feet / leg swelling

[Guest guest]

The following was written a couple of years ago by a CMTer who is no longer

in any support group as far as I know. It may be helpful for some of you.

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Swollen feet and legs are a common problem for neuromuscular patients. My

legs are ghastly too. They look fine when I am lying down, but the minute I

sit up they turn hideous shades of red and purple and gray. Some days they

get really swollen and look like sausages by bedtime. Blue-Footed Boobies,

the lot of us!

My nursing background taught me the physiology behind all this so I'll share

what I learned. (No quiz, I promise!)

The heart pumps blood through the arteries under high pressure. As the

arteries branch out into smaller arteries and then into tiny capillaries,

pressure decreases. Oxygen is removed from the blood in the capillaries and

then the " used " blood flows into veins for the trip back to the lungs for

re-oxygenation. Unfortunately, the pressure generated by the heartbeat has

been lost by then and the blood relies on simple back pressure to move back

up to the heart. This is aided by muscle activity - ordinary muscle movement

" squeezes " the veins and pushes the blood along. The veins have little

one-way valves all along the way that keep blood from draining backward as it

is pushed upwards.

When muscle movement is lost, it becomes much harder to get the blood back up

from the legs. It pools in the veins and causes them to get distended. Water

seeps from distended veins out into the tissue and your legs and feet swell

(edema). With repeated episodes of swelling, the little veins become damaged

- leaky - and water seeps into the tissues even more easily. At the same

time, the valves are collapsing under the heavy weight of all that blood that

is pooled on top of them. That damage to the valves is permanent. Without the

valves, the blood pools in the feet even worse than before and remaining

valves are under even more pressure.

A little scarier is that the lousy circulation allows the blood to pool and,

when not in motion, blood tends to start to clot. A blood clot (thrombus) can

form and not only further impede circulation, but break loose and travel to

the brain or lungs. (Big trouble!) Luckily, that doesn't seem to happen to us

as often as it seems like it should, but we need to let our doctor know

immediately if one leg suddenly seems much more swollen or if the swelling

doesn't go down overnight as it usually does, and especially if it becomes

painful.

Long term, the lousy circulation begins to affect the skin of the legs and

feet. It becomes fragile and heals very slowly when injured. Even without

injury " stasis ulcers " can appear - open wounds that just won't heal because

the blood flow to the skin is so poor. (It is my goal to be around long

enough to develop one of these! )

Treatments for swollen legs cannot " cure " them, they can only minimize and

slow the damage down.

Hospitals often use devices to improve blood flow to the feet of patients who

are going to be stuck in bed for a while in order to reduce the risk of blood

clots. TED (elastic or compression) stockings are by far the most common. By

simply squeezing the legs and feet a little, they help keep the veins from

getting distended. Hospitals also use types of " boots " that inflate and

deflate to help pump the blood along. One study apparently showed that simple

alternating pressure on the soles of the feet greatly improves flow, so some

brands of boots simply apply waves of pressure to the bottom of the foot.

One essential part of treatment is to lie down and elevate your legs above

the level of your heart at intervals during the day. It doesn't have to be

for long periods of time, 15 minutes or even 5, but it does have to be in a

reclining position. Putting your feet up on a footstool - even way, way up -

without " unfolding " at the hips is very minimally helpful as that bend

squeezes off blood flow too. And, yes, I know only too well how hard that

simple bit of preventive medicine can be to carry out. Even with push-button

recliner, I cannot elevate my feet that high without assistance and

assistance is not available most of the day. But lying as far back as

possible and elevating your feet as high as possible is better than nothing.

Another thing to look at is the chairs you sit in. Is your wheel chair

properly fitted to you or just an " off the rack " one? You need to make sure

that your leg to footrest distant is short enough that there is minimal

pressure at the back of the lower thigh and knee. Having your legs " dangle "

is sure-fire circulation problems. Try raising your foot rest an inch or so.

If you have added a wheelchair cushion since the footrest height was set, you

need to adjust it to make up for the height of the cushion.

I have found that my recliner made things worse instead of better. All the

weight of my legs was resting on the calves and that really cut off

circulation. I have added a strip of foam pillow across the foot rest right

under my ankles to take some of the weight off my calves and that has helped

considerably.

Another thing that helps is muscle activity. Granny's old rocking chair

served a real purpose beside putting babies to sleep! I find that on days

when I am most active (interpret that as days when I am frequently hauled in

and out of my chair and forced to stagger a few steps, whining all the way!)

the swelling is minimized. I guess I have some muscle left in my legs, even

though I sure can't feel 'em!

Limiting salt intake used to be high on the list of things to do to minimize

swelling, but the need for that is questioned these days. I guess it is

enough to say don't overindulge with salty foods.

If you complain about swollen ankles and feet to your doctor, odds are he

will whip out the old prescription pad and put you on diuretics. I have real

reservations about this simply because I am very much aware that many of us

are borderline dehydrated half the time anyway. It gets hard to reach a

drink, or hard to swallow, or it is simply too hard to get to the bathroom

(you men have it made!) so we don't drink as much as we should. Diuretics

cause your kidneys to remove more water from your blood stream. The " thicker "

blood is then able to " sponge up " more water on its travels through the body

so it does reduce the edema. It does nothing about the real problem of poor

blood flow however. Using diuretics for swollen legs is kind of like taking a

diuretic to lose weight - sure it works, but it doesn't solve the problem.

I certainly won't say diuretics should never be used -- if nothing else works

well enough to keep the swelling under control, they need to be used because

the swelling further damages the veins and valves and the situation just gets

worse. But the other things described above should be implemented first and

diuretics last.

To reduce the risk of blood clots, be sure you are well hydrated (another

reason not to use diuretics). If you even suspect that you may have a clot in

one leg, DO NOT massage the area! Elevate it and call your doctor. Hope all

that makes sense!