Pressure Ulcer Prevention for Wheelchair-Bound Athletes
Wheelchair-bound athletes should use advanced static wheelchair cushions combined with pressure-relieving push-ups performed gradually every 15-30 minutes, along with daily skin inspection and multicomponent prevention strategies. 1, 2
Core Prevention Strategy
The foundation of pressure ulcer prevention in wheelchair users requires a bundled approach with standardized protocols, multidisciplinary team involvement, designated skin champions, ongoing education, and sustained audit and feedback. 1 This multicomponent strategy has demonstrated significant clinical improvements and cost savings (approximately $11.5 million annually in one hospital system). 1
Wheelchair Cushion Selection
Advanced static cushions are strongly recommended over standard wheelchair cushions for athletes at increased risk. 1 The evidence shows moderate-quality support for advanced static surfaces reducing pressure ulcer incidence compared to standard options. 1
One study noted increased withdrawal rates due to discomfort with the Jay cushion compared to standard cushions, but this should not deter use of advanced static options as the overall benefit outweighs temporary discomfort. 1
Pressure-Relieving Maneuvers
Athletes must perform pressure-relieving push-ups, but the technique of returning to seated position is critical—they should reposition gradually and gently, not "fall" back into the wheelchair. 3 Research demonstrates that skin loads increase nonlinearly during sitting-down, with greater load/time slope at early skin-support contact, making this the most vulnerable period for tissue injury. 3
Current guidelines recommend pressure-relieving movements every 15 minutes, though compliance data shows only 20.8% of wheelchair users move once per hour, with 54.7% moving less frequently. 4 For athletes, adherence to the 15-30 minute interval is essential despite physical capability to perform movements independently. 4
Daily Skin Assessment Protocol
Visual and tactile examination of high-risk areas must occur at least once daily, focusing on: 2
- Ischial tuberosities (primary pressure point when seated)
- Sacrum
- Heels (if feet rest on footplates)
Athletes should check for early signs including non-blanchable erythema, increased warmth, or tissue changes. 2 Repositioning every 2-4 hours with pressure zone checks remains necessary even with specialized cushions. 2
Additional Preventive Measures
Prophylactic multilayer foam dressings should be applied to the sacrum and ischial areas for high-risk athletes. 5 This represents best practice beyond repositioning alone. 5
Nutritional support with high-protein supplementation is recommended, particularly for athletes with increased metabolic demands or any nutritional deficits. 5 Malnutrition significantly increases pressure ulcer risk. 6
Moisture management is crucial—keep skin clean and dry, addressing any incontinence or excessive perspiration from athletic activity promptly. 5
Risk Assessment
Perform individualized risk assessment considering: 1
- Duration of wheelchair dependence
- Presence of sensory deficits
- Previous pressure ulcer history (scarred tissue is more vulnerable, especially hypertrophic scars) 3
- Nutritional status
- Comorbid conditions affecting tissue integrity
The Braden, Norton, or Waterlow scales can assist clinicians without expert gestalt, though all have low sensitivity and specificity. 1 Clinical judgment combined with objective assessment is appropriate. 1
Critical Pitfalls to Avoid
Never use donut cushions—they are explicitly contraindicated as they concentrate pressure around the perimeter, creating a tourniquet effect that impairs central tissue circulation. 5 No quality evidence supports their use. 5
Avoid prolonged static positioning even during athletic training or competition—pressure relief cannot be deferred for performance. 4
Do not rely solely on cushion technology without active pressure-relieving maneuvers, as even specialized cushions require regular repositioning. 2
Monitoring and Adjustment
If skin changes occur despite optimal prevention, reassess the entire prevention bundle within 6 weeks and modify the approach. 7 Document wound characteristics including size, depth, and any signs of infection (warmth, purulence, odor). 7
For athletes with existing pressure injuries, the location and severity must guide cushion selection and activity modification. 2 Early mobilization should be combined with cushion use as soon as medically stable. 2