ESSENTIALS OF COMPRESSION — Lymphedema therapist: Consider gradient, dosage, adjustability, wall stability
By Bryan Groleau
When I began utilizing compression as a lymphedema therapist 17 years ago, I could have counted the compression products available to my patients on one hand, but thanks to advancements and industry growth, there are now more options than ever before.
I think most would agree that compression is fundamental in the treatment of lymphedema and advanced vein disease; however, it’s important to understand not all compression is created equal. I have vast experience treating all types of lymphedema from oncology-related lymphedema and lymphatic filariasis to phlebolymphedema and associated venous leg ulcers.
Throughout my career, I’ve seen advanced compression products remarkably improve patient care and quality of life, and in some circumstances, even salvage limbs. I currently travel the country as an educator for mediUSA, giving talks on compression for lymphedema and wound care. Practitioners often ask what specific products I recommend because with so many products to choose from, determining the best for a patient’s needs can be overwhelming.
Compression is the most recommended treatment method for patients with venous leg ulcers, as evidenced in a meta-analysis completed by the American Venous Forum and Society of Vascular Surgery1. This invaluable study provides data-driven support for compression as a critical component in the treatment of venous leg ulcers.
When selecting compression, it’s important to identify the function(s) or mechanism(s) we are trying to facilitate and understand how specific compression types can stimulate those functions. For example, while supporting the calf muscle pump is of utmost importance to increase venous return and reduce swelling, not all types of compression support this mechanism.
When people hear the term “compression,” socks are usually the first thing that come to mind, but compression encompasses products used in all stages of treatment, from the bandages used during active treatment of wounds and lymphedema to the various compression garments – socks included – that are prescribed for at-home maintenance care once a patient has been discharged.
In order to choose the best compression for a patient’s needs, we must consider multiple key factors including gradient, dosage, adjustability, and wall stability – or what I like to call “The Essentials of Compression.”
The distribution of pressure is the first thing we should look at when applying compression, whether treating a patient for lymphedema or venous leg ulcers, or long-term maintenance following the reduction of swelling or wound healing. Gradient compression delivers the highest level of pressure in the distalmost part of the limb and then slowly reduces in pressure proximally up the limb to promote distal to proximal blood and lymph flow, combatting the effect of gravity.
By Law of Laplace, areas with a smaller radius will have greater pressure than areas of larger radius when equal pressure is applied. In other words, a gradual reduction in pressure will occur when a compression bandage provides equal tension from the area of smallest circumference to the area of largest circumference (e.g. from ankle to knee)2.
Gradient compression can be obtained by applying multilayer compression systems or adjustable Velcro compression systems, which are able to provide equal pressure around a limb’s natural contour. When prescribing compression garments for long-term maintenance, choosing a high-quality product that has been tested and proven to provide gradient compression is crucial to ensuring a patient’s venous or lymphatic disease will be managed properly.
The concept of gradient may sound basic, but all too often when I’m evaluating newly referred patients, I find this essential has been missed. I have had many patients show up to treatment wearing elastic tubular stockinet on their legs, which does not meet the gold standard of compression for a venous leg ulcer as elastic tubular stockinet does not offer near the appropriate level of compression nor the necessary gradient. These products could potentially take on the opposite intended effect by compressing the wider circumferences more than the smaller circumferences, promoting flow from proximal to distal.
When it comes to bandaging a patient, ensuring gradient requires use of the right materials; the less elastic a product is, the more control we have on providing the appropriate distribution of pressure. Although single-layer elastic bandages have historically been used for treating patients with venous and lymphatic disease, these bandages are inferior to today’s sophisticated compression products. I recommend bandaging products with minimal or no elastic. Specialized multilayer systems such as the 2-layer, 3-layer, 4-layer and adjustable Velcro compression wraps are more effective in combating the disease process.
In addition to gradient, we must consider dosage to maximize the effectiveness of compression for patients with venous and lymphatic disease. The following figure from the 2015 study by Harding et al3 compares ambulation among patients with vein disease and those with healthy veins.
