R e s e a r c h a r t i c l e S p i n a l C o r d I n j u r e d P a t i e n t s ’ K n o w l e d g e o f P r e s s u r e S o r e s A B S T R A C T : Despite much effort being put into educating spinal cord injured patients on pressure sore prevention, pressure sores remain a m ajor cause o f morbidity and mortality. This study sought to establish: i) paraplegics’ knowledge on pressure sore prevention prior to discharge; ii) the influence o f knowledge on pressure sore occurrence during hospitalization; Hi) sources o f paraplegics’ knowledge on pressure sore prevention. A total o f twenty-six men and two women with paraplegia aged between 18 and 45 years partici­ pated in the study. A prospective pre-test post-test method using a structured questionnaire was used to test paraplegics ’ knowledge on pressure sore prevention. The fir s t interview was done within one week o f mobilising in a wheelchair and the second one after two months or a fe w days before discharge. Pressure sore occurrence and the source o f knowledge were also recorded. The results showed that paraplegics’ knowledge on pressure sore prevention at discharge is incomplete. Knowledge gain does not seem to determine whether one will develop pressure sores or not. Physiotherapists (89%), nurses (82%) and occupational therapists (68%) are the main educators o f paraplegics on pressure sore prevention in rehabilitation hospitals. KEY WORDS: PARAPLEGIA, SPINAL CORD INJURY, PRESSURE SORES MUDZI W, M.Sc'; STEWART A, M.Sc Medicine2; EALES C, PhD2 1 Ruw a Reh abilitation Hospital. Faculty o f Health Sciences, Departm ent of Physiotherapy, University of the W itw atersran d. A research project done at the University of the W itwatersrand in partial fulfillment of the MSc. degree in Physiotherapy. INTRODUCTION D in s d a le (1 9 7 4 ) p u ts th e d e a th toll am o n g spinal co rd injured p atien ts due to p ressu re sores at betw een 7% and 8%. B etw een 5% and 50% o f spinal cord in ju red p atien ts d ev elo p p ressu re sores d u rin g the perio d o f acu te care nursin g and reh a b ilitatio n . B etw een 25% and 85% o f all spinal cord in ju red patients d e v e lo p p re s s u re so re s d u rin g th e ir life tim e th at are d eb ilita tin g and life th rea ten in g (D in sd ale, J974; R ich ard so n and M ey er, 1 9 8 1; M ak leb u st, 1999). P re ssu re so res rem ain a m ajo r ca u se o f m o rb id ity and m o rtality in spinal cord injured patients. T h e ex p e n se s incurred in m anaging p ressu re so res in spinal cord injured p atien ts d u rin g th eir lifetim e ran g e fro m a q u a rte r o f a m illion to tw o m illron A m erican d o llars (L ucke, 1999). M o o d y (1987) p u t the co st o f p ressu re sores to th e N a tio n a l H ea lth S e rv ic e in th e U nited K ingdom at 20 0 m illion p ounds p er year. T h e co sts asso ciated w ith the h o sp ital and health sy stem in general include nu rses’ time, m aterials used, pres­ sure reliev in g aids, d rugs and ex ten d ed stay s in h o s p ita ls (D e V ivo, 1997). A s m en tio n ed by M a n ley (1978), in fo r­ m atio n ab o u t the in cid en ce o f pressu re sores and asso ciated fac to rs in South A fric a is lim ited. H is 1978 study d o n e at G ro o te S ch u u r h o sp ital in C ap e Tow n p u t the co s t o f p ressu re sore treatm en t in ex cess o f 2 m illio n R an d s p er an n u m in the W estern C ap e alone. A lth o u g h p ressu re sores cau se untold m isery and su ffe rin g to th e p atien t, d elay ed reh a b ilita tio n and a hu g e drain on the