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Evidence-Based Physiatry: Cochrane Corner

Are Risk Assessment Tools Effective for the Prevention of Pressure Ulcers Formation?

A Cochrane Review Summary With Commentary

Afridi, Ayesha DPT; Rathore, Farooq Azam MD, MBBS, FCPS

Author Information
American Journal of Physical Medicine & Rehabilitation: April 2020 - Volume 99 - Issue 4 - p 357-358
doi: 10.1097/PHM.0000000000001379
  • Free

The aim of this commentary is to apply a rehabilitation perspective to the published Cochrane Review “Risk assessment tools for the prevention of pressure ulcers” by Moore and Patton (, under the direct supervision of Cochrane Wounds Group. This Cochrane Corner is produced in agreement with American Journal of Physical Medicine & Rehabilitation by Cochrane Rehabilitation.


Pressure ulcers also known as bed sores, pressure sores, or decubitus ulcers are “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.”1 People with compromised mobility (who are bed or wheelchair bound) and elderly patients with inability to change body position for long time are more prone to develop pressure ulcers.2 The complications associated with pressure ulcers include localized infection, cellulitis, osteomyelitis, delayed wound healing, pain, depression, poor quality of life, and a high risk of mortality.3,4 The cost of treatment of pressure ulcers is very high,5 and prevention strategies aimed at reducing their incidence can have positive effects on patients and the overall health care system.6 Use of pressure ulcer risk assessment tools and scales has been recommended by guidelines, and many different scales are currently used,7 but their reliability and validity have not been confirmed in different settings.8 A Cochrane Review searched for evidence to find out whether risk assessment tools were effective in preventing pressure ulcers.7


What Is the Aim of This Cochrane Review?

The aim of this Cochrane Review was to assess the effectiveness of structured and systematic pressure ulcer risk assessment tools in the prevention of pressure ulcers in any health care setting.

What Was Studied in the Cochrane Review?

The population addressed in this review was patients of either sex or any age, in any health care setting with any medical condition with no previous pressure ulcer at the time of enrollment in the study. The interventions studied were structured and systematic pressure ulcer risk assessment tools, including Braden pressure ulcer risk assessment, Waterlow pressure ulcer risk assessment, and Ramstadius pressure ulcer risk assessment scale. The intervention was compared with other pressure ulcer risk assessment tools or with clinical judgment alone. The primary outcome of the study was new pressure ulcer formation of any grade confirmed by visual inspection of the skin. The secondary outcomes of the review were as follows: (a) severity of the new pressure ulcers as assessed by a validated pressure ulcer severity assessment tool; (b) time to ulcer development; and (c) pressure ulcer prevalence at the end of the study point.

Search Methodology of the Cochrane Review

This review is an update of a Cochrane Review first published in 2008 and updated in 2014. The Cochrane Wounds Specialized Register, Cochrane Central Register of Controlled Trials, Ovid MEDLINE including in-process and other nonindexed citations, Ovid Embase, and EBSCO CINAHL Plus (Cumulative Index to Nursing and Allied Health Literature) were searched up to February 2018. Studies were included without any restrictions of language, date of publication, or study setting.

What Are the Main Results of the Cochrane Review?

The review included two randomized controlled trials conducted in acute care hospitals (published in 2009 and 2011) without any new trials for this updated version. There were 1487 individual participants studied in these trials. The first study enrolled 256 patients in a military hospital who had a Braden score of less than 18 and followed them up for 8 wks. They did not mention the age and sex distribution of the participants. The second study involved 1231 participants, and all admitted patients were included in the study. Both of the trials had 3 arms, the groups being Braden risk assessment tool and training, clinical judgment and training, and only clinical judgment for the first study, whereas the second study’s third entailed Waterlow risk assessment tool, Ramstadius risk assessment tool, and clinical judgment.

The review found the following:

  • There was uncertainty (very low-quality evidence) that use of the Braden risk assessment tool and training when compared with risk assessment using a combination of clinical judgment/training or use of clinical judgment alone reduces the incidence of pressure ulcers.
  • There was low-quality evidence that use of Waterlow pressure ulcer risk assessment tool was associated with little or no difference regarding the incidence or severity of pressure ulcers when compared with either clinical judgment alone or the use of Ramstadius risk assessment tool.
  • The use of Ramstadius pressure ulcer risk assessment tool showed little or no difference in pressure ulcer incidence and severity of new pressure ulcers when compared with pressure ulcer risk assessment using clinical judgment alone.

The secondary outcomes including “time to pressure ulcer development” and “pressure ulcer prevalence” were not reported in any study.

How Did the Authors Conclude on the Evidence?

The authors concluded that there is low to very low quality of evidence that the use of structured pressure ulcer risk assessment tools such as Braden, Waterlow, and Ramstadius risk assessment tools is more effective than risk assessment using clinical judgment. The use of these tools resulted in little or no difference in the incidence or severity of new-onset pressure ulcers in hospitalized patients. However, both studies were conducted in acute care hospital settings, and there is a need to perform similar studies in other settings too.

What Are the Implications of the Cochrane Evidence for Practice in Rehabilitation?

Many patients in need of indoor rehabilitation have compromised mobility, which places them at the risk of development of pressure ulcers. These may include patients with stroke, spinal cord injury, traumatic brain injury, and long bone fractures. Although skin care and pressure ulcer prevention are primarily the domain of rehabilitation nurse, it should be considered a shared responsibility of the multidisciplinary rehabilitation team.9 This is especially relevant for the low-resource countries where there is shortage of trained rehabilitation nurses, and mostly, the physicians make decisions regarding patient care. Because there is no high-quality evidence that use of a risk assessment tool reduces incidence of new-onset pressure ulcer, we recommend rehabilitation professionals perform routine risk assessment for pressure ulcers using clinical judgment. This might be helpful in identifying pressure ulcers at an early stage and reduce long-term morbidity and increased cost associated with pressure ulcers. There is also a need for large and better trials to assess the effectiveness of different pressure ulcer risk assessment tools in a variety of settings and diseases.


We thank Cochrane Rehabilitation and Cochrane Wounds Group for reviewing the contents of the Cochrane Corner.


1. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance: Prevention and treatment of pressure ulcers: quick reference guide. 2014. Available at: Accessed November 26, 2019
2. Moore Z, Cowman S: Pressure ulcer prevalence and prevention practices in care of the older person in the Republic of Ireland. J Clin Nurs 2012;21:362–71
3. Khor HM, Tan J, Saedon NI, et al: Determinants of mortality among older adults with pressure ulcers. Arch Gerontol Geriatr 2014;59:536–41
4. Pressure ulcers. Available at: Accessed November 26, 2019
5. Demarré L, Van Lancker A, Van Hecke A, et al: The cost of prevention and treatment of pressure ulcers: a systematic review. Int J Nurs Stud 2015;52:1754–74
6. Moore Z, Cowman S, Conroy RM: A randomised controlled clinical trial of repositioning, using the 30° tilt, for the prevention of pressure ulcers. J Clin Nurs 2011;20:2633–44
7. Moore ZE, Patton D: Risk assessment tools for the prevention of pressure ulcers. Cochrane Database Syst Rev 2019;1:CD006471
8. Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Lopez-Medina IM, et al: Risk assessment scales for pressure ulcer prevention: a systematic review. J Adv Nurs 2006;54:94–110
9. Gottrup F, Holstein P, Jørgensen B, et al: A new concept of a multidisciplinary wound healing center and a national expert function of wound healing. Arch Surg 2001;136:765–72
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