When the Traditional Approach is Not an Option—Then What?
Compression is an essential component for the acute treatment and long-term management of chronic edema conditions.1 However, clinically, it is not unusual that patients present with comorbidities, environmental challenges, and /or behaviors that preclude the consistent use of standard of care compression therapy. Delay in the onset of care due to staffing, patient’s availability, and patient’s specific “challenges” require resourceful thinking and can often be a source of learning example for caregivers and medical providers alike.
Meet Sue—a 65-year-old female who presented to an edema management clinic with a history of progressive lower extremity (LE) swelling over the last 6 months. In addition, over the last 2 weeks, the patient’s caregivers had noted an area of “weeping” on the right anterior medial lower leg with no apparent wound. Per the family and primary care medical notes, there have been no changes in general health or medical regimen over the last 6 months to explain the progressive LE swelling. Her past medical history was significant only for schizophrenia and Parkinson’s disease. Work-up performed by the medical provider included a doppler, which was negative for blood clot, and basic lab work-up, which revealed no abnormal findings.
Clinical evaluation was notable for a well-dressed, well-cared for African American female with bilateral LE swelling in dependent distribution (right > left) (Figure 1). Of note, the feet appeared relatively less involved than the lower leg and ankle. She was minimally verbal and could transfer and ambulate short distances with minimal hand-held assistance of family. Clinical exam noted for trophic changes consistent with stage III lymphedema including (+) Stemmer sign, lipdermatosclerotic tissue changes, acanthosis, papilloma, and thickened skin folds. Scant weeping was observed from right LE anterior shin area, though no definitive wound could be identified. The LE were of normal temperature and dorsalis pedis pulse was present.
The treating clinician provided assessment of secondary lymphedema and recommended a course of modified complete decongestive therapy (CDT). Due to a conflict between the patient’s transportation and treatment slot availability, there was a delay in the start of care for 1.5 weeks. Additionally, the family expressed some concerns as to whether the patient would tolerate compression wrap as she previously did not tolerate over-the-counter knee-high stockings (“TEDs” hose, as described by her family) prescribed by her medical doctor. The clinician issued longitudinal elastic stockinette sewn at toe to mimic a “sock,” which provided about 8 mm Hg to 10 mm Hg compression per manufacturer. The family was educated with basic skin care (hygiene and moisturizer) and instructed with a home exercise program of basic range of motion of LE. In addition, the family was encouraged to have the patient frequently walk throughout the day and to make sure she got back to bed every night for a minimum of 6 to 8 hours if possible.
When the patient returned in 1.5 weeks to begin CDT, her LEs were significantly smaller and the “weeping” from the lower leg had resolved (Figure 2). When the family was asked if there had been any other change in her medical care, they replied they had only performed the recommend skin care, used the longitudinal elastic stockinette “socks,” and assisted the patient back to bed each night. Although the patient’s condition was significantly better, there was still swelling and trophic changes. Therefore, the treating clinician initiated CDT to include manual lymphatic drainage and application of a 2-layer cohesive wrap, including wrapping of the toes. The patient’s caregiver was directed to leave it in place until the next visit in 3 days unless the patient could not tolerate the compression, at which time the caregiver was instructed to remove it and resume use of the elastic stockinette “sock.” Upon return, the family reported that the patient was agitated by the wrap, so they removed it after 1 day and resumed use of the “sock.” The patient’s LEs were progressively smaller and had notable resolution of previous trophic changes (Figure 3). The patient’s family was instructed to continue with use of the longitudinal stockinette and activity regimen. Patient was discharged to family care.
Figure 1. Initial presentation.
Figure 2. First follow-up visit: the patient had been using longitudinal elastic stockinette, basic skin care, and assisted back to bed nightly for a goal of 6–8 hours.
Figure 3. Follow-up 1 week later, patient continued use of longitudinal elastic stockinette.
Question: What did this case study teach us?
Answer: The best solution is treating the problem, not the symptom. The edema was a symptom of a behavior (sitting up all the time with legs in the dependent position)—change the behavior and the symptom resolves.
