Key Insights On Treating Wounds With Edema

Compression hose and compression pumps can be effective options to reduce edema in wound care patients. These expert panelists discuss how to optimize prescriptions of these devices and touch on when to involve other medical specialists.

Q:

Do you prescribe compression hose for patients with edema?

A:

Cynthia Cernak, DPM, will prescribe compression hose depending on several factors. When presented with cases of edema, she determines the following: the degree of edema present, the cause of the edema and if the patient has primary or secondary edema or lymphedema. In her practice, Dr. Cernak sees several factors that result in edema including but not limited to pregnancy, underlying diseases, medications, congestive heart failure, kidney disease, venous insufficiency, and psoriasis of the liver.

In patients with mild edema, Dr. Cernak finds the edema usually resolves on its own if patients modify their diet to decrease salt intake, increase water consumption and implement a walking program. For those with venous insufficiency that has no other metabolic cause, she advises ruling out congestive heart failure and kidney issues because compression and backed-up fluid can place increased stress on those organs.

When a patient presents to Dr. Cernak’s office with symptoms of little to no edema in the morning but worsening edema throughout the day, and if those patients have no pitting edema, she will routinely order a venous flow Doppler to evaluate for valvular insufficiency. For patients with valvular insufficiency that appears to be the only reason for the edema, she is comfortable prescribing compression hose for treatment.

Kazu Suzuki, DPM, CWS, often prescribes compression garments for lower extremity edema, whenever he sees swollen legs that are bothersome to the patients or otherwise impeding wound healing based on his observation. Dr. Suzuki routinely recommends starting with low-level compression, about 10 to 20 mmHg of a mild compression garment (knee-high stockings or socks), and increasing compression strength as tolerated.

More often than not, Dr. Suzuki prefers prescribing adjustable compression garments such as Circaid wraps (Performance Health) or FarrowWrap (Jobst USA). He notes these garments are very adjustable and much easier to apply, and remove in comparison with traditional compression stockings without any assistive features (such as zippers and liners). Dr. Suzuki notes one can prescribe compression hose using third-party durable medical equipment companies, such as Prism Healthcare and Byram Healthcare, as long as the practice meets documentation requirements.

Michael DeBrule, DPM, will also use compression hose routinely for patients who have spider or varicose veins, “tired legs,” or a history of venous ulceration.

When compression hose is the prescriptive remedy for edema treatment, Dr. Cernak says it is important to address the upper leg as well as the lower leg, noting that waist high compression hose is most likely necessary. When waist high compression hose is required, she suggests it might be easiest for patients to use two pairs of 20 mmHg support hose rather than attempting to struggle with a 40 mmHg support hose.

Q:

What do you do if your patients cannot adhere with wearing compression hose?

A:

Dr. Suzuki acknowledges this is a “tough but frequent problem” in practice. He says most “therapeutic level” compression stockings require 20 to 30 mmHg of compression strength but finds most of his patients do not have enough hand strength or dexterity to wear the stockings and take them off appropriately every single day.

“This is exactly why I almost never prescribe standard compression stockings unless I can ensure that my patients can be compliant with the regimen of wearing the garment every single day,” maintains Dr. Suzuki.
When patients cannot wear compression hose, Dr. DeBrule will try Velcro compression wraps. He says they are much easier for the patients to don, come in a variety of sizes and strengths, and are comfortable for most patients.  

In addition, some of Dr. DeBrule’s patients have done well with TubiGrip (Mölnlycke Health Care), an elastic tubular bandage which is cut to length and pulled on like an open-toe sock. “One of my patients with lymphedema tried everything under the sun but TubiGrip was the only product he could tolerate,” says Dr. DeBrule.

If compressive hose, a walking program, physical therapy, elevation and control of salt in the diet have failed to control the edema and if the patient has diagnosed, untreated lymphedema, Dr. Cernak warns there is an increasing risk of infection, ulceration and pain. Therefore, she suggests prescribing a lymphedema pump, which Medicare may cover for patients with lymphedema.  

Dr. Cernak has referred some patients with mild to moderate lymphedema to a physical therapist specializing in lymph drainage, saying the combination of lymph drainage with increased movement helps the body remove the excessive fluids. For patients who follow the prescriptive remedy of increased movement and continue with increased movement, she says this can become a long-term solution.   

One may treat severe edema with medication, such as diuretics, according to Dr. Cernak. As she notes, long-term management should focus on treating the underlying cause of the swelling. Causes include congestive heart failure, cirrhosis, kidney disease, kidney damage, trauma to the venous system and the lower leg including trauma related to radiation therapy for cancer, and an inadequate lymphatic system also related to removal of lymph nodes due to cancer surgery. When dealing with one of the aforementioned underlying causes, Dr. Cernak says one should only use treatment with compression after consulting with vascular doctors and primary care physicians.
 

