Abstract

Background

Pressure, from lying or sitting on a particular part of the body results in reduced oxygen and nutrient supply, impaired drainage of waste products and damage to cells. If a patient with an existing pressure ulcer continues to lie or bear weight on the affected area, the tissues become depleted of blood flow and there is no oxygen or nutrient supply to the wound, and no removal of waste products from the wound, all of which are necessary for healing. Patients who cannot reposition themselves require assistance. International best practice advocates the use of repositioning as an integral component of a pressure ulcer management strategy. This review has been conducted to clarify the role of repositioning in the management of patients with pressure ulcers.

Objectives

To assess the effects of repositioning patients on the healing rates of pressure ulcers.

Search methods

For this third update we searched the Cochrane Wounds Group Specialised Register (searched 28 August 2014); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 7); Ovid MEDLINE (2013 to August Week 3 2014); Ovid MEDLINE (In‐Process & Other Non‐Indexed Citations 29 August, 2014); Ovid EMBASE (2012 to 29 August, 2014); and EBSCO CINAHL (2012 to 27 August 2014).

Selection criteria

We considered randomised controlled trials (RCTs) comparing repositioning with no repositioning, or RCTs comparing different repositioning techniques, or RCTs comparing different repositioning frequencies for the review. Controlled clinical trials (CCTs) were only to be considered in the absence of RCTs.

Data collection and analysis

Two authors independently assessed titles and, where available, abstracts of the studies identified by the search strategy for their eligibility. We obtained full versions of potentially relevant studies and two authors independently screened these against the inclusion criteria.

Main results

We identified no studies that met the inclusion criteria.

Authors' conclusions

Despite the widespread use of repositioning as a component of the management plan for individuals with existing pressure ulcers, no randomised trials exist that assess the effects of repositioning patients on the healing rates of pressure ulcers. Therefore, we cannot conclude whether repositioning patients improves the healing rates of pressure ulcers. The effect of repositioning on pressure ulcer healing needs to be evaluated.

Author(s)

Zena EH Moore, Seamus Cowman

Abstract

Plain language summary

Repositioning for treating pressure ulcers

Pressure ulcers (also known as bed sores, pressure sores and decubitus ulcers) are localised areas of tissue damage caused by excess pressure and shearing forces. Pressure ulcers mainly occur in people who have limited mobility, nerve damage or both. Pressure, from lying or sitting on a particular part of the body, results in oxygen and nutrient deprivation to the affected area. Repositioning involves moving the individual into a different position in order to remove or redistribute pressure from a part of the body. If a person with an existing pressure ulcer continues to lie or bear weight on the affected area, the tissues become depleted of blood flow and there is no oxygen or nutrient supply to the wound, and no removal of waste products from the wound, all of which are necessary for healing. People who cannot reposition themselves require assistance. International best practice advocates the use of repositioning as an integral component of a pressure ulcer management strategy. The authors of this review found no studies that were eligible for inclusion in the review. Therefore, we do not know whether repositioning people makes any difference to the healing rates of pressure ulcers.

Author(s)

Zena EH Moore, Seamus Cowman

Reviewer's Conclusions

Authors' conclusions 

Implications for practice 

There is no randomised controlled trial (RCT) evidence that addresses the question of whether repositioning patients improves the healing rates of pressure ulcers. Although repositioning is a practice with good face value, there is no available RCT evidence to provide specific guidance for practice. Weight bearing directly onto an existing pressure ulcer will cause vascular obstruction which will eliminate capillary blood flow to the pressure ulcer. Therefore, it is reasonable to suggest that individuals with pressure ulcers are repositioned to avoid depriving the wounded area of oxygen and nutrients which are needed for tissue repair.

Implications for research 

Repositioning is an integral component of pressure ulcer management strategies and is widely utilised in clinical practice. To date, there is no RCT evidence available to identify whether repositioning makes any difference to the healing rates of pressure ulcers. There is a need for a large cluster‐randomised study, correctly powered, with treatment groups comparable at baseline, allocation to groups concealed, blinded outcome assessment and intention‐to‐treat analysis, to confirm the role of repositioning in the healing of pressure ulcers. Cluster randomisation involves the randomisation of units rather than individuals to the different arms of a study, for example units within a hospital, rather than individual patients (MRC 2002). Cluster randomised trials are used for a number of reasons; increased efficiency, increased compliance with the study protocol and avoidance of contamination (Donner 2004). Contamination is said to occur when an intervention is given to an individual but may affect others within the trial (Puffer 2005). For example, in a repositioning trial, care staff using a specific repositioning regime (e.g. the 30 degree tilt) may find it more practical to administer the intervention to all those who meet the inclusion criteria in a specific unit, rather than administer different repositioning regimes to different patients within the same unit.

Repositioning trials need to consider the effects of the following on the healing rates of pressure ulcers:

• The effects of different repositioning regimes, for example, the 30 degree tilt versus the 90 degree lateral rotation.
• The effects of different frequencies of repositioning, for example, 2 hourly turning, 3 hourly turning, 4 hourly turning etc.
• The effects of different repositioning regimes, in combination with a pressure redistribution mattress.
• The effects of different frequencies of repositioning, in combination with pressure redistribution mattress.

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