Volume 26 Number 2

Key messages

• The global incidence of pressure ulcers in patients with spinal cord injury is 0.23 (95% CI, 0.20-0.26), and the prevalence reaches 32.36% (95% CI, 28.21-36.51), with significant heterogeneity reported across studies.
• Pressure ulcers are more common in developing countries in comparison with developed countries.
• Prioritisation of proper reporting of PUs, enhancing the overall quality of healthcare services and implementing targeted, context-specific preventive strategies are essential to reduce the burden of PUs in patients with SCI.

Introduction

Spinal cord injury (SCI) is associated with substantial functional impairments and mortality. It often results in several complications, such as pressure ulcers (PUs), which significantly elevate the disease burden and reduce the health-related quality of life.^1,2 Chen et al (2022) indicated that respiratory problems, urinary tract infections and PUs are the three most common complications in studies conducted in China regarding patients with SCI.³

The pooled results from 229 studies indicated that the overall incidence rate of SCI was 23.77 (95% CI, 21.50-26.15) per million people.⁴ The World Health Organisation reported that more than 15 million people are living with SCI globally in 2024.⁵ Chen et al (2022) reported the incidence of SCI in China to be between14.6 and 60.6 per million.³

The development of PUs is multifactorial, and more than 200 risk factors are described in the research evidence.⁶ Di Prinzio et al identified 30 risk factors in evidence for the development and recurrence of PUs in patients with SCI.⁷ The higher risk of PUs among patients with SCI is caused by immobility, insensate skin or a range of incontinence issues.⁸ Other risk factors related to the PU recurrence are history of PUs and duration of SCI, especially more than 10 years post-injury, with the highest incidence in the first year after injury.⁹ Study findings indicate that more than 1 in 5 individuals with SCI will develop PUs.¹⁰ Many of the PUs in this SCI population become deep wounds with prolonged healing depending on the patient’s state.^11,12

The pressure ulcer risk assessment scale helps with the treatment and management of individuals with SCI.¹³ According to the European Pressure Ulcer Advisory Panel, PUs are classified into the following stages: (I) intact skin with a localised area of non-blanchable erythema, which may appear differently in darkly pigmented skin; (II) partial-thickness loss of skin with exposed dermis; (III) full-thickness skin loss, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) is often present; (IV) full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Two additional stages, “unstageable full-thickness pressure injury” and “deep tissue injury,” are also recognised.¹⁴ Superficial pressure injuries, including stages (I) and (II), are the most common stages.¹⁵

Although the risk of PU is highly individualised, various flexible prevention strategies can be implemented. These include proper bed and seating positioning, pressure relief manoeuvres, and staff, patient and family education. The evidence suggests avoiding the 90° lateral position due to the high pressures and PU risk over the trochanters.¹⁶ The most effective interventions for preventing pressure ulcers fall into four categories: PUs prevention bundles, repositioning with the use of surface support, prevention of medical device-related injuries, and access to expertise.¹⁷ Video-based education and the application of fatty acids to the skin may also help prevent pressure ulcers in individuals at high risk.¹⁸ In contrast, Atkinson and Cullum stated that the effects of most interventions for preventing PUs in people with SCI are highly uncertain and recommended further research for clarifications, especially randomised trials.¹⁹

For treatment, various dressings, including pine resin salve, hydrocolloid, hydrogel, polyurethane, silver-based, and ibuprofen-releasing foams, are available to promote healing. The quality of evidence supporting both prevention and treatment strategies is generally low to very low.¹⁸ The topic of pressure ulcer management is covered in current guidelines using the GRADE methodology.²⁰

Hospital-acquired PUs pose a significant and costly challenge to the healthcare system. In 1992, Kuhn and Coulter stated that 1.7 million patients annually develop PUs with associated healthcare costs of US$8.5 billion.²¹ The cost of preventing PUs ranges from €2.65 to €87.57 per patient per day across various settings. Meanwhile, the cost of treating PUs varied between €1.71 and €470.49 per patient per day, depending on the setting.²² Current research suggests that future economic evaluations of PU prevention should use transparent, standardised, and appropriate methods to enable comparison of different approaches.^23,24 One study conducted in the Czech Republic using the rigorous methodology for PU cost-of-illness analysis found the total cost of PU treatment excluding pharmacotherapy, had a median of €678, while including pharmacotherapy, the median cost rose to €929. Treatment costs were higher for younger patients.²⁵

Data on the incidence rate and prevalence of PUs in individuals with SCI is essential for assessing burden, formulating prevention strategies, planning healthcare, and guiding future research. No overview of reviews on this topic was identified based on our preliminary search. Moreover, the study design used (an overview of reviews) enables the summary of available evidence to provide a better understanding of this specific topic in a broad context.²⁶

Incidence rate is defined “as a measure of morbidity based on the number of new episodes of illness arising in a population over a period of time.“²⁷ While prevalence is “a measure of morbidity based on current levels of disease in a population.”²⁸

Therefore, the aim of this review was to estimate the incidence and prevalence of PUs in individuals with SCI. The research question is stated as follows: What is the prevalence and incidence of pressure ulcers among patients with spinal cord injury? 

