1 Definitions
1.1 Pressure and stiffness
2 Medical compression devices
2.1 Medical compression stockings (MCS)
2.1.1 Types of knit
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Flat-knit with seams, machine-made, with at least one knitted thread and one inserted elastic thread in every second course. These stockings can be produced to fit very closely and apply a high level of compression. Commercially available flat knit MCS are generally stiffer; however, they are also more inflexible, making them harder to slip on over folds of tissue. These properties (greater stiffness + inflexibility + harder to slip on) are not found in circular-knit stockings. In flat-knit stockings, individual courses can be added or eliminated. They can therefore be adapted to unusual leg circumferences, e.g., with highly developed lymphedema. The stocking is knitted as a single piece and stitched together, with a seam at the back of the leg.
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Single- and double-surface circular-knit with seams, machine-made, with at least one knitted thread and one inserted elastic thread in every second course. These MCS are produced with a specific number of needles on a knitting cylinder. Additional courses cannot be either added or eliminated. The stocking can only be adapted to the shape of the leg by altering the size of the course (tight or loose knitting) or the tension of the threads. There are therefore limitations on the shaping of circular-knit MCS. Limbs with very small circumferences and extreme changes in circumference or deep folds of tissue cannot be provided with circular-knit stockings.
2.1.2 Quality features
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Calf stockings (A–D)
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Knee-length stockings (A–F)
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Thigh stockings (A–G)
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Compression support tights (A–T)
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with or without a shoulder cap
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with or without an incorporated or separate glove
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Number
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Length: A–D calf stockings, A–F knee-length stockings, A–G thigh stockings, A–T compression support tights
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Compression class (CCL): I to IV
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Indication and diagnosis
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Device number or description
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Check made-to-measure production if necessary
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Toe: open or closed
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Made-to-measure production
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Auxiliary elements: e.g., fly opening, pelottes, zip closure, panty part with compression
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Flat knit
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Stiffness
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Closures: e.g., sticky tape, hook-tape (Velcro), waistband
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Resupply
CCL | Intensity | Pressure/mmHg | kPA |
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I | Slight | 18–21 | 2.4–2.8 |
II | Medium | 23–32 | 3.1–4.3 |
III | High | 34–46 | 4.5–6.1 |
IV | Very high | 49 and more | 6.5 and more |
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Polyamide (PA, Nylon®, Perlon®)Polyamide thread fabrics are resistant to ageing, insects, rot, moths, and microorganisms. The maximum moisture content is 0.06%.
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Elastane (EL, Lycra®)This material consists of 85% polyurethane (PU). The highly elastic threads are resistant to almost all diluted acids and alkaline, as well as oil and grease. They resist ageing, light and temperatures up to 150 °C. The moisture absorbance is very low, 1.5%.
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Cotton (CT)Cotton is a fiber which covers the seeds of the cotton plant (Malvaceae), an annual shrub which usually grows 2 to 3 m high. Raw CT normally contains 83–85% pure cellulose. CT can be boiled and sterilized; static charging is low. Its elasticity is approximately 40%, and the moisture content under normal conditions is 8%.
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Elastodiene (ELA, natural rubber)The raw material is the sap of the rubber tree (natural latex), harvested by cutting slits in the bark. ELA is remarkable for its extraordinarily high elasticity and distensibility. It is not resistant to grease or many chemical substances. It is destroyed by high temperatures (e.g., for sterilization). The moisture absorbance is low.
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Rayon (CV, viscose)In contrast to cotton, rayon is a regenerated cellulose thread, a chemical thread. Its moisture content varies between 5 and 15% and it is used as a substitute for cotton. Like cotton, it has high moisture absorbance (swelling capacity 85–120%).
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MicrothreadsThis is a general description for polyamide and polyester threads (moisture content 0.5–4%). They are substantially thinner than natural threads, with a fineness of 0.1–1 dtex, i.e., 10,000–100,000 m of thread weigh 1 g. Well-known materials made of microthreads are Tactel® and Trevira Finesse®.
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Colors, patterns, and trimmingsBoth flat- and circular-knit MCS are available in a wide range of colors, which helps to make therapy more acceptable. There are also MCS in different patterns, with different types of knit and trimmings.
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New developments—auxiliary elementsTo increase wearer comfort and adherence, many MCS include ceramic capsules woven into the stocking which release conditioning substances. In other models, the actual threads are enriched with conditioning substances. If necessary, they can be re-impregnated after the stocking has been washed a few times. MCS are also available with silver-coated threads to reduce bacterial colonization of the skin.
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Producer
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Product name
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Fiber content
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Compression class
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Stiffness
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Stocking type or size
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Product care and washing symbols
2.1.3 MCS donning and doffing aids
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Paralysis
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Age-induced loss of strength
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Arthrosis/rheumatism
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Severe obesity
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Extensive stiffness of the spine/hip/knee
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Degenerative diseases in the hands or hand region
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Sequelae from injuries/amputations
2.2 Phlebological compression bandage (PCB)
2.2.1 Bandage types
2.2.2 Materials
2.2.3 Bandage width and length
2.2.4 P-LA-C-E
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P (pressure)—exerted by the compression bandage on the limb;
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LA (layers)—wrapping of the material over itself, whether it consists of one or more components;
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C (components)—type of materials used in the manufacture of the individual components; and
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E (elasticity)—enabling the material to apply high pressure to the limb at rest.
