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Helpful advice relating to compression treatmentin venous disorders

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The aim of this brochure is thereforeto set out the relationships betweenthe disease patterns and the healing-promoting effects of a compressionbandage in order to bring about anunderstanding of the sense and pur-pose of this measure. It may make iteasier for you to find the necessarystaying power and ability to activelycooperate in order to become symp-tom free.

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Published byPAUL HARTMANN AG89522 HeidenheimGermanyhttp://www.hartmann.info

© PAUL HARTMANN AG

Dear patient,

The treatment of the so-called “leg orvenous disorders” is often veryprotracted and requires a great dealof patience and discipline. This fact isnot always easy for the patient tocope with, which frequently alsoresults in medical instructions onlybeing partially followed, or the treat-ment even being discontinued.Particularly affected by this iscompression treatment as applyingthe elasticated bandages is generallyconsidered complicated and wearingthe bandage or the stocking is felt tobe a nuisance. However, withoutcompression there is no noticeableimprovement in venous disorders.

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These transport the blood now carry-ing waste material to the right ventricle. From there it reaches thepulmonary circulation where it givesoff the carbon dioxide resulting frommetabolisation, is enriched with freshoxygen and returns to the circulationvia the left ventricle.

However, within the blood circulationsystem the veins do not only havetransporting tasks to fulfil. They alsoregulate the circulating quantity ofblood, i.e. they must always supplythe heart with sufficient blood,whereby the quantity varies depend-ing on the respective physical stresson the body (e.g. at rest, workingmuscles, shock etc.). For this reasonaround 85 % of the total quantity ofblood is found in the veins which inturn can only store it as they are veryelastic and easily extensible.

Whereas the blood in the arteries isdriven forward by the pumpingaction of the heart, various otherauxiliary mechanisms are required fortransporting it back as the cardiacoutput is no longer sufficiently effec-tive in the venous part of the circula-tion. This applies particularly to thereturn of blood from the legs. Due to the upright posture ofhumans the blood has to be“conveyed uphill”, so to speak,against gravity to the right ventricle.

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In order to be able to understandhow venous disorders come aboutsome knowledge about the bloodcirculation system is required first ofall. Its main task is to supply themuscles and tissues with oxygen andnutrients and to remove the resultingmetabolic waste, respectively.

To this end the oxygen and nutrient-rich blood is conveyed from the leftventricle via the arteries andarterioles to the outermost regionsof the body, the capillary areas. Capillaries are ultra-fine capillaryvessels that allow oxygen to beexchanged and at the same time actas links between the arteries andveins. Oxygen and nutrients arepressed through pores in the capillarywalls and, vice-versa, breakdownproducts are absorbed again by thecapillaries and transferred into theveins.

Schematic presentation of theblood circulation:1) - left ventricle, 2) - arteries, 3) - capillary area, 4) - veins, 5) - right ventricle, 6) - pulmonarycirculation

How do venous disorders comeabout?

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If the veins or venous valves arealtered by certain causes andinfluences, they lose the ability ofadapting elastically to the varyingquantities of blood. The veins remainpermanently dilated and the venousvalves can no longer close. Thereturn of blood to the heart is consid-erably impaired resulting in danger-ous blood congestion in the veins.Fluid and metabolic waste materialsthat have not been removed collectin the body tissues bringing aboutincreasing “swamping”. Thiscondition is initially experienced asheavy, swollen legs. Then skinchanges gradually become visibleuntil finally, if not treated in time,eczema and lower leg sores, the so-called "ulcerated legs", appear.

The causes which bring about suchpathological changes in the venoussystem can be various in nature. Theyinclude hereditary or age-related lossof elasticity of the vein walls, hormo-nal influences during pregnancy and,in the case of predisposition bytaking the “pill” (oral contraceptive),changes in the coagulation propertiesof the blood with the risk of clot formation and subsequent phlebitis,e.g. as a result of operations, injuriesor serious infectious diseases.

However, all these processes areaccelerated by a civilisation-relatedphenomenon which is lack ofexercise. The useful effect of themuscle vein pump is so impaired bythis that even minor additionalstresses can often lead to serious disorders in the venous system.

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Here the muscle vein pump comesinto action as the most importantand effective aid to transporting.During natural movement the calfmuscles contract and relax inrhythmic alternation. During contrac-tion the veins are constricted and the blood is forced upwards. But inorder for it not to fall back again, theveins have venous valves at regularintervals that can close like a sluicegate so that the blood can only flowin one particular direction, i.e.towards the heart. When the musclesrelax the veins expand again and thepressure in the emptied vascular sections falls, thereby sucking inblood again which during the nextcontraction is again forced upwards.

The principle of the muscle veinpump:When the muscle is relaxed the relevant vein section fills with blood(1) which during the next contractionis again transported further upwards(2). The venous valves prevent theblood from falling back.

