Publication search

Compression therapy for venous and lymphatic conditions may be delivered via a range of treatment modalities using many different technologies, depending on the patient's condition and needs. Clinical decision-making relies on accurate assessment of the patient, their presenting and underlying clinical condition, skill and training of the applier and the available resources. However, changes in the patient's condition or lifestyle may necessitate re-evaluation of the treatment pathway. Generally, compression bandages and Velcro wraps are used in the intensive acute phase of treatment, with self-management using compression hosiery or wraps being used for long-term maintenance to prevent recurrence. Although guidelines recommend the highest class of compression hosiery for maximum effectiveness, clinical evidence shows practical challenges associated with application and tolerance of higher pressures and stiffness. An audit of a new type of compression garment was conducted, and it showed that incorporating stiffness into circular knitted hosiery helped overcome some of these challenges with improvements in limb size, skin softening and wound size. Additionally, self-management was facilitated by the ease of donning and doffing.

Background

Adjustable Compression Wraps (ACW) are used as an alternative to flat-knitted compression stockings (CS) in the maintenance phase of complex decongestive therapy treating of lymphoedema.

Methods

Self-applied ACW and custom-made CS were compared using sub-compression interface pressure measurements in vivo. Measurements were recorded using manometer-based Picopress®-devices in a sample of n = 30 probands with bilateral symmetric lymphostatic lower leg oedema. Legs were randomised to CS side and ACW side. Following standardised instruction and initial pressure measurements for both systems, ACW pressure measurements were repeated after 2 and 4 hours. Static Stiffness Index and pressure gradients between measuring points B1-C were calculated.

Results

ACW showed resting pressures and SSI in therapeutic ranges and significantly higher than CS (p < 0.01; p < 0.001). ACW reached significantly higher working pressures (p < 0.001). Resting pressure sub-ACW did not show significant pressure drops after 2 and 4 hours, without re-adjusting. Average pressure gradients between ACW and CS did not differ significantly.

Discussion

The pressure values reached with ACW underline their therapeutic effects. Pressures under self-applied ACW are relatively stable, even without re-adjusting. Self-application is interpreted as effective. A thorough instruction of patients is essential.

Ziel

110 Jahre nach Heinrich Fischers Veröffentlichung “Eine neue Therapie der Phlebitis” (7) möchten wir Daten aus unseren mobilen Grenzflächen-Druckmessungen unter nicht nachgiebigen Fischer-Verbänden veröffentlichen. Wir zeigen die biologisch physikalischen Gesetzmäßigkeiten auf, die über das Phänomen des biphasischen Druckaufbaus für die deutlich höheren Arbeitsdruckwerte unter nicht nachgiebigen Materialien im Vergleich zu nachgiebigen Kompressionsmedien beim schnellen und ausgedehnten Gehen verantwortlich sind.

Methoden

Wir verwendeten das von der Universitäts-Hautklinik Tübingen in Zusammenarbeit mit dem MIPM 1996 entwickelte Kompressionsdruck-Messsystem MCDI-1 (20) in der Spezialversion PIVI. Es arbeitet mit einem piezoresistiven Sensor. Darüber modellierten wir einen fixierten nicht nachgiebigen Unterschenkelkompressionsverband nach Heinrich Fischer (18). Die Gehstreckenlänge betrug 2 km, die Gehgeschwindigkeit 5,5 km/h. Die auf dem Handydisplay wiedergegebenen Einzelwerte wurden mit einer Digitalkamera gefilmt und danach zur Auswertung in Super-Slow-Motion ausgelesen. Dasselbe Verfahren durchlief ein Kompressionsstrumpf (KKl-2).

Ergebnisse

Bis zu einer Gehstreckendistanz von ca. 300 m liegen Fischer-Verband und Kompressionsstrumpf (KKl-2) mit intermittierenden Druckamplitudenspitzen von 80 mmHg gleichauf. Danach entwickelt sich die Phase 2 des biphasischen Druckanstiegs unter dem nicht elastischen Verband: Die Druckamplitudenspitzen steigen kontinuierlich weiter an, bis nach ca. 800 m ein Plateau mit einem durchschnittlichen Spitzendruck von 200 mmHg erreicht wird. Die Druckspitzendauer beträgt < 1/10 Sekunde.

Schlussfolgerung

3 Kraftquellen sind an der Druckgenese bei der Kompressionstherapie beteiligt: 1. der externe Anpressdruck des Kompressionsmediums, 2. die interne Kraft aus der Filament-Gleit-Schwellung der kontrahierenden Muskulatur, 3. die interne Kraft aus der zeitverzögert einsetzenden belastungsabhängigen vaskulär-metabolischen Pumpeffekt-Schwellung der Muskulatur. Sie ist verantwortlich für das spezifische Phänomen des biphasischen Druckanstiegs unter nicht nachgiebigen Kompressionsmedien. Der Anpressdruck (Anlagedruck) des Kompressionsmediums wirkt bei der nachgiebigen und nicht nachgiebigen Kompressionstherapie gleichermaßen. Die beiden internen Kraftquellen (Filament-Gleit-Schwellung und Pumpeffekt-Schwellung) summieren sich und entfalten nach Gehstrecken größer 800 m biphasisch eine Kraft, die je nach Steifheit des nicht nachgiebigen Materials im Binnenraum unter dem Verband (für < 1/10 sec.) vollständig in Druckkraft übergeht. Unter einer nachgiebigen Kompression verpufft diese Energie zum größten Teil in der Elastizität des textilen Materials. Beim flotten und ausgedehnten Gehen entwickeln sich deshalb (biphasisch) signifikant höhere Druckamplituden als unter elastischer Kompression. Als Resümee behält der alte phlebologische Leitsatz (15) “Therapie mit nicht nachgiebigen Verbänden und einem Laufprogramm, Halten des Ergebnisses mit Kompressionsstrümpfen” weiterhin seine berechtigte Gültigkeit.

