This action might not be possible to undo. Are you sure you want to continue?
TITLE: Prevention Practice Differences Among Persons With Spinal Cord Injuries Who Rarely Versus Frequently Sustain Pressure Ulcers SOURCE: Rehabilitation Counseling Bulletin 48 no3 139-45 Spr 2005 The magazine publisher is the copyright holder of this article and it is reproduced with permission. Further reproduction of this article in violation of the copyright is prohibited. To contact the publisher: http://www.proedinc.com/
Michael L. Jones Irmo Marini John R. Slate ABSTRACT Pressure ulcers are common among people with spinal cord injury (SCI) and not only are costly to treat but also affect the quality of life of those affected by them. Despite a plethora of literature on prevention, there are few wellness studies focusing on the practices of people who do not develop pressure ulcers. This preliminary study sought to compare persons with spinal cord injury with consistent healthy skin histories to those with chronic pressure ulcer problems, focusing on behavioral habits of self-care. Data from 86 individuals 6 to 17 years postinjury were gathered by a mail and telephone survey investigating demographics and behavioral management lifestyle practices and factors attributed to success in preventing ulcers. Chi-square and follow-up analyses of variance indicated the group practices of those relatively ulcer free, who were female, were employed, weighed less, performed frequent pressure releases, experienced fewer ulcers during the first year, were less likely to smoke, consumed less alcohol, had fewer incontinence or moisture problems, had more sensation in the buttocks region, and were more physically active. Relevance to rehabilitation counselors in working with this population and addressing this debilitating problem is explored. People with spinal cord injury (SCI) face increased risk for developing pressure
1997). and social goals for individuals with SCI (Stover. 1996. They can result in time missed from work or school for the individual and the caregiver. Teodorescu. Kosiak (2002) described causal factors such as pressure. sacrum (23%).000 to $78. in rare cases. Grimm. 2002). Pires & Adkins. Individuals with paraplegia have the highest rate of recurrence. with the most popular theory being insufficient blood flow and decreased oxygen delivery to specific pressure points on the body for generally 1 or more hours (Wilhelmi & Neumeister. estimated at 80% (Wilhelmi & Neumeister. and 30% will experience recurrent pressure ulcers (Niazi. Other epide-miological studies indicate that 36% to 50% of persons with SCI who develop pressure ulcers will subsequently develop another ulcer within 1 year following initial healing. vocational. Kronowitz. Byrne. It is estimated that up to 80% of persons with SCI will develop a pressure ulcer sometime in their life. and scapula (5%) (Lui. and long-term hospi-talization account for an estimated $6.5 billion annually (Centers for Disease Control. The most commonly cited areas for pressure ulcers to occur are the ischium (24%). 1999).ulcers (decubiti) that are debilitating and potentially life threatening. & Buell. and Stage 4 including skin necrosis involving the bone or joint with or without infection (Wilhelmi & Neumeister. National Institute for Disability and Rehabilitation Research. Stage 2 defined as a blister or other break in the dermis with or without infection. 1996. trochanter (15%). 2002). 2002). The estimated cost of treating severe pressure ulcers may exceed $50. heel (8%). equipment and wound care. The consequences of this largely preventable problem can be severe and can. 1990. Skin-related complications are the leading cause of failure to achieve educational. Costs for treatment. . & Viehbeck. Stage 3 described as subcutaneous destruction into the muscle with or without infection.000 per occurrence (Pires & Adkins. There are also multiple indirect emotional and physical costs for lengthy periods of inactivity. 1996). result in death. Salzberg. Severity is measured with a diagnosis of pressure sore staging. Wilhelmi & Neumeister. Pressure ulcers are also expensive to treat. 2002). 1994). Hale. with Stage 1 described as reddening of the skin for 1 or more hours after relief of pressure. The etiology of pressure ulcers is well documented. & Bauman.