h ea lth serv ice, they are m ore o ften than not, a v o id ab le (W aterlow , 1988). P rev en tio n , is ag reed by m any au th o rs and clin ic ian s, to be the trea t­ m ent o f ch o ice. T h is m u st be d o n e th ro u g h p atien t e d u c atio n d u rin g the initial acu te p h ase o f h o sp italisatio n . A ny reh a b ilita tio n p ro g ra m m e fo r spinal co rd in ju red p atien ts m u st in clu d e e d u ­ cation for prevention o f tissue breakdow n. T h e m ain aim in reh a b ilita tio n o f the spinal cord injured p atien t is to attain the h ig h e st p o ssib le fu n ctio n al capacity w ith in a short h o sp ital stay. T h e w hole reh a b ilita tio n p ro cess is aim ed at p rep a r­ ing p atien ts for se lf-c are in the h om e setting. W hen te ach in g fu n ctio n al in d e ­ pen d en ce, p ressu re ca re ed u c atio n is an in teg ral p art o f the p ro g ram m e. T he m ain g o al o f p atien t ed u catio n fo r spinal cord injured p atien ts is to h elp p atien ts im p lem e n t p o sitiv e ch o ice s req u ired to p rev e n t p ressu re sores (G a rb e r e t al., 1996; S ap o u n tzi - K rep ia, et al., 1998). P atie n t ed u catio n o n p ressu re care norm ally includes teaching o f risk factors such as im m obility, p o sitio n in g , m e d ica­ tions, m o istu re, n u tritio n and h y d ration. In addition an ato m ical and physio lo g ical ch an g es are ex p lain ed . M o st o f th e lite ­ ratu re av a ila b le fo cu ses on m ech an ical and p h y sio lo g ica l cau ses o f p ressu re sores. A few stu d ies h av e looked at the in flu en ce o f ed u catio n al and behavioural in terv en tio n s in h elp in g p rev en t pressure sores (A n d erso n and A n d b erg , 1979; R o d rig u e z and G arber, 1994; G arb er et al., 1996). C O R R E S P O N D E N C E TO: W M udzi R u w a R eh ab ilitatio n H o sp ital P.O. B o x 4 8 0 R u w a, Z im b a b w e Tel: +263 91 26 0 227 (cell) + 263 73 2 6 5 1 /2 8 3 9 (w) SA J o u r n a l o f Physiotherapy 2001 V o l 57 No 4 9 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) G arber, e t al (1996) e x a m in e d p re s ­ sure so re p rev en tio n and m a n ag e m en t techniques by spinal cord injured patients in th e com m unity. T h e resu lts o f th eir stu d y sh o w ed th a t d isc h a rg e d spinal co rd in ju red p atien ts h ad in c o m p le te in fo rm atio n on p rev e n tio n tech n iq u es p rio r to d isc h arg e into the com m unity. T h ey p o in te d o u t that the ed u c atio n o f sp in al c o rd in ju red p atien ts o n sk in care is a h o sp ital-b ased activ ity and th at it is n o t kn o w n w h at in fo rm atio n is reta in ed o r w h at b eh a v io u rs are p rac tice d afte r o r at d isch arg e. S u m iy a e t al (1 9 9 7 ) co n c lu d e d th at 7 2 % (3 9 p a tie n ts ) o f p a tie n ts w ith p a ra p le g ia w ho h ad d ev e lo p e d p ressu re sores d ev e lo p e d them d u e to in su fficien t k n o w led g e o r im p ro p er tech n iq u es for p rev en tio n . R o d rig u e z and G a r b e r ’s (1 9 9 4 ) study lo o k e d in p a rt a t th e k n o w le d g e d is ­ c h a rg ed spinal co rd in ju red p atien ts had on p ressu re so re p rev en tio n . T h e ir study sh o w ed that w h at p atien ts k new ab o u t p ressu re ca re w as n o t w h at they d id in p ractice. T h e k n o w led g e th at p atien ts reta in ed w as in co m p lete an d w as not effectiv ely tran slated into p ressu re sore p rev e n tio n strateg ies. T h ey also c o m ­ m ented th at it is n o t k n o w n how m uch