Section 1- Skin Health
1.1 – A Top Priority
Skin integrity is a life-long priority for people living with a spinal cord injury. This is because a spinal cord injury leaves you at high risk for developing pressure sores.
Pressure sores can start small and turn into a serious problem. They can keep you in bed for weeks or even months. Untreated pressure sores can lead to other medical complications; the most devastating are autonomic dysreflexia, loss of a limb or even death.
The key to skin integrity is prevention. After a spinal cord injury, you’ll need to spend time every day paying careful attention to your skin. And as you first adjust to life with a spinal cord injury, you’ll need to learn new skills to keep your skin healthy, like doing a skin check and pressure relief.
1.2 – How the Skin Works
The skin is the largest organ in the body and it is just as important as your heart or your lungs. It does a few different things:
• It protects the tissues and organs underneath from moisture, foreign substances and bacteria;
• It helps to control body temperature and fluid levels;
• And, it allows us to feel touch, pressure, temperature and pain.
Our skin gets the food and oxygen it needs to stay healthy from blood vessels.
The skin has an amazing ability to repair itself, but it can be damaged by prolonged pressure. If pressure cuts off the blood supply to the skin for an extended period of time, this can lead to damage to the skin & underlying structures.
1.3 – After a Spinal Cord Injury
A spinal cord injury can affect the skin in a number of ways:
• Prolonged sitting or lying in one position can lead to pressure damage, especially over bony areas.
• Next, you may not notice when your skin is being damaged by pressure, burning or freezing.
• Finally, your skin can be more vulnerable to breakdown from swelling, too much or too little moisture, and friction.
Many people experience swelling in their legs and feet. This causes the skin to stretch making it more fragile. Think of what happens when you blow up a balloon: as it gets bigger, the rubber stretches, making it weaker.
Wet skin is fragile. It can be caused by sweating, failing to dry off completely after a shower, or problems with bladder or bowel accidents.
Winter weather can cause dry skin that cracks easily.
Muscle spasms, poor positioning and sliding in a wheelchair or in bed can result in skin damage from rubbing or friction.
A person with a spinal cord injury needs to give his or her skin special attention every day.
• Your best line of defense is to check your own skin. If you are unable to check your skin independently, make sure you can direct someone else to check it properly.
• Over time, you can keep you skin healthy with regular pressure relief, good hygiene, keeping a proper moisture balance, avoiding friction and quitting smoking.
1.4 – Pressure Sores
A pressure sore is any redness or break in the skin caused by too much pressure for too long. In the same way that pinching a garden hose cuts off the water supply, pressure applied to the skin can cut off the blood supply, leading to damage.
A sore, sometimes called a pressure ulcer, can happen on any part of your body where pressure is applied to the skin. Typically, sores appear on areas called “boney prominences,” where the bones are close to the skin, without much padding; for example the shoulders, elbows, hips, buttocks, and ankles. In these areas, the bones put pressure on the skin from the inside, so that a hard surface on the outside can pinch off the blood circulation.
Be careful: pressure sores can form easily, often quickly, and for reasons you may not have thought about. Buttons or zippers, shoes, braces, or any hard object that puts pressure on your skin can cause a sore. Straps on leg bags, and parts of your wheelchair can also cause a sore. Even sitting on the couch without repositioning and pressure relief can cause a sore.
People often underestimate the seriousness of a red spot and delay getting help, so that they end up with a serious problem. It’s important to realize that pressure sores are like icebergs. What you see on the surface is often much smaller than the damaged area under the skin. When you see what looks like a red spot, take it seriously and get the help you need.
Section 2 – Skin Care Skills
2.1 – Healthy Habits
After a spinal cord injury you need to pay special attention to your skin, probably a lot more than you ever did before. By building good habits, you can keep your skin healthy.
The first part of your skin care program is doing a daily skin check:
• Check your skin for new marks or signs of redness on a daily basis, before you get out of bed in the morning and after you go to bed in the evening; if you need to, you can use a long-handled mirror or direct an attendant to check your skin.
