CompressionS20l

408 PART VI « Mechanical Agents N

amputation, over skin damaged by burns, and to edematous the interstitial space. The fluid that is pushed out of the veins into
limbs. the interstitial space is then taken up by the lymphatic capillaries
to be returned to the venous circulation at the subclavian veins.
INCREASES TISSUE TEMPERATURE This fluid, known as lymphatic fluid (lymph), is rich in
Most compression devices except devices with built-in cooling protein, water, and macrophages.
mechanisms increase the temperature of superficial tissue A healthy diet and vascular system, combined with muscle
because the devices insulate the area to which they are applied. contraction, ensure that the appropriate amount of fluid exits the
Although this temperature increase is not a direct effect of veins and flows back toward the heart. Dysfunction in any of
compressive forces, it has been proposed that the warmth these mechanisms can increase movement of fluid from the
increases the activity of temperature-sensitive enzymes such as vessels into the extravascular space or reduce flow of venous
collagenase, which breaks down collagen. 8 It is possible that blood or lymph back toward the heart, thus forming edema.
compression garments control scar formation by this mechanism. Major causes of edema include venous or lymphatic obstruc-
tion or insufficiency, increased capillary permeability, and
Clînical Indications for increased plasma volume due to sodium and water retention. 9
ExternaiOUTLINE Compression
CHAPTER
Edema caused by venous or lymphatic insufficiency or
of deep venous
dysfunction thromboses
can be helped (DVT), tothus
by compression; facilitate residual
these forms of
EDEMA
Effects of Externai Gompression limb shaping after amputation, or to facilitate the healing of
Causes ofVenous
Improves Edema and Lymphatic Circulation Limits edema are discussed13 in detail in the following sections.
Shape and Size of Tissue Increases Tissue Temperature
venous
Edemaulcers.
may' also occur after exercise, trauma, surgery, burns,
Edema is caused by increased fluid in the interstitial spaces of
Clinical Indications for Externai Compression
the Edema
body. Fluid equilibrium in the tissues is maintained by the or infection because of the increase in blood flow and vascular
balance between hydrostatic pressure and osmotic pressure Clinical
capillary Pearl
permeability that occurs with the acute inflammation
Prevention of Deep Venous Thrombosis Venous
inside associated with these events. Increased vascular capillary
Stasis Ulcers Residual Limb Shaping After Hydrostatic pressure is
and outside the blood vessels. Compression is usually
determined byControl
bloodofpressure andScarring
the effects of gravity. Osmotic permeability increases the usedfluidtoflow controlout peripheral edema
of the capillaries,
Amputation Hypertrophic
but can also be applied to prevent
causing an accumulation of fluid at the site of trauma the formation of deep or
pressure is determined
Contraindications by the
and Precautions for concentrations of proteins inside
Externai Compression
vein thromboses, to facilitate
and Contraindications
outside the vessels. Higher
for Intermittent hydrostatic
or Sequential pressurePumps
Compression inside the infection. Edema caused by acuteresidual limb shaping
inflammation is describedafter in
Precautions
amputation,
Chapter 3. or to facilitate the healing of venous ulcers.
vessels pushesforfluid
Intermittent
out ofor Sequential Compression
the vessels, Pumps
and higher osmotic
Adverse Effects of Externai Compression Application Techniques
pressure inside the vessels, because of the higher protein Airline travel can also cause edema, probably as a result of
Compression Bandaging Compression Garments Velcro Closure Devices
concentration, keeps fluid inside the vessels (Fig. 20.1). prolonged sitting and reduced externai air pressure. A systematic
Intermittent Pneumatic Compression Pump Parameters for Intermittent review
Effects of 10 of randomized Externaitrials withCompression
a total of 2856 subjects
Pneumatic Compression Pumping Documentation Examples showed that wearing compression stockings for flights of at least
Clinical Case Studies Chapter Review Glossary References IMPROVES VENOUS AND LYMPHATIC
7CIRCULATION
hours significantly reduced the incidence of edema associated
10
© Clinical Pearl with
The flying.
controlled application of externai compression has a range
of effects on theisbody
Pregnancy alsothat
associated
vary withwith edema formation,
the pressure applied andpar- the
In a healthy body, hydrostatic pressure pushing fluid out of ticularly in the legs. Contributors
4 include increased blood
nature of the device used. Both static and intermittent
the blood vessels and osmotic pressure keeping fluid inside volume, altered venous
the blood vessels are almost balanced. compression devices cansmoothincrease muscle tone, and
circulation increased
by increasing
pressure within the veins caused by the gravid
hydrostatic pressure in the interstitial space outside the blood uterus reducing
and
venous return from the lower body,
lymphatic vessels. This increase in extravascular pressure leading to venouscan
insufficiency
limit the outflow and leg from
of fluid edema. Intermittent
the vessels into the pneumatic
interstitial
Under normal circumstances, the hydrostatic pressure compression
space, where(IPC) it tendsmaytoreduce ankle edema
pool, keeping fluid during
in the pregnancy,
circulatory
pushing fluid out of the veins is slightly higher than the osmotic although this edema may also signal preeclampsia, which needs
system, where it can circulate. Intermittent compression may
pressure keeping fluid in, resulting in a slight loss of fluid into careful
improvemonitoring
circulationbymore a physician."
effectively than static compression
A variety
because of medical
the varying amount conditions,
of pressureincluding
may milkcongestive
fluids fromheart the
failure (CHF), cirrhosis, acute renal
5,6 disease,
distal to the proximal vessels. When venous and lymphatic diabetic glomeru-
lonephritis,
vessels are malnutrition,
compressed, and the fluid radiation
withininjury,them may cause
is pushed
Flow into vessels peripheral and central edema by altering circulation or osmotic
proximally. When compression is then reduced, the vessels open
pressure
and refîllbalance.
with new Edema
fluid from
from these causes should
the interstitial space, notready
be treated
to be
Compression is an inward-directed mechanical force that with compression because it may worsen the overall health of the
increases externai pressure on the body or a body part. pushed proximally at the next compression cycle. Sequential
patient.
multichamber compression is thought to provide more effective
Compression is generally used to improve fluid balance and
circulation or to modify the formation of scar tissue. Fluid milking than
Edema single-chamber,
Caused by Venous intermittent compression because
Insufficiency
balance is improved by increasing hydrostatic pressure in sequential multichamber
Peripheral compression can
veins carry deoxygenated bloodcause
froma wave of vessel
the periphery
the interstitial space so that the pressure becomes greater in the back' to the heart. In a healthy vascular system, the fluid
constriction moving in a proximal direction, ensuring that is
resting
interstitial space than in the vessels. Ihis can limit or reverse pushed along
hydrostatic the vessels toward the heart rather than
venous pressure at the entrance to the right atrium ofin a distal
57
outflow of fluid from blood vessels and lymphatics. Keeping direction.
the ' Improving
heart averages 4.6 mmcirculation can benefit
Hg; this pressure increases patients
by with
fluid in, or returning it to, the vessels allows the fluid to edema, may
0. 77 mm helpHgprevent
for eachDVT formation
centimeter belowin high-risk patients,
the right atrium to
circulate rather than accumulate in the periphery. Compression and may
reach an facilitate
average healing
of 90 mm of ulcers
Hg atcaused by venous
the ankle. 12
When stasis.
the calf
can be static—exerting a constant force, or intermittent—with muscles
LIMITScontract,
SHAPEthey AND exert
SIZE a pressure of approximately 200 mm
OF TISSUE
the force varying over time. With intermittent compression, Hg
Staticoncompression
the outsidegarments
of the orveins, whichcanpushes
bandaging also acttheas ablood
form
pressure may be applied to the entire limb at the same time, or it proximally
that, having through the veins.
an elastic After the contraction,
compression element or pressure
being lesson
may be applied sequentially, starting distally and progress- ing the veins falls to about 10 to 30 mm Hg, allowing
extensible than natural skin, limits the shape and size of new the veins to
proximally. refill. A healthy amount of skeletal muscle
tissue growth. This effect is exploited when compression activity, such as
FIGURE 20.1 Effects of hydrostatic and osmotic pressure on tissue fluid
The primary clinical application for compression is to
balance. occurs
bandagingduring walking orarerunning
or garments appliedorover
withresidual
any limbs after
control peripheral edema caused by vascular or lymphatic
dysfunction. Compresssion can also be applied to help prevent
the formation
407
410 PART VI Mechanical Agents CHAPTER 20 • Compression 409

Healthy vessels Unhealthy vessels

Entrance of
Muscles Cervical thoracic duet into
contracting lymph vein
node
Right
lymphatic Thymus
duet gland

• Valves open • Valves open

• Forward flow • Forward Axillary
flow
lymph
Aggregated
node
lymphoid nodules
(Peyer’s patches) in
intestinal wall Thoracic
duet

Muscles
relaxed Spleen

Red
bone
marrow

• Valves closed • Valves unable to close

• No backflow • Backflow

FIGURE 20.2 Normal and abnormal valves in venous and lymphatic vessels and their relation to backflow.

rhythmical isometric muscle contraction, exerts a milking action Cisterna

that propels the blood in the veins from the periphery back Lymphedema
chyli

toward the heart. Muscle contraction is the primary force As explained previously, the hydrostatic pressure that pushes
Inguinal
propelling both lymphatic and venous flow. Valves within the fluid out of the veins normally exceeds the osmotic pressure
lymph
vessels prevent backflow of the fluid, ensuring that the fluid keeping fluid inside node them. This causes fluids and proteins to
moves proximally toward the heart rather than being pushed flow into the interstitial space, producing lymph. To prevent this
toward the distal extremities (Fig. 20.2). lymph from accumulating, the lymphatic system acts as an
Lack of physical activity, dysfunction of the venous valves accessory channel that returns this fluid to the blood circulation.
caused by degeneration, or mechanical obstruction of the veins The lymphatic system consists of a large network of vessels and
by a tumor or inflammation can result in venous insufficiency nodes through which the lymphatic fluid flows. Lymphatic
and accumulation vessels are found in almost every area where there are blood
FIGURE 20.3of fluid incirculation.
Lymphatic the periphery.
(From Thibodeau GA, Patton KT: Anatomy and physiology, ed 6, St Louis, 2006, Mosby.)
vessels. Lymph flows along these vessels, passing through
numerous lymph nodes, to empty into the subclavian veins (Fig.
© Clinical Pearl 20.3). Lymph
congenital disorder nodesof the arelymphatic
concentrated
vessels,in whereas
the axillary, throat,
secondary
Q Clinical Pearl
groin, and paraaortic
lymphedema is caused by areassomewhere
otherthey filterorthe
disease lymph, remov-
dysfunction. An
Lack of physical activity, venous or lymphatic valve ing bacteria and other foreign particles. Thedisease,
lymphatic
Low serum albumin, lymphatic obstruction, abnormal example of primary lymphedema is Milroy in vessels
which aof
dysfunction, or venous obstruction all can result in the right
lymphatic vessel distribution, and reduced activity all can person hasarm terminate aplastic,
hypoplastic, in the right lymphatic
or varicose andduet and empty
incompetent
peripheral edema. into the right subclavian vein. The lymphatic vessels from
cause lymphedema. lymphatic vessels. Patients with primary lymphedema oftenall
otherbackflow
have areas terminate in the thoracic
in the lymphatic duetand
vessels, andthe empty
rate into the left
of protein
subclavian vein.
reabsorption across Once the lymphatic
vessel wallsfluidisreenters
usuallytheslowed.
circulatory
In
system, it is processed
The most common cause of venous insufficiency is secondary lymphedema, lymphatic flow is impaired by blockage by the kidneys along with other fluids,
Decreased levels
inflammation of the ofveins,plasma
known proteins cause fluid
as phlebitis. to
Phlebitis orwaste products,ofand
insufficiency theelectrolytes
lymphatics.and then eliminated.
accumulate
thickens theinvessel
the extravascular
walls and damagesspace because
the valves.theThickening
osmotic Fluidmost
The flows common into the causelymphatic
of secondary system lymphedema
because the
pressure
and lossthat normally of
of elasticity keeps fluid inwalls
the vessel the lymphatic
elevates the vessels and
hydrostatic concentra-is tion
worldwide of proteins
filariasis, a diseaseinside the lymphatic
characterized vesselsofis
by infestation
the veins in
pressure is the
reduced.
venousIf system,
the totalwhile leveldamage
of plasmato the generally higher than in the interstitial
valves the lymphatics and obstruction of the lymph vessels and
protein space. As with thenodes
veins,
decreases belowtotheflow
allows blood normal rangeproximal
in both of 6 to 8 and
g/dLdistal
or if the level
directions, byflow along
microscopic the lymphatic
filarial worms. vessels
Although in a
this proximal
disease is direction
common
ofrather
plasma
thanalbumin falls below
just proximally 3.3 g/dL,
through lymphedema
the veins, when the is muscles
likely independs
Asia, it on muscle
is rare in the activity,
Unitedsuch as walking
States, Australia,orand running,
Europe. which
In
tocontract
result. A(see
healthy
Fig. diet
20.2).andTheadequate proteinflow
retrograde reducesarethe the
absorption compresses
developedtheworld,vesselsinfection,
and their neoplasm,
valves and radiation
prevents backflow.
therapy,
required to keep
circulation plasma protein blood
of deoxygenated at an appropriate
out of thelevel. When
veins, Decreased
thus trauma, levelsarthritis,
surgery, of plasma proteins,
chronic venousparticularly
insufficiency, albumin;
and
lymphedema is caused
increasing pressure in thebyvenous
hypoproteinemia,
system if fluid this underlying
inflow mechanical obstruction of the lymphatics;
from the lipedema are the main causes of secondary lymphatic abnormal distribution
problem
arterial should
system be is addressed
unchanged.first Thetoelevated
prevent venous
further edema of lymphatic
pressure obstruction, 13 vessels or lymph nodes; and reduced activity all
with cancer treatment with lymph node removal or
formation and into
pushes fluid otherthe
adverse space, causing edema. If the radiation
consequences.
extravascular can resultbeing in most
reduced lymphatic
common. Otherflow
causes andof the formationinof
lymphedema
Lymphedema
limbs can be primary
are in a dependent position,or thesecondary,
edema willalthough it is
worsen further lymphedema.
the United States include mechanical obstruction of the vessels
usually
becausesecondary.
of increasedPrimary lymphedema
hydrostatic pressureis caused
caused byby gravity.
a by a tumor or inflammation, dysfunction of the valves
 CHAPTER 20 • Compression 411

