A Systematic Review of Therapeutic Interventions for Pressure Ulcers After Spinal Cord Injury

Article Outline

• Abstract
• Methods
  • Direct Versus Indirect Indicators of Prevention
  • Prevention of Pressure Ulcers
    • Electrical stimulation
  • Conclusions
  • Pressure Relief Practices
  • Conclusions
  • Wheelchair Cushion Selection
  • Conclusions
  • Thickness of Lumbar Support
  • Conclusions
  • Specialized Seating Clinics
  • Conclusions
  • Education
  • Conclusions
  • Behavioral Contingencies
  • Conclusions
  • Telerehabilitation and Pressure Ulcer Management
  • Conclusions
  • Treatment of Pressure Ulcers
    • Electrical stimulation for pressure ulcer healing
  • Conclusions
  • Laser Treatment for Pressure Ulcer Healing
  • Conclusions
  • US/UVC for Pressure Ulcer Healing
  • Conclusions
  • Effects of Nonthermal Pulsed Electromagnetic Energy Treatment
  • Conclusions
  • Anabolic Steroid Agents
  • Conclusions
  • Effectiveness of Dressings
  • Conclusions
  • Maggot Therapy
  • Conclusions
• Conclusions
• References
• Copyright

Abstract 

Regan MA, Teasell RW, Wolfe DL, Keast D, Mortenson WB, Aubut JL, for the Spinal Cord Injury Rehabilitation Evidence Research Team. A systematic review of therapeutic interventions for pressure ulcers after spinal cord injury.

Objective

To systematically review evidence on the prevention and treatment of pressure ulcers in those with a spinal cord injury (SCI).

Data Sources

For this evidence-based review, the following data sources were used: MEDLINE/PubMed, CINAHL, EMBASE, and PsycINFO.

Study Selection

To be selected for inclusion in the current review, there had to have been an intervention, studies had to have 3 or more subjects, and 50% or more of the participating group had to have an SCI.

Data Extraction

Data extracted included study design, subject demographics, inclusion and exclusion criteria, study type, sample size, outcome measures used, and study results.

Data Synthesis

Articles selected for this review were organized into 1 of 2 categories: prevention or treatment. Within each broad category, several smaller ones were created, and articles were grouped according to the prevention (direct or indirect) or treatment intervention discussed.

Conclusions

Of the 26 articles selected for inclusion in the systematic review, 7 were randomized controlled trials (RCTs) that dealt with treatment for pressure ulcers, and there was 1 RCT on prevention. Despite the cost-effectiveness of prevention, little research exists on preventative interventions, and what does exist is mostly level 4 evidence. More research is needed for both prevention and treatment, but especially the former.

Key Words: Paraplegia, Pressure ulcer, Quadriplegia, Rehabilitation

List of Abbreviations: HD, hydrocolloid dressing, HVPC, high-voltage pulsed current, HVPGS, high-voltage pulsed galvanic stimulation, IT, ischial tuberosity, MDT, maggot debridement therapy, NAC, Needs Assessment Checklist, NMES, neuromuscular electrical stimulation, PEDro, Physiotherapy Evidence Database Scale, PUSH, Pressure Ulcer Scale for Healing, RCT, randomized controlled trial, SCI, spinal cord injury, SCIRE, Spinal Cord Injury Rehabilitation Evidence, P_TCo₂, transcutaneous oxygen tension, US, ultrasound, UVC, ultraviolet C radiation

PRESSURE ULCERS ARE serious, secondary complications of SCI. Although preventable in most situations, pressure ulcers may disrupt rehabilitation, prevent persons with SCI from working or attending school, interfere with community reintegration, and affect quality of life.¹, ², ³, ⁴ When the pressure ulcer is severe, it can lead to further disability, decreases in mobility, loss of independence, the need for surgical interventions, and fatal infections.³, ⁵

Pressure ulcers have been defined as a lesion on any skin surface that results from pressure or pressure in combination with shear force and/or friction.⁵, ⁶, ⁷, ⁸ The primary cause is felt to be externally applied pressure for a prolonged period over bony prominences, such as the sacrum and IT. This leads to ischemia of overlying soft tissues, which ultimately can lead to necrosis.⁶, ⁹, ¹⁰ While the ulcer may appear confined to the skin, it may take weeks before the true size and depth of the ulcer is known.¹¹ In addition, muscle is more sensitive than skin to ischemia caused by pressure.¹

Pressure ulcers are staged according to the degree of tissue damage observed. The staging system developed by the National Pressure Ulcer Advisory Panel in 1989¹² and recently revised in 2007⁸ is widely used and supported.¹³, ¹⁴ It consists of 4 stages that range in severity from stage I (which involves intact skin) to stage IV (full-thickness tissue loss; table 1). In community-dwelling persons with SCI, 25% of pressure ulcers are classified as severe (stage III or IV).² Another type of pressure ulcer is suspected deep tissue injury. This injury looks like a bruise on intact skin but may rapidly progress to involve deeper layers, despite treatment.⁸, ¹⁵

Table 1. Stages of Pressure Ulcers

NOTE. From the National Pressure Ulcer Advisory Panel.⁸

Cost data on pressure ulcers in SCI populations are difficult to obtain.¹⁶ In a case study of a community-dwelling person with paraplegia, Allen and Houghton¹⁶ demonstrated that the cost of 3 months of accelerated wound treatment to heal a stage III ulcer was $27,632 Canadian, with approximately half the cost paid for by the person. In the United States, for persons with SCI, it has been estimated that the cost of care for pressure ulcers is about $1.2 to 1.3 billion annually, whereas prevention would cost about one tenth of this.⁴, ¹⁷, ¹⁸ Despite the attention given to preventative strategies by rehabilitation and public health professionals, pressure ulcers are common among persons with an SCI.¹⁹ Annual incidence rates range from 20% to 31% and prevalence rates from 10.2% to 30%.¹¹, ¹⁷

