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372 CliniCalManageMentofthelowerliMb
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TABLE8.5
Stage Approach Reason
Dressing Initially super-
Skin cleansing,
drying and
moisturising to
remove exudate
and protect the
acid mantle of
the skin are key
to protect the
skin and prevent
infection
(Voegeli2008;
Todd2014).
(Continued)
absorbent
polymer dressings, which act
to absorb and retain exudate
under compression therapy,
may provide an eective
line treatment. These
rstdressings work to retain the
uid within the dressing and
provide a high moisture
vapour transfer
rating (MVTR).
Once compression has begun
to take eect to slow down
the exudate, dressings can be
stepped down to simple
non-
adherent dressings, thus
reducing the negative eect
on the compression dose as
the limb circumference is
less altered (Ritchie2018).
These three interventions are
the cornerstone of good limb
management (Ritchie2018).
To protect the
wound and
periskin from
maceration.
Table8.4 further
explores the
components
of hygiene.
wound
WHAT IS COMPRESSION THERAPY AND HOW
DOES IT WORK?
Compression therapy is an essential treatment for people who have a
diagnosis of venous disease, venous leg ulceration, lymphovenous disease or mixed aetiology venous/arterial ulceration (for mixed aetiology
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it is normally at a reduced dose, discussed later in this chapter). Compression therapy is referred to here within the context of these diagnoses. For patients who have signicant peripheral arterial disease
or limb-
threatening ischaemia, it is recommended that referral to a
specialist is initiated; if acute limb- threatening ischaemia is identied
then an urgent referral for emergency intervention is required. If a
person who is diagnosed with diabetes presents with a foot ulceration,
they should also be referred urgently for specialist assessment (Wounds
UK2022). See Table8.6 for contraindications, cautions, and red ags in
compression therapy. While compression is a cornerstone of management for lymphoedema, the needs of the more complex patient with
lymphoedema are outside the scope of this book.
Compression therapy is also referred to as graduated compres-
sion therapy. This term refers to the fact that the dose of compression
TABLE8.6
Contraindications to
compression therapy Cautions in compression therapy
Presence of signicant peripheral
arterial disease is a
contraindication to any
compression therapy. This is
identied through an absolute
pressure value of less than
mmHg, an ankle brachial
60
pressure index (ABPI) of less
than 0.6 or visual observation of
the signs of critical ischaemia
(Partsch and Mortimer2015).
Visual signs of critical ischaemia
are a strict contraindication and
require an urgent referral. These
can be summarised using the
6Ps approach: Pain at rest,
Pallor, Pulselessness,
Paraesthesia, Perishingly cold,
Paralysis. One or more of these
symptoms should trigger an
urgent referral.
Contraindications andcautions incompression therapy.
Patients who have a mixed aetiology
ulceration, an ABPI of 0.6–0.8 and
absolute values of 60
above may be considered for a
lower dose of compression therapy
subject to a holistic assessment
(Partsch and Mortimer2015).
Deep vein thrombosis (DVT): if the
patient is already receiving
compression therapy it is necessary
to pause the therapy while DVT
status is conrmed. Once
anticoagulant therapy is
commenced, compression therapy
may also be recommenced
(BLS2021).
mmHg and
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(Continued)
TABLE8.6 (Continued)
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Contraindications to
compression therapy Cautions in compression therapy
Patients presenting with a diabetic
foot ulceration should be
referred to the appropriate local
service within 24 hours
(NWCSP 2023).
Acute deteriorating heart failure:
the practitioner should be aware
of red ags that may indicate an
acute episode of deteriorating
heart failure that requires urgent
escalation. Symptoms of this
may include oedema of the
trunk, increasing breathlessness
(either at rest or on exertion), a
rapid recent increase in weight,
increased reports of waking up
due to breathlessness or the
inability to lay at due to
breathlessness (Atkin and
Byrom2022).
Suspected skin cancer should be
referred immediately for
investigation and compression
therapy should not be applied
(www.nationalwound
carestrategy.net).
Patients who have diabetes should
not be excluded from compression
therapy. The practitioner should
identify if the patient has a diabetic
foot ulceration requiring urgent
multidisciplinary team referral
(NWCSP 2023) of if they have
another type of ulceration, for
example venous or mixed aetiology,
but with the coof diabetes.
