No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Inelastic Leg Compression Is More Effective to Reduce Deep Venous Refluxes than Elastic Bandages
Abstract
Deep venous refluxes play an important triggering role for the development of venous leg ulcers. Compression therapy is able to reduce these refluxes depending on pressure and the kind of material being used.
To compare the efficacy of compression bandages of varying pressure and material (elastic, long-stretch versus inelastic, short-stretch bandages, four-layer bandages).
Venous volume (VV) and venous filling index (VFI) as a quantitative parameter of venous reflux were measured using an airplethysmograph (APG) in a total of 21 patients presenting with venous leg ulcers and deep venous refluxes. Bandage pressure was measured in every experiment. The influence of elastic and inelastic bandages with increasing pressure and the changes in these parameters using different bandages with the same pressure were investigated.
The initial median value of VFI without compression was 8.45 ml/sec. VV and VFI were significantly reduced by increasing external pressure, more strongly with inelastic than with elastic material. With a pressure of 25 mmHg inelastic bandages diminished VFI to a median of 3.25 ml/sec while the elastic material did not even approach this value with a pressure of 40 mmHg (4.25 ml/sec). Applying bandages of different material with the same pressure of 30 mmHg, the most intense reduction of VV and VFI was obtained by inelastic and by four-layer bandages. The effect on venous reflux was statistically significantly superior with inelastic compared to elastic material.
Using the same bandage pressure, inelastic material is more effective at reducing deep venous refluxes than elastic bandages in patients with venous ulcers. Four-layer bandages show similar efficacy to inelastic bandages.
... La compression réduit le volume veineux d'une jambe en position couchée comme debout. Mesurée par pléthysmographie à air sur 21 patients souffrant d'une insuffisance veineuse profonde sévère (reflux en veine poplitée et ulcère), cette réduction est plus importante avec un dispositif inélastique qu'élastique [46,47]. Pour une pression appliquée de 30 mmHg, la réduction du volume veineux observée est de l'ordre de 30 %. Cette réduction est d'autant plus importante que la pression est plus forte [47]. ...
... Mesurée par pléthysmographie à air sur 21 patients souffrant d'une insuffisance veineuse profonde sévère (reflux en veine poplitée et ulcère), cette réduction est plus importante avec un dispositif inélastique qu'élastique [46,47]. Pour une pression appliquée de 30 mmHg, la réduction du volume veineux observée est de l'ordre de 30 %. Cette réduction est d'autant plus importante que la pression est plus forte [47]. Pour une autre équipe, avec le même dispositif, le volume veineux chez les patients variqueux est réduit par la compression de 18-23 mmHg ; plus importante avec une pression plus forte, il n'est cependant pas réduit chez les sujets sains, insuffisants veineux profonds ou souffrant de lymphoedème [48]. ...
Medical compression dates back to centuries and is still a matter of many questions. A major one is “how this treatment works”, which remains unclear. Numerous are physiological changes under compression at various levels of macro-and microcirculations. Pressure exerted by medical devices is variable from patient to patient and consequently dose-effect link is hard to interpret. Nonetheless, three major effects of compression therapy can be highlighted: the calf muscle-pump increase, the cutaneous fluid drainage and the decrease of transmural pressure in vein walls.
... Due to their completely different pressure ranges, IB has been proved to be significantly more effective than EB in reducing venous reflux in patients with deep 9 and superficial 10 venous insufficiency. Venous reflux, measured by Air Plethysmography 9 and Duplex scanner, 10 was significantly more reduced by IB when applied with a supine pressure of 20 and 40 mm Hg. ...
... Due to their completely different pressure ranges, IB has been proved to be significantly more effective than EB in reducing venous reflux in patients with deep 9 and superficial 10 venous insufficiency. Venous reflux, measured by Air Plethysmography 9 and Duplex scanner, 10 was significantly more reduced by IB when applied with a supine pressure of 20 and 40 mm Hg. Applying the material with a strong supine pressure of 60 mm Hg, both bandages are almost equally effective but EB is painful and not tolerated for long periods. ...
Leg ulcers have a venous pathophysiology in the vast majority of cases (1–4). Superficial or deep venous insufficiency and deep vein obstruction produce ambulatory venous hypertension due to venous reflux and venous pumping function impairment. The impaired venous hemodynamics is the key pathophysiologic mechanism leading to skin damage through several intermediate steps. Fibrin cuff formation around the microvessels, impairing gases (O2, CO2) exchange (5), white cells entrapment (6) causing skin necrosis, growth factors inhibition (7) producing a stagnation of the healing process have been considered involved in ulcer onset and maintenance. The treatment of venous leg ulcers (VLU) must be based on the correction of the hemodynamic impairment which can be achieved conservatively by means of compression therapy, walking and leg elevation or by means of invasive procedures (open surgery, endovascular procedures as endovenous Laser ablation, radiofrequency, foam sclerotherapy, conservative hemodynamic treatment). Compression therapy is frequently considered the first treatment option and it is the only therapeutical procedure which achieved the grade 1A in most recent guidelines or consensus documents (8–10). The crucial point is choosing the most effective compression modality. There are clear evidences that inelastic is more effective than elastic material in counteracting the venous hemodynamic impairment (11–14) that should „ensure” a superior effectiveness in promoting a higher healing rate of VLU, which are due to venous hemodynamic impairment. When looking at evidences we have some data showing that the higher the compression pressure the higher the healing rate (9, 15–17) and this is clearly in favors of inelastic bandages which exert a much higher pressure that elastic materials. On the other side we have many papers claiming a greater effectiveness of elastic stockings or elastic bandaged compared with inelastic material (18–30). Nevertheless studies comparing elastic and inelastic devices have so many flaws that their conclusions are hard to trust (31). Aim of this work is providing updated information about compression therapy effects on venous hemodynamic and the most effective compression modality to achieve the best outcome in VLU treatment.
... Compression represents one of the most important forms of intervention in the treatment of lymphedema, assisting in the removal of excessive fl uids as well as maintaining any achieved improvements in size. In these cases low-elastic materials are the most recommended (5,6) and can be compared to the action of aponeurosis (5) . ...
... Compression represents one of the most important forms of intervention in the treatment of lymphedema, assisting in the removal of excessive fl uids as well as maintaining any achieved improvements in size. In these cases low-elastic materials are the most recommended (5,6) and can be compared to the action of aponeurosis (5) . ...
The objective of the present study was to evaluate the working pressures at the interface between the skin and compression sleeves made of ‘gorgurão’ (cotton-polyester textile) used in the treatment of lymphedema of the arms. Twenty measurements of working pressures between the skin and ‘gorgurão’ sleeves for each of fi ve patients suffering from lymphedema of the arms were taken. For this evaluation, an apparatus developed by Godoy & Braile, which dynamically measures the working pressure at half-second was utilized. Two sensors were placed in the medial region of the biceps muscle. In all evaluations, it was proved that resting pressures are recorded depending on the manner in he sleeve is used and that the sleeves cause variations in the working pressures. In conclusion, low-elastic ‘gorgurão’ sleeves are an alternative method of compression in the treatment of lymphedema. Key words: Sleeves, dynamics
... 12 Differentiating wraps in terms of composition does not clear up their physical ability to address clinical questions conversely to pressure and stiffness, which are key characteristics for bandages and ACDs and have a strong link with physiological effects. [13][14][15][16][17] For instance, medical compression stockings have much less stiffness than bandages, and both do not treat the same stages of chronic venous insufficiency. 16,[18][19] Stiffness is not the only characteristic that gives the physiological effect, but it contributes to a great proportion of the results and is thought to play a part in the effectiveness of bandages in oedema, lipodermatosclerosis, and ulcers. ...
Adjustable Compression Devices (ACDs), also known as wraps, offer a promising alternative treatment to bandages in complicated stages of chronic venous disorders. Nevertheless their characterisation and clinical place depending on their stiffness, are still pending questions. We propose a new approach to measuring stiffness in vivo in a small group of individuals Measurement of the Static Stiffness Index (SSI) of two adjustable compression devices commercially available in 10 healthy volunteers. Ten healthy volunteers of 37.6±8.6 years old (25-50), mean, Standard Deviation (SD), and range, respectively, participated in the study. SSI was measured at the resting pressure of 30 mmHg for both ACDs at point B1. SSI was 21.9±10.3 mmHg (0-33) for Coolflex and 12.5±6.2 (0.6-24.6) for Compreflex. At a cut-off level of 10 mmHg of SSI, 10 % of volunteers for Coolflex and 30 % for Compreflex were under the cut-off level. The SSI measured in vivo made it possible to discriminate between wraps and estimate the percentage of patients who would better respond to this treatment.
... 17 Inelastic bandages are more effective in supporting the muscle pump, reducing venous diameter, reflux and ambulatory venous hypertension. [18][19][20][21] They are more comfortable at rest but produce higher increases in pressure during activity and thus also work against the re-swelling of edema too. On the other hand, elastic bandages maintain a force level for a longer period of time and continue to provide the necessary pressure level when the edema is reduced. ...
