RESEARCH ARTICLESupport surfaces for pressure ulcerpre

RESEARCH ARTICLE
Support surfaces for pressure ulcer
prevention: A network meta-analysis
Chunhu Shi
1*, Jo C. Dumville1, Nicky Cullum1,2
1 Division of Nursing, Midwifery & Social Work, School of
Health Sciences, Faculty of Biology, Medicine &
Health, University of Manchester, Manchester Academic Health
Science Centre, Manchester, United
Kingdom, 2 Research and Innovation Division, Manchester
University NHS Foundation Trust, Manchester
Academic Health Science Centre, Manchester, United Kingdom
* [email protected]
Abstract
Background
Pressure ulcers are a prevalent and global issue and support
surfaces are widely used for
preventing ulceration. However, the diversity of available
support surfaces and the lack of
direct comparisons in RCTs make decision-making difficult.

Objectives
To determine, using network meta-analysis, the relative effects
of different support surfaces
in reducing pressure ulcer incidence and comfort and to rank
these support surfaces in
order of their effectiveness.
Methods
We conducted a systematic review, using a literature search up
to November 2016, to iden-
tify randomised trials comparing support surfaces for pressure
ulcer prevention. Two review-
ers independently performed study selection, risk of bias
assessment and data extraction.
We grouped the support surfaces according to their
characteristics and formed evidence
networks using these groups. We used network meta-analysis to
estimate the relative
effects and effectiveness ranking of the groups for the outcomes
of pressure ulcer incidence
and participant comfort. GRADE was used to assess the
certainty of evidence.
Main results

We included 65 studies in the review. The network for assessing
pressure ulcer incidence
comprised evidence of low or very low certainty for most
network contrasts. There was mod-
erate-certainty evidence that powered active air surfaces and
powered hybrid air surfaces
probably reduce pressure ulcer incidence compared with
standard hospital surfaces (risk
ratios (RR) 0.42, 95% confidence intervals (CI) 0.29 to 0.63;
0.22, 0.07 to 0.66, respec-
tively). The network for comfort suggested that powered active
air-surfaces are probably
slightly less comfortable than standard hospital mattresses (RR
0.80, 95% CI 0.69 to 0.94;
moderate-certainty evidence).
PLOS ONE | https://doi.org/10.1371/journal.pone.0192707
February 23, 2018 1 / 29
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OPEN ACCESS
Citation: Shi C, Dumville JC, Cullum N (2018)
Support surfaces for pressure ulcer prevention: A
network meta-analysis. PLoS ONE 13(2):
e0192707. https://doi.org/10.1371/journal.
pone.0192707
Editor: Yih-Kuen Jan, University of Illinois at
Urbana-Champaign, UNITED STATES
Received: September 27, 2017
Accepted: January 29, 2018
Published: February 23, 2018
Copyright: © 2018 Shi et al. This is an open access
article distributed under the terms of the Creative
Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in
any medium, provided the original author and
source are credited.
Data Availability Statement: All relevant data are
within the paper and its Supporting Information

files.
Funding: This work was supported by a President’s
Doctoral Scholarship to CS from the University of
Manchester. The funder had no role in study
design, data collection and analysis, decision to
publish, or preparation of the manuscript. We also
received some analytical advice from the Complex
Reviews Support Unit, which is funded by the
National Institute for Health Research (project
number 14/178/29).
https://doi.org/10.1371/journal.pone.0192707
http://crossmark.crossref.org/dialog/?doi=10.1371/journal.pone.
0192707&domain=pdf&date_stamp=2018-02-23

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Conclusions
This is the first network meta-analysis of the effects of support
surfaces for pressure ulcer
prevention. Powered active air-surfaces probably reduce
pressure ulcer incidence, but are
probably less comfortable than standard hospital surfaces. Most
prevention evidence was
of low or very low certainty, and more research is required to
reduce these uncertainties.
Introduction
Pressure ulcers are localised injuries to the skin and/or
underlying tissue, which are also
known as pressure injuries, pressure sores, decubitus ulcers and
bedsores [1]. Pressure ulcers
represent a serious heath burden with a point prevalence of
approximately 3.1 per 10,000 in
the United Kingdom (UK) [2]. It has been estimated that the
treatment of pressure ulcers costs
approximately 4% (between £1.4 and £2.1 billion) of the total
health budget of the UK (1999/
2000 financial year) [3].

Pressure ulcers are caused by localised pressure and shear [1],
thus intervention to alleviate
pressure and shear is an important part of pressure ulcer
prevention. Support surfaces (e.g.
mattresses, overlays, integrated bed systems) are designed to
work towards preventing pressure
ulcers primarily in this way [4]. Various types of support
surfaces have been developed with
different mechanisms for pressure and shear relief including (1)
redistributing the weight over
the maximum body surface area; (2) mechanically alternating
the pressure beneath body to
reduce the duration of the applied pressure [5]; or (3)
redistributing pressure by a combination
of the above, allowing health care professionals to change the
mode according to a person’s
needs [6]. Support surfaces are made from a variety of
construction materials (e.g. foam) and
have different functional features (e.g. low-air-loss) [4].
Identification of the optimum support
surface from the diverse options available requires evidence on
their relative effectiveness in
terms of how well they prevent the incidence of new pressure
ulcers [2].

Currently, seven systematic reviews containing meta-analyses
have summarised rando-
mised controlled trial (RCT) and quasi-randomised trial
evidence to inform choice of support
surface [7–13]. Of these reviews, one high-quality Cochrane
review includes all studies covered
by the remaining six reviews and offers the most comprehensive
summary of current evidence
[9]. However, all these reviews (including the Cochrane review
[9]) use an outdated support
surface classification systems [5] now superseded by the recent
internationally agreed NPUAP
Support Surface Standards Initiative (S3I) classification system
[4]. Additionally, the reviews
all use pairwise meta-analysis to synthesise evidence for head-
to-head comparisons of support
surfaces. There remains a lack of evidence on the relative
effects of different support surfaces,
in part due to a lack of head-to-head RCT data across the
plethora of treatment options
available.
To tackle this problem, an advanced meta-analysis technique,
network meta-analysis, can

be employed. The approach can simultaneously compare
multiple competing interventions in
a single statistical model whilst maintaining randomisation as
with standard meta-analysis
[14–16]. The network meta-analysis has the following
advantages. Firstly network meta-analy-
sis can produce “indirect evidence” for a potential comparison
where a head-to-head compari-
son is unavailable. A network can be developed to link the
direct evidence of, say, A vs. B and
B vs. C (i.e. evidence from studies with A vs. B and B vs. C as
head-to-head comparisons), via a
common comparator (i.e. B in this example) to derive an
indirect estimate of A vs. C. Sec-
ondly, both indirect and direct evidence can be used together
which then improves the
Support surfaces for pressure ulcer prevention
February 23, 2018 2 / 29
Competing interests: The authors have declared
that no competing interests exist.

precision of effect estimates. Thirdly, effect estimates from
network meta-analysis can be
linked to probabilistic modelling to allow the ranking of
treatments based on which is likely to
be the most effective for the outcome of interest, which is likely
to be the second best and so
on. This is a valuable approach for considering the results of the
network across multiple inter-
ventions in a single measure [14–16].
The aim of this work was to synthesise the available evidence
from RCTs in a network
meta-analysis to: (1) assess the relative effects of different
classes of support surfaces for reduc-
ing pressure ulcer incidence in adults in any setting; (2) to
assess the relative effects of different
classes of support surface in terms of reported comfort; and (3)
to rank all classes of support
surface in order of effectiveness regarding pressure ulcer
prevention.
Methods
This review was preceded by a protocol and registered
prospectively in PROSPERO
(CRD42016042154). This report complies with the relevant
PRISMA extension statement [17]

(see S1 File).
Search strategy
As the most comprehensive summary of available evidence in
the topic of our review, the cur-
rent Cochrane review had identified and included 59 RCTs and
quasi-randomised trials com-
paring support surfaces for pressure ulcer prevention, with a
database search up to April 2015
[9].
We performed an update search of the following databases for
the current Cochrane review:
the Cochrane Wounds Specialised Register (10 August 2016);
the Cochrane Central Register
of Controlled Trials (CENTRAL) (2016, Issue 7); Ovid
MEDLINE (1946 to 10 August 2016);
Ovid EMBASE (1974 to 10 August 2016); EBSCO CINAHL
Plus (1937 to 10 August 2016).
Additionally, we searched the Chinese Biomedical Literature
Database (1978 to 30 November
2016). There was no restriction on the basis of language or
publication status (see S2 File for
Ovid MEDLINE Search Strategy).

