How to guidesEffective compression therapy

Effective compression therapy

Complex wounds, How to guides, Leg Ulcers, Skin integrity | K Vowden, P Vowden

Understanding compression levels
Bandage systems and compression hosiery are graded according to the level of compression they generate. Several classification systems exist. To avoid confusion when describing the level of compression applied to the limb, WUWHS suggests using the following terminology (2008):

  • Mild (less than 20mmHg)
  • Moderate (20-40mmHg)
  • Strong (40-60mmHg)
  • Very strong (greater than 60mmHg).


Strong compression (>40mmHg) is generally recommended for the treatment of a venous leg ulcer. For some patients factors such as mild arterial disease, neuropathy or cardiac failure render strong compression unsafe or painful and mild or moderate compression may be required (eg using inelastic compression). Patients with more severe arterial disease should not receive compression (Marston and Vowden, 2003).

 

Factors affecting sub-compression system pressure
Using a compression system (bandages or hosiery) alone does not guarantee a level of compression. Pressure will vary according to the limb size and shape, level of calf muscle activity, the bandage or hosiery characteristics, bandage width and the degree of overlap and the application tension. Many of these factors are controlled by the bandager whose skills will also affect the graduation of compression and the comfort and durability of the bandaging.

Most bandage systems give advice on variations to accommodate differing ankle circumference. Larger limbs, ie those with a higher circumference, will require a higher classification bandage to exert the desired level of compression. Similar constraints apply to hosiery. Careful measurement and fitting is important as is the choice of hosiery itself; the characteristics of circular (elastic) and flat knit (inelastic) differ in a similar way to bandages.

Assessing patients before application
Arterial assessment using Doppler ultrasound to calculate the ankle brachial pressure index (ABPI) should be undertaken before considering compression therapy (SIGN, 2010; Vowden and Vowden, 2001). The ABPI defines both the level of compression and the need for onward referral to vascular specialists. In addition, before selecting patients for application of compression, assess the skin condition and limb shape, as well as the presence of neuropathy or cardiac failure and patient-known allergies as these may affect both the level of compression and the components of the compression system used (Marston and Vowden, 2003). The assessment process should identify potential problems that may affect healing and recurrence.

Assessment should also identify potentially vulnerable areas such as bony prominences, which may require padding for protection. Padding may add to the comfort of the bandage but excessive padding may reduce compression levels and lead to bandage slippage and generate a bulky bandage system. When assessing for hosiery, consider the patients' and their carers' ability to apply and remove stockings.

Choosing and applying compression
A recent Cochrane review has identified that multi-component
bandage systems have been shown to be more effective than single-component bandage systems (ranging from cohesive single layer through to zinc paste bandages and Unna's boot)  in healing venous leg ulcers (O'Meara, 2009). Box 1 highlights the requirements for an ideal compression system.

The choice of compression system for each patient will depend on the results of the assessment process, the patient's preferences, healthcare professionals' skills and the available resources. Effective compression should provide a balance between exerting too little pressure, which is ineffective, and too much pressure, which causes damage or is not tolerated by the wearer. Other considerations may relate to the bulk of the bandage, the impact on footwear and temperature discomfort during hot weather. If the chosen bandage system is bulky ensure that the patient has or is provided with suitable footwear. This will encourage mobilisation, increase the effectiveness of treatment and aid concordance.

For compression to be fully effective, patients should be provided with appropriate education on the underlying disease and be encouraged to elevate their legs when resting (WUWHS, 2008).

Choosing and using hosiery

Hosiery remains the mainstay of prevention, but 2-layer 'strong' hosiery systems can also be an effective method of providing compression therapy in selected patients with small, low exudate wounds. Such patients can be encouraged to self-care under the supervision of an appropriate healthcare professional. Provision of application aids can help to facilitate this.

It is important to measure the leg accurately and select appropriately sized hosiery with the correct compression level. Ensure that the patient is shown how to apply the hosiery and understands when to wear the garment. Give instruction on skin care and hosiery maintenance, including washing and drying. Hosiery constituents vary and it may be necessary to try different makes of stocking if concordance is to be improved for individual patients.

