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Skin Integrity and Pressure Injuries

Using Telerehabilitation for Delivery of Prevention or Treatment Programs

Telerehabilitation has been defined as “the use of telecommunication technology to deliver rehabilitation services at a distance” (Vesmarovich et al. 1999; p. 264). Telerehabilitation allows for visual and verbal interaction between an individual with SCI and a health care provider. Impaired mobility and great distances to specialized SCI centers often make follow-up care difficult for individuals with SCI (Mathewson et al. 2000; Galea et al. 2006). Telerehabilitation has the potential to deliver medical rehabilitation including education, nutritional and psychosocial elements of health care at a distance thereby facilitating continuity of care (Galea et al. 2006). Shorter lengths of stay have potentially increased the need for education post-discharge and technology can be used to continue education begun during inpatient rehabilitation including education on pressure injury prevention and care of ulcers if they occur. Continuation of pressure injury prevention education and early detection and intervention via technology may reduce the need for hospitalization related to pressure injuries (Phillips et al. 2001). The use of a videophone capable of transmitting high resolution images, and verbal interactions between nurse, patient and caregiver could mean accurate and timely assessment and treatment of wounds and improved healing (Mathewson et al. 1999). In a study conducted at a mock home setting, Hill et al. (2009) found “video conferencing was better overall than the use of the telephone when assessing the detailed clinical characteristics of a pressure injury (p. 200).” Both were found to be useful when assessing for the presence of a pressure injury.

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 telerehabilitation for wounds of various etiologies including SCI) telerehabilitation as a promising approach for delivering pressure injury prevention and management to people with SCI.

