Improvement of Refractory Peripheral Edema With Multilayered Compression Bandaging: A Case Report

Abstract

Background and Purpose

Lower extremity edema, which can be caused by several factors, is often poorly managed with commonly prescribed compression stockings and diuretics. Diuretics are often erroneously given in all forms of edema and may cause problems because their long-term application may induce chronicity of the edema due to disturbance of the renin-angiotensin relationship. Compression therapy, although effective against venous edema, is widely underused.

Case Description

A 64-year-old man with a history of hypertension, coronary artery disease, psoriasis, and multiple myeloma was admitted to the hospital for neutropenic fever, right lower extremity (RLE) cellulitis, bilateral lower extremity (BLE) weakness, RLE pain, and significant BLE edema. The patient was referred to a lymphedema-certified therapist to apply lower extremity multilayered compression bandaging and document serial limb circumference measurements.

Outcomes

The patient's weight decreased from 94.5 kg on day 1 of compression bandaging to 86.3 kg on day 7. The circumferences of the affected limbs also decreased.

Discussion

This case demonstrates the utility of multilayered compression bandaging, typically used in the management of lymphedema, in the control of peripheral edema that is refractory to diuretic therapy.

Peripheral edema is a common feature not only in populations with advanced cancer but also in a wide variety of other patient populations.¹ However, peripheral edema is seldom recognized by primary medical services as a factor that contributes to decreased mobility and functional deficits. The management of lower extremity edema, in general, includes a wide variety of options such as leg elevation, compression therapy, exercise, weight loss, reduced dietary salt intake, and diuretics.² Compression therapy is the recommended treatment for venous edema^3,4 and lymphatic disorders.^5,6 In most reports, compression improves venous hemodynamics, increasing lymphatic flow and cutaneous microcirculation. Compression bandaging is often underutilized in practice; instead, most patients with peripheral edema are treated primarily with diuretics,^5,7 and most patients with refractory edema are treated with a multistep approach that is dictated by their initial response to diuretics.⁸ Here, we present a case in which multilayered compression bandaging was used to manage refractory lower extremity edema.

Case Description

The patient, a 64-year-old man with a history of hypertension, coronary artery disease, and psoriasis, had been diagnosed with multiple myeloma 8 years previously and treated with chemotherapy, autologous stem cell transplant, and radiation therapy to the T9-L1 vertebrae. He was hospitalized for neutropenic fever; right lower extremity (RLE) cellulitis; bilateral lower extremity (BLE) weakness, which was greater in the right extremity; RLE pain; and significant BLE edema. The patient was treated with cefepime and vancomycin for his RLE cellulitis and pneumonia. His physical examination was significant for 3 + pitting BLE edema, decreased light touch sensation to RLE distally, 3/5 strength to RLE, and 4/5 strength to LLE. Improvement of his RLE cellulitis was noted. For his BLE edema, he received furosemide (40 mg daily) and was prescribed compression stockings by the vascular surgery service after peripheral artery disease and cardiac insufficiency were ruled out. Magnetic resonance imaging demonstrated stable thoracic compression compared with prior imaging scans as well as a chronic lumbosacral synovial cyst. An electrodiagnostic study showed active and chronic lumbosacral radiculopathy affecting multiple nerve roots along with mild axonal sensory and, to a lesser extent, motor symmetric peripheral neuropathy in the lower extremities. BLE venous Doppler ultrasonography revealed no deep vein thrombosis, and the patient's ankle brachial index and toe brachial index were within normal range.

The patient continued to have BLE weakness with long phases of immobile sitting, with resultant significant BLE edema and fatigue, which affected his gait and daily activities. A physiatrist evaluated factors that contributed to the patient's lower functional independence measure (FIM) scores and determined that the patient needed an intense rehabilitation program in an interdisciplinary setting; thus, he was transferred to the acute inpatient rehabilitation unit.

After the patient was transferred to the inpatient rehabilitation unit, it was noticed that he had severe edema that was refractory to diuretic treatment and impeding rehabilitation progress. Furthermore, the patient had difficulty donning and doffing previously prescribed compression stockings. In addition to traditional rehabilitation, the patient was referred to a certified lymphedema therapist to start lower extremity multilayered compression bandaging and the physiatrist specifically requested serial limb circumference measurements.

The multilayered compression bandaging was applied as follows for each leg. First, non-adhesive elastic bandages (Elastomull, BSN Medical, Charlotte, NC) were applied circumferentially to all toes. A tubular bandage (Tricofix, BSN Medical) was applied from the metatarsal heads to the infrapatellar region. Next, a 12-cm foam bandage (CompriFoam, BSN Medical) was applied from the metatarsal heads to the infrapatellar region. Finally, an 8-cm short-stretch compression bandage (Comprilan, BSN Medical) was applied in a figure-8 pattern over the ankle, and a 10-cm Comprilan compression bandage was applied from the calf to the infrapatellar region with compression decreasing proximally. The bandages were applied daily for 7 days (with removal and reapplication each day).

The patient's limb circumference measurements improved, as noted in the Table. The patient consistently reported no leg pain or shortness of breath on days when he received compression bandaging by the certified lymphedema therapist. The patient's albumin (3.7 g/dL), blood urea nitrogen (14 mg/dL), and creatinine (0.83–0.90 μmol/L) levels were within normal limits when he received compression bandaging. His FIM scores for locomotion improved from requiring maximum assistance to ambulate 80 feet on day 1 of compression therapy to requiring only contact-guard assistance to ambulate 170 feet on day 8. His weight and body mass index (BMI) improved from 94.5 kg (BMI 36) on day 1 of compression therapy to 86.3 kg (BMI 33) on day 7. Once there was significant improvement of his BLE edema, he was fitted with 20–30 mm/Hg compression stockings.

