Swelling of the Feet and Legs
By PALS Diane Huberty, CNRN
(reprinted by permission)
Swollen feet and legs are a common problem for
neuromuscular patients. Although it is probably impossible to prevent swelling
entirely because it is due to the lack of muscle action in our legs, it is very
important to do what we can to minimize it from the first. Left unaddressed, it
quickly becomes a vicious cycle of swelling leading to damage leading to
increased swelling. As a nurse, I knew that, but still had to learn it the hard
way! My legs are ghastly. They look fine when I am lying down, but the minute I
sit up they turn hideous shades of red and purple and blue and grey. If I am
not careful to prevent as much swelling as I can, they are swollen like
sausages by noon, miserably uncomfortable and absolutely painful by evening. It
is worse in hot weather and in cold weather they are impossible to warm up if
they get cold.
In order to understand how to minimize it, it is
important to understand why the swelling occurs, so let's begin there. (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 another load of oxygen. 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 surrounding
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 and more
likely to fail.
As
miserable as swollen legs are, things can get worse. . .
The most common complication of swollen feet is a
burning discomfort that can be downright painful. I haven't read a full
textbook explanation for this but my interpretation is that the excess fluid
that comes between the capillaries and cells deprives the tissues of an
adequate blood supply. The burning sensation is sort of the "needles
and pins" feeling we get from cutting off blood supply to an arm or leg --
but on a micro-level because it is primarily the skin layers that are affected,
not the deeper muscle tissue as when arteries are compressed. This doesn't
happen ordinarily -- people with good circulation in their legs can handle the
temperature changes much better because the microcirculation is not damaged and
functions properly to regulate temperature.
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 (A stroke - just what we
need - more paralysis and speech problems!) or to the lungs (A pulmonary
embolus. Painful, and can land you in intensive care on a ventilator if it
doesn't kill you outright). 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 more swollen or if the swelling doesn't go down
overnight as it usually does, and especially if the leg becomes painful. If you even suspect that you may have a clot
in one leg, DO NOT MASSAGE THE AREA! Elevate it and call your doctor. To reduce
the risk of blood clots, we also need to be sure we drink enough to stay well
hydrated.
Long term, the lousy circulation begins to affect
the skin of the legs and feet. It becomes fragile and heals very slowly when
injured. If the problem continues over many years, the skin becomes
yellow-brown in color. Even without injury open wounds called "stasis
ulcers" can appear. They are extremely hard to heal because the blood flow
to the skin is so poor.
Doctors
aren't very good about helping with swelling. The first thing they will say is
to put your legs up to minimize the swelling but they don't tell you how to do
that effectively. They will offer prescriptions for TED (elastic or compression)
hose (somewhat helpful) and "water pills (which should be used as a last
resort only).
The first thing to look at is the chairs you sit
in. A recliner may seem like the ideal
way to keep your feet up and swelling down but it is NOT! There are two big
problems with most recliners. First, the footrest section is made in such a way
that all the weight of your legs rests on the calves. That is really bad for
circulation. Second, putting your feet up - even way, way up - without
"unfolding" at the hips is very minimally helpful, possibly even
detrimental as that bend interferes with the already difficult job of moving
blood upward to your heart. Lift chairs are wonderful and most of them are
recliners, but if you spend most of your time in a recliner, I strongly
recommend that you bring the footrest up only when you lower
the backrest.
Whether you sit in a regular chair, recliner, or a
wheel chair, it must be properly fitted to you. You need to make sure that your
leg to floor/footrest distance is short enough that there is minimal pressure
at the back of the lower thigh and knee. Having your legs "dangle" is
a sure-fire way to cause swelling! Put
a box/platform under your feet (an old hard side suitcase worked great for me -
lightweight and had a handle) or raise your footrest an inch or so. The
objective is to make certain there is minimal pressure on the
back of your knees/thighs. If you have add a ROHO or other cushion you need to
adjust your platform/footrest upward to make up for the height of the cushion.
The best treatment for leg swelling that I have
found is something that I discovered entirely by accident: More time in bed.
