Empower your career: Upskill In Edema Management

As a dedicated therapist, occupational therapist, or nurse, you understand the importance of continuously improving your skills and knowledge to provide the best care for your patients. One area of specialization that can significantly enhance your clinical practice is lymphedema and edema management.

By upskilling in this field, you can expand your expertise, improve patient outcomes, and advance your career. In this article, we will explore the benefits of lymphedema and edema management certification for therapists and provide valuable insights into its impact on patient care.​

What Does It Mean to Be Lymphedema Certified?

Lymphedema certification is a professional credential that signifies advanced training and expertise in the assessment, treatment, and management of lymphedema and edema. Achieving lymphedema certification demonstrates your commitment to providing specialized care to patients with lymphatic disorders, enabling you to offer evidence-based interventions and comprehensive treatment plans.

How Can Education and Skill in Managing Edema Help Your Career?

  1. Increased Opportunities: Obtaining lymphedema certification opens up new opportunities for career advancement and specialization. Employers and healthcare facilities often prioritize hiring certified therapists due to their advanced knowledge and skill set in managing lymphedema and edema. This certification can set you apart from other candidates and make you a valuable asset to any team.
  2. Expanded Patient Base: With the rise in the prevalence of lymphatic disorders, the demand for skilled therapists in this area is growing. By becoming certified, you position yourself to cater to a broader patient population, including those suffering from post-surgical swelling, cancer-related lymphedema, chronic venous insufficiency, and other conditions. This can significantly expand your patient base and enhance your professional reputation.
  3. Improved Referral Networks: Lymphedema and edema management certification can help you establish strong referral networks with physicians, surgeons, and other healthcare professionals. Your specialized expertise in managing lymphatic disorders will make you a trusted resource for colleagues seeking knowledgeable therapists for their patients’ needs.

Need some edema management resources for your clinic? Download these free ones here

How Can Including Edema Management Strategies Help Your Patient Care?

edema management

1. Enhanced Treatment Efficacy: By upskilling in lymphedema and edema management, you will gain a comprehensive understanding of the latest evidence-based techniques and modalities. This knowledge will enable you to develop tailored treatment plans that address the specific needs of your patients. Implementing effective edema management strategies can lead to improved treatment outcomes, reduced swelling, enhanced mobility, and increased patient satisfaction.

2. Holistic Patient Care: Lymphedema and edema management certification equips you with the skills to take a holistic approach to patient care. You will learn how to assess and address not only the physical symptoms but also the emotional and psychosocial aspects of living with lymphatic disorders. By providing comprehensive care, you can empower your patients to better manage their condition, improve their quality of life, and achieve optimal wellness.

If You Can’t Afford to Become Certified, What Options to Upskill Do You Have?

While obtaining formal certification is highly recommended, there are alternative options to upskill in lymphedema and edema management if cost is a barrier:

edema management

1. Workshops and Continuing Education: Attend workshops, seminars, and conferences focused on lymphedema and edema management. These educational events often provide valuable insights, hands-on training, and updates on the latest research and treatment approaches.

2. Online Resources: Take advantage of online resources, such as webinars, educational videos, and articles, which can offer valuable information on edema management techniques, assessment tools, and case studies.

3. Peer Collaboration: Engage in professional networking and collaborate with experienced therapists who specialize in lymphedema and edema management. Participate in peer mentorship programs and seek guidance from knowledgeable colleagues to enhance your skills and knowledge.

Support for Certified Therapists:

If you are already certified and seeking ongoing support, there are several resources- right here!-  available to you:

1. CEU offering: We here at ARC LOVE edema management! Our best selling course “Edema Management in In-Patient Rehabilitation” provides specialized training to enhance your clinical skills- and set up your own program.

2. Edema Management Resources: ARC Seminars also offers a collection of edema management resources for your clinic, including assessment tools, educational materials, and product recommendations – always updated with new findings! Check it out

3. Lymphedema Journal Club: Stay up-to-date with the latest research and advancements in lymphedema management by joining the Lymphedema Journal Club, a quarterly interdisciplinary meeting of the minds

4. Online Videos: Access informative videos on lymphedema and edema management techniques on platforms like YouTube. Videos like Lymphedema Management Techniques and Edema Management: Approaches and Strategies provide valuable insights and demonstrations of various treatment approaches.

As a therapist, occupational therapist, or nurse, upskilling in the field of lymphedema and edema management can have a profound impact on your clinical practice. By obtaining lymphedema certification or pursuing alternative avenues to enhance your skills, you can expand your career opportunities, improve patient care outcomes, and establish yourself as a trusted expert in managing lymphatic disorders.

Take the initiative to invest in your professional development and unlock the benefits that lymphedema and edema management certification can offer – it may be a second wind to your career!

Want to gain more skill in treating edema? Join us for the next ‘Edema Management in Inpatient Rehab LIVE class!

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Non-healing Wounds and how to Address them

Non-healing wounds can be a challenging aspect of patient care for nurses, physical therapists, and occupational therapists. These wounds can significantly impact a patient’s quality of life and require specialized strategies for effective healing. 

But what causes non-healing wounds, and how do we address them?

Here, we explore the underlying causes, characteristics, various strategies to assist in the healing of non-healing wounds. 

What Causes Wounds That Won’t Heal?

non-healing wound

Non-healing wounds can have multiple underlying causes, making a comprehensive assessment crucial. Here are some common factors that contribute to delayed wound healing:

  1. Poor Circulation: Reduced blood flow to the wound area can impede the delivery of oxygen and nutrients necessary for healing.
  2. Infection: Bacterial, viral, or fungal infections can compromise the body’s natural healing processes, leading to delayed wound healing.
  3. Chronic Diseases: Conditions such as diabetes, peripheral vascular disease, or autoimmune disorders can impair the body’s ability to heal wounds effectively.
  4. Nutritional Deficiencies: Inadequate intake of essential nutrients, especially protein, vitamins (A, C, and E), and minerals (zinc and iron), can hinder wound healing.

What Do You Call a Wound That Never Heals?

A wound that fails to heal over an extended period is often referred to as a chronic or non-healing wound. These wounds typically exhibit delayed or stalled healing progress despite appropriate interventions and time.

Signs of Unhealed Wounds:

Recognizing the signs of unhealed wounds is essential for prompt intervention and management. Some common indicators include:

  1. Persistent Redness: The wound bed remains red or inflamed beyond the expected healing timeframe.
  2. Excessive Drainage: Continued or increased wound exudate that fails to diminish over time may suggest impaired healing.
  3. Lack of Granulation Tissue: Absence or insufficient growth of granulation tissue, which is vital for wound healing, can be an indication of a non-healing wound.
  4. Increasing Wound Size: Wounds that continue to expand or fail to reduce in size despite appropriate care require further evaluation.

Download this free, 12-page wound care resource for your patients with diabetes!

How to Treat a Non-Healing Surgical Wound:

Addressing non-healing surgical wounds necessitates a comprehensive approach. Here are some strategies commonly employed by healthcare professionals:

  1. Wound Debridement: Debridement, the removal of dead or non-viable tissue, is crucial for promoting wound healing. It helps eliminate barriers to
  2. Advanced Dressings: Utilizing appropriate wound dressings, such as hydrogels, foams, or collagen dressings, can create an optimal healing environment by regulating moisture, promoting granulation tissue formation, and protecting against infection. Protecting the skin around where a wound is likely to occur is also key to in ongoing prevention.
  3. Negative Pressure Wound Therapy (NPWT): NPWT involves applying controlled suction to the wound, enhancing blood flow, reducing edema, and promoting healing by facilitating the removal of excess fluid and debris. 
  4. Offloading and Pressure Redistribution: In cases where pressure ulcers contribute to non-healing wounds, implementing offloading techniques, specialized cushions, or therapeutic support surfaces can relieve pressure and promote healing. 
  5. Including lymphatic drainage: When you see a large non-healing wound, lymphatic drainage may not be the first priority springing to mind. But including manual lymphatic drainage as well as compression can have a huge effect on a previously non-healing wound, and make all the difference to a wound that may have been resistant to other treatments for quite some time. If the wound bed is not receiving ‘healthy’ circulation, it is unlikely to be able to heal well. Lymphatic management will promote healthy circulation as well as removal of unhelpful molecules.
  6. UpskillingMaking sure that you own hands-on skills, wound care education and knowledge are up to date is crucial. Updates and changes to the current management of wound happen frequently, and as a nurse or physical/occupational therapist, it definitely behooves you to stay on top of current trends. Taking our Wound Care course is a great place to get started, as it focuses in on strategies that you will be able to implement, outside-the-box thinking, and ultimately practical treatment options for any therapist. See why it gets 5 stars- every time!

