While it is true that anyone can get a pressure sore, individuals with spinal cord injury (SCI) are at particularly high risk. The statistics certainly bear this out: in fact, it is estimated that a staggering 80% of individuals with spinal cord injury will have at least one pressure sore during their lifetime, while 30% will have more than one.1
Its relatively mild label belies its gravity. Pressure sores—known to most laypeople as “bed sores” but also referred to in the medical community as pressure ulcers or decubitus ulcers—are injuries to the skin and the underlying tissue. When hospital patients, particularly those with SCI, sit or lie in the same position for too long, the flow of blood is cut off to that area. As a result, oxygen and vital nutrients are restricted from maintaining healthy tissue. After some time—different for each patient—the “starving” tissue begins to die, and a pressure sore starts to form. Typically, the sores appear on parts of the body over weight-bearing, bony prominences, such as hips and heels.2
It is no wonder that SCI patients are far more prone to pressure sores than patients with other diagnoses: normally, the nerves send messages of pain or feelings of discomfort to the brain, indicating that the person must change position. But the damage to the spinal cord prohibits those messages from reaching their intended destination.
The potential complications of pressure sores are numerous. Besides being life-threatening, they can spread infection to various parts of the body, including the blood, heart, and bones. What is more, they can result in amputation or autonomic dysreflexia, an overactivity of the autonomic nervous system when an irritating stimulus is introduced to the body below the level of spinal cord injury at a T-5 level and above.
There are four stages of pressure sores, with the fourth stage being the most acute. Before discussing how to prevent and treat pressure sores, it is instructive to understand and recognize these stages:
Stage One: Skin is red or discolored; the redness or change in color does not fade within 30 minutes after pressure is applied and subsequently removed.
Stage Two: The topmost layer of the skin is broken. As a result, a shallow open sore is created, in which drainage may be present.
Stage Three: The break in the skin is deeper than Stage Two, extending through the dermis (second skin layer) into the subcutaneous and fat tissue.
Stage Four: The breakdown extends into the muscle and may even go down as far as the bone. A great deal of dead tissue and drainage generally accompany the breakdown.2
Ultimately, the best way to treat pressure sores is to prevent them from happening in the first place. Prevention encompasses a wide variety of tactics; while each tactic may require minor modification from patient to patient, the following list represents a commonly accepted approach that should prove effective in a majority of cases:
Body Positions. The patient’s position is perhaps the most crucial factor in relieving pressure on the sore and reducing the incidence of new ones. While in bed, the patient should absolutely avoid lying on the pressure sore; using pads or pillows to position the body will help relieve the pressure on specific areas. Because lying directly on the hip bone can increase the chances for a sore, a 30-degree position is recommended. Patient should keep their lower legs elevated when lying on their back by placing a thin foam pad or pillow under the lower part of the legs.
Turning. Patients should be turned frequently, and the skin should be carefully examined between turns. This should be done every 2 hours initially, with turning time increased when hyperemia (a condition in which blood congests in a particular area of the body) over bony prominences is unable to resolve within 30 minutes. In addition to turning, all positions, including the prone position and side-lying, should be employed.
Sitting. At the beginning of the patient’s hospitalization, sitting should be limited to a maximum of 1 hour (although it can be increased every few days if hyperemia resolves within 30 minutes). The ideal sitting position is to place the patient’s buttocks as far back as possible in the chair; footrests should be adjusted to permit the knees to be at or slightly below the level of the hips. Pressure reliefs should be performed frequently.
Equipment. The equipment used in the hospital should be as similar as possible to the equipment that will be used after the patient is discharged to the home setting. Air-flotation and air-fluidized beds, for example, are suitable for hospital use in the beginning or to treat pressure ulcers but are not recommended for home use. Cushions can be a very effective element during the healing phase, and can be used in both wheelchairs and beds. Most cushions are made of foam or gel and filled with air or water; since each exhibits different properties related to maintaining skin temperature, humidity, and stability, the choice of which ones to use should be considered carefully.
Nutrition. Maintaining healthy skin is one of the key approaches to avoid pressure sores, and nutrition is the single most important way to accomplish that objective. Since diets rich in vitamins A and C help keep skin healthy, the patient should be encouraged to consume generous amounts of fruits and vegetables.3 A healthy circulatory system helps prevent pressure sores by providing adequate blood flow to all parts of the body. It is also crucial for people with SCI to maintain sufficient amounts of calcium and vitamin D, which helps the body absorb calcium. Protein also plays a role in helping SCI patients avoid pressure sores.
