By: Marta Ostler, PT, CWS, CLT, DAPWCA, and Janet Wolfson, PT, CLWT, CWS, CLT-LANA
Editor's Note: On April 2, 2020, WoundSource hosted its first ever virtual conference, WoundCon Spring 2020. The conference hosted 13 CME/CE accredited sessions that were attended by over 6,000 health care professionals around the world. The response was so enthusiastic, we asked some of our speakers to answer the most frequently asked questions on their subjects. This is the third blog of a 13-part series; access the full series here.
Do you see lymphedema in patients with uncontrolled diabetes? In our population of obese diabetic patients, we see very minimal lymphedema. Could this be the result of the hyperosmotic state of the blood in response to the hyperglycemia?
Janet: As described by Dr. Tony Reid, in his article on diabetes, “. . . Diabetes generally causes damage to the arteries and capillaries, and lymphedema is the result of damage to the lymphatic system. Together, these diseases result in damage to both the arterial and lymphatic systems and both lead to damage to the subcutaneous tissue, connective tissue and skin. The result is increased swelling, decreased levels of oxygen in the skin and connective tissue and susceptibility to infection." So the hyperglycemia causes degradation of arterioles and affects the nutrition to the skin and the vessels leading from it. Infection damages the lymphatic vessels, nerves, and veins, making a vicious circle of edema and infection leading to chronic lymphedema and damage to tissue, especially in the lower extremities.
What are the causes of secondary lymphedema?
Janet: In the developed world, venous disease is the biggest contributor to secondary lymphedema (phlebolymphedema), with surgical procedures that damage lymph nodes or vessels coming in second. In the more rural countries, filariasis (a parasitic infection) is the main cause of lymphedema. Other things that can lead to lymphedema include trauma, radiation, chronic infection, and obesity (For more information, visit www.lymphcareusa.org). Many risk factors for lymphedema have been identified, including non-accidental injury, such as venipuncture and chronic health problems linked to obesity, such as diabetes, hypertension, and cardiovascular disease.
Can you comment, is it better to have some compression if the patient cannot tolerate higher mmHg compression, such as 30mmHg and above?
Marta: It is always better to have some compression than no compression. Specifically, if we are talking about the lower leg, knee and below. It is important to figure out why your patient is saying that they cannot tolerate the compression. For example, is there a medical reason why they cannot tolerate the pressure? Are there other garment types that are better, such as flat knit verses circular knit, that would be more tolerable? Tolerable compression is not about the pressure, such as 30 or 20 mm Hg, but rather about the type of compression that is applied. It’s about the physics of the product.
Compression garments that are composed of primarily elastic fibers are less tolerable at higher pressures. However, those that are composed of flat knit fibers or Velcro closure devices are more tolerable at higher pressure. This is also based on the level of mobility of the patient. The stiffness of the garment is the most important thing. The stiffer the garment, the more tolerable the compression.
How much fluid does the lymphatic system return to the circulatory system, then?
Marta: The lymphatic system moves approximately 10% of the fluid in the body. The lymphatic fluid is composed of protein, minerals, bacteria, and water.
When a patient asks why their compression garment is removed at night, what would be the best reply?
Marta: A compression garment needs to be removed at night if it is a garment that could constrict their vessels when they are not moving. This type of garment tends to be more of a circular knit garment. These garments have a low working pressure and a high resting pressure. They tend to squeeze the leg when the patient is resting, and they move with the leg when the patient is up walking.
If ABI is over 1.3, let’s say in a diabetic client, is compression contraindicated? I guess what I am asking is if a patient’s ABI is 1.3 or higher, is it harmful for compression or just ineffective because of calcified vessels?
Marta: Wonderful question. There are a lot of different opinions on compression in diabetic patients. The key is knowing what type of compression is safer for your patient. The research supports leaning toward garments with high working pressure and low resting pressure for patients with a lower ABI (ankle-brachial index). Remember, when we compress patients, we are compressing all three systems: arterial, venous, and lymphatic. Therefore, the type of compression applied will affect all three systems a bit differently. High working and low resting pressures are safest with these types of patients and much more tolerable for all. Yes, calcified vessels can cause issues with fluid return. Some patients will not be able to tolerate more aggressive forms of compression because their vessels are not able to handle the flow, or any flow. Doing a vascular screen is a must prior to compression therapy.
About The Authors
Marta Ostler is the owner of Purpose Physical Therapy in Sheridan, Wyoming. Purpose Physical Therapy offers mobile services, both skin and physical rehabilitation, to its clients. Marta recently left St. Vincent’s Healthcare in Billings, MT, where she worked as a Physical Therapist focusing on patients with ulcers and edema/lymphedema. She is a Physical Therapist, Certified Wound Specialist, and Certified Lymphatic Therapist. Marta specializes in chronic wound management, as well as lymphedema/edema treatment and management. She currently works with all types of patients with deficits in mobility, functional strength, and functional independence. Marta is the founder of the Wound Clinic, a department of Sheridan Memorial Hospital, as well as a member of the American Academy of Wound Management, the American Professional Wound Care Association, and the American Board of Wound Healing. Marta also serves on the Board for the American Board of Wound Healing and the Association for the Advancement of Wound Care.
Janet Wolfson is a Physical Therapist by education, and a Wound and Lymphedema Therapist by passion. Janet has extensive experience in Wound/Lymphedema care, particularly in geriatric settings including Wound and Lymphedema clinics, skilled nursing facilities, acute, rehab and long-term acute care. Janet Wolfson’s career as a physical therapist lead her to specialize in wound care and manual lymphatic drainage. Her focus in educational training extends to wound management skills including debridement, differential diagnosis of lower extremity edema, dressing selection, and pressure ulcer prevention. Janet is a Diplomat of the American Academy of Wound Management, current member of the Association for the Advancement of Wound Care, current member of the Editorial Advisory Board for WoundSource and past board member of the Lighthouse Lymphedema Network.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.