The false premise in measuring body-support interface pressures for preventing serious pressure ulcers

Presently, commercial cushioning products for pressure ulcer prevention are being evaluated for their protective effect exclusively based on interfacial pressures between the cushion/mattress and the patient. However, interface pressures cannot predict elevated mechanical stresses in deep tissues adjacent to bony prominences. Such deep tissue stress concentrations are associated with local ischaemia and hypoxia, which over time result in deep tissue necrosis, particularly of muscle tissue. In order to demonstrate this phenomenon, a physical phantom of the mechanical interaction between the ischial tuberosities (IT) and gluteus muscles of the buttocks was built, incorporating geometric replica of the human IT and real (bovine) muscle tissue. Internal muscle stresses directly under the IT were five to 11-fold greater than stresses at more distal locations, and a Pearson correlation test showed that they could not have been predicted from the interface pressures in the phantom. Accordingly, though pressure ulcer prevention clinics which utilize routine sitting pressure measurements report effective outcomes, the present results highlight a problem in using body-support pressure measurements to predict the risk for pressure-related deep tissue injury.     

Real-Time Patient-Specific Finite Element Analysis of Internal Stresses in the Soft Tissues of a Residual Limb: A New Tool for Prosthetic Fitting

Fitting of a prosthetic socket is a critical stage in the process of rehabilitation of a trans-tibial amputation (TTA) patient, since a misfit may cause pressure ulcers or a deep tissue injury (DTI: necrosis of the muscle flap under intact skin) in the residual limb. To date, prosthetic fitting typically depends on the subjective skills of the prosthetist, and is not supported by biomedical instrumentation that allows evaluation of the quality of fitting. Specifically, no technology is presently available to provide real-time continuous information on the internal distribution of mechanical stresses in the residual limb during fitting of the prosthesis, or while using it and this severely limits patient evaluations. In this study, a simplified yet clinically oriented patient-specific finite element (FE) model of the residual limb was developed for real-time stress analysis. For this purpose we employed a custom-made FE code that continuously calculates internal stresses in the residual limb, based on boundary conditions acquired in real-time from force sensors, located at the limb-prosthesis interface. Validation of the modeling system was accomplished by means of a synthetic phantom of the residual limb, which allowed simultaneous measurements of interface pressures and internal stresses. Human studies were conducted subsequently in five TTA patients. The dimensions of bones and soft tissues were obtained from X-rays of the residual limb of each patient. An indentation test was performed in order to obtain the effective elastic modulus of the soft tissues of the residual limb. Seven force sensors were placed between the residual limb and the prosthetic liner, and subjects walked on a treadmill during analysis. Generally, stresses under the shinbones were ∼threefold higher than stresses at the soft tissues behind the bones. Usage of a thigh corset decreased the stresses in the residual limb during gait by approximately 80%. Also, the stresses calculated during the trial of a subject who complained about pain and discomfort were the highest, confirming that his socket was not adequately fitted. We conclude that real-time patient-specific FE analysis of internal stresses in deep soft tissues of the residual limb in TTA patients is feasible. This method is promising for improving the fitting of prostheses in the clinical setting and for protecting the residual limb from pressure ulcers and DTI.     

Real-Time Finite Element Monitoring of Sub-Dermal Tissue Stresses in Individuals with Spinal Cord Injury: Toward Prevention of Pressure Ulcers

