Self-care strategies to prevent venous leg ulceration ...

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Self-care strategies to prevent venous leg ulceration recurrence Recurrence of venous leg ulcers is common. Annemarie Brown discusses self-care strategies that can play a role in the prevention of recurrence

Venous leg ulcers are common and take a long time to heal. Recurrence of leg ulcers occurs frequently, with some estimates suggesting 70% of ulcers will recur. Preventing recurrence would reduce costs to the NHS, as well as improve quality of life for patients. Encouraging patients to self-care is key to preventing recurrence of venous leg ulcers. Self-care includes the use of compression therapy, physical activity, mobility and leg elevation. It is likely that practice nurses will be responsible for encouraging patients to perform self-care in order to prevent venous leg ulcer. Key words | Leg ulcer | Self-care | Recurrence | Wound healing

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enous leg ulcers are common and often take months or even years to heal (Finlayson et al, 2009). Recurrence frequently occurs and has been estimated to be as high as 70% (Vowden and Vowden, 2006; Etufugh and Phillips, 2007; Venable, 2015). As a result, venous leg ulceration must be viewed as a chronic condition (Brown, 2010). With an ageing population, it is anticipated that the incidence of venous leg ulceration will increase, highlighting the need to prevent recurrence, which is costly and has a negative effect on quality of life (Kapp et al, 2014). The focus for many commissioned leg ulcer services tends to be on healing rates as outcome measures, rather than prevention of recurrence (Dowsett, 2012). The key to the prevention of recurrence is ensuring patients understand that the condition is chronic and that ulcers may well recur, but if they undertake selfcaring prevention strategies, the recurrence rate can be reduced (Gonzalez, 2017). Education programmes, which deliver both patient education and engage patients with venous leg ulceration

Annemarie Brown, lecturer, School of Health and Human Sciences, University of Essex, Southend on Sea, Essex Email: [email protected] Submitted 30 Janaury 2018; accepted for publication following peer review 15 February 2018

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to self-care, have been found to reduce the incidence of recurrence (Brooks et al, 2004; Freeman et al, 2007; Shanley and Moore, 2012; Miller et al, 2014a; 2014b); however, these are not widely available. Lindsay Leg Clubs provide an ideal environment for education and encouraging patients to self-care; however, although growing in number, they are not available in all localities (Clark, 2010). It is likely, therefore, that health professionals in general practice and other community settings will be responsible for encouraging patients to perform self-care prevention strategies. A review of the literature on preventing ulcer recurrence identified key components for self-care, which included the use of compression therapy, physical activity, mobility and leg elevation (Brown, 2012; Finlayson et al, 2015). These will now be discussed in more depth, and strategies will be suggested to encourage patients to perform them.

Compression hosiery A Cochrane review found that there is some evidence that compression hosiery post-healing may reduce recurrence at 3 years compared to no compression hosiery, and that a higher level of compression appears to be more effective in reducing the recurrence of leg ulcers (Nelson and Bell-Syer, 2014). Compression hosiery is considered to be one of the most important interventions to reduce ulcer recurrence, although adherence rates as low as 35% have been reported (Heinen et al, 2007; Raju et al, 2007; Kapp et al, 2013). The optimum level of compression to reduce recurrence is considered to be 25–35 mmHg Class 3 hosiery; however, many patients find this difficult to apply and it is more beneficial to select a class of compression that is acceptable to the patient based on the principle that some compression is better than none (Bainbridge, 2013; Nelson and Bell-Syer, 2014; Venable, 2015). Health professionals, however, need to be aware of the variation between the classes of compression, dependant on the country of manufacture. Table 1 outlines the different classes of compression and when to use them.

Circular knit or flat knit Compression hosiery can be either ‘off the shelf’ or custom-made, which is made according to the patient’s

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Table 1. Compression classes and their recommended use British Standard Compression (UK)

Compression level

French AFNOR

German RAL

When to use

1

14–17 mmHg

10–20 mmHg

18–21 mmHg

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Light support and/or pregnancy

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Flight socks

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Superficial/early varicose veins

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Medium support

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Varicose veins—medium severity or during pregnancy

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Venous ulcer treatment and prevention of recurrence

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Mild swelling/lymphoedema

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Firm support

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Severe varicose veins

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Gross leg swelling

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Venous ulcer treatment and prevention of recurrence