Prevention of pressure ulcers requires the recognition of significant risk factors, which effect either the intensity and duration of pressure or the tissue tolerance for pressure.²⁰ Identified risk factors include limitations in activity and mobility, injury completeness, moisture from bowel and/or bladder incontinence, lack of sensation, muscle atrophy, nutritional status, and being underweight.¹¹, ¹⁷, ¹⁹

Prevention of pressure ulcers begins at the time of injury and is a lifelong commitment for those living with SCI or their caregivers.²¹ Typical prevention recommendations made during rehabilitation include examining skin daily to allow for early detection; minimizing moisture and incontinence, and keeping skin clean and dry; regular pressure relief every 15 to 30 minutes by performing a lateral bend, forward lean, or vertical push-up¹, ⁹; having an individually prescribed wheelchair with a pressure redistribution cushion, and a power or manual tilt/recline feature if manual pressure relief is not possible¹; ensuring that all equipment is functioning properly; decreasing or stopping smoking, and limiting alcohol consumption; and eating a well balanced, nutritionally complete diet, which includes monitoring of weight to detect undesirable trends.¹, ²² Persons with SCI and their caregivers must learn the importance of following a skin care regimen, recognize potential consequences of a pressure ulcer, and begin to take responsibility for maintaining healthy skin.⁹, ²³, ²⁴ To promote sustainable outcomes, health care professionals must assist persons with SCI to determine which preventative strategies are realistic for them to implement, based on their life circumstances, and must help them identify ways to integrate these preventative strategies into daily schedules.²⁵

Given the significant personal and societal consequences of pressure ulcers, it is prudent to understand the existing evidence for prevention and treatment interventions, and to identify future directions for research on pressure ulcer management. Prevention and treatment interventions for pressure ulcers post-SCI will be examined in the following review article.

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Methods 

A systematic review of all relevant literature published from 1980 to 2007 was conducted using multiple databases (MEDLINE/PubMed, CINAHL, EMBASE, PsycINFO) and our standardized SCIRE methodology.²⁶ Search terms included pressure ulcers (skin sores, decubitus ulcer, ischemic ulcer, bed sores, or skin sores) paired with spinal cord injuries, tetraplegia, paraplegia, or quadriplegia. Over 17,000 titles were reviewed for version 1 of the SCIRE project (http://www.icord.org/scire). For the current review, 26 articles met inclusion criteria, consisting of English language interventional studies with a sample size of 3 or greater, and with at least half the study population having an SCI.

A quality assessment was conducted for each article, using either the PEDro²⁷ assessment tool (for RCTs) using questions 2 through 10, or the Downs and Black²⁸ tool for nonrandomized studies. With the PEDro tool, the higher the score, the better the quality of the study, with the following cutpoints used: 9 to 10, excellent; 6 to 8, good; 4 to 5, fair; and less than 4, poor. The Downs and Black²⁸ tool consists of 27 questions that evaluate the level of (1) reporting, (2) external validity, and (3) internal validity (both bias and confounding). It was modified slightly because of ambiguity in the last question; thus, the highest score any reviewed article could receive was 28, with a higher score indicating higher methodologic quality.²⁸ Five levels of evidence, based on a modified Sackett scale, were used to summarize the data²⁹ (table 2).

Table 2. Levels of Evidence

NOTE. From Straus et al.²⁹

The results of the quality assessment and a brief study summary were tabulated for each study as follows: PEDro or Downs and Black²⁸ score, study design, inclusion/exclusion criteria (when stated), a brief summary of intervention outcomes, and study results.

Direct Versus Indirect Indicators of Prevention 

It should be noted that outcome assessment for pressure ulcer prevention can be measured via either direct or indirect means. That is, the effectiveness of preventative interventions can be determined by direct indicators, like pressure ulcer incidence, or by indirect indicators, like IT pressure mapping or P_TCo₂ levels.

Prevention of Pressure Ulcers 

Electrical stimulation has been used since the 1960s to enhance the healing of various chronic wounds, including pressure ulcers in both able-bodied people and persons with an SCI.¹⁸, ³⁰, ³¹ Given that the primary cause of pressure ulcers is felt to be externally applied pressure over bony prominences like the ischial tuberosities,⁹ investigators have studied the role of electrical stimulation for reducing ischial pressures and redistributing seating interface pressures, both of which might assist with pressure ulcer prevention³² (table 3).

Table 3. Electrical Stimulation

Abbreviations: ASIA, American Spinal Injury Association; D&B, Downs and Black²⁸ quality assessment scale score.

Bogie and Triolo³³ studied changes in interface pressure distribution at the support/surface interface after 8 weeks of NMES delivered via an implanted neuroprosthesis for standing and transfers. The neuroprothesis consisted of bilateral epimysial electrodes, a multichannel stimulator, and bilateral gluteal electrodes. After healing associated with the implantation, subjects began 8 weeks of NMES exercise using 3 different stimulation patterns. Duration and modes (eg, unresisted vs resisted) of exercise changed from 15 to 30 minutes (week 1) up to 120 minutes (week 7 or 8) as muscles became conditioned. After 8 weeks of NMES, mean ischial regional interface pressure uniformly decreased postexercise assessment (P<.01).

