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Skin Integrity and Pressure Injuries

Education and Prevention Programs

Education and prevention programs for individuals with SCI have evolved over the past few years, with growing recognition that to have a lasting impact on lifelong pressure management and skin care, the approaches to education and prevention programs must be multifactorial with consideration for situational challenges and individuality of needs (Tung et a. 2015). Education programs provide knowledge and emphasize behaviours intended to reduce the risk of pressure injury occurrence (Bogie 1995; Rodriguez & Garber 1994; Schubart et al. 2008). Although there is much diversity about specific educational programming conducted across various settings, typical approaches in inpatient rehabilitation include structured programs, often delivered in group lecture formats (question and answer), augmented by unstructured, informal “just-in-time” education delivery and content driven educational materials such as pamphlets, information sheets, websites or binders (Lawes et al. 1985; Wolfe et al. 2012, Tung et al. 2015).Typically this education is delivered while the individual is an inpatient at a time when they and their family are adjusting to a diagnosis of SCI and are likely suffering from information overload. Under these circumstances, an individuals’ ability to appreciate the knowledge and behaviours necessary to prevent pressure injuries over their lifetime is likely compromised (Garber et al.1996; Potter et al. 2004; Schubart et al. 2008). With shorter lengths of stay, there is less time to deliver prevention education and fewer opportunities for reinforcement of acquired knowledge. This means that individuals with SCI are being discharged with potentially less information on pressure injury prevention (Garber et al.1996). The focus has shifted from solely inpatient education to ongoing management programs for people in the community living with a SCI (Tung et al. 2015). There continues to be limited data on the specific education needs required by individuals with SCI at risk for pressure injury formation (May et al. 2006; Schubart et al. 2008). Systematic reviews by Cogan et al. (2017) and Baron et al. (2018) also found variability in programs and supports across studies reviewed. Cogan et al. found non-significant outcomes between control and intervention groups in the 5 studies that met their inclusion criteria. In Baron et al.’s review of 15 studies, only 1 was identified as demonstrating significant improvement in skin status; this study examined structured versus standard education, further supporting the need to individualize programs for short and long term pressure management needs.

