Patients' perceptions of chronic leg ulcers

Venous leg ulcer pain and its characteristics

This study investigated the prevalence, severity and characteristics of pain associated with venous leg ulceration. Sixty-five patients suffering with venous leg ulceration were randomised to one of three treatment groups over a 12-week treatment period. All patients received short-stretch compression bandaging. Data were collected by use of a visual analogue scale and the McGill Pain Questionnaire. Seventy per cent of patients reported pain on entry to the study and within 2 weeks of effective treatment initial pain was dramatically reduced. Patients typically described their pain as throbbing, sharp, itchy, sore and tender. The affective nature of pain was often described as tiring and patients evaluated their pain as being annoying and nagging. This study highlights the importance of pain associated with venous leg ulceration.

Compression bandaging: are practitioners achieving the ideal sub-bandage pressures?

Compression bandaging is the mainstay of conservative management of patients with venous ulceration. But debate is growing over what levels of pressure to apply and how to balance this with what patients can tolerate.

Randomised, comparative study of three primary dressings for the treatment of venous ulcers

In this article, we describe a randomised trial in which two established primary dressings - Comfeel (Coloplast, UK) and Granuflex improved formulation (Convatec, UK) - were compared to Cutinova foam (Beiersdorf Medical, UK) in the management of venous leg ulcers. Patients that met the study trial criteria were randomised to receive one of the three primary dressings. All ulcers were secondarily bandaged with Comprilan (Beiersdorf Medical, UK) short-stretch compression. The three dressings were compared in terms of their ability to promote ulcer healing (closure rate and healing rate) and reduce the prevalence and severity of ulcer-associated pain, over a 12-week period. The ease with which dressings could be used in a busy outpatient clinic setting was also considered. On enrollment, groups were well matched in terms of all of the patient and ulcer parameters studies. Six patients were withdrawn for reasons unrelated to study dressings or trial procedures. Following non-parametric analysis of the study data, the three dressings were found to be equally effective at promoting ulcer healing and alleviating ulcer-associated pain. Study personnel rated Cutinova Foam as easy, if not easier, to use than Comfeel or Granuflex. This study suggests that Cutinova Foam is as safe and effective as both Comfeel and Granuflex, in the treatment of venous leg ulcers.

Living with a pressure ulcer: a descriptive study of patients' experiences

This qualitative study explored the perceptions and feelings of patients with pressure ulcers. Five participants who had suffered from pressure ulcers extending into the subcutaneous tissue and deep fascia were interviewed. A semi-structured interview technique was used, in which participants were asked a series of open questions based on the reviewed literature and the author's clinical experience. Content analysis was used to analyse the interview transcripts. The following themes emerged: pain, exudate levels, loss of independence, emotional factors, worry about healing, relationships, body image and social isolation.

Health related quality of life in patients with venous ulceration: use of the Nottingham health profile

INTRODUCTION

The Nottingham health profile (NHP) has been used in several studies of patients being treated for chronic venous leg ulceration, though there is a paucity of information on the validity of the NHP in this patient group. This study was carried out to determine this validity and to compare and contrast the results with a previous study that had used the MOS short form 36 (SF-36) in this patient group.

METHODS

Patients in four health trusts suffering from venous ulceration were interviewed at entry and after 12 weeks of treatment using high compression bandaging. Information was collected on ulcer history, general medical history, and the NHP was completed at both time points. After 12 weeks, a record was made of whether all areas of ulceration had cleared from the patients' legs (healed) or whether some ulceration remained (unhealed).

RESULTS

Of the 383 patients who made up the study population, 37% experienced complete healing of their ulceration after 12 weeks of treatment. While internal consistencies of the NHP scores were reasonable (Cronbach's alpha > 0.63), there were a high proportion of patients who scored 0 (best possible health) at entry into the study, most notably for social isolation (67.5%), emotional status (48.9%) and energy (47.4%). Despite these limitations, there was strong evidence that treatment led to significant improvements in all dimensions of the NHP for the total group (all p < 0.01). These improvements were greatest in patients whose ulcers healed compared with patients whose ulcers failed to heal for bodily pain (mean difference d = 9.4, p = 0.004). Patients whose overall health status improved had significantly greater improvements for all dimensions of the NHP (p < 0.05).

