Compression therapy in line with individual requirements Symptom-based stocking selection
Medical compression stockings are part of the basic therapy for vein problems. Whenever they’re prescribed, however, they must always be tailored to the patient’s individual requirements, says Dr. Stefanie Reich-Schupke, a professor of phlebology at Ruhr University Bochum, Germany.
Bauerfeind life: What are the components of a modern non-invasive method for diagnosing vein problems today?
Prof. Reich-Schupke: First of all , a thorough case history needs to be produced in order to determine the patient’s condition and whether symptoms indicating a vein problem exist. Indications of such a problem include heavy legs, a tendency for swelling to occur in the evening or in warm temperatures, and discoloration of the legs and feet. After the case history is completed, both the patient’s legs should be clinically examined from top to bottom, and this examination should also include an inspection and palpation. Here, the physician should be looking for signs of a vein problem – in particular a large number of spider veins, the presence of varicose veins, brownish discoloration in the lower leg and scars or open areas in the ankle region. The next step is to conduct an ultrasound examination using a Doppler probe. The latter can detect incorrect blood flows (reflux) in superficial and deep veins. Any time an invasive or interventional procedure is planned for a treatment , an image-based diagnosis using color duplex ultrasound technology should be performed in advance. This not only helps detect incorrect flows, it also provides information on vessel morphology, which in turn allows us to evaluate valve functions and clearly identify stenoses or occlusions. Other functional examinations can also be performed – for example a digital photoplethysmogram (DPPG) or a venous congestion plethysmography (VCP). In the case of elderly patients, or if the case history or clinical examination indicates something suspicious, it makes sense to conduct an arterial Doppler ultrasound examination to determine the ankle-brachial index (ABI) and in this manner evaluate the extent of arterial perfusion.
“The stronger and more pronounced the damage, the greater the resting pressure and
material strength should be.”
Prof. Dr. med. Stefanie Reich-Schupke
How do you decide on a course of customized treatment after all the things you mentioned have been done?
Prof. Reich-Schupke: When you’re dealing with a vein problem that needs to be treated, for example varicose veins, you need to examine the extent of the diagnosed condition and symptoms while also taking into account accompanying factors like medications already being taken, or other illnesses already present. Once you’ve done that , you can decide which treatment is best for the patient. Various surgical , interventional , and chemical options are currently used to treat vein problems. Generally, all of these are combined with compression therapy, at least for a certain period of time. If no cause-related treatment for a vein problem is to be performed, then a physician should at least try to use a conservative treatment approach with compression stockings in order to relieve symptoms, prevent complications, and slow the progression of the condition. This type of compression therapy also needs to be customized.
What do physicians need to take into consideration when prescribing compression stockings?
Prof. Reich-Schupke: The “compression logic” recently developed by experts assumes a standard treatment approach with
compression class (Ccl) 2 and a medium material strength.1 In the case of accompanying compensated peripheral arterial disease (PAD), for example, the Ccl should be lowered – in other words the resting pressure should be reduced. With obese patients, on the other hand, it makes sense to increase the material strength of the stocking.
“Based on the positive clinical results, I have to say I’m a big fan of class 1 when it’s combined with a high degree of material strength.”
Prof. Dr. med. Stefanie Reich-Schupke
The current guidelines and the Medical Aids Directory intentionally refrain from firmly recommending individual compression materials, and thus the corresponding contact pressures, for specific indications. Clinical experience has shown that it makes much more sense to choose a compression therapy on the basis of the patient’s symptoms. The following four questions are very important here. First: Which indication is present that would warrant compression therapy? The stronger and more pronounced the damage, the greater the resting pressure and material strength should be. Second: Does congestion still exist or should the compression therapy be used as a preventive or maintenance measure? Adaptive compression systems or compression bandages with padding on the inside should be used to relieve congestion. Stockings have proved to be effective in maintenance therapies. Third: Which concomitant illnesses, if any, are present? The presence of osteoarthritis of the hand or leg joints, arterial circulatory disorders, adiposity, or neurological diseases will have an influence on the material selection.
Finally: What type of expectations and wishes does the patient have with regard to the treatment? It’s essential that the patient wears the compression clothing for several hours throughout the day. This means compromises will occasionally be necessary. Ultimately, I don’t need to prescribe a stocking for someone who doesn’t want to wear it.
What role does the stiffness of the material play?