Compression pressure changes in dynamic conditions under textile compression devices have a critical impact on the success of compression therapy. Models exist to predict the level of compression pressure, but not the actual change in pressure. This paper aims to derive a formula to accurately determine the pressure change under textile compression devices, to investigate the factors influencing the pressure change and to verify their effects through theoretical analysis. Firstly, a formula based on Laplace’s law is presented which mathematically describes the dependencies of pressure changes. Secondly, a simulation is carried out to demonstrate the effect of these dependencies on pressure changes using theoretical textile curve functions. Finally, the effect of these dependencies is demonstrated by testing short- and long-stretch bandages in a tensile testing machine and using the recorded material curves to simulate a theoretical application of these bandages to the lower limbs. The results show that the change in pressure is not solely determined by the intrinsic properties of the material, but is influenced by several variables, including the mechanical performance of the textile materials during stretching, the target pressures for application of the textile material, and the body geometries to which the material is applied. Pressure change cannot be a constant for textile compression devices such as bandages. The research increases the understanding of the factors that influence pressure changes in compression device materials. The findings may have implications for the design and selection of compression textiles in clinical applications.
... The inelastic material should be preferred in venous ulcer treatment due to its higher hemodynamic effectiveness than the elastic material. [25][26][27][28][29] If venous ulcers are due to a venous hemodynamic impairment, the most effective compression modality in counteracting the hemodynamic impairment should be the most effective one in favoring venous ulcer healing. In addition, the studies comparing elastic and inelastic materials have many methodological flaws that make their conclusions hard to trust. ...
Background
The effectiveness of compression therapy (CT) and the best compression modality choice are questioned in many clinical stages of chronic venous disease (CVD). This work aims to obtain information on indications, contraindications, and the best treatment option for CT in different clinical scenarios of CVD.
Method
An online survey was made among members of the International Compression Club, experts in CT.
Results
The experts apply CT in all clinical stages of CVD, even when evidence is missing. Regarding compression materials, experts use inelastic materials in the advanced stages of CVD and compression stockings in the early or chronic stages of CVD.
Conclusion
The authors highlight the gap between experts’ practical use of CT and evidence-based medicine results. They also suggested that, given the cost of randomized clinical trials aimed at specifying specific indications for different devices, artificial intelligence could be used for large-scale practice surveys in the future.
... In contrast, the second category has a working pressure that is not much higher than the resting pressure [6], if not the same [9], and a continuously high resting pressure, making it less tolerable. In the literature, compression has been studied for various clinical conditions [10,11]. Specifically, numerous studies have compared the use of shortstretch bandages with long-stretch bandages for venous leg ulcers [12,13] and lymphedema (primary and secondary) [14]. ...
Introduction and importance
Hand edema is a common post-surgical or traumatic complication in orthopedic patients, necessitating effective treatment interventions. This study aimed to investigate the effects of two different types of bandages, along with finger flexion exercises, on managing hand edema.
Case presentation
Our orthopedic patients with post-surgical or traumatic hand edema and three non-edematous hands were enrolled in the study. A mixed model effect with fixed factors of time (pre-post) and bandage type (M, C, N), and random factors of hand, edema, fingers, and phalanges was applied. The bandage types were circular with short elastic bandage (M) and circular with elastic bandage (C). Finger flexion exercises involved alternating contractions of extrinsic and intrinsic flexors. Randomization ensured unbiased allocation to bandage types.
Clinical discussion
The M bandage demonstrated a significant reduction in hand edema by effectively moving free fluids, reinforcing tissue hydrostatic pressure, and facilitating venous and lymphatic flow. On the other hand, the C bandage did not produce significant pre-post differences in hand circumference.
Conclusions
The combination of a circular bandage with finger flexion exercises shows promise in reducing hand edema in orthopedic patients. Particularly, the stiff bandage M exhibited superior efficacy compared to the elastic one C in reducing hand circumference. These findings provide valuable insights for clinical practice, offering an effective strategy for managing hand edema and promoting better patient outcomes.
... Inelastic materials or short-stretch multicomponent bandages that do not give way to the expanding muscle during walking are able to produce great differences between resting and working pressure and high-pressure peaks. Such bandages are both comfortable at rest and more effective in improving venous hemodynamic in standing position and during muscle exercise compared with elastic bandages or compression stockings [33,34,57,58]. These materials give way to the muscle expansion and exert a sustained pressure that is similar in supine and standing positions and during work without any pressure peaks. ...
This article presents the guidelines for the management of VLUs developed by The Society For Wound Care and Research (SWCR).
... Wearing LSB increased pressure by 8 mmHg for standing position, while using SSB had a significant increase by 25 mmHg and higher working pressure [15]. Two studies found that SSB is superior in healing venous ulcers and reducing venous reflux over LSB [16,17]. Moreover, some others proved that short-stretch and Unna's boot were found to support the pump function better than long-stretch CBs (evidence level A) [18,19]. ...
Compression therapy using bandages or socks is the most common treatment for venous leg ulcers and edema. This article aims to compare the compression between long- and short-stretch bandages (LSB and SSB, respectively). Load-elongation curves, cyclic loading, and elastic recovery are investigated for both Cotton/Polyamide/Polyurethane and 100% bleached cotton bandages as LSB and SSB, respectively. Static (resting)
and dynamic (working) pressures are measured on seven male legs, 31 ± 3.6 years old, using both two and three layers bandaging. Picopress pressure tests are performed on the ankle and mid-calf positions at gradual decreasing compression from the ankle to the knee. The deviation percentage between the experimental results by Picopress and theoretical calculations using Laplace’s law and Al-Khaburi equations is compared. LSB recovered approximately 99% of its original length after stress-relaxation whereas SSB recovered only 93% of its original length after 5 days of cyclic load-relaxation. Moreover, SSB lost approximately 28.6% of its activity after wearing on the human leg for 5 days.
... Other studies have observed a better improvement of venous return with short-stretch bandages compared to long-stretch bandages (Mosti, Mattaliano, andPartsch 2008) (H. Partsch, Menzinger, andMostbeck 1999) . ...
... Other studies have observed a better improvement of venous return with short-stretch bandages compared to long-stretch bandages (Mosti, Mattaliano, andPartsch 2008) (H. Partsch, Menzinger, andMostbeck 1999) . ...
Elastic compression of the lower leg is the traditional preventive and curative treatment of venous insufficiency. After presenting the medical strategies related to compression therapies, this chapter develops current advances in clinics as well as in engineering and outline the more important knowledge arising from this review. Compression hosiery acts by providing pressure to the leg. Pressure generation using socks mainly depends on the stiffness and the size of the socks, the size of the leg, but also the leg morphology. In the case of bandages, the role of friction must be outlined, as the main factor in maintaining the bandage wrapped around the leg, but also as an influencing factor in pressure generation. Besides generated pressure, response of superficial veins to compression also depends on the vein size and the fat stiffness. But mechanical assessments should not mask the importance of other factors such as muscular contraction or nurse formation. An important impact of these results would be head towards an improved personalization of compression treatment.
... 75 The viscoelastic nature of compression bandages means the interface pressure applied decays over time 24,76 concurrently with a reduction of venous volume, and consequential decreased circumference of the lower limb decreasing pressure over time. 77,78 Performance of a compression bandage over time (8 hours) has been shown to depend on the yarn type and fabric structure with interface pressure reducing less in a fabric with greater yarn density. 76 Ruznan et al. 24 showed multiaxial stress-relaxation behaviour of a compression bandage over time (up to 120 hours) was a key parameter affecting performance, noting a rapid drop in pressure (i.e. ...
Background:
Compression is a common therapy for management of chronic disease, including oedema of the lower limb. Modern compression interventions exert pressure on the lower limb through use of one or more materials which exert pressure against the limb over time. Where these materials are textiles, they range from elastic to inelastic, and are produced using knitting, weaving, or other textile technologies which can be manipulated to control performance properties. Thus, understanding of both the materials/textiles and the human body is needed if the most appropriate compression device and treatment strategy is to be used. Neither is independent of the other. This review aims to enhance understanding of critical textile performance properties and how selection of textiles may affect treatment efficacy when managing chronic oedema of the lower limb.
Method:
Relevant papers for review were identified via PubMed Central® library, and Google Scholar using keywords associated with textile-based treatments of the oedematous lower limb and wider interdisciplinary factors.
Results:
Assessment of the disorder, the severity of oedema, and location of fluid accumulation are required to inform treatment of chronic oedema. While the need to understand the patient is well established (e.g. age, sex, body mass index, skin thickness and colour, patient compliance with treatment), information about preferred compression systems and material structures, and inherent properties of these, is generally lacking.
Conclusion:
Greater detail about materials used (e.g. fabric structure, number and order of layers, fibre content) and patient diagnosis (e.g. underlying cause, severity, location of oedema; patient age and sex; evidence of compliance with treatment; pressure exerted; lower leg shape, size, and properties of the tissue) is needed to facilitate advances in efficacy of compression treatment. Reduced limb swelling with a textile-based treatment occurs simultaneously with changes to the textile itself. Textiles cannot be considered inert.