caused by degeneration, and accidental damage to the lymphat-

ics during non-cancer-related surgery. Most research has been
done on breast cancer-related upper extremity lymphedema, but
there is a growing interest and body of work on cancer- related
lower extremity lymphedema.14
Adverse Consequences of Edema
Edema of any origin can impair range of motion (ROM), limit
function, and cause pain. Persistent chronic edema, particularly
lymphedema, can cause collagen to be laid down in the area,
leading to subcutaneous tissue fibrosis and hard induration of the
skin. This edema may eventually cause disfiguring and disabling
contractures and deformities (Fig. 20.4). Chronic edema also
increases the risk of infection because tissue oxygenation is
reduced; this risk is further elevated with lymphedema because
of the presence of a protein-rich environ- ment for bacterial
growth.13,15 Advanced chronic lymphatic or venous obstruction
may result in cellulitis, ulceration, and, if unmanaged, parţial
limb amputation.15 These more serious sequelae are more likely
to occur if pressure from excess fluid accumulated in the
interstitial extravascular spaces causes arterial obstruction.
Chronic venous insufficiency often causes itching due to stasis
dermatitis and brown pigmentation of the skin due to
hemosiderin deposition. These signs are com- monly seen on the
medial lower leg (Fig. 20.5). Early control of edema can help
prevent the progression and development of signs and symptoms
of chronic edema and its associated complications.

© Clinical Pearl

Edema can lead to restricted ROM, pain, disfigurement,

infection, ulceration, amputation, itching, brown skin
pigmentation, and funcţional impairment.

How Compression Reduces Edema

Compression is thought to control edema by increasing
extravascular hydrostatic pressure and promoting circulation.
Underlying causes of edema, such as infection, malnutrition,
inadequate physical activity, or organ dysfunction, must be
addressed to achieve an optimal outcome and to prevent
recurrence of the edema.
Compression of a limb with a static or intermittent device
increases the pressure surrounding the extremity that coun-
terbalances any increased osmotic or hydrostatic pressure that
was causing fluid to flow out of the vessels into the extravascular
space. If sufficient compression is applied, the hydrostatic
pressure in the interstitial spaces becomes greater than the
pressure in the veins and lymphatic vessels, reducing outflow
from the vessels and causing fluid in the interstitial spaces to FIGURE 20.4 (A) Lymphedema caused by elephantiasis. (B) Lymphedema
return to the vessels. Once fluid is in the vessels, it can be affecting function. (A, From Goldstein B, ed: Practicai dermatology, ed 2, St
circulated out of the periphery, preventing or reversing edema Louis, 1997, Mosby; B, from Walsh D, Caraceni AT, Fainsinger R, et al:
formation. Intermittent sequential compression may also help to Palliative medicine, Philadelphia, 2008, Saunders.)
move the fluid proximally through the vessels.
PREVENTION OF DEEP VENOUS THROMBOSIS
A DVT is a blood ciot (thrombus) in the deep veins. The risk for
DVT formation increases when local circulation is
412 PART VI ' Mechanical Agents
FIGURE 20.5 Venous stasis ulcer. Note the areas of darkened skin around
the ulcer caused by hemosiderin deposits. (From Cameron MH, Monroe LG:
Physical rehabilitation: evidence-based examination, evalu- ation,
and intervention, St Louis, 2007, Saunders.)
reduced because slowly flowing blood can coagulate and form a
thrombus. Therefore any intervention that increases the
circulatory rate may reduce this risk. Risk factors for DVT
formation include older age, surgery, trauma, hospital or nursing
home confinement, cancer, central vein catheteriza- tion,
transvenous pacemaker, prior superficial vein thrombosis,
varicose veins, paralysis, use of oral contraceptives, pregnancy,
and hormone therapy.16 DVT formation is most common in
immobilized patients, and more than 50% of all DVTs occur in
hospitalized patients and patients in nursing homes. Other
known risk factors account for 25% of DVTs, and 25% are of
unknown cause.17
DVTs can cause a postthrombotic syndrome, characterized
by pain, swelling, and skin changes in the area of the thrombus,
but a more significant health risk occurs if the thrombus
becomes dislodged and blocks the blood supply to the lungs,
causing a pulmonary embolus. Such blockage may cause
shortness of breath, respiratory failure, or death. Therefore
preventing the formation of DVTs in at-risk patients is
imperative.
Various approaches including compression stockings, IPC,
calf muscle electrical stimulation, and anticoagulant medications
reduce the risk of DVT formation. A 2014 Cochrane Collabora-
tion systematic review and meta-analysis of 19 studies
evaluating the efficacy of graded compression stockings for
DVT preven- tion mostly in postoperative patients found that
graded compression stockings used alone reduced the overall
risk of DVT formation from 21% in control groups to 9% in
treated groups.1 Compression therapy is also probably effective
for preventing postthrombotic syndrome.18 The length of the
compression stocking is probably not important. A 2012
systematic review comparing knee-length with thigh-length
compression stockings for DVT prevention found insuficient
evidence to recommend one over the other.19 IPC devices
applied to the foot and calf (Fig. 20.6) also reduce the incidence
of DVT formation in hospitalized patients. A 2005 meta-analysis
of 15 studies in 2270 surgical patients found that intermittent
compression reduced the risk of DVT formation by 60%.20
FIGURE 20.6 Use of intermittent pneumatic compression to prevent deep vein
thrombosis (DVT) formation in a bedridden patient. (Courtesy DJO, Vista, CA.)
Notably, although a 2010 systematic review based on four
randomized controlled trials did not find that physical methods
significantly reduced the frequency of DVT after acute stroke, 21
the results of a later large, randomized controlled trial with
almost 3000 patients published in 2013 found an absolute risk
reduction of 3.6% for DVT and fewer deaths with IPC as
compared to no IPC in patients who have had a stroke. 22
Therefore some authors recommend IPC devices as an
alternative to anticoagulant medication for DVT prophylaxis
when high bleeding risk prevents the use of anticoagulant
medication.23
Air flights lasting 8 hours or longer also increase the risk of
DVT formation in people with additional risk factors. 24 A 2006
systematic review of 10 studies concluded that wearing
compression stockings during flights lasting 7 hours or longer
substantially reduced the number of asymptomatic DVTs.10
Compression is thought primarily to reduce DVT formation
by improving venous blood flow, thus reducing venous stasis
and the opportunity for thrombus formation.25 Intermittent
compression may also inhibit tissue factor pathways that iniţiate
blood coagulation or may degrade thrombi by enhancing
fibrinolytic activity.26'29
VENOUS STASIS ULCERS
A venous stasis ulcer is an area of tissue breakdown and
necrosis that occurs in areas of impaired venous circulation (see
Fig. 20.5). The exact mechanism by which poor venous
circulation causes ulcers is still unknown, but it is thought that
increased venous pressure and deep venous reflux lead to
endovascular and inflammatory changes which provide a setting
for ulcer formation.30'32 Skin changes associated with
inflammation can then cause flbrosis, impaired wound healing,
and ulceration. It used to be thought that venous stasis ulcers
were caused by poor tissue oxygenation in areas of poor venous
circulation, but this is unlikely because it has been found that
tissue oxygen levels are generally in the normal range in areas of
venous ulcers.29 Compression is the treatment of choice for
treating and preventing the recurrence of venous stasis ulcers.
 414 PART VI • Mechanical Agents CHAPTER 20 • Compression 413

