Appendix 1 Contents

Evidence tables
Evidence table: patient assessment 2
Evidence table: wound evaluation and measurement 8
Evidence table: psychological issues and compliance 10
Evidence table: staff training and education 14

The management of patients with venous leg ulcers Recommendations: Appendix 1 1

Evidence table: patient assessment

Current assessment practice
Study Design Results Comments Conclusions
Cornwall et al 1986 Cross-sectional study of all Prevalence of leg No information on response rates Lack of clinical assessment of
patients with leg ulcers known to ulceration=0.18% of epidemiological survey patients with limb ulceration in
To identify all active leg ulcers in
GPs and district nurses the community has led to long
a defined population 62% of patients with leg ulcers
periods of ineffective and often
Sampling: all eligible patients had never attended any hospital
UK inappropriate treatment
despite having an open infected
Setting: regional health district
wound A national initiative is required to
improve management of leg

Elliott et al 1996 Cross-sectional 53% response rate Small sample size Required standards for leg ulcer
assessment are not being met
To assess the prevalence of leg 30 district nurses and 10 50% of respondents used visual No information on sampling
ulcer disease, identify current community hospital nurses assessment alone; method
practices used in leg ulcer surveyed by audit questionnaire
30% used Doppler ultrasound; Percentage of those trained in
treatment and evaluate treatment within a trust
leg assessment form and visual Doppler or skill mix of sample not
Sampling: not specified assessment mentioned
Setting: Highland Communities 15% used Doppler and visual Study included because of
Trust assessment; implications for patient outcomes
and training
5% used assessment form and
visual assessment

Lees & Lambert 1992 Cross-sectional survey of 70 85% of patients with lower limb Use of computerized prospective
district nurses using a ulceration had been seen by a data may decrease accuracy -
To assess the prevalence of lower
questionnaire doctor during the history of their verification of patient hospital
limb ulceration within the
ulcer; 42% were seen by their GP appointments with medical
community health district and Sampling: convenience
only if requested by the district records would have improved
evaluate current patterns of
Setting: Newcastle community nurse reliability
health district
35% had been examined in More information on who does
hospital for their ulceration by a initial assessment and when
specialist (7% by a vascular would have been useful
No details on questionnaire used
Only 14% of patients with
ulceration had been treated by

Roe et al 1993 Cross-sectional 79% check for foot pulses with Sampling strategy not specified The importance of referral and
or without Doppler pain assessment need
To describe the current 146 district nurses in 3 district Comparability of findings in other
management of leg ulcers by health authorities/community 55% asseses patient’s experience regions would be of interest
community nurses trusts of pain Community nurses would benefit
from further information on the
UK Sampling: unspecified 71% measure the ulcer
aetiology and clinical
Setting: Mersey regional health 63% refer a non-healing ulcer for management of leg ulcers
a medical opinion
Community nurses who qualified
28% would give advice on before 1981 could benefit most
analgesia and 7 nurses would from further education
recommend the patient for
Educational initiatives designed
referral to a consultant
to disseminate research evidence
6 would refer patients with for good practice in the
rheumatoid or diabetic ulcers for management of leg ulcers in
specialist advice needed

Stevens et al 1997 Before-after audit Audit demonstrated that 81% of No breakdown by aetiology Adequate training in the
patients had not been assessed appropriate techniques of
To examine the effect of a Interviews with 79 patients Report rather than research
to determine the aetiology of assessment and treatment are
multidisciplinary community and identified from district nursing format
their ulcer prior to treatment required
hospital leg ulcer service on caseloads currently being treated
Research material relating to
patient outcomes and quality of for ulceration, using a Pain and immobility levels were
practice used (rather than
life questionnaire based on the substantially higher than
material addressing main
Nottingham Health Profile (NHP) population norms (p<0.05)
UK hypothesis because study design
compared to population norms
inappropriate )
Sampling: unspecified
Setting: community mental
health trust

2 The management of patients with venous leg ulcers Recommendations: Appendix 1

Evidence table: patient assessment

Pulse palaption
Study Design Results Comments Conclusions
Brearley et al 1992 Cross-sectional Over 10% of assessments Doctors only Implications for staff training:
diagnosed PVD in asymptomatic assessment of peripheral pulses
To assess the accuracy with 4 patients with peripheral
limbs and pulses were reported by inexperienced observers is
which different observers can vascular disease and one
in over 10% of limbs where unreliable. Pulse assessments
detect peripheral pulses asymptomatic
these were absent should be used only in
UK 50 observers (medical) combination with blood pressure
Vascular surgeons agreed over
measurements or other objective
Sampling: unspecified the palpability of 48/50 pulses
Setting: unspecified Surgical trainees and non-
vascular surgeons fail to detect
23% of palpable popliteal pulses
and 40% of posterior tibial

Callam et al 1987a & b Survey 65% of those with low Doppler Implications for staff training and
pressures had palpable pulses for recommending use of
To ascertain how frequently All patients receiving treatment
5% of those with normal Doppler objective criteria such as Doppler
arterial impairment could be for chronic leg ulceration (limit
pressures had impalpable pulses measurements of ABPI.
detected by simple non-invasive set at 600) were examined and
means interviewed by senior surgical 21% had an APBI of 0.9 or less
registrar and 10% had an index of 0.7 or
Sampling: convenience

Setting: Lothian and Forth Valley
Health Board

Magee et al 1992 Claudicant group of 33 patients Overall agreement for dorsalis Small sample - only one nurse The poor results of the trainees
(66 limbs) and control group of 5 pulse was 67%, while the overall and the nurse in palpating pulses
To investigate observer variation Previous training of staff not
patients (10 limbs) examined level of agreement for posterior in claudicants with normal ankle
in assessment of pedal vessels by mentioned
during same period by 4 tibial was 53% pressures suggest that acquired
pulse palpation and Doppler
observers (consultant, registrar, Small number of controls relative skill is required
auscultation The consultant performed best in
senior house officer and vascular to ‘test’ patients
palpating pulses in both DP and A careful history and palpation of
UK clinic nurse) with no knowledge
PT arteries with pressure indices Results not corrected for chance the important proximal pulses at
of patient’s history
>0.9 The consultant was femoral and popliteal level,
Sampling: unspecified for significantly better than the nurse supplemented by Doppler studies
patients or staff (p<0.01) is recommended
Setting: unspecified In the claudicant group, indices
measured by the four observers
varied by more than -/+0.15 in
only 8 limbs (12%)

Moffatt et al 1994 Ankle pulses palpation of Sensitivity for lack of pulses as a Nil inclusion/exclusion criteria Palpation of pedal pulses by
patients presenting with predictor of arterial disease (ABPI community nurses is a poor
To investigate the ability of Nil studies of reproducibility of
ulcerated limbs compared with <0.9) was 63% with a specificity predictor of arterial disease and
district nurses to detect lower methods
ABPI of 75% and positive predictive must by used in combination with
limb arterial disease by palpation
value of 35% Study period not specified ABPI
of ankle pulses Sampling: sequential patients
Using only the absence of Unsure whether blinded Only when arterial disease is
UK Setting: community ulcer clinics
palpable pulses would lead to interpretation of the reference excluded should compression be
37% of patients with arterial standard and pedal pulse applied
disease being treated palpation

The management of patients with venous leg ulcers Recommendation: Appendix 1 3

so that a smaller change in ABPI will be recognized Setting: hospital department of as significant vascular surgery The size of the difference in repeat ABPIs required to demonstrate significant change should be broadened to is possible have received formal training measurements as performed by 2 newly qualified doctors paired lower than those recorded by the the ones in experiment 2 may Measurements that reveal a junior medical staff with a vascular technician technician.33 to Repeat ABPIs to assess the technicians +0. Evidence table: patient assessment Doppler studies Study Design Results Comments Conclusions Fisher et al 1996 Before-after Overall time between tests was a Vascular technicians rather than Differences arose solely as a median of 51 days (10-103) nurses were used result of variations in To determine the variation of Examination of preoperative and measurement ABPI measurements in routine post-operative ABPIs in 130 Rate of change in observed ABPIs clinical practice limbs in 123 patients by vascular after surgery was from -0. with nearly 30% have had more experience in significant fall in ABPI should be UK vascular studies during training repeated by a more experienced 2 different newly qualified The differences in 46 ABPIs taken person doctors who had undertaken a by the doctors with training and formal initial 40 min training technicians were distributed secession paired with one of the more normally same two vascular technicians Sampling: unspecified Setting: unspecified Clinical Predictors Study Design Results Comments Conclusions Nelzen et al 1994 Cross-sectional The predictive value did not No information on who did The most useful clinical predictor exceed 0.74 for any single clinical assessments and whether of venous ulcer was the presence To report data on the clinical All patients with current chronic predictor or not assessor blinded to case of varicose veins This finding history and appearance of ulcers leg ulcers (827) were identified status highlights the importance of and analyze the diagnostic value and a random sample of 382 Combinations of predictors did performing non-invasive of classical clinical predictors of studied in detail not substantially raise the haemodynamic investigation to venous leg ulcers predictive value Sampling: random make a proper aetiological Sweden diagnosis .25 results of intervention or Australia progression of disease should be Mean time between tests: 51 No net change occurred in the compared with a mean ABPI days ABPI between tests determined from multiple Sampling: consecutive this study 26% of Setting: Skarabourg legs with venous ulcer also had detectable arterial insufficiency 4 The management of patients with venous leg ulcers Recommendations: Appendix 1 .21 when the ABPI has not been determined from multiple observations Ray et al 1994 Cross-sectional The majority of the 76 APBIs More details about the skill mix Junior doctors should not perform measured by doctors without of the newly trained doctors ABPI measurements until they To examine the accuracy of ABPI 37 patients formal Doppler training were would be useful .

