See All Evidence Sections
Skin Integrity and Pressure Injuries

Incidence and Prevalence

Pressure injuries, is the term used in the current document, to acknowledge that pressure related tissue damage includes stages of harm before an ulcer is visible. Pressure injures have also been called pressure ulcers, decubitus ulcers, ischemic ulcers, pressure sores, bed sores or skin sores, have been defined as a “localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure injuries; the significance of these factors is yet to be elucidated.” (National Pressure Injury Advisory Panel 2007). The NPIAP (2019) identify that the primary cause of pressure injuries is felt to be externally applied pressure over bony prominences such as the sacrum and ischial tuberosities (IT), for a prolonged period of time. Because pressure can be exerted while the body is in different positions, the term “decubitus” is no longer commonly used to describe pressure injuries as it refers only to pressure injuries acquired while “lying down.” Applied pressure leads to decreased blood supply to the overlying soft tissues (i.e., tissue ischemia) and can ultimately cause tissue necrosis (Lamid & Ghatit 1983; Crenshaw & Vistnes 1989; Bogie et al. 1995). DeLisa and Mikulic (1985) have noted that “the visible ulcer represents only the tip of the iceberg or the apex of the lesion” (p. 210). Erba et al. (2010), using 3 dimensional analyses of silicone moulds, confirmed the pyramidal shape of stage IV ischial ulcers in all 10 paraplegic patients included in their study. Deeper tissues, such as muscle, are more sensitive than skin to ischemia caused by pressure (Daniel et al. 1981; Nolan and Vistnes 1980). Deep tissue injuries have been added as a distinct pressure injury in the National Pressure Injury Advisory Panel’s 2019 updated pressure injury staging system (Black et al. 2007).

Table 1 reflects the various ways that pressure injury incidence and prevalence is reported: by grade, by location, in paraplegia versus tetraplegia, in people with SCI from traumatic or non-traumatic origin, by time since injury and by jurisdiction (e.g., health-care setting vs. living in community or by geographic region).

Author Year; Country
Research Design
PEDro Score
Sample Size
Methods Outcome
Onigbinde et al. 2012
Nigeria
Observational
N=318
Population: Mean age: 42.7 yr; Gender: males=204, females=114; Injury etiology: SCI=159, orthopaedic=123, head injury=36.
Data Collection: A structured questionnaire was used by hospital staff to gather information on socio-demographic and health data including age, diagnosis, date of admission, the date of skin breakdown (if any) and site of any ulcer.
1. Mean age of participants was 42.7±15.1 yr.
2. 44 inpatients developed nosocomial pressure injuries within the three mo study period.
3. The mean age of those who developed pressure injuries was 41.18±13.98 yr. The incidence rate was 13.84%.
4. Among those who developed pressure injuries, 22 (50%) had spinal cord injuries. Therefore, of 48 people with a SCI, 45.8% developed a pressure injury.
5. Of the 44 inpatients with pressure injuries, 32 (72.7%) were men and 12 (27.3%) women.
6. The period between time of admission and first appearance of pressure injury ranged from 3-90 days, with a median of 25 days.
7. At onset, only four (9.1%) ulcers were classified as stage 2 ulcers, after 90
days, 23 (52.3%) ulcers were at stage 2.
8. Of the 44 patients who developed pressure injuries, 38 developed them at the sacrum, 20 on the heels and two at the occiput.
Taghipoor et al. 2009
Iran
ObservationalN=5995
Population: Median age ranges: 21-30 and 30-40 yr; Gender: males=71.8%, females=28.2%; Injury etiology: traumatic=63.2%, non-traumatic=35.2%.
Data Collection: Patients who received financial, medico-social, and rehabilitative support provided by the State Welfare Organization of Iran.
1. Overall incidence of pressure injury was 39.2% (71.8% traumatic, 28.2% nontraumatic)
2. Age was a factor associated with pressure injury in patients with nontraumatic SCI, but not level of injury, education, and occupational status.
3. Only occupation and education were factors associated with pressure injury in traumatic SCI (p<0.01), but not age.
Nogueria et al. 2006
Brazil
Observational
N=47
Population: Age ranges: <20 yr=8, 21- 30=17, 31-40=5, 41-50 yr=7, 51-60=3, >60=3; Gender: males=45, females=2; Level of injury: C=19, T=21, L=7.

Data Collection: Database on patients who received care at Ribeirão Preto Medical School Hospital das Clínicas.

