People with spinal cord injury living life in a wheelchair are at greater risk of skin damage like pressure sore areas due to loss of feeling and reduced sensation to parts of their body. Combined with loss of muscle function, poor circulation and often poor nutrition people with spinal cord injury often develop pressure sores. Left unattended these can quickly become life threatening.
While both vulnerable, people with quadriplegia and tetraplegia are more susceptible than those with paraplegia due to the reduced capacity and strength in upper limbs to reposition or shift their body weight in a wheelchair or bed. It’s important to check skin on a daily basis in order to reduce the risk of developing problems such as pressure sores.
CLEANING AND CREAMS
Clean skin daily, dry thoroughly and avoid leaving soap residue behind as it will over dry your skin. Soaps labeled antibacterial tend to strip your skin of it’s natural acidity therein ability to fight minor infections. Avoid using to many products, talcum powders are fine if removed and reapplied daily else they may “cake up” trapping moisture in causing skin breakdown. Pay particular attention to areas where skin meets eg groin, under breasts, underarms.
Moisturizing lotions and creams keep skin supple though take care in areas where the bone is close to skin surface such as shoulders, hips, tailbone. I generally only put creams on such areas of a night as sitting on moist skin is not a good idea. Moist skin breaks down rapidly as will very dry skin. Remove any incidence of contaminants such as urine or faeces as soon as possible, these burn increasing the potential for damage. Take care cutting finger and toe nails, they are usually easier to trim when softened after soaking or shower. Don’t cut too short, I once had a carer snip the skin off the tip of my finger along with the nail. I like filing a whole lot more now.
PRESSURE SORES CAN KILL
Superman, Christopher Reeve died as a result of septicemia, blood poisoning due to a badly infected decubitus ulcer (pressure sore). I myself spent 18 months in bed with a pressure sore. Tried seaweed dressings, hydrogels, alginates, colloidial silver, pawpaw cream, emu oil, manuka honey, you name it. A store bought aloe vera gel proved most effective for me. I spent so long in bed with this damn pressure area I became very frustrated and started to rip on the one person who wanted me out of bed most, my Mum.
THE KEY TO HEALING PRESSURE AREAS
The number one best way to heal a pressure area is to stop putting pressure on it. Get off it and stay off it. When you have a burn on your hand you don’t stick it under the hot water tap again do you? Eight hours sitting on a pressure area equals eight days in bed just to get back to where you were. Once completely healed stay off the pressure area for at least another week. Then it’s vital to gradually build up your “sitting time” again. An hour a day is hard to stick to but you must if you want to get out of that bed in the long term. After a week of 1hr/day stick to 2 hours uptime/day, the following week 4hrs, 8hrs and so forth.
WHAT TO LOOK FOR
- Reddened areas
- Damp soft white areas
- Rashes, pimples, blisters, bumps
- Cuts, bruises, scrapes, scratches, insect bites
- Hard lumps beneath the skin surface
- Marks from seams or elastic binding
- Dry flaky skin
Often you won’t see a pressure area until it’s too late. They can develop beneath the skin as a small pea sized cyst. If you are lucky enough to feel or notice one early do all you can to stay off it. The unlucky have seemingly fine skin one day and a weeping open sore requiring treatment and weeks of bed rest the next. Worse even they can track. Tracking happens when the cyst is unable to break through to the skin surface usually because of the constant pressure. It is forced to track a tunnel through to a skin surface where it can break through, when they do it’s bad news.
One case I’ll never forget was a room mate in hospital. Terry a paraplegic liked to drink and party spending weeks at a time 24/7 in his manual wheelchair. A cyst originating from his ischium tuberosity (bum bone) tracked and broke through on top of his thigh. They lanced the origin site and pushed sterile solutions through daily to flush out the decay. They would remove us from the room as the smell was so nauseating, I can still smell it 14 years later. Don’t let this happen guys, be vigilant and train your carers to look for these things.
PRESSURE AREA PREVENTION
Daily skin inspections as above are key along with common sense and proper use of equipment. Ordinarily we unconsciously move when uncomfortable. Without such movement blood supply is lost to the skin tissue, it begins to breakdown and die. People with spinal cord injury usually don’t have the ability to unconsciously or voluntarily move some limbs or even their entire body. Forced to sit or lay in one position for long periods cutting blood supply to the skin under pressure. Changing position will allow blood flow to return and maintain healthy cells. Doing any one or all of the below pressure changes in your wheelchair for 30-60 seconds several times daily is beneficial.