Table.

Bilateral Lower Extremity Circumference Measurements With Compression Bandaging

	Circumference Measurements (cm)b
Site	Day 1	Day 2	Day 3	Day 7	Reduction, Day 7–Day 1 (%)
Right MTPa	27.0	24.4	23.0	23.0	4.0 (15%)
Right ankle	27.0	25.2	23.0	23.0	4.0 (15%)
20 cm below right knee	44.5	40.7	38.7	37.2	7.3 (16%)
Right knee	45.0	43.5	41.4	41.4	3.6 (8%)
Left MTPa	26.0	24.5	22.7	23.0	3.0 (12%)
Left ankle	26.5	24.2	23.1	23.0	3.5 (13%)
20 cm below left knee	43.0	38.4	36.2	37.2	5.8 (13%)
Left knee	44.4	43.4	40.0	40.0	4.4 (10%)

^aMTP = metatarsophalangeal joint.

^bThe measurements were not taken on days 4 through 6.

Role of the Funding Source

This case report was supported in part by the National Institutes of Health/National Cancer Institute under award number P30CA016672. The funder played no role in the reporting of this case.

Discussion

This case highlights the importance of rehabilitation specialists in the management of lower extremity edema in an acute inpatient rehabilitation setting. Patients with severe lower extremity edema that impairs mobility should be referred to a physiatrist who can consider all options—including medication adjustments—for edema management. The long-term application of diuretics may be one important co-factor for maintaining edema.

Patients should also be referred to a physical therapist to tailor a program for exercise and improvement of locomotion skills during and after edema treatment. For patients who are unable to fit into a compression stocking due to severe edema, a referral to a certified lymphedema therapist should be made for appropriate compression therapy options. In our case, the patient was originally prescribed compression stockings, which are commonly used to treat lower extremity edema. However, it is often difficult to fit patients who have severe edema with appropriately sized compression stockings, so clinicians should be vigilant about using alternative treatment options for severe and refractory lower extremity edema.

Before the application of compression bandaging, patients should receive a full assessment that includes the extent of edema and level of mobility as well as evaluation of any allergies and neurological, cardiac, and skin conditions.⁹ Severe arterial occlusive disease is a contraindication for compression therapy.³ Compression bandages must be applied by trained personnel^3,4 and changed according to the degree of drainage. Lower extremity ischemia can develop if compression bandages are applied too tightly; therefore, patients should be instructed to remove the bandage if discoloration of the toes, numbness, or tingling occurs.³

The choice of initial compression therapy (elastic, inelastic, single layer, or multilayer) is based on numerous factors, including pain level, patient compliance, the presence and size of venous ulcers, and the availability of resources (eg, trained personnel who can apply and reapply complex bandaging systems).³ In general, bandages are used to treat venous disease ulceration⁹ and lower extremity edema,¹⁰ and compression stockings are used to prevent recurrence after the ulcer has healed⁹ and once swelling is reduced.¹⁰

Main factors to be considered when a compression bandage is applied include the following: 1) pressure (magnitude of compression applied), 2) layers, 3) components (materials to provide different functions, such as padding, protection, and retention), and 4) elastic properties that may be inelastic (rigid or short-stretch bandages) or elastic (long-stretch bandages).¹¹ For simple, double-layer bandages, the terms “elastic” and “inelastic” are recommended.¹¹ Multilayered compression bandaging tends to make the final bandage system stiff and behave as an inelastic system, even if elastic materials are used, due to the friction generated between layers.¹¹ Compression therapy should start with a therapy phase, in which inelastic material is used, followed by maintenance with compression stockings when no more edema reduction can be achieved.

Circumferential measurements of the affected limb(s) are a simple and inexpensive method to estimate edema, and a difference of more than 2 cm between the affected and unaffected sides is considered clinically significant.¹² Regular documentation of these measurements is an essential tool for monitoring lower extremity edema during compression therapy. Measurements can be taken at any site on the extremity as long as the clinician uses anatomic landmarks to repeat measurements at the same site.¹² In complete decongestive therapy for lymphedema, limb circumference measurements are taken weekly to see if improvement is continuing or has plateaued.⁶ In our patient, limb measurements were documented on 3 consecutive days and on the last day of multilayered compression bandaging therapy, at which time the edema had stabilized and the patient was able to be fitted with compression stockings.

This case demonstrates the role of rehabilitation specialists, which enabled the addition of multilayered compression bandaging to control refractory peripheral edema. As the edema improved, the patient began to adhere to walking more frequently and was able to significantly improve his ambulation distance with less physical assistance from the physical therapist. This synergistic effect of compression bandaging and walking exercise was essential to maintaining edema reduction because inelastic compression works best in combination with walking,³ which produces a massaging effect with each step.

More research is necessary to better define the role of the combination of physical therapy, compression therapy, and pharmacological treatment in managing refractory peripheral edema for patients with multiple comorbidities. In addition, more research should be conducted on the roles of progressive compression bandaging and rehabilitation specialists’ care in the multidimensional treatment of refractory peripheral edema. Implementing standards for documenting serial limb circumference measurements and weight is important for lower extremity peripheral edema compression bandaging. Without appropriate measures, such as serial limb circumference measurements, it is difficult to know whether compression bandaging is reducing refractory peripheral edema or not. Due to the multidimensional nature of edema, a multidimensional approach is needed for peripheral edema management.

Ethics Approval

Written patient consent was obtained.

Funding

This project was supported in part by the National Institutes of Health/National Cancer Institute (ref. no. P30CA016672).

Disclosure and Presentations

The authors completed the ICJME Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.

This case report is adapted in part from a presentation made at the Multinational Association of Supportive Care in Cancer, Vienna, Austria, on June 30, 2018.