Author Year Country
Research Design
Score
Total Sample Size
Methods Outcome
Systematic Reviews
Baron et al. 2018
Canada
Review of published
articles from 1970-2016
AMSTAR=6
N=15
Method: Conduct a literature review onthe content and effective of skin care selfmanagement interventions for people with
SCI.
Databases: MEDLINE, Embase.
PsychINFO, CENTRAL, CINAHL,
REHABDATA, CIRRIE, PeDro, ERIC and (World Health Organization International
Clinical Trials Registry and Meta-Register of Controlled Trials.
Level of evidence: 10 RCTs, 5 NonRCTs.
Questions/measures/hypothesis: Aim1: To better understand the content of interventions designed for skin care; Aim2: to focus on the effectiveness of RCTs aimed at skin care management.
1. 15 studies reviewed 17 different Behaviour Change Technique (BCT) interventions, with 5 general intervention types: Structured education programs (2 RCTs, 3 NonRCTs); Telehealth (3 RCTs, 1 NonRCT); Wheelchair skills training (3
RCTs); Risk assessment and
feedback (1 RCT, 1 Non-RCT); Body positioning skills training (1 RCT).
2. Mediators of skin care measured included: Knowledge (2 studies used
the Pressure injury Knowledge Test); Self-efficacy (measured in 1 study using a validated scale adapted to PU); Skills relating to skin care (4 studies, three used Wheelchair Skills Training Questionnaire, 1 study measured body positioning).
3. 7/10 RCTs measured skin status; only one intervention significantly
improved skin status compared to controls (structured education versus standard education).
Cogan et al. 2017
USA
Review of published
articles from 1999-2014
AMSTAR
Method: Conduct a systematic review of the efficacy of behavioural or educational interventions in preventing pressure injuries in community-dwelling adults with
SCI.
Databases: Cochrane, Clinical Trials,
PubMed, Web of Science. Search
combined related terms for pressure
injuries, SCI, and behavioural
intervention.
Level of evidence: 3 RCTs, 2 quasiexperimental. Questions/measures/hypothesis: No specific hypotheses were tested by the authors.
1. 444 records were screened for inclusion, only 5 studies met inclusion criteria with a total of 513 participants.
2. One study used telephone sessions to deliver education, and another study used enhanced education methods. One study supported family members and caregivers. Two studies used relaxation, and stress/mood
management for depression and wellness.
3. The results on pressure injury/skin breakdown outcomes were non-significant between groups in all 5 studies (p>0.05).
Gelis et al. 2012
France
Review of published
articles between
2000-2010
AMSTAR=4
N=6
Method: Systematic literature review of clinical trials written in English or French, with a human population. Article must pertain to pressure injuries.
Databases: PASCAL, Biomed, PubMed, Cochrane Library.
Level of evidence: level 2 evidence (4 RCTs), level 4 (2 pre-post).
Questions/measures/hypothesis:
1. Determine the place of therapeutic
patient education (TPE) in persons at risk of and/or those who have pressure injuries and make recommendations for clinical practice.
1. Four RCTS and two clinical trials.
2. No studies focused on specifically an elderly population.
3. TPE had a positive impact on the occurrence and severity of pressure
injuries.
4. Two yr post-intervention showed to have an impact on recurrence rate compared to controls (33% vs. 90%, p=0.007).
3. The impact of TPE on depression and quality of life were conflicting.
Interventional Studies
Kim & Cho
(2017)
South Korea
RCT
PEDro=4
NInitial=51
NFinal=47
Population: Experimental Group (n=24): Mean age=42yr; Gender: males=17, females=7; Level of Injury: Cervical=4, Thoracic=15, Lumbar=5; ASIA Classification: A=12, B=4, C=6, D=2; Mean time since injury=49.8 mo. Control Group (n=23): Mean age=36.7yr; Gender: males=20, females=4; Level of Injury: Cervical=3, Thoracic=14, Lumbar=6; ASIA Classification: A=15, B=3, C=2, D=3; Mean time since injury=65.8 mo.
Intervention: 6 hospitals were randomly allocated to the experimental group or the
control group. The experimental group received an 8 wk self-efficacy
enhancement program (small group
education for 2.25 hrs in the 1st week for education and skill training, face-to-face counselling in the 5th week, telephone counselling for 10-15 minus in 3rd and 7th wks, and computer-based demonstrations at 3-, 5-, and 7- wks, and maintained a self-management journal). The control
group was given a pressure injury
prevention information booklet.
Outcome Measures: Self-care knowledge tool, self-efficacy tool, self-care behaviors assessment tool, pressure injury incidence.
1. There was no significant difference between the experimental and controls groups with regards to
baseline demographics or clinical characteristics, except for the occupation after injury (P=0.036).
2. Self-care knowledge, self-efficacy and self-care behaviours all improved in
both groups but the experimental group showed significantly greater