• The first sign of a pressure sore is a red spot that may also be warm to the touch. In darker skin tones the area may look blue or purple or gray. If you or your attendant find a mark, you can check it by pressing on it with a finger. If it doesn’t change colour quickly, you should try to identify the cause and then seek medical attention. If it does change colour, continue to monitor the area. If it’s not better after 24 hours, you should contact your skin care team.
Your skin care program includes other important elements:
• Pressure relief: If you have a higher-level injury, in particular, you’ll need to pay a lot of attention to pressure relief, by leaning from side to side, leaning forward, hooking your arm, pushing up, using tilt—throughout the day. At first you’ll need to think a lot about doing this every few minutes; over time, it should become a habit; you’ll find more information on pressure relief in Section 3.
Pressure relief is also important when you’re in bed. If you’re unable to turn yourself, and if you don’t have proper mattress, you may need to get help so you can be turned regularly, at least every 2 hours.
• Diet & water: Make sure you eat enough protein, especially if you have a wound that is healing; and drink one and a half to two litres of water every day.
• Moisture balance: Dry skin results from many causes, including thyroid problems, medication, and extreme weather. You may find it helpful to apply moisturizer to your skin on a regular basis; Wet skin is fragile. Make sure you dry yourself off thoroughly after showering—especially the nooks and crannies. Also, problems with bladder or bowel accidents can leave the skin wet and vulnerable to breakdown.
• Transfer techniques: Take care not to scrape or rub the skin on your rear end or your legs and feet when you transfer.
• Nail care: Keep your toenails trimmed—you may need to see a health care professional for help with this.
• Skin-friendly clothes and footwear; you’ll find more information in Section 3 on what you need to look for when you buy clothes & footwear.
• Equipment: keep your cushions, wheelchairs and other equipment in good repair, and watch out for anything that could catch, rub, or otherwise harm your skin.
2.2 – Areas to Monitor
There are certain parts of the body that have a much greater risk of skin breakdown. These are areas where the bone is closer to the skin and where pressure can be created, for instance:
• The tailbone, located at the bottom of the spine;
• The sit bones, located roughly in the centre of each buttock;
• The shoulder blades and elbows;
• The hips;
• The heels and
• The ankles, inside and out.
The tailbone and sit bones are exposed to pressure while you are sitting in your wheelchair or on any other surface.
The elbows can develop pressure sores from leaning on them to stabilize your upper body.
The hips and ankles may be exposed to pressure when you lie in bed, especially on your side.
The back of your head and shoulder blade can develop sores when you lie on your back for long periods of time.
Other at-risk areas include:
• The heels, which can develop sores from lying in bed, or from shoes and hard surfaces like footplates;
• The toenails, which can become ingrown;
• Around the knees – from lying in bed without a pillow between your legs or from rubbing against the front part of your wheelchair; and
• The shoulders – from lying in bed or from the push handles of your wheelchair.
2.3 – Autonomic Dysreflexia
Autonomic dysreflexia is a serious medical condition that can affect people with a spinal cord injury, particularly above the T6 level. You should be aware of the symptoms of AD and know what to do about it.
Autonomic dysreflexia is caused by a harmful or unpleasant stimulus, such as a pressure sore or a full bladder or bowel. Different people experience different symptoms, and you may notice a variety of signs including goose bumps, flushing, unusual sweating, dizziness, nausea, light headedness and a sudden, painful headache.
In every case, though, autonomic dysreflexia is accompanied by a sudden spike in blood pressure to a level much higher than what is normal for you.
It’s important to find out what stimulus is causing the dysreflexia and relieve or remove it. So if you find yourself experiencing these symptoms, you should begin by inspecting your skin for signs of pressure sores, and checking whether you need to drain your bladder or empty your bowel.
If you’re not able to resolve the issue and end the episode of autonomic dysreflexia within an hour, or if you develop a headache or chest pain, you should call 911.
2.4 – Problem-Solving
Problem-solving is a useful way to deal with situations when you’re not sure what to do. Here’s a handy 5-step method for solving problems you encounter with your skin.