Compression can improve venous circulation. Improving CHF or cardiomyopathy, one must ensure that the increased
circulation may reduce adverse effects of poor venous flow, fluid load that could be placed on the heart by the shifting of
diminish the risk of vascular ulcer formation, and facilitate fluid from the periphery in response to treatment with
healing of previously formed ulcers.33,34 compression will not be detrimental to the patient. In such cases,
Compression increases the rate of healing of venous stasis the patient’s physician should always be consulted before
ulcers.33 Compression may facilitate healing by improving compression therapy is begun.
venous circulation, reducing venous pooling and reflux, All forms of compression are contraindicated in patients
improving tissue oxygenation, altering white cell adhesion, and with symptomatic heart failure (because of the risk of system
reducing edema. Multilayered compression (two or four layer) overload) and in patients with a thrombus (because of the risk of
is more effective for healing venous ulcers than single-layer dislodgment) and may not be appropriate if an arterial
compression, with systems including elastic components being revascularization has been performed on the involved limb. In
most effective. Consistently wearing compression stockings also addition, the clinician must evaluate for the presence and
reduces the likelihood of venous ulcer recurrence. 34 Wearing severity of arterial insufficiency before compressing a limb. This
compression stockings consistently is essential. Venous ulcers is most often determined by calculating the ankle-brachial
have been found to recur more often in patients who wear index (ABI). If the ABI is less than 0.6, all forms of static
compression stockings less often.35 IPC may be used to treat compression are contraindicated. If the ABI is greater than 0.8,
venous stasis ulcers that do not heal using other methods, and, at standard or full compression (30 to 40 mm Hg) may be used.
least in the short term, patient compliance may be higher with When the ABI is between 0.5 and 0.8, the compression pressure
this than with other methods of compression.36 should be reduced to between 23 mm Hg and 27 mm Hg. If the
patient also has neuropathy, careful monitor- ing is necessary
because they may fail to recognize symptoms of ischemia such
as pain, numbness, or tingling.
© Clinical Pearl
Particular care should be taken when applying and removing
Compression therapy is the cornerstone of treatment for compression bandages and garments to avoid trauma to healing
FIGURE 20.7 Compression for residual limb shaping. (Courtesy Silipos,
FIGURE 20.8stasis
venous Hypertrophic
ulcers. scarring. (From Cameron
Multilayered MH, Monroe
compression LG:
is more tissue or fragile skin. Details of contraindications and
Niagara Falls, NY.)
Physical rehabilitation: evidence-based examination,
effective than single-layer compression. evaluation, and precautions for the use of compression pumps are provided next.
intervention, St Louis, 2007, Saunders.)
CONTRAINDICATIONS FOR INTERMITTENT OR
CONTROL OFCOMPRESSION
SEQUENTIAL HYPERTROPHIC SCARRING
PUMPS
reducing the hyperproliferation
Compression that underlies
is generally contraindicated excessiveof
in the presence Hypertrophic scarring is a common complication of deep
arterial 45insufficiency because compression of the arterial vessels
scarring. ^burns and other extensive skin and soft tissue injuries. Normal
CONTRAINDICATIONS
mayWhen
further compression is applied
impair arterial flow,toaggravating
control hypertrophic
the condi- scar
tion. skin is pliable, is esthetically pleasing, and has clearly identifi-
formation,
However, treatment
surprisinglyis generally initiatedhasoncebeen
compression the new
foundepi-to for
ableIntermittent
layers, whereas or hypertrophic
Sequential scars are not pliable, have a
thelium
sometimeshas facilitate
formed and the ishealing
continued for 12insufficiency
of arterial months or longerulcers. Compression
raised and ridged Pumps appearance, and do not have clearly
until the scar hasfound
A meta-analysis reached
thatmaturity and isdemonstrated
some studies no longer growing.
improved • identifiable skin
Heart failure or layers
pulmonary (Fig.edema
20.8). Hypertrophic scars result in
Compression
wound healing canwith
be applied
IPC in with elastic
patients withbandages, self-adherent
severe peripheral artery • poor cosmesis
Recent or acuteandDVT, thethrombophlebitis,
development oforcontractures that may
pulmonary embolism
wraps,
diseasetubular
who were elastic cotton supports,
not candidates or custom-fit
for surgery. 37
elastic
It is possible that restrict ROM and function.
• Obstructed lymphatic or venous returnThe risk of hypertrophic scarring is
garments.
compression With any these
helped of these, the by
patients compression pressure
reducing chronic is
edema increased with delayed healing,
• Severe peripheral arterial disease a deep wound, repeated trauma,
maintained
that places at approximately
pressure 20 tovessels.
on the arterial 30 mmHowever,
Hg. It isbecause
recom-of • infection, or the
Acute local skinpresence
infection of a foreign
(e.g., cellulitis)body and in individuals
mended
the riskthat the compression
of further impairmentdevice be worn
of arterial flow23withto compression,
24 h/day to • with a genetic
Significant predisposition.
hypoproteinemia Hypertrophic
(protein scarring is most
levels <2 g/dL)
achieve maximum
compression not be 41used
shouldbenefit. Common
on most complications of this
patients with peripheral • common aroundorthe
Acute trauma sternum, upper back, and shoulders.
fracture
treatment include skin irritation, constriction of circulation, and
artery disease. Although
• Arterial many approaches, including surgery, pharma-
revascularization
restricted joint motion. ceuticals, passive stretch with positioning, massage, and silicone
RESIDUAL LIMB SHAPING AFTER AMPUTATION gel, are used to control the formation of hypertrophic scars,
Residual limb reduction and shaping are required to prepare for compression is the standard, first-line approach. Based on a
©funcţional
Clinical Pearlweight bearing on a prosthetic device. The residual systematic review of 28 articles, compression for at least 23 h/
limb must be shaped so that the prosthesis maintains its position Heart Failure
day with 20 toor30Pulmonary
mm Hg of Edema pressure is recommended to
To alignment
and control hypertrophic
and promotes scar formation,
weight bearing compression
on appropriate
producing Excessive
20 to 30 mm Hg ofonforce should be worn for 23 Although
decrease scar height dependent
edema of the and erythema. parts41ofMany
the body is a common
mechanisms have
structures. pressure unprotected bony prominences consequence
been proposed of CHF, to compression
explain the pumps effectsshould not be used toon
of compression
to 24 h/day for 12 months or longer.
should be avoided to promote comfort and function and to limit treat edema ofscarring.
hypertrophic this origin because the
Compression may shift of fluid
directly shapefromthe the
scar
the risk of tissue breakdown (Fig. 20.7).38 peripheral
tissue by to the central
acting as a mold circulation may increase
for the growth of newstress
tissue.onIt the
also
Both static and intermittent compression are used for limb failing organformation
decreases system. CHF resultsedema
of local from a and decrease in the collagen
improves ability
Contraindications and Precautions
shaping, although intermittent for the residual
compression can reduce ororientation.
efficiency Compression
of cardiac muscle may also contraction
improve and the subsequent
extracellular
limb in approximately
Externai Compression half the time required by other techniques, 39 decreased cardiac output.
matrix organization This increases
in hypertrophic venous
scars and pressure and
may increase
and acontraindications
Few temporary prosthesis may to
apply achieve ideal stump shaping
all compression even
devices; sodium and water
collagenase retention,
activity which
as a result of cause
increasededema.
skinTreating
temperature CHFor
more quickly
however, than with compression
when compression bandaging
is used to treat edema or or impaired
pneumatic requires
increaseddecreasing
releasetheofloadprostaglandin
on the heart, whereas
E2.8'42 compression
Alternatively,
40
compression.
circulation, When intermittent
the underlying cause ofcompression is used
these problems for be
should limb increases the cardiac
compression load by
may control scarincreasing
formationthe by amount
inducingoflocalfluid in
tissue
shaping, it is applied in conjunc- tion with an elastic
addressed before compression therapy is initiated. Compression bandage. the veins.43Thus
hypoxia or by compression
altering the tends to aggravate
release the underlying
and activity of matrix
Compression
therapy will be reduces residual
ineffective limb size because
and contraindicated in casesit where
Controls condition, resulting inthought
metalloproteinases worseningto beedema and potentially
involved causing 44
in wound healing.
postsurgical
edema is causededemaby and prevents
blockage stretching
of the of theorsoft
circulation, tissuesisby
if there other more serious side effects such as pulmonary
Compression has been shown to induce apoptosis (cell death) edema as
accumulated
active infection fluids.
or malignancy in the affected extremity. When CHF progresses. Peripheral edema caused by
and to regulate cytokine release in hypertrophic scars, thus CHF is usually
peripheral edema is caused by cardiovascular disease such as bilateral and symmetrical.

Pulmonary edema occurs with prolonged or severe CHF. It
is the result of elevated lung capillary pressure, causing fluid to
leave the circulation and accumulate in alveolar air spaces in the
lungs. Compression is contraindicated when pulmonary edema
is present because compression increases the fluid load of the
vascular system and pressure in the lung capillaries, potentially
aggravating this serious medical condition.
................ \
■ Ask the Patient
• "Do you have any heart or lung problems?’’
• “Do you have difficulty breathing?”
• “Are you taking any medications for your heart or blood
pressure?”
• “Do you have swelling in both legs?”
> Assess
\ » C h e c k for the presence of bilateral edema
Compression should not be used to treat edema until the
clinician has ascertained that the edema is not a result of CHF or
pulmonary edema.
Recent or Acute Deep Venous Thrombosis,
Thrombophlebitîs, or Pulmonary Embolism
Although compression is recommended for DVT prevention,
intermittent compression should not be used when the patient is
known to have a DVT, thrombophlebitis, or a pulmonary
embolus because the thrombus may become dislodged or the
embolus may travel. This can occur because of direct
mechanical agitation of the ciot by compression or because of
increased circulation produced by compression. If a thrombus or
embolus becomes dislodged, it may travel in the bloodstream to
a distant site and lodge in a location where it impairs blood flow
to an organ sufflciently to cause organ damage, severe
morbidity, or even death. For example, an embolus in the
pulmonary arteries produces approximately a 30% mortality
rate, whereas an embolus that lodges in the arteries supplying
the brain may cause stroke or death. Compression can help
prevent the formation of DVTs, but it should not be used when it
is thought that a thrombus may already be present.
.......................................................... ......................... \
' Ask the Patient
• “Do you have pain in your calves?”
• “How long have you not been walking?”
iAssess
« Check for Homans sign (discomfort in the calf on
forced dorsiflexion of the foot), a sign of thrombosis in
the leg
Further evaluation by a physician should be requested if the
clinician suspects that there may be a thrombus in the deep veins
of the leg. The use of compression should be delayed until the
patient has been cleared for the presence of thromboses or
thrombophlebitis in the area to be treated.
Obstructed Lymphatic or Venous Return
Although compression is recommended for treatment of edema
due to lymphatic or venous insufficiency, compression is
contraindicated when lymphatic or venous return is completely
obstructed because increasing the fluid load of the vessels in
CHAPTER 20 • Compression 415
such cases cannot reduce the edema until the obstruction has
been removed. Lymphatic or venous return maybe obstructed by
a thrombus, radiation damage to the lymph nodes, an inguinal or
abdominal tumor, or other masses. With parţial obstruction of
the vessels or complete occlusion of only a few of the vessels,
treatment with compression may enhance the functioning of
intact collateral vessels.
■ Ask the Patient
• “Do you know why you have swelling in your legs/
arms?”
« “Is something obstructing your circulation?”
If there is complete lymphatic or venous obstruction,
compression should not be used. Such obstruction may need to
be treated surgically. When there is parţial obstruction,
compression maybe used in conjunction with careful monitor-
ing of the patients response to the treatment to ensure that the
treatment is helping to resolve the edema, rather than just
shifting the fluid to a more proximal area of the affected limb.
Severe Peripheral Artery Disease
Compression should not be used in patients with severe
peripheral artery disease because it can aggravate this condition
by closing down diseased arteries, further impairing circulation
in the area.
.................................... .. . .... ..... ..............................
® Ask the Patient
• “Do you get pain in your calves when walking?”
J
• If an ulcer is present: “Have you had problems with
your arteries, for example, heart bypass surgery or
v bypass surgery in your legs?”
Pain in the calves while walking can be the result of
intermit-
tent claudication, a sign of peripheral artery disease. A history
of bypass surgeries suggests the presence of arterial disease in
other areas.
.................................................... v
' Assess
• d painful. They occur most often on the
interdigital spaces between the toes or on the lateral
malleolus.
0
Request that an ABI be obtained. This is generally
performed by vascular Services and is a measure of the
ratio of systolic blood pressure in the lower extremity
to systolic blood pressure in the upper extremity.
Compression should generally not be applied if the ABI
is less than 0.6, indicating that blood pressure at the
ankle is less than 60% of that in the upper extremity,
and should be applied with caution with lower
\ compression force if less than 0.8.
Acute Local Skin Infection
A local skin infection is likely to be aggravated by the
application
of compression because the sleeves and skin coverings used
 416 PART VI • Mechanical Agents
CHAPTER 20 • Compression 417

