Compression therapy in patients with venous leg ulcers

Review Article Submitted: 15.1.2016 Accepted: 6.5.2016 Conflict of interest J. Dissemond has received consulting or lecture fees from: 3M, BSN, Hartmann, Lohmann & Rauscher and Urgo. K. Kröger has received consulting or lecture fees from: 3M, BSN, Hartmann, Lohmann & Rauscher, Urgo and Smith & Nephew. C. Münter has received consulting or lecture fees from: BSN, Hartmann and Urgo. K. Protz has received consulting or lecture fees from: 3M, Bauerfeind, BSN, Hartmann, Lohmann & Rauscher, medi, Smith & Nephew and Urgo. All other authors declare no conflict of interest.

DOI: 10.1111/ddg.13091

Compression therapy in patients with venous leg ulcers

Joachim Dissemond1, Bernd Assenheimer2, Anke Bültemann3, Veronika Gerber4, Silvia Gretener5, Elisabeth Kohler-von Siebenthal6, Sonja Koller 7, Knut Kröger8, Peter Kurz9, Severin Läuchli10, Christian Münter 11, Eva-Maria Panfil12, Sebastian Probst13, Kerstin Protz14, Gunnar Riepe15, Robert Strohal16, Jürg Traber 17, Hugo Partsch18 (1) Department of Dermatology, Venereology, and Allergology, University Hospital Essen, Germany (2) ICW (Initiative Chronic Wounds) and Wund-D.A.CH., School of Nursing, University Medical Center, Tübingen, Germany (3) ICW, Wound Center/Vascular Surgery, Asklepios Medical Center, Harburg, Germany (4) ICW and Wund-D.A.CH., Consulting and Training in Wound Management, Spelle, Germany (5) SAfW (Swiss Association for Wound Care), St. Urban 67, Langenthal, Switzerland (6) SAfW, Spitex Interlaken area, Unterseen, Switzerland (7) AWA (Austrian Wound Association), Institute for Functional Phlebosurgery, Gottsdorf, Austria (8) ICW, Department of Vascular Medicine, Angiology, HELIOS Medical Center Krefeld LLC, Krefeld, Germany (9) AWA and Wund-D.A.CH., WPM Wound Care Management, Bad Pirawarth, Austria (10) SAfW and Wund-D.A.CH., Department of Dermatology, University Hospital, Zurich, Switzerland (11) ICW, Group Practice Bramfeld, Hamburg, Germany (12) SAfW, University Hospital Zurich, Switzerland (13) SAfW and Wund-D.A.CH., ZHAW Zurich University of Applied Sciences, School of Health, Winterthur, Switzerland (14) ICW, Bachstraße 75, 22083, Hamburg, Germany (15) ICW, Community Hospital Mittelrhein LLC, Center for Vascular Medicine and Wound Care, Koblenz, Germany (16) AWA and Wund-D.A.CH., Feldkirch State Hospital, Department of Dermatology and Venereology, Feldkirch, Austria (17) SAfW and Wund-D.A.CH., Center for Venous Disorders Bellevue, Surgery/ Vascular Surgery FEBVS, Phlebology SGP, Kreuzlingen, Switzerland (18) AWA and Wund-D.A.CH., Steinhäusl 126, 3033, Altlengbach, Austria

Summary Wund-D.A.CH. is the umbrella organization of the various wound care societies in German-speaking countries. The present consensus paper on practical aspects pertinent to compression therapy in patients with venous leg ulcers was developed by experts from Germany, Austria, and Switzerland.

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© 2016 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2016/1411

Review Article Compression in leg ulcers

In Europe, venous leg ulcers rank among the most common causes of chronic wounds. Apart from conservative and interventional wound and vein treatment, compression therapy represents the basis of all other therapeutic strategies. To that end, there are currently a wide variety of materials and systems available. While especially shortstretch bandages or multicomponent systems should be used in the initial decongestion phase, ulcer stocking systems are recommended for the subsequent maintenance phase. Another – to date, far less common – alternative are adaptive Velcro bandage systems. Medical compression stockings have proven particularly beneficial in the prevention of ulcer recurrence. The large number of treatment options currently available enables therapists to develop therapeutic concepts geared towards their patients’ individual needs and abilities, thus resulting in good acceptance and adherence. Compression therapy plays a crucial role in the treatment of patients with venous leg ulcers. In recent years, a number of different treatment options have become available, their use and application differing among German-speaking countries. The present expert consensus is therefore meant to outline concrete recommendations for routine implementation of compression therapy in patients with venous leg ulcers.

Preamble Wund-D.A.CH. is the umbrella organization of the various wound management societies in German-speaking countries. Founded by the ICW (Chronic Wounds Initiative, Germany), AWA (Austrian Wound Association), and SAfW (Swiss Association for Wound Care), it is now supported by numerous other scientific societies and associations in these countries. A key objective of Wund-D.A.CH. is the promotion of projects aimed at improving the quality of wound care. The present practice-oriented consensus was developed on the basis of the 2nd edition of the “Consensus Recommendations on Compression Therapy” issued by the ICW in 2012 [1, 2]. From October 2014 to January 2016, experts designated by the various professional societies (from said countries) compiled a list of statements that included data derived from the ICW consensus recommendations as well as newly developed systems and new scientific knowledge. Using the multistep Delphi technique, these statements were subsequently assessed, allowing for the development of the updated und completely revised consensus recommendations presented herein. Authorized by the original authors, passages taken verbatim from the original consensus recommendations have been properly marked (references 1 and 2).