Improving concordance
A patient's initial experience with compression therapy may colour their subsequent opinion of this form of therapy. Patients should be engaged in treatment planning and be provided with sufficient information for them to understand the rationale for treatment. Adherence with treatment is also dependent upon patient motivation, which can be affected by factors such as social isolation or treatment discomfort. Effective symptom control, either with dressings or analgesia, can improve quality of life and patient tolerance of compression therapy, aiding concordance (Briggs and Nelson, 2010). Miller et al (2011) in their study on predicting concordance concluded that pain, wound size and depth and patient age all influenced concordance.

For further guidance on the use of compression therapy in venous leg ulcers, please see the recommended treatment pathway developed by the International Leg Ulcer Advisory Board (Marston and Vowden, 2003. Available from www.woundsinternational.com)

References

  • Barwell JR, Davies CE, Deacon J, et al (2004) Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): randomised controlled trial. Lancet 5;363(9424):1854-9
  • Beldon P (2006) Bandaging: which bandage to use and when. Wound Essentials 2006;4:52-61
  • Briggs M, Nelson EA (2010) Topical agents or dressings for pain in venous leg ulcers. Cochrane Database of Systematic Reviews 4:CD001177
  • Callam M (1992) Prevalence of chronic leg ulceration and severe chronic venous disease in western countries. Phlebology 7(Suppl):6-12
  • Clark M (2003) Compression bandages: principles and definitions.  In: EWMA Position Document. Understanding compression therapy. London: MEP Ltd. 5-7
  • Eklof B, Rutherford RB, Bergan JJ, et al (2004) Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg 40(6):1248-52
  • Hopkins A, Worboys F (2005) Understanding compression therapy to achieve tolerance. Wounds UK 1(3):26-34
  • Marston W, Vowden K (2003) Compression therapy: a guide to safe practice. In: EWMA Position Document. Understanding Compression Therapy. London: MEP Ltd. 11-7
  • Miller C, Kapp S, Newall N, et al (2011) Predicting concordance with multilayer compression bandaging. J Wound Care 20(3):101-2,4,6 Passim
  • Moffatt CJ (2004) Factors that affect concordance with compression therapy. J Wound Care 13(7):291-4
  • O'Meara S, Cullum NA, Nelson EA (2009) Compression for venous leg ulcers. Cochrane Database of Systematic Reviews 1:CD000265
  • Partsch H (2003) Understanding the pathophysiological effects of compression. In: EWMA Position Document: Understanding compression therapy. London: MEP Ltd. 2-4
  • Partsch H (2005) The use of pressure change on standing as a surrogate measure of the stiffness of a compression bandage. Eur J Vasc Endovasc Surg 30(4):415-21
  • SIGN (2010) Management of Chronic Venous Leg Ulcers. Edinburgh: Scottish Intercollegiate Guidelines Network
  • Venous Forum of the Royal Society of Medicine. Berridge D, Bradbury AW, Davies AH, et al (2011) Recommendations for the referral and treatment of patients with lower limb chronic venous insufficiency (including varicose veins). Phlebology 26(3):9-3
  • Vowden KR, Barker A, Vowden P (1997) Leg ulcer management in a nurse-led, hospital-based clinic. J Wound Care 6(5):233-6
  • Vowden P, Vowden K (2001) Doppler assessment and ABPI: Interpretation in the management of leg ulceration. World Wide Wounds, March.
  • World Union of Wound Healing Societies (WUWHS) (2008) Principles of best practice: Compression in venous leg ulcers. A consensus document. London: MEP Ltd.

 

Authors: Vowden K, Nurse Consultant Wound Care; Peter Vowden, Vascular Surgeon and Visiting Professor of Wound Healing Research. Bradford Teaching Hospitals NHS Foundation Trust and The University of Bradford

Supported by Activa Healthcare

related resources