If this is identied the practitioner
should ensure there is no
peripheral neuropathy, which can
be done by undertaking a 10
monolament test or toe touch test
(see Chapter5 for further
discussion on this).
Chronic heart failure: in patients
presenting with chronic stable
heart failure compression therapy
is often necessary to prevent the
lower limbs from swelling,
lymphorrhoea and infection.
Astaged approach to compression
application may be necessary
(Atkin and Byrom2022) and may
require supervision and support
from a more experienced colleague.
Known sensitivities or allergies are
important to be aware of when
using compression therapy, and
some manufacturers recommend a
patch test prior to the use of their
products, for example for bandages
containing zinc paste.
morbidity
g
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reduces from the ankle as it goes up the leg, causing blood and uid
to be pushed back up the leg into the central circulatory system to
counteract venous hypertension and swelling in the lower limb. This
action of compression therapy and moving uid is explained later in
the chapter using Pascal’s and Laplace’s laws. Without the correct
dose of this essential treatment, wounds on the lower limb will not
heal and will almost certainly worsen, putting the patient at risk of
further wound breakdown, infection, cellulitis and even sepsis (Hopkins2020; Wounds UK2022).
Venous pathophysiology can be further sub-
divided into structural pathology, for example venous incompetency and/or venous
obstruction or functional venous disease such as calf/foot muscle
pump failure or inactivity; many people will present with a combination of both (Wounds UK2022). Compression therapy will support
with both pathologies, but additional referrals for adjunct treatment
may also be necessary and helpful for the person (see Table8.7). Frequently patients will present with a combination of structural and
functional challenges that impact and aggravate each other
(Wounds UK2022).
Compression therapy causes actions on the haemodynamic and
lymphatic systems to protect homeostasis in the lower limb. Table8.8
oers an overview of what compression does to the lower limb to
TABLE8.7
Functional venous disease Structural venous disease
This is normally related to
immobility, inactivity, altered
gait or biomechanics, which
aects the foot and calf muscle
pumps (there is more about this
in Chapter4).
Increase in movement and
exercise are advocated.
Consider referrals to podiatry for
orthotics and/or physiotherapy
to increase ankle range
of motion.
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Subdivision ofvenous pathologies.
This is normally related to valve
incompetence or obstruction
causing chronic venous
hypertension and associate
inammation (there is more about
this in Chapters1 and5).
Refer for duplex scan to refute or
conrm valve incompetency or
obstruction.
May be suitable for surgery to correct
in some cases.
376 CliniCalManageMentofthelowerliMb
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TABLE8.8
Increases pressure on the skin and underlying structures to counteract the
force of gravity (squeeze) and supports the foot, calf and thigh pumps in
moving uid and blood along the haemodynamic and lymphatic systems.
Improves the overall skin condition, particularly if used in combination
with a robust and sustained commitment to skin hygiene, exfoliation and
moisturisation.
Prevents backow of venous blood, which causes venous reux and pooling
of blood in the veins.
Prevents blood components such as proteins from leaking into the
surrounding tissues.
Reverses venous hypertension in the supercial veins by reducing vein
diameter in elastic systems or occluding the veins in inelastic systems
(see Table8.1).
Manages swelling by supporting the lymphatic system in returning uid up
the limb through reabsorption of interstitial uid.
Prevents leucocyte adhesion to the endothelial cells, thus addressing
inammation.
What does compression therapy do?
promote good leg health and address unwanted pathophysiologies
that occur.
Compression therapy should be considered, similarly to any
other therapy or medication, in terms of dose. Therefore, it is essential that the correct dose of a therapy is administered by the practitioner to ensure it is eective. For most people where the holistic
assessment has ruled out the presence of signicant arterial disease,
the optimum dose is at least 40
mmHg and anything less than strong
compression (see Table8.9) is a reduced or sub- optimal dose and may
be likened to taking half a paracetamol for a headache, thus inadequate and futile. Historically there has been an acceptance within the
clinical arena that ‘any compression is better than none’ or that
40 mmHg is the ‘gold standard’. However, this is not the case, with
more recent literature highlighting that for many patients the optimum dose, strong compression, is at least 40 mmHg (see Table8.9)
(Wounds UK2022).
