On the Move pad – a portable multipurpose pad: User feedback

Abstract

Context/Objective

Hard-shell toilet seats may compromise safety and hinder the participation of individuals at risk for pressure injuries (PIs) when using these facilities away from home in public, hotel, or family/friend restrooms. Moreover, people often add “wash-cloths” for additional padding for comfort, and to reduce the risk of PIs due to pressure or shearing on their wheelchairs surfaces. This study investigated the utilization of portable pads, initially designed for toilet use but adaptable to various places and contexts, while examining pad usability.

Design

A cross-sectional descriptive survey design.

Setting

Inpatient care, outpatient care, and community setting.

Participants

45 individuals at risk of PIs.

Results

Participants extended the use of these pads beyond toilets, employing them as wheelchair armrest and leg rest pads in other settings. Feedback from a customized questionnaire indicated high levels of usefulness (8.5/10) and ease of use (9.1/10) attributed to the pads. Among the features, the top three favored were ease of use, comfort/cushioning, and function. Participants expressed a desire for a variety of sizes and colors to enable versatile usage and suggested incorporating a pocket for storing small items.

Conclusions and Relevance

Individuals at risk of PIs require cushioning not only on hard-shell toilet seats, but also for additional padding, protection and enhancing the use of wheelchairs. Rehabilitation professionals can play a crucial role in educating and training both clients and caregivers to understand PI prevention, enabling them to effectively leverage the pads in appropriate situations, thereby enhancing their comfort in their wheelchairs during social engagement.

Introduction

Sitting-acquired pressure injuries (PIs) are a medical complication among wheelchair users, including individuals with spinal cord injuries (SCI), multiple sclerosis, stroke, amyotrophic lateral sclerosis, etc. The prevalence of PIs in the U.S. general population is up to 17% (1). However, among wheelchair users, although this may vary across different groups of wheelchair users, it increases significantly to approximately 85% (2). PIs pose a significant health concern for wheelchair users as they not only reduce mobility and engagement in everyday activities but can also lead to amputation, septic infection, and death (3, 4).

The etiology of PI formation is multi-factorial with temperature, moisture, mechanical compression, and shear of the skin, muscle, and fat tissues against bony protuberances as contributing factors (5, 6). The time required for tissue damage to develop is inversely proportional to the applied external mechanical loads at the interface; there is minimal risk to develop a PI at a low capillary occlusive pressure (typically < 70 mmHg) but PIs can develop rapidly at higher applied pressures (7–11). The magnitude, direction, and duration of the applied external mechanical forces are critical parameters for controlling PI formation. Individuals with physical or neurological conditions may spend a significant amount of time sitting in wheelchairs and on other support surfaces. Sitting concentrates ∼50% of a person’s body weight onto only ∼8% of the body’s surface area which, with a long enough duration, can exceed the threshold of mechanical loading at which PI formation begins, particularly over the sacrum and ischial tuberosities (12). Compliant seat cushions made with foams, gel, and air cell arrays are widely used to reduce the magnitude of the peak interface pressure by increasing the contact surface area and providing immersion and envelopment of the seated person while using their wheelchair (13, 14).

However, PIs often occur when seated on other surfaces such as a hard-shell toilet seat. When seated on a hard-shell toilet seat or an unpadded commode chair less than 4% of the body surface must support 50% of the body mass, which greatly increases PI risk. Current clinical strategies emphasize reducing the duration and magnitude of external mechanical loads through frequent repositioning and the use of pressure-distributing seating supports. However, the risk of PIs remains elevated in individuals with SCI, particularly for those who are unable to efficiently perform independent pressure relief and those who may require an extended time (15–90 minutes) for voiding due to their health condition. It is estimated that only 13.9% of individuals at risk receive sufficient and adequate repositioning assistance, primarily due to the caregiving workload (15).

