LORMA COLLEGES

COLLEGE OF PHYSICAL AND RESPIRATORY THERAPY

PT in INTEGUMENTARY

Activity #1

LORMA COLLEGES
Carlatan, City of San Fernando, La Union
October 20, 2022

This Medical Background on

Decubitus Ulcer

Is Submitted to the
Physical Therapy Department

In Partial Fulfillment to the Requirements

On Subject
PT in INTEGUMENTARY

Submitted by:
Abdulrahman Salim Saad Zgama
A. Medical Background

1. INTRODUCTION
Decubitus ulcer is also known as a pressure ulcer, pressure sore, or
bedsore. It's a condition where soft tissue or underlying tissue over a bony
prominence is injured by peripheral circulatory disturbance or unrelieved
pressure over a localized area, resulting in ischemic necrosis by hypoxia
and nutritional deficiency. A decubitus ulcer is typical skin damage of long-
term bed-rest patients and patients with vascular disease, sensory neuron
lesion, diabetes, dementia, and spinal cord injury, frequently occurring in
soft tissues. Physical therapists, by mastering the physical therapy
interventions according to the symptoms and diagnosis of the decubitus
ulcer, should prevent secondary infections or complications not to mention
curing decubitus ulcer.
People most at risk of bedsores have medical conditions that limit their
ability to change positions or cause them to spend most of their time in a
bed or chair. Bedsores can develop over hours or days. Most sores heal
with treatment, but some never heal completely. You can take steps to help
prevent bedsores and help them heal.
Decubitus ulcers often occur on the skin covering bony areas. The most
common places for a decubitus ulcer are your:
• Hips
• Back
• Ankles
• Buttocks
This condition is common among people who are older and people who
have decreased mobility. Left untreated, infections can spread to the blood,
heart, and bones and become life threatening.
But it’s important to know that bedsores can be treated. An individual’s
outlook depends on several factors, including underlying medical conditions
as well as the stage of the ulcer.
Stages
Decubitus ulcers occur in stages. There’s a staging process to help your
healthcare professional diagnose and treat you.
Stage 1 and 2 ulcers usually do not require surgery, but stage 3 and 4
ulcers may.
Stage 1
The skin isn’t broken, but it’s discolored. The area may appear red if you
have a light complexion. The discoloration may vary from blue to purple if
you have a darker complexion.
For example, if you have a lighter complexion, a sore can turn red instead
of turning lighter when you press on it. The sore will stay red for at least 30
minutes. It may also:
• feel warm to the touch
• look swollen
• be painful
• itch
• burn
Stage 2
A break in the skin reveals a shallow sore or cut that may leak pus. The
sore may also look like a blister filled with fluid. It affects the first
(epidermis) and possibly the second (dermis) layers of skin.
The ulcer hurts, and the surrounding skin may be discolored.
Stage 3
The ulcer is much deeper within the skin, affecting your fat layer. You
should not be able to see bones or tendons.
The sore looks like a crater and may be foul smelling.
Stage 4
This ulcer is very deep and affects many tissue layers, possibly including
the bone. There is a lot of dead tissue and pus. Infection is likely in this
stage. You may be able to see:
• Muscle
• Bones
• Tendons
• Joints

Unstageable
Sometimes, it’s not possible to measure the depth of a sore or the amount
of tissue damage that has occurred. This makes it difficult to fully evaluate
and stage an ulcer.
This may be due to the presence of a hard plaque called an eschar inside
the sore. The sore may look:
• Tan
• Brown
• Black

Ulcers can also contain discolored debris known as slough that may
appear:
• Yellow
• Tan
• Green
• Brown

Your doctor may need to remove the eschar or slough to determine the full
extent of the ulcer. Further imaging or surgical evaluation of the area may
be required.
2. CLASSIFICATION
• Pressure ulcers - (also known as pressure sores or bedsores) are
injuries to the skin and underlying tissue, primarily caused by
prolonged pressure on the skin. They can happen to anyone, but
usually affect people confined to bed or who sit in a chair or
wheelchair for long periods of time.

• Diabetic ulcer - is caused due to the peripheral circulatory

disturbance rather than pressure, and it leads to the formation of
gangrene on the feet or toes Most diabetic ulcers are black and
associated with localized edema. Gangrene located on the medial
malleolus indicates a decubitus ulcer from the peripheral venous
circulatory disturbance, and small gangrenes located sporadically on
the soft tissues mean a decubitus ulcer from the peripheral arterial
circulatory disturbance. Unlike pressure ulcers, diabetic ulcers require
hyperbaric chamber treatment in an early stage.
3. DEFINITION OF TERMS
Diabetes is a chronic (long-lasting) health condition that affects how your
body turns food into energy.
Pressure is the force applied on or against the skin.
Gangrene is the death of body tissues due to a blocked blood supply
and/or infection.
Necrosis is the death of cells.
Ulcer is an open sore on an external or internal surface of the body,
caused by a break in the skin or mucous membrane that fails to heal.
Itch is an uncomfortable sensation on the skin that causes a desire to
scratch.
Swollen is (especially of a part of the body) become larger or rounder in
size, typically as a result of an accumulation of fluid.

