Compression Therapy in Wound Healing

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Compression Therapy in Wound Healing

Postby professorbilby » Mon Sep 25, 2006 8:25 am

Compression Therapy in Wound Healing

By Michael A. Maier, DPM, CWS

Podiatry Online

The efficacy of compression therapy for venous stasis ulcers is widely accepted and clearly evidenced by the use of a variety of wraps, bandages and stockings. (1, 2) Patients often describe visits to wound clinics where Unna boot applications and weekly follow-up are nearly reflexive for all comers with leg ulcers. Although inappropriate in some cases, the relative success of this protocol is probably due to the well-known benefits of moist wound healing (3) and compression therapy. Edema control, however, also plays a critical role in healing a variety of wounds beyond the classic venous stasis ulcer. This article will focus on six basic principles of compression therapy podiatrists need to know in order to individualize treatment to specific patient needs and wound characteristics.

1. Identify the cause(s) of edema

The presence of edema alone is not an indication for compression therapy. There are many causes for lower extremity swelling, such as lymphedema, cellulitis, chronic venous insufficiency, deep venous thrombosis, lipedema and certain drugs. (4) A thorough history, physical exam and diagnostic tests help identify causes amenable to compression therapy, such as lymphedema. It is equally important to identify causes of edema for which compression is contraindicated, such as dependent edema in a limb arising from a patient's attempt to relieve ischemic rest pain.

2. Establish an accurate wound diagnosis

As with the causes of lower extremity edema, foot and leg ulcers have varied etiologies. Again, a complete history, clinical examination and diagnostics are critical. An example is the 64-year-old non-diabetic female who presented with a painful ulcer on the mid-calf, present for six months, which had been incorrectly diagnosed as a venous stasis ulcer.

This painful mid-calf ulcer was originally misdiagnosed and treated as a venous stasis ulcer. Biopsy confirmed a diagnosis of pyoderma gangrenosum.

Sequential Unna boot applications and a variety of topical treatments offered no improvement. Clinical features included a raised violaceous border with peripheral undermining. Biopsy confirmed a diagnosis of pyoderma gangrenosum. The patient was subsequently treated with intralesional steroids.

3. Assess calf muscle pump function

Both the venous circulation and lymphatics are low pressure systems. Since fluid return in the lower extremities is accomplished with the assistance of muscle contraction, inadequate muscle tone leads to foot and leg edema. The following case illustrates this point.

A 45-year-old male underwent an elective ankle fusion for post-traumatic arthritis. The arthrodesis healed but the lateral incision dehisced. He was treated with a variety of wound care products as well as multiple failed skin grafts over the course of one year. On physical exam, pedal pulses were normal and there was 3+ pitting edema in the lower leg and foot. Radiographs were normal.

Aggressive compression therapy was initiated with a three-layer compression wrap and local wound care. Peri-wound dermatitis was treated with a high-potency topical steroid. This protocol was continued with sequential compression wrap applications. Ultimately, the wound healed completely and he was advanced to below-knee compression stockings with 40-50mmHg.

4. Account for interstitial fluid excess

Physical examination often reveals no significant edema. However, interstitial edema can impair healing. Although the specific mechanism is unclear, Miller (5) suggested healing may be impaired by increased distance for diapedesis from capillary bed to cell, restricted ability to remove metabolites and cell debris, deposition of fibrin around the capillaries, and leukocyte obstruction of capillaries.

One could argue that interstitial edema exists in all wounds, and therefore compression therapy may be of almost universal benefit. There is some truth to this argument as evidenced by the many wound types that heal with compression therapy. For example, Armstrong and Nguyen [6] studied the effect of a pulsatile pneumatic foot compression system (from Kinetic Concepts, Inc., in San Antonio, Texas) on wound healing in 97 diabetic patients following surgical debridement of foot infections. Patients were randomized to functioning or placebo (non-functioning) devices. Researchers found a significantly higher proportion of healing in the active group and concluded that edema reduction may be a useful adjunct in wound healing after incision and drainage of infected diabetic foot ulcers.

5. Adjust compression therapy to accommodate concomitant peripheral arterial disease.

The presence of arterial disease alone is not a contraindication to compression therapy. Thorough assessment of perfusion is critical to all patients with lower extremity wounds and can be accomplished with a variety of modalities.(7,8) An example is the diabetic patient with a venous stasis ulcer on the left medial ankle, 3+ pitting edema in both lower legs, and delayed capillary refill in the digits. Pulse volume recordings are shown in the image below.