9. eg: Makes important point that when over 12 months were recorded in patients present with recurrence To investigate the progression of Follow-up = ‘at least 1 year’ how/where recruited. assessments correctly identifying aetiology To report the results of a single- prospectively) 2% as arterial and 13% as mixed before commencement of therapy visit ulcer clinic aetiology 4 were secondary to Sampling: convenience (n=88) UK lymphoedema. (risk of 23 out of 79 (29%) limbs of ulceration nurses may apply arterial disease in a group of referral bias) 55 patients (79 recently ulcerated compression bandaging without patients with healed leg ulcers legs) with ABPI > 0.Evidence table: patient assessment Progression of arterial disease Study Design Results Comments Conclusions Scriven et al 1997 Cross-sectional results reported 14% limbs ABPI < 0.8 representativeness of sample or repeating ABPI measurement UK attrition rates Sampling: consecutive unclear whether length of time Setting: not specified ulcers healed taken into account diagnostic criteria not stated clearly appears to have used only 1 criteria (ABPI) to define arterial disease (ABPI does not constitute a diagnosis but is indicator of underlying arterial disease) multiple counting of individuals use of word ‘significant’ without results unclear whether adjustment for important prognostic factors The management of patients with venous leg ulcers Recommendation: Appendix 1 5 . 79% Unsure regarding timing of Stresses the importance of (although says patients studied ulcers were classified as venous. 1 as a BCC and 2 Arterial status measured with of uncertain aetiology ABPI. Duplex scanning Clinical history with respect to Setting: leg ulcer clinic previous DVT was unreliable as an indicator of deep venous function Simon et al 1994 Cohort ‘Significant’ reductions in ABPI Details on study lacking.

patients pain and 14% had severe pain relating to pre-treatment To evaluate graduated duration of ulcer) compression bandaging (selected Sampling: convenience because includes of descriptive Not a random sample Follow-up: 12 weeks statistics on pain assessment) No information on how pain Setting: NHS Trust UK measured Hamer et al 1994 Survey Preliminary results show that Control group analysis not pain (38%) and restriction of available To evaluate the perceptions Leg ulcer patients. Hospital their pain as ‘aching’ while at the the impact of having a leg ulcer Anxiety and Depression Scale.05) Dunn et al 1997 Longitudinal audit study on 30 72% suffered with moderate No stratification analysis (eg . 65 years and mobility (31%) were the worst patients have of their leg ulcers over Baseline characteristics of things about having an ulcer and the impact leg ulcers have on respondents not reported Sampling: random lifestyle 53% did not want more No breakdown by aetiology Setting: Wirral Health Authority information about their leg ulcer Hofman 1997 Prospective 69% said pain the worst thing No information on refusal Patients in the study did not all about leg ulcer. Health Locus of ulcer Control The intensity of pain was Sampling: random sample of 88 inversely proportional to the patients > 65 years matched ABPI.of these 27% diagnostic criterion patients with venous leg ulcers were prescribed no analgesia Follow-up: unsure/? 6 months Assessment of pain is an Sweden/UK important but neglected part of Setting: leg ulcer clinics at the management of venous Malmo and Oxford over a period ulceration of 6 months using a validated verbal pain rating scale 6 The management of patients with venous leg ulcers Recommendations: Appendix 1 . supporting the notion that with health age-matched controls ulcers with an arterial component Setting: Wirral Health Authority are more painful (p<0. Life ulcer patients (70%) described perceptions of their leg ulcers and No information on response rates Satisfaction Index. time of the interview. the majority of leg venous ulcers or other aetiologies To investigate patients’ measures such as NHP. 64% reported /follow-up rates get relief by leg elevation and this To assess the prevalence. Evidence table: patient assessment Pain assessment Study Design Results Comments Conclusions Chase et al 1997 Phenomenological participant Pain was rated as one of the Further research needs to be observation of 37 patients major problems related to leg conducted to determine whether To examine the lived experience ulcer disease the kind of pain venous ulcer of healing a venous ulcer for Sampling: convenience patients’ experience necessitates patients treated in an ambulatory Follow-up: 1 year unique approaches to surgical clinic management Setting: ambulatory surgical clinic USA population in an urban teaching hospital Cullum & Roe 1995 Survey using semi-structured Using the McGill Pain Unsure if sample restricted to interview and established health Questionnaire. severity Interviews of 140 patients the pain was ‘horrible’ or should not be used as a and diagnostic utility of pain in Sampling strategy not specified Sampling: consecutive ‘excruciating’ . 31% on well-being and life-style short form McGill Pain experienced pain from their leg UK Questionnaire.

the diabetic patients of active leg ulcers among Swedish survey using a Inter-observer reliability not prevalence of isolated foot ulcers diabetic patients structured history and objective assessed was 1. co-morbidity) number failed to heal (42%.08-9.2). a significantly greater type of bacteria appears to affect profile of patients with leg ulcers factors (aetiology. healing rate Sampling: unspecified Australia p<0. or 2.5% (95% CI 2.small sample in which the diagnosis of To report on 3 case studies of malignant leg ulcers may be malignant leg ulcers delayed UK Baldursson et al 1995 Record audit of 10913 patients 0. relative to the risk for the Sweden Sampling population normal population of developing non-melanoma skin-cancer on the lower limb was 5.21% of patients in this study Study findings dependent on the with venous leg ulcer matched developed a SCC in their ulcer accuracy of medical records To obtain an estimate of the with Swedish Cancer Registry (possibility of recorder error.80 (95% CI 3.3) assessment to assess disease Sweden Sampling: random selection from 827 patients with leg ulcers Setting: Skarabourg county Yang et al 1996 Descriptive study from data The frequency of malignant Results may not be generalizable A biopsy should be taken from all collected between 1988-1995 ulcers were 4. selection and carcinoma in venous ulcers ulcers of developing SCC in their limbs surveillance bias) ulcers. relative risk of squamous cell Risk for patients with venous leg registrations of SCC in lower misclassification.29) Nelzen et al 1993 Cross sectional Point prevalence of active leg Unsure of validity of case Arterial impairment is present in ulcers in diabetic patients was ascertainment a majority of ulcerated legs of To estimate the point prevalence 414 leg ulcer patients from a 3.2 per 100 leg ulcer rates and a higher proportion of not respond to treatment malignant ulcers in patients 981 patients (2448) ulcers 75% were basal cell carcinoma malignant ulcers were found in presenting with leg ulcers Sampling: consecutive and 25% were squamous cell this study compared to other Australia carcinoma reported frequencies Setting: specialised leg ulcer clinic at a tertiary teaching hospital Bacteriology Study Design Results Comments Conclusions Skene et al 1992 Randomized parallel group Bacteria present at initial 4 months may be insufficient The presence of bacterial controlled trial assessment was entered into a follow-up contamination seems to be of To evaluate the prognostic factors proportional hazards model as a little relevance to venous ulcer in uncomplicated venous leg ulcer Assessment of a hospital vascular Unsure of how bacterial growth possible covariate but did not healing healing (chosen for information unit with community based ascertained (swabs?) enter the final model on bacterial growth) treatment Unsure if outcome assessment UK 200 patients with clinical and blinded objective evidence of uncomplicated venous leg ulceration and an initial ulcer diameter of >2cm Sampling: unsure Follow-up: 4 months Setting: hospital vascular unit Trengove et al 1996 52 patients with venous or Of the 26 ulcers in which 4 or Nil report of losses to follow-up The number of types of bacteria venous and arterial disease more bacterial groups were present rather than the specific To investigate the bacterial Nil adjustment for prognostic participating in RCT present.01) No definition of failure of Wound swabs are not necessary Follow-up: ? 6 months progression of healing in the routine treatment of these Setting: Fremantle hospital leg unsure if documentation each wounds ulcer clinic visit made by same observer The management of patients with venous leg ulcers Recommendation: Appendix 1 7 .8% (95% CI 1.4 per 100 leg ulcer as Australia has high skin cancer suspicious ulcers or ulcers that do To evaluate the frequency of patients.8-4.3-2.Evidence table: patient assessment Other ulcers Study Design Results Comments Conclusions Ackroyd & Young 1983 3 case studies Illustration of the different ways Case study .

026.99 computerised method times each within a single clinic visit then scanned into a USA computer to calculate wound surface area Sampling: consenting volunteers Experienced family nurse practitioner Setting: Veterans Affairs Medical Centre Buntinx et al 1996 Cross-sectional Average inter-observer Accuracy of measurement or Classification by colour was agreement was 75% for intra-observer agreement not moderate to good To study the inter-observer 20 patients with 21 pressure inflammation. 76% for local measured variation in wound evaluation in sores. 29% (0-58) and 55% (21-89) Only small number of leg ulcers Inter-observer agreement was Sampling: convenience in patient sample very good for assessment of size Average observer agreement Setting: geriatric department of and area of wounds for 6 possible scores was 76% Intra-class correlation not used University Hospital and group Kappa was 59% (95% CI 41-77) Etris et al 1994 Cross-sectional Correlation coefficient between Study conduct details lacking Both the photo and tracing the 2 methods was 0. digital testing of planimtetry. Cronbach’s alpha was determining healing progress wound area calculations using a traced onto transparent film 3 0. 2 arterial and 3 venous Moderate agreement was found heat.98 respectively). performed at weekly intervals when compared with although stereophotogrammetry until the ulcer healed or for a stereophotogrammetric methods is time-consuming and requires maximum of 7 intervals and had limited reliability specialist skills Sampling (patients): convenience Setting: metropolitan rehabilitation hospital and community nursing setting 8 The management of patients with venous leg ulcers Recommendations: Appendix 1 . 85% for pus. Evidence table: wound evaluation and measurement Study Design Results Comments Conclusions Ahroni et al 1992 Cross-sectional For all 50 sets of tracings the Intra-rater reliability not Placing the current tracing over a mean coefficient of variation was examined previous tracing is helpful in To establish the reproducibility of 50 diabetic foot ulcers were 0. measuring leg ulcer healing standard and concurrent validity healing in any setting (r= 0. the Kundin Australia r= 0. the respective a group of physicians and nurses ulcers Small samples of both patients in assessment of signs of group kappa values and 95% CIs and observers infection Netherlands 3 physicians and 3 nurses were 47% (19-85). Stereophotogrammetry.97 methods were accurate and To evaluate the predictability and 65 patients with an ulcer 60 patients but 450 observations reproducible accuracy of the photo and tracing diagnosed secondary to either Inter-site variability accounted for P-value of correlation coefficient method for wound size venous insufficiency or diabetes only 54% of total variability in not specified measurement mellitus 1-100 cm2 present for a these observations minimum of 4 weeks Intra-class correlation not used USA Sampling: subjects from RCT Unclear who did the assessments Setting: not reported Johnson & Miller 1996 Cross-sectional Comparisons using digital Analysis did not correct for Subjective methods (Healing and planimetry and the Kundin chance Johnson scales) should not be To compare the reliability and Leg ulcers were measured with Wound Gauge supported the use considered as suitable methods validity of 4 methods of stereophotogrammetry as the of these methods for monitroing for measuring healing.99. The planimetry and the Kundin Wound Gauge and the Johnson Healing and Johnson scales did Wound Gauge are suitable and Healing scales was not show concurrent validity methods for measuring healing.

more important d) a digitizer Evaluating wound depth wound Sampling: Peripheral vascular requires different methods clinic Setting: unclear The management of patients with venous leg ulcers Recommendation: Appendix 1 9 .91) or for 3 more time than use of a paper grid measurements (p=0. validity No information on prior training hospital with a well-defined leg the two raters for either would size and feasibility of grid and experience of the nurses ulcer were eligible (60 leg ulcers) technique measurements to a tape measure The greater accuracy of the grid is 2 registered nurses Intra-rater: no significant good for medium to large USA independently measured each differences occurred for either wounds and those whose shapes ulcer and kept the results raters in the 3 tape are irregular The grid takes no separate from each other measurements (p=0. Although the To establish intra-rater and inter. examiner and technique may be c) hand-held planimeter. equipment b) placing the transparency on graph paper and counting the Consistent use by the same squares.99) Inter. calculate wound areas more measuring wound surface from prior to data collection made tester reliability was also high quickly than using a grid most transparency film tracings 2 tracings of each wound to (intra-class correlation=0. 3 physical therapists without area was high (intra-class generalizability planimeter can be used to rater reliability of 4 methods of training or practice sessions correlation=0.99) community nurses would not estimate wound area by USA have this rather expensive a) a ruler. both raters measurements were significantly greater Tape accuracy decreased with larger size ulcers Grid accuracy varied with the shape of the ulcer Majeske 1992 Cross-sectional Inter-rater reliability for each Physiotherapists rather than The ruler method was less method of determining wound district nurses may restrict accurate.Evidence table: wound evaluation and measurement Study Design Results Comments Conclusions Liskay et al 1993 Cross-sectional Patients from a Inter-rater: no significant Intra-class correlation not used Use of the plastic grid is a reliable dermatology clinic of a teaching differences were noted between and valid method to determine To compare the reliability.97-0.51) tape measure Setting: dermatology clinic Good correlations were obtained Sampling: convenience between tape and grid measurements by both raters Wound size was significantly overestimated by the tape compared to the grid Validity Compared to computer- generated tracings.

