The goals of rehabilitation are to improve function, decrease secondary morbidity, and enhance health-related quality of life. Unfortunately, many individuals with disorders requiring rehabilitation are affected by pressure injuries (PIs), which can have a significant negative impact on quality of life. The goal of this chapter is to describe the benefits of utilizing telerehabilitation in the treatment of PIs.
Pressure wound, pressure ulcer, pressure sore, pressure injury, or decubitus are interchangeable terms. Many different descriptions cover this condition, but the optimal description to use is pressure injury (PI), defined as “A pressure injury is 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 and/or friction.” In this chapter, the term PI will be used, because this covers all aspects of skin and tissue damage.
Categorization of Pressure Injury
A PI appearing as intact skin with nonblanchable redness of a localized area or as partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough, is termed category 1 and 2 pressure ulcer, respectively. In a more severe PI, there will be a full thickness skin loss, with visible subcutaneous fat, termed category 3, or even exposed bone, tendon, and muscle, termed category 4. Finally, there is the full thickness tissue loss PI, in which the base of the ulcer is covered by slough and/or eschar, termed unstageable PI, and the suspected deep tissue PI, with unknown depth, purple or maroon localized area of discolored intact skin, or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Table 12.1 shows the different categorizations of PIs.
Amongst people with PIs, those who suffer from spinal cord injury (SCI) are at particular risk due to paralysis, reduced skin sensitivity, and skin that is exposed to moisture for extended periods of time. Individuals with SCI and PI are often hospitalized for long periods of time and need frequent outpatient care for both treatment and monitoring. Traveling can also cause more difficulties for persons who have to travel long distances to get to a hospital. Traveling can worsen the condition or cause new PIs to develop. It is therefore important to have follow-up options for this group, without the need to travel to outpatient clinics. These issues, while not as well researched, are similar with individuals with other diagnoses who are at risk for PI such as people who are at bed rest for long periods, people in the intensive care unit (ICU), people who recently underwent hip surgery, and people suffering from neurodegenerative neuromuscular diseases such as multiple sclerosis and amyotrophic lateral sclerosis, as well as stroke and brain injury. Due to changes in body mass index, reduced activity, and function in general, as well as skin losing its elasticity, the elderly are also at a particular risk of developing a PI.
The prevalence of PI among persons with SCI varies between 35% and 80%, depending on how different studies define PI, and depending on the time since the SCI when the PI occurrences were measured. The occurrence of PIs in people with and without SCIs also depends on underlying health conditions. The overall prevalence of PI in acute care hospitals varies between 6.7% and 15%. However, the total percentage of those who develop such ulcers is most likely higher, especially in high-risk groups, such as patients with hip fracture and patients in the ICU.
Health-reported quality of life (HRQoL) is reduced in persons with long-standing SCI and especially in persons with comorbidities. Australians with SCI have rated their physical health status as worse than the general population, and PI has caused an adverse impact on the HRQoL and self-esteem of patients with SCI. PIs most often occur when one or more known risk factors are present, such as impaired nutritional status, reduced or impaired general condition, reduced mobility and activity, and moisture, shear and friction, as well as reduced ability to perceive stimuli. People with spinal cord lesions and other forms of paralysis that lead to reduced sensorimotor function and use of wheelchairs are particularly vulnerable. PI can also cause serious complications, with consequences for the individual consumer as well as for the capacity of the health care service. PIs occur at home, in institutions, and in hospitals. All care providers must have basic knowledge in preventing PIs in their care receivers, due to the fact that people with disabilities have an increased risk of incurring PI, and that PI can be difficult to treat. There is a need to monitor the occurrence of PI, both as part of quality improvement measures and as a basis for management and leadership in hospitals and in the community. Red marks and damage to the skin can be signs that something has changed, for example, weight gain or weight reduction, changed surface pressure, changed transfer techniques, a new life situation, and so on.
When pressure damage has occurred, measures must be taken to limit the scope and encourage healing of the PI. Having the necessary knowledge and competency will make the care providers available to take care of the consumer’s needs, treat them, and guide colleagues. All professional groups that see bare skin must be able to recognize red marks that indicate that a PI is developing, and relevant professional groups must be familiar with general procedures for evaluating and treating PIs.
