Compression therapy study has global implications

 

The results of a recently published study promises to change the way patients with leg infections and swelling are managed.

Cellulitis is a common and painful bacterial skin infection, contributing to about 130,000 emergency department presentations per year, with about 70,000 of those requiring admission to hospital.

These are startling statistics, says Elizabeth Webb, APAM, who three years ago initiated research to test whether compression therapy could prevent recurrent cellulitis of the leg.

In her world-first randomised trial, skilled lymphoedema therapists applied compression therapy on 41 of 84 patients with chronic oedema of the leg and recurrent cellulitis.

The practice resulted in a lower incidence of recurrence of cellulitis than conservative treatment, showing it to be an effective non-pharmaceutical intervention.

The prestigious New England Journal of Medicine has recently published her research work in the article ‘Compression therapy to prevent recurrent cellulitis of the leg’.

While Elizabeth is thrilled at the prospect of having her work widely read on a national and international level, providing cellulitis sufferers with an effective non- drug approach to treatment is what really excites her.

‘A lot of physios have worked on this project, and it’s great to share this news. We now know that in patients with chronic oedema and recurrent cellulitis compression therapy can reduce the risk of another leg infection by 77 per cent.

'This is more effective than any other treatment we know of, including antibiotics,’ she says.

‘Having the work published in the Journal will, hopefully, help us gain much quicker exposure to GPs, who could then educate their patients on the benefits of compression therapy and further involve more physiotherapists to translate this knowledge into practice.’

Elizabeth led the study with support of the lymphoedema physiotherapy team at Calvary Public Hospital Bruce, ACT. It forms the basis of her PhD studies at the University of Canberra.

‘Lots of patients who develop cellulitis end up in hospital and out of work for weeks,’ she says, ‘and of those, many would benefit from oedema management; but, unfortunately they are not always being referred to lymphoedema physiotherapists. Hopefully this will now change.

'On the back of this study, we really need to be educating GPs and hospital physicians to refer these patients on to us so that we can manage them effectively.’

Chronic oedema of the leg is a risk factor for cellulitis, and refers to swelling that persists for three months or longer.

While it has various and often mixed causes, the principal cause may be increased capillary filtration or failure of lymphatic drainage, which results from conditions such as lymphoedema, venous hypertension, immobility, obesity and heart failure.

Before this ground-breaking research, daily use of compression garments on the leg was being recommended to prevent cellulitis recurrence, but there was limited evidence from trials supporting its effectiveness.

Each participant in Elizabeth’s single-centre, nonblinded trial had chronic oedema of the leg and a history of two or more episodes of cellulitis in the same leg in the two years before referral to the trial.

Participants were referred to the trial by their GP or after attending hospital for treatment.

A total of 183 patients were screened, and 84 were enrolled from June 2017 through to February 2019. Forty-one participants were assigned to the compression group, and 43 to the control group.

At the time of a planned interim analysis, when 23 episodes of cellulitis had occurred, six participants (15 per cent) in the compression group and 17 (40 per cent) in the control group had had an episode of cellulitis and the trial was stopped for efficacy to ensure all patients could receive the compression bandaging.

A total of three participants (seven per cent) in the compression group and six (14 per cent) in the control group were hospitalised for cellulitis. Most quality-of-life outcomes did not differ between the two groups.

No adverse events occurred during the trial. The halt to the trial highlighted the effectiveness of the treatment.

‘We reduced hospitalisations by 50 per cent, and we also found that over 12 months, leg volume was reduced by approximately 250mls between the ankle and the knee.

'We’ve effectively shown that compression therapy reduces the risk of cellulitis by a magnitude of 77 per cent, which is larger than research evaluating the efficacy of antibiotics, which is really exciting.’

Her research has the potential to not only change people’s lives, but to provide a more coordinated approach for medical and allied health professionals in providing management and treatment of the underlying risk factors, as well as the infection.

This, in turn, has  the potential to minimise psychosocial impacts on patients and significantly reduce ongoing healthcare costs.

‘Chronic oedema, or lymphoedema, is a really, really common condition, but unfortunately, it’s massively underdiagnosed and undertreated because it’s not very well known.

'Management can make a significant impact on the quality of life for people and their families, and on healthcare costs.

'Compression therapy is wonderful because it not only prevents cellulitis, it minimises leg swelling, which reduces leg volume. So, for a lot of patients this will increase their level of comfort, help them move more easily, as well as improve their skin condition.’

Elizabeth studied physiotherapy at the University of Sydney, graduating in 2011. She initially planned to study medicine, but switched to physiotherapy.

It’s a decision she hasn’t regretted as the profession enables her to spend time with allied and medical health professionals in a supportive, collegial environment.

Her interest in lymphoedema came when completing her honours under the guidance of Professor Sharon Kilbreath and Dr Liz Dylke in 2011.

‘They really sparked my interest in lymphoedema. Later I found out Calvary Hospital had a specialist lymphoedema service that I quickly applied for.

'Once there, my amazing manager, Gemma Arnold, coached and encouraged me to really develop a love for lymphoedema.’

A Master of Public Health followed, leading on to the compression therapy research, which, with support from Associate Professor Dr Bernie Bisset, has turned into a PhD.

‘In terms of being able to do research, we’re very lucky as we have one of the largest lymphoedema services in Australia, managing about 900 patients per year, which made this research possible.

'And I’m really hoping that because The New England Journal of Medicine is so broadly read and trusted by doctors, they will actually read the report, take the findings on board and put them into practice.

'However, we also need our profession to advocate for this treatment to local doctors.’

Elizabeth’s future goals include completing a cost analysis on this recent project to determine if this therapy is cost-effective, and finishing her PhD studies.

However, she is taking a break from work for the next 12 months to spend time with her newborn.

‘I would really love to continue to promote awareness of chronic oedema, as I just love working with these patients.

'Because it’s a chronic condition, you get to know patients really well over a long period of time and form great therapeutic relationships, which is such a lovely part of the job.

‘What’s even better is that physiotherapists can now be very confident that compression therapy does prevent cellulitis in patients with chronic oedema and a history of recurrent cellulitis.

'The results of the study will seriously change the way that we manage patients with leg infections and swelling on a global level.’

>> Access Elizabeth’s research paper here.

 

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