Assessment: pressure redistribution mattresses

In this phase, the trained health professional should complete a comprehensive and person-centred assessment. This optimises the assistive technology (AT) selection process for the person with spinal cord injury (SCI).

Assessment is a customised and iterative process that informs clinical reasoning for the trained health professional and ultimately guides decision-making for all stakeholders—the person with SCI, their support network and the trained health professional.

The assessment approach should be tailored to the person with SCI and potential AT solutions. Assessment includes consideration of person, occupation and environment factors.

Tip

Use the mattress assessment and evaluation tool to structure data capture and generate trial criteria.

Goal setting

Early, collaborative goal setting clarifies the person’s priorities, informs clinical reasoning, and manages expectations across all stakeholders. Goal setting should involve all stakeholders to promote negotiation about the scope of the AT selection process, as well as the expected AT outcomes.

Example goals:

Maintain skin integrity (no new pressure injuries) and reduce need for overnight turns.
Improve sleep comfort and pain management.
Enable safe, efficient bed mobility and transfers for activities of daily living and care tasks.

Person and clinical profile

Capture the snapshot factors that shape pressure redistribution mattress choice.

Demographics: Gender, current age, age at injury, usual address where the mattress will be used.
Anthropometrics: height, weight, body habitus.
Medical history: level of injury, surgeries, diabetes, vascular disease, autonomic dysreflexia, continence issues, recent illness/surgery, nutrition, smoking, pain.
Neuromuscular: spasm/tone, contractures, muscle wasting below level of injury.
Living context: alone vs supported; who else is involved in skin care and AT; relevant care supports.
Funding context: Identify potential funding body and eligibility requirements e.g. NDIS, NIISQ, MASS, DVA, MAC

Skin integrity and sensation

Identify pressure vulnerable areas and sensory considerations that influence immersion/offloading needs.

Skin status: current/previous pressure injuries (location, stage/grade, duration, probable cause), persistent redness, scarring, irradiated or grafted sites.
High risk zones: sacrum, ischial tuberosities (ITs), heels.
Sensation profile: impaired vs intact, patchy, distorted, hyper/hyposensitive; tolerance of movement/vibration
Allergy / material sensitivity: history of latex/rubber sensitivity or contact dermatitis to covers/adhesives.

Tip

Document your findings: Use the skin table (sites, duration, cause, description) and local photo protocols.

Functional requirements in bed

Define what the mattress must support or enable to meet goals.

Bed mobility: rolling, bridging, ability to self-turn (or reliance on timed/assisted turns).
Activities of daily living in bed: bladder/bowel care, dressing/undressing, drying, slide sheet and sling insertion/removal.
Stability needs: edge sitting, resistance to “sinking” when rolling or using a slide sheet.

**spasm/tone** See also MAT: “Spasm / tone profile” for surface selection implications when spasms affect in bed tasks.

Transfers and bed access

Consider the person with SCI’s requirement from the mattress for safe transfers. Mattress stability and height critically affect safety.

Transfer method/equipment: wheelchair or mobile shower commode chair type/height, slide board, hoist, other aids used for transfers.
Mattress height: if height is critical for the person with SCI’s safe independent or assisted transfers record the preferred range. Consider how the mattress interfaces with the prescribed bed (e.g. an electric bed may assist to overcome height differences between mattress and wheelchair/MSCC).
Edge stability: requirements for sitting/positioning at the side of bed e.g., in preparation for transfer.
Care tasks around bed: space and positioning needed for support network.

*Note:* See also MAT “Spasm / tone profile” if spasms affect transfer stability; consider edge support and safety sides as indicated.

Continence and microclimate considerations

Moisture and heat strongly influence pressure redistribution mattress choice and mattress cover selection.

Bladder/bowel routines in bed: positions used, frequency, need to raise head end.
Microclimate: sweating, deep skin folds, hot/humid environments, incontinence.

Important

Do not add overlays on pressure redistribution mattresses (e.g., fitted protectors/continence pads) that compromise immersion and effectiveness – plan alternatives.

Cognitive, behavioural and monitoring capacity

Match technology complexity with the person’s ability to use it safely.

Consider: cognitive impairment, mental health or substance use issues.
Monitoring: who will check skin, covers, alarms and settings?
Implications: need for “set-and-forget” systems, simple controls, lockouts, or carer oversight.

Bed, environment and equipment compatibility

Ensure the environment can safely support the proposed pressure redistribution mattress.

