Living with venous leg ulceration: issues concerning adherence

What specific challenges do patients with chronic wounds encounter when attending medical appointments related to wound care? A systematic review

BACKGROUND

Chronic wounds can pose a significant challenge for patients and healthcare professionals including the morbidity and associated costs. It is therefore essential to understand the specific challenges faced by patients to make wound care services more effective and convenient for the patient population.

AIM

Using the PEO model, this systematic review aims to explore the specific challenges patients with chronic wounds encounter when attending medical appointments related to wound care.

METHOD

A systematic search of publications using MEDLINE, Ovid EMBASE, CINAHL databases was conducted in April 2024, and relevant articles were reviewed. Data extraction and a narrative synthesis approach was undertaken. The evidence-based librarianship (EBL) checklist assessed the methodological quality of the studies included. The primary outcome was to identify the specific challenges faced by patients with chronic wounds who attend medical appointments related to wound care. The secondary outcome was to determine wound healing progression, quality of life, complications of wound care, and adverse effects of wound care.

RESULTS

Six studies between the years 2014 and 2024 described the specific challenges faced by patients with chronic wounds in a hospital or clinic setting. All six studies mentioned the pain and unwanted physical inactivity collectively affected the daily life of the patients and their capability of attending appointments. Increased cost of attending wound care appointments and travelling were elucidated by four studies. Increased waiting time during the appointments were also described by four studies. Additionally, two studies mentioned the difficulties of accessing public transport and heavy reliance on private transport because of the physical inability associated with the wound.

CONCLUSION

This systematic review identified several challenges faced by patients with chronic wounds when attending medical appointments. Key issues include increased waiting times, and the excessive cost of appointments. Pain, discomfort, and physical limitations further complicated attendance, particularly for distant clinics, leading to reliance on expensive private transport. Additionally, three studies reported decreased quality of life. These findings highlight the need for more effective and convenient wound care services for patients.

Improving Adherence to Wearing Compression Stockings for Chronic Venous Insufficiency and Venous Leg Ulcers: A Scoping Review

PURPOSE

Patient adherence to wearing compression stockings in the management of chronic venous insufficiency (CVI) and venous leg ulcers (VLUs) is low. Poor adherence with compression stockings contributes to recurrence and impaired healing of VLUs. As such, the purpose of this review was to report on the scientific evidence related to adherence and explore modifiable factors which impact adherence with compression stockings.

METHODS

A systematic search was conducted from inception to 31 October 2019. Following the PRISMA-ScR Checklist, PubMed, Medline, CINAHL, Cochrane, Embase, OT Seeker and Web of Science were explored using search terms: compression/compression stocking/compression garment/compression sock/stockings/garments and adherence/compliance/concordance.

RESULTS

We identified 2613 papers of which 125 full text papers were assessed for eligibility and 69 met inclusion criteria. Papers were grouped and charted by concepts relevant to the research questions and narratively synthesized. Several dominant themes emerged, and a conceptual framework was developed incorporating modifiable variables, adherence itself, and outcomes related to adherence. Specifically considering interventions to improve adherence, only five of 14 randomized controlled trials were able to demonstrate improvements in adherence through unidimensional approaches. All nine of the case studies/series demonstrated a positive impact on adherence, eight of which described a personalized multidimensional approach. A lack of consensus around defining, measuring, and quantifying adherence with compression stockings was identified, resulting in wide variation in reported adherence rates.

CONCLUSION

Inconsistency in the definition and measurement of adherence limits meaningful interpretation of the literature. No individual intervention has consistently demonstrated improved adherence. Multidimensional interventions show promise but require further investigation with high-quality trials. Improving adherence appears to improve health outcomes in VLU /CVI populations but there is a lack of information directly linking improved adherence with cost outcomes.

TRIAL REGISTRATION

Open Science Framework: ACTRN12620000544976p.

