Compression therapy for venous leg ulcers

Venous Leg Ulcers: The Need to Incorporate Age-Friendly 4M's in Management

Venous leg ulcers develop due to a complex set of conditions routed in lower extremity edema and inflammation. Even though older adults are disproportionally affected by these wounds, the guidelines discuss best practices without keeping in mind the age-friendly 4M's-what Matters Most, Mobility, Medications, and Mentation/Mood. This article reviews the management and treatment of venous leg ulcers, but with a geriatric medicine focus. Compression therapy, mobility optimization, and social isolation reduction are highlighted for our older adult population.

The Efficacy of Extracorporeal Shockwave Therapy Compared with Compression Therapy in Healing Venous Leg Ulcers

Background: Innovative methods of physical therapy delivered via modern medical devices have significantly extended the possibility of applying conservative treatments in healing venous leg ulcers. The primary objective of this study was to compare the therapeutic efficacy of selected mechanical physical therapies (intermittent pneumatic compression vs. radial extracorporeal shockwave vs. focal extracorporeal shockwave) vs. standard care in the treatment of venous leg ulcers over a 4-week period. Materials: This study included 69 patients, comprising 45 females (65%) and 24 males (35%), with a mean age of 67.1 ± 8.6 years (range: from 52.0 to 80.0 years). Methods: The patients were allocated into four groups: the IPC group was treated with intermittent pneumatic compression therapy, the R-ESWT group was treated with radial extracorporeal shockwave therapy, the F-ESWT group was treated with focal extracorporeal shockwave therapy, and the SC group was treated with standard care. Results: After one month of therapy, the median percentage decrease in wound total surface area after treatment was as follows: in the IPC group, there was a 52.9% decrease (range: 3.3-100%); in the R-ESWT group, there was a 31.6% decrease (range: 2.4-95.8%); in the F-ESWT group, there was an 18.0% decrease (range: 1.9-76.1%); and in the SC group, there was a 16.0% decrease (range: 1.5-45.8%). Conclusions: All the studied therapies caused a statistically significant reduction in the surface area of venous leg ulcers. The best results were observed with the intermittent pneumatic compression, while the radial and focal extracorporeal shockwave therapies appeared less effective. The standard care alone turned out to be the least effective. Our results did not show statistically significant changes in the values of RBC deformability at the investigated shear rates.

Wound cleansing and care in treating leg ulcers: a commentary on a Cochrane systematic review

Leg ulcers pose a significant challenge to healthcare services, requiring effective wound cleansing strategies to promote healing and prevent complications. Large amounts of nursing time is spent managing patients with venous leg ulcers (VLUs), with an average appointment time of approximately 30 minutes. Yet, there is a lack of clear guidance for the treatment of VLUs, with nurses adopting a wide range of cleansing practices. This commentary provides an overview of existing evidence on wound cleansing and care in treating leg ulcers, for the benefit of healthcare professionals working within clinical practice.

Burkholderia cepacia skin-related ulceration: a case report

Treatment of infected wounds remains a major challenge for clinicians. Antimicrobial stewardship is an important pillar in wound treatment and, as the role of bacteria in wound repair is not well understood, new treatment options and products are constantly being developed to tackle local infection and biofilm. This case report describes a case of antibiotic-resistant Burkholderia cepacia skin infection and subsequent leg ulceration in an 86-year-old man during the COVID pandemic in Italy, which was successfully treated in a conservative way using 1% acetic acid and silver oxysalts in conjunction with compression bandage.

Venous, Arterial, and Neuropathic Leg Ulcers With Emphasis on the Geriatric Population

Leg ulcers are a common and often serious problem in older adults. Underlying conditions that increase risk include age-related increases in chronic venous insufficiency, peripheral artery disease, connective tissue and autoimmune conditions, reduced mobility, and diabetes mellitus (DM). Geriatric patients have a higher risk of multiple wound-related complications including infection, cellulitis, ischemia, and gangrene, any of which may lead to further complications including amputation. The very presence of these lower extremity ulcers in the elderly negatively impacts their quality of life and ability to function. Understanding and early identification of the underlying conditions and wound features are important for effective ulcer healing and complication mitigation. This targeted review focuses on the three most common types of lower extremity ulcers: venous, arterial, and neuropathic. The goal of this paper is to characterize and discuss the general and specific aspects of these lower extremity ulcers and their relevancy and impact on the geriatric population. The top five main results of this study can be summarized as follows. (1) Venous ulcers, caused by inflammatory processes secondary to venous reflux and hypertension, are the most common chronic leg ulcer in the geriatric population. (2) Arterial-ischemic ulcers are mainly due to lower extremity vascular disease, which itself tends to increase with increasing age setting the stage for an age-related increase in leg ulcers. (3) Persons with DM are at increased risk of developing foot ulcers mainly due to neuropathy and localized ischemia, both of which tend to increase with advancing age. (4) In geriatric patients with leg ulcers, it is important to rule out vasculitis or malignancy as causes. (5) Treatment is best made on a case-by-case basis, considering the patient's underlying condition, comorbidities, overall health status, and life expectancy.

