Section: CME Category: Vascular

The Use of Compression in Lower Extremity Pathology

Marie Williams, DHL, DPM

Marie L Williams, DPM defines lymphedema, its etiologies and management. Dr Williams outlines in detail various methods for treating specific types of edema and contraindications to treatment.

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Goals and Objectives
  1. Identify the pathological need for compression
  2. Apply multilayered compression for lower extremity pathology
  3. Understand the different types of modalities to reduce edema in the lower limb
  4. Recognize contraindications to specific modalities
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    Release Date: 03/16/2018 Expiration Date: 12/31/2020

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  • TAPE STARTS – [00:00]

    Male Speaker 1: At this point, I'm going to re-introduce Marie Williams who obviously has been on my boat a few times. I too, like Stan, have big boats and she will be sharing the use of compression in the lower extremity pathology. Please welcome Marie Williams.

    Marie Williams: Well, thank you. And I'm honored to be here with this group lecturing. Also I just wanted you to notice how many boats Dr. Schoenhaus has and he continues to buy all these boats because now he is going to Florida a lot of times. If you ever need a boat, you just call 1800 Harold and he will definitely let you borrow one. So I'm going to talk to you about a subject that is an interesting subject, compression. We do it all the time. Sometimes we do it in areas where we just want to immobilize something. Sometimes we do it just to reduce swelling for a venous disease and sometimes we just want to hold the patient still. So really compression is a whole technology that has evolved over the years. It's not just an Ace bandage anymore. And so I wanted to kind of go over a little bit about that. I really wanted you to identify and understand that there are pathologic needs for compression and know how to apply them. What is a multilayered compression and also understand the different types of modalities. There are so many out there for us to use. I think that when you look at the lower extremity, you're looking at it from this point of view. This is a patient who comes in and you think, well, I should try to do something about that. There is not much you can do. That’s been there forever. It has components of lymphedema, venous insufficiency and definitely other medical conditions. And you can see that what's really cool about that is that the foot is spared. It's an interesting problem. Anyway, that’s more of an interest. I don't think we have a lot of modalities that will fix that maybe in this new world of compression, maybe a boot and things but let's just move on. I just want to give you a better understanding. What is edema? It's actually an accumulation of fluid in the intracellular tissue resulting from abnormal fluid volume. So that’s what you're trying to do. You're trying to get rid of that abnormal fluid volume constantly. It's important to know the etiology of the edema because you have localized problems, systemic problems, traumatic injuries. And then you have medication induced and there are other causes, sometimes there are tumors and cancers that we haven't even identified. So edema is not a simple subject. I don't think that anything that we do when we see someone with edema and we look at that. We need to come with a true diagnosis. So is it localized or systemic? Is it pitting or nonpitting? Is it unilateral? Is it bilateral? These are the things you ask yourself as you go down that diagnostic tree to decide how you're going to approach the problem. So this is a little busy slide, but what's important is it shows that when you have someone with unilateral edema, one of the most important things that you have to identify is, is it a DVT? Because if you miss that point, then you're in trouble. So what I do is I see someone who comes in with edema of the one leg, the first thing I do is a venous ultrasound. It's a simple test. It's easy and you can then find out, you go, okay great. It's not a problem with the venous system as far as a blood clot. So now you're going to start to look at other etiologies and now you can start to compress that limb because you're not afraid that it has a clot. So you want to take a look at unilateral. When you have a bilateral edema, bilateral edema is a little bit more complex in the sense of deciding where you're going to go with this. So you look at that and you think of your venous problems, your renal problems and one of the things that we miss a lot of times is the medical conditions of the patient. Is it medically induced? Is it cardiac induced? Is it renal induced? Or do they have actually some type of tumor or cancers that’s creating these edemas? So just be aware. The most important point of this is that be aware that there are many, many etiologies and that just wrapping the leg is not the answer. Lymphedema is a systemic problem. It is part of the circulatory system and it is vital for the immune system. And so the lymphedema is caused by a blockage of the system. So you're actually getting blockage of the immune system or the lymphatic system. It commonly is affected in one of the arms or legs.


