Summary

There is level 2 evidence (from one prospective controlled trial: Kanno et al. 2009) that supports the use of ultrasonography to extend the yield of routine inspection and palpation of suspected or early stage pressure injuries in people with SCI.

There is level 3 evidence (from one case control study: de Heredia et al. 2012) that magnetic resonance imaging can predict the development of osteomyelitis in non-healing pelvic pressure injuries in patients.

There is level 4 (from one case series study: Loerakker et al. 2012) that reliance on circulatory biomarkers as an indication of muscle damage secondary to deep tissue injury in the SCI population cannot be recommended at this time.

There is level 2 evidence (from two prospective controlled trial and one cohort study: Lui et al. 2015; Lui et al. 2006b; Ferguson et al. 1992) supported by level 4 evidence (from five pre-post studies, and two case series studies: Smit et al. 2012, 2013a, 2013b; Gyawali et a. 2011; Bogie & Triolo 2003; Van London et al. 2008; Liu et al. 2006a) that electrical stimulation decreases ischial peak pressures during stimulation.

There is level 4 evidence (from one pre-post study: Bogie & Triolo 2003) that electrical stimulation may increase blood flow at sacral and gluteal areas post-SCI.

There is level 2 evidence (from two prospective controlled trials and one pre-post study: Lui et al. 2006a; Mawson et al. 1993; Bogie & Triolo 2003) that electrical stimulation may increase tissue oxygenation post-SCI.

There is level 4 evidence (from two pre-post studies: Di Caprio et al. 2016; Previnaire et al. 2016) showing that fat grafting using the participants own body fat may be considered as a prevention strategy for some people when all other prevention strategies have been unsuccessful.

There is level 2 evidence (from one prospective controlled trial: Hobson 1992) and level 4 evidence (from one case control study: Gutierrez et al. 2004) to support not generalizing pressure mapping data from able-bodied subjects to SCI subjects.

There is level 4 evidence (from one prospective controlled trial: Brienza & Karg 1998) to support not generalizing pressure mapping data from the elderly population to the SCI population.

There is level 2 evidence (from one cohort study: Kennedy et al. 2003) showing that early attendance at specialized seating assessment clinics increases the skin management abilities of individuals post SCI.

There is level 1b evidence (from two RCTs: Rintala et al. 2008; Garber et al. 2002); and 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.

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.

There is level 2 evidence (from one cohort study: Richard-Denis et al. 2017) that indicated, for pre-operative prevention for the SCI population, a multi-layer foam dressing is not superior in preventing sacral pressure injuries compared to viscoelastic polymer gel mattress over a foam stretcher pad.

There is level 1 evidence (from seven RCTs: Karsli et al. 2017; Houghton et al. 2010; Cukjati et al. 2001; Adegoke & Badmos 2001; Karba 1997; Jercinovic 1994; Griffin 1991) that electrical stimulation accelerates the healing rate of stage III and IV pressure injuries when combined with standard wound management.

There is level 1 evidence (from two RCTs: Taly et al. 2004; Nussbaum et al. 1994) that laser treatment has no added benefit in pressure injury healing post-SCI than standard wound care alone.

There is level 1b evidence (from one RCT: Nussbaum et al. 1994) that the combination of US/UVC with standard wound care decreases wound healing time of pressure injuries post SCI; there is no evidence to support the benefit of UVC or US, used individually.

There is level 1b evidence (from one RCT: Salzberg et al. 1995) that pulsed electromagnetic energy accelerates healing of stage II and III pressure injuries post SCI.

There is level 1b evidence (from one RCT: Sundby et al. 2018) that intermittent negative pressure (INP) device plus standard wound care (SWC) is effective for wound healing compared to SWC alone in SCI patients home care.

There is level 1b and level 2 evidence (from one RCT and one prospective controlled study: Dwivedi et al. 2017; Srivastava et al. 2003) that negative pressure wound therapy (NPWT) has shown to reduce levels of MMP-8, increase the rate of healing, reduce exudate production and enhance the rate of formation of red granulation tissue when compared to conventional wet gauze alone.

There is level 1b evidence (from one RCT and one pre-post study: De Laat et al. 2011; Coggrove et al. 2012) that topical negative pressure facilitates wound healing for pressure injuries in people with SCI and other patient etiologies.

There is level 4 evidence (from one case series: Dessy et al. 2015) that vacuum-assisted closure (VAC) therapy does not promote wound healing and may cause rare complications including foam-fragment retention within the wound.

There is level 2 evidence (from one prospective controlled trial: Kloth et al. 2001) that normothermic dressings may improve healing of pressure injuries post SCI.

There is level 4 evidence (from two pre-post tests: Keast & Fraser 2004; Vair et al. 2015) that recombinant human erythropoietin aids in the healing of stage IV chronic non-healing pressure injuries post SCI.

