Multilayer Bandaging Research Articles

Effect of elasticity on subbandage pressure of three layer tubular compression bandages in healthy volunteers: a RCT

To estimate the difference between mean interface sub-bandage pressures of two multilayer compression bandage systems in healthy volunteers when supine, standing, exercising and during recovery. Inelastic and elastic compression bandages were randomised to opposite limbs of each participant. Sub-bandage interface pressures for both bandages were compared within person. Participants and study staff were aware of the treatment. A pressure transducer measured sub-bandage pressures on the medial aspect of the lower leg, at the transition of the gastrocnemius muscle into the Achilles tendon (B1). The difference in interface pressure for the two different compression bandages was measured at level B1 during supine resting, standing, exercise and recovery. We defined the pressure difference between active standing and lying as a measure of stiffness, and amplitude as the range of pressures during plantar flexion while standing. The two bandage systems (inelastic and elastic) were applied from the base of the toes to just below knee and remained in place for the duration of the experiment. Elastic bandage consisted of three layers of graduated tubular bandage (83% cotton, 9% Lycra, 8% polyamide). Inelastic or short-stretch bandage consisted of 100% cotton crepe bandage. Interface sub-bandage pressures varied during different activities, but the mean difference in interface pressures between inelastic and elastic bandages was consistently at least 13 mm Hg. Stiffness was 7.3 mm Hg higher in the inelastic group (95% CI 5.1-9.5). The estimated difference in amplitude of sub-bandage pressure between the bandages during exercise was 15.5 mm Hg (95% CI 12.2-18.9). We found in vivo interface sub-bandage pressures varied with the type of bandage and activity phase. Inelastic bandages resulted in an increased mean interface sub-bandage pressure when resting and recovering, which was further increased when standing or exercising. Bandage stiffness and amplitude were also greater for inelastic compared with elastic bandages. None.

Pharmacological treatment in patients with C4, C5 and C6 venous disease

A range of surgical, endovenous, physical and medical treatments are available for patients with chronic venous disease. The aim of this review was to evaluate the evidence for pharmacological agents used for the treatment of chronic venous disease. A literature search was performed using Pubmed, Embase, Cochrane and Google Scholar databases. The initial search terms 'varicose vein', 'venous ulcer', 'venous disease' and 'lipodermatosclerosis' were used to identify relevant clinical studies of pharmacotherapy in patients with chronic venous disease (C4-C6). A huge range of naturally occurring and synthetic drugs have been studied in patients with chronic venous disease. For patients with C4 venous disease, micronized purified flavonoid fraction (MPFF), oxerutin, rutosides and calcium dobesilate may reduce venous symptoms and oedema. MPFF and pentoxifylline have been shown to improve venous ulcer healing when used in addition to multilayer compression bandaging. The clinical benefits of other medications remain unproven. Reliability of meta-analyses was limited by study heterogeneity, small sample sizes and lack of long-term follow-up. In prospective randomized studies, MPFF (Daflon(®)), other flavonoid derivatives and pentoxifylline have demonstrated clinical benefits in patients with C4-C6 venous disease. Pharmacotherapy should be part of a range of treatment options in the modern management of patients with chronic venous disorders.

Traitement des lymphœdèmes des membres

The treatment of lymphedema aims to reduce the volume and prevent infectious and joints mobility complications. This treatment rarely cure and is usually symptomatic; thus it should be continued throughout the life. The erysipelas and lymphangitis are common complications of lymphedema. Erysipela is always of streptococcal origin and requires systemic antibiotics. The risk of recurrent erysipelas on lymphedema is high. In case of large swelling associated with significant dermal sclerosis, it may lead to decrease joint mobility and functional impairment. The skin cares, manual lymph drainage, compression therapy with bandages and exercises are the four pillars of the complex decongestive therapy of limb lymphedema. Compression is the most important treatment. Lymphedema can be improved by only bandages, but a sustained improvement of lymphedema cannot be seen without bandages. The effectiveness of treatment must be evaluated by objective methods, measuring the perimeters of members or volumes. The management of lymphedema includes three phases: attack or initial treatment that aims to reduce volume of the lymphedema and maintenance phase to maintain the result and finally withdrawal phase. In the attack phase, we use complex decongestive therapy, mainly multilayer inelastic bandaging and manual lymphatic drainage (MLD). In the maintenance phase, we use elastic compression (stockings or sleeves) possibly associated with MLD. At all stages skin care and exercises are used. Adjuvant treatments may be useful (intermittent pneumatic compression, drug treatment). Surgery is rarely used except for genital lymphedema. The therapeutic management of lymphedema is difficult but has a variety of techniques. The complex decongestive therapy is very effective to restore a better quality of life even though it does not provide a cure for lymphedema.