It is also worthy of note that 40 mmHg is not the recommended
dose for all patients and that some may require more, for example
because they are taller than 180 cm (Wounds UK 2022) or because
they have an occupation that requires them to stand for long periods,
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TABLE8.9
Dose Indications subject to full holistic assessment and
Mild (<20
Moderate
(20–40 mmHg)
Strong (40–60
Very strong
(>60
Source: Adapted from WUWHS (2008).
The dierent doses ofcompression therapy.
ankle brachial pressure index (ABPI)
measurement
mmHg) Early intervention for mild swelling or wounds to
the lower limb. Can be initiated without ABPI if
no red ags are observed (www.nationalwoundcarestrategy.net).
Also see discussion regarding early intervention in
Chapter9.
In mixed aetiology ulceration, can be initiated
following a full holistic assessment including
ABPI (Vowden etal.2020).
Also see explanation of the pathology of mixed
ulceration in Chapter1 and its assessment in
Chapter4.
mmHg) Suitable for those with venous ulceration subject to
full holistic assessment including ABPI (Wounds
UK2022b).
Normally used within a specialist setting, or under
mmHg)
specialist supervision and in lymphoedema
management (Health Service Executive
(Ireland)2022).
for example a chef or hairdresser, who during the day may require an
additional dose to counteract the eects of gravity on the limb. In
many clinical areas this is considered advanced compression practice, and therefore escalation to a specialist service may be indicated
on local treatment pathways and policies. Sub- optimal dosing of
compression therapy can be considered as causing harm and if identied without a sound clinical rationale may be considered as harm
to the patient (Broadhead etal.2018). Table8.9 highlights the dierent doses of compression therapy as agreed by the World Union of
Wound Healing Societies (2008).
When considering the dose of compression therapy there are
four areas that it is important to understand. These are listed in
Table8.10 and discussed next.
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TABLE8.10
compression therapy.
Area Explanation Applicability
Interface
pressure
(Partsch and
Partsch2005)
Stiness index
(Charles2012)
Laplace’s law
(Clark2003)
Pascal’s law
(Schuren and
Mohr2010)
Four areas toconsider when understanding doses of
Also known as
sub-
bandage
pressure.
Can refer to static
stiness index (SSI)
or dynamic stiness
index (DSI).
Can be applied to
compression therapy
to explain how the
dose can be aected,
either deliberately
or unknowingly.
Also known as Pascal’s
principle.
Interface pressure is the
preferable term as it is
applicable beyond bandage
use to hosiery and wraps.
Stiness index is applicable to
all forms of compression
treatment.
This is important when
thinking about achieving a
therapeutic dose of
compression.
Pascal’s law is an important
principle because
compression therapy is
creating a pressurised area
to redistribute uid. This is
of particular importance
when we think about
achieving graduated
compression therapy, as we
want to ensure we move
uid from the distal part of
the lower limb towards
the proximal.
Interface Pressure
The interface pressure may also be referred to as sub- bandage pressure. It is the amount of pressure at the interface of the limb and the
compression therapy. This is a reliable predictor of the dose of
compression the limb receives from the bandage or other compression
garment, such as a wrap or compression hosiery stocking (Charles2012).
Eective compression treatment will provide a balance between
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exerting too little pressure and too much pressure on the lower limb.
As discussed earlier in this chapter, for most patients with venous
ulceration and subject to a full holistic assessment, a dose of at least
40
mmHg should be applied at the ankle (Wounds UK2022). Too little
pressure (which may also be described as too low a dose) is ineective
in terms of its eciency as a treatment, as it will not work. This may
cause the patient to lose faith in compression as a treatment. Too much
pressure (which may be described as too high a dose) may cause pressure damage to the lower limb, in particular to bony prominences,
such as the tibial crest or dorsum of the foot, where the interface pressure between the compression and the limb is higher than, for example, softer areas of tissue, such as the calf. Too much or too little
compression will aect the eciency of the therapy and may be
uncomfortable for the person, thus achieving the correct dose as with
all therapies is of paramount importance.
