The Past, Present, and Future of Pressure Injury Prevention in Patients with Spinal Cord Injury

INTRODUCTION For the 35th anniversary of Advances in Skin & Wound Care, a variety of thought leaders have been invited to share their insight into a range of topics of current interest to the field. In this special installment of Practice Reflections, Dr David Brienza reflects on some of the seminal research on and innovations around pressure injuries (PIs) in patients with spinal cord injury (SCI), Dr Karen E. Campbell humanizes the current state of research in this area, and Dr Stephen Sprigle describes some of the factors that will govern the future of SCI/PI management and prevention. THE PAST As more and more people survived SCI beginning in the mid-20th century, those survivors were greeted with immense health and disability challenges. Preventing PIs was and is one of those challenges. For people with SCIs, immobility and lack of sensation conspire with decreased soft tissue resiliency and impaired blood flow responses to increase the risk of PIs. Past estimates of PI incidence were as high as 80%. Today, the incidence has dropped significantly, but it is still too high. As we look back at the most important innovations and discoveries that influenced the progress, a better understanding of PI etiology, implementation of corresponding prevention protocols, innovations in seat cushion technology, advanced wheelchair seating functions, and other healthcare advances have all contributed. A clearer picture of how PIs resulted from the forces exerted over bony prominences emerged because of work such as that of Michael Kosiak, who showed an inverse relationship between minimal pressure magnitude and shortest duration for exposed tissue to be injured.1 We would later learn that both ischemia and excessive cellular deformation contribute to the damage at the high and low pressure ranges, respectively.2 This knowledge resulted in prevention protocols that specified frequent offloading for people with SCI and general guidance for limits on pressure exposure. Knowing that lowering externally applied pressure reduced risk for tissue injury sparked the next significant development in PI prevention: innovative support surfaces. The interconnected air cell cushion introduced in the early 1970s was the first of many designs that allowed many people with SCI to sit longer in their wheelchairs without injury. Interface pressure measurement technology introduced in the 1980s helped developers evaluate their support surface technologies and assisted clinicians and users to assess their individual conditions.3 Use of interface pressure mapping technology also confirmed that people with SCI typically have higher pressure over the bony prominences of their pelvises compared with others. Support surface technology continued to advance to consider other factors such as excessive heat, high humidity, and friction. Even with the increased knowledge and advances in support surfaces, PI incidence was still too high. Researchers continued searching for and found many other contributing causes. Salzberg et al4 published a risk assessment scale with 15 factors for people with SCI including tobacco use, completeness of SCI, urinary incontinence, autonomic dysreflexia, and other comorbidities. Importantly, some of the risk factors identified are modifiable. Other factors have been examined and associated with risk, but most studies have identified that sensory and motor function are among the most significant predictors with higher risk associated with more severe impairment to mobility and functional independence.5,6 Advancements in power wheelchair technology and related practices evolved to combat the risk associated with immobility for people with SCI. Features such as powered tilt and recline were developed and applied to increase a person’s ability to offload and redistribute weight. The early work of Hobson7 demonstrated the positive effects of tilt and recline. The use of tilt and recline to help prevent PIs was advocated by the Rehabilitation Engineering and Assistive Technology Society of North America in a position paper in 2009.8 Jan et al9 showed the positive effects of the technique on skin blood flow. Health insurance providers now regularly pay for these weight-redistributing features to help lower risk. From the 1950s until the present, PI etiology has become better understood. The new knowledge has helped to identify those people with SCI who are at risk and why. Prevention now focuses on controlling and limiting forces applied to the body and changing modifiable risk factors related to general health and self-care. The technology that has been put into practice to reduce incidence over these years has been primarily support surface-related, with a focus on reducing time and magnitude of potentially damaging forces on soft tissue. Much progress has been achieved, but there is still more room for improvement. THE PRESENT: WOUND AND SKIN CARE IN THE SCI POPULATION This practice reflection is based on my clinical, education, and research experience in Canada. I have chosen to focus on three areas or themes that I see as relevant: interprofessional teams, patient self-management, and the impact of the pandemic on individuals with SCI. These three themes were chosen to reflect the human side of PI prevention and treatment in people with SCI. Interprofessional Teams The growth of interprofessional SCI wound care teams has occurred in Canada within rehabilitation programs because of a need for specialized care for this population. Even as we change the term from pressure sore to ulcer to injury, as wound care clinicians we learned over the last many years that people with an SCI and their body structure, physiology, and therefore their wounds are different than individuals with no SCI and a PI. So, within the specialty of wound care came the subspecialty of SCI and wound care. Included in this are clinical rehabilitation experts of seating, mobility, nutrition, nursing, and physiatry, to name a few, and research by clinicians, engineers, and biomedical experts developing technology needed to improve wound healing and mobility, reduce complications, and improve quality of life. Included in the interprofessional team are the persons with an SCI; they are central and in charge of their care. Even within best practice guidelines, we now see either guidelines specifically for PIs and SCI, or a subsection within the guide on individual groups such as SCI. When I compare Advances in Skin & Wound Care’s article published 35 years ago in their very first issue on the use of hydrocolloid dressings in wound healing to what the current best practice is, so much has changed. Specialized research into adjunctive therapies such as electrical stimulation, mobility and seating devices, and nutrition have shown how we can have a better response to PI prevention and treatment. Even though these specialized teams have developed within the five SCI rehabilitation sites in my province, this has not spread effectively to home and community care, hospitals, or long-term care. Barriers include finances to build and support these teams as well as inconsistent communication