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Lymphoedema

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Gross lymphoedema

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Lipoedema

2

3


4

18–24 mmHg

25–35 mmHg

–

20–30 mmHg

30–40 mmHg

>40 mmHg

precise measurements. Hosiery can be circular knit or flat knit. The selection of compression hosiery depends on several factors. Circular-knit hosiery is produced from a continual yarn and knitted in a cylindrical shape (Linnitt and Davies, 2007). This is available on FP10 and tends to be reasonably acceptable to most patients; however, if the patient’s legs are outside of average measurements or have an unusual shape, custom-made hosiery may be needed. ‘Off the shelf’ hosiery may not fit very well and may slide down or roll into skin creases and cause skin damage (Linnett and Davies, 2007). Flat-knit hosiery is knitted on a flat bed and then joined at the seams and can be either ‘off the shelf’ or custommade. This type of hosiery, also available on FP10, is particularly suitable for patients with severe leg swelling and is the compression of choice in the management of lymphoedema as the fabric mimics the action of inelastic compression bandaging and gently massages lymphatic fluid evenly up the leg on mobilising (Linnett and Davies, 2007). This is because flat knit hosiery has high working pressures and low resting pressures, whereas circular hosiery has continuous high working pressures due to the elasticity within the fabric of the hosiery. As a result, circular knit hosiery in patients with moderate to severe leg oedema will result in the fluid being pushed further up the leg. Flat-knit hosiery is not as cosmetically acceptable to patients as it is bulkier in appearance; however, anecdotally from clinical experience, some patients find it easier to apply. Due to the manufacturing process, it is possible to include zip and ankle pads if required; in circular knit hosiery, these additions would cause the fabric to ladder (Linnitt and Davies, 2007).


23–32 mmHg

34–46 mmHg

>49 mmHg

Tip 1. ●●

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Always start with the lowest level of compression and increase gradually depending on the patient’s tolerance Even a low class of compression is better than none at all

Common problems with adherence to compression hosiery Lack of knowledge

The difficulty in persuading patients to wear compression hosiery post-healing has been subject to discussion in the literature over many years (Jull et al, 2004; Raju et al, 2007; Van Hecke et al, 2009a; Brown, 2011; Bainbridge, 2013; Balcombe et al, 2017). One of the most significant explanations for this has been found to be a lack of understanding on the part of the patient (Yarwood-Ross and Haigh, 2013). Studies have found that up to 50% of patients did not understand the cause of their leg ulcer and therefore the need to wear compression hosiery once their ulcer had healed (Van Hecke et al, 2009b; Bainbridge, 2013). In order to address this, several patient education programmes have been developed with some success (Shanley and Moore, 2012; Miller et al, 2014a; 2014b). This may increase the patient’s level of knowledge; however, the patient may still not wear his/her compression hosiery (Van Hecke et al, 2011). Unfortunately, just giving out information will not necessarily result in adherence, as there are several other factors which may influence the patient’s decision (Brown, 2010; Yarwood-Ross and Haigh, 2012; Bainbridge, 2013). Other factors, such as whether the patient believes that compression hosiery will help prevent ulcers returning; whether they feel the benefit of not having a leg ulcer outweighs the difficulties in applying the hosiery; how

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Tip 2. ●●

Assess your patient’s understanding of the benefits of compression hosiery

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Listen to their concerns and identify key barriers to wearing hosiery

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Work with the patient to come up with acceptable solutions this impacts on their daily life; and if they have the confidence that they will be able to apply hosiery and persevere, despite the application difficulties (Bandura, 1977; Rosenstock et al, 1988; Bainbridge, 2013). Health professionals also need to be mindful that compression hosiery can be painful when first applied and warn the patient to expect this in the initial stages (Briggs and Closs, 2006). Finally, the patient–health professional relationship can be an important factor in achieving concordance. Determining their health beliefs, identifying the key barriers which may dissuade the patient from applying hosiery, giving consistent information in small bitesize chunks and testing recall (teach back techniques), together with involving them fully in their care by offering them a choice of hosiery will help to motivate the patient and encourage adherence (Bainbridge, 2013; YarwoodRoss and Haigh, 2012; Kapp et al, 2013).

Application and removal difficulties Another key barrier to wearing compression hosiery is the difficulty patients may experience in donning and doffing their hosiery, particularly if they are immobile or find bending over difficult (Kapp et al, 2013; Balcombe et al, 2017). Balcombe et al (2017) reviewed the literature on donning and doffing devices available and identified three categories of devices available: ●● Devices to assist in the application and removal of compression hosiery ●● Altered compression stocking design ●● Adjustable compression wrap devices.