improvements after 8wks (p<0.001, respectively).
3. One participant in the control group developed a pressure injury during the
8wk test period, while none in the experimental group did. This difference was not statistically significant (p=0.49).
Guihan et al. 2014
United States
PEDro=7
RCT
N=143
Population: Mean age=59.3 yr; Gender: males=139, females=4; Level of injury: cervical=60, thoracic=76, lumbar=7; ASIA classification: A=101, B=15, C=17, D=10; Mean time since injury=24.0 yr; Pressure injury stage: III or IV.
Intervention: Treatment group (n=71): Self-management intervention, consisting
of 7 group conference calls lasting 45-60 min and motivational interviewing
intervention consisting of 8 one-on-one telephone counselling calls at pre-set times over 24 weeks.
Control group (n=72): Education
intervention, equivalent to intervention group in terms of number and timing of sessions and who delivered it. Intervention
emphasized teaching and advice giving while not including skills training and motivational interviewing.
Outcomes: Skin Care Behavior Checklist; Skin status; Skin-related visits and admissions, Communication with Providers
Scale, Self-Efficacy scale and descriptive measures (demographics, SCI factors and pressure injury characteristics); assessed at baseline, 3 & 6 months post-discharge.
1. No significant differences between the 2 groups in baseline demographics,
medical, SCI or pressure injury characteristics; half had pressure injuries at discharge from hospital and
had a high rate of comorbid conditions, (osteomyelitis 19.5%, diabetes 39.5%
and depression 40.6%).
2. Study was designed with 80% power to detect a 30% difference between groups, but had only 143 participants so the study has less than 50% power.
3. At 3 mo and 6 mo, greater self-reported improvement in skin care
behaviours in the intervention group at
3 and 6 months but it was not statistically significant (P=0.2; P=.04 respectively).
4. No significant differences were observed between groups in terms of Skin Care Behaviour Checklist, Skin status (skin worsening), skin-related
visits, or skin-related admissions.
5. More than half of participants (combined groups) (n=75, 52.8%)
experienced skin worsening, half of which were reported within the 3 months post-discharge, usually in the
first month.
Rintala et al. 2008
USA
RCT
PEDro=6
N=41
Population: Mean age=29-78 yr; Gender: males; Injury etiology: SCI=39, multiple sclerosis=2; Level of injury: cervical=39%, thoracic=56%; Severity of injury: complete=68%.
Intervention: SCI and multiple sclerosis patients receiving surgical repair of a stage III or IV pressure injury were randomized into 3 groups:
Group 1: received an enhanced education and monthly structured follow-up intervention (via telephone) for 2 yr after discharge;
Group 2: received monthly contacts (via mail) for up to 2 yr after discharge to assess skin status, but no education;
Group 3: received minimal contact by mail every 3 mo for up to 2 yr after discharge to assess skin status but no education.
Outcome Measures: Recurrence of
pressure injuries or 2 yr after discharge.
1. Group 1 had a significantly longer time
before recurrence of pressure injuries than other groups, p=0.002; while no significant difference was seen between Group 2 and 3.
2. Individuals were ulcer free longer if many yr had passed since their last surgery.
3. Health status had no significant effect on staying ulcer free.
4. For those with no previous ulcer surgery, persons in Group 1 were ulcer free longer than those in Group 2 or 3 (19.6 vs. 10.1 or 10.3 mo).
5. Ulcer recurrence occurred in 1/3 of Group 1 (33.3%) compared to Group 2 (60%) and Group 3 (90%).
Garber et al. 2002
USA
RCT
PEDro=5
N=41
Population: Mean age=53 yr; Gender: males=41; Injury etiology: SCI=39, multiple sclerosis (MS)=2; AIS: A=28, B=10, D=1, MS=2; Time since injury=17 yr.
Intervention: Intervention group (n=20): four 1-hr enhanced education sessions dealing with management and prevention of pressure injuries and structured follow-up (monthly
telephone contact regarding skin status and use of prevention behaviours).
Control group (n=21): Standard
educational information given with no
structured follow-up (periodic telephone contact to address skin status only). All subjects followed for 2 yr after discharge or until recurrence of pelvic pressure injury.
Outcome Measures: Demographic and health information questionnaire; Pressure injury knowledge test; Health beliefs questionnaire; Multidimensional health locus of control scale.
1. At discharge, both groups had an improvement on the pressure injury knowledge test, but more pressure
injury knowledge was acquired within the intervention group (p<0.03).
2. At discharge, no notable differences were found on the health beliefs questionnaire and the
multidimensional health locus of control scale.
3. Even though both groups
