Using Technology to Detect Erythema Across Skin Tones.

OBJECTIVE: To examine the effectiveness of the ColorMeter DSM III (ColorMeter; Cortex Technology) at grouping individuals by skin tone and measuring erythema/skin discoloration after erythema induction across skin tones. METHODS: This pre/post experimental study induced erythema on a convenience sample of 61 healthy adults. Skin tone at baseline was measured using the ColorMeter, Munsell Soil Color Chart 5YR (Munsell), and Pantone SkinTone Guide (Pantone) and compared with the Eumelanin Human Skin Colour Scale (Eumelanin Scale) groupings. Erythema and melanin values on the arm immediately and after recovery time were compared with baseline values. Melanin was measured at five body regions on the face and arm. RESULTS: Participants were predominantly women (64% [n = 39] women, 36% [n = 22] men) and young (mean, 28.8 ± 14.3 years); 5% (n = 3) were Hispanic, 26% (n = 16) Asian, 29% (n = 18) Black, 38% (n = 23) White, and 7% (n = 4) identified with more than one race. ColorMeter lightness (L*) and melanin measures were strongly correlated with both Munsell and Pantone values. Munsell skin tone groups were not aligned with Eumelanin Scale groupings. Most participants were in the Eumelanin intermediate-low group, and this changed depending on which body location melanin value was used. The change in erythema from baseline did not differ significantly across skin tone groups at the ulnar head, but on the forearm at the delayed time point, significant differences existed between light and both medium and dark skin tone groups (P = .001; 95% CI, 0.04-0.37). CONCLUSIONS: The ColorMeter provides an effective objective measure of skin tone and erythema/discoloration across various skin tones and may improve on current standards for detection. The proposed Eumelanin Scale-Modified provides additional sensitivity for persons with medium skin tones.

Necessary Products for the Prevention and Treatment of Pressure Injuries: Lessons Learned That Translate Beyond the COVID-19 Pandemic.

OBJECTIVE: To identify the challenges encountered in obtaining the required support surfaces and products to meet pressure injury (PrI) prevention and treatment needs during COVID-19. METHODS: The authors used SurveyMonkey to gather data on healthcare perceptions and the challenges experienced regarding specific product categories deemed necessary for PrI prevention and treatment in US acute care settings during the pandemic. They created three anonymous surveys for the target populations of supply chain personnel and healthcare workers. The surveys addressed healthcare workers' perceptions, product requests, and the ability to fulfill product requests and meet facility protocols without substitution in the categories of support surfaces and skin and wound care supplies. RESULTS: Respondents answered one of the three surveys for a total sample of 174 respondents. Despite specific instructions, nurses responded to the surveys designed for supply chain personnel. Their responses and comments were interesting and capture their perspectives and insights. Three themes emerged from the responses and general comments: (1) expectations differed between supply chain staff and nurses for what was required for PrI prevention and treatment; (2) inappropriate substitution with or without proper staff education occurred; and (3) preparedness. CONCLUSIONS: It is important to identify experiences and challenges in the acquisition and availability of appropriate equipment and products for PrI prevention and treatment. To foster ideal PrI prevention and treatment outcomes, a proactive approach is required to face daily issues or the next crisis.

Reducing pressure with the goal of improving outcomes: a retrospective chart review of cushion evaluations and recommendations at one seating clinic.

