Abstract
Study Design
Narrative review.
Objectives
Pressure ulcers are a common complication in people with reduced sensation and limited mobility, occurring frequently in those who have sustained spinal cord injury. This narrative review summarises the evidence relating to interventions for the prevention and treatment of pressure ulcers, in particular from Cochrane systematic reviews. It also aims to highlight the degree to which people with spinal cord injury have been included as participants in randomised controlled trials included in Cochrane reviews of such interventions.
Setting
Global.
Methods
The Cochrane library (up to July 2017) was searched for systematic reviews of any type of intervention for the prevention or treatment of pressure ulcers. A search of PubMed (up to July 2017) was undertaken to identify other systematic reviews and additional published trial reports of interventions for pressure ulcer prevention and treatment.
Results
The searches revealed 38 published systematic reviews (27 Cochrane and 11 others) and 6 additional published trial reports. An array of interventions is available for clinical use, but few have been evaluated adequately in people with SCI.
Conclusions
The effects of most interventions for preventing and treating pressure ulcers in people with spinal cord injury are highly uncertain. Existing evaluations of pressure ulcer interventions include very few participants with spinal cord injury. Subsequently, there is still a need for high-quality randomised trials of such interventions in this patient population.
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References
Defloor T. The risk of pressure sores: a conceptual scheme. J Clin Nurs. 1999;8:206–16.
The National Pressure Ulcer Advisory Panel. NPUAP Pressure Ulcer Stages/Categories. 2016. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ (Accessed 6th October 2017).
Spilsbury K, Nelson A, Cullum N, Iglesias C, Nixon J, Mason S. Pressure ulcers and their treatment and effects on quality of life: hospital inpatient perspectives. J Adv Nurs. 2007;57:494–504.
Hall J, Buckley HL, Lamb KA, Stubbs N, Saramago P, Dumville JC, et al. Point prevalence of complex wounds in a defined United Kingdom population. Wound Repair Regen. 2014;22:694–700.
Coleman S, Gorecki C, Nelson EA, Closs SJ, Defloor T, Halfens R, et al. Patient risk factors for pressure ulcer development: systematic review. Int J Nurs Stud. 2013;50:974–1003.
Marin J, Nixon J, Gorecki C. A systematic review of risk factors for the development and recurrence of pressure ulcers in people with spinal cord injuries. Spinal Cord. 2013;51:522–7.
Lindgren M, Unosson M, Fredrikson M, Ek AC. Immobility—a major risk factor for development of pressure ulcers among adult hospitalized patients: a prospective study. Scand J Caring Sci. 2004;18:57–64.
Teasell RW, Arnold JM, Krassioukov A, Delaney GA. Cardiovascular consequences of loss of supraspinal control of the sympathetic nervous system after spinal cord injury. Arch Phys Med Rehabil. 2000;81:506–16.
Sheerin F, Gillick A, Doyle B. Pressure ulcers and spinal-cord injury: incidence among admissions to the Irish national specialist unit. J Wound Care. 2011;14:112–5.
Lala D, Dumont FS, Leblond J, Houghton PE, Noreau L. Impact of pressure ulcers on individuals living with a spinal cord injury. Arch Phys Med Rehabil. 2014;95:2312–9.
Taghipoor KD, Arejan RH, Rasouli MR, Saadat S, Moghadam M, Vaccaro AR, et al. Factors associated with pressure ulcers in patients with complete or sensory-only preserved spinal cord injury: is there any difference between traumatic and nontraumatic causes? J Neurosurg Spine. 2009;11:438–44.
Nogueira PC, Caliri MH, Haas VJ. Profile of patients with spinal cord injuries and occurrence of pressure ulcer at a university hospital. Rev Lat Am Enferm. 2006;14:372–7.
Richardson RR, Meyer PR. Prevalence and incidence of pressure sores in acute spinal cord injuries. Paraplegia. 1981;19:235–47.
