Treatment approaches of stage III and IV pressure injury in people with spinal cord injury: A scoping review

Context The treatment of pressure injury (PI) stage III and IV in people with spinal cord injury or spinal cord disorder (SCI/D) requires a multidisciplinary and surgical involvement. Objectives This scoping review aims to identify published relevant surgical multidisciplinary treatment approaches, describe the elements and evaluate the effectiveness of the approaches. Methods We searched PubMed and Medline databases for studies about treatment approaches for people aged ≥18 years with chronic SCI/D and PI stage III or IV over ischium, trochanter or sacrum published between January 1990 and December 2021 in English or German language. Two independent reviewers screened the articles. One reviewer extracted information on study author(s), year of publication, study title, study design, country of origin, sample size as well as data on elements and effectiveness of the approaches. Results 10 different approaches were described in two retrospective cohort studies, three case series, five discussion papers, one review and one guideline. All approaches included debridement, flap surgery, pressure relief and immobilization as well as infection control. Some approaches described elements such as risk screening (7/10), osteomyelitis treatment (8/10), nutritional therapy (8/10), physiotherapy, occupational therapy and psychology (6/10), spasticity control (7/10), and prevention and education (6/10). Only one study reported on the effectiveness of the approaches. Conclusion There are key elements for surgical multidisciplinary treatment approaches. However, due to differences in the content of some of these elements and missing elements in some approaches, comparability is difficult and the effectiveness of the complex approaches remains uncertain.


Introduction
Pressure injury (PI) is one of the most frequent complications in people with spinal cord injury or spinal cord disorder (SCI/D). 1 The lack of sensation as well as limited motor function and mobility increase the risk of developing PIs in this population. 2 PIs most commonly occur over the sacrum and coccyx, ischium and trochanter. [3][4][5] The lifetime incidence of PIs in people with SCI/D is up to 95%. 6 It is a serious and costly secondary condition that significantly limits quality of life. 1,7,8 While PI stage I and II are mostly treated conservatively, surgery is generally recommended for stage III and IV. 9,10 Surgical management can be very effective for complex PI. 10 Still, the complication rates are high, usually ranging between 30% and 50%. 11,12 Complications are divided into minor and major complications. 13 In contrast to minor complications, major complications require reoperation. 13 Approximately 16% of people are affected by major complications. [14][15][16] Postoperative complications include wound dehiscence, bleeding, hematoma, recurrence, partial necrosis or total flap necrosis. 14,17 In addition, complications increase length of hospital stay and costs. 11,15 The implementation of multidisciplinary treatment approaches, however, should not only decrease complication rates, but also length of hospital stays and treatment costs. 11,18 The complex health condition of PIs requires a multilayered, coordinated involvement of different disciplines and professions. 8,[10][11][12] The idea of a structured multidisciplinary treatment is consistent with the understanding of the World Health Organization's (WHO) International Classification of Functioning, Disability and Health (ICF). 19 The bio-psycho-social model of the ICF is used to describe functioning including their structures, functions, activity and participation, environmental and personal factors. 20 It can be combined with the International Classification of Diseases (ICD 10) to address the diagnosis of the person, but also their activity and participation in the biopsychosocial context. 10,20 In general, there is no standard in the clinical management of PIs in people with SCI/D. 21 There is a current discussion of surgical treatment approaches involving a complementary multidisciplinary approach (e.g. paraplegiologists, surgeons, physiotherapists, occupational therapists, nutritional therapists etc.) for people with SCI/D and stage III and IV PI such as the Basel Decubitus Concept. 7,11,15 However, deeper insights on the various treatment approaches and their effectiveness are lacking. The Basel Decubitus Concept, for example, has been developed based on years of experiences and only single aspects of the concept are evidence-based. 11 To reduce complication rates in the future, it is first necessary to clarify how stage III and IV PI should be treated in people with SCI. A scoping review is the best method to summarize knowledge in a complex health condition and treatment approach when randomized trials are still missing. 22 Therefore, we performed a scoping review with the aim of providing an overview of different surgical multidisciplinary treatment approaches of stage III and IV PI in people with SCI/D. An additional objective of our review is to describe the elements and effectiveness of these approaches. The present study is the first scoping review of PI treatment approaches in people with SCI/D.

