Abstract
The paper describes the current views on the cause of a sub-class of pressure ulcers known as pressure induced deep tissue injury (DTI). A multi-scale approach was adopted using model systems ranging from single cells in culture, tissue engineered muscle to animal studies with small animals. This has led to a clear understanding on two damage mechanisms associated with the development of DTI. Direct deformation results from high, but physiologically relevant, strains and is a process that leads to the first signs of cell damage within minutes. Ischaemic damage is caused by occlusion of blood vessels, but takes several hours to develop. The paper ends with some clinical consequences.
Similar content being viewed by others
References
Bader, D. L. The recovery characteristics of soft tissue following repeated loading. J. Rehab. Res. Dev. 27:141–150, 1990.
Bosboom, E. M. H., C. V. C. Bouten, C. W. J. Oomens, F. P. T. Baaijens, and K. Nicolay. Quantifying pressure sore related muscle damage using high-resolution MRI. J. Appl. Physiol. 95:2235–2240, 2003.
Bosboom, E. M. H., C. V. C. Bouten, C. W. J. Oomens, H. W. M. van Straaten, F. P. T. Baaijens, and V. S. Maderich. Quantification and localisation of damage in rat muscles after controlled loading; a new approach to study the aetiology of pressure sores. Med. Eng. Phys. 23:195–200, 2001.
Bosboom, E. M. H., M. K. C. Hesselink, C. W. J. Oomens, C. V. C. Bouten, M. R. Drost, and F. P. T. Baaijens. Passive transverse mechanical properties of skeletal muscle under in vivo compression. J. Biomech. 34(10):1365–1368, 2001.
Bouten, C. V. C., M. M. Knight, D. A. Lee, and D. L. Bader. Compressive deformation and damage of muscle cell subpopulations in a model system. Ann. Biomed. Eng. 29:153–163, 2001.
Bouten, C. V. C., C. W. J. Oomens, F. P. T. Baaijens, and D. L. Bader. The aetiology of pressure sores: skin deep or muscle bound? Arch. Phys. Med. Rehab. 84(4):616–619, 2003.
Breuls, R. G. M., C. V. C. Bouten, C. W. J. Oomens, D. L. Bader, and F. P. T. Baaijens. Compression induced cell damage in engineered muscle tissue: an in vitro model to study pressure ulcer aetiology. Ann. Biomed. Eng. 31(11):1357–1365, 2003.
Ceelen, K. K., A. Stekelenburg, S. Loerakker, G. J. Strijkers, D. L. Bader, K. Nicolay, F. P. T. Baaijens, and C. W. J. Oomens. Compresion-induced damage and internal tissue strains are related. J. Biomech. 41(16):3399–3404, 2008.
Ceelen, K. K., A. Stekelenburg, J. L. J. Mulders, F. P. T. Baaijens, and C. W. J. Oomens. Validation of a dedicated finite element model of skeletal muscle compression with MR tagging measurements. J. Biomech. Eng. 130(6):061015, 2008.
Daniel, R. K., D. L. Priest, and D. C. Wheatley. Etiological factors in pressure sores: an experimental model. Arch. Phys. Med. Rehab. 62:492–498, 1982.
Gawlitta, D., K. J. M. Boonen, C. W. J. Oomens, F. P. T. Baaijens, and C. V. C. Bouten. The influence of serum-free culture conditions on skeletal muscle differentiation in a tissue-engineered model. Tissue Eng. Part A 14(1):161–171, 2008.
Gawlitta, D., W. Li, C. W. J. Oomens, F. P. T. Baaijens, D. L. Bader, and C. V. C. Bouten. The relative contributions of compression and hypoxia to development of muscle tissue damage: an in vitro study. Ann. Biomed. Eng. 35(2):273–284, 2007.
Gawlitta, D., C. W. J. Oomens, F. P. T. Baaijens, and C. V. C. Bouten. Evaluation of a continuous quantification method of apoptosis and necrosis in tissue cultures. Cytotechnology 46:139–150, 2005.
