Conference Insights
“Compression A-Z” Extended Q&A
12/10/2020
- Tips and tricks for Champagne legs
- Short answer: Padding
- Long answer: Realize don’t have to completely restore normal shape of limb rather decrease the circumferential variance (really large to really small need to be adjusted to reflect a slow taper) to optimize compression wrap staying in place. Also see this issue with patients with muscle atrophy (think elderly folks that aren’t walking or those with neurological issues like SCI, CVA, post-polio). Compression applied to these limbs result in really small lower leg but then may result in worsening forefoot swelling. In these patients, some padding (simple abd pad placed around back of leg) is sufficient. Be mindful when adding padding to not add too much to compromise mobility and/or footwear.
- Video for toe wrap: https://www.woundsresearch.com/video/applying-toe-wrap-two-layer-cohesive-compression
- Textured product sun glitz or other product
- Short answer: sun glitz is a product that lymphedema therapist use directly on skin at the top of a bandage system (thigh or upper arm) to hold the bandage up – it comes in a non-slip foam roll that can be cut to size (https://www.bandagesplus.com/foam-bandage-by-sun-glitz);it is reusable; it should be used only on intact skin
- Long answer: Longitudinal Elastic Stockinette (EdemaWear) or Fuzzy Wale Compression is my go-to for textured product that is easily layered under other compression applications ranging from two layer cohesive to a multi-layer lymphedema wrap with ½ gray foam. In my clinical experience I have found that it does an excellent job breaking down the fibrotic tissue (lipodermatosclerotic tissue), improves edema reduction and wound healing results
- What to use as a wrap when transitioning b/t wound care -> outpatient lymphedema clinic
- Short answer: Any of your short stretch cohesive, appropriately applied can be used as a transition as they can remain in place for up to 7 days.
- Long answer: There is a huge misperception regarding compression applications that are appropriate for lymphedema vs. venous edema vs. lipedema vs. orthopedic/post-surgical/traumatic edema vs. dependent edema. In very simple terms edema is edema. The cause is the same… insufficiency of the lymphatics. Although the cause of the swelling may vary, treatment is compression. The ideal compression for all forms of edema/swelling is a bandage/garment that will optimize lymphatic and venous function while not impairing arterial circulation. The difference is the patient …. the person you are applying the compression on and where you are applying it!!! This is where the S.T.R.I.D.E. approach to compression. Compression should be matched to patients Shape, Tissue texture, amount of Refill, individualized Issues (link to online reference can be found on the Journal of Wound Care Resource page).
- Should you refer to vein clinic those with recurrent ulcerations?
- Short answer: YES!
- Longer answer: Any patient who presents with signs/symptoms of CVI, PAD, or h/o recurrent ulcerations should be referred to a vascular specialist – especially those with recurrent ulcerations to check both arterial and venous function. The other important thing to remember to do is talk to your patients about modifiable risk factors: hygiene, weight, diet, blood sugar, and activity level. Far too often patients are sleeping in chairs because of chronic low back pain, not bathing regularly, eating poorly, morbidly overweight, not taking their medications, just being unhealthy. The wound doesn’t develop in isolation of vascular disease. Chronic non-healing wounds are multi-factorial. When patients ask me if they are going to have to deal with this for the rest of their lives, I will frankly reply, ‘Yes – unless you address modifiable risk factors.’ It is important that we engage the patient in their own care. We are not healing the wound. We are creating an environment in which the wound has the most opportunity to heal. And as the patient is with themselves 24hrs /day, 7days /week it is important that they are active participants in their care.
- Textured product tubigrip vs? Do you apply first?
- Short Answer: Longitudinal elastic stockinette – EdemaWear – Fuzzy Wale Compression
- Long Answer: I do apply the EdemaWear first with only a minimal contact layer between the wound and the EdemaWear. A recently published study demonstrated that the inclusion of EdemaWear under compression applications created a unique distribution of pressure across the sensor. This pattern of pressure distribution is mirrored in the skin and along wound margins when used under compression. I have antidotally observed healing in scalloped pattern, even punched out arterial wounds with incorporation of this textured product
- Compression for post skin grafting scar management
- Short Answer: 2 layer cohesive evenly applied
- Long Answer: Ideally should use compression before graft is placed to optimize macro- and micro-circulation BEFORE the graft for optimal survival of the graft and also optimal cosmetic outcomes.
- Zinc and calamine wraps macerate the wounds
- Short Answer: No - not the foam zinc/foam calamine
- Long Answer: My only experience has been with the foam version of the 2 layer cohesive – this is made by Milliken – Coflex with Zinc/Calamine
- How to get compression bandages reimbursed
- Short answer: network and plan ahead
- Long answer: Local a DME in your area – if patient has open wound, short stretch bandages (those used by lymphedema therapist – i.e., Comprilan, Rosidal K, BiaForm, LoPress, SoftCompress); additionally, as outpatient PT/OT can bill for application of bandage per body part – have to look at charge reimbursement.
- I am going to get you a longer answer to this one – have email to Brandy McKeown who is a therapist in private practice
- Recommendation for compression pump post infection
- Short answer: YES!
- Long answer: IPC can be used once see infection is improving. But remember, IPC is not a stand-alone treatment; should be use as adjunctive treatment with other compression modalities
- Patient with ABI 0.7 to 0.8 , not surgery candidate.
- Sustainable compression without reimbursement
- Short Answer: Educate patients, work with your facility to make options available
- Long Answer: This is a huge issue and deserves a longer post but suffice it to say… First and foremost, you must educate your patients and yourself/your staff!! All compression is not created equal. (S.T.R.I.D.E. reference here). One size does NOT fit all. I tell patients you get what you pay for. A sock from local drug store is not designed or sized for most of the patients we are seeing in the wound care clinic. Patients need to understand that compression products purchased from local drug store are not of the same quality as those produced by compression manufacturer. The quality of the materials, dosage supplied is not regulated therefore no guarantee. Second, you know your patients. There are people who do have the money to afford a product that will work if you educate them and explain that they do need it – that it is medically necessary. Now be prepared if you make a recommendation you need to be specific. Do NOT just send your patient to the local DME to be fitted. Realize that what the DME stocks may not be the garment that your patient needs. Be specific!!! All major manufacturers offer a continuum from light circular knit, stiffer circular knit, soft flat knit, regular flat knit and adjustable wraps. Third, be creative. Work with your facility to offer direct purchase of compression thru the facility. Could offer payment plans to allow patient to pay off garments in monthly payments. Look into grants that might be available to assist those who meet eligibly criteria (local foundation), apply for a grant to offer support.
- Payment when switching between long stretch /short stretch in outpatient lymph clinic:
- I am assuming they are asking about reimbursement for bandages which we will answer in the other post.
