- Email: [email protected]
Reviews and Abstracts
32
Journal of Tissue Viability 1998 Vol 8 No 4
REVIEWS AND ABSTRACTS Pressure Sore Prevention & Wound Management Policy of Wandsworth Community Health and St Georges Healthcare NHS Trusts This policy is the result of a collaborative venture between an acute trust and a community trust and has been prepared by a multidisciplinary working group. It comprises four sections: pressure sores, wound management, fistula in ano and diabetic foot ulcers. Each section is presented in the same format introduction, aims and objectives, definitions/classification, assessment, relevant aspects of care, education, audit, references and appendices. The purpose of the policy and it's specific setting is set out in the foreword. The policy is clearly written and obviously based on the relevant literature. Attempts have been made throughout to support statements with evidence. It must be recognised that some of the evidence is expert opinion rather than derived from clinical trials. However, that is the reality of the current tissue viability evidence base and not a particular criticism of this policy. The policy follows a logical construction which is important in this type of material. It is rather surprising to find a section on fistula in ano as this is not a topic commonly found within a tissue viability policy. The leg ulcer section is rather scant with no mention of the role of bandages. It may have been useful to have included the leg ulcer policy within this document. There is a praiseworthy attempt to illustrate some of the potential causes of pressure sores, Unfortunately, the impact is lost through the poor quality of the illustrations (scanned images subsequently photocopied). This situation is all too common when producing documents with little or no budget. The policy is presented in a substantial ring binder which will allow for easy updating. The pages had to be turned carefully to ensure that the paper did not rip. Overall, this policy looks to be a helpful guide for the clinicians for whom it was prepared. It can also serve as a reference for those who have no experience in preparing this type of document. Carol Dealey, Research Fellow, University Hospital, Birmingham.
Myth and Reality in Wound Care. Williams C, Young T. Dinton: Quay Books, 1998. 137pp. This book considers some aspects of wound management, intending to dispel some of the myths and rituals that continue to form the basis of practice in many healthcare settings.
Prior to the first chapter there is a self assessment questionnaire consisting of 14 questions on various aspects of tissue viability. This is designed to identify deficits in the reader's knowledge on the subject before reading the main text. The questionnaire is repeated again at the end of the book in order to evaluate learning. The material is divided into 5 chapters, each of which examines some commonly held beliefs about that aspect of tissue viability in a question and answer format. These subjects are: wound healing, wound cleansing/infection, pressure sores, leg ulcers and wound management. Some recommendations for practice are provided, drawn from references that are given at the end of each chapter. A general concluding chapter summanses certain issues raised within the text as a whole. Generally it is a well organised and easy to read text. It is not original in its design but provides a good structure for the subject considered. The idea of addressing some of the socalled 'we've always done it this way!' attitudes that still occur all too frequently in wound care, and in nursing generally, is welcomed. In agreement with the authors, we all know how frustrating and demoralising it can be to find practices occurring for which research has repeatedly failed to find any support. However, one could not help feeling that the authors were searching for the 'holy grail' of wound care in attempting to find sound research-based evidence to demystify the myths that surround wound management. This is, in part, acknowledged by the authors in the foreword. The subject areas chosen for examination are relevant, but the ability to do this in one book is a task worthy of a much larger tome. This is demonstrated by the slightly superficial nature of the analysis in each chapter, particularly those concerned with pressure sores and leg ulcers. The half filled pages in these chapters are disappointing when so many of the points raised begged expansion. Several of the conclusions drawn from the references are somewhat generalised and their application questionable. The quotation (p52) from Rodeheaver (1989) 'don't put into a wound what you wouldn't put into your eye', as a recommendatron for practice, is an example of this. One questions how far we would be in wound management with just saline, water and perhaps chloramphenicol. There is some acknowledgement of contrasting opinions and weak supporting literature, ie in wound cleansing but generally, this is lacking and certainly would have provided more substance to the aim of the book as a whole. The arguments, therefore, are not presented in sufficient detail and the recommendations should not be taken at face value as a result. However, the fact that references are provided does encourage the reader to use them as a starting point from
Journal of Tissue Viability 1998 Vol 8 No 4 which to consider the evidence for themselves, hopefully taking into account a critique of the research methodology used. It is felt that the tables included within the text add little to enhance or clarify the information already provided and therefore are perhaps unnecessary. The cartoon drawings illustrate amusing scenarios relating to the text. However, the format of the index may cause some frustration to users since it alphabetically lists all the myths addressed in the text. It would be possibly more useful if key words were listed rather than the whole myth or ritual. The self-assessment questions are a good guide as a starting point for learning but printed duplication of the assessment is questioned. From an academic point of view, it is interesting to note inconsistencies in the formatting of some chapter headings throughout the book i.e. 'no. 18' and '19' are noted, but obviously this is the publisher's domain.