4. EPIDEMIOLOGY

Pressure between the bony prominence and external surface occludes the
capillaries. The normal capillary pressure ranges from 16 to 33 mm Hg in
different segments. External pressure of more than 33 mm Hg occludes the
blood vessel so that the underlying and surrounding tissues become anoxic
and if the pressure continues for a critical duration, cell death will occur,
resulting in soft tissue necrosis and eventual ulceration.

As the new definition suggests, prolonged pressure is the leading

contributing factor. It has been proven that there is an inverse relationship
between the degree of pressure and the duration of pressure.
Uninterrupted higher pressure requires shorter time while continuous lower
pressure will require longer time to cause tissue necrosis and pressure
ulceration.

Application of high pressure for shorter duration not only causes tissue
necrosis due to blockage of capillaries but also produces pressure effect on
the larger vessels causing thrombosis, more often venous thrombosis.
Hence, the deleterious effect of high pressure for short duration is much
more than that of low pressure for a longer duration. This has been proven
by the observation that when the high pressure is relieved, ischemia
persists because of effects on the adjacent larger vessels; while on relief
from low pressure, the normal hyperemic response compensates for the
temporary ischemia and the tissue does not undergo degeneration.

Due to the effect of pressure, the ischemic degenerative changes occur at

all the levels simultaneously affecting the skin, subcutaneous fat, muscle
and fascia if any between the bony prominence and the pressure causing
surface. If subcutaneous necrosis occurs, ulceration will be clinically seen
when the necrotic skin gives way. Hussain reported that for a specific
pressure the obliteration of skin and subcutaneous vessels is more as
compared to those of the underlying muscle. But the tissue damage is
more in the muscle after mechanical loading than in the skin. Because of
this the existing staging of pressure sores may not be justifiable. This
needs to be studied further before any change in the prevailing staging is
recommended.

One may question why different points in the body have different
prevalence of ulceration. The variation in the pressure at different points
during common postures is one explanation. The average pressure over
the ischial tuberosity and the surrounding area exceeds 100 mm Hg during
sitting, at the sacral region it is 40-60 mm Hg in the supine position, while it
is 70-80 mm Hg over the trochanteric region in the lateral lying down
position.

Another reason for the differential incidence is the difference in the amount
of soft tissue between the skin and the bony prominences. Sacrum and
trochanters are devoid of much soft tissue covering. Effectively the skin
directly covers these pressure points with very little interposition of soft
tissue cushion, thus increasing the risk of ulceration as compared to the
rest of the body.
The prevalence of Grade 3 – 4 Decubitus Ulcers is as high as 3% and it
goes up to 4% in the older population receiving nursing care in institutions.
2/3 of ulcers occur in patients over 70 years of age. 83% of inpatients with
ulcers develop them within 5 days of hospitalization. Incidence rates in
hospital range from 1% to 30% with higher rates in ICU.

5. PHYSIOLOGY
Pressure injuries are typically described in terms of location and depth of
involvement. The hip and buttock regions account for up to 70% of all
pressure injuries, with ischial tuberosity, trochanteric, and sacral locations
being most common. The lower extremities account for an additional 15-
25% of all pressure injuries, with malleolar, heel, patellar, and pretibial
locations being most common (see the images below).

The remaining small percentage of pressure injuries may occur in any

location that experiences long periods of uninterrupted pressure. The nose,
chin, forehead, occiput, chest, back, and elbow are among the more
common of the infrequent sites for pressure injuries. No surface of the body
can be considered immune to the effects of pressure.
Pressure injuriescan involve different levels of tissue. Muscle has been
proved to be most susceptible to pressure. However, Daniel and Faibisoff
found that muscle rarely was interposed between bone and skin in normal
weightbearing positions in cadaver and clinical dissections.

