Compression therapy is considered standard of care for patients with venous ulcers and other edema-causing problems of the extremities. Unfortunately, questions arise about the appropriate use of compression therapy in certain situations, even though the patient care would be improved with its use. It has been stated many times that patients with vascular insufficiency cannot be treated with compression therapy, for fear of making their circulation worse and causing harm. This shows a lack of understanding of the basic physiology of how different compression devices work. By carefully choosing the appropriate compression dressing, all patients in need of compression therapy may be treated safely.

Elastic compression bandages are the most frequently used devices for compression therapy. When elastic bandages are applied to the extremity, whether 1,2,3, or 4 layers, pressure is applied to the skin and underlying structures. Even though there are suggested maximum pressures to generate when applying these bandages, the risk of using more pressure than is safe for any patient, especially one with vascular insufficiency, resulting in skin and tissue damage is always foremost in the practitioners mind. As a result, elastic compression bandages are rarely applied appropriately.¹

A second type of compression, inelastic or short-stretch compression, has been found to be more appropriate for treating patients with vascular insufficiency due to the different mechanism of action in providing compression. When a bandage that does not stretch is applied to the extremity, it is applied with a lower pressure on the skin (resting pressure).² This protects the skin from excess pressure when the extremity is at rest. Pressure is generated when the muscles under the bandage contract. Since the bandages do not stretch, the expansion of the muscle is restricted and pressure develops. This pressure is evenly distributed throughout the muscle compartments in addition to the subcutaneous tissues according to Pascal’s Law. When the muscle relaxes, the pressure under the bandage returns to the original resting pressure. This assures that patients with vascular insufficiency who are treated with short-stretch compression bandages and then subsequently develop pain because of reduction of circulation, can stop the activity, allowing the blood flow to return to resting levels without damage to the tissues.

Clinical trials have shown that reducing the edema in swollen extremities including ones with vascular insufficiency will actually increase the blood flow and improve the healing.^2,3 Other studies have shown that judicious use of short-stretch compression bandages can effectively reduce the edema and improve healing in these high risk patients with vascular insufficiency.⁴

Many times practitioners are faced with other disease processes that are associated with swelling of the extremity but are reluctant to use compression therapy for fear of causing more harm than good. One such disease is cellulitis. Cellulitis is a bacterial infection of the skin which is manifested by a red, swollen leg.⁵ Recent work has shown that as many as 30% of patients felt to have cellulitis actually do not and are treated inappropriately.^6,7 Cellulitis is accompanied by a swollen extremity due to an accumulation of edema and/or lymphatic fluid. Lymphedema fluid is a significant problem because the high protein content encourages bacterial growth.⁵ The presence of edema fluid inactivates the normal antimicrobial properties of the skin, lowering the body’s ability to resist and fight infection.⁸ Removal of the edema and lymphedema fluid with compression therapy improves and speeds up the resolution of cellulitis by increasing blood flow and the concentration of antibiotic in the tissues.⁹ It also results in a more rapid reduction of erythema of the extremity due to the underlying inflammatory reaction.¹⁰ Unfortunately, many are concerned with compressing an infected extremity, but recent work has shown that using compression as a part of the therapy for cellulitis is safe and effective.¹⁰

Another disease that results in a swollen extremity is that of deep venous thrombophlebitis. The fear in treating this problem with compression therapy is that it will dislodge the blood clots in the extremity, resulting in a pulmonary embolus. Experience and research has shown just the opposite to be true. Judicious compression therapy actually increases flow in the venous system, preventing further clotting in susceptible veins. By occluding superficial veins, we prevent clotting. There is no evidence that judicious compression therapy in limbs with acute deep venous thrombosis increases the incidence of pulmonary embolus.^8,11 The only contraindication to using compression therapy is if the extremity is too painful to allow it.¹¹

A similar question arises when discussing patients with swollen limb due to congestive heart failure. Can compression therapy be used in the treatment of these patients? The answer is yes. As long as the patient does not have acute pulmonary edema and is being treated for the congestive heart failure, compression therapy is safe and effective.⁸ Removal of the edema fluid from the lower extremities reduces the volume of fluid the struggling heart has to manage.

All compression bandages are not the same. Elastic compression works by “squeezing” the extremity to apply pressure. Short-stretch compression works by allowing muscle contraction to generate the needed pressure. Each has its own indications for use in the patient with a venous ulcer and a swollen extremity. The second item is that appropriate use of the appropriate compression dressing will enable even patients with vascular insufficiency to be treated effectively and safely.

Removal of edema and lymphedema fluid is beneficial for the treatment of most any medical problem either acute or chronic. The inflammatory properties of the edema fluid can result in delayed wound healing and damage to the tissues with associated lipodermatosclerosis and even changes associated with lymphedema. In most every condition associated with a swollen extremity, judicious compression therapy can be used to improve the problem and benefit the patient.

Case Study

Patient was discharged from the hospital with oral antibiotics and sent to the wound care center for therapy.

Treatment: The wound care center recommended compression therapy. Short-stretch compression therapy was instituted on the first wound center visit and bandages were changed weekly. Antibiotics were discontinued after 1 week.

Regards,

Terry Treadwell, MD, FACS

[email protected]