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AUTHOR: Jones, Michael L.; Marini, Irmo; Slate, John R.

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

2002). trochanter (15%). Teodorescu. They can result in time missed from work or school for the individual and the caregiver. 1997). & Bauman. There are also multiple indirect emotional and physical costs for lengthy periods of inactivity. vocational. and long-term hospi-talization account for an estimated $6. The estimated cost of treating severe pressure ulcers may exceed $50. National Institute for Disability and Rehabilitation Research. 1999). & Viehbeck. Severity is measured with a diagnosis of pressure sore staging. The etiology of pressure ulcers is well documented. 1996). estimated at 80% (Wilhelmi & Neumeister. sacrum (23%). Costs for treatment. 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. and social goals for individuals with SCI (Stover. 2002). Individuals with paraplegia have the highest rate of recurrence. Pressure ulcers are also expensive to treat. 1996. 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. 1996. 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 Stage 4 including skin necrosis involving the bone or joint with or without infection (Wilhelmi & Neumeister. 2002). Grimm. Kosiak (2002) described causal factors such as pressure.ulcers (decubiti) that are debilitating and potentially life threatening. Byrne. Kronowitz. The most commonly cited areas for pressure ulcers to occur are the ischium (24%).5 billion annually (Centers for Disease Control. Wilhelmi & Neumeister.000 per occurrence (Pires & Adkins. . in rare cases. heel (8%). & Buell. 1990. with Stage 1 described as reddening of the skin for 1 or more hours after relief of pressure. Salzberg. The consequences of this largely preventable problem can be severe and can. Pires & Adkins. 1994). result in death. Skin-related complications are the leading cause of failure to achieve educational. Hale. 2002). equipment and wound care.000 to $78. Stage 2 defined as a blister or other break in the dermis with or without infection. and 30% will experience recurrent pressure ulcers (Niazi. Stage 3 described as subcutaneous destruction into the muscle with or without infection.

early detection. Because many people with SCI are at lifelong risk. In addition. 1999. 1998. Patient education strategies on an outpatient basis are often nonexistent or limited. Therefore. it is imperative that they develop effective strategies for preventing severe pressure ulcers. With aggressive management. Previous prevention research supports patient education regarding proper skin care. Although skin care and pressure ulcer prevention education is widely conducted at most model spinal cord injury centers. transcutaneous oxygen. aging (blood flow decreases after the fifth decade of life). if any. if ever. Rischbeith. Jelbart. Despite what we know about pressure ulcers and methods of prevention. regardless of whether persons are living near one of the 16 model centers across the nation. we explored what behavioral management wellness strategies/habits persons with SCI who rarely. such as neuromuscular electrical stimulation. sustain a pressure ulcer use in their daily lives and compared this group with those who have recurrent problems with pressure ulcers. 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? . There are virtually no studies of people who have lived for years with SCI and have not developed pressure ulcers. temperature increases. and endocrine disorders. pressure releases.. prevention is covered at lesser specialized hospitals. alcohol. 2002). Little is known about why some individuals have recurring problems and others remain relatively ulcer free. nutrition. and smoking effects as well as more expensive intervention strategies. serious pressure sores can be prevented in the majority of cases. it is unknown as to how much. and intervention. the problem persists.friction and shearing. nutrition (protein insufficiency inhibits ulcer healing). Four research questions were posed: 1. anemia. managed care's shorter length-of-stay policies for persons with spinal cord injury (e. Wilhelmi & Neumeister. & Marshall.g.. fewer than 60 days on average) may affect the content and quality of prevention strategies provided. edema. and skin flap surgery (Lui et al.

As one requirement of the Model Systems program. as shown in Table 1. para/tetraplegia). 2. We sent out the preliminary survey to 200 prospective participants (100 with and 100 without a history of ulcers).2. 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. 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. 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 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. and 5 years postinjury. 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. and 16-20 years). This stratified sampling procedure resulted in 12 cells of individuals. All prospective participants were at least 6 years postinjury. and years since injury (6-10 years. patients are contacted for a follow-up visit or interview annually at 1. with a . On the basis of this stratified sampling procedure. we established a sampling stratified by level of neurologic impairment (complete/incomplete injury. Department of Education. 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). To achieve equivalent groups.S.

complete sample of 45 individuals in the ulcer-free group and 41 individuals in the pressure ulcer group. We successfully contacted 86 participants and completed the follow-up interviews. TABLE 1. 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 . We received responses back from 100 participants. had no problems with pressure ulcers). The distribution of these participants according to the sampling frame is noted in Table 1. for a response rate of 43%.follow-up mailing 1 month later. split about evenly between those with a history of ulcers and those who were ulcer free. and 2 indicated that they were ambulatory and. therefore. We attempted telephone interviews with 96 of the respondents (2 did not consent to interviews. resulting in a final.

