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  • Multi-Layer Compression Wraps

    Multi-Layer compression wraps contain elastic (long stretch) materials or nonelastic (short stretch fabrics) or a combination of both.

    • Elastic materials (long stretch) contain the ability to apply various amounts of compression using the stretch (elastomer) fiber spandex. In addition, the elastomer allows the fabric to apply therapeutic interface compression levels with changes in local circumference changes due to loss or increases in edema. These fabrics stretch in excess of 100%. When the tension is released the elastic fabric should return to its original length.

    • Inelastic materials (short stretch) contain few spandex or elastomeric fibers producing minimal amounts if any elongation or degree of stretch. They therefore require considerable amount of tension to be applied and can only produce minimal if any elongation or degree of stretch.

  • Creep

    Creep is defined as the deformation of a material, in this case fabric, due to an applied amount of tension or stretch. A fabric that has significant creep loses compression when wrapped around the limb. For example a fabric that is stretched 100% from 8 inches in length to 16 inches in length should return to his normal configuration of 8 inches length after the release of any tension or stretch. The degree to which it does not return to 8 inches (possibly to 10 inches or 11 inches) is reflective of the degree of creep. This deformation of the fabric is due to the amount of tension and the length of time during which the tension was applied. The clinical results of creep can be shown by research by Hegarty et al which demonstrated that two layer multilayer wrap systems can lose as much as 25% of their compression in five hours of time. They also demonstrated that four-layer multi-layer wrap systems can lose as much as 10% of their compression in only five hours.2 These findings illustrate the creep found in these systems, reducing the amount of applied compression and contributing to the wrap not remaining in place on the lower leg. After a few days of application, wrap systems can slide down to the middle of the leg. This creates friction and bunching of the fabric which and can lead to secondary ulceration often located on the anterior tibial crest.

    The distal leg displacement of a wrap system has often been misinterpreted to be reflective only of loss of limb circumference due to edema reduction. But in reality distal displacement of the wrap system is also due to the “creep” of the fabric and the loss of compression related thereto. Wrap systems losing compression during treatment makes them non-effective towards the goal of wound healing.

    It’s interesting to note that properly manufactured hosiery maintains more constant levels of compression with less creep for an extended period of time. This is because the compression levels required are engineered into the fabric using the appropriate elastomers and stitch construction allowing precise compression application. In addition, hosiery reacts like a long stretch fabric maintaining compression applied with changes in local circumferences.

  • Vascular Wrap

    As result of this research a new Vascular Wrap was developed with stretch characteristics similar to hosiery fabric performance.

    This long stretch fabric contains a high amount of spandex which allows for varying amounts of tension to be applied, the continuous application of compression with the reduction of edema and stable compression levels due to minimal creep. This Vascular Wrap is part of a multi-layer wrap system consisting of two layers. The first layer is a terry fabric sleeve contoured to fit the lower leg. The second layer in this new system is the new vascular elastic wrap. In this system the primary compression is applied ONLY through the second elastic wrap layer.

  • Smart Sleeve

    The Vascular Wrap and sleeve mentioned in the above paragraph is also available with smart technology. This “Smart Sleeve” system indicates the amount of interface compression in mmHg as wrapping is being applied (sub bandage pressure). This allows the provider to measure, adjust, and document the amount of pressure applied with each dressing application. It also allows consistency of compression from one application to the next with one provider applications and from one provider and another when multiple providers may in a group practice setting. It also allows one to assess the appropriate degree of compression that best accelerates the rate of wound healing. The system can also indicate the level of compression being applied when the patient returns for wound dressing changes. Because of the unique design of the sensor and Smart Sleeve the cost of the system is kept at a competitive price. The following treatment course is incorporated into this algorithm.

    Proposed Interface Pressure Measurement Guidelines: (measuring the sub bandage pressure)

    1. During initial application to obtain selected therapeutic pressure

    2. During each subsequent visit

    3. Prior to removal of bandage dressing for wound inspection

    4. During application of a fresh new dressing

    5. Prior to removal of wound dressing at the end of treatment

    Regimen should become standard of care.