Research also has shown that, with increasing interface pressures over bony prominences, regional blood flow is adversely affected.⁹, ³⁰ Electrical stimulation has been shown to change blood flow to skin and muscle. It is believed that, by increasing regional blood flow, tissue viability is enhanced, thereby assisting with pressure ulcer prevention⁹, ¹⁸, ³², ³³, ³⁴ (table 4).

Table 4. Effects of Electrical Stimulation on Regional Blood Flow

Abbreviations: ASIA, American Spinal Injury Association; D&B, Downs and Black²⁸ quality assessment scale score.

Mawson et al³⁵ administered HVPGS to 29 subjects lying supine. Baseline P_TCo₂ levels were compared with levels reached at the end of 30 minutes of HVPGS. The authors found that the P_TCo₂ level at the end of stimulation was 66±18mmHg or 35% higher (F=39.42, P<.001).

Bogie and Triolo³³ administered 8 weeks of NMES to 8 subjects using implanted gluteal electrodes. They then assessed unloaded gluteal tissue blood flow by measuring local P_TCo₂. While the results did not achieve statistical significance, baseline mean unloaded P_TCo₂ levels increased by 1% to 36% in 5 of the 8 subjects.

Conclusions 

There is limited level 4 evidence that electrical stimulation decreases ischial pressures post-SCI. There is level 4 evidence that electrical stimulation may increase blood flow at sacral and gluteal areas post-SCI.

Pressure Relief Practices 

Current clinical practice regarding pressure relief education is based on the premise that the absence of regular pressure relief places the person with SCI at a higher risk for pressure ulcers.³ The techniques chosen for pressure relief depend on the physical and cognitive status of the individual. When a manual weight shift cannot be performed, 1 alternative is a mechanical reclining or power tilt wheelchair. It has been suggested that pressure relief optimally should be performed every 15 to 30 minutes for 30 to 120 seconds, depending on the technique¹ (table 5).

Table 5. Pressure Relief Practices

Abbreviation: D&B, Downs and Black²⁸ quality assessment scale score; T_CPo₂, transcutaneous oxygen tension.

A retrospective chart review of 46 subjects with an SCI seen in a seating clinic noted that approximately 2 minutes of pressure relief was required to raise transcutaneous oxygen tension to unloaded levels for most subjects.³⁶ The required duration of pressure relief was more easily sustained by the subjects leaning forward or side to side, or having the wheelchair tipped back by 65° or higher compared with a vertical lift for pressure relief.

Henderson et al³⁷ pressure-mapped 10 subjects with SCI at the IT and over a circumscribed area around the IT. Subjects were placed in 4 different positions: sitting upright at rest in a neutral position, tipped back 35° from vertical, tipped back 65° from vertical, and leaning forward as far as was comfortable. When the subjects were in a forward-leaning and 65° tipped-back position, there was a statistically significant pressure reduction at the IT and over the circumscribed area (forward lean: 78% reduction at IT, 70% reduction over circumscribed area [P<.05]; 65° tipped back: 47% reduction at IT, 36% reduction over circumscribed area [P<.05]); this compared with a 27% reduction at the IT, and to a 17% reduction over the circumscribed area (P>.05) in the 35° tipped-back position. While the pressure reduction for the 65° tipped-back position was statistically significant, it was not felt by the authors to be optimal to prevent pressure ulcer development.

These findings suggest that a forward-leaning position is the most effective pressure relief technique, if sustained for an appropriate period. Leaning side to side, having the wheelchair tipped back by 65° or more, or doing a pressure relief lift for an appropriate length of time (ie, 2min) also was effective. The traditional pressure relief lift (15–30s) was ineffective at reducing tissue oxygen levels to unloaded levels.

Conclusions 

There is level 4 evidence to support the forward-leaning position as the most effective method of pressure relief. There is level 4 evidence that a 15-second to 30-second vertical lift is not effective.

Wheelchair Cushion Selection 

Wheelchair cushion selection is important when an individual with an SCI is prescribed a wheelchair. Bogie et al⁹ noted that 47% of pressure ulcers occurred over the IT and sacrum and were therefore more likely to have been initiated while the patient was seated. When optimizing wheelchair cushion selection for a person with SCI, the degree of pressure reduction and redistribution³⁸ and temperature effects³⁹, ⁴⁰ along with individual characteristics such as level of SCI (paraplegia or tetraplegia), pressure relief abilities, transfer techniques, and lifestyle must be considered.³⁸, ⁴¹ Seat cushioning can be made from various materials; it may be static or dynamic (typically accomplished with air bladders)³⁸, ⁴¹; and it may be incorporated into upright, powered tilt, or reclined wheelchairs (table 6).

Table 6. Wheelchair Cushion Selection

Abbreviations: ASIA, American Spinal Injury Association; BMI, body mass index; D&B, Downs and Black quality assessment scale score²⁸; GP, greatest pressure; WO-BPS, sitting upright with partially removed ischial support and enhanced lumbar support posture.

In the study conducted by Burns and Betz,⁴² 3 wheelchair cushions were tested: dry flotation (ROHO High Profile),^a gel (Jay 2),^b and dynamic (ErgoDynamic),^c the last consisting of 2 air-filled bladders, the H-bladder (shaped like the letter H) and the IT-bladder. These were compared under high pressure conditions (upright sitting or IT-bladder inflated) and low pressure conditions (seat tilted back 45° or H-bladder inflated). When the pressure placed on the ischial tuberosities was analyzed, the pressure was higher during upright sitting than in the tilted back position for both the dry flotation and the gel cushion (P<.001), with the dry flotation cushion providing more pressure relief than the gel cushion during upright sitting (112 vs 128mmHg, P=.01). Mean pressure with the IT-bladder inflated cushion (157mmHg) was greater than upright pressures for either the dry flotation or gel cushions (111 and 128mmHg, respectively; P<.01). Most importantly, ischial tuberosity pressure for the dynamic cushion during H-bladder inflation in an upright position was comparable to the pressure for the dry flotation cushion in a tilted back position (71 vs 74mmHg, P=.91) and significantly less than the pressure obtained with the gel cushion (71 vs 86mmHg, P<.05).