Devices to assist in applying and removing hosiery There are currently several devices available on the market to aid in the application and removal of compression hosiery, for example Acti-Glide (L&R formerly Activa Healthcare), Easy Fit Donning Aid (Juzo UK), Easy-Slide Range (Credenhill), which are made of slippery fabrics. Every patient who has been identified as having difficulty in donning and doffing their hosiery, should have an application guide prescribed, which are also available on

Tip 3. ●●

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Always consider prescribing an aid when prescribing compression hosiery Try to obtain a selection of sample aids to show your patient before prescribing Consider alternative types of compression if hosiery is a problem

FP10. Health professionals should check the manufacturer’s instructions prior to prescribing, since some of the aids are available in different sizes, for open or closed toe hosiery application, and for use when the patient is seated. There are also a range of rigid applicators available, such as Medi Butler (Medi UK) and Sockaid (Urgo Medical); again, these are available on FP10. Unfortunately, the majority of these aids still require a certain level of manual dexterity and the ability to bend down, even when seated, which can be problematic for some patients. These products are continually evolving and future developments in the production of these aids will ensure that these problems are minimised.

Altered compression stocking design and adjustable compression wrap devices More recently, compression hosiery kits comprised of lightcompression inner stockings and high-compression outer stockings, which when worn together produce therapeutic levels of compression, have appeared on the market (Balcombe et al, 2017). Although they were designed for ulcer healing, there is some evidence that certain patients find these easier to apply than conventional compression hosiery and they may be suitable for the prevention of recurrence (Balcombe et al, 2017). Examples include Activa leg ulcer kits (L&R formerly Activa Healthcare); Altipress 40 Leg Ulcer Kit (Urgo Medical) and Ulcer X (Sigvaris). There are also some kits available where the outer stocking has a zip for easier application, for example, Alleviant Ulcer Care Kit (Jobskin) and JOBST UlcerCare (BSN Medical). Health professionals are advised to familiarise themselves with the level of compression these provide as some may use British Standard, AFNOR or RAL compression classes (Table 1).

Adjustable compression wrap devices Fairly recent additions to the market are the adjustable short-stretch wrap compression garments which have been designed to enable patients to self-manage their venous oedema in the initial phases of treatment (Mosti et al, 2015). These devices are rigid and work on similar principles to inelastic compression, in that they deliver high working pressures and low resting pressures and the Velcro straps mean that patient can easily apply them independently (Tickle et al, 2017). Originally designed to encourage self-care management of open leg ulceration, there is some evidence that these offer an effective alternative to compression bandaging (National Institute for Health and Care Excellence, 2015; Tickle et al, 2017). Examples include juxtacures (Medi UK), JOBST FarrowWrap (BSN Medical) and ReadyWrap (L&R formerly Activa Healthcare). More research is required to assess how effective these devices are for the prevention of recurrence, and health professionals also need to consider the reasonably high initial unit cost. However, to offset this, many of these products have a lifespan of up to 12 months, compared to the average of 3 months for most compression hosiery.



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Other recommended self-care activities

Physical activity and mobility

The consensus in the literature is that in order to prevent ulcer recurrence, patients should be encouraged to undertake more exercise and have an increased level of physical activity (Heinen et al, 2007; Jull et al, 2009; O’Brien et al, 2014). Currently, however, there is no definitive guidance on how much, how often, and what type of exercise would be beneficial (Brown, 2017). Heinen et al (2012) found fewer ulcer recurrences in those patients who performed leg exercises and walked for 10 minutes five times weekly. Strenuous exercise, such as running, or playing hockey or tennis was found by Heinen et al (2007) to be a risk factor for the development of ulceration, although this fact was not further explored. In view of the ambiguity around the level of exercise required to prevent recurrence, patients should be advised to follow the Department of Health and Social Care’s guidance (2011) that older adults should perform at least 150 minutes of moderate intensity activity, such as brisk walking or ballroom dancing in bouts of 10 minutes or more per week, or 30 minutes on at least 5 days per week.