Experiences of Venous Leg Ulcer persons following an individualised nurse-led education: protocol for a qualitative study using a constructivist grounded theory approach

INTRODUCTION

Venous leg ulcers are slow-healing wounds with a high risk of recurrences. To prevent recurrences and promote healing, different nurse-led educational interventions have been developed. The impact of these interventions on self-management is ambiguous. Also, how persons with a venous leg ulcer experiences these educational sessions are poorly described.

AIM

This study protocol presents the methodology to provide a comprehensive explanation of participants' journeys-of how they experience their individualised education sessions concerning self-management.

METHODS AND ANALYSIS

A constructivist grounded theory approach according to Charmaz involving 30 participants will be used. Data will be collected through semistructured face-to-face interviews. Interviews will be transcribed verbatim and analysed with initial and focus coding using MAXQDA. Data collection and data analysis will occur iteratively, focusing on constant comparison to obtain well-developed categories. Categories will be reinforced using existent literature.

ETHICS AND DISSEMINATION

This pre-results study is embedded in a clinical trial (NCT04019340) and approved by ethical committee of the canton of Geneva (CCER: 2019-01964). A theory will emerge from participants' journeys informing future education sessions for patients with venous leg ulcers. The findings will be disseminated through peer-reviewed publications and communications.

Theory and Practice of Compression Therapy for Treating and Preventing Venous Ulcers

Compression therapy is the basis for treating the cause of venous ulcers and preventing recurrence. Various systems are currently available for applying compression and adapting them to patients' needs can improve adherence to treatment. Understanding the principles that underlie compression therapy is essential for success. Although this paper focuses mainly on venous ulcers, compression has also proven beneficial for other conditions, such as lymphedema and wounds resulting from injury or inflammation.

An evaluation of short-stretch compression systems for chronic lower-limb leg ulcers

An evaluation of a new short-stretch compression system (CoFlex UBZ, TLC and TLC Lite, Aspen Medical Europe Ltd) was undertaken in four leg ulcer clinics. A total of 19 patients aged 42-93 years were treated for up to 4 weeks, or until healed. Collated data included age, underlying diseases, leg ulcer type, ulcer duration and current treatment. The evaluation included quality of life measurements, wear time, slippage, exudate strikethrough and pain using a numerical pain score. Patients were asked to document sleep patterns. Compression was applied according to clinical need. Inclusion criteria were non-healing wounds on the lower limb existing for more than 6 weeks that were suitable for compression. Exclusion criteria included patients with untreated peripheral disease, ankle-brachial pressure index (ABPI)<0.5 or those unable to consent. Staff were asked to rate performance, wear time, fluid handling and conformability. Wound tissue types improved significantly for n=16 (84%) patients. Pain scores reduced significantly by week 2, n=11 (58%) patient leg ulcers had improved, n=2 (11%) patients in standard compression noted a marked reduction in malodour and sloughy tissue. n=16 (84%) rated the overall performance as 'very good' or 'good'. A detailed cost analysis was undertaken on one patient, suggesting a potential cost saving of £186.92 per month and a cost efficiency saving of 43.4%.

The perspectives of adults with venous leg ulcers on exercise: an exploratory study

OBJECTIVE

Exercise has the potential to offer a range of health benefits in addition to improving healing outcomes for people with venous leg ulcers (VLUs). However, despite evidence-based recommendations, most of these individuals do not engage in regular exercise. The aim of this study was to gain an understanding of the perspectives of adults with VLUs, in relation to exercise.

METHOD

This was a qualitative design using semi-structured interviews and discussions. Ten participants with venous leg ulceration volunteered to participate. Recruitment was through a specialist wound clinic. Verbatim data were collected by an experienced moderator using a semi-structured guide. Data saturation was reached after three group discussions and two interviews. A random selection of transcripts was sent back to the participants for verification. Thematic content analysis was used to determine major themes and categories. Two transcripts were independently analysed, categories and themes independently developed, cross checked and found comparable. Remaining transcripts were analysed using the developed categories and codes.