In addition. Little is known about why some individuals have recurring problems and others remain relatively ulcer free. 2002). edema. 1998. and endocrine disorders. pressure releases. temperature increases. Previous prevention research supports patient education regarding proper skin care. regardless of whether persons are living near one of the 16 model centers across the nation. transcutaneous oxygen. early detection. Although skin care and pressure ulcer prevention education is widely conducted at most model spinal cord injury centers. aging (blood flow decreases after the fifth decade of life).. we explored what behavioral management wellness strategies/habits persons with SCI who rarely.g. and intervention. managed care's shorter length-of-stay policies for persons with spinal cord injury (e. There are virtually no studies of people who have lived for years with SCI and have not developed pressure ulcers. it is unknown as to how much. nutrition. 1999. Jelbart. if ever. Four research questions were posed: 1. Therefore. the problem persists. if any. Patient education strategies on an outpatient basis are often nonexistent or limited. & Marshall. Because many people with SCI are at lifelong risk. it is imperative that they develop effective strategies for preventing severe pressure ulcers.friction and shearing. Is there a differential effect in pressure ulcer prevention strategies for persons with SCI with healthy skin versus similarly injured persons with pressure ulcer problems? . prevention is covered at lesser specialized hospitals. Wilhelmi & Neumeister. such as neuromuscular electrical stimulation. Rischbeith. With aggressive management. and smoking effects as well as more expensive intervention strategies.. nutrition (protein insufficiency inhibits ulcer healing). serious pressure sores can be prevented in the majority of cases. Despite what we know about pressure ulcers and methods of prevention. and skin flap surgery (Lui et al. fewer than 60 days on average) may affect the content and quality of prevention strategies provided. alcohol. sustain a pressure ulcer use in their daily lives and compared this group with those who have recurrent problems with pressure ulcers. anemia.
11-15 years. Is there a differential effect in occurrence of pressure ulcers between those persons with SCI with healthy skin versus similarly injured persons with pressure ulcer problems when compared by health and wellness behaviors? 4. 2. To achieve equivalent groups. and years since injury (6-10 years. we established a sampling stratified by level of neurologic impairment (complete/incomplete injury. we randomly selected prospective participants from a database of patients who had received initial rehabilitation in a health system designated as an SCI Model System of Care by the U. patients are contacted for a follow-up visit or interview annually at 1. We sent out the preliminary survey to 200 prospective participants (100 with and 100 without a history of ulcers).2. and 16-20 years).S. The database included 203 former patients who presented at one of these three follow-up visits (or reported during a follow-up interview) with one or more pressure ulcers (pressure ulcer group) and 300 former patients with no such documented history of pressure ulcers (ulcer-free group). All prospective participants were at least 6 years postinjury. as shown in Table 1. Is there a differential effect in occurrence of pressure ulcers between those persons with SCI with healthy skin versus similarly injured persons with pressure ulcer problems when compared by demographic factors? 4. Department of Education. and 5 years postinjury. On the basis of this stratified sampling procedure. with a . This stratified sampling procedure resulted in 12 cells of individuals. Is there a differential effect in occurrence of pressure ulcers between those persons with SCI with healthy skin versus similarly injured persons with pressure ulcer problems when compared by disability-specific characteristics? Method Sample We attempted to enroll a sample of 50 individuals with a history of pressure ulcers (the pressure ulcer group) and 50 individuals who had been essentially ulcer free for the past 5 years. para/tetraplegia). As one requirement of the Model Systems program.
and 2 indicated that they were ambulatory and.follow-up mailing 1 month later. TABLE 1. therefore. had no problems with pressure ulcers). complete sample of 45 individuals in the ulcer-free group and 41 individuals in the pressure ulcer group. Stratified Sample and Distribution of Parti of Participants Across Cells Level of injury Incomplete para Complete tetra Complete para Incomplete tetra Years postinjury (20% ) (30% ) (250% ) (25% ) Sampling frame for respondent selection[supa] 6-10 (42% ) 8 13 11 11 11-15 (48% ) 10 14 12 12 16-20 (10% ) 2 3 2 2 Sample of respondents with history of pressure ulcers[supb] 6-10 (41% ) 0 6 4 7 11-15 (56% ) 5 8 6 4 . for a response rate of 43%. We successfully contacted 86 participants and completed the follow-up interviews. resulting in a final. We received responses back from 100 participants. We attempted telephone interviews with 96 of the respondents (2 did not consent to interviews. split about evenly between those with a history of ulcers and those who were ulcer free. The distribution of these participants according to the sampling frame is noted in Table 1.