Verschueren JH, Post MW, de Groot S, van der Woude LH, van Asbeck FW, Rol M. Occurrence and predictors of pressure ulcers during primary in-patient spinal cord injury rehabilitation. Spinal Cord. 2011;49:106–12.
Scheel-Sailer A, Wyss A, Boldt C, Post MW, Lay V. Prevalence, ___location, grade of pressure ulcers and association with specific patient characteristics in adult spinal cord injury patients during the hospital stay: a prospective cohort study. Spinal Cord. 2013;51:828–33.
van der Wielen H, Post MW, Lay V, Gläsche K, Scheel-Sailer A. Hospital-acquired pressure ulcers in spinal cord injured patients: time to occur, time until closure and risk factors. Spinal Cord. 2016;54:726–31.
Moseley AM, Elkins MR, Herbert RD, Maher CG, Sherrington C. Cochrane reviews used more rigorous methods than non-Cochrane reviews: survey of systematic reviews in physiotherapy. J Clin Epidemiol. 2009;62:1021–30.
Tricco AC, Tetzlaff J, Pham B, Brehaut J, Moher D. Non-Cochrane vs. Cochrane reviews were twice as likely to have positive conclusion statements: cross-sectional study. J Clin Epidemiol. 2009;62:380–6.e1.
National Clinical Guideline Centre. The prevention and management of pressure ulcers in primary and secondary care. NICE Clinical Guidelines, No. 179. Methods, evidence and recommendations, commissioned by the National Institute for Health and Care Excellence, London, 2014.
Higgins JPT, Green S, (editors). Cochrane handbook for systematic reviews of interventions version 5.1.0: The Cochrane Collaboration. www.cochrane-handbook.org; updated 2011.
McInnes E, Jammali-Blasi A, Bell-Syer SE, Dumville JC, Middleton V, Cullum N. Support surfaces for pressure ulcer prevention. Cochrane Database Syst Rev. 2015;9:CD001735.
Gillespie BM, Chaboyer WP, McInnes E, Kent B, Whitty JA, Thalib L. Repositioning for pressure ulcer prevention in adults. Cochrane Database Syst Rev. 2014;4:CD009958.
Moore ZE, Cowman S. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database Syst Rev. 2014;2:CD006471.
Moore ZE, Webster J. Dressings and topical agents for preventing pressure ulcers. Cochrane Database Syst Rev. 2013;8:CD009362.
Zhang Q, Sun Z, Yue J. Massage therapy for preventing pressure ulcers. Cochrane Database Syst Rev. 2015;6:CD010518.
Moore ZE, Webster J, Samuriwo R. Wound-care teams for preventing and treating pressure ulcers. Cochrane Database Syst Rev. 2015;9:CD011011.
Langer G, Fink A. Nutritional interventions for preventing and treating pressure ulcers. Cochrane Database Syst Rev. 2014;6:CD003216.
Economides NG, Skoutakis VA, Carter CA, Smith VH. Evaluation of the effectiveness of two support surfaces following myocutaneous flap surgery. Adv Wound Care. 1995;8:49–53.
Gentilello L, Thompson DA, Tonnesen AS, Hernandez D, Kapadia AS, Allen SJ, et al. Effect of a rotating bed on the incidence of pulmonary complications in critically ill patients. Crit Care Med. 1988;16:783–6.
Han J, Li G, Wang A. Control study on pressure sore prevention for patients accepting posterior spinal surgery. Chin Nurs Res. 2011;25:308–10.
Westby MJ, Dumville JC, Soares MO, Stubbs N, Norman G. Dressings and topical agents for treating pressure ulcers. Cochrane Database Syst Rev. 2017;6:CD011947.
Naing C, Whittaker MA. Anabolic steroids for treating pressure ulcers. Cochrane Database Syst Rev. 2017;6:CD011375.
Han XY, Li HL, Su H, Cai H, Guo TK, Liu R, et al. Topical phenytoin for treating pressure ulcers. Cochrane Database Syst Rev. 2017;2:CD008251.