Compression therapy works on the lower limb to cause a rise and
fall in pressure, which is linked to normal movement such as walking, plantarexion, dorsiexion or ankle rotation. With the application of an eective compression system during these movements,
intermittent pressure of peaks and troughs occurs. These peaks and
troughs in pressure serve to massage and support the deep leg veins
and more supercial veins to expand and then narrow with the movement of the limb. This movement also causes movement of the lymphatics to promote the movement of lymph uid. These intermittent
pressure peaks provide pressure increases on the veins and lymphatics, which support the damaged or overloaded structures by mimicking the action of a healthy undamaged system (Partsch and
Partsch2005). This interface pressure should be a therapeutic resting
pressure and an intermittent high working pressure. What this means
is that when the calf muscle is active the compression therapy causes
a squeeze on the lower limb and an increase in interface pressure,
and when the muscle is resting this pressure decreases.
Stiffness Index
The static stiness index describes the stiness of a bandage or other
compression system such as compression hosiery. The dynamic stiness
characterises the dierence between the working pressures and the resting pressure created by the compression system on the lower limb; that
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Elastic
Inelastic
60
40
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is, the peaks and troughs in pressure when the calf muscle is active and
moving or when it is relaxed (resting) and therefore more accid
(Partsch2005). This pressure dierence occurs in part due to a change in
the limb circumference as it expands and hardens during movement
and becomes softer and more relaxed during rest. This expansion and
relaxation happen during walking or movement of the lower limb.
The stiness index can be dened as the increase in interface
pressure based on the dierence of pressure from the resting to the
working pressure. Dierent systems are said to have a higher or lower
static stiness index. Thus, an elastic bandage system is said to have
a lower static stiness as the dierence in pressure (measured in
mmHg) is said to have less dierence between resting and moving.
An inelastic bandage is described as having a higher static stiness
index as the sti nature of the bandage creates high working pressures and low resting pressures (Partsch2005). Therefore the intermittent raising and lowering of interface pressure is a more
pronounced prole. Having a higher static stiness index indicates a
lower resting pressure, which can be more comfortable for the person
in compression when they are not active and especially at night (see
Figure8.7).
Laplace’s Law
Laplace’s law can be applied to compression therapy to explain how
the dose can be aected, either deliberately or unknowingly. This is
because the pressure exerted by compression therapy is directly proportional to the tension with which the practitioner applies it and the
number of layers that are applied, but inversely proportional to the
circumference of the limb (Clark2003). This law is shown in Figure8.8.
To many this equation can feel quite overwhelming, and this
may go some way towards explaining why within the clinical arena
many practitioners do not understand how to apply this theory to
mmHg
mmHg
FIGURE8.7 Static stiness for elastic and inelastic bandages.
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Closed
Open
Closed
Open
Clinical Management ofthe Lower Limb 381
P + T × N × 4620 (k)
C × W
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FIGURE8.8 Laplace’s law.
practice. This section aims to break down the application of Laplace’s
law to encourage evidence- based eective practice.
P is the sub- bandage or interface pressure (as described earlier).
However, it is important to appreciate that this pressure or dose can be
aected by several factors and as a practitioner it is essential to recognise and understand these if we are to heal ulceration (Clark2003)
(see Table8.11).
Pascal’s Law
Pascal’s law (sometimes referred to as Pascal’s principle) is the principle of transmission of uid through the application of pressure. It
states that pressure exerted anywhere in a conned container that
contains uid will transmit the uid equally in all directions throughout the conned container. This is an important principle when
using compression therapy because compression therapy is creating
a pressurised area to redistribute uid (Schuren and Mohr 2010).
This is of particular importance when we think about achieving
graduated compression therapy, as we want to ensure we move uid
from the distal part of the lower limb towards the proximal. Therefore, if we also consider Laplace’s law (described earlier), as the leg
circumference naturally increases from ankle to thigh graduated
compression therapy should be achieved, with the subsure decreasing from the distal aspect of the leg to the proximal, and
therefore the uid is transmitted in the right direction. A further consideration is the need to compress the foot. If adequate compression
is not applied to the foot, then uid will be transmitted from the leg
distally towards the foot and toes, which risks causing harm to them.
bandage pres-
ANTI- INFLAMMATORY ACTION OF
COMPRESSION THERAPY
One of the lesser- known advantages of compression therapy is its
action as an anti- inammatory intervention (see Table8.12) (Partsch
and Mortimer2015).
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