Subepidermal moisture surrounding pressure ulcers in persons with a spinal cord injury: A pilot study

Objective

Characterization of a non-invasive method of quantifying subepidermal moisture (SEM) surrounding stages III and IV pressure ulcers (PrUs) in spinal cord injury (SCI).

Design

Prospective, single-visit, single-rater, observational study, using repeated-measures analysis.

Method

Setting-inpatient units of one VA SCI Center.

Participants

Convenience sample of 16 subjects with SCI with stage III or IV PrUs over sacrum or ischium.

Interventions

Measurement with the MoistureMeter-D, a hand-held device using 300 MHz electromagnetic waves.

Outcome measures

Dielectric constant, a dimensionless number which increases with the moisture content. Each subject had a PrU site and a control site. Measurements were made at each site, on intact skin, at four points spaced angularly around the site, in triplicate.

Results

(1) Short-term, single-rater relative error was 2.5%. (2) Order effect: first readings were higher than second readings in 55 of 64 measurement sets. Order effect was significant for control sites (P < 0.0001) but not for PrU sites. (3) Angular effect: SEM varied by angle at the PrU sites (P < 0.01); 12 o''clock position the highest and 6 o''clock the lowest. (4) Ability to differentiate PrUs from intact skin: SEM at PrU sites was greater by 9.0% than control sites (P < 0.05). (5) Site effect: SEM was higher at sacral locations than ischial at control sites by 20% (P < 0.005).

Conclusions

SEM differentiates PrUs from intact skin. Future study designs must take into account order, angular, and site effects on this measure. This information will inform designers of future studies of SEM in healing of PrUs.     

Comprehensive management of pressure ulcers in spinal cord injury: Current concepts and future trends

Abstract

Pressure ulcers in spinal cord injury represent a challenging problem for patients, their caregivers, and their physicians. They often lead to recurrent hospitalizations, multiple surgeries, and potentially devastating complications. They present a significant cost to the healthcare system, they require a multidisciplinary team approach to manage well, and outcomes directly depend on patients' education, prevention, and compliance with conservative and surgical protocols. With so many factors involved in the successful treatment of pressure ulcers, an update on their comprehensive management in spinal cord injury is warranted. Current concepts of local wound care, surgical options, as well as future trends from the latest wound healing research are reviewed to aid medical professionals in treating patients with this difficult problem.     

A pilot study evaluating protein abundance in pressure ulcer fluid from people with and without spinal cord injury

Abstract

Objective

To determine whether the biochemistry of chronic pressure ulcers differs between patients with and without chronic spinal cord injury (SCI) through measurement and comparison of the concentration of wound fluid inflammatory mediators, growth factors, cytokines, acute phase proteins, and proteases.

Design

Survey.

Setting

Tertiary spinal cord rehabilitation center and skilled nursing facilities.

Participants

Twenty-nine subjects with SCI and nine subjects without SCI (>18 years) with at least one chronic pressure ulcer Stage II, III, or IV were enrolled.

Outcome measures

Total protein and 22 target analyte concentrations including inflammatory mediators, growth factors, cytokines, acute phase proteins, and proteases were quantified in the wound fluid and blood serum samples. Blood samples were tested for complete blood count, albumin, hemoglobin A1c, total iron binding capacity, iron, percent (%) saturation, C-reactive protein, and erythrocyte sedimentation rate.

Results

Wound fluid concentrations were significantly different between subjects with SCI and subjects without SCI for total protein concentration and nine analytes, MMP-9, S100A12, S100A8, S100A9, FGF2, IL-1b, TIMP-1, TIMP-2, and TGF-b1. Subjects without SCI had higher values for all significantly different analytes measured in wound fluid except FGF2, TGF-b1, and wound fluid total protein. Subject-matched circulating levels of analytes and the standardized local concentration of the same proteins in the wound fluid were weakly or not correlated.

Conclusions

The biochemical profile of chronic pressure ulcers is different between SCI and non-SCI populations. These differences should be considered when selecting treatment options. Systemic blood serum properties may not represent the local wound environment.     