o f the in fo rm atio n tau g h t a b o u t p ressu re ca re is reta in ed by p atien ts at d ischarge. T h ere are no stu d ies that h av e e x a ­ m in ed the level o f k n o w led g e p atien ts h a v e at d is c h a rg e . N o stu d ie s h a v e ev a lu a ted the effectiv en ess o f p atien t e d u c a tio n p ro g ra m m e s o n p re s s u r e sore p rev en tio n d u rin g h o sp italisatio n . O nly a few stu d ies h av e d es crib ed the level o f k n o w led g e on p ressu re sore p r e v e n tio n o f s p in a l c o r d in ju r e d p atients in the com m unity. (G arber e t al., 1996; R o d rig u e z an d G arber, 1994). I t is n o t k n o w n w hy p re su m a b ly retain ed in fo rm atio n is n o t tran slated into effec tiv e strateg ies fo r p ressu re sore m a n ag e m en t (G arber, e t al., 1996). T h e n eed to o b jectiv ely e v a lu a te the effec­ tiv en ess o f ed u c atio n al p ro g ra m s d u rin g p a tie n ts’ h o sp italisatio n c a n n o t be o v e r­ em p h asised (G a rb e r et al., 1996). We n eed to fin d ou t how m uch in fo rm atio n is retain ed at d isch arg e (R o d rig u ez and G arber, 1994). A few stu d ies h av e d es crib ed w ho a c tu a lly is in v o lv e d in th e c lin ic a l ed u catio n o f spinal cord in ju red p atien ts. B asta (1991) looked at source(s) o f know ­ led g e o f spinal co rd in ju red p atien ts for p re ssu re so re p rev e n tio n . T h is study rev e ale d th a t nu rses sp en t m o re tim e e d u c atin g spinal co rd in ju red p atien ts th a n o th e r p ro fe s s io n a ls . T h e stu d y n o ted th at d o cto rs, o ccu p atio n al th e ra­ pists, p h y sio th erap ists an d o th e r clien ts w e re also in s tru m e n ta l in p ro v id in g in fo rm a tio n on p re s s u re so re p r e v e n ­ tio n d u rin g reh a b ilita tio n o f sp in al co rd injured p atien ts. T h e p u rp o se o f th is stu d y was: 1. To e s ta b lis h th e k n o w le d g e p a r a ­ pleg ics h av e on p ressu re ca re and s o re s d u rin g th e h o s p ita lis a tio n p erio d an d at d isch arg e. 2. To estab lish w h eth e r th is k n o w led g e has an in flu en ce on the o cc u rre n ce o f p ressu re so res d u rin g h o sp italisatio n . 3. To estab lish the so u rce(s) fro m w hich para p leg ic s g e t m o st o f th e ir k n o w ­ le d g e re g a rd in g th e p re v e n tio n o f p ressu re sores METHOD E th ic al cle a ra n c e w as o b ta in e d fro m th e C o m m ittee fo r R esearch on H um an S u b je c ts a t th e U n iv e r s ity o f th e W itw a te r s r a n d ( p r o to c o l n u m b e r: M 0 0 0 4 1 9 ). A ll su b jects sig n ed in fo rm ed co n s en t p rio r to th e ir p articip a tio n in the study. T h e p u rp o se an d p ro ce d u re fo r the w h o le study w as ex p lain ed to th e subjects. T h e s tu d y in c lu d e d p a r a p le g ic s ad m itted to tw o sp in al in ju ries units in Jo h an n esb u rg , o n e a g o v ern m e n t run h o sp ital and o n e a p riv a te h o sp ita l. T h e s e p a tie n ts c a m e m a in ly fro m the g rea ter Jo h a n n esb u rg are a w ith all the h o sp itals b ein g fee d ers to the tw o units. T h e null h y p o th eses w ere stated as (i) T h ere is no sig n ific an t d iffe ren ce in k n o w led g e g ain b etw een p ara p leg ic s w h o d e v e lo p p re s s u r e so re s an d th o se w ho d o not. (ii) T h e k n o w led g e g ain on p ressu re so re p rev e n tio n in p ara p leg ic s d o es not in flu e n ce the o cc u rre n ce o f p ressu re sores. P atien ts w ere selected