increase the moisture and temperature of the area encourage the ■ Ask the Patient A
■ of
growth Ask the Patient If a chronic skin infection is present,
microorganisms.
J
• “When did
Adverse your injury
Effects happen?” Compression^
of Externai
• “Do you
single-use have that
sleeves high blood
avoid pressure? If so, is it wellfrom one
cross-contamination ^The
«“Do you knowadverse
if a boneeffects
was broken?”
potentially of compression generally reiate
patientcontrolled
to anotherwith medication?”
or reinfection of the same patient may be used
■ Assess to aggravating a condition that is causing edema or is impairing
to apply intermittent compression.
^ « Resting blood pressure____________________________^ circulation if excessive pressure is used. When edema is the
result of heart,
Arterial kidney, or liver failure or circulatory obstruction,
Revascularization
■ Ask the Patient compression compression
Intermittent may aggravateisthecontraindicated
underlying condition. Also, if
after arterial
• "Do too much pressure is used, the compression device may cause
The you have any skin infections in the area to be treated?”
clinician should check with the patient’s physician for revascularization surgery because of the risk of occluding
soft tissue injury or act as a tourniquet, impairing arteriH
■ Assess
guidelines on blood pressure limits. arterial vessels and preventing blood from reaching the extremi-
• Inspect the skin for rashes, redness, or skin breakdown circulation
ties, leading and causing ischemia
to ischemia. If the patientand has
edemahad or compressing
recent arterial
Cancer indicating the possible presence of infection peripheral nerves.46,50
revascularization, If ischemia
elevation of theisextremity
prolonged, andimpaired
exercisehealing
may
Compression can increase circulation, which may disturb or be or used
tissue death canedema.
to decrease occur. When compression is effective in
dislodge metastatic tissue promoting metastasis or may improve reducing edema in an extremity, it is recommended that if this
tissue nutrition promoting tumor growth. Although no reports fluid accumulates at the proximal end of the extremity or where
' Ask the Patient
metastasis or accelerated tumor growth caused by the extremity attaches to the trunk, it should be mobilized using
have describedHypoproteinemia
Significant • “Have To
massage. youminimize
had surgery theonprobability
your arteries?”of adverse circulatory
the use of
Although compression,
peripheral edema itis is generallysymptom
a common recommended of severethat
■Assess
effects from treatment with compression, it is recommended that
compression not be
hypoproteinemia, whenapplied where aprotein
the serum tumor level
is present
is lessor than
when2 it
the°patient
Look for always
scars be thatmonitored closely
would indicate for undesired
vascular surgery,changes
^ in
is thought
g/dL, that an
reSulting increase
edema should in not
circulation
be treatedmaywith cause a tumor to
compression blood pressure
especially on theorlegs edema, particularly with the first application of
move orreturning
because grow more fluid rapidly. However,
to the vessels willcompression
further loweris the fre-
the treatment or with changes in treatment parameters.
quentlyprotein
serum used concentration,
to control lymphedema that results
potentially causing severe from
adverse the
treatment of breast
consequences, cancercardiac
including with mastectomy or radiation.
and immunological dysfunc- Application Techniques
Experts PRECAUTIONS FOR INTERMITTENT OR_____
in this
tion. field hypoproteinemia
Severe vary in their opinions can occurregarding
because theofsafety of this SEQUENTIAL
inadequate Compression can be applied in several
COMPRESSION PUMPS ways, depending on the
47 49
treatment
food andincreased
intake, the precautions
nutrientto losses,
be applied. ' Although
or increased some patients clinical presentation and the treatment goals. Static
nutrient
experts do notresulting
requirements considerfromthe anpresence or history
underlying disease.of malignancy to *compression
PRECAUTIONS can be applied with bandages or garments, whereas
contraindicate the use of compression, others recommend intermittent compression can be applied with electrical
ravoiding the use of compression in areas close to A
for Intermittent
the pneumatic pumps. or Sequential
Static compression can be used to help
■ Ask the
malignancy, and Patient
still others recommend not applying this type of control Compressionedema caused Pumps by venous or lymphatic dysfunction or
• “Have you
intervention untilrecently lost weight?”
the patient has been cancer-free for 5 years. In inflammation. • Impaired sensation Lymphedemaor mentationmanagement has focused on
• “Have you changed
general, most experts agree your diet?”
that the use of compression need not complete • Uncontrolled hypertension
decongestive therapy, which consists of manual
be • restricted
“Do you have any other
during the disease?”
time that patients are receiving lymphatic • Cancer drainage (MLD), compression, skin care, and light
Assess
chemotherapy, hormone therapy, or biological response exercise. • Superficial However,peripheral
basednerves
on current evidence, some recom-
• Checkfor
modifiers thetreatment
laboratory ofvalues section of the patient’s
their cancer. mendations suggest putting less emphasis on MLD and more on
chart for the serum protein level early diagnosis, weight control, exercise, and compression. The
v J optimal therapy
Impaired Sensation and or optimal
Mentation type of compression for
The
Ask use
the
of
Patient should be delayed until the patient’s Compression
compression lymphedemashould require be further
applied research
with and tocontinue
caution patients to
withbe
9
If edema results from the treatment of breast cancer: controversial. 52-56
impaired sensation or mentation because such patients may be
serum protein level is greater than 2 g/dL.
“Are you receiving chemotherapy, hormone therapy, or unable Static compression
to recognize can be used
or communicate whentopressure
form the shape of
is excessive
Acute Trauma
biological or Fracture
response modifiers for treatment of your cancer?” oramputated painful. residual limbs in preparation for the use of a
* Assess
Intermittent compression is contraindicated immediately after prosthetic device or to control scar formation after burn injury.
acute*Determine
trauma because how recently
compressionthe cancer diagnosis
may cause was motion
excessive Static and intermittent compression, used alone or together, can
' Ask the Patient ^
at the made
site of trauma, increasing bleeding, aggravating the acute be applied to help prevent the development of DVT in bedridden
• “Do you have normal feeling in this area?”
inflammation, or destabilizing an acute fracture.46 Such effects patients (see Fig. 20.6). Standard compression therapy for
■ Assess
can further damage the site of injury and can impair healing. venous ulcers generally involves bandaging, sometimes with
If the cause of edema isshouldunknown • Sensation in the area
Intermittent compression be and
usedtheforpatient has signs
treating post-of ^ aIPC, to control edema and promote ulcer healing and
Alertness and orientation____________________________^
cancer such
traumatic edema as only
recentafter
unexplained
the iniţial changes in body weight
acute inflammatory phaseor compression stockings to maintain edema control and prevent
constant
has passed, pain that does
bleeding has not change,
stopped, andtreatment
the area with compression ulcer recurrence.
is mechanically
stable. Static compression, as provided by stockings can
should be deferred until a follow-up evaluation that rule out
or wraps, Compression garments or low levels of intermittent
malignancy has been performed by a physician. COMPRESSION
compression may be used BANDAGING
if the patient has impaired sensation or
may be used immediately after acute trauma to prevent edema
Compression bandaging
mentation; however, such patients is recommended by the monitored
must be carefully Agency for
and reduce bleeding.
Superficial Peripheral NervesDirectly after an injury, static compression
Healthcare
for adverse Research
effects suchandasQuality
skin guidelines
irritation or for the treatment
aggravated edemaof
is frequently applied in conjunction with rest, ice, and elevation 13
Peroneal nerve palsy has been documented after the application caused lymphedema.
by constriction Early of in the intreatment
garments tight areas. of lymphedema,
to optimize the control of pain, edema, and50,51 inflammation.
of intermittent sequential compression. Significant weight compression bandages generally provide more effective edema
loss resulting in loss of fat and muscle mass around the peroneal control than compression garments, although upper extremity
Qnerves
Clinical predispose these nerves to injury from compression Uncontrolled
mayPearl funcţional statusHypertension
is worse.37 Therefore bandages are usually used
devices. When compression is applied over an area where there Compression
early in should
treatment tobereduce
applied with whereas
edema, caution garments
to patientsarewith
used
Immediately after acute trauma, static compression, often uncontrolled
is a superficial nerve, particularly in a patient with significant later to maintain edema control. hypertension because compression can further
in conjunction elevate blood pressure by increasing the vascular
restingfluid load.
weight loss, thewith rest, ice,
clinician should andmonitor
elevation, can be
closely forapplied
symptoms Compression bandages work by applying or working
to prevent edema and reduce bleeding. Do not apply Blood pressure should be monitored frequently while treating
of nerve compression, including distal changes in or loss of pressure or a combination of the two. Resting pressure is
intermittent compression immediately after acute trauma these patients, and treatment should be stopped if their blood
sensation or strength.
because this can aggravate bleeding or destabilize the site. pressure increases above the safe level determined by their
physician.
 418 PART VI * Mechanical Agents

FIGURE 20.9 Development of working pressure. (A) Muscle relaxed. (B)

Calf muscle contracting and pressing against Unna boot to compress the
veins.

exerted by elastic when it is put on stretch. An elastic bandage

exerts this pressure whether the patient is moving or immobile.
Working pressure is produced by active muscles pushing
against an inelastic bandage (Fig. 20.9) and is produced only
when the patient is moving and contracting the muscles.
Compression bandages come in varying degrees of extensibility
and may be applied as a single layer or in multiple layers. Types
of compression bandages include long-stretch, short- stretch,
multilayered, and semirigid bandages.
A long-stretch bandage (also known as high-stretch
bandage) can extend by 100% to 200%. These bandages provide
the greatest resting pressure because they exert the greatest
restoring force. When stretched, a long-stretch bandage typi-
cally applies approximately 60 to 70 mm Hg pressure. These
highly elastic bandages provide little to no working pressure
because they stretch rather than resist when the muscles expand.
Long-stretch bandages are most effective for applying
compression to immobile patients or limbs. Examples of long-
stretch bandages include Ace wraps and Tubigrip (ConvaTec,
Skillman, NJ). In general, it is recommended that if high-stretch
bandages, such as a new Ace wrap, are used to control edema,
they should be applied with only moderate tension to avoid
excessive resting pressure because without activity, the high
resting pressure provided by this type of bandage may impair
circulation. FIGURE 20.10 Application of a four-layer compression bandage. (From
A short-stretch bandage (also known as low-stretch Cameron MH, Monroe LG: Physical rehabilitation: evidence-based
bandage) has low elasticity, with 30% to 90% extension. These examibation, evaluation, and intervention, St Louis, 2007, Saunders.)
bandages produce a low resting pressure but cause resistancfe
and high working pressure during muscle activity. Because low- short-stretch bandages are Comprilan (Smith & Nephew/
stretch bandages provide a degree of both resting and working Beiersdorf, London, UK) and Artico (Activa Healthcare, Burton-
pres- sures, they can be somewhat effective during activity or at upon-Trent, UK).
rest. For an inelastic bandage to produce working pressure, the Multilayered bandage systems use a combination of inelastic
patient must have a funcţional calf muscle and a funcţional gait and elastic layers to apply moderate to high resting pressure
pattern. Short-stretch bandages are most useful during exercise through the use of two, three, or four layers of different bandages
when the activity of the muscles results in high working (Fig. 20.10). For example, one type of multilayered bandage
pressure; generally they do not control edema effectively or
improve circulation in a flaccid or inactive limb. Examples of
 420 PART VI • Mechanical Agents CHAPTER 20 • Compression 419

