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Faerber G, Fennema P, Hirsch T, Szuba A, Kahle B. Benefits of an Adjustable Compression Garment System for the Reduction of Chronic Leg Oedema (ACROE Study). Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00477-5. [PMID: 38866131 DOI: 10.1016/j.ejvs.2024.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/09/2024] [Accepted: 06/05/2024] [Indexed: 06/14/2024]
Abstract
OBJECTIVE This study aimed to assess whether a specific adjustable compression garment (ACG) system (Coolflex Standard Calf and Coolflex Standard Foot; Sigvaris Inc.) promotes self-care in patients with chronic leg oedema. Secondary aims were to assess the effectiveness of this ACG in reducing oedema, improving patient reported outcomes, and determining the patients' degree of satisfaction with the handling of the wrap. METHODS This was a multicentre prospective observational study. The study included 99 adult patients aged 18 - 90 years presenting with chronic oedema of the lower extremity, which encompasses conditions such as lymphoedema, venous oedema, and phlebolymphoedema. At baseline, all patients received an ACG. After two to three days and after six weeks, their overall satisfaction with the therapy was assessed. Leg volume was determined in a contactless manner during the baseline and follow up visits. All patients completed the cross cultural adaptation of the Lymphoedema Functioning, Disability and Health Questionnaire for Patients with Lymphoedema of the Lower Extremity in Germany (Lymph-ICF-UG). RESULTS A total of 86 patients completed the study and were followed up for six weeks. At the final six week follow up, 82 (95.3%) of the 86 subjects indicated that they were able to put on the wrap independently or with a little help from relatives. The overall satisfaction rate was 88.0% (95% confidence interval [CI], 79.64 - 93.9%). The mean leg volume reduction from baseline to six weeks was -4.7% (95% CI -6.3 - -3.0%; p < .001). Lymph-ICF-UG scores and scores in all domains improved significantly from baseline to the final follow up. CONCLUSION The ACG used in this study was found to promote self-care in a high proportion of patients with chronic leg oedema. A significant reduction in oedema was observed.
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Affiliation(s)
| | - Peter Fennema
- AMR Advanced Medical Research, Männedorf, Switzerland
| | - Tobias Hirsch
- Practice for Internal Medicine and Vascular Diseases, Halle, Germany
| | - Andrzej Szuba
- Department of Angiology and Internal Medicine, Wrocław Medical University, Wrocław, Poland
| | - Birgit Kahle
- Department of Dermatology, University of Schleswig-Holstein - Campus Lübeck, Lübeck, Germany
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2
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Payne D. Reducing the burden: managing lymphoedema and its complications. Br J Community Nurs 2024; 29:296-300. [PMID: 38814832 DOI: 10.12968/bjcn.2024.29.6.296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Lymphoedema effects approximately 200 000 people in UK. It is a chronic condition without a cure but there is much that can be done to ease and manage these complications. This article looks at the eight most common complications, providing advise on how to manage them, derived from the literature and the author's own experience. It also presents advise on how nurses can promote self-management of these complications, promoting patients' self-care.
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3
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Ochalek K, Kurpiewska J, Gradalski T. Adjustable Compression Wraps (ACW) vs. Compression Bandaging (CB) in the Acute Phase of Breast Cancer-Related Arm Lymphedema Management—A Prospective Randomized Study. BIOLOGY 2023; 12:biology12040534. [PMID: 37106735 PMCID: PMC10135916 DOI: 10.3390/biology12040534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/27/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023]
Abstract
The objective of this study is to compare the effectiveness, comfort and possibilities of the self-application of adjustable compression wraps (ACW) with compression bandaging (CB) in the acute phase of treatment in advanced upper-limb lymphedema. In total, 36 patients who fulfilled the admission criteria were randomly assigned into ACW-Group (18 patients), or CB-Group (18 patients). Treatment in both groups lasted for two weeks. In the first, all patients were educated in applying adjustable compression wraps (ACW-Group) or self-bandaging (CB-Group) and treated by experienced physiotherapists. In the second week, the use of ACW and CB was continued by the patients themselves at home. In both groups, a clinically significant reduction in the affected limb volume was found after the first week (p < 0.001). A further decrease in the affected limb volume within the second week was noted only in the CB-Group (p = 0.02). A parallel trend was found in the percentage reduction in the excess volume after one and two weeks of compression therapy. Within two weeks, both groups achieved a significant improvement in decreasing lymphedema-related symptoms, but women from the ACW-Group reported complications related to carrying out compression more frequently (p = 0.002). ACW can reduce lymphedema and disease-related symptoms, but based on the results it is difficult to recommend this method as an alternative option in the acute phase of CPT among women with advanced arm lymphedema.
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Affiliation(s)
- Katarzyna Ochalek
- Faculty of Motor Rehabilitation, Institute of Clinical Rehabilitation University of Physical Education, 31-571 Krakow, Poland
- Lymphedema Clinic, St. Lazarus Hospice, 31-380 Krakow, Poland
- Correspondence:
| | - Joanna Kurpiewska
- Lymphedema Clinic, St. Lazarus Hospice, 31-380 Krakow, Poland
- Chair of Orthopaedics, Traumatology and Rehabilitation, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, 30-705 Krakow, Poland
| | - Tomasz Gradalski
- Lymphedema Clinic, St. Lazarus Hospice, 31-380 Krakow, Poland
- Chair of Palliative Medicine, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, 30-705 Krakow, Poland
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Abstract
Lymphoedema is more than 'swollen legs'; it is an unpleasant condition that affects approximately 260 000 people in the UK. This article briefly looks at what the lymphatic system is and what lymphoedema is. It then looks at compression wraps and argues for wider use with patients, as they can promote self-care in patients.
