Improved healing rates for chronic venous leg ulcers: pilot study results from a randomized controlled trial of a community nursing intervention

Investigating low rates of compliance to graduated compression therapy for chronic venous insufficiency: A systematic review

Chronic venous insufficiency (CVI) is a chronic lower limb progressive disorder with significant burden. Graduated compression therapy is the gold-standard treatment, but its underutilisation, as indicated in recent literature, may be contributing to the growing burden of CVI. The aim of this systematic review is to determine the reasons for poor compliance in patients who are prescribed graduated compression therapy in the management of chronic venous insufficiency. A systematic review of the literature was conducted to identify the reasons for non-compliance in wearing graduated compression therapy in the management of chronic venous insufficiency. The keyword search was conducted through Medline, PubMed, CINAHL, Cochrane library, AMED, and Embase databases from 2000 to April 2023. Qualitative and quantitative studies were included with no study design or language limits imposed on the search. The study populations were restricted to adults aged over 18 years, diagnosed with chronic venous insufficiency. Of the 856 studies found, 80 full-text articles were reviewed, with 14 being eligible for the review. Due to the variability in study designs, the results were summarised rather than subjected to meta-analysis. There are five main overarching themes for non-compliance, which are physical limitations, health literacy, discomfort, financial issues, and psychosocial issues with emerging sub-themes. Graduated compression therapy has the potential to reduce the burden of chronic venous insufficiency if patients are more compliant with their prescription.

A qualitative exploration of adherence to wearing removable cast walkers in patients with diabetic foot ulcers

OBJECTIVE

To explore adherence to wearing removable cast walkers (RCWs) among patients with diabetic foot ulcers (DFUs).

METHOD

A qualitative study was conducted by interviewing patients with active DFUs and using knee-high RCWs as their offloading treatment. The interviews were undertaken at two diabetic foot clinics in Jordan, using a semi-structured guide. Data were analysed through content analysis by developing main themes and categories.

RESULTS

Following interviews with 10 patients, two main key themes with a total of six categories were identified: theme 1-reporting of adherence levels was inconsistent, included two categories: i) a belief in achieving optimal adherence, and ii) non-adherence was often reported indoors; and theme 2-adherence was a consequence of multiple psychosocial, physiological and environmental factors, which included four categories: i) specific offloading knowledge or beliefs influenced adherence; ii) severity of foot disease influenced adherence; iii) social support benefitted adherence; and iv) physical features of RCWs (the usability of the offloading device) impacted adherence.

CONCLUSION

Patients with active DFUs reported inconsistent levels of adherence to wearing RCWs which, after deeper investigation, seemed to be due to participants' misperceptions of the optimal adherence. Adherence to wearing RCWs also seemed to be impacted by multiple psychosocial, physiological and environmental factors.

Effect of educational interventions on wound healing in patients with venous leg ulceration: A systematic review and meta-analysis

Educational interventions for patients with venous leg ulceration (VLU) may promote adherence and self-management, however, their effect on wound healing is unclear. A systematic literature search was performed and randomised controlled trials with a focus on educational interventions were included. Wound healing was analysed by assessing wound healing rate, ulcer size, and the PUSH Score. Additional outcomes comprised pain, quality of life, and functional ability. The study protocol for this work is registered at PROSPERO 2020 (ID: CRD42021286152). Nine studies were included in this meta-analysis. The odds ratio for wound healing was 1.91 (95% CI, 0.99-3.67, P = .053) in favour of educational interventions compared to usual care. Ulcer size reduction was higher (MD: -7.22; 95% CI, -11.91 to -2.53, P = .003) in patients following educational interventions. Included studies also showed significant effects on pain, quality of life, and functional analysis, though no quantitative synthesis was feasible. The overall risk of bias showed some concerns. Educational interventions aim to actively involve patients in their treatment, thereby appearing to be able to have a positive impact on wound healing within 12 weeks. Consequently, integrating educational approaches to routine wound care may be a promising strategy to improve treatment of VLU.

