The importance of evidence-based news in graduated compression for healthy subjects

While compression therapy is of the treatment options for patients suffering with venous insufficiency and chronic wounds, this could also present benefits for healthy subjects. Following his presentation at the International Union of Phlebology chapter meeting (UIP 2019; 25–27 August, Krakow, Poland) on elastic lower limb compression, Sergio Gianesini (Ferrara, Italy) cuts through the noise of “fake news” to review recent studies on graduated compression.

Graduated compression stockings (GCS) have demonstrated scientific validity in the management of impaired venous and lymphatic drainage of the lower limbs.¹ Proper compression has also been validated in healthy subjects exposed to prolonged occupational standing² and conditions associated with oedema, such as pregnancy³ and prolonged flights.⁴  At the same time, the market of compression garments for sportsmen has been increasing, with the global compression wear and shape market expected to reach $5.576 million by 2022.

However, fake news often miscommunicates the key message of public compression awareness, which is also disrupted by the general lack of data collection regarding compression in healthy subjects. In the last few years, our research group has focused on collecting data on this topic, mainly pointing out the role of GCS in lower limb volume and perceived exertion control for those sitting, standing and walking.

In a first investigation, 24mmHg below-knee GCS (20–30mmHg class) were compared with no compression in a standardised walk of 30 minutes. In order to standardise the participant’s physical activity, the validated Tanaka equation was used during cardiac monitoring on a treadmill, consisting of, as per the definition, 70% of an individual’s estimated maximal heart rate (208—0.7 x age).⁵ Lower limb volume was calculated by tape measurement according to the truncated cone formula,⁶ while the perceived exertion was assessed by the validated Borg scale (six no effort, 20 maximum effort).⁷

The results showed that walking for 30 minutes at a standardised pace without GCS leads to no significant lower limb volume change, while using 24mmHg below-knee GCS is associated with a significant reduction by approximately 4%. Moreover, the use of this kind of compression leads to a significant decrease in perceived exertion (from 13 to 11 at the Borg Scale). The conclusion of this work is that specific analysis of the graduated pressure level is able to positively impact the perceived exertion.

We were not able to find literature related to the difference between continuous and intermittent walking in terms of leg venous drainage. For this reason, we planned another investigation using the model of a golf player’s intermittent walk. Indeed, golfers are often walking toward the golf ball, stopping before shooting it, then starting to walk again. The study population was randomised to sham stockings, 18mmHg and 23mmHg below-knee stockings.

The results showed that walking for 18 holes wearing sham stockings leads to a significant increase in lower limb volume (5%). In the 18mmHg group, a non-significant 1% volume reduction was observed. In the 23mmHg group, leg volume significantly decreased by 4%. Perceived exertion was assessed by Borg’s scale, and in the 23mmHg group—unlike the 18mmHg cohort—there was a significant reduction.

Interestingly, the 23mmHg group included a sub-population using footless GCS, which showed no significant difference with the group using 23mmHg GCS covering also the foot, both in terms of limb volume and perceived exertion.⁹ These data underline the importance of proper compression dose selection in order to positively impact the perceived exertion during intermittent walking calf pump activation, a model that is similar to normal everyday walking activity.

With the aim of understanding more about the performance of GCS and the potential impact of  lower limb shape, we assessed in another investigation lower limb volume variations after 30 minutes of sitting, standing and standardised walking on a treadmill with and without 16–20mmHg below-knee GCS.

Interface pressure measurements were performed in B (ankle point of minimum girth) and B1 (area at which the achilles tendon changes into the calf muscles).¹⁰ The outcomes demonstrated that 16–20mmHg GCS are able to significantly decrease the lower limb volume after 30 minutes of sitting, standing and walking. Interestingly, among the three different conditions, only after 30 minutes of walking using GCS was the extracellular fluid significantly reduced, as revealed by the bioimpedance analysis.

Even more interestingly, the interface pressure analysis showed that more than one third of interface pressure profiles present a more progressive (less pressure in the ankle) than graduated gradient, following the different lower limb shape.¹¹ Previously published data show that progressive profiles are actually exhibiting an even more pronounced effect on the ejection fraction improvement,¹² while present data confirm a similar effect on total lower limb volume reduction.¹¹

A final investigation stimulated us to perform another study dedicated to the volume variations of  different leg segments with and without GCS. This work was carried out in the context of a much larger data collection run during flights. Indeed the topic of GCS use during prolonged flights remains an area in need of further investigation, with different recommendations currently being given by a number of different guidelines.¹³

The study involved the evaluation of the different leg segment volume variations after 4 hours of flight, comparing 15­–20mmHg below-knee GCS to a non-graduated normal ankle sock. GCS use was associated with no significant lower limb volume variation, demonstrating the oedema formation control. Normal ankle sock use was associated with a significant increase in lower limb volume (5.2%). Interestingly, the different leg sectors showed heterogeneous volume changes, both in the GCS and sock group, demonstrating that the mechanism of fluid shifts is still to be fully elucidated, both with and without GCS on.¹⁴

In conclusion, investigations like the ones reported here will help us to develop a better understanding of oedema and GCS performance in different physiological conditions, paving the way for a better use of the compression tool both in sport-science and pathological scenarios. Indeed, the world of sport is in extreme need of more homogeneous and reliable data on compression than what has already been reported.¹⁵ At the same time, education of healthcare professionals and patient compliance related to compression use is still in need of improvement and what has been reported here could help with this process.¹⁶

Last but not least, considering the growing market related to compressive garments, fundamental care from educational, scientific and institutional bodies must be focused on counteracting fake news and claims not based on evidence regarding the potential benefits of compressive items that have not been properly certified. Indeed, one of the main topics during the upcoming v-WINter 2021 Dubai meeting will be the creation of an international consensus for the creation of a booklet dedicated to patient fake-news-free information; a document that will surely include a fundamental compression tool.

Sergio Gianesini is a surgeon at the University of Ferrara, Italy and adjunct assistant professor at USUHS University (Bethesda, USA). He is president of the venous-lymphatic World International Network foundation (v-WIN), vice president of the International Union of Phlebology (UIP), associate-editor of International Angiology Journal and editor of Phlebology Journal.

References:

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9. Gianesini S, Tessari M, Menegatti E, et al. Comparison between the effects of 18- and 23-mmHg elastic stockings on leg volume and fatigue in golfers. Int Angiol.2017 Apr;36(2):129-135.
10. Partsch H, Clark M, Bassez S, et al. Measurement of lower leg compression in vivo: recommendations for the performance of measurements of interface pressure and stiffness: consensus statement. Dermatol Surg 2006; 32: 224-32.
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12. Mosti G, Partsch H. Compression stockings with a negative pressure gradient have a more pronounced effect on venous pumping function than graduated elastic compression stockings. Eur J Vasc Endovasc Surg.2011 Aug;42(2):261-6.