Patients with a spinal cord injury (SCI) are susceptible to deep tissue injury (DTI), a necrosis in excessively deformed muscle tissue overlying bony prominences, which, in wheelchair users, typically occurs in the gluteus muscles under the ischial tuberosities. Recently, we developed a generic real-time, subject-specific finite element (FE) modeling method to provide monitoring of mechanical conditions in deep tissues deformed between bony prominences and external surfaces. We previously employed this method to study internal tissue loads in plantar tissues of the foot [Yarnitzky, G., Z. Yizhar, and A. Gefen. J. Biomech. 39:2673–2689, 2006] and in muscle flaps of residual limbs in patients who underwent transtibial amputation (Portnoy, S., G. Yarnitzky, Z. Yizhar, A. Kristal, U. Oppenheim, I. Siev-Ner, and A. Gefen. Ann. Biomed. Eng. 35:120–135, 2007). The goal of the present study was to adapt the method to study the time-dependent mechanical stresses in glutei of patients with SCI during wheelchair sitting, continuously in real-time, and to compare the trends of internal tissue load data with those of controls. Prior to human studies, the real-time FE model—adapted to study the buttocks during sitting—was validated by comparing its predictions to data from a physical phantom of a buttocks and to non-real-time, commercial FE software. Next, real-time, subject-specific, FE models were built for six participating subjects (3 patients with SCI, 3 controls) based on their individual anatomies from MRI scans. Subjects were asked to sit normally in a wheelchair, on a ROHO cushion, and to watch a 90 min movie. Continuous interface pressure measurements from a pressure mat were used as subject-specific boundary conditions for real-time FE analyses of deep muscle stresses. Highest peaks of compression, shear and von Mises stresses throughout the trial period, and averages of peaks of these stresses were recorded over the trial for each individual. These parameters generally had 3-times to 5-times greater values in patients with SCI compared with controls. Likewise, stress doses, defined as the integration of peak compression stress over time, were ∼35-times and ∼50-times greater in the subjects with SCI, the values referring to the highest of all peaks recorded throughout the trial, and to average of peaks over the trial, respectively. We believe that by allowing—for the first time—practical and continuous monitoring of internal tissue loads in patients with motosensory deficits, without any risk or interruption to their lifestyle, and either at the clinical setting or at home, the present method can make a substantial contribution to the prevention of severe pressure ulcers and DTI.     

Noncontact diffuse correlation spectroscopy for noninvasive deep tissue blood flow measurement

A noncontact diffuse correlation spectroscopy (DCS) probe has been developed using two separated optical paths for the source and detector. This unique design avoids the interference between the source and detector and allows large source-detector separations for deep tissue blood flow measurements. The noncontact probe has been calibrated against a contact probe in a tissue-like phantom solution and human muscle tissues; flow changes concurrently measured by the two probes are highly correlated in both phantom (R(2)=0.89, p<10(-5)) and real-tissue (R(2)=0.77, p<10(-5), n=9) tests. The noncontact DCS holds promise for measuring blood flow in vulnerable (e.g., pressure ulcer) and soft (e.g., breast) tissues without distorting tissue hemodynamic properties.     

Comparison of computational analysis with clinical measurement of stresses on below-knee residual limb in a prosthetic socket

Interface pressures and shear stresses between a below-knee residual limb and prosthetic socket predicted using finite element analyses were compared with experimental measurements. A three-dimensional nonlinear finite element model, based on actual residual geometry and incorporating PTB socket rectification and interfacial friction/slip conditions, was developed to predict the stress distribution. A system for measuring pressures and bi-axial shear stresses was used to measure the stresses in the PTB socket of a trans-tibial amputee. The FE-predicted results indicated that the peak pressure of 226 kPa occurred at the patellar tendon area and the peak shear stress of 50 kPa at the anterolateral tibia area. Quantitatively, FE-predicted pressures were 11%, on average, lower than those measured by triaxial transducers placed at all the measurement sites. Because friction/slip conditions between the residual limb and socket liner were taken into consideration by using interface elements in the FE model, the directions and magnitudes of shear stresses match well between the FE prediction and clinical measurements. The results suggest that the nonlinear mechanical properties of soft tissues and dynamic effects during gait should be addressed in future work.     

Development of a non-linear finite element modelling of the below-knee prosthetic socket interface

A non-linear finite element model has been established to predict the pressure and shear stress distribution at the limb-socket interface in below-knee amputees with consideration of the skin-liner interface friction and slip. In this model, the limb tissue and socket liner were respectively meshed into 954 and 450 three-dimensional eight-node isoparametric brick elements, based on measurements of an individual's amputated limb surface; the bone was meshed into three-dimensional six-node triangular prism elements, based on radiographic measurements of the individual's residual limb. The socket shell was assumed to be a rigid boundary. An important feature of this model is the use of 450 interface elements (ABAQUS INTER4) which mimic the interface friction condition. The results indicate that a maximum pressure of 226 kPa, shear stress of 53 kPa and less than 4 mm slip exist at the skin-liner interface when the full body weight of 800 N is applied to the limb. The results also show that the coefficient of friction is a very sensitive parameter in determining the interface pressures, shear stresses and slip. With the growth of coefficient of friction, the shear stresses will increase, while the pressure and slip will decrease.     

