Compression Pitfalls: Improving Patient Adherence With Compression Therapy

  It is a well-accepted fact that compression therapy is considered the standard of care for patients with chronic venous insufficiency (CVI). In the absence of significant lower extremity arterial disease, the use of different types of compression wraps and garments are often the single most effective component of CVI treatment. The external pressure of the compression wrap on the underlying venous system assists the calf muscle pump in the return of blood to the heart and lungs from the lower extremities, decreasing the venous hypertension that is the causative factor in many lower extremity ulcerations. Observing the effect of compression on patients with ulcers related to CVI can be an incredibly rewarding experience for the clinician because when appropriately applied, edema reduction is rapid and ulcer improvement is sure to follow. However, we are often faced with patients who are unable to maintain these wraps and dressings for the time period that they are supposed to be worn. It is a frequent occurrence to have patients return to the clinic with their compression wrap out of place or worse, having taken it off at home. Regardless of advanced dressing options and alternative treatments, CVI therapy without adequate compression usually results in further ulcer breakdown.

  Patients report difficulty tolerating their compression therapy for a multitude of reasons including:
    •A poorly fitting wrap or garment
    •Inability to apply garment
    •Pain
    •Discomfort related to heat and tightness of the wrap
    •Cost

  Other issues noted by practitioners are:
    •Drainage strike-through leading to a moist, soiled bandage
    •Patient lifestyle
    •Practitioner error in application

  Some issues are patient dependent, some are related to clinician ability and some issues with adherence to treatment are financially driven. Health care providers who render compression therapy need to be aware of common problems and errors related to the use of compression so that we may help our patients not only to increase their compliance level but also achieve goals and outcomes related to peripheral edema and wound management.

Appropriate Fit for the Patient

  Just as patients come in all shapes and sizes, so do their extremities. We are all familiar with the “bottle neck” deformity seen with CVI patient but often times, there are other tissue abnormalities seen that will affect the appropriate fit and feel of the compression wrap. Lymphedema and surgical changes can require more complex wrapping skill and forethought by the attending clinician.

  Extra foam or cotton padding may be required to apply uniform compression over surgical “shelf” deformities as well as soft tissue folds and hypertrophic areas. Boney and painful prominences will require extra care to prevent additional pain and pressure in susceptible limbs. The ability to maintain uniformity of compression over tissue abnormalities will improve patient satisfaction as well as wear time. Ultimately this also affects cost to the patient and/or the clinic, helping to assure the treatment is more efficient as well as cost effective.

  Extremity shape and contour aren’t just important considerations with compression wraps. Compression hose that aren’t appropriately sized for the patient may result in wrinkles in the garment, causing pressure areas or diminished blood flow circumferential.

  There are ready sized compression garments that may be appropriate for some patients and are often less expensive, however, custom fit hose will often result in a much better fit and greater adherence with treatment. Custom fit garments can be manufactured to allow for patient specific contours and can be sewn with zippers, allowing a patient to independently donn the stocking. Hosiery that is measured and fabricated to fit the individual patient is less likely to slip, slide and wrinkle.

Patient Ability to Apply Compression Hose

  Many of our patients that require the use of compression garments are elderly, obese, have musculoskeletal or neurological disorders and overall, diminished mobility. Donning compression garments requires lower extremity and spinal flexibility, upper extremity strength, hand and finger dexterity and usually, reasonably good eyesight.

  There are several products on the market designed to assist the less mobile patient with donning and doffing their compression garments. These include: Juzo® Slippie Gator (Juzo USA Inc, Cuyahoga Falls, OH), Mediven® Stocking Butler (Medi USA, Whitsett, NC), and the Jobst® Stocking Donner(Jobst BSN Medical, Charlotte, NC). In addition, patients may also get a better grip on the hose to pull them on and off by using regular household rubber gloves. If a greater grip is needed, there are ribbed gloves on the market specifically designed for compression hose application (Sigvaris, Peachtree City, GA). Appropriate moisturizing of the skin will also aid in less traumatic application. Specific donning apparatus may also require the use of either an open toe or close toe variation. This should be considered when prescribing the garment.