We also searched other resources: ClinicalTrials.gov and WHO
International Clinical Trials
Registry Platform (ICTRP) (24 August 2016), the Journal of
Tissue Viability via hand-search-
ing (1991 to November 2016), and the reference lists of seven
previously published systematic
reviews [7–13].
Eligibility criteria
We included published and unpublished RCTs, comparing
pressure-redistribution support
surfaces—mattresses, overlays, and integrated bed systems—in
adults at risk of pressure ulcer
development, in any setting. We excluded studies of seating and
cushions, limb protectors,
turning beds, traditional Chinese medicine-related surfaces and
home-made support surfaces.
Recent concern about the validity of RCTs from China led us to
only consider those with
full descriptions of robust randomisation methods (e.g. random
number tables) as eligible
[18, 19].
Our primary outcome was pressure ulcer incidence. We
considered this outcome as either

the proportion of participants developing a new ulcer at the
latest trial follow-up point (or the
pre-specified time point of primary focus if this was different to
the longest follow-up point)
or time-to-pressure ulcer incidence. The secondary outcome was
patient-reported comfort on
support surface (measured as the proportion of patients
reporting comfort).
February 23, 2018 3 / 29
Selection of studies
Two reviewers independently assessed the titles and abstracts of
the search results for relevance
and then independently inspected the full text of all potentially
eligible studies. Because the
non-Chinese database search was an updated search of the
Cochrane review published by
McInnes and colleagues [9], all studies included by the
Cochrane review were checked again
for relevance. Disagreements were resolved by discussion
between the two reviewers and

involvement of a third reviewer if necessary.
Data extraction
Where eligible studies had been previously included in McInnes
et al [9], one reviewer checked
the original data extraction of these studies and extracted
additional data where necessary, and
another reviewer checked all data. Two reviewers independently
extracted data for new
included studies. Any disagreements were resolved by
discussion and, if necessary, with the
involvement of a third reviewer. Where necessary, the authors
of included studies were con-
tacted to collect and/or clarify data.
The following data were extracted using a pre-prepared data
extraction form: basic charac-
teristics of studies (e.g. country, setting, and funding sources);
characteristics of participants
(including eligibility criteria, average age, proportions of
participants by gender, and partici-
pants’ baseline skin status); description of support surfaces and
details on any co-interven-
tions; number randomised, follow-up durations; drop-outs;
primary and secondary outcome

data.
In order to assign support surfaces to intervention groups, we
extracted full descriptions
from included studies where possible. However, when necessary
we supplemented the infor-
mation provided with that from external sources such as other
publications about the same
support surface, manufacturers’ and/or product websites and
expert clinical opinion [20].
Classification of interventions. Support surfaces in included
studies were classified using
the NPUAP system [4] and assigned to one of 14 intervention
groups [21] (see S3 File for the
detailed steps and Table 1 for the 14 intervention groups).
Risk of bias assessment
We used Cochrane’s Risk of Bias tool to assess risk of bias of
each included study [22]. For new
included studies, two reviewers independently assessed domain-
specific risk of bias [22]. For
studies included by McInnes and colleagues [9], previous
judgements were checked by two
reviewers independently and, where required, updated. Any
discrepancy between two review-

ers was resolved by discussion and a third reviewer where
necessary.
We then followed GRADE principles to summarise the overall
risk of bias across domains
for each included study [23]. After this, we applied the
approach proposed by Salanti and col-
leagues [24] to judge the overall risk of bias (referred to hereon
as “study limitations”) for
direct evidence (i.e. pairwise meta-analysis), network contrasts,
and the entire network. Three
categories were used to qualitatively rate study limitations: no
serious limitations; serious limi-
tations; and very serious limitation.
Data synthesis and analyses
We conducted all meta-analyses based on a frequentist
framework with a random effects
model [25]. All estimates are presented as risk ratios (RR) with
95% confidence intervals (CIs).
When presenting summaries of findings, we also calculated the
absolute risk of an event for a
specific intervention group compared with that for a standard
hospital surface. The baseline

February 23, 2018 4 / 29
risk used was the outcome on standard hospital surfaces (the
median risk across studies that
provided data for the outcome).
We performed pairwise meta-analyses in RevMan, calculated I-
squared (I
2
) measures and
visually inspected the forest plots to assess statistical
heterogeneity [26]. We then conducted
network meta-analysis in STATA1 (StataCorp. 2013) using
published network commands
Table 1. 14 intervention groups, explanations and selected
examples from included studies.
Intervention groups Reviewers’ explanations Selected examples
(with support surface brands if possible)
Powered/non-powered reactive
air surfaces
A group of support surfaces constructed of air-cells, which
redistribute body weight over a maximum surface area (i.e. has

reactive pressure redistribution mode), with or without the
requirement for electrical power
Static air mattress overlay, dry flotation mattress (e.g., Roho,
Sofflex), static air mattress (e.g., EHOB), and static mode of
Duo 2
mattress
Powered/non-powered reactive
low-air-loss air surfaces
A group of support surfaces made of air-cells, which have
reactive
pressure redistribution modes and a low-air-loss function, with
or without the requirement for electrical power
Low-air-loss Hydrotherapy
Powered reactive air-fluidised
surfaces
A group of support surfaces made of air-cells, which have
reactive
pressure redistribution modes and an air-fluidised function, with
the requirement for electrical power
Air-fluidised bed (e.g., Clinitron)

Non-powered reactive foam
surfaces
A group of support surfaces made of foam materials, which
have
a reactive pressure redistribution function, without the
Convoluted foam overlay (or pad), elastic foam overlay (e.g.,
Aiartex, microfluid static overlay), polyether foam pad, foam
mattress replacement (e.g. MAXIFLOAT), solid foam overlay,
viscoelastic foam mattress/overlay (e.g., Tempur, CONFOR-
Med,
Akton, Thermo)
Non-powered reactive fibre
surfaces
A group of support surfaces made of fibre materials, which have
a
reactive pressure redistribution function, without the
Silicore (e.g., Spenco) overlay/pad

Non-powered reactive gel
surfaces
A group of support surfaces made of gel materials, which have a
Gel mattress, gel pad used in operating theatre
Non-powered reactive
sheepskin surfaces
A group of support surfaces made of sheepskin, which have a
Australian Medical Sheepskins overlay
Non-powered reactive water
surfaces
A group of support surfaces based on water, which has the
capability of a reactive pressure redistribution function, without
the requirement for electrical power
Water mattress

Powered active air surfaces A group of support surfaces made of
air-cells, which
mechanically alternate the pressure beneath the body to reduce
the duration of the applied pressure (mainly via inflating and
deflating to alternately change the contact area between support
surfaces and the body) (i.e. alternating pressure (or active)
mode), with the requirement for electrical power
Alternating pressure-relieving air mattress (e.g., Nimbus II,
Cairwave, Airwave, MicroPulse), large-celled ripple
Powered active air surfaces and
non-powered reactive foam
surfaces
A group of support surfaces which use powered active air
surfaces
and non-powered reactive foam surfaces in combination
Alternating pressure-relieving air mattress in combination with
viscoelastic foam mattress/overlay (e.g., Nimbus plus Tempur)
Powered active low-air-loss air
surfaces

A group of support surfaces made of air-cells, which have the
capability of alternating pressure redistribution as well as low-
air-
loss for drying local skin, with the requirement for electrical
power
Alternating pressure low-air-loss air mattress
Powered hybrid system air
surfaces
A group of support surfaces made of air-cells, which offer both
reactive and active pressure redistribution modes, with the
Foam mattress with dynamic and static modes (e.g. Softform
Premier Active)
Powered hybrid system low-
air-loss air surfaces
A group of support surfaces made of air-cells, which offer both
reactive and active pressure redistribution modes as well as a
low-
air-loss function, with the requirement for electrical power

Stand-alone bed unit with alternating pressure, static modes and
low air-loss (e.g., TheraPulse)
Standard hospital surfaces A group of support surfaces made of
any materials, used as usual
in a hospital and without reactive nor active pressure
redistribution capabilities, nor any other functions (e.g. low-air-
loss, or air-fluidised).
Standard hospital (foam) mattress, NHS Contract hospital
mattress, standard operating theatre surface configuration,
standard bed unit and usual care
https://doi.org/10.1371/journal.pone.0192707.t001
February 23, 2018 5 / 29
https://doi.org/10.1371/journal.pone.0192707.t001
and network graph packages [27, 28] (see S4 File for STATA
commands used in the review). A
consistency model was fitted to estimate relative effects [29].
Following this, we calculated the

relative rankings of intervention groups and presented the
surface under the cumulative rank-
ing curve (SUCRA) percentages [27]. For any outcome, we
performed network meta-analysis
only if intervention groups could be connected to form a
network; however, we did not
exclude comparisons of support surfaces assigned to the same
group from the overall system-
atic review. The full dataset is available on request.
We assessed the transitivity assumption for each network by
comparing the similarities of
study-level characteristics across direct comparisons within the
network [30]. When data were
insufficient for this assessment, we assumed that the transitivity
assumption was met. Inconsis-
tency between direct and indirect evidence was examined
globally by running the design-by-
treatment interaction model and locally by using the node-
splitting method and inconsistency
plot test [28, 31–33]. We also explored the sensitivity of the
global inconsistency finding to
alternative modelling approaches by running a post hoc
sensitivity analysis using the model of
Lu and Ades [34]. It is worth noting that because the model of

Lu and Ades [34] depends on
the ordering of treatments in the presence of multi-arm studies
[28] the design-by-treatment
interaction model was used in the main analysis. We then
evaluated the common network het-
erogeneity using the tau-squared (tau
2
) and the I
2
measure and the 95% CIs of I
2
, and decom-
posed the common network heterogeneity to inconsistency and
within-study heterogeneity in
R to locate the source of heterogeneity [35]. The heterogeneity
was considered as low, moder-
ate, or high if I
2
= 25%, 50%, or 75%, respectively [36].
When important inconsistency and/or heterogeneity occurred,
we followed steps proposed
by Cipriani and colleagues [37] to investigate further. Of these
steps, we performed pre-speci-
fied subgroup analyses for funding sources [38] and risk of bias

