Presenter:

• Letitia Y. Graves, PhD, RN | Assistant Professor, School of Nursing, University of Texas Medical Branch at Galveston; Research Health Scientist, Louis Stokes Cleveland VA Medical Center

Moderator:

• E. Foy White-Chu, MD, CMD | Associate Professor of Medicine, Oregon Health and Science University; Medical Director, Wound Healing Center, Portland VA Healthcare System

Why This Webinar Matters for Wound Care Clinicians

Pressure injuries in patients with spinal cord injury (SCI) are one of the most predictable complications in rehabilitation medicine, and one of the hardest to prevent. The numbers are clear: up to 30% of patients with chronic SCI will develop a pressure injury, roughly 49% will experience one during Acute rehab, and about 70% of those with chronic SCI will go on to have recurrent pressure injuries.

What makes this webinar particularly valuable is that Dr. Graves doesn’t just review the epidemiology. She walks through the current evidence base and shows where it falls short, including a critical finding that many clinicians may not expect: the evidence supporting standard behavioral and educational interventions for pressure injury prevention in SCI is weak. That has implications for how clinicians frame conversations with patients, how rehab protocols are structured, and where research investment should go.

The presentation also introduces emerging genomic and epigenomic research that is beginning to explain why some individuals with SCI develop recurrent pressure injuries while others with similar injury profiles do not. This line of inquiry points toward precision rehabilitation, a concept that could reshape how this population is managed long-term.

Spinal Cord Injury: A Systems-Level Condition

Dr. Graves opened with a review of SCI fundamentals, emphasizing a point that clinicians outside of SCI-specific care may underappreciate: spinal cord injury affects every organ system below the neurologic level of injury, not just motor and sensory pathways.

SCI is classified broadly as traumatic (the majority of cases) or non-traumatic (from disease or degeneration). Motor and sensory loss is categorized as tetraplegia (both arms and legs affected) or paraplegia (trunk and/or lower extremities). The higher the injury on the spinal cord, the more severe the functional impact. Injuries at C2 or C3 affect respiratory muscles. Lower lumbar injuries may affect bladder, bowel, and leg function.

Incomplete tetraplegia is the most frequent neurological category, with incomplete and complete paraplegia occurring at roughly equal rates.

Shifting Demographics in SCI

The traditional SCI patient profile, a young male injured in a motor vehicle accident or recreational activity, is changing in ways that directly affect pressure injury risk.

Key demographic shifts:

• The average age of SCI onset in the U.S. has increased from a mean of 29 years to approximately 43 years.
• In Canada, the average age of onset has risen by 13 years.
• Falls have become an increasingly common mechanism of injury, corresponding with the aging of the general population.
• Acute hospital stays and rehab lengths of stay have decreased.

These shifts matter for wound care because they create two distinct patient profiles that may require different approaches: younger patients living decades with a disability, and older patients acquiring SCI later in life with pre-existing comorbidities. Dr. Graves noted that we still don’t fully understand the differences between aging with a long-standing SCI and developing a new SCI in the context of an already-aging body.

Shorter rehab stays also mean patients are discharged into the community earlier, potentially before they’ve had adequate education on skin monitoring and pressure relief, increasing the window for pressure injury development outside of supervised care.

Why SCI Is Itself a Risk Factor

SCI creates a unique set of conditions that predispose patients to pressure injuries beyond simple immobility:

• Reduced vascularity and cutaneous hypoxia below the injury level
• Loss of protective sensation (the body’s signal to shift weight is absent)
• Decreased voluntary movement
• Altered temperature regulation

These factors are intrinsic to the injury itself and are present regardless of how well a patient adheres to prevention protocols.

The consequences extend beyond the wound. Pressure injuries in SCI patients curtail social functioning, delay rehab progress, drive hospital readmissions and extended stays, and reduce overall quality of life. Dr. Graves also noted evidence linking pressure injury development in hospitalized SCI patients to depression, suicidal ideation, and suicide attempts.

What the Evidence Says About Risk Assessment

Risk factors for pressure injury in SCI fall into three categories:

1. Biomechanical and physiological factors: Shear, friction, loss of nervous system communication (the absent signal to reposition), reduced perfusion
2. Systemic health and comorbidities: Nutritional status, diabetes, circulatory conditions, history of prior pressure injuries
3. Rehab and patient-specific factors: Demographics, age, education, injury characteristics (level and completeness)

Dr. Graves referenced two key studies. A 2009 systematic review stratified risk factors across acute and chronic SCI stages and found that evidence in the acute phase was generally low-quality and inconclusive. In the chronic phase, demographic factors (gender, education, work status, marital status, age at injury) had moderate to strong evidence as risk factors.

A 2020 study by Silva and colleagues looked at rehab and post-rehab risk factors and arrived at similar conclusions. In the rehab phase, tetraplegia, complete injury, low functional independence scores, and history of recurrent pressure injury were all associated with higher pressure injury risk. Post-rehab risk factors mirrored the 2009 findings.

The practical takeaway: strong evidence exists for identifying who is at risk. What remains weak is the evidence for what to do about it.

The Prevention Problem

Standard prevention strategies, including pressure relief schedules, skin monitoring, smoking cessation, and nutritional support, are logical and widely recommended, however the evidence supporting their effectiveness in SCI specifically is inconclusive.

