Alleviating Venous Ulcer Pain
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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).
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