Author YearCountry
Research Design
Score
Total Sample Size
Methods Outcome
Telephone and Pressure Injury Management
Arora et al.
2017
Australia
RCT
PEDro=8
Ninitial=120
Nfinal=115
Population: Int (n=60): Mean age= 35yr; Gender: males=52, females=8; Level of Injury: ASIA Classification: A=52, B=3, C=2, D=0, Unknown=3. Con (n=60): Mean age= 36yr; Gender: males=54, females=6; Level of Injury: ASIA Classification: A=47, B=2, C=8, D=1, Unknown=2.
Intervention: Intervention group (Int) received weekly advice by telephone for 12 wk about the management of their pressure injuries from a trained healthcare professional. Advice pertained to seating, bed overlays, cushions, equipment, diet, nutrition, wound dressings, pressure management techniques, moisture management and when to seek medical or nursing consult. Control group (Con) received standard care 12wk follow-up.
Outcome Measures: Primary outcome: Pressure injury depth, Pressure injury Scale for Healing (PUSH). Assessments completed at baseline and 12 weeks.
1. The mean between-group difference for the size of the PU at 12 wks was 2.3 cm2 favouring the intervention group (p=0.08), however the depth was not significantly different after 12 weeks when comparing treatment and intervention groups (p=0.17).
2. A statistically significant betweengroup decrease in PUSH score was seen in favour of the intervention group (p=0.02).
3. Inconclusive findings for outcomes for pressure injury undermining and depth, participant and clinicians’ subjective impressions about pressure injury improvement.
4. Improvements noted on Braden scale, primarily related to nutrition and moisture.
5. Participants’ rating of their confidence in managing their pressure injury were rated as high (7.3 on 10 point scale.
6. Intervention group participants were satisfied with the telephone intervention (8.6 on 10 point scale); control group was 6.5.
Telehealth and Pressure Injury Management
Houlihan et al. 2013
USA
RCT
PEDro=6
N=142
Population: Mean age=48.2 yr; Gender: males=51, females=55; Injury etiology: SCI=106, Multiple Sclerosis=36, Level of injury (SCI): paraplegia=54, tetraplegia=46. Medical history: depression=55, pressure injury=66.
Intervention: CareCall (telehealth program with interactive voice response) access for 6 mo (unlimited call-in access and received calls 1x/wk) vs. normal care.
Outcome Measures: Pressure injury Scale for Healing (PUSH) tool v.3.0, Patient Health Questionnaire -9 (PHQ-9), Cornell Services Index (CSI), and Craig Hospital Inventory of Environmental Factors – Short Form.
1. Overall there was no positive impact on pressure injuries at 6 mo; however, a significant difference in percentage with ≥1 pressure injuries for females in the intervention group (p=0.04).
2. Among those with depressive symptoms at baseline, severity at 6 mo differed between groups (p=0.038).
3. There were no between group differences in terms of healthcare utilization.
4. Participants using Carecall selfreported increased health-care availability (p=0.043) although other factors (i.e., availability at baseline, time and age) were more powerful predictors of this.
Phillips et al. 1999
USA
Case Control
NInitial=37; NFinal=35
Population: Mean age=35 yr.
Intervention: Videoconferencing was used to assist patients in treating and monitoring pressure injuries. Patients were divided into 3 groups: telephone, videophone, and standard care.
Outcome Measures: Number of pressure injuries, emergency room (ER) visits, hospitalizations, doctor’s visits annually, and employment rate.
1. Overall it was found that the video group reported the largest number of ulcers, followed by the standard care group and the telephone group.
2. The standard care group reported the lowest number of ER visits, hospitalizations, and health care provider visits.
3. The numbers of visits were similar for the other two groups.
4. Over half the members of each group had no hospitalizations during the study period. It was also noted that 26% of the subjects had returned to work 6 mo after injury.
Vesmarovich et al. 1999
USA
Case Series
N=8
Population: Age range= 38-78 yr; Gender: males=8, females=0.
Intervention: The outpatient nurse using the Picasso Still Image Videophone conducted 1x/wk telerehabilitation visits. Subjects and family members received 30 minutes of education; equipment was sent home with subjects. Interviews were conducted to determine level of satisfaction
Outcome Measures: Number of ulcers healed, satisfaction.
No statistical results reported
1. Subjects were seen approximately seven times (range 1-18 visits).
2. Seven wound sites healed completely and two needed surgery. Subjects and family were highly satisfied.
Internet and Pressure Injury Management
Hilgart et al. 2014
United States
Post-test
N=7
Population: Mean age=36.14 yr; Gender: males=2, females=5; Level of injury: tetraplegia=5, paraplegia=2; Mean time since injury=10.43 yr.
Intervention: Participants had 6 weeks of access to use the iSHIFTup program, an Internet intervention designed to improve skin care behaviour. Assessments were administered after the intervention was completed.
Outcome Measures: Program usage (login, completion of 4 components – cores, modules, diary, and follow up), Internet Evaluation and Utility Questionnaire (IEUQ) which measures participants’ experiences and perceptions of an internet intervention; Internet Impact and Effectiveness Questionnaire (IIEQ) which measures participants’ perceptions of the internet intervention in relation to perceived effectiveness in resolving or preventing the target health condition.
1. In terms of program usage over the 6-week intervention period, average use was 14.86 (SD 10.75). All participants may have diary entries (avg 19.57, SD 13.21), all completed at least 1 module (avg 6.86, SD 4.45), and all 3 cores. All 7 completed at least 1 follow-up and 1 module.
2. In terms of IEUQ, 100% of participants reported that the program was mostly or very helpful and acceptable, the program was very easy to comprehend, they mostly or very much liked the layout, and they would likely return to the program.
3. In terms of IEUQ, 86% of participants reported that the program was very easy and convenient to use, was mostly or very engaging, was mostly or very useful, credible, mostly or very satisfying and enjoyable, was trustworthy, and had no privacy concerns, and was a good mode of delivery.
4. In terms of IIEQ, 100% of participants found the program helpful in improving skincare routines and
managing skincare as well as reported knowledge gains in skincare and pressure injury prevention.
5. In terms of IIEQ, 86% of participants found that the program was very helpful in providing behavioural support for skincare activities, was somewhat or very effective for long-term use, was easy to follow through with program recommendations, and helpful in being confident in tracking daily skincare activities.

