Practical Perspectives: Understanding Venous Leg Ulcers and the Importance of Compression Therapy

Practical Perspectives is a new sponsored column from 3M, St. Paul, MN. The company will provide insights on various wound and skin care conditions including venous leg ulcers and incontinence-associated dermatitis. Additionally, this column will discuss clinical application of some of the company’s products, share perspectives from industry experts, and provide information about the importance of skin and skin integrity.  

Venous leg ulcers (VLUs), also known as venous stasis ulcers, are among the most common chronic wounds, impacting nearly 3 million people worldwide. Approximately 1% of the Western population at some point will experience a VLU.¹ The majority of VLUs can be prevented through effective management of venous insufficiency. Once they develop, venous wounds can persist for weeks or months if not managed effectively, which means they can negatively impact patient quality of life and place a costly burden on the patient and the health care system. 

Clinical studies² demonstrate compression therapy can significantly increase VLU healing rates and reduce the likelihood of recurrence. However, compression therapy is not widely used, largely due to gaps in clinician understanding of VLUs and compression therapy. VLUs are managed by a variety of different clinical specialists, contributing to variability in referral pathways, diagnoses, and treatment. 

A number of common clinician misperceptions surround VLUs and the role of compression therapy in the treatment of VLUs. 

Myth 1: Patients on compression therapy should be bedridden. Fact: one of the most important things for VLU patients on compression therapy to do is to ambulate. Pumping of the calf muscle enhances the therapeutic effect of compression.³ Unless the patient has restricted mobility for other reasons, the clinician should encourage him/her to maintain activity during compression treatment. 

Myth 2: Compression should not be used on patients with arterial disease. Fact: compression can be used on patients with mild to moderate arterial disease. Vascular work-up, such as taking an ankle-brachial pressure index (ABPI), is necessary before initiating compression. If the ABPI is between 0.5 and 0.8, an appropriate 2-layer compression system providing 20 mm Hg to 30 mm Hg compression can be applied as part of a comprehensive medical plan of care.⁴ 

Myth 3: All compression bandage systems are the same. Fact: numerous attributes should be considered when selecting a compression therapy system. In 2014, an international group of experts in leg ulcers and venous disease gathered to identify how to encourage wider adoption of compression therapy by simplifying the key principles involved. These global experts outlined attributes of the ideal compression therapy system within a consensus recommendation document, Simplifying Venous Leg Ulcer Management.⁴ These attributes include:

• Delivers therapeutic compression and has high stiffness (ie, the pressure generated is effective during mobilization and is well-tolerated during rest); 
• Permits good anatomical fit;
• Stays in place (ie, does not slip);
• Comfortable;
• Allows patients to wear their own shoes and maintain normal gate;
• Easy to apply and remove; and
• Requires minimal training in fitting and application.

Although traditional compression therapies such as an Unna Boot or 4-layer bandage work, they are often not ideal because they are not comfortable for patients and may become loose, leading to more frequent changes. Treatments that aren’t compatible with daily life won’t have high rates of patient adherence to care protocols. In fact, VLU healing time can be twice as long when patients are unable or unwilling to consistently use compression therapy.⁵ 

The good news is that treatment options have evolved in recent years. Multicomponent compression therapy systems such as 3M^™ Coban^™ 2 Layer Compression System, also known as a “short-stretch compression” therapy system, have changed the game for both clinicians and patients. 

Coban 2 Layer Compression Systems provide sustained, therapeutic compression for up to 7 days, and because the bandages are low-profile and comfortable to wear, patients are more likely to keep them on, thereby increasing compliance and the potential for more effective treatment.^5-8 A retrospective analysis⁹ conducted in the UK showed initiating therapy with Coban 2 Layer Compression System resulted in increased healing rates and lower cost of treatment.

Conclusion

Compression therapy has been clinically proven to accelerate VLU healing time and to decrease the rate of recurrence, contributing to better quality of life for patients. Clinicians should take time to better understand the methods and benefits of compression therapy. As compression therapy has evolved in recent years, its use has become easier for clinicians, increasing patient comfort and cooperation. Clinicians are advised to consider compression therapy as a standard practice for their VLU patients. 

References

1. Graham ID, Harrison M, Nelson E, Lorimer K, Fisher A. Prevalence of lower-leg ulceration: a systematic review of prevalence studies. Adv Skin Wound Care. 2003;16(6):305–316.

2. Nelson EA, Bell-Syer SE. Compression for preventing recurrence of venous ulcers. Cochrane Database Syst Rev. 2014;9:CD002303.

3. Yang D, Vandongen YK, Stacey MC. Effect of exercise on calf muscle pump function in patients with chronic disease. Br J Surg. 1999;86(3):338–341.

4. Harding K, Dowsett C, Jelnes R, et al. Simplifying venous leg ulcer management. REcommendations from an expert working group [Consensus recommendations]. Wounds Int. 2015;1–25. Available at: www.woundsinternational.com. Accessed May 24, 2016.

5. Moffat C, Edwards L, Collier M, et al. A randomized controlled 8-week crossover clinical evaluation of the 3M^™ Coban^™ 2 Layer Compression System versus Profore^™ to evaluate product performance in patients with venous leg ulcers. Int Wound J. 2008;5(2):267–279. 

6. Schuren J, Andreas C. Pressure and slippage during 48 hours of compression therapy: a study on healthy volunteers. Poster presented at the Symposium on Advanced Wound Care. Orlando, FL. April 17–20, 2010. 

7. Hampton S, Kerr A, Crossley M. Summary of five case studies on the treatment of venous leg ulcers with a new two layer compression system in a community setting. 2006. Data on file at 3M.  

8. Schnobrich E, Solfest S, Bernatchez S, Zehrer C, Tucker J, Walters SA. Seven-day, In-use assessment of a unique, innovative compression system. Poster presented at the Symposium on Advanced Wound Care. San Antonio, TX. April 30–May 3, 2006. Data on file at 3M. 

9. Guest JF, Gerrish A, Ayoub N, Vowden K, Vowden P. Clinical outcomes and cost-effectiveness of three alternative compression systems used in the management of venous leg ulcers. J Wound Care. 2015;24(7):300-310.

Practical Perspectives is made possible through the support of 3M, St. Paul, MN. The opinions and statements of the clinicians providing Practical Perspectives are specific to the respective authors and are not necessarily those of 3M, Ostomy Wound Management, or HMP Communications. This article was not subject to the Ostomy Wound Management peer-review process.