6. ETIOLOGY
Impaired mobility is probably the most common reason why patients are
exposed to the prolonged uninterrupted pressure that causes pressure
injuries. This situation may be present in patients who are neurologically
impaired, heavily sedated or anesthetized, restrained, demented, or
recovering from a traumatic injury. These patients cannot alter their position
far enough or often enough to relieve the pressure. Prolonged immobility
may lead to muscle and soft tissue atrophy, decreasing the bulk over which
bony prominences are supported.
Contractures and spasticity often contribute to ulcer formation by repeatedly
exposing tissues to trauma through flexion of a joint. Contractures rigidly hold
a joint in flexion, whereas spasticity subjects tissues to repeated friction and
shear forces. Skin breakdown and pressure injuries may frequently be found
under and between toes and on the palm of the hand.
Inability to perceive pain, whether from neurologic impairment or from
medication, contributes to pressure injuries by removing one of the most
important stimuli for repositioning and pressure relief. Conversely, pain from
surgical incisions, fracture sites, or other sources may make the patient
unwilling or unable to change position.
The quality of the skin also influences whether pressure leads to ulceration.
Paralysis, insensibility, and aging lead to atrophy of the skin with thinning of
this protective barrier. A decrease in epidermal turnover, a flattening of the
dermal-epidermal junction, and a loss of vascularity occur with advanced
age.
In addition, the skin becomes more susceptible to minor traumatic forces,
such as the friction and shear forces typically exerted during the moving of a
patient. Trauma that causes re epithelialization or skin tears removes the
barrier to bacterial contamination and leads to transdermal water loss,
creating maceration and causing the skin to adhere to clothing and bedding.
Incontinence or the presence of a fistula contributes to ulceration in several
ways. These conditions cause the skin to be continually moist, thus leading
to maceration. In addition, frequent soiling has the effect of regularly
introducing bacteria into an open wound.
Bacterial contamination, though not truly an etiologic factor, must be
considered in the treatment of pressure injuries, in that it can delay or prevent
wound healing. These lesions are warm, moist reservoirs for bacterial
overgrowth, where antibiotic resistance may develop. A pressure injury may
progress from simple contamination (as in any open wound) to gross
infection (indicating bacterial tissue invasion). This may lead to uncommon
but life-threatening complications (eg, bacteremia, sepsis, myonecrosis,
gangrene, or necrotizing fasciitis).
Malnutrition, hypoproteinemia, and anemia reflect the overall status of the
patient and can contribute to tissue vulnerability to trauma as well as cause
delayed wound healing. Poor nutritional status certainly contributes to the
chronicity often seen in these lesions and inhibits the ability of the immune
system to prevent infections. Anemia indicates poor oxygen-carrying
capacity of the blood. Vascular disease and hypovolemia also may impair
blood flow to the region of ulceration.
In patients with normal sensitivity, mobility, and mental faculty, pressure
injuries are unlikely. Conscious or unconscious feedback from the areas of
compression leads them to change position, thereby shifting the pressure
from one area to another long before any irreversible ischemic damage
occurs. In individuals who cannot avoid long periods of uninterrupted
pressure, the risk of necrosis and ulceration is increased. These individuals
cannot protect themselves from the pressure unless they consciously
change position or are helped to do so.
7. PATHOPHYSIOLOGY
In 1873, Sir James Paget described the production of pressure ulcers
remarkably well, and his description is still quite accurate today. Many
factors contribute to the development of pressure injuries, but pressure
leading to ischemia and necrosis is the final common pathway.
In this view, pressure injuries result from constant pressure sufficient to
impair local blood flow to soft tissue for an extended period. This external
pressure must be greater than the arterial capillary pressure (32 mm Hg) to
impair inflow and greater than the venous capillary closing pressure (8-12
mm Hg) to impede the return of flow for an extended time.
Tissues are capable withstanding enormous pressures for brief periods, but
prolonged exposure to pressures just slightly above capillary filling
pressure initiates a downward spiral toward tissue necrosis and ulceration.
The inciting event is compression of the tissues against an external object
such as a mattress, wheelchair pad, bed rail, or other surface.
Lindan et al documented ranges of pressure applied to various anatomic
points in certain positions. The points of highest pressure with the patient
supine included the sacrum, heel, and occiput (40-60 mm Hg). With the
patient prone, the chest and knees absorbed the highest pressure (50 mm
Hg). When the patient is sitting, the ischial tuberosities were under the most
pressure (100 mm Hg). Obviously, these pressures are greater than the
end capillary pressure, which is why these are the areas where pressure
injuries are most common.
Shear forces and friction aggravate the effects of pressure and are
important components of the mechanism of injury (see the image below).
Maceration may occur in a patient who has incontinence, predisposing the
skin to injury. Pressure, shear forces, and friction cause microcirculatory
occlusion and consequent ischemia, which leads to inflammation and
tissue anoxia. Tissue anoxia leads to cell death, necrosis, and ulceration.