Healing non-healing wounds requires a multidimensional approach, considering factors like circulation, infection control, chronic diseases, and proper nutrition. By employing strategies such as debridement, advanced dressings, NPWT, and pressure redistribution, nurses and therapists can play a vital role in facilitating the healing process. Continual education and access to relevant resources further empower healthcare professionals to provide the best care possible for patients with non-healing wounds.

Remember, each patient is unique, and individualized treatment plans should be developed in collaboration with the interdisciplinary healthcare team. By staying updated with the latest advancements in wound care and applying evidence-based strategies, nurses and therapists can make a significant impact on improving the healing outcomes for their patients.

Want to upskill in Wound Care? Check out our incredibly popular and well-received course, A Comprehensive Guide to Wound Care: Tools for the Everyday Clinician, available as a live, virtual, or even self-paced offering for 7 Contact Hours/CEUs!

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Lymphedema Management And The Role Of The Physical Therapist

Lymphedema is a chronic condition that affects millions of people worldwide. As a physical therapist, you play a crucial role in managing this condition and improving the quality of life for your patients.

To provide the best care, it’s essential to understand the different stages of lymphedema and tailor your interventions accordingly. Here we will delve into the stages of lymphedema and discuss the vital role physical therapists play in each stage.

Lymphedema is usually categorised into three stages – and each stage can be approached with different clinical goals and objectives.

Stage 0: Preclinical or Latent Stage

The preclinical stage, also known as stage 0 lymphedema, is often overlooked but holds significant importance. During this stage, patients may not exhibit any visible swelling or overt symptoms, but they may experience subjective sensations such as heaviness, tingling, or tightness in the affected limb.

As a physical therapist, your role in this stage involves educating patients about risk reduction strategies, emphasizing skin care, promoting regular exercise, and providing self-management techniques. Early intervention and education can help prevent or delay the progression of lymphedema.

Download our (free!) Edema Management Ebook here! Resources to manage swelling in any setting are included!

Stage 1: Mild or Reversible Stage

Stage 1 lymphedema involves mild swelling that is reversible with appropriate treatment. Physical therapists play a critical role in managing this stage by implementing complete decongestive therapy (CDT). CDT comprises manual lymphatic drainage (MLD), compression therapy, exercise, and skin care.

MLD, a gentle massage technique, aids in rerouting lymph flow and reducing swelling. Physical therapists may also teach patients self-MLD techniques for daily maintenance. Additionally, prescribing appropriate compression garments and devising tailored exercise programs are integral components of your role in this stage.

Want to learn to Teach your patient Diaphragmatic Breathing? Check out this video!

Stage 2: Moderate or Spontaneously Irreversible Stage

In stage 2 lymphedema, patients experience a moderate increase in swelling that may not fully reduce with elevation or rest. This stage is characterized by the formation of fibrotic tissue, leading to irreversible changes in the affected limb.

As a physical therapist, your role is focused on managing and minimizing the progression of lymphedema-related complications. CDT remains a cornerstone of treatment, but you may need to incorporate advanced techniques such as multi-layered bandaging and pneumatic compression devices. Your expertise in manual techniques, scar management, and exercise prescription becomes crucial in this stage.

Stage 3: Severe or Lymphostatic Elephantiasis

Stage 3 lymphedema represents the most advanced and severe form of the condition. Patients in this stage experience significant swelling, skin changes, and potential functional impairments. As a physical therapist, your role involves implementing complex interventions to manage symptoms, improve lymphedema limb function, and enhance quality of life.

Customized compression garments, lymphatic massage, skin care, and exercises tailored to individual needs are essential components of therapy. Collaborating with other healthcare professionals, such as wound care specialists, may also be necessary to address concurrent complications.

Physical therapists play a pivotal role in the comprehensive management of lymphedema across its various stages. From early education and prevention strategies to advanced treatment modalities, their expertise is indispensable in improving patient outcomes and enhancing their overall well-being.

By understanding the different stages of lymphedema and tailoring interventions accordingly, you as a physical therapist can provide exceptional care and support to their patients, empowering them to lead fulfilling lives despite this chronic condition.

If you found this program development article helpful, you’ll love our popular and engaging seminar on the topic of Edema Management. Check it out and read more right here: Edema Management in In-patient Rehabilitation!

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The Value of Physical Therapy in Wound Care

Wound care is far more than just changing a dressing!  When dealing with wounds, there are many things to consider. 

It’s important to take note of how the wound formed in the first place, in order to prevent further wounds from developing.  It’s also very important to know what type of wound it is – as all wounds are not created equal!  You also want to take note of how the wound may be impacting the way the person is able to move around and function in their environment.  Once you know what you’re dealing with, you can develop a plan to treat it.   There are many different team members that can (and should!) be involved in the wound care process… one of them being Physical therapists!

If you are not sure where or how to start your wound care journey, this course is a must for you: A Comprehensive Guide to Wound Care: Tools for the Everyday Clinician

Let’s explore some of the ways a Physical Therapist can be an effective member of a wound care team. 


The best-case scenario is to stop the wound before it starts!  This is where persistent patient and caregiver education can make a huge difference.  There are many disease processes that put patients at higher risk for developing wounds, such as diabetes, chronic venous insufficiency, spinal cord injury, etc.  Each situation will be different from the next, but providing various tools and resources to these patients is essential.  Many times this will include footwear or positioning devices to provide protection and/or prevent high pressure on bony prominences. 

Direct and Indirect Wound Care:

There are also many ways that a Physical therapist can provide direct wound care or provide an adjunct treatment that would facilitate faster healing through increasing circulation, etc.  Here are some examples of how a physical therapist can affect changes in wounds:

  • Sharp Debridement – Sharp debridement is a component of physical therapy wound management involving the use of forceps, scissors or a scalpel to remove devitalized tissue, foreign material or debris from a wound bed.  Depending on the state you are practicing in, this may require extra training before putting it into practice. 
  • Pulsed lavage with suctionThis is a method of wound cleansing that allows for more control over the pressure of the irrigation used.  This allows for more bacteria to be removed as well as loose necrotic tissue and debris left on the wound bed.  Continued research is needed to identify the exact parameters (or psi) to use for each specific type of wound, but this is a great option for PTs to use in wound cleansing.
  • Electrical stimulation – High-voltage pulsed current (HVPC) can be used to increase capillary perfusion, and therefore increase oxygenation of the wound bed.  This will then encourage granulation and fibroblast activity and speed up wound healing.
  • Ultrasound – Physical therapists use therapeutic ultrasound to deliver mechanical vibrations of a high or low frequency to promote cellular healing.  Physical therapists frequently use therapeutic ultrasound to ease pain, improve circulation, and improve soft tissue mobility. In addition, using ultrasound can assist in wound and injury healing, pain relief, and the reduction of inflammation.
  • Laser – Laser therapy can help to create a more ideal environment for wound healing by promoting an highly oxygenated setting and helps bring more needed nutrition and white blood cells to the area to promote healing.
  • Ultraviolet light therapy – According to reports, ultraviolet therapy is a promising addition to treatment for chronic wounds infected with resistant bacteria because it kills bacteria and speeds up wound healing.  Psoriasis, atopic dermatitis, vitiligo, mycosis fungoides, and hand/feet eczema all benefit from ultraviolet therapy.  Despite the fact that ultraviolet therapy has been shown to be effective in the treatment of wounds and other skin conditions and that physical therapists play a significant role in its application, anecdotal evidence suggests that this treatment method is not commonly used in regular clinical practice.
  • Negative pressure wound therapy – A technique known as negative pressure wound therapy (NPWT) aids in wound healing by removing fluid and infection. The wound is covered with a special dressing (bandage) and a gentle vacuum pump is attached.
  • Lymphatic drainage and compression bandage techniques – In order for a wound to heal, it has to have a certain balance in its environment.  If too many “toxins” are present, the wound will take longer to heal.  This is where the lymphatic system comes in!  If there is edema present with the wound, we must clear the area of the stagnant lymphatic fluid in order for the “toxins” to be flushed out and the wound to get the nutrients to it that it needs. 

