2

Characterization of compression bandage

2.1 Introduction
Chronic leg ulcer is a common health problem, particularly of the elderly. It is
estimated that on an average 2 per 1000 population have active leg ulcers. This
figure is rising to around 20 per 1000 in individuals over 80 years of age. With the
growing population, these figures are set to rise further, increasing the demand
for leg ulcer treatment in the future. So far there is no effective drug treatment
for leg ulcer and a correct application of graduated compression is the single
most effective means of healing venous ulcers [1–3]. It has been found that,
with correct compression therapy, it is possible to heal more than 90 percent
of leg ulcers. Bandaging is considered to be one of the primary methods for
applying compression, and is preferred for the patients who require frequent
dressing changes and recommended during the therapy phase of treatment. To
counteract the increased intravenous pressure caused by venous disease, the
sub-bandage pressure provided by the compression bandage should exceed
40 mmHg. However, it is generally considered that a pressure between 30 and
50 mmHg at the ankle will ensure reduction of venous hypertension without
causing undue discomfort to the patient or damage to the skin. A range of
different bandages that are being used for compression therapy are available
today, differing in terms of the fabric used, extensibility, stiffness and the
way they are manufactured. The present chapter reviewed the different types
of compression bandage, their classification and characterization, and recent
works or progress in the field of compression bandage, which would expose
the reader to new ideas and perspectives towards an effective treatment.

2.2 Principles of bandaging

The application of compression therapy redistributes blood from the venous
system into the central parts of the body in case of the patients with poor
blood flow either due to lack of enough pressure or failure of the valves to
work properly. Figure 2.1(a) shows that the ankle pressure is different when
the subject is lying, rising, standing and walking for a normal and diseased
 Characterization of compression bandage 21

person. So, when a normal person stands still, the pressure of venous blood in
the leg increases from knee to foot because of gravity. Compression bandage
should produce gradient pressure from foot to knee to propel blood towards
heart (Fig. 2.1b). When a nurse applies a bandage, the patient’s legs should be
put at the same level, so that pressures in legs are almost same.

Figure 2.1  (a) Changes of ankle pressure, (b) pressure gradient due to compression

But if improper and widely varying pressure is applied by inexperienced

doctor or nurse, condition of patient may become adverse to the further
treatment with this therapy; worse still may lead to amputation.

2.3 Terminology
• Elasticity: It is the ability of the bandage to recover to its original length
after being extended or stretched [4]. Otherwise stated, it represents the
bandage capacity to resist the applied force. The elasticity in the bandage
is significantly dependent on the fibers or elastomeric yarns inserted
lengthwise in the bandage structure. However, this is not frequently used
and adopted internationally for the bandage classification. Instead the
extensibility of the bandage is commonly used for the classification and
characterization of the bandage.
• Extensibility: The extensibility of the bandage is described by its ability
to stretch, when force is applied. Extensibility of the bandage is defined
as the elongation of the bandage under a load of 10 N/cm. It is measured
experimentally and expressed as a percentage of the initial length at
rest. Short-stretch compression bandages have 10–100% extensibility,
whereas long-stretch compression bandages have extensibility greater
22 Science of compression bandage

than 100%. As a result, short-stretch bandages generate very high sub-

bandage pressures during exercise due to muscle contraction and the
stiffness of the material and maintain low pressure during rest due to their
low elasticity. By contrast long-stretch bandages exert moderately high
pressures which are almost the same at rest and during walking.
• Hysteresis: It indicates the bandage ability to recover its original length
after being extended and is correlated with viscoelastic characterization
of the bandage, frictional characteristic of different layers and elasticity
of the material.
• Elastic power: It is the amount of force required to stretch the bandage to
a predetermined length. This helps to determine the amount of interface
or sub-bandage pressure a bandage will produce at a fixed elongation.
• Lock-out: It is defined as the extension point beyond which the physical
structure of the bandage prevents further stretching or lengthening.
• Stiffness: It is the capacity of the bandage to resist to muscle expansion
when contracted [5]. It is defined as the increase in the interface pressure
when the circumference of the limb increases by 1 cm. The European
pre-standard on compression hosiery (CEN) defines ‘stiffness’ of
compression hosiery as the pressure increase (in mmHg) per centimetre
of circumference increase of the leg [6,7]. In simple words, stiffness is a
measure of how the pressure under the bandage changes during walking
or exercise.
• Interface pressure: It is defined as the sub-bandage pressure generated by
the bandage at the interface between the bandage and skin. It is frequently
expressed in mmHg.
• Resting or supine pressure: It is the interface pressure applied by the
bandage in static condition and is measured on the lower limb in the
supine position.
• Standing pressure: It is the interface pressure applied by the bandage
when the patient stands.
• Working pressure: It is the pressure exerted by the bandage when the
person walks. This is generated due to the resistance of the bandage
oppose to the expansion of the limb circumference.
• Static Stiffness Index (SSI): It is defined as the difference between
standing and supine interface pressure measured at the lower limb part
showing a maximal increase of limb circumference, which is at the
transition of the gastrocnemius muscle into the Achilles tendon (the so
called B1 level according to European Committee for Standardization,
ENV 12718:2001) [8]. Values are measured using pressure transducers
positioned in the medial gaiter area. SSI values above 10 indicate a high
level of stiffness [9].
 Characterization of compression bandage 23

• Dynamic Stiffness Index: Stiffness of the bandage while walking has been
termed as ‘dynamic stiffness index’ by Stolk et al. [10].

