5

Compression under dynamic state

5.1 Introduction
Compression therapy is used for providing therapeutic pressure for the
treatment of venous and lymphatic diseases. The application of the external
compression helps to minimize the effect of venous hypertension by directing
fluid from the interstitial spaces back into the vascular and lymphatic
compartments [1–3]. The exercising of the calf-muscle pump and foot pump
helps in returning the blood to the heart and decreases the excess pressure in
the foot veins [4]. The calf-muscle pump acts to compress and release the deep
veins using the muscle action, hence creating extra pressure and encouraging
the return of blood to the heart. The function of calf-muscle pump gets
enhanced during compression therapy when an inelastic bandage (short-stretch
bandage) is wrapped to the limb. Extensive research works have been done
by several researchers to assess dynamic performance of different bandages
[5–20]. Inelastic bandages have been shown to create a high resistance to
expand when pressure is applied through internal muscle contraction and joint
movement. These bandages act like an artificial valve suppressing refluxes
during each muscle systole, generating a higher peak working interface
pressure and greater pressure amplitude during the movement of calf-muscle
pump, hence indicating that these materials are preferable for use when the
calf muscle is active. While in a long-stretch bandage, the force produced by
the action of the calf muscle expands the bandage, thereby losing some of its
therapeutic pressure.
The in vivo results of the interface pressure exerted by different
compression bandages in healthy volunteers in different positions (supine,
sitting, standing, exercising etc.) have been reported in the literatures [17–
19]. The variations in the circumference of the leg have also been reported
for different volunteers during walking on a treadmill. The largest difference
in the circumference between the maximal dorsiflexion and maximal plantar
flexion positions of the foot occur at the transition of the gastrocnemius
76 Science of compression bandage

muscle into the Achilles tendon (the so called B1 level according to ENV
12718:2001). The circumference varies at different parts of the leg and
also varies from person to person [22,23]. This variation in circumference
of leg is the deciding factor on the amount of the stretch occurring to a
bandage wrapped over the leg and hence this determines the interface
pressure variation. These above facts indicate that the clinical outcomes of
compression therapy depend on the stiffness of the materials as well as on
the muscle movement.
The in vivo pressure measurement should be done on the medial aspect
of the lower leg, at the B1 position according to ENV 12718:2001. The in
vivo measurement is intrusive for the volunteer, and hence it could also
cause discomfort. The procedure of in vivo pressure measurement at the
B1 region must be done with accuracy and this is not always practicable
with wounded patients. To overcome such problems of direct measurement,
the chapter describes in vitro measurement system to obtain the interface
pressure exerted by the compression bandage on a mannequin surface under
dynamic state. The change in circumference of leg during muscle movement
is simulated using an artificial leg-segment model comprising of an air
bladder fixed over a mannequin part. The dynamic behaviors of bandages
under different conditions are analyzed through this model. The impact of
the major factors namely – bandage extensibility, applied force and change
in circumference of the mannequin leg on the interface pressure during one
cycle of expansion or contraction of air bladder have been analyzed. The
interaction effects of these main factors on the interface pressure are also
identified.

5.2 Materials and experimental methods

5.2.1 Design and development of the prototype for
dynamic case
The amounts of circumferential change at different parts of the leg because
of calf muscle movement are reported in the literature [23]. A prototype was
used to simulate the amount of circumferential change in the leg because of
human calf muscle expansion or contraction using air bladder expansion or
contraction. The principle employed relates the change in air pressure in the
bladder on application of an external pressure by the bandage to the interface
pressure developed [25–29].
 Compression under dynamic state 77

Figure 5.1  Schematic diagram of the leg-segment prototype used for dynamic analysis