Manual lymphatic drainage (MLD) is a gentle, stretching massage that helps move lymphatic fluid out of swollen limbs by stretching the skin. It is not the same as a traditional massage. In order to facilitate the flow of lymphatic fluid, MLD focuses specifically on the lymph vessels. Your unaffected areas receive therapy first, allowing the fluid to “decongest” the area or move out of the affected area. MLD helps open the leftover working lymph gatherers and move protein and liquid into them, as well as to assist with accelerating lymph liquid course through the lymphatics.  A multi-layered compression bandage complex used in conjunction with manual lymphatic drainage techniques will further facilitate the movement of lymph out of the area of the wound, which will allow for the wound healing process to move forward.

  • Exercise In many instances, weakness and/or diminished mobility worsen wounds. An exercise program will be created by a physical therapist so that the person with a wound can move around their environment as safely as possible without risk of injury. Physical activity and exercise can sometimes speed up the healing process by improving circulation to the area and relieving pressure around the area through frequent repositioning.
  • Scar management – There are several techniques a Physical therapist can use to help manage scars after a wound has healed.  These include massage, myofascial release, cupping, stretching, taping, IASTM, and desensitization. 

How do I get started in wound care?

Don’t delay!  Wound care is already within your scope of practice as a Physical therapist!  You can start with the basics and go from there.  There are several training courses to become more skilled as you gain more confidence.  A Comprehensive Guide to Wound Care: Tools for the Everyday Clinician is a great one to start with.  This course will give you all the necessary knowledge and tools that you can use with your patients right now!  This course not only with give you the confidence to start treating wounds, but will also allow you to have more informed discussions with the team and become part of the decision making process for what to include in the plan of care.

How do I become a specialist in Wound Care?

If you’re looking to continue your wound care journey, there are several options out there for Physical therapists to become certified specialists.  Check these out and see what you would need to do to qualify and apply for these certifications.

Board-certified Wound Management Clinical Specialist

Certified Wound Therapist

Certified Wound Specialist

Want to upskill in Wound Care? Check out our incredibly popular and well-received course, A Comprehensive Guide to Wound Care: Tools for the Everyday Clinician, available as a live, virtual, or even self-paced offering for 7 Contact Hours/CEUs!

Like this article? Sign up to our mailing list for a weekly education right to your inbox! We promise to treat your email with the respect and love it deserves 🙂

The Best Shoes to use when Engaging in Lymphedema Therapy

When your patient has chronic edema or lymphedema, your therapy may need to include Complete Decongestive Treatment (CDT). CDT includes manual lymphatic drainage, compression, skin care, exercises, and patient education- and is the gold standard of treatment for those with swelling issues. It, however, can come with some complications- namely, what are the best shoes I can wear when I am getting treated for lymphedema?

Complete Decongestive Therapy is an essential treatment tool that all physical and occupational therapists should have in their arsenal- to read more about the benefits of CDT, check out some of our other edema-related articles!

When it comes to the practicalities of these techniques, however, one issue that patients and therapists can both bump on a lot is – “what are the best shoes can I wear when I am going through though the ‘compression stage’ of lymphedema treatment?”. Using short stretch bandages and foam as a part of your multilayered compression wrap is widely accepted to be the best way to treat fibrosis, edema, and get great results- but it can make the foot bulkier and thus impossible to get into previously used shoes. So, what to do?

Grab some edema management resources for your clinic right here!

Well, firstly- assure your patient that using short stretch bandages and foam is likely to be a relatively short-term part of their treatment. The overarching goal usually is to get the person into a compression garment that they can use long-term, which are far less bulky. Using adjustable bandages is essential for the initial phase of treatment, as the persons limb may be decongesting rapidly, as well as requiring an increased level of compression. Once the limbs have decongested to the stage where a garment can be used, they are often able to return to the footwear they were using previously. In the meantime, I suggest to my patient to get some larger, adjustable shoes that they can use during this phase pf treatment. Depending on the physical status and lifestyle demands, the person may even want more than one pair of shoes they can use- which can increase costs. Therefore, I’m including here some of the favorite shoes that I have personal experience with, don’t break the bank, and that I recommend to my patients, as well as the pros and cons of each!  

1.Darco Body Armor Cast shoe

You may already be familiar with the phrase Darco shoe, which has been synonymous with a ‘cast shoe’ in medical circles. The old style of cast shoe was a flat base with straps- and essentially merely acted to save the base of the foot or cast from contact with the floor. These certainly didn’t do much for walking or support!

This new style of Darco shoe is far better, as it offers a lot of structure and support, as well as being adjustable to the size of the foot within the bandages. These have been among the best shoes our patients with lymphedema have used. I also like that this shoe has a rubberized sole for walking outdoors, and that you can order them in singular, which can work well for your patient who has unilateral edema. Right now, this shoe can be ordered for $25.99 on Amazon, or $20 on the Walmart website.  

2.Top adjustable slipper

best shoes lymphedemaThese slippers are clearly very appropriate for a bandaged foot, as they have a deep, top-sided Velcro opening that accommodates the bandages and adjusts as the bandages flattens and the foot decongests. This shoe has been reported to be very comfortable by all he patients I have had that have used it- where it comes short is on the weather- accessibility, as well as the aesthetic (depending on the age range and preferences of your client).

If your client wants to have an indoor and an outdoor shoe, this is definitely a good choice for indoor shoe, to keep the bandages clean and keep your client from slipping. I would advise a client to order these in a half size up. Right now, these slippers run $22 on Amazon.  

3.Extra wide Velcro sneaker

best shoes lymphedemaFor indoor/outdoor use, these wide sneakers are a good option, especially for your more active patients who will be covering a lot of ground, and need something supportive. These shoes have been a popular choice amongst my active clients, as they can be ordered in one size up and will accommodate the bandages well. There are several color options also, which is important- your client should feel engaged in this process as much as possible to have a sense of ownership over their wellness journey.

The main drawback to this shoe is that, although they accommodate a good amount, they are somewhat less spacious than an option like the DARCO shoe. If this is the shoe that your client selects, you may want to adjust the thickness of your bandage and use the inherent compression of the shoe to help maintain the ideal pressure level on the foot. This shoe is also far better if you are ordering shoes in winter or your live in a wetter part of the world! Currently, $39.98 on Amazon.  

4.Diabetic shoes

best shoes lymphedemaDiabetic shoes can be a helpful corner of the market to explore, as they typically prioritize the shoe’s ability to expand. They should also have soft material and no rough inner edges that can injure the foot (or, for our purposes, snag on the bandages). There are often a range of options to choose from, including open toe, sandal, closed, etc. When looking at diabetic shoe options for your client, however, make sure that they are adjustable enough to be able to accommodate a bulky bandage on one or both sides. If your person has unilateral edema, they should still be able to wear both shoes.

