Assistive technologies for self-managed pressure ulcer prevention in spinal cord injury: a scoping review

Development and Use of Assistive Technologies in Spinal Cord Injury: A Narrative Review of Reviews on the Evolution, Opportunities, and Bottlenecks of Their Integration in the Health Domain

Assistive technologies are increasingly taking a leading role in supporting people with spinal cord injury (SCI). This narrative review of reviews intends to contribute by making a map point investigating the integration of ATs in SCI. The methodology of the review was based on: (I) a search of PubMed and Scopus and (II) an eligibility assessment using specific parameters. The outcome highlighted the following: -The evolution of ATs considered in the context of SCI, considering ATs as both products and/or services in standalone and/or networked devices, and as processes of delivery. -Innovative technologies could play an important role in improving the quality of life and in minimizing costs in healthcare. -The international scientific community has identified ATs as one of the six strategic development areas in SCI. The overview also allowed the detection of some problems: (I) The ethical and regulatory aspects have been addressed in a weak way and only in specific and limited cases. (II) There is a lack of studies on the use and applications of ATs in SCI with a focus in multiple domains (e.g., costs, acceptance, dissemination, problems, regulatory aspects, ethical aspects, and other issues important for integration into the health domain). This review highlights the need for further studies and activities focused on integrating consensus in multiple domains, including ethics and regulations, to aid researchers and decision-makers in the field.

Predictors of hospital-acquired pressure injuries in patients with complete spinal cord injury: a retrospective case-control study

BACKGROUND

Despite current best practices, pressure injuries (PI) remain a devastating and prevalent hospital-acquired complication for patients with acute traumatic spinal cord injuries (SCIs). This study examined associations between risk factors for PI development in patients with complete SCI, such as norepinephrine dose and duration, and other demographic factors or lesion characteristics.

METHODS

This case-control study included adults with acute complete SCIs ASIA-A, who were admitted to a level-one trauma center between 2014-18. A retrospective review was implement using data on patient and injury characteristics, including age, gender, level of SCI (cervical vs. thoracic), Injury Severity Score (ISS), length of stay (LOS) and mortality; presence/absence of PI during their acute hospital stay; and treatment factors such as spinal surgery, mean arterial pressure (MAP) targets, and vasopressor treatment. Multivariable logistic regression evaluated associations with PI.

RESULTS

Eighty-two out of 103 eligible patients had complete data, and 30 (37%) developed PIs. Patient and injury characteristics, including age (Mean: 50.6; SD:21.3), location of SCI (48 cervical, 59%) and ISS (Mean 33.1; SD:11.8), did not differ between PI and non-PI groups. Logistic regression analysis revealed that male gender (OR:34.1; CI₉₅:2.3-506.5, p = 0.010) and increased LOS (log-transformed; OR:20.5, CI₉₅:2.8-149.9, p = 0.003) were associated with increased risk of PI. Having an order for a MAP > 80mmg (OR:0.05; CI₉₅:0.01-0.30, p = 0.001) was associated with a reduced risk of PI. There were no significant associations between PI and duration of norepinephrine treatment.

CONCLUSIONS

Norepinephrine treatment parameters were not associated with development of PI, suggesting that MAP targets should be a focus for future investigations for SCI management. Increasing LOS should highlight the need for high-risk PI prevention and vigilance.

Staying Pressure Injury Free: The Role of Modifiable Behaviors

OBJECTIVE

To investigate the association of behavioral factors with retrospective reports of staying free from pressure injuries (PIs) during a 12-month period for people with chronic spinal cord injury (SCI).

DESIGN

Cross-sectional survey.

SETTING

Data collection was completed at an academic medical center in the Southeastern United States in collaboration with a specialized treatment center and 2 public health registries that use population-based approaches to identify all incident cases of SCI within the state.

PARTICIPANTS

The participant cohort was composed of 3817 adults (N=3817) with traumatic SCI of at least 1-year duration.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Self-reported recall of staying PI-free for 12 months vs having 1 or more PIs.

