Spinal Cord Injury and Pressure Sores Glen W. White, Ph.D. Meghan Zavodny and Sam Ho Research and Training Center on Independent Living at the University.

Spinal Cord Injury and Pressure Sores

Glen W. White, Ph.D.Meghan Zavodny and Sam Ho

Research and Training Center on Independent Living

at the University of Kansas

This training is sponsored through a

grant from the Christopher and Dana

Reeve Foundation

Special thanks to…• The Christopher and Dana Reeve Foundation

• Centers for Disease Control

• Ann Sullivan Center of Perú

• Dra. Liliana Mayo and Staff members

• Scott Richards, Ph.D. – Spain Rehabilitation Center, University of Alabama at Birmingham

• Suzanne Groah, M.D., M.S.P.H. – National Rehabilitation Hospital, Rehabilitation Research & Training Center on Secondary Conditions in the Rehabilitation of Individuals with Spinal Cord Injury

Special thanks to…

• Sam Ho

• Jaime Huerta

• Monica Ochoa

• And special thanks to Julio Chojeda for translation of materials from English to Spanish…

Acknowledgement of sources used for this presentation: Yes You Can! (Paralyzed Veterans of America) SCI: A Manual for Healthy Living (TIRR) Pressure Sores (RTC/IL & PVA) Pressure Ulcers: What You Should Know (by the

Consortium for Spinal Cord Medicine)

Presentation Review

• Define pressure sores

• Identify Personal risk factors

• Identify Environmental risk factors

• Causes of pressure sores

• Prevention of pressure sores

Pressure Sores- A Major Problem

• What are pressure sores?

– Areas of skin or soft tissue damage caused by excessive pressure or pressure of long duration

– Pressure cuts off blood supply to skin and causes death to tissue cells

– Also called pressure ulcers, bedsores or decubitus ulcers


Why are pressure sores so important to prevent?

• Most often they are very preventable!!

• Personal independence and mobility become very limited

• Slow healing process

• Possibly life-threatening

Pressure Sores- A Major Problem• 50% of all wheelchair users get a pressure

sore at least once in their life.

• In the USA over 6 billion dollars are spent on treating pressure sores and other skin problems per year.

• Pressure sores severely limit mobility and can lead to death if not treated properly.

• Once a severe pressure sore develops it weakens the skin and makes more pressure sores more likely once the sore has healed.


• 30% of SCI population develop pressure sore each year

– 7% hospitalized

• 50% of body weight supported on an 8% sitting area surface

50

8


Costly in dollars and lives• Major cause of hospitalization

• Can lead to death

• Medical expenditures

• Treatment of a single sore can range in costs between $30,000-$90,000 US$

Four Levels of Pressure Sore Grading

GRADE 1

• Skin not broken

• Redness does not fade

• May be hard or swollen

Possible Causes• Tight clothing

• Prolonged pressure

• Wrinkled sheets

GRADE 2

• Broken skin

• Reddened surface layer

• The skin produces moisture on the affected area

Possible Causes• Prolonged sitting

• Tight-fitting clothes


GRADE 3

• Extends into sub-surface of skin

• Crater-like surface

• Noticeable drainage

• May have odor

Possible Causes• Incontinence - urine/feces

• Continued pressure

• Angular bones (ischial tuberosities)

• Types of Wheelchair cushions• Poor hygiene and cleanliness


GRADE 4• Extends into muscle,

and into the bone

• Infection of the bone

• Drainage

• Major tissue damage

Possible Causes• Previous history of

pressure sores

• Prolonged pressure, incontinence

• Sharp angular bones

• Types of wheelchair cushions• Poor hygiene and cleanliness


Who Is More at Risk?

People with:• Paralysis or coma

• Spinal cord injuries (paraplegic, quadriplegic)

• Multiple sclerosis

• Orthopedic surgeries

• Spina Bifida

• Any condition with limited mobility and sensation

Braden Scale For Predicting Pressure Sore Risk

Risk factors include:• Limited mobility

• Exposure to moisture

• Inability to change body position

• Inadequate nutrition

• Lack of sensory perception

Braden Scale For Predicting Pressure Sore Risk

Sensory perception 1. Completely limited 2. Very limited 3. Slightly limited 4. No impairmentMoisture 1. Constantly moist 2. Very moist 3. Occasionally moist 4. Rarely moistActivity 1. Bedfast 2. Chairfast 3. Walks occasionally 4. Walks frequentlyMobility 1. Completely limited 2. Very limited 3. Slightly limited 4. No limitationNutrition 1. Very poor 2. Probably inadequate 3. Adequate 4. ExcellentFriction and shear 1. Problem 2. Potential problem 3. No apparent problem

High risk scores:

•17-18 or lower, in nursing home

•16-17 or lower, in hospitals

Personal factors Environmen

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Personal Risk Factors

Knowledge

• Does not know what causes pressure sores

• Health care professionals do not properly instruct patients how to avoid pressure sores

• Does not know how to do frequent weight shifts

Health Beliefs

• Does not take personal accountability for self-health

• Believes in fate versus empowered approach to maintaining health


High-Risk Behaviors

• Poor nutrition/eating habits

• Incontinence—Loss of control of bowel and bladder

• Does not practice regular routine to empty bowel and bladder to avoid incontinence.