PURPOSE: To describe the current seating recommendations made by a seating clinic for wheelchair users who presented with a Pressure Injury (PrI) or history of PrI. METHODS: Retrospective review of electronic medical records of 133 adults who used a wheelchair as their primary means of mobility who had a cushion evaluation during which interface pressure mapping data was documented. RESULTS: Clinicians adjusted 71% of participants' wheelchair cushions, including 49% who received a new cushion, and 37% of participants' wheelchairs. The most common adjustments besides receiving a new cushion were: addition of an underlay, adjusting the inflation of a cushion, and adjustments to the foot or back support of the wheelchair. Forty-five participants only received adjustments (i.e. no new cushion), while 23 participants only received education and feedback rather than equipment modifications. Those 23 participants had significantly lower Peak Pressure Index (PPI) than those who received equipment modifications (mean [95% CI] 76.7 [59.1, 94.3] versus 111.6 [102.1, 121.2] respectively, p = 0.001). The PPI was reduced by an average of 22.5 mmHg from the initial to final seating system amongst those who received modifications ([13.9-31.0], p<.001). CONCLUSIONS: The seating clinicians considered interface pressure mapping in their decision-making and effectively reduced interface pressures with their interventions. Cushion replacement is important when someone presents with a PrI. However, adjusting an existing wheelchair cushion and/or seating system provides important additions and alternatives to consider for reducing interface pressure. There is also a role for education about proper use of equipment, weight shifts, and alternate seating surfaces.IMPLICATIONS FOR REHABILITATIONA cushion evaluation may involve evaluating more than one cushion configuration and using pressure mapping to compare the best options.To address perceived wheelchair cushion issues, posture and positioning should be evaluated and adjusted as necessary, in addition to evaluating the cushion itself.Common positioning modifications include: modifying/adding cushion underlays or inflation and foot and back supports in response to clients' changing postural needs and wheelchair components coming out of optimal position due to wear and tear.Adjustments to the wheelchair and cushion aim to distribute body weight over a larger surface area, reduce pressure at high-risk locations, improve posture, and increase function. These adjustments should consider individual's specific needs and goals, while also being mindful of funding barriers.

The relationship between in-seat movement and pressure ulcers in wheelchair users with SCI/D.

OBJECTIVE: To identify parameters that are associated with time at pressure, are most related to pressure ulcer outcomes, and that may be used to influence pressure ulcer (PrU) outcomes in future intervention studies. DESIGN: Analysis used datasets from cross-sectional and longitudinal observational studies. Wheelchair-usage and in-seat metrics thresholds were optimized to differentiate individuals in PrU or No PrU groups. Logistic regression identified the demographics and in-seat activity metrics that impacted PrU outcomes. SETTING: General Community. PARTICIPANTS: Fifty individuals with spinal cord injuries and/or disorders (SCI/D) who use a wheelchair as their primary mobility device. 22 subjects were within the first year following injury and 28 had been using a wheelchair for over 2 years. Twenty-one participants reported PrU outcomes. INTERVENTIONS: Not applicable. OUTCOME MEASURES: Time in chair, pressure relief frequency, weight shift frequency, percentage of seated time that the subject is active (CoP Percent Active), frequency of in-seat movement, unloading event frequency, maximum time between events, and number of transfers. RESULTS: Optimal cutoff thresholds for the most significant in-seat movement metrics included: unloading event frequency of 3.1 times per hour (OR 0.353, 95% CI [0.110, 1.137]), maximum time between events of 155.4 min (OR 2.888, 95% CI [0.886, 9.413]), and CoP Percent Active of 2.6% (OR 0.221, 95% CI [0.063, 0.767]). When individuals were more active than these cutoffs, significantly more individuals were in the no pressure ulcer group. In predictive modeling, CoP Percent Active was the in-seat movement metric that significantly predicted PrU outcomes. The model was improved by adding age, occupation, and injury completeness. CONCLUSION: Of the 4 significant predictors in the model, only CoP Percent Active was modifiable. Therefore, an opportunity exists to design approaches to modify behavior. However, the results illustrate that the key to preventative movement may be through functional movement as opposed to scheduled, routine pressure reliefs.

Movement Patterns of Transient and Prolonged Positioning Events in Nursing Home Residents: Results from the TEAM-UP Trial.

