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AC TA V U LNO L 2009;7

Compression therapyin the treatment of leg ulcers

G . M O STI, V. M ATTALIAN O , R. PO LIG N AN O , M . M ASIN A*

*M em bers of the A IU C Com pression Study G roup w ho agreed w ith the consensus statem ent: G iuseppe N ebbioso, Sim oneSerantoni, Fabrizio M ariani, Enzo G iraldi, G iacom o Failla, Paolo Tanasi, Sergio Bruni, G iorgio G uarnera, Battistino Paggi, M arisadi Vincenzo, Riccardo C onte, Paolo Palum bo, G iovanni Farina, Aldo Crespi, Anna Lom bardi, Cinzia Lunghi, Lucia M arigo, AdrianaVison, M assim o M antero.

Vol. 7, N o. 3 ACTA V U LN O LO G ICA 1

Preface

The group of experts who developed this consensus document has to be congra-tulated for delivering clear and updated guidelines on the management of leg ulcersby compression.A classification of compression devices is proposed that is based more on the

performance in vivo than on laboratory data from the producers alone. This has beco-me possible by the introduction of devices measuring the sub-bandage pressure onthe individual leg, which is the dosage of compression therapy. Pressure measure-ment has improved our understanding of compression management and is also

very useful for training purposes. Since most of the bandages performed in daily prac-tice consist of mixture of several types of materials, all with different elastic properties,

the physical data alone given for the individual components are insufficient todescribe the performance of the final bandage.The complex effects of compression are explained as a logic basis for the clinical

indications that do not only concentrate on venous ulcers but also include compli-cated situations like arterial and mixed ulcers and lymphatic involvement.

In the last part of the document cost-effectiveness of compression treatment isdiscussed. We are living in an era in which sometimes easy and modern local

wound care is suggested to be able to replace cumbersome and old-fashionedcompression treatment. There is no doubt that compression is the essential part ofulcer therapy which cannot be replaced, but only supplemented by local dressings.

After the ulcer is healed ongoing compression is mandatory in order to preventulcer recurrence. The costs for the compression stockings needed in this phase arecertainly lower than the treatment costs of a new ulcer.

I hope and wish that this AIUC consensus will not only support the daily work ofthe Italian wound healing group but will also help and convince those who have totake care of leg ulcer patients outside the specialists community every day.

H ugo Partsch, M .D .Professor of D erm atology and Angiology.M edical U niversity of Vienna M ay 2009


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M O STI CO M PRESSIO N TH ERAPY IN TH E TREATM EN T O F LEG U LCERS

Introduction

T he effectiveness of com pression therapyin the treatm ent of leg ulcers is w ellknow n since ancient tim es1. Currently, thanksto m any studies assessing its therapeutic effi-cacy 2, com pression therapy has been granteda level A recom m endation 3,4. Com pressionhas proven useful in m any types of leg ulcers

and is a key-treatm ent in phlebo-lym phaticdiseases. N evertheless, even today, the ter-m inology used is not clear and a there is acom plete lack of agreem ent on classification.The follow ing proposal for a term inology

and classification could be a useful tool toestablish a com m on vocabulary and a betterm utual understanding.

Definition

Elastic compression:w e suggest to discard

this term and to adopt the internationallyrecognized term Com pression therapy.Com pression therapy can be applied w ithelastic and inelastic m aterials: the term elasticcom pression can raise the im pression thatonly elastic m aterials are used in this treat-m ent and this could be m isleading.Elasticity:the capacity of the bandage to

return to its original form after being stret-ched; it is due to the addition of elasticthreads inserted lengthw ise in the bandage.Based on their elasticity, the bandages aredivided into elastic and non-elastic.Elasti c power:determ ined by the strength

required to obtain a specific extension. Pow er

determ ines the am ount of pressure a banda-ge w ill produce at a fixed extension.Tension:initially produced by the force

used to stretch the bandage; once the ban-dage is applied, ten sion m aintainabilitydepends on the elastom eric properties(H ysteresis curve of extension and retrac-tion) of the m aterial used, w hich in turndepends on the type of fiber and fabrication.Extensibility:the extension capacity of the

bandage w hen stretched. It is determ ined bym easuring the extension of the bandagew hen a w eight of 10 N ew ton (N ) per cm isapplied.The extensibility is m easured in the labo-

ratory and expressed as a percentage of thelength at rest and is currently the only cha-racteristic provided by bandage m anufactu-rers. This has no clinical significance unlessthe grade of elasticity and strength of thebandage is indicated at the sam e tim e. Infact, forces of very different intensity m ustbe applied 5 to different bandages to reach asim ilar extension. Based on the their exten-sibility bandages are divided into: stretchable(short, m edium and long stretch) and unstret-chable.Lock-out:defines the point w hen the phy-

sical structure of the bandage prevents furtherlengthening after a fixed extension has beenreached. For exam ple short stretch banda-ges (extensibility 40-70% ) should reach am axim um extension of 70 % w hile a longstretch bandage could exceed 140% .Hysteresis:indicates the capacity of the ela-

stic m aterial to return to its original state afterbeing stretched and is correlated to its exten-sibility, the visco-elastic properties of thefabric and the friction betw een the variousspires6.This principle is represented in the Load-

Extension curveof an elastic fabric: the trac-tion applied m akes the bandage longer inthe resting position than its initial lengthbecause the deform ation has been causedby the absorption of energy that is not retur-ned (Fig. 1). This indicates the loss of elasti-

2 A CTA VU LN O LO G ICA Septem ber 2009

Introduction

N.B. extensibility and elasticity are m istakenlyconsidered synonym s but they arecom pletely different:*extensibility is the capacity of the bandage tostretch w hen pulled

*elasticity is the capacity of the bandage to returnto its original state after being stretched


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CO M PRESSIO N TH ERAPY IN TH E TREATM EN T O F LEG U LCERS M O STI

Thom as)8,9: the applied pressure w ill be direc-tly proportional to the tension (T) of the ela-stic m aterial and the num ber (n) of spiresapplied, w hile it w ill be inversely proportio-nal to the radius (r) of the com pressed surfaceand the w idth (h) of the bandage.According to the Laplace law , applying a

bandage w ith the sam e tension, the pressu-

re w ill decrease w hen the radius of the lim bincreases. Therefore, w ithout changing theapplied tension, w e have a decreased pres-sure from the bottom tow ards the top dueto the reverse conical conform ation of theleg. Based on the radius of the anatom icalstructure w e m ust be aw are that the pressu-re exerted by the bandage is extrem ely strongon the A chilles tendon and on the tibial cre-st (very sm all radius) w hile it w ill be less atthe back of the calves (w ide radius) and nega-


city of a bandage betw een extension andretraction. Presum ably hysteresis influencesthe stability of the bandage and the m aintai-nability of pressure over tim e but there is nosolid data to confirm this claim .In ter face pressure:the pressure exerted by

the bandage that is m easured in the interfa-ce betw een bandage and skin. This m easu-

rem ent can be now adays easily perform edw ith sim ple and low -cost devices recentlyput in the m arket7.The pressure exerted by the bandage

depends on the fabric, the elastom eric cha-racteristics of the bandage, on the tensionapplied, the num ber of overlapped layersand the anatom ical characteristics (size andshape) of the lim b being bandaged. Thequantity of the interaction of these events isexpressed by the Laplace Law (review ed by

Figure 1. Load-extension curves of different m aterials.


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tive at retrom alleolar space. Therefore, it is

advisable to increase the radius in all thoseareas w ith a sm all radius and a high risk oftoo strong pressure, by protecting the acuteangle w ith padding m aterial (cotton, viscoseor foam ).O n the other hand, the radius of the sur-

face to be bandaged m ust be reduced byapplying supplem entary pads to increasethe pressure in all those anatom ic areas w he-re a low pressure w ould be applied becau-se of the anatom ical shape (a convex areaw ith a w ide radius, a flat surface or even aconcavity).

The pressure exerted by the bandage variesdepending on the conditions (static or inm otion): therefore, w e w ill refer to supinepressure, standing pressureand w orkingpressure10. Their m easurem ent in vivo andthe stiffness calculation w ere recom m endedand som e rules for a correct m easurem entgiven 11.Resting (or supine) pr essure: the pressure

applied at rest depends, as previously m en-tioned, on the tension given to the banda-ge, overlapping layers, radius of the leg andw idth of the bandage. The resting pressure isa static pressure and is m easured on the legin the supine position.Standing and worki ng pressur e: it is the

pressure exerted by the bandage w hen thepatient stands or w alks respectively. It resultsfrom the resistance the bandage opposes tothe expansion of the contracting m uscle andis directly proportional to the stiffness of thebandage: the greater stiffness of the bandage,the higher the standing and w orking pres-sure.


Standing pressure is alw ays m easured in

the standing position in the im m obile patientand is a static pressure, w hile w orking pres-sure is m easured during m ovem ent.Stiffness: the ability of the bandage to oppo-

se to m uscle expansion w hen contracted; itdepends on w hat type of m aterial the ban-dage is m ade of. W hen inelastic, the banda-ge is less distensible and has greater stiff-ness. The capacity to oppose to m uscularvolum e increase w hen standing and w alkingcan generate peaks of high pressure (60-80m m H g) able to occlude the venous systeminterm ittently and therefore, restore a sort of

valvular function. This in turn, reduces thereflux and the am bulatory venous hyperten-sion 12.The European Com m ittee for Standardi-

zation (CEN )13 defines the stiffness as theincrease of bandage pressure w hen the cir-cum ference of the lim b increases by 1 cm :standing pressure supine pressure/actualincrease in calf volum e. The stiffness of thebandage calculated in accordance w ith theCEN definition calls for the sim ultaneousm easurem ent of the interface pressure andvolum etric variations of the lim b w hich can

be done by using a plethysm ographic straingauge. The calculated stiffness index show edan extrem ely high specificity and sensitivityin distinguishing elastic and non-elastic ban-dages14. The disadvantage of this m ethod isthat it requires com plex equipm ent, not avai-lable in all phlebological laboratories, and istim e consum ing.For sim plification it w as suggested to

neglect the actual increase of the circum fe-rence by standing up and to define the StaticStiffness Index 15,16 by the difference betw eenstanding and sup ine pressure m easured at

the leg segm ent show ing a m axim al increa-se of leg perim eter, w hich is usually situated10-12 cm above the ankle (B1 region).W hen com pared to the stiffness index cal-

culated according to the C EN recom m enda-tions, the Static Stiffness Index has dem on-

Laplace law P = Tn/rhP = pressure exerted on the skinT = tension applied to the bandagen = num ber of spires appliedr = radius of com pressed areah = bandage w idth

Stiffness Index (CEN) Static Stiffness Index (H . Partsch)

standi ng pressu re-supi ne pressu re stand ing pressu re-supi ne pressu re

V calf diam eter (standing supine) 1


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3. Partsch H et al. Evidence B ased C om pression Therapy.

