September 2014

Compression stockings: Progress and pitfalls

9vascularResearch supports the use of compression stockings for managing peripheral edema, venous insufficiency, and venous leg ulcers. But, outside the laboratory, issues related to patient compliance and achieving a proper stocking fit remain significant clinical challenges.

By Greg Gargiulo

Compression is a specialized type of therapy that works by applying graduated pressure to the leg that is highest at the ankle and decreases as it reaches the knee. In effect, compression therapy improves venous return and pump function, reduces venous reflux, accelerates venous flow and redistributes blood to the central section of the body.1,2

The use of compression therapy dates back as far as the age of Hippocrates in the 5th century BCE, when its primary use was for the treatment of leg ulcers and venous disorders.3 Today, compression therapy is a component of treatment for numerous phlebological disorders. It can be used either individually or in conjunction with other therapeutic strategies, and is particularly effective for patients with venous insufficiency, including some who also have diabetes, who develop venous leg ulcers (VLUs) or edema.4-9

LER-RG-Products-ad-compression-socks

There are a number of methods for applying external graduated compression, but the devices used most commonly are graduated compression stockings and short extension bandages.8,10

Patients may be either custom-fitted or prescribed off-the-shelf compression garments, which are available in a wide range of pressures, from mild (< 15 mm Hg) to high (> 40 mm Hg) at the ankle.9,11-13 But this variety of available options also means that one of the most important issues for clinicians who outfit patients with compression garments is sizing.14

Sizing can be a time-consuming, cost-ineffective, and generally stressful process for medical professionals and, when patients are not fitted into compression garments properly, it can lead to pain and negatively affect compliance.14,15 Appropriate use of compression therapy is necessary for patients with venous insufficiency-related conditions to improve, and not wearing garments as prescribed has been associated with a higher likelihood of VLU recurrence.16 Practitioners must therefore assure compression stockings fit properly and address other issues that affect patient compliance to maximize the devices’ clinical benefit.17

“If people wear them, they’ll have success with them, but they have to want to wear them,” said Dean Mason, OST, CPed, treasurer of the Pedorthic Footcare Association and owner of North Shore Pedorthics and Orthotics in Lorain, OH. “There are a lot of people who just don’t want to deal with the trouble because it’s too much, but in the long run, they are the only ones that lose out.”

Venous leg ulcers

An estimated 5% to 8% of the world’s population suffers from chronic venous disease, and 1% to 2% go on to develop VLUs.18 This percentage grows to about 3% to 5% of the global population older than 65 years and, in the US, approximately 500,000 to one million people suffer from chronic VLUs.8

Compression therapy is considered the gold standard for treating VLUs and has been found to minimize or reverse the associated vascular changes by forcing fluid from the interstitial spaces back into the vascular and lymphatic compartments.11 Single or multicomponent compression bandages applied by a trained medical professional and changed by them once or twice a week are typically recommended as initial treatment for VLUs.19

A number of studies support the use of compression therapy for treating initial VLUs,6,8 and healing rates as high as 97% can be achieved in patients who are compliant.20

Ashby et al found that a four-layer bandage and two-layer compression stockings were equally effective for healing VLUs.6 Dolibog et al compared five different types of compression therapy for VLUs and concluded that compression stockings and multilayer bandaging were just as effective as an intermittent pneumatic compression system for healing at two months, while Unna boots and short stretch bandages were significantly less effective.8

Preventing recurrence

Perhaps even more important than healing VLUs, though, is preventing recurrence. In patients with persistent hypertension, ongoing compression therapy can help reduce VLU recurrence rates, which can be as high as 70%.21

Fashionable alternatives for medical compression, providing up to 30-40 mm Hg of compression, can help improve patient compliance. (Photo courtesy of medi USA)

Fashionable alternatives for medical compression, providing up to 30-40 mm Hg of compression, can help improve patient compliance. (Photo courtesy of medi USA)

“The idea is, once you get somebody healed after a VLU, you don’t want to just send them home,” said Mary Shannon, DNP, CRNP, owner of Shannon Wound Care Consultants in Chicora, PA. “You want to prevent a recurrence, so we’ll try to get them in some type of compression before leaving. Everybody wins with some sort of compression.”

Once a VLU has “healed”—though this term is used loosely due to the high likelihood of future issues—practitioners typically change the type of compression therapy they used during the healing process to one that places more responsibility in the hands of patients.6,7,17

“The fact is that keeping something healed does not require the same degree of strength of compression as healing something,” said David Armstrong, DPM, MD, PhD, director of the Southern Arizona Limb Salvage Alliance and professor of surgery at University of Arizona in Tucson. “So a multilayer bandage is our favorite approach for treating VLUs, but once the wound has healed, we’ll usually favor class III [30-40 mm Hg] compression stockings.”

