1. METHODS OF COMPRESSION THERAPY PUTTIN THE SQUEEZE ON!! NORTHEAST WYOMING SKIN AND WOUND SYMPOSIUM

2. OBJECTIVES 1. Understand the role compression play in wound care 2. Understand the types of compression options available in wound care 3. Recognize the appropriate patient for compression therapy 4. Apply various products for compression therapy.

3. COMPRESSION THERAPY WHAT??? Compression therapy is the application of pressure to the lower extremities. It is recognized treatment of choice for recurrent venous leg ulcers. Compression therapy systems include hosiery, tubular bandages and bandage systems comprising two or more components. These systems aim to provide graduated compression to the lower limb in order to improve venous return and to reduce edema http://wwundsinternational.com/pdf/content_10802.pdfw.wo

4. HOW DO WE DEFINE THIS IN PRACTICE ELASTIC INEALSTIC STATIC DYNAMIC WRAPS HOSE HELP!!!!!

5. PURPOSE 1. Counteract the force of gravity and promote the normal flow of venous blood up the leg 2.Acts on the venous and lymphatic systems to improve venous and lymph return and reduce edema Meissner,M, Lower Extremity Venous Anatomy, Interventional Radiology, Sept. 2005, ; 22(3): 147-158

6. WHAT IS NORMAL????

7. WHAT IS “NORMAL” STRUCTURE VENOUS SYSTEM DEEP VEINS SUPERFICIAL VEINS PERFORATORS Semin Intervent Radiol. Sep 2005; 22(3): 147–156.

9. FUNCTION Reflow of the oxygen-poor blood from the muscles and tissues to the heart. VENOUS VALVES function in a one-way direction 2011 Dr. Peter-Michael Rücker

10. WHAT IS ABNORMAL??

11. ANATOMICAL FAILURE Venous Wall Physical Properties: Reduced Strength Venous Valves Primary Venous Disease: degenerative damage Secondary Venous Disease: DVT Calf Pump 90% of venous return is through these 3 Fletcher, Moffatt, Partsch, Vowden, Vowden: Principles of Compression in venous disease, a practioner’s guide to treatment and prevention of venous leg ulcers; Wounds International: 2013

12. LYMPHATICS MEM: Manual Edema Mobilization “Pre” Lymphedema High Protein Edema

13. VENOUS PRESSURE = EDEMA Ambulatory Venous Hypertension: The elevated pressure in the leg vein during walking. Partsch, H; compression therpay of venous ulcers;, Hemodynamic effects depend on interface pressure and stiffness; EWMA Journal 2006, vol 6 NO2.

14. How Much Pressure Is Normal?? Resting Pressure: -40 mmHG Standing: + 30-40 mmHG Ambulation: -70-90 mmHg Partsch H, Annuals Vascular Disease 2012

15. DOES EDEMA EFFECT WOUND HEALING??? Inflammation Fibrosis Induration Ischemia

16. Beidler et al, Multiplexed analysis of matrix metalloproteinases in leg ulcer tissue of patients with chronic venous insufficiency before and after compression therapy. Wound Rep Regen 16:642-648, 2008. Elevated MMP-1 in Venous Ulcers

17. NO COMPRESSION/ COMPRESSION

18. Common Clinical Presentation

20. WHAT MUST WE DO ABOUT IT? COUNTERACT GRAVITY COMPRESSION THERAPY

21. La Places Law Pressure = N x T x 4620 C x W ■ N = Number of layers applied – the more layers, the greater the pressure ■ T = Bandage tension – the greater the force applied, the greater the pressure ■ C = Limb circumference/ shape – the smaller the circumference at any given point, the greater the pressure ■ W = Bandage width – the narrower the bandage, the greater the pressure World Union of Wound Healing societies (WUWHS). Principles of best practice: Compression in venous leg ulcers. A consensus document. London: MEP Ltd,2008

22. WHAT TO DO BEFORE COMPRESSION ABI: ANKLE/BRACHIAL INDEX Greater than 0.90 = normal 0.71 – 0.90 = mild obstruction 0.41 – 0.70 = moderate obstruction Less than 0.40 = severe obstruction

24. WHAT IS ADAQUATE COMPRESSION Overcome intravenous pressure, adjusted to body position Exert a sub-bandage resting pressure that is well tolerated in a resting position Provides a pressure increase when the patient rises to a standing position: (50-70mmHG) Provide external compression improving venous reflux during walking Fletcher, Moffatt, Partsch, Vowden, Vowden: Principles of Compression in venous disease, a practioner’s guide to treatment and prevention of venous leg ulcers; Wounds International: 2013 Partsch, H; compression therpay of venous ulcers;, Hemodynamic effects depend on interface pressure and stiffness; EWMA Journal 2006, vol 6 NO2.

25. STIFFNESS The relationship between the resting and working pressures of a compression device Achieved through use of inelastic bandages in multiple layers Measured in SSI(Static Stiffness Index) LOW SSI: <10: KNITTED STOCKING, ELASTIC BANDAGES MED SSI: FLAT KNITTED STOCKING HIGH SSI: >10 SHORT STRETCH,MULTICOMPONENT BANDAGES, ZINC PASTE WRAPS, VELCRO WRAPS Partsch, H; compression therpay of venous ulcers;, Hemodynamic effects depend on interface pressure and stiffness; EWMA Journal 2006, vol 6 NO2.