RESULTS

Among the 3817 participants, 74% were male, 76% were non-Hispanic White, and mean age was 48 years, with an average of 12 years post SCI. Based on self-report assessment, 67% reported being PI-free in the past year. After controlling for the demographic and injury characteristics, we found that those in the clinical cohort and those who reported healthy diets and planned exercise at least once a week were more likely to be PI-free; being underweight and high frequency of prescription medication use for spasticity, pain, and depression were negatively associated with being PI-free. Smoking, alcohol use, nonmedical substance use, and prescription medication misuse were not statistically significant in the multivariate model.

CONCLUSIONS

There are several significant behavioral predictors of being PI-free, and consideration of these factors may be used to develop tailored strategies to promote healthy skin maintenance and the prevention of multiple, severe, and recurrent PI.

Pressure Injuries and Management after Spinal Cord Injury

Spinal cord injury (SCI) results in motor paralysis and sensory loss that places individuals at particularly high risk of pressure injuries. Multiple comorbidities associated with autonomic, cardiovascular, pulmonary, endocrine, gastrointestinal, genitourinary, neurological, and musculoskeletal dysfunction makes it even more likely that pressure injuries will occur. This manuscript will review the structure and function of the integumentary system, and address the multidisciplinary approach required to prevent and manage pressure injuries in this vulnerable population.

Current Approaches in Telehealth and Telerehabilitation for Spinal Cord Injury (TeleSCI)

Purpose of Review

Telehealth and telerehabilitation in spinal cord injury (teleSCI) is a growing field that can improve access to care and improve health outcomes in the spinal cord injury population. This review provides an overview of the recent literature on the topic of teleSCI and provides insights on current evidence, future directions, and considerations when using teleSCI for clinical care.

Recent Findings

TeleSCI is used most often for preventive health; management of chronic pain, anxiety, and depression; and rehabilitation-related interventions. As video telehealth becomes mainstream, growth in wearable monitors, bio and neurofeedback mechanisms, and app-based care is expected.

Summary

TeleSCI is growing in prevalence, demonstrates positive impact on health outcomes, and requires ongoing study to identify, refine, and implement best practices.

The content and effectiveness of self-management support interventions for people at risk of pressure ulcers: A systematic review

BACKGROUND

Pressure ulcers are a common complication with a high impact on well-being and quality of life in people with impaired mobility and/or dysfunctional pain sensations. Prevention is therefore crucial. However, persons at risk seem to experience difficulties in adhering to self-management regimens that can help to prevent or diminish the development of pressure ulcers. Self-management support interventions might help to improve their self-management skills.

OBJECTIVES

To review the content, components and effectiveness of self-management support interventions on clinical and behavioral outcomes for people at risk of pressure ulcers.

METHODS

A systematic literature search for the period of January 2000 to February 2020 was conducted in five databases (CINAHL, Cochrane, PsycINFO, PubMed, and Web of Science). Inclusion criteria were: (1) studies including persons at a high risk of pressure ulcers; (2) studies investigating interventions focused on self-management support; (3) studies describing clinical and behavioral outcomes related to prevention and care of pressure ulcers. All studies were independently screened on title, abstracts and full text by two researchers. The PRISMS taxonomy of 14 components was used to code intervention content.

RESULTS

The search yielded 5297 papers, which resulted in the inclusion of 16 papers on self-management support interventions for persons at risk of pressure ulcers. Interventions focused mostly on 'Information about condition and/or management' (13 interventions), 'Training in practical self-management activities' (7 interventions), and 'Training in psychological strategies' (6 interventions). 'Provision of equipment' was not investigated. The intensity of the interventions varied in delivery mode, frequency and duration. Improvements were found in clinical outcomes in four studies and in behavioral outcomes in ten studies. Four studies showed improvements in clinical outcomes and ten studies in behavioral outcomes. Knowledge was positively influenced in eight studies.

CONCLUSION

Self-management support interventions show potential. The extensiveness and intensity of the interventions seem to be predictive for the effectiveness, but specific content components cannot be recommended. This review revealed recommendations for future research and international consensus should be reached about patient-relevant outcomes.

