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E. Makuc
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Compression Therapy inUlcer Care
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GiovanniMosti
12
12.1 Introduction
Leg ulcers are very often due to supercial or
deep venous disease (both because of venous
obstruction or insufciency) [1–4]. Ambulatory
venous hypertension, the hemodynamic result of
the venous disease, is the key pathophysiologic
mechanism, leading to skin damage and nally
venous ulcers, through several but not completely
understood mechanisms.
Fibrin cuff formation around the microvessels,
impairing gases (O2, CO2) exchange [5], white
cells entrapment [6] causing skin necrosis, and
growth factor inhibition [7] producing a stagnation of the healing process, have been considered
as the ultimate pathophysiologic mechanisms in
venous leg ulcer (VLU) formation and maintenance, due to blood stasis in the lower leg.
The VLU treatment must be based on the correction of the venous hemodynamic impairment,
leading to VLU through a cascading mechanism.
Fixing venous hemodynamics can be achieved by
means of invasive procedures (open surgery,
endovascular procedures such as endovenous
laser ablation, radiofrequency, foam sclerotherapy, and conservative hemodynamic treatment)
but also conservatively by compression therapy
(CT), walking, and leg elevation.
In this chapter, updated information about CT
effects will be provided, not only on venous
hemodynamics. The whole set of CT effects
results in the high effectiveness of CT in signicantly increasing the VLU healing rate. In addition, they are of utmost importance in achieving a
high healing rate also in leg ulcer with different
pathophysiology.
12.1.1 Evidence-Based Compression
Therapy
Compression therapy is considered the cornerstone of VLU treatment and is recommended in
all national and international guidelines on VLU
treatment. Furthermore, it is the only therapeutical procedure that achieved the level of evidence
1A in many guidelines [8, 9]. No other ulcer
treatment achieved the same level of evidence.
Compression therapy can be applied with different compression materials and devices. The crucial point is choosing the most effective
compression modality, which is still matter of
debate.
12.1.2 Elastic andInelastic Materials
G. Mosti (*)
Angiology Department, Clinica MD Barbantini,
Lucca, Italy
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. Maruccia et al. (eds.), Pearls and Pitfalls in Skin Ulcer Management,
https://doi.org/10.1007/978-3-031-45453-0_12
All available compression devices (elastic and
inelastic bandages, elastic stockings, adjustable
compression wraps, and hybrid pumps) are basi-
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G. Mosti
cally made up of elastic or inelastic material.
When wrapped on the leg, they exert a compression pressure, which, according to the Laplace
law, depends on the stretch applied to the compression material, the number of turns of compression material, and the radius of the leg
segment [10].
Elastic and inelastic materials have com-
pletely different physical characteristics.
Elastic or long-stretch material (represented
by elastic stockings or elastic bandages with an
extensibility higher than 100%) gives way to
muscle expansion, which occurs during standing
and physical activity. This results in a very low
Static Stiffness Index (SSI) [11, 12], the difference between the standing and the supine pres-
sure, which represents the most important
indicator of elasticity/inelasticity of compression
devices. The SSI is <10mmHg, which characterizes the elastic range. Also, the difference
between diastolic and systolic pressure during
muscular activity, responsible for the so-called
massaging effect [13] of compression devices
over the calf muscle, is very low. These characteristics are consistently maintained independently on the applied pressure and material (if
elastic stockings or elastic bandages). In conclusion, elastic material exerts a quite sustained
pressure (Figs. 12.1 and 12.2). In addition, it
tends to regain its initial length when stretched
and this “return force” is directly related to the
stretch applied to the bandage. When applied too
Fig. 12.1 Compression pressure recording of an elastic
stocking (II class according to the RAL regulatory: mm
23–32mmHg). Compression pressure increase by dorsiexions, standing up, and walking is very small: sustained
pressure. Compression pressure never overcomes the
intravenous pressure (red line), and it is unable to narrow/
occlude the veins. Small circles represent veins never nar-
rowed/occluded. DSI: Dynamic Stiffness Index is the difference between diastolic and systolic pressure performing
foot dorsiexions in supine position; SSI: Static Stiffness
Index is the difference between standing and supine positions. WPA: Walking pressure amplitude is the difference
between systolic pressure and diastolic pressure while
walking
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Fig. 12.2 Compression pressure recording of an elastic
bandage exerting about 40mmHg in supine position. The
dynamic characteristics are the same as with elastic stockings despite a much higher exerted pressure. Compression
pressure never overcomes the intravenous pressure (red
line), and it is unable to narrow/occlude the veins. Small
circles represent veins never narrowed/occluded by elastic
stretched, the “squeezing effect” of the elastic
material can be painful and not tolerated by the
patients after a short time from application. As a
consequence, when properly stretched, an elastic
bandage will exert a supine pressure of
30–40 mmHg. This pressure will rise by
4–8 mmHg in standing position and will never
approach the intravenous pressure resulting in
inability to narrow or occlude the veins and to
exert a substantial hemodynamic effect. If we
wanted to use elastic material to exert a very
strong pressure in standing position, necessary to
occlude the leg veins, elastic bandages should be
applied with strong stretch or several elastic
stockings must be superimposed: In both cases,
the “squeezing effect” of these materials will be
painful and poorly tolerated (Fig.12.3).