1. Overall incidence of pressure injury was 42.5% (mean=2.3 pressure injury per patient).
2. Incidence by number pressure injury: 0=27 (57.4%), 1=7 (15.0%), 2=5 (10.6%), 3=4 (8.5%), 4=3 (6.4%), 5=1 (2.1%).
3. Incidence of pressure injury by grade: Grade 1=10.9%, Grade 2=17.4%, Grade 3=6.5%, Grade 4=13.0%, Unknown=52.2%.
4. Most common regions of pressure injury: sacrum=36.9%, heel=17.4%, gluteal=10.8%), ischium=10.8%), coccyx=6.5%.
Raghaven et al. 2003
United Kingdom
Observational
N=427
Population: Mean age: 47±14.7 yr; Gender: males=76.0%, females=24.0%; Mean time since SCI: 13.0±10.6 yr; Etiology of injury: traumatic SCI=425, spina bifida=2.
Data Collection: Postal survey assessing pressure injury among individuals with SCI in the community who were being followed
by the medical centre.
1. Point prevalence was 23%.
2. *Incidence of Grade 1=12.4%, Grade 2=10.3%, and Grade 1 and 2=0.5%.
3. Most common pressure injury sites: heel=10.8%, sacrum=14%, and
gluteal=23.7%.
4. 55% had a Grade 2+ pressure injury at any point since their SCI.
5. Current smoking and regular inspection of skin was associated with the
occurrence of pressure injury.
*N=45 patients not included in these results.
Walters et al. 2002
USA
Observational
N=99
Population: Most patients were >50 yr and had their SCI >10 yr ago.
Data Collection: A database was created to track patients’ self-reported long-term SCI complications following rehabilitation.
1. Overall prevalence was 38%.
2. Pressure injury occurred primarily in sacral, ischial, and trochanteric areas (71%).
Klotz et al. 2002
France
Observational
N=1668
Population: Mean age: 43.6 yr, Gender: males=80%, females=20%; Level of injury: C1-C2=10.5%, C3=13.1%, C4=15.4%, C5=13.9%, C6=13.4%, C7-C8=10.4%; Mean time since injury: 12.9 yr
Data Collection: Tetrafigap survey – a self-reported questionnaire given to individuals in rehabilitation.
1. 19.7% of re-hospitalization cases were due to pressure injuries.
Chen et al. 1999
USA
Observational
N=1649
Population: Mean age: 36.5 yr, Gender: males=79%, females=21%; Level of injury: incomplete tetraplegia (31%), complete paraplegia (29%), complete tetraplegia (20%), and incomplete paraplegia (19%); Time since SCI: 3 yr=702, 2 yr=716, 1 yr=231.
Data Collection: Information was collected from the National SCI Statistical Center
1. Incidence of pressure injury by grade: Grade 1=27.3%, Grade 2=54.5%, Grade 3=11.9%, Grade 4=3.2%, Unknown=2.8%.
2. Participants in rehabilitation; 63.9 had one ulcer, 21.2% had two ulcers, 10.5% had three ulcers, and 4.3% had four or more ulcers.
3. Pressure injuries were found most in the sacrum (39%), heels (13%) and ischium (8%).
4. Higher percentage of pressure injuries for participants with complete injuries; 23.1% of complete paraplegia, and 39.5% of complete tetraplegia had at least one ulcer.
Mckinely et al. 1999
USA
Observational
N=20354
Population: Time since injury: 1 yr=6,776, 2 yr=5,744, 5 yr=4,100, 10 yr=2,399, 15 yr=1,285, 20 yr=500.
Data Collection: Information was collected from the National SCI Statistical Center (NSCISC) database of all patients admitted from 1973 and had a follow-up phone evaluation in 1986-1998.
Prevalence of pressure injury by time since SCI:
1. 1 yr (n=4,978), 2 yr (n=3,421), 5 yr (n=2,079), 10 yr (n=1,073), 15 yr (n=450), 20 yr (n=102). Prevalence of pressure injury by time since SCI and level of injury:
2. Incomplete Paraplegia – 1 yr=5.6%, 2 yr=8.3%, 5 yr=10.9%, 10 yr=14.5%, 15 yr=18.4%, 20 yr=12.5%.
3. Complete Paraplegia – 1 yr=22.3%, 2 yr=24.5%, 5 yr=25.5%, 10 yr=28.2%, 15 yr=26.7%, 20 yr=29.8%.
4. Incomplete Tetraplegia – 1 yr=9.3%, 2 yr=10.2%, 5 yr=11.5%, 10 yr=18.4%, 15 yr=20.8%, 20 yr=13.3%.
5. Complete Tetraplegia – 1 yr=25.2%, 2 yr=26.4%, 5 yr=27.2%, 10 yr=25.1%, 15 yr=27.6), 20 yr=40.6%.
6. Individuals who sustained SCI from acts of violence were the most common etiology for pressure injuries.
7. Individuals with paraplegia had the highest prevalence of grade 3 and 4 ulcers (9.1%)
Anson & Shepherd 1996
USA
Observational
N=348
Population: Mean age: 37 yr; Gender: males=81.9%, females=18.1%; Level of injury: C0-C4=67, C5-C8=123; T1- T11=100, T12-S5=50; Time since SCI: 1-2 yr=90, 3-5 yr=88, 6-10 yr=10, 11-15 yr=41, >15 yr=27.
Data Collection: Information was collected when patients returned to outpatient clinics for routine follow-up examinations.
Incidence of all grades of pressure injury by time since SCI:
Grade 1 or 2=83.3%, Grade 3 or 4=16.6%.
Incidence of Grade 1 or 2 pressure injury by time since SCI:
1. 1-2 yr=92.3%; 3-5 yr=82.4%, 6-10 yr=96.5%, 11-15 yr=94%, >15 yr=68.4%.
Incidence of Grade 3 or 4 pressure injury by time since SCI:
2. 1-2 yr=7.7%, 3-5 yr=17.6%, 6-10 yr=13.5%,11-15 yr=16%, >15 yr=31.6%.
3. The most common locations were foot/heel (27%), sacrum (18.3%), and ischium (18.2%).
4. The most common identified etiology for pressure injuries were lack of weight shifts, postural problems, hot water burns, and improper turning in bed.