... Vários estudos demonstraram que a eficácia hemodinâmica da terapia de compressão depende principalmente de dois fatores: pressão de interface e a rigidez (Partsch et al., 2006). consequentemente a um aumento do volume expelido em doentes com insuficiência venosa (Partsch, 1984;Partsch, Menzinger, & Mostbeck, 1999;Partsch & Partsch, 2005). É por estes motivos que a terapia compressiva melhora as taxas de cicatrização (O'Meara et al., 2012). ...
... Der korrekt angelegte Kurzzugverband reduziert den venösen Druck und den venösen Reflux an den unteren Extremitäten stärker als elastische Verbände oder elastische medizinische Kompressionsstrümpfe [37,38]. Eine Unterpolsterung mit Schaumstoff oder Watte unter den Kurzzugverband vermeidet schmerzhafte, gerötete Einschnürungen und trägt zum dauerhaften Anpressdruck bei, wird jedoch oft auch als zu warm und zu voluminös auftragend erlebt [39]. ...
Für die Therapie phlebologischer und lymphologischer Krankheitsbilder sowie konstitutioneller Ödemerkrankungen ist eine Auseinandersetzung mit innovativen Konzepten der medizinischen Kompressionstherapie essenziell. Es wird empfohlen, medizinische Kompressionsstrümpfe symptomorientiert immer mit der niedrigsten wirksamen Kompressionsklasse zu verordnen, um die Tolerierbarkeit einer Kompressionstherapie zu optimieren. Ebenso kann ein medizinischer Kompressionsstrumpf mit integrierter Pflegeformel, aber auch die Anwendung einer zusätzlichen Hautpflege die Lebensqualität sowie Compliance bei Patient*Innen mit chronischer venöser Insuffizienz bessern. Eine Optimierung der Ulkustherapie kann durch die Anwendung von Zweikomponenten-Kompressionsstrumpfsystemen gelingen. Diese bestehen aus einem Unterstrumpf und einem festen äußeren Kompressionsstrumpf, verbessern die venöse und kapilläre Hämodynamik bei gutem Tragekomfort und führen zur Abheilung von venösen Ulzerationen. Mehrkomponentenverbände und Kurzzugverbände haben sich in der Entstauungsphase eines Ödems bewährt. Mehrkomponentenverbände sorgen über mindestens 5 Tage für einen dauerhaften Anpressdruck und bieten sich für die ambulante Behandlung mit selteneren Verbandwechseln an. Zur Kompression bei Patient*Innen mit arteriell-venösem Ulcus cruris (ABI [Knöchel-Arm-Index] >0,5) können speziell entwickelte Lite-Versionen der Mehrkomponentenverbände sicher eingesetzt werden.
... 5,6 Compression of veins that have inadequate valve function produces an increase in orthograde flow (towards the heart) and a reduction in venous reflux. 7 Phlebography and duplex ultrasonography have shown that the application of appropriate levels of compression reduces the diameter of larger veins, 7 so it reduces the local blood volume redistributing blood to central parts of the body. 8 Despite an understanding of the physiological mechanisms of compression and scientific evidence (clinical trials and meta-analysis) 9 supporting a grade 1A (imperative and extremely recommendable) and/or 1B (favorable but not imperative) recommendation, compression is underused for the treatment of CVD. ...
Objective
To determine the frequency of use of elastic compression stockings in patients with lower extremity chronic venous disease.
Methods
An explorational, prospective, transversal, observational, descriptive, analytical study including 168 patients was performed. We identified the proportion of patients using elastic compression stockings. The odds ratio (OR) was used to determine the relation between elastic compression stocking use and previous medical attention for chronic venous disease.
Results
Only 59 patients (35.1%) were using elastic compression stockings at the time of the study. We determined that the patients who had received previous medical attention to manage chronic venous disease in their lower extremities were >3 times more likely to use elastic compression stockings than patients who had not received previous medical attention (OR = 3.3, p < 0.0001).
Conclusions
Although there is sufficient evidence of the effectiveness of elastic compression stockings for treating chronic venous disease in the lower extremities, their use is relatively infrequent (35.1%).
... Many studies have demonstrated the effectiveness of compression therapy (CT) in the treatment of veno-lymphatic insufficiency. [1][2][3][4] In daily practice, therapists are often faced with a lack of patients' adherence to treatment and especially regarding CT. 5 The causes are multiple and it is up to the therapist to understand them, to provide personalised solutions for their patient, and thus boost the wearing of the compression depending on the stage of the illness, in addition to other aspects of treatment. ...
... В условиях венозного и лимфатического стаза, отека, нарушения барьерной функции кожи создаются благоприятные условия для бактериальной контаминации и колонизации трофической язвы, что сопровождается развитием острого индуративного целлюлита. Бактериальная агрессия приводит к расширению площади некробиотического процесса, развитию фиброза кожи и подкожной клетчатки, дальнейшему угнетению нарушенного лимфатического оттока и микроциркуляции, вызывая специфическую микробную сенсибилизацию организма и усугубляя трофические расстройства [11,13]. ...
... In contrast to this, the new system keeps the CP constant for several days. 11 Different experimental studies in the past have demonstrated that a pressure of around 60 mmHg in the upright position together with the massaging effect at calf level reduce venous reflux 19,20 and ambulatory venous hypertension, 21 thereby enhancing the efficacy of the venous calf pump. 8,9 Bandages applied with higher pressure over the calf could also be shown to reveal stronger beneficial effects on the calf muscle pump. ...
Introduction:
Bandage application does not exert consistent compression pressure, leading to extremely variable compression when applied to patients. A new elastic bandage can exert a predefined pressure independently of healthcare providers and the size of the wrapped limb. The bandage system includes a series of non-stretchable patches that when applied to the bandage make it stiff. The aim of this work was to assess, in an experimental setting, the venous ejection fraction (EF) from the lower leg and the tolerability of this new bandage in a group of patients affected by superficial venous incompetence.
Methods:
EF was measured using strain gauge plethysmography under baseline conditions and the bandage was applied with a supine pressure of 20 and 30 mmHg, with and without the stiff patches, in 25 patients with severe venous reflux in the great saphenous vein. The interface pressure of the bandages was measured simultaneously in the medial gaiter area.
Results:
All patients showed EF values that were significantly reduced compared with normal individuals. Elastic bandages with an average pressure of 20 and 30 mmHg in the supine position achieved a slight improvement in EF, and, after applying non-stretchable patches on the same bandage with similar resting pressure, EF was restored to its normal range (p < .001). Improvement in EF correlates with the pressure differences between standing and lying pressure and between muscle systole and diastole during exercise.
Conclusion:
This study confirms that inelastic is much more effective than elastic compression for improving impaired venous haemodynamics. The test material can be applied with a predetermined pressure, which considerably enhances the consistency of application, and it is easily transformed into an inelastic system just by applying stiff patches without any stretch and without significantly increasing the comfortable supine pressure.
... In a consensus conference on compression bandages the following pressure ranges were defined (Table 1). 4 Various investigations have demonstrated that inelastic compression in a range of more than 40 mmHg has more intensive effects on the venous hemodynamics in patients without arterial occlusions. [12][13][14] In contrast to elastic material these pressures are well tolerated as firm, but not painful. ...
... In a consensus conference on compression bandages the following pressure ranges were defined (Table 1). 4 Various investigations have demonstrated that inelastic compression in a range of more than 40 mmHg has more intensive effects on the venous hemodynamics in patients without arterial occlusions. [12][13][14] In contrast to elastic material these pressures are well tolerated as firm, but not painful. ...
p>Severe forms of chronic venous insufficiency and lymphedema require strong compression-pressure, which exceeds the pressure exerted by medical compression stockings (>40 mmHg). The aim was to investigate if patients are able to apply a Velcro-band compression device (Circaid Juxta Lite™) themselves with sufficient pressure. Thirty-one patients (CEAP C6=23, C5=5, C3=2, mixed ulcer=1) applied Juxta Lite™ on their own legs after a short instruction and were asked to readjust the pressure by their subjective feeling. Sub- bandage pressure was measured after application and 24 h later. In 30 patients without arterial occlusive disease the median sub- bandage pressure values on day 1 and day 2 were 44,5 mmHg (IQR 42-48), and 46 mmHg (IQR 44-48,25) respectively. One patient with an arterialvenous leg ulcer showed pressures of 34 and 36 mmHg. All measured pressure values corresponded to the pursued target range, demonstrating that adequate self application of Velcro bands is feasible and that patents can maintain this pressure by re-adjustment.
Source: this paper is an abridged translation of Mosti G, Partsch H. Druckmessungen unter Klettverschluss-Kompression - Selbstbehandlung durch feste, unelastische Beinwickelung. Vasomed 2017;5:212-6. </p
... Selbst der Anlagedruck spielt eine untergeordnete Rolle. Entscheidend für die Entwicklung hoher Arbeitsdrucke ist die Stiffness der Kompressionsmittel (1)(2)(3)(4)(5)(6) ...