Gawlitta, D., C. W. J. Oomens, D. L. Bader, F. P. T. Baaijens, and C. V. C. Bouten. Temporal differences in the influence of ischemic factors and deformation on the metabolism of engineered skeletal muscle. J. Appl. Physiol. 103(2):464–473, 2007.
Gefen, A., B. V. Nierop, D. L. Bader, and C. W. J. Oomens. Strain-time cell-death threshold for skeletal muscle in a tissue-engineered model system for deep tissue injury. J. Biomech. 41:2003–2012, 2008.
Hermann, E. C., C. F. Knapp, J. C. Donofrio, and R. Salcido. Skin perfusion responses to surface pressure-induced ischemia: implication for the developing pressure ulcer. J. Rehab. Res. Dev. 36:109–120, 1999.
Linder-Ganz, E., S. Engelberg, M. Scheinowitz, and A. Gefen. Pressure-time cell death threshold for albino rat skeletal muscles. J. Biomech. 39:2725–2732, 2006.
Linder-Ganz, E., N. Shabshinb, Y. Itzchakb, and A. Gefen. Assessment of mechanical conditions in sub-dermal tissues during sitting: a combined experimental-MRI and finite element approach. J. Biomech. 40:1443–1454, 2007.
Loerakker, S., D. L. Bader, F. P. T. Baaijens, and C. W. J. Oomens. Which factors influence the ability of a computational model to predict the in vivo deformation behaviour of skeletal muscle. Comp. Meth. Biom. Biomed. Engng. 16(3):338–345, 2013.
Loerakker, S., E. Manders, G. J. Strijkers, K. Nicolay, F. P. T. Baaijens, D. L. Bader, and C. W. J. Oomens. The effects of deformation, ischemia, and reperfusion on the development of muscle damage during prolonged loading. J. Appl. Physiol. 111(4):1168–1177, 2011.
Mimura, M., T. Ohura, M. Takahashi, R. Kajiwara, and N. Ohura. Mechanism leading to the development of pressure ulcers based on shear force and pressures during a bed operation. Wound Repair and Regen. 17(6):789–796, 2009.
National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline. Washington DC: National Pressure Ulcer Advisroy Panel, 2009.
Oomens, C. W. J., W. Zenhorst, M. Broek, B. Hemmes, M. Poeze, P. R. G. Brink, and D. L. Bader. A numerical study to analyse the risk for pressure ulcer development on a spine board. Clin. Biomech. 28:736–742, 2013.
Peirce, S. M., T. C. Skalak, and G. T. Rodeheaver. Ischemia-reperfusion injury in chronic pressure ulcer formation: a skin model in the rat. Wound Repair Regen. 8:68–76, 2000.
Reddy, N. P., H. Patel, and T. A. Krouskop. Interstitial fluid flow as a factor in decubitus ulcer formation. J. Biomech. 14:879–881, 1981.
Reswick, J. B., and J. E. Rogers. Experience at Rancho Los Amigos Hospital with devices and techniques to prevent pressure sores. Bedsore Biomech. 1976:301–310, 1976.
Stekelenburg, A., D. Gawlitta, D. L. Bader, and C. W. J. Oomens. Deep tissue injury: how deep is our understanding? Arch. Phys. Med. Rehab. 89:1410–1413, 2008.
Stekelenburg, A., C. W. J. Oomens, G. J. Strijkers, L. A. H. J. de Graaf, D. L. Bader, and K. Nicolay. A new MR-compatible loading device to study in vivo muscle damage development in rats due to compressive loading. Med. Eng. Phys. 28:331–338, 2006.
Vandenburgh, H. H., P. Karlisch, and Farr L. Maintenance of highly contractile tissue-cultured avian skeletal myotubes in collagen gel. Vitro Cell. Dev. Biol. 24(3):166–174, 1988.
Author information
Authors and Affiliations
Corresponding author
Additional information
Associate Editor Amit Gefen oversaw the review of this article.
Rights and permissions
About this article
Cite this article
Oomens, C.W.J., Bader, D.L., Loerakker, S. et al. Pressure Induced Deep Tissue Injury Explained. Ann Biomed Eng 43, 297–305 (2015). https://doi.org/10.1007/s10439-014-1202-6
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10439-014-1202-6