Decubitus ulcer formation is multifactorial (external and internal factors),

but all these results in a common pathway leading to ischemia and
necrosis. Tissues can sustain an abnormal amount of external pressure,
but constant pressure exerted over a prolonged period is the main culprit.
External pressure must exceed the arterial capillary pressure (32 mmHg) to
impede blood flow and must be greater than the venous capillary closing
pressure (8 to 12 mmHg) to impair the return of venous blood. If the
pressure above these values is maintained, it causes tissue ischemia and
further resulting in tissue necrosis. This enormous pressure can be exerted
due to compression by a hard mattress, railings of hospital beds, or any
hard surface with which the patient is in contact.
Friction caused by skin rubbing against surfaces like clothing or bedding
can also lead to the development of ulcers by contributing to breaks in the
superficial layers of the skin. Moisture can cause ulcers and worsens
existing ulcers via tissue breakdown and
maceration.

8. SIGNS AND SYMPTOMS

The following important information should be obtained from the history:
• Overall physical and mental health, including life expectancy
• Previous hospitalizations, operations, or ulcerations
• Diet and recent weight changes
 • Bowel habits and continence status
• Presence of spasticity or flexion contractures
• Medications and allergies to medications
• Tobacco, alcohol, and recreational drug use
• Place of residence and the support surface used in bed or while sitting
• level of independence, mobility, and ability to comprehend and
cooperate with care
• Underlying social and financial support structure
• Presence of specific cultural, religious, or ethnic issues
• Presence of advanced directives, power of attorney, or specific
preferences regarding care
• Information related to the current ulceration - Pain, foul odor or
discharge, natural history of the present ulcer, and associated medical
cause of the ulcer

A thorough physical examination is necessary to evaluate the patient’s

overall state of health, comorbidities, nutritional status, and mental status.
After the general physical examination, attention should be turned to the
wound.
For the purposes of workup and treatment, it is helpful to stage the
pressure injury according to the system promulgated by the NPUAP, as
follows:
• Stage 1 pressure injury - Nonblanchable erythema of intact skin
• Stage 2 pressure injury - Partial-thickness skin loss with exposed
dermis
• Stage 3 pressure injury - Full-thickness skin loss
• Stage 4 pressure injury - Full-thickness skin and tissue loss
 • Unstageable pressure injury - Obscured full-thickness skin and tissue
loss
• Deep pressure injury - Persistent nonblanchable deep red, maroon or
purple discoloration.

9. COMPLICATIONS
Complications of pressure ulcers, some may be life-threatening, include:
• Cellulitis - Cellulitis is an infection of the skin and connected soft
tissues. It can cause warmth, redness and swelling of the affected
area. People with nerve damage often do not feel pain in the area
affected by cellulitis.
• Bone and Joint Infections - An infection from a pressure sore can
burrow into joints and bones. Joint infections (septic arthritis) can
damage cartilage and tissue. Bone infections (osteomyelitis) can
reduce the function of joints and limbs.
• Cancer - Long-term, non-healing wounds (Marjolin's ulcers) can
develop into a type of squamous cell carcinoma.
• Sepsis - Rarely will a skin ulcer lead to sepsis.

10. DIFFERENTIAL DIAGNOSIS

The differential diagnosis of sacral decubitus ulcers include:

• Diabetic ulcers
• Venous ulcers
• Pyoderma gangrenosum
• Osteomyelitis

11. TESTS AND MEASURES

Assessment of Decubitus Ulcer
 • When physical therapists assess decubitus ulcer, they should check
the following ten evaluation factors:
• After ocular inspection and palpation, record the result.
• Observe the shape and the color of the tis- sues adjacent to the
decubitus ulcer and record the result.
• Record the kinds and the amount of the exudate.
• If it smells, figure out the kinds and the degree of the smell.
• Check if there are symptoms of inflammation or infection.
• Examine if there is a trace of being pressured or stimulated.
• If there is an edema, figure out the location and the degree of it.
• After recording the location of the decubitus ulcer, measure the size
and the depth of it.
• Take a photograph of the site of the decubitus ulcer.
• If the decubitus ulcer is caused by a wound (abrasion, penetrating
injury, laceration), figure out the kind of it.
The Guidelines for Recording
• After the assessment of decubitus ulcer is finished, record the result
on a PT progress note according to the following ten guidelines:
• Record the site of the decubitus ulcer. Record the stage of the
decubitus ulcer
• according to NPUAP categories.
• Measure the size and the depth of the decubitus ulcer and record the
result.Assess the depth of the decubitus ulcer tunnel that is under the
skin and invisible to the naked eye.
• Examine the color of the decubitus ulcer (red, yellow, black) and
assess the percent- age of the decubitus ulcer that is covered on the
skin.
• Record the shape (concentration, viscosity, color) and the amount of
the exudate.
• After cleansing the decubitus ulcer with saline solution, record the
smell associated with necrosis.
• Observe the edema, inflammation, or sclerosis of the tissues adjacent
to the decubitus ulcer and record it.
 • Observe the condition (dry, wet, loose, tense, warm) of the skin
adjacent to the decubitus ulcer.
• If there is a pain, record its relevance to the decubitus ulcer and the
pain intensity in VAS (visual analog scale).

