Let me introduce you to Betty. She is that typical 64-year-old woman who enters your clinic with a few small wounds on her lower legs, some minor skin discoloration and a slight amount of edema, seeking your advice and care to heal her wounds. As you investigate her history, you learn she has suffered from tired and achy legs for several years, she experiences swelling of her lower legs and the wounds she is now struggling with have been present for more than six months. You complete your exam and conclude her diagnosis of chronic venous disease with active ulceration, your stereotypical C6 disease. Your next step is to order compression bandaging such as Unnas boots, a multi-layer compression bandage kit or the newer adjustable inelastic compression wraps along with appropriate wound management protocols and dressings.
Fast forward 12 weeks later and Betty has been back to your office at least twice a week to have her wounds cared for and for reapplication of the compression bandages. She has responded well to the compression therapy and her wounds are now nearly healed, and it is time for you to discharge her from your care. As a well-versed practitioner of venous disease, you understand that it was the proper application of compression therapy that resulted in the healing of Betty’s wounds, and more importantly, you know that continued application of compression therapy would be required to prevent recurrence of her ulcers, resulting in Betty being a satisfied patient of your practice and living an improved quality of life.
Determining The Compression Prescription
So now you have a key decision to make—what type and what level of compression therapy should you recommend to Betty upon discharge? You recall the research by Dr. Dragan Milic presented at the 2010 American Venous Forum on the recurrence rates of venous ulcers where he studied the dosage of compression and its affect on ulcer recurrence. The study of 338 recently healed ulcer patients were randomized to elastic compression stockings that provided a) 24 mmHg compression on average or b) 40 mmHg compression on average in the standing position, indicating that recurrence rates after a three-year follow-up were 36% and 20% respectively.1 As such, your decision is to have Betty utilize compression therapy on an ongoing basis that would provide near 40 mmHg of compression, but the question becomes how can you achieve the desired higher level of compression?
As a 64 year-old, Betty is showing signs of arthritis in her hands and fingers; her upper body strength is somewhat diminished, and reaching her feet is moderately difficult. In talking with her about her need for high levels of compression therapy, you know that a recommendation of elastic compression stockings might prove difficult for her to use, and as such she will stop her treatment and will eventually return to your office to begin the healing process over again with her now recurrent ulcers.
What experience has shown us is that most practitioners simply assume that Betty is not able or willing to use 30-40 mmHg elastic stockings and so:
- 30 to 40 mmHg compression stockings are prescribed with no consideration if Betty is able to apply them everyday;
- 20 to 30 mmHg elastic stockings are recommended on the basis that some compression therapy is better than no compression, which is true, but not the only option; or
- No compression therapy is prescribed at all and simply hope the patient remains healed
Furthermore, we also see larger sizes prescribed to make the stocking easier to apply, but which results in a lower dosage of compression. Think about it, if you were to prescribe a pharmaceutical that caused stomach issues, you would investigate other options that minimized this side effect and not simply reduce the dosage of the active ingredient required. So why should we not look for other solutions for providing the needed levels of compression therapy that are suitable and usable by Betty?
The question becomes what can we offer Betty that will enable her to successfully use the higher levels of compression we desire for her so that we can manage her venous disease and prevent the recurrence of her ulcerations?
As it turns out, there are several approaches currently available to Betty that we need to share with her and determine which approach is best for her and her lifestyle.
Donning Devices For Compression Wear
Manufacturers of elastic compression stockings have been aware for some time that the difficulty in donning higher compression level stockings has negatively impacted the willingness of patients to use compression therapy. As such, numerous mechanical devices, rubber gloves, floor pads, slippy devices and other accessories have been developed and marketed over the years to help Betty stretch the stocking over her foot, making it easier to apply the stocking. In addition, devices are also available to help her remove the stocking at the end of the day.
All of these devices are available for purchase at most local providers of compression stockings and will last for years. This makes donning aids a good investment for the patient whose lifestyle is such that they desire to wear the most current and fashionable elastic compression stockings while understanding that they require the higher compression levels to remain healthy.
Multi-Layer Stockings
Another option that the compression manufacturers brought to the market decades ago is the concept of a double-layer stocking. This approach is based on the concept that Betty is able to apply a 15-20 mmHg stocking with relative ease, followed by the application of a second stocking over the first of 20-30 mmHg or 30-40 mmHg in order to achieve the desired dosage of compression therapy (30-40 or 40-50 mmHg). Because of the nature of elastic compression, it is known that compression is cumulative, so a stocking of 25 mmHg applied over a stocking of 15 mmHg will produce approximately 40 mmHg collectively.
