Good quality nursing care and having a good belly laugh now and again is the best medicine for patients with venous leg ulcers, according to a BMJ report of a five-year study that examined the effectiveness of adding ultrasound therapy to standard care and found, contrary to expectations, that it did not speed up healing.

Lead researcher Professor Andrea Nelson, from the University of Leeds’ School of Healthcare in the UK, and colleagues, concluded that traditional nursing care, which is cheaper and easier to deliver, worked just as well.

People with varicose veins or mobility problems often get leg ulcers which result from poor blood flow back to the heart from the feet and lower legs. These wounds are painful and ugly and can really impair a person’s quality of life.

With good nursing care, most leg ulcers clear up within 12 months, but a significant number can take longer to heal, and the older and larger they get, the harder it becomes, which is why researchers are keen to find new ways to speed up the healing process.

It also likely that the number of people with leg ulcers will grow because of the rising prevalence of obesity.

“The key to care with this group of patients is to stimulate blood flow back up the legs to the heart,” said Nelson, explaining that the best way to do that is “with compression bandages and support stockings – not ‘magic wands’ – coupled with advice on diet and exercise.”

“Believe it or not, having a really hearty chuckle can help too. This is because laughing gets the diaphragm moving and this plays a vital part in moving blood around the body,” she added.

Nelson explained that while the “healing energy” of low-dose ultrasound can make a difference to some medical conditions, this is not the case with venous leg ulcers.

Nelson and colleagues from the Universities of York and Teeside, and several NHS Trusts, set out to test ultrasound as a potential way to speed up healing of leg ulcers because a number of small studies had suggested it might.

They focused on the ulcers that were hard to heal, and had not cleared up after six months or more.

Their study compared using low dose, high frequency ultrasound every week for up to 12 weeks with standard care against standard care alone.

They found that ultrasound made no difference to healing rates, quality of life, or ulcer recurrence.

The participants, who were randomly assigned to the two groups, were 337 patients being treated by district nurses, or through attending community leg ulcer clinics, and hospital outpatient clinics in 12 urban and rural settings (11 in the UK and one in the Republic of Ireland).

More specifically, the results showed there was no signficant difference between the groups in:

  • Healing time: even after adjusting for ulcer area, duration, use of bandaging, and study centre.
  • Percentage of participants with ulcers healed by 12 months.
  • Change in ulcer size at four weeks.
  • Time to complete healing of all ulcers.
  • Rate of recurrence of healed ulcers.
  • Health-related quality of life: on both physical and mental health scores.

However, there were significantly more adverse events in the ultrasound group.

The researchers also found there was a significant link between time to heal and the ulcer size, with larger and older ulcers taking longer. Centres with high recruitment rates also showed the highest healing rates, they noted.

Nelson said there is a need to find ways of helping patients with persistent leg ulcers, but it looks like ultrasound is not one of them.

She said we should focus on “what really matters, which is good quality nursing care”.

“There really is no need for the NHS to provide district nurses with ultrasound machines. This would not be money well spent,” said Nelson.

Adding ultrasound to standard care would raise the cost by nearly £200 per patient.

“Use of weekly, low dose, high frequency ultrasound for hard to heal venous leg ulcers: the VenUS III randomised controlled trial.”
Judith M Watson, Arthur R Kang’ombe, Marta O Soares, Ling-Hsiang Chuang, Gill Worthy, J Martin Bland, Cynthia Iglesias, Nicky Cullum, David Torgerson, E Andrea Nelson, on behalf of the VenUS III Team.
BMJ, 2011; 342:d1092, Published online 8 March 2011.

Additional source: University of Leeds (press release, 8 Mar 2011).

Written by: Catharine Paddock, PhD