Vasa 2004; 34: suppl. 63 Partsch H . D o w e still needcom pression bandages? H aem odynam ic effects of com -pression stockings and bandages. Phlebology 2006;21:132-138.

4. Vin F. International consensus conference on com -pression. Phlebologie 2003;56:31567

5. Thom as S. Bandage and bandaging. The science behindthe art. Care Science and Practice 1990;8(2): 57-60.

6. W U W H S. Com pression bandaging: com pression invenous leg ulcers. A consensus docum ent. London;M EP Ltd 2008. Pag.2

7. M osti G ., Rossari S. L'im portanza della m isurazionedella pressione sottobendaggio e presentazione di unnuovo strum ento di m isura. Acta Vulnol 2008; 6: 31-36.

8. Thom as S. The use of the Laplace equation in the cal-culation of sub-bandage pressure. W orld W ide W ounds2002 (updated 2003).

9. Stem m er R. Teoria e pratica del trattam ento elasto-

com pressivo. Chirurgia vascolare P. Belardi vol. II cap.48 pag.575-593 Ed. M inerva M edica10. H aid H ., Schoop W .: Eine neue M ethode zur M essung

und Registrierung des Andruckes unter Kom pression-sverbanden. M ed. W elt 1965;37:21103.

11. Partsch H , Clark M , Bassez S et al. M easurem ent oflow er leg com pression in vivo: recom m endations forthe perform ance of m easurem ents of interface pressureand stiffness. D erm Surg 2006;32:224-233.

12. Bassi G l., Stem m er R.: Traitem ents m caniques fonc-tionnels en phlbologie. Piccin, Padova, 1983.

13. European C om m ittee for Standardization (CEN ). N on-active M edical D evices. W orking G roup 2 EN V 12718:European Pre-standard 'M edical Com pression H osiery.'CEN TC 205. Brussels: CEN , 2001.

14. M osti G B, M attaliano V.: Sim ultaneous changes of legcircum ference and interface pressure under differentcom pression bandages. EJVES 33:476-482;2007.

15. Partsch H . The use of pressure change on standing asa surrogate m easure of the stiffness of a com pressionbandage. Eur. J. Vasc. Endovasc. Surg. 2005; 30: 415-421

16. Partsch H . The static stiffness index: a sim ple m ethodto assess the elastic property of com pression m aterialin vivo. D erm atol. Surg.2005; 31 625-30

17. Partsch H ., Clark M ., M osti G . et al. Classification ofcom pression bandages: practical aspects. D erm . Surg.2008; 34(5); 600-9.

18. EW M A focus docum ent: LYM PH O ED EM A bandagingin practice. M edical Education Partnership Ltd; 2005.


strated the sam e sensitivity and a very sligh-

tly low er specificity 14: for all these reasonsits use is highly recom m ended.High (strong) or Low (mil d) pr essur e: w e

suggest to disregard non-specific term s andalw ays to refer to clear pressure ranges (seeClassification section); speaking about m ild,m oderate, strong or very strong pressure w em ust know and agree on the pressure rangew e refer to.Elastic bandage: m aterial w ith a m axim al

extensibility of >100% can be called elastic,or long stretch.In elastic ban dage: m aterial w ith a m axi-

m al extensibility of


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At present an international or European con-sensus for bandage classification doesnt exists.Bandages are com m only classified based on: extensibility elasticity m aterial function (fixing, com pression)

Classification of bandages based ontheir extensibility

The bandage m aterials can be distinguishedin: inextensible (zinc oxide bandage, Circ-

Aid) short stretch (extensibility 70%

140% ).

Classification of bandages based ontheir elasticity

Elastic bandage(usually w ith long stretchas w ell) exerts its pressure w hen stretched. O none hand the elastic bandage tends to returnto its original length w hen extended (squeezingeffect) on the other the bandage gives w ay tothe m uscle expansion. G iven these characte-ristics, the difference betw een resting and stan-ding pressure is very low (SSI1 low er than 10)as w ell as the systo-diastolic difference duringw alking. The bandage m ay exert a sustainedpressure not w ell tolerated or unbearable espe-cially at rest.

In elastic bandage: (w ith short stretch orinextensible m aterial) exerts its effect by resi-sting the increase of m uscle volum e duringstanding and w alking; it produces a significantincrease in the standing and w orking pressu-re, proportional to its stiffness so that the legw ill give w ay. Inelastic bandages exert an inter-m ittently strong or very strong pressure, rela-tively low at rest, therefore w ell tolerated, andhigh during m uscular exercise; this causes aninterm ittent vein occlusion w hen the externalpressure exceeds the intravenous pressure so

restoring a kind of valve m echanism . The SSIw ill alw ays be high (greater than 10).The in elastic non-stretchable bandage(zinc

oxide or velcro bandages) is included in thisgroup in a special position because of the inva-riability of its physical qualities2. These m aterialsdo not extend and do not return to their origi-nal shape w hen stretched (inextensibility, ine-lasticity). The SSI is high, the highest obtainedby com pression devices. The resting pressure

can be very low w hen the bandages are appliedw ithout stretch or high if the bandage is appliedexerting m ore or less high stretch; in the first casethis type of bandage is exceptionally w ell tole-rated also in the supine resting position.

Classification of bandages based ontheir function

It com es from the English standard (BS 7505:1995)3 that distinguishes the bandages in: conform ing stretch bandage (padding,

elastocrepe bandages) light support bandages (restricting lim bm ovem ent and exerting an interm ittent pres-sure). com pression bandages that exert a m ild

(up to 20 m m H g), m edium (up to 30 m m H g),strong (up to 40 m m H g) and very strong pres-sure (up to 60 m m H g).The pressure exerted by the bandage is cal-

culated at rest on a fixed ankle circum ference(23 cm ) w ith a bandage overlapping by 50% .M ore recently a new classification has been

proposed based on the 4 m ain characteristics

of com pression bandages: Pressure, Layers,Com ponents, Elasticity: PLA CE classification 4.W e propose that AIU C adopts this classificationof com pression bandages.The bandages w ill be classified based on: pressure exerted at rest at the B 1 region

in the supine position:mild(< 20 m m H g),medium(20-40 m m H g),strong(40-60 m m H g)and very strong(> 60 m m H g) (Tab. I). layers: mu lti-l ayer or sin gle layer; it is

im portant to consider that the only single layercom pression system is the elastic stocking. All


Classification


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laboratory but only in vivo, m easuring the exer-

ted pressure and calculating the SSI. In this caseit is better to distinguish the bandages in highstiffnessif the SSI is m ore than 10 and low stiff -nessif the SSI is less than 10 (Tab. III).Each bandage can be classified based on

these characteristics. Tab. IV show s som eexam ples.

Elastic stockings

Elastic stockings m ust also be classifiedbecause there is no accepted international stan-dard for them either.

Elastic stocking can be divided into 3 cate-gories 5:Preven ti ve or support stocki ngs:up to 18

m m H g: com pression is restricted at the anklearea and dim inishes rapidly w ith the increasein circum ference of the leg. They are distin-guished based not on exerted pressure but ontheir thickness m easured in D enier (m easu-ring unit of thickness of thread: 1 D enier (D EN )= w eight in gram s of 9 K m of thread).The com pression at the ankle is variable

depending on the D EN : 40 D EN : 60 m m H g

TABLE II. Classifi cation of ban dages based on layersan d components.

Classification of the bandages by layers and com ponents

Single layer single-com ponent bandagesM ulti-layer single-com ponent bandagesM ulti-layer m ulti-com ponent bandages

TABLE III. Classif icati on of ban dages based on ela-stici ty and stif fness.

Single-com ponent bandages M ulti-com ponent bandage kit

Elastic Low stiffnessInelastic H igh stiffness

TABLE IV. Some examples of bandages classi fi ed by PLACE. It must be observed tha t the pressure range dependson the stretch exerted dur in g applicati on. All bandages can also be appli ed wi th medi um or low pr essur e. Whenapplied accordi ng to manufactu rer recommendati ons bandages shoul d exert the in di cated pressure range.

Bandage Pressure Layers Com ponents Elasticity

Ptter bandage Very strong M ulti-layer Single-com ponent InelasticProfore Strong M ulti-layer M ulti-com ponent H igh stiffnessRosidal sys Very strong M ulti-layer M ulti-com p onent H igh stiffnessCoban 2L Strong M ulti-layer M ulti- com ponent H igh stiffnessU nna boot Strong M ulti-layer M ulti-com ponent H igh stiffnessElastic stocking M ild/m edium Single-layer Single-com ponent ElasticElastic kit M edium /strong M ulti-layer M ulti-com ponent Low stiffness


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m arket but they didnt show any evidence ofbeing m ore effective than the form er.There is no room for all these stockings in

the treatm ent of skin ulcers.

Therapeut ic stockings

The only stockings that have a place in thetreatm ent of skin ulcers; they are m ade accor-ding to the specifications defined by N ational

Institutes w ho certify the quality in term s offabrication and exerted pressure according tothe com pression class they belong to.The pressure exerted by elastic stocking is

m easured in the laboratory on an artificiallycylindrical ankle.It is different from country to country even

w ithin the sam e com pression class (Tab V).Another m eaningful param eter is the pressure-decrease from the ankle to the calf and thethigh. Tab. VI show s the pressure-decreaseaccording to the European Com m ittee forN orm alization (CEN )6; it m ust be underlined

that there are national differences regardingthis param eter as w ell.In Italy there is no specific standard for ela-

stic stocking and som e Italian m anufacturershave adopted the RAL G Z 387 standard.