Systematic review of adapted physical activity and therapeutic education of patients with chronic venous disease

BACKGROUND

Chronic venous disease (CVD), comprising impaired lower limb venous return, will lead to chronic distal venous pressure overload manifested by various clinical signs and symptoms and resulting in diminished quality of life. The CEAP (Clinical, Etiology, Anatomy, and Pathophysiology) classification of CVD distinguishes six stages (C0-C6) using clinical, etiologic, anatomic, and pathophysiologic parameters. In the present study, we analyzed the effects of adapted physical activity (APA) and patient-oriented therapeutic education (PTE) programs on the clinical signs, symptoms, and quality of life of patients with CVD.

METHODS

Our analysis, in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) recommendations, included a search of PubMed, CINAHL and LiSSa databases, using a single search equation.

RESULTS

A total of 21 studies were selected for analysis. The analysis revealed first, that patients at stage C0 to C5 had had access to an APA program. This therapy alleviated the clinical signs and symptoms and improved the patients' quality of life. The beneficial effects of APA were greater in the programs that had included aquatic activities than in the program that were exclusively dry-land programs. Second, patients at stage C6 had predominantly followed a PTE program. This therapy showed beneficial effects on the clinical signs and symptoms. However, the quality of life had rarely been assessed.

CONCLUSIONS

At present, APA and PTE programs comprise useful and complementary therapeutic options for the care of patients with CVD. Two of the studies included in our review had evaluated the effects of combining these two approaches, notably in the context of balneotherapy, and reported promising results.

Nurse-led patient education for persons suffering from a venous leg ulcer in outpatient's clinics and homecare settings: A scoping review

AIM OF THIS STUDY

To provide an overview of the available nurse-led individualized educational interventions, for persons with Venous Leg Ulcer (VLUs) in an outpatient or homecare settings.

MATERIALS AND METHODS

For this scoping review, a search was performed between December 2019 and January 2020. To identify sources of evidence a systematic search was conducted in PubMed, CINAHL, Embase, PsychINFO, Web of Science and LiSSa as well as in clinical trial registers to identify sources of evidence. All types of evidence associated with a nurse led-intervention were included.

RESULTS

Fifteen sources of evidence met the inclusion criteria. Educational sessions varied in modality, content and duration. Education sessions were face to face and supported by written materiel. The content focused on compression therapy and exercises. The duration and numbers of sessions varied. The most reported health related outcomes was wound healing.

CONCLUSION

This scoping review provides a broad overview of the available evidence and ongoing research for individualized nurse-led education persons with VLUs. Variability in the literature was found, which suggests that more intervention studies are needed to test and evaluate efficacy of nurse-led patient education.

Psychosocial factors of patients with venous leg ulcers and their association with healing

Objectives: To identify psychosocial factors present in patients with venous leg ulcers and the association that these factors have in the healing of venous leg ulcers. Methods: An integrative review of the quantitative studies in MEDLINE, Scielo and Cochrane Library databases, between 2008 and 2019, using the keywords, psychosocial factors, venous ulcer, wound healing, anxiety and depression in English, Spanish and Portuguese. Results: sixteen studies were included. The psychosocial factors present in patients with venous ulcers were depression, anxiety, feelings of helplessness, subjective well-being, self-esteem, loneliness and spirituality. Stress, a negative perception of venous ulcer, living alone and severe experience of symptoms such as pain and depression have statistically significant associations with longer periods of healing. Conclusions: Depression is one of the most frequently measured factors and present in this population. The available evidence on the association of psychosocial factors with the healing of venous ulcers is low.

Factores psicosociales en los pacientes con úlceras venosas y su asociación con la cicatrización

Objetivo: Identificar los factores psicosociales presentes en pacientes con úlceras venosas y la evidencia disponible sobre la asociación que estos factores tienen con la curación de este tipo de heridas. Métodos: Revisión integradora de la literatura de estudios cuantitativos en las bases de datos MEDLINE, Scielo y Cochrane Library entre los años 2008 y 2019, utilizando las palabras clave, factores psicosociales, úlcera venosa, cicatrización de heridas ansiedad y depresión en idioma inglés, español y portugués. Resultados: Dieciséis estudios fueron incluidos. Los factores psicosociales presentes en los pacientes con úlceras venosas fueron depresión, ansiedad, sentimientos de impotencia, bienestar subjetivo, autoestima, soledad y espiritualidad. El estrés, una percepción negativa de la úlcera venosa, vivir solo y la experiencia severa de síntomas como dolor y depresión tienen asociaciones estadísticamente significativas con periodos más prolongados de curación. Conclusión: La depresión es uno de los factores psicológicos medido y presente con mayor frecuencia en esta población. La evidencia disponible frente a la asociación de los factores psicosociales con la curación de úlceras venosas es escasa.