Q:

When do you consult other specialties, such as vascular surgery or a lymphedema therapist?

A:

Dr. DeBrule will consult other specialties when patients are not improving, such as when patients need something besides support hose, a diuretic or compression wraps. For edema associated with venous ulceration, he usually refers to a vascular specialist; for heart disease, an internist; for varicose or spider veins, a phlebologist; for lymph dysfunction, a vascular specialist; and for deep venous thrombosis, an emergency room physician.  

Drs. Suzuki and Cernak also work very closely with vascular specialists (vascular surgery, interventional radiology and interventional cardiology) for various arterial and venous problems. Dr. Cernak says vascular specialists more aggressively treat venous disease with sclerosing. She emphasizes the importance of evaluating arterial flow in patients.

In addition, Dr. Suzuki will work with a local lymphedema therapist who was trained in Europe for the manual lymphedema drainage method. He notes this therapist can offer massage therapy for the lymphatic system, compression bandaging and custom compression garments, which patients often use for arm swelling after breast cancer treatment.

Dr. Suzuki notes lymphedema (or swollen legs in general, evidenced by a bowtie test, or by patients not being able to pinch a dorsal foot skin above the second toe) is rarely a surgical disease. Rather, he says lymphedema is most likely managed with physical therapy methods like compression stockings and compression bandages, and intermittent compression pumps.  

Q:

Do you prescribe a compression pump or similar medical device for edema reduction?

A:

Dr. Suzuki prescribes intermittent compression pumps for lower extremity lymphedema. He says pumps are helpful if (“and that’s a big if”) the patient can be adherent in using compression pumps every day. He recommends patients use the leg pump 30 minutes a day twice a day to start. Dr. Suzuki also advises patients “they cannot overdose on (the) leg pump” and they can use the pump as often and as long as they wish in order to control their leg edema.

Although some clinicians are concerned of pumping the leg for patients with congestive heart failure, Dr. Suzuki was not able to find good evidence against providing appropriate leg compression. He says providing leg compression is safe as long as patients are followed appropriately by their cardiologist. He recommends working closely with cardiologists, who may assist in prescribing and adjusting diuretics as necessary for swollen lower extremities.

In contrast, Dr. DeBrule does not use compression pumps. He says he has not seen enough studies indicating the efficacy, safety and cost-effectiveness of compression pumps.

Dr. Suzuki cites issues with insurance coverage for compression pumps. About a decade ago, he says it was “very easy” to get Medicare coverage for therapeutic leg pump prescription but notes documentation requirements are lot stricter today for Medicare and HMOs (PPOs will generally cover compression pumps). Dr. Suzuki says for compression pumps, Medicare requires patients to meet at least one criteria in all four of the following categories:

• A diagnosis of lymphedema either secondary to cancer (I89.0 or I97.2) or hereditary/congenital (Q82.0) or six months of non-healing ulcers
• Notes demonstrating no significant improvement after four weeks of compression/elevation/exercise
• At least two sets of calf measurements at least four weeks apart showing the patient has not significantly improved
• At least one key severity term (hyperkeratosis, hyperpigmentation, papillomas, elephantiasis, hyperplasia, or lymphorrhea)

Dr. Suzuki adds that Medicare requires physicians attest to the following statement: “The patient’s bilateral/right/left lower extremity swelling is caused in part by primary lymphedema with symptoms including hyperkeratosis and hyperpigmentation. I recommend a lymphedema pump to treat the lymphedema. The patient’s calf circumference is XXcm and XXcm, (measurements that are) unchanged compared to the calf circumference four weeks ago. The calf measurements have been taken over the four-week time period (and have) not improved with compression, exercise and leg elevation.”

Dr. Suzuki works with Tactile Medical, which manufactures and distributes medical grade leg pumps. If the insurance coverage is an issue, he may recommend a generic leg pump (Air-relax, Air Relax), which is a basic “squeeze and hold” sequential compression pump that may work to control leg edema.

Dr. Suzuki adds that there is a device that is similar-looking but is more of a high-pressure intermittent leg pump (ArtAssist, ACI Medical), which is indicated to increase arterial blood flow to the legs. He says clinicians can prescribe this pump for patients with peripheral arterial disease, especially those who were told they could not have surgical or endovascular intervention. He has anecdotally heard from physicians who manage patients with critical limb ischemia (who have exhausted surgical or endovascular therapy) with arterial leg pumps and cilostazol (Pletal) with good results.

Dr. Cernak is a partner with the Weil Foot and Ankle Institute in Kenosha, Wis.

Dr. DeBrule is in private practice at Midwest Podiatry Centers in Richfield, Minn.

Dr. Suzuki is in private practice at the Suzuki Wound Care Clinic in Beverly Hills CA. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles CA. He can be reached at Kazu.Suzuki@cshs.org.