Compression therapy

Types of compression devices

Współczesna kompresjoterapia opiera się na zastosowaniu różnych wyrobów uciskowych, które można sklasyfikować według ich elastyczności, konstrukcji oraz przeznaczenia. W codziennej praktyce najczęściej stosuje się:

• bandaże kompresyjne krótkorozciągliwe: zwane potocznie „sztywnymi”, charakteryzują się ograniczoną elastycznością, co oznacza, że rozciągają się jedynie w minimalnym stopniu. Są produkowane z materiałów zawierających niewielką ilość włókien elastycznych. Dzięki temu wyróżniają się zdolnością do generowania wysokiego ciśnienia roboczego, które jest szczególnie odczuwalne podczas aktywności fizycznej, np. w trakcie chodzenia. Z kolei w stanie spoczynku (np. podczas siedzenia) zapewniają niskie ciśnienie spoczynkowe, co pozwala na komfort Pacjenta i minimalizuje ryzyko nadmiernego ucisku w bezruchu. Tego typu bandaże znajdują szerokie zastosowanie w terapii różnych schorzeń układu krążenia i limfatycznego. Są szczególnie skuteczne w leczeniu obrzęków limfatycznych, żylnych oraz mieszanych. Wykorzystuje się je również w bardziej zaawansowanych przypadkach, takich jak aktywne owrzodzenia żylne, gdzie wymagane jest intensywne i szybkie działanie terapeutyczne w celu przyspieszenia gojenia ran oraz poprawy mikrokrążenia.

• long-stretch (elastic) bandages: are characterised by high elasticity, are made of materials containing a high proportion of elastic fibres, generate lower working pressure and higher resting pressure; they are mainly used for moderate oedema, for venous prophylaxis and in situations where greater comfort is needed; this subgroup includes elastic bandages and some hosiery (knee socks, stockings, tights).

• multi-layer systems: are advanced systems used in compression therapy by experienced personnel; they consist of several layers (usually 2-4) with different properties that work together to form an effective compression system. Multilayer systems act like short-stretch bandages, generating high pressure during movement and lower pressure at rest, but due to their special design they remain in place for up to 5-7 days. They are particularly recommended for patients with venous ulcers of the shin (C5-C6).

• knee-high socks, stockings and compression tights: are the most commonly used graduated compression garments by Patients; these garments are made of elastic materials that provide adequate compression and comfort; they are knitted in the round. These types of devices must be precisely tailored to the dimensions of the Patient's leg.
• adaptive compression systems (medical adaptive compression systems, MAC) are a relatively new category of compression devices; they combine the features of traditional bandages and compression stockings. The term 'adjustable compression wrap systems' is also common in international nomenclature.

At the Phlebology Clinic, we use products from renowned manufacturers such as: MEDI, SIGVARIS and JUZO. These are companies that have specialised in the production of top-quality compression products for several decades.

Tribulation class - what is it?

Compression products are classified by compression forcewhich they exert on the limb. The compression force is given in millimetres of the column of mercury (mmHg). The European Compression Classification System for compression garments was developed to unify standards and facilitate the selection of the appropriate compression class (CCL). It is important to remember that compression is not measured directly in the tissues, but at the interface between the compression garment and the skin (so-called interface pressure).

In European nomenclature, we distinguish between four compression classes:

• CCL1 (18-21 mmHg - light compression): products of this type are mainly used for prophylaxis, slight oedema and a feeling of heaviness in the legs.
• CCL2 (23-32 mmHg - medium compression): compression strength recommended most commonly for venous disease, pregnant women, secondary prevention, moderate oedema and after intravenous and surgical procedures on the venous system.
• CCL3 (34-46 mmHg - high compression): Products with this compression strength are used in the treatment of advanced venous insufficiency and complicated forms (C4-C6 according to CEAP) and post-thrombotic syndrome.
• CCL4 (from 49 mmHg - very firm compression): compression strength used in severe cases of lymphoedema and in advanced venous conditions.

Ciśnienie wywierane na kończynę dolną przez wyroby uciskowe jest stopniowane. Najwyższe wartości ucisku stwierdza się w okolicy kostki, gdzie zazwyczaj rozpoczyna się działanie terapeutyczne, wspomagające przepływ krwi i limfy wbrew sile grawitacji. Następnie ciśnienie to zmniejsza się stopniowo w kierunku dogłowowym, osiągając najniższy poziom na wysokości około jednej trzeciej górnej części uda. Taki gradient ucisku zapewnia optymalne wsparcie dla układu żylnego i limfatycznego, ułatwiając powrót krwi do serca oraz redukując zastoje płynów w kończynach dolnych.

