Bob VogelQ. I’m 55 and in my 20th year as a C7 quad. I stay active, eat a healthy diet and do nightly “mirror-skin-checks.” My skin has always looked good with no red areas until six months ago when I got a minor scrape on my butt cheek during a transfer. Within a week it swelled and opened up and was diagnosed as a deep tissue injury. I ended up needing a skin flap and many months in bed to heal.

I’ve used an air flotation cushion since rehab. It has always protected my skin. My wound care specialist said that new research in pressure injury suggests that over the years, scar tissue has likely been slowly developing deep in the tissues near my ischium, and the scrape likely set the wound in motion.

This is the first time I’ve heard of a deep tissue injury, and I’m still trying to wrap my head around how this happened. Anything you can tell me about it, especially options to avoid another one, will be appreciated.

— Stacy

A. As in many areas of medicine, researchers’ knowledge of how pressure sores — now often referred to as “pressure injuries”— continues to evolve. Until the early 2000s, known causes of tissue injury were pressure — which reduces or stops blood flow to the tissue — along with heat and moisture. Research has shown that additional causes are serious bumps and/or shear (pushing and pulling of tissue against bone), which can damage capillaries (tiny blood vessels) and deprive surrounding tissue of blood. This occurs below the skin surface and causes damage from the inside out. In 2007 the National Pressure Ulcer Advisory Panel added “suspected deep tissue injury” to its pressure injury staging scale, and a few years back the word “suspected” was dropped, which led to the current term, “deep tissue injury,” or DTI.

For more on deep tissue injury, I turned to Darren Hammond, a certified wound specialist and clinical support and education specialist for Motion Composites.* “These days many of the deep tissue injuries that clinicians are seeing, particularly with acute rehab stays that are so short [due to insurance guidelines], are caused by transfer failures where a person lands on a tire or something hard,” says Hammond. “This is where the research of Dr. Amit Gefen comes into play. Gefen has done important MRI studies that show deep tissue stresses and strains — and how these stresses lead to deep tissue injury.”

Hammond and Gefen worked together. Gefen had established that DTI can be caused not only by an acute incident but also by repetitive small traumas to deep tissues. “We had an ‘aha’ moment,” says Hammond. “I said that some people have poor transfer habits and bump a wheel or plop heavily on the surface they are transferring to. Even though this causes micro trauma, at the end of the day when doing a mirror-skin check, things look good.” This fit together with Gefen’s research that shows DTI can be the result of repeated minor trauma.

Each sloppy transfer causes a micro trauma in the deep tissue that heals. The problem is that every healed micro trauma becomes scar tissue that is less resilient then regular tissue, thus more susceptible to injury. Deep tissue micro traumas are cumulative, each adding another bit of scar tissue. Let’s say a person has poor transfer technique frequently. Over the years, scar tissue from repeated micro trauma adds up, and the area gets bigger and bigger, becoming more susceptible to injury and damage. Then something like a scrape or moisture from a bladder accident causes a small skin breakdown, something that normally would heal quickly. However, the underlying scar tissue causes it to escalate into a deep tissue injury.

This helps explain one reason why wheelers that have gone years or even decades with no pressure injury — or even skin redness — can suddenly find themselves with a deep tissue injury that seemingly popped up out of nowhere.

The takeaway is to treat each transfer as if it is a climbing move. Be certain of your hand holds, make sure your butt is going to clear your tire and gently lower your butt onto your chair or surface. Treat your butt like it is made of eggs: The slightest bump will crack them. This is even more important as you age, beginning in your 50s and beyond, because we start to lose muscle mass, which makes paying attention to proper body mechanics as well as staying in shape and managing your weight critical. It turns out that being too thin as well as too heavy puts extra strain on your skin and tissues.

Another area to watch out for during transfers is avoiding shear and friction, says Hammond. “You want to avoid shear and friction not only during transfer, but also in your chair,” he says. “On the other hand, there is a balance. You need enough friction on your cushion to hold you in place for good posture. It is a delicate balance. If your cushion doesn’t hold you in place, you will develop posture and shoulder problems.”

Gefen offers additional strategies to avoid tissue injury in his paper on detection and prevention of DTI (see resources). The study discusses the importance of proper weight and positioning, a topic in itself that deserves discussing with a clinician versed in seating. For instance, increasing seat bucket dump helps reduce pressure because it puts more pressure on your thighs every time you lean forward and/or push your chair, which in turn offloads the ischial areas.

Of course, doing a mirror check is still necessary. Also, try and get a sense of what your skin feels like when it is healthy (if you have sensation), says Hammond. A change in temperature (warm or hot) as well as moisture, or an area that feels unusually firm can all be early warning signs of pressure injury.

Last but not least, don’t forget to use a cushion on car seats and any firm surfaces. I even use a cushion on the couch. When traveling by air, I always sit on my wheelchair cushion in the airline seat. I also carry a portable cushion — a ROHO adaptor pad — which I use while I’m sitting on frequently rock-hard aisle chairs on my way to my airline seat. The adaptor pad also works great on shower benches.

*Bob Vogel is an ambassador for Motion Composites and receives payment from the company for representing it at trade shows.

• “Deep Tissue Pressure Sores,”
• Dr. Gefen: “A Review of Deep Tissue Injury Development, Detection and Prevention: Shear Savvy,”
• ROHO Adaptor Pad,
• “New Study Helps in Choosing Cushions,”
• Model Systems Knowledge Translation Center, “Skin Care and Pressure Sores in Spinal Cord Injury,”