The Assessment Tools for Decubitus Ulcer

Peripheral Vascular Examination
Decubitus ulcer is associated with gangrene formation by peripheral
circulatory disturbance, so physical therapists, before stepping into physical
therapy intervention, should examine the peripheral vascular
(arterial/venous) circulation of the patients with diabetes.
Peripheral Arterial Examination
The rubor of dependency test evaluates the condition of peripheral arterial
circulation. The test is performed by observing the color change of the
patient’s lower extremity after that is passively elevated and returned
• Note the color of the foot while the patient is in the supine position
(normal, pink).
• Elevate the patient’s leg to an angle of 60°, hold it for 1 min, and
observe the color of the lower extremity (abnormal, pink color
disappeared).
• Return the leg to the original position and observe the color (normal,
foot color returns to pink in seconds; abnormal, it takes more than 30
s for the color to return).
Peripheral Venous Examination
• The venous filling time test is used to examine the condition of
peripheral venous circulation. It is proceeded by measuring the time
taken to fill the emptied veins after the patient’s extremity is elevated
and returned.
 • While the patient is in the supine position, elevate the patient’s lower
extremity and hold it for a minute.
• Return the extremity and let it hang off the bed. 3 Note the time taken
to fill the emptied veins (normal, filled within 15 s; venous
insufficiency, filled within 5 s; arterial insufficiency,
• takes more than 20 s).
Peripheral Vascular CT Angiography
• After injecting the contrast media into the blood vessels, make a visual
measurement of the time taken for the intravascular concentration of
contrast media to reach the maximum peak. This enables the
diagnosis of aneurysm or varix caused by decubitus ulcer and the
three- dimensional assessment of patency and stenosis.

12. DIAGNOSTIC TOOL

Braden scale
• Braden scale is a risk assessment tool made up of six indicators:
sensory perception, moisture, activity, mobility, nutrition, and friction.
Each indicator is scored 1–4 (1–3 for friction) with total score ranging
6–23. The lower the total score, the higher the risk for decubitus
ulcer. As for inpatients, a score of 15–18, a score of 13–14, and a
score of 13 or lower indicate low risk, middle risk, and high risk,
respectively. In the case of non-patient elderly, a score of 17 or lower
indicates high risk of pressure ulcer.
PUSH scale
• PUSH scale (Pressure Ulcer Scale for Healing scale), developed by
the NPUAP, sorts out the pressure ulcer with respect to surface area,
exudate, and type of wound tissue, and each category is scored
accordingly. The progression of pressure ulcer can be assessed by
comparing the total scores.
Pressure ulcer healing chart
 • Pressure ulcer healing chart, also developed by the NPUAP, allows
to monitor and record trends in PUSH scores over time .