Leg exercises and elevation Exercises, such as heel raises on stairs, toe curls with a towel, toe extensions and standing calf stretches (Figure 1)have been shown to improve calf muscle pump and increase the rate of venous return in a 12 month study (Padberg et al, 2004; Roaldsen et al, 2006). These exercises could be performed easily at home using stairs and some even in a seated position (Brown, 2012). The recommendation is that initially patients perform 3 sets of 6 minutes each, resting for 5 minutes between sets, working up their own personal limits of tolerance (Jull et al, 2009). Very little difference in calf pump function was noted between the patients who wore compression when exercising to those who did not. The evidence to support elevation as a recurrence prevention strategy is inconclusive; however, physiologically, elevating limbs above the level of the heart will aid venous return by gravity and reduce oedema (Dix et al, 2005). Unfortunately, this may prove impossible for many patients to achieve due to orthopaedic problems and pain. Interestingly, elevation appears to be more beneficial in reducing ulcer recurrence if patients do not wear compression while elevating their legs (Heinen et al, 2004). In addition, reducing oedema will make the application of compression hosiery easier, particularly if hosiery is applied first thing in the morning immediately after getting out of bed. There is no consensus in the literature on the optimum timescales or degree of elevation, therefore patients should be encouraged to lie on the bed for at least one hour daily after lunch and to apply their hosiery as soon as possible after waking in the morning.

Conclusion This article has discussed the literature on the main selfcare strategies that patients should be encouraged to undertake to prevent their venous ulcer recurring. Some


Figure 1. Exercises, such as heel raises on stairs, toe curls with a towel, toe extensions and standing calf stretches can improve calf muscle pump and increase the rate of venous return practical tips and solutions are suggested to overcome some of the barriers patients and health professionals may face in reaching a concordant relationship. The author has developed a simple assessment tool, based on self-efficacy, which can be administered by health professionals to identify the key areas that patients may have difficulty in when performing self-care activities, and as a result they will be able to implement strategies to improve the patient’s confidence in performing these (Brown, 2013). The tool is available to all health professionals, free of charge on request. pn

Tip 4. ●●

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ncourage patients to perform foot exercises and use the stairs as E much as possible risk walking and moderate activity has been found to help reduce B recurrence of venous ulcers Reassure the patient that these activities will not increase pain atients should make resting on their bed for 1 hour part of their P daily routine ncourage patients to apply their hosiery first thing in the morning E before swelling starts to develop

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CPD reflective points ●●

Reflecting on your practice, do you think your patients are fully aware of liklihood of recurrence of their leg ulcer? Do they understand the role they can play in preventing further ulcers? How could you improve on this?

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What are the main problems associated with adherence to compression therapy? What strategies can be used to overcome these?

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What advice on physical activity would you give your venous leg ulcer patients?

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How will this article change your clinical practice?

Bainbridge P. Why don’t patients adhere to compression therapy? Br J Community Nurs. 2013;Suppl:S35-6, S38-40 Balcombe L, Miller C and McGuiness W (2017) Approaches to the application and removal of compression therapy: A literature review. Br J Community Nurs. 2017;22(Sup10):S6-S14. https://doi.org/10.12968/ bjcn.2017.22.Sup10.S6 Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84(2):191–215. https://doi. org/10.1037/0033-295X.84.2.191 Briggs M, Closs SJ. Patients perceptions of the impact of treatments and products on their experience of leg ulcer pain. J Wound Care. 2006;15(8):333–337. https://doi. org/10.12968/jowc.2006.15.8.26941 Brooks J, Ersser SJ, Lloyd A, Ryan TJ. Nurse-led education sets out to improve patient concordance and prevent recurrence of leg ulcers. J Wound Care. 2004;13(3):111–116. https://doi. org/10.12968/jowc.2004.13.3.26585 Brown A. Managing chronic venous leg ulcers: time for a new approach? J Wound Care. 2010;19(2):70–74. https://doi. org/10.12968/jowc.2010.19.2.46969 Brown A. Achieving concordance with compression therapy. Nursing and Residential Care. 2011;13(11):537–540. https:// doi.org/10.12968/nrec.2011.13.11.537 Brown A. Life-style advice and self-care strategies for venous leg ulcer patients: what is the evidence? J Wound Care. 2012 Jul;21(7):342–350, 346, 348–350. https://doi.org/10.12968/ jowc.2012.21.7.342 Brown A. Encouraging self-care in venous leg ulceration. Journal of General Practice Nursing. 2017;3(1): 44-50 Clark M. A social model for lower limb care: the Lindsay Leg Club Model. European Wound Management Association Journal. 2010;10: 38–40 Department of Health and Social Care. Fact Sheet 5 Physical Activity Guidelines for Older Adults (65 yrs+). 2011. https://www.gov.uk/government/uploads/system/uploads/ attachment_data/file/213741/dh_128146.pdf (accessed 27 February 2018) Dix FP, Reilly B, David MC et al. Effect of leg elevation on healing, venous velocity and ambulatory venous pressure in venous ulceration. Phlebology: The Journal of Venous Disease. 2005;20(2):87–94. https://doi. org/10.1258/0268355054069179 Dowsett C. Modernising leg ulcer services through preventing recurrence. Wounds UK. 2012;8(1):53–58 Etufugh CN, Phillips TJ. Venous ulcers. Clin Dermatol. 2007;25(1):121–130. https://doi.org/10.1016/j. clindermatol.2006.09.004 Finlayson K, Wu ML, Edwards HE. Identifying risk factors and protective factors for venous leg ulcer recurrence using a theoretical approach: A longitudinal study. Int J Nurs