Elastic ki ts

At the m om ent kits available on the m arketfor the treatm ent of skin ulcer are m ade upw ith tw o elastic stockings: one stocking thatexerts a pressure of 18-24 m m H g and is left in


situ day and night to fix the dressing and gua-rantee a m inim al com pression day and night.It is rem oved only w hen the dressing is chan-ged. The second stocking, exerting a pressureof 23-32 m m H g, is w orn only during the dayand is rem oved at bedtim e.If the stocking w ould be classified accor-

ding to the PLA CE classification it w ill be acom pressive device w ith a m ild/m edium pres-sure single layer, single com ponent and elastic.

In the case of the kit it w ill be classified asa com pressive device w ith a m edium /strongpressure, m ulti-layer, m ulti-com ponent w ith alow stiffness (Tab IV).

References

1. Partsch H . The Static Stiffness Index (SSI)- a sim plem ethod to assess the elastic property of com pressionm aterial in vivo. D erm atol Surg 2005;31:625-630.


3. British Standard Institute. Specification for the elasticproperties of flat, non-adhesive, exstensible fabric ban-

dages. BS 7505:1995, London, British Standard Institute1995.4. Partsch H ., Clark M ., M osti G . et al. Classification of

com pression bandages: practical aspects. D erm atol.Surg. 2008; 34(5); 600-9.

5. M ariani F. (Coordinator) Consensus Conference onCom pression T herapy, IIa edizion e. Ed. M inervaM edica, Torino 2009. Pag. 11-16.

6. CEN /TC 205 W G 2 n 179 (1996) e 196 (1998)

TABLE VI. Pressur e-decrease from an kle to calf and th igh dependi ng on pressur e exerted a t an kle level a t r est(accordin g CEN).

Com pression class B ankle B1 C calf F o G thigh

I 100% 80-100% 60-80% 30-60%II 100% 80-100% 60-80% 20-50%

III 100% 80-100% 50-70% 20-40%IV 100% 80-100% 50-70% 20-40%

TABLE V. Pressure exerted by elastic stockin g at B poin t dependi ng on d if ferent Nati ona l Standar ds. Values in

mmHgCom pression class CEN U K FR CH D

I 15-21 14-17 10-15 18-21 18-21II 23-32 18-24 15-20 26-33 25-32III 34-46 25-35 20-36 36-48 36-46IV >49 >35 >36 >54 >58

N .B. O ur recom m endation is that elastic stockingare classified based only on the pressure exerted atankle level and not on an aspecific com pressionclassso that there is no possibility of confusionbetw een the different standards.


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stitial fluid that determ ines a clinically evi-dent accum ulation in the tissue. The am ountof accum ulated fluid depends on the per-m eability of the capillary w alls (coefficientof filtration) and the hydrostatic and oncoticpressure gradient betw een blood and tissue.The difference in oncotic pressure causes areabsorption tow ards the com partm ent w he-re the oncotic pressure is higher. The con-nection betw een these factors is represen-ted by the Starling equation 13.O edem a is the first sym ptom of deteriora-

tion in chronic venous insufficiency (IVC)and can evolve tow ards an actual interstitialim pairm ent w ith capillary throm bosis, hypo-xia and tissue necrosis that lead to lipoder-m atosclerosis and ulceration.The correction of venous hypertension and

oedem a is of crucial im portance in the treat-m ent of clinical m anifestations of venoushypertension and can be obtained by com -pression therapy: applying an external pres-sure on the skin surface it counteracts the

pathologic intravenous pressure.In CVI com pression therapy has dem on-strated positive effects on venous, lym phaticand arterial m acro- and m icrocirculation.

Effects on venous macro-cir culati on

Com pression increases the interstitial pres-sure and reduces the venous diam eter; the-se tw o effects lead to a) an increase of bloodand lym ph velocity and of the anterogradeflow (tow ards the heart) b) a reduction of


Introduction

Skin ulcers of the low er leg represent aserious pathology that affects 1 to 2% of thepopulation 1, especially the elderly, and cau-se an extrem e disruption in the quality of lifeof the patients and their fam ilies.Studies on com pressive therapy have show n

how bandages and elastic devices not onlyconstitute a valid treatm ent of this pathology

but are extrem ely cost-effective2

. W hen thebandage is used together w ith m oist dressingsan even higher healing rate is reached 3,4.Recently understanding pathophysiological

m echanism s consistently im proved but seve-ral aspects are to be further investigated 5-10.

Venous hypertension

The great saphenous vein pressure atankle level in the standing or sitting positionis equal to the hydrostatic pressure produ-ced by the height of the colum n of bloodbetw een the right atrium and the point w he-re the pressure is m easured (from 50 to 100m m H g) and is exactly the sam e both in ahealthy subject and a p atien t w ith veininsufficiency.In a healthy subject, the com bined action

of the m uscle pum ps of the foot and calfduring m ovem ent and the efficiency of thevenous valve system (valvulo-m uscularpum p, PVM ), causes a reduction of pressu-re to 20-30 m m H g 11. In a patient w ith venousinsufficiency (IVC) the incom petence of thevenous valves and the consequent venous

reflux cause less pressure reduction: this iscalled am bulatory venous hyp ertension.Som etim es, in m ore severe cases, the pressurecan even increase.It is caused m ainly by the unsuccessful frac-

tioning of the colum n of pressure by theincom petent valves and produces an increasein the hydrostatic pressure 12). This influencesthe m icrocirculation and creates an im balan-ce betw een the filtration pressure and inter-stitial fluid reabsorption, causing oedem a.O edem a is defined as an increase of inter-

Physiopathology of compressive therapy

The Starling equation

Jv= K f([Pc-Pi] [c-i]

W here:Jvis the net fluid m ovem ent betw een com part-m ents.

Kfis filtration coefficientPcis the capillary hydrostatic pressurePiis the interstitial hydrostatic pressurecis the capillary oncotic pressureiis the interstitial oncotic pressure


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blood viscosity, com pression prevents parie-

tal m icro throm bosis14, ischem ic tissue dam a-ge and cell death.Com pression reduces and softens lipoder-

m atosclerosis and, therefore, favours skin cir-culation by reducing tissue pressure 23,26.Furtherm ore, com pression reduces capillaryfiltration, increases the reabsorption of liquidsand proteins thanks to the higher tissue pres-sure 21, and exerts a fibrinolytic action.Finally, com pression releases anti-inflam -

m atory, anti-coagulatory, fibrinolytic andvasodilating m ediators from the endothelialcells.

These m ediators together w ith the reduc-tion of the oedem a produces a reduction ofpain and inflam m atory reactions extrem elyfrequent in venous insufficiency and pro-m otes ulcer healing 27. Com pression therapyalso seem s to reduce free radicals even if them echanism is not yet clear27.

Effects on lymphati c system

Som e effects of bandaging are explained byits effect on the lym phatic drainage but them assive oedem a reduction seem s correlated

m ore to a filtration reduction at capillary level(especially venous) than to an increasedlym ph drainage. Com pression can a) reducecapillary filtration w ith a reduction of lym pha-tic overload, b) increase lym phatic reab-sorption, especially of w ater (the reabsorptionof proteins is poor and this requires constantcom pression w hen dealing w ith chronicoedem a to prevent their reappearance), c)stim ulate the flow of lym phatic and venousfluid tow ards the non com pressed areas, d)increase the contraction of the lym phangion6,29,30 e) soften the fibroslerotic tissue. Thisoccurs thanks to the effect of com pression onthe m icrocirculation (acceleration of flow ,detachm ent of w hite blood corpuscles fromthe endothelium and prevention of furtheradhesion) and to its capacity to m odulateinflam m atory receptors and m ediators [CD 14and CD 44, the interferon receptor (IFN R),tum our necrosis factor-alpha (TN F-), verylate antigen-4 (VLA -4), recep tor TN F -1(TN FR1)].The com bination of these actions lead to a


pathologic reflux c) a red uction of thehydrostatic and trans-m ural pressure. Thefinal result is a reduction of the filtrationpressure, w ith reduced loss of capillary fluid,

and an increased reabsorption of fluid intothe lym phatic vessels resulting in the reduc-tion and subsequent disappearance of oede-m a 14-17.Also docum ented: an increase in ejection

fraction 18,19, a reduction in valve overloading 6

and a decrease in the interstitial pressure inthe long term 17.All these effects result in a reduction of t sta-

sis and venous hypertension, im proving anddelaying the clinical m anifestations of IVC.

Effects on micr ocircula tionVenous am bulatory hypertension causes

significant alterations to m icrocirculation.The neutrophils are activated, stuck to the

endothelial cells and release cytokines, freeradicals, protelolytic enzym es and plateletactivation factors20 causing endothelial dam a-ge. The slow ing dow n of the flow and thegreater blood viscosity causes capillary m icro-throm bosis resulting in avascular areas andcell death 21. Lipoderm atosclerosis is alsoresponsible for skin hypoxia caused by thereduced skin perfusion due to the high tissuepressure 23. Finally, venous hypertension leadsto a filtration of protein m acrom olecules andto fibrin deposits around the capillaries; the-se fibrin cuffs have been blam ed to reducethe exchange of oxygen and nutrients pro-voking tissue dam age 24. In addition they m ayact as a scaffold for fibrosis.Com pression accelerates the m icrocircu-

latory blood flow , favours the leucocytesdetachm ent from the endothelial cells andreduces further adhesion 25; by decreasing

Lym phangion is the segm ent of a collectorbetw een tw o valves. The valves direct the flow(from peripheral tow ards central and from thedeep to the superficial system ) and prevent refluxw ith spontaneous contractions. Activity, respiratoryrhythm , artery pulsation and also bandaging canstim ulate and increase the lym phangion contrac-tion.


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effectiveness of m ulti com ponent bandages in

the treatm ent of venous ulcers34-39.O ther types of com pression therapy have

a precise and effective role in reducing oede-m a and in m aintaining the results: elasticdevices 30, interm ittent pneum atic com pres-sion 41 and m anual lym ph drainage.C om pression therapy rem ains the only

treatm ent w ith a high evidence grade (gradeA) in the treatm ent of venous stasis ulcers,recom m ended by The Cochrane Library(evi-dence based m edical docum entation).

References

1. M orison M , M offatt C. Leg U lcers. Second edition ,M osby 1994.

2. Callam M J, H arper D R, D ale JJ, Ruckley CV. Chronic legulceration: socio-econom ic aspects. Scott. M ed.J. 33,1988: 358-60.

