16. Prevention of Skin Breakdown

Assess for risk of pressure injuries using the Braden Scale, and refer to rehabilitation specialist if high risk (Score < 12).

The Problem

Individuals with spinal cord injury (SCI) are at life-long risk for developing pressure injuries (sores / ulcers) due primarily to poor sensation and circulation. Incidence of pressure injuries (or decubiti) in the spinal cord injury population is estimated at 20-31% annually, and point prevalence at 10-30%, increasing with age. Pressure injuries are considered at least 50% preventable, and the cost of prevention is one-tenth the cost of treatment. Skin breakdowns result as a complex inter-relationship of multiple risk factors, including being underweight, smoking, malnutrition, incontinence, decreased mobility, diabetes and spasticity. Especially vulnerable areas are the sacrum and feet.
ressure sores have very significant consequences for functioning, health and quality of life.

Evidence-based Best Practice

Best practice for pressure sore prevention includes:

  1. Risk assessment — The Braden scale is an evidence-based measure for predicting pressure sore risk. It has been shown to have good sensitivity for individuals with SCI, and to have excellent reliability.
  2. Individualized prevention plans and education.

Effective prevention is highly customized to individual lifestyles, and oriented toward the formation of good skin care habits. Patient knowledge about prevention of pressure injuries declines over time post-rehabilitation, and a specialized interdisciplinary approach is recommended for best results. Prevention typically includes seating optimization, pressure relief techniques, nutrition and lifestyle counseling. Recent research has focused on electronic prompts for periodic pressure relief, and on the skin’s microclimate and controlling temperature and humidity with prophylactic dressings, although evidence is sparse.

Key Reference

Atkinson, R. A., & Cullum, N. A. (2018). Interventions for pressure ulcers: A summary of evidence for prevention and treatment. Spinal Cord, 56(3), 186-198. doi:10.1038/s41393-017-0054-y

Actionable Nuggets (4th ed., 2019)

Additional References (since 2016)

Smit, C. A., De Groot, S., Stolwijk-Swuste, J. M., & Janssen, T. W. (2016). Effects of electrical stimulation on risk factors for developing pressure ulcers in people with a spinal cord injury: a focused review of literature. American journal of physical medicine & rehabilitation95(7), 535-552.

Kottner, J., Black, J., Call, E., Gefen, A., & Santamaria, N. (2018). Microclimate: A critical review in the context of pressure ulcer prevention. Clinical Biomechanics, 59, 62-70. doi:10.1016/j.clinbiomech.2018.09.010

Cornish, L. (2017). The use of prophylactic dressings in the prevention of pressure ulcers: A literature review. British Journal of Community Nursing, 22(Sup6), S26.

Davies, P. (2016). Role of multi-layer foam dressings with Safetac in the prevention of pressure ulcers: a review of the clinical and scientific data. Journal of wound care25(1 Suppl), S1-S4.

Vos-Draper, T. L., & Morrow, M. M. B. (2016). Seating-related pressure injury prevention in spinal cord injury: A review of compensatory technologies to improve in-seat movement behavior. Current Physical Medicine and Rehabilitation Reports, 4(4), 320-328. doi:10.1007/s40141-016-0140-7

Sonenblum, S. E., & Sprigle, S. H. (2018). Some people move it, move it. for pressure injury prevention. The Journal of Spinal Cord Medicine, 41(1), 106-110. doi:10.1080/10790268.2016.1245806