Poza podziałem na compression classes (CCL) Compression garments can differ in their material (elastic, non-elastic), weaving construction (round- or flat-weave) and length (knee-length socks, stockings, classic tights or maternity tights).

In compression therapy extensibility of the product (elastic bands or finished hosiery) is defined quite simply. Extensibility refers to the ability of the material from which the product is made to stretch under force and return to its original shape.

A distinction is made between 3 main stretching levels: small (below 70% output length), medium (in the range of 70 to 140%) and large (above 140%).

Highly elastic products (long stretch) generate less working pressure (when moving) and those with low elasticity (short stretch) generate higher working pressure.

Round products (used most often) are manufactured on cylindrical machines and feature a uniform, seamless construction, which makes them more flexible and comfortable to wear.

Flat products on the other hand, are made on flat machines, have an additional seam and, although thicker and stiffer, can be made to measure according to the patient's individual measurements. This is particularly important with atypical limb shapes and in advanced stages of venous disease, lymphoedema, fat oedema or with mixed swellings (very common in daily phlebology practice), such as venous-lymphoedema.

Indications for use of compression therapy

Compression therapy is used in many clinical situations. The most common indications for its use include:

• prophylaxis of venous disorders (people with standing, sitting, long journeys);
• oedema in venous insufficiency of the lower limbs;
• advanced venous disease (stages C4-C6 according to CEAP;
• swelling in pregnancy;
• following surgery on the venous system;
• prevention of venous thrombosis after trauma, immobilisation (e.g. after fractures, orthopaedic, neurosurgical or gynaecological operations);
• venous thrombosis (acute and subacute phase);
• prevention of post-thrombotic syndrome;
• lymphoedema (lymphatics);
• fatty (lipid) oedema.

Compression devices used in the first stages of venous disease

In the treatment of the initial stages of venous insufficiency (C0-C2 according to CEAP) shall in principle be used products circular (knee socks or compression stockings) of compression class CCL1 or CCL2. These types of high-elastic products have an intermediate effect between low- and high-stretch bandages, providing higher resting compression than flat compression products. The knitted fabric from which they are made is stretchable and elastic at the same time, so they easily return to their original form when stretched, generating resting compression regardless of movement, even when sitting or standing.

Venous hypertension and the role of primary prevention in the development of venous disease

Venous hypertension is a condition of increased pressure in the venous system of the lower extremities, which is a major cause of the development of chronic venous disease. Under normal conditions, when walking, the pressure in the superficial veins falls from about 80-100 mmHg (resting pressure) to 20-30 mmHg (working pressure) due to the efficient work of the calf muscle pump and venous valves. When this mechanism fails, the working pressure remains above 40 mmHg, initiating adverse changes in the venous vessels.

Early stages of venous disease (CEAP C0-C2) is the ideal time to introduce compression therapy. The use of compression products as early as the first symptoms, such as the feeling of heaviness in the legs or the appearance of vascular spider veins (C1)It helps to effectively reduce venous pressure. Compression therapy supports the muscle pump and counteracts the backlog of blood in the shin veins. Compression products of the second compression class (CCL2: 23-32 mmHg) are the gold standard in the prevention of the development of varicose veins (C2) and progression of venous disease.

Sports compression therapy

Sports compression therapy differs slightly from classic medical compression therapy, mainly in purpose and compression strength. Compression products used in sports are mainly aimed at improving performance, speeding up recovery and preventing injuries. The compression force used in sports compression is usually lower than in medical products and is in the range of 15-25 mmHgwhich corresponds to compression class I according to the European CCL scale. This compression strength provides comfort during physical activity while supporting muscle function and improving blood flow, in contrast to higher compression classes (CCL 2-4) used in the treatment of venous disease.

Nowadays, sports compression therapy is an important part of the training of both professional and amateur athletes. Properly selected compression products not only improve performance during exercise, but also speed up recovery and reduce the risk of injury.

In some sports products, especially those designed for post-exercise recovery, slightly higher compression values (up to 20-30 mmHg) can be found. These types of recovery products are mainly recommended after intense exercise rather than during activity.