2.4 Bandage construction

Different fabric construction has been frequently used for the preparation
of compression bandages. In general terms, a textile fabric is defined as an
assembly of fibers, yarns or combinations of these. There are many ways to
manufacture a textile fabric. Each manufacturing method is able to produce
a wide range of fabric that depends on the raw materials used, equipments,
the machinery employed and the manufacturing processes involved. The
commonly used manufacturing processes that have been used are knitting,
weaving, braiding and nonwoven technology. Some of the basic constructions
used for bandage manufacturing are as follows:
• Woven: Woven construction consists of two sets of perpendicular yarns
(also known as warp and weft yarns) that are interlaced together with the
help of weaving process (Fig. 2.2). The longitudinal yarns are called the
warp yarns and the lateral threads are the weft yarns. During the weaving
process, the warp threads run along the length of the loom and are held
taut. For the interlacement, the weft threads are made to insert across the
shed created by the parallel sets of warp yarns.

Figure 2.2  Woven construction

• Knitted: Knitted construction consists of intersecting loops that are

produced by a knitting process. It is characterized by courses and wales.
24 Science of compression bandage

A course is defined as the row of knitted loops while a wale is the column
of the loop. The quality of fabric is related to the courses and wales per
unit length present in the fabric and also on the total number of loops per
unit area. Knitted fabrics are categorized in warp knitted and weft knitted
structure (Fig. 2.3). In weft knitted fabric, the yarn follows the path across
the length of the fabric during knitting. While in the warp knitted fabric,
the yarn follows the path along the length of the fabric.

Figure 2.3  (a) Weft knitted construction, (b) Warp knitted construction

• Nonwovens: Nonwovens are also used commonly for the preparation

of padding material for the multi-layer compression bandaging system.
Nonwovens are defined as the manufactured sheet, web or batt of
directionally or randomly oriented fibers that are bonded by friction,
cohesion or adhesion. Figure 2.4 shows the picture of a needle punch
nonwoven material.

Figure 2.4  Needle-punch nonwoven material

 Characterization of compression bandage 25

• Spacer fabric: Spacer fabric is a three-dimensional knitted fabric which

consists of two separate knitted substrates. These two separate substrates
are kept apart by spacer yarn. Spacer fabrics are much like a sandwich
and feature with two complementary slabs of fabrics with a third layer
tucked in between.

2.5 Classification
Bandages are classified based on their elasticity, extensibility and material
function [4,12]. On the basis of material functions, bandages can be classified
according to BS 7505:1995 as:
• Type 1: Light-adjusting bandages (for fixing local wound covers)
• Type 2: Light-supporting bandages
• Type 3: Compression bandages
–  3A: Light
–  3B: Moderate
–  3C: High
–  3D: Extra high
The pressure range for each class of compression bandage is measured at
rest on a fixed ankle circumference (23 cm) with a bandage overlapping by
50%. Different countries follow their different range of pressure for the above
compression class as given in Table 2.1 [5].

Table 2.1  Pressure range used for the classification.

Type BS 7505 Level of Pressure (British Pressure (German

compression standard) standard)

3A Light Up to 20 mmHg 18.4–21.2 mmHg

3B Moderate 21–30 mmHg 25.1–32.1 mmHg

3C High 31–40 mmHg 36.4–46.5 mmHg

3D Very high 41–60 mmHg >59 mmHg

On the basis of extensibility, bandages are classified as:

• Inextensible (Zinc oxide bandage)
• Short-stretch (Extensibility <70%): These bandages ideally lock out at
30–40% stretch. These impart high working pressure and low resting
pressure. Due to their low elasticity, they do not conform well to changes
in leg volume, which may lead to frequent re-application. For example,
Comprilan, Lastolan, Coban 2, Acrylastic.
• Medium-stretch (70% < Extensibility < 140%)
26 Science of compression bandage

• Long-stretch (Extensibility >140%): These bandages usually do not lock

out until about 140% stretch. These bandages exert high working and
resting pressure. It can be uncomfortable at night due to high resting
pressure. For example, Surepress, Setopress, Rowden Foote, Tensopress.
Bandages can also be classified based on layers, components, elasticity,
pressure, etc. Elastic stocking is the only single-layer compression system.
Bandages are mostly considered as multi-layer compression system even they
are overlapped by 50%. Bandaging system is considered as single-component
when made up of one material, and considered as multi- component when
composed of several components. On the basis of layers and components,
bandages can be classified as:
• Single-layer single-component bandages
• Multi-layer single-component bandages
• Multi-layer multi-component bandages
Table 2.2 shows the examples of some of commercially available single-
layer compression system and their details. Among these, long-stretch Perfecta
strong was found most effective as it maintains almost equal pressure to leg,
while lying and standing.

