RehabWire - Volume 6, Number 9, November 2004.


This edition of RehabWire highlights current research, both NIDRR-funded and from other projects, on pressure sores. These projects focus on treatment and prevention through health education.

NIDRR Projects: Focused to Innovate.

Rehabilitation Engineering Research Center on Wheeled Mobility, University of Pittsburgh (H133E990001) led by David M. Brienza, PhD, Clifford Brubaker, PhD. William Peterson, Project Officer.
Abstract: The RERC on Wheeled Mobility investigates the use of dynamic seating for reducing spasticity and enhancing seating comfort; investigates the biomechanical characteristics of soft tissue related to the risk of developing pressure ulcers and the relationship between pressure measurements and pressure ulcer incidence, develops and validates the use of outcomes measures for seating and mobility intervention; and investigates the use of the web as a seating decision support tool for consumers.
For more information, visit or contact Mary Jo Geyer, Associate Director, at 412/383-6571.

Development of a Pressure Ulcer Prevention Beliefs Instrument for Persons with Spinal Cord Injury. Rehabilitation Institute Research Corporation (H133G010058), led by Rosemarie B. King, PhD, RN. Phillip Beatty, Project Officer.
Abstract: This project develops a measure that clinicians can use to assess the health beliefs of persons with SCI regarding pressure ulcer (PU) prevention. The goals of the study are to: (1) develop an instrument to measure PU-prevention health beliefs that is reliable by collecting qualitative data on perceptions about PU risk and seriousness, barriers to and benefits of preventive skin care, and confidence in performing skin care; (2) develop a health beliefs instrument that is structurally and theoretically valid; and (3) describe the pressure ulcer prevention beliefs of 375 persons with recent or chronic SCI. The project uses qualitative data to develop questionnaire items on perceptions about PU risk and seriousness, barriers to and benefits of predict skin-care, and confidence in performing skin care. The measure is used to describe and predict skin-care behaviors. Statistics used to determine reliability and validity of the measure include internal consistency reliability, exploratory factor analysis, Rasch analysis, and hierarchical multiple regression analyses. Findings facilitate the development of health belief-based interventions that address the multifactorial basis of risk for PU development. The addition of skin care health beliefs to risk prediction instruments should increase the predictive power of such instruments.
For more information, contact Dr. King at 312/908-8038.

A Study of Biophysical and Microvascular Function of Individuals with SCI: Implications for Alternating Pressure Support Surfaces. University of Pittsburgh (H133G040222), led by David M. Brienza, PhD. William Peterson, Project Officer.
Abstract: The specific aims of this research study are to: (1) characterize blood flow control mechanisms (e.g. metabolic, neurogenic, and myogenic controls) via laser Doppler blood flow using Wavelet analysis in individuals with SCI; (2) investigate the use of alternating pressure for enhancing skin blood flow in SCI; (3) compare the effect of neurogenic control of cutaneous microcirculation on the strength of blood flow responses to alternating pressure in SCI with T-6 above and below; and (4) compare the effect of soft tissue properties on the strength of blood flow responses to alternating pressure in SCI with T-6 below and unimpaired subjects. These studies provide insight into mechanisms important to the configurations of optimal parameters for enhancing blood flow in SCI population, and provide a valid method for the evaluation of alternating pressure devices.
For more information, contact Jean Webb at 412/383-6586.

Daily Living Context and Pressure Sores in Consumers with Spinal Cord Injury. University of Southern California (H133G000062) led by Florence Clark, PhD, OTR. Kristi E. Wilson, PhD, Project Officer.
Abstract: This project examines the beliefs and practices underlying the activities, habits, and daily routines of 18 ethnically diverse consumers with SCI. The intent is to document how personality, lifestyle patterns and choices, and environmental context mutually interact within the individually constructed lives of consumers to influence the development of pressure sores. The problem of recurrent, medically serious pressure sores represents a key challenge to the ability of individuals with SCI to experience a full and satisfying life. Although prior research has documented that the development of pressure sores is in general linked to psychosocial and environmental variables, there is a need to obtain new, consumer-centered information about how pressure sores can be minimized through personally tailored adaptive strategies that are responsive to the opportunities and difficulties embedded in the unique sets of everyday circumstances that characterize individual lives. A variety of data collection procedures, including participant observation as well as interviews with consumers, their caregivers, and other associated persons, are analyzed to generate results that are comprehensive and trustworthy. These results are used to develop a series of applied products, including: (1) a consumer-oriented self-help manual; (2) a set of guidelines for rehabilitation practice; and (3) a lifestyle-oriented occupational therapy treatment model. Consumer representatives contribute to all aspects of the project to ensure that it is relevant and maximally useful to the target population.