Methods
This scoping review followed the methodological framework for conducting a scoping study by Arksey and O'Mally and Levac et al. 22,23 Moreover, we used the checklist of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extensions for Scoping Reviews (PRISMA-ScR) 24 (Appendix Table  1). This scoping review was not registered and no review protocol was produced.

Literature search strategy
We performed a systematic literature search for treatment approaches in the databases PubMed and Medline. The search strategy consisted of three constructs related to PIs, treatment and SCI/D. The following terms were used: "pressure injury", "pressure sore", "bedsore", "decubitus", the MeSH term for "pressure ulcer", "treatment concept", "treatment", the MeSH Term "spinal cord injury", "spinal lesion" and "SCI" (Appendix Table 2). We applied the following filters: studies involving humans, English or German language as well as studies published from January 1990 until the end of December 2021. The search was conducted for the last time on January 6th of 2022.

Study selection and appraisal
We defined the inclusion criteria following the extended PICOS framework ( population, intervention, comparison, outcome, study design) 24 (Appendix Table 3). The following inclusion criteria were decisive for the relevance of the articles: (1) Studies about people aged ≥18 years with SCI/D or similar syndrome; (2) Studies about PI stage III and/or IV over ischium, trochanter or sacrum; (3) Studies in the acute or rehabilitation setting in the chronic phase of SCI/D; and, (4) Studies that describe surgical multidisciplinary treatment approaches of PI.
As most common, PIs stage III and IV occur over the sacrum and coccyx, ischium and trochanter, we excluded studies about PIs at other sites. 25  Selection process, data synthesis, level of evidence and methodological quality We extracted the study title, authors, first author, citation, journal or book, publication year and DOI number. To ensure reliability of the title and abstract, two blinded researchers (CF, MaB) independently screened at least 20% of the identified articles. In case of an agreement rate of >95%, only one reviewer (CF) continued screening. If it was unclear whether the article should be included or excluded based on the title or abstract, the reviewers read the abstract respectively the full text. To make the final decision on inclusion, the reviewers read all remaining articles in full. If the reviewers (CF, MaB) did not reach a consensus, a third reviewer (ASS) decided on inclusion or exclusion. The next step was to summarize the diagnostic and treatment elements of the approaches, called elements from here. To this end, we created several tables. We included only those studies in the table that provided information on the particular element. One reviewer (CF) used the modified Sackett Scale from 1 to 5. 26 This is a tool to determine the strength of the study in terms of the type of design used. 26 Two reviewers (CF, MaB) also assessed the methodological quality of the included studies. For this purpose, we used the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) 27 checklist for observational studies, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 28 checklist for reviews and the German Instrument for Methodological Guideline Appraisal (DELBI) 29,30 for guidelines. Due to a lack of methods, we did not assess the methodological quality of the discussion papers.

Study selection
In total, the electronic search for treatment approaches identified 963 articles, 509 from PubMed and 454 from Medline. Two reviewers (CF, MaB) independently screened 21% of the titles, abstracts and full text of the found literature in PubMed and Medline. The reviewers (CF, MaB) disagreed on four articles. The third reviewer (ASS) included two articles and excluded two because they were not multidisciplinary and surgical treatment approaches. The agreement rate between the two reviewers (CF, MaB) was 96.5%. Thus, only one reviewer (CF) continued with the rest of the literature. Finally, we considered twelve articles on treatment approaches as eligible (Fig. 1).

Study characteristics, level of evidence and methodological quality
We identified one review, one guideline, three case series, two cohort studies and five discussion papers on treatment approaches for people with SCI/D and stage III and VI PI. Meier et al., Kreutzträger et al. and Rieger et al. described the so-called Basel Decubitus Concept. 5,11,15 The other approaches were not specifically named ( Table 1).
The assessment of the methodological quality of the review by Thomas showed that none of the methodological requirements of the PRISMA checklist were adequately addressed (Appendix Table 8 Table 9). Moreover, the guideline of the Consortium for Spinal Cord Medicine scored only half of the possible methodological quality points on the DELBI checklist (Appendix Table 10).

Treatment approaches
The evaluations of the approaches revealed 12 different elements. We found the following elements in the studies: PI classification, debridement, flap surgery, pressure relief and immobilization, infection control, osteomyelitis treatment, wound conditioning, risk screening, therapies ( physio-, occupational therapy and/or psychology), nutritional therapy, spasticity control and prevention and education ( Table 2).

