Search Methods For Identification Of Studies
Details of the search strategy for the original version of this review are available in .
The following electronic databases were searched, without date or language restrictions, to identify RCTs that investigated the use of bandages or stockings for the treatment of venous leg ulcers:
Cochrane Wounds Group Specialised Register
The Cochrane Central Register of Controlled Trials
The following search strategy was used in the The Cochrane Central Register of Controlled Trials :
#1 MeSH descriptor Occlusive Dressings explode all trees #2 MeSH descriptor Stockings, Compression explode all trees #3 :ti,ab,kw #4 #5 MeSH descriptor Leg Ulcer explode all trees #6 or or or or :ti,ab,kw #7 #8
The search strategies for Ovid MEDLINE, Ovid EMBASE and Ovid CINAHL can be found in , and respectively. The Ovid MEDLINE search was combined with the Cochrane Highly Sensitive Search Strategy for identifying randomised trials in MEDLINE: sensitivity and precisionmaximizing version Ovid format . The EMBASE and CINAHL searches were combined with the trial filters developed by the Scottish Intercollegiate Guidelines Network .
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How Is Venous Leg Ulcer Diagnosed
For all ulcer patients, it is recommended to take a close look at the medical history:
- personal or familiar history of varicose veins, treated or not
- personal or family history of deep vein thrombosis and/or superficial vein thrombosis and/or pulmonary embolism
- personal history of significant trauma or lower limb surgery
- a previous venous ulcer
- presence of diabetes
Your health care professional will examine your leg, both when youre standing up and lying down.
Theyâll also feel your pulse at the ankles to make sure the arteries in your leg are working properly. To rule out peripheral arterial disease as a possible cause of your symptoms, your health care professional will carry out a test known as a Doppler study.
Further examinations might be done in order to assess the blood flow in your veins.
Compression Stocking Use To Heal Venous Ulcers
Venous disease occurs when a vein is not functioning properly causing a disturbance of normal one-way blood flow usually causing venous insufficiency. This is the cause of varicose veins and at worst, venous ulcers leading to limb loss. An experienced surgeon has recieived highly specialized training in venous disease and is a part of most vascular, general surgical, and cardiothoracic/vascular training programs. When encountering a patient with a venous leg ulcer, you must first determine the cause. This begins with a history and physical examination and probably an ultrasound which uses sound waves to create images. This provides the clinician with detailed information about the venous system and will show sites where the reflux is occurring. Most venous ulcers occur just above the ankle. I think it is important to remember that some patients with venous disease also have arterial disease which may hamper healing of the venous ulcer. A quick way to determine if significant arterial disease is present is to perform ankle-brachial indices in the office. Clinically significant arterial disease is defined using a cut-off of the ABI of below 0.8. This may influence the need for further testing and influence the type of treatment for the venous ulceration.
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Looking After Yourself During Treatment
The following advice may help your ulcer heal more quickly.
- Try to keep active by walking regularly. Sitting and standing still without elevating your legs can make venous leg ulcers and swelling worse.
- Whenever youre sitting or lying down, keep your affected leg elevated.
- Regularly exercise your legs by moving your feet up and down, and rotating them at the ankles. This can help encourage better circulation.
- If youre overweight, try to reduce your weight with a healthy diet and regular exercise.
- Stop smoking and moderate your alcohol consumption. This can help the ulcer heal faster.
- Be careful not to injure your affected leg, and wear comfortable, well-fitting footwear.
You may also find it helpful to attend a local healthy leg club, such as those provided by the Lindsay Leg Club Foundation, for support and advice.
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Healing Serious Venous Ulcers
There is some evidence that compression socks can even help to heal venous ulcers that have already developed faster than bandages alone. Talk to your medical professional to see how compression socks can fit into your treatment plan for improved healing and less downtime from living your best life.
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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.
Effects On Leg Ulcer Recurrence
Four trials examined the effects of compression stockings treatment on ulcer recurrence for patients with healed venous leg ulcers. We were able to conduct a meta-analysis of two trials comparing two different strengths of compression stockings on the risk of ulcer recurrence . Ulcer recurrence was defined as epithelial breakdown anywhere below the knee lasting more than four weeks and requiring bandage treatment in one study , and as a skin break failed to heal in six weeks in the other study . The meta-analysis included data from 399 participants and showed that compression stockings class 2 significantly reduced leg ulcer recurrence compared to compression stockings class 1 at 12months. Hence, if 175 per 1000 patients receiving class 1 compression stockings experience ulcer recurrence, the corresponding number among patients who receive class 2 stockings will be 91 per 1000. We have moderate confidence in the effect estimate .