Exploration of Effects of Graduated Compression Stocking Structures on Performance Properties Using Principal Component Analysis: A Promising Method for Simultaneous Optimization of Properties

This paper focuses on the comfort properties of graduated and preventive compression stockings for people who work long hours in standing postures and for athletes for proper blood circulation. The present study was conducted in order to investigate the effects of the yarn insertion density and inlaid stitches on the performance of the compression stockings. The effects of these parameters on the thermo-physiological comfort properties were tested with standard and developed methods of testing. All compression stockings were maintained with class 1 pressure as per German standards. The structural parameters of the knitted fabric structures were investigated. The stretching and recovery properties were also investigated to determine the performance properties. The theoretical pressure was predicated using the Laplace’s law by testing the stockings’ tensile properties. The compression interface pressures of all stockings were also investigated using a medical stocking tester (MST) from Salzmann AG, St. Gallen, Switzerland. Correlation between the theoretical pressures and pressures measured using the MST system were also assessed. The current research used a multi-response optimization technique, i.e., principal component analysis (PCA), to identify the best structure based on the optimalization of the above-mentioned properties. The results also revealed that samples with higher insertion density levels exhibit better comfort properties. The results showed that sample R1 was the best sample, followed by R2 and P. In addition, all developed stocking samples exhibited better comfort properties than the control sample from the market.

Modified compression therapy in mixed arterial-venous leg ulcers: An integrative review

Leg ulcers remain an increased burden to healthcare cost and morbidity in modern society. While most leg ulcers are venous in origin, recognition and prompt identification of concomitant arterial occlusive disease is critical to determine underlying aetiology and subsequent management. This integrative review presents the current evidence to establish the role of modified compression therapy (MCT) in treatment of mixed arterial venous leg ulcers (MAVLU). A literature search was conducted using the electronic databases CINAHL, MEDLINE, PUBMED, and Embase. Ten studies met the eligibility criteria and were subsequently analysed. Our review concludes that MCT, with compression pressures between 20 and 30 mmHg, can promote healing in MAVLU with moderate arterial insufficiency (0.5 ≤ ABPI ≤0.8). If ABPI is <0.5, MCT can be considered once restoration of acceptable ABPI is achieved. Intolerance, lack of response or further deterioration of disease within 3 months should prompt further arterial imaging and intervention. MCT is generally well tolerated with no adverse outcomes reported. A holistic yet individualised approach is vital in order to account for all factors influencing this patient-led decision-making process, ultimately ensuring effective treatment, which improves patient's quality of life and reduces socioeconomic burden of the disease.

A dual pressure indicator, two-layer compression system for treatment of venous leg ulcers: a review

OBJECTIVE

Venous leg ulcers (VLUs) are considered the most frequent category of hard-to-heal limb ulcers. Although evidence-based care of VLUs suggests that compression therapy plays a pivotal role in the standard of care, patient adherence is considered low, with at least 33% non-compliance, either due to perceived problems from clinicians regarding their own competency in applying the bandages, or from the patient finding the wrapping bothersome. For many years, four-layer bandaging has been considered the 'gold standard', but application can be difficult and may also prove uncomfortable for patients. Accurate application may be facilitated by a stretch indicator which has been engineered to act as a surrogate for appropriate pressure application that can address the skill concern, while fewer layers can save clinicians' time and improve the quality of life of patients. Here, we review the literature supporting a two-layer system which combines elastic (long stretch) and inelastic (short stretch) components as well as both layers having graphic markers to define that the dressing has been applied at the proper tension.

METHOD

An initial search was conducted on PubMed and then followed up by a manual search of Google Scholar to retrieve evidence of different levels, in order to evaluate the outcomes of use of the specific two-layer compression system with pressure indicators in the management of patients presenting with VLUs.

RESULTS

A total of four papers discussing the specific compression system in question were identified from 32 publications retrieved from PubMed, while a further six were retrieved from Google Scholar. These 10 publications were considered relevant to the two-layer system and were analysed for the outcomes of care, including wound healing, appropriate application, time-saving and better patient acceptance and adherence.

CONCLUSION

Previous authors have demonstrated that two-layer systems are equivalent to four-layer systems. However, the ability to reproducibly apply appropriate compression has remained a question. The papers reviewed demonstrate that evidence suggests that the two-layer compression bandage system with indicators provides continuous, consistent and comfortable treatment that may be easier to apply with accurate pressure levels due to their indicator systems, and therefore, is a procedure that may increase patient adherence and acceptability to the wound therapy.