Figure 5.1 shows the schematic diagram of the prototype used for
obtaining the interface pressure exerted by the bandage under dynamic
conditions. An air bladder was made and wrapped around the wooden
mannequin limb of having similar circumference at B1 level of the
volunteer reported in the literature. The circumference value at B1
level varies from person to person and hence many sub-sections of the
mannequin having different circumference values were made. For a
simpler model and also for fixing air bladder properly to each of the
sub-sections of the mannequin, a round shape for each of the sub-section
of the mannequin was taken to obtain desired circumference level. For
the bladder to be placed on the mannequin, it was first glued at the end
with rubber adhesive to form an endless air tube and then fixed at the
round shaped profile that was created on the mannequin surface. The
expansion or contraction of the air bladder was done using a cylinder
piston system. The reciprocating movement of the piston was given using
a motor assembly which rotates at a constant speed. This reciprocating
movement of the piston withdraws or pumps air into the air bladder, which
causes the contraction or expansion of the air bladder, hence simulating
the calf muscle contraction or expansion during exercising. The amount
of the circumferential change of the mannequin surface was controlled
by changing the relative position of the piston inside the cylinder
which controls the amount of air pumped or withdrawn into or from the
bladder respectively and, hence controlling expansion or contraction of
the bladder. Figure 5.2 shows the experimental set-up for the interface
pressure measurement under dynamic case.
78 Science of compression bandage

Figure 5.2  Experimental set-up for measuring interface pressure under dynamic state

The circumference of the lower limb changes during walking because

of calf muscle activities. Maximum change in circumference of the limb is
found at the B1 level located at the transition of the gastrocnemius muscle
into the Achilles tendon. It has been reported that on an average 35% of the
limb circumference at the B1 level expands at the posterior side, whereas
65% does not expand at all during movement [23]. Also, the shape of the
leg is not perfectly cylindrical at the B1 level. These variations in the shape
of the limb and also the irregular circumfential changes at the B1 level
could affect the interface pressure variations under dynamic conditions.
The proposed model does not account for these complex changes in the leg
during ambulatory conditions. For a simpler model, a round or cylindrical
shape for the mannequin was used in this study. The amount of variation in
extension of the bandage was precisely controlled through this leg-segment
model.

5.2.2 Recording of interface pressure under dynamic

state
The bladder placed on the mannequin limb was first inflated with air using a
hand pump to a particular pressure (Pio) with pumping assembly through an
inlet air tube which goes inside the bladder from one end. The bandage was
then wrapped over the mannequin limb containing the bladder. This wrapping
exerted some additional pressure (P) on the bladder, which was duly observed
by the change in the air pressure in the bladder and the total pressure (PTo)
was obtained. Then by deducting the initial bladder pressure (Pio) from the
 Compression under dynamic state 79

final total pressure reading (PTo), the resting interface pressure (RP) exerted by
the bandage is obtained. The resting interface pressure (RP) is defined as the
initial interface pressure applied by the bandage upon application without any
dynamic movement given to the air bladder.
After positioning of the bandage on the air bladder, the bladder was made
to expand or contract using cylinder-piston arrangement as discussed above.
The air pressure inside the bladder was recorded over one cycle of the piston
movement by real time measurement. The interface pressure in one cycle can
be obtained in the similar way by deducting the air pressure Pi(t) (without
bandage on the bladder) from the final pressure reading PT(t) (with bandage
on the bladder). Figure 5.3 explains the method of obtaining the interface
pressure from the air pressure measured during one cycle.

Figure 5.3  A typical diagram to obtain interface pressure during one cycle of bladder
expansion or contraction from the air pressure measurement

5.2.3 Variables used for analyzing pressure variation

under dynamic state
The dynamic stiffness index (DSI) and the static stiffness index (SSI) have
been frequently used to describe the change in interface pressure under
80 Science of compression bandage

dynamic conditions [12,24]. DSI of the bandage indicates the increase in

the interface pressure when the limb circumference increases by 1cm, while
the SSI gives the difference of the interface pressure at standing and supine
positions. In this work, different parameters i.e., the resting interface pressure
(RP), the working interface pressure (WP) and the additional interface
pressure are defined and used to evaluate pressure variation under dynamic
conditions. These parameters obtained from the leg-segment prototype acted
as good indicators to assess bandage beahvior under static and dynamic state
of the limb.
The resting interface pressure (RP) indicates the initial interface
pressure applied by the bandage upon application, without any dynamic
movement given to the air bladder while the working interface pressure
(WP) indicates the average interface pressure exerted by the bandage
during a cycle of circumferential variations of the bladder surface. The
additional interface pressure was then calculated by subtracting the resting
interface pressure (RP) from the working interface pressure (WP). The
additional interface pressure gives the amount of an extra interface pressure
exerted by the bandage during a cycle because of dynamic movements of
the bladder.

