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Interface Pressures – what do they mean to and for the Patient? Science meets clinical Practice Jeanette Muldoon Independent Clinical Commercial Researcher ICC Gothenburg 2019
Interface Pressures – what do they mean to and for the Patient?
Science meets clinical Practice
Jeanette Muldoon Independent Clinical Commercial Researcher
ICC Gothenburg 2019
Different needs for different stakeholders –
Researchers, Manufacturers, Clinicians, Patients The healing cascade
Different needs for different stakeholders – Researchers, Manufacturers, Clinicians, Patients – The healing cascade
Science of compression – What does it mean for each stakeholder –pressures, stiffness, tolerability, clinical effectiveness, lifestyle choices
Method
Literature review of science and clinical practice
Informal interviews with nurses in the UK and physical therapists from the USA. Both groups manage patients with vascular and lymphatic conditions
Clinicians provided patient feedback - how do patients see their care?
Do patients, relatives, carers or practitioners apply the device?
Factors that affect interface pressures
• Measurement method – Picopress is the most reliable (Partsch, Mosti 2010)
Sensor type, position of sensor, position of subject, time of test
• Compression materials – pressure, stiffness, amplitudesbandages – non cohesive, cohesive, adhesive, elastic, non elasticstockings – circular knit, flat knit Wraps, night time garments
• Application method, padding underlayer, layering and applier skills
• Patient and on-limb factors – size, tissue texture, muscle tone, underlying conditions, ankle and general mobility
Measurement methods, compression materials
Science that relates to real life Balancing effectiveness with tolerability
Elasticity (resistance) in bandages affects pressure (MacDonald et al 2003, Partsch 2007).
With elastic bandages EV and EF are below the normal range even when applied with high stretch, producing a resting pressure that is barely tolerable.
During standing and exercise, pressure increases are higher with inelastic bandages compared with elastic bandagesResting pressures are lower for tolerability (Mosti et al 2008)
Pressures drop after applicationOedema reduction and material fatigue contribute to pressure drops
Compression hosiery – Stiffness is an important factor Compression wraps – ability to self apply
Picopress readings – Wraps compare well with SSBNote pressure drops and amplitudes
Compression Wrap * Compression Wrap * Cohesive SSB **
0hr 24 hr 0hr and at 15 minImages -J Muldoon and H Charles
Images - J Muldoon and H Charles *ReadyWrap ** Actico Bandage
Factors affecting interface pressures - Application method
• Layering and overlap taking into account friction caused by cohesive / adhesive materials (Partsch 2007)
• Figure of eight, spiral, Fischer technique, Putter technique (Charles 2012)
• Padding material and targeted pressures (Hopkins et al 2011)
• Applier skill (Partsch 2007)
Compression wraps
If applied by patients they may be loosened / removed and reapplied for comfort e.g. at night or at points during the day using the compression interval regime (Bock , Ehmann 2018)
In this case pressures will be similar to when first applied
Reassessment should be done to monitor therapeutic effects
Lymphoedema bandaging Healthy legs n=18; Lymphoedema legs n=6Whitaker et al 2015
0 Hours Mean Supine Mean Standing Mean SSI
mmHg mmHg
Healthy legs 69 (44-85) 87 (49-128) 19 (4-43)
L Patients 65 (60-71) 82 (68-98) 16 (8-36)
24 hours
Healthy legs 42 (29-52) 58 (37-82) 15 (6-30)
L Patients 32 (22-39) 47 (29-65) 15 (7-27)
Pressures are just a number and may not always relate to clinical conditions
Factors affecting interface pressures Patient factors
• Palliative care: oedema reduction may be less important, or the patient’s ability to tolerate compression may diminish (Towers et al)
• Tissue density. Pressures on healthy volunteers differ to those of lymphoedema patients due to tissue changes (Whitaker, Williams et al 2015)
• Skin folds and irregular shapes that need padding for the bandage to make contact (Graham 2007) or extra strapping (Hopkins 2011)
• Limb size (MacDonald 2003), patient’s height and foot size (Hopkins 2017)
• Foot pump action (Lindsay et al 2008)
• Wound and skin condition. Infection, pain, excess fluid management
Pitting oedema, Skin folds, irregular limb shape, exudate damage, wound site, guttering and pruning after compression
(pictures by kind permission of C Graham, D Campbell, S Hampton, H Charles)
Clinical decision making
Very little research into clinical decision making and patients’ preference for in depth knowledge of compression. Studies relate mostly to all healthcare
