Risk factors

Spinal-specific intrinsic risk factors can vary depending on the level of SCI.

Autonomic system

An SCI above T6 can affect the autonomic system. Impairment to the autonomic system can cause:

• Circulatory changes secondary to vasodilation, pooling of blood and impaired heart contractility.
• Loss of thermoregulatory control, which can lead to temperature and sweating dysfunction, causing increased skin temperatures.

Respiratory system

Upper thoracic and cervical SCI’s present a higher risk of impairment to respiratory muscles. Impaired respiratory function can impact oxygenation to the skin and muscles which can increase risk to skin integrity and impair skin repair.

Spasticity

SCI’s at and above T12 have reflex arcs intact, which can cause spasticity and tone. Spasticity can increase friction to the skin and underlying tissue.

Muscle atrophy

• Significant muscle loss can occur below the level of SCI, secondary to loss of innervation. Predominantly, this occurs in the first twelve weeks following a new SCI. Ongoing changes to muscle bulk can occur across the person’s lifespan in muscles that are denervated.
• Areflexic injuries at or below L1 are at greater risk of significant muscle wasting because of flaccid paralysis. This results in a loss of tone or secondary spasticity followed by muscle atrophy, which can lead to an increased risk of developing pressure injuries.
• Muscle atrophy can be caused by lowered testosterone levels, which can occur with chronic SCI.

A person’s level of function and independence can impact their transfer abilities, seated posture, bed mobility or equipment needs. These outcomes influence additional extrinsic risk factors for the person. See Extrinsic factors (below) for more information.

Depending on their physical and cognitive function, the person with SCI should be given the necessary education and skills to assess, and manage, their own skin care.

Considerations include their ability to:

• Perform skin checks and/or engage their support team to assist with this task.
• Reposition and transfer themselves, with good technique.
• Manage their continence and equipment maintenance.
• Problem-solve issues as they arise or seek help if/when necessary.

Motor impairment can compromise the person’s:

• Ability to change positions to relieve pressure.
• Ability to correct posture and evenly distribute weight in sitting.
• Muscle pump, reducing tissue circulation and increasing the risk of oedema.

Sensory impairment can compromise the person’s:

• Ability to recognise when to offload tissue and when tissue damage has occurred.
• Proprioception, causing potential problems with balance and coordination.
• Ability to distinguish between hot and cold temperatures, increasing the risk of burns.

Development of heterotopic ossification can:

• Limit joint range.
• Impact seated posture.
• Become a focal point of increased pressure.

Contractures or reduced range of motion can impact:

• Positioning.
• Ability to offload pressure points.

Previous damage to the skin

Scar tissue has reduced tensile strength, vascularity, and flexibility compared to healthy tissue, increasing the risk of recurrent skin breakdown.

Continence

Incontinence can increase moisture exposure to the skin and change the skin’s pH, making it more vulnerable to breakdown. People with SCI should maintain continence and have a management plan to prevent potential issues.

Oedema

Oedema is a significant risk for people with mobility impairment.

Metabolic syndrome

There is an increased incidence of metabolic syndrome in people with SCI. This is related to inflammatory changes and can increase the risk of weight gain, cardiovascular changes and the development of diabetes.

Comorbid injuries

Other injuries such as fractures can affect the ability to maintain skin integrity.

People may be exposed to a variety of environmental factors at the time of their SCI and the acute phase of care that can place their skin at risk. These include:

• Firm surfaces – such as at the scene of injury, on transport trolleys, or during radiological imaging.
• Debris – including glass, sand, twigs, or leaves, which may be present in the hair or on the skin.
• Clothing and personal items – that may cause pressure or friction.
• Weather conditions – such as prolonged exposure to heat, direct sunlight, or cold surfaces (e.g., lying on the ground overnight).
• Medical devices – including cervical collars, electrodes, intravenous cannulas, oxygen masks or tubing, and urinary catheters, which can cause pressure or skin injury if not monitored closely.

Equipment

People with SCI typically use a range of equipment and assistive technologies to support daily living and functional independence. These may include pressure-relieving cushions, wheelchairs, mattresses, adjustable beds, slings, showering and hygiene aids, as well as medical devices such as cervical collars, abdominal binders, compression garments, and other orthoses. Equipment should be properly fitted, regularly maintained, and selected with pressure care needs in mind to minimise the risk of skin breakdown

Personal care

Education for the person with SCI and their support network is essential to promote proactive skin management. Education should include performing skin checks, recognising early skin changes and seeking advice or assistance to manage skin care.

Moisture and Microclimate

Thermoregulatory dysfunction, sensory impairment, and wheelchair dependence can contribute to challenges in managing moisture and maintaining an optimal skin microclimate. These issues are particularly relevant in Queensland’s hot and humid climate. Prolonged sitting with limited airflow, contact with synthetic fabrics, and incontinence can elevate skin moisture and temperature, increasing the risk of pressure injuries and skin breakdown.

Lifestyle

Work, travel, recreational, and cultural activities can influence equipment choices for people with an SCI. These factors may affect the type of equipment used (e.g. sports wheelchairs), as well as sitting duration, postural changes, and the range of surfaces encountered (e.g., car seats or ground-level seating).

Funding

Access to appropriate funding impacts the ability to obtain, maintain, and service necessary equipment. Limited funding may delay equipment replacement or repairs, increasing the risk of secondary complications.

Geographic location

Living in regional or remote areas may limit access to equipment trials, hire services, and ongoing maintenance. This can restrict equipment options and may result in the use of devices that are suboptimal or not suited to the individual’s clinical or functional needs.