    It can in some cases be both arms, both legs. You'll see this a lot of time post surgeries. You'll see in the arms a lot when they do a node dissection for cancers. You'll see it in the leg if they do a dissection there or if you have a medical condition that causes lymphedema. It can be a congenital problem but it's usually incurable. However, it is important that you can try to control it. And as I said, there are a lot of modalities out there now that will help you with this problem. It's something that plagues people for a quite a long time and it is sometimes debilitating especially in the young population. It has three main functions. Basically, it drains excess fluid and it maintains the balance of the fluid in the blood versus the lymphatic system. So it causes a hemostasis. If that gets out of balance, you'll have this leaking over into the interstitial tissues. It is also important because the lymph system also fights infection. And it actually has a diagnostic thing where it helps to absorb the fats so you have the lymphatic system that absorbs the fluid and the lipids from the lower extremities and transport them to the blood. So it has a lot of value. There is primary lymphedema and it is caused by a genetic mutation and then there is secondary lymphedema, which is caused by other complications or conditions such as infection or inflammatory processes. It's very interesting that one of the infectious disease groups that we work with whenever they have patients with cellulitis, they never really talk to us about compressing. Everyone wants us to wrap them, get the swelling out. Even though they're treating them medically with antibiotics, they want us to get rid of that extra fluid and it's partly because they want the lymph system to be well controlled. Secondary causes of lymphedema are cancer, radiation therapy, infection and inflammatory conditions like rheumatoid arthritis, dermatitis, eczemas, cardiac disease, cardiovascular problems. And you can have underlying venous problems as well as lymph problems in conjunction. And also you have injury or trauma that can create a lymphedema type problem as a secondary cause. So if you treat these conditions, your lymphedema will be controlled. Some of the complications, you can get lymphangitis or skin infection. And sometimes it becomes, as I said, very debilitating for a patient where you have a unilateral edema from lymphedema in a young person who now doesn't want to wear dresses and in female population, they can't wear their heels. They get very, very plagued by it. So it can really affect them. So you're always trying to help reduce that edema. When you look at edema, you want to then look at it from an infection point of view. You have edema versus cellulitis, so you're looking at a leg with severe cellulitis and you just don't want to write that off as a venous problem or a lymph problem because now you have an infectious problem. So it's important to understand edema is just not that simple. So treatments of edema in general; people are always asked for reducing their salt intake in their diet. All the medical guys in my practice when they have patients come with edema, they will have the patient on diuretics, which has its own little complication by itself, but many of them are like "should I take my water pill today" or "I didn't take my water pill today because I'm coming to your office, you know and I don't want to have a problem with their diuretics." Compression stockings and also body positioning -- how many times have you told your patients to go home and elevate their legs, get them up, get off of them. So these are definite treatments for simple edema. Not all types of edema require treatment. The edema that doesn't require treatment are those in pregnancy or menstrual cycles, that’s usually not a treatable problem. It goes away after the pregnancy and that you don't really have to worry about for treatment. Sometimes if it's very excessive in pregnancy, compression stockings are simple. There is also peripheral edema with ascites and that’s usually treated slowly to minimize the side effects of rapid fluid loss. Early on, I had a case where I actually did take somebody who had severe edema of the legs, but didn't really consider that there was an ascites and you can overload the patient with fluid and put them into failure.


