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SCI: Pressure Ulcers (2003)


Byrne DW, Salzberg CA. Major risk factors for pressure ulcers in the spinal cord disabled: a literature review. Spinal Cord 1996:43:255-263.

PubMed ID: 8963971
Study Design:
Narrative Review
R - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:
  • To provide an overview of published reports on the principal risk factors for pressure ulcers in persons with spinal cord injury
  • Most pressure ulcer research has been on the elderly. The drastically altered physiology of persons with SCI makes the risk factors and thresholds for each of these risk factors unique.
Inclusion Criteria:
  • Medical, nursing, and nutritional research literature that pertained to risk factors for pressure ulcer development.
Exclusion Criteria:
  • Not described.
Description of Study Protocol:

Recruitment:  Methods for article inclusion not described.

Design:  Narrative Review

Blinding Used (if applicable):  not applicable

Intervention (if applicable):  "Critically evaluated” the research literature.

Statistical Analysis:  Statistical analysis not completed.

Data Collection Summary:

Timing of measurements:  not applicable

Dependent Variables

  • Risk factors for pressure ulcers listed as “major” and “potential” as they apply to SCI  

Independent Variables

  • Spinal cord injury

Control Variables

Description of Actual Data Sample:

Initial N:  190 citations

Attrition (final N):  190

Age:  not mentioned

Ethnicity:  not mentioned

Other relevant demographics:


Location:  Worldwide studies


Summary of Results:

15 Major Risk Factors

Severity of SCI

  • Decreased activity
  • Immobility
  • Completeness of the SCI
  • Urine incontinence/moisture
  • Autonomic dysreflexia/severe spasticity.

Preexisting Conditions

  • Advanced age (age 35 and 65)
  • Tobacco use/smoking
  • Cardiac disease/abnormal electrocardiogram
  • Diabetes/poor glycemic control
  • Renal disease
  • Impaired cognitive function
  • Residing in a nursing home/hospital.

Malnutrition and Anemia

  • Hypoalbuminemia/hypo-proteinemia (albumin<3.5)
  • Anemia (hemoglobin<12, hematocrit<36).

Potential Nutritional Risk Factors

  • Negative nitrogen balance
  • Hypocholesterolemia
  • Low BMI/thinness
  • Inadequate fluid intake/dehydration
  • Poor nutritional intake
  • Achexia/pronounced emaciation
  • Obesity
  • Inadequate serum ascorbic acid or zinc
  • Ideal body weight below normal
  • Triceps skinfold below normal
  • Inadequate protein intake (as percent RDA)
  • Vitamin deficiencies in general
  • Low serum calcium, magnesium, vitamin D and Vitamin E deficiencies.
Author Conclusion:

There is no question that preventing pressure ulcers is far less expensive than treating them. Patients with multiple risk factors are in a high-risk group and should be enrolled in a comprehensive program for preventing pressure ulcer. Pressure ulcer prevention in a high-risk group of SCI deserves a high priority in future health care and insurance reforms. The 15 major risk factors help make such a prevention program more manageable.

Funding Source:
Government: New York State Dept. of Health, CDC
Foundation associated with industry:
Reviewer Comments:
Inadequate sample size on many SCI studies is noted.  Authors’ methods for search, selection, and critical appraisal not described. Statements in paper thoroughly referenced. Small sample size and issues related to generalizing from pressure studies on elderly are the only limitation mentioned. Some discrepancies in the literature pointed out.
Quality Criteria Checklist: Review Articles
Relevance Questions
  1. Will the answer if true, have a direct bearing on the health of patients? Yes
  2. Is the outcome or topic something that patients/clients/population groups would care about? Yes
  3. Is the problem addressed in the review one that is relevant to dietetics practice? Yes
  4. Will the information, if true, require a change in practice? Yes
Validity Questions
  1. Was the question for the review clearly focused and appropriate? Yes
  2. Was the search strategy used to locate relevant studies comprehensive? Were the databases searched and the search termsused described? No
  3. Were explicit methods used to select studies to include in the review? Were inclusion/exclusion criteria specified andappropriate? Wereselectionmethods unbiased? No
  4. Was there an appraisal of the quality and validity of studies included in the review? Were appraisal methodsspecified,appropriate, andreproducible? ???
  5. Were specific treatments/interventions/exposures described? Were treatments similar enough to be combined? ???
  6. Was the outcome of interest clearly indicated? Were other potential harms and benefits considered? Yes
  7. Were processes for data abstraction, synthesis, and analysis described? Were they applied consistently acrossstudies and groups? Was thereappropriate use of qualitative and/or quantitative synthesis? Was variation in findings among studies analyzed? Were heterogeneity issued considered? If data from studies were aggregated for meta-analysis, was the procedure described? No
  8. Are the results clearly presented in narrative and/or quantitative terms? If summary statistics are used, are levels ofsignificance and/or confidence intervals included? Yes
  9. Are conclusions supported by results with biases and limitations taken into consideration? Are limitations ofthe review identified anddiscussed? Yes
  10. Was bias due to the review's funding or sponsorship unlikely? Yes