Brienza and Karg⁴³ had 12 subjects with SCI sit on 3 different surfaces (flat foam, initial contour, and final contour) while measuring interface pressures using a pressure-sensing pad. Subjects with SCI had greater depth values than elderly subjects without SCI (N=30), and the mean maximum depth of the final contour was deeper for the group with SCI, suggesting that pressure distributions for the subjects with SCI were more sensitive to support surface characteristics than for the elderly subjects without SCI.

Seymour and Lacefield³⁹ evaluated 8 cushions (gel: Jobst pad,^d Spenco^e; water: Jobst cushion^d; air-filled: Bye Bye Decubiti,^f Alternating Pressure^g; foam: Luxaire,^h Durafoam,^g Tri-Pad^g) for pressure, temperature effects, and subjective factors influencing cushion purchase. While data indicated a wide variability in pressure measurements in individual subjects seated on the 8 cushions, the air-filled cushion (Bye Bye Decubiti) had the best pressure readings. The alternating pressure and foam cushions had consistently higher temperature readings across both groups, which could increase tissue susceptibility to pressure ulcer formation.³⁹, ⁴⁰

Garber³⁸ evaluated 7 cushions (air-filled: Bye Bye Decubiti, Roho; flotation: Aqua Seat, Stryker Gel; foam: Stainless Comfy Hard Foam, Temper Foam; foam/flotation combination: Jay) based on the amount of pressure reduction achieved, and noted how frequently each cushion was prescribed to subjects with quadriplegia and paraplegia. The Roho cushion produced the greatest pressure reduction in most subjects (51%) and was prescribed more often for subjects with quadriplegia than with paraplegia (55% vs 45%).

Makhsous et al,⁴¹ in a case-control study, exposed subjects to two 1-hour protocols: alternate, where sitting posture was alternated dynamically every 10 minutes between normal (sitting upright with ischial support) and sitting upright with partially removed ischial support and lumbar support, and normal (normal posture plus pushups performed every 20 minutes). These investigators found that the anterior portion of the seat cushion had a larger contact area among those with tetraplegia compared with those in the other groups. It also was determined that those with an SCI had a larger contact area in the midportion of the seat cushion. There were significant differences between the groups when looking at the average pressure over the whole seat (P<.001) and the total contact area on the seat cushion. Sitting upright with partially removed ischial support and lumbar support posture, the average pressure for the tetraplegia group was higher than it was for the other groups (P<.001). Most importantly, the total contact area on the posterior portion of the cushion was less for sitting upright with partially removed ischial support and lumbar support posture for all groups. As well, peak interface pressure was lower for all groups, with the greatest decrease from normal posture seen in the tetraplegia group. The average pressure increased on the anterior and middle portion of the cushion in all groups.

The results of these studies and the apparent interindividual variation inherent in those with an SCI (eg, paraplegia vs tetraplegia) support the practice of specialized pressure-mapping assessments to assist with individualized wheelchair cushion prescriptions. None of these studies included direct evidence of pressure ulcer prevention associated with a particular practice or cushion type. Objective findings, such as pressure mapping together with the clinical knowledge of the prescriber and the clients' subjective reports, need to be considered when prescribing a wheelchair seat cushion for an individual with an SCI, so as to minimize pressure ulcer risk factors.

Conclusions 

There is level 3 evidence that various cushions or seating systems (eg, dynamic vs static) are associated with potentially beneficial reductions in seating interface pressure or pressure ulcer risk factors, like skin temperature.

Thickness of Lumbar Support 

Shields and Cook⁴⁴ discussed the role that spinal deformities, like kyphosis, may play a role in the formation of pressure ulcers in persons with chronic SCI. In previous research on nondisabled subjects, they had demonstrated that the addition of lumbar support reduced highest seated buttock pressure (>.915kg/cm²) and was associated with a change in pelvic tilt. If those findings were to hold true in the SCI population, the authors noted that this could lead to ways to assess postures while seated for appropriate pressure distribution⁴⁴ and augment electric wheelchair backrests by adding an automated lumbar support system, potentially providing a mechanism for continuous pressure shifts.

In the Shields and Cook⁴⁴ study, 18 SCI and 18 able-bodied subjects were studied to test the effects of varying lumbar support thickness (0, 2.5, 5.0, 7.5cm) on seated buttock pressures at the ischial tuberosities. Within the SCI group, a 2% decrease in mean highest seated buttock pressure (>.915kg/cm²) was seen with the 7.5-cm lumbar support compared with a 90% reduction within the able-bodied group. With the 5-cm and the 2.5-cm lumbar support, there was an increase in mean high pressure of 13% and 12%, respectively, compared with reductions in the able-bodied group of 80% and 25%, respectively. Surprisingly, the findings showed that the addition of lumbar support to wheelchairs had a minimal effect on reducing highest seated buttock pressure at the ischial tuberosities of subjects with chronic SCI of 3 years or more (table 7).

Table 7. Thickness of Lumbar Support

Abbreviation: D&B, Downs and Black²⁸ quality assessment scale score.