medical self esteem (p<0.05) but there was no quicker healing and many of and the impact of having a leg Anxiety and Depression Scale. Limitations to mobility. although and psychological well-being of a Aetiology not specified disability spectrum. lower than matched controls.05) than the Convenience sample greater feelings of loneliness or ulceration with a matched group measure of common controls dissatisfaction that the controls of controls Data collection procedures psychosomatic symptoms. difference in anxiety levels those factors which diminish ulcer on well-being and life-style short form McGill Pain However.01) and health worries described significantly greater problems To compare the perceived health with controls using the General and concerns (p<0. lower life satisfaction and with health age-matched controls less social contact (p<0.01) and more did not report significantly group of chronic lower leg problems scare and a 9-item negative affect (p<0.05) Setting: Wirral Health Authority Flett et al 1994 Survey of convenience sample of Leg ulcer patients reported more Matching procedure not Ulcer patients reported 14 leg ulcer patients matched pain (p<0. there were more quality of life would disappear UK Questionnaire. ‘limits powerlessness and disability To examine the lived experience and accommodation’. health and pain ratings different for cases and controls NZ Sampling: convenience through Small sample size without a district nurses power calculation Setting: Dunedin No comparative baseline table Conclusions restricted in view of lack of comparative baseline data More information on reliability and validity of some instruments 10 The management of patients with venous leg ulcers Recommendations: Appendix 1 . Hospital group (p<0. Evidence table: psychological issues and compliance Quality of life Study Design Results Comments Conclusions Charles 1995 Phenomenology Patients experienced pain. psychological and social To examine the quality of life 4 patients selected Aetiology unknown quality of life suffering that patients’ with leg experienced by people who have Sampling strategy or setting not Control group needed to see if ulcers experience lived with leg ulceration for many specified results differ from population years norms UK Chase et al 1997 Phenomenological participant Four major themes emerged: ‘a Patients experience pain. observation of 37 patients forever healing process’. lack of Sample size very small Nurses should acknowledge the effective help and a reduced physical. Health Locus of depressed patients with leg with the ulcer Control ulcers than without Patients with malodorous ulcers had Sampling: random sample of 88 higher anxiety and depressions patients > 65 years matched cores.05). activity of healing a venous ulcer for Sampling: convenience ‘powerlessness’ and ‘who cares ’ and socializing were also patients treated in an ambulatory Follow-up: 1 year experienced surgical clinic Setting: ambulatory surgical clinic USA population in an urban teaching hospital Cullum & Roe 1995 Survey using semi-structured Patients with leg ulcers had Unsure if sample restricted to Appropriate assessment and interview and established health significantly lower scores for life venous ulcers or other aetiologies treatment (compression for To investigate patients’ measures such as NHP Life satisfaction than the control venous ulcers) will facilitate perceptions of their leg u lcers No information on response rates Satisfaction Index.

economic classes but the different socio-economic classes employment. Setting: as above including feelings of fear. social isolation. leisure Sampling: convenience of more than 5 years duration ulceration can result in activities and mobility Setting: Lothian and Forth Valley than other social classes consideration restriction of UK activities which in 5% of cases 21% had moderate or severe leads to loss of employment limitation of work representing prolonged periods of work or inability to continue with their occupation 42% experienced moderate or severe limitation of their leisure activities The management of patients with venous leg ulcers Recommendation: Appendix 1 11 . arterial and mixed of the results perceived health subjective perception of health The global NHP score for leg venous-arterial aetiology with related to quality of life ulcer patients was M=173% Analysis of NHP scores difficult to sex. Possibility for recall survey skilled or unskilled background prognosis appears to be less and asses the effect of leg bias had a higher percentage of ulcers favourable when it occurs Leg ulceration on employment. anger. using the first section of the NHP Non-random sample Sampling: consecutive Setting: Department of Dermatology Phillips et al 1994 Cross-sectional 65% had severe pain No breakdown by aetiology Morbidity from leg ulcers can substantially reduce many aspects To assess the financial.and age adjusted normal interpret Sweden score values. social and 73 patients with chronic leg 81% stated their mobility was Inadequate reporting of of a patient’s quality of life psychological implications of leg ulcers presenting to vascular adversely affected multivariate results ulcers surgery or dermatology services 76% said that their financial No control group or population at University medical centre USA situation was adversely affected norm comparisons interviewed using standardized by the ulcer personal interview schedule Nil reports of reliability and 68% reported that the ulcer had validity of instrument used Sampling: not specified a negative emotional impact. depression and negative self-image Walshe 1995 Qualitative: phenomenological Pain and impaired mobility were Small sample size the major restrictions described To describe the experience of Unstructured interviews No information on how patients living with a venous leg ulcer conducted with 13 informants in recruited their homes UK Poor response rate (13/26) Sampling: purposeful random sample Setting: one health district Socio economic factors Study Design Results Comments Conclusions Callam et al 1988 Survey of 600 patients receiving No increased incidence of chronic No significance testing Chronic leg ulceration does not treatment for chronic leg leg ulceration in the more seem in this study to be more To report the relative incidence of Unsure of method used to ulceration in any branch of the disadvantaged socio-economic common in the lower socio- chronic leg ulceration in the measure effect of leg ulcer on health services at the time of the groups but patients with a semi.Evidence table: psychological issues and compliance Quality of life continued Study Design Results Comments Conclusions Lindholm et al 1993 Comparative analysis between Pain scores were elevated in all Did not control for aetiology The presence of a leg ulcer has a 125 patients with leg ulcers of categories of patients which may have explained some marked impact on patients To describe leg ulcer patients’ venous.

with mean wounds with normative data based on in physical and social functioning differences in excess of 20 points USA British samples and poorer general health and for 5 sub-scales limitations in physical and Sampling: not stated Duration of the ulcer for >24 emotional roles months was related to healthier Setting: wound healing clinic perceptions in terms of pain and attached to university teaching general health. measured by asking subjects poor healers may have less access To examine the effects of patient Follow up: 1 month economic status as measured by previous occupation As older to appropriate dressings and characteristics and environmental Sampling: convenience occupational status (p=0. hostility. Dimensions examined between cases and controls life small However. Evidence table: psychological issues and compliance Healing and quality of life Study Design Results Comments Conclusions Johnson 1995(a) Longitudinal. Pain in (p=0. may have directly or indirectly successful ulcer healing on Follow-up: 12 weeks hostility and cognition scores been the cause of the healing psychological factors Setting: Charing Cross were all significantly improved at rather than a result of it UK 12 weeks Hospital/Riverside Health Authority Measurement of quality of life Study Design Results Comments Conclusions Franks et al 1992 Self-administered symptom rating There was no significant Not sure if psychiatric morbidity The impact of venous disease on test to cases and matched difference in psychiatric morbidity necessarily measures quality of psychiatric well-being may be To examine the impact of venous controls. the result may be disease on quality of life by the scale include anxiety. explained 24% of the variance in this may explain why physiologic associated with poorer healing therapeutic and psychosocial Medical Outcomes Study Social healing rate factors explain major variance in rates in the venous sample rather determinants of leg ulcer healing Support scale healing rates than measures of self-efficacy Australia and social support Sampling: partly random Short follow-up period selection and partly convenience Follow up: 1 month Community-residing older people from home-nursing lists with venous and venous-arterial disease (n=156) Johnson 1995(b) Descriptive comparative study Healers and non-healers differed Uncertain if occupational status Practitioners must consider that significantly only on socio.03) age group many may not have medical care factors on the healing of leg ulcers Setting: Patients ≥ 60 years using with poor healers more likely to been employed home nursing services in two be from lower occupational Unclear if self-rated health Australia status Australian cities measured using a validated instrument Short follow-up period Moffatt et al 1991 Longitudinal Symptom Rating Test scores and Uncontrolled study therefore Difficult to ascertain in absence of pain scores improved over 12 reduced depression and hostility control group To examine the effect of Sampling: convenience weeks. cognition of controls may bias results and somatic Results aggregated (venous ulcer Sampling: patients were drawn grouped in ‘venous disease’) from a larger investigation of prevalence of venous disease More information of reliability required Setting: 3 general practices Price & Harding 1996 63 patients with a variety of Patients rated themselves Mixed aetiology Patients with chronic leg conditional producing chronic significantly lower on 7 of the 8 ulceration rate themselves as To examine the usefulness of the Small sample size wounds on the leg (minimum subscales. with other variables. less vitality. ulcer adjusted for in analysis . more restriction matched groups. including pain on mobility were To identify the physiologic. Anxiety. Increased pain on mobility Not clear if age or duration of Physiologic determinants Wound Status Index. possibly because hospital patients have reduced expectations of recovery over time Further research is needed to investigate the sensitivity of the SF-36 to changes over time for this group and to compare the performance of this tool with a form of outcome measure specifically designed for patients with leg ulcers 12 The management of patients with venous leg ulcers Recommendations: Appendix 1 . Mobility Index. using Edema Index. Self-Efficacy scale. depression. biased due to low response rate Low response rate of controls UK depression. experiencing more functioning well below age- SF-36 in patients with chronic leg duration of 3 months) compared pain.002).

02) significantly venous ulcers in compliant and stasis ulcer decreased initial ulcer healing non-compliant patients Sampling: all patients 1974-1989 USA Setting: hospital vascular clinic Samson & Showalter 1996 Cohort Stocking use was good in 47%. cognitive status of patients Setting: patients presenting to ulcer management etc) leg ulcer clinics UK The management of patients with venous leg ulcers Recommendation: Appendix 1 13 . USA Sampling: convenience difficult to don 21% and too hot 4% Follow-up = ‘more than’ 6 months Recurrence rates in noncompliant patients were 96% compared Setting: 2-person private practice with 4% in patients who wore stockings appropriately Taylor 1992 (unpublished) Semi-structured interview No patient fully complied with Small sample size (n=12) Patients require education to see technique their care plan the benefit and rationale for To examine the problems and Inclusion/exclusion criteria not compression bandaging perceptions patients experience Sampling: convenience applied? (case definition of leg in complying with venous leg ulcer.02) and fewer recurrences for venous ulceration Information needed on whether (p=0. forgot instructions 25%. inaccuracies in To document the healing %-age severe chronic venous pretreatment ulcer duration of > medical records and long-term recurrence rate of insufficiency treated for venous 9 months (p=0. 24(5):905 Mayberry et al 1991 Retrospective medical record Noncompliance with elastic Possibility of surveillance bias. Did not specify who classified poor in 23% and negligible in compliance and report the To analyze patient compliance 56 patients with documented 30% Reasons for not wearing reliability of the compliance and to evaluate cost of deep venous insufficiency and stockings included expense measure compression stocking therapy ulceration (78%).0001) and a selection bias. review of 119 patients with stockings (p<0.004) Sampling: unsure the compliant group differed USA from the non-compliant group on Follow-up: 1-156 months prognostic/ Setting: nurse managed/physician Socio-demographic factors supervised ambulatory clinic in academic medical centre Other methodological problems outlined by Scriven JM & London NJM in Letter Journal of Vascular Surgery 1995.Evidence table: psychological issues and compliance Compliance Study Design Results Comments Conclusions Ericksson et al 1995 71 patients (99 venous ulcers) Patients who strictly complied Unsure of reliability of analysed by a retrospective had significantly faster healing measurement of compliance To evaluate a treatment program review of clinic records (P=0.