Introduction Compression therapy is a scientifically sound, widely applied, interdisciplinary, and well-established treatment modality relevant to professionals of various specialties, which is used

in a number of conditions such as venous disorders, thromboses, lymphedema, or lipedema [3, 4]. Very good results have also been achieved in the treatment of various kinds of edema, for example, following accidents [5]. The expert consensus presented below primarily focuses on compression therapy in patients with venous leg ulcers. In Europe, chronic venous insufficiency (CVI) is the most important pathophysiological factor in patients with chronic leg ulcers, constituting roughly 70 % of all cases [6]. Chronic venous insufficiency denotes the findings and symptoms associated with chronic venous hypertension, which results in persistently impaired venous return from peripheral to central veins. The most important causes of CVI are postthrombotic syndromes (PTS), venous valve insufficiency, varicose veins, or vascular malformations. Other predisposing factors include higher age, pregnancy, obesity, and (occupational) activities done in a standing position [4, 7, 8]. Adequate and skilled compression therapy – in conjunction with exercise – is the basis for successful treatment of patients with venous leg ulcers, and numerous randomized controlled studies have provided scientific evidence as to its effectiveness [9–11]. In addition, this should always be complemented by individually adjusted wound treatment based on the various phases of wound healing [12]. However, with respect to the latter, the evidence base is significantly poorer [13]. Based on an adequate diagnostic workup, many patients may also benefit from treatment specifically targeting the underlying causes, including interventional or surgical procedures. Superficial venous insufficiency, for example, is frequently treatable, and pelvic vein obstructions may be revascularized [14, 15].


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Basic principles of compression therapy Depending on the position of the body, compression therapy improves venous return [16]. The consistent pressure applied to the veins results in a decrease in vessel diameter, in reduced transmural pressure, and thus in a flow rate that is almost twice as high. In a lying position, pressure values as low as 15 mmHg are sufficient to constrict superficial and deep veins, which subsequently leads to an acceleration in blood flow. To achieve this while standing up, significantly higher pressure values (60–90 mmHg) are required [17]. Compression with a stiff, rigid material provides stable support for the leg muscles, thereby increasing the effects of the muscle pump, which in turn results in improved venous return [18]. The latter leads to edema reduction as well as pain relief. The question as to whether leg ulcer patients might potentially benefit from additional compression of the thighs cannot be unequivocally answered based on current literature. Although strong nonelastic thigh bandages may reduce venous return [18], there are as yet no reports on accelerated ulcer healing. Moreover, additional thigh compression is likely to result in poorer adherence, which has similarly been described for the use of thromboembolic devices (TEDs) [19] and compression stockings for the prevention of PTS [20]. Thus, although thigh compression may indeed be applied in individual cases, it is currently not recommended as standard treatment for venous leg ulcers. In the short term, properly applied compression therapy results in peripheral decongestion; in the long term, in the prevention of tissue remodeling as well as ulcer healing [11]. In addition, compression therapy has beneficial effects in the prevention of recurrences [4, 9]. With regard to microcirculation, compression decreases fluid filtration into the tissue and increases lymphatic drainage. Another effect is the release of vasoactive antiinflammatory mediators by endothelial cells, which is relevant to ulcer healing [21]. The postulate formulated by Starling in 1896 with respect to the absorption of tissue fluid by veins and lymphatic vessels has been critically questioned in recent years. It has been shown that, while arteries and veins filter fluid into the tissue, it is primarily absorbed by lymphatic vessels [22]. The application of compression bandages requires comprehensive experience and regular training. Correct application may be learned, for example, by doctors, nurses, lymph therapists or – following proper training – relatives. Given that proper self-bandaging may in practice only be done by very few patients, it should not be recommended [23]. Here, ulcer stocking systems or adaptive compression bandages, which may usually be applied by patients or their relatives, represent an alternative that ensures sustained, sufficient compression therapy with the patient’s active participation. Such self-management may lead to improved acceptance

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and cooperation on the part of patients [24]. The goal is to achieve effective, well-fitting compression without pressure damage or limb deformation. The pressure exerted by compression bandages depends on the tightness with which they are wrapped, the curvature or the radius of the particular segment of the extremity, and the material/fabric. According to Laplace’s law, the pressure decreases with increasing leg circumference (inverse proportionality), unless there is a change in other parameters. In compression therapy, the physiological morphology of the leg thus ensures a decreasing pressure gradient. In practice, many bandages are wrapped too loosely, even by experienced users [25, 26]. Consequently, proper compression techniques should be practiced on a regular basis; in this context, pressure sensors may aid in checking for adequate pressure application [27, 28]. The indication for and prescription of compression therapy is the physician’s responsibility, who also assumes medical responsibility for considering potential contraindications. The adequate and skilled application is the job of a qualified nurse, who should also critically consider indications and contraindications. The strength of the compression to be applied has to correspond to the therapeutic goal and thus adjusted according to treatment stage. In this context, the following phases may be distinguished:  

Decongestion phase: control of CVI, edema reduction, and ulcer healing Maintenance phase: prevention of edema and avoidance of recurrences.