[39]; as well as four exploratory
sub-group analyses: setting, considering operating theatre as
setting or not, baseline skin sta-
tus, and follow-up duration. Additionally, we performed one
sensitivity analysis to assess the
impact of missing data (i.e. a complete case analysis for the
main analysis, followed by a
repeated analysis with missing data added to the denominator
but not the numerator) and
another one for the impact of unpublished studies by removing
them from the analysis.
Assessing the certainty of evidence
We assessed the potential for publication bias by considering
the completeness of the literature
search (i.e. inspecting the scope of the literature search, and
assessing the volume of unpub-
lished data located), and plotting the funnel plot for each
pairwise meta-analysis that included
more than 10 studies and a comparison-adjusted funnel plot for
the network [24, 27, 40]. To
obtain a meaningful comparison-adjusted funnel plot, we
ordered the intervention groups by
assuming that small studies are likely to favour advanced
support surfaces [27]. Finally, we fol-

lowed the GRADE approach proposed by Salanti and colleagues
[24] to assess the certainty of
evidence from the network meta-analysis for each network
contrast and the ranking of inter-
vention groups: the overall certainty could be rated from high,
moderate, low to very low.
Results
Search results
The search identified 2,816 records. Full-text screening of 108
potentially eligible studies led to
inclusion of 22 studies; eight published in English (one of the
eight was then associated with an
included study in the McInnes and colleagues’ review [9]) and
14 studies published in Chinese.
We also identified two on-going studies [41, 42]. In addition,
our rescreening of the 59 studies
included by McInnes and colleagues [9] identified 44 as
specifically eligible for this review. In
February 23, 2018 6 / 29

total therefore we included 65 studies in the review (see Fig 1,
and S5 File for a reference list of
included studies). Three were unpublished (one is a conference
abstract [43] and two are
research reports [44, 45].
Trial and study population characteristics
The characteristics of included studies are summarised in Table
2. The 65 studies enrolled a
total of 14,332 participants (median of study sample sizes: 100;
range: 10 to 1,972). Setting was
specified in 63 of 65 study reports (97%) and included accident
and emergency departments
and acute care, intensive care units, general medical wards,
orthopaedic centres, operating the-
atres, and long-term care settings (i.e. nursing homes, extended
care facilities, rehabilitation
wards, long-term units).
Fig 1. Flow diagram of included studies.
https://doi.org/10.1371/journal.pone.0192707.g001
February 23, 2018 7 / 29

https://doi.org/10.1371/journal.pone.0192707.g001
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Week 3 Assignment Child Maltreatment Policies Brochure
This assignment focuses on analyzing policies about child
maltreatment in the United States where, as noted in the Week
Three Instructor Guidance and the Rubin (2012) recommended
readings for Week Three, it is a growing national issue. This
assignment is another opportunity to further apply 21st century
technology skills as you create an informational brochure meant
to inform the public in a variety of potential environments about
child maltreatment in the United States and in a specific state of
your choosing. Your finished brochure will be included in your
website as part of the Week Six Final Project. Beyond reading
the Week Three Instructor Guidance and the recommended
chapters from Rubin (2012), review the , the , the , and the to
learn about child maltreatment and policies related thereto.
Create your assignment using the content and written
communication instructions below. Use the Grading Rubric to
review your assignment before submission to ensure you have
met the distinguished performance for each of the components
described below. For additional assistance, review the Week
Three Instructor Guidance and, if needed, contact the instructor
for further clarifications using the Ask Your Instructor
discussion. Additionally, add the flyer as a link or attachment to
the page on your website titled Child Protection Services &
Child Maltreatment.
Content Instructions
Using a digital software program such as Microsoft Publisher or
, create a single-page, 3-panel, front-to back brochure that
informs the public about the realities of child maltreatment in
the United States and a specific state of your choosing. The
brochure should be designed to appeal to audiences in a variety
of settings, such as offices of school counselors or nurses,
community centers and outreach facilities, public health
facilities, and social services departments. Use the “Save As”

option to save your brochure as a PDF. Submit the PDF version
as your assignment for evaluation and include the attachment or
link if constructed from an online source such as Lucidpress to
your website.
· Title (1 point): Include an engaging title for the brochure.
· Maltreatment Information (2 points): Include a description of
what constitutes child maltreatment, abuse, or neglect; tips for
prevention, tips for parents or caregivers, and reporting abuse.
Include at least two supporting resources cited in-text and in a
References section.
· Statistical Data (1 point): Include at least three items of
statistical data, audience-appropriate graphics, and two-to-three
points about child maltreatment in the United States and your
selected state. Include at least two supporting resources cited
in-text and in a References section.
· Policy or Program Resource (3 points): Describe at least two
policies, programs, models, or other source of support for
parents, caregivers, schools, or others. Include at least two
supporting resources cited in-text and in a References section.
· References: (1 point): Include a references section with at
least four scholarly sources in addition to the Rubin (2012)
textbook for any summarized, paraphrased, or quoted material
in your brochure, including images and graphics. All sources in
the references section should be used and cited correctly within
the body of the assignment.
· Formatting (1 points): Brochure is a PDF, 8.5x11 inches in
size, single-page, 3-panel, front-to-back design that uses
graphics, and has a consistent theme/format to augment the
readability of the brochure.
Written Communication Instructions
· Syntax and Mechanics (1 point): Display meticulous
comprehension and organization of syntax and mechanics, such
as spelling and grammar. Written work contains no errors and is
very easy to understand.
Carefully review the for the criteria that will be used to
evaluate your assignment.

Top of Form
Week Three Instructor Guidance
Welcome to Week Three of EDU644: Child and Family
Welfare! Please be sure to review the Week Three homepage
for this course to see the specific learning outcomes for the
week, the schedule overview, the required and recommended
resources for the week, an introduction to the week, and a
listing of the assessments for the week. Next, be sure to read
this entire Instructor Guidance page.
Overview
review the Week Three homepage for this course to see the
specific learning outcomes for the week, the schedule overview,
the required and recommended resources for the week, an
introduction to the week, and a listing of the assessments for the
week. Next, be sure to read this entire Instructor Guidance page.
Knowledge gained in Week Two provides you with background
information on the role of child protection agencies.
Furthermore, you examined various resources supporting
families at risk, leading you toward the beginning stages of
construction of your website. In Week Three, you further add
to your website with specific information and resources
pertaining to child maltreatment and homelessness.
Finally, perhaps the most interesting and engaging opportunity
this week involves sharing your early website design with
others in the course, reviewing others’ websites, and engaging
in reciprocal feedback for the purpose of expanding your ideas
and improving upon your website as you progress toward the
Final Project in Week Six.
Remember that the Instructor Guidance provides additional
instruction and resources to assist you with the weekly
assessments. Please be sure to review the Instructor Guidance.

As indicated, this week the discussions focus on sharing your
website with others and create a graphic comparing five factors
pertaining to homeless efforts in two major cities in the United
States; Chicago and New York. The assignment on Child
Maltreatment Policies involves creating an informational
brochure about child maltreatment on a national level and
forming an analysis of the child maltreatment policies in a state
of your choosing. The information shared in the Intellectual
Elaboration section below will help inform your work for this
week.
Intellectual Elaboration
“The first step towards change is awareness. The second step is
acceptance.” Matthew Branden
As we embark this week on our learning of two very serious
topics, child maltreatment and homelessness, consider the quote
above. Consider your role and responsibility in your current
and/or anticipated professional position. Awareness,
acceptance, and change are an integral part of what one can
expect to experience when working with children and families
at risk.
Child Maltreatment
View the Institute of Medicine’s (2014) approximately 2 minute
video to learn about research in child abuse and neglect. The
information here will help inform the work you do for this
week’s assignment. Note that child maltreatment continues to
be a serious issue for the future of America’s children.
According to the Centers for Disease Control (CDC), there are
four types of maltreatment including emotional abuse, physical
abuse, sexual abuse, and neglect (Centers for Disease Control,
2014). While policies, programs, and resources exist for
preventing and treating child maltreatment, the level of support
is lacking while the demand for assistance has been steadily

increasing (Institute of Medicine, 2013).
Due to the impact of families in crises, the level of child
maltreatment has been an increasing problem. Even though the
extent of physical child abuse may be declining, the impact of
emotional child abuse and neglect presents an ever-increasing
problem (IOM, 2013). In fact, one of the most prevalent issues
is child neglect in regards to medicine, education, and food.
Think about the impact these issues have on school-aged
children and their ability to learn and achieve academic success.
Every state in the U.S has laws requiring certain professionals
to report concerns of child abuse or neglect. Such professionals
often include teachers, social workers, medical and mental
health professionals, and child care providers. Additionally,
specific procedures are typically established for mandated
reporters to make referrals to child protective services (Child
Welfare Information Gateway, 2014).
Professionals working with children and families who may be at
risk must be aware of what constitutes child maltreatment,
abuse, or neglect and understand the laws of their state for
mandatory reporting. Further, having knowledge of and access
to a variety of support systems and resources for children and
families is an essential part of one’s practice. Consider a second
quote, this time by Mahatma Gandhi; “Be the change that you
want to see in the world”. How can you spread awareness and
create change as it pertains to child maltreatment and neglect?
The assignment this week gives you the opportunity to exercise
this in a simple, yet potentially effective way.
A related issue to child maltreatment for children and families
at risk has been homelessness. Even families with full-time
jobs are not always able to provide adequate shelter or care for
their families. The result is a higher level of government
subsidies for housing and more families in homeless shelters.