The main drawback with these shoes is that they are a bit pricier than the other options explored here. However, these may be the best shoes that your patient with lymphedema will wear even beyond the stage of treatment- which may not be able to be said for an item such as the Darco shoe! Have a look at these diabetic shoes- currently $58 on Amazon.  

Working with a client with chronic edema can be a challenge, and any support and advice we can offer to make their lives easier and eliminate decision fatigue can often be very well received. I would recommend noting the best shoes that work well for your current clients with lymphedema, and keeping a list of options that they may want to consider, if the current situation is not working!

If you are interested in learning more practical tips and techniques to help manage and treat chronic swelling, be sure to check out our course,  Edema Management in In-Patient Rehab for applicable advice from a seasoned clinical problem-solver!

Interested in more clinical tips, articles, and resources for your practice? Sign up for our bi-weekly mailing list below! We promise to treat your inbox with the respect and love it deserves 🙂

6 Common Skin Infections you might see with Chronic Edema

Chronic edema and skin infections go hand-in-hand. Chronic, un-resolving edema may have many causes- including, but not limited to dependency/immobility, Chronic vascular insufficiency, diabetes, CVA, lymphedema, renal or cardiac disease, and so on. Given the prevalence of these conditions amongst our patients, it goes without saying that we encounter clients with chronic edema… a lot!

Treating swelling is an important part of the plan of care, and cannot be overlooked for a patient under our care. However, and area that, as clinicians, we should also be keenly aware of- are the skin infections that this client is much more likely to encounter as a result of their chronic edema.

Want to upskill your practice in treating and managing chronic edema? Check this out!

When working with a patient with chronic swelling, we should be sure to educate them about various infections that they may have a high risk of developing. This way, the client will be alert to potential signs of skin issues and seek medical treatment/pause their edema management program.

So, first- why is a person with chronic edema more likely to develop various skin infections? To answer this, we have to look at the processes involved in chronic swelling. Swelling often initially develops as an inflammatory response to an insult or trauma- and in a functional system, the lymphatics will kick into gear to move this fluid, returning it back into the lymphatic system for cleansing and eventually the circulatory system where it is eliminated naturally. 

The lymphatic system also has a vital role in fighting disease and infection, through the movement and monitoring of lymph fluid. When this system is overwhelmed (by chronic edema) or impaired, it is not effective in countering disease. This again leads to a predisposition to developing skin infections.  

If, however, the fluid remains in the tissues (lymphostasis), it can cause complicated skin issues. This is in large part owing to the content of that lymphatic fluid. The purpose of the lymphatic fluid is to transport various molecules from the tissues, including protein, fatty acids, cells and particles, bacteria, fungal/dirt and dust spores, cancer cells and other inflammatory substances, and any other cells that may require cleansing or transport out of tissues for a healthy system.  

Confusingly, the presence of edema in the tissues (lymphatic congestion) can often present as reddened/darker skin, with pain, heat, and swelling. This can make it trickier to parse apart actual infection from congestion. Congestion requires edema management, whereas infection requires medical attention as well as ongoing skin and swelling treatments.

Have a look at these 4 characteristic skin changes that can occur with chronic swelling!

As a result of this lymph fluid stagnating in the interstitial spaces and tissues of peripheries, skin infections may develop in response to the inflammatory properties of the lymph and the molecules with it.

So what skin infections are you likely to encounter when working with a person with chronic edema? Let’s take a look at the 7 most common skin infections you should know about, and be educating your patients/caregivers about as well!


The most common of the skin infections that affect those with chronic edema and lymphedema is cellulitis. Cellulitis is a bacterial infection, which can either enter through a break in the dermis or through an area of inflamed tissue. Many people with chronic edema or lymphedema may experience this skin infection as a recurring condition, that can arise when their limb is particularly congested or swollen.cellulitis skin infections edema

Signs of cellulitis includes: a feeling of general malaise, fever, pain, nausea/vomiting; a red or purplish, painful, and swollen rash in the affected region, which may spread if left untreated. It is important to reassure your patient that this infection in non-contagious, which may be a distressing thought to them.

Treatment of cellulitis is urgent- left unattended, it has the capability to spread further into the skin and tissues, cause serious illness, and further impair the lymphatic system in the region, which will lead to long term swelling (and in turn, a higher risk for future cellulitis). We can see now why cellulitis can recur so frequently in those with chronic edema.

The borders of cellulitis are diffuse and can reach into lower layers of skin and tissue than other infections. It may also spread along tendons and muscles.

Cellulitis requires immediate antibiotic administration to heal. As a clinician you should advise your patient to demarcate the edges of the rash, and be able to report as to whether it has spread (and how quickly). Compression can also help to prevent further swelling, help the infection clear more quickly, and reduce pain- Although, if the person is participating in an edema management program involving the use of manual lymphatic drainage.

For more information about the diagnosis and treatment of cellulitis in those with chronic edema, read the British Lymphology Society Consensus Document on Cellulitis.  


Also a common skin infection affecting those with chronic swelling, erysipelas affects the superficial layer of skin. It is a bacterial infection, similar to cellulitis- however erysipelas affects the skin nearer to the surface, whereas cellulitis often involved deeper tissues and structures. Erysipelas will present as a fiery, red rash, with clearly delineated (sometimes referred to as “map-like” borders).

Erysipelas bacteria may also enter through a break in the skin, such as an abrasion, insect bit, ulcer, or burn. Signs of erysipelas are a raised, bright red (not dark) rash, with clear and sharp borders. It can spread if left untreated, and as before, can become a recurring condition for a client already predisposed to infection.

Erysipelas is treated with antibiotics, either oral or IV (depending on the severity of the condition). Treating the edema through elevation, cold packs, and compression will also help with clearing the infection.  


Lymphangitis, an inflammation of the lymphatic system and channels. Infected lymph fluid travelling through the lymph vessels is the cause of lymphangitis, and also its defining characteristic.

An infection enters the lymphatic channel through a wound or skin break- commonly an insect bite, or a large abscess that is facilitating an inflow of bacteria into the lymphatic system. Chronic lymphangitis may also occur as a result of recurrent acute bacterial lymphangitis infections.

Lymphangitis presents as a red streak or several red streaks spanning from the site of open skin, which ay be warm, are soft and not raised, tender, and swelling.  The person with lymphangitis may feel feverish/flu-y, malaise, elevated pulse, and sometimes enlarged lymph nodes.

Antibiotics are used to treat lymphangitis, and the person should be educated to monitor for worsening swelling after the course of the antibiotics, as the lymphatic system may be impacted and at risk for future lymphedema.  

Grab these Free Edema Resources for your clinic!


Folliculitis is an infection and or irritation of the hair follicle. Damaged follicles may the site of a bacterial infection, complicating the folliculitis further. It has been linked in those with chronic edema to Intermittent Pneumatic Compression, lack of skin care, use of hot tubs, or shaving of curly hairs and subsequent ingrown hairs.

Though not excessively major as an infection, folliculitis has the possibility to develop into a more serious condition, especially if affecting a person with lymphedema/chronic swelling. Folliculitis usually will present as tiny red or white bumps around the hair follicle, which can become pustulus, itchy, and painful.

This condition can be prevented in those with chronic edema by avoiding tight clothes; not shaving arms/legs, or shaving with care; meticulous skin care and use of barrier cream; avoiding hot tubs and heated pools.  

Fungal infections

fungal skin infectionFungal infections can occur commonly in Stage 2 and Stage 3 lymphedema. In chronic edema, skin may lose its architecture and skin folds can develop- which are dark, moist breeding grounds for fungal growth. Infections may also pop up on the skin as a result of skin conditions such as hyperkeratosis or papillomatosis, which can hold moisture and can lead to fungal infection.