Preliminary findings of the USC-Rancho Los Amigos Pressure Sore study has revealed that pressure wounds are affected by a complex, individualized interplay of protective buffers and liabilities that exist within the everyday lives of adults with spinal cord injury, and that the ability to prevent pressure sores is only as strong as the most vulnerable risk-relevant component in a person’s life. Another key finding is that persons with spinal cord injury live in a precarious balance, such that circumstances beyond their control (e.g., unexpected life events, emergence of comorbidities, or a reduction in financial resources) can eventuate in the development of a pressure sore. Additionally, and of most impact from an occupational point of view, is the discovery that a crucial risk factor is the recurrent tension between the need to achieve a full, active life and the need to constrain one’s activities to prevent pressure sores.
For more information, visit or contact Janis Wise at 323/442-2851.

The Rocky Mountain Regional Spinal Injury System. Craig Hospital (H133N000001), led by Daniel P. Lammertse, MD, Gale G. Whiteneck, PhD. Theresa San Agustin, MD, Project Officer.
Abstract: The Rocky Mountain Regional Spinal Injury System emphasizes research and significant contributions that have been made in the areas of SCI costs of care, aging, outcome assessment, high tetraplegia, neurorehabilitative surgery, and program evaluation, as well as participation in randomized controlled multicenter clinical trials. An integrated research agenda includes a controlled clinical trial of therapy for shoulder pain and evaluations of longitudinal outcomes of surgery for spinal cord myelopathies, recovery from pressure sore surgery, perimenopausal symptoms and treatments in women with SCI, the issues of women who provide assistance to a partner with SCI, and the impact of environmental barriers on the full participation in of people with SCI.
For more information, visit or contact Scott Manley, EdD at 303/789-8214.

Missouri Model Spinal Cord Injury System. University of Missouri/Columbia (H133N000012), led by Laura H. Schopp, PhD, ABPP. Phillip Beatty, Project Officer.
Abstract: The Missouri Model Spinal Cord Injury System (MOMSCIS) is committed to developing, implementing, and evaluating innovative research promoting independent living and community integration among persons with spinal cord impairment. The study focused on the effect of a consumer-directed personal assistance services training intervention on consumer satisfaction, independent living and community integration. The study developed, implemented and evaluated the in-person Individualized Management of Personal Assistant/Consumer Teams (IMPACT) workshop. Workshop participants received information on preventing and treating secondary medical conditions, including pressure sores, urinary tract infections, bowel and bladder management, autonomic dysreflexia, pain management, chronic fatigue, and thermoregulation, and information on relationship issues, such as hiring and firing, communication styles and strategies, assertiveness, and team building. Study objectives were: 1) to determine the effect of the IMPACT workshop on consumer satisfaction, the incidence of secondary conditions, activity, and participation (as defined by the ICF); 2) to determine the effect of the IMPACT workshop on personal assistants’ job satisfaction, job stress and attrition; and 3) to provide online resources to the disability community, including an online personal assistant training manual for consumers and assistants, and an online resources database. Activity and participation were measured by the PARTicipation Survey for persons with Mobility Limitations (PARTS/M).
For more information, visit or contact Larry Nossaman at 573/884-2899.

Northern New Jersey Spinal Cord Injury System. Kessler Medical Rehabilitation Research and Education Corporation (KMRREC) (H133N000022), led by David Tulsky, PhD. Theresa San Agustin, MD, Project Officer.
Abstract: The Northern New Jersey Spinal Cord Injury System (NNJSCIS) attempts to improve outcomes for persons with SCI through novel interventions and expanded service delivery options. The NNJSCIS has an interdisciplinary system of rehabilitation care specifically designed to meet the needs of individuals with SCI. It includes emergency medical services; acute care; psychological, social, and vocational services; peer support; independent living services; community and job placement, long-term community follow-up; and health maintenance. Some of the research and demonstration projects target three of the most common secondary conditions (pressure ulcers, shoulder pain, and urinary tract infections). Other studies promote wellness by reducing obesity, examine the relation between health literacy and outcomes, and identify risk factors and prevent potential problems. One project operationalizes the newly developed Clinical Practice Guidelines. The NNJSCIS contributes to the National Statistics Data Center.
For more information, visit or contact Dr. Tulsky at 973/243-6849.

