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CME Wound Care

Best Practice for Treatment of Phlebolymphedema

Heather Hettrick, PT, PhD, CWS, CLT-LANA, CLWT

Heather Hettrick, PT, PhD, CWS, CLT-LANA, CLWT defines the phases of compression therapy. Dr Hettrick also defines the role of manual lymphatic drainage in the management of edema. Dr Hettrick concludes with an overview of the various types and indications of compression therapy available.

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Goals and Objectives
  1. Define the phases of compression therapy
  2. Understanding the role of lymphatic drainage in the management of edema
  3. Understanding the various types of compression wraps and devices
  4. Appropriate evaluation of patients for compression therapy
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  • CPME (Credits: 0.75)

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    Release Date: 03/16/2018 Expiration Date: 12/31/2018

  • Author
  • Heather Hettrick, PT, PhD, CWS, CLT-LANA, CLWT

    Associate Professor
    Department of Physical Therapy
    Nova Southeastern University
    Ft Lauderdale, FL

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  • Lecture Transcript
  • TAPE STARTS – [00:00]

    Heather Hettrick: Alright. So we're going to move into talking about best practices for treatment of phlebolymphedema and what I'll end with too. So I'll talk about the gold standard. This is typically something done by certified lymphedema therapist, but I'll give you some tips and tools that you will be able to take back with you start on Monday morning to at least start treating with -- and talking your patients how to manage some of this on their own. So basically, as Jim has said we wanted -- any patient with lower extremity edema, any patient with lower extremity wound, you want to do your vascular studies, you want to do your ABI and you want to determine if you want to send them also for venous duplex, but don’t just have them check for DVT. Make sure you ask about reflex and insufficiency studies too because we really want to appreciate the overall health of the venous and the arterial system. And why is that important is because it'll guide our compression decisions, but it'll also guide whether or not the person can tolerate any form of debridement therapy. So these values are very-very important. You will some variations in the literature. The one we are currently using was published in 2011. It is fairly widely accepted, but the cut-off, again normal is 1 to 1.2, higher would be those calcified vessels and really anything under 0.8 or even some people are saying if they're little more aggressive 0.6, you have to be careful about how you compress. It doesn't mean you cannot compress them, but you'll use a lighter compression and you might have to modify you approach. Again as Jim has said some compression is better than no compression. Compression doesn't work when it's in the closet. Okay. So we got to really match the type of compression to what the patient can deal and what they can tolerate. So again these slides just kind of run through the different values for the ABI. Again if you do have somebody with calcified vessels such as with diabetes, it's best to get a toe brachial indexes as Dr. McGuire [phonetics] has suggested. So these slides just kind of run through that a little bit. And again these are guidelines that tell you -- guidelines for the types of compression you can use. And at this point, they're usually talking about stockings or garments. So they talk about different classes and also forms of compression. So you're fine doing really any type of compression or any type of debridement appropriate for the patient when you have ABI values of 0.8 or higher, but when we start getting lower, that’s when we have to modify our approach in both compression and debridement. And that’s what these are talking about where 0.5 to 0.8, it's moderate PAD, but you still can use some compression for these patients, but we want to appreciate what those values are. That’s why it's not just a number. Those numbers are linked basically to guidelines for interventions. [off mic conversation]. No. I mean sometimes you can feel it because you'll feel maybe a bounding pulse. Sometimes you can hear it on the Doppler. I know sometimes people complain they don't want to do the ABI because it's time intensive. So trick with that is start with the readings on the ankle. If you can't get readings on the ankle, just refer them out and get them done. Otherwise you will spend time getting the brachial studies and then you will come down try to do the ankle and if you can't get the ankle, then the whole test is complicated.

