Inelastic Compression Research Articles

Venous ulcer treatment requires inelastic compression

SummaryLeg ulcers have a venous pathophysiology in the vast majority of cases (1–4). Superficial or deep venous insufficiency and deep vein obstruction produce ambulatory venous hypertension due to venous reflux and venous pumping function impairment. The impaired venous hemodynamics is the key pathophysiologic mechanism leading to skin damage through several intermediate steps. Fibrin cuff formation around the microvessels, impairing gases (O2, CO2) exchange (5), white cells entrapment (6) causing skin necrosis, growth factors inhibition (7) producing a stagnation of the healing process have been considered involved in ulcer onset and maintenance. The treatment of venous leg ulcers (VLU) must be based on the correction of the hemodynamic impairment which can be achieved conservatively by means of compression therapy, walking and leg elevation or by means of invasive procedures (open surgery, endovascular procedures as endovenous Laser ablation, radiofrequency, foam sclerotherapy, conservative hemodynamic treatment). Compression therapy is frequently considered the first treatment option and it is the only therapeutical procedure which achieved the grade 1A in most recent guidelines or consensus documents (8–10). The crucial point is choosing the most effective compression modality. There are clear evidences that inelastic is more effective than elastic material in counteracting the venous hemodynamic impairment (11–14) that should „ensure” a superior effectiveness in promoting a higher healing rate of VLU, which are due to venous hemodynamic impairment. When looking at evidences we have some data showing that the higher the compression pressure the higher the healing rate (9, 15–17) and this is clearly in favors of inelastic bandages which exert a much higher pressure that elastic materials. On the other side we have many papers claiming a greater effectiveness of elastic stockings or elastic bandaged compared with inelastic material (18–30). Nevertheless studies comparing elastic and inelastic devices have so many flaws that their conclusions are hard to trust (31). Aim of this work is providing updated information about compression therapy effects on venous hemodynamic and the most effective compression modality to achieve the best outcome in VLU treatment.

Limestone mechanical deformation behavior and failure mechanisms: a review

In this paper, several mechanical deformation curves of limestone are reviewed, and the effects of temperature, confining pressure, and fluid are discussed. Generally, Mohr–Coulomb is used for limestone brittle fracture. The characteristic of low temperature cataclastic flow and the conditions and constitutive equations of intracrystal plastic deformation such as dislocation creep, diffusion creep, and superplastic flow are discussed in detail. Specifically, from the macroscopic and microscopic view, inelastic compression deformation (shear-enhanced compaction) of large porosity limestone is elaborated. Compared with other mechanics models and strength equations, the dual porosity (macroporosity and microporosity) model is superior and more consistent with experimental data. Previous research has suffered from a shortage of high temperature and high pressure limestone research; we propose several suggestions to avoid this problem in the future: (1) fluid-rock interaction research; (2) mutual transition between natural conditions and laboratory research; (3) the uniform strength criterion for shear-enhanced compaction deformation; (4) test equipment; and (5) superplastic flow mechanism research.

Two divergent paths: compression vs. non-compression in deep venous thrombosis and post thrombotic syndrome.

Use of compression therapy to reduce the incidence of postthrombotic syndrome among patients with deep venous thrombosis is a controversial subject and there is no consensus on use of elastic versus inelastic compression, or on the levels and duration of compression. Inelastic devices with a higher static stiffness index, combine relatively small and comfortable pressure at rest with pressure while standing strong enough to restore the “valve mechanism” generated by plantar flexion and dorsiflexion of the foot. Since the static stiffness index is dependent on the rigidity of the compression system and the muscle strength within the bandaged area, improvement of muscle mass with muscle-strengthening programs and endurance training should be encouraged. Therefore, in the acute phase of deep venous thrombosis events, anticoagulation combined with inelastic compression therapy can reduce the extension of the thrombus. Notwithstanding, prospective studies evaluating the effectiveness of inelastic therapy in deep venous thrombosis and post-thrombotic syndrome are needed.