Conclusions 

There is level 3 evidence that adding lumbar support to the wheelchair of those with a chronic SCI has a negligible effect on reducing seated buttock pressures at the IT. As a consequence, it is unlikely to have a role in pressure ulcer prevention post-SCI.

Specialized Seating Clinics 

Education regarding the prevention of pressure ulcers post-SCI includes an emphasis on taking personal responsibility for maintaining healthy skin through personal care, inspection of skin, pressure relief, and the correct use of prescribed equipment.⁹ The incorporation of seating clinics into both inpatient and outpatient rehabilitation programs has been shown to reduce the incidence of pressure ulcers and readmission rates as a result of pressure ulcers.⁴⁵ Seating clinics not only provide education but also make recommendations for appropriate seating systems based on interface pressures, thermography, and assessments of tissue viability. Verbal and visual feedback are provided to the individual with an SCI, and active participation is encouraged³⁶, ⁴⁵, ⁴⁶ (table 8).

Table 8. Specialized Seating Clinics

Abbreviations: D&B, Downs and Black²⁸ quality assessment scale score; NAC 1, NAC administered within 1 month of mobilization; NAC 2, NAC administered on admission to the predischarge ward; SSA, seating assessment clinic.

Kennedy et al⁴⁶ studied 50 patients with an SCI participating in a comprehensive rehabilitation program. The participants were divided into 3 groups—group 1 (attendance at seating assessment clinic prior to NAC administered within 1 month of mobilization), group 2 (attended seating assessment clinic between their first and second NAC), and group 3 (no attendance at seating assessment clinic)—to determine whether attendance at a seating assessment clinic would improve skin management ability, as evidenced by lower to be achieved scores on the skin subscale of the NAC. The NAC was administered within 1 month of mobilization and on admission to the predischarge ward.⁴⁶ Optimal timing of attendance at the seating assessment clinic also was studied. Results indicated significant differences between group 1 and group 3 both at 1 month of mobilization (P<.05) and on admission to the predischarge ward (P<.01) assessments. Skin management to be achieved scores were significantly lower among participants who attended a seating assessment clinic before their first NAC at both time points. Significant differences also were observed between to be achieved scores at first and second NAC within all groups: group 1 (P<.001), group 2 (P<.01), and group 3 (P<.01).⁴⁶

Conclusions 

There is level 2 evidence showing that early attendance at specialized seating assessment clinics increases the skin management abilities of persons post-SCI. Attendance at a seating assessment clinic is an adjunct to the skin management abilities learned during a comprehensive rehabilitation program.

Education 

Education programs for pressure ulcer prevention designed for persons with SCI provide knowledge and emphasize specific behaviors, which, when adhered to on a regular basis, are intended to reduce the risk of pressure ulcer occurrence.⁹, ⁴⁷, ⁴⁸ Most education is delivered as part of an inpatient rehabilitation program when patients and families are adjusting to a diagnosis of SCI and also during a time of potential information overload that may compromise an appreciation of knowledge and behaviors they will need to prevent pressure ulcers over the course of their lifetimes.²⁴, ⁴⁸ With shorter lengths of stay, the time available for education is also reduced, and persons with SCI are being discharged with potentially less information and fewer opportunities for reinforcement of acquired knowledge.²⁴ While pressure ulcer prevention education is a key part of rehabilitation, there are few data available on the specific educational needs required by persons with SCI at risk for pressure ulcer development⁴⁸ (table 9).

Table 9. Education

Abbreviations: MS, multiple sclerosis; PU, pressure ulcer.

In an RCT conducted by Garber et al²³ while still in the hospital, those in the treatment group (n=20) were provided with four 1-hour sessions of structured education on the prevention and management of pressure ulcers. Education presented at the sessions included information regarding nutrition, pressure redistribution surfaces for the bed and wheelchair, and pressure ulcer etiology. The control group (n=21) received only standard education regarding preventative practices. After discharge, the groups were followed for 2 years.

Improvement on the pressure ulcer knowledge test was noted in both groups on discharge from the hospital; however, it differed significantly between the groups (P<.03), with those in the treatment group gaining more knowledge about preventing pressure ulcers. No significant differences were noted on the multidimensional Health Locus of Control Scale and the Health Beliefs Questionnaire between the 2 groups at discharge. Two years posttreatment, it was noted that both groups had retained most of the knowledge they had been given during their hospitalization, but the level of knowledge retained by the control group was substantially below that of the treatment group: 60.8% versus 68% on the pressure ulcer knowledge test.²³

Conclusions 

There is level 2 evidence that providing enhanced pressure ulcer prevention education is effective at helping persons with SCI gain and retain this knowledge. However, no evidence exists regarding whether this enhanced education results in a reduction in pressure ulcer formation.

Behavioral Contingencies 

Despite the knowledge available on pressure ulcers and prevention strategies, pressure ulcers continue to occur in persons with SCI.¹⁹ Little information exists about why certain individuals do not practice the health-sustaining behaviors that they are taught and that are required to optimize skin care and prevent pressure ulcers.⁴, ²⁴ There is a subset of patients who experience recurrent pressure ulcers because of nonadherence to recommended prevention strategies. Patients with recurrent pressure ulcers may lack incentives to follow prevention behaviors.⁴ What is not known is whether rewarding positive preventative strategies reduces the severity or likelihood of a patient developing pressure ulcers.

