1151
Pressure Distribution at the Seating Interface of Custom-
Molded Wheelchair Seats: Effect of Various Materials
Dimitrios P. Apatsidis, MEng, Stephan E. Solomonidis, BSc, Shona M. Michael, PhD
ABSTRACT. Apatsidis DP, Solomonidis SE, Michael SM.
Pressure distribution at the seating interface of custom-molded
wheelchair seats: effect of various materials. Arch Phys Med
Rehabil 2002;83:1151-6.
Objective: To identify which of 4 materials has the most
favorable pressure distribution when used in custom-molded
seats (CMSs) to assist clinicians in providing appropriate seat-
ing for wheelchair-bound individuals who are prone to develop
pressure ulcers.
Design: Repeated-interface pressure measurements for all
materials, followed by statistical analysis.
Setting: The general community and referral centers.
Participants: Seven subjects, 5 with cerebral palsy, 1 with
Schilder’s disease, and 1 with postmeningitis effects. All sub-
jects were seated in a CMS and had spinal deformities.
Interventions: Viscoelastic polyurethane foams (Pudgee,
Sunmate) and gels (Floam™, Jay) were used as inserts in the
CMSs. Evazote foam was used as a control material.
Main Outcome Measures: Pressure readings were taken at
the seat interface with pneumatic pressure sensors and the
Talley Pressure Monitor. Peak pressure readings, mean pres-
sure ratio, and peak pressure ratio for the different materials
were compared.
Results: Foams, Sunmate in particular, produced lower
peak-interface pressures and also showed better pressure dis-
tribution than did gels.
Conclusion: Foams are the preferred insert material with
CMSs when increased tissue breakdown risk is present.
Key Words: Posture; Pressure ulcers; Rehabilitation;
Wheelchairs.
© 2002 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
HEELCHAIR USERS WHO are severely disabled may
W require custom-molded seats (CMSs) to maintain their 1
comfort and function while in their wheelchairs. A CMS (fig 1)
tends to be the seat of choice for wheelchair users who have a
gross spinal deformity and a severely impaired sitting ability.2
CMSs are known to reduce pressure at the seating interface to
a greater extent than do standard seats.2 However, in attempting
to achieve a functional sitting posture for patients in CMSs,
excessive loading can result, which may cause pressure or
decubitus ulcers.3 Areas most commonly affected are those
From the Bioengineering Unit, University of Strathclyde, Glasgow (Apatsidis,
Solomonidis); and the West of Scotland Mobility and Rehabilitation Centre, Southern
General Hospital, Glasgow (Michael), UK.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the author(s) or upon any
organization with which the author(s) is/are associated.
Correspondence to Dimitrios P. Apatsidis, MEng, Bioengineering Unit, University
of Strathclyde, Wolfson Centre, 106 Rottenrow, G4 0NW Glasgow, UK, e-mail:
dimitrios.apatsidis@strath.ac.uk. Reprints are not available.
0003-9993/02/8308-6976$35.00/0
doi:10.1053/apmr.2002.33987
associated with bony prominences, such as the ischial tuberos-
ities and the greater trochanters.4
A pressure ulcer can range from a simple skin rash to a
region of tissue necrosis extending down to the underlying
bone. Periods of prolonged sitting by wheelchair users add to
the likelihood of ulceration.5 Once an ulcer forms, it is both
difficult and costly to treat, and the risk of ulcer recurrence is
increased. It is estimated that the United Kingdom spends
between £180 and £321 million annually for the treatment of
decubitus ulcers,1 of which 36% to 50% result from sitting in
a wheelchair.6 The most commonly accepted cause of skin
ulcer pathogenesis in the seated patient is prolonged and ex-
cessive pressure applied on certain blood and lymphatic vessels
underlying the skin at the seating interface. This effect is
usually amplified when there is little or no muscle bulk be-
tween the skin and bony prominences.1 The increased pressure
on the blood vessels causes a decreased blood supply and can
result in hypoxia at local tissues, whereas occluded lymphatic
drainage can cause damage in deeper tissues.
In a study of interface loading, the size of the resulting
applied load and its direction at all points on the seat interface
are important. The magnitude of the applied load determines
the degree of deformation or squeezing of the soft tissues at the
seating interface, which is the result of the opposing forces of
body weight and reaction from the seat surface.7 Large, unre-
lieved reaction forces obviously will produce a large deforma-
tion and therefore high internal stresses in the tissues, stresses
that must be avoided. The distribution of the resulting reaction
force over the seating interface is another important aspect.
Sharp peaks of loading at the interface will produce large
deformation and high internal stresses in the tissues combined
with possible shear stresses on superficial tissues. A reaction
force that is uniformly distributed over the interface and small
in magnitude will reduce the resulting deformations or squeez-
ing of the soft tissues. The risk of ulceration is therefore
reduced.8
In custom-molded seating, susceptible areas at the body-seat
interface may require a special intervention to reduce the
likelihood of decubitus ulcer formation. The most common
method of altering the loads in these areas is to create a recess
in the area of the seat that is causing concern and to fill it with