13. MEDICAL MANAGEMENT

Medical Treatment
• The Goal of Decubitus Ulcer Management
• Doctor’s and physical therapists’ goals of decubitus ulcer
management are the following.
• Protect the decubitus ulcer and tissue surrounding it to prevent an
additional injury.
• Relieve tissue tension surrounding the decubitus ulcer.
• Protect the area around the decubitus ulcer
• from epidemiology stress from the patient’s
• activities.
• Decrease the virus microbes around the decubitus ulcer.
• Improve the process of decubitus ulcer
• management.
• Prevent new decubitus ulcer formation.
Other Medicine Treatment
• Injecting antibiotics (bacitracin, polysporin, neomycin, etc.) is effective
to prevent of the decubitus ulcer. Antiseptic drugs are not
recommended for a decubitus ulcer patient because the drugs remain
in the body. To use neomycin, it has to be checked if the decubitus
ulcer patient has an allergic reaction to it.
Surgical Treatment
• If the decubitus ulcer’s necrotic tissue is big or treatment is impossible
through dressing, then surgery is needed (skin graft, flap). Surgery for
 decubitus ulcer involves in removing ulcers and infected bone,
trimming the protrusion bone, and suturing the skin with healthy
tissues. Transplantable tissue should be able to provide an enough
bearing capacity and durability. The surgery method is decided by the
decubitus ulcer’s location, size, and depth. Some choices of surgical
methods are a simple repair, a local skin flap, and a free skin flap.
• Simple repair is conducted by pulling both sides of normal tissue and
stitching them up when ulcers are small. Skin graft is a surgical
procedure transplanting another part of the skin to the lesion if the
ulcer is filled with granulation tissues). A local skin flap is used to
restore the ulcer area through a surgical procedure that takes a
healthy flap of the skin tissue from around the decubitus ulcer. A free
skin flap is a surgical procedure that takes a healthy flap of the skin
from another area of the body and uses it to restore the ulcer area.
Treatment of Decubitus Ulcer According to Each Stage
• Stage 1 decubitus ulcer (erythema exists
• which does not become pale by pressure) Remove the factors
causing pressure and keep the skin clean. Take action to prevent
• friction and shear forces.
• Stages 2 and 3 decubitus ulcer (granulation
• tissue has been formed without discharge secretion)
• Keep moisture around the decubitus ulcer and protect the tissue from
the infection.
• Stages 2 and 3 decubitus ulcer (granulation tissue has been formed
with discharge secretion)
• Keep moisture around the decubitus ulcer, protect the tissue from the
infection, and absorb the exudates.
• Stage 4 decubitus ulcer (necrotic tissue has been formed without
discharge secretion)
 • Keep moisture around the decubitus ulcer and protect the tissue from
the infection. Soften the tissue through debridement.
• Stage 4 decubitus ulcer (necrotic tissue has been formed with
discharge secretion)
• Keep moisture around the decubitus ulcer and protect the tissue from
the infection after conducting debridement, and absorb the exudates.
Dressing
• Dressing is a basic method treating decubitus ulcer. There are two
types of decubitus ulcer dressing: gauze dressing and wet dressing.
Gauze dressing
• By placing dry gauze after sterilizing the ulcer area, the gauze
dressing absorbs the exudates and protects the decubitus ulcer by
keeping the ulcer area sterilized. However, the gauze dressing does
not keep moisture for a long time and does not protect against the
infection.
Wet dressing
• Keeping moisture of the decubitus ulcer
• Area shortens the ulcer’s and soft tissue’s treatment times and it also
helps to prevent scars. Choose a hydrocolloid, hydrogel, or
polyurethane dressing depending on the decubitus ulcer’s condition.
14. PT GOALS AND OUTCOMES
Management of Decubitus Ulcer aims to:
• Protect the decubitus ulcer and tissue surrounding it to prevent an
additional injury.
• Relieve tissue tension surrounding the decubitus ulcer.
• Protect the area around the decubitus ulcer from epidemiology stress
from the patient’s activities.
• Decrease the virus microbes around the decubitus ulcer.
• Improve the process of decubitus ulcer management.
• Prevent new decubitus ulcer formation.

15. EXERCISE THERAPY

Exercise therapy for decubitus ulcer focuses on aerobic exercise and
enhancing peripheral circulation. When a compression decubitus ulcer has
occurred, promote the circulation of ulcer through increasing a patient’s
deep breathing and enhancing the pump functions of the calf muscle.
Patients who have a compression decubitus ulcer on their legs should do
aerobic exercise, for example, increasing the amount of time they spend
exercising by walking on the treadmill or the ground or riding a stationary
bicycle for 15 to 40 min. They should do these exercises three or fi ve times
a week with the intensity at 60–80 % of their HRmax. When trying to
enhance the peripheral circulation, conduct ankle-pumping exercises 20
times a set, and do two or three sets per day. After that, do heel raise
exercises ten times a set, three sets a day. With these exercises, the
dietary treatment will be more effective.

16. MANUAL THERAPY

A decubitus ulcer surgery such as a skin graft or flap leaves a scar. A scar
will limit the epidermis and subcutaneous tissue’s mobility through its
adherence to the surrounding tissues. It can cause pain inside the scar.
Some patients can have more pain than others especially on rainy days or
in humid environments because their sensitivity to pain has increased. Skin
rolling and scar tissue release are effective ways to relieve pain and
increase skin mobility.
Skin Rolling
Physical therapists hold the wounded skin softly with their thumb and index
finger and roll it up, down, and diagonally When a sutured wound is too
thick for rolling, hold the skin farthest away from the wound and roll the skin
by moving toward the center. Conduct skin rolling in a variety of ways.
However, before conducting the skin rolling, remove the skin’s oil from the
skin of therapist and patient, and keep the area clean.