as they w ere ad m itte d at the tw o h o sp itals. P atien ts w ere in clu d ed in th e study if they w ere p ara p leg ic an d ag e d b etw een 18 an d 45 years. T h ey w ere n o t in clu d ed in the study if they had any k n o w n chronic d iseases e.g. diabetes, had a red u ced level o f co n scio u sn e ss o r had any o rth o p aed ic c o n d itio n th at m ade p ressu re r e lie f d iffi­ c u lt e.g. fra ctu red arm . T h e q u e s tio n n a ire so u g h t to estab lish p a tie n ts ’ k n o w led g e on: • A n ato m ical and physio lo g ical changes afte r injury • D efin itio n o f p ressu re so re an d risk factors • S u sce p tib ility o f skin areas to p re s­ sures sores • P re v en tio n m e th o d s w hen u sin g a w heelchair, in bed and o th e r m easures to p rev e n t p ressu re sores • D ete ctio n o f early w arn in g signs o f skin b reak d o w n • C o n seq u en c es o f skin ca re n eg lect • S o u rce o f k n o w led g e on p ressu re care D ata w ere co llec te d u sin g a p re-test p o st-te st m ethod. T w o in terv iew s w ere co n d u c te d w ith patients to test th eir k n o w led g e on p ressu re ca re an d sores usin g a stru ctu red q u estio n n aire. T h e first in te rv iew w as co n d u c te d d u ring th e f ir s t w e e k o f p a t ie n t s b e in g m o b ilise d in w h eelch airs. T h e seco n d in te rv iew w as c o n d u c te d w ith in fiv e d ay s o f d isc h a rg e o r w hen p a tie n ts ’ len g th o f stay w as tw o m onths. P atien ts w ere ask ed to recall the in fo rm atio n u n d e r g iv e n s u b h e a d in g s as sh o w n ab o v e . N o c lu e s w ere g iv e n to aid w ith th e ir recall. T h e q u es tio n n a ire w as a d m in istered on both o cc asio n s by the researcher. P a tie n ts ’ re s p o n s e s w e re m a rk e d ag a in st a set o f p rep ared co rrec t re s p o n s ­ es. T h e resp o n se s w ere w eig h ted to p ro ­ d u c e a p o s s ib le c o r r e c t to ta l o f 54 fo r the in te rv iew and co n v erted into a p ercen tag e. T h e p erc en ta g e then re p re ­ sen ted p a tie n ts ’ k n o w led g e on p ressu re care. T h e d iffe ren ce s in p erfo rm an ce b e tw e e n th e f irs t an d se c o n d te sts m e a s u re d th e k n o w le d g e g a in . T h e o cc u rre n ce o f p ressu re sores w as also rec o rd e d as w ell as p a tie n ts ’ source o f k n o w led g e on p ressu re care. A p atien t w as o n ly rec o rd e d as h av in g a p ressu re so re if they h ad a g rad e II stag e w o u n d o r m ore. 10 SA J o u r n a l o f P hysiothera py 2001 V o l 57 No 4 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) N o ch an g es w ere m ad e to the w ay th a t patients w ere no rm ally ed u c ated on p ressu re sore prev en tio n . D escrip tiv e statistics w ere used to describ e p atien ts’ k n o w led g e on p ressu re so re p revention. K n o w led g e g ain w as an a ly se d u sin g th e R an k S um Tw o- S a m p le (M a n n -W h itn e y ) te s t u sin g the first an d seco n d in terv iew results. T h e rela tio n sh ip b etw e en k n o w led g e an d o cc u rre n ce o f p ressu re sores w as an aly sed using th e s tu d e n ts’ tw o -sam p le ‘t ’-test. T h e rep eatab ility o f the q u e s­ tio n n a ire w as assessed usin g th e m eth o d p ro p o sed by B land an d A ltm a n (1986). T h e R ep eatab ility C o e ffic ien t (R C ) w as ca lc u lated using a m eth o d a d o p ted by th e B ritish S tan d ard s Institution. S ig n ifica n ce w as set a t the 0.05% co n fid e n ce level fo r all tests. T h