    [Off Mic Conversation]


    Heather Hettrick: Yes. Right. And sometimes you need to get paid for an ABI, I guess depending on where you practice, you need to have the waveform printout. But the waveforms are helpful because they'll tell you are you triphasic, biphasic, monophasic and that can definitely be helpful to know just the level of destruction, but you don't have to see it. It's typically pretty safe to assume although you know you're not supposed to assume anything, but it's pretty safe to assume that patient with longstanding diabetes are going to have some compressible component because of the PAD or PVD that’s associated with it. So it doesn't mean you can't do an ABI on them, but if you get those high levels, it's not as accurate to be best to have them get toe pressures. Okay. So this is the gold standard for lymphedema and it's called complete decongestive therapy. The reason why I like it so much is it's really not rocket science. It's really pretty simple when we think about it. It's all just basic techniques. It's delivered in two phases. And basically, when you have a new patient coming in, he finally gets diagnosed and you're appreciating what's going on with that patient. We start with phase one which is what's called the intensive phase. And this is really clinician driven. So this is you the clinician working with your patient to try to decongest them as much as possible. And what we do it is a lot of skin and nail care. We do tremendous amount of patient education. We do manual lymph drainage which I'll talk about which is a manual technique to redirect the lymphatic flow. We do the appropriate form of compression and usually during this phase, we use short stretched compression bandages to get masses reduction in lymph size and we also do basic remedial exercises.

    00:05:10

    We want to get these patients moving even if it's little thing like ankle pumps, wrist pumps, range of motion type exercises because we want to engage that venous pump as well. Then when your patient has reduced down to a manageable level and you'll know that because you are taking your regular circumferential measurements, it's in about two weeks maybe three weeks are not decongesting anymore, that’s basically time to move them into phase two which is the maintenance phase. So unlike phase 1 which is clinician driven, phase 2 is patient driven and it's for life. And again remember this is a disease with no cure, but it's highly manageable. So all the time you are working with them on phase 1, you are preparing them and training them to how to do all those components that they'll continue to do in phase 2, but they'll do it on their own. So it’s the skin and nail care, how to recognize when there is a potential for infection or cellulitis. How to do self manual lymph drainage, how to do self compression, will transition them into different types of compressions, stockings or garments or wraps at this point that they can wear as maintenance for life and they will continue to do some basic exercises during this time. And the biggest thing is really letting them know that the more they comply and adhere with this program the better. Now in the perfect world such as in Germany, these patients will check themselves into the Foldi clinic for two to three months and they will get twice daily treatments five to six days a week. We don't do that here, right? So we're lucky if we can see these patients three times a week. Ideally, it would be five times a week but usually it's one, two or three times a week. So our treatment may last a little bit longer, but we can still get very good results with these patients. And the more they learn to do on their own, the better their results are going to be too. So again this is just a synopsis of phase 1 which is skin and nail care and decompression bandaging exercises and the training. And then you can see that in phase 2, it's really the same thing. They're going to continue with that all those components, but one of the big things that changes is the type of compression that they're going to be using during phase 2. So traditionally, how we manage chronic venous insufficiency --we got to get them moving, right? We got to engage those hemodynamics at ankle pump. As Jim was talking about, we see these patients with lipodermatosclerosis, right? And that affects ankle mobility the big way. So we've got to really try to work on anything to get that ankle pump working better. So we'll do walking with compression on. We'll do ankle range of motion exercises. We'll do stretching. All those things can really-really help along with short stretch, multilayered compression bandaging. And these are great even when there is wound present. So they work really well, the two-layer, three-layer, four-layer type devices. They can use -- long-term day use only of compression garments. So again if it's lower extremity usually around 30 to 40, sometimes a little bit more if they can tolerate it. And if they're active, we'll do skin care, wound care. Is there a candidate for corrective venous procedures, that’s great. If they have an underlying arterial component, again you want that worked up to understand and appreciate how that’s going to impact your care. And then sometimes they might be on a short-term use of diuretics, but I would caution that that’s only done if they're receiving complete decongestive therapy and I'll explain why. It has to do with manual lymph drainage. Phlebolymphedema, again we do modified CDT. We'll do short-stretched multilayer compression bandaging. We might move them to over-the-counter custom garment or device with these wraps, the Velcro type closures for daytime use. The wraps you can also use at nighttime. So the common theme here though whether you're treating, if there is such a thing now as "pure CVI versus phlebolymphedema" is compression. Compression is the cornerstone therapy. And it's really important because it's what's going to maintain the reduction in fluid volume. We can mobilize the fluid all day long, but unless we maintain it and keep it contained, it's going to come right back. And sometimes it comes back with force like rebound effect. So again compression and hemodynamics, proper selection in use of compression supports the hemodynamics of that AVL system, right? So it will reduce venous volume because it's supporting the function of those veins making those valves functional and proper again which will thereby reduce venous reflux reducing that venous congestion. It will decrease that ambulatory venous hypertension which causes pressure on to the lymphatic system causing lymphatic hypertension which ultimately when you reduce all that hypertension, it reduces the edema which supports the arterial system.

