Blog posts of '2021' 'November'


Thursday 18th November is the world-wide STOP pressure injury day, a day designated to increase awareness about pressure injury prevention – for both health professionals and the public. Word-wide STOP pressure injury day started in 2012 following a meeting of Spanish speaking wound care organisations, with the European Pressure Ulcer Advisory Panel later joining and encouraging other countries to participate.

The aim of the day is to raise awareness of pressure injuries and how to prevent them. Key messages are:

  • with the right knowledge and care, pressure injuries can be avoided.
  • all health professionals, carers, family/whanau members and patients have important roles to play in prevention.
  • skin care matters.

World-wide STOP pressure injury day may be a recent initiative; however, pressure injuries have been with us for some time – albeit under an assortment of names. Looking at an article by Agrawal and Chauhan (2012), pressure injuries have been recognised as a disease entity since the early ages  - evidence of pressure injuries have been found in Egyptian mummies, some of which are more than 5000 years old. 

Hippocrates (460-370 B.C) had described pressure injuries in associated with paraplegia with bladder and bowel dysfunction, while in the 16th century a French army barber-surgeon wrote about a wounded French aristocrat developing a pressure injury that was later healed with good nutrition, pain relief and debridement.

In the 19th century Jean-Martin Charcot hypothesized that pressure injuries were related to damage of the central nervous system, where he classified pressure injuries into decubitus acutus, chronicus and ominosus. The classification of decubitus ominosus was given asCharcot observed that many patients who developed eschar of the sacrum and buttocks died soon afterwards. Brown-Sequard opposed Charcot’s theory and proved that if pressure is avoided in guinea pigs with spinal cord injury, a pressure injury can be avoided or an existing pressure injury healed.

An article by Levine in 2019 discussed the role of orthopaedic surgeon and spinal injury specialist J. Darrell Shea, who proposed a sequential four stage decubitus classification system in 1975, from which the current staging guidelines have evolved from. This was not the first attempt at a pressure injury staging system, with earlier classifications systems proposed by Guttman and Campbell, with Guttman linking treatment plans to each stage and Campbell acknowledging the need for surgical management for advanced stages.

Interest in a staging system accelerated in the mid-20th century because of World War II casualties, which included thousands of men with paraplegia and spinal cord injuries. Medical developments during the war increased the number of severely injured casualties surviving the battlefield, with advancements in surgical techniques resulting in the first report of surgical closure of a decubitus ulcer (with the aid of penicillin) being published in 1945. The post war years saw several publications appear in regard to pressure injury treatment, in particular treatment of pressure injuries in young males.

Shea proposed a simplified four stage system or pressure injury progression, with acknowledgement of the role that friction and maceration play in addition to pressure. Like earlier systems, each grade was linked to specific treatment recommendations. Shea also recognised that pressure injuries could start at either the surface, or deep within tissue adjacent to the bone – using the term ‘closed pressure sore’ - which we now classify as a deep tissue pressure injury. Shea’s proposal for a sequential four-stage system was an attempt to better understand and treat pressure injuries, stating that ‘one cannot properly treat a lesion that is not well understood’.

Shea’s grading system was adopted and modified by the National Pressure Ulcer Advisory Panel and distributed in 1992. Over time we have further increased our understanding of pressure injuries, including a wider range of populations (such as critical care and geriatric populations) and the role that aging and chronic disease play.   Our increased understanding on pressure injuries have resulted in the staging system evolving over time, including how the staging system is meant to be used and factors we need to consider when devising a treatment plan.

Today the majority of us have ready access to a wide range of resources for pressure injury prevention and management, with a large amount of information captured in the International Guidelines.   The International Guidelines represent a collaboration of the Pan Pacific Pressure Injury Alliance (PPPIA), the European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure Injury Advisory Panel (NPIAP), resulting in a resource that is evidence based and easy to access – with hard copy or e-book options readily available. Last year a smart phone app was launched, allowing evidence-based recommendations to be available at our fingertips. If you are interested in the procedure as to how the Clinical Practice Guideline was updated, the article can be found here.

For world-wide STOP pressure injury awareness day, we have compiled a list of resources available around our region, but a resource in particular I would like to single out is the patient stores from the Health, Quality and Safety Commission in New Zealand.  As health professionals we have an understanding of what a pressure injury can mean in terms of length of stay in hospital, or what equipment a person may need, or what additional care support a person might need at home, however the patient stories bring home the reality of what it means for the person when they get a pressure injury, in particular the isolation that comes from extended bed rest or the practicalities of managing such a wound. Further information on these case studies can be found here.

Pan Pacific Resources

The Pan Pacific Pressure Injury Alliance is made includes Australia and New Zealand as members with Japan, Korea, and China as associate members. Learn all about it here.

Resources you might like to explore on the PPPIA website

  • 2019 International Guideline here. 
  • Pressure Injury flowcharts here.
  • The Official Pressure Injury Prevention Guideline App here.
  • PPPIA - Classification Images for different skin tones here. 

 Permobil have collaborated with PPPIA to produce Wheelchair Seating Pocket Guide 

New Zealand Resources

  • New Zealand Wound Care Society here.
  • ACC resource page here.
  • Case Studies in New Zealand here.
  • New Zealand Spinal Trust - Importance of skin checks here.

Additional Resources

Pressure Injury Risk Assessments

Blog References

Agrawal, K. & Chauhan, N. (2012) Pressure ulcers: Back to the basics. Indian J Plas Surg 45(2) 244-254 doi: 10.4103/0970-0358.101287

Levine, J. (2019) Historical Perspective on Pressure Injury Classification: The Legacy of J. Darrell Shea. Advances in Skin & Wound Care 32(3) 103-106

Rachel Maher
Clinical Education Specialist
Rachel Maher graduated from the University of Otago in 2003 with a Bachelor of Physiotherapy, and a Post Graduate Diploma in Physiotherapy (Neurorehabilitation) in 2010. 
Rachel gained experience in inpatient rehabilitation and community Physiotherapy, before moving into a Child Development Service.Rachel moved into a Wheelchair and Seating Outreach Advisor role at Enable New Zealand in 2014, complementing her clinical knowledge with experience in NZ Ministry of Health funding processes. 
Rachel joined Permobil in June 2020, and is passionate about education and working collaboratively to achieve the best result for our end users.