A new method of assessing the mechanical properties of patient support systems (PSS) using a phantom. A preliminary communication

Pressure ulcers are a major problem worldwide believed to affect over 5% of all hospital in-patients, and countless others in the community at large. Many types of Patient Support Systems (PSS) are sold as pressure ulcer prevention equipment, but no consensus exists as to their mechanical efficacy. The use of human volunteers to assess the mechanical properties of PSS introduces non-repeatability and variability in results which cannot give a statistically significant difference in performance between systems. Mechanical testing without human volunteers provides faster evaluations of PSS, with improved precision and repeatability. An instrumented articulated anthropometric phantom has been developed to investigate the distortion of simulated soft body "tissues" of the buttock and sacral areas due to precise and repeatable static loading on a PSS. The weight of the phantom can be adjusted to 50, 70 and 90 kg and can be applied with the torso inclined at 0 degrees, 45 degrees and 80 degrees. Validation of the phantom by measuring interface pressure using a force sensing array mat indicates that the phantom represents realistic physiological loading conditions. The new method of measuring the distortion of the "artificial tissues" provides a highly selective ranking of PSS.     

The Compression Intensity Index: a practical anatomical estimate of the biomechanical risk for a deep tissue injury.

Pressure-related deep tissue injury (DTI) is a severe form of pressure ulcer that initiates in compressed muscle tissues under bony prominences, and progresses superficially towards the skin. Patients with impaired motosensory capacities are at high risk of developing DTI. There is a critical medical need for developing risk assessment tools for DTI. A new anatomical index, the Compression Intensity Index: CII=(BW/Rt);[1/2], which depends on the body weight (BW), radius of curvature of the ischial tuberosities (R) and thickness of the underlying gluteus muscles (t), is suggested for approximating the loading intensity in muscle tissue during sitting in permanent wheelchair users, as part of a clinically-oriented risk assessment for DTI. Preliminary CII data were calculated for 6 healthy and 4 paraplegic subjects following MRI scans, and data were compared between the groups and with respect to a gold standard, being a previously developed subject-specific MRI-finite-element (MRI-FE) method of calculating muscle tissue stresses (Linder-Ganz et al., J. Biomech. 2007). Marked differences between the R and t parameters of the two groups caused the CII values of the paraplegics to be approximately 1.6-fold higher than for the healthy (p<0.001), thereby indicating on the sensitivity of this parameter to the pathoanatomical changes that occur in the buttocks with paraplegia. Data of CII correlated reasonably with the gold standard calculations of MRI-FE muscle stresses (correlation coefficient 0.65). Since CII measurements do not require highly-specialized biomechanical numerical analyses such as MRI-FE, CII has the potential to serve as a practical, quick, and cost-effective approximation of the loading intensity in muscles of wheelchair-bound or bedridden patients. Hence, CII measurements can be integrated into DTI-risk-assessment tools, the need of which is now being discussed intensively in the American and European Pressure Ulcer Advisory Panel meetings.     

Evaluation of a new sitting concept designed for prevention of pressure ulcer on the buttock using finite element analysis

Excessive compressive load induces pressure related soft tissue damage, i.e. pressure ulcer (PU), in buttock area in wheelchair users. In solving this problem, our previous study has introduced a concept of Off-Loading sitting, which partially removes the ischial support to reduce pressure under buttocks. However, the effect of this sitting concept has only been evaluated using the interface pressure and tissue perfusion measurements. The objective of this investigation was to evaluate the Off-Loading posture for its ability to reduce internal pressure and stress in deep buttock tissues. This evaluation was performed on a 3D finite element (FE) model which was established and validated in a sitting posture and has realistic material properties and boundary conditions. FE analysis in this study confirmed that the pressure relief provided by Off-Loading posture created profound effect in reducing the mechanical stress within deep tissues. It was concluded that Off-Loading posture may prove beneficial in preventing sitting related PU.     