A New Two Component Compression System Turning an Elastic Bandage into an Inelastic Compression Device: Interface Pressure, Stiffness, and Haemodynamic Effectiveness

Bandage application does not exert consistent compression pressure, leading to extremely variable compression when applied to patients. A new elastic bandage can exert a predefined pressure independently of healthcare providers and the size of the wrapped limb. The bandage system includes a series of non-stretchable patches that when applied to the bandage make it stiff. The aim of this work was to assess, in an experimental setting, the venous ejection fraction (EF) from the lower leg and the tolerability of this new bandage in a group of patients affected by superficial venous incompetence. EF was measured using strain gauge plethysmography under baseline conditions and the bandage was applied with a supine pressure of 20 and 30mmHg, with and without the stiff patches, in 25 patients with severe venous reflux in the great saphenous vein. The interface pressure of the bandages was measured simultaneously in the medial gaiter area. All patients showed EF values that were significantly reduced compared with normal individuals. Elastic bandages with an average pressure of 20 and 30mmHg in the supine position achieved a slight improvement in EF, and, after applying non-stretchable patches on the same bandage with similar resting pressure, EF was restored to its normal range (p<.001). Improvement in EF correlates with the pressure differences between standing and lying pressure and between muscle systole and diastole during exercise. This study confirms that inelastic is much more effective than elastic compression for improving impaired venous haemodynamics. The test material can be applied with a predetermined pressure, which considerably enhances the consistency of application, and it is easily transformed into an inelastic system just by applying stiff patches without any stretch and without significantly increasing the comfortable supine pressure.

First principle study: parametric investigation of the mechanics of elastic and inelastic textile materials for the determination of compression therapy efficacy

Vascular diseases are among the most common diseases in the world. Whether acute or chronic cases, compression therapy by bandaging is a well-known treatment for the majority of these diseases. In the textile processing of bandages, the influence of material chemistry (e.g. viscosity), the laws of physics (e.g. resiliency), and the medical requirements in the therapy must be taken into account. Furthermore, knowledge of the textile material helps us to understand why bandages do or do not have the desired effect. This paper provides a study of the Dynamic Hysteresis Coefficient (DHC) and lengthening, allowing the examination of compression bandage systems used in phlebology and lymphology using a novel measurement parameter. Compression bandage systems were subjected to a dynamic hysteresis test on a dynamometer, enabling estimation of the DHC and the lengthening (Δ L2) after five consecutive cycles. Evaluation of the findings indicates that the therapeutical stiffness index of the compression bandages can be reliably estimated using this new method. These findings show that inelastic compression bandage systems with elastomers can achieve a sustainable compression therapy over several days. DHC and Δ L2 are proven to be highly reliable parameters for comparing different compression bandage systems.

What is the existing evidence supporting the efficacy of compression bandage systems containing both elastic and inelastic components (mixed-component systems)? A systematic review.

To analyse current evidence on the efficacy of bandage systems containing both elastic and inelastic components (mixed-component systems). International consensus on the efficacy of types of compression systems is difficult to achieve; however, mixed-component systems are being promoted as combining the best properties of both elastic and inelastic bandage systems and increasingly being used to treat venous leg ulcers in practice. A systematic literature review. Search terms such as venous leg ulcer, varicose ulcer, leg ulcer, compression, bandage, elastic, inelastic, short stretch, healing rate, interface pressure, mixed component, two-layer, four-layer and multi-layer were used in database and hand searches in several combinations. Limits were set for years 2005-March 2015 and English-language publications. A total of 475 studies were identified at initial search, and following elimination from abstract and title, this was reduced to 7. A further study was identified on Google Scholar, bringing the final number of studies fitting inclusion criteria to 8. The following subgroups relating to outcomes of efficacy were identified: ulcer healing, maintenance of interface pressure, slippage, ease of application and patient quality of life. Mixed-component systems were found to have comparable ulcer healing rates to alternative compression systems and be easy to apply; have similar abilities to maintain pressure as four-layer bandages and better abilities than short-stretch bandages; have less slippage than alternative systems; and to be significantly associated with several favourable quality of life outcomes. Clinician skill in bandage application was an uncontrolled variable in all eight papers included in the review, which may limit reliability of findings. This review synthesises existing evidence on the efficacy of mixed-component systems and encourages clinicians to regard them as an effective alternative to purely elastic or inelastic compression systems. Additionally, it highlights the importance of clinician skill in bandage application as a crucial determinant of effective compression.