OBJECTIVE: To characterize transient and prolonged body position patterns in a large sample of nursing home (NH) residents and describe the variability in movement patterns based on time of occurrence. METHODS: This study is a descriptive, exploratory analysis of up to 28 days of longitudinal accelerometer data for 1,100 NH residents from the TEAM-UP (Turn Everyone and Move for Ulcer Prevention) clinical trial. Investigators analyzed rates of transient events (TEs; less than 60 seconds) and prolonged events (PEs; 60 seconds or longer) and their interrelationships by nursing shift. RESULTS: Residents' positions changed for at least 1 minute (PEs) nearly three times per hour. Shorter-duration movements (TEs) occurred almost eight times per hour. Residents' PE rates were highest in shift 2 (3 pm to 11 pm ), when the median duration and maximum lengths of PEs were lowest; the least active time of day was shift 3 (11 pm to 7 am ). Three-quarters of all PEs lasted less than 15 minutes. The rate of TEs within PEs decreased significantly as the duration of PEs increased. CONCLUSIONS: The NH residents demonstrate complex patterns of movements of both short and prolonged duration while lying and sitting. Findings represent how NH residents naturally move in real-world conditions and provide a new set of metrics to study tissue offloading and its role in pressure injury prevention.

An Exploratory Analysis of the Role of Adipose Characteristics in Fulltime Wheelchair Users' Pressure Injury History.

Aim: The goals of this study were 1) to identify the relationship between adipose (subcutaneous and intramuscular) characteristics and pressure injury (PrI) history in wheelchair users and 2) to identify subject characteristics, including biomechanical risk, that are related to adipose characteristics. Materials and Methods: The buttocks of 43 full-time wheelchair users with and without a history of pelvic PrIs were scanned in a seated posture in a FONAR UPRIGHT® MRI. Intramuscular adipose (the relative difference in intensity between adipose and gluteus maximus) and the subcutaneous adipose characteristics (the relative difference in intensity between subcutaneous adipose under and surrounding the ischium) were compared to PrI history and subject characteristics. Results: Participants with a history of PrIs had different subcutaneous fat (subQF) characteristics than participants without a history of PrIs. Specifically, they had significantly darker adipose under the ischium than surrounding the ischium (subQF effect size = 0.21) than participants without a history of PrIs (subQF effect size = 0.58). On the other hand, only when individuals with complete fat infiltration (n = 7) were excluded did individuals with PrI history have more fat infiltration than those without a PrI history. The presence of spasms (µ intramuscular adipose, 95% CI with spasms 0.642 [0.430, 0.855], without spasms 0.168 [-0.116, 0.452], p = 0.01) and fewer years using a wheelchair were associated with leaner muscle (Pearson Corr = -0.442, p = 0.003). Conclusion: The results of the study suggest the hypothesis that changes in adipose tissue under the ischial tuberosity (presenting as darker SubQF) are associated with increased biomechanical risk for pressure injury. Further investigation of this hypothesis, and the role of intramuscular fat infiltration in PrI development, may help our understanding of PrI etiology. It may also lead to clinically useful diagnostic techniques that can identify changes in adipose and biomechanical risk to inform early preventative interventions.

Pressure redistributing in-seat movement activities by persons with spinal cord injury over multiple epochs.

Pressure ulcers, by definition, are caused by external forces on the tissues, often in the regions of bony prominences. Wheelchair users are at risk to develop sitting-acquired pressure ulcers, which occur in the regions of the ischial tuberosities, sacrum/coccyx or greater trochanters. As a means to prevent pressure ulcers, instruction on performing pressure reliefs or weight shifts are a part of the rehabilitation process. The objective of this study was to monitor the weight shift activity of full-time wheelchair users with acute spinal cord injury over multiple epochs of time in order to determine consistency or routine within and across epochs. A second objective was to evaluate the accuracy of self-reported pressure relief frequency within each measurement epoch. A wheelchair in-seat activity monitor was used to measure weight shifts and other in-seat movement. The data was classified into multiple in-seat activity metrics using machine learning. Seventeen full-time wheelchair users with spinal cord injury were measured within multiple epochs, each lasting more than 1 week. Across all in-seat activity metrics, no consistent pattern of activity changes emerged. None of the in-seat activity metric changed in any one direction across a majority of subjects. Subjects tended to over-estimate their frequency of performing pressure reliefs. Self-reported pressure relief behaviors are not reliable, and therefore, cannot be used to evaluate preventative behaviors either clinically or within research. This study had the capability of fully investigating in-seat movements of wheelchair users. The results indicated that in-seat movement does not reflect a routine, either in pressure reliefs, weight shifts or other functional in-seat movements. This study has illustrated the complexity of assigning causation of pressure ulcer occurrence to seated behaviors of wheelchair users and identifies the need for improved clinical techniques designed to develop routine behaviors to prevent pressure ulcers.