Telerehabilitation in Pressure Injury Follow-Up
Telerehabilitation has changed our options for offering medical services to patients. Moreover, telerehabilitation has also changed our possibilities for sharing knowledge to health care providers, and knowledge transfer can be performed through peer mentoring, courses, and training, both virtual and on-site. Changing weather conditions, climate change, and pandemics with the need to reduce the risk of infection have led to new possibilities for reaching out to patients in hospitals and outpatient clinics. Telerehabilitation is a way to overcome the barriers of distance, and several different services are available to patients in need of long-term rehabilitation. Telerehabilitation makes PI rehabilitation services more accessible and results in a more coordinated and secured transfer of knowledge between the patient, regional, or local services and other necessary providers throughout the course of treatment. If consumers and residents receive proper PI treatment at the right place and time, through comprehensive and coordinated health care services that are adapted to the individual’s specific needs, healing of PIs will be optimized and there can be a rapid return to the individual’s premorbid functional level.
Care for PIs should be offered at a local level, where consumers live, so they can remain functional and have their lives disrupted as little as possible by the PI. Thus rehabilitation professionals have a responsibility to educate, support, and mentor local health care providers about treatment of PI. It is also important that the organization of health care services includes and secures the provision of rehabilitation services, no matter the geographical location of the care provider or care receiver.
A telerehabilitation model should aim to take advantage of active involvement and feedback based on experience and evaluation from consumers, their families, and local health care services. Studies have reported that when rehabilitation services are carried out in a consumer’s familiar surroundings they are more pertinent to everyday life. This is important for consumers with complex needs and in need of long-term follow-up such as individuals with SCI and PI. Thus providing informed care at a local level contributes to proper use of the health resources with reduced consumption of travel costs and in-hospital services.
Videoconferencing is a way of offering communication directly to consumer and provider simultaneously, and videoconference collaboration can be performed with specialized health care providers (the rehabilitation hospital) located in one area, while the care receivers and/or local care providers and other collaborators are located in another. Other collaborators can include health care professionals at other hospitals, representatives for employers, school, the assistive aids office, the social welfare benefit office, and an interpreting service, as shown in Fig. 12.1 .
Using telerehabilitation makes it easier to provide PI care using a modern means of communication, which in turn simplifies provider-to-provider communication and improves the consumer’s accessibility to health care providers and other collaborators. These communication channels are also an effective way to perform PI follow-up regarding education, knowledge transfer, prevention, and treatment. Good health care services are characterized by effective, coordinated, safe, and secure services and include the care receivers. Telerehabilitation ensures continuity and utilization of resources in a proper way, as well as accessibility and regional distribution of services, and puts the consumer in the center of the service. Thus a proper PI service should include knowledge translation, competence, and quality in the field of support and education not only to patients and relatives, but also to local care providers, taking care of everyday health care services. Accordingly cooperation between local authorities, consumer organizations, and other relevant partners is strengthened in ways that benefit society socioeconomically.
Telerehabilitation for PI follow-up can be performed in several ways. Sometimes it is necessary for the providers to communicate directly to other care providers or to other caregivers, and direct communication to the consumer is often useful. However, store and forward communication, where still photos or videos are sent to health care receivers or users, can also be a suitable solution where the consumers or local care providers need general information.
Different means of web-based treatment or online education are also solutions that can give both care receivers and care providers evidence-based knowledge and guidance regarding prevention and treatment.
The Multidisciplinary Team and Telerehabilitation in Pressure Injury Follow-Up
The multidisciplinary rehabilitation team includes a large number of different health care professionals ( Fig. 12.2 ), and a smaller selection of necessary team members can participate in meetings, depending on the issue.
All participants in the PI treatment team must know the risk factors for PI development. These risk factors affect healing and therefore affect planning of further rehabilitation. Fig. 12.3 provides an overview of overall risk factors that must be known by members of the care team, regardless of where rehabilitation takes place.