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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 patient’s clinical history, physical examination andassessment of the individual’s 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 patient’s 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.
Description Of The Condition
Leg ulcers are open skin wounds on the lower leg that can last weeks, months or even years. They occur as a consequence of arterial or venous insufficiency, or both. Less frequently, chronic leg ulceration may occur due to some other disease, such as rheumatoid disease or rarer conditions . Most leg ulcers are the result of venous disease , where blood flow in the veins can be impaired by vein damage, obstruction and calf muscle pump failure . These problems mean that blood no longer returns efficiently from the legs to the heart and the pressure within the veins rises . The precise chain of events that links high venous pressures with skin breakdown and subsequent chronic wounds is not fully understood.
Leg ulcers of mixed aetiology usually involve a combination of venous and arterial disease. Open skin ulceration that is due solely to limb ischaemia is less common.
The making of a differential diagnosis of the underlying aetiology of a specific leg ulcer is made by taking a clinical history, physical examination, laboratory tests and other assessments . Typically, the latter includes an assessment of the arterial blood supply to the leg using the anklebrachial pressure index , measured using a handheld Doppler ultrasound scanner.
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Adapted To Individual Needs
Within the treatment of venous leg ulcer compression therapy is essential for treating the underlying disease. Venous leg ulcer is often accompanied by oedema which needs to be reduced as it inhibits wound healing. The circaid product range offers two options matched to the planned therapy.
If there are large circumferences respectively oedema circaid juxtacures is the option to choose as it allows for oedema reduction thanks to its possibility to adapt to decreasing leg circumferences.
If there is no or only slight oedema circaid juxtalite, a ready-made adjustable compression device, is the alternative to ulcer compression stockings for patients who have challenges with compression stockings.
- circaid® compressive undersock
Easy-to-apply liner with targeted compression for foot and ankle
Additional compression for the toes
Data Analysis And Synthesis
As the scope and nature of the available evidence was not known in advance, the development of categories and grouping for mapping purposes was developed iteratively as the data was extracted and tabulated. See Appendix 1 for data extraction template. Aligning with Jabareens methodology,26 data was synthesized narratively by categories defined during the mapping process, to allow flexibility in development of themes to bring coherence to the data. A conceptual framework was logically constructed, around the theme of adherence.26,28 Using bibliographic analyses, papers were grouped by year of publication and further categorized using the Levels of Evidence Pyramid.29 As we were particularly interested to find out if any interventions have been able to influence adherence, RCTs and case reports/series were further analyzed to address the research questions. An analysis was conducted using frequencies supplemented by a narrative review. For consistency, data about adherence rates was converted from raw scores into a percentage to allow comparison across studies.
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What Is The Treatment For Leg Ulcer
If you are diagnosed with venous leg ulcer, you are probably already working closely with a wound clinic or your physician and a certified fitter in the management of the wound.
Control and heal the wound: medical compression plays an important rule
The primary treatment of a venous leg ulcer includes controlling any infection and healing the wound. This may take several months, depending of the size of the wound. Managing pain and minimizing the edema as well as protecting the healthy skin are important.
Compression helps to improve vein circulation in your legs and to treat swelling. It plays an important role in the healing of your wound and in post-wound care.
Traditionally, short-stretch compression bandages are used in the initial phase of treatment of large ulcers until healing is nearly complete or the patient can be fitted in a knee-length graduated compression stocking at 30-40 mmHg or higher.
Compression stocking systems
Also, compression stocking systems are available. They consist of a normal compression stocking and a patented low-compression understocking. These systems offermany benefits above and beyond those of bandages:
With appropriate treatment, most venous leg ulcers heal within 3 to 4 months.
Once your wound is healed, you should continue wearing your compression stockings for life to prevent development of another ulcer.
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How Does Compression Therapy Help Heal Ulcers
Compression therapy works by applying controlled pressure to the surface veins, keeping their diameter small and forcing blood back into the deep vein system which in turn pushes the blood uphill towards the heart. Improved blood flow aids in the healing of active ulcers and in preventing ulcer recurrences.
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Cleaning And Dressing The Ulcer
The first step is to remove any debris or dead tissue from the ulcer and apply an appropriate dressing. This provides the best conditions for the ulcer to heal.
A simple non-sticky dressing will be used to dress your ulcer. This usually needs to be changed once a week.
Many people find they can manage cleaning and dressing their own ulcer under the supervision of a nurse.
