WOUND MANAGEMENT

10 Journal of Community Nursing May/June 2013, volume 27, issue 3

Key words:Lower leg venous ulcerationShort-stretch compression bandageStatic stiffness indexVenous ulcerationActico®2C

The focus of compression bandaginghas been directed towards ease ofapplication, comfort, tolerability andeffectiveness. This article reports on atwo-centre non-comparative evaluationof the new two component short-stretch bandage kit (Actico®2C) in acase series with the aim of establishinghow comfortable and effective thebandage is in a real life situation.

Aaron Knowles Tissue Viability Podiatrist,Eastbourne Wound Healing CentreDr Hildegard Charles Visiting Lecturer,Buckingham UniversityAgnes Collarte Tissue Viability Nurse,Central London Community Healthcare NHSTrustAnna Coulborn Lymphoedema Specialistand Tissue Viability Nurse, Wound HealingCentre, EastbourneSylvie Hampton Tissue Viability Consultant,Wound Healing Centre, Eastbourne

Article accepted for publication: March 2013

Evaluation of a newtwo componentinelastic compressionbandage kit

with short-stretch systems12.The benefitsof alternating the high working pressuresand lower resting pressures to aid venousreturn and the pumping action stimu-lated by the foot and calf muscles havebeen well documented14. These effectshave also been beneficial in assistinglymph flow in the presence of oedema15.Patients who are non-concordant in

wearing compression bandages maymerely be reflecting a desire to live anormal lifestyle, rather than living withbandages that are uncomfortable orunsightly to wear, or that hinder move-ment16. Indeed, the practical aspects ofsafely managing patients can presentother challenges:

• Patients: pain, concordance, ability towear normal clothing, whether or notthe wound will heal

• Clinicians: ease of application,treatment choices, training, patientconcordance

Thus, a product that helps addresssome of these challenges would bebeneficial.

The studyWhen a new product enters the market,practitioners must be assured that it‘does what it says on the tin’. Compres-sion bandaging efficiency testing isundertaken in the laboratory beforepatient use, but only patient and nurseexperience will establish its effective-ness, and patient tolerability.This article reports a two-centre non-comparative evaluation of a newbandage system, Actico®2C (ActivaHealthcare UK [known as Rosidal TCSoutside the UK]). This non-comparativecase series evaluated the comfort andeffectiveness of the bandage in the ‘reallife’ situation, and formed part of a largerinternational study of 95 patientoutcomes using Actico®2C. The bandagesystem is latex free and comprises a layerof foam padding with a natural cottonskin protection layer in a single bandage

Research on the negative effects ofleg ulceration on patients’ qualityof life and how this can be dramat-

ically improved with effective treatmentand compression therapy has beenwidely published1,2. Compression band-aging for venous disease has been usedfor millennia3 and, over this time, newbandages and compression devices havebeen developed. In addition to the effec-tiveness of the compression system, thefocus has been directed towards ease ofapplication and user comfort.Venous leg ulceration is due to

sustained venous hypertension; bloodfrom the limb is not effectivelyreturned to the heart due to the failureof valves in the perforating veins4.Arterial leg ulcers occur as a result ofreduced arterial blood flow. The mostcommon causes of poor blood supplyare atherosclerosis or peripheralvascular disease5. Mixed aetiologyulcers can therefore be due to eitherpoor blood supply to the lower limb orpoor blood removal from the lowerlimb6-8.Research has suggested that compres-

sion with short-stretch inelastic bandagesmay be used safely and effectively in thisgroup of patients where accurate assess-ment has been conducted and caresupervised by a specialist practitioner9.

Compression therapyShort-stretch bandages are applied at fullstretch to achieve the required sub-bandage pressures to reduce oedema andpromote ulcer healing10. Newer systemscomprise bandages with squares orcircles to guide the application of correctpressures11. Recent studies have concen-trated on investigating the differencebetween elastic and inelastic bandagesystems and static stiffness indices12,13. Aninelastic or short-stretch bandage willcause a higher hydrostatic pressureincrease12. A good static stiffness index(SSI), the difference between the sub-bandage pressure on the distal lower legminus the lying position, is achieved

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WOUND MANAGEMENT

which distributes compression evenly,and a second short-stretch compressionlayer. It can be used for up to seven daysand is available in kits for ankle sizes18–25cm and 25–32cm.One urban and one semi-rural site in

the United Kingdom (EastbourneWound Healing Centre [EWHC], andthe Central London Community Health-care NHS Trust Leg Ulcer Clinic[CLCH]) participated. The sixteenpatients recruited were aged between 22and 89 years old; aetiologies includedvenous leg ulceration, mixed aetiologyulceration and stage one oedema. Allhad a history of non-concordance orwere happy to evaluate anotherbandage for comfort. The evaluationperiod was two to six weeks; change ofcompression bandage was determinedby condition, but where possible,remained in place for up to seven days.These patients were all fully informed ofthe evaluation, each agreed to take partand provided signed consent. Approvalfor all evaluations at the EWHCrequired the approval of the local ethicscommittee.Patient assessment included Doppler

ultrasound to determine ankle brachialpressure index (ABPI), limb size, generalhealth and co-morbidities.