To evaluate changes in nursing knowledge. Feedback given on actual technique are sustained studies will include multi-layer consisting of feedback from a pressures and continues bandages) pressure monitor and advice from UK feedback given from monitor an experienced bandager while each nurse practised Additional follow-up periods important factors in improving bandaging would be useful sub-bandage pressure profile Follow-up: 2 weeks Examination of patient outcomes Sampling: self-selected (eg . Evidence table: staff training and education Study Design Results Comments Conclusions Bell 1994 Pilot descriptive structured 4 identified a good blood supply. skill-mix of with introduction of training. bandagers-unspecified Setting: not specified Luker & Kenrick 1995 Pre-post test 2 group Experimental groups knowledge Sampling strategy not specified experimental design scores significantly improved To evaluate the impact of a leg Uneven group sizes (p=<0. care for at least 1 patients/week with leg ulcer Sampling: non-probability convenience Dealey 1998 Pre.and post-training test to There was significant Scant information sampling. improved healing rates) would be useful Setting: not reported 14 The management of patients with venous leg ulcers Recommendations: Appendix 1 . respect to leg ulcers compared to 95%CI 5. skill-mix etc) Nelson et al 1995a 18 nurses who had attended leg Difference in bandage proficiency 11/18 returned for repeat testing Improvements effected by ulcer study days (mix district and score between the baseline and training sustained at 2 weeks To examine the effect of: a Small sample size (though non- hospital) applied bandage to post-training readings was <0. knowledge (94% able to use nurses prior to study. 11 to improve their knowledge of the physiology of wound healing identified absence of infection the physiology of wound healing Inclusion criteria: 2 years post- Eire and 12 identified rest as factors graduate. numbers of UK nurses aware that they should use compression bandages for venous ulcers increased from 27% to 98%) Logan et al 1992 Cross-sectional Pressures produce by Small sample size Lack of experience or training inexperienced bandagers were was an important factor in the To compare sub-bandage 10 patients much more variable than those of observed inconsistency of results pressures produced by 10 bandagers (5 experienced experienced bandagers and in achieving target pressures experienced and inexperienced nurses and 5 inexperienced in leg bandagers bandaging) UK Sampling: patients-volunteers. Nursing knowledge improved evaluate changes in nursing improvement in level of nursing method of education. time span knowledge and practice with Doppler at end of programme of pre. work in a hospital that enhance wound healing in outpatient department with leg venous leg ulcers ulcer clinics. qualified nurses should be set up To examine nurses’ knowledge of Small.01 bandage tension indicator and parametric tests used) Tension guides are not sufficient volunteers leg using normal and maintained after 2 weeks pressure monitor on bandaging to produce an acceptable technique and then used a <0. Nil response rate An educational programme for interview of 18 RGNs from 2 14 identified adequate nutrition.1-7.5) ulcer information pack on 171 community nurses in 5 Non-randomized groups and no reported practice health authorities information on comparability of UK Sampling: not specified nurses in experimental and control sites pre and post test Follow-up=6 weeks respondents. therefore difficult to substantiate conclusions that leg ulcer pack was effective No adjusting for potential confounders (years of experience.01 Self-selected group skill To examine the bandaging bandage pressure profile marked bandage to indicate skills of nurses to what extent Single layer bandage used Bandage position and overlap are recommended extension improvements in bandaging (though authors state future also important Training.0001. non probability sample Dublin hospitals 1 identified walking/exercise.

data completed for knowledge and reported significant for assessment. changes in scores for the video proved to be a valuable To evaluate the impact of a No baseline information on assessed pre and post-training experimental groups were highly adjunct to the study days. However. and reported practice of nurses in training etc) practice treatment and general the management of leg ulcers knowledge. but appears to UK certain areas were poor results be no adjustment for were found both pre.Evidence table: staff training and education Study Design Results Comments Conclusions Nelson & Jones 1997 Non-randomized groups After exposure to the training Uneven group sizes The clinical information pack and (experimental and control) were pack. training pack on the knowledge groups (skill mix. there were Non-randomized.and post. differences were Would be valuable to see if Multi-layer bandage systems are technique of 25 nurses and 12 greater for the 2 single-layer technique improved over time easier to apply and more To compare levels of compression doctors both experienced and bandages than for the 2 multi. confounding in analysis. consistent pressures are achieved achieved in the application of inexperienced in the application layer systems tested than with single-layer both multilayer compression of compression bandaging compression bandaging with bandage systems and single-layer systems on a healthy volunteer both experienced and bandages by both inexperienced inexperienced practitioners and experienced practitioners Sub-bandage pressure was measured using an Oxford Specialist training in the UK Pressure Monitor II application of high compression bandaging is required The management of patients with venous leg ulcers Recommendation: Appendix 1 15 . test Roe et al 1994 Descriptive survey by group 64% respondents reported they Sampling method not specified Nurses require further questionnaire in 3 trusts within would apply compression information and knowledge To investigate the nursing Mersey area of 146 district bandaging to venous ulcers only about the normal physiology of management of patients with nurses the leg and aetiology of leg ulcers chronic leg ulcers Only 6 described the is required to reduce variation in Sampling: not specified recommended technique for UK practice compression bandaging Stockport et al 1997 Evaluation of bandaging In general.

16 The management of patients with venous leg ulcers Recommendations: Appendix 1 .

Appendix 2 Effective Health Care Bulletin (Compression therapy for venous leg ulcers. 1997) The management of patients with venous leg ulcers Recommendations: Appendix 2 1 .

2 The management of patients with venous leg ulcers Recommendations: Appendix 2 .

recurrence of venous leg ensure adequate nurse ulcers. However. high compression therapy. layer or short stretch including patient bandages. pressure (ABPI) rather than feel for foot pulses alone. leg ulcer management. community nursing ■ Use of compression services and relevant stockings should be hospital specialists so as to encouraged to prevent the co-ordinate services. can discussed with providers of significantly improve primary care and healing rates. The contents of this bulletin are likely to be valid for around one year. using stanozolol or oxerutins. disease are not suitable for NHS Centre for Reviews especially in older people. ■ Routine application of high compression therapy using ■ Community nurses should one of a number of be adequately trained in systems such as 3-. Unna’s boot or assessment and bandage compression stockings. There is wide variation in Arterial disease can be and Dissemination. or 4. by which time significant new research evidence may have become available. possibly with the addition of intermittent pneumatic ■ The issues raised in this bulletin should be compression. AUGUST 1997 VOLUME 3 NUMBER 4 ISSN: 0965-0288 Effective Health Care Compression therapy for Bulletin on the effectiveness of health service interventions for venous leg ulcers decision makers ■ Venous leg ulcers are a ■ Patients with arterial major cause of morbidity. and evidence of diagnosed more accurately unnecessary suffering and if highly trained operators University of York costs due to inadequate measure the ratio of ankle management of venous leg to brachial systolic ulcers in the community. . practice. application. there is education and establish little evidence to support systems to monitor the use of drug therapy standards of care.

36. 1 A venous ulcer diagnosing venous ulceration.16 4-layer17 problems) in approximately 20% of or short stretch bandages18 cases of leg ulceration. A range of (two using Tensopress and one greater than 10cm2.14 and prevalence increases with age in the Cochrane Library. which apply varying levels of low compression (using 2 EFFECTIVE HEALTH CARE Compression therapy for venous leg ulcers AUGUST 1997 .13 increasingly advocated in the UK.1 The importance of leg stockings.12 Numerous types of effective (1991 prices) of which nursing wound dressings. The evaluated intermittent pneumatic methods used in this systematic compression. A leg ulcers in survey of 301 patients with leg the USA is ulcers in the Wirral found 26 Unna’s boot. deep vein thrombosis and those compression.5–7 Leg effectiveness of dressings. compression: Six RCTs assessed ulceration is strongly associated debridement or skin grafts which whether compression therapy was with venous disease (e. 20 2-layer. 39 Overall.000 in bulletin does not consider the B.14 on evaluations. 6 Audits have uncertainty Annual costs to the NHS of leg shown wide variation in the however. The up to around 20 per 1. bandages and method. is viewed B.1 Leg ulceration is a leg ulcers are managed by GPs and elasticity. B. A. (Table 1).g. varicose are the subject of future review better than no compression veins and a history of deep vein work. on venous ulcer healing in a wide effectiveness of different forms of range of age groups. 2 Compression short stretch bandaging from toe to bandaging is skin.1 Compression versus no people over 80 years. and on methods of compression bandages. 28 bandages and 59 topical whilst 4-layer bandaging is preparations in use. a summary population have active leg ulcers appendix and given in more detail is available elsewhere. 1). A similar audit in Stockport knee identified 31 different dressings. 3 hospital settings.2 High compression versus low of 26%10 to as high as 69% at one as a key component of treatment compression: Three RCTs year being reported.3.16–35 Two of compression in the treatment of these incorporated economic venous ulceration.000 review15 are outlined in the quality of trials is poor.10 different ulceration: Leg ulcers are areas of materials with “loss of skin below the knee on the A. 37 and 2 Fig. a history of compression systems are used (see Setopress as a component) with Box). more popular.4 stockings are used in the preferred treatment of venous leg ulcers and treatment for the prevention of recurrence. Twenty randomised controlled This issue of Effective Health Care trials (RCTs) evaluated different summarises the results of research forms of compression bandaging on the effectiveness and cost. as ulceration have been estimated to clinical management of leg to the most be as high as £230–400 million ulcers.2 The management of venous varying leg or foot which take more than 6 leg ulceration: Most people with degrees of weeks to heal”. different primary dressings in use in other parts and 42 different preparations of Europe being applied to the surrounding Fig.8 Arterial disease is compression provided either by present (alone or with venous Unna’s boot.38. the About 1. 35 2 compared interventions to prevent compression stockings with recurrence.5–3. in the form of recurrence with re-ulceration rates bandaging or stockings. Leg ulcer disease is typically chronic and patients with active therapy One study showed that compression therapy was more ulceration for more than 60 years Below-knee compression cost-effective because the faster have been documented. The time is a major element.5.19. Background unable to wear compression using A. Compression improve healing rates compared to treatments using no compression.0 per–21 These show that thrombosis).11 People at when venous leg ulceration occurs compared elastic high higher risk of recurrence include in the absence of significant compression 3-layer bandaging those with a previous ulcer size arterial disease (Fig 2).17 wide variation in reported knee (lowest).9 There is graduated from toe (highest) to healing rates saved nursing time. common chronic recurring community nurses but a There is condition and a major cause of significant number are managed in considerable morbidity and suffering (Fig.