Surveys were mailed to prospective participants. alcohol and cigarette use. responses to signs of problems. Results Preliminary results from the mail survey and telephone interviews are presented in Table 2. Tetra = tetraplegia. and data entries were checked for accuracy. A data clerk entered all data into a Microsoft Excel database. frequency of skin checks and pressure releases. Measures and Procedures Data were collected using a mailed survey and a follow-up telephone interview. summarized below. Para = paraplegia. bowel and bladder care. weight and nutritional habits. The survey and follow-up interview included demographic questions about type of seat cushion used. [supc]N = 45.3% ) 0 1 0 0 Note. Pearson chi-square and univariate analysis of variance (ANOVA) were used to determine statistically significant differences . living circumstances. [supb]N = 41. and a research nurse completed follow-up telephone interviews. hospitaltaught prevention strategies.16-20 (2. shower method. daily time sitting in wheelchair. creative strategies used to prevent pressure ulcers. [supa]Used for each group. sleep habits. exercise practices.4% ) 0 1 0 0 Sample of respondents with healthy skin[supc] 6-10 (47% ) 5 7 1 8 11-15 (51% ) 5 9 4 5 16-20 (2. and factors attributed to success in preventing ulcers. number of daily transfers.
03 Frequency of weight shifts (min) 61 83 57 62. Differences between groups with a probability of occurring by chance of less than . The use of an F test over a t test tends to be appropriate when sample sizes are over 30 and group sizes are unequal.1 2.7 . as initially it was from a convenient sample.2 Number of daily transfers* 4.5 7.5 5.19 14. such as our Yes-No questions.6 9. and were present on our independent variables.28 6.5 35.05 are noted with an asterisk. Differences in Responses to Selected Survey Items for the Pressure Ulcer (PU) and Ulcer-Free (UF) Groups PU group (n = 41) UF group (n = 45) Survey item M SD M SD Years of education 13.2 16.5 4.5 38.between the two groups.4 3. such as group membership and gender.2 15. as in the case of this study.3 3.6 2.5 157.3 8. as might be suspected in the current sample.19 Weight (in pounds)* 175.2 Alcoholic drinks/week 6. ANOVA procedures were conducted when continuous data were available for our dependent variable and categorical data were available for our independent variable. Chi-squares were used when categorical data were present on our dependent data.2 Number of cigarettes/day 16. It also tends to be more robust to violations of normality.1 Hours out of bed 14. TABLE 2.67 5.2 7.
14 6.0 (18) Employed* 21.8 (26) Catheter leakage problems 39 (16) 28.7 (3) Pressure ulcer since 1st year postinjury 48.8 (8) Pressure ulcer 1st year postinjury 24.8 (20) 17.8 (8) Hospitalization for pressure ulcers 43 (18) 11.4 (10) 6.1 (7) 40.9 3.1 (5) Sensation below injury level 51.2 (28) Can you sense buttock discomfort? Yes 39 (16) 57.1 Hospitalizations for pressure ulcers 2.96 1.36 1.Glasses of non-alcohol/day 8.6 (16) Do you smoke? Yes 26.2 (1) .9 (13) Anal leakage problems* 17.8 (11) 17.3 (10) 46 (21) Married 39 (16) 35.50 0.7 5.1 (7) 2.71 % of Respondents % of Respondents PU group PU group Female* 17.2 (21) 62.
