People with spinal cord injuries may no longer receive pain signals in their brain when something is irritating their skin. The result can be abrasions, openings in the skin or much deeper issues like pressure ulcers. In this installment of the Living With a Spinal Cord Injury series from Jefferson Moss-Magee Rehabilitation, we discuss the risk factors for such injuries and offers tips on how to prevent them.
The Living With a Spinal Cord Injury series is made possible by a gift from David and Barbara Loeb.
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Narrator: Your skin protects you from infection, keeps you warm or cool and transmits feelings to your brain through its nerve endings. But when an area of the skin experiences a loss of blood flow it can easily cause a pressure injury.
Jacobs: Most often after you sustained a spinal injury there are significant changes that happen in the ability for your body to communicate. So there's disruption of the communication between your brain, your spinal cord and also your muscles.Additionally, there are changes in your sensation. So that means that you no longer can feel the same things. You don't get those signals that something is hurting you. A pressure injury can be something as simple as an abrasion or superficial opening in your skin, but it can be also as devastating as extending into deep damage of underlying soft tissue that can even go down to your muscle or bone. So people that have spinal injuries are actually in the highest disability risk group to develop a pressure injury. One of the biggest reasons is because you now have neurologically impaired skin. The nervous system changes that occur after an injury include reduction in your circulation, oxygen delivery to your tissue, capillary dilation and constriction is altered, and even the elasticity in both your skin and underlying soft tissue is now negatively impacted thus increasing your risk to develop a pressure injury. Risk factors for pressure injuries include sitting or lying in the same position for too long, sitting or lying on hard objects, moisture from bladder or bowel accidents, spasticity causing rubbing of the skin, clothing or shoes that are too tight, lack of use or disrepair of specialized cushions and mattresses, other medical problems such as poor nutrition, smoking, diabetes, heart disease, depression and substance abuse.
Alysse: I had a cushion that was foam and the foam developed a break in it. So I used duct tape to tape it closed and then put the covering back on. And the duct tape - a wrinkle in the duct tape - that just happened to be right underneath my hip bones is what caused the pressure injury. Yeah, I was pretty mortified. And then I also developed pressure ulcers on my heels because I was really stupid and wore shoes that were really pretty but they were too small.
Narrator: There are a few basic techniques to help you prevent pressure injuries. Using a skin inspection mirror, you or your caregiver should always check your skin twice a day for early signs of pressure injury. You're looking for red or darkened skin areas that don't lighten within 30 minutes after pressure has been removed, skin that feels warm or looks bruised, any tears or openings in your skin, and any hard lumps underneath your skin. Most pressure injuries occur over bony areas. Be sure to always check your sacrum, tailbone, sitting bones, elbows, shoulder, blades and heels during your daily skin inspections.
Jacobs: So normally, for an example, when I'm sitting watching the television for two hours I would get uncomfortable on my bottom. I would shift my weight in the chair. Again you don't get those signals any longer so you no longer are shifting your weight routinely, so that has to become part of your normal practice of what you do every day/. Every twenty to thirty minutes you need to be shifting your weight when you're sitting on your bottom. Same thing with sensation. If I put my shoelaces and tie them too tight on my feet I won't get any signals that that is too tight and it's bothering me. So I won't know I need to untie my shoelaces to make my foot more comfortable. That can develop into a pressure injury also. Part of the sensation disruption is also that you can possibly burn yourself. You're not feeling those signals so you have to be very cautious in regards to your daily activities - what you're doing. You have to think about testing the water before you take your shower, retesting it even during your shower. You need to wear sunscreen in the summer just to protect your skin from burning because you won't get those signals that something is hurting you any longer. Repositioning and rolling in bed should occur every two hours. The use of pillows or wedges will help you maintain a good position during the night. A special mattress should be ordered for your bed that will help to distribute your weight more evenly.
Alysse: I get in and start positioning myself on the right side. I use a sheepskin underneath my bottom legs so that the bony prominence in my knee and my ankle are resting on something very soft. And then I put a pillow in between my legs, and I make sure that the top leg is on it so that the ankle bone is not against the mattress. And then I prop myself up with a pillow behind me so that I stay pretty much on my side so there's no hip - my hip or my sacrum is really never touching the mattress all night long.
Narrator: When seated, a customized cushion to help distribute your weight will reduce your risk of skin breakdown. Be sure the cushion is inflated and positioned correctly. Always check your posture to make sure you are upright and well supported.
Jennifer: I watch the amount of time I'm in bed. I watch the amount of time that I'm in one spot. if I am in the chair I do a lot of weight shifts every 20 minutes, every half an hour. In the chair like this is pretty easy to do your weight shifts. And trust me the last thing that anyone and with a spinal cord injury or anyone that's not able-bodied, the last thing they want is it's a pressure ulcer. They take forever to heal. They stink. They hurt. They're not fun to have.
Jacobs: You need to really look at what you do on a daily basis - what your normal activities are - and think about how can what I'm doing and how I am moving impact my skin in a bad way. Surfaces, particularly anything hard, is a problem potentially to increase your risk to develop a pressure injury. Bedpans, commodes that are not padded, bumping up and down stairs to get to the second floor, sitting in the car driving on a trip for hours at a time not sitting on your specialized wheelchair cushion, those are all risk activities that you really need to think through and make sure you're doing prevention measures such as your weight shifting, pressure reliefs very aggressively, and using your team to potentially order some specialized equipment that will help to reduce that risk.
Narrator: Being connected with your rehabilitation doctor and the rehab team will provide you with the best education and recommendations to assure you stay healthy and can manage any skin challenge you might experience as someone living with an SCI.
- Autonomic Dysreflexia
- Emotional Health
- Skin Care
- Medical Complications
- Sexual Intimacy
- Respiratory Care
- Bladder Management
- Bowel Management
- Neurologic Changes
- Care for the Caregiver
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