Compression stockings, which are intended to be worn all day, every day, are regarded as the most appropriate treatment to prevent recurrence, experts say, and support for their effectiveness is well documented.16,22

Kapp et al17 found that two types of compression stockings (moderate compression of 23-32 mm Hg at the ankle, and high compression of 34-46 mm Hg at the ankle) reduced VLU recurrence compared with previously reported rates. The risk of recurrence at 26 weeks was three times higher for the moderate compression group than for those applying high-compression stockings. The researchers also pointed out that patient compliance was a strong indicator of effectiveness and should be a primary focus of management strategies.

“I think we need more evidence on the effectiveness of compression stockings for ulcer healing,” said Suzanne Kapp, BN, a research fellow at the Royal District Nursing Service Institute in Victoria, Australia. “Stockings are mainly used for preventing recurrence, but they can also be applied instead of bandages as an initial treatment for ulcers, and that could be a new strategy for approaching these conditions.”

Levels of compression

Fashionable alternatives for medical compression, providing up to 30-40 mm Hg of compression, can help improve patient compliance. (Photo courtesy of Sigvaris USA)

Fashionable alternatives for medical compression, providing up to 30-40 mm Hg of compression, can help improve patient compliance. (Photo courtesy of Sigvaris USA)

Another major use of compression stockings is for treating peripheral edema, which is a common clinical finding and is especially prevalent in patients with diabetes.9 Patients with diabetes, however, must receive additional care since they have a two to five times greater risk for developing peripheral arterial disease (PAD) than people with normal glucose levels.23 For this reason, standard compression therapy of moderate or high pressures is risky, as it may compromise arterial circulation in those with PAD and reduce both compliance and effectiveness.9 As a result, milder levels of compression are often recommended instead.

According to Mason, “The normal standards for edema are going to be much lower, around eight to fifteen millimeters of mercury, which are very lightweight and just enough to keep the fluid from collecting in the extremities.”

In one study,9 compression stockings with a slightly higher level of compression than that mentioned by Mason (18-25 mm Hg) were given to diabetic patients with edema and a mean ankle brachial index of 1.10 for four weeks to determine if this pressure level would have any negative effects. The stockings significantly reduced swelling in the calf and foot, and patients did not experience any adverse events, suggesting the stockings were safe and did not compromise vascularity.

Although mild compression therapy appears to be generally accepted as a safe and effective approach for patients with edema and diabetes, there is less agreement about the precise level of pressure needed for managing VLUs.24

Compression stockings are available in the following classes: over-the-counter (< 15 mm Hg), class I (15-20 mm Hg), class II (20-30 mm Hg), class III (30-40 mm Hg), or class IV (> 40 mm Hg). According to a 2014 UpToDate article on the management of lower extremity chronic venous disease, a stocking that is at least a class II should be prescribed to be effective for treating VLUs.13 For patients with more severe signs and symptoms that don’t improve, however, some recommend a higher-grade class III stocking as the next course of action.13

For women, fashionable medical compression options include full-length pantyhose in addition to calf-high or thigh-high stockings; all lengths can provide up to 30-40 mm Hg of compression. (Photo courtesy of medi USA)

For women, fashionable medical compression options include full-length pantyhose in addition to calf-high or thigh-high stockings; all lengths can provide up to 30-40 mm Hg of compression. (Photo courtesy of medi USA)

“This range is considered to be effective and acceptable by the patients,” said Jerzy Chudek, MD, PhD, professor in the department of pathophysiology at the Medical University of Silesia in Katowice, Poland. “The effectiveness increases with the pressure, but stockings become more cumbersome for dressing.”

But some clinicians tend to avoid higher pressures due to potential compliance issues.

“We as a general rule do not prescribe higher than twenty to thirty millimeters of mercury, mainly because the [stockings with] higher pressures are so hard to put on, patients end up not using them at all,” Shannon said. “So even though patients might need higher compression, it’s better to have some compression than none.”

In clinical practice, the level of pressure prescribed is determined based on various factors, including the severity of the wound and the height and limb size of the patient.7

The variety of available compression therapy garments can complicate clinical decisions even further. Compression bandages and stockings may be either single- or multilayered, have elastic or inelastic components or both, and come in a variety of lengths. As noted, bandages are typically used for healing and stockings for preventing recurrence; the research suggests that multicomponent systems containing elastics are most effective, and knee-high stockings appear to be a length generally well tolerated by and sufficient for most patients.13,24

Off-the-shelf compression stockings offer a cost-conscious alternative to customized compression stockings.

