The Wound Healed… Now What? - Skin Integrity Vegas · selection for the lower extremity Suzie Ehmann, PT DPT CLWT CWS CLT-LANA Clinical Specialist - Edema Management Program Atrium

The Wound Healed… Now What?

Utilizing S.T.R.I.D.E.™ algorithm to optimize compression garment

selection for the lower extremity

Suzie Ehmann, PT DPT CLWT CWS CLT-LANA

Clinical Specialist - Edema Management Program

Atrium Health Stanly

Albemarle, NC USA

Disclosures

• Suzie Ehmann– Director of Compression Education, ILWTI

– Clinical Consultant/speaker: 3M, Compression Dynamics, L&R, Jobst, Milliken, Urgo

– Unrestricted education grant: Compression Dynamics

S.T.R.I.D.E.™ project was supported through an unrestricted educational grant from Sigvaris, Inc.

Objectives✓Discuss the impact of both dosage and stiffness as it

relates to the dynamic performance of a compression garment

✓Demonstrate knowledge of the different compression garment categories for lower extremity compression

✓ Identify 6 patient specific characteristics that need to be taken into consideration when choosing a compression garment

―Shape

―Texture

―Refill

― Issues

―Dose

―Etiology

Wounds Healed!!!Now What?!?!

©Suzie Ehmann PT DPT CWS CLWT CLT-LANA

What would you do?

A. Send him with a prescription to the local DME for ‘compression stockings’

B. Issue Tubigrip/elastic stockinette

C. Discharge – no follow-up recommendations for compression

Why do we use compression?

• Enhances circulation―Venous―Lymphatic―Arterial

The case for compression (Venous)

• Maximizes venous return

―Improves volume and rate of venous flow

o Reduces venous reflux

o Enhances calf muscle pump

o Reduces venous HTN

―Reduces capillary ultrafiltration

• Damstra, R. Diagnostic and therapeutical aspects of lymphedema. Rabe Medical Publishing 2013.

• Rabe, E., Partsch, H., Hafner, J., Lattimer, C., Mosti, G., Neumann, M., & Carpentier, P. (2018). Indications for medical compression stockings in venous and lymphatic disorders: An evidence-based consensus

statement. Phlebology, 33(3), 163-184.

• Harding, K., Dowsett, C., Fias, L., Jelnes, R., Mosti, G., Öien, R., ... & Senet, P. (2015). Simplifying venous leg ulcer management: consensus recommendations. Wounds International.

CompressionFiltration

• Reduce vein diameter • Increase venous flow • Reduced venous reflux


The case for compression (lymphatic)

• Maximizes lymphatic function

―Reduced ultrafiltration decreases lymphatic load

―Increases interstitial tissue pressureo Increases lymph reabsorption

o Stimulates lymphangion contractions

―Reduces inflammation

―Promotes wound healing

―Breaks down fibrotic tissue

• Damstra, R. Diagnostic and therapeutical aspects of lymphedema. Rabe Medical Publishing 2013.

• Rabe, E., Partsch, H., Hafner, J., Lattimer, C., Mosti, G., Neumann, M., & Carpentier, P. (2018). Indications for medical

compression stockings in venous and lymphatic disorders: An evidence-based consensus statement. Phlebology, 33(3), 163-184.

Case for Compression (Arterial)

• Positive effects on arterial inflow- Increase of arterial flow demonstrated with intermittent or

moderate sustained pressure (9 - Mosti 2018 , 12- Iabichella 2012 )

- Lower extremity forefoot-to-knee compression bandaging resulted in increase in leg pulsatile blood flow because of increases in both peak flow and pulse-width. (13 - Mayrovitz HN, MacDonald JM. 2010)

o Hypothesized arteriolar vasodilation due to either/or myogenic arteriolar response and a shear dependent venous effect with possible additional effect on arterial pulse-wave speed

o Decreased in leukocyte effects in the distant microvascular due to the more vigorous arterial hemodynamic state

• Negative effects on arterial inflow- Skin blood perfusion (SBF) significantly reduced when

compression (40mmHg) applied to the dorsum of the foot and tibia

(14 - Mayrovitz HN, Sims N. 2003)


Power of compression

Tissue changes

Volume reduction

Volume reduction

Tissue changes

Reduce the edema… Reduce inflammatory

response…Resolution of skin

changes!!!