5.2.4 Design of experiment

Three important factors namely the bandage extensibility, the applied force
and the circumferential change of the mannequin surface were chosen to
analyze their impacts on the interface pressure during one cycle of expansion
or contraction of air bladder. Three levels (low, medium and high) were
chosen for the factor bandage extensibility. The extensibility of a bandage
is defined as the extension under a load of 10 N/cm and is expressed as a
percentage of the initial length [ENV 12718:2001]. Based on the bandage
extensibility, the bandages are classified as short-stretch (Extensibility <70%),
medium-stretch (70%< Extensibility <140%), and long-stretch (Extensibility
>140%). Bandages from all three classes were chosen in this study to ensure
each class of the bandages is represented in the evaluation. Three different
samples of commercially available compression bandages were chosen
whose constructional parameters are listed in Table 5.1. These three classes
of the bandages, short-stretch, medium-stretch and long-stretch were actually
representing the low, medium and high levels respectively for the factor,
bandage extensibility.
 Compression under dynamic state 81

Table 5.1 Details of bandage.

Fibre Yarn linear Thread density

proportion Fabric density (tex) Fabric (per cm)
Sample Construction Extensibility
thickness weight
type type (%)
Cotton Nylon (mm) (GSM) Ends/ Picks/
Warp Weft
(%) (%) warps wefts

Short-
Woven 75 25 0.5 40 25 191 18 31 45
stretch

Medium-
Woven 100 – 0.86 56 35 345 19 28 95
stretch

Long-
Woven 100 – 1.36 60 68 521 18 26 145
stertch

The circumference of the leg at different parts changes during walking

which ranges from 0 to 2 cm and the maximum circumferential change
is obtained at the B1 level of the volunteer while walking on treadmill as
reported [23]. To cover the entire range of circumferential change of the
normal leg during exercise, the circumference of the mannequin leg was made
to change by an amount of 0.5, 1 and 1.5 cm which actually represents the
low, medium and high levels respectively of the change in circumference of
the mannequin leg. Two levels of applied force, low and high, were chosen
for the experimental plan. Bandages were applied to the mannequin leg with
an applied force of (3 N) and (6 N) which represent the low and high levels
respectively of the applied force. The circumference of the mannequin limb
including air bladder used for the testing was 43.8 cm. The number of bandage
layers was kept constant at two during the study for all the samples.

5.2.5 Statistics
A complete factorial design was prepared to obtain the additional interface
pressure at all combinations of levels of the factors. An N-way ANOVA for a
fixed effect model was performed to determine the factors or the combination of
the factors which were significantly affecting the additional interface pressure
during cycle. A p-value less than 0.05 was considered as statistically significant.

5.3 Results and discussion

5.3.1 Tensile characteristic of the bandages
The tensile tests were done to study the variations in tensile moduli of different
bandage samples, to have an understanding of the extension characteristics of
82 Science of compression bandage

the bandages at higher extension level. The initial length of each specimen
for tensile testing was 10 cm and the width of the specimen was 5 cm.
The specimens were extended to different levels of strain at a fixed-rate of
extension (100 mm/min).

Figure 5.4  Tensile characteristics of the bandages having varying extensibility

The tensile tests helped to characterize the elastic property of the bandage.
Figure 5.4 shows increasing instantaneous modulus with increasing strain for
all the bandages. The instantaneous tensile modulus at a particular stress was
highest for the short-stretch bandage and lowest for the long-stretch bandage.
Also, it was observed that at higher strain level the value of the instantaneous
modulus was higher for all the bandages. This shows the distensible property
of the bandage at higher strain level and, hence more force is required for the
further extension in the bandage.

