Avoiding, treating and managing pressure ulcers when you have a spinal injury

For a person with a spinal injury in a wheelchair, the risk of pressure ulcers (also known as pressure sores or bed sores) is very high. Indeed, according to the Spinal Injuries Association, people who are paraplegic have an 80% chance of developing reoccurring pressure ulcers.

Being in a wheelchair is obviously the biggest hazard, as it means continuous pressure on the skin and tissues that are in contact with the person’s chair. But when a wheelchair is an essential part of your life, how can you avoid, treat and manage your pressure ulcer risk?

In this article, our live-in spinal injury carers share how they support our clients to minimise and live with this risk to keep their skin as healthy as possible.

What are pressure ulcers?

A pressure ulcer occurs when there is continuous, unrelieved pressure on a part of the body, often where bones are close to the skin. The skin and its underlying tissues need blood to flow through their tiny vessels, and if this becomes cut off due to pressure it stops the vital flow of oxygen to that area and waste products build up.

This buildup of waste products is what causes redness, swelling, bruising, heat and/or a shiny appearance in that area. As the skins begins to break down you may see blisters, cracks and dryness. If the person with the spinal injury has sensation in that area they may feel pain, but as pressure ulcers are more likely to occur the more complete a spinal injury is, pain may not be felt. This means that a person with a spinal injury often doesn’t have the same ‘early warning’ signal that a person without a spinal injury might have.

Why and how to check for pressure ulcers

The most important aspect in avoiding pressure ulcers is getting to know your skin, or the skin of the person you are supporting. Identifying where you/the person are most at risk of pressure ulcers and conducting twice daily checks of yours/the person’s skin is the first step in prevention. You are looking for any unusual marks that might indicate the beginning of a pressure ulcer. To make these checks a regular part of life, many people do them at set points in the day – IE: morning and evening.

If you/your carer notice an unusual mark, we would recommend the ‘Blanching Test’ as described by the Spinal Injuries Association in their ‘Pressure ulcers the basics’ factsheet:

“Press on the red, pink or darkened area with your finger. The area should go white; remove the pressure and the area should return to red, pink or darkened colour within a few seconds, indicating good blood flow.

If it does not change colour then damage has occurred to capillaries under the skin and should be allowed to recover by ensuring the area remains completely pressure free.”

Treating and managing pressure ulcers when you have a spinal injury

Catching pressure ulcers early is vital to minimise their impact. Any unusual marks should never be ignored. Investigate their origin and begin treatment as soon as possible. Our live-in spinal injury carers recommend:

• Immediate bed rest to ensure the pressure is taken off the damaged area of skin/tissue. Delaying this can mean a much longer period of bed-rest is required, which can affect every aspect of your/the person’s life.
• Obtain professional advice from a district nurse, Tissue Viability Nurse (TVN), Spinal Cord Injury Nurse and/or your/the person’s GP.
• Begin any treatment that you know has worked previously or that is now recommended for you/the person you are supporting. Treatment needs to be consistently applied for it to be effective as quickly as possible.
• Keep a photographic record of the pressure ulcer to enable professionals supporting you/the person to monitor the pressure ulcer and provide advice and treatment as needed.
• Ensure you/the person with a spinal injury has the help they need at home whilst bed rest is required, either from family/friends or a professional. We have been providing spinal injury care since 1994, and can offer short or long-term spinal injury support, including respite care that can be arranged with minimal notice if you/the person with a spinal injury is unexpectedly on bed rest and needs support with healthcare, personal care and domestic tasks.
• Eat healthily (a high protein diet will help the tissues and skin to heal) and remain well hydrated.

Avoiding pressure ulcers when you have a spinal injury

A key aim of our live-in spinal injury carers is to reduce the chances of our clients developing a pressure ulcer to begin with, given how disruptive pressure ulcers can be to a person’s life and the potential for long-term problems in the area of the pressure ulcer. Alongside regularly checking client’s skin, other preventative measures that our live-in carers recommend include:

• The person with a spinal injury relieving pressure through leaning and lifting techniques, with or without the support of a family member/their live-in carer depending on the person’s needs. Pictorial examples of these techniques (with instructions) are available from the United Spinal Association (with a downloadable PDF to print if needed).
• The person always having a pressure relieving cushion on their wheelchair. These cushions will lose their effectiveness over time with regular use, so they should be replaced once they are less supportive/showing signs of wear. The person should also have protection when in bed if they spend long periods lying down. This could include an airflow mattress and/or heel protectors.
• Supporting the person to have good posture in their wheelchair to try and evenly distribute their weight. If this is something you/the person you are supporting struggles with, an OT or seating clinic run by your local spinal cord injury centre may be able to help.
• Using moving and handling aids that have been recommended as these ensure that the person is moved in the most optimal way to ensure their skin/tissues aren’t damaged.
• Helping the person to find clothing that isn’t too tight and won’t dig into their skin.
• Keeping the person’s skin clean and dry. In practice this means changing any incontinence products regularly, and using any recommended barrier creams or sprays during every change to help to maintain skin integrity.
• Ensuring that any other long-term physical health conditions that the person has, for example diabetes, are well-managed. People who are diabetic are more at risk of skin problems. Also being aware that mental health problems, like depression, can mean a person struggles with self-care. This may make it more likely that they will develop a pressure ulcer or that one will go undetected for longer.
• Supporting the person to drink lots of water to dilute their urine to make it less abrasive on their skin, and overall good hydration, linked with a healthy (higher protein) diet, stable weight (not over or under weight), quitting smoking and drinking alcohol within recommended limits will all help to keep the skin of a person with a spinal injury as healthy as possible.

Further information

• National Wound Care Strategy Programme
• React to Red
• NICE: Pressure ulcers prevention and management

Find out more about how ENA Care Group could support you or your family by calling 0800 4334 413 or emailing care@ena.co.uk.