Table 2.2  Single-layer compression system.

Type of Examples Length Longitudinal Composition

Compression (stretched) extensibility
Rosidal K 10 cm × 5 m ~90% 100% cotton
67% cotton
Rosidal sys Tg tube To be cut –
Short-strech 33% viscose
10 cm × 2 m 100%
Rosidal soft Padding
× 0.2 cm polyurethane
96% cotton
Perfecta super 10 cm × 7 m ~160 %
4% elastane
94% cotton
Perfecta strong 10 cm × 7 m ~170%
Long-stretch 6% elastane
25% cotton
Velpeauveine plus ~120% (70%
10 cm × 4 m 67% viscose
forte transverse)
8% elastodien

Some examples of multi-layer compression system are as follows [13,14]:

• The 2LB (KTwo® [Urgo Medical, Shepshed, Loughborough]): The 2LB
is a multi-layer compression bandage system consisting of two different
bandages:
Layer 1: K-Tech®, a light compression, medium-stretch bandage (75%)
Layer 2: K-Press®, a cohesive, long-stretch bandage (160%)
 Characterization of compression bandage 27

The above system is used to achieve the required average pressure of 40

mmHg.
• The 4LB (Profore [Smith & Nephew, Hull]): The 4LB system is a multi-
layer compression system composed of four separate bandages:
Layer 1: Profore 1 (Softban natural), a sub-wadding bandage, 100%
polyester
Layer 2: Profore 2 (Softcrepe), a light, conformable, short-stretch bandage
(60–70%)
Layer 3: Profore 3 (Litepress), a light compression, long-stretch bandage
(180%)
Layer 4: Profore 4 (Coplus), a flexible, cohesive, long-stretch bandage
(140%).
This system can be used to provide more than 40 mmHg pressure to the
ankle.
• The SSB (Actico® [Activa, Burton-on-Trent]): The SSB system is a
multi-layer compression bandage system composed of two separate
bandages:
Layer 1: Flexi-Ban sub-wadding bandage, 100% polyester
Layer 2: Actico, a short-stretch, cohesive bandage, composed of cotton,
polyamide and elastane
The SSB system is used to provide a high working pressure (>80 mmHg)
and to generate a low resting pressure (i.e. when the patient is supine).
A new standard for the classification of the bandages has been introduced
recently based on main characteristics of compression bandages [4]. This is
PLACE classification and has been adopted by AIUC compression group. In
this the bandages are classify based on four major characteristics (Fig. 2.5):
• Pressure
• Layers
• Components
• Elasticity

Classification

Pressure Layers Components Elasticity

- Mild (< 20 mmHg) - Single layer - Single-component - Elastic

- Medium (20-40 mmHg) - Multi layer - Multi component - Inelastic
- Strong (40-60 mmHg)
- Very Strong (> 60 mmHg) - Low stiffness
- High stiffness

Figure 2.5  PLACE classification of bandage

28 Science of compression bandage

Classification of some of the standard commercially available compression

bandages are presented in Table 2.3 [4].

Table 2.3  PLACE classification of some commercial bandages.

Bandage Pressure Layers Components Elasticity

Elastic kit Medium/strong Multi-layer Multi-component Low stiffness

Elastic stocking Mild/medium Single-layer Single-component Elastic

Coban 2L Strong Multi-layer Multi-component High stiffness

Profore Strong Multi-layer Multi-component High stiffness

Unna boot Strong Multi-layer Multi-component High stiffness

Rosidal sys Very strong Multi-layer Multi-component High stiffness

Pütter bandage Very strong Multi-layer Single-component Inelastic

2.6 Compression efficiency of bandages

Several important factors need to be present for a health practitioner to use
compression systems, like knowing how to use different compression systems,
knowing the best available compression systems for the treatment, being able
to identify the etiology of the ulcer, and the willingness of the patient to agree
to the commencement of compression treatment and for this to be sustained
[22]. Clinical effectiveness of different types of compression system has been
studied by many researchers. The assessment of compression therapy is best
undertaken by Randomized Controlled Trails (RCTs) and to follow the healing
of chronic venous diseases for longer period. It has been highlighted from
many RCTs that various compression systems heal more ulcers and improve
the physical dimension of quality of life compared with no compression
[23,24]. It has been also demonstrated that a very high compression may lead
to pressure damage for the patients with poor arterial supply [25].
Different modes of compression treatment are available for chronic
venous diseases. Surgical correction of incompetent venous valves is also
being used for the treatment of venous leg ulcers. It has been found through
RCTs that venous surgery results in a significant haemodynamic benefit for
legs with venous ulceration and may abolish incompetence in some calf
perforators [26,27]. However, it is evident from the current literature that
superficial surgery of incompetent venous valves is connected with similar
ulcer healing rates to compression alone, but with less recurrence of ulcers
 Characterization of compression bandage 29