• Does not practice weight shifts to relieve pressure on buttocks

Primary Prevention Nutrition

Poor nutrition a factor

• Weakens immune system

• Encourages swelling and slow oxygenation of cells

• More rapid tissue breakdown

• Slower healing process

• Muscle atrophy leaves bones closer to skin

Dehydration

• Fluid and chemical imbalances

Primary PreventionPerform regular self-inspection of the skin

• Conduct inspections with adequate light

• Check skin daily:

• Sitting bones

• Tailbone

• Side of hips

• Heels

• Or anywhere bone protrudes

Personal Risk Factors• Scarring from previous pressure sores

• Lack of awareness for risk factors

• Smoking

– Healing process disrupted or stalled

– Constricts blood vessels

RegularVessel

Constrictedblood vessel


• Fluctuation in weight

– Losing/gaining weight

• Unable to self-direct mobility

– Cannot independently move self

– Cannot direct someone to help

• Length of time you have been disabled

• Severity of your disability


• Pregnancy risk factors:– Weight of baby

– Holding baby

– Carrying baby


• Aging

– Increased risk for pressure sores

– Why?

• Thinning of top layer of skin

• Stiffening and loss of elasticity (scarring)

• Small blood vessels become restricted and reduce blood flow

Environmental Risk Factors• Inadequate equipment

– Cushions

• Become brittle and hard

• Do not hold air to support body

• Foam may become too weak and not provide adequate support

– Wheelchairs

• Not properly maintained—can cause injury and unanticipated secondary conditions

• Do not properly fit the user (too big or too small of a size)

Environmental Risk Factors• Mattresses

• Wrinkled

• Harsh/loose matter

• Clothing

– Not fitting properly

– Too tight• Jeans

• Shirts/blouses

• shoes

Environmental Risk Factors

Catheters

– Indwelling catheters

– External catheters

• Problem

– Pressure sores can develop on penis if catheters are not carefully monitored

Prevention of Pressure Sores• This section

will describe ways to help reduce risk and prevent pressure sores to help you stay healthy and independent!

Primary PreventionPressure Relief

• These pictures identify key areas where pressure sores frequently develop

• The person’s position should be changed at least every 2 hours when lying in bed


• This picture identifies key areas where pressure sores frequently develop

• Wheelchair users should do wheelchair pushups or shift their weight at least every 10-15 minutes, or have someone help them do so

Assistive TechnologySome technologies

include Dynamic and moving surfaces to reduce pressure

Examples:

• Alternating pressure

• Pulsating pads

• Air-fluidized bed

Assistive TechnologyWheelchair Cushions

Examples:

• Air

• Gel

• Polyurethane foam

• Hybrid 2 foam pillow

• Phase change material

Assistive TechnologyWheelchair Cushions

Examples:

• Individualized Air cells

• Also called “floatation cushions”

Assistive Technology

Static surfaces• Change shape of

surface when weight applied

Examples:

• Egg-crates

• Gel overlays

Assistive TechnologyBed Environment

• Cushioning to relieve constant pressure

• Examples:• Egg-crate cushions

• Mattress overlays

• Water mattresses or water-filled mattress inserts

• Foam rubber (for heels)

Assistive TechnologyStanding Wheelchairs

• The use of a standing wheelchair can also help to reduce pressure

• Both mobility and lifting functions can be either powered or manual

Primary PreventionPressure Relief Behaviors

Wheelchair pushups

• Pushups from wheelchair every 15-30 minutes

• Shifting weight (5-10 seconds or longer)


How to do a wheelchair pushup• Make sure brakes are on

• Each hand on arm rests (or wheels if no armrests)

• Push down extending both elbows, elevating body from seat

• Elevate buttocks from wheelchair surface 3 seconds or longer


How to do a wheelchair side bend• Make sure brakes are on

• Swing one arm rest down

• Hold onto other armrest and lean to opposite side

• Elevate one buttock for at least 3 seconds

• Repeat on other side


How to do a wheelchair front bend• Make sure brakes are on

• Lean forward (with chest to knees)

• Elevate buttocks for at least 3 seconds

• Return to upright position by pushing off of knees, handles, or armrests


Reducing pressure on the buttocks

• Research studies found:

• Duration more important than intensity

• Evenly distributed pressure less damaging

• Moderate pressure for long periods more damaging than intense for short periods

• Low diastolic pressure associated with pressure sores

Primary PreventionPressureMapping for

“HOT SPOTS”

