Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 44

PRESSURE ULCER PREVENTION AND TREATMENT FOLLOWING SPINAL CORD INJURY

NPWT has risks. In 2011 the FDA issued a
death and injury report of 6 deaths and 97
injuries for a total of 12 deaths and 174 injuries
reports since 2007 with NPWT devices. The
most serious complication was bleeding which
occurred in patients with blood vessel grafts in
the leg, breastbone and groin wounds, and
patients being managed with anticoagulation.
In addition, wound infections occurred in more
than half of the cases and were related to the
retention of dressing pieces in the wounds,
resulting in a delayed recovery and requiring
wound exploration, surgical removal of dead
tissue, and drainage. Additionally, Citak et al.
(2010) reported a rare complication of
necrotizing fasciitis during and after NPWT for
category/stage IV pressure ulcer in an individual
with paraplegia. Contraindications for NPWT
include necrotic tissue with eschar present,
untreated osteomyelitis, non-enteric and
unexplored fistulas, malignancy in the wound,
exposed vasculature, exposed nerves, exposed
anastomotic site, and exposed organs.
A D J U N C T I V E T HE RA PIE S A ND BIOLOGICS

There are a number of interventions that are
in use in some facilities but that do not have
strong supporting scientific evidence. However,
we would be remiss if we did not acknowledge
that they are in use clinically. The mention of
these products is to inform the reader/clinician/
researcher that these are being used but not to
the extent that they could be recommended
because the evidence is not strong.
Ultrasound Therapy
Low-frequency, low-intensity ultrasound (as
opposed to high frequency ultrasound, which is
used in imaging and musculoskeletal therapy)
delivers energy through mechanical vibrations in
the form of sound waves to cause cavitation and
streaming. Mechanical wound treatment with low
frequency ultrasound disrupts bacterial biofilm
and mechanically removes necrotic tissue.
In a case series involving 5 patients with
sacral pressure ulcers and compromised mobility
(SCI, ventilator/mobility dependent or persistent
vegetative state), low frequency low intensity
ultrasound therapy resulted in 100% granulation
and decreased wound size in four of the patients
(Schmuckler, 2008). It has been shown to rapidly
debride unstageable pressure ulcers (Medrano
and Beneke, 2008).

Laser Therapy
Lasers have been in use since the 1960s
without solid evidence for effectiveness. Taly et al.
(2004), in a randomized double-blind controlled
trial, treated 35 subjects with category/stage III
and IV pressure ulcers with multiwavelength light
therapy. The intervention did not influence overall
healing of the pressure ulcers.
Skin Substitutes
Skin substitute biomaterials are commonly
referred to by terms that include bioengineered
skin equivalents, tissue-engineered skin, tissueengineered skin constructs, biological skin
substitutes, bioengineered skin substitutes, skin
substitute bioconstructs, living skin replacements,
and bioengineered alternative tissue. Intended to
mimic the histological structure of normal skin or
the properties of the extracellular matrix, their
key role is to deliver growth factors, provide
extracellular matrix proteins, and to attract
differentiated cells (e.g., fibroblasts, endothelial
cells) or stem cells to the wound. They accelerate
and augment the intrinsic healing process in the
wound and support wound bed preparation.
Two clinical studies have shown the effects of
cultured skin equivalents on closure of pressure
ulcers. Phillips and Pachas (1994) applied
autologous cultured keratinocyte grafts to 17
pressure ulcers on seven individuals and found
that 65% of the ulcers closed completely after an
average of two graft applications. Yamashita et al.
(1999) evaluated granulation tissue formation and
epithelialization following application of an
allogeneic cultured dermal substitute to five cases
of category/stage III or IV pressure ulcers. They
observed that granulation tissue developed early
and that epithelialization was complete by 7
weeks in all the individuals.
Growth Factors
Two clinical studies have examined the effect
of recombinant platelet-derived growth factor
(PDGF) on the healing of pressure ulcers. In a
randomized controlled trial, Robson et al. (1992a)
treated the pressure ulcers of 20 individuals with
different concentrations of PDGF or placebo.
After 28 days, only ulcers treated with 100 µg/mL
of PDGF decreased their volume to a mean of 6%
of their original volume as compared with
placebo-treated ulcers that decreased to 22% of
their original volume. In a follow-up, multicenter,
randomized double blind study, Mustoe et al.
(1994) evaluated the effects of two aqueous
concentrations of PDGF and an aqueous placebo
on category/stage III and IV pressure ulcers in 45
individuals. After 28 days ulcers treated with 300
µg/mL of PDGF decreased to 40% of their

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