Redefining What's Possible

The Mattress Matrix - Four Keys to Pressure Care Success | EP 7 | Redefining What’s Possible

• Independent Living Specialists • Season 1 • Episode 7

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In this episode of the Redefining What’s Possible podcast, host Sarah Uncle, Head of Clinical Education at ILS, is joined by Bradley Fowler from Forte Healthcare, an Australian manufacturer specialising in patient support surfaces, medical mattresses and pressure care equipment. Together, they unpack what therapists need to consider when prescribing a pressure care mattress, exploring the four key clinical factors of pressure, shear, mobility and microclimate. Bradley explains how different mattress constructions and materials influence tissue loading, comfort and sleep quality, how to interpret pressure mapping without over-relying on the images, and why shear and bed mobility are just as important as pressure redistribution. The conversation closes with practical take-home messages for clinicians and a powerful real-life story of how the right cooling mattress transformed a teenager’s sleep and skin health.

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Welcome to Redefining What's Possible, your guide to Assistive Technology in Australia. Join us as we explore practical applications of AT featuring expert interviews and the latest industry insights to enhance your professional development and to improve client outcomes. Welcome to this episode of the Redefining What's Possible podcast. I'm your host, Sarah Uncle. I'm the head of clinical education for ILS and I trained as an occupational therapist. And today I'm joined by Bradley Fowler. Bradley works for Forte Healthcare and they're an Aussie company who are leading the way in the design and manufacture of patient support surfaces, medical mattresses and pressure care equipment. Bradley has been with Forte for five years and he's part of the clinical education team. So Bradley, I want to warmly welcome you to the podcast today. Thanks for having me on. You're very welcome. Now I've been very lucky to have many conversation with Bradley around pressure injury prevention and pressure injury treatment. And he is very well read, very well researched and knows all the latest evidence. So I'm thrilled that he's here to educate us. And I'm going to talk to him today about what we need to consider when we are prescribing a pressure care mattress. So Bradley, my first question for you is a little bit broad, but I wanted to ask you what the key considerations a. therapist needs to address when they are considering prescribing a pressure care mattress. Yeah, that's a difficult one because of pressure injuries tends to be not a very simple subject. Obviously, they're very, that's a very important thing in terms of healthcare where it's a horrible thing to have a pressure injury and a lot of people get it. A lot more than we realize. Yeah. But a big reason why it's such a often is referred to as an epidemic, pressure injury epidemic, right? We all know what that word means, but I think the difficult thing is there's so many factors that contribute to a pressure injury, right from the type of person, right you know, to the type of environment they live in. So when you say what are the key things to look at from a therapist point of view, you've got to consider we're looking at a mattress, right? So there's so many clinical boxes to tick, which a lot of research helps, but at the end of the day, it's still a mattress. So I'm gonna split it into two parts. There's a clinical side and there's like the life side of it. So from a clinical point of view, we can very much focus on the term pressure. That's definitely the first and foremost and most key consideration is how can we reduce or mitigate pressure? The second most important thing I'd say is the term we call shearing, which is more of a horizontal force against the body. So when people are moving, I'm sure there's gravity, there's pulling and pushing forces against the body as well. But there's two more considerations I'd for sure. say a therapist has got to look at. One is mobility, which is sounds kind of obvious we're talking about mobility, but a mattress more often than not can sometimes can actually restrict mobility. and the last one being probably the least known out of out of these four things is term microclimate which is a term we use for the heat and moisture against someone's skin whether it's in combination with pressure and things like that. So these four factors, pressure, shearing, mobility, microclimate, are four clinical considerations we always, any pressure type of service, so not just mattresses, but cushions and recliners and anything that's in that same category, I always look at those four factors. at the end of the day, the day I'd always look at how does the person using this product, again whether it is a recliner cushion mattress, are they even comfortable, are they having a good night's sleep on it, which is the second very big area we've got to consider. Yeah, because sleep is really important. It's important, particularly if someone is unwell and needing to recover or even in situations like end of life and comfort is such a priority. Absolutely I mean we can we can certainly focus on those areas but even just for the average human, right? Sleep is a, we spend so many years of our life sleeping because it is such an important part part of life so we've got to consider it. Yeah, absolutely. Okay, well