remembered pressure injury knowledge obtained 2 yr prior, the intervention group maintained a higher level of pressure injury knowledge (68%) than did the control group (60.8%) at 2 yr post-discharge.
Schubart 2012
USA
Pre-post
NInitial=15; Nfinal=14
Population: Median age=37 yr; Gender: males=10, females=5; Level of injury: cervical=8, thoracic=5, lumbar=2.
Intervention: Interactive e-learning
program about pressure injury prevention and management completed over a two wk timeframe. Follow-up questionnaire.
Outcome Measures: (1) Internet
evaluation and utility questionnaire; (2) Internet impact and effectiveness
questionnaire; (3) Internet adherence
questionnaire; (4) Knowledge acquisition using a questionnaire (based on the Needs Assessment Checklist) assessing skin and posture management, mobility and transfers, and wheelchair/equipment.
1. Program rated “mostly” or “very” easy to use, with the information being understandable and useful.
2. The impact of increasing confidence in prevention/detection of pressure injuries was rated “mostly” (n=4) and “very” (n=10).
3. Adherence was rated as “slightly” (n=2), “somewhat” (n=10), and “very” (n=2), with the mean sitting lasting 45 minutes.
4. Mean total knowledge scores increased from 92 to 106. Means by subsection: skin and posture, 39 to 49; mobility, 32 to 34; and equipment, 20 to 23. The greatest improvement was
shown for skin checks and prevention of skin problems (p<0.005).
Thietje et al. 2011
Germany
Pre-post
N=214
Population: Level of injury: paraplegia=122, tetraplegia=92.
Intervention: Neurological examinations of patients admitted between January 2005 and May 2008.
Outcome Measures: (1) Performance of everyday tasks using the Spinal Cord Injury Measurement (SCIM) II; (2) Knowledge of pressure injuries and bladder management pre and post-discharge using the Knowledge Boberg Score; (3) Patients asked source of knowledge. Measures were taken at admission, 1 and 3 mo post-admission, and 6, 18 and 30 mo post-discharge.
1. Total SCIM II was higher at discharge compared to admission (p<0.001). Scores increased until 18 mo post-discharge.
2. Mean knowledge scores increased from admission to discharge (5.4 to 11.2, p<0.001). At discharge knowledge was rated as poor, average or good for 22.4%, 30.4% and 47.2%,
respectively. Poor knowledge was more common in older adults (65+, p<0.001).
3. Clinical staff and special hospital courses were knowledge resources.
Post-discharge, they were general practitioners and physiotherapists
Brace & Schubart 2010
USA
Pre-post
N=20
Population: Mean age=47 yr; Gender: males=13, females=7; Level of Injury: cervical=7, thoracic=6, lumbar=6.
Intervention: E-learning Program Learning section. Completion of the Living and Looking section was optional. The focus of the program was pressure injury knowledge.
Outcome Measures: A newly developed 20 question test administered pre-, and
post-e-learning program.
1. Pressure injury knowledge improved in
16 of 18 individuals, 1 had a decrease in score and 1 had perfect scores at both time points. Median scores pre
and post being 65 and 92.5
respectively.
2. A lack of knowledge pertaining to pressure injury prevention was shown before the e-learning program.
May et al, 2006
Canada
Pre-post
NInitial=27; Nfinal=23
Population: Mean age=33.7 yr;
Gender=18 male, 5 female; Level of injury: Cervical complete=4, Cervical
incomplete=7, Thoracic complete=7,
Thoracic or Lumbar incomplete=5; Average
Intervention: Participants completed inpatient rehabilitation program which included an 8 wk lecture series two times per wk with content including pressure sore prevention techniques among others.
Outcome Measures: 29-item Multiple Choice Questionnaire (MCQ), Life Situation Scenarios (LSS) (problem-solving ability), Perceived Importance.
1. 18 of the 23 participants maintained or improved their knowledge from baseline (i.e., admission) with average scores at admission vs discharge vs
follow-up of 22.26 vs 24.09 (p=0.041) vs 24.22 (p=0.023)
2. Every participant demonstrated some
improvement in problem-solving ability for some of the 12 topics; however
individual scores remained unchanged or declined for some as well. For the content topic of skin care there was a trend toward improvement (admission
to follow-up) (p=0.012; adjusted level of significance=0.004).
3. Topics related to bladder care, bowel care, and skin cares were consistently
rated as important at all 3 assessment times.
Jones et al. 2003
USA
Pre-post
Study 1: NInitial=8;NFinal=6
Study 2: NInitial=4;NFinal=3
Population: Mean age=25-40 yr; Gender: males=6, females=2; Level of injury paraplegia; Time since injury=12-20 yr.
Intervention: Study 1 – Behavioural
Intervention: 3 primary components-health plan, clinic visits and financial rewards.
Study 2 – Behavioural intervention: 2
treatments components were implemented (Health plan and visits) during the initial phase. Phase 2 – which began after the
patient began to experience skin problems (Included visits plus payment).