Exercise Training as an Adjunctive Therapy for Chronic Venous Insufficiency Patients: Evidence from Research to Practice

Chronic venous insufficiency, which is defined as a condition relevant to persistent ambulatory venous hypertension, is a common cause of venous leg ulcers. Compression therapy is commonly used to relieve ambulatory venous hypertension and heal leg ulcers. Exercise is considered as adjunctive therapy, targeting calf muscle pump function, to additionally favor the compression treatment for facilitating the healing process. Different exercise training regimens for promoting wound healing and its relevant outcomes are reviewed and discussed in this study.

Clinical and cost efficacy of advanced wound care matrices in the treatment of venous leg ulcers: a systematic review

BACKGROUND

Venous leg ulcers (VLUs) are hard-to-heal, recurrent and challenging to treat. Advanced wound care matrices (AWCMs) have been developed to supplement conventional therapies. These costly AWCMs warrant careful comparison as healthcare expenditures are subjected to increasing scrutiny.

AIM

This study was designed to compare AWCMs in their ability to heal VLUs and their cost efficacy through a systematic review of randomised controlled trials (RCTs).

METHOD

An organised search of Medline, Cochrane Library, Central and CINAHL databases identified RCTs that compared AWCMs to standard compression therapy in the healing of VLUs. Bias was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies. Eight studies analysing bilayered skin substitute (BSS) (Apligraf), dehydrated human amnion/chorion membrane (dHACM) (Epifix), human fibroblast-derived dermal substitute (HFDDS) (Dermagraft), extracellular wound matrix (ECM) (Oasis), advanced matrix (AM) (Talymed) and matrix wound dressing (MWD) (Promogran) met the inclusion criteria.

RESULTS

Four studies reported significant improvement over standard therapy: BSS, dHACM, ECM and AM. Incremental cost per additional successful treatment was determined for each trial, ranging from $2593 (MWD) to $210,800 (HFDDS).

CONCLUSION

Our consolidated analysis of eight major RCTs of AWCMs in the treatment of VLUs revealed a great variation in clinical and cost efficacy among these products. The included trials were inconsistent in methodology, and these limitations should be noted, but, in the absence of RCTs to compare these products, our systematic review may serve as a guide for practitioners who seek to optimise wound healing while considering cost efficacy.

Velcro compression wraps as an alternative form of compression therapy for venous leg ulcers: a review

The first-line treatment for venous leg ulcers (VLUs) is compression therapy, most commonly, with compression bandages. A similar treatment measure is used for lymphoedema in the form of Velcro compression wraps (VCWs). However, the use of VCWs for VLUs is less evident, and a direct comparison to compression bandaging is not evident. This review explores the evidence to support the use of VCWs for the treatment of VLUs in order to raise awareness of alternative forms of compression therapy. Nine primary research studies were analysed, from which four key themes emerged: quality of life, cost of treatment, ulcer healing time and pressure maintenance. The findings suggest that VCWs decrease material costs by at least 50%, and further savings may be realised by reducing the costs associated with nursing time. The benefits of promoting self-care, maintaining compression, and eliciting greater healing rates are clearly evident, and the impact on quality of life is substantiated.

Textile-based compression therapy in managing chronic oedema: Complex interactions

BACKGROUND

Compression is a common therapy for management of chronic disease, including oedema of the lower limb. Modern compression interventions exert pressure on the lower limb through use of one or more materials which exert pressure against the limb over time. Where these materials are textiles, they range from elastic to inelastic, and are produced using knitting, weaving, or other textile technologies which can be manipulated to control performance properties. Thus, understanding of both the materials/textiles and the human body is needed if the most appropriate compression device and treatment strategy is to be used. Neither is independent of the other. This review aims to enhance understanding of critical textile performance properties and how selection of textiles may affect treatment efficacy when managing chronic oedema of the lower limb.

METHOD

Relevant papers for review were identified via PubMed Central® library, and Google Scholar using keywords associated with textile-based treatments of the oedematous lower limb and wider interdisciplinary factors.

RESULTS

Assessment of the disorder, the severity of oedema, and location of fluid accumulation are required to inform treatment of chronic oedema. While the need to understand the patient is well established (e.g. age, sex, body mass index, skin thickness and colour, patient compliance with treatment), information about preferred compression systems and material structures, and inherent properties of these, is generally lacking.

CONCLUSION

Greater detail about materials used (e.g. fabric structure, number and order of layers, fibre content) and patient diagnosis (e.g. underlying cause, severity, location of oedema; patient age and sex; evidence of compliance with treatment; pressure exerted; lower leg shape, size, and properties of the tissue) is needed to facilitate advances in efficacy of compression treatment. Reduced limb swelling with a textile-based treatment occurs simultaneously with changes to the textile itself. Textiles cannot be considered inert.