As people with chronic edema and lymphedema may have difficulty with adequate washing and drying of their feet and toes, fungal infections may set in here also. These infections are highly contagious and can be transferred by infected footwear, socks, and liners.

Signs and symptoms of fungal infections include irritation, scaly rash, greenish discoloration, redness and itchiness, a distinctive odor, and blistering.

Prevention of fungal infections are the best treatment, as with most infections. Meticulous skin hygiene, towel drying, use of anti-fungal sprays and powders can help to prevent fungal infections from setting in and occurring. If an infection has set in, a physician must be consulted, and medicated creams may be prescribed to treat the infection.  

Contact dermatitis

dermatitis skin infection edemaContact dermatitis is an infection that can occur as an allergic reaction to a foreign or irritating substance. In people with chronic edema, it can occur as a reaction to bandaging, use of pumps, or other irritants.

It presents as itchy, red, swollen, inflamed skin, which may feel as though its burning or tender.  The skin can become very dry, which may lead to cracking or tightness and even blistering.

Treatment for contact dermatitis, especially for those getting treatment for lymphedema, it is beneficial to use barrier lotions and creams between dressings and bandages; anti itch creams; identification of the irritant and avoiding of it when possible; steroid creams and possibly oral medications.  


Skin infections and issues are to be expected when working with clients who have chronic edema, and as clinicians it is imperative to include education about this when we work with out clients with chronic edema.

This is a topic that I routinely address several times to make sure that the person is aware of varying signs and symptoms to look for, when to seek medical advice and how to increase comfort at home, and- importantly- how to avoid the development of these common skin infections in the first place, if possible.

Want to learn more about types of swelling, assessment, creating a plan of care, and providing effective management? Check out our ever popular course, Edema Management in Inpatient Rehab for a comprehensive, practical information. You are going to love the hands-on, evidence based techniques that you can use to greatly improve your patient outcomes!


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Occupational Therapy and Diabetes- check out these 5 uncommon goals!

Occupational therapy and diabetes… are there some overlooked opportunities?

As an OT who spends much of her clinical career in an inpatient rehab setting, or treating lymphedema outpatient- I see a LOT of people with diabetes! Diabetes Mellitus is a pervasive issue, affecting 1 in 10 people in America, and leading to a host of unpleasant health complications. Have you ever wondered if your occupational therapy role could be less compensatory and more focused when it comes to setting goals and working with your patient with Diabetes? Here, I’m going to focus on some of the essential ways an OT can be instrumental in treating a person who has DM in a holistic and practical way.

Re-thinking Diabetes

occupational therapy diabetes

Firstly- you may think you don’t need to know any more about diabetes- what it is and who it affects. Older people who have sugar issues, right? Well, perhaps surprisingly, DM can come in more than two forms.

A proposed reclassification system from a researchers in Finland and Sweden, in 2018, broke up Diabetes into 5 sub groups, instead of the usual Type 1 and Type 2. Why do this? It became clear that by dividing Diabetes into these subgroups, correlations between each group and increased risk of developing certain complications became clear. Of course- it clearly follows that by knowing why the Diabetes developed that future health impairments would be easier to predict.

Yes- by defining the type, we can now identify who is at what risk of developing differing complications- such as amputation, kidney damage, retinopathy, and cardiovascular diseases.

These ‘types’ of diabetes were:

Group 1: Severe autoimmune diabetes (SAID) –   Corresponds to Type 1 diabetes and latent autoimmune diabetes in adults (LADA) and is characterized by onset at a young age, poor metabolic control, impaired insulin production and the presence of GADA antibodies
Group 2: Severe insulin-deficient diabetes (SIDD) –   Includes individuals with high HbA1C, impaired insulin secretion and moderate insulin resistance. This group had the highest incidence of retinopathy
Group 3: Severe insulin-resistant diabetes (SIRD) –   Characterized by obesity and severe insulin resistance. This group had the highest incidence of kidney damage
Group 4: Mild obesity-related diabetes (MOD) –   Includes obese patients who fall ill at a relatively young age
Group 5: Mild age-related diabetes (MARD) –   This is the largest group and consists of the most elderly patients

As healthcare practitioners, this brings us closer to providing a patient-specific plan of care, as opposed to the same treatment to every person with diabetes. In occupational therapy, this drives us even further to educate patients about their increased risk for certain outcomes, teach them how to monitor their health and what ‘red flags’ to be alerted to, given their specific sub-classification of Diabetes.

How can occupational therapy be most effective when working with people with diabetes?

Occupational therapists can be key practitioners with people with diabetes over several domains of function. When a client with diabetes presents into a setting like hospital and inpatient rehab, OTs are *sometimes* reduced to mostly teaching compensatory methods- such as strength and endurance building, and education about doing what the dietician tells them to. But what if there were more specific, and less common goals that we could be focusing on?

Let’s go through and examine some Occupational Therapy-specific goals that can be set when working with diabetes- and how to meet them!

  1. Health awareness and Education

OT uncommon goal? “independently use a tracking and planning device to manage a healthy diet and exercise program.”


Occupational therapists are uniquely positioned to help people examine their lifestyles and the intersection between the person, environment, and their occupation. Often, lifestyle adaptation and modification must occur to ensure that healthy choices are being made to ensure ongoing wellness- and who better to evaluate the ability to modify the environment than OTs!

Helping your patient examine their current roles, routines and habits is the first step in the self-monitoring and awareness your client will need to cultivate. If your client needs to change their diets and exercise habits, you can help them track their food intake- where, what and when they are eating, how their mood and environmental triggers may be hindering their efforts, and how to modify these external cues to create a more sustainably health-focused lifestyle.

As an OT, you can also help you patient with the technological skills they may need to use a smartphone app (if they use a device). A great list of some apps that are free and easy to use can be found- right here.

Self-tracking is all well and good, but for lasting success, planning ahead is also crucial! Empower your client to plan out meals and snacks, monitor their own insulin levels, and engage in an easy to achieve and sustainable exercise program- however that looks for your client.

2. Community integration/Socialization

OT uncommon goal? “Engage in a social activity based around food or exercise once per week in a healthful manner”

Socialization and being part of a community is an important aspect of holistic treatment. If you teach your client to manage their insulin, prepare safe meals and complete a HEP at home, they will be safe for a while- but it isn’t sustainable! Social isolation is a major problem that can have its own health risks.

Therefore, incorporating a community integration goal from the get go, that addresses making healthful choices in a restaurant (such as looking the menu up ahead of time, or having a few key items to order), as well as linking exercise to a social activity (such as a walking program) may be a powerful means of creating an atmosphere of motivation and independence for your client. After all, doing things together is way more fun that going it alone!

3. Leisure

OT uncommon goal? “Make a diabetic friendly dessert once a week” or “join a diabetic-friendly exercise group”

occupational therapy diabetes

Leisure goals can often be more satisfying to work on than, say, a BADL goal! Drilling down on your patients interests can be a way of accessing a more playful way of looking at, and meeting, their overarching health goals. Does your client love to cook/bake? Help them look up diabetic friendly recipes that can help scratch that itch (think- low sugar ice cream, almond butter cookies, or anything from this list). If your person has shown that they can track their carbs and understand balance, then they can still have fun with food!

Diabetic-friendly exercise groups can be a great resource for fun, making connections and learning more about the condition (and how to handle it in an ongoing way). Help your client look into local groups, or even online support groups that they can lean into to make their exercise program more enjoyable and east to integrate into their lives. 

If an exercise group specific to diabetes is not available, then help the person find an exercise/movement output that is meaningful to them! This may be empowering them to find a walking partner, a swimming class, or another activity such as gardening that will help them to move their body in an enjoyable way.