Homelessness Defined
The face of homelessness in the United States is changing. As
such, the issue pertaining to homelessness in society as well as
consideration for homeless people must change. There are
several common and rather derogatory terms for someone who is
homeless. According to Joel John Roberts, CEO of People
Assisting the Homeless (PATH Partners), it is appropriate and
non-offensive to use the terms homeless Americans or simply,
homeless when describing one living on the streets (Poverty
Insights, May 29, 2012). Others find it more appropriate to put
the person before the condition and instead, refer to this
classification of people as one who is homeless. Regardless of
the terminology, children and families that are homeless are
prevalent in the United States and require support from
knowledgeable educators, medical providers, and social services
in order to thrive.
Varying definitions of homelessness
According to the National Health Care for the Homeless
Council, there is more than one “official” definition of
homelessness but health centers that are funded by the U.S.
Department of Health and Human Services (HHS) define a
homeless individual as one “without permanent housing who
may live on the streets; stay in a shelter, mission, single room
occupancy facilities, abandoned building or vehicle; or in any
other unstable or non-permanent situation” (NHCHC, 2014).
The United States Department of Housing and Urban
Development (HUD) classifies homelessness two ways;
chronically homeless and episodic or fluctuating homelessness.
HUD defines one who is chronically homeless as “a person
sleeping in a place not meant for human habitation (e.g. living
on the streets) or living in a homeless emergency shelter”
(2007, p.3). An episode of homelessness is “A separate,
distinct, and sustained stay on the streets and/or in a homeless

emergency shelter” (p.4).
Review the video from . The video is approximately three-
minutes long and explores the plight of Americans who are
employed yet homeless.
Then, view the video from to further explore homelessness in
the United States.
Now, consider your impressions of what homelessness looks
like in America. Do your impressions align with either of the
images below? As the videos explain, the homeless have many
different voices and faces in the United States today.
Homeless man
Homeless veteran
Homeless woman
Assessment Guidance
This section includes additional specific assistance for excelling
in the discussions and assignment for Week Three beyond what
is given with the instructions for the assessments. If you have
questions about what is expected on any assessment for Week
Three, contact your instructor using the Ask Your Instructor
discussion before the due date.
Discussion 1: Website Sharing and Feedback
This discussion is another opportunity to demonstrate your
mastery with the first two course learning outcomes:
“Distinguish groups and behaviors considered at risk” and
“Evaluate various resources and organizations that provide
information and support for families at risk.”

In Discussion 1, you will obtain feedback on your website
designed in the Week Two Assignment. Thus, you can continue
to refine your website based on the comments and suggestions
provided by fellow students in the class. By following the
direction provided in the Guided Response prompt, each student
should acquire specific feedback on both the content currently
represented in their website as well as observations and
suggestions regarding the overall website design and
organization.
Discussion 2: Tale of Two Cities and Homelessness
This discussion is an opportunity to demonstrate your mastery
with the third course learning outcome, “Examine social
services policies that support families at risk.” The purpose of
this discussion is to expose you to a variety of effective
resources for two diversely populated U.S. cities; Chicago and
New York and make comparisons between each regarding the
statistical data, and the policies, programs, and resources
available. Doing so will expand your current knowledge of the
issue of homelessness in the United States and guide you toward
making a recommendation to one of the cities for serving groups
and individuals that are homeless. You might also elect to
discuss a particular policy or resource you discovered during
your investigation that could potentially benefit a different city
in the U.S. such as the place in which you reside.
You will learn through this discussion that policies to support
youth homelessness vary by local, state, and federal programs
and resources. The potential for the uneven distribution of
assistance to the homeless youth or lack of resources can lead to
glaring problems in the care and the support with these policies.
For example, the homeless youth may or may not be able to
improve their situation based on the local, state, or federal
approaches.

Last, you will use your choice of software or digital tool
organize the information you glean from each of the resources
for both cities that are detailed in the Week Two Assignment
description. Since you are tasked with comparing and
contrasting between the two cities, you should create a graphic
organizer that supports this concept such as a Venn diagram.
When posting your response you will attach the graphic
organizer you create and add a 1-2 paragraph description.
Follow the Guided Response prompt so as to engage in critical
thinking with your peers as it pertains to the comparisons and
contrasts made from each city. Figure 1 below shows a simple
example of how a Venn diagram might be structured for this
assignment using the SmartArt tools in Microsoft Word.
Figure 1
Categories to compare and contrast include:
· Prevalence of youth homelessness (stats)
· Populations of homeless people (stats)
· Policies offering support
· Your choice of additional interesting and/or important
information you discovered
Assignment: Child Maltreatment Policies Brochure
This assignment is another opportunity to demonstrate your
mastery with the third course learning outcome, “Examine
social services policies that support families at risk.” The
purpose of this assignment is two-fold; first, to show what you
know about issues and resources pertaining to child
maltreatment, and second to communicate the information in
such a way as to reach people who may need the information.
As such, you have another opportunity to be creative by using a
digital software program of your choice to construct an

informative brochure on the subject. Think of places you
typically find brochures and the purpose they serve. Also,
consider the kinds of brochures that catch your eye and
ultimately provide you with the most essential information
needed. You will create a 3-panel, two-sided brochure so as to
include graphics and required information outlined in the
assignment overview. Figure 2 below shows an example of a 3-
panel brochure:
Figure 2
There are numerous related links within each website provided
in the assignment instructions that can provide even more
information to support your work as well as additional
recommended resources listed for this week. Consider these or
conduct a new search from your state of residence to add
information about the topic specifically pertaining to your state.
Additionally, take note of the design of these websites reviewed
for this discussion and the features you enjoy about the sites as
this will further assist you with the website you are creating.
Your finished brochure will also be included in your website
and later reviewed by fellow classmates during Week Five so as
to gain feedback for the purpose of improving your work in
preparation for the Final Project in Week Six.
References
Child Welfare Information Gateway (2014). Mandated
Reporting. U.S. Department of Health and Human Services,
Administration for Children and Families. Retrieved from
https://www.childwelfare.gov/responding/mandated.cfm
Defining chronic homelessness: A technical guide for HUD

Programs. (September, 2007). HUD’s Homeless Assistance
Program. Office of Community Planning and Development and
the Office of Special Needs Assistance Programs. Retrieved
from
https://www.hudexchange.info/resources/documents/DefiningCh
ronicHomeless.pdf
Figure 2. Retrieved from http://m.alexwhyte.com/portfolio/8
Institute of Medicine of the National Academies of Sciences
(2014, September 12). New directions in child abuse and
neglect research [Video file]. Retrieved from
http://iom.edu/Reports/2013/New-Directions-in-Child-Abuse-
and-Neglect-Research.aspx
National Health Care for the Homeless Council (2014). What is
the official definition of homelessness? Retrieved from
http://www.nhchc.org/faq/official-definition-homelessness/
Roberts, Joel J. (2012, May 29). Homeless Americans: What’s
in a name? Poverty Insights: A National dialogue on poverty,
homelessness, and housing. Retrieved from
http://www.povertyinsights.org/2012/05/29/homeless-
americans-whats-in-a-name/
RT. (2013, October 22). America's working destitute: Full-time
jobs, yet homeless [Video file]. Retrieved from
http://youtu.be/0BszHshieSc
The Economist. (2013, July 23). Poverty's new address in
America [Video file]. Retrieved from
http://youtu.be/ly718xGmeBk
Understanding Child Maltreatment (2014). Fact Sheet. Centers
for Disease Control. Retrieved from
http://www.cdc.gov/violenceprevention/pdf/understanding-cm-

factsheet.pdf
Required Resources
Articles
Hirst, E. J. (2013, May 27). . Chicago Tribune. Retrieved from
http://articles.chicagotribune.com/2013-05-27/news/ct-met-
homeless-youth-chicago-20130528_1_youths-hotline-shelter
· This newspaper article discusses the data suggesting a rise in
homelessness in the city of Chicago. This is a required resource
for the Week Three Discussion 2 where you compare Chicago
and New York policies and services for groups who are
homeless.
Saulny, S. (2012, December 8). . The New York Times.
Retrieved from http://www.nytimes.com/2012/12/19/us/since-
recession-more-young-americans-are-
homeless.html?pagewanted=all&_r=1&
· This newspaper article discusses the rise in homeless youth in
New York after the recession of the 2000s. This is a required
resource for the Week Three Discussion 2 where you will
compare homeless policies and services in Chicago and New
York.
Steinberg, N. (2012, April 29). . Chicago Sun Times. Retrieved
from http://www.suntimes.com/news/steinberg/12212932-
452/few-options-for-homeless-young-people-in-chicago.html
· This newspaper article discusses the plight of youth who are
homeless in the city of Chicago. This is a required resource for
the Week Three Discussion 2 where you compare Chicago and
New York policies and services for groups who are homeless.
Websites
. (http://www.allchicago.org/division/chicago-alliance)
· This website is to the All Chicago organization that works to
eradicate homelessness in the city of Chicago. This is a required
resource for the Week Three Discussion 2 where you compare
Chicago and New York policies and services for groups who are
homeless.
California Department of Health Care Services. (n.d.). .
Retrieved from

http://www.dhcs.ca.gov/services/Pages/ChildrensHealth.aspx
· This website of the California Department of Health Care
Services provides links to a variety of resources about
children’s and youth health services. This website is a required
resource for the Week Three Assignment about child
maltreatment.
Centers for Disease Control and Prevention. (2014). . Retrieved
from http://www.cdc.gov/violenceprevention/childmaltreatment
· This comprehensive website provides a succinct introduction
to the topic of child maltreatment and numerous resources for
the prevention of and policies related to child maltreatment.
This website is a required resource for the Week Three
Assignment about child maltreatment.
Chicago Coalition for the Homeless. (2014). . Retrieved from
http://www.chicagohomeless.org/programs-
campaigns/advocacy-public-policy/no-youth-alone/
· This is the website for the Chicago Coalition for the
Homeless. This is a required resource for the Week Three
Discussion 2 where you compare Chicago and New York
policies and services for groups who are homeless.
. (http://capacares.org)
· This website page focuses on the programs and services
available from the CAPA organization. This website is a
required resource for the Week Three Assignment about child
maltreatment.
Child Help. (n.d.). . Retrieved from
https://www.childhelp.org/childhelp-approach/?a=prevention-
programs
· This website page provides links to programs offered by the
Child Help Organization. This website is a required resource for
the Week Three Assignment about child maltreatment.
Covenant House New York. (2014). . Retrieved from
http://www.covenanthouse.org/homeless-charity/new-york
· This organizational website is for the Covenant House, which
is an organization working to address issues of homelessness in
New York. This is a required resource for the Week Three

Discussion 2 where you will compare homeless policies and
services in Chicago and New York.
Safe Horizon. (n.d.). . Retrieved from
http://www.safehorizon.org/page/streetwork-homeless-youth-
facts-69.html
· This website explores homelessness in New York providing
facts and figures about the rates of homelessness and services
available for homeless youth. This is a required resource for the
Week Three Discussion 2 where you will compare homeless
policies and services in Chicago and New York.
Recommended Resources
Text
Rubin, A. (2012). Retrieved from https://redshelf.com
· Chapter 15: The HOMEBUILDERS® model of intensive
family-preservation services
· Chapter 18: Parenting wisely: Enhancing wise practice for
service provides
Websites
Dilov-Schultheis, D. (n.d.). . Retrieved from
http://www.ehow.com/how_6177310_use-microsoft-office-
create-flyers.html
· This how-to website gives step-by-step instructions for
creating a flyer in Microsoft Publisher. This website is a
recommended resource for the Week Three Assignment where
students create a flyer about child maltreatment in the United
States.
. (https://www.lucidpress.com)
· Lucidpress provides a way to quickly create digital documents
such as brochures for sharing and viewing on a computer,
tablet, or smartphone and is perfect for print. Free accounts are
available as well as a range of account options for purchase.
Review the before deciding to use this digital source.