“Almost everybody uses premade compression stockings for a real simple reason: cost,” said Mason, who noted that, though prices for off-the-shelf stockings range from about $6 to up to $70 for knee-high versions and up to $100 for full-length stockings, custom stocking prices begin at $150 and run up to $600.

The cost of compression therapy, even with premade stockings, has been identified as one of several reasons patients discontinue use despite having received strict instructions to wear them indefinitely.10

“The posthealing phase—which is when compression stockings are recommended—often requires a lifelong commitment to a treatment that can be hard to get on and off, is often managed by the person alone, and is expensive, since stockings should be replaced every three to six months,” Kapp said. “Often life intervenes and the person’s legs may not be a priority, as many older people have other chronic conditions to manage.”

Compliance

For women, fashionable medical compression options include full-length pantyhose in addition to calf-high or thigh-high stockings; all lengths can provide up to 30-40 mm Hg of compression. (Photo courtesy of Sigvaris USA.)

For women, fashionable medical compression options include full-length pantyhose in addition to calf-high or thigh-high stockings; all lengths can provide up to 30-40 mm Hg of compression. (Photo courtesy of Sigvaris USA.)

Patient compliance is a major obstacle, as reported rates of adherence to daily use vary from 33% to 52%.18 In addition to cost, other factors that influence compliance include older age, being overweight, lack of motivation, duration of treatment, and patient acceptance, which is often based on appearance, comfort, and difficulty donning and doffing.25

Reich-Schupke et al evaluated the role of age and weight in compression therapy and found that patients either older than 60 years or with a body mass index (BMI) greater than 25 kg/m2 had more VLUs and greater difficulty donning and doffing compression garments than patients who were younger or had lower BMIs.25

Shannon et al found that 73% of patients claimed to wear their stockings every day—which researchers believe may be unreliable—but results further highlighted trouble with putting stockings on and removing them as the leading reasons for noncompliance.18

“Patients often hate them,” Armstrong said. “It’s hard to put these things on if you’re svelte, but for someone who’s older or larger, it’s incredibly more difficult. But the good news is there are some strategies, like application aids or donning aids, which have been found to be somewhat helpful.”

Another major component of adherence requiring a great deal of attention is sizing. As previously reported in LER (see “Compression stockings: One size definitely does not fit all,”), one of the best ways to ensure compliance is to ensure that a stocking has been properly fitted.

This does not always happen. Nørregaard et al11 evaluated the fit of three brands of off-the-shelf compression stockings using two standardized measuring methods and found that, at best, 54% patients achieved adequate fit (assessed using the three-point measuring method) with one brand of stocking. Other brands performed even more poorly, particularly when the fit was assessed at seven points on the limb, and one brand could not be fit properly on any patients.

The researchers called for major improvements in the sizing approach and fitting recommendations for stockings to ensure they are having the intended effects.

In a 2010 review of compression sizing in Plastic Surgical Nursing, the author, a compression garment manufacturer, suggested compression stockings be made with a balance between functionality and comfort as the primary focus, and that both design and fabric—with elastic fabrics being a necessity—be addressed in this process. In addition, he emphasized the need for careful measurements when outfitting patients with compression garments, and that sizing tools should continue to be developed to promote a standardized measuring system for the compression garment industry.14

Patient education

In addition to improving sizing issues, experts say a focused effort is needed to both educate patients about the importance of wearing compression stockings daily and to address limitations that may prevent them from using the devices—especially for the elderly and overweight—by implementing assistive strategies and encouraging weight management.18,26

“I think the key is to get people to believe and understand that compression therapy is effective and useful, and the big conundrum is to get people to care about something that they have to do every single day, and to get them to put something around their body that’s a pain in the neck,” Armstrong said.

Patients also need to be aware that, according to Shannon, “This is not a condition that can be fixed. It can be managed. It won’t go away, and you usually have to wear your compression stockings for life.”

Future clinical trials that evaluate optimal pressures, types of devices, and new sizing strategies in greater detail will also help refine guidelines and better ensure patients are receiving the most appropriate compression therapy to regulate their condition and keep symptoms at bay.8,11,17,27

Greg Gargiulo is a freelance medical writer based in the San Francisco Bay Area.

