Maintaining healthy skin after a spinal cord injury (SCI)

Why is skin care important after a spinal cord injury (SCI)?

Skin breakdown is one of the most common secondary complications associated with an SCI. Most episodes of skin breakdown are preventable, although unexpected skin injuries can occur. If a pressure injury does develop, it is important to implement management techniques early, to promote healing and prevent further deterioration of the wound.

If left untreated or poorly managed, a pressure injury can have catastrophic effects on a person’s quality of life, potentially resulting in a lengthy hospital stay and further disability, such as reduced mobility, deconditioning, decreased dependence, surgery and infection or sepsis – potentially resulting in death.

Why does having an SCI increase the risk of a pressure injury?

An SCI can increase risk through intrinsic and extrinsic risk factors. Read both sections on intrinsic and extrinsic risks to understand underlying causes and risks for skin breakdown in SCIs.

Intrinsic risk factors

Generic intrinsic factors

The following generic intrinsic factors can affect skin integrity and should be assessed as risk factors for skin breakdown:

  • Increased age. Skin becomes thinner and more fragile with age.
  • Body weight. Being underweight or overweight can place the skin at risk.
  • Skin colour. Darker, pigmented skin can make it more difficult to observe early changes to the skin.
  • Mental health. Psychosocial issues can affect the ability to manage self-care.
  • Smoking. Smoking affects oxygenation to the tissue, which can delay wound healing.
  • Nutrition. Malnutrition increases the risk of skin breakdown.
  • Pre-existing co-morbidities. Pre-existing conditions, such as diabetes and sleep apnoea, can affect oxygenation and tissue health.

Spinal specific intrinsic risk factors

Neurological level of injury

Spinal-specific intrinsic risk factors can vary depending on the point of injury along the spine.

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

Spinal cord injuries above L1 present a higher risk of impairment to respiratory muscles. In particular, injuries in the higher-level cervical levels present the greatest risk of damage to the respiratory function, which can impact oxygenation to the skin and muscles.

Spasticity

Spinal cord injuries 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

  • After an SCI, there can be significant muscle loss below the level of injury, secondary to loss of innervation. Predominantly, this occurs in the first twelve weeks following a new SCI. There are ongoing changes to muscle bulk 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.

Function and independence

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.

Musculoskeletal changes

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.

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

Previous damage to the skin

Scar tissue has less strength, impaired circulation and flexibility than healthy tissue. These factors increase the risk of recurrent breakdown.

Continence

Incontinence can increase moisture exposure to the skin and change 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 (fluid retention) 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.

Extrinsic factors

Generic extrinsic risk factors

Pressure, shear, friction and skin microclimate are generic extrinsic contributing factors that can lead to skin breakdown.

Pressure is direct downward pressure applied to the tissue over an underlying, bony prominence, that can obstruct circulation to the tissue. High pressures, reduced tissue bulk and prolonged pressure, increase the risk of developing pressure injuries.

Shear occurs when forces moving in opposite directions are applied to the underlying tissue. An example of this is a person sliding down a bed where the tissue is ‘pulled up’ as the person slides down the bed, causing compression of the blood vessels.

Friction is the superficial rubbing of the skin against a surface such as a heel rubbing on the sheets.

Skin microclimate is the term used to describe the interaction between skin temperature and moisture, at the skin surface. 

Spinal specific extrinsic risk factors

Skin care considerations for new SCI

People who are newly injured may be exposed to a variety of environmental factors that can place their skin at risk.

The health professional needs to be hypervigilant, as the person with an SCI will be entirely dependent on others for their skin care.

Extrinsic factors that a newly injured person may be exposed to can include:

  • Firm surfaces, including the scene of injury, transport trolleys and radiology departments.
  • Debris from the time of injury, such as glass, sand, twigs and leaves in the hair or on the skin.
  • Items or clothing on the person at the time of injury.
  • Exposure to the environment, such as being outside on a hot day in the sun or a cold night on the ground.
  • Medical devices such as collars, electrodes, intravenous cannulas, oxygen therapy and urinary catheters.

Equipment

People with SCI can use a multitude of equipment and assistive technology in their daily lives. These may include cushionswheelchairsmattressesbeds, slings, showering and hygiene aids as well as medical devices such as collars, binders, compression stockings or orthoses.

Personal care

It is important to educate the person’s supports on performing skin checks, understanding changes and seeking advice and/or assistance to manage skin care.

Moisture and Microclimate

Impaired thermoregulation, sensory impairment and being wheelchair-dependent can lead to difficulties managing moisture and microclimate. This can be a particular issue in Queensland’s climate of high temperatures and humidity. In addition, the combination of being seated with no to minimal airflow to the skin, prolonged contact with synthetic fabrics and incontinence can increase moisture and skin temperature. 

Lifestyle

People with SCI engage in a wide variety of work, travel, leisure and cultural activities. These can influence what additional equipment is used, such as a sports chair, time spent sitting, postural changes and other surfaces a person may sit on – for example, car seats or the ground.

Funding

Some people have limited funding, which can limit the ability to maintain and service equipment.

Person’s location

Regional and remote areas may have issues with service providers maintaining equipment, as well as access to trial and hire of equipment. This can also limit the choice of equipment, resulting in the use of equipment that is not suited to their needs.

References

Pressure injury prevention, Clinical Excellence Queensland.

Pressure Injury, best practice for clinicians and management by Australian Commission on Safety and Quality on Hospital-acquired complication.

Skin Integrity and Pressure Injuries Following Spinal Cord Injury
Hsieh J, Benton B, Titus L, Gabison S, McIntyre A, Wolfe D, Teasell R. (2022). Pressure Ulcers Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 7.0. 1-90.