Article

A Study of Leg Edema in Immobile Patients

April 2014
Circulation Journal 78(7)

Source
PubMed

Authors:

Background: Our objectives were to elucidate the pathophysiology of leg edema in immobile patients and to discuss reasonable management of this condition. Methods and results: The 30 patients with leg edema had visited our clinic between April 2009 and March 2013; they suffered from severe gait disturbance, had no significant venous abnormalities detected using duplex ultrasound, and did not have any systemic diseases that could cause leg edema. Here, we review their symptoms, examinations, and treatments. Among 59 edematous legs of the 30 patients, 30 legs (51%) had symptoms that indicated advanced chronic venous insufficiency. The ankle range of motion and calf : ankle circumference ratio were abnormal in only 3 (5%) and 10 (17%) of the legs, respectively. The severity of edema and subcutaneous inflammation, which was confirmed using ultrasonography, was significantly influenced by gravity. Air plethysmography and lymphangioscintigraphy were completed in 15 and 10 patients, respectively, neither of which revealed any significant abnormalities. Reasonable success for all patients was achieved by compression therapy and physical therapy without medications. Conclusions: It was assumed that leg edema in these immobile patients was mainly caused by venous stasis because of the immobility itself, not because of anatomical problems. The patients were successfully managed by compression and physical therapy alone.

Gravity magnetic resonance imaging measurement of muscle pump change accompanied by aging and posture

Article

Full-text available

Jan 2021

Aim To date no age‐comparative study has been reported about effect of exercise on muscle pump action change, while its effect is suggested to differ in ages. This study aims to clarify the changes in muscle pump action with aging by measuring the muscle and vein area, and blood flow in lower legs. Methods Subjects were healthy volunteers and consisted of three groups: young age group (N = 20), middle age group (N = 20) and old age group (N = 16). The lower leg flexor muscle area and popliteal vein area were measured by using T1‐weighed magnetic resonance imaging at the condition pre‐ and post‐ankle exercise in three positions. Moreover, popliteal blood flow velocity was also measured using phase contrast magnetic resonance imaging. Results The elderly had the highest number of individuals who had exercise habits (p < .001). In a multiple linear regression analysis, sitting posture, leg muscle volume, and rate of change in the soleus muscle were significantly related to blood flow velocity change. Conclusions No difference was found in the changes in muscle pump action with age. The study results suggested that elderly people with exercise habits might be able to maintain the muscle pump action.

Development of a Minimum Data Set Registry for Chronic Venous Insufficiency of the Lower Limbs

Article

Full-text available

Oct 2019

The purpose of this study was to develop a minimum data set (MDS) registry for the prevention, diagnosis and treatment of chronic venous insufficiency (CVI) of the lower limbs. We designed the instrument in two phases, comprising a literature review and an e-Delphi study to validate the content. We obtained a total of 39 documents that we used to develop a registry with 125 items grouped in 7 categories, as follows: Patient examination, venous disease assessment methods, diagnostic tests to confirm the disease, ulcer assessment, treatments to manage the disease at all its stages, patient quality of life, and patient health education. The instrument content was validated by 25 experts, 88% of whom were primary healthcare and hospital nurses and 84% had more than 10 years' experience in wound care. Using a two-round Delphi approach, we reduced the number of items in the MDS-CVI to 106 items. The categories remained unchanged. We developed an MDS for CVI with seven categories to assist healthcare professionals in the prevention, early detection, and treatment history of CVI. This tool will allow the creation of a registry in the primary care setting to monitor the venous health state of the population.

Narrative Review of the Pathogenesis of Stasis Dermatitis: An Inflammatory Skin Manifestation of Venous Hypertension

Article

Full-text available

Mar 2023

Plain Language Summary Stasis dermatitis is a skin disease that affects the legs, most often of older people, with chronic venous insufficiency. Chronic venous insufficiency is when veins cannot return blood from the legs back to the heart. This leads to high blood pressure in veins and causes blood in those veins to flow backwards. If stasis dermatitis is left untreated, complications, including skin ulcers, can result. Other skin symptoms of stasis dermatitis include itchiness, scaling, and discoloration. Such skin symptoms can have a negative effect on a person’s quality of life. Inflammation that lasts a long time is likely the main link between the skin changes seen in people with stasis dermatitis and the increased pressure in leg veins. Several molecules are associated with the inflammation observed in stasis dermatitis, including white blood cells, matrix metalloproteinases, phosphodiesterase 4, and interleukin-31. Treatment for stasis dermatitis should focus both on the underlying chronic venous insufficiency and the associated skin issues. Identifying inflammatory markers and pathways could help treat the signs and symptoms associated with stasis dermatitis, including the skin symptoms.

Basic Study for the Quantitative Diagnosis of Edema Focusing on Ultrasound Propagation Time Waveform Information

Article

Full-text available

Dec 2022

Objective We conducted a research on a simple diagnosis of edema. We aimed to develop a safe and inexpensive method using ultrasound. Because B-mode imaging systems are expensive and specialized, we focused on the ultrasound propagation time waveform information. Experiment Experiments were conducted using a custom-made ultrasonic transducer. Measurements were performed on individuals with and without edema, and the results are discussed in this paper based on propagation time waveform information and frequency analysis. Summary Based on the results, we found three indices with a high possibility of understanding the state of edema. The first index was edema thickness, the second was the standard deviation of edema thickness, and the third was the shape of the frequency spectrum of the ultrasound propagation time waveform. The results indicated that the presence of edema can be easily and quickly determined by determining the thickness of the edema at the measurement point near the ankle (measurement point D) on the front surface of the lower limbs and performing frequency analyses.

Prolonged Sitting Causes Leg Discomfort in Middle Aged Adults: Evaluation of Shear Wave Velocity, Calf Circumference, and Discomfort Questionaries

Article

Full-text available

Jul 2022

Introduction: Prolonged sitting causes leg discomfort. We evaluated shear wave velocity (SWV) of leg muscles, leg circumference, and leg discomfort associated with 2 h sitting. Methods: Twenty-one middle-aged men and 19 middle-aged women participated in the study. SWV and leg circumference was measured just after sitting, 60 min, 120 min, and after 3 min of leg raising. Leg discomfort was assessed before sitting and 120 min. Results: SWV was significantly greater in men than women and increased over time, and decreased with leg raising. The percentage increase in lower leg circumference was significantly greater in women than in men, and it increased over time. Leg discomfort significantly increased after 120 min in both men and women. Discussions: Because SWV is proportional to an increase in intramuscular compartment pressure in the lower leg, intramuscular compartment pressure increased over time with sitting and decreased with leg raising. Considering the changes in SWV and leg circumference, it was inferred that prolonged sitting causes an increase in intramuscular compartment pressure and intravascular blood volume, as well as an increase in water content in the leg subcutaneous tissue. Leg discomfort was estimated to be due to increased intra-leg fluid. Brief leg raising may resolve leg edema and discomfort.

Risk Factors in Patients with Venous Stasis-Related Skin Lesions without Major Abnormalities on Duplex Ultrasonography

Article

Full-text available

Aug 2016

Purpose: To clarify the risk factors for venous stasis-related skin lesions in the legs in patients without major abnormalities on duplex ultrasonography (DUS). Methods: Fifty patients (nine males and 41 females, age 27–93 years) with symptoms of C4 or greater according to the Clinical, Etiological, Anatomical, Pathological (CEAP) classification, but having no abnormalities on DUS were reviewed for known risk factors for chronic venous insufficiency (CVI) such as older age (>70 years), obesity (body mass index [BMI] >30 kg/m²), short walking distance (<200 m/day), reduced ankle range of motion (<20°), and occupation requiring prolonged standing (>8h per day). Results: The risk factor was different between male and female patients; although all patients had at least one of the above risk factors, the most commonly found risk factor in male patients was occupation requiring prolonged standing (63%), while advanced age (78%) and limited walking distance (83%) were risk factors in female patients. Conclusions: Although male and female patients had different risk factors, insufficient walking seemed to be closely related to the development of venous stasis-related skin lesions.

TWO COMMON PROBLEMS IN PHYSIATRY CLINICS: VENOUS DISEASE AND LOWER LIMB PAIN

Article

Full-text available

Nov 2015

Venous diseases and lower limb pain are common problems in physiatry clinics. Because of having different treatment modalities, it is necessary to distinguish whether they are associated or not. Learning more about venous diseases is crucial for physiatrists, so we tried to review the literature for overview our knowledge. A PubMed search was performed for studies relating to venous diseases and lower limb pain from 2005 to 2015. Publications were retrieved by using search terms for venous diseases and lower limb pain. Relevant references from these studies were also retrieved. No filters were applied to limit the retrieval by study type. Patients with lower limb pain should be asked for symptoms of venous diseases which may include burning, tingling, muscle cramp, swelling, sensation of heaviness, itching skin, restless leg, leg tiredness and fatigue, as well as pain. Because venous diseases are frequently the cause of pain, discomfort, loss of working days, deterioration of health-related quality of life and disability. As physiatrists, we should know the nature of venous diseases. At least, we should gain adequacy to diagnose lower limb pain related to venous diseases for referring cardiovascular surgery clinics. Physiatrists should provide complementary treatment modalities to reduce edema and pain, and to improve joint mobility and muscle strength in patients with venous diseases.

Our treatment approach in a super obese patient with lipedema: a case report lipedema

Article

Full-text available

Oct 2023

Conditions that cause edema in the lower extremities are frequently seen in the community. When it is bilateral, conditions such as heart failure, kidney failure, nephrotic syndrome, etc. usually come to mind. Lipedema, which should be considered in order to make a diagnosis, is more common than expected. Lymphedema and lipedema are often delayed in diagnosis and are progressive disorders. Lipedema is a disease that is frequently seen in women, results in fat accumulation in the extremities and especially in the legs, the origin of which has not been fully resolved, and has a hereditary role. The reason why it is frequently seen in women is thought to be the possibility of women being estrogen dependent. Another trigger is obesity. Although its prevalence in the general female population is reported to be around 10%, the cause of lipedema is still unknown. Increasing awareness among physicians about this condition will facilitate diagnosis. With this case report, we wanted to draw attention to the increasing incidence of lipedema due to obesity and many factors.