a pressure-relieving material (fig 2). Two issues must be ad-
dressed when selecting seating interface materials. A suitable
material is one that minimizes the value of the resultant load
and redistributes that load more evenly over a larger interface
area.8
Various interface materials are now in clinical use.9-12 They
fall into 2 categories: viscoelastic foams and polymeric gel
packs. The viscoelastic foams generally conform well to the
body’s shape because of their viscous behavior, and they
provide firm support because of their elastic properties. An
advantage in the use of the foams is that they can be cut into
any required shape. Some viscoelastic foams, such as Sun-
mate,a are available in different stiffness grades to compensate
for a patient’s weight and the depth of the recess. The gel
packs, on the other hand, are commonly available in standard
sizes. They are filled with a viscous gel, which has no elastic
Arch Phys Med Rehabil Vol 83, August 2002
1152 PRESSURE DISTRIBUTION IN CUSTOM-MOLDED WHEELCHAIR SEATS, Apatsidis
Fig 1. CMS comprising hard thermoplastic outer shell with inner
Evazote lining.
properties, and therefore they do not tend to return to their
original shape once they are deformed by the body weight.
Gels that have high viscosity are more stable but are stiffer
when exposed to a sudden load application.1 However, there is
limited comparative data on the clinical performance of the
materials themselves and with each other, both in standard
wheelchair seating and in custom-molded seating. Clinical staff
members who provide seating are often confronted with situ-
ations in which a decision on the type of seat insert material
within a CMS must be made on the basis of their personal
experiences.
This study’s objectives were to compare the efficacy of 4
materials in reducing peak pressures while at the same time
redistributing the peak pressure under the bony prominences
over a larger area of the interface within a CMS. The 4
materials commonly used for this application were tested and
compared with one another and with a control material. Pres-
sure readings at the seating interface were collected with spe-
cialized clinical equipment. The data were analyzed with an
appropriate statistical method.
Arch Phys Med Rehabil Vol 83, August 2002
METHODS
Participants
The study received approval from the ethics committee of
the Southern General Hospital in Glasgow, UK. Study subjects
were selected from among patients who had been provided
with a wheelchair CMS from the seating clinic at the West of
Scotland Mobility and Rehabilitation Centre. The study popu-
lation was unable to walk; had severely impaired sitting ability;
and had, in most cases, a significant spinal deformity and
contractures in the lower limbs.
None of the subjects had a decubitus ulcer at the time of the
study, but they had all experienced pressure-related skin prob-
lems over at least 1 buttock and were believed to be at high risk
to developing decubitus ulcers again. None had undergone a
surgical procedure to close a pressure ulcer. An existing recess
in each subject’s custom-molded wheelchair seat had an insert
of 1 of the 4 test materials. This selection criterion provided a
means of positioning the test materials on each subject’s own
seat. A further selection criterion was that subjects could par-
ticipate without experiencing discomfort or anxiety. Most par-
ticipants were unable to give written consent because of phys-
ical or cognitive impairment. However, their caregivers
discussed the testing protocol with them and together, agreed to
participation in the study.
Seven subjects (4 women, 3 men) participated. Their mean
weight was 41⫾19.12kg (range, 20.5– 80kg). The average age
was 40.29⫾14.42 years (range, 21– 65y). Five subjects had
cerebral palsy, 1 had postmeningitis effects, and 1 had
Schilder’s disease—a brain disease that is associated with
spastic paralysis and results in mental deterioration and unco-
ordinated limb muscle function. All subjects had scolioses with
Cobb angles from about 20° to 90°.
Instrumentation
Numerous pressure-mapping systems for the seating inter-
face have been developed,13 but the Talley Pressure Monitorb
was selected for this study because of its dynamic nature of
data collection. The device consists of 2 parts: a main unit that
contains 2 pumps for inflating and deflating the pneumatic
sensors and the sensor matrix (fig 3). The first pump creates a
vacuum in all the sensors that are connected to the pumps by
small plastic tubes. The load is applied externally on the sensor
matrix in the form of the subject’s body weight. The second
pump then pressurizes the matrix until the walls of the sensors
begin to separate. The pressure in the sensor at that instant
equals that of the external load and represents the pressure at
the seating interface at that particular location. The maximum
pressure that can be achieved in a sensor is 246mmHg. This
process is repeated for all 24 sensors of the matrix consecu-
tively for as long as the data collection continues.
Fig 2. The recess is carved
into the seat surface. The gap
is refilled with one of the in-
serts. Reaction forces under
the presence of load in form of
body weight.
 PRESSURE DISTRIBUTION IN CUSTOM-MOLDED WHEELCHAIR SEATS, Apatsidis
Fig 3. The main unit of the instrumentation and the setup of the
sensor matrix as used for the interface-pressure measurements.