    So you don't want to do that. Your job is very important although it gets minimized because it's "just edema", just be aware of that. So this is where the point of the lecture -- that’s why we are here, right types of compression. So now that you have a problem, you have to figure out what you're going to use for the problem and there are so many -- I don't know if I was here 20 years ago lecturing, I would say, okay, so the types of compression, get your Ace bandage out, make sure you wrap it right. And then I leave, you know. We are done. Or get your little -- you have your -- Coban is out for a long time, get your Coban and wrap up the leg. Anyways, but look at what has happened over years of studying and research, they found that there is all types of compression; bandages, dressing, techniques and we will go through them. So bandages are either elastic or inelastic. They have short stretch or long stretch. They're either very highly compressive, mildly compressive. They're multilayered and now there are actually pumps out there. So you have the pump systems as well. Pumps have been around a long time but they're becoming more and more better technology, so that people can actually get better results as well. So some of the key principles that you use in your compression concepts is to aim at -- to counteract the forces of gravity and promote normal flow of the venous blood up the leg. And also compression acts on the venous and lymphatic systems to improve both of those systems and return it back to as close to normal and reduce the edema. Compression therapy is believed to exert its positive pressure on the venous ulcers by increasing fibrinolysis and reducing venous hypertension and improving the cutaneous microcirculation. So this is what you're also trying to do as you put these on venous wounds or venous insufficiency. The other principle here is that it has two main mechanisms of action. There is a static effect that exerts pressure or a resting pressure and then there is a dynamic effect where you're having constant changing in volume with ambulation. When you apply external pressure, it will increase the pressure in the limb. This will actually distribute evenly according to Pascal's law, which I'll show you. The greater the pressure increase in the lower limb, the greater the force that pushes the fluid out of the limb. So here is a picture of that. This is called Pascal's law. I think we learned this in high school maybe earlier but I don't know. Pascal's Law is basically if you exert or apply pressure on one point of the liquid, it transmits equally in all directions. So it's a type of pressure that you're exerting, you'll actually get equal compression along that area forcing equal pressure in all directions. That’s what you're trying to do with your compression. Now, this slide is just showing you all the products. If you take a look on that slide, here you have the short stretch, you have the long stretch, the multilayered, then there is the multilayered Lite and also the high elastic. So when you look at this little slide and you notice -- let see if I have a pointer here -- so here you have the short stretch. These are the bandages that don't have -- they're very stiff. They don't have a lot of pull and they actually do lead to compression that is more in the gait; when you're walking, it works with you. The long stretch, here is another couple of examples of long stretch type elastic and then you have the multilayered, which we use a lot of these multilayered dressing. Profore came out very strong early on in all the wound care centers. And then what came out down the road is this multi-layered Lite which you have the Coban Lite and you have this actual Profore Lite, three-layered and two-layered compression, which is actually something that you use while you're trying to exert pressure from the outside, equal pressure and you use that in ambulation and not at rest; patients with ambulation do best with that. They're not elastic. They're actually very much non-elastic in their stretch as opposed to your Ace bandage type dressings and your basic Coban or elastic bandages that you can see here. Now the Ace bandage in the patient in the bed that’s lying in the hospital that’s not going anywhere might be an okay thing to do, but if you really want to get patient ambulatory, that’s when you're going to start looking at these multilayered compression dressings.