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Affiliation(s)
- Drew Payne
- Member of the Royal College of Nursing, Community Nurse with Whittington Health
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5
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Pannier F, Noppeney T, Alm J, Breu FX, Bruning G, Flessenkämper I, Gerlach H, Hartmann K, Kahle B, Kluess H, Mendoza E, Mühlberger D, Mumme A, Nüllen H, Rass K, Reich-Schupke S, Stenger D, Stücker M, Schmedt CG, Schwarz T, Tesmann J, Teßarek J, Werth S, Valesky E. S2k guidelines: diagnosis and treatment of varicose veins. DER HAUTARZT; ZEITSCHRIFT FUR DERMATOLOGIE, VENEROLOGIE, UND VERWANDTE GEBIETE 2022; 73:1-44. [PMID: 35438355 PMCID: PMC9358954 DOI: 10.1007/s00105-022-04977-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/23/2022] [Indexed: 11/29/2022]
Affiliation(s)
- F Pannier
- Praxis für Dermatologie und Phlebologie, Helmholtzstr. 4-6, 53123, Bonn, Germany.
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6
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Bergmann A, Baiocchi JMT, de Andrade MFC. Conservative treatment of lymphedema: the state of the art. J Vasc Bras 2021; 20:e20200091. [PMID: 34777487 PMCID: PMC8565523 DOI: 10.1590/1677-5449.200091] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 10/08/2020] [Indexed: 11/22/2022] Open
Abstract
This article aims to discuss the possibilities of conservative and non-pharmacological treatments for lymphedema. A non-systematic review of the literature was carried out, including studies involving human subjects with different types of lymphedema. Several approaches to lymphedema treatment have been reported and Complex Decongestive Therapy (CDT) has been considered the most effective treatment for limb lymphedema. Other conservative treatments have been proposed such as Taping, Extracorporeal Shock Wave Therapy, Acupuncture, Photobiomodulation Therapy, Endermologie, Intermittent Pneumatic Compression, and Low-frequency, Low-intensity Electrotherapy. The choice of the therapeutic approach to be employed should consider lymphedema characteristics, the therapist's experience, and the patient's wishes. In addition, since this is a chronic condition, the patient must adhere to the treatment. To this end, the therapeutic proposal may be the key to better control of limb volume.
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Affiliation(s)
- Anke Bergmann
- Instituto Nacional de Câncer, Rio de Janeiro, RJ, Brasil
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7
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[Medical compression therapy of the extremities with medical compression stockings (MCS), phlebological compression bandages (PCB), and medical adaptive compression systems (MAC) : S2k guideline of the German Phlebology Society (DGP) in cooperation with the following professional associations: DDG, DGA, DGG, GDL, DGL, BVP. German version]. Hautarzt 2021; 72:137-152. [PMID: 33301064 DOI: 10.1007/s00105-020-04734-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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8
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Rabe E, Földi E, Gerlach H, Jünger M, Lulay G, Miller A, Protz K, Reich-Schupke S, Schwarz T, Stücker M, Valesky E, Pannier F. Medical compression therapy of the extremities with medical compression stockings (MCS), phlebological compression bandages (PCB), and medical adaptive compression systems (MAC) : S2k guideline of the German Phlebology Society (DGP) in cooperation with the following professional associations: DDG, DGA, DGG, GDL, DGL, BVP. Hautarzt 2021; 72:37-50. [PMID: 33386416 PMCID: PMC8692288 DOI: 10.1007/s00105-020-04706-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2020] [Indexed: 02/02/2023]
Affiliation(s)
- E Rabe
- Emeritus Klinik und Poliklinik für Dermatologie und Allergologie, Universitätsklinikum Bonn (AöR), Venusberg-Campus 1, 53127, Bonn, Germany.
