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Veins and Lymphatics 2013; volume 2:e8

[Veins and Lymphatics 2013; 2:e8] [page 23]

Experimental study on efficacy
of compression systems with 
a high static stiffness index
for treatment of venous ulcer
patients 
Anneke Andriessen,1 Martin Abel2
1Andriessen Consultants, Malden & UMC
St. Radboud, Nijmegen, The Netherlands;
2Medical & Regulatory Affairs, Lohmann
& Rauscher, Rengsdorf, Germany

Abstract

The experimental study measured interface
pressure and static stiffness index of four dif-
ferent compression systems in fifty-two
healthy volunteers. For the study interface
pressure (3 cm ø probe was placed at the
anatomical B1 point) was recorded on applica-
tion of the compression systems every 15 min
for 4 h, in supine, standing, while sitting and
during walking. For this purpose a portable
Kikuhime (Harada Corp., Osaka, Japan)
device was used. Further static stiffness index
(SSI) was calculated. The evaluated systems
were: short stretch bandage system (SSB)
Rosidal sys (Lohmann & Rauscher, Rengsdorf,
Germany), multi-layer bandaging (LSB)
Profore (Smith & Nephew, Hull, UK), vari-
stretch bandage (VSB) Proguide (Smith &
Nephew) and tubular compression (CS)
Rosidal mobil (Lohmann & Rauscher). The
mean interface pressure of SSB, LSB and VSB
was significantly higher (P<0.05) in each
position measured over 4 h, compared to CS. In
supine VSB showed high-pressure levels, up to
60 mmHg, which remained high. The other

systems had more tolerable levels of about 30
mmHg. Interface pressure exerted on limbs is
an indicator of their clinical effect. The exper-
imental study results showed different pat-
terns of interface pressure and SSI, which may
enable clinicians to predict the frequency of
bandage application, supporting an adequate
and safe choice of bandage system. 

Introduction

The paper was presented at the
International Compression Club Meeting in
Vienna 2012 and discussed an experimental
study that was previously published.1 The study
aimed to compare interface pressure and stat-
ic stiffness index (SSI) of four different com-
pression systems that are currently in use for
venous leg ulcer and lymphedema treatment of
the lower limbs.  

Materials and Methods

For the experimental study fifty-two ambula-
tory adults with healthy legs, were recruited at
random in the study center, after they had
given informed consent.1 Excluded were those
with an allergy against one of the used materi-
als; arterial occlusive disease (ABPI less than
0.8); ulcers on the lower limb; lower limb
edema; known history of dermatological prob-
lems such as eczema or cellulites. The evaluat-
ed systems were: short stretch bandage system
(SSB) Rosidal sys (Lohmann & Rauscher,
Rengsdorf, Germany), multi-layer bandaging
(LSB) Profore (Smith & Nephew, Hull, UK),
vari-stretch bandage (VSB) Proguide (Smith &
Nephew) and tubular compression (CS)
Rosidal mobil (Lohmann & Rauscher).

Interface pressure (IP) (3 cm ø probe was
placed at the anatomical B1 point) was record-
ed on application of the compression systems
and every 15 min for 4 h, in supine, standing,
while sitting and during walking. For this pur-
pose a portable Kikuhime (Harada Corp.,
Osaka, Japan) device was used. Measure -
ments during walking were recorded while
subjects walked on a treadmill for at least 5
min at normal pace.

Correspondence: Anneke Andriessen, Zwenkgras
25, 6581 RK Malden, The Netherlands. Tel. 31 24
3587086.
E-mail: anneke.a@tiscali.nl

Key words: interface pressure, static stiffness
index, compression for venous leg ulcers.

Conference presentation: part of this paper was
presented at the International Compression Club
(ICC) Meeting on Stiffness of Compression
Devices, 2012 May 25, Vienna, Austria
(http://www.icc-compressionclub.com/).

Contributions: the authors contributed equally.

Conflict of interests: MA is an employee of
Lohmann & Rauscher (Rengsdorf, Germany), the
company that provided the study products. A lim-
ited educational grant was received from
Lohmann & Rauscher for conducting the study.

Received for publication: 4 October 2012.
Revision received: 1 November 2012.
Accepted for publication: 15 November 2012.

This work is licensed under a Creative Commons
Attribution 3.0 License (by-nc 3.0).

©Copyright A. Andriessen and M. Abel, 2013
Licensee PAGEPress, Italy
Veins and Lymphatics 2013; 2:e8
doi:10.4081/vl.2013.e8

Figure 1. Mean interface pressure in supine, sitting, standing and
walking (N=52). IP, interface pressure; SSB, short stretch bandage
system; LSB, multi-layer bandaging; VSB, vari-stretch bandage;
CS, tubular compression.

Figure 2. Static stiffness index (N=52). SSB, short stretch bandage
system; LSB, multi-layer bandaging; VSB, vari-stretch bandage;
CS, tubular compression.

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Primary outcome measure
Interface pressure measured in supine, sit-

ting, standing and walking and SSI.
Parametric or non-parametric tests (SPSS:
IBM Corp., Armonk, NY, USA) were used where
appropriate. Mann-Whitney U or paired T-test
were used for intragroup and per group com-
parisons of the IP measured in the different
positions and over time. 

Results

The mean interface pressure of SSB, LSB
and VSB was significantly higher (P<0.05) in
each position measured over 4 h, compared to
CS (Figure 1). In supine VSB showed high-
pressure levels, up to 60 mmHg, which
remained high. The other systems had more
tolerable levels of 30 mmHg. Measurements in
sitting showed similar trends. All compression

systems maintained pressure levels in walking
of at least 40 mmHg (Table 1). The SSI was the
highest for SSB with 20 and remained 19
throughout the study period. LSB followed with
an SSI of 18, reduced to 15, where the SSI for
VSB went from 17 to 12 and CS with an SSI of
6 lagged behind (Figure 2).