At the Warsaw Phlebology Clinic we have been recommending for many years sports products with name of CEP (Medi launched them in 2007). It is a line of compression products dedicated to active people, athletes, as well as patients who want to be more active and enjoy the full benefits of sport after having their venous disease treated at our facility.

CEP's product range includes. compression socks of varying lengths (reaching the ankle, calf, below the knee - our most frequently recommended), characterised by a special construction providing graduated compression with anatomical side fit and anti-abrasion technology.

At the Phlebology Clinic, we offer you a specialised selection of sports compression after a medical or nursing consultation. The selection always takes place after anthropometric measurements with their matching to the type of sports activity.

Compression therapy for long flights and travel

Long air journeys, especially those lasting more than 4-6 hours, can significantly increase the risk of developing deep vein thrombosis of the lower legs. Immobilisation in a seated position significantly reduces the work of the shin musculo-articular pump, which normally actively supports the return of venous blood to the heart. In addition, flexion of the legs at the knees and at hip level can lead to pressure on the large venous vessels, significantly slowing blood flow.

Reduced cabin pressure and the tendency to consume less fluid during the flight exacerbate these adverse phenomena, increasing blood viscosity and the risk of thrombus formation (especially in the intramuscular veins). Compression devices applied during travel, using the effect of resting pressure graded on the lower limbs (highest at ankle level, decreasing towards the thigh), improves venous blood flow towards the heart, prevents blood retention and the formation of oedema, and significantly supports the proper function of venous valves. All this significantly reduces the risk of thrombus formation.

Travel thromboprophylaxis is particularly recommended for people in high-risk groups. These include individuals:

• with varicose veins of the lower limbs;
• after a history of venous thrombosis;
• users of hormonal contraception;
• in pregnancy (especially from the 2nd trimester upwards);
• with obesity;
• following recent surgery or with limb immobilisation;
• oncology treatment.

At thromboprophylaxis for long journeys, the most common are: knee-length socks or elastic stockings with graduated compression (CCL1 or CCL2), individually tailored to the person's legs (so-called made-to-measure products).

Compression therapy after intravenous and simple surgical procedures

The use of compression devices after venous surgery is one of the key elements influencing the therapeutic effect and the patient's comfort in the early postoperative period. Properly administered compression therapy after venous procedures:

• reduces pain;
• significantly reduces the risk of complications (venous thrombosis and haematomas);
• supports the healing process of the treated tissues;
• accelerates the beneficial cosmetic effect (reduces the risk of skin discolouration).

Recommendations for the use of compression after venous surgery in the Department of Phlebology.

Type of compression device:

• compression stockings - models providing compression at a compression class II level (CCL2) are recommended; compression stockings are always selected by qualified nursing staff, just before the procedure itself;
• compression and adhesive bandages - can be used supportively on the first or second day after surgery; especially for larger vessels or more invasive procedures on the venous system.

Duration of use of compression devices in the postoperative period:

• After minimally invasive intravenous procedures such as intravenous laser therapy (EVLA), vein taping or sclerotherapy, it is recommended to wear compression devices for 5-14 days, including continuous use for the first 24 hours after the procedure;
• after mini-flebectomy combined with intravenous procedures, compression should be applied for 14 to 21 days; it all depends on the extent of the intervention and the doctor's specific recommendations. For the first day or two after surgery, we additionally use adhesive bandages to significantly reduce bruising and postoperative swelling.

Compression devices are best worn early in the morning, before getting out of bed or after a short rest. Carefully spread the product over the leg to avoid creases that can cause discomfort or skin damage.

If you have problems putting the garment on, you should get help from your family or use special appliances (applicators) to make it easier to put the garment on, such as a glide foot, butler, Doff N'Donner or Easy-Slide. Compression garments should be washed regularly, according to the manufacturer's instructions, to maintain their elasticity and compression properties. The use of softeners, which can damage the elastic fibres, should be avoided.

