.(2004).TheNationalPressureUlcerLong-Term CareStudy:Pressureulcerdevelopmentinlong-termcareresidents.Journal of the American Geriatrics Society,52, Kernozek, T. W.,& Lewin, J. E. K.(1998). Dynamic seating interfacepressuresduringwheelchairlocomotion:influence ofcushiontype. OTJR: Occupation, Participation and Health, 18, Lewis,M.,Pearson,A.,&Ward,C.(2003).Pressureulcerpreventionandtreatment:Transformingresearchfindingsinto The American Journal of Occupational Therapy 749

7 consensus-basedclinicalguidelines.international Journal of Nursing Practice, 9, NationalResearchCouncilInstituteforBiodiagnostics.(2006). Pressure ulcers.retrievednovember5,2007,fromhttp://ibd. nrc-cnrc.gc.ca/research/spectroscopy/2_pressure_ulcers_e.html Nixon, J., Cranny, G., Iglesias, C., Nelson, A. E., Hawkins, K.,Phillips,A.,etal.(2006).Randomised,controlledtrial of alternating pressure mattresses compared with alternating pressure overlays for the prevention of pressure ulcers: PRESSURE(pressurerelievingsupportsurfaces)trial.British Medical Journal,332,1 5. Pancorbo-Hidalgo,P.L.,Garcia-Fernandez,F.P.,Lopez-Medina, I. M.,& Alvarez-Nieto, C.(2006). Risk assessment scales forpressureulcerprevention:asystematicreview.journal of Advanced Nursing, 54, Pellow,T.R.(1999).Acomparisonofinterfacepressurereadingsforwheelchaircushionsandpositioning:Apilotstudy. Canadian Journal of Occupational Therapy, 66, Schmeler,M.,&Buning,M.E.(1999).Pressure mapping center for assistive technology. Pittsburgh,PA:UniversityofPittsburgh, UPMCHealthSystemDepartmentofRehabilitationScience andtechnology. Schoonhoven, L., Grobbee, D. E., Donders, A. R., Algra, A., Grypdonck,M.H.,Bousema,M.T.,etal.(2006).Prediction ofpressureulcerdevelopmentinhospitalizedpatients:atool forriskassessment.quality and Safety in Health Care, 15, Shechtman,O.,Hanson,C.S.,Garrett,D.,&Dunn,P.(2001). Comparingwheelchaircushionsforeffectivenessofpressure relief:apilotstudy.occupational Therapy Journal of Research, 21, Stinson,M.D.,Porter-Armstrong,A.P.,&Eakin,P.A.(2003). Pressuremappingsystems:Reliabilityofpressuremapinterpretation.Clinical Rehabilitation, 17, ThomasHess,C.(2004).Caretipsforchronicwounds:Pressure ulcers.advances in Skin and Wound Care, 17, NEW Practice Guidelines From AOTA Press! ISBN-13: Occupational Therapy Practice Guidelines for Adults With Traumatic Brain Injury By Kathleen Golisz, OTR, OTD Using an evidence-based perspective and key concepts from the Occupational Therapy Practice Framework, this guideline provides an overview of the occupational therapy process for adults with traumatic brain injury (TBI), including definition, epidemiology, stages of recovery, referral, evaluation, and interventions throughout the various recover phases. This publication is designed to help occupational therapists and occupational therapy assistants, as well as individuals who manage, reimburse, or set policy for occupational therapy services, understand the contribution of occupational therapy in treating adults with TBI. This guideline also can serve as a reference for parents, school administrators, educators, and other school staff; health care facility managers; education and health care regulators; third-party payers; and managed care organizations. Order #2214 AOTA Members: $49 Nonmembers: $69.50 To Order, call AOTA, or visit BK November/December 2009, Volume 63, Number 6