Application Short-stretch bandages are applied atfull stretch which can be recognisedwhen the bandage ‘locks out’. Thismakes pressure indicators redundant.When applied, the bandage does notexpand when the calf muscle expands,therefore the force of the muscle isdirected back into the leg and notwasted by expanding the bandage17. TheActico® ‘Safe-Loc' system®, a key featureof the kit, ensured that bandages wereapplied at full stretch.As with all compression bandage

systems, extra padding protection ofbony prominences and vulnerable limbsis essential. Where the ankle circumfer-ence is less than 18cm, it is recommendedthat a system that allows for variation ofthe bandage layers with single units suchas Actico® and Flexiban®.

ResultsSixteen patients completed theevaluation. The outcomes were:

• Two patients completely healed attwo weeks (12.5 per cent)

• Two patients completely healed at sixweeks (12.5 per cent)

12 Journal of Community Nursing May/June 2013, volume 27, issue 3

Box 1: Case studies

Case study 1A 78-year-old gentleman had a 29-year history of leg ulceration (mixed aetiology).High exudate levels necessitated daily dressing changes; managementinterventions had included super-absorbent dressings, skin protection and a ‘light’compression system (3M™ Coban™ 2 Compression System) for the mixedaetiology vascular status. On entry to the study, the wound measured 18.76cm2 (Figure a). The Actico©2C

bandage kit was applied over a super-absorbent dressing, which was changedevery four days. Figure b shows the wound 18 days after treatment, when exudatevolumes had decreased, the wound appeared shallower and had reduced in size to13.67cm2.Although the bandages tended to unravel a little at the top of the leg, this was

managed by taping that did not affect the tissue or healing. The patient describedthe bandage system as being “perfect”, commenting that “it did not stick to theother leg or bed sheets overnight.”

Case study 2This 81-year-old female had a history of depression and multiple co-morbidities.Vascular status could not be recorded using the dopplex® ABIlity system, althoughhandheld Doppler produced biphasic, dull sounds. History confirmed that theulcer was a mixed venous arterial ulcer. Her ulcer was painful and moderatelyexuding; pre-study treatment included wool, Setopress® and 3M™ Coban™ 2 overthe dressings to manage the exudate, and skin protectant for the peri-wound area.The patient had been non-concordant and did not like compression. It was decidedto try the Actico©2C compression bandage kit over the same dressings to managethe exudate, alleviate the pain and to encourage ulcer healing. The patient did notfeel that the bandage was any better or worse, although she scored the newbandage as being less tight than the previous regimen and she agreed to remain inthe evaluation. Figure c shows the wound on day one of the bandage applicationand figure d shows improvements in wound condition and the peri-wound at day25. The clinician preferred this system over the alternative bandages as it helped toresolve concordance issues.

Figure a: The wound on day of first application

Figure b:The wound after 18 days of treatmentwith Actico®2C

Figure c: The wound on day one of applicationof Actico©2C

Figure d: The wound after 25 days of treatmentwith Actico©2C

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• One patient achieved >50 per centhealing at six weeks

• One patient moved into hosiery attwo weeks

• One patient moved into ActiLymph®

Class 2 hosiery due to unmanagedoedema and is now doing well

• Seven patients improved during theevaluation and continued withActico®2C

All patients described the applicationand the wearing of Actico®2C as ‘verycomfortable’ and there were no problemswith concordance. The bandages werecomfortable both during the day and atnight, and only minimal slippage wasnoted (Figure 1). The ability to self-bandage was noted by patients, and allreported a reduction in oedema andconsequently, an improvement in anklemovement which allowed them to wearshoes. The new foam layer of Actico®2Chas a cotton, skin friendly layer whichcombines well with the use of emollients.No adverse skin reactions were notedduring and after the evaluations.

Comments from patients included:

“Most comfortable bandage I have everworn”

“Much better with wearing shoes than anyother bandage system”

Comments from nurses included:

“Feels very light and easy to use”

“The same easy method of application with‘Safe-Loc’ as Actico”

“The comfort layer conformed well to the leg”

Two patients continued using it once theevaluation finished.

