Our contemporary understanding of the aetiology of pressure ulcers/pressure injuries.

In 2019, the third and updated edition of the Clinical Practice Guideline (CPG) on Prevention and Treatment of Pressure Ulcers/Injuries has been published. In addition to this most up-to-date evidence-based guidance for clinicians, related topics such as pressure ulcers (PUs)/pressure injuries (PIs) aetiology, classification, and future research needs were considered by the teams of experts. To elaborate on these topics, this is the third paper of a series of the CPG articles, which summarises the latest understanding of the aetiology of PUs/PIs with a special focus on the effects of soft tissue deformation. Sustained deformations of soft tissues cause initial cell death and tissue damage that ultimately may result in the formation of PUs/PIs. High tissue deformations result in cell damage on a microscopic level within just a few minutes, although it may take hours of sustained loading for the damage to become clinically visible. Superficial skin damage seems to be primarily caused by excessive shear strain/stress exposures, deeper PUs/PIs predominantly result from high pressures in combination with shear at the surface over bony prominences, or under stiff medical devices. Therefore, primary PU/PI prevention should aim for minimising deformations by either reducing the peak strain/stress values in tissues or decreasing the exposure time.

A comparison of air-cell and gel surgical table pads and an evaluation of the influence of pressure distribution and other factors on pressure injury prevention.

Guidelines for pressure injury prevention consider the use of pressure-redistributing pads to prevent tissue deformation. However, limited research exists to assess the pressure distribution provided by the operating tables and the effectiveness of pressure-redistributing pads in preventing pressure injuries. In this study, we compared the pressure distribution properties of two surgical table pads and identified parameters influencing pressure injury outcomes after a lengthy surgical procedure. Twenty-seven patients undergoing left ventricular assist device implantation surgery participated in the study. Participants were randomly assigned to use either an air cell-based pad or a gel pad. Interface pressure was recorded during the surgery. We analyzed the effect of surgical table pad type, interface pressure distribution and pressure injury outcomes and analyzed what characteristics of the patients and the interface pressure are most influential for the development of pressure injuries. Comparing the interface pressure parameters between the air-cell group and the gel group, only the peak pressure index x time was significantly different (p < 0.05). We used univariate logistic regression analysis to identify significant predictors for the pressure injury outcome. The support surface was not significant. And, among patient characteristics, only age and BMI were significant (p ≤ 0.05). Among the interface pressure parameters, pressure density maxima, peak pressure index x time, and coefficient of variation were significant for pressure injury outcome (p ≤ 0.05). Peak pressure index, average pressure, and the surgery length were not statistically significant for pressure injury outcomes.

An exploratory study analyzing demographics and opinions of assistive technology professionals within the complex rehab technology industry.

This exploratory study investigated the demographics of Assistive Technology Professionals (ATPs) regarding their age, education, certifications, ethnicity, gender, veteran status, disability status, method of financial compensation, company type, and category. In addition, it analyzed opinions on the Complex Rehab Technology (CRT) industry regarding education level and licensure. An 18-question survey developed and disseminated by the University of Pittsburgh in collaboration with the National Coalition for Assistive & Rehab Technology (NCART) resulted in 252 responses from current ATPs in the Supplier/Manufacturing industry. The average age of respondents of 51.9 years showed to be above the national average workforce age of 42.2 years. Data were analyzed as a whole and by comparing answers for respondents below and above the average age. 92.4% of the respondents were Caucasian and 79.0% were male showing a need for diversity in the field. Forty-five percent of the younger age group had additional certifications compared to 30% of the older group. 79.8% of all respondents would recommend the ATP profession to someone looking for a career. Findings support the need to increase awareness of the ATP supplier/manufacturing profession to attract younger professionals including those from minority groups. Findings also support the need for additional training for the profession.

Implementing local cooling to increase skin tolerance to ischemia during normal seating in people with spinal cord injury.