Classification of PI
The treatment of PIs starts with the PI categorization. 3,6,7,11,15,31,32 Therefore, the classification of the Guideline of the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance should be consulted. 3,11,15,32 This guideline will be referred to as the EPUAP Guideline hereinafter for convenience.

Debridement
All approaches describe a debridement as the baseline of surgical treatment because it is the most efficient method of wound cleaning. 3,[5][6][7]9,11,15,[31][32][33][34][35] During the surgical debridement, all necrotic tissue and infected bone should be removed. 3,5,33,34 The debridement can be carried out with a scalpel, electrocautery, rongeur or curette. 3 Moreover, anesthesia is often indicated because of autonomic dysreflexia, pain and/or bleeding. 3 Ljung et al. and Rieger et al. perform the debridement with pseudotumor technique. 6 In this procedure, the wound margin is incised at a sufficient distance in healthy tissue, the ulcer margins are sutured together with retaining sutures and the ulcer is excised, taking any necrosis and surrounding scar tissue with it. 5 Furthermore, Tadiparthi et al. mention to use methylene blue in order to trace the extent of any sinus tract formation. 7 Ljung et al. remove the underlying bone and make it smooth and less prominent. 6 Debridement and surgical closure in the same procedure was described by Ljung et al. and Tadiparthi

Osteomyelitis treatment and infection control
In the majority of stage IV PIs an osteomyelitis is present 9 and often results from bacterial contamination of exposed bone. 3 Osteomyelitis should be addressed prior to flap surgery with a radical debridement. 5,31 Figure 1 Flow chart documenting the study selection.   35 x Note: PI, pressure injury. In case of an exposed bone, bone biopsy during the debridement or before closure is the gold standard for the diagnosis of osteomyelitis. 3,7,9,[31][32][33] The deep culture and histopathology of a bone biopsy determines the duration of antibiotic treatment. 32 If osteomyelitis is not present, the postsurgical antibiotic treatment varied from five days up to approximately two weeks. 6,7,9,15 The administration of antibiotics in people with osteomyelitis range from one week up to three months. 3,[5][6][7]9,33,34 Antibiotics were administered in different ways (Appendix Table 5). According to the Consortium of Spinal Cord Medicine, antibiotics are administered parenterally. 3 Ljung et al. treated all individuals with intravenous antibiotics for the first three days. 6 In contrast, Sørensen et al. applied intravenous antibiotic therapy for the first two weeks and oral antibiotics thereafter. 9 Jordan et al. described six weeks of intravenous antibiotics in the outpatient setting prior to reconstruction in cases of osteomyelitis. 31

Pressure relief and immobilization
Postsurgical pressure relief and immobilization were mentioned as an important element in all studies. 3,[5][6][7]9,11,15,[31][32][33][34][35] After surgery, complete bed rest is recommended as well as a continuous relief of pressure. 3,5,9,15,31,33 The immobilization period varied from two to eight weeks. [5][6][7]11 Furthermore, data indicate that several pressure-reducing devices are superior to standard mattresses, with a relative risk reduction of around 70%. 35 The articles reviewed mention various mattresses for pressure relief: air-fluidized, low-airloss, vascularized bed, pressure relieving heat bed, Clinitron bed, and alternating pressure mattress. 5,6,9,11,15,31,32,35 Wound conditioning The assessment and local dressing of wounds were done with the TIME framework (Tissue, Infection/ Inflammation control, Moisture imbalance, and Epithelial advancement). 11,33 Therefore, Meier et al. remove the necrosis, treat the infection only with local disinfection if possible, change moist dressings three times daily or perform negative pressure wound therapy. 11 Kreutzträger et al. either irrigated the wound and used Lavanid twice daily or they applied negative pressure wound therapy in the surgical room at a 3-day interval. 15 Rieger et al. applied moist dressings and negative pressure wound therapy for deep wounds. 5 Kruger et al. also recommended negative pressure wound therapy and electrical stimulation as important options in PI management. 32