Nursing Interventions Aimed at Persons with Venous Ulcers: an Integrative Review

Objectives: This work sought to identify and describe the theoretical foundations, components, duration, delivery mode, and results of the nursing interventions aimed at persons with venous ulcers as available in the literature. Materials and method: Integrative review between 2000 and 2018 in the Pubmed, Ovidnursing, and EBSCOhost electronic databases. Results: This review includes 16 articles. Most of the interventions were of educational nature; three were developed in the community (through the Leg Club model) and the other ones were delivered by a nursing professional, face to face. The minimum time of duration for these was eight weeks, with telephone follow up. The most-common result variables were venous ulcer healing and reduction of the wound area. Conclusions: Diversity existed in relation with the components of the interventions and the results expected. Report of the interventions must be reinforced, along with the use of nursing theories that support their design.

Chronic wounds in Australia: A systematic review of key epidemiological and clinical parameters

Chronic wounds are a significant problem in Australia. The health care-related costs of chronic wounds in Australia are considerable, equivalent to more than AUD $3.5 billion, approximately 2% of national health care expenditure. Chronic wounds can also have a significant negative impact on the health-related quality of life of affected individuals. Studies have demonstrated that evidence-based care for chronic wounds improves clinical outcomes. Decision analytical modelling is important in confirming and applying these findings in the Australian context. Epidemiological and clinical data on chronic wounds are required to populate decision analytical models. Although epidemiological and clinical data on chronic wounds in Australia are available, these data have yet to be systematically summarised. To address these omissions and clarify the state of existing evidence, we conducted a systematic review of the literature on key epidemiological and clinical parameters of chronic wounds in Australia. A total of 90 studies were selected for inclusion. This paper presents a synthesis of the evidence on the prevalence and incidence of chronic wounds in Australia, as well as rates of infection, hospitalisation, amputation, healing, and recurrence.

A systematic review of community Leg Clubs for patients with chronic leg ulcers

Aim

Appraise the evidence on the outcomes of Leg Clubs on ulcer healing, psychosocial outcomes, patient safety, cost and experiences of Leg Club members.

Background

The Leg Club is a community-based social model of care in 30 UK locations and nine overseas for treating patients with chronic leg wounds. However, its cumulative effectiveness has not been reviewed to-date.

Methods

Systematic review of primary research relating to the impact and quality of care of Leg Clubs treating patients with leg ulcers. Six electronic databases were systematically searched using the MeSH term ‘leg ulcer’, including other representative terms, in combination with ‘Leg Club’. The quality of individual studies was assessed using appraisal tools. The confidence in the quantitative evidence was evaluated using Grading of Recommendations Assessment, Development and Evaluation (GRADE); and the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) assessed the quality of qualitative findings.

Findings

A total of 17 relevant publications were identified. Out of the 17 articles, four publications represent findings from randomised controlled trial (RCT). Thus, evidence from 14 independent studies involving at least 532 participants were included in the synthesis of this review. The quality of the evidence varied across the different outcomes and were mostly low or of very low quality. Findings from one underpowered RCT from Australia reporting on clinical, patient-reported outcomes and economic outcomes were evaluated as moderate quality. Studies indicate that the Leg Club model has a positive impact on ulcer healing and recurrence, mood, sleep, quality of life and pain. Moreover, only three studies assessed wound infections and reported no infections had occurred during treatment at the Leg Clubs. Economic evaluations find Leg Clubs to be probably more cost-effective than usual care. Both patients and nurses projected positive views about the Leg Clubs, with particular emphasis on improved social interactions and delivery of patient-centred care.