The purpose of this study was to investigate the effectiveness of local cooling in reducing reactive hyperemia after ischemia at the ischial tuberosities for people with spinal cord injury (SCI) during normal seating. The degree of the reactive hyperemic response is indicative of the extent of cellular stress caused by the ischemia. We hypothesized that reactive hyperemic skin blood flow (SBF) responses will be lower when local cooling is implemented by the wheelchair seat cushion. This study used a repeated measures design, and each subject underwent two conditions: normal seating with temperature control 'on' (cooling) and 'off' (non-cooling) for 30 min. Twenty-three participants with traumatic SCI were recruited. SBF and skin temperature were collected before, during and after seating. SBF signals were processed with short-time Fourier analyses to examine the underlying vascular control mechanisms, including the following (corresponding frequency bands): metabolic (0.0095-0.02 Hz), neurogenic (0.02-0.05 Hz), and myogenic (0.05-0.15 Hz) spectral densities. Our results showed that with cooling, skin temperature decreased (range -0.4 ~ -3.1 °C, p = 0.002), and reactive hyperemia parameters (normalized peak SBF and perfusion area) were reduced (p = 0.02, p = 0.033, respectively). In addition, changes in normalized peak SBF (non-cooling - cooling) was moderately correlated with changes in normalized metabolic and neurogenic spectral densities. Our findings suggested that local cooling has a positive effect on reducing the cellular stress caused by ischemia during normal seating. Metabolic and neurogenic SBF control mechanisms may play a minor role. Further exploration of the effect of temperature control on pressure injury prevention is warranted.

Medical Rehabilitation: Guidelines to Advance the Field With High-Impact Clinical Trials.

The purpose of this Special Communication is to summarize guidelines and recommendations stemming from an expert panel convened by the National Institutes of Health, National Center for Medical Rehabilitation Research (NCMRR) for a workshop entitled The Future of Medical Rehabilitation Clinical Trials, held September 29-30, 2016, at the NCMRR offices in Bethesda, Maryland. The ultimate goal of both the workshop and this summary is to offer guidance on clinical trials design and operations to the medical rehabilitation research community, with the intent of maximizing the effect of future trials.

A Randomized Clinical Trial of Wheeled Mobility for Pressure Injury Prevention and Better Function.

OBJECTIVES: To evaluate the effectiveness of wheelchair assessment and configuration on pressure injury incidence, mobility, and functioning in a wheelchair. DESIGN: Randomized controlled trial with participants individually randomized into intervention and control groups. SETTING: Nursing home. PARTICIPANTS: Nursing home residents aged 60 and older who used wheelchairs and were at risk for pressure injuries (N=258). INTERVENTION: Treatment and evaluation, individually configured wheelchair and skin protection cushion; control and evaluation, facility-provided wheelchair and skin protection cushion. MEASUREMENTS: Pressure injury incidence, Nursing Home Life Space Diameter score, Functioning Every Day in a Wheelchair-Capacity (FEW-C) score, and Wheelchair Skills Test (WST) score. RESULTS: No differences in pressure injuries (p=.77) were found. Pelvic rotation (odds ratio (OR)=0.15, 95% confidence interval (CI)=0.03-0.70, p=.02) and Day 14 WST skill score (OR=0.74, 95% CI=0.60-0.91, p=.004) were significant predictors of pressure injuries. Significant differences were observed between groups in change in FEW-C independence scores between before randomization and endpoint (p=.03) and before randomization and 14 days (p=.04). CONCLUSION: Participants with individually configured wheelchairs improved more in the safe and effective use of their wheelchairs than residents with facility-provided wheelchairs. The outcomes indicated that nursing home residents functioned safely at a higher level in their wheelchairs if their devices were individually configured using a comprehensive wheelchair and seating assessment process. There was no difference in the incidence of pressure injuries between the two groups. TRIAL REGISTRATION: NCT01275313.

Inflammatory Mediators Associated With Pressure Ulcer Development in Individuals With Pneumonia After Traumatic Spinal Cord Injury: A Pilot Study.

OBJECTIVE: To identify the inflammatory mediators around the time of pneumonia onset associated with concurrent or later onset of pressure ulcers (PUs). DESIGN: Retrospective. SETTING: Acute hospitalization and inpatient rehabilitation unit of a university medical center. PARTICIPANTS: Individuals (N=86) with traumatic spinal cord injury (SCI) were included in the initial analyses. Fifteen of the 86 developed pneumonia and had inflammatory mediator data available. Of these 15, 7 developed PUs and 8 did not. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Twenty-three inflammatory mediators in plasma and urine were assayed. The differences in concentrations of plasma and urine inflammatory mediators between the closest time point before and after the diagnosis of pneumonia were calculated. RESULTS: Initial chi-square analysis revealed a significant (P=.02) association between pneumonia and PUs. Individuals with SCI and diagnosed pneumonia had nearly double the risk for developing PUs compared with those with no pneumonia. In individuals with pneumonia, Mann-Whitney U exact tests suggested an association (P<.05) between the formation of a first PU and a slight increase in plasma concentrations of tumor necrosis factor-alpha (TNF-α), and a decrease in urine concentrations of TNF-α, granulocyte-macrophage colony-stimulating factor (GM-CSF), and interleukin (IL)-15 after onset of pneumonia. CONCLUSIONS: These findings suggest that a relatively small increase in plasma TNF-α, and decreases in urine TNF-α, GM-CSF, and IL-15 from just before to just after the diagnosis of pneumonia could be markers for an increased risk of PUs in individuals with pneumonia after traumatic SCI.