STICKS study \u2013 Short-sTretch Inelastic Compression bandage in Knee Swelling following total knee arthroplasty \u2013 a feasibility study

BackgroundPostoperative knee swelling is common and impairs early postoperative function following total knee arthroplasty. It was hypothesised that the use of a short-stretch, inelastic compression bandage would reduce knee swelling and improve pain and early function. The aim of this study was to provide preliminary data and test feasibility with a view to informing a larger, future trial.MethodsFifty consecutive patients selected for primary total knee arthroplasty underwent distance randomisation to receive a short-stretch, inelastic compression bandage or a standard wool and crepe bandage for the first 24 h postoperatively. Study feasibility including recruitment rates, retention rates and complications were analysed. The Oxford Knee Score, the EQ-5D-3L index score, knee swelling, knee range of motion, visual analogue pain score and length of stay were compared between groups. Analysis of covariance (ANCOVA) was performed adjusting for the preoperative measurement.ResultsSixty-eight percent of eligible patients were recruited into the trial. The retention rate was 88%. There were no complications regarding compression bandage use. There was a greater mean but non-significant improvement in Oxford Knee Score (p = 0.580; point estimate = 2.1; 95% CI −3.288 to 7.449) and EQ-5D-3L index score (p = 0.057; point estimate = 0.147; 95% CI −0.328 to 0.005) in the compression bandage group at 6 months. There was no significant difference between groups regarding knee swelling, knee range of motion, visual analogue pain score, complications and length of stay.ConclusionPreliminary data suggests that the use of an inelastic, short-stretch compression bandage following total knee arthroplasty is a safe technique that is acceptable to patients. A larger, multicentre trial is required to determine its effect postoperatively.Trial registrationThe study was registered with Current Controlled Trials, identifier: ISRCTN86903140. Registered on 30 May 2013.

A Combined Therapy Protocol to Improve Lower Extremity Muscle-Pumping Function and Lymphatic Drainage for Venous Ulcer Healing

Objectives: To conduct a registry-based evaluation of a therapy protocol for chronic venous ulcers involving the improvement of lower extremity muscle-function along with lymphatic drainage and inelastic compression.Method: We observed sixty-five patients with lower extremity venous ulcers secondary to chronic venous insufficiency until the end of treatment or the last available follow-up. The treatment protocol involved a series of sequential exercises with short-stretch bands performed thrice weekly: An hour of lymphatic drainage preceded each exercise session, associated with lymphomyokinetic passive activities using the RB3030 device. All patients underwent inelastic compression either with an Unna boot or with short-stretch bands. Perimetry was conducted at two different levels of the foot, and at five distinct levels of the leg, using a regular commercial tape. The ulcer wound was photographed along with an object with a pre-established, standard dimension. The area of each wound was then estimated through the Imagej software (National Institutes of Health) using a freehand drawing surrounding its border. Generalized linear models measured the association between therapy and outcomes, including the change in ulcer area, time-until-healing, and foot and ankle perimetry.Results: Most of the patients were female, with 20% presenting a diagnosis of diabetes mellitus, 66.2% of hypertension, and 3.1% presenting signs of arterial insufficiency. Ulcer location was similarly distributed across sides (23.1% vs. 21.5), demonstrating similar percentages of previous deep vein thrombosis (9.2% on the right and 6.2% on the left side). Average healing time was 37.24 days. Most ulcers (95.7%) healed within the study period. Compared to their counterparts, patients with greater than 22 degrees of ankle range of motion presented an improved reduction in ulcer area size: 1.78 (1.56, 2.03) versus 2.85 (2.23, 3.64), respectively.Conclusions: Therapies involving combined muscle strengthening, lymphatic drainage and compressive inelastic therapy should be part of chronic venous ulcer treatments.

Recalcitrant Venous Leg Ulcers May Heal by Outpatient Treatment of Venous Disease Even in the Presence of Concomitant Arterial Occlusive Disease