... Regarding the type of bandage, inelastic compression bandages show a low, tolerable resting pressure and a more effective activation of the deep venous system and calf muscle pump with ambulation (working pressure) compared to elastic materials. 12,13 The Juxta Reduction Kit® (JRK) is a non-elastic compression device, suitable for self-management, which can be tailored to the circumference of the leg. The device allows full ROM, so ambulation and exercise will not be impaired. ...
... Em estudo sobre bandagens utilizando-se a plestimografia, mostrou-se que as de baixa elasticidade são efetivas na redução do volume venoso e tempo de retorno venoso quando em pé e com atividade. 6 Outra particularidade das bandagens de baixa elasticidade é que elas aumentam a amplitude de pressão durante o exercício e diminuem a pressão enquanto repouso. 7 O objetivo do presente estudo foi avaliar a tolerância de uma bandagem co-adesiva de baixa compressão no tratamento do linfedema. ...
of the lymphatic system. The objectives of this study were to evaluate the tolerance of a co-adhesive dressing with lowelasticity in the treatment of patients with lymphoedema in a city with high temperatures (30 to 40 degrees). A total of 25 female and five male patients with ages ranging from 17 to 68 years (mean age 56 years old) were evaluated. The tolerability and durability, when one or more layers of dressing were employed and the principal complaints of the patients were assessed.Co-adhesive dressings with low-elasticity with an easy application were well-tolerated in 27 of the patients. The durability was greater with an increased number of layers. Prurido occurred in 10 patients, but specific care with the use of creams relieved the symptoms and improved tolerance. In conclusion, co-adhesive dressings with low-elasticity are well tolerated in hot weather in the treatment of lymphoedema. The greater number of layers increases the durability of the dressings.
Dressings; Co-
Objective
To report pressure and stiffness, in healthy volunteers, of a new compression device with an air bladder inflated by a pump to regulate pressure.
Methods
The device was applied to 60 legs of 30 volunteers and set to exert different pressures of 20–50 mmHg. The exerted pressure was measured in supine and standing positions and during simple physical exercises; static stiffness index, dynamic stiffness index, and walking pressure amplitudes were calculated.
Results
The exerted pressure showed a good correlation with the expected pressure at each pressure range. The stiffness indices were >10 mmHg in the range of inelastic materials. The device was considered very easy to apply and use by the testing researchers.
Conclusions
The device stiffness is in the same range as the inelastic bandages. Consequently, similar hemodynamic effectiveness could be expected but must be proved. Unlike inelastic bandages, this device was easy to apply and use.
Compression therapy (CT) is the mainstay of venous leg ulcer (VLU) care caused by venous disease resulting in ambulatory venous hypertension. CT is able to counteract the venous hemodynamic impairment and prevent/treat leg edema having a negative impact on ulcer healing. A strong compression is necessary to counterbalance the impaired venous hemodynamics, and a light compression is able to treat/prevent edema. Inelastic devices (inelastic bandages and adjustable compression wraps), able to overcome the intravenous pressure and to restore a valve mechanism, are preferred in large and long-standing VLU. Inelastic bandages are difficult to apply and need a proper education of the healthcare personnel. Adjustable compression wraps are easier to apply, even by the patients themselves allowing self-management and significant cost-saving. In case of small and recent onset venous ulcers, elastic kits, made up of two superimposed stockings and exerting a moderate pressure, can be used. The first layer maintains the dressing in place, stays overnight, and is removed for ulcer cleansing and dressing change. The second layer will be applied during the day to achieve the correct pressure. Compression can be applied also in mixed ulcers provided that arterial disease is moderate and compression pressure is not >40 mmHg.
Objective
Although compression therapy (CT) is considered a crucial conservative treatment in chronic venous disease, strong evidence is missing for many clinical indications. This literature review aims to point out what strong evidence we have for CT and all the clinical scenarios where strong evidence still needs to be included.
Methods
The research was conducted on MEDLINE with PubMed, Scopus and Web of Science. The time range was set between January 1980 and October 2022. Only articles in English were included.
Results
The main problem with CT is the low scientific quality of many studies on compression. Consequently, we have robust data on the effectiveness of CT only for advanced venous insufficiency (C3-C6), deep vein thrombosis and lymphedema. We have data on the efficacy of compression for venous symptoms control and in sports recovery, but the low quality of studies cannot result in a strong recommendation. For compression in postvenous procedures, superficial venous thrombosis, thromboprophylaxis, post-thrombotic syndrome prevention and treatment, and sports performance, we have either no data or very debated data not allowing any recommendation.
Conclusions
We need high-level scientific studies to assess if CT can be effective or definitely ineffective in the clinical indications where we still have a paucity of or contrasting data.
Venous leg ulcers (VLUs) are the most severe complication caused by the progression of chronic venous insufficiency. They account for approximately 70–90% of all chronic leg ulcers (CLUs). A total of 1% of the Western population will suffer at some time in their lives from a VLU. Furthermore, most CLUs are VLUs, defined as chronic leg wounds that show no tendency to heal after three months of appropriate treatment or are still not fully healed at 12 months. The essential feature of VLUs is their recurrence. VLUs also significantly impact quality of life and could cause social isolation and depression. They also have a significant avoidable economic burden. It is estimated that the treatment of venous ulceration accounts for around 3% of the total expenditure on healthcare. A VLU-free world is a highly desirable aim but could be challenging to achieve with the current knowledge of the pathophysiology and diagnostic and therapeutical protocols. To decrease the incidence of VLUs, the long-term goal must be to identify high-risk patients at an early stage of chronic venous disease and initiate appropriate preventive measures. This review discusses the epidemiology, socioeconomic burden, pathophysiology, diagnosis, modes of conservative and invasive treatment, and prevention of VLUs.
Background:
Adjustable compression wraps (ACWs) may represent the future of compression for the treatment of the most severe stages of chronic venous diseases and lymphedema. We tested in five healthy subjects: Coolflex® from Sigvaris®; Juzo wrap 6000®, Readywrap® from Lohmann Rauscher®; Juxtafit® and Juxtalite® from Medi®, Compreflex® from Sigvaris®. The objective of this pilot study was to study the stretch, interface pressures, and Static Stiffness Index (SSI) of the six ACWs applied to the leg.
Methods:
The stretch was evaluated by stretching the ACWs to their maximum length. Interface pressure measurements were performed using a PicoPress® transducer and a probe placed at point B1. Interface pressures were measured in the supine resting position and in the standing position. We calculated the SSI. We started the measurements at 20 mmHg in the supine position and increased the pressures by 5 mmHg to 5 mmHg.
Results:
Coolflex® (inelastic ACW) cannot exceed a maximum pressure of 30 mmHg at rest with a maximum SSI of approximately 30 mmHg. Juzo wrap 6000® (a 50% stretch) and Readywrap® (a 60% stretch) have a profile of stiffness very near one to the other. The optimal stiffness for Juzo is from 16 mmHg to of 30 mmHg for a resting pressure between 25 mmHg and 40 mmHg. For Readywrap, the optimal stiffness is from 17 mmHg to 30 mmHg with a maximum SSI of 35mmHg. The optimal application zone of this wrap at rest is 30 to 45 mmHg. Juxtafit®, Juxtalite® and Compreflex® (respectively 70%, 80%, 124% stretch) can be applied with pressures above 60 mmHg but with maximum SSI of 20 mmHg for Circaid® and>30 mmHg for Compreflex®.
Conclusions:
This pilot study allows us to propose a classification of wraps according to their stretch: inelastic ACW and short or long stretch ACW (50-60% and 70%, 80%, and 124% stretch). Their stretch and stiffness could help to better determine what could be expected of ACWs in clinical practice.
Compression therapy is an integral part of the treatment of venous stasis ulcers, wounds with an edematous component, and for treating limb lymphedema. Sub-bandage pressures above or below an optimal range are detrimental to achieving the goal of edema reduction. Most agree that compression application should achieve pressures between 30 to 40 mmHg 1,2 with a therapeutic pressure gradient from distal to proximal portions of the limb. 3 Deviations from such a therapeutic strategy may not only hinder progress but can be responsible for tissue damage and/or impairment of circulation. In clinical settings there are no readily available means of determining whether therapeutic pressures have been achieved or exceeded. We must rely upon the training and expertise of the therapist. A sub-bandage feedback monitoring system would enable therapists to perfect their technique in achieving the required pressures levels and a therapeutic gradient. In addition the feedback system would likely prove beneficial as a learning tool for students learning compression therapy techniques. Our goal was to determine if feedback, in the form of monitored sub-bandage pressures during lower extremity compression bandaging would help to teach or optimize sub-bandage pressures achieved. This was a quasi-experimental study with a one-group pretest/posttest design. Four experienced lymphedema therapists who regularly use compression bandaging in their treatment for lymphedema were instructed to bandage the lower leg of a single test subject using short stretch bandages to achieve a gaiter pressure of 40mmHg and a therapeutic pressure gradient. They were instructed to use a standard spiral bandaging technique. Bandages consisted of an initial layer of polyester padding to prevent excessive pressure over bony areas. 4,5 Subsequent layers consisted of various widths (8 cm, 10 cm and 12 cm) short stretch bandages. Sub-bandage pressures were monitored with thin resistive sensors linked to a calibrated digital readout device (BandaPress® Bioscience Research Institute, Ft. Lauderdale FL). The sensors were placed at 10 and 20 cm from the lateral malleolus which were designated as gaiter and mid-calf locations respectively. Each therapist was given a total of six trials with each trial separated by 30 minutes. During the first three trials no feedback was offered to the therapist regarding the pressures they had achieved. Prior to starting the next three trials they were informed of the results for their previous trails and feed back information as to pressures achieved was provided immediately after each subsequent trial. During the first three trials, these experienced therapists missed their targets with average pressures at gaiter and mid-calf of 51.9 and 60.5 mmHg respectively. However, for trials that followed feedback, the corresponding average pressures achieved were 38.8 and 27.5 mmHg. See figures 7 & 8. Our goal was to determine if feedback, in the form of monitored sub-bandage pressures during lower extremity compression bandaging, would help to teach or optimize sub-bandage pressures achieved. Physicians, medical providers and medical compression instructors need to have assurance that compression bandages are being applied in a pressure specific, graduated manner and that therapeutic levels are being achieved and not exceeded. Bandaging requires a well-trained experienced therapist who can adjust tension, layers, and padding to the individual patient. Training using this form of sub-bandage monitoring pressure optimizes the sub-bandage pressures achieved during compression bandaging.