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In principle in all forms of venousdisorder there is the problem thatalthough the secondary symptomscan be influenced, the causes of thedisease itself cannot. For example, inthe case of superficial varicose veinsan improvement can be broughtabout by sclerotization or surgery,but the trigger factor, such as predis-posed loss of elasticity of the veinwalls however remains and requiresconstant medical supervision.

The aim of every venous treatment,particularly in the case of diseases ofthe deep veins that cannot be oper-ated on, is therefore to eliminate theacute effects such as congestion,ulcers etc. and to prevent progressionof the disease. Indispensable in thiscase is the correct compression of theleg: during the acute treatment witha compression bandage andsubsequently, in order to maintainthe achieved results, with a bandageor an individually adapted compres-sion stocking.

To support this, vein drugs are usuallyprescribed that can help make thedevelopment of congestion more difficult or in the case of existingoedemas to promote the eliminationof fluids.

Last but not least adopting an appropriate lifestyle protects againstprogression of the disease.

Schematic presentation of thevenous system of the legs1) - superficial veins (dark blue), 2) - deep veins (light blue), 3) - communicating veins

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The various disease patterns ofvenous disorders are also assessed inaccordance with the area of the veinswhich is affected by the disorder,how severe it is and how long itlasts. In the case of diseases of thesuperficial veins, the so-calledvaricose veins or varices occur, whichare easily recognised by their typicalwinding course. If such diseasesremain restricted to the superficialsystem, the healthy veins deeperdown are usually able to make up forthis deficiency in the return of blood.However, if the disorder spreads viathe communicating veins into thedeep veins within the leg muscles,ever more serious disease patternsoccur, in the worst case up to the formation of ulcers.

The situation where a disease of thedeep veins is caused by a previousleg thrombosis has just as seriousconsequences. During the “healingprocess” scarring changes occur onthe vein walls that also hinder thereturn of the blood to the heart. Theconsequences such as blood conges-tion and inability of the venousvalves to close in time again lead toswamping of the tissue and to legsore.

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In a pathologically dilated vein thevenous valves can no longer fulfiltheir valve function. The blood fallsback resulting in congestion andfinally swamping of the tissue.

By way of the compression bandagethe veins are constricted, the venousvalves close again, the return of thevenous blood is normalised.

However, at the same time the compression bandage acts as a firmsupport for the leg muscles and thereby helps and improves the action of the natural vein pump, themuscles and joints. In conjunctionwith movement the compressionbandage therefore brings perceptiblerelief as soon as it is applied.

How does the compressionbandage work?

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The effect of a compression bandageis easy to understand. It encloses theleg with such firm pressure that thepathologically dilated veins are constricted. In this way the venousvalves can close again, the flow-rateof the venous blood increases andthe return is normalised.

Mit der wieder funktionierendenRückströmung des Blutes werden

With the restored return flow of theblood the fluid accumulated in thedamaged tissue and the waste products are also removed. Swellingsand oedemas disappear. Open ulcerscan heal. The risk of new inflamma-tions and blood clots occurring isconsiderably reduced.

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� Unroll the bandage directly on theskin during application (4) and pull both edges evenly in the direction of application. Never pullaway from the leg otherwise the two woven edges are unevenly tensioned and strangling furrows are created (5).

� The bandage is picked up so that the rolled up part of the bandage is on top and points outward. Onlyin this manner is it possible to unroll the bandage on the leg (3).

General tips for applying a compression bandage

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Applying a well-fitting compressionbandage is an art that can be learnedbut which admittedly requires a certain amount of practice. Thefollowing tips are intended to assistyou and to help avoid makingmistakes.

� The compression bandage must beapplied in the morning immediatelyafter getting up. Do not walk around first otherwise the decon-gestion of the leg that has taken place during the night is cancelledout. Incidentally, for effective decongestion you should raise your legs during the night, where-by the hollows of the knee should not sag. Therefore raise the bed, a wedge at the foot end is not enough.

� To apply the bandage the foot must always be placed at a right angle (1).

� Depending on the size and circum-ference of the leg, 8 cm or 10 cm wide bandages for compression bandages are best suited on the lower leg (2).

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� Generally finished bandages remain effective over a longer period of time when a second bandage is applied over the first bandage in the opposite direction of application (8).

� It is beneficial if another person (relative, neighbour) can apply thebandage for you as in this way thepressure distribution and fit of the bandage can be better regulated than when applying it yourself.

Seen overall, a properly appliedbandage should give you a feeling ofa firm hold, and the pain mustrecede. If this is not the case or ifeven new pain occurs that does notdisappear when walking, thebandage must necessarily be removedand then reapplied.

Walking should be enjoyable again.And the more you move about in thebandage the better the treatmentsuccess. However, for this you do ofcourse need the right footwear thatfits well and has flat heels.Remember that with too high heelsthe joint muscle pump is brought toa standstill again.

Equally, sitting or standing too longshould be avoided. However if foroccupational reasons this cannot beavoided you should try to put yourlegs up every now and then or to dofoot exercises.