number of daily transfers. frequency of skin checks and pressure releases. shower method. Pearson chi-square and univariate analysis of variance (ANOVA) were used to determine statistically significant differences . hospitaltaught prevention strategies. and factors attributed to success in preventing ulcers. daily time sitting in wheelchair. creative strategies used to prevent pressure ulcers. weight and nutritional habits. A data clerk entered all data into a Microsoft Excel database. responses to signs of problems. summarized below. sleep habits. Surveys were mailed to prospective participants.3% ) 0 1 0 0 Note. exercise practices.16-20 (2. [supb]N = 41. Tetra = tetraplegia. bowel and bladder care. Results Preliminary results from the mail survey and telephone interviews are presented in Table 2. [supa]Used for each group. and data entries were checked for accuracy. and a research nurse completed follow-up telephone interviews. [supc]N = 45. The survey and follow-up interview included demographic questions about type of seat cushion used. Para = paraplegia. alcohol and cigarette use.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. living circumstances. Measures and Procedures Data were collected using a mailed survey and a follow-up telephone interview.

6 2. Differences between groups with a probability of occurring by chance of less than .2 Number of cigarettes/day 16. TABLE 2. as initially it was from a convenient sample.1 Hours out of bed 14. such as group membership and gender.5 5. Chi-squares were used when categorical data were present on our dependent data. 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. 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.67 5.3 3.19 Weight (in pounds)* 175.between the two groups. It also tends to be more robust to violations of normality.7 .05 are noted with an asterisk.2 15.6 9. ANOVA procedures were conducted when continuous data were available for our dependent variable and categorical data were available for our independent variable.28 6. and were present on our independent variables. such as our Yes-No questions.5 38.1 2.2 16.03 Frequency of weight shifts (min) 61 83 57 62. as in the case of this study.3 8.2 Number of daily transfers* 4.5 157.5 7. as might be suspected in the current sample.19 14.2 Alcoholic drinks/week 6.2 7.5 4.5 35.4 3.

2 (21) 62.2 (28) Can you sense buttock discomfort? Yes 39 (16) 57.1 Hospitalizations for pressure ulcers 2.8 (26) Catheter leakage problems 39 (16) 28.7 (3) Pressure ulcer since 1st year postinjury 48.71 % of Respondents % of Respondents PU group PU group Female* 17.4 (10) 6.9 3.1 (7) 2.1 (5) Sensation below injury level 51.8 (11) 17.6 (16) Do you smoke? Yes 26.9 (13) Anal leakage problems* 17.7 5.3 (10) 46 (21) Married 39 (16) 35.8 (8) Hospitalization for pressure ulcers 43 (18) 11.96 1.50 0.0 (18) Employed* 21.2 (1) .14 6.Glasses of non-alcohol/day 8.1 (7) 40.8 (20) 17.36 1.8 (8) Pressure ulcer 1st year postinjury 24.

05.1 (39) 86.) than those in the ulcer-free group (M = 157. p < .90. and whether they were more likely to report pressure ulcers requiring medical treatment since the first year postinjury.7 (39) Note. F(1.N = 18) = 5. N = 37) = 5. 84) = 4.001 (n = 5 for the ulcer-free group).28 transfers. Participants in the pressure ulcer group were heavier (M = 175. p < . p < . A disc4iminant ANOVA was conducted to . The groups further differed with regard to gender. F(1. with a significantly higher percentage of males in the pressure ulcer group. X[sup2](1. compared with an average of 4.05 (n = 27 for the ulcer-free group). p < . To analyze research questions having continuous data. A statistically significant difference was also noted between the two groups in the typical number of wheelchair transfers performed daily. using a Yes-No question. They also were more likely to report pressure ulcers requiring medical treatment since the first year postinjury. As might be expected. N = 18) = 11. checks were made to ensure the appropriateness of using parametric techniques. n = 3 for the ulcer-free group) reported experiencing pressure ulcers requiring medical treatment during their first year after injury.37.05.5 lbs. an ANOVA was performed. X[sup2] (1. That is.74.). Respondents in the ulcer-free group had an average of 7. more individuals in the pressure ulcer group (n = 10. *p < . Numbers in parentheses indicate number of respondents. To determine whether weight differences were present between our two groups. X[sup2] (1.87.76. p < .67 transfers for the pressure ulcer group. 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.05. checks of skewness and kurtosis were found to be within normal limits. as was the homogeneity of variance test. For all parametric analyses reported herein.05. no statistical assumptions were violated. 93) = 4.Taught ulcer prevention techniques 100 (41) 100 (45) Still use prevention techniques 95.5 lbs.