Contact sensitivity in patients with venous leg ulcer: A multi-centric Indian study

Venous leg ulcers are the most common form of non-healing leg ulcers. They are subjected to treatments such as topical medications, dressings, and compression therapies. This can lead to exposure to a number of allergens with subsequent sensitisation and contact dermatitis of the regional skin. This may contribute to the poor ulcer healing. To detect the various contact sensitisers in patients with venous leg ulcers through patch testing, patients from 6 centres across India with venous leg ulcers of longer than 6 weeks duration were enrolled for the study. They were patch tested using a special parch test kit with 27 antigens. A total of 172 patients were included in the study; 82 (48.2%) tested positive for at least 1 antigen. Among them, polyvalent sensitisation was noted in 71% of patients. Wood tar mix (10.4%) and the framycetin (8.7%) were the most common allergens. There is a high frequency of allergic sensitisation to various ingredients of topical therapies used in the venous ulcer management, which may interfere with wound healing. Avoiding them can help obtain a better therapeutic outcome.

Evidence-Based Clinical Practice Points for the Management of Venous Ulcers

Venous ulcer is an extremely common aetiology of lower extremity ulceration, which affects approximately 1% population in most of the countries, and the incidence rate increases with age and female gender. Proper assessment and diagnosis of both the patient and ulcer are inevitable in order to differentiate venous ulcers from other lower extremity ulceration and to frame an adequate and individualised management plan. Venous ulcers generally persist for weeks to many years and are typically recurrent in nature. This consensus aims to present an evidence-based management approach for the patients with venous ulcers. Various management options for venous ulcers include compression therapy, minimally invasive procedures like sclerotherapy and ablation techniques, surgical procedures, debridement and medical management with micronised purified flavonoid fraction (MPFF). Compression therapy is the mainstay treatment for venous ulcer. However, in failure cases, surgery can be preferred. Medical management with MPFF as an adjuvant therapy to standard treatment has been reported to be effective and safe in patients with venous ulcer. In addition to standard therapy, diet and lifestyle modification including progressive resistance exercise, patient education, leg elevation, weight reduction, maintaining a healthy cardiac status and strong psychosocial support reduces the risk of recurrence and improves the quality of life in patients with venous ulcer.

The effect of age and compression strength on venous leg ulcer healing

Objectives The aim of the study is to compare proportions of venous leg ulcers healed in patients treated with two different sub-bandage pressure values in relation to age. Methods The study included 102 outpatients with venous leg ulcers, one group with moderate compression pressure of 35-40 mmHg and the second with high pressure >45 mmHg. Each group was divided into two subgroups according to the age (≥65 vs. <65 years). Computerized planimetry was used to measure the size of the ulcers at 6, 12, 18 and 24 weeks. Results Kaplan-Maier analysis showed high pressure leads to higher proportion of healed venous leg ulcers, compared to moderate pressure, in patients aged ≥65 years (57.6% vs. 28%) and in patients <65 years (53.8% vs. 36%) (p < 0.05). Conclusion The study showed that higher compression pressure leads to higher proportions of venous leg ulcers healed, independent of age and could be safely preferred in older patients.

Approaches to the application and removal of compression therapy: A literature review

Compression therapy is used in the treatment of venous disorders, lymphoedema and burns. Adherence to compression therapy is reported to be poor, due to a number of factors, including difficulty in applying and removing the compression garments. A literature review was conducted to identify aids, equipment and other approaches to ease the application and removal of compression therapy garments. Some 12 studies were identified. Most studies focused on chronic venous insufficiency and venous ulcers. Four methods of easing compression garment application and removal were identified: (1) devices to assist in application and removal; (2) altered compression stocking design; (3) adjustable compression wrap devices; and (4) education. Patients prescribed compression therapy should be educated on how to apply and remove the compression garments, and have application devices made available to them.

The external microenvironment of healing skin wounds

The skin wound microenvironment can be divided into two main components that influence healing: the external wound microenvironment, which is outside the wound surface; and the internal wound microenvironment, underneath the surface, to which the cells within the wound are exposed. Treatment methods that directly alter the features of the external wound microenvironment indirectly affect the internal wound microenvironment due to the exchange between the two compartments. In this review, we focus on the effects of temperature, pressure (positive and negative), hydration, gases (oxygen and carbon dioxide), pH, and anti-microbial treatment on the wound. These factors are well described in the literature and can be modified with treatment methods available in the clinic. Understanding the roles of these factors in wound pathophysiology is of central importance in wound treatment.