  • Compression Level and Proper Usage

    Pressures used in compression grading systems are based on measurements produced on a model of a limb and taken at the ankle during laboratory testing. The standards that have been adopted for hosiery are relatively international. There are minor differences of a few mmHg between different countries but generally they are very close to each other using 3 or 4 compression levels.

    The compression description is based on the range of compression applied to the ankle within a fitting range. For example a 20-30 mmHg hosiery fitting an 8” to 9” ankle will apply no less than 20 mmHg at an 8” ankle and no more than 30 mmHg at 9” ankle. Note typical fitting chart for compression hosiery from one company. Note that for knee length circumferential measurements are measured at the ankle and mid-calf while length is measured from the proximal leg the posterior if you’re aspect of the heel. Measurements were added for full length as noted below. The pressure measurements known in figure 3 refers to the level of the ankle when ordering knee length or thigh length stockings.

     

     

     

     

     

     

     

    The following are the US compression standards for hosiery:

    • 15-20 mmHg – Improves circulation, reduce swelling, controversial treatment telangiectasia/varicosities

    • 20-30 mmHg – Chronic venous insufficiency, Treatment/prevention of varicosities

    • 30-40 mmHg – Treatment of chronic venous insufficiency and ulcers

    • 40-50 mmHg – Treatment of chronic venous insufficiency and ulcers

    Due to Pascal’s law of physics the interface pressure has direct one-to-one relationship between the pressure applied to the skin and that produced internally within the limb. 40 mm Hg applied to the skin circumferentially delivers 40 mmHg internally. The effects are dramatic. Hugo Partsch in one of his articles demonstrates that only 6 mm of interface pressure applied to the mid-thigh of the patient with an abnormal thigh shape and extremely engorged saphenous vein and deep femoral vein not only reduces the cross-sectional diameter of both of the veins by 50% but also changes the shape of the thigh from an abnormal muscular mass to a rounded functional muscular unit. The effect of an externally applied interface pressure is dramatic and is not appreciated as much as should be. In fact, “when properly prescribed,” it has a significant effect on the internal structures of the limb without any invasive therapeutic aspect. This greatly reduces risk while performing a very functional therapeutic response. Recently an international consensus has as recommended the following system for categorizing Compression bandage systems:

     

     

    Commentary: Kravitz, S, R, 5 The compression bandage system levels described above bring in many questions. The most important is why these ranges differ from those described for hosiery which have been accepted on a global basis. The ranges of pressure should be the same independent of the device that is providing the therapy. Ideally compression hosiery, multilayer compression wraps and pneumatic compression units should all utilize the same ranges of compression therapy. This allows for easy transfer from one type of device to another. For example a patient with an ulcer using a multilayer wrap at 40 mmHg at the ankle could then be changed to utilizing either a 30-40 or 40-50  compression hosiery. Have different ranges of therapy for different devices is confusing and complicates transferring from one form of therapy to another.  All of these devices deliver the compression in the same manner with identical affects and are based on Laplace’s law and Pascal’s Law.

  • Differences Between Inelastic and Elastic Compression Systems

    Compression systems may contain both inelastic and elastic materials. Most multi-layer systems (two- and four-layer) behave as an inelastic system if they contain at least one inelastic component. This is because in these systems the inelastic layer becomes the limiting factor in allowing the applied device to expand and stretch with increased swelling. This is especially true with four-layer systems which apply increased rigidity due to the number of layers of material which tend to interlock on each other decreasing the overall elasticity of the device.