3. M orrell CJ. Setting a standard for leg ulcer assessm ent.J W ound C are, Apr 1996, 316:173-75.

4. Lam bourne LA . Clinical audit and effective change inleg ulcer services. J W ound Care, Sept 1996, 316:348-51.

5. Stem m er R, M arescaux J, Furderer C. Il trattam entocom pressivo degli arti inferiori. D er H autarzt. Sprinter-Verlag 1980.

6. Partsch H . Com pression therapy of the legs. A review .D erm atol Surg O ncol 1991;17:799-805.

7. Stacey M C, Falanga V, M arston W , M offatt C, et al. Theuse of com pression therapy in the treatm ent of venousleg ulcers: a recom m ended m anagem ent pathw ay.EW M A Journal 2002; 2(1): 9-13.

8. H afner J, Botonakis I, Burg G . A com parison of m ulti-layer bandage system s during rest, exercise, and over2 days of w ear tim e. Arch D erm atol 2000; 136: 857-63.

9. Partsch H , M enzinger G , Blazek V. Static and dynam icm easurem ent of com pression pressure. In: Blazek V,Schultz-Ehrenburg U (Eds). Frontiers in com puter-aided visualization of vascular functions. A achen:Verlag, 1997.

10. EW M A Position D ocum ent - Stansted N ew s Lim ited,Bishops Stortford, G ran Bretagna, Viking Print Services,G B, Ed. Jane Jones

11. Bergan JJ et al. Chronic venous disease. N Engl J M ed.2006 A ug 3;355(5):48898.

12. Franceschi C. Teoria e pratica della cura C H IVA . Cap.II

A/B/C/D Pag. 19-59 Il ruolo del bendaggio elasticonella terapia delle ulcere venose13. Landis EM , Pappenheim er JR. Exchange of substances

through the capillary w all. In: H andbook of PhysiologyCirculation. W ashington: Am Physiol Soc 1963 (sect 2); II.

14. Em ter M . M odification du flux sanguin dans les veinesdes m em bres infrieurs aprs com pression. Phlbologie1991;44:481-4.

15. Stoberl C, G abler S, Parstch H . IndicationsgerechteBestrum pfung M essung der venosen Pum pfunction.Vasa, 1989, 18, 35-9

16. Bollinger A, Leu A J, H offm an U . M icrovascular chan-ges in venous desease: an update. Angiology 1997;48: 27-32

17. Allegra C . The role of the m icrocirculation in venousulcers. Phlebolym phology. 1994; 2:3-8.


clear increase in the m icrocirculatory flow

and a reduction of inflam m ation w ith tissuesoftening.

Effects on the ar terial system

Precautions m ust be taken w hen applyinga bandage to a p atient w ith arterial diseasebecause, if interface pressure exceeds theintra-arterial pressure (w hen considerablyreduced), there is a critical reduction in thearterial flow w ith serious ischem ic com pli-cations. Before applying the bandage, arte-rial pressure and flow m ust be carefully

checked (objective exam ination to revealarterial m urm urs, pulse, D oppler velocim e-try and Ankle-Brachial Pressure Index, ABPI).Conventional com pression therapy m ust notbe applied w hen the A BPI is less than 0,5 (inthis case revascularization is m andatory)H ow ever; interm ittent pneum atic pressurecould be indicated w hen revascularizationis not possible. Com pression m ust be appliedw ith reduced pressure w hen A B PI isbetw een 0,5 and 0,8, ideally by an expertbandager. In patients w ith an A BPI in thisrange, the bandage does not necessarily

reduce the arterial flow but, on the contrary,can increase the pulsatile flow 31), reduce thevenous pressure and im prove the artero-venous gradient 32.In particular inelastic bandage applied w ith

low pressure at rest, can be beneficial in caseof leg oedem a by acting like the interm ittentpneu m atic pressure prom oting oedem areduction and increase of arterial flow ; infact, the pressure peaks during m ovem entsim ulate those used in interm ittent pneum a-tic com pression.

Conclusions

A bout 70% of leg ulcers, presenting avenous or veno-lym phatic aetiology, can betreated w ith an adequate com pression the-rapy. It has been noted that this therapy redu-ces the evolution of CVI, prevents post throm -botic syndrom e 33 and favours ulcer healing(about 60-70% of ulcers heal w ithin 12-24w eeks). M any studies have confirm ed the


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18. Partsch H , M enzinger G , M ostbeck A. Inelastic leg

com pression is m ore effective to reduce deep venousrefluxes than elastic bandages. D erm atol Surg 1999;25: 695-700.

19. M osti G , M attaliano V, Partsch H . Inelastic com pressionincreases venous ejection fraction m ore than elasticbandages in p atients w ith superficial venous reflux.Phlebology 2008;23:287294

20. Sm ith PC. The m icrocirculation in venous hyperten-sion. Cardiovasc Res 1996;32: 789-95.

21. Bollinger A, Fagrell B. Clinical Capillaroscopy. N ewYork: H ofgrefe & H uber 1991.

22. Pappas PJ, You R, Ram eshw ar P, G orti R, et al. D erm altissue fibrosis in patients w ith chronic venous insuffi-ciency is associated w ith increased transform ing grow thfactor-beta1 gene expression and protein production.J Vasc Surg 1999; 30:1129-45.

23. Chant A. The biom echanics of leg ulceration. Ann RColl Surg Engl 1999;81:80-85.

24. Brow se N L, Burnand KG . The cause of venous ulce-ration. Lancet 1982;2:243-5.25. Abu-O w n A, Sham i SK, Chittenden SJ, et al. M icroan-

giopathy of the skin and the effect of leg com pressionin patients w ith chronic venous insufficiency. J VascSurg 1994;19:1074-83.

26. G niadecka M . D erm al oedem a in lipoderm atosclerosis:distribution, effects of posture and com pressive therapyevaluated by high frequency ultrasonography. ActaD erm Venereol 1995;75:120-24.

27. M urphy M A, Joyce W P, Condron C, Bouchier-H ayesD . A reduction in serum cytokine levels parallels hea-ling of venous ulcers in p atients undergoing com -pression therapy. Eur J Endovasc Surg 2002;23:349-52.

28. D ai G , Tsukurov O , Chen M , G ertler JP, K am m RD .Endothelial nitric oxide production d uring in-vitrosim ulation of external lim b com pression. Am J PhysiolH eart Circ Physiol 2002;282:2066-75

29. Fldi E, Jnger M , Partsch H . The science of lym phoedem abandaging. EW M A focus docum ent. Lym phoedem a ban-daging in practice. London M EP Ltd; 2005:2-4.

30. Fldi M , Fldi E, K ubik S (eds). Textbook of Lym -

phology for Physicians and Lym phedem a Therapists.

San Francisco, CA: U rban & Fischer, 2003.31. M ayrovitz H N . Com pression-induced pulsatile blood-flow changes in hum an legs. Clin Physiol 1998; 18:117-124

32. D elis KT, N icolaides A N . Effect of interm ittent pneu-m atic com pression on foot and calf on w alking distan-ce, hem odynam ics and quality of life in p atients w itharterial claudication: a prospective random ized con-trolled study w ith 1 year follow -up. Ann Surg 2005;-241:431-441.

33. Brandjes D PM , Bller H R, H eijboer H , H uism an M V, deRijk M , Jagt H et al: Random ised trial of effect of com -pression stockings in patients w ith sym ptom atic proxi-m al-vein throm bosis. The Lancet 1997; 349: 759-62.

34. Partsch H . in M anagem ent of leg ulcersCurr. Probl.D erm atol. Ed. G . Burg vol. 27, 1999

35. O M eara S, Cullum N A, N elson EA . Com pression forvenous leg ulcers (Review ). The Cochrane Library

2009, Issue 1.36. M offatt CJ, Franks PJ. Venous leg ulceration: Treatm entby high com pression bandaging. O stom y W oun dM anagem ent, 1995; 41(4) 16-25.

37. M offat CJ, Franks PJ, O ldroyd M , Bosanquet N , Brow nP, G reenhalgh RM , M cCollum CN . Com m unity clinicsfor leg ulcers and im pact on healing. British M edicalJournal, 1992; 305, 1389-1392.

38. Blair SD , W right D D , Backouse CM , Riddle E, M cCollumCN . Sustained com pression and healing of chronicvenous ulcers. British M edical Journal, 1988; 297, 1159-1161.

39. Sim on D A, Freak L, Kinsella A, W alsh J, Lane C, G roarkeL, M cCollum C. Com m unity leg ulcer clinics: a com -parative study in tw o health authorities. BM J 1996; 312:1648-1651.

40. H orakova M A, Partsch H . U lcres de jam be dorigineveineuse: indications p our les bas de com pression?

Phlbologie 1994; 47: 53-57.41. N elson EA , M ani R, Vow den K . Interm ittent pneum a-tic com pression for treating venous leg ulcers. CochraneD atabase of System atic Review s 2008.



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congestive heart failure), im provem ent ofm icrocirculation 3-12.The inelastic (or high stiffness) bandage

show s a greater haem odynam ic effect becau-se it produces higher pressures peaks duringw alking starting from a low er resting pressureand is therefore m ore com fortable. The bet-ter haem odynam ic effect (com pared to elasticm aterial) seem s to be correlated not only tohigher orthostatic pressure but also to the

intrinsic characteristics of the inelastic m ate-rial that has the cap acity of producing ahigher difference betw een resting and stan-ding pressure and higher w alking pressuream plitudes (m assage effect)10,11.This greater haem odynam ic effect is the

m ost likely explanation for the fact that thebest results in venous ulcers have been repor-ted w ith high pressure, m ulti com ponent,inelastic bandages13,14. Concerning the endlessdiscussion on the presum ed superiority ofelastic bandages com pared to inelastic itshould be m ade clear that in all studies repor-

ting this com parison15-25

actually bandagesw ith high stiffness and not elastichave beenused 26. In the treatm ent of sm all ulcers ofrecent appearance, elastic tubular system s orelastic stocking kits capable of providing astanding pressure 40 m m H g. have alsodem onstrated to be as effective as banda-ging 27-31.A s the effects of com pression are m uch

greater during m ovem ent, the patient m ust beencouraged to w alk. In case of im m obile orin poorly m oving patients physiotherapy isrecom m ended.