RESULTS

Regardless of their current exercise routine, participants reported exercising before venous leg ulceration and expressed an interest in either becoming active or maintaining an active lifestyle. Overall, four themes emerged from the findings: i) participant understanding of the relationship between chronic venous insufficiency and exercise patterns; ii) fear of harm impacts upon positive beliefs and attitudes to exercise; iii) perceived factors limit exercise; and iv) structured management facilitates exercise.

CONCLUSION

The value of exercise in improving outcomes in VLUs lies in its capacity to promote venous return and reduce the risk of secondary conditions in this population. Despite motivation and interest in being exercise active, people with VLUs report many obstacles. Further exploration of mechanisms that assist this patient population and promote understanding about management of barriers, coupled with promotion of enabling factors, is vital for improving their exercise participation.

Incorporating novel solutions to lower-limb problems into compression formularies

This study investigates the effect of a new short-stretch two-layer compression system in eight patients with common chronic lower-limb conditions in three locations in the UK. Chronic leg ulcers are the most common type of lower-limb ulceration with 70% caused by chronic venous hypertension. An appropriate level of compression is proven to heal chronic venous leg ulcers. The study was only a small sample of patients; however, the underlying conditions included chronic venous eczema, diabetes, sarcoma, cellulitis and mixed-aetiology ulcers. During the study, the UK experienced some of the hottest temperatures in the last 30 years. This had an impact on five patients, who noted an increase in malodour associated with their leg ulcers. CoFlex TLC (Aspen Medical Europe Ltd) foam comfort layer is impregnated with cyclodextrin-a naturally based oligosaccharide known to reduce malodour. The zinc-impregnated foam bandages in this study were viewed very favourably by both patients and staff, particularly those who had chronic venous eczema.

Drawtex: breaking the vicious circle of cellular and molecular imbalances

Uncontrolled cellular and molecular activity in the inflammatory phase of healing will determine whether a wound becomes chronic. Assessment and interventions designed to remove the barriers to healing are essential in order to break the vicious cycle and to kick-start healing in chronic wounds. This product focus gives an overview of the inflammatory phase of the wound healing continuum; discusses how the imbalance of matrix metalloproteinases/tissue inhibitors of matrix metalloproteinases occurs; how this imbalance manifests itself clinically within the wound; and what health professionals can do in order to tip the balance in favour of healing. It discusses a new wound dressing, Drawtex, which combines three modes of action to maintain a moist wound environment in order to debride, manage exudate and reduce bioburden by locking harmful proteases into its core. Case studies are presented where Drawtex has been used to achieve healing in wounds that were not responding to treatment.

Foot sling for the treatment of diurnal leg oedema: effect due to foot muscle pump stimulation?

Hintergrund und Design: Prospektive Pilot-fallserie zur Beurteilung der Effektivität, Verträglichkeit und Einfachheit der Anwendung einer neuartigen Fußschlinge (Stimfeet) zur Behandlung von habituellen Beinödemen.

Patienten und Methoden: Eingeschlossen wurden acht Patientinnen mit nachweisbarer prätibialer Dellenbildung bei habituellen Beinödemen. Hämodynamisch relevante Refluxe oder Obstruktionen der Beinvenen wurden duplexsonographisch ausgeschlossen. Die Patientinnen erhielten eine einwöchige ganztägige Behandlung mit medizinischen Kompressionsstrümpfen (MKS) bis zum Knie (18–23 mmHg) und nach zweitägiger Pause mit Stimfeet (maximal vier Stunden ohne Unterbrechung) oder umgekehrt. Vor und nach jeder Behandlungswoche erfolgten jeweils zwei wasserplethysmographische Volumenmessungen pro Bein. Mittels standardisierter Fragebögen wurden die Effektivität, Verträglichkeit und Einfachheit der Anwendung evaluiert. In einem Patiententagebuch wurden die Nebenwirkungen dokumentiert.