    An inelastic bandage has high stiffness when compared to an elastic bandage. In short the term stiffness and the term of elasticity are opposite ends of a continuum. For a number of years these differences have been described using the concept known as “Static Stiffness Index” also known as SSI. The SSI has been used as a method to assess the relative stiffness of multilayer wraps. It is based on the concept that there is an increase in interface pressure when changing position from and non-weigh bearing to a weight bearing stance. This principle has been the basis of many scientific articles and measuring the stiffness or rigidity of many devices. However, University-based research produced by Kravitz et al. demonstrated significant questions and reliability of the SSI and published a well-known article challenging the static stiffness index as not clinically relevant and or inconsistent.4 The in vitro data from this study is based on solid laws of physics and mathematics. The fact that this data conflicts with a large number of in vivo studies raises questions about the previously published studies and the measuring techniques utilized. Measurements for SSI have typically been taken at the location known as “B 1” which is found on the medial aspect of the leg at the junctions of the upper and middle one third’s. The device typically utilized to measure the pressure in these research projects is the Picopress which is a crown-shaped air bladder measuring device. The B1 location overlies significant muscle and tendon tissue which when nonweight bearing is soft and flaccid allowing all the Picopress to sink into the soft tissue when non-weight bearing. However, upon weight-bearing these muscles become active, the subcutaneous tissue becomes rigid and the probe is forced to move and be pushed outward against the overlying bandage or other compressive device. The result is an increase in point pressure due to the prominence of the measuring device but there is not an overall increase in pressure circumferentially. The researchers at North Carolina State University hypothesized that prior in vivo measuring was misinterpreted. They had concluded that the in vivo research had misinterpreted the data as pressure around the limb while they were actually reading an artifact of the measuring device. Factors leading to this conclusion include the relative shape of the Picopress in combination with the change in the relative firmness of the subcutaneous tissue when transposition and from and non-weight-bearing to weight bearing. The SSI principle is not supported by benchmark science and the laws of physics.1,4

    Laplace’s law dictates that when a device is applied circumferentially around the limb the only way the interface pressure can increase is if there is an increase in the limb circumference. Thus SSI is based on the assumption that there is an increase in circumference when transpositioning from non-weight-bearing to weight-bearing. Kravitz et al. with University-based data from schools of engineering and textiles demonstrated that there was no consistent increase in circumference at the level of the ankle and that the most subjects measured had a decrease in circumference at the mid-calf when standing versus non-weight-bearing. These results do not only challenge the principle of SSI but also point to discrepancies in compression therapy. For example it has been stated that zinc oxide impregnated gauze bandages, known as the Unna boot in the medical circles, effectively increases venous return in ambulating versus not ambulatory patients. But this assumption is based on the previously accepted principle of SSI meaning that there is an increase in interface pressure with the Unna boot when transpositioning from a non-weight-bearing to weight-bearing and/or walking activity. The research cited in this document however brings that assumption into question. If there is no increase in limb circumference there can be no increase in interface pressure when walking versus non-weight-bearing using the zinc oxide impregnated gauze bandages. Conclusion: Unna boot and similar devices do not increase venous return in ambulatory versus non-weight-bearing patients. To be clear that is not to say that ambulation does not increase venous return. It definitely does have that effect. However, herein described in vitro data suggests the use of an applied Unna boot or similar device does not enhance venous return.

  • How Compression Works

    Stiff (short stretch fabrics) have a very limited range of therapeutic compression with a very sharp rise in the stress strain curve as
    shown on the graph below. This stress strain curve demonstrates that short stretch fabrics cannot expand with increased swelling and an increase in diameter of the limb. Therefore an increase in leg edema when wrapped with stiff fabrics can cause significant increases in the interface pressure due to the lack of fabric elasticity. At the same time any decrease in limb circumference due to a decrease in edema allows soft tissue to separate from the overlying compression wrap thus preventing it from applying compression to the limb.