| | - E Földi
- Földiklinik, Rösslehofweg 2-6, 79856, Hinterzarten, Germany
| | - H Gerlach
- , Zehntstr. 25, 68519, Viernheim, Germany
| | - M Jünger
- Klinik und Poliklinik f. Hautkrankheiten, Universitätsmedizin, Ferdinand Sauerbruchstraße, 17475, Greifswald, Germany
| | - G Lulay
- Klinik für Gefäß- u. Endovaskularchirurgie, Phlebologie-Lymphologie, Frankenburgstr. 31, 48431, Rheine, Germany
| | - A Miller
- Dermatologische Praxis, Wilmersdorfer Str. 62, 10627, Berlin, Germany
| | - K Protz
- Wundforschung, Universitätsklinikum Hamburg-Eppendorf, Bachstr. 75, 22083, Hamburg, Germany
| | - S Reich-Schupke
- Privatpraxis für Haut- und Gefäßmedizin, Wundtherapie, Hertener Str. 27, 45657, Recklinghausen, Germany
| | - T Schwarz
- Praxis für Gefäßmedizin, Konrad Goldmann Str. 5b, 79100, Freiburg, Germany
| | - M Stücker
- Klinik für Dermatologie, Venerologie und Allergologie, St. Josef Hospital, Ruhr-Universität Bochum, Gudrunstraße 56, 44791, Bochum, Germany
| | - E Valesky
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - F Pannier
- Praxis für Dermatologie & Phlebologie, Helmholtzstr. 4-6, 53123, Bonn, Germany
- Dermatologische Universitätsklinik Köln, Cologne, Germany
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9
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Premnath S, Nour E, Abdelhaliem A, Rowlands T, Kuhan G. A higher body mass index means worse satisfaction outcome in obese patients undergoing varicose vein surgery. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2021. [DOI: 10.4103/ijves.ijves_131_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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10
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Abouelazayem M, Elkorety M, Monib S. Breast Lymphedema After Conservative Breast Surgery: An Up-to-date Systematic Review. Clin Breast Cancer 2020; 21:156-161. [PMID: 33358602 DOI: 10.1016/j.clbc.2020.11.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/28/2020] [Accepted: 11/27/2020] [Indexed: 10/22/2022]
Abstract
Although arm lymphedema following breast cancer treatment is a common complication; breast lymphedema following treatment is not uncommon. Several risk factors were found to contribute to breast lymphedema, including axillary surgery, high body mass index (BMI), increased bra cup size, adjuvant chemotherapy, locoregional and radiotherapy boost, and upper outer quadrant tumors. We aimed to provide a review to help avoiding or management of breast lymphedema. The search term 'breast lymphedema' was combined with 'breast conservative surgery' and was used to conduct a literature research in PubMed and Medline. The term lymphedema was combined with breast, conservative, and surgery to search the Embase database. All papers published in English were included with no exclusion date limits. A total of 2155 female patients were included in this review; age ranged from 26 to 90 years. The mean BMI was 28.4 of the studies that included patients who underwent conservative breast surgery. Incidence of breast lymphedema ranged from 24.8% to 90.4%. Several risk factors were linked to breast lymphedema after conservative breast surgery, such as BMI, breast size, tumor size, tumor site, type of surgery, and adjuvant therapy. Treatment options focused on decongestive lymphatic therapy, including manual lymphatic drainage, self-massaging, compression bras, or Kinesio taping. Breast lymphedema is a relatively common complication, yet there is no clear consensus on the definition or treatment options.
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Affiliation(s)
- Mohamed Abouelazayem
- Surgical Department, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Mohamed Elkorety
- West Hertfordshire Breast Care Unit, West Hertfordshire Hospitals NHS Trust, Albans, UK
| | - Sherif Monib
- West Hertfordshire Breast Care Unit, West Hertfordshire Hospitals NHS Trust, Albans, UK.
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11
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Borman P, Koyuncu EG, Yaman A, Calp E, Koç F, Sargut R, Karahan S. The Comparative Efficacy of Conventional Short-Stretch Multilayer Bandages and Velcro Adjustable Compression Wraps in Active Treatment Phase of Patients with Lower Limb Lymphedema. Lymphat Res Biol 2020; 19:286-294. [PMID: 33270499 DOI: 10.1089/lrb.2020.0088] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Compression is the most important component of complete decongestive therapy (CDT), but there is no standard best method for applying compression. The aim of this study was to evaluate the comparative efficacy of conventional multilayer short-stretch bandaging, and a velcro adjustable compression wrap with regard to volume reduction, ultrasonographic measurements, functional-status, and quality of life (QoL) in the active CDT period of patients with lower limb lymphedema. Methods and Results: The demographic and clinical variables of lower limb lymphedema patients were recorded. All patients received skin care education, manual lymphatic drainage, and supervised lyphedema exercises, and were randomly allocated to Group1 (multilayer short-stretch bandaging-Rosidal-K®) or to Group 2 (adjustable-compression-velcro-wrap-Circaid Reduction-kit®) for a duration of 3 weeks with 15 sessions. Limb volumes were assessed by perometer. Ultrasonographic measurements included subcutaneous soft tissue thickness. The functional disability and QoL were evaluated by the Lower Extremity Functional Scale and LYMQOL-Leg (Lymphedema Quality of Life Questionnaire-Leg), respectively, at baseline, after CDT, and at first-month follow-up. Thirty-six patients (10 male and 26 female) with mean age of 51.6 ± 11.7 years were included. Fourteen patients had primary and 22 patients had secondary lymphedema. The median duration of lymphedema was 68 months. Significant improvements in volumes and ultrasonographic measurments were observed in both groups at the end of therapies, and improvements sustained up to a month. Appearance, symptoms, and overall QoL-subscores were improved only in Group 2. Conclusion: In conclusion, adjustable compression velcro-wrap performed as a part of CDT can greatly reduce the volume similiar to conventional multilayer bandages, as well as improve the QoL. It can be a comfortable alternative to the conventional multilayer bandages in the active treatment phase of the CDT.
