WOUND OFFLOADING AND ITS IMPORTANCE IN HEALING

Offloading is a strategic redistribution and reduction of pressure on specific areas of the body to help with healing and prevent further wounds or complications. Healing is often difficult on the plantar surfaces of the feet on which pressure is applied from ambulation as well as on the surfaces of the bony prominences of the body when sitting or lying down. Understanding offloading and its non-weight-bearing implications is one vital component of wound healing.

Pressure on wounds and other vulnerable tissues may inhibit the healing process and increase the risk of complications. When a wound is present, the body needs the most favorable circumstances and time to heal. The body weight places a lot of pressure on the feet and ankles when standing and walking, then on the back and sacrum pressure points when sitting or lying down. This pressure can impede new skin and tissue from growing as well as stop new blood vessels from forming to supply needed oxygen and nutrients to the healing wound. If there is continued pressure on the wound, it will most certainly delay healing or the wound may not heal at all.

One common problem with inadequate offloading is developing deep tissue injury and pressure ulcers or decubitus ulcers. These are injuries to the skin and underneath the skin caused by prolonged pressure on the skin. These often arise on bony prominences of the body such as the heels, ankles, hips, tailbone or buttocks, back, shoulder blades and spine, the back side of the head, elbows, and knees. This is one of the most significant aspects of long-term care, to prevent decubitus ulcers as people who have medical conditions which keep them immobile or from changing positions are at the most risk. Pressure sores can develop over hours or days and while most heal with treatment, some never heal completely and need to be taken care of consistently.

Another contributing issue is when fluid build-up or swelling causes a higher risk of wounds developing on the legs, especially in those diagnosed with chronic venous stasis. The more swelling there is, the more pressure there is on the skin that can cause breakdown while the swelling also stretches the tissues making it harder for blood vessels to deliver the essentials for wound healing.

OFFLOADING THE LEGS AND FEET

1. Staying in bed

This is probably one of the easiest ways but this may not always be possible as life goes on for most people despite the wound. Nevertheless, in some cases, bedrest may be the best way to prevent further problems with leg and foot wounds if deemed necessary.

2. Elevating legs when seated

Another wound care staple for leg wounds especially with associated leg swelling is elevation to take off pressure from fluid buildup onto the skin and onto the wound. Blood pools on the legs when seated and elevating the legs will counteract to promote venous return. Elevating the legs allows blood and fluids to drain from the lower extremities.

3. Offloading shoes

Special shoes allow people to still be up on their feet while taking off pressure from areas of concern. There are shoes mainly for balance and stability when standing and also meant to alleviate pressure and discomfort when walking. These shoes essentially lift the wound site or pressure points while still giving enough support for stability and ambulation. This also includes the use of surgical shoes made to be easily accessible and fit to the foot/feet along with the bandages post-op. It serves to offload and prevent the surgical site from moving and flexing which can hamper healing or cause further damage like a wound dehiscence.

4. Assistive devices

There are several assistive devices to take the weight off from the foot and therefore relieve pressure on the wounds including but not limited to crutches, a walker, a scooter, or a wheelchair to use ideally with offloading shoes.

OFFLOADING PRESSURE POINTS

1. Adequate and appropriate skincare

Keep skin clean and dry as much as possible. Wash with a gentle wound cleanser and pat dry, do not rub or use harsh chemicals that weaken skin integrity. Do a gentle cleansing routine regularly to limit exposure to excess moisture, urine, or stool. Use moisture cream barriers or protective creams such as zinc oxide cream like a diaper rash cream for surrounding tissues. Change dressings/bedding as needed and do not leave saturated dressings/bedding on for too long as this will worsen a wound or start a new one.

2. Nutritional sufficiency

Given that a balanced nutrition or diet that is appropriate for certain medical conditions is necessary for overall health, some particular nutrients do help with wound healing and avoiding pressure sores. Adding protein, vitamin A, and zinc into the dietary intake or supplements can do wonders with wound healing as well as strengthen the skin by increasing the collagen levels making skin firmer and less prone to breakdown.

3. Frequent turning

Doctor’s orders include turning and changing position every 2 hours for offloading. Repositioning reduces the duration of pressure and provides space for the skin to breathe and get more oxygen to the tissues. Constant pressure on a specific area leads to a lack of oxygen and other nutrients causing skin cells to die and become necrotic.

4. Pillows and wedges

Using wedges if done right, can be very effective in reducing pressure on the sacral and back area. Wedges are deemed better compared to pillows as wedges can retain their form and not sag as much as pillows making them inefficient later on. They lift/tilt the body on one side helping with frequent position changes especially for those who are bedbound. Pillows can be comfortable and useful in keeping in between knees to prevent them from rubbing on each other causing pressure/friction wounds. Use cushions or special pillows recommended by a doctor as some may not be as beneficial as one would think. For one, do not use a doughnut cushion to offload the sacrum/buttock as they redistribute pressure on surrounding tissue which can cut off blood supply and cause new wounds. Opt for a gel cushion that is specially designed to provide pressure relief and comfort especially for wheelchair users or those who are subject to prolonged sitting.

5. Low air loss mattress

Low-air loss mattresses are designed to prevent and treat pressure ulcers. They have multiple inflatable air tubes alternatingly inflating and deflating copying the movement of a person shifting in bed or a patient being turned by someone else which then results in the patient never staying in one position for any extended length of time. This mechanism relieves pressure under the body with special attention to bony prominences helping with keeping air and blood circulation to prevent, manage, and treat pressure injuries.

6. Physical therapy or activities as able

Physical activity and being able to move the body more from staying in bed for prolonged periods can do wonders for wound healing. It takes pressure off the contact surfaces to bed and helps with blood circulation. The more the blood can circulate more naturally throughout the body, the more the wound and skin can receive the healing cells needed.

In case there is confusion between offloading vs. non-weight bearing, non-weight bearing refers to complete elimination of any weight or force placed on the wound/tissue while offloading is minimizing or removing any weight or force that could be placed on the wound/tissue. Non-weight bearing is a form of offloading however not all forms of offloading are considered non-weight bearing.

Ultimately, the goal of offloading is to reduce surface contact pressures and shearing force while allowing for support, stability, and comfort with a reasonable amount of ambulation as appropriate to provide the best environment possible for wound healing and prevent complications.

If unsure which offloading method is best for you or your loved ones, ask for help from the professionals. Book an appointment with your doctor for assessment and evaluation which would be best and deemed medically necessary under your health plan.

Author

Jenna Wishnew Dr Wishnew is a Board Certified General Surgeon practicing in the North Texas area She specializes in general surgery, gastroparesis, wound care, vein concerns and robotic surgery.