Current bed: type/size (standard, profiling/hinged, hi-low), presence of rails/hip/knee breaks. Mattress cords and air hoses must free from impingement or dislodging by any moving parts of the bed.
Required mattress dimensions: length X width; thickness/height constraints (transfers, hoist clearance).
Access & safety: under‑bed clearance and lateral reach for hoists; rail gaps/entrapment risks; cable management to reduce trip hazards.
Power: outlet location and number of access points; reliability; need for backup/transport mode (planning only – feature selection is Section 4)
Other factors: partner bedsharing; pets; smoking in bed.

Important

Rail gap compliance: Ensuring that the spaces between the mattress, bed rails and bed frame remain within safe limits to prevent entrapment of the head, neck, chest or limbs. Mattresses that are too soft, too narrow or significantly thicker can alter gaps and increase entrapment risk; check gaps against bed rail safety guidelines during trial and setup.

Body assessment

Mechanical Assessment Tool (MAT)

The MAT is a comprehensive assessment tool used to evaluate a person with SCI’s body positioning, posture and seating needs for the desired AT.

The MAT is completed to assess relevant areas of the body with respect to:

joint range of motion
muscle power
muscle length
muscle tone
influence of spasm and/or spasticity
skeletal alignment

Important

The MAT is an essential assessment tool to be completed for pressure redistribution mattress assessment, trial and prescription.

For pressure redistribution mattress the assessment is completed:

sitting in the existing mattress
lying supine
sitting out of the existing mattress (e.g. supported sitting on the edge of relatively firm surface, such as a treatment plinth if possible)