A pilot study evaluating protein abundance in pressure ulcer fluid from people with and without spinal cord injury

Objective

To determine whether the biochemistry of chronic pressure ulcers differs between patients with and without chronic spinal cord injury (SCI) through measurement and comparison of the concentration of wound fluid inflammatory mediators, growth factors, cytokines, acute phase proteins, and proteases.

Design

Survey.

Setting

Tertiary spinal cord rehabilitation center and skilled nursing facilities.

Participants

Twenty-nine subjects with SCI and nine subjects without SCI (>18 years) with at least one chronic pressure ulcer Stage II, III, or IV were enrolled.

Outcome measures

Total protein and 22 target analyte concentrations including inflammatory mediators, growth factors, cytokines, acute phase proteins, and proteases were quantified in the wound fluid and blood serum samples. Blood samples were tested for complete blood count, albumin, hemoglobin A1c, total iron binding capacity, iron, percent (%) saturation, C-reactive protein, and erythrocyte sedimentation rate.

Results

Wound fluid concentrations were significantly different between subjects with SCI and subjects without SCI for total protein concentration and nine analytes, MMP-9, S100A12, S100A8, S100A9, FGF2, IL-1b, TIMP-1, TIMP-2, and TGF-b1. Subjects without SCI had higher values for all significantly different analytes measured in wound fluid except FGF2, TGF-b1, and wound fluid total protein. Subject-matched circulating levels of analytes and the standardized local concentration of the same proteins in the wound fluid were weakly or not correlated.

Conclusions

The biochemical profile of chronic pressure ulcers is different between SCI and non-SCI populations. These differences should be considered when selecting treatment options. Systemic blood serum properties may not represent the local wound environment.     

Exploring the first pressure injury and characteristics of subsequent pressure injury accrual following spinal cord injury

Context/Objective: Clinicians have guidance on prevention and treatment of pressure injuries, but little is known regarding characteristics of patients who develop additional pressure injuries. Thus, our objective was to explore the first pressure injury and characteristics of individuals who develop subsequent pressure injuries during acute care and inpatient rehabilitation following spinal cord injury.Design: Secondary analysis of longitudinal data from a cohort of adults following initial traumatic spinal cord injury.Setting: Urban acute care hospital and inpatient rehabilitation facilities.Participants: A convenience sample of adults (n = 38) who developed at least one pressure injury during acute care and inpatient rehabilitation.Interventions: Not applicable.Outcome Measures: The primary outcomes were number of additional pressure injuries and stage of care during which they occurred, prior to community discharge.Results: A covariate-adjusted model revealed that participants with ASIA D injury had a 67% decrease in the rate of additional pressure injury incidence compared to participants with ASIA A injury (Rate Ratio = .33, 95% CI [0.13, 0.88]). The severity of the first pressure injury had no significant association with subsequent pressure injury incidence (P = .10).Conclusion: These findings indicated that individuals with greater sensory and motor loss had an increased risk of developing additional pressure injuries compared to individuals with less impairment. These results are meaningful for stakeholders interested in understanding factors associated with developing subsequent pressure injuries during the index rehabilitation stay and provide a foundation for future research in this area.     

High-voltage electrical stimulation for the management of stage III and IV pressure ulcers among adults with spinal cord injury: demonstration of its utility for recalcitrant wounds below the level of injury

Context

Patients with spinal cord injury (SCI) have many factors that are associated with pressure ulcer formation, including paralysis, loss of sensation, poor nutrition, anemia, and skin maceration related to incontinence. Treatment of these ulcers involves relieving pressure, improving nutrition and skin hygiene, treating infections, removing necrotic tissues, and applying the appropriate dressings. However, some cases are not responsive to the above treatment. Electrical stimulation (ES) is thought to enhance soft tissue healing through promotion of protein synthesis, inhibition of bacterial growth, facilitation of epithelial tissue migration, improvement of blood flow, and tensile strength. This data is mainly based on evidence from animal studies and very few rigorously controlled studies conducted in humans.

Objective

To demonstrate the effectiveness of ES in the treatment of recalcitrant pressure ulcers.