When my husband was working, I spent about seven hours in bed at night and then
would lie back in my recliner for another two or three hours in the afternoon.
Even with that, my legs were swollen by noon, miserably uncomfortable by
evening and absolutely painful by bedtime. Last year when my husband retired, I
was able to go to bed at the usual time, listen to books on tape for an hour or
two, and then sleep late in the morning. Instead of spending 10 hours lying
with my feet up in two separate sessions, I began spending 10 hours or more in
bed all at one stretch. Within a matter of days after starting this routine, I
noticed that the swelling was minimal. Now I don't even have to lie down in the
afternoon in order to be comfortable in the evening. I don't know if this is
due to spending more time lying down at one stretch, spending all my lying down
time in a bed rather than a recliner, getting more sleep, or some combination
of the three. All I know is that in this has made an incredible difference for
me. Not only has it made my problems with swelling minimal, I feel better in
general. Now I simply stay in bed until
I really feel like I am ready to get up rather than trying to catch up with
naps. I seem to need about 10 hours of
sleep these days. Even though my
sleeping in is inconvenient at times, it is much easier for my caregivers if I
spend a longer stretch in bed rather than going back and forth, I prefer not
having to take time out to lie down in the middle of the afternoon, I am not
too tired and miserable to do anything in the evening, I sleep much better at
night since I don't nap during the day, and I have more energy and
stamina.
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! Even passive range of motion exercises help.
Keep cool. A few minutes of sitting in the summer
sun is all it takes to turn my feet into balloons. (Blood vessels dilate when
we are warm.) Simply keeping my legs in the shade makes a difference, but I have also been known to pour cold water
over my feet on really hot days when I need to be outside. Wet socks and tennis
shoes are still more comfortable than that miserable burning sensation of
swollen feet!
Sometimes
I also have problems with a burning sensation in my feet in bed at night. It
doesn't start until my feet began to warm up. This is very consistent with what
happens during the day if my feet get too warm (sitting near a heater or, in
the summertime, sitting with my legs and feet in the sun). It can get really
bad in the middle of the night if I have the electric blanket on and my feet
get really warm. That is a real nuisance because the rest of my body gets
really chilled and I can't move at all if I pile on extra blankets. So, in cold
weather I and up sleeping with the electric blanket on, but my feet sticking
out!
For some people, this burning pain becomes severe
and doesn't seem to be relieved by getting the swelling down. This might be the end result of long term or
severe swelling. Some people find that aspirin (not tylenol) helps. Do not take aspirin if you are on anticoagulants
(medications to thin the blood). If burning pain is felt when swelling has not
been a problem, discuss it with your neurologist.
Limiting salt intake used to be high on the list of
things to do to minimize swelling, and your doctor may suggest it, but the need
for that is questioned these days. I guess it is enough to say don't
over-indulge with salty foods.
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.
You can ask your doctor for a prescription for these stockings, but
unless you have strong hands and arms, you will need help getting them on.
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. With help from your doctor you may
be able to get your insurance to cover the cost of this equipment. It is not
complicated to use, but you must be very careful to make sure that it is not
rubbing anywhere and causing breakdown of the skin.
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 because many of us are borderline
dehydrated half the time anyway. (Another contributing factor for the
development of blood clots.) 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 cause of the edema -- 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 really
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 all the things described above should be
implemented first before diuretics are even considered.
Diane Huberty is a retired RN. She worked
general Med-Surg units, then 5 years in Critical Care where she began
specializing in Neuro and earned Neuro Certification (CNRN). Diane was diagnosed with ALS in 1985 at the
age of 37. When her hospital opened a Neuro Unit, she was selected for the
position of Neuroscience Educator. She
was able to continue working in that
position until 1995, when arm weakness and fatigue made it too difficult to
continue and she retired. Through the
internet, Diane communicates daily with other ALS patients and keeps up
on research, treatments and care issues. In addition to maintaining and posting
a set of ALS Frequently Asked Questions on the ALS newsgroup
(sci.med.diseases.als), she has her own ALS website
which focuses on nursing care rather than research. Diane can be contacted by email
at " liveletdie@att.net ".