Power of compression…at the tissue level

• Distribute force of compression

• Break down fibrotic tissue → address “lymphostatic” fibrosis

―Different density of foamso Comprex

o 1/2inch gray foam

o Rolled white foam

―Chip pads―Swell spots―Textured compression

o Fuzzy wale elastic compression

o Flat knit garments

o Nighttime garments

o Bandage liners

EdemaWear®

Solaris Swell Spots and Jovi Pak

Solaris Tribute Jobst Relax

Flat Knit (textured)• Jobst• Juzo• L&R• Medi


Power of compression…at the tissue level

6 months flat knit

1-week flat knit

2 wks of bandagingInitial Presentation

Case Example

Flat Knit Garment-Stiff-Texture


Effect of textured Garments

Solaris Tribute Wrap

• Textured• Velcro adjustable• Nighttime garment (but can also be use as reduction device)

• Compression garment significantly increased StO2 levels in both seated positions

Chohan A, Haworth L, Sumner s, Mairi Olivier, Birdsall D, Whitaker J. Examination of the effects of a new compression garment on skin tissue oxygenation in healthy volunteers. Journal of Wound Care. July 2019;28(7).

Compression beyond the vessels . . .• Supports tissues that has lost elasticity

―Maintain fluid reduced by MLD → preserve treatment effects

―Facilitates optimal venous and lymphatic function

Compression to Reduce

Compression to Maintain

Intensive Phase

MaintenancePhase


Indications for medical compression stockings

• Medical Compression Stockings (MCS) to provide improvement of CVD symptoms (oedema, skin changes, pain, QoL)

• MCS to reduce recurrence of VLUs

• MCS (‘ulcer kits’) to improve VLU healing and reduce pain

• MCS for acute venous disorders and in the initial phase after greater saphenous vein treatment

• MCS for treatment of symptomatic post thrombotic syndrome (PTS)

• MCS for lymphoedema management.

Rabe E, Partsch H, Hafner J et al. Indications for medical compression stockings in venous and lymphatic disorders: An evidence-based consensus statement. Phlebology: The Journal of Venous Disease 2018; 33(3):163–184. doi:10.1177/0268355516689631

Q1 -What Compression

Level?Q2- Which garment?


How do you currently choose your compression products?A. I go strictly by the literature recommendations

B. I prescribe TED hose b/c that is all most people can get on

C. I write 20-30mmHg because it works for ‘most people’

D. I write a generic script (issue knee high compression stocking class II) and let the fitter/DME make the choice of which compression product

Q1- What dosage?

https://www.magonlinelibrary.com/page/jowc/resources

WE did the work for you!



Q2 -Which garment do you pick?

• Choices…• Coverage area

- Knee high

- Thigh high

- pantyhose

• Textile construction - Circular knit

- Flat knit

- Velcro adjustable wrap

• Brand name (L&R/Medi/Jobst/Juzo/Sigvaris) vs. generic (i.e. Walmart/Walgreens/CVS)

If dosage was all that mattered, all 30-40mmHg garments would have the same effectiveness….

19

but they do not….WHY?

Therapeutic Compression…more than a number

• Interaction of physical properties of garment―Construction of the garment/bandage alternative

o Types of textile (elastic vs. non-elastic)

o Layering of compression

• Size/shape of the limb

• Location of swelling

• Quality of the tissue

• Chronicity of the swelling

• Activity of the wearer


Dosage Pressure vs. Stiffness (9, 17-18)

• Pressure – force that is created by the elastic recoil of the product on the tissue

― Dosage (mmHg)― Resting pressure― IP

• Stiffness – force that is created by the resistance to expansion of the product

― Stiffness: the pressure increase per 1cm increase in leg circumference (19)

― The stiffer the compression the greater the pressure fluctuations― The stiffer the compression the greater the therapeutic effect

Photo Courtesy: Karen Bock MPT CWS CLT-LANA


Beyond Dosage…Stiffness Matters

• Stiffness provides insight into the performance during posture changes and movement and impacts edema prevention and hemodynamics (Hirai 2008, Hirai 2010, vander Wegen-Franken CP 2008, Partsch H 2006)

✓ Dosage describes the inward pressure that a garment exerts on the body as a result of its elastic recoil (Bjork R, Ehmann S 2019)

✓ While stiffness describes the resistance of the garment to the expansion (Bjork R, Ehmann S 2019)

– such as when an area of body swells

– tissue expands due to muscle contraction


van deWegen-Franken, C. P. M. (2009). Medical elastic compression stockings (Doctoral dissertation, Erasmus MC: University Medical Center Rotterdam).