stockings. DSI: Dynamic Stiffness Index is the difference
between diastolic pressure and systolic pressure performing foot dorsiexions in supine position; SSI: Static
Stiffness Index is the difference between standing and
supine positions. WPA: Walking pressure amplitude is the
difference between systolic pressure and diastolic pressure while walking
Advantage of Elastic Materials: They, both
stockings and bandages, usually as single component, are easy to apply. Very often, they can be
managed by the patients themselves or by their
relatives who easily learn to correctly apply this
kind of material.
Inelastic material (short stretch or inextensible bandages, adjustable compression wraps, and
hybrid pumps) exerts its effect by resisting the
increase in muscle volume during muscular contraction in standing position and during physical
activity (the leg will give way), so producing
high-pressure peaks when standing or walking
compared with elastic, long-stretch devices even
when applied at the same resting pressure (compare Figs.12.2 and 12.4). Inelastic material does
not have any elastic ber and does not have any
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G. Mosti
Fig. 12.3 Compression pressure recording of an elastic
bandage applied with high stretch to exert a very strong
standing pressure. It can be noticed that also the supine
pressure must be very strong as the pressure increase by
standing up is very small with elastic material. The elastic
material applied in this way is able to overcome the intravenous pressure, but this strong and sustained pressure
can be painful. Small circles represent veins never nar-
return force: It does not “squeeze” and can be
applied with full stretch.
The modern composite, multilayer and multicomponent bandages, including a padding layer
with inelastic material as main component, exert
a relatively low and well-tolerated pressure at rest
but a much higher pressure, often >70–80mmHg
during standing. The SSI is always >10, which
characterizes the inelastic range. The strong or
very strong pressure peaks during muscular exercise will overcome the intravenous pressure,
intermittently occluding the vein and so restoring
a kind of valve mechanism [14] (Fig.12.5).
rowed/occluded by elastic bandages. DSI: Dynamic
Stiffness Index is the difference between diastolic pressure and systolic pressure performing foot dorsiexions in
supine position; SSI: Static Stiffness Index is the difference between standing and supine positions. WPA:
Walking pressure amplitude is the difference between
systolic pressure and diastolic pressure while walking
In a few words, the inelastic material is able
to adapt to the body position by exerting a relatively low pressure in the resting position (comfortable) and a strong or very strong pressure in
standing position and during muscle activity
(effective) coming close to an ideal compression
device [15].
Unfortunately, the multilayer, multicomponent inelastic bandages are difcult to apply and
require expert and well-educated personnel. In a
series of papers, it was demonstrated that only 10
to 60% (depending on the paper) of expert health
personnel treating venous ulcers were able to
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Fig. 12.4 Compression pressure recording of an inelastic
bandage exerting a supine pressure of 60 mmHg.
Compression pressure increase by dorsiexions, standing
up, and walking is very high: intermittent compression
with high-pressure peaks able to overcome the intravenous pressure (red line) restoring a kind of valve mechanism. Small ellipses represent veins always narrowed/
occluded by strongly stretched elastic bandages. DSI:
apply the target pressure with different inelastic
bandages [16–20].
12.1.3 Which Compression Material
forUlcer Treatment?
Solid data in favor of elastic or inelastic material as the best choice to optimize VLU healing did not exist at the being time. There are
clear pieces of evidence that inelastic is more
effective than elastic material in counteracting
venous hemodynamic impairment [14, 21–24].
This “should ensure” a greater effectiveness in
Dynamic Stiffness Index is the difference between diastolic pressure and systolic pressure performing foot dorsiexions in supine position; SSI: Static Stiffness Index is
the difference between standing and supine positions.