Norman G, Dumville JC, Moore ZE, Tanner J, Christie J, Goto S. Antibiotics and antiseptics for pressure ulcers. Cochrane Database Syst Rev. 2016;4:CD011586.
Aziz Z, Bell-Syer SE. Electromagnetic therapy for treating pressure ulcers. Cochrane Database Syst Rev. 2015;9:CD002930.
Dumville JC, Webster J, Evans D, Land L. Negative pressure wound therapy for treating pressure ulcers. Cochrane Database Syst Rev. 2015;5:CD011334.
Dumville JC, Keogh SJ, Liu Z, Stubbs N, Walker RM, Fortnam M. Alginate dressings for treating pressure ulcers. Cochrane Database Syst Rev. 2015;5:CD011277.
Dumville JC, Stubbs N, Keogh SJ, Walker RM, Liu Z. Hydrogel dressings for treating pressure ulcers. Cochrane Database Syst Rev. 2015;2:CD011226.
Chen C, Hou WH, Chan ES, Yeh ML, Lo HL. Phototherapy for treating pressure ulcers. Cochrane Database Syst Rev. 2014;7:CD009224.
McGinnis E, Stubbs N. Pressure-relieving devices for treating heel pressure ulcers. Cochrane Database Syst Rev. 2014;2:CD005485.
Moore ZE, Cowman S. Wound cleansing for pressure ulcers. Cochrane Database Syst Rev. 2013;3:CD004983.
McInnes E, Dumville JC, Jammali-Blasi A, Bell-Syer SE. Support surfaces for treating pressure ulcers. Cochrane Database Syst Rev. 2011;12:CD009490.
Baba-Akbari Sari A, Flemming K, Cullum NA, Wollina U. Therapeutic ultrasound for pressure ulcers. Cochrane Database Syst Rev. 2006;3:CD001275.
Wong JK, Amin K, Dumville JC. Reconstructive surgery for treating pressure ulcers. Cochrane Database Syst Rev. 2016;12:CD012032.
Moore ZE, Cowman S. Repositioning for treating pressure ulcers. Cochrane Database Syst Rev. 2015;1:CD006898.
Moore ZE, van Etten MT, Dumville JC. Bed rest for pressure ulcer healing in wheelchair users. Cochrane Database Syst Rev. 2016;10:CD011999.
Hollisaz MT, Khedmat H, Yari F. A randomized clinical trial comparing hydrocolloid, phenytoin and simple dressings for the treatment of pressure ulcers [ISRCTN33429693]. BMC Dermatol. 2004;4:18.
Kraft MR, Lawson L, Pohlmann B, Reid-Lokos C, Barder L. A comparison of Epi-Lock and saline dressings in the treatment of pressure ulcers. Decubitus. 1993;6:42–4,46,48.
Nussbaum EL, Biemann I, Mustard B. Comparison of ultrasound/ultraviolet-C and laser for treatment of pressure ulcers in patients with spinal cord injury. Phys Ther. 1994;74:812–23. Discussion 24–5.
Kaya AZ, Turani N, Akyüz M. The effectiveness of a hydrogel dressing compared with standard management of pressure ulcers. J Wound Care. 2005;14:42–4.
Bauman WA, Spungen AM, Collins JF, Raisch DW, Ho C, Deitrick GA, et al. The effect of oxandrolone on the healing of chronic pressure ulcers in persons with spinal cord injury: a randomized trial. Ann Intern Med. 2013;158:718–26.
Subbanna PK, Margaret Shanti FX, George J, Tharion G, Neelakantan N, Durai S, et al. Topical phenytoin solution for treating pressure ulcers: a prospective, randomized, double-blind clinical trial. Spinal Cord. 2007;45:739–43.
Salzberg CA, Cooper-Vastola SA, Perez F, Viehbeck MG, Byrne DW. The effects of non-thermal pulsed electromagnetic energy on wound healing of pressure ulcers in spinal cord-injured patients: a randomized, double-blind study. Ostomy Wound Manag. 1995;41:42–4, 46, 48 passim.
de Laat EH, van den Boogaard MH, Spauwen PH, van Kuppevelt DH, van Goor H, Schoonhoven L. Faster wound healing with topical negative pressure therapy in difficult-to-heal wounds: a prospective randomized controlled trial. Ann Plast Surg. 2011;67:626–31.
