Original research| Volume 100, ISSUE 6, P1042-1049, June 2019

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What Lies Beneath: Why Some Pressure Injuries May Be Unpreventable for Individuals With Spinal Cord Injury

Published:December 07, 2018DOI:



      To investigate intersections between pressure injury (PrI) history, muscle composition, and tissue health responses under physiologically relevant loading conditions for individuals with spinal cord injury (SCI).


      Repeated measures study design with annual follow-up for up to 3 years.


      Tertiary care center.


      Persons with SCI (N=38). Exclusion criteria included having an open pelvic region PrI at the time of recruitment, presence of systemic disease, and/or known sensitivity to contrast.


      Not applicable.

      Main Outcome Measures

      Gluteal muscle composition, ischial interface pressures, tissue oxygenation.


      Ischial region mean interface pressures are the same for individuals with or without a PrI history. Tissue oxygenation is lower during sitting for persons with a PrI history. Individuals with >15% gluteal intramuscular fat were statistically highly significantly (P<.001) more likely to have a history of severe or recurrent PrI. Intramuscular adipose tissue (IMAT) levels within the gluteal muscle may remain low over time or muscle tissue in the gluteal muscle region may be almost entirely replaced by IMAT. In the current study cohort, it was found that muscle composition also continues to change over time even for individuals with long-standing SCI.


      Soft-tissue compositional changes, specifically IMAT, provides a reliable indicator of PrI history and may provide a key to personalized PrI risk status for persons with SCI. The current findings confirm that interface pressure mapping alone is a limited indicator for PrI development.


      List of abbreviations:

      2D (2 dimensional), 3D (3 dimensional), CT (computed tomography), DTPrI (deep tissue pressure injury), IMAT (intramuscular adipose tissue), IP (interface pressure), IV (intravenous), PrI (pressure injury), ROI (region of interest), SCI (spinal cord injury), TcPO2 (transcutaneous oxygen pressure)
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        • Bogie K.
        • Ho C.
        • Washington M.
        • et al.
        Interdisciplinary essentials in pressure ulcer management.
        in: Fehlings M. Vaccaro A. Boakye M. Rossignol S. Ditunno J. Burns A. Essentials of spinal cord injury. Thieme, New York2012: 158-180
        • Black J.M.
        • Edsberg L.E.
        • Baharestani M.M.
        • et al.
        National Pressure Ulcer Advisory Panel. Pressure ulcers: avoidable or unavoidable? Results of the National Pressure Ulcer Advisory Panel Consensus Conference.
        Ostomy Wound Manage. 2011; 57: 24-37
        • Edsberg L.E.
        • Langemo D.
        • Baharestani M.M.
        • Postauer M.E.
        • Goldberg M.
        Unavoidable pressure injury: state of the science and consensus outcomes.
        J Wound Ostomy Continence Nurs. 2014; 41: 313-334
        • McKinley W.O.
        • Jackson A.B.
        • Cardenas D.D.
        • DeVivo M.J.
        Long-term medical complications after traumatic spinal cord injury: a regional model systems analysis.
        Arch Phys Med Rehabil. 1999; 80: 1402-1410
        • Ho C.H.
        • Bogie K.
        The prevention and treatment of pressure ulcers.
        Phys Med Rehabil Clin N Am. 2007; 18: 235-253
        • Bader D.L.
        The recovery characteristics of soft tissues following repeated loading.
        J Rehabil Res Dev. 1990; 27: 141-150
        • Bader D.L.
        • Gant C.A.
        Changes in transcutaneous oxygen tension as a result of prolonged pressures at the sacrum.
        Clin Phys Physiol Meas. 1988; 9: 33-40
        • Groah S.L.
        • Schladen M.
        • Pineda C.G.
        • et al.
        Prevention of pressure ulcers among people with spinal cord injury: a systematic review.
        PM R. 2015; 7: 613-636
        • Carda S.
        • Cisari C.
        • Invernizzi M.
        Sarcopenia or muscle modifications in neurologic diseases: a lexical or patophysiological difference?.
        Eur J Phys Rehabil Med. 2013; 49: 119-130
        • Castro M.J.
        • Apple Jr., D.F.
        • Staron R.S.
        • Campos G.E.
        • Dudley G.A.
        Influence of complete spinal cord injury on skeletal muscle within 6 months of injury.
        J Appl Physiol. 1999; 86: 350-358
        • Wu G.A.
        • Bogie K.M.
        Not just quantity: gluteus maximus muscle characteristics in able-bodied and SCI individuals--implications for tissue viability.
        J Tissue Viability. 2013; 22: 74-82
        • Bogie K.M.
        • Powell H.L.
        • Ho C.H.
        New concepts in the prevention of pressure sores.
        Handb Clin Neurol. 2012; 109: 235-246
        • VanGilder C.
        • MacFarlane G.D.
        • Harrison P.
        • Lachenbruch C.
        • Meyer S.
        The demographics of suspected deep tissue injury in the United States: an analysis of the International Pressure Ulcer Prevalence Survey 2006-2009.
        Adv Skin Wound Care. 2010; 23: 254-261
        • National Pressure Ulcer Advisory Panel
        National Pressure Ulcer Advisory Panel (NPUAP) announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury.
        (Available at:)
        • Kim J.H.
        • Wang X.
        • Ho C.H.
        • Bogie K.M.
        Physiological measurements of tissue health; implications for clinical practice.
        Int Wound J. 2012; 9: 656-664
        • Wu G.A.
        • Lombardo L.
        • Triolo R.J.
        • Bogie K.M.
        The effects of combined trunk and gluteal neuromuscular electrical stimulation on posture and tissue health in spinal cord injury.
        PM R. 2013; 5: 688-696
        • Bogie K.M.
        • Nuseibeh I.
        • Bader D.L.
        Early progressive changes in tissue viability in the seated spinal cord injured subject.
        Paraplegia. 1995; 33: 141-147
        • Chai C.Y.
        • Bader D.L.
        The physiological response of skin tissues to alternating support pressures in able-bodied subjects.
        J Mech Behav Biomed Mater. 2013; 28: 427-435
        • Bogie K.M.
        • Nuseibeh I.
        • Bader D.L.
        Transcutaneous gas tensions in the sacrum during the acute phase of spinal cord injury.
        Proc Inst Mech Eng H. 1992; 206: 1-6
        • Fife C.E.
        • Smart D.R.
        • Sheffield P.J.
        • Hopf H.W.
        • Hawkins G.
        • Clarke D.
        Transcutaneous oximetry in clinical practice: consensus statements from an expert panel based on evidence.
        Undersea Hyperb Med. 2009; 36: 43-53
        • Schneider C.A.
        • Rasband W.S.
        • Eliceiri K.W.
        NIH Image to ImageJ: 25 years of image analysis.
        Nat Methods. 2012; 9: 671-675
        • Gefen A.
        • Levine J.
        The false premise in measuring body-support interface pressures for preventing serious pressure ulcers.
        J Med Eng Technol. 2007; 31: 375-380
        • Swash M.
        • Brown M.M.
        • Thakkar C.
        CT muscle imaging and the clinical assessment of neuromuscular disease.
        Muscle Nerve. 1995; 18: 708-714
        • Fung Y.C.
        Biomechanics: mechanical properties of living tissues. Vol. 568. Springer, New York1993
        • Verschueren J.H.
        • Post M.W.
        • de Groot S.
        • van der Woude L.H.
        • van Asbeck F.W.
        • Rol M.
        Occurrence and predictors of pressure ulcers during primary in-patient spinal cord injury rehabilitation.
        Spinal Cord. 2011; 49: 106-112
        • Hauck K.D.
        • Wang S.
        • Vincent C.
        • Smith P.C.
        Healthy life-years lost and excess bed-days due to 6 patient safety incidents: empirical evidence from English hospitals.
        Med Care. 2017; 55: 125-130
        • Markova A.
        • Mostow E.N.
        US skin disease assessment: ulcer and wound care.
        Dermatol Clin. 2012; 30 (ix): 107-111
        • Phillips C.J.
        • Humphreys I.
        • Fletcher J.
        • et al.
        Estimating the costs associated with the management of patients with chronic wounds using linked routine data.
        Int Wound J. 2016; 13: 1193-1197