In the decongestion phase, the primary goal is edema reduction, improvement of microperfusion, and/or ulcer healing. Hence, strong compression has to be ensured, which may be achieved by using short-stretch bandages alone, as well as multicomponent systems or adaptive compression bandages. In this phase, bandages have to be changed more frequently than in the maintenance phase. Pronounced edema and rapid decongestion may result in swift loosening of the bandage, which, at least when using short-stretch bandages, should then be changed on a daily basis [29]. However, it has been shown that, depending on the initial pressure, twice-weekly changes may also be effective [30]. Nevertheless, when using highly fluid-absorbent wound dressings for severely exuding wounds, (multiple) daily renewal of (secondary) bandages may become necessary in individual cases. Over time, adequate and skilled compression brings about a decrease in wound exudate as well as lower leg decongestion; change intervals may subsequently be extended. Following completion of the initial decongestion phase, the maintenance phase begins. By that time, edema reduction has been initiated, and venous leg ulcers have frequently



transitioned into a progressive healing process. In the absence of edema, the tissue is not as resilient to the pressure exerted by bandages, which therefore leads to greater pressure on osseous structures such as the tibia or ankle. Hence, at least the edge of the tibia, the fibula head, and the ankle region should be padded. Compression during the maintenance phase should just be strong enough to prevent renewed edema formation. Following successful decongestion, ulcer stocking systems are frequently useful [31]. The latter are associated with less impairment of patients’ quality of life; shoes will fit better and – irrespective of the individual affected – optimal interface pressure is ensured.

Working pressure and resting pressure The distinction between resting and working pressure is necessary to understand the effects of compression therapy. Resting pressure is the result of compression of the extremity at rest. It corresponds to the force exerted by the bandage when the muscles are relaxed. Working pressure is the pressure generated through the interaction of muscle contraction and compression when the body is in motion; it arises from the resistance the bandage exerts to counteract muscle movement. The less the bandage yields in this process, the higher the working pressure. Both kinds of pressure depend on the material used, the number of layers applied as well as the force with which the compression has been applied. Given

that the working pressure is generated by active muscle contraction, it is always higher than the resting pressure. When applying compression, pressure values may be checked with simple-to-use measuring instruments [1, 2].

Materials and systems In German-speaking countries, the sheer variety of materials and systems available allows for nearly all patients to receive individually adjusted compression therapy (Table 1). Stiffness refers to the ability of the bandage to remain rigid and to withstand changes in (calf) muscle shape on exertion. Stiffer bandages lead to high pressure peaks (60–80 mmHg) when the calf muscles contract, thus facilitating efficient venous blood flow [2].

Short-stretch bandages Short-stretch bandages are bandages with low elasticity (up to 100 %). They are characterized by high working and low resting pressures, and should be applied with a resting pressure of 40–60 mmHg, which, however, quickly drops to lower values [17, 32]. While this may lead to good acceptance overnight, the bandages should be renewed prior to getting up the next morning (Figure 1). Usually made of cotton, such compression bandages are typically available in widths of 6, 8, 10, and 12 cm and lengths of 5, 6, 7, and 10 m.

Table 1 Exemplary selection of systems for compression therapy used in patients with venous leg ulcers in German-speaking countries (modified after Partsch). Type

Examples

Indication

Self-application

Stiffness

Nonelastic bandages

Varicex®, Varolast®, ALEGRO®

Decongestion phase

No

Very high

Short-stretch bandages

Comprilan®, Pütter®, Rosidal K®, Urgoband®

Decongestion phase

No

High

Long-stretch bandages

Dauerbinde®, Lastodur®, Perfekta®

Decongestion phase

No

Low

Multicomponent systems

Coban 2®(lite), Compri2®, Profore®, Pütter Pro 2®, Rosidal TCS®, Rosidal sys®, UrgoK2® (lite)

Decongestion and maintenance phase

No

High

Ulcer stocking systems

Jobst UlcerCare®, mediven ulcer kit®, Tubulcus®, ULCER X®, Venotrain ulcertec®

Maintenance phase

Yes

Moderate

Adaptive compression bandages

circaid juxtacures®, ReadyWrap®


Yes

High

MCS

JOBST UltraSheer/Classic®, mediven plus®, Venosan®, VenoTrain®

Prevention of recurrence

Yes

Moderate

IPC

lympha-mat®


Yes

Variable

Hybrid systems

Actitouch®


Yes

Variable

Abbr.: MCS, medical compression stockings; IPC, Intermittent pneumatic compression.


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Figure 1 Compression bandage with underpadding and two shortstretch bandages applied according to the Sigg technique. Materials (a), tubular gauze (b), underpadding (c), first short-stretch bandage (d), second short-stretch bandage (e), finished compression bandage (f).

Short-stretch bandages are meant to achieve high interface pressures. Given the frequently rapid pressure drop in the initial decongestion phase, they should be checked at short intervals (preferably on a daily basis) and, if necessary, renewed [1, 2, 5].

Long-stretch bandages Short-stretch bandages are bandages with low elasticity (up to 100 %). They are characterized by high working and low resting pressures, and should be applied with a resting pressure of 40–60 mmHg, which, however, quickly drops to lower values [15, 30]. While this may lead to good acceptance overnight, the bandages should be renewed prior to getting up the next morning (Figure 1). Usually made of cotton, such compression bandages are typically available in widths of 6, 8, 10, and 12 cm and lengths of 5, 6, 7, and 10 m. Short-stretch bandages are meant to achieve high interface pressures. Given the frequently rapid pressure drop in the initial decongestion phase, they should be checked at short intervals (preferably on a daily basis) and, if necessary, renewed [3].