CONCLUSION

The NHP, has limitations in terms of a large floor effect (best possible health), but has similar internal consistency to the SF-36 in patients with leg ulceration. However, unlike the SF-36, the NHP is sensitive to change in the patients' ulcer status, and should therefore be considered in studies of venous leg ulcer healing.

Compliance with science: benefits of developing community leg clubs

As a district nurse providing leg ulcer management in a rural community, the author was aware that the effectiveness of compression therapy was, in many cases, compromised by poor compliance to treatment. Once the author had researched the underlying causes of non-compliance, she addressed the issues by developing innovative leg ulcer clinics ('Leg Clubs') to provide holistic care in an environment of patient empowerment, destigmatization and peer support. Analysis of data acquired over an 11-month period illustrates that this new approach has yielded significant reductions in the incidence of non-compliance, allowing the benefits of compression therapy to be realized.

Shaping the trajectory of patients with venous ulceration in primary care

OBJECTIVE

To explore the patient's experience of venous ulceration and how it is shaped within primary care.

DESIGN

Qualitative grounded theory study.

PARTICIPANTS AND SETTING

Thirty-nine patients, 33 nurses and 14 general practitioners in a major health district in England.

RESULTS

The findings indicate that patients with the chronic condition of venous hypertension are handled in an anomalous way within primary care when they present with ulcers on their lower limbs. The trajectory projections for the patients are not developed from the usual basis of a medically defined condition-specific diagnosis but from a symptom-specific diagnosis. This leads to an unusual context of care where there is a serious but unrecognized conflict of focus between the nurses and their patients. The nurses in this study tended to set priorities related to the ulcer and to the underlying pathology, whereas the patients wanted help in pain management and in normalizing their lives. The patients eventually came to a position of 'guarded alliance'2 that in this study took one of three forms: adapting and enduring, emphasizing the positive, or negotiating for comfort.

CONCLUSION

The acute care approach applied to patients with this chronic condition led to a situation where the professionals usurped the self-care potential of the patients and navigated rather than piloted them through an acute phase of an underlying chronic illness. This in turn, led to poor quality of life for many of the patients and to frustration for the nurses who were failing to achieve the outcomes they desired. Both perspectives need to be encapsulated into the treatment approach for patients with this condition: healing the ulcer and normalizing the patients' lives can and should form the basis of care.

Iodoflex and Iodosorb in the treatment of venous leg ulcers

This article reviews the use of Iodoflex and Iodosorb in chronic venous leg ulcers. A description of prevalence and quality of life issues is given. Application and method of use of Iodoflex and Iodosorb in venous leg ulcers is then detailed along with relevant clinical evidence. A case study describes the use of Iodoflex in a difficult-to-heal venous leg ulcer.

The pathophysiology of different types of leg ulcers

Leg ulcers are wounds on the leg of 6 weeks or more duration, and may range in size from very small to very large. They are caused primarily by deterioration in the peripheral circulation of the affected individual, although this may arise from a number of conditions. This article discusses the major conditions leading to the formation of a leg ulcer, in order to improve understanding of the rationale for leg ulcer management techniques.

Quality of life in leg ulcer assessment: patients' coping mechanisms

An increase in autonomous practice and the need to evidence professional update puts demands on individual nurses to reflect on their knowledge and practice. Community nurses have become expert at managing wounds, particularly leg ulcers, and using a variety of assessment strategies. However, reflections focused on the expert patient and their coping mechanisms may suggest that holistic assessment and treatment of these patients requires consideration of additional factors. The introduction of quality of life (QoL) tools may provide the rationale for an individual patient's nursing care in this specific context. Placing emphasis on the social and psychological impact of living with a leg ulcer - from the patient's perspective - may direct collaborative assessment and informed decision making.