Compression therapy in pregnant women

Pregnancy is a special period in a woman's life, also from a venous point of view. Hormonal changes, increased body weight and a significantly enlarging uterus significantly affect the functioning of the venous system as a whole, leading to an increased risk of venous insufficiency and venous thrombosis. In addition, during pregnancy there is an increase in the volume of circulating blood and a weakening of vessel walls, which promotes swelling, a feeling of heaviness in the legs and the appearance of varicose veins in the pelvis, intimate area and on the legs. Properly selected and applied compression therapy not only effectively prevents complications, but also reduces swelling, improves circulation and significantly increases the comfort of life of the mother-to-be, allowing her to function better on a daily basis.

Why is the use of compression therapy in pregnancy so important?

– prevention of limb swelling - The increased circulating blood volume in a pregnant woman and adverse hormonal changes (increased levels of gestagens and oestrogen) often lead to oedema, especially in the legs and ankles. Compression therapy - in addition to improving venous outflow - additionally reduces limb oedema by reducing fluid filtration pressure in the tissues and promoting lymph outflow from the lymphatic vessels.

– support of venous blood circulation - an enlarged abdomen, the uterus often impedes the normal outflow of venous blood at the level of the iliac vessels and the inferior vena cava drainage; this is compounded by the phenomenon of pelvic venous insufficiency, which together overload the venous system of the lower limbs. The compression exerted by compression garments promotes the return of venous blood towards the heart, preventing excessive stasis in the venous vessels. This also reduces the development of varicose veins on the legs. 

– protection against venous thrombosis - pregnancy is a period of increased risk of deep vein thrombosis superficial thrombophlebitis; compression therapy improves blood flow and prevents blood stasis, which significantly reduces the risk of thrombus formation in the venous system. thrombosis

What compression products are recommended during pregnancy?

Compression therapy in the treatment of venous thrombosis

Venous thrombosis is a serious vascular condition requiring prompt management and comprehensive treatment, in which compression therapy plays a key role, both in the acute phase and in the prevention of late complications resulting from the so-called post-thrombotic syndrome.

The mechanism of action of compression therapy in venous thrombosis is complex. Properly administered compression therapy in acute thrombosis works by reducing the diameter of the venous vessels, which forces blood to flow and prevents backflow. This results in faster recanalisation of the lumen of the thrombosed vessel. In addition, the compression reduces inflammation in the vessel wall and surrounding tissues and effectively reduces tissue oedema.

Compression treatment is implemented as soon as possible from the onset of symptoms of venous thrombosis (together with anticoagulant treatment), after ruling out all contraindications, especially peripheral artery disease.

Compression selection in the treatment of venous thrombosis:

• w superficial thrombophlebitis we usually use compression class II (CCL2, 23-32 mmHg)
• w deep vein thrombosis Class II (CCL2) or Class III (CCL3, 34-46 mmHg) is used.

At hyperacute and acute phase of venous thrombosis (up to 2 weeks after its onset) - especially in the case of severe oedema - short-stretch bandages or multi-layer systems are sometimes used, as well as adjustable adaptive systems together with a base compression that provides an elastic device.
At subacute phase (2-8 weeks) and chronic (more than 8 weeks) of venous thrombosis is switched to compression stockings. In the Department of Phlebology, Class II compression (CCL2) is usually used at this stage.

The duration of compression therapy depends on the individual case:

• In superficial thrombophlebitis: 4-8 weeks
• in deep vein thrombosis: usually lasts a minimum of 4-6 months
• longer if risk factors persist.

Treatment monitoring should include regular limb circumference measurements (a sign of oedema reduction), assessment of complaints and follow-up venous Doppler ultrasound examinations.

Compression therapy in the prevention of post-thrombotic syndrome

Post-thrombotic syndrome is the most common late complication of deep vein thrombosis, affecting up to 40-50% patients who have developed deep vein thrombosis. Properly managed compression therapy can significantly reduce this risk.

In the prevention of post-thrombotic syndrome, early initiation of compression therapy is crucial. Compression therapy should be implemented as soon as possible after the diagnosis of venous thrombosis - ideally within the first 24 hours. In patients with advanced venous thrombosis, long-term compression therapy (CCL2, CCL3) is recommended for a minimum of 12-24 months after an episode of venous thrombosis. If PTS symptoms or risk factors persist, compression therapy is used indefinitely.

Compression therapy is a fundamental element of both the treatment of venous thrombosis and the prevention of post-thrombotic syndrome. Its effectiveness depends on early implementation, proper selection of the method and regularity of use (this element is the most difficult to implement by the Patient). Appropriate patient education and active participation in the therapeutic process are particularly important.