• Not all patients want to be involved in decision making. Each patient must be assessed individually (Levinson W, 2005 USA)
• Clinicians often overestimate patients’ willingness to assume an active role (Florin J 2006 Sweden)
• Many patients can’t participate in shared decision making due to lack of knowledge
• Concordance with compression is poor and patients need to be convinced of the importance of wearing compression Dereure O 2013 France
Interviews
“ I just tell my patients what they need to know to make their legs better. This involves all aspects of care. I do not wish to confuse them”
“ Patients are told that the bandages / wraps / stockings will feel firm and supportive I try to avoid using the word tight”
“ If patients are given the right information and they can see improvements, they are more likely to be concordant”
“With the right compression and simple instructions patients can be self caring”
“ Reassessment is more important than only looking at pressures”
Clinician interviews
“We only have 15 minutes per leg per episode of care. It’s important for patients to have the right messages about treatment and application without complicated instructions. ” We have taught patients to apply wraps themselves”
“Some patients do wish to know about what is being applied and how it works. We find booklets are useful”
“We need to use language that patients understand. Most patients do not understand science. Many everyday nurses do not understand pressures / stiffness
Comments from Patient: “Please don’t blind me with science. I just want to know what will happen to me” “I want to be able to go to the shops”. “I want to be able to wear my shoes”.
Summary
Manufacturers - pressures and stiffness for product development and details of pressures, stiffness, clinical evidence, instructions, indications for use and training.
Clinicians - technology underpinning each device, understand positioning for clinical decision making and how to use effectively within a treatment pathway. Explain in simple terms to patients for concordance and to encourage patient reporting outcomes for continued assessment.
Patients need to understand their conditions, what the treatment will be and what this will mean for them to facilitate near normal lifestyles and a good quality of life long term.
References
Partsch H, Mosti G (2010). Comparison of 3 portable instruments to measure compression pressure. Int. Aniology, Oct 29 (5): 426-30
MacDonald J, Sims N, Mayrovitz H (2003) Lymphedema, Lipedema and the open wound. The role of compression therapy. Surg. Clin N Am;83: 639-58
Partsch H (2007) Assessing the effectiveness of multilayer inelastic bandaging. Journal of Lymphoedema Vol 2, No 2
Mosti G, Mattaliano V, Partsch H (2008) Inelastic compression increases venous ejection fraction more than elastic bandages in patients with superficial venous reflux. Phlebology; 23:287–94.
Mosti G, Cavezzi A Partsch Campana (2015) Adjustable Velcro Compression devices are more effective than Inelastic Bandages in reducing venous oedema in the initial treatment phase: A randomised controlled trial. European Society for Vascular Surgery.
Hopkins A, Bull R, Worboys F (2017) Needing more: the case for extra high compression for tall men in UK leg ulcer management. ICC mtg 2016 Vol 6 No 1
Towers A, Hodgson P, Shay C, Keeley V (2010) Care of palliative patients with cancer-related lymphoedema B J of Lymph 5 (1):72-80
Joseph-Williams 2014 Knowledge is not power for patients: A systematic review and thematic synthesis of patient-reported barriers and facilitators to shared decision making Patient Education and Counseling Vol 94, Iss 3, Pages 291-309
References Continued
Hopkins A, Worboys F, Bull R, Farrelly I 2011 Compression strapping: the development of a novel compression technique to enhance compression therapy and healing for ‘hard-to-heal’ leg ulcers Int. Wound Journal 474-483
Charles, H 2012 The function and composition of next generation bandages Wounds UK Vol 18 (1) 16-19
Bock K, Ehmann S 2018 Compression choices EWMA poster Kraow
Graham C, Johnston L, Burke M (2007) Management of a Patient with Lymphoedema Poster Presentation at Wounds UK Conference, Harrogate
Dereure O, Vin F, Lazareth I, Bohbot SCompression and peri-ulcer skin in outpatients’ venous leg ulcers: results of a French survey Journal of Wound Care Vol 14 (6)
Florin J, (2006) Patient participation in clinical decision‐making in nursing: a comparative study of nurses’ and patients’ perceptionsJournal of Clinical Nursing Volume 15, (12)
Levinson W, (2005) Not all Patients want to Participate in Decision Making Journal of General Internal Medicine, Volume 20, (6)