Demonstration of a Model Spinal Cord Injury System Center. Thomas Jefferson University Hospital (H133N000023), led by John F. Ditunno, Jr., MD. William Peterson, Project Officer.
Abstract: The Regional Spinal Cord Injury Center of Delaware Valley (RSCICDV) is a comprehensive program of coordinated patient care, education, and research activities. The RSCICDV: (1) conducts on-site research focusing on improved outcome measures to meet Federally established objectives; (2) refines and improves the RSCICDV’s operational services and demonstration projects; and (3) conducts four development projects including development of an SCI web site, implementation of an SCI Care Path, development of a Pressure Sore Program, and employing persons with SCI through hireAbility.
For more information, visit or contact Mary Patrick at 215/955-6579.

The staff of NARIC join in recognizing the achievements of Christopher and Dana Reeve in advocating for spinal cord injury research. More information on the Christopher & Dana Reeve Paralysis Resource Center can be found at

New Research: Selections from REHABDATA

Moussavi, R. M., Garza, H. M., Eisele, S. G., Rosriguez, G., Rintala, D. H. (2003) Serum levels of vitamins A, C, and E in persons with chronic spinal cord injury living in the community. Archives of Physical Medicine and Rehabilitation, 84(7), 1061-1067. NARIC Accession Number: J45732.
Produced under grant number: H133B40011
Abstract: This study compares serum levels of vitamins A, C, and E among individuals with spinal cord injury to those levels normally found in the general population and describes their association with demographic and injury-related data, health status, nutritional behaviors, and occurrence of pressure ulcers. A significant number of participants (16 to 37 percent) had serum levels below the norm for each vitamin. Being older or older at onset of injury was associated with higher serum levels of vitamins A and E. Vitamin A was also related to better function and health status and with not having a pressure ulcer with the past 12 months. No relationships were found with vitamin C.

Newsam, C. J., Lee, A. D., Mulroy, S. J., Perry, J. (2003) Shoulder EMG during depression raise in men with spinal cord injury: The influence of lesion level. Journal of Spinal Cord Medicine, 26(1), 59-64. NARIC Accession Number: J46233.
Produced under grant number: H133G10101
Abstract: Describes study conducted to determine the influence of lesion level on shoulder muscle electromyographic activity during a depression raise maneuver in men with spinal cord injury. The depression raise maneuver is commonly performed to relieve skin pressures and avoid skin ulceration. Participants were grouped according to level of injury: C7 tetraplegia, C6 tetraplegia, high paraplegia, and low paraplegia. Results showed that individuals with tetraplegia lacked normal strength of the primary muscles used by those with paraplegia for the depression raise. Alternate methods of pressure relief should be considered for people with tetraplegia.

Ammer, M. L., Brienza, D. M., Geyer, M. J. (2002) A survey of alternating pressure seat cushions. In R. Simpson (Ed.), Proceedings of the RESNA 25th International Conference: Technology and Disability: Research, Design, Practice and Policy (pp. 333-335). Arlington, VA: RESNA Press. NARIC Accession Number: O14561.
Abstract: Paper reports findings from survey conducted to determine the characteristics of alternating pressure seat cushions currently available in the United States.

Bogie, K., Triolo, R. J., Chae, J. (2002) Dynamic pressure relief for the wheelchair user with long-term therapeutic neuromuscular electrical stimulation. In R. Simpson (Ed.), Proceedings of the RESNA 25th International Conference: Technology and Disability: Research, Design, Practice and Policy (pp. 169-171). Arlington, VA: RESNA Press. NARIC Accession Number: O14509.
Abstract: Study investigated whether long-term use of neuromuscular electrical stimulation (NMES) can reduce the risk of tissue breakdown and pressure sore development in people with spinal cord injury. Results showed that applications of NMES in the gluteus maximus of regular wheelchair users could provide dynamic seated pressure relief due to intrinsic changes in the paralyzed muscle.

Elliott, T. R., Kurylo, M., Chen, Y., Hicken, B. (2002) Alcohol abuse history and adjustment following spinal cord injury. Rehabilitation Psychology, 47(3), 278-290. NARIC Accession Number: J44303.
Produced under grant number: H133N50009
Abstract: Study examined the relationship between alcohol abuse history and (1) depression and acceptance of disability and (2) the occurrence of pressure sores during the first 3 years following spinal cord injury. One hundred seventy-five people completed the Michigan Alcoholism Screening Test (MAST), the Inventory to Diagnose Depression (IDD), and the Acceptance of Disability Scale on admission to an inpatient rehabilitation program. One hundred five participants were evaluated for pressure sores. Results indicate that alcohol abuse was not associated with depression or disability acceptance. Severe alcohol abuse history was associated with pressure sores over the 3 years.