Clinically oriented real-time monitoring of the individual’s risk for deep tissue injury

Spinal cord injury patients are under daily risk for developing deep tissue injury which is a severe pressure ulcer that initiates in soft tissues at the bones’ proximity. We aimed to formulate a patient-specific biomechanical model that can continuously monitor internal tissue stresses in real time. We adopted a formulation solving an axisymmetric contact problem of a finite-thickness, elastic layer (soft tissue), and a rigid spherical indentor (ischial tuberosity). We utilized finite element analyses to expand the formulation for large deformations. Sensitivity analyses showed that the soft tissue mechanical properties are the most influential factors in this modeling. We then used synthetic surface pressure data and actual surface pressures recorded under the buttocks of five paraplegic wheelchair users to demonstrate clinical feasibility. Output parameters were designed to be simple so that they can be easily interpreted by the user. Specifically, we calculated peak and average internal von Mises stress and stress dose, under each buttock, and also a time-dependent stress asymmetry index, to account for frequency of posture adjustments. Inter-subject variability was higher than the intra-subject variability. The heaviest subject had the highest maximal and average peak internal soft tissue stress. We believe that this method holds a high potential for clinical applications.     

Effects of intermittent electrical stimulation on superficial pressure, tissue oxygenation, and discomfort levels for the prevention of deep tissue injury

The overall goal of this project is to develop effective methods for the prevention of deep tissue injury (DTI). DTI is a severe type of pressure ulcer that originates at deep bone–muscle interfaces as a result of the prolonged compression of tissue. It afflicts individuals with reduced mobility and sensation, particularly those with spinal cord injury. We previously proposed using a novel electrical stimulation paradigm called intermittent electrical stimulation (IES) for the prophylactic prevention of DTI. IES-induced contractions mimic the natural repositioning performed by intact individuals, who subconsciously reposition themselves as a result of discomfort due to prolonged sitting. In this study, we investigated the effectiveness of various IES paradigms in reducing pressure around the ischial tuberosities, increasing tissue oxygenation throughout the gluteus muscles, and reducing sitting discomfort in able-bodied volunteers. The results were compared to the effects of voluntary muscle contractions and conventional pressure relief maneuvers (wheelchair push-ups). IES significantly reduced pressure around the tuberosities, produced significant and long-lasting elevations in tissue oxygenation, and significantly reduced discomfort produced by prolonged sitting. IES performed as well or better than both voluntary contractions and chair push-ups. The results suggest that IES may be an effective means for the prevention of DTI.     

Preventive Effects of Poloxamer 188 on Muscle Cell Damage Mechanics Under Oxidative Stress

High oxidative stress can occur during ischemic reperfusion and chronic inflammation. It has been hypothesized that such oxidative challenges could contribute to clinical risks such as deep tissue pressure ulcers. Skeletal muscles can be challenged by inflammation-induced or reperfusion-induced oxidative stress. Oxidative stress reportedly can lower the compressive damage threshold of skeletal muscles cells, causing actin filament depolymerization, and reduce membrane sealing ability. Skeletal muscles thus become easier to be damaged by mechanical loading under prolonged oxidative exposure. In this study, we investigated the preventive effect of poloxamer 188 (P188) on skeletal muscle cells against extrinsic oxidative challenges (H₂O₂). It was found that with 1 mM P188 pre-treatment for 1 h, skeletal muscle cells could maintain their compressive damage threshold. The actin polymerization dynamics largely remained stable in term of the expression of cofilin, thymosin beta 4 and profilin. Laser photoporation demonstrated that membrane sealing ability was preserved even as the cells were challenged by H₂O₂. These findings suggest that P188 pre-treatment can help skeletal muscle cells retain their normal mechanical integrity in oxidative environments, adding a potential clinical use of P188 against the combined challenge of mechanical-oxidative stresses. Such effect may help to prevent deep tissue ulcer development.     