Methods

Retrospective case series describing the care of adults with SCI and recalcitrant pressure ulcers. ES was applied directly into the wound bed: 60 minutes per session, 3–5 times per week; with an intensity of 100 milliamperes and a frequency of 100 pulses per second. Polarity was negative initially and was switched weekly. The amplitude and wave form were maintained throughout.

Results

The long-standing (11–14 months) pressure ulcers were completely healed after 7 to 22 weeks of treatment with high-voltage ES.

Conclusion/clinical relevance

This case series demonstrates the effectiveness of ES for enhanced healing of Stage III–IV ulcers otherwise unresponsive to standard wound care. Further study is needed to identify the most effective protocol for ES therapy in the treatment of recalcitrant pressure ulcers.     

The impact of a pressure ulcer prevention educational program based on the health belief model for persons with spinal cord injury

Study designPre- and post- trial.ObjectivesTo determine the changes of health belief levels after a pressure ulcer (PrU) prevention educational program based on the Health Belief Model (HBM)SettingDepartment of Rehabilitation Medicine, University Medical Centre, Malaysia.MethodsThis study was conducted between May 2016 and May 2018. We created a multidisciplinary structured PrU prevention education program based on the HBM, consisting of didactic lectures, open discussions and a practical session. The content of the program was based on several PrU prevention guidelines. The education program focused on a group of 6–10 participants, and was conducted by a multidisciplinary team; i.e. doctor, physiotherapist, occupational therapist and a nurse. The skin care belief scales (SCBS) questionnaire was administered pre, post and 8-week post intervention, which measured the 9 domains of HBM. The data from the study was analyzed using repeated measures ANOVA to assess the effectiveness of the program.ResultsThirty spinal cord injured participants who fulfilled the inclusion and exclusion criteria completed this study. The results of the education program show statistically significant effects on Susceptibility; F (2,58) = 12.53, P < 0.05, Barriers to Skin Check Belief; F(2,58) = 5.74, P > 0.05, Benefits to Wheelchair Pressure Relief Belief; F(1.65,47.8) = 3.97, P < 0.05, Barriers to Turning and Positioning Belief; F(2,58) = 3.92, P < 0.05 and Self-Efficacy; F(1.7,49.11) = 4.7, P < 0.05.ConclusionsA structured HBM based education program is shown to improve health beliefs level in five SCBS domains. This education program is recommended for PrU prevention within the spinal cord injured population.ImplicationsA multidisciplinary structured HBM based education program may improve the current method of PrU prevention education.     

Biomarkers for recurrent pressure injury risk in persons with spinal cord injury

Objective: To investigate potential linkages between pressure injury (PrI) recurrence following spinal cord injury (SCI) and muscle-based and circulatory biomarkers, specifically fatty metabolites and inflammatory cytokines.

Design: Observational study.

Setting: Tertiary Care Center.

Participants: 30 individuals with complete or incomplete SCI. Study participants either had never developed a PrI (Group I) or had a history of recurrent PrI (Group II).

Interventions: Not applicable.

Outcome Measures: Gluteal muscle histology, immunohistochemistry, muscle-based and circulatory fatty metabolites and inflammatory cytokines.

Results: Gluteal intramuscular adipose tissue (IMAT) was greater than 15% in most Group II (83%) individuals. Muscle tissue histology confirmed intramuscular structural differences. Fatty acid binding protein 4 (FABP4) and fatty acid binding protein 3 (FABP3) were reliably detected in muscle and blood and significantly correlated with IMAT (P?<?0.001). FABP4 was significantly higher in Group II muscle and blood (P?<?0.05). FABP3 was significantly higher in Group I muscle (P?<?0.05). Circulatory FABP3 levels were lower for Group I. Inflammatory biomarkers were more reliably detected in blood. Colony-Stimulating Factor-1 was slightly higher in Group II muscle. Circulatory interleukin-13 was significantly higher (P?<?0.01) in Group I. Vascular endothelial growth factor (VEGF-A) was significantly increased (P?<?0.05) in Group I muscle and blood.

Conclusion: Identifying individuals with SCI at highest risk for recurrent PrI may impact patient management. IMAT content evaluation illustrates that muscle quality is a key biomarker. Low circulatory inflammatory biomarker expression potentially limits clinical significance for between group differences. Circulatory levels of FABP4 hold great potential as a recurrent PrI risk biomarker.     

