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. 2019 Jul 12;16(5):1080–1086. doi: 10.1111/iwj.13142

An observational study of the maintenance of the 30° side‐lying lateral tilt position among aged care residents at risk of developing pressure injuries when using the standard care pillow and a purpose‐designed positioning device

Suzanne Kapp 1,✉, Marie Gerdtz 1, Amit Gefen 2, Roshani Prematunga 1,3, Nick Santamaria 1
PMCID: PMC7949259  PMID: 31298490

Abstract

The aim of the study was to evaluate the maintenance of the 30° side‐lying lateral tilt position among aged care residents at the risk of developing pressure injuries when using the standard care pillow and a purpose‐designed positioning device. An observational study was conducted. Participants were monitored during positioning under two conditions, with pillows and with a fluidised positioner. Body angle measurements were taken at three time points (baseline, 1 hour, and 2 hours) on 10 occasions. Repeated‐measures analysis assessed the difference in the degree of the angle of the body. The sample (n = 12) had an average age of 83 years, and the participants were immobile when in bed. The average angle with the pillow condition was 26.7° at baseline, 21.5° at 1 hour, and 16.6° at 2 hours. The average angle with the fluidised positioner condition was 30.7° at baseline, 29.3° at 1 hour, and 26.8° at 2 hours. The main effects of Condition and Time were significant: Condition: F(1,11) = 14.378, P < .001, Time: F(2,22) = 45.858, P < .001. There was a statistically significant interaction between the effects of Condition and Time on the average lateral tilt position, F(2,22) = 15.574, P < .001. The lateral tilt body position was better maintained with the positioning device than the pillow. Further research is required to determine the effectiveness of the fluidised positioner for pressure injury prevention.

Keywords: aged care, fluidised positioner, patient positioning, pressure injury prevention, pressure ulcer

1. INTRODUCTION

Facility‐acquired pressure injuries (also known as pressure ulcers) affect patients in the acute, community, and residential aged care settings.1 Many aged care residents are at risk of developing pressure injuries as factors associated with their development, such as reduced mobility, peripheral neuropathy, cognitive impairment and incontinence,1 and stiffening of the tissues associated with ageing or diabetes,2 are common among this group. The prevalence of pressure injuries in residential aged care facilities (which are also known as nursing homes or long‐stay homes) is 12% in Australia,3 and prevalence is also high internationally.4, 5 Pressure injuries cause pain, inconvenience, social difficulties, infection leading to sepsis or osteomyelitis, renal failure, and a resulting increased risk of death.1 The cost of this condition in the residential aged care setting is US$13.95 million6 per annum in Australia.

Positioning patients is an essential intervention to minimise the risk of pressure injuries.1 Positioning refers to placing and supporting the patient to stay in a resting position7 and is usually undertaken with devices that can help to position the patient reliably, securely, safely, and comfortably.1 The goal of positioning is to redistribute pressure and shear forces and stresses, and the resulting skin and internal tissue deformations, to different anatomical sites. When conducted effectively, that is, when the desired body position is supported and maintained over time, the pressure and shear experienced in a vulnerable area of the body can be adequately redistributed, and irreversible tissue damage can be prevented.8 Body positioning is particularity important for patients who cannot position themselves independently or effectively, such as immobile aged care residents, ventilated individuals, or those connected to cardiac and other monitoring equipment.

Positioning in a 30° lateral tilt position in bed, which can redistribute pressure and shear away from the sacral area, is an effective strategy to prevent pressure injuries in this anatomical location.1, 9 Pillows are typically placed along the resident's back to support this position; however, pillows do not maintain shape and flatten under the bodyweight forces, a phenomenon demonstrated in research conducted by Powers.10 This flattening of the pillow, or an alternative situation where the pillow slides away from the original position, can lead to a reduction of the angle of the lateral tilt position and movement of the posterior aspect of the body backward towards the bed's surface.7 When this occurs, the result can be an increased risk of the body sustaining pressure and shear to an area that may not yet have been adequately relived. This in turn may lead to pressure injury development.

Devices that are purpose designed for patient positioning may offer advancements on the usual care pillow, which was not designed for patient positioning or pressure injury risk management. The fluidised positioner (Z‐Flo, Mölnlycke Health Care, Gothenburg, Sweden) is a purpose‐designed device that conforms to and supports the body during positioning. Computational modelling conducted by Katzengold and Gefen11 has shown that the fluidised positioner provides good immersion and envelopment. Later work specifically demonstrated that the material contents of the device adequately conforms to the contours of the body, which effectively distributes pressures and shear, and that the contents of the device relaxes under bodyweight forces, thereby providing potentially protective and therapeutic properties.