Risk screening
According to the Consortium for Spinal Cord Medicine, the assessment and diagnostics of the following comorbidities should be performed and addressed prior to surgery: cardiovascular disease, pulmonary disease, peripheral vascular disease and diabetes. 3 Cigarette smoking impairs flap healing. 3 Therefore, preoperative smoking cessation is indicated because it reduces the risk of smoking-related complications. 3,7 Preoperative assessments by the Consortium for Spinal Cord Medicine also includes wound bioburden, presence of osteomyelitis, management of bowel and bladder, urinary tract infection, evaluation of recurrent PIs, heterotopic ossification and anesthesia. 3 The Basel Decubitus Concept includes a standard laboratory examination focused on examination of infection, anemia, electrolytes, kidney, liver function and as already mentioned before a nutrition profile. 11 Further, examination of pulmonary functioning, breathing therapy, electrocardiogram, thoracic radiography as well as examination of the lower extremities and spine through standardized range of motion are performed. 11 Neurological examination using the International Standard for Neurological Examination in SCI (ISNCSCI) is also part of the concept to detect any changes in the neurological senso-motoric system. 11 Furthermore, they identified the following risk factors for PI occurrence: age, male sex, lower level of education, complete spinal lesion and malnutrition. 15 Moreover, they found that male sex and AIS A score were risk factors for postsurgical complications such as delayed wound healing and reoperation. 15 Fähndrich et al. According to Thomas, the Norton Score and Braden Scale are tools to assess the risk of PI. 35 Using the five risk factors of the Norton score, theoretically, individuals at high risk of PI can be identified. 35 Therapies The Basel Decubitus Concept as well as the multidisciplinary approach by Tadiparthi et al. include psychotherapy, social support, physiotherapy and occupational therapy. 5,7,11,15 The Basel Decubitus Concept also includes nutritional counseling. 11,15 Subsequently, everyone should undergo a full psychological assessment and treatment 32 because they are at high risk for depression due to the long immobilization phase 3 and because psychotherapy can improve the person's condition 11,33 as well as patient compliance. 32 Physical and occupational therapists provide transfer training, evaluation of seating position, wheelchair pressure mapping assessment, initiating functional electrical stimulation, mobilization of the lower extremities and education as secondary prevention. 3,5,6,11,15 They also inspect the technical devices of the person, such as wheelchair, cushion, or mattress. 15 3,11,15 Malnutrition is associated with the risk of developing PIs, but also with poor wound healing and loss of the cushioning effect of the skin and subcutaneous tissue. 5,[32][33][34][35] Thus, malnutrition should be treated by administering protein, caloric supplementation as well as micronutrients such as vitamins and minerals. 3 Higher protein intake was achieved either by optimized nutrition with protein supplementation 15 or by individually calculated protein intake with 1.2-1.5 grams protein/kg bodyweight. 5,32,35 The concrete recommendations for nutrition differed among the approaches. The following parameters were mentioned to be assessed: fasting blood sugar, liver function panel, folate, vitamin B12, vitamin C, omega-3-fatty acids, prealbumin, albumin, total protein, hemoglobin, hematocrit, total lymphocyte count, transferrin, nitrogen balance, total cholesterol, creatinine, amino acids, c-reactive protein, magnesium, iron and zinc 3,5,32,34,35 (Appendix Table 7).

Spasticity control
Spasticity and contractures are considered risk factors for skin breakdown in people with SCI/D. 32,33 Before flap surgery, spasticity control should be optimized since muscle spasms can tear open fresh surgical incisions. 3,31 According to two studies, spasticity has to be suppressed with anti-spasm agents to prevent excessive movements. 31,34 In addition, surgery, oral pharmacology, muscle blocks with botulinum toxin, nerve blocks with alcohol or phenol, intrathecal baclofen therapy, preliminary flexor tendon releases, casts or intraoperative tenotomy are described. 3,9,32 After surgery, spasticity should be controlled with external fixation for a few weeks to prevent tearing of the flap. 9, 15 Kreutzträger et al. include considerations about spasticity. 15 Spasticity control, however, is not explicitly mentioned as a element among the Basel Decubitus Concept. 5,11,15 Prevention of secondary complications and education Patient education is part of the treatment of PIs. 5,11,32 It includes instructions on how to perform weight shifts and transfers, how to manage the PI, how to prevent new PIs or recurrence and how to maintain wheelchair cushions. 3,7,31,32 Pursuant to Shenaq & Dinh, the best and most economical method of PI treatment is prevention. 34 Based on Meier et al., prevention of secondary complications and education further consists of the re-evaluation of the seating position, the seating cushions and the transfer techniques. 11 In addition, strength training of the upper extremities and local functional electrical stimulation are included. 11 Meier et al. also evaluate the outpatient environment including auxiliaries and the need for nursing support, and in cases of work reintegration, the workload. 11 Furthermore, according to the Consortium for Spinal Cord Medicine, daily skin control, especially over bony prominences, is essential to detect early skin breakdown in order to prevent PI stage III and IV. 3 This can be done by self-inspection with a long-handled mirror and camera or by caregivers and professionals, when self-inspection is not possible. 3 The skin should be assessed for changes in skin color and texture. 3 In addition, the skin should be touched to assess warmth, wetness, hardness, or softness. 3

