Alleviating Venous Ulcer Pain

8/1/2010
0 Comments
4597 reads

Author(s):

Laura Bolton, PhD, FAPWCA, Adjunct Associate Professor, Department of Surgery, UMDNJ, WOUNDS Editorial Advisory Board Member and Department Editor

Reference: Amsler F, Willenberg T, Blättler W. In search of optimal compression therapy for venous leg ulcers: A meta-analysis of studies comparing divers bandages with specifically designed stockings. J Vasc Surg. 2009;50(3):668–674.

Rationale: Compression is considered the most important conservative intervention for venous leg ulcers. High, multi-layer compression appears to improve outcomes more than low or one-layer compression. Advantages of medical compression stockings (CS) remain to be evaluated.

Objective: Compare effectiveness of CS with compression bandages (CB) in a systematic review and meta-analysis.

Methods: The authors searched MEDLINE, Current Contents, EMBASE, and the Cochrane Library for relevant combinations of the terms: venous insufficiency, leg, pain, edema, ulcer, compression therapy, bandages, stockings, hosiery, and randomized trials and requested related evidence from EUROCOM, the scientific arm of the coalition of European compression stocking manufacturers. All CS RCTs published in English, German, or French plus derivative references with a CS intervention in a RCT were included in a systematic review and meta-analysis of healing and pain. Outcomes were percentage of subjects with the target ulcer completely healed in 12–16 weeks (primary), measured pain during CS or CB wear, and time to complete ulcer healing. The meta-analysis used Cochrane Collaboration Review Manager 4.2.

Results: Eight prospective open-label RCTs on 342 CS subjects and 346 CB subjects with open venous ulcers met the search criteria. All subjects were randomized to parallel-groups except in one crossover study. Most studies excluded non-venous ulcer etiology, infection, an ankle/brachial systolic blood pressure ratio < 0.8 or < 0.9, diabetes, heart failure, or cancer. All studies used calf-length stocking systems with all but one reporting sub-stocking (24-56 mmHg) and sub-bandage (27 mmHg–49 mmHg) interface pressure. All five RCTs with statistically significant differences in percent healed in 12-16 weeks favored CS (65% healed) over CB (47% healed; meta-analysis P < 0.00001). No RCT favored CB on any target outcome. CS healing time averaged 11.6 weeks compared to 14.8 weeks for CB (meta-analysis P = 0.0002). Among the 108 CS and 111 CB subjects with measured pain scores, subjects wearing a CS consistently reported less pain than those wearing a CB (meta-analysis P < 0.0001). A novel graph shows that these results are robust independent of baseline differences in ulcer size (range: 0.1 cm2–210 cm2) and duration (1 week–9 years).

Authors’ Conclusions:Compression stockings (CS) support a higher rate of healing and are better tolerated than compression bandages (CB).

Clinical Perspective

References:

1. Arnold TE, Stanley JC, Fellows EP, et al. Prospective, multicenter study of managing lower extremity venous ulcers. Ann Vasc Surg. 1994;8(4):356–362.

2. Heyneman A, Beele H, Vanderwee K, Defloor T. A systematic review of the use of hydrocolloids in the treatment of pressure ulcers. J Clin Nurs. 2008;17(9):1164–1173.

3. Wyatt D, McGowan DN, Najarian MP. Comparison of a hydrocolloid dressing and silver sulfadiazine cream in the outpatient management of second-degree burns. J Trauma. 1990;30(7):857–865.

4. Nemeth AJ, Eaglstein WH, Taylor JR, Peerson LJ, Falanga V. Faster healing and less pain in skin biopsy sites treated with an occlusive dressing. Arch Dermatol. 1991;127(11):1679–1683.

5. Hermans MH. Hydrocolloid dressings versus tulle gauze in the treatment of abrasions in cyclists. Int J Sports Med. 1991;12(6):581–584.

6. Briggs M, Nelson EA. Topical agents or dressings for pain in venous leg ulcers. Cochrane Database Syst Rev. 2003;(1):CD001177.

7. World Health Organization Pain Ladder. Available at: http://www.who.int/cancer/palliative/painladder/en/. Accessed: July 1, 2010.

8. Martin JL, Koodie L, Krishnan AG, Charboneau R, Barke RA, Roy S. Chronic morphine administration delays wound healing by inhibiting immune cell recruitment to the wound site. Am J Pathol. 2010;176(2):786–799.

9. Association for the Advancement of Wound Care (AAWC). Summary algorithm for venous ulcer care with annotations of available evidence. Malvern, PA: Association for the Advancement of Wound Care. 2005; National Guideline Clearinghouse. Available at: www.guideline.gov. Accessed: July 7, 2010.

10. Nemeth KA, Harrison MB, Graham ID, Burke S. Understanding venous leg ulcer pain: results of a longitudinal study. Ostomy Wound Manage. 2004;50(1):34–46.

11. Guarnera G, Tinelli G, Abeni D, Di Pietro C, Sampogna F, Tabolli S. Pain and quality of life in patients with vascular leg ulcers: an Italian multicentre study. J Wound Care.

2007;16(8):347–351. 12. Romanelli, M. Objective measurement of venous ulcer debridement and granulation with a skin color reflectance analyzer. WOUNDS. 1997;9(4):122–126.