Halstead, L. S., Dang, T. D., Elrod, M. W., Convit, R., Rosen, M. J., Woods, S. (2002) Distant evaluation of skin health: Teleassessment of individuals in remote settings with spinal cord injury and pressure ulcers. In M. J. Rosen and D. E. Lauderdale (Eds.), Proceedings of the State of Science Conference on Telerehabilitation and Applications of Virtual Reality (pp. 11-13). Washington, DC: NRH Press. NARIC Accession Number: O14717.
Produced under grant number: H133E990007
Abstract: Describes study that compared teleassessments to live assessments of pressure ulcers in individuals with spinal cord injury. Teleassessment was conducted using images obtained with a digital camera and a standard wound database. Results were compared to those from live assessment performed in a clinic examination room. The highest percent of agreement between the 2 methods were for Stage I and II ulcers and wounds on the foot and ankle. The lowest percent agreements were for Stages III and IV sounds and lesions on the sacrum.

Keeler, C., Placek, E., Yap, R., Sabelman, E. E. (2002) Time sequence of pressure changes during weight relief activities on different wheelchair cushions. In R. Simpson (Ed.), Proceedings of the RESNA 25th International Conference: Technology and Disability: Research, Design, Practice and Policy (pp. 360-362). Arlington, VA: RESNA Press. NARIC Accession Number: O14568.
Abstract: Study investigated whether a wearable motion analysis system would identify pressure relief patterns that would be useful in monitoring the development of pressures sores. Data on motion and pressure relief patterns was collected from 5 people with spinal cord injury doing pressure relief exercises. Results confirmed that the exercises could be distinguished from other citifies using pressure data.

LaHaie, H. C., Rorrer, R. A. L., Blake, D. J., Kennedy, P. (2002) Relationship of wheelchair pushrim forces and pressures at the body-seat interface in manual wheelchair users. In R. Simpson (Ed.), Proceedings of the RESNA 25th International Conference: Technology and Disability: Research, Design, Practice and Policy (pp. 348-350). Arlington, VA: RESNA Press. NARIC Accession Number: O14566.
Abstract: Study measured wheelchair pushrim forces, body-seat interface pressure, and upper extremity motion during manual wheelchair propulsion. Findings suggest that the more efficient the user is in propelling the wheelchair, the smaller the pressure differential is during propulsion.

McKinley, W. O., Gittler, M. S., Kirshblum, S. C., Stiens, S. A., Groah, S. L. (2002) Spinal cord injury medicine. 2. Medical complications after spinal cord injury: Identification and management. Archives of Physical Medicine and Rehabilitation, 83(3), Suppl 1, S58-S64. NARIC Accession Number: J43090. Produced under grant number: H133N000015
Abstract: Self-directed learning module reviews the diagnosis and treatment of medical complications associated with spinal cord injury. Describes treatment approaches for common medical complications that impact rehabilitation, including pressure ulcers, unilateral lower-extremity swelling, spasticity, autonomic dysreflexia, orthostatic hypotension, and pain.

McKinley, W. O., Tewksbury, M. A., Godbout, C. J. (2002) Comparison of medical complications following nontraumatic and traumatic spinal cord injury. Journal of Spinal Cord Medicine, 25(1), 88-93. NARIC Accession Number: J44781.
Produced under grant number: H133N000015
Abstract: Study compares the incidence of medical complications secondary to spinal cord injury (SCI) in patients with nontraumatic and traumatic SCI. Prospective data collected included medical complications, injury characteristics, demographics, and rehabilitation outcomes. Individuals with traumatic SCI developed medical complications at a higher frequency in the following areas: deep vein thrombosis, pressure ulcers, autonomic dysreflexia, pneumonia, orthostatic hypotension, and spasticity. Individuals with nontraumatic SCI were more likely to have wound infections during rehabilitation. No significant differences were found between the 2 groups in the incidence of depression, urinary tract infection, heterotopic ossification, pain at admission, and gastrointestinal bleeding.

Wang, J., Brienza, D. M., Karg, P., Bertocci, G. (2002) Viscoelastic properties of buttock soft tissues with pressure ulcer susceptibility. In R. Simpson (Ed.), Proceedings of the RESNA 25th International Conference: Technology and Disability: Research, Design, Practice and Policy (pp. 330-332). Arlington, VA: RESNA Press. NARIC Accession Number: O14560.
Produced under grant number: H133E990001
Abstract: Study compares properties of buttock soft tissues in subjects with spinal cord injury (SCI) and a history of pressure ulcers without and subjects without SCI. Significant differences were found between the 2 groups in the material properties, reduced relaxation parameters, and elastic response curves.

