Randomized controlled trial comparing treatment outcome of two compression bandaging systems and standard care without compression in patients with venous leg ulcers. J Vasc Surg. 2012;55:1376-1385. [PMID: 22429451 DOI: 10.1016/j.jvs.2011.12.019]

Effects of physical activity as an adjunct treatment on healing outcomes and recurrence of venous leg ulcers: A scoping review

Healing time is protracted and ulcer recurrence is common in patients with venous leg ulcers. Although compression is the mainstay treatment, many patients do not heal timely. Physical activity may be a clinically effective adjunct treatment to compression to improve healing outcomes. This scoping review provides a broad overview of the effect of physical activity as an adjunct treatment to compression on wound healing and recurrence. We followed the six-step framework developed by Arksey and O'Malley. We searched electronic databases and trial registration websites for relevant studies and ongoing trials. Two authors independently screened and selected articles. Findings were presented in a descriptive statistical narrative summary. We consulted and presented our findings to the wound consumer group to ensure the relevance of our study. Physical activity interventions in 12 out of the 16 eligible studies consisted of only one component, eight studies were resistance exercises, three studies reported ankle and/or foot range of motion exercises, and one study reported aerobic/walking exercises. The remaining four studies involved multicomponent exercise interventions. Resistance exercise combined with ankle and/or foot range of motion exercise minimised ulcer size on day 12 (intervention group: 4.55 ± 1.14 cm² vs. control group: 7.43 ± 0.56 cm² ) and improved calf muscle pump performance on day 8 (ejection fraction: 40%-65%; residual volume fraction: 56%-40%). We identified one study that reported ulcer recurrence rate with no clinical difference in the intervention group versus the control group (i.e., 12% in intervention vs. 5% in control). Our review identified that resistance exercise was the most common type of physical activity intervention trialled in the published literature. Resistance exercise combined with ankle and/or foot range of motion exercise appears to be effective adjunct treatments; however, the overall evidence is still relatively weak as most programmes had a short intervention period which limited clinical outcomes.

Compression bandages or stockings versus no compression for treating venous leg ulcers

BACKGROUND

Leg ulcers are open skin wounds on the lower leg that can last weeks, months or even years. Most leg ulcers are the result of venous diseases. First-line treatment options often include the use of compression bandages or stockings.

OBJECTIVES

To assess the effects of using compression bandages or stockings, compared with no compression, on the healing of venous leg ulcers in any setting and population.

SEARCH METHODS

In June 2020 we searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (including In-Process & Other Non-Indexed Citations), Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions by language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials that compared any types of compression bandages or stockings with no compression in participants with venous leg ulcers in any setting.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed studies using predetermined inclusion criteria. We carried out data extraction, and risk-of-bias assessment using the Cochrane risk-of-bias tool. We assessed the certainty of the evidence according to GRADE methodology.

MAIN RESULTS

We included 14 studies (1391 participants) in the review. Most studies were small (median study sample size: 51 participants). Participants were recruited from acute-care settings, outpatient settings and community settings, and a large proportion (65.9%; 917/1391) of participants had a confirmed history or clinical evidence of chronic venous disease, a confirmed cause of chronic venous insufficiency, or an ankle pressure/brachial pressure ratio of greater than 0.8 or 0.9. The average age of participants ranged from 58.0 to 76.5 years (median: 70.1 years). The average duration of their leg ulcers ranged from 9.0 weeks to 31.6 months (median: 22.0 months), and a large proportion of participants (64.8%; 901/1391) had ulcers with an area between 5 and 20 cm2. Studies had a median follow-up of 12 weeks. Compression bandages or stockings applied included short-stretch bandage, four-layer compression bandage, and Unna's boot (a type of inelastic gauze bandage impregnated with zinc oxide), and comparator groups used included 'usual care', pharmacological treatment, a variety of dressings, and a variety of treatments where some participants received compression (but it was not the norm). Of the 14 included studies, 10 (71.4%) presented findings which we consider to be at high overall risk of bias. Primary outcomes There is moderate-certainty evidence (downgraded once for risk of bias) (1) that there is probably a shorter time to complete healing of venous leg ulcers in people wearing compression bandages or stockings compared with those not wearing compression (pooled hazard ratio for time-to-complete healing 2.17, 95% confidence interval (CI) 1.52 to 3.10; I2 = 59%; 5 studies, 733 participants); and (2) that people treated using compression bandages or stockings are more likely to experience complete ulcer healing within 12 months compared with people with no compression (10 studies, 1215 participants): risk ratio for complete healing 1.77, 95% CI 1.41 to 2.21; I2 = 65% (8 studies with analysable data, 1120 participants); synthesis without meta-analysis suggests more completely-healed ulcers in compression bandages or stockings than in no compression (2 studies without analysable data, 95 participants). It is uncertain whether there is any difference in rates of adverse events between using compression bandages or stockings and no compression (very low-certainty evidence; 3 studies, 585 participants). Secondary outcomes Moderate-certainty evidence suggests that people using compression bandages or stockings probably have a lower mean pain score than those not using compression (four studies with 859 participants and another study with 69 ulcers): pooled mean difference -1.39, 95% CI -1.79 to -0.98; I2 = 65% (two studies with 426 participants and another study with 69 ulcers having analysable data); synthesis without meta-analysis suggests a reduction in leg ulcer pain in compression bandages or stockings, compared with no compression (two studies without analysable data, 433 participants). Compression bandages or stockings versus no compression may improve disease-specific quality of life, but not all aspects of general health status during the follow-up of 12 weeks to 12 months (four studies with 859 participants; low-certainty evidence). It is uncertain if the use of compression bandages or stockings is more cost-effective than not using them (three studies with 486 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