Brewer RD, Mihaldzic N, Dietz A. The effect of oral zinc sulfate on the healing of decubitus ulcers in spinal cord injured patients. Proc Annu Clin Spinal Cord Inj Conf. 1967;16:70–2.
Ho CH, Bensitel T, Wang X, Bogie KM. Pulsatile lavage for the enhancement of pressure ulcer healing: a randomized controlled trial. Phys Ther. 2012;92:38–48.
Jull AB, Cullum N, Dumville JC, Westby MJ, Deshpande S, Walker N. Honey as a topical treatment for wounds. Cochrane Database Syst Rev. 2015;3:CD005083.
Sebern MD. Pressure ulcer management in home health care: efficacy and cost effectiveness of moisture vapor permeable dressing. Arch Phys Med Rehabil. 1986;67:726–9.
Martinez-Zapata MJ, Martí-Carvajal AJ, Solà I, Expósito JA, Bolíbar I, Rodríguez L, et al. Autologous platelet-rich plasma for treating chronic wounds. Cochrane Database Syst Rev. 2016;5:CD006899.
Knighton DR, Doucette M, Fiegel VD, Ciresi K, Butler E, Austin L. The use of platelet derived wound healing formula in human clinical trials. Prog Clin Biol Res. 1988;266:319–29.
Knighton DR, Ciresi K, Fiegel VD, Schumerth S, Butler E, Cerra F. Stimulation of repair in chronic, nonhealing, cutaneous ulcers using platelet-derived wound healing formula. Surg Gynecol Obstet. 1990;170:56–60.
Anitua E, Aguirre JJ, Algorta J, Ayerdi E, Cabezas AI, Orive G, et al. Effectiveness of autologous preparation rich in growth factors for the treatment of chronic cutaneous ulcers. J Biomed Mater Res B Appl Biomater. 2008;84:415–21.
Gulati S, Qureshi A, Srivastava A, Kataria K, Kumar P, Ji AB. A prospective randomized study to compare the effectiveness of honey dressings vs. povidone iodine dressing in chronic wound healing. Indian J Surg. 2014;76:193–8.
Dat AD, Poon F, Pham KB, Doust J. Aloe vera for treating acute and chronic wounds. Cochrane Database Syst Rev. 2012;2:CD008762.
Thomas D, Goode P, LaMaster K, Tennyson T. Acemannan hydrogel dressing versus saline dressing for pressure ulcers: a randomised, controlled trial. Adv Wound Care. 1998;11:273–6.
Thomas DR, Goode PS, LaMaster K, Tennyson T. Acemannan hydrogel dressing versus saline dressing for pressure ulcers. A randomized, controlled trial. Adv Wound Care. 1998;11:273–6.
Kranke P, Bennett MH, Martyn-St James M, Schnabel A, Debus SE, Weibel S. Hyperbaric oxygen therapy for chronic wounds. Cochrane Database Syst Rev. 2015;6:CD004123.
Orenczuk K, Mehta S, McIntyre A, Regan M, Teasell R. A systematic review of the efficacy of pressure ulcer education interventions available for individuals with SCI. Can J Nurs Inform. 2011;6.
Gélis A, Stéfan A, Colin D, Albert T, Gault D, Goossens D, et al. Therapeutic education in persons with spinal cord injury: a review of the literature. Ann Phys Rehabil Med. 2011;54:189–210.
Cogan AM, Blanchard J, Garber SL, Vigen CL, Carlson M, Clark FA. Systematic review of behavioral and educational interventions to prevent pressure ulcers in adults with spinal cord injury. Clin Rehabil. 2017;31:871–80.