Risk factors for a pressure-related deep tissue injury: a theoretical model

Pressure-related deep tissue injury is the term recommended by the United States National Pressure Ulcer Advisory Panel to describe a potentially life-threatening form of pressure ulcers, characterized by the presence of necrotic tissue under intact skin, and associated with prolonged compression of muscle tissue under bony prominences. In this study, a theoretical model was used to determine the relative contributions of the backrest inclination angle during prolonged wheelchair sitting, the muscle tissue stiffness and curvature of the ischial tuberosities (ITs) to the risk for injury in the gluteus muscles that pad the IT bones during sitting. The model is based on Hertz’s theory for analysis of contact pressures between a rigid half-sphere (bone) and an elastic half-space (muscle). Hertz’s theory is coupled with an injury threshold and damage law for muscle—both obtained in previous studies in rats. The simulation outputs the time-dependent bone–muscle contact pressures and the injured area in the gluteus. We calculated the full-size (asymptotic) injured area in the gluteus and the time for injury onset for different sitting angles α( (90–150°), muscle tissue long-term shear moduli G (250–1,200 Pa) and bone diameters D (8–18 mm). We then evaluated the sensitivity of model results to variations in these parameters, in order to determine how injury predictions are affected. In reclined sitting (α = 150°) the full-size injured area was ∼2.1-fold smaller and the time for injury onset was ∼1.3-fold longer compared with erect sitting (α = 90°). For greater G the full-size injured area was smaller but the time for injury onset was shorter, e.g., increasing G from 250 to 1200 Pa decreased the full-size injured area ∼2.5-fold, but shortened the time for injury onset 6.2-fold. For smaller D the time for injury onset dropped, e.g., decreased ∼1.5-fold when D decreased from 18 to 8 mm. Interestingly, the full-size injured area maximized at D of about 12 mm but decreased for smaller or larger D. The susceptibility to sitting-acquired deep tissue injury strongly depends on the geometrical and biomechanical characteristics of the bone–muscle interface, and, particularly, on the radius of curvature of the IT which mostly influenced the size of the wound, and on the muscle stiffness which dominantly affected the time for injury onset.     

Real-time subject-specific analyses of dynamic internal tissue loads in the residual limb of transtibial amputees

Transtibial amputation (TTA) prosthetic-users may risk the integrity of their residuum while trying to maintain everyday activities. Compression of the muscle flap between the truncated bones and the prosthetic socket may cause pressure ulcers and deep tissue injury (DTI). We hypothesize that mechanical stresses in the muscle flap are higher when walking over complex terrains than during plane gait, and so, the residuum could be at risk for DTI when walking over these terrains. Accordingly, we evaluated internal soft tissue stresses in the residuum at the vicinity of the tibia in 18 prosthetic-users (7 vascular, 11 traumatic). For this purpose, we developed a portable monitor that calculated subject-specific internal stresses in the residuum in real-time. Each subject was studied while walking on plane floor, grass, stairs and slope. We found that internal stresses were the highest while subjects descended a slope, during which internal peak and root mean square (RMS) stresses were approximately 40% and 50% greater than in plane gait, respectively. Peak and RMS stresses calculated while descending a slope were approximately 2 times higher for the sub-group of vascular subjects compared to traumatic, but were similar between the two sub-groups for other ambulation tasks. Overall, the present internal stress monitor is a practical tool for real-time evaluation of internal stresses in the residuum of TTA prosthetic-users in the clinical setting or outdoors. Pending integration of appropriate dynamic tissue injury thresholds, the device can be utilized for alerting to the danger of DTI.     

Use of MRI images to measure tissue thickness over the ischial tuberosity at different hip flexion

The goal of this experiment was to investigate changes in the thickness of the soft tissue overlying the ischial tuberosity (IT) due to changes in hip flexion angle and the addition of a sitting load. Eleven healthy subjects were tested. An apparatus constructed from foam blocks and an air bladder was used to position the subjects in different postures within an MRI tube. MRI images of the buttocks and thigh were obtained for four postures: Supine, 45° Hip Flexion, Non-Weight-Bearing 90° Hip-Flexion, and Weight-Bearing 90° Hip-Flexion. The thickness of muscle, adipose tissue, and skin was measured between the IT tip and skin surface, perpendicular to the cushion placed beneath the thighs. The tissue overlying the IT was found to be significantly (P < 0.001) thinner in 90° Hip-Flexion (73.8 ± 9.0 mm) than in the supine position (135.9 ± 8.1 mm). Muscle thickness decreased significantly from Supine to Non-Weight-Bearing 90° Hip-Flexion (59.1 ± 8.5%, P < 0.001), and further decreased from Non-Weight-Bearing to Weight-Bearing 90° Hip-Flexion (46.2 ± 7.9%, P < 0.001). Under Weight-Bearing 90° Hip-Flexion, the muscle tissue deformed significantly (P < 0.001) more than the adipose tissue and skin. We concluded that the tissue thickness covering the IT significantly decreased with hip flexion, and further decreased by nearly half during loading caused by sitting. In addition, the muscle tissue experienced the largest deformation during sitting. The results of this study may improve our understanding of risk factors for pressure ulcer development due to changes in tissue padding over the IT in different postures.     