Detection of posture and mobility in individuals at risk of developing pressure ulcers

Pressure mapping technologies provide the opportunity to estimate trends in posture and mobility over extended periods in individuals at risk of developing pressure ulcers. The aim of the study was to combine pressure monitoring with an automated algorithm to detect posture and mobility in a vulnerable population of Spinal Cord Injured (SCI) patients. Pressure data from able-bodied cohort studies involving prescribed lying and sitting postures were used to train the algorithm. This was tested with data from two SCI patients. Variations in the trends of the centre of pressure (COP) and contact area were assessed for detection of small- and large-scale postural movements. Intelligent data processing involving a deep learning algorithm, namely a convolutional neural network (CNN), was utilised for posture classification. COP signals revealed perturbations indicative of postural movements, which were automatically detected using individual- and movement-specific thresholds. CNN provided classification of static postures, with an accuracy ranging between 70-84% in the training cohort of able-bodied subjects. A clinical evaluation highlighted the potential of the novel algorithm to detect postural movements and classify postures in SCI patients. Combination of continuous pressure monitoring and intelligent algorithms offers the potential to objectively detect posture and mobility in vulnerable patients and inform clinical-decision making to provide personalized care.

Feedback improves compliance of pressure relief activities in wheelchair users with spinal cord injury

STUDY DESIGN

Prospective cross-sectional pre-post pilot study.

OBJECTIVES

This pilot study aimed to evaluate the potential for improving pressure relief behaviour in wheelchair users with spinal cord injury (SCI) using a novel feedback system based on textile pressure sensor technology.

SETTING

In- and out-patient clinic of the Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland.

METHODS

Nine wheelchair users with SCI (3 females, 50 ± 12 years of age, 2 tetra- and 7 paraplegics) were equipped with a feedback system (sensomativewheelchair) for three continuous weeks. The system consists of a textile pressure mat and a mobile smartphone application that reminds participants to perform missing pressure reliefs during regular and unobserved wheelchair usage in a customized manner. Pressure reliefs were detected using a subject-specific random forest classifier. Improvements of relief quality, duration and frequency were analysed by comparing week 1 (baseline) with no feedback, i.e., only pressure data recorded, against week 2 (with feedback). Carry-over effects of improved relief behaviour were studied in week 3 (no feedback, pressure data only recorded).

RESULTS

All participants increased their relief frequency and performed in median 82% (IQRs: 55%-99%) of the required reliefs while using the feedback system, whereas the median relief frequency was only 11% (IQRs: 10%-31%) during the baseline condition. Every participant who did not perform reliefs of sufficient duration (based on the recommendations of the therapist) during week 1 showed a significant improvement while using the feedback system.

CONCLUSION

Subject-specific feedback using the novel feedback system may have the potential for improving the regularity of an individual's relief activities, and may ultimately be an instrument for reducing the risk of developing pressure ulcers.

Biomechanical monitoring and machine learning for the detection of lying postures

BACKGROUND

Pressure mapping technology has been adapted to monitor over prolonged periods to evaluate pressure ulcer risk in individuals during extended lying postures. However, temporal pressure distribution signals are not currently used to identify posture or mobility. The present study was designed to examine the potential of an automated approach for the detection of a range of static lying postures and corresponding transitions between postures.

METHODS

Healthy subjects (n = 19) adopted a range of sagittal and lateral lying postures. Parameters reflecting both the interactions at the support surface and body movements were continuously monitored. Subsequently, the derivative of each signal was examined to identify transitions between postures. Three machine learning algorithms, namely Naïve-Bayes, k-Nearest Neighbors and Support Vector Machine classifiers, were assessed to predict a range of static postures, established with a training model (n = 9) and validated with new input from test data (n = 10).

FINDINGS

Results showed that the derivative signals provided a means to detect transitions between postures, with actimetry providing the most distinct signal perturbations. The accuracy in predicting the range of postures from new test data ranged between 82%-100%, 70%-98% and 69%-100% for Naïve-Bayes, k-Nearest Neighbors and Support Vector Machine classifiers, respectively.

INTERPRETATION

The present study demonstrated that detection of both static postures and their corresponding transitions was achieved by combining machine learning algorithms with robust parameters from two monitoring systems. This approach has the potential to provide reliable indicators of posture and mobility, to support personalised pressure ulcer prevention strategies.

Selecting Evidence-Based Content for Inclusion in Self-Management Apps for Pressure Injuries in Individuals With Spinal Cord Injury: Participatory Design Study

BACKGROUND

Technological solutions, particularly mobile health (mHealth), have been shown to be potentially viable approaches for sustaining individuals' self-management of chronic health conditions. Theory-based interventions are more successful, as evidence-based information is an essential prerequisite for appropriate self-management. However, several reviews have shown that many existing mobile apps fail to be either theoretically grounded or based on evidence. Although some authors have attempted to address these two issues by focusing on the design and development processes of apps, concrete efforts to systematically select evidence-based content are scant.