They also were more likely to report pressure ulcers requiring medical treatment since the first year postinjury.7 (39) Note. F(1. For all parametric analyses reported herein.90. using a Yes-No question.).05.05. no statistical assumptions were violated.) than those in the ulcer-free group (M = 157.67 transfers for the pressure ulcer group. X[sup2](1.05.N = 18) = 5. A disc4iminant ANOVA was conducted to . with a significantly higher percentage of males in the pressure ulcer group. compared with an average of 4.87.28 transfers.5 lbs. n = 3 for the ulcer-free group) reported experiencing pressure ulcers requiring medical treatment during their first year after injury. N = 37) = 5. X[sup2] (1.76. 93) = 4.05. checks of skewness and kurtosis were found to be within normal limits. A statistically significant difference was also noted between the two groups in the typical number of wheelchair transfers performed daily. F(1. *p < . p < . p < .37. Numbers in parentheses indicate number of respondents.5 lbs. p < . Participants in the pressure ulcer group were heavier (M = 175.1 (39) 86. As might be expected. and whether they were more likely to report pressure ulcers requiring medical treatment since the first year postinjury. as was the homogeneity of variance test. Respondents in the ulcer-free group had an average of 7.001 (n = 5 for the ulcer-free group). N = 18) = 11. 84) = 4. more individuals in the pressure ulcer group (n = 10.Taught ulcer prevention techniques 100 (41) 100 (45) Still use prevention techniques 95.74. To analyze research questions having continuous data. A Pearson chi-square was conducted to determine whether individuals in the pressure ulcer group reported experiencing pressure ulcers requiring medical treatment during their first year after injury. checks were made to ensure the appropriateness of using parametric techniques. X[sup2] (1. The groups further differed with regard to gender. To determine whether weight differences were present between our two groups. p < . an ANOVA was performed.05 (n = 27 for the ulcer-free group). p < . That is.
each group was asked what self-practices they believed to be the most important in preventing serious pressure ulcers. our findings indicate that individuals who are relatively ulcer free are likely to be female. Discussion It is important to note that results from this study are preliminary.05 (n = 1 for the ulcer-free group). First.33.05. canonical correlation = . A statistically significant discriminant function was obtained. N = 7) = 4. as well as being more active regarding frequent pressure releases or "squirming" in their wheelchair. to consume less alcohol.244). In general.. p < . employed. Statistically significant differences between groups. Regarding type of cushion used. accounting for 6% of the variance in group members (e. X[sup2] (1. One final key difference between groups was that the ulcer-free group reported having more sensation below their level of injury than did the pressure ulcer group. whereas those in the ulcer-free group were more likely to use gel-type (e.. X[sup2] (1.g.g. p < . marital status.95. and to have fewer incontinence problems and greater sensation in the buttocks region. years of education.g. Several limitations with this study should be noted. Employment status was found to contribute significantly to this differentiation-almost half (n = 21) of the ulcer-free participants were employed. those in the pressure ulcer group were more likely to identify frequent skin checks and early intervention as important success factors. respondents in the pressure ulcer group were more likely to use air bladder cushions (e. and nonsmokers. Participants in the pressure ulcer group had significantly more leakage problems from anal discharge than did participants in the ulcer-free group. These findings support many of the risk/nonrisk factors already reported in the literature as associated with pressure ulcers. current living status. or height. were noted for three success factors: Participants in the ulcer-free group were more likely to identify general activity level or "squirming" (shifting in their chair) and sensation in the buttocks as important success factors. compared with 24.05 (n = 1 for the ulcer-free group). categorization of . N = 7) = 5.determine whether group membership could be differentiated on the basis of employment status. ps < .3% (n = 10) of those in the pressure ulcer group. to weigh less. Roho). Jay) cushions. weight. race.. Finally.
this preliminary examination does indicate a number of areas that warrant further investigation. This is reflected by the fact that a sizable percentage of participants in the ulcer-free group reported having ulcers during or after their first year postinjury that required medical treatment (6. are just a periodic snapshot of the patient. Eleven percent (n = 5) of those in the ulcer-free group had been hospitalized at some point for treatment of a pressure ulcer.participants into the pressure ulcer and ulcer-free groups was based on limited information and is somewhat erroneous. The follow-up visits. Respondents in the pressure ulcer group were more likely to conduct or have an . activity level may serve as an important marker variable in the identification of individuals who are at greater risk for developing pressure ulcers after discharge from inpatient rehabilitation. First. If a more definitive relationship between activity level and ulcer prevention can be established. A second limitation of this study is that much of the information reported is based on self-reports by participants. the pressure ulcer group included those with a documented ulcer at one or more follow-up visits. The ulcer-free group comprised those with no ulcers documented at a follow-up visit. Despite the limitations noted above. A second interesting difference between groups is the value they placed on skin checks as a prevention measure: Individuals in the pressure ulcer group were twice as likely to identify skin checks as an important prevention technique compared to the ulcer-free group. individuals in the ulcer-free group also engaged in more transfers daily. documented in the SCI Model Systems database. Related to activity level. the fact that individuals in the ulcer-free group identified overall activity level and "squirming" as important success factors in preventing ulcers is worth further investigation. however.7% [n = 3] during the first year and 17. who may have ulcers at other times of the year that do not get documented at follow-up. They were also more likely to identify sensation in the buttocks (which may lead to more squirming) as a factor important to success in preventing ulcers.8% [n = 8] since the first year). We originally categorized participants into two groups based on the presence of pressure ulcers at the time of their annual follow-up visits. especially with respect to their self-care and other pressure ulcer prevention practices.