Previous research on the use of fluidised positioners in patients is scant. One study evaluated the inclusion of the fluidised positioner in a model of pressure injury prevention care in an intensive care unit in the United States12 and reported that the device was effective for redistributing pressure (measured method was not described) and also reported a reduction in the incidence of pressure injuries from 65% in the previous year to 20% in the year following the practice change. Another study was conducted with intensive care unit patients and provided staff perspectives on the potential effectiveness of the positioner for pressure injury prevention.13 Staff (n = not stated) reported that the device did not move from position once moulded for purpose, that patients appeared comfortable when the device was in use, and that use of the device resulted in the resolution of moisture issues associated with the previously used foam device. A 45% reduction in hospital‐acquired pressure injuries was reported during the 12 months following the introduction of the fluidised positioner.13 More recently, a study conducted in Australia compared intensive care unit patients (n = 64) who received the fluidised positioner for occipital pressure management with a historical control (n = 63) and reported the incidence of occiput pressure injuries and the feasibility of device use according to nurses (n = 65).14 The incidence of pressure injuries in the intervention group was 3% compared with 25% in the historical control group, and the majority of the bedside nurses reported that the device shapes and moulds well and is easy to use and clean. These previous evaluations indicate that the fluidised positioner is safe, acceptable, and may be helpful for positioning patients.

Purpose‐designed positioning devices are recognised as an emerging therapy for pressure injury prevention;15 however, it is imperative that any device used for body positioning effectively supports the body, specifically that it assists to keep the body in the desired position, until the next scheduled position change. This is particularly the case when a side‐lying lateral tilt position is required for the prevention of sacral pressure injuries among aged care residents. Current evidence suggests that two interventions, the 30° lateral tilt position9 and turning schedules,16 can prevent pressure injuries; however, neither intervention can be optimally effective if the patient's position is not maintained between scheduled position changes. This co‐dependency has been largely overlooked in the pressure injury prevention research that has been conducted to date.

1.1. Study aim

The aim of the study was to evaluate the maintenance of the 30° side‐lying lateral tilt position among aged care residents at risk of developing pressure injuries when using the standard care pillow and a purpose‐designed positioning device.

2. METHOD

2.1. Design

An observational study was conducted.

2.2. Population and setting

The study population included older people who experienced reduced mobility, frailty, cognitive deficit, and were at a high risk of pressure injury development. The population typically required a high level of assistance with activities of daily living, for example, mobilising, continence, and hygiene. The study setting was a 64‐bed residential aged care facility (also known as a long‐term care home or a nursing home) situated in a regional area in the State of Victoria, Australia. The staff mix in the setting included registered nurses, enrolled nurses, and personal care attendants (health workers) who worked under the supervision of senior nursing staff.

2.3. Site preparation

Residents of the facility, and their significant others, were invited to a 30‐minute study information session 2 weeks prior to the study commencing. Use of the fluidised positioner was demonstrated, and data collection and study outcomes were explained. A 60‐minute training session was then conducted with 15 staff members (registered nurses, enrolled nurses, and personal care workers) and focused on the function and use of the fluidised positioner. A further 25 staff members participated in one‐on‐one training (with the researcher and study participants) at the bedside prior to providing care to study participants.

2.4. Eligibility

Residents were eligible to participate in the study if they:

  • Were aged ≥18 years of age.

  • Were at high risk of pressure injury development according to the Braden Scale for Predicting Pressure Sore Risk.17

  • Required the assistance of nurses and/or personal care workers to position their body in bed.

2.5. Sample

A purposive, convenience sample of 12 participants was sought for the study. Pragmatic factors influenced the sample size, specifically the available funding and time constraints.

2.6. Screening and recruitment

Screening and recruitment were conducted independent of the research team. Senior nursing staff at the participating site screened all residents for eligibility, and if a resident met the eligibility criteria, an information sheet and consent form was posted to each eligible resident or the person responsible for consenting for the resident if they were unable to consent for themselves. Consent forms were returned to the university or handed to senior nursing staff at the facility.

2.7. Usual care

The usual care intervention was the use of a standard pillow that is used for all pillow‐related purposes (eg, under the head for comfort, against the body for positioning, and under the heels for elevation of the feet) in the participating facility. Other devices, such as foam wedges, were not used for positioning in the participating facility. The pillows that were in use during the study were typically not labelled; however, the “Sleepmaster Cura+tic medical pillow” (Jason Commercial) was identified as the pillow that was purchased when replacement pillows were required. Pillows used in the study setting are designated “single patient use” and are covered with a pillow case.