There is level 2 evidence (from one prospective controlled trial: Singh et al. 2014) that advanced wound therapy using local applications of PRP seems to be a promising alternative to standard saline dressings in PI healing.

There is leve 2 evidence (from one prospective controlled trial: Singh et al. 2015) that local application of PRP may reduce bacterial presence and colonization in PIs.

There is level 4 evidence (from one case series and one post-test: Sell et al. 2011; Biglari et al. 2015) that supports the possibility of platelet-rich plasma therapy facilitation of reactivated healing in severe, non-healing pressure injuries, post-SCI.

There is level 2 evidence (from one flawed RCT: Bauman et al. 2013) that does not support the use of oxandrolone (anabolic steroid) to facilitate healing of serious pressure injuries post SCI. However, very limited, earlier level 4 evidence (from one case series: Spungeon et al. 2001) did lend some support for the use of oxandrolone to promote healing of stage III and IV pressure injuries post SCI.

There is Level 1 evidence (from one RCT: Hollisaz et al. 2004) that completion of healing for stage I and II pressure injuries is greater with an occlusive hydrocolloid dressing compared to phenytoin cream or simple dressing post-SCI.

There is Level 2 evidence (from one RCT: Kaya et al. 2005) that occlusive hydrogel-type dressings heal more pressure injuries than conservative treatment post-SCI.

There is level 1 evidence (from one RCT: Subbanna et al. 2007) that topical phenytoin shows a trend towards healing of stage I and II pressure injuries post-SCI.

There is level 2 evidence (from one RCT: Scevola et al. 2010) that platelet gel dressings when used within the first 2 weeks of treatment can trigger earlier granulation tissue proliferation toward pressure injury healing, post-SCI.

There is level 1 evidence (from one RCT: Ho et al. 2012) underpins the use of pulsatile lavage hydrotherapy debridement for Stage III and IV pressure injuries secondary to SCI.

There is level 5 evidence (from one observational study: Bogie et al. 2013) that pulsatile lavage therapy, used in conjunction with standard infection control standards, is likely a safe debridement method for Stage III and IV pressure injuries in people with SCI.

There is level 2 evidence (from one prospective controlled trial and one observational study: Wang et al. 2010; Sherman et al. 1995) that supports the use of maggot therapy as an adjunctive therapy for pressure injury debridement post-SCI.

There is level 4 evidence (from one post-test study: Erba et al. 2010) that supports the use of silicone moulding as a radical en bloc debridement method for pyramidal shaped grade IV pressure injury cavities in people with SCI.

There is level 4 evidence (from one pre-post study: Banks & Ho 2008) that topical oxygen therapy may improve healing of pressure injuries post-SCI.

There is level 2 evidence (from one cohort study: Velasco et al. 2015) that the application of Tissucol Duo during surgical treatment of PrUs in patients with SCI has been shown to be effective in reducing postoperative complications and in shortening the duration of the hospital stay with a consequent savings in costs.

There is level 3 evidence (from one post-test: Ljung et al. 2017) that a structured treatment programme regulating pre- and postoperative care and rehabilitation can help raise health status of SCI pressure injury patients.

There is level 4 evidence (from one case series: Yusmindo et al. 2014) that proximal amputations of the lower limbs are procedures that can be considered as part of the treatment for complicated pressure injuries. In properly selected patients, it can reduce the number of hospital stays, and improve the quality of life and functional outcome.

There is level 5 evidence (multiple studies: Table 27) that supports various surgical repair methods for persistent, severe thigh and buttock pressure injuries secondary to SCI, as a beneficial treatment option.

There is level 4 evidence (from one pre-post study: Biglari et al. 2012) that supports the use of MedihoneyÒ for improved healing rate as well as residual soft, elastic scars in persistent stage III and IV pressure injuries in individuals with SCI.

There is level 3 evidence (from one case control study: Liu et al. 2013) that supports the use of CRFSO over ARO to accelerate pressure injury healing but it needs to be noted that objective outcome assessment was not clearly outlined.

There is level 4 evidence (from one pre-post study: Brewer et al. 2010) for arginine supplementation for pressure injury healing.

There is level 2 evidence (from one prospective controlled trial: Tzen et al. 2013) that localized cooling is not a viable pressure injury prevention strategy that is effective for individuals with SCI. Conversely, with neurological control of vasoconstriction and capillary smooth muscle contraction, those without SCI may benefit from microclimate controlled surfaces as a pressure injury prevention strategy.

There is level 2 evidence (from one cohort study: Lane et al. 2017) that implementing evidence-based guidelines on smoking cessation in persons with spinal cord injuries can improve pressure injury healing.

There is level 4 evidence (from one series: Jugun et al. 2016) that recurrences of pressure injury infection may be caused by reinfections from extrahospital factors other than surgical debridements, flap use, or duration of antibiotic therapy.