Barriers and enablers to patient recruitment for randomised controlled trials on treatment of chronic wounds: A systematic review

Randomised controlled trials represent the gold standard in intervention efficacy evaluation. However, suboptimal recruitment affects completion and the power of a therapeutic trial in detecting treatment differences. We conducted a systematic review to examine the barriers and enablers to patient recruitment for randomised controlled trials on chronic wound treatment. Review registration was under PROSPERO 2017:CRD42017062438. We conducted a systematic search of Ovid MEDLINE, EBSCOhost CINAHL, Ovid Cochrane Library, Ovid EMBASE, and Ovid PsycINFO databases in June 2017 for chronic wound treatment randomised controlled trials. Twenty-seven randomised controlled trials or qualitative studies met the inclusion criteria. Among the 24 randomised controlled trials, 21 were assessed as low quality in relation to recruitment, and 3 were assessed as high quality. All 27 studies reported barriers to recruitment in chronic wound randomised controlled trials. The reported barriers to recruitment were: study-related, patient-related, clinician-related, health system-related, and/or operational-related. No study reported recruitment enablers. To enhance randomised controlled trial recruitment, we propose the need for improved integration of research and clinical practice. To alleviate the problems arising from inadequate reporting of randomised controlled trials, the Consolidated Standards of Reporting Trials Statement could include an additional item on recruitment barriers. This approach will allow for increased awareness of the potential barriers to recruitment for Randomised controlled trials (RCTs) in both wound management and other health care research.

Wound centres-how do we obtain high quality? The EWMA wound centre endorsement project

OBJECTIVE

Different types of multidisciplinary concepts for treating non-healing wounds have been developed. However, there is insufficient evidence on the quality of multidisciplinary wound centres, and a limited number of evaluation systems have so far been developed. The lack of an international wound centre evaluation/certification system is the basis for the European Wound Management Association (EWMA) Wound Centre Endorsement Project. The project aims to describe the minimum requirements for a wound management centre. These requirements have been defined as a basis for evaluation and endorsement of wound centres inside as well as outside a hospital setting (in- and outpatient clinics).

METHOD

The endorsement programme focused on wound centre characteristics such as: target population; types of centres; and choice of model used. The method used to develop the EWMA wound centre endorsement programme was an evaluation of the quality of the different types of established wound centres across and outside Europe. Criteria and procedures for endorsement of wound centres were developed and pilot projects were performed outside Europe in two in-patient centres in China and one outpatient centre in Brazil.

RESULTS

The EWMA endorsement procedure includes the following steps: initial application; review of centre data provided via the application form and follow-up dialogue; visit to the wound centre; final report and endorsement; and re-endorsement. A follow-up visit was arranged in connection with the re-endorsement. Experiences from the pilot studies have so far indicated that the endorsement process is not only a quality declaration, but may also result in positive developments, such as increased visibility, increased patient flow, increased healing rates, and decreased amputation rate.

CONCLUSION

Development of endorsement systems focusing on the minimum requirements for a wound management centre is required to support the development of high-quality wound centres which provide health-care services according to recent evidence of current best practice. The EWMA Wound Centre Endorsement Project is the first international programme of its kind and this may, in the future, support the establishment of international collaboration and knowledge sharing about the development and maintenance of high-quality wound centres.

Interventions for helping people adhere to compression treatments for venous leg ulceration

BACKGROUND

Chronic venous ulcer healing is a complex clinical problem that requires intervention from skilled, costly, multidisciplinary wound-care teams. Compression therapy has been shown to help heal venous ulcers and to reduce recurrence. It is not known which interventions help people adhere to compression treatments. This review is an update of a previous Cochrane review.

OBJECTIVES

To assess the benefits and harms of interventions designed to help people adhere to venous leg ulcer compression therapy, to improve healing and prevent recurrence after healing.

SEARCH METHODS

In June 2015, for this first update, we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. We also searched trial registries, and reference lists of relevant publications for published and ongoing trials. There were no language or publication date restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of interventions that aim to help people with venous leg ulcers adhere to compression treatments compared with usual care, or no intervention, or another active intervention. Our main outcomes were ulcer healing, ulcer recurrence, quality of life, pain, adherence to compression therapy and number of people with adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data, assessed the risk of bias of each included trial, and assessed overall quality of evidence for the main outcomes in 'Summary of findings' tables.