However. bandages Tensoplus* (Smith & useful over non-adhesive bandages such Nephew) as Elastocrepe and paste bandages. London. 95% CI: 2. pneumatic compression was used Compression Class 1 . 29 and a compression systems over single AUGUST 1997 Compression therapy for venous leg ulcers EFFECTIVE HEALTH CARE 3 .96. 1. One trial however. their another RCT in which patients although the latter trial was very quality is summarised in Table 8. for light support of minor strains and sprains. Principal bandage in mainland Europe. randomised to receive medium compared with both a kit that support from class 2 compression provides all the constituents to The advantage of multilayer high stockings (32%) (p=0.65).g. Thomas’s Cohesive Co-Plus* (Smith & Nephew) Self-adherent so preventing slippage. No differences were stockings in people with healed compression: Several types of high found in the healing rates. 33.38.medium support Used to treat more severe varicosity and to prevent venous ulcers in patients with stockings or Unna’s boot (pooled thin legs OR = 10. because these studies that 3–5 year recurrence rates some of which have been were small in size. they Light support only crepe* (many For holding dressings in place. 26 and with Unna’s boot27.light support Used to treat varicose veins in addition to compression stockings Class 2 . can be worn compression Nephew) continuously for up to 1 week. Prevention patients were healed at 12–15 weeks with high compression levels of compression using materials available on of recurrence (Odds Ratio = 2. 95% CI: 1.3) (Table 6).strong support For treatment of severe chronic venous hypertension and severe varicose veins (Table 7). Adapted from Morison57 and 2 small trials which found more ulcers healed at 24 weeks Type of Examples Performance Characteristics Compression using 4-layer bandaging than were healed using a single layer. a single wash other compression bandages have support reduces pressures obtained by about 20% been shown to be effective.30 No statistically Seven RCTs comparing 3. A trial comparing 4-layer be effective in management of venous ulcers. shaped tubular bandage. 40-60% of pressure lost in first 20 with 3-layer bandaging is however.37 Inelastic Short-stretch bandage e. sustainable for a week. can be adhesive compression bandage Setopress* (Seton) washed and reused (Table 5). The advantage of higher significant difference in outcome interventions to prevent compression was confirmed in was found in either study. as a layer appear not to have been directly manufacturers) within a multilayer bandage.g.22–24 More regimen adapted to achieve similar C. graduating to 17 mmHg at the A combination of 2 compression orthopaedic padding. orthopaedic bandage (Odds Ratio = 4.034). with either 4-layer or short stretch small (Table 3). 18.9. recurrence were identified. minutes after application being carried out at St.4.3. Tensopress. increase the rate of healing Other multilayer systems are compared to a short stretch in use e. bandaging healed faster than C.40 Multilayer high ‘Charing Cross’ 4 layer Designed to apply 40 mmHg pressure at compression bandage comprising: the ankle.25 been compared with short recurrence rates achieved with stretch25. ulcers. showed compression systems are available. stockings has been shown to crepe. compression Comprilan (Beiersdorf) Reusable with slight stretch giving low B.8) Class 3 . plaster-type dressing used ulcers healed when intermittent in USA. we cannot be were lower in patients using strong compared directly in RCTs. The confident that there are not support from class 3 compression original ‘Charing Cross’ 4-layer clinically important differences in stockings (21%) than in those bandage (see Box) has been effectiveness (Table 4). Box Examples of compression bandages commonly used in the management of venous layer systems is shown by 1 large leg ulcers.26. small studies showed that more Unna’s boot Non compliant. 28 and without compression B. Elset. prescription. used alone it Even though 3-layer. class 2 make up a 4-layer bandage.1 Compression stockings: No those receiving a paste bandage Four-layer bandaging has also RCT was found which compared with outer support. knee. Coban* (3M) compression well sustained Compression stockings have also been used to treat current ulcers. 2-layer and compression/ light Nephew) only gives light support. compared with 4-layer bandaging pressures from crepe alone are too low to in RCTs.3 Different types of high in 4 RCTs. Coban. Hospital.31–33 Surepress* (Convatec) Light Elastocrepe* (Smith & Low pressures obtained. High elastic Tensopress* (Smith & Sustained compression.4 Intermittent pneumatic resting pressure but high pressure during compression treatment: Two activity. 39 and to prevent ulcers in patients with large-diameter legs *often used as component of multi-layer system Elastocrepe) (Table 2).0. 95%CI: padding.

5 ulcers.58 said to decrease capillary stockings) (Table 10). Attrition: none transparent film dressings (OpSite) Mean duration I 1: 3. I 2: 10%.2 I1: 12 (75%). were better received class 2 compression showing reduced recurrence with tolerated by patients (Table 9).45 neither drug reduced recurrence.04] stockings however. I 1: 7 ulcers <6 mths. [p = 0. I 2 group 87 ulcers I1: 9 contained 3 patients with 2 ulcers USA I2: 8.4. I2: 4.003] I1: 4 layer bandage Mean duration I2: conventional treatment (FP10 non. I2: polyurethane moisture vapour permeable. I2: 25% UK I1: short stretch bandage applied by project Mean duration (mths) Ulcers increased in size nurse (Rosidal K) I1: 32.2%) USA I1: Unna’s boot [p = 0. 67%. patients in the bandage + Tensoplast) porcine skin group were crossed over to double layer bandage Follow up: 2 mths Kikta et al 1988 19 84 patients from vascular surgery clinics with Mean ulcer area (cm2) N.003] Follow-up: 3 mths 5 ulcers >6 mths Total average wkly treatment costs and cost of district nursing time were less in I1 [p = 0. I2: 26% Attrition: I1: 12. and varicose veins are eradicated carried out in addition to the use an anabolic steroid which has been compared in 2 small of elastic stockings. Decrease in ulcer area and volume Sweden I1: Skintec porcine skin dressing (no I1: 60%. I3: 80%.B. I2: 21% I2: ‘usual treatment’ applied by district nurse Attrition: I1:3. I 2: 3 (21%) UK Community setting [p = 0. 43 Both trials found that drug therapy at 5 years.005] I2: polyurethane foam dressing (Synthaderm) Mean duration: not stated Attrition: I2: 9 Follow up: unclear possibly 1 yr Sikes 1985 21 13 male patients (42 ulcers).2 I1: 18/19 (94. These drugs have conflicting results. and rutoside trials with the drug stanozolol study was small and poorly (Paroven) an oxerutin which is (both combined with compression reported (see Table 9).05] I1: Unna’s boot mean of 3. a convenience Mean ulcer area Completely healed sample from outpatient vascular surgery clinic not stated but I 1 had a mean I1: 17/21 (81%). I2: 35% [p=0.7%). I2: 3 Follow up: 3 mths Eriksson 198416 44 patients. I2: 7/17 (41. I2: 6. I2: 15 I1: 71%. however the increases fibrinolysis. setting unclear Not stated No statistical analysis reported.ulcers healed at 15 wks I1: 64%. I2: 15/39 (38%) I1: 45 Follow up: 6 mths I2: 51 Life table analysis . I2: >84 I2: 9 ulcers <6 mths. Median time to healing (days) compression) 9 ulcers >6 mths I1: 55.2 Pharmacological and surgical One trial appeared to show a interventions: Two drugs have Surgery in which incompetent moderately reduced rate of been investigated for their effects communicating veins are ligated recurrence when surgery was on leg ulcer recurrence: stanozolol. These gave permeability. I2: 32. 69 ulcers in 66 patients. one showing a been compared with placebo in 2 lower recurrence rate with surgery RCTs in which all patients also within 1 year44 and the other 4 EFFECTIVE HEALTH CARE Compression therapy for venous leg ulcers AUGUST 1997 .9 yrs Follow up: 1 yr Taylor et al 17 30 patients referred to the clinic by GPs Mean ulcer area (cm2) Complete healing I1: 5. C. 90% compression) I2: Metallina aluminium foil dressing (no Atttrition: I2:6 compression) I3: double layer bandage (ACO paste In the ‘middle’ of the trial. 0%. I2: 25 I1: 0%. I2: 16 Rubin et al 1990 20 36 consecutive ambulatory patients Mean ulcer area (cm ) 2 Completely healed I1: 76.01] Complication rate I1: 0%.6 I1: Unna’s boot Completely healed at 6 mths I2: Duoderm hydrocolloid dressing Mean duration (wks) I1: 21/30 (70%). Table 1 RCTs of compression versus no compression (alone/usual treatment) I = Intervention Study Patients and interventions Initial ulcer size & Results duration Charles 1991 18 53 community-based patients from inner Mean ulcer area (cm2) Complete healing London I1: 12.5 yrs.41 stockings.42. I2: 15/21 (71%) USA of 3 ulcers and I 2 had a [p>0.

5 I3: 34. I2: 19/67 (28%).46 assessment of leg ulcer patients is that careful assessment of all There is debate about how arterial lacking. I2: 84% I1: 82%. patients were only followed up for Tensopress+ Tensoshape I1: 11. I2: 20 Follow up: 3 mths Northeast et al 106 patients presenting to outpatient clinic Not stated Complete healing 199023 I1: 51%.05] I1: elastic compression (Setopress) + Median duration (mths) medicated paste bandage + elasticated 10 Attrition: 7 patients (10 ulcers) viscose stockinette I 2: inelastic bandage (Elastocrepe) + medicated paste bandage + elasticated viscose stockinette 1 wk prior to treatment patients wore Setopress bandage Follow up: 16 wks Duby et al 1993 25 67 patients (76 legs) Mean ulcer area (cm2 ) Complete healing (ulcers) I1: 13.01] I1: elastic compression: Soffban+ Mean duration (mths) However.3 12 wks and at this point a large number of I2: non-elastic compression: Soffban + I2: 11. I 3: 23% UK I1: orthopaedic wool + short stretch bandage I2: 11.1. 95% CI: 0. I2: 8.5 Follow up: 3 mths Table 3 Comparing between different multilayer high compression systems Study Patients and interventions Initial ulcer size & Results duration McCollum et al29 232 patients from community leg ulcer services Percentage <10cm2 Complete healing I1: 82%.2 UK I1: Charing Cross 4-layer bandage I2: "Trial bandage": Tubifast + separate strips Attrition: I 1: 4. UK Male and female I2: 11. Diagnosis considerable damage can be caused by inappropriately applying undertaken routinely by nurses. I2: 7 Attrition: I1: 16%. I2: 7 (35%) UK [p>0.0 [p = 0. patients is important. I 2: 84% UK I1: ‘original’ Charing Cross 4-layer Median duration: (wks) (p>0.5 I2 patients were almost healed.2.05) I 2: new proprietary 4-layer (Profore system) I1: 8. I2: 8/18 (44%) Odds Ratio = 1. I 2: 64% I 1: 3-layer bandage (Calaband + Elastocrepe [p = 0. Research into the precision and The high rates of co-morbidity in high compression in patients with accuracy of the nursing patients with leg ulceration mean arterial and small vessel disease. Elastocrepe + Tensoplusforte Attrition: I1:8.6 I1: 8/17 (47%). I2: 44%. Table 2 RCTs of elastic high compression bandaging versus low compression Study Patients and interventions Initial ulcer size & Results duration Callam et al 199222 132 patients from leg ulcer clinics (multicentre) Mean ulcer area (cm2 ) Complete healing I1: 8.3 Attrition: none I 2: 4-layer bandage (orthopaedic wool + crepe bandage + Elset + Coban) Mean duration (mths) I 3: paste bandage (Icthopaste) + support I1: 26.1 I1: 40%.01] UK + Tensogrip) I 2: 3-layer bandage (Calaband + Tensopress Attrition: 3 + Tensogrip) Follow up: 3 mths Gould et al24 39 ambulatory patients (46 ulcers) from Mean ulcer area (cm2 ) Healed or progressed general practices attending outpatient clinic 7.7 bandage (Elastocrepe and Tubigrip) I2: 20. I2: 2 of lint applied horizontally + Setopress + Tubifast (to secure bandage) [Patients were stratified by ulcer size] Follow up: 3 mths D.2 I1: 35/65 (54%).2–5. This is status should be assessed and particularly the case as whether this assessment should be AUGUST 1997 Compression therapy for venous leg ulcers EFFECTIVE HEALTH CARE 5 .9 (Comprilan) + Tricofix net covering I3: 12.44 I1: 11 (58%). I2: 15% Follow up: 6 mths Wilkinson et al 35 legs in 29 patients recruited through district Mean ulcer area (cm2 ) Complete healing 199730 and practice nurses I1: 11.

