Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 12

12

PRESSURE ULCER PREVENTION AND TREATMENT FOLLOWING SPINAL CORD INJURY

after their acute rehabilitation. Results from Lloyd
et al. (1993) indicate that a lower level of
education is linked to less understanding of and
follow-through on complex recommendations for
managing chronic conditions. Supporting this
hypothesis, Chen et al. (2005) reported a higher
prevalence of ulcers in those with less than a high
school education.
E N V I R O N M E N T /FA CILIT Y IMME DIAT E LY POST SCI

In a study of 100 persons admitted to a
specialty SCI unit in England, investigators
reported that. Individuals admitted within one
week of injury were significantly less likely to
develop pressure ulcers than those admitted after
one week (Aung and el Masry, 1997). Persons
admitted to specialty SCI units of US SCI Model
Systems within 72 hours of injury have been
shown to have a lower prevalence of ulcers with
lesser severities than those admitted later
(Richardson and Meyer (1981); Yarkony and
Heinemann, 1995). This has been attributed to
the familiarity of the clinicians in the SCI units
with the potential secondary complications of
SCI including pressure ulcers and the
implementation of preventive measures.

SCI Related Risk Factors
L E V E L A N D C O MPLE T E NE S S OF INJ URY

In one analysis of the data collected on
pressure ulcers within the US Model Systems,
persons with complete injuries seemed to be
at greater risk than those with incomplete
injuries and those with cervical injuries seemed
to be at greater risk than those with lower
level injuries (Richardson and Meyer (198l)).
In another analysis, level of injury was not found
to be a significant risk factor (Chen 2005).
In a study of VA patients with SCI, Salzberg et al.
(1996) found that complete SCI was significant,
but level of injury was not. Mawson et al. (1988)
and Curry and Casady (1992) found no
statistical significance related to the development
of pressure ulcers based upon completeness or
level of injury immediately post injury. However,
recently, Verschueren et al. (2011) found
tetraplegia and motor completeness of injury
to be significant risk factors for developing
pressure ulcers.
D U R AT I O N O F I NJ URY

Whiteneck et al. (1985) reported that
individuals with high tetraplegia and longer
duration of SCI were more likely to have an ulcer.
Hirschwald et al. (1990) and Furher et al. (1993)
also found that longer duration of SCI was
associated with greater likelihood of having an

ulcer. Smith et al. (2008) showed that among
veterans completing a health survey, having an
injury more than 30 years was associated with the
presence of pressure ulcers. Chen and colleagues
(2005) conducted a multicenter cohort study
of more than 3000 individuals from 9 US Model
systems for SCI followed annually to examine
age-time period-duration patterns of pressure
ulcer prevalence among persons with spinal cord
injury residing in the community. They found a
significant trend toward increasing pressure
ulcer prevalence in recent years (1994-2002)
compared to the years 1984-1993 which could
not be explained by aging, years since injury, or
demographic and clinical factors. Pressure
ulcer risk appeared to be steady during the first
10 years post-injury and increased 15 years
post-injury.
USE OF MEDI CAL DEVI CES

Black et al. (2010) in a study of pressure
ulcers in a medical center found that
approximately 1/3 were medical-device related.
Apold and Rydrych (2012) analyzed pressure
ulcer data from 34 hospitals and found the
following distribution for pressure ulcers
associated with medical devices: cervical orthoses
(22%), other types of immobilizers (17%), oxygen
tubing (13%), stockings or positioned boots
(12%), and nasogastric tubes (8%). The authors
attribute these device-related pressure ulcers to
the non-removal of these devices due to the lack
of awareness of the need to periodically remove
or reposition them to maintain skin integrity and
the lack of guidance on when and how to remove
them. Factors associated with cervical orthosis
related pressure ulcers are the time period to
cervical orthosis removal and the orthosis type
(Ackland et al., 2007).
ACTI VI TY AND MOBI LI TY

Activity, as distinguished from mobility,
refers to involvement of the person in recreation,
such as athletics, social pursuits as well as
vocational endeavors. In an investigation
of 219 individuals with SCI, Salzberg et al. (1996)
related that a decreased level of activity was the
most significant risk factor in developing pressure
ulcers. In a subsequent study involving analysis
of 800 individuals with SCI, Salzberg et al. (1998)
similarly reported that a restricted level of
activity was the most significant risk factor for
pressure ulcer development. In 2004, Krause et
al. reported the results of a survey of over 800
non-ambulatory subjects followed in a large
subspecialty hospital. Factors found to be
protective against developing ulcers included
being fit and participating in planned exercise.
Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury

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