Compression Stocking Treatments For Leg Ulcers
Venous stasis ulcers are commonly called leg ulcers. They develop in areas where blood pools and swelling interferes with the movement of oxygen and nutrients through the tissues. They generally appear just above the ankle on the inside of the leg and can be very painful. Typically, a red, irritated skin rash develops into an open wound.
Leg ulcers are usually recurrent, and open ulcers can persist from weeks to years. The most common early leg ulcers symptoms are chronically swollen ankles, brown staining on the skin around the ankles, and there may also be dull aching, cramping, or feeling of heaviness in the legs and feet that becomes worse after prolonged standing.
A gradient compression stocking that fits properly can temporarily reduce the discomfort and skin damage effects. These stockings achieve this result by providing a controlled amount of pressure that is greatest at the ankle and that gradually decreases as it moves up the leg. This increased pressure in the tissue of the lower area can help to prevent swelling, and promote better circulation.
However, these stockings must be worn while standing, are often difficult to put on, and generally lose some of their compression as time goes by, requiring regular replacement. Although gradient compression stockings are effective only temporarily, other highly-effective, non-surgical leg ulcers treatment is available.
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Health Technology Under Review
Medical-grade graduated compression stockings apply higher pressure to the ankle region, gradually decreasing the pressure in higher areas of the leg. Recent studies have also examined the potential benefits of progressive compression, where the pressure increases in the higher areas of the leg.19 Compression therapy is an essential concept in the treatment of venous and lymphatic insufficiency.15 The most commonly used compression therapy systems for venous leg ulcers are compression bandages that can provide sustained compression and aid ulcer healing. Other forms of compression therapy for venous leg ulcers include boots and intermittent pneumatic devices. Once a venous leg ulcer is healed, compression stockings are used to reduce edema and ulcer recurrence.
There is no worldwide standard to grade the level of compression pressure. Medical-grade compression stockings are categorized by the manufacturers according to the pressure they are supposed to apply to the leg however, the described pressure may not accurately reflect the actual level of compression because there are other factors that can influence the pressure actually applied. For example, the elasticity of the stocking can break down with use. The technique used to put on and remove the stocking, as well as patient characteristics such as the shape and circumference of the leg, can also affect the level of compression achieved.14
Study Selection Data Extraction And Analysis
We included systematic reviews and randomized controlled trials according to the following criteria: study population of elderly with venous insufficiency and swollen legs without recent deep vein thrombosis evaluating the preventive effects of European standard compression stockings class 2 or 3 compared to a different class of compression stockings, other interventions to promote venous backflow or no intervention assessed on thrombosis, leg ulcer and mobility or other health related outcomes such as pain, discomfort, quality of life or post-thrombotic syndrome . Compliance was not defined as an outcome in the original protocol, but following feedback, we included compliance as a secondary outcome post hoc.
Two reviewers independently assessed the titles and abstracts of records identified by the search. Records appearing to meet the inclusion criteria and those with insufficient details were obtained in full text. Two reviewers independently assessed the full text publications according to a pre-defined inclusion form. Any discrepancies were resolved by consensus.
The first author described the included trials with regard to population, intervention, comparison, outcome and main results in tables. Another reviewer checked the extracted information. Two reviewers independently assessed the methodological quality of included studies using the Risk of Bias assessment tool .
Table 1 Confidence in effect estimates with interpretation
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Intermittent Pneumatic Compression For Treating Venous Leg Ulcers
Venous leg ulcers can be caused by a blockage or breakdown in the veins of the leg. Compression, using bandages or hosiery , can help heal ulcers. However, they do not always work, and some people are not willing or able to wear them. Intermittent pneumatic compression uses an air pump to inflate and deflate an airtight bag wrapped around the leg. This technique is also used to stop blood clots developing during surgery. However, the review of trials found conflicting evidence about whether or not IPC is better than compression bandages and hosiery. Intermittent pneumatic compression is better for healing leg ulcers than no compression. . Some studies suggest IPC might be a beneficial addition to bandages for some ulcers, but these studies might be biased. Delivering the IPC therapy in a rapid manner by inflating and deflating the IPC device more quickly resulted in more ulcers being healed than with a slower deflation regime.
IPC may increase healing compared with no compression. It is unclear whether it can be used instead of compression bandages. There is some limited evidence that IPC may improve healing when added to compression bandages. Rapid IPC was better than slow IPC in one trial. Further trials are required to determine the reliability of current evidence, which patients may benefit from IPC in addition to compression bandages, and the optimum treatment regimen.
Two trials found no difference between IPC and compression bandages alone.