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Artificial limb rehabilitation for older people with a leg amputated at or above the knee because of blood circulation problems

Problems with inadequate circulation in the legs (dysvascularity), particularly in people over the age of 60 years, can be so severe that they need a leg amputated. This may be as high as at or above the knee. Accompanying medical conditions (co‐morbidities) such as diabetes, cardiovascular or heart disease can affect a person's rehabilitation. When an above or through knee artificial limb (prosthesis) is fitted, it is hard to regain mobility and function and some people choose to use a wheelchair. Motivation, comfort, cosmetic appearance, functionality, reliability, ease of use, previous mobility and the extra exertion needed to use an artificial leg are all potentially important factors that affect a person's independence and their use of the prosthesis. Fear of falling, number of falls, social circumstances, help and support from other people are also important influences. The review authors searched for trials comparing different types of rehabilitation that may benefit the mobility or function in older people using an artificial limb.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2015

Effectiveness of surgery for people with leg or back pain due to symptomatic spinal stenosis

Spinal stenosis is the narrowing of the spinal canal in the lower back region caused by thickening of the soft tissues and bones. It is a common condition for which surgery is usually performed after non‐surgical treatments (such as physiotherapy) have failed to bring sufficient relief to patients. Spinal stenosis is a common cause of low back pain that radiates to the legs, and it is more common in older adults. Surgery for lumbar spinal stenosis normally involves taking pressure off the spinal cord or spinal nerves (known as decompression) by removing bone and soft tissues from around the spinal canal. Another common surgical approach is to fuse two or more vertebrae together after decompression in the patient whose spine seems to be unstable. The usefulness of some types of surgery for lumbar spinal stenosis, however, has been questioned, and previous studies have reported that patients who receive fusion are more likely to have major complications and higher costs when compared with patients who undergo decompression only. More recently, spinal implants were created to help indirectly reduce pressure in the spinal canal and at the same time stabilise the bones. However, these implants have also been linked to worse outcomes (e.g., higher reoperation rates) when compared to conventional decompression.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2016

Interventions for leg cramps in pregnancy

Sodium supplements may decrease the number of cramp attacks experienced by women in pregnancy but the effect is slight. Calcium is of no benefit. The evidence of benefit for magnesium is stronger. Multivitamin and mineral supplements also seem to help but the relevance of this is unclear as the preparation used contained twelve separate constituents and it is not possible to discover which of these was effective, or indeed if there was synergy between constituents. There is a theoretical risk that sodium supplementation could raise blood pressure. It is unlikely that magnesium supplementation would be harmful at the suggested doses.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2015

Pentoxifylline for treating venous leg ulcers.

Venous leg ulcers are a common, recurring and disabling condition. The mainstay of treatment is the use of firm compression bandages or stockings to support the veins of the leg. Some leg ulcers take many months or years to heal and treatment is aimed at preventing infection and speeding up healing. Pentoxifylline is a tablet taken to improve blood circulation. The review of trials suggests that pentoxifylline, 400 mg tablet taken three times a day, increases the chance of healing.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Ginkgo biloba for people with leg pain while walking (intermittent claudication)

The main symptom of peripheral arterial disease (PAD) is leg pain in one or both calves while walking. Typically, this pain occurs during walking and is relieved by a short period of rest. This clinical phenomenon is called intermittent claudication (IC). Peripheral arterial disease is caused by progressive narrowing of the arteries in one or both legs and is a manifestation of systematic atherosclerosis, possibly leading to cardiovascular events. Conservative treatment consists of treatment for cardiovascular risk factors and symptomatic relief by exercise therapy and pharmacological treatments. One of the pharmacotherapeutical options is Ginkgo biloba extract, which is derived from the leaves of the Ginkgo biloba tree and has been used in traditional Chinese medicine for centuries. It is a vasoactive agent which is believed to have a positive effect on walking ability in patients with PAD. This review shows that people using Ginkgo biloba could walk 64.5 metres further, which was a non‐significant difference compared with the placebo group. Overall, there is no evidence that Ginkgo biloba has a clinically significant benefit for patients with PAD.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

Electromagnetic therapy (EMT) for treating venous leg ulcers

Venous leg ulcers (which appear as open sores) can be caused by a blockage or breakdown in the veins of the legs. Compression of the leg, using bandages or hosiery (stockings), can help heal most of these ulcers. Electromagnetic therapy is also sometimes offered. Electromagnetic therapy is not a form of radiation or heat, but uses an electromagnetic field to try to promote healing. This review of clinical trials concluded that there is no high quality evidence about whether electromagnetic therapy speeds the healing of venous leg ulcers and its effect is unclear.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2015

Oral zinc supplements for treating leg ulcers

Most leg ulcers (open sores, usually on the lower leg) usually heal with good wound care, including wound dressings. However even with good wound care leg ulcers may take weeks or months to heal. Leg ulcers often cause distress to patients and are costly for health services. Failure to heal may be due to poor nutrition which reduces the ability of the body to repair itself. Minerals such as zinc are necessary for good healing and so it has been thought that taking zinc sulphate tablets might aid healing of ulcers. We found six trials that used zinc to treat leg ulcers but all were too small to show a benefit even if one exists. Furthermore the methods used in the existing trials mean that their results were possibly biased.On the basis of the evidence we have so far it appears that taking zinc tablets does not improve leg ulcer healing, however better quality trials are needed.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Intermittent pneumatic compression for treating venous leg ulcers.