OBJECTIVE

The objective of this study was to present a procedure for the participatory identification of evidence-based content to ground the development of a self-management app.

METHODS

To illustrate the procedure, we focused on the prevention and management of pressure injuries (PIs) in individuals with spinal cord injury (SCI). The procedure involves the following three steps: (1) identification of existing evidence through review and synthesis of existing recommendations on the prevention and self-management of PIs in SCI; (2) a consensus meeting with experts from the field of SCI and individuals with SCI to select the recommendations that are relevant and applicable to community-dwelling individuals in their daily lives; and (3) consolidation of the results of the study.

RESULTS

In this case study, at the end of the three-step procedure, the content for an mHealth intervention was selected in the form of 98 recommendations.

CONCLUSIONS

This study describes a procedure for the participatory identification and selection of disease-specific evidence and professional best practices to inform self-management interventions. This procedure might be especially useful in cases of complex chronic health conditions, as every recommendation in these cases needs to be evaluated and considered in light of all other self-management requirements. Hence, the agreement of experts and affected individuals is essential to ensure the selection of evidence-based content that is considered to be relevant and applicable.

Prevention strategies for secondary health conditions in people with spinal cord injury: a scoping review protocol

OBJECTIVE

The objective of the review is to map existing evidence and to provide an overview of the prevention strategies for secondary health conditions that have been reported in people with spinal cord injuries.

INTRODUCTION

Spinal cord injury is a physical disability caused by a lesion in the spinal cord resulting in a loss of sensory and motor function below the affected area. In the lifespan of a person living with spinal cord injury, at least one preventable secondary health condition will develop. These conditions can be predictable and potentially prevented.

INCLUSION CRITERIA

This review will consider studies that include participants 18 years and over with spinal cord injury and report on prevention strategies for secondary health conditions (e.g. pressure sores, urinary tract infection, pain) at all levels of disease prevention (primary, secondary and tertiary level). Studies of any design conducted in a clinical (hospital and primary healthcare facility), home or community-based setting will be considered.

METHODS

A three-step search strategy will be used in this review, with an initial search of MEDLINE (PubMed) and CINAHL. Databases to be searched include: PubMed, PEDro, CINAHL, Embase, Scopus, Health Source: Nursing/Academic Edition and SPORTDiscus. Government resources (Department of Health website), World Health Organization, Google Scholar and OpenGrey will be searched for unpublished studies. Titles and abstracts will be screened by two independent reviewers. Studies that meet the inclusion criteria will be retrieved and assessed. Results will be presented in narrative and tabular form.

Development of a comprehensive mobile assessment of pressure (CMAP) system for pressure injury prevention for veterans with spinal cord injury

Objective: This paper reports the iterative redesign, feasibility and usability of the Comprehensive Mobile Assessment of Pressure (CMAP) system's mobile app used by Veterans with SCI.Design: This three-year, multi-staged study used a mixed-methods approach.Setting: Minneapolis VA Health Care System, Minneapolis, Minnesota.Participants: Veterans with spinal cord injury (N = 18).Interventions: Veterans with spinal cord injury engaged in iterative focus groups and personal interviews, sharing their needs and desires for the CMAP app redesign. App developers used these data for the redesign. The redesigned CMAP app was tested for six-weeks in users' homes.Outcome Measures: Quantitative (surveys) and qualitative (interviews) methods measured feasibility for self-management of seating pressure. Qualitative data were audio recorded, transcribed, anonymized, and coded. Survey data were analyzed using summary statistics.Results: After the CMAP system's redesign, the in-home use interview found: (1) any tool that can assist in prevention and monitoring of skin ulcers is important; (2) the desired key features are present in the app; (3) the main barrier to CMAP use was inconsistent functionality; (4) when functioning as expected, the live pressure map was the central feature, with reminders to weight shift also of high importance. The survey found: power wheelchair users tended to score closer than manual wheelchair users to the positive response end ranges on two separate surveys.Conclusions: Overall both the power and manual wheelchair users reported that they wanted to use the system, felt confident using the system, and that the functions of the system were well integrated.