MAIN RESULTS

One randomised controlled trial was added to this update making a total of three. One ongoing study was also identified.One trial (67 participants) compared a community-based Leg Club® that provided mechanisms for peer-support, assistance with goal setting and social interaction with home-based care. There was no clear difference in healing rates at three months (12/28 people healed in Leg Club group versus 7/28 in home-based care group; risk ratio (RR) 1.71, 95% confidence interval (CI) 0.79 to 3.71); or six months (15/33 healed in Leg Club group versus 10/34 in home-based care group; RR 1.55, 95% CI 0.81 to 2.93); or in quality of life outcomes at six months (MD 0.85 points, 95% CI -0.13 to 1.83; 0 to 10 point scale). The Leg Club may lead to a small reduction in pain at six months, that may not be clinically significant (MD -12.75 points, 95% CI -24.79, -0.71; 0 to 100 point scale, 15 point reduction is usually considered the minimal clinically important difference) (low quality evidence downgraded for risk of selection bias and imprecision).Another trial (184 participants) compared a community-based, nurse-led self-management programme of six months' duration promoting physical activity (walking and leg exercises) and adherence to compression therapy via counselling and behaviour modification (Lively Legs®) with usual care in a wound clinic. At 18 months follow-up, there were no clear differences in healing rates (51/92 healed in Lively Legs group versus 41/92 in usual care group; RR 1.24 (95% CI 0.93 to 1.67)); rates of recurrence of venous leg ulcers (32/69 with recurrence in Lively Legs group versus 38/67 in usual care group; RR 0.82 (95% CI 0.59 to 1.14)); or adherence to compression therapy (42/92 people fully adherent in Lively Legs group versus 41/92 in usual care group; RR 1.02 (95% CI 0.74 to 1.41)). The evidence from this trial was also downgraded to low quality due to risk of selection bias and imprecision.A single study compared patient education delivered via video with education delivered by text (pamphlet). However, no outcomes relevant to this review were reported.We found no studies that investigated other interventions to promote adherence to compression therapy.

AUTHORS' CONCLUSIONS

It is unclear whether interventions designed to help people adhere to compression therapy improve venous ulcer healing and reduce recurrence. There is a lack of trials of interventions that promote adherence to compression therapy for venous ulcers.

Contribution of the Leg Club model of care to the well-being of people living with chronic wounds

OBJECTIVE

Social support impacts well-being. Higher levels of social support encourage treatment adherence and aid healing in people living with chronic wounds. The Leg Club model of care harnesses social support mechanisms to improve patient outcomes. This study investigated whether social support mechanisms available through a Leg Club environment influenced well-being.

METHOD

Participants were community Leg Club members. Socio-demographic data was collected, and the Well-being in Wounds Inventory (WOWI) administered to assess 'wound worries,' 'personal resources,' and 'well-being'. Participants' perceived social situation, length of time attending a Leg Club, wound duration, and feelings about their physical appearance were also measured.

RESULTS

The subjects recruited (n=49) were aged between 50 and 94 years (mean=75.34, standard deviation=10.31). Membership of a Leg Club did impact well-being factors. Time spent at a Leg Club improved 'personal resources' over time. 'Perceived social situation' predicted key aspects of well-being, as did 'time spent attending a Leg Club' and 'feelings about physical appearance.' Social support and relief from social isolation were important aspects of Leg Club membership for participants.

CONCLUSION

Attending a Leg Club enhances well-being in people living with a chronic wound; social support has an important role to play in this relationship. Future research should consider the specific interplay of social support mechanisms of Leg Club, and other relevant wound-related variables to optimise patient well-being and treatment outcomes.

DECLARATION OF INTEREST

The Urgo Foundation funded this project. The authors have no conflicts of interest to declare.

Influence of psychosocial factors on coping and living with a venous leg ulcer

This clinical focus and literature review describe the effect of psychosocial factors on coping and living with a venous leg ulcer (VLU). The associated stressors of living with a VLU include: pain, loss of self-esteem, and social isolation, with subsequent negative emotions that could potentially lead to anxiety and depression. The ability to cope with a VLU depends upon the individual, with some patients employing negative coping strategies such as denial, depending on the stage of the illness and level of acceptance reached (Husband, 2001; Brown, 2014). Psychosocial interventions by health professionals have been shown to reduce the stress of living with a VLU, to improve a patient's coping ability, and subsequently enhance wound healing. This article highlights the importance of holistic assessment and joint treatment planning, to incorporate patients' psychosocial needs and individual coping methods in order to reduce the associated stress of living with a VLU.