to weigh less. First. X[sup2] (1. Participants in the pressure ulcer group had significantly more leakage problems from anal discharge than did participants in the ulcer-free group. Discussion It is important to note that results from this study are preliminary. p < . 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.05.. or height. to consume less alcohol.. p < . each group was asked what self-practices they believed to be the most important in preventing serious pressure ulcers. Finally.33. N = 7) = 5. categorization of . X[sup2] (1. current living status. Employment status was found to contribute significantly to this differentiation-almost half (n = 21) of the ulcer-free participants were employed. In general. Several limitations with this study should be noted. 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. and nonsmokers. marital status.05 (n = 1 for the ulcer-free group). those in the pressure ulcer group were more likely to identify frequent skin checks and early intervention as important success factors. Roho). N = 7) = 4. ps < .3% (n = 10) of those in the pressure ulcer group. Jay) cushions. years of education. A statistically significant discriminant function was obtained. whereas those in the ulcer-free group were more likely to use gel-type (e..244). accounting for 6% of the variance in group members (e. canonical correlation = . as well as being more active regarding frequent pressure releases or "squirming" in their wheelchair. Statistically significant differences between groups. employed.g.05 (n = 1 for the ulcer-free group). weight. race. our findings indicate that individuals who are relatively ulcer free are likely to be female.g. Regarding type of cushion used.determine whether group membership could be differentiated on the basis of employment status. These findings support many of the risk/nonrisk factors already reported in the literature as associated with pressure ulcers.g.95. respondents in the pressure ulcer group were more likely to use air bladder cushions (e. and to have fewer incontinence problems and greater sensation in the buttocks region.

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. are just a periodic snapshot of the patient.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. A second limitation of this study is that much of the information reported is based on self-reports by participants. however. If a more definitive relationship between activity level and ulcer prevention can be established. 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. Related to activity level. individuals in the ulcer-free group also engaged in more transfers daily. The follow-up visits. Eleven percent (n = 5) of those in the ulcer-free group had been hospitalized at some point for treatment of a pressure ulcer. documented in the SCI Model Systems database.participants into the pressure ulcer and ulcer-free groups was based on limited information and is somewhat erroneous. Despite the limitations noted above. 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. First. Respondents in the pressure ulcer group were more likely to conduct or have an . 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. the pressure ulcer group included those with a documented ulcer at one or more follow-up visits.8% [n = 8] since the first year). The ulcer-free group comprised those with no ulcers documented at a follow-up visit. this preliminary examination does indicate a number of areas that warrant further investigation. especially with respect to their self-care and other pressure ulcer prevention practices. We originally categorized participants into two groups based on the presence of pressure ulcers at the time of their annual follow-up visits.

regular fluid intake. Being confined to bed rest for weeks or months in severe cases leads to boredom and may affect self-esteem and affect. research is needed to verify the actual practices of those who are able to maintain success in preventing pressure ulcers.attendant conduct daily skin checks (63% [n = 261 compared with 46% [n = 21] of respondents in the ulcer-free group). no smoking. hygiene. Rehabilitation counselors working in employment or mental health settings may not perceive any direct need to be knowledgeable about pressure sores. strong relationships regarding mortality and chronic illness effects for persons who perceive good subjective well-being or health. indirectly this most common secondary complication of spinal cord injury may profoundly affect the lives of their clients. Those with recurring pressure sores may be unable to maintain employment. are optimistic. future research should also be directed at more cognitive factors related to wellness practices involving positive psychology. Research has shown fairly consistent. 20% [n = 8]). indicating that these individuals may be flexible in adjusting their care practices. school attendance. as well as problems with accessible transportation. and moderate drinking (Craig Hospital. exercise. 2004). or relationships. frequent pressure releases anywhere between 15 and 30 minutes apart. Although our study focused more on behavioral differences in prevention of pressure ulcers between a mostly ulcer-free group versus a recurring ulcer group. Counselors can assist clients in prevention . perceive their skills at work or play to adequately match the challenge). feel competent. 2002). diet. daily skin checks. and have good support systems (Marini & Chacon. 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. With the approximate 70% unemployment rate among persons with SCI at any given time. Hospital-based prevention education strategies typically stress wearing loose clothing. Given the importance placed on skin checks as part of the self-care routines taught to patients during initial rehabilitation. keeping the skin clean and moisture free. many persons with SCI remain unchallenged and isolated in their lives. however.. are maximally challenged mentally in their lives (e.g.