Mixed ulcers (venous and arterial)

In these ulcers the rationale of bandagingis the sam e as for venous ulcers although anaccom panying arterial disease m ust be con-sidered.The type of bandage and exerted pressu-

re are the sam e as already m entioned if thearterial dam age is m inim al and the ankle-


Com pression therapy is indicated both forthe treatm ent and for the prevention of recur-rence of m any types of skin ulcer1: venous ulcer w ith no com plications m ixed ulcer arterial ulcer lym phatic ulcer ulcer caused by other factors recurrence prevention of venous and

m ixed ulcer

A precise diagnostic w ork-up of the ulceris necessary before proceeding to bandage.For this purpose a D oppler exam ination ism andatory to calculate the ankle-brachialindex (ABPI). The D oppler exam ination cansupply useful inform ation on the quality ofarterial in-flow in the four lim bs; the quo-tient betw een the systolic arterial pressurefound at the ankle and the highest pressurefound in the arm represents the A BPI thatshould be above 1 or 0.95 12.In all uncertain cases the patient m ust

undergo a colour duplex ultrasound to loca-

te the location and extent of a possible athe-rosclerotic disease.

Venous ulcers

Rationale: reduce/elim inate venous hyper-tension; the pressure exerted by the banda-ge m ust be strong enough to equal or exceedthe am bulatory venous hypertension duringw alking; The transm ural pressure is reducedw hich then reduces filtration and favoursfluid re-absorption.

The effects of com pression in venous insuf-ficiency are: reduction of vein volum e andincrease of venous flow velocity, reduc-tion/elim ination of both superficial and deepvenous reflux, im provem ent of the m usclepum ping and an increase of ejection frac-tion, reduction of am bulatory venous hyper-tension, increase of lym phatic drainage,reduction of oedem a, shifting of blood volu-m e into the central com partm ent (be carefulw hen dealing w ith patients suffering from

Compression therapy: clinical indications


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friction points, for instance Achilles or pre-

tibial tendon, and the sole of the foot.Since a great am ount of fluid is shifted

from the tissue into the central circulation,the use of diuretcs and cardiotonics are reque-sted in patients w ith heart disease to preventcongestive heart failure.

Other ulcers (vasculitis, pyodermagangraenosum, connective tissue

diseases)

Rationale: com pression therapy is also

justified for these ulcers because it reducesstasis and therefore it is able to treat/preventoedem a. There is an increase of the flowvelocity in the m icrocirculation; a reduceddeposition of circulating im m unocom plexes;a reduced production of inflam m ation m edia-tors (cytokines, TN F-), and an increase oflym ph-drainage 39. O nce again the com pres-sion should be carried out using an inelastic


Lymphatic ulcers

Rationale:reduction of oedem a, rem odel-ling of leg, prevention of skin lesions.An inelastic, m ultilayer and m ulti com po-

nent bandage is indicated. The pressure ran-ge m ust be strong to very strong consideringthe fast pressure drop due to the oedem areduction. The pressure level should be low e-red in case of usual co-m orbidities like, forinstance, arterial disease. The bandage needsto be renew ed frequently especially in theinitial phase of treatm ent because it tends torapidly lose effect, due to a m assive reduction

of the oedem a.Special care m ust be taken in: m odelling of the shape of the leg by fil-

ling the skin folds and adding supplem entaryprotection to prevent the bandage from slip-ping. protection of the skin (often very fragi-

le in these patients), also w ith use of em ol-lients and supplem entary protection at high

TABLE I. In di cati ons for compression th erapy: summar y.

D iagnosis

Venous ulcers

M ixed ulcers

Arteriopathic ucers

O ther ulcers

Prevention of recurrence

Reccom ended tream ent

Com pression w ith strong or very strong p ressure; inelasticm ulti com ponent bandage

M ild arteriopathy w ith ABPI >0,8: strong p ressurecom pression can be done; inelastic m ulti com ponent banda-ge; possible additional protection for projecting bones ortendons m oderate arteriopathy (ABPI 0,5-0,8) or severe(ABPI 0.8: does not require strongpressure com pression; m edium pressure ; inelastic m ulticom ponent bandage; possible additional protection forprojecting bones or tendonsm oderate arteriopathy (ABPI 0,5-0,8): low pressure com pres-sion; inelastic m ulti com ponent bandage; possible additional

protection for projecting bones or tendonssevere arteriopathy (ABPI < 0,5) abstain from com pressiontherapy; revascularization of lim b indicated. IPC w hensurgery is not possible

M ild or m edium pressure com pression; inelastic m ulticom ponent bandage; possible additional protection forprojecting bones or tendons

Elastic stockings III or II class com pression

Alternative

Elastic kits or tubularsystem s that guaranteean orthostatic pressureof at least 40 m m H g

Elastic bandage to bew orn during the day thatcan be applied by thepatient or patients fam ily


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bandage; a m edium or m ild pressure can be

sufficient for this category of ulcer. Particularattention m ust be placed on the protection ofskin and projecting bones and tendons.

Prevention of recurrence

A n elastic stocking is necessary to m ain-tain the result and preven t recurren cies.H igher pressure is m ore effective than low erpressure (II class com pression: grade A ):the m axim um elastic com pression tolera-ted by the patient should be prescribed 40-42.Patients com pliance: it is im portant that

the patient is m otivated tow ards recoveryand cooperates actively in the therapy.In particular, in com pression therapy it is

im portant to encourage the patient to w alkcorrectly because it is only during m ovem entthat the bandage is m ost effective.Lastly the patient m ust be told to rest fre-

quently during the day, in sup ine positionw ith legs lifted up to favour the blood flow ,and to avoid sitting or standing for longperiods.

To be remembered Com pression therapy is fundam ental in

the treatm ent of alm ost all ulcers. Before applying com pression therapy,

an accurate diagnosis m ust be m ade: in par-ticular the presence of a significant arterialdisease m ust be ruled out, as it is the only realcontra-indication to bandaging. The patients m obility or restricted m obi-

lity does not indicate the use of a particulartype of bandage. The cost of com pression therapy m ust

be kept in m ind: reusable m aterial m ust be

favoured to m inim ize costs. Patients suffering from venous ulcers

should be considered for abolishm ent ofvenous reflux by surgery, endovenous pro-cedures, sclerotherapy or w ear com pressionsystem s all their lives to prevent recurrence.

References

1. M ariani F. (Coordinator) Consensus Conference onCom pression Therapy, IIa edizione. Ed. M inerva M edica,Torino 2009. Pag. 30-32.

2. W hite C . Interm ittent claudication. N Engl J M ed.

2007;356:1241-50.3. Partsch B, M ayer W , Partsch H . Im provem ent of am bu-latory venous hypertension by narrow ing of the fem o-ral vein in congenital absence of venous valves.Phlebology 1992;7:101-4.

4. Ibegbuna V, D elis KT, N icolaides AN , Aina O . Effect ofelastic com pression stockings on venous hem odyna-m ics during w alking. J Vasc Surg. 2003 Feb;37(2):420-5.

5. O duncu H , Clark M . W illiam s RJ. Effect of com pressionon blood flow in low er lim b w ounds. Int W ound J.2004 Jun;1(2):107-13.

6. Partsch H . Com pression therapy in venous leg ulcers.H ow does it w ork? Journal of Phlebology. 2002;2:129-136.

7. Van G eest AJ, Veraart JC, N elem ans P, N eum ann H A.The effect of m edical elastic com pression stockingsw ith different slop e values on oedem a. M easurem ents

underneath three different types of stockings. D erm atolSurg. 2000 26:244-7.8. M ayrovitz H N , Larsen PB. Effects of com pression ban-

daging on leg pulsatile blood flow . Clin Physiol 1997;17:105-17.

9. Lofferer O , M ostbeck A , Partsch H . N uclear m edicinediagnosis of lym phatic transport disorders of the low erextrem ities. Vasa 1972; 1: 94-102.

10. Partsch H , M enzinger G , M ostbeck A . Inelastic legcom pression is m ore effective to reduce deep venousrefluxes than elastic bandages. D erm atol Surg1999; 25:695-700.

11. M osti G , M attaliano V, Partsch H . Inelastic com pressionincreases venous ejection fraction m ore than elasticbandages in patients w ith superficial venous reflux.Phlebology 2008;23:28792.

12. G ohel M S, Barw ell JR, Poskitt KR, W hym an M R Role ofsuperficial venous surgery in patients w ith com bined

superficial and segm ental deep venous reflux. Eur JVasc Endovasc Surg. 2004 Jan;27(1):106-7.13. O M eara S, Cullum N A, N elson EA . Com pression for

venous leg ulcers (Review ). The Cochrane Library2009, Issue 1.

14. Partsch H et al. Evidence Based C om pression Therapy.Vasa 2004; 34: suppl. 63 Partsch H . D o w e still needcom pression bandages? H aem odynam ic effects of com -pression stockings and bandages. Phlebology 2006;21:132-138.

15. Franks PJ, M oody M , M offatt CJ et al. Random ised trialof cohesive short-stretch versus four-layer bandagingin the m anagem ent of venous ulceration. W ound RepReg 2004;12:157-162.

16. M offatt CJ, M cacullagh L, O Connor et al. Random izedtrial of four-layer bandage system s in the m anagem entof chronic venous ulceration. W ound Rep Reg 2003;11:166-171.

17. Fletcher A, Cullum N , Sheldon TA . A system atic reviewof com pression treatm ent for venous leg ulcers. BM J1997;315:576-580

18. Callam M J, H arper D R, D ale JJ et al. Lothian ForthValley leg ulcer healing trialpart 1: elastic versusnon-elastic bandaging in the treatm ent of chronic legulceration. Phlebology 1992;7:136-41.

19. D uby T, H ofm an D , Cam eron J et al. A random izedtrial in the treatm ent of venous leg ulcers com paringshort stretch bandages, four layer bandage system , anda lon g stretch-paste band age system . W ou nds1993;5:276-9.

20. U kat A, Konig M , Vanscheid W et al. Short stretch ver-sus m ultilayer com pression for venous leg ulcers: acom parison of healing rates. JW C 2003;12:139-143.