Validity and reliability of a pressure ulcer monitoring tool for persons with spinal cord impairment

Objective

The purpose was to provide support for validity and reliability of the spinal cord impairment pressure ulcer monitoring tool (SCI-PUMT) to assess pressure ulcer (PrU) healing.

Design

Expert panels developed a 30-item pool, including new items and items from two established PrU healing tools, to represent potential variables for monitoring PrU healing. Subjects were prospectively assessed weekly for each variable over a 12-week period.

Setting

Data collection was conducted on a cohort of inpatients and outpatients in one Spinal Cord Injury/Disorders Center in the Veterans’ Health Administration.

Subjects

A convenience sample of Veterans (n = 66) with spinal cord impairment (SCI) was recruited. Eligible subjects had at least one PrU (n = 167) and a history of SCI for longer than 1 year.

Interventions

Not applicable.

Outcome Measure

A change in PrU volume was calculated using VeV Measurement Documentation software and a digital imaging camera.

Results

Content validity was established for a pool of items designed to gauge PrU healing. Exploratory factor analysis (construct validity) identified a parsimonious set of seven items for inclusion in the SCI-PUMT to assess PrU healing. The SCI-PUMT was found to explain 59% of the variance of the volume across the study. Inter-rater reliability was 0.79 and intra-rater reliability ranged from 0.81 to 0.99 among research assistants. Similar levels of reliability were subsequently established among registered nurses, who used the SCI-PUMT in the clinical setting.

Conclusions

The final version of the SCI-PUMT was determined to be valid, reliable, and sensitive in detecting PrU healing over time in Veterans with SCI.     

The relationship of pressure ulcers, race, and socioeconomic conditions after spinal cord injury

Objective:

To identify risks factors associated with pressure ulcers (PrU) after spinal cord injury (SCI) by examining race and indicators of socioeconomic status (measured by income and education). We hypothesize African Americans will have a greater risk for PrUs than whites, but this relationship will be mediated by the 2 socioeconomic status indicators.

Design:

Cohort study.

Setting:

A large rehabilitation hospital in the southeastern US.

Participants:

1,466 white and African American adults at least 1-year post-traumatic SCI.

Outcome Measures:

(a) PrUs in the past year, (b) current PrU, (c) surgery to repair a PrU since injury.

Results:

In preliminary analyses, race was significantly associated with having a current PrU and with having surgery to repair a PrU since injury. In multivariable analyses, the relationships of PrU with having a current PrU and with having surgery to repair a PrU were both mediated by income and education such that the relationships were no longer significant. Lower income was associated with increased odds of each PrU outcome. After controlling for other variables in the model, education was associated with increased odds of having a current PrU.

Conclusion:

These findings help clarify the relationships between race and socioeconomic status with PrUs after SCI. Specifically, a lack of resources, both financial and educational, is associated with worse PrU outcomes. These results can be used by both providers and policy makers when considering prevention and intervention strategies for PrUs among people with SCI.     

大腿剔骨皮瓣修复脊髓损伤患者髋关节周围难治性压疮

目的:探讨修复脊髓损伤患者髋关节周围危及生命难治性压疮的方法和疗效。方法:2012年3月至2015年6月,采用高位股骨截骨或髋离断形成血供丰富的大腿剔骨肌皮瓣修复8例脊髓损伤患者髋关节周围危及生命的难治性压疮。其中男7例,女1例;年龄35~68岁,平均(52.0±2.6)岁。病程10个月~7年,平均(2.9±0.2)年。所有患者为包括2个部位以上的复杂压疮,除1例未引起髋关节感染外,其余7例压疮均合并同侧髋关节内感染。单个压疮表面面积最小3 cm×3 cm,最大12 cm×15 cm。术后观察感染控制,创面愈合,营养状况改善和生活质量提高情况。结果:8例患者均获得随访,随访时间3个月~2年,平均1.3年。所有患者皮瓣成活,其中5例创面Ⅰ期愈合,2例皮瓣愈合不良,经扩创缝合后Ⅱ期愈合。1例远段小块皮瓣坏死,经换药愈合。术中尿道损伤1例,经尿道修补痊愈。所有创面得到有效覆盖,局部感染控制,营养情况及生活质量较术前明显改善,随访期间,无创面感染及皮瓣覆盖部位压疮复发病例。结论:大腿剔骨肌皮瓣能有效修复脊髓损伤患者髋关节周围危及生命的难治性压疮创面。虽以失去整个下肢为代价,但在没有其他更好的办法时,它仍然是一种挽救生命的好方法。     

Surgery for pressure ulcers improves general health and quality of life in patients with spinal cord injury

Study Design:

Prospective clinical study.