I2: 12. UK crepe. Coban) Follow up: 1 yr Colgan et al 27 30 patients at routine venous ulcer out-patient Median ulcer area (cm2) Complete healing: clinic I1: 7.54 I3: Lyofoam dressing + Setopress compression I2: £66. I2: 2 hydrocolloid dressing (Tegasorb) I1: 7. Median ulcer area (cm2) Complete healing outpatient clinic I1: 9.18] I1: Hydrocolloid dressing (Duoderm) + graduated compression (Coban wrap) Mean duration (wks) Attrition: I1: 7.4 I1: 69%. short I 1: 18. attending leg ulcer I1: 7.and outpatients Mean ulcer area (cm2) Complete healing I1: 18.14 . age > 18 years. I 2: 6 I2: Unna’s boot I1: 95 I2: 96 Follow up: 3 mths Table 5 RCTs of multilayer high compression systems versus single-layer bandage systems Study Patients and interventions Initial ulcer size & Results duration Nelson et al 1995 31 200 patients referred by GPs and community Mean ulcer area (cm2) Complete healing nurses.4.34 USA I1: 4-layer bandage (Profore) Attrition: not stated I2: Unna’s boot Follow up: 6 wks Inelastic compression versus single layer bandage Cordts et al 199234 43 patients. I2: 60% I1: 4-layer bandage (orthopaedic wool. diff. I2: 24 stretch. 95% CI: 1. I2: 6/14 (43%) USA I2: 6. I2: 0. Coban) Median duration (mths) Attrition: I1: 4 I2: short stretch (orthopaedic wool. >18 yrs. I 2: 8.6. I2: 83% I1: self adhesive 1-layer bandage (Panelast [no sig.5.4. I2: 8/20 (44%) Slovenia I1: 4-layer bandage (Profore) I2: single layer bandage (Porelast) + Mean duration (mths) Attrition: I1: 4.9. Table 4 RCTs of elastic high compression bandaging versus inelastic compression Study Patients and interventions Initial ulcer size & Results duration Duby 199325 See Table 2 London and 30 ambulant patients Median ulcer area (cm2) Healing rate Scriven26 I1: 12.24 bandage I3: £58. I2: 10.9 Follow up: 6 mths Travers et al 27 patients attending leg ulcer clinic Mean ulcer area (cm2) Reduction in ulcer area 199233 I1: 31 I2: 23 I1: 86%.8. I 2: 9. I3: 12 compression sock) Mean bandage costs in IR£ I2: 4-layer bandage (Profore) (4LB) I1: £82.1 I1: 8/16 (50%).16 I1: 60%.2 I1: 7/20 (44%).33 Follow up: 3 mths Knight & 10 patients randomly chosen from patients at Not stated Average rate of ulcer healing (cm2/ wk) McCulloch 199628 a wound care centre I1: 1. I2: 49% UK clinic Odds ratio = 2. Patients were also randomised to oxpentifylline or placebo] Follow up: not stated Kralj & Kosicek 32 40 in. I 2: 6. I3: 20 I1: 6/10 (60%) Ireland I2: 7/10 (70%) I1: modified Unna's boot (paste bandage + Median duration (mths) I3: 2/10 (20%) Elastocrepe + Elastoplast + class II I 1: 24. Elset. I 2: 11 Attrition: greater in I1 than I 2 crepe + Elset + Coban) I2: single layer bandage (Granuflex adhesive compression bandage) [Primary dressing randomised to knitted viscose dressing or hydrocolloid dressing.3–4.] UK Acryl) Mean duration (mths) I2: 3-layer bandage (Calaband + Tensopress I1: 23 I2: 35 Bandage costs equivalent + Tensogrip) Attrition: none Follow up: 6 mths 6 EFFECTIVE HEALTH CARE Compression therapy for venous leg ulcers AUGUST 1997 .3 Mean duration (mths) I1: 4-layer bandage (orthopaedic wool + I1: 15.0 [p = 0. I2: 17. male and female.

05] (Sigvaris– removed at night) I1: 2. The cut-off point below which compression is E.3. or interactions between. by trained nurses.05] Table 7 RCTs of intermittent pneumatic compression treatment Study Patients and interventions Initial ulcer size & Results duration Coleridge Smith et 45 patients (48 ulcers) attending venous ulcer Median ulcer area (cm2) Completely healed al 199038 outpatient clinic I1: 17. I 2: 49. twice a week after cleansing Follow up: 6 mths Arterial disease of the leg is most applying compression to people who did not routinely have access commonly detected by a with arterial disease. An nurse training.5.4 . Two large Cross’ 4-layer bandaging resulted leg ulcers was often inadequate. ABPI measurement has using 4-layer bandaging was also blood pressure at the ankle to that been shown to be unreliable when shown in a second small trial.55 I1: 7/10 (70%). I 2: 12/12 (100%) I 1: Unna’s boot only I2: 0. No intention to treat analysis Follow up: 18 mths carried out. I2: 6. that similar improvements in healing could be generally not applied in clinical practice is often quoted as 0. I2:3 Follow up: 3 mths [p<0. I2: 3. I 2: 10/21 (48%) patients UK I1: graduated compression stockings Median duration (yrs) [p = 0.49 Reliability can provide information on the relative ratio is measured using a hand. and protocols for viewed as indicative of some treatment and referral. I2: 10/14 (71%) but 3 of I1: Unna’s boot + Kerlix roll + elastic bandage these were transferred from I1 USA I2: open toe. compression ABPI ratio of less than 1.47.9. with a sphygmomanometer.0 I1: 13/25 (52%). I2: 21/25 (84%) I 1: Short stretch bandage (Rosidal K) Austria I 2: Thrombo stocking + compression stocking Mean duration (mths) [p < 0. held Doppler ultrasound together if people are highly trained.17 in the arm (the ankle:brachial carried out by inexperienced These 2 trials do not however.847 of care achieved without the use of clinics or by using other high however. I 2: 5 Attrition: I1:6.59. It is arterial impairment. assessment alone. Horakova & 59 patients attending a dermatology clinic Mean ulcer area (cm2 ) Complete healing Partsch 199437 I1: 3. below knee graduated Median duration compression stockings 4.47 The ABPI operators.9 pneumatic compression used daily in the home I1 contained patients with 2 ulcers Follow up: 3 mths Attrition: none McCulloch et al 22 patients attending vascular surgery clinic Mean ulcer area (cm2 ) Completely healed 199439 I1: 0.2.50. 48 Even to the 4-layer bandage (55%). be significantly improved impact of.0 is bandaging. showed that care delivered in leg ulcer clinics. pressure index ABPI).9 had palpable foot their usual treatment at home cause of the ulcer based on visual pulses.009] I2: I1 + intermittent sequential gradient I1: 3. Table 6 RCTs of compression stockings versus compression bandaging Study Patients and interventions Initial ulcer size & Results duration Hendricks & 21 patients attending outpatients clinic Median ulcer area (cm2) Complete healing Swallow 198536 2.4 I1: 8/10 (80%). 51 the various elements of setting. however.53 AUGUST 1997 Compression therapy for venous leg ulcers EFFECTIVE HEALTH CARE 7 .35 combination of general clinical though ABPI measurement The clinic was also more cost- examination and either manual appears to be better than manual effective.52 studies have shown that 67% and in better healing at 1 year (65%) Another survey reported that 50% 37% of limbs respectively with an than in patients who continued of nurses made a diagnosis of the ABPI <0. with the consequent risk of provided by their district nurse. higher cut-off of 0.45. A survey in Leeds found that There is generally poor agreement following a treatment protocol district nurses’ knowledge of the between manual palpation of foot which included use of ‘Charing assessment and management of pulses and ABPI. many trials use the A recent trial in Sheffield (Table 11) compression therapies.5 yrs Patients cross between arms depending on progress.4 .8 I1: 1/24 (4%) patients. Improved healing palpation of foot pulses or by palpation for excluding arterial associated with specialist clinics measuring the ratio of the systolic disease.0 USA I2: I1 + intermittent one cell pneumatic Attrition: none compression applied for one hour. Organisation possible for example.

5 I1: 24% I 2: 32% UK Adjusted RR = 1.65–2.034] UK I1: Class 2 stockings I2: Class 3 stockings Refitting and supply of new stockings every 4 months Follow up: 5 yrs Stacey et al 30 patients with 41 previously ulcerated limbs I 1: 8 had evidence of past Ulcer recurrence: 198858 attending surgical outpatients DVT I1: 1 (5% limbs). outcome drawals by and [arms] calculation? bility or assessment reported intention exclusion treatment by group to criteria groups with treat/life reported reasons table method Franks et al ✓ 166 [2] ✓ not stated ✓ not stated none stated ✓ 199510 Harper et al ✕ 300 [2] not stated concealed not stated ✕ ✕ ✓ 199541 McMullin et ✓ 48 limbs [2] not stated not stated not stated ✓ ✓ but no unclear al 1991 42 but double blind for individual so assume previously details for allocation ulcerated previously concealment limbs ulcerated limbs Lagatolla et brief 105 [2] not stated not stated not stated not stated X (reasons ✓ al 199545 given for 22 withdrawals but a further 19 people are missing from the data) Stacey et al ✓ 30 (41 not stated not stated only for not stated not stated unclear 198861 limbs) [2] venous status Stacey et al brief 55 (68 not stated not stated ✓ not stated ✓ ✕ 199044 limbs) [2] Wright et al brief 138 [2] ✓ concealed ✓ ✓ not stated ✓ 199143 randomisation code Table 9 RCTs of prevention of recurrence of venous ulceration using compression stockings and venous surgery Study Patients and interventions Initial ulcer size & Results duration Franks et al 199510 166 patients from community leg ulcer clinics Median ulcer (cm2) Recurrence rate at 18 mths with newly healed ulcers. mean age 72 yrs I1: 3. UK) Median ulcer duration: (mths) 0. 50(68%) Harper et al 300 patients with newly healed venous leg Not stated recurrence within 36–60 mths 199541 ulcers I1: 32%. Limbs rather than patients were randomised Follow up: 1 yr 8 EFFECTIVE HEALTH CARE Compression therapy for venous leg ulcers AUGUST 1997 . walk freely Overall 83% all day wear (no difference) Follow up: 18 mths I1: 4(4%): 27(29%). I2: 5 (24% limbs) I2:10 had evidence of past UK I1: surgery – ligation of incompetent DVT Attrition: not stated communicating veins and ablation of incompetent superficial veins plus permanent below-knee elastic stockings (Sigvaris) I2: stockings – below-knee stockings (Sigvaris) NB. I 2: 3. Table 8 Quality of RCTs of interventions to prevent recurrence of venous ulcers Study Clear Sample A priori Method of Baseline Blinded With. 61(67%) I2: 1(1%): 23(31%).7.3. Analysed inclusion size sample size randomisation compara. I2: 21% [p=0. 95% CI I1: class 2 below knee stockings (Medi. I2: 2.04] I2: class 2 below knee stockings (Scholl) I 1: 5. walk+aid.0 Attrition: none stated New stockings prescribed every 3 months Mobility (chairbound.16.

