Compression Therapy Guidelines for Lower Extremity Oedema

Original Editor - Stacy Schiurring based on the course by Diane Merwarth

Top Contributors - Stacy Schiurring and Jess Bell  

Introduction

Compression therapy is the application of controlled external pressure to the affected treatment area. This controlled pressure functions to improve venous blood flow, prevent "blood pooling", and promote lymphatic draining. These therapeutic goals are achieved through the use of graduated compression, where the pressure is highest at the ankle and gradually decreases up the leg, effectively pushing fluid out of the tissues and back towards the heart. Compression therapy has a number of functions, including decreasing oedema, improving circulation, improving tissue oxygenation, and promoting wound healing. Compression therapy can also reduce pain as it helps to remove excess fluid from healing tissues.

Mechanisms of Compression Therapy

Compression therapy leads to increased venous return. The pressure applied through compression therapy helps to narrow the veins, which improves the circulation of fluid out of the tissues and extremities and back towards the heart. Compression also squeezes the lymphatic vessels, helping to remove excess fluid from the tissues. Thus, compression therapy leads to increased lymphatic drainage.

Under normal circumstances, the muscle pump action applies pressure to the veins, which aids in blood flow. Compression therapy enhances this effect by providing external pressure that supports muscle contraction.

Compression therapy for the lower extremities is designed to have a graduated compression, with the tightest pressure at the ankle. Pressure decreases gradually up the leg, ensuring that fluid is effectively pushed towards the heart.

By applying pressure to the tissues, compression therapy can reduce the amount of fluid accumulating in the interstitial spaces, leading to decreased oedema.

Compression Therapy in Clinical Practice

Oedema can occur in any part of the body, but it is most common in the legs and feet. A few common causes of oedema in the lower extremities include venous insufficiency, lymphoedema, heart failure, renal failure, cirrhosis, and trauma.

"... medical compression therapy should only be applied after a thorough screening of the patient to assess for contraindications or precautions for compression." -- Diane Merwarth, PT

Patient Assessment and Screening

Before initiating compression as part of a care plan, a thorough assessment should be performed that includes:

• wound location
• wound size and depth
• amount of drainage
• periwound skin condition
• presence of infection in the treatment area
• presence of pain
• circulation status
• underlying medical conditions that could affect wound healing

Circulation assessments can include: palpation of pulses (dorsalis pedis, posterior tibial), the ankle-brachial index (ABI) calculation and capillary refill and rubor of dependency testing. The following optional videos provide clinical demonstrations of these assessments:

Ankle-brachial index (ABI) and ankle-brachial pressure index (ABPI) are interchangeable terms for the same non-invasive diagnostic test that compares blood pressure measurements between the ankle and arm to screen for peripheral artery disease (PAD). While both terms describe the same test, the term ABPI is preferred in a wound care context, particularly when evaluating patients with leg ulcers to assess arterial circulation before determining appropriate treatment approaches. Both ABI and ABPI are used in this article.

Contraindications and Precautions to Compression Therapy

Peripheral Arterial Occlusive Disease

Using compression therapy in patients with peripheral arterial occlusive disease, especially when combined with venous insufficiency, reduces lower extremity oedema. Reducing peripheral oedema has the added benefit of improving arterial flow and tissue perfusion, reducing the severity of the arterial occlusive disease. When considering compression therapy for patients with peripheral arterial occlusive disease, providers must balance the risks and benefits of initiating compression and select the appropriate method of compression.

In cases of severe peripheral arterial occlusive disease, which is identified as an ankle-brachial pressure index (ABPI) of ≤ 0.5, ankle pressure < 60mmHg, or toe pressure < 30mmHg, compression therapy is contraindicated. While there are some reports of possible benefit with appropriate compression and careful monitoring, additional research is needed.

For moderate peripheral arterial occlusive disease, which is identified as an ABPI of 0.6-0.8, compression therapy with appropriate compression and careful patient monitoring may be considered (precaution).

Congestive Heart Failure

The severity of heart failure can be determined using the New York Heart Association (NYHA) classification system. The use of compression therapy exclusively for oedema management in individuals with heart failure has not been studied extensively. However, there is some support for its use in the management of venous insufficiency in the presence of heart failure.

In cases of severe disease, as indicated by NYHA IV, compression therapy is contraindicated. For moderately severe disease, precautions should be in place when using local leg compression therapy for people with stable congestive heart failure. These cases require very careful monitoring for patient safety.

Allergy to Compression Materials

Sustained compression therapy is contraindicated in patients with a confirmed allergy to compression materials. Additionally, caution should be used for patients with severe diabetic neuropathy or those at risk of skin necrosis due to poor circulation, although low-pressure compression might still be safe in some cases.

