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Oecubitus Ulcers
Pathophysiology and the Role of Massage Therapists

By Kalyani Premkumar

Originally published in Massage Bodywork magazine, October/November 2005. Copyright 2005. Associated Bodywork and Massage Professionals. All rights reserved.

Reddening of skin can have different implications for different people. For some, a blush is a show of emotion; a bruise, a sign of injury; spider nevi, a localized change in the development of blood vessels. But to a person at risk, redness of skin that refuses to blanch is ominous -- the genesis of decubitus ulcer.

Decubitus ulcers, pressure ulcers, pressure sores, or bed sores have plagued humans since antiquity, as evidenced by large buttock and shoulder ulcers noted in an ancient Egyptian mummy.1 Approximately 1.5 to 3 million Americans are affected by pressure ulcers, with a higher incidence for those in nursing homes (33 percent), orthopedic wards (31 percent), and general hospitals (17 percent).2 The U.S. economic impact is estimated to be more than $3 billion per year.3


What are Pressure Ulcers?
As the name suggests, these are ulcers (lesions due to loss of tissue) in skin and underlying tissue caused by long, intense pressure that cuts off blood supply to the local tissue, resulting in cell injury and cell death.4,5

All cells require an adequate, continuous oxygen supply to function. When this decreases, cell response depends on the host organ. For example, brain cells and myocardial cells die from lack of oxygen within a few minutes. Skin cells can survive without oxygen for up to two hours. Studies measuring oxygen tension in skin of healthy subjects show that the pressure required to cut off oxygen supply varies with the location of skin on the surface of the body. A pressure of 150 gm/cm2 can bring the skin oxygen tension to zero if applied over a bony prominence. On the other hand, a pressure of over 175 gm/cm2 applied over a muscle group does not produce any changes in skin oxygen tension. Therefore, loading a skin area over a bony prominence with pressure high enough to cut off blood capillary flow can cause cell death if applied for more than two hours. At this pressure, underlying capillaries collapse with thrombus formation and are changed irreversibly.

The intensity of pressure needed to cut off blood flow varies from individual to individual and even within the same individual in different states of health. For example, if a person is dehydrated, or is elderly with frail skin, even the slightest pressure may cut off blood flow. In addition, the hardness of the support surface, presence or absence of subcutaneous tissue, site of the pressure, weight of the individual, nutritional status, and condition of skin (e.g., dermatitis, atrophy) all have an impact. Unfortunately, only the hardness of the support surface and the site of pressure can be easily altered.

Normally, pain invoked by ischemia causes a person to move voluntarily or involuntarily shift position to relieve pressure over skin. A healthy person moves at least four times per hour during the night. This works out to pressure over a bony prominence, such as the sacrum, for 15 minutes -- a duration insufficient to cause pressure ulcers.


Who is at Risk for Pressure Ulcers?
Any condition that reduces the frequency of voluntary or involuntary movements; decreases the closing pressure of capillaries; decreases oxygen carrying capacity; increases tissue demand for oxygen; reduces availability of albumin, vitamins, and trace elements needed for viability of cells; or reduces the resistance of skin to infection can put a person at risk for bed sores. A list of some conditions is given below.


Figure 1: Classical sites for pressure ulcers. Used with permission from Neil O. Hardy, Westpoint, Conn.

Classical Sites for Pressure Ulcers
Depending on body position, five sites over bony prominences have been identified as regions most prone to pressure ulcer formation. These are: sacrum (supine position), lateral malleolus (lateral), greater trochanter (lateral), ischium (sitting), and the calcaneus (supine). The occiput and elbow, among others, are also prone (see Figure 1).


Figure 2A

Classification of Ulcers
Pressure ulcers are classified into four stages (see Figures 2A-D) and the prognosis and treatment options vary with each. Stage I is a non-blanchable redness of intact skin. In Stage II, there is further damage ranging from swelling and heat, to superficial ulcers. Stage III involves full-thickness skin loss with or without damage to muscle or supporting structures such as tendons or joint capsules. In Stage IV, the bone is affected.


