04 | Health Behaviour

Health Maintenance - A Patient-Provider Partnership

General Introduction

Health maintenance is considered a key outcome in the long-term care of persons with spinal cord injury (SCI). An person's health behaviour plays a major role in maintaining his or her health. Such behaviour encompasses a range of strategies that can be undertaken by the person and supported by the rehabilitation team. A key strategy toward health maintenance is the prevention of adverse events and comorbidities.1 2

Individual health behaviour such as leading a healthy lifestyle may prevent and influence the development of complications. By offering education, counseling and training, rehabilitation programs hope to support a person with SCI toward preventing many avoidable complications and secondary conditions.

Health Maintenance

Health maintenance is an important outcome in persons with SCI that can be achieved through preventative strategies such as health behaviour promotion. Health behaviour promotion cover a spectrum of activities and interventions from the educational to the clinical. Such health behaviours on the part of the person with SCI can include activities like eating properly, getting enough rest and exercise, maintaining a healthy weight, drinking in moderation and not smoking. 2 3 Note however that solely focusing on preventative behaviours may be ineffective in reducing the long-term risk of secondary complications such as pressure ulcers (PUs). Promoting an overall healthy lifestyle and considering various approaches toward health maintenance may be equally if not more valuable. 4

Clinical interventions that foster health maintenance may include routine health monitoring and the treatment of complications such as pain and sexual dysfunctions.1

Box 1 | Health Maintenance and Secondary Complications in SCI

The prevention of secondary complications is a main objective of health maintenance. In SCI common complications include pressure sores, spasticity, urinary infections, pulmonary complications and pain. Gender-specific issues can also affect SCI patients including sexuality and fertility complications.1 5 6

Notably, the World Health Organization (WHO) has addressed this issue by including health maintenance aspects in the International Classification of Functioning, Disability and Health (ICF). Here, they fall under the term, “looking after one’s health,” meaning “ensuring physical comfort, health and physical and mental well-being.” Maintaining one’s health is further defined as “caring for oneself by being aware of the need and doing what is required to look after one’s health, both to respond to the risks to health and to prevent ill-health.” 7 Note that these definitions clearly place the responsibility for health maintenance on the person with the health condition.

The importance of the person's involvement in his or her own health maintenance can be seen when dealing with pressure ulcers, also known as bedsores or decubitis. 8 Pressure ulcers (PUs) are the most common medical complications experienced by persons with SCI followed by pneumonia and genitourinary issues.1 5

"Pressure ulcers (PUs) are the most common medical complications experienced by persons with SCI followed by pneumonia and genitourinary issues."

Box 2 | Pressure Ulcers

The National Pressure Ulcer Advisory Panel (NPUAP) and the European Pressure Ulcer Advisory Panel (EPUAP) define PUs as a "localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear". 9 In addition, PUs cause inadequate blood supply and death of cells and tissue. 10 The area where ulcers are found depends on whether an individual is bed-bound or a wheelchair user and on which body part is affected. About 95% of PUs occur in the lower part of the body. 11

PUs are generally classified by different stages of severity from stage 1 through 4. An additional stage called unstageable or unclassified stage is also available for the United States. These stages reflect progressing depth and the extent of lesions, and are defined as follows: 9

Stage 1: Non-blanchable redness of intact skin and may be accompanied by changes in skin temperature, tissue consistency and/or sensation. Although dark skin may not show visible blanching, the color of the skin may differ from the surrounding area. Nevertheless, detecting stage 1 PUs remain difficult in persons with dark skin tones.

Stage 2: Partial thickness skin loss involving epidermis, dermis or both. The ulcer is usually superficial and presents clinically as an abrasion, blister or shallow crater.

Stage 3: Full thickness skin loss involving damage to or necrosis of subcutaneous tissue. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Clinically, the ulcer presents as a deep crater with or without undermining of adjacent tissue. The depth of the PU is dependent on which body part it is located.

Stage 4: Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures e.g. tendon joint capsule. The ulcer can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making the occurence of infection (osteomyelitis) and inflammation (osteoitis) of the bone or bone marrow more likely. Exposed bone/muscle is visible or directly palpable. Often includes undermining and tunneling. The depth of the PU is dependent on which body part it is located.

Common complications of PUs include increased mortality, osteomyelitis and sepsis (i.e. a systemic inflammatory response). 11

The prevalence of PU amongst persons with SCI range from 15% to approximately 45% 5 12 13 14 and increases with time post-injury. 15 In order to prevent PUs, risk factors must be identified. The Braden Scale for Predicting Pressure Ulcer Risk is one instrument that can be used to determine the risk of developing ulcers. 16 17 The risk of developing ulcers is influenced by multiple factors that include: 18 19

  • Physical/medical factors including the level and completeness of injury, activity and mobility, bladder, bowel and moisture, comorbidities such as incontinence, and an in ability to feel pain (especially in complete SCI)
  • Psychological and social factors including psychological distress, cognitive impairment, smoking, substance abuse, and treatment adherence
  • Extrinsic factors such as type of wheelchair, cushion and surface of bed
  • Demographic factors such as age (increasing risk over 40), duration of injury and education (lower education is linked to health outcomes in general)

These risk factors help to point out which patients require more closer observation and support in preventing PUs. 18 19

The presence of PUs also influences the length of stay at hospital, resulting in greater treatment costs than other SCI-associated medical complications. 4 14 Left untreated, PUs can lead to systemic infections and can be life-threatening. However, they are preventable and most often, treatment is successful.

Treatment guidelines for health professionals recommend the following interventions: 18 20

  1. prevention considerations
  2. correction of underlying factors, including nutritional support
  3. debridement options, infection control and wound care
  4. stage-dependent interventions that range from conservative treatment to surgical closure methods

Given the frequency and seriousness of PUs among persons with SCI, treatment and health maintenance efforts are essential. This encompasses the person’s health behaviour and understanding of his or her responsibilities and involvement in the interventions.

"...treatment and health maintenance efforts are essential. This encompasses the person’s health behaviour and understanding of his or her responsibilities and involvement in the interventions."

In illustrating one person's experience with PUs, this case study aims to show that promoting health behaviours is the first step toward health maintenance. To achieve success the responsibility for the interventions must be shared by rehabilitation team and the person with SCI alike.

ICF Research Branch CoordinatorICF Research Branch in cooperation with the WHO Collaborating Centre for the Family of International Classifications in Germany (at DIMDI)

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