APPLICATION TECHNIQUE COMPRESSION BANDAGE

20.1
Equipment Required_____________ Disadvantages
• Cohesive gauze, foam, or cotton underbandage • Does not reverse edema when used alone
• Bandages of appropriate elasticity • Effective only for controlling edema formation
• Cotton or foam for padding • Requires moderate skill, flexibility, and level of cognition to apply
• Compression not readily quantifiable or replicable
Procedure___ __ • Bulky and unattractive
1. Remove clothing and jewelry from the area to be treated. • Inelastic bandages do not control edema in flaccid limb
2. Inspect the skin in the area.
3. Apply foam or cotton padding around anatomical indentations.
4. Dress and cover any wound according to the treatment regimen being
used for that wound.
5. Apply a cohesive gauze, foam, or cotton under the bandage to protect
the skin from the compression bandage and to minimize slipping of the
compression bandage. Start distally and progress proximally.
6. Apply the compression bandage, starting distally and progressing
FIGURE
proximally.
20.11 Unna
Whenboot. applying
(Froma bandage
CamerontoMH,
the Monroe
lower extremity,
LG: Physical
first apply
rehabilitation:
it evidence-based examination, evaluation, and intervention, St Louis, 2007,
Saunders.)
around the ankle to fix the bandage in place, then wrap the foot, and
then bandage the leg and thigh. Wrapping around the foot should be
from medial to lateral when on the dorsum of the foot, in the direction of
pronation.60 When applying a bandage to the upper extremity, first apply
it to the wrist to fix it in place, then wrap the hand, and then bandage the
system (Profere; Smith & Nephew) provides approximately 40
forearm and arm. For aii areas, slightly more tension should be applied
mm Hg of resting
distally pressure
than proximally, andatthe
the ankle,should
bandage graduating to in
be applied 17a mmfigure-Hg
58
at theeight
knee. The
manner (Fig.layers
20.13).of bandages provide protec- tion and The steep figure-eight
absorption, as well as compression. This type of bandage system tums aid the
is Advantages
most commonly ________________
used for the treatment and prevention of comformability of the
• Inexpensive
venous leg ulcers and can maintain high compression for up to 1 bandage, accomodating
• Quick
week afterto application.
apply once skill is mastered
A 2012 systematic review of 48 trials
contours in the leg.
• Readily available A
concluded that multicomponent bandaging is more effective than
• Extremity can be used during treatment
single-component compression in the treatment of venous leg
• Safe for acute conditions FIGURE 20.13 Elastic compression wrap of the foot, ankle, and leg.
ulcers and that including an elastic component is more effective Note the figure-eight wrap at the ankle. (Redrawn from Morrison M, Moffat C:
than using mainly inelastic constituents. 33 Examples of A colour guide to the assessment and management of leg ulcers, ed 2,
multilayered bandages include Profere and Dyna-Flex. London, 1994, Mosby.)
A semirigid bandage formed of zinc oxide-impregnated
gauze is commonly used to exert working pressure. When this
type of bandage is applied to the lower extremity, it is known as
working
an Unna pressures.
boot (Fig.Inelastic
20.11). Thisor low-stretch
bandage is garments, whichto
typically used FIGURE 20.12 Foam padding around anatomical indentations.
provide more working
treat venous pressure,Zinc
stasis ulcers. are not made because theygauze
oxide-impregnated are
too difficult
bandages to put on
become softand takewet
when off; tohowever, low-stretch
allow molding Velcro
around the
closure
involvedstatic
limb compression
and then harden devices
as theythatdry
aretoeasier
ferm to use are
a semirigid indentations, such as the ankles, pieces of foam or cotton cut to
available.
boot. The boot is left on the patient for 1 to 2 weeks and is then size should be placed in these indentations before the bandage is
Off-the-shelf
removed stockings,
and replaced. An known
Unna boot as antiembolism stock-
provides a sustained applied (Fig. 20.12).
ings, provide force
compression a lowof compression
35 to 40 mm force
Hg.of approximately 16 to 18
mm Compression
Hg and are used to prevent
bandages DVT formation
are generally applied in bybedridden
wrapping
patients (Fig. 20.14). These stockings
them around the limb in a figure-eight manner, starting are not intended to
distally Clinical Pearl
provide sufficientproximally.
and progressing compression to prevent
Circular, DVT formation
circumferential, or
and spiral For all types of compression bandages, compression should
alter circulation
wrappings are when the lower
generally not extremities
recommended are inbecause
a dependent
these be greatest distally and gradually decrease proximally.
position. Thesecan
configurations stockings
result inshould
uneven fit pressure
snugly but and comfortably
thus uneven
around FIGURE 20.14 Antiembolism stockings, (Courtesy Covidien, Mansfield,
control the lower extremities,
of edema. The bandageand theybeshould
should applied betightly
worn by the
enough
patient
to apply24moderate,
hours a comfortable
day except when bathing.without
compression Knee-high and
impairing COMPRESSION GARMENTS
MA.).

thigh-high Compression garments are recommended by the Oncology

circulation.stockings
To avoidhave the been fbund to bandage
compression be similarly efficient
slipping in
on the
reducing venous stasis, and bandages
knee-higharestockings are more Nursing
A pressureSociety
of 202013
to 30guidelines
mm Hg for the treatment
is generally of lymph-
appropriate to
skin, cohesive gauze or foam often applied under
comfortable to bandages
wear and wrinkle edema,13 and compression stockings have been shown to reduce
the compression directly againstless than thigh-high
the patient’s skin. Soft control formation of scar tissue or upper extremity lymphedema,
stockings. 60 the occurrence
whereas 30 to 40 mmof postthrombotic
Hg pressure willsyndrome
control lower DVT. 59
afterextremity
cotton may be used as an underwrapping to absorb sweat and to
Garments provide variouspatients.
degrees
61 of compression and are
helpCustom-fit and off-the-shelf
distribute pressure more evenly. compression garments that edema in most ambulatory
provide sufficient available in custom-fît sizes for all areas ofgradient
the bodysoandthatin
For all types ofcompression
bandages, itto is control edema that
recommended and tension
counteract
and Some garments provide a pressure
the standard off-the-shelf sizes for the limbs. They are generally
thuseffects of gravity
compression on circulation
should be greatest in active
distallypatients or to
and should compression is greatest distally and decreases proximally.
modify scar formation after burns are alsoanavailable in different made of washable
Although Lycra
off-the-shelf spandexcan
stockings and nylon and
improve havecirculation
venous moderate
gradually decrease proximally to achieve appropriate pressure
thicknesses
gradient. To and withconsistency
maintain different degrees
of pressure of around
pretensioning
anatomicalto and control edema in most patients, custom-fit garmentsand
elasticity to provide a combination of moderate resting may be
provide pressure ranging from 10 to 50 mm Hg (Fig. 20.15). necessary in severe conditions or when an individual’s limb
 422 PART VI • Mechanical Agents
CHAPTER 20 • Compression 421

Garments need to be replaced if there is a significant change

in limb size, which may occur with changes in edema or in body
weight. For the compression device to be effective and to avoid
the expense of purchasing many sets of garments, it is
recommended that a patient use bandages to treat edema initially,
while limb size is still diminishing, and that compression
garments be ordered when the limb size appears to have
stabilized.
Successful treatment in the long-term management of
lymphedema requires successful fitting of a compression
garment and the individuals ability to safely don and doff the
garment. Goals to address donning and doffing the garment
should include the following:
1. Patient will independently don and doff compression
garment with (or without) use of assistive device as needed.
FIGURE 20.16 Stocking butler and rubber gloves to assist with donning
2. Caregiver
FIGURE 20.15 will independently don and doff compression
Upper extremity compression garment. (From Fairchild compression stockings. (From Cameron MH, Monroe LG: Physical
garment
SL: Principleswith (or without)
and techniques use of
of patient assistive
care, ed 5, St device as needed.
Louis, 2013, Saunders.) rehabilitation: evidence-based examination, evaluation, and intervention, St
A sample SOAP note for a therapy session in donning and Louis, 2007, Saunders.)
doffing a compression garment follows:

S: Pt reports difficulty with donning and doffing compression

contours
garment.do not match off-the-shelf sizing. Custom-fit garments difficulty wearing compression devices as recommended (Fig.
O:may
Focus include options
of treatment on such
donning as and
zippers andcompression
doffing reinforced padded 20.16) . A patients belief that wearing stockings is
areas to improve
garment ease ofmanagement
for long-term use and fit and are effective in
of lymphedema in Rnormal-
UE. worthwhile and that the stockings are comfortable to wear may
izing venous inflow
Pt instructed properin method
many for cases in which
donning off-the-shelf
and doffing be the greatest determinants of adherence. 63 It is recommended
62
garments are ineffective.
compression For sizingthree
garment. Pt performed to be appropriate,
trials of donning both that compression garments be replaced approximately every 6
custom-fit
and doffingand off-the-shelf
compression compression
garment. garments
She initially should be
required months because they lose compression force over time. 34
fitted whenassistance;
minimal edema is minimal.
however, withIhis is generally
repeated done
trials, shefirst
wasthing Machine washing preserves pressure delivery better than hand
inable
theto morning
don and doff or the
after treatmentgarment
compression with independently.
an intermittent washing.
compression
Education waspump. Garments
provided are and
on wear available for both ofupper and
care schedule
lower extremities, as well as for the trunk and head (see Fig.
stocking.
A:20.15). They are also
Pt demonstrates available
ability in a number
to independently donofandcolors.
doff © Clinical
FIGURE PearlVelcro closure compression device. (From Cameron MFi,
20.17
Compression
compression garments
garment for RareUE.sometimes difficult
She verbalizes for patients Monroe LG: Physical rehabilitation: evidence-based examination, evaluation,
understanding
toofput on and care
wear take schedule. For optimal
off, especially for patients with poor Vision, and intervention, benefit,
St Louis, 2007,compression
Saunders.) garments must be worn
P:manual
Follow updexterity, coordination,
next treatment sessionortobalance
ensure and for patients who
continued for 23 to 24 h/day, every day. Because the garments lose
areindependence
weak or cannot with reach
donning their
andfeet. Assistive
doffing devices, such as
of compression compression force over time, they should be replaced about
thegarment
stockingforbutler
R UE. and rubber gloves, can assist with donning every 6 months.
compression stockings, but many people still have
VELCRO CLOSURE DEVICES
Readily removable and adjustable compression devices that
fasten with Velcro straps are also available (Fig. 20.17).
APPLICATION
Although they can improve TECHNIQUE 20.2 ease of removal
patient acceptance, COMPRESSION GARMENT
can also decrease adherence. These devices provide inelastic
compression similar to an Unna boot, but the patient can adjust
the Compression garments shouldduring
amount of compression be applied
dailybyactivities.
gathering them
Withup, placing
optimal • Less expensive than intermittent compression devices for short-term
them on the distal area first, and then gradually unfolding them proxi- mally. use
use, companies claim that these devices provide 30 to 40 mm Hg
Because higher compression
gradient compression. 62 garments have greater pretensioning, some
Because the Velcro bands are non- • Thin and attractive, available in various colors
patients have difficulty putting them on. A number of devices have been • Safe for acute condition
stretch, the amount
developed of compression
to assist with doesmay
this, or the patient notwear
decrease with
two sets the
of lower • Can be used 24 h/day
agecompression
of the device.
garments to provide a total compression equal to the sum of the
two. For example, the patient could wear two pairs of 20 mm Hg compression
• Preferred over compression bandages by patients
INTERMITTENT PNEUMATIC
stockings instead of one COMPRESSION
pair of 40 mm Hg stockings to achieve the same Disadvantages
PUMP
effect.
• When used alone, may not reverse edema that is already present
IPC pumps are garments
Compression used toneed provide theevery
to be worn forceday for
for atintermittent
least 23 h/day
• More expensive than most bandages
and removedThe
compression. only while
pumpbathing to most effectively
is attached via a hose control
to aedema, improve
chambered • Need to be fitted appropriately
circulation,
sleeve placedoraround
control the
scarinvolved
formation. limb
In general,
(Fig. with proper
20.18). of FIGURE
care, these
Methods • Require20.18 Intermittent pneumatic compression being applied for
strength, flexibility, and dexterity to put on
garments last about 6 months, after which time they lose their elasticity and treatment of lymphedema. (Courtesy Vasocare.)
application differ slightly among pumps, and specific instruc- • Hot, particularly in warm weather
no longer exert the appropriate amount of pressure.
tions for the application of intermittent compression are provided • Expensive for long-term use because they need to be replaced at least
withAdvantages
all pumps. General instructions for applying most pumps are should every 6 months,
always and patient
begin the requires
course atofleasttherapy
two identical
undergarments so
medical
that one is available when the other is being laundered
given in Application Technique 20.4. Although intermittent supervision.
compression is suitable for home use, the patient Once edema has been satisfactorily reduced with the pump,
• Compression quantifiabie (unlike bandaging)
• Extremity can be used during treatment (unlike a pump) the clinician should determine whether control will be main-
tained with continued use of the pump or if better results