e rep eatab ility o f th e q u estio n n a ire w as e s ta b lis h e d b y in te rv ie w in g 20 p atien ts tw ice on tw o co n sec u tiv e days an d estab lish ed by th e m eth o d p ro p o sed by B lan d an d A ltm an (1986). U sin g the m eth o d a d o p ted b y th e B ritish S tandards In stitu tio n , th e R eliab ility C o efficien t (R C ) fo r th e q u estio n n a ire w as 3 units. T h is m eans th a t w e w o u ld ex p e ct tw o scores fro m tw o co n sec u tiv e interview s w ithin a short space o f tim e e.g. d ay 1 and day 2, to be w ith in 3 units o f each other. T his w as co n s id ered to lerab le an d h en ce th e q u e s tio n n a ire w as repeatable. RESULTS T h e resu lts p rese n ted are fo r a sam ple o f 28 p atien ts o u t o f the original 30. O n e w as w ith d raw n afte r su stain in g a fractu re o f the left arm . T h e o th e r one w as d isc h a rg e d p rem a tu rely (w ith o u t p rio r n o tice) d u e to fin an cial p roblem s. M in im u m age w as 19, m ean ag e 26.6 an d m a x im u m a g e 4 4 fo r th e to tal sa m p le (N = 28). From the total sam p le 15(53,6% ) w ere b elo w the ag e o f 30. A total o f 11 subjects (39% ) d ev elo p ed pressure sores d u ring the research period. F o r the p ressu re sore g roup, th e m in i­ m um k n o w led g e g ain w as 6.1% w h ile th e m a x im u m k n o w le d g e g a in w as 184.6%. F o r the n o pressu re so re group, th e m in im u m p e r c e n ta g e g a in w a s -26.8% w h ile m ax im u m p erc en ta g e gain w as 1550% . A m ax im u m g ain o f 1550% su g g e sted the p rese n ce o f o utliers. T h e ou tliers w ere fo u r p eo p le w ho started w ith a score in Test 1 < 7% in the no p ressu re sore g roup. T h e ir m ajo r gain ca u se d a sk ew ed d istrib u tio n and hence th ere w as n eed fo r an a d ju stm e n t (by rem o v al o f o u tliers) w hen d o in g fu rth er calcu latio n s on the data. O f th e total p atien t sam p le 24 (86% ) m e n tio n e d b o d y c h a n g e s r e la te d to a ltered sen satio n , p araly sis an d red u ced m obility b u t o nly 1 (4% ) m e n tio n ed altered b lo o d c irc u latio n as a change. M o re than 95% o f th e total p atien ts rec alle d th a t p ressu re sores are cau sed by u n reliev ed p ressu re in e ith er lying o r sitting. T he pelvic areas (sacrum 93% , ischium 86% an d g re a te r tro ch a n ter 82% ) as b ein g p ro n e to pressu re sores w ere m en ­ tio n ed m ost. O th er areas th a t receiv ed th e m o st m en tio n w ere heels (61% ), elb o w s (61% ) an d the m edial and lateral k n ee co n d y les (54% ). P re ssu re r e lie f w as the m o st know n m eth o d o f p rev en tio n o f p re ssu re sores w hen u sin g a w heelchair. O n ly 8 (29% ) p atien ts m en tio n ed th e u se o f cu sh io n s as a m eans o f p rev e n tin g p ressu re sores. K eep in g se lf dry, w h ich in clu d es b ow el an d b la d d e r m a n a g e m e n t, w as o n ly m en tio n ed by a total o f 4 (24% ) people. N ob o d y m en tio n ed th e use o f a co rrect size w h ee lch a ir and av o id an ce o f hard o b jects such as p ieces o f fo o d in the w heelchair. A ll p atien ts m e n tio n ed tu rn ­ ing in b ed as a p ressu re sore p rev en tio n m ethod. A ll th e o th e r m eth o d s w ere m entioned by less than h a lf o f the patients. N o n e o f the su b jects m e n tio n e d safety. S tage I o f p ressu re so re d ev e lo p m e n t w as w ell rec alle d by m o st p atien ts. It is h o w ev e r iro n ic th a t only 5 (45% ) from th o se w h o d e v e lo p