2.8. Interventional care

The interventional device was the Mölnlycke “fluidised positioner” Mölnlycke Health Care AB. Sweden, https://www.molnlycke.us/products-solutions/molnlycke-z-flo-fluidised-positioner/. The fluidised positioner is comprised of a polyurethane bag that contains polydimethylsiloxane (a viscous fluid mix). The fluidised positioner can be moulded by hand to the shape required for each specific use and can therefore contour to the individual's body shape. The positioner maintains the shape to which it is moulded and does not flatten over time, thereby supporting the patient to maintain the desired body position over time. The positioner can subsequently be remoulded to the shape required for the next position change. It can be used with specialised beds and mattresses, and the device is approved for use in Australia (Therapeutic Goods Administration ARTG 282967) for patient‐positioning purposes. It is “single patient use”, is covered by linen such as a pillow case, and is cleaned by wiping with non‐alcohol‐based cleaning wipes that are routinely available in health care facilities.

2.9. Data collection

Data collection occurred over a 3‐week period. Body angle measurements of each participant were taken at three time points (baseline, 1 hour, and 2 hours) on 10 occasions over five consecutive days. The first five occasions of data collection occurred while the participant used the pillow, and the second five occasions of data collection occurred while the participant was using the fluidised positioner. Each occasion of observation included a baseline measurement of the body angle (taken immediately following the placement of the participant in the side‐lying lateral tilt position) and two subsequent measures that occurred 1 hour and then 2 hours from the baseline measure. Baseline data collection coincided with the times that the participant was usually repositioned, and the majority of the data was collected between 8:00 pm and 12:00 am.

The angle of the participant's body was measured with an iPhone digital gravity inclinometer application, which was placed consistently on the suprasternal notch. The use of this method was informed by the process utilised in previous research and personal correspondence with the investigator10 and by evidence of an acceptable level of reliability and validity of the iPhone digital gravity inclinometer application when compared with usual measurement devices used for related purposes in health care.18, 19, 20

Members of the research team piloted and refined the measurement process with three healthy volunteers in a laboratory prior to commencing the study. This involved confirming the process for identifying the suprasternal notch and the placement of the measurement device. During the study, the suprasternal notch of each participant and the placement of the iPhone were identified and agreed on by the PI and the research nurse following recruitment of each participant. The pressure injury (PI), observed by the research nurse, completed all the body angle measurements during the study.

2.10. Outcome

The outcome of interest in this study was the change in the angle of the participant's body when in the 30° side‐lying lateral tilt position. Participant characteristics were collected to describe the sample, including age, gender, presence of skin wounds, and the frequency of positioning. Pressure risk was assessed using the Braden Scale.17

2.11. Analysis

All study data were entered into SPSS (IBM SPSS Statistics for Mac, Version 22.0, IBM Corp, Armonk, New York) for analysis. Descriptive statistics was used to describe the sample. Repeated‐measures analysis (two‐way repeated‐measures analysis of variance [ANOVA]) with Time and Condition as within‐subject effects was used to assess the difference in the degree of the angle of the body (therefore, the maintenance of the side‐lying lateral tilt position) for the pillow and the fluidised positioner conditions. An average score was computed for each of the three time points (baseline, 1 hour from baseline, and 2 hours from baseline) from the 10 occasions for both the pillow condition (five occasions) and the fluidised positioner condition (five occasions).

2.12. Ethics and funding

The study was approved by the Human Research Ethics Committee of Northeast Health in Wangaratta, Victoria Australia. Funding for the project was provided by Gandel Philanthropy. Mölnlycke Health care AB, Göteborg Sweden provided the devices free of charge for use in the study.

3. RESULTS

Participant recruitment and data collection was carried out during May and June 2018. At the commencement of the study, there were 64 individuals in residence at the aged care facility. Nearly half of these residents (n = 31) were mobile and/or not at high risk of pressure injury development. Of the remaining 33 residents, 20 required the assistance of nurses and/or personal care workers to position their body in bed, and 15 proceeded to participate in the study (n = 3 provided their own consent, and n = 12 were consented for by a “person responsible”). The three participants who had consented for themselves subsequently reported that they did not intend to lie in the side‐lying lateral tilt position when in bed, and therefore, in these cases, the data required for the analysis were not able to be obtained. No participants withdrew from the study.