Dependent Leg Edema in Older Patients with or without Skin Lesion

Article

Full-text available

Jun 2023

Objective: This study aimed to clarify the features and causes of dependent edema (DE) in the legs of patients in geriatrics. Patients and Methods: We retrospectively reviewed 224 patients with DE, aged ≥65 years, who visited our clinic from April 2009–March 2022. DE was defined as bilateral leg edema in patients without known systemic edemagenic conditions, venous insufficiency confirmed by duplex venous scanning, or a cancer treatment history in the pelvic/inguinal lesions. Results: The median patient age was 77 years (range: 65–94 years), where 74% were female. Overall, 198 patients (88%) had gait disturbances caused mainly by musculoskeletal disorders, but 58 (26%) walked without aid. Compared with patients with DE only (N=129), patients with DE and venous stasis-related skin lesions (N=95) included a larger number of those with obesity than did those with DE only (26% vs. 14%, p=0.02). Conclusion: The primary cause of DE in older patients was the sedentary lifestyle secondary to aging and gait disturbance, not solely because of reduced leg function. The complications of obesity are associated with increased venous stasis-related skin lesions.

Stasis Dermatitis: An Overview of Its Clinical Presentation, Pathogenesis, and Management

Article

Full-text available

Feb 2023
AM J CLIN DERMATOL

Stasis dermatitis is a chronic inflammatory skin disease of the lower extremities. It typically occurs in older individuals and is the cutaneous manifestation of venous hypertension caused by venous reflux. Such retrograde venous blood flow is the result of incompetent venous valves, valve destruction, or venous obstruction. Stasis dermatitis is eczematous. The associated impairment of venous valves may cause swelling of the legs, leading to serious conditions including venous ulcerations. Diagnosis can be challenging because of its clinical resemblance to other skin conditions and poor clinical recognition by physicians. The cornerstones of stasis dermatitis treatment are compression therapy to ameliorate pain and swelling, topical treatments to alleviate secondary skin changes, and interventional treatment options to correct the underlying causes of venous reflux. Given the central role of inflammation of the lower extremities in driving the cutaneous changes characteristic of stasis dermatitis, new therapeutic approaches that target the inflammation are under clinical evaluation in patients with stasis dermatitis.

Validation of predictive factors for infection in adults with chronic leg ulcers: A prospective longitudinal study

Article

Dec 2019

Aims and objectives: To validate the ability of factors to predict infection in adults with chronic leg ulcers over a 12-week period. Background: Leg ulcers affect approximately 3% of older adults and are often hard to heal. Infection is a leading contributor for delayed healing, causing delayed wound healing, increased hospitalisation, increased healthcare costs and reduced patient quality of life. The importance of early identification of infection has been highlighted for decades, yet there is little known about factors that are associated with increased risk for infection in this specific population. Design: A longitudinal, prospective observational study in a single centre. Methods: Between August 2017 and May 2018, a total of 65 adults with chronic leg ulcers were prospectively observed for a 12-week period. Patients were recruited from an outpatient wound clinic at a tertiary hospital in Australia. Data were collected from recruitment (baseline), and each visit (weekly or fortnightly) up until 12 weeks. Descriptive statistics were calculated for all variables. A Cox proportional hazards regression model was used to identify predictive factors for infection. The TRIPOD guidelines for reporting were followed (See Supplementary file 1). Results: The sample consisted of 65 adults with chronic leg ulcers and 9.2% of these had their ulcer infected at baseline. Two predictive factors, using walking aids and gout, were found to be significantly related to increased likelihood of developing infection within 12 weeks. Conclusion: The present study showed that patients, who either used walking aids and/or were diagnosed with gout were at greater risk for infection compared to those without these factors. Relevance to clinical practice: These findings provide new information for clinicians in early identification of patients at risk of infection, and for patients in enhancing their awareness of their own risk.

A scoping review on Chronic Venous Disease and the development of a Venous Leg Ulcer: The role of obesity and mobility

Article

Oct 2019

Objective: The risk factors obesity and reduced mobility are not well known in the development of a Venous Leg Ulcer (VLU). The aim of this scoping review is to explore the mechanisms by which obesity and reduced mobility contribute the development of a VLU in patients with Chronic Venous Disease (CVD). Methods: For this scoping review a search was performed in May 2019 in the Cochrane Library and Pubmed to identify studies on the working mechanisms of obesity and mobility in developing a VLU. Hand searches were performed to find additional studies explaining the working mechanisms (indirectly related to the VLU). Two reviewers independently reviewed the abstracts and full-text articles. Results: Twenty-eight studies met our eligibility criteria. Disturbed range of ankle motion and gait can lead to a reduced Calf Muscle Pump (CMP) function which leading to a venous outflow disorder. Increased abdominal pressure due to obesity can lead to a venous outflow obstruction and increased adipose tissue mass results in an increase in adipokine secretion. The venous outflow disorder, outflow obstruction and increased adipokine secretion can all lead to chronic systemic inflammation, increased endothelial permeability and hence microcirculatory dysfunction. This alone can result in a VLU. Conclusion: Obesity and reduced mobility can lead to a reduction of the CMP function, an increase in abdominal pressure and an increase in adipose tissue mass. This can simultaneously lead to haemodynamic changes in the macro- and microcirculation of the lower extremities and eventually in a VLU. In patients with obesity and reduced mobility the microcirculation alone can lead to skin changes and eventually a VLU. Therefore, early recognition of CVD symptoms in patients with obesity and reduced mobility is crucial to diagnose and treat CVD to prevent a VLU.

Compression Therapy Using Bandages Successfully Manages Acute or Subacute Lipodermatosclerosis

Article

Full-text available

Jan 2019

We report nine cases with acute or subacute lipodermatosclerosis treated successfully using multilayer bandages. All patients were women aged 52–90 years. Before presenting to our clinic, all patients had been treated for a tentative diagnosis of cellulitis caused by bacterial infection or inflammation of unknown cause for 3–19 weeks without improvement. Initially, we instructed all patients or their caregivers regarding the bandaging technique to achieve an interface pressure of >40 mmHg. Subsequently, this technique was continued by patients/caregivers. Symptoms subsided within 2–7 weeks in all patients except one who had been noncompliant with the compression therapy.

Pitting Oedema in a Patient with Lumbar Disc Herniation: Case report of an unusual association

Article

Full-text available

Jan 2018
Sultan Qaboos Univ Med J

Oedema refers to the excessive accumulation of fluid within intercellular tissues as a result of disequilibrium between the capillary hydrostatic and oncotic pressure gradients. Lumbar disc herniation (LDH) commonly causes lower back pain and radicular leg pain. We report a 57-year-old female who presented to the neurosurgery clinic of the Bam University of Medical Sciences, Bam, Iran, in 2015 with pain and pitting oedema in the bilateral lower extremities. Magnetic resonance imaging confirmed a diagnosis of LDH of the L3–L4 and L4–L5 vertebrae. The patient subsequently underwent a bilateral laminotomy and foraminotomy of the involved vertebrae to relieve her pain. Following the surgery, there was a complete resolution of the LDH-related symptoms as well as the oedema. Although LDH has never before been associated with oedema, it may nevertheless cause lower limb oedema in exceptional and rare cases, as highlighted in this patient.

A Potential Tool for the Study of Venous Ulcers: Blood Flow Responses to Load

Article

Dec 2017

Venous ulcers are deep wounds that are located predominantly on the lower leg. They are prone to infection and once healed have a high probability of recurrence. Currently, there are no effective measures to predict and prevent venous ulcers from formation. Hence, the goal of this work was to develop a Windkessel-based model that can be used to identify hemodynamic parameters that change between healthy individuals and those with wounds. Once identified, these parameters have the potential to be used as indicators of when internal conditions change, putting the patient at higher risk for wound formation. In order to achieve this goal, blood flow responses in lower legs were measured experimentally by a Laser Doppler Perfusion Monitor (LDPM) and simulated with a modeling approach. A circuit model was developed on the basis of the Windkessel theory. The hemodynamic parameters were extracted for three groups: legs with ulcers ("wounded"), legs without ulcers but from ulcer patients ("non-wounded"), and legs without vascular disease ("healthy"). The model was executed by two independent operators, and both operators reported significant differences between wounded and healthy legs in localized vascular resistance and compliance. The model successfully replicated the experimental blood flow profile. The global and local vascular resistances and compliance parameters rendered quantifiable differences between a population with venous ulcers and healthy individuals. This work supports that the Windkessel modeling approach has the potential to determine patient specific parameters that can be used to identify when conditions change making venous ulcer formation more likely.

Objective assessment of leg edema using ultrasonography with a gel pad

Article

Full-text available

Aug 2017
PLOS ONE

Ultrasonography (US) is useful for visual detection of edematous tissues to assess subcutaneous echogenicity. However, visualization of subcutaneous echogenicity is interpreted differently among operators because the evaluation is subjective and individual operators have unique knowledge. This study objectively assessed leg edema using US with a gel pad including fat for normalization of echogenicity in subcutaneous tissue. Five younger adults and four elderly people with leg edema were recruited. We compared assessments of US and limb circumference before and after the intervention of vibration to decrease edema in younger adults, and edema prior to going to sleep and reduced edema in the early morning in elderly people. These assessments were performed twice in elderly people by three operators and reliability, interrater differences, and bias were assessed. For US assessment, echogenicity in subcutaneous tissue was normalized to that of the gel pad by dividing the mean echogenicity of subcutaneous tissue by the mean echogenicity of the gel pad. In younger adults, the normalized subcutaneous echogenicity before the intervention was significantly higher than that after the intervention. In elderly people, echogenicity indicating edema was significantly higher than that after edema reduction. Edema was detected with accuracy rates of 76.9% in younger adults and 75.0% in elderly people. Meanwhile, limb circumference could be used to detect edema in 50.0% of healthy adults and 87.8% of elderly people. The intra-reliability was excellent (intraclass correlation coefficient > 0.9, p < 0.01), and the inter-reliability was good (intraclass correlation coefficient > 0.7, p < 0.01) for normalized subcutaneous echogenicity. Bland-Altman plots revealed that inter-rater differences and systematic bias were small. Normalized subcutaneous echogenicity with the pad can sensitively and objectively assess leg edema with high reliability. Therefore, this method has the potential to become a new gold standard for objective assessment of leg edema in clinical practice.