(2001) Journal of Rehabilitation Medicine and Science, V2, 1-99. NARIC Accession Number: O13959.
Produced under grant numbers: H133G60183, H133N000029, H133E003001, H133B70011, H133B980024
Abstract: This issue presents overviews and news updates from grant-funded clinical research programs at Rancho Los Amigos, including the Pressure Ulcer Management Research Program.

Ashok, P., Foster, C., Kurian, M., McLaughlin, J., Nielsen, M. (2001) A breakthrough in wheelchair technology: A modular backrest with dynamic cushioning. In R. Simpson (Ed.), Proceedings of the RESNA 2001 Annual Conference: The AT Odyssey Continues (pp. 367-369). Arlington, VA: RESNA Press. NARIC Accession Number: O14249.
Abstract: Paper on the design, development, and initial evaluation of a wheelchair backrest designed for comfort and prevention of pressure sores. The design concept involves multiple axes of adjustment and a novel “floating” pad.

Bain, D., Ferguson-Pell, M., Wain, G. (2001) Risk factors for pressure ulcers: Set in stone? In R. Simpson (Ed.), Proceedings of the RESNA 2001 Annual Conference: The AT Odyssey Continues (pp. 292-294). Arlington, VA: RESNA Press. NARIC Accession Number: O14224.
Abstract: Preliminary study to identify candidate risk factors for progression of pressure sores from grade 1 to grade 2 and beyond. The authors conclude that factors that factors which predispose individuals to grade 1 pressure sores may not be the same as those which determine whether a grade 1 pressure sore will progress or resolve.

Brienza, D. M., Karg, P. E., Geyer, M. J., Kelsey, S., Trefler, E. (2001) The relationship between pressure ulcer incidence and buttock-seat cushion interface pressure in at-risk elderly wheelchair users. Archives of Physical Medicine and Rehabilitation, 82(4), 529-533. NARIC Accession Number: J41786.
Produced under grant number: H133G70076
Abstract: Study examining the relationship between pressure ulcer incidence and buttock-wheelchair seat cushion interface pressure measurements among older adult wheelchair users. The incidence of sitting-induced pressure ulcers over a 1- to 12-month period was compared to interface pressure measurements made using a flexible pad with a 15 x 15 pressure sensor array. Results indicate that higher interface pressure measurements are associated with a higher incidence of seating-induced pressure sores.

Creasey, G. H., Brennan, P., Paulsen, D. F. (2001) Pressure ulcer prevention with interactive learning (P.U.P.I.L.). NARIC Accession Number: O14294.
Produced under grant number: H133G50067
Abstract: Final report of project aimed at designing, creating, and disseminating interactive teaching materials for pressure ulcer prevention. Includes a copy of the multimedia CD-ROM produced under the grant.

Eltorai, I.M., Schmitt, J. K. (eds.) (2001) Emergencies in chronic spinal cord injury patients, 3rd edition. NARIC Accession Number: R08249.
Produced under grant number: H133N00022
Abstract: Text provides guidelines for managing emergencies in patients with spinal cord injuries (SCI). Following a foreword by Joel A. DeLisa, President and CEO, Kessler Medical Rehabilitation Research and Educational Corporation, each chapter addresses a specific aspect of emergency management: autonomic dysreflexia; acute and chronic cardiovascular problems; pulmonary complications; SCI ventilator-dependent patients; gastrointestinal, urologic, hyperglycemic, psychiatric, and psychosocial emergencies; fluid and electrolyte disorders and acute renal failure; pulmonary embolism and deep venous thrombosis; acute arterial occlusion of the lower extremities; spasticity; acute and chronic pain; long-bone fractures; dislocation in the lower extremities; osteomyelitis due to pressure ulcers; decubitus ulcers; minor burns; pregnancy, thermoregulation; infections; fever; and nursing management of the complications of SCI.

Morris, J. D. (2001) Pressure relieving movements made during sleep: Do these occur during windows of opportunity? In R. Simpson (Ed.), Proceedings of the RESNA 2001 Annual Conference: The AT Odyssey Continues (pp. 283-285). Arlington, VA: RESNA Press. NARIC Accession Number: O14221.
Abstract: Study examining relations between patterns of turning during sleep and tissue-interface pressures at 10 anatomical points prone to pressure sores. Participants were 20 healthy individuals. Results indicate that turning was related to REM-NREM transitions. The incidence of movement was found to be linked to levels of tissue anoxia. This linkage is modeled as a logarithmic relationship between maximum period of immobility and tissue anoxic level.