Table : Effect Of Limb Circumference On Performance Ofapplication Aids
|34-27 mmHg||26-19 mmHg|
A second product, Surepress, has a series of rectangles of twodifferent sizes knitted into the structure along the midline of thebandage. These rectangles are designed to allow the bandage toachieve a target pressure of 40 mmHg to legs of differentsizes.
The smaller rectangle is intended for ‘normal’ legs with anankle circumference in the range of 18-26 cm. The large square isfor ‘large’ legs with ankles greater than 26 cm circumference. Adetailed description of the performance of the Surepress bandagehas been published previously.
The use of application aids has been shown to reduce variabilityand produce more consistent levels of sub-bandage pressure,particularly amongst relatively inexperienced bandagers.
Venous Leg Ulcers: The Extent Of The Problem And Management With Compression
Leg ulceration is typically a chronic recurring condition with duration of episodes of ulceration ranging from a matter of weeks to more than 10 years .
A systematic review of the epidemiological literature from developed countries reported prevalence rates for any aetiology of open lower limb ulceration ranging from 1.2 to 11.0 per 1000 population . Recent surveys undertaken in the UK collected data from populations in Wandsworth, London , Hull and East Yorkshire , and Bradford and Airedale primary care trust . The prevalence of venous leg ulceration was estimated as 0.23 per 1000 population in London , 0.44 per 1000 in Hull and East Yorkshire , and 0.39 per 1000 in Bradford . The lower estimates in the recent UK surveys relative to the earlier worldwide literature searches done during 2000 might be explained by improvements in treatment as well as the broad versus narrow selection criteria for leg ulcers . The epidemiological data have consistently suggested that prevalence increases with age and is higher among women .
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Clinical Need And Target Population
Venous leg ulcers may cause social, personal, financial, and psychological burdens on patients and are a significant burden on the health care system. People with leg ulcers commonly report pain, itching, and sleep disturbance.3,4 The majority of people with venous leg ulcers are of advanced age, have a higher body mass index,5 and suffer from other health problems and/or impaired mobility that could affect their overall well-being as well as the healing process.6 The high recurrence rate of venous leg ulcers creates a clinical challenge, adding to the burden on clinicians and on the health care system.
Incidence and Prevalence of Venous Leg Ulcers
Prevalence studies undertaken nationally and internationally have produced estimates that between 1.5 and 3.0 per 1,000 people have active leg ulcers.7,8 In Ontario, the prevalence of active lower limb ulcers in people over the age of 25 years was estimated to be 1.8 per 1,000 people,9 with about three quarters over the age of 65. Harrison et al1 found that in Ontario, 50% of people with lower limb ulcers had leg ulcers, 35% had foot ulcers, and 15% had leg and foot ulcers.9 A large Swedish population-based study showed that 36% of all leg ulcers are caused by abnormalities in the venous system.10 Based on these findings, we estimate that 0.65 per 1,000 people in Ontario over the age of 25 years have active venous leg ulcers.
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Ethics Approval And Consent To Participate
The study protocol has been approved by the Clinical Research Ethics Committee of Hospital Gregorio Marañón . This study has been recorded in Clinical Trials.gov site with the code NCT02364921.
The project respects the basic ethical principle of autonomy, beneficence, nonmaleficence and distributive justice and will be conducted according to the basic principles of the Declaration of Helsinki . The study will follow the standards of Good Clinical Practice and current Spanish legislation for this type of study. The study will also comply with the Law on the protection of personal data and the rights of access, rectification, cancellation and objection that the patients may exercise.
All patients will be duly informed, and their informed consent will be requested in writing.
The project has had a favourable assessment from the Central Commission on Research of the Primary Care Management of Madrid.
In terms of respecting data confidentiality, the Principal Investigator and the professionals responsible for monitoring and reviewing the information shall have access to the CRFe. We plan to monitor the registration of CRFs at 3 points over the course of the study: once the first patient of each centre has been enrolled, once half of the planned sample has been obtained and at the end of the follow-up.
Characteristics Of Excluded Studies
|Falanga 1998||Treatment groups differed systematically other than in terms of the compression systems used. One group received a topical application of human skin equivalent plus a nonadherent primary dressing and an elastic bandage the other received a nonadherent primary dressing, paste bandage and elastic bandage.|
|Olofsson 1996||Treatment groups differed systematically other than in terms of compression systems used . In addition, several different types of compression were used within each group, meaning that the relative effectiveness of each system would be difficult to estimate.|
|Comparison is venous reflux surgery versus compression but both study groups received the same type of compression system.|
|Comparative study, unclear whether RCT.|
|Participants||60 patients with venous leg ulcers|
|Proportion of patients with complete healing|
|424 patients with venous leg ulcers.|
|300 patients with venous leg ulcers.|
|Interventions||4LB vs compression with 2 components .|
|Patients with noninfected leg ulcers eligible to receive compression.|
|Interventions||Different shortstretch compression systems and different dressings.|
|Outcomes||Healing mentioned, but no data provided.|
|100 patients with venous leg ulcers.|
|Interventions||Paste bandage vs compression bandage with 2 components.|
|Outcomes||Proportion of patients with complete healing.|
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Nd Choice: Coban 2 Multi Layer Compression Bandage Kit
- Achieves the same levels of compression as four layer. It may lead to greater concordance for patients and should therefore be the preferred choice.