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Long-stretch bandages Made of cotton as well as a certain percentage of polyamide, elastane (spandex, Lycra), and viscose, long-stretch bandages are characterized by a high elasticity (more than 100 %), as well as high resting and low working pressures. Active movement therefore leads to bandage expansion, which results in hardly any resistance during muscle contraction and no effects that would facilitate venous return. Due to their ability to adapt to movement as well as changes in the shape of the extremity, the associated pressure drop is lower than with nonelastic bandages. Due to the risk of pressure damage, using individual long-stretch bandages for the purpose of strong compression is not recommended. Given the high resting pressure, immobile patients in particular are at risk for severe constrictions when using long-stretch bandages, especially in case of longer resting periods. Compression therapy exclusively consisting of long-stretch bandages should not be applied overnight [1, 2, 32].



Nonelastic bandages Nonelastic bandages such as zinc paste bandages are marked by very high working pressures and, even after a short period, only very low resting pressures. Elasticity is below 10 %. In patients with CVI, their use is limited to the early decongestion phase. Zinc paste bandages either consist of rigid gauze or an elastic fabric, which is soaked in zinc gel or zinc paste. Applied wet, the bandage develops its compression pressure by hardening. The dried bandage is rigid and can hardly slip off. When applying rigid zinc paste bandages, a number of specific aspects have to be considered. During wrapping, the bandage may be cut after each turn. Subsequent molding of the bandage to the contours of the extremity is crucial. To finish, zinc paste bandages may be wrapped over by a shortstretch bandage (Fischer bandage); they are usually left in place for several days [32]. A variant of ‘semi-rigid’ compression bandages are alginate bandages. One advantage of such bandages, which are soaked in calcium alginate paste, is that residues on the skin may easily be removed with lukewarm water, and that they may be applied in circular turns.

Multicomponent systems Various manufacturers offer ready-made bandage systems for the lower leg, referred to as multicomponent systems. They comprise two, three, or four components, and usually contain padding, compression, and fixation bandages [8, 33]. One advantage is that these bandage systems do not require elaborate compression techniques or any consideration with regard to the tightness with which they are applied. This usually results in excellent tolerability and patient satisfaction [27]. Some systems even have visual indicators on the bandages (Figure 2). These indicators assist in achieving optimal pressure, as the shape of the printed symbols objectively changes when adequately prestretched [34]. Compared to bandages without such indicators, the interface pressures thus achieved are more frequently within the required therapeutic range [35]. Both reusable as well as disposable products are commercially available. The use of cohesive bandages as outer layer increases rigidity, thereby improving venous pump power while walking, even in case of low resting pressure. Depending on the underlying disease, these bandage systems may then remain in place for up to seven days during the maintenance phase. They rarely slip down, and – depending on the extent of edema – continuously maintain interface pressure until the next bandage change. In case of pronounced edema during the decongestion phase as well as heavily exuding wounds, more frequent, individually adjusted bandage change intervals are warranted [1, 2].

Figure 2 Materials used in a multicomponent system (a). The first layer is a white short-stretch bandage with cotton padding (b); the second layer consists of a cohesive long-stretch bandage (c). By forming round circles, visual indicators confirm the proper application of the bandage.

Ulcer stocking systems Ulcer stocking systems usually consist of two components, an understocking and a below-the-knee compression stocking. They are available as ready-to-use products in different sizes and lengths. In addition, there are also made-to-measure models. In most models, the understocking already exerts a therapeutically effective resting pressure; in addition, the


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underlying wound dressing is protected and held in place (Figure 3). The compression stockings are available with materials both in flat as well as in circular knitting quality, in various colors, and some even with a zipper. Thus, individual patient needs and abilities can be taken into account in the selection. Following brief training, many patients are able to independently don and doff these stocking systems. Unlike compression bandages, whose quality depend on the experience of the individual applying them, adequately measured ulcer stocking systems ensure a constant (prescribed) interface pressure. Particularly in mobile patients with florid venous ulcers, these stocking systems may be a reasonable alternative to compression bandages following initial decongestion. Another advantage of a two-component stocking is that the understocking may remain in place at night and thus protect the underlying dressing. Moreover, understockings with a higher interface pressure facilitate continuity during compression therapy. During the day, the compression stocking ensures the compression required for ulcer healing. For many patients, switching to an ulcer stocking system results in an increase in quality of life and wearing comfort, with fewer limitations in the selection of footwear and clothing [36]. Thus, as long as ulcerations are present during the maintenance phase, ulcer stocking systems represent the therapeutic option of (first) choice.

Adaptive compression bandages An alternative hitherto rarely used in German-speaking countries, adaptive compression bandages are also referred to as wrap systems or Velcro systems. For the treatment of leg ulcers, below-the-knee bandages have recently become available (Figure 4). However, especially with regard to lymphedema, it is expected that systems covering the entire leg (lower leg and thigh) will also be approved in coming months and years. Patients can usually put on these compression systems themselves. The compression pressure may be segmentally adjusted and thus regulated through multiple Velcro strips. The mode of action of these nonelastic compression bandages is, on the one hand, based on the adjustable interface pressure acting on the leg, and on the other hand, on the high wall stability of the material used. In addition, pressure loss is avoided by readjusting the Velcro strips. This leads to effective edema reduction, particularly in the decongestion phase, and allows for effective compression therapy, which may potentially be applied by patients themselves [37, 38].

