A Guide To Compression Dressings For Venous Ulcers

Author(s): 
Nancy Slone-Rivera, MS, ANP-C, CWON, CFCN, and Stephanie C. Wu, DPM, MSc

   Clinicians should place initial orders for compression socks prior to ulcer closure as many insurance companies will not pay for compression hose if no active ulcer exists. If the patient has lower leg edema, a compression bandage may initially be needed for edema reduction prior to sock measurement. Measurement is simple but essential. It usually consists of measuring the lower leg length and calf and ankle circumference. Customized fit stockings may be necessary for some patients. Some medical supply stores have a compression specialist on staff. However, this service seems to be less frequently available. Prescriptions for compression stockings from medical supply stores should include not only compression strength but patient measurements as well.

   One would prescribe compression strength according to the severity of disease. Graduated compression of 30 to 40 mmHg at the ankle is recommended for chronic venous insufficiency and prevention of ulcer recurrence. It is important to mention that current stocking classifications are not standardized. In other words, a “class II” sock may represent 20 to 30 mmHg for one manufacturing company and 30 to 40 mmHg for another. Labels such as mild, moderate, firm and strong may also represent different strengths between companies.

   Many insurance agencies will only pay for 30 to 40 mmHg stockings. Since compression hose needs to be replaced at least yearly, if not every three to six months, the patient cost can be high, especially when the socks are not reimbursed. Patients are often tempted to look for cheaper alternatives via mail order or online catalogues. However, one must encourage patients to be cautious regarding these entities as compression gradients may not be validated or even specified, there may be fewer options in size available, and the quality of the material may not be as durable. Reputable medical supply companies will take orders, bill insurances and deliver to the patient. Most will provide doctors’ offices with special order forms to facilitate the process.

   Several companies make two-layer compression socks with the two layers intended to be worn together to achieve the prescribed compression. Many patients find the two layer systems easier to apply than the single layer socks. When using compression stockings, patients should receive instruction that it is best to shower in the evening and then don their socks first thing in the morning before edema has a chance to accumulate in the limb. It is important to emphasize to patients that “first thing in the morning” means before getting out of bed, not after breakfast or the morning news.

   Clinicians may employ compression stockings for the treatment of smaller ulcers with manageable drainage instead of multi-layer bandages. Dual layer socks are often less disruptive over an ulcer dressing.36

   One of the factors contributing to poor stocking compliance is application difficulty. Venous ulcer prevalence increases with age. Compounding this situation are the realities that comorbidities of musculoskeletal problems, neurological problems, fragility and lack of significant other assistance also increase with age.5 Although assistive donning devices are available, they are generally not covered by insurance carriers. Having a clinic assortment of application aids can help determine which would be most helpful.

   Anti-embolic stockings are not appropriate for treating chronic venous disease. These stockings are made for patients who are non-ambulatory, non-mobile or bedridden to prevent venous thrombus. They have a very low graduated compression, typically only 8 to 18 mmHg, which cannot overcome the high pressures associated with ambulatory venous hypertension.37 They are not intended for long-term use and lose their elasticity over a couple of weeks.

Comments

As a disclosure, I am VP of Farrow Medical, which manufactures short stretch garments. This is a long comment.

I would like to clarify a point with regard to the definitions herein of inelastic versus short stretch, which I believe, as stated, allow for confusion, even historically, predating 2006.

I don't believe inelastic products are historically considered to be products with 30 to 70% stretch. In fact, Foldi specifically distinguishes between short stretch and inelastic.

Why would they be separated in textbooks and yet be referred to by others as the same or similar?

If a product with less than 15% stretch, as an example, is applied, there are several issues.
1. You are not really sure how much compression is being applied because the amount of compression is directly related to how hard the provider is pulling. Does the provider know how hard he is he is pulling? Does the next person applying know how hard he or she is pulling?
2. Products with this amount of stretch don't work terribly well over joints, such as the anterior ankle, and this can cause ulcerations.
3. True inelastic products are generally reserved in wound centers for patients with a low AB index, and they are applied with very little tension, meaning they are applying little if any significant resting compression. They depend upon a higher working compression to reduce/control edema.
4. If the leg decreases significantly in circumference as a result of higher working compression levels generated, the garment can slide down and the higher working compression advantage would be lost until readjusted.

"Short stretch" products are applied with some stretch and hence, inherent in that stretch is some tension, which translates into ~some~ compression. As the authors appropriately state, this compression level can fall of rather abruptly with time. Short stretch bandages, traditionally, are manufactured of 100% cotton and depend a good degree on the weave of the product to produce the tension and hence compression. So if a product which has some stretch but little sustained elastic compression of its own is applied near its maximal stretch, it would essentially function as inelastic, although if the leg reduced in size, it "might" shrink along with the leg, but also provide a lower working compression level.

If, however, a product with short (limited or low) stretch AND elastic fibers was used, the compression would not fall off as quickly and the performance would be hybridized with other elastic compression garments. By hybridized, I mean provide a steady lower resting compression (like a stocking) AND a higher working compression (more like inelastic).

Why is this important?

In my opinion, with elastic short stretch products ...
1. The short stretch can better cue you in to the amount of tension being applied by feeling the abruptness of the short stretch and hence the tension level.
2. The stretch allows for better functionality over joints.
3. The short stretch generally allows for more consistent low resting compression and higher working compression levels (working like a pump when the patient ambulates when properly applied). (It is sometimes referred to as a poor man's pump.)
4. The product can shrink some if the leg decreases in size, limiting slippage and the need for adjustments.

As a clinical example, in a chair-bound nursing home resident, a truly inelastic product that is properly applied might apply very little resting compression (or if too tight could be a tourniquet). A short stretch product with elastic fibers would apply some sustained resting compression with the potential for higher working compression when properly applied. Long stretch wraps have the potential to produce highest sustained resting compressions, which can be a little more hazardous if not professionally applied, and lower working compressions unless applied with a significant (potentially more dangerous) amount of tension.

Conversely, if a patient had poor arterial circulation, the provider may opt to apply a product that is "inelastic" with very little tension applied because a lower resting compression has a lower potential to block arterial circulation, but still has the potential to provide a higher working compression to help reduce/control edema. Note that this would work best if the calf muscle pump was functional.

One last point. A product that is inelastic applied and just barely snug would apply a low resting compression when vertical, but very little, if any, when lying down. Short stretch would apply more resting compression than inelastic when lying down. Long stretch would generally provide the most compression when lying down (and the least potential for high working compression when vertical). So patients with impaired arterial circulation are generally safer with inelastic, then short stretch products, when they lie down, as opposed to long stretch, IF compression is safe be applied at all depending on the situation.

Add new comment