WPA: Walking pressure amplitude is the difference
between systolic pressure and diastolic pressure while
walking
promoting a higher healing rate of VLU, which
is due to the venous hemodynamic impairment. In addition, we have pieces of evidence
that the higher the compression pressure the
higher the healing rate [25–27] and this is
clearly in favor of inelastic bandages effective
in exerting a much higher standing pressure
compared with elastic materials.
Amazingly, we have many papers claiming a
greater effectiveness of elastic stockings or bandages compared with inelastic material [28–41].
Unfortunately, studies comparing elastic and
inelastic devices have so many aws that their
conclusions are hard to believe [42].
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G. Mosti
Fig. 12.5 Compression pressure recording of an inelastic
bandage exerting a reduced supine pressure of 40mmHg.
Compression pressure increase by dorsiexions, standing
up, and walking is still very high: intermittent compression with high-pressure peaks is still able to overcome the
intravenous pressure (red line) again restoring a kind of
valve mechanism. Please notice the difference in pressure
behavior of the elastic material applied with the same resting pressure in Fig.12.2. The succession of small circles
12.1.4 Comparing Compression
Materials
In almost all trials comparing different compression devices, the exerted pressure was almost
never measured despite it represents the dosage
of compression, the most important parameter
concerning CT, and even if compression pressure
measurement is easy to perform with accurate
and cheap devices [43, 44].
When compression pressure is not measured,
we approximately know the elastic stocking
pressure because it is declared by the manufac-
and ellipses represent veins narrowing/occluding at every
muscle contraction during physical exercise. DSI:
Dynamic Stiffness Index is the difference between diastolic pressure and systolic pressure performing foot dorsiexions in supine position; SSI: Static Stiffness Index is
the difference between standing and supine positions.
WPA: Walking pressure amplitude is the difference
between systolic pressure and diastolic pressure while
walking
turing company. Unfortunately, we cannot know
the bandage pressure that can be extremely variable [45, 46] as it only depends on the stretch
applied to the bandage, layers overlap, radius of
different parts of the leg and, as a matter of fact,
on the health personnel skillness that is usually
poor [16–20]. As a consequence, not measuring
the compression pressure, it is impossible to
know if the bandages were correctly applied.
They could have been applied too stretched,
becoming painful and dangerous or, much more
frequently, too loose, becoming ineffective [16].
In addition, not measuring the pressure and cal-
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culating the SSI, an amazing mistake in almost
all studies comparing elastic and inelastic bandages was made.
In these studies [28–35], the prototype of elastic material is the so-called four-layer bandage,
which was considered elastic by denition as it is
made up of four different elastic components.
Nevertheless, by measuring supine and standing
pressure and calculating the SSI of the nal bandage, it was possible to show that SSI of the fourlayer bandage is in the inelastic range. It may
happen that the superimposition of different
components and the friction between the layers
change the elastic properties of the nal bandage,
making it inelastic [47]. In conclusion, all these
studies report a comparison between two different inelastic bandages and the reported different
outcomes in terms of healing rate may depend on
the greater experience of dedicated personnel in
applying the four-layer bandage.
The second comparison, inelastic bandages
vs. elastic stockings [36–41], has many major
aws, too.
First of all, it has to be underlined that the
elastic stockings taken into consideration for
comparison are actually elastic kits or tubular
devices exerting a supine pressure of about
40mmHg or more and higher stiffness compared
to a single stocking (although always in the range
of elastic material) due to the friction between the
two components. In addition, the sub-bandage
pressure, once again, was not measured, and the
skillness of health providers, usually poor, was
not reported. As a consequence, it could well
have happened that a good elastic kit was compared with a poorly applied bandage. In the only
one paper where the compression pressure was
measured, the inelastic bandage was applied with
a pressure lower than that of the elastic kit. It is
completely reasonable that the elastic kit provided a better outcome: This is exclusively due to
the poor application of the inelastic bandage [39].
In a few studies where compression pressure
was measured [26, 39, 40], it was demonstrated
that the higher the pressure the higher the healing
rate and this conclusion is in favor of inelastic
bandages even despite the conclusion of author’s
papers. In fact, as well proved, inelastic bandages,
when correctly applied, exert a compression
pressure denitely higher than elastic material.