Background:

Pressure ulcers interfere with the rehabilitation process in patients with spinal cord injury (SCI) and are a significant deterrent to participation in activities that contribute to independent, productive, and satisfying life.

Objective:

To evaluate the effect of surgery for pressure ulcers on general health and quality of life in patients with SCI.

Setting:

Tertiary care center in northern India.

Methods:

Various types of flap surgery were performed on 30 patients with SCI and 32 pressure ulcers (stages III and IV). Outcome was evaluated using general improvement in health (hemoglobin, serum proteins, and general well-being), patient satisfaction, and global quality of life scores (according to the visual analog scale).

Results:

At admission, the mean values of global quality of life, hemoglobin, serum albumin, and total serum proteins were 50.15 (range, 30–65), 8.75 g/dL (range, 6–12 g/dL), 3.12 g/dL (range, 2.9–4.3 g/dL), and 5.21 (range, 5–6.2 g/dL), respectively. At 6-month follow up, mean values of global quality of life score, hemoglobin, serum albumin, and total serum proteins were 87.36 (range, 44–96), 10.85 g/dL (range, 8.2–13.5 g/dL), 3.89 g/dL (range, 3.2–4.5 g/dL), and 6.43 g/dL (range, 5.85–6.70 g/dL), respectively. The overall rise in quality of life scores, hemoglobin, serum albumin, and total serum proteins was statistically significant. Most of the patients (76.7%) reported improvement in subjective well-being, and 83.3% were satisfied with the ultimate outcome of the surgery.

Conclusion:

Results suggest that surgery for stages III and IV pressure ulcers offers the greatest benefit to the patients in terms of improvement in general health (anemia, hypoproteinemia, and general well-being) and quality of life.     

Decreasing pressure injuries and acute care length of stay in patients with acute traumatic spinal cord injury

ObjectivesIdentifying factors associated with the occurrence of pressure injuries (PI) during acute care and with longer length of stay (LOS), focusing on modifiable factors that can be addressed and optimized by the acute rehabilitation team.DesignProspective cohort study.SettingA single Level-1 trauma center specialized in SCI care.ParticipantsA cohort of 301 patients with acute TSCI was studied.Outcome measuresThe primary outcome was the occurrence of PI during acute care stay. The secondary outcome was acute care LOS. Bivariate and multivariate logistic or linear regression analyses were performed to determine the association between non-modifiable factors and outcomes (PI of any stage and acute LOS), whereas bivariate and hierarchical multivariate logistic or linear regression analyses were used for modifiable factors.ResultsWhen controlling for the level and severity of the TSCI, the occurrence of pneumonia (OR = 2.1, CI = 1.1–4.1) was significantly associated with the occurrence of PI. When controlling for the level and severity of the TSCI, the occurrence of medical complications (PI, urinary tract infection and pneumonia) and lesser daily therapy resulted in significantly longer acute care LOS (P < .001).ConclusionsPrevention of PI occurrence and the optimization of the acute care LOS represent crucial challenges of the acute rehabilitation team, as they are significantly associated with higher functional outcomes. Patients who develop pneumonia may benefit from more aggressive prevention strategies to reduce PI occurrence. Systematic protocols for the prevention of complications as well as greater volume of therapy interventions should be considered to optimize the acute care LOS.     

Potentially modifiable risk factors among veterans with spinal cord injury hospitalized for severe pressure ulcers: a descriptive study

Context/objective

Pressure ulcers (PrUs) are a serious, costly and potentially life-long complication of spinal cord injury (SCI). Co-morbid conditions increase PrU risk, adding to the health behavior challenges faced by people with SCI. Little is known about medical co-morbidities, health beliefs, risk, protective behaviors, and readiness to improve skin care behaviors in people with SCI. This study describes the potentially modifiable medical and behavioral risk factors among veterans with SCI and severe (Stage III/IV) PrUs.

