Although lymphoedema is not directly responsible for leg ulcer development, it can affect wound healing1. This is due to reduced oxygenation of the tissues resulting from the presence of oedema2. As such, skin damage to an oedematous limb may lead to ulceration. Ulceration can also follow superficial infection3 – resulting in delayed wound healing.
Mortimer and Rockson4 state that ‘it may be better to consider the presence of chronic oedema as synonymous with the presence of lymphoedema, as all oedema represents relative lymph drainage failure’. Peripheral oedema on assessment is usually classified according to possible systemic causes, such as local obstruction, heart failure, infection, nephrotic syndrome, injury, or tumours.
The assessment approach taken needs to appreciate that there is usually more than one cause of oedema, taking into account the central role of the lymphatic system in drainage and tissue fluid balance4.
Veno-lymphoedema leg ulcers (also known as lymphovenous ulcers) and venous ulcers represent distinct yet overlapping challenges in wound care4.
Venous ulcers primarily result from venous insufficiency, characterized by venous stasis, increased hydrostatic pressure, and the breakdown of skin barriers5.
Accurate differentiation between the ulcer types is critical, as management varies significantly, and despite their differing aetiologies, both conditions benefit significantly from interventions that enhance lower limb blood flow and reduce oedema.6,7,8
Veno-lymphoedema leg ulcer treatment challenges
Conventional treatments, such as compression therapy, are the cornerstone treatment for venous ulcers but are often contraindicated or problematic in mixed veno-lymphatic conditions, such as veno-lymphoedema leg ulcers1.
The key reasons for this include the risk of exacerbating ischemia in patients with coexisting peripheral arterial disease (PAD), discomfort or pain due to extreme swelling, and the potential for compression bandages to cause further skin breakdown in fragile or infected tissues1.
Additionally, improper application or excessive compression can worsen lymphatic damage. As a result, alternative approaches currently focus on manual lymphatic drainage (MLD), and skin protection1. This underscores the need for individualized, multidisciplinary management strategies for patients with veno-lymphoedema leg ulcers, advocating for caution in applying compression therapy and promoting further research into safe and effective alternative or adjunctive therapies.
The potential for Neuromuscular Electrostimulation
Neuromuscular electrostimulation (NMES) has emerged as a promising adjunctive therapy to enhance blood flow and lymphatic function in the lower limbs9.
NMES involves the application of low-frequency electrical impulses to elicit lower limb muscle contraction via stimulation of a nerve, increasing venous and lymph system return and tissue perfusion9.
The literature supports that NMES can improve lymphatic function. In this study9, lymphatic imaging (with use of a radioactive dye) was used to identify changes in lymph behaviour resulting from the use of the wearable NMES device. The results confirmed increased lymphatic function.
The potential for the geko® device
In this recently published multi-centre randomised self-controlled trial10, the geko device, a wearable neuromuscular electrostimulator, demonstrated significantly increased venous, arterial and microcirculatory blood flow, transporting oxygenated blood to the wound bed, facilitating a doubling in the rate of healing in venous leg ulcer patients versus compression alone.
The geko device is also clinically proven to mitigate the inflammatory environment critical to tissue repair through the reduction of oedema. This published case report11 describes the experience of a veno-lymphoedema patient with chronic renal failure causing episodes of lower leg blistering resulting in wounds. Before the geko device use, he had received twice daily dressing changes with frequent infections for 5 years, with amputation and haemodialysis predicted as the eventual outcomes. Following geko device adjunctive use, his episodes of blistering with open wounds reduced, along with accelerated healing, a reduction in fibrotic oedema and a return to more normal skin integrity. His mobility and ankle range of motion rapidly increased. Additionally, his renal function improved during the treatment, with a reduction in serum creatinine to the point that haemodialysis was no longer being considered. The improvements increased his mobility, activity, and quality of life. The results were remarked on as unprecedented in the experience of his care team.
For individuals with veno-lymphoedema-related leg ulcers, the geko device represents a novel, non-invasive approach with the proven ability to reduce oedema and accelerate wound healing – and save12 health system costs.
The geko device is now available on prescription and is on the NHS Supply Chain.
References
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