Having a spinal cord injury (SCI) can put you at increased risk for skin problems. One of the most serious skin complications is known as a pressure injury. Pressure injuries, also called pressure ulcers or bedsores, are wounds on the skin from unrelieved pressure due to prolonged immobility and shearing forces from sliding across surfaces. Pressure injuries result from a lack of blood flow when soft tissues are compressed between bony prominences and external surfaces such as a wheelchair or bed. The lack of blood flow damages the tissue and can cause it to die from insufficient oxygen. If enough damage is done, a wound will occur. A pressure injury can occur in as little as 2 hours of unrelieved tissue pressure.
People with SCI are at increased risk of pressure injury because they have paralysis, meaning they cannot feel or move parts of their body. In people without a spinal cord injury, the body has protective mechanisms that prevent pressure injury. When prolonged pressure starts to damage the tissue, the nerves send signals to the brain that result in small changes in position to restore blood flow. This even happens when sleeping at night. However, because spinal cord injury causes nerve damage, this protective mechanism does not function normally. Even though the tissue is in need of oxygen, the brain does not “get the message”. Due to paralysis, no changes in position occur. It is also more difficult to move paralyzed areas of the body, leading to prolonged periods where the individual sits or lays in the same position.
However, pressure injuries are not unavoidable. By taking certain measures to promote skin health, pressure injuries are often preventable even for people with SCI. Keep reading to learn about how you can take care of your skin and reduce your risk of pressure injury.
Always Check Your Skin
Skin inspection should be done at least daily and should be considered an essential part of your self-care routine. It is one of the most important things you can do to reduce your risk of pressure injury. If you cannot feel certain parts of your body, the only way to know if your skin is healthy and intact is by observation. Plan a skin inspection as a part of your regular routine, during a time when you are undressed anyway — like after a shower or when getting dressed and undressed. Many individuals inspect the skin both in the morning when getting out of bed and in the evening again when getting out of the wheelchair. Having a caregiver assist with skin inspection can be helpful, as they can see areas such as the back and buttocks. If a caregiver is not available to assist, the use of a mirror or a cell phone camera can help with a full body assessment.
Where To Look
Pressure injuries tend to develop on bony prominences. Bony prominences are bones that are close to the skin's surface and feel hard to the touch. Learn to identify high-risk areas for pressure injury on the body. These include buttocks, hips, the tailbone area, shoulders, elbows, knees, ankles, heels and even the back of the head. These areas are more susceptible to pressure injury because they have the least amount of cushioning. Focus on the bony prominences on parts of the body that you cannot feel or move normally. These are the areas of highest risk.
What To Look For
When assessing the skin, take note of the color. Changes in skin color are often the first sign that tissue damage from pressure is occurring. In lighter-skinned individuals, look for pink or red areas. In darker-skinned individuals, the color changes may look dusky or bruised. Sometimes areas of skin damage will also feel warmer, cooler, softer, or firmer than healthy skin. Get familiar with what healthy skin looks and feels like so you can identify changes early and act before deep tissue damage has occurred. Many times, if the cause of the pressure is addressed in the early stages of a pressure injury, it will not open into a wound.
If you find a discolored area, you can check the severity of the damage by pressing your finger into the area of skin discoloration. If the area turns white when pressed with a fingertip, and then immediately turns red or dusky again when the finger is removed, this indicates that no long-term damage has occurred, and the discoloration should resolve within 24 hours. If the area does not turn white when you press your finger into it or persists more than 24 hours, it is likely that some damage has occurred and further intervention is warranted.
Taking Pressure Breaks
When in a wheelchair, pressure breaks are imperative for skin health. Pressure breaks, also known as weight shifts, are maneuvers used to reposition the body and allow blood flow to return to the areas that you sit on. If you have sufficient arm function, you can do these maneuvers in a self-propelled wheelchair. If you have a higher-level spinal cord injury and limited arm function, you may need an electric wheelchair with tilt-in-space and recline features to adequately relieve the pressure to your buttock area. Most experts recommend taking pressure breaks every 30-60 minutes. It may take several minutes to fully restore blood flow to the area. Talk to your healthcare provider about how often you should take pressure breaks and for how long. Here is a guide on how to perform pressure relief maneuvers based on your type of wheelchair:
Pressure relief is also crucial to treating an early-stage pressure injury to prevent it from getting worse. The first step in a pressure injury treatment plan is to relieve the pressure, also known as “offloading”. This will allow blood flow to return to the area and reoxygenate the tissues. Offloading is accomplished by using pillows or foam wedges and body positioning to take body weight off a bony prominence.
If there is a pressure injury to the back, tailbone, sacrum, buttocks, or ischium, minimize time spent sitting directly on the area. Consider using pillows to position the body in alternating side-lying positions when in bed. Remember to change sides at least every 2 hours as pressure injuries can also occur on the sides of the hips. If there is a pressure injury on the hip, rotate positioning between the other two body surfaces without injury – the back and the other hip. If there is a pressure injury on the heels or legs, use pillows or heel-lift boots to raise the heels off the mattress.
