Excepts from Podiatry Today, September issue:
Questions And Answers On Compression For Lower Extremity Edema
Lower extremity compression can be very effective for reducing edema. These expert panelists discuss the use of compression hose and how compression pumps can be an alternative for patients who cannot wear the hosiery. They also discuss appropriate consults to lymphedema and vascular therapists.
Do you prescribe compression hose for patients with edema?
Kazu Suzuki, DPM, CWS, frequently prescribes compression hose after ensuring that the patient does not have leg ischemia. Given that most of his patients are elderly women, he says “pretty much all of them” have some type of leg edema that will benefit from some type of compression hose, which will reduce fatigue and discomfort in their legs. He also emphasizes that vascular exam and skin perfusion testing before applying compression are imperative because the patients over 70 years of age and patients with diabetes over 50 years of age are at high risk for leg ischemia.
Eric Lullove, DPM, also prescribes compression hose but says one should first establish if patients can put on the hose. Kathleen Satterfield, DPM, tends not to prescribe compression hose because of this issue. Since her lymphedema patients are obese, Dr. Satterfield says they cannot negotiate putting on the hosiery and the expensive hose ends up unused in a drawer. In addition, some of her patients have opened up their wounds or sustained friction wounds by putting on compression hose.
If Dr. Lullove’s patients cannot wear 30 to 40 mmHg stockings, he will try 20 to 30 mmHg or 15 to 25 mmHg. Dr. Lullove says some compression is better than none. For mild edema, Dr. Suzuki may recommend non-prescription strength (8 to 12 mmHg) hose. For patients with wounds, he prescribes prescription strength (20 to 30 or 30 to 40 mmHg) compression hose or uses multi-layer compression bandages. He adds that “most patients will do fine with 20 to 30 mmHg, while large and active young adults, for example, a young construction worker or plumber, will require 30 to 40 mmHg, as the hydrostatic pressure in his leg veins can be tremendous.”
Dr. Suzuki asks patients to seek out brand names such as Sigvaris, Medi, Jobst and Juzo. While Dr. Suzuki notes that these brands are relatively expensive, he says they are durable. He also notes that commonly available T.E.D. hose (Kendall Healthcare Products) are good for prevention of deep vein thrombosis (DVT). However, Dr. Suzuki concedes the hose does not apply graduated compression and may not be effective at reducing edema and healing ulcers.
Dr. Lullove says some patients do better with Farrow Wraps (Farrow Medical Innovation) as opposed to compression stockings.
What do you do if your patients cannot comply with using compression hose?
Dr. Satterfield recommends pneumatic compression devices for home use on a daily basis for patients with edema. “A patient can sit at home, watch a little TV while using these and be adherent,” notes Dr. Satterfield. “There is no struggle getting them on and off so it is not wasted money.”
While the older compression pumps had some potential problems creating genital lymphedema and potential clotting, Dr. Satterfield notes the newer models, with the addition of more compression chambers, seem to have overcome any problems. She emphasizes the importance of combining the therapy with ongoing manual lymphatic drainage.
Likewise, if a leg ulcer has been non-healing for more than six months, Dr. Suzuki may prescribe lymphedema pumps that patients can use at home in addition to compression hose or compression bandages. As he notes, the pumps come with large leg air bladders that “milk” the leg(s) from the distal to proximal direction, which effectively reduces leg edema. He recommends that patients use the pump for one hour, two to three times per day, at home.
NormaTec USA is one company that dispenses lymphedema pumps while dozens of other companies make similar leg pumps, according to Dr. Suzuki.
The pumps can help with Dr. Suzuki’s patients who cannot put on compression hose. “It is actually quite common to hear from my patients that their hands and arms are not strong enough to put on compression hose, even with various gadgets to help them put on the hose,” acknowledges Dr. Suzuki.
Dr. Lullove has a number of strategies for patients who cannot wear compression stockings. He has patients use a vasopneumatic compression pump system like Bio Compression (Bio Compression Systems) as part of their daily maintenance. He suggests patients have discussions with their primary care physician or cardiologist because sometimes the patients need help with diuresis and/or management of congestive heart failure or fluid balance issues.
Physical therapy, improving walking endurance and strengthening the calf are other helpful options, notes Dr. Lullove.
In addition to pumps, Dr. Suzuki suggests using Velcro-based compression wraps, such as Farrow Wrap and Circ-Aid™ (Circ-Aid Medical Products), which offer compression sleeves with multiple Velcro wraps. This makes them highly customizable even for unevenly swollen legs that need compression, notes Dr. Suzuki.
When do you consult other specialties, such as vascular surgery or a lymphedema therapist?
Dr. Lullove routinely refers patients for lymphedema therapy. For the most part, he says the cause of edema is related to chronic venous stasis congestion and failure of the calf-pump system. Dr. Lullove says such patients require more physical therapy/manual lymphatic massage and compression than those with pedal edema. Only infrequently do his patients have a true primary or secondary lymphedema, notes Dr. Lullove.
Dr. Satterfield “immediately” makes lymphedema consults in appropriate patients and emphasizes that managing the condition is a team effort. Given that lymphedema is a chronic condition, she notes that treatment is palliative and it is crucial to have a medical team on board.
As Dr. Suzuki notes, the conventional wisdom dictates that one should close the venous ulcer with wound care and/or skin grafts, and then send the patient to vascular specialists for vein ablation and closure. Dr. Suzuki says the prevailing thinking was this approach could prevent a recurrent leg ulceration.
However, after recent discussions with his local vascular specialists, Dr. Suzuki prefers to send his patients sooner for vein assessment. The reason for that is that current methods of vein ablation, such as VNUS Closure™ (Covidien) and sclerosing injections, are much less invasive and can occur in an office setting, according to Dr. Suzuki. In contrast, he says old methods like vein stripping and the Linton procedures were very invasive, painful and often created large surgical wounds afterwards.
As for the patients with lymphedema, once their leg wounds heal, Dr. Suzuki ensures patients receive follow-up in a lymphedema clinic and with lymphedema therapists. He says such patients need lifelong therapy consisting of manual lymphedema drainage massage, pumping, compression wrapping or garments in order to keep their limb size manageable.
Dr. Lullove is in private practice in Boca Raton and Delray Beach, Fla. He is a Staff Physician at West Boca Medical Center in Boca Raton. Dr. Lullove is a Fellow of the American College of Certified Wound Specialists.
Dr. Satterfield is the Director of Medical Education at the Western University College of Podiatric Medicine in Pomona, Calif. She is a Fellow and President-Elect of the American College of Foot and Ankle Orthopedics and Medicine.
Dr. Suzuki is the Medical Director of Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo, Japan.
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