Toilet or commode chair seat covers designed to assist individuals at risk of developing PIs come in three fundamental styles: air-filled, gel-filled, and foam cushions. They can be beneficial in individuals’ own homes, but all of them have several notable shortcomings when it comes to traveling, visiting friends, or using public facilities: (1) Difficult installation  – The seat covers are secured by two or more straps that snap on either side, or they can be attached using double-stick foam tape or glue. Attaching the straps sometimes requires good hand dexterity to snap them into place. The double-stick foam tape or glue often leaves a residue that needs to be cleaned, rendering the seat unsuitable for the next person. (2) Cleaning Challenges  – To maintain proper personal hygiene, the seat cover should be machine washable. However, many air-filled seat covers are not machine washable, and seat covers that are attached using double-stick foam tape or glue cannot be frequently washed. (3) Lack of compactness and lightweight  – Seat covers need to be portable for use on toilets other than the one at home. However, gel-filled and foam seat covers are large, which makes them not easily portable in a discreet manner within a backpack or carrying case. (4) Incompatibility  – Depending on the type of toilet seat (e.g. oval, or round), the carried seat cover may not fit properly on the toilet. If a seat cover doesn’t match the toilet seat is forcibly used, pressure may concentrate in one area of the buttocks, potentially leading to a fall. This is of great concern for individuals at risk for pressure injuries (PIs) having to use public, hotel, or family/friend bathroom facilities away from home; as they often have no other option, but to use them at their own risk. The concerns of not being able to use the toilet safely still limit people with SCI at risk for PIs from participating in the community and accessing travel and leisure destinations, even 30 years after the passage of the Americans with Disabilities Act (ADA).

The “On the Move” portable pad was developed to alleviate the toilet use-related discomfort and pressure loading for individuals at risk of PIs and to broaden and ensure genuine access to travel, school/employment, and leisure destinations. The “On the Move” portable pad is an innovative product that has been granted two patents (16, 17). It is cost-effective (expected price around $25 or less), portable (no adhesives used for attachment, reusable without leaving marks or causing toilet damage), compact and lightweight (easily carried in a purse, bag, or small backpack, weighing less than a pound), ergonomic (simple installation and removal, doesn't require strong hand dexterity, adjustable to users’ needs/preferences), and machine washable (ensuring good personal hygiene maintenance). The objective of this study was to assess the usability of the “On the Move” pad and gather user feedback to possibly enhance the device and identify potential applications. In addition, this study investigated the general use of pads beyond their inherent application for toileting activities.

Methods

Study design and participants

This study used a cross-sectional descriptive survey design. The inclusion criteria for study participants were individuals aged 18 and older, who experienced mobility difficulties and expressed willingness to participate in the study. The exclusion criterion was individuals with current PIs. Study participants were recruited through the [Masked for Review] registry and at national and local events for people with disabilities. The study was approved by the [Masked for Review] Institutional Review Board (IRB; STUDY21060091).

On the Move pad

The “On the Move” pad is an ergonomically designed modular portable cushion for use with toilets and similar surfaces in direct contact with body structures. The pad was initially designed to meet the need for a functional, travel-friendly toilet cushion. A schematic drawing and photos are displayed in Fig. 1. The main features of the pad include: the pad fits nearly every surface including toilet seat without the use of adhesives. Uses a non-slip surface of nanomaterial to stick to the toilet seat without creating a residue or leaving marks. Fits both toilet seats with an open front and complete round or oval designs. Can fit both adult and pediatric-sized toilets. Furthermore, flexible structure (e.g. neoprene) with hook-and-loop fastening allows the pad to conform and securely attach to a wide variety of surfaces including toilet seats, and wheelchair frames, armrests, and thigh supports. The design requires little hand dexterity or function to install and secure.

Figure 1.

(A) Schematics and (B) photographs showcasing key features of On the Move pad.