Pulse volume recordings for a diabetic patient with a venous stasis ulcer and severe small vessel arterial disease.

Below-knee compression stockings with 20-30mmHg were used in order to accommodate the severe small vessel disease. The wound slowly healed despite persistent 1- 2+ pitting edema.

Compression therapy based on the ABI alone, without assessment of distal perfusion, may have precipitated ischemic changes in the digits.

In general, titration of compression therapy in patients with arterial disease should account for wound location, skin friability, levels and severity of arterial disease, and amount of edema. Frequent and careful follow-up will permit adjustments to therapy and limit adverse outcomes.

6. Account for individual wound characteristics

Before deciding on compression therapy, be sure to consider the following:

Drainage/Depth of wound: Moderate to heavy drainage as well as deeper wounds merit more frequent dressing changes.

Possibility of infection: Wounds with clinical evidence of active infection should not be compressed. Suspected abcesses or deep space infections should be thoroughly incised and drained prior to initiation of any compression therapy.

Location of wound: Wound location alone does not preclude the use of compression therapy. For example, the plantar forefoot pressure ulcer may exhibit delayed healing in the absence of treatment for leg edema.

Thorough and frequent wound assessment will help dictate the parameters of compression therapy for each patient.

Compression therapy is a useful tool in the treatment of a variety of lower extremity wounds. These general guidelines will assist the clinician in identifying those wounds for which compression therapy is appropriate.

References

1. Trent JT, et al. “Venous ulcers: pathophysiology and treatment options.” Ostomy Wound Management. May 2005, Vol. 51(5), pages 38–54.

2. Felty CL and Rooke TW. “Compression therapy for chronic venous insufficiency.” Seminars in Vascular Surgery. March 2005, Vol. 18(1), pages 36-40.

3. Seaman S. “Dressing selection in chronic wound management.” Journal of the American Podiatric Medical Association. Jan 2002, Vol. 92(1), pages 24-33.

4. Young JR. “The swollen leg. Clinical significance and differential diagnosis.” Cardiology Clinics. Aug 1991, Vol. 9(3), pages 443-56.

5. Miller S. “Compression Therapy for Foot Wounds: Overview and Case Reports.” Wounds. Oct 2005, Vol. 17(10), pages 278-281.

6. Armstrong DG and Nguyen HC. “Improvement in healing with aggressive edema reduction after debridement of foot infection in persons with diabetes.” Archives of Surgery. Dec 2000, Vol. 135(12), pages 1405-1409.

7. Gahtan V. “The noninvasive vascular laboratory.” Surgical Clinics of North America. Aug 1998, Vol. 78(4), pages 507-18.

8. Abularrage CJ, et al. “Evaluation of the microcirculation in vascular disease.” Journal of Vascular Surgery. Sep 2005, Vol. 42(3), pages 574-581.

Part One

http://www.podiatryonline.com/main.cfm? ... omptherapy

Compression Therapy in Wound Healing – Part II

A wide variety of compression modalities are available to treat lower extremity edema with or without ulceration as well as to prevent recurrence of healed wounds. Rather than provide a comprehensive list, this article outlines broad categories with specific features to make selection an easier task. It is important to remember that compression therapy should be customized for each patient, regardless of wound etiology. Thorough perfusion assessment and identification of a latex allergy is critical before initiation of any compression regimen.

Basic compression modalities can be divided into three main categories:

elastic dressings;
multi-layer dressings; and
compression stockings.

Both elastic and multi-layer dressings are used more often in the setting of active lower extremity ulceration. Once healed, patients are usually advanced to various compression stockings for long-term, daily use. As with wound care products, certain compression garments and bandages can be combined for maximum efficacy depending on individual patient and wound characteristics.

Elastic Compression Bandages

Elastic compression bandages can be subdivided into three categories:

variable stretch;
measured stretch; and
short stretch.

An Ace® bandage is the most common example of a variable stretch bandage. There are differences between manufacturers, but in general these are readily accessible and easy to use. As with any compression wrap, the Ace may require frequent re-wrapping throughout the day. In general, the Ace bandage should be reserved for extremely short-term use in patients with only mild edema and non-complex, superficial wounds. Care needs to be taken to apply the wrap with consistent stretch and overlap to avoid complications such as a tourniquet effect and skin trauma.