6. Callam MJ, Ruckley CV, Harper DR, et al.(1985). Chronic ulceration of the leg: extent ofthe problem and provision of care. BrMedJ. (Clin Res Ed) 290; 6485: 1855–66

7. Baker SR, Stacey MC, Jopp-McKay AG, etal. (1991). Epidemiology of chronic venousulcers. Br J Surg. 78; 7: 864–67

8. Cheatle TR, Scott HJ, Scurr JH, et al.(1988). Causes of venous ulceration: a newhypothesis. Br Med J (Clin Res Ed). 296; 6638:1726–7

9. Neil K, Turnbull K. (2012) Use of specialistknowledge and experience to manage patientswith mixed leg ulcers. J Wound Care. 21; 4:169–174

10. Beldon P. (2006) Compression bandaging:avoiding pressure damage. Wound Care. 13; 6(Suppl): 6–14

11. World Union of Wound Healing SocietiesDocument (2008) Principles of Best Practice:Compression in venous leg ulcers. A consensusdocument. MEP Ltd, London

12. Partsch, H. (2005) The Static Stiffness Index:A Simple Method to Assess the Elastic Propertyof Compression Material In Vivo. DermatolSurg. 31; 625–30

13. Charles H. (2012) The Function and Compo-sition of next Generation Bandages. WoundsUK. 8; 1: 16–19

14. Mosti G, Matalliano V, Partsch H. (2008)Inelastic compression increases ejection frac-tion more than elastic bandages in patients withsuperficial venous return. Phlebology. 28:287–94

15. Damstra R, Brouwer E, Partsch H. (2008)Controlled comparative study of relationbetween volume changes and interface pres-sure under short stretch bandages in leglymphoedema patients. Dermatologic Surg. 34:1–7

16. Brown A. (2005) Chronic leg ulcers, part 1:do they affect a patient’s social life? Br J Nurs.14; 18: 894–8

17. Acton C, Charles H, Hopkins A. (2006) Areshort-stretch bandages better than long-stretch? Wounds UK. 2; 2: 90–2

The system presents a potential solutionto low concordance and mixed aetiology,as illustrated by the case studies (Box 1),part of the EWHC evaluation.

ConclusionThe nurses reported on the ease of useand feeling confident with the simple‘Safe-Loc’ application. Patients’ needsand lifestyles should always be takeninto consideration when selecting treat-ments with compression bandaging.This new two component leg ulcer kithas proved to be easy to use, effectiveand comfortable and is suitable for thetreatment of venous leg ulcers with orwithout mild oedema, and ulcers ofmixed aetiology with caution. Asevidenced in the case studies, 'light'compression systems are not always as comfortable for patients as might beexpected. However, the patients in this case series found Actico®2Ccomfortable, a factor that promotesconcordance.

There is an argument for clinical posi-tioning of Actico®2C in the treatment ofvenous ulcers with uncomplicatedoedema.

References1. Edwards H, Courtney M, Finlayson K, et al.(2009) A randomised controlled trial of acommunity nursing intervention; improvedquality of life and healing for clients withchronic leg ulcers. J Clin Nurs. 18; 11: 1541–9

2. Charles H. (2004) Does leg ulcer treatmentimprove patients’ quality of life? J Wound Care.13; 6: 209–13

3. Thomas S. (1998) Compression bandaging inthe treatment of venous leg ulcers. World WideWounds. Available at: www.worldwide-wounds.com/1997/september/Thomas-Bandaging/bandage-paper.html

4. Grey JE, Harding K, Enoch S. (2006) ABC ofwound healing. Venous and arterial leg ulcers.Br Med J. 332; 7537: 347–50

5. Moffatt C. (2001) Leg Ulcers. In: Murray S(ed). Vascular Disease: Nursing and Management.Whurr Publishers Ltd, London

13Journal of Community Nursing May/June 2013, volume 27, issue 3

Figure 1: Actico®2C on application and one week later showing minimal slippage

Images by kind permission of theWound Healing Centre, East-bourne and the Central LondonCommunity Healthcare NHSTrust.

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Call our customer care line: 08450 606707 (International enquiries: +44 1283 576800)or visit our website at: www.activahealthcare.co.uk1 Lancaster Park, Newborough Road, Needwood, Burton on Trent, Staffordshire DE13 9PD.Activa®, Actico® and Safe-Loc® are registered trademarks of Activa Healthcare Ltd. ADV106 V1.1

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1. Mazzei S et al, 2012. First results of an observational study in 80 leg ulcer patients with a new Two-Component-System (TCS). Poster presentation Wounds UK 2012 Wound Care Conference 12-14th November 2012.

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