Objective
National guidelines in the United Kingdom recommend regular exercise for individuals with venous leg ulceration, yet data for the effect of exercise on ulcer healing and recurrence are sparse. This study aimed to quantify the evidence for exercise in venous ulcer healing with respect to the primary outcomes of proportion of healed ulcers and rate of ulcer recurrence. Secondary outcomes were improvement in ulcer symptoms, ulcer healing time, quality of life, compliance and reported adverse events.
Methods
The review followed PRISMA guidelines using a registered protocol (CRD42021220925). The MEDLINE and Embase databases, as well as the Cochrane Controlled Trials Register, Clinicaltrials.gov, European Union Clinical Trials, International Standard Randomised Controlled Trial Number registries were searched on 6th April 2022 and included articles comparing exercise therapy and compression to compression alone. Data for proportion of healed ulcers were pooled with fixed effects meta-analysis.
Results
After screening 1046 articles, seven reports were included with 121 participants allocated to exercise and 125 to compression. All articles were randomised-controlled trials and reported ulcer healing at 12 weeks, with a pooled relative risk of ulcer healing of 1.38 for exercise versus compression (95% CI 1.11 – 1.71). Only one article reported on recurrence and data pooling was not performed; no difference between exercise and usual care was demonstrated. Compliance with exercise ranged from 33-81%. The included studies demonstrated low enrolment, a high risk of bias and the majority of the trials failed to demonstrate any differences in activity completed by the intervention and control arms.
Conclusions
There is paucity of evidence examining leg ulcer recurrence after exercise programmes and no evidence to show exercise is beneficial. Furthermore, the quality of evidence supporting exercise as an adjunct to ulcer healing is very low and trials demonstrate serious methodological flaws, chiefly in recording activity undertaken by participants in the intervention arm. Future randomised-controlled trials should implement activity monitoring and standardise reporting of key patient, ulcer and reflux characteristics documented hereafter to enable future meaningful meta-analysis to demonstrate the role of exercise as an adjunct to VLU healing.
Objective
Often people with lymphoedema and vascular conditions are prescribed layered compression garments to assist them in donning their garments and improve treatment compliance. However, there is little evidence measuring the interface pressure produced by these layered garments. This study aimed to explore the pressures produced by layering high and low class below knee compression garment combinations, quantify graduation of these combinations, and understand the effect that layer order has on the interface pressure.
Methods
This study utilised a mechanical test design to measure interface pressure at four sites (B: smallest ankle, B1: below calf, C: widest calf, and D: below knee) for thirty combinations of low- and high-class compression garments using a PicoPress.
Results
The results demonstrated a pattern consistent with graduation for sites B1 to D in 100% of garment combinations. However, graduation reversed from sites B to B1 in 100% of garment combinations, possibly due to limitations regarding the shape of the model limb. The results indicated no significant difference in interface pressure when the higher-class garment was applied as the bottom layer compared to the top layer. There was a strong correlation (R>0.95, p<0.001) between the actual pressures produced by combinations of garments and the expected pressure based on the addition of pressures of individual garments.
Conclusions
Graduation was observed from site B1 to D, indicating that double layering of these garment combinations maintained guideline adherence. Layering garments produces pressures that are generally cumulative of the pressures of each garment alone, with some variance. Due to the uncertainty of the B results in this study, clinical implications in relation to the primary aim are limited. The findings from the secondary aim suggest that clinically, garment wearers can don their layered garments in any order and achieve the same interface pressure results.
Unravelling the history of compression therapy, clarifying 'lighter' compression and compression tips for practical application
Venous leg ulcers (VLUs) affect as many as 20% of patients with advanced chronic venous insufficiency and are associated with significant morbidity and health care costs. VLUs are the most common cause of leg ulcers; however, other etiologies of lower extremity ulcerations should be investigated, most notably arterial insufficiency, to ensure appropriate therapy. Careful clinical examination, standardized documentation, and ultrasound evaluation are needed for diagnosis and treatment success. Reduction of edema and venous hypertension through compression therapy, local wound care, and treatment of venous reflux or obstruction is the foundation of therapy. As key providers in venous disease, interventional radiologists should be aware of current standardized disease classification and scoring systems as well as treatment and wound care guidelines for venous ulcers.
Venous leg ulcer due to chronic venous insufficiency is cause by venous hypertension of the leg. It is difficult to cure and easy to recurred. Basic treatment is compression therapy by elastic stocking and bandage. Reimbursement of compression therapy was initiated from April of 2020 in Japan. Investigation of venous and arterial insufficiency with venous duplex and ankle brachial pressure index is essential for diagnosis of venous leg ulcer. Mainstay of treatment is life style modification and compression therapy. Elastic stocking and bandage are used for treatment and prevention of recurrence with careful consideration of adherence. It is important for health care professional to learn how to choose and apply compression therapy with individualize manner for each patient.
The effectiveness of compression therapy in the treatment of venous leg ulcers has been confirmed in many scientific studies. The healing process depends on many of its parameters, such as the type of compression bandages, their elastic properties and sub-bandage pressure. However, there is no standard protocol that would ensure success for all patients. A pressure of about 83 mmHg provides complete compression for both superficial and deep veins; however, applying compression bandages under such high pressure is a difficult task, even for experienced therapists. Here, we present the case of a 61-year-old woman with approximately 2.5-year-old venous ulcer in her left leg due to chronic venous insufficiency (CVI). Our study aimed to show that routine pressure control at each bandage renewal using the Kikuhime device, as well as their twice daily application in the first week of therapy reduced the healing time of a venous leg ulcer with an area of about 20 cm² to four weeks.
Zusammenfassung
Hintergrund Die in der Erhaltungsphase der komplexen physikalischen Entstauungstherapie notwendige Kompressionstherapie kann anstelle von Flachstrick-Kompressionsstrümpfen (FS) auch mit vom Patienten selbst anzulegenden Bandagen erfolgen, den sogenannten medizinischen adaptiven Kompressionssystemen (MAK).
Methoden MAK und FS wurden mittels In-vivo-Druckmessungen unter der von Probanden selbst angelegten Kompression direkt verglichen. Dazu wurden Drücke über Picopress®-Messgeräte und Sensoren (Microlab Elettronica, Italien) an n = 30 Patienten mit beidseitigen, symmetrischen, lymphostatischen Ödemen der Unterschenkel erfasst. FS und MAK wurden seitenrandomisiert zugewiesen. Nach Standardeinweisung und initialen Druckmessungen beider Systeme wurden MAK im Zeitverlauf von 2 und 4 h Tragedauer erneut gemessen. Static-Stiffness-Index (SSI) sowie Druckgradienten der Messhöhen B1-C wurden berechnet.
Ergebnisse MAK zeigen Ruhedruckwerte und SSI im therapeutischen Bereich, die signifikant höher ausfallen als bei FS (p < 0,01 bzw. p < 0,001). MAK erreichen signifikant höhere maximale Arbeitsdrücke (p < 0,001). Die Ruhedruckwerte von MAK zeigen nach 2 und 4 h, ohne Nachjustieren, keinen relevanten Druckabfall. Die mittleren Druckgradienten, bezogen auf die Messhöhen B1-C, unterscheiden sich nicht signifikant zwischen den Methoden.
Diskussion Die mit MAK erreichten Druckparameter untermauern deren therapeutische Effektivität. Die Anwendung von MAK ist auch ohne Nachjustieren druckstabil. Die Anwendung (Selbstanlage) kann als therapeutisch wirksam eingestuft werden. Eine gute Einweisung der Patienten ist jedoch bedeutsam.
Leg ulcers have a venous pathophysiology in the vast majority of cases [1–4]. Superficial or deep venous insufficiency and deep vein obstruction produce ambulatory venous hypertension due to venous reflux and venous pumping function impairment. The impaired venous hemodynamics is the key pathophysiologic mechanism leading to skin damage through several intermediate steps.