12.1.5 Compression Therapy
andVenous Hemodynamics
The venous pressure in the legs depends on body
position: It is very low in supine position, it
increases in the sitting position, and it is maximal
in standing position. Actually, in the sitting and
standing still position the hydrostatic venous
pressure results from the unbroken column of
uid that extends from the right heart to the foot
that can be easily measured by calculating the
distance from the right heart and the ankle in
these different positions. The venous pressure is
about 70–80 mmHg in standing still position
both in normal individuals and in patients with
venous disease. In normal subjects, this pressure
decreases signicantly during active movements
(e.g., walking) down to 20–30mmHg due to the
combined effect of muscle pumping and venous
valve function, which fragments the blood column and reduces the hydrostatic venous pressure
[48]. In patients with venous insufciency, valve
failure causes the venous blood column to remain
unbroken even during ambulation. As a
consequence, hydrostatic pressure will minimally decrease during and immediately after
ambulation or could even increase in case of
venous obstruction [49, 50]. This is what we call
ambulatory venous hypertension (AVH), which
causes venous congestion that will be transmitted
to capillaries (capillary hypertension), which, in
turn, will activate the abovedescribed mechanisms leading to venous ulcer.
Compression therapy increases the transmural
pressure increasing the extra-venous pressure.
When the exerted pressure is strong enough to
overcome the intravenous pressure (70–80mmHg
in normal subjects), it will narrow or occlude the
leg veins. This is the prerequisite for the hemodynamic effectiveness of compression therapy. It
was shown that a low external pressure of about
20mmHg is effective in narrowing or occluding
the veins in the supine position, but the compression pressure requested for veins occlusion must
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rise to 50mmHg in the sitting position and close
to 70–80 mmHg in the standing position [51].
These data were conrmed by studies with magnetic resonance imaging (MRI) showing that in
the standing position a pressure of 40mmHg is
not able to occlude the veins that are completely
occluded with a pressure of 80 mmHg [52]
dened as very strong [53]. Such external
pressure may occlude the veins at every step during physical activity restoring a kind of valve
mechanism, which reduces the AVH [14] by
reducing the venous reux [21, 22] and increasing the calf pumping function [23, 24].
In all the studies on venous hemodynamics,
inelastic material was shown to be signicantly
more effective than elastic material. Inelastic
material is able to reduce venous reux and
increase venous pumping function even at a low/
mild pressure range of 20–40mmHg [54], which
has an important implication when inelastic
compression necessary to improve venous hemodynamics must be applied with reduced pressure
in patients mixed arterial-venous ulcers
(Fig.12.4).
Finally, inelastic material maintains its hemodynamic effect overtime despite a signicant
pressure drop as the stiffness of the bandage is
well maintained as proved by the roughly
unchanged SSI and “massaging effect” [55].
12.1.6 Is Inelastic Compression
Always Mandatory forUlcer
Treatment?
Looking at hemodynamics, inelastic material,
exerting strong or very strong pressure, could be
considered as best treatment option to maximally increase the ulcer healing rate. Actually,
when correctly applied to exert a strong pressure, inelastic bandages can achieve an ulcer
healing rate close to 100% in 3-month treatment, which was never reported for elastic
material [56].
Nowadays, we need to consider another treatment option: the adjustable compression wraps
(ACW) based on Velcro® closing systems that are
becoming more and more widespread. These
devices are quite inelastic (Fig. 12.6) and as
effective as inelastic bandages in terms of
improvement of the impaired venous hemodynamics [57, 58]. At the same time, they are very
easy to use and can be applied and re-adjusted
even by the patients themselves after a very short
wearing and education time (about 2 h) [59].
Actually, even with limited pieces of evidence,
ACW have been proven to be more effective than
Unna Boot bandage [60], than four-layer [61]
and two-layer bandage [62] in achieving VLU
healing.
New adjustable compression wraps with air
bladder sewed inside the device that can be manually inated to increase pressure and stiffness
(Fig.12.7) are now available but not yet tested in
the clinical setting.
Elastic kits too offer an alternative option
as they were shown to be effective in getting
healing, especially in small ulcers of recent
onset. Having said that the comparison
between inelastic bandages and elastic kits is
not trustable as it was burdened with major
flaws but just considering the effectiveness of
elastic kits in getting ulcer healing, we can
realize that elastic kits were able to achieve
ulcer healing in 36 to 96% of patients with
small ulcers of recent onset in 3 to 4 months
[23, 24, 26–29]. As ACWs, elastic kits do not
require expert personnel to be applied and
allow self-management.
In conclusion, when assessing the best treatment option for VLU compression therapy, we do
not have strong pieces of evidence in favor or
elastic or inelastic materials but we have data
enough to suggest inelastic material as the most
effective treatment modality. In this case, we may
choose between inelastic composite bandages
(difcult to apply) or ACW easy to apply and
allow self-management.
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