Association between presence of pneumonia and pressure ulcer formation following traumatic spinal cord injury.

OBJECTIVE: To determine if the presence of pneumonia and pressure ulcers are associated in individuals with an acute spinal cord injury during acute care and rehabilitation hospitalizations. DESIGN: Retrospective, secondary analyses of data obtained from the Spinal Cord Injury Model Systems enrolled from 1993 until 2006 Setting: Acute care hospitalization and inpatient rehabilitation facilities Participants: A cohort of individuals hospitalized in acute care (n = 3,098) and inpatient rehabilitation (n = 1,768) was included in the analysis. Frequencies of pressure ulcer formation and episodes of pneumonia were noted in both settings. INTERVENTIONS: Not applicable. OUTCOME MEASURES: Pressure ulcer formation and diagnosis of pneumonia Results: The development of pressure ulcers, including stage I, was 20.3% acute care and 21.1% during in inpatient rehabilitation. Multivariate logistic regression analyses revealed a significant association of pneumonia with occurrence of pressure ulcers (P ≤ 0.001, OR = 2.3 and 2.2 respectively), the American Spinal Injury Association Impairment Scale grades (P < 0.001), and utilization of mechanical ventilation (P < 0.01) in both settings. CONCLUSION: A higher presence of pressure ulcers was found in individuals with pneumonia, after adjusting for injury severity, age, sex, and utilization of mechanical ventilation. Impaired inflammatory response and decreased mobility in individuals with pneumonia may predispose these individuals to develop pressure ulcers. Surveillance and preventive measures for pressure ulcers should be rigorous in individuals with SCI and pneumonia.

Feasibility of freehand ultrasound to measure anatomical features associated with deep tissue injury risk.

Deep tissue injuries (DTI) are severe forms of pressure ulcers that start internally and are difficult to diagnose. Magnetic resonance imaging (MRI) is the currently preferred imaging modality to measure anatomical features associated with DTI, but is not a clinically feasible risk assessment tool. B-mode ultrasound (US) is proposed as a practical, alternative technology suitable for bedside or outpatient clinic use. The goal of this research was to confirm US as an imaging modality for acquiring measurements of anatomical features associated with DTI. Tissue thickness measurements using US were reliable (ICC=.948) and highly correlated with MRI measurements (muscle r=.988, p ≤ .001; adipose r=.894, p ≤ .001; total r=.919; p ≤ .001). US measures of muscle tissue thickness were 5.4mm (34.1%) higher than MRI, adipose tissue thickness measures were 1.6mm (11.9%) lower, and total tissue thickness measures were 3.8mm (12.8%) higher. Given the reliability and ability to identify high-risk anatomies, as well as the cost effectiveness and availability, US measurements show promise for use in future development of a patient-specific, bedside, biomechanical risk assessment tool to guide clinicians in appropriate interventions to prevent DTI.

Predictive validity of the Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) in acute care and inpatient rehabilitation in individuals with traumatic spinal cord injury.

OBJECTIVE: To evaluate the validity of the Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) during acute care and inpatient rehabilitation following spinal cord injury (SCI) by determining critical cutoff points and assessing the ability to predict risk for pressure ulceration (PrU). DESIGN: Retrospective. METHODS: Sensitivity, specificity, and area under the curve (AUC) for the receiver operating characteristic were determined for the scale's ability to predict PrU 2-3 and 5-7 days after administrating the SCIPUS during acute care, and 5-7 and 14-21 days after administrating the SCIPUS during inpatient rehabilitation. RESULTS: During acute hospitalization, SCIPUS's ability to assess risk for PrUs within 2-3 days was determined at cutoff score of 15 with 100% sensitivity and 75% specificity, AUC = 0.85. The scale was unable to assess PrU risk at 5-7 days, AUC < 0.6 at cutoff score of 13. During inpatient rehabilitation, the scale was unable to assess PrU risk at 5-7 and 14-21 days, AUC < 0.6 at cutoff score of 9. CONCLUSIONS: The SCIPUS could predict PrU occurring within 2-3 days following administration during acute, but unable to predict over a longer term within acute or inpatient rehabilitation. Improved PrU risk assessment following SCI may be possible with modification to the SCIPUS.

Early Detection of Pressure Ulcer Development Following Traumatic Spinal Cord Injury Using Inflammatory Mediators.