If using compression bandages or stockings, people with venous leg ulcers probably experience complete wound healing more quickly, and more people have wounds completely healed. The use of compression bandages or stockings probably reduces pain and may improve disease-specific quality of life. There is uncertainty about adverse effects, and cost effectiveness. Future research should focus on comparing alternative bandages and stockings with the primary endpoint of time to complete wound healing alongside adverse events including pain score, and health-related quality of life, and should incorporate cost-effectiveness analysis where possible. Future studies should adhere to international standards of trial conduct and reporting.

Strategies and challenges in the treatment of chronic venous leg ulcers

Evaluating patients with chronic venous leg ulcers (CVLUs) is essential to find the underlying etiology. The basic tenets in managing CVLUs are to remove the etiological causes, to address systemic and metabolic conditions, to examine the ulcers and artery pulses, and to control wound infection with debridement and eliminating excessive pressure on the wound. The first-line treatments of CVLUs remain wound care, debridement, bed rest with leg elevation, and compression. Evidence to support the efficacy of silver-based dressings in healing CVLUs is unavailable. Hydrogen peroxide is harmful to the growth of granulation tissue in the wound. Surgery options include a high ligation with or without stripping or ablation of the GSVs depending on venous reflux or insufficiency. Yet, not all CVLUs are candidates for surgical treatment because of comorbidities. When standard care of wound for 4 wk failed to heal CVLUs effectively, use of advanced wound care should be considered based on the available evidence. Negative pressure wound therapy facilitates granulation tissue development, thereby helping closure of CVLUs. Autologous split-thickness skin grafting is still the gold standard approach to close huge CVLUs. Hair punch graft appears to have a better result than traditional hairless punch graft for CVLUs. Application of adipose tissue or placenta-derived mesenchymal stem cells is a promising therapy for wound healing. Autologous platelet-rich plasma provides an alternative strategy for surgery for safe and natural healing of the ulcer. The confirmative efficacy of current advanced ulcer therapies needs more robust evidence.

Strategies and challenges in the treatment of chronic venous leg ulcers

Evaluating patients with chronic venous leg ulcers (CVLUs) is essential to find the underlying etiology. The basic tenets in managing CVLUs are to remove the etiological causes, to address systemic and metabolic conditions, to examine the ulcers and artery pulses, and to control wound infection with debridement and eliminating excessive pressure on the wound. The first-line treatments of CVLUs remain wound care, debridement, bed rest with leg elevation, and compression. Evidence to support the efficacy of silver-based dressings in healing CVLUs is unavailable. Hydrogen peroxide is harmful to the growth of granulation tissue in the wound. Surgery options include a high ligation with or without stripping or ablation of the GSVs depending on venous reflux or insufficiency. Yet, not all CVLUs are candidates for surgical treatment because of comorbidities. When standard care of wound for 4 wk failed to heal CVLUs effectively, use of advanced wound care should be considered based on the available evidence. Negative pressure wound therapy facilitates granulation tissue development, thereby helping closure of CVLUs. Autologous split-thickness skin grafting is still the gold standard approach to close huge CVLUs. Hair punch graft appears to have a better result than traditional hairless punch graft for CVLUs. Application of adipose tissue or placenta-derived mesenchymal stem cells is a promising therapy for wound healing. Autologous platelet-rich plasma provides an alternative strategy for surgery for safe and natural healing of the ulcer. The confirmative efficacy of current advanced ulcer therapies needs more robust evidence.