Medical compression stockings In the maintenance phase, following ulcer healing, medical compression stockings (MCS) are superior to compression bandages [31, 39]. Unlike compression bandages, which fre-

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Figure 3 Materials used in a ulcer stocking system (a). The white stocking exerts only low interface pressure, secures the wound dressing, and facilitates donning of the actual compression stocking (b). The below-the-knee compression stocking is subsequently put on (c).

quently slip and appear bulky, MCS impact patients’ quality of life less. They produce a constant interface pressure, and shoes fit better. In addition, MCS are available in a variety of colors and special designs, for example, patterns or rhinestones. However, copayments are usually required. Pressure levels of MCS are geared towards the condition to be treated, and should be adjusted; hence, they must not be the same along the course of the leg. Typically, pressure levels are highest around the ankle, and then decrease proximally. Depending on the manufacturer, stockings are available in



Figure 4 Adaptive compression bandage. In this system, compression pressure can be adjusted between 20–50 mmHg by Velcro strips. Materials (a), tubular gauze (b), securing the bandage with Velcro strips (c), checking of pressure values (d), compression sock is donned (e), finished compression bandage (f).

various lengths. Besides length, the corresponding circumference of the legs also have to be taken into account. Should ready-to-wear circular knit stockings not be available in a size that fits the patient, made-to-measure stockings (possibly flat knit products) may also be prescribed. Ideally, measuring should be done in the morning, when the leg is decongested. In patients with lower leg ulcers, below-the-knee compression usually suffices. Above-the-knee stockings are required in case of edema around the knee, deep vein thrombosis extending up to the thigh, following varicose vein surgery, or in patients with lymphatic disorders.

Intermittent pneumatic compression (IPC) As regards intermittent pneumatic compression therapy (IPC), there are various devices available on the market, consisting of single- or multi-chamber cuffs (for the entire leg) and a control unit (Figure 5) [40]. In German-speaking countries, this form of treatment is also referred to as device-based intermittent compression (AIC). Following cuff application, up to twelve chambers are sequentially filled with air via a tube system, generating precisely adjustable pressure levels between 12 and 200 mmHg. Graduated compression from distal to proximal alternates with intervals of pressure reduction/relief. Consequently, the effects of IPC

are similar to those achieved by repeatedly applying compression bandage. Venting corresponds to bandage removal; the following pressure build-up, to its reapplication. Particularly in bedridden or (partially) immobile patients, such treatment allows for the function of the muscle pump to be simulated, the function of veins and lymphatic vessels to be supported, and venous drainage to be improved. To ensure venous return to the heart, there should be no hip flexion; patients should therefore either lie down or sit with their knees slightly bent. One advantage of IPC is that it enables exact pressure settings. Treatment usually takes 30–60 minutes, and may be repeated several times a day. Multichamber boot systems with small overlapping air chambers have a more even effect on the edematous leg. Compartmentalizations, constrictions, and oscillatory flow of lymphatic fluid with adverse strain on the valves are thus avoided. Subsequently, IPC devices may also be used at home. In individual cases, devices listed in the therapeutic device catalog can be prescribed at the expense of the statutory health insurance company. However, the reasons for such a prescription should be stated in writing and attached to the prescription form. Intermittent pneumatic compression replaces neither manual lymphatic drainage nor compression therapy. It merely serves as an adjuvant and is particularly useful in immobile patients [41, 42].


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Figure 5 Intermittent pneumatic compression therapy (IPC). The extremity to be treated is placed in the (still) deflated cuff (a). An electronic control device (b) is used to adjust the pressure gradient, treatment intervals, and overall treatment duration, resulting in intermittent inflation of the twelve-chamber cuffs (c).

Other systems for compression therapy Treatment with hybrid systems involves continuous compression of the lower legs using pneumatic pressure cuffs; in addition, it allows for intermittent compression therapy, for example, while sitting [43].

Classification and prescription of compression levels Compression classes exclusively apply to MCS, not to bandage systems. The “Quality Label Association MCS” has defined standard compression classes that, provided proper circumference measurement, refer to the interface pressure exerted around the ankle [44]:

Medical compression stockings differ with respect to their compression class as well as with regard to their material/fabric and its elasticity. It is the patient’s diagnosis that primarily determines what kind of stocking (which length and which compression class) is prescribed. In addition, however, it should always be attempted to ascertain the patient’s (therapeutic) acceptance in advance. When prescribing MCS, the relevant parameters must be clearly indicated, depending on the specifications used in that particular country. For compression bandages, the following classification is recommended according to international consensus recommendations:    

   

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Compression class I: 18–21 mmHg, Compression class II: 23–32 mmHg, Compression class III: 36–46 mmHg, Compression class IV: > 49 mmHg.

Mild: 60 mmHg.

These values refer to in vivo measurements in the medial B1 area (end of the Achilles tendon/ calf muscle insertion), measured while lying down [45].



Donning and doffing devices Donning and doffing devices make it easier for patients with limited mobility, obesity, or decreased strength to don and doff their compression stockings; at the same time, they help protect the fabric. In individuals with persistent ulcers, the slider device in particular also prevents wound dressings from slipping. Patients should be individually informed in advance about the various option, thus enabling them to determine which model best suits their needs and physical abilities [46]. Said devices primarily consist of frames and sliders; they are suitable for putting on open-toe as well as closed-toe stockings, or they may simply facilitate donning and doffing. A new variant is the Doff N’Donner system. Use of nubby rubber or household gloves results in better grip, and also reduces the risk of damage to the fabric, for example through nails [47]. Donning and doffing devices are approved as therapeutic devices and may be prescribed at the expense of the statutory health insurance.