18 Different Class II Garments – static

stiffness ranged from 1.7 to 10.32!

Different stiffness . . .Different therapeutic

benefit

Beyond the Dosage… Stiffness Matters• Multiple researches have found variations of stiffness of MCS

independent of dosage and type of knitting

• There is a statistically significant difference in capillary filtration rate, and consequently in the development of edema,….. between elastic compression stockings with the same compression (mmHg), but a low slope profile (lower stiffness) and a high slope profile (higher stiffness). (Van Geest AJ 2000)

• In patients with a strong tendency to develop edema it may be advisable to prescribe stockings with a high slope profile (stiffness). (Van Geest AJ 2000)

• Although compression devices may apply similar resting pressures, materials with no stretch or short-stretch bandages produce higher peak pressures when standing or walking compared with the effects obtained with long-stretch devices (Partsch H 2006)


Hemodynamic Efficacy… • Interface pressure• Stiffness

Patient comfort

Working pressure

Resting pressure

Exo –Strong

Flat knit OTC

Dynamic performance of a compression application dependent on:

1. Dosage

2. Stiffness

3. Patient presentationa) Tissue texture/type of swelling

b) Activity level

c) Patient ability – compression doesn’t work if they can’t get the product on


Wounds Healed!!!Now What?!?!

Need compression garment

What are my choices?

Garment Categories

27

Garment Categories

Circular KnitStiffer Circular

KnitFlat Knit Wraps Night Decongestive

StiffnessLower

Higher

Specialty Category


Circular Knit

Circular Knit: Knitted in circular configuration, using one-cylinder

size. Garment is tube shaped, finished with sewing.


Circular Knit = Long Stretch

• Over the counter (OTC) and custom

• Long Stretch― high resting pressure/low working pressure

• Pros – cosmetically more appealing―Provides gradient sequential compression―Readily available and reasonably cost―Insurance coverage with open wound

• Con – average size fit (what if patient is not average size)

―Durability―Fabric digs in at skin folds –> Can make swelling worse―Difficult to apply


Stiffer Circular Knit

Stiffer Circular Knit:• denser knitting pattern• high modulus inlay yarns• more even distribution of dosage• higher containment (stiffer)

Garment category, dosage and size

Circular Knit (CK) (Sheer), 30-40mmHG, medium

Profile: Average mmHg

% Gradient (%mmHg compared to ankle)

Average Stiffness

Foot 16.28 47% 1.14

Ankle 34.51 100% 1.3

Calf 17.51 51% 0.44

Thigh 8.85 26% 0.15

Ankle Circumference Range

21.5-25.5

Garment category, dosage and size

Stiffer Circular Knit (SCK), 30-40mmHG, medium

Profile: Average mmHg % Gradient (%mmHg compared to ankle)

Average Stiffness

Foot 25.95 71% 2.74

Ankle 36.46 100% 3.18

Calf 24.71 68% 1

Thigh 15.5 43% 0.46

Ankle Circumference Range

21.5-25.5


Flat Knit

➢ Flat Knit: Knitted in linear configuration. Garment lays flat and is joined together with a knitted seam.

