A Guide To Compression Dressings For Venous Ulcers

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

Other Considerations To Keep In Mind

Venous insufficiency is very common and is the most likely cause of lower extremity edema.38 However, it is imperative to consider other causes of edema, especially in a population with multiple significant comorbidities.39,40 Prior to initiating compression therapy, one must ensure adequate arterial circulation. Studies have shown that up to 30 percent of people with lower extremity ulceration have concomitant peripheral arterial disease.41

   Physical assessment including an ABI is often indicated. An ABI > 1.3 suggests poorly compressible vessels and an arterial Doppler with segmental and toe waveforms/pressures may be necessary.42 Most experts agree that an ABI 16,35,43 Patients with ABI readings between 0.5 and 0.8 may benefit from modified bandaging that offers a reduced compression of 15 to 25 mmHg.44

   One must tailor compression therapy to the patient. Due to the initial discomfort that may occur with compression therapy, it may be necessary to begin with less compression and gradually increase to the indicated pressure. Patients who have a negative first experience with compression may be less willing to continue the treatment.35

   Multiple factors have been implicated as contributing to poor therapy adherence.45 One of the inconveniences with compression bandages is the necessity to keep the dressing dry. There are devices that one can slip on over the leg to seal from the shower water. However, application may be difficult in patients with poor dexterity, strength or balance. Many patients are creative with large garbage bags.

   Addressing this issue at the initiation of therapy will assist with maintaining a safe environment for the patient. Once therapy is established and progressing, it may be possible to coordinate visits with the patient and have them remove the bandage and shower prior to the visit. If there is assistance in the home, the patient might use short stretch bandages and one can teach the family how to remove and reapply these bandages safely after bathing. Remember to validate competence prior to allowing unsupervised application.

   One should initiate patient education regarding the necessity for compression — both for ulcer treatment and for lifelong maintenance — at the first visit. An understanding of the pathophysiology of the disease helps with therapy adherence.46 However, ulcer recurrence is often associated with failure to wear the compression socks or use the venous pump as directed. Continued reinforcement at every visit is essential.

In Conclusion

Podiatrists frequently encounter venous ulcerations and chronic venous insufficiency in the clinical setting. The standard of care for management includes graduated compression therapy. It is important to rule out other potential causes of lower extremity edema and ensure vascular adequacy prior to the initiation of therapy. One should also consider the individual needs of each patient prior to choosing a compression plan of care.

   Ms. Rivera is an instructor at the Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science in Chicago. She is also a nurse practitioner with a specialty in wound and foot care at the Center for Lower Extremity Ambulatory Research (CLEAR).

   Dr. Wu is the Director of the aforementioned CLEAR at the Scholl College of Podiatric Medicine. She is an Associate Professor for the Center for Stem Cell and Regenerative Medicine at the School of Graduate and Postdoctoral Studies at the Rosalind Franklin University of Medicine and Science. Dr. Wu is also an Associate Professor in the Surgery Department and the Associate Dean of Research at the aforementioned Scholl College of Podiatric Medicine.

References

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.

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