    00:09:55

    So those systems are so interrelated and I think that’s why it's so important to appreciate them in the context of how they impact one another. I wanted to bring this up to you. So is MLD, manual lymph drainage an effective treatment for open wounds. And we're starting to find out the answer is actually yes. So this is kind of exciting. So we know that exudate is composed mainly of water, but it has a lot of other factors in it too. And in chronic wounds, we know there is that wound milieu, right? It's just lot of -- it's like a stagnant pool like you saw on the first picture I put up there. And you'll find enzymes, matrix metalloproteinases, growth factors, waste products, endotoxins, whole bunch of things, good and bad. But what we want to do is mobilize them. We want to get them out of that area because as you saw in some of those imaging pictures, there is that dermal backflow. There is stagnation. There is that stagnant pool just sitting there and it's not going anywhere. And those cells and enzymes and all things are caustic to that local wound environment. We want to do what we can to mobilize them. And we can do that through manual lymph drainage. So I'll explain about that in a one second. There were some interesting studies that show how much fluid is actually lost through exudates. It's one study looked in burns and another study looked in venous leg ulcers. But this is important because our patients can become dehydrated and they lose a significant amount of protein actually out of that wound fluid. So patients go, okay, I'm going to stop drinking a lot of water and I'm not going to eat protein any more. It's like, no, no, no, don't do that. You don't want them limiting their fluid intake, maybe coffee and other things, but you don't want them limiting water intake. You don't want them limiting protein intake. It's really important that they eat a well balanced diet. There are some evidence coming out suggesting reducing the inflammatory foods is helpful for these patients because again what system manages immunity and inflammation is the lymphatic system. So sometimes those low inflammatory diets can be helpful. So when we look at this -- I like to call this our cabinet of curiosities. So on wound care, we have lots of really cool things we can do with our patients, right? There is 3000 plus dressings we might be able to use. We've cellular and tissue based products. We've a whole host of biophysical agents, IASTM being one of them. We have alternatives therapies, maggots and leeches. We have all source of debridement. We have compression and we have manual techniques. And I think the manual techniques, especially manual lymph drainage gets overlooked or manual edema mobilization. So that’s what we're going to talk about. So this was one study. I won’t read it to you. But what they did is they basically looked at venous flow during manual lymphatic drainage applied to different areas of the lower extremity in patients with and without venous insufficiency. And what they found is that the MLD technique increased blood flow in both the deep and superficial veins. It also had a side effect of helping arterial system. And they suggested that MLD should be applied along the route of venous vessels to improve venous return. Well, that makes sense because what also follows the route of the venous vessels is the lymphatics. So MLD is not only beneficial for mobilizing lymphatic fluid, it actually helps stimulate good venous return as well, why? because of the AVL relationship. This study -- actually the next study looked -- I promise there is another study. This study looked at lymphatic transport in patients with CVI and venous leg ulcers following sequential pneumatic compression. So they used a sequential pneumatic compressive device. And they found that the study provided really visible confirmation of lymphatic dysfunction at an early stage in the early etiology of the venous ulcer and demonstrated that -- sorry that the potential therapeutic mechanism of sequential pneumatic compression therapy helps in that it removes that excess fluid, that stagnation of fluid that can lead to ulceration but also lead to stagnation and all those other associated skin changes. So the ability of SPC therapy to restored fluid balance to proximal movement of lymph and interstitial fluid may explain it's value in hastening venous ulcer healing. So what's this doing is it's mobilizing fluid and stopping that stagnation which thereby helps improve wound healing but also helps reduce the edema that’s commonly associated with that as well. So what's important to realize is manual lymph drainage can be performed around the wound. And sometimes this is where the training comes in that can be helpful, but I think anybody even not certified can learn how to do it safely and effectively. And the idea is to appreciate the venous anatomy but also the lymphatic anatomy in that area. And what you can do is you can direct fluid away from that wound to intact functional lymphatic vessels.