Dr. Graves cited two systematic reviews that arrived at the same conclusion:

• Kogan and colleagues found no positive evidence to support the efficacy of behavioral or educational interventions in preventing pressure injuries in adults with SCI. Their argument: a singular focus on behavior minimizes the multifactorial nature of pressure injury development, which includes genetics and micro-environmental factors.
• Groah and colleagues (2015) found that current guidelines cannot be considered evidence-based and recommended re-evaluation of existing guidelines, including turning intervals, for this high-risk population.

The standard two-hour turning schedule and regular pressure relief intervals that are embedded in current practice guidelines have not been validated with strong evidence for the SCI population. That doesn’t mean they should be abandoned. It means the evidence base needs to catch up, and clinicians should understand that adherence to these protocols alone may not be sufficient for prevention.

Wound Healing in SCI: Why Chronic Wounds Develop

The normal four-phase wound healing process (hemostasis, inflammation, proliferation, remodeling) is disrupted in SCI patients by the same physiological factors that create pressure injury risk in the first place: impaired circulation, reduced oxygenation, ongoing pressure, and susceptibility to infection.

Dr. Graves emphasized the remodeling phase as a particularly critical window. New tissue that forms during healing is structurally weaker than the original skin. In a patient who will return to sitting in a wheelchair over that same tissue, this weakness creates direct vulnerability to re-injury, which helps explain why recurrence rates are so high.

Genomics and the Case for Precision Rehabilitation

There is emerging research on why pressure injury susceptibility varies between individuals with otherwise similar SCI profiles.

Dr. Graves’ research group has found:

• Genomic profiles demonstrating increased intramuscular adipose tissue (IMAT) that correlates with recurring pressure injury risk. As muscles below the injury level atrophy and convert from muscle to fat, the tissue loses its protective capacity.
• Genetic variants identified in transcriptomic and genomic analyses that suggest a biological basis for recurrent pressure injury susceptibility.
• Inflammatory, senescence, and metabolic pathways showing modulation at both the genome and transcriptome level. Ongoing multi-omic analysis is examining how these pathways interact.

Dr. Graves’ work in social epigenomics is investigating how environmental and lifestyle factors (diet, sleep, stress, neighborhood) activate or silence genes through DNA methylation, which may explain why patients with the same injury level and similar behavioral profiles have very different pressure injury outcomes.

During the Q&A, Dr. Graves noted that glucose metabolism and fatty acid metabolism pathways are showing up most prominently in current analyses, consistent with the IMAT findings. APOE has not appeared as a factor so far.

The practical implication is that the field is moving toward precision rehabilitation, using a patient’s unique genetic profile, environment, and lifestyle data to tailor prevention and treatment rather than relying on one-size-fits-all guidelines. This is early-stage work. The datasets are small, the analysis is ongoing, and the SCI population’s heterogeneity makes large-scale genetic studies difficult, but the direction is clear.

Technology-Assisted Monitoring

Dr. Graves highlighted several technology-based tools that can support patients in the community:

• Smartphone apps that prompt daily skin checks, pressure relief, and hydration/nutrition reminders
• Wearable devices that collect real-time data and allow patients with limited hand or arm function to monitor their skin independently
• Adaptive cameras that give patients the ability to photograph and inspect their own skin regardless of upper extremity function, then share images with their providers

These tools are particularly relevant given the trend toward shorter rehab stays and earlier community discharge.

The Veteran Population

A Q&A exchange addressed whether military veterans are disproportionately affected. Dr. Graves confirmed that much of her research group’s work is conducted in veteran populations at VA Spinal Cord Injuries and Disorders Centers. She noted that environmental factors specific to military service (combat exposure, deployment conditions) may influence gene expression in ways that differ from civilian populations, though direct comparisons have not yet been conducted. Active-duty military research in this area tends to focus more on traumatic brain injury than SCI-specific pressure injury.

What This Means for Clinicians

Dr. Graves’ presentation raises several practical considerations:

Risk assessment is necessary but not sufficient. Clinicians should continue using established screening tools while recognizing that current evidence does not support any single prevention protocol as reliably effective in SCI populations.

Behavioral interventions alone won’t close the gap. The multifactorial nature of pressure injury in SCI means that patient education and behavioral modification, while important, are not enough. Biological susceptibility plays a role that is only beginning to be understood.

Documentation and standardization matter. Variability in how wounds are measured, classified, and reported across institutions limits the ability to compare findings and build the evidence base.

Patient engagement needs to be collaborative. Open communication, shared goal-setting, and acknowledgment of what is and isn’t within the patient’s control can improve adherence and reduce the frustration that comes with recurrent injuries.

Watch the precision rehabilitation space. As genomic and epigenomic research matures, the tools available to clinicians for risk stratification and individualized prevention will change.

Featured video: Watch the full WHS Education Committee webinar on YouTube

This article is a summary of a WHS Education Committee webinar presented March 2025, featuring Dr. Letitia Y. Graves, moderated by Dr. E. Foy White-Chu. It is intended as a clinical reference for wound care professionals and does not replace formal medical training or clinical judgment. The WHS Education Committee does not endorse specific commercial products.