21. Scriven JM , Taylor LE, W ood AJ et al. A prospective



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Venous ulcers m ostly effect the elderly,w hose quality of life is significantly w orseneddue to the pain and their isolation, becauseof m alodorous secretions. This em erges fromnum erous observational studies am ong w hi-ch is a recently published Italian study 1.U nfortunately, venous ulcer treatm ent is

still too often inadequate and consequentlyineffective although evidence available indi-cates that com pression therapy is w ithoutdoubt very effective. In particular, strongpressure com pression results m ore effectivethan m ild pressure com pression 2.The cost-effectiveness of com pression the-

rapy is difficult to calculate because of the dif-ferent types of com pression, the patientscharacteristics (in relation to com orbility) andassistance setting. For this reason the publi-cations in the Cochrane review do not pro-vide sufficient data to establish a cost-effec-tiveness relation for each therapy 2.In order to exam ine the econom ical aspects

of com pression therapy in m ore detail, PeterFranks applied a cost-effectiveness m odel tothe clinical results of 5 studies relative to thecosts sustained by the N ational H ealth Service(N H S) in the U nited K ingdom 3.These studiesdescribed random clinical experiences andexperim ents published about 10 years ago 4-8 inw hich the results of tw o different approa-ches in m anaging patients w ith venous ulcersw ere reported.A system atic approach w ith the applica-

tion of strong pressure m ulti-com ponent com -pression on all patientsw as com pared to a

traditional approach (that is w ithout the syste-m atic use of strong pressure m ulti-com po-nent com pression). The clinical and econo-m ical data relative to traditional treatm entusually refer to the period before the intro-duction of a system atic approach using strongcom pression. All studies agree that the hea-ling rate at 12 w eeks is around 20-26% w ithtraditional treatm ent. M orrell and Sim on 4,5

report that the introduction of special surge-ries for the ulcers treatm ent increases thehealing rate at 12 w eeks ranging from 34%

(M orrell) to 42% (Sim on). In random clinicalstudies the healing rates are m uch higher(72-75% ) but this data appears in relation tothe criteria of patient selection.In order to obtain a result as near as pos-

sible to an average local H ealth D epartm entpractice, Franks selected M orrells data 4, theonly study reporting a healing rate at 12, 24and 52 w eeks. This study presents clinicalresults in the system atic use of m ulti-com -ponent com pression low er than the otherstudies, allow ing a cautious assessm ent. Ifw e com pare treatm ent costs of system aticcom pressionand the traditional approa-ch, there is an obvious advantage in thew eekly cost for the system atic com pressiontreatm ent. In fact the higher unit cost of them ulti-com ponent bandage is w idely com -pensated by the im provem ent of the otherparam eters, in particular the interval betw eenthe dressings, that is doubled, and the m uchfaster healing tim e (Tab. I).

In the clinical setting the system atic com -pression therapy ap proach produces anincrease by 10% in healing rate and a shortertreatm ent period by about 20% (Tab. II). Thenum ber of recurrencies is roughly the sam ebut this is not caused by the treatm ent of theulcer but by the m anagem ent of patients andtheir disease after the healing. The differen-ce in annual costs depends on bandage m ate-rial costs (> for the m ulti-com ponent), tim eneeded to for each application (largely thesam e), the num ber of w eekly applications(about half for the m ulti-com ponent), reco-

very tim e (20% low er for the m ulti-com po-nent) and the recovery percentage (> for them ulti-com ponent). In conclusion, the savingof m oney and tim e in the system atic com -pression therapy approach is significant.A lim itation in Franks analysis is that only

the ulcers that can be treated w ith strongpressure have been taken into consideration.In fact there is a general agreem ent on lim i-ting strong pressure treatm ent to uncom pli-cated venous ulcers.Franks considerations cannot be applied to


The cost- effectiveness analysis of the use of bandagesin the treatment of vascular ulcers


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treatm ent takes up 50% of the D istrict N urses

tim e 14.From the point of view of the H ealth

D epartm ent it is of prim ary im portance toprovide the m ost effective treatm ent at thelow est cost.From the patients point of view the cost-

effectiveness relation of the treatm en tdepends on both the elem ents related to theulcer (dim ension, duration and lim b m obility)and elem ents not related to venous patho-logy. The availability of effective treatm entdepends also on the accessibility to the treat-m ent centres (m obility level, transport costetc.), and the suppression of cultural barriersthat cause the patient to consider the disea-se ineluctable.In the p ast it w as already indicated that

m ostly people w ith m odest living conditionsw ere affected w ith venous ulcers but alsorecent research underline the im portance ofelem ents such as social class, loneliness andthe accessibility of heating at hom e 15-16.In Italy, the availability of com pression the-

rapy is lim ited by the N ational H ealth Serviceregulations, resulting in an insufficient access

to bandages and an inadequate distributionof professional proficiency, especially in thedom estic area.It is discouraging to note that, in spite of

evidence published in the Cochrane Library 2,in our country there isnt any reim bursem entof cost of bandages and elastic stockings.O nly the A utonom ous Province of Bolzanoapproved (B.U . 14 January 1986) the reim -bursem ent of com pression bandages, zincpaste bandages and therapeutic com pressionstockings. Also the reim bursem ent for com -


ulcers accom panied by a m ore or less seriousreduction in the arterial flow or m ovem entlim itation, for w hich strong pressure ban-dages are not advised or even contraindi-cated 12.Another lim it of the evaluation that Franks

him self points out in the data analysis, is thatonly the final costs of treatm ent w ere com -pared, neglecting the total costs sustained bythe N ational H ealth to m aintain a speciali-zed departm ent able to provide system aticcom pression treatm ent. To guarantee theavailability of a D oppler ultrasound diagno-sis and the continuous training of personnel,has a cost that reduces the m argins obser-ved.Furtherm ore a defined point of observa-

tion needs to be chosen w hen dealing w iththe socio-econom ic aspects of treatm ent. Ifthe cost-effectiveness relation for the H ealthD epartm ent providing the assistance is con-sidered or if the patients prospective in term sof individual costs and quality of life are con-sidered the results are very different.The econom ic im pact of venous ulcer treat-

m ent for the H ealth System is neverthelessvery high. Som e English research on costsof m edication m aterials and bandages esti-m ate a cost of betw een 2-3% of the nationalhealth budget13-14; furtherm ore, venous ulcer

TABLE I. Weekly costs (non healed lesion s) fr om

Franks PJ, modif ied.System atic U sualcom pression therapytherapy

Cost % Cost %

N ursing cost 24 (60,0) 24 (80,0)M edication/bandages 13 (32,5) 3 (10,0)O ther costs 3 (7,5) 3 (10,0)Total w eekly cost 40 30Frequency (w eekly) 1,1 2,2Total w eekly cost 44 66

NO TES O N CO STS1.1 = 1,5 euro ()2. U sual Therapy = data based on 2000 prices published in

Sim ons study (3)3. Strong com pression bandages (4 com ponents) = costProfore(9)

4. Nursing cost = average cost of a local Health D epartm entnurses visit including transport (8)

5. Bandage changing frequency: usual therapy = data based onM orrells studies (4) Freak (10) and Sim on (3); com pressiontherapy = data baed on M orrell (4) e Sim ons study (10)

TABLE II. Estimated costs and resul ts (from Fran ks,

based on Morrels data, modifi ed)System atic Usualcom pression therapy

herapy

U lcer healing at 12 w eeks 34% 24%U lcer healing at 24 w eeks 58% 42%U lcer healing at 52 w eeks 71% 60%A verage healing tim e 19-20 35-36

w eeks w eeksRecurrencies (w ithin 52 w eeks) 17 (24% ) 13 (22% )Average cost per patient 1.205 2.135H ealing cost 1.697 3.558


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pression bandage application in the practice

(about 8.00) is absolutely inadequate. O ftentherefore, the patient him self has to buy thenecessary m aterial to be treated. The scarceeconom ical resources and high product costm ean that a large num ber of patients espe-cially the elderly, are excluded from this effec-tive treatm ent17.Furtherm ore, patients w ith venous ulcers

often have a lim ited m obility that reducestheir possibility o f undergoing surgery.These patients are referred to out-patientservice w hose nurses are not expert in ban-daging and have inadequate m aterial avai-

lable.These lim its to the use on adequate dres-

sing and com pression still exist despite theresult of a recent Italian study of patients trea-ted at hom e. This study reported a significantclinical, econom ical and m anagem ent im pro-vem ent obtained by organizing assistancebased on diagnostic support, professional trai-ning and adequate product availability. Evenif this study took into consideration m ostlypressure related lesions, in the few patientsw ith vascular skin ulcers, positive clinical andeconom ical results w ere registered; as w ell

as the advantage of a rapid recovery, thehigher unit cost linked to the use of m oistw ound dressings and specific bandages, w ascom pensated by the low er frequency of appli-cation and rapid recovery 18.

References

1. G uarnera G , Tinelli G , Abeni D , D i Pietro C, Sam pognaF, Tabolli S. Pain and quality of life in patients w ithvascular leg ulcers: an Italian m ulticentre study. JW ound Care. 2007 Sep ;16(8):347-51.

2. O M eara S, Cullum N A, N elson EA . Com pression for

venous leg ulcers (Review ). The Cochrane Library2009, Issue 1.3. Franks PJ, Posnett J. Cost-effectiveness of com pres-

sion Therapy. U nderstanding com pression Therapy .EW M A po sition docum ent. M EP, 2003 (H ttp://ew -m a.org).

4. Sim on D A, Freak L, K insella A, W alsh J, et al. Com -m unity leg ulcer clinics: a com parative study in tw ohealth authorities. BM J 1996; 312: 1648-51.

5. M orrell CJ, W alters SJ, D ixon S, Collins K, et al. Costeffectiveness of com m unity leg ulcer clinics: random i-sed controlled trial. BM J 1998. 316: 1487-91.

6. Taylor AD , Taylor RJ, M arcuson RW . Prospective com -parison of healing rates and therapy costs for conven-tional and four-layer high-com pression bandaging treat-m ents for venous leg ulcers. Phlebology 1998; 13: 20-24.

7. M arston W A, Carlin RE, Passm an M A, Farber M A, KeagyBA. H ealing rates and cost efficacy of outpatient com -

pression treatm ent for leg ulcers associated w ith venousinsufficiency. J Vasc Surg 1999; 30:491-98.8. M offatt CJ, Sim on D A, Franks PJ, Connolly M F, et al.

Random ised trial com paring tw o four-layer bandagesystem s in the m anagem ent of chronic leg ulceration.Phlebology 1999; 14: 139-42.

9. N etten A, Curtis L. U nit Costs of H ealth and Social Care2000. Personal Social Services Research U nit, U niversityof Kent.

10. D rug Tariff. London: The Stationery O ffice, 2002.11. Freak L, Sim on D , Kinsella A , M cCollum C, et al. Leg

ulcer care: an audit of cost-effectiveness. H ealth Trends1995; 27: 133-36.