Facilitators and Barriers for Implementing an Internet Clinic for the Treatment of Pressure Injuries

Background: Pressure injuries (PIs) represent a frequent, often preventable, secondary complication of spinal cord injury (SCI) with serious consequences to health, societal participation, and quality of life. Specialized knowledge and service delivery related to treatment and prevention are typically located within major health centers. Introduction: For persons with SCI living at home, it can be challenging to access specialized PI care. A telehealth approach could help mitigate this challenge. This multisite pilot investigation assessed the feasibility of integrating information technologies within the management of PIs. Materials and Methods: Each study site formed a specialized interdisciplinary care team that identified components of their standard clinical care pathway and examined how they could be integrated with study technologies. A monitoring system was utilized to enable patients and caregivers to exchange clinical information with the care team. Results: Clinician and patient focus groups were completed to identify facilitators and barriers for long-term implementation. Findings demonstrate that this method of service delivery is feasible but requires further development. Discussion: This model of care requires refinement to address technological, regulatory, and clinician acceptance barriers; however, increased access to these services has the potential for improving PI healing or prevention rates in comparison with those not able to access specialized services. Conclusions: This project demonstrates that PI treatment services can be delivered effectively through the internet. Future trials can investigate efficacy and cost-effectiveness of this model of care to inform sustained implementation.

Medical and Musculoskeletal Concerns for the Wheelchair Athlete: A Review of Preventative Strategies

Adaptive sports refers to organized sporting activities that are practiced by individuals with disabilities and are worthwhile to maintain physical and psychological health. As adaptive sports participation continues to rise, health care providers must have an enhanced understanding of injury and illness patterns specific to the adaptive athlete. Early recognition and prevention are important to ensure safe and successful participation in sport. The present review aims to provide a framework for diagnosis and prevention of common conditions specific to the wheelchair athlete. In particular, autonomic dysreflexia, impaired thermoregulation, urinary tract infection, and pressure injuries, as well as shoulder pain, upper-extremity entrapment neuropathies, and osteoporotic fractures will be discussed.

Improving Self-Management Skills Among People With Spinal Cord Injury: Protocol for a Mixed-Methods Study

Background

Most people with spinal cord injury will develop secondary complications with potentially devastating consequences. Self-management is a key prevention strategy for averting the development of secondary complications and their recurrence. Several studies have shown that self-management programs improve self-management behaviors and health outcomes in individuals living with chronic conditions such as asthma, diabetes, hypertension, and arthritis. Given the burgeoning health care costs related to secondary complications, we developed an alternative electronic health–based implementation to facilitate the development of self-management skills among people with spinal cord injury.

Objective

This study aims to evaluate the efficacy of a self-management app in spinal cord injury populations. The primary outcome is attainment of self-selected, self-management goals. Secondary outcomes include increases in general and self-management self-efficacy and reductions in self-reported health events, health care utilization, and secondary complications related to spinal cord injury. This study also aims to explore how the intervention was implemented and how the app was experienced by end users.

Methods

This study will employ a mix of qualitative and quantitative methods. The quantitative portion of our study will involve a rater-blinded, randomized controlled trial with a stepped wedge design (ie, delayed intervention control group). The primary outcome is successful goal attainment, and secondary outcomes include increases in self-efficacy and reductions in self-reported health events, health care utilization, and secondary conditions related to spinal cord injury. The qualitative portion will consist of semistructured interviews with a subsample of the participants.

Results

We expect that the mobile self-management app will help people with spinal cord injury to attain their self-management goals, improve their self-efficacy, reduce secondary complications, and decrease health care utilization.

Conclusions

If the results are positive, this study will produce credible new knowledge describing multiple outcomes that people with spinal cord injury realize from an app-based self-management intervention and support its implementation in clinical practice.

Trial Registration

ClinicalTrials.gov NCT03140501; http://clinicaltrials.gov/ct2/show/NCT03140501 (Archived by WebCite at http://www.webcitation.org/73Gw0ZlWZ)

International Registered Report Identifier (IRRID)

PRR1-10.2196/11069

Self-management interventions for skin care in people with a spinal cord injury: part 1-a systematic review of intervention content and effectiveness

Study design

Systematic review.