Unravelling nocebo effect: the mediating effect of anxiety between anticipation and pain at wound dressing change

AIMS AND OBJECTIVES

The purpose of this study was to examine the mediating effect of anxiety in the relationship between anticipation and pain in people with chronic wounds.

BACKGROUND

Pain is common in people with chronic wounds. Anticipation or negative expectation of discomfort has been shown to have an augmenting effect on pain; also known as nocebo hyperalgesia.

DESIGN

This was a cross-sectional study with repeated measures.

METHODS

Prior to dressing change, anticipatory pain level was evaluated by a 11-point numerical rating scale and anxiety by the Six-items State-Trait Anxiety Inventory (STAI-6). During wound dressing changes, pain was measured before dressing removal, at dressing removal, at cleansing and dressing application using the numerical scale.

RESULTS

Analysis was completed based on the data from a convenience sample of 96 patients. Participants reported more pain at cleansing and dressing removal than baseline. High levels of anticipation, anxiety and pain at dressing change for wounds were related to heavy exudate and wound that were covered with necrotic tissue. Finally, the relationship between anticipation and pain perception was mediated by anxiety.

CONCLUSION

Anticipation of pain triggers anxiety that can lead to increased pain.

RELEVANCE TO CLINICAL PRACTICE

There is a need to incorporate evaluation of anxiety and personal expectations as part of comprehensive pain assessment. Clinicians should be aware of the impact of emotions and anticipation on overall pain experience.

Exploring Resilience When Living with a Wound - An Integrative Literature Review

The psychological impact for patients with wounds can be significant, and adverse psychological effects frequently occur when there are permanent changes in the body’s structure or function. Evidence suggests that anxiety, depression and stress can adversely affect the wound healing process. An integrative review examined any paper that discussed any patient in any health care setting who had experienced a psychological impact from the experience of having a wound and the experience of being resilient in that context. Ninety nine papers were located in the initial search with twelve meeting the inclusion criteria and being reviewed. A review of the papers identified that improvement and maintenance of quality of life was perceived to be an important aspect of patient management, but none focused on resilience as a primary endpoint. Further research is required into the clinical benefits of resilient behaviours in patients living with a wound.

The role of the wound care nurse: an integrative review

The role of the wound care nurse has developed to meet the need for expert wound care advice. Internationally, the role has developed with a variety of different titles. Although all positions have some common tasks and obligations, there remain gaps in knowledge around the role of the wound care nurse. This article aims to determine the state of knowledge in relation to the context of practice, scope of practice and impact of the wound care nurse. An integrative review design was used to allow a broad search strategy and to gather papers from a variety of sources. A multi-method search strategy of the literature published between 1980-2011 was undertaken. This included 5 electronic databases, a thesis search and manual search. It was found that the characteristics of the patients wound care nurses care for reflect an ageing population and disease processes, including diabetes and obesity. Internationally, there is little consensus on the level of competence, educational requirements and qualifications required to practise as a wound care nurse. There was some evidence that the wound care nurse improved healing times and decreased pressure injury prevalence.

The clinical effectiveness of two compression stocking treatments on venous leg ulcer recurrence: a randomized controlled trial

Venous leg ulcers affect up to 3% of people aged 65 years and older, present significant pain and suffering, and are associated with long episodes of health care. These chronic wounds recur at rates of up to 69%. A double blind randomized controlled trial was conducted in a home nursing setting in Victoria, Australia to compare the effectiveness of a 23 to 32 mm Hg (moderate) and a 34 to 46 mm Hg (high) compression stocking treatment on venous ulcer recurrence. Participants (n = 100) were monitored for 26 weeks. Study wound recurrence was low (11.8%), and the average time to recurrence was 77.91 days. Adherence to treatment was low (44%) with nonadherence significantly higher in the high-compression stocking group, χ(2)(1) = 8.827, P = .003. Regression modeling found that adherence to treatment significantly predicted study wound recurrence, Wald(1) = 7.917, P = .005. Estimated hazard ratios showed that participants who did not adhere were 9 times more likely to have their wound recur. Risk of recurrence was 3 times greater for those randomized to moderate compression when compared with the high-compression stocking. Implementing strategies that optimize adherence to compression will reduce ulcer recurrence. Once this has been realized, the potential to adhere to high-compression treatment would further reduce the risk of recurrence.