33
For the practitioner new to tissue viability, therefore, the material presented provides useful information as a point from which to begin an analysis of the evidence surrounding some wound care practices. But for the experienced practitioner, there is little new information. The idea of dispelling myths associated with wound care is coveted by many healthcare practitioners and researchers in the field, but part of the reason that it has not been achieved is that the reliable evidence just does not exist. therefore the autti.ors certainly were setting themselves a difficult task. The concept of a book, or even a series of books, such as this is excellent, but as a recommendation, it would be useful to expand the arguments and provide a more analytical approach to the evidence provided. Amanda Tong BN(Hons) RGN, FAETC, Lecturer, Tissue Viability, Buckinghamshire Chiltems University College, Bucks.
ABSTRACTS OF PRESENTATIONS GIVEN AT THE SOCIETY'S 30th CONFERENCE IN LEEDS ON 1/2 APRIL 1998 Wound Care in the Real World Amanda Champion, RGN, Clinical Research Nurse; Julia Davey RGN, DN, Clinical Nurse and Mary Jones, BN, RGN, DN, Senior Clinical Research Nurse, Bridgend General Hospital, South Wales It is well documented that a holistic, multidisciplinary approach
to wound care enhances the healing process 1•2 • In reality, however, it is not always possible to follow these principles completely, as they are dependent on the individual patients' requirements and wishes. Recent treatment of a 61-year-old man with a non-healing, chronic, venous leg ulcer, with associated eczema, highlighted the problems that can occur. The solutions we used were within the constraints dictated by the patient. Stasis eczema is a common complicating factor of venous leg ulceration, which affects the healing process and can also increase pain and discomfort3 • The management of this patient utilised a team approach, but taking his lifestyle into consideration resulted in a holistic approach being difficult to fully implement. The patient lived in a mobile home and was employed as a car mechanic. Many treatments were used prior to our involvement, but using a combination of compression therapy over the application of a zinc oxide impregnated medicated stocking resulted in gradual improvement4 • Progress was further enhanced by referral to a dermatologist for appropriate topical treatment of the eczema. Although the treatment of this patient did not involve any new or unusual therapies, it was highlighted that wound care, particularly in the community must be co-ordinated, flexible and responsive to patients and their "real life" situations. References 1. Morrison M, Moffat C, Bridel-Nixon J, Bale S. Patient assessment in nursing management of chronic wounds: 2nd ed. London: Mosby, 1997: 69. 2. Stotts NA, Wipke-Tevis D. Co-factors in impaired wound healing. Ostomy Wound Management 1996, 42(2): 42-46. 3. Kulozic M, Powell SM, Cherry G, Ryan TJ. Contact
4.
sensitivity in community based leg ulcer patients. Clinical & Experimental Dermatology 1988; 13: 82-84. Struckman J. Compression stockings and their effect on the venous pump- a comparative study. Phlebology 1986; 1: 37-45.
Criteria for Mattress Selection Cheryl E Dunford, Clinical Nurse Specialist in Tissue Viability, Salisbury District Hospital and Heather Newton, Clinical Nurse Specialist in Tissue Viability, Royal Cornwall Hospitals.
The Department of Health has demanded that the incidence of pressure sores be reduced 1• Given current knowledge, the most cost-effective strategies for meeting this target are unclear. However, it has been shown that patients at increased risk of developing sores should be placed on a pressure reducing mattress, shown to be better than the standard hospital mattress 2 • The current restraints on budgets, including those for equipment monies mean that any equipment purchased must be both clinically effective and last a long time. When selecting a foam pressure reducing mattress, the following important criteria should be considered: information on foam and cover materials clinical evidence of pressure reducing properties independent comprehensive clinical!laboratory testing conformation to CE marking and British Standards proven longevity warranties, company support including training. References 1. Department of Health. Health of the nation. London: HMSO, 1991. 2. Callum N, Deeks J, Fletcher A, Long A, Mouneimne H, Sheldon T et al. The prevention and treatment of pressure sores: how effective are pressure-relieving interventions and risk assessment for the prevention and treatment of pressure sores? Effective Health Care 1995; 2(1).