Methods 

This overview of reviews consolidates evidence from multiple research syntheses and provides a broader understanding of the evidence regarding the prevalence and incidence rate of PUs in patients with SCI. The PRIOR statement was used for reporting this review.²⁹ The checklist is attached in Appendix A.

Eligibility criteria

The PEO framework (Participants, Exposure and Outcome) was used to formulate the eligibility criteria. 

Participants: The general population. 

Exposure: Spinal cord injury. 

Outcome: Prevalence and incidence rate of pressure ulcers (also known as pressure injuries). 

Timing: Studies published from 2014 onwards.

Setting and study design: We included research syntheses, such as systematic reviews and literature reviews that report the prevalence and incidence of PUs in patients with SCI. We defined systematic reviews as peer-reviewed studies with attributes of systematic methodologies, such as searching at least two databases and clearly reporting the research questions. Primary studies were excluded because the overview of reviews summarises the secondary research. Additionally, the scoping reviews were excluded because their aim to map existing literature does not correspond with our research question.

Information sources

The search was run on 18 November 2024, to identify all relevant research syntheses related to PUs in patients with SCI. We searched MEDLINE (Ovid) and Epistemonikos as this combination is the most appropriate for identifying systematic reviews for an overview of reviews.³⁰

Search strategy

The search strategy contained Medical Subject Headings (MeSH) and search terms relevant to “spinal cord injury“ and “pressure ulcers“. We applied a publication date limit up to 2014 for MEDLINE (Ovid) within the search strategy. The search strategies, both for MEDLINE (Ovid) and Epistemonikos, are available in Appendix B. We did not apply any limitations regarding language. We also reviewed the references of the included systematic reviews for any additional relevant evidence.

Selection process

The retrieved records were uploaded into Zotero (AGPL). The deduplication of records was performed using The Systematic Review Accelerator (Bond University Institute for Evidence-Based Healthcare), leaving 653 titles and abstracts to be screened for inclusion.³¹

The records were uploaded to Rayyan so that the title/abstract and full-text screening could be conducted.³² The title/abstract and full-text screening were conducted independently by two reviewers. The discrepancies were resolved by discussion among the author team. The screening process was initiated by a pilot test of the eligibility criteria on a small sample of articles.

We didn‘t face the overlapping systematic reviews regarding their outcomes.

The PRISMA 2020 flow diagram was used to describe the information flow through the several phases of the overview of reviews development process.³³

Data collection

Relevant details were extracted by two reviewers using a modified JBI data extraction tool with a mutual check.³⁴

The overlap of included studies was assessed by calculating the corrected covered area (CCA). Pre-determined overlap thresholds were used for the interpretation of overlap (0–5%: slight, 6–10%: moderate, 11–15%: high, >15%: very high).^35,36 The overlap was presented visually using the validated instrument GROOVE.³⁷

Risk of bias assessment

The critical appraisal was conducted independently by two reviewers using the JBI tool for critical appraisal of systematic reviews.³⁴ Conflicts were resolved by discussion and reaching a consensus. The visualisation of critical appraisal results was performed using RevMan 5.4.³⁸

We didn’t reevaluate the risk of bias in primary studies. The assessment of the risk of bias in individual primary studies would require a detailed evaluation of each study, including its methodology and interpretation, which exceeded the scope of this review. However, in evaluating the reviews, we focused on the methodological quality and potential bias of these reviews to ensure that the results are reliable and relevant.

Synthesis method

The data were summarised and presented in the included conceptual synthesis. The evidence was synthesised narratively, and the characteristics of the included studies were presented in tabular form. We recorded data on heterogeneity and subgroup analyses. In our review, we did not perform an assessment of the certainty of evidence due to the variability and methodological differences across the studies, which raised concerns about potential inconsistencies in the ratings.