This layering design enables a patient such as Betty to more easily apply two lower compression stockings versus donning a single high compression stocking. The single piece high compression stocking is exponentially more difficult to apply than the multi-layer stocking but you can still meet the targeted compression. In addition, the inner stocking or liner of a multilayer system provides a smoother and slicker surface that allows the outer stocking to slide more easily over the foot and up the leg. An additional benefit of the dual-layer systems is that it is possible for the patient to remove the outer stocking at night and remain in the inner stocking overnight, providing additional benefits of compression therapy and edema management while sleeping if needed.
Inelastic Adjustable Compression Wraps
A more recent innovation in compression therapy has been the advancement of inelastic adjustable compression wraps often referred to as Velcro® devices. These devices are compression wraps that have a series of bands that wrap around the leg and are attached using hook and loop patches. Compression is applied simply by administering more or less tension to the bands. By wrapping the garment around the leg rather than trying to stretch and pull over the foot and heel, Betty can quite easily don a high level of compression to her leg without the exertion associated with elastic compression stockings. These devices have become more and more popular with patients that require higher levels of compression, who are older and/or patients that have impaired functionality of their hands and back. An additional advancement in several of these types of products is the ability to control and maintain the desired dosage of compression with the invention of a Built-In Pressure™ system which enables the patient to reproducibly set the compression level to the prescribed level of mmHg.
Another consideration when choosing an inelastic adjustable compression wrap over an elastic stocking system is the compression effect produced by inelastic systems.
Based on the stretch characteristics of elastic materials, a traditional compression stocking will provide a fairly static compression level regardless of the position or movement of the patient. An inelastic garment will produce a more dynamic compression system where the compression level will actually vary under the garment when the patient is active or moving. This dynamic effect generates a pumping action around the calf pumps that has been shown to improve the venous hemodynamics over elastic stockings of equal compression level. Bender, Fronek and Arkans presented data at the 2012 American College of Phlebology Annual Congress showing that chronic venous insufficiency patients experienced an average 19% reduction in venous volumes when using an elastic stocking providing an average of 32 mmHg while those using an inelastic compression wrap set to the same 32 mmHg average compression level experienced an average 35% reduction. Furthermore, these same patients experienced a 25% reduction in venous filling index with the elastic stocking and a 39% reduction with the inelastic compression wrap.2 Some compare the dynamic compression effect of the inelastic compression wrap to a traditional short stretch bandage. The advantages of the inelastic wraps are the patient’s ability to self don and verify compression levels where bandaging does not allow for this ease of use.
As such, when discussing compression therapy options with Betty, one should also recognize her underlying condition and consider if she would be better served by not only a higher level of compression therapy but also if a dynamic compression device might result in a better outcome from the traditional stocking.
Applying Compression Wear Prescription Concepts to Your Practice
All in all, we need to realize that when our patients require compression therapy, the options are numerous and that as with any other form of treatment you provide, you should individualize your recommendation to enable the highest level of concordance with your patient as to the compression therapy approach they should pursue. Perhaps Betty would succeed with a single layer high compression elastic stocking or perhaps she requires a donning aid of some sort or maybe an inelastic adjustable compression wrap is better suited for her. Or sometimes even a combination of approaches is warranted to enable Betty to alter her approach based on her daily lifestyle situation.
If you are referring patients to a local supplier for compression products, it is vital that patients be properly trained and serviced as you would do in your clinic when you are dispensing compression to patients. The 15 minutes it takes to teach a patient how to don and doff the selected compression garment can make all the difference in compliance and comprehension of the benefits of long-term compression usage for the patient.
Whatever the option(s) ultimately selected, I cannot stress enough the importance of discussing the various compression options with Betty so she is an active participant in the decision on what is best. What we cannot allow to happen is for Betty to fail in her compression treatment therapy and continue living an impaired quality of life associated with chronic venous disease or lymphedema.
Dean J Bender is currently President of CircAid Medical Products and Vice President of Marketing and Business Development of Medi USA Inc. He is married with one daughter living in Terrell, North Carolina.