Venous leg ulcers (open sores) can be caused by a blockage or breakdown in the veins of the leg. Compression, using bandages or hosiery (stockings), can help heal ulcers. However, they do not always work, and some people are not willing or able to wear them. Intermittent pneumatic compression (IPC) uses an air pump to inflate and deflate an airtight bag wrapped around the leg. This technique is also used to stop blood clots developing during surgery. However, the review of trials found conflicting evidence about whether or not IPC is better than compression bandages and hosiery. Intermittent pneumatic compression (IPC) is better for healing leg ulcers than no compression. . Some studies suggest IPC might be a beneficial addition to bandages for some ulcers, but these studies might be biased. Delivering the IPC therapy in a rapid manner by inflating and deflating the IPC device more quickly resulted in more ulcers being healed than with a slower deflation regime.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Flavonoids for treating venous leg ulcers

Venous leg ulcers (which appear as open sores) can be caused by a blockage or breakdown in the veins of the legs. Compression of the leg, using bandages or hosiery (stockings), is known to help heal venous ulcers. Flavonoids, which are commonly used as food supplements, occur in a variety of plant‐based foods and beverages, including cocoas, chocolates, teas and red wines. They are sometimes used to try to promote ulcer healing in the leg. This review of clinical trials concluded that there is some evidence to show that flavonoids can help heal venous leg ulcers, however, many trials were not reported well, and we could not know for certain whether the apparently beneficial effects were real or not. This meant that we could not draw firm conclusions, or recommend routine use of flavonoids for people with leg ulcers. Larger and better conducted trials are needed to assess the true clinical effect of flavonoids.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

Skin grafts to improve leg ulcer healing

Approximately 1% of people in industrialised countries have a leg ulcer at some time, mainly caused by poor blood flow back from the legs towards the heart. Skin grafts, either using the patient's own skin, artificial skin or donor skin/cells, have been evaluated to see whether they improve the healing of ulcers. The review of trials found evidence that tissue‐engineered skin composed of two layers increases the chance of healing. There was not enough evidence to recommend any other type of graft, and further research is required.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

Staples versus sutures for closing leg wounds after vein graft harvesting for coronary artery bypass surgery

Surgical wounds are usually closed by using either an interrupted or continuous suture using absorbable or non absorbable suture materials. Skin staples are an alternative to sutures and are usually used at the discretion of the surgeon. Skin wound closure with metallic clips is considered to be a fast and effective alternative to sutures. Furthermore, it is commonly believed that staples are less traumatic and may reduce wound complications. This makes the use of staples attractive as it may reduce the risk of postoperative wound complications.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2011

Do additional surgical techniques at the lower end of bypasses in the leg improve the chance of the bypass working and saving the leg from amputation?

If the artery to the lower leg is blocked, replacement of the blocked segment with a bypass graft can save the leg from amputation and reduce the pain resulting from inadequate blood supply to the leg. The best material to use for a bypass graft is the patient's own vein (autologous vein). If a suitable vein is not available, then an artificial tube (synthetic graft) is used. The outcome from these synthetic grafts is less favourable than with autologous veins if the graft extends to below the knee. This review looked at six trials, with a combined total of 885 patients, which compared different methods of making these grafts. Results from two trials which looked at the effect of inserting a cuff of vein at the lower end of the synthetic graft before attaching it to the artery below the knee are conflicting. With one study showing that the bypass graft remains functional for a longer period of time and in the other study no benefit was seen. If a synthetic graft is made in a fashion imitating the shape of a vein cuff, then the same benefit can be achieved. The results also show that when short lengths of vein are joined together to form a sufficiently long graft, the bypass works for longer, although this does not result in fewer amputations. Finally, there is no added benefit for graft patency or amputation rate if a connection is made between the artery and the vein (fistula) when constructing a vein cuff with the synthetic graft but the operation takes longer.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

A 'test and treat' strategy for elevated wound protease activity for healing in venous leg ulcers

Venous leg ulcers are a common and recurring type of chronic wound. Compression therapy (bandages or stockings) is used to treat venous leg ulcers. Dressings which aim to protect the wound and provide an environment that will help it to heal are used underneath compression. Protease‐modulating dressings are one of several types of dressing available.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2016

Chronic wounds: Venous leg ulcers: Do skin grafts help?

There are a number of different types of skin grafts that can be used to treat leg ulcers caused by venous insufficiency. There is a lack of research on most of them, but some studies suggest that bilayer artificial skin made from human cells can improve the likelihood of venous leg ulcers healing within six months.

Informed Health Online [Internet] - Institute for Quality and Efficiency in Health Care (IQWiG).