APPLICATION TECHNIQUE 20.3
Equipment Required_______ __________
• Stockinette
• Velcro closure device
Procedure __
1. Remove clothing and jewelry from the area to be treated.
2. Inspect skin for infection and wounds.
3. Dress and cover any wound according to the treatment regimen being
used for that wound.
4. Apply stockinette.
5. Apply Velcro closure device and close it, starting at the foot and working
upward toward the knee.
would be obtained with a compression garment or bandage. In
general, because a compression pump is used for only a number
of hours each day, the patient should use a static compression
device between treatments with the pump to maintain the
reversal of edema produced by the pump. In patients with
chronic venous insufficiency and resulting edema and leg ulcers,
adding intermittent compression to the use of compression
stockings may accelerate wound healing64,65 and has been
recommended if compression stockings have been used
unsuccessfully for 6 months.65 Intermittent compression
generally is not used to decrease the formation of scar tissue
because compression is required at all times for this effect.
Despite ongoing controversy in the literature regarding the
use of compression pumps for treatment of lymphedema, IPC is
widely used for this indication, generally as a component of a
lymphedema management program that may include manual
lymphatic drainage and compression bandaging or garments. 56 A
2012 systematic review of IPC for lymphedema concluded that
IPC may provide additional benefit beyond that from only
wearing compression garments.67 More recent studies also
suggest that IPC, particularly high-pressure IPC to 120 mm Hg, 68
can promote reduction of lymphedema, possibly by enhancing
formation of fluid channels in the tissue. 69 Further study is
needed on the treatment of lymphedema with pneumatic
compression.70,71
PARAMETERS FOR INTERMITTENT
PNEUMATIC COMPRESSION PUMPING
Inflation and Deflation Times
Inflation time is the period during which the compression sleeve
is being inflated or is at the maximal inflation pressure; deflation
time is the period during which the compression sleeve is being
deflated or is fully deflated. For the treatment of edema or
venous stasis ulcers or for DVT prevention, the inflation time is
generally between 80 and 100 seconds, and the deflation time is
generally between 25 and 50 seconds to allow for venous
refilling after compression. No difference in volume reduction
was found in patients with upper extremity lymphedema between
90-second inflation/90-second deflation compared with 45-
second inflation/ 15-second deflation. 72 For residual limb
reduction, these periods are generally shorter, with inflation time
between 40 and 60 seconds and deflation
CHAPTER 20 • Compression 423
VELCRO CLOSURE COMPRESSION
DEVICES
Advantages__________________
• Easier for patient to apply than compression garments providing
comparable compression
• Does not lose effectiveness with use or washing
• Can adjust the tightness of the device depending on activity
Disadvantages
• Easy to remove, with decreased effectiveness if patient removes device
• Loosening Velcro straps reduces compression to levels that may be
insufficient for controlling edema
time between 10 and 15 seconds. Usually, pressure is applied in
approximately a 3:1 ratio of inflation to deflation time; it is then
adjusted if necessary according to the patients tolerance and
response.
Inflation Pressure
Inflation pressure, which is the maximum pressure during
inflation time, is measured in millimeters of mercury (mm Hg).
Most units can deliver between 30 and 120 mm Hg of inflation
pressure. When a single-chamber sleeve is used to provide
intermittent compression, the chamber inflates to the maximum
pressure and then deflates. When a multichamber sleeve is used
to provide sequential compression, the distal segment inflates
first to the maximum pressure, and then, as it deflates, the more
proximal segments inflate sequentially, generally to a slightly
lower pressure. Some recommend that inflation pressure should
not exceed diastolic blood pressure in the belief that higher
pressures may impair arterial circula- tion; however, because the
tissues of the body protect arterial vessels from collapse, higher
pressures may be used if this is necessary to achieve the desired
clinical outcome and does not cause pain, although close patient
supervision is recommended when higher pressures are used. For
all indications, inflation pressure is generally between 30 and 80
mm Hg and frequently is just below the patients diastolic blood
pressure. Because venous pressure is usually lower in the upper
extremi- ties than in the lower extremities, the lower end of the
pressure range, 30 to 60 mm Hg, is generally used for the upper
extremities, and the higher end of the range, 40 to 80 mm Hg, is
generally used for the lower extremities. Lower pressures are
generally recommended for residual limb reduction and shaping
and to treat posttraumatic edema rather than the problems caused
by venous insufficiency.
The ideal amount of pressure for the treatment of edema due
to venous or lymphatic insufficiency is controversial. Clinical
practice guidelines for treatment of lymphedema indicate that
lower pressures, 30 to 60 mm Hg, are safer and may still be
effective for this condition,66'73 but a recent study found that
adding IPC at 120 mm Hg to manual lymphatic drainage and
multilayer bandaging was significantly more effective for
controlling lower extremity edema than adding IPC at 60 mm Hg
or not adding IPC at all. 68 This may be in part because the
pressure achieved in the tissue fluid is lower
424 PART VI • Mechanicai Agents CHAPTER 20 • Compression 425

TABLE 20.1 Recommended Parameters for Application of Intermîttent Compression

APPLICATION TECHNIQUE 20.4 INTERMITTENT PNEUMATIC
Inflation/Deflation Time Infiation Pressure Treatment
COMPRESSION PUMP—cont’d
Problem______________________________________in Seconds (ratio)_______________(mm Hg) Time (h) 2-
Edema, DVT prevention, venous stasis ulcer 80-100/25-50 (3:1) 30-60 UE; 40-80 LE 3 2-3
although single-use vinyl sleeves are also available when there is selection of any of these parameters, the parameters used clinically are
Residual
concernlimb
aboutreduction
cross-contamination. The Neoprene and nylon 40-60/10-15(4:1)
sleeves can be 30-60 UE; 40-80
based on an understanding of theLEpathoiogy being treated and from
machine
DVT, Deep washed
venous in warm LE,
thrombosis; water andextremity;
lower air dried UE,
or dried
upperatextremity.
low heat in a drier. measures of the patient’s blood pressure and comfort, as well as the
The sleeves provide intermittent or sequential compression, depending on observed efficacy of treatment in the individual patient. Most protocols
their design, Single-chamber sleeves provide intermittent compression only, use an infiation pressure slightly below the patient’s diastolic blood
and sleeves composed of a series of overlapping chambers can inflate pressure, although higher pressures can be used, and aii units come
74
than in the compression
sequentially, chambers
starting distally of an IPC
and progressing device.to produce
proximally, Treatmenta milking frequency withranging
treatmentfrom threebased
guidelines timeson per
their week
design toandfour times per
manufacture. The
with infiation
effect on thepressures
extremity. below
As noted,30sequential
mm Hgcompression
is not likely has to affect
been shown to day. Forparameters
most applications,
listed in Tabletreatments
20.1 cover the ofranges
2 to 3suggested
hours once or
by most
circulation
result inor more
tissuecomplete
form and therefore
emptying of theis not
deeprecommended for of twice a pump
veins, better control day are recommended. The frequency and duration of
manufacturers.
any condition.
lymphedema, and greater increase in fibrinolytic activity than single-chamber, treatment 10. Provideshould be thewith
the patient minimum
a means tonecessary to the
caii you during maintain good
treatment.
intermittent compression and is therefore preferred for most applications. 75'77 edema control Measure and or record
satisfactory
the patient’sprogress toward
blood pressure thetreatment,
during goals ofand
TotalSingle-chamber
Treatmentand Time. Total treatment
multichamber sleeves aretime recommenda-
available in a variety of treatment discontinue treatment if the systolic or diastolic pressure exceeds the
(Table 20.1).
tions lengths
vary from and 1 to 4 for
widths hours per treatment,
treatment of upper orwith treatment
lower extremities of various limits set for the patient by the physician.
sizes. When a compression pump is used for the treatment of edema, it is 11. When the treatment is complete, turn off the unit, disconnect the tubing,
recommended that the sleeve be long enough to cover the entire invoived and remove the sleeve and the stockinette.
limb so that fluid does not accumulate in areas of the limb proximal to the end 12. Remeasure and record limb volume in the same manner as in step 5.
APPLICATION
of the sleeve. When a compressionTECHNIQUE
pump is used for the20.4 INTERMÎTTENT
prevention of DVT 13. Reinspect PNEUMATIC
the patient’s skin.
formation, calf-high or thigh-high sleeves can be used because both COMPRESSION
have 14. Remeasure PUMPand document the patient’s blood pressure.
been found to be effective for this application. 15. Apply a compression garment or bandage to maintain the reduction in
8. Attach the hose from the pneumatic compression pump to the edema
Equipment Required ____ __________ flow of bloodbetween
in the veinstreatments
toward the andheart.
after discontinuing the use of a
With chronic venous
sleeve. Pumps vary in size and complexity from small home units compression pump. Maximum reduction of the
edema is is
usually achieved
• Intermittent pneumatic compression unit
intended for the treatment of one extremity to larger clinical units that
insufficiency or lymphatic dysfunction, elevating limbs generally
by using the pump for 3 to 4 weeks.
• Inflatable sleeves for upper and lower extremities
can be used to treat four extremities at different settings aii at one time
less effective in reducing edema because the fluid is trapped within
• Stockinette
(Fig. 20.21).
fibrotic tissue and cannot return as readily to the venous or lymphatic
Advantages
• Blood pressure
9.
cuff
Set the appropriate compression parameters including infiation
capillaries, from where it can flow back to the central circulation.
• Actively moves fluids and therefore may be more effective than static
• Stethoscope
and deflation times, infiation pressure, and total treatment time. Since
4. Measure and record the patient’s blood pressure.
devices, particularly for a flaccid limb
• Tape measure
few research data are presently available to guide precise
5. Measure and record the limb circumference at a number of places with
•reference
Compression quantifiable
to bony landmarks, or take volumetric measurements by
Procedura •displacement
Can provide sequential compression
of water from a graduated cylinder.
1. Determine that compression is not contraindicated for the patient or the
• Requires iess finger and hand dexterity to apply than compression
6. Place a stocking or stockinette over the area to be treated and smooth
bandages
out aii or garments
the wrinkles (Fig. 20.19).
condition. Be certain to oheck for signs of DVT, including calf pain or
tenderness associated with swelling. Take the patient’s history or check
•
7. Apply the sleeve to
Can be used fromreverse and(Fig.
the unit control edema
20.20). Reusable sleeves made of
the chart for CHF, pulmonary edema, or other contraindications that •washable
Use can be supen/ised
Neoprene in a are
and nylon patient who isused,
generally noncompliant with static
may be the cause of the edema. compression
2. Remove jewelry and clothing from the treatment area, and inspect the Disadvantages____________________________
skin. Cover any open areas with gauze or an appropriate dressing.
3. Place the patient *in a comfortable position, with the affected limb
• Used only for limited times during the day and therefore not appropriate
for modification of scar formation
elevated. Limb elevation reduces the pain and edema caused by
venous insufficiency if applied soon after these symptoms develop, as
• Generally requires a static compression device to be used between
treatments
elevation allows gravity to accelerate the
• Expensive to purchase unit or to pay for regular treatments in a clinic
• Requires moderate comfort using machinery to apply
• Requires electricity
• Extremity cannot be used during treatment
• Patient cannot move about during treatment
• Pumping motion of device may aggravate an acute condition

FIGURE 20.21 Intermittent compression units. (Courtesy Chattanooga/ DJO,

Vista, CA.)