Outcome Measures: Severity of pressure sores were recorded at each level; Ulcer severity – was classified using Average Pressure injury Scale for Healing (PUSH) tool.
Study 1:
1. PUSH decreased from baseline by an average of 10.5 points per participant.
2. Six participants were hospitalized (not during the intervention) a total of 16
times during baseline for treatment of pressure injuries.
3. Fewer hospitalizations were also noted during the post-intervention phase compared to the baseline
phase. Average monthly cost of care decreased from $6262.00/participant to $235.00 (US)
Study 2:
4. Mean PUSH scores decreased from baseline by 8.3 points (visits only) and
a further 3.1 points (visits & payment phase).
5. Total number of hospitalizations decreased from 1.67 (baseline) to 0.33 (intervention and postintervention phase).
Ghaisas et al. 2015
United States
Case series
N=25
Population: Mean age=45.5 yr; Gender: males=23, females=2; Level of injury: paraplegia=18, tetraplegia=6, undetermined=1; Severity of injury: complete=20, incomplete=5; Mean time since injury=20.5 yr.
Intervention: Secondary analysis of a subset of participants from the intervention group of a randomized controlled trial (Lifestyle Redesign for Pressure injury Prevention in Spinal Cord Injury 2) were analyzed regarding the relationship between changes in lifestyle and changes in pressure injury status. Data collected
from 1,922 documented notes, an average of 40.9 notes per participant.
Outcomes: Qualitative description of
patterns behaviour or lifestyle changes
relating to pressure injury development and lifestyle changes Behaviour change was conceptualized as eliminating discrete behaviours that increase pressure injury risk or adopting behaviours that reduce risk. Lifestyle change was the altering of one’s daily life routines, adapting the physical and/or social environment, and developing a mindset that is cognizant of risk in everyday life
situations.
1. Of the 47 cases reviewed, only 25 experienced pressure injuries and had clear patterns of lifestyle and behaviour changes.
2. Participants’ characteristics in this
secondary analysis closely mirrored the full study.
3. Four patterns of lifestyle changes as they relate to pressure injury development were identified: 1)Positive pressure injury changes
accompanied by positive
lifestyle/behaviour changes (n=19), 2) Negative or no pressure injury changes accompanied by positive
lifestyle/behaviour changes (n=3), 3)Positive pressure injury changes accompanied by minor or no lifestyle/behaviour changes (n=1), 4)Negative or no pressure injury
changes accompanied by minor or no lifestyle/behaviour changes (n=2).
Cobb et al. 2014
Canada
Case Series
N=143
Population: Pre-cohort (n=70): Mean age=47.29 yr; Gender: males=61, females=9; Level of injury: C1-C4=23, C5- T1=27, T2-T10=8, T11-L2=11, L3-S3=1; ASIA classification: A=27, B=4, C=15, D=23, Missing=1.
Post-cohort (n=73): Mean age=46.90 yr; Gender: males=58, females=15; Level of injury: C1-C4=18, C5-T1=22, T2-T10=12, T11-L2=21, L3-S3=0; ASIA classification: A=26, B=9, C=13, D=25.
Intervention: To evaluate the
implementation of a Pressure injury
Prevention Initiative (PUPI) with a goal of decreasing the incidence of PU’s after admission and severity if they did occur, through a standardized and rigorous assessment and intervention process to ensure optimal care of patients. The protocol developed focused on 1) increased vigilance in skin monitoring by
occupational therapist (OT), 2) OT use of a standardized assessment process, and 3) convenient access to necessary
equipment. Pre-intervention population (Pre-cohort) (n=70) vs. post-intervention population (post-cohort) (n=73); all data were collected retrospectively.
Outcomes: Screening for pressure
injuries; Therapeutic Support Service
(TSS) upgrade; Pressure injury incidence; Short-Form-36; Functional Independence Measure; Life Satisfaction Test-11.
1. Baseline comparison between Cohort 1 & 2 found they were comparable for
distribution of demographic and injury variables.
2. Screening for pressure injuries significantly increased from 31% to 60% (p<0.001) and the percentage of patients with a completed Braden assessments significantly increased from 13% to 55% (p<0.001).
3. No significant difference for number of patients receiving TSS upgrade
between cohorts, but the percentage of patients receiving TSS upgrade
from OT significantly increased from 31% to 70% (p=0.02).
4. No significant differences for number of patients with pressure injuries based on chart documentation, but
the number of patients identified with pressure injuries according to OT skin care assessments significantly increased from 14% (cohort 1) to 33%(cohort 2) (p=0.002).
5. No significant differences for total number of pressure injuries and pressure injury recurrences were observed.
5. No significant differences observed in terms of Short-Form-36, Functional Independence Measure, or Life Satisfaction Test-11.