- Pressure lifts, pushing down on armrests to lift bottom off seat
- Leaning side to side or backwards periodically
- Bending forward over your knees
- Reclining the seat of your electric wheelchair
- Having someone tilt you back in your manual wheelchair
- Triggering spasm
Always use your wheelchair cushion, if the cover is in the wash don’t use a towel, sheepskin or anything as it takes away from the seats pressure relieving properties. Sitting on your cushion without a cover is best. In bed, body parts can be padded with pillows, sheepskin etc. to keep bony prominences free of pressure. Get into the habit of checking your body position for correct alignment and pressure-free positioning.
CORRECT POSITIONING EQUIPMENT
Use good quality equipment and ensure it fits you properly. Incorrect and poorly fitting pressure relieving equipment will obviously lead to pressure sores. An Physiotherapist or Occupational Therapist can recommend and organize the most suitable types of equipment for you. Many medical companies will allow you to trial their equipment.
CHOOSING A WHEELCHAIR
Does it support your back? Are your armrests and footrests the right height? I know quite a few people who have developed pressure blisters on their heels as a result of their foot plates being to high. Ask if it is possible to have electric tilt fitted. I’m in a Quantum Vibe at the moment, I can tilt the whole wheelchair back to 55 degrees providing good pressure relief.
JAY AND ROHO WHEELCHAIR CUSHIONS
There are two main types, air and gel. I tried an air filled Roho cushion and found the Jay2 gel cushion gives me greater stability and balance. I can sit up for 16 hours no problem. Only ever use the cover that comes with your cushion or none. Knead the gel every morning prior to sitting on it, or check the air pressure regularly. Your cushion should be replaced approx every three years before it starts to lose it’s pressure relieving ability. Many paraplegics don’t require a $900 cushion and use eggshell foam and/or a sheepskin.
PRESSURE RELIEVING MATTRESS
Are you using a pressure relieving mattress? There are many types from laytex to electric powered air mattresses. Again I’ve seen many develop heel blisters because their feet press hard against the bed end. You may be able to use an over bed triangle and you can get a material ladder like aid you hook your wrists into rung by rung and pull yourself up or help roll over. I use an Alpha Care air mattress on a laytex base electric powered bed. I can lay in one position for 16 hours no problem.
SUITABLE CATHETERS AND CLOTHING
Is the correct size catheter being used? Is it being changed frequently enough? Leg bag straps should be firm not over tight. Some run the tubing down their pants leg, as a quadriplegic I prefer it to come out the top of my pants in case I need to mess with it. Just avoid tight waistlines, pressing the tubing hard against your skin anywhere can cause blisters. Avoid seams by taking rear pockets off jeans. Be aware metal studs, zippers, buckles etc. get hot in the sun and can burn you.
SPLINTS AND BRACES
Do they fit properly? Do you do skin checks after wearing them? There is a huge range of thermoplastics and other materials for making all kinds of splints these days. If you wear splints check any bony points eg wrists ankles daily as part of your skin care routine.
Avoid Sunburn. Don’t put plates of hot food on your lap without protection. In a car, keep feet away from the heater outlet. Place protection between feet and car floor if not wearing shoes. Check vinyl seats before sitting to make sure they aren’t too hot. Cover exposed pipes in your kitchen and bathroom sink to protect your legs from burns. Sit a safe distance from heat sources such as heaters, campfires, bbqs, fireplaces. Sweaty damp skin will break down fast, dry any sweaty or wet skin under pressure. Avoid heating pads like electric blankets.
In areas where there is extreme cold dress warmly to prevent frostbite. Dressing in layers of clothing will provide extra warmth and can be removed if need to prevent overheating. Don’t put frozen foods in your lap without protection.
Your skin tolerances can change due to the increased body temperature that occurs with a fever. You may find that you cannot lie in one position as long. Fever is often accompanied by sweats, dry damp bony areas frequently.
The amount of weight a person carries not only affects the ability to do activities and health but can affect skin care. Too much – Being overweight can cause increased pressure on bony areas. Delayed healing may occur because there are fewer blood vessels in fat tissue. Too little weight can also cause problems. Excess pressure over bony areas may occur because there is less padding (muscle and fat) over these surfaces. In addition, underweight persons may lack the proper nutrition to maintain healthy skin.
SPASM AND SPASTICITY
Spasticity may cause your arms and/or legs to bump against an object, or to fall off your armrest or footrest, and be injured. Spasm are often repetitive and may also cause your skin to rub against something (for example; tight bed sheets), which can produce an open pressure area. Do all you can to prevent pressure areas in the first place as scar tissue becomes more prone to future break downs and pressure areas will continually re-occur. Did you know skin is the body’s largest organ? Take good care of it.
Angi Cappelli – Occupational Therapist
Graham Streets – MSC Founder