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� The pressure exerted by the bandage must be strongest in the ankle area and gradually decrease towards the knee. Too great pressure in the calf area causes dangerous congestions. Therefore tighten the bandage more at the ankle and decrease the pressure slowly in accordance with the shape of your leg (6).

� How to check if the correct level ofcompression has been produced: when the bandage is initially applied the toes should take on a slight bluish colour, but return again to their natural skin colour when walking.

� Also always covered by the bandage is the foot area from the metatarsophalangeal joints and the heel so that all congestions can only be pressed upwards (7).

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and afterwards via the lower edgeinto the arch of the foot. After a furt-her circular turn over the midfoot,the bandage is taken back to theankle across the ankle joint line, …

and then following the contour ofthe leg it encloses the calf in steepturns.

It should be noted that the bandageis unrolled with the hand flat on thelower leg and only tightened in thedirection of unrolling. The bandagemust not lose contact with the skin.

Applying a compression bandage

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Keeping the foot at right angles thefirst turn of the bandage starts at themetatarsophalangeal joints and runsoutwards.

After 2 – 3 turns around the midfoot,the bandage then covers the heeland comes back to the instep overthe medial malleolus.

With another two turns the edges ofthe first heel wrap are additionalfixed. The bandage initially goes overthe top edge around the ankle, …

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Then the bandage is taken onceagain over the midfoot and then inthe same manner as the first one,steeply upwards and then backagain.

The finished bandage is secured withadhesive tape.

The bandaging technique illustratedhere is a modified Pütter bandageconsisting of two short-stretchbandages applied in the counter-rotating technique. This techniqueensures high strength and betterdurability of the bandage.

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From the hollow of the knee, thebandage is wrapped one time aroundthe leg and from there follows thecontour of the leg back down, covering any gaps in the bandage.

The second bandage is in the opposiste direction from outside toinside on the ankle, the first turn running over the heel to the instep.

Two further turns fix first the upperand then the lower edge of the heelwrap.

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Long-stretch bandages, such as Lastodur straff (tight) and Lastodurweich (soft), have the highest exten-sibility of all bandage materials. Theyadapt well to the shape of the legand exert a uniform continuous pressure that acts on the superficialvein area. Bandages comprisinglong-stretch bandages are thus wellsuited for follow-up treatment afterthe acute symptoms have eased offas well as for treatment to maintain the achieved condition. The bandage can be applied by the patient himself/herself.

In principle, however, in the case ofbandages consisting of long-stretchbandage it must always be ensuredthat they are removed at night andafter longer periods of rest as otherwise the fine blood vessels inthe skin are too strongly compressedby the high continuous pressure.

Facts worth knowing aboutcompression bandages

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An effective compression bandagemust firmly enclose the leg so thatthe pathologically dilated veins arenarrowed. The more rigid thebandage material is the stronger thepressure that is exerted inwards onthe veins.

The most rigid are zinc pastebandages. After application, theyproduce semi-rigid, unyielding band-ages. Because of their non-elasticproperties, among all the bandagingmaterials these are the ones whichcan offer the greatest resistance toactive muscles. They therefore exert a working pressure so intense that itextends deep into the subfascialregions and rapidly reduces swelling.The zinc paste bandage is thereforeused both in the acute phase oftreatment as well as to maintain theachieved results and can only beproperly applied by a physician.

Short-stretch bandages, such as Lastobind, Idealhaft or the Pütterbandage, exert an equally high pressure. Due to their relatively lowextensibility they produce a highbandage compression which is alsosufficient to influence the pathologi-cal conditions in the deep vein areas.

They also adapt well to the changesin the circumference of the leg as thecongestion reduces.

Bandages consisting of short-stretchbandages are used to initiate andcontinue treatment, e.g. untilcomplete decongestion or healing ofan ulcer. Such bandages are appliedby a physician, but after appropriateinstruction during the course of treatment this can also be learnedand carried out by the patient or ahelper.

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Dear patient,

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As a supplement to the personalexplanations by your physician, thissmall brochure is intended to giveyou a comprehensive overview of thecauses, the consequences and thetreatment of venous diseases. Anoverview that makes it clear thateven with all the medical skillavailable your own active cooperationis essential for the success of thetreatment and that without compres-sion there can be no decisiveimprovement in venous leg disorders.

Particularly important in this connec-tion is the aftercare that is usuallyrequired even after the alleviation ofthe acute symptoms and after epidermisation of an ulcer. After all,it is a case of you as the patientaccepting the fact that in spite ofeverything you are not by any means“cured” as the deep-down underlyingproblem cannot be eliminated.

Thus everything would start all overagain if the development of new congestions is not prevented by thecompression bandage or the com-pression stocking.

Even if wearing a bandage or astocking is not very pleasant incertain situations, compared withrenewed symptoms and pain it finallyremains the lesser of two evils.

If this brochure has been able to contribute to forging a greaterunderstanding for the need for compression treatment and hasencouraged you to assist in deter-mining your future medical well-being yourself, then it has fulfilled its intended purpose.