Summarized Level 5 Evidence Studies

In a secondary analysis of a national cross-sectional survey within the Swiss Spinal Cord Injury Cohort Study, Hug et al. (2018) found that General Self-Efficacy scale results were not association with the data gathered from the 5 PU preventative behaviour items of the Spinal Cord Injury Lifestyle scale. The participants in this survey were community based; positive associations were noted with skin-care prevention items and receiving formal or informal support at home regarding skin-care. The authors suggest that availability of home support may be a factor that can be modified to affect the skin-care preventative behaviour. This is consistent with the suggestions by Guihan et al. (2014). The authors also suggest that the use of a general self-efficacy scale were too general to capture the specific needs and circumstances affecting preventative behaviour in this population. In a secondary analysis of a subset of participants from a larger ethnographic study, Fogelberg et al. (2016) explored the role habits played pre and post injury in relation to pressure injury development. The findings suggest that habits established before injury supported development of pressure management habits in some but not in all participants. However, the study findings do suggest that the integration of pressure management strategies into life habits is important, and that the provision of education related to the pressure risks needs to be expanded to assisting the person to developing new life habits related to pressure management.

Discussion

Overall, most investigations reviewed above have demonstrated that specific educational programming can be beneficial for pressure injury prevention in persons with SCI, This aligns with results reported by Gelis et al. (2012) in a systematic review of therapeutic patient education directed toward persons at chronic risk of pressure injury formation, with 5 of 6 studies in this review involving persons with SCI. These authors noted a low level of evidence (Level 2 resulting in Grade B recommendations), acknowledging the relative immaturity of the literature in this area. Additionally, Gelis et al. (2012) noted limitations associated with biomedical thinking resulting in clinicians focusing on “educating” their patients (i.e., dissemination strategies) rather than adopting more behavioural approaches (Jones et al. 2003) or those that are grounded in adult learning principles as noted by May et al. (2006). The scoping review conducted by Tung et al. (2015), who identified that approaches for pressure management found in the literature were moderately successful at educating but found that the effect of these prevention strategies on incidence is not well studied.

Although the various and specific educational experiences imparted over an inpatient rehabilitation stay are difficult to characterize, two studies have reported knowledge gains in pressure injury prevention methods associated with general inpatient rehabilitation programming as assessed at admission versus discharge, as well as at a later follow-up (May et al. 2006; Thietje et al. 2011). Thietje et al. (2011) did not specify particular aspects of the educational programming provided, however, they noted that significant knowledge gains were achieved by discharge and maintained at 30 months with patients identifying rehabilitation physicians, physiotherapists and nurses as the most important knowledge resources as well as in-hospital special courses. May et al. (2006) reported similar findings in knowledge gain at discharge and retention at 6 months post discharge as assessed by a customized multiple choice questionnaire developed by a clinical nurse educators and former patients. Notably, May et al. (2006) did characterize a main component of the educational experience provided to patients as involving an 8-week lecture series with classes held twice a week with content including pressure sore prevention techniques along with many other topics relevant to persons with SCI. Skin care, along with bladder and bowel care, was consistently reported by patients as the most important issue in relation to a variety of topics usually deemed relevant within SCI rehabilitation (May et al. 2006). Perhaps the most significant finding associated with this study was that problem-solving ability, as assessed using a qualitative Life Situation Scenario approach, was only marginally improved from admission to discharge and many patients continued to demonstrate poor problem-solving ability (i.e., applying knowledge to behavioural actions) at discharge. May et al. (2006) noted that the lecture series approach was likely not effective in this regard as it did not incorporate adult learning strategies (e.g., focus on perceived learning needs, readiness to learn, active learning).