34
Journal of Tissue Viability 1998 Vol 8 No 4
The Multidisciplinary Team and Costs in the Treatment of Foot Ulcers Deidre Browning, Chailey Heritage. CHAli,EY HERITAGE is a rehabilitation and development centre for children and young people with severe and complex physical disabilities. The Tissue Trauma clinic at Chailey often has referrals for children and young people who have developed pressure ulcers on their feet. Over the last I 0 years these ulcers have been treated successfully by using protective plaster casts. The multidisciplinary team is an important aspect of our work at Chailey and with ulcers of the feet members would include, our plaster technician, who has developed special skills in the application of plaster casts for children and young people with physical disabilities, physiotherapists, orthotists, podiatrists, rehabilitation engineers and the tissue viability nurse. Multidisciplinary teamwork in wound care has been described by Springett and Greaves 2 and Wilding 3. Knowles4 also descibes work of the diabetic foot clinic. Use of an EVA boot in diabetic wound healing has been described by Marland and Walker1 amongst others. The clients attending our clinics are children and young people with complex physical disabilities. They may lack or have altered sensation or my have involuntary movements. Their circulation and nutritional status are often poor. When they attend with an ulcer on the foot it is assessed, the cause identified and appropriate dressing applied. The foot is then padded well and a dynacast cast is applied. This is both to protect the foot from further trauma and to allow the dressing time to work. The cast is changed weekly until the ulcer is healed. Often at this stage, the cast may be reapplied for a further period to allow the tissue to strengthen. During this time adjustments are made to foot wear, splints or wheelchairs to prevent recurrence of the problem. References Browning D. A team approach to pressure relief for people I. with disabilities. Journal ofWound Care 1977; 6(6): 298-300. Springett K, Greaves S. Study: a multidisciplinary 2. approach to prevent foot ulceration. Journal of Tissue Viability 1996; 5(4): 32-33. Wilding M. The role of the chiropodist in wound care. 3. Journal of Tissue Viability 1995; 5(4): 124-126. Knowles EA, Gem J, Boulton AJM. The diabetic foot: the 4. role of the multidisciplinary team. Journal of Wound Care 1996; 5(10): 452-454. Marland E, Walker C. Use of the EVA boot in a patient with 5. a foot ulcer. Journal of Wound Care 1997; 6(7): 319-320. Browning D. Using a cast to manage a pressure sore. 6. Journal of Wound Care 1997; 6(7): 317.
Pressure Relieving Effect of Alternating Pressure Air Mattresses Shyam Rithalia and Mahendra Gonsalkorale, Rehabilitation, University of Salford.
Department of
Introduction Many different types of alternating pressure air mattresses (APAMs) are in use, but few high quality randomised controlled trials (RCTs) are available on which to base purchasing decisions 1• Faced with this situation, physiological measurements are being increasingly used as a surrogate. The most commonly quoted method, both by researchers and commercial vendors of support surfaces, has been the discrete
measurements of maximum, mmtmum and mean or average interface pressure at specific bony promineuces 2 • Since both time and pressure are important factors in the formation of pressure ulcers, it would be useful to know the magnitude and duration of low pressures in the assessment of alternating surfaces 3 . In this study, a two-parameter continuous time-based method was developed to quantify the pressure relief index (PRI) achieved by different APAMs. The PRI at any given IP threshold is defined as: the length of time (minutes) IP remains below the chosen threshold in one hour, divided by 60. Material and Methods The present study evaluated two different commercially available APAMs. These included the two most widely used large-celled mattresses; a two-cell, I 0 minutes cycle mattress (Nimbus 2, Huntleigh Healthcare, Luton) and a three-cell, 7.5 minute cycle alternating pressure air system (Airwave, Pegasus Airwave Ltd, Rants). Since the action of a dynamic support surface is time varying, it is important that any pressure relieving 'performance' indicator takes this factor into account. Continuous measurements of interface pressure, transcutaaneous oxygen (tcP0 2) and carbon dioxide (tcPC0 2) tensions were carried out under the sacrum when each subject was lying supine on the mattress. For pressure relief (PR) calculations as a percentage of the cycle the IP thresholds were set at 30, 20 and 10 mm Hg. Data were expressed as the mean ± standard deviation (mean ± SD). Results and Discussion Results using eleven healthy volunteers indicated that the PRI was sensitive to the design of the APAM, principally inflation pressure, cycle time and inflation sequence. The time interval calculated over one hour when IP remained below three arbitrarily chosen thresholds of 30, 20 and 10 mm Hg was for longer (p<0.001) on a two-cell, low pressure mattress (57±5.6, 41.9±5.0 and 25.8±2.8 minutes) than a three-cell, high pressure system (43.3±15.3, 18.3±5.0 and 13.3±2.0 minutes). Transcutaneous oxygen levels integrated over time also indicated that the two-cell system retained oxygen levels closer to the unloaded baseline than the three-cell system (p
