Transcript: Frank Aviles Jr., PT, CWS, FACCWS, CLT-LANA, ALM, AWCC, DAPWCA

Hello, my name is Frank Aviles. I'm a physical therapist by trade. I'm in the wound care/lymphedema space, and I'm starting a new position at My Life Rehab and Wellness doing lymphedema and wound care.

Compression therapy is very important when we're treating venous leg ulcers and other conditions alluding to swelling. And what we're doing is we're applying external pressure to the extremity, and we're using different devices. It could be bandages, it could be stockings, it could be a special device. And applying this external pressure, adequate pressure, it's helpful with the patients that have venous hypertension. Usually that's what we're trying to do is decrease filtration at the capillary level. And so when we, in the wound care world, when we're looking at compression, the lower extremity, what we're looking for is those patients that do not have a normal valve system, or they have reflux, a condition that's allowing fluid to not be reabsorbed, and what we're looking is to restore that normal pressure. 

So at the ankle when we compress, optimally we're looking at 40 millimeters of mercury compression, and then as we go up, using the same tension, also the law of Laplace, at the calf, because its wider, is going to give you a 17 millimeters compression. And so to finalize compression therapy, we're using different materials to provide a pressure gradient to move fluid from the lower extremity back to the heart. 

And so every patient needs to have a tailored evaluation, because it's not just about which product we're going to use, but it's what's the patient's condition? What is their mobility like? What is the strength? We're writing a consensus statement paper right now, and there's a lot more that people don't realize, but we also have to understand the underlying pathology. 

A lot of these products, and I'm going to go over a few, usually in our world, we talk about short stretch and long stretch. So long stretch is usually your ACE wrap that we don't usually use for patients with venous hypertension. What we'd rather use is the other component, short stretch. And the reason for that is because it has a high working pressure, but resting. What that translates to is, when I'm walking, I'm enhancing the calf pump mechanism to move blood back up to the heart. And so one category is elastic compression, and a lot of times we include compression bandages here, or stockings I might say, tubular bandages, and also compression wraps. And so what we're trying to do is provide sustained, constant pressure while the patients at rest also. And so we have garments, and they have different levels. And elastic compression, this is more your short stretch bandage or your Unna Boots that we talked about. And this provides the higher pressure during the activity. So what we want to do is pump that blood back up to the heart. And so a lot of times the indication is for the patients that are mobile, but we have to make sure that we understand how to apply it properly. 

You know, some payers say that this is not a skilled service or application to put on, but I have to differ, because you have to take in a lot of consideration. Of course, everybody knows some multilayer components, 2, 3, 4 layers, and that provides graduated compression. It's durable, but it needs a skill, usually 7-day wear time. There's also other devices, adjustable compression devices, like your Velcro straps or pneumatic compression devices. So there's another category there that we could utilize also. There's IPC devices, intermittent pneumatic compression. Usually these are used in the lymphedema world, and of course there's differences of opinions, so I'll leave that up to the viewer to decide. And so it is best to determine your patient's mobility, functional level, also do they have support, in order to determine which one of these would be best for them. And I'm telling you that not every patient will end up with the same. 

So compression therapy being contraindicated, I alluded to the fact, and we're writing a position paper, and I'm going to tell you that there's new research out there, but I'm going to go back to the standard contraindication just for safeguard. Because unless your policies change to the new research, you know there'll be other ramifications that you don't want to go there. But absolute contraindication, severe peripheral disease, some people give it a specific number like an ankle brachial index. And I'm going to tell you that it is important to make sure that you do a vascular screening for patients that you're compressing, because the data shows that 20% of the patients that have chronic venous insufficiency or ulcers, that they have a mixed component in arterial. And I've seen that way too often. Even patients with lymphedema, the risk factors have been there, and if I were to compress, it wouldn't have been pretty.

Another one, the standard usually it has been acute deep vein thrombosis. Now again there's new data coming out, but I'm going to keep that for this interview still as a contraindication. Also untreated congestive heart failure, usually and we've seen this in our clinic as well, that if a patient was compressed, and the medication was not where it needed to be, by the time they get to the lobby, they're out of breath. And so that could be a contraindication untreated CHF. But also consider the other part of it. You know, I've seen patients with poor ejection fraction. And so if they have a poor ejection fraction, again, we're going to probably put that patient back in the ICU unit. And there's no standard, you know, there's the literature indicates a certain percentage. And so work with your cardiologist to see what that would be for your patients. 