Design

Cross-sectional observational design.

Setting

6 VA SCI Centers.

Participants

Convenience sample from a larger intervention study of 148 veterans hospitalized for PrUs.

Interventions

Not applicable.

Outcome measures

Knowledge, PrU risk, skin protective behaviors, health beliefs, and practices, health locus of control, skin worsening.

Results

Most ulcers were stage IV (73%) and about half had 2+ PrUs. Participants reported a mean of 6.7 co-morbid conditions (respiratory, gastrointestinal, renal disease/urinary tract infection, autonomic dysreflexia, diabetes, bowel/bladder incontinence). Potential intervention opportunities include proactive assistance with management of multiple chronic conditions, substance abuse, nutrition, adherence to skin protective behaviors, readiness to change, and access to resources. Overall knowledge about PrUs was low, especially for how to prevent PrUs and what to do if skin breakdown occurs.

Conclusion

Future research should address whether comprehensive models that include patient self-management, decision support and health care system, and proactive behavior change assistance for patients help reduce PrU incidence and recurrence in persons with SCI.

Trial Registration

http://clinicaltrials.gov/ct2/show/{"type":"clinical-trial","attrs":{"text":"NCT00105859","term_id":"NCT00105859"}}NCT00105859     

Team size in spinal cord injury inpatient rehabilitation and patient participation in therapy sessions: The SCIRehab Project

Context/objective

Rehabilitation teams generally are described as consisting of a single representative of 6–8 disciplines, but research suggests that the number of individuals involved may be much larger. This study aimed to determine the size of teams in spinal cord injury (SCI) rehabilitation, and the effect of team size on patients'' active participation in their treatment sessions.

Design

Prospective observational study.

Setting

Six SCI rehabilitation centers.

Participants

A total of 1376 patients with traumatic SCI admitted for first rehabilitation.

Interventions

Not applicable.

Outcome measures

Number of treatment sessions, by discipline and overall clinician rating of active participation of the patient; Treatment Concentration Index (TCI) calculated as Σp_k² (where p refers to the proportion of treatment sessions delivered by team member k).

Results

The average patient was treated by 39.3 different clinicians. The numbers were especially high for physical therapy (mean: 8.8), occupational therapy (7.2), and nursing (16.1). TCI was 0.08 overall; it varied by discipline. TCI was negatively correlated with length of stay, except for psychology. Participation ratings were minimally affected by the number of sessions the patient and the therapist had worked together.

Conclusions

In SCI rehabilitation, teams are at least as large as suggested by previous research. However, this may not mean lack of familiarity of patient and therapist with one another, or alternatively, the possibly weak therapeutic alliance does not affect the patients'' active participation in their sessions. Further research is needed to determine whether there are negative effects on rehabilitation outcomes.     

Factors associated with upper extremity contractures after cervical spinal cord injury: A pilot study

Objective: To examine the prevalence of joint contractures in the upper limb and association with voluntary strength, innervation status, functional status, and demographics in a convenience sample of individuals with cervical spinal cord injury to inform future prospective studies.

Design: Cross-sectional convenience sampled pilot study.

Setting: Department of Veterans Affairs Research Laboratory.

Participants: Thirty-eight participants with cervical level spinal cord injury.

Interventions: Not applicable.

Main Outcome Measures: Contractures were measured with goniometric passive range of motion. Every joint in the upper extremity was evaluated bilaterally. Muscle strength was measured with manual muscle testing. Innervation status was determined clinically with surface electrical stimulation. Functional independence was measured with the Spinal Cord Independence Measure III (SCIM-III).

Results: Every participant tested had multiple joints with contractures and, on average, participants were unable to achieve the normative values of passive movement in 52% of the joints tested. Contractures were most common in the shoulder and hand. There was a weak negative relationship between percentage of contractures and time post-injury and a moderate positive relationship between percentage of contractures and age. There was a strong negative correlation between SCIM-III score and percentage of contractures.