The size and density of the matrix’s sensors affect the
accuracy of the readings and the probability that data will be
collected from an area of peak loading. The larger the sensors
in diameter, the further they are from each other and the more
likely it is that a pressure concentration will fall between them
without being read. Smaller-size sensors can be placed closer
together to form a more dense grid of data collection points.
Also, the number of sensors placed on a given size of array will
be larger and will give a clearer picture of the pressure distri-
bution over the interface. The thickness and material properties
of the sensors must be carefully selected because they can
cause inaccurate readings if they are unable to stretch appro-
priately.1 The diameter of the PVC-made sensors in our system
was 20mm, with a total thickness of 2mm. The array size was
15⫻15cm2.
The instrumentation was tested for its ability to give repro-
ducible readings. This was achieved by taking 3 consecutive
readings for 1 subject on the control material. Between read-
ings, the subject was hoisted out of the wheelchair seat and
seated back again in an attempt to simulate a real testing
situation. The time between each data collection was approx-
imately equal to the time that was required to change the insert
material in the testing situation (ie, about 2min). The readings
were repeatable, and the pattern of the interface pressure was
similar in all 3 cases.
Materials
The CMS itself consists of a hard thermoplastic outer shell
that is vacuum formed over a plaster-of-paris mold that is
obtained by casting the patient with the vacuum consolidation
method.14 The inner lining of that harder shell consists of a soft
foam, which, in the case of our subjects, was Evazote.c This
was used as the control material. This material—a closed-cell,
cross-linked ethylene copolymer foam— has no exceptional
pressure-relieving properties and is usually the basic lining
material for the CMS. The materials under consideration were
either polymeric gel packs (Otto Bock Floam™,d Jaye gel) or
viscoelastic foams (Pudgee,a Sunmate) as shown in figure 4.
Sunmate is available in different stiffness grades, ranging from
extra soft to firm, and has a density of 80kg/m3. It is available
in thicknesses ranging from 0.5cm in the firm-grade cushion,
which is mainly used for shoe insole applications, up to 8cm
thickness in the soft-grade cushion. We used mainly medium
stiffness-grade foam. The insert thickness was in the range of
1153
2 to 6cm. (Subject 2 had a thick insert.) The inserts were either
cut from 1 piece of foam or made by gluing 2 pieces together.
Pudgee is even more slow-flowing, which helps it to conform
well to the body shape. The density of this material is 320kg/
m3, and it is available in the same thicknesses as Sunmate. The
inserts that were used had exactly the same geometric shape as
those made from Sunmate. The difference between the Jay and
the Floam is their viscosity. Floam is a composite of a light-
weight gel and foam. The purpose of the foam is to reduce
flattening out when under load. The Floam has a higher vis-
cosity than does the Jay gel pack.
Protocol
Each subject and his/her individual caregiver agreed to the
study protocol after a thorough explanation of the procedure
and the instrumentation. The first session with the participants
involved the collection of physical data and background health
information, as well as an examination of the wheelchair seat
and its dimensions and characteristics. The shape, thickness,
and material type of the existing insert were recorded. If the
dimensions of the existing seat insert were such that an equiv-
alent insert could be manufactured with all 4 tested materials,
this was done. If the existing seat insert was too large for an
equivalent insert to be made, an Evazote reference liner (fig 4)
was made to fill in part of the original recess. A smaller recess
that could be filled with inserts of all materials was formed
within the liner.
The second session involved the actual data-set acquisition.
The subjects were lifted out of their seats, with the help of their
caregivers, using a mechanical hoist. In cases in which a
reference liner was used, the sensor matrix was pinned onto it
after the insert material was inserted into the template’s recess
and placed onto the subject’s seat. After positioning the sub-
jects’ backs into their seats, several markers were placed onto
their bodies with their equivalent mirror points on the seat to
help in the reproduction of the sitting position. The caregivers
helped identify the standard sitting position of the participants
within the CMS. The Talley Pressure Monitor was activated for
10 minutes to ensure the collection of sufficient values for each
sensor. With an average sampling speed of 0.6 seconds per
scan, each sensor collected a total of 40 readings in every cycle.
These values were eventually averaged, giving 1 reading for
each sensor on each of the tested materials. The same proce-
dure was repeated for all the materials tested in this study. The
complete session lasted between 60 and 70 minutes. Even
Fig 4. The reference liner with the Evazote (control), Pudgee, Sun-
mate, Floam, and Jay insert materials in appropriate dimensions.
Arch Phys Med Rehabil Vol 83, August 2002
1154 PRESSURE DISTRIBUTION IN CUSTOM-MOLDED WHEELCHAIR SEATS, Apatsidis