e d p re s s u re so res m en tio n ed bro k en skin as a sign o f h a v in g a p re ssu re sore. T w en ty o n e (7 5 % ) p atien ts said they w o u ld notify health p erso n n el in the ev e n t o f th eir d ev elo p in g a p ressu re so re w h ile only 12 (43% ) m en tio n ed the n e e d to rem o v e p ressu re fro m th e affec ted site. M o st p atien ts m e n tio n e d d eath as a c o n s eq u e n ce o f p ressu re c a re n eg lect w h ile n o n e am o n g th o se w ho d ev e lo p e d p re ss u re so res m e n tio n e d le n g th e n e d ho sp ital stay as a co n seq u en ce. Table 1: Rank Sum Two-Sample (Mann-Whitney) Test for Knowledge G ain for the Pressure Sore and N o Pressure Sore Groups after adjusting for the outliers. Pressure Sore Groups Rank Sum Sample Size (N) U Statistics Mean Rank Pressure Sores 113 11 47 10.3 No Pressure Sores 187 13 96 14.4 Total 300 24 Two-Tailed P-value for normal approximation 0.16 Cases included 24 10 Missing cases 0 The p value of 0 .16 indicates that the null hypotheses can be accepted. This stated that there was no significant difference in the knowledge gain between those who developed pressure sores and those who did not. Table 2: Students' Two-Sample 't' test results for influence of knowledge gained on occurrence of pressure sores for the total group after adjusting for the outliers. Pressure Sore Groups Mean Sample Size (N) Standard Deviation Standard Error Pressure Sores 49.95 11 52.76 15.91 No Pressure Sores 73.03 13 57.09 15.83 At 95% Confidence Interval, p-value = 0.32 The p value of 0.32 indicates that the null hypotheses can be accepted. This stated that there was no significant difference in the influence of knowledge gain on the occurrence of pressure sores. T h e p hysiotherapist (98% ) w as the m ost involved professional in p ressu re sore p rev en ­ tio n ed u catio n fo llo w ed by th e n u rse (82% ) an d o cc u p atio n al th e ra p ist (68% ) re sp e c ­ tively. O n ly o n e in d iv id u al rep o rted h av in g u sed p o sters as a so u rce o f in form ation. S A J o u r n a l o f P hysiotherapy 2 0 0 1 V o l 5 7 No 4 11 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) DISCUSSION T h e re su lts c le a rly sh o w th a t th e in fo rm atio n p arap leg ics had on p ressu re sore prevention was incom plete. A lthough th ere w as ev id en t g ain in k n o w led g e, the am o u n t o f in fo rm atio n th at p arap leg ics c o u ld recall at d isc h arg e reg ard in g p re s ­ su re sore p rev en tio n w as not ad eq u ate. T h is a g re e s w ith th e fin d in g s by R odriguez and G arb er (1994) and Garber, e t al. (1 9 9 6 ) w h o se stu d ies lo o k ed at d isc h arg ed spinal co rd injury patients. T h e rea so n w hy th e ir su b jects co u ld no t recall ad e q u ate in fo rm atio n on p re s­ su re sore p rev en tio n m eth o d s w as, as they su g g ested , m o st p ro b ab ly b ecau se p a tie n ts w e r e d is c h a r g e d in to th e co m m u n ity w ith less in fo rm atio n . T his ap p ears to have been a rea so n ab le c o n ­ clu sio n b ec au se as the resu lts fo r this research show, p arap leg ics w ho w ere ju s t ab o u t to b e d isc h arg ed from the tw o h o sp itals into the co m m u n ity did no t have co m p lete in fo rm atio n on p re s ­ su re sore prevention. R o d rig u e z an d G a rb e r ( 1994) fo u n d th at w eig h t shift o r tu rn in g w h en in bed w ere th e m ost o ften -p ractice d p ressu re so re p rev en tio n tech n iq u es. T h is finding is su p p o rted by the fact th at turning