Potential Complications of Compression Therapy

Common complications associated with compression therapy include skin irritation, pruritus, discomfort and/or pain with compression use. Less common complications include forefoot oedema and lymphoedema. Rare but potentially health-threatening complications of compression therapy include allergic skin reaction, the spread of bacterial or fungal infection, soft tissue damage or necrosis (including limb necrosis), nerve damage, arterial impairment, venous thromboembolism, and cardiac decompensation.

Compression Therapy Guidelines

The following recommendations and precautions for medical compression therapy were proposed in a 2020 international consensus statement. The main goal of this report was to provide guidance on how to avoid common complications of compression therapy using proper assessment and screening techniques.

Patients receiving compression therapy should be screened for conditions that increase the risk of complications, and compression devices should be checked for proper fit and application. Contraindications for compression therapy must also be considered to prevent adverse effects.

Proper skin care is essential to prevent irritation, especially in patients with sensitive skin. This includes managing dryness and itching, which are common issues with compression therapy.

To prevent allergic reactions, compression devices should avoid potentially allergenic substances, such as certain dyes and materials (e.g. rubber).

It is essential to address discomfort and pain. If patients experience discomfort or pain, especially around the ankle or foot, the cause should be investigated, including checking for correct fitting, pressure levels, and proper bandaging techniques.

For patients developing swelling in the forefoot or toes, additional compression pieces should be considered to include these areas, particularly in cases of lymphoedema or immobility.

If bacterial or fungal infections occur beneath compression devices, they should be treated with appropriate topical medications. Systemic treatment may be needed if systemic symptoms like fever are present.

Consider modifying or adjusting the compression if compression materials contribute to infections (e.g. lateral pressure on toes causing interdigital maceration).

It is essential to avoid pressure on bony areas. Compression can exert higher pressure on sensitive areas (tibia, malleoli, fibular head), leading to tissue damage. These areas should be monitored for skin lesions, and extra padding under the compression may be needed to protect them.

To avoid soft tissue damage or necrosis, lower compression pressures should be used, and careful fitting and padding should be applied.

Precautions must be taken for people with frail skin. Older patients or those with frail, atrophic skin (e.g. due to ageing or polyneuropathy) should receive extra care, with padding and proper fitting to minimise the risk of skin damage.

Compression therapy may lead to nerve damage, particularly in areas like the fibular head. Ensure proper sizing, avoid excessive pressure, and monitor for symptoms like numbness or foot drop to manage this complication.

Before starting compression therapy, assess the patient's arterial circulation (e.g. ABI assessment). If peripheral arterial disease is present, compression may need to be avoided or carefully adjusted.

Compression therapy should not be used for patients with severe peripheral arterial occlusive disease (ABPI of ≤ 0.5, ankle pressure < 60mmHg, or toe pressure < 30mmHg), as it may exacerbate tissue damage. Inelastic compression materials may be safer in these cases.

In patients with impaired perfusion (ABI <0.9), closely monitor the effects of compression on arterial blood flow to prevent non-healing skin breaks, even with low-pressure devices.

After bypass surgery to improve peripheral arterial pressure, compression therapy can be used if it does not directly compress the bypass conduit. Extra caution should be taken with superficial bypasses.

Compression therapy can be risky for patients with cardiac insufficiency or heart failure, so precautions must be taken.

• Compression should generally be avoided in severe heart failure (NYHA IV) and used with caution in NYHA III. For these patients, mild compression is preferable and should be gradually increased. Clinical monitoring is essential to avoid complications like worsened heart function or fluid buildup in the lungs.
• Studies show that mild compression in less severe heart failure (NYHA I and II) is usually safe, with benefits like reduced swelling.

The use of compression therapy in acute venous thrombosis remains controversial, with current evidence showing mixed recommendations. Please note that the term acute venous thrombosis is a general term that describes when a clot forms in a vein. It includes both deep and superficial vein thromboses. While some studies suggest compression therapy may improve pain and swelling in people with deep vein thrombosis (DVT), the American Society of Hematology 2020 guidelines actually recommend against the routine use of compression stockings for these patients, citing very low certainty in the evidence. For superficial vein thrombosis (SVT), properly applied compression therapy is considered one of the standard therapeutic options alongside warm compresses and anti-inflammatory medications for symptomatic relief. The risk of dislodging clots causing pulmonary embolism (PE) is not supported by recent studies, making compression safe in these cases when combined with anticoagulant treatment. Healthcare providers should follow current professional guidelines and make individualised decisions based on patient-specific factors rather than assuming compression therapy is universally safe or recommended for all people with venous thrombosis.

