Simulations of skin and subcutaneous tissue loading in the buttocks while regaining weight-bearing after a push-up in wheelchair users

Pressure ulcers (PUs) are common in patients who chronically depend on a wheelchair for mobility, such as those with a spinal cord injury (SCI). In attempt to prevent the formation of PUs, pressure relieving maneuvers, such as push-ups, are commonly recommended for individuals with SCI. However, very little is known about skin and subcutaneous fat tissue load distributions during sitting and in particular their development during the process of regaining weight-bearing after a push-up. Knowledge on how these loads evolve during sitting-down is critical for understanding the susceptibility of skin to PUs. Considering the potential practical implications on guidelines for wheelchair users, we studied herein the build-up of shear loads in skin and subcutaneous fat using a model of the buttocks of a single SCI subject. Using 12 variants of our finite element (FE) model, we determined the shear loads in skin and subcutaneous fat tissues under the ischial tuberosities when sitting down on foam cushions with different stiffness properties, in healthy skin and scarred skin conditions, focusing on the time course of the build-up of tissue loads. We found substantial differences between the loading curves of skin and fat: While the fat was loaded at a nearly constant rate, skin loads increased nonlinearly - with a greater load/time slope at early skin-support contact. In the context of tissue health and prevention of PUs, this indicates that the more sensitive period with respect to skin integrity is at initial skin-support contact. We further found that the edges of a pre-existing scar are more susceptible to injury, and the greater risk for that is when a hypertrophic scar is present. Despite that this is a theoretical modeling study with associated limitations, we believe that it is already appropriate to recommend to patients to reposition themselves gradually and gently, and not to "fall" back into the wheelchair after finishing a push-up maneuver.