Other studies have tested the effectiveness of more specific educational programming. For example, Brace and Schubart (2010) and Schubart (2012) have conducted pre-post, pilot studies examining the effectiveness of an interactive eLearning program designed to prevent pressure injuries in persons with SCI as applied during inpatient rehabilitation (n=18) or following discharge to home (n=14), respectively. In each case, knowledge, as assessed by performance on a customized test about this topic, was significantly improved immediately after completing the online module. In addition, Schubart (2012) reported that participants rated aspects of the program’s ease of use and utility very high as well as providing positive self-reports on perceived knowledge gain and improved self-efficacy about pressure injury prevention.

In an RCT conducted by Garber et al. (2002), inpatients awaiting pressure injury surgery were randomly assigned to an intervention group (n=20) that received four 1-hour sessions of enhanced education on the prevention and management of pressure injuries. Information presented at the sessions included education regarding preventative strategies such as skin inspection, weight shifts/turns, nutrition and pressure redistribution surfaces for the bed and wheelchair, as well as pressure injury etiology. The control group (n=21) received standard education regarding preventative practices. After discharge, the groups were followed for two years or until recurrence of pelvic pressure injury. Improvement on the pressure injury knowledge test was noted in both groups upon discharge from hospital; however, it was significantly different between the groups (p<0.03), with those in the intervention group gaining more knowledge about preventing pressure injuries. No significant differences were noted on the multidimensional Health Locus of Control Scale and the Health Beliefs Questionnaire between the two groups at discharge. Two years post treatment, it was noted that both groups had retained most of the knowledge they had gained during their hospitalization, but the level of knowledge retained by the control group was below that of the treatment group: 60.8% versus 68% on the pressure injury knowledge test.

In a parallel study, Rintala et al. (2008) randomized similar subjects into three groups: Group 1 (N=20) had received enhanced education sessions. Group 1 was followed through structured monthly telephone contact where they were questioned regarding skin status, pressure injury preventative behaviors and reminded of behaviors they were not using. Group 2 (N=11) were contacted monthly by mail to assess skin status only and group 3 (n=10) were contacted every three months by mail to assess skin status. If those in groups 2 and 3 had not responded in two weeks, they were contacted by telephone. Group 1 had a significantly longer time before recurrence of pressure injuries (19.6 months, p=0.002) while no significant difference was reported between group 2 or 3. For persons who had not had previous pressure injury surgery, the enhanced education and structured follow-ups extended their ulcer free time. As well, less people in group 1 had a recurrence of a pressure injury (33.3%) versus group 2 (60%) and group 3 (90%). In summary, those individuals who received an enhanced education and structured follow-up, showed more improvement on the pressure injury knowledge test at discharge, retained more of this knowledge 2 years post intervention and had fewer recurrences of pressure injuries. For those individuals who went on to have a recurrence, time to recurrence was much longer.

To the point in time of this last study, it was the only investigation described in this section to include an assessment of health status as well as to include behavioural aspects to their intervention After this time point, research in this area in general, was strengthened considerably by adopting more fulsome outcome measurement approaches to evaluate the effectiveness of interventions (i.e., assessing behavior change directly in addition to its impact on health) as well as by incorporating theory-based behavior change strategies as parts of an intervention.

Early pressure injury prevention was examined by Guihan et al. 2014 through the lens of a Chronic Care Model, focusing on self-management through engagement education, improving motivation and skill building. This multisite, single blind RCT study compared self-management and motivational interviewing interventions to an education only control group over a 6 month period post discharge from 6 VA centres with participants who had been admitted due to chronic and/or severe pressure injuries. This study found that at 3 and 6 months test times that there were differences between the two groups in relation to skin care behaviours, and skin status but no comparisons were statistically significant. They also found that less than one third of the intervention group participated fully and 15% of the control group. The authors question whether these interventions are effective for people with chronic and/or severe pressure injuries, identifying the factors related to comorbidities as high and potentially confounding as they did not address them. The authors also report their study had less than 50% power instead of the anticipated 80% due to challenges with recruiting amongst this specific subset of the SCI population, despite recruiting from 6 centres.