Spinal Cord (2018) 56:186–198
https://doi.org/10.1038/s41393-017-0054-y
REVIEW ARTICLE
Interventions for pressure ulcers: a summary of evidence for
prevention and treatment
Ross A. Atkinson 1 ● Nicky A. Cullum1,2
Received: 6 October 2017 / Revised: 18 December 2017 /
Accepted: 19 December 2017 / Published online: 25 January
2018
© International Spinal Cord Society 2018
Abstract
Study design Narrative review.
Objectives Pressure ulcers are a common complication in people
with reduced sensation and limited mobility, occurring
frequently in those who have sustained spinal cord injury. This
narrative review summarises the evidence relating to
interventions for the prevention and treatment of pressure
ulcers, in particular from Cochrane systematic reviews. It also
aims
to highlight the degree to which people with spinal cord injury
have been included as participants in randomised controlled
trials included in Cochrane reviews of such interventions.
Setting Global.
Methods The Cochrane library (up to July 2017) was searched
for systematic reviews of any type of intervention for the
prevention or treatment of pressure ulcers. A search of PubMed
(up to July 2017) was undertaken to identify other
systematic reviews and additional published trial reports of

interventions for pressure ulcer prevention and treatment.
Results The searches revealed 38 published systematic reviews
(27 Cochrane and 11 others) and 6 additional published trial
reports. An array of interventions is available for clinical use,
but few have been evaluated adequately in people with SCI.
Conclusions The effects of most interventions for preventing
and treating pressure ulcers in people with spinal cord injury
are highly uncertain. Existing evaluations of pressure ulcer
interventions include very few participants with spinal cord
injury. Subsequently, there is still a need for high-quality
randomised trials of such interventions in this patient
population.
Introduction
Aetiology and prevalence of pressure ulcers
Pressure ulcers (PUs), sometimes known as pressure
injuries, decubitus ulcers or bed sores, are wounds that
involve the skin or underlying tissue, or both. They are
localised areas of injury occurring most often over bony
prominences, such as at the sacrum or heel, where
prolonged pressure and sheer forces act to damage tissues
and reduce perfusion, causing changes in the tissue
and ultimately leading to the wound [1]. PUs are
graded according to a number of systems, one widely
recognised system being that of the National Pressure Ulcer
Advisory Panel [2]. These wounds have a range of serious
negative consequences and can severely impair quality of
life [3].
Prevalence estimates vary dependent on the population
assessed, the methods of data collection and how a PU is
defined (for example, whether stage I PUs are included). It
has been estimated that the point prevalence of pressure

ulceration in the total adult population is 0.31 per 1000
population [4]. As well as poor perfusion and poor skin
status, reduced mobility and autonomic dysreflexia are
major risk factors for pressure ulceration [5–8]. Therefore,
people with spinal cord injury (SCI) are a particular group
in whom PUs are common due to impaired sensation,
reduced mobility and prolonged sitting; a number of studies
have estimated the prevalence of PUs among people with
SCI, which may be in the range of 30–60% [9–16]. Whilst
reducing pressure injuries is a major target for many health
systems in general, those with SCI are a group at
* Ross A. Atkinson
[email protected]
1 Division of Nursing, Midwifery & Social Work, School of
Health
Sciences, Faculty of Biology, Medicine & Health, Manchester
Academic Health Science Centre, The University of Manchester,
Manchester, UK
2 Research and Innovation, Manchester University NHS
Foundation
Trust, Manchester, UK
1
2
3
4
5
6
7
8
9
0
()
;,

:
http://crossmark.crossref.org/dialog/?doi=10.1038/s41393-017-
0054-y&domain=pdf
0054-y&domain=pdf
0054-y&domain=pdf
http://orcid.org/0000-0001-8976-2754
http://orcid.org/0000-0001-8976-2754
http://orcid.org/0000-0001-8976-2754
http://orcid.org/0000-0001-8976-2754
http://orcid.org/0000-0001-8976-2754
mailto:[email protected]
particularly high risk of this complication, and which may
be underserved by research evidence.
This article aims to provide an overview of the evidence
relating to PU prevention and treatment, in particular
drawing on Cochrane systematic reviews since they are
widely regarded as rigorous and comprehensive summaries
of research [17, 18]. It also aims to assess the degree to
which people with SCI have been included as participants in
trials of PU interventions.
Interventions for PU prevention and treatment
A wide range of interventions is used in the prevention and
treatment of PUs. Key preventative interventions include
those which aim to redistribute pressure at the interface
between the skin and the support surface (e.g., the many
types of mattress and cushion). Key treatment interventions
include support surfaces and also wound dressings. The UK
National Institute for Health and Care Excellence commis-

sioned the National Clinical Guideline Centre to produce a
detailed clinical guideline for the prevention and
management of PUs in primary and secondary care, which
contains a list of interventions used in clinical practice [19].
The main types of intervention are summarised in Box 1.
Systematic reviews
Systematic reviews address clear, focused questions and
use systematic and explicit methods to identify, select and
critically appraise all the relevant research. Within a
PU – pressure ulcer; *One ‘empty’ review was of wound-care
teams for both preven�ng and trea�ng pressure ulcers (Moore
et al. 2015).
Returned search records
(n = 50)
Relevant Cochrane
reviews
(n = 27)
Excluded records
(related to other wound
types; not wound related;
withdrawn publica�ons)
(n = 23)
PU specific
(n = 23)
Preven�on reviews

(n = 6)
Reviews
with data
(n = 4)
‘Chronic’ or ‘Complex’
wounds
(n = 4)
Treatment reviews
(n = 17)
‘Empty’
reviews
(n = 2)*
Preven�on reviews
(n = 0)
Treatment reviews
(n = 4)
Reviews
with data
(n = 14)
‘Empty’
reviews
(n = 3)
Reviews
with data
(n = 4)

‘Empty’
reviews
(n = 0)
Fig. 1 Flow chart summarising results from search of The
Cochrane Library
Box 1. Key interventions for pressure ulcers
Prevention
Pressure ulcer risk assessment
Skin assessment
Repositioning
Pressure redistribution devices, e.g., mattresses, cushions, limb
protectors
Treatment
Pressure redistribution devices, e.g., mattress, cushion
Wound dressings
Nutritional assessment
Interventions for pressure ulcers 187
Ta
b
le
1
T
ri
al
s
an
d

p
ar
ti
ci
p
an
ts
in
cl
u
d
ed
in
C
o
ch
ra
n
e
re
v
ie
w
s
o
f
in
te
rv
en
ti
o
n
s
fo

r
p
re
v
en
ti
n
g
p
re
ss
u
re
u
lc
er
s
L
ea
d
au
th
o
r
(d
at
e
p
u
b
li
sh

ed
)
T
it
le
T
o
ta
l
n
o
.
o
f
in
cl
u
d
ed
st
u
d
ie
s
T
o
ta
l
n
o

.
o
f
p
ar
ti
ci
p
an
ts
N
o
.
o
f
tr
ia
ls
w
it
h
S
C
I
p
ar
ti
ci
p
an
ts
(n

o
o
f
p
ar
ti
ci
p
an
ts
w
it
h
S
C
I)
M
ai
n
o
b
se
rv
at
io
n
s
o
f
ef
fe
ct
a

Q
u
al
it
y
o
f
ev
id
en
ce
M
cI
n
n
es
(S
ep
te
m
b
er
2
0
1
5
)
[2
1
]
S
u

p
p
o
rt
su
rf
ac
es
fo
r
p
re
ss
u
re
u
lc
er
p
re
v
en
ti
o
n
5
9
1
2
4

7
1
2
(1
8
)
F
o
am
al
te
rn
at
iv
es
to
st
an
d
ar
d
h
o
sp
it
al
fo
am
m
at

tr
es
se
s
m
ay
re
d
u
ce
th
e
in
ci
d
en
ce
o
f
p
re
ss
u
re
u
lc
er
s
in
p
eo

p
le
at
ri
sk
;
p
re
ss
u
re
re
li
ev
in
g
o
v
er
la
y
s
o
n
th
e
o
p
er
at
in
g
ta

b
le
m
ay
re
d
u
ce
p
o
st
o
p
er
at
iv
e
p
re
ss
u
re
u
lc
er
in
ci
d
en
ce
;

