Table 1.

Identified studies on pressure ulcers and QoL post-SCI

Reference	Research design/population/objective/QoL outcome measures	Findings
Sapountzi-Krepia et al.24	Design: Cross-sectional survey Population: 98 persons with post-traumatic paraplegia (62% male), mean age 31.4 yrs Objective: To measure the impact of pressure sores and urinary tract infections (UTI) on the everyday life activities of persons with post-traumatic paraplegia QoL outcome measures: Sarno Functional Life Scale (SFLS)	Persons were more likely to be less involved in everyday life activities if they had a pressure sore (P = 0.021) Similarly, persons were much less likely to be involved with outdoor activities if they had a pressure sore (P = 0.034) and UTI P = 0.044) Persons with pressure ulcers were more likely to be less involved with social relations (P = 0.019)
Fuhrer et al.5	Design: Cross-sectional survey Population: 140 (100 men) persons with SCI, mean age 36.2 yrs (±11.5), mean YPI 10.6 yrs (±7.8) Objective: To examine the prevalence and correlates of pressure ulcers in terms of their number, severity, and anatomical location were studied in community-dwelling persons with SCI QoL outcome measures: Craig Handicap Assessment and Reporting Technique (CHART)	1. 33% of their sample had at least one Stage I pressure ulcer, and within that group, persons with more severe ulcers (Stage III or IV) had significantly ↓ means scores on the Occupation (P < 0.001) and Mobility (P < 0.05) dimensions of CHART than those with less severe pressure ulcers (Stage I or II)
Westgren and Levi25	Design: Cross-sectional survey Population: 320 persons (261 men) with SCI, mean age 42 (17–78 yrs), YPI ≤4 yrs and ≥4 yrs Objective: To determine associations between major outcome variables after SCI and QoL QoL outcome measures: Short Form Health Survey (SF-36)	1. Pressure ulcers yielded a strong effect size with ↓ scores on the physical functioning (P = 0.001) sub-scale of SF-36
Krause53	Design: Cross-sectional survey Population: 1017 (69% male) persons with SCI, mean age at onset 29.1, mean YPI 13.3 yrs Objective: To identify the relationship between two skin sores related variables and multiple indicators of life adjustment after SCI QoL outcome measures: Life Situation Questionnaire-Revised (LSQ-R)	All 7 subjective-well being scores were significantly related to the number of sores, with respondents with no sores having significantly superior scores on 6 of 7 scales (except negative emotions) than those with moderate or severe sores The “No sores” group reported significantly ↑ self-rated adjustment (P ≤ 0.001) than those with moderate or severe sores The number of sores were significantly related to employment status (P ≤ 0.001), as 42% of the group with no sores were working compared with 30% of those with 1–4 sores and 28% of those with 5 or more. As well, the number of sores and days adversely impacted by sores were correlated with poorer adjustment in nearly every area of life studied
Saladin and Krause52	Design: Cross-sectional survey Population: 475 (60% male) consumers with SCI, approx. equal distributions of Caucasians, African-Americans, Hispanics, and American-Indians, mean age at onset 29.3 yrs, mean YPI 12.8 yrs Objective: Compare the prevalence of pressure ulcer and barriers to treatment in the event of ulcer development as a function of race-ethnicity in persons with SCI QoL outcome measures: Sections of the Life Situation Questionnaire-Revised (LSQ-R); Reciprocal Social Support Scale (RSS)	1. Individuals with higher levels of social support scores were less likely to report a current pressure ulcer (P = 0.033)
Anson et al.41	Design: Cross-sectional survey and longitudinal survey Population: 125 persons with SCI, 18 yrs+ and YPI > 1 yr Objective: (1) To explore relationships among social support, adjustment, and secondary complications in persons with SCI; and (2) to investigate the potential effects of persons' perceptions that they contribute to the social support of others as well as received social support from others QoL outcome measures: Reciprocal Social Support (RSS) scale	Social adjustment was associated with the presence and number of days spent with pressure ulcers Persons with low social support had ↑ (P = 0.037) number of skin sores, and ↑ (P = 0.013) number of days spent with a sore than persons with high social support
Krause et al.63*	Design: Cross-sectional survey Population: 97 (78% males) American-Indians with SCI, mean age 40.4 yrs, YPI 12.4 yrs Objective: To identify factors related to risk for poor health outcomes and secondary in a sample of American-Indians with SCI QoL outcome measures: Reciprocal Social Support (RSS) scale	Half the participants reported at least one pressure sore in the past year and 28.7% reported two or more pressure sores in the past year Pressure sores were not predictive of any of the health outcomes
Anderson and Andberg47	Design: Cross-sectional survey Population: 141 (114 males) subjects with spinal cord dysfunction with motor and sensory deficits, mean age 34 yrs, YPI 10.5 yrs. The sample was divided into: Group 1 – 58 persons with paraplegia; Group 2 – 83 persons with tetraplegia; The groups were further sub-divided into: Group A – individuals with no time lost because of pressure sores in the last 2 yrs; Group B – individuals who lost time. Objective: To determine if psychosocial factors, not purely mechanical aspects, play an important role in the incidence of pressure sores QoL outcome measures: Satisfaction with Activities of Life (SATIS) and Responsibility in Skin Care (RESPON); Tennessee Self-Concept Scale (TSCS)	The group with paraplegia reported a greater (P ≤ 0.005) number of activity interrupted days due to pressure sores compared to persons with tetraplegia There were differences (P ≤ 0.005) in the mean scores that the groups (A and B) received for RESPON and SATIS. Individuals with a recent pressure sore history of no time lost scored higher on RESPON (both in practice and in attitude toward maintaining the integrity of the skin) and on SATIS compared to individuals who lost time RESPON was significantly associated with pressure sore incidence in the expected direction: As the subject reported ↑ RESPON, he/she also tended to report fewer days interrupted and hospitalized/year due to pressure sores A ↑ SATIS score was (P ≤ 0.01) associated with fewer days lost due to pressure sores The relationship between self-esteem and the incidence of pressure sores in groups (A and B) only approached significance (P = 0.085)