Determination of whether aids, like a wheelchair, are dangerous to a consumer or the environment must be performed, for example, if the cognitive function is reduced. The physician and psychologist are important in clarifying this issue.
Is a wheelchair suitable for multiple purposes such as wheelchair racing and general community mobility or is it best suited indoors? Here, it is important that the physiotherapist clarify what the patient is able to do in terms of exercise. The occupational therapist is important in relation to facilitation of necessary pressure-relieving measures, as well as the acquisition of aids, including wheelchair cushions and mattresses. It is important that the wheelchair fit the intended use, for example, what happens if the back of the chair is folded? Is folding possible? What does the patient need? Is it impossible to get hold of a wheelchair or cushion? Is it possible to make a cushion of foam rubber? A needs assessment should be conducted by team members. It is also important to check the possibility of receiving new assessments on a regular basis, for example, assess age and how well the assistive device works in relation to the use it was intended for, and whether the consumer is comfortable with the use. How easy is it to repair damage and when should the assistive device be replaced? Seating pressure measurement is recommended to ensure that the correct cushion is selected in the wheelchair and that the cushion has the best pressure distribution, and seating comfort. The same should be applied when choosing a mattress. Observation of the skin in relation to morning and evening care should be conducted either by nurses at the hospital or local care providers. Any incontinence issues must also be addressed by the physician, nurse, or other personnel with necessary competency.
Adjusting rehabilitation services is also important, for example, if a consumer is ambulatory; it can be difficult to work on ambulation with shoes or bracing that are the cause of the ongoing PI, or if the shoes exacerbate PIs that are already present. Shoes with straps over the back of the foot are an example of footwear that is unsuitable if there is ongoing PI or risk of PI in this area. Shoes with stiff heel caps can also cause pressure to the heels and be a risk factor for PI development. An orthotist or orthopedic technician is a good resource for clarifying issues regarding what shoes to wear. A physiotherapist should contribute with training and treatment of body areas that are particularly exposed to stress, for example, shoulder strain if the consumer uses a manual wheelchair. Seat balance and positioning can cause pressure in several body areas, in addition to friction if the seat slides forward in the chair. All care providers must observe whether seating comfort, balance, and positioning are appropriate.
If the consumer suffers from lower extremity edema, it is important to focus on pressure prevention alongside treatment of the swelling. Elevation of the legs while the person is in a sitting position will cause the seat to slide forward and the individual may be exposed to pressure and friction. The result is increased risk of pressure damage. All care providers must ensure that the consumer sits in a good and pressure-relieving manner. Compression stockings and tilt of the wheelchair to elevate the legs are recommended solutions for lower extremity edema, as well as appropriate medical therapies.
Chronic or periodic pain can cause difficulties in finding comfortable sitting and lying positions. This can result in restless sitting and lying, which in turn can result in friction and an increased risk of PI. Pain-relieving medication and treatment are appropriate. The same goes for mental health, mood swings, and depression. Mental health issues can have a negative effect on self-care, which in turn will increase the risk of PIs. A psychologist or psychiatrist should be involved if an individual with disability has mental health issues and a social worker is important to follow-up income and social welfare benefits. Telerehabilitation can be also used together with on-site consultations to offer multidisciplinary assessments of the patient’s state of health, body functions and structures, environmental factors, and ongoing activity.
Use of Telerehabilitation in Pressure Injury Management, Prevention, and Treatment with the International Classification of Functioning, Disability, and Health Framework
PI is a complex condition that requires close cooperation between the health care providers and the consumer to be able to identify and map problem areas and set treatment goals. The International Classification of Functioning, Disability and Health, known more commonly as ICF ( Fig. 12.4 ), is the World Health Organization’s (WHO) framework for measuring health and disability at both individual and population levels. The ICF model is a framework for describing function and disability in relation to a state of health and is a good starting point for conducting a comprehensive, multidisciplinary identification of the risk of PI in consumers. The model gives a description of the level of function within environmental factors affecting a person’s ability for activity and participation. Telerehabilitation is a well-suited modality to include in the ICF framework regarding follow-up of PIs.