16. Prevention of Skin Breakdown

Actionable Nuggets for SCI (3rd ed., 2016)

Assess for risk of pressure injuries using the Braden Scale, and refer to rehabilitation specialist if high risk.

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. Skin breakdowns result as a complex inter-relationship of multiple risk factors, including being underweight, smoking, malnutrition, incontinence, decreased mobility, diabetes and spasticity.

Link to Braden Scale for Predicting Pressure Sore Risk

Evidence-based Best Practice:

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 sores have very significant consequences for functioning, health and quality of life. Care for episodic pressure ulcers consumes approximately ¼ of all the resources spent on the SCI population.

Pressure injuries are considered at least 50% preventable, and the cost of prevention is one-tenth the cost of treatment; yet patient knowledge about pressure injuries is low and declines over time post-rehabilitation. Effective prevention must be highly customized to individual lifestyles, and oriented toward the formation of good skin care habits. A specialized interdisciplinary approach is recommended, including nutrition and lifestyle counseling, seating optimization and rehabilitation.

The Braden scale is an evidence-based measure for predicting pressure sore risk. It has been shown to be a sensitive tool for individuals with SCI and to have excellent reliability for those living in the community.

Scoring is as follows:   Very High Risk< 9
High Risk10 – 12
Moderate Risk13 – 14
Mild Risk15 – 18

Key reference:

    Groah, S. L., Schladen, M., Pineda, C. G., & Hsieh, C. H. J. (2015). Prevention of Pressure Ulcers Among People With Spinal Cord Injury: A Systematic Review. PM&R7(6), 613-636.

Additional References (chronological order):