Skin Perfusion Responses under Normal and Combined Loadings: Comparisons between Legs with Venous Stasis Ulcers and Healthy Legs

Article

Full-text available

Aug 2015

Venous ulcers, also known as stasis ulcers, are skin wounds often found at the medial surface of the lower leg. These wounds are related to chronic venous insufficiencies and affect almost 2.5 million patients every year in the United States. Eighteen participants with venous stasis ulcers on at least one leg and twenty healthy participants were tested. Normal and combined normal and shear loadings were applied to each lower leg and local blood perfusion was monitored. Basal perfusion, post-occlusive reactive hyperemia as well as changes in perfusion due to different loadings were compared. Legs with existing venous stasis ulcers ("wounded legs") had the highest reactive hyperemia and basal perfusion values. Legs without ulcers but from participants with venous stasis ulcers ("non-wounded legs") had intermediate reactive hyperemia, and healthy legs exhibited the lowest values. Wounded legs also exhibited the largest decrease in blood perfusion under both normal and combined loadings. Non-wounded legs decreased perfusion similarly to healthy legs under normal loadings; however, non-wounded legs exhibited larger decreases in blood flow than healthy legs in response to shear and normal loading together. These results suggest that patients with venous stasis disease have abnormal responses to tissue loading and raise the possibility that this technique may have the potential to identify patients at risk for developing a venous stasis ulcer. Moreover, they emphasize the importance of studying shear loading in addition to normal loading in attempting to understand the pathophysiology of this disease. Copyright © 2015 Elsevier Ltd. All rights reserved.

Differentiation of High and Low Output Lymphatic Failure Using Qualitative Lymphangioscintigraphy

Article

Full-text available

Jul 2015

To use qualitative lymphangioscintigraphy (LAS) findings to differentiate leg edema caused by high and low output lymphatic failure. LAS was performed in legs with secondary lymphedema (LE), i.e., low output failure (N = 79), and functional venous insufficiency (FVI), i.e., high output failure (N = 56), and normal legs (N = 26). Whole body images were obtained, 15, 60, and 180 min after technetium-99m injection. The rate and timing of visualization of lymphatic structures, washout out of tracer, and presence of dermal backflow were assessed. The most significant finding for differentiating LE from other conditions was not the visualization of lymphatic structures, but the washout of the tracer from the leg trunk (LE 27%, FVI 100%, normal leg 100%, P <.0001). On the other hand, the most significant finding for differentiating FVI from other legs was the visualization of inguinal lymph nodes at 15 min (LE 11%, FVI 82%, normal leg 8%, P <.0001). We found that the lack of washout from the leg trunk was most suggestive of a low output status of the lymphatic system, while earlier visualization of inguinal lymph nodes was suggestive of a high output status.

Morphological analysis of the effects of intraoperative transrectal compression of the prostate during high-intensity focused ultrasound for localized prostate cancer: Compression of the prostate during HIFU

Article

Mar 2015
INT J UROL

To evaluate the effects of transrectal compression of the prostate for intra-operative prostatic swelling and intraprostatic point shift during high-intensity focused ultrasound treatment of localized prostate cancer. Patients treated with whole-gland high-intensity focused ultrasound as primary monotherapy for localized prostate cancer were enrolled in the study. Using the standard and compression method, the volumes of degassed water in the balloon covering the high-intensity focused ultrasound probe were 50 mL and 80-160 mL, respectively. To identify prostatic swelling and shift during high-intensity focused ultrasound and the volume occupied by the non-enhanced area, three-dimensional prostate models were reconstructed using ultrasound and contrast-enhanced magnetic resonance imaging. In comparison with the standard (n = 40) and compression (n = 48) methods, intraoperative increase in the prostate volume (21% vs 5.3%; P = 0.044), intraprostatic point shift (4 mm vs 2 mm, P = 0.040 in the transition zone; 3 mm vs 0 mm; P = 0.001 in the peripheral zone) and the volume occupied by the non-enhanced area (89% vs 96%; P = 0.001) were significantly suppressed. The biochemical disease-free survival rate in patients treated using the compression method was significantly improved relative to the standard method (92.6% vs 76.5%; P = 0.038). Regarding complications, there was no significant difference in the rate of urethral stricture (P = 0.9), urinary tract infection (P = 0.9), incontinence (P = 0.3), erectile dysfunction (P = 0.9) or recto-urethral fistula between the patients treated using the standard and compression methods. Intraoperative transrectal compression suppresses intraoperative increase in the prostate volume and intraprostatic point shift during high-intensity focused ultrasound, having the potential to achieve precise whole-gland and lesion-targeted focal therapy. © 2015 The Japanese Urological Association.

Assessment of Leg Ulceration

Chapter

Apr 2024

Do Not Overlook Dependent Edema

Article

Full-text available

Mar 2024

Acupuncture Alone and Combination Therapy with Acupuncture and Kampo Formulas are Effective for the Management of Leg Edema漢方外来における下肢浮腫に対する鍼治療と鍼および漢方薬併用治療前後の変化

Article

Jan 2023

Twenty patients with bilateral localized lower leg edema were treated with acupuncture alone followed by combination therapy with acupuncture and Kampo formulas. The effects of treatment were examined after the first acupuncture session. Lower limb circumference significantly decreased from 29.1 ± 6.8 cm to 28.1 ± 7.0 cm (mean ± SD) (p < 0.01). In addition, the area of ankle edema decreased from 22.6 ± 10.6 cm² to 14.2 ± 7.2 cm² (p < 0.05). Subcutaneous tissue thickness, as measured via ultrasound, significantly decreased at the lower limbs and ankles from 10.4 ± 3.8 mm to 7.8 ± 3.4 mm and 10.1 ± 2.9 mm to 8.2 ± 3.0 mm, respectively (p < 0.05). In contrast, there was no change in subcutaneous echogenicity observed in the lower limbs. Following acupuncture, patients underwent combination therapy with acupuncture and Kampo formulas. As a result, area of ankle edema significantly decreased from 24.1 ± 2.5 cm² to 3.0 ± 2.1 cm² (p < 0.01). Moreover, symptoms resolved with respect to edema and coldness (p < 0.05). However, no change was observed in laboratory parameters. This study highlights the efficacy of acupuncture in improving lower leg edema. In addition, combination therapy with acupuncture and Kampo formulas seemed to be effective in the treatment of leg edema.

Evaluation and Management of Patients with Leg Swelling: Therapeutic Options for Venous Disease and Lymphedema

Article

Jun 2021

Lower extremity swelling is a common condition which has a variety of etiologies and can be challenging to diagnose and manage. Swelling is usually the result of the accumulation of interstitial fluid in the subcutaneous tissues. Common etiologies include systemic, superficial, and deep venous, and lymphatic disorders. Leg swelling can occur bilaterally or unilaterally, with venous disorders being one of the most common causes of unilateral lower extremity edema.

Inaktivitätsödem

Chapter

Jan 2021

Limitations to self-management of adjustable compression wraps in the elderly: results of a prospective cohort study

Article

Mar 2021
Int Angiol

Background: Adjustable compression wraps are used for treating lymphedema and chronic venous insufficiency. These diseases often affect elderly patients with associated pathologies or other limiting factors. These can prevent the self-application of the device by patients on themselves. A better understanding of these factors or the associated pathologies in the elderly is important before prescribing or not prescribing a wrap. Methods: The objective of this prospective cohort study was to determine the main factors that prevent the self-application of the device (Circaid JuxtaliteR) to the lower limb in the elderly. A private nurse selected the first 30 retired subjects over 65 years of age seen at home for routine nursing care. After a demonstration, she asked them to put on the wrap in order to reach a pressure of 40 mmHg in the calf (point B1). She recorded the pressures as the subjects applied the wrap twice in a row. The next day, the subject repeated the application of the wrap twice. We considered that an average pressure of more than 30 mmHg is recommended to treat venous edema or ulceration. Results: 30% of the subjects put on the wrap by themselves with an average pressure of at least 30 mmHg. Age is not a limiting factor. Obesity, gripping difficulties, cognitive impairment and low social status seem to be factors limiting the daily self-management of an adjustable compression wrap in the elderly. Conclusions: The self-management of adjustable compression wraps in the elderly person encounters obstacles that need to be known. The investigation has revealed that obesity, gripping difficulties, cognitive impairment and low social status are limiting factors. Age was not shown to be a limiting obstacle.

Extracellular Fluid Content in the Legs of Patients with Chronic Venous Disease

Article

Aug 2020

Purpose This study aimed to determine the factors that affect the extracellular fluid (ECF) content in the legs of patients with chronic venous disease (CVD). Procedures Bioimpedance analysis and air plethysmography (APG) were performed in 79 patients with CVD who visited our clinic between September 2016 and March 2019. The normal right legs (N) of 14 healthy volunteers were also reviewed for comparison. The ratio of extracellular fluid resistance (Re) of the leg to that of the arm (ReL/ReA) was used to express the ECF content in the tested leg. The severity of CVD was expressed using the clinical, etiological, anatomical, and pathophysiological (CEAP) classification. Main findings The ReL/ReA decreased as the CEAP class increased (N: median; 0.81 [range 0.66–0.95], C0-1: 0.79 [0.60–0.98], C2: 0.77 [0.56–1.08], C3: 0.67 [0.57–0.85], C4: 0.64 [0.44–0.89]). Older age, female sex, and CEAP class affected the ReL/ReA, but body mass index did not. The ReL/ReA did not correlate with the parameters that were derived from APG, including the venous filling index. Conclusions We found that the ECF content in legs of patients with CVD might be primarily affected by patient-related factors and CEAP class, as opposed to venous hemodynamics.

Bioelectrical impedance analysis of leg edema and its association with venous functions in patients with saphenous varicose veins

Article

Mar 2020
Int Angiol

Background: To quantitatively evaluate edema of the lower legs in patients with saphenous varicose veins, and to determine the association between leg edema and venous hemodynamics of the lower legs. Methods: The data of 140 patients with saphenous varicose veins visiting Eniwa Midorino Clinic from April 2018 to November 2019 were retrospectively analyzed. Body composition values, including mass index (BMI), extracellular water / total body water (ECW/TBW) of each leg, and skeletal muscle mass of each leg, were measured by segmental multi-frequency bioelectrical impedance analyzer. Overall venous hemodynamics of the leg, including functional venous volume, venous filling index (VFI), and ejection fraction, was assessed using air-plethysmography. Saphenous and deep vein reflux was evaluated by duplex scan. Results: A total of 140 patients (58 men and 82 women) with a mean age of 66.0 years (range, 21 to 84 years) were analyzed. On visual inspection, 204 legs had saphenous-type varicose veins, while 76 legs did not. The legs were divided into 2 groups according to the presence or absence of leg edema, which was defined as ECW/TBW ≥ 0.390 and < 0.390, respectively; 178 legs had leg edema and the remaining 102 legs had no leg edema. In univariate analysis, there were significant differences in age, sex, the presence of saphenous varicose veins, hypertension, and VFI between legs with edema and those without edema. Multivariable logistic regression analysis for leg edema detected age, female gender, and VFI as an independent risk factor for leg edema. Conclusions: Leg edema was objectively evaluated by bioelectrical impedance analysis in patients with saphenous varicose veins. Older age, female gender, and increased venous reflux were identified as independent risk factors for leg edema.

