Risk factors
A spinal cord injury (SCI) can increase risk to skin integrity through intrinsic and extrinsic risk factors.
Intrinsic risk factors
The following factors can affect skin integrity and should be assessed as risk factors for skin breakdown:
- Age: skin becomes thinner, less elastic and more fragile with advancing 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 skin changes.
- Mental health. Psychosocial factors can affect the ability to adequately attend to self-care.
- Smoking. Smoking impairs tissue oxygenation, which can delay wound healing.
- Nutrition. Malnutrition impairs skin integrity, repair and maintenance.
- Pre-existing co-morbidities. Conditions, such as diabetes and sleep apnoea, can affect oxygenation and tissue health.
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.
Extrinsic risk factors
Pressure, shear, friction and skin microclimate are generic extrinsic contributing factors that can lead to skin breakdown.
Pressure is direct downward force 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.
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.
Pressure injury prevention Clinical Excellence Queensland (2021).
Pressure Injury Australian Commission on Safety and Quality on Hospital-acquired complication (2018).
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.