    So remember that you want to do a gradient compression, you need to apply the bandage at a very consistent pressure. Pressure is exerted on the limb as related to Pascal's law in a number of layers sometimes. So when you look at this compression therapy, it has two mechanism of action. You have the static effect or the resting pressure and a dynamic effect due to the changing circumference of the limb during walking and that’s really important because you're definitely looking at a situation as you're putting these dressings on where the patient is either non-ambulatory, ambulatory and you're making those decisions. Actually, walking is one of the best ways to reduce edema. So putting someone at rest when you're trying to decrease the edema that they have in their legs is probably not always the best thing. You want to apply external pressure that will increase the pressure in the limb. This, as I said, was according to Pascal's law. The greater the pressure increased in the limb, the greater the force that pushes the fluid out. I like this slide because it actually shows you where the technology has come and how many different products you have to make a decision on. So you can see here that you have all these types of dressing, simple Ace bandage and then the types of multilayered compression systems that come in a box. It's very simple. You don't need to buy the box, you can put it on or you have the simple Tubigrip. And then you have the Farrow type wraps for long-term. So you can see that there is a lot of decision making that you're going to make when you're deciding on what type you're going to use for what kind of problem. The long stretch elastic bandage has extensibility greater than 100% to 120%. It's a low static stiff index and they're mostly used for people at rest. Then you have the short-stretch bandages that have an extensibility of less than 100 to 120 and it has a high-static stiffness index. We talk a lot about the stiff index as it's just a matter of deciding is the patient is ambulatory or is the patient at rest and why you're doing that. So these elastic bandages in the long stretch offer a maintained pressure over longer periods of time. They exert pressure from the outside of the leg expanding and recoiling as the calf muscle contracts and relaxes. And these wraps are often inexpensive like the Ace bandage type problem. Sometimes you put cotton padding underneath to apply as a first layer just to make it more comfortable. And it's also for injuries such as ligamentous injuries, ankle sprains or any type of distortion or contusions, subluxations and that’s where the long stretch comes in. Lot of times you're throwing Ace bandage on postop surgery. You are just, kind of, keeping that dressing in place so that it doesn't slip or slide. Other treatments are for venous disease or thrombosis, but mostly the long stretch is for the traumatic injuries. Also the elastic behavior provides a constant pressure which is almost the same at rest and at work and therefore it leads to a low-static stiffness index which is important at the patient, as I said, that’s not ambulatory. This type of action is particularly recommended for the immobile. This is an example of a long stretch. It's not an Ace bandage, but here is someone with an acute ankle sprain. You don't really want him to walk on it. So you just take a little soft roll here and then you put a little Coban to just get rid of some of that edema and immobilize it. They're not walking on this. They're not using their lymphatics system or their venous system to help do pumping action initially. That might be where a long stretch may come in simply. The short stretch gets to be a little bit more involved. It delivers a low-resting pressure and a high-working pressure. It produces a continuous massage effect on the calf muscle, so that ambulation is a good thing. It helps to pump the swelling and massage the effects of the area and it causes the venous flow from the superficial network to the deep system and that’s what you're trying to do to reduce edema in the venous system. So you want external pressure from the venous superficial system through the perforators into the deep system, that’s what you're working to do. The short-stretch bandages are applied from the base of the toes to the knee or above and they're actually applied so that you have padding on the skin, you're protecting the skin, you're actually overwrapping the layers of the dressing so that they work well with calf pumping. So you're always considering how much they're walking and how much the ambulation is and the exercises to help the bandage work.


    Now, everyone has known about the paste bandage, the Unna boot or the Unna boot type bandages, the zinc oxide gelatin type bandages and there are self adhering elastic wrap, there are wraps that are applied over the actual paste bandage, but these are a little bit more of a compressive dressing. They're semi-rigid and they can maintain in place for up to weeks sometimes and they don’t get removed at night. They're good for increased wound healing around a venous wound, but they're a bit stiff. If you put a paste bandage on improperly, you can create wounds. I think that if you -- early on people were putting these on and I have patients coming in my office. They would have like little cuts in their legs because the bandages were on too tight. They weren't tucked in and folded properly and there was a whole -- there used to be a whole lecture just on how to put on an Unna boot. So just remember that that can be damaging. The multilayered systems include soft padding to help reduce any skin irritations and absorb the skin and moisture. And they also have padding over bony prominences and add bulk and padding to the ankles and in areas where you might have breakdown in the heels. And this is done on graduated compression usually equal to 40 mm of pressure although if I ask my resident to put it on with 40 mm of pressure, I'm sure we wouldn't know if it was really done, but it is in graduated fashion. When you have a condition like this, you think of a multilayered bandage because a) you want to reduce edema and b) you have to do something for that horrible skin irritation. So you just want to make sure that you're also protecting for any kind of fungal problem, bacterial problem as you put these multilayered dressings on. Multilayered compression, as I said, goes from toes to the knees, soft padding first and then you're going to put your short-stretch bandage on if you want a multilayered. Remember that it's not like Ace bandage. It's very stiff. You don't have a lot of stretch. And then this is another type of bandage, that’s the Coban Lite where you're putting it on and it does not have a lot of stretch, you just lay it on and it's stiff. And you have dress stockings, we have actually told our patients to go out and get the bower black or JOBST type stocking, make sure you get them at 10-20, 30-40 mm of pressure. It depends on the problem and long-term stockings are very, very important in maintaining reduction of the venous disease. The subject that I love is this Kinesio tape technology on the body's natural healing process. I use K-tape on everything except headaches and I probably could figure it, we use it for postop edema. We use it for quite a few, reducing our edema of the lower limbs. I'm going to show you a couple of things, but we do use it. It exhibits its efficiency through activation of the neurologic and the circulatory systems. Kinesio tape gives support and stability to the muscles and joints without affecting the circulation and range of motion. It is also used for muscle inhibition, increased circulation, increased lymphatic drainage and reducing pain. When you put it on, it lifts or raises the skin up so that you get the best flow to the lower extremity. So, as I said, I use it with my postop patients for bunions and hammertoes and ankle sprains and on and on. So a combination of this with -- I use this tape -- you can use it for plantar fasciitis, post surgical edema, ankle sprains and injuries. A lot of the chiropractors and also you see the Olympic athletes, they use it along the spine, on the shoulder. It's everywhere now in all different colors and kinds. It can actually create reduced subtalar joint swelling and this elastic therapeutic tape and there are all types of kinesiology tape now. There is RockTape, there is K-tape, there is a bunch and they're online and people know about them. But they actually structurally lift the skin opening up the superficial lymphatic systems and pathways to reduce edema. It provides lymphatic drainage, so that’s where you get your less discomfort and pain. And I want to go back for a second. I'll show you a picture of where we used that in combination, so you know, but this is a great tool that you should have to help you reduce the edema. Sometimes I'll put it around the wounds and over the legs, but you'll see.