though multiple testing sessions would have provided more

reliable data, we used a single session to reduce the duration of
the trials for the subjects and to make it easier to reproduce the
exact sitting position of each subject within the seat.

Data Analysis
To evaluate the pressure-relieving properties, we had to
know the individual peak pressure of every subject on the
different materials. The peak reading for a subject was always
given either by the same sensor or by one in the close vicinity,
depending on the accuracy of reproducing the same sitting
posture and location after each material replacement. All val-
ues were put into 1 group and distinguished only by the
material type.
To identify which of the tested materials had the most
beneficial effect in reducing the peak pressure under the prom-
inent bony aspects of each subject, it was decided to use the
single peak reading of the pressure matrix for each subject on
every individual material. The resulting data were collated and
processed as a stand-alone group. This was a way to produce a
population large enough for statistical comparison, comprising
7 readings for each of the 5 materials. The statistical method
used was a 2-way analysis of variance (ANOVA). In this
method, the averages for all the different material types are
compared with each other. This method considers 2 different
factors. In this case, the first was the subject number and the
other was the type of insert material. Both subject and material
were included as response factors in the analysis.
To assess the efficacy of the materials in redistributing the
peak pressure under the bony prominences over a large inter-
face area, 2 new terms were defined: the mean pressure ratio
and the peak pressure ratio. The first term is a quotient of the
average of the values immediately surrounding the peak value
divided by the peak value itself for each subject and material
individually. Peak pressure ratio is a similar quotient but refers
to the least of the surrounding values only. For the sensors
shown in figure 5, the mean pressure ratio is calculated by
dividing the average of the readings of sensors 1 to 6 by the
peak reading itself, whereas the peak pressure ratio is calcu-
lated by dividing the least of the readings of sensors 1 to 6 by
the peak reading. Both values are indicators of the uniformity
of loading at the seating interface. In this way, it is determined
how well each of the materials distributes the pressure because
a more beneficial material creates larger quotients (ie, the
neighboring sensors measure less sharp differences to the peak
reading).
The collected data were processed as described earlier,
which produced the data mean pressure ratio and peak pressure
ratio. All the data were again put together and processed by a
1-way ANOVA. Also, in this method, the averages for all the
different material types are compared with each other. The
discriminating factor for the data was only the material type.
The subject number was not included as a factor because of the
normalization that results from dividing the readings by the
peak reading, which is already in direct relation to each sub-
ject’s body weight.
The Pearson product-moment correlation test was performed
to examine possible relationships between response values,
such as peak pressure or pressure distribution, and predictors,
such as body weight and gender. Material type and subject
were not considered as predictors because they were used as
factors in the ANOVA. The correlation study was performed
pairwise to define the absolute effect of each predictor on the
collected data.
Fig 5. The sensor matrix used for data collection. The highlighted
sensor is an example of a peak pressure reading. Numbers 1 to 6
indicate all sensors surrounding the one with the peak reading.
RESULTS
The peak pressure values, as recorded by the Talley Pressure
Monitor, and the pressure ratio values, as they were calculated,
revealed significant differences among the materials. The re-
sults of the 2-way ANOVA on the peak pressure readings
indicated that the control material reduced peak pressure sig-
nificantly less than any of the insert materials. This shows that
the inserts do have a pressure-relieving effect. In addition, the
results showed a significantly higher peak pressure value for
Floam than for the other inserts (for Jay, P⫽.03; for Pudgee,
P⫽.02; for Sunmate, P⫽.02).
One-way ANOVA statistical testing showed (table 1) that
the foams have significantly better pressure-distributing abili-
ties than the Jay gel (for Sunmate, P⫽.03; for Pudgee, P⫽.05)
when all the sensors surrounding the peak value were consid-
ered (ie, the mean pressure ratio). However, when taking into
account the lowest value of those surrounding the peak value
(ie, the peak pressure ratio), only Sunmate had a significantly
(P⫽.02) better pressure distribution than Jay. Pudgee did not
show the same significant differences to the Jay, although the
mean values were similar between Sunmate and Pudgee
(.525⫾.165 and .485⫾.230, respectively).
All mean pressure ratios, as well as the peak pressure ratios,
are shown in table 2. This table permits easy comparison of the
behavior of each tested material for the study population as a
whole and for each participant individually. The data for all
subjects show increased ratios for the Pudgee and especially for
the Sunmate. A higher value for the pressure ratios means a
less severe change in interface pressure between a peak pres-
sure area and a neighboring area.
The results of the Pearson product-moment correlation test
are shown in table 3. The correlation between the peak pressure
data and its predictors did not yield any significant relation-
ships. A second correlation study for mean and peak pressure