Kim and Cho (2017) based their study on Bandura’s social cognitive theory of self-efficacy. The program focused on promoting self-care behaviours, self- care knowledge, and self-efficacy as a means to prevent pressure injuries. They randomly allotted 3 of the 6 participating hospital into the control or experimental groups. The control group received an education booklet. Their 8 week program included many of the strategies/approaches used in the above studies, combining education using booklets, computer slides, videos, demonstration/observation and practice of skills, computer demonstration, and counselling via phone and face to face. While both groups demonstrated improvements in self-care knowledge, self-care behaviours and self-efficacy, the experimental group demonstrated a significantly greater improvement in these areas, suggesting the mixed methods used was beneficial in improving pressure injury prevention knowledge. However, the effect of this approach on pressure injury incidence longer term was not explored in this study.

Cobb et al. (2014) concluded from their retrospective pre-post study of a Pressure injury Prevention Initiative (PUPI) that best practices for assessment and documentation improved but there were no significant changes in pressure injury incidence or in the severity of ulcers if they did occur, over the 20 month study timeframe. However, Cobb cites other similar studies where improvements in pressure injury incidence were found and questioned whether the methodology used in this study was robust enough.

Jones et al. (2003) examined the effectiveness of several behavioural strategies (i.e., rewards, counselling and creation of an action plan) in four small pilot studies that examined pressure injury status and health care utilization. Results showed great variability in the average Pressure injury Scale for Healing (PUSH) scores with all behaviour strategies. For some participants PUSH scores were lower by 10.5 points from baseline; no hospitalizations were required and costs declined from $6,263.00 (US) to $235.00 (US). Of these participants only a few maintained the lower PUSH scores post-intervention. Although this was a very small study, results suggest that for some people when behavioural contingencies were introduced, positive behaviours resulted and were sustained. More research is needed to determine if behavioural contingencies (i.e., rewards) and other behavioural strategies offer some benefit for some people in pressure injury prevention post SCI.

Ghaisas et al. (2015) completed a secondary analysis of data collected from the intervention group of a randomized control study in which participants’ received the Pressure injury Prevention Program (PUPP); this program is based on the findings from Lifestyle Redesign for Pressure injury Prevention in Spinal Cord Injury study. This secondary analysis focused on the relationship between lifestyle and behaviour changes implemented during the intervention and the development/progression of pressure injuries. The study identified four patterns in the relationship between lifestyle and behaviour changes and pressure injury change. There was a larger proportion of participants who had positive lifestyle or behaviour changes that related to an improvement in pressure injury status (n=19/25).

The 2013 Canadian Best Practice Guideline for Prevention and Management of Pressure injuries in People with SCI provided a Level IV recommendation (based on studies of self-management approaches used within various chronic diseases) to promote self-management for people with SCI by helping them to learn, consistently apply, and incorporate into their daily lives the effective and appropriate pressure injury prevention strategies.

Conclusion

There is level 1b evidence (from two RCTs: Rintala et al. 2008; Garber et al. 2002); level 2 evidence (from 1 lower RCT: Kim & Cho 2017); and level 4 evidence (from four pre-post studies: May et al. 2006; Brace & Schubart 2010; Schubart et al. 2012; Jones et al. 2003 ) that providing enhanced pressure injury prevention education, including behaviour contingencies and strategies, is effective at helping individuals with SCI gain and retain this knowledge, reduce pressure injury severity and decreased health care costs.

There is level 1b evidence (from one RCT: Guihan et al. 2014) suggesting that for the SCI population with chronic and/or severe pressure injuries, an enhanced prevention program using individual motivational intervention and group self-management training does not improve skin protective behaviours or pressure injury outcomes.

There is level 4 evidence (from two pre-post studies: Schubart et al. 2012; Brace & Schubart 2010) that online eLearning modules may improve knowledge on prevention of pressure injuries among persons with SCI.

There is level 4 evidence (from one case series study: Cobb et al. 2014) suggesting that a formal pressure injury prevention program can improve best practice adherence in an acute care facility.

There is level 1b evidence (from one RCT: Rintala et al. 2008) that providing enhanced pressure injury education and structured follow-up is effective in reducing recurrence of pressure injuries especially in those individuals with no previous history of pressure injury surgery.

There is level 4 evidence (from one case series study: Ghaisas et al. 2015) to suggest that an intervention that focus on reducing risk through lifestyle, particularly habits and behaviour changes are related to improvements in the uptake of pressure management strategies, therefore improvements in pressure injury status.

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