Tratamiento con prendas de presión

Compression garments are the basis of lymphoedema treatment. They are indicated after reduction of the edema as maintenance therapy. They can also be used to prevent the appearance of lymphoedema and its complications. The garment exerts compression directly proportional to the tissue tension and inversely proportional to the limb size. It depends on the material and knitting technique used, with greater pressure on the distal level than on the proximal one. The tissue may be circular or flat and the garment standard or custom made. The time of daily use is unclear. The education of the patient is important regarding the continued and constant use of the garment. Several randomized clinical trials have suggested that compression therapy is effective, and that the best results are achieved in the initial stages with multilayer bandaging followed by the garment. No evidence exists regarding differences between combination therapy and compression alone. Search strategy PubMed, Tripdatabase and Cochrane Library were searched.

Factors influencing breast cancer-related lymphedema volume after intensive decongestive physiotherapy

Lymphedema treatment is based on an intensive decongestive physiotherapy phase of volume reduction followed by a long-term maintenance phase. Factors influencing the morbid lymphedema volume increase during maintenance were analyzed. Among 867 consecutive women recruited and followed in a single lymphology unit, 682 were analyzed. The other 185 were not analyzed because of an initial lymphedema volume <250 ml, <20% lymphedema volume decrease during the intensive phase, or they were lost to follow-up. Lymphedema volume was recorded prior to and at the end of intensive phase, and at each follow-up visit. During follow-up, treatment failure was defined as a lymphedema volume increase of ≥50% of the total reduction obtained during the intensive phase. Median lymphedema volume was 936 ml before and 335 ml after intensive decongestive physiotherapy (P < 0.0001). Median follow-up was 28 months. During the maintenance phase, the risk of treatment failure at 1, 2, and 4 years was estimated to be 38.1%, 53.1%, and 64.8%, respectively. Wearing an elastic sleeve during the day and an overnight multilayer low-stretch bandage (median, four nights per week; interquartile range, 2-6) significantly decreased the risk of treatment failure [hazard ratio, 0.53, (0.34-0.82), P = 0.004], whereas manual lymph drainage adjunction to those therapeutic components did not. The risk of treatment failure was also associated with weight and body mass index at inclusion. Risk of maintenance-therapy failure after intensive decongestive physiotherapy was associated with patients characteristics (younger age, higher weight, and body mass index), while elastic sleeve and bandage were associated with better maintenance results. Paradoxical effect of manual lymph drainage is likely to be related to indication bias.

Improving venous ulcer healing: designing and reporting randomised controlled trials

The randomised controlled trial (RCT) is often considered the gold standard for judging the benefits of treatments. The application of randomised controlled clinical trials to treatments of venous ulcer healing has lagged behind that of other areas of medicine. To interpret the results of an RCT, readers must understand a variety of aspects of their design, analysis and interpretation. Venous ulcer disease has a high prevalence and has a significant socioeconomic impact in most parts of the world. The management of venous ulcers causes a considerable strain on the health system and is likely to worsen in future. The multi-layer high compression system is described as the current gold standard for treating venous ulcers. A recent meta-analysis of bandaging systems found that multi-layer compression bandages appeared to be superior to single-layer bandages in promoting venous ulcer healing. However, it was noted that many of the studies had small sample sizes and the quality of research in the area was poor. The consolidating standards of reporting trials (CONSORT) statement can help clinicians to discern high-quality studies from ones of poorer quality. This paper discusses how CONSORT can help clinicians and researchers to design and report quality studies to contribute to evidence-based venous ulcer healing.