Pocket and pad design allows the cushioning to be easily removed to make the entire system machine or hand washable to encourage good hygiene. It also can be easily cleaned with sanitary wipes or a similar approach. The pocket is made of a low-friction material (e.g. micro-fiber nylon) to provide a highly flexible seating surface to comply with the user’s body and to provide low friction to minimize shearing at the body surface and within the body tissue. Pocket size can be selected to accommodate individuals who desire or require thicker padding for greater immersion. In addition, the pad is compact (4 in wide x 7 in long when folded together, the height (>1 in) depends on the thickness of the pads), and lightweight (i.e. weighs about ¼ of a pound). It is easily stored in a plastic bag (e.g. Ziploc bag) to be discreetly placed in a purse, small bag, or small backpack between uses. Moreover, the pad can be manufactured and sold at low cost (likely priced around $25 or less) to be available to a wide variety of people who need it.

Protocol

We collected data from participants expressing interest in the pad from September 2021 to August 2023. Each participant was provided with a set of pads and a concise introduction in-person, outlining its features and potential applications. Hands-on demonstrations were also provided for toilet use and various other applications.

To obtain feedback, we provided a REDCap link for participants to use after trying out the pad. We encouraged participants to explore alternative application options during usage at home and in their community, and to share pictures showcasing these alternative application options. While we encouraged participants to provide feedback after a week or longer of use, some shared their feedback within a week.

Measures

We utilized a customized self-reported questionnaire developed for this study. The questionnaire consisted of 12, 7 questions regarding the “On the Move” pad, and 5 questions for participants’ demographics. The “On the Move” pad questions were: (1) “How did you use the “On the Move” pad?” Participants were asked to respond using the options as follows, (a) Toilet seat pad, (b) Wheelchair armrest pad, (c) Wheelchair leg rest pad, (d) Shin guard, (e) Forearm guard, (f) Shoulder strap pad, and (g) Other, please specify. (2) “On a scale of 0 to 10, how useful did you find the “On the Move” pad?” Participants were asked to rate from 0 as extremely useless to 10 as extremely useful. (3) “On a scale of 0 to 10, how easy was the “On the Move” pad to use?” Participants were asked to rate from 0 as not easy at all to 10 as extremely easy. (4) “Please rank the following features (size, weight, adjustability, ease of use, comfort/cushioning, function, versatility, and ability to wash/launder) of the “On the Move” pad, and please tell us why you selected your number one feature.” Participants were asked to rank the features from 1 (liked best) to 8 (liked least) and provide the reason. (5) “Is there any other feature not mentioned that you liked about the pad?” and (6) “If anything, what would you like to see changed?” were open-ended questions, and participants were asked to provide their own responses. (7) “Would you use this product if it were available?” Participants were asked to response yes or no. Demographic questions included age, gender, race/ethnicity, diagnosis, and type of mobility device they are currently use. This self-administrated questionnaire took 5–10 minutes to complete.

Statistical analysis

Participants who skipped answers to questions, except for questions number 5 and 6, were excluded from the analysis. Descriptive statistics were used to analyze “On the Move” pad-related questions and demographics. The rankings of the features of the “On the Move” pad were determined by calculating the average of the sum of rankings assigned to each feature by participants. The feature with the lowest average score indicates the most favored, whereas the feature with the highest average score indicates the lowest ranked.

Results

A total of 61 responses were collected, after excluding 16 responses with missing data, 45 responses were analyzed. The demographic characteristics of the study participants are presented in Table 1. The mean age of the participants was 53.0 ± 14.4 years (range 27–81 years; n = 44). Most participants reported they were in their 50s or 60s (53.3%), male (91.1%), White or Caucasian (55.6%), have spinal cord injury/disorder (75.7%), and use a manual wheelchair for mobility (40.2%).

Table 1.

Demographic characteristics (n = 45).