When observing pressure changes in a healthy limb during supine, standing and walking positions, there is a significant drop in pressure with ambulation. However, the pressure does not drop dramatically during ambulation in a limb with vein dysfunction even though the calf-muscle pump is still present.
This malfunction in the valves causes high pressure to be sustained and signifies poor venous return. Figure 1 shows this difference in pressure during minute 3 with an average variance of 30-50mmHg indicating the amount of compression needed to combat advanced vein disease and/or phlebolymphedema.
Research shows that compression for vein disease is dose-dependent, with 30-40mmHg being the standard recommended protocol. If we downgrade the level of compression based on a patient’s inability to don and doff a product, we prolong the healing process and increase the likelihood for recurrence.
When patients struggle to apply compression socks with the recommended dose of compression on their own, I will suggest using either mediven Dual Layer elastic stockings or products that feature adjustable Velcro straps for ease of donning, such as the Circaid Juxtalite and Circaid Juxtalite HD as these products provide measurable compression.
Although generally more expensive than elastic compression socks, adjustable Velcro products can prove more cost-effective in the end for patients unable to don elastic socks on their own. As I explain to my patients, spending money on a less expensive product that can’t be fully utilized is like throwing money away, while investing in a more functional compression system will always be money well spent.
Adjustability should be a consideration when choosing compression garments for all patients, particularly those who experience fluctuation in edema and those managing self-care. Adjustable Velcro compression products can greatly improve consistency, compliance, and outcomes and have been used for years to help patients better manage their long-term treatment regimen following discharge.
Products such as the Circaid Juxtalite now make it possible for patients to receive compression during the treatment of venous leg ulcers when a wound is still open, and are now being prescribed earlier in the treatment process. Adjustable Velcro compression products are even covered under Medicare Part B when prescribed while an open wound is present.
Patients treated with adjustable Velcro compression also experience a faster reduction of swelling because of this increased consistency. Unlike inelastic bandages, which have been shown to demonstrate a 50 percent reduction in surface pressure within 24 hours, adjustable Velcro compression products do not show prolonged reduction in surface pressure due to their ability to be readjusted and reset whenever pressure lessens.4
Treatment frequencies for chronic wounds and lymphedema vary from clinic to clinic, but based on my experience, the average patient receives treatment and reapplication of compression by a multidisciplinary team 2-3 times per week. It’s quite common to see bandages that were applied during treatment out of place during subsequent visits. This occurs because most patients are unable to effectively re-bandage on their own when swelling reduces and/or when their bandage falls.
As a result, the swelling has an opportunity to refill. A practical solution to this problem is to utilize adjustable Velcro compression which can enable the patient or caregiver to readjust the compression needed to improve consistency and reduce swelling faster.
In a 40-leg comparison study conducted by Mosti et al., 50 percent of patients with chronic venous edema whose legs were treated with adjustable Velcro compression experienced faster reduction in edema than those whose legs were treated with inelastic bandages. The legs treated with inelastic bandages achieved a 19 percent reduction, whereas adjustable Velcro compression obtained 26 percent reduction.
The surface pressure on legs treated with inelastic bandages reduced by 50 percent or more within 24 hours, whereas legs treated with adjustable Velcro products did not show a decrease in surface pressure because the product could be readjusted to maintain consistent compression4.
The improvement in consistency made possible by adjustable Velcro products can be a game-changer for many cases as most patients are not seen daily. The average venous leg ulcer takes 6 months to heal5, but it seems to me that by increasing consistency with compression, this 6-month average could be dramatically improved. While adjustability might not be necessary for every scenario, it is always worth asking whether a patient will benefit more from the features offered by adjustable Velcro compression.
The final factor I urge practitioners to consider when choosing compression wall-stability, which relates specifically to the management of edema and lymphedema. Compression can be categorized into two types based on the materials used: elastic compression and inelastic compression.
