Skin problems among the wheelchair users: a prospective cross-sectional study

Background:

Skin is the largest and the outermost body organ. It is directly affected by the external environment. The biomechanical differences in wheelchair users compared to healthy people make them prone to different risk factors of skin problems. Nevertheless, these patients are under-represented in the dermatologic literature.

Objective:

The primary objective was to determine the frequency of different skin problems among wheelchair users. The secondary objective is to determine the different precautions they are taking to prevent these problems.

Methods:

The prospective study followed a cross-sectional design, conducted during the period of the coronavirus disease 2019 curfew between May and June 2020. The survey’s link was distributed among adult wheelchair users in Saudi Arabia. The questionnaire was administered using google forms. All statistical analyses were performed using SPSS version 22.

Results:

The results show that the vast majority of wheelchair users (85%) experienced skin problems. Pressure ulcer (PU) is the most frequently reported skin condition (54%), followed by traumatic wounds, fungal infections, and hand skin dryness and thickening. The commonest preventive measure was using cushions to avoid PUs.

Conclusion:

Most of wheelchair users reported having a history of skin complaints, of which PU was the most common followed by traumatic wounds and fungal infections. Thus, spreading awareness of the risk factors and preventive methods would help them avoid its development and prevent its negative impact on quality of life. Assessing the different kinds of wheelchairs and cushions to avoid PUs would be an interesting area for future studies.

Introduction

Highlights

• Cross-sectional study to assess skin complications frequency among wheelchair users.

• Eighty-five percent of wheelchair users reported skin complications.

• Pressure ulcer is the most common skin complication in wheelchair users.

• Age is a statistically significant risk factor of pressure ulcers.

• Traumatic wounds, tinea pedis, and xeroderma are also commonly reported.

Wheelchair users have completely different biomechanical characteristics compared to healthy people. This leads to differences in the areas prone to pressure, friction, or injuries. Consequently, some dermatological conditions can be seen more frequently in wheelchair users than in healthy individuals. Unfortunately, this group of patients is under-represented in the dermatologic literature. In the 2017 national statistics of Saudi Arabia, there are 12 366 individuals who cannot walk1. Pressure ulcers (PUs), a common complaint in this population, are caused by prolonged pressure against the skin decreasing blood flow and increasing friction and moisture, leading to increased tissue damage and decreased healing capability2,3; these have been addressed from different angles by several studies4. No studies have assessed PU prevalence in wheelchair users in Saudi Arabia. The incidence in nursing homes in the United States has been assessed to range between 2.2 and 23.9%5. The incidence has been reported by Brienza et al. 6 to be 17.6%. Nevertheless, little is known about the prevalence and risk factors of other dermatological conditions affecting these people. In our study, we aim to highlight common dermatological conditions in wheelchair users. We also addressed PU risk factors and preventive measures. This would help to shed some light on common dermatological problems in these under-represented patients.

Methods

Study design and participants

The prospective study followed a cross-sectional design and was conducted during the period of the coronavirus disease 2019 curfew between May and June 2020. The survey’s link was distributed among adult wheelchair users in Saudi Arabia, and the questionnaire was administered using Google Forms. The first page showed the study purpose, confidentiality statement, and the time needed for completion; once the individuals agreed to participate, they began responding to the survey’s items. Participant inclusion criteria included being an adult (≥18 years), a permanent wheelchair user, of Saudi nationality, and voluntarily agreeing to answer all questions. We excluded all incomplete and duplicate responses. This work has been prepared in line with the STROCSS (Strengthening the reporting of cohort, cross-sectional and case-control studies in surgery) criteria to ensure good reporting quality7.

Outcomes

The primary outcome is to assess the frequencies of dermatological complications among wheelchair users. The secondary objective is to assess the preventive measures taken by wheelchair users to avoid PU and other complications.

Ethical approval and registration

The study was approved and registered by the Qassim University Ethical Committee (18/5/2020; No.: 19-12-08). The study has been retrospectively registered in the Research Registry (www.researchregistry.com) with the unique identifying number: researchregistry84678.

Study instrument

The study used a self-administered questionnaire that was composed by the study investigators after reviewing the literature. The questionnaire was piloted on 15 wheelchair users before being adapted and approved for use. It consists of a series of questions concerning respondents’ demographics including age group and marital status (divorced and widowed individuals were considered as singles). Additionally, the study tool included items about disability-related information, such as the ability to move the lower back without help, type (e.g. paraplegia or quadriplegia) and the cause of disability (congenital or injury or disease). The third page covered aspects related to wheelchair use and characteristics such as time in use per day and cushion type, if any. In the last section, respondents were asked if they had ever suffered from a list of skin disorders, including PUs, tinea pedis, tinea cruris, lower limb traumatic wounds, and hand skin dryness or thickening, among others. Furthermore, the respondents reported what measures they have used to prevent or alleviate PUs and whether their suffering from PUs has affected their psychological status.