Pressure redistribution mattress measurement	Body measurement used (how to measure during MAT)	Clinical considerations & risks
Mattress length	Measure recumbent body length in supine. Confirm segmental distances: – head to sacrum – sacrum to heel This identifies where the pelvis and heels will sit on the mattress and ensures the person is supported without overhang.	– Segmental measurements ensure correct positioning of high-risk areas (sacrum, heels) on the mattress. – Prevents head or heel overhang, reducing shear and focal pressure. – Confirms alignment with heel relief zones or heel slopes. – A mattress that is too short increases heel shear and coccygeal loading. – A mattress that is too long can extend beyond the bed frame, increasing entrapment risk. – Consider future growth or weight changes that may affect fit over time.
Mattress width ‑Acromial width ‑Trochanteric width	Measure biacromial width at the widest point across the acromion processes (supine or supported sitting). Measure bitrochanteric width at the widest point across the greater trochanters (same position as above for consistency. During the MAT, observe rolling (active or assisted) to gauge lateral excursion (how far trunk/pelvis/knees move laterally), including the effects of tone/spasm and postural asymmetry.	– Select a mattress width that safely accommodates lateral excursion during rolling without limb or pelvic overhang. – Avoid lateral entrapment risks at bed rails/frame; confirm rail gap compliance when wider widths are chosen. – Broader shoulder/pelvic breadth and asymmetries (e.g., windswept, rib flare) may necessitate additional width for safe repositioning. – Increased tone/spasm can cause sudden lateral shifts—insufficient width increases edge instability and fall risk. – Too narrow → limited rolling, higher shear, and increased pressure risk at shoulders/greater trochanters/knees. – Too wide → reduced carer reach and may increase effort required for bed mobility.
Target surface height for transfers/hoist	In edge sitting, measure popliteal height to determine the person’s functional transfer height. Identify the person’s preferred transfer height range (for seated pivot or stand pivot transfers). Confirm hoist yoke/pivot frame reach and under‑bed clearance relevant to mattress height and bed frame design.	Guides the choice of mattress thickness to achieve a safe and functional bed height.Too high → increased risk of failed seated pivot transfers or inability to position feet flat on the floor.Too low → increased effort for stand pivot transfers and reduced independence.Clearance risk: Thicker mattresses may block hoist legs from rolling under the bed, compromising a vertical lift path.Headroom risk: Thicker mattresses raise the person, reducing the hoist’s usable lift height and increasing shear/drag risk.Height changes should be flagged for trial, as bedding and mattress immersion will alter final surface height.
Safe Working Load (SWL) and immersion need	Include current weight and typical fluctuation. Assess abdominal girth/central adiposity in supine & sitting.	– Ensures safe working load (SWL) compliance. – Higher body mass + smaller contact area increases bottoming out risk, particularly in upright/Fowler positions. – May require deeper mattress cells, increased immersion, or hybrid surface solutions.
Heel protection (need for heel slope/zone) *SY: need to add image here Image source: silvercross.com	Palpate calcaneus to identify bony prominence. Check ankle plantarflexion and dorsiflexion ROM. Observe calf bulk in supine and assess ability to offload heels.	– High heel injury risk → prioritise heel slope/heel zone mattress features or adjunct offloading supports. – Limited ankle dorsiflexion and prominent/bony heels increase focal pressure and shear. – Ensure load is transferred through the calves rather than creating a point load on the heels.
Sacral/IT load risk in Fowler	Observe pelvic tilt (especially posterior tilt) and pelvic obliquity in Fowler. Assess lumbar posture—degree of lordosis vs kyphosis. Palpate/observe sacral and ischial tuberosity prominence when semi upright.	– Posterior pelvic tilt combined with thoracolumbar kyphosis increases direct sacral loading in Fowler. – Consider surfaces that manage sacral shear forces and micro‑movements during repositioning. – Plan for a bottom out check in upright/Fowler during trial, not just in supine.
Head/neck support needs	Check occiput shape and prominence in supine and Fowler. Assess cervical ROM, particularly flexion and extension tolerance in both positions. Observe natural head posture and whether the neck tends to flex forward or extend when semi upright.	– Prominent occiput combined with limited cervical extension increases risk of occipital pressure hot spots. – May require softer/contoured head zone or a tailored pillow strategy to redistribute load. – Optimise head support to prevent unnecessary elevation that may increase sacral loading in Fowler.
Lateral stability / side walls	Measure trunk width and observe rib flare in supine and sitting. Assess ability to edge sit safely (balance, control, need for hands for support). Note whether the patient collapses laterally or requires side support to maintain midline.	– May require firmer side edges (foam side walls) to improve edge sitting stability and assist safe transfers. – Inadequate side edge support increases risk of sliding, loss of balance, or falls when sitting on the bed edge. – Firmer edges also improve carer access and reduce manual handling risk during transfers.
Microclimate requirement	Note perspiration patterns, especially in hot/humid environments. Identify skin folds (abdomen, groin, axilla) and any existing maceration or moisture damage in supine or side lying. Observe incontinence frequency and impact on skin integrity.	– Hot/humid conditions, deep skin folds, and incontinence increase moisture associated skin damage risk—consider microclimate managing surfaces (e.g., low air loss) and breathable covers. – Tailor surface selection to manage both moisture and shear, particularly in high-risk zones.
Sensation & movement tolerance	Complete sensory exam—identify absent sensation, patchy areas, hypersensitivity, or allodynia. Observe tolerance to movement in Fowler (e.g., grimacing, guarding, anxiety, dysreflexia triggers in SCI). Apply small perturbations or minor surface shifts to assess sensitivity to vibration, noise, or motion.	– Intolerance to movement, airflow, or noise → avoid high motion alternating surfaces or select models with wider inflate/deflate ratios or longer cycle times. – Consider static or constant low-pressure modes for comfort or pain management. – Optimise comfort settings to support sleep quality and reduce agitation or pain related guarding.
Spasm / tone profile	Observe spasm triggers in supine and side lying (e.g., hip/knee position, foot contact, sudden touch, or stretch). Note amplitude, direction, and frequency of spasms, including whether limbs return to a neutral resting position or remain in a patterned posture. Identify tone patterns (flexor/extensor dominance) and whether tone increases with noxious stimuli, movement, or positional change.	– Unpredictable or high amplitude spasms may require surfaces with increased stability (firm edge support, reduced lateral roll). – Anti shear covers and surface materials can reduce tone triggering friction and unintended shear. – Consider bed‑rail padding or safety sides to prevent limb injury during spasms. – Avoid overly soft, unstable, or deeply immersive surfaces that compromise control, safety, or ease of repositioning.
Fixed postures / contractures	Measure fixed angles at the hip, knee, and ankle in supine and side lying. Assess comfortable hip rotation range (ER/IR) in supine to identify rotational bias. Note whether contractures alter limb alignment, affect midline posture, or create focal bony loading areas.	– Fixed flexion deformities may require profiling, wedges, or contouring to maintain alignment and prevent forced extension. – Hip external rotation can expose the lateral malleolus to pressure—plan appropriate support and check interface during mattress trial. – Ensure the chosen surface accommodates contracted postures without increasing shear or forcing unsupported ranges.
Asymmetries (pelvis / spine)	Identify pelvic obliquity (height difference) and pelvic rotation in supine. Observe spinal curvature, including scoliosis and any rib hump, especially in side lying and semi upright. Note whether asymmetry alters contact area or shifts loading toward one hemipelvis.	– Asymmetry can concentrate load onto one ischial tuberosity or greater trochanter, increasing local pressure risk. – May require higher immersion surfaces, zoned support, or contouring to distribute load more evenly. – Ensure mattress width accommodates the person’s asymmetrical shape and allows safe rolling/positioning without forcing contact against the side wall.
Abdominal mass / chest shape	Observe anteroposterior (AP) chest depth in supine and semi upright. Measure/estimate abdominal girth and note how the abdomen behaves in Fowler (e.g., shifts upward toward the chest, spreads laterally). Monitor breathing comfort in Fowler: look for signs that the person is keeping their chest/abdomen rigid (e.g., shallow upper chest breaths, minimal tummy movement, holding themselves “stiff,” increased effort or accessory muscle use, saying it’s “hard to get a full breath”). Note any signs of reduced diaphragm movement or increased work of breathing.	– A heavy abdomen in Fowler can increase sacral loading and heat/sweating—consider microclimate management and fowler assist features that reduce shear under load. – Ensure the mattress allows adequate immersion for pressure redistribution without excessive sinking that makes breathing harder. – Trial small positioning adjustments (e.g., incremental head of bed elevation, slight tilt, gentle knee flexion) and choose the surface/setting that maintains comfortable, easy breathing. – Document any breathing improvement/worsening with angle changes or surface modes to support device selection. – Consider joint review with Physiotherapy to monitor or support the respiratory assessment and optimise positioning/surface choice.
Limb length discrepancy	Measure ASIS to medial malleolus bilaterally in supine to identify true leg length difference. Observe how each limb rests on the surface—note if the shorter limb floats or lacks full contact. Check heel contact in Fowler and side lying to identify any asymmetrical loading.	– A shorter limb may float, reducing contact and stability, while the longer limb’s heel may bear excess load, increasing unilateral heel injury risk. – Consider local zoning, contouring, or small positional adjustments to equalise loading across both limbs. – Ensure heel protection strategies are applied asymmetrically if required (e.g., heel slope, offloading, or wedges). – Confirm limb alignment and pressure distribution during trial, as discrepancies often become more pronounced in Fowler.

