CLINICAL PRACTICE Chronic edema: Where have all the ankles gone? Chronic edema is often untreated or managed ineffectively, resulting in frustration and even abandonment of treatment modalities. If the symptom is left untreated, individuals may suffer physical issues ranging from decreased mobility, to pain and discomfort, to altered limb shape and skin appearance. These physical issues can lead to social issues related to occupational tasks, daily living, and social and sexual confidence, which in turn lead to psychological issues such as negative body image, fear, anger, isolation and reduced self-esteem.1 By contrast, when the condition is treated and successfully managed, individuals not only see significant improvement in their edema but also reap the benefits in their quality of life. Successful treatment is attained by identifying the contributing factors, addressing treatable causes, combining various therapies and managing the conditions with a global perspective. Causes of chronic edema Chronic edema is a symptom or secondary response, with varying causes such as hereditary disposition; various medical conditions including venous insufficiency, lymphedema and heart and kidney conditions; pregnancy; and occupational risk factors. With so many causes, it is hard to quantify the number of Canadians affected. However, in a four-week study, it was estimated that 192 people receiving care would consume $1 million annually in nursing care services and $260,000 in wound care supplies.2 Edema is more likely to be treated and successfully managed if its cause can be diagnosed and the underlying condition treated. Assessment During assessment of edema, it is essential to examine three of our body systems in conjunction with management of other co-morbidities: the arterial, venous and lymphatic systems. The arterial system is responsible for transportation of oxygenated blood and nutrients to the cells via the heart pump, arteries and capillaries. The venous system returns the oxygen-poor and waste-laden blood back to the organs and heart for cleansing and re-oxygenation via the calf muscle pump, venules, veins and valves. The lymphatic system is an accessory system for the flow of fluid from tissue spaces into the circulatory system via a complex network of lymph nodes, lymph ducts, lymphatic tissues and lymph capillaries. It is also a major component of the immune system. Diagnosis A comprehensive medical history should be taken to gather information about medications, underlying health problems, surgeries, infections, recent travel and previous use of compression, along with a physical exam of the skin, limb size and shape, and nature of edema. In conjunction with this, a vascular assessment that examines the arterial blood flow is essential to screen for contraindications for compression therapy. The calf muscle pump is an essential component of venous blood return. Its action is dependent on good range of motion of the ankle that allows a proper heel strike and “toe off” gait. If the ankle’s range of motion is dysfunctional, the treatment plan could be further enhanced by the addition of physiotherapy or occupational therapy. Risk factors include age, hormones (which both decrease the elasticity of the veins), smoking, obesity, the number of pregnancies the individual has had, occupation and immobility. Environments where an individual sits or stands for long periods, or is more sedentary, can lead to and aggravate a pre-existing issue with edema; this is often related to the inactivity of the calf muscle pump. Treatment and management Prior to considering an optimal treatment pathway, it is important to determine the underlying cause(s) of the edema and rule out any contraindications such as uncontrolled congestive heart failure or severe peripheral arterial disease. Treatment of the edema itself with compression, where appropriate, is key before proceeding to the management phase. How does compression work? It reduces the cross-section of the dilated veins, supports the function of the venous valves to prevent backflow and increases the speed of the venous blood flow by enhancing the muscle contraction forces within the limb. If edema is extensive, it is important to reduce it with a layered compression bandage wrap that, when applied by a trained and skilled professional, will obtain optimal results. Upon reduction of the edema, it is important that the patient be fitted with compression garments before the wrap is discontinued. An accurate fit would include measurement, dispensing and confirmation of fit to facilitate a seamless transition from wrap to stockings. Compression garment options Compression stockings. A variety of fabrics, shapes and features, help fitters address lifestyle requirements. Adjustable compressive wraps. In some cases, reusable garments with Velcro straps can address donning needs more effectively than a stocking type of garment. An experienced fitter should be involved in these cases to ensure the suitability of this type of garment. Donning and doffing. It is equally important to be sure either that the individual can both put the garment on and take it off independently, or has supports in place to assist. Various devices are available to assist independent donning/doffing, but these should be trialled to determine the most appropriate device. Compression stocking gloves are essential to assist with donning and doffing, preventing holes and keeping the stockings’ shape. Successful maintenance therapy The key to successful maintenance compression therapy is to educate your client on the importance of daily compression, a donning/ doffing device (if required), care and replacement of the garment(s) and the importance of exercise, skin care and diet. References available upon request. Patricia Coutts, RN, IIWCC, is a wound care specialist and clinical trials coordinator at the Toronto Regional Wound Clinic in Mississauga, ON. Tracey Cameron has been a certified fitter at Shoppers Home Health Care for 11 years. CASE 1 Active 30-year-old physiotherapist in her fifth month of pregnancy. Her legs are tired and achy, with edema late in the day. Treatment: Assess underlying cause(s) of edema. Management Compression: 15–20 or 20–30 mm Hg compression stocking and— depending on varicosities, severity and location of late-day edema— either calf or thigh length. Fabric: Breathable, fashionable and functional. Solution options: Sock-style in a calf-length and thigh-length stocking fabric. CASE 2 Sixty-year-old chef and co-owner of a restaurant. His BMI is within the normal range. He has an open area on malleolus. By the end of the day, he notices swelling, and the open area tends to leak fluid. Treatment: Following an assessment, wound dressings and layered compressive wraps are suggested to help heal the wound. Management Compression: 20–30 or 30–40 mm Hg in a calf- or thigh-length stocking. Fabric: Functional, breathable, durable and robust, most likely in a sock-style to encourage daily wear. Solution options: Sock-style or robust compression. It is key to educate the client on the importance of daily wear to prevent him from experiencing recurring ulcerations. Donning and doffing ability confirmed and a device for donning and doffing explored if necessary for independence. CASE 3 Sixty-five-year-old male developed swelling of the left leg following knee replacement. Mildly obese and has difficulty finding pants that will accommodate leg swelling; on medication for depression. Treatment: Seek a proper diagnosis and treat with decongestive therapy via appropriate channel such as manuallymph drainage (MLD) , sequential pump and/or compression wrap. Assess client for counselling needs, although depression may subside as treatment becomes more successful. Educating the individual will support adherence to the care plan. Management Compression: Based on the assessment, location of edema and fitting concerns, a calf- or thigh-length stocking in a 30–40 mmHg compression, if possible, or a 20–30 mmHg may be used. Fabric: Flat-knit custom to address fitting needs. Solution options: Flat-knit custom garment. Optional maintenance may include the use of a compressive wrap at night, use of a sequential pump and/or MLD.