Discussion

Vesmarovich et al. (1999) described the use of telerehabilitation delivered via a videophone system that transmitted still images and audio to treat stage III and IV ulcers. While no statistical results were reported, 7 out of 12 ulcer sites healed. Using the same videophone system, Philips et al. (1999) divided SCI participants into 3 groups. The videophone group had the highest number of identified and/or reported ulcers. The annualized data for emergency room (ER) visits, hospitalizations and health care visits were similar for the video and telephone groups while hospitalizations and visits were less in the standard care group. No differences were significant at p<0.05. However a small non-randomized sample size and several other limitations were identified to inform future investigations.

Results of these two small studies fail to support the use of this form of telerehabilitation in delivery of cost effective prevention strategies and early pressure injury identification and treatment. However, Houlihan et al. (2013) did achieve some positive results by employing interactive voice response (IVR) telephone called “CareCall” to enable virtual health care to monitor and assess patients’ health with respect to pressure injuries and depression and to increase appropriate use of health resources such as preventative outpatient clinics and to reduce ER visits. Participants (N=142) were randomized into either a control (i.e., usual care) or intervention (i.e., “CareCall”) group and received service over a 6 month period. Those receiving “CareCall” received weekly automated calls and could call into the service at any time to receive algorithm-based, branched-logic modules (scripts of content deemed relevant to their health concerns). The scripts were delivered by both clinicians and persons with spinal cord disease and were developed through consideration of health behavior change theory (i.e., Social Cognitive Theory and Transtheoretical Model) to promote healthy behaviours. Using this approach, women were found to have reduced pressure injury incidence over the study period (p<0.0001) for the “CareCall” group versus control, whereas men did not. There was no difference in healthcare utilization between the two groups although the intervention group did self-report perceived increases in health-care availability.

Arora et al. (2017) explored effectiveness of intervention at a distance using weekly telephone contact as the higher tech options are not feasible in low-and middle-income countries. This study was a multi-site RCT in India and Bangladesh. The intervention group received weekly telephone consultations from an experienced health care professional, on a wide variety of factors. The control group received standard care. The size of the pressure injury was the primary outcome measure, which showed greater improvement in the intervention group (P=0.08). The intervention group also felt more confident in being able to manage their pressure injury, had improvements on their Braden scale scores and their PUSH scores. The authors question whether the size of the treatment effect was meaningful. The authors also suggested that there was some indication that there was a greater benefit to health and wellness from the regular telephone contact that just for the pressure injuries based on the World Health Organization Disability Assessment Schedule score between group difference (95% CI 0.8-3.8), but again they questioned the treatment effect meaningfulness.

Hilgart et al. (2014) explored the effectiveness of intervention using an internet format called iSHIFTup. This program was developed and tested previously, with this study focusing on the participants’ perceived effectiveness of the program in relation to prevention. The authors report that the majority of participants found the program easy to use, effective and useful to enable them to implement the strategies recommended from the program and to independently manage their skin care. It is suggested that this type of intervention holds promise for ongoing education and intervention regardless of the distance from the facility.

Conclusion

There is level 1b evidence (from one RCT: Houlihan et al. 2013) that telerehabilitation using an automated call-in system with built-in theory-based behavior change strategies may make a significant difference for women but not men in preventing pressure injuries post SCI.

There is level 4 evidence (from one case series: Vesmarovich et al. 1999) that telerehabilitation via videophone to support clinical interactions and digital photography does not make a significant difference in the prevention and treatment of pressure injuries post SCI.

There is level 2 evidence (from one RCT: Arora et al. 2017) that treatment intervention provided by telephone has potential to provide a low cost means of treatment intervention in low-and middle-income countries.

There is level 4 evidence (from one post-test study: Hilgart et al. 2014) that a comprehensive prevention program provided using an internet format has potential to meet ongoing needs for pressure management beyond the hospital/rehabilitation facility.

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