Hrev_master Veins and Lymphatics 2013; volume 2:e12 [Veins and Lymphatics 2013; 2:e12] [page 37] The use of strapping to increase local pressure: reporting of a sub-bandage pressure study Alison Hopkins,1 Fran Worboys,1 Hugo Partsch2 1Accelerate CIC, London, UK; 2Private practice, Vienna, Austria Abstract High compression is the gold standard for venous ulcer management. This brief report presents the results of a sub-bandage pressure study that investigated the pressures received from compression therapy in the region of the retromalleolal fossa. The study tested the hypothesis that therapeutic compression is not achieved behind the malleolus. The results confirm this, showing that less that 5-mmHg sub-bandage pressure is achieved despite high compression at the B1 level. This report demonstrates that the application of novel strapping below the malleolus substantially increases the compression at rest, standing and dorsiflexion. The clinical implications of this are discussed. Introduction The development of the strapping tech- nique has been discussed and presented pre- viously.1 This technique was developed in response to the clinical complexities seen in lower limb ulceration where the ulcers are on the foot or behind the malleolus in the retro malleolal fossa. These sites typically prove dif- ficult to heal with standard high compression therapy. This small study tested the hypothe- sis that standard high compression does not apply adequate pressure in this region; that therapeutic compression is only achieved at B1 or gaiter area. Standard compression ther- apy is ineffective in the retro-malleolal fossa region due to bandage hammocking from the heel to the malleolus. This study aimed to test this hypothesis and provide some evidence for the clinician and patient experience of this novel technique. Materials and Methods The sub-bandage pressures were obtained using a Picopress® [Microlab Elettronica Sas, Roncaglia di Ponte San Nicolò (PD), Italy] with probes at standard B1 plus the retromalleolus fossa, both medially and laterally. Cohesive inelastic compression (Actico, Lohmann & Rauscher GmbH & Co. KG, Neuwied, Germany) was applied using a standard regime of 10 cm spiral or a non-standard 8cm in a figure of 8 from the toes. These regimes were compared with additional strapping. Strapping was applied in a fan distribution1 (Figure 1). Sub- bandage pressures were collated at resting, standing and at dorsiflexion. Results The mean pressures at B1 using cohesive inelastic regime were 42 mmHg at rest and 62 mmHg on standing. Figure 2 demonstrates the range of sub-bandage pressures exhibited from the probe placed behind the malleolus. When the probe was placed in the inner/medi- al or outer/lateral retromalleolal fossa, the pressures were under 5 mmHg at rest, stand- ing and on dorsiflexion. With the application of strapping, pressures in this region increased, ranging from 25 mmHg to 48 mmHg (Figures 2-4). Correspondence: Alison Hopkins, Accelerate CIC, Mile End Hospital, Bancroft Road, London E1 4DG, UK. Tel. +44.0208.223.8331 - Fax: +44.020.8223.8863. E-mail: alison.hopkins2@nhs.net Key words: venous ulceration, compression, stiff- ness, sub-bandage. 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: AH, FW, co-developer of the novel strapping technique, investigator and analysis; HP, advised in study design, investigation and results. Conflict of interests: the authors declare no potential conflict of interests. Received for publication: 31 October 2012. Revision received: Not required. Accepted for publication: 22 January 2013. This work is licensed under a Creative Commons Attribution 3.0 License (by-nc 3.0). ©Copyright A. Hopkins et al., 2013 Licensee PAGEPress, Italy Veins and Lymphatics 2013; 2:e12 doi:10.4081/vl.2013.e12 Figure 1. Fan strapping. Figure 2. Range of sub-bandage pressures. No n- co mm er cia l u se on ly Conference presentation [page 38] [Veins and Lymphatics 2013; 2:e12] Discussion and Conclusions This simple study confirmed the hypothesis that standard high compression does not pro- vide compression to the retromalleolal area despite achieving high pressures in the B1 area. Thus this region does not receive thera- peutic compression. The use of a strapping technique has been shown to significantly increase compression to this area. The authors contend that this is of clinical significance. Where there is non-healing ulceration below the ankle and on the foot, this technique targets that area. High compression can be focused on the site without resorting to increasing compression through multiple lay- ers of bandage from toe to knee; thus manage- ment is tailored to the patient and limb improving tolerance of treatment. Patients report that they feel the additional pressure from the straps, that it promotes a support to the ankle and offers pain relief. This novel technique impacts on compression stiffness and also assists in reshaping the foot and anatomical shape of the malleolal fossa; the latter has often been lost through edema and reduced ankle range of motion. The pressures demonstrated at the ankle region through the use of the strapping dispute the promotion of standardized compression regimes for all patients. The strapping technique was developed in a primary care trust. The authors claim this is a key factor in having a venous ulcer prevalence of 0.14 per 1000.2 References 1. Hopkins A, Worboys F, Bull R, Farrelly I. Compression strapping: the development of a novel compression technique to enhance compression theory and healing for ‘hard to heal’ leg ulcers. Int Wound J 2011;8:474-83. 2. Hopkins A, Worboys F, Posnett J. Low wound prevalence and cost burden: the impact of a multidisciplinary wound spe- cialist team. EWMA J 2012;12:18-9. Figure 3. Lateral ankle, no straps. Figure 4. Lateral ankle, with straps. No n- co mm er cia l u se on ly