Practical implementation of compression bandaging using short-stretch bandages

more evenly distributed, thus further enhancing the effectiveness of the compression. Irrespective of the material and the preferred wrapping technique used, the following principles should be considered when applying a compression bandage on the lower leg [1, 2]: 







 

There are various wrapping techniques for the application of compression bandages (according to Sigg, Fischer, Pütter, or variations thereof). With regard to the eventual quality of a compression bandage, the type of wrapping technique used is less relevant than the trained and skilled handling of the fabric by the individual applying the bandage. Minimum requirements for a compression bandage on a normally shaped lower leg include a tube bandage for skin protection, padding material, and at least two short-stretch bandages whose width corresponds to the calf circumference, for example 8 and 10 cm. Whether a third bandage is necessary will depend on the circumference and length of the lower leg. Ideally, a fixation bandage is applied at the end. Each additional bandage layer increases the stiffness of the compression bandage. Finally, the second half of the tube bandage is pulled over the compression bandage and secured, hence forming an additional layer to protect against contamination and prevent slipping. Left to the discretion of the individual applying them, the bandages may be wrapped in the same or in opposite directions. The additional use of long-stretch bandages depends on the extent of edema. While this may be useful during the decongestion phase, it is usually not beneficial during the maintenance phase. In this context, however, advanced lymphedema may represent an exception. Suitable padding materials include, for example, cotton or foam pads, which can be individually adapted. By using pressure pads, especially around anatomical protuberances, pressure can be



 

 



Tubular cotton gauze, two and a half to three times the length of the lower leg, is pulled up to the popliteal fossa. Its primary function is to prevent skin damage and to hold the ankle in dorsiflexion when applying the compression bandage. The distal (protruding) end of the tubular gauze is, if possible, held by the patient, or alternatively tucked between the toes or put on the shoulder of the individual applying the bandage. On top of the tubular gauze, a cotton or reusable foam bandage is wrapped as underpadding, which ends a few centimeters below the popliteal fossa. Wrapping of a compression bandage should always start as far distally as possible. One should therefore begin at the metatarsophalangeal joints, follow the course of the toes, and include the heel. With the exception of the toes, the entire lower leg has to be bandaged. Especially in case of associated lymphedema, the toes have to be bandaged as well. During bandaging, the foot should be placed at a right angle to the lower leg and in a mid-position between pronation and supination. Achieving such a neutral position in the upper and lower ankle joint is facilitated by active patient cooperation. If the patient is unable to elevate the lateral edge of the foot during dorsiflexion, the therapist must establish the neutral position by passively elevating the lateral edge of the foot by pressing on the head of the 5th metatarsal. Two initial circular turns are meant to anchor the bandage. The width of individual bandages should not be wider than the diameter of the body part to be wrapped. Thus, individuals with narrow feet require 6 cm wide bandages around the foot and subsequently, depending on the circumference of the lower legs, 8–10 cm. At least two bandages are required; possibly more, depending on leg circumference and length. The bandages should be held with the rolled part facing upwards and pointing towards the lateral side of the leg, thus enabling easy “unrolling”. During application, the bandage is held close to the leg and wrapped around while ensuring constant tension, which allows for even application of the bandage material. In case of only intermittent tension, the two edges of the bandage are unevenly stretched, with the associated


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risk of constrictions, tension blisters, neural damage, or pressure necrosis. If the bandage is applied with consistent tension, there is an automatic decrease in pressure along the increasing leg circumference. Wrapping the bandage too tightly in certain areas should be avoided, as this increases pressure in those areas, potentially giving rise to constrictions. The bandage is completed by folding the proximal end of the tubular gauze over the bandage, while the distal end is pulled up to the popliteal fossa and secured with adhesive strips. Staples, which are supplied in the packaging of many bandages, harbor the risk of injury. They must therefore not be used to secure bandages [27].



The use of underpadding should always be offered. If, for individual reasons, patients decline or do not tolerate such underpadding, it is recommended that at least the ankles, the anterior edge of the tibia, the extensor tendon – which protrudes during dorsiflexion – as well as the fibular head be padded. A distinction has to be made between underpadding aimed at preventing pressure injuries and the use of certain pads, which are meant to optimize pressure distribution. Given the uneven shape of the leg, there is no even distribution of pressure in the area around the ankle. In order to compensate for such anatomical inconsistencies – for example, in the region between Achilles tendon, calcaneus, and ankle – special pressure pads can be applied. Many patients have dry and flaky skin, at times also associated with pruritus. This highlights the importance of adequate skin care with medical skin care products (for example, urea 4–10 %) during compression therapy [48]. The use of ingredients with a high potential for contact sensitization, such as Peruvian balm, propolis, milking grease, or calendula ointment, should be avoided [49].

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



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Care of bandages and stockings As regards the care of reusable elastic compression bandages and stockings, manufacturer instructions are to be followed. The most common care instructions include the following [1, 2]: 

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In general, elastic compression bandages may be used several times. However, the elasticity of their fabric deteriorates not only due to repeated use but also as a result of washing. Most bandages may be washed roughly 10–15 times before losing their elasticity [50]. However, there are also systems that, according to manufacturer instructions, may be washed and used up to 50 times.

