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Compression Hosiery

Compression hosiery is a much neglected area, and might well be
described as the Cinderella of community pharmacy services. Its poor image dates
from the very thick and unglamorous old fashioned stockings available before
1988. However, the past 10 years have seen considerable change. My own interest
began some years ago when, while looking through a cupboard belonging to a close
relative, I discovered a cache of several packets of elastic stockings, all
unworn.

This raised important questions: How often is this situation repeated in
homes throughout the country? How many pairs of stockings paid for using NHS
money are sitting unused in patients' wardrobes? How many patients are going
untreated, and at what cost to the taxpayer of the subsequent treatment
required? A few years ago, the blame would have been placed fairly and squarely
at the door of the non-compliant patient. Now the story is different, and at
least part of the blame would be shifted to the healthcare professionals for
failing to recognise that the co-operation of the patient is a prerequisite of
treatment. In other words, concordance not compliance is the key.

There is a belief among patients that "elastic stockings" are for varicose
veins, and that is true, but it is not even half the story. There is also a
belief, even among some medical, pharmaceutical and nursing personnel, that
elastic stockings are "all the same". This is certainly not true.

Compression hosiery is a general term embracing many different types of
garment and it is necessary to make a clear distinction between the graduated
compression hosiery, which is included in the Drug Tariff1, and the remainder.
It is a common misuse of the terminology to refer to all elastic hosiery as TED.
TED is the Kendall brand name for its anti-embolism stockings and stands for
Thrombo Embolism Deterrent. Anti-embolism stockings are not in the Drug Tariff,
but they are sometimes seen in the community. They are usually white and an
enquiry to the patient will often elicit the explanation that they were supplied
by the hospital to be worn for six weeks post-operatively, but as "they are more
comfortable than the others" they are worn in preference to the graduated
compression hosiery subsequently prescribed. Such substitutions should be
discouraged because anti-embolism stockings do not provide graduated
compression.

 

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Pharmacists may be interested to note that the Hosiery & Allied Trades
Research Association (HATRA) scale used in Britain to measure the pressure
exerted by stockings differs from the Hohenstein scale used in the rest of
Europe. As such, a compression rating of 20mm on the Hohenstein scale will not
be equivalent to a 20mm compression rating on the HATRA scale. The differences
arise partly from the method used to knit the garment and partly from the method
used to measure the pressure. It is likely that Britain will soon have to
conform to European standards in this area, as in so many others.

Physiology and function

In the body, the purpose of the veins is to return de-oxygenated blood to the
heart. Within the legs there is a distinction made between deep veins and
superficial veins. The deep veins lie beneath the deep fascia of the leg,
usually covered by the lower limb muscles. Much larger in diameter than the
superficial veins, their main function is to return blood from the limbs to the
heart. The superficial veins are situated in the subcutaneous fat and their
function is thermo-regulatory. Since evolutionary man began to walk upright, a
heavy burden has been placed on the circulation in the lower limbs, where the
pressure of blood entering the veins, opposed by gravity, is very low and has
insufficient energy to return to the heart on its own.

Pressure of the
venous return is assisted by the venous pump system, which comprises a series of
pumps in the foot, calf and thigh. The deep veins of the lower limb are
surrounded by skeletalmuscle; when the muscles contract the veins are compressed
and blood is expelled from them (Fig 1). Thus regular contraction during walking
pumps blood back to the heart: with the muscles in a relaxed state, no pumping
occurs (Fig 2). All veins in the legs contain flap-like valves, which ensure
upward flow towards the heart

 

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In some cases, with advancing years, the venous return and venous pump can
become less efficient and the circulation of the limb(s) starts to deteriorate.
This is known as venous insufficiency and often the first visible sign is
varicose veins. The first event in the development of varicose veins is the
failure of the flap valves, often in the "link" veins between superficial and
deep veins. Because of deterioration of the valve, a small amount of reverse
flow towards the distal parts of the leg occurs. Under these circumstances, the
valves are said to be incompetent, the pressure on the capillaries causes them
to distend, the blood can then pool and the wall thickens and becomes itchy,
painful and unsightly. Thus is a varicose vein formed. Varicose veins are
associated with a wide range of symptoms including itching, pain, cramps and
swelling. Approximately 70 per cent of leg ulcers are caused by venous disease².