Jones et al⁴ conducted 2 separate small studies. The behavioral intervention in the first study (n=6) consisted of a health plan, clinic visits, and financial rewards ($50 a visit as long as ulcer-free), all of which were implemented at the same time. In the second study (n=3), a health plan and visits were implemented in phase 1 of the study; payments were added if a patient experienced new skin problems. Results from the first study revealed that average PUSH scores were lower by 10.5 points from baseline at the end of the intervention phase. No hospitalizations were required and, ultimately, costs during the intervention phase went from $6263 (United States) to $235 (United States). In the postintervention phase, 3 subjects were able to maintain lower PUSH scores and 3 were not. In the second study, mean PUSH scores decreased from baseline by 8.3 points (visits only) and a further 3.1 points when payments were added. PUSH scores rose again in 2 out of 3 participants during the postintervention phase. The mean number of hospitalizations dropped from 1.67 (baseline) to 0.33 (intervention and postintervention; table 10).

Table 10. Behavioral Contingencies

Abbreviation: D&B, Downs and Black²⁸ quality assessment scale score.

Conclusions 

There is very limited level 4 evidence to suggest that the introduction of behavioral contingencies is associated with a reduction in pressure ulcer severity and decreased health care costs.

Telerehabilitation and Pressure Ulcer Management 

Impaired mobility and distance to specialized SCI centers often make follow-up care difficult for persons with SCI.⁴⁹, ⁵⁰ Telerehabilitation has the potential to deliver medical rehabilitation, nutritional, and psychosocial elements of health care at a distance using telecommunication technology, thereby facilitating continuity of care.⁴⁹ Pressure ulcer management is 1 area in which telerehabilitation currently is being used⁵¹ (table 11).

Table 11. Telerehabilitation and Pressure Ulcer Management

Abbreviations: D&B, Downs and Black²⁸ quality assessment scale score; ED, emergency department.

Vesmarovich et al⁵¹ described the use of telerehabilitation delivered via a videophone system that transmitted still images and audio to treat stage III/IV ulcers. While no statistical results were reported, 7 of 12 ulcer sites healed. Phillips et al,⁵² using the same videophone system, divided SCI participants into 3 groups: information delivered by telephone, information delivered by video, and standard care. The video group had the highest number of identified and/or reported ulcers during the study. The annualized data for emergency department visits, hospitalizations, and health care visits were similar for the video and telephone groups, and were tracked weekly. Hospitalizations and health care visits, tracked every 8 to 12 weeks, were less in the standard care group. Fifty-five percent of each of the 3 groups had no hospitalizations. Repeat emergency department visits and hospitalizations appeared to be driven by a small number of people; no significant differences were noted between the 3 study groups.⁵²

Conclusions 

There is level 4 evidence that telerehabilitation does not make a significant difference in the prevention and treatment of pressure ulcers post-SCI.

Treatment of Pressure Ulcers 

The therapeutic effect of electrical stimulation for wound healing has been well documented since the 1960s, especially for wounds not responding to standard forms of treatment.¹⁸, ³⁰, ³¹ Despite the use of electrical stimulation to promote wound healing, there remains a lack of clear understanding about how it works to facilitate tissue repair, although a variety of cellular actions (eg, migration and activation of key cells) have been purported as a mechanism of action.⁵³

Some of the effects of electrical stimulation on wound healing include decreased healing time, increased collagen synthesis, increased wound tensile strength, increased rate of wound epithelialization, and enhanced bactericidal effects.³⁰ Electrical stimulation also has been shown to improve tissue perfusion and reduce edema formation, indirectly stimulating healing by improving oxygen delivery to tissue.⁵³ The literature shows high variability about which type of electric current and application protocol is effective for a specific patient or ulcer type¹⁸ (table 12).

Table 12. Electrical Stimulation for Pressure Ulcer Healing

Abbreviations: A, asymmetric biphasic; AC, low-frequency pulsed current; B, symmetric biphasic; D&B, Downs and Black²⁸ quality assessment scale score; DC, direct current; MC, microcurrent.

Griffin et al⁵⁴ showed the efficacy of direct HVCP for the healing of pelvic pressure ulcers in subjects with SCI. Compared with a placebo group, the subjects treated with HVPC experienced a greater percentage reduction in wound surface area at day 5 (P=.03), day 15 (P=.05), and day 20 (P=.05). Stefanovska et al⁵⁵ showed that the healing rate for wounds treated with low-frequency pulsed current was significantly better than for groups treated with direct current or conventional treatment alone (P=.003). Baker et al³¹ demonstrated that, for ulcers that responded to any form of electrical simulation (good responses), asymmetric biphasic stimulation (group A) was most effective for enhanced wound healing. Wounds that already were exhibiting signs of healing in the control group, with the subsequent addition of either protocol A or B (symmetric biphasic), experienced a greater healing rate (43.3%±12.5% change/wk) versus the control period (9.7%±3.4% change/wk). Adegoke and Badmos⁵⁶ found that the surface area of grade IV pelvic pressure ulcers treated with interrupted direct current and nursing care decreased by 22.2% versus 2.6% with sham treatment. While there were differences in the type and duration of electric current applied in the 4 studies, all the studies demonstrated that, when used in conjunction with standard wound management, electrical stimulation can accelerate the healing rate of pressure ulcers in patients with SCI.

Conclusions 

There is level 1 evidence from 2 RCTs to support the use of electrical stimulation to accelerate the healing rate of stage III/IV pressure ulcers when combined with standard wound management.

Laser Treatment for Pressure Ulcer Healing 

Lasers have been used as a therapeutic modality for wound healing since the 1970s. Laser treatments are felt to act during the proliferative phase of wound healing to promote fibroblast activity and increase granulation tissue formation in nonhealing, chronic wounds. Currently the use of lasers to promote wound closure in chronic wounds is not supported by evidence.⁵³ The Consortium for Spinal Cord Medicine¹ reviewed the literature on adjunct wound therapies, including laser treatments, and did not identify enough supporting evidence to recommend lasers for the treatment of pressure ulcers in persons with SCI. The 2 studies presented in this article support the conclusion of the consortium (table 13).