Figure 2B
Once developed, pressure ulcers can take a long time to heal (weeks to months) and may cause the patient considerable pain and discomfort, particularly if the ulcers become infected or if the patient has to undergo surgery for wound debridement. Infection from the ulcer can spread to other parts of the body, complicating matters. Discharge from the wound comprising of dead tissue and pus (if infected) can emit a foul odor, adding to the discomfort of the patient and those around. Being difficult to treat once developed, decubitus ulcers are best prevented.


Figure 2C

How Can Pressure Ulcers be Prevented?
Prevention depends on identifying those at risk and eliminating prolonged pressure over bony prominences. Positioning the person at 30 degrees oblique reduces pressure on all five classical sites. A variety of special beds, such as air-fluidized beds, foam mattresses, and cushions, are available to reduce pressure over susceptible areas. In immobilized individuals, frequent turning can reduce the duration of exposure to pressure. Individuals need to be turned at least once every two hours to prevent ulcer formation. Care should be taken to reduce the shearing force and friction while turning. Unfortunately, the need for frequent turning increases the risk of back strain among caregivers.


Figure 2D
Further management of additional risk factors, such as infection, fever, anemia, etc., can reduce the incidence of pressure ulcers.


How is the Condition Treated?
Bed sores can be treated by facilitating wound healing. Healing is speeded by restoring blood supply through relieving pressure, wet wound dressing (hydrocolloid occlusive dressing, polyurethane film dressing), removing dead tissue, and preventing infection. For those in Stages III and IV, plastic surgery using skin grafts or myocutaneous flaps may be considered. Newer treatment includes application of growth factors, among others.

It has been shown that wounds heal better if kept moist. The tissue takes up oxygen and expels carbon dioxide more easily in a wet environment. Also, epithelial cells migrate only in a moist environment and achieve optimal mitotic activity under dressing material that maintains a temperature about equal to that of body temperature.

Removal of dead tissue (debridement) is an important step that needs to be taken for healing to occur. One form of treatment that was used in ancient days is maggot therapy. The larvae of certain flies have been purposely used to remove dead tissue.6 Maggots of flies, such as the blowfly, live on dead tissue. By placing the maggots in pressure ulcers, dead tissue is removed. In addition, maggots secrete ammonia that makes the environment alkaline -- preventing growth of many types of microorganisms. They also produce proteolytic enzymes (that help break down dead tissue) and many antimicrobial and growth promoting agents. Today, with the increasing incidence of resistance to antibiotics, failing immune system, and chronic infections, interest in maggot therapy has resurfaced, and as of 2000, more than 50 centers in the United States use this technique. Apparently, maggots are better at this than surgeons. Though a cheap and effective form of treatment, using live maggots is abhorrent to many patients and caregivers.

Hyperbaric oxygen (oxygen at high pressure) is also being used as a form of treatment.7 At this pressure, more oxygen dissolves in the plasma, thereby increasing the availability of oxygen to tissues. It also prevents growth of anaerobic microorganisms.

Electrical stimulation is another form of treatment that has the potential to speed up wound healing.8 When injury occurs, there is a small current noted between the skin and the injured tissue. Electrical stimulation mimics this current and initiates cellular processes such as cell proliferation, stimulation of growth factors, and collagen formation, speeding up wound healing. Electrical current improves arterial blood flow and reduces tissue edema and capillary permeability, thus increasing tissue oxygenation. Electrical current is thought to have antibacterial effects.

While the key is prevention, the search still continues for better forms of therapy for decubitus ulcers.


Implications for Massage Therapists
Given that pressure ulcers are more common in the elderly and those with diminished mobility, massage therapists and other bodyworkers can play an important role in the well-being of those at risk.

Massage improves circulation locally by helping to move venous blood and lymph toward the heart, thereby facilitating the supply of oxygenated blood to the tissue. The heat/cold packs used also play a part in increasing/reducing blood flow to the tissue. Passive movements used by the therapist help reduce adhesion formation in immobile tissues and joints. Most of all, massage improves the overall sense of well-being in these touch-deprived individuals.