The sample included in the analysis (n = 12) was predominately female (n = 8, 66%) and had an average age of 83 years (min. 74 years, max. 97 years). All participants scored 12 or less on the Braden Scale and were therefore screened as being at high risk of pressure injury development. None of the participants had pressure injuries or other skin wounds. All participants required full assistance to position themselves in bed (were immobile in bed) and had a nursing care plan for managing pressure risk, which included an overnight positioning schedule.

A two‐way repeated‐measures ANOVA was conducted that examined the effect of the Condition (pillow and fluidised positioner) and Time (baseline, 1 hour later, 2 hours later) on the average lateral tilt position. There was a statistically significant interaction between the effects of Condition and Time on the average lateral tilt position, F(2,22) = 15.574, P < .001.

Simple main effects analysis showed that the average lateral tilt position was not different between the pillow condition and the fluidised positioner condition at baseline (P = .064). The average lateral tilt position was 29.3 for the fluidised positioner and 21.5 for the pillow when measured 1 hour later (P = .003). The average lateral tilt position was 26.8 for the fluidised positioner and 16.6 for the pillow when measured 2 hours later (P = .001) (Figure 1).

Figure 1.

Figure 1

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Time points between the conditions (control and treatment)

Simple main effects analysis showed that the average lateral tilt position was different for the pillow between the different time points (P < .001). For the pillow condition, baseline average lateral tilt position was 26.7, 1 hour later was 21.5, and 2 hours later was 16.6 (Figure 2).

Figure 2.

Figure 2

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Control condition and treatment condition between each time point

Simple main effects analysis showed that, for the fluidised positioner, the average lateral tilt position at baseline was 30.7 and 2 hours later was 26.8 (P = .007), while the average lateral tilt position 1 hour later was 29.3 and 2 hours later was 26.8 (P = .022). However, the average lateral tilt position was not different between the values at baseline and 1 hour later for the fluidised positioner (Figure 2).

4. DISCUSSION

Facility‐acquired pressure injuries are a serious, life‐endangering health concern, and despite advancements in prevention and care, they continue to occur at an unacceptable rate in all care settings and particularly in residential aged care.3 Positioning when in bed is an essential intervention for pressure injury prevention,1 and devices that interact safely with the body and optimise the effectiveness of positioning have the potential to improve the care provided to patients, prevent pressure injuries, and reduce the cost of this condition to individuals and society.

The aim of the study was to evaluate the maintenance of the 30° side‐lying lateral tilt position among aged care residents at risk of developing pressure injuries when using the standard care pillow and a purpose‐designed positioning device. This aim was achieved with preliminary findings on the outcome of interest established. Our study found that the difference in the measurements between the pillow and fluidised positioner conditions became larger as time increased and that the difference was smaller for the fluidised positioner condition compared with the pillow condition between the three time points, findings that were statistically significant. The use of the purpose‐designed fluidised positioner therefore was associated with better maintenance of the side‐lying body position when compared with use of the pillow.

Our results are complementary to the positive findings of the computational modelling of pressure and positioning with the fluidised positioner reported by Katzengold and Gefen,11 which suggested that the fluidised positioner provides immersion and envelopment characteristics and that the contents of the device relaxes under bodyweight, providing protective and therapeutic properties. Our results also align with the findings of Powers,10 who identified that a purpose‐designed multicomponent positioning system better maintained body angle when compared with usual care pillows at 1 hour post‐positioning. Our study differs by the type of intervention device and reports the body angle at 2 hours following positioning providing evidence that reflects a real‐world time frame as this more closely corresponds to recommended turning schedules among care recipients at a high pressure risk.1 Our research did not consider the role of foam wedges for positioning as these devices are not used for lateral positioning in this setting and have been reported to be associated with excessive heat, moisture, and skin irritation.13 It is noted, however, that foam wedges may be used for a range of positioning purposes and that maintenance of the side‐lying body position, or other positions when using this type of device, is unknown.