Controlling compression bandaging pressure in leg ulcer research trials: A summary of the literature

Compression bandaging remains the ‘gold standard’ intervention for the treatment of venous leg ulcers. Numerous studies have investigated the effect of a large variety of compression bandaging techniques and materials on venous leg ulcer healing. However, the majority of these studies failed to monitor both actual bandage application pressures and the bandaging competency of participating clinicians. A series of literature searches to explore the methods, practices, recommendations and results of monitoring compression bandaging pressures in leg ulcer research trials were undertaken. This included investigating the reliability and validity of sub-bandage pressure monitors and the degree to which compression bandaging achieves the recommended sub-bandage pressure. The literature revealed inconsistencies regarding the monitoring of sub-bandage pressure and in sub-bandage pressures produced by clinicians. This creates difficulties when comparing study outcomes and attempting to develop evidence-based practice recommendations.

Adaptive compression therapy for venous leg ulcers: a clinically effective, patient-centred approach

A prospective, randomised, 12-week study was performed to evaluate the efficacy and tolerability of two compression methods for venous leg ulcers (VLUs); a new adaptive compression therapy (ACT) system, combining intermittent and sustained pneumatic compression (n = 38) and a conventional four-layer bandage system (n = 52). Primary outcomes were ulcer healing and safety. Secondary outcomes were comfort, compliance, ulcer pain, patient-perceived product performance and quality of life. Ulcer healing rate was similar (31·6% versus 42·3%, respectively, P = 0·30) between the treatments. Adverse events and patient-rated comfort were also similar. Average daily usage for the dual system was 10·5 and 1·8 hours in the sustained and intermittent modes, respectively, representing its use during 71% of waking hours. Predicted final ulcer pain was also similar (P = 0·68). Performance was subjectively better for adaptive compression and significantly higher for exudate management (P = 0·04), skin protection (P < 0·001), removal ease (P = 0·0007), bathing (P < 0·0001) and sleep comfort (P = 0·0405). The adjusted final quality-of-life score was 0·1025 higher for adaptive compression (P = 0·0375). Subjects with healed ulcers attained higher final scores than unhealed subjects (P = 0·0004). This study provides evidence that ACT is comparably efficacious to successfully heal VLUs compared with four-layer bandage management but is better accepted and achieves higher patient-reported quality-of-life scores in these challenging patients.

Terapias compressivas no tratamento de úlcera venosa: estudo bibliométrico

Introdução: Úlceras de origem venosas são lesões cutâneas que geralmente acometem o terço inferior das pernas. O tratamento dessas feridas é dinâmico e depende da evolução das fases da reparação tecidual. Esse tratamento inclui métodos clínicos e cirúrgicos, sendo a terapia compressiva o método não cirúrgico mais frequentemente utilizado. Dentre as terapias compressivas, destacam-se as bandagens inelásticas e elásticas, meias elásticas e pressão pneumática intermitente. Objetivo: O presente estudo pretendeu identificar o perfil da produção científica nacional e internacional que descrevesse terapia compressiva e úlcera venosa classificando-o de acordo com: cronologia de publicação, procedência, periódicos em que estão publicadas, avaliação do “Qualis” — Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Capes), distribuição da abordagem metodológica, análise do conteúdo das publicações e comparar, quando possível, os dados apresentados nessa revisão. Método: Estudo bibliométrico realizado nas bases de dados Medline, Lilacs e CINAHL no qual se utilizaram os descritores “Varicose Ulcer/therapy”, “Compression Bandages”, “Wound Healing” e o operador booleano AND entre os anos de 2009 a 2013. Resultados: Foram selecionados 47 artigos; a maioria publicada em 2012 (n = 12; 25,53%), nos Estados Unidos (n=14; 29,78%) e Reino Unido (n=14; 29,78%), em revistas de especialidade vascular (n=19; 40,42%), com avaliações A2 (n=13; 27,65%) e B1 (n=13; 27,65%). A maior parte da metodologia utilizada nos estudos selecionados era tipo “estudos clínicos” (n= 30; 63,82%). Dentre os estudos clínicos e metanálises, apenas 30% (n= 14) apresentavam como objetivo principal avaliação da terapia compressiva e pretenderam estudar comparativamente eficácia de bandagens elásticas, inelásticas, meias elásticas, pressão pneumática intermitente e ausência de terapia compressiva no tratamento de úlceras venosas. Conclusão: Há preocupação da comunidade científica com a busca do tratamento eficaz para as úlceras venosas, porém a distribuição mundial de publicações é desigual. Evidenciou-se que a terapia compressiva não é o objeto principal na maioria dos trabalhos selecionados, o que leva ao interesse em terapias adjuvantes ou complementares a essa. Ficou evidente a necessidade da terapia compressiva, porém não há consenso sobre qual pressão deva ser utilizada para se obter melhores resultados na cicatrização; portanto, são necessários mais estudos que avaliem as interferências das diversas pressões sobre o processo de reparo tecidual. Também há carência de estudos que comprovem a ação da pressão pneumática intermitente com associações ou não de bandagens elásticas.