OBJECTIVE: To identify changes in concentrations of inflammatory mediators in plasma and urine after traumatic spinal cord injury (SCI) and before the occurrence of a first pressure ulcer. DESIGN: Retrospective; secondary analysis of existing data. SETTING: Acute hospitalization and inpatient rehabilitation sites at a university medical center. PARTICIPANTS: Individuals with a pressure ulcer and plasma samples (n=17) and individuals with a pressure ulcer and urine samples (n=15) were matched by age and plasma/urine sample days to individuals with SCI and no pressure ulcer (N=35). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Plasma and urine samples were assayed in patients with SCI, capturing samples within 4 days after the SCI to a week before the formation of the first pressure ulcer. The Wilcoxon signed-rank test was performed to identify changes in the inflammatory mediators between the 2 time points. RESULTS: An increase in concentration of the chemokine interferon-γ-induced protein of 10kd/CXCL10 in plasma (P<.01) and a decrease in concentration of the cytokine interferon-α in urine (P=.01) were observed before occurrence of a first pressure ulcer (∼4d) compared with matched controls. CONCLUSIONS: Altered levels of inflammatory mediators in plasma and urine may be associated with pressure ulcer development after traumatic SCI. These inflammatory mediators should be explored as possible biomarkers for identifying individuals at risk for pressure ulcer formation.

Feasibility of Using Mobile Health to Promote Self-Management in Spina Bifida.

OBJECTIVE: To determine feasibility of using the interactive Mobile Health and Rehabilitation (iMHere) system in spina bifida and its effects on psychosocial and medical outcomes. DESIGN: In a randomized controlled trial, 13 intervention participants using the iMHere system and receiving usual care and 10 control participants receiving usual care were followed for 1 year. RESULTS: Feasibility of use of the system was demonstrated by participants using a customized smartphone system for reminders to conduct various self-care tasks, upload photos of wounds, manage medications, complete mood surveys, and for secure messaging. High usage of the system was associated with positive changes in the subscales of the Adolescent Self-Management and Independence Scale II. CONCLUSION: Use of the iMHere system in spina bifida is feasible and was associated with short-term self-reported improvements in self-management skill. This system holds promise for use in many diverse chronic care models to support and increase self-management skills.

Inducible protein-10, a potential driver of neurally controlled interleukin-10 and morbidity in human blunt trauma.

OBJECTIVE: Blunt trauma and traumatic spinal cord injury induce systemic inflammation that contributes to morbidity. Dysregulated neural control of systemic inflammation postinjury is likely exaggerated in patients with traumatic spinal cord injury. We used in silico methods to discern dynamic inflammatory networks that could distinguish systemic inflammation in traumatic spinal cord injury from blunt trauma. DESIGN: Retrospective study. SETTINGS: Tertiary care institution. PATIENTS: Twenty-one severely injured thoracocervical traumatic spinal cord injury patients and matched 21 severely injured blunt trauma patients without spinal cord injury. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Serial blood samples were obtained from days 1 to 14 postinjury. Twenty-four plasma inflammatory mediators were quantified. Statistical significance between the two groups was determined by two-way analysis of variance. Dynamic Bayesian network inference was used to suggest dynamic connectivity and central inflammatory mediators. Circulating interleukin-10 was significantly elevated in thoracocervical traumatic spinal cord injury group versus non-spinal cord injury group, whereas interleukin-1ß, soluble interleukin-2 receptor-α, interleukin-4, interleukin-5, interleukin-7, interleukin-13, interleukin-17, macrophage inflammatory protein 1α and 1ß, granulocyte-macrophage colony-stimulating factor, and interferon-γ were significantly reduced in traumatic spinal cord injury group versus non-spinal cord injury group. Dynamic Bayesian network suggested that post-spinal cord injury interleukin-10 is driven by inducible protein-10, whereas monocyte chemotactic protein-1 was central in non-spinal cord injury dynamic networks. In a separate validation cohorts of 356 patients without spinal cord injury and 85 traumatic spinal cord injury patients, individuals with plasma inducible protein-10 levels more than or equal to 730 pg/mL had significantly prolonged hospital and ICU stay and days on mechanical ventilator versus patients with plasma inducible protein-10 level less than 730 pg/mL. CONCLUSION: This is the first study to compare the dynamic systemic inflammatory responses of traumatic spinal cord injury patients versus patients without spinal cord injury, suggesting a key role for inducible protein-10 in driving systemic interleukin-10 and morbidity and highlighting the potential utility of in silico tools to identify key inflammatory drivers.

Effectiveness of local cooling for enhancing tissue ischemia tolerance in people with spinal cord injury.