Indications for Use:
- For the treatment of venous leg ulcers, venous oedema and lymphoedema.
- For use in patients with ABPI between 0.8 and 1.3.
Suitability For Compression Hosiery
It is important for the clinician to assess the individual patient and each limb for suitability for compression treatment before application. Documentation of the patients clinical history, physical examination andassessment of the individuals attitude and level of knowledge regarding their diagnosis and compression therapy, can help in the planning of individualised care.
Adopting a systematic approach to assessment will help to identify the most suitable type and class of stocking required.
The physical assessment must include:
Evaluation of the peripheral limb circulation. This is achieved by the use of a Doppler ultrasound to estimate the ankle brachial pressure index . High levels of compression are contraindicated when there issignificant arterial impairment
Consideration of the patients age, dexterity and anyother disabilities. This will influence the type of hosieryprescribed.
Skin assessment. It is important to check for areas ofvulnerability, especially newly healed ulcers where theskin is friable. Vulnerable areas may need protection.
Allergies. Possible allergens should be noted. Elastane,nylon and Lycra are all used in varying amounts in theproduction of compression hosiery. To reduce potential allergies all fibres are coated with cotton. Where a patient is shown to be allergic to one of the fibres use of a cotton tubular bandage under the stocking couldprevent irritation.
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Summary Of Main Results
There was limited evidence on ulcer recurrence, with three trials reporting this outcome . One reported no cases of recurrent ulceration in participants receiving singlecomponent elastic compression, the 4LB or fourcomponent compression comprising a paste bandage when rates were assessed during a sixmonth followup period following 12 weeks of treatment . Another trial that compared application of the 4LB in the context of a specialist clinic with usual care by the district nurse did not detect a statistically significant difference between groups for recurrence rates, or time to recurrence, during the oneyear trial period . In an evaluation of tubular compression versus compression bandages, significantly lower recurrence rates were detected in the group receiving tubular compression at one year . It is likely that the majority of included trials lacked the statistical power and duration of followup required to detect meaningful recurrence rates following treatment with compression therapy.
This review has attempted to take account of recent recommendations concerning the classification and description of different systems of compression . This update refers to the numbers of components in compression systems rather than the number of layers, as it has been argued that the number of components is more meaningful.
Compression Bandages Or Stockings Versus No Compression For Treating Venous Leg Ulcers
Compared with not using compression, compression therapy that uses bandages or stockings to treat venous leg ulcers:
probably heals venous leg ulcers more quickly
probably increases the number of people whose ulcer has completely healed after 12 months
probably reduces pain and
may improve some aspects of peoples quality of life.
However, there is still uncertainty about whether or not compression therapy causes unwanted side effects, and if the health benefits of using compression outweigh its cost.
What are leg ulcers?
Leg ulcers are open skin wounds on the lower leg that can last weeks, months or even years. Most leg ulcers are caused by venous diseases that affect the circulation of blood in leg veins. Venous leg ulcers can cause distress and pain to patients, and can be very costly to the health service.
What did we want to find out?
Standard treatment options for venous leg ulcers often include compression therapy. This involves applying external pressure around the lower leg to help the return of blood from the legs to the heart. Compression therapy uses bandages, stockings or other devices.
We wanted to find out if compression therapy delivered by bandages and stockings compared with no compression:
heals venous leg ulcers
improves peoples quality of life
has health benefits that outweigh the costs and
Venous leg-ulcer healing and unwanted effects
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Working Pressure And Resting Pressure
The distinction between resting and working pressure is necessary to understand the effects of compression therapy. Resting pressure is the result of compression of the extremity at rest. It corresponds to the force exerted by the bandage when the muscles are relaxed. Working pressure is the pressure generated through the interaction of muscle contraction and compression when the body is in motion it arises from the resistance the bandage exerts to counteract muscle movement. The less the bandage yields in this process, the higher the working pressure. Both kinds of pressure depend on the material used, the number of layers applied as well as the force with which the compression has been applied. Given that the working pressure is generated by active muscle contraction, it is always higher than the resting pressure. When applying compression, pressure values may be checked with simple-to-use measuring instruments , .
Treating An Infected Ulcer
An ulcer sometimes produces a large amount of discharge and becomes more painful. There may also be redness around the ulcer.
These symptoms and feeling unwell are signs of infection.
