DOI: 10.7860/JCDR/2022/57927.

17282
Case Report

Influence of Physiotherapy in the Vigilant

Physiotherapy Section

Revitalisation of Decubitus Ulcer:

A Case Report
Neha Nilesh Bhagdewani1, Anam R Sasun2, Shubhangi Patil3

ABSTRACT
Decubitus ulcer seems to be the most typical side-effects seen in chronic patients due to postspinal cord injury, various neurological
conditions and prolonged periods of immobilisation. This is a type of skin and soft tissue lesion that develops as a result of prolonged
or continuous skin pressure. All of the pressure sensitive sites are the occiput, trochanters, sacrum, malleoli and heel. A 43-year-
old male patient experienced road traffic accident that resulted in cervical spinal cord injury and was bed ridden for the past five
months, developing grade 4 bed sores over bilateral buttocks and sacral region. Magnetic Resonance Imaging (MRI) of the dorsal
spine revealed cervical canal stenosis with neural forminal stenosis and neural impairment at C3-C4 to C6-C7 disc levels. Braden
score and functional independence measures were the outcome measures used to evaluate patient condition. Physiotherapy
was initiated to deal with symptoms such as lower limb weakness, bed sores in the bilateral buttock and sacral region and hand
activities. It entailed a variety of therapeutic approaches aimed at teaching patient transfers and bed mobility as well as making
the patient functionally independent. Laser therapy had been used to speed wound healing and to explore if it is beneficial in
combating massive, chronic pressure sores. In this case, it was also demonstrated that advanced physiotherapy rehabilitation,
which included laser therapy, was advantageous to the patient and led to significant outcomes after a spinal cord injury.

Keywords: Cervical spinal cord injury, Laser therapy, Outcome measures, Physiotherapy rehabilitation

CASE REPORT buttock and sacral region and for hand activities physiotherapy
A 43-year-old male patient came to the Casualty Department with was initiated. Admission to the hospital was done after five months
the main complaint of lower limb paraparesis. The patient had a for the present complaint and physiotherapy rehabilitation began
history of a Road Traffic Accident (RTA) that occurred five months after five days of admission according to the timeframe. The patient
back, resulted in head trauma, loss of consciousness and cervical was attentive, oriented to time, place and person. Intelligence and
cord injury. Cervical canal stenosis with neural forminal stenosis memory were normal on general evaluation, according to the Mini-
and neural impairment at C3-C4 to C6-C7 disc levels revealed Mental State Examination (MMSE) [2]. When limbs were palpated,
on Magnetic Resonance Imaging (MRI) of the dorsal spine on day they had  reduced muscle strength in their bilateral lower limbs,
three of the accident. There was minimal  collection of fluid in the scoring a 0/5 for lower limb and 3/5 for upper limb on the Manual
prevertebral region at the C4-C5 vertebral level [Table/Fig-1]. Patient Muscle Testing (MMT) scale [3]. Deep and cerebral sensations were
underwent surgery to treat cervical myelopathy after a month. unaffected but active Range of Motion (ROM) in the joints of both
Antibiotics, analgesics, antacids, antiepileptics, and other supportive lower limbs was compromised. Babinski sign was positive in the
medicines were given to the patient postoperatively. Vital signs, right ankle jerk response. Bladder and bowels were both significantly
haemodynamics and neurological state were all stable in the patient. affected. On local  examination, a bed sore measuring 10×15 cm
The patient had been bed ridden for the past five months. Grade 4 on the left side and 8×12  cm on the right side was found, along
bed sores over bilateral buttocks and sacral region were present [1]. with skin discoloration that seemed to be black with foul smelled
drainage. The Functional Independence Measures (FIM) score
was 75/126 and the Braden score was 7/23 [4,5]. [Table/Fig-2,3]
showing illustrations of bed sores before and after therapy.

[Table/Fig-2]: Decubitus ulcer before treatment.

