Maintaining healthy skin after a spinal cord injury (SCI)

A list of generic intrinsic factors that can affect skin integrity and should be assessed as risk factors for skin breakdown.

• Increased risk with increased 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 
• Psychosocial issues can affect the ability to manage self-care
• Smoking: affects oxygenation to the tissue
• Nutrition: malnutrition increases the risk of breakdown
• Pre-existing co-morbidities such as diabetes and sleep apnoea affecting oxygenation and tissue health

Neurological level of injury

Autonomic system

A SCI above T6 can cause impairment of the autonomic system. Impairment to the autonomic system can cause:

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

Respiratory system

Impairment of respiratory muscles can occur, secondary to injuries above L1 with higher level cervical levels having the greatest impairment of respiratory function. This can impair oxygenation to the skin and muscles.

Spasticity

SCI at and above T12 has reflex arcs intact, and this can cause spasticity and tone. Spasticity can increase shear and friction to the skin and underlying tissue.

Muscle atrophy

• After 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 wasting because of flaccid paralysis. This results in a loss of tone or secondary spasticity that results in 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 for more information.

Depending on their physical and cognitive function, the person with SCI should be provided education and taught 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 with good technique
• manage their continence and equipment maintenance
• problem-solve issues as they arise or know where to seek help

Musculoskeletal changes

Motor impairment causes the following:

• impaired ability to change positions to relieve pressure
• impaired ability to correct posture and evenly distribute weight in sitting
• impaired muscle pump that reduces tissue circulation and increases the risk of oedema

Sensory impairment causes the following:

• impaired ability to recognise when to offload tissue and when tissue damage has occurred
• impaired proprioception
• impaired ability to distinguish between hot and cold temperatures, increasing the risk of burns

Development of heterotopic ossification can:

• limit joint range
• impact seated posture
• be 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 less strength, impaired circulation and flexibility than healthy tissue. These factors increase the risk of recurrent breakdown.

Continence

Incontinence can cause moisture to the skin and change skin pH. This makes it more vulnerable to breakdown. People with SCI should maintain continence and have a management plan to prevent 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.

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 occlude 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. 

A person who has a new SCI

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

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 cushions, wheelchairs, mattresses, beds, slings, showering and hygiene aids as well as medical devices such as collars, binders, compression stockings or orthoses.

Personal care

Educate person’s supports on performing skin checks, understanding changes and seeking advice and/or assistance to manage.

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 the high heat and humidity in Queensland. In addition, being seated with no to minimal airflow to the skin, 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 impact on 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 and lead to use of equipment not suitable for their needs.