Liu LQ, Moody J, Traynor M, Dyson S, Gall A. A systematic review of electrical stimulation for pressure ulcer prevention and treatment in people with spinal cord injuries. J Spinal Cord Med. 2014;37:703–18.
Liu L, Moody J, Gall A. A quantitative, pooled analysis and systematic review of controlled trials on the impact of electrical stimulation settings and placement on pressure ulcer healing rates in persons with spinal cord injuries. Ostomy Wound Manag. 2016;62:16–34.
Lala D, Spaulding SJ, Burke SM, Houghton PE. Electrical stimulation therapy for the treatment of pressure ulcers in individuals with spinal cord injury: a systematic review and meta-analysis. Int Wound J. 2016;13:1214–26.
Stratton RJ, Ek AC, Engfer M, Moore Z, Rigby P, Wolfe R, et al. Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta-analysis. Ageing Res Rev. 2005;4:422–50.
Reddy M, Gill SS, Kalkar SR, Wu W, Anderson PJ, Rochon PA. Treatment of pressure ulcers: a systematic review. JAMA. 2008;300:2647–62.
Regan MA, Teasell RW, Wolfe DL, Keast D, Mortenson WB, Aubut JA, et al. A systematic review of therapeutic interventions for pressure ulcers after spinal cord injury. Arch Phys Med Rehabil. 2009;90:213–31.
Groah SL, Schladen M, Pineda CG, Hsieh CH. Prevention of pressure ulcers among people with spinal cord injury: a systematic review. PM R. 2015;7:613–36.
Tran JP, McLaughlin JM, Li RT, Phillips LG. Prevention of pressure ulcers in the acute care setting: new innovations and technologies. Plast Reconstr Surg. 2016;138(3 Suppl):232S–40S.
Arora M, Harvey LA, Glinsky JV, Nier L, Lavrencic L, Kifley A, et al. Electrical stimulation for treating pressure ulcers (Protocol). Cochrane Database Syst Rev. 2016;5:CD012196.
Joyce P, Moore ZEH, Christie J, Dumville JC. Organisation of health services for preventing and treating pressure ulcers (Protocol). Cochrane Database Syst Rev. 2016;3:CD012132.
Porter-Armstrong AP, Moore ZEH, Bradbury I, McDonough S. Education of healthcare professionals for preventing pressure ulcers (Protocol). Cochrane Database Syst Rev. 2015;4:CD011620.
O’Connor T, Moore ZEH, Dumville JC, Patton D. Patient and lay carer education for preventing pressure ulceration in at-risk populations (Protocol). Cochrane Database Syst Rev. 2015;12:CD012006.
Walker RM, Keogh SJ, Higgins NS, Whitty JA, Thalib L, Gillespie BM, et al. Foam dressings for treating pressure ulcers (Protocol). Cochrane Database Syst Rev. 2014;10:CD011332.
Choo J, Nixon J, A. NE, McGinnis E. Autolytic debridement for pressure ulcers (Protocol). Cochrane Database Syst Rev. 2014;10:CD011331.
Keogh SJ, Nelson EA, Webster J, Jolly J, Ullman AJ, Chaboyer WP. Hydrocolloid dressings for treating pressure ulcers (Protocol). Cochrane Database Syst Rev. 2013;2:CD010364.
Baron J, Swaine J, Presseau J, Aspinall A, Jaglal S, White B, et al. Self-management interventions to improve skin care for pressure ulcer prevention in people with spinal cord injuries: a systematic review protocol. Syst Rev. 2016;5:150.
Kim JY, Cho E. Evaluation of a self-efficacy enhancement program to prevent pressure ulcers in patients with a spinal cord injury. Jpn J Nurs Sci. 2017;14:76–86.
Clark F, Pyatak EA, Carlson M, Blanche EI, Vigen C, Hay J, et al. Implementing trials of complex interventions in community settings: the USC-Rancho Los Amigos pressure ulcer prevention study (PUPS). Clin Trials. 2014;11:218–29.