Routine practice requires monitoring. I 2: 13 Taylor et al17 See Table 1 Large variability in the way bandages are applied and the F.8 I1: 34%.9 I1: 65%. Implications • The most effective intervention for the treatment of venous leg pressures achieved have also been observed. unless intermittent pneumatic evidence that maintenance of good operators are well trained. compression techniques in AUGUST 1997 Compression therapy for venous leg ulcers EFFECTIVE HEALTH CARE 9 .5. I 2: 3/30 Switz) I 2: placebo tablet + stockings as in I 1 Follow up: not stated how much beyond 6 mths treatment Stacey et al. However. Table 10 RCTs of pharmacological interventions for the prevention of recurrence of venous ulceration Study Patients and interventions Initial ulcer size & Results duration Lagatolla et al 136 patients with healed venous ulcers Not stated I1: 10/42 recurrences (24%) 199545 attending outpatients clinic I2: 13/41 recurrences (32%) UK I 1: Stanozolol 5mg bd for 12 months plus Life table analysis: increased ulcer-free compression stockings survival in surgery group (NS) I 2: surgery – ligation of calf. I2: 13 Follow up: 5 yrs McMullin et al 48 limbs with healed venous ulcers out of a Not stated Recurrence of ulceration: 199142 total of 85 limbs in 60 patients being treated I1: 7/25 limbs (20%) for lipodermatosclerosis I2: 4/23 limbs (17%) UK [p>0.55 but there is some alone.24.or 3-layer well trained bandagers obtained compression therapy) is more (multilayer) or short stretch better and more consistent pressure accurate when based upon the bandages. measurements can be application of one of these high feedback and supervision. perforating veins plus compression stockings Attrition: I 1: 9. I2: 13/49 I1: 6/24 limbs (5/17 pts) UK I1: Stanozolol 5 mg bd for 9 months + below I2: 1/25 limbs (1/20 pts) knee graduated stockings (Sigvaris) Number of limbs with post- I 2: Ligation of the incompetent communicating thrombotic changes: Attrition: I1: 8.7 statistically significant difference in healing I2: ‘usual care’ from district nurses at home rate p = 0. I2: 32% UK I1: Oxerutins (Paroven. UK) 500 mg bd Additional illnesses [p = 0. possibly result in improved bandaging manual palpation of foot pulses with the addition of technique. 68 limbs of 54 patients with healed venous Number of limbs with normal Limbs in which ulcers recurred within 12 199044 ulcer deep veins mths I1: 9/49.6] I 1: Stanozolol 5 mg bd + below knee class II graduated compression stocking (Venosan.52. More experienced or • Diagnosis of arterial status (to ulcers is high compression determine eligibility for provided by 4. I 2: 29. I2: 16. Zyma.02 – 0.03 log rank test Follow up: 1 yr Attrition: I 1: 16. I 2: 8. 55 unreliable. ABPI compression. I2: 12/49 superficial veins + stockings as I1 (stockings worn continuously and replaced every 6 mths) Follow up: 12 mths Wright et al 138 patients with recently healed venous ulcer Mean duration (mths) Cumulative recurrence at 18 mths 199143 recruited at first follow up appointment I1: 8.93 log rank test] + below knee class II graduated elastic No significant differences stockings between groups Attrition: not stated I2: identical placebo + stockings as in I1 Stockings replaced where necessary at 3-monthly intervals. I 2: 9 veins and eradication of all visible varicose I1: 15/49. Attrition: I1: 6/30. 95% I 1: 4-layer bandaging delivered by project Mean duration (mths) CI: -0. Overall there is a nurses in clinic I1: 27.54 Training of nurses can ABPI measurement than compression stockings.9. I2: 55% UK Difference in percentage healed = 11. Unna’s boot or results.2 . equal numbers in each group randomised to surgery Follow up: 18 mths Table 11 RCTs of compression from trained nurses and/or specialised clinics versus usual district nurse treatment Study Patients and interventions Initial ulcer size & Results duration Morrell et al35 233 ambulant patients from 8 clinics who had Mean ulcer area (cm2 ) Complete healing at 12 mths suspected venous ulcers I1: 16.

Chronic ulceration of the leg: extent of and purchasers and providers certain groups of patients the problem and provision of care. there as to co-ordinate services. J Wound Care 1997. 1989. Dorman M. BMJ included because in RCTs 1997. Orthopaedic wool In particular there is a need to from maintenance therapy to investment programs. there is little evidence language was carried out using 18 to support the use of drug 12. Br J Surg important that it is used • The Royal College of Nursing is 1992. available in mid-1998. Callam M. and adverse outcomes due to working independently. Monk B. Stevens J. Curr Ther active ulceration. Age Ageing • Use of compression stockings research 1995. Scott Med J 1988. BMJ should consider how this can be confers any added benefit. Harrow: Scutari systems and their components • Further RCTs of sufficient size Press. district nurse services and prevalence in a Scottish community. treatment of venous stasis ulcers. Prospective comparison of healing rates incorrectly treated arterial and therapy costs for conventional and disease or excessive four layer high compression bandaging treatments of venous leg ulcers.290:1855–6. Oldroyd M. • High compression bandage In: Cullum N. and the which compared healing rates University of York: NHS Centre for proportion with uncomplicated Reviews and Dissemination. Relevant journals and conference 13. The methodological using stereophotogrammetry. and Comparison of different treatments of as this design is more susceptible outcome (e. whether surgery for 5. Risk factors for leg ulcer recurrence: a randomised trial of two types of Appendix: Methods used to review the compression stocking. Costs of venous ulcers: community. UK of 4-layer bandaging. Bosanquet N. Cornwall J. rates of healing using a checklist. 2. Roe B. 1996. and 1985.33:358–60. Ruckley C. the statistically significant differences proportion of patients whose 15. systems to monitor standards of 3. 1995:113–124. Sheldon TA. Marcuson RW. should be encouraged for the 11. Dale J. Leg ulcers: community nurses. a component of most determine the most cost. is effective high compression not available on prescription. CINAHL and EMBASE. vary in their availability in the and follow-up are necessary. Harper D. Callam M. Thesis]. compression). The management of care. Dore C. people with venous ulcers • The issues raised in this bulletin References should have a significant impact should be discussed with on healing rates and save time providers of primary care and 1. Sarkany I. therapy using stanozolol or MEDLINE. Chronic ulcers of the leg: a study of spent by community nurses. process (e. Lambert D.10:54–55.g. using a new treatment with venous ulcers receiving high historical controls were excluded 16. systems. Liden S. 4. correctly so that sufficient (but leading the development of a 8.56 Unpublished. Nursing Standard 1996.g. It is expected ulcers within a community ulcer service.79:1032–1034. Leg Ulcers: nursing management. Community nurses assessment and management. made readily available to the additional importance (if 6. J Wound Care 1995. Br J Surg 1986. Outcome of A systematic review of research prevention of recurrence. Cullum N. A electronic databases including community/hospital leg ulcer service. oxerutins. the prevalence of venous leg ulcers: a controlled study to bias.g. Despite the promotion in the relevant hospital specialists so Health Bull (Edinb) 1983. Undertaking systematic confidently attributed to a reviews of research on effectiveness: CRD determined by ABPI guidelines for those carrying out or particular treatment. it is health district. NHS Centre for Reviews and in outcomes can be more arterial status has been Dissemination. to monitor standards of care as and unpublished RCTs which 14. proportion of Res 1984. Chronic leg ulceration: the not excessive) pressure is clinical guideline on leg ulcer Lothian and Forth Valley Study [ChM applied. supervision and establish compression techniques. Recurrence of leg be better trained and monitored Care bulletin. Moffatt C. is little reliable evidence for its ensure nurse training and Chronic leg ulceration: socio-economic superiority over other high aspects. Dale J. once proper compression • Whichever high compression systems are in place. Harrington M. and bandage application.41:310–4. by two reviewers 17. in leg ulcer management. et al. Lewis J. 1992. compression therapy). quality of each study was assessed patients healed. et al. Eriksson G. the measured ulcer healing were A systematic review of compression proportion of appropriately therapy for venous leg ulcers. Dickson D. Ruckley C. Harper D. Roe B. 10 EFFECTIVE HEALTH CARE Compression therapy for venous leg ulcers AUGUST 1997 . Franks PJ. Clin with no restriction on date or Exp Dermatol 1982. et al. measured by structure (e. any) of the organisation of care epidemiology and aetiology. Callam M. However.73:693–6.6:62–68. editors. Leg ulcer care: the need for a proceedings were handsearched • Systems should be put in place and experts consulted. Published cost-effective community service.4:56–62. 10. and other practitioners should based on this Effective Health 9. et al. Callam M. Fletcher A.24:490–494. Cullum N. Phlebology padding. leg ulcers: current nursing practice. Studies commissioning reviews. that the guideline will be including patient assessment.7:397–400.35:678–84.supp 1:44–46. measurement. University of Dundee. Prevalence of lower limb ulceration in an urban approach is employed. Taylor AD. CRD Report 4.315. Freak L. et al. high compression systems. Eklund A. Franks P. Lees TA. 7. Taylor RJ. trained staff).