Arch Phys Med Rehabil Vol 83, August 2002

 PRESSURE DISTRIBUTION IN CUSTOM-MOLDED WHEELCHAIR SEATS, Apatsidis 1155

Table 1: Means and Standard Deviations Measured on the Talley Pressure Monitor for All Materials, Including Significant Differences

Insert Materials (n⫽7) Peak Pressure (mmHg) Mean Pressure Ratio Peak Pressure Ratio

Evazote (control) 157⫾23.58 .556⫾.205 .367⫾.210

Floam 110.62⫾25.05* .567⫾.245 .346⫾.229
Jay 69.7⫾27.7*† .537⫾.227 .310⫾.136
Pudgee 84.38⫾15.41*† .649⫾.203‡ .485⫾.230
Sunmate 84.86⫾21.09*† .661⫾.178*‡ .525⫾.165‡

* Mean value is significantly different from that of control.

†
Mean value is significantly different from that of Floam insert.
‡
Mean value is significantly different from that of Jay insert.

ratios also showed no significant correlation between the data
and the predictors.
DISCUSSION
The study showed significant differences between the tested
materials in use as seating interface pressure relief in custom-
molded seating. All materials significantly reduced the peak
pressure at the seating interface compared with the Evazote
lining. The foams and the Jay gel produced significantly lower
peak pressures when compared with the Floam insert, which
places it last in terms of peak pressure relief. The foams
additionally had a significantly improved pressure distribution
at the site of interest compared with the Jay gel.
As shown in table 1, the effects of Floam in terms of peak
pressure relief was the least favorable of all the tested materi-
als, except in 1 subject. This subject’s seat was much less
contoured than those of other subjects and was almost similar
to the seat of a standard wheelchair. Floam material was
originally designed as a pressure-relieving insert for use in
standard wheelchair cushions covering the entire seating area.
We are convinced that size and shape of the seat cutout was
important in the results of Floam in this study. The purpose for
which this material was designed was different from its appli-
cation in this study. The use of more than 1 sachet of Floam gel
with variable diameters and thickness might have improved its
performance when used in combination with the CMS. The
ability to select the depth of the recess in the CMS would
probably improve the pressure-distributing characteristics of
the Floam insert. This would also be true with the Jay gel,
which showed reduced pressure-distributing abilities.
The correlation study results show that any product of the 1-
and 2-way ANOVA is the exclusive consequence of the seat-
ing-interface material used. It was shown that for the peak
pressure data, the use of unaltered readings and the import into
a single block of data produced results that depended only on
the material type. All other predictors did not interfere with the
readings because they showed no correlation with the collected
data. Our results are consistent with those reported by other
investigators.15 In the matter of the pressure-distribution read-
ings, the correlation study did not reveal any significant corre-
lation between the individuals’ body weights and the pressure
distributions. This means that the adjusted readings used were
free of any effect from this important predictor and showed
only the role of the insert materials in altering the pressure
distribution. Although body weight plays a role in the magni-
tude of the peak pressure that is generated, for each subject it
was the same for all materials tested. This explains the lack of
any correlation between this factor and the outcome values (ie,
peak pressure and mean and peak pressure ratio) (table 3).
Most of the study subjects were of low to average body
weight and body build, except 1 subject (subject 2) who had a
heavier build. Our overall experience shows that most of the
participants in this study had a body build that is reasonably
common in the CMS user group. Higher peak pressures are
expected for patients with a heavier physique, such as subject
2. However, the effect of body weight on pressure distribution
was not noteworthy (table 2).
It is likely that posture, and pelvic obliquity in particular,
would have had a profound effect on the measured pressure
data. However, subjects’ posture within their seats was kept the
same for each of the tested insert materials. The effect of
altering the sitting posture will be addressed in future work.
In the case of peak pressure ratio, significant differences
were only shown between the Sunmate and the Jay but not the
Pudgee and the Jay (table 1), despite similar average values
between them. However, the P values are not the exclusive
parameter for the evaluation of the results. It is valuable also to
appreciate the average values of the data set, even if they do not
produce significant P values.
It is unlikely that bottoming out would have occurred in the
case of the gels because of the small size of the seat cutouts in
relation to the size of the inserts, which puts limits on the
lateral migration of the gels. To prevent the foams from bot-
toming out, we consulted tables supplied by the manufacturers
in selecting the appropriate insert thickness. The gels suffered
from 2 main limitations when compared with the foams. The
first was the limited variability of the insert thickness and the
other was the excessive migration of their viscous filling. It is

Table 2: Comparison of Mean and Peak Pressure Ratios for All Materials and for Each Participant

Mean Pressure Ratio Peak Pressure Ratio

Participants Participants
Insert Materials 1 2 3 4 5 6 7 1 2 3 4 5 6 7

Evazote .55 .63 .58 .36 .64 .72 .35 .16 .46 .49 .23 .48 .66 .08
Floam .57 .77 .37 .59 .44 .70 .49 .18 .70 .19 .27 .15 .64 .28
Jay .61 .54 .76 .39 .53 .49 .50 .35 .29 .52 .31 .34 .05 .31
Pudgee .71 .74 .89 .58 .47 .70 .49 .58 .67 .77 .43 .21 .59 .16
Sunmate .60 .71 .69 .29 .64 .80 .71 .57 .60 .54 .18 .52 .70 .57