Buttock tissue response to loading in men with spinal cord injury.

OBJECTIVE/BACKGROUND: Despite the fact that most people with a spinal cord injury who use a wheelchair for mobility are considered at-risk for pressure ulcer (PrU) development, there still exists a spectrum of risk amongst this group. Efforts to differentiate risk level would benefit from clinical tools that can measure or predict the buttocks response to loading. Therefore, the goal of this study was to identify how tissue compliance and blood flow were impacted by clinically-measurable risk factors in young men with SCI. METHODS: Blood flow at the ischial tuberosity was measured using laser Doppler flowmetry while the seated buttock was unloaded, and loaded at lower (40-60 mmHg) and high (>200 mmHg) loads. Tissue compliance of the buttock was measured using the Myotonometer while subject were lifted in a Guldmann Net. RESULTS: Across 28 participants, blood flow was significantly reduced at high loads, while no consistent, significant changes were found at lower loads. At 40-60 mmHg, blood flow decreased in participants with a pressure ulcer history and lower BMI, but stayed the same or increased in most other participants. The buttock displaced an average of 9.3 mm (2.7 mm) at 4.2 N, which represented 82% (7%) of maximum displacement. BMI was related to the amount of buttock tissue displacement while smoking status explained some of the variation in the percent of max displacement. CONCLUSION: Wide variability in tissue compliance and blood flow responses across a relatively homogeneous population indicate that differences in biomechanical risk may provide an explanation for the spectrum of PrU risk among persons with SCI.

Wheelchair use in ultra-lightweight wheelchair users.

PURPOSE: The goal of this study was to describe how ultra-lightweight wheelchair users use their wheelchairs during everyday mobility. METHOD: We instrumented a convenience sample of 69 ultra-lightweight wheelchair users with a seat switch to measure their occupancy, and an accelerometer on their wheel to measure distance wheeled, time spent wheeling and daily bouts of mobility. RESULTS: On the median day, subjects wheeled 83 bouts and 1.4 km over 45 min. A typical bout of mobility was 8.3 m in length, lasting 20 s and occurring at a speed of 0.44 m/s. Fast (>1 m/s) and long (>2 min) bouts represented less than 4% of bouts and were more common among younger participants and those who were employed or a student. CONCLUSIONS: Highly functional manual wheelchair users present with a significant mobility disability, moving far less than their ambulating peers despite moving with similar mobility characteristics. The typical bout characteristics - short and slow bouts - are consistent with indoor mobility and transitions between functional activities. For wheelchair users, it highlights the importance of manoeuverability and the need for prescription and training to emphasize manoeuverability. Implications for Rehabilitation Measurement of wheelchair use, both how and how much, might provide unique insight to what equipment would be most appropriate for an individual. Participants who used an ultralight wheelchair presented with a significant mobility disability, wheeling only 1.7 km/day on average. Fast (>1 m/s) and long (>2 min) bouts are uncommon, representing less than 4% of bouts. Younger participants and those who were employed or a student were more likely to wheel one fast and long bout per day. Because wheelchair mobility was dominated by short, slow bouts, prescription and training need to emphasize maneuverability.

3D anatomy and deformation of the seated buttocks.