Table 13. Laser Treatment for Pressure Ulcer Healing

Taly et al⁵⁷ studied 35 subjects with an SCI (64 ulcers) using multiwavelength light therapy compared with standard wound care alone. Overall, no significant differences were found between the 2 groups with regard to the number of ulcers healed or the time required for ulcers to heal.

Nussbaum et al⁵⁸ studied 16 patients with an SCI and compared standard wound care alone with standard care combined with either laser or US/UVC. In this study, laser treatment combined with standard wound care had the least effect on wound healing compared with either standard care or US/UVC. A significant difference was found between the US/UVC and the laser groups, with the US/UVC treatment producing the greater effect on wound healing.

Conclusions 

There is level 1 evidence (from 2 RCTs) to suggest that laser treatment has no added benefit in pressure ulcer healing post-SCI over standard wound care alone.

US/UVC for Pressure Ulcer Healing 

Houghton and Campbell⁵³ note that both US and UVC have been used in the treatment of chronic wounds. US acts mainly during the inflammatory stage of wound healing to activate the release of chemical messengers from cells, resulting in changes to the amount and strength of scar tissue.⁵³ The bactericidal effects of UVC suggest that it is best used for the treatment of chronic, infected wounds in which there is an excess of surface bacteria or bacteria have become resistant to antibiotic therapy. There is research to support consideration of UVC in the treatment of chronic infected wounds, but therapeutic US has no added benefits when used to treat pressure ulcers.⁵³ The Consortium of Spinal Cord Medicine¹ found minimal data specific to the use of US or UVC to treat pressure ulcers in SCI.

In 1 small RCT (N=16), Nussbaum et al⁵⁸ demonstrated that, compared with standard wound care alone or laser combined with standard wound care, US/UVC plus standard wound care generated a greater effect on wound healing over a shorter period of time. However, as US and UVC were alternated over 5 days and provided in combination to a single treatment group, conclusions cannot be drawn as to the individual effects of either US or UVC (table 14).

Table 14. US/UVC for Pressure Ulcer Healing

Conclusions 

There is level 1 evidence, from 1 small RCT, to suggest that combining US/UVC with standard wound care decreases the wound healing time of pressure ulcers post-SCI, but no evidence exists to clarify whether UVC or US, used alone, exerts any beneficial effect.

Effects of Nonthermal Pulsed Electromagnetic Energy Treatment 

Electromagnetic energy acts during the proliferative stage of wound healing to increase production of granulation tissue formation. Other beneficial effects include increased blood and oxygen availability to tissues and decreased tissue edema.⁵³ Keast et al,²² while updating best practice recommendations for the prevention and treatment of pressure ulcers, recommend considering electromagnetic fields as 1 adjunct modality for stimulating closure of chronic nonhealing pressure ulcers (table 15).

Table 15. Nonthermal Pulsed Electromagnetic Energy

Salzberg et al⁵⁹ evaluated the effects of nonthermal pulsed electromagnetic energy for the healing of stage II/III ulcers in patients with SCI, assessing effects in stage II ulcers and stage III ulcers separately. In those with stage II ulcers (n=10), a greater proportion of ulcers healed (84%) after 1 week of active treatment versus a sham treatment (40%; P=.01). For complete healing, the treatment group healed in a median of 13 days versus 31.5 days among controls (P<.001). Given that there were a larger number of ulcers with size greater than 60cm² in the sham group, the data were reanalyzed, and the results obtained were consistent with the initial findings: again, treated patients with stage II ulcers experienced a greater proportion of lesions healed at 1 week (P=.002), and the number of days to being fully healed was fewer (P=.007). In those with stage III ulcers, healing was also associated with pulsed electromagnetic energy treatment: 3 of 5 healed within an average of 43 days, while 0 of 5 healed in the sham group. Ulcer area decreased 70.6% with active treatment versus 20.7% with the sham treatment.

Conclusions 

There is level 1 evidence from 1 RCT to support the efficacy of pulsed electromagnetic energy to accelerate the healing of stage II and III pressure ulcers post-SCI.

Anabolic Steroid Agents 

Impaired nutritional status and decreased nutritional intake are significantly associated with the development and healing of pressure ulcers.¹ The use of anabolic steroids and increased protein intake have been associated with promoting anabolism, weight gain and, in turn, wound closure in burn patients.¹ An anabolic steroid agent may also promote closure of nonhealing pressure ulcers in the SCI population because pressure ulcers are associated with an increased metabolic rate and catabolism.⁶⁰

In a case series of 9 subjects with stage III or IV pressure ulcers, Spungen et al⁶⁰ demonstrated complete healing in 8 of 9 subjects 3 to 12 months after daily administration of 20mg oxandrolone. Given the small size of this case series, further research is needed to determine the role of anabolic steroid agents (oxandrolone) for the promotion of healing of stage III and IV pressure ulcers post-SCI (table 16).

Table 16. Anabolic Steroid Agents

Abbreviations: D&B, Downs and Black²⁸ quality assessment scale score; PU, pressure ulcer.

Conclusions 

There is very limited level 4 evidence to support the use of anabolic steroid agents (oxandrolone) to promote the healing of stage III and IV pressure ulcers post-SCI.