The role of perforators in chronic venous insufficiency

The treatment of incompetent calf perforating veins (ICPVs) has been ascribed an important role in the therapeutic strategy for reducing superficial venous hypertension in patients with advanced chronic venous insufficiency (C4-C6). Since the open approach to ligation of ICPVs was developed by Linton over 70 years ago, there has been an evolution toward less invasive techniques with lower morbidity. This paper will review the evidence for interruption of ICPVs through a series of systematic analyses of (1) subfascial endoscopic perforating surgery (SEPS) and (2) percutaneous thermal ablation techniques (PAPS). The effectiveness and morbidity of each approach will be discussed as well as the strength of evidence supporting that technique. While there are numerous case series that suggest that SEPS is beneficial for ulcer healing and for the prevention of ulcer recurrence, the sole two RCTs that have compared either open division or SEPS for ICPVs have failed to show a statistical advantage for ICPV ablation. The results of these studies are clouded by the inclusion of patients who received concomitant treatment of their great saphenous vein (GSV). The evidence for PAPS is based on a few (n = 5) case series in peer-reviewed journals, which are limited by small patient populations, limited follow-up, and a focus on surrogate outcomes (occlusion of the perforator) rather than clinical or functional outcomes. Moreover, most of these series were carried out in patients with mild disease. Sclerotherapy of ICPVs, by either liquid or foam, shows promise, but requires greater evidence. Our current approach for limbs with C4-C6 disease is to treat the GSV first and limit treatment of ICPVs to those with high volume flow and large-diameter ICPVs. [corrected]

リンパ浮腫治療への弾性包帯の応用─とくに多層包帯法について─

リンパ浮腫治療への弾性包帯の応用─とくに多層包帯法について─

Comparison of low-strength compression stockings with bandages for the treatment of recalcitrant venous ulcers

To compare the proportion and rate of healing, pain, and quality of life of low-strength medical compression stockings (MCS) with traditional bandages applied for the treatment of recalcitrant venous leg ulcers. A single-center, randomized, open-label study was performed with consecutive patients. Sigvaris prototype MCS providing 15 mm Hg-25 mm Hg at the ankle were compared with multi-layer short-stretch bandages. In both groups, pads were placed above incompetent perforating veins in the ulcer area. The initial static pressure between the dressing-covered ulcer and the pad was 29 mm Hg and 49 mm Hg with MCS and bandages, respectively. Dynamic pressure measurements showed no difference. Compression was maintained day and night and changed every week. The primary endpoint was healing within 90 days. Secondary endpoints were healing within 180 days, time to healing, pain (weekly Likert scales), and monthly quality of life (ChronIc Venous Insufficiency Quality of Life [CIVIQ] questionnaire). Of 74 patients screened, 60 fulfilled the selection criteria and 55 completed the study; 28 in the MCS and 27 in the bandage group. Ulcers were recurrent (48%), long lasting (mean, 27 months), and large (mean, 13 cm2). All but one patient had deep venous reflux and/or incompetent perforating veins in addition to trunk varices. Characteristics of patients and ulcers were evenly distributed (exception: more edema in the MCS group; P = .019). Healing within 90 days was observed in 36% with MCS and in 48% with bandages (P = .350). Healing within 180 days was documented in 50% with MCS and in 67% with bandages (P = .210). Time to healing was identical. Pain scored 44 and 46 initially (on a scale in which 100 referred to maximum and 0 to no pain) and decreased within the first week to 20 and 28 in the MCS and bandage groups, respectively (P < .001 vs .010). Quality of life showed no difference between the treatment groups. In both groups, pain at 90 days had decreased by half, independent of completion of healing. Physical, social, and psychic impairment improved significantly in patients with healed ulcers only. Our study illustrates the difficulty of bringing large and long-standing venous ulcers to heal. The effect of compression with MCS was not different from that of compression with bandages. Both treatments alleviated pain promptly. Quality of life was improved only in patients whose ulcers had healed.

Breast cancer-related lymphoedema: implications for primary care

As more women are surviving breast cancer, long-term complications of treatment that affect quality of life, such as lymphoedema, gain greater importance (Tsai et al, 2009). The various approaches to treating lymphoedema include skin care, elevation of the affected arm, the use of compression hosiery, multi-layer bandaging, massage (manual lymphatic drainage), and sometimes surgery. The increasing number of women who survive breast cancer partnered with the tendency to care for more patients in the community mean that community nurses may find themselves at the forefront of the management of this patient group, becoming more responsible for side-effects of treatment and the disease. This article will discuss lymphoedema, its treatments along with relevant evidence, illustrating current practice.