Effectiveness of treatment approaches
Only the study by Tadiparthi et al. examined effectiveness of the treatment approach with all detected elements ( Table 2) by comparing outcome measures before and after implementing their multidisciplinary approach. 7 They reported a decrease in the readmission rate due to complications from 14% to 5.5% and a reduction in the inpatient stay upon readmission from 65 to 45 days. 7  outcomes and lowered recurrence rates, readmissions and healthcare costs. 7

Stage III and IV PI treatment approaches
The scoping review identified twelve studies from Europe and North America published between 1990 and 2019 that included comprehensive description of multidisciplinary treatment approaches. All these multidisciplinary treatment approaches included the elements debridement, flap surgery, pressure relief and immobilization as well as infection control. In contrast, spasticity control, psychological support or education were missing in some approaches. Furthermore, the authors of the articles reviewed described different contents of the elements related to debridement, flap surgery, immobilization, antibiotic treatment and nutritional therapy.
Regarding debridement, neither the EPUAP nor the German-Speaking Medical Society for Paraplegiology (DMGP) recommends single or serial debridement. 2,4 The wound, however, must be free of infection and necrosis at the time of surgical coverage. 4 New evidence on soft-tissue reconstruction suggests that only a minimal number of previous debridement should to be performed before surgery. 36 Early coverage in a single-stage procedure is associated with earlier healing, reduced infection and shorter hospital stay. 36 In contrast, delayed coverage promotes microbial colonization, biofilm development, recurrence of OM, and development of drug resistance. 36 Regarding flap surgery techniques, all authors of the articles reviewed described the tensor fascia latae flap for trochanteric PIs as the best standard. 5,7,9,11,15,32 In contrast, no consistent practice of flap surgery of ischial and sacral PIs could be found, not even within the Basel Decubitus Concept. 5,7,9,11,15,31,32 The EPUAP guideline on prevention and treatment of PI does not recommend flap technique for trochanter, ischium, and sacrum. 2 The EPUAP comments only on the tissue type, which is selected based on the clinical condition of the individual, the available tissue, the anatomical location of the PI, and the surgeon's preference. 2 In contrast, the S1 guideline of the DMGP recommends the gluteal fasciocutaneous rotational flap or the gluteal (myo-) fasciocutaneous rotational flap for ischial PIs and a dorsal fasciocutaneous thigh flap for sacral PIs. 4 The inconsistent practice and recommendations may be due to the fact that the type of flap surgery depends on the surgeon's experience and preferences, the size of the PI, the surrounding tissue, previous surgery in that region or multiple PI near the reconstruction area. 2,4 This could also be the reason why different surgeons report good success rates with different flap techniques.
After surgery, immobilization is required. 11 Regarding the mattress, there is a weak recommendation of the EPUAP with a strength of evidence B1 to assess the relative benefits of using an air fluidized bed to facilitate healing while reducing skin temperature and excessive hydration in individuals with stage III or IV PIs. 2 In contrast, the use of alternating pressure air mattresses varies. 2 Moreover, the authors using the Basel Decubitus Concept describe different durations of immobilization after flap surgery. In the 90s, individuals were immobilized for six weeks. Since 2015, an immobilization period of six or four weeks has been used, depending on the person's condition, second reconstruction or diagnosed osteomyelitis. 5,11,15,37 Neither the EPUAP nor the DMGP guideline contains recommendation on the duration of immobilization after flap surgery. This also applies to the duration of antibiotic treatment in people with and without osteomyelitis. 2,4 New evidence suggests that the duration of antibiotic treatment should be adjusted to the severity of osteomyelitis to reduce the development of antibiotic resistance and avoid early postsurgical complication. 38 Furthermore, in the Basel Decubitus Concept bone biopsies are meanwhile taken during the debridement to determine the antibiotic therapy for the specific bacteria. 38 Comparable differences were also found regarding nutritional parameters and therapeutic approaches. The EPUAP found that there is only low evidence that measurements of hematological and nutritional status can predict the development of PI. 2 In contrast, the authors agreed that protein intake should be increased in people with PIs and that malnutrition is associated with the risk of developing PIs. Both aspects are in accordance with the EPUAP guideline. 2 The EPUAP guidelines strongly recommends to conduct a complete nutrition assessment for adults with a PI and to provide a nutritional screening for individuals at risk of PIs (strength of evidence of B2, respectively B1). 2 Furthermore, there is a strong recommendation with a strength of evidence B1 to provide 1.25-1.5 g protein/kg body weight per day for adults with PIs who are malnourished or at risk of malnutrition. 2 This recommendation is not SCI/D specific. Regarding nutritional supplementation, the EPUAP weakly recommends, with a strength of evidence of B1, to provide high-calorie, high-protein, arginine, zinc and antioxidant nutritional supplements for adults who are malnourished or at risk for malnutrition. 2 In the Basel Decubitus Concept two nutrition tools are used: SNST and NRS. 11,15 The SNST was developed for people with SCI/D. 11,15 The EPUAP provides no recommendation of malnutrition measurement tools for people with SCI/D. 2 However, according to the EPUAP guideline, the non-spinal cord injury specific NRS tool has good psychometric properties when used to screen nutritional status of older adults. 2 According to the DMGP, spasticity is an additional treatment measure to avoid increased mechanical stress. 4 Individually optimized antispastic therapy should be aimed for. 4 Consequently, it is recommended to include spasticity in the treatment approach.
Thus, comparison of the twelve articles with existing guidelines reveals the lack of conclusive data, particularly regarding the technique of ischial and sacral flap surgery, the duration of antibiotic treatment in people with and without osteomyelitis as well as the duration and type of immobilization, such as the choice of pressure-relief devices. Furthermore, there is a lack of evidence on how nutritional and blood parameters should be measured, which parameters should be assessed as well as which parameters are relevant and need to be addressed for successful PI treatment.