Any positioner for pressure injury prevention should be biomechanically safe and effective in transferring the bodyweight forces without causing concentrated mechanical loads in tissues at or near the body‐support contact sites. As an example, for a positioner that is in frequent use but does not provide a safe interaction with the body tissues, consider the donut‐shaped head positioner. These head positioners are typically made of gel or foam and are aimed to off‐load the occiput in a supine position, which inflicts concentrated compression and shear tissue stresses at the perimeter of the off‐loading site.21 In contrast, a good positioner for either general use or a specific body part should have structure and material components that allow it to intimately conform to the body contours and, hence, deliver the bodyweight forces as uniformly as possible over the contact sites. Likewise, a good positioner should have viscoelastic properties so that body‐device contact forces would relax after the positioning manoeuvres.11 Biomechanical work indicates that, in addition to a sustainable body position, the positioner studied here has the capacity to very closely conform to the body surfaces, that is, it provides good envelopment, as well as effective stress relaxation in the soft tissues.11

4.1. Strengths and limitations

The study generated preliminary evidence of the maintenance of the 30° side‐lying lateral tilt position when using the standard care pillow compared with a purpose‐designed positioning device among aged care residents at risk of developing pressure injuries. Given that the maintenance of body position is essential for positioning to be effective, the study provides some justification for investment in more controlled research that considers the role of devices for pressure injury prevention. The evaluation was conducted in a real‐world situation, which is essential for research to be clinically applicable and meaningful, and the evaluation represents a judicious use of the time of participants, the participating sites time, and the study funding. Limitations of the study include the small, convenient, and non‐randomised sample and the short‐term follow‐up period. The findings should be interpreted with caution given that the data collection was attended by one individual and the associated risk of bias.

4.2. Recommendations

The findings of the study provide some justification for the choice of the fluidised positioner in future research that seeks to prevent pressure injuries among high‐risk aged care residents. Future research should also examine the temperature and microclimate properties induced by pillows compared with the fluidised positioner in aged care patients given that these properties are generally unknown, although it has been suggested that the propensity of pillows is to retain heat and promote sweating and moisture.22 Infection control outcomes are also of interest given that the fluidised positioner appears easy to clean, and hospital pillows are reported to be difficult to clean and disinfect and are therefore regarded as a known reservoir for microorganisms.23, 24

5. CONCLUSION

This evaluation study found that the purpose‐designed fluidised positioner was associated with better maintenance of the side‐lying body position when compared with positioning using pillows. This study has highlighted the potential contribution of the fluidised positioner to achieving the intended goal of turning and positioning, that is, optimally maintaining the patients position between position changes.

ACKNOWLEDGEMENTS

The authors acknowledge the support and contribution from the study participants and those who consented on their behalf, the staff, and management at Illoura Aged Care in Wangaratta, Victoria Australia; Mrs Fional Kendall the research nurse; and Dr Sandy Clarke from the Statistical Consulting Centre at The University of Melbourne. They sincerely thank Gandel Philanthropy for funding the study and its commitment to supporting initiatives that seek to prevent pain and suffering and make a positive and lasting difference in the lives of vulnerable older people. Funding for the project was provided by Gandel Philanthropy. Mölnlycke Healthcare AB, Göteborg Sweden provided the devices free of charge for use in the study.

Kapp S, Gerdtz M, Gefen A, Prematunga R, Santamaria N. An observational study of the maintenance of the 30° side‐lying lateral tilt position among aged care residents at risk of developing pressure injuries when using the standard care pillow and a purpose‐designed positioning device. Int Wound J. 2019;16:1080–1086. 10.1111/iwj.13142