 

 





When applying a compression bandage, only new or washed bandages should be used. For hygienic reasons, bandages are to be washed on a daily basis (at up to 95°C). For hygienic reasons, stockings are to be washed on a daily basis either by hand or using the delicate cycle in a washing machine (separately in a laundry net at 30–40°C). Mild detergents or special stocking detergents should be used. The use of fabric softeners, heavy-duty laundry detergents, or hair shampoos should be avoided, as they frequently contain softeners. Stockings and bandages are to be dried on a drying rack (lying flat). Neither a radiator nor a dryer should be used. Stockings should not be ironed, chlorinated, or chemically cleaned. Damaged stocking should not be self-repaired, for example, by darning; rather, contact to a specialized dealer should be sought.

Compression therapy and exercise The pressure generated by compression physically narrows the veins, thus increasing blood flow and decreasing venous reflux. These effects therefore primarily come to the fore when patients are actively moving. Patients should therefore be encouraged to move about when wearing compression bandages or stockings, and to do foot exercises such as moving the feet in a circular motion or up and down. Especially by activating the calf muscle pump and by enhancing ankle mobility, these exercises improve the effects of compression therapy [51]. Patients with venous leg ulcer should do controlled walking exercises during compression therapy in order to prevent stiffening of the ankle and activate the calf muscle pump. As a memory aid for patients: sitting and standing is bad; walking and lying is better [1, 2, 44].

Compression therapy in case of immobility Patients are frequently affected by muscular atrophy and are, regardless of compression bandages, at an increased risk of developing pressure ulcers. Even adequately applied compression may increase that risk. Compression therapy in bedridden patients therefore always requires a special indication and monitoring [1, 2]. Given that immobile individuals who predominantly spend their time in a sitting position (for example, in a wheelchair) frequently develop leg edema, compression therapy is usually indicated that patient group. However, since the



active muscle pump is missing, compression therapy alone is not sufficiently effective. Here, treatment plans including IPC or passive supportive exercises are useful [52]. A concept referred to as ‘active bed rest’ has been described, which involved pre- and postoperative conditioning – for an average of seven days – in patients with refractory venous ulcers and surgical intervention. In that study, improved compliance in particular was achieved through bed rest, leg elevation, and targeted training programs [53].

Contraindications for compression therapy Based on clinical experience, there is a number of contraindications that have to be taken into account with regard to compression therapy [1, 2].

   

     

Absolute contraindications: Advanced PAD (critical ischemia) Decompensated heart failure, Septic phlebitis, Phlegmasia cerulea dolens. Relative contraindications: Mild to moderate PAD, Advanced peripheral polyneuropathy, Chronic compensated heart failure, Intolerance or allergy to the materials used, Treatment-related pain, Florid infectious diseases, for example, initial phase of erysipelas/cellulitis.

Impaired arterial circulation Prior to initiating compression therapy, pedal pulses should always be palpated. Although readily palpable pedal pulses argue against advanced peripheral artery disease (PAD), they are not conclusive. Further workup, preferably including measurement of the ankle-brachial pressure index (ABI), is therefore warranted [1, 2]. By definition, systolic ankle pressure values below 50 mmHg or an ABI below 0.5 are consistent with critical ischemia. Unlike IPC, continuous compression is strictly contraindicated in these patients. At absolute pressure values above 50 mmHg or an ABI between 0.5 and 0.8, compression therapy is generally feasible. In this context, short-stretch bandages with an initial pressure < 40 mmHg should be used, and patients closely monitored [54]. Another alternative for patients are multicomponent systems, designed to ensure lower pressure values around 20 mmHg. Adaptive compression bandages or IPC may also be used; here, applied pressure values have to be adjusted to the specific si-

tuation at hand, which means they have to be lower than the measured ankle pressure. Observing these precautions, many patients with mixed leg ulcers and clinically relevant edema may be treated with compression therapy [55].

Polyneuropathy Properly applied compression in patients with polyneuropathy, for example, due to diabetes, is basically feasible. However, polyneuropathy causes patients to lose their ability to feel too strong a compression or bandages or stockings that are too tight, as well as insufficient padding. Thus, given the lack of patient feedback regarding pain and pressure, there is an increased risk of tissue damage. In these patients, removal of compression bandages/stockings at short intervals may be required in order to examine the leg for pressure marks. Here, too, the use of a low-pressure IPC may be helpful.

Heart failure Heart failure is another contraindication reported in the literature. It should be noted that only decompensated heart failure represents a contraindication, as the patient’s condition may deteriorate due to excess intravascular fluid. While chronic compensated heart failure, which commonly affects elderly individuals, does not represent a strict contraindication, close patient monitoring is nevertheless warranted. If these patients require compression therapy, the amount of additional fluid that may potentially enter the cardiovascular system has to be taken into consideration. Decongestion should be gradually intensified, and the compression bandage applied in a careful manner. It is the physician’s responsibility to provide patients with compression therapy that is adequately adjusted to their individual situation. The initial pressure should be below 20 mmHg (mild compression), and bandages should initially only be applied to one extremity [16]. In many cases, heart failure patients benefit from compression therapy, as it prevents leg edema when applied during the day. The latter effect frequently also reduces nocturia as a sign of nocturnal fluid redistribution [1, 2].

Allergy There are only few studies on the prevalence of allergies to compression materials. Allergies in the form of urticaria (hives, type I or immediate-type allergy) or allergic contact dermatitis (type IV or delayed-type allergy) to polyamide, elastane (spandex), cotton, or viscose are rare. Allergies to components of rubber or latex are more common; they are caused by compression bandages made of elastic fibers or cohesive bandages coated with latex [56]. As regards stockings, many allergic reactions are caused by components of the adhesive edges or the dyes. Dark colors in particular have greater allergenic


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potential, which is why colored bandages or stocking systems should be avoided in patients with venous leg ulcers. Individuals with a history of silicone allergy may resort to silicone-free compression bandage systems [1, 2, 49].