AIM: To describe the 3D anatomy and deformation of the buttocks during sitting. MATERIALS AND METHODS: The buttocks of 4 able-bodied individuals and 3 individuals with spinal cord injury were scanned sitting in a FONAR Upright MRI. T1-weighted Fast Spin Echo scans were collected with the individuals seated on a custom wheelchair cushion to unload the ischial tuberosities (ITs) and seated on a 3 inch foam cushion. Multi-planar scans were analyzed, and the muscle, bone and adipose tissue was manually segmented for 3D rendering and analysis of the quantity, geometry, and location of tissues. RESULTS: The gluteus maximus was positioned lateral and posterior to the IT, covering the inferior portion of the IT for only 2 able-bodied participants. Adipose thickness directly under the IT did not differ by diagnosis, nor did it have a consistent response to loading. However, the envelopment of the IT by the surrounding adipose tissue was much greater in two of the participants with spinal cord injuries. These two subjects also had the most curved skin surface as the tissue wrapped around the IT. Tissue strains around the ischium were most visible in the adipose and connective tissue. The gluteus maximus displaced and distorted upwards, posterior and lateral, away from the inferior IT. CONCLUSIONS: Multi-planar imaging is necessary to investigate anatomy and deformation of the buttocks. 5 out of 7 participants did not sit directly on muscle. The tissue beneath their ITs was predominantly composed of fat and connective tissue, suggesting that these tissues might be most vulnerable to injury.

3-dimensional buttocks response to sitting: a case report.

AIM OF THE STUDY: The aim of this study was to describe an individual's 3-dimensional buttocks response to sitting. Within that exploration, we specifically considered tissue (i.e., fat and muscle) deformations, including tissue displacements that have not been identified by research published to date. MATERIALS AND METHODS: The buttocks anatomy of an able-bodied female during sitting was collected in a FONAR Upright MRI. T1-weighted Fast Spin Echo scans were collected with the individual seated on a custom wheelchair cushion with a cutout beneath the pelvis ("unloaded"), and seated on a 3″ foam cushion ("loaded"). 2D slices of the MRI were analyzed, and bone and muscle were segmented to permit 3D rendering and analyses. RESULTS: MRIs indicated a marked decrease in muscle thickness under the ischial tuberosity during loaded sitting. This change in thickness resulted from a combination of muscle displacement and distortion. The gluteus and hamstrings overlapped beneath the pelvis in an unloaded condition, enveloping the ischial tuberosity. But the overlap was removed under load. The hamstrings moved anteriorly, while the gluteus moved posterior-laterally. Under load, neither muscle was directly beneath the apex of the ischial tuberosity. Furthermore, there was a change in muscle shape, particularly posterior to the peak of the ischial tuberosity. CONCLUSION: The complex deformation of buttocks tissue seen in this case study may help explain the inconsistent results reported in finite element models. 3D imaging of the seated buttocks provides a unique opportunity to study the actual buttocks response to sitting.

Manual wheelchair use: bouts of mobility in everyday life.

Background. This study aimed to describe how people move about in manual wheelchairs (MWCs) during everyday life by evaluating bouts of mobility or continuous periods of movement. Methods. A convenience sample of 28 MWC users was recruited. Participants' everyday mobility was measured using a wheel-mounted accelerometer and seat occupancy switch for 1-2 weeks. Bouts of mobility were recorded and characterized. Results. Across 29,200 bouts, the median bout lasted 21 seconds and traveled 8.6 m at 0.43 m/s. 85% of recorded bouts lasted less than 1 minute and traveled less than 30 meters. Participants' daily wheelchair activity included 90 bouts and 1.6 km over 54 minutes. Average daily occupancy time was 11 hours during which participants wheeled 10 bouts/hour and spent 10% of their time wheeling. Spearman-Brown Prophecy analysis suggested that 7 days were sufficient to achieve a reliability of 0.8 for all bout variables. Conclusions. Short, slow bouts dominate wheelchair usage in a natural environment. Therefore, clinical evaluations and biomechanical research should reflect this by concentrating on initiating movement, maneuvering wheelchairs, and stopping. Bouts of mobility provide greater depth to our understanding of wheelchair use and are a more stable metric (day-to-day) than distance or time wheeled.

Validation of an accelerometer-based method to measure the use of manual wheelchairs.