	Number	Percentage
Age
18–29	4	8.9
30–39	6	13.4
40–49	5	11.1
50–59	11	24.4
60–69	13	28.9
70–79	4	8.9
80+	1	2.2
Prefer not to answer	1	2.2
Gender
Male	41	91.1
Female	3	6.7
Prefer not to answer	1	2.2
Race/Ethnicity
Black or African American	11	24.4
Asian	0	0
White or Caucasian	25	55.6
Hispanic or Latino	5	11.1
American Indian or Alaskan native	0	0
Native Hawaiian or other pacific islander	0	0
Two or more races	3	6.7
Prefer not to answer	1	2.2
Diagnosis
Spinal cord injury/disorder	34	75.7
Multiple sclerosis	2	4.4
Musculoskeletal disorder	2	4.4
Lower extremity amputation	1	2.2
Neurological disorder	1	2.2
Prefer not to answer	5	11.1
Mobility device (select all that apply; n = 77)
Cane	4	5.2
Quad cane	1	1.3
Crutches	3	3.9
Walker	7	9.1
Wheeled walker	7	9.1
Manual wheelchair	31	40.2
Powered wheelchair	15	19.5
Scooter	5	6.5
Other	2	2.6
Prefer not to answer	2	2.6

Table 2 presents the findings about how participants utilized the pads. Around 20% of the participants indicated using the pads as toilet seat pads, yet a considerable number also used the pads for functions beyond just toilet use. Over 30% of the participants affixed the pads to their wheelchair leg rests or the wheelchair frame to alleviate pressure on their leg caused by contact with the wheelchair leg rests or frame. Approximately 20% of the participants applied the pads to the armrests of their wheelchairs, employing them as supplementary elbow support to distribute weight and lower surface friction. Examples of various utilizations of the pad are shown in Fig. 2.

Table 2.

How did you use the On the Move pad? (Select all that apply; n = 81).

	Number	Percentage
Toilet seat pad	16	19.8
Wheelchair armrest pad	16	19.8
Wheelchair leg rest pad	25	30.8
Shin guard	5	6.2
Forearm guard	6	7.4
Shoulder strap pad	2	2.4
Other	11	13.6
Handcycle/arm ergometer	3
Lumber support	1	–
Wheelchair under-thigh pad	1	–
Padding for chest strap	1	–

Figure 2.

Examples of various utilizations of the On the Move pad. (A) Toilet seat cover, (B) wheelchair leg frame, (C) Shin guard for foot strap, (D) Headrest for handcycle, (E) Thigh support, (F) Wheelchair armrest, (G) Console cushion assists in transferring between the front passenger's and the driver's seat.

The scores for usefulness and ease were 8.5 ± 1.7 and 9.1 ± 1.4, respectively. Regarding the features of the pad, the three best favored features were ease of use, comfort/cushioning, and function, while the three least favored features were size, weight, and ability to wash/launder (although the pad is machine washable), see Fig. 3. Versatility was ranked fifth, yet numerous participants highlighted versatility as the reason behind their most favored feature, other than versatility itself. Examples of participant responses include statements such as “Because it is easy to use, I use it for multiple places” in relation to the ease-of-use feature, and “it works well for several tasks” concerning the function feature.

Figure 3.

Features of On the Move pad, ranked from best (lowest score) to least (highest score) favored.

A desirable feature reported was for the material of the pad. The material in contact with the skin has low skin adherence and could mitigate injuries caused by shear forces. Participants reported size (n = 16), pocket (n = 4), and color (n = 3) as features they would like to see changed. Participants expressed a desire for a greater variety of sizes and colors to be available. Additionally, they preferred the addition of a pocket to store credit/debit/identification cards, cell phones, or other small items. Approximately 93 percent of the participants (n = 42) expressed a desire to purchase the pad if it were available.

Discussion

This study investigated the utilization of the “On the Move” pad in various places and contexts, assessed its usability, and explored potential avenues for improvement based on feedback from the pad users. An intriguing finding was that the participants in our study wanted to use the pads in many different situations and contexts. This indicates rationale that it could be helpful in a clinical context. The “On the Move” pad could make wheelchairs more comfortable for wheelchair users. Many wheelchair users find wheelchairs uncomfortable and sometimes even painful (18, 19). For instance, shearing and increased pressure of lower extremities into wheelchair frame, causing skin breakdown or abrasion and sometimes sores in serious cases. Also, increased weight bearing onto bony prominence leading to pain in the elbows and shoulders. These discomfort issues could be alleviated by placing the “On the Move” pads in multiple areas on the wheelchair. Our findings revealed second most favored feature was that participants wanted pads of different sizes and colors, which may indicate a desire to use these pads for extra cushioning in different areas on their wheelchairs and with other devices.