Ergebnisse: MKS führten zu einer größeren Volumenreduktion (mittleres Δ rechts: 39,00 g, links: 24,44 g) verglichen mit Stimfeet (mittleres Δ rechts: 5,06 g, links: 2,81 g). Die Ergebnisse unterschieden sich jedoch nicht signifikant (t-test: rechts: p=0,55, links: p=0,63). In Bezug auf weniger Einschränkung (n=5), Komfort (n=6), Reduktion der Symptome (n=5), Verbesserung der Lebensqualität (n=5), Verbesserung der Arbeitsbedingungen (n=5) und den Erwartungen entsprechend (n=5) bevorzugten mehr Patientinnen den MKS. Die Einfachheit der Anwendung wurde gleich bewertet. Die am häufigsten dokumentierten Nebenwirkungen von Stimfeet waren Druck- und Schürfstellen (n=6) und Verrutschen/Notwendigkeit der Fixierung (n=5).

Schlussfolgerung: MKS waren der neuartigen Fußschlinge in der Behandlung habitueller Beinödeme überlegen. Bei einer Minderheit der Patientinnen führte die neuartige Fußschlinge jedoch zur Besserung der Beschwerden und Ödemreduktion. Die Wirksamkeit wird möglicherweise durch eine Stimulation der Fußmuskelpumpe bedingt. Methoden zur Aktivierung der Fußmuskelpumpe stellen eine neue Therapieoption für die Behandlung von Beinödemen dar.

Encouraging patients to self-care - the preliminary development and validation of the VeLUSET©, a self-efficacy tool for venous leg ulcer patients, aged 60 years and over

Venous leg ulceration has a high recurrence rate. Patients with healed or frequently recurring venous ulceration are required to perform self-care behaviours to prevent recurrence or promote healing, but evidence suggests that many find these difficult to perform. Bandura's self-efficacy theory is a widely used and robust behaviour change model and underpins many interventions designed to promote self-care in a variety of chronic conditions. By identifying areas where patients may experience difficulty in performing self-care, interventions can be developed to strengthen their self-efficacy beliefs in performing these activities successfully. There are currently a variety of self-efficacy scales available to measure self-efficacy in a variety of conditions; but not a disease-specific scale for use with venous ulcer patients. The aim of this study, therefore, was to develop and validate a disease-specific, patient-focused self-efficacy scale for patients with healed venous leg ulceration. This scale will need further validation studies; however, it is ready for use in clinical practice and will enable practitioners to identify those patients who may need additional support in performing self-care activities to prevent recurrence.

Why don't patients adhere to compression therapy?

This article explores the psychological influences on patients and their choices over adopting (or not) the advice of health-care professionals (HCPs) with regard to their own health. The article will examine some key theories by reviewing studies as well as examining how the patient-HCP relationship has evolved over time to try and improve patient adherence. Although specifically focusing on the area of venous leg ulcers and compression therapy, the theories relate to many health conditions. Despite health advice and compression treatments being the cornerstone of ulcer prevention and recurrence when adhered to, patient adherence levels are often persistently poor, both anecdotally and via clinical study. This article attempts to explain what influences a patient's adherence.

Negative pressure wound therapy: improving the patient experience Part 2 of 3

Despite the clear benefits of negative pressure wound therapy (NPWT) as a treatment for wounds, it is essential that greater focus is given to the patient experience of this treatment. In particular, it is important that any unpleasant consequences, such as pain, stress, and skin trauma are minimised, so as to promote quality of life and healing. This article presents part two of three studies which aim to explore ways in which the patient experience of NPWT can be improved. In this study, the views of wound care clinicians (n=12) were investigated in greater depth through semi-structured interviews. Findings indicate a pressing need to minimise pain, particularly through ongoing assessment and collaboration with patients, and also through the use of appropriate dressings, films and other products that promote patient comfort. Additionally, it is evident that greater education is needed for both nurses and patients about NPWT, in order to promote high-quality care and patient wellbeing.