Results

The electronic searches yielded 653 records after removing duplicates. After screening titles and abstracts, we excluded three studies based on full-text screening. The list of included and excluded studies with reasons for exclusion is available in Appendix C. We considered three reviews as eligible for inclusion in this overview of reviews.¹⁰,^39,40 The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram is shown in Figure 1.

 

Figure 1. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.
Source: Page MJ, et al.³³
This work is licensed under CC BY 4.0.

 

Risk of bias included studies

The ratings for the included research syntheses based on the JBI critical appraisal tool(35) are summarised in Table. 1. One study was identified as the literature review. So, the overall quality of this study in all domains is low consequently.³⁹

 

Table 1. Risk of bias of included studies

 

Two included reviews reported the quality of primary studies. Shiferaw et al (2020) excluded four low-quality primary studies based on the Newcastle-Ottawa scale. The overall quality of the included studies was moderate to high.⁴⁰ Chen et al (2020) utilised a 14-item standardised instrument developed by Kuijpers and colleagues for the assessment of primary studies. The overall quality of the included studies was considered moderate to high in 26 studies out of 29 included.¹⁰

Primary study overlap

The overlap of primary studies covered in research syntheses was 11.29. This result indicates high overlap. A graphical representation of the overlap is available in Figure 2. However, we have to interpret this overlap in terms of the variability of presented outcomes in these reviews: incidence rate, reported by Chen et al¹⁰, and prevalence reported by Shiferaw et al⁴⁰. So, several primary studies were used to report data on both prevalence and incidence.

 

Figure 2. Graphical Representation of Overlap for OVErviews (GROOVE)

 

Summary of results

The research syntheses included in this overview consist of one literature review³⁹ and two systematic reviews.^40,10 The extraction table is presented in Appendix D.

Table 2 presents the characteristics of the three included studies. The review³⁹ was published in 2015, and the two studies^10,40 were published in 2020. The reviews are based on a total of 62 primary studies, and these primary studies cover the publication range from 1986 to 2019.^41,42 The primary studies reviewed encompass both retrospective and prospective study designs.

 

Table 2. Characteristics of included studies

 

Zakrasek et al³⁹ assessed both prevalence and incidence rates of PUs. Chen et al¹⁰ focused on the incidence rate of PUs, and Shiferaw et al⁴⁰ on the prevalence of PUs.

Zakrasek et al³⁹ concentrated on “low” and “middle-income” countries as defined by the World Bank. Chen et al¹⁰ was not limited by income or geographical area and covered hospital-acquired and community-acquired settings. While Shiferaw et al⁴⁰ covered only primary studies reporting hospital-based data.

Chen et al^l0 and Shiferaw et al⁴⁰ conducted a meta-analysis of included studies with high heterogeneity. Shiferaw et al⁴⁰ faced high heterogeneity (I2 = 97.1%, p <0.001). As a result, the subgroup analysis was performed based on the study design. This analysis showed that the highest prevalence of PUs was reported in a study with cohort design, reaching 34.85% (95% CI:28.50–41.19; I2=88.4%). Shiferaw et al’⁴⁰ also noted that a high magnitude of pressure ulcers was observed among studies covering the African continent, 41.94% (95% CI:1.70–52.18, I2=72.7%). So, the overall results are affected by high heterogeneity. The analyses suggest that the source of heterogeneity may lie in the geographical location of the study or study design. There was high heterogeneity (I2=99.1%, p=0.000) among the included studies by Chen et al as well.¹⁰

The publication bias is represented in Chen et al’s review reporting incidence rate.¹⁰ Egger’s regression test revealed publication bias, indicating that studies with positive results were more likely to be accepted and published than those with negative results. However, publication bias assessment was missing in Shiferaw et al’s review⁴⁰, which reported prevalence. Shiferaw et al also confirmed that based on sensitivity analysis, no single study affected the overall magnitude of PUs among SCI.

The global incidence of PUs in patients with SCI

The global incidence of PUs related to patients with SCI was 0.23 (95% CI:0.20–0.26), based on Chen et al.¹⁰ In the context of geographical distribution, the pooled incidence was the highest in South American countries, 0.43 (95% CI:0.28–0.57). The pooled incidence in Asian countries reached 0.16 (95% CI:0.06–0.25) and was the lowest in comparison with other regions, such as 0.36 (95% CI:0.16–0.56) in African countries, 0.25 (95% CI:0.14–0.37) in European countries, and 0.23 (95% CI:0.19–0.27) in North American countries.

