Gaps in SCI Research for Lower Limb

Gap: Lower Limb Edema After SCI

Source of Evidence

http://sci.washington.edu/info/newsletters/articles/15_spr_edema.asp

While there are no studies on lower limb edema after SCI, there are recommendations based on general leg edema management from cardiovascular and diabetic populations, as well as clinical consensus from SCI practitioners.

Recognizing Lower Limb Edema

Lower limb edema is common after SCI. Lower limb edema may require treatment if there is substantial edema, edema with pitting, edema which impacts shoe fitting, or cellulitis (infection of the skin due to pooling), edema can even affect bladder management.

Management

Elevation

Elevating the feet above the hip (heart) can help counter the effects of gravity and drain the fluid back to the heart. This can be done at night or intermittently throughout the day. Studies in non-SCI populations have shown that elevating at least 30 degrees for 15 minutes can reduce some edema.

Compression Stockings

Compression stockings (typically 20-30 mm Hg) can be prescribed by a physician and purchased at standard medical supply stores, lighter compression 15-20 mm Hg can be purchased without a prescription. Stockings can be difficult to put on, especially for those with less hand function and a number of assistive devices can help with donning. Custom stockings may be required for severe cases of swelling or wrapping with therapeutic compression bandages until transition to standard compression stockings. It is important to ensure that the stockings are applied without wrinkles and to check skin daily after stocking use. Stocking is to be applied in the morning and removed when going to bed.

Medication

If edema cannot be controlled with conservative treatments, diuretic medication prescribed by a physician may be necessary to reduce body fluid and then transition the patient to more conservative methods. Diuretics should not be used for routine use, as they have side effects including lowering blood pressure and they can affect bladder management.

Gap: Footcare After SCI

Source of Evidence

Although ingrown toenails are cited in the Autonomic Dysreflexia literature as an aggravating stimulus there are no SCI-specific studies on more global foot care and its management after SCI. There are recommendations based however on footcare for individuals with diabetes drafted by the Canadian Association of Wound Care (CAWC – http://cawc.net/en/index.php/public/feet/) as well clinical consensus from SCI practitioners.

Recognizing Footcare Issues

Individuals with SCI have numerous issues that can arise on their feet that can lead to significant secondary complications if not addressed and prevented. These include: nail care and ingrown toenails, wounds, fungal infections, dermatitis and burns, and mechanical trauma.

Management

• Daily skin checks to ensure no open areas, no deep tissue trauma, and no fungal or dermatitis evident.
• Edema management including compression socks if indicated.
• Ensure proper fitting shoes including purchasing them at time of day when edema is at its greatest Increase skin checks on feet when shoes are new (every 2 hours).
• May need to purchase shoes 1 size larger for easier application – consider Velcro to fasten closed-toed shoes best to prevent trauma.
• Wear shoes in and outside the house (ambulatory or not).
• Inspect shoes for abnormalities and shake out before applying.
• Consultation of a podiatrist or foot care nurse to manage nails if unable to do independently.
• Change socks daily Do not smoke as this affects circulation.
• Dry feet well and between the toes Moisturize dry skin as needed.