Choosing compression to heal venous leg ulceration

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Una Adderley

There is a robust evidence base to support the use of compression therapy for healing venous leg ulceration and for preventing ulcer recurrence. The most recent version of the Cochrane Review1 on the effectiveness of compression and the relative effectiveness of different compression systems on venous leg ulcer healing included 48 randomised controlled trials (RCTs) reporting 59 comparisons. Although the methodological quality of the evidence is variable, there is overwhelming evidence that multi-layer high compression systems greatly increase the chances of healing compared to no compression. A more recent review and update of the evidence came to the same conclusion.2 Similarly, although there is very little evidence on the use of compression to prevent recurrence of venous ulcers, the overwhelming evidence of effectiveness for healing makes it highly likely that compression is also highly effective at preventing recurrence.3

However, a series of audits show that a significant proportion of patients with venous leg ulcers never get compression or their compression will not be sufficiently high to be effective. A point prevalence survey of wounds in North East England found that 46% of people with venous leg ulceration were not in compression.4 A subsequent survey using similar methodology undertaken in one English healthcare district found that 25% of people with venous leg ulcers were not in compression.5 A more recent survey found a slightly better situation, with 87.6% of people with venous leg ulcers in compression but only 67.8% were in full compression (i.e. equivalent to the recommended 40mmHg).6 In a recent retrospective cohort analysis of patient records, more than 50% of people with a leg ulcer had no recorded diagnosis.7

Not all these patients will have ulceration due to venous disease, but those that do are unlikely to be in compression. Although some of these audits are now quite old, the recent publications suggest that the situation may have worsened. The reasons for the sub-optimal use of compression are unclear but are likely to be with lack of confidence8 and lack of knowledge.

According to the meta-analyses cited above,1,2 multi-component systems are more effective than single-component systems, but two-component systems appear equivalent to four-layer bandaging in terms of healing. The Cochrane meta-analysis suggests faster healing with four-layer bandaging than with short-stretch bandaging, but high-compression stockings are associated with better healing at two to four months than short-stretch bandaging.

In terms of cost-effectiveness, four-layer is more cost effective than short-stretch bandaging. However, since the meta-analyses were conducted, the VenUS IV trialhas  found no difference in venous ulcer healing between four-layer bandaging and two-layer below-the-knee compression hosiery. Nevertheless, hosiery is slightly more cost-effective, with a slightly higher quality of life.

Recently, velcro wrap devices (which have traditionally been used to manage lymphoedema) are being marketed to treat venous leg ulceration. These offer a potentially useful new way to apply compression, but their clinical and cost effectiveness is currently unknown. The Human Tissue Authority has recently advertised for expressions of interest to undertake an RCT into this intervention for healing venous leg ulceration.

The challenge is in how to translate this research evidence into clinical practice. Firstly, we should be offering compression as a first-line treatment, but we need to acknowledge the challenges around receiving compression therapy. As a treatment, it has a major impact on the patient experience.

People with venous leg ulcers are more likely to wear compression if they believe it is effective. As clinicians, we need to share our knowledge with our patients, so they can make a truly informed choice.10 Patients are also more likely to wear compression if it is comfortable, so we need to help them choose an effective system that they are likely to tolerate.11 Finally, we need to be realistic about pain: leg ulcers and compression can be very uncomfortable, especially at the beginning of treatment. We need to address pain, and offer appropriate analgesic therapy.12

In the UK, cost is less of an issue from the patient perspective as most products are available on prescription. However, there are cost implications from the healthcare provider perspective. We need to be aware of the issue of cost-effectiveness and make informed decisions about the products we recommend to our patients. Finally, we need to accept that patients do not like wearing thick, unflattering hosiery.13 Appearance matters, so it is important to find an acceptable compression solution.

In an ideal world we would be able to offer each patient a wide selection of compression options, but this is not without its challenges. The different types of compression all require considerable knowledge and skill in application, and this is especially true of compression bandaging. Furthermore, patients vary widely in shape and length of leg and what they find acceptable.

Ideally, a patient will receive care from a clinician who has expert knowledge about them as an individual, coupled with expert knowledge about all the available forms of compression. In reality, this is unlikely. All we can do is try to be as knowledgeable as possible about the patient in front of us by listening to them, making sure we keep our tool box of compression therapies adequately stocked, and develop skills and knowledge about the systems we use.

Una Adderley is the Director of the National Wound Care Strategy programme in the UK, as well as a lecturer in Community Nursing at the University of Leeds, Leeds, UK.

References

1. O’Meara S, Cullum N, Nelson EA, Dumville JC. Compression for venous leg ulcers. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD000265. DOI: 10.1002/14651858.CD000265.pub3.
2. Nelson EA, Adderley U. Venous leg ulcers. Systematic review 1902. BMJ Clinical Evidence. http://clinicalevidence.bmj.com/x/systematic-review/1902/overview.html 2016 January
3. Nelson EA, Bell‐Syer SEM. Compression for preventing recurrence of venous ulcers. Cochrane Database of Systematic Reviews 2014, Issue 9. Art. No.: CD002303. DOI: 10.1002/14651858.CD002303.pub3.
4. Srinivasaiah, N., Dugdall, H., Barrett, S. & Drew, P. J. 2007. A point prevalence survey of wounds in north-east England. Journal of Wound Care, 16, 413-419.
5. Vowden, K. & Vowden, P. 2009. The prevalence, management and outcome for patients with lower limb ulceration identified in a wound care survey within one English health care district. Journal of Tissue Viability, 18, 13-19.
6. Cullum N, Buckley H, Dumville J, Hall J, Lamb K, Madden M, et al. Wounds research for patient benefit: a 5-year programme of research. Programme Grants Appl Res 2016;4(13)
7. Guest, J. F., Ayoub, N., Mcilwraith, T., et al. 2015. Health economic burden that wounds impose on the National Health Service in the UK. BMJ Open [Online], 5.
8. Adderley, U. J. & Thompson C. Confidence and clinical judgement in community nurses managing venous leg ulceration – A judgement analysis. Journal of Tissue Viability, Volume 26 , Issue 4 , 271 – 276 .
9. Ashby RL, Gabe R, Ali S, et al. VenUS IV (Venous leg Ulcer Study IV) – compression hosiery compared with compression bandaging in the treatment of venous leg ulcers: a randomised controlled trial, mixed-treatment comparison and decision-analytic model. Health Technology Assessment (Winchester, England). 2014;18(57):1-vi. doi:10.3310/hta18570.
10. Jull, A.B; Mitchell, N; Aroll, J et al Factors influencing concordance with compression stockings after venous leg ulcer healing Journal of Wound Care, 03/2004, Volume 13, Issue 3.
11. Moffatt, C; Kommala, D; Dourdin, N et al Venous leg ulcers: patient concordance with compression therapy and its impact on healing and prevention of recurrence International Wound Journal, 10/2009, Volume 6, Issue 5
12. Van Hecke, Ann; Grypdonck, Maria; Defloor, Tom A review of why patients with leg ulcers do not adhere to treatment Journal of Clinical Nursing, 02/2009, Volume 18, Issue 3.
13. Madden, M. 2015. The ghost of Nora Batty: A qualitative exploration of the impact of footwear, bandaging and hosiery interventions in chronic wound care. Chronic Illness, 11, 218-229

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