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Stud. 2015;52(6):1042–1051. https://doi.org/10.1016/j. ijnurstu.2015.02.016 Finlayson K, Edwards H, Courtney M. Factors associated with recurrence of venous leg ulcers: A survey and retrospective chart review. Int J Nurs Stud. 2009;46(8):1071–1078. https:// doi.org/10.1016/j.ijnurstu.2008.12.012 Freeman E, Gibbins A, Walker M, Hapeshi J. Look After Your Legs: patients experience of an assessment clinic. Br J Community Nurs. 2007;12 Sup1:S19–S25, S22–S25. https:// doi.org/10.12968/bjcn.2007.12.Sup1.23047 Gonzalez A. The Effect of a patient education intervention on knowledge and venous ulcer recurrence: results of a prospective intervention and retrospective analysis. Ostomy Wound Manage. 2017;63(6):16–28 Heinen MM, van der Vleuten C, de Rooij MJM, Uden CJT, Evers AWM, van Achterberg T. Physical activity and adherence to compression therapy in patients with venous leg ulcers. Arch Dermatol. 2007;143(10):1283–1288. https://doi. org/10.1001/archderm.143.10.1283 Heinen M, Borm G, van der Vleuten C, et al. The Lively Legs self-management programme increased physical activity and reduced wound days in leg ulcer patients: results from a randomized controlled trial. Int J Nurs Stud. 2012;49(2):151– 161. https://doi.org/10.1016/j.ijnurstu.2011.09.005 Heinen MM, Achterberg T, Reimer WS, Kerkhof PCM, Laat E. Venous leg ulcer patients: a review of the literature on lifestyle and pain-related interventions. J Clin Nurs. 2004;13(3):355–366. https://doi.org/10.1046/j.13652702.2003.00887.x Jull AB, Mitchell N, Aroll J, et al. Factors influencing concordance with compression stockings after venous leg ulcer healing. J Wound Care. 2004;13(3):90–92. https://doi. org/10.12968/jowc.2004.13.3.26590 Jull A, Parag V, Walker N, et al. The PREPARE pilot RCT of home-based progressive resistance exercises for venous leg ulcers. J Wound Care. 2009;18(12):497–503. https://doi. org/10.12968/jowc.2009.18.12.45606 Kapp S, Simpson K, Santamaria N. Perspectives on living with and self-treating venous leg ulcers: A person’s story and a health care perspective [online]. Wound Practice & Research: Journal of the Australian Wound Management Association. 2014;22(2):98–101 Kapp S, Miller C, Donohue L. The clinical effectiveness of two compression stocking treatments on venous leg ulcer recurrence: a randomized controlled trial. Int J Low Extrem Wounds. 2013;12(3):189–198. https://doi. org/10.1177/1534734613502034 Linnitt N, Davies R. Fundamentals of compression in the management of lymphoedema. Br J Nurs. 2007;16(10):588–592, 590, 592. https://doi.org/10.12968/ bjon.2007.16.10.23503 Miller C, Kapp S, Donohue L. Sustaining behaviour changes following a venous leg ulcer client education program. Health Care (Don Mills). 2014a; 2(4):324–337. https://doi. org/10.3390/healthcare2030324 Miller C, Kapp S, Donohue L. Examining factors that influence the adoption of health-promoting behaviours among people with venous disease. Int Wound J. 2014b;11(2):138–146. https://doi.org/10.1111/j.1742-481X.2012.01050.x Mosti G, Cavezzi A, Partsch H, Urso S, Campana F. Adjustable Velcro compression devices are more effective than inelastic bandages in reducing venous edema in the initial treatment phase: a randomised controlled trial. Eur J Vasc Endovasc Surg. 2015;50(3):368–374. https://doi.org/10.1016/j.ejvs.2015.05.014 Nelson EA, Bell-Syer SEM. Compression for preventing recurrence of venous ulcers. Cochrane Database Syst Rev. 2014;(9):CD002303. https://doi.org/10.1002/14651858. CD002303.pub3. National Institute for Health and Care Excellence. The Juxta CURES adjustable compression system for treating venous