Carlson M, Vigen CL, Rubayi S, Blanche EI, Blanchard J, Atkins M, et al. Lifestyle intervention for adults with spinal cord injury: Results of the USC-RLANRC Pressure Ulcer Prevention Study. J Spinal Cord Med. 2017:1–18. https://doi.org/10.1080/10790268.2017.1313931
Nussbaum EL, Flett H, Hitzig SL, McGillivray C, Leber D, Morris H, et al. Ultraviolet-C irradiation in the management of pressure ulcers in people with spinal cord injury: a randomized, placebo-controlled trial. Arch Phys Med Rehabil. 2013;94:650–9.
Arora M, Harvey LA, Glinsky JV, Chhabra HS, Hossain S, Arumugam N, et al. Telephone-based management of pressure ulcers in people with spinal cord injury in low- and middle-income countries: a randomised controlled trial. Spinal Cord. 2017;55:141–7.
Dwivedi MK, Bhagat AK, Srivastava RN, Jain A, Baghel K, Raj S. Expression of MMP-8 in pressure injuries in spinal cord injury patients managed by negative pressure wound therapy or conventional wound care: a randomized controlled trial. J Wound Ostomy Cont Nurs. 2017;44:343–9.
Brown T. It’s time for alltrials registered and reported. Cochrane Database Syst Rev. 2013;4:ED000057.
Brassington I. The ethics of reporting all the results of clinical trials. Br Med Bull. 2017;121:19–29.
Cochrane. Cochrane Central Register of Controlled Trials (CENTRAL). 2017. http://www.cochranelibrary.com/about/central-landing-page.html.
Guyatt GH, Oxman AD, Kunz R, Vist GE, Falck-Ytter Y, Schünemann HJ, et al. What is “quality of evidence” and why is it important to clinicians? BMJ. 2008;336:995–8.
Schünemann HJ, Oxman AD, Higgins JP, Vist GE, Glasziou P, Guyatt GH. Chapter 11: presenting results and ‘Summary of findings’ tables. In: Higgins JP, Green S, editors. Cochrane handbook for systematic reviews of interventions version 5.1.0 (updated March 2011). The Cochrane Collaboration. www.cochrane-handbook.org.
Cullum N, Buckley H, Dumville J, Hall J, Lamb K, Madden M, et al. Wounds research for patient benefit: a 5-year programme of research. Program Grants Appl Res. 2016;4:13.
Drolet BC, Johnson KB. Categorizing the world of registries. J Biomed Inform. 2008;41:1009–20.
Gliklich RE, Dreyer NA, Leavy MB. Registries for evaluating patient outcomes: a user’s guide. In: Gliklich RE, Dreyer NA, Leavy MB, editors. 3rd ed. 2 Volumes. Rockville, MD: Agency for Healthcare Research and Quality; 2014.
Hsieh JM, A, Wolfe D, Lala D, Titus L, Campbell K, Teasell R. Pressure ulcers following spinal cord injury. In: Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, et al, editors. Spinal cord injury rehabilitation evidence. Version 5.0. 2014. p. 1–90 (University of British Columbia, Vancouver, Canada).
Acknowledgements
Thanks to Naomi Shaw (Information Specialist, Cochrane Wounds) for assisting with the search of The Cochrane Library, and to Louise O’Connor (Advanced Nurse Practitioner, Tissue Viability, Manchester University NHS Foundation Trust) for her critical reading of the manuscript. The authors (RAA and NAC) of this article were partly funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Greater Manchester. The funder had no role in the design of the study, data collection and analysis, decision to publish or preparation of the manuscript. However, the project outlined in this article may be considered to be affiliated to the work of the NIHR CLAHRC Greater Manchester. The views expressed in this article are those of the authors and not necessarily those of the NHS, NIHR or the Department of Health.
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Atkinson, R.A., Cullum, N.A. Interventions for pressure ulcers: a summary of evidence for prevention and treatment. Spinal Cord 56, 186–198 (2018). https://doi.org/10.1038/s41393-017-0054-y
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DOI: https://doi.org/10.1038/s41393-017-0054-y
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