Patient Reports of Pain with Compression

  When patients report pain with compression, there can be multiple causative reasons. The most crucial that should be assessed is appropriate blood flow. Compressing the arterial system on patients with even mild peripheral arterial disease can cause pain in the best-case scenario and ischemia in the worst. Arterial disease should always be ruled out prior to administering compression therapy. If a patient who has been utilizing compression therapy suddenly begins complaining of pain in the affected extremity, the arterial system should be assessed to ensure that an acute event has not occurred. Patients with peripheral neuropathy may also complain of pain with compression. With these patients, a short stretch compression system offering lower resting pressures may be best utilized. Some patients simply need to be graduated slowly into higher compression wraps or even garments, particularly if they’ve never worn them before. Single layer, lighter compression products that may be applied like a sleeve may ease the transition. One example is Tubifast® (Molnlycke Health Care, Norcross, GA). The need for medications to assist with pain control must also be evaluated by the prudent practitioner. In some cases, the value of the compression modality needs to be weighed against the level of pain. If the pain level is too great, and the patient is not able to tolerate the compression, compliance with the therapy is doomed. Always take into account patient goals as well as treatment objectives.

Discomfort Related to Heat or Climate

  In hot, humid locations, most of us wear environmentally appropriate clothing (shorts, tee shirts and flip flops). This is not the case for patients wearing compression wraps or garments. Compression wraps for CVI patients are worn from the metatarsal heads to tibial plateau. The entire lower leg is then wrapped in, often, multiple layers of dressing, making this area quite warm and often causing excess perspiration for these folks. If patients can tolerate the warmth of the wrap, as clinicians we need to make sure that the contact layer is absorptive enough to wick away any perspiration formed so that the wrap does not become saturated. There are lighter systems on the market now that tend to be more comfortable for patients in these situations, these include Profore Lite (Smith and Nephew, Largo, FL) and 3M Coban 2 Layer Lite (3M, St. Paul, MN). Patients wearing compression garments will report that the synthetic fabric is quite warm, particularly if worn under pants or slacks. Counsel patients on wearing lighter clothing that will allow greater breathability as well as trying to stay in cooler environmental situations if possible. Reinforce the need for the ongoing compression as the lifestyle change that it typically is.

Cost of the Compression System

  The cost of most compression wrap systems is fairly comparable across the product line and most are now reimbursable. Multilayer compression systems tend to be more expensive than paste bandages but all of these are appropriate during the wound-healing phase. For continued treatment of the edema that is not only the causative factor in the ulcer but is the long-term symptom of the disease, compression garments are required. These are much more expensive and only reimbursed by federal payers if ordered while the patient has an open ulcer. Custom fit garments are also more expensive than “off the shelf”, standard fit sizes, but also tend to offer a better, and more patient specific fit and feel. Other alternatives to the garments are wraps made from inelastic straps that are secured with Velcro® (Velcro Industries, B.V.) tabs. Examples include Farrow Wrap Trim-To-FitTM (Farrow Medical Innovations, Bryan, TX) and Juxta-LiteTM (CircAid Medical Products). Patient education and practice on application of these is critical to safe and effective treatment.

Patient Lifestyle

  Patient lifestyle can be one of the most important factors in determining whether your patient will adhere to their compression treatment regimen. Patients who are unable or choose not to keep dressings clean and dry will have great difficulty in maintaining wear time in a compression wrap for more than a day or two. Choose compression wrap products that will allow the patient to wear shoes if possible and make sure that the wound dressing under the wrap has the needed absorptive capabilities as well as antimicrobial properties needed for several days wear. This will reduce the chance of embarrassing drainage “strike through” that can soil clothing as well as helping to keep bacteria at bay that may lead to colonization, infection and odor.

  One dapper patient, treated by this author, insisted on wearing narrow legged pants and tassled loafers. To be able to slide easily into his shoes, he actually used duct tape over his heals as a smooth barrier between the compressive conform layer and the heel of his shoe. This did not diminish the effectiveness of the wrap; it was creative, and definitely “a guy thing”. Gone are the days of all of our compression patients being older, more sedentary and often retired. Many of our patients still lead very active lifestyles and continue to work part if not full time. Again, recognizing and affirming our patient’s goals for treatment and their needs, forces us to look at options that will allow them to maintain their present activity level and therefore improve adherence to the treatment plan with compression. Physically Active patients may also need low profile compression wraps that will allow them to apply regular shoes and clothing. There are options for multilayer lower profile wraps that include previously mentioned Profore Lite (Smith and Nephew, Largo, Fla) and 3MTM Coban 2 Layer Lite (3M, St. Paul, MN). Compression hose now also come in a variety of styles and colors, improving their aesthetic value to the patient. Hosiery material that is more comfortable and pleasing to the eye is more likely to be worn in everyday situations by patients. Compression garments that look and feel more like “regular” hosiery and socks make a patient feel less like a “CVI patient” and more like and individual that happens to suffer from CVI.

