This month the Evidence Corner brings you evidence on compression of venous insufficiency ulcers. Though it is the keystone of conservative management of venous insufficiency ulcers, compression therapy is surrounded by controversy. A Cochrane review examines the evidence on what levels and types of compression work to heal venous ulcers, while a literature summary alerts readers on how to apply that compression and other key variables, which will determine whether the compression your patients are receiving will deliver the outcomes they need.

Compression for Venous Leg Ulcers

Cullum N, Nelson EA, Fletcher AW, Sheldon TA. Compression for venous leg ulcers (A Cochrane Review).

Available at: http://www.update-software.com/ccweb/cochrane/revabstr/ab000265.htm.

Accessed September 13, 2002.

Rationale: About one percent of people in industrialized countries will have a leg ulcer at some time. Most of these result from venous insufficiency and are managed by applying firm compression bandages or stockings. It was not clear until this disciplined literature search which of the many available compression garments is the most effective in setting the stage for venous ulcer healing.

Objective: Assess effectiveness and cost effectiveness of compression bandages and stockings in treating venous leg ulcers.

Methods: A standardized Cochrane search was conducted of available literature from 19 databases, publications, presentations, conference proceedings, and professional contacts, covering all trials evaluating healing effects of compression bandaging or stockings as treatment for venous leg ulcers. Data were extracted using objective criteria and verified by two independent reviewers.

Results: Twenty-two trials reporting 24 comparisons of compression modalities were identified. Data analysis revealed that:
• Compression was more effective than no compression (4 of 6 trials)
• Multilayered elastic compression was more effective than multilayered nonelastic compression (5 trials)
• There was no difference in healing rates with multilayered high-compression systems of four or fewer layers (3 trials)
• No healing differences were found with different elastomeric multilayered systems (4 trials)
• Multilayered high compression was more effective than single layer compression (4 trials)
• Compression stockings were more effective than short-stretch bandages (1 trial)
• There were insufficient data to draw conclusions about the relative cost effectiveness of these compression modalities.

Conclusions: Compression increases venous leg ulcer healing rates, high compression is more effective than low compression, and multilayered compression is more effective than single-layered compression. However, there are no clear differences in healing efficacy with use of different numbers of layers as long as high compression is consistently applied.

Clinical Perspective: These findings have the potential to revolutionize venous leg ulcer care and outcomes. Venous ulcers are unlikely to heal with the best local care unless venous insufficiency and resulting edema1 are alleviated by aiding venous return with sustained, graduated, high compression.

Is Compression Being Properly Used?

Moore Z. Compression bandaging: Are practitioners achieving the ideal sub-bandage pressures?

J Wound Care 2002;11(7):265–8.

Rationale: Compression bandaging is the cornerstone of venous leg ulcer management, but it remains unclear exactly what sub-bandage pressures are needed to get results, how caregivers can provide these levels of compression consistently, and how to balance this with what patients can tolerate.

Objective: Identify the variables that can make the difference between success and failure of compression therapy for venous insufficiency ulcers.

Methods: A literature search explored variables contributing to venous ulcer outcomes in response to compression therapy.

Findings: Though high compression (~35–40mmHg) has been shown in the literature to enhance venous ulcer healing, as discussed in the Cochrane review above, few studies have explored the effects of these levels of compression on venous function. Many studies exploring efficacy of different bandaging systems have not examined actual sub-bandage pressures, which depend on:
• Patient adherence to the compression therapy prescribed
• Patient position: recumbent, sitting, or standing
• Proper and consistent application of the compression therapy
• Dimensions of the patient’s leg: thin legs receive higher compression; all else are equal
• Elasticity of the compression: with elastic compression, less variable between exercise and rest
• Capacity of compression bandaging to maintain high compression for the duration of wear.

Conclusions: While compression therapy is an integral component in the conservative management of venous leg ulceration, multiple sources of variability in amount and duration of compression applied have lead to controversy in the field about the most efficacious bandaging systems.

Clinical Perspective: Sustained, graduated high-compression therapy sufficient to aid venous return and reduce edema is good for venous ulcer healing. However, compression bandages or stockings will work only if patients wear them, properly applied, to deliver appropriate compression levels and gradients.