Conclusions: Joint contractures were noted in over half of the joints tested. These joint contractures were associated with decreased functional ability as measured by the SCIM-III. This highlights the need the need for detailed evaluation of the arm and hand early after injury as well as continued monitoring of joint characteristics throughout the life course of the individual with tetraplegia.     

Effect of platelet rich plasma gel in a physiologically relevant platelet concentration on wounds in persons with spinal cord injury

The objective of the study was to investigate the use of a 1·3 times normal platelet concentration platelet-rich plasma (PRP) gel to move chronic wounds towards healing in persons with spinal cord injury (SCI). The study design was a case series of 20 persons with SCI with non healing wounds. The outcome measures were, in wound area, volume, undermining and sinus tracts/tunnels (ST/Ts), calculated average, (i) percent of change from baseline, (ii) change per day from baseline, (iii) number of treatments and (iv) number of weeks. In a mean of 4·0, after treatments over 3·4 weeks, the wounds closed on an average of 47·9% in area and 56·0% in volume. Undermining closed on an average of 31·4% using 3·5 treatments over 2·6 weeks. ST/Ts closed on an average of 26·1% after 2·3 treatments over 1·5 weeks. Clinical relevance by percent of positive responders and their response: in area, 90·0% of the subjects responded positively, the average reduction was 53·8%. In volume, 90·0% responded, with an average reduction of 67·3%. Of four subjects with undermining, 75% closed 47·0% on average. Of the three with ST/Ts, 100% closed 26·1% on average. Average haemoglobin and haematocrit levels were below normal. To conclude, 1·3× PRP gel appears to progress chronic, non healing wounds in SCI patients into the granulation phase of healing quickly. Review of the literature shows these results may not be applied to all PRP preparations.     

Physical activity promotion to persons with spinal cord injury by health and exercise professionals: A scoping review

Objectives:Health and exercise professionals (HEPs) are ideal promoters and valued messengers of physical activity (PA) information among persons with spinal cord injury (SCI). However, little is known about what strategies used by HEPs increase PA behavior in persons with SCI, or what factors influence HEPs when promoting PA to persons with SCI. The purposes of this scoping review were to (1) ascertain the extent, range and nature of the literature, (2) identify strategies used by HEPs that are associated with an increase in PA behavior for persons with SCI, and (3) identify the facilitators and barriers to PA promotion by the HEPs.Methods:A comprehensive search was undertaken. Search terms were expanded surrounding three key terms: PA, promotion, and SCI.Results:Twenty-four articles representing 18 unique studies were identified. HEPs predominantly consisted of physiotherapists, occupational therapists, and leisure trainers/therapists. Most interventions were delivered by HEPs to persons with SCI in in-patient rehabilitation centres and community-based settings. Tailored exercise programs and on-going counseling support were considered essential for increasing PA behavior. HEPs’ common barriers to PA promotion were perceived lack of time, education, and training.Conclusion:A need to improve and sustain SCI-specific PA knowledge and education was identified if PA promotion is to become a structured and integral component of practice. This study provides valuable information for interventions to increase PA behavior among persons with SCI by improving PA promotion by HEPs.     

The association of age,pain, and fatigue with physical functioning and depressive symptoms in persons with spinal cord injury

Context/objective

To describe the relationship of pain and fatigue with physical and psychological functioning in adults with spinal cord injury (SCI).

Design

Cross-sectional survey.

Setting

Community-based survey.

Participants

Convenience sample of individuals with SCI.

Intervention

Not applicable.

Outcome measures

Physical functioning (Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Functioning item bank items), depression (Patient Health Questionnaire-9 (PHQ-9)), pain severity (0–10 Numerical Rating Scale (NRS)), and fatigue (0–10 NRS).

Results

Pain and fatigue were independently associated with depression, but only pain was associated with physical functioning. Additionally, depression was more severe among middle-aged participants relative to younger or older participants. Physical functioning declined with increasing age, as well as with higher level of injury.

Conclusions

The findings support the need for continued development of effective treatments for both pain and fatigue in order to prevent and mitigate the negative effects these symptoms can have on functioning.