Peripheral arterial occlusive disease (PAOD) is reported in about 15-20% of patients with venous leg ulcers (VLU). In such cases arterial recanalization is often recommended, and compression therapy is considered a contraindication when the ankle brachial pressure index (ABPI) is<0.8. The aim of this study was to compare the outcome of patients with recalcitrant VLU, both without any arterial impairment ("pure venous recalcitrant leg ulcer" [pvRLU]) and with associated PAOD ("mixed arterial and venous recalcitrant leg ulcer" [mavRLU]), by treating only the venous disease. The records of 180 outpatients with recalcitrant ulcers treated between January 2011 and July 2014 were reviewed retrospectively. In total, 109 were affected by pvRLU and 71 by mavRLU, with moderate PAOD defined by an ABPI between 0.5 and 0.8. In addition to the same local wound dressing, the patients received ultrasound guided foam sclerotherapy of the refluxing superficial veins and a modified inelastic compression with a pressure ≤ 40mmHg. No patient was referred for arterial revascularization. The patients were followed until ulcer healing. Patients with pvRLU and mavRLU showed comparable demographic characteristics. Twenty-five patients were lost to follow up and the outcomes were analyzed in 93 patients with pVLU (85.4%) and in 62 patients with mavRLU (87.4%). The maximum time to complete healing was 48 weeks in the pvRLU group and 52 weeks in the mavRLU group (p=.009), The median healing time was 23 (pvRLU) versus 25.5 weeks (mavRLU) (p=.030). Deep venous incompetence (p<.001), ulcer surface area (p<.001), arterial disease (p=.002), and ulcer duration (p<.010) were risk factors for prolonged healing. Treatment of recalcitrant leg ulcers by treating venous incompetence by foam sclerotherapy and modified compression is successful, even if underlying moderate PAOD is not actively treated.

Managing lower limb oedema with compression therapy.

British Journal of Community NursingVol. 20, No. 6 CommentManaging lower limb oedema with compression therapyNina LinittNina LinittSearch for more papers by this authorNina LinittPublished Online:4 Jun 2015https://doi.org/10.12968/bjcn.2015.20.6.286AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Damstra RJ, Partsch H (2013) Prospective, randomized, controlled trial comparing the effectiveness of adjustable compression Velcro wraps versus inelastic multi-component compression bandages in the initial treatment of leg lymphedema. J Vasc Surg 1(1): 13–19 Medline, Google ScholarElvin S (2015) Cost efficacy of using Juxta CURES TM and UCS TM debridement cloths. Journal of Community Nursing 29(2) Google ScholarLawrence G (2015) EP471. Compression therapy using an innovative system. Poster presented at EWMA 2015, London, 13–15 May Google ScholarLymphoedema Framework (2006) Best Practice for the Management of Lymphoedema. International Consensus. MEP Ltd, London Google ScholarMoffat C (2015) Patients' concordance with compression therapy. Presentation at EWMA 2015, London, 13–15 May Google ScholarNaylor C, Imison C, Addicott R et al. (2013) Transforming our health care system. Ten priorities for commissioners. bit.ly/1L75WwH (accessed 19 May 2015) Google Scholar FiguresReferencesRelatedDetailsCited byCompression therapy for non‐venous leg ulcers: Current viewpoint13 October 2019 | International Wound Journal, Vol. 16, No. 6 2 June 2015Volume 20Issue 6ISSN (print): 1462-4753ISSN (online): 2052-2215 Metrics History Published online 4 June 2015 Published in print 2 June 2015 Information© MA Healthcare LimitedPDF download

Short-stretch inelastic compression bandage in knee swelling following total knee arthroplasty study (STICKS): study protocol for a randomised controlled feasibility study

BackgroundEnhanced recovery programmes in total knee arthroplasty are well established. Post-operative knee swelling is common and impairs early post-operative function. The use of a short-stretch, inelastic compression bandage is hypothesised to reduce knee swelling and improve pain and early function. A study was designed to test feasibility with a view to informing a larger, future trial and to provide preliminary data.Methods/designThis is a randomised controlled feasibility study. Fifty consecutive patients selected for primary total knee arthroplasty will be enrolled in the trial. Patients with a BMI >35, latex allergy or neurological or peripheral vascular disease are excluded. Patients are randomised by distance randomisation to receive a compression bandage for 24 hours after surgery or a standard wool and crepe bandage. The bandages are applied by one of two consultant surgeons who have had training with their application. Knee swelling, range of motion and pain scores will be compared pre-operatively and at day 1, day 2 and at 6 weeks between groups. The Oxford knee score and EQ-5D health status will be compared pre-operatively and at 6 months between groups. Recruitment rates, retention rates, resource allocation, completeness of data collection, and tolerance and complications with the compression bandage are recorded. Descriptive statistics are used to calculate a standard deviation for post-operative knee swelling in the groups and to perform a power calculation incorporating anticipated patient retention rates to inform a future trial. Preliminary data will be analysed using the independent samples t-test for equal distributions and the Mann-Whitney U for unequal distributions with the significance denoted at P <0.05.DiscussionEnhanced recovery programmes have revolutionized the management of total knee arthroplasty. There is a paucity of clinical data regarding the efficacy of compression bandages. Large, randomised controlled trials are uncommon in orthopaedic surgery. The results of this study will provide feasibility and preliminary data prior to the construction of a larger, multicentre study.Trial registrationThe study was registered with Current Controlled Trials (ISRCTN86903140) on 30 May 2013.