➢ Seamless Flat Knit: Knitted on flat bed (flat knit) machine but with continuous, circular knitting


Flat Knit = Short Stretch

• Over the counter & Custom• Low resting pressure, high working

pressure

• Pros – can be custom made for almost any shape with accurate pressure distribution• Coarser fabric d/t thicker yarn results in a

“stiffer” garment• Can layer garments for ease of application• Address hand/foot swelling • Micro-massage =

• Cons – expensive• Heavy fabric, not as cosmetically appealing


Adjustable Wraps

• Hand Cut & Sewn• Die Cutting Machine• Laser Cutting Machine

Different Textiles = Different Stiffness

Different Application TechniqueInterlacing

Overlapping

Pros: easier to applyUsed for reduction and maintenance phasePatient can adjustCovered by insurance with open wound

Cons: application errorPatient can adjustHotMultiple pieces


Night Garments

Night Garments: Garments designed with Lymphatic Alternating Pressure Profiles (LAPP™)

• Using incongruent foam, to soften fibrotic tissue and maintain or reduce edema/lymphedema

• Low resting pressure• OTC and custom available


Decongestive Garments

Decongestive Garments: Category of adjustable wraps that can be cut to shape or trimmed on site to accommodate serial edema reduction.

(Ready-To-Wear (RTW) wraps can be used to reduce edema/lymphedema as well, provided the adjustable sizing range can accommodate the reduction, and the lymphedema etiology is appropriate for that type of use.)

Different materials = Different StiffnessDifferent application techniques


Garment Categories & Subcategories

Circular Knit

Light

Regular

Firm


Light

Regular

Firm

Flat Knit

L = Light

R = Regular

F = Firm

Wraps

Light

Regular

Firm

Night

Light

Regular

Firm

Decongestive

Light

Regular

Firm

Compression Options

Lower HigherStiffness/Containment

Lower

Higher

Stiffness/Containment


Matching patient presentation to compression option using S.T.R.I.D.E.™

What is S.T.R.I.D.E.™?

• Extensive literature review summarizing the science of compression textiles

• Define garment categories

• Offers a practical, step by step guide to compression selection✓ matching compression textile to patient presentation

Garment Categories

Circular KnitStiffer Circular

KnitFlat Knit Wraps Night Decongestive


Taking Compression Garment Selection in S.T.R.I.D.E.™

Selection of compression garment necessitates matching compression garment to the patient presentation and abilities.

•Shape – What is shape of leg? Where is the swelling?

•Texture – What is the texture of the tissue? Textile Texture?

•Refill – How quickly does the swelling rebound? Swelling at night?

• Issues – Precautions? Functional limits? Caregiver support? Costs?

•Dosage – Dosage based on underlying medical etiology

•Etiology – diagnoses and co-morbidities contributing to the edema

S.T.R.I.D.E.


Textile Specific

Patient Specific

Socio-economical (cost and support)

Mobility/Functional Impairments

Quality of Swelling

Location of swelling

Garment Style

Texture

Stiffness

Dosage

Effective compression selection is a balancing act


Take it in S.T.R.I.D.E.™

Copyright ILWTI 2018, all rights reserved 41

SAsk: 1. Where is the edema? 2. Do limb measurements

fit into OTC sizes?

Genitals

Pelvis

Thigh

Calf & Ankle

Knee

Foot & Toes

LOWER = Lower Body (pelvis & genitals, thigh & knee, calf & ankle, foot & toes)

❑ Pelvis & Genitals → Pantyhose, Biker Shorts, Capris, Genital Pads

Thigh & Knee → Pantyhose, Thigh-High Garments, Knee Wraps

Calf & Ankle → Calf & Below Knee Garments

Foot and Toes → Foot Wraps, Toe Caps

S



TAsk: What is the TISSUE TEXTURE?

= Watery • Soft, pliable, easily pits, <30sec rebound• Negative Stemmer’s sign & Bjork Bow Tie Test• Contained with elastic or stiffer textiles • Reduces with adjustable compression or multi-

layered compression bandaging

= Fatty • Spongy, redundant tissue• Loss of anatomical architecture• Negative Stemmer’s Sign & Bjork Bow Tie Test• Supported and shaped by stiffer garments that

bridge folds

= Fragile

• Thin, fragile skin prone to skin tears• Skin protected by layering two lighter

compression garments, adjustable wraps, or double covered inlay yarns

= Putty• Early fibrotic changes with putty consistency• Pits with firm, prolonged pressure, >30sec rebound• Positive Stemmer’s Sign & Bjork Bow Tie Test• Contained with stiffer textiles• Softens with textured textiles• Reduces with adjustable garments or multi-layered

compression bandaging

= Woody

• Fibrotic changes with firm, woody consistency• Does not pit to deep pressure• Positive Stemmer’s Sign & Bjork Bow Tie Test• Contained with stiffer textiles• Softens with textured textiles• Reduces with multi-layered compression

bandaging with foam



TAsk: What type of textile is needed?