Discussion

The IP for LSB and VSB in supine of ±60
mmHg were higher than usually reported. LSB
and VSB are defined systems, SSB is a variety
of compression systems. LSB has an elastic
layer (extensibility >100%), SSB consists of
short-stretch materials (extensibility±70%).
By applying LSBs’ elastic layers over each
other, with a cohesive bandage as the outer
layer, the final system is stiffer.2 This was also
shown in our study1 and is in line with what
was demonstrated by Mosti and Partsch.2-5

In a clinical study6-8 two groups were treated
with compression and one group received no
compression. In selected patients IP and SSI
was measured for the two compression sys-
tems LSB and SSB. The static stiffness index
remained higher than 10 in both compression
groups for one week, the duration of bandage
application, despite of bandage pressure loss
(Figure 3). The reduction in ulcer area from
weeks 12 to 24 in the LSB group and usual care
group (moist wound healing dressings, no
compression) was not significant (P=0.67 and
P=0.16), where a statistically significant
reduction in ulcer area was observed in the
SSB group (P=0.047) (Figure 4). Both com-
pression systems treated groups showed effec-
tive ulcer healing with faster and better ulcer
area and pain reduction for SSB, which may be
explained by the higher SSI of the system. 

Limitations
This was an experimental study on healthy

Conference presentation

[page 24] [Veins and Lymphatics 2013; 2:e8]

Table 1. Experimental study (N=52): interface pressure measured in supine and walking.

mmHg SSB LSB VSB CS Paired T-test
Supine Walking Supine Walking Supine Walking Supine Walking

Mean 40.68 (±5.01) 56.11 (±5.01) 48.12 (±4.57) 69.59 (±6.24) 48.96 (±3.99) 66.21 (±4.02) 37.82 (±0.58) 40.04 (±1.77) Supine: SSB, LSB, 
(±SD) VSB vs CS: P=0.05
Median 41 (39-60) 57 (52-80) 50 (44-59) 73 (64-90) 51 (46-60) 69 (64-80) 40 (39-41) 42 (40-45) Walking: SSB, LSB, 
(range) VSB vs CS: P=0.05
SSB, short stretch bandage system; LSB, multi-layer bandaging; VSB, vari-stretch bandage; CS, tubular compression; SD, standard deviation.

Figure 3. Clinical study (N=321): interface pressure and static
stiffness index. IP, interface pressure; SSI, static stiffness index;
SSB, short stretch bandage system; 4LB, four-layer bandage sys-
tem; SD, standard deviation.

Figure 4. Clinical study (N=321): ulcer area reduction at 12 and at 24
weeks. SSB, short stretch bandage system; 4LB, four-layer bandage
system; UC, usual care (a moist wound healing dressing and no com-
pression); ANOVA, analysis of variance; SD, standard deviation.

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Conference presentation

[Veins and Lymphatics 2013; 2:e8] [page 25]

legs over a 4-h period where typically the sys-
tems are left in place for 3-4 days up to 1 week.
Moreover the device that was used to measure
IP is not suitable to leave in place for over 4 h.
Based on our results it is not possible to pre-
dict what the pressure levels would be over this
period on for instance venous leg ulcer
patients with edema. 
However the reported results from a clinical

study,6,7 suggest that when using the SSB and
LSB compression systems in venous leg ulcer
patients with edema, the IP levels are main-
tained at a therapeutic level over a week. For
this study another, more suitable measurement
device [Picopress®, Microlab Elettronica Sas,
Roncaglia di Ponte San Nicolò (PD), Italy]3 was
used to measure IP levels. This device can be
left in place for several days up to a week, pro-
viding clinically relevant information.3

Conclusions

Interface pressure exerted on limbs is an
indicator of their clinical effect. The study
results showed different patterns of interface

pressure and SSI, which may enable clinicians
to predict the frequency of bandage applica-
tion, supporting an adequate and safe choice
of bandage system. This approach may
increase the patients’ participation in, and
compliance with, compression therapy, thereby
saving on costs and nursing time.

References

1. Wong IKY, Man MBL, Chan OSH, et al.
Interface pressure and static stiffness
index of four compression systems. J
Wound Care 2012;21:161, 164, 166-7.

2. Mosti G, Mattaliano V, Partsch H. Inelastic
compression increases venous ejection
fraction more than elastic bandages in
patients with superficial venous reflux.
Phlebology 2008;23:287-94. 

3. Mosti G, Partsch H. Inelastic bandages
maintain their hemodynamic effective-
ness over time despite significant pres-
sure loss. J Vasc Surg 2010;52:925-31.

4. Mosti G, Mattaliano V, Partsch H. Influence
of different materials in multicomponent

bandages on pressure and stiffness of the
final bandage. Dermatol Surg 2008;34:631-
9.

5. Partsch H. The use of pressure change on
standing as a surrogate measure of the
stiffness of a compression bandage. Eur J
Vasc Endovasc Surg 2005;30:415-21.

6. Wong IKY, Andriessen A, Charles HE, et al.
Randomized controlled trial comparing
treatment outcome on quality of life of two
compression bandaging systems and stan-
dard care without compression in patients
with venous leg ulcers. JEADV 2012;26:
102-10.

7. Wong IYK, Andriessen A, Lee DTF, et al.
Randomized controlled trial comparing
treatment outcome of two compression
bandaging systems and standard care
without compression in patients with
venous leg ulcers. J Vasc Surg 2012;55:
1376-85.

8. Partsch H. The static stiffness index (SSI):
a simple method to assess the elastic prop-
erty of compression material in vivo.
Dermatol Surg 2005;31:625-30.

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