Choosing Heel Protection Products
Pressure ulcers have been a serious healthcare issue for many decades. In fact, today, the NHS spends some £1.4m per day in dealing with them and of course this does not sum up the total economic and emotional cost. Pressure ulcers are often thought of as preventable and even a “failure of care” but they are a result of many factors both mechanical and medical and this complexity is perhaps the reason why we so often see them.
Once upon a time I saw a product for pressure ulcer protection when based in the Cleveland Clinic in Ohio and this led to the creation of Anatomical Concepts (UK) Ltd. The PRAFO range of ankle foot orthoses have evolved to be popular and effective devices for the prevention and treatment of pressure ulcers at the heel area of vulnerable individuals.
A pressure ulcer, also known in the past as a pressure sore or bedsore, is an area of skin and often deeper tissue damage that occurs as a result of prolonged pressure on the skin. Pressure ulcers most commonly develop on areas of the body that are over a bony prominence and subject to constant pressure, such as the heels, ankles, hips, and tailbone. They can also occur on the elbows, shoulders, and back of the head. We will focus on the heel area but the same principles apply.
What causes a presure ulcer?
Pressure ulcers are caused by a lack of blood flow to the affected area, which can lead to localised tissue death and the development of a sore or wound. They are more common in people who are bedridden or who have limited mobility, as well as in older adults and those with chronic medical conditions such as diabetes or spinal cord injury. Risk factors for pressure ulcers include poor nutrition, incontinence, and a lack of regular movement or repositioning. Pressure ulcers can range in severity from red, irritated areas of skin to deep, open wounds. Treatment may include wound care, medication, and regular repositioning to help prevent further damage. A GOV.UK site summarises some of the facts and approaches to this problem.
In actual fact, describing these ulcers as pressure ulcers is still a simplification as in there are other “mechanical factors” involved - particularly the mechanical factor - shear - which is inevitable whenever tissue is in contact with a support surface. The simple act of changing position on a bed where heels are dragged along relative to the mattress can contribute to shear. Similarly contact between a heel and a support surface which causes the deformation of tissue generates shear as well as pressure. This matters because shear is much more destructive of vulnerable tissue than pressure alone. For this reason, it is important that a vulnerable area of tissue such as the heel area is suspended to have absolutely no contact with a support surface.
Products for heel protection
As anyone can easy see, there are many products that are aimed at help protection but they are certainly not all created equal. Here is the way we think about it. Of course the obvious function to provide with any device is relief from pressure, friction and shear between vulnerable tissue and any support surface. But to be effective and maximise continuity care we have to think more broadly than this.
The diagramme outlines the design considerations taken into account with the PRAFO designs. Some of these factors may not be obvious but can serve as a guide when considering whether a particular product is suitable for an individual case.
Areas protected - the PRAFO designs of course set out to protect the heels, toes, malleoli - and in fact the plantar surface of the foot. It is important to know that when you off-load the heel area you do not inadvertantly increase the load in adjacent areas. PRAFO designs may use a tissue-friendly, soft, Kodel liner or a pad and strap design if dressings are needed.
Pressure relief expectations - In our way of thinking, the only way of eliminating destructive mechanical effects is to completely remove pressure, shear - and contact from the vulnerable heel area. There is no safe level of pressure.
Adjustability - Ideally a single device needs to accomodate a wide range of sizes and be suitable for left and right legs. Many products on the market cannot accomodate pre-existing deformity at the foot and ankle because they are not adjustable. Some patients may need the mechanical stiffness of the PRAFO type design to resist deformities developing in the first place.
Ease of fitting - The product being used should be easy to apply by any competent person - whether in hospital, care home or domestic setting
Control of foot position - A product may be fine with an immobile patient but what happens if they are not immobile? Does the product remain in place and continue to offer protection? What happens if you want to mobilise the person? Can this be done safely whilst maintaining pressure ulcer protection.
Nature of usage - Sometimes there is a tendancy to respond to the immediate problem without thinking about what comes next. In healthcase we need to be sensitive to continuity of care. For example, with a stroke patient, if I use a product for heel protection that “works” but the patient meanwhile develops a plantar flexion contracture we have compromised continuity of care. The importance of the metal upright structure of the PRAFO designs is sometimes overlooked but this ensures that continuity of care is not compromised. The designs can always be adjusted to accomodate existing deformity and prevent contractures whilst the patient is in bed and yet still be safely used for mobilising the protected patient at the earliest opportunity.
We are proud to work with the PRAFO (Pressure Relief Ankle Foot Orthosis) which has proven effectiveness for heel ulcer prevention and treatment. We stock the range for next day supply to customers across the UK. You can learn more about the various designs on this site.