The purpose of sharing this real-life case example is not to suggest that simply having your patient get back to bed every night will have a significant effect as it did for Sue. However, it does highlight the importance of looking at ALL causes of edema.
A quick primer on chronic edema
Edema is an accumulation of fluid in the intercellular tissue that occurs when the capillary filtration is greater than the lymphatic drainage.2 Thus, it can be argued that all edemas have a lymphatic component.2 There are some clinicians who want to neatly silo edema diagnosis to either purely “filtration edema” (capillary filtration greater than a functioning lymphatic system) or purely “lymphedema” (normal capillary filtration in the setting of a malfunctioning lymphatic system). However, due to the dynamic and ever-changing balance between capillary filtration and lymph drainage, there are few clinical edemas that could be categorized into those specific classifications.3 Thus, chronic edema, an umbrella term, can used to describe edema which has been present for more than 3 months and includes both “lymphedema” and chronic edemas related to chronic venous insufficiency, immobility, cancer treatment, lipedema, obesity, and/or congenital vascular malformation.2
The etiology of chronic swelling can be varied. Acute swelling of the limb over a period of less than 72 hours is more characteristic of deep vein thrombosis, cellulitis, trauma, and recent initiation of calcium channel blockers.4 Chronic accumulation of more generalized edema is typically due to onset of exacerbation of chronic systemic conditions such as congestive heart failure, renal disease, or hepatic disease.4 Dependent edema (edema that is worse with LE dependent position that improves with elevation) is likely due to venous insufficiency.4 In clinical situations, such as the elderly with multiple comorbidities, there are many factors that contribute to the etiology of the chronic swelling, including immobility, heart failure, chronic venous insufficiency, and medication side effects.2
When it comes to treatment recommendations for chronic edema, of whatever origin, optimal outcomes are achieved when there is adequate management of ALL the contributing comorbidities. Mobility and positioning throughout the day and night is often overlooked or deprioritized. Operating in conjunction with the lymphatic system, a critical “anti-edema” mechanic in the LE is the calf muscle pump.5 Incorporation of it increased mobility and altered positioning throughout the day, which is paramount for edema management success.
As was evident in the case study, Sue’s comorbidities, including altered mobility with reduced calf muscle pump due to Parkinsonian gait, limited activity, and sleeping in a chair with the legs in a dependent position, had an additive effect, resulting in the progressive swelling presentation. Making simple adjustments to Sue’s position and mobility in conjunction with light compression (8 mm Hg-10 mm Hg longitudinal elastic stockinette sewn into a “sock”), which were inexpensive, easy for the family to apply, and tolerable for the patient, added up to a successful outcome.
Immobility is a huge issue that can significantly contribute to progression of LE swelling. Have you asked your patient where they sleep? Have you addressed all the potential causes of edema?
Suzie Ehmann, PT, DPT, CWS, CLT-LANA, is Certified Lymphedema Therapist at Atrium Health Stanly and a member of the Wound Care Learning Network Editorial Board.
References
1. Gianesini S, Obi A, Onida S, et al. Global guidelines trends and controversies in lower limb venous and lymphatic disease: narrative literature revision and experts' opinions following the vWINter international meeting in Phlebology, Lymphology & Aesthetics, 23-25 January 2019. Phlebology. 2019;34(1 Suppl):4–66. doi:10.1177/0268355519870690
2. Moffatt C, Keeley V, Quere I. The concept of chronic edema–a neglected public health issue and an international response: the LIMPRINT Study. Lymphat Res Biol. 2019;17(2):121–126. doi:10.1089/lrb.2018.0085
3. Mortimer PS. The pathophysiology of lymphedema. Cancer. 1998;83(12 Suppl American):2798–2802.
4. Trayes KP, Studdiford JS, Pickle S, Tully AS. Edema: diagnosis and management. Am Fam Physician. 2013;88(2):102–110.
5. Goddard AA, Pierce CS, McLeod KJ. Reversal of lower limb edema by calf muscle pump stimulation. J Cardiopulm Rehabil Prev. 2008;28(3):174–179. doi:10.1097/01.HCR.0000320067.58599.ac