= Elastic • Textile with greater extensibility• Sustained pressure• Broad sizing ranges• Lower containment• i.e. Circular Knit or cut & sew garments

= Stiffer • Stiffer textile with less extensibility • Offers higher containment • Supports and shapes tissue• i.e. Stiffer Circular Knit, Flat Knit, or Wraps

= Textured • Textured textile with Lymphatic

Alternating Pressure Profiles (LAPP)• Warms and softens fibrotic tissue• i.e. Night Garments

= Adjustable • Adjustable compression that can

accommodate for changes in limb girth• Edema reducing capabilities• Improved ease of donning & doffing• i.e. Wraps and Decongestive Garments

= Layered • Layering one compression product over another• Useful over wound dressing, fragile skin • Can improve ease of donning• Increases stiffness (1)• i.e. ulcer care liner, 2 lighter compression garments

Take it in S.T.R.I.D.E.™ T

Assess limb for:

❑Soft fatty tissue❑Shallow or deep folds

Ask: How well does this textile BRIDGE across folds?

• BRIDGING is the ability of a garment to connect from one area of skin to another, without sinking into creases

• Thicker, stiffer garments bridge better than thinner, more elastic garments

Circular Knit Flat knit



R

SL = Slow Refill: Edema gradually increases to pre-compression size over the course of 24 hours or more. Choose elastic or stiffer garments with Light or Regular containment.

RR = Rapid Refill: Edema starts increasing almost immediately after removal of compression, and returns to pre-compression size or greater within 8 hours. Requires more robust containment. Choose stiffer or adjustable garments with Firm containment. Consider layering garments during the day.

Ask: Does the edema refill during the day only, or both day and night?Ask: How fast does the limb increases in size after the compression is removed?

Refills during the day →Choose Day Garments

Refills overnight → Add Night Garments



• Thicker, stiffer garments provide higher containment

• Thinner, more elastic garments provide less containment

Containment relates to STIFFNESS

R Ask: Will the edema shape this garment,or will the garment shape the edema?

What is Containment?

Containment: The abilility of a garment to prevent the expansion of

edema and to maintain the ideal shape of a limb after therapeutic

decongestion.

- A function of stiffness1, thickness and sustainable2 pressure (garment fatigue).

(Monika Hubner, Tracy Green, Robyn Bjork, 2015)

1circular and longitudinal

2low pressure drop over the day and over the treatment period

Copyright ILWTI 2018, all rights reserved

Garment Categories & Subcategories

Circular Knit

Light

Regular

Firm


Light

Regular

Firm

Flat Knit

L = Light

R = Regular

F = Firm

Adjustable Wraps

Light

Regular

Firm

Night Garments

Light

Regular

Firm

Decongestive

Light

Regular

Firm

Lower Higher





IISSUES → Consider precautions, contraindications, mobility, strength, financial, caregiver

support, past experience, etc.

Ask: What are the barriers to success?

Precautions:Mild or moderate Peripheral Arterial Disease (PAD)

Peripheral neuropathy

Chronic, compensated Congestive Heart FailureChronic Renal FailureDifficulty donning & doffing garment - consider patient’s dexterity, finger and grip strength, hip flexion, caregiver support, etc.Dermatitis, eczema, and other skin conditionsLymphorrheaMinor skin infections Fabric sensitivitiesMalignancy

Take it in S.T.R.I.D.E.™Contraindications:

❑ Acute-untreated cellulitis or other major skin infections

❑ Acute-decompensated Congestive Heart Failure, Pulmonary Edema

❑ Acute Myocardial Infarction

❑ Serious, non-controlled Hypertension

❑ Untreated Renal Failure

❑ Undiagnosed, untreated Cancer

❑ Acute-untreated Deep Vein Thrombosis or Thrombophlebitis

❑ Severe Peripheral Arterial Disease (ABI <0.5 or Absolute Systolic Ankle Pressure <70mmHg), and s/p Arterial Bypass Grafting


Disclaimer: Precautions and contraindications listed are guidelines only and do not replace medical advice.