Now, infection. Now, we've been saying throughout the years that infection is a contraindication. And let me tell you, the reason behind that is that when you have an infectious process, you have a lot of vasodilation. So you have fluid coming out and filtrating to the tissue. And so we want to make sure that infection is addressed. And so I know there's new thinking. People are saying we can compress with infection, but I will say until that infection is resolved, you know, that could be a contraindication. Also, allergies to materials could be a contraindication. Patients with a sensitivity to the material could be a relative contraindication. And if a patient is a spinal cord injury or limited mobility you can't compress them the same way, because it's all about the dynamics and the vein pressures. These patients are usually laying down, and so you have to treat them you have to pad them a little more, less tension on there. 

And lastly let me see, I'm teaching a course tomorrow on this, but also the elderly, and be careful with adherence or with compliance, because what I see out there is that a lot of times we don't take the time to explain, and the patient feels this tightness, which to them is very uncomfortable, but it may be normal. And so we have to educate them. Or it could be that we decrease attention a little bit so when they come back we can increase it as well. And so we have to make sure that we tailor it to that. And Dr. Fedor Lurie, actually I heard him speak at a conference 3 years ago, and he said when you make the patient part of, whether it's research or part of a plan, there were 85% compliant. And so compression is key to what we do, so make sure that you take your time to explain to the patient what's happening.

Helping patients with a history of nonadherence is kind of tricky. You know, what you have to remember is you've got to treat everybody as an individual. A lot of times what I see is that something and don't assume that everybody's in the same boat. And so you have to address different barriers. You’ve got to provide support. So when you're doing your evaluation, find out who the support members are. Do they have somebody at home that can help with that? If there's any problems, you know, what to do. And so one, identifying barriers, it could be discomfort or pain, so why not, you know, if it's too tight, maybe back it off a little bit. If that difficulty applying the product, let's just talk about garments. A lot of people may not have the strength. And so there's different products that can help them apply or remove the products. I wear compression all the time and I'm trying, there's so many different products out there to help you. If it's financial constraint, that happens a lot. It may be that you have to look at other alternatives that are not so costly. Now we do have the Lymphedema Treatment Act that is helping with that, but you know there may be certain cases where you may have to have help. 

The other constraint is, and we talked about this, is lack of understanding on the patient’s side. You know I've gone to my mom's doctor's appointment, she does have swelling, a touch lymph, well, she has lymphedema, and nobody understands it. And English is not her first language, and when they explain something so fast, you know, she agrees with them, but she doesn't understand. So we have to make sure that we're speaking at their level. And so, foster a collaborative plan. Make sure you get the patient involved, providing education, motivation. A lot of times I show them the measurement when I'm treating them to show them that, yes, it is reducing in size and they love that. Actually I give them a chart and they can see. So what we want to do is pretty much simplify the care that they're getting. 

As far as there's also different type of population. For example, there's patients that have odd shape extremities, maybe a lobule here or there. This is where collaborative will help because you can't treat these patients the way you do with your standard care of patients. And it could be, I mean, just an example, think of the inverted bottle, a champagne bottle patients. I can't tell you how many patients come from other clinics and they can't stand that compression, because what they fail to do is to build up the extremity and make it into a nice cone shape. But instead, you have a small ankle, which we know Laplace Law, you're applying more pressure there and it's very uncomfortable. And so there's other technology, and incentives too, that we can help increase compliance. I don't have it with me, but I have a little sensor that I can apply as I'm training people and you can see on your phone how much pressure you're providing, and you know that's an incredible thing to have, because I've seen people put not the desired compression level, but they've gone way low or way high, and that could be detrimental to the patient especially if they already have an existent arterial disease complication.

For a final comment I want to say that, to me, when you applying compression, there's an art to it. And there's various levels, there's 9, 10 different types of compression. Make sure you educate yourself on all of them ,indications, contraindications. But you have to make sure that the patient is part of the team because, if they don't wear it then you're not going to be successful. And if you look at the wounds that we have, venous like ulcers, the data shows that they have a problem with healing. Applying the right compression, appropriate compression, has long-term effects. Healing outcomes are going to be positive in addition to increasing the patient's quality of life.