Conjunto Mínimo Básico de Datos para la prevención, diagnóstico y tratamiento de la Insuficiencia Venosa Crónica. Serie Documentos de Posicionamiento GNEAUPP nº 15.

Book

Full-text available

Oct 2018

Effects of intermittent pneumatic compression treatment on clinical outcomes and biochemical markers in patients at low mobility with lower limb edema

Article

Jul 2018

Objective: We aimed to evaluate the effects of intermittent pneumatic compression (IPC) in patients at low mobility with leg edema. Methods: A pilot, two-arm, randomized controlled clinical trial was performed. Fifty patients (age, 58.4 ± 9 years; male, 14), randomly allocated to a group (IPC) undergoing 1 month (n = 29) of an in-home cycle of IPC and to a control (C) group (n = 21), were studied. Leg edema was evaluated by measuring subcutaneous thickness (high-resolution ultrasound) and circumferences (metric tape), both assessed at different levels of the lower limbs, and volume (water plethysmography). Ankle range of motion (ROM, goniometer), quality of life (QoL) by the 36-Item Short Form Health Survey, and a pool of plasma inflammatory markers were also evaluated. Results: Edema significantly decreased in the IPC group (for all outcome measures, P < .0001), whereas it significantly increased in the C group (P < .0001). Ankle ROM was significantly enhanced in the IPC group (dorsiflexion, P < .0001; plantar flexion, P = .002) and remained stable in the C group. QoL showed an improvement in the IPC group, particularly significant for the general health subscale (P = .004), whereas no changes were highlighted in the C group. The two groups exhibited different trends and variations for some plasma inflammatory markers, mainly for granulocyte colony-stimulating factor. Conclusions: In a sample of patients at reduced mobility with leg edema, IPC treatment was effective in reducing the edema, improving the ankle ROM, and determining a positive impact on QoL together with a slight modulation of some plasma inflammatory markers.

Lymphedema techniques to manage edema after SCI: a retrospective analysis

Article

Full-text available

Jun 2018
SPINAL CORD

Study design: Retrospective analysis of treatment data for a cohort of clients with spinal cord injury (SCI) who received therapy for management of edema. Objective: To evaluate the safety, feasibility, and benefit of a modified lymphedema treatment approach for treatment of chronic lower extremity edema in persons with SCI. Setting: A specialty rehabilitation hospital in Atlanta, GA, USA. Methods: Certified lymphedema therapists with experience in SCI rehabilitation modified standard complete decongestive therapy (CDT) techniques to accommodate sensory and motor impairments and ensure skin safety. Therapists applied the modified CDT (mCDT) approach as part of treatment in 59 adults with SCI and lower extremity edema. Limb volume was measured using standardized volumetric measurement, pitting was scored using a standardized scale (range 0-4), and edema characteristics were determined to be present or absent. Outcomes of the mCDT intervention were analyzed for 105 lower extremities. Results: Outcomes indicated that mCDT was associated with significant reduction in limb volumes, with a mean decrease of 11 ± 7.6%. Significant decreases were also observed in pitting edema and edema-specific characteristics, mean pitting scale score was reduced from a 3/4 to a 1/4. Minor adverse events were identified in a small number of patients. Conclusions: We found the mCDT approach to be safe and well-tolerated by the patients with SCI. The intervention was associated with decreased edema, and was feasible for use in a clinical setting. We recommend considering this mCDT approach for management of edema in individuals with SCI, while remaining vigilant about skin inspection.

Differentiation of functional venous insufficiency and leg lymphedema complicated by functional venous insufficiency using subcutaneous tissue ultrasonography

Article

Sep 2016

Objective To use subcutaneous ultrasonography to differentiate legs with edema because of obesity-related functional venous insufficiency (FVIob), immobility-related FVI (FVIim), secondary lymphedema (LE), LE complicated by obesity (LEob), and LE complicated by immobility (LEim). Methods Ninety-nine legs with edema (16 FVIob, 32 FVIim, 22 LE, 9 LEob, and 20 LEim), and 10 normal legs were examined. Subcutaneous tissue ultrasonography was performed at eight points (medial, lateral, upper, lower, thigh, and calf) in each leg. Subcutaneous echogenicity (SEG) and subcutaneous echo-free space (SEFS) were assessed, and each graded as 0, 1, and 2 according to their severity. Results In normal legs, SEG and SEFS were graded 0 in almost all parts of the leg. SEG was diffusely increased in FVIob, whereas SEG was increased in accordance with gravity in FVIim (upper medial thigh, 0.6 ± 0.5 vs lower medial calf, 1.2 ± 0.4; P < .001). In LE, SEG was increased in the medial side, particularly evident in upper thigh (upper medial thigh, 1.1 ± 0.4 vs upper lateral thigh, 0.6 ± 0.6; P < .01). SEFS was increased in accordance with gravity in all of these legs (FVIob: upper medial thigh, 0.2 ± 0.4 vs lower medial calf, 0.7 ± 0.8; P = .05; FVIim: upper medial thigh, 0.1 ± 0.2 vs lower medial calf, 1.3 ± 0.7; P < .0001; LE: upper medial thigh, 0.4 ± 0.7 vs lower medial calf, 0.9 ± 0.9; P < .05). The increases of SEG and SEFS in legs with LEob or LEim were diffuse and similar. As determined via stepwise logistic regression analyses, the increases in SEG in the upper medial thigh and SEFS in the lower medial thigh in LE cases, the increases in SEG in the upper lateral thigh and SEFS in the lower lateral thigh in cases with obesity-related leg edema (ie, FVIob and LEob), and the increase in SEFS in the lower lateral calf in cases with immobility-related leg edema (ie, FVIim and LEim) were determined to be significant factors to characterize each leg edema. Conclusions Differences in the extent and distribution of SEG and SEFS might help in differentiating LE from FVIob and FVIim, although assessment of LE complicated by obesity vs immobility remains difficult.

Adherence to and efficacy of different compression methods for treating chronic venous insufficiency in the elderly

Article

Oct 2015
Phlebology

Objectives: To investigate the adherence to and efficacy of different compression methods in elderly patients. Methods: A retrospective review of compression therapy in 120 elderly patients (≥65 years) with chronic venous insufficiency was performed to study the initially preferred compression method, adherence to each method, and its efficacy. Results: Initially, an oversize strong stocking (24%), an appropriate size moderate stocking (19%), and bandages (37%) were equally preferred. Adherence at 1 month was 69%, 96%, and 91%, respectively, and they reduced ankle circumferences in C3 patients by 1.8 ± 1.9 cm, 0.3 ± 1.7 cm, and 2.9 ± 1.7 cm, respectively. The improvement rates of C4 symptoms were 79%, 60%, and 91%, respectively. Only three patients (2%) preferred an appropriate size strong stocking. Conclusions: In elderly patients, an appropriate size strong stocking was not preferred. The best adherence was achieved by using a moderate stocking, while the best efficacy was achieved by using bandages.

Effect of three-size too large strong stocking on venous hemodynamics in normal subjects

Article

Mar 2015

To study the differences in impact on venous hemodynamics between larger size strong graduated elastic compression stockings (GECS) and appropriate size strong/moderate GECS. In healthy legs fitted for a small (Group S; n = 8) and large (Group L; n = 8) GECS, air plethysmography was performed without GECS, with an appropriate size strong GECS (GECS1), with a three-size too large strong GECS (GECS2), and with an appropriate size moderate GECS (GECS3) in this order. In Group S, interface pressure with GECS2 was equal to or higher than that with GECS3. Decreased venous volume, unchanged ejection volume, and decreased residual volume were achieved by GECS, but differences in these parameters among GECS were not observed. Although insignificant, a similar tendency was found in Group L. A larger size strong GECS seemed to have equivalent interface pressure and impact on venous hemodynamics compared to an appropriate size moderate or strong GECS. © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

Subcutaneous Tissue Ultrasonography in Legs with Dependent Edema and Secondary Lymphedema

Article

Full-text available

Apr 2014

To elucidate the differences in subcutaneous ultrasound findings between dependent edema (DE) and secondary lower extremity lymphedema (LE). Twenty legs in 10 patients with DE and 54 legs in 35 patients with LE, who first visited our clinic between April 2009 and December 2012, were studied retrospectively. Subcutaneous echogenicity and echo-free space (EFS) were assessed at 8 points on the thigh and leg using an 8-12 MHz ultrasound transducer. In DE, echogenicity was increased most in the lower leg, without a difference between the medial and lateral side. The EFS was most remarkable in the lower leg, and the lateral side was more severe. In the early stages of LE, echogenicity was similarly increased in the medial thigh and in the leg, while remarkable EFS was observed only in the lower leg. As clinical severity progressed, echogenicity increased in all parts of the lower extremity. EFS also increased in all parts of the leg, but the lower leg was still the most severe. Echogenicity seemed to progress differently in DE and LE, but EFS progressed similarly and according to gravity. The current ultrasound findings may have added some diagnostic value in differentiating these conditions.

Significance of Ultrasound Examination of Skin and Subcutaneous Tissue in Secondary Lower Extremity Lymphedema

Article

Full-text available

Jul 2013

To clarify whether ultrasound findings of skin and subcutaneous tissue represent the severity of lymphedema. Thirty-five patients with secondary lower extremity lymphedema caused by intrapelvic lymph node dissection during cancer surgery, who first visited our clinic between April 2009 and March 2012, were studied retrospectively. At their first visit, skin thickness, subcutaneous tissue thickness, and subcutaneous echogenicity were assessed at 8 points on the thigh and leg of both legs using an 11-MHz ultrasound transducer. These findings correlated with the International Society of Lymphology (ISL) clinical stage. Skin thickness, subcutaneous tissue thickness, and subcutaneous echogenicity all showed significant positive correlation with the ISL stage. However, measuring skin and subcutaneous tissue thicknesses was not feasible in 29%-71% of scanning points in stage III legs because of poor delineation of boundaries at the dermo-hypodermal junction and the upper boundary of the muscular fascia. However, subcutaneous echogenicity was assessable at all scanning points and was linearly correlated with ISL stage. Evaluating subcutaneous echogenicity is feasible even with low-resolution ultrasound and reflects the ISL stage. These findings may thus be valuable to objectively represent the severity of extremity lymphedema.