The reported incidence was higher in developing countries than in developed countries: 0.27 (95% CI:0.17-0.37) and 0.22 (95% CI:0.19–0.26) respectively.¹⁰

The hospital and community-acquired PU incidence was reported as 0.22 (95% CI:0.19–0.26) and 0.26 (95% CI:0.20–0.32), respectively.¹⁰

The annual incidence of PUs ranged from 0.05 to 0.48, with the highest at 0.48 in 2011 and the lowest at 0.05 in 2018.¹⁰

Zakrasek et al confirmed that data on the incidence of PUs among SCI patients are highly variable.³⁹

The global prevalence of PUs in patients with SCI

The global pooled magnitude of PUs among patients with SCI was 32.36% (95% CI, 28.21-36.51), based on Shiferaw et al⁴⁰. In the context of the study continent, the highest magnitude of PUs was observed among studies conducted in Africa, 41.94% (95% CI, 31.70-52.18) of included studies. The lowest magnitude of PUs was reported in North America, 24.12% (95% CI, 28.14-46.81), compared to Europe, 37.47% (95% CI, 28.14-46.81), and Asia, 32.07% (95% CI, 27.99-36.15).⁴⁰

Zakrasek et al summarised that it is impossible to accurately report the true prevalence of SCI-related PUs in the developing world. The main factors include the problematic definition of the concept of the ‘developing world’, the specificities for reporting PUs in these regions and the heterogeneous results among studies. They also stated that “if only a rough estimate, the findings above do suggest that the prevalence of PUs in patients with SCI in developing nations is greater than in the developed world.”³⁹

Included recommendations

The included studies suggest that developing strategies to monitor and improve pressure relief practices in individuals with SCI is essential for reducing the incidence of PUs. Policymakers, as well as health professionals, are encouraged to address the growing burden of PUs in SCI patients by raising patient awareness, supporting adherence to preventive measures and enhancing safety, lowering treatment costs, and developing efficient treatment plans. The findings also provide a reference point for clinicians to emphasise standardised care and quality improvement. Policymakers should implement context-specific preventive strategies to decrease the burden of PUs in SCI patients and improve the overall quality of healthcare services.^10,39,40

Discussion

This overview of reviews included three research syntheses representing 62 primary studies and identified data on prevalence and incidence rates globally. The data suggested a global pooled magnitude of PUs among patients with SCI of 32.36% (95% CI:28.21–36.51). The global incidence of PUs was 0.23 (95% CI:0.20–0.26) in patients with SCI. This evidence is based on data from primary studies published between 1989 to 2019.

The evidence included confirms that there are higher incidence rates and prevalence in developing countries (based on World Bank identification). Moreover, the evidence indicates that hospitals and clinics in developing countries may not have the financial resources or infrastructure to monitor all PUs.⁴³ These findings are supported also by Anthony et al (2021)⁴⁴. This systematic review performed a meta-analysis of the prevalence of PUs in Africa and reported a very high prevalence of 44% (95% CI, 31%-57%) among patients with SCI. However, the included studies show high heterogeneity (I2=94%). Also, the studies from the African region are based on the younger population.⁴⁴ In this context, Jorge at al(2018) confirmed for individuals with SCI that PU formation was significantly higher in the lower income brackets (OR 2.1, 95%, CI:1.5–3.0, p<0.001).⁴⁵

The incidence rate is also influenced by the reporting timeframe. Prevalence studies should focus on point prevalence, while incidence studies should clearly define the period during which ulcers are recorded. Chen et al¹⁰ conducted an analysis of the incidence of PUs among SCI patients in both hospital and community-based settings, which were examined separately in their review. Nevertheless, it remains unclear whether the “hospital setting” refers to the acute or long-term phase of care. From a clinical perspective, further clarification and distinction between phases would be valuable for a more comprehensive understanding of PU incidence in SCI patients.^44,10 White et al⁴⁶ reported that approximately 30 to 40 per cent of patients with SCI develop PUs during the acute and convalescent phase. The US National Spinal Cord Injury Statistical Center indicates 25.2% PUs occurrence in first year since discharge from rehabilitation. However, the proportion of PUs among SCI patients increases depending on post-injury year.⁴⁷

The development and recurrence of PUs among patients with SCI are influenced by a number of factors. Prevalence and incidence rates provide insight into whether these factors are minimised in particular contexts and settings. Marin et al⁴⁸ identified five domains for 18 risk factors: sociodemographic, neurological, functional, clinical, biological and medical care management. Other studies also deal with lifestyle factors⁴⁹ or level of paralysis. Cowan et al⁵⁰ found that PU rates were much higher in quadriplegic and paraplegic patients compared to long-term care residents without paralysis, with hemiplegic patients showing a similar prevalence to non-paralysed residents. PU prevalence was significantly higher in paraplegic patients compared to those with quadriplegia when the risk factor of paraplegia versus quadriplegia was isolated.⁵⁰

The interpretation of results is constrained by significant heterogeneity among the studies. While the included reviews partially identified sources of this heterogeneity, our analysis faced several limitations.