Arch Phys Med Rehabil Vol 83, August 2002

1156 PRESSURE DISTRIBUTION IN CUSTOM-MOLDED WHEELCHAIR SEATS, Apatsidis
Table 3: Pearson Correlation P Values for Peak Pressure and
Mean and Peak Ratios
Predictors
Body Weight Gender
Peak pressure data .320 .388
Mean pressure ratio .073 .266
Peak pressure ratio .121 .169
not possible to attach 2 individual sachets of the gel together to
vary insert thickness, whereas the foams, which are already in
different thicknesses, make it easier to achieve the most appro-
priate shape and size for the cutout. This gains importance
when considering the nonsymmetric shape of CMSs.
The second limitation was that the size of the inserts could
actually have been too large for the existing size of the cutouts,
thus building up pressure within the gel sachet because of the
constraint of the sides of the cutout.
Some studies have been published on the use of the cushions
for pressure relief in standard wheelchair seats, and the pres-
sure-distributing characteristics of the different cushions have
been compared.16 In general, these studies have shown the Jay
cushion to be among the most effective cushions for pressure
relief. These cushions contain the polymeric gel we tested in
this study (Jay insert material). The other materials we evalu-
ated were not included in previous wheelchair cushioning
studies so no comparative data are available concerning their
performance in other seating systems. It is apparent that the
behavior of a seat insert material can vary enormously from 1
type of seat to another. Any information about these materials
gained from other seating systems can be used only as a general
indicator of how the materials perform in the CMS. The sub-
jects in this study also differed greatly from subjects involved
in the testing of wheelchair cushioning in other studies, be-
cause of their spinal deformities.
This study’s findings are now the basis for selecting the
materials to be used at the West of Scotland Mobility and
Rehabilitation Centre seating clinic as inserts within CMS for
people who are at risk of developing decubitus ulcers. The
number of pressure-related skin problems experienced by
wheelchair users in CMS since this change in our practice has
been reduced.
CONCLUSION
The study has shown that materials recessed within a cus-
tom-molded seating system can reduce the loading in particular
areas of the interface. Viscoelastic foams, particularly Sun-
mate, are more suitable materials than polymeric gels for this
application because they significantly reduce the peak pressure
occurring at the seating interface while concurrently distribut-
ing the load more evenly.
Arch Phys Med Rehabil Vol 83, August 2002
Acknowledgment: The contribution of all materials by the sup-
pliers is much appreciated.
References