Assessment of Ligamentous Injuries of the Knee: Four Different Approaches John Saunders, student and Shyam VS Rithalia, lecturer, Department of Rehabilitation, University of Salford; William G Ryan and Anthony J Banks, Consultant Orthopaedic Surgeons, Royal Boston Hospital. Introduction One of the most debilitating sports injuries often sustained by young adults is the derangement of the ligamentous structure
Journal of Tissue Viability 1998 Vol8 No 4 supporting the knee joint. Observation of patients with anterior cruciate ligament (ACL) deficiency has shown that approximately one third do well with no surgical treatment, one third change their lifestyle to accommodate their bad knee but do not need surgery and one third need surgery for unacceptable symptoms 1• The disparity between objective clinical assessment of ACL instability and the subjective symptoms of the patient is an unanswered problem for surgeons and relatively fit, active patients alike. Most researchers have found it difficult to demonstrate a significant correlation between the results obtained using devices and the pathology of the knee ligament2 • This paper presents the results of 4 modalities used for the assessment of ACL and attempts to correlate subjective and objective findings. Materials and Methods Twenty-four unilateral ACL deficient patients underwent assessment using the Lysholm clinical assessment score 3 ; static stiffness testing with the Salford Ligament Tester (SLT); muscle power and stamina testing with the Biodex Dynamometer; and hamstring muscle reflex assessment using EMG measurements in or to quantify changes in muscle spindle sensitivity. The Salford Tester consists of a couch with inclined backrest and a metallic trough to accommodate the thigh. A displacement transducer is placed over the tibial tubercle and a load transducer allows the application of up to 160 Newton force to tibia in either direction. The applied force displaces the tibia anteriorly and posteriorly, and a closed-loop response curve is recorded during the complete cycle. The trace is recorded twice to make sure the test is repeatable. The uninjured leg is tested first and it is used as the control for each patient.
3S
Results and Discussion We found significant differences between the normal and affected limbs for all parameters tested with regard to ligament stiffness; hamstring reflex latency and size; and muscle power in hamstrings and quadricepts. Mean SLT stiffness was 13.4 N mm· 1 for the normal leg (paired t-test, p<0.02). The only significant correlation between symptoms and physical findings was the association between quadriceps and hamstrings weakness and level of symptoms. The findings illustrate that several components contribute to the overall picture of symptomatology in ACL deficient patients and highlights the importance of physiotherapeutic techniques in rehabilitation both as the main treatment modality and as an adjunct to surgical ACL reconstruction. References Noyes FR, Matthews DS, Mooar PA, Grood ES. The 1. symptomatic anterior cruciate-deficient knee. Part II: the results of rehabilitation, activity modification, and counselling of functional disability. Journal of Bone and Joint Surgery 1983; 65A(2): 163-174. Steiner ME, Brown C, Zarins B, Brownstein B, Koval PS, 2. Stone P. Measurement of anterior and posterior displacement of the knee. A comparison of the results with instrumented devices and with clinical examination. Journal of Bone and Joint Surgery 1990; 72A(9): 13071314. Lysholm J, Gillquist J. Evaluation of knee ligament 3. surgery results with special emphasis on use of a scoring scale. Journal of Sports Medicine 1982; 10(2): 150-154
PRODUCT NEWS Recent New Wound Care Products
Recent Additions to the Drug Tariff Month
Product
Size(s)
Aug98
Actisorb Plus
Sept 98
Primapore
Sept 98
Mefilm
Sept 98
Algisite M
Sept 98
Melgisorb
10.S X lO.Scm lO.S X 10.Scm 6 X 8.3cm 8.2S X 12cm 8.2S X 18cm 8.2S X 2Scm 12 X 3Scm 6 X 7cm 10 X 12.7cm 10 X 2Scm IS X 21.Scm S X Scm 10 X 10cm IS X 20cm S X Scm 10 X lOcm 10 X 20cm
Price(£) (Sept 98) 2.20 4.00 0.14 0.22 0.32 0.37 0.80 0.37 0.99 1.93 2.4S 0.72 1.49 4.00 0.71 1.48 2.78
ALGISITE M (Smith and Nephew) alginite wound dressing CARBOFLEX (ConvaTec) an odour control dressing a sterile non-adhesive dressing with an absorbent wound contact layer (containing Kaltostat and Aquacel), an activated charcoal central pad and a smooth water resistant top layer indicated for the management of malodorous acute and chronic wounds may be used as a primary dressing for shallow wounds or with deeper wounds as a secondary dressing over wound fillers may be used on infected malodorous wounds under • medical supervision together with appropriate antibiotic therapy and frequent monitoring of the wound should not be cut to size place the fibrous (non-shiny) surface on wound or cavity filler with non-infected wounds, may be left undisturbed for •
•
Journal of Tissue Viability 1998 Vol 8 No 4