OBJECTIVE: To investigate the effects of localized cooling and cooling rate on pressure-induced ischemia for people with and without neurological deficits. DESIGN: A 2 × 3 mixed factorial design with two groups: (1) people with spinal cord injury (SCI) and (2) people without neurological deficits (control), and three test conditions: (1) pressure only, (2) pressure with fast cooling (-4°C/min), and (3) pressure with slow cooling (-0.33°C/min). SETTING: University laboratory. PARTICIPANTS: Fourteen controls and 14 individuals with SCI. INTERVENTIONS: Pressure on the sacrum was 0.4 kPa for 5 minutes, then 8 kPa for 20 minutes, and finally 0.4 kPa for 15 minutes. Fast and slow cooling to 25°C applied during 8 kPa of pressure. OUTCOME MEASURES: Reactive hyperemia and its spectral densities in the metabolic, neurogenic, and myogenic frequency ranges. RESULTS: In controls, reactive hyperemia was greater in pressure only as compared with both cooling conditions. No change was noted in all spectral densities in both cooling conditions, and only neurogenic spectral density increased without cooling. In subjects with SCI, no difference was noted in reactive hyperemia among conditions. However, metabolic and myogenic spectral densities increased without cooling and all spectral densities increased with slow cooling. No change was noted in all spectral densities with fast cooling. CONCLUSION: Local cooling reduced the severity of ischemia in controls. This protective effect may be masked in subjects with SCI due to chronic microvascular changes; however, spectral analysis suggested local cooling may reduce metabolic vasodilation. These findings provide evidence towards the development of support surfaces with temperature control for weight-bearing soft tissues.

Teaching self-management skills in persons with chronic lower limb swelling and limited mobility: evidence for usability of telerehabilitation.

The purpose of this study was to evaluate the usability of telerehabilitation as a method of teaching self-management for chronic swelling of the lower limbs in persons with limited mobility. An in-home telerehabilitation self-management education protocol for chronic swelling of the lower limbs, termed Telerehabilitation to Empower You to Manage and Prevent Swelling (TR-PUMPS), was implemented using the Versatile and Integrated System for Telerehabilitation (VISYTER) software platform. Participants (n=11) were 36-79 years old, predominately female (72.7%) and diagnosed with a variety of health conditions. Participants' perceived usability scores of the remote delivery of TR-PUMPS was high with a median score of 6.67 (range 4.90 - 7.00) on a Likert scale: 1= disagree to 7= agree. There was no correlation between participants' familiarity with information technology and their perception of telerehabilitation usability. These results support telerehabilitation as a viable method for teaching a home-based, self-management protocol for chronic swelling.

Design and development of a telerehabilitation self-management program for persons with chronic lower limb swelling and mobility limitations: preliminary evidence.

This paper describes design and development of a self-management program, delivered by telerehabilitation (TR), to address the problem of chronic lower limb swelling in persons with limited mobility. The 18.6 million persons with limited mobility in the USA are at increased risk for chronic lower limb swelling and related secondary complications, including cellulitis and skin ulcers. Over time, chronic swelling often progresses to lymphedema, an incurable condition requiring lifelong care. Without successful self-management, lymphedema and its related complications inevitably worsen. Access and adherence to appropriate treatment are challenging for persons with limited mobility. Program development involved a structured process to establish content validity (videos and manuals), readability, suitability, and selection of a TR platform to deliver the educational program. Our goal was to develop a program that would engage patients in self-management skills. The TR software platform chosen, Versatile and Integrated System for Telerehabilitation (VISYTER) was designed to facilitate face-to-face delivery of an interactive home-based self-management program via the internet in real time. Results demonstrated validity of the educational program and ease of use with TR. Future plans are to evaluate ability of this approach to promote self-management skills, home monitoring, and improved management of persons with lymphedema and limited mobility.

Measuring interface pressure and temperature in the operating room.

BACKGROUND: There is a high incidence of pressure ulcers (PrUs) during long hours of surgery. Interface pressure and temperature are considered risk factors for PrU development. OBJECTIVE: The objective of this study was to determine a methodology to measure interface pressure and temperature during long hours of surgery consistently. SAMPLE: Five patients undergoing liver transplants were recruited from the University of Pittsburgh Medical Center. METHODS AND OUTCOMES: Interface pressure and temperature were measured with pressure mapping and temperature mapping for the duration of the surgery. After the surgery, an 8-hour skin check over 48 hours was performed. RESULTS: Pressure mapping and temperature mapping are appropriate to quantify interface pressure and temperature during surgery. CONCLUSION: This study shows that measuring interface pressure and temperature using pressure and temperature mats is feasible. Further studies are necessary in order to validate the methodology in other types of surgery.