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Words on Wounds
A forum to discuss the latest news and ideas in skin and wound care.
Thursday, June 14, 2012
Leg Ulcer Survey Results

Leg ulceration is a chronic health condition that is often complicated by other co-existing conditions such as poor circulation. Approximately 20% to 30% of individuals with legs ulcers have evidence of mild to moderate circulation problems and the number continues to increase due to an aging population and high prevalence of diabetes. Existing guidelines endorse the need to reduce the strength of compression for the management of mixed venous arterial ulcers. However, consensus is lacking in the type of modified compression that is most appropriate for the varying degree of circulation compromise (ankle brachial index [ABI] between 0.5 and 0.8). To date, there is no randomized controlled trial that evaluates the efficacy of compression therapy for the treatment and management of mixed leg ulcers.

In the recent poll on this website, 95% of the voters agreed that we need a practice document to provide guidance and standardize care for mixed leg ulcers. We also completed a survey of more than 400 clinicians focusing on the knowledge, attitude, and practice in this patient population. Of interest, 84% of the clinicians agreed that compression should be considered for the care of mixed leg ulcers, but 56% indicated that compression should not be used if ABI is less than 0.8. There seems to be some inconsistency in how mixed leg ulcers are defined and whether compression should be used. More than 75% of the respondents agreed that most clinicians do not have the knowledge to manage mixed venous arterial leg ulcers. In summary, there is a pressing need to generate different levels of evidence to address this growing clinical issue to ensure patient safety and cost-effective care.

Dr. Kevin Woo said:
Dear Edwin, I do agree that there is a vast knowledge gap in the management of people with chronic edema and co-existing circulation problem. According to a recent scan of the literature, available empirical evidence that can be integrated into practice is lacking. Even best practice guidelines did not adequately address and provide concrete guidance on the management of mixed venous arterial leg ulcers. We are currently working on a number of initiatives to address this practice gap. I would encourage you to collect your data and that would be a great case series to describe your management approach and outcomes. Kevin Y. Woo, MSc, PhD, RN, ACNP, GNC(c)
Dr. Edwin P. Monroy said:
This has been a big topic of discussion for the physical therapists in our department that are seeing primarily patients with lymphedema/wounds. We run into the issue of patients being referred to us sometimes without the needed information (i.e., ABIs with toe pressures) and/or with ABIs <0.8. We still provide compression (usually short stretch) but we monitor them closely with their primary care practitioner's blessing. Even those with moderate occlusion do show benefits with low compression. How low of compression is it? Any protocols? Without compression, how do you deal with their weeping edema or the blockage of microvascular flow secondary to their fluid buildup? Most of our patients who come in now are also diabetic, so how accurate are the ABIs w/toe pressures when you don't have other diagnostic tools (i.e., SPP)? This is a topic that does not get discussed enough! Edwin Monroy PT, DPT, CLT
About the Author

Kevin Y. Woo, PhD, RN, ACNP, GNC(C), FAPWCA
Kevin Y. Woo, PhD, RN, ACNP, GNC(C), FAPWCA, is Assistant Professor, School of Nursing, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada; Adjunct Research Professor, MClSc Program, School of Physical Therapy, and Faculty of Health Sciences, Western University, London, Ontario; Wound Care Consultant, West Park Healthcare Centre, Toronto, Ontario, and Clinical Web Editor, Advances in Skin & Wound Care.