Scar Tissue Release

Ask the patient which sutured wound is the most sensitive, and press it with
the tip of an index finger. The therapists’ fingers should turn clockwise and
the therapists should continue to ask a patient which sutured wound is the
most sensitive. At this point, repeat the scar tissue release to induce a
loosening of the tissue through light compression and retrogression of the
tissue Pain and bleeding may occur during this process. When relaxation
doesn’t occur near the tip of therapists’ fingers, slowly remove the
compression. After the treatment, patients may feel loose and may want to
sleep. Let them rest comfortably and keep them warm with sheets.

Physical Agent Modalities:

Whirlpool Bath Treatment
Remove the dressing of decubitus ulcer and use a whirlpool bath for 10 min
with 92 ~ 98 °F water (Fig. 3.19). If contracture is bad due to the decubitus
ulcer, do light extensional movements and joint motion exercises while in
the whirlpool. After the whirlpool bath, clean the ulcer with a physiologic salt
solution. The whirlpool bath removes dirty ulcer fragments, bacteria,
exudates, and blood residue, reduces pain, and stimulates the decubitus
ulcer healing through hydrating the ulcer areas with water. The therapists
should wear gloves, a mask, a head cover, and a clean robe to prevent the
secondary infection when conducting a whirlpool bath treatment.

Ultraviolet Therapy
Ultraviolet radiation is effective to improve immunity by creating vitamin D
while sterilizing the area around the decubitus ulcer Ultraviolet therapy
destroys decrepit cells, improve regrowth of cells, and boost treatment for
the decubitus ulcer by causing a crust to form on the necrotic tissues.
Ultraviolet radiation has three different forms, which are UVA, UVB, and
UVC The shortest wavelength UVC is used in the therapy because UVC
stimulates the fibroblast which creates collagen, kills bacteria and viruses,
and boosts the transfer of oxygen to the ulcer tissues through expanding
the veins. Use an ultraviolet lamp 2 ~ 4 in. away from the area of the
decubitus ulcer and start with a 1° erythemal dose for a level 1 ~ 2 ulcer
and 2° erythemal for a level 3 ~ 4 ulcer, and gradually increase the dose.
The treatment time is determined by the intensity with the distance of the
ultraviolet lamp.

17. Electrotherapy
Iontophoresis is a drug electrotherapy that passes local activating ions to
scar tissues of the decubitus ulcer by using continuous anode and cathode
penetrating into the skin Iontophoresis has an anesthetic effect that can
reduce pain and inflammation on the area of the decubitus ulcer. This effect
depends on the type of drugs used for the electrode. Using copper for the
positive and negative poles has a sterilizing effect, and using
dexamethasone and Xylocaine for both poles reduces inflammation.
Magnesium boosts the relaxation of the muscles and salicylate reduces the
edema. Using an acetate acid cathode degrades calcium deposits and
using a chloride cathode increases skin adhesion. Arrange the drug
electrode and the reduction electrode 4–6 in. apart from each other and
determine the treatment time depending on the amount of the drugs and
the intensity of the therapy. Usually, it is conducted every other day for 3
weeks. Do not use iontophoresis on insensitive part of the skin or on
granulation tissue. Stop immediately if signs of an allergic reaction.

18. PREVENTION
Your doctor or a physical therapist can make recommendations to reduce
the likelihood of experiencing bedsores. They may recommend:
• changing positions in bed at least every 2 hours
• if you use a wheelchair, aiming to: sit upright, shift your sitting position
every 15 minutes, and use a cushion that redistributes your weight
• regularly checking your skin for signs of pressure sores, if you’re
hospitalized or otherwise immobilized
• using pillows or a pressure-reducing mattress to prevent new sores
from forming in vulnerable areas
• wearing clothing that isn’t too tight or loose or that bunches up under
you
• wearing special padding on pressure points including elbows and
heels
• quitting smoking, if you currently smoke
 • dietary modifications for adequate nutrition and possibly working with
a registered dietitian
• staying hydrated
• exercising as much as possible, such as taking short walks a couple
of times per day or sitting up and stretching.

19. POSITION
The posturing of decubitus ulcer patients can prevent deformities and
complications of decubitus ulcer. when a patient is standing in one position
for a long time, a pillow or a cushion is used to prevent aggravating the
decubitus ulcer by dispersing pressure on the protrusion bones:
Supine position
Supine position is lying down with shoulders parallel to the hips and straight
back- bones. Placing a small pillow or a cervical roll under the patient’s
head is necessary. The height of the pillow should not make the neck and
body bend too much or round shoulders.
Placing a small cushion under the knees helps to make the patient
comfortable and prevent lumbar lordosis. If a cushion is too big, it may
cause contracture on the iliopsoas and hamstring so the long time used
should be avoided. To disperse the pressure on the heel, a small towel can
be used, but it should be used carefully to avoid hyperextension. Don’t let
the patient’s arms fall outside of the bed; put them next to the body or on
the chest.