If your ulcer becomes infected, it should be cleaned and dressed as usual.
You should also elevate your leg most of the time. You’ll be prescribed a 7-day course of antibiotics.
The aim of antibiotic treatment is to clear the infection. But antibiotics do not heal ulcers and should only be used in short courses to treat infected ulcers.
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Intermittent Pneumatic Compression With Or Without Compression Versus Compression Alone
Berliner et al. reviewed eight studies, three of which showed that compression pumps could alleviate symptoms of CVI and assist with the healing of longstanding chronic ulcerations. A systematic Cochrane review identified four trials of IPC + Compression versus compression alone . Only one trial showed lesser time to heal and increased rate of reduction in ulcer area, although it could not identify any difference in ulcer healing between the two groups. Further studies are required to assess the status of IPC as alternative/adjuvant to compression and to optimize cycle times and IPC duration per day to effectively heal VLU.
Development Of Compression Bandages
Bandages have a history stretching back thousands of years tothe time of the ancient Egyptians, who used simple woven fabrics,often coated with adhesives, resins and other medicaments asdressings to aid wound healing. Like some of the bandages usedtoday, these were made from non-extensible fabric and probablyrequired considerable skill on the part of the user to ensurecorrect application.
In the 17th century, Pierre Dionis who was Surgeon-in-Ordinaryto the queen of France and to the Empress Maria Theresa of Austria,recommended the use of rigid lace-up stockings made from coarselinen or dog skin to apply compression in the treatment of legulcers: the bandages available at that time were not suitable forthe application of sustained, controlled compression because oftheir inelastic nature. It was not until the middle of the 19thcentury that the first elasticated bandages, containing naturalrubber, were manufactured. In 1878, Callender published a letter inthe Lancet which described the use of these materials in themanagement of varicose veins.
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Note: Differences Between This Review And The Previous Versions:
Bandage The Leg Ulcers
Leg Ulcer is an open wound or a sore on the legs caused by a break in the skin that allows air and bacteria to get into the underlying tissue. The compelling reason for this condition is poor blood circulation. Also, it can be caused by an injury which breaks the skin. In addition, they are more common in females but can affect both women and men of any age. If they are treated in the initial stage, then leg ulcer can be cured without any complications. Otherwise, the area of breakdown will increase in size and become a chronic leg ulcer. Bandaging technique has changed little over the years. In the UK bandages are applied using a spiral or figure-of-eight technique and run from the base of the toes to just below the tibial plateau.
Causes of leg ulcer:
- Pain in the affected area
- Pus in the affected area
- Increasing wound size
- Generalized pain or heaviness in the legs
It is necessary to have assessment before performing the bandage. The measurement of ankle circumference is vital to safe compression bandaging. Ankle-brachial index ABI test is a simple way to check how well the blood is flowing for peripheral artery disease. Ultrasonography is a fundamental methods of assessing the state of the arterial and venous systems of the lower leg before performing the bandage.
Treatment: Bandaging Techniques for the Leg Ulcers:
Compression Bandages Type:
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Strengths And Limitations Of This Review
A strength of this review is its breadth and overview of the topic, also the new synthesis of information to aid understanding of adherence with compression within this patient group.
This review also had some limitations. Firstly, some factors with potential to impact adherence were excluded on the basis that they are non-modifiable at the time of intervention, such as climate, cognitive ability, and religious beliefs. This was an intentional decision, to focus the review results and conclusions on modifiable factors more able to be targeted with subsequent clinical research. Finally, the search was limited to the English language as language translation was beyond the scope of this work. A further three studies ,, that met inclusion criteria appear in Appendix 2 but are not cited in other tables or key themes within this review.
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Appendix: Definitions Relevant Tobandaging
In order to understand the science of bandaging, it is firstnecessary to become familiar with the following terms anddefinitions.
The extensibility of a bandage, determines the changein length that is produced when the bandage is subjected to anextending force. Extensibility is usually expressed in the form ofa percentage which relates the stretched to the unstretched length.It may be measured using a constant rate of traverse machine suchas an Instron, which extends the bandage at a predetermined ratewhilst recording the tension developed within it. If theconstruction of the bandage is such that when it is stretched pasta given point the textile components prevent further extension,even though the elastomeric fibres may not have reached the limitof their elasticity, lock out is said to haveoccurred.
Power or modulus determines the force that isrequired to bring about a specified increase in bandage length. Thegreater the power, the larger the force that is required.
Elasticity determines the ability of bandage subjectedto an extending force in the manner described above, to resist anychange in length and return to its original length once the appliedforce has been removed.
Compression implies the deliberate application ofpressure in order to produce a desired clinical effect. It isusually achieved by the use of elasticated stockings or anappropriate bandage, and is most commonly used to control oedemaand reduce swelling in the treatment of venous disorders of theleg.
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