REVIEWS AND ABSTRACTS Pressure Sore Prevention & Wound Management Policy of Wandsworth Community Health and St Georges Healthcare NHS Trusts This policy is the result of a collaborative venture between an acute trust and a community trust and has been prepared by a multidisciplinary working group. It comprises four sections: pressure sores, wound management, fistula in ano and diabetic foot ulcers. Each section is presented in the same format introduction, aims and objectives, definitions/classification, assessment, relevant aspects of care, education, audit, references and appendices. The purpose of the policy and it's specific setting is set out in the foreword. The policy is clearly written and obviously based on the relevant literature. Attempts have been made throughout to support statements with evidence. It must be recognised that some of the evidence is expert opinion rather than derived from clinical trials. However, that is the reality of the current tissue viability evidence base and not a particular criticism of this policy. The policy follows a logical construction which is important in this type of material. It is rather surprising to find a section on fistula in ano as this is not a topic commonly found within a tissue viability policy. The leg ulcer section is rather scant with no mention of the role of bandages. It may have been useful to have included the leg ulcer policy within this document. There is a praiseworthy attempt to illustrate some of the potential causes of pressure sores, Unfortunately, the impact is lost through the poor quality of the illustrations (scanned images subsequently photocopied). This situation is all too common when producing documents with little or no budget. The policy is presented in a substantial ring binder which will allow for easy updating. The pages had to be turned carefully to ensure that the paper did not rip. Overall, this policy looks to be a helpful guide for the clinicians for whom it was prepared. It can also serve as a reference for those who have no experience in preparing this type of document. Carol Dealey, Research Fellow, University Hospital, Birmingham.
Myth and Reality in Wound Care. Williams C, Young T. Dinton: Quay Books, 1998. 137pp. This book considers some aspects of wound management, intending to dispel some of the myths and rituals that continue to form the basis of practice in many healthcare settings.
Prior to the first chapter there is a self assessment questionnaire consisting of 14 questions on various aspects of tissue viability. This is designed to identify deficits in the reader's knowledge on the subject before reading the main text. The questionnaire is repeated again at the end of the book in order to evaluate learning. The material is divided into 5 chapters, each of which examines some commonly held beliefs about that aspect of tissue viability in a question and answer format. These subjects are: wound healing, wound cleansing/infection, pressure sores, leg ulcers and wound management. Some recommendations for practice are provided, drawn from references that are given at the end of each chapter. A general concluding chapter summanses certain issues raised within the text as a whole. Generally it is a well organised and easy to read text. It is not original in its design but provides a good structure for the subject considered. The idea of addressing some of the socalled 'we've always done it this way!' attitudes that still occur all too frequently in wound care, and in nursing generally, is welcomed. In agreement with the authors, we all know how frustrating and demoralising it can be to find practices occurring for which research has repeatedly failed to find any support. However, one could not help feeling that the authors were searching for the 'holy grail' of wound care in attempting to find sound research-based evidence to demystify the myths that surround wound management. This is, in part, acknowledged by the authors in the foreword. The subject areas chosen for examination are relevant, but the ability to do this in one book is a task worthy of a much larger tome. This is demonstrated by the slightly superficial nature of the analysis in each chapter, particularly those concerned with pressure sores and leg ulcers. The half filled pages in these chapters are disappointing when so many of the points raised begged expansion. Several of the conclusions drawn from the references are somewhat generalised and their application questionable. The quotation (p52) from Rodeheaver (1989) 'don't put into a wound what you wouldn't put into your eye', as a recommendatron for practice, is an example of this. One questions how far we would be in wound management with just saline, water and perhaps chloramphenicol. There is some acknowledgement of contrasting opinions and weak supporting literature, ie in wound cleansing but generally, this is lacking and certainly would have provided more substance to the aim of the book as a whole. The arguments, therefore, are not presented in sufficient detail and the recommendations should not be taken at face value as a result. However, the fact that references are provided does encourage the reader to use them as a starting point from
Journal of Tissue Viability 1998 Vol 8 No 4 which to consider the evidence for themselves, hopefully taking into account a critique of the research methodology used. It is felt that the tables included within the text add little to enhance or clarify the information already provided and therefore are perhaps unnecessary. The cartoon drawings illustrate amusing scenarios relating to the text. However, the format of the index may cause some frustration to users since it alphabetically lists all the myths addressed in the text. It would be possibly more useful if key words were listed rather than the whole myth or ritual. The self-assessment questions are a good guide as a starting point for learning but printed duplication of the assessment is questioned. From an academic point of view, it is interesting to note inconsistencies in the formatting of some chapter headings throughout the book i.e. 'no. 18' and '19' are noted, but obviously this is the publisher's domain.