An RCT to compare a bio-cellulose wound dressing with a non-adherent dressing in VLUs

OBJECTIVE

To compare the efficacy of a bio-cellulose dressing (BWD) versus a non-adherent wound contact layer in venous leg ulcer (VLU) outpatients.

METHOD

In a prospective, randomised, controlled multicentre study, 48 VLU patients were randomised to receive compression bandages and either standard care (non-adherent dressing; n=23) or a BWD (Suprasorb X; n=25). VLUs were evaluated for debridement efficacy, time to 75-100% granulation and ≥ 50% re-epithelialisation, reduction of ulcer size and patient-reported ulcer pain, comparing the status at day 0 and weekly, over a 12-week study treatment period.

RESULTS

Thirty-three patients (n=18 BWD and n=15 control dressing) were included in the analysis. Autolytic debridement was significantly faster in the BWD group, with an 84% removal of yellow tissue compared with 26% in the control group, over the 12-week period (p < 0.0001). A median of 25 days were required to achieve 75-100% granulation in the BWD group vs 36 days for controls. A median of 36 days was taken to achieve ≥ 50% re-epithelialisation in the BWD group vs 50 days for controls. Patient-reported ulcer pain reduced significantly faster in the BWD group (p < 0.05), by week 7, 100% of patients reported no pain, compared with 63% of controls.

CONCLUSION

Autolytic debridement was faster and more effective in the BWD group compared with standard care, as was pain reduction. Although the time to healing was shorter with the BWD vs standard care, the difference was not statistically significant.

DECLARATION OF INTEREST

This study was supported by Xylos Corporation. The study product was called X-Cell at the time, and is now available as Suprasorb X (Lohmann & Rauscher). Each principal investigator (Alvarez, Phillips, Menzoian, Etris-Brown) and respective clinical centre received funding for the conduct of the study. Each site executed a clinical study agreement independently with the sponsor. The sponsors had no role in the design and conduct of the study, in the collection, analysis, or interpretation of data, or in the preparation of the manuscript, review, or approval of the manuscript. None of the authors received administrative, technical or material support for the conduct of this study. The authors have no relevant financial interest in this article.

Compression therapy: clinical and experimental evidence

AIM

A review is given on the different tools of compression therapy and their mode of action.

METHODS

Interface pressure and stiffness of compression devices, alone or in combination can be measured in vivo. Hemodynamic effects have been demonstrated by measuring venous volume and flow velocity using MRI, Duplex and radioisotopes, venous reflux and venous pumping function using plethysmography and phlebodynamometry. Oedema reduction can be measured by limb volumetry.

RESULTS

Compression stockings exerting a pressure of ~20 mmHg on the distal leg are able to increase venous blood flow velocity in the supine position and to prevent leg swelling after prolonged sitting and standing. In the upright position, an interface pressure of more than 50 mmHg is needed for intermittent occlusion of incompetent veins and for a reduction of ambulatory venous hypertension during walking. Such high intermittent interface pressure peaks exerting a "massaging effect" may rather be achieved by short stretch multilayer bandages than by elastic stockings.

CONCLUSION

Compression is a cornerstone in the management of venous and lymphatic insufficiency. However, this treatment modality is still underestimated and deserves better understanding and improved educational programs, both for patients and medical staff.

Compression for venous leg ulcers

BACKGROUND

Up to one percent of people in industrialised countries will suffer from a leg ulcer at some time. The majority of these leg ulcers are due to problems in the veins, resulting in an accumulation of blood in the legs. Leg ulcers arising from venous problems are called venous (or varicose or stasis) ulcers. The main treatment is the application of a firm compression garment (bandage or stocking) in order to aid venous return. There is a large number of compression garments available and it was unclear whether they are effective in treating venous ulcers and, if so, which method of compression is the most effective.