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Affiliation(s)
- Pinar Borman
- Ankara City Hospital, Department of Physical Medicine and Rehabilitation, Bilkent, Ankara, Turkey.,Department of Physical Medicine and Rehabilitation, Kastamonu University Medical Faculty, Kastamonu, Turkey
| | - Esra G Koyuncu
- Department of Physical Medicine and Rehabilitation, University of Hacettepe Faculty of Medicine, Ankara, Turkey
| | - Ayşegül Yaman
- Department of Physical Medicine and Rehabilitation, Gulhane Education and Research Hospital, Ankara, Turkey
| | - Emel Calp
- Department of Physical Medicine and Rehabilitation, University of Hacettepe Faculty of Medicine, Ankara, Turkey
| | - Funda Koç
- Department of Physical Medicine and Rehabilitation, University of Hacettepe Faculty of Medicine, Ankara, Turkey
| | - Rüveyda Sargut
- Department of Physical Medicine and Rehabilitation, University of Hacettepe Faculty of Medicine, Ankara, Turkey
| | - Sevilay Karahan
- Department of Biostatistics, University of Hacettepe Faculty of Medicine, Ankara, Turkey
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12
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Tidhar D, Deutscher D, Armer JM. Lymphoedema, a significant health problem in Israel: A descriptive community-based study. Int Wound J 2020; 20:1343-1360. [PMID: 33236836 PMCID: PMC10088862 DOI: 10.1111/iwj.13523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 11/03/2020] [Accepted: 11/07/2020] [Indexed: 11/27/2022] Open
Abstract
Lymphoedema (LE) is recognised as a chronic disabling disease. Knowledge on patient characteristics, treatments, and outcomes in Israel is lacking. The aim of the study was to (a) describe demographic and health characteristics, treatments, utilisation, and functional outcomes of patients receiving physical therapy due to LE in a large nationwide healthcare provider in Israel; and (b) assess the feasibility of conducting a future practice-based evidence (PBE) study. This is a retrospective observational cohort study. Descriptive analyses of an electronic medical record database were performed. Data from 6013 patient episodes were analysed. A high proportion of patients had two or more comorbidities (80%) and chronic medication use (85%) with increasing rates over the 8-year period. The most frequent LE classification was stage 2 (45%). A majority of LE was in the lower limbs (51%) with increasing rates over the years. The most frequent treatment-related activity was measuring limb circumference and the most frequent intervention was educating for self-management. This study provides a first comprehensive description of patient characteristics receiving physical therapy for LE in Israel. The available database offers an opportunity for PBE studies. Recommendations for improvements in specific data collection processes were identified.
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Affiliation(s)
- Dorit Tidhar
- Department of Physical Therapy, Maccabi Healthcare Services, Netivot, Israel
| | - Daniel Deutscher
- Maccabitech Institute for Research and Innovation, Maccabi Healthcare Services, Tel-Aviv, Israel
| | - Jane M Armer
- Sinclair School of Nursing, University of Missouri, Columbia, Missouri, USA
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13
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Mansur AT, Ozker E, Tukenmez Demirci G. A case of elephantiasis nostras verrucosa treated successfully by a new type of compressive garment. Dermatol Ther 2020; 33:e14348. [DOI: 10.1111/dth.14348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 08/29/2020] [Accepted: 09/07/2020] [Indexed: 11/27/2022]
Affiliation(s)
- A. Tulin Mansur
- Department of Dermatology Baskent University Istanbul Hospital Istanbul Turkey
| | - Emre Ozker
- Department of Health Sciences School of Medicine, Acibadem Mehmet Ali Aydinlar University Istanbul Turkey
| | - Gulsen Tukenmez Demirci
- Department of Dermatology School of Medicine, Acibadem Mehmet Ali Aydinlar University Istanbul Turkey
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14
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Stephen E, Samuel V. Venous ulcer management: Frontier unconquered. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2020. [DOI: 10.4103/ijves.ijves_48_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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15
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Shavit E, Alavi A. Compression therapy for non-venous leg ulcers: Current viewpoint. Int Wound J 2019; 16:1581-1586. [PMID: 31606946 DOI: 10.1111/iwj.13247] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 09/18/2019] [Indexed: 11/30/2022] Open
Affiliation(s)
- Eran Shavit
- Division of Dermatology, Department of Medicine, Women's College Hospital, University of Toronto, Toronto, Canada
| | - Afsaneh Alavi
- Division of Dermatology, Department of Medicine, Women's College Hospital, University of Toronto, Toronto, Canada
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16
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Ehmann S, Bock K. Case report to demonstrate the need for selection criteria for optimal adjustable Velcro wrap prescription. J Wound Care 2019; 27:S10-S17. [PMID: 29334016 DOI: 10.12968/jowc.2018.27.sup1.s10] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Compression, in the form of either a compression bandage or a compression stocking, has been touted as the gold standard for treatment of swelling and venous leg ulcers (VLUs). Adjustable Velcro wraps have been marketed as compression alternative. Although there is a growing body of evidence to support use of these products, there has not been a critical evaluation of the functionality of the devices to best matching product to patient presentation and ability to use the device effectively. Unlike compression garments, which are classified by compression category (class I/II or flat knit/circular), there is not an algorithm to direct health professionals to best match a specific adjustable Velcro wrap to an individual patient presentation. This small case series demonstrates that although each product performed as marketed in vitro, performance in clinical setting varied greatly dependent on patient presentation and functional skill level.