    Ghaisas, S., Pyatak, E. A., Blanche, E., Blanchard, J., & Clark, F. (2015). Lifestyle changes and pressure ulcer prevention in adults with spinal cord injury in the Pressure Ulcer Prevention Study lifestyle intervention. American Journal of Occupational Therapy69(1), 1-10.
    Kisala, P. A., Tulsky, D. S., Choi, S. W., & Kirshblum, S. C. (2015). Development and psychometric characteristics of the SCI-QOL Pressure Ulcers scale and short form. The Journal of Spinal Cord Medicine, 38(3), 303–14. http://doi.org/10.1179/2045772315Y.0000000017
    Tung, J.Y., Stead, B., William, M., Ba, P., & Milos, P. (2015). Assistive technologies for self-managed pressure ulcer prevention in spinal cord injury: A scoping review. Journal of rehabilitation research and development52(2), 131.
    Zanca, J. M., Heyn, P., Horn, S., Charlifue, S., Hsieh, C. H. J., Brienza, D. M., … Backus, D. (2015). Evaluating Your Pressure Ulcer Prevention Plan: A problem-solving worksheet for people with spinal cord injury and their health care providers. Archives of Physical Medicine and Rehabilitation, 96(11), 2089–2090. http://doi.org/10.1016/j.apmr.2015.03.001
    Stansby, G., Avital, L., Jones, K., & Marsden, G. (2014). Prevention and management of pressure ulcers in primary and secondary care. National Institute for Health and Care Excellence. UK: National Clinical Guideline Centre.
    Eslami, V., Saadat, S., Habibi Arejan, R., Vaccaro,  a R., Ghodsi, S. M., & Rahimi-Movaghar, V. (2012). Factors associated with the development of pressure ulcers after spinal cord injury. Spinal Cord, 50(12), 899–903. http://doi.org/10.1038/sc.2012.75
    King, R. B., Champion, V. L., Chen, D., Gittler, M. S., Heinemann, A. W., Bode, R. K., & Semik, P. (2012). Development of a measure of skin care belief scales for persons with spinal cord injury. Archives of physical medicine and rehabilitation93(10), 1814-1821.
    Vaishampayan, A., Clark, F., Carlson, M., & Blanche, E. I. (2011). Preventing pressure ulcers in people with spinal cord injury: targeting risky life circumstances through community-based interventions. Advances in skin & wound care24(6), 275-84.
    Guihan, M., & Bombardier, C.H. (2012). Potentially modifiable risk factors among veterans with spinal cord injury hospitalized for severe pressure ulcers: A descriptive study. Journal of Spinal Cord Medicine35(4), 240-50.
    Regan, M., Teasell, R.W., Keast, D., Aubut, J.L. Foulon, B.L., & Mehta, S. (2012). Pressure ulcers following spinal cord injury. In Eng, J.J., Teasell, R.W., Miller, W.C., Wolfe, D.L., Townson, A.F., Hseich, J.T.C., et al. editors. Spinal Cord Injury Rehabilitation Evidence. Version 4.0. Vancouver, p 1-39.
    Vaishampayan, A., Clark, F., Carlson, M., & Blanche, E.I. (2011). Preventing pressure ulcers in people with spinal cord injury: Targeting risky life circumstances through community-based interventions. Advances in Skin and Wound Care24(6), 275-84.
    Jackson, J., Carlson, M., Rubayi, S., Scott, M.D., Atkins, M.S., Blanche, E.I., Saunders-Newton, C., et al. (2010). Qualitative study of principles pertaining to lifestyle and pressure ulcer risk in adults with spinal cord injury. Disability and Rehabilitation32(7), 567-78.
    Thomas, D.R. (2010). Does pressure cause pressure ulcers? An inquiry into the etiology of pressure ulcers. Journal of the American Medical Directors Association11(6), 397-405.
    Regan, M., Teasell, R.W., Keast, D., Aubut, J.L., Foulon., B., & Mehta, S. (2010). Pressure ulcers following a spinal cord injury. In Eng, J.J., Teasell, R.W., Miller, W.C., Wolfe, D.L., Townson, A.F., Hseich, J.T.C., et al. editors. Spinal Cord Injury Rehabilitation Evidence. Version 3.0. Vancouver
    Dunn, C.A., Carlson, M., Jackson, J.M., & Clark, F.A. (2009). Response factors surrounding progression of pressure ulcers in community-residing adults with spinal cord injury. American Journal of Occupational Therapy, 63(3), 301-9.
    European Pressure Ulcer Advisory Panel & National Pressure Ulcer Advisory Panel. (2009). Pressure Ulcer Prevention: Quick Reference Guide. Washington DC: National Pressure Ulcer Advisory Panel.
    Fogelberg, D., Atkins, M., Blanche, E.I., Carlson, M., & Clark, F. (2009). Decisions and dilemmas in everyday life: Use of wheelchairs by individuals with spinal cord injury and the impact on pressure ulcer risk. Topics in Spinal Cord Injury and Rehabilitation15(2), 16-32.
    Foxley S., & Baadjies R. (2009). Incontinence-associated dermatitis in patients with spinal cord injury. British Journal of Nursing, 18(12), 719, 721-3.
    Gelis, A., Dupeyron, A., Legros, P., Benaim, C., Pelissier, J., & Fattal, C. (2009). Pressure ulcer risk factors in persons with SCI: Part I: Acute and rehabilitation stages. Spinal Cord, 47(42), 99-107.
    van Loo, M.A., et al. (2009). Care needs of persons with long-term spinal cord injury living at home in the Netherlands. Spinal Cord48(5), 423-8. http://dx.doi.org/10.1038/sc.2009.142
    Kottner, J., Halfens, R., & Dassen, T. (2009). An interrater reliability study of the assessment of pressure ulcer risk using the Braden scale and the classification of pressure ulcers in a home care setting. International Journal of Nursing Studies,46(10), 1307-12. http://dx.doi.org/10.1016/j.ijnurstu.2009.03.014
    Guihan, M., Garber, S.L., Bombardier, C.H., Goldstein, B., Holmes, S.A., & Cao, L. (2008). Predictors of pressure ulcer recurrence in veterans with spinal cord injury. Journal of Spinal Cord Medicine, 31(5), 551-9.
    Kennedy, P., et al. (2003). The effect of a specialist seating assessment clinic on the skin management of individuals with spinal cord injury. Journal of Tissue Viability13(3), 122-5.
    Kernozek, T.W., Wilder, P.A., Amundson, A., & Hummer, J. (2002). The effects of body mass index on peak seat-interface pressure of institutionalized elderly. Archives of Physical and Medical Rehabilitation83(6), 868-71.
    Consortium for Spinal Cord Medicine (2001). Pressure ulcer prevention and treatment following spinal cord injury: a clinical practice guideline for health-care professionals. Journal of Spinal Cord Medicine24 Suppl 1, S40-101. http://www.pva.org/site/News2?page=NewsArticle&id=7658
    Krause, J.S., et al. (2001). An exploratory study of pressure ulcers after spinal cord injury: relationship to protective behaviors and risk factors. Archives of Physical Medicine & Rehabilitation82(1), 107-13. http://dx.doi.org/10.1053/apmr.2001.18050
    Wellard, S., & Lo, S.K. (2000). Comparing Norton, Braden and Waterlow risk assessment scales for pressure ulcers in spinal cord injuries. Contemporary Nurse9(2), 155-60.
    Salzberg, C.A., et al. (1996). A new pressure ulcer risk assessment scale for individuals with spinal cord injury. American Journal of Physical Medicine & Rehabilitation75(2), 96-104.
    Bergstrom, N., et al. (1995). Using a research-based assessment scale in clinical practice. Nursing Clinics of North America30(3), 539-51.
    Dover, H., et al. (1992). The effectiveness of a pressure clinic in preventing pressure sores. Paraplegia30(4), 267-72. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=1625896