Discussion

Annual prevalence rate reports range from 10.2% to 38% (DeLisa & Mikulic 1985; Byrne & Salzberg 1996; Walters et al. 2002). Chen et al. (2005) reported an increasing pressure injury prevalence in recent years not explained by aging, years since injury or varying demographics. Risk of pressure injuries was steady for the first 10 years and increased 15 years post injury. Fuhrer et al. (1993) noted that less severe pressure injuries (stages I and II) comprised about 75% of the total number of ulcers observed, with the 25% as more severe (stage III and IV).

When reported overall (no breakdown by grade, location), incidence rates as high as 71.8% have been published (Taghipoor et al. 2009), although these reflect biases in the study population associated with participants limited to having low income, and motor- and sensory-complete injuries. In an Iranian study, overall incidence rates of pressure injuries were reported as 28.2% in patients with non-traumatic SCI and 71.8% in those with SCI secondary to traumatic etiology (Taghipoor et al. 2009). The highest incidence by grade of severity is grade II (Raghaven et al. 2003) and the most common pressure injury site is the sacrum (Nogueria et al. 2006; Raghaven et al. 2003; Chen et al. 1999). Anson and Shepherd (1996) inferred that continuous prevention diligence (e.g., patient education, follow-up and extended medical care) may decline after 15 years post-injury as reflected by the simultaneous increase in grade III and IV ulcers (11-15 yr=16%; >15 yr=31.6%) and decrease in grade I and II ulcers (11-15 yr=94%; >15 yr=68.4%).

Although the United States Model Systems report a peak in rehospitalization as a result of pressure injuries at five years post-discharge from initial rehabilitation (Cardenas et al. 2004), pressure injuries were still one of the most common secondary complications at annual follow-ups (McKinley et al. 1999). Prevalence continued to increase up to 20 years post-injury for individuals with a complete injury. Prevalence for those with an incomplete injury peaked at 15 years post-injury and decreased from there when seen at 20-year follow-up. Not surprisingly, pressure injury prevalence was highest in individuals with a complete versus incomplete injury (McKinley et al. 1999). Prevalence continued to increase in both groups over time until 15 years post-injury. Fortunately, people with incomplete injuries saw a slight decrease in prevalence on 20-year follow-up. The difference in prevalence rates was further amplified between those with paraplegia versus tetraplegia, with the latter being more heavily plagued with pressure injuries in general. However, those with either complete paraplegia or tetraplegia continued to reflect increasing pressure injury prevalence at the 20-year follow-up.

When a pressure injury is severe and not treated aggressively it can lead to further disability (e.g., reduced mobility, dependence, surgical intervention, amputation, fatal infection; Krause 1998). It has been estimated that 7-8% of those who develop pressure injuries will die from related complications (Richards et al. 2004). Due to the increasing life expectancy for those who sustain an SCI, the risk of developing pressure injuries is even greater; thus, recognition of risk factors and pressure injury prevention is a priority and daily concern for both individuals with SCI and health care providers.

Related Downloads
Outcome Measures
Related Toolkits
Related Videos