1. Ham R, Aldersea P, Porter D. Wheelchair users and postural
seating. A clinical approach. New York: Churchill Livingstone;
1998.
2. Nelham RL. The manufacture of moulded supportive seating for
the handicapped. Biomed Eng 1975;10(Pt 10):379-81.
3. Nelham RL. Seating for the chairbound disabled person—a survey
of seating equipment in the United Kingdom. J Biomed Eng
1981;3:267-74.
4. Kang TE, Mak AF. Development of a simple approach to modify
the supporting properties of seating foam for pressure relief. J
Rehabil Res Dev 1998;35(Pt 1):52-60.
5. Reswick JB, Rogers J. Experiences at Rancho Los Amigos Hos-
pital with devices and techniques to prevent pressure sores. In:
Kennedi RM, Cowden JM, Scales JT, editors. Bedsore biome-
chanics. London: MacMillan; 1976. p 301-10.
6. Zacharkow D. Wheelchair posture and pressure sores. Springfield
(IL): CC Thomas; 1984.
7. Bennett L, Kavner D, Lee BY, Trainor FS, Lewis JM. Skin stress
and blood flow in sitting paraplegic patients. Arch Phys Med
Rehabil 1984;65:186-90.
8. Garber SL, Krouskop TA. Body build and its relationship to
pressure distribution in the seated wheelchair patient. Arch Phys
Med Rehabil 1982;63:17-20.
9. Sprigle S, Faisant TE, Chung KC. Clinical evaluation of custom-
contoured cushions for the spinal cord injured. Arch Phys Med
Rehabil 1990;71:655-8.
10. Sprigle S, Chung KC, Brubaker CE. Reduction of sitting pressures
with custom contoured cushions. J Rehabil Res Dev 1990;27:135-
40.
11. Brienza DM, Lin CT, Karg PE. A method for custom-contoured
cushion design using interface pressure measurements. IEEE
Trans Rehabil Eng 1999;7:99-108.
12. Michael SM, Walker PS. Clinical trial of body-contoured wheel-
chair cushioning. Clin Rehabil 1990;4:229-34.
13. Ferguson-Pell M, Cardi M. Pressure mapping systems. Pressure
mapping systems can add a powerful tool to a therapist’s seating
and positioning evaluations. TeamRehab Rep 1992:28-32.
14. Ring ND, Nelham RL, Pearson FA. Moulded supportive seating
for the disabled. Prosthet Orthot Int 1978;2:30-4.
15. Medical Devices Agency. The effects of posture, body mass index
and wheelchair adjustment on interface pressure. Medical Devices
Agency Report. London: UK Dept of Health; July 1997. Report
No. MDA 97/20.
16. Medical Devices Agency. Wheelchair cushions static and dy-
namic, a comparative evaluation, special issue. Cushion Evalua-
tion Report. Medical Devices Agency. London: UK Dept of
Health; June 1997. Report No. PS4.
Suppliers
a. Dynamic Systems Inc, 235 Sunlight Dr, Leicester, NC 28748.
b. Talley Medical, Premier Way, Abbey Park Industrial Estate, Rom-
sey, Hampshire SO51 9AQ, UK.
c. Zotefoams Plc, 675 Mitcham Rd, Croydon, Surrey CR9 3AL, UK.
d. Otto Bock Health Care, 3000 Xenium Ln N, Minneapolis, MN
55441.
e. Southwest Medical, 513 W Thomas, Phoenix, AZ 85013.