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Departments: Guest Editorial

The Role of Daily Activities in Pressure Ulcer Development

Clark, Florence PhD, OTR; Rubayi, Salah MD; Jackson, Jeanne PhD, OTR; Uhles-Tanaka, Debra MA; Scott, Michael MD; Atkins, Michal MA, OTR; Gross, Kathleen OTR; Carlson, Michael PhD

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Pressure ulcers are a serious complication of spinal cord injury (SCI).1 Although pressure ulcers are often assumed to be preventable,2 research suggests that more than three fourths of individuals with an SCI will develop a pressure ulcer over the course of their lifetime.1-3 The total annual cost to treat these ulcers is nearly $1.5 billion.1-3 Not only can pressure ulcers be potentially life-threatening, but they can also impede the rehabilitation process and significantly disrupt the quality of life of persons with an SCI.1

Because the pressure ulcer problem among persons with an SCI is so severe, it is important for clinicians to develop a full understanding of the underlying contributing factors in attempting to reduce pressure ulcer risk. Research has demonstrated that in the realm of lifestyle choices, factors such as poor fitness, inadequate nutrition, unemployment, decreased social involvement, substance abuse, and emotional stress can increase the risk for developing pressure ulcers.4-8 By focusing on generalizable quantitative relationships between variables, these researchers have demonstrated that, on average, individuals with an SCI who manifest a particular risk factor have a greater likelihood of developing a pressure ulcer.

Lifestyle and Pressure Ulcers

A complimentary research strategy-examining the personally derived lifestyle configurations of at-risk individuals-has the potential to add an important new dimension to our understanding and treatment of SCI-linked pressure ulcers. This strategy begins with the observation that in living his or her life, every person sculpts a unique existence that reflects an interconnected network of psychological traits, goals, values, preferred activities, environmental opportunities and challenges, habits, routines, and personal health practices. Embedded in the context of his or her daily activities and concerns, each individual has a distinctive pattern of pressure ulcer risk.

For example, a patient on our service had enrolled in a computer training course because he was fascinated by the prospect of learning graphic design and Web page preparation. In taking a detailed history, we discovered that he often became so engrossed in his computer work that he lost track of the passage of time, which led to periods of motionless sitting and the onset of a pressure ulcer. Thus, his high level of interest in computers, his tendency to become deeply focused when performing meaningful activity, and his relative inattention to postural adjustments combined to form a potent, personally relevant context of risk for pressure ulcer development within his everyday life.

Not only does this example highlight why examining personal patterns of activity is relevant to the occurrence of pressure ulcers, but it also demonstrates the potential for such a focus to lead to innovative self-help and therapeutic strategies. For example, one possible means of reducing pressure ulcer risk in this patient would be to use a timer to remind him to change his seating position.

A Look at Lifestyle Redesign

An emphasis on examining an individual's daily activities points to several interesting research questions. For example, which underlying processes pertaining to activity choices, patterns of rest and fatigue, social influences, availability of attendant care, or feelings of hope and self-worth will translate into an increased or decreased risk for pressure ulcers? How much individual variation is present in the daily activities that affect pressure ulcers? What perceptions do individuals have regarding the origin of their pressure ulcers, what are their strategies for attempting to combat the problem, and how can they successfully enact such strategies within the ongoing context of their everyday lives? The answers to such questions may have immense practical importance.

An innovative therapeutic concept called "lifestyle redesign" underscores the usefulness of examining individuals' daily activities. Initially developed as a means for achieving lasting changes in healthful daily activity,9-10 the lifestyle redesign approach is intended to help individuals implement self-directed personally meaningful enhancements in lifestyle and routine to promote health and a sense of well-being. Key themes that underlie the lifestyle redesign approach include establishing meaningful dialogue between the therapist and the individual, incorporating the individual's existing knowledge of how daily activities affect health and quality of life, and identifying practical strategies for promoting healthful lifestyle changes, given the individual's unique constellation of attitudes, goals, and environmental opportunities and challenges.11

Lifestyle redesign treatment is holistic, humanistic, and concerned with effecting lasting changes in activities that comprise an individual's daily routines. In a large-scale randomized experiment, the lifestyle redesign approach was shown to reduce a variety of health declines among community-dwelling elders, many of whom faced disability-related challenges.12 To the degree that concrete lifestyle factors create pressure ulcer risk, the lifestyle redesign approach may offer a viable therapeutic option for reducing their occurrence.

Future Research Directions

With respect to the conduct of research, a qualitative methodological approach is likely to represent the most promising strategy for documenting the connection between personalized activity and pressure ulcer development. Qualitative research techniques are ideally suited to capture the complex, fluid adaptive efforts and processes that characterize individuals' daily lives. Insofar as they allow for prolonged, in-depth contact with study participants,13-14 such procedures also permit a sufficiently deep understanding of key issues that influence daily activities, such as motivation and accompanying mental states.

To summarize, we contend that careful research on individualized patterns of activity and lifestyle has the ability to fill in a key piece of the puzzle surrounding the problem of pressure ulcer development. Such research should complement, but not replace, other work that is currently ongoing.

References

1. Consortium for Spinal Cord Injury Medicine. Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury: A Clinical Practice Guideline for Health Care Professionals. Washington, DC: Paralyzed Veterans of America; 2000.
2. Maynard FM. Ethical issues in pressure ulcer management. Topics in Spinal Cord Injury Rehabilitation 1996;2(1):57-63.
3. Pires M, Adkins R. Pressure ulcers and spinal cord injury: scope of the problem. Topics in Spinal Cord Injury Rehabilitation 1996;2(1):1-8.
4. Byrne DW, Salzberg CA. Major risk factors for pressure ulcers in the spinal cord disabled: a literature review. Spinal Cord 1996;34:255-63.
5. Sapountzi-Krepia D, Dimitrialou A. Post traumatic paraplegics living in Athens: the impact of pressure sores and UTIs on everyday life activities. Spinal Cord 1998;36:432-7.
6. Krause JS. Skin sores after spinal cord injury: relationship to life adjustment. Spinal Cord 1998;35:51-6.
7. Rodriguez GP, Garber SL. Prospective study of pressure ulcer risk in spinal cord injury patients. Paraplegia 1994;32:150-8.
8. Vidal J, Sarrias M. An analysis of the diverse factors concerned with the development of pressure sores in spinal cord injured patients. Paraplegia 1991;29:261-7.
9. Clark F. The Eleanor Clark Slagle Lecture: Occupation embedded in a real life: interweaving occupational science and occupational therapy. Am J Occup Ther 1993;47:1067-78.
10. Clark F, Larson B, Richardson P. A grounded theory of technique for occupational storytelling and story making. In: Zemke R, Clark F, editors. Occupational Science: The Evolving Discipline. Philadelphia, PA: FA Davis; 1996. p 373-92.
11. Jackson J, Carlson M, Mandel D, Zemke R, Clark F. Occupation in lifestyle redesign: the well elderly study occupational therapy program. Am J Occup Ther 1998;52:326-6.
12. Clark F, Azen SP, Zemke R, et al. Occupational therapy for independent-living older adults: a randomized clinical trial. JAMA 1997;278:1321-6.
13. Patton MQ. Qualitative Evaluation and Research Methods. Newbury Park, CA: Sage Publications; 1990.
14. Glesne C, Peshkin A. Becoming Qualitative Researchers: An Introduction. White Plains, NY: Longman; 1992.

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