Compression of venous ulcers: standardizing standard care.

Venous legulcers (VLUs) are common, affectingupwardof 1% of adults and with increasing incidence and prevalence with advancing age. Venous leg ulcers are associatedwith reduced quality of life and significant health care costs in addition to sustained ambulatory venouspressure (venoushypertension),whichmostoftenresults from thrombosis and/or valve disease, affecting the superficial, perforator, or deep veins.As a result, calfmusclepumpdysfunctionensues, leading to ulcer formation. Standard care withmultilayered compression wraps is aimed at reversing these changes, and applicationofwell-deliveredcompressionachieveshealing inup to 75% of patients. Applying compression, however, is a challenge. Often viewedbypatients andpractitioners as cumbersome,uncomfortable, andoppressive, compression interruptspatients’ lives by altering their bathinghabits and the clothes and shoes they wear. In this issueof JAMADermatology,Zarchi and Jemec1 report that even those with moderate confidence in their ability to apply compression vary substantially in compression application, with less than one-third applying optimal compression, suggesting patients may not be getting the treatment prescribed.2 Given that dermatologists often see patients with VLUs, addressing the gap of providing substandard compression is important. The initial barrier toward change is for practitioners to appreciate the importance of compression in healing VLUs.Without optimal compression, substandard care is provided. Practitioners should understand compression systems and recommend the appropriate system. For example, elastic compression (Coban2 [3M] or Profore [Smith and Nephew])providescompressionwhenpatientsareeitherwalking or resting and differs from inelastic compression (Unna Boot),whichapplies compressiononlywhenpatientsarewalking (the latter is more desirable in patients with mild arterial insufficiency). Next, it is critical, given the variability in compression applied, that well-trained and experienced personnel apply compression. This need typically causes patients to visit a physician’s office, seek treatment at awound center, or usehomehealth services once or twiceweekly, depending on the amount of exudate. Application of compression by patients or untrained caregivers, such as family members, risks inappropriate provision of care; however, recent work suggests firm compression stockings (30-40 mm Hg) may result in similar outcomes for selected patients.3 Education and training of practitioners, staff, and patients about the importance and application of compression are key. Related article page 730 Research Original Investigation Compression Therapy for Venous Leg Ulcers

Report from the 2013 meeting of the International Compression Club on advances and challenges of compression therapy.

The International Compression Club, a collaboration of medical experts and industry representatives, was founded in 2005 to develop consensus reports and recommendations regarding the use of compression therapy in the treatment of acute and chronic vascular disease. During the recent meeting of the International Compression Club, member presentations were focused on the clinical application of intermittent pneumatic compression in different disease scenarios as well as on the use of inelastic and short stretch compression therapy. In addition, several new compression devices and systems were introduced by industry representatives. This article summarizes the presentations and subsequent discussions and provides a description of the new compression therapies presented.

Comment to: Prospective, randomized, controlled trial comparing the effectiveness of adjustable compression Velcro wraps versus inelastic multicomponent compression bandages in the initial treatment of leg lymphedema. J Vasc Surg 2013;1:13-9.