let's unpack some of those things you just spoke about and let's start with pressure. mean pressure is something that it's there, right? It's the person's body weight with gravity. We can't take that away. So how does a mattress actually work to mitigate pressure? Historically, we've split our strategy into managing pressure into two types of management. One being, like you said, gravity is always gonna be there. As long as you're here on earth, you're gonna have gravity. But the first strategy is to, sure, we've got lumps and bumps all over the human body. Unfortunately, we're not a flat plank. So how do we spread out that pressure over the body? It's what we call pressure redistribution. The second strategy is something we've used for a number of decades now as well. It's a term, pressure relief. So it's physically, how can that mattress physically take pressure off? And there's a couple of ways we can do that. It could be like an alternating air mattress or it could be a top mattress which physically turns or even not that aside from the mattress, it could be. external caregivers physically turning or repositioning someone to physically relieve pressure. That's good. I know often manufacturers, will have pressure mapping images to kind of show how well their mattress disperses pressure. Can you help us understand how to read a pressure map and how we can actually compare mattresses from different manufacturers or even different mattresses from the same manufacturer? Like how do we actually use those images that get put forward for us to look at? Yeah, I noticed a good distinction you've made there between one manufacturer and comparing multiple, which can both be a big thing with pressure mapping is comparing, for example, Forte's mattress A and mattress B versus two companies. But the biggest consideration is when you are comparing multiple manufacturers, because a lot of us have different technology in the pressure mapping system. So they're measuring at different pressure ranges. measuring to different accuracy, could be 5 to 10% accuracy. Some of them, the biggest one being the different test subject. So some of these test subjects might be six foot tall, the others might be really, really short, or some people have a wider surface area. So pressure has a different reading if you're wider versus if you're longer, for example. And comparing that can be almost impossible. So something I always look at with the pressure map, you if you're looking at the different colour grading scales where you've got a red point, you've got higher pressure, where you might have yellow or orange, it might be lower, green lower, blue might be lowest pressure, but where you have no pressure, there's always gonna be a blank space. And there's always particular parts of the body which show up a bit blank space, where you've got sort of peaks and troughs between the head and feet. And the biggest way to compare an effective distribution mattress is a mattress that has bigger or more gaps is often a lower performing mattress, irrespective of what lovely pressure reading it might look like outside of that. If there's gaps, the chances are for your awkwardly shaped client, that's not going to be able to adjust to their shape. So a map with less gaps is a better performing one in general. But always, you know, the thing as well to consider is it is not a very accurate representation of what's happening deeper into the skin. It's aside from only being 5 to 10% accurate. And considering that your experience in prescribing other equipment or your supervisor's experience or other people in your team, that is often a far better gauge of effectiveness. of a product, than a single pressure map will be. So yeah, it can form part of your judgment, but your experience will always outplay a pressure map. That's actually really good advice on how to look at pressure mapping images because it gets confusing. And what you've explained explains why it's confusing. But to know, okay, you're looking for how much of the body is actually in contact with the pressure mat rather than the colors it's showing. That's really good advice. Thank you. it's often about sort of evening the playing field between all these different pictures you might be seeing. It's just a nice way of getting a nice average result. Yeah, yeah, good advice. Okay, you talked about shear. I know from the research I've done, shear is a very big factor in how pressure injuries actually form. So what is the mattress doing? Like how does it actually work to mitigate shear? Well, there's, again, there's multiple ways and reasons why we might have shearing against our body. I guess I'll first start with understanding what is shear to a certain degree. and the most, the most common use case we could say of where we're seeing shear is from the good old adjustable bed. We've got all these lovely functions which are great for mobility and comfort, lifting backrests and things, but unfortunately adjustable beds can't be perfectly made to suit every single person's body shape and sizes and widths and heights. And sometimes those bed angles work against gravity. And what happens is we end up getting our bones and our soft tissues, our skin surface. moving in the opposite direction to each other. And so when we're talking about a pressure injury as a result from pressure, it's because we're squishing all those soft tissues. When we're thinking about shearing, it's essentially the same thing. Instead of squishing, we're stretching