Step 1—Identify the problem: Start by getting a clear picture of what’s wrong. Before you jump to conclusions, take the time to investigate. Inspect your skin thoroughly and pay special attention to areas you might normally overlook.
Step 2—Find the cause: Once again, you want to be thorough; look at your equipment, clothes or shoes, and think about any activities or circumstances that may be causing the problem. Does it have to do with the way you transfer? Or, does it result from sitting on an unusual surface – like a car seat?
Step 3—Brainstorm solutions: Using the information you have, think of a number of possible solutions. You may be able to address the problem yourself and prevent the situation from getting worse. In some cases though, the only solution is to get help.
Step 4—Try one & evaluate results: Try one of the solutions you identified, starting with the one that seems best. If it works…great! Just make sure to follow-up and ensure that the problem is truly solved. If it doesn’t work, try another solution. You may need to repeat this step several times.
Step 5—Know when to ask for help: Don’t try to take everything on by yourself. When it comes to something as important as your skin, it’s better to be safe than sorry, so when in doubt, ask for help. You should recognize the signs of a serious pressure sore that requires medical attention.
2.5 – Your Skin Care Team
If you have a pressure sore or another skin problem, don’t try to go it alone. There are professionals who can help you heal your wound.
A wound care specialist has training to help people manage their wounds by providing treatment, prevention and a care plan. They will teach you what you need to do to promote healing, for instance dressing changes. They will also help you problem-solve to determine what caused the wound and how to make sure it doesn’t happen again.
• If you have a relationship with a wound care nurse or specialist, contact them. Otherwise, you can see your family doctor.
• You can also try contacting a home care agency; ask if they have a wound care specialist on staff.
• You may need a referral from your family doctor, and you may be able to have a nurse visit your home to help you deal with your wound care.
• Another option may be your nearest spinal cord injury rehab center, seating clinic, or equipment vendor.
You should seek help if you notice a new red spot that doesn’t go away after 24 hours, if you skin is broken or blistered, or if you notice an unusual smell or discharge in your clothing or wetness on your cushion.
Remember this is important and needs to be taken seriously. Don’t try and cut corners or hope that it will just go away.
2.6 – Taking PART
You are an active part of your health care team, in fact, you’re the centre of the team. To get the most out of your relationships with your health care professionals, you just need to take PART. PART stands for Prepare, Ask, Repeat, and Take action. Here’s how it works:
Step 1-Prepare: before your appointment or visit, prepare your questions and other important information, and write them down. For instance, you may want to record when a spot or wound appeared, or how it changes over time.
Step 2-Ask: make sure you ask your health care professional about your concerns and questions, and especially if he or she says something you don’t understand.
Step 3-Repeat: clarify what you’ve been told by repeating it back.
Step 4-Take Action: follow through on the advice you receive; this can mean making changes to your lifestyle and habits.
Section 3: Skin Check
3.1 – Skin Check
Check your skin for new marks and signs of redness twice a day. Focus on the areas that are at risk for pressure sores. Many people do this first thing in the morning, at bedtime, or when they shower or do their bowel routine.
Over time, you’ll learn which areas or your body parts are problems for you. But you should always be on the lookout for new problem areas, so make sure you scan your whole body.
Just like brushing your teeth, or any other daily habit, this is something you build into your daily routine. You also need to pay special attention to checking your skin whenever you sit on a new or different surface, like a wheelchair cushion, or in a car or plane.
You may need to play around with different equipment to do your skin check. You may want to use a large mirror, or one with a handle so you can see the back of your body.
If you work with an attendant, you can direct them to help you with your skin check. Tell them clearly where to look and what to look for. For example: “look at my tailbone and tell me if you see any red marks or spots.” If they see something, ask them to describe it, or position you to hold a mirror so you can see it.
Be careful when you play sports, and if you’re out in the rain or snow, because your skin is more likely to break down when it’s wet.
If you master the routines of your daily skin checks, you can prevent skin problems from interfering with your life!