Funding information Gandel Philanthropy, Grant/Award Number: NA

REFERENCES

  • 1. National Pressure Ulcer Advisory Panel , European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance . Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Osborne Park, Australia: Cambridge Media; 2014. [Google Scholar]
  • 2. Gefen A, Gefen N, Linder‐Ganz E, Margulies S. In vivo muscle stiffening under bone compression promotes deep pressure sores. J Biomech Eng. 2005;127(3):512‐524. [DOI] [PubMed] [Google Scholar]
  • 3. Graves N, Zheng H. The prevalence and incidence of chronic wounds: a literature review. Wound Pract Res. 2014;22(1):4‐19. [Google Scholar]
  • 4. Capon A, Pavoni N, Mastromattei A, Di Lallo D. Pressure ulcer risk in long‐term units: prevalence and associated factors. J Adv Nurs. 2007;58(3):263‐272. [DOI] [PubMed] [Google Scholar]
  • 5. Moore Z, Cowman S. Pressure ulcer prevalence and prevention practices in care of the older person in the Republic of Ireland. J Clin Nurs. 2012;21(3/4):362‐371. [DOI] [PubMed] [Google Scholar]
  • 6. Graves N, Zheng H. Modelling the direct health care costs of chronic wounds in Australia. Wound Pract Res. 2014;22(1):20‐33. [Google Scholar]
  • 7.Positioining Techniques in Long‐term Care. Self‐Directed Learning Package for Healthcare Providers; 2007. https://rnao.ca/bpg/guidelines/resources/positioning-techniques-longterm-careselfdirected-learning-package-health-ca. Accessed December 6, 2018.
  • 8. Wounds International . Pressure Ulcer Prevention. Pressure, Shear, Friction and Microclimate in Context. UK: Wounds International; 2010. [Google Scholar]
  • 9. Moore Z, Cowman S, Conroy R. A randomised controlled clinical trial of repositioning, using the 30° tilt, for the prevention of pressure ulcers. J Clin Nurs. 2011;20:2633‐2644. [DOI] [PubMed] [Google Scholar]
  • 10. Powers J. Two methods for turning and positioning and the effects on pressure ulcer development. J Wound Ostomy Continence Nurs. 2016;43(1):46‐50. [DOI] [PubMed] [Google Scholar]
  • 11. Katzengold R, Gefen A. What makes a good head positioner for preventing occipital pressure ulcers. Int Wound J. 2018;15(2):243‐250. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12. Clements L, Moore M, Tribblea T, Blake J. Reducing skin breakdown in patients receiving extracorporeal membranous oxygenation. Nurs Clin North Am. 2014;49(1):61‐68. [DOI] [PubMed] [Google Scholar]
  • 13. Brennan M, Laconti D, Gilchrist R. Using Conformational Positioning to Reduce Hospital‐Acquired Pressure Ulcers. J Nur Care Qual. 2014;29(2):182‐187. https://doi.org./10.1097/NCQ.0b013e3182a79ca9 [DOI] [PubMed] [Google Scholar]
  • 14. Michelle Barakat‐Johnson M, Lai M, Gefen A, Coyer F. Evaluation of a fluidised positioner to reduce occipital pressure injuries in intensive care patients: a pilot study. Int Wound J. 2017;16(2):424‐432. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15. Alves P, Creehan S, Gefen A, Santamaria N, Trevellini C. Meeting report: pressure injury prevention: clinical outcomes explained by robust scientific evidence: a panel discussion. Wounds Int. 2017;8(3):46‐53. [Google Scholar]
  • 16. Gillespie B, Chaboyer W, McInnes E, Kent B, Whitty J, Thalib L. Repositioning for pressure ulcer prevention in adults. Cochrane Database Syst Rev. 2014;(4):CD009958. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17. Bergstrom N, Braden BJ, Laguzza A, Holman V. The Braden scale for predicting pressure sore risk. Nurs Res. 1987;36(4):205‐210. [PubMed] [Google Scholar]
  • 18. Kolber M, Pizzini M, Robinson A, Yanez D, Hanney W. The reliability and concurrent validity of measurements used to qualify lumbar spine mobility: an analysis of an iPhone® application and gravity based inclinometry. Int J Sports Phys Ther. 2013;8(2):129‐138. [PMC free article] [PubMed] [Google Scholar]
  • 19. Modest J, Clair B, DeMasi R, et al. Self‐measured wrist range of motion by wrist‐injured and wrist‐healthy study participants using a built‐in iPhone feature as compared with a universal goniometer. J Hand Ther. 2018;17:12. [DOI] [PubMed] [Google Scholar]
  • 20. Wellmon R, Guliek D, Paterson M, Guliek C. Validity and reliability of 2 goniometric mobile apps: device, application, and examiner factors. J Sport Rehabil. 2016;25(4):371‐380. [DOI] [PubMed] [Google Scholar]
  • 21. Levy A, Kopplin K, Gefen A. Device‐related pressure ulcers from a biomechanical perspective. J Tissue Viability. 2017;26(1):57‐68. [DOI] [PubMed] [Google Scholar]
  • 22. Krapfl L, Langin C, Pezzella P. Does incremental positioning (weight shifts) reduce pressure injuries in critical care patients? J Wound Ostomy Continence Nurs. 2017;44(4):E1‐E2. [DOI] [PubMed] [Google Scholar]
  • 23. Weernink A, Severin W, Tjernberg I, Dijkshoorn L. Pillows, an unexpected source of acinetobacter. J Hosp Infect. 1995;29(3):189‐199. [DOI] [PubMed] [Google Scholar]
  • 24. Mottar R, Roth M, Allen M, Gerber R, Jeffers B. Pillow talk: examining pillow cores in a regional burn center. Am J Infect Control. 2006;34(5):E107‐E108. [Google Scholar]

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