[28,29]. Compression bandaging in addition to surgical correction does not

show improved rate of venous ulcer healing as compared to compression
alone, but results in a larger proportion of ulcer-free time and also decrease the
recurrence of venous ulcers at 4 years [30]. It can be concluded that patients
with chronic venous leg ulcers will gain from the addition of simple surgery
of incompetent venous valves to avoid ulcer recurrence.
External pressure is provided to the limb using different modes of
compression like compression stockings, compression bandages, intermittent
pneumatic compression, etc. Eight RCTs summarized in a systematic
review by Amsler et al. [31] found that higher proportion of ulcers healed in
compression stockings than bandages (63% versus 47%) and concluded that
leg compression with compression stockings has a positive impact on healing,
and is easier to apply. They studied high-strength compression stockings
exerting high pressure (4.1 to 7.4 kPa) and found that the proportion of venous
ulcers healed is greater with compression stockings than bandages in all RCTs
and the average time of healing is shorter with stockings. However, the effect
of compression with low-strength stockings providing low pressure at the
ankle (2 to 3.3 kPa) was not different from that of compression with bandages
[32]. Intermittent pneumatic compression (IPC) was found to be more efficient
for immobile patients as compared to conventional compression stockings
and bandages [33]. For immobile, wheelchair-bounded patients, IPC produces
pressure waves on the leg by inflation and deflation of the air-filled garments,
thus mimicking the working and resting pressure applied by bandages. Seven
RCTs summarized in a systematic review by Nelson et al. [34] found that IPC
increases venous ulcer healing compared with no compression. There was no
clear evidence found whether IPC promotes healing when added to treatment
with bandages, or if it can be used separately instead of bandages.
Bandaging systems vary significantly in their ability due to differences
in their structure and the presence of different material and produce different
compression outcomes. Omeara et al. [35] reviewed and summarized six
RCTs comparing different bandaging system. They found multi-component
compression bandaging systems are more useful than single-component
bandaging systems. Multi-component systems containing an inelastic
bandage appear less effective than those composed of elastic constituents.
Palfreyman et al. [36] reviewed many RCTs and also observed that there is a
statistically more benefit from elastic and multi-layer system in terms of the
number of venous ulcers healed. It has been observed from many RCTs that
four layers bandaging systems show faster ulcer healing as compared to short-
stretch bandaging systems [37–41]. However, multi-layer multi-component
bandaging systems consisting inelastic bandages were found to result in higher
and faster reduction of leg volume compared with other bandaging systems
30 Science of compression bandage

[42,43]. This intended volume reduction causes a significant reduction of

interface pressure from initial values.
Inelastic bandaging systems were also found to produce a significant
improvement in venous pumping by increasing ejected volume and ejection
fraction, reduce venous reflux (backflow) and accelerate the leg ulcer healing
as compared with other bandaging systems or compression stockings [44–50].
The functioning of the foot pump and calf-muscle pump helps in returning the
venous fluid to the heart and minimizing the excess pressure in the foot veins.
These pumps act to compress and release the deep veins using the muscle
movement, hence encouraging the return of venous blood. The working of
calf-muscle pump gets enhanced during compression treatment when a short-
stretch bandage is wrapped to the limb. Short-stretch compression bandages
have been found to provide a high resistance to expand when pressure is
applied through internal muscle contraction and joint movement (working
pressure). These bandages behave like an artificial valve suppressing refluxes
during each muscle movement, generating a higher peak interface pressure
and greater pressure amplitude during physical movements, hence indicating
that these bandages are preferable for use when the muscle movements are
active. While in a long-stretch bandage, the pressure generated by the action
of the muscle movements expands the wrapped bandage, thereby losing some
of its therapeutic pressure.
It is finally concluded that treatment with compression improves healing
as compared to no compression; multi-layer compression is more useful than
single-layer compression or low compression. However, it has been observed
that the most clinically effective treatment is not always the cost effective. The
use of compression bandaging systems was found to be more cost effective
compared with a system of care where compression is not systematically
offered [51–53]. Four-layer compression bandaging systems were showed to
be more cost-effective system compared with short-stretch bandaging systems
despite the fact that the four-layer compression bandaging systems are four
times more expensive than the typical dressing used in a usual care regimen
[54–56]. This is due to lower frequency of dressing changes in multi-layer
systems. It is concluded from the above studies that systematic treatment with
compression systems provide same compression benefits and is more cost-
effective compared with usual care.

