A person with a spinal cord injury (SCI) is at risk of developing a pressure injury due to impaired sensation and muscular atrophy. Other factors include reduced vascular supply, dependent oedema, heat and moisture.
Occupational therapy intervention to assist with skin management should take place when the person with an SCI:
- has intact skin, however the clinician has identified that they have a high-risk profile
- is on bed rest with a pressure injury
- has recently had a pressure injury and their skin has healed.
The occupational therapy intervention should be part of a multidisciplinary team review.
Occupational therapy review
When the person with an SCI has intact skin but has a high risk of developing a pressure injury, the occupational therapist should:
- provide education about skin care management and causes of pressure injuries such as pressure care equipment, mobility and regular pressure relieving, microclimate, positioning, shearing risks and clothing
- review equipment, posture, quality of transfers and functional ability as below.
When the person with an SCI is on bed rest with a pressure injury the occupational therapist should:
- inspect their skin
- discuss possible causes of the pressure injury
- examine their equipment
- organise an appropriate mattress
- provide advice about positioning and bed mobility
- gather information about their daily routine including how functional activities are performed
- consider care needs – to facilitate bed rest and to prepare for gradual return to seating when skin has healed
- explore ways in which the person can continue in their life roles e.g. access to alternative technology to support work whilst on bed rest.
When the pressure injury has healed and the person with an SCI is able to start a gradual return to seating protocol, the occupational therapist should consider the following.
Pressure redistribution and relief
- Do seating surfaces provide the person with adequate pressure redistribution?
- Consider wheelchair cushions, toileting and showering equipment and car cushions.
- Is their method of weight shifting safe and effective for pressure relief?
- Consider ability to lean forward, side lean or use tilt in space function and to sustain that position for sufficient time to ensure adequate offloading.
- Does the person have a symmetrical sitting posture?
- For example, someone with a pelvic obliquity may bear more weight (and more pressure) on one ischial tuberosity than on the other.
- Does it meet the person’s needs?
- Does it fit them well?
- Is it well maintained?
- Consider wheelchair and cushion, mobile shower commode, mattress, hoist and sling, car and exercise equipment.
- Does it provide the person with adequate pressure relief and redistribution?
- Does the mattress offer enough support so that they are not resting on the bed frame (bottoming out)?
- Does the person clear all surfaces well during all transfers?
- Are their transfers level or downhill?
- If transferred with a hoist, does the person shear in the sling during transfers?
- Is the edge of the sling in contact with the healed skin?
- Can the person check his or her own skin?
- Long-handled mirrors or assistive technology, such as a web cam, can assist. Alternatively, ensure that a carer performs regular skin checks.
- Is the person aware of the importance of wearing soft footwear and seamless breathable clothing to avoid pressure on skin (e.g. to avoid zips, large buckles, belts, jeans, hard leather shoes)?
- Has the person’s level of functioning declined?
- Transfers, ability to pressure relieve, bed mobility and shoulder integrity.
When assessing seating and sleeping surfaces it may be useful to use a system to measure the pressure between the person and his or her seat or mattress (interface pressure). This may require the use of a pressure mapping device or a referral to a seating clinic.
Clinical guidelines or information
- Agency for Clinical Innovation. Pressure Injury Toolkit for Spinal Cord Injury and Spina Bifida. Sydney: Agency for Clinical Innovation; 2021 [cited 5 March 2021].
- Carville, K. Wound Care Manual. 7th ed. Osborne Park. WA: Silver Chain Nursing Association Incorporated; 2017.
- Consortium for Spinal Cord Medicine. Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury: Clinical Practice Guidelines for Health Care professionals. 2nd ed. Washington DC: Paralyzed Veterans of America; 2014 [cited 5 March 2021].
- Haesler, E (Ed.). Prevention and treatment of pressure ulcers/injuries: clinical practice guideline. The international guideline. 3rd E. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pacific Pressure Injury Alliance. 2019.
This is an international consensus document developed by the National Pressure Injury Advisory Panel (US), European Pressure Ulcer Advisory Panel, and the Pan Pacific Pressure Injury Alliance (including Australian Wound Management Association).
The Quick Reference Guide can be downloaded for free from the website. Hard copies of the Clinical Guidelines and Quick Reference Guide can be purchased.
- Houghton PE, Campbell KE and CPG Panel. Canadian Best Practice Guidelines for the Prevention and Management of Pressure Ulcers in People with Spinal Cord Injury. A Resource Handbook for Clinicians. Toronto: Ontario Neurotrauma Foundation; 2013 [cited 20 March 2021].
These guidelines are FREE and at 300+ pages are very comprehensive!
- Swanson T, Asimus M, McGuiness, B (Editors). Wound Management for the Advanced Practitioner. Melbourne: IP Communications; 2014.
- Agency for Clinical Innovation. Pressure Injury Toolkit for Spinal Cord Injury and Spina Bifida: Resources for Consumers and Carers. Sydney: Agency for Clinical Innovation; 2021 [cited 21 March 2021].
- Consortium for Spinal Cord Medicine. Pressure Ulcers: What You Should Know A guide for People with Spinal Cord Injury. Washington DC: Paralyzed Veterans of America; 2002 [cited 20 March 2021].
- Model Systems Knowledge Translation Center. Skin Care and Pressure Sores (set of 6). Arlington: Model Systems Knowledge Translation Center; 2009 [cited 20 March 2021].
- Queensland Spinal Cord Injuries Service. Skin Care: Return to Sitting after a Skin Breakdown. Woolloongabba: Queensland Spinal Injuries Service; 2020 [cited 20 March 2021].