3.2 – Pressure Relief
Here’s a good saying to remember: If you want to prevent pressure sores, you need to practice pressure relief.
People with spinal cord injuries need to develop good daily habits of shifting their weight often, so that they avoid putting continuous pressure on any one part of the skin.
At first, you’ll want to work with your therapists to determine the best weight shifting options for you. They can help you with techniques to perform your weight shift effectively.
You may find you need to be especially conscious of your body position and the pressure you are putting on different body parts, like your elbows. This can be challenging if your sensations like touch and pressure are impaired, so you may need to pay special attention to what you are doing while you develop good habits.
The goal is to get to a point where you instinctively shift your weight on a constant basis during your daily routine. Here’s how to develop these habits:
• Start by fully shifting your weight on a regular schedule, for example every 15 – 20 minutes;
• If you forget, try using an alarm or a timer to remind you to do your weight shift;
• Over time, you should find that you can incorporate a program of constant weight shifting and pressure relief into the rest of your activities.
3.3 – Cushions and Equipment
When it comes to wheelchair cushions, there are different surface types like air, foam, gel, fluid, and a combination of these. There are also different shapes and sizes.
The first time you choose a cushion and mattress type, your therapist will work with you to find the best options and write the prescription that you’ll need to purchase the item.
When you’re living in the community, you can access outpatient services like the seating clinic or an occupational therapist to help you as your needs change over time. Maintaining good posture saves your skin. If you are having problems with skin or posture, or if your circumstances change, you will need to re-assess your fit.
When you try a new cushion, you should carefully check your skin for redness.
You may want to take a cushion with you when travelling on a plane or going on a long drive. And you may require more than one cushion for different activities, like sports.
Proper positioning is very important—make sure you take the time. If you’re working with an attendant, instruct them on how to position you—you’ll be more comfortable and you’ll avoid skin problems.
Besides your wheelchair cushions, your occupational therapist can help you choose a bed, a mattress, as well as bathroom equipment like a shower commode or a bath bench and a raised toilet seat. Once you have the right equipment, it’s important for your own safety to keep it clean and in good working order.
3.4 – Clothing
After a spinal cord injury, you need to look at different things when you’re going shopping for clothes and shoes.
• Take care to avoid pressure build-up from clothes on your skin;
• You may choose to buy your clothes a size bigger;
• Be careful on how your clothes fit on your body. If they’re too tight, they can cause a problem, but if they’re too loose and wrinkled, you could end up sitting on a crease;
• You should definitely avoid sitting on buttons, zippers, pockets and other items that can cause pressure points;
• You may choose not to wear undergarments because of the seams that can cause a pressure area.
• And finally, be careful with abdominal binders and leg bags, especially straps that are too tight.
3.5 – Footwear
When you buy shoes, you may want to get them one size bigger, since your feet swell when you’re in a wheelchair.
• Make sure there is plenty of room in your toes. Avoid shoes that pinch or put pressure anywhere on your foot;
• Check the back of the shoe and make sure the heel fits. Make sure the back of the shoe is not too firm; this can lead to a pressure sore on your heel.
If you wear stockings, be very careful that there are no wrinkles, and make sure the elastic is in good condition.
When you buy socks, and when you put them on, look at the seam; make sure there’s no pressure on your toes.
3.6 – Dealing With a New Wound
What do you do when you find an area of redness on your skin after a skin check?
If you and your attendant find a mark, you can check it by gently pressing on it with a finger. If it doesn’t change colour quickly, you should seek medical attention.
If it does, continue to monitor the area. If it’s not better after 24 hours, seek medical attention.
Contact your family doctor or your wound care team for advice on treatment.
Here are some do’s and don’ts of dealing with a new wound:
• Do look for the cause;
• Do remove the cause of pressure (for example: a zipper, buttons, a shoe, etc.);
• Do call your family doctor or wound care specialist.
• Don’t rub it – this will only make it worse;
• Don’t put a band-aid on it, because this can cause friction and may make it worse;
• Don’t put a thick dressing on it (like a foam dressing) as this will add pressure.