As discussed in previous columns, venous leg ulcers (VLUs), also known as venous stasis ulcers, are 1 of the most common chronic wounds, impacting nearly 3 million people worldwide. About 1% of the western population will experience a VLU in their lifetime.1 Clinical studies demonstrate compression therapy can significantly increase VLU healing rates and reduce the likelihood of recurrence.2 Yet compression therapy is not widely used, largely due to gaps in clinician understanding of VLUs and compression therapy.
John M. Macdonald, MD, FACS, Board Certified General and Thoracic Surgeon, has spent the last 20 years dedicating himself to the clinical and research aspects of wound care and lymphedema. Dr. Macdonald is the past president of the Association for the Advancement of Wound Care (AAWC). He is the founder and Secretary for the World Alliance for Wound and Lymphedema Care, (WAWLC) based in Geneva, Switzerland. In the first 2 days after the earthquake in Haiti on January 12, 2010, Dr. Macdonald established the wound care program and the Haitian Relief Tent Hospital in Port-au-Prince through the University of Miami and Project Medishare. Dr. Macdonald is the Medical Director of the Wound and Lymphedema program now located at the Hospital Bernard Mevs in Port-au-Prince.
As one the foremost experts on venous leg ulcers and compression therapy, Dr. Macdonald sat down with 3M to share his opinions and perspective on the importance of this therapy, how it has evolved, and where it is headed.
In your opinion, why is compression therapy underutilized when it comes to various conditions such as VLUs?
Compression therapy is underutilized for multiple reasons — from the absence of understanding the pathophysiology of edema and lymphedema as it affects wound healing to not knowing the role of bandage stretchability and seeing treatment failure with long stretch. Other factors that affect underutilization include: a history of failure because of poor technique, fear of compressing what appears to be an infected wound, economic constraints in resource-poor nations, and patient compliance influenced by climate, mobility issues, and “vanity” (ie, patients don’t want to wear something in public).
Unna Boot has been seen as the predominate approach to compression therapy. What evolutions have you seen in your career from both a treatment and an understanding standpoint?
Probably the most important is the increased understanding that venous ulcers are not the only indication for compression. Compression therapy has been used to address a variety of conditions including edema and lymphedema. Additionally, there has been continued acceptance and understanding of short stretch as the gold standard of care.3 I’ve also seen a continued emphasis on clinician training with regard to treatment techniques and working with compression therapy solutions.
One of the more recent efforts to guide treatment is a consensus document. Two years ago, an international group of experts in leg ulcers and venous disease gathered to identify how to encourage wider adoption of compression therapy by simplifying the key principles involved. They authored a document, Simplifying Venous Leg Ulcer Management, which provides an indepth look at VLU assessment and diagnosis, compression therapy, and best practices in wound and skin care management. It is a great resource to keep advancing the discussion and understanding of VLUs.
Perhaps one of the more significant shifts I have seen has been the evolution of technology. Unna Boot continues to be a technology that works, but systems like 3M™ Coban™ 2 Layer Compression Systems from 3M have modernized the technology even more and addressed key patient needs from comfort to mobility. I often liken Unna Boot to the Model T and Coban 2 Layer to a brand new Mercedes. Both have an engine. Both are going to get you where you need to go. But one is a more advanced technology that addresses key patient needs.
Why are these evolutions important to understand?
Educational advances are the foundation of effective compression. Without an appreciation of these principles, compression will be ineffective in most cases. I say that because some compression is often better than no compression, but there needs to be a widened clinical understanding so patients see the benefits of proper compression therapy.
Short stretch versus long stretch: can you help explain the difference?
The aspect of stretch applies to elasticity. Short stretch allows the range of 1 inch or less of hand-held stretch. Long stretch will double or triple the elasticity range. An over-the-counter bandage such as an elastic bandage is the long stretch example. A short-stretch bandage has a stretchability of 20 mm Hg to 30 mm Hg compression and closely resembles normal physiology by producing pulsatile force on the veins and lymphatics. As opposed to arterial flow, venous and lymphatic flow is regulated by outside pressure, primarily muscle contraction. Low pressure at rest allows filling. High pressure with muscle contraction advances the flow in the vessel.
You have seen some challenging patients with your work in Haiti. How has compression therapy played an important role?
Compression therapy is a mainstay component in our approach to wound care in Haiti. It addresses a fundamental principle in universal wound healing, which emphasizes the need to control periwound edema and lymphedema. Of the 60 to 80 patients with lower extremity wounds seen in our wound clinic daily, 80% will be given some degree of compression.
Additionally, Haiti is a major area for lymphatic filiariasis. Short-stretch compression applied by trained lymphedema therapists has dramatically improved the morbidity and suffering of these patients.
What are the biggest mistakes you have seen clinicians makes in the treatment of conditions like VLUs?
As I have traveled the world to educate on compression therapy for the treatment of various conditions and lower leg wounds, I continue to encounter the same 2 issues: not knowing the indications and poor technique, which is often due to a lack of training.
The literature now establishes the importance of short-stretch compression in multiple etiologies of lower extremity wounds. Controlling periwound edema and lymphedema is a principle of wound healing. Negative pressure wound therapy removes wound fluid directly from the chronic wound; effective compression does the same thing by moving chronic wound fluid past obstructed lymphatics and into normal lymphatics. In my teaching and education, I continue to stress the principle that most lower extremity wounds require short-stretch compression and the role Coban 2 Layer plays in healing. n
1. Graham ID, Harrison MB, Nelson EA, Lorimer K, Fisher A. Prevalence of lower-leg ulceration: a systematic review of prevalence studies. Adv Skin Wound Care 2003;16(6):305–316.
2. Nelson EA, Bell-Syer SE. Compression for preventing recurrence of venous ulcers. Cochrane Database Syst Rev 2014;9:CD002303.
3. Harding K, et al. Simplifying venous leg ulcer management. Consensus recommendations. Wounds Int J. 2015. Available at: www.woundsinternational.com. Accessed November 4, 2016.