Version: September 23, 2015

Alginate dressings for venous leg ulcers

Venous leg ulcers are a common and recurring type of chronic or complex wound which can be distressing for patients and costly to healthcare providers. Compression therapy, in the form of bandages or stockings, is considered to be the cornerstone of venous leg ulcer management. Dressings are applied underneath bandages or stockings with the aim of protecting the wound and providing a moist environment to aid healing. Alginate dressings contain substances derived from seaweed and are one of several types of wound dressings available. We evaluated the evidence from five randomised controlled trials that compared either different brands of alginate dressings, or alginate dressings with other types of dressings. In terms of wound healing, we found no good evidence to suggest that there is any difference between different brands of alginate dressings, nor between alginate dressings and hydrocolloid or plain non‐adherent dressings. Adverse events were generally similar between treatment groups (but not assessed for alginate versus plain non‐adherent dressings). Overall, the current evidence is of low quality. Further, good quality evidence is required before any definitive conclusions can be made regarding the use of alginate dressings in the management of venous leg ulcers.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2015

Compression hosiery (stockings) for preventing venous leg ulcers returning

Venous leg ulcers (open wounds on the lower leg) can be caused by a blockage or breakdown in the veins of the legs. Compression, using bandages or hosiery (stockings), can help heal most of these ulcers and is also widely used after healing to prevent ulcers returning. One small trial confirms that compression reduces ulcer recurrence compared with no compression. There is some evidence that people wearing high rather than moderate‐compression hosiery are less likely to get a new ulcer. It is not clear whether moderate strength hosiery is better tolerated than high compression. There is, therefore, some evidence that compression hosiery might prevent ulcers, but the evidence is not strong.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Topical agents or dressings for reducing pain in venous leg ulcers

Venous leg ulcers are often painful, both during and between dressing changes, and during surgical removal of dead tissue (debridement). Dressings, topical creams and lotions have been promoted to reduce the pain of ulcers. Two trials tested a dressing containing ibuprofen, however, the pain measures and time frames reported were different. One trial indicated that pain relief achieved over 5 days with ibuprofen dressings could represent a clinically relevant reduction in pain. The other trial found no significant difference in the chance of pain relief, measured on the first night of treatment, for ibuprofen dressings compared with foam dressings. This trial, however, was small and participants were only followed for a few weeks, which may not be long enough to assess whether the dressing affects healing. There was evidence from five trials that a local anaesthetic cream (EMLA 5%) reduces the post‐procedural pain of debriding leg ulcers but there was insufficient evidence regarding any side effects of this cream and its impact on healing.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Angioplasty versus conservative management of intermittent claudication, leg pain on walking

Intermittent claudication is evident as pain in the leg that becomes apparent when walking and is relieved by rest. The pain is the result of insufficient blood flow to the calf muscles when exercising, generally because of atherosclerotic changes in the leg arteries so that a section becomes narrowed or blocked. People with mild disease are advised to stop smoking, exercise, and take low‐dose aspirin to prevent heart attack or stroke. There is no widely accepted medication to treat claudication. Angioplasty involves using a balloon, laser or mechanical device threaded down a leg artery to widen and open the narrowed or blocked section. Possible side effects of the procedure include blood clots and movement of blood clots and debri (emboli). The immediate effect may be to relieve the symptoms but narrowing can reoccur.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2008

Low molecular weight heparin for prevention of venous thromboembolism in adults with lower‐leg immobilization in an outpatient setting

Immobilization of the lower limb with plaster cast or brace in adult patients is associated with deep venous thrombosis (DVT). In order to prevent this complication preventive treatment with anticoagulants is often used, most commonly low molecular weight heparin (LMWH). Different indications for the use of LMWH are given in existing national guidelines. Therefore we searched the literature for trials on this topic, in order to develop an evidence‐based stand on this matter.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Foam dressings for venous leg ulcers

Venous leg ulcers are a common and recurring type of chronic wound. Compression therapy (bandages or stockings) is used to treat venous leg ulcers. Dressings that aim to protect the wound and provide a moist environment to aid ulcer healing are applied beneath compression devices. Foam dressings are one of several types of dressing available. We evaluated the evidence from 12 randomised controlled trials that either compared different types of foam dressings, or compared foam dressings with other types of wound dressings. We found no evidence to suggest that polyurethane foam dressings are significantly better or worse than hydrocellular foam dressings in venous leg ulcer healing. Similarly, we found no evidence to suggest that foam dressings are significantly better or worse than other types of dressings (paraffin‐impregnated gauze dressings, hydrocapillary dressings, hydrocolloid dressings, knitted viscose dressings, or protease‐modulating matrix dressings), for the healing of venous leg ulcers. We found insufficient evidence to draw any conclusions regarding: adverse events, quality of life, costs, pain, or dressing performance. Overall, the current evidence is of low or unclear methodological quality. This limits the making of any specific recommendations regarding the use of foam dressings. Further, good quality evidence is required before definitive conclusions can be made regarding the role of foam dressings in the management of venous leg ulcers.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

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