• Compression or infiation pressure

Documentation • Total treatment time
When applying externai compression, document the following: • Patient’s response to the treatment Documentation is
• Type of compression device typically written in the SOAP format.
• Area
FIGURE 20.19ofApplication
the bodyofbeing treated
stockinette before application of compression The following examples summarize only the modality
• Infiation and deflation times
sleeve. FIGURE 20.20
component Application ofand
of treatment compression
are notsleeve.
intended to represent a
comprehensive plan of care.
 426
428 PART
PART VI VI • Mechanical
> Mechanical Agents
Agents
CHAPTER 20 » Compression 427

pretreatment blood pressure during 2-week course of

EXAMPLES
CLINICAL CASE STUDIES —cont’d treatment.
ICF
Based CLINICAL
Evaluation
Restore
for
arm40
LEVELCURRENT
on
UEright
that
hours the
right
by and
ParticipationReduced
motion
compressionpatient?is
using
ROM
Ib
of andfor
arm CASE
Goals
rightmeasurement
Body
ActivityReduced
so all
patient's
50%to
UE girth
ROM STUD.ES-.on,
structureIncreased
daily
workImprove
ofconsidered
lifting
STATUSGOALS
100% history,
equals
becomes and
left toleranceAble
isof
normalfunctionand
with
work
theover
arm
equal lymphatic
girth
to left
next
When applying a compression bandage to the left ankle after an
3 amonths
rightactivities
asan
girthControl
hours
UE Iofedema
intervention
loss
to use and
and
right
System
ROM to
reduce
for
inUE
within lift
until
this
her
3
right months
upper extremity blocked? What parts of the history lead you Treatment: IPC R UE, 80 s/30 s, 50 mm Hg, 2 h twice daily.
acute
because sprain, document
it provides both the following:and the milking action of
compression Passive
After 1 ROM treatment: R elbow R 500 140cc; degrees
after 2flexion,weeks-5ofdegrees treatment: R
to this conclusion? Is malignancy a concern when
sequential distal-to-proximal compression. To control the Key Studies
extension.
450 cc. or Reviews
S: Pt reports
formation L ankle between
of edema swelling that increases
treatments within the
thePM.pneumatic A:A:
1.Good response
Futolerating
MR, Deng to
J, compression
Armerwell, JM: with with
Putting IPC,
evidence withedema,
reduced
into practice:
Pt treatment decreased increased
O: Ankle angirth R 9 inches, L 10% wasinches, 3 days ago,thebefore edema,
device, inelastic bandage applied during day to R hand function, and no change in BP over 2 pain.
increased
cancer-related funcţional
lymphedema, ROM,Clin decreased
J Oncol Nurs weeks.
placement of elastic bandage. P:P:Instruct Pt on
provide a high working pressure. When the reduction of edema IPChome
18(suppl):68-79,
Continue R UE, use 80ofs/30
2014. IPCs,device50 mm2 Hg, h once 2 h daily.
twice daily
Today, L which
plateaus, ankle girth
usually 10 inches.
takes 2 to 3 weeks, pumping can be Instruct
This Pt on
systematic application
review of bandages
evaluated 75 or compression
selected articles from
When R UE volume stabilizes, consider fitting for
gradually discontinued. elastic
Treatment: Replaced The patientbandage to Lcontinue
should ankle andtoleg,usefigure-
the garment 2009
compression toto R 2014
UE after
garment.andIPC. supportedFollow-up 1 week forbandages
compression
bandageseight, andwheninstructed
working Pt or inexercising
bandage her application.
upper extremity. If reassessment.
and compression garments, as well as complete
A: patient
the Pt responding to treatment,
is not compliant withwith reduced
long-term use edema 3 days after
of bandages, a When decongestive
applying compression therapy withhose the highest
to prevent level DVTof evidence
injury. garment may be used. However, because this
compression formation, for best
document clinicalthe practice.
following:
P: Continue
type of garment high-stretch
is made elastic bandage toelastic
of a moderately L ankle and leg.
material that 2.CASEPoageSTUDY E, Singer 20.2
M, Armer J, et al: Demystifying
developsPt to limited
keep LE elevated.
working pressure, it may not be as effective as S: Ptlymphedema:
not oriented; bedridden. development of the lymphedema putting
Venous Stasis Ulcer Examination
an inelastic bandage in maintaining edema control during evidence
O: Negative into practice
Homans’ sign. cârd,
No other Clin signs
J Oncol Nurs 12:951-
of DVT
Whenorapplying IPC to the right arm toactivity.
treat lymphedema, History 964, 2008.
formation.
exercise other heavy upper extremity The patient
document ţhe following: JU is This
a 65-year-old
Treatment: article man with
describes
Compression aboth
development
hose full-thickness
LEs, and venous
content
approximately stasis
of the 20 mm
shouid not.be measured for fitting of a compression garment at
ulcer Hg on compression.
his distal
2006 Oncology medialNursing left leg.Society He reports lymphedemathat the clinical
ulcer is
the initiation of treatment because a garment fitted at that time
S: Pt reports decreasing R UE edema in the past 2 weeks and is minimally painful
will soon be too big if pumping or bandaging reverses any A: Bedriddenpractice atatrisk
Ptguideline. 1/10 on the
for This
DVT. pain which
guideline, scale was but reviewed
requires
now able to use a key with her R hand. frequent
edema. Measurement for fitting of the garment shouid be P: Pt to wear compression hose 23 h/day while in bed.ofInstruct
dressing
and confirmed changes to be because
current ina large
2013 amount fluid
O: Pretreatment arm volume to elbow: R 530 cc, L 410 cc. leaksother
from (µit. The ulcer has been
https://www.ons.org/practice-resources/pep/ present for 4 to 6 months § and
performed when limb volume stabilizes. caregivers in compression hose program.
BP pretreatment: 135/80 mm Hg; during and immediately after is gradually getting larger.
lymphedema; accessedThe only treatment
November being provided
11,2015),
Optimal treatment parameters at the initiation of treatment,
treatment: 140/85 mm Hg. No overall change in for the ulcer is gauze compression
recommends dressing application, bandaging which the patient
in addition to
when the sequential IPC pump is being used, are 80 to 100
changes two completeor three times a daytherapy
decongestive when he and notices
treatment seepage.of
seconds of inflation and 25 to 35 seconds of deflation, with a
This infections
wound has forsignificantly
management impacted
of lymphedema. JU’s activities. He
maximum inflation pressure of 30 to 60 mm Hg, potentially
stopped attending biweekly bingo games and weekly church
increasing up to 120 mm Hg if needed. The lowest inflation Prognosis
Services 4 months ago because he found that prolonged sitting
pressure that achieves reduction of edema shouid be used to Although
made his the left recommendations
leg swell and hurt of experts
and because in the field hevary wasfor
minimize the risk of collapsing the superficial lymphatic or
embarrassed by his weeping ulcer. He has decreased hisof
treatment of lymphedema, most agree that some form
venous vessels. CLINICAL For most CASE patients,STUDIES
treatment with the pump for compression
physical activityis at indicated.
home, Compression
spending most canofprovide
the day working
sittingor
2 to 3 hours once or twice per day is sufficient. AII parameters restinginpressure to control fluid flow out of thethan venous circula-
The
ICF,be following case these studies summarize andthe concepts ROM,of indoors his recliner with his legs
radiation therapy at that time and has had no recurrence of the up, rather gardening
may adjusted
International within
Classification ranges
for Funotioning, to achieve
Disability optimal
Health edema
model;
tion and into the lymphatic circulation and can promote the
compression formalignancy.
2 hours when FR has the beenweather advised permitted.
by herHe reports to
physician that his
reduce
without discussed
pain and in
range of motion; UE, upper extremity.this chapter. Based on the scenarios
control with least disruption of the patient’s movement of fluid through the lymphatic vessels. Some
presented, an evaluation of the clinical findings and shouid
goals of ankle
the use is often
of her uncomfortable
right arm and to move and
to elevate it when that possible
swellingto
regular activities. Compression bandages or garments expertswhen recommend using specialthan massage techniques in
treatment are proposed. These are followed by a discussion worsens
control the swelling. he is upright At her forrequest,
longer she an hashour.been referred to
notof
bePPICO
|+
1 (Intervention)CompressiontherapyAND
worn at all times
(Population)Patients
CFIND
(Comparison)No
TermsNatural
the“compression
being factors
used.
THE except
compression
with symptoms
Language
EVIDENCE
therapy”
to be [text word]
considered (5)
for
therapy (“Compression
due bathing when Bandages"
PubMed pump is OR
in selecting compression as the
[MeSH]
the Search
to chronic lymphedema(“Lymphedema”
ExampleSample conjunction
JU had
therapy
with compression
for coronary
further management artery bypass to surgery
of her
promote2 lymphatic
lymphedema. years ago, flow, at
[MeSH] OR “Lymphedema" [text word])
indicated intervention andmassage,
in selectionexercise,
of the idealand compression which time the left saphenous vein was removed toand
particularly in proximal areas such as the axilla the trunk,
be used for
Appropriate use of activity Systems
to aid Review
device and treatment parameters to promote progress toward the graft.or He divert is flow in areas
currently taking where lymphatictofunction
medication control is
modifica- tion shouid be considered, in addition to treatment compromised and where most compression devices are with not
the goals of treatment. FR appears
hypertension. well overall. She is alert and cooperative
with compression, to achieve the optimal outcome for this effective. Without
testing. She reports such that her additional
pain severity treatment, today compression
is 5/10 after
patient. The patient’s blood pressure shouid be monitored Systems
alone mayReview allow fluid proximal to the
CASE doing light chores around the house thiscompression
morning. She device
reports to
before, during,STUDY
and after20.1 use of the compression pump. If it JUaccumulate,
is a well-appearing
“minimal” particularly
weakness man.
and He if ROM is alert,
proximal cooperative,
lymphatic
restrictions in and right eager
function upper is
becomes excessively elevated, the pressure, and if necessary toimpaired.
return to She the activities
Chronic Lymphedema extremity. does not that report contributed
swelling. to his quality of life.
the dura- tion, of pumping shouid be reduced. During pumping, He has no atrophy
Although the use oforcompression self-reported weakness,
generally is not ROM recom-
theExamination
patient’s upper extremity shouid be elevated above the Tests and Measures
restrictions,
mended in or the sensory
presence changes
of active in malignancy,
either upperbecause or lower this
History
level of her heart. This is most readily achieved if the patient The objective
extremities.
patient has hadexamination no recurrence reveals
of hermoderate
disease after pitting moreedema thanof 5
FRsupine
lies is aand 40-year-old
places her female
arm on acarpenter.
pillow. She has chronic the rightmost arm expertsand forearm,
years, agreewith thatcircumferential
compression measurements may be used.
lymphedema of her right upper extremity and complains of pain Tests and Measures
of 7 inches at the right wrist compared
Documentation Although the lymphatic circulation in with
this 6patient
inches at is theclearlyleft
and swelling in this extremity that worsens with use but is JUimpaired,
has 11
wrist, a shallow,
inches atflat
the ulcer
right with
elbow a red base
compared fully
with covered
9% inches withat
the fact that the severity of her edema varies,
S:moderately
Pt reports swelling
alleviated andby pain, severityand
elevation 4 to avoiding
8/10, in Ruse UE ofthatthe granulation
the left elbow, tissue, and approximately
14 inches 5the
cm x elevation,
10midbiceps
cm in area on the
O (Outcome) Reduction of pain AND (“pain reduction” and swelling; resolving to some extent with at rest andright compared
indicates that
worsens She
extremity. with use
ratesand heratpain
the end of theas
severity day.
4 to 8/10. She first distal
[text word] OR “Range of the lymphatic circulation in the right upper extremity isthe
with medial
11 inches left leg,
at the with
same darkening
level on of
the intact
left. skin
The around
swelling also
not
O:noticed
Pretreatment: Moderate
the swelling 2 orpitting
3 yearsedema ago, R arm
but and forearm.
at that time it ulcer.
causes Edemamoderate of therestriction
left and
foot, of ankle,elbow, andwrist, leg is noted.
hand, andAnkle
increased ROM Motion, Articular” [MeSH] completely blocked, therefore compression isfingernot
R wrist circumference
occurred only after extensive7 inches,useR midbiceps
of her upper 14 inches,
exVemity L at girth,
ROM. measured
Passive at the medial
elbow ROM was malleolus,
measured is 9 as inches 130 on degreesthe
OR “ROM” [text word]) contraindicated.
wristthe
work; circumference
swelling was 6 inches,
mild and L midbiceps
resolved with 11 inches.
a night’s rest. right and and
flexion 10/2 -10 inches degrees on the left. No signs
extension on theofright edema are noted
compared with
AND (“Humans” [MeSH]
Passive
Over ROM
the last R elbow
year, 130 degrees
the sweiiing flexion, -10Now,
has worsened. degreesit never inIntervention
the degrees
145 right lower flexion extremity.
and full Ankle extension ROMonisthe +10 left.degrees
The skinofof
AND English [lang])
extension.
resolves fully and is easily aggravated by even light activity at dorsiflexion
Initially,
the patient’s anto intermittent
60 degrees
right plantar flexion
sequential
upper extremity pneumatic
appears onthin,
theflaky,
right and
pump and
canred, 0be
Treatment:
work
Linkor to byIPC
yardto
search R UEand
work,
results 80 sshe
inflation, 25 s deflation
has reduced her work for hours
total by degrees
used
and her toofapply
dorsiflexion
blood compression.
pressure to 50is degrees
This
120/80 form of
mm plantar
of Hg. AII flexion
compression other on the
is tests,
likely
treatment time 2 h.
50%. left.
to The
produce
including patient’s blood
the quickest
shoulder ROM pressure
and and most is 140/100
uppereffective
extremity mm Hg.
reversal of edemaare
sensation,
Posttreatment:
FR reportsMinimal edemaago
that 8 years R armsheandhadforearm.
a right R wrist
mastectomy within normal limits. ■
circumference 6/ inches, R midbiceps
with 16 lymph nodes removed as part of her treatment for
2 12 inches.
Continued
breast cancer. She was treated with chemotherapy and
 CHAPTER 20 » Compression 429