A
u
st
ra
li
an
st
an
d
ar
d
m
ed
ic
al
sh
ee
p
sk
in
s
m
ay
p
re
v
en
t
p
re
ss
u
re

u
lc
er
s
M
ix
ed
(n
o
G
R
A
D
E
as
se
ss
m
en
t
p
er
fo
rm
ed
)
G
il
le
sp

ie
(A
p
ri
l
2
0
1
4
)
[2
2
]
R
ep
o
si
ti
o
n
in
g
fo
r
p
re
ss
u
re
u
lc

er
p
re
v
en
ti
o
n
in
ad
u
lt
s
3
5
0
2
0
(0
)
T
h
er
e
is
in
su
ffi
ci
en
t

ev
id
en
ce
to
co
n
cl
u
d
e
w
h
et
h
er
m
o
re
fr
eq
u
en
t
re
p
o
si
ti
o
n
in

g
o
r
u
se
o
f
d
if
fe
re
n
t
p
o
si
ti
o
n
s
is
ef
fe
ct
iv
e
in
re
d
u
ci
n
g

p
re
ss
u
re
d
am
ag
e
V
er
y
lo
w
(u
si
n
g
G
R
A
D
E
)
M
o
o
re
(F
eb

ru
ar
y
2
0
1
4
)
[2
3
]
R
is
k
as
se
ss
m
en
t
to
o
ls
fo
r
th
e
p
re
v
en
ti

o
n
o
f
p
re
ss
u
re
u
lc
er
s
2
4
8
5
0
(0
)
T
h
er
e
is
n
o
re
li
ab
le

ev
id
en
ce
to
su
g
g
es
t
th
at
th
e
u
se
o
f
st
ru
ct
u
re
d
,
sy
st
em
at
ic

p
re
ss
u
re
u
lc
er
ri
sk
as
se
ss
m
en
t
to
o
ls
re
d
u
ce
s
th
e
in
ci
d
en
ce
o

f
p
re
ss
u
re
u
lc
er
s
O
n
e
st
u
d
y
at
o
v
er
al
l
h
ig
h
ri
sk
o
f
b
ia

s;
o
n
e
st
u
d
y
at
o
v
er
al
l
lo
w
ri
sk
o
f
b
ia
s
(n
o
G
R
A
D
E
as

se
ss
m
en
t
p
er
fo
rm
ed
)
M
o
o
re
(A
u
g
u
st
2
0
1
3
)
[2
4
]
D
re
ss

in
g
s
an
d
to
p
ic
al
ag
en
ts
fo
r
p
re
v
en
ti
n
g
p
re
ss
u
re
u
lc
er
s
9

1
5
0
1
0
b
(0
)
T
h
er
e
is
in
su
ffi
ci
en
t
ev
id
en
ce
fr
o
m
R
C
T
s
to

su
p
p
o
rt
o
r
re
fu
te
th
e
u
se
o
f
to
p
ic
al
ag
en
ts
ap
p
li
ed
o
v
er
b
o
n

y
p
ro
m
in
en
ce
s
to
p
re
v
en
t
p
re
ss
u
re
u
lc
er
s
V
er
y
lo
w
(u
si
n
g

G
R
A
D
E
)
T
o
ta
l
7
3
1
4
9
5
9
2
(1
8
)
a
F
o
r
m
ai
n
o
u
tc

o
m
e
re
la
ti
n
g
to
p
re
v
en
ti
o
n
(e
.g
.,
in
ci
d
en
ce
o
f
p
re
ss
u
re
u
lc

er
at
io
n
)
b
O
n
e
tr
ia
l
in
cl
u
d
ed
p
at
ie
n
ts
ad
m
it
te
d
fo
r
p
o
st
er
io

r
sp
in
al
su
rg
er
y
(p
ro
ce
d
u
re
s
in
cl
u
d
in
g
ce
rv
ic
al
sp
o
n
d
y
lo
si
s,
lu

m
b
ar
sp
in
al
st
en
o
si
s,
lu
m
b
ar
h
er
n
ia
te
d
d
is
c
an
d
sp
in
al
co
rd

tu
m
o
u
r)
,
b
u
t
th
es
e
p
at
ie
n
ts
w
er
e
n
o
t
cl
as
se
d
as
h
av
in
g
sp
in

al
co
rd
in
ju
ry
(H
an
et
al
.
[3
0
])
188 R. A. Atkinson, N. A. Cullum
Ta
b
le
2
T
ri
al
s
an
d
p
ar

ti
ci
p
an
ts
in
cl
u
d
ed
in
C
o
ch
ra
n
e
re
v
ie
w
s
o
f
in
te
rv
en
ti
o
n
s
fo
r
tr

ea
ti
n
g
p
re
ss
u
re
u
lc
er
s
L
ea
d
au
th
o
r
(d
at
e
p
u
b
li
sh
ed
)
T
it

le
T
o
ta
l
n
o
.
o
f
in
cl
u
d
ed
st
u
d
ie
s
T
o
ta
l
n
o
.
o
f
p
ar

ti
ci
p
an
ts
N
o
.
o
f
tr
ia
ls
w
it
h
S
C
I
p
ar
ti
ci
p
an
ts
(n
o
.
o
f
p
ar

ti
ci
p
an
ts
w
it
h
S
C
I)
M
ai
n
o
b
se
rv
at
io
n
s
o
f
ef
fe
ct
a
Q
u
al
it
y
o

f
ev
id
en
ce
W
es
tb
y
(J
u
n
e
2
0
1
7
)
[3
1
]
D
re
ss
in
g
s
an
d
to
p
ic
al

ag
en
ts
fo
r
tr
ea
ti
n
g
p
re
ss
u
re
u
lc
er
sb
5
1
2
9
4
7
4c
(1
3
2
)

T
h
er
e
is
in
su
ffi
ci
en
t
ev
id
en
ce
to
d
et
er
m
in
e
w
h
ic
h
d
re
ss
in
g
s
o

r
to
p
ic
al
ag
en
ts
ar
e
th
e
m
o
st
li
k
el
y
to
h
ea
l
p
re
ss
u
re
u
lc
er
s,

an
d
it
is
u
n
cl
ea
r
w
h
et
h
er
an
y
tr
ea
tm
en
ts
ex
am
in
ed
ar
e
m
o
re

ef
fe
ct
iv
e
th
an
sa
li
n
e
g
au
ze
L
o
w
o
r
v
er
y
lo
w
(u
si
n
g
G
R
A
D

E
)
N
ai
n
g
(J
u
n
e
2
0
1
7
)
[3
2
]
A
n
ab
o
li
c
st
er
o
id
s
fo
r
tr
ea

ti
n
g
p
re
ss
u
re
u
lc
er
s
1
2
1
2
1
(2
1
2
)
T
h
er
e
is
n
o
h
ig
h

-q
u
al
it
y
ev
id
en
ce
to
su
p
p
o
rt
th
e
u
se
o
f
an
ab
o
li
c
st
er
o
id
s
in
tr

ea
ti
n
g
p
re
ss
u
re
u
lc
er
s
V
er
y
lo
w
(u
si
n
g
G
R
A
D
E
)
H
ao
(F

eb
ru
ar
y
2
0
1
7
)
[3
3
]
T
o
p
ic
al
p
h
en
y
to
in
fo
r
tr
ea
ti
n
g
p

re
ss
u
re
u
lc
er
s
3
1
4
8
2
(1
0
9
)
It
is
u
n
ce
rt
ai
n
w
h
et
h
er
to

p
ic
al
p
h
en
y
to
in
im
p
ro
v
es
u
lc
er
h
ea
li
n
g
fo
r
p
at
ie
n
ts
w
it
h

g
ra
d
e
I
an
d
II
p
re
ss
u
re
u
lc
er
s
L
o
w
(u
si
n
g
G
R
A
D
E
)
N

o
rm
an
(A
p
ri
l
2
0
1
6
)
[3
4
]
A
n
ti
b
io
ti
cs
an
d
an
ti
se
p
ti
cs

fo
r
p
re
ss
u
re
u
lc
er
s
1
2
5
7
6
1
(2
7
)
T
h
e
re
la
ti
v
e
ef
fe

ct
s
o
f
sy
st
em
ic
an
d
to
p
ic
al
an
ti
m
ic
ro
b
ia
l
tr
ea
tm
en
ts
o
n
p
re
ss
u

re
u
lc
er
s
ar
e
n
o
t
cl
ea
r
L
o
w
(u
si
n
g
G
R
A
D
E
)
A
zi
z
(S
ep

te
m
b
er
2
0
1
5
)
[3
5
]
E
le
ct
ro
m
ag
n
et
ic
th
er
ap
y
fo
r
tr
ea
ti
n
g

p
re
ss
u
re
u
lc
er
s
2
6
0
1
(3
0
)
T
h
e
re
su
lt
s
p
ro
v
id
e
n
o
st
ro

n
g
ev
id
en
ce
o
f
b
en
efi
t
in
u
si
n
g
el
ec
tr
o
m
ag
n
et
ic
th
er
ap
y
to

tr
ea
t
p
re
ss
u
re
u
lc
er
s
O
v
er
al
l
u
n
cl
ea
r
ri
sk
o
f
b
ia
s
(n
o
G

R
A
D
E
as
se
ss
m
en
t
p
er
fo
rm
ed
)
D
u
m
v
il
le
(M
ay
2
0
1
5
)
[3
6
]