The goal of this project was to develop and validate a methodology for measuring manual wheelchair movement. The ability to study wheelchair movement is necessary across a number of clinical and research topics in rehabilitation, including the outcomes of rehabilitation interventions, the long-term effects of wheelchair propulsion on shoulder health, and improved wheelchair prescription and design. This study used a wheel-mounted accelerometer to continuously measure distance wheeled, and to continuously determine if the wheelchair is moving. Validation of the system and algorithm was tested across typical mobility-related activities of daily living, which included short slow movements with frequent starts, stops, and turns, and straight, steady state propulsion. Accuracy was found to be greater than 90% across wheelchair and wheel types (spoke and mag), propulsion techniques (manual and foot), speeds, and everyday mobility-related activities of daily living. Although a number of approaches for wheelchair monitoring are currently present in the literature, many are limited in the data they provide. The methodology presented in this paper can be applied to a variety of commercially available products that record bi-axial accelerations, and used to answer many research questions in wheeled mobility.

A robust wheelchair pressure relief monitoring system.

It is essential to prevent pressure ulcers for people with spinal cord injuries (SCI). Pressure ulcer is likely to develop when there is excessive pressure on the body tissue for lengthy durations. Therefore, persons with SCI, who usually spend long time sitting in wheelchairs, are advised to perform regular pressure reliefs in their daily lives. This paper proposes a system for the monitoring of wheelchair users' pressure relief behaviors. The system utilizes piezo resistive sensors beneath a wheelchair cushion to monitor pressure, and employs supervised learning techniques to classify a wheelchair user's pressure relief status. Key features of the system include robustness and not interfering with cushion performance or the daily activities of wheelchair users. The system works well on different types of cushions, and achieves 91% sensitivity and 89% specificity based on tests on different wheelchair users.

Distinct tilting behaviours with power tilt-in-space systems.

PURPOSE: To characterise the use of tilt-in-space systems and to form recommendations for tilt prescription and training based upon its use. METHOD: Wheelchair occupancy and seat position of 45 full-time power wheelchair users were monitored for 1-2 weeks using an accelerometer, occupancy switch and data logger. Demographics, pressure ulcer history, functional and physical presentations of their disability, and sensation were also documented. RESULTS: Participants spent 12.1 h in their wheelchairs daily, with a median typical position of 8° (0°-47°). The median participant tilted every 27 min (0.1-16.6 tilts per occupancy hour). Pressure-relieving tilts (i.e. a tilt ≥30° for ≥1 min) were performed, on average, once every 10 h (0-2.2/h). Participants spent 19% of their seated time tilted past 15°. Seventeen participants utilised the tilt feature frequently and spent >20% of the time in multiple positions. The remaining participants sat in a single tilt range for >80% of the time. CONCLUSIONS: Given the limited pressure relief compliance, alternative approaches to pressure relief and improved training may be needed for some clients. Wheelchair design and prescriptions may also need to reflect participants' preferences for sitting in small and medium tilts and changing position frequently.

The participation and activity measurement system: an example application among people who use wheeled mobility devices.

PURPOSE: To present the Participation and Activity Measurement System (PAMS), a system designed to examine activity and participation among people who use wheeled mobility devices. METHODS: Description of PAMS' components and an example of its application among people who use tilt-in-space wheelchairs. RESULTS: PAMS combines objective and subjective descriptions of mobility-based activities within a person's home and community. By applying technologies such as wheel revolution counters, seat occupancy sensors and global positioning systems, PAMS captures diverse metrics of wheelchair use including destinations, wheeled distance, duration of occupancy and the use of specialised features such as tilt. These metrics also provide the basis for a prompted recall interview designed to elicit contextual data about wheelchair use within a person's home and community. A recent study among people who use tilt-in-space wheelchairs demonstrates the components and application of PAMS. CONCLUSIONS: The combination of objective and subjective data afforded by the application of PAMS reflects a complex relationship between wheelchair use and the role of mobility as people go about their daily home and community activities. PAMS can be adapted to a variety of research questions and may be used as an alternative or supplement to self-report assessments of activity and participation.