The physiotherapist is a highly respected member of the wound-care team in the

USA. While assisting in all aspects of wound care, including debridement and
dressing selection and application, the physiotherapist also provides a unique
function. The numerous physical agents, such as electrical stimulation, ultrasound,
hydrotherapy and heat all have benefits to offer the patient in contributing to
healing. The background knowledge of biomechanics possessed by members of
this discipline likewise enhances the services of the wound-care team.
Physiotherapists recommend strategies to relieve or redistribute pressure for those
confined to bed or wheelchair or for the ambulatory individual with an insensate
foot. It is perceived that physiotherapists who remain uninvolved in wound care are
a major untapped resource with great potential for promoting wound healing.
There are many things we as physiotherapists can assess and provide treatment
for to support our senior clients with chronic lower ulcers. Gait training with or
without aids, transfer techniques, mobility, pressure redistribution, electrophysical
agents, and muscle strength and balance to name a few.

A pressure ulcer, sometimes called a "bed sore," is a skin injury that occurs in
about 40,000 people every year. Usually, pressure sores happen when people are
very ill for a long period of time and are not able to change their position in a bed or
a chair. People who have conditions such as dementia and spend a lot of time in a
bed or a chair might not even realize that they need to change their position.

The device itself creates pressure. Humidity and heat develop between the device
and the skin changing the microclimate of the skin. Often these devices must be
secured tightly to assure a proper seal which, in turn, creates pressure in unusual
areas rather than the bony prominences. The materials used to secure the device
(e.g. tape, straps) may make it difficult to inspect the underlying skin beneath them.
All of these factors increase the risk of pressure ulcers

Pressure ulcers are, as their name implies, caused primarily by unrelieved

pressure. They usually occur over bony prominences such as the sacrum or the
heel but can occur on any part of the body subjected to pressure. Approximately
70% of all pressure ulcers occur in the geriatric population. Pressure ulcers can be
a major source of infection and lead to complications such as septicemia,
osteomyelitis, and even death. Prevention of pressure damage to the skin and the
underlying tissue is an essential part of treatment in at-risk patients

Providing resistive calf muscle strengthening exercises (i.e.: heal lifts, resistive
dorsiflexion/plantar flexion exercises, walking with adequate ankle range) and/or
improving ankle range of motion, have been shown in the literature to enhance
lower extremity hemodynamics and positive trends towards venous leg ulcer
healing.(9) To evaluate the true effectiveness of exercise with respect to chronic
lower leg wound healing and prevention, more robust studies are
required. Despite this, the importance of exercise for this population is recognized
in the literature, and should not be overlooked.

Seniors can have complex medical, cognitive, psychosocial and environmental issues
impacting the status of their chronic lower leg wound. We as physiotherapists, have the
training and ability to assist these individuals to reach their personal goals and maximize
healing with respect to their lower leg ulcer. Best practice guidelines for wound care
management recognize the need for specialist training in exercise. Whether you are a
physiotherapist who is part of a team or working on your own, with the collaboration of
your client, you can play an essential role in the rehabilitation of their lower leg wound
healing status, and ultimately their quality of life.

Epidemiology

Advanced age favors the formation of PU due to the loss of skin elasticity,
insufficient skin hydration and loss of sensitivity, among other factors that may be
aggravated if associated with chronic diseases such as hypertension and diabetes
mellitus, as well as the use of vasoactive drugs that hinder a good tissue perfusion.
In a study conducted in a Family Health Program with 40 elderly subjects, we
investigated the nursing diagnosis "impaired skin integrity," in which one might
observe the following defining characteristics: breaking the skin (epidermis) in 85%
of cases and destruction of skin layers on 55% of them. These characteristics are
similar to the risks for PU. These related factors are common to the elderly
evaluated in our study as changes in skin turgor, impaired immune system and
mechanical factors(18).

Pressure ulcers are, as their name implies, caused primarily by unrelieved

pressure. They usually occur over bony prominences such as the sacrum or the
heel but can occur on any part of the body subjected to pressure. Approximately
70% of all pressure ulcers occur in the geriatric population. Pressure ulcers can be
a major source of infection and lead to complications such as septicemia,
osteomyelitis, and even death. Prevention of pressure damage to the skin and the
underlying tissue is an essential part of treatment in at-risk patients

Wound Assessment

• Stage ulcer according to the National Pressure Ulcer Advisory Panel (NPUAP)
injury severity guidelines, 2003. Staging can only occur after necrotic tissue has
been removed allowing complete visualization of the ulcer bed.
Stage I: Pressure ulcer is an observable pressure-related alteration of intact skin
whose indicators as compared to an adjacent or opposite area on the body may
include changes in one or more of the following: skin temperature (warmth or
coolness), tissue consistency (firm or boggy feel), and/or sensation (pain, itching).
The ulcer appears as a defined area of persistent redness in lightly pigmented skin,
whereas in darker skin tones, the ulcer may appear with persistent red, blue, or
purple hues

Stage II: Partial-thickness skin loss involving epidermis and/or dermis. The ulcer is
superficial and presents clinically as an abrasion, blister, or shallow cráter

Stage III: Full thickness skin loss involving damage or necrosis of subcutaneous
tissue that may extend down to, but not through, underlying fascia. The ulcer
presents clinically as a deep crater with or without undermining of adjacent tissue

Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis, or
damage to muscle, bone, or supporting structures (e.g. tendon, joint capsule).
Undermining and sinus tracts also may be associated with Stage IV pressure
ulcers.

Stage X: Ulcer covered by necrotic tissue or eschar. Unable to accurately stage

ulcer

CONCLUSIONS

Geriatric fellows need to improve their knowledge and confidence with regard to
pressure ulcer care to become competent as clinicians and educators for this
condition. Specific curricular guidelines and a validated knowledge assessment
instrument on pressure ulcers are needed to improve the educational effectiveness
of a geriatrics fellowship.
https://www.hindawi.com/journals/ulcers/2013/413604/

http://onlinelibrary.wiley.com/doi/10.1111/j.1742-
481X.2010.00699.x/epdf?r3_referer=wol&tracking_action=preview_click&show_checkout=1&pur
chase_referrer=onlinelibrary.wiley.com&purchase_site_license=LICENSE_DENIED

http://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=0e1ed7fb-165d-4cb3-
a187-64da4b415504

https://www.ncbi.nlm.nih.gov/pubmed/9677994

https://journals.lww.com/aswcjournal/Abstract/2003/01000/Pressure_Ulcer_Education__A_Pilot
_Study_of_the.13.aspx