Interventions for helping people adhere to compression treatments for venous leg ulceration

BACKGROUND

Chronic venous ulcer healing is a complex clinical problem that requires intervention from skilled, costly, multidisciplinary wound-care teams. Compression therapy has been shown to help heal venous ulcers and to reduce the risk of recurrence. It is not known which interventions help people adhere to compression treatments.

OBJECTIVES

To assess the benefits and harms of interventions designed to help people adhere to venous leg ulcer compression therapy, and thus improve healing of venous leg ulcers and prevent their recurrence after healing.

SEARCH METHODS

In May 2013 we searched The Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; EBSCO CINAHL; trial registries, and reference lists of relevant publications for published and ongoing trials. There were no language or publication date restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of interventions that help people with venous leg ulcers adhere to compression treatments compared with usual care, or no intervention, or another active intervention. Our main outcomes were number of people with ulcers healed, recurrence, time to complete healing, quality of life, pain, adherence to compression therapy and number of people with adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data, assessed the risk of bias of each included trial, and assessed overall quality of evidence for the main outcomes in 'Summary of findings' tables.

MAIN RESULTS

Low quality evidence from one trial (67 participants) indicates that, compared with home-based care, a community-based Leg Club® clinic that provided mechanisms for peer-support, assistance with goal setting and social interaction did not result in superior healing rates at three months (12/28 people healed in Leg Club clinic group versus 7/28 in home-based care group; risk ratio (RR) 1.71, 95% confidence interval (CI) 0.79 to 3.71); or six months (15/33 healed in Leg Club group versus 10/34 in home-based care group; RR 1.55, 95% CI 0.81 to 2.93); or in improved quality of life outcomes at six months (MD 0.85 points, 95% CI -0.13 to 1.83; 0 to 10 point scale). However, the Leg Club resulted in a statistically significant reduction in pain at six months (MD -12.75 points, 95% CI -24.79, -0.71; 0 to 100 point scale), although this was not considered a clinically important difference. Time to complete healing, recurrence of ulcers, adherence and adverse events were not reported.Low quality evidence from another trial (184 participants) indicates that, compared with usual care in a wound clinic, a community-based and nurse-led self-management programme of six months' duration promoting physical activity (walking and leg exercises) and adherence to compression therapy via counselling and behaviour modification (Lively Legs®) may not result in superior healing rates at 18 months (51/92 healed in Lively Legs group versus 41/92 in usual care group; RR 1.24 (95% CI 0.93 to 1.67)); may not result in reduced rates of recurrence of venous leg ulcers at 18 months (32/69 with recurrence in Lively Legs group versus 38/67 in usual care group; RR 0.82 (95% CI 0.59 to 1.14)); and may not result in superior adherence to compression therapy at 18 months (42/92 people fully adherent in Lively Legs group versus 41/92 in usual care group; RR 1.02 (95% CI 0.74 to 1.41)). Time to complete healing, quality of life, pain and adverse events were not reported. We found no studies that investigated other interventions to promote adherence to compression therapy.

AUTHORS' CONCLUSIONS

There is a paucity of trials of interventions that promote adherence to compression therapy for venous ulcers. Low quality evidence from two trials was identified: one promoting adherence via socialisation and support (Leg Club®), and the other promoting adherence to compression, leg exercises and walking via counselling and behaviour modification (Lively Legs®).These trials did not reveal a benefit of community-based clinics over usual care in terms of healing rates, prevention of recurrence of venous leg ulcers, or quality of life. One trial indicated a small, but possibly clinically unimportant, reduction in pain, while adverse events were not reported. The small number of participants may have a hidden real benefit, or an increase in harm. Due to the lack of reliable evidence, at present it is not possible either to recommend or discourage nurse clinic care interventions over standard care.

Psychological stress and pain in wound care, part 2: a review of pain and stress assessment tools

Several tools are available for the assessment and measurement of stress and pain. While it takes time and money to train practitioners in their use, this will soon be offset by benefits in terms of patient care, satisfaction and reduced costs.