This study was conducted as a prospective, randomized, controlled trial at the Lymphedema Department at Nij Smellinghe Hospital in Drachten, The Netherlands, from January 2010 to August 2011. The study enrolled 30 patients hospitalized for non-operative treatment of moderate to severe lymphedema of the leg, not responsive to ambulatory lymphedema treatment with compression and manual lymph drainage for at least 6 weeks. The participants were randomized into two groups. Group A was treated with the Juxta-Fit ACW (CircAid Medical Products, San Diego, CA, USA), consisting of an initial protective cotton tube liner covered by an adjustable inelastic compression wrap. The adjustable compression Velcro (ACV) wrap devices were individually tailored to patient legs. Group B was treated by means of a three-component Trico IMC system (BSN Medical GmbH, Hamburg, Germany) consisting of an initial protective layer (Tricofix; BSN Medical GmbH) and covered with two layers of synthetic cast wadding (Delta-Rol S; BSN Medical GmbH). Two layers of Trico (12 cm x 4 m) bandaging material were applied over the synthetic cast wadding. In both groups, the initial systems were removed after 2 h. After the initial application, the patients in Group A reapplied ACVs in co-operation with the hospital staff, and they were further instructed as to how readjust the straps for the remainder of the study. In Group B, the staff applied new bandages during the following 24 h. After application of both compression systems, all patients were encouraged to move as much as possible. No other therapeutic intervention was performed before or during the study period. Leg volumetry was performed on both groups before bandage application, after removal of the initial bandages (i.e. 2 h later), and after the second removal (i.e. 24 h later). Interface pressures were sampled in both groups by a PicoPress pressure transducer (Microlab Elettronica, Roncaglia di Ponte San Nicol&ograve;, Italy). The median lymphedema leg volume before bandaging was 3570 mL for the ACV group, and 3268 mL for the inelastic multicomponent compression (IMC) bandages group. After 2 h, a median volume reduction of 3.1% was measured in the ACV group compared with 2.4% in the IMC group, which was not significant. After 24 h, the median volume reduction was 339 mL in the ACV group and 190 mL in the IMC group (P&lt;0.05). The median initial interface pressures were 53 mmHg for ACV and 49 mmHg for IMC bandages. In the next 2 h, interface pressures dropped significantly: by 26.1% under ACV, and 50% under IMC (both P&lt;0.001). After 2 h, compression materials were reapplied: ACVs were reapplied by the patients under supervision, while IMC bandages by the staff. Median interface pressures after bandage renewal were 52 mmHg for ACV and 53 mmHg for IMC. After 24 h, median interface pressures decreased significantly to 33 mmHg underneath ACV and to 25 mmHg underneath IMC (P&lt;0.001). Patients&rsquo; interventions in the ACV group were recorded. During the second phase of the study, nine patients made 26 readjustments: the ACV was tightened 14 times and loosened 12 times. In the present study, there was significantly greater edema reduction by ACV after 24 h than with the IMC bandaging system, despite the same initial compression pressure. Patients were allowed to tighten ACVs when they felt them loose. This also led to an increase of the working pressure, producing a stronger massaging effect during walking. The ACV system was less bulky compared with IMC; therefore, it was easier for patients to wear shoes and to walk. So far, ACV has been mainly used in the maintenance phase of lymphedema treatment. Patients&rsquo; involvement in their own treatment is a part of self-management and is becoming more and more common in chronic disease management. In principle, patients who are able to put on their shoes should also be able to apply the ACV system. In cases where self-application is a problem, such as extreme obesity, relatives may be able to take over home-therapy. Stiff material generally exerts a stronger massaging effect during walking, but leads to an immediate pressure loss due to edema reduction. This disadvantage of pressure loss is compensated by the readjustment of the straps by the patients. Cost effectiveness aspect was not included in the study deliberately, although ACV is much more expensive than a traditional IMC.

Elastic or inelastic compression in patients with leg ulcer and restricted mobility?

In patients with leg ulcer and restricted mobility, compression with elastic material is often preferred based on the concept that it is more effective as it exerts a sustained higher resting pressure while inelastic material is believed to exert a very low resting pressure and to work only during movement. The aim of this study is to demonstrate that elastic and inelastic material can exert similar pressure at rest and that inelastic material can produce a much higher pressure during sitting and light exercise in ulcer patients with restricted mobility. In 30 patients (12 men, 18 women mean age 76.3&plusmn;9.1 years, range 63-80) with leg ulcers and severely reduced mobility we applied consecutively elastic and inelastic bandages with the same resting pressure of 40 mmHg. Pressure changes were measured while the patient was sitting and standing and during active and passive muscle contractions. The pressure differences between standing and supine and sitting and supine position were calculated as well as between muscle systole and diastole during active and passive contractions. Starting with the same resting pressure inelastic bandages produce significantly higher pressure peaks in the sitting and standing position and during the muscular systole both during active and passive exercise compared to elastic bandages (P&lt;0.001). The results show that inelastic bandages, applied with the same pressure as elastic bandages at rest, will exert much higher pressures even during minimal or passively induced muscle contractions. The concept that elastic compression should be used in patients with reduced mobility needs to be reconsidered.