When we consider the qualities of elastic, it’s easy to understand that a product made from elastic will have more stretch and give than an inelastic product will. Inelastic materials have a greater impact on the calf muscle pump mechanism than elastic and provide a stronger support-wall during muscle contraction than elastic materials, a pressure known as “working pressure.”
On the other hand, “resting pressure” –or pressure when the muscle pump is at rest—is much higher with elastic compression than inelastic compression which is not ideal when stimulating venous and lymphatic return6. With my patients, I have found that compression products made from inelastic materials maintain a much sturdier hold and are also more effective at containing edema than compression made from elastic materials.
In my experience in working with clinicians across the country, I’ve noticed that when choosing compression, most are inclined to recommend 30-40mmHg socks as these garments have long been considered the norm. In circumstances where compression socks fail to manage edema as expected, practitioners may question why the patient’s garment did not work; after all, the dose of compression fit the standard protocol.
However, compression level is not the issue here; it’s the material. Even though the compression socks provide the correct dose of compression, the elastic fibers can allow for too much stretch and aren’t always strong enough to combat edema. In contrast, inelastic products are able to effectively contain and reduce edema thanks to greater wall-stability.
CHOOSING COMPRESSION FOR TRANSITION
AND MAINTENANCE CARE FOR LEG ULCERS
Transition products prepare patients for the maintenance stage following discharge. Products for transition often involve adjustable Velcro compression which work whether a limb further reduces or even refills a bit and reduce the risk for recurrence7. In addition to traditional compression socks, I recommend making sure all patients have at least one compression product that can combat potential exacerbations such as increased swelling.
Compression socks offer numerous benefits: They are low-profile, available in various size ranges, and allow patients to self-manage in public without bringing attention to their disease. However, they don’t offer adjustability and are unable to accommodate fluctuation in edema.
In summary, gradient, dosage, adjustability, and wall stability should be considered when selecting compression products – from the bandages we use during treatment to the garments we prescribe for transition and maintenance care. By applying these essentials of compression, we can enhance the treatment process and improve our patients’ quality of life, for life. VTN
1O’Donnell TF, Passman MA, Marston WA., Ennis WJ, Dalsing M, Kistner RL, … & Stoughton J. Management of venous leg ulcers: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. Journal of Vascular Surgery. 2014. 60(2), 3S-59S.
2Principles of compression in venous disease: a practitioner’s guide to treatment and prevention of venous leg ulcers. Wounds International. 2013. Available to download at www.woundsinternational.com
3Harding K, et al. Simplifying venous leg ulcer management: Consensus Recommendations. Wounds International. 2015. Available to download at www.woundsinternational.com
4Mosti 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 Randomized Controlled Trial. European Journal of Vascular and Endovascular Surgery. 2015;50(3):368-374. doi:10.1016/j.ejvs.2015.05.014
5Parker CN, Finlayson KJ, Edwards HE. Predicting the likelihood of delayed venous leg ulcer healing and recurrence: development and reliability testing of risk assessment tools. Ostomy Wound Manage. 2017; 63(10):16-33. doi:10.25270/owm.2017.1633
6Partsch H, Menzinger G, Mostbeck A. Inelastic leg compression is more effective to reduce venous refluxes than elastic bandages. Dermatol Surgery. 1999 Sep 25 (9): 695-700. doi:10.1046/j.1524-4725.1999.98040.x
7Nelson EA, Bell-syer SE. Compression for preventing recurrence of venous ulcers. Cochrane Database of Syst Rev. 2014; (9): doi:10.1002/14651858.CD002303.pub3
Bryan Groleau, COTA/L, CLT-LANA, WCC, LLE, CLWT, has been a lymphedema and wound therapist since 2003 with a focus on lower extremity lymphedema and wounds. Throughout his career, Bryan has treated extensively in both outpatient and home care settings and managed lymphedema and wound care teams for multiple clinics and home health agencies. Currently, he is a national senior clinical education manager for mediUSA, and also serves on the medi for help medical missions project to treat and educate on lymphedema and wound care for those with lymphatic filariasis in Léogâne, Haiti.