2.7 Smart compression bandages

• A wide bandage fabric: This bandage is highly elastic in either warp
or weft or both the direction and is also easily tearable (Fig. 2.6). The
tearing capacity is obtained by utilizing spun crape threads with S and
 Characterization of compression bandage 31

Z twisting directions (high twisted single cotton threads and/or staple

fiber threads of different twisting directions) [15]. In order to improve the
tearing capacity, the fabric additionally undergoes chemical treatment to
incorporate metal oxides (e.g., 5 g of titanium dioxide, silicon dioxide,
aluminum oxide per kg of fabric) from their corresponding hydrolysable
metal salts. For improving elasticity, covered polyurethane and/or rubber
threads are incorporated between symmetrically arranged spun crape
threads twisted in opposite directions. The bandage formed in this way
has high transverse stability and is tearable in longitudinal direction. To
obtain additional elasticity, the fabric may be coated in both sides with
latex having an anti-ager of an aqueous emulsion (e.g. 2,6-di-tert.-butyl-
4-methylphenol).

Figure 2.6  Large scale plane view of the wide bandage.

• Compression bandage with leno pair incorporated: The fabric includes

cotton weft yarn and textured polyester or nylon warp yarn (Fig. 2.7).
When the bandage is in normal (without stretch) condition, the leno
pairs remain in pre-tensioned state. Leno pairs are incorporated in
warp direction to provide high frictional resistance between warp and
weft yarns particularly to improve the durability of the bandage, where
frequent washing is necessary [16].
32 Science of compression bandage

Figure 2.7  Bandage with pre-tension leno weaves

• Visual indication of compressive force: Visual indication of compressive

force applied by a compression bandage is provided by forming a
continuous pattern of repeated geometric shapes in the bandage strip with
indicator yarn. The continuous pattern is formed, so that the shape of each
geometric shape is changed when tension is applied to the bandage and
shape of the deformed pattern is indicative of compression force applied
(Fig. 2.8).

Force applied

Bandage with marked rectangles Bandage after application of force

Figure 2.8  Mechanism to obtain constant stretch

• Bandage with controlled compressive force: In case of ordinary
bandages, it is important to apply the bandage at correct tension,
which is sufficiently high to enable them to maintain an effective-level
compressive force under the bandage over a period of time. Another
disadvantage is associated with those bandages that if they are stretched
too much during the application, the compressive force over the bandage
may be overly great and cause damage, for example by restriction of
blood supply. The bandage manufactured by Smith & Nephew [17]
achieves an effective compressive force at an extension of between 20%
and 60% after which any further extension of the bandage is accompanied
by only a small increase in compressive force. The bandage is made of a
synthetic elastomeric polymer containing tri-block A-B-C copolymer. A
 Characterization of compression bandage 33

and C blocks are hard blocks (e.g. styrene) having sufficiently high glass
transition temperature to form crystalline or glass domain at the working
temperature of the polymer. B block is a soft block having considerably
low glass-transition temperature, e.g. polymers based on ethylene-
butylene. The bandage comprises a knitted or woven fabric containing
both inelastic and elastic yarns, in which elastic yarns comprise the tri-
block copolymer (Fig. 2.9). Copolymers of this type are commercially
available under the trade name Cariflex, Kraton, etc. In this bandage, a
styrene-butadiene-styrene elastomer available as Kraton G 27 was woven
together with textured nylon 6.6 yarn into a plain weave in warp direction
using cotton as weft.

Figure 2.9  Bandage with controlled compressive force

• Compression therapy with effective skin care: A major drawback of

wearing conventional medical compression stockings is that the skin
dries out fast and easily gets rough. The Venotrain micro balance [18] is
a medical compression stocking offering effective compression therapy
in combination with a long-lasting and tangible skin care effect. While
wearing this new product, a concentrated mixture of oils, vitamin E and
urea is gradually released from the fibres onto the patient’s legs. The
skin only absorbs as much care as it needs in order to readjust its natural
balance. It stimulates and regenerates the skin cells, keeps the moisture
level of the skin in balance and soothes and relaxes the skin making it
tender and smooth. It is composed of 55–65% polyamide and 35–45%
elastane.
34 Science of compression bandage

• Bandage pressure sensor: In this bandage, a pressure sensor has been

integrated for providing an indication of the pressure applied by a bandage
to a human or animal body. The sensor comprises an elongate flexible
support strip (Fig. 2.10) adapted to be placed between a bandage and the
body. The support strip carries a flat pressure sensitive portion, whose
electrical properties vary with applied pressure perpendicular to the general
plane of the support strip. The sensor is connected to a display unit with the
help of flat flexible conductors. The patient’s limb is clad with a stocking
for comfort, so that the sensor does not touch the skin directly. Whilst the
bandage is wound, the switch in the display unit is turned on, then the
display indicates the pressure applied. This help doctors and nurses to apply
the compression bandage with correct pressure [19].

Figure 2.10  Bandage with integrated pressure sensor, (a) pressure sensor with display
unit, (b) sensor arrangements at different layers

• Electro-conductive yarn as pressure sensor: The textile pressure sensing

element was constructed from electro-conductive yarns as a single sheet of
fabric. The elements include multiple compressible junctions. Each junction
comprises two overlapping electro-conductive yarns separated by a gap. The
gap is filled with a resilient compressible material (Fig. 2.11). The sensor
may be a capacitive sensor where the gap is filled with a dielectric material.
By measuring the capacitance of the overlapping conductors and the size
of the gap, pressure can be determined at that junction. Alternatively, the
sensor may be a resistive sensor, where the gap is filled with a compressible
conductive material, whose resistance varies with compression and
resistance is measured to determine applied force [20].
 Characterization of compression bandage 35

Figure 2.11  Use of electro conductive yarns as pressure sensor in smart bandage,
(a) junction between electro conductive warp and weft yarns,
(b) large view of the bandage fabric

• Electrically controllable compression bandage: This is a unique active

bandage with integrated elastomeric actuators. By electrically controllable
compression system, the bandage can massage muscle groups of leg,
support the blood circulation or provide relief to tired legs. An elastomeric
film is coated on both sides with electrodes. The electrodes are connected
with a circuit to apply a voltage U (Fig. 2.12). The electrostatic pressure
acts and the film become thinner and expand in horizontal plane. Due
to expansion short-circuit happens, which helps the elastomeric film to
move back to its original position [21].

Figure 2.12  Working principle of electrically controllable compression bandage

36 Science of compression bandage

• Three-dimensional knitted single-layer bandage: Multi-layer compression

bandaging system comprises crepe bandage, padding bandage,
compression bandage and adhesive bandage. The whole system is bulky
and provides discomfort to the patient. With a view to replace both the
compression and padding bandages, 3D knitted single-layer bandage
have been introduced which is produced by spacer technology [57]. The
fabric sample contains two different layers of fabric that are combined
with an inner spacer yarns. The construction allows using different
materials for its layers and spacer yarns and hence could be engineered
for a wide range of applications. It provides softness, good resilience and
a cushioning effect to the body.

References
1. Mosti, G. (2012), Compression and venous surgery for venous leg ulcers,
Clinics in Plastic Surgery 39, 269–280.
2. Vicaretti, M. (2010), Compression therapy for venous disease, Australian
Prescriber 33, 186–190.
3. Blattler, W. and Zimmet, S.E. (2008), Compression therapy in venous
disease, Phlebology 23, 203–205.
4. Mosti, G. Mattaliano, V. Polignano R. and Masina, M. (2009), Compression
therapy in the treatment of leg ulcers, Acta Vulnologica 7, 113–135.
5. Clark, M. (2003), Compression bandages: principles and definitions,
Position Document, European Wound Management Association (EWMA),
Medical Education Partnership Ltd. London 5–7.
6. ENV 12718:2001, Medical compression hosiery, General product
information, replace standard, Brussels (2001).
7. Partsch, H. (2005), The use of pressure change on standing as a surrogate
measure of the stiffness of a compression bandage, European Journal of
Vascular and Endovascular Surgery 30, 415–421.
8. Partsch, H. (2005), The static stiffness index (SSI) – a simple method to
assess the elastic property of compression material in vivo, Dermatologic
Surgery 31, 625–630.
9. Leskovec, N.K. Pavlovic, M.D. and Lunder, T. (2008), A short review of
diagnosis and compression therapy of chronic venous insufficiency, Acta
Dermatovenerol Alp Panonica Adriat 17, 17–21.
10. Stolk, R. Wengen, C.P.M. and Neuman, H.A. (2004), A method for
measuring the dynamic behaviour of medical compression hosiery during
walking, Dermatologic Surgery 30, 729–736.
11. BS 7505:(1995), Specification for the elastic properties of flat, nonadhesive,
extensible fabric bandages, British Standards Institute, London (1995).
 Characterization of compression bandage 37

12. Thomas, S. (1997), Compression bandaging in the treatment of venous

leg ulcers, World Wide Wounds.
13. Hanna, R. Bohbot, S. and Connolly, N. (2008), A comparison of interface
pressures of three compression bandage systems, British Journal of
Nursing (Tissue Viability Supplement) 17(20):S16–24.
14. Das, R. and Das, A. (2010), Compression bandage: a better tomorrow
without leg ulcer, Asian Textile Journal 19 (10), 49–55.
15. Schafer, E. and Herald, J. (1984), Wide bandage fabric, United States
Patent, 4424808
16. Hampton, R. and Hanes, F. (1980), Woven elastic compression bandage,
United States Patent, Patent no. 4207885.
17. Miller, N.D. (1998), Woven or knitted elastic bandages having controlled
compressive forces, United States Patent, Patent no. 5749843.
18. Junger, M. and Riebe, H. (2006), A world’s novelty: venotrain micro
balance combining compression therapy with effective skin care- a
randomised, controlled, prospective, explorative study, 7th Annual
Meeting, European Venous Forum, London.
19. Taylor, M. (2008), Bandage pressure sensor, United States Patents,
Application Publication, US 2008/0306407 A1.
20. Sandbach, D.L. and Chapman, C. (2008), Textile pressure sensor, UK
Patent Application, GB 2 443208 A.
21. Munch-Fals, J. Benslimane, M.Y. Gravesen, P. and Stenstroem, T. (2006)
Electro active elastic compression bandage, United States Patents,
Application Publication, Pub no. US 2006/0079824 A1.
22. Annells, M. Oneill, J. and Flowers, C. (2008), Compression bandaging
for venous leg ulcers: the essentialness of a willing patient, Journal of
Clinical Nursing 17, 350–359.
23. Clarke-Moloney, M. Obrien, J.F., Grace, P.A. and Burke, P.E. (2005),
Health-related quality of life during four-layer compression bandaging
for venous ulcer disease: a randomised controlled trial, Irish Journal of
Medical Sciences 174,21–25.
24. Obrien, J.F. Grace, P.A., Perry, I.J., Hannigan, A. Clarke-Moloney, M.
and Burke, P.E. (2003), Randomized clinical trial and economic analysis
of four-layer compression bandaging for venous ulcers, British Journal of
Surgery 90, 794–798.
25. Callam, M.J. Harper, D.R., Dale, J.J. and Ruckley, C.V. (1987), Arterial
disease in chronic leg ulceration: an underestimated hazard? Lothian and
Forth Valley leg ulcer study, British Medical Journal 294, 929–931.
26. Gohel, M.S. Barwell, J.R. Earnshaw, J.J. Heather, B.P. Mitchell, D.C.
Whyman, M.R. and Poskitt, K.R. (2005), Randomized clinical trial of
38 Science of compression bandage

compression plus surgery versus compression alone in chronic venous

ulceration (ESCHAR study)-haemodynamic and anatomical changes,
British Journal of Surgery 92, 291–297.
27. Gohel, M.S. Barwell, J.R. Wakely, C. Minor, J. Harvey, K. Earnshaw,
J.J. Heather, B.P. Whyman, M.R. and Poskitt, K.R. (2005), The influence
of superficial venous surgery and compression on incompetent calf
perforators in chronic venous leg ulceration, European Journal of
Vascular and Endovascular Surgery 29, 78–82.
28. Barwell, J.R. Davies, C.E. Deacon, J. Harvey, K. Minor, J. Sassano, A.
Taylor, M. Usher, J. Wakely, C. Earnshaw, J.J. Heather, B.P. Mitchell,
D.C. Whyman, M.R. and Poskitt, K.R. (2004), Comparison of surgery
and compression with compression alone in chronic venous ulceration
(ESCHAR study): randomised controlled trial, Lancet 363, 1854–1859.
29. Howard, D.P. Howard, A. Kothari, A. Wales, L. Guest, M. and Davies,
A.H. (2008), The role of superficial venous surgery in the management
of venous ulcers: a systematic review, European Journal of Vascular and
Endovascular Surgery 36, 458–465.
30. Gohel, M.S. Barwell, J.R. Taylor, M. Chant, T. Foy, C. Earnshaw, J.J.
Heather, B.P. Mitchell, D.C. Whyman, M.R. and Poskitt, K.R. (2007),
Long term results of compression therapy alone versus compression plus
surgery in chronic venous ulceration (ESCHAR): randomised controlled
trial, British Medical Journal 335, 1–6.
31. Amsler, F. Willenberg, T. and Blattler, W. (2009), In search of optimal
compression therapy for venous leg ulcers: a meta-analysis of studies
comparing diverse bandages with specifically designed stockings, Journal
of Vascular Surgery 50, 668–674.
32. Brizzio, E. Amsler, F. Lun, B. and Blattler, W. (2010), Comparison of
low-strength compression stockings with bandages for the treatment of
recalcitrant venous ulcers, Journal of Vascular Surgery 51, 410–416.
33. Partsch, H. (2008), Intermittent pneumatic compression in immobile
patients, International Wound Journal 5, 389–397.
34. Nelson, E.A. Mani, R. Thomas, K. and Vowden, K. (2011), Intermittent
pneumatic compression for treating venous leg ulcers, Cochrane Database
of Systematic Reviews 2, 1–34.
35. Omeara, S. Cullum, N.A. Nelson, E.A. and Dumville, J.C. (2012),

Compression for venous leg ulcers Cochrane Database of Systematic
Reviews 1, 1–192.
36. Palfreyman, S.J. Lochiel, R. and Michaels, J.A. (1998), A systematic
review of compression therapy for venous leg ulcers, Vascular Medicine
3, (301–313).
 Characterization of compression bandage 39

37. Castonguay, G. (2008), Short-stretch or four-layer compression bandages:

an overview of the literature Ostomy Wound Management 54, (50–55).
38 Gannon, R. (2007), A review of the four-layer vs the short-stretch bandage
system, British Journal of Nursing 16, (S14–S21).
39. Milic, D.J. Zivic, S.S. Bogdanovic, D.C. Jovanovic, M.M. Jankovic,
R.J. Milosevic, Z.D. Stamenkovic, D.M. and Trenkic, M.S. (2010), The
influence of different sub-bandage pressure values on venous leg ulcers
healing when treated with compression therapy, Journal of Vascular
Surgery 51, 655-661.
40. Nelson, E.A. Iglesias, C.P. Cullum, N. Torgerson, D.J. and Venus,

I.C. (2004), Randomized clinical trial of four-layer and short-stretch
compression bandages for venous leg ulcers (VenUS I), British Journal of
Surgery 91, 1292–1299.
41. Omeara, S.O. Tierney, J. Cullum, N. Bland, J.M. Franks, P.J. Mole, T.O.
and Scriven, M. (2009), Four-layer bandage compared with short-stretch
bandage for venous leg ulcers: systematic review and meta-analysis of
randomised controlled trials with data from individual patients, British
Medical Journal 338, 1–9.
42. Damstra, R.J. Brouwer, E.R. and Partsch, H. (2008), Controlled,
comparative study of relation between volume changes and interface
pressure under short-stretch bandages in leg lymphedema patients,
Dermatologic Surgery 34, 773–778.
43. Lamprou, D.A. Damstra, R.J. and Partsch, H. (2011), Prospective,
randomised, controlled trail comparing a new two-component compression
system with inelastic multicomponent compression bandages in the
treatment of leg lymphedema, Dermatologic Surgery 37, 985–991.
44. Bergan, J.J. and Sparks, S.R. (2000), Non-elastic compression: an
alternative in management of chronic venous insufficiency, Journal of
Wound Ostomy and Continence Nursing 27, 83–89.
45. Hirai, M. Niimi, K. Iwata, H. Sugimoto, H. Ishibashi, H. Ota, T. and
Nakamura, H. (2009) A comparison of interface pressure and stiffness
between elastic stockings and bandages Phlebology 24, 120–124.
46. Mosti, G. Mattaliano, V. and Partsch, H. (2008), Inelastic compression
increases venous ejection fraction more than elastic bandages in patients
with superficial venous reflux Phlebology 23, 287–94.
47. Mosti, G. and Partsch, H. (2010), Is low compression pressure able to
improve venous pumping function in patients with venous insufficiency?,
Phlebology 25, 145–150.
48. Mosti, G. and Partsch, H. (2010), Inelastic bandages maintain their
hemodynamic effectiveness over time despite significant pressure loss,
Journal of Vascular Surgery (2010) 52, (925931).
40 Science of compression bandage

49. Quilici, B.C. Gildo, C.J. De-Godoy, J.M. Quilici, B.S. and Augusto, C.R.
(2009), Comparison of reduction of edema after rest and after muscle
exercises in treatment of chronic venous insufficiency, International
Archives of Medicine 2, 18–22.
50. Spence, R.K. and Cahall, E. (1996), Inelastic versus elastic leg compression
in chronic venous insufficiency: a comparison of limb size and venous
hemodynamics, Journal of Vascular Surgery 24, 783–787.
51. Franks, P.J. and Bosanquet, N. (2004), Cost-effectiveness: seeking value
for money in lower extremity wound management, International Journal
of Lower Extremity Wounds 3, 87–95.
52. Marston, W.A. Carlin, R.E. Passman, M.A. Farber, M.A. and Keagy,
B.A. (1999), Healing rates and cost efficacy of outpatient compression
treatment for leg ulcers associated with venous insufficiency, Journal of
Vascular Surgery 30, 491–498.
53. Oien, R.F. and Ragnarson-Tennvall, G. (2006), Accurate diagnosis and
effective treatment of leg ulcers reduce prevalence, care time and costs,
Journal of Wound Care 15, 259–262.
54. Betts, J. (2005), Four-layer elastic bandages were most cost effective than
multi-layer inelastic bandages for healing venous leg ulcers, Evidence-
Based Nursing 8, 26.
55. Franks, P.J. and Posnett, J. (2003), Cost-effectiveness of compression
therapy, Position Document, European Wound Management Association
(EWMA), Medical Education Partnership Ltd. London 8–10.
56. Pham, B. Margaret, H.B. Chen, M.H. and Carley, M.E. (2012), Cost-
effectiveness of compression technologies for evidence-informed leg
ulcer care: results from the Canadian Bandaging Trial, BMC Health
Services Research 12, 1–8.
57. Rajendran, S. and Anand, S.C. (2007), Design and development of three-
dimensional structures for single-layer compression therapy, Fourth
International Conference and Exhibition on Healthcare and Medical
Textiles 16 –18 July (2007), Bolton, UK.