Innovations in the management of chronic oedema

Chronic oedema is a common problem faced in primary care and community nurses are ideally placed to identify and manage uncomplicated cases. Lymphoedema and chronic lower limb oedema are conventionally treated with multi-layer bandaging followed by compression hosiery, however new innovations are becoming available to help manage this complex condition. This article outlines the basic management of chronic oedema and discusses treatments that are available in specialist lymphoedema clinics such as FarrowWrap™. A case study of the use of FarrowWrap™ is provided to illustrate how effective intensive treatments can be.

Risk factors related to the failure of venous leg ulcers to heal with compression treatment

Compression therapy is the most widely used treatment for venous leg ulcers and it was used in different forms for more than 400 years. Published healing rates of venous ulcers obtained with compression therapy vary widely from 40-95%. According to numerous studies, it has been suggested that the application of external pressure to the calf muscle raises the interstitial pressure resulting in improved venous return and reduction in the venous hypertension. Several risk factors have been identified to be correlated with the failure of venous leg ulcers to heal with compression therapy (longer ulcer duration; large surface area; fibrinous deposition present on >50% of the wound surface and an Ankle Brachial Pressure Index (ABPI) of <0.85. An open prospective single-center study was performed in order to determine possible risk factors associated with the failure of venous ulcers to heal when treated with multi-layer high compression bandaging system for 52 weeks. In the study, 189 patients (101 women, 88 men; mean age 61 years) with venous leg ulcers (ulcer surface >5 cm(2); duration >3 months) were included. The study excluded patients with arterial disease (ABPI <0.8), heart insufficiency with ejection fraction (EF) <35, pregnancy, cancer disease, rheumatoid arthritis, and diabetes. Based on clinical opinion and available literature, the following were considered as potential risk factors: sex, age, ulceration surface, time since ulcer onset, previous operations, history of deep vein thrombosis, body mass index (BMI), reduction in calf circumference >3 cm during the first 50 days of treatment, walking distance during the day <200 meters, calf:ankle circumference ratio <1.3, fixed ankle joint, history of surgical wound debridement, >50% of wound covered with fibrin, depth of the wound >2 cm. Within 52 weeks of limb-compression therapy, 24 (12.7%) venous ulcers had failed to heal. A small ulceration surface (<20 cm(2)), the duration of the venous ulcer <12 months, a decrease in calf circumference of more than 3 cm, and emergence of new skin islets on >10% of wound surface during the first 50 days of treatment were favorable prognostic factors for ulcer healing. A large BMI (>33 kg/m(2)), short walking distance during the day (<200 m), a history of wound debridement, and ulcers with deepest presentation (>2 cm) were indicators of slow healing. Calf:ankle circumference ratio <1.3, fixed ankle joint, and reduced ankle range of motion were the only independent parameters associated with non-healing (P < .001). The results obtained in this study suggest that non-healing venous ulcers are related to the impairment of the calf muscle pump.

Breast cancer-related lymphoedema: risk factors and treatment

Lymphoedema is a condition where there is an obstruction of the flow of lymph, partnered with a swelling of the limb. Within the breast cancer arena lymphoedema can occur in the arm where the cancer was/is. The various approaches to treating lymphoedema include skin care, elevation of the affected arm, the use of compression hosiery, multi-layer bandaging, massage (manual lymphatic drainage), or even surgery. This article will discuss the treatments for lymphoedema along with relevant evidence and illustrate current practice.