Prone position
The prone position makes a patient’s shoulder and backbone parallel to
each other. Patients, who have feelings in their arms or don’t have any
problem communicating, put their arms next to the body or head. But
physical therapists should ask the patents if their arms feel numbness or
become insensitive when they are in the prone position for a long period of
time. Decubitus ulcer can occur or become worse because of the nerve
compression and poor circulation.
When a patient is in prone position, put a small pillow under their head and
turn the patient’s head to one side or put on table with a Armrests and face
control tables help patients to have a comfortable position because patients
can have enough spaces and supports for their heads. This table is used to
keep a patient’s neck balanced . Putting a pillow under a patient’s stomach
can reduce lumbar lordosis. Putting towels under the shoulder increases
scapular adduction. and protect the humerus head by reducing ten- sion on
the adductor canal between the scapulas. Relax the pelvis and lumbar and
reduce the hamstring muscle tension by putting a small pillow or a roll
under the patient’s ankle. But a big pillow may cause the hamstring
muscles to contract by bending the knees.

Side-lying position
The side-lying position is a position when the patient is located at the
middle of the bed and arranges the head, body, and pelvis. Make the
patient’s hip and knee joints semi flexed Support the upper legs with a
couple of pillows and locate lower legs a little bit to the back. Let the lower
part of the legs support the patient’s pelvis and lower half of the body.
Prevent a patient’s upper body from inclining through supporting the
brachial with a pillow in front of patient’s chest.
Increase the body’s comfort and safety with the patients arm. If protection
is needed under the bony spur concerned with the decubitus ulcer
development due to the compression, put a pillow at the distal end of the
limb and put a second pillow under the bony spur. Avoiding the direct
compression to the bony spur is the most important in a long- term side-
lying position. Therefore, side- lying position against something should be
considered.

Sitting position
• A stable chair needs to be used for patients
• in the sitting position. A patient’s foot should rest on the floor or a prop
of a wheelchair. The femoral buttocks tissue and deep tissue shouldn’t
be compressed from the edge of chairs or the wheelchairs. Use more
than one pillow when a patient sits against the treatment table and let
the patient support the upper part of the body When the patient has
been leaned against the back of the chair for a long time, put a
cushion on the patient’s back. Move the patient’s arms to their knees
or onto the armrests. When patients are sitting for a long period of
time, make them do push-ups holding the armrests and lifting their
hips, move their upper body to the left and right, or bend their upper
body every 15 min to relieve hip compression. Using a special
 wheelchair with a tilt-in-space or a reclining back will be more
comfortable.

Changing Position
• Because the continuous compression is the reason of decubitus
ulcers, change position at least every 2 h when a patient is lying down
and every 15 min when a patient is sitting. When a patient is lying
down on their side (watching TV), lay down making the body 30° to
the floor in any direction following the 30° angle law Keep a 30° angle
of the patient’s arms, legs, and even head by using pillows.

20. EDUCATION
Patient Education must include the following information:
1. Patient’s diagnosis
2. Symptoms management
3. Postural and positioning re-education
4. Proper transfers and early mobilization
5. Prevention of secondary decubitus ulcer formation
6. Proper dressing and removal procedure
7. Risk factors re-education
8. Proper skin care approach
9. Home program of safe exercises
10. Activity modification
11. Promotion of active, healthy lifestyle

REFERENCE:
Integumentary Physical Therapy, Ji-Whan Park & Dae-In Jung, 1st edition.
https://www.healthline.com/health/pressure-ulcer
https://www.mayoclinic.org/diseases-conditions/bed-sores/symptoms-
causes/syc-
20355893#:~:text=Bedsores%20%E2%80%94%20also%20called%20pres
sure%20ulcers,%2C%20ankles%2C%20hips%20and%20tailbone.
https://www.ncbi.nlm.nih.gov/books/NBK553107/#:~:text=Stage%20I%3A%
20The%20skin%20is,cross%20the%20fascia%20beneath%20it.
https://www.woundsource.com/blog/what-decubitus-ulcer
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3495374/#:~:text=Pressure
%20ulcers%20have%20been%20recognized,of%20such%20ulcers%20an
d%20wounds.
https://www.physio-
pedia.com/Pressure_Ulcers#:~:text=Decubitus%20ulcers%2C%20also%20
termed%20bedsores,pressure%20exerted%20on%20the%20skin.&text=O
ccur%20at%20bony%20areas%20of,than%20medial)%2C%20and%20occi
put.
https://emedicine.medscape.com/article/190115-overview#showall