Inelastic compression therapy - Is it superior to elastic compression therapies?

Inelastic versus elastic leg compression in chronic venous insufficiency – what are the effects on venous hemodynamics

In the venous disease of the lower limbs, compression therapy is considered as an important component of the treatment. There are many ways to deliver the compression therapy to the legs in the venous disease patients.  Compression therapy can treat venous stasis, venous hypertension, and venous edema. Different methods of compression therapy have been described periodically over the last 2,000 years. In addition to static compression, specialized compression pumps have been developed to treat resistant edema. A technique of massage called manual lymphatic drainage has emerged to treat primary and secondary lymphedema. Objectives of compression therapy are to reduce the swollen limb to minimum size, maintain that size, and allow the patient to participate in the care of his limb whenever possible. Reduction therapy is achieved by limb elevation, compression pumps as necessary, and compression wraps. Maintenance therapy largely consists of compression wraps or compression stockings. Nonelastic devices have found a place in treating severe lymphedema but it should be emphasized that periodic follow-up must be done during maintenance therapy so that adjunctive maintenance measures can be added as needed. In tropical countries under humid conditions people find it difficult to tolerate the compression therapies unlike those living in the cold countries. People (farmers) working in the wet fields refuse to wear the compression bandages. We need to need monitor the compression therapy measures at regular intervals and make sure that the people regularly apply them.

A brief history of compression

Descriptions of limb compression therapy are found in the Corpus Hippocraticum (450-350 BC). Because the Greeks believed that “all wounds, especially those of the lower limbs, contradict standing, sitting or walking,” they used compression to counter the adverse effects of gravity and upright posture. Guy de Chauliac, a French anatomist and surgeon, published the first mention of compression therapy for varicose veins in Chirurgica magna (1363), a leading reference textbook for almost four centuries. Giovanni Michele Savonarola (1440) formalized “conservative treatment” for varicose veins. His Practica describes how bandages should be started at the distal part of the limb and worked upward to the proximal portion. Savonarola’s successor at Padua University was Fabricio d’Aquapendente (1537-1619), who further refined these bandaging methods. The first description of laced stockings (made from dog leather) can be found in his De chirurgicis operationibus. (Contrary to popular belief, this is not the reason why “going barefoot” came to be known as “airing out your dogs”). William Harvey’s 17^th century description of the circulation of blood led to an understanding of the physiological rationale for limb compression. By the latter 18^th century, Johann Christian Anton Theden (1714-1797) was postulating that compression “reduces somewhat the flow of humours, stimulates the activity of the skin over the suffering areas and increases the returning flow of humours.”The use of sponges under a compression device (to apply additional pressure over specific areas) was introduced by E. Home and others (1797). The need for a bandage that could be applied by the patient led H.A. Martin in Boston to develop a clothless bandage made of pure rubber, which could be placed directly atop the skin and held in place by another bandage. Thomas Baynton advocated adhesive bandages and promoted their use after they became commercially available toward the end of the 19^th century. The zinc oxide paste dressing, introduced by P.G. Unna in 1885, is still in use today. Ready-to-use zinc oxide bandages came onto the market after the First World War (Varicosan, Glauco, Weicosana, others). Modern elastic stockings were born on October 26, 1948 when William Brown, of Middlesex, England, submitted a patent for compression hose.

The first compression pumps were introduced in 1902 when Hofmeister proposed a treatment for arm edema in which the limb was placed within a metal cylinder filled with mercury. In 1917, Hartel used an air-filled tube for the same purpose. Hammersfahr (1931) published his treatment of venous stasis using an air cushion that filled and emptied rhythmically. Karl Linser developed a massage boot that utilized an air-filled chamber in which the pressure varied as the subject walked.

Manual lymphatic drainage has been used to remove extremity edema for more than 50 years. The original technique used soft massage to stimulate lymphatic vessels and propel fluid through their channels. Because 20% or more of patients with chronic venous insufficiency also have a component of lymphedema, manual lymphatic drainage may have a role in a compression therapy program for chronic venous insufficiency.

Nonelastic devices. The Circaid® (see Fig) provides rigid nondistensible resistance to the limb. It can be applied over a compression stocking for additional compression.

Topical compression therapy provides a means to treat or prevent these adverse effects. Limb compression (1) alters the tissue pressure gradient, which reduces edema formation and increases edema resorption; (2) reduces the caliber of the veins and increases venous flow velocity; (3) reduces orthostatic reflux, residual volume, and ambulatory venous pressure (in part, by re-recruiting venous valves and reducing reflux in the perforating vessels); and (4) improves the effectiveness of the muscle pump.

Mayberry et al (1991) - In 16 patients with CVI – compression therapy affect was studied on – femoral, popliteal vein velocities (duplex scan), reflux and ambulatory venous pressures direct measurement. Although stocking produced substantial superficial vein, they produced only modest increases in the popliteal vein velocity and no significant improvement in deep venous hemodynamics. These authors analysed another 8 studies (previous) and said the differences in the findings were due to consistencies in the study designs.

R K Spence et al (1996 -JVS) found that inelastic compression (see fig Circaid) has a significant effect on deep venous hemodynamics by decreasing venous reflux and calf muscle pump function better than compression stockings. They concluded that initially the superficial reflux should be adequately treated with stockings. Those with extensive clinical symptoms caused by abnormal deep venous hemodynamics and primary calf muscle pump dysfunction may benefit more from the inelastic compression.