Measured stretch bandages have indicator markings to help the person applying the wrap know when the desired compression strength is achieved. Examples of these include: Setopress® and SurePress™ bandages (from ConvaTec). Both of these have rectangles along the entire length of the wrap. With consistent stretch, the rectangles become squares, indicating 30-40mmHg compression strength. The primary difference between the two wraps is the material. The Setopress wrap is made of very soft, pliable material and is a good choice for patients with friable skin. The SurePress wrap is a much heavier material and should be considered for patients with moderate to severe edema and indurated skin. Both can be used over a primary layer of cotton batting to protect the skin.

ConvaTec's Tubigrip® is another measured stretch compression bandage. These are long rolls of elastic stockinette that come in various sizes. Patients are sized according to their ankle and calf circumferences and desired level of compression. As with the compression wraps, these are not intended for long-term daily use or as the sole means of compression in patients with moderate to severe edema.

Short stretch bandage examples include Jobst's Comprilan® and Hartmann-Conco's LoPress®. In contrast to the measured stretch bandages, these are less elastic and have better memory. Short stretch bandages are often used with layered cotton batting or foam in the treatment of lymphedema, recalcitrant edema or resistant, indurated skin changes due to their relative durability and strength.

Multi-Layer Compression Wraps

Multi-layer compression wraps are available in two-, three- and four-layer versions. The most widely recognized two-layer wrap is the Unna boot. Multiple versions of this wrap are made by different companies: Unna-Flex™ (ConvaTec), Tenderwrap® Unna Boot (Kendall) and Gelocast® Unna Boot (Beiersdorf). The primary layer is an elastic bandage impregnated with non-hardening zinc oxide paste or calamine. This is covered by an outer self-adherent bandage. Although somewhat messy to apply, this modality is effective for moderate dermatitis and facilitates moist wound healing.

Various dry multi-layer compression wraps are also available, such as two-layered ProGuide™ (Smith & Nephew), three-layered Dyna-Flex® (Johnson & Johnson) and four-layered Profore™ (Smith & Nephew). These consist of a contact layer(s), elastic layer and, in the case of the latter two, an outer self-adherent bandage. A primary dressing is applied to ulcers prior to wrap application.

Multi-layer wraps are particularly useful in the acute phase of wound healing as well as for initial edema reduction. Once leg swelling is controlled, as evidenced by visible skinfolds on dressing removal, patients can be advanced to compression stockings. Multi-layer wraps can be continued for patients who do not consistently wear recommended compression stockings or for those who require compression 24 hours a day. Frequency of dressing change should be individualized based on wound drainage characteristics, clinical signs of infection, and ulcer depth and extent.

Compression Stockings

Compression garments are available in a wide variety of styles, sizes and compression strengths. TED® hose (Kendall-Futuro Co.) are perhaps the most widely used compression garments, particularly in inpatient settings. These are available in both knee-high and thigh-high lengths and both open and closed toe designs. Often referred to as an “anti-embolism stocking,” this garment applies a gradient compression, greatest at the ankle and gradually decreasing proximally.

Compression stockings designed for long-term daily wear are categorized according to the style (i.e. knee-high, thigh-high and pantyhose), compression strength and specific features such as open vs. closed toe and material weight. Garments should be selected according to the distribution and amount of edema, skin quality and severity of any concomitant arterial disease. Compression strength varies by manufacturer, but in general, can be divided into the following:

8-15mmHg
15-20mmHg
20-30mmHg
30-40mmHg
40-50mmHg (Contraindicated in patients with any peripheral arterial disease).

number of assist items can be used with compression stockings. Easy Slides® (Jobst) are useful for patients with poor hand strength or difficulty in reaching their toes.

Stocking liners are lightweight garments that provide little compression but can be used under a compression stocking to hold wound dressings in place. Lastly, stasis pads can be used to augment compression for ulcers located in “anatomic valleys,” such as between the medial malleolus and calcaneus

Basic compression therapy is a useful, effective tool for podiatrists and clinicians who treat lower extremity wounds. In cases of severe recalcitrant edema or chronic lymphedema, referral to specialized clinics may be needed. These clinics employ advanced modalities including various pumps and pneumatic compression sleeves. In the most difficult cases, treatment may include manual lymphatic drainage (MLD), in which a trained therapist assists fluid drainage with various manual massage techniques.

Part Two

http://www.podiatryonline.com/main.cfm? ... mptherapy2

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