Objectives

To review the content and effectiveness of skin care self-management interventions for people with SCI.

Setting

International.

Methods

We searched electronic bibliographic databases, trial registers, and relevant reference lists. Eligibility criteria for the reviews of intervention content and effectiveness were identical with the exception of study design. The review of intervention content included non-randomized and randomized controlled trials (RCTs). The review of effectiveness included RCTs. A Behavior Change Technique (BCT) taxonomy of 93 BCTs was used to code intervention content. Intervention effects on outcomes of interest are summarized descriptively. Effect sizes were calculated, and the Cochrane risk of bias tool applied.

Results

In all, 15 studies testing 17 interventions were included in the review of intervention content. Interventions in these studies included 28 BCTs. The most common were “instructions on how to perform behavior” (16 interventions), “credible source” (12 interventions), and “social support (unspecified)” (9 interventions). Ten RCTs were included in the review of intervention effectiveness and they measured knowledge, self-efficacy, and skills relating to skin care/pressure ulcer (PU) prevention, skin care behaviors, skin status (PU prevalence, severity, and time to PU), and health-care utilization for skin problems. Evidence to support intervention effects on these outcomes was limited, particularly for clinical outcomes. Risk of bias assessments was often inconclusive due to poor reporting.

Conclusions

There is potential to design SCI skin care interventions that include currently untested BCTs. Further research and better consistency in outcome measurements and reporting are required to synthesize evidence on effectiveness.

Trunk Function and Ischial Pressure Offloading in Individuals with Spinal Cord Injury

OBJECTIVE

To determine if there is a relationship between trunk function and offloading of the ischial tuberosities in individuals with Spinal Cord Injury (SCI).

DESIGN

Prospective cross-sectional evaluation.

SETTING

Sub-acute rehabilitation hospital.

PARTICIPANTS

Fifteen non-ambulatory participants with complete or incomplete traumatic and non-traumatic SCI, American Spinal Injury Association Impairment Scale (AIS), Classification A-D.

OUTCOME MEASURES

Isometric trunk strength using a hand held dynamometer, the ability to reach using the multidirectional reach test and offloading times of the ischial tuberosities using a customized pressure mat.

RESULTS

Participants who were able to engage in the multidirectional reach test were defined as "Reachers", whereas individuals who were unable to engage in the multidirectional reach test were defined as "Non-Reachers". Trunk strength was significantly higher in Reachers compared with Non-Reachers (P < 0.05). Offloading times over the left and right ischial tuberosities were lower in Non-Reachers when compared with Reachers, however the results were statistically significant only for offloading over the right ischial tuberosity (P < 0.05). There was no correlation between trunk strength and pressure offloading times for both groups.

CONCLUSIONS

Regardless of an individual's ability to engage in a reaching task, participants with spinal cord injury spent more time offloading the left ischial tuberosity compared with the right ischial tuberosity. The study highlights the need to identify factors that may contribute to offloading behavior in individuals with spinal cord injury who lack sufficient trunk strength.

Protocol for a scoping review of skin self-care of people with spinal cord injury

INTRODUCTION

In recent years, increasing methodological references have been used in scientific research; these are points of support in the search for evidence, formulation and elaboration of instruments, scales, guideline and protocols. However, significant variability currently exists in scoping review conduct and reporting, thus limiting the potential of the methodology to advance research and practice about skin self-care of people with spinal cord injury (SCI). Our objective was to perform a scoping review protocol within the health rehabilitation context of people with SCI, focusing on skin self-care.

METHODS AND ANALYSIS

The protocol was developed by using the scoping review methodological framework proposed by Arksey and O'Malley and further refined by the Joanna Briggs Institute, incorporating insights from more recent innovations in scoping review methodology. Sensitive searches of 13 electronic databases from 2007 to 2017 will be supplemented by grey literature searches. Two reviewers using a tool developed for this scoping review will screen eligible studies.

ETHICS AND DISSEMINATION

The scoping review will undertake a secondary analysis of previously collected data and does not require ethical approval; however, the ethical precepts of copyright will be respected. The results will facilitate a better understanding of the practical health rehabilitation context of people with SCI, the impacts of these rehabilitations and how to build an evidence base for this work in the future.