4. Basic ADL goals

OT Uncommon goal: “Independently manage self-care of lower legs”

This goal, as the preceding ones, can have many subcomponents. As clients with Diabetes are at high risk for Peripheral Artery Disease and Neuropathy, the Occupational therapist can teach the client to monitor for, or treat, the symptoms that they may be at risk for. This goal may seem self explanatory, but all too often the foot care component of diabetic management can be vague, non sepcifc, or left up to the nurse/podaotrust to complete. OTs have a great oportyunitie at this pont to teach a client how to complete their own self management, what red flags to be midful of, and how to modify their current routine to include this step.

To download a self check sheet, and other helpful resources- get our FREE ‘Ultimate Guide to the management of the Diabetic Foot

Neuropathy is mot commonly associated with the feet, but can also affect the distal upper extremities.

5. Foster a sense of empowerment and control

OT uncommon goal: “Use active and passive reinforcements to facilitate an environment of success and control in order to boost self-efficacy and esteem.”

The person who has contracted Diabetes may be feeling overwhelmed, disappointed, out of control, or even grieving for a former “way of life” wherein they felt well, had more self-regard and less restrictions. A disease of diabetes, I think we could all agree- is very much a condition of “cannot’s”- “you can’t eat that” “you must do this” “you can’t skip this medication, or this exercise, or essential step”. I am in no way advocating a romantic, rose-tinted view of this condition- it is serious, and can lead to even more serious complications if treated incorrectly. However, I strongly believe that as OTs, we take a holistic and person-centered approach to everything we do. Part of this may be heading off issues such as a flagging self-image, a sense of powerlessness or even depression, before they occur (or preventing them from getting worse!).

Use of techniques such as temptation bundling (doing one favorite activity with a less preferred one), such as listening to music when planning out your weekly meals; or positive, specific affirmations left as reminders in places people can see (examples from this list include “I create good health by talking about and thinking about my wellness.” and “I most love the parts of me that need love the most right now.”

As with many different aspects in occupational therapy, thinking outside the box can make a huge difference in the lives of our patients with diabetes. By focusing on ‘uncommon’ goals such as these, we may transition away from more compensatory strategies and into a more empowering and holistic space.

If you want to learn more about wounds and wound management, have a look at our LIVE or SELF-PACED course, A Comprehensive Guide to Wound Care: Tools for the Everyday Clinician! This course offers 7 Cont-ed units, practical downloadable tools and resources, and is taught by an expert wound care specialist who makes the education accessible to everyone. Check it out!

Like this article? Sign up to our mailing list for a weekly education right to your inbox! We promise to treat your email with the respect and love it deserves 🙂

Edema Management- Set up your own program and maximize your results!

Edema management. It is not something that you can expect at every hospital… inpatient rehab… or even outpatient facility. Yet, I doubt there are many clinicians who wouldn’t agree- this is a big issue for our patients!

Edema is one of the most chronically underdressed issues, particularly in rehab. The reasons for this are many! It can be masked by other issues, such as medical fragility; it can hide in plain sight, for those who have had slowly worsening chronic swelling; or it can simply be written off as ‘not my area’, by therapists, nurses, and physicians. And a dedicated edema management program? Usually nowhere to be found!

This combination adds to the problem of edema. Under-recognized as an issue, it often is left to slowly progress over time, adding in a host of complicating factors along the way. Untreated edema will contribute to a lack of mobility; a higher risk for skin infections and breakdown; decreased independence and ability to engage in the community, and more. In fact, addressing edema can be incredibly helpful! Here, we can prevent our clients from entering this ‘vicious cycle’ of progressive disability and impairment.

And yet- it isn’t! But maybe, that should change.

edema management program set up

Many in-patient rehabilitation facilities have dedicated programs for the wellness of their clients; such as brain injury/stroke/disease-specific care/palliative. These specialized services empower the clinicians and provide resources to the clients to have a more successful outcome. A specialized edema management program, however, are less commonplace – even though edema is a debilitating issue for many patients.

Edema can occur from an orthopedic injury, be neurological in nature, or even congenital. Patients who present to inpatient rehab post-surgery, CVA, or trauma, are likely to have issues with swelling. A process wherein that edema is identified, addressed as part of the plan of care, and continued follow up support given, results in far better outcomes for the patient and carer.

Setting up any type of program is intimidating- and an edema management program is no different. Let’s have a look at the reasons we should be advocating for this service, and how you can be instrumental in setting up this service in-house!

So why should we include edema management in the plan of care?

Firstly, the clinical reasons:

Mobility. The person is clearly more likely to be able to move around, walk for longer, and transfer in and out of bed if they are not struggling with heavy and edematous limbs. Stiffness and discomfort experienced with edematous limbs, also makes it more difficult for our patients to move around. They may be discouraged from ambulation by how strenuous they may find walking on heavy and stiff limbs.

This, naturally, does not help with their goals in rehab. It also impairs their chronic edema issues, and will compound upon the lack of circulation and muscle strength. In a nutshell: Swelling -> less walking -> more swelling!!

Related to this point- treating the person’s swelling is going to improve their skin integrity, aid with wound healing, and decrease the number of infections that they contract. Chronic edema is known to be a cause of cellulitis and erysipelas, both of which can continue to recur if the swelling is untreated. Wounds do not heal as quickly and as well as they might when the circulation around the wound is impaired. Additionally, stagnating lymphatic fluid leads to a cascade of unusual skin conditions, predisposing your client to skin breakdown and infections.

Download our limb girth measurement and tracking forms right here!

Footwear considerations are also key. A person with chronic and worsening edema is likely to have difficulties finding and maintaining proper footwear. This has a functional impact on their community involvement, and leave them at risk for skin breakdown and injury. Our patients should be able to don their shoes to be an active part of their community and to protect their feet- but many people with undertreated edema resort to wearing cast shoes or some other suboptimal option for community engagement. A common goal in inpatient rehab (for both OT and PT) is applying footwear/walking in shoes.

Now: the non-clinical reasons!

Aside from the clinical reasons to treat edema (of which we have so many!), there are also a host of administrative reasons to begin to address this issue. We all are working in a system, which we should strive to make as efficient and fair as possible, with best outcomes. Providing sub-standard care is unethical, AND inefficient!

From an administrative point of view- first in line is the reduction of re-admissions. We are sure to have fewer re-admissions and a higher quality of health if the patient is at a lesser risk of infections with improved skin integrity.  It is also important to note that chronic edema has a progressive nature and will not just “go away by itself” if ignored. Thus, it is important to address it early on in their rehab stay, and make sure our patients are aware of the warning signs.

Additionally- it will set you and your facility apart from other places. The lack of knowledge of edema and the means to treat it in the healthcare is astounding! As clinicians, we are in a fantastic position to advocate for and educate our patients (and ourselves!), to prevent the continual worsening of edema. As we know it can lead to permanent disability, we should be educating healthcare workers all around us to recognize that this is not a transient symptom.

Patient satisfaction is, of course, hand-in-glove in addressing the areas mentioned here! Your patients are going to be so appreciative of the attention given to an issue that may have previously been completely unaddressed, and the more positive outcomes that will arrive with the treatment. Anecdotally, I have found that my patients are so grateful to be heard and treated for this condition, saying things like “I didn’t know I could do anything for this” “No one was ever listening to me about this” and “I can’t believe how much better I feel”.

Lastly, and importantly when it comes to getting the resources and support of your administration, is the marketability of a program like this. Referring doctors, referring facilities, and liaisons will be able to advertise and refer appropriate patients when there are the systems to address the areas they need.

Right! I’m convinced. But where do I start?

First- you should begin by up-skilling in the area of edema management.

Getting some practical skills that you will need in the area of edema management will be crucial in setting up a successful program- this is, after all, a clinical intervention- and you should have the clinical knowhow to support the program. There are several options to upskill- once of which is to become a certified lymphedema therapist (CLT). Becoming a CLT will provide you with a lot of clinical skills and background, intensive practice in manual drainage techniques and compression bandaging. If your facility is investing in its staff, in terms of continuous professional development and program set-up, they may pay for, or reimburse, your registration fees.