I


D

DOSAGE = mmHg: Compression pressure measured in millimeters of mercury.

S.T.R.I.D.E.Take it in S.T.R.I.D.E.™

DOSAGE labeling of compression garments refers to the mmHg at the ANKLE or WRIST ONLY!

Ask: What is the appropriate dosage based on medical diagnoses, precautions, contraindications, and underlying edema etiologies?

DTake it in S.T.R.I.D.E.™

STIFFNESS

DOSAGE

As stiffness of the garment increases,dosage can decrease and still maintain effectiveness




ELYMPHEDEMA (LE)❑ Stage 0: A latent or sub-clinical condition where swelling is not yet evident despite

impaired lymph transport, subtle alterations in tissue fluid/composition, and changes in subjective symptoms. It may exist months or years before overt edema occurs.

❑ Stage 1: Early accumulation of fluid relatively high in protein content (e.g., in comparison with “venous” edema) which subsides with limb elevation. Pitting may occur. An increase in various types of proliferating cells may also be seen.

❑ Stage 2: Limb elevation alone rarely reduces the tissue swelling and pitting is manifest.

❑ Late Stage 2: Limb may not pit as excess subcutaneous fat and fibrosis develop.❑ Stage 3: Lymphostatic elephantiasis where pitting can be absent and trophic skin

changes such as acanthosis, alterations in skin character and thickness, further deposition of fat and fibrosis, and warty overgrowths have developed.

Executive Committee. (2016). The diagnosis and treatment of peripheral lymphedema: 2016 consensus document of the International Society of Lymphology. Lymphology, 49(4), 170-184.



ELIPEDEMA (LIP)❑ Stage 1: Normal skin surface with enlarged hypodermis.❑ Stage 2: Uneven skin texture with indentations in the fat, larger mounds of tissue growing

as unencapsulated masses.❑ Stage 3: Thickening and hardening of the subcutis with large nodules and protruding fat

pads, especially on the thighs and around the knees.❑ Stage 4: Lipedema with lymphedema (lipo-lymphedema), (+) foot swelling, (+) stemmer

sign

• Dayan, E., Kim, J. N., Smith M. L., Seo, C. A., Damstra, R. J., Schmeller, W., Frambach, Y., Carmody, M. A., F.ldi, E., & Rockson, S. G. (2017). Lipedema - The disease they call FAT: An overview for clinicians. Boston, MA: Lipedema Simplified Publications, The Friedman Center for Lymphedema Research and Treatment at The Center for Advanced Medicine at Northwell Health in collaboration with Lymphatic Education & Research Network (LE&RN).

• Lontok, E., Briggs, L., & Donlan, M. (2017). Lipedema: A giving smarter guide. Santa Monica, CA: The Milken Institute.

❑ Type I: Pelvis, buttocks and hips ❑ Type II: Buttocks to knees, with folds of fat around the inner side of the

knee❑ Type III: Buttocks to ankles❑ Type IV: Arms❑ Type V: Lower leg



E❑ DEPENDENT (DEP) = Edema resulting from dependency of body part and lack

of movement.❑ CONGESTIVE HEART FAILURE (CHF) = Edema resulting from inability of the

heart to effectively pump, resulting in fluid retention in the body.❑ CHRONIC KIDNEY DISEASE (CKD) = Edema resulting from insufficient or

failure of kidney function, resulting in fluid retention in the body.❑ OBESITY (O)= Co-morbidity contributing to the edema❑MEDICATIONS (MEDS) = Edema caused by medications, as a side effect.

This is NOT Compression…

Take it in S.T.R.I.D.E.™ - Case example I


Photos Courtesy of Suzie Ehmann, used with permission

S.T.R.I.D.E.™ - Case Example I


Ask: Where is the edema?

✓ Thigh = Thigh high✓ Calf & Ankle = Calf & Below Knee Garments

✓ Foot and Toes = Foot Wraps, Toe Caps

Ask: Do the measurements match the sizing charts?✓ YesAsk: Is RTW an option, or is Custom needed?

