Health maintenance is considered a key outcome in the long-term care of spinal cord injury (SCI) patients. An individual patient’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 individual and supported by the health care team. A key strategy toward health maintenance is the prevention of adverse events and comorbidities.1

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

Health Maintenance

Health maintenance is an important outcome in SCI patients that can be achieved through preventative strategies such as health behaviour promotion. The promotion of health behaviour may cover a spectrum of activities and interventions from the educational to the clinical. Such behaviours on the part of the patient can include activities like eating properly, getting enough rest and exercise, maintaining a healthy weight, drinking in moderation and not smoking.5 Clinical interventions may include routine health monitoring and the treatment of complications such as pain and sexual dysfunctions.6

There is, however, little evidence that supports the positive effects of such interventions on health maintenance after a patient has been released from the rehabilitation program.9 Once away from the rehabilitation facility, it is incumbent upon the patient to bear the responsibility for preventing SCI-related complications.

Box 1 | Health Maintenance and Secondary Complications in SCI

The prevention of secondary complications is a key aspect of health maintenance.2 In SCI common complications include pressure sores, spasticity, urinary infections, pulmonary complications and pain.34 Gender-specific issues can also affect SCI patients including sexuality and fertility complications.

Notably, the World Health Organization 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.”7 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.” 8 It is important to note that these definitions clearly place the responsibility for health maintenance on the patient.

An example can be seen in one common complication affecting persons with SCI over a lifetime - the occurrence of pressure ulcers (PU), also known as bedsores or decubitis.10 After pneumonia and genitourinary issues, PU are one of the most frequent SCI-associated medical complications experienced by patients.1112

After pneumonia and genitourinary issues, pressure ulcers are one of the most frequent SCI-associated medical complications.

Box 2 | Pressure Ulcers

Pressure ulcers are lesions that result from unrelieved pressure, shearing or friction to any part of the body, particularly bony protruding areas, causing inadequate blood supply and cellular necrosis. 15 Areas where ulcers are found will depend on whether an individual is bed- or wheelchair-bound and include tailbone, buttocks, shoulder blades, spine, hip bones and so on.

These ulcers are generally classified by different stages of severity (from I through VI and unstageable).16 These stages reflect progressing depths and extents of lesions and are defined as follows:17

Stage 1: Observable pressure-related alteration of intact skin, which may include changes in skin temperature, tissue consistency and/or sensation.
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 that may extend down to, but not through, underlying fascia. Clinically, the ulcer presents as a deep crater with or without undermining of adjacent tissue.
Stage 4: Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures e.g. tendon joint capsule. Undermining and sinus tracts also may be associated with stage 4 ulcers.

Common complications of pressure ulcers include increased mortality, sepsis and osteomyelitis. Sepsis is a systemic inflammatory response and osteomyelitis is an infection of the bone or bone marrow. The latter has been reported in 38% of patients with infected ulcers.18 Pressure ulcers can develop rapidly, and the prevalence amongst SCI patients range from 20% to 60%.19

In order to prevent ulcers, risk factors must be identified. The Braden Scale for Predicting Pressure Ulcer Risk is one method of determining a risk for developing ulcers.20 The risk of developing ulcers is influenced by multiple factors that include:2122

  • 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, substance abuse, and treatment adherence
  • Extrinsic factors such as pressure stress, shearing, microtraumata, injuries, and wheelchairs
  • Demographic factors such as age (increasing risk > 40), duration of injury (the likelihood of PU increases with time since SCI) and education (lower education is linked to health outcomes in general)

Many of the predictive factors have been investigated, and point out for which patients closer prevention support is warranted e.g. patients living with SCI more than 5 years may need closer monitoring.23 The presence of PU also influences the length of stay at hospital, resulting in greater treatment costs than other SCI-associated medical complications.

Left untreated, PU can lead to systemic infections and be life-threatening. However, they are preventable and most often, treatment is successful.

Treatment guidelines for health professionals recommend the following interventions:2425

  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 PU among SCI patients, treatment and prevention efforts are essential. This encompasses the patient’s understanding of his or her responsibilities and involvment in the interventions.

Although preventable under most circumstances, PU can result in keeping individuals from working, attending school and reintegrating into communities.13 Furthermore, the prevalence of such PU increases over time following the injury.14

Both the treatment of PU and their subsequent prevention are central aspects of overall health maintenance and therefore a rehabilitative outcome of vital importance. Considering this, preventative aspects of a patient's health behaviour plays an important role.

The preventative aspects of a patient's health behaviour plays an important role.

In examining one patient’s affliction with pressure ulcers, this case study aims to show that promoting health behaviours are one premise for achieving health maintenance. However, to achieve success the responsibility for the respective interventions should be shared by health professionals and patient alike.