Practitioner Error in Application

  When patients complain that a compression wrap has slipped down or is uncomfortable, we need establish the reason. Is it that the patient can’t tolerate the pressure or the warmth of the wrap? Was the appropriate type of compression wrap selected and applied to the patient’s extremity? Was peripheral arterial disease ruled out? Was the wrap applied effectively by a skilled clinician? Prior to any compression therapy, as stated earlier, the peripheral arterial system needs to have been assessed objectively by vascular studies if PAD is even remotely suspected. Once, it is established that the patients arterial system is patent, the appropriate type of wrap needs to be selected based on the presence of ulcers or not, the type of compression required, the goals of therapy and the patients abilities and lifestyle. Only a skilled, competency trained clinician should be applying a compression wrap. There is too much room for error in the application of compression wraps whether they are single layer, 2 layer or multilayer. A poorly applied wrap can not only cause breakdown of the existing ulcer and formation of new ulceration but in the worst case scenario, can lead to limb ischemia and loss. The pain from an improperly fitting wrap will cause patients to remove the wrap early and result in less than adequate treatment. Clinics should strive to not simply educate staff on compression, including physiology of venous and arterial flow but the indications and contraindications of therapy. Staff should then demonstrate competency on the use of every type of wrap used in the clinic as well as the appropriate removal and this skill should be re-evaluated or peer-tested on a regular basis.

  Patients who require dressing and wrap changes in between clinic visits will often rely on nurses and therapists outside of the clinic to appropriately reapply their bandages and compression. If home health care agency personnel are not appropriately trained in this skill, the progress that may have been previously gained may be lost quickly. If your clinic staff members are noticing errors in wrapping from a particular agency, a good alternative to “firing the agency” is offering a training session for their staff at your clinic. This can be done “one on one”, when shared patients come in for clinic visits. Education opportunities for their entire home care staff can also be provided by trained and certified wound care specialists in your facility. This will not only improve patient care but will spread the wealth of knowledge and can serve as a marketing tool for your clinic. In a competitive healthcare environment where reimbursement is critical, this can be a win-win situation for the clinic and the agency as well as helping to achieve wound healing for your collective patient population.

Cost and Reimbursement Issues

  The cost of different types of compression wraps varies just as reimbursement for them ranges from little to adequate depending on the service providing the treatment. More and more, we are finding patients underinsured or uninsured. Cost effective, patient-centered clinics will have at least one person on staff that makes every attempt to stay abreast of reimbursement changes and issues as they relate to not only the different products and modalities used in the clinic but also your Medicare carrier’s local coverage determinations. Maintaining open, friendly lines of communication with product vendors as well as the agencies and facilities that you serve will better alert you to changes in other healthcare avenues that may ultimately affect the continuity of care for your patients. This enhanced knowledge will allow the physicians in the clinic to prescribe not only clinically sound but cost effective options for patients in a changing healthcare environment.

In Conclusion

  The importance of compression therapy is well known by wound care practitioners. This fact needs to be explained to our patients and reinforced on a regular basis as it is more often than not, a lifestyle change and not simply a short-term treatment option. Through assessment of our patients and their vascular system is paramount when appropriately prescribing compression be it via wrap, hosiery or pumps. All staff members should be trained not simply on application of a wrap or garment but on the physiology surrounding the disease process. All clinicians should understand why we are treating the patient using these methods and the expected outcomes. Demonstrating clinical competency should be a mandate in each clinic so that patient adherence and goals of treatment are optimized. Full compliance with compression therapy depends on staff knowledge and skill as well as making sure that the patient is a full partner in the treatment process.

Val Sullivan is a Physical Therapist and a board Certified Wound Specialist through the American Academy of Wound Management. She is the Clinical Manager of Advanced Wound Care Services and Hyperbaric Medicine at Capital Regional Medical Center in Tallahassee, FL. A clinician and educator in Wound Management for the past 16 years, Val has lectured and presented on local, regional and national levels as well as publishing articles on wound management and education.

As a member of the American Physical Therapy Association (APTA) and its Section on Clinical Electrophysiology and Wound Management, Val is the Practice Committee Chairperson for the Wound Management Special Interest Group. She has been an active member of the Association for the Advancement of Wound Care, serving on the Quality of Care Task Force. She is also a member of multiple Clinical Advisory Boards and is on the Board of Directors of the Save A Leg, Save A Life Foundation.