The journey to chronic pain: a grounded theory of older adults' experiences of pain associated with leg ulceration

This study aimed to develop a grounded theory to describe and explain the experience of pain and its impact, as reported by the individuals who had pain associated with chronic leg ulceration. The Strauss and Corbin grounded theory approach was used. In-depth interviews were undertaken with 11 people aged ≥ 65 years from Leeds in the north of England. All participants were cared for by home care nurses and had painful leg ulceration. The emergent grounded theory centered on a core category of "The journey to chronic pain." The theory suggested a trajectory consisting of three phases that the patient experiences, where the end result is a chronic pain syndrome. In phase 1, leg ulcer pain has predominantly acute nociceptive properties, and if this is not managed effectively, or ulcers do not heal, persistent pain may develop with both nociceptive and neuropathic properties (i.e., phase 2). If phase 2 pain is not managed effectively, patients may then develop refractory long-term pain (phase 3). Those who progress to phase 3 tend to experience negative consequences such as insomnia, depression, and suicidal ideation. Only when health care professionals understand and acknowledge the persistent and long-term nature of the pain in this patient group can the pain be managed effectively.

Working in partnership with patients to promote concordance with compression bandaging

Patients may be tempted to remove their compression bandages if they find them uncomfortable, particularly at night. Working in partnership with patients to select bandages that they find tolerable and then applying them in a way that promotes comfort will encourage concordance with this therapy.

A meta-synthesis of research on leg ulceration and neuropathic pain component and sequelae

Leg ulceration represents a substantial health problem, and pain is likely to be an associated symptom. The aim of this meta-synthesis was to undertake a systematic review of qualitative studies investigating the experience of chronic painful leg ulceration. This study undertook the meta-synthesis approach described by Sandelowski and Barroso (2003), which is a synthesis and re-interpretation of the findings from several qualitative studies. Findings were extracted and synthesized. The overarching theme was that patients with chronic leg ulceration suffer from persistent pain with associated sequelae. Word descriptors used by participants also suggested that patients have neuropathic pain. In addition, findings from the meta-synthesis suggested that pain associated with chronic leg ulcer may have a neuropathic pain component. Pain associated with leg ulceration is likely to have nociceptive properties as well as neuropathic properties. If neuropathic pain is not identified and managed effectively, patients are at risk of developing a chronic pain condition with associated sequelae, such as poor sleep, depression and suicidal ideation. It is proposed that early identification and management may enable appropriate pain management which may prevent or reduce the associated risks.

The impact of vascular leg disorders on physical activity in methadone-maintained adults

Chronic venous disorders (CVD) and peripheral arterial disease (PAD) may affect diverse physical activity domains. How CVD and PAD and other relevant variables affect physical activity was examined in 569 opioid-addicted adults. Both CVD and PAD were significantly inversely related to daily walking, sports, and active living. Effects remained significant in the latent variable regression after controlling covariates. Overall activity was very low; most participants walked less than a half mile daily and rarely engaged in sports. Motivation for physical activity was the strongest predictor (β = .55) of daily physical activity. Health-care professionals promoting physical activity for injection users should consider the vascular health of their legs and motivational variables in addition to general health.

Comparison of bodily pain: persons with and without venous ulcers in an indigent care clinic

PURPOSE

The purpose of this study was to examine bodily pain and its relationship with functional status, perception of control, coping, and depression for patients with and without venous ulcers who were receiving care in an urban, primary care clinic for low-income adults.

METHODS

We used an exploratory, cross-sectional design. Participants (N = 301) completed demographic, pain severity and pain interference with function, depression, control, and coping questionnaires. Seventy patients (23.3%) had venous ulcers and 231 (76.7%) did not.