Do leg ulcer clinics improve patients' quality of life?

The aim of this prospective study was to measure quality of life in patients with chronic leg ulcers. All eligible, consenting patients who attended the leg ulcer clinic at the Repatriation General Hospital (Tasmania, Australia) during the 16-month study period were included. Patients completed questionnaires on their first visit and at follow-up which occurred, on average, eight weeks later. This study found an improvement in three quality-of-life indicators--pain, sleep and mobility--over an average of eight weeks' treatment involving one to three visits to the clinic and home visits by primary care nurses. Of the 57 patients, 53 (93%) indicated that their wound had improved following attendance at the clinic. The cost-effectiveness of providing treatment in a dedicated leg ulcer clinic has been the focus of many previous studies. This study emphasises the additional benefits a dedicated clinic may have in improving quality of life in patients with chronic leg ulcers. Such benefits ought to be considered when allocating resources to leg ulcer services.

Health promotion in leg ulcer management in the community

This article acknowledges the substantial progress that has been made in leg ulcer management in recent years. However, there needs to be greater emphasis on health promotion, quality of life, general patient well being and promoting health within illness. Incorporating health promotion activities within venous leg ulcer management strategies may serve to empower patients to participate more fully in their care. Nurses' awareness needs to be raised to ensure that the assessment process is used as a tool to promote holistic care and not merely as a checklist to provide baseline information on the patient's health status. A series of factors highlighted during assessment are explored to demonstrate the potential for health promotion.

The impact of minor acute wounds on quality of life

A study was undertaken to explore the experiences of patients with minor acute wounds following discharge from either inpatient or day care. The sample comprised patients attending the plastic surgery dressing clinic of a district general hospital. Patients whose wounds were considered to be chronic were not included. A conceptual framework was developed from the literature, postulating that the patient is 'eclipsed' by the wound and enters the sick role before healing and recovery take place. A self-administered questionnaire was used to collect data for a mainly quantitative analysis, with some open questions to indicate avenues for further study. Unfortunately, the response rate was low, and insufficient data were obtained for effective analysis. However, trends were identified which indicated that these wounds had a significant impact on patients and their families, and recommendations were made for future studies. The survey would need to be repeated on a larger, more representative sample and include semi-structured interviews to produce generalizable results.

Living with chronic venous leg ulcers: a descriptive study of knowledge and functional health status

A descriptive design was used to identify the functional health status and knowledge level of individuals living at home with chronic venous leg ulcers (N = 21). Limitations in physical function and vitality were moderate to severe, impacting on study participants' productive activities and activities of daily living. Severe to moderate pain was experienced by 19% of the participants. In addition, knowledge deficits were apparent regarding the cause and treatment of leg ulcers. Findings of this study suggest the importance of assessing these factors in addition to the wound when caring for individuals in the community with chronic venous leg ulcers.

Older women's experience of living with chronic leg ulceration

In this study the authors sought to gain insight into the lives of older women, to focus on the experience of living with leg ulcers and to explore women's views by talking to them about their experiences. Twelve English-speaking women aged over 70 years who had experienced leg ulceration for 3 years or more were interviewed. Analysis of the interview text revealed two overarching themes: (i) gaining and maintaining control over vulnerable limb(s); and (ii) lifestyle consequences of chronic leg ulceration and impaired mobility. These themes contained several subthemes including: (i) nagging pain; (ii) self-expertise and infection; (iii) leakage, smell and embarrassment; (iv) fighting for skin and limb integrity; (v) wearing non-preferred apparel; (vi) loneliness; and (vii) coping, determination and hope. The findings of this research show that elderly women who live with leg ulcers experience multiple consequences. While the everyday problems of living with an unhealed would are addressed by the community nurse, other more subtle consequences may be overlooked. Recognition of the complex and sometimes hidden concerns of these women could help to avert the sense of helplessness which currently exists.

The development of an in-house leg ulcer management course

A description of a course designed to standardise leg ulcer management.