in bed and pressure relief w hen in the w heel­ ch a ir w ere the m ost recalled m eth o d s o f p ressu re so re prev en tio n in th is study. H o w ev er u n lik e th eir study w h ere the use o f c u sh io n s w as ran k ed as the m o st im p o rtan t m eth o d o f p ressu re sore p re­ v en tio n it o n ly receiv ed a m en tio n fro m 29% o f the total sam p le fo r this study. T h is m ight be b ecau se cu sh io n s w ere not e m p h asised as b ein g im p o rtan t d u ring p ressu re so re prev en tio n ed u catio n . A s a re su lt o f b u d g etary co n s tra in ts so m e p ara p leg ic s are b ein g m o b ilised w ith o u t c u sh io n s a t th e reh a b ilita tio n h o sp itals an d this m ig h t ac co u n t fo r the p erceiv ed la ck o f im p o rta n ce o f cu sh io n s. A n d e r s o n an d A n d b e r g ( 1 9 7 9 ) sh o w ed the p sy c h o so cia l w ell b ein g o f p atien ts has an effect on the ab ility o f p atien ts to u n dergo any fo rm o f e d u c a ­ tion. T h is are a n eed s to be investigated b ec au s e m any p arap leg ic p atien ts spend a lo t o f tim e in th e d en ial stage, still c o p in g w ith th e ir su d d e n d isa b ility . L ea rn in g such vital te ch n iq u e s is likely to be the last th in g they are ready for at this stage. S o m e p a tie n ts ’ len g th o f stay is d e te r­ m in e d by fiscal ra th e r than m ed ical c o n s id e ra tio n s . T h is d o e s n o t allo w p atien ts to g ain ad e q u ate k n o w led g e on p ressu re sore p rev en tio n , as p atien ts are in c re asin g ly b ein g d isch arg ed afte r short hospital stays. Early, effective ed ucation on p ressu re so re p rev en tio n is essential. G arber, e t al. (1 9 9 6 ) co n c lu d e d that little e m p h a s is w as b e in g g iv e n to m a n ag e m en t actio n o n c e a p ressu re so re has d eveloped. T h is ap p e ars also to have b een the ca se in this study w h ere the m ajo rity o f p atien ts (75% ) th o u g h t the b est thing w as ju s t to n o tify the health p erso n n el ab o u t th e p ressu re sore. O nly 4 3 % o f th e to tal s a m p le s a id th ey w o u ld have to rem o v e pressu re from the affected area. T h ere is a n eed to e m p h asise the fact that p rev en tio n and successful m an ag em en t o f pressu re sores is th e in d iv id u al’s resp o n sib ility an d not th a t o f the hospital. T h e fin d in g th a t k n o w le d g e g ain d o es no t h av e a sig n ific an t in flu en ce on w h e th e r o n e d ev elo p s p ressu re sores o r not su g g ests a d isc re p an c y betw een w h at is d o n e in p rac tice and w h at p ara­ p le g ic s k n o w a b o u t p re s s u r e so re p rev en tio n . T h is ag rees w ith R o d rig u e z an d G a rb e r (1994) ‘s findings. T h is is how ever d ifficu lt to q u an tify because o n e n eed s to first lo o k at th e d eg re e o f a d h eren ce to the prevention p rogram m es am o n g spinal co rd p atien ts. A s show n by S u m iy a e t al (1997), an im p ro v em en t in se lf-c are am o n g p a ra ­ plegics helps in preventing pressure sores. T h e ab ility o f p atien ts to g ain ad e q u ate in fo rm atio n on p ressu re so re prev en tio n d u rin g reh a b ilita tio n is th rea ten e d by red u c ed len g th o f stay an d the p resen t e m p h asis th at is b ein g p la ce d on fin an ­ cial in stead o f m ed ical sense. T h is stu d y show ed th at p h y sio th e ra ­ p ists are the m o st involved p ro fessio n als in th e ed u c atio n o f spinal co rd in ju red p atien ts in a reh a b