压疮的评估、预防和治疗研究进展

压力性溃疡（PU）简称压疮,是皮肤或皮下组织由于压力、剪切力或摩擦力而导致的皮肤、肌肉和皮下组织的局限性损伤,常发生在骨隆突处。压疮是长期卧床及危重患者最常见的并发症之一,严重降低患者生活质量,增加治疗费用;严重者可继发感染、脓毒症、败血症等导致全身衰竭而死亡。本文从流行病学、危险预测因素及评估量表、预防、伤口局部和全身性治疗、护理及未来研究方向等方面对压疮的研究进展进行综述。     

Quantitative sonoelastography for the in vivo assessment of skeletal muscle viscoelasticity

A novel quantitative sonoelastography technique for assessing the viscoelastic properties of skeletal muscle tissue was developed. Slowly propagating shear wave interference patterns (termed crawling waves) were generated using a two-source configuration vibrating normal to the surface. Theoretical models predict crawling wave displacement fields, which were validated through phantom studies. In experiments, a viscoelastic model was fit to dispersive shear wave speed sonoelastographic data using nonlinear least-squares techniques to determine frequency-independent shear modulus and viscosity estimates. Shear modulus estimates derived using the viscoelastic model were in agreement with that obtained by mechanical testing on phantom samples. Preliminary sonoelastographic data acquired in healthy human skeletal muscles confirm that high-quality quantitative elasticity data can be acquired in vivo. Studies on relaxed muscle indicate discernible differences in both shear modulus and viscosity estimates between different skeletal muscle groups. Investigations into the dynamic viscoelastic properties of (healthy) human skeletal muscles revealed that voluntarily contracted muscles exhibit considerable increases in both shear modulus and viscosity estimates as compared to the relaxed state. Overall, preliminary results are encouraging and quantitative sonoelastography may prove clinically feasible for in vivo characterization of the dynamic viscoelastic properties of human skeletal muscle.     

坐姿下不同组织压力性损伤生物力学研究

目的 探讨坐姿下臀部压力性损伤易发部位以及不同软组织的生物力学响应,为有效预防深层组织压力性损伤提供参考。 方法 基于臀部 CT 扫描数据,建立坐位臀部有限元模型,包括骨骼、肌肉、脂肪和皮肤组织及坐垫模型,利用生死单元模拟组织损伤。 对比实验坐垫界面压力测量数据与有限元模拟结果,验证模型有效性。 模拟坐位力学状态,研究软组织的应力、应变情况,分析不同软组织中的压应力及超出极限值后可能造成的损伤情况。结果 通过对比坐垫模型仿真结果与实验界面压力测量结果,证明模型有效。 坐位时坐骨结节下方软组织区域出现应力集中现象。 其中,臀大肌组织中的横向压应力峰值约为 38 kPa,剪切应力峰值约为 3. 4 MPa;而脂肪组织中的最大压应力与剪切应力峰值分别为 22 kPa 与 4. 5 MPa,均未出现在坐骨结节正下方。 结论 软组织受到一定时间和大小的压力载荷作用,可能出现深层组织损伤。 当保持坐姿一定时间后,应及时变换体位,以降低压力性损伤出现的概率。 研究结果为预防压力性损伤提供生物力学依据,具有重要的临床研究价值。     

Two-layered quasi-3D finite element model of the oesophagus

Analysis of oesophageal mechanoreceptor-dependent responses requires knowledge about the distribution of stresses and strains in the layers of the organ. A two-layered and a one-layered quasi-3D finite element model of the rat oesophagus were used for simulation. An exponential pseudo-strain energy density function was used as the constitutive equation in each model. Stress and strain distributions at the distension pressures 0.25 and 1.0 kPa were studied. The stress and strain distributions depended on the wall geometry. In the one-layered model, the stress ranged from -0.24 to 0.38 kPa at a pressure of 0.25 kPa and from -0.67 to 2.57 kPa at a pressure of 1.0 kPa. The stress in the two-layered model at the pressure of 0.25 and 1.0 kPa varied from -0.52 to 0.64 kPa and from -1.38 to 3.84 kPa. In the two-layered model, the stress was discontinuous at the interface between the muscle layer and the mucosa-submucosa layer. The maximum stress jump was 1.67 kPa at the pressure of 1.0 kPa. The present study provides a numerical simulation tool for characterising the mechanical behaviour of a multi-layered, complex geometry organ.