RESULTS

Participants were generally male (53%, n = 159), mostly African American (92%, n = 277), and ranged in age from 22 to 74 years (M = 49.5, SD = 8.5). Persons with and without venous ulcers did not differ significantly based on gender, race, number of pain sites (n = 3.3), or self-rated health. Those with leg ulcers were significantly older, had more health problems, and were more likely to have pain-related disability. The pain descriptors used by patients with venous ulcers were sharp (89%), nagging (87%), tiring (87%), and throbbing (87%). Patients with leg ulcers reported significantly lower average pain (M = 6.0) than those without leg ulcers (M = 6.6) and greater 24-hour pain relief from treatments or medications (55% vs 44%). Patients with venous ulcers reported greater control over their pain and greater coping with pain. The 2 groups did not differ significantly on depression, life control, or purpose in life scores.

CONCLUSIONS

Compared to patients without venous ulcers, those patients with venous ulcers rated their pain lower and reported higher coping and control over pain, which may be reflected in better subjective pain management despite having more pain sites and disability related to pain. Pain management for indigent patients with and without venous ulcers remains a concern and needs further study.

Venous leg ulcers: patient concordance with compression therapy and its impact on healing and prevention of recurrence

Moffatt Christine, Kommala Dheerendra, Dourdin Nathalie, Choe Yoonhee. Venous leg ulcers: patient concordance with compression therapy and its impact on healing and prevention of recurrence. ABSTRACT This study aimed to review available data on the reasons attributed to patient non concordance with compression therapy for the treatment of venous leg ulcers (VLUs), the frequency of non concordance and its effects on clinical outcomes. The biomedical literature was searched for publications on VLUs, compression therapy and concordance over the past 20 years. Physical, aesthetic and cosmetic factors, patient lack of education about VLUs, cost of therapy and issues with treatment by clinicians were all reported to influence concordance with compression therapy. The search identified 10 studies reporting patient concordance with compression stockings or bandages; while non concordance ranged from 2% to 42% of patients in three randomised controlled trials, it was generally higher in real-world studies, ranging from 9.7% to 80%. Another set of six studies indicated that the healing rate was half and the median time to complete healing was twice as long when patients were not concordant. Further, recurrence rates were 2-20 times greater when patients did not comply with the use of stockings following VLU healing. In conclusion, published biomedical literature has documented that non concordance with compression therapy negatively impacts the outcome of VLUs, highlighting the need to improve patient concordance to maximise therapeutic benefits.

The improvement of wound-associated pain and healing trajectory with a comprehensive foot and leg ulcer care model

PURPOSE

Pain is a major concern for subjects with chronic wounds, but its optimal management remains elusive. The aim of this study was to validate an organized pain management approach using the Wound Associated Pain model in subjects with chronic leg and foot ulcers.

DESIGN

We completed a prospective cohort study that documented pain in chronic wound subjects over a 4-week period.

SUBJECTS AND SETTING

A total of 111 subjects with chronic leg and foot ulcers were recruited from the community and ambulatory wound care clinics.

RESULTS

Using a systematic approach based on the Wound Associated Pain model, we demonstrated improved overall wound healing outcomes in 111 subjects with chronic leg and foot ulcers. Using an 11-point numerical rating scale, the average level of pain was reduced from 6.3 at week 0 to 2.8 at week 4 (P < .001). The average healing rate was 0.39 cm per week and the average relative reduction in size was 59.36% (t = 2.31; P = .023). To examine the relationship between pain and wound healing, pain levels were compared in subjects who achieved wound closure and those who did not. The mean pain score was 1.67 for the healed subjects in contrast to 3.21 for those who did not achieve complete wound closure (P < .041).

CONCLUSIONS

A comprehensive patient assessment can improve chronic leg and foot ulcer wound-related pain and healing rates. The mean pain scores are lower for patients with healed ulcers than for those who do not obtain complete wound closure.

Case studies evaluating 3M's two-layer compression system: Coban 2

Compression therapy is the cornerstone of venous leg ulcer management. In this evaluation of a Two-layer compression bandage system, the article focuses upon the performance of the bandage together with the patients' perspective regarding comfort and acceptability when carrying out normal daily activities. Twenty patients were recruited into the evaluation, and four case studies are presented here as an example of the evaluation.