    00:14:58

    And it’s a very light technique. It's just enough to stretch the dermis not so much that -- it's not like an effleurage or petrissage or traditional massage because it's not massage. It's just enough to stretch the skin to allow pull on those [Indecipherable] [00:15:13] filaments to allow those lymphatic capillaries to open up to allow the fluid to come in. So people always ask what is it feel like. If you ever stroked a newborn's head or if you are stroking the cat, it's a very light technique. And the way you do it is you provide a stretch to allow that fluid to come in and open those capillaries and then you direct it. So it's a stretch and direct and I'll walk you through that. So we know that we use different types of compression for patients with phlebolymphedema. There is a lot of thought that has to go in what's going to be appropriate. These thoughts are how our patients are presenting if wounds are present. What the integumentary status is. The presence of lobes can be quite challenging as well or significant panus that can be quite challenging. We don't want to put compression over those without addressing those because we could induce a pressure necrosis. So we have to factor in a lot of things. But remember compression can lead to high capillary permeability which leads to excess protein in interstitial space. It's kind of squeeze those out. That’s okay as long as we're mobilizing that fluid. It has a high oncotic -- causes high oncotic pressures created by the proteins that again will draw more fluid from the capillaries because remember it's going to attract water. Then you have compression of the limbs can lead to loss of free water concentrating the proteins. Anytime you concentrate proteins, you're going to attract more water. And why compression alone is not successful. So we're talking about that gentleman you just showed, right? He is upset because compression isn't working. It's not -- it's helping but it's not working because it's not mobilizing the protein. The protein doesn't know where to go. There is nobody in there saying go this way, go this way. That’s what MLD does and I'll explain that. So we all know what this is, right? I used to do this every day when I lived in Los Angeles. So the way I like to view lymphedema or the problem with lymphedema is that there is an accident somewhere in the person's body. There is something causing stagnation, a blockage, a disruption to the lymphatic system. And wherever that’s happening, we're going to see backflow after that. So there is an accident on the 405 Freeway. Everything behind that builds up, right? And we've all been there. It's not fun, right? So what we need to do when we see this happen, what happens? The police come in and they start rerouting traffic around the accident, right? They'll take them on the shoulder. They might take them to city streets. That’s what we do with manual lymph drainage. We show the fluid you can't go this way, but you can go this way. We have to redirect it and because it works off suction and siphoning, it learns to follow that path of least resistance. So if you're that first person at the top of that accident, you follow the police officer, right? They're going to direct you where to go. Everybody behind you, they just follow you and that’s exactly what manual lymph drainage does to that fluid burden. All of sudden, it realizes, oh, I can go here and that’s the beauty of that system. It's so amazing how it's been created to accommodate for structural changes and problems. So you have an accident or there is construction, it doesn't always have to be an accident, right? leads to traffic. The police come in and reroute and sometimes for long term use, they might put in cones and detours or signs. Well, that’s our compression. Cones and detours are our compression. So in order to maintain that new traffic pattern in order for that lymphatic flow to know where to go, we need to continue to support it through the compression. Once you redirect it and show where to go, it will go there automatically. And that’s why, the manual lymph drainage component is so critically important. Okay. So there is lot of compression and this is always challenging. This is the same thing with dressing. It's like what do I use. So you want to start with dressing, you start with how much fluid you have present. So here we're talking about everything from non stretch to short stretch to long stretch to compression stockings, garments that can be over-the-counter or custom compression wraps which are the Velcro type closure devices or strappings. And then of course, you have your different types of pumps, intermittent or sequential pneumatic compression pumps. And there are two concepts that are really important to understand with it and it's working pressure and resting pressure. So compression bandages differ in both elasticity and extensibility. So how well they work essentially. And it's based off of working and resting. So working pressure by definition is the pressure the bandage is set against the muscles working underneath. So when the person is up walking around or they're ambulating or they're active during the day, that’s how much pressure the bandages are putting against those muscles.