12. W orld U nion od W ound H ealing Societies (W U W H S)Principle of best practice: com pression in venousleg ulcers: a consensus docum ent. London, M EP Ltd,2008.

13. W ilson E. H ealth trends , 1989.

14. Bosanquet N , Franks PJ , M offatt C et alii, Com m unityleg ulcer clinics: cost-effectiveness.H ealth Trends. 1993-94;25(4):146-8.

15. Franks PJ, M offatt CJ, Con nolly M , B osanquet N ,O ldroyd M I, G reenhalgh RM , M cCollum CN : Factorsassociated w ith H ealing Leg U lceration w ith H ighCom pression. Age ad Ageing, 1995: 24: 407-410.

16. M argolis D J, Berlin JA, Strom BL: Risk factors associa-ted w ith the Failure of a venous leg U lcer to H eal.Arch. D erm atol, 1999; 135.920.

17. Polignano R: Analisi dei problem i nella gestione delleulcere venose degli arti inferiori. H elios Aggiornam entiin W ound Care, 2000,1,4.

18. M asina M . et al. O ttim izzazione delle risorse nellagestione dei pazienti affetti da ulcere cutanee in assi-stenza dom iciliare: una esperienza gestionale. Sanitpubblica e privata. 2005, n. 1, pag 75-79.



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LA TERAPIA CO M PREN SIVA N EL TRATTA M EN TO D ELLE U LCERE CU TAN EE M O STI


La terapia compressiva nel trattamentodelle ulcere cutanee

G . M O STI, V. M ATTALIAN O , R. PO LIG N AN O , M . M ASIN A*

*Com ponenti del G rup po di Studio Terapia Com pressivadi AIU C che hanno revisionato e concordato con il docum en-to: G iuseppe N ebbioso, Sim one Serantoni, Fabrizio M ariani, Enzo G iraldi, G iacom o Failla, Paolo Tanasi, Sergio Bruni, G iorgioG uarnera, Battistino Paggi, M arisa di Vincenzo, Riccardo Conte, Paolo Palum bo, G iovanni Farina, Aldo Crespi, Anna Lom bardi,Cinzia Lunghi, Lucia M arigo, Adriana Vison, M assim o M antero.

Prefazione

Mi devo congratulare con il gruppo di esperti che hanno sviluppato questo docu-mento di consenso per aver prodotto linee guida chiare ed aggiornate sul trattamentodelle ulcere delle gambe mediante terapia compressiva.

In questo documento viene proposta una classificazione dei presidi compressivibasata pi sulla loro performance in vivo che sui dati di laboratorio forniti dai produttoristessi. Questo diventato possibile grazie allintroduzione di sistemi di misura della pres-sione sottobendaggio nella singola gamba che esprime il dosaggio della terapia com-pressiva. La misura della pressione ha migliorato la nostra comprensione della terapiacompressiva ed anche molto utile ai fini delladdestramento alla compressione.

Poich la maggior parte dei bendaggi eseguiti nella pratica quotidiana consistononella combinazione di diversi tipi di materiale, tutti con differenti propriet elastiche,le caratteristiche fisiche di ogni singolo componente sono insufficienti a descrivere laperformance del bendaggio finale.

I complessi effetti della compressione sono spiegati come fondamento logico per leindicazioni cliniche che non si concentrano solo sulle ulcere venose ma includonoanche quadri clinici complicati come le ulcere arteriose e miste e linteressamento lin-fatico.

Nellultima parte del documento viene discusso il rapporto costo/beneficio dellaterapia compressiva.

Noi viviamo in unepoca in cui, qualche volta, si pensa che il trattamento locale faci-le e moderno sia capace di sostituire la vecchia e ingombrante terapia compressiva.

Non c alcun dubbio che la compressione sia una parte essenziale della terapia del-lulcera che non pu essere rimpiazzata ma solo integrata dalla terapia locale. Dopo chelulcera guarita proseguire la compressione obbligatorio per evitare la recidiva del-lulcera il cui trattamento certamente pi dispendioso del proseguimento della tera-pia compressiva.

Io spero e mi auguro che questo documento di consenso di AIUC non solo supportiil lavoro quotidiano di chi aderisce a questa associazione ma anche che aiuti e convin-ca tutti coloro che giornalmente si prendono cura di questa patologia al di fuori di que-sta comunit di specialisti.

H ugo Partsch, M .D .Professore of D erm atologia e A ngiologiaU niversit di M edicina di Vienna M aggio 2009


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M O STI LA TERA PIA CO M PREN SIVA N EL TRATTA M EN TO D ELLE U LCERE CU TA N EE

Lefficacia della terap ia com pressiva neltrattam ento delle ulcere degli arti inferiori ben conosciuta fin dallantichit 1. A ttual-m ente, grazie a m olti studi che ne ricono-scono lefficacia terapeutica 2, alla terap iacom pressiva stato riconosciuto un gradodi evidenza m olto elevato 3, 4. La com pressio-ne si dim ostrata utile in m olti tipi di ulceradelle gam be e rappresenta sicuram ente untrattam ento chiave nella cura delle m alattieflebo-linfatiche.Ciononostante non vi chiarezza, ancor

oggi, sulla term inologia usata e vi una tota-le m ancanza di accordo sugli aspetti classifi-cativi.La proposta di un accordo sulla term ino-

logia e sulla classificazione serve a fornireuno strum ento utile per un linguaggio con-diviso ed una m iglior com prensione reci-proca.

Definizioni

Si suggerisce innanzitutto di abbandonarela dizione Elastocom pressionee di adotta-re la term inologia internazionalm ente rico-nosciuta di Terapia com pressiva.La terapia com pressiva si esercita infatti

m ediante m ateriali elastici, poco elastici etotalm ente anelastici. Il term ine elastocom -pressione sem bra invece sottintendere chesi usino, in questo trattam ento, solo m ateria-li elastici e questo pu essere fonte di errorio incom prensioni.

Elasti ci t: la cap acit della benda diriprendere la form a originale quando sia sta-ta estesa; essa dovuta allaggiunta di fili ela-stici nel senso longitudinale della benda. Inbase allelasticit i bendaggi si suddividono inelastici ed anelastici.Potenza elastica: determ inata dalla forza

richiesta per ottenere un determ inato allun-gam ento.Tensione: prodotta inizialm ente dalla forza

esercitata per estendere la benda; una voltaconfezionato il bendaggio il m antenim ento

della tensione applicata dipende dalle pro-priet elastom eriche (isteresi - curve di allun-gam ento e retrazione) del tessuto usato aloro volta dipendenti dai tipi di filato e daim etodi costruttivi.Estensibi li t: la capacit di allungam en-

to della benda se sottoposta a stiram ento. Sideterm ina m isurando lallungam ento dellabenda quando vi si applichi un carico di 10N ew ton (N ) per cm di altezza. Lestensibilitviene m isurata in laboratorio ed espressacom e percentuale della lunghezza a riposo ed, attualm ente, lunica caratteristica che civiene fornita dalle com pagnie costruttrici dibende. Essa non ha alcuna rilevanza clinicase non viene contem poraneam ente indicatoil grado di elasticit e di potenza della ben-da. Infatti vi sono delle bende alle quali, perraggiungere unestensione sim ile, devonoessere applicate forze di intensit m olto diver-sa 5.In base allestensibilit i bendaggi si sud-

dividono in: inestensibili estensibili (a corto, m edio e lungo allun-

gam ento).Bloccaggio: quella condizione per cui

una volta raggiunta una data estensione lastruttura fisica della benda im pedisce ulte-riori allungam enti. Ad esem pio le bende acorta estensibilit (40-70% ) dovrebbero bloc-carsi raggiunto il 70% che il m assim o del-la loro estensibilit m entre le bende a lungaestensibilit dovrebbero bloccarsi oltre il140% .

Isteresi:indica la capacit del m aterialeestensibile di recuperare la sua dim ensioneoriginale dopo che sia cessata la forza defor-


Introduzione

N.B.estensibilited elasticitvengono erronea-m ente considerati sinonim i m entre il loro signifi-cato com pletam ente diverso:*estensibilit la capacit della benda di allungarsiquando sottoposta ad una forza traente

*lelasticit la capacit della benda di riprende-re le sue dim ensioni originali una volta che siastata estesa


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24/43


Secondo la legge di Lap lace, a parit ditensione applicata, la pressione decrescercon laum entare del raggio di curvatura del-larto e quindi, senza variare la tensione diapplicazione, per la conform azione a conorovesciato della gam ba, otterrem o una pres-sione decrescente dal basso verso lalto. Inbase ai raggi di curvatura delle strutture ana-tom iche dobbiam o anche sapere che la pres-sione esercitata dal bendaggio fortissim asul tendine di Achille e sulla salienza osseadella cresta tibiale (raggio di curvatura m ol-to piccolo) m entre sar ridotta posteriorm enteal polpaccio (raggio di curvatura am pio) eaddirittura nulla se non negativa a livello del-le cavit retrom alleolari.D ovrem o quindi aum entare il raggio in

m odo tale da ridurre la pressione in tutte learee anatom iche a raggio ridotto e quindi arischio di essere sottoposte ad una pressionetroppo elevata; dovrem o, ad esem pio,aum entare il raggio con lapplicazione dicotone di G erm ania, viscosa o gom m a pium aper proteggere le sporgenze ossee o tendinee(sm ussare gli spigoli).D ovrem o invece ridurre il raggio della

superficie da bendare con lapplicazione dispessori supplem entari per aum entare la pres-sione in tutti quelle aree anatom iche in cuiverrebbe applicata una pressione ridotta (unazona convessa con un raggio di curvatura

grande, una superficie piana o addiritturauna concavit).La pressione esercitata dal bendaggio varia

a seconda delle condizioni di staticit o dim ovim ento. Si parler, quindi, di pressionesupina, pressione ortostatica (o standing)

e pressione di lavoro10. La loro m isurazio-

ne in vivo ed il calcolo della rigidit (stiff-ness) sono state raccom andate ed stata defi-nita una serie di norm e a cui attenersi peruna corretta m isurazione