Chronic edema of the lower extremities: International consensus recommendations for compression therapy clinical research trials

Article

Full-text available

Aug 2012
Int Angiol

Chronic edema is a multifactorial condition affecting patients with various diseases. Although the pathophysiology of edema varies, compression therapy is a basic tenant of treatment, vital to reducing swelling. Clinical trials are disparate or lacking regarding specific protocols and application recommendations for compression materials and methodology to enable optimal efficacy. Compression therapy is a basic treatment modality for chronic leg edema; however, the evidence base for the optimal application, duration and intensity of compression therapy is lacking. The aim of this document was to present the proceedings of a day-long international expert consensus group meeting that examined the current state of the science for the use of compression therapy in chronic edema. An expert consensus group met in Brighton, UK, in March 2010 to examine the current state of the science for compression therapy in chronic edema of the lower extremities. Panel discussions and open space discussions examined the current literature, clinical practice patterns, common materials and emerging technologies for the management of chronic edema. This document outlines a proposed clinical research agenda focusing on compression therapy in chronic edema. Future trials comparing different compression devices, materials, pressures and parameters for application are needed to enhance the evidence base for optimal chronic oedema management. Important outcomes measures and methods of pressure and oedema quantification are outlined. Future trials are encouraged to optimize compression therapy in chronic edema of the lower extremities.

Chronic peripheral oedema: The critical role of the lymphatic system

Article

Full-text available

Sep 2004

Oedema is an excess of interstitial fluid and is an important sign of ill health in clinical medicine. It may occur in the lungs (pulmonary oedema), the abdominal cavity (ascites) and other body cavities (synovial, pericardial and pleural effusions) but in this article only peripheral (subcutaneous) oedema is discussed. In medical practice peripheral oedema tends to get pigeonholed according to possible systemic or peripheral causes eg heart failure, nephrotic syndrome, venous obstruction or lymphoedema. This viewpoint fails to appreciate the many dynamic physiological forces contributing to oedema development and in particular the central role of the lymphatic drainage system in tissue fluid balance. Consequently, the clinician’s approach to chronic oedema is often misguided and the necessary medical intervention inappropriate, for example, empirical use of diuretics. In this article we propose a system for managing peripheral oedema, which is based on physiological principles, that can then guide treatment. Why is chronic oedema important? Besides being a physical sign of a potentially fatal systemic condition such as heart failure, chronic oedema impairs local cell nutrition due to increased interstitial diffusion distances of oxygen and nutrients so tissue viability can become compromised. Swollen limbs can be painful, giving rise to impaired mobility as well as a predisposition to infection and blistering progressing to ulceration. Chronic oedema is a common problem in the community particularly for district nurses. A recent epidemiological study in South West London estimated a crude prevalence of 1.33/1000 population rising to one in 200 people over the age of 65. 29% of the oedema cases had experienced cellulitis in the preceding year with one quarter of these cases requiring admission. Oedema caused time off work in more than 80% of sufferers and employment status was affected in 9%. Quality of life suffered, with clear deficits in many domains of the well-validated SF-36 questionnaire.1

Risk factors for erpsipelas of the leg (cellulitis): Case-control study

Article

Full-text available

Jul 1999

To assess risk factors for erysipelas of the leg (cellulitis). Case-control study. 7 hospital centres in France. 167 patients admitted to hospital for erysipelas of the leg and 294 controls. In multivariate analysis, a disruption of the cutaneous barrier (leg ulcer, wound, fissurated toe-web intertrigo, pressure ulcer, or leg dermatosis) (odds ratio 23.8, 95% confidence interval 10.7 to 52.5), lymphoedema (71.2, 5.6 to 908), venous insufficiency (2.9, 1.0 to 8.7), leg oedema (2.5, 1.2 to 5.1) and being overweight (2.0, 1.1 to 3.7) were independently associated with erysipelas of the leg. No association was observed with diabetes, alcohol, or smoking. Population attributable risk for toe-web intertrigo was 61%. This first case-control study highlights the major role of local risk factors (mainly lymphoedema and site of entry) in erysipelas of the leg. From a public health perspective, detecting and treating toe-web intertrigo should be evaluated in the secondary prevention of erysipelas of the leg.

Bilateral Leg Edema, Obesity, Pulmonary Hypertension, and Obstructive Sleep Apnea

Article

Full-text available

Aug 2000
ARCH INTERN MED

Pulmonary hypertension is usually due to an underlying cardiac or pulmonary condition. An association between unexplained pulmonary hypertension and bilateral leg edema in primary care patients was found previously. We undertook this study to identify the frequency of obstructive sleep apnea (OSA) in ambulatory, adult patients with pulmonary hypertension who initially presented with bilateral leg edema. Twenty ambulatory adults with bilateral leg edema, echocardiocardiographic evidence of pulmonary hypertension (estimated pulmonary artery systolic pressure >30 mm Hg) without left ventricular dysfunction, and no clinically apparent pulmonary disease [corrected] were enrolled from a suburban family practice and an inner-city family practice during a 3-year period. Spirometric assessment, pulse oximetry, rheumatologic evaluation, polysomnography, and questionnaire information regarding risk factors for pulmonary hypertension were obtained for each subject. Fifteen patients (75%) completed the study. Almost all of the subjects were obese. Nine (60%) of the 15 had OSA. None of the subjects demonstrated an obstructive pattern on spirometric evaluation results, but 9 (60%) had a restrictive spirometry pattern, consistent with their obesity. None of the subjects had daytime hypoxemia. Systemic hypertension was present in two-thirds of the subjects with OSA, and was absent in all of the subjects who lacked OSA. Bilateral leg edema in obese primary care patients is associated with both OSA and modest pulmonary hypertension. If these findings are generalizable, then bilateral leg edema may be an important clinical marker for underlying OSA.

The third circulation: Radionuclide lymphoscintigraphy in the evaluation of lymphedema

Article

Full-text available

Feb 2003

Lymphedema-edema that results from chronic lymphatic insufficiency-is a chronic debilitating disease that is frequently misdiagnosed, treated too late, or not treated at all. There are, however, effective therapies for lymphedema that can be implemented, particularly after the disorder is properly diagnosed and characterized with lymphoscintigraphy. On the basis of the lymphoscintigraphic image pattern, it is often possible to determine whether the limb swelling is due to lymphedema and, if so, whether compression garments, massage, or surgery is indicated. Effective use of lymphoscintigraphy to plan therapy requires an understanding of the pathophysiology of lymphedema and the influence of technical factors such as selection of the radiopharmaceutical, imaging times after injection, and patient activity after injection on the images. In addition to reviewing the anatomy and physiology of the lymphatic system, we review physiologic principles of lymphatic imaging with lymphoscintigraphy, discuss different qualitative and quantitative lymphoscintigraphic techniques and their clinical applications, and present clinical cases depicting typical lymphoscintigraphic findings.

Venous edema of the lower limbs

Article

Jan 2006
Phlebolymphology

P. Priollet

Revision of the CEAP classification for chronic venous disorders: Consensus statement

Article

Jan 2004
J VASC SURG

Re-evaluation of qualitative lymphangioscintigraphic findings in secondary lower extremity lymphedema

Article

Dec 2013
SURG TODAY

To re-evaluate whether qualitative lymphangioscintigraphy (LAS) findings are sensitive enough to diagnose or classify the clinical severity of lower extremity lymphedema. LAS was performed in 78 extremities with lymphedema and 24 extremities without lymphedema between April, 2009 and March, 2012. We assessed the proportion of extremities in which there was no visual evidence of the ilioinguinal lymph nodes (LN-60) or the lymphatic trunk (Tr-60) 60 min after tracer injection, the number of visualized ilioinguinal lymph nodes (#LN), and the proportion of extremities with dermal backflow (pDBF) and lymph stasis (pLS). These were associated with the International Society of Lymphology (ISL) clinical stage. LN-60, Tr-60, #LN, pDBF, and pLS, especially when extending into both the thigh and lower leg, were significantly associated with the ISL stage. The sensitivity of LN-60, Tr-60, and #LN <2 for diagnosing lymphedema was 49, 47, and 59 %, respectively, with no significant difference among these parameters for consecutive ISL stages. None of the above measures was sufficiently sensitive to diagnose lymphedema or classify the severity of the disease; however, each of these criteria can aid in diagnosis, by excluding other diseases and assessing disease pathophysiology.

Reporting standards in venous disease: An update

Article

Apr 1995
J VASC SURG

At the request of the Ad Hoc Committee on Reporting Standards of the Joint Council of the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery, this report updates and modifies "Reporting standards in venous disease" (J VASC SURG 1988;8:172-81). As in the initial document, reporting standards for publications dealing with (1) acute lower extremity venous thrombosis, (2) chronic lower extremity venous insufficiency, (3) upper extremity venous thrombosis, and (4) pulmonary embolism are presented. Numeric grading schemes for disease severity, risk factors, and outcome criteria present in the original document have been updated to reflect increased knowledge of venous disease and advances in diagnostic techniques. Certain recommendations of necessity remain arbitrary. These standards are offered as guidelines whose observance will in our opinion improve the clarity and precision of communications in the field of venous disorders. (J VASC SURG 1995;21:635-45.)