Another aspect to consider is that pad users may not require an additional bag or storage space to transport these pads when using public restrooms. Once users become accustomed to using these pads in various situations, they could conveniently carry them and apply them for diverse purposes, including use in public restrooms when needed. Additionally, the pads are designed to be washable, allowing users to wash them immediately if necessary after public use, thereby reducing the risk of contamination.

Usefulness and ease of use received high scores from the participants. This high score also appears in the findings regarding the favored features of the pad. Ease of use was reported as the most favored feature. Although this pad may pose challenges for those who have difficulty using hook-and-loop, when compared to other devices, individuals with limited hand function demonstrated ability to install and remove the pads easily and intuitively. Furthermore, the ease of use allows users to utilize the pads for different purposes as needed. Comfort and cushioning, and functionality were ranked second and third among the favored features. This suggests that the pads may effectively mitigate PIs by providing additional cushioning for their intended purpose.

Size, weight, and ability to wash/launder were ranked as the least favored features. However, there was no distinct underperformer, and the scores were not significantly different from those of the other features (ranging from 0.9 to 2.7 in the 1–8 scoring system). This may suggest that these three features were rated as less favored, not due to any flaws or issues, but rather because the three most favored features were relatively more preferred. This hypothesis is supported by the fact that none reported that the performance of any three features was poor.

This study poses clinical implications for healthcare providers. Rehabilitation professionals, including occupational therapists, physical therapists, and nurses, are responsible for ensuring that their clients are using their mobility devices in a comfortable manner. Approximately 93% of study participants expressed an interest in purchasing this product if it were available. This response indicates that many wheelchair users may not be sufficiently comfortable in their current wheelchair, and they may recognize the potential benefits of these versatile pads. Therefore, rehabilitation professionals should address the discomfort and needs of their clients using mobility devices. If discomfort is present, it is essential to leverage the therapist's expertise to provide adequate cushioning to the appropriate location of the client's mobility device. Rehabilitation professionals can assist clients in customizing pads to suit their needs and provide training and education to both clients and caregivers, ensuring effective use of the pads.

Several recommendations for future studies are proposed. First, to enhance the generalizability of findings, it is advisable to include a more diverse participant group, considering factors such as age, gender, ethnicity, and types of mobility limitations. Furthermore, in addition to the usability features highlighted in this study, evaluating the durability and sustained usability of the pads from a long-term perspective would contribute depth to the research. Lastly, this study primarily focuses on assessing pad usability. To strengthen the evidence, it is recommended to conduct a comparative analysis, including factors such as usability, cost-effectiveness, and effectiveness in preventing PIs, with other existing solutions.

Conclusion

The study found that once research participants were introduced to the versatility of the “On the Move” pad for extra cushion to enhance comfort, reduce pain and risk for skin break down; the applications exceeded the original intended use of hard-shell toilet seat pad. With its user-friendly design, effective cushioning, and practical attributes, its versatility and adaptability extend to various uses and contexts. Rehabilitation professionals would need to train and educate both clients and caregivers to optimize the utility of the pads in suitable contexts. This effort will contribute to enhancing clients’ health outcomes and fostering increased social engagement and overall contribute to their quality of life.

Funding Statement

This research was funded by Paralyzed Veterans of America; Rehabilitation Research and Development Center, US Department of Veterans Affairs (Grant #: B2988C); and Technology Transfer Assistance Program, US Department of Veterans Affairs.

Disclaimer statements

Disclosure statement Cooper’s are inventors on the above noted patents.

Author contributions All authors significantly contributed to the manuscript.

Data availability statement Data available on request from the authors.