them. And there's a couple of really important things to consider there because a pressure injury can happen in, you know, essentially there's two pathways to a pressure injury. One is we're restricting the blood flow. due to the collapse of our tiny capillaries inside our soft tissues. Or the second one, and probably lesser known one, is damage due to physical pressure and it damaging the tiny cells within our skin. So the two completely separate ways to get a pressure injury and shearing affects both of those. In fact, what research they found is when you've got that shearing stretch against the skin or against the soft muscle tissues in particular. damage can actually, widespread damage cannot start to occur within 15 minutes. And then when we're considering, yeah, it's really, really quick. And we're considering the blood flow, which is a second, still important, but it's a second factor. Our capillaries, they've found they actually collapse easier when they're under shear strain. So when we've got shearing occurring, we need less gravity to result in the blockage of that blood flow. that's really important. It's, call it the first cousin of pressure because it's really closely related, the same thing. So when we're thinking about a mattress and we're thinking about, I would think about the word friction. So when we've got the skin gripping against any surface, our number one goal is to reduce friction because if we've got less friction or no friction, ideally have no shearing underneath the skin. The, again, like pressure, it's something we can't entirely remove. can't have a shear free. Yes, I wish we could because it does contribute to a majority of pressure injuries, but we can reduce it. And even just the simple fact of pressure against the skin actually stretches those tissues. those kind of tissues getting squished and just from... purely pressure, no horizontal forces. The tissues around it are all stretched. So even in just straight pressure, they're shearing. simply redistributing pressure effectively is a big first step. The second one is how can we reduce friction, which could be different types of fabrics that slide against each other with foam mattresses, if we can break the mattress up into more sections so it's less stiff, essentially. then we've got less of a resistance against us. And there's great strategies. Yes, so cutting up a foam into a castellated pattern or even just splitting a mattress horizontally in half into two sections allows two parts of the mattress to slide against each other. And having a thinner mattress tends to reduce as well. So the thicker a mattress is, the more a backrest of a bed will push someone forward as it lifts up. So a thinner mattress tends to be a little better from a shearing perspective. There's also strategies, I'm sure you'll have more content on this, but different from a actual bed platform, there's a lot we can do there, different technologies like auto regression, et cetera, something you can always look out for. Yeah, that's good. And always the cover as well with the stretchiness in the cover. just to try and take some of that shearing force away from skin and tissue. Stretchy covers, that's why we don't want beds loaded up with incontinence products. Yeah. Yeah. So a stretchy cover allows like whatever technology or research someone's put into a mattress and all the standards you've got to test to and we're talking about pressure mapping, all these things we do. And then you stick a non stretchy surface on top of it, like an incontinence pad or, you know, multiple doonas or heated blanket, so many things like that. And then all that effort and funding that's gone into that mattress. you've just thrown out the window, you might as well be lying on the lounge room carpet or something because you're restricting the performance, say. yeah. And it's so important that everybody understands that and that we communicate that not just among therapists, but around caregivers and even the end user themselves to understand that we really are preventing the mattress doing its job for loading up the bed. Yeah, that's good. Is there a way that we can standardise like test for shear? Is there any standardised test for that? like there is with pressure mapping for pressure, is anything like that for shear? There is much less common than a pressure map. There is standards that we can test too. Most notably is a set of standards set out by a RESNA from out in the US, R-E-S-N-A. You can look it up and get your hands on the standards and see the different tests which we run here in Australia. But from a shearing perspective, it is so difficult because where shearing force occurs on the body, is not necessarily at the surface where the skin is. It's down deeper inside the muscle tissue or next to the bone, which, you know, it's impossible to test that far deeply into someone's tissues. But we can test things like how stiff a mattress is. So there's a particular test called the horizontal stiffness test, which means we essentially have a mannequin, we pull it and test how much pull back force there is. For example, when someone repositions in bed or imagine the backrest, how much resistance there is, which is the best we can get out of a standardised shearing test. And there are ways we can add a particular shearing sensor to that surface. But again, that's measuring right at the surface and not deep in the tissue. Yeah, okay, good point. So maybe in the future there'll be something with MRI or ultrasound