Harding-Okimoto64	Design: Qualitative study and cross-sectional survey Population: 5 persons with SCI and pressure ulcers, mean age 49.6 yrs, mean YPI 18.6; 5 persons with SCI without pressure ulcers, mean age 47.6, mean YPI 23.8 Objective: To determine if there is any difference in self-concept and body-image between persons with SCI and pressure ulcers and those with SCI and no pressure ulcers QoL outcome measures: Body Cathexis-Self-Cathexis Scale; Qualitative interviews	The sample without pressure ulcers had a ↑ mean score on the Body Cathexis Scale than did the sample with ulcers (statistical significance not reported) With regard to the Self Cathexis scale, persons with pressure ulcers had ↑ scores than those without (statistical significance not reported) Interviews revealed that persons with pressure ulcers had disparaging self-views about his/her appearance. They also had more difficulty in accepting physical appearance and did less actual inspection of skin integrity
Gordon et al.75	Design: Cross-sectional and Retrospective survey; Population: 566 persons (79.4% male) with SCI, mean age 26.1 ± 10.4, YPI range 1–4 yrs Objective: To examine the occurrence of pressure sores during inpatient rehabilitation and scores on personal adjustment QoL outcome measures: Human Service Scale (HSS)	Presence of pressure sores was negatively correlated to scores on HSS Social sub-scale (P < 0.02) and Economic Self-Esteem sub-scale (P < 0.007) Scores on HSS Self-Esteem sub-scale were also correlated with other independent variables (i.e. sex, race, impairment, and occupation)
Lyons and Sorenson62	Design: Cross-sectional survey Population: 36 (27 males) persons with SCI, mean age 42 yrs, YPI range 2–46 yrs Objective: To describe subject perceptions related to the presence of a pressure ulcer & to compare QoL with those without an ulcer QoL outcome measures: Ferrans & Powers Quality of Life Index Spinal Cord Injury Version-III (QLI)	Compared to AB reference norms, persons with SCI+ pressure ulcer had ↓ scores on the total QLI (P < 0001), health and functioning sub-score (P < 0.001), psychological/spiritual sub-score (P < 0.001), family sub-score (P < 0.001), and the social and economic sub-score (P < 0.01) Compared to SCI reference norm without pressure ulcer, persons with SCI + pressure ulcer had ↓ scores on the total QLI (P < 0.01), the health and functioning sub-score (P < 0.001), the social and economic sub-score (P < 0.05), and on the psychological/spiritual sub-score (P < 0.001)
Singh et al.76	Design: Prospective clinical study Population: 30 patients with traumatic SCI resulting in pressure ulcers (stages III and IV). Eligibility criteria included: failure of conservative treatment to heal pressure ulcers, minimum regular follow up of 6 months, and injury below C4 Objective: To evaluate the effect of surgery for pressure ulcers on general health and quality of life in patients with SCI QoL outcome measures: Patient satisfaction questionnaire; Visual Analog Scale	There was a statistically significant rise in mean quality of life scores, from 50.15 (range 30–65) at baseline to 87.36 (range 44–96) at 6-month follow-up Most of the patients (76.7%) reported improvement in subjective well-being and 83.3% reported satisfaction with the outcome of the surgery
Langemo et al.79	Design: Phenomenological qualitative study Population: 8 respondents (4 with SCI), mean age 35.75 yrs. Objective: To explore the phenomena of the lived experience of having a pressure ulcer to determine the essential structure of the experience QoL outcome measures: N/A; Qualitative interviews	The themes relevant to QoL that emerged included: (1) life impact and changes; (2) psychospiritual impact With regard to life impact, having a pressure ulcer affected the physical domain in that it was difficult to deal and accept the mandatory bed rest and immobility needed for healing of the ulcer. Interruption of sleep was also discussed Other life impact sub-themes were social in that having an ulcer can be isolating since they were confined to one room, and one person discussed the financial impact In terms of psychospiritual impact, sub-themes of body image change, struggle with stereotypes, desire/struggle for control and independence, and spiritual impact emerged
Jackson et al.80	Design: Qualitative study Population: 20 persons with SCI and a history of pressure ulcers Objective: To identify overarching principles that explain how daily lifestyle considerations affect pressure ulcer development in adults with SCI QoL outcome measures: N/A; Qualitative interviews	1. The study led to identification of 8 interrelated daily lifestyle principles: perpetual danger, change/disruption of routine, decay of prevention behaviors, lifestyle risk ratio, individualization, simultaneous presence of prevention awareness and motivation, lifestyle trade-off, and access to needed care, services, and supports.

yrs, years; YPI, years post-injury; N/A, not applicable.

*Krause et al.⁶³ also used the Craig Handicap Assessment Reporting Technique (CHART), but only used a few items. Based on this issue, and the lack of association with pressure ulcers, it was decided to exclude this part of the study from the present review.