     

    However long stretch fabrics possess a much broader range of therapeutic compression demonstrated by the flatter stretch strain curve as shown above. The fabric used in the new sleeve wrap described in this document possesses the flexibility for a long range therapeutic compression (long stretch or elastic fabric) with a high-end spike acting like a short stretch bandage at the end of the stress strain curve. The flatter portion of the curve demonstrates its ability to expand and thus provide a therapeutic level of compression. Alternatively the flat portion of the curve also demonstrates that as edema reduces the fabric still maintains therapeutic compression allowing it to further reduce edema and enhance venous return. Additionally, as the muscles contract with ambulation there is a resultant increased internal limb pressure directly related to the applied interface pressure from the overlying bandage. This increase in limb internal pressure causes a reduction in the circumference of the deep veins enhancing proximal outflow to further reduce edema.

    To reiterate, Pascal’s law demonstrates that externally applied circumferential pressure produces an increase of pressure internally to the limb that is distributed evenly throughout the lower leg. This has a compressive effect reducing the diameter of the veins within the lower leg. If there is not inherent valvular disease, a decrease in deep vein circumference causes the repositioning of the valves which allows them to function normally driving venous return proximally. The rate of blood flow through the veins increases, a proxy for internal pressure and the measurement of the interface pressure applied.

  • Graduated Compression

    Graduated compression is defined as a pressure gradient where the mid-calf measures 80% that of the ankle and the thigh measures 80% that of the mid-calf. When a compression bandage is applied at the same tension from the ankle up through the lower leg a gradual reduction in pressure from the ankle to the knee will occur automatically. Due to the increase in diameter of different portions of the limb. This is the rationale and why it is important when prescribing compression hosiery or a multilayer wrap that the diameter of the ankle be measured and recorded. That is why the pressure ranges used to identify hosiery and multilayer wraps is taken at the level of the ankle. You must know the pressure at the ankle to then assess and make sure garment is applying 80% of that at the calf and for full length garments, 80% percent of the calf measurement at the mid-thigh. The impact of these variables is defined by Laplace’s law.
  • Key Points

    When bandages are applied with the same tension to the lower leg, compression will be highest at the ankle and gradually decrease going up the leg — this is known as graduated compression.

    • The circumference of the limb inversely affects the pressure underneath the bandage (interface pressure). The smaller the radius of curvature of the area (bony prominences) the greater the likelihood of pressure damage.

    • Applying compression with the bandage system may require adjustment dependent upon the diameter of the leg. While the larger limbs may require increased tension care should be applied when applying multi-layer bandaging to a slim, narrow leg to avoid high levels pressure.

    Additionally each layer applied is additive. So if one were applying a two-layer wrap system with 50% overlap using 20 mm of compression will easily achieve 80 mm of compression at the ankle. A four-layer system can double that amount. Measuring pressure prevents excessive amounts of compression while at the same time providing consistency from one application to the next and from one provider to the next. This new technology should become a standard therapy for documentation and to help protect the provider and most importantly protect the patient.

  • References

    1. Hegarty-Craver, M., Kwon, C, Oxenham, W, Grant, E., Reid, L. Towards characterizing the pressure profiles of medical compression hosiery: an investigation of current techniques, The Journal of the Textile Institute. 2014. 106: 757-767

    Medical compression hosiery is prescribed according to the pressure it applies to a limb. There are many devices available for measuring this pressure,  but  differences in the design of  the  systems  used,  measurement locations, protocols, and operators result in different pressures being measured for the same garment. This article explores the construction of these compression-measuring devices and the sensing involved in order to highlight the potential causes of these discrepancies. The Tension–Elongation profiles of six compression hosiery samples were then measured, and a method of verifying the point pressure measurements from current techniques was proposed and tested. The results of this analysis show that there was an average discrepancy of 1–5 mmHg between point pressure measurements and those predicted from the Tension–Elongation profiles.  With respect to on-body  measurements, this technique predicted a maximum change in pressure of 3 mmHg for the samples tested.