ABC of arterial and venous disease: Swollen lower limb---2: Lymphoedema

Article

Jun 2000

P. S Mortimer

Elastic Multilayer Bandages for Chronic Venous Insufficiency: Features of Our Technique

Article

Jan 2012

Objectives: To evaluate the interface pressure (IP) and stiffness of our elastic multilayer bandages (eMLB). Methods: Three medical staff wrapped the legs of 10 healthy volunteers with one to six rolls of elastic bandages. The IP was measured at the medial aspect of the lower leg at the level of transposition of the medial gastrocnemius muscle into the Achilles tendon (level of B1) with the patient supine and then standing, for each number of bandages worn. The static stiffness index (SSI) was calculated as a difference between these IPs. Results: The IPs in the standing position increased linearly for up to five bandages (21.8 ± 7.2, 32.5 ± 6.1, 41.8 ± 8.5, 52.0 ± 10.4, 60.3 ± 11.8, and 66.7 ± 13.4 mmHg, with one to six bandages). SSI also increased linearly for up to five bandages (6.8 ± 5.1, 10.2 ± 4.8, 13.4 ± 7.2, 17.4 ± 8.8, 19.7 ± 9.1, and 20.4 ± 9.4 mmHg, with one to six bandages). No significant technical variation in the IP was observed among the three operators. Conclusions: Our eMLB provided stable, predictable and sufficient IPs and SSIs in healthy volunteers.

Interface Pressures Derived from Oversize Compression Stockings

Article

Jan 2012

Objectives: To clarify interface pressures (IP) derived from class II and III oversize stockings. Methods: Healthy volunteers with legs fitting size S (n = 10), M (n = 6), or L (n = 6) stockings wore class II and III stockings of various sizes up to 5L. IPs were measured in the supine and the standing position with each stocking on. Results: In the subjects with size S legs, the IPs in the standing position while wearing S and M class III stockings were 43.5 ± 4.7 and 40.4 ± 5.4 mmHg respectively. These IPs were significantly higher than the IP while wearing the S size class II stocking (33.3 ± 5.9 mmHg). IPs derived from L, LL, 3L, 4L, 5L class III stockings were not significantly different from IP with the S size class II stocking. The results were similar for the subjects with size M legs while wearing the size M and L class III stockings and for the subjects with size L legs while wearing the size L and LL class III stockings vs. the appropriate size class II stocking. Conclusion: Based on these findings, a larger size class III stocking can provide similar or even higher IPs compared to an appropriate size class II stocking.

Lower limb cellulitis and its mimics Part II. Conditions that simulate lower limb cellulitis

Article

Aug 2012

Several common conditions can mimic cellulitis, creating a potential for misdiagnosis and incorrect management. The most common disorders mistaken for lower limb cellulitis include venous eczema, lipodermatosclerosis, irritant dermatitis, and lymphedema. The dermatologist is often consulted when a patient has failed to respond to therapy, and a thorough knowledge of the differential diagnosis is essential. This article focuses on entities that can mimic cellulitis, with an emphasis of elements of the history and physical examination that can help to distinguish between lower limb cellulitis and its simulators.

A nodule on the forehead

Article

Jul 2012

Loop Diuretic Use at Discharge Is Associated With Adverse Outcomes in Hospitalized Patients With Heart Failure - A Report From the Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD)

Article

May 2012
CIRC J

Loop diuretics are commonly used in patients with heart failure (HF) to remove retained fluid and improve symptoms. However, they may potentially worsen outcomes in HF. It remains unknown whether the use of loop diuretics is associated with adverse HF outcomes in routine clinical practice. We thus determined the effects of loop diuretic use at discharge on long-term mortality and rehospitalization among patients hospitalized with HF. The Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD) prospectively studied the characteristics and treatments of a broad sample of patients hospitalized with worsening HF and followed for 2.1 years. Among a total of 2,549 HF patients, loop diuretics were used by 2,015 patients (79%), but not 534 patients (21%). The mean age was 70.7 years and 60% were male. Etiology was ischemic in 32% and mean left ventricular ejection fraction was 42%. After adjustment for covariates, discharge use of loop diuretics was associated with significant adverse risks of cardiac death (adjusted hazard ratio [HR] 2.348, 95% confidence interval [CI] 1.246-4.423, P=0.008) and rehospitalization (adjusted HR 1.427, 95% CI 1.040-1.959, P=0.027). Among patients hospitalized with worsening HF, loop diuretic use at discharge was associated with long-term adverse outcomes, which suggests that routine chronic use of loop diuretics may be harmful for patients with HF.

Epidemiology and aetiology of C4-6 disease

Article

Oct 2010
Phlebology

AW Bradbury

Although our understanding of chronic venous insufficiency (CVI) has improved, many important questions remain unanswered. Ensuring that patients are appropriately referred for specialist assessment and then receive evidence-based, cost-effective treatment continues to be challenging. The lifetime of risk of chronic venous ulceration (CVU) is around 1% with approximately 10% ulcers being open at any one time. The incidence skin changes disease is about 10 times greater (10%). However, many of the studies upon which these estimates are based are old and/or methodologically flawed. There is reason to believe that the incidence, prevalence and characteristics of CVI/CVU may have changed considerably over the last 10-20 years and that future change is likely. Further cross-sectional and longitudinal epidemiological studies are required to establish the size and nature of the health-care need going forward in developed and increasingly developing countries. CVI culminating CVU is primarily the result of sustained ambulatory venous hypertension, which in turn arises from superficial and/or deep venous reflux with or without deep vein obstruction. However, there are many other elements to this complex condition, for example, microvascular dysfunction; calf muscle pump efficiency; dermal inflammation; disordered fibroblast function and matrix production; failure of epithelialization; congenital and acquired thrombophilia; malnutrition, obesity and diet; and bacterial colonization. None of the currently available treatment modalities is entirely satisfactory and novel therapies based upon a clearer understanding of the disease at the psychological, genetic, mechanical, microvascular and microscopic level are required.

Article

Mar 2009

Compression therapy is the most widely used treatment for venous leg ulcers and it was used in different forms for more than 400 years. Published healing rates of venous ulcers obtained with compression therapy vary widely from 40-95%. According to numerous studies, it has been suggested that the application of external pressure to the calf muscle raises the interstitial pressure resulting in improved venous return and reduction in the venous hypertension. Several risk factors have been identified to be correlated with the failure of venous leg ulcers to heal with compression therapy (longer ulcer duration; large surface area; fibrinous deposition present on >50% of the wound surface and an Ankle Brachial Pressure Index (ABPI) of <0.85. An open prospective single-center study was performed in order to determine possible risk factors associated with the failure of venous ulcers to heal when treated with multi-layer high compression bandaging system for 52 weeks. In the study, 189 patients (101 women, 88 men; mean age 61 years) with venous leg ulcers (ulcer surface >5 cm(2); duration >3 months) were included. The study excluded patients with arterial disease (ABPI <0.8), heart insufficiency with ejection fraction (EF) <35, pregnancy, cancer disease, rheumatoid arthritis, and diabetes. Based on clinical opinion and available literature, the following were considered as potential risk factors: sex, age, ulceration surface, time since ulcer onset, previous operations, history of deep vein thrombosis, body mass index (BMI), reduction in calf circumference >3 cm during the first 50 days of treatment, walking distance during the day <200 meters, calf:ankle circumference ratio <1.3, fixed ankle joint, history of surgical wound debridement, >50% of wound covered with fibrin, depth of the wound >2 cm. Within 52 weeks of limb-compression therapy, 24 (12.7%) venous ulcers had failed to heal. A small ulceration surface (<20 cm(2)), the duration of the venous ulcer <12 months, a decrease in calf circumference of more than 3 cm, and emergence of new skin islets on >10% of wound surface during the first 50 days of treatment were favorable prognostic factors for ulcer healing. A large BMI (>33 kg/m(2)), short walking distance during the day (<200 m), a history of wound debridement, and ulcers with deepest presentation (>2 cm) were indicators of slow healing. Calf:ankle circumference ratio <1.3, fixed ankle joint, and reduced ankle range of motion were the only independent parameters associated with non-healing (P < .001). The results obtained in this study suggest that non-healing venous ulcers are related to the impairment of the calf muscle pump.

Superficial Fascial System (SFS) of the Trunk and Extremities

Article

Jul 1991
PLAST RECONSTR SURG

Ted E. Lockwood

Surgeons and anatomists have largely ingored the superficial fascia of the body. In fact, many anatomists have doubted the existence of this fascia as a distinct entity. The superficial fascia does exist and is functionally important. Understanding the anatomy and pathologic changes with age of the superficial fascial system (SFS) of the trunk and extremities may help explain body-contour deformities and provide the anatomic basis for surgical correction. The anatomy of the superficial fascial system was studied in 12 fresh and embalmed cadavers, cross-sectional cadaver segments, and 20 body-contour patients. The superficial fascial system is a connective-tissue network that extends from the subdermal plane to the underlying muscle fascia. It consists primarily of one to several thin, horizontal membranous sheets separated by varying amounts of fat with interconnecting vertical or oblique fibrous septae. Superficial fascial system anatomy varies with sex, adiposity, and body region. The topographic landmarks of the human body are largely the result of superficial fascial system anatomy (zones of adherence) and its relationships with fat and muscle fascia. The primary function of the superficial fascial system is to encase, support, and shape the fat of the trunk and extremities and to hold the skin onto the underlying tissues. With age and sun damage, the entire skin-superficial fat-superficial fascial system unit relaxes and stretches, resulting in ptotic soft tissues, pseudo-fat deposit deformity, and cellulite. There are two types of cellulite in women. Primary cellulite, or cellulite of adiposity, is due to hypertrophied superficial fat cells and is not amenable to surgical treatment. Secondary cellulite, or cellulite of laxity, results from laxity of the skin and soft tissues as a result of age, sun damage, or massive weight loss, or after liposuction. Secondary cellulite is surgically correctable by lifting techniques. Superficial fascial system suspension is an important adjunct to body-contour surgery of the trunk and extremities. Similar to the SMAS role in rhytidoplasty, repair of the superficial fascial system diffuses the tension on the skin flap, more effectively lifts areas of soft-tissue ptosis, and provides longer-lasting support. In addition, the superficial fascial system suspension allows more normal contours in both static and dynamic activities. The superficial fascial system repair has been used to enhance the following body-contour procedures: abdominoplasty, thigh-buttock lift, back-flank lift, medial thigh lift, inframammary fold reconstruction, and augmentation mammaplasty.