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Gianesini S, Obi A, Onida S, Baccellieri D, Bissacco D, Borsuk D, Campisi C, Campisi CC, Cavezzi A, Chi YW, Chunga J, Corda D, Crippa A, Davies A, De Maeseneer M, Diaz J, Ferreira J, Gasparis A, Intriago E, Jawien A, Jindal R, Kabnick L, Latorre A, Lee BB, Liew NC, Lurie F, Meissner M, Menegatti E, Molteni M, Morrison N, Mosti G, Narayanan S, Pannier F, Parsi K, Partsch H, Rabe E, Raffetto J, Raymond-Martimbeau P, Rockson S, Rosukhovski D, Santiago FR, Schul A, Schul M, Shaydakov E, Sibilla MG, Tessari L, Tomaselli F, Urbanek T, van Rijn MJ, Wakefield T, Wittens C, Zamboni P, Bottini O. 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; 34:4-66. [PMID: 31495256 DOI: 10.1177/0268355519870690] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Guidelines are fundamental in addressing everyday clinical indications and in reporting the current evidence-based data of related scientific investigations. At the same time, a spatial and temporal issue can limit their value. Indeed, variability in the recommendations can be found both among the same nation different scientific societies and among different nations/continents. On the other side, Garcia already published in 2014 data showing how, after three years in average, one out of five recommendations gets outdated (Martinez Garcia LM, Sanabria AJ, Garcia Alvarez E, et al. The validity of recommendations from clinical guidelines: a survival analysis. CMAJ 2014;186(16):1211–1219). The present document reports a narrative literature revision on the major international recommendations in lower limb venous and lymphatic disease management, focusing on the different countries’ guidelines, trends and controversies from all the continents, while identifying new evidence-based data potentially influencing future guidelines. World renowned experts’ opinions are also provided. The document has been written following the recorded round tables scientific discussions held at the vWINter international meeting (22–26 January 2019; Cortina d’Ampezzo, Italy) and the pre- and post-meeting literature search performed by the leading experts.
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Affiliation(s)
| | - Andrea Obi
- 2 University of Michigan, Ann Arbor, MI, USA
| | | | | | | | - Denis Borsuk
- 6 Clinic of Phlebology and Laser Surgery, 'Vasculab' Ltd, Chelyabinsk, Russia
| | | | | | - Attilio Cavezzi
- 9 Eurocenter Venalinfa, San Benedetto del Tronto (AP), Italy
| | - Yung-Wei Chi
- 10 University of California, Davis Vascular Center, Sacramento, CA, USA
| | | | | | | | | | | | - Josè Diaz
- 15 Vanderbilt University Medical Center, Nashville, TN, USA
| | - Julio Ferreira
- 16 Instituto Brasilerio de Flebologia, Sao Paulo, Brazil
| | | | | | - Arkadiusz Jawien
- 19 Collegium Medicum, University of Nicolaus Copernicus, Bydgoszcz, Poland
| | | | | | | | | | - N C Liew
- 24 Putra University, Serdang, Malaysia
| | - Fedor Lurie
- 25 Jobst Vascular Institute, Toledo, OH, USA
| | | | | | | | | | | | | | | | - Kurosh Parsi
- 32 St. Vincent's Hospital, University of NSW, Sydney, Australia
| | | | | | | | | | - Stanley Rockson
- 37 Stanford University School of Medicine, Stanford, CA, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Cees Wittens
- 44 Maastricht University Medical Center, Maastricht, Netherlands.,45 Uniklinik Aachen, Aachen, Germany
| | | | - Oscar Bottini
- 46 Universidad de Buenos Aires, Buenos Aires, Argentina
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Yoshida S, Koshima I, Imai H, Uchiki T, Sasaki A, Fujioka Y, Nagamatsu S, Yokota K. Lymphaticovenular anastomosis and venous arterialization in coexisting Raynaud's phenomenon and lymphedema: A case report. Microsurgery 2019; 39:553-558. [PMID: 31287178 DOI: 10.1002/micr.30490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/13/2019] [Accepted: 06/21/2019] [Indexed: 11/11/2022]
Abstract
Raynaud's phenomenon is highly prevalent in the general population. The optimal medical management for patients with severe Raynaud's phenomenon remains unclear. Venous arterialization (VA) may be considered as a salvage procedure when no distal vessels are available for vascular reconstruction. Surgical treatments for lymphedema, including lymphovenous anastomosis (LVA), are becoming popular alternatives to conservative therapy. Here, we report on a patient with comorbid primary Raynaud's phenomenon and lymphedema in whom both VA and LVA were performed. The patient was a 60-year-old woman with an edematous right upper limb and pain and cold sensitivity in the middle, ring, and small fingers that was refractory to medication. Indocyanine green lymphography and computed tomography angiography suggested coexistence of lymphedema and primary Raynaud's phenomenon. VA and LVA were performed to reduce the risks of cellulitis and amputation. Computed tomography angiography was performed regularly after surgery to examine the arterialized venous system and Doppler echography to search for developing branches. Five months later, three branches of the arterialized veins that flowed proximally at the level of the hand and wrist were ligated. By around 1 year after surgery, the lymphedema index in the affected upper limb had improved from 116 to 103 and the patient's numerical rating scale score for intractable pain and cold sensitivity had improved from 6-7 to 1-2. We believe that the combination of VA and LVA in the early stages of primary Raynaud's phenomenon and lymphedema was effective in this case.