    One of the things that we talk about in our residency program is improper dressings. In these pictures, these dressings, I'm just pointing out the couple of things. Here you have a bandage here, but what about all that edema, you know, on top of the leg, in the bottom of the foot. And now what you're going to create is a problem now proximally. How about this? It looks like the wound is doing okay, but look at all the ridges and all the compression that was abnormally done. The lady is like what's wrong with my leg. You're like, oh, that’s not good. And how about our patient here. This is a patient that had a Charcot foot and doing okay and all of the sudden, he comes in with this huge wound in the front of his foot because the bandage was so tight and of course he is neuropathic, couldn't feel it and we're looking at that guy. Okay, now we have a major problem that was created and I can tell you that bandages can create problems, so just be very, very careful that you don't do that. This is something I call combined therapy because I have a lady here that came in. She has a lot of edema in this foot compared to this foot. I don't know exactly what it is even to this day. She had a venous ultrasound normal, x-rays normal, MRI says soft tissue swelling but etiology unknown. So we don't quite know, but she is plagued by the fact that her foot is so swollen and it's painful. So I actually combined my treatment with the Kinesio tape. So what I did was I put it at the tip of toes and I put a long stretch on it right there and a long stretch here. That actually helps to lift the skin, produce a lymphatic drainage to the foot. That helps to reduce the pain and edema in the foot and then I combined it with a soft padding, soft roll and Kerlix. And then I put a Coban but this was more of a way to reduce the edema while she was still moving and she came in with a lot less pain, lot less swelling just within 48 hours. So remember that you can combine the therapies, make sure that you understand what you're using. There are reps all around telling they have all their products out there you can see them, feel them, touch them. You have had workshops on them to make a proper decision on the use of your products. Remember that there are complications. Sometimes you do not want to take this and compress someone who has severe arterial disease or maybe an uncompensated congestive failure because you can put them in failure and make it worse. Also you can be careful in these guys that have the severe arterial problems that maybe that compression is just a little bit too much. So I would like to thank you for letting me be here this weekend. I enjoyed it. I wanted to just make a mention that in the next year or so, Dr. Schoenhaus will be getting airplanes and we will be flying some places I don't know yet. So he will let us know next -- so just come next year so you can see what planes he has. Thank you.


    TAPE ENDS - [28:24]