Air-plethysmography and the effect of elastic compression on venous hemodynamics of the leg

Article

Feb 1987
J VASC SURG

Leg volume changes during exercise have been measured in absolute units (milliliters) by means of a new method of air-plethysmography. Venous volume (VV), venous filling time, and venous filling index on standing from the recumbent position, ejected volume (EV) and ejection fraction (EF = EV x 100/VV) with one tiptoe movement, and residual volume (RV) and residual volume fraction (RVF = RV x 100/VV) after 10 tiptoe movements were measured in normal limbs, limbs with superficial venous incompetence, and limbs with deep venous disease. The same measurements were repeated with a graduated medium compression stocking in limbs with SVI and graduated high compression stockings in limbs with DVD. Ambulatory venous pressure was measured at the same time, with a needle in a vein in the foot. The results indicate that this method of air-plethysmography is not only of diagnostic value but offers a new and unique technique to assess and study the hemodynamic effects of different forms of elastic compression. The lower ambulatory venous pressure, produced by the elastic compression, was the result of a reduction in reflux and an improvement in the calf muscle ejecting ability during rhythmic exercise.

Reporting standards in venous disease: An update. International Consensus Committee on Chronic Venous Disease

Article

May 1995
J VASC SURG

At the request of the Ad Hoc Committee on Reporting Standards of the Joint Council of the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery, this report updates and modifies "Reporting standards in venous disease" (J Vasc Surg 1988;8:172-81). As in the initial document, reporting standards for publications dealing with (1) acute lower extremity venous thrombosis, (2) chronic lower extremity venous insufficiency, (3) upper extremity venous thrombosis, and (4) pulmonary embolism are presented. Numeric grading schemes for disease severity, risk factors, and outcome criteria present in the original document have been updated to reflect increased knowledge of venous disease and advances in diagnostic techniques. Certain recommendations of necessity remain arbitrary. These standards are offered as guidelines whose observance will in our opinion improve the clarity and precision of communications in the field of venous disorders.

The significance of calf muscle pump function in venous ulceration

Article

Jan 1995
J VASC SURG

Patients with clinically evident chronic venous insufficiency were evaluated to relate the degree of insufficiency and calf muscle pump dysfunction to venous ulceration. Sixty-nine limbs in 55 patients with chronic venous insufficiency by Society for Vascular Surgery/International Society for Cardiovascular Surgery Classification were compared in three groups: classes 1 and 2 with no history of ulceration (19 limbs); class 3 with healed ulceration (20 limbs); and class 3 with active ulcers (30 limbs). Air plethysmography measurements of outflow fraction, venous volume, venous filling time, venous filling index, ejection fraction, ejection volume, residual volume fraction, and residual volume were made. In 62 of the 69 limbs, color-flow duplex ultrasonography was used to determine the pattern of reflux. The outflow fraction was normal in 84%, 75%, and 77% of nonulcerated, healed, and ulcerated limbs. The venous filling index was abnormal in most limbs (nonulcerated 95%, healed 90%, ulcerated 98%) but not significantly different among groups. Differences in calf muscle pump function were significant. Ulcerated limbs had significantly poorer ejection fractions (p = 0.0002) and greater residual volume fractions (p = 0.0006) than nonulcerated or healed limbs. By ultrasonography, deep and superficial vein incompetence was present in most limbs and was not statistically different among groups. Although venous insufficiency was not measurably different among groups, limbs with active venous ulcers had significantly poorer calf muscle pump function than those with healed ulcers or with no history of ulceration. Venous insufficiency is necessary but not sufficient to cause ulceration, and a deficiency of the calf muscle pump is significant to the severity of venous ulceration.

Gravitational Syndrome and Tensile Properties of Skin in the Elderly

Article

Feb 1998

To evaluate the influence of gravitational edema due to chronic venous insufficiency upon the tensile properties of skin. A total of 30 women aged 66-75 years participated in the study. Evaluations were made twice in the same subjects following the use or nonuse of daytime elastic compression. Mechanical properties of the skin were measured in the midportion of the legs using a computerized suction device. The consistency of skin which shows abnormal rheological characteristics at the site of gravitational edema was significantly modified by compression therapy. Both skin extensibility and hysteresis were increased after wearing tight stockings although the biologic elasticity remained unchanged. Noninvasive measurements of the tensile properties of the skin represent an objective assessment of the severity of leg edema and of its correction by compression therapy.

Effect of exercise on calf muscle pump function in patients with chronic venous disease

Article

Mar 1999

Musculoskeletal dysfunction may be associated with poor calf muscle pump function in patients with chronic venous ulceration. The aim of this study was to evaluate the effects of physical exercise on calf muscle pump function. Twenty patients were recruited into a 6-week intensive exercise programme. Calf muscle function and calf muscle pump function were assessed using an isokinetic device and air plethysmography respectively, before and after the exercise programme. There was significant improvement in calf muscle pump function, measured as increased ejection fraction and decreased residual fraction (P < 0.05); however, venous reflux was not altered (P > 0.05). Calf muscle strength and endurance parameters all increased, but not significantly (P > 0.05). Poor calf muscle pump function in patients with chronic venous ulceration can be improved by physical exercise.

Change of calf muscle function in chronic venous disease

Article

Jul 1999
Cardiovasc Surg

The aim of this study was to assess calf muscle function in patients with chronic venous disease and recently healed venous ulcers. Forty-nine consecutive patients with recently healed proven venous leg ulcers and 20 age- and sex-matched control subjects were entered into this study. Both patients and control subjects underwent duplex scan evaluation of their leg veins and isokinetic measurement for calf muscle strength and endurance. Calf muscle function was significantly impaired in patients with chronic venous disease compared with control subjects. Both peak torque/body weight (strength), P = 0.049 (CI 0.3-18.4%) and total work (endurance), P = 0.05 (Cl 6.01-97.6 Nm) were reduced. This study has shown that patients with chronic venous disease have a significant impairment of calf muscle function compared with healthy control subjects. This study suggests that there is a need to evaluate whether a programme to improve muscle strength may be of benefit in both healing and preventing the recurrence of chronic venous ulcers.

Amlodipine, Enalapril, and Dependent Leg Edema in Essential Hypertension

Article

Mar 2000
Hypertension

Calcium channel blockers (CCBs) blunt postural skin vasoconstriction, an autoregulatory mechanism that minimizes gravitational increases in capillary pressure and avoids fluid extravasation when standing. To evaluate the dose-response relation between this pharmacological interference and dependent edema, a frequent side effect of CCBs during antihypertensive treatment, skin blood flow (laser Doppler flowmetry) at the dorsum of the foot, both supine and with the limb passively placed 50 cm below the heart level, and leg weight (Archimedes principle) were measured at baseline, during increasing doses of the dihydropyridine amlodipine (5 and 10 mg UID each for 2 weeks), and after drug withdrawal in 10 hypertensive men. Because angiotensin-converting enzyme inhibitors may attenuate ankle swelling by CCBs, those parameters were evaluated according to a similar design during amlodipine (10 mg UID) and enalapril (20 mg UID) combined (n=10). As a control, the effect of enalapril monotherapy (10 and 20 mg UID for 2 weeks each) was evaluated in a third series of patients (n=8). Amlodipine (5 mg UID) increased leg weight without modifying postural vasoconstriction (the percent skin blood flow decrease from horizontal to dependent position), which indicates that extravascular fluid shift was independent of postural skin vasoconstriction. At 10 mg UID, however, amlodipine blunted postural vasoconstriction and increased leg weight further, which suggests that skin blood flow autoregulation limited additional fluid transfer. Both parameters normalized after drug withdrawal. Enalapril per se did not affect cutaneous vasomotion or leg weight but reduced the amount of dependent fluid extravasation by the CCB despite a persistent antagonism for postural vasoconstrictor responses.

Swollen lower limb - 2: Lymphoedema

Article

Jul 2000

Peter S Mortimer

Investigation of Chronic Venous Insufficiency: A Consensus Statement

Article

Dec 2000
CIRCULATION

Ardrew Nicolaides

This consensus document provides an up-to-date account of the various methods available for the investigation of chronic venous insufficiency of the lower limbs (CVI), with an outline of their history, usefulness, and limitations. CVI is characterized by symptoms or signs produced by venous hypertension as a result of structural or functional abnormalities of veins. The most frequent causes of CVI are primary abnormalities of the venous wall and the valves and secondary changes due to previous venous thrombosis that can lead to reflux, obstruction, or both. Because the history and clinical examination will not always indicate the nature and extent of the underlying abnormality (anatomic extent, pathology, and cause), a number of diagnostic investigations have been developed that can elucidate whether there is calf muscle pump dysfunction and determine the anatomic extent and severity of obstruction or reflux. The difficulty in deciding which investigations to use and how to interpret the results has stimulated the development of this consensus document. The aim of this document was to provide an account of these tests, with an outline of their usefulness and limitations and indications of which patients should be subjected to the tests and when and of what clinical decisions can be made. This document was written primarily for the clinician who would like to learn the latest approaches to the investigation of patients with CVI and the new applications that have emerged from recent research, as well as for the novice who is embarking on venous research. Care has been taken to indicate which methods have entered the clinical arena and which are mainly used for research. The foundation for this consensus document was laid by the faculty at a meeting held under the auspices of the American Venous Forum, the Cardiovascular Disease Educational and Research Trust, the European Society of Vascular Surgery, the International Angiology Scientific Activity Congress Organization, the International Union of Angiology, and the Union Internationale de Phlebologie at the Abbaye des Vaux de Cernay, France, on March 5 to 9, 1997. Subsequent input by co-opted faculty members and revisions in 1998 and 1999 have ensured a document that provides an up-to-date account of the various methods available for the investigation of CVI.

