OVERVIEW: ACUTE STAGE REHABILITATION: SKIN CARE AND SITTING

  1. Pressure Management in Bed

    • The patient should be turned every 2 hours and the extremities should be placed in positions that maintain joint range of motion (elbows in extension, ankles dorsiflexed to neutral) during the acute stage. As skin tolerance improves, the time spent in each position can be increased gradually.
    • There are 8 lying positions: supine, prone, right and left side-lying, right and left semiprone, and right and left semisupine. The prone and semiprone positions can only be used if the spine is stable. In the prone position, hips and knees are extended, flexion contractures are prevented, time can be increased to several hours, and sleep can be uninterrupted through the night.
    • Pillows or foam rubber can be used to relieve pressure on boney prominences and prevent contact between skin areas.

  2. Pressure Management in Wheelchair - To prevent skin sores from sitting in a wheelchair:
    • Periodic pressure reliefs, either assisted or unassisted, should be performed every 15-20 minutes, in which the buttocks are lifted off the seat or the patient's weight is shifted forward or to the side. As skin tolerance improves, the time between pressure reliefs can be increased.
    • The patient's buttocks should be placed far back in the chair.
    • The footrests should be adjusted to permit the knees to be at or slightly below the level of the hips.
    • Pressure-distributing cushions should be used; the Roho cushion is effective in relieving pressure at the seating surface (Yuen & Garrett, 2001)

  3. Sitting
    • As soon as the patient's spinal stability (with or without orthosis) is established, sitting and other out-of-bed activities should be initiated to prevent the negative physical and psychological effects of extended bed rest.
    • When upright postures are initiated, patients should be gradually accommodated to the new position to prevent orthostatic hypotension, a transient, but common problem in patients with injuries above T6. A reclining wheelchair and/or increasing upright positions in bed can be used to develop tolerance to upright positions. Thigh-high antiembolic stockings and abdominal binders can facilitate venous return and prevent a sudden drop in blood pressure, which can result in dizziness, vomiting, and loss of consciousness.
    • Mild dizziness should be expected in many patients learning to sit and can be addressed by elevating the legs and/or reclining the wheelchair. While learning to sit, patients can do strengthening exercises and pressure reliefs, begin wheelchair propulsion, and practice stabilizing the trunk, leaning from side to side, and controlling their body's motion.

The PoinTIS SCI Physical Therapy site of the SCI Manual for Providers is based on information in Spinal Cord Injury: Functional Rehabilitation, by M.F. Somers, Norwalk, CT, Appleton & Lange, 1992, and information in "Respiratory Rehabilitation of the Patient with a Spinal Cord Injury", by J.L. Wetzel, B.R. Lunsford, M.J. Peterson, and S.E. Alvarez, Chapter 28 in Cardiopulmonary Physical Therapy, S. Irwin and J.S. Tecklin, eds., St. Louis, Mosby, 1995, unless otherwise indicated.