Primary PreventionAvoid Shearing Forces

• Shearing is friction between two surfaces sliding against each other

Examples:• Bed tilted, body slides• Slide into sitting position

Prevention• Bed sheets cleaned and

fitted to bed• Avoid scraping body

parts when transferring (abrasions)

Primary PreventionKeeping Dry

Moisture is a factor

• Softens and weakens skin and tissue below

• Increases tissue destruction by 10 percent

• Keep clothing, bedding, and wheelchair cushions dry

• Avoid plastic-lined incontinence pads

• Keep at risk areas clean

• Make sure that skin isn’t too dry, either

Primary Prevention Nutrition

• Meet with doctor or nutritionist

• Develop healthy eating habits

• Well balanced diet• High in protein

• Vitamin C and zinc

• Take daily vitamins to help maintain healthy skin

Early Detection of Pressure Sore Development

Self inspection to check for: • Redness

• Difficult to see on dark-skinned persons

• Look for open sores

Difficult-to-see locations• Use mirror with long handle• Have personal assistant do skin inspection

Early Detection of Pressure Sore Development

(Is sore infected?)

Warning signs:• Thick yellow or

green pus• Bad smell from

sore• Redness or warmth

around sore

• Swelling around sore

• Tenderness around sore

• Fever or chills

• Mental confusion or difficulty concentrating

Secondary PreventionIf infection spreads

Cleaning and care• Keep clean and free of dead tissue

• Rinse with sterile salt-water solution (saline) to remove extra fluid and loose tissue

• Cleaning and care of wound requires different approaches depending upon the severity of the pressure sore

Treatment Techniquesonce a severe pressure sore develops

Debridement • High-pressure

irrigation

• Whirlpool therapy

• Pack wound with clean dressing with sterile saline solution

Novel Treatment Techniques

Negative Pressure Wound Therapy•Pressure sore is sealed under a partial vacuum•Clears out edema•Increases blood flow to wound


Hyperbaric Oxygen Treatment

•Patient spends time in a hyperbaric chamber

•Increases O2 flow to wound

•Air is 100% O2


Electrical Stimulation Therapy

•amplifies “injury current” in wound area

•alters cell membrane permeability to hasten healing


Stem Cell Therapy

•patient’s bone marrow mononuclear cells are added to wound

•reduced hospital stays by 50% in one study

Outdated Treatment Techniques(These are NOT recommended!)

Home remedies:

• Sugar and honey

• Heat lamps

• Alcohol rub and talcum powder

• Povidine-iodine

• Massaging redness

Secondary PreventionCleaning and care

for stage 1 and 2 sores:

• Keep area exposed

• Free of pressure

• Use sterile bandages soaked with saline solution to keep moist.

• Gently massage areas around the sore to stimulate circulation, but don’t irritate the pressure sore area

Secondary PreventionWhat to look for when sore is healing

• Sore size gets smaller

• Less fluid drainage

• Healthy tissue begins to grow

• Light red/pink

• Lumpy and shiny

• May take 2 to 4 weeks before healing is noticeable


for stage 3 sores:

• Keep area moist using a sterile saline solution

• Keep off the affected area, no pressure should be applied

• Have a physician or other health care provider monitor the sore for any problems


for stage 4 sores:

• Debridement

• Extensive surgery (surgical flap)

• Have a physician monitor the sore to determine best course of treatment

• Extremely serious and can be associated with infections leading to death

Surgical flap procedure to repair a Surgical flap procedure to repair a grade four pressure soregrade four pressure sore

Surgical flap procedure to repair a grade four pressure sore Œ

• The grade four pressure sore has been cleaned up in preparation for surgery

• Note that the tissue destruction has gone all the way to the bone!

Surgical flap procedure to repair a grade four pressure sore

• The skin donor site is selected for tissue removal and placement over the current pressure sore over the sacral area

Surgical flap procedure to repair a grade four pressure sore Ž

• A large incision is made to remove the skin from the donor site


• The tissue from the donor site is lifted and rotated in preparation for placement near the hole left by the grade 4 pressure sore.


• The piece of donor skin is in place over the grade 4 pressure sore and the flap of tissue from the donor site has been rotated to cover the remaining area.

Other treatment techniques for serious pressure sores

New treatments

• New dressings and topical agents

• Hormonal growth agents

• Hyper-baric oxygen chamber to facilitate new growth

• Monitors to prompt regular wheelchair pushups

Review of Today’s Session

Today we:

• Discussed the significance of pressure sores

• Defined pressure sores

• Identified personal risk factors

• Described the causes of pressure sores

• Discussed primary and secondary prevention strategies to avoid pressure sores

Spinal Cord Injury and Pressure Sores Glen W. White, Ph.D. Meghan Zavodny and Sam Ho Research and Training Center on Independent Living at the University.

Documents

pressure sores glen

excessive pressure

severe pressure sore

lifethreatening slide

spanish slide

spinal cord injury slide

dana reeve foundation

areas of skin