because of silos of care both within our healthcare pathways and even within our electronic documentation systems. For example, facilities have developed firewalls within electronic systems for privacy and security, resulting in clinicians who cannot view important diagnostic tests; specialist reports; and details on visits to other clinics, hospitals, or care centers. Self-management The need for patients to self-manage and to advocate for their own care has become even more important in the era of cuts and reduced services. The push for self-management has resulted in consumer groups such as SCI Ontario, which advocates with consumers regarding public policy and service requirements. These groups provide education and support for members to seek best practice in PI prevention and treatment. I believe this approach is essential, with consumers having access to information online and virtual access to consultation with specialists. Individuals with SCI want to be in charge of their own health, as they should be. During the most recent times of the pandemic, this became even more important, when individuals had to manage their own wound care treatments, such as electrical stimulation. This, I believe, has shown us that self-management is possible, and as a result, individuals are more independent and less reliant on caregivers. As an outcome, people with SCI can deal with care issues more effectively than those who do not self-manage. Communication with the person with an SCI is a barrier in some places, with clinicians not involving the individual as an equal partner, assuming the person does not need to know equal information to make an informed decision. Although this is improving, some clinicians assume incorrectly that they know best and follow a more patriarchal or medical model of care. Impact of the Pandemic As the pandemic raged in early 2020, many people were afraid to visit hospitals, even in urgent situations. For people with SCI, this resulted in deterioration of PIs to a more advanced stage than what occurred before the pandemic. Clinic visits and surgeries for PIs were not deemed essential, so they were cancelled. Individuals with SCI and COVID-19 who ended up in the ICU developed PIs in uncommon body locations because of proning protocols. Access to home support was reduced significantly as caregivers were stretched with an ever-increasing workload. Even if individuals had access to paid caregivers, often their regular worker was replaced with someone who was not familiar with their care, or no one was available to provide care. Even access to medical supplies, such as gloves, masks, and hand sanitizers, was limited as first and/or greatly increased in price. Although there were many problems during the pandemic, it also showed us that many clinic visits could be held virtually, and many wound care tasks could be managed by the person with SCI. This supported self-management and made attending appointments much easier. THE FUTURE OF PI PREVENTION IN SCI The future of prevention in SCI will be governed, largely, on a commitment to prevention. This commitment has yet to be realized in a coordinated and comprehensive fashion. Yet, several things are on the near horizon and are merely waiting on us to commit to ending this solvable—yet highly complex—problem. Four areas are highlighted, although many more exist. Monitoring Coupled with Large Datasets We have developed systems and techniques to aggregate huge amounts of data that can be used to draw causal inferences about tissue damage. Consider tracking laboratory values for persons with SCI and identifying markers that have been shown to be associated with PI. This analysis involves identifying an index episode (PI) and a look-back to identify laboratory and physiologic parameters that change before the index episode. By identifying these markers, we can identify people who are at immediate risk and intervene accordingly. This capability exists now, and our only barrier is gaining access to a dataset and doing the work. Direct Monitoring of Tissue Stress and Damage Tissue damage results from mechanical and/or physiologic stress. Technologies are being developed with the ability to monitor tissue stress as a means to drive preventive interventions. Two types of diagnostic technologies will exist: (1) tools that people use daily or weekly to interrogate tissues and (2) user-worn technologies that work throughout the day during everyday life. These technologies will use sensors currently under development but not yet focused on tissue health. Point-of-care tools that can be used at home will target identification of stressors or incipient damage that require attention. These will be based on the many technologies being used and developed today for noninvasive monitoring. For example, physiochemical and acoustic technologies can measure tissue oxygenation, and tissue compliance has direct implications for PI prevention. User-worn technologies will include undergarments or instrumented dressings populated with sensors to monitor tissue stress. These devices will report near-real-time stress conditions, thereby allowing people to intervene quickly. This will doubtless involve an app that sends a “Get Off Your Butt!” notification. The challenge of both will lie in usefulness—a combination of utility and usability. Utility, as embodied by performance, will be solved more easily than usability. A commitment to user-centered design will be needed to ensure these technologies are useful to those who need it. New Seating and Mobility Technologies The development of seating and mobility technologies for persons with SCI has been steady and productive. We already have mobility technologies that permit different postures and positions that redistribute pressures but can envision new technologies that integrate better into everyday life. We have technology to sequence through erect sitting, recline, tilt, and standing. However, we have not committed to studying the frequencies of pressure-redistributing movements that result in prevention. All technologies that support variable postures, whether powered wheelchair seating or exoskeletons, will need to facilitate multiple activities of daily living. This is currently not the case. Attending to functional activities while addressing tissue health is needed. Availability of Technologies The sole reason that many technologies are not readily available or under development is policy, not technical capability. This is a solvable problem that will require a combination of “working together” and building evidence of value-defined as benefit/cost. The US’ Medicare program is a resource management rather than an insurance program; accordingly, it has shown no interest in assessing the value of providing proper equipment for persons with disabilities. Further, manufacturers of rehabilitation and assistive technology have shown little interest in supporting coordinated and unbiased assessment of value. We need a “champion” with power. I am hopeful that insurance companies will analyze the data available to them and determine that proper equipment saves money and results in better health.

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