Quantified hemodynamics of compression garments

Various forms of compression therapy have been utilized for centuries in the treatment of venous disease, with inelastic bandage systems being used in the more acute treatment of severe venous disease and elastic compression stockings used for long-term management of the disease. However, with the advancement in inelastic adjustable compression wraps, we now have the option to consider long-term management of venous disease with an inelastic system and not just elastic systems. The aim of this study was to compare the hemodynamic effect of elastic compression stockings and inelastic compression wraps on venous disease patients when both products are applied to provide the same level of compression. Utilizing the APG device (ACI Medical, San Marcos, CA, USA), venous volumes, venous filling indexes and ejection fraction measurements were captured on 10 patients with varying degrees of venous disease. Measurements were obtained for each patient at baseline (without compression), with either 30-40 or 20-30 mmHg elastic compression stockings (ECS) and an inelastic compression wrap (ICW) (Juxta-CUREStm by Circaid Medical, San Diego, CA, USA). The compression level of the ECS was measured at the B1 point utilizing a Picopress&reg; [Microlab Elettronica Sas, Roncaglia di Ponte San Nicol&ograve; (PD), Italy] and the ICW was adjusted to provide the exact compression level as the ECS in order to compare the effects of inelasticity versus elasticity independent of compression differences. As expected, the use of compression therapy significantly improved all measures of hemodynamics although it was found that the ICW (average static stiffness 14.3) further improved the measures over ECS (average static stiffness 2.4). Average venous volumes were reduced over baseline with ECS by 19% while ICW showed a reduction of 35%. Average venous filling indexes were reduced with ECS by 25% and 39% with ICW. The ejection fractions for both devices, ECS and ICW, improved an average of 27%. When applying the same compression level, the stiffness associated with ICW can further improve the venous hemodynamics of venous disease patients over ECS. For certain patients, using ICW could prove to be a significant benefit in the management of their disease.

Overview of the Development of Design Recommendations for Eccentrically Braced Frame Links with Built-Up Sections

Among the new additions to the 2010 AISC Seismic Provisions are design requirements for eccentrically braced frame links with built-up box sections. Such links do not require lateral bracing in many cases because built-up box shapes have superior lateral torsional stability relative to wide flange sections. The 2010 Seismic Provisions include requirements for built-up box link flange width-to-thickness ratio and other important design considerations. However, the limits on web width-to-thickness ratio default to those used for built-up box beams or columns and are inadequate for links with large inelastic shear and compression strains. Such limits are important for preventing web buckling under shear and/or flexural compression. This paper presents an overview of research on the design and behavior of links with built-up box sections, including the development of recommendations for web width-to-thickness limits and corresponding web stiffener spacing requirements and flange width-to-thickness limits for these link sections. The highlighted research program included derivation of design requirements based on plate buckling considerations; a full-scale, single-story eccentrically braced frame test; a parametric study on the impact of link cross-sectional parameters on link inelastic rotation capacity; and a series of large-scale tests on isolated links.

Elastic or inelastic compression? Reported evidence from clinical trials

Evidence for compression therapy found in literature mainly comes from clinical studies, preferably randomized controlled trials (RCTs) and systematic reviews (SR), which are often complemented by research data, expert opinion or by data from technology assessment or regularization documents. Differences between materials/methods/intervention in clinical trials can be partly explained by variability in focus, or due to country specific issues. Results from RCTs and SRs, and the interpretation of these results may vary depending on definitions used and the adequacy of data. In the first place, the baseline comparability of study groups depends very much on the accuracy of the diagnosis. Secondly, results will very much depend on the intervention used, whether compression is used alone, or whether it is part of a more complex management like decongestive treatment including other physical methods, surgery, or pharmacological treatment. A third consideration relates to the outcome parameters, the methods used to measure them, and the length of follow-up. Properties of compression materials have been redefined and standardized, and new insights in the physiological effects of compression treatment have shaken existing myths and dogmas in this field. RCTs using out-dated definitions and classifications of materials have led to systematic reviews and recommendations based on the same misunderstanding; it is left to the alert reader to interpret their results with caution.