Of course, getting the certification is not mandatory for treating these issues. Edema treatment is well within the scope of Physical and Occupational Therapists and nurses! Check out Edema Management in In-Patient Rehabilitation for a comprehensive seminar that focuses specifically on how to incorporate these skills into your practice.

Second- do your assessment of need.

Do an audit, a chart review, or even a straw poll of the patients that you and your colleagues are currently seeing. Would any of them benefit from an program such as this one being in house? Do they have swelling, pain, skin issues, wounds that could be treated if an edema management program was set up? I have found, when working in in-patient rehab, that 70-80% of my patients would benefit to some degree. Swelling, skin issues, and high risk conditions such as diabetes will all be appropriate for preventative care, if not treatment.

Gaining this information will strengthen the need for your program, and get extra support from your colleagues and administrators. It will also provide a baseline that you can point to, of people who need services that are not provided.

Thirdly- Educate your staff and colleagues.

Educating your team as to what you wish to add is crucial. Change can be challenging, as especially with a condition as poorly understood as edema. By including your therapy, nursing, and admin team from the start- it can be tackled together! Educate your team about: the misconceptions of edema; the people who will be appropriate for this program; and what interventions your program will include. Explain the different bandage materials that you will be using, so that floor staff will have a heads up! You will want to clearly delineate what is expected and what will be changing, and how you can be contacted for further insights or if there are any issues.

If possible, try to assemble a sub team that can help set up your program, handle issues, and help you educate. Include wound care, nursing, RNT, PT, OT and anyone else you think would be a great advocate!

Fourthly- set up your program and examine what you need.

edema management program development with ARC seminars

In order to begin your program, you will require supplies, resources, assessment tools, and informational packets. I always recommend that people run a smaller, easy-to-manage pilot group to begin with- 10 patients, who all have LE needs, for example. Prepare the order for supplies, the HEPs and plans, and any other tools you need for this group. Note your documentation and admin requirements. Make sure you are using subjective and objective outcome measures to track their progress, and take photographs as much as is possible!

It may be worth exporting their results onto a chart, or writing up a comprehensive report. This way, you can track their results and figure out what worked best. Pointing to their outcomes will also provide support for your program! If you need further supplies or more expensive equipment in the future; having this data will be invaluable.

Read this article to learn how to boost patient compliance with edema management!

Setting up an Edema Management Program will not be easy- but I guarantee, it will change your practice forever! This under-recognized and mismanaged condition only complicates the lives of our patients. Having a dedicated service will maximize your outcomes! No matter where you work- you’ll see the need.

If you found this program development article helpful, you’ll love our popular and engaging seminar on the topic of Edema Management. Check it out and read more right here: Edema Management in In-patient Rehabilitation!

Interested in more clinical tips, articles, and resources for your practice? Sign up for our bi-weekly mailing list below! We promise to treat your inbox with the respect and love it deserves 🙂

How to Improve Diabetic Neuropathy and Foot Ulcers

The prevalence of diabetes continues to increase in the US (and worldwide) each year.  Of all the complications that can arise, diabetic neuropathy is the most common – present in approximately 50% of people diagnosed.  Diabetic Neuropathy can lead to other disabilities such as Diabetic foot ulcers, amputation, gait and balance impairment, and so on.  It’s imperative that we, as clinicians, are equipped to properly identify the risks; and educate our patients and their caregivers to prevent such disability from occurring.

Risk Factors:

how to improve diabetic neuropathy and foot ulcers self check

There are certain risk factors that may be present prior to a diabetic foot ulcer forming.  These include poor control of blood sugar, cigarette smoking, previous foot ulcers and amputations, and most commonly, diabetic neuropathy and peripheral vascular disease.

Diabetic Neuropathy – As mentioned, this is very common among the diabetic population and can be very costly to their health.  Diabetic Neuropathy happens when nerves become damaged from chronic uncontrolled high blood sugar.  This damage can affect various parts of the nervous system that control motor, sensory, or autonomic functions – all of which can contribute to the patient developing a diabetic foot ulcer.  If the nerves that control muscular control of the feet have been damaged, the patient may start posturing their feet in a way that is biomechanically destructive.  This can cause increased pressure on bony prominences and other abnormalities and put their feet at higher risk for forming ulcers. 

Diabetic neuropathy can also be characterized by pain and/or numbness in the legs and feet if the sensory nerves have been damaged.  The pain is often directly associated with the nerve damage itself and is not in relation to an environmental or outward source of pain. 

Numbness, on the contrary, presents other concerns. If a diabetic foot ulcer has started to develop, the person may not feel pain or other sensations usually associated with wounds. This may allow the wound to progress unnoticed, as the patient continues to bear weight over the ulcer.  When autonomic dysfunction occurs, this can lead to changes in perspiration leaving the skin overly dry and prone to cracking.

Peripheral Vascular Disease – Smoking and Diabetes are among the most powerful risk factors in developing PVD.  PVD is characterized by atherosclerotic changes of the blood vessels where the arterial walls gradually harden and narrow as plaque builds up inside.  This restricts blood flow and limits the amount of oxygen and nutrients the blood can carry to that area.  Some studies show an important distinction that PVD in a person with Diabetes mostly occurs in the femoral and tibial arteries. Other risk factors (such as smoking) will affect more proximal vessels.  The nature of PVD makes it easy to imagine why this would put a person with Diabetes at risk for developing a foot ulcer – the feet are not getting the oxygen and nutrients they need to sustain healthy tissue! 

The prevalence of PVD among people with Diabetes is difficult to pin down due to the variability of symptoms. Some people may present as asymptomatic.  A great way for clinicians to help identify the presence of PVD is the Ankle-Brachial Index.  Research has shown this to be highly sensitive and specific when compared to angiographically confirmed disease… and the great news for us is that it doesn’t require any fancy equipment!

For great resources to use in the clinic, check out our ‘Ultimate Guide to Managing the Diabetic Foot’!

Time for healing:      

Wounds often take a longer time to heal for a person with diabetes, and here’s why:

Diabetic Neuropathy – As mentioned above, this could be a risk factor for developing diabetic foot ulcers to begin with, but it is also a major player in the wound healing process.  If the nerve damage is contributing to a sensory loss… the person is going to be at a very high risk to reinjure/reopen the wound site again and again.  They can’t feel it, so it won’t be “a problem” for them until it’s too late.  A vicious cycle! 

how to improve diabetic neuropathy and foot ulcers self check

Peripheral Vascular Disease – Blood flow with good oxygenation and nutrition supply is essential to proper wound healing.  When this is compromised, as it is in people with PVD, the body simply does not have the fundamentals that it needs to move through the wound healing process and repair tissues.  If a more severe lack of oxygenated blood exists, this could lead to ischemia and necrosis of the tissues, which would then need to be debrided… making the wound larger.  In other cases it could lead to gangrene and eventual amputation.

Infection – Diabetic foot ulcers are often at higher risk for infection, which would then prolong the healing process.  When a person has diabetes, they produce certain enzymes and proteins that make the immune response less effective.  So, when a diabetic foot ulcer is present and bacteria enters in, your body is already at a disadvantage in fighting off infection and moving on to healing the wound. 

Prevention is Key!

If you or someone you know is at risk for developing diabetes, it is imperative to take steps toward prevention!  This is sometimes easier said than done. But, making small changes at a time will give you the best results… by far! Don’t take everything on all at once. If you’re a clinician healing your patients and their families, don’t overwhelm them with information – start slow.

Check out this page to get great tips and resources from the American Diabetes Association on how to prevent Diabetes!

But if Diabetes is already present, there are plenty of ways we can still help our patients prevent complications, such as Diabetic neuropathy and foot ulcers. 