[Table/Fig-3]: Healing of ulcer after therapy. (Images from left to right)

Therapeutic Intervention
[Table/Fig-1]: Magnetic resonance imaging of dorsal spine. The patient was given the following interventions while in bed: upper
limb strength training, lower extremity passive motions, position into
After taking the informed consent from the patient, for symptoms prone and lateral lying, hand activities, passive stretches [Table/
such as weakness in both lower limbs, bed sores in the bilateral Fig-4]. Laser therapy was also given for four weeks with a 15 day
Journal of Clinical and Diagnostic Research. 2022 Dec, Vol-16(12): YD01-YD03 1
 Neha Nilesh Bhagdewani et al., Influence of Physiotherapy in Bed Sores www.jcdr.net

follow-up. The non contact, continuous beam emission (non pulsing) DISCUSSION
at 658 nm wavelength, Light cure Gallium-Aluminum-Arsenide Decubitus ulcers, commonly known as bed sores or pressure
(GaAlAs) class IV near-infrared laser was applied. The following ulcers, are skin and soft tissue injuries that develop as a result of
dosage parameters were used: 7-10 watts power; dose range continual or sustained skin pressure over bony areas [8]. First,
6 J/cm2-9 J/cm2; sacral area (10×5) cm2 at different energy densities; second, third and fourth stage incidence rates for pressure ulcers
treatment time ranged between 8-15 minutes for ulcer five times per were 45% (95% CI: 34-56), 45% (95% CI: 34-56), 4% (95% CI: 3-5)
week for one month [6]. The grid method was used to spread the and 4% (95% CI: 2-6), respectively. The orthopaedic surgery ward’s
wound area and the application was done with a non contact probe patients had the highest incidence of pressure ulcers (18.5%) (95%
moving at 1cm/second [Table/Fig-5]. The pretreatment and post- CI: 11.5-25) [9]. Pressure ulcers are progressive in nature, largely
treatment follow-up and outcomes are shown in [Table/Fig-6]. caused by pressure and shear and are most frequently observed in

Goals Reasoning Intervention (activities given)

To explain the condition to the Skin discolouration, ulceration, Patient education: As indicated in [Table/Fig-7], the patient’s position was changed for every
patient and their relatives. drainage, or a foul odour from the ulcer two hours. Water mattresses were recommended to the patient. They were also taught
site, as well as sense of discomfort, are about eating a healthy, balanced diet, washing their bodies with a gentle sponge or cloth,
all warning indicators [7]. and using a moisturiser and lotion on the skin. The patient was instructed to keep his groin
clean and dry.
To relieve joint pain by Stretched muscles can support more Stretching: To prevent contractures quadriceps, hamstrings and adductor muscles of both
lengthening painful and tight weight and achieve full range of lower limbs were administered.
muscles. motion with ease [7].
To encourage blood flow and It can help the patient by stimulating Range of motion exercises: The patient was given ankle toe movements, heel slides, straight
prevent stiff joints. and strengthening neuronal leg raises and hip abduction ROM exercises. Because the patient’s upper limbs are strong
connections in the spinal cord [7]. enough, ROM exercises had been tried on his own [7].
To sustain muscle mass. Maintaining muscle mass will make Strengthening exercises: Transitions, bed mobility, and locomotor re-education all demand
daily chores easier to perform upper arm muscular strengthening as seen in [Table/Fig-8,9]. The patient was given task-
and regain independence after a spinal oriented reaching, manipulating and grasping activities using a smiling ball, rubber band, and
cord injury [7]. holding glass, as well as upper extremity weight-bearing exercises for postural support.
To maintain physical and mental Neuroadaptive alterations rarely emerge Home-based physiotherapy programs: When patients with sacral ulcers sit properly in upright
fitness. after a single physiotherapy session. As or forward lean positions, their weight moves onto their thighs and away from the sacrum,
a result, physiotherapy activities must speeding up the healing process of grade III-IV bed sores.
be performed at home [7].
[Table/Fig-4]: Shows therapeutic intervention with goals and reasoning.

Dosage
Treatment week Power (watts) Site and time (minutes) ­(joules/cm2)
Week 1 10 Sacral area- 15 minutes 9
Week 2 10 Sacral area- 15 minutes 9
Week 3 7 Sacral area- 8 minutes 6
Week 4 7 Sacral area- 8 minutes 6
[Table/Fig-5]: Depicts the laser therapy intervention week by week.