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Affiliation(s)
- Shuhei Yoshida
- The International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
| | - Isao Koshima
- The International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
| | - Hirofumi Imai
- The International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
| | - Toshio Uchiki
- Plastic and Reconstructive Surgery, Hiroshima University, Hiroshima, Japan
| | - Ayano Sasaki
- Plastic and Reconstructive Surgery, Hiroshima University, Hiroshima, Japan
| | - Yumio Fujioka
- Plastic and Reconstructive Surgery, Hiroshima University, Hiroshima, Japan
| | - Shogo Nagamatsu
- Plastic and Reconstructive Surgery, Hiroshima University, Hiroshima, Japan
| | - Kazunori Yokota
- Plastic and Reconstructive Surgery, Hiroshima University, Hiroshima, Japan
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19
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Mosti G, Mancini S, Bruni S, Serantoni S, Gazzabin L, Bucalossi M, Polignano R, Mariani F, Luca B, Partsch H. Adjustable compression wrap devices are cheaper and more effective than inelastic bandages for venous leg ulcer healing. A Multicentric Italian Randomized Clinical Experience. Phlebology 2019; 35:124-133. [PMID: 31234752 DOI: 10.1177/0268355519858439] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Compression therapy by inelastic bandages is highly effective in achieving venous leg ulcer healing. Inelastic bandages may be expensive as they need to be changed and discarded at every dressing change. In addition, correct application is difficult in the clinical practice, even by expert healthcare personnel. The aim of our work was to assess whether adjustable compression wraps are more cost effective and more effective than inelastic bandage to achieve venous leg ulcer healing. Methods Sixty-six venous leg ulcer patients were randomized to be treated by adjustable compression wrap (CircAid® JuxtaCure®) ( n = 33) and inelastic bandage (Coban 2 Layer®) ( n = 33). Study duration was 12 weeks. During weekly visits, the ulcers were cleansed and dressed with the same products, and the only variable was the compression device. Ulcer size, ulcer pain, patient’s perception of compression systems, and compression pressure were assessed during the visits, and the material cost was evaluated at the 12th week. Results Adjustable compression wraps were significantly cheaper than bandages (p < 0.0001) and were also more effective (not significantly) in achieving ulcer healing. To heal one ulcer patient, €228 had to be spent when applying an adjustable compression wrap and €381 if inelastic bandages were used. About 26/33 (78.8%) patients in the adjustable compression wrap group were healed after 12 weeks versus 23/33 (69.7%) in the inelastic bandage group (n.s.). Ulcer pain was reduced by both compression devices. Patient perception of compression pressure was similar with both compression devices. Compression pressure was similar at application but better maintained by adjustable compression wrap over time. Conclusions Adjustable compression wraps are significantly cheaper and more effective (not significantly) in achieving venous leg ulcer healing. Self-applicable, adjustable compression wraps are therefore a powerful, cost-effective alternative to inelastic bandages in treating venous leg ulcer.
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Affiliation(s)
- Giovanni Mosti
- Angiology Department, MD Barbantini Clinic, Lucca, Italy
| | - Stefano Mancini
- Heart and Vascular Surgery Department, University of Siena, Siena, Italy
| | - Sergio Bruni
- Outpatient Department for Hard-to-Heal skin ulcers, San Giuseppe Hospital, Empoli, Italy
| | - Simone Serantoni
- Vascular Ulcers and Diabetic Foot Surgery Unit, Villa Fiorita Clinic, Prato, Italy
| | - Luca Gazzabin
- Vascular Ulcers and Diabetic Foot Surgery Unit, Villa Fiorita Clinic, Prato, Italy
| | | | | | | | - Bastiani Luca
- Institute of Clinical Physiology, Italian National Research Council e CNR, Pisa, Italy
| | - Hugo Partsch
- Emeritus, Medical University of Vienna, Vienna, Austria
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20
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Bjork R, Ehmann S. S.T.R.I.D.E. Professional Guide to Compression Garment Selection for the Lower Extremity. J Wound Care 2019; 28:1-44. [DOI: 10.12968/jowc.2019.28.sup6a.s1] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The following supplement is a rare example of a paper that combines clinical experience and theoretical knowledge on textiles used in compression therapy. The authors' intention is to propose a decision support system for choosing specific compression devices, which can be adjusted to counteract the individual signs and symptoms in an optimally adopted way. The document concentrates on compression devices which can be self-applied by the patients—compression stockings and adjustable wraps. The acronym ‘S.T.R.I.D.E.’, incorporating both textile characteristics and clinical presentation, stands for: Shape, Texture, Refill, Issues, Dosage and Etiology. The intent of the mnemotechnical value is to highlight that successful compression includes more than dosage alone. In addition to dosage, etiology and patient presentation need to be incorporated, including a patient's physical ability to use compression effectively as part of the daily routine, thereby promoting adherence. The suggested algorithms provide a valuable guide to stride across the important, but still underestimated field of medical compression therapy and will help to put the prescription of a specific product on a more rational basis. Enjoy reading! Hugo Partsch Emeritus Professor Medical University of Vienna, Austria
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Affiliation(s)
- Robyn Bjork
- International Lymphedema and Wound Training Institute, Alaska, US
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21
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Stather PW, Petty C, Howard AQ. Review of adjustable velcro wrap devices for venous ulceration. Int Wound J 2019; 16:903-908. [PMID: 30900365 DOI: 10.1111/iwj.13116] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 02/25/2019] [Accepted: 02/28/2019] [Indexed: 11/26/2022] Open
Abstract
Compression therapy is the mainstay of treatment for patients with venous leg ulcers. Current gold standard is 4 layer bandaging, which has a significant impact on patients comfort, ability to wear their own shoes, and quality of life, as well as taking significant time to apply, and losing compression over time. This systematic review aims to evaluate the use of Velcro wrap devices for the treatment of venous ulceration. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were used to identify articles reporting the use of Velcro wrap devices in patients with venous ulceration. Sixteen articles were identified (14 case series, 1 randomised trial, and 1 audit) reporting on 192 patients. There were reports of improved time to healing, reduced cost by >50%, reduced number and duration of nursing appointments, and improved quality of life in patients in Velcro wrap devices. Although the evidence remains poor, Velcro devices have potential to improve outcomes for patients with venous ulceration and further good quality studies should be undertaken to evaluate these further.