  • Get blood sugar under control – This seems obvious, right?  But it’s often very difficult for people to do in real life.  There are so many factors that play into this, from food preferences, habits, culture, family support, etc.  It’s important to get as many team member as possible involved to help reinforce the small changes that the patient will need to make along the way.
  • Follow up with appropriate practitioners – Depending on the risk factors identified, ensure your patient is seeing the experts they need.  Some examples are: Endocrinologist for management of diabetes; Vascular Surgeon or Interventional Radiologist for management of PVD; Dietician for nutritional recommendations; Community based support groups for Psychosocial support; and of course Physical and Occupational therapy!
  • Footwear recommendations – Especially if the person is presenting with Diabetic Neuropathy, you want to ensure that they have proper footwear to support their feet and prevent any unnecessary pressure of shearing of their skin.  They may need to wear certain types of socks; and need education on how to properly don them in order to prevent bunching of the material within the shoe.  They may do well with a wider size to allow more room, or they may need specially ordered Diabetic shoes.  The Healthy Feet Store may be a great resource for some patients!
  • Daily self-check/foot inspection – Once this becomes a habit, it will be an invaluable part of your Diabetic patient’s routine.  This can be an effective way for prevention of diabetic foot ulcers through getting the patient to be more engaged in their care.  They will need a long-handled mirror or a mirror they can place on the floor under their feet.  Here are the steps involved:
    • Skin inspection – Look at the skin on the top of your feet, the soles of your feet and in between your toes.  (Use the long-handled mirror for places you are unable to see.)  Observe for: cuts, scrapes, bruises, dirt/grime, blisters, discoloration, or developing calluses.  Anything that is new or abnormal should be noted.
    • Nail inspection – Look at your toenails for uneven edges, broken nails, ingrown toenails, or signs of infection.
    • Sensation – Feel all over your feet for changes such as numbness, increased sensitivity, lumps/bumps, cold areas, tingling or painful areas.
    • Smell – Try to smell the skin for fungal or bad odors. A change in smell or a bad odor can indicate a problem or a possible infection.
    • Hygiene – Clean your feet of any dirt or grime and dry the skin very well. This will help to prevent any possible infections. Wash using warm, not hot water, and do not soak your feet. Apply lotion and rub it in until feet are dry.

As with many different aspects in healthcare, prevention certainly is key!  But more often then not we are seeing patients after their conditions have become chronic and they are already experiencing a host of complications.  It is no different with our patients with Diabetes.  Identifying what is already present and what they are at continued risk for is where we can still play a role in prevention.  We can prevent the progression of their disease or prevent the development of complications by providing education and strategies to make the changes they need to make more attainable.

If you want to learn more about wounds and wound management, have a look at our LIVE or SELF-PACED course, A Comprehensive Guide to Wound Care: Tools for the Everyday Clinician! This course offers 7 Cont-ed units, practical downloadable tools and resources, and is taught by an expert wound care specialist who makes the education accessible to everyone. Check it out!

Like this article? Sign up to our mailing list for a weekly education right to your inbox! We promise to treat your email with the respect and love it deserves 🙂

3 Wound Care Treatments… that will Blow Your Mind!

Wound care treatment can be weird…and wonderful! You’re probably familiar with some of the more commonly seen wound care treatments- such as absorbent dressings, chemical debriders, barrier creams and even impregnated gauze. However, in parts of the world that these conventional treatments might not be available, other wound care treatment options are employed… and can be far more effective than you would think!

Wound treatment dressings serve multiple purposes- a moist environment at the interface of the wound; a barrier between the wound and microorganisms; and non-toxic, non-allergenic, non-sensitizing agents. Wound dressings can also contain anti-inflammatory substances, proteins, vitamins, and other wound healing properties.

Here we take a closer look at three weird and wonderful wound care treatments that you may never have heard of. Do you think any of these could be useful where you work?

Fish Skins

Fish skin has been increasingly used, and recently FDA approved, to act as a ‘scaffold’, or support network, to skin. Products made from dried and processed fish skin (in which allergens are no longer present) act as an extracellular matrix- which is a group of proteins and starches which play a vital role in skin and wound recovery- when placed on wounds. In healthy skin, a matrix surrounds cells and binds them to tissue. This boosts the growth of new skin. However, in chronic wounds, this structure does not form, and so the extracellular matrix made from the fish skin product provides the cells of the body a structure that they can grow around, so that healthy tissue may form. As the product is biodegradable and natural, it eventually becomes absorbed into the wound as the healthy skin grows over.

Fish skin is rich in nutritious materials, including Omega 3 fatty acids, that are naturally anti-inflammatory. This also helps speed up healing in chronic wounds and skin breakdown.

Sterilized fish skin can be used to aid with collagenase transfer and ease pain; and can be easier that gauze when it comes to dressing changes for burns. You can see fish skin used in countries such as Brazil and Denmark, to successfully help with diabetic wounds, burns, or non-healing injuries.

To download a FREE E-Book: ‘The Ultimate Guide to Managing the Diabetic Foot” click here!


Here’s another food-based super product: bananas! Banana leaves and peels have been used for many years in certain countries. The leaves have been proven, in more recent times, to have medicinal properties. This can make them an acceptable alternative to more costly, synthetic wound care materials- especially in developing countries. Banana leaves cool the skin and do not stick to open wounds. Several studies have examined the use of banana leaf dressings, which were shown to result in rapid epithelization and less pain during wound changes than typical gauze-and-Vaseline dressings. Clinical research has shown that banana leaf dressings also can reduce pain and help protect wounds from infection, as well as aiding healing.

Banana peels have been aid with skin regeneration and re-mineralization and have anti-inflammatory and pain relieving properties. Healing occurs at a DNA level, with some of the compounds found in banana peels increasing cell proliferation, inducing and enhancing the healing process. They also contain vitamins, minerals and antioxidants.

Another reason to use banana leaves and peels? They are antimicrobial! Lab testing has demonstrated that banana peel extract significantly inhibits growth of bacteria. They are free, widely available in tropical countries, and easy to apply and use.

Learn more: Ostomy Management for clinicians- 6 goals and how to meet them!


And lastly in our foodstuff-based interventions for wound care- honey! You may or may not have heard of the antibacterial, powerful effects of honey for wound healing. People have used honey for centuries, for all manner of wounds and skin conditions, and it now has commercialized products inspired by its medicinal properties (honey-impregnated dressings and ointments such as MediHoney or TheraHoney).

Honey is central in wound healing for many reasons- including its broad-spectrum antibacterial effect. Honey can kill and block possibly harmful infections, through a combination od hydrogen peroxide and methylglyoxal, which, in Manuka honey, can withstand significant dilution by wound exudate and still maintain enough activity to inhibit bacteria growth.

It also has anti-inflammatory and osmotic effects owing to its high sugar content- drawing water from issues and allowing for an outflow of lymphatic fluid (as can also be seen with negative pressure wound therapy/Wound VACs).

Honey has an acidic pH which stimulates oxygenation of the tissues- integral to wound healing; and has bioactivities that stimulate an immune response, suppress inflammation, and bring on autolytic debridement.

Research comparing the effects of honey with alternative wound dressings and topical treatments on the healing of acute and/or chronic wounds concluded that honey can heal partial thickness burns and infected post-operative wounds more quickly that conventional treatment (which included polyurethane film, paraffin gauze, soframycin-impregnated gauze, etc.).

As you can see, the science behind the healing of wounds encompasses many weird and wonderful treatments! Have you experienced any of these methods to assist in wound healing where you work? What do you think?

Interested in learning more about wound care, and practical approaches to assessment, treatment, and documentation? Check out A Comprehensive Guide to Wound Care, our immensely popular, continuing education course for nurses and therapists, and see for yourself how you can target the #1 issue that keeps patients from returning home. Available live- In person and Virtual!

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