N
eg
at
iv
e
p
re
ss
u
re
w
o
u
n
d
th
er
ap
y
fo
r
tr
ea
ti
n
g
p
re
ss
u
re
u

lc
er
s
4
1
4
9
1
(1
2
)
T
h
er
e
is
cu
rr
en
tl
y
n
o
ri
g
o
ro
u
s
R
C
T

ev
id
en
ce
av
ai
la
b
le
re
g
ar
d
in
g
th
e
ef
fe
ct
s
o
f
n
eg
at
iv
e
p
re
ss
u
re

w
o
u
n
d
th
er
ap
y
co
m
p
ar
ed
w
it
h
al
te
rn
at
iv
es
fo
r
th
e
tr
ea
tm
en
t

o
f
p
re
ss
u
re
u
lc
er
s
V
er
y
lo
w
(u
si
n
g
G
R
A
D
E
)
D
u
m
v
il

le
(M
ay
2
0
1
5
)
[3
7
]
A
lg
in
at
e
d
re
ss
in
g
s
fo
r
tr
ea
ti
n
g
p
re
ss

u
re
u
lc
er
s
6
3
3
6
0
(0
)
T
h
e
re
la
ti
v
e
ef
fe
ct
s
o
f
al
g
in
at
e

d
re
ss
in
g
s
co
m
p
ar
ed
w
it
h
al
te
rn
at
iv
e
tr
ea
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systematic review, data are collected from the included
studies, re-presented and frequently re-analysed. Sometimes
the data analysis in a systematic review involves combining
the results of several separate studies (‘meta-analysis’) to
provide a more precise estimate of the effect of an inter-
vention [20]. The Cochrane Database of Systematic
Reviews is one source of such reviews.
The aim of this narrative review is to summarise the
evidence in relation to the effectiveness of interventions for
the prevention and treatment of PUs, in particular from
Cochrane systematic reviews. It also aims to highlight the
degree to which people with SCI have been included as
participants in randomised controlled trials (RCTs) of such
interventions.
Methods
Systematic reviews of interventions for the
prevention and treatment of PUs: search of The
Cochrane Library
A range of Cochrane systematic reviews has been under-
taken to summarise the current evidence from RCTs of
interventions for the prevention and treatment of PUs. A
search of The Cochrane Library (Box 2) up to July 2017
revealed 50 results (reviews only), 27 of which are relevant
to this review (i.e., they evaluate interventions for the pre-
vention or treatment of PUs; Fig. 1). Of these, 23 reviews
evaluate interventions specifically relating to PUs, and 4
relate to several types of chronic or complex wound
including PUs. Twenty-one reviews found trials, which
were eligible for inclusion, whilst five were ‘empty’ reviews
(see ‘Empty reviews’) and another, whilst including various
types of wound, did not include any patients with PUs. Of
the 50 retrieved results from the search, 23 reviews were not

relevant to this overview (i.e., because they focused on
other wound types).
Search of PubMed
A search of PubMed was undertaken to determine which
other (non-Cochrane) systematic reviews of interventions
for PUs specifically in people with SCI had been carried
out. The search used the following terms: systematic[sb]
AND (((pressure injur*) OR (pressure ulcer*)) AND (spinal
cord injur*)). This search revealed eight relevant results (see
‘Other published systematic reviews’); a further three were
found using a general Internet search (see ‘Other published
systematic reviews’).
A second PubMed search of trials (published results and
protocols) using the terms (Therapy/Narrow[filter]) AND
(((pressure injur*) OR (pressure ulcer*)) AND (spinal cord
injur*)) revealed six trial reports and one trial protocol in
addition to those that had been included in Cochrane sys-
tematic reviews (see ‘Additional PU trials in people with
SCI’).
Results
Prevention of PUs
Five Cochrane reviews that together include 73 RCTs
specifically focus on interventions to prevent PUs [21–25]
whilst two evaluate interventions for both prevention and
treatment of PUs [26, 27]. Table 1 summarises the number
of RCTs and participants included in the four prevention
reviews for which data were available from the searches
undertaken, the main conclusions drawn from these reviews
and the quality of the evidence on which they are based (see

also ‘Empty reviews’).
It is evident that a very small proportion of participants in
the 73 prevention trials covered by the five Cochrane
reviews on PU prevention were people with SCI. Just 18
participants from two RCTs [28, 29] included in a review of
support surfaces for PU prevention [21] were reported as
having SCI out of a total of 12 471 participants across 59
trials in that review (0.14%). None of the other Cochrane
reviews of interventions for prevention of PUs included
participants with SCI [22–25], meaning that only 0.12%
(18/14 959) participants were affected by SCI across all five
prevention reviews. One review of nine trials (1501 parti-
cipants), which investigated dressings and topical agents for
preventing PUs [24] included a trial in which 100 partici-
pants underwent posterior spinal surgery [30]. However,
those participants underwent surgery for cervical spondy-
losis, lumbar spinal stenosis, lumbar herniated disc or spinal
cord tumour, and so have not been classed here as being
participants with SCI.
Treatment of PUs
Sixteen Cochrane systematic reviews assessed the evidence
for the effectiveness of interventions for PU treatment
[31–46], with two others assessing interventions for both
prevention and treatment [26, 27]. Table 2 summarises the
Box 2. Cochrane Library search strategy
#1 MeSH descriptor: [Pressure Ulcer] explode all trees
#2 (pressure near/2 (ulcer* or sore* or injur*)):ti,ab,kw
#3 (decubitus near/2 (ulcer* or sore*)):ti,ab,kw
#4 (bedsore* or bed next sore*):ti,ab,kw
#5 #1 or #2 or #3 or #4

number of RCTs and participants included in the 14
reviews, which included at least one trial (three reviews that
included no trials are described later in ‘Empty reviews’),
the main conclusions drawn from these reviews and the
quality of the evidence on which they are based.
Across the 14 systematic reviews of treatment interven-
tions there were 145 included RCTs involving 14 166 par-
ticipants. Only 604 (4.3%) of these participants were
described as having SCI (confined to 10 of the trials
[47–56]: note that Nussbaum et al. [49] was included in
three reviews [31, 43, 57]; Hollisaz et al. [47] was included
in two reviews [31, 33]; and Kaya et al. [50] was included
in two reviews [31, 34]). Although a trial [58] included in
one review [31] did include participants with ‘disorders of
the spinal cord’ it was unclear whether these participants
had SCI, or how many participants were included.
Systematic reviews investigating interventions for
‘chronic’ or ‘complex’ wounds more generally
In addition to the PU-focussed reviews mentioned above, a
further four Cochrane reviews relate more broadly to
‘wounds,’ ‘chronic wounds’ or ‘acute and chronic wounds,’
some of which were PUs.
A systematic review of autologous platelet-rich plasma
for treating chronic wounds [59] included 10 trials
(442 participants). The Cochrane review concluded that it
was unclear whether platelet-rich plasma influences the
healing of chronic wounds other than foot ulcers associated
with diabetes. Whilst two trials appeared to include two

participants with PUs, these were not participants with
SCI [60–62].
A systematic review of honey as a topical treatment for
wounds [57] included a total of 26 RCTs (3011 partici-
pants). The review concluded that although honey may
speed the healing of partial thickness burns and surgical
wounds, its effect on other wounds such as PUs is highly
uncertain. Whilst one trial included adult orthopaedic
patients with PUs [63], there was no evidence from the
review that these were participants affected by SCI.
Dat et al. [64] conducted a systematic review of aloe vera
for treating acute and chronic wounds, which included
seven trials (347 participants). The review concluded that
there was an absence of high-quality evidence from RCTs
to support the use of aloe vera (in the form of topical agents
or dressings) as a treatment for acute and chronic wounds.
One included trial was an RCT, which compared a hydrogel
dressing derived from the aloe plant with a saline gauze
dressing (applied daily) and included only participants with
PUs (n = 41) [65, 66]. However, it is unclear whether this
included people with SCI.
Whilst concluding that hyperbaric oxygen therapy may
improve the healing of diabetic foot ulcers, a review of 12
trials of this intervention for treating chronic wounds
(577 participants) identified none investigating its use in
PUs [67].
‘Empty’ reviews
Of the 27 reviews identified by the search of The Cochrane
Library, five are ‘empty’ reviews in that the systematic
searches undertaken revealed no published data from RCTs.
These include reconstructive surgery [44] and repositioning

[45] for treating PUs, and bed rest for PU healing in
wheelchair users [46]; wound care teams for preventing and
treating PUs [26], and massage therapy for prevention [25].
This is somewhat surprising, given that some of these
treatments are widely administered to people with SCI.
Whilst no conclusions can be drawn from such ‘empty’
reviews, they can be useful in highlighting the paucity of
evidence in these particular areas and perhaps increase their
priority as a research topic. This may hopefully lead to high-
quality trials being carried out on interventions where there
is a theoretical basis that they may work (perhaps informed
by existing evidence from non-RCTs). Indeed, the process
of systematic reviewing facilitates the provision of some
insight into the type of research, which could be undertaken
to address a particular problem, for example, in the
‘Implications for research’ section of a systematic review.
Specifically, systematic reviews may be able to shed light
Table 3 Registered Cochrane
review protocols (as of
September 2017)
Lead author Date published Title
Arora [79] May 2016 Electrical stimulation for treating pressure
ulcers
Joyce [80] March 2016 Organisation of health services for
preventing and treating
pressure ulcers
O’Connor [82] December 2015 Patient and lay carer education
for preventing pressure
ulceration in at-risk populations