Schlüsselwörter

Arbeitsdruck, Ruhedruck, Grenzflächen-Druckmessung, Biphasische Druckentwicklung, Filament-Gleit-Schwellung, Pumpeffekt-Schwellung, nicht nachgiebiger Kompressionsverband, nachgiebige textilelastische Kompression.

Background

Evidence supports the use of adjustable compression wraps (ACW) in the intensive phase of complex decongestive therapy (CDT), whereas evidence of its use in the maintenance phase of oedema therapy is sparse.

Methods

Randomised controlled non-inferiority trial in the maintenance phase of oedema therapy (CDT phase II) of symmetric lymphostatic oedema of the lower leg. Oedema therapy was performed with ACW and custom-made flat knit compression stockings (FCS) as a reference therapy in parallel over 3 days in n = 30 subjects. The primary outcome was lower leg volume as measured with perometer. Safety of ACW self-application and the patient perspective were secondary outcomes.

Results

ACW is non-inferior to custom-made FCS in CDT phase II of lymphostatic lower leg oedema. The differences of volume effects lie within the apriori defined equivalence interval of ± 50 ml (p = 0.163; 95 %-CI [ − 38.2; + 6.8]). Self-administration of ACW has shown no relevant side effects. ACW are easier to put on and off, while wearing comfort is comparable.

Conclusions

ACW are an alternative therapy option in the maintenance phase of CDT. Self-application seems to be safe, subject to diligent instruction of patients. Patients with difficulties putting on and off compression stockings could benefit from the use of ACW. Patients with pronounced limb volume may need to wear shoes with bigger sizes when wearing ACW. Further research with a longer observation time is to follow.

Objective:

A small-scale quality improvement study to determine the clinical effectiveness and patient satisfaction of the long-handled monofilament fibre (Debrisoft®) debriding lolly on foot ulcers that were considered to be slow healing in nature.

Methods:

This was a non-comparative, small-scale quality improvement study conducted on ulcers with slough (non-fibrous) at the ulcer base. The longhandled monofilament fibre (Debrisoft®) debriding lolly was used to treat seven patients during ulcer management, following the Trust's guidance for podiatric ulcer treatment.

Results:

Improvement was noted to the majority of ulcers within the second to third week and visible changes were evident, particularly in healing times and slough reduction. Both user and patient satisfaction were high.

Conclusion:

The long-handled monofilament fibre (Debrisoft®) debriding lolly provides an easy-to-use method of debriding foot ulcers. It allows easy access to difficult areas and enables the healing mechanism to commence. Patients verbally reported positive satisfaction when the long-handled monofilament fibre (Debrisoft®) debriding lolly was used.

Introduction:

Maceration is the elixation of the skin by prolonged exposure to moisture impeding healing due to failure of skin protection and possible microbial infections. Chronic wounds are often colonized by different kinds of microorganisms, mostly S.aureus and P.aeruginosa. Bacterial load on the wound surface perpetuates an inflammatory environment. It is of interest to elucidate dressing performance by comprehensive in vitro testing including binding capacity for elastase, determination of antibacterial activity, and assessment of fluid handling capability.

Methods:

A hydroactive dressing (HAD) consisting of cellulose/ethyl-sulfonate-cellulose fibres has been investigated. An in vitro maceration model was used to quantify and evaluate fluid uptake, fluid distribution, and shape changes. Binding capacity for elastase was determined over 24h. Determination of antimicrobial activity was performed according to JIS L 1902:2008 against S.aureus and P.aeruginosa.

Results:

HAD exhibited significantly higher fluid uptake than an alginate (AD) or a sodiumcarboxymethylcellulose dressing (SCD). It was shown that it possess a distinctly higher form stability. The SCD already macerated before the dressing was completely soaked while leakage with HAD and AD was only observed after they were completely gelled. HAD is further able to reduce the activity of elastase in vitro. And it exhibited a strong antibacterial activity against S.aureus and a significant antibacterial activity against P.aeruginosa.

Conclusions:

Performance of dressings can be assessed and compared under standard conditions in vitro. Here, HAD is able to reduce elastase activity, inhibit bacterial growth, and possess superior fluid handling capacity compared to AD and SCD.

Aim:

A National Best Practice Statement for the holistic management of venous leg ulcers¹ presents a treatment pathway, originally developed by Atkin and Tickle². The aim was to revise this treatment pathway to reflect new evidence³.

Method:

The treatment pathway was originally developed to reflect published RCT evidence for venous intervention reducing episodes of reoccurrence (ESCHAR trial)⁴ and with leg ulcer hosiery kits as first line as a result of the publication of the VenUS lV study⁵. The treatment pathway has been used since 2016 and needed further updating to reflect the recent evidence investigating the impact of early venous ablation in patients with venous leg ulcers (EVRA)⁶.

Results / Discussion:

In a group of 34 patients with leg ulceration the implementation of this pathway into everyday clinical practice has been shown after 3 months to deliver a number of benefits including increased healing rates, improved documentation and a reduction of nursing visits⁷;

 From 0% to 76% having their leg ulcer diagnosis recorded

 From 34% to 76% having their ABPI recorded

 From 13% to 83% use of compression therapy

 From 7% to 56% healing or signs of healing

 43% reduction in nursing visits

Conclusion:

It is vital to ensure that current research evidence is adopted within frontline services as soon as possible. Formalised evidence-based pathways provide a practical treatment guide and can help reduce unwanted variations, as standardising clinical processes through the use of a pathway is known to optimise the quality of treatments and improve patient satisfaction.