or something like that. that is a good point. Like there has been very specific research done using MRI, for example, to look at what actually happens underneath the tissue. there are publicly available research to encourage you to try and look for it. And it sort of is an eye-opener when you get an MRI of shearing happening, actually. Wow, that's a lot of force happening to the soft tissue that I didn't realize was happening. Yeah. the outside looks like a great bed and mattress. From the inside, it's a different story, right? So perhaps that will become more accessible. Can't imagine every mobility store showroom to have an MRI machine in it to test the shear, but maybe there is. who knows? Okay, let's move on. You talked about bed mobility and how can a mattress encourage bed mobility or discourage bed mobility? And what should we think about when we are considering that as a therapist? Sometimes these factors we're talking about, for example, pressure and mobility can actually kind of work against each other. So it's as a manufacturer, it's important we know how different materials we use in a mattress, different foams and air technology and the likes, how they impact on the pressure or impacts mobility. as a very common example is the use of memory foams in a mattress. used for decades and decades is memory foam and the reason is it's yeah it's great for managing pressure it's super conforming it's nice and comfortable that people have loved it for decades however when we're considering mobility a memory foam as the name suggests it has a memory right so when you you put pressure into memory foam it slowly reacts back to its original shape so if you're someone with lower mobility, you've got to actually fight against the memory foam to mobilise or to roll out of bed or to get into bed. If you're fighting against that memory foam, as great as it is for pressure, you know, your motivation, for example, to get out of bed in the morning is probably lower. So sometimes we can almost compromise, it might feel like sometimes even we're compromising on pressure, but for the simple fact that actually mobilise easier. Yeah, so they are different types of foam that makes mobility easier for people with low mobility. Yes, yes. there's kind of the ‘baddie’ memory foam and more recent developments have come out in the last few years of a type of foam which we term a response foam. So the term response as opposed to memory is the exact opposite. So a response foam, you press it, it can be super plush, soft, conforming, but it has an immediate response back to its original shape. And there's also some further benefits to it as well being which we'll talk about a little later, but from a heat point of view, memory foam tends to be a hotter. Responsive foams tend to be a lot more open and breathable, but purely from a mobility point of view, you'll see from our perspective anyway, and I hope a lot of others do it as well, is a more bouncy responsive foam on the top. Sure, you put your hand on it and it feels plush, but you don't get that stuck feeling in the mattress. And there's simple things we can do, like where there's the edge of the mattress foam. tends to collapse a lot easier at an edge. So something we've done for literally the last 17, 18 years as manufacturing in this industry is a firm bolster edge. And it's just something we've done since day one, but not every time is that a part of the pressure matrix you're looking at. And it's an important part because it means safe sit to stand transfers from the edge of the bed. Yeah, it's really important. Preventing falls is very important. Okay, let's talk about microclimate. You just alluded to it, talking about how memory foam is tightly poured and can sort of trap heat. So what is done within a mattress to help manage the heat and the moisture that can build up in skin? I suppose the biggest culprit to the buildup of that is the management of incontinence, which is a big part of a lot of these, a lot of equipment, but particularly a mattress. And managing that means we've got to have a watertight material, which also happens to mean it's somewhat airtight as well, which means an airtight material against the breathable skin means we tend to have a buildup of heat and moisture. Now we can't ignore the fact we do need to manage liquids and we do need to manage the fact that there is, we have to have watertight materials. So sometimes I find the biggest factor to consider when someone's getting their first waterproof material on a mattress is adjust the room temperature according to it. if you've always slept on that. that same old mattress for the last decade and you've always had the room temperature set at the exact 19 degrees, whatever it is, just throw it down one or two degrees from day one because then your body's going to adjust better. But in terms of what we actually do to the mattress, there is, you know, the biggest factor is that outside cover. sure, someone needs the waterproof, go for it. But if they don't actually need it, a lot of higher level pressure mattresses come standard with a waterproof cover. So there's a lot of options out there now to opt for a non waterproof material if they don't need it. So it'll firstly, massive impact on comfort and heat. But then inside the mattress as well, we need to encourage airflow. some foams, foam in general, but some foams are particularly bad at managing airflow. The good old memory foam we've been talking about, again, tends to be a closely tightly