    00:20:03

    So this is the pressure from the inside when the muscles are working. They're heating that compression and it's forcing venous blood flow back up to the heart and it's supporting lymphatic flow as well. So this actually affects the deep vessels the most and this is why this is so important because you're getting venous and lymphatic return without working pressure. Resting pressure is the pressure that bandage exerts on the tissue while resting. So all of us sitting here if anybody is wearing compression, how much resting pressure you have is based off of how much it's squeezing you essentially while you're at rest. So this is pressure from the outside, outside coming in. It tends to be fairly static and it affects more of the superficial vessels. This is sometimes really what we know as interface pressure. But these are really important concepts and questions you should ask some of the different manufacturers about what's -- is this the high working pressure, low resting pressure or the opposite. So what you can see here is just non stretch which is typically the inelastic bandages or commonly known with Unna boot where they have a very high working pressures but not a lot of resting pressure. They provide excellent containment. It facilitates the calf muscle pump only during ambulations. So I think it's really important this isn't put on patients that are bedbound. They need to have an active muscle pump in order for this to be used safely and effectively. The problem is they can slide or bunch down if you get a massive reduction in edema. And so you can get a little bit of an edging effect and that can actually lead to some integumentary compromise. Short stretch is really the gold standard for any type of lymphedema associated edema which we now know is most forms of edema, right? So they only stretch 30% to 60% of their length compared to long stretch or typically ACE bandages, right? which can stretch to 140% to 300%, they're lot more extensible. But what's nice is again these have a high working low resting. So they support the system while mobile, but they're not going to be so snug and tight that they're going to occlude venous return, lymph return or arterial return while somebody is at rest. That’s the opposite of what happens with long stretch. So this is why we don't want to be using ACE wraps in our patients that truly have lymph edema or phlebolymphedema. Again it really helps support calf muscle pump during ambulation. It's safe to apply up to 40 mm of mercury in patients even with an ABI of 0.5. And studies have found that are cited here that it can increase arterial blood flow by 28% and actually increase venous return by 103% when they're applied properly. And there is a lots of different forms of short stretch compression, but these work amazingly well. And then you have the long stretch here. So ACE bandage, I know it's a brand name. It really just stands for all cotton elastic. Okay the Becton Dickinson company. I know it’s like Jeopardy question [Laughing]. Then you have compression stockings or garments. So one thing I'll say -- you know lot of these are really good. This or this during active reduction of edema or in the presence of an open wound. And once you kind of get the edema managed and under control or at the plateau and you get that wound pretty close to being resolved, you want to start considering what are they going to need for lifetime management, right? Maybe they can use over-the-counter garment or stocking. Maybe, they need custom, but these can be very helpful. And as Dr. McGuire had said, can they don and doff them. If they can't put it on, then it's not going to be a good choice for them. One cheap thing that you can suggest for your patients to help with donning and doffing is just getting them kitchen gloves that have kind of texture on the fingers that can actually provide a nice friction for them to help pull on their garments if they have trouble with that. But there are different donning and doffing aides out there and lot of the companies that sell the stockings or the garments have version of their own donning and doffing aides that you can potentially suggest for your patient. But typically these are going to be worn during the day. You don’t want your patients wearing these at night. It's too much compression for nighttime. So they might have to switch to a short stretched bandage during the nighttime. Now some of the newer compression, this should actually say [Indecipherable] [00:24:27] instead of devices, I'm sorry about that, but this is basically -- these are nice options for patients because they can wear these both during the day and at night for patients that have a lot of difficulty with mobility which is lot of our patients or they have difficulty with their hands. Maybe, they're arthritic or whatever else might be going on. If they really struggle with wearing compression, these are nice option for them because they're self adjusting. So patients can put them on and they can make them snug or loosen them depending on how it's feeling