Measuring health-related quality of life in patients with venous leg ulcers

INTRODUCTION

The effect on quality of life by healing leg ulcers is not known and no validated disease-specific tool is available for measuring health-related quality of life (HRQoL) for people with venous leg ulcers. The objective of this paper was to compare four generic instruments [MOS 36-Item Short-Form Health Survey (SF-36); EuroQol (EQ); McGill Short Form Pain Questionnaire (SF-MPQ) and the Frenchay Activities Index (FAI)] used for measuring HRQoL in people with venous leg ulcers, and to offer guidance on the most appropriate tool for researchers.

METHODS

Two hundred and thirty-three patients with venous leg ulcers were recruited as part of a randomised controlled trial of the cost-effectiveness of community leg ulcer clinics. Subjects completed questionnaires containing the four instruments on three occasions (initial assessment, 3 and 12 months). The discriminative and evaluative properties of the four instruments were compared.

RESULTS

All four instruments were acceptable to patients, taking a mean of 19.3 (SD 6.3) min to complete. At initial assessment, the SF-MPQ had poorer discriminative properties than the other three instruments and was not able to distinguish between the different patient groups in relation to age and ulcer duration. The FAI was good at discriminating between the different patient groups (at initial assessment) in relation to age, mobility and ulcer size. At the three-month follow-up, the SF-MPQ was more responsive than the other measures and detected changes in HRQoL, whereas the EQ and SF-36 did not. At 12 months, the SF-MPQ still identified differences and the SF-36 and EQ also did at this stage.

CONCLUSION

In the absence of a validated condition-specific tool for measuring changes in general health status for patients with venous leg ulcers, we make the following recommendations. For evaluating the outcome of interventions with a short-term follow-up (three months) in a clinical study we recommend the SF-MPQ and for 12-month follow-up in a clinical study the SF-36, with or without the SF-MPQ.

A systematic review of compression therapy for venous leg ulcers

The aim of the study was to determine the relative effectiveness of compression therapies used in the treatment of venous leg ulcers. Randomized controlled trials (RCT) were sought using a search strategy that aimed to identify relevant RCT by searching eight electronic databases (including Medline, Embase and CINHAL), conference proceedings and hand searching key journals. In addition, citations within papers were scrutinized to identify any relevant studies. Suitability for inclusion in this review was determined by a critical appraisal of key determinants of the quality of the trials. Trials that included patients of mixed ulcer aetiology were excluded unless the results of patients with venous disease were reported separately. Data was extracted independently by two reviewers and synthesized quantitatively and qualitatively. Losses to follow-up/withdrawals were assumed to be failures of treatment. A total of 132 articles were identified, and of these eight fulfilled the inclusion criteria. The remaining 126 trials were excluded due to trial design flaws, the inclusion of mixed/arterial aetiology ulcers or because they were non-RCT. Meta-analysis using a random-effects model showed the benefits of multi-layer and elastic compression bandages. It was concluded that more high-quality trials are required and that more emphasis should be placed on economic and quality of life data to try to ascertain the cost-effectiveness and utility of the treatment options available.

Perceived health in a randomised trial of treatment for chronic venous ulceration

STUDY OBJECTIVE

To observe changes in perceived health in patients during a clinical trial of treatments for venous leg ulceration.

DESIGN

Randomised prospective factorial trial in patients with venous ulceration. Each patient randomised to a bandage, dressing and a drug. Perceived health assessed at entry and after 24 weeks.

SETTING

Outpatient departments and patient's home.

PATIENTS

Two hundred patients presenting to two vascular services in Falkirk and Edinburgh with chronic (duration > 2 months) non-healing venous ulceration. STATISTICAL ANALYSIS AND MAIN RESULTS: Analysis using the Nottingham Health Profile revealed that after 24 weeks there were significant improvements in all subscores (p < 0.01) with the exception of social isolation (p = 0.081). Patients with healed ulceration had improved in energy, pain, emotion, sleep and mobility compared with those whose ulceration failed to heal (p < 0.05). Patients randomised to four layer bandaging had significantly better energy (diff = 7.9, 95% CI 0.2, 15.6, p = 0.04) and mobility (diff = 4.5, 95% CI 0.0, 9.0, p = 0.046). This difference could be explained largely by the improved healing of patients randomised to this bandage system (67/97 vs. 50/103, OR = 2.37, 95% CI 1.31, 4.27).