The role of massage therapists in relation to pressure ulcers is only at the prevention level, though. Since massage involves touching (examining) the body of clients, massage therapists can play an important role in identifying the onset of pressure ulcers. They could very well be the first to spot the telltale sign of erythema that does not blanch (Stage I of pressure ulcers). Pressure ulcers, if caught at this stage, are easier to treat.

If ulcers are already developed, no matter what stage, therapists should not massage over or around the area.9 Bed sores often appear deceptively small, despite extensive damage to the underlying tissue over a wide region in and around the ulcer. Since blood flow is already diminished, pressure from massage may further decrease skin blood flow and increase the risk of deep-tissue injury. Also, the movement of tissue may slow down healing.

Massage over other parts of the body may be indicated. Position clients so that undue pressure is not placed over bony prominences -- especially over the five classical sites. A 30 degree oblique position may be appropriate. Avoid raising the head of the bed as greater shearing forces are exerted on the skin. Active and passive range-of-motion exercises may be performed in bedridden individuals. Excessive pressure and force should not be used. If erythema, blisters, or ulcers are noticed while massaging susceptible individuals, bring it to the notice of nurses or other caregivers at once. Since massage tends to lower blood pressure, clients with severe orthostatic hypotension, or who have been on prolonged bed rest, have to be warned against changing positions abruptly.

Since pressure ulcers take a long time to heal -- sometimes many months -- it places a great burden not only on the client but also on caregivers. Adding to the burden, those at risk for decubitus ulcers often have a plethora of other associated clinical problems. Keeping the local environment clean to prevent infection and speed up healing, and regular turning of the patient to avoid prolonged pressure in any one region, can be a demanding task. Massage can be of great benefit to the caregiver as well.

Decubitus is derived from the Latin word decumbo -- meaning "lying down." In contrast to its name, this is one condition that can be prevented and treated by mobility rather than bed rest.


Kalyani Premkumar, MBBS, M.D., MSc., Ph.D., a physician and certified massage therapist, is an assistant professor at the College of Medicine, University of Saskatchewan, and an instructor at the Center for Complementary Health Education, Mount Royal College, Calgary, Canada. She is the author of The Massage Connection -- Anatomy and Physiology; Pathology A to Z -- A Handbook for Massage Therapists; and Medical Terminology -- A Beginner's Guide.


References
1 Rowling JT: Pathological changes in mummies. Proc R Soc Med 54:409; 1961.
2 Pressure Ulcers. In: Grimley EJ, Franklin WT, Lynn BB, Michel JP, Wilcock GK ed. Oxford Textbook of Geriatric Medicine. Oxford: Oxford University Press; 2000.
3 Braddock M, Campbell CJ, Zuder D. Current therapies for wound healing: electrical stimulation, biological therapeutics, and the potential for gene therapy. International Journal of Dermatology 1999;38:808-817.
4 Resnick NM, Dosa D.Geriatric Medicine.Kasper DL, Fauci AS, Longo DL et al. editors. Harrison's Principles of Internal Medicine. 16th Ed. New York: McGraw Hill; 2005.
5 European Pressure Ulcer Advisory Panel. Pressure Ulcer Treatment Guidelines. Available at www.epuap.org/gltreat ment.html. Accessed 2003.
6 Dossey L. Maggots and Leeches. When Science and aesthetics collide. Alternative Therapies. 2002 July/August 12-16.
7 Hyperbaric oxygen (HBO) coming into own as safe, effective treatment for vast array of ills. International Council for Health Freedom Newsletter. June 99, 3 (2) 40.
8 EBM Reviews -- Cochrane Database of Systematic Reviews Flemming, K. Cullum, N. Electromagnetic therapy for treating pressure sores. [Systematic Review] Cochrane Wounds Group Cochrane Database of Systematic Reviews. 3, 2005
9 Premkumar K. Pathology A to Z -- A Handbook for Massage Therapists. Calgary: VanPub Books; 2000.






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