26. Types of Bandages Non-Stretch Short –Stretch Long -Stretch

27. Non-Stretch ZINC PASTE BANDAGES

28. Short Stretch Bandages that stretch to less than 100% of their original length: minimal extensibility High Working Pressure/Low Resting Pressure

30. Long Stretch Expands over 100% of its original length Low Working Pressure/High Resting Pressure Contains Elastomeric Fibers : fibers that are able to stretch and return to almost their original size. World Union of Wound Healing societies (WUWHS). Principles of best practice: Compression in venous leg ulcers. A consensus document. London: MEP Ltd,2008

31. NOTE BECAUSE OF THEIR ABILITY TO SUSTAIN PRESSURE, SOME CLINICIANS BELIEVE THAT ELASTIC MATERIAL MAY BE MORE EFFECTIVE THAN INELASTIC MATERIALS FOR IMMOBILE PATIENT OR THOSE WITH A FIXED ANKLE, BUT LESS APPRIOPRIATE AND MORE UNCOMFORTAVLE FOR PATIENT WITH IMPAIRED PERIPHERAL PERFUSION. FURTHER RESEEARCH IS REQUIRED TO CONFIRM THIS AND CLINICIANS SHOULD BE AWARE THAT INELASTIC MATERIAL CAN PROVDE PRESSURE PEAKS EVEN DURING SMALL ANKLE FLEXIONS. World Union of Wound Healing societies (WUWHS). Principles of best practice: Compression in venous leg ulcers. A consensus document. London: MEP Ltd,2008

32. Other compression devices

34. Hose/Support Stockings Made of elasticated textile STYLES: KNEE, THIGH, PANTYHOSE LENGTHS CUSTOM OR OFF THE SHELF Can be used as first line treatment in patient with small ulcers. 2-component systems

35. LEVELS OF COMPRESSION Class I: 14-18 mmhg: Anti-Embolism hose Not a therapeutic level of compression Class II: 18-24 mmhg: dependent edema, non- ambulatory, CHF Class III: 25-35mmhg: Venous Insufficiency Class IV: Lymphedema, need to have active muscle movement

37. Intermittent Pneumatic Compression EVIDENCE SUGGESTS A boot comprising air-filled chambers attached to an electric pump- used in combination with compression bandaging may be more effective that bandaging alone. Schuler JJ, Maibenco T, Megerman J, Ware M, Montalvo J; Treatment of chronic venous ulcers using sequential gradient intermittent pneumatic compression; Phlebology / Venous Forum of the Royal Society of Medicine; 1996, vol 11,issue 3.

38. Things To Consider ETIOLOGY OF WOUND PATIENTS MOBILITY PATIENTS ACCESS TO CARE ULCER SITE PATIENTS TOLERANCE

39. TAKE HOME PEARLS CONSIDER COMPRESSION IN LOWER EXTREMITY ULCERS DO ARTERIAL SCREENING BE COMPETENT IN COMPRESSION WRAPPING PICK YOUR PATIENTS EXERCISE!!!

40. EXERCISE!! CALF RAISES CALF STRETCHES MARCHES DAILY WALKING UP AND DOWN STAIRS SWIMMING

41. FUN CASES

42. PLAYING WITH DOCTORS

43. EVEN CROSS-FIT HAS WOUNDS!!

44. Case Study Etiology: 47 year old male,DFU/cellulitis: left great toe: suspected osteomylitis, able to probe to bone PMHX: DM, PVD, obesity, LE edema, CABG x 3 Age: 4 weeks old Previous treatment: Gauze packing, sorbact, hydrofera blue, hypochlorous acid

45. Wound Dimensions :Pre: 1.2 cm x 1.3 cm x 1.2 cm Post: closed Treatment: Endoform, hydrofera blue: both moistened with hypochlorous acid, as healing progressed did also use adaptic and non- adherent dressing, compression and TCC Length of Treatment: 10/21-11/11: endoform treatment 45

46. 1.2 x 1.3 x 1.2 cm: undermining: 11:00/2.0 cm 46

47. .4 x.4 x.3 cm/ undermining 12-6 /2 mm and 6-12/ 2 mm 47

48. .5 x.5 x.3 cm/ no undermining. 48

49. .2 x.2 x.1 cm 49

50. .1 x.1 x.1 cm 50

51. closed 51

52. Case Study Etiology: DFU: heel left foot, in a 49 year old male, second wound in the same location Age: approximately 10 months old, re-occurring wound x 2, had 7 months of treatment prior to us seeing us Previous treatment: CROW walker, topical wound care Wound Dimensions :Pre: 2.5 x 4 x.1 cm/Post: closed Treatment Length of Treatment

53. Treatment: Endoform, Hydrofera blue: moistened with hypochlorous, absorptive dressings, compression and TCC Length of Treatment: began endoform: 10/21-12/9, wound closed 12/16 53

54. 4.0 x 2.5 x.1 cm 54

55. 4.0 x 2.1 x.1 cm 55

56. 3.0 x 3.5 x.1 cm 56

57. 1.0 x 3.4 x.1 cm: islands of epithelium developing 57

58. Photos (2 minimum)

59. 1.5 x 3.1 x.1 cm 59

60. 60

61. 3.0x 2.0 x.1 cm 61

62. Three small areas now 1.0 x.3 x.1 1.0 x.2 x.1.2 x.2 x.1 62

63. .3 x.2 x.1cm 63

64. closed 64

65. Case Study Etiology: DFU in a 59 year old male, ulcer present for over one year. Age: one year Previous treatment: telfa, and foam Wound Dimensions : Pre: 2.2 x 2.2 x.2 cm/ Post: closed

66. Treatment: Endoform, Hydrofera blue: both moistened with hypochlorous acid, compression and TCC Length of Treatment: started endoform 11/25, 12/2 66

67. 1.5 x 1.9 x.1 cm

68. 68

69. .7 x.5 x.1 cm 69

70. closed 70

71. THANK YOU!!!!