16. Prevention of Skin Breakdown

Actionable Nuggets for SCI (2nd ed., 2013)

The Problem:Man with hand on wheelchair

Individuals with spinal cord injury (SCI) are at life-long risk for developing pressure 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.

Actionable Nugget

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


Additional information: Bradenscale for predicting pressure sore risk

Evidence-based Best Practice:

Pressure ulcers are considered at least 50% preventable, and the cost of prevention is one-tenth the cost of treatment; yet patient knowledge about pressure ulcers 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.

Incidence of pressure ulcers (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 onsequences for functioning, health and quality of life. Care for episodic pressure ulcers consumes approximately ¼ of all the resources spent on the SCI population.

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:

Total Score
Very High Risk < 9
High Risk 10 – 12
Moderate Risk 13 – 14
Mild Risk 15 – 18

Key reference:

    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.

Additional References:

    Bergstrom, N., et al. (1995). Using a research-based assessment scale in clinical practice. Nursing Clinics of North America, 30(3): 539-51. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=7567578
    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 Medicine, 24 Suppl 1: S40-101.
    Dover, H., et al. (1992). The effectiveness of a pressure clinic in preventing pressure sores. Paraplegia, 30(4): 267-72. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=1625896
    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 Rehabilitation, 15(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.
    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 Medicine, 35(4): 240-50.
    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.
    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 Rehabilitation, 32(7): 567-78.
    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 Viability, 13(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 Rehabilitation, 83(6): 868-71.
    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.
    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 & Rehabilitation, 82(1): 107-13. http://dx.doi.org/10.1053/apmr.2001.18050
    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.
    Salzberg, C.A., et al. (1996). A new pressure ulcer risk assessment scale for individuals with spinal cord injury. American Journal of Physical Medicine & Rehabilitation, 75(2): 96-104.
    Thomas, D.R. (2010). Does pressure cause pressure ulcers? An inquiry into the etiology of pressure ulcers. Journal of the American Medical Directors Association, 11(6):397-405.
    van Loo, M.A., et al. (2009). Care needs of persons with long-term spinal cord injury living at home in the Netherlands. Spinal Cord, 48(5): 423-8. http://dx.doi.org/10.1038/sc.2009.142
   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 Care, 24(6): 275-84.
    Wellard, S., & Lo, S.K. (2000). Comparing Norton, Braden and Waterlow risk assessment scales for pressure ulcers in spinal cord injuries. Contemporary Nurse, 9(2): 155-60.