CONCLUSIONS

Improvements in perceived health were significantly greater in patients whose ulcers had completely healed. Methods of treatment which offer improved healing for patients with venous leg ulceration are likely to improve patients' perceived health status.

Cost effectiveness of community leg ulcer clinics: randomised controlled trial

OBJECTIVES

To establish the relative cost effectiveness of community leg ulcer clinics that use four layer compression bandaging versus usual care provided by district nurses.

DESIGN

Randomised controlled trial with 1 year of follow up.

SETTING

Eight community based research clinics in four trusts in Trent.

SUBJECTS

233 patients with venous leg ulcers allocated at random to intervention (120) or control (113) group.

INTERVENTIONS

Weekly treatment with four layer bandaging in a leg ulcer clinic (clinic group) or usual care at home by the district nursing service (control group).

MAIN OUTCOME MEASURES

Time to complete ulcer healing, patient health status, and recurrence of ulcers. Satisfaction with care, use of services, and personal costs were also monitored.

RESULTS

The ulcers of patients in the clinic group tended to heal sooner than those in the control group over the whole 12 month follow up (log rank P=0.03). At 12 weeks, 34% of patients in the clinic group were healed compared with 24% in the control. The crude initial healing rate of ulcers in intervention compared with control patients was 1.45 (95% confidence interval 1.04 to 2. 03). No significant differences were found between the groups in health status. Mean total NHS costs were 878.06 pounds per year for the clinic group and 859.34 pounds for the control (P=0.89).

CONCLUSIONS

Community based leg ulcer clinics with trained nurses using four layer bandaging is more effective than traditional home based treatment. This benefit is achieved at a small additional cost and could be delivered at reduced cost if certain service configurations were used.

Measuring health-related quality of life in venous disease: practical and scientific considerations

An important and often neglected aspect in the evaluation of patient outcomes in venous disease is quality of life. This paper addresses the why, what, and how of measuring health-related quality of life (HRQL) in venous disease by providing an overview of practical and scientific considerations in developing and using measures of HRQL in general. It begins with a brief overview of developments in the field of measuring HRQL and the definition of HRQL. This is followed by a consideration of issues relevant to the assessment of HRQL including generic and disease-specific measures, multiple components of HRQL, different methods of measurement, measuring change, and cultural appropriateness of HRQL measures. In the next section, criteria for evaluating the scientific credibility and practical utility of HRQL measures are outlined, followed by a description of some widely used generic and disease-specific measures of HRQL, including measures of HRQL in chronic venous disorders of the leg (CVDL).

Living with a venous leg ulcer: a descriptive study of patients' experiences

This study aimed to describe the experience of living with a venous leg ulcer from the patient's perspective, to answer the question 'What is it like to live with a venous leg ulcer?' Investigating the experience of illness is important in understanding how disease processes affect people, how they understand and cope with these processes, and how care may be given most effectively. Little research was identified which examined these areas with reference to people with leg ulceration. A qualitative approach was taken in the following study, using phenomenological methods to describe the experience of venous leg ulceration. Informal unstructured interviews were conducted with 13 informants, guided by their descriptive priorities. Tape recordings were then transcribed and analysed for recurrent themes and their meanings. It was found that certain symptoms of ulceration, principally pain, were the overwhelming feature of the experience. These symptoms caused significant restrictions in people's lives, particularly in their ability to walk and go out. Treatment was not described as being efficacious in ameliorating these symptoms, but nevertheless great confidence and trust was placed in the expertise of nurses. People coped with the experience mainly by a process of normalizing its components. It is concluded that if treatment is to meet the needs of those suffering venous leg ulceration, then symptom control must be the highest priority.