and they're safe enough to be worn during the day or at night. And then of course we have the intermittent compression chamber -- intermittent pneumatic compression. Not all IPCs are created equally just like not all swelling is created equally. So it's really you've got to match that type of device to your patient's needs. One thing I'll say is that I think there is a place for pneumatic compression after complete decongestive therapy as part of these two at the maintenance phase because it can be used as adjunctively to help those patients maintain their fluid reductions. But what you have to be careful about is making select the right type of device. There are newer devices out there that were designed and built with the lymphatic system in mind. They have a lot more chambers. They provide clearing and flowing mechanism and the nice thing is unlike some of the traditional pumps where you have leg sleeve or arm sleeve, great at mobilizing the fluid but where is it pushing at? Patients aren't happy with that, right? Well, great my arm and leg looks better, but all this is like huge. So some of these newer devices actually have trunk components. So even though you might be mobilizing the fluid up which is where you wanted to go, it will also address some of the truncal component which can be very helpful for your patients as well. Okay. So in general when you're thinking about compression, you want to start with a compression bandage or a system, the two, three or four-layer system and then progress to a stocking or garment or a wrap once they decongested. Okay. And again, these are -- we're working with the traffic here. So compression bandages are systems when they're still really large, edematous and swollen. Maybe, they have integumentary impairment because these are going to support the reduction and decongestion and help facilitate ulcer resolution. This is the time hopefully to getting some form of complete decongested therapy. Once they have reduced and now traffic is moving again, right? we've redirected that flow. We can move them in to something long-term whether it's stocking or garment or some type of wrap depending on what the patient needs because now we're not going to supporting mechanism, we're going for a maintenance. So it's going to maintain that reduction because once the compression is gone, they can have a significant rebound edema and they can be starting from square one again. So lots of things to consider with our patients, right? Not just their vascular assessment, do they have loss of protective sensation so they know if it's too tight, can they feel that? What is their balance like? What's their activity like? Can they wear shoes? What's their judgment? Do they understand their medical condition? Do they understand why we're asking them to wear these things that don't feel good, right? the compression therapy. We also want to make sure you know if they have other system failures, hepatic, cardiac or renal. If they're stable, you can compress them. It's fine once they're stable. Same thing, if somebody has an active cellulitis, general rule of thumb is they've been on antibiotic for 24 to 72 hours, it's safe to resume therapy with them again. You just don’t want to do it initially because it's so effective you can mobilize and push that infection somewhere else. But other big factors are the size of the extremity, the shape, the skin integrity and we have to prepare the extremity. Sometimes we have to bolster those lobes and support those lobes so that when we put it under compression, we're not going to cause a pressure necrosis. What about all those redundant tissue folds? What loves to be in there? Yeah, yeast, fungus. I found a remote control one time in the patient's abdominal fold. You know you find a lot of things in there. [Laughing] She ended up with a pretty severe pressure injury, but it's really important we address those folds, moisture lesions, [Indecipherable] [00:28:49] dark moist murky areas, right? So we got to get in there. There is good moisture management system. There is skin fold management system out now. Using antifungal powders can be helpful, but we have to address those lobes as well. Keep them clean, keep them dry, very-very important. And then, beyond the scope of today, but there is a lot of different ways we can use foam. We call them chip bags and it's kind of open cell foam that we can use to really work on very fibrotic areas and that can be employed under the compression and it provides kind of like micro massage or stimulatory effects. If you go back to avocado, you then have that really unripe avocado. When you use these types of foam devices under compression, it softens that avocado and it really helps work break down that fibrotic areas. It's really kind of nice. Patients are so pleased when you start to show that there is a reduction in their fibrosis. So again edema is related to phlebolymphedema, require lifelong compression management. Patient sometimes will say, well, I don't want to wear it because I have a wedding to go to this weekend.

