Sunday, 26 February 2017

#ClinicSpeak: pressure ulcers in MS

If you have a pressure ulcer you need to do something about it. #ClinicSpeak #MSBlog 

Dogs are increasingly being used as diagnosticians in medicine to help sniff out cancers and other metabolic conditions by using their ultra-sensitive sense of smell and their ability to learn and be trained. One condition that doesn't require a dog's nose are pressure ulcers. Patients with pressure ulcers have a characteristic smell; the bacteria and organisms that live in the ulcer produce odorants that is hard for the trained clinician to miss. 


Two week's ago when I collected one of my patients from the waiting room her odour told me that she had developed a pressure sore. My heart sank; the time and effort that goes into treating a pressure ulcer is enormous. Not to mention preventing it from reoccurring in the future. 

When I was training to be a neurologist pressure ulcers were the norm in patients with more advanced MS. Over the last two decades it is now unusual to see pressure ulcers. I say that, but in the last two years they are beginning to be more common. Why? I suspect like any other healthcare problem they are an indicator of austerity Britain; cut health and social care spending and you will see pressure sores becoming a problem again. In MS pressure ulcers are at the vanguard of a failing healthcare system

The paper below finds that pressure ulcers have a major impact on QoL for pwMS and they are strongly linked to problems with mobility. 


We are in the process of developing a C-QUIT (continuous quality improvement tool) with the idea of it being the 'carrot' and 'stick' to help drive adoption of the policies in the 'Brain Health: Time Matters' document. One metric that may get into the final tool is the proportion of pwMS with advanced disease who develop pressure ulcers. Pressure ulcers, or the lack of pressure ulcers, are a very good index of the quality care of care someone who is immobile is receiving. Do you agree? Keeping someone who is wheelchair, or bed, bound healthy and free of pressure sores takes resources and effort, not to mention love and compassion.  


If you are a carer, or a family member, of someone with advanced MS and they have a pressure ulcer or early skin changes suggestive of an early pressure ulcer, don't ignore the problem. Early intervention, or prevention, of pressure ulcers is better than having to wait until they are a problem. 

Please note that pressure ulcers are typically confined to people with advanced MS; if we can prevent, or delay, people getting advanced MS we should reduce this problem substantially. This is another reminder for us to treat MS early and effectively.

PaperpileMcGinnis et al. What is different for people with MS who have pressure ulcers: A reflective study of the impact upon people's quality of life? J Tissue Viability. 2015 Aug;24(3):83-90.

BACKGROUND: Multiple Sclerosis (MS) is a progressive, degenerative disease of the central nervous system. People with advanced disease who have compromised mobility, activity, sensory and/or cognitive abilities are at risk of pressure ulcers. Having a pressure ulcer has a substantial impact on a person's quality of life; a generic pressure ulcer Health Related Quality of Life (HRQL) framework has been used in this study.

AIM: To explore the views and opinions of patients with MS who have a pressure ulcer using a thematic framework and compare these to the general pressure ulcer population.

METHODS: Data for six MS patients was obtained through secondary analysis of transcripts from semi-structured interviews conducted during two studies which were part of a programme of HRQL Research.

FINDINGS: Patients with MS reported that their pressure ulcer affected their lives physically, psychologically and socially. All were confined to bed (as part of their pressure ulcer treatment) and therefore unable to participate in activities. Difficulties with movement and activity were partially attributed to the MS. Patients with MS did not report feeling ill with their pressure ulcer and expressed positive emotions and optimism. Pain or discomfort was a feature of the pressure ulcer for most patients.

CONCLUSIONS: Pressure ulcers have a major impact on QOL for all patients. Problems with mobility and activity associated with the pressure ulcer were confounded by the MS.

3 comments:

  1. I don't have pressure ulcers but wanted to know how to prevent and treat them. The NHS Choices web site page has a guide about preventing and treating them. The prevention points include changing position, nutrition, checking skin and quit smoking. The MS Society web site has a fact sheet (free to download) about ulcers and how they are formed.
    Including, Shearing - This is when layers of skin are forced to slide
    over each other or over deeper tissue. It can be caused
    by sliding down or being pulled up a bed or chair.

    Transfers - Moving from a bed to a chair, for example,
    can also shear the skin and cause damage, so it is
    important to take care to avoid knocking or dragging
    your body.
    Friction -This can happen when clothing rubs against
    the skin and removes the top layer of skin. This can be
    caused by poor lifting and moving techniques.
    Numbness - MS can sometimes cause changed
    sensations or a loss of feeling in certain areas. This
    might mean that you can't feel the uncomfortable sensation
    of pressure building up, so you don't change position
    to relieve the pressure.
    Pain - If your MS causes you a lot of pain, you may be
    reluctant to change position for fear of triggering more
    pain - and therefore pressure can build up.
    Dampness - This may be caused by sweat, a weeping
    wound or incontinence, and it can make skin more
    vulnerable to damage. (MS Society)

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  2. As an Occupational Therapist I see poor seating a lot of the time that contributes to pressure sores.
    For example if feet are not touching the floor or foot plate, more pressure will be applied to the sacral region. At least 18% of body weight should go through the feet whilst seated. This will also improve posture and relive some of the pressure in the sacral region.
    Also, in the community pressure cushions are handed out but the seat it will be used in is not assessed. Using the pressure cushions in an inappropriate chair can cause the load in the feet to reduce and more pressure will go through the sacral region causing the pressure cushion to be useless and not relieve pressure.

    In conclusion I feel patients should receive full seating assessments especially if they have reduce mobility and wheelchair assessments. Pressure cushions are useful if they are provided as part of a full seating assessments and used in the correct chair and education for the patient should reduce the risk of pressure sores.

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  3. A wake up call indeed.

    I agree with Kay that choice of cushions is crucial. I often wondered why OT's were prepared to recommend such expensive cushions.

    I would add mattress to the list.

    Since breaking my tibia in May 2015 I have been unable to turn in bed and have therefore lain in the same position for nearly two years. The hospital mattress has saved my life.

    The care of my Carers (largely my wife but also, lately, a paid carer) have combined with the less-austere Australian health care system to ensure that my skin is watched carefully and that I am out and about enough to keep my position changing.

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