A comparison of inferface pressures of three compression bandage systems

To measure and compare the interface pressures achieved with two compression bandage systems - a four-layer system (4LB) and a two-layer short-stretch system (SSB) - with a new two-layer system (2LB), which uses an etalonnage (performance indicator) to help achieve the correct therapeutic pressure for healing venous leg ulcers - recommended as 40 mmHg. 32 nurses with experience of using compression bandages applied each of the three systems to a healthy female volunteer in a sitting position. The interface pressures and time taken to apply the systems were measured. A questionnaire regarding the concept of the new system and its application in comparison to the existing two systems was then completed by the nurses. The interface pressures achieved show that many nurses applied very high pressures with the 4LB (25% achieving pressures > 50 mmHg) whereas the majority of the nurses (75%) achieved a pressure of < 30 mmHg when using the SSB. A pressure of 30-50 mmHg was achieved with the new 2LB. The SSB took the least time to be applied (mean: 1 minute 50 seconds) with the 4LB the slowest (mean: 3 minutes 46 seconds). A mean time of 2 minutes 35 seconds was taken to apply the 2LB. Over 63% of the nurses felt the 2LB was very easy to apply. These results suggest that the 2LB achieves the required therapeutic pressure necessary for the management of venous leg ulcers, is easy to apply and may provide a suitable alternative to other multi-layer bandage systems.

Lymphedema in Prader–Willi syndrome

A 20-year-old woman with Prader-Willi syndrome presented with heaviness and swelling in the lower legs and feet, which had developed after a fall. Lymphoscintigraphy showed a disturbed lymphatic drainage pattern in both lower extremities. Based on the clinical findings and the results of lymphoscintigraphic examination we made the diagnosis of lymphedema. The patient was successfully treated with manual lymphatic drainage in combination with multilayer compressive bandaging. After edema reduction, elastic compressive stockings were fit. To the best of our knowledge, this is the first report on primary lymphedema in a patient with Prader-Willi syndrome, an association that is probably often missed.

The relationship between cytokine concentrations and wound healing in chronic venous ulceration

The importance of wound cytokine function in chronic venous leg ulcers remains poorly understood. This study evaluated the relationship between local and systemic concentrations of wound cytokines and wound healing in patients with chronic venous ulceration. This prospective observational study was set in a community- and hospital-based leg ulcer clinic. Consecutive patients with chronic leg ulceration and ankle-brachial pressure index >0.85 were prospectively investigated. All patients were treated with multilayer compression bandaging. Wound fluid and venous blood samples were collected at recruitment and 5 weeks later. In the wound fluid and venous blood, cytokines and factors reflecting the processes of inflammation (interleukin 1beta, tumor necrosis factor-alpha), proteolysis (matrix metalloproteinases-2 and -9), angiogenesis (basic fibroblast growth factor [bFGF], vascular endothelial growth factor), and fibrosis (transforming growth factor-beta(1) [TGFbeta(1)]) were measured. Ulcer healing was assessed using digital planimetry at both assessments. The study comprised 80 patients (43 men, 37 women). Median (range) ulcer size reduced from 4.4 (0.1-142.4) cm(2) to 2.2 (0-135.5) cm(2) after 5 weeks (P < .001; Wilcoxon signed rank), although 17 of 80 ulcers increased in size. The volume of wound fluid collected strongly correlated with ulcer size (Spearman rank = 0.801, P < .01). Initial wound fluid concentrations of bFGF correlated with ulcer size (Pearson coefficient = 0.641, P < .01), and changes in wound fluid TGFbeta(1) concentrations inversely correlated with changes in ulcer size (Spearman rank = -0.645, P = .032). There were no significant correlations between changes in other factors and ulcer healing. Wound fluid and serum cytokine concentrations correlated poorly. Wound fluid collection volume correlates with ulcer size. Ulcer healing correlated with increased concentrations of TGFbeta(1), possibly reflecting increased fibrogenesis in the proliferating wound. Aside from this, there was a large variation in wound and serum cytokine levels that largely limits their usefulness as markers of healing.