and have good support systems (Marini & Chacon. indirectly this most common secondary complication of spinal cord injury may profoundly affect the lives of their clients. Given the importance placed on skin checks as part of the self-care routines taught to patients during initial rehabilitation. Rehabilitation counselors working in employment or mental health settings may not perceive any direct need to be knowledgeable about pressure sores. however. research is needed to verify the actual practices of those who are able to maintain success in preventing pressure ulcers. Those with recurring pressure sores may be unable to maintain employment. regular fluid intake. are optimistic. diet. 2002). Research has shown fairly consistent. keeping the skin clean and moisture free. 20% [n = 8]). hygiene. strong relationships regarding mortality and chronic illness effects for persons who perceive good subjective well-being or health. indicating that these individuals may be flexible in adjusting their care practices. 2004). as well as problems with accessible transportation.attendant conduct daily skin checks (63% [n = 261 compared with 46% [n = 21] of respondents in the ulcer-free group).. future research should also be directed at more cognitive factors related to wellness practices involving positive psychology. no smoking. With the approximate 70% unemployment rate among persons with SCI at any given time. daily skin checks. whereas respondents in the ulcer-free group were more likely to indicate that the frequency of checks varied based on need (38% [n = 17] vs. Being confined to bed rest for weeks or months in severe cases leads to boredom and may affect self-esteem and affect. are maximally challenged mentally in their lives (e. feel competent. Counselors can assist clients in prevention . Although our study focused more on behavioral differences in prevention of pressure ulcers between a mostly ulcer-free group versus a recurring ulcer group. Hospital-based prevention education strategies typically stress wearing loose clothing. or relationships. frequent pressure releases anywhere between 15 and 30 minutes apart. exercise. perceive their skills at work or play to adequately match the challenge). and moderate drinking (Craig Hospital. school attendance. many persons with SCI remain unchallenged and isolated in their lives.g.
exercise habits. nutritional intake. including Nautilus. hand cycles. skin care advice. This latter option is unwise. As our and other research indicates. work. Persons with high-level tetraplegia (C5 or higher) should have an electric or manual tilt-in-space . wrist weights. important questions to initially have answers to are what the client is doing or wanting to accomplish (e. functional mobility in terms of transferring and ability to perform pressure releases. Depending on length of time away from home or personal assistants. school). weight gain further enhances the likelihood of pressure ulcers. however. several issues must be addressed. Excellent information on nutritional intake for those with paraplegia versus tetraplegia. In specifically assessing this group. persons with high-level tetraplegia who are unable to empty their leg-bag or who independently catheterize will need to have someone come into the setting at specific times to assist in voiding (typically every 4-6 hours if they keep up with regular fluid intake) or reduce their fluid intake so they will not need to empty their bladder or leg-bag at work or school. as regular fluid intake minimizes the occurrence of bladder infection and skin breakdown for persons with SCI.. Persons with SCI need to reduce caloric intake and be aware that protein-enriched diets enhance the healing of pressure ulcers. and client strategies to deal with them. smoking/drinking habits. There are numerous adapted exercise equipment options for those with tetraplegia and paraplegia. Specifically related to school or work.g. Nutritional information is also important because of the sedentary lifestyle of persons with SCI. Bibliotherapy can be used to provide clients with information about exercise alternatives for persons with SCI (Craig Hospital. history of problems with pressure sores. Such questions provide the counselor with a picture of where some initial insight toward intervention or education may be needed. and so on. exercise pointers.efforts in several ways. 2004). and many other helpful topics are available on the Craig Hospital Web site. ultralight wheelchairs. Another consideration that will have likely been previously discussed but needs to be reinforced is the ability to release pressure in the buttock area.