ilita tio n setting. T he n urses an d o cc u p atio n al th erap ists fo l­ low them respectively. C a u tio n h o w ever n eed s to be ex e rcise d w h en in terp retin g th ese results. In terv iew s w ere d o n e by a p h y sio th erap is t w ho w as n o t w o rk in g at e ith er o f the tw o reh a b ilita tio n h o sp itals in volved in th e study. H ow ever, th e fact th at patients k n ew fro m the in troductions d o n e d u rin g th e first in terv iew m ig h t have sw ay ed the results in fav o u r o f physiotherapists (w ithout taking anything aw ay from them though). P revious stu d ies (B asta, 1991) have show n nu rses as b ein g m ore e n g a g ed in p re s s u r e so re e d u c a tio n th a n o th e r p ro fe ssio n s fo llo w ed b y th e ra p ists, a fin d in g th a t is not very d iffe ren t from this study. T h e reaso n w hy th erap ists m ight have scored such a high popularity as p ressu re so re ed u c ato rs is th a t they sp en d m o re tim e w ith p atien ts than any o th e r p ro fe ssio n a l at this stag e o f re h a ­ b ilitatio n . T h e sam e reaso n can also be u sed to ex p lain n u rs e s ’ in v o lv em en t as p ressu re so re ed u cato rs. L im ita tio n s o f th e Study: 1. T h e targ et p o p u la tio n (sp in al cord in ju ry p atien ts) is m uch b ig g e r and m ore d iv e rse than the stu d ied sam p le an d h en c e cau tio n n ee d s to b e e x e r­ c ised w hen ex tra p o latin g th ese results to the en tire p o p u latio n . 2. A lth o u g h h a v in g k n o w le d g e is a p re-re q u isite for a p ressu re sore free life , th e re a re o th e r fa c to rs th a t c o n trib u te to p ressu re so re form ation, w h ich c a n n o t b e co n tro lled . CONCLUSION AND RECOMMENDATIONS Spinal co rd in ju red p a tie n ts ’ k n o w led g e on p ressu re so re p rev en tio n (at the two h o sp itals stu d ied ) at d isc h arg e appears to be in co m p lete. T h ey are b ein g d is­ ch a rg ed into the co m m u n ity w ith in ad e­ q u a te in fo rm a tio n o n p re s s u re s so re p rev en tio n , w hich is a ca u se for concern a b o u t th e ir ab ility to co p e w hen a t hom e. K n o w led g e gain does not seem to d e te r m in e w h e th e r p a tie n ts w ill g e t p ressu re sores o r not. T h is show s a d isc re p an c y b etw e en w h at p arap leg ics recall on p ressu re so re p rev en tio n and w h at they actu ally d o in practice. P h y sio th e ra p ists (9 8 % ), n u rses (82% ) an d o cc u p atio n al th e ra p ists (68% ), in that order, are the lead in g so u rces o f p ressu re care k n o w led g e fo r spinal co rd in ju re d p atien ts in th e tw o h o sp itals studied. C lin ica l R eco m m en d a tio n s: 1. T h e re is a n eed to ev alu ate p a ra ­ p le g ic s ’ k n o w le d g e a t le a s t th re e w ee k s b efo re d isc h arg e to estab lish 12 SA J o u r n a l o f P hysiothera py 2001 V o l 57 No 4 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) I th eir w eak areas o f k n o w led g e and im p ro v e them b efo re d ischarge. 2. P atie n t ed u catio n sh o u ld b e spread o u t th ro u g h o u t th eir length o f stay (en tire reh ab ilitatio n p erio d ) and no t ju s t co n fin ed to th e first few w eeks. 3. T h ere is a n eed to in v o lv e p a tie n ts’ fa m ilie s an d frie n d s in e d u c a tio n p ro g ram m es so th at they can h elp to rein fo rce th eir k n o w led g e esp ecially w hen p atien ts are d isc h arg ed thus allo w in g for continuity. 4. 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