OBJECTIVES

To undertake a systematic review of all randomised controlled trials (RCTs) evaluating the effects on venous ulcer healing of compression bandages and stockings.Specific questions addressed by the review are:1. Does the application of compression bandages or stockings aid venous ulcer healing? 2. Which compression bandage or stocking system is the most effective?

SEARCH METHODS

For this second update we searched: the Cochrane Wounds Group Specialised Register (31 May 2012); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 5, 2012); Ovid MEDLINE (1950 to May Week 4 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations 30 May 2012); Ovid EMBASE (1980 to 2012 Week 21); and EBSCO CINAHL (1982 to 30 May 2012). No date or language restrictions were applied.

SELECTION CRITERIA

RCTs recruiting people with venous leg ulceration that evaluated any type of compression bandage system or compression stockings were eligible for inclusion. Eligible comparators included no compression (e.g. primary dressing alone, non-compressive bandage) or an alternative type of compression. RCTs had to report an objective measure of ulcer healing in order to be included (primary outcome for the review). SECONDARY OUTCOMES of the review included ulcer recurrence, costs, quality of life, pain, adverse events and withdrawals. There was no restriction on date, language or publication status of RCTs.

DATA COLLECTION AND ANALYSIS

Details of eligible studies were extracted and summarised using a data extraction table. Data extraction was performed by one review author and verified independently by a second review author.

MAIN RESULTS

Forty-eight RCTs reporting 59 comparisons were included (4321 participants in total). Most RCTs were small, and most were at unclear or high risk of bias. Duration of follow-up varied across RCTs. Risk ratio (RR) and other estimates are shown below where RCTs were pooled; otherwise findings refer to a single RCT.There was evidence from eight RCTs (unpooled) that healing outcomes (including time to healing) are better when patients receive compression compared with no compression.Single-component compression bandage systems are less effective than multi-component compression for complete healing at six months (one large RCT).A two-component system containing an elastic bandage healed more ulcers at one year than one without an elastic component (one small RCT).Three-component systems containing an elastic component healed more ulcers than those without elastic at three to four months (two RCTs pooled), RR 1.83 (95% CI 1.26 to 2.67), but another RCT showed no difference between groups at six months.An individual patient data meta-analysis of five RCTs suggested significantly faster healing with the four-layer bandage (4LB) than the short stretch bandage (SSB): median days to healing estimated at 90 and 99 respectively; hazard ratio 1.31 (95% CI 1.09 to 1.58).High-compression stockings are associated with better healing outcomes than SSB at two to four months: RR 1.62 (95% CI 1.26 to 2.10), estimate from four pooled RCTs.One RCT suggested better healing outcomes at 16 months with the addition of a tubular device plus single elastic bandage to a base system of gauze and crepe bandages when compared with two added elastic bandages. Another RCT had three arms; when one or two elastic bandages were added to a base three-component system that included an outer tubular layer, healing outcomes were better at six months for the two groups receiving elastic bandages.There is currently no evidence of a statistically significant difference for the following comparisons:⋅alternative single-component compression bandages (two RCTs, unpooled);⋅two-component bandages compared with the 4LB at three months (three RCTs pooled);⋅alternative versions of the 4LB for complete healing at times up to and including six months (three RCTs, unpooled);⋅4LB compared with paste bandage for complete healing at three months (two RCTs, pooled), six months or one year (one RCT for each time point);⋅adjustable compression boots compared with paste bandages for the outcome of change in ulcer area at three months (one small RCT);⋅adjustable compression boots compared with the 4LB with respect to complete healing at three months (one small RCT);⋅single-layer compression stocking compared with paste bandages for outcome of complete healing at four months (one small RCT) and 18 months (another small RCT);⋅low compression stocking compared with SSB for complete healing at three and six months (one small RCT);⋅compression stockings compared with a two-component bandage system and the 4LB for the outcome of complete healing at three months (one small, three-armed RCT); and,⋅tubular compression compared with SSB (one small RCT) for complete healing at three months.

SECONDARY OUTCOMES

4LB was more cost-effective than SSB. It was not possible to draw firm conclusions regarding other secondary outcomes including recurrence, adverse events and health-related quality of life.

AUTHORS' CONCLUSIONS

Compression increases ulcer healing rates compared with no compression. Multi-component systems are more effective than single-component systems. Multi-component systems containing an elastic bandage appear to be more effective than those composed mainly of inelastic constituents. Two-component bandage systems appear to perform as well as the 4LB. Patients receiving the 4LB heal faster than those allocated the SSB. More patients heal on high-compression stocking systems than with the SSB. Further data are required before the difference between high-compression stockings and the 4LB can be established.