During my first rehabilitation following the onset of SCI, I was sharing a room with a patient who was suffering from pressure ulcers. Seeing her suffer, I promised myself then I would not allow that to happen to me. But just three months after I returned home, I had my first ulceration. And now I’m back here again two years later with my second. 
 —Monica, January 2007

It had been over two years since Monica had needed to be hospitalized. At the age of 67, she had suffered a spinal cord injury (SCI) that resulted from an emergency surgery to treat an aortic aneurysm.

The SCI was one of the unfortunate costs of a procedure that likely saved her life. However, three months later she developed her first pressure sore. Monica had always feared pressure ulcers and had hoped to avoid them. But after the initial ulcer’s treatment and despite her hopes, she made only limited efforts to prevent them from forming.

The lifestyle habits that put her at risk were deeply settled. To her detriment, she actively worked to put the risks of pressure ulcers out of her mind. In doing so, she continued to act irresponsibly with regard to prevention, smoking and insufficiently caring for her skin. Understandably, this was an eventual failure in maintaining her health and preventing complications.

To her dismay two years after her rehabilitation, a new ulceration developed, and as we shall see, this can be a deadly serious complication.

Risk Prevention, Health Behavior and Health Maintenance in SCI Patients

Following an SCI, patients face the challenge of developing a spectrum of new health behaviors that allow them to both manage and overcome their physical limitations and to prevent further SCI-related complications such as pressure ulcers.

Some of these behaviors are essential for survival and others help to maintain quality of life. Therefore, education and behavior adaptation in the areas of prevention strategies can be viewed as one of the major aims of the rehabilitation process.²⁶  In order to successfully treat and prevent complications like Monica’s pressure ulcers, a rehabilitative strategy is needed that undertakes a two-pronged approach, including both contributions from health professionals, as well as efforts from the patient him- or herself.

The health care team is concerned not only with the medical treatment but importantly also the prevention of pressure sores by strengthening and integrating the patient’s self-management capacity and performance, being an integral part of health behavior.

This behavior includes following the treatment procedures and performing the necessary preventative interventions (known as self-management). The patient’s contribution to her health centers on these latter components. Both treatment and prevention strategies should be based on a bio-psycho-social as well as environmental understanding.^27,28

Box 3 illustrates one model of risk and protective behaviors.

Box 3: Health and Risk Behavior

In the example of the pressure ulcer, it is hoped that a patient will engage in specific protective behaviors: •    follow her health team’s evidence-based treatment scheme (e.g. taking prescribed medication), •    translate the theoretical knowledge she gains into her daily routine (e.g. undertaking skin control activities) — strengthen healthy activities (e.g. exercise and nutrition) •    avoiding those activities that potentially increase the risks of ulcerations (e.g. smoking, increased pressures on the areas of skin at risk).

However, it must be stated that although much is known about prevention, pressure ulcers and related health behavior, the condition remains prevalent among SCI patients. Furthermore, it is not entirely clear why “some patients do not establish and maintain the health behaviors necessary for optimal skin care and pressure ulcer prevention.”^32,33