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KEY POINTS ●●

Venous leg ulcers are common and take a long time to heal. Recurrence of leg ulcers occurs frequently, with some estimates suggesting 70% of ulcers will recur

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The key to the prevention of recurrence is ensuring patients understand that the condition is chronic and that ulcers may well recur, but if they undertake self-caring prevention strategies, the recurrence rate can be reduced

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Compression hosiery is the mainstay of prevention of recurrence, but adherence to compression can be challenging

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Physical activity, leg exercises and elevation all have a part to play

in community settings. J Adv Nurs. 2009b;65(2):337–347. https://doi.org/10.1111/j.1365-2648.2008.04871.x Van Hecke A, Grypdonck M, Beele H, Vanderwee K, Defloor T. Adherence to leg ulcer lifestyle advice: qualitative and quantitative outcomes associated with a nurse-led intervention. J Clin Nurs. 2011 Feb;20(3-4):429–443. Medline doi:10.1111/j.1365-2702.2010.03546.x Venable J. Prescribing compression stockings to prevent recurrent leg ulcers. Nurse Prescribing. 2015;13(1): 38-42. https://doi.org/10.12968/npre.2015.13.1.38 Vowden P, Vowden K. Effective compression therapy – how to guide. Wound Essentials. 2006; 7(2) November. Yarwood-Ross L, Haigh C. Managing a venous leg ulcer in the 21st century, by improving self-care. Br J Community Nurs. 2012;17(10):460, 462-5. https://doi.org/10.12968/ bjcn.2012.17.10.460


leg ulcers MIB25 Medtech Innovation Briefing. 2015. https:// www.nice.org.uk/advice/mib25 (accessed 27 February 2018) O’Brien J, Finlayson K, Kerr G, Edwards H. The perspectives of adults with venous leg ulcers on exercise: an exploratory study. J Wound Care. 2014;23(10):496–509, 500–509. https://doi.org/10.12968/jowc.2014.23.10.496 Padberg FT Jr, Johnston MV, Sisto SA. Structured exercise improves calf muscle pump function in chronic venous insufficiency: a randomized trial. J Vasc Surg. 2004;39(1):79– 87. https://doi.org/10.1016/j.jvs.2003.09.036 Raju S, Hollis K, Neglen P. Use of compression stockings in chronic venous disease: patient compliance and efficacy. Ann Vasc Surg. 2007;21(6):790-5 Roaldsen KS, Rollman O, Torebjörk E, Olsson E, Stanghelle JK. Functional ability in female leg ulcer patients — a challenge for physiotherapy. Physiother Res Int. 2006;11(4):191–203. https://doi.org/10.1002/pri.337 Rosenstock IM, Strecher VJ, Becker MH. Social learning theory and the health belief model. Health Educ Q. 1988;15(2):175– 183. https://doi.org/10.1177/109019818801500203 Shanley E, Moore Z. A Cluster Randomised Controlled Trial of the Leg Ulcer Prevention Programme (LUPP) in Venous Leg Ulcer Patients within an Irish Community Care Setting. Unpublished Master of Science by Research, Royal College of Surgeons, Ireland. 2012. http://epubs.rcsi.ie/mscrestheses/17 (accessed 27 February 2018) Tickle J, Ovens L, Mahoney Ket al. (2017) A proven alternative to compression bandaging: clinical review of juxtacures. J Wound Care. 2017; 26(Sup4a):S1-S24. https://doi. org/10.12968/jowc.2017.26.Sup4a.S1 Van Hecke A, Grypdonck M, Defloor T. A review of why patients with leg ulcers do not adhere to treatment. J Clin Nurs. 2009a;18(3):337–349. https://doi.org/10.1111/j.13652702.2008.02575.x Van Hecke A, Grypdonck M, Beele H, De Bacquer D, Defloor T. How evidence-based is venous leg ulcer care? A survey

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