Statistical analysis

Taking into consideration the percentage reported by Brienza et al.6, 17.6%, with a CI of 80% and a margin of error of 5%, the minimal sample size has been calculated using Epi-Info software to be 95 participants. Data were entered, processed, and analyzed using IBM SPSS Statistics for Windows, version 22 (IBM Corp.). Sociodemographic variables like age group, marital status, type and cause of disability, and wheelchair characteristics are presented as frequencies and percentages. χ ² was used to assess the relationship between various categorical variables and the presence of PUs, while Fisher’s exact test was used when appropriate. Statistical tests were considered significant at P less than 0.05.

Results

A total of 114 wheelchair users responded, of which 13 responses were excluded because of incompleteness or duplications. A total of 101 responses were included in the analysis. The majority of respondents were 18–29 years old, followed by the (30–39) and (40–49) age groups. More than half of the respondents were single (57.4%). The most common disability was paraplegia (63.4%), with more than two-thirds of all respondents reporting the ability to move their lower back (69.4%). Almost half of the respondents stay in their wheelchairs for 5–10 h per day. Other demographic and disability-related information is presented in Table 1.

Table 1.

Sociodemographic and health characteristics of the participants (n=101).

		Pressure ulcer [n (%)]
Variable	Total [n (%)]	Yes	No	P
Age
18–29	33 (32.7)	17 (51.5)	16 (48.5)	0.012*
30–39	30 (29.7)	23 (76.7)	7 (23.3)
40–49	28 (27.7)	13 (46.4)	15 (53.6)
50–59	7 (6.9)	2 (28.6)	5 (71.4)
60 +	3 (3)	0 (0)	3 (100)
Disability
Quadriplegia	17 (16.8)	11 (64.7)	6 (35.3)	0.486
Paraplegia	64 (63.4)	35 (54.7)	29 (45.3)
Others	20 (19.8)	9 (45)	11 (55)
Social status
Single	58 (57.4)	33 (56.9)	25 (43.1)	0.567
Married	43 (42.6)	22 (51.2)	21 (48.8)
Ability to move lower back
Yes	70 (69.4)	35 (50)	35 (50)	0.177
No	31 (30.7)	20 (64.5)	11 (35.5)
Wheelchair use/day
<5 h	28 (27.7)	13 (46.4)	15 (53.6)	0.478
5–10 h	48 (47.5)	29 (60.4)	19 (39.6)
>10 h	25 (24.8)	13 (52)	12 (48)
Cushion
Yes	73 (72.3)	42 (57.5)	31 (42.5)	0.316
No	28 (27.7)	13 (46.4)	15 (53.6)

Tests used: Pearson’s χ ² and Fisher’s exact tests (bold).

^*Statistical significance at P<0.05.

Skin complications were reported by 85% of respondents. More than half of the participants (55%) experienced having PUs at least once during their lives. The buttocks (65.5%), thighs (34.5%), back (21.8%), and feet (16.4%) were the most frequent locations. The second most frequently reported skin complication was lower limb traumatic wounds, reported by 39%. Tinea pedis (24%) and skin dryness (20%) were also commonly reported. As shown in Table 2, only 14.8% of the participants did not report any skin problems. Half (47%) of those who had a skin complication reported that it affected their psychosocial status.

Table 2.

Reported skin complications

Skin complication	Total=101 [n (%)]
Pressure ulcer	55 (54.5)
Traumatic wounds	39 (38.6)
Tinea pedis	24 (23.8)
Hand dryness/thickening	20 (19.8)
Tinea cruris	4 (4)
None	15 (14.8)

Individuals with quadriplegia and an inability to move the lower back have shown higher rates of PU. Interestingly, PUs were reported more often by people using cushions than those sitting without cushions. Participants sitting in their wheelchairs for less than 5 h per day reported PUs less often than those sitting for more than 5 h. All of the above-mentioned differences are statistically nonsignificant. Age group was the only factor significantly associated with a history of PUs (P=0.012), with younger participants being more affected.