. 47(3). & Bau-man. In many instances.. In our study. D. 2003. Teodorescu.. R.htm. M. Finally.. Kosiak. M.. (2002). Cutting the fat. clients should be encouraged to discuss this several-minute release strategy and its implications with employers. R. fromhttp://www. Kurylo. T. Chen. Craig Hospital. clients can still be attentive/ productive during this time. REFERENCES Centers for Disease Control. they may negotiate taking a shorter break if at work. Rehabilitation Psychology. S.craighospital. some persons with SCI go through life relatively ulcer free and are able to maintain healthy and productive lives. (2002). V. B. Although persons with SCI statistically have a high probability of sustaining one or more pressure ulcers throughout their lives. M. and if not. First Colloquium on Preventing Secondary Disabilities Among People with Spinal Cord Injuries. Y. Kronowitz. Lui. H. Further study is needed regarding the wellness behaviors and cognitions of those with SCI who experience few problems with ulcers over a lifetime. The recommended frequency for persons who use wheelchairs is typically 15 to 30 minutes. Kurylo. Transcutaneous oxygen tension in subjects with tetraplegia with and . (1999). Prevention and rehabilitation of pressure ulcers. & Hicken. Retrieved February 27. from http://www. 2002). documented literature on smoking and substance abuse indicates the negative effect these habits have on skin health as well as respiratory function and therefore should be placed on high priority for client education regarding the risk factors involved when engaging in these behaviors (Elliot. J. Alcohol abuse history and adjustment following spinal cord injury. 278-290. Grimm. an overwhelming number of participants in the nonpressure ulcer group reported squirming or pressure lifts as a key to avoiding ulcers..wheelchair that allows them to recline. The chances of sustaining a pressure sore can be minimized when a holistic wellness approach is taught and practiced in self-care activities specific to SCI.com/pubs/bedsorePubO2. Retrieved February 2. 2004.org/SCI/METS Elliot. W. & Hicken.woundheal.. GA: Author. (1990). A. (2004). Atlanta. Chen. Depending on the type of job or school situation.
& Viehbeck. & Adkins. Wilhelmi.com/plastic/topic462. Pires. 75. Priorities for Fiscal Years 1998-1999 for Certain Centers and Projects. & Chacon. A. Recent demographic and injury trends in people served by the Model Spinal Cord Injury Care Systems. Pressure ulcers and spinal cord injury: Scope of the problem.. 443-445. 1372-1382. Go. & Neumeister. The implications of positive psychology and wellness for rehabilitation counseling education. National Institute for Disability and Rehabilitation Research. Neuromuscular electrical stimulation keeps a tetraplegic subject in his chair: A case study. Rischbeith. S. (1998). I. Nobunaga. Hale. National Institute on Disability and Rehabilitation Research: Notice of Proposed Funding. B... G6922-G6925. Stover. Rehabilitation Education. 21(3). R. C. Niazi.. (2002). L.without pressure ulcers: A preliminary report.-M. H... (1994).htm ADDED MATERIAL .S. Topics in Spinal Cord Injury Rehabilitation. 62. R. Pressure ulcers. 2(1). 80. surgical treatment and principles. M.. Skin complications other than pressure ulcers following spinal cord injury. 36. M. M. Advances in Wound Care. Federal Register. & Marshall. D.. (1996). A. M... Spinal Cord. Z. Jelbart. A. 36(3).. Archives of Physical Medicine and Rehabilitation. Marini.. (1996). 38-42. Recurrence of initial pressure ulcers in persons with spinal cord injuries. U. Salzberg. 2002. M. & Karunus. (2002). from http://www. B. 1-8.. Department of Education. & Buell. Journal of Rehabilitation Research and Development. 202-206. Retrieved February 14. 987-993. K. Byrne. B. Archives of Physical Medicine and Rehabilitation. J. February 14).emedicine. R. 16(2). 149-164. (1999). (1997).
This action might not be possible to undo. Are you sure you want to continue?