Outcome measures

Outcome measures are selected according to the person’s goals, clinical presentation, environment and the specific assistive technology being considered. Succinct, validated tools can complement clinical reasoning and help identify pressure related risk, guide trial priorities and support education.

For assessment, trial and prescription of a pressure redistribution mattress, consider the following outcome measures:

Braden Scale: evaluates sensory perception, moisture, activity, mobility, nutrition and friction/shear.
Waterlow Pressure Risk Assessment Scale: identifies overall pressure injury risk.
Interface pressure mapping (if available): supports clinical reasoning and user education and can help prioritise trial options. (Interpret alongside clinical signs and not in isolation.)

Alert

Interface Pressure Mapping

IPM example of bed positioned at different angles.

Interface pressure mapping (IPM) can assist in comparing how different mattresses support immersion, envelopment and peak pressure distribution.

IPM is most useful as an adjunct to clinical assessment when evaluating the suitability of a pressure redistribution surface. It can:

Support comparison between different mattresses or surface settings
Provide visual feedback to assist person and carer education, demonstrating how position, posture and surface selection influence pressure exposure
Help identify areas of relatively high pressure or reduced immersion that may not be immediately apparent on clinical inspection

Interpretation of IPM data must never be used in isolation. Results must be considered alongside:

sensory status
skin integrity and pressure injury history
body morphology and asymmetry
bed mobility and movement patterns
transfer methods and functional requirements

IPM technology has known limitations, including sensitivity to movement, calibration requirements, and variability between systems and set‑ups.

Importantly, short‑term pressure mapping does not guarantee long‑term pressure protection. Ongoing monitoring, reassessment and clinical reasoning remain essential throughout mattress trial and prescription.

Spinal Cord Injury Independence Measure (SCIM) – A disability‑specific measure designed for people with spinal cord injury. It evaluates functional independence across self‑care, respiration and sphincter management, and mobility. Useful for tracking change over time and informing assistive technology needs within SCI rehabilitation.
Canadian Occupational Performance Measure (COPM) – A client‑centred tool that captures a person’s self‑identified priorities across occupational performance and satisfaction. It supports collaborative goal setting, highlights meaningful outcomes, and demonstrates change following interventions such as assistive technology provision.
Functional Independence Measure (FIM) – Assesses physical and cognitive disability across motor and cognitive domains. It provides a standardised score reflecting the level of assistance required in daily activities, helping to contextualise functional capacity during AT assessment and prescription.
Goal Attainment Scale (GAS) – A structured method for setting personalised goals and rating the extent to which they are achieved. It captures individualised outcomes not always reflected in standardised measures and is particularly useful when evaluating the impact of specific AT interventions.

Resources

Outcome Measures & Risk Assessment Tools

Mattress Assessment and Evaluation Tool [ [Tool]

QSCIS

Includes an evaluation tool – important for obtaining client feedback.

Braden Scale [Tool]