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Affiliation(s)
- Philip W Stather
- Department of Vascular Surgery, Colchester Hospital University NHS Foundation Trust, Colchester, UK
| | - Carroll Petty
- Department of Vascular Surgery, Colchester Hospital University NHS Foundation Trust, Colchester, UK
| | - Adam Q Howard
- Department of Vascular Surgery, Colchester Hospital University NHS Foundation Trust, Colchester, UK
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22
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Health and economic benefits of advanced pneumatic compression devices in patients with phlebolymphedema. J Vasc Surg 2019; 69:571-580. [DOI: 10.1016/j.jvs.2018.04.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 04/07/2018] [Indexed: 11/19/2022]
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Pujol-Blaya V, Salinas-Huertas S, Catasús ML, Pascual T, Belmonte R. Effectiveness of a precast adjustable compression system compared to multilayered compression bandages in the treatment of breast cancer–related lymphoedema: a randomized, single-blind clinical trial. Clin Rehabil 2019; 33:631-641. [DOI: 10.1177/0269215518821785] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To compare the effectiveness of a precast adjustable compression system with that of multilayered compression bandages in the treatment of breast cancer–related lymphoedema. Design: Multicenter, randomized, single-blind parallel-group clinical trial. Setting: The rehabilitation services of four general university hospitals. Subjects: Patients with upper limb breast cancer–related lymphoedema. Interventions: All the patients received manual lymphatic drainage, followed by a precast adjustable compression system or multilayered compression bandages, according to the group allocation. The treatment included 10 consecutive sessions over a two-week period from Monday to Friday, followed by some sessions on three alternate days per week, until the patient received a tailored compression garment. Primary measurements: The patients were evaluated just before the treatment, after 10 sessions and at three months posttreatment. The primary outcome was the change in excess lymphoedema volume. Secondary outcomes were changes in the symptoms of pain, heaviness, tightness and hardness. Analyses were performed using an intention-to-treat approach. Results: In all, 42 patients were included; there were 22 in the precast adjustable compression system group and 20 in the multilayered compression bandages group. Both groups exhibited significant decreases in excess volume and symptoms after 10 sessions and at three months. There were no significant differences regarding excess volume or symptoms between the precast adjustable compression system and multilayered compression bandages groups after 10 sessions and at the three-month follow-up exam. Conclusion: The precast adjustable compression system and the multilayered compression bandages have similar efficacy for the reduction of excess lymphoedema volume or symptoms.
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Affiliation(s)
- Vicenta Pujol-Blaya
- Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Sira Salinas-Huertas
- Hospital Universitari de Bellvitge, Barcelona, Spain
- Universitat de Barcelona, Barcelona, Spain
| | - M Luisa Catasús
- Hospital Universitari de Bellvitge, Barcelona, Spain
- Universitat de Barcelona, Barcelona, Spain
| | - Teresa Pascual
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Roser Belmonte
- Universitat Autònoma de Barcelona, Bellaterra, Spain
- Hospital Mar-Esperança, Parc de Salut Mar, Barcelona, Spain
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
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Todd M, Stubbs C, Pugh S. Mobiderm Autofit: an adjustable sleeve that enables patients to self-manage lymphoedema. Br J Community Nurs 2018; 23:S22-S28. [PMID: 29906197 DOI: 10.12968/bjcn.2018.23.sup4.s22] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Lymphoedema can result in debilitating physical and psychosocial morbidity and when combined with other chronic comorbidity, often requires holistic, specialist management that encompasses all the complex and compounding problems. Self-care is an integral component of any treatment strategy, however, the patient must be fully prepared and ongoing support should be provided. Self-care consists of managing the symptoms of lymphoedema but should include other fundamental aspects of healthy living, for example, maintaining a healthy weight and activity levels. To improve self-care, compression manufacturers have been instrumental in designing new ways of applying compression. Mobiderm Autofit armsleeves have been designed to improve the donning and wearing of compression sleeves in all patients. This product is especially useful for night-time wear and in the presence of fragile skin, or for those who only require reduced compression. The benefits of this garment are demonstrated in three case studies.
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Affiliation(s)
- Marie Todd
- Lymphoedema Clinical Nurse Specialist, Glasgow Specialist Lymphoedema Service, Scotland
| | - Charlotte Stubbs
- (case study author), Deputy Clinical Nurse Manager, Wolverhampton Lymphoedema Service, Compton Hospice
| | - Stacy Pugh
- (case study author), Lymphoedema Clinical Nurse Manager, Wolverhampton Lymphoedema Service, Compton Hospice; Honorary Lecturer, University of Wolverhampton; and trainer at Lymphoedema Training Academy
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Balcombe L, Miller C, McGuiness W. Approaches to the application and removal of compression therapy: A literature review. Br J Community Nurs 2017; 22:S6-S14. [PMID: 28961047 DOI: 10.12968/bjcn.2017.22.sup10.s6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Compression therapy is used in the treatment of venous disorders, lymphoedema and burns. Adherence to compression therapy is reported to be poor, due to a number of factors, including difficulty in applying and removing the compression garments. A literature review was conducted to identify aids, equipment and other approaches to ease the application and removal of compression therapy garments. Some 12 studies were identified. Most studies focused on chronic venous insufficiency and venous ulcers. Four methods of easing compression garment application and removal were identified: (1) devices to assist in application and removal; (2) altered compression stocking design; (3) adjustable compression wrap devices; and (4) education. Patients prescribed compression therapy should be educated on how to apply and remove the compression garments, and have application devices made available to them.