Post-treatment compression: duration and techniques

Compression treatments used the following intervention for varicose veins range from no compression, to elastic stockings and compression bandaging. There is no consensus on the strength or duration of compression which should be applied following a particular treatment. The author reviews the evidence that has led him to reach his own viewpoint on this subject. Compression stockings are often prescribed after treatment of varicose veins, but these in general exert a much lower pressure in the thigh compared with firm inelastic compression bandages. It has been shown by objective investigation that it takes a pressure of 10-15 mmHg in the supine position and 40-50 mmHg in the standing position to occlude a superficial vein in the thigh. The author has published a study in which three groups of patients were studied following varicose vein surgery. One group received a strong medical compression stocking, the second group an inelastic bandaging system which achieved 63 mmHg compression in the standing position and an eccentric compression system which achieved 98 mmHg in the standing position. Adverse events after surgery were most frequent in the stocking group with fewer in the inelastic compression bandage group and fewest in the eccentric compression group. A further study has been published by another author in which elastic compression has been compared with eccentric compression following endovenous laser ablation of the saphenous vein. Eccentric compression reduced postoperative pain. Unfortunately, very little data are available to indicate the period for which compression should be applied following varicose vein treatment. In comparison to compression treatments following varicose vein surgery where the actual level of compression has been measured, higher levels of compression are more effective than lower levels in moderating postoperative pain and complications. Strong compression can be achieved by inelastic bandaging or by eccentric compression systems. Far fewer data are available to indicate the duration for which postoperative compression is required.

Prospective, randomized, controlled trial comparing the effectiveness of adjustable compression Velcro wraps versus inelastic multicomponent compression bandages in the initial treatment of leg lymphedema.

Inelastic multicomponent compression (ICM) bandages applied by specialized medical staff are the standard of care for compression therapy of lymphedema of the extremities. However, new adjustable compression wraps (ACWs), which can be applied by patients themselves and, up to now, have been mainly recommended for the maintenance treatment phase of lymphedema, may be an important step toward the self-management of the initial treatment phase. This prospective, randomized, controlled comparative study assessed the effectiveness of an ACW in the treatment of leg lymphedema, compared with the traditional treatment with conventional IMC bandages. Included were 30 hospitalized patients admitted due to moderate to severe unilateral lymphedema (stages 2-3) of the leg. The primary outcome measures in both groups were reduction in volume of the affected leg and interface pressure after 2 and 24 hours. Patients were randomized into two groups of 15 patients: group A received ACW and group B received IMC bandages, both applied by experienced staff. After 2 hours, the staff replaced IMC bandages and the patients applied ACW, as previously instructed. Finally, compression was removed after 24 hours. Classic water displacement volumetry was performed before compression and after 2 hours and after 24 hours of compression. The interface pressure was measured immediately after application of compression, 2 hours after compression, before and after compression renewal, and finally, after 24 hours. Patients in the ACW group were allowed to adjust the wrap themselves when they considered it necessary. The reduction in median volume after 2 hours was 109 mL (interquartile range [IQR], 64-271 mL; -3.1%) in the ACW group and 75 mL (IQR, 41-135; -2.4%) in the IMC group (not significant). After 24 hours, the reduction in median volume was 339 mL (IQR, 231-493 mL; -10.3%) in the ACW group and 190 mL (IQR, 113-296 mL; -5.9%) in the IMC group (P < .05). The interface pressure dropped significantly after 2 and 24 hours in the IMC group (-50% and -6%), but significantly less in the ACW group (-26% and -44%), mainly due to self-readjustment. The median pressures achieved after self-application of ACW (52 mm Hg; IQR, 44-61 mm Hg) were of the same order as those produced by the nurses after the first application of ACW (53 mm Hg; IQR, 39-59 mm Hg), with less variation. In patients with moderate to severe lymphedema ofthe legs, ACW achieved a significantly more pronounced reduction in volume after 24 hours than IMC bandages. Patients were able to apply and adjust the device after being instructed in its use and after an initial 2-hour period of wear. Autonomous handling of ACW seemed to improve the clinical outcome and isa promising step toward self-management involving effective compression.