work. Bibliotherapy can be used to provide clients with information about exercise alternatives for persons with SCI (Craig Hospital. and many other helpful topics are available on the Craig Hospital Web site. Nutritional information is also important because of the sedentary lifestyle of persons with SCI. In specifically assessing this group. several issues must be addressed. 2004). as regular fluid intake minimizes the occurrence of bladder infection and skin breakdown for persons with SCI. Another consideration that will have likely been previously discussed but needs to be reinforced is the ability to release pressure in the buttock area. 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 our and other research indicates. ultralight wheelchairs. Specifically related to school or work. Excellent information on nutritional intake for those with paraplegia versus tetraplegia.. Such questions provide the counselor with a picture of where some initial insight toward intervention or education may be needed. Persons with SCI need to reduce caloric intake and be aware that protein-enriched diets enhance the healing of pressure ulcers.efforts in several ways.g. school). nutritional intake. important questions to initially have answers to are what the client is doing or wanting to accomplish (e. Depending on length of time away from home or personal assistants. smoking/drinking habits. wrist weights. There are numerous adapted exercise equipment options for those with tetraplegia and paraplegia. exercise pointers. and so on. Persons with high-level tetraplegia (C5 or higher) should have an electric or manual tilt-in-space . including Nautilus. functional mobility in terms of transferring and ability to perform pressure releases. however. and client strategies to deal with them. skin care advice. exercise habits. weight gain further enhances the likelihood of pressure ulcers. This latter option is unwise. hand cycles. history of problems with pressure sores.

M. R. Kurylo.wheelchair that allows them to recline. Alcohol abuse history and adjustment following spinal cord injury. J. Teodorescu. D.com/pubs/bedsorePubO2. Prevention and rehabilitation of pressure ulcers. & Hicken. Depending on the type of job or school situation. Y. Transcutaneous oxygen tension in subjects with tetraplegia with and . 2002). M... from http://www. The recommended frequency for persons who use wheelchairs is typically 15 to 30 minutes. Grimm. REFERENCES Centers for Disease Control. & Bau-man. 2003. In our study.woundheal.. (1990). GA: Author.. some persons with SCI go through life relatively ulcer free and are able to maintain healthy and productive lives. Atlanta. Further study is needed regarding the wellness behaviors and cognitions of those with SCI who experience few problems with ulcers over a lifetime. In many instances. 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. Retrieved February 2.htm. Finally. 47(3). Kurylo. fromhttp://www. W. S. and if not.craighospital. Lui. (1999). (2002). Although persons with SCI statistically have a high probability of sustaining one or more pressure ulcers throughout their lives. Craig Hospital. Rehabilitation Psychology. Kosiak. B.. Chen. (2002). (2004)..org/SCI/METS Elliot. clients should be encouraged to discuss this several-minute release strategy and its implications with employers. H. Kronowitz. T. they may negotiate taking a shorter break if at work. 2004. A. First Colloquium on Preventing Secondary Disabilities Among People with Spinal Cord Injuries.. & Hicken. 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. an overwhelming number of participants in the nonpressure ulcer group reported squirming or pressure lifts as a key to avoiding ulcers. Chen. clients can still be attentive/ productive during this time. Cutting the fat. V. M. 278-290. Retrieved February 27. R.

K. (2002). 443-445. Rehabilitation Education. G6922-G6925. 1-8. from http://www. H. & Buell.. Rischbeith. National Institute on Disability and Rehabilitation Research: Notice of Proposed Funding. M. & Neumeister. (1996). 2(1). 1372-1382. & Chacon. Advances in Wound Care. (2002).. 36. U. & Marshall. National Institute for Disability and Rehabilitation Research.. Hale... S. 21(3). surgical treatment and principles. Journal of Rehabilitation Research and Development. B.. 149-164. B.. Go. The implications of positive psychology and wellness for rehabilitation counseling education. M. (1999).S. Marini. Wilhelmi. Niazi. Byrne. Archives of Physical Medicine and Rehabilitation. February 14). A. R. 36(3). C.without pressure ulcers: A preliminary report. A. M. 2002. Spinal Cord. 75. Recent demographic and injury trends in people served by the Model Spinal Cord Injury Care Systems..com/plastic/topic462. & Viehbeck. Priorities for Fiscal Years 1998-1999 for Certain Centers and Projects. Archives of Physical Medicine and Rehabilitation. Jelbart. Recurrence of initial pressure ulcers in persons with spinal cord injuries. D.. Pressure ulcers. Stover.. (1998). R.htm ADDED MATERIAL . Retrieved February 14. 202-206. (1997). M. 38-42. J.-M. Z. Pires.emedicine. Skin complications other than pressure ulcers following spinal cord injury. Topics in Spinal Cord Injury Rehabilitation. Nobunaga. Federal Register. Salzberg. B. Pressure ulcers and spinal cord injury: Scope of the problem. 987-993. (1994). 62. M. I. Department of Education. Neuromuscular electrical stimulation keeps a tetraplegic subject in his chair: A case study.. L.. 80. 16(2). & Adkins.. A. R. (1996). & Karunus.

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