Level of evidence and methodological quality
The level of evidence of the included studies is low, with ten of the twelve studies providing no evidence according to the modified Sackett Scale. Furthermore, we considered the methodological quality of the included studies to be low because half of the studies were discussion papers with no scientific evidence. Furthermore, certain parts of the methodology were lacking in the remaining studies. In particular, the description of statistical methods including the control for confounding and explanations of missing values were missing. However, the eligibility criteria, the definition of the variables, data sources and measurements as well as considerations of biases had not been reported either. In addition, the review by Thomas did not consider eligibility criteria, information sources, search strategy, selection and data collection process, data items, effect measures, synthesis of methods, biases and certainty assessment. Hence, it did not fulfill any item of the methods of the PRISMA-ScR checklist (Appendix Table 8 and 9) and is therefore more of a discussion paper. 28 In particular, the guideline of the Consortium for Spinal Cord Medicine did not fully meet the requirement of a systematic method. Moreover, only one of the studies measured effectiveness. 7 Thus, the approaches are not comparable. Furthermore, the studies retrospectively observed only a small population. 6,7,11,15,31 Consequently, the effectiveness of the multidisciplinary approaches and single interventions remains uncertain. While the approaches contain uniform core elements, the additional elements still need to be defined. Experts should first agree on required elements of the treatment approach in a structured consensus conference based on the evidence. To evaluate the effectiveness of the entire approach, the next step could be to conduct prospective cohort studies to compare the outcomes such as complication rates, length of hospital stays and costs before and after implementation of the treatment approach. Prospective cohort studies with larger sample sizes are needed to provide solid evidence of effectiveness and improve the treatment stage III and IV PI in people with SCI/D.

Conclusion
Although there are key elements on multidisciplinary treatment approaches of stage III and IV PI in people with SCI/D, evidence on the effectiveness of the entire treatment approaches is still low because only one study has examined the effectiveness. Before assessing the effectiveness, experts should first agree on the elements and their contents. This could be achieved through a consensus conference. Thereafter, prospective cohort studies comparing outcomes before and after implementation of treatment approaches are necessary to assess effectiveness and guide clinical quality management for this cost-intensive health condition.
All authors approved the final version of the manuscript.
Funding This scoping review was not funded.

Conflicts of interest
Authors have no conflict of interests to declare.