The number of feasible research syntheses included in this study is low, with the most published more than three years ago. The lack of evidence on the prevalence and incidence rate of PUs among patients with SCI and high heterogeneity makes the results only likely generalisable for interpretation. So, we recommend conducting recent systematic reviews on this topic, which should incorporate recent primary studies.^51,52,50

However, after the first submission of our overview of reviews, a new, relevant, systematic review was identified as a journal pre-proof that addresses the incidence of pressure ulcers (PU) among SCI patients.⁵³ Its findings align with Chen et al’s¹⁰ conclusions. Jie Xu (2025) concluded that the overall incidence of PU among SCI patients is 28.8% (95% CI:24.2–33.4). The highest incidence is reported in South American countries, 65.3% (95% CI:55.9–74.7), and the lowest incidence was in Asian countries, 20.9% (95% CI:12.8–28.9). The new review interestingly points out the declining global incidence of PU in SCI patients. PU incidence rate was 33.9% (95% CI:27.1–40.7) before 2005 and 27.1% (95% CI:20.8–33.3) from 2016–2024.⁵³

The main strength of this review lies in its robust methods. We used a broad search strategy, conducted the critical appraisal of included studies using standardised tool and performed an overlap analysis of primary studies. We followed the PRIOR statement guidelines for reporting an overview of reviews. Although this PRIOR statement is targeted at healthcare intervention, it could be used as a support for other types of overview of reviews.²⁹

Based on our findings, we recommend developing and implementing strategies to regularly monitor risk of PU formation and PU prevalence in individuals with SCI, ensuring accurate reporting and reflection of recent event data. Enhancing patient education and fostering collaboration between policymakers and clinicians are also essential.⁵⁴ Additionally, regular evaluation of preventive and treatment strategies will help ensure desired outcomes and allow for necessary adjustments in clinical practice. To support the above-mentioned activities the European Wound Management Association (EWMA) is leading a project called Pressure Injury Recurrence, and this review will contribute to the project outcomes.⁵⁵

Conclusion

This overview of reviews included three research syntheses representing 62 primary studies and identified data on the prevalence and incidence of PUs in patients with SCI rates globally. The included evidence reported a global PU incidence of 0.23 (95% CI:0.20–0.26) among SCI patients, a global PU pooled magnitude of 32.36% (95% CI:28.21–36.51) among SCI patients, and highlighted significant heterogeneity and varying rates of PU, which are very prevalent among SCI patients, especially in developing nations. The evidence is supported by data from primary studies conducted between 1989 and 2019.

Implication for clinical practice and further research

Based on this overview of reviews, we recommend conducting a new research synthesis reflecting current data from primary studies since 2020. Recent research syntheses on prevalence and incidence rates of PUs among patients with SCI are desirable, along with proper reporting of this secondary complication and the phases of care in which PUs are more likely to occur. Policymakers should prioritise the implementation of targeted, context-specific preventive strategies to significantly reduce the burden of PUs in patients with SCI, thereby enhancing the overall quality of healthcare services for this vulnerable population.

Conflict of Interest

The authors declare no conflicts of interest.

Funding

The authors received no funding for this study.

Contributions of authors

Conceptualisation, full-text screening (AP); search strategy, overlap analysis (AL); Data extraction (TF); critical appraisal (TF, AL); methodology, Ti/Ab screening, drafting, final manuscript approval (AL, TF, AP).

Author(s)

Alena Langaufova¹ PhD, Tereza Friessova¹*, Andrea Pokorna¹ Prof
¹Department of Health Sciences, Faculty of Medicine, Masaryk University, Brno, Czech Republic

*Corresponding author email tereza.friessova@med.muni.cz

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Supplementary information

Appendix A

PRIOR Checklist
(Gates M, Gates A, Pieper D, et al. Reporting guideline for overviews of reviews of healthcare interventions: development of the PRIOR statement. BMJ 2022;378:e070849. doi:10.1136/bmj-2022-070849.)

 

Appendix B

Ovid MEDLINE(R) ALL 1946 to November 15, 2024
The search was conducted on 18 November 2024 at 9:00 am (CET).

 

Appendix C

Included studies

 

Appendix D

Extraction table