For patients with skin infections or inflammatory conditions, like erysipelas, cellulitis, or vasculitis, compression may help reduce inflammation and swelling when combined with appropriate antibiotics. However, compression should only be used when the infection is under control to avoid complications.

For at-risk patients with "borderline indications" (those at risk but not definitively contraindicated for compression), compression therapy should be personalised, with careful assessment of the risks and benefits. For these people, using lower-pressure compression, modified materials, and padding can help reduce pressure risks while still providing therapeutic benefits.

Compression System Treatment Options

"... some compression is better than no compression, the pressure should be active during mobility and at rest, and the goal of therapeutic compression is to provide graduated compression with a bandaging system that is appropriately applied. -- Diane Merwarth, PT

Table 1. Comparison of compression therapy options

	Description	Benefits	Risks
Multi-layer compression systems	Come in two-, three-, or four-layer systems Provide graduated compression	More comfortable for patients to wear Can be left in place for up to 7 days Maintains constant pressure for up to 7 days with even pressure distribution Provides an adequate balance between resting and working pressures Protects against trauma Can be used on highly draining wounds Can be used for larger legs and active patients	Appropriate training is needed for proper application Cannot be reused Expensive
Short-stretch (inelastic) bandages	Bandages that stretch no more than 60% of their original length	Low resting pressure and high working pressure Tend to be more comfortable for the patient Reusable	Need to be applied at full stretch Require frequent reapplication as oedema in limb decreases Minimally absorptive, not suitable for wounds with medium to heavy drainage
Inelastic paste bandages	Zinc oxide paste boot Can be considered a multi-layer system as an elastic wrap is typically applied over the paste boot	Low resting pressure; high working pressure during gait Cost effective Comfortable for patients to wear Protect against trauma Full ambulation possible and minimal activity interference with wear	Pressure changes over time Appropriate training is needed for proper application Do not accommodate highly draining wounds, no way to manage fluctuating oedema Cannot be reused
Adjustable hook and loop systems	"Velcro" attachment method	Can be easily adjusted throughout the day for fluctuations in girth High upfront cost, but last a long time	Do not include the foot
Long-stretch (elastic) bandages	Bandages that can stretch more than 100% their original length	Provide sustained compression during rest and activity Can be washed and reused	Appropriate training is needed for proper application High resting tension causes high risk of overcoming capillary closing pressure and risk of ischaemic soft tissue injury
Compression garments	Tight-fitting elastic garments such as stockings, hose, pants, or shirts	Variety of pressures available Customisable for patient's needs and fit	Can be challenging to fit Difficult to don and doff Must be removed when patient is recumbent Costly—should be replaced every 6 months
Tubular bandages	Seamless, cylindrical bandages, can be made of netted or solid material	Multiple widths to accommodate changes in leg shape from ankle to knee Usually need at least 2 widths for best pressure Inexpensive	Only last a couple of weeks before they lose their elasticity
Longitudinal bandages	Elastic fibres run vertically	Do not require multiple widths to accommodate leg shape Comfortable Easy to don
Intermittent pneumatic compression devices	Apply external pressure using a cylinder pump that encircles the leg The repeated inflation/deflation of the pump mimics the effect of repeated application of compression bandages or calf muscle pump action	Can be used as a "rescue" intervention after failure of other compression methods Appropriate for patients who cannot tolerate sustained pressure or have restricted mobility

Factors Affecting Compression System Selection

Multiple factors can affect what compression therapy system is selected. These include factors unique to the patient's medical and personal needs. When selecting the type of compression therapy, it is necessary to consider patient risk factors (vascular considerations, leg girth, sensation status), wound status, product availability, product cost, and patient factors (compliance, ability to don and doff, appearance, comfort).

Compression Bandages Clinical Pearls

• Always begin at the base of the patient's toes and end just below the knee
• The bandage should always cross the leg at an angle, not straight across
• The ankle should be in a neutral position when the bandage is applied
• The anterior ankle should always be padded
• Assess for appropriate compression: two fingers should easily fit under the compression wrap at the toes and knee
• Wash the entire leg (not just the wound) at every dressing change, and apply lotion as needed
• Ensure the patient or care provider knows they have permission to remove the compression bandage if the patient experiences pain or any other concern—remember to provide education on how to follow up if the compression has been removed

Additional Resources

• Evidence and Guidelines Compression Therapy Campaign (European Wound Management Association)
• Rabe E, Partsch H, Morrison N, Meissner MH, Mosti G, Lattimer CR, et al. Risks and contraindications of medical compression treatment–A critical reappraisal. An international consensus statement. Phlebology. 2020 Aug;35(7):447-60.