Hemodynamic Effects of Supervised Calf Muscle Exercise in Patients With Venous Leg Ulceration

Article

Dec 2001
ARCH SURG-CHICAGO

Because more than two thirds of patients with venous ulcer have an impaired calf muscle pump, enhancement of its ejecting ability with physical training may generate an improved hemodynamic milieu sufficient to promoting ulcer healing. This study evaluated the effects of short-term supervised calf exercise on calf muscle pump function and venous hemodynamics in limbs with venous ulceration. Prospective controlled study. University-associated tertiary care hospital. The study consisted of 2 groups. An exercise group comprised 10 patients (median age, 72 years) receiving supervised isotonic calf muscle exercise for 7 consecutive days. A control group comprised 11 patients matched with those in the exercise group for age, sex, ulcer size, and ulcer duration (all, P>.09). Patients in both groups had perimalleolar venous leg ulcers, impaired calf muscle function (ejection fraction, <60%), and full ankle joint movement. After providing a complete clinical history, both groups underwent a physical examination, venous duplex scanning, and air plethysmography. The venous filling index, venous volume, residual venous volume, and residual volume fraction of the calf on standing were measured plethysmographically at baseline and on day 8, in addition to calf muscle endurance as determined by the maximal number of plantar flexions performed against a fixed 4-kg resistance during 6 minutes (1 flexion/s). Operators were blinded to the subject's group. Exercise in the first group entailed consecutive active plantar flexions using a standardized 4-kg resistance pedal ergometer. Subjects daily completed 3 sets of flexions of 6 minutes each. All patients had short-stretched compression bandaging. The ejected venous volume and ejection fraction were evaluated in both groups at baseline and on day 8. Both groups had a similar hemodynamic performance at baseline for all the variables evaluated (P>.10). After 7 days of exercise, patients in the exercise group improved their ejected venous volume by 67.5%, ejection fraction by 62.5%, residual venous volume by 25% (all 3, P =.006), and their residual volume fraction by 28.6% (P =.008). Changes in the control group within the same period were small (all, P>.10). By day 8, the exercise group had a significantly better ejected venous volume (P<.001) and ejection fraction (P<.001) than the control group. The venous filling index and the venous volume did not change (P>.50) in either study group. Calf muscular endurance in the exercise group increased 135%, from a median 153 plantar flexions at baseline to 360 on day 7 (P<.001). By increasing the muscular endurance, efficacy, and power of the calf muscle, isotonic exercise improves its ejecting ability and the global hemodynamic status in limbs with venous ulceration. Prospective evaluations of the clinical effects of calf muscle pump strengthening for the treatment of venous leg ulceration are indicated by the results of this study.

Wakefield TW; American Venous Forum International Ad Hoc Committee for Revision of the CEAP Classification. Revision of the CEAP classification for chronic venous disorders: consensus statement

Article

Jan 2005
J VASC SURG

The CEAP classification for chronic venous disorders (CVD) was developed in 1994 by an international ad hoc committee of the American Venous Forum, endorsed by the Society for Vascular Surgery, and incorporated into "Reporting Standards in Venous Disease" in 1995. Today most published clinical papers on CVD use all or portions of CEAP. Rather than have it stand as a static classification system, an ad hoc committee of the American Venous Forum, working with an international liaison committee, has recommended a number of practical changes, detailed in this consensus report. These include refinement of several definitions used in describing CVD; refinement of the C classes of CEAP; addition of the descriptor n (no venous abnormality identified); elaboration of the date of classification and level of investigation; and as a simpler alternative to the full (advanced) CEAP classification, introduction of a basic CEAP version. It is important to stress that CEAP is a descriptive classification, whereas venous severity scoring and quality of life scores are instruments for longitudinal research to assess outcomes.

The Static Stiffness Index: A Simple Method to Assess the Elastic Property of Compression Material In Vivo

Article

Jul 2005

Hugo Partsch

The efficacy of compression therapy depends mainly on the exerted pressure and on the stiffness of the material. To propose a simple method by which pressure and stiffness can be assessed in the individual patient. Using a pressure transducer (Kikuhime small probe, MediTrade, Soro, Denmark) the sub-bandage pressure is measured on the medial aspect of the lower leg at the transition of the gastrocnemius muscle into the Achilles' tendon. The pressure difference between active standing and lying is defined as the static stiffness index (SSI). Results: The accuracy and precision of the probe are good. Unna boot bandages (Lohmann-Rauscher, Vienna, Austria) and multilayer short-stretch bandages show a significantly higher SSI than long-stretch bandages and round-knitted class II stockings. The SSI values are lower than 10 mm Hg for elastic, long-stretch material and higher than 10 mm Hg for inelastic, short-stretch material. In future compression trials, pressure and stiffness measured in vivo should be declared.

Approach to Leg Edema of Unclear Etiology

Article

Mar 2006

A common challenge for primary care physicians is to determine the cause and find an effective treatment for leg edema of unclear etiology. We were unable to find existing practice guidelines that address this problem in a comprehensive manner. This article provides clinically oriented recommendations for the management of leg edema in adults. We searched on-line resources, textbooks, and MEDLINE (using the MeSH term, "edema") to find clinically relevant articles on leg edema. We then expanded the search by reviewing articles cited in the initial sources. Our goal was to write a brief, focused review that would answer questions about the management of leg edema. We organized the information to make it rapidly accessible to busy clinicians. The most common cause of leg edema in older adults is venous insufficiency. The most common cause in women between menarche and menopause is idiopathic edema, formerly known as "cyclic" edema. A common but under-recognized cause of edema is pulmonary hypertension, which is often associated with sleep apnea. Venous insufficiency is treated with leg elevation, compressive stockings, and sometimes diuretics. The initial treatment of idiopathic edema is spironolactone. Patients who have findings consistent with sleep apnea, such as daytime somnolence, loud [corrected] snoring, or neck circumference >17 inches, should be evaluated for pulmonary hypertension with an echocardiogram. If time is limited, the physician must decide whether the evaluation can be delayed until a later appointment (eg, an asymptomatic patient with chronic bilateral edema) or must be completed at the current visit (eg, a patient with dyspnea or a patient with acute edema [<72 hours]). If the evaluation should be conducted at the current visit, the algorithm shown in Figure 1 could be used as a guide. If the full evaluation could wait for a subsequent visit, the patient should be examined briefly to rule out an obvious systemic cause and basic laboratory tests should be ordered for later review (complete blood count, urinalysis, electrolytes, creatinine, blood sugar, thyroid stimulating hormone, and albumin).

Oedema as a risk factor for multiple episodes of cellulitis/erysipelas of the lower leg: A series with community follow-up

Article

Dec 2006

N H Cox

Cellulitis of the lower leg is a common problem with considerable morbidity. Risk factors are well identified but the relationship between consequences of cellulitis and further episodes is less well understood. To review risk factors, treatment and complications in patients with lower leg cellulitis, to determine the frequency of long-term complications and of further episodes, and any relationship between them, and to consider the likely impact of preventive strategies based on these results. Patients with ascending, presumed streptococcal, cellulitis of the lower leg were identified retrospectively from hospital coding. Hospital records, together with questionnaires to both general practitioners and patients, were used to record subsequent complications and identifiable risk factors for further episodes. Of 171 patients, 81 (47%) had recurrent episodes and 79 (46%) had chronic oedema. The concurrence of these two factors was strongly correlated (P < 0.0002). Based on 143 completed questionnaires, oedema was apparently due to or persistently asymmetrical after the cellulitic episode in 52 (37%), and 19 (13%) had ulceration attributed to, rather than causing, cellulitis. Of those with three or more episodes, half did not lead to hospital admission. Toeweb maceration was reported in only 15% of questionnaires. Use of antibiotic treatment for more than 28 days was associated with a reduced risk of leg ulceration or of prolonged oedema compared with shorter courses, but neither difference was statistically significant. This study demonstrates that the true frequency of postcellulitic oedema, as well as that of further episodes, is probably underestimated. Furthermore, there is a strong association between these factors, each of which is both a risk factor for, and a consequence of, each other, and for which intervention (reduction of oedema or more prolonged antibiotic therapy) may reduce the risk of recurrent infection. By contrast, self-reporting of toeweb maceration is low, so attempts to reduce the risk of recurrent cellulitis by treatment of tinea pedis or bacterial intertrigo may fail.

Mobility in Patients with Venous Leg Ulceration

Article

Apr 2007
EUR J VASC ENDOVASC

To compare mobility in patients with venous leg ulcers to matched controls and determine the influence of mobility, age and ulcer size on ulcer healing. 25 leg ulcer patients, and 25 matched controls wore a mobility monitor (ActivPAL, PAL Technologies Ltd, Glasgow, Scotland)) which recorded the number of steps and amount of time spent walking, standing, sitting or lying for a one-week period. A walking index was calculated. The ulcer group were treated with compression bandaging and ulcer healing recorded over 12 weeks. There were 13 female subjects in each group. The median age was 70.5 (range 30-89) years. There was no difference in the amount of time either group spent standing, walking and resting. There was a significant reduction in the number of steps taken and in the walking index in the ulcer group compared to controls (ulcer group, median 6,685 steps/day, range 2074-17,999; control group median 8750, range 4917-16,043, p<0.05, Mann Whitney u test). Smaller ulcers and ulcers of recent onset were most likely to heal within 12 weeks (p=0.005 and p=0.011 respectively, Chi squared test). The percentage of time spent mobilising and resting did not influence ulcer healing (r(s)=-0.125; p=0.55). Mobility patterns among patients with leg ulcers are not significantly different to age matched controls. Ulcer patients take fewer steps per week compared to controls indicating they have reduced calf muscle pump function. Further studies are required to determine whether therapies which increase calf muscle activity have a role in ulcer treatment.

Intermittent pneumatic compression in immobile patients

Article

Jul 2008
Int Wound J

Hugo Partsch

The purpose of this study is to stress the value of using intermittent pneumatic compression (IPC) in immobile patients. The use of IPC helps prevent limb oedema and the associated skin changes frequently seen on the legs of the immobile patient. Oedema formation is caused by an increase of fluid extravasation, while skin changes including leg ulcers are mainly because of a deficiency of the venous and lymphatic pumps. Conventional compression stockings and bandages impede leg swelling but are less efficient in supporting the deficient veno-lymphatic pump when patients are unable to move. In this situation, actively compressing the limb using IPC is a very meaningful and effective treatment option. Because of a lack of literature on the specific indication of IPC in immobile patients, experimental studies and randomised controlled trials in similar situations are reviewed. IPC is a very effective although underused treatment modality, especially in immobile, wheelchair-bound patients. By inflation and deflation of the air-filled garments, IPC produces cycles of pressure waves on the leg, thus mimicking the working and resting pressures applied by compression bandages. IPC not only reduces leg swelling but also augments the veno-lymphatic pump, which is essential for the restoration of the damaged microcirculation of the skin.

The diagnosis and treatment of peripheral lymphedema: 2013 Consensus Document of the International Society of Lymphology

Jan 2013
LYMPHOLOGY
1-11

International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2013 Consensus Document of the International Society of Lymphology. Lymphology 2013; 46: 1 -11.

Annual report on government measures for persons with disabilities (summary)

Jan 2005

Cabinet Office Japan

Cabinet Office Japan. Annual report on government measures for persons with disabilities (summary) 2005. http://www8.cao.go.jp/ shougai/english/annualreport/2005/1-1.html (accessed April 22, 2014).

A Study of Leg Edema in Immobile Patients

Abstract

No full-text available

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