[Table/Fig-8]: Patient was performing upper limb (90° upper limb flexion).
Day of discharge Follow-up
[Table/Fig-9]: Patient was performing full range exercise. (Images from left to right)
Outcome Day of (After a month of (­After 15 days of
measures ­admission treatment) ­discharge from hospital)
bedridden, chair bound, or immobile individuals. The failure of the
Braden scale 7/23 13/23 17/23
reactive hyperaemia cycle in the pressure prone area continues to
Functional
independence 75/126 95/126 95/126
be the most significant etiopathology [10]. The diagnosis of infection
measures is difficult and is dependent on a mix of primary and secondary
0/5 for lower 1/5 for lower limb 1/5 for lower limb clinical symptoms, tissue in the wound, the condition of the wound
Manual muscle limb muscles muscles muscles environment, inflammation indicators and findings from the gold-
testing 3/5 for upper 4/5 for upper limb 4/5 for upper limb
standard microbiological investigation of targeted samples. Important
limb muscles muscles muscles
clinical criteria known as NERDS-STONEES are used to distinguish
[Table/Fig-6]: Illustrates the pretreatment and post-treatment follow-up and outcomes.
between deep tissue infection and critical colonisation when making
an infection diagnosis. Pressure ulcer infections occur 5-80% of
the time and biofilm is present in 90% of cases [11].
In this case report, it was shown that in contrast to the other studies
listed below, very advanced physical therapy rehabilitation, which
included patient education, laser treatment, stretches, strength
training, range of motion exercises, and home-based exercise
regimens, had a significant positive impact on the patient’s quality
of life. The present state of knowledge and improved therapeutic
options for pressure ulcers has received special attention. Similar
to a study done by Bhattacharya S and Mishra RK, role of
stress relieving  items like pillows and mattresses in the therapy
strategy was also highlighted in the case report [10]. Exercises
were used in spinal cord injury treatment to increase functioning.
Because each spinal cord injury is different, each person needs a
customised rehabilitation approach. Following a spinal cord injury, a
physiotherapist will assess one’s functional skills, provide a specific
[Table/Fig-7]: Positioning done with the help of pillows. training program, and assist patients in achieving realistic recovery
2 Journal of Clinical and Diagnostic Research. 2022 Dec, Vol-16(12): YD01-YD03
www.jcdr.net Neha Nilesh Bhagdewani et al., Influence of Physiotherapy in Bed Sores

objectives [12]. There are currently a number of different ways to treat necessary training, by using different therapeutical techniques.
a wound, like debridement, improved dressings, use of antibiotics Effect of Laser therapy in treating large, chronic pressure sores had
and reconstructive surgery. also been studied.
The benefits and drawbacks of both the present and newer
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PARTICULARS OF CONTRIBUTORS:
1. Intern, Department of Community, Ravi Nair Physiotherapy College Datta Meghe Institute of Medical Sciences, Sawangi, Wardha, Khamgaon, Maharashtra, India.
2. Intern, Department of Community, Ravi Nair Physiotherapy College Datta Meghe Institute of Medical Sciences, Sawangi, Wardha, Gondia, Maharashtra, India.
3. Professor and Head, Department of Community, Ravi Nair Physiotherapy College Datta Meghe Institute of Medical Sciences, Sawangi, Wardha, Khamgaon, Maharashtra, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: PLAGIARISM CHECKING METHODS: [Jain H et al.] Etymology: Author Origin
Neha Nilesh Bhagdewani, •  Plagiarism X-checker: Jun 06, 2022
Intern, Department of Community, Ravi Nair Physiotherapy College, Datta Meghe •  Manual Googling: Sep 20, 2022
Institute of Medical Sciences, Sawangi, Wardha-4422001, Maharashtra, India. •  iThenticate Software: Sep 23, 2022 (6%)
Email id: nbhagdevani@gmail.com

Author declaration: Date of Submission: May 20, 2022

•  Financial or Other Competing Interests:  None Date of Peer Review: Jun 11, 2022
•  Was informed consent obtained from the subjects involved in the study?  Yes Date of Acceptance: Sep 26, 2022
•  For any images presented appropriate consent has been obtained from the subjects.  Yes Date of Publishing: Dec 01, 2022

Journal of Clinical and Diagnostic Research. 2022 Dec, Vol-16(12): YD01-YD03 3