Offloading should also be done as a preventative measure. Check all footwear to ensure it is not causing pressure or leaving marks on the foot. Shoes with a wide toe box are often ideal for avoiding pressure on the toes. Make sure clothing is smooth and not bunched up underneath you, as this can cause skin damage. When in bed, ensure the heels are always “floated” off the mattress using pillows or heel-lift boots. Heels left sitting overnight on a mattress may develop pressure injuries. If possible, avoid keeping the head of the bed above 30 degrees and try to lay flat. The head and neck can be propped up with pillows for comfort. Keeping the head of the bed low when lying down will spread body weight across a larger area and reduce pressure to the buttock area.
Utilize Appropriate Support Surfaces
Pressure-reducing support surfaces are mattresses and wheelchair cushions that help redistribute pressure and cushion bony prominences. If you have a history of pressure injuries or are at high risk for pressure injury development, pressure-reducing support surfaces may decrease your risk of wounds. Low air loss mattress and alternating pressure mattresses can be used in the home to provide a safer sleeping surface for your skin. Static air flotation cushions or alternating pressure cushions can be used in the wheelchair. Having appropriate support surfaces is important and can go a long way toward pressure injury prevention for individuals with SCI. Talk to your doctor about obtaining these items and see a specialist to ensure you have the correct cushion on your wheelchair. Many rehabs have outpatient seating clinics that can evaluate your wheelchair seat and recommend the ideal cushion for your lifestyle. Physical or occupational therapists can also be an excellent resource for learning how to perform pressure relief maneuvers. It is important to remember that even with high-level support surfaces, pressure breaks and repositioning are still recommended to restore blood flow to bony prominences.
Skin Care for Strong, Healthy Skin
It is important to keep your skin healthy and strong. Healthy skin is more resistant to breakdown. Conversely, unhealthy skin may succumb more quickly to pressure and develop wounds.
Strive to keep your skin clean and dry. Use gentle PH balanced soaps and moisturizers to keep your skin strong and healthy. Skin that is routinely exposed to urine or feces can become compromised and, subsequently, more likely to develop a pressure injury. One way of reducing moisture exposure is making sure you are adhering to your bladder and bowel program. Successful bladder and bowel management can minimize episodes of incontinence and thus reduce the amount of time your skin is exposed to these substances. If your bladder or bowel program is not working well and you frequently experience incontinence, talk to your doctor. There may be other techniques or medications that can help. Remember to minimize the layers of clothing and bedding under your body. Extra layers trap heat and moisture, which can weaken the skin and make it more prone to breaking down. If your skin is routinely exposed to moisture from incontinence or sweat, consider use of a protective barrier ointment or diaper cream to the area, usually applied 1-2x daily and reapplied as needed.
Nutrition And Hydration Matters
While it is not always the first thing we think of in terms of wound prevention, nutrition and hydration are also crucial for skin health. Protein and essential nutrients and vitamins are the building blocks of healthy tissue. Avoid dehydration by consuming enough fluids. Try to eat lean protein such as chicken, fish, beans, or soy every day. Also include a variety of fruits and vegetables, as these provide vitamins and other nutrients. If you are not able to eat a balanced diet with sufficient protein and nutrients, you may benefit from a nutritional supplement. Talk to your doctor about your specific nutrition and hydration requirements for wound prevention.
What To Do If You Get a Wound
If you develop a wound on a bony prominence, the first thing you should do is relieve pressure to the area. This may mean you need to get out of your wheelchair and into bed, even if it means changing your plans for the day. Don’t forget that you must rotate between other body surfaces as you offload the area with the pressure injury, or you may develop additional wounds. After you have offloaded the area, contact your doctor right away so the wound can be evaluated. You may benefit from seeing a wound specialist who can utilize advanced wound products and special treatments to help the wound heal more quickly and avoid complications. Your doctor can refer you to a wound clinic for an evaluation. If special dressings are recommended by your doctor, you will need a DME company to provide them. A quality DME company and wound care supplier such as ABC Medical will carry many advanced wound products and work with your doctor and insurance company to optimize coverage and reduce out-of-pocket costs for wound care supplies. Another benefit of using a DME company is having dressings you need shipped directly to your home, eliminating the need to travel to a store for products. If you have any questions about wound products, please contact one of our wound product specialists today.
A Final Word
If you have just started on your SCI journey, proper skin care as outlined above might feel overwhelming. But rest assured, just like other hygiene regimens in your life, you learned them step-by-step over time and they became routine. Much of your life is currently a ‘routine’, even though it does not feel like it (because it is a routine). The same can be said of building a routine around skincare to avoid pressure injuries.
You are not alone. Countless others have gone before you. If you’d like to talk to one of our SCI peer mentors – successful individuals who are far down the road on their own SCI journey – then contact us today through our Navigator program. ABC Medical’s Navigator program was specifically designed to help individuals with SCI live life on their own terms. We are here to help. (www.kmtnavigator.com)
- Brienza DM, Campbell KE, Sprigle S. The Past, Present, and Future of Pressure Injury Prevention in Patients with Spinal Cord Injury. Adv Skin Wound Care. 2022;35(2):84-86. doi:10.1097/01.ASW.0000803604.78848.11
- Stinson M, Schofield R, Gillan C, et al. Spinal cord injury and pressure ulcer prevention: using functional activity in pressure relief. Nurs Res Pract. 2013;2013:860396. doi:10.1155/2013/860396
Disclaimer: This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. For medical advice, please speak with your healthcare provider.