CLINICAL CASE STUDIES-cont d

ParticipationDecreasedReturn
Restricted
ActivitySitting
Whystructureulcer
left
dependent
to
gardening,of
bingo,
churchattendance
attendance2
60
doeslower
minfor
andbingo,
leftIncrease
thisdistalthat
anddependent
with
up
months
gardening,
Body
toLESitting
patient
extremitymatches
ankle ROMROM and
2right
towithin
left
hleft
functionEnlarging
havechurch
Increased
ankle
match walking
ankle
a with
andto
girth
venous
ankle LE
prior
limitedwalking
girth
right girthReduce
level
andvenous
leftulcer?
stasis
and
ankle LEHeal
prevent
ROM edema
tolerated
stasis
theso
What
ulcer ulcer
other Key Studies or Reviews
aspect of the patient's examination is a matter of concern?
recurrence 1. O’Meara S, Cullum N, Nelson EA, et al: Compression
What would you teii this patient about the lifetime use of for venous leg ulcers, Cochrane Database Syst Rev
compression? What measurement needs to be taken before (11):CD000265, 2012.
compression is applied to this patient? This systematic review of 48 randomized controlled trials
Evaluation and GoalsICF LEVEL CURRENT STATUS GOALS with 4321 participants concluded that compression
increases ulcer healing rates compared with no
compression. Multicomponent Systems are more
effective than single-component systems, and
multicomponent systems containing an elastic bandage
appear to be more effective than systems composed
mainly of inelastic constituents. Two component
bandage systems appear to work as well as the four-
layer bandage.
2. Nelson EA, Bell-Syer SE: Compression for preventing
recurrence of venous ulcers, Cochrane Database Syst Rev
(9):CD002303, 2014.
This systematic review of four trials with 979 participants
concluded that compression hose reduce the rate of
venous ulcer recurrence compared with no
compression, and recurrence may be lower with high
rather than medium compression hose.
However, patients have high rates of intolerance
for compression hose.
Prognosis
JU presents with loss of skin and subcutaneous tissue
integrity, requiring him to change wound dressings frequently
and placing him at risk for local infection and possible sepsis.
His ulcer and edema of the distal lower extremity are probably
ICF, International Classification for Functloning, Disability and Health
model; LE, lower extremity; ROM, range of motion.
a result of poor venous circulation. Compression is an
indicated intervention because it can improve venous
circulation to facilitate wound healing and edema control.
Specialized dressings that are more absorbent and less
1P(Intervention)Compression
(Population)Patients
C (Comparison)No
PICO TermsNatural
Ulcer/Therapy”
with symptoms
therapyAND
Language
OR “compression
[MeSH]1+
compression
due(“Compression
to venoustherapy
ExampleSample
ORFIND
“venous
therapy” stasis
[text
stasis
Bandages”
PubMed
ulcer”
word])
THE EVIDENCE [text ©
ulcer(“Varicose
[MeSH]
Search
word])
adherent than gauze should be used to reduce the frequency
of dressing changes and thus reduce the potenţial for wound
trauma and inconvenience to the patient. Contraindications for
the use of compression including arterial insufficiency, heart
failure, and DVT should be ruled out before initiating treatment
with compression. The patient’s history of cardiac bypass
surgery suggests the possibility of arterial insufficiency in the
lower extremities, although the presence of edema and the
conforma- tion of the leg ulcer indicate that it is probably a
result of venous rather than arterial insufficiency. To rule out
arterial insufficiency, an ABI should be obtained, and
compression should be applied only if this is above 0.8. The
presence of unilateral rather than bilateral edema indicates that
this patient’s edema is probably not a result of cardiac failure.
O (Outcome) Reduction of pain and AND “Wound Healing/ Assessment for Homans sign should be performed to rule out
swelling; increased Physiology” [MeSH] quality a DVT before treatment with compression is initiated.
of life
Intervention
AND (“humans”
lnitially, JU was treated with intermittent compression applied
[MeSH] AND English
with a sequential pneumatic pump twice a week, with static
[lang])
Link to search results compression with a two-layer bandage system between

Continued
 430 PART VI • Mechanical Agents
CHAPTER 20 • Compression 431

Keloid: Excessive scarring that extends beyond the boundaries

ofCLINICAL
the original siteCASE STUDIES-cont d
of skin injury.
Long-stretch bandage: An elastic bandage that can extend by
pumping sessions. The pump was used to reduce the edema It is essential that the patient continue to wear a
100% to 200% and provides high resting pressure; also called
through the milking action associated with sequential distal- to- compression stocking after the ulcer has healed because his
a high-stretch bandage.
proximal intermittent compression, and edema control was circulatory compromise puts him at high risk for recurrence of
Lymphatic fluid (lymph): Fluid rich in protein, water, and
maintained by the continuous compression of the compression edema and tissue breakdown in this extremity.
macrophages that is removed from the interstitial space by the
bandage system boot. Recommended treatment parameters
lymphatic system and is returned to the venous system.
for the sequential IPC pump to promote circulation and control
Documentation
Lymphatic system: A system of vessels and nodes designed to S: Pt reports a nonhealing ulcer present for 4 to 6 months on
edema are 80 to 100 seconds of inflation and 25 to 35 seconds
carry excess fluid from the interstitial space to the venous his L medial lower extremity and increased edema of his L
of deflation, with a maximum inflation pressure of 30 to 60 mm
system and to filter the fluid, removing bacteria and other LE.
Hg and treatment duration of 2 to 3 hours. Adjustments should
foreign particles. O: Pretreatment: 5 cm x 10 cm shallow ulcer on the distal
be made within these ranges to achieve optimal edema control
Lymphedema: Swelling caused by excess lymphatic fluid in the medial L leg, with darkening of intact skin around the ulcer.
without pain and with least disruption of the patient’s regular
interstitial space. L ankle girth measured at the medial malleoius is 10^” and
activities. The Unna boot shouid be worn at aii times between
Osmotic pressure: Pressure determined by the concentration of R ankle girth is 9”. L ankle ROM 0 to 50 degrees, R ankle
intermittent compression treatments. if the compression
proteins inside and outside blood vessels that contributes to ROM +10 to 60 degrees.
bandage is not tolerated, compression stockings providing 30
movement of fluid into or out of blood vessels and lymphat- Treatment: IRC to L leg at 80 s inflation and 35 s
to 40 mm Hg of pressure may be worn between pumping
ics; also known as oncotic pressure when the term is applied deflation, and maximum inflation pressure of 50 mm Hg x
treatments. Because stockings are easier to remove and
to blood. 2 h.
reapply than the compression bandage system, if necessary
Phlebitis: Inflammation of the veins; the most common cause of
the frequency of pumping may be increased to once or twice Posttreatment: Ulcer unchanged in size after one treatment. L
venous insufficiency.
per day. A Velcro closure compression device would also be a ankle girth 10 inches.
Resting pressure: Pressure exerted by elastic when put on
good option between intermittent compression treatments. The A: Good response to treatment. No adverse effects.
stretch.
patient’s blood pressure should be monitored before, during, P: Continue twice-weekly treatments with intermittent
Short-stretch bandage: A bandage with low elasticity and 30%
and after using the compression pump. If his blood pressure sequential pneumatic compression at 80 s inflation and 35
to 90% extension that provides a low resting pressure but a
increases, the force and if necessary the duration of pumping s deflation, and maximum inflation pressure of 50 mm Hg
high working pressure during muscle activity; also called a
should be reduced. An appropriate dressing should be placed for 2 h. Pt should wear two-layer compression bandage
low-stretch bandage.
on the ulcer site before the compression sleeve, bandage, or between intermittent compression treatments and may
Static compression: Steady application of pressure.
stocking is applied. A single-use sleeve should be used for switch to compression hose when ulcer begins to heal.
Unna boot: A semirigid bandage made of zinc oxide-
pumping, or an occlusive barrier should be placed over the Reassess each time patient comes for intermittent
impregnated gauze that is applied to the lower extremity to
ulcer during pumping to avoid cross-contamination. compression treatment and Unna boot application.
exert pressure.
Venous insufficiency: Decreased abiiity of the veins to return
blood to the heart.
Venous stasis ulcer: An area of tissue breakdown and necrosis
that occurs as a result of impaired venous return.
Working Review
Chapter pressure: Pressure produced by active muscles Glossary
pushing against
1. Compression an inelastic
applies bandage.directed force to the
an inwardly Ankle-brachial index (ABI): Ratio of systolic blood pressure at
tissues, increasing extravascular pressure and venous and the ankle to systolic blood pressure in the upper arm
lymphatic circulation. (brachium). An ABI lower than 1, indicating lower blood
2. Externai compression can be used to control edema, prevent pressure at the ankle than in the arm, suggests reduced distal
the formation of DVT, facilitate venous stasis ulcer healing, lower extremity blood flow due to peripheral artery disease.
and shape residual limbs after amputation. Antiembolism stockings: Knee-high or thigh-high stockings that
3. Compression devices include compression bandages, provide low compression force to prevent DVT formation.
compression garments, Velcro closure devices, and Compression: The application of a mechanical force that
pneumatic pumps. Bandages and garments provide static increases externai pressure on a body part to reduce swelling,
compression and can be worn throughout the day, whereas improve circulation, or modify scar tissue formation.
pneumatic pumps provide intermittent compression for Deep venous thrombosis (DVT): Blood ciot in a deep vein.
limited periods of time. Edema: Swelling caused by increased fluid in the interstitial
4. The choice of compression device depends on the problem spaces of the body.
being treated and the ability of the patient to comply with the Hydrostatic pressure: Pressure exerted by a fluid, for example,
treatment. in the blood vessels. It is determined by the force of the heart
5. The use of compression is contraindicated in patients with and gravity and contributes to movement of fluid into or out of
heart failure, pulmonary edema, DVT, thrombophlebitis, blood vessels and lymphatics.
pulmonary embolism, obstructed lymphatic or venous Hypertrophic scarrîng: Excessive scarring with a raised and
return, peripheral artery disease, skin infection, hypopro- ridged appearance that does not extend beyond the
teinemia, and trauma. Caution should be used in patients boundaries of the original site of skin injury. This type of scar
with impaired sensation or mentation, uncontrolled has poor flexibility and can result in contractures and poor
hypertension, or cancer and in the application of cosmesis.
compression over superficial peripheral nerves. Intermittent compression: Pressure that is alternately applied
6. The reader is referred to the Evolve website for additional and released and is usually applied by a pneumatic
resources and references. compression pump.