Prof. Reich-Schupke: The effectiveness of compression therapy ultimately depends on the working pressure, in other words the combined pressure generated by the compression material and the patient’s muscles. Working pressure can be influenced by resting pressure and material strength/stiffness. Patients often find a high degree of resting pressure to be uncomfortable, and this is especially true of patients who suffer from an accompanying PAD or neurological deficits in their legs. Medical compression stockings with a high degree of resting pressure are also more difficult to put on and remove. Here, one could therefore choose a lower resting pressure combined with a strong, short stretch material with a high degree of stiffness in order to maintain the desired working pressure on the leg. A higher degree of stiffness should also be chosen if the patient has a bulky leg per se, due to obesity, for example.
When do you prescribe compression class 1?
Prof. Reich-Schupke: Based on the positive clinical results, I have to say I’m a big fan of class 1 when it’s combined with a high degree of material strength. Studies also show that class 1 makes it possible to alleviate symptoms, heal ulcers, and prevent relapses. In addition, class 1 stockings are generally better tolerated by patients, who tend to wear such stockings more consistently than products with a higher resting pressure. Patients are also often able to put on and take off the stockings without assistance. Regardless of the compression class used, it makes sense to prescribe an aid for putting on and taking off the stockings for patients suffering from osteoarthritis in the joints of their fingers, or if the mobility of their hips or knees is restricted. I would also point out that I’m very pleased that assistance with putting on and taking off compression class 1 stockings can now be prescribed by a physician. The fact that this was previously not possible led to a situation over the last few years in which many patients who needed someone to help them put on and take off stockings were not prescribed class 1 stockings – although they should have been – or else had to make a major effort and submit individual requests to get the costs covered.
“Studies also show that class 1 makes it possible to alleviate symptoms, heal ulcers, and prevent relapses.”
Prof. Dr. med. Stefanie Reich-Schupke
When do flat-knit compression products absolutely have to be used?
Prof. Reich-Schupke: The current recommendations – in the guidelines as well – are based on experience and expert opinions. For me, the following criteria would necessitate the use of flat-knit products: a difference of circumference of more than one centimeter per centimeter of leg length, or if the thigh is more than 2.5 times thicker than the ankles; toes that have been so severely affected that toe caps need to be used; the presence of deep skin folds that need to be covered by a stiff material. These criteria generally often apply to patients with lymphedema and/or lipedema, as well as those with post-thrombotic syndrome or substantial adiposity with an accompanying leg edema.
What’s your opinion of special solutions such as those used for the treatment of venous ulcers, or a combined venous-arterial condition?
Prof. Reich-Schupke: Ulcer compression stocking systems like VenoTrain ulcertec have very much proved their worth in terms of treating and preventing the recurrence of venous leg ulcers. The level of acceptance of these systems among patients in our out-patient clinic is very high.
VenoTrain angioflow is a completely new product for treating patients suffering from chronic venous insufficiency (CVI) and concomitant compensated PAD. I should also point out that VenoTrain angioflow has had no competing product on the market to date. VenoTrain angioflow has been proven to not reduce acral perfusion, and the data that has been obtained shows that it can be classified as safe for this critical patient group as well. Patients are very pleased by the fact that it’s easy to put on, fits comfortably and – because of its low resting pressure – doesn’t lead to calf pain during rest periods. In addition, an individual VenoTrain angioflow product selection can be prescribed by a physician?
1 Kröger K. et al., Verordnungslogik von medizinischen Kompressionsstrümpfen bei Patienten mit chronischer venöser Insuffizienz, vasomed, 29. Jg., 4/2017, 199–201.
Images: Bauerfeind (4), Stefan Durstewitz
Prof. Dr. med. Stefanie Reich-Schupke believes it’s important to choose a compression therapy on the basis of a patient’s symptoms.
- The stronger and more pronounced the damage, the greater the resting pressure and material strength should be.
- Patients tend to tolerate Ccl1 combined with a high degree of material strength better than a product with a higher resting pressure.
- In the case of conditions such as venous leg ulcers or CVI combined with early-stage PAD, special solutions can be prescribed – in the form of a specifically named product as well.
Prof. Dr. med.
is Director of the Phlebology Study Center at the Vein Center of the dermatology and vascular surgery clinics at Ruhr University Bochum. The dermatology and venereology specialist has held the Bauerfeind AG endowed Professorship for Phlebology at Ruhr University Bochum since January 2017.
(As of: Oktober 2018; Image: Stefan Durstewitz)