11

.Pressione supin a o di ri poso: la pressio-

ne applicata a riposo e dipende, com e detto,dalla tensione che diam o alla benda, da quan-to la sovrapponiam o, dal raggio di curvatu-ra della gam ba e dallaltezza della benda.La pressione di riposo una pressione sta-

tica e viene m isurata, per definizione, sul-larto in posizione supina.Pressione ortostati ca ( o stan di ng) e pres-

sione di lavoro:sono le pressioni esercitate dalbendaggio quando il paziente assum e la posi-zione eretta statica oppure cam m ina. Esserisultano dalla resistenza che la benda oppo-ne alla espansione dei m uscoli al m om entodella loro contrazione e sono direttam enteproporzionali alla rigidit della benda: m ag-giore la rigidit della benda pi alte sono lapressione ortostatica e di lavoro.La pressione ortostatica viene sem pre m isu-

rata nellarto in posizione eretta im m obile ed una pressione statica m entre la pressione dilavoro viene m isurata durante il m ovim ento.Rigidi t (o sti ffness) : la cap acit della

benda ad opporsi allespansione del m usco-lo al m om ento della sua contrazione e dipen-de dal m ateriale usato nella sua costruzione.Essa sar tanto m aggiore quanto m inore lelasticit della benda e pi corta la sua esten-sibilit. La capacit di opporsi al cam bio del-la geom etria m uscolare in ortostatism o ed inm ovim ento pu generare alti picchi presso-ri (60-80 m m H g) in grado di occludere inm odo interm ittente il sistem a venoso e ripri-stinare, quindi, una sorta di m eccanism o val-

volare. Q uesto porta a sua volta una ridu-zione del reflusso e della ipertensione val-volare deam bulatoria 12.Il Com itato Europeo per la Standardiz-

zazione (CEN )13 definisce la Stiffness com elincrem ento della pressione del bendaggio


Legge di Laplace P = Tn/rhP = pressione esercitata sulla superficie cutaneaT = tensione del tessuto elasticon = num ero di spire applicater = raggio di curvatura della superficie com pressah = altezza benda

Indice Statico di Stiffness (H . Partsch) Indice Statico di Stiffness (CEN )

SSI=pressione ortostatica pressione supina

m SSI=pressione ortostatica pressione supina

1 diam etro polpaccio (ortostatism o-supino)


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sem pre una qualche sovrapposizione della

benda; il term ine m ulticom ponente defini-sce m eglio i bendaggi com posti di pi m ate-riali

2,17

sinora definiti com e m ultistrato.N ella letteratura anglosassone si incontra-

no spesso i term ini long stretch bandagecom e sinonim o di elastic bandageo shortstretch bandagecom e sinonim o di inela-stic bandage. Q uesta term inologia pu gene-rare confusione perch vengono usati com esinonim i 2 caratteristiche elasticited esten-sibilitche sono invece m olto diverse (v.sopra). N e necessaria una chiara definizio-ne.Long str etch: si intende un bendaggio ela-

stico costituito da m ateriale con unestensi-bilit >100% .Shor t str etch: si intende un bendaggio ane-

lastico costituito da bende con unestensibi-lit m assim a < 100% ; il bendaggio anelasticonella letteratura anglosassone com prendequelli costituiti da bende totalm ente ine-stensibili fino a quelli short stretch. Pertantosono definiti anelastici tutti i bendaggi conunestensibilit < 100% .

Bibliografia

1. N egus D . H istorical background. In Leg ulcers: a prac-tical approach to m anagem ent. O xford: Butterw orth-H einem ann 1991; 3-10.

2. O M eara S, Cullum N A, N elson EA . Com pression forvenou s leg ulcers (Review ). The Cochrane Library2009, Issue 1.

3. Partsch H et al. Evidence B ased C om pression Therapy.Vasa 2004; 34: suppl. 63 Partsch H . D o w e still needcom pression bandages? H aem odynam ic effects of com -pression stockings and bandages. Phlebology 2006;21:132-138.

4. Vin F. International consensus conference on com -pression. Phlebologie 2003;56:31567

5. Thom as S. Bandage and bandaging. The science behind

the art. Care Science and Practice 1990;8(2): 57-60.6. W U W H S. Com pression bandaging: com pression invenous leg ulcers. A consensus docum ent. London;M EP Ltd 2008. Pag.2

7. M osti G ., Rossari S. L'im portanza della m isurazionedella pressione sottobendaggio e presentazione di unnuovo strum ento di m isura. Acta Vulnol 2008; 6: 31-36.

8. Thom as S. The use of the Laplace equation in the cal-culation of sub-bandage pressure. W orld W ide W ounds2002 (updated 2003).

9. Stem m er R. Teoria e pratica del trattam ento elasto-com pressivo. Chirurgia vascolare P. Belardi vol. II cap.48 pag.575-593 Ed. M inerva M edica

10. H aid H ., Schoop W .: Eine neue M ethode zur M essungund Registrierung des Andruckes unter Kom pression-sverbanden. M ed. W elt 1965;37:2110-3.


(dato dalla resistenza offerta dalle bende)

allaum ento di 1 cm della circonferenza del-larto secondo la form ula:

pressione ortostatica pressione supina/reale increm ento volum etrico del polpaccio.

La stiffness del bendaggio calcolata inaccordo con la definizione del CEN necessi-ta della m isura sim ultanea di pressione diinterfaccia e variazioni volum etriche dellar-to m ediante pletism ografia strain gauge.Lindice di stiffness cos calcolato ha m ostra-to una sensibilit ed una specificit elevatis-

sim e nel distinguere bendaggi elastici ed ane-latici14. Q uesto m etodo presenta lo svantag-gio di richiedere unattrezzatura com plessa,non disponibile in tutti i laboratori flebologici,e necessita di m olto tem po per la sua esecu-zione.Per sem plicit stato proposto di consi-

derare sem pre pari ad 1 cm laum ento deldiam etro del polpaccio passando dalla posi-zione supina a quella eretta per cui la for-m ula sem plificata sar: pressione ortostaticapressione supina/1 ossia pressione orto-statica pressione supina. Tale indice, defi-nito com e Indice Statico di Stiffness (SSI)15, 16,deve essere m isurato nel segm ento di gam -ba che m ostra il m assim o increm ento volu-m etrico nel passaggio dalla posizione supinealla posizione in piedi e che situato circa 10-12 cm al di sopra del m alleolo interno,m edialm ente alla tibia (punto B1).Se confrontato con lIndice di Stiffness m isu-

rato secondo la definizione del CEN , lIndiceStatico di Stiffness ha m ostrato la stessa sen-sibilit ed una specificit lievem ente inferioreper cui se ne consiglia ladozione proprio in

virt della sua sem plicit di calcolo

14

.Alta/bassa pressione:si suggerisce di abban-donare term ini aspecifici e di riferirsi sem -pre a precisi valori pressori (vedi il paragrafoClassificazione). Q uando parliam o di pres-sione leggera, m oderata, forte o m olto fortedobbiam o conoscere e concordare sui valo-ri pressori a cui questi term ini si riferiscono.Bendaggio mu ltistrato/mul ticomponen te

(vedi il paragrafo Classificazione); il term inem ultistrato usato in m aniera im propria:tutti i bendaggi sono m ultistrato perch c


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11. Partsch H , Clark M , Bassez S et al. M easurem ent of

low er leg com pression in vivo: recom m endations forthe perform ance of m easurem ents of interface pressureand stiffness. D erm Surg 2006;32:224-233.


13. European C om m ittee for Standardization (CEN ). N on-active M edical D evices. W orking G roup 2 EN V 12718:European Pre-standard 'M edical Com pression H osiery.'CEN TC 205. Brussels: CEN , 2001.

14. M osti G B, M attaliano V.: Sim ultaneous changes of legcircum ference and interface pressure under differentcom pression bandages. EJVES 2007; 33:476-482.

15. Partsch H . The use of pressure change on standing as

a surrogate m easure of the stiffness of a com pressionbandage. Eur. J. Vasc. Endovasc. Surg. 2005; 30: 415-421

16. Partsch H . The static stiffness index: a sim ple m ethodto assess the elastic property of com pression m aterialin vivo. D erm atol. Surg.2005; 31 625-30

17. Partsch H ., Clark M ., M osti G . et al. Classification ofcom pression bandages: practical aspects. D erm . Surg.2008; 34(5); 600-9.

18. EW M A focus docum ent: LYM PH O ED EM A banda-ging in practice. M edical Education Partnership Ltd;2005.



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alla loro rigidit: la gam ba che cede. Il ben-daggio anelastico, quindi, esercita la sua pres-sione soprattutto durante il m ovim ento conrelativa contrazione m uscolare. N e risulta unapressione interm ittente, relativam ente bassaa riposo e quindi ben sopportata, ed alta om olto alta in ortostatism o e durante leserci-zio m uscolare. Q uesto provoca una occlu-sione interm ittente del lum e venoso quan-do la pressione esterna supera la pressioneintravenosa e restaura una sorta di m eccani-sm o valvolare. La differenza pressoria traposizione supina e ortostatica o di lavorosar sem pre elevata (SSI m aggiore di 10). Ilbendaggio anelastico in estensibil erientra inquesto gruppo m a in una collocazione par-ticolare in quanto caratterizzato dallinvaria-bilit delle sue qualit fisiche 2. Q uesto ben-daggio viene confezionato con m ateriali com ele bende allossido d i zi ncoo materi ali invelcroche non si distendono e non hannoalcuna tendenza a riprendere la loro form a

originaria quando sottoposti a stiram ento (inestensibilit e anelasticit). La differenza trapressione di riposo e pressione di lavoro m olto elevata, la pi alta ottenibile col ben-daggio. La pressione di riposo p u esseredebole o nulla in caso di applicazione senzatrazione oppure elevata se la benda vieneapplicata esercitandovi una trazione pi om eno forte. N el prim o caso questo tipo dibendaggio ottim am ente tollerato anche incondizioni di riposo supino.Classificazione delle bende in base alla

loro funzione

una classificazione derivata dalla nor-m ativa inglese (BS 7505:1995)3 che divide lebende in: bende di fissaggio (cotone di G erm ania,

m ousse, bendaggi coesivi leggeri) bende leggere che riducono lescursio-

ne articolare ed esercitano una pressioneinterm ittente bendaggi com pressivi che esercitano

una pressione leggera (fino a 20 m m H g),m edia (fino a 30 m m H g), forte (fino a 40m m H g) o m olto forte (fino a 60 m m H g)

Vol. 7, N o. 3 ACTA

1 Compression Therapy..

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