    00:29:57

    Can I get away with it? It's like, yeah, you probably can but what happens is, oh they need to wear it for a week and they don't wear it for two weeks, right? So if they get used to wearing it regularly and the way we help facilitate that is getting them into something that they can tolerate and that they can use because as he says some compression is better than no compression. There is all the techniques out there saying, well for this, you use this amount of compression. But if they're not going to be able to tolerate it, it's not appropriate for them. So if you need to step them down and get them little bit lighter to build it up, that’s fine. Maybe later they can start to tolerate a higher compression. So it's baby step. It's negotiation with our patients. So we have to understand, can they manage it? What about hygiene. That’s a big factor with our patients too. Or the presence of skin impairment. And it's one thing to say, okay put these on and come back next week. We have to see that they know how to put them on properly. So we want that return demonstration and this is a lot of what we practice during phase 1 so that they get used to knowing how they're going to do this on their own. We have to think about cost and use and cognition and safety. Obviously, a custom fit compression garment or stocking is the best option for some of these patients, but it's more expensive. So we have to think about what our options are. And then there are different types of products out there too. Circular-knit is one of the more common ones that’s woven in circular fashion, really right off the machine. It provides pretty good recoil. It's more constrictive, more economical. I think there is a lot upstairs that are of the circular-knit variety and then there is flat-knit. Flat-knit is really what's recommended for patients with lymphedema because it's actually fabric sewn into the shape of the patients arm or leg. Has great containment, so really holds that limb and it tends to not fold or bunch sometimes like other types of compression can. So there is little stretch or recoil. So it tends to be a little bit more comfortable for patients that are intolerant to compression, but it is custom, so it is more expensive for these patients. So we just have to think about those different types of things. Also as Dr. McGuire said, remember Medicare only usually reimburses for compression if the wound is present. So you want to be ordering these types of thing while there is still a wound. An argument I have though is you know wound isn't healed until the scar is mature, right? So I don't know if that’s an argument that we can use but just because it's re-epithelialized doesn't mean that wound is healed. And in fact those first few weeks, they only have 20% tensile strength. That’s when they tend to break down again. So we have to protect them. At three to four months, we have got 40% maybe tensile strength and we're -- hopefully ever, we're going to ever get to is 80% tensile strength. So technically, a wound is still resolving or healing until it's reached maturation and scar tissue. And we know that because the scar tissue becomes pale, planar and pliable versus red, raised and rigid. And I think that’s an important thing to factor as well because the wound and shape of limb might look different when we order it by the time they need it. So it's just a kind of little bit of game you have to play. Again, remember garments should not be used to reduce the edema but to maintain the edema reduction. So after phase 1, this is an option for them in phase 2. Remember garments are for day use only. The wraps and other alternatives can be used at night or during the day too. So these are just basically some contraindications and precaution, just very general for compression overall. You will know this from your basic H and P working with your patients. But remember with precautions, it's okay to -- you can do some compression in the presence of mild-to-moderate PAD as long as you know what you're doing and you have your studies to back up your values. Peripheral neuropathy, again if somebody does have loss of protective sensation or neuropathy for any reason, they have [Indecipherable] [00:34:03] in the cognition and they know how to check and assess, it's okay to use it as long as you feel that their judgment is okay. Cognitive or safety concerns, you have to weigh those too. Maybe the patients can't do it, but they do have a caregiver that can help. Incontinence can be an issue often time leading to soiling of the compression, poor patient tolerance or their inability to don and doff. You have to weight those factors in and determine what might be right for your patients. Okay. So I'm going to end there and turn it over to you. Dr. Gibbons [phonetics]