✓ RTW


S




TAsk: What is the TISSUE TEXTURE?

= Putty

= Woody




TChoose the applicable TEXTILE(s)

= Putty

= Woody

• Needs stiffer textile to contain edema

• Needs textured textile to soften fibrotic tissue

• May benefit from adjustable compression




RRAPID REFILL

Needs garment with REGULAR or FIRM Containment

REFILLS DAY AND NIGHT Needs Day & Night Garments




I✓ ABI > 0.95✓ Obese /difficulty reaching feet✓ h/o CVA with left side weakness and dexterity issues✓ Cost – patient has to pay out of pocket (may want to

consider garments with multiple functions)




D✓ Firm FLAT KNIT 20 to 30mmHg✓ Layer 15 to 20mmHg firm circular knit for

additional stiffness if donning an issue✓ Dosage guaranteed by manufacturer x 6mos




EAsk: What are the underlying causes of the edema?

✓ CVI - C4✓ PTS✓ Lymphedema✓Obesity✓ CVA with altered gait/muscle pump

65GARMENT CHOICE: Flat knit with donning aide

GARMENT CHOICE: Flat knit (Custom or RTW) or Adjustable Velcro Wrap, 20 to 30mmHgChose the flat knit with donning aide as pt not able to manipulate the Adjustable straps, unable to reach feet, flat knit most economical options for this patient


Clinical Compression Garment Pearls• Medical Management is KEY!!

Compression garment will NOT treat this!!!Medical Management followed by complete decongestive therapy

Clinical Compression Garment Pearls• Medical Management is KEY!!• Not all compression garments are equal• Compression garments should be used to maintain a volume reduction

• If still have sizeable swelling after bedrest need reduction first

• Compression Garments are for day time use only ✓no sleeping in garments✓Exception is Velcro adjustable garments and night time garments

• TED HOSE are NOT compression• If looking for lighter compression, consider longitudinal compression

• One PRODUCT does NOT fit all• This is for bandaging and garments• Compression needs to be matched to the individual presentation

(S.T.R.I.D.E.™)

Questions



Thank You!!

[email protected]

[email protected]

Be part of the compression revolution!!

Questions? ? ?

References

• Damstra, R. Diagnostic and therapeutical aspects of lymphedema. Rabe Medical Publishing 2013.• Rabe, E., Partsch, H., Hafner, J., Lattimer, C., Mosti, G., Neumann, M., & Carpentier, P. (2018). Indications for medical compression

stockings in venous and lymphatic disorders: An evidence-based consensus statement. Phlebology, 33(3), 163-184.• Harding, K., Dowsett, C., Fias, L., Jelnes, R., Mosti, G., Öien, R., ... & Senet, P. (2015). Simplifying venous leg ulcer management:

consensus recommendations. Wounds International.• Rabe, E., Partsch, H., Hafner, J., Lattimer, C., Mosti, G., Neumann, M., & Carpentier, P. (2018). Indications for medical compression

stockings in venous and lymphatic disorders: An evidence-based consensus statement. Phlebology, 33(3), 163-184.• Mosti G, Iabichella ML, Partsch H. Compression therapy in mixed ulcers increases venous output and arterial perfusion. Journal of

Vascular Surgery 2012;55(1):122–8. • Mayrovitz HN, Macdonald JM. Medical compression: effects on pulsatile leg blood flow. International Angiology 2010;29(5):436–41.• Chohan A, Haworth L, Sumner s, Mairi Olivier, Birdsall D, Whitaker J. Examination of the effects of a new compression garment on

skin tissue oxygenation in healthy volunteers. Journal of Wound Care. July 2019;28(7).• Partsch H et al. Measurement of lower leg compression in Vivo: recommendations for the performance of measurements of

interface pressure and stiffness. Dermatol Surg. 206 Feb:32(2):224-32. • van deWegen-Franken, C. P. M. (2009). Medical elastic compression stockings (Doctoral dissertation, Erasmus MC: University

Medical Center Rotterdam

Documents

The Wound Healed… Now What? - Skin Integrity Vegas · selection for the lower extremity Suzie Ehmann, PT DPT CLWT CWS CLT-LANA Clinical Specialist - Edema Management Program Atrium