packed. So it's attracts heat that holds it in. So alternatively, we can use foams like a response, which is great. Or physically we can just with our technology like castellated foams or particular patterns of cuts in foam, we can do to encourage airflow through the mattress, which will only be effective for someone that has mobility. So as long as someone's mobilising. the kind of trapped air inside the mattress as long as that can flow in and out. That's very helpful. And then, you know, on the other hand, the good old alternating air mattress is a great alternative for managing heat, even aside from its pressure management side, managing heat. It's a great strategy using an alternating air mattress because you're pulling in and out air from the mattress. Sometimes it worked a little bit too good and some, a lot of people actually feel quite uncomfortable as a result. And that might be where our hybrid type mattresses fit in to get a nice middle ground. But there are a few ways we can address microclimatic. Yeah, that's good. I've had clients who've been very cold on their alternating air mattress and a lot of education is to go into explaining why. Because it's actually on purpose, the mattress is trying to keep their skin cool and dry. Again, again, it's a good old trick we were just talking about with the aircon or heater in the room. If someone's getting their first alternating air mattress, preempt that they're going to be colder unless they're a prolific sweaty sleeper, but pre-adjust the room because you know they're going to feel colder. Yeah, that's really good advice. Okay, Bradley, we've covered a lot. So if you can sort of sum up and give us three main takeaways for therapists to keep top of mind when they are considering pressure care mattresses, what would those three things be? Number 1 is So the four factors we talked about is it's very easy to look down the road of how good is this mattress at managing pressure by itself. But the reality is all four of those factors kind of work together. So if you're comparing different products from different manufacturers, look at all four factors of pressure, mobility, shear, microclimate as one whole, because you could get a mattress that's great at pressure, but terrible at microclimate, for example. The second one being which we didn't really talk about much, but I do want to get this point across is you can always tick every single clinical box, looking at the factors and things, but unless that client's comfortable and unless they have some sense of choice in choosing something on that product or mattress can be very, very small. But if they've got some element of choice, A and B, then they're more likely to use it like they should. And I think experience will be the biggest thing that will teach you this, but using tools like pressure mapping, for example, it's something that's pushed out by a lot of manufacturers as, look at our awesome pressure mapping. But reality is the reliability of that printed onto someone's brochure is quite low. And unless they've got, you know, accurate resource there to tell you how accurate the measurements are and type of pressure mapping and the grade to which the measurements are and things like that, it is particularly unreliable. So keep that in mind is yes, pressure mapping is a factor, but use your experience as the biggest factor in your decision making. So can you describe a moment when assistive technology significantly changed a client's life and how did that impact you? Oh, that's a big one because there's been so many, even though we're kind of a step back from a lot of the people that are doing physical trials in the showrooms and things like that. But we do get quite a lot of involvement and feedback. One that I often talk about when I ask a similar question is a child that we, a teenager actually, that had had significant issues with managing heat. for over a decade that had really, really bad heat problems, which we used a particular type of mattress of ours, which included a cooling gel foam in it. This is about four years ago now. And we sent a mattress off to one of the showrooms to trial. And this teenager, they actually had the first night without sweating all night for the first time in over a decade. And the feedback we got from that was pretty cool because to literally have that profound impact for the first time in a decade I thought that was pretty cool. Yeah, that's very cool. That's making a difference in someone's life in a way that matters, cause to have a good night's sleep and not wake up feeling hot and sweaty, and then the protection from pressure injuries that would come from not getting hot and sweaty, yeah, that was a good day at work. Bradley, I want to say a big thank you to you for coming and for sharing your knowledge and expertise all around pressure care mattresses and all of the considerations you discussed with us today. So a really big thank you for sharing your wisdom with us. No, thanks so much for having me on. I wish we had a couple more hours to talk about it because it's kind of glossed over the surface. But both of us from both companies, Forte and ILS are very accessible from education and both companies run a lot of PT education, et cetera. So that's where we're really deep and ask questions and things. Absolutely and we would both love to do that for anybody who would like to connect with us and learn more. So thank you so much for joining us in this episode and we will catch you in the next one. Bye.