Varicose veins are a common condition of pregnancy said to be caused by
hormonal changes, increased weight, and the physical pressure of the foetus on
the femoral vein.

As a consequence of the impaired venous valves, the pump action of the
skeletal muscle will be insufficient to squeeze the blood upwards, and the
venous pressure will tend to increase. This increased venous pressure gives rise
to the condition known as "chronic venous insufficiency", recognised in the
first place by skin changes.

Initially, brown patches appear as a result of the deposition of haemosiderin
(a breakdown product of haemoglobin) in the skin. High pressure in the post
capillary venules of the skin causes red blood cells to escape into the tissues.
The next stage is scarring, in which the skin and subcutaneous tissues become
scarred and indurated. This indicates that the onset of ulceration is likely
and, indeed, severe skin damage ultimately results in ulcer formation (Figs 4, 5
& 6 overleaf). It is clear, then, that the blood can be pushed upwards towards
the heart by applying to the limb external pressure, greatest at the ankle,
gradually decreasing towards the thigh. This is exactly what graduated
compression hosiery is designed to do (Fig 7 ): it opposes the increased venous
pressure and improves venous insufficiency and all the associated problems. The
amount of pressure required depends upon the severity of the condition³.

Graduated compression hosiery is also used in the treatment of varicose
ulcers. Although studies have identified that the severity of underlying venous
disease is related to intractable ulceration, very little is known about the
associated risk factors⁴. There is, however, thought to be a genetic
component.

Treatment failure is one of the reasons for such deterioration. First, the
patient or doctor may fail to recognise that there is a problem; secondly,
inappropriate prescribing or supply may be the cause; the patient may use the
stockings incorrectly or not wear them at all; and finally, ineffective and ill
fitting hosiery may be uncomfortable and can be damaging to the patient's legs.

On the other hand, patients who wear their stockings can expect to see an
improvement in their condition; they should feel less discomfort, and so be able
to work better, and take more exercise. Thus patients can help their own long
term prospects and avoid becoming a future problem for their carers and the NHS.
It must be emphasised, however, that this happy prospect depends on getting the
right stockings which the patient will want to wear. It is possible.

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Economics

Chronic venous insufficiency, then, is an important
problem, being the cause of 70 per cent of leg ulcers; however recurrent leg
ulcers are a significant problem, with 69 per cent of newly healed ulcers
recurring within a year⁵. It has also been shown that about two
thirds of patients who have been diagnosed and treated, experience two or more
episodes of ulceration, with 21 per cent of patients experiencing more than six
episodes⁶. Clearly, the economic implications of this are
considerable. Statistics from the Scottish Pharmacy Practice Division show that
in Dumfries and Galloway there were 1715 prescriptions for compression hosiery
at a cost of £17,975.85 during the period from December, 1995 to November, 1996.
It is interesting to speculate how many of the stockings remain unworn, and how
much of this taxpayers' money will have been wasted.

However the cost to the UK in unworn stockings pales into insignificance
compared with the cost of untreated venous insufficiency resulting in varicose
ulcers. This amounts to many millions of pounds a year. Four layer bandaging is
currently considered the most effective treatment for leg ulcers, but it is
extremely time-consuming in terms of community nursing and thus a serious burden
of cost to the NHS. Furthermore, the bandages are not included in the Drug
Tariff.

In one study, research by McCollom, Freak et al⁷ indicated that
over £236m was spent each year on largely ineffective leg ulcer care. Other
estimates have put the figure as high as £400m and have also suggested that this
mainly ineffective treatment might account for 60 per cent of all community
nursing time⁸.

There is clearly a problem with non-compliance in the early stages of venous
disease. Equally clearly, there is a huge potential for patient benefits,
savings to the NHS, and reduction of workload. Improved compliance might
actually result in a twofold financial advantage. First, there would be less
wastage from unworn appliances and secondly there would be fewer crises
requiring more expensive hospital and/or specialist nursing care.

Compression Hosiery,
Support hose - Legluxe.com