Multilayer compression bandaging in the acute phase of deep-vein thrombosis has no effect on the development of the post-thrombotic syndrome

The purpose of this randomized study was to evaluate the influence of immediate multilayer compression bandages before application of elastic stockings in the acute phase of deep-vein thrombosis (DVT) on development of the post-thrombotic syndrome (PTS). Sixty-nine patients with acute symptomatic DVT were randomized to immediate bandaging (n = 34) or no bandaging (n = 35). After reduction of edema sized-to-fit elastic stockings were applied in all patients after 7-14 days. Follow-up visits and non-invasive examinations were planned after 7, 30 and 90 days and 1 year. Venous outflow resistance (VOR) was measured by strain gauge plethysmography. Thrombosis score (TS) and reflux were measured by duplex scanning. After one year patients were evaluated for clinical PTS using both the clinical scale of the CEAP classification and the Villalta score. Improvement of clinical symptoms and decrease of leg circumference was better on day 7 in the bandaging group, but after 1 and 3 months clinical symptoms had improved equally in both groups. In 7 patients in the no-bandaging group a bandage was applied after all because of persistent edema after 10 days. There were no differences in VOR, TS and reflux. Using the CEAP classification the incidence of PTS was 39% in patients with bandages and 42% in patients without bandages (RR 0.91, 95% CI 0.50-1.66). Using the Villalta score the incidence of PTS was resp. 29 and 33% (RR 0.87, 95% CI 0.41-1.8). There was no difference in severity of PTS. Immediate multilayer compression bandaging in the acute phase of DVT is effective in reducing edema and complaints in the first week, but has no effect on thrombus regression, valve incompetence and the development of clinical PTS after 1 year.

A community nursing guide: multilayer lymphoedema bandaging

Multi-layer lymphoedema bandaging (MLLB) has been clinically proven to reduce oedema, improve skin complications and reduce infection. MLLB differs from four layer bandaging traditionally used to treat leg ulceration. This article identifies some of the differences between the two methods, suggests when best to use MLLB, describes an MLLB technique and considers the implications for training.

Influence of Different Materials in Multicomponent Bandages on Pressure and Stiffness of the Final Bandage

The physical characteristics of bandage kits, in which different materials are combined, cannot be predicted by laboratory tests. They can only be assessed in vivo by measuring the interface pressure and calculation of stiffness. The objective was to investigate pressure and stiffness of some widely used multicomponent, multilayer bandages and to investigate the effect of modifications of their components. Twelve healthy volunteers were investigated. Interface pressure and stiffness were measured in the lying and standing position after application of four-layer elastic bandage (Profore, Smith & Nephew, Hull, UK), two-layer elastic bandage (Proguide, Smith & Nephew), and four-layer short-stretch bandage (Rosidal sys, Lohmann & Rauscher GmbH, Neuwied, Germany) applied according to the manufacturer's recommendations and after some modifications of the padding layer. Both Profore, made up of elastic, and Rosidal sys, made up of inelastic components, fulfill the criteria for bandages with high stiffness. The stiffness of Proguide, consisting of elastic components, is in a gray zone between elastic and inelastic materials. Altering the padding layers changes the stiffness of these bandages completely. Pressure and stiffness of composite bandage kits differ from the physical properties of their components. Modifying the padding layers leads to a change of these physical properties that can only be assessed by in vivo tests on the human leg.

The treatment of venous leg ulcers with a specifically designed compression stocking kit

SummaryTraditionally, venous leg ulcers are treated with firm nonelastic bandages. Medical compression stockings are not the first choice although comparative studies found them equally effective or superior to bandages. Patients, methods: We report on a multi-center randomized trial with 60 patients treated with either short stretch multi-layer bandages or a two-stocking system (Sigvaris® Ulcer X® kit). Three patients have been excluded because their ankle movement was restricted to the extent that they could not put on the stockings and 1 patient withdrew consent. Patient characteristics and ulcer features were evenly distributed. The proportion of ulcers healed within 4 months and the time to completion of healing were recorded. Subjective appraisal was assessed with a validated questionnaire. Results: Complete wound closure was achieved in 70.0% (21 of 30) with bandages and in 96.2% (25 of 26) with the ulcer X kit (p = 0.011). Ulcers with a diameter of up to about 4cm healed twice as rapidly, the larger ones as fast with the stocking kit as with bandages. The sum of problems encountered with bandages was significantly greater than that observed with the stocking kit (p &lt; 0.0001). Pain at night and in the morning was absent with stockings but reported by 40% and 20% in the bandage group, respectively. The cardinal features associated with delayed or absent healing were ulcer size and pain. Conclusions: Common venous ulcers can readily be treated with the ulcer X compression kit provided the ankle movement allow its painless donning. Bandages, even when applied by the most experienced staff are less effective and cause more problems.