REFERENCES
  1. Moffatt C. Compression Therapy in Practice. Wounds UK Books; Aberdeen, Scotland; 2007.
  2. Royal College of Nursing. The Nursing Management of Venous Leg Ulcers. London, UK; Royal College of Nursing; 2006.
  3. Gladfelter J. Compression garments 101. Plast Surg Nurs 2007;27(2):73-77.
  4. Partsch H. Varicose veins and chronic venous insufficiency. Vasa 2009;38(4):293-301.
  5. Partsch H, Pluor M, Colderidge Smith P, et al. Indications for compression therapy in venous and lymphatic disease. Consensus based on experimental data and scientific evidence under the auspices of the IUP. Int Angiol 2008;27(3):193-219.
  6. Ashby RL, Gabe R, Ali S, et al. Clinical and cost-effectiveness of compression hosiery versus compression bandages in treatment of venous leg ulcers (Venous leg Ulcer Study IV, VenUS IV): a randomized controlled trial. Lancet 2014;383(9920):871-879.
  7. Guest JF, Charles H, Cutting KF. Is it time to re-appraise the role of compression in non-healing venous leg ulcers? J Wound Care 2013;22(9):453-460.
  8. Dolibog P, Franek A, Taradaj J, et al. A comparative clinical study on five types of compression therapy in patients with venous leg ulcers. Int J Med Sci 2013;11(1):34-43.
  9. Wu SC, Crews RT, Najafi B, et al. Safety and efficacy of mild compression (18-25 mm Hg) therapy in patients with diabetes and lower extremity edema. J Diabetes Sci Technol 2012;6(3):641-647.
  10. Ziaja D, Kocelak P, Chudek J, Ziaja K. Compliance with compression stockings in patients with chronic venous disorders. Phlebology 2011;26(8):353-360.
  11. Nørregaard S, Bermark S, Gottrup F. Do ready-made compression stockings fit the anatomy of the venous leg ulcer patient? J Wound Care 2014;23(3):128-135.
  12. Stemmer R, Marescaux J, Furderer C. Compression treatment of the lower extremities particularly with compression stockings. Hautarzt 1980;31(7):355-365.
  13. Alguire PC, Mathes B. Medical management of lower extremity chronic venous disease. UpToDate website. http://www.uptodate.com/contents/medical-management-of-lower-extremity-chronic-venous-disease. Updated August 18, 2014. Accessed August 28, 2014.
  14. Watkins WB. Compression garment sizing: challenges, issues and a solution. Plast Surg Nurs 2010;30(2):85-87.
  15. Moffat C, Kommala D, Dourdin N, Choe Y. Venous leg ulcers: patient concordance with compression therapy and its impact on healing and prevention of recurrence. Int Wound J 2009;6(5):386-393.
  16. Nelson EA, Bell-Syer SE. Compression for preventing recurrence of venous leg ulcers. Cochrane Database Syst Rev 2012;8:CD002303.
  17. Kapp S, Miller C, Donohue L. The clinical effectiveness of two compression stocking treatments on venous leg ulcer recurrence: a randomized controlled trial. Int J Low Extrem Wounds 2013;12(3):189-198.
  18. Shannon MM, Hawk J, Navaroli L, Serena T. Factors affecting patient adherence to recommended measures for prevention of recurrent venous ulcers. J Wound Ostomy Continence Nurs 2013;40(3):268-274.
  19. Keller A, Müller ML, Calow T, et al. Bandage pressure measurement and training: simple interventions to improve efficacy in compression bandaging. Int Wound J 2009;6(5):324-330.
  20. Mayberry JC, Moneta GL, Taylor LM Jr, Porter JM. Fifteen-year results of ambulatory compression therapy for chronic venous ulcers. Surgery 1991;109(5):575-581.
  21. McDaniel HB, Marston WA, Farber MA, et al. Recurrence of chronic venous ulcers on the basis of clinical, etiologic, anatomic, and pathophysiologic criteria and air plethysmography. J Vasc Surg 2002;35(4):723-728.
  22. Nelson EA, Harper DR, Prescott RJ, et al. Prevention of recurrence of venous ulceration: randomized controlled trial of class 2 and class 3 elastic compression. J Vasc Surg 2006;44(4):803-808.
  23. Jude EB, Oyibo SO, Chalmers N, Boulton AJ. Peripheral arterial disease in diabetic and nondiabetic patients: a comparison of severity and outcome. Diabetes Care 2001;24(8):1433-1437.
  24. O’Meara S, Cullum N, Nelson EA, Dumville JC. Compression for venous leg ulcers. Cochrane Database Syst Rev 2012;11:CD000265.
  25. Jull AB, Mitchell N, Arroll J, et al. Factors influencing concordance with compression stockings after venous leg ulcer healing. J Wound Care 2004;13(3):90-92.
  26. Reich-Schupke S, Murmann F, Altmeyer P, Stücker M. Compression therapy in elderly and overweight patients. Vasa 2012;41(2):125-131.
  27. Zarchi K, Jemec GB. Delivery of compression therapy for venous leg ulcers. JAMA Dermatol 2014;150(7):730-736.
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