33
For the practitioner new to tissue viability, therefore, the material presented provides useful information as a point from which to begin an analysis of the evidence surrounding some wound care practices. But for the experienced practitioner, there is little new information. The idea of dispelling myths associated with wound care is coveted by many healthcare practitioners and researchers in the field, but part of the reason that it has not been achieved is that the reliable evidence just does not exist. therefore the autti.ors certainly were setting themselves a difficult task. The concept of a book, or even a series of books, such as this is excellent, but as a recommendation, it would be useful to expand the arguments and provide a more analytical approach to the evidence provided. Amanda Tong BN(Hons) RGN, FAETC, Lecturer, Tissue Viability, Buckinghamshire Chiltems University College, Bucks.
ABSTRACTS OF PRESENTATIONS GIVEN AT THE SOCIETY'S 30th CONFERENCE IN LEEDS ON 1/2 APRIL 1998 Wound Care in the Real World Amanda Champion, RGN, Clinical Research Nurse; Julia Davey RGN, DN, Clinical Nurse and Mary Jones, BN, RGN, DN, Senior Clinical Research Nurse, Bridgend General Hospital, South Wales It is well documented that a holistic, multidisciplinary approach
to wound care enhances the healing process 1•2 • In reality, however, it is not always possible to follow these principles completely, as they are dependent on the individual patients' requirements and wishes. Recent treatment of a 61-year-old man with a non-healing, chronic, venous leg ulcer, with associated eczema, highlighted the problems that can occur. The solutions we used were within the constraints dictated by the patient. Stasis eczema is a common complicating factor of venous leg ulceration, which affects the healing process and can also increase pain and discomfort3 • The management of this patient utilised a team approach, but taking his lifestyle into consideration resulted in a holistic approach being difficult to fully implement. The patient lived in a mobile home and was employed as a car mechanic. Many treatments were used prior to our involvement, but using a combination of compression therapy over the application of a zinc oxide impregnated medicated stocking resulted in gradual improvement4 • Progress was further enhanced by referral to a dermatologist for appropriate topical treatment of the eczema. Although the treatment of this patient did not involve any new or unusual therapies, it was highlighted that wound care, particularly in the community must be co-ordinated, flexible and responsive to patients and their "real life" situations. References 1. Morrison M, Moffat C, Bridel-Nixon J, Bale S. Patient assessment in nursing management of chronic wounds: 2nd ed. London: Mosby, 1997: 69. 2. Stotts NA, Wipke-Tevis D. Co-factors in impaired wound healing. Ostomy Wound Management 1996, 42(2): 42-46. 3. Kulozic M, Powell SM, Cherry G, Ryan TJ. Contact
4.
sensitivity in community based leg ulcer patients. Clinical & Experimental Dermatology 1988; 13: 82-84. Struckman J. Compression stockings and their effect on the venous pump- a comparative study. Phlebology 1986; 1: 37-45.
Criteria for Mattress Selection Cheryl E Dunford, Clinical Nurse Specialist in Tissue Viability, Salisbury District Hospital and Heather Newton, Clinical Nurse Specialist in Tissue Viability, Royal Cornwall Hospitals.