2.2.5 Material tolerance
2.2.6 Labelling
2.2.7 Distensibility
2.2.8 Durability
2.2.9 Pressure values and pressure profile of PCB
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Distensibility
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Type
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Width
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Elasticity
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Relaxation
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Number of wraps
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Bandaging technique
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Moisture absorbance
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Care and washing
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Circumference of limb
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Configuration of limb
2.2.10 Desired local pressure
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Slight: <20 mmHg
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Medium: ≥20–40 mmHg
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High: ≥40–60 mmHg
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Very high: >60 mmHg
2.2.11 Bandaging techniques
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Each layer of the bandage system shall be wrapped over the preceding layers.
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The ankle should be positioned at a right angle (dorsiflexion).
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In the lower leg, the compression bandage is applied up to the head of the fibula; in the thigh, up to the proximal thigh.
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Due to the geometry of the leg, the pressure applied with the same distension of the bandage reduces as the radius increases from distal to proximal.
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The bandage shall not be applied with points of high pressure, strangulating, or constrictions, or cause pain.
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The PCB material and application technique shall be adapted to the requirements of the patient’s medical condition.
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A cotton tubular bandage down to below the knee serves to protect the skin.
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Inner padding can help to prevent pressure ulcers.
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Pressure padding and pelottes can increase the effectiveness of bandaging.
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Fixing clips often present a risk of injury; they are only to be used to fix the bandage outside the padding, not on the inside (see supplier’s information). Strips of sticking plaster are suitable for fixing the tail of the bandage.
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The width of the bandage is adapted to the shape and diameter of the limb.
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At least two bandages are normally required to obtain the required compression.
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The foot should always be in its physiological position (dorsiflexion).
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Ensure that proper pressure in each layer is applied from the start. Slack turns, for example on the front part of the foot, can lead to the formation of edemas.
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The roll of bandage is kept under permanent tension and unrolled directly onto the skin, so that the bandage follows the contours of the leg smoothly.
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Pulling individual turns too tight disturbs the pressure gradient. Strangulating constriction can lead to vein congestion (and even an increased risk of thrombosis), pressure damage to nerves, or necrosis.
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In cases of pronounced edema of the front part of the foot, or pronounced lymphedema, the toes shall also be compressed to avoid influence of the edema.
2.2.12 Care
2.2.13 Materials for the decongestion phase
2.3 Medical adaptive compression systems (MAC)
3 Indications for medical compression therapy
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Improvement of venous symptoms
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Improvement in quality of life in chronic vein diseases
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Prevention and treatment of venous edema
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Prevention and treatment of venous skin alterations
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Eczema and pigmentation
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Dermato-liposclerosis and atrophie blanche
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Venous leg ulcer treatment
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Mixed (arterial and venous) leg ulcer (respecting contraindications: see Recommendation 31)
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Prevention of recurrent venous leg ulcer
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Pain reduction in venous leg ulcer treatment
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Varicose veins
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Initial phase after varicose vein therapy
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Functional venous incompetence (cases of obesity, people who work sitting/standing for extended periods)
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Venous malformations
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Superficial venous thrombosis
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Deep leg venous thrombosis
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Arm vein thrombosis
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Condition after thrombosis
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Post-thrombotic syndrome
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Thromboprophylaxis in mobile patients
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Lymphedema
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Edema during pregnancy
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Post-traumatic edema
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Post-surgery edema
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Post-surgery reperfusion edema
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Idiopathic cyclic edema
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Lipedema from stage II
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Congestion following immobility (arthrogenous congestion syndrome, paresis, and partial paresis of the limb)
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Work-induced edema (people who work sitting/standing for extended periods)
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Medication-induced edema, when substitution is impossible
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Obesity with functional venous incompetence
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Inflammatory skin diseases on the legs
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Nausea and dizziness in pregnancy
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Symptoms of congestion during pregnancy
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Condition after a burn
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Scar treatment
4 Contraindications for phlebological compression therapy [35]
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Advanced peripheral arterial occlusive disease (if any of these parameters is exceeded: ABPI <0.5, arterial pressure at the ankle <60 mmHg, toe pressure <30 mmHg, or TcPO2 <20 mmHg at the back of the foot). If inelastic materials are used, compression treatment can still be attempted with arterial pressure at the ankle between 50 and 60 mmHg under close clinical supervision [36].
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Decompensated heart failure (NYHA III + IV)
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Septic phlebitis
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Phlegmasia cerulea dolens
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Pronounced weeping skin changes
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Intolerance to compression material
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Severe sensitivity disturbances of the limb
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Advanced peripheral neuropathy (e.g., with diabetes mellitus)
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Primary chronic polyarthritis