    00:35:10

    [Off Mic Conversation]

    Yeah he healed in between. Yeah. Great. Maybe it's resolving and it's closing, it's not healed. I think that’s the thing. It becomes a semantics thing. Right. You're right.

    Unidentified Speaker 2: This is what we have to do. You have hit nail on the head [Indecipherable] [00:35:36] long-term care. And what they do after we get that wound closed.

    [Off Mic Conversation]

    Use the word close and putting your documentation that this wound is still resolving and you expect healing within two years because it's not healed. So what they do in long-term care is they take our bed away from us that pressure redistribution device, nothing has changed. The patient is still immobile. They still have nutrition and hydration issues. All the comorbidities, they take the bed away and what happens in two weeks with that pressure injury. It opens again. Because we put in our documentation that it was healed. So maybe if we change our documentation, then maybe CMS will, at some point in time, get the message that we keep banging on their door.

    [off mic]

    Heather Hettrick: So when you see that really hyperkeratotic tissue or lot of lymphorrhea that’s crusted, I'm not going to say brand name, but there is new monofilament debriding pads which work phenomenally well on these patients. And there are companies out there, I don't know if there is any here, but you wet it with saline. You can even do with portable water. It's very gentle. It's like 14 million little monofilaments that basically scrub that area and you can remove a significant amount of hyperkeratosis and crust basically on these patients. And they really don't even -- it's not painful. So it’s a really nice alternative form of debridement for this patients. And then what I would do is follow it up with some type of very gentle lotion eucerin, lymphoderm, lubriderm, those types of things work really well. I tend again to look for things that have an olive oil base or a coconut oil base because they don't shut off respiration of the skin. So personally I tried to avoid petrolatum based products and things along that line are obviously dyes and perfumes because that can aggravate the venous stasis or venous dermatitis. But you kind of have to experiment sometimes and find what works best for your patient, but the olive oil based products work really well and now we can find them much more readily. You know patients ask can I put BB oil on or things along that line or Vaseline and I try to encourage them not to because those can tend to be very-very occlusive. But there are some products made specifically lymphedema skin and you can find those by Dr. Google [Laughing] basically who is the answer to everything, but lymphoderm is one of them. And there is -- I'm blanking on the name, I have to think of it in a minute, but there are good products out there. But they need a good moisturization. You don't put it on before manual lymph drainage. So manual lymph drainage doesn't need any type of lubrication. You put it on after right before you put them in compression.

    Unidentified Speaker 3: If you're looking at coconut oil, you want fractionated and I also recommend you get organic, organic fractionated coconut oil because fractionated stays liquid. Even when the room gets cool, this stays liquid. Coconut oil is completely absorbed in the skin and it does not leave anything on the skin topically and it does get into lymphatic and so I suggest you use something organic.

    Okay we are closing the lecture. Yes ma'am.

    Heather Hettrick: Yeah, that’s a good question. There is little plastic [Indecipherable] [00:39:45] that they use for baby's heads and things like that. I think done gently, you could use something like that. I think you just have to be careful on how you do that. Yeah, I don't think that would be a problem and they're definitely inexpensive, but you would want to be just tested just to make sure you're not doing too much because you can over do a good thing as well. Absolutely, I think that could be helpful.


    TAPE ENDS - [32:30]