Compression bandages are commonly used for the treatment of chronic venous insufficiency. They apply a pressure onto the leg, called interface pressure, which is one of the key aspects of the treatment. The objective was to better understand the mechanisms impacting interface pressure applied by compression bandage on the lower leg. In collaboration with clinicians and a medical devices manufacturer, a biomechanical approach was proposed. This approach was composed of experimental pressure measurements and the numerical simulation of bandage application. Two preliminary studies, experimental and numerical, showed the limitations of the use of Laplace’s Law (current standard) for interface pressure computation. These studies also questioned the possible impact of bandage surface properties (bandage-to-bandage friction coefficient) on interface pressure. They also showed the need to consider soft tissues deformation induced by bandage application. Two characterization methods were designed for the identification of patient-specific soft tissue mechanical properties and the measurement of bandage-to-bandage friction coefficient. A new methodology for the prediction of interface pressure was developed thanks to the combination of the numerical simulation of bandage application and the leg geometry parametrization. The results were then confronted to experimental measurements. Finally, a clinical study was designed to investigate the pressure applied by superimposed compression bandages (very common in clinical practice for the treatment of venous ulcers).
Unter konservativer Therapie soll hier die Therapieform verstanden werden, die auf jede Art der aktiven invasiv manipulativen oder aktiv systemisch oder lokal lytischen Verminderung der Thrombusmenge bzw. Thrombusausdehnung verzichtet.
The compression pressure, which corresponds to the dosage of compression therapy, has been widely neglected up to now, not only concerning scientific literature, but also in clinical practice. It is evident that compression pressures in the upright position and during walking are clinically more relevant than just the resting pressure. The Static Stiffness Index (SSI), which is the difference between standing and resting pressure, is a valuable parameter characterising the efficacy of a specific compression product to narrow/occlude the venous lumen. This is a prerequisite for reducing venous reflux and exerting a massaging effect necessary to improve the venous pumping function during movement. This article provides an overview of the recent literature on the SSI, which supports the recommendations of the International Compression Club. In addition, it aims to provide an insight on the importance of the SSI in daily practice, as an educational tool as well as in defining the properties of applied compression therapy in clinical research.
To evaluate the effectiveness of community clinics for leg ulcers.
All patients with leg ulceration were invited to community clinics that offered treatment developed in a hospital research clinic. Patients without serious arterial disease (Doppler ankle/brachial index > 0.8) were treated with a high compression bandage of four layers.
Six community clinics held in health centres in Riverside District Health Authority supported by the Charing Cross vascular surgical service.
All patients referred to the community services with leg ulceration, irrespective of cause and duration of ulceration.
Time to complete healing by the life table method.
550 ulcerated legs were seen in 475 patients of mean (SD) age 73.8 (11.9) years. There were 477 venous ulcers of median size 4.2 cm2 (range 0.1-117 cm2), 128 being larger than 10 cm2. These ulcers had been present for a median of three months (range one week to 63 years) with 150 present for over one year. Four layer bandaging in the community clinics achieved complete healing in 318 (69%) venous ulcers by 12 weeks and 375 (83%) by 24 weeks. There were 56 patients with an ankle/brachial arterial pressure index < 0.8, indicating arterial disease. The 50 patients with pressure index < 0.8 > 0.5 were treated with reduced compression, and 24 (56%) healed by 12 weeks and 31 (75%) by 24 weeks. The figures for overall healing for all leg ulcers were 351/550 (67%) at 12 weeks and 417/550 (81%) at 24 weeks, compared with only 11/51 (22%) at 12 weeks before the community clinics were set up.
Community clinics for venous ulcers offer an effective means of achieving healing in most patients with leg ulcers.
Comparison of four layer bandage system with traditional adhesive plaster bandaging in terms of (a) compression achieved and (b) healing of venous ulcers.
Part of larger randomised trial of five different dressings.
Outpatient venous ulcer clinic in university hospital.
(a) Pressure exerted by both bandage systems was measured in the same 20 patients. (b) Healing with the four layer bandage was assessed in 148 legs in 126 consecutive patients (mean age 71 (SE 2); range 30-96) with chronic venous ulcers that had resisted treatment with traditional bandaging for a mean of 27.2 (SE 8) months.
(a) Four layer bandage system or traditional adhesive plaster bandaging for pressure studies; (b) four layer bandaging applied weekly for studies of healing.
(a) Comparison of pressures achieved at the ankle for up to one week; (b) complete healing within 12 weeks.
(a) Four layer bandage produced higher initial pressures at the ankle of 42.5 (SE 1) mm Hg compared with 29.8 (1.8) for the adhesive plaster (p less than 0.001; 95% confidence interval 18.5 to 6.9). Pressure was maintained for one week with the four layer bandage but fell to 10.4 (3.5) mm Hg at 24 hours with adhesive plaster bandaging. (b) After weekly bandaging with the four layer bandage 110 of 48 venous ulcers had healed completely within 12 (mean 6.3 (0.4)) weeks.
Sustained compression of over 40 mm Hg achieved with a multilayer bandage results in rapid healing of chronic venous ulcers that have failed to heal in many months of compression at lower pressures with more conventional bandages.
Air plethysmography (APG) was compared with clinical assessment and light reflection rheography (LRR) in 68 patients with venous insufficiency (129 limbs). The aim of this study was to investigate the possibilities and limitations of this device for general phlebological practice. Out of the 68 patients, 9 were not able to perform the total investigation protocol (13%). The reflux measurement and the ejection capacity of the calf muscle pump correlated well with severe venous disease, but poorly with mild or absent signs of venous insufficiency. Abnormal refill time measured with LRR was in accordance in 82% with increased reflux with APG. A normal refill time was only correlated in 60% of the cases with a normal reflux APG test. it was not possible to distinguish between deep and superficial insufficiency, it is concluded that APG did not turn out to be the handy method for quick and accurate screening of venous insufficiency patients, its place in the clinical evaluation for venous patients is not yet clear.
This study was set up to evaluate the interface pressure underneath short stretch (approximately 70% elasticity) and elastic (approximately 170% elasticity) bandages at different places and at several intervals during 7 days. Furthermore measurements were taken during active walking on a treadmill at a certain speed. A total of 39 legs from 35 subjects (33 known with venous insufficiency and two healthy probands) were investigated in time. 15 legs of 11 healthy subjects were studied during active walking. Interface pressure recordings were made with the aid of an Oxford Pressure Measurement MK II (CPM) machine. The cells were placed at twelve different areas of the leg and recordings were made in supine position. The pressure underneath the short stretch bandage showed a rapid decreases in pressure in supine position (80.5 mmHg to 43.6 mmHg after 3 hours and 26.3 after 7 days). In the elastic bandages the pressures stayed high in all positions. At the Achilles tendon, dorsal foot and pretibial area extreme high pressure were found up to 150 mmHg continuing to stay high in the elastic bandages. During walking the maximal and minimal pressure were statistically different (p < 0.05) in favor of the short stretch bandage. It can be concluded from the study that short stretch bandages are not only safer and more economical in the treatment of patients with venous complaints, but are also more effective because of their better walking pressures.
Compression therapy is a powerful method for the treatment of all sorts of swollen extremities. Its effects depend on several factors, including: underlying disease, exerted pressure and body position, and compression material.
Objective
To determine whether elastic or non-elastic bandaging is more effective in healing chronic venous ulcers.
Design
Randomized trial with factorial design and interaction analysis, enabling independent evaluation of both bandaging and dressings within the single-trial format. The duration of treatment was 12 weeks or until ulcer-healing, whichever occurred sooner.
Setting
The Leg Ulcer Clinics of Edinburgh and Falkirk and District Royal Infirmaries, Scotland.
Patients
132 patients with chronic leg ulcers and clinical evidence of chronic venous disease, and excluding those with Doppler ultrasound ankle/brachial pressure indices of less than 0.8, diabetes or rheumatoid disease. There were 28 withdrawals who were classified for analysis as treatment failures.
Interventions
Elastic or non-elastic multilayer bandage systems were applied using similar application techniques by a team of trained nurse specialists. All other treatments were standardized, including the randomization of dressings to either a knitted viscose or a hydrocellular polyurethane dressing.
Main outcome measure
Complete ulcer healing.
Results
In the elastic group 35 out of 65 ulcers (54%) healed within 12 weeks compared with 19 out of 67 (28%) in the non-elastic group (95% confidence limits for percentage healed, 9% to 42%). Ulcer pain was also reported significantly less often in the elastic group (48% of visits versus 29%; p=0.03).
Conclusion
When applied by similar multilayer bandaging techniques, elastic bandaging was significantly better than non-elastic bandaging in the treatment of chronic venous leg ulcer.