Discussion

Due to the online nature of the survey, our results represent mainly young and middle-aged adults. Although this limits the generalizability of the results, it reduced the confounding degenerative risk factors seen in elderly patients. PUs are one of the most common complications in disabled individuals after a spinal cord injury9. Up to half of all seated people with disabilities would develop a pressure ulcer at some time during their lifetime10. As seen in Table 2, PU is the most common dermatological complication. Its lifetime prevalence was 54.4%, which is similar to the prevalence previously reported in Thailand (54.3%)11 and the UK (58%)12. In agreement with the findings of Kovindha et al. 11, the buttocks were the most commonly affected site. Regarding PU risk factors, the only statistically significant variable was the younger age groups of 30–39 and 18–29 (P=0.012). Both groups were found to have higher rates of congenital causes compared to older ones. Young age at the time of injury was reported to be a risk factor for PU in spinal cord injury patients13. Wall et al. 10 proposed that the degree of disability and the ability to transfer are important risk indicators of PU. Our results showed that people who are unable to move their lower back were at a nonsignificantly higher risk. PU was reported by 67% of the participants with a car accident-induced disability. Spinal cord injury is known to be a significant risk factor for PU14.

The second most reported skin condition was lower limb traumatic wounds. This mechanically logical complication was reported by 39% of respondents. No specific patient characteristics were found to be associated with this complication in our data. In a comparison of different types of disabilities, Klenck et al. 15 reported lower limb injuries to be more common in blind and cerebral palsy patients. Wheelchair athletes more commonly had PUs and upper limb injuries15. Moreover, soft tissue injuries, skin blisters, and abrasions were the most commonly reported injuries among wheelchair athletes16. Tinea pedis was reported by 24% of individuals in our study; it was nonsignificantly more common among older adults. However, elderly people are more suspectable to developing superficial skin infection in general17.

The use of skin protection cushions and well fitted wheelchairs are considered to be effective methods in the protection against PU6. As is common practice by wheelchair users, wheelchair cushions were used by 72% of the participants. Most of them use regular sponge (46.6%) or air-cell-based (38.4%) cushions. Avoiding continuous pressure by changing their position was reported by 51.3% of individuals. Assessing the different kinds of cushions and the different features of wheelchairs, and perhaps wheelchairs with position changing and air cushions features, would be interesting areas for future studies. Regarding skin health and quality of life, half of the participants with skin complications reported that skin disorders negatively affected their psychosocial status. Higher rates of psychological impact were reported in wheelchair users with PU by Kovindha et al. 11.

The study is limited by the online nature of the survey and the fact that response rates could not be measured. In addition, gender, level of education, and employment status were not included in the study variables. We also regret not asking about the number of years spent using a wheelchair, as this could have had an impact. The small sample size may also limit the generalizability of results, although the prevalence of PU was comparable with rates in the literature.

Conclusion

Although under-represented in the literature, skin complications are common among wheelchair users. PUs are the most commonly reported complication in our participants, followed by traumatic wounds, tinea pedis, and tinea cruris. These complications, especially PUs, are important causes of financial and health burden in this population. In addition, the secondary complications of these wounds could be fatal. Preventive educational programs to these patients and to health professionals taking care of these patients are important for both individuals and the health system. Despite immense developments in wheelchairs, they remain limited in preventing PUs. Further developments, focusing on pressure ulcer prevention, would be helpful for all these patients.

Ethical approval

The study was approved by Qassim University Ethical Committee (18/5/2020; No: 19-12-08).

Consent

The first page of the questionnaire was a detailed informed consent. Participants were able to fill the questionnaire only if they give their written agreement.

Sources of funding

There is no financial support and sponsorship.

Author contribution

A.A.: supervisor of the literature review, study design, data management, analysis, and writing the manuscript; A.A.: literature review, data collection, introduction, and results writing; W.A.: literature review, data management, introduction, and results writing. R.A.: literature review, data collection, data management, introduction, and results writing; A.A.: literature review, data collection, data management, writing introduction, and first draft of the results; F.T.: literature review, results, and discussion writing; M.A.: data management and analysis, results, and discussion writing.

Conflicts of interest disclosure

Authors declare having no any conflict of interest related to this manuscript.

Research registration unique identifying number (UIN)

1. Name of the registry: research registry.

2. Unique Identifying number or registration ID: researchregistry8280.

3. Hyperlink to your specific registration (must be publicly accessible and will be checked): https://researchregistry.knack.com/research-registry#userresearchregistry/registerresearchdetails/6318e662ff3c350021adea45/

Guarantor

Dr Azzam Alkhalifah.

Provenance and peer review

Not commissioned, externally peer reviewed.