The Department of Health has demanded that the incidence of pressure sores be reduced 1• Given current knowledge, the most cost-effective strategies for meeting this target are unclear. However, it has been shown that patients at increased risk of developing sores should be placed on a pressure reducing mattress, shown to be better than the standard hospital mattress 2 • The current restraints on budgets, including those for equipment monies mean that any equipment purchased must be both clinically effective and last a long time. When selecting a foam pressure reducing mattress, the following important criteria should be considered: information on foam and cover materials clinical evidence of pressure reducing properties independent comprehensive clinical!laboratory testing conformation to CE marking and British Standards proven longevity warranties, company support including training. References 1. Department of Health. Health of the nation. London: HMSO, 1991. 2. Callum N, Deeks J, Fletcher A, Long A, Mouneimne H, Sheldon T et al. The prevention and treatment of pressure sores: how effective are pressure-relieving interventions and risk assessment for the prevention and treatment of pressure sores? Effective Health Care 1995; 2(1).
34
Journal of Tissue Viability 1998 Vol 8 No 4
The Multidisciplinary Team and Costs in the Treatment of Foot Ulcers Deidre Browning, Chailey Heritage. CHAli,EY HERITAGE is a rehabilitation and development centre for children and young people with severe and complex physical disabilities. The Tissue Trauma clinic at Chailey often has referrals for children and young people who have developed pressure ulcers on their feet. Over the last I 0 years these ulcers have been treated successfully by using protective plaster casts. The multidisciplinary team is an important aspect of our work at Chailey and with ulcers of the feet members would include, our plaster technician, who has developed special skills in the application of plaster casts for children and young people with physical disabilities, physiotherapists, orthotists, podiatrists, rehabilitation engineers and the tissue viability nurse. Multidisciplinary teamwork in wound care has been described by Springett and Greaves 2 and Wilding 3. Knowles4 also descibes work of the diabetic foot clinic. Use of an EVA boot in diabetic wound healing has been described by Marland and Walker1 amongst others. The clients attending our clinics are children and young people with complex physical disabilities. They may lack or have altered sensation or my have involuntary movements. Their circulation and nutritional status are often poor. When they attend with an ulcer on the foot it is assessed, the cause identified and appropriate dressing applied. The foot is then padded well and a dynacast cast is applied. This is both to protect the foot from further trauma and to allow the dressing time to work. The cast is changed weekly until the ulcer is healed. Often at this stage, the cast may be reapplied for a further period to allow the tissue to strengthen. During this time adjustments are made to foot wear, splints or wheelchairs to prevent recurrence of the problem. References Browning D. A team approach to pressure relief for people I. with disabilities. Journal ofWound Care 1977; 6(6): 298-300. Springett K, Greaves S. Study: a multidisciplinary 2. approach to prevent foot ulceration. Journal of Tissue Viability 1996; 5(4): 32-33. Wilding M. The role of the chiropodist in wound care. 3. Journal of Tissue Viability 1995; 5(4): 124-126. Knowles EA, Gem J, Boulton AJM. The diabetic foot: the 4. role of the multidisciplinary team. Journal of Wound Care 1996; 5(10): 452-454. Marland E, Walker C. Use of the EVA boot in a patient with 5. a foot ulcer. Journal of Wound Care 1997; 6(7): 319-320. Browning D. Using a cast to manage a pressure sore. 6. Journal of Wound Care 1997; 6(7): 317.
Pressure Relieving Effect of Alternating Pressure Air Mattresses Shyam Rithalia and Mahendra Gonsalkorale, Rehabilitation, University of Salford.