Effectiveness of Dressings 

Because of the estimated costs associated with pressure ulcers and their treatment, various dressing types used with the SCI population have been investigated, including hydrogel⁶¹ and hydrocolloid dressings.⁶² When HDs are placed over the wound, fluids are absorbed, causing the dressing to swell and form a gel.⁵³, ⁶³ The outer surface of the dressing allows for exchange of water vapor and protects the wound from outside contamination. HDs also create a moist wound environment and are believed to act by accelerating wound debridement. They are cost effective because patients can wear the dressing for 3 to 5 days, and they are available in a sheet form as well as a paste or granules that are used to fill deeper wounds such as stage II and III pressure ulcers.¹, ⁵³, ⁶⁴

A hydrogel dressing creates a healing environment by retaining moisture and rehydrating tissue; autolytic debridement and filling of any dead space in the wound.⁶⁴, ⁶⁵ It is believed that hydrogel dressings promote faster healing, provide protection against wound contamination, are acceptable to patients, decrease pain, and have been found to be cost effective⁶⁵ (table 17).

Table 17. Effectiveness of Dressings Post-SCI

Abbreviations: PC, phenytoin cream; PU, pressure ulcer; SD, simple dressing.

Hollisaz et al,⁶² in an RCT involving 83 subjects, found that those in the HD group (n=28) seemed to have the greatest completion of healing regardless of the location and stage, compared with those in the phenytoin cream group (n=28) or simple dressing group (n=27; P<.005). When considering stage I ulcers, those in the HD group healed faster than those in the other 2 groups (P<.005). For stage II ulcers, HD-treated ulcers healed better than simple dressing–treated ulcers (P<.005) but no better than phenytoin cream–treated ulcers. When looking at the area of injury, gluteal ulcers healed more completely in the HD group than in the other 2, whereas the healing of sacral ulcers did not differ between the 3 groups.

Kaya et al⁶¹ compared the effectiveness of applying an occlusive hydrogel–type dressing to a povidone-iodine–soaked gauze dressing. Although those using the hydrogel dressing experienced a somewhat higher rate of healing, no statistically significant differences were noted between the 2 groups. The 21 subjects in the treatment group did have significantly more wounds heal than the 13 controls (P<.04).

Conclusions 

There is level 1 evidence from a single RCT that completion of healing for stage I and II pressure ulcers is greater with an occlusive HD compared with phenytoin cream or simple dressing. There is level 2 evidence from another single, small RCT that occlusive hydrogel–type dressings heal more pressure ulcers than conservative treatment.

Maggot Therapy 

Maggot therapy, also called MDT, is a treatment for wound healing that has been practiced for several centuries; however, with the development of various antibiotics, this therapy began to lose its popularity after World War II. More fashionably called myasis or biosurgery, MDT uses specially bred larvae of the Lucilia sericata species. L sericata larvae do not damage healthy dermis or subcutaneous tissue, but can destroy healthy epithelium; thus, epithelium protection is mandatory with MDT. Maggots assist with the debridement of wounds by secreting digestive enzymes that dissolve necrotic tissue; these enzymes also contain antibacterial substances that assist with disinfecting wounds.⁶⁶, ⁶⁷ Maggot therapy is associated with an increase in wound granulation tissue debridement and disinfection, and is felt to accelerate wound healing (table 18).⁶⁶, ⁶⁷

Table 18. Effectiveness of Maggot Therapy

Abbreviation: D&B, Downs and Black²⁸ quality assessment scale score.

In 1 non-RCT conducted by Sherman et al,⁶⁸ 8 of 20 patients diagnosed with pressure ulcers (stage III or IV) were treated with maggot therapy. All 8 patients underwent 3 weeks of conventional treatment, followed by maggot therapy. All necrotic wounds were debrided within 1 week of maggot treatment, and wound healing was faster among the 8 who had received maggot therapy than in the 12 who had not.

Conclusions 

There is level 2 evidence from 1 study to support the use of maggot therapy as an adjunctive therapy for nonhealing pressure ulcers post-SCI.

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Conclusions 

Numerous authors cited in this article have noted that pressure ulcers, though largely preventable, remain a common, potentially serious lifelong secondary complication of SCI. Pressure ulcers have the potential to affect overall quality of life and to disrupt rehabilitation, vocational and educational pursuits, and community reintegration.¹, ², ³, ⁴ Pressure ulcers lead to increased hospital readmission rates with longer lengths of stay.⁶⁹ While pressure ulcer prevention is more cost effective than treatment, pressure ulcers continue to be a major issue.⁴, ¹⁷, ¹⁹

Many of the 15 prevention studies reviewed had very small sample sizes. There was level 2 evidence to support early attendance at seating assessment clinics and provision of enhanced pressure ulcer prevention education; level 3 evidence that various cushions and seating systems have potentially beneficial effects; and level 4 evidence to support use of electrical stimulation, forward-leaning position for pressure relief, and behavioral contingencies. There was evidence to show that telerehabilitation, the addition of lumbar support to wheelchairs, and the 15-second to 30-second vertical lift for pressure relief were not effective. More rigorous research is needed in all areas of pressure ulcer prevention post-SCI to determine effective interventions so evidence-based conclusions may guide education and practice.

Eleven articles were found that studied treatment interventions post-SCI. While there were a small number of articles and generally small sample sizes, there was level 1 evidence to support electrical stimulation, US/UVC, and pulsed electromagnetic energy as adjunctive therapies to standard wound management. There also was level 1 evidence to support the use of an occlusive HD for healing of stage I and II pressure ulcers. Interventions that are well supported by evidence need to be incorporated into treatment plans for persons with SCI who have nonhealing pressure ulcers. Nonetheless, more research needs to be done to assess treatment interventions in the SCI population.

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