Scientific evidence of compression treatment

EDITORIAL

Scientific evidence of compression treatment

Marcondes Figueiredo

Doutor em Ciências, Universidade Federal de São Paulo – Escola Paulista de Medicina (UNIFESP-EPM), São Paulo, SP, Brazil. Especialista, Angiologia e Cirurgia Vascular, SBACV

Correspondence

Evidence-based medicine arose in 1991, with the initial purpose of, from patients' individual expectations, establishing the best investigational models and therapeutic approaches, based exclusively on the best available medical literature. This practice aims to overcome the clinical authority/expertise system as the source of knowledge, a deep-rooted routine in medicine. This is an authoritarian, excluding exercise (as it inhibits opposing opinions), based on the conclusions of an individual alone or, at the most, of a health care facility or school. Practice enhancement should be based on the knowledge of the best available scientific evidence, disregarding personal and isolated opinions, thus improving science and favoring science-related democracy.1

Elastic compression therapy, although its mechanism of action has been demonstrated in several scientific publications, remains as an empirical approach within the medical literature. We have a different understanding, since such mechanism is very well-defined as compression lowers edema, reduces the volume of the superficial venous system, improves calf muscle pump ejection fraction, reduces vein diameter, and restores valvular competence. Such benefits are limited to the time of stocking use, since, after stockings are taken off, the hemodynamic effect they cause cease within about 1 hour.2

Therapeutic and prophylactic indications for the use of compression stockings, bandages and pneumatic compression are well-established within the scope of evidence-based medicine. The International Compression Club homologated such evidence in a meeting held November 2007, in Paris.^3,4 The following two tables show indications (Table 1) and post-procedure use of compression (Table 2) (only grade 1A and 1B evidence are recommended).5

Table 1
– Elastic compression stockings

Indications	Compression (mmHg)			Bandages	IPC
	10-20	20-30	30-40
C0 s	1B
C1 s	1B
C1 s post-sclerotherapy		1B
C2 a,s	1B	2B
C2 s pregnancy	1B	1B
C3 prevention	1B
C3 therapy		2B
C4 B		1B	1B
C5		2B	1A
C6			1B	1A	1B

a = asymptomatic; IPC = intermittent pneumatic compression; s = symptomatic.

Table 2
– Post-procedure use

Indications	Compression (mmHg)			Bandages	IPC
	10-20	20-30	30-40
VTE
Prevention	1A				1A
Therapy			1B	1B
PTS
Prevention			1A
Therapy			2B		1B
Lymphedema
Therapy			1B	1B	1B

IPC = intermittent pneumatic compression; PTS = post-thrombotic syndrome; VTE
= venous thromboembolism.

Concerning the interpretation of the tables presented, some conclusions can be drawn, as described below:

Grade of evidence for the use of 20 mmHg compression stockings is:

- Prevention of occupational edema: 1B;

- Initial cases according to CEAP (clinical, etiological, anatomical, and pathophysiological) (C0 and C1 s): 1B;

- Prevention of venous thromboembolism: 1A.

Grade of evidence for the use of 20-30 mmHg compression stockings is:

- Post-sclerotherapy of spider veins: 1B;

- Prevention of venous insufficiency symptoms during pregnancy: 1B;

- Prevention of venous edema in CEAP 3 patients: 1B.

Grade of evidence for the use of 30-40 mmHg compression stockings is:

- Treatment of deep venous thrombosis: 1B;

- Prevention of post-phlebitic syndrome: 1A;

- Treatment of CEAP 4 patients: 1B;

- Treatment of open venous ulcer: 1B;

- Prevention of ulcer relapse (CEAP 5): 1A.

Grade of evidence for the use of elastic and non-elastic compression bandages is:

- Healing of venous ulcers with Unna's boot or multilayer bandage: 1A;

- Reduction of post-operative bleeding after varicose vein surgery: 1B.

Grade of evidence for the use of intermittent pneumatic compression is:

- Prevention of venous thromboembolism: 1A;

- Treatment of lymphedema and post-thrombotic syndrome: 1B.

Therapeutic compression stockings are considered the clinical treatment of choice for venous insufficiency in the lower limbs. Therefore, this should be seen as the first treatment option. Morning measurements of the affected limb, the type of stockings to be used (3/4, 7/8, pantyhose, or pregnancy), and the indication of the best compression in mmHg ensure a successful therapy with the patient.

It should be taken into account that prescription of compression should be as strict as pharmacological prescription. Furthermore, an adaptation period should be considered in the prescription of stockings, since not all patients will get used to this therapeutic option.

References

• 1. Nobre M, Bernardo W. Medicina baseada em evidência: expandindo limites. In: Nobre M, Bernardo W. Prática clínica baseada em evidência. Rio de Janeiro: Elsevier; 2006.
• 2. Figueiredo MA, Filho AD, Cabral AL. Avaliação do efeito da meia elástica na hemodinâmica venosa dos membros inferiores de pacientes com insuficiência venosa crônica. J Vasc Bras. 2004;3:231-7.
• 3. International Compression Club [site na internet]. Berndorf, Austria. http://www.icc-compressionclub.com/index.php
• 4. Partsch H, Flour M, Smith PC, International Compression Club. Indications for compression therapy in venous and lymphatic disease consensus based on experimental data and scientific evidence. Int Angiol. 2008;27:193-219.
• 5. Guyatt G, Gutterman D, Baumann MH, et al. Grading strength of recommendations and quality of evidence in clinical guidelines: report from an American College of Chest Physicians Task Force. Chest. 2006;129:174-81.

Publication Dates

• Publication in this collection
  02 Oct 2009
• Date of issue
  June 2009