Department of
Introduction Many different types of alternating pressure air mattresses (APAMs) are in use, but few high quality randomised controlled trials (RCTs) are available on which to base purchasing decisions 1• Faced with this situation, physiological measurements are being increasingly used as a surrogate. The most commonly quoted method, both by researchers and commercial vendors of support surfaces, has been the discrete
measurements of maximum, mmtmum and mean or average interface pressure at specific bony promineuces 2 • Since both time and pressure are important factors in the formation of pressure ulcers, it would be useful to know the magnitude and duration of low pressures in the assessment of alternating surfaces 3 . In this study, a two-parameter continuous time-based method was developed to quantify the pressure relief index (PRI) achieved by different APAMs. The PRI at any given IP threshold is defined as: the length of time (minutes) IP remains below the chosen threshold in one hour, divided by 60. Material and Methods The present study evaluated two different commercially available APAMs. These included the two most widely used large-celled mattresses; a two-cell, I 0 minutes cycle mattress (Nimbus 2, Huntleigh Healthcare, Luton) and a three-cell, 7.5 minute cycle alternating pressure air system (Airwave, Pegasus Airwave Ltd, Rants). Since the action of a dynamic support surface is time varying, it is important that any pressure relieving 'performance' indicator takes this factor into account. Continuous measurements of interface pressure, transcutaaneous oxygen (tcP0 2) and carbon dioxide (tcPC0 2) tensions were carried out under the sacrum when each subject was lying supine on the mattress. For pressure relief (PR) calculations as a percentage of the cycle the IP thresholds were set at 30, 20 and 10 mm Hg. Data were expressed as the mean ± standard deviation (mean ± SD). Results and Discussion Results using eleven healthy volunteers indicated that the PRI was sensitive to the design of the APAM, principally inflation pressure, cycle time and inflation sequence. The time interval calculated over one hour when IP remained below three arbitrarily chosen thresholds of 30, 20 and 10 mm Hg was for longer (p<0.001) on a two-cell, low pressure mattress (57±5.6, 41.9±5.0 and 25.8±2.8 minutes) than a three-cell, high pressure system (43.3±15.3, 18.3±5.0 and 13.3±2.0 minutes). Transcutaneous oxygen levels integrated over time also indicated that the two-cell system retained oxygen levels closer to the unloaded baseline than the three-cell system (p
Assessment of Ligamentous Injuries of the Knee: Four Different Approaches John Saunders, student and Shyam VS Rithalia, lecturer, Department of Rehabilitation, University of Salford; William G Ryan and Anthony J Banks, Consultant Orthopaedic Surgeons, Royal Boston Hospital. Introduction One of the most debilitating sports injuries often sustained by young adults is the derangement of the ligamentous structure
Journal of Tissue Viability 1998 Vol8 No 4 supporting the knee joint. Observation of patients with anterior cruciate ligament (ACL) deficiency has shown that approximately one third do well with no surgical treatment, one third change their lifestyle to accommodate their bad knee but do not need surgery and one third need surgery for unacceptable symptoms 1• The disparity between objective clinical assessment of ACL instability and the subjective symptoms of the patient is an unanswered problem for surgeons and relatively fit, active patients alike. Most researchers have found it difficult to demonstrate a significant correlation between the results obtained using devices and the pathology of the knee ligament2 • This paper presents the results of 4 modalities used for the assessment of ACL and attempts to correlate subjective and objective findings. Materials and Methods Twenty-four unilateral ACL deficient patients underwent assessment using the Lysholm clinical assessment score 3 ; static stiffness testing with the Salford Ligament Tester (SLT); muscle power and stamina testing with the Biodex Dynamometer; and hamstring muscle reflex assessment using EMG measurements in or to quantify changes in muscle spindle sensitivity. The Salford Tester consists of a couch with inclined backrest and a metallic trough to accommodate the thigh. A displacement transducer is placed over the tibial tubercle and a load transducer allows the application of up to 160 Newton force to tibia in either direction. The applied force displaces the tibia anteriorly and posteriorly, and a closed-loop response curve is recorded during the complete cycle. The trace is recorded twice to make sure the test is repeatable. The uninjured leg is tested first and it is used as the control for each patient.
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Results and Discussion We found significant differences between the normal and affected limbs for all parameters tested with regard to ligament stiffness; hamstring reflex latency and size; and muscle power in hamstrings and quadricepts. Mean SLT stiffness was 13.4 N mm· 1 for the normal leg (paired t-test, p<0.02). The only significant correlation between symptoms and physical findings was the association between quadriceps and hamstrings weakness and level of symptoms. The findings illustrate that several components contribute to the overall picture of symptomatology in ACL deficient patients and highlights the importance of physiotherapeutic techniques in rehabilitation both as the main treatment modality and as an adjunct to surgical ACL reconstruction. References Noyes FR, Matthews DS, Mooar PA, Grood ES. The 1. symptomatic anterior cruciate-deficient knee. Part II: the results of rehabilitation, activity modification, and counselling of functional disability. Journal of Bone and Joint Surgery 1983; 65A(2): 163-174. Steiner ME, Brown C, Zarins B, Brownstein B, Koval PS, 2. Stone P. Measurement of anterior and posterior displacement of the knee. A comparison of the results with instrumented devices and with clinical examination. Journal of Bone and Joint Surgery 1990; 72A(9): 13071314. Lysholm J, Gillquist J. Evaluation of knee ligament 3. surgery results with special emphasis on use of a scoring scale. Journal of Sports Medicine 1982; 10(2): 150-154
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