    2. Hegarty-Craver, M., Grant, E., Kravitz, S., Reid, L., Kwon, C., Oxenham, W. Research into compression fabrics used in compression therapy and assessment of their impact on treatment regimens, Journal of Wound Care, Academy of physicians in wound healing supplement. 2014. 23: S14-S22

    The objective of this paper is to provide a definition for interface compression that uses essential principles of engineering science. This definition discusses factors that influence the amount of applied pressure, including the size of the limb, the amount of fabric tension (graduated pressure profile), the number of layers, and the material creep characteristics. Laplace’s law has been applied to compression therapy. Tension-extension profiles have been derived for different types of compression fabric to demonstrate the effects of resistance and friction. Force-time profiles have been derived for different types of fabric compression systems to demonstrate the effects of creep (creep is defined generally as the irreversible deformation of a material over time in the presence of a constantly applied load). Here, the fabric compression systems were applied to a test-bed that supplied a constant force to the fabric; creep was taken as the

    loss of compression (pressure) over time.

    Laplace’s law has been interpreted for compression therapy. The amount of fabric tension is determined by the extent to which it is stretched during application, as well as by changes in the size of the limb. The fabric’s relative elasticity, which is quantified by the rigidity index and is related to the slope of the tension-extension profile, dictates the amount that the applied force changes with extension. Compression systems that use multiple layers of fabric are generally more resistive to stretching than single-layer systems. Friction acting between the layers, as well as the added force from each layer, serves to increase the overall compression of these systems. As the applied force rises, the amount of pressure supplied by the fabric increases. However, when the same force (or fabric extension) is used, the applied pressure is less when distributed over a larger surface area. In other words, as the circumference of the limb increases, the pressure decreases. This is the driving principle behind graduated compression. In addition to the changes in fabric tension resulting from extension, the creep characteristics of the material affect the amount of compression provided throughout the wear cycle.

    Based upon the interpretation of the material properties of compression fabrics (tension-extension profile, number of fabric layers, and creep), new therapeutic guidelines have been established, and others clarified.

    3. Hegarty-Carver, M., Grant, E., Kravitz, S., Kwon, C., Reid, L. Simulated pressure changes in multi-layer, multi-component wrap systems when transitioning from rest to standing, Journal of Wound Care, Academy of physicians in wound healing supplement. 2015 24: S14-S20

    The largest changes in circumference were used to simulate the pressure changes under the multi-layer, multi-component products using Laplace’s Law. While the pressure differences were large for the zinc plaster product, pressure changes ranged from 5-I0 mmHg for the other, more elastic products. Additionally it was noted that the leg decreased in circumference at the B1  level and calf for the majority of participants when transitioning from sitting to standing. This decrease in size results in a decrease in bandage tension and applied pressure.

    4. Kravitz, S, Hegarty-Carver, M, Reid, L. Challenging current concepts in compression therapy: static stiffness index is not consistent and not clinically relevant, Journal of Wound Care, North American Supplement,  2016 26: S4-S8

    Once a circumferential force is delivered to a limb by a compression device, any change in total force is dependent upon a change in circumference, with the rate of change (excluding fabric creep) being dependent on the stress strain curve of the device. Compression is defined as the total amount of circumferential force applied to the surface (interface compression) of a cylinder at a known circumference. This article addresses the pre-conceived and well accepted principle that interface compression delivered by a compression device substantially increases with the position of the limb based on the positions of sitting (non-weight-bearing) to standing and/or during muscle activity (ankle dorsiflexion). Using engineering parameters and clinical measurements, the authors demonstrate that changes in interface pressure are minimal if any, and that the current concept should be modified accordingly.

    5. Kravitz, Steven, R. DPM, FAPWHc Commentary provider: Academy of Physicians in Wound Healing, Founder and Executive Director; Council for Medical Education and Testing, (CMET), Executive Director; Physician Certified in Wound Healing-CMET: Temple University School of  Podiatric Medicine, Philadelphia, PA; Assistant  Professor; Carolon Healthcare Products, Medical Director; International Compression Club, member