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Affiliation(s)
- Lauren Balcombe
- Undergraduate student, La Trobe University, Prahran, Australia
| | - Charne Miller
- Senior Lecturer, La Trobe University, Prahran, Australia
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Lee N, Pugh S, Cooper R. Haddenham easywrap as part of self-management in lymphoedema and lipoedema: The patient perspective. Br J Community Nurs 2017; 22:S50-S57. [PMID: 28961045 DOI: 10.12968/bjcn.2017.22.sup10.s50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Self-management and the use of adjustable velcro compression wraps are not new concepts and quite often both can form part of the maintenance phase of treatment in those with lymphoedema or lipoedema, as well as those diseases in which compression therapy is advised as long-term management. The aim of this article is to identify some aspects that contribute to effective self-management and how the use of easywrap adjustable velcro compression wraps have improved quality of life for those with lymphoedema, chronic oedema and lipoedema. Case studies are given from patients to demonstrate the individual experience of living with lymphoedema or lipoedema, how this has impacted on daily life, and how using easywrap has helped as part of self-management.
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Affiliation(s)
| | - Stacy Pugh
- Palliative Care Lymphoedema Clinical Nurse Manager, Wolverhampton Lymphoedema Service, Compton Hospice; Honorary Lecturer, University of Wolverhampton; Trainer at Lymphoedema Training Academy
| | - Robin Cooper
- Vascular/Lymphoedema Nurse Specialist, Salisbury District Hospital
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27
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Affiliation(s)
- Nora For-Szabo
- Registered General Nurse,Older Persons Unit, HMP Norwich, West Suffolk Professionals
| | - Scott Ralph
- Registered General Nurse, Clinical Lead, Older Persons Unit, HMP Norwich
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28
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Affiliation(s)
- Marie Todd
- Lymphoedema CNS, Greater Glasgow and Clyde NHS
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29
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Abstract
Deep vein thrombosis (DVT) is a prevalent disease. About 20 to 30% of patients with DVT will develop postthrombotic syndrome (PTS) within months after the initial diagnosis of DVT. There is no gold standard for diagnosis of PTS, but clinical signs include pitting edema, hyperpigmentation, phlebectatic crown, venous eczema, and varicose veins. Several scoring systems have been developed for diagnostic evaluation. Conservative treatment includes compression therapy, medications, lifestyle modification, and exercise. Compression therapy, the mainstay and most proven noninvasive therapy for patients with PTS, can be prescribed as compression stockings, bandaging, adjustable compression wrap devices, and intermittent pneumatic compression. Medications may be used to both prevent and treat PTS and include anticoagulation, anti-inflammatories, vasoactive drugs, antibiotics, and diuretics. Exercise, weight loss, smoking cessation, and leg elevation are also recommended. Areas of further research include the duration, compliance, and strength of compression stockings in the prevention of PTS after DVT; the use of intermittent compression devices; the optimal medical anticoagulant regimen after endovascular therapy; and the role of newer anticoagulants as anti-inflammatory agents.
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Affiliation(s)
- Federico Silva Palacios
- Department of Vascular Medicine, Cardiovascular Section, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Suman Wasan Rathbun
- Department of Vascular Medicine, Cardiovascular Section, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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30
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Cooper G. A wealth of information to apply to lymphoedema management. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2017; 26:200-202. [PMID: 28230433 DOI: 10.12968/bjon.2017.26.4.200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Garry Cooper, Lecturer in Adult Nursing and Lymphoedema, Birmingham City University, considers how increasing knowledge in the field needs to be translated into effective, patient-focused services.
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Abstract
Ageing affects not only individuals but also society. It occurs throughout the western world. The ageing process may lead to the development of conditions, such as chronic oedema, as well as comorbidities such as osteoarthritis. These comorbidities can make the management of chronic oedema even more difficult. This is an especially important consideration when tailoring individualised care plans, such as exercise, as conditions such as rheumatoid arthritis can limit patients' ability to manage their oedema. Despite challenges, education can improve patient outcomes when evidence-based practice is used.
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Affiliation(s)
- Garry Cooper
- Lecturer and Practitioner, Compton Hospice Education & Training Centre, Wolverhampton
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Ehmann S, Whitaker J, Hampton S, Collarte A. Multinational, pilot audit of a Velcro adjustable compression wrap system for venous and lymphatic conditions. J Wound Care 2016; 25:513-20. [DOI: 10.12968/jowc.2016.25.9.513] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- S. Ehmann
- Clinical Specialist, Carolinas HealthCare System Stanly
| | - J.C. Whitaker
- Director and Nurse Consultant, Senior Lecturer - University of Central Lancashire, Northern Lymphology Ltd
| | - S. Hampton
- Wound Care Consultant Nurse, 74 Battle Road, Hailsham, UK
| | - A. Collarte
- Tissue Viability Specialist Nurse, University of Central Lancashire UK
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