In order to effectively perform weight shifts and use the correct technique during body transfers, the patient needs to maintain a healthy body weight. A diet that includes foods high in complex carbohydrates, such as breads, pasta, cereals, or starchy vegetables, helps to maintain a healthy body weight by providing a feeling of fullness for a longer period of time than with simple carbohydrates.3 It is also important to include foods high in fiber, which are integral to an effective bowel program for people with SCI, as moisture from bowel and bladder accidents weakens skin and causes it to break down more quickly.4
It should be noted that while being overweight can be a detriment to people with SCI and can contribute significantly to the incidence of pressure sores, being underweight can have negative ramifications as well. In their study of 560 people with SCI, Krause et al3 found that being underweight was consistently associated with a higher risk of pressure sores.
Despite the health care provider’s best efforts, a patient may still get one or more pressure sores. (Interestingly, many patients whose caretakers perform regular pressure releases may get pressure ulcers, while the reverse is also true—patients who do not do pressure releases do not necessarily get pressure ulcers.)5 Once a patient does get a pressure sore, there are effective ways to treat it. With proper care, most pressure sores will heal, leaving few, if any, complications. Following are the recommended treatment options for the various stages of sores:
- Keep pressure off the sore;
- Maintain good hygiene by washing with mild soap and water, rinsing well, and gently patting dry;
- Evaluate the patient’s diet to ensure that there is enough protein, calories, vitamins A and C, zinc, and iron;
- Review the patient’s mattress, wheelchair cushion, transfers, pressure releases, and turning techniques for the root cause of the sore;
- If friction is the source of the problem, a protective transparent dressing may help protect the area.2
The same steps should be followed as for Stage One, with the added step of consulting the health care provider for possible further treatment (ie, wound cleansing with saline solution and transparent dressings). Signs of infections also should be reason to consult with the health care provider.2
The same steps should be followed as for Stages One and Two, with the added step of again consulting the health care provider for further treatment. Wounds in this stage often require additional care with special cleaning or debriding agents. A different packing agent and, occasionally, antibiotics (creams or oral medication) may be required.2
Wounds at this stage should be left exclusively to the health care provider, as they might require surgery.2
Besides understanding how to treat sores at their various stages of severity, it is necessary to recognize the signs that indicate a sore is actually healing. One of the most obvious is that the sore will get smaller. Additionally, pinkish tissue will normally begin to form along the edges of the sore and move toward the center. Smooth or bumpy surfaces of new tissue may begin to appear. Bleeding also may be present, a positive sign that improved blood circulation, which helps healing, is occurring.
There are a few promising breakthroughs in reducing the incidence of pressure sores. A new study is investigating the use of neuromuscular electrical stimulation (NMES), which can change the characteristics of paralyzed muscles to improve their long-term response to loading, especially while seated in a wheelchair.6
Pressure mapping is another technique that can help pinpoint the most likely areas of concern for each individual patient.
In the end, however, recognition of pressure sores’ potential appearance and proactive strategies to prevent them are the optimal approach. Naturally, the therapist or health care provider needs to be keenly aware of the techniques and tactics to help avoid these scourges, as well as how to treat them in the event they do appear. But responsibility also falls on the patient to be their own best self-advocate. Through proper education, the patient will understand how to give instructions to the caregiver in bed positioning, turning, and skin checks—huge demands for the caregiver once the patient returns home.
Stacy McDonough, MS, PT, is a clinical leader in the Physical Therapy Department at New England Rehabilitation Hospital, Woburn, Mass. For more information, contact .
- Prevention of pressure sores through skin care. Available at: www.spinalcord.uab.edu/show.asp?durki=21486. Accessed January 19, 2007.
- Spinal cord injury: skin and pressure sores. Available at: www.sci-info-pages.com/skin_pres.html. Accessed January 19, 2007.
- Disability/condition: no more sores: preventing pressure sores for people with SCI. The role of nutrition. Available at: www.ncpad.org/disability/fact_sheet.php?sheet=118&view=all&PHPSESSID=. Accessed January 19, 2007.
- Klebine P, Lindsey L, Oberheu AM. Prevention of pressure sores through skin care. Spinal Cord Injury InfoSheets. Board of Trustees, University of Alabama; 2000.
- New findings in pressure ulcer prevention and treatment. Available at: depts.washington.edu/rehab/sci/updates/02sp_prevent_ulcer.html. Accessed January 19, 2007.
- SCI program: pressure sore prevention and treatment. Available at: [removed]fescenter.case.edu/Start_Here/Patients/SCI/sci_programs_pressure.htm[/removed]. Accessed January 19, 2007.