Objective: To assess the effect of femoral vein compression in a patient with congenital avalvulae. Design: Single patient study. Setting: Department of Dermatology; Teaching Hospital, Vienna, Austria. Patient: A single patient with the rare condition of congenital absence of venous valves. Interventions: Compression of the thigh using a thigh cuff. Main outcome measures: Ambulatory venous pressure measurement. Results: The ambulatory venous pressure was reduced when the thigh calf pressure was increased in excess of 70mmHg. Conclusion: Thigh compression in a patient with congenital absence of venous valves resulted in a temporary valve mechanism permitting orthograde flow during muscle systole, but inhibiting venous reflux.
Twenty-one patients with stasis leg ulcers were randomly assigned to two groups. The first group was treated with Unna's boots, while the second was treated with elastic support stockings with graded compression from 24 mm/Hg pressure at the ankle to 16 mm/Hg pressure at the calf. The ulcers on seven of ten legs (70%) treated with Unna's boots and on 10 of 14 legs (71%) treated with elastic support stockings healed. Although the two groups were small, there was no statistically significant difference between their success rate in healing stasis leg ulcers (p = 0.9394). Both treatment groups showed significant changes in lower limb volume, calf circumference, and ankle circumference, although there was no statistically significant difference between the two groups. If healing times are calculated, however, the average healing time in the Unna boot-treated group was 7.3 weeks, while patients treated with support stockings took an average of 18.4 weeks. If one patient whose ulcerations almost encircled her calves and took 78 weeks to heal is excluded, patients treated with support stockings had an average healing time of 11.8 weeks.
Compression therapy is a powerful method for the treatment of all sorts of swollen extremities. Its effects depend on several factors, including: underlying disease, exerted pressure and body position, and compression material.
In many centers the standard treatment for venous stasis ulcers consists of UB dressings. A new dressing, DuoDERM hydroactive dressing (HD), has recently been used extensively for the treatment of venous stasis ulcers. Because of this trend, a prospective, randomized trial of these two dressings was undertaken. Sixty-nine ulcers (39 HD and 30 UB) were randomized. End points were complete healing and development of complications necessitating cessation of treatment. Time to healing, cost of treatment, and patient convenience were also evaluated. Twenty-one of 30 ulcers (70%) healed with UB therapy compared with 15 of 39 ulcers (38%) treated with HD (p less than 0.01, CST). Life-table healing rates at 15 weeks were 64% for UB compared with 35% for HD (p = 0.01, log rank test). Ten of 39 patients (26%) receiving HD had complications compared with no complications in the UB group (p = 0.004, FET). For those patients whose ulcers healed, there was no significant difference (p = 0.51, STT) in the mean time required for healing or the average weekly cost of dressing materials between the HD group (7.0 weeks at +11.50 per week) and the UB group (8.4 weeks at +12.60 per week). Those patients treated with HD reported a significantly greater level of convenience than those patients with UB (p = 0.004, STT). Although treatment with HD led to better patient acceptance, those patients receiving UB therapy had a significantly greater rate of healing and a significantly lesser incidence of complications than those patients treated with HD.
Leg volume changes during exercise have been measured in absolute units (milliliters) by means of a new method of air-plethysmography. Venous volume (VV), venous filling time, and venous filling index on standing from the recumbent position, ejected volume (EV) and ejection fraction (EF = EV x 100/VV) with one tiptoe movement, and residual volume (RV) and residual volume fraction (RVF = RV x 100/VV) after 10 tiptoe movements were measured in normal limbs, limbs with superficial venous incompetence, and limbs with deep venous disease. The same measurements were repeated with a graduated medium compression stocking in limbs with SVI and graduated high compression stockings in limbs with DVD. Ambulatory venous pressure was measured at the same time, with a needle in a vein in the foot. The results indicate that this method of air-plethysmography is not only of diagnostic value but offers a new and unique technique to assess and study the hemodynamic effects of different forms of elastic compression. The lower ambulatory venous pressure, produced by the elastic compression, was the result of a reduction in reflux and an improvement in the calf muscle ejecting ability during rhythmic exercise.
Twenty-one patients with stasis leg ulcers were randomly assigned to two groups. The first group was treated with Unna's boots, while the second was treated with elastic support stockings with graded compression from 24 mm/Hg pressure at the ankle to 16 mm/Hg pressure at the calf. The ulcers on seven of ten legs (70%) treated with Unna's boots and on 10 of 14 legs (71%) treated with elastic support stocking healed. Although the two groups were small, there was no statistically significant difference between their success rate in healing stasis leg ulcers (p = 0.9394). Both treatment groups showed significant changes in lower limb volume, calf circumference, and ankle circumference, although there was no statistically significant difference between the two groups. If healing times are calculated, however, the average healing time in the Unna boot-treated group was 7.3 weeks, while patients treated with support stockings took an average of 18.4 weeks. If one patient whose ulcerations almost encircled her calves and took 78 weeks to heal is excluded, patients treated with support stockings had an average healing time of 11.8 weeks.
The acute and long-term effect of elastic stockings has been evaluated in 20 patients (20 limbs) with grade 2 venous disease. The sites of venous reflux were determined with colour flow duplex scanning. Air Plethysmography was used to measure the amount of venous reflux and the ejecting capacity of the calf muscle pump. The patients were classified in to two different groups, A and B. Both groups of patients wore elastic stockings for four weeks. In group A (no. = 9) the measurements were done before, during and one day after the removal of the stockings, whereas in group B (no. = 11) the last measurements were done immediately after the removal of the stockings. Patients that showed improvement in their haemodynamics were re-examined a week later. Elastic compression appeared to be beneficial in both groups. The application of the elastic stockings improved reflux and the residual volume fraction in both groups and the ejecting capacity of the calf muscle pump in group B. Immediately after the removal of the stockings (Group B) all the measurements regressed to the initial values with the exemption of the residual volume fraction. However, one week later, the latter also regressed to the original value. It is concluded that the beneficial effect of elastic stockings on the venous haemodynamics is present mainly when the stockings are worn. It is completely abolished within a day after their removal.
The purpose of this study was to validate the diagnostic capabilities of the most commonly used noninvasive modalities for evaluation of chronic venous insufficiency.
Twenty limbs in 20 patients were studied with air plethysmography (APG), photoplethysmography (PPG), and duplex ultrasonography. Ten limbs (group 1) were clinically without any venous disease. Group 2 consisted of 10 limbs with severe, class 3 venous stasis. Duplex ultrasonography, complemented with Doppler color-flow imaging was used to examine the superficial and deep venous systems to identify reflux.
Ultrasonography identified deep venous reflux in eight of 10 limbs in group 2. Severe superficial reflux was identified in the two remaining limbs. Seven limbs with deep reflux also demonstrated severe superficial reflux. Superficial venous reflux was identified in one leg in group 1. APG accurately separated normal limbs from those with reflux. Parameters that were significantly different (p < 0.05) between the two groups were the venous filling index, (group 1 = 1.37 +/- 1.16 ml/sec, group 2 = 29.5 +/- 6.2 ml/sec.), venous volume (group 1 = 107 +/- 10.1 ml, group 2 = 220 +/- 22.5 ml), ejection fraction (group 1 = 52.5% +/- 2.3%, group 2 = 32.5% +2- 4.6%), and residual volume fraction (group 1 = 21.4 +/- 2.0%, group 2 = 52.1% +/- 2.5%). PPG refill times were significantly shortened in group 2 versus those of group 1 (6.4 +/- 0.89 sec vs 20.2 +/- 1.1 sec). The sensitivity of PPG refill times to identify reflux was 100%, but the specificity was only 60%, whereas the sensitivity and specificity for the residual volume fraction was 100%. The venous filling index was able to identify reflux and determine whether only superficial reflux was present with a sensitivity of 100% and a specificity of 90%. The kappa coefficient of agreement between duplex scanning and APG was 0.83, whereas between duplex and PPG it was only 0.47.
APG accurately identifies limbs with and without venous reflux when compared with duplex ultrasonography. APG is a better method of evaluating clinically significant venous reflux than PPG. PPG is a sensitive method of detecting reflux, but the specificity is poor, and PPG refill times cannot accurately predict the location of reflux. The combination of APG and duplex ultrasonography provides the best means of assessing venous reflux.
The best way to quantitate venous reflux is still a matter of debate. Duplex-derived valve closure time (VCTs) have been used recently because they can be measured easily. We examined the relationships between VCT and duplex-obtained quantitation of venous volume and between VCT and air plethysmography (APG). Sixty-nine legs in 45 patients with varying clinical degrees of chronic venous insufficiency were studied by duplex scan and APG. VCTs were compared with duplex-derived flow calculations and with APG-derived venous filling index and residual volume fraction. The patient's mean age was 47.5 +/- 13.9 years; the mean duration of their symptoms was 13 +/- 4 years. Twenty percent had a history of deep venous thrombosis, and 29% had undergone venous surgery. No correlation was found between VCT and flow volume or between VCT and flow at peak reflux at any of the anatomic locations studied: saphenofemoral junction, greater saphenous vein, lesser saphenous vein, superficial femoral vein, profunda femoris vein, and popliteal vein. Likewise, no correlation was found between total VCT and APG-derived venous filling index or between total flow volumes and APG-derived residual volume fraction. Total VCT and total flow volumes did, however, have a moderate correlation (r = 0.65; p = 0.0003). Duplex-derived VCTs, although extremely useful in determining the presence of reflux, do not correlate with the magnitude of reflux, and should not be used to quantitate the degree of reflux.