Infectious diseases In the acute phase of infectious diseases such as erysipelas/ cellulitis, compression therapy of the affected leg should not be applied during bed rest. Although there is no clear scientific evidence, there is expert consensus that compression therapy should only be used after the acute phase, once the patient is afebrile and able to be up and about.

towards the needs of patients and their families, and address the way they experience the disease as well as their ideas in a non-judgmental manner. Not all patients with wounds actually want to achieve complete wound healing. Terms such as “unreasonable” or “non-compliant” have no place in this context, neither does playing the blame game. Frequently, patients cannot follow certain instructions because they do not understand them, cannot implement them, or because they do not agree with their disease concept. Important elements of patient-centered care include [59]:  

Complications and side effects



Anyone who applies a compression bandage has to be cognizant of the potential side effects associated with it. During each bandage change, the leg has to be carefully inspected for possible pressure marks, skin lesions, and atypical swelling that may have occurred due to local constrictions. In the decongestion phase, edema reduction should be documented by regular measurements of the circumference around the ankle and calf. Pain is always an alarm sign. Compression that causes pain has to be removed immediately. While patients with acute thrombosis or florid leg ulcer may initially experience a newly applied compression bandage as too tight, it must not be painful. If the pain does not subside within a few minutes or improves after taking a few steps, the bandage should be removed. When employing IPC, low pressure values should initially be used, which may subsequently be gradually increased; pain should be avoided [57]. The pressure values selected should be documented during each treatment session. Pressure marks and erythema during compression therapy primarily occur on the anterior edge of the tibia as well as the ankles, Achilles tendons and the dorsal aspects of the feet. Particularly relevant risk factors include impaired sensory/pain perception. Pressure marks are indicative of excessive (local) compression, stockings that are too tight, as well as insufficient padding. For example, compression therapy can cause peroneal nerve injury at the level of the fibular head, which is clinically characterized by foot drop (a patient’s inability to dorsiflex the foot). Adequate padding in this anatomical region is therefore essential when applying compression bandages [1, 2].



Patient-centered attitude with regard to the implementation of compression therapy Patient-centered care requires a cooperative behavior from the entire treatment team [58, 59]. Such care should be geared

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Identifying, caring about, and respecting the ideas, values, and needs of patients, Coordination of continuous and timely medical care, Relief from pain and suffering, Listening and communicating, Providing information and education, Shared decision making, Promoting wellness and a healthy lifestyle.

For patients and their relatives, venous leg ulcers frequently have serious consequences with regard to physical, psychological, and social aspects, and there is usually considerable impairment in quality of life [24, 60–62]. Not all patients succeed in adequately wearing the prescribed compression garments. The problem as regards the implementation of compression therapy in everyday life is particularly evident for MCS, less so for bandages. The reasons for this are manifold. For example, many patients complain about the lack of wearing comfort, pain, pruritus, oozing wound exudate, difficulties putting on shoes as well as aesthetic and cosmetic problems [29, 63]. Moreover, patients frequently do not fully understand the relationship between compression and wound healing, and they have their own ideas about side effects, which may result in concerns about the prescribed treatment [62, 64].

Shared decision making and patient education Decisions with respect to certain therapies should always be made in cooperation with patients and their family, a process referred to as shared decision making. Although the beneficial effects of compression therapy are known, it is still unclear which interventions may improve adherence [47]. Patient-centered care helps define realistic goals. In joint discussions with patients, and based on an understanding attitude, the ideas of patients with regard to wound etiology, wound healing, use of compression therapy, and realistic options for its integration into everyday life should be addressed. For example, by wearing two stockings of lower compression



classes on top of each other, higher pressure levels may be achieved due to additive effects. Possibly, the use of zippers or the prescription of individual components – such as forefoot socks, stockings, and Capri or cycling shorts – may be helpful. As regards stocking systems, patients should always be informed about donning and doffing devices [46]. Prior to employing IPC, patients should receive proper training, which include the need to comprehensibly document circumference measurements as well as selected pressure values. For patients and their relatives, readily understandable information on basic pathophysiological disease aspects, therapeutic effects, and other supportive measures should be the basis of joint decision making. In this context, brochures geared towards patient needs, with large font size, pictures, and understandable language, may be useful [65–67].

Conclusion In Europe, venous leg ulcers rank among the most common causes of chronic wounds. Following proper workup to rule out relevant differential diagnoses as well as contraindications, and imbedded in a wound management concept, compression therapy should be carried out. The latter marks the basis for treatment and prevention of recurrences in patients with venous leg ulcers. Properly implemented, it usually leads to significant improvement in quality of life.

Acknowledgments Structured coordination of an interdisciplinary and interprofessional expert consensus process is an enormous challenge. We would like to thank Mr. Stefan Krasnik for taking on this challenge and doing an excellent job on behalf of WundD.A.CH. We would also like to thank the following companies for their financial support: Bösl Medizintechnik, BSN Medical, Lohmann & Rauscher, Medicare, Paul Hartmann and Urgo. Correspondence to Prof. Dr. med. Joachim Dissemond University Hospital Essen Department of Dermatology, Venereology, and Allergology Hufelandstraße 55 45122 Essen, Germany E-mail: [email protected]

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