Porter-Armstrong [81] April 2015 Education of healthcare
professionals for preventing pressure
ulcers
Walker [83] October 2014 Foam dressings for treating pressure
ulcers
Choo [84] October 2014 Autolytic debridement for pressure
ulcers
Keogh [85] February 2013 Hydrocolloid dressings for treating
pressure ulcers
on what types of patient, intervention, comparison and
outcome might be worthy of investigation (known as the
‘PICO’ model). However, despite being updated three times
since the initial version, the most recent version of the
review on repositioning for treating PUs has still failed to
unearth any relevant evidence from RCTs [45]. This pos-
sibly implies either that the research community has not
been responsive to this important review, or that a high-
quality RCT of this type of intervention may be extremely
difficult to undertake.
Other published (non-Cochrane) systematic reviews
Of course the evidence synthesised only by Cochrane sys-
tematic reviews is not a comprehensive summary of the
entire field of PU research. Nor does this review represent
all of the studies, which include participants with SCI.
As well as Cochrane systematic reviews, a number of

other systematic reviews of interventions for PUs have been
published. These include behavioural and educational
interventions [68–70]; electrical stimulation [71–73]; and
nutritional support [74]. Others have more broadly assessed
a range of interventions for treatment [75, 76] or prevention
[77, 78] of PUs within a single review.
Eight of the 11 systematic reviews, which were returned
by the search, focussed specifically on people with SCI,
which may be an added benefit. Two reviews that included
meta-analyses (seven trials, 386 participants [72]; eight
trials, at least 302 participants [73]) suggested that electrical
stimulation may aid the healing of PUs in people with SCI
[72, 73]. However, heterogeneity was shown to be high in
the studies included in both of these reviews, which also
included at least one non-RCT [72, 73]. An upcoming
Cochrane review of electrical stimulation for treating PUs
will further add to the evidence base for this intervention
[79].
Another review of enteral nutritional support for the
prevention and treatment of PUs also included a meta-
analysis of five RCTs (1325 participants), but this included
studies of patients both with and without SCI [74]. Whilst
that review concluded that some oral nutritional supple-
ments were associated with lower incidence of PUs in at
risk patients (compared with routine care), a more recent
Cochrane review (23 RCTs, 7047 participants) suggested
that there is no clear evidence of benefit associated with
nutritional interventions for either prevention or treatment
of PUs [27].
A systematic review of therapeutic interventions for PUs
following SCI provided a narrative summary of a number of
studies evaluating wheelchair cushions [76]. The review
highlighted evidence that suggests various types of cushion

or seating system are associated with potentially beneficial
reductions in seating interface pressure or PU risk factors
(such as skin temperature) [76]. However, the …
Cochrane
Library
Cochrane Database of Systematic Reviews
Repositioning for pressure ulcer prevention in adults (Review)
Gillespie BM, Chaboyer WP, McInnes E, Kent B, Whitty JA,
Thalib L
Gillespie BM, Chaboyer WP, McInnes E, Kent B, Whitty JA,
Thalib L.
Repositioning for pressure ulcer prevention in adults.
Cochrane Database of Systematic Reviews 2014, Issue 4. Art.
No.: CD009958.
DOI: 10.1002/14651858.CD009958.pub2.
www.cochranelibrary.com
Copyright © 2015 The Cochrane Collaboration. Published by
John Wiley & Sons, Ltd.

https://doi.org/10.1002%2F14651858.CD009958.pub2
https://www.cochranelibrary.com
Cochrane
Library
Trusted evidence.
Informed decisions.
Better health.
T A B L E O F C O N T E N T S
HEADER................................................................................
...............................................................................................
.......................... 1
ABSTRACT............................................................................
...............................................................................................
.......................... 1
PLAIN LANGUAGE
SUMMARY.............................................................................
.......................................................................................... 2
BACKGROUND......................................................................
...............................................................................................
......................... 3
OBJECTIVES..........................................................................
........................................................................................... ....
......................... 4

METHODS..............................................................................
...............................................................................................
........................ 4
RESULTS...............................................................................
...............................................................................................
.......................... 8
Figure
1.............................................................................................
...............................................................................................
...... 9
Figure
2.............................................................................................
...............................................................................................
...... 11
Figure
3.............................................................................................
...............................................................................................
...... 13
Figure
4.............................................................................................
...............................................................................................
...... 14
DISCUSSION..........................................................................
...............................................................................................
......................... 16
AUTHORS'
CONCLUSIONS......................................................................
...............................................................................................
...... 17

ACKNOWLEDGEMENTS........................................................
...............................................................................................
......................... 18
REFERENCES.........................................................................
.................................................................................... ...........
........................ 19
CHARACTERISTICS OF
STUDIES................................................................................
.................................................................................. 22
DATA AND
ANALYSES............................................................................
...............................................................................................
......... 29
Analysis 1.1. Comparison 1 2h versus 3h repositioning on
standard hospital mattresses, Outcome 1 Pressure ulcer risk
(category
1 to
4)...........................................................................................
...............................................................................................
...........
29
standard hospital mattresses, Outcome 2 Pressure ulcer risk
(category
2 to
4)...........................................................................................
...............................................................................................
...........

29
viscoelastic foam mattresses, Outcome 1 Pressure ulcer risk
(category
1 to
4)...........................................................................................
...............................................................................................
...........
30
viscoelastic foam mattresses, Outcome 2 Pressure ulcer risk
(category
2 to
4)...........................................................................................
...............................................................................................
...........
30
Analysis 3.1. Comparison 3 30o tilt 3-hourly overnight versus
90o tilt overnight, Outcome 1 Pressure ulcer risk (category 1 to
4).... 31
APPENDICES.........................................................................
...............................................................................................
......................... 31
WHAT'S
NEW.......................................................................................
...............................................................................................
........... 35
CONTRIBUTIONS OF

AUTHORS..............................................................................
..................................................................................... 36
DECLARATIONS OF
INTEREST..............................................................................
....................................................................................... 36
SOURCES OF
SUPPORT...............................................................................
...............................................................................................
. 36
DIFFERENCES BETWEEN PROTOCOL AND
REVIEW.................................................................................
................................................... 36
INDEX
TERMS...................................................................................
...............................................................................................
............. 36
i
Cochrane
Library
Trusted evidence.
Informed decisions.
Better health.

[Intervention Review]
Repositioning for pressure ulcer prevention in adults
Brigid M Gillespie1, Wendy P Chaboyer1, Elizabeth McInnes2,
Bridie Kent3, Jennifer A Whitty4, Lukman Thalib5
1NHMRC Centre of Research Excellence in Nursing, Centre for
Health Practice Innovation, Menzies Health Institute
Queensland, GriGith
University, Brisbane, Australia. 2Nursing Research Institute, St
Vincent's Health Australia (Sydney) and Australian Catholic
University
(ACU), School of Nursing, Midwifery and Paramedicine,
Australian Catholic University, Darlinghurst, Australia. 3School
of Nursing and
Midwifery, Deakin Centre for Quality and Risk Management,
Deakin University, Melbourne, Burwood, Australia. 4School of
Pharmacy, The
University of Queensland, Brisbane, Australia. 5Department of
Community Medicine, Kuwait University, Safat, Kuwait
Contact address: Wendy P Chaboyer, NHMRC Centre of
Research Excellence in Nursing, Centre for Health Practice
Innovation, Menzies
Health Institute Queensland, GriGith University, Brisbane,
Queensland, Australia. [email protected]
Editorial group: Cochrane Wounds Group

Publication status and date: Edited (no change to conclusions),
published in Issue 2, 2015.
Citation: Gillespie BM, Chaboyer WP, McInnes E, Kent B,
Whitty JA, Thalib L. Repositioning for pressure ulcer
prevention in adults.
Cochrane Database of Systematic Reviews 2014, Issue 4. Art.
No.: CD009958. DOI: 10.1002/14651858.CD009958.pub2.
A B S T R A C T
Background
A pressure ulcer (PU), also referred to as a 'pressure injury',
'pressure sore', or 'bedsore' is defined as an area of localised
tissue damage that
is caused by unrelieved pressure, friction or shearing forces on
any part of the body. PUs commonly occur in patients who are
elderly and
less mobile, and carry significant human and economic impacts.
Immobility and physical inactivity are considered to be major
risk factors
for PU development and the manual repositioning of patients in
hospital or long-term care is a common pressure ulcer
prevention strategy.
Objectives
The objectives of this review were to:
1) assess the eGects of repositioning on the prevention of PUs
in adults, regardless of risk or in-patient setting;
2) ascertain the most eGective repositioning schedules for
preventing PUs in adults; and

3) ascertain the incremental resource consequences and costs
associated with implementing diGerent repositioning regimens
compared
with alternate schedules or standard practice.
Search methods
We searched the following electronic databases to identify
reports of the relevant randomised controlled trials: the
Cochrane Wounds
Group Specialised Register (searched 06 September 2013), the
Cochrane Central Register of Controlled Trials (CENTRAL)
(2013, Issue 8);
Ovid MEDLINE (1948 to August, Week 4, 2013); Ovid
EMBASE (1974 to 2013, Week 35); EBESCO CINAHL (1982 to
30 August 2013); and the
reference sections of studies that were included in the review.
Selection criteria
Randomised controlled trials (RCTs), published or unpublished,
that assessed the eGects of any repositioning schedule or
diGerent patient
positions and measured PU incidence in adults in any setting.
Data collection and analysis
Two review authors independently performed study selection,
risk of bias assessment and data extraction.
1

mailto:[email protected]
https://doi.org/10.1002%2F14651858.CD009958.pub2
Cochrane
Library
Trusted evidence.
Informed decisions.
Better health.
Main results
We included three RCTs and one economic study representing a
total of 502 randomised participants from acute and long-term
care
settings. Two trials compared the 30º and 90º tilt positions
using similar repositioning frequencies (there was a small
diGerence in frequency
of overnight repositioning in the 90º tilt groups between the
trials). The third RCT compared alternative repositioning
frequencies.
All three studies reported the proportion of patients developing
PU of any grade, stage or category. None of the trials reported
on pain, or
quality of life, and only one reported on cost. All three trials
were at high risk of bias.
The two trials of 30º tilt vs. 90º were pooled using a random
eGects model (I2 = 69%) (252 participants). The risk ratio for
developing a PU in

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