Compression of the lower extremity is the mainstay of therapy in patients who have chronic venous insufficiency. We evaluated the ability of two forms of compression-elastic stockings and an inelastic compression garment-with air plethysmography to determine how well they corrected abnormal deep venous hemodynamics in patients who had class III chronic venous insufficiency and how well this correction was sustained over time.
Patients had measurements taken with no compression, with a 30 to 40 mm Hg below-knee stocking, and with the inelastic compression garment 2 hours and 6 hours after donning the garments. Therapies were compared with baseline and with themselves over time.
Inelastic compression maintained limb size and reduced venous volume better than no compression or stockings over time (ankle circumference at 2 hr vs 6 hr: baseline, 24.7 +/- 7 cm vs 26.1 +/- 1.1 cm; stocking, 23.9 +/- 1.1 cm vs 26.2 +/- 1.2 cm; inelastic compression, 25.4 +/- 1.1 cm vs 25.4 +/- 0.9 cm; venous volume at 2 hr vs 6 hr: baseline, 97.5 +/- 14.1 ml vs 105.2 +/- 17.9 ml; stocking, 112.4 +/- 29.7 ml vs 77.5 +/- 13.2 ml; inelastic compression, 72.2 +/- 14.1 ml vs 56.1 +/- 10.2 ml). At 6 hours, the ejection fraction was increased and the venous filling index was significantly less with inelastic compression compared with the stocking and baseline (ejection fraction at 6 hr: baseline, 61.6% +/- 6.9%; stocking, 75.9% +/- 17.7%; inelastic compression, 78.8% +/- 12.2%).
Inelastic compression has a significant effect on deep venous hemodynamics by decreasing venous reflux and improving calf muscle pump function when compared with compression stockings, which may exert their primary effect on the superficial venous system.
Air plethysmography has been useful in assessing patients who have chronic venous insufficiency. Limb reflux times determined by color-flow-assisted duplex scanning have been shown to correlate with the severity of chronic venous insufficiency. The purpose of this study was to compare air plethysmographic measurements with reflux times obtained by color-flow-assisted duplex scanning in patients with chronic venous insufficiency.
One hundred twenty-two limbs in 61 consecutive patients with various stages of chronic venous insufficiency were evaluated; air plethysmographic and color-flow-assisted duplex scans were performed at the same sitting. Fifty-nine of the patients had venous ulceration. Values obtained by air plethysmographic scans included venous filling index, ejection volume, residual volume, ejection fraction, and residual volume fraction. Color-flow-assisted duplex scan values included reflux times in the deep and superficial venous segments and total and mean limb reflux times.
Using the Pearson correlation, the venous filling index was found to correlate significantly with total limb venous reflux times, mean total limb reflux times, and venous reflux times in the deep venous system, as determined by color-flow-assisted duplex scans (p < 0.001).
Limb reflux time as determined by color-flow-assisted duplex scans correlated significantly with the air plethysmographic variable accepted as a measure of the severity of venous reflux, the venous filling index. This study confirms the validity of total limb reflux times in the quantification of chronic venous insufficiency.
The relationship between deep and superficial venous reflux and healing of venous ulceration by non-operative compression therapy has not been studied previously.
A total of 155 patients with chronic venous ulcers underwent duplex ultrasonography before treatment with compression bandaging at a hospital-based venous clinic.
At 24 weeks, 104 (67 per cent) of ulcers had healed. There was no significant difference in the pattern of either deep or superficial venous reflux between healed and non-healed ulcers except with respect to the popliteal vein. In healed ulcers, 39 scans (38 per cent) indicated competence of the above-knee popliteal vein compared with five (10 per cent) in the non-healing group (P < 0.001, chi 2 test). Similarly, 43 scans (42 per cent) showed below-knee popliteal vein competence in the healed ulcers compared with only five (10 per cent) performed in legs remaining ulcerated (P < 0.001, chi 2 test).
Popliteal vein incompetence is an indicator of poor response to compression therapy for venous ulceration.
Objective
To compare the efficacy of a long-stretch bandage with that of a short-stretch compression bandage.
Design
Prospective evaluation of healing of venous leg ulcers in blindly randomized groups of patients.
Setting
Bispebjerg Hospital, Copenhagen, Denmark.
Patients
Forty-three patients with venous leg ulcers were included. Forty legs in 40 patients were evaluated at 1 month (34 patients), 6 months (32 patients) or 12 months (27 patients).
Interventions
Both types of bandage were used at a width of 10 cm and applied using the same spiral bandaging technique.
Main outcome measures
Ulcer healing and ulcer area reduction.
Results
Healed ulcers after 1 month were observed in 27% of the long-stretch group and in 5% of the short-stretch group ( p = 0.15); after 6 months the corresponding figures were 50% and 36% ( p = 0.49) and after 12 months 71% and 30% ( p = 0.06). Using life-table analysis the predicted healing rate in the long-stretch group after 12 months was 81% and for the short-stretch group 31% ( p = 0.03). The mean of relative ulcer areas at 1 month was 0.45 for the long-stretch group and 0.72 for the short-stretch group ( p = 0.07), at 6 months the corresponding figures were 0.81 and 0.60 ( p = 0.25) and at 12 months 0.25 and 0.95 ( p = 0.01).
Conclusions
The present study appears to indicate a Positive influence of the elasticity of a compression bandage on venous ulcer healing.
Ulcus cruris: abheilung unter konservativer therapie-eine prospektive studie
- W Mayer
- W Jochmann
- H Partsch
Mayer W, Jochmann W, Partsch H. Ulcus cruris: abheilung unter
konservativer therapie-eine prospektive studie. Wiener Medizinisch
Wochenschrift 1994;144:250-2.
Validation of air plethysmography, photoplethysmography, and duplex ultra-sonography in the evaluation of severe venous stasis
- Bays Ra Da Healy
- Atnip Rg
- M Neumyer
- Thiele
- Bl
Bays RA, Healy DA, Atnip RG, Neumyer M, Thiele BL. Validation of air plethysmography, photoplethysmography, and duplex ultra-sonography in the evaluation of severe venous stasis. J Vasc Surg 1994;20:721–7.
Reduktion der venösen ambulatorischen hypervonie durch veneneinengung
- H Partsch
Partsch H. Reduktion der venösen ambulatorischen hypervonie
durch veneneinengung. z. Arzt Fortbildung 1986;80:123-6.
Reduction of venous reflux by compression: a comparison between short and long stretch material
- G Menzinger
- M Horakova
- W Mayer
- H Partsch
Menzinger G, Horakova M, Mayer W, Partsch H. Reduction of
venous reflux by compression: a comparison between short and
long stretch material. Phlebology 1995;10:(suppll):888-91.
Static and dynamic measure-ment of compression pressure Frontiers in computer-aided visualisation of vascular func-tions
- H Partsch
- G Menzinger
- Blazek
Partsch H, Menzinger G, Blazek V. Static and dynamic measure-ment of compression pressure. In: Blazek V, Schultz-Ehrenburg U, eds. Frontiers in computer-aided visualisation of vascular func-tions. Düsseldorf: VDI Verlag, 1988:145–53.
Hazards of compres-sion treatment of the leg and estimated from Scottish surgeons
- Callam Mj
- Cv
- Jj Dale
- Harper
Callam MJ, Ruckley CV, Dale JJ, Harper DR. Hazards of compres-sion treatment of the leg and estimated from Scottish surgeons. Br Med J 1987;295:1382.
Kompressionsstrümpfe zur behandlung venöser unterschenkelgeschwüre
- H Partsch
- M A Horakova
Partsch H, Horakova MA. Kompressionsstrümpfe zur behandlung
venöser unterschenkelgeschwüre. Wiener Medizinisch Wochenschrift
1994;144:242-9.
Investigation of patients with deep vein thrombosis and chronic venous insufficiency
- Nicolaides
- Sumner
Nicolaides AN, Sumner DS. Investigation of patients with deep vein
thrombosis and chronic venous insufficiency. London: Med-Orion,
1991:49.
Reduction of venous reflux by compression: a compari-son between short and long stretch material. North American Soci-ety of Phlebology 9th Annual Congress
- H Partsch
Partsch H. Reduction of venous reflux by compression: a compari-son between short and long stretch material. North American Soci-ety of Phlebology 9th Annual Congress, February 25–27, 1996.
Reduction of venous reflux by compression: a comparison between short and long stretch material
- H Partsch
Partsch H. Reduction of venous reflux by compression: a comparison between short and long stretch material. North American Society of Phlebology 9th Annual Congress, February 25-27, 1996.
Static and dynamic measurement of compression pressure
- H Partsch
- G Menzinger
- V Blazek
Partsch H, Menzinger G, Blazek V. Static and dynamic measurement of compression pressure. In: Blazek V, Schultz-Ehrenburg U,
eds. Frontiers in computer-aided visualisation of vascular functions. Düsseldorf: VDI Verlag, 1988:145-53.