Unna's boot versus Duoderm CGF Lothian Forth Valley leg ulcer healing hydroactive dressing plus compression 49. A comparative prospective randomised trial of class 2 following training. A 45. 35. Tavistock Square.24:871–5. Fisher C. et al. Unpublished Advances in Wound Care 1994. J Vasc 32.A Compendium of standard for leg ulcer assessment.7:22–26. 54. Teevan M. 53. stanozolol and stockings in the 19.294:929–931. Callam M. A Improvements in bandaging technique 28. Presented at 36. systems in the treatment of venous prevention of venous ulceration.6:233–238. Cameron J. et al. McCulloch J. 48. et al. 1992. Unpublished. Ruckley C. Acad Dermatol 1985. 1996. al.75:436–439. Housley E. J District Nursing 1991. Moffatt C. McMullin G. Hendricks W. Randomised trial comparing Profore London: Wolfe Publishing. versus elastic support stockings. Jaffrey G. Kinsella A. are London WC1H 9JR. Clinical Research and Practice 39. Ruckley C. London: RSM. Wright D. et al. Kosicek M. 1992. 57. O'Hare L. bandaging method in maintaining circulation in patients with leg ulcers. Arch Surg 1990. Morrell J. Groarke L. 41. please send details to Medical Editors Trial randomised controlled trials. et al. Burnand K. chronic venous leg ulcers. indicated? Phlebologie 1994. Wilkinson E. et al. Presented at Phlebology 1995. Presented at European Wound Oxerutins in the prevention of Management Association.6:339–340. London N. 23. Cooper S. Campbell S. A of chronic venous ulceration.77:1050–1054. BMJ.7:478–83. 1993. Milan 1997. Lancet. 43. Layer G. Management of atherosclerotic peripheral arterial Royal Society of Medicine Venous of stasis leg ulcers with Unna's boot disease. Franks P. Dale J. surgeons. Amnesty for Randomised Controlled Trials If you have been involved in a randomised The editors of BMJ. et al. et al. Harper D. Macintyre CCA.1:23–26. Callam M. Harper D. J Enterostomal Arterial disease in chronic leg Therapy 1985. ulcer clinics. randomised trial of BMJ 1987. Harper D. J Wound Care 1996. Dale J. J Wound 1992. Northeast A. et al.7:59–63. A 38. Russel B. 1990. J Wound Care study between two compression and class 3 elastic compression in the 1995. Evaluation of a transparent on venous ulcer healing. Horakova AUGUST 1997 Compression therapy for venous leg ulcers EFFECTIVE HEALTH CARE 11 . Surg 1988. or by elastic stockings. produced by experienced and 40. Scanlon E. 34. Colgan MP. ulceration: randomised controlled trial. et al.125:489–90. Br J Surg Trial of two bandaging systems for 44. Variability of ankle and brachial Increased compression expedites systolic pressures in the measurement venous ulcer healing. comparative trial of single-layer and Hazards of compression treatment of multi-layer bandages in the treatment the leg: an estimate from Scottish 20. Eastham ulcers. Sikes E.4:181–4. nursing management of wounds. et al. et al. McCulloch J. Cordts P. Ray SA. Meyer J. Travers J. randomised trial in the treatment of Sequential gradient pneumatic 52.part 1: elastic versus non-elastic in the management of venous leg Reliability of ankle:brachial pressure bandaging in the treatment of chronic ulcers. Layer G. Health Trends Repair 1996. Setting a system. Fowkes FG.78:1269–1270.108:871–5. BMJ 1987. The aim is to ensure Amnesty. Harper D. randomised trial of Unna's Phlebology 1995. 22. Simon D. Coleridge Smith effectiveness. Dale J. prevention of recurrent venous prospective.15:480–6. A colour guide to the 29. A prospective. Venous leg Variation in measurement of ankle- bandages in the treatment of chronic ulcers: are compression bandages brachial pressure index in routine venous ulcers.2:133.295:1382. four-layer bandage system. et al.7:136–41. et al.10:79–85. Wilson N. Kikta M. Keachie J. of venous ulceration. Phlebology dressing in the treatment of stasis 1992. to meta@ucl. Walters S. Leg Symposium on Advanced Wound Care ulcer care: an audit of cost and Medical Research Forum on Wound 42. Taylor RS.5:276–9. Nelson T. 1988. Callam M. A 26. et al. Thomas S. Unna's boot vs polyurethane foam dressings for the treatment of venous 33.4:134–138. that all RCTs. Stacey M. Kralj B. ulceration. ulcers of the lower limb. et al. et al. Wounds . Phlebology 1995. Burnand K. A comparison of perforating vein multi-layer bandages in the treatment ligation. Barbenel I.42:128–133. Compression healing of 31. et al. Srodon PD. Ruckley C. et ulceration: an underestimated hazard? al. Leeds: Leeds venous leg ulcers comparing short compression enhances venous ulcer Community and Mental Health. clinical practice.suppl 1:872–873. Gould DJ. trial . 47. Intermittent pneumatic compression improves venous ulcer healing. Makin G. The efficacy of fibrinolytic 1995. et Phlebology 1991. index measurement by junior doctors. Elliot E. J Am 1988. Management Publications. 25. Fax: 0171 383 6418. randomised trial of single layer and D. Scriven JM. Lagattolla NRF. four layer bandage healing: a randomised trial. assessing the treatment of healed venous ulcers. Buttfield S. Harding E. enhancement with stanzolol in the treatment of venous insufficiency. J Wound Transcutaneous oxygen tension in Care 1997.47:53–57. J Vasc Surg 1992. Duby T. Burnett A. Blair S. Logan R. et al. 18. Morison M.27:133–6. Charles H. Nelson E. Swallow R. comparison of sub-bandage pressures (personal communication).5:173–175. Leg ulcer care. Nelson E. by surgery to the communicating veins 30. 56. Surgery system. Short stretch versus long stretch 37. Burnand KG. Neal M. Plecha E. Hanrahan L. McCollum CN. Alexander J. 21. et al. 24. recurrence in chronic venous Calf pump function in patients with London: Macmillan. Dalziel K. published or unpublished. and long stretch-paste bandage 1990.12:90–98. Unpublished. Makeham V. Ellison DA. Marler K. Unpublished. Rubin Collins K. insufficiency leg ulcers. leg ulceration. Br J Surg 1990.Pensylvania: Health P. McBride C. 51. Coleridge-Smith P. Unpublished. Watkin G. Lawrence M. Randomised 46. stretch bandages. Hoffman D.81:188–190. Sarin S.117. of venous leg ulcer. et al. et al. A cheaper alternative to the inexperienced bandagers. Gibson B.suppl 1:915–916. Harding EF. J Vasc Surg 1996.12:116–20. Schuler J. Phlebology Br J Surg 1994.4:6–7. Layer G. J Wound Care 27. healed venous ulcers is not improved Br J Surg 1991. Cost-effectiveness of community leg 50. Partsch H. Freak L. Cost comparisons in the management Care 1993. A randomised prospective Assessment of new one-layer adhesive not sufficient to detect impaired arterial study. Hasty J. BMA House. 55. registered so that reviews of research can be more Alternatively the information can be sent by e-mail comprehensive and avoid publication bias. Ankle pulses are ulceration. and the original four layer bandage. 58. boot versus hydroactive dressing in the treatment of venous stasis ulcers. Knight CA. Annals of Internal controlled trial which has not been published in full. J Epidemiol Community Health Forum. Medicine and several other leading medical journals including trials that have only been published as an have announced an anmesty for unpublished abstract. Stacey M. prolonged limb compression and effects J Wound Care 1995.

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Oxford Ms. George’s Hospital. Centre for Evidence-Based Nursing. Ms. Maureen Benbow* Institute of Nursing. Karin von Degenberg The management of patients with venous leg ulcers Recommendations: Appendix 3 1 . Mary McClarey Consultant Surgeon Leg Ulcer Specialist Nurse Bedford General Hospital. Dr. Churchill organizations Hospital. Oxford St. Ross Scrivener University of Leeds Royal College of Paediatrics and Child Leighton Hospital. Falkirk Dr. Department of Public Health and Ms. Rosalyn Anderson St. London Primary Care Nurse Advisor North West Regional Health Authority unable to be contacted or did not Mr. Alison Rylands* (formerly of University of Liverpool). Stephen Blair* Professor of Community Nursing Consultant Surgeon Ms. Debra Humphris* Royal College of Physicians Nursing Home Inspectorate CHAIR. SCHARR/RCGP Pharmaceutical Advisor Tameside FHSA Mr. Christine Moffatt* Nursing Officer Director of Education & Clinical Appendix 3 Department of Health. Millie Carter Mrs. HSMU. Aileen McIntosh Health Care Evaluation Unit. Pippa Gough Mr. Trish Powell** (Royal College of Nursing) Dr. Janice Cameron* Ms. Cathy Maddaford* Public Health Medicine. Steven Tristram* ** only reviewed updated General Practitioner Mr. Lesley Duff Professional Nurse Advisor Birkenhead Victoria Central Hospital. Ralph Hammond** reply in response to request to Professional Adviser review updated guidelines Chartered Society of Physiotherapists. Wirral Health Ms. Karin von Degenberg* Leg Ulcer Specialist Nurse Nursing Officer Royal Berkshire & Battle Hospitals Ms. Tom Keighley* Ms. Stephen Bridgeman (now University of Manchester) RCN Representatives Consultant Mrs. London Practice. Churchill University Hospital of Manchester Hospital. Michael Deighan* Dr. Andrea Nelson* Reader Research Fellow Centre for Evidence Based Nursing. Ms. University of Manchester Consultant in Public Health Medicine North West Regional Health Authority Ms Liz Edwards* District Nurse Facilitator Dr. Peter Mortimer* Contributors to Director of Clinical Measurement Consultant Skin Physician Dermatology Department. Dermatology Department. Bedford Ms. Elizabeth McInnes Ms. George’s. Catherine’s Hospital. London Dr. Hofman** conference participants have been Leg Ulcer Nurse Specialist Representatives of professional updated as far as possible) Wound Healing Institute. Leeds NHS Trust (Centre for Evidence-Based Nursing) Ms. Mandy Wearne* conference participant who was King’s College. Victoria Thomas Department of Nursing. Wallasey Surgical Materials Testing Laboratory * original consensus conference Bridgend General Hospital. Falkirk Royal Infirmary. Nicky Cullum Leg ulcer and pressure area care. People who worked on University of York York these guidelines Ms. the guidelines Churchill Hospital. Barbara Gibson* participant who also reviewed Mid Glamorgan Clinical Nurse Specialist updated recommendations. Tissue Viability Nurse Mr. Brian Gilchrist* recommendations. CONSENSUS CONFERENCE Victoria Central Hospital. Nicky Cullum* Ms. Carol Dealey* Quality Manager (University of Manchester) Tissue Viability Nurse St. London Dr. Oxford Dr. Wallasey Mrs. University of Liverpool (Centre for Evidence-Based Nursing) Smith and Nephew Mrs. London Primary Care. Judy Mead Director Chartered Society of Physiotherapy Mrs. RCN Clinical Guidelines London Project Group (Please note that most of the places of employment of the original consensus Ms. Helen Noakes Professor. The Hampshire Clinic. Birkenhead Moseley Hall Hospital. Royal College of Psychiatrists Clatterbridge Hospital. Andrea Nelson DoH. Jenny Allen* Ms. Ann McMahon Professor Charles McCollum* Leg Ulcer Specialist Nurse Professor of Surgery Ms. Jackie Dark** Ms. Mrs. D. George Cherry* Dr. Steven Thomas Director* Consensus Group Members Victoria Central Hospital. Liz McInnes Victoria Central Hospital. Wallasey Ms. Penny Irwin Mrs. Basingstoke Lecturer no asterisk=original consensus Department of Nursing Studies. Mike Callam* Mr. Birmingham Ms. Wirral Regional Clinical Audit Co-ordinator Ms. Ian Mansell* Ms. Liz O’Neill* Professor Karen Luker Mrs. Bebington University of Liverpool Mr. Parson’s Green Clinic. Helen Noakes (in alphabetical order) Technical Services Representative Department of Nursing. Debbie Murdoch Dermatology Department. Crewe Professor Karen Luker* Health Mr.