The improvement of wound-associated pain and healing trajectory with a comprehensive foot and leg ulcer care model

PURPOSE

Pain is a major concern for subjects with chronic wounds, but its optimal management remains elusive. The aim of this study was to validate an organized pain management approach using the Wound Associated Pain model in subjects with chronic leg and foot ulcers.

DESIGN

We completed a prospective cohort study that documented pain in chronic wound subjects over a 4-week period.

SUBJECTS AND SETTING

A total of 111 subjects with chronic leg and foot ulcers were recruited from the community and ambulatory wound care clinics.

RESULTS

Using a systematic approach based on the Wound Associated Pain model, we demonstrated improved overall wound healing outcomes in 111 subjects with chronic leg and foot ulcers. Using an 11-point numerical rating scale, the average level of pain was reduced from 6.3 at week 0 to 2.8 at week 4 (P < .001). The average healing rate was 0.39 cm per week and the average relative reduction in size was 59.36% (t = 2.31; P = .023). To examine the relationship between pain and wound healing, pain levels were compared in subjects who achieved wound closure and those who did not. The mean pain score was 1.67 for the healed subjects in contrast to 3.21 for those who did not achieve complete wound closure (P < .041).

CONCLUSIONS

A comprehensive patient assessment can improve chronic leg and foot ulcer wound-related pain and healing rates. The mean pain scores are lower for patients with healed ulcers than for those who do not obtain complete wound closure.

Guidelines for the management of venous leg ulcers: a gap analysis

BACKGROUND AND AIM

Since 1998, many leg ulcer practice guidelines were developed. The aim of this paper is to describe the methodological and clinical content quality of those guidelines. Methods PubMed, CINAHL, Cochrane Library and websites known for publishing or collecting clinical practice guidelines were explored from 1998 up to June 2006. Reference lists of all identified guidelines were reviewed for other guidelines to be included. Guidelines were eligible if they were written in English, Dutch, French or German, if the scope was the treatment of venous leg ulcers, if the guideline was systematically developed and if the steps in guideline development were reported clearly. Seven guidelines were critically appraised.

RESULTS

The venous leg ulcer guidelines were clearly based on evidence. The stakeholder involvement varied during the development process. Especially patients' perspectives were often not considered. There was no uniform method used to weigh the evidence. Limited attention was given to pain and lifestyle advice recommendations. A paucity of information on compliance, quality of life, organizational aspects of care and economic evaluation data was given. Most of the guidelines failed to consider the issues of dissemination and implementation. Revisions of the guidelines for leg ulcer treatment were often not available.

CONCLUSION AND IMPLICATIONS FOR FUTURE GUIDELINE DEVELOPERS

It is recommended that leg ulcer guidelines should incorporate a multidisciplinary approach and patient involvement is necessary. Extensive background information and the formulation of the rationale are needed. The development of an implementation guide that addresses the barriers particular to the adoption of guidelines for leg ulcer treatment could support the process of implementation. Recommendations on pain, lifestyle advice, compliance and other quality-of-life issues should be incorporated in guidelines for leg ulcer treatment.

The Leg Club model in the Australian context

Leg Clubs are an innovative approach to the holistic treatment of leg ulcers. They are run in a social context by community nurses who deliver ongoing support and treatment for a wide spectrum of lower limb pathology. This article looks at how the Leg Club model has been established in Australia.

A cost-effectiveness analysis of two community models of care for patients with venous leg ulcers

AIM

To conduct a cost-effectiveness analysis based on data from a randomised controlled trial comparing traditional community home nursing with a community Leg Club model for chronic venous leg ulcer management in the south-east metropolitan area of Queensland, Australia.

METHOD

Participants were randomised to the Leg Club (n=28) or home visits (n=28). Data were obtained on resources/related costs incurred by the service provider, clients and carers, and the community.

RESULTS

From the collective perspective (service provider, clients and carers, and the community), at six months the incremental cost per healed ulcer was dollars AU515 (Euros 318) and the incremental cost per reduced pain score was dollars AU322 (Euros 199). For the service provider, Leg Club intervention resulted in cost savings and better health effects when compared with home nursing.

CONCLUSION

On both clinical and economic grounds, the Leg Club model appears to be more cost-effective than traditional home nursing for the treatment of chronic venous leg ulcers. However, clients and the local community contribute substantial financial and in-kind support to the operation of both services.