VOL: 97, ISSUE: 48, PAGE NO: 48
Monica Carcary, RGN, is a primary nurse, Community Rehabilitation Unit, St Mary's Hospital, LeedsIntermittent sequential compression therapy (ISCT) is effective in reducing oedema of the lower limbs (Vowden, 2001) and can improve circulation of blood in the affected areas (Sayegh, 1987).
Intermittent sequential compression therapy (ISCT) is effective in reducing oedema of the lower limbs (Vowden, 2001) and can improve circulation of blood in the affected areas (Sayegh, 1987).
The community rehabilitation unit at St Mary's Hospital in Leeds caters for patients with a variety of neurological conditions - for example, multiple sclerosis, cerebral palsy and cerebral vascular accident, all of which can result in reduced levels of mobility. Dependent oedema of the lower limbs is a symptom of reduced mobility which is often overlooked in patients with these conditions. However, it is important that it should be treated, as swollen limbs may result in heaviness, discomfort, further reduction in mobility and impaired function (Mortimer, 1995). Poorly managed dependent oedema can also result in skin and tissue changes, ranging from dry flaky skin in uncomplicated oedema to hyperkeratosis in cases of chronic swelling (Veitch, 1993).
Patients are usually admitted to the unit for two weeks to improve and maintain functional ability and independence, and ISCT often forms part of the treatment. As a number of patients had expressed an interest in buying an ISCT system, staff at the unit decided to evaluate the impact of a model which would be appropriate for use at home.
Lower limb oedema and ISCT
Repeated contraction and relaxation of the calf muscle which takes place during exercise is important to maintain satisfactory blood flow in the deep veins of the lower leg (Hoffman, 1995). If an individual has restricted movement in the lower limbs and blood is not being propelled effectively through the veins fluid can escape into the interstitial spaces, resulting in oedema. ISCT aims to gently massage this excess fluid from the interstitial spaces back into the venous and lymphatic vessels.
ISCT involves the use of a garment made up of a number of chambers that fill with air in sequence. This is placed over the affected limb and the chambers inflate and deflate according to a predetermined pattern. The peristaltic cycle moves from the distal to the proximal end of the limb and ensures the proximal flow of fluid by always having the fully pressurised chamber behind the inflating chamber.
Patients were assessed by a nurse for the use of ISCT on admission to the unit. Contraindications to this therapy include deep vein thrombosis in the previous six weeks, congestive cardiac failure, acute pulmonary oedema and acute infection. The patients' limbs were examined for the degree and severity of swelling, skin condition and colour. Medical assessment and approval for ISCT based on the clinical findings was sought before the start of treatment in all cases.
Six patients with uncomplicated dependency oedema were approved for ISCT during the evaluation period. They were given information on dependent oedema and advised that it was not likely to improve without intervention. A full explanation of ISCT was provided and questions were encouraged. It was made clear that it would be the patient's decision to proceed with ISCT and that treatment could be declined at any point.
If patients had a degree of mobility they were taught simple exercises to encourage the pumping action of the calf muscle - for example, ankle rotation, wriggling of toes and extension and flexion of the foot. All patients were encouraged to elevate their legs whenever possible. The importance of skin care was emphasised to maintain skin integrity and, as suggested by Todd (1996), a daily skin care regime was advised on a long-term basis.
One of the most important factors in managing oedema is the use of compression hosiery (Dale and Gibson, 1992). Patients undergoing ISCT were informed of the need for this to minimise the leakage of fluid back into the tissues. Care was taken by the nurses when measuring patients for the hosiery to ensure a correct and comfortable fit, as this encourages their proper use (Armstrong, 1997).
Before starting ISCT, limb circumference measurements were taken at the ankle, calf, above the knee and at the thigh in both legs of each patient. These measurements were repeated at the end of the two-week treatment period.
The model used for the evaluation was the TM500 system from Talley Medical. This was considered to be generally affordable by people attending the unit. It has a cycle time of five minutes and the pressure within the chambers can be set between 40-120mmHg. Each garment has an internal lining to prevent skin pinching and marking between pressure cells.
The ISCT regimen consisted of one or two 60-minute sessions per day, depending on patient preference. The pressure was set at 40mmHg, based on the advice of the lymphoedema nurse specialist and the manufacturer's instructions.
Satisfaction with the ISCT therapy was evaluated by observation and through patient comments. Although limb volume measurements would have given a more accurate objective assessment of reduction in limb size, in this instance limb circumference was considered to provide adequate information when used in conjunction with the patient's perception of the therapy.
Most of the patients noticed a reduction in swelling and limb size, although the amount varied in each individual. One patient commented that her legs felt less tight and heavy. She found that less effort was involved in moving her legs and it was easier to transfer from bed to chair. The patient felt that the change had given her greater confidence to continue to live independently.
The application of compression hosiery is often difficult for patients and carers. Four patients found this easier following ISCT due the reduction in limb size.
A frequent response to wearing tight compression stockings is a feeling of claustrophobia. This is particularly true among people with multiple sclerosis who may experience increased sensitivity in their feet to heat and pressure (Kemp, 1996). During the evaluation period and since it has been observed that ISCT has helped a number of patients to make the transition to wearing compression hosiery.
Two patients with multiple sclerosis found the limb spasm they experienced as a result of their condition was reduced or less severe. This was particularly noticeable during treatment sessions and may have been a result of the massaging effect of the ISCT. All the patients found the therapy soothing and refreshing. Half found that their foot size had reduced enough for them to wear normal footwear. One patient who had agreed to ISCT to improve her circulation as her feet always felt cold found the therapy beneficial in this respect.
Generally, the participants in this evaluation felt rested by having to take time out to lie on their beds during therapy. This enforced change of position also has the potential to be of benefit in reducing the risk of pressure ulcers, as many patients normally spent many hours sitting in their wheelchairs.
Although this evaluation is limited by the small number of patients involved, both nurses and patients felt that it was a beneficial and informative exercise. Many of the participants found that, in addition to reducing their lower limb oedema, ISCT had improved their quality of life.
Based on this evaluation a number of patients bought an ISCT system for use at home. They suggest that this has given them a sense of control and involvement in one aspect of their condition.
Further research is necessary to support the general findings of this small evaluation, but in the meantime ISCT continues to be used in the unit to manage dependent oedema as part of individual treatment programmes.