5.3.2 Analysis of variance (ANOVA)

An N-way analysis of variance for fixed effect model was used to test
hypothesis about the main factor and their interaction effects on the additional
interface pressure. Table 5.2 shows the value of additional interface pressure at
all possible levels of combination of the above chosen factors. The observation
may be described by the linear statistical model:
 Compression under dynamic state 83

Y = µ + BEi + AFj + CCk + (BE × AF)ij + (BE × CC)ik + (CC × AF)jk

i = − 1, 0,1
+ εijk  j = − 1, 0,1
 k = − 1, +1

where μ is the overall mean effect, BEi is the effect of the ith level of factor BE
(Bandage extensibility), AFj is the effect of the jth level of factor AF (Applied
force), CCk is the effect of the kth level of factor CC (Change in circumference
of the mannequin); (BE×AF)ij, (BE×CC)ik and (CC×AF)jk are the effects of
the interaction between BE and AF, BE and CC, and AF and CC respectively;
Eijk is the random error component. The null hypotheses about main and
interaction effects are H0: BEi = AFj = CCk = 0 and H0: (BE×AF)ij = (BE×CC)
ik
= (CC×AF)jk = 0, respectively. The null hypothesis is rejected if the p-value
is less than 0.05 and the effects are considered as statistically significant.

Table 5.2  Additional interface pressure (kPa) obtained under dynamic state.

Change in circumference of the mannequin leg

0.5 cm 1 cm 1.5 cm
Bandage
type
Applied force Applied force Applied force

3N 6N 3N 6N 3N 6N

Short-stretch 1.0 (0.05) 1.1 (0.06) 1.6 (0.08) 2.1 (0.11) 2.7 (0.12) 3.4 (0.14)

Medium-stretch 0.7 (0.04) 0.9 (0.05) 0.8 (0.04) 1.1 (0.05) 1.2 (0.07) 2.0 (0.12)

Long-stretch 0.4 (0.02) 0.6 (0.03) 0.5 (0.03) 0.8 (0.04) 0.7 (0.04) 1.2 (0.04)

Note: Values in the bracket represent standard error

Table 5.3 shows the N-way ANOVA for a fixed effect model to identify
the main and interaction effects of the factors on the additional interface
pressure during one cycle of bladder expansion or contraction. It can be clearly
observed that the main effects (BE, CC and AF) are statistically significant (p
< 0.05). The interaction effects (BE×CC) and (CC×AF) are also statistically
significant at 95% level of confidence.
84 Science of compression bandage

Table 5.3  ANOVA results to check the significant difference in the mean values of the
additional interface pressure at various levels of the factors.

Sum of Degree of
Source Mean square Fcalculated Ftable p_value
square freedom
**BE 38.91 2 19.44 324.74 6.94 0
**CC 28.86 2 14.43 241.07 6.94 0.0001

**AF 5.24 1 5.24 87.54 7.71 0.0007

**BE.CC 10.04 4 2.51 41.93 6.39 0.0016

BE.AF 0.15 2 0.07 1.22 6.94 0.3858

**CC.AF 1.26 2 0.63 10.55 6.94 0.0254

Error 0.24 4 0.06

Total 84.67 17

Note: The factors significant at 95% level of confidence are denoted by. ** (BE – bandage
extensibility; CC – change in circumference of the mannequin; AF – applied force)

5.3.3 Effect of bandage extensibility

All the samples were tested for the effect of bandage extensibility on the
interface pressure during one cycle of air bladder expansion or contraction.
Table 5.2 shows that with decreasing extensibility of the bandage the
additional interface pressure increases keeping the level of all other factors
same. At same levels of applied force (6 N) and change in circumference (1.5
cm), short-stretch bandage (Extensibility = 45%) produces higher additional
interface pressure (3.4 kPa) while long-stretch bandage (A, Extensibility
= 145%) produces lower additional interface pressure (1.2 kPa). It is also
observed from the (Table 5.3) that the bandage extensibility significantly
affects the pressure variation in dynamic state (p-value < 0.05).
Short-stretch bandage showed the highest interface pressure variations
within one cycle while long-stretch bandage showed the lowest. This was
mainly due to the fact that short-stretch bandage was less distensible and
had greater stiffness than other bandages. The instantaneous modulus for the
short-stretch bandage was higher than the long-stretch bandage due to which
short-stretch bandage is not able to expand easily when the bladder expands;
hence the excessive air pressure was directed back into the bladder and not
wasted by expanding the bandage. Therefore, it can be inferred that the short-
stretch bandages show a higher peak working pressure and a larger pressure
amplitude than long-stretch bandages under ambulatory conditions.
 Compression under dynamic state 85

5.3.4 Effect of change in circumference

It is observed from (Table 5.2) that the additional interface pressure for
all the bandages increases with increase in the change in circumference of
the mannequin leg keeping level of all other of factors same. At low level
of applied force (3 N), the short-stretch bandage showed lower value of
additional interface pressure (1 kPa) for smaller change in circumference (0.5
cm), while at larger change in circumference (1.5 cm), it showed 2.7 kPa
value of additional interface pressure. This is because of larger variation of
stress in the bandage due to more change in the length of bandage.
It is also clearly evident from (Table 5.2) that the effect of change in
circumference on interface pressure is more prominent for short-stretch
bandage as compared to long-stretch bandage. At low level of applied force
(3 N), short-stretch bandage shows a change of 1.6 kPa in the additional
interface pressure when the level of change in circumference is increased
from 0.5 cm to 1.5 cm, while long-stretch bandage shows a change of 0.3 kPa
in additional interface pressure for the same change in the level of the change
in circumference. This indicates that for a short-stretch bandage the dynamic
variation of the interface pressure increases more rapidly with increasing
the muscle expansion or contraction of the leg as compared to long-stretch
bandage. It can be inferred from the above results that the compression
efficiency of a same bandage would differ for different patients if their muscle
activities are different.

5.3.5 Effect of applied force

All the bandage samples were applied onto mannequin surface with two levels
of force (low and high) keeping level of all other factors same. It is observed
from Fig. 5.5 that as the level of force on the bandage material is varied from
low to high, additional interface pressure increases for all the samples. It can
be seen from that at the same level of the change in the circumference (1 cm),
short-stretch bandage produces an additional interface pressure of 1.6 kPa and
2.1 kPa respectively at low and high levels of applied force. This was because
of variations in instantaneous tensile modulus at different stress levels for
the bandage samples (Fig. 5.4). All the samples become less extensible at
higher level of extension as the instantaneous tensile modulus increases with
increasing extension.
The interaction effect between the factor, applied force and change in
circumference, is also statistically significant (p = 0.0254) which indicates
that the interface pressure variations is more enhanced for an active calf
muscle function when the bandage is applied at higher tension. Therefore, it
86 Science of compression bandage

can be inferred that the pressure variations due to short-stretch bandage could
be enhanced to a greater extent when applied at higher tension level and also
with increasing circumference because of calf muscle activities. There could
also be detrimental effects of blood flow because of these changes in interface
pressure variations and hence there is a need for utmost caution and clarity for
the bandage application.

Figure 5.5 Effect of applied force on additional interface pressure

5.4 Conclusions
The work in the present chapter involved the analysis of interface pressure
exerted by different compression bandage using a prototype simulating
the behavior of calf-muscle pump. The principle of the prototype involved
the withdrawing or pumping of air in the air bladder using cylinder-piston
arrangement and measuring the air pressure changes on application of
an external pressure. The factors chosen for the study were the bandage
extensibility, the applied force and the change in circumference of the
mannequin leg. The working interface pressure exerted by a short-stretch
bandage was higher than a long-stretch bandage. Also, larger variations in
 Compression under dynamic state 87

the interface pressure were obtained with increasing applied force and also
with increasing the amount of circumferential change of the mannequin.
These factors were also interacting with each other and significantly affect
the interface pressure variations under dynamic conditions